Insights in Public Health

Abstract

Home visiting services are cost-effective and improve the health of children and families among those at increased risk. From 1985–2008, home visiting services in Hawai‘i were provided primarily through state funding of the Hawai‘i Healthy Start Program, but the program was severely reduced due to the economy and state budget changes over the past decade. The Maternal and Child Health Branch (MCHB) in the Family Health Services Division responded to these changes by seeking out competitive grant opportunities and collaborations in order to continue to promote home visiting services to those children and families in need. In 2010, the MCHB was awarded a federally funded Maternal, Infant and Early Childhood Home Visiting (MIECHV) grant for home visiting services to promote maternal, infant, and early childhood health, safety and development, strong parent-child relationships, and responsible parenting. In 2011, the MCHB was also awarded a competitive MIECHV development grant that funded the re-establishment of the hospital Early Identification program. Families in need of additional support identified through this program are referred for family strengthening services to a network of existing home visiting programs called the Hawai‘i Home Visiting Network (HHVN). The HHVN is supported by MIECHV and a small amount of state funds to assist programs with capacity building, training, professional development, quality assurance, and accreditation/certification support. The MIECHV grant requires that programs are evidence-based and address specific outcome measures and benchmarks. The HHVN provides home visiting services to families prenatally through 5 years of age that reside in specific at-risk communities, and is aimed at fostering positive parenting and reducing child maltreatment using a strength-based approach by targeting six protective factors: (1) social connections, (2) nurturing and attachment, (3) knowledge of parenting and child development, (4) parental resilience, (5) social and emotional competence of children, and (6) concrete supports for parents. This article provides an introduction to the HHVN as a diverse network of evidence-based home visiting programs with services currently available on all islands, and highlights aspects of home visiting programs that support the Family-Centered Medical Home (FCMH) model. The HHVN provides important services to families at risk and uses evidence-based practices to yield positive results. Health care professionals can support this network to promote the health of children and families by being aware that these home visiting services exist and encouraging families at-risk to participate. Continued collaboration and expanded partnerships with health providers can help strengthen the home visiting network and improve outcomes for children and families in Hawai‘i.

Background

Home visiting services are effective in addressing the needs of families at-risk including reducing child maltreatment, improving maternal and child health, increasing school readiness, and increasing knowledge of child development and positive parenting.¹ One case of child abuse is estimated to result in a lifetime cost of over $210,000 for the surviving victim.² These costs include medical costs, productivity losses, criminal justice costs, and special education, and are estimated at $124 billion in the United States annually for confirmed child abuse and neglect cases; so efforts to prevent the occurrence of child abuse have the potential to realize significant cost savings as well as improve health. In addition to preventing child abuse or neglect, home visiting programs have the opportunity to promote health across families and have a large impact on those they serve by offering education on safe sleep, accident prevention, healthy nutrition, breastfeeding, and other important areas of child health. Overall home visiting services have recently been estimated to save from $1.80 to $5.70 for every dollar invested.³ These savings are actualized by investing in home visiting programs that increase positive outcomes for families at-risk and reduce the dependence on public resources to address such things as child abuse and neglect, poor birth outcomes, poor school readiness, and attenuated academic achievement. To establish and clarify the effectiveness of home visiting programs to improve child health and reduce child maltreatment, the Department of Health and Human Services (DHHS) initiated the Home Visiting Evidence of Effectiveness (HomVEE) review of randomized clinical trials and quasi-experimental designs of home visiting models.¹ HomVEE results indicated that 12 home visiting models demonstrated positive effects and met the DHHS criteria for designation as an evidence-based model.⁴

Since starting as a pilot in one site in 1985 with expansion to a statewide system in 2001, the home visiting services funded through the MCHB in the state of Hawai‘i have been implemented in a para-professional service model with goals to improve family functioning, promote child health and development, and prevent child abuse and neglect through the Hawai‘i Healthy Start (HHS) Program.⁵ In 2007, HHS had a statewide home visiting program on all six (6) islands with a total of 17 sites and served 4,553 families statewide. In 2009, when the economy experienced a severe downturn, HHS closed all but two program sites, and discontinued its Early Identification (EID) component in all birthing hospitals. The number of children enrolled in home visiting dropped significantly to just 227 and 295 children in 2010 and 2011, respectively. In 2010, The State of Hawai‘i Department of Health, Family Health Services Division, Maternal and Child Health Branch received grant funds from the Maternal, Infant, Early Childhood Home Visiting (MIECHV) program, administered by the Health Resources and Services Administration (HRSA) to resume evidence-based home visiting services in the State of Hawai‘i, resulting in the establishment of the Hawai‘i Home Visiting Network (HHVN). This funding continues through FY2015 with possible expansion of home visiting services following this period based on available federal funds as determined by Congress.

Hawai‘i Home Visiting: Practice Models

The HHVN is comprised of 4 of the MIECHV evidenced-based home visiting models identified through HomVEE: Early Head Start (EHS),⁶ Healthy Families America (HFA),⁷ Home Instruction of Parents of Preschool Youngsters (HIPPY),⁸ and Parents As Teachers (PAT),⁹ and two culturally specific promising practice home visiting models: Pulama I Na Keiki, “Cherish the Children” (PINK)¹⁰ and Kulia I Ka Nu‘u, “Strive for the Highest Peak.”¹¹ The HRSA MIECHV funds allowed the HHVN to support implementation of home visiting on all islands using the variety of evidence-based and culturally specific promising practices to address the varied needs of Hawai‘i's diverse community. The multiple models assist the home visiting programs to best address the varied needs of those receiving services. The HHVN was created via a competitive application process for programs implementing evidence-informed or evidence-based home visiting models. As a result, ten non-profit community based organizations established the HHVN, which is supported by state and federal (HRSA MIECHV) funds and are providing home visiting services in specific communities on all islands throughout the state.

HHVN Evidence-Based Home Visiting Models

The four evidence-based home visiting models provided via the HHVN and their service areas are described below. Table 1 also shows a listing of the home visiting model and service areas for each community based organization.

Table 1.

HHVN members providing home visiting services by model, program name, organization, and service area (as of January 2014).

Model	Program Name	Name of Organization	Service Area
Early Head Start	Early Head Start	Family Support Hawai‘i (FSH) - Kona	Kona / Census Tract 214–215
Early Head Start	Early Head Start	Maui Family Support Services (MFSS)	Maui Island
Early Head Start	Early Head Start	Parents and Children Together (PACT) Early Head Start	Kailua, Kaneohe, Waimanalo, Central O‘ahu
Healthy Families America	Healthy Start	Child & Family Service (CFS) - Kaua‘i	Lihue / Census Tract 404–405
Healthy Families America	Healthy Start	Child & Family Service (CFS) - O‘ahu	Central Oahu, Leeward Oahu, Waianae
Healthy Families America	Healthy Start	Maui Family Support Services (MFSS)	Lana‘i
Healthy Families America	Healthy Start	Parents and Children Together (PACT) Early Head Start	Downtown - Kalihi / Census Tract 46–62
Healthy Families America	Healthy Start	Young Women's Christian Association (YWCA)	East Hawai‘i Island Puna
Home Instruction for Parents of Preschool Youngsters	HIPPY	Keiki O Ka ‘Aina Family Learning Centers of Hawai‘i (KOKA)	Ewa - Kalaeloa / Census Tract 83–85, 9803 Kapolei - Makakilo / Census Tract 86, 115 Kona / Census Tract 214–215 Wailuku / Census Tract 306–313
Parents as Teachers	PAT	Keiki O Ka ‘Aina Family Learning Centers of Hawai‘i (KOKA)	Ewa - Kalaeloa / Census Tract 83–85, 9803 Kapolei - Makakilo / Census Tract 86, 115 Kona / Census Tract 214–215 Wailuku / Census Tract 306–313
Parents as Teachers	Ho‘ala	The Institute for Native Pacific Education & Culture (INPEACE)	Waianae / Census Tract 99–100 Moloka‘i
Promising Practice	Kulia I Ka Nu‘u Strive for the Highest Peak	Keiki O Ka ‘Aina Family Learning Centers of Hawai‘i (KOKA)	Ewa, E. Honolulu, Koolaupoko, W. Honolulu, Wahiawa, Waianae
Promising Practice	Pūlama I Na Keiki Project (PINK) Cherish the Children	Alu Like	Hawai‘i Island (Captain Cook, Holualoa, Kailua-Kona, Kealakekua, Honaunau) Maui (Kahului, Kihei, Kula, Makawao, Pukalani, Paia, Puunene, Wailuku) O‘ahu (Aiea, Ewa Beach, Haleiwa, Honolulu, Kahuku, Kaneohe, Kapolei, Mililani, Pearl City, Wahiawa, Waialua, Waianae, Waimanalo, Waipahu)

Early Head Start (EHS):

“EHS targets low-income pregnant women and families with children from birth through age 3, most of whom are at or below the federal poverty level or who are eligible for Part C services under the Individuals with Disabilities Education Act in their state. The program provides early, continuous, intensive, and comprehensive child development and family support services. EHS home-based services include weekly 90-minute home visits and two group socialization activities per month for parents and their children.”⁶ EHS program services provided through the HHVN are available on the islands of Hawai‘i, Maui, and O‘ahu (Table 1).

Healthy Families America (HFA):

“HFA goals include reducing child maltreatment, increasing utilization of prenatal care, improving parent-child interactions, and promoting children's school readiness. HFA programs offer hour-long home visits at least weekly until children are 6 months old, with the possibility for less frequent visits thereafter. Visits begin prenatally or within the first three months after a child's birth and continue until children are between 3 and 5 years old. In addition, many HFA sites offer parent support groups and father involvement programs.”⁷ HFA program services provided through the HHVN are available on the islands of Hawai‘i, Kaua‘i, Lana‘i, and O‘ahu (Table 1).

Home Instruction for Parents of Preschool Youngsters (Hippy Age 3-5Years:

“HIPPY aims to promote preschoolers' school readiness and support parents as their children's first teacher by providing instruction in the home. HIPPY offers weekly, hour-long home visits for 30 weeks a year, and two-hour group meetings monthly or at least six times a year. The home visiting paraprofessionals are typically drawn from the same population that is served by a HIPPY site, and each site is staffed by a professional program coordinator who supervises the home visitors.”⁸ HIPPY program services provided through the HHVN are available on the islands of Hawai‘i, Maui, and O‘ahu (Table 1).

Parents as Teachers (PAT):

“The goal of the PAT program is to provide parents with child development knowledge and parenting support, provide early detection of developmental delays and health issues, prevent child abuse and neglect, and increase children's school readiness. The PAT model includes one-on-one home visits, monthly group meetings, developmental screenings, and a resource network for families. Parent educators conduct the home visits using structured visit plans and guided planning tools.”⁹ PAT program services provided through the HHVN are available on the islands of Hawai‘i, Maui, Moloka‘i, and O‘ahu (Table 1).

Culturally-Specific Promising Practices

In addition to the 4 evidence-based home visiting models, MIECHV funds allow for home visiting models that have yet to demonstrate evidence of effectiveness but are deemed a promising practice. In Hawai‘i, there are two (2) culturally-specific promising practices in the HHVN, Kulia I Ka Nu‘u and Pulama I Na Keiki. These two promising practices do not receive implementation funds directly through the HHVN, but are members of the HHVN and are provided with training and technical assistance to support their journey to becoming an evidence-based home visiting model.

Kulia I Ka Nu‘u works with families with children age 2.5–5 years old and integrates a Montessori approach with Native Hawaiian culture. This program aims to support parents to ensure their child's school readiness and school success. Parent educators work with mothers and fathers to learn more about Native Hawaiian values and practices and incorporate these cultural values into the curriculum, which covers literacy, math, art, social studies, and science.¹¹ Kulia I Ka Nu‘u provides services only on the island of O‘ahu (Table 1).

Pulama I Na Keiki (PINK) provides services to Native Hawaiian families prenatally until the child turns 3 years old and assists families in identifying and learning more about their cultural traditions and the value of strengthening these cultural aspects within their family life. PINK acknowledges the rich cultural diversity of families in Hawai‘i, such that, in addition to Hawaiian cultural values, the cultural values of parent's family of origin are also supported and integrated into the curriculum. Parent educators provide culturally based information about prenatal health, childbirth, child development, and child rearing.¹⁰ Pulama I Na Keiki, provides services on the islands of Hawai‘i, Maui, and O‘ahu (Table 1).

These programs highlight and celebrate the cultural diversity of families living in Hawai‘i by strengthening not only Native Hawaiian values and cultural traditions, but, also the cultural values, traditions and practices of each parent's family of origin. As members of the HHVN, the goal is to develop a base of evidence supported by data to demonstrate model fidelity and positive outcomes for families and children. The HHVN will continue to provide technical assistance in preparing for and conducting evaluations to establish effectiveness of these culturally-specific home visiting models.

Hawai‘i Home Visiting: Priority Populations and Benchmarks

In an effort to improve outcomes for families at-risk and to reduce costs of providing services to address the needs of families at-risk, the HRSA MIECHV program identified 8 priority populations to provide evidence-based home visiting services supported by MIECHV funding. In alignment with this vision, the HHVN provides services to these 8 priority populations:

• Families at-risk or in at-risk communities (eg, families of children with low birth weight, families with a history of infant mortality, communities with high levels of poverty, high school dropout, unemployment, receiving high rates of governmental assistance, and those with a high rate of child abuse and neglect)

• Low-income families

• Pregnant women under age 21

• Families with a history of child abuse or neglect

• Families with a history of substance abuse

• Families that have users of tobacco in the home

• Families who have or have had a child/children with low student achievement

• Families who have a child/children with developmental delays or disabilities

• Families that include individuals who are serving or formerly served in the Armed Forces, including such families that have members in the Armed Forces who have had multiple deployments outside of the United States

All families who enroll in a voluntary evidence-based home visiting program within the HHVN are provided with weekly home visits for at least the first 6 months, after which, in collaboration with the family, the frequency of home visits is adjusted to one or two times per month. Home visitors provide families with information about a child's social and emotional needs, tools for supporting healthy child development, and also assess the child's or children's development using a standardized screening tool with the Ages and Stages Questionnaires (ASQ-3 and ASQ-SE).^12,13 Home visitors guide parents in a variety of parent-child interactions that are a key element in fostering healthy attachment between parents and children. Home visiting programs support parents to increase their confidence in being a parent. The family's needs are assessed during each home visit and appropriate supports are provided to assist families, such as referrals to programs like the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), Temporary Assistance Needy Families (TANF) and Supplemental Nutrition Assistance Program (SNAP). Help is also provided in obtaining active insurance coverage, conducting reviews to ensure that all child-well visits are completed and immunizations are up to date, and screenings/appropriate referrals for domestic violence and post-partum depression are made.

The HHVN currently aims to:

• Address the diverse needs of children and families living in at-risk communities by offering a diverse array of evidence-base home visiting program experiences;

• Extend services beyond 3 years of age, up to age 5 years with the inclusion of the HIPPY Program;

• Provide services on all islands through the state;

• Develop a training institute to ensure home visitor competencies are supported across home visiting models;

• Integrate the HHVN into a comprehensive, early childhood system through participation with Executive Office of Early Learning, Early Childhood Community of Educators, and integration with the Family-Centered Medical Home (FCMH);

• Represent diverse models and varying interests of families with the potential to engage and retain families from a variety of backgrounds and communities.

As part of the expansion of evidence-based home visiting services supported by MIECHV funds, the HHVN aims to address six legislatively-mandated benchmark areas identified by HRSA MIECHV:

• Improve Maternal and Newborn Health

• Reduce child injuries, abuse, neglect or maltreatment, and reduce emergency department visits

• Improve School Readiness and Achievement

• Screen for Domestic Violence

• Increase family economic self-sufficiency

• Coordinate referrals to community resources and supports

In addition to addressing these benchmark areas, the HHVN is committed to providing ongoing training and technical assistance to local agencies within the HHVN through the development of a home visitor training institute and the integration of Continuous Quality Improvement (CQI) processes within each implementing agency, within each home visiting model and across the HHVN.

In 2013, the HHVN provided home visiting services to 410 families and 444 children and completed 4,816 home visits, which is approximately a 50% increase from the number of children served in 2011 prior to receiving MIECHV federal funding. As a result of program development, home visiting services provided by the HHVN are expected to increase dramatically in 2014, potentially increasing enrollment by 25%–30%.

Home Visiting Network: Collaborations and Partnerships

Early Identification (EID) Program

As the HHVN expands the availability of home visiting services, the system for identifying potentially eligible families for home visiting services through the Early Identification (EID) program is expanding as well (Table 2). The EID program under the HFA model focuses on screening within birthing hospitals. Under the expansion of this EID in HHVN, efforts are made to reach families earlier through outreach to pregnant women as well as in birthing hospitals. EID providers use different approaches on each island to reach pregnant women, such as participating in community fairs and events, building relationships with community health centers, and direct community outreach (eg, door-to-door). EID screens pregnant women and families with newborns for risk factors using a 15-point screen and determines MIECHV/HHVN program eligibility. EID also serves as liaison between families and other resources to support families in the community. Within birthing hospitals, the EID program identifies individuals living in communities at higher risk. In 2013, EID screened 4,928 families of which 66% were eligible and offered home visiting services. Families not eligible or not interested in receiving home visiting services were connected to other resources in the community. Currently, EID services located in birthing hospitals are provided at Kapi‘olani Medical Center for Women and Children on O‘ahu, Hilo Medical Center, Kona Community Hospital, Maui Memorial Medical Center, and Wilcox Memorial Hospital on Kaua‘i (Table 2). These hospitals accounted for 51.7% of births in hospitals in Hawai‘i in 2008–2010, which represents about 9,900 births annually.¹⁴

Table 2.

HHVN members providing Early Identification services by organization, hospital, and service area (as of January 2014).

Name of Organization	Contact Information	Hospital	Service Area
Catholic Charities Hawai‘i (CCH)	808-527-4680 808-527-4690	Kapi‘olani Medical Center for Women and Children	Central O‘ahu, Leeward O‘ahu, Waianae / Census Tract 99–100 Downtown - Kalihi / Census Tract 46–62 Ewa - Kalaeloa / Census Tract 83–85, 9803 Kapolei - Makakilo / Census Tract 86, 115
Child & Family Service (CFS) - Kaua‘i	808-245-5914	Wilcox Memorial Hospital	Lihue / Census Tract 404–405
Family Support Hawai‘i (FSH) - Kona	808-334-4127	Kona Community Hospital	Kona / Census Tract 214–215
Young Women's Christian Association (YWCA)	808-930-5746 808-930-5719	Hilo Medical Center	Hilo / Census Tract 201–211, 219–221
Maui Family Support Services (MFSS)	808-242-0900	Maui Memorial Medical Center	Wailuku/ Census Tract 306–313

Collaboration with Executive Office of Early Learning

The HHVN also aims to build collaborative relationships with other agencies, providers, and communities across the state to support maternal and child health across a spectrum of systems. The HHVN is actively involved with the Executive Office of Early Learning with the goal of developing a comprehensive early childhood system within the state, which consists of various public and private partnerships to support the healthy development of families and children. The HHVN is working with the Early Childhood Educational System with the goal of implementing a standardized child development assessment tool, which will assist providers and agencies within the state to have consistent communication and assessment of a child's development as the child transitions through the various educational settings: home, preschool, pre-kindergarten, and kindergarten.

Collaboration with the Family-Centered Medical Home (FCMH)

In addition to providing home visiting services, the HHVN also supports the FCMH model as home visitors work with families to build communicative and supportive relationships with their pediatricians and develop collaborative processes for sharing relevant information that will assist families who are often engaged in different childhood systems.

One of the specific benchmarks within the HHVN is to ensure that all children enrolled receive all of their immunizations and complete their child well-visits. Therefore, home visitors aim to work in collaboration with the family pediatrician to monitor and support families in the completion of these visits. Additionally, home visitors administer a standardized screening tool, the Ages and Stages Questionnaire (ASQ) that parents are able to complete themselves in advance of seeing a health care provider, which has been shown to identify and help parent's articulate concerns they may be having about their child's development. Home visitors administer and review the results of the ASQ with parents and provide parents with referrals to address any potential developmental delays, as well as provide some basic enhancements for parents where possible. In 2013, 99% of children enrolled in HHVN services received at least one development screen. The HHVN offers training and technical assistance to administer the developmental screening test and works in collaboration with the Early Childhood Educational System and the Executive Office of Early Learning to establish a consistent method for assessing child development across the state.

Home visitors also monitor other benchmarks such as the frequency of emergency department visits by caregivers and children as well as their insurance status with the goal of reducing the number of non-emergency visits to the emergency department and connecting all families to health insurance coverage.

The HHVN is actively involved in building relationships with community health centers and providers as another strategy to reach prenatal families at risk through the EID program. The HHVN began collaboration with the American Academy of Pediatrics, Hawai‘i Chapter in late 2013 to evaluate and assess the best methods for communication and building relationships between pediatricians and home visitors. Information is collected through focus groups and open discussion forums in order to identify and address any challenges and obstacles to establishing a FCMH for each family. Health care providers are encouraged to support prenatal families in receiving home visiting services when they are approached in the hospital following the birth of their baby or they may contact the EID program during pregnancy for those families that may benefit from these services (Table 2).

Summary

The HHVN aims to address the diverse needs of families and children residing in at-risk communities across the state through the implementation of four evidence-based home visiting models: EHS, HFA, HIPPY, and PAT and two locally developed culturally appropriate interventions. Investment in evidence-based home visiting models has been shown to reduce costs by $1.80 to $5.70 for every dollar invested in home visiting programs.³ In addition to these benefits, the HHVN also strives to embed itself within the context of multiple early childhood systems, such as the Early Childhood Educational System, by collaborating with educators and providing training on a standardized child development tool to support children and families as they transition from home visiting programs into the educational system. The HHVN is also building relationships with pediatricians and exploring ways to enhance communication in support of a FCMH model. Additionally, the HHVN EID program continues to reach out to community health centers to increase enrollment of pregnant women.

With the goal of continued expansion and sustained support for the HHVN, braided funding from State and Federal resources will allow the HHVN to continue to grow and increase home visiting services by expanding into additional at-risk communities and establishing EID programs in more birthing hospitals across the state. The HHVN provides important services to families at risk and uses evidence-based practices to yield positive results. Health care professionals can support this network to promote health of children and families through being aware that these home visiting services exist, and encouraging families at-risk that are approached by HVHN outreach workers to participate. Continued collaboration and expanding partnerships with health providers could help strengthen the home visiting network and improve outcomes for children and families in Hawai‘i.