home visit h

What makes a virtual home visit a visit?

What can count as a home visit during covid.

Phone and video visits can count as a virtual home visit, while texting does not.

Some families have limited access to minutes for phone calls or data for video chats.  Texting can be a very effective way to maintain contact with families can be a powerful way to connect with families during this crisis.  Dr. Bruce Perry talks about the therapeutic value of texting, especially now.  It is important to note that a text conversation, even one of significant length, does not “count” as a home visit.  Despite this, we encourage sites to maintain contact and relationship with families, using whatever methods they find to be effective, whether or not they are able to “count”  these connections as home visits.

Video Visit: YES

Texting: no, phone visit: yes, all contacts are important, home visit or friendly chat what makes a virtual home visit a visit.

Healthy Families America sites are responding to new challenges related to the current COVID-19 pandemic with resilience and are making families a priority despite barriers to services.  Recognizing that families with young children still need support, sites and staff have adapted and are supporting families remotely, often through phone and video calls.  As programs adapt, many are wondering about whether they are still truly doing home visiting at this time.

The Healthy Families America Best Practice Standards are a great resource for sites seeking guidance in this area.  The following is included in the definition of Home Visit in the glossary:

Typically, home visits occur in the home, last a minimum of an hour and the child is present.   Extenuating circumstances may occur where visits take place outside the home, be of slightly shorter duration than an hour, or occur with the child not present. These may be counted as a home visit only if the overall goals of a home visit and some of the focus areas (listed below) have been addressed. Also, in very limited, special situations such as when severe weather, natural disaster or community safety advisory impedes the ability to conduct a home visit with a family, a virtual home visit, via phone (skype, FaceTime or other video technology preferred), can be counted when documented on a home visit record and the goals of a home visit are met including some of the focus areas (below).

Promotion of positive parent-child interaction/attachment:

• Development of healthy relationships with parent(s)
• Support of parental attachment to child(ren)
• Support of parent-child attachment
• Social-emotional relationship
• Support for parent role in promoting and guiding child development
• Parent-child play activities
• Support for parent-child goals, etc.

Promotion of healthy childhood growth & development:

• Child development milestones
• Child health & safety,
• Parenting skills (discipline, weaning, etc.)
• Access to health care (well-child check-ups, immunizations)
• School readiness
• Linkage to appropriate early intervention services

Enhancement of family functioning:

• Trust-building and relationship development
• Strength-based strategies to support family well-being and improved self-sufficiency
• Identifying parental capacity and building on it
• Family goals
• Building protective factors
• Assessment tools
• Coping & problem-solving skills
• Stress management & self-care
• Home management & life skills
• Linkage to appropriate community resources (e.g., food stamps, employment, education)
• Access to health care
• Reduction of challenging issues (e.g., substance abuse, domestic violence)
• Reduction of social isolation
• Crisis management

Supervisors and Family Support Specialists may want to review this definition and the focus areas to ensure that the work that they are doing fits the definition of a home visit.  Additional information about the definition of a home visit, and the use of HFA’s service levels in response to this crisis can be found on the full COVID-19 Guidance for HFA sites page.

What is it that makes a phone call or video chat a home visit?

As sites move forward with phone and video connections with families, they may find that it can be challenging to distinguish a remote home visit from other phone or video calls.  It is possible to have a relatively brief call with a parent and address some of the focus areas above.  Does that mean it was a home visit?

There are many similarities between a regular phone or video contact with a parent and a virtual home visit.  Both are friendly and comfortable, both involve checking in on the well being of the family, both create opportunities for social connection.  With so many similarities, home visitors and supervisors may be wondering how to make sure that what we are doing is home visiting.

How to make sure you are doing home visiting:

Schedule it and call it a visit- Make sure the family knows your intention to make this a visit.  Avoid unscheduled virtual visits when possible.  Scheduling visits allows the FSS and the family to come to agreement about a time when the parent is likely to be available for an extended call and it sets some expectations about what the call will be about.

Be prepared – Hold the family in your mind ahead of the visit. Think about what you know about them, about the child’s developmental status, about their goals and needs.  Be flexible and follow the family’s lead but have a plan in mind as you prepare to start your visit.

Act with intentionality – Bring awareness to your self and your intentions each time you speak or interact with a family during a virtual visit.  Many times, this is what is missing from an informal check-in phone call.  Consider use of Reflective Strategies and other elements of HFA’s trauma-informed approach.

Be fully present-   This can be challenging for HFA staff working from their homes and may require home visitors to be strategic about where they are in their own home during visits.  While on the call or connecting through video, create space in the same way you would do in person: allow for quiet moments, notice feelings, attune to the parent.  Be an active listener: when your mind wanders, use Mindful Self-Regulation to bring yourself back into connection with the family.

Observe Parent Child Interaction and “bring the baby into the call” – Have CHEERS in mind throughout the virtual visit as you observe the interaction between parent and child (keep your virtual tip sheet for CHEERS handy).  When conversation veers away from the child, be intentional about bringing the parent child relationship back into focus.  Ask parents “How is the baby reacting to all of this stress?” or “It sounds like you are feeling isolated- how do your feelings show up in his behaviors?”.  Invite parents to record videos throughout the week of their routines and play with the baby so they can share them with you!  Using video to reflect together on parent strengths is a powerful way to promote attachment and nurturing parenting.

Use your curriculum, community resources and screening tools – Things like sharing parenting curriculum and connecting families to needed community resources will feel familiar to the parents you work with and will help staff and parents distinguish a visit from a regular phone call.  Whenever possible, complete regularly used screening tools such as ASQ-3 and perinatal depression screenings with families during virtual visits.  Continuing “regular” home visit activities can bring a sense of normalcy for staff and families.

When in doubt, support the family- connections with families that don’t fit the definition of a home visit are absolutely valuable.  Families in communities everywhere are facing additional stressors related to increased isolation and economic challenges.  HFA sites should make every effort to connect regularly with families, using whatever modalities are available to the families (including phone calls, texts and even notes and letters).  Dr. Bruce Perry has shared that even 3 minutes of connection can reduce stress and regulate us.

A brief contact with a caring compassionate home visitor can make a difference for a family, whether it is “counted” as a home visit or not.

The predictability and comfort that a safe and healthy relationship with a Family Support Specialist offers to parents is more important than ever right now.  HFA encourages sites to be creative and flexible in serving families with young children in these unprecedented and uncertain times, and we are grateful for the efforts of staff in sites in communities everywhere for the difference they are making in the lives of parents and young children.

Want to contact us?

Interested in learning more about our home visiting programs or helping transform childhoods and communities? Get in touch—we’ll respond as quickly as we can.

Look out for your health

A UnitedHealthcare® HouseCalls visit is a no-cost, yearly health check-in that can make a big difference. 

Call 1-866-799-5895 ,

TTY 711,  to schedule your visit.

HouseCalls brings yearly check-in care

To you at home.

Connect for up to a full hour of 1-on-1 time with a licensed health care practitioner. Every visit includes a physical, tailored recommendations on health care screenings and plenty of time to ask questions that matter to you.

After your visit, HouseCalls connects with your primary care provider (PCP) to help keep them informed about your health. It's a great way to feel confident knowing an extra set of eyes is looking out for you between regular PCP visits.

What is a HouseCalls visit? 

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Say hello to HouseCalls.

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HouseCalls is our way of looking out for your health, so you can focus on your future. Here’s what it’s all about.

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Once a year, a licensed health care practitioner can come to your home to spend up to an hour with you on your health and wellness.

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It's designed to be easy, convenient and informative.

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You'll get a head-to-toe exam, important health screenings and plenty of time to talk about your health goals.

We'll also provide guidance on managing your health and if you need it, give you referrals for other health plan resources and services.

HouseCalls is a great way to stay on top of your health between regular doctor's visits.

At the end of your visit, you'll get a personalized checklist so you can feel more confident in what to discuss with your regular doctor.

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If you're wondering how much all of this is going to cost, the best part is, there is no extra cost to you. It's included in your health plan.

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A HouseCalls visit takes place in the comfort of your own home or by video if you prefer.

So, say hello to HouseCalls and invite us in for a visit today.

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Access one of the most popular UnitedHealthcare offerings, at no cost to you

Schedule your visit

Call 1-866-799-5895 , TTY 711

Monday–Friday, 8 a.m.–8:30 p.m. ET

Your in-home health check-in

• Up to a full hour with a licensed health care practitioner
• Ask the questions that matter to you and get valuable health tips
• No cost — it's included in your health plan

Get rewarded

Meet your friendly housecalls medical staff.

Just like the professionals you see in your regular doctor’s office, our licensed health care practitioners may be nurse practitioners, physician assistants or medical doctors. They’re state licensed and maintain national certification.

We perform background checks on these professionals to provide additional peace of mind for our members. Your loved ones, caregivers or friends are welcome to be present during the visit — it’s up to you.

Ready to open the door to better health?

Getting ready for your housecalls appointment, tips to help you prepare:  .

• Wear shoes that are easily removed to have your feet checked
• Make a list of upcoming appointments with your PCP and specialists
• Make sure all of your medications, both prescription and over-the-counter vitamins and supplements, are in their original bottles for our review
• If you record blood pressure readings, please have your results available for review
• If you have diabetes, please have your blood glucose meter handy
• Make a list of questions and concerns you’d like to discuss

During your appointment

• You'll have up to a full hour of 1-on-1 time with your health care practitioner for a physical, select lab tests, health screenings and more
• A HouseCalls visit can be completed while sitting at your kitchen table or in the living room, and you can use the time to ask any health-related questions
• The visit is tailored to your individual needs, so screenings and conversation topics can vary

After your appointment

Less travel time. more face time..

Think of HouseCalls as an extra layer of care — valuable 1-on-1 time you don't always get in the doctor's office. And it's tailored to your individual needs.

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Have a question?

Find answers to frequently asked questions.  

If you have a specific question about your upcoming appointment or need to reschedule, call us at 1-866-799-5895, TTY 711 , Monday–Friday, 8 a.m.–8:30 p.m. ET

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Home visits: A practical approach

University of South Carolina Department of Family and Preventive Medicine, Columbia ; Virginia Tech Carilion Family Medicine Residency Program, Roanoke [email protected]

The authors reported no potential conflict of interest relevant to this article.

This service, which significantly improves outcomes for many patients, is beneficial in this time of COVID-19.

PRACTICE RECOMMENDATIONS

❯   Consider incorporating home visits into the primary care of select vulnerable patients because doing so improves clinical outcomes, including mortality rates in neonates and elders. A

❯   Employ team-based home care and include community health workers, nurses, pharmacists, social workers, chaplains, and others. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence

B Inconsistent or limited-quality patient-oriented evidence

C Consensus, usual practice, opinion, disease-oriented evidence, case series

Mr. A is a 30-year-old man with neurofibromatosis and myelopathy with associated quadriplegia, complicated by dysphasia and chronic hypercapnic respiratory failure requiring a tracheostomy. He is cared for at home by his very competent mother but requires regular visits with his medical providers for assistance with his complex care needs. Due to logistical challenges, he had been receiving regular home visits even before the ­COVID-19 pandemic.

After estimating the risk of exposure to the patient, Mr. A’s family and his physician’s office staff scheduled a home visit. Before the appointment, the doctor conducted a virtual visit with the patient and family members to screen for COVID-19 infection, which proved negative. The doctor arranged a visit to coincide with Mr. A’s regular appointment with the home health nurse. He invited the patient’s social worker to attend, as well.

The providers donned masks, face shields, and gloves before entering the home. Mr. A’s temperature was checked and was normal. The team completed a physical exam, assessed the patient’s current needs, and refilled prescriptions. The doctor, nurse, and social worker met afterward in the family’s driveway to coordinate plans for the patient’s future care.

This encounter allowed a vulnerable patient with special needs to have access to care while reducing his risk of undesirable exposure. Also, his health care team’s provision of care in the home setting reduced Mr. A’s anxiety and that of his family members.

H ome visits have long been an integral part of what it means to be a family physician. In 1930, roughly 40% of all patient-physician encounters in the United States occurred in patients’ homes. By 1980, this number had dropped to < 1%. 1 Still, a 1994 survey of American doctors in 3 primary care specialties revealed that 63% of family physicians, more than the other 2 specialties, still made house calls. 2 A 2016 analysis of Medicare claims data showed that between 2006 and 2011, only 5% of American doctors overall made house calls on Medicare recipients, but interestingly, the total number of home visits was increasing. 3

This resurgence of interest in home health care is due in part to the increasing number of homebound patients in America, which exceeds the number of those in nursing homes. 4 Further, a growing body of evidence indicates that home visits improve patient outcomes. And finally, many family physicians whose work lives have been centered around a busy office or hospital practice have found satisfaction in once again seeing patients in their own homes.

The COVID-19 pandemic has of course presented unique challenges—and opportunities, too—for home visits, which we discuss at the end of the article.

In the elderly, home visits have reduced functional decline, nursing home admissions, and mortality by 25% to 33%.

Why aren’t more of us making home visits?

For most of us, the decision not to make home visits is simply a matter of time and money. Although Medicare reimbursement for a home visit is typically about 150% that of a comparable office visit, 5 it’s difficult, if not impossible, to make 2 home visits in the time you could see 3 patients in the office. So, economically it’s a net loss. Furthermore, we tend to feel less comfortable in our patients’ homes than in our offices. We have less control outside our own environment, and what happens away from our office is often less predictable—sometimes to the point that we may be concerned for our safety.

Continue to: So why make home visits at all?

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Partner News

Home Visiting Peer Reviewed Literature Updates Copy News Link Link copied to clipboard

• Enhancements, Adaptations, and Innovations
• Family Engagement
• Home Visiting Infrastructure
• Participant Characteristics
• Precision Paradigm
• Research Design and Methods
• Service Coordination
• Virtual Home Visiting

Each month, HARC will share recently published peer-reviewed home visiting research articles. Articles were identified via a Google Scholar alert, thus the list may not include all published articles. Below are the links to this peer reviewed home visiting literature, by month.

OPEN ACCESS: Carleton, R. A., DiGirolamo, A. M., McGarrie, L., Whitmore, A., & Gilmer-Hughes, A. (2024). Factors associated with service referrals and uptake in Early Head Start: The importance of care setting. Infants & Young Children, 37 (2), 131-141. https://doi.org/10.1097/IYC.0000000000000263

Nguyen, J. N. J., Mensah, F., Goldfeld, S., Mainzer, R., & Price, A. (2024). The complementary impacts of nurse home visiting and quality childcare for children experiencing adversity. Australian Journal of Social Issues, 00 , 1-18. https://doi.org/10.1002/ajs4.331

Williams, V. N., Franco-Rowe, C. Y., Lopez, C. C., Allison, M. A., & Tung, G. J. (2024). Structural and relational factors for successful cross-sector collaboration in home visiting: A multiple case study. BMC Health Services Research, 24 (316), 2-11. https://doi.org/10.1186/s12913-02410719-4

TRADITIONAL PUBLISHING: Ahn, E., Ruopeng, A., Jonson-Reid, M., & Palmer, L. (2024). Leveraging machine learning for effective child maltreatment prevention: A case study of home visiting service assessments. Child Abuse and Neglect, 151 . https://doi.org/10.1016/j.chiabu.2024.106706

Sampson, M., Yu, M., Mauldin, R., Gonzalez, L., & Mayorga, A. N. (2024). Home visits for postpartum depression intervention among low-income Latinas: Results from the PST4PPD Project. Social Work in Public Health, 39 (2), 141-155. https://doi.org/10.1080/19371918.2024.2319862

Shaw, D. S., Mendelsohn, A. L., Morris-Perez, P. A., & Weaver Krug, C. (2024). Integrating equifinality and multifinality into the of prevention programs in early childhood: The conceptual case for use of tiered models. Development and Psychopathology . Advance online publication. https://doi.org/10.1017/S095457942400021X

Viswanathan, M., Rains, C., Hart, L. C., Doran, E., Sathe, N. Hudson, K., Ali, R., Jonas, D. E., Chou, R., & Zoltor, A. J. (2024). Primary care interventions to prevent child maltreatment: Evidence report and systematic review for the US Preventive Services Task Force. JAMA, 331 (11), 959-971. https://doi.org/10.1001/jama.2024.0276

PDF OF MARCH PEER-REVIEWED LITERATURE  

OPEN ACCESS: Ahun, M. N., Ali, N. B., Hentschel, E., Jeong, J., Franchett, E., & Yousafzai, A. K. (2024). A meta-analytic review of the implementation characteristics in parenting interventions to promote early child development. Annals of the New York Academy of Sciences , 10.1111/nyas.15110. Advance online publication. https://doi.org/10.1111/nyas.15110  Conti G, Smith J, Anson E, et al. (2024) Early Home Visits and Health Outcomes in Low-Income Mothers and Offspring: 18-Year Follow-Up of a Randomized Clinical Trial. JAMA Network Open, 7 (1):e2351752. https://doi.org/10.1001/jamanetworkopen.2023.51752

Harden, B. J., Osofsky, J. D., Alexander, C. (2024). The Effects of Trauma on Parenting and Caregiving. In: Osofsky, J.D., Fitzgerald, H.E., Keren, M., Puura, K. (eds) WAIMH Handbook of Infant and Early Childhood Mental Health. Springer, Cham. https://doi.org/10.1007/978-3-031-48627-2_26

Lewey, J., Beckie, T. M., Haywood, L., B., Brown, S. D., Garovic, V. D., Khan, S. S., Miller, E. C., Sharma, G., & Mehta, L. S. (2024). Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement from the American Heart Association. Circulation, 149 (7), e330-e346. https://doi.org/10.1161/CIR.0000000000001212

Xavier, J. F., Khanlou, N., Nielsen, L. S., & Moradian, S. (2024). Enhancing paternal support: A concept analysis of social support for first-time fathers. Nursing Forum . Advance online publication. https://doi.org/10.1155/2024/2803795

TRADITIONAL PUBLISHING:

Heller, S. S., Covert, H. H., Drnach-Bonaventura, G., Gilkerson, L., Kallemeyen, L., Lichtveld, L. Y., Sherman, M., & Taylor, C. A. (2024). Preventative intervention home visitation programme for mothers with fussy infants: a mixed methods, pilot assessment of maternal self-efficacy, mental health, infant-bonding, and programme experiences. Early Child Development and Care. Advance online publication. https://doi.org/10.1080/03004430.2024.2315437 McKelvey, L.M., Cook, G.A., Hughes-Belding, K., Fitzgerald, H.E. (2024). Infant and Early Childhood Home Visiting. In: Osofsky, J.D., Fitzgerald, H.E., Keren, M., Puura, K. (eds) WAIMH Handbook of Infant and Early Childhood Mental Health. Springer, Cham. https://doi.org/10.1016/j.chiabu.2015.09.008

Yu, X., Meghea, C. I., Raffo, J. E., Meng, R., Vander Meulen, P., Lloyd, C. S., & Roman, L. A. (2024). Community Health Workers: Improving Home Visiting Engagement of High-Risk Birthing People in Segregated Neighborhoods. Journal of Public Health Management and Practice . Advance online publication. https://doi.org/10.1097/PHH.0000000000001861

PDF OF FEBRUARY PEER-REVIEWED LITERATURE

OPEN ACCESS: Conti G, Smith J, Anson E, et al. (2024) Early Home Visits and Health Outcomes in Low-Income Mothers and Offspring: 18-Year Follow-Up of a Randomized Clinical Trial. JAMA Network Open, 7 (1):e2351752. https://doi.org/10.1001/jamanetworkopen.2023.51752

McConnell, M. A. (2024). Toward a nuanced assessment of the role of intensive home visiting in improving outcomes for families: Commentary on Caterine et al. (2023). Journal of Child Psychology and Psychiatry . Advance online publication. https://doi.org/10.1111/jcpp.13951 Stark, D. R., & Westheimer, M. (2024). An equity accelerator strategy: Parents developing careers in an early childhood literacy program. Journal of Family Diversity in Education, 6 (1), 69-77. https://doi.org/10.53956/jfde.2024.187

TRADITIONAL PUBLISHING: Beeber, L. S., Gasbarro, M., Knudtson, M., Ledford, A., Sprinkle, S., Leeman, J., McMichael, G., Zeanah, P., & Mosqueda, A. (2024). A Mental Health Innovation for Nurse Home Visiting Program Shows Effectiveness in Reducing Depressive Symptoms and Anxiety. Prevention science : the official journal of the Society for Prevention Research, 25 (1), 126–136. https://doi.org/10.1007/s11121-023-01574-6

Burak, E. W., & Wachino, V. (2023). Promoting the Mental Health of Parents and Children by Strengthening Medicaid Support for Home Visiting. Psychiatric services (Washington, D.C.), 74(9), 970–977. https://doi.org/10.1176/appi.ps.20220608

Kim, H., Song, E. J., & Windsor, L. (2024). Evidence-Based Home Visiting Provisions and Child Maltreatment Report Rates: County-Level Analysis of US National Data From 2016 to 2018. Child Maltreatment, 29 (1), 176-189. https://doi.org/10.1177/10775595221107533

Miller, E. B., Canfield, C. F., Roby, E., Wippick, H., Shaw, D. S., Mendelsohn, A. L., & Morris-Perez, P. A. (2023). Enhancing early language and literacy skills for racial/ethnic minority children with low incomes through a randomized clinical trial: The mediating role of cognitively stimulating parent–child interactions. Child Development, 00 , 1–14. https://doi.org/10.1111/cdev.14064

West, A., Williams, K., Daniels, J. & Correll, L. (2024). Feasibility, acceptability, and usefulness of a screening tool for caregiver learning differences in early childhood home visiting: Staff and caregiver perspectives. Prevention Science . Advance online publication.  https://doi.org/10.1007/s11121-024-01642-5  

PDF OF JANUARY PEER-REVIEWED LITERATURE

OPEN ACCESS: Brekke, M., Småstuen, M.C., Glavin, K., Amro, A., Solberg, B., Utne Øygarden, A., Saether, K. M., & Haugland, T. (2023). The impact of New Families home visiting program on first-time mothers’ quality of life and its association with social support: a non-randomized controlled study.  BMC Public Health, 23 (2457), 1-14. https://doi.org/10.1186/s12889-023-17285-0 Hancock, C. L. (2023). Ideologies of poverty and implications for decision-making with families during home visits. Linguistics and Education, 78 , 1-13. https://doi.org/10.1016/j.linged.2023.101231 Zijlstra, A., Joosten, D., van Nieuwenhuijzen, M., & de Castro, B. O., (2023). The first 1001 days: A scoping review of parenting interventions strengthening good enough parenting in parents with intellectual disabilities. Journal of Intellectual Disabilities, 0 (0), 1-22. https://doi.org/10.1177/17446295231219301   PDF OF DECEMBER PEER REVIEWED LITERATURE

OPEN ACCESS: Chazen-Cohen, R., Von Ende, A., & Lombardi, C. (in press). Parenting and family self-sufficiency services contribute to impacts of Early Head Start for children and families. Frontiers in Psychology , 14.  https://doi.org/10.3389/fpsyg.2023.1302687 Saether, K. M., Fagerlund, B. H., Glavin, K., & Jøranson, N. (2023). First-time parents’ support needs and perceived support from a child health service with the integrated New Families home visiting programme. Qualitative Health Research, 0 (0), 1-13. https://doi.org/10.1177/10497323231208972 TRADITIONAL PUBLISHING: Johnson, H., Fifolt, M., Knight, C., Wingate, M., Becker, D., & Preskitt. (2023). Promotion of school readiness in home visiting: Creating a key driver diagram for continuous quality improvement. Early Child Development and Care. Advance online publication. https://doi.org/10.1080/03004430.2023.2285699 Marshall, J., Merlo, K., Buro, A., Vereen, S., Koeut-Futch, K., Pelletier, C., & Ankrah, E. (2023). Mixed-methods evaluation of home visiting workforce wellbeing and telework in Florida. Children and Youth Services Review, 155 , 1-9. https://doi.org/10.1016/j.childyouth.2023.107306 Stewart, S. L., Applequist, K. L., & Seanez, P. (2023). Promoting coordination and collaboration in tribal home visiting programs in the United States. Maternal and Child Health Journal . Advance online publication. https://doi.org/10.1007/s10995-023-03847-6 Williams, V. N., Marshall, J., Richey, M., & Allison, M. (2023). Engaging community in prioritizing outcomes to improve family health in evidence-based nurse home visiting: Using a modified e-Delphi Method. Maternal and Child Health Journal . Advance online publication. https://doi.org/10.1007/s10995-023-03839-6 PDF OF NOVEMBER PEER REVIEWED LITERATURE   

OPEN ACCESS: Kapp, J. M., Hall, B., & Kemner, A. (2023). Assessing the feasibility of partnering with a home visiting program for early childhood obesity prevention. Maternal and Child Health Journal . Advance online publication. https://doi.org/10.1007/s10995-023-03780-8 Vicente, J. B., Pegorin, T. C., Santos, A. L. O., & Veríssimo, M. L. O. R. (2023). Interventions for child development based on the Touchpoints Model: Scoping Review. Revista Latino-Americana de Enfermagem, 31 ,(e4035), 1-15. https://doi.org/10.1590/1518-8345.6732.4035 TRADITIONAL PUBLISHING: O’Neill, K., Burrell, L., Peplinski, K., Korfmacher, J., Zagaja, C., McGready, J., & Duggan, A. (2023). Early childhood home visiting’s initial transition to virtual visits in response to the COVID-19 pandemic. Children and Youth Services Review . Advance online publication. https://doi.org/10.1016/j.childyouth.2023.107213 Williams, V., Franco-Rowe, C., Lopez, C., Allison, M. A., Olds, D. L., & Jackson Tung, G. (2023). Coordination of family’s care in an evidence-based nurse home visiting program. Journal of Interprofessional Care . Advance online publication. https://doi.org/10.1080/13561820.2023.2266452 Zhang, Y., Edwards, R., Korfmacher, J., & Hans, S. (2023). Young, low-income mothers’ social relationships and involvement in doula home visiting services. Children and Youth Services Review . Advance online publication. https://doi.org/10.1016/j.childyouth.2023.107228 PDF OF OCTOBER PEER REVIEWED LITERATURE   

OPEN ACCESS: Fagerlund, B. H., & Glavin, K. (2023). Public health nurse reflections on implementing the New Families home visiting programme: A qualitative study. Nursing Open , 00 , 1-9. https://doi.org/10.1002/nop2.1996 Hancock, C. L. (2023). Ideologies of poverty and implications for decision-making with families during home visits. Linguistics and Education , 78 , 1-13. https://doi.org/10.1016/j.linged.2023.101231 Richardson, M. B., Toluhi, A. A., Baskin, M. L., Budhwani, H., Julian, Z. I., Knight, C. C., Sinkey, R., Szychowski, J. M., Tita, A. T., Wingate, S. S., & Turan, J. M. (2023). Community and systems contributors and strategies to reduce racial inequities: Provider perspectives. Health Equity , 7.1 , 581-591. https://doi.org/10.1089/heq.2023.0114 Williams, V. N., Franco-Rowe, C., Knudtson, M., Tung, G., & Allison, M. (2023). Changes in cross-sector collaboration between nurse home visitors and community providers in the United States: A panel survey analysis. Health Services Review . Advance online publication. https://doi.org/10.1111/1475-6773.14242 TRADITIONAL PUBLISHING: Franck, L. S., Johnson, I., Mehra, R., Remy, L., & Rienks, J. (2023). A qualitative analysis of low-income pregnant and parenting caregivers’ experiences with home visiting in California during the first two years of the COVID-19 pandemic. Journal of public health management and practice . Advance online publication. https://doi.org/10.1097/PHH.0000000000001820 Goldberg, J. L., Sparr, M., Rosinsky, K., Lloyd, C. M., Till, L., Harris, P., Crowne, S., Fortune, B., & Higgins, C. (2023). Co-designing a conceptual framework of home visiting implementation quality. Children and Youth Services Review . Advance online publication. https://doi.org/10.1016/j.childyouth.2023.107161 Guterman, N. B., Bellamy, J. L., Banman, A., Harty, J. S., Jaccard, J., & Mirque-Morales, S. (2023). Engaging fathers to strengthen the impact of early home visitation on physical child abuse risk: Findings from the Dads Matter-HV randomized controlled trial. Child Abuse & Neglect , 143 , 1-13. https://doi.org/10.1016/j.chiabu.2023.106315 Knight, C., Johnson, K. M., Keane, K., Mckitt, T., & Fenn, H. (2023). Improving anxiety and depression in pregnant mothers participating in nurse home visitation. Journal of Psychosocial Nursing and Mental Health Services, 0 (0), 1-7. https://doi.org/10.3928/02793695-20230919-06 PDF OF SEPTEMBER PEER-REVIEWED LITERATURE   

OPEN ACCESS: Al-Taiar, A., Kekeh, M. A., Ewers, S., Prusinski, A. L., Alombro, K. J., & Welch, N. (2023). Virtual home visits during COVID-19 pandemic: mothers’ and home visitors’ perspectives. BMC Pregnancy Childbirth, 23 (577), 1-14. https://doi.org/10.1186/s12884-023-05896-9 Labella, M. H., Raby, K. L., Bourne, S. V., Trahan, A. C., Katz, D., & Dozier, M. (2023). Is Attachment and Biobehavioral Catch-up effective for parents with insecure attachment states of mind? Child Development, 00 , 1–8. https://doi.org/10.1111/cdev.14002 TRADITIONAL PUBLISHING: Appleyard Carmody, K., Murray, K. J., Williams, B., Frost, A., Coleman, C., & Sullivan, K. (2023). Enhancing early parenting in the community: Preliminary results from a learning collaborative approach to scale up Attachment and Biobehavioral Catch-up. Infant Mental Health Journal, 00 , 1–15. https://doi.org/10.1002/imhj.22081 Beeber, L. S., Gasbarro, M., Knudtson, M., Ledford, A., Sprinkle, S., Leeman, J., McMichael, G., Aeanah, P. & Mosqueda, A. (2023). A Mental health innovation for nurse home visiting program shows effectiveness in reducing depressive symptoms and anxiety. Prevention Science . Advance online publication. https://doi.org/10.1007/s11121-023-01574-6 Gourevitch, R. A., Zera, C., Martin, M. W., Zhou, R. A., Bates, M. A., Baicker, K., & McConnell, M. (2023). Home visits with a registered nurse did not affect prenatal care in a low-income pregnant population. Health Affairs, 42 (8), 1152-1161. https://doi.org/10.1377/hlthaff.2022.01517 Huffhines, L., Herman, R., Silver, R. B., Low, C. M., Newland, R., & Parade, S. H. (2023). Reflective supervision and consultation and its impact within early childhood-serving programs: A systematic review. Infant Mental Health Journal, 00 , 1–34. https://doi.org/10.1002/imhj.22079 Innocenti, M. S., Vilaseca, R., & Roggman, L. (2023). PICCOLO: Observing and coaching caregiver-child interaction to support early development in children with and without disabilities. In L. Provenzi, S. Grumi, & R. Borgatti, R. (Eds.), Family-Centered Care in Childhood Disability (pp. 115-147). Springer, Cham. https://doi.org/10.1007/978-3-031-34252-3_7 Toluhi, D., Yusuf, B., Kihlström, L., Vereen, S., & Marshall, J. (2023). Precarity and work-family balance: Fathers’ workplace demands and perinatal home visiting participation. Early Child Development and Care. Advance online publication. https://doi.org/10.1080/03004430.2023.2249255 PDF of AUGUST PEER-REVIEWED LITERATURE

OPEN ACCESS: Hancock, C. L., & Cheatham, G. A. (2023). How Early Head Start home visitors foster or impeded shared decision-making with families. Journal of Research in Childhood Education . Advance online publication. https://doi.org/10.1080/02568543.2023.2195460   Huber, L. T, Molthen, F., Cook, G., Hughes-Belding, K. (2023). Facilitating caregiver-child interactions in home visiting: A qualitative observational study. Infant Mental Health Journal, 44 (4), 526-540. https://doi.org/10.1002/imhj.22063 Spinosa, C. Z., Burrell, L., Bower, K. M., O’Neill, K., & Duggan, A. K. (2023). Moving toward precision in prenatal evidence-based home visiting to achieve good birth outcomes: Assessing the alignment of local programs with their national models. BMC Health Services Research, 23 (812), 2-15. https://doi.org/10.1186/s12913-023-09815-8 TRADITIONAL PUBLISHING: Dozier, M., & Bernard, K. (2023). Intervening early: Socioemotional interventions targeting the parent-infant relationship. Annual Reviews, 5 . Advance online publication. h ttp://doi.org/10.1146/annurev-devpsych-120621-043254 Guastaferro, K. (2023). Applying the Multiphase Optimization Strategy (MOST) to the Prevention of Child Maltreatment: A Vision for Future Multicomponent Interventions. In: Shenk, C.E. (eds) Innovative Methods in Child Maltreatment Research and Practice. Child Maltreatment Solutions Network. Springer, Cham. https://doi.org/10.1007/978-3-031-33739-0_6 Guterman, N. B, Bellamy, J., Banan, A., Harty, J. S., Jaccard, J., & Mirque-Morales, S. (2023). Engaging fathers to strengthen the impact of early dhme visitation on physical child abuse risk: Findings from the Dads Matter-HV randomized controlled trial. Child Abuse and Neglect, 143 . Advance online publication. https://doi.org/10.1016/j.chiabu.2023.106315 Latham, N., Young, J., Wilson, J., & Gray, M. (2023). Measuring success: Program fidelity of Queensland’s child health home visiting services. A document analysis. Australian Journal of Primary Health . Advance online publication. https://doi.org/10.1071/PY23002 Meghea, C. I., Raffo, J. E., Yu, X., Meng, R., Luo, Z., Vander Meulen, P., Lloyd, C. S., & Roman, L. A. (2023). Community health worker home visiting, birth outcomes, maternal care, and disparities among birthing individuals with Medicaid insurance. JAMA Pediatrics . Advance online publication. https://doi.org/10.1001/jamapediatrics.2023.2310   Price, A., Bryson, H., Mensah, F. K., Kenny, B., Wang, X., Orsini, F., Gold, L., Kemp, L., Bruce, T., Dakin, P., Noble, K., Makama, M., & Goldfeld, S. (2023). Embedding nurse home visiting in universal healthcare: 6-year follow-up of a randomised trial. Archives of Disease in Childhood . Advance online publication. https://doi.org/10.1136/archdischild-2023-325662   PDF of JULY 2023 PEER-REVIEWED LITERATURE

OPEN ACCESS:

Bentley, B., Hoang, T. M. H., Arroyo Sugg, G., Jenkins, K. V., Reinhart, C. A., Pouw, L., Accove, A. M., & Tabb, K. M. (2023). Parent perceptions of an early childhood system’s community efforts: A qualitative analysis. Children, 10 (6), 1001. https://doi.org/10.3390/children10061001   Tazza, C., Ioverno, S., & Pallini, S. (2023). Home-visiting programs based on the Brazelton approach: A scoping review. European Journal of Pediatrics . Advance online publication. https://doi.org/10.1007/s00431-023-05048-3

TRADITIONAL PUBLISHING

Campbell, K. A. (2023). Her strength: Reflections on nurse home-visiting. Public Health Nursing, 00 , 1-3. https://doi.org/10.1111/phn.13218

Lee, J. Y., & Lee, S. J. (2023). Implementing a text messaging intervention to engage fathers in home visiting. Maternal and Child Health Journal . Advance online publication. https://doi.org/10.1007/s10995-023-03718-0 Mersky, J. P, Jeffers, N. K., Lee, C. P., Shlafer, R. J., Jackson, D. B. & Gomez, A. (2023). Linking adverse experienes to pregnancy and birth outcomes: A life course analysis of racial and ethnic disparities among low-income women. Journal of Racial and Ethinic Disparities . Advance online publication. https://doi.org/10.1007/s40615-023-01647-w  

Ross, A. M., Rahman, R., Huang, D. & Kirkbride, G. (2023). Investigating correlates of home visitor burnout, compassion fatigue, and compassion satisfaction in New York State: Implications for home visiting workforce development and sustainability. Maternal and Child Health Journal . Advance online publication. https://doi.org/10.1007/s10995-023-03727-z

Xia, S., Hefyan, M., McCormick, M. P., Goldberg, M., Swinth, E., & Huang, S. (2023). Home visiting impacts during the pandemic: Evidence from a randomized controlled trial of child first. Journal of Family Psychology . Advance online publication. https://doi.org/10.1037/fam0001121

PDF OF JUNE 2023 PEER REVIEWED LITERATURE 

Cook, K. D., Fisk, E., Lombardi, C. M., & v Leer, K. F. (2023). Caring for whole families: Relationships between providers and families during infancy and toddlerhood. Early Childhood Education Journal . Advance online publication. https://doi.org/10.1007/s10643-023-01491-x

O’Donnell, R., Savaglio, M., Halfpenny, N., Morris, H., Miller, R., & Skouteris, H. (2023). A mixed-method evaluation of Cradle to Kinder: An Australian intensive home-visitation program for significantly disadvantaged families. Children and Youth Services Review , 150 , 1-14. https://www.sciencedirect.com/science/article/pii/S0190740923002116

Bagwell-Gray, M. E., Grube, W., Mendenhall, A., Jen, S., Olaleye, O., & Sattler, P. (2023). A qualitative exploration of caregivers’ experiences with the Attachment and Biobehavioral Catch-up (ABC) parenting program. Infant Mental Health Journal, 44 , 406-421. https://doi.org/10.1002/imhj.22057

Bromer, J., Ragonese-Barnes, M., & Korfmacher, J. (2023). Home visiting in home-based child care: Staff and provider experiences. Children and Youth Services Review, 150 , 1-15. https://doi.org/10.1016/j.childyouth.2023.106997

Brown, S. M., McConnell, L., Zelaya, A., Doran, M., & Swarr, V. (2023). Tailored nurse support program promoting positive parenting and family preservation. Nursing Research , 10.1097/NNR.0000000000000662. Advance online publication. https://doi.org/10.1097/NNR.0000000000000662

Hohman, E. E., Savage, J. S., Stansfield, B. K., & Lavner, J. A. (2023). Sleep SAAF responsive parenting intervention for Black mothers impacts response to infant crying: A randomized clinical trial. Academic Pediatrics . Advance online publication. https://doi.org/10.1016/j.acap.2023.04.012

Kotake, C., Fauth, R. C., Stetler, K., Goldberg, J. L., Silva, C. F., & Manning, S. E. (2023). Improving connections to early childhood systems of care via a universal home visiting program in Massachusetts. Children and Youth Services Review, 150 , 1-8. https://www.sciencedirect.com/science/article/pii/S0190740923001901

Lewis, K. N., Tilford, J. M., Goudie, A., Beavers, J., Casey, P. H., & McKelvey, L. M. (2023). Cost-benefit analysis of home visiting to reduce infant mortality among preterm infants. Journal of Pediatric Nursing . Advance online publication. https://doi.org/10.1016/j.pedn.2023.05.003

Londoño Tobón, A., Condon, E., Slade, A., Holland, M. L., Mayes, L. C., & Sadler, L. S. (2023). Participation in an attachment-based home visiting program is associated with lower child salivary C-Reactive protein levels at follow-up. Journal of Developmental & Behavioral Pediatrics , 44(4), e292-e299. https://doi.org/10.1097/DBP.0000000000001180

Martin, L., Ingalls, A., Barlow, A., Kushman, E., Leonard, A., Russette, H. & Haroz, E. E. (2023). Respecting diverse journeys on many roads: First Peoples of North America can guide us on our path toward precision home visiting. AlterNative: An International Journal of Indigenous Peoples . Advance online publication. https://doi.org/10.1177/11771801231169272   PDF OF MAY 2023 PEER-REVIEWED LITERATURE

Bonakdar Tehrani, M., Baird, K., Trajkovski, S., & Kemp, L. (2023) Having to manage: Culturally and linguistically diverse mothers’ lived experiences with sustained nurse home visiting programs. BMC Health Services Research 23 (354), 1-9. https://doi.org/10.1186/s12913-023-09315-9

Burak, E. W., & Wachino, V. (2023). Promoting the mental health of parents and children by strengthening Medicaid support for home visiting. Psychiatry   Online. https://doi.org/10.1176/appi.ps.20220608

Kuhn, M., & Higgins, J. (2023). Strengthening early intervention home visitation quality: A focus on partnerships and interactions. Topics in Early Childhood Special Education . Advance online publication.  https://doi.org/10.1177/02711214231162828

McPherran Lombardi, C. M., Cook, K. D., & Fisk, E. (2023). Family ecological resources and risks: The moderating role of Early Head Start. Early Childhood Research Quarterly, 64 , 216-228. https://doi.org/10.1016/j.ecresq.2023.04.001

Mersky, J. P., Lee, C. T. P., & Jackson, D. B. (2023). Life-course adversity and sleep disturbance among low-income women with children. Sleep Health . Advance online publication. https://doi.org/10.1016/j.sleh.2023.02.007

Pais, J. & Sexer, L. S. (2023). The effectiveness of a Parents as Teachers home visitation program on school readiness: An application of complier average causals effects analysis. Journal of Evidence-Based Social Work . https://doi.org/10.1080/26408066.2023.2201233

Wasik, B., & Bryant, D. (2023). Home visits and Engagement. Encyclopedia of Social Work . Retrieved 3 Apr. 2023, from https://oxfordre.com/socialwork/display/10.1093/acrefore/9780199975839.001.0001/acrefore-9780199975839-e-1237 PDF OF APRIL 2023 PEER-REVIEWED LITERATURE

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Replicating and Scaling Up Evidence-Based Home Visiting Programs: The Role of Implementation Research

Diane Paulsell, MPA Mathematica Policy Research, USA January 2022 , Rev. ed.

Introduction

Over the past two decades, a growing number of home visiting programs have been developed and implemented in North America and internationally to support parents with young children. In the US, home visiting programs for families with pregnant women and young children operate in all 50 states, the District of Columbia, 5 territories, and 22 tribal communities, with an estimated 335,000 families receiving  more than 3.7 home visits. 1 The majority of these programs implement home visiting models that are evidence-based, meaning that they have interventions based on rigorous evaluation; some programs also implement emerging models that do not yet have rigorous evidence to support their implementation. 1

Over the past decade, the US government has substantially increased funding for evidence-based home visiting models. In 2010, the US Congress included the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) in the Patient Protection and Affordable Care Act (ACA) as a national strategy for improving the health and well-being of families with pregnant women and children ages birth to 5. The ACA provided grants to states and stipulated that at least 75 percent of the funds must be spent on home visiting models with evidence of effectiveness based on rigorous evaluation. In 2019, the US Congress reauthorized MIECHV at $400 million a year for an additional 5 years. In the field of home visiting, an increasing number of programs have been rigorously evaluated and have demonstrated evidence of effectiveness in outcome domains such as parenting, maternal and child health, child development and school readiness, reductions in child maltreatment, and family economic self-sufficiency. 2,3,4,5 As of 2020, the US Department of Health and Human Services identified 21 home visiting programs with rigorous evidence of effectiveness. 6

Identifying core components of interventions found to be effective and understanding what it takes to implement those components with fidelity to the program model is critical to successful replication and scale-up of effective programs and practices in different community contexts and populations. 7 There is growing recognition in the early childhood field of the importance of effective implementation and the need for implementation research that can guide adoption, initial implementation, and ongoing improvement of early childhood interventions. 8,9,10 The promise of implementation research and using data to drive program management is compelling because it offers a potential solution to the problem of persistent gaps in outcomes between at-risk children and their more well-off peers. This article discusses implementation research in the home visiting field, how such research can be used to strengthen programs and improve targeted outcomes, and the conditions and supports necessary for effective implementation.

Simply adopting an evidence-based home visiting program and meeting the initial start-up requirements of the model developer is not enough to ensure that it will produce the positive effects for children and families found in evaluation research. 11 Home visiting services should be implemented with fidelity to the program model. For example, home visitors should have required qualifications, visits should occur at the intended frequency and duration, visit content should be delivered as intended, and the quality of services provided to families should be high. Moreover, service providers need adequate supports and resources to sustain implementation with a high degree of fidelity over time. 12,13

Research Context

While the body of rigorous research on the effectiveness of home visiting programs has grown substantially in recent years, research on implementation lags behind. 10,14 Research reports and articles typically provide only minimal information about how programs are implemented and their fidelity to the program model. 10 As national and local governments, communities and service providers seek to scale up the use of evidence-based home visiting programs, research is needed to develop program fidelity standards and measures, understand the conditions necessary for high-fidelity implementation, and create tools to assess implementation and support program improvement.

Key Research Questions

This review is designed to address two questions:

What do we know about fidelity of implementation in evidence-based home visiting programs?

What conditions and resources are necessary to support and sustain high-fidelity implementation over time?

Recent Research Results

Researchers have developed a number of theoretical frameworks that define implementation fidelity. 15,16,17 Most include adherence to the program model, dosage, quality, and participants’ responsiveness and engagement in services; some include the quality of participant-provider relationships.

While research on fidelity in home visiting programs is fairly sparse, studies have documented some components, such as dosage and duration of services, home visit content, and participant-provider relationships. Research shows that families typically receive roughly half of the number of home visits expected. 12,18,19 Research also shows that many, perhaps most, families enrolled in home visiting programs drop out before their eligibility ends. 12,20,21 Some home visiting studies have varied the dosage that families were offered and found that fewer home visits produced outcomes similar to higher levels of exposure. 22

Systematic study of activities and topics discussed during home visits is essential for understanding whether content was delivered as intended and how content varies across families and over time. While most programs provide curriculum guidelines and training for home visitors, research suggests that content is not always delivered as planned and varies across families. For example, multiple studies have found that, despite program objectives that emphasize parenting, little time or emphasis was placed on parent-child interactions. 23,24 A study of Early Head Start found that, on average, home visitors spent 14 percent of each home visit on activities designed to improve parent-child interactions. 25 Fidelity frameworks also emphasize the importance of developing positive participant-home visitor relationships, since these relationships may influence the extent of parent engagement and involvement in home visits. 12,20,26,27 Some research indicates that higher-quality relationships are associated with better outcomes for children. 28,29

Best practice and emerging research suggest that home visiting staff need training, supervision and fidelity monitoring, a supportive organizational climate, and mental health supports to sustain high-fidelity implementation over time. 20 The effect of these kinds of supports have not been well studied, but some research on similar interventions indicates implementation of evidence-based practices with fidelity monitoring and supportive consultation predicts lower rates of staff turnover, as well as lower levels of staff emotional exhaustion relative to services as usual. 30,31,32 Moreover, a supportive organizational climate has been associated with more positive attitudes toward adoption of evidence-based programs. 32

Research Gaps

More research is needed to guide decisions about adoption, adaptation and replication, and support scale-up of evidence-based home visiting programs. For example, research is needed to determine the thresholds of dosage and duration of services necessary to positively affect family and child outcomes. Planned variation studies, in which program components, content, home visitor training, or dosage of services is varied, can identify core dimensions of implementation that are critical for achieving program impacts, as well as dimensions that could be adapted for different contexts and populations without threatening the program’s effectiveness.

To facilitate these studies, more work is needed to develop implementation measures. While some measures have been developed – such as observational measures of home visiting quality and scales for assessing the participant-home visitor relationship – their validity and reliability have not been sufficiently tested with different populations and service delivery contexts. 20,33,34,35

Conclusions

As interest in the promise of evidence-based home visiting programs to improve outcomes for children and families grows, policymakers and practitioners need guidance about how to implement them effectively and sustain high-fidelity implementation over the long term. While the body of implementation research on home visiting programs is growing, more work is needed. Research shows that most programs do not deliver the full dosage of services intended, and families often drop out of programs before their eligibility ends. Variation also exists in adherence to intended activities and topics covered during home visits. Emerging research points to the importance of supportive supervision, fidelity monitoring, and organizational climate to support home visitors and maintain support for the evidence-based program. Additional research on these topics can provide guidance and tools for promoting successful implementation of evidence-based home visiting and adaptation of program models to different populations and contexts.

Implications for Parents, Services and Policy

Supporting high-fidelity implementation of evidence-based home visiting programs has the potential to improve outcomes for at-risk children and families. Policymakers and funders should use the available research on implementation and encourage future work to guide decisions about how to scale up evidence-based programs effectively and support them over time. For example, implementation research can be used to assess the readiness of local agencies to implement home visiting programs with fidelity. Government and other funders can use implementation research to structure requirements for monitoring and reporting on specific dimensions of implementation. Government and funders at all levels can support these efforts by creating data systems to facilitate fidelity monitoring and use of data for program improvement. Moreover, implementation research can inform staff training and ongoing technical assistance. For parents, the implication is that participation and engagement matter. Parents must understand the goals of the program they are enrolling in and the expectations for taking up and participating in services. To achieve intended dosage, program staff may need to help parents address barriers to their participation.

Researchers should continue building the knowledge base about how to implement home visiting programs effectively by reporting information on implementation alongside results of rigorous effectiveness evaluations. Additional research on the replication and scale-up of home visiting programs should be conducted to identify the conditions, processes, and supports associated with achieving and sustaining high-fidelity implementation.

National Home Visiting Resource Center. 2020 Home Visiting Yearbook . Arlington, VA: James Bell Associates and the Urban Institute; 2020.

Avellar SL, Supplee L. Effectiveness of home visiting in improving child health and reducing child maltreatment. Pediatrics 2013; 132 Suppl 2:S90-S99.

Filene J, Kaminski J, Valle L, Cachat P. Components associated with home visiting program outcomes: A meta-analysis. Pediatrics 2013;132 Suppl 2: S100-S109.

Peacock S, Konrad S, Watson E, Nickel D, Muhajarine H. Effectiveness of home visiting programs on child outcomes: A systematic review. BMC Public Health  2013;13:17.

Supplee L, Paulsell D, Avellar S. What works in home visiting programs? In: Nelson K, Scheitzer D, eds. What Works in Child Welfare . Washington, DC: Child Welfare League of America Press; 2012:39-61.

HomVEE Team. Early childhood home visiting: reviewing evidence of effectiveness.  OPRE Report #2020-126. Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, U.S. Department of Human Services. 2020.

Fixsen DL, Blase KA, Naoom SF, Wallace F. Core implementation components. Research on Social Work Practice 2009;19(5):531-540.

Avellar S, Paulsell D. Lessons learned from the home visiting evidence of effectiveness review . Princeton, NJ: Mathematica Policy Research; 2011.

Kaderavek JN, Justice LM. Fidelity: an essential component of evidence-based practice in speech-language pathology. American Journal of Speech-Language Pathology 2010;19(4):369-379.

Paulsell D, Del Grosso P, Supplee L. Supporting replication and scale-up of evidence-based home visiting programs: Assessing the implementation knowledge base. American Journal of Public Health 2014;104(9): 1624-1632.

Durlak JA, DuPre EP. Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation. American Journal of Community Psychology 2008;41(3-4):327-350.

Boller K, Daro D, Del Grosso P, Cole R, Paulsell D, Hart B, Coffee-Bordon B, Strong D, Zaveri H, Hargreaves M. Making replication work: Building infrastructure to implement, scale up, and sustain evidence-based early childhood home visiting programs with fidelity . Washington, DC: Children’s Bureau, Administration for Children and Families, U.S. Department of Health and Human Services; 2014.

Hargreaves M, Cole R, Coffee-Borden B, Paulsell D, Boller K. Evaluating infrastructure development in complex home visiting systems. American Journal of Evaluation 2013;34(2):147-169.

Supplee LH, Metz A. Opportunities and challenges in evidence-based social policy. SRCD Social Policy Report 2015;28(4):1-16.

Daro D. Replicating evidence-based home visiting models: A framework for assessing fidelity. Princeton, NJ: Mathematica Policy Research; 2010.

Carroll C, Patterson M, Wood S, Booth A, Rick J, Balian S. A conceptual framework for implementation fidelity. Implementation Science 2007;2:40.

Berkel C, Mauricio AM, Schoenfelder E, Sandler IN. Putting the pieces together: An integrated model of program implementation. Prevention Science 2010;12(1):23-33.

Kitzman HJ. Effective Early Childhood Development Programs for Low-Income Families: Home Visiting Interventions During Pregnancy and Early Childhood. In: Tremblay RE, Boivin M, Peters RDeV, eds. Spiker D, Gaylor E, topic eds. Encyclopedia on Early Childhood Development [online]. https://www.child-encyclopedia.com/home-visiting/according-experts/effective-early-childhood-development-programs-low-income-families . Published: February 2004. Accessed January 18, 2022.

Riley S, Brady AE, Goldberg J, Jacobs F, Easterbrooks MA. Once the door closes: Understanding the parent-provider relationship. Children and Youth Services Review 2008;30(5):597-612.

Duggan A, Portilla XA, Filene JH, Crown SS, Hill CJ, Lee H, Knox V. Implementation of Evidence-Based Early Childhood Home Visiting: Results from the Mother and Infant Home Visiting Program Evaluation. OPRE Report #2018-76A. Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. 2018.

Love JM, Kisker EE, Ross CM, Schochet PZ, Brooks-Gunn J, Paulsell D, Brady-Smith C. Making a difference in the lives of infants and toddlers and their families: The impacts of Early Head Start. Princeton, NJ: Mathematica Policy Research; 2002.

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Peterson, C. A., Luze, G. J., Eshbaugh, E. M., Jeon, H. J., & Kantz, K. R. Enhancing parent-child interactions through home visiting: Promising practice or unfulfilled promise? Journal of Early Intervention 2007;29:199-140.

Hebbeler KM, Gerlach-Downie SG. Inside the black box of home visiting: A qualitative analysis of why intended outcomes were not achieved. Early Childhood Research Quarterly 2002;17(1):28-51.

Vogel CA, Boller K, Xue Y, Blair R, Aikens N, Burwick A, Stein J. Learning as we go: A first snapshot of Early Head Start programs, staff, families, and children. OPRE Report #2011-7. Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. 2011.

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How to cite this article:

Paulsell D. Replicating and Scaling Up Evidence-Based Home Visiting Programs: The Role of Implementation Research. In: Tremblay RE, Boivin M, Peters RDeV, eds. Spiker D, Gaylor E, topic eds. Encyclopedia on Early Childhood Development [online].  https://www.child-encyclopedia.com/home-visiting/according-experts/replicating-and-scaling-evidence-based-home-visiting-programs-role . Updated: January 2022. Accessed April 23, 2024.

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History and Development of Home Visiting in the United States

Social justice movements before 1950, the war on poverty and prevention of child maltreatment, expansion of home visiting in recent decades, home visiting outside the united states, poverty, child health, and home visiting, national evaluation and evidence of effectiveness, home visiting and the medical home, recommendations and position statement, community pediatricians, large health systems, managed care organizations, and accountable care organizations, researchers, the aap endorses and promotes the following general policy positions and advocacy strategies:, conclusions.

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• Committee on Child abuse and Neglect, 2016–2017

Early Childhood Home Visiting

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James H. Duffee , Alan L. Mendelsohn , Alice A. Kuo , Lori A. Legano , Marian F. Earls , COUNCIL ON COMMUNITY PEDIATRICS , COUNCIL ON EARLY CHILDHOOD , COMMITTEE ON CHILD ABUSE AND NEGLECT , Lance A. Chilton , Patricia J. Flanagan , Kimberley J. Dilley , Andrea E. Green , J. Raul Gutierrez , Virginia A. Keane , Scott D. Krugman , Julie M. Linton , Carla D. McKelvey , Jacqueline L. Nelson , Emalee G. Flaherty , Amy R. Gavril , Sheila M. Idzerda , Antoinette “Toni” Laskey , John M. Leventhal , Jill M. Sells , Elaine Donoghue , Andrew Hashikawa , Terri McFadden , Georgina Peacock , Seth Scholer , Jennifer Takagishi , Douglas Vanderbilt , Patricia G. Williams; Early Childhood Home Visiting. Pediatrics September 2017; 140 (3): e20172150. 10.1542/peds.2017-2150

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High-quality home-visiting services for infants and young children can improve family relationships, advance school readiness, reduce child maltreatment, improve maternal-infant health outcomes, and increase family economic self-sufficiency. The American Academy of Pediatrics supports unwavering federal funding of state home-visiting initiatives, the expansion of evidence-based programs, and a robust, coordinated national evaluation designed to confirm best practices and cost-efficiency. Community home visiting is most effective as a component of a comprehensive early childhood system that actively includes and enhances a family-centered medical home.

Recent advances in program design, evaluation, and funding have stimulated widespread implementation of public health programs that use home visiting as a central service. This policy statement is an update of “The Role of Preschool Home-Visiting Programs in Improving Children’s Developmental and Health Outcomes” (2009) and summarizes salient changes, emphasizes practical recommendations for community pediatricians, and outlines important national priorities intended to improve the health and safety of children, families, and communities. 1 By promoting child development, early literacy, school readiness, informed parenting, and family self-sufficiency, home visiting presents a valuable strategy to buffer the effects of poverty and adverse early childhood experiences that influence lifelong health.

The term “home visiting” refers to an evidence-based strategy in which a professional or paraprofessional renders a service in a community or private home setting. Home visiting also refers to the variety of programs that employ home visitors as a central component of a comprehensive service plan. 2 Early childhood home-visiting programs may be focused on young children, children with special health care needs, parents of young children, or the relationship between children and parents, and they can use a 2-generational strategy to simultaneously address parental and family social and economic challenges. 3  

Home-visiting programs vary widely with regard to target populations and goals. Many successful home-visiting models are directed toward mothers and infants in high-risk groups, such as adolescent mothers and single-parent families. Other models concentrate on specific populations, such as recently incarcerated adolescents, children with special needs, or immigrants. Some programs are designed to identify risk factors, such as environmental hazards and maternal mental health, but others include mentoring, coaching, and other therapeutic interventions. Many employ independently licensed health professionals, but others depend on trained paraprofessionals (including community health workers) drawn from the communities they serve. Community-based care coordination (including housing, transportation, and nutritional support) often are service components. Integration with the family-centered medical home (FCMH) has been a recent focus for program improvement and medical education. 4  

Home visiting began in the United States in the 1880s as an activity of each of 3 social justice movements. Derived from the British models developed a few decades earlier, home visitors were deployed to promote universal kindergarten, improve maternal-infant health through public health nursing, and support impoverished immigrant communities as part of the philanthropic settlement house movement. From the late 19th through the early 20th century, teachers and public health nurses visited communities and families to provide in-home education and health care to urban women and children. These efforts were based on the assumptions still held that education is the most powerful strategy to lift children out of poverty and that the lifelong health of families in immigrant and poor neighborhoods is improved by addressing the social and economic aspects of health and disease. 5  

From the Great Depression through World War II, funding for social initiatives decreased and philanthropic support for home visitors declined. After the relatively prosperous postwar period, renewed interest developed in antipoverty activities, including home visiting, especially in the context of the Civil Rights Movement. In the 1960s, home visiting became an important component of the government’s so-called War on Poverty. Home visiting was and remains integral to programs such as Head Start, although it is applied on a limited basis compared with Early Head Start, for which home visiting is a central service component. A decade later, many home-visiting programs shifted to include case management, intending to help families achieve self-sufficiency and link them to other broad community support services. 6 Improving school readiness, moderating poverty-related social risk determinants, reducing environmental safety hazards, and promoting population-based health remain core goals of contemporary home visiting.

In the last quarter of the 20th century, home visiting gained renewed attention as a strategy for the prevention of child abuse and neglect, promotion of child development, and improvement of parental effectiveness. C. Henry Kempe, MD, called for a home visitor for every pregnant mother and preschool-aged child in his 1978 Abraham Jacobi Memorial Award address. 7 He suggested that integral to every child’s right to comprehensive care is the assignment of a home health visitor to work with the family until each child began school. The visionary pediatrician who developed the concept of the medical home, Cal Sia, MD, reiterated Kempe’s call to action in his 1992 Jacobi Award address 8 based on his experience with Hawaii’s Healthy Start Program, which is an innovative, statewide home-visiting initiative to prevent child abuse and neglect. Another pioneer in modern home visiting, David Olds, PhD, initiated the Nurse-Family Partnership (NFP) with families at risk in Elmira, New York, in 1978. 1  

Before 2009, at least 22 states recognized the critical role of home visitors within statewide systems for at-risk pregnant mothers, infants, and toddlers from birth to 5 years old. States legislated funding for home-visiting programs while insisting on proof of effectiveness, fiscal accountability, and continuous quality improvement. Even during the Great Recession that followed the US financial crisis of 2007 to 2008, some state governments enacted home-visiting legislation to ensure long-term sustainability through innovative financing mechanisms and the strategic allocation of limited public resources.

In 2009, the American Recovery and Reinvestment Act (Public Law Number 111-5) included $2.1 billion for the expansion of Head Start and Early Head Start (including the home-visiting components of Early Head Start) to benefit young children in low-resource communities. The next year, the Patient Protection and Affordable Care Act of 2010 (ACA) (Public Law Number 111-148) designated $1.5 billion, allocated over 5 years, for the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV). The Health Resources and Services Administration currently administers the MIECHV in collaboration with the Administration for Children and Families. The allocations to states, territories, and tribal entities are designed to support the implementation and evaluation of evidence-based home-visiting programs regarding specified goals and objectives. All 50 states, the District of Columbia, and 5 US territories have home-visiting programs. 9 In addition, ACA funding provides support for home-visiting initiatives to serve American Indian and Alaskan native children through the Tribal MIECHV program. 10  

Nineteen home-visiting models have met the criteria of the US Department of Health and Human Services (HHS) for evidence of effectiveness through the Home Visiting Evidence of Effectiveness (HomVEE) review. Supported by federal grants through the MIECHV, states receive funding to implement 1 or more evidence-based models designated eligible by the MIECHV that best meet the needs of particular at-risk communities. The program objectives must improve outcomes that are statutorily defined and must include increased family economic self-sufficiency, improved health indicators (eg, a reduction in health disparities) in target populations, and improved school readiness. After 2013, potential program outcomes were expanded to include reductions in family violence, juvenile delinquency, and child maltreatment. 11 A review of 4 common programs illustrates the range of measurable outcomes. Healthy Families America identifies family self-sufficiency as a principal objective measured by a reduction of dependence on public assistance. 12 Early Head Start and other home-visiting programs focus on the promotion of child development and positive family relationships. NFP is designed to improve prenatal health, maternal life course development, and positive parenting. 13 Parents as Teachers promotes child development and school readiness. 14  

Home visiting for families with young children is an early intervention strategy in many industrialized nations outside of the United States. In several European countries, home health visiting is provided at no cost to the family, participation is voluntary, and the service is embedded in a comprehensive maternal and child health system. 3 While visiting young mothers at home, public health nurses in other countries provide many child health-promotion services that are provided by pediatricians in the United States. For instance, Denmark established home visiting in 1937 after a pilot program showed lower infant mortality rates linked with the services of home visitors. France provides universal prenatal care and home visits by midwives and nurses, who educate families about smoking, nutrition, drug use, housing, and other health-related issues.

The Early Start program in New Zealand targets families with 2 or more risk factors on an 11-point screening measure that includes parent and family functioning. Randomized controlled trials showed improvement in access to health care, lower hospitalization rates for injuries and poisonings, longer enrollment in early childhood education, and more positive and nonpunitive parenting. 15 , 16 The Dutch NFP program, VoorZorg, was found to reduce victimization and perpetration of self-reported intimate partner violence during pregnancy and 2 years after birth among low-educated, pregnant young women, 17 and there were fewer reports of child abuse. At 24 months, measurable improvements were evident in the home environments of participating families, and the children exhibited a significant reduction in internalizing symptoms. 18  

Paraprofessionals (ie, trained but unlicensed lay people) are often employed as home visitors in low-resource areas of the world. In Haiti, for example, community health workers trained by Partners in Health improve the care of those with HIV, multidrug-resistant tuberculosis, and such waterborne illnesses as cholera. In southern Mexico and other areas in Central America, “promotoras de salud,” or community health workers, coordinate with lay midwives to care for expectant mothers in rural, isolated, and other low-resource regions. Promotoras are deployed in many regions in the United States and have been recognized by HHS for their ability to reduce barriers and improve access to culturally informed and linguistically appropriate health care. 19  

More than 1 in 5 young children in the United States live in families with incomes below the federal poverty level, and more than 2 in 5 live at less than twice that level. 20 Living at or below 200% of the federal poverty level places children, 21 especially infants and toddlers, at high risk for adverse early childhood experiences that lead to lifelong detrimental effects on health, education, and vocational success. 22 Home visitors can help families attain economic self-sufficiency by linking them to community support services (such as quality preschool) while encouraging parents to enroll in training opportunities that lead to employment. Although they differ in structure, targeted populations, and intended outcomes, high-quality home-visiting programs deliver family support and child development services that provide a foundation for physical health, academic success, and economic stability in vulnerable families that are at risk for the adverse effects of poverty and other negative social determinants of health.

By applying multigenerational interventions, home visiting may improve child health and family wellbeing in many domains. Individual neuroendocrine-immune function, behavioral allostasis, and relational health are all established in the first 3 years of life, 23 when home visiting is most often applied. 24 The emerging science of toxic stress indicates that poverty and its accompanying problems, such as food insecurity, may disrupt the architecture and function of the developing brain. 25 , 26 Home visitors have the opportunity to assess risk and protective factors in families, identify potential adversity, and intervene at the earliest opportunity. By promoting supportive relationships, reducing parental stress, and increasing the likelihood of positive experiences, home visiting may help avoid the deleterious behavioral and medical health outcomes associated with child poverty. 27 , – 31  

Young mothers in poverty disproportionately suffer moderate to severe symptoms of maternal depression, elevating the risk of poor developmental and educational outcomes for their children. 32 Almost 1 in 4 mothers who are near or below the federal poverty level experience significant depression, but few obtain appropriate treatment. In-home cognitive behavioral therapy is a novel treatment modality for maternal depression that has proved to be effective in early trials. 33 Combining in-home cognitive behavioral therapy with other home-visiting programs, such as Early Head Start, that promote positive parenting and infant development provides a model of 2-generational care that has the potential to mitigate the effects of poverty and improve both family financial stability and school readiness. 34  

Home-visiting programs are most effective when they are components of a community-level, comprehensive early childhood system that reaches families as early as possible with needed services, accommodates children with special needs, respects the cultures of the families in the communities, and ensures continuity of care in a continuum from prenatal life to school entry. 35 , 36 An early childhood system may include safety-net resources (such as supplemental food and subsidies for housing, heating, and child care), adult education, job training, cash assistance, quality child care, early childhood education, and preventive health services. 37 Communicating the strengths and risk factors of individual families to the FCMH may further increase the coordination of care and efficient use of services. 38  

When the MIECHV program was established by the ACA, HHS established the HomVEE review of the research literature on home visiting. 11 Results of that review are used to identify home-visiting service delivery models that meet HHS criteria for evidence of effectiveness because, by statute, at least 75% of the funds available from the ACA are to be used for programs that use service delivery models that are evidence based. The HomVEE conducts a yearly literature search to identify promising studies of home-visiting models. It includes only studies that are considered to meet quality standards on the basis of overall design (only randomized controlled trials or quasiexperimental studies are included) and design-specific criteria. Studies that meet criteria for entry are then assessed for outcomes in the following 8 domains, as defined by HHS:

Child health;

Maternal health;

Child development and school readiness;

Reductions in child maltreatment;

Reductions in juvenile delinquency, family violence, and crime;

Positive parenting practices;

Family economic self-sufficiency; and

Linkages and referrals.

To meet HHS criteria for evidence of effectiveness, home-visiting models must demonstrate favorable outcomes in either 1 study with results in 2 or more domains or 2 studies with significant benefits in the same domain. To be included, study designs must meet evaluation quality standards, and outcomes need to show statistically significant benefits using nonoverlapping analytic samples. As of April 2017, the 18 models that meet these standards (along with 2 programs that do not meet criteria for implementation) with target populations, ages of participants, and outcomes for which there is evidence are listed in Table 1 . 11  

Home-Visiting Programs Meeting HHS Criteria for Evidence of Effectiveness (as of April 2017)

Reference: https://www.mathematica-mpr.com/our-publications-and-findings/publications/home-visiting-evidence-of-effectiveness-review-executive-summary-april-2017 . Descriptions of specific home-visiting programs by state can be accessed at: https://homvee.acf.hhs.gov/models.aspx .

Outcomes: (1) child health; (2) maternal health; (3) child development and school readiness; (4) reductions in child maltreatment; (5) reductions in juvenile delinquency, family violence, and crime; (6) positive parenting practices; (7) family economic self-sufficiency; and (8) linkages and referrals.

A rapidly expanding evidence base documents the benefits of high-quality home-visiting programs, especially when they are integrated in a comprehensive early childhood system of care. 39 Home visiting has been shown to increase children’s readiness for school, promote child health (such as vaccine rates), and enhance parents’ abilities to promote their children’s overall development. There is evidence that home visiting reduces the risk of both child abuse and unintended injury. 16 , 40 Maternal health is improved by more frequent prenatal care, better birth outcomes, and early detection and treatment of depression. 41 Outcome studies have established the effectiveness of home visiting by nurses or community health workers in reducing child maltreatment, 42 improving birth outcomes, 43 and increasing school readiness. 44  

A close examination of the evidence of effectiveness published in 2015 by the HomVEE review provides additional insights about the potential benefits and limitations of current models of home visiting. 11 Of the 44 models assessed in 2015, 19 showed improvements in at least 1 primary outcome measure, and 15 had favorable effects on secondary measures. These results are consistent with both the broad scope of many of the models as well as the likelihood that improvements in 1 domain sometimes lead to benefits in another (eg, positive parenting improving child development). All 19 models that showed positive results had evidence of sustained benefits for at least 1 year after enrollment.

In addition to the 19 models approved in 2015, 8 of the 25 that were not approved had evidence of benefit, perhaps because of stringent criteria for study quality and number. Even among programs showing positive outcomes, there was not a high level of consistency across domains. For example, only 7 of 19 models demonstrated benefits in the same domain across 2 or more studies. Many effect sizes were fairly small (approximately 0.2 SDs) but comparable to those seen in many studies of programs located in other settings (eg, early child education). 45 However, modest effect sizes in studies concerning developmental delay can result in important population-level effects given the high proportion of children in low-income families (nearly 20%) meeting criteria for early intervention services. 46 , 47  

Longitudinal studies within the HomVEE review of the NFP have shown improvements in adolescent mental health, in middle school achievement, over substance use and/or criminality immediately after high school, as well as in overall maternal and child mortality. 48 , – 50 Other studies document the persistence of beneficial outcomes after population-level scaling. A study of Durham Connects (also known as Family Connects) showed more than 80% participation and 84% adherence among all mothers delivering in Durham, North Carolina, during an 18-month period. 51 Researchers in this study, using rigorous methodology, documented important and beneficial effects on child health, including a 59% reduction in emergency medical care, an increase in positive parenting, successful linkages to community services, and improved maternal mental health. In addition, a large-scale study of SafeCare home-based services showed reductions in reports to child protective services after a scale-up of the program in Oklahoma. 52 These beneficial outcomes of rigorous program evaluation counterbalance other studies that found little or no benefit after a scale-up, such as the finding of reduced implementation fidelity and limited benefit after scaling up Hawaii’s Healthy Start Program. 53  

Other studies document the capacity of home visiting to successfully target specific high-risk populations and implement interventions of varying intensity specific to the intended outcome. For example, Computer-Assisted Motivational Intervention, when applied in combination with home visiting, successfully reduced subsequent pregnancies among pregnant teenagers. 54 Other 2-generational interventions, including Family Spirit (which targets American Indian teen-aged mothers) and Family Check-Up (which targets young mothers with depression), improved behavioral problems in infants and young children as well as the mental health of the young mothers. 55 , – 57  

Finally, the outcomes documented by the HomVEE need to be considered in the context of a number of meta-analyses and systematic reviews that have been conducted other than the HomVEE. One of the most cited is a meta-analysis that documented significant benefits across 4 broad domains, including child development, child abuse prevention, childrearing, and maternal life course. 58 Benefits were maximized when specific rather than general populations were targeted, when interventions used professionals versus paraprofessionals, and when interventions were more specifically focused on parental rather than child wellbeing. 59 , – 61  

Integration of home visiting with the medical home expands the multidisciplinary team into the community, enhancing the goals of communication, coordination of care, and comprehensive care. With effective leadership, the pediatric or FCMH may become a community hub that connects early education and child development activities with health promotion to support maximum outcomes for children and families. The Institute for Healthcare Improvement has described the triple aim as improvement of the health of populations, improvement of the quality of care and experience of each patient, and the reduction of per capita cost. The history of home visiting also reveals another triple aim of improving health, preparing children for education, and reducing poverty. An advanced medical home that reaches out to the community by collaborating with or integrating a high-quality home-visiting program has the potential of meeting both sets of triple aims. 62 , 63  

Some important factors that are common among home-visiting programs that are also characteristic of an FCMH include an emphasis on relationships, the provision of culturally informed care, coordination with other community support agencies, an emphasis on strength-based assessments, and collaboration with families to support self-identified goals. Of particular importance is the relationship that develops between the visitor and the family engaging in a natural environment and the consequent improvement in the relationships among family members. 64 As more has been learned about toxic stress and its negative effect on the life trajectory, close and nurturing relationships have emerged as a most important protective factor. The home visitor can extend the support of the medical home into the community and provide an important link for the family to the relationship with a compassionate pediatric practitioner while improving family relational health. 65  

The integration or colocation of home visiting with the medical home presents many opportunities for synergy and collaboration. The joint statement from the Academic Pediatric Association and the American Academy of Pediatrics (AAP) regarding integration of the FCMH with home visiting emphasizes the potential for coordinated anticipatory guidance, improved early detection, and enhanced community involvement. 66 Recommendations in the joint statement include integrated, computerized record systems; the creation of a joint registry; coverage of home visiting by payers, including Medicaid and the Children’s Health Insurance Program; and supporting the evaluation of coordination between an FCMH and home visiting. In a collaborative model, referrals between a pediatric practitioner and the home visitor may constitute a warm handoff (face-to-face introduction), increasing the likelihood that family concerns are communicated and addressed. For example, a home visitor has the opportunity to complete developmental screening with the parent in a child’s natural environment. The results of screening may be communicated to the pediatric practitioner for use and comparison with the developmental assessment during health-promotion visits. A shared chronic condition care plan facilitates common therapeutic goals, linkages to community resources, and follow-up on referrals. Particularly helpful have been home-visiting strategies for children with diabetes or asthma. Researchers have associated home visiting with improvements in symptoms, urgent care use, and family quality of life. 67  

Home visiting may be used effectively as an adjunctive strategy in comprehensive community-based programs serving children. Although not approved for MIECHV funding, Healthy Steps for Young Children is a comprehensive primary-care model that may include on the treatment team a home visitor who supports positive parenting, provides in-home developmental assessment, and links the family more strongly to the medical home. 68 The example of Healthy Steps illustrates the significant potential benefits from improved collaboration between the medical home and community home-visiting programs. These include common documentation, centralized intake services, strength-based assessments, colocation of home visitors in the pediatric practice, and multidisciplinary team meetings convened by the practice. Through these coordinated activities, home visitors are in partnership with the medical home to build parental resilience, promote child development, and support healthy family relationships. 66 , 69 Other models that similarly employ home visiting as an adjunctive strategy, such as the Health Resources and Services Administration’s Bridging the Word Gap Research Network 70 , 71 and the New York City Council’s City’s First Readers program, exemplify systematic linkages among the medical home, home-visiting programs, and other community-based services with early childhood education. 63 , 72  

Because home-visiting models and programs cross many health systems and involve many funding sources, this policy divides recommendations into the following 3 levels: community pediatricians, large health systems, and researchers. The section concludes with AAP-supported federal and state advocacy strategies.

Provide community-based leadership to promote home-visiting services to at-risk young mothers, children, and families;

Be familiar with state and local home-visiting programs and develop the capacity to identify and refer eligible children and pregnant mothers;

Consider opportunities to integrate or colocate home visitors in the FCMH;

Recognize home-visiting programs as an evidence-based method to enhance school readiness and reduce child maltreatment;

Recognize home visiting as a promising strategy to buffer the effects of stress related to the social determinants of health, including poverty; and

Serve as a referral source to home-visiting programs as a strategy to engage families in services and strengthen the connection between home visiting and the medical home.

Develop a continuum of early childhood programs that intersects or integrates with the FCMH;

Ensure that home-visiting programs are culturally responsive, linguistically appropriate, and family centered, emphasizing collaboration and shared decision-making;

Ensure that all home-visiting programs incorporate evidence-based strategies and achieve program fidelity to ensure effectiveness;

Support the use of trained community health workers, especially in lower-resourced, tribal, and immigrant communities; and

Develop training and certification programs for community health workers to ensure quality and fidelity to program expectations.

Improve understanding of how to engage difficult-to-reach and high-risk communities and populations, including immigrant families, families with low literacy and/or health literacy and limited English proficiency, families that are socially isolated, and families living in poverty in evidence-based home-visiting programs;

Improve understanding of how to take successful programs to scale while maintaining fidelity;

Improve understanding of how to optimize links between evidence-based home-visiting programs and the medical home;

Determine the degree to which the medical home and strategies using multidisciplinary and integrated interventions can provide added value to and synergy with evidence-based home-visiting programs;

Determine the degree to which home-visiting programs can augment the medical home in the prevention or mitigation of chronic disease, such as asthma and obesity, and associated morbidities;

Improve understanding of how to tailor the implementation of evidence-based home-visiting programs to diverse populations with heterogeneous strengths and challenges; and

Investigate and establish the cost-effectiveness and return on investment of home-visiting programs as well as program components.

The continuation and expansion of federal funding for evidence-based home-visiting programs;

Public support for the dissemination of home-visiting programs that meet the HomVEE criteria for evidence of effectiveness as well as other programs with early and promising evidence of potential effectiveness;

The establishment of state systems that integrate home-visiting infrastructure (such as data collection and evaluation) into a comprehensive early childhood service system;

Coordination across state agencies and health systems that serve young children to build an efficient and effective infrastructure for home-visiting programs;

The simplification and standardization of referral processes in and among states to improve the coordination of care and integration of home-visiting services with the medical home; and

The inclusion of home-visiting experience in community pediatrics education and exposure by residents and medical students to the evidence of effectiveness of home-visiting models.

The objectives of contemporary home-visiting programs have strong roots in public health, early childhood education, and antipoverty efforts. Home visiting has expanded rapidly in the recent past, with the current generation of programs providing strong evidence of effectiveness in many domains of family life. Rigorous national outcome evaluations substantiate that home-visiting programs are effective in the promotion of healthy family relationships, improvement of overall child development, prevention of child maltreatment, advancement of school readiness, and improvement of maternal physical and mental health. By linking families to opportunities such as employment and continuing education, home visiting increases family economic stability and thereby is a successful antipoverty strategy. Home-visiting programs have shown the most effectiveness when they are components of community-wide, early childhood service systems. With pediatrician leadership, the FCMH can serve as the hub for coordinating community-based, family support programs at the intersection of early education with public health promotion designed to help children avoid the lifelong effects of early childhood adversity.

American Academy of Pediatrcs

Patient Protection and Affordable Care Act

family-centered medical home

US Department of Health and Human Services

Home Visiting Evidence of Effectiveness

Maternal, Infant, and Early Childhood Home Visiting Program

Nurse-Family Partnership

Dr Duffee was intimately involved with the concept, organization, and design during the early phases of writing, he reviewed the contributions of the other authors, consolidated the contributions (along with his own) into the final product, took responsibility for responding to comments and direction from staff and the Board of Directors, and reviewed the references in detail to ensure that the evidence supports the recommendations; and Drs Kuo, Legano, Mendelsohn, and Earls assisted with revisions; and all authors approve the final manuscript as submitted.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

L ead A uthors

James H. Duffee, MD, MPH, FAAP

Alan L. Mendelsohn, MD, FAAP

Alice A. Kuo, MD, PhD, FAAP

Lori Legano, MD, FAAP

Marian F. Earls, MD, MTS, FAAP

Council on c ommunity Pediatrics Executive Committee , 2016–2017

Lance A. Chilton, MD, FAAP, Chairperson

Patricia J. Flanagan MD, FAAP, Vice Chairperson

Kimberley J. Dilley, MD, MPH, FAAP

Andrea E. Green, MD, FAAP

J. Raul Gutierrez, MD, MPH, FAAP

Virginia A. Keane, MD, FAAP

Scott D. Krugman, MD, MS, FAAP

Julie M. Linton, MD, FAAP

Carla D. McKelvey, MD, MPH, FAAP

Jacqueline L. Nelson, MD, FAAP

Jacqueline R. Dougé, MD, MPH, FAAP – Chairperson, Public Health Special Interest Group

Kathleen Rooney-Otero, MD, MPH – Section on Pediatric Trainees

Camille Watson, MS

Council on Early Childhood Executive Committee , 2016– 20 17

Jill M. Sells, MD, FAAP, Chairperson

Elaine Donoghue, MD, FAAP

Marian Earls, MD, FAAP

Andrew Hashikawa, MD, FAAP

Terri McFadden, MD, FAAP

Alan Mendelsohn, MD, FAAP

Georgina Peacock, MD, FAAP

Seth Scholer, MD, FAAP

Jennifer Takagishi, MD, FAAP

Douglas Vanderbilt, MD, FAAP

Patricia Gail Williams, MD, FAAP

Laurel Murphy Hoffmann, MD – Section on Pediatric Trainees

Barbara Sargent, PNP – National Association of Pediatric Nurse Practitioners

Alecia Stephenson – National Association for the Education of Young Children

Dina Lieser, MD, FAAP – Maternal and Child Health Bureau

David Willis, MD, FAAP – Maternal and Child Health Bureau

Rebecca Parlakian, MA – Zero to Three

Lynette Fraga, PhD – Child Care Aware

Charlotte Zia, MPH, CHES

Committee on Child a buse and Neglect , 2016–2017

Emalee G. Flaherty, MD, FAAP

Amy R Gavril, MD, FAAP

Sheila M. Idzerda, MD, FAAP

Antoinette “Toni” Laskey, MD, MPH, MBA, FAAP

Lori A. Legano, MD, FAAP

John M. Leventhal, MD, FAAP

Harriet MacMillan, MD – American Academy of Child and Adolescent Psychiatry

Elaine Stedt, MSW – Department of Health and Human Services Office on Child Abuse and Neglect

Beverly Fortson, PhD – Centers for Disease Control and Prevention

Tammy Hurley

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BRIAN K. UNWIN, MAJ, MC, USA, AND ANTHONY F. JERANT, M.D.

Am Fam Physician. 1999;60(5):1481-1488

See editorial on page 1337 .

With the advent of effective home health programs, an increasing proportion of medical care is being delivered in patients' homes. Since the time before World War II, direct physician involvement in home health care has been minimal. However, patient preferences and key changes in the health care system are now creating an increased need for physician-conducted home visits. To conduct home visits effectively, physicians must acquire fundamental and well-defined attitudes, knowledge and skills in addition to an inexpensive set of portable equipment. “INHOMESSS” (standing for: i mmobility, n utrition, h ousing, o thers, m edication, e xamination, s afety, s pirituality, s ervices) is an easily remembered mnemonic that provides a framework for the evaluation of a patient's functional status and home environment. Expanded use of the telephone and telemedicine technology may allow busy physicians to conduct time-efficient “virtual” house calls that complement and sometimes replace in-person visits.

In 1990, the American Medical Association (AMA) reported that approximately one half of primary care physicians polled in a national survey indicated that they performed home visits. 1 Although most of the physicians surveyed perceived home visits to be an important service, the majority performed only a few such visits per year. 1 Consistent with these self-reported behaviors are data indicating that only 0.88 percent of Medicare patients receive home visits from physicians. 2 In addition, the Health Care Financing Administration reported charges for only 1.6 million home visits in 1996, an extremely small percentage of the total number of annual physician-patient contacts in the United States. 3 These statistics stand in sharp contrast to medical practice before World War II, at which time about 40 percent of patient-physician encounters were in the home. 4

The low frequency of home visits by physicians is the result of many coincident factors, including deficits in physician compensation for these visits, time constraints, perceived limitations of technologic support, concerns about the risk of litigation, lack of physician training and exposure, and corporate and individual attitudinal biases. Physicians most likely to perform home visits are older generalists in solo practices. Health care providers who have long-established relationships with their patients are also more likely to utilize house calls. Rural practice setting, older patient age and need for terminal care correlate with an increased frequency of home visits. 5

Rationale for Home Visits

Studies suggest that home visits can lead to improved medical care through the discovery of unmet health care needs. 6 – 8 One study found that home assessment of elderly patients with relatively good health status and function resulted in the detection of an average of four new medical problems and up to eight new intervention recommendations per patient. 8 Major problems detected included impotence, gait and balance problems, immunization deficits and hypertension. Significantly, these problems had not been expected based on information obtained from outpatient clinic encounters. Other investigators have demonstrated the effectiveness of home visits in assessing unexpected problems in patient compliance with therapeutic regimens. 9 Finally, specific home-based interventions, such as adjusting the elderly patient's home environment to prevent falls, have also yielded health benefits. 10

Beyond the potential benefit of improved patient care, family physicians who conduct home visits report a higher level of practice satisfaction than those who do not offer this service. 5 Physicians with more positive attitudes about home visits are more likely to have conducted house calls during training. 11 Faculty mentorship and longitudinal exposure in training appear to be important for the development of positive attitudes toward home visits. 5 However, in 1994, only 66 of 123 medical schools offered specific instruction in the role and conduct of home visits. 12 Although 83 percent of the medical schools offered students the opportunity to participate in home visits, only three of the 123 schools required students to make five or more such visits. 12

Home Health Care Industry

Physician home visits have largely been supplanted by the extensive use of home health care services, a $22.3 billion industry that augments a medical system largely comprising facility-based health care providers. 13 The mean annual frequency of home health referrals was 43 per provider in a study published in 1992. 14

Family physicians have authorization and supervision responsibilities for a broad spectrum of skilled services that can be offered in the home. Such services include home health nursing, assistance from home health aides, and physical, occupational and speech therapy. Other health care support services are provided by medical supply companies, respiratory therapists, nutritionists, intravenous therapy services, hospice organizations, respite care services, Meals-on-Wheels volunteers and bereavement support staff. Family physicians also work extensively with social workers, who provide invaluable assistance in coordinating these services.

Thus, effective use of home care services has become a core competency for family physicians. In 1998, the AMA published the second edition of Medical Management of the Home Care Patient: Guidelines for Physicians . 15 The basic physician home care responsibilities outlined in that document are listed in Table 1 . 15

Recent data suggest that many physicians do not have the necessary knowledge and skills to perform these tasks effectively. For example, a survey found that 64 percent of physicians who had signed claims for care plans that were later disallowed had relied on a home health agency to prepare the plan of care, and 60 percent were not aware of the homebound requirement for home services. 16 Thus, increased physician education about home visits seems necessary if the responsibilities and obligations created by the expansion of home health care industry are to be fulfilled.

Types of Home Visits

The four major types of home visits are illness visits, visits to dying patients, home assessment visits and follow-up visits after hospitalization ( Table 2 ) . 17 , 18 The illness home visit involves an assessment of the patient and the provision of care in the setting of acute or chronic illness, often in coordination with one or more home health agencies. Emergency illness visits are infrequent and impractical for the typical office-based physician.

The dying patient home visit is made to provide care to the home-bound patient who has a terminal disease, usually in coordination with a hospice agency. The family physician can provide valuable medical and emotional support to family members before, during and after the death of a patient in the home environment. Family assistance involves evaluating the coping behaviors of survivors and assessing the medical, psychosocial, environmental and financial resources of the remaining family members.

The assessment home visit can also be described as an investigational visit during which the physician evaluates the role of the home environment in the patient's health status. An assessment visit is often made when a patient is suspected of poor compliance or has been making excessive use of health care resources. Medication use can be evaluated in the patient who is taking many drugs (polypharmacy) because of multiple medical problems. Evaluation of the home environment of the “at-risk” patient can reveal evidence of abuse, neglect or social isolation. Patients and family members who are trying to cope with chronic problems such as cognitive impairment or incontinence may particularly benefit from this evaluation. A joint assessment home visit facilitates coordination of the efforts of home health agencies and the physician. Finally, an assessment home visit is invaluable in assessing the need for nursing home placement of a frail elderly patient with uncertain social support.

The hospitalization follow-up home visit is useful when significant life changes have occurred. For example, a home visit after the birth of a new baby provides an excellent opportunity to discuss wellness and prevention issues and to address parental concerns. A home visit after a major illness or surgery can be useful in evaluating the coping behaviors of the patient and family members, as well as the effectiveness of the home health care plan.

Many aspects of physician home care have not been evaluated in the literature. However, it seems likely that properly focused and conducted home visits can enhance home health care delivery, improve patient satisfaction and strengthen the doctor-patient relationship.

Conducting the Home Visit

Equipment and planning.

Most equipment for a home visit can still be carried in the family physician's “black bag” ( Table 3 ) . Some additional items may be acquired from the patient's home.

One of the keys to conducting a successful home visit is to clarify the reason for the visit and carefully plan the agenda. Preplanning allows the physician to gather the necessary equipment and patient education materials before departure. The physician should have a map, the patient's telephone number and directions to the patient's home. The physician, patient and home care team should set a formal appointment time for the visit. Coordinating the house call to allow for the presence of key family members or significant others can enhance communication and satisfaction with care. Finally, confirming the appointment time with all involved parties before departure from the office is a common courtesy to the family as well as a wise time-management strategy.

HOME VISIT CHECKLIST: “INHOMESSS”

The INHOME mnemonic was devised to help family physicians remember the items to be assessed during the home visit directed at a patient's functional status and living environment. 19 This mnemonic can be expanded to “INHOMESSS,” which incorporates investigations of safety issues, spiritual health and home health agencies ( Table 4 ) . 19

Immobility . Evaluation of the patient's functional activities includes assessment of the activities of daily living (bathing, transfer, dressing, toileting, feeding, continence) and the instrumental activities of daily living (using the telephone, administering medications, paying bills, shopping for food, preparing meals, doing housework). The physician can ask the patient to demonstrate elements of the daily routine, such as getting out of bed, performing personal hygiene and leisure activities, and getting in and out of a car. Corrective interventions can be directed at any deficiencies noted. For example, modified pill-bottle caps can be obtained for the patient who has trouble opening medication containers because of a condition such as arthritis.

Nutrition . The physician should assess the patient's current state of nutrition, eating behaviors and food preferences. Permission to look in the refrigerator or cupboard can be obtained by asking open-ended but directed questions. For example, the physician might say, “We have been working hard on your diet to control your diabetes. Would you mind if I look in your refrigerator to see the types of foods you eat?” Improvements in product labeling allow the physician to assess serving sizes and the nutritional value of foods with relative ease. Healthy food preparation techniques can also be reviewed with the patient.

Home Environment . The patient's home environment should allow for privacy, social interaction and both spiritual and emotional comfort and safety. A safe neighborhood with close proximity to services is important for many older patients. The home may reflect pride in the patient's family and past accomplishments and reveal the patient's interests and hobbies. The physician should not make assumptions about social class or material wealth based on the patient's physical environment.

Other People . Having the patient's social support system present at the home visit clarifies the roles and concerns of family members. During routine visits, the physician can assess the availability of emergency help for the patient from family members and friends and can clarify specific issues, such as who is to serve as surrogate for the patient in the event of incapacitation. Discussion of a durable power of attorney and a living will may be more comfortably performed during the home visit than in the usual clinic visit. Evaluation of the caregiver's needs and risk of burnout is critically important.

Medications . To remedy or avoid polypharmacy, the physician must evaluate the type, amount and frequency of medications, and the organization and methods of medication delivery. An inventory of the patient's medicine cabinet can provide clues to previously unidentified drug-drug or drug-food interactions. A home medication review can also allow a direct estimate of patient compliance, uncover evidence of “doctor shopping” and identify the use or abuse of over-the-counter medications and herbal remedies.

Examination . The home visit should include a directed physical examination based on the needs of the patient and the physician's agenda. Practical, function-related examination techniques may include having the patient demonstrate getting on and off the toilet or in and out of the bathtub. The physician can have the patient demonstrate proper technique for the self-monitoring of blood glucose levels. In addition, the physician can weigh the patient and obtain a blood pressure measurement. In-person correlation of home and office measures provides useful information for future telephone and clinic contacts.

Safety . Common home safety issues are listed in Table 5 . The goal of the home safety assessment is to determine whether the patient's environment is comfortable and safe (no unreasonable risk of injury). To raise the subject, the physician should simply state the intention to identify and help modify potential safety hazards. For example, furniture placement or throw rugs may create problems for an elderly patient with gait instability, or the tap water may be so hot that the patient is at risk for scald injury. 20

Spiritual Health . If the home contains religious objects or reading materials, the physician can ask about the influence of spiritual beliefs on the patient's sense of physical and emotional health. This information may provide the impetus, as desired by the patient, for a discussion of spirituality as a coping and healing strategy.

Services . Having members of cooperating home health agencies present for the house call can enhance communication and cooperation among the physician, patient and agencies. Existing orders can be clarified, priorities for future care can be established and other perspectives on the care plan can be solicited. The patient's relationship with home health agency providers can also be assessed.

Elements of the INHOMESSS mnemonic may be used independently, based on the needs of the patient and the physician's agenda. For example, the physician may wish to focus on polypharmacy and safety in a patient with a recent fall, or to assess mobility and the extent of social support in a patient with newly diagnosed Alzheimer's disease. Figure 1 presents the major elements of the home visit in a checklist format that facilitates comprehensive assessment.

INTEGRATING HOME VISITS INTO CLINICAL PRACTICE

Lack of reimbursement and the busy pace of office practice are the reasons commonly cited for not conducting house calls. Poorly organized, sporadic home visits may indeed interfere with clinical practice. Therefore, it is important to develop a systematic approach for planning home visits. 21

Most practices will benefit from using home visits with patients who have difficulty accessing outpatient facilities because of sensory impairment, immobility or transportation problems. Removing such logistically difficult appointments from the clinic schedule and performing them in the home setting may actually enhance clinic functioning. Clustering home visits by geographic location and within defined blocks of time may also improve efficiency. Finally, nurse practitioners and physician assistants can conduct visits as part of a home health care delivery team.

The 1999 Current Procedural Terminology codes and corresponding Medicare reimbursement rates for common types of home visits are listed in Table 6 . 22

Telephone Calls and Telemedicine

Proactive telephone calls are an underutilized method of conducting highly focused and time-efficient “virtual” home visits. 23 Provider-initiated telephone calls can be used to reassure family members after a patient has had an acute illness or has been hospitalized. 23 These calls can also be helpful in reinforcing patient compliance with new medications, following patients with chronic diseases and reducing inappropriate use of primary care clinic or office services. 24

Telemedicine is the use of communication technologies, such as two-way video-conferencing, to provide patient care across distances. A variety of institutions are exploring these technologies as methods of delivering health care in the home. 25 , 26

Final Comment

As fewer patients are admitted to hospitals and hospital stays become ever briefer, the medical complexity of home care will increase, as will the demand for both in-person and “virtual” physician home visits. Physicians interested in obtaining additional information about home care provision can contact the American Academy of Home Care Physicians (P.O. Box 1037, Edgewood, MD 21040; Web address: http://www.aahcp.org/ ).

Shut in, but not shut out [Editorial]. Am Med News. 1996;39:47.

Meyer GS, Gibbons RV. House calls to the elderly: a vanishing practice among physicians. N Engl J Med. 1997;337:1815-20.

Boling PA. House calls [Letter]. N Engl J Med. 1998;338:1466.

Starr P. The social transformation of American medicine. New York: Basic Books, 1982:359.

Adelman AM, Fredman L, Knight AL. House call practices: a comparison by specialty. J Fam Pract. 1994;39:39-44.

Arcand M, Williamson J. An evaluation of home visiting of patients by physicians in geriatric medicine. Br Med J. 1981;283:718-20.

Fabacher D, Josephson K, Pietruszka F, Linderborn K, Morley JE, Rubenstein LZ. An in-home preventive assessment program for independent older adults: a randomized controlled trial. J Am Geriatr Soc. 1994;42:630-8.

Ramsdell SW, Swart J, Jackson JE, Renvall M. The yield of a home visit in the assessment of geriatric patients. J Am Geriatr Soc. 1989;37:17-24.

Bernardini J, Piraino B. Compliance in CAPD and CCPD patients as measured by supply inventories during home visits. Am J Kidney Dis. 1998;31:101-7.

Tideiksaar R. Environmental adaptation to preserve balance and prevent falls. Top Geriatr Rehabil. 1990;5:178-84.

Knight AL, Adelman AM, Sobal J. The house call in residency training and its relationship to future practice. Fam Med. 1991;23:57-9.

Steel RK, Musliner M, Boling PA. Medical schools and home care. N Engl J Med. 1994;331:1098-9.

Goldberg AI. Home healthcare: the role of the primary care physician. Compr Ther. 1995;21:633-8.

Boling PA, Keenan JM, Schwartzberg JG, Retchin SM, Olson L, Schneiderman M. Home health agency referrals by internists and family physicians. Am Geriatr Soc. 1992;40:1241-9.

American Medical Association. Medical management of the home care patient: guidelines for physicians. 2d ed. Chicago: The Association, 1998:1–60.

Klein S. Guidance for home care physicians. Am Med News. 1998;41:5-6.

Cauthen DB. The house call in current medical practice. J Fam Pract. 1981;13:209-13.

Scanameo AM, Fillit H. House calls: a practical guide to seeing the patient at home. Geriatrics. 1995;50:33-9.

Knight AL, Adelman AM. The family physician and home care. Am Fam Physician. 1991;44:1733-7.

Huyer DW, Corkum SH. Reducing the incidence of tap-water scalds: strategies for physicians. Can Med Assoc J. 1997;156:841-4.

American Academy of Home Care Physicians. Making house calls a part of your practice. Edgewood, Md.: American Academy of Home Care Physicians, 19981;1–35.

Kirschner CG, ed. Current procedural terminology: CPT. Standard ed. Chicago: American Medical Association, 1999:26–8.

Studdiford JS, Panitch KN, Snyderman DA, Pharr ME. The telephone in primary care. Prim Care. 1996;23:83-102.

Wasson J, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG. Telephone care as a substitute for routine clinic follow-up. JAMA. 1992;267:1788-93.

Jerant AF, Schlachta L, Epperly TD, Barnes-Camp J. Back to the future: the telemedicine house call. Fam Pract Management. 1998;5:18-22.

Johnson B, Wheeler L, Deuser J. Kaiser Permanente Medical Center's pilot tele-home health project. Telemed Today. 1997;5:16-8.

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Nursing Home Visit

Description

A nursing home visit is a family- nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities. In performing  home visits, it is essential to prepare a plan of visit to meet the needs of the client and achieve the best results of desired outcomes.

• To give care to the sick, to a postpartum mother and her newborn with the view teach a responsible family member to give the subsequent care.
• To assess the living condition of the patient and his family and their health  practices in order to provide the appropriate health teaching.
• To give health teachings regarding the prevention and control of diseases.
• To establish close relationship between the health agencies and the public for the promotion of health.
• To make use of the inter-referral system and to promote the utilization of community services

The following principles are involved when performing a home visit:

• A home visit must have a purpose or objective.
• Planning for a home visit should make use of all available information about the patient and his family through family records.
• In planning for a home visit, we should consider and give priority to the essential needs if the individual and his family.
• Planning and delivery of care should involve the individual and family.
• The plan should be flexible.

The following guidelines are to be considered regarding the frequency of home visits:

• The physical needs psychological needs and educational needs of the individual and family.
• The acceptance of the family for the services to be rendered, their interest and the willingness to cooperate.
• The policy of a specific agency and the emphasis given towards their health programs.
• Take into account other health agencies and the number of health personnel already involved in the care of a specific family.
• Careful evaluation of past services given to the family and how the family avails of the nursing services.
• The ability of the patient and his family to recognize their own needs, their knowledge of available resources and their ability to make use of their resources for their benefits.
• Greet the patient and introduce yourself.
• State the purpose of the visit
• Observe the patient and determine the health needs.
• Put the bag in a convenient place and then proceed to perform the bag technique .
• Perform the nursing care needed and give health teachings.
• Record all important date, observation and care rendered.
• Make appointment for a return visit.
• Bag Technique
• Primary Health Care in the Philippines

2 thoughts on “Nursing Home Visit”

Thanks alots for the impressive lessons learnt from the principal of community health care and nursing home

Home visit nursing

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Home Visiting Services During the COVID-19 Pandemic: Program Activity Analysis for Family Connects

Anna rybińska.

1 Center for Child and Family Policy, Duke University, Duke, Box 90539, Durham, NC 27708 USA

Debra L. Best

2 Department of Pediatrics, Duke University School of Medicine, UMC, Box 3675, Durham, NC 27710 USA

W. Benjamin Goodman

Winona weindling, kenneth a. dodge.

3 Sanford School of Public Policy, Duke University, Box 90245, Durham, NC 27708 USA

Early reports highlighted challenges in delivering home visiting programs virtually during the COVID-19 pandemic but the extent of the changes in program implementation and their implications remains unknown. We examine program activity and families’ perceptions of virtual home visiting during the first nine months of the pandemic using implementation data for Family Connects (FC), an evidence-based and MIECHV-eligible, postpartum nurse home visiting program.

Description

Aggregate program implementation data for five FC sites for January-November of 2019 and 2020 are compared. The COVID-19 Modification Survey is used to analyze families’ reactions to virtual program delivery.

Post-pandemic onset, FC’s program completion rates amounted to 86% of the pre-pandemic activity level. Activity in key components of the intervention—home-visitor education and referrals to community agencies—was maintained at 98% and 87% of the pre-pandemic level respectively. However, education and referrals rates declined among families of color and low-income families. Finally, families reported a positive response to the program, with declines in feelings of isolation and increases in positive attitudes toward in-person medical care-seeking due to FC visits.

Conclusions

During the first nine months of the COVID-19 pandemic, families’ interest in home visiting remained strong, performance metrics were maintained at high levels, and families responded positively to the virtual delivery of home visiting. Home visiting programs should continue implementation with virtual modifications during the remainder of the pandemic but attention is needed to address growing disparities in access to home visiting benefits among marginalized communities.

Significance

Home visiting programs temporarily transitioned to providing services virtually when the Covid-19 pandemic started. Reports about home-visiting program activity using virtual means post-pandemic onset remain scarce and families’ perceptions of virtual home-visiting services remain understudied. In this paper, we compare program activity for a universal postpartum home-visiting program (Family Connects) between pre-pandemic in-person services and post-pandemic onset virtual services. Families’ reactions to virtual home-visiting services are also described. Findings can be used to inform maternal, infant, and early childhood home visiting programs’ implementation during the continuing public health emergency to support program staff and participating families.

Introduction

Home visiting programs are an established public health service designed to promote maternal and infant health and family well-being. In the United States, $400 million in federal funds are allocated annually to evidence-based home visiting programs through the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) (Health Resources & Services Administration, 2020 ). In 2019 alone, 1,540,000 American parents and children participated in visiting programs supported by MIECHV (Health Resources & Services, Administration, 2020 ).

During the ongoing COVID-19 pandemic, most home visiting models transitioned from in-home visits to virtual visiting (Zero To Three, 2020 ) and faced a daunting challenge of delivering care and intervention without in-home presence. The shift generated questions about the feasibility of delivering federally-funded programs via virtual means and the appropriateness of using federal and local funds to support home visiting services which are delivered virtually rather than in-person. At the same time, families with small children have been severely affected by unemployment, lack of childcare, and isolation from extended family during the pandemic (Cluver et al., 2020 ). In these unprecedented times, virtual home visiting services constitute an essential connection for families, addressing immediate needs and connecting families to community agencies for further support (Williams et al., 2020 ).

How has home visiting fared during the pandemic? Early evidence about the impact of COVID-19 on home visiting comes from home visiting staffs’ self-reports collected in spring and summer of 2020 (Marshall et al., 2020 ; Self-Brown et al., 2020 ). These findings indicate that home visiting programs remained operational during the pandemic, but performance was affected by challenges in virtual program delivery (for instance, limited internet connectivity or lack of adequate devices to participate in telehealth) and COVID-19 related disruptions in providers’ and families’ daily routines (such as lack of adequate child care or need to home school) (Marshall et al., 2020 ; Self-Brown et al., 2020 ).

What remains unknown is the impact of virtual delivery and the pandemic on home visiting program performance metrics such as program uptake, follow-through rates, and adherence to evidence-based program components such as community referrals. In addition, little is known about families’ perception of receiving home visiting via virtual means during the pandemic. We address these questions by examining program activity during the pandemic for Family Connects (FC), a MIECHV-eligible, brief postnatal nurse home visiting program.

Additionally, research is needed to analyze home visiting program activity among marginalized populations in the United States post-pandemic onset. Populations with existing vulnerabilities and inequitable access to resources and health care constitute a large proportion of home visiting programs’ participants (Health Resources & Services Administration, 2016 ) and greatly benefit from home visiting services (Administration for Children and Families, 2020 ). Because marginalized communities are disproportionately affected by the pandemic (Kirby, 2020 ; Raifman & Raifman, 2020 ), home visiting programs are uniquely positioned to provide crucial support for vulnerable families in times of unprecedented hardship if equitable access to home visiting interventions and their key aspects is maintained. In this paper, we present FC program activity across racial and ethnic and social class lines with respect to evidence-based program components of nurse education provision and referral rates.

Family Connects Model and Its Modifications During Covid-19

FC is a universal nurse home visiting program first implemented in Durham, North Carolina in 2009 and currently serving families in 23 communities across the United States (Family Connects International, 2019a , 2019b ). Under the FC protocol, families residing in participating communities are invited to participate in the program shortly after birth. Enrolled families receive an integrated home visit (IHV) from a registered nurse about three weeks after the delivery. During the visit, family strengths and needs in four domains: health care, infant care, home safety, and parental well-being are assessed. When needs are identified, the nurse provides education and supportive guidance and—if need for long-term support is identified—connects the family with community resources. Nurses may also offer one to two follow-up home visits or phone calls for continued assessment and intervention, based on clinical judgment. Four weeks after the IHV, a FC team member follows up with a post-visit connection call to assess family satisfaction and confirm successful connections with community resources. Findings from two randomized controlled trials of FC have shown high participation rates, strong connections to community resources, high family satisfaction, and positive impact on reducing maternal mental health problems, infant emergency medical care costs, and Child Protective Services investigations (Alonso-Marsden et al., 2013 ; Dodge et al., 2013 , 2014 , 2019 ; Goodman et al., 2019 , 2021 ).

FC mandated all sites transition to provide services to families via virtual means on March 18, 2020. Within the modified virtual protocol, FC sites offer two approaches to substitute the traditional in-home visit: (1) a modified IHV or (2) a structured supportive call. During the modified IHV, the nurse follows the standard IHV procedure, but the physical assessment of the caregiver and the infant have been replaced by detailed questions about caregiver’s and infant’s health. The nurse also provides guidance across the domains indicated in the standard IHV. The supportive call is a shorter intervention which simulates the IHV protocol. The caregiver is asked about feeding, mood, healthcare access, concerns, and need for follow-up. Brief education is delivered with specific attention to postpartum warning signs. The call ends with a summary of family strengths, a review of recommendations, and a plan for follow-up. Post-pandemic onset, the follow-up protocol still includes one to two phone calls based on the nurse’s judgement and a final connection call at four weeks post-visit.

Data and Methods

Research protocols for this study were approved by the Duke University Health Systems IRB (Protocol #00105777) and Duke University Campus IRB (Protocol #2021-0197). The study received an IRB waiver of informed consent. Two data sources are used: the FC program activity data and the COVID-19 Modification Survey. We selected FC program activity data from March to November in 2019 and 2020 for five certified and mature sites (N = 7791 scheduled visits). Mature sites are defined as sites with over 18 months of activity before January 2020 and demonstrated program fidelity. Our selection of mature FC sites for the program performance analysis assures that no changes or expansion of the program in the respective areas took place in 2019 and 2020, and activity should be comparable between 2019 and 2020 net of any exogenous shocks. Consequently, changes in program activity in 2020 can be interpreted as resulting from the disruptions due to the pandemic and transition to virtual means.

First, several program performance metrics are analyzed: number of scheduled visits, visit completion rates, time to completed visit, frequency of guidance provision (that is, the percentage of visits during which the nurse addressed families’ needs through education and guidance), and community referral rates (that is, the percentage of visits during which the nurse offered a community referral to address needs in addition to providing education and guidance). Completion rates during the pandemic account for both the modified IHVs and the structured supportive calls.

Second, we report education/provision and community referral rates stratified by the caregiver’s race and ethnicity and by the family’s source of insurance. Race and ethnicity categories mirror the language used in the FC database: non-Hispanic white (thereafter white), non-Hispanic Black (thereafter Black), Hispanic, and non-Hispanic other. For source of insurance, we distinguish between families using private insurance and families using Medicaid or uninsured. Socio-demographic indicators are not available for families that did not complete the visit and we cannot comment on FC’s population reach across specific subpopulations.

To analyze changes in program implementation during the COVID-19 pandemic, performance metrics are compared for two periods: March 1st–Nov. 30th, 2019 (pre-pandemic) and March 1st–Nov. 30th 2020 (post-pandemic onset). The cut-off in March reflects the shift towards state mandated closures (White House Communications, 2020 ) and the beginning of the FC transition to virtual means in 2020. As a sensitivity analysis, we introduced a cut-off in mid-March and obtained numerically and substantively similar results. November was the last month for which the implementation data were available at the time of submission.

Last, to examine families’ perceptions of the FC virtual visits, we use the COVID-19 Modification Survey conducted between May and November 2020. The Modification Survey is a short, 6-item, questionnaire distributed via phone call or e-mail approximately four weeks after the completed visit. The survey was designed as anonymous and not linked to other information about the family or FC visit, in order to accelerate IRB protocol approval and facilitate survey distribution. Families are asked whether the amount of contact with FC was satisfactory and how FC affected their feelings of social isolation and concerns about in-person medical care seeking. Across the five selected sites, 330 families who received a FC visit completed the survey (response rate 54.8%). We present percentage distributions of answers for each relevant question item from the survey.

Changes in post-pandemic FC activity are presented in Fig.  1 and Table ​ Table1 1 below. Pre-pandemic, on average 438 visits were scheduled monthly in the five analyzed FC sites compared to 427 visits post-pandemic onset, indicating a 2.5% decline in scheduling activity. Completion rates averaged at 76.5% pre-pandemic and declined by 10.9% to 68.1% post-pandemic onset. In the first nine months post-pandemic onset, 78.9% of all virtual visits were completed as modified IHVs and 21.1% were completed as structured supportive calls.

Family Connects’ program activity. Pre-pandemic data for March-Nov. 2019. Post-pandemic data for March-Nov. 2020. Metrics calculated using infant’s date of birth to delineate analysis time period

Changes in Family Connects’ program activity post-pandemic onset

Family Connects’ program implementation data, five mature and certified Family Connects sites. Scheduling activity and completion rates calculated using a sample of 7,791 scheduled visits and using infant’s date of birth to delineate analysis time period. Education and referral activity metrics calculated using a sample of 5,112 completed visits (in-person IHVs and modified virtual IHVs) and using date of visit to define analysis time

The average age of the infant at the moment of the in-person visit pre-pandemic was 27.9 days. During the virtual delivery post-pandemic onset, the time to completed visit was shorter, with infants’ mean age at visit equaling to 23.2 days. Modified IHVs were completed sooner post-birth (mean infant age of 22.6) than structured supportive calls (mean infant age of 25.7 days).

Figure  2 represents frequency of education and guidance provision during the FC visit. Among families who completed traditional in-person IHVs before the pandemic, 96.4% of families received education and guidance during the in-person visit. In comparison 96.1% received these services during the modified virtual IHV post-pandemic onset. Further, across all four designated race/ethnicity subpopulations, the level of education provision was high pre-pandemic onset. On average, 98.3% of families with Black caregivers and 98.7% of families with Hispanic caregivers received guidance compared to 93.9% of families with white caregivers. After the pandemic onset, rates of education provision declined by 2.4% among Hispanic families but remained largely unchanged for all other groups (see also Table ​ Table1). 1 ). Respectively 98.1% of families using Medicaid or uninsured and 94.4% of families using private insurance received education provision pre-pandemic. The post-pandemic onset values for education provision remained very similar, at 97.5% for families with Medicaid or uninsured and 94.4% for families with private insurance.

Provision of education during FC visits. Pre-pandemic data for March-Nov. 2019. Post-pandemic data for March-Nov. 2020. Education provision calculated using a sample of 5112 completed visits (in-person IHVs and modified virtual IHVs) and using date of visit to define analysis time. Due to data limitation, no information about education and referral activity is available for post-pandemic structured supportive calls

FC staff offered community referrals to 49.9% of visited families pre-pandemic onset and to 43.7% of families post-pandemic onset, a decline of 12.3% (Fig.  3 and Table ​ Table1). 1 ). We observed variation in referral rates across families of different racial and ethnic background before the pandemic. About 61.6% of families with Black caregivers were offered a referral, compared to 70.0% of families with Hispanic caregivers and 36.0% of families with white caregivers. Among families of Black and Hispanic caregivers, referral rates declined post-pandemic onset, by 15.3% and 39.5% respectively. In contrast, more families of white caregivers received community referrals post-pandemic onset, an increase of 8.7%. Among families using Medicaid and uninsured families, 67.8% were offered a referral during the FC in-person visit pre-pandemic onset compared to 29.1% of families using private insurance. About 57.3% of Medicaid/uninsured families were offered a referral once the pandemic started, a decline of 15.5%. At the same time, the proportion offered a referral among families with private insurance increased by 3.5%, to 30.1%.

Community referral rates during FC visits. Pre-pandemic data for March-Nov. 2019. Post-pandemic data for March-Nov. 2020. Referral rates calculated using a sample of 5112 completed visits (in-person IHVs and modified virtual IHVs) and using date of visit to define analysis time. Due to data limitation, no information about education and referral activity is available for post-pandemic structured supportive calls

Based on data from the COVID-19 Modification Survey (Fig.  4 ), 89.0% of families reported that the frequency of conversations with FC nurses was just right post-pandemic onset. Further, 65.1% of surveyed families reported that their feelings of isolation during the pandemic decreased because of their contact with the FC nurse. In addition, 61.6% of families reported being worried about seeking in-person routine medical care for themselves or their newborn infant during the pandemic. Among these families, 61.7% reported that their concerns declined because of their conversations with the FC nurse.

Families’ self-reported reception of Family Connects’ visits during the COVID-19 pandemic from the COVID-19 Modification Survey (N=330). *Question asked only among respondents who reported mild to severe worries about seeking routine medical care during COVID-19 for themselves or their baby

Maternal, infant, and early childhood home visiting programs experienced a tremendous disruption in activities during the COVID-19 pandemic, a time when support for families with small children was extremely important. Data from Family Connects, a postpartum nurse home visiting intervention that transitioned to virtual delivery in March 2020, demonstrates that FC recruited comparable numbers of families into the program pre- versus post-pandemic onset. Completion rates declined slightly, by 10.9% post-pandemic onset compared to pre-pandemic, but remained high at 68.1% of scheduled visits. Further, key components of the intervention, the provision of education and community referrals with respect to four key domains of family well-being (health care, infant care, home safety, and parental well-being), were maintained at high levels during virtual delivery post-pandemic onset. FC staff provided education to 96.1% of the caregivers (compared to 96.4% pre-pandemic) and offered referrals for community agencies to 43.7% of caregivers (compared to 49.9% pre-pandemic). Finally, we report that families were satisfied with the level of communication with FC staff and reported decreased feelings of isolation and reduced concerns about seeking in-person services after the FC visit.

Taken together, these findings demonstrate the feasibility of transitioning a home visiting program to virtual means, meriting continued implementation and state support for home visiting interventions. We thus recommend that during the ongoing public health emergency, home visiting programs continue implementation with virtual modifications and that existing funding sources continue or grow. In addition, we suggest that the virtual home visiting protocol established during the COVID-19 pandemic can serve as a blueprint for virtual outreach in future emergency situations. During emergencies such as hurricane or wild fire evacuations, virtual services might provide necessary consultations and community connections for families. Similarly, virtual services can lead to expansion of the home visiting reach by offering virtual visits to families reluctant to welcome a nurse into their home or to families in remote areas. In summary, even though the COVID-19 imposed modifications to home visiting might be temporary, we expect the option of virtual delivery to remain within the portfolio of services offered by home visiting programs.

While we conclude that the transition to virtual means of home visiting delivery during COVID-19 was successful for FC, we recognize that in-person and in-home observations are evidence-based components of home visiting interventions, demonstrated to improve family well-being. The impact of virtual delivery (that is, whether this mode is associated with positive outcomes for families) is unknown. Consequently, a rigorous evaluation of the impact of virtual delivery on health outcomes, e.g., infant development, parental mental health or parent-infant relationship, is necessary. We also suggest future studies for FC about potential obstacles to virtual visit completion to remedy declining follow-through rates. Potential reasons for the small decline in program completion could include poor internet/cell data access, families’ lack of time to complete visits, or staffing shortages with home visiting nurses delegated to COVID-19 relief efforts.

Additionally, while we document declines in community referral rates, we cannot explain why these declines are observed. On one side, a decline in referrals might indicate that, during the pandemic, FC nurses recognize the difficulty families have in attending community services (because the services have closed or the family is reluctant to reach out) and so the nurses are taking on the task of addressing the need during the visit rather than connecting the family to a community agency. On the other hand, a decline in provision of education and referrals might indicate that some needs are not being reported adequately by the parents or assessed fully by the nurses, whilst before, needs would have been observed directly by the nurse visiting the home and performing physical examinations. Future research should address these unanswered questions.

As home visiting programs continue services virtually and consider future changes to the intervention protocols, careful consideration should be devoted to issues of equal access to the interventions and their benefits for all families within participating communities. Findings in this paper show that while the community connections of affluent families and white families increased during the pandemic, these linkages weakened for low-income families and families of color. These noteworthy differences in program activity might reflect lack of access to services necessary for virtual home visiting, such as broadband internet, but also disproportionate impact of the pandemic on these communities. Thus, a priority of future research ought to be a critical examination of the reasons behind lower community referrals among minority and low-income families and an investigation of potential community alignment solutions to improve connectedness among historically marginalized families.

Acknowledgements

We acknowledge the contributions of many staff members and community leaders in implementing Family Connects and its evaluation. The authors thank Phil Nousak for his assistance with data management and 4 anonymous reviewers for their helpful comments on previous versions of the manuscript.

Author Contributions

All Authors participated in study conception and design. Dr. Rybińska carried out the program activity analyses and interpreted the data, drafted the initial manuscript, and reviewed and revised the manuscript. Drs. Best, Dodge, and Goodman participated in interpretation of data and reviewed and revised the manuscript. Ms. Weindling carried out analyses for the COVID19 Modification Survey and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work .

Funding for this research was provided by The Duke Endowment (TDE #20-01-SGO) and the R01HD069981 grant from the Eunice Kennedy Shiver National Institute for Child Health and Human Development.

Declarations

Drs. Best, Dodge, and Goodman acknowledge participation in Family Connects model dissemination. As the founder of Family Connects, Dr. Dodge provides periodic, in-kind consultation to sites implementing Family Connects. As director of research for Family Connects, Dr. Goodman supports local evaluation efforts at some dissemination sites. As medical director and national director of implementation for Family Connects, Dr. Best oversees site training and advises on local site clinical implementation work for dissemination sites. The other authors declare no conflict of interest.

Research protocols for this study were approved by the Duke University Health System’s IRB (Protocol #00105777) and the Duke University Campus IRB (Protocol #2021-0197).

Not applicable.

Data used in this research are deidentified participant data. Data are collected and managed by the Center for Child & Family Health, a community non-profit in Durham, NC, that serves as the national training and dissemination hub for Family Connects program. Data are not publicly available.

Code is not publicly available per study protocol guidelines.

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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Anna Rybińska, Email: [email protected] .

Debra L. Best, Email: [email protected] .

W. Benjamin Goodman, Email: [email protected] .

Winona Weindling, Email: [email protected] .

Kenneth A. Dodge, Email: ude.ekud@egdod .

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LA CROSSE — In a visit to a purple region of Wisconsin on Monday, Vice President Kamala Harris announced new rules for nursing home staffing and rallied voters around abortion as the race for the presidency remains extremely tight in the battleground state.

"This is a moment where we must stand up for foundational, fundamental values and principles," Harris told supporters during a campaign event at the La Crosse Center. "Here's the other piece that I will say: When we think about what is at stake, it is absolutely about freedom."

The trip to La Crosse reflects Democrats' efforts to make abortion a key factor in motivating turnout for President Joe Biden, including among voters in purple areas or even the traditionally red Milwaukee suburbs.

Women affected by abortion bans in other states campaigned for Biden in Waukesha County last week , and Harris brought a similar message to the area in January . Biden administration officials have also made frequent trips to Milwaukee and Madison this year, both Democratic strongholds.

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"There is a clear line between where we are now and who is to blame," Harris said. "The former president was very clear with his intention — he would fill and appoint three members of the U.S. Supreme Court with the intention that they would overturn the protections of (Roe v. Wade)."

More: Wisconsin abortion laws: What to know after Arizona ruling

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"So I would much rather allow or have the state government and local governments in charge of the requirements of nursing care facilities, and — anything to do with the citizens of this state, I'd rather have state governments and local governments handle that than some dictate from the federal government that causes more problems or exacerbates more problems than it solves."

New Marquette poll shows abortion is top issue for Democratic voters

In the latest Marquette University Law School poll released last week , 24% of Democratic voters said they consider abortion their most important issue in deciding who to vote for, followed by the economy. For independent and Republican voters, 5% of those groups saw abortion as their top issue.

"People will say to me, 'Well, Sarah, aren't folks just over that whole abortion issue? Haven't they just moved on?" Secretary of State Sarah Godlewski said before Harris' speech. "I am just as mad today as when I heard about the Supreme Court overturning Roe, and I know that I'm not alone."

While abortion was the leading issue among Democratic participants, the economy was the No. 1 issue for all respondents in the survey, followed by immigration and abortion policy. Voters saw Biden better at handling abortion and health care, and Trump better on the economy and immigration.

A majority of registered voters in Wisconsin, 54%, also said they favor a national ban on abortion after 15 weeks of pregnancy with exceptions for rape, incest and the life and health of the mother.

Johnson, in comments to reporters at the Wisconsin Manufacturers & Commerce, again called for a statewide referendum that would put the question of when to ban abortion to voters.

Democrats campaigning on abortion outside of blue strongholds

While Democrats have also highlighted abortion access in suburban Milwaukee, the La Crosse area is much more purple and voted for Biden in 2020. In 2020 , La Crosse County voted 56% for Biden, compared to Trump's 42%.

While Biden officials have stopped in Milwaukee and Madison most frequently, they've also visited Superior on the Minnesota border , Green Bay and the Menominee Nation in northeastern Wisconsin.

More: Did the 2020 presidential election in Wisconsin really come down to a few votes per ward?

La Crosse is located in the 3rd Congressional District, one of two truly competitive U.S. House districts in Wisconsin. The seat is currently held by Republican Rep. Derrick Van Orden. Democrats are focusing more energy on the race compared to the last cycle.

Van Orden has raised much more money than his prospective Democratic challengers, small-business owner Rebecca Cooke and state Rep. Katrina Shankland from Stevens Point.

Neither were spotted at the campaign event, though Democratic U.S. Rep. Mark Pocan from Madison praised Shankland alongside other state legislators from the area in his remarks at the campaign event. Pocan has endorsed Shankland in the race.

Pocan called Van Orden a "chauvinist" and said western Wisconsin is "represented in Congress by someone who has been endorsed by the most extreme groups on abortion."

Jessie Opoien contributed to this report from Madison.

See photos of President Joe Biden’s visit to Tampa

• Chris Urso Times staff
• Douglas R. Clifford Times staff
• Jefferee Woo Times staff

President Joe Biden made a campaign visit to Tampa this afternoon, where he focused on abortion and tried to tie rival Donald Trump to abortion restrictions in the state and across the country.

Biden spoke at Hillsborough Community College’s Dale Mabry campus in Tampa. Near the campus, dozens of demonstrators gathered to protest the president over the United States’ support of Israel’s war against Hamas, the death of civilians in Gaza and other issues.

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Chris Urso is the photo director who oversees news and sports coverage. Reach him at [email protected].

Douglas R. Clifford is a staff photographer. Reach him at [email protected].

Jefferee Woo is a staff photographer. Reach him at [email protected].

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