View From Washington

Home Visiting – How did We Get Here and Where are We Going?

By Brent Ewig, MHS
Director of Public Policy & Government Affairs, AMCHP    

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act. As we’ve reported what seems like constantly over the past two years, this law creates a Maternal, Infant, and Early Childhood Home Visiting Programs that will for the first time provide a dedicated federal funding stream to support the expansion of home visiting programs. 

Created as a new section in the Title V statute, this provision represents one of the most exciting and significant changes to the program – and just in time to coincide with our 75th Anniversary of Title V. With a strong focus on expanding evidence-based models, the law will provide $1.5 billion in mandatory funding to states over the next five years. Now the action turns to the states to begin the crucial work on implementation.  

We are all now anxiously awaiting the federal guidance to support that implementation. No official U.S. Department of Health and Human Services (HHS) guidance has been released as this column is being written - but is reportedly coming soon [Editor’s note: HHS guidance was released on June 10]. So while we wait, we thought it would be worthwhile to take a brief look at some of the highlights in the history of home visiting. As the Minnesota Department of Health points out in a fascinating timeline included in a training manual for home visitors in their state, there were elements of home visiting in the United States going back to colonial times. In the 19th century, Florence Nightingale – considered the pioneer of the nursing profession – stressed the importance of home care skills and home visiting in the training of nurses, and nurses were assigned to specific districts across England. 

Home visiting also was a key element in the work done in Settlement Houses by our foremothers in the maternal and child health field, and many public health and child welfare agencies continued to expand utilization of home visiting throughout the past century. It was certainly an important strategy employed by programs like Head Start growing out of the Great Society era as well as national efforts focused on preventing child abuse and neglect. 

In 1991, the U.S. Advisory Board on Child Abuse and Neglect actually recommended that the “federal government immediately begin phasing in a national universal home visiting program for all children beginning in the neonatal period.” However, without adequate federal leadership or resources the expansion of home visiting in the past two decades has proceeded on an uneven basis, with state leaders and advocates doing their best to implement programs using a patchwork quilt of resources and no dedicated source of federal funding. 

Despite these obstacles, Kay Johnson reported last year that at least 40 states and territories are currently implementing a range of home visitation models through various state programs. Her study entitled State-based Home Visiting Strengthening Programs Through State Leadership serves as one of the best resources on the current state of home visiting programs. 

A turning point occurred in July 2007 when presidential candidate Barack Obama perhaps ushered in modern era of home visiting when he called for an expansion of home visiting as part of his platform to address poverty in the United States.  

Building on this momentum, AMCHP’s board of directors passed a policy statement in April 2009 reiterating our support of home visiting as a strategy that works and calling for federal efforts to sustain and increase investments. This policy supported our subsequent advocacy for home visiting to be included in national health reform legislation, and to build the program upon the strong foundation represented by the federal state partnership inherent in the the Title V MCH program.  

As action on health reform got underway on Capitol Hill, AMCHP joined a number of partners in this advocacy, and in the end – despite a rocky path and several tribulations - the final health reform package delivered the new program. 

So, what happens next? In a perhaps unprecedented move, the law actually directs the Secretary of HHS to “ensure that the Maternal and Child Health Bureau and the Administration for Children and Families collaborate” in carrying out many of the components of the law. By most indications, these two branches of HHS are working together expeditiously to provide states with the necessary guidance to complete the required needs assessment by the September deadline.  

In the meantime, in a May 7 memorandum to interested stakeholders, HHS has asked states to 1) familiarize themselves with the legislative provisions, 2) begin collecting the specified information needed to support a needs assessment, and 3) begin connecting key state agencies to discuss how to coordinate, particularly with existing needs assessments.  

So that is where things stand as of late May 2010. We are certain that imminent federal guidance will accelerate planning and implementation action in the states, and look forward to supporting the next chapter in the history of home visiting.