By Joan Wightkin, DrPH
Assistant Professor, Department of Community and Behavioral Health, Louisiana State University Health Sciences Center
The May/June Pulse on evidence-based practice (EBP) included many valuable topics ranging from the integration of quality improvement and epidemiology; "promising" practices and the AMCHP Innovation Station; the Florida redesign of their Healthy Start Program toward a more research-informed and evidence-based intervention; and the Home Visiting Research Network informing home visiting policy and practice. Title V leaders faced with the difficult decisions for allocating limited Title V funds benefited from this information.
The federal Patient Protection and Affordable Care Act (ACA), signed into law in 2010, established the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. At least 75 percent of the MIECHV funding must go to implement one of 13 evidence-based home visiting models and up to 25 percent may go to "promising approaches" that are rigorously evaluated.
Title V leaders weighed variables, such as cost, existing investments and infrastructure, and politics, in order to decide which was the right model for the state. An underlying principle of Title V programs is to reach a large proportion of a state maternal and child population, focusing on the highest risk subpopulations. More costly models may be passed over unless the primary state consideration is the proven impact and cost benefit of the model. Long standing Title V interventions that receive Medicaid reimbursement may not be considered an evidence-based practice, yet provide needed support services to large numbers of low-income pregnant women and young children.
The beliefs of policymakers, agency partners, and consumers influence the uptake of or resistance to new programs that may be more costly than existing interventions. A new model may change the type of provider, requiring the difficult task of building a new infrastructure in state Title V programs for training, quality improvement, and reporting.
Building strong evaluation capacity has been a principle of Title V programs in the past decades, to ensure that all investments are worthy of public funding. MIECHV allows further growth of Title V program evaluation capacity and expertise.
The experience of two Title V programs, Louisiana and Michigan, illustrate the decision making and challenges involved in changing the direction of Title V investments amidst the backdrop of evidence-based practice and MIECHV.
The Michigan Maternal and Infant Health Program (MIHP) began as a public health intervention providing population-based services to pregnant women and infants in the state. Eight years ago, MIHP began a redesign of the intervention as a shared partnership between the state Public Health and Medical Services (Medicaid) Administration. MIHP targets all Medicaid-eligible pregnant women and infants up to age one and is the largest program in the state providing support services to improve birth outcomes and promote maternal and infant health. Nurses and social workers assess the health and psychosocial needs of a pregnant woman, work with the client to develop a care plan, and refer her to needed health and social services.
Influenced by the MIECHV, the Michigan legislature passed Act 291 in 2012 requiring its state departments to restrict home visiting funding to programs that are evidence based or, "(h)ave data or evidence demonstrating effectiveness at achieving positive outcomes for pregnant women, infants, children, or their families…an active evaluation of each promising program, or there must be a demonstration of a plan and time line for that evaluation…(with a) projected time frame for transition from a promising program to an evidence-based program."
MIHP is considered a promising practice and is undergoing an evaluation that has already shown positive outcomes for utilization of prenatal care and well-baby visits among MIHP participants. Additionally,Title V leaders have incorporated evidence-based practices and screening tools in their redesign of MIHP. The hope is to transition MIHP from a promising to an evidence-based practice.
In 1999, Louisiana Title V began to shift funding to implement the Nurse Family Partnership (NFP) Program, one of the evidence-based home visiting models approved for funding in MIECHV. Over the next decade, NFP funding sources were diversified and increased from an initial $1 million investment to more than $12 million in 2010. Following the passage of the ACA, the NFP program was the intervention chosen for Louisiana MIECHV.
When Louisiana began NFP, there were few if any resources for clients in need of Infant Mental Health services, and the Title V program chose to add a mental health professional trained in Infant Mental Health to support the teams of nurse home visitors. In addition, each NFP nurse received 30 hours of training in Infant Mental Health. Louisiana was awarded a MIECHV Competitive Grant for promising practices, and some of the MIECHV funding is being dedicated to conducting an evaluation of the Infant Mental Health intervention.
Other examples of Louisiana Title V EBPs include having staff to support strong MCH epidemiology and evaluation capacity and to provide content expertise to ensure fidelity to other evidence-based interventions funded by MCH, such as breastfeeding promotion and teen pregnancy prevention. In addition to providing content expertise for MCH investments, Louisiana Title V staff provides expert consultation and training to agency partners, including the state child care and child protection agencies.
MIECHV has helped move Title V programs further toward EBP in states such as Michigan and Louisiana. In addition, MIECHV funding requirements have helped state child-serving agencies become more effective collaborators.
The Title V Early Childhood Comprehensive Systems initiatives in both Michigan and Louisiana evolved over the past decade into strong interdependent partnerships among state agencies, jointly developing policies and programs to build an early childhood system. MIECHV has taken that a step further in requiring agencies to plan, evaluate, and report together on indicators of comprehensive early childhood systems in these states.
The focus on evidence-based practice has helped Title V leaders be better stewards of government spending. Federal MIECHV policy has helped states remove the remaining "silos" that separate child-serving agencies and has created opportunities for states to succeed in reaching their shared goal of children being healthy and ready to learn by the time they start kindergarten.