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Implementing Healthy Families America (HFA)®

Meets DHHS criteria for an evidenced based model

Implementation Experiences

Last Updated

April 2017


Summary of Sources

Information in this section is based on studies included in the HomVEE review. For HFA, we reviewed 51 studies, including 23 randomized controlled trials or quasi-experimental designs and 28 implementation studies. (Please see the study database for a list of the studies.)

In the sections below, we consider all pieces of research about a particular sample to be a single study. For example, eight publications were based on the same group of participants in Hawaii Healthy Start and are cited as one study. There are 51 publications across 31 distinct samples.


Characteristics of Model Participants

The average age of mothers varied across studies, ranging from about 18 to 27 (18 studies). The participants in several studies were teenage mothers (13 studies). Four of the studies reviewed reported on the age of the children in the program. In one study, the average age of a child at program entry was 28 days. In another study, all children were younger than age 6 months when they entered the program. A third study found that at enrollment, 49 percent of parents were pregnant and 43 percent had children from birth to 6 months old. In a fourth study, almost two-thirds of mothers enrolled prenatally. Of those mothers who enrolled postpartum, the average age of the children upon enrollment was 4 months.

Program participants primarily were mothers (17 studies). One study noted that 40 percent of families had a father who was involved in HFA activities.

Programs served racially and ethnically diverse families (25 studies). The percentage of participants who identified as white ranged from 10 to 100 (19 studies); 5 to 100 percent identified as African American (16 studies); and 9 to 87 percent identified as Hispanic (16 studies). Two to 41 percent of participants identified as Asian, Pacific Islander, or Filipino (five studies); 1 to 23 percent identified as American Indian, Native Hawaiian, or Alaska Native (five studies); and 1 to 28 percent identified as another or multiple races (12 studies).

Many of the studies reviewed reported participants’ socioeconomic characteristics (22 studies). Thirteen to 59 percent of program participants were employed (seven studies). Seventeen to 77 percent of program participants received or were eligible for public assistance, such as Medicaid or cash assistance (six studies); and 57 to 63 percent had household incomes below the federal poverty level (two studies).

The education level of participants varied across samples (14 studies). In some studies, 21 to 69 percent of program participants were high school graduates or had obtained a high school equivalency degree (nine studies). Other studies reported that 41 to 72 percent of program participants had less than a high school education (12 studies).

Seven to 26 percent of participants were married (four studies); 69 to 94 percent were single or unmarried (nine studies); and 39 to 100 percent were first-time mothers (12 studies).


Location and Setting

Programs were located in 16 states (28 studies). Studies occurred in every Census region of the United States, including:

  • South (12 studies);
  • West (11 studies);
  • Midwest (five studies);
  • Northeast (six studies); and
  • Pacific (two studies).

Two studies examined many program sites from around the nation, including one that examined more than 100 HFA programs and one that examined 278 programs.

Programs were implemented in the following settings1 (20 studies):

  • Urban (18 studies);
  • Rural/small towns (14 studies); and
  • Suburban (eight studies).

A variety of agencies implemented HFA, including:

  • Community agencies focused on families, child welfare, or human services (six studies);
  • Hospitals (three studies); and
  • State, county, and local health, child welfare, and human service departments (three studies).

1 The number of studies reported in each category does not sum to the total number of studies reporting program setting because some studies examined multiple settings.


Staffing and Supervision

Key staff included paraprofessional home visitors, sometimes called family support workers (21 studies), and family assessment workers who assessed program participants (six studies). In some programs, the home visitors were nurses (three studies). Other staff included child development specialists (three studies); parent educators (two studies); administrative or clinical supervisors (six studies); and other administrative positions including executive directors, program directors, program managers, program coordinators, and team leaders (nine studies).

The minimum educational qualification required of the home visitors was a high school diploma (eight studies). Thirty to 90 percent of home visitors had some college (eight studies), and 33 to 100 percent had a bachelor’s degree or higher (nine studies). Home visitors had background experience in social work, substance use disorder treatment, child development, mental health, family studies, nursing, or related fields or relevant experience working with at-risk families and individuals (10 studies). Home visitors had four years of home visiting experience (four studies) and three years’ tenure with the HFA program (one study).

The recommended minimum educational qualification for supervisors was a master’s degree plus three years of relevant experience or a bachelor’s degree with five years of relevant experience (four studies). One study stated that all of the supervisors had a master’s degree. A survey of 278 HFA programs found that 40 percent of supervisors had graduate degrees, 50 percent were college graduates, 9 percent had an associate’s degree, and one percent had only a high school diploma. The same study noted that supervisors typically had eight years of home visiting experience and four years’ tenure with HFA programs. Supervisors had background experience in social work, family counseling, psychology, human development, sociology, public health, or related fields (four studies).

The amount of pre-service training staff received varied across samples. Some studies reported that home visitors received 10 to 180 hours of pre-service training (five studies). Other studies reported that the amount of pre-service training staff received ranged from one to five weeks (six studies). Training topics included:

  • HFA goals, services, and operating procedures (four studies);
  • Community resources (four studies);
  • Child abuse and neglect identification and reporting (four studies);
  • Child growth, health, and development (three studies);
  • Domestic violence prevention (three studies);
  • Program assessments (three studies);
  • Parent-child interaction (two studies);
  • Crisis intervention and problem solving (two studies);
  • Communication skills (two studies);
  • Substance use disorders (two studies);
  • Cultural competence or sensitivity (two studies);
  • Confidentiality (two studies);
  • Goal setting for families (one study);
  • Building trusting relationships (one study);
  • Drug-exposed infants (one study);
  • Strategies for supporting positive outcomes (one study); and
  • Strength-based service delivery (one study).

The amount of pre-service training supervisors received also varied across samples. Some studies reported that supervisors received 40 to 100 hours of pre-service training (two studies). Other studies reported that supervisors received pre-service training ranging from three days to one week (two studies). Supervisors received pre-service training on similar topics covered in the home visitor training but also included training on promoting quality services (two studies), supervisory role and techniques (one study), and family dynamics (one study).

Ongoing training for home visitors included training on specific topics (four studies) and conferences and institutes (two studies). Home visitors participated in 4 to 10 trainings per year (three studies). Ongoing training topics included:

  • Parental risk factors and domestic violence (three studies);
  • Child abuse and neglect (three studies);
  • Substance use disorders (three studies);
  • Child care (two studies);
  • Child health and development (two studies); and
  • Curriculum (one study).

Supervisors also received in-service training (five studies), including conferences (one study) and half-week trainings several times a year (one study). Supervisors received ongoing training on parental risk factors and domestic violence (two studies); child health and development (one study); substance use disorders (one study); and child care (one study). One study reported that a program had difficulty finding supervisors with the desired qualifications. The program had to provide additional supervisor in-service training to address gaps in supervisor qualifications.

Formal supervision meetings typically occurred weekly (four studies) for 1.5 to 2 hours (four studies). During the meetings, home visitors reviewed their cases and discussed issues participants faced (seven studies). Supervisors observed home visitors in the field as part of supervision (three studies).

Home visitors had caseloads of 15 to 25 families (four studies). Home visitors who worked with families facing greater obstacles and challenges tended to have fewer cases (one study).


Model Components

Although HFA’s core component was home visiting, other services were also provided (21 studies). Several studies described the content of the home visiting component (23 studies). Postnatal visits focused on (1) improving the parent-child relationship through instruction, reinforcement, and modeling of parent-child activities (18 studies); (2) improving parents’ understanding of child development and age-appropriate behaviors (13 studies); (3) promoting child health and development by supporting healthy behaviors, proper nutrition, and facilitating linkages to and encouraging appropriate use of well-child visits, immunizations, and community resources (15 studies); and (4) enhancing parental self-sufficiency by reinforcing strengths; building problem-solving skills; strengthening family support networks; helping parents address issues such as substance use, mental illness, and domestic violence; supporting family functioning; and making referrals to community services as needed (eight studies). The HFA model allows programs to offer services and activities that correspond to the specific needs of their communities and families (13 studies).

HFA requires that families be enrolled prenatally or within three months of birth. Services are intended to continue until at least the child’s third birthday, and preferably until the child’s fifth birthday. The intensity of services varied across studies (25 studies). Most studies reported that home visits should occur weekly (24 studies). Others described the recommended frequency as a progression from weekly to quarterly, or other decrease in frequency, as families become more self-sufficient (13 studies). Home visits were intended to last at least 60 minutes (four studies).

In addition to home visits, programs provided participants parent support group meetings, workshops, celebrations, trainings, and outings. Participants were also referred to education, health, economic, employment, and family support services in their community (12 studies).

Programs used a variety of tools for family assessment or screening (20 studies), including:

  • Kempe Family Stress Checklist (FSC) or the Parent Survey (a revised version of the FSC) (10 studies);
  • Ages and Stages Questionnaire® (ASQ) (seven studies);
  • Maternal Social Support Index (MSSI) (two studies);
  • Adult-Adolescent Parenting Inventory (AAPI) (two studies);
  • Infant/Child Monitoring Questionnaire (one study);
  • Center for Epidemiologic Studies Depression Scale (CES-D) (one study);
  • Nursing Child Assessment Satellite Training (NCAST) Feeding Scale and the NCAST Teaching Scales (one study);
  • Key to Interactive Parenting Scales (KIPS) (one study);
  • Healthy Families Parenting Inventory (HFPI) developed by Healthy Families Arizona (one study);
  • CRAFFT screening tool® (one study) [CRAFFT is a mnemonic acronym of first letters of key words in the six screening questions];
  • Child Abuse Potential Inventory (one study);
  • Home Measurement of the Environment (one study); and
  • Parenting Stress Index (one study).

Programs used curricula to guide home visits (11 studies), including:

  • Parents as Teachers® curriculum (five studies);
  • Partners for Healthy Babies® (three studies);
  • Partners for Learning Curriculum and Activity Cards (one study);
  • Helping Babies Learn: Developmental Profiles and Activities for Infants and Toddlers (one study);
  • Great Beginnings® (one study);
  • Growing Great Kids® (one study);
  • Model Bonding/Parent Child (one study); and
  • Life Coping Skills (one study).


Model Adaptations or Enhancements

Two of the studies reviewed described additional enhancements that were offered along with HFA services. These adaptations included (1) a father involvement initiative that worked with the state’s HFA programs to increase their awareness of strategies that might increase father involvement (one study); and (2) a component designed to serve families affected by substance use and/or HIV in addition to the basic HFA model (one study).



The average number of home visits families received over the course of the program ranged from 23 to 43 (five studies), with the average number of visits from birth to 12 months postpartum ranging from 13 to 34 (three studies). One study found that the median number of prenatal home visits was seven. Another study found that the average number of prenatal visits was four, but the median was just one visit. Several studies noted that for many families the number of annual home visits decreased over the years enrolled in HFA but could vary depending on the intensity of services needed (six studies). The average duration of home visits was about one hour (two studies).

Families remained in the program an average of 14 to 23 months (nine studies). After six months, 70 to 80 percent of families were still in the program (three studies); 51 to 68 percent remained in the program through 12 months (seven studies); and after 24 months, 30 to 55 percent of families were still participating (three studies).


Lessons Learned

The studies reviewed discussed lessons learned about implementation, including lessons related to recruitment and enrollment, engagement and retention, the home visitor and family relationship, referrals, staff training and supervision, and program management (16 studies).

Recruitment and enrollment. Several studies reported on ways to improve recruitment and enrollment of families into HFA (five studies). One study recommended partnering with health clinics and physicians to expand referral networks. Other suggestions included targeting families from vulnerable populations, including pregnant women, first-time mothers, and low-income mothers (three studies). In contrast, one study recommended that the HFA intervention be made available to all mothers in the state. Another study recommended allowing mothers to enroll after their child’s first year, when children enter the toddlerhood stage of development.

Three studies focused on lessons related to the intake process. Families were screened and assessed to determine a child’s health and development status and to determine a family’s level of stress and high-risk behavior (two studies). Some families were concerned about screening questions covering sensitive topics, including history of abuse, substance use, and criminal activity; and the nature of the program (one study). To make participants more comfortable, the authors suggested that workers (1) provide a clear rationale for why the participant was selected; (2) emphasize that the program is not just for first-time, single, or low-income mothers; (3) explain the purpose of the screening questions; and (4) frame the program’s purpose within the broad goal of giving children a healthy start. One study noted that home visitors and staff members should be empowered to share the results of these assessments with families to better address psychosocial risks and challenging behavior. Another study stressed the importance of culturally competent intake workers.

Engagement and retention. Studies emphasized the importance of engaging and retaining families in order to provide needed services (11 studies). One study recommended focusing more on re-engagement of families than on initial engagement. Other studies recommended the following strategies to enhance participant retention: match families to a home visitor based on shared characteristics (two studies), address scheduling difficulties between home visitors and families (two studies), engage families in culturally competent ways (one study), and use assessments to determine the appropriate level of service intensity for families (one study). Studies also recommended that home visitors have flexibility in conducting the intervention, such as when and where they meet with families (three studies). One study recommended providing home visitors with the flexibility to continue to visit families who move out of the program’s catchment area.

Home visitor and family relationship. Studies described lessons related to the relationship between home visitors and families (eight studies). Relationship building and strong interpersonal skills were key to establishing trust with and supporting families (six studies). Both substance use in families and program staff turnover made building relationships with families difficult (two studies). One study reported that most participants viewed their relationship with their home visitors as more like a friendship than a parenting or teaching association, and placed value on having a trusting, informal relationship. The authors suggest that the relationships are like that of a traditional extended family and facilitate implementation of the model. Families viewed home visitors more positively and as more effective when they were flexible, stayed focused on the families and their needs, and helped support positive parenting behaviors (six studies).

Referrals to community resources. Some studies found that referrals to community resources were infrequent and occasionally ineffective because the resources were insufficient to meet the needs of the family, or because families were reluctant to accept the referrals (two studies). In one study, some families reported feeling overwhelmed by the wide range of service options presented to them. Families needed to negotiate with an array of health, early childhood education, child care, and family support providers that may not all have been working to achieve the same goal. The study suggested home visitors help families negotiate these services and collaborate with these other agencies and services to coordinate their attempts to achieve family-centered goals.

Staff training and supervision. Several studies reported implementation lessons related to staff training. One study found that home visitors felt adequately trained to support positive parenting behaviors, but they reported being unprepared to address parental risk factors such as maternal depression. Other studies recommended increasing home visitor training and supervision on maternal depression, how to provide emotional support to families, as well as providing home visitors with resources to make referrals to other community agencies (four studies). Another study discussed areas in which staff across several HFA programs indicated that they needed further training. These topics included leadership development, employee retention, infant mental health, substance use, and maternal depression, and to a lesser extent, cultural diversity, child development, creative outreach, family retention, and engaging fathers in services.

One study suggested that supervisors should carefully monitor home visitor caseloads and provide continual support and training on how to work with families with many risk factors and who have other psychosocial risks to help prevent home visitors from feeling overburdened by the needs of the families.

Program management. Several studies included lessons on program start-up and operation (10 studies). Studies noted the importance of assessing the performance of staff and the effectiveness of training, and engaging in quality assurance (five studies). One study recommended establishing a career ladder for home visitors to facilitate staff retention. Employing a workforce that has characteristics similar to those of the families the program serves might also help reduce staff turnover (one study). Studies cautioned that (1) documentation and paperwork can become burdensome for home visitors (one study); and (2) budget cuts can lead to increased staff turnover, which can impede relationships with families (two studies). One study recommended combining the home visitor and family assessment roles into a single position. Another study stressed the importance of clarifying expectations and increasing the transparency of systems and operations when an HFA program is implemented through a public/private partnership.