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Implementing Family Connects

Meets HHS criteria for an evidenced based model

Materials and Forms to Support Implementation

Last Updated

April 2018


Operations Manuals

Family Connects is a manualized intervention. A tool kit and training manual provide information on community development, hiring and training, service delivery, and quality assurance.


Service Delivery Forms

Service delivery forms include an explanation of the privacy policy; a consent form for conducting home visits and sharing information with physicians and community agencies; a parent contact form; and forms for service referrals and recommendations. Depending on the implementing agency, additional forms for collecting medical record information might be necessary. Information is collected and stored in electronic databases:

  • A nurse database contains information on demographic and health information about the mother and baby; referrals made, existing services used, and medical home(s); and risk assessment results. 
  • A post-visit database contains parent-reported information on the outcomes of referrals made, new needs of the family, and customer satisfaction.


Assessment Tools

Home visitors administer the Family Support Matrix, a risk and needs assessment tool. The tool assesses 12 risk factors across the following four domains: (1) support for health care (parent health, infant health, and health care plans); (2) support for caring for the infant (child care plans, parent-child relationship, and management of infant’s crying); (3) support for a safe home (household safety and material supports, family and community safety, and history with parenting difficulties); and (4) support for parents (parent well-being, substance abuse, and social support). The home visitor also uses the tool to document an approach for addressing any identified risks or family needs, such as a follow-up home visit or community referral.

Additionally, parents complete three standardized screening tools to screen for depression (Edinburgh Postpartum Depression Scale), intimate partner violence (Conflict-Tactics Scale), and substance use (CAGE Adapted to Include Drugs or CAGE-AID). The screening tools are completed by the mother on laptops or tablets and scored instantaneously for discussion during the home visit.



Nurse home visitors follow a proprietary home visit protocol.


Available Languages

Materials, contact forms, consent forms, and screening tools are available in English and Spanish.


Fidelity Measurement

To obtain initial and re-certification as a Family Connects site, sites must document their adherence to the 13 essential model elements. To assess ongoing fidelity to the home visit protocol, supervisors review nurse home visitors’ family risk assessment interviews. This can be done in person during a visit or via an audio-recording. Supervisors independently complete a fidelity checklist and then conduct inter-rater agreement checks on a random sample of interviews. These fidelity checks are completed at nurse certification and quarterly throughout a year.


Fidelity Standards

Sites are required to adhere to 13 model elements:

  1. The local program is community-based, with community ownership, and is seen as part of the community continuum of care for newborns and their parents. There must be a community advisory board and ongoing stakeholder communications.
  2. The local program is universal. All families with newborns in a defined service area (a region, city, neighborhood, or health system) are eligible.
  3. Home visitors are registered nurses.
  4. The initial home visit includes a systematic health and psychosocial assessment of the family’s strengths, risks, and needs. 
  5. Home visitors are trained to provide systematic education in response to parent questions or nurse observations about difficulties adapting to the newborn (such as breastfeeding or the “baby blues”). 
  6. Home visitors provide other anticipated support and guidance, such as on the benefits of having infants sleep on their backs and spend waking time on their stomachs.
  7. Families and nurses plan for individualized connections to community resources, including referrals and direct links to the services. 
  8. There is an initial home visit with an option for one to two more visits and follow-up telephone calls, as needed, to complete the assessments, provide further intervention, and link families to local services and resources.
  9. One month after case closure, sites conduct a brief survey by telephone or email to inquire about client satisfaction and linkages.
  10. Available community resources are compiled in a web-based format and/or printed directory and updated regularly to identify gaps in community services.
  11. Sites must make a direct link with the local department of social services to facilitate the family’s access to and knowledge about eligible services, such and Medicaid and Supplemental Nutrition Assistance Program (SNAP, also known as food stamps) benefits.
  12. Systematic quality assurance includes monitoring of community penetration, protocol adherence, accurate assessment of family risks and needs, inter-rater reliability of the assessment tool, and consumer satisfaction.
  13. Sites have electronic documentation of the home visits, other contacts with families, and families’ community service needs.



The information contained on this page was last updated in April 2018. Recommended Further Reading lists the sources for this information. In addition, the information contained in this profile was reviewed for accuracy by the Family Connects National Service Office on January 10, 2018. HomVEE reserves the right to edit the profile for clarity and consistency.