Implementing Health Access Nurturing Development Services (HANDS) Program

Information in this section is based on studies included in the HomVEE review. For the Health Access Nurturing Development Services (HANDS) program, we reviewed eight studies, including four quasi-experimental designs (QEDs) and four standalone implementation studies. (Please see Studies for Implementation Experiences for a list of the studies and to link to the characteristics of the samples examined in the effectiveness studies.)

HANDS is a statewide Kentucky program that was first implemented in 15 pilot sites in 1999. Two of the implementation articles we reviewed were about the same study. Because of this overlap, we refer to these as one study. The two other implementation studies we reviewed were conducted approximately three and eight years after the pilot phase. Program features reported during the pilot phase may have been modified; therefore, subsequent studies may report slightly different information. The four QEDs we reviewed were about the same trial, so these are referred to as one study. Two of the QEDs focused on subsamples of participants in two different geographical areas in the state. However, we describe the characteristics of the full group of participants. Thus, we reviewed eight articles of four separate studies.

More than 20,000 participants enrolled in HANDS from 2000 through 2004 (one study). Another study reported that 2,253 women enrolled in HANDS from July 2011 to June 2012.

The main participants were mothers or expectant mothers. Families were eligible to participate through their child’s second birthday (all studies).

Most participants were white (86 to 88 percent across two studies), 8 to 9 percent were African American, 2 to 3 percent were Hispanic, and 1 to 3 percent were other or multiple races. None of the studies reported on the average age of participants.

Thirty-six percent of the mothers had completed high school or earned a General Educational Development (GED) certificate, 45 percent had dropped out of high school, and 4 percent had less than an eighth-grade education (one study). Another study reported that 33 percent of the mothers had less than 12 years of education.

Most mothers were unemployed and had annual incomes of less than $20,000 (75 and 92 percent, respectively) (one study). Seventy-eight percent of mothers received Medicaid, 5 percent had private insurance, and 92 percent received assistance from Women, Infants, and Children (WIC) (one study).

Most of the mothers (63 percent) were single, 33 percent were married or lived with a partner, and the rest were divorced or separated. Limited data on fathers indicated that most were employed and had attended at least some high school (65 and 79 percent, respectively) (one study).

Participation in the program was voluntary (three studies).

The program operated in Kentucky (all studies) and included an urban, rural, and suburban mix (three studies).

HANDS was implemented by county health departments throughout the state. Sites met regularly with a locally based interagency council representing local government, assistance agencies, local businesses, and health care providers (three studies).

Four types of staff implemented the program: (1) assessors evaluated potential clients’ eligibility for services, (2) program coordinators oversaw the program and supervised staff, (3) home visitors met regularly with families, and (4) clerical or administrative staff supported the program (two studies). HANDS also employed regional technical assistants to support sites (one study). To consolidate resources, staff in many counties served more than one role. Coordinators, for example, may have also functioned as assessors or home visitors, and some coordinators oversaw more than one county. Staff, particularly assessors, may have had other job duties in the health department besides HANDS. In some sites, interagency council members (such as obstetricians) referred clients to HANDS or helped train staff (pilot study).

Coordinators and assessors were mainly registered nurses (RN), licensed practical nurses, or licensed social workers. In one study, an RN or social work license was required to conduct the assessment. Home visitors were typically paraprofessionals with some public health background or had a bachelor’s degree in a related field (pilot study). Another study reported that both professionals and paraprofessionals served as home visitors. Professional staff included licensed public health nurses, social workers, college graduates with case management experience, and individuals with advanced training in early childhood education. Paraprofessionals were required to be at least age 18. Experience levels varied across sites, but most HANDS staff had prior experience in home health (typically as aides). Many home visitors, for example, had been involved in another statewide program that followed young pregnant women through their child’s first birthday (two studies).

All HANDS staff in the state participated in a pre-service training held at a central location (two studies). In the early implementation phase, the training lasted four days for coordinators and five days for home visitors and assessors. Program coordinators often attended more than one training. Pre-service training was described as interactive—with lecture, discussion, and role-playing—and trainees were assigned homework at the end of each day. Some implementing agencies and collaborating agencies provided additional training for home visitors. In some cases, additional training was offered to those staff who lacked prior experience in home health. Hospital staff in one county presented information on relevant topics, such as breastfeeding and infant nutrition (pilot study). Home visitors in at least a few sites shadowed another home visitor as part of their training (two studies). Another study reported that both professional and paraprofessional home visitors received pre-service training and that paraprofessionals received intensive ongoing training, particularly during the first two years of employment.

Coordinators supervised staff and were sometimes responsible for staff in partner counties (pilot study). Another study reported that paraprofessional home visitors were supervised by a licensed public health nurse or social worker. The format for supervision was not standardized, resulting in varied quality across sites (two studies). However, as part of later implementation, the frequency and length of supervision was standardized, and supervisors typically reviewed charts, caseloads, and case-specific issues, and documented their discussions with staff on a standard form. Some supervisors viewed this time as an opportunity to mentor home visitors. Technical assistants were available to support supervisors in their role (one study).

Caseloads varied considerably across sites. In one site, for example, staff had an average caseload of 15 to 18 families. In another, staff had a caseload of 30 families, including some who persistently missed appointments. Sites attempted to distribute caseloads evenly across staff, and some overbooked staff to account for likely program dropouts. Staff were expected to complete more than three visits per day, though two visits was more realistic (one study).

HANDS was modeled after the Healthy Families America program and was designed to be consistent with the Hawaii Healthy Start initiative. HANDS adapted the Hawaii Healthy Start model to follow children until age 2 instead of age 5 (two studies).

 

HANDS staff conducted home visits to help parents develop parenting skills and meet basic needs, such as housing, food, and health care. Program services were offered beginning during pregnancy or up to three months after delivery until the child’s second birthday (one study). Home visits were frequent at first and tapered off as parents reached important milestones in developing parenting skills or self-sufficiency (one study). Visits occurred monthly during pregnancy and weekly for at least two months after the child’s birth. Parents met with home visitors biweekly or monthly at later stages, with telephone calls between visits. Visits could be more frequent for mothers with difficult pregnancies or few supports (pilot study). There was also an option for a less intensive structure, although HANDS still emphasized to staff that they should be persistent and creative in engaging hard-to-reach families (one study). In addition to home visits, one site created a support group for the mothers so they could connect with other mothers (pilot study).

Clinics within the health department, and sometimes primary care providers, screened first-time pregnant women and referred those who demonstrated a minimum level of need to HANDS for a thorough assessment (two studies). To be eligible for the program, women had to have at least two risk factors, including unemployment, isolation, history of substance abuse, unstable housing, limited parent education, domestic violence, poor prenatal care, or maternal depression (one study). A HANDS assessor evaluated women based on their financial situation, level of education, living situation, and pregnancy history. Both parents were encouraged to attend, although, in most cases, the mother attended alone or brought her mother. The assessment lasted one to two hours and covered knowledge of child developmental milestones; attitudes toward physical punishment; knowledge of discipline alternatives; childhood history, including any history of abuse; and relationship with the child’s father. Responses were scored with a detailed scoring system. Women who were not invited to participate in HANDS because they were at lower risk were given reference materials about other health department programs that targeted new mothers (pilot study). Another study reported that the assessment covered perceptions of the new infant, parental substance abuse, poor mental health, current stressors, parental history of abuse as a child, coping skills and support system availability, anger management skills, plans for discipline, unrealistic expectations of the child, and the child being unwanted or at other risk for poor bonding.

HANDS visits were flexible, yet structured to include specific topics that matched the child’s developmental stage (one study). Visits focused on the quality of parent-child interaction, parental sensitivity to the growing infant’s needs, and general knowledge about child development. HANDS emphasized home safety and a positive social and psychological home environment. HANDS eventually used a standardized curriculum, called “Growing Great Kids’ (one study).

Some Spanish-speaking families were assigned to a bilingual home visitor (one study).

 

None of the studies reviewed included information on adaptations or enhancements.

None of the studies reviewed included information on the level of services participants actually received.

Most visits lasted about two and a half hours (including travel time and logistics). It took two to three years for most participants to complete the curriculum, although not all participants completed all the components (one study).

Three studies contained several lessons about implementing the model, including (1) developing the worker-family relationship; (2) targeting services; (3) staff structure, qualifications, and training; and (4) other programmatic features.

Developing the worker-family relationship. Building trust between the home visitor and parent was critical to a quality relationship, which in turn was necessary for engagement (three studies). Families were more open to services after workers clarified the program’s mission, convinced families they were not related to child protective services, and demonstrated their commitment to the family’s welfare (one study). Matching families to home visitors based on their personalities, style, and culture was important (two studies).

Two studies suggested similar steps home visitors could take to develop the relationship. These steps included (1) introduce themselves to the family during the assessment (even if briefly); (2) get to know extended families, if appropriate; (3) set expectations for the program’s services; (4) show enthusiasm for the program; (5) offer ideas, rather than directives, to empower families; (6) share personal experiences; (7) be relaxed, nonthreatening, and nonjudgmental; (8) provide parents with a calendar listing home visit dates and times; (9) act “at home,’ regardless of the meeting location, to show acceptance; (10) provide concrete assistance, such as helping parents navigate the social services system, access tangible services, and provide specific tips on child rearing; (11) accompany parents to appointments and help them mediate experiences with physicians; (12) research answers to questions they do not know to show commitment; and (13) focus on the needs of the children and the caregiving role of the parent, not the parent’s lifestyle choices. It is also important to empower families by setting boundaries and helping families overcome a sense of disenfranchisement, while displaying confidence (one study).

Targeting services. Three studies described lessons or gave recommendations to help sites better target families.

• Home visitors should be persistent in trying to reach families, but should also honor resistance from families unwilling to participate, and emphasize to child protective services that families must enroll voluntarily. Staff should increase awareness of HANDS through the media, schools, and community centers (one study).
• Families who were ambivalent or not fully engaged at the initial assessment never fully engaged, and some families who enrolled never intended to participate. Staff questioned the justification for persisting in trying to reach these families. In general, families with extremely high needs and chaotic lifestyles, as well as those with stronger support systems and more physical, intellectual, and emotional resources, were difficult to retain. Families in which the mother returned to work or school, or had prior involvement with child protective services, were also more likely to exit early. Hispanic families with relatively stable living situations were less likely to leave the program (one study).
• Staff exercised subjectivity in assessing a client’s needs and determining who should participate. Some staff felt that the eligibility requirements were too stringent, so they would help a mother become eligible (one study). Some staff felt the program should be expanded to non-first-time mothers and other primary caregivers (two studies).

Staff structure, qualifications, and training. It is important to have a bilingual home visitor to promote family-home visitor bonding (two studies). Bottlenecks and logistical challenges emerged from requiring staff to serve dual roles or have job duties outside of HANDS and the increased travel burden to program coordinators serving more than one county (pilot study). Two studies suggested HANDS staff receive training on (1) child-rearing, (2) establishing boundaries while developing a rapport, (3) reporting dangerous behavior and drug use, (4) building relationships, and (5) facilitating engagement. Staff would welcome refresher trainings, retreats, and brainstorming sessions, in part to help overcome their sense of isolation. Staff also reported that they benefited from shadowing other home visitors (one study).

Other programmatic lessons. A few additional programmatic lessons emerged across studies.

• Streamline the assessment process because staff felt it was lengthy, intrusive, and off-putting (one study).
• Staff need to be flexible when scheduling home visits and honor requests to change an appointment (three studies).
• The following may increase attrition: staff turnover, delays between the parent’s initial expression of interest and receipt of services, and reducing the frequency of visits when parents graduated to a higher level. Staff suggested adding incentives, such as children’s toys or baby supplies, to improve completion rates (one study).
• Two studies described the varied role of interagency councils. Counties with fewer resources viewed collaboration with local agencies as a necessity, whereas counties in which collaboration was new did not (pilot study). Staff should prioritize and improve the collaborations, in part by resolving typical issues, such as frequency and content of meetings (one study).