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, home visitor satisfaction, and program management.
Recruitment and enrollment. Several studies reported on ways to improve recruitment and enrollment of families into HFA (seven studies). One study recommended partnering with health clinics and physicians to expand referral networks. Another study recommended that programs develop relationships with local social service departments because child welfare–involved families may be interested in and benefit from home visiting services. If a relationship was established, this study suggested that social service agencies might be encouraged to refer expecting or new mothers to the program. Other suggestions included focusing on families from vulnerable populations, including pregnant women, first-time mothers, low-income mothers, and child welfare–involved families (four studies). In contrast, four studies recommended broadening the focus population. One of the studies 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. The third study found that families with more than one child participated similarly to families with only one child. The findings suggest that families with more than one child should not be ineligible due to engagement concerns because they may be as likely as families with one child to successfully complete services. The fourth study noted that focusing on families with one child excludes families who could benefit from services.
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 (15 studies). One study noted that retention was affected by factors such as participant mobility, immigrant status and deportations, incarceration, homelessness, and the poor quality of follow-up information. Another 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), consider the family’s needs when determining the appropriate level of service intensity for families rather than relying on a standard programmatic requirement (two studies), engage families in culturally competent ways (one study), and support home visitors in tailoring services to the needs of the families (one study).
Studies also recommended that home visitors have flexibility in conducting the intervention, such as when and where they meet with families (four studies). One study recommended providing home visitors with the flexibility to continue to visit families who move out of the program’s catchment area.
Two studies focusing on father engagement observed that residential fathers—those who lived in the same household as the children—were more likely to attend home visiting sessions. However, home visitor caseloads included several father types such as biological resident, biological non-resident, non-biological resident, and non-biological non-resident. Therefore, the authors suggest that model developers and programs consider training home visitors on engaging with different father types (one study). Another study used several strategies to engage fathers in the program. Strategies included hiring male workers, changing visit times to accommodate fathers, training workers to include fathers in home visiting, providing separate home visits for mothers and fathers held at the same time with two home visitors, scheduling one-on-one sessions with the father and child, and hosting a fathers’ group where home visitors provided fathers with information on parenting skills, child development, and other topics of interest.
Another study observed that no teenage mothers completed the program, which suggested that the program might not meet the unique needs of this population.
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. Two studies found that home visitors felt adequately trained to support positive parenting behaviors, but home visitors reported being unprepared to address challenges such as maternal depression and child abuse. One of these studies noted that home visitors felt that the amount of information provided during their initial training was overwhelming, and they requested that training focus on specific challenges they may encounter. Several studies reported that home visitors expressed a need for more training on the following topics (seven studies):
- Recognizing the symptoms and understanding diagnoses and medications for mental health issues, such as maternal depression and substance use (seven studies);
- Providing emotional support to families (four studies);
- Making referrals to other community agencies (four studies);
- Understanding child development (one study);
- Understanding infant mental health (one study);
- Child abuse reporting processes (one study);
- Understanding the needs of teenage parents (one study);
- Understanding and interpreting assessments (one study);
- Retaining families and engaging fathers (one study);
- Accessing community resources and programs (one study);
- Completing paperwork (one study);
- Leadership development (one study);
- Employee retention (one study);
- Creative outreach approaches (one study); and
- Understanding cultural diversity (one study).
To strengthen home visitor competence, one study noted a need for ongoing training that links the intervention’s theory with program implementation.
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. Another study recommended that in addition to serving monitoring and accountability purposes, supervision should be reflective, individualized to the home visitor, flexible, and need-based. This study suggested that supervision take a more administrative and clinical approach while focusing on challenging cases rather than discussing entire caseloads. This study also suggested that supervisors make themselves available to meet at a pace and frequency that works best for a particular home visitor.
Home visitor satisfaction. One study recommended that programs have a prescribed curriculum or a set of standard curricula. This study found that when home visitors had a prescribed curriculum, they reported greater job satisfaction, may have experienced less stress, and felt more comfortable performing job tasks.*
Program management. Several studies included lessons on program start-up and operation (14 studies). Studies noted the importance of assessing the performance of staff and the effectiveness of training, and engaging in quality assurance (five studies), although another study noted that assessing implementation fidelity is challenging because of HFA’s flexibility in content and structure (one study). 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 also cautioned that (1) documentation and paperwork can become burdensome for home visitors (two studies) 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.
If programs chose to enroll multiparous families, program mangers recommended that they be assigned to more experienced home visitors because the families often have more complex needs (one study).
Another study found that more than one-third of home visitors were providing case management and other supportive services even though these activities are not described in the model guidelines. The home visitors noted that sometimes families’ basic needs had to be addressed before the home visitor could introduce the curriculum. The author recommended that programs acknowledge the potential need for case management services and encourage home visitors to discuss with their supervisors how to address families’ need for support services.
*HomVEE did not review the rigor of the design used in this manuscript because the analysis did not include a comparison group.