Implementing Resources, Education, and Care in the Home (REACH)

Last updated: June 2011

Model Overview

Implementation Support

The Resources, Education and Care in the Home (REACH) program was a multiagency service model developed by faculty and staff of the University of Illinois at Chicago and developed and implemented in collaboration with the Chicago Department of Public Health (CDPH), the Chicago Visiting Nurses Association (VNA), and Westside Future, a community-based social service agency.
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Theoretical Model

No information is available.
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Target Population

REACH targeted infants born to low-income teenage mothers, mothers with limited or no prenatal care, infants and mothers discharged early from the hospital, and families with psychosocial problems. Most REACH families resided in densely populated, low-income communities with public housing units.
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Targeted Outcomes

REACH was designed to prevent and reduce infant morbidity and mortality in high-need, high-risk Chicago communities.
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Model Components

REACH included case management provided by a hospital-based registered nurse case manager who coordinated mothers’ contacts with participating REACH agencies, made referrals to social service organizations, and provided counseling.


The first home visit occurred two weeks after hospital discharge and was conducted by a two-person team that included a community health advocate (CHA) and the registered nurse case manager. Each mother received a physical and psychological assessment and each infant received a physical and developmental assessment. The team also completed an environmental assessment of the home and observed mother-child interaction. Families with no identified acute issues during the first home visit received three subsequent visits at the infant’s age of six to eight weeks, 4 months, and 8 months. A public health nurse or aide from the CDPH collected information on the infant’s health and development. A final visit occurred at 12 months, during which the two-person registered nurse case manager and CHA team returned and conducted a physical and developmental examination of the infant, reviewed family program records, and verified immunizations.

If problems were identified during the first home visit, the family was referred to VNA. VNA conducted a home visit within seven days to address the identified issues; these families did not receive a visit at six to eight weeks. After the issues had been addressed, the family was referred back to the nurse case manager for reassignment to the standard program schedule.

Telephone or mail contact was used to check the outcome of referrals, address concerns voiced by mothers, confirm appointments and follow up regarding missed appointments, verify immunization status, and verify the most recent address. Monthly newsletters mailed to mothers provided age-appropriate information and reminded them to contact staff if they planned to move.

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Model Intensity and Length

REACH required home visits at the ages of two weeks; six to eight weeks; and 4, 8, and 12 months, with additional visits as necessary.

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REACH was implemented in six communities in Chicago, Illinois.

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Adaptations and Enhancements

REACH has evolved into a program called REACH Futures, which gives the community health worker a greater role in service provision and interaction with the family as part of a nurse-managed team.

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Implementation Notes

The information contained on this page was last updated in June 2011.

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