Implementing SafeCare®

Entries in this row combine information across all versions of SafeCare. Only SafeCare Augmented meets HHS criteria for an evidence-based home visiting model. For SafeCare itself, there are no manuscripts about high- or moderate-quality impact studies. Some other versions of SafeCare have at least one such manuscripts. Planned Activities Training (a SafeCare module) and Cellular Phone Enhanced Planned Activities Training (a SafeCare module with an add-on) show evidence of effectiveness.

Last updated: July 2018

This report summarizes information on how a given model was implemented in the studies reviewed. The report includes only information provided in (1) implementation studies and (2) effectiveness studies that rate moderate or high. These studies vary in the level of detail they provide about implementation features. Thus, the report does not provide an exhaustive picture of how the model was implemented across the programs studied. HomVEE notes, in the text or in parentheses, the number of studies that reported information on a given implementation feature.

Implementation experiences

Summary of sources

Information in this section is based on studies included in the HomVEE review. For SafeCare,* we reviewed 11 studies, including 4 randomized controlled trials, 1 single-subject study, and 6 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.)

In the following sections, we consider all pieces of research about a particular sample to be a single study. For example, three publications were based on the same group of participants and are cited as one study. There are 10 distinct samples across the 11 publications.

*SafeCare did not meet HHS criteria for an evidence-based model. Only SafeCare Augmented (an enhancement of the SafeCare model) meets HHS criteria for an evidence-based model. In addition, Planned Activities Training (a SafeCare module) and Cellular Phone Enhanced Planned Activities Training (a SafeCare module with an add-on) showed evidence of effectiveness.

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Characteristics of model participants

The primary participants were mostly mothers; some sites served only mothers (three studies) and some included fathers (two studies).

The average maternal age ranged from 26 to 28 years (four studies). The average child’s age ranged from 3 to 5 years (three studies).

The programs served racially and ethnically diverse families (four studies). The percentage of program participants that were African American ranged from 7 to 83 percent. The percentage of program participants that were white ranged from 8 to 38 percent. The percentage of participants that were Hispanic ranged from 6 to 64 percent.

The percentage of program participants who were unemployed ranged from 31 to 50 percent (two studies). About 30 percent of participants were full-time students, 30 percent worked full or part time, and 18 percent were full-time homemakers (one study). About 60 percent of participants had a high-school diploma or general equivalency diploma (GED) (two studies), and 38 percent received Temporary Assistance for Needy Families (TANF) (one study).

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Location and setting

Programs were located in several states, including the following:

  • California
  • Georgia
  • Indiana
  • Kansas
  • Oklahoma
  • Washington

One program was located in Kansas City, but the state was not specified.

Implementing agencies included a local nonprofit social service organization and state agencies with active contracts to provide family preservation services in one or more counties.

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Staffing and supervision

SafeCare employed service providers from diverse backgrounds, such as graduate students, undergraduate research assistants, nurses, and caseworkers (five studies). One program manager was a graduate student who hired and supervised behavioral parenting specialists (one study). Most of these specialists had recently received their bachelor’s degrees; others were graduate students in psychology, behavior analysis, counseling, education, social work, and other related fields.

The behavioral parenting specialists had to have at least a bachelor’s degree and one year of human service experience. They were supervised by a licensed psychologist (one study).

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Model services

The program included only home visiting (six studies). According to the studies that reported this information, home visits encompassed baseline and follow-up assessments, observations, and trainings with parents (five studies). The parent training included three modules: health, home safety, and Planned Activities Training, which focuses on parent-child interactions. During the parent trainings, home visitors explained the rationale for each concept, modeled the concepts for the parents, encouraged the parents to practice the steps, and then provided feedback (three studies). Each module was intended to be covered over five weeks (one study). The Planned Activities Training module consisted of five to seven sessions conducted about weekly (one study).

The full service period was intended to last 18 to 20 weeks, depending on parents’ progress in meeting skill-based criteria for each module. Home visits were intended to occur weekly and last one to two hours (two studies).

One study described a streamlined version of the home safety module received by families enrolled in Project 12-Ways, a precursor to SafeCare. The module was designed to reduce home safety hazards to children younger than 5 years old. The program covered up to five topics from the Home Accident Prevention Inventory (HAPI): poisoning by solids and liquids; suffocation by mechanical objects; fire and electrical hazards; suffocation by ingested objects; and firearms. The streamlined version of the module included (1) an audio slideshow to instruct parents on relevant home safety hazards and model ways of making the hazards inaccessible, such as installing safety latches; (2) self-feedback stickers, designed as a white circle with a red circumference and diameter representing “No’ to place on storage areas accessible to children; (3) home safety accessories including safety latches, electrical and switch plates, and electrical tape; and (4) a home safety review manual consisting of images from the slideshow and guidelines for using the “No’ stickers and safety accessories. Counselors from Project 12-Ways visited homes twice per topic and made unannounced follow-up home safety checks about every two to three weeks until families completed Project 12-Ways. Counselors assessed home safety using the HAPI during each visit.

One study described the Planned Activities Training module of the model. The module aimed to teach parenting strategies to improve parent-child interactions and prevent challenging child behavior. Parenting strategies included establishing limits and rules, planning and explaining activities in advance, and employing positive interaction skills.

The families that enrolled in SafeCare were assessed in various ways, such as via questionnaires, direct observations of parent-child interactions, and direct behavioral assessment of parents’ health care skills as well as home safety (five studies). The assessments took place at the start and end of each of the three modules (health, home safety, and Planned Activities Training).

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Model adaptations or enhancements

Four of the studies reviewed were based on (1) an enhancement to the SafeCare model, (2) a SafeCare module with an add-on, or (3) an adaptation of the SafeCare model.

SafeCare Augmented. SafeCare was augmented with Motivational Interviewing plus additional training for home visitors to identify and respond to imminent child maltreatment and risk factors of substance abuse, depression, and intimate partner violence (two studies). As part of the enhancement, called SafeCare Augmented, monitors certified by the national developers trained and observed home visitors for model fidelity, and a member of the Motivational Interviewing Network of Trainers provided pre- and in-service motivational interviewing training. Local experts in intimate partner violence, substance abuse, and mental health provided ongoing case consultation. SafeCare Augmented was further modified for high-risk rural communities (one study).

Cellular Phone Enhanced Planned Activities Training. In addition to receiving the Planned Activities Training module sessions via home visits, Cellular Phone Enhanced Planned Activities Training participants received a cell phone at their initial visit to facilitate contact with their home visitor (one study). The Cellular Phone Enhanced Planned Activities Training guidelines recommended that home visitors call participants between home visits (about once a week); send twice-daily text messages (about 10 messages a week); and encourage parents to call for advice, information, or support. The timing, duration, and frequency of calls was guided by parent preferences, although the home visitor attempted to ensure that no more than five days passed without a home visit or telephone contact. During telephone calls, home visitors asked open-ended questions about how the parents were doing generally and with their practice of Planned Activities Training strategies as well as about the parents’ interactions with their children and their children’s behavior. Text messages reinforced the parents’ use of Planned Activities Training strategies. Home visitors individualized text messages based on the focus of their recent home visits.

UCLA Parent-Child Health and Wellness Project. The UCLA Parent-Child Health and Wellness project adapted a variant of the SafeCare model for an Australian context (one study). Several adaptations were necessary. Language was changed to reflect Australian usage, such as changing the word “crib’ to “cot.’ The content was modified to reflect cultural differences, including making a section on firearms optional. In addition, all project materials were checked with Australian agencies and altered to conform to Australian standards. For example, the original curriculum teaches the use of sunscreen to prevent sunburn whereas Australia recommends covering up and keeping out of the sun between 11 a.m. and 3 p.m. Finally, the project materials were checked by a small advisory group of parents with intellectual disabilities for readability and presentation. On their advice, color and graphics were added and language simplified to increase accessibility and enhance interest for parents with low literacy skills.

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None of the studies reviewed included information about (1) how many home visits program participants actually received, (2) the length of the visits, or (3) the average duration of participants’ enrollment in SafeCare.

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Lessons learned

Two of the reviewed studies described several lessons learned about implementation: (1) fidelity monitoring is crucial to the achievement of successful implementation (two studies); (2) participants prefer in-person home visits, rather than a mix of video and in-person trainings (one study); and (3) at-risk participants are more responsive to direct-learning strategies (one study).

In another study, authors interviewed SafeCare providers in 11 sites to learn what adaptations their programs were making to better serve diverse families and what additional adaptations they felt were needed. Authors found that, overall, providers perceived the model to work well with diverse populations and did not recommend systematically adapting the SafeCare intervention for specific populations. Instead, providers recommended individualizing SafeCare for specific local populations or families, an approach they were already taking. The modifications that providers made to individualize SafeCare for local populations and families point to lessons about (1) strategies for family engagement, (2) the accessibility of materials, and (3) the need for flexibility in scheduling sessions.

  • Family engagement. Providers emphasized the importance of engaging families and gaining trust during initial visits. Some providers observed that matching families to home visitors based on language was critical for engagement, and that matching based on race or ethnicity could help improve engagement. For families with extensive histories with child protective services, providers suggested explaining mandatory reporting requirements to build open communication and trust.
  • Accessibility of materials. Providers recommended making the materials more accessible by reducing their literacy levels, incorporating more pictures, adding culturally specific examples, and improving translations. Authors noted that lowering literacy levels and adding pictures could be valuable to SafeCare participants of all backgrounds.
  • Service flexibility. Providers recommended being open to meeting outside of families’ homes and being respectful of families who missed appointments for ethnic celebrations or rituals.

In a study of a statewide effort to integrate SafeCare into the state child welfare system, 295 individual providers of direct child welfare services from 50 private agencies were trained to deliver SafeCare. In that state, public child welfare workers investigated child maltreatment and then typically referred cases to direct child welfare service providers at private agencies. Researchers found that although providers were able to perform well during training and implement SafeCare in the field with high fidelity, the level of implementation was low: only 25 percent of providers implemented SafeCare following training. Researchers noted that even with free training and support, broad-scale implementation could not be achieved without planning at the organizational and systems levels. Specifically, providers noted two problems: (1) local child welfare staff were less aware of SafeCare than other existing programs and (2) SafeCare was added as a distinct service requiring referral (rather than being integrated into an existing program) and therefore competed for referrals with existing programs. The study authors noted that sufficient awareness about SafeCare was more difficult to achieve in larger states with many counties and agencies.

Authors of a study of SafeCare Augmented suggest that training providers to identify and address risk factors such as depression, substance use, and domestic violence can help initiate and maintain family engagement.

The study of the development and initial testing of Cellular Phone Enhanced Planned Activities Training described implementation lessons. The study authors reported that mothers responded positively to Cellular Phone Enhanced Planned Activities Training, feeling that the number of messages and calls was “just right.’ Of the various types of texts received, mothers were more likely to respond to texts asking a direct question rather than those offering a supportive comment or a Planned Activities Training prompt. Parents reported especially liking messages that suggested family activities to do in the community; parents often reported attending events that they otherwise would not have.

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