I wrote last week about the Prevention and Public Health Fund, which the Affordable Care Act (ACA) created to invest in improving overall population health – with the hope that improved health will help slow the growth of healthcare costs. Another provision of the ACA that aims to reduce future healthcare costs is “Maternal, Infant, and Early Childhood Home Visiting Programs” (Section 2951). Three studies published in the latest supplemental issue of the American Journal of Public Health address this type of program.
Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programs send trained professionals to the homes of parents of infants and young children to promote child health and development and reduce child abuse, neglect, and injuries. The Nurse-Family Partnership is probably the most widely known and extensively researched home-visit model; it enrolls vulnerable (generally, low-income and teenaged) first-time mothers while they’re pregnant and links them with public-health nurses who visit them during their pregnancies and the first two years of their children’s lives. The nurses provide “guidance for the emotional, social, and physical challenges these first-time moms face.” In the stories on the Nurse-Family Partnership website, that guidance ranges from teaching 17-year-old Shanice relaxation techniques and how to interpret her baby’s cries to equipping 19-year-old Amanda with self-confidence and an action plan to leave an abusive boyfriend. (For an even more in-depth story, read Katherine Boo’s fascinating 2006 New Yorker piece “Swamp Nurse.”)
Professor David Olds and his colleagues developed the nurse-family partnership model and conducted the first randomized trial of it in Elmira, New York. Followup studies conducted after the children reached age 15 found that the children whose mothers received visits had 48% fewer verified incidents of child abuse or neglect and were 58% less likely to have been convicted of a crime, while visited women had spent 20% less time on welfare.
Reductions in child abuse, criminal convictions, and time on welfare translate into public savings, as well as harder-to-quantify improvements in quality of life. A Washington State Institute for Public Policy analysis of a nurse-family partnership program for low-income families calculated that a program investment of $10,291 per participant yielded $22,781 in savings due to reduced crime, child abuse, disruptive behavior, substance abuse, and need for public assistance, as well as children’s greater likelihood of graduating high school and securing employment. That’s a net savings of $13,181 per participant, as well as a big reduction in suffering.
Birth spacing and enrollment factors
In a study just published in the American Journal of Public Health (AJPH), Katherine Yun and colleagues examined the impact of the Pennsylvania Nurse-Family Partnership on birth spacing for first-time Latina mothers. Short intervals between pregnancies are associated with higher risks for preterm births and low-birthweight babies, and the national 2020 Healthy People goals include reducing the number of pregnancies that occur within 18 months of a previous birth.
In this study, Yun et al used client data from 23 Pennsylvania NFP programs, welfare eligibility files, and birth certificate files to compare birth spacing in two groups: Latina women who were enrolled in an NFP program for their first child’s birth and who had received some form of welfare assistance in the previous year (the enrollee group) and demographically similar Latina women who had received some form of welfare but were not enrolled in an NFP program (the non-enrollee group). The study sample included women who delivered first-born babies in Pennsylvania between 2003 and 2007, with followup through the end of 2009 to identify subsequent births to the same mothers.
The researchers found a decrease in the risk of short interpregnancy intervals (18 months or fewer) for Latinas enrolled in the program compared to the nonenrollees. When considering all age groups in the sample, 22.9% of enrollees and 25.8% of non-enrollees had conceived second children within 18 months. When considering only those age 18 and under at first birth, the difference was greater: 24.3% compared to 28.9%. (Findings for both analyses were statistically significant.) The authors note that these effects “were smaller than those seen in an NFP randomized controlled trial that included a large cohort of Latina women,” but that the difference “might reflect expected changes in program effects after wide-scale implementation outside of the experimental setting … [or] secular trends, such as declines in the US adolescent birth rate over the past 2 decades.”
In discussing the study limitations, the authors note that although they used propensity score models to create a matched sample of non-enrollees, there might be unmeasured differences between the women who enrolled in the program and those who didn’t, which could bias the results. Factors influencing at-risk first-time mothers’ enrollment in a home visitation program are the subject of another study appearing in the same issue of the AJPH.
Neera K. Goyal and colleagues studied enrollment in the Hamilton County, Ohio Every Child Succeeds program, which sends visitors to at-risk mothers’ homes during pregnancy and the first year of the child’s life. The model emphasizes “early prevention during pregnancy, education in child development and health, parenting skills, and maternal economic self-sufficiency.” Women are eligible if they are unmarried, younger than 18, or low-income. Using vital statistics records and census data as well as referral and enrollment information, the researchers identified factors associated with referral and enrollment in the home-visitation program. They found:
Results demonstrated that referral was more likely among those with lower education and in women living in communities with higher levels of social deprivation. However, once women were referred to home visiting, enrollment was paradoxically less likely for those with lower education and higher community levels of social deprivation. This suggested that despite appropriate referrals among the target, eligible population, there was lack of engagement among women at highest risk who were perhaps most in need of home visiting.
Getting public-health services to those who can benefit from them most is often a challenge. In another study published in the same AJPH issue, researchers look at a program that takes a different approach: It seeks broad enrollment, and then targets more-intensive interventions to those most in need, rather than seeking to enroll only high-need participants.
Casting a wide net in Durham
Kenneth A. Dodge and colleagues examined emergency care episodes in a child’s first six months of life, comparing families randomly assigned to the Durham Connects program to those who were not. Unlike the more narrowly targeted home-visit programs, Durham Connects is available to families regardless of income (or other maternal characteristics) and whether or not the birth is a first birth. During the 18-month study period (July 1, 2009 – December 31, 2010), the families of babies born on even-numbered days were assigned to the program, and those with odd-numbered birth dates were not.
Durham Connects begins in the hospital when the mother gives birth and a staff member explains the program and asks for enrollment consent. Parents who agree to participate receive one to three home visits during the baby’s first 3-12 weeks and a staff member followup (by phone or in person) one month later. During their visits, nurses evaluate health and psychosocial risks in four areas known to affect child wellbeing: “(1) parenting and child care (child care plans, parent–infant relationship, and management of infant crying); (2) family violence and safety (material supports, family violence, and past maltreatment); (3) parent mental health and well-being (depression and anxiety, substance abuse, and emotional support); and (4) health care (parent health, infant health, and health care plan).” The nurses also provide up to 20 brief “teaching moments,” offer extended education on specific topics (crying, breastfeeding, etc.) as needed, and help connect families to relevant community resources.
Subsequent interventions vary depending on risk scores, with low-risk families receiving little further contact and those with higher scores receiving referrals to community services and followup communications. Those whose scores show imminent risk receive emergency interventions; only 1% of the families completing the program fell into this category.
The researchers obtained records from the two hospitals at which the participant births occurred and tallied the number of emergency department visits and overnight hospital stays the infants had in the six months following their initial release from the hospital. Their analysis found that Durham Connects infants had 59% fewer emergency medical care episodes in their first six months of life than did infants in the control group. Based on the costs of those episodes, they calculated that every dollar spent on the program saved $3.02 per infant in emergency-care costs in the first six months of life. “For a community the size of Durham with an average of 3187 resident births per year and a Durham Connects intervention cost of $700 per birth, a community annual investment of $2 230 900 in the Durham Connects program would yield a community-wide emergency health care cost savings of $6 737 318 in the first 6 months of life,” Dodge et al conclude.
The Durham Connects program, the authors note, was designed to be implemented at the population level, not just offered to a group of high-risk families. This universal delivery can reduce the stigma that can otherwise reduce enrollment in programs for low-income or otherwise at-risk mothers. Dodge et al also report that while home-visiting programs are promising, none has yet scaled up successfully. As scale-up occurs, penetration and retention can decline, while quality and fidelity can degrade. And, they point out, scaled-up programs rely on communities having sufficient resources to provide the services to which home visitors might connect eligible families. In contrast, they write, Durham Connects “was delivered universally in a mid-sized community with a high rate of poverty.”
Durham Connects is a nonprofit founded with support from Duke University, the Durham County Health Department, hospitals, the Department of Social Services, and the nonprofit Center for Child and Family Health; The Duke Endowment funded its multi-year pilot. In addition to Durham Connects, which is available to all local families, the county offers other programs for higher-need families, and Durham Connects nurses often help assure that eligible families obtain these additional services.
Uncertain outlook for federal funding
The Department of Health and Human Services (HHS) has been distributing the ACA-appropriated MIECHV money to state entities “that have implemented high-quality, evidence based home visiting programs.” Most recently, 13 states received a total of $69.7 million. Because the ACA requires that entities serving high-risk populations get priority when grants are awarded, programs like Durham Connects are unlikely to receive money from this funding stream. As research on the impacts of different home-visit models accumulates, communities may decide to seek other sources of funding for programs like Durham Connects that serve larger populations with lower per-participant costs.
The Affordable Care Act only appropriated funding for MIECHV programs through fiscal year 2014. Grantees are required to report to HHS by the end of 2015 on their improvements in benchmark areas, including improvements in maternal and newborn health; prevention of child injuries, abuse, and neglect; improvement in school readiness and achievement; and reduction in crime or domestic violence.
Maternal and child health advocates will be advocating for Congressional reauthorization of MIECHV program funding. Brent Ewig of the Association of Maternal and Child Health Programs notes that funding the program at existing levels for another five years would cost $2 billion, and still only reach a small portion of the eligible population.
As studies continue to demonstrate the long-term benefits of home-visit programs, local and state officials probably recognize that supporting these programs makes financial sense. However, with all states except Vermont having legal requirements for balanced budgets, it can be hard for states to make expenditures now for savings that will show up in future budget years. Although politics can make it hard for Congress to increase spending on public programs like MIECHV, there are no legal constraints on its ability to invest in children’s health today in order to reduce future unemployment and Medicaid spending. For lawmakers seeking to improve children's lives, supporting home-visit programs is one evidence-based way to do so.
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