1. Name of Your Practice (Program Name)

BPS2011-6

AMCHP Best Practice Submission Form

BACKGROUND

1. Name of your practice (program name):

Every Child SucceedsEvidence-Based Home Visitation

2. Please provide a description/abstract of the practice you are submitting in 200 words or less which address the following 1.) Project goals 2.) Activities undertaken to develop the practice 3.) How was project/practice success measured 4.) What makes this a remarkable practice, and 5.) How will others benefit from learning about this practice.

Goals of the programinclude promoting positive birth outcomes, healthy child development, good parent-child relationships, safe and stimulating home environments and self-sufficiency.

Critical to developing our practice was determining the target population: single, low income, first-time mothers, who often lack access to healthcare. Engaging moms prenatally or just after birth allows ECS to impact the trajectory of high- risk children during the most important time in their development, ages 0-3.

From there, activities included implementing evidence-based home visitation models; building a robust data collection and reporting system to capture learnings; using continuous quality improvement techniques; and adding program enhancements to improve outcomes and respond to family and community needs – all leading to innovative strategies.

Every Child Succeeds assesses maternal and child outcomes by collecting data at every home visit (350,000+ to date) and analyzing these data over time. Outcomes of the program are well documented. To measure ECS’s significant impact on infant mortality, researchers used a case-control design (Pediatrics, 2007).

ECS’s commitment to rigorous evaluation, innovative applications, careful implementation and consistent outcome documentationare remarkable. Others will benefit from learning about this practice by understanding how adoption of continuous quality improvement in home visitation can lead to stronger outcomes.

3. What is the primary population focus for your best practice?Check all that apply.

Children

Infants/Newborns

Women

4. Please provide information about the location of the practice - i.e., is the practice state-wide or in one area of the state/community? What is the approximate sample size?

Every Child Succeeds operates in sevencounties: Boone, Campbell and Kenton counties in Northern Kentucky, and Brown, Butler, Clermont and Hamilton counties in Southwest Ohio.

5. Describe the audience or practitioner who would benefitfrom learning about this practice?

Maternal and child health administrators, leaders and practitioners

6. What is the primary issue focus(es) for your best practice?Check all that apply.

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BPS2011-6

Access to Health Care

Birth Outcomes

Data, Assessment, & Evaluation

Health Inequity/Disparities

Health Promotion

Intentional/Unintentional Injuries

Prenatal Care

Service Coordination & Integration

Substance & Tobacco Use

Workforce & Leadership Development

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BPS2011-6

7. Please describe the specific need for this practice, i.e.,what data or evidence do you have regarding your target population that shows this is a problem? Cite specific literature and local or state data as appropriate.

Every Child Succeeds was begun in an effort to address the emerging research of the time describing the critical nature of the 0-3 window for achieving the foundational brain development necessary for long-term successful outcomes in the lives of children. Optimal brain development is the result of proper childcare and nurturing, appropriate medical care, interactive experiences for the child and the maintenance of a safe and supportive environment during those years. Decades of research concludes that children born into high-risk homes face great challenges in achieving optimal development. In 2009, according to birth certificate records, in the seven counties ECS serves, 5,450 births were to first-time, at-risk parents (who would qualify for ECS services). The need in the community is for children born into at-risk homes to receive the safe, healthy, nurturing start they need to achieve the cognitive, physical, social and emotional development that is necessary for success in school and in life.

8. What are the overall goals and key objectives of your practice?

Every Child Succeeds is a collaborative program that provides home visits focused on proper child development for first-time, at-risk mothers, their babies and families on a regular basis from the time of pregnancy until the child's third birthday. ECS’s goal is to ensure that all children have an optimal start in life. Specifically, ECS works to achieve the following objectives: decrease abuse and neglect; reduce unintentional injuries; strengthen the parent-child relationship; improve utilization of diagnostic services; encourage good health practices; link families with primary care services; promote an optimal environment for learning and emotional growth; encourage the development and self-care of mothers; and begin the school readiness process. Furthermore, ECS aims to increase its effectiveness in meeting this goal year after year, through effective business operations, sustained and improved participant outcomes, and efficiencies of program delivery and costs.

DESIGN

9. What is the theoretical foundation (e.g., Social Change Theory) for your practice? List any theories used, and explain how they were applied. If multiple theories were used, explain how they fit together to form the basis of your practice.

Every Child Succeeds uses two national models of home visiting (Healthy Families America and Nurse-Family Partnership) that are augmented by organizational enhancements including continuous quality improvement, a strong public-private partnership, community collaboration, and integrated supplemental interventions (e.g., maternal Depression Treatment Program). The home visiting models are guided by several theories of prevention science. These include the ecological model which acknowledges contributions to risk and resilience from individual, family, community, and cultural sources; the transactional model from developmental psychopathology that emphasizes the dynamic interplay of risk and protective factors in child development; social learning theory that emphasizes social reinforcement and modeling as powerful tools for learning; and community participation research that underscores the importance of community involvement and collaboration for the building and sustaining of high impact social programs. Continuous quality improvement (CQI) is based on the Model for Improvement (adopted by the American Academy of Pediatrics and the Institute of Healthcare Improvement. This is a highly systematic approach to CQI, and to our knowledge we are the only home visiting program and prevention approach that has adopted this rigorous system and published in this area.

10. Did you base your practice on existing tools (guidelines, protocols, models or standards such as Bright Futures guidelines)? If so, please specify which ones and explain how they were used in the practice.

Yes, our practice is based on national, evidence-based models: Nurse Family Partnership/Partners in Parenting Experience (one provider agency), Healthy Families America/Parents as Teachers (13 provider agencies) and Bright Futures. These tools are used to provide practitioners with a solid grounding in the theories behind home visitation and with developmentally-appropriate information and activities to guide the practice with families.

11.How did you adapt these tools to your practice? Be specific about changes to the model that were made, portions that were not used, and why adaptations weremade.

We adapted these tools over time to make them more useable, to increase the focus of our program, to decrease variability and to enhance services. A brief description offour of the major adaptations includes:

ECS Home Visit Planning Guidesintegrate curricula and assist home visitors in preparing for visits with families. Guides are divided into four program phases: Prenatal, Infancy, Toddler and Preschool. The Guides address six domains: Parental Health, Parenting, Child Development, Personal and Environmental Safety, Social Supports, and Life Course Development. The Guides are structured to provide a comprehensive home visit. Training ensures that visitors use guides while allowing families to drive the service.

Quality Improvement:Using the Model for Improvement, we systematically collect data on multiple process and outcome indicators to reflect program impact. These data are produced monthly and quarterly in CQI formats including trend charts, red-green charts, and control charts. Data are transparent such that all agencies view their performance as well as their peers relative to program impacts. Improvement projects are conducted throughout the organization to conduct “small tests of change,” sometimes involving a single family or home visitor. PDSA (Plan-Do-Study-Act) cycles are implemented to identify new practices to improve performance. A key value of CQI is that it allows program to adapt evidence-based models to local conditions in a systematic and data-driven way. As a result, it is a solution to the inevitable problems encountered when evidence-based programs developed in highly controlled conditions circumstances are applied in real world settings.

Success Priorities: Identified activities and outcomes considered essential for the child’s development and family functioning. There are six Success Priorities for each developmental period: Prenatal, Infancy, Toddler and Preschool. Examples include: Breastfeeding, Medical Home, Child Development and Parental Education attainment. Each family receives a certificate at the end of each developmental period highlighting achievement of Success Priorities.

ECS/Avondale Partnership: We’ve adapted the intervention with a community engagement overlay in one of the urban communities surrounding Cincinnati Children’s Hospital Medical Center. Elements include community partnerships; Group sessions for mothers and fathers; creative outreach; and community penetration.

12. What was your process to incorporate peer/stakeholder input and lessons learned throughout the implementation? (Quality Improvement)

At its creation, Every Child Succeeds was born from a collaborative effort including a variety of community stakeholders. This is reflected by the three founding partners of the organization (Cincinnati Children’s Hospital Medical Center, United Way, Community Action Agency) as well as the multiple meetings of business leaders, early childhood specialists, and community organizations that occurred during the planning and implementation stages. ECS continues to engage the community at all levels of the organization. We are a transparent organization, consistent with the principles of continuous quality improvement. As noted, ECS has a robust CQI program that is “bottom-up” in its thinking and focuses improvement efforts based upon organizational and community input.

13. Describe your evaluation process, including short term and long term outcomes that were measured. Explain the methods of evaluation such as whether you used a controlgroup, how people were selected to participate in the practice, and the potential biases of this process.

The ECS evaluation and research plan was developed to meet the multiple objectives of the organization. As a “real world” community-based program with an integrated evaluation and research component, the evaluation and research plan had the following overarching objectives:

1. Provide reliable and valid data on child and family functioning in order to document outcomes.
2. Collect data on potential moderators and mediators of outcomes.
3. Use data to improve the program locally.
4. Use data to identify new areas of inquiry that are subsequently examined using rigorous designs and funded through external research grants.

Control Group and Design. It was recognized that a control group was important to answer specific questions about the effectiveness of the program and mediators and moderators of outcomes. Community concerns regarding a clinical trial design led to the decision to use a quasi-experimental design in which all participants would receive home visitation services and data would be collected with all participants.

Measures. Home visitation is designed to yield positive outcomes in a variety of domains. These include child health, child development, child social and emotional functioning, nurturant parenting, maternal substance use, and maternal lifecourse. Moreover, there are a number of factors that may moderate or mediate outcomes. As a result, there are numerous relevant variables that can be measured in home visitation. Selection of instruments was driven by the need to measure multiple domains to document key outcomes, feasibility, home visitor and mother burden, usefulness for home visitors in providing services, interest expressed by various ECS constituents, and cost. Some variables were selected based on hypotheses about their importance to functioning and outcomes (e.g., depression), while others were selected in anticipation of the need to document specific outcomes (e.g., immunizations) relative to benchmarks. We selected a battery of measures of child and family functioning that were designed to address and balance the needs described above.

Data Management. A robust and flexible data management system is essential for a successful evaluation and CQI program. We developed eECS, a web-based system uniquely designed to meet the needs of ECS. Home visitors gather and upload data to eECS, which in turn provides real time access to information by ECS administration and evaluators. eECS is used to provide standard reports to home visitors and agencies, generate invoices for billing, and manage data for subsequent analysis.

14. Does your best practice relate to any of the 18 National Title V/MCH Block Grant Performance Measures?

Yes:

• NPM #7: Percent of 19 to 35 month olds who have received full schedule of age appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Haemophilus Influenza, Hepatitis B.
• NPM#11: Percent of mothers who breastfeed their infants at 6 months of age.
• NPM#15: Percentage of women who smoke in the last three months of pregnancy
• NPM#18: Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester.

IMPLEMENTATION

15. What was the timeframe of your practice(i.e., implementation to completion or is it ongoing)?

Ongoing.

16. What did your practice cost in terms of resources (e.g, type/amount of personnel, funds, supplies/materials, etc.)? Include a calculation of cost per client.

Using a business model in a social service world has resulted in programming cost-effectiveness. The ECS program achieves the very positive outcomes noted here at an approximate cost of $2,600 per family, per year. Two other home visitation programs that also experience positive outcomes and success in their client populations, and on which we based our basic home visitation curriculum, provide a benchmark, which ECS is well below. Nurse Family Partnership reports an approximate cost of $4,500 per family, per year, and Healthy Families America reports $3,348 per family, per year.

17. If this practice involved collaboration, who were your partners?

Every Child Succeeds (ECS) is an organization that was founded in collaboration and has successfully operated via collaboration for ten years. The United Way of Greater Cincinnati (UWGC) took the lead in identifying a community need and then acting as the central organizer to pull together the community resources and leadership available to address this need. UWGC brought together Cincinnati-Hamilton County Community Action Agency/Head Start (CAA), for its extensive access to at-risk families in Greater Cincinnati, and Cincinnati Children’s Hospital Medical Center (CCHMC), for its research capabilities and academic rigor, to address this issue in which social health and medical health intertwine. To provide ongoing leadership, the three organizations agreed to form one central organization, dedicated to the selected population and drawing on the resources of all three founding groups: Every Child Succeeds (ECS) was born.

ECS was formed to act as the permanent central leader in addressing early childhood wellness. United Way continues to provide leadership as well as significant funding for ECS, and they further efforts by using their access to the public and private sectors to continuously shape the local social agenda. Representatives from UWGC, CAA and CCHMC sit on the ECS Board of Directors, thus providing ongoing leadership, direction and decision-making for our organization.

We decided to collaborate with existing social service agencies to fulfill our need for qualified home visitors, and we now partner with 14 agencies, located in various communities of Greater Cincinnati and Northern Kentucky. ECS provides training and an extensive curriculum for home visitors to follow with at-risk mothers and their children ages 0-3. In this model, ECS provides central management: dedicated resources for leadership, long-term planning, marketing, billing, fundraising and other operational activities. The agencies we partner with are decentralized service providers: they provide a large client referral base, a wider reach into the community, efficient and cost-effective service delivery and professional knowledge. Agency home visitors can focus solely helping families. A managing supervisor from each agency serves on the Lead Agency Council, two members of which serve on the ECS Board. In this way, the management structure allows for a fluid feedback loop of information between ECS partners, leaders, administration and the service providers. Sharing of best practice information and results at all levels of ECS operations ensures high-quality programming, which has ultimately resulted in our incredible outcomes.

18. Were there other factors in your state or community that influenced the launch of this practice (e.g., legislation, new leadership, release of data, etc)? Please describe how these contributed.

Brain research
ECS was formed in 1999 by a partnership among Cincinnati Children’s Hospital Medical Center, the United Way of Greater Cincinnati and Cincinnati-Hamilton County Community Action Agency. Leaders in these groups and in the local business community responded to research that clearly shows the birth to age three window as a time of incredible growth and development for a child – physically, emotionally and cognitively. Nurturing parent-child interactions are necessary for children to develop optimally and, without such, developmental shortfalls can be difficult or even impossible to overcome later in life. Poor access to healthcare and lack of appropriate care and nurturing at home put children at risk for slowed brain development, accidents and a disadvantaged start in school, leading to long-term academic struggles. ECS was created to give high-risk mothers a way to ensure an optimal start in life for their children.