Social worker conducting a home visit with a new mother

commentary

(The RAND Blog)

April 17, 2015

MIECHV Reauthorization: Recommendations from Research

Photo by lostinbids/iStock

by M. Rebecca Kilburn and Grace Evans

The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program was established as part of the Patient Protection and Affordable Care Act of 2010. The MIECHV program represents the first time that the federal government has allocated recurring funding specifically for home visiting programs meant to improve health, educational and other outcomes for young children and families. This program provides funding to states and tribal communities to support voluntary home visiting for families that are expecting a baby or have a child younger than kindergarten entry age.

Funding for MIECHV was recently extended through fiscal year 2017. As with the program's previous extension, Congress chose not to make policy changes to the program and simply provided additional funding. In the event that Congress decides to make policy changes to MIECHV in the future, research that has examined home visiting programs can inform possible recommendations.

First, consider a few features of MIECHV that are worth keeping.

A noteworthy feature of the MIECHV program is that it requires states to use 75 percent of their funding to support home visiting models that are evidence-based (meaning that scientific research has shown these models to be effective). By concentrating the majority of the MIECHV funding for direct services on models that have already been proven to improve outcomes for children and families, the chances are greater that MIECHV funds will have their intended impact.

But just using an evidence-based model does not itself guarantee that child and family outcomes will be improved—it is also necessary that the model be implemented well. The MIECHV effort recognizes this and complements its evidence-based program requirements with both implementation requirements and implementation supports to further raise the likelihood that states will realize the potential of home visiting. For the former, states accepting MIECHV funding are required to engage in some best practices in evidence-based program implementation, such as conducting needs assessments, identifying goals, collecting and reporting outcome data, and engaging in continuous quality improvement. The latter— implementation supports provided to states by the program— include training and professional development in a variety of formats such as webinars, an interactive website portal, and in-person consulting and training. In addition, the federal program has contracted with a technical assistance team that provides states with expert guidance on data collection, outcomes measurement, and other evaluation-related activities.

The MIECHV program allows each state to select home visiting models that best meet the needs of families in that state. The MIECHV program has designated 17 home visiting models as evidence-based, and there are many variations in the structure and goals of these models. Indeed, the research shows us that there is a diverse set of home visiting models that are effective. Home visiting models differ in the outcomes that they improve, the families they target, and the services they deliver, as well as in the programs' intensity and scale of operation. For example, models are designed to address a range of family outcomes, including child maltreatment, parents' mental health, and children's physical disabilities. Models can also vary by focusing on serving families with children of various ages, or a program can begin when the mother is pregnant.

Allowing states to select among a set of effective models also allows states to deploy models that are feasible in their context. The availability of a qualified workforce– those having certain skills or credentials— and other local contextual factors may play a role in determining which home visiting model is appropriate for an area. MIECHV allows states to determine their areas of greatest need and deploy evidence-based home visiting models tailored to meet these needs while keeping their available resources in mind. For example, states may choose to focus on helping infants with developmental disabilities or parents with substance abuse problems. The state can also evaluate local context and resources, such as the available workforce: For example, a program employing mental health clinicians as home visitors won't be feasible in an area lacking a pool of such clinicians. And local contexts that can be considered also include family demographics: For instance, a program without parent education materials in Mandarin may be impractical in areas with large ethnic Chinese populations.

When reauthorizing MIECHV, if Congress wants to maximize the likelihood of the program's success, it might also consider some additional features:

Include supports for the discovery and evaluation of new evidence-based models. While MIECHV includes a separate funding stream of competitive development grants that provides funding to states to test and evaluate innovations in home visiting, the program lacks a path by which these unevaluated models can ever be designated as evidence-based: There is no funding to actually evaluate the “promising” models. The requisite evaluations can be very expensive and represent a substantial barrier to the discovery of the next evidence-based model. The program's support for innovation and discovery of new evidence could be strengthened by better facilitating the evaluation of promising, potentially effective models.

Consider whether ongoing funding to particular states should be tied more closely to the state's implementation performance. Research shows that monitoring organizational performance measures—such as the number of families served and the number of open positions filled—and linking them to incentives in performance-based accountability systems is an effective component of improving public services. For example, while MIECHV funds come with many specifications and requirements, it's not clear whether there have been consequences— or additional support— to generate improvement when a project serves fewer families than specified in the proposal and award. Linking continued funding to the measured organizational performance of states and targeting technical assistance to states based on performance could further promote quality improvement.

Continue to evaluate the growing evidence base to resolve open questions about the value of home visiting. MIECHV includes requirements for rigorous evaluations at the national level as well as instructions regarding ongoing evaluation by state and tribal grantees. However, as the MIECHV data accumulate, there will be additional opportunities to examine the validity of rationales underlying public investments in home visiting. For example, because evidence indicates that home visiting can prevent negative outcomes later in children's lives, it could represent an opportunity for the public sector to shift from a treatment paradigm to a prevention paradigm: Could delivering home visiting on a large scale improve population level outcomes such as low birth weight rates or child maltreatment rates measured across a community or state? So far, home visiting services have not yet served enough eligible families to enable us to answer this question, but continuing analyses of MIECHV can help fill that gap.

Another yardstick of success for home visiting programs' effectiveness is cost-benefit analyses to show if society as a whole will yield returns from investments in the program. Evidence suggests that in addition to improving child and family outcomes, home visiting can reduce taxpayer costs in the long run by reducing future spending such as ER visits, special education, or foster care. Precise data on costs have not been collected for all the models, and many home visiting benefits, such as improvements in positive parenting practices, are difficult to monetize. Due to these limitations, only eight of MIECHV's 17 evidence-based models have been examined using cost-benefit analyses. For five of these models, the estimated benefits exceed the costs, because the home visiting programs reduced future government spending in areas like emergency room visits and child protective services costs, and increased tax revenues from parents' earnings. MIECHV can encourage more frequent collection of cost data and cost-benefit analysis to shed more light on the overall economic value of home visiting as well as the relative economic value of different models.

As written, MIECHV's authorization statute includes many features that suggest it would achieve its intended impacts. As Congress works to reauthorize the program, policymakers should preserve these components and consider changes that could further boost MIECHV's effectiveness. By maintaining requirements that the majority of state grants be used to implement evidence-based programs while allowing states the flexibility to consider their local needs and abilities, Congress improves chances that MIECHV will help improve outcomes for families. New funding supports for testing innovation in the home visiting field could add variety to existing evidence-based programs, and tying continued funding to state implementation performance would ensure that federal dollars are being used effectively. Continuing its emphasis on data and evaluation and expanding it to include population level questions and performing more cost-benefit analyses will also help answer some outstanding questions that underpin the rationale behind home visiting.


Rebecca Kilburn is a senior economist and Grace Evans is a legislative analyst at the nonprofit, nonpartisan RAND Corporation.

Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.