Mother and child

Introduction to Getting To Outcomes® for Home Visiting

Getting To Outcomes® for Home Visiting (GTO-HV) is an approach to program planning and management aimed at supporting communities and other groups who are interested in implementing a home visiting program. We define a program as a set of activities that comprises a well-defined curriculum and supports clearly stated goals.

You might be reading this manual because you are considering implementing a home visiting program in your community. Or you may have already determined that you will be implementing a home visiting program and must decide between the many options available. You may have explicit direction from funders or constituents specifying the types of outcomes that must be improved, or even the exact program that must be implemented. This manual provides support and useful tools for any of these situations.

The first GTO manual was published by the RAND Corporation in 2004, to help communities develop or improve substance abuse prevention programming (Chinman, Imm, & Wandersman, 2004). From there, GTO was made into an implementation support intervention that included three elements:

  1. A GTO manual
  2. Training
  3. Technical assistance.

Since the first GTO manual was published, GTO interventions and their related manuals have been developed for other programs aimed at different content areas. These content areas include teen pregnancy, underage drinking, homelessness, children's mental health, and emergency preparedness. This manual focuses on home visiting programs specifically. It is important to note that the steps described in this manual can be applied in any program, including broader policies, strategies, or initiatives.

GTO has been recognized as one of the leading frameworks for improving the performance of health and human services. For example, the 2004 manual was given the Outstanding Publication Award from the American Evaluation Association in 2008. It is being used by the Centers for Disease Control and Prevention (CDC) to structure the organization's teen pregnancy prevention efforts in multiple community-based settings. As of September 2012, the original GTO manual has been downloaded over 100,000 times from the RAND Corporation website.

GTO first and foremost promotes accountability. We define accountability as the "systematic inclusion of critical elements of program planning, implementation, and evaluation in order to achieve results" (Chinman, Imm, & Wandersman, 2004). Funders and the general public are increasingly demanding this type of accountability, in which programmatic decisions are made with the goal of attaining the greatest impact possible. Achieving the greatest impact is about consciously connecting all of your decisions and actions to the results you want.

Research has shown that the GTO intervention improves program staff's ability to deliver high-quality programs and ultimately improves the overall quality of human service program delivery (Chinman, Tremain, Imm, & Wandersman, 2009; Chinman et al., in press). That research showed that the three elements of GTO (the manual, training, and technical assistance) worked together to achieve success. Therefore, it is recommended that this GTO manual be supplemented with training and technical assistance, where possible, to achieve the maximum impact.

How to use the GTO-HV manual

We strongly recommend that you read through the manual in its entirety before proceeding further. An understanding of the whole process from beginning to end will help you to understand the role of each step in the process and to make decisions along the way that are right for your community.

After this and another introductory chapter, this manual is organized in chapters representing 10 steps that will help guide your planning, implementation, and evaluation processes. The steps are:

  1. Identify the needs and resources that already exist in your community.
  2. Identify goals and desired outcomes based on what you found in Step 1.
  3. Find programs that help you achieve your goals.
  4. Review program choices for best fit.
  5. Determine the capacities needed for implementation.
  6. Make a plan for implementation.
  7. Evaluate the implementation process.
  8. Evaluate the outcomes of the program.
  9. Improve the program with Continuous Quality Improvement (CQI).
  10. Plan for program sustainability.

Each of the 10 steps includes

  • an explanation as to why your community would want to complete each step, and how it can help you maximize your results
  • suggested methods on how your community might go about addressing each step and supporting tools to help you in this process
  • an example of how a fictional community, Townville, went through the step
  • a discussion of how the step links to other steps within the GTO model.

We have included in the manual some extra materials, over and above the basic information you need in each step. We have indicated these sections with icons to identify what sort of help each section offers:

checklist icon

Checklists: things to think about before you begin the program and as you complete each step.

town icon

Townville examples: the work completed by one imaginary town as its leaders planned, implemented, and evaluated a Getting To Outcomes for Home Visiting program.

tip icon

Tips, resources, and other helpful extras: advanced tips, lists of resources, examples, and more. We shorten the name of this category to "Tips" within the manual.

tools icon

Tools: worksheets to help you plan, implement, and evaluate your program.

Remember that GTO is useful at any stage of a program's lifecycle. While the steps are numbered and there is an overall order to them, you may need to skip around and pick and choose depending on your particular needs. In general, Steps 1 through 6 address issues prior to implementation, and Steps 7 through 10 address the period after implementation has begun. However, the steps should be revisited regularly over time.

Because GTO can be used and revisited at any stage of program implementation, you can think of the steps as a "painter's palette" of elements from which you can choose to plan, implement, and evaluate your program. The diagram on the next page shows each of the 10 GTO steps (they are abbreviated in the graphic), represented as a painter's palette.

Tip A. The 10 GTO Steps Are Like a Painter's Palette

The 10 GTO Steps

What is home visiting?

Raising a child is an important and challenging job, and all parents and other caregivers need information, skills, advice, and encouragement to be successful. Families with additional risk factors, such as poverty, lack of social support, substance use, or teen parenthood, face an even more difficult path. Home visiting programs are designed to provide the information, skills, and support that help parents raise healthy, happy, and productive families.

A home visiting program is a program that is delivered in the home to provide individuals and families from diverse backgrounds with an established curriculum of information, skills, social support, and other forms of assistance. In this manual, we focus on home visiting programs for families of young children; home visiting programs also exist for other populations, such as the elderly.

Many different home visiting programs exist, and these programs can be quite diverse. Despite their diversity, most home visiting programs for families (Sweet & Applebaum, 2004):

  • Are delivered in the home; however, certain components may take place outside of the home
  • Train and mentor parents or expectant parents rather than working directly with children
  • Focus on families with children ages five and younger or expectant parents
  • Focus on prevention of issues that might occur later in a child's life.

While home visiting programs share the core elements noted above, they may vary in other important ways, such as the:

  • Outcomes that the program has been shown to improve
  • Types of families that the program is intended to serve
  • Costs associated with program implementation
  • Types of staff that are required to deliver services and the training that the staff must have.

Are home visiting programs effective?

Research studies have shown that home visiting programs can help families. Analyses combining data from a range of different home visiting programs have shown that families that receive home visits do better on a variety of dimensions compared with families that do not receive home visits. Some of these improved outcomes include (Council on Community Pediatrics, 2009)

  • Improved parenting skills
  • Reduced child behavioral problems
  • Improved child intellectual development
  • Improved maternal employment and education
  • Reduced postpartum/postnatal depression
  • Reduced frequency of unintentional injuries among children
  • Enhanced quality of social supports to mothers
  • Improved rates of breastfeeding.

To achieve the positive outcomes described above, the process of program selection, implementation, and evaluation must be done well. The purpose of GTO-HV is to help communities and other groups do just that: better choose, plan, implement, evaluate, and sustain home visiting programs.

The first few steps of GTO-HV help communities determine which program is best-suited to address their needs given their capacities. Capacities, in this case, refer to resources, such as funding and staff, needed to plan, implement, and evaluate the home visiting program. After program selection, GTO-HV can be used to support communities in implementing the chosen program well, evaluating and improving the program, and sustaining the program in the long term.

Welcome to Townville!

Throughout this manual, we present an example of a fictitious community—Townville—that is considering implementing a home visiting program. The Townville examples will show how the Townville community coalition responds to the instructions in each of the steps.

Townville is a small, rural community, pretty far from the nearest city. Community leaders know that families in their community have been struggling with a number of issues, and they have decided to explore whether a home visiting program might offer Townville's families the support they need.

Follow Townville's progress throughout this manual: You will see how the coalition fills out the worksheets and responds to other issues that are raised in the process of planning, implementing, and evaluating GTO. The lessons that the Townville community coalition learns are applicable in any type of community.

Before you begin the 10 GTO-HV steps

GTO-HV will work best when certain elements of readiness have been established before launching into the 10 steps (Johnson, Collins, & Wandersman, 2013). Therefore, before you begin the 10 GTO steps, it is important to assess whether your organization and community are really ready to implement home visiting.

The next chapter will introduce you to the tasks that must be accomplished before GTO-HV can be successfully implemented. This preliminary foundation should be in place before moving onto Step 1 of the GTO-HV manual.

Setting up a Home Visiting Community Coalition

Usually, one organization in a community, or an individual from that organization, takes the lead role in planning, developing, and implementing a GTO program. You and/or the "lead agency" serve as the central point for development of the plan.

Mother with child outdoors

Getting Started: Are You Ready to Implement GTO-HV?

Checklist A. Readiness

  1. Are you interested in implementing a home visiting program or improving/modifying a current home visiting program in your community?

    Yes → Proceed to Question 2.

    No → This toolkit is intended for individuals, organizations, or communities who are currently implementing or planning to implement a home visiting program. This toolkit also might help you to decide whether home visiting is right for you. If you are interested in implementing a different type of program, you can still use this manual, but all of the examples will be related to home visiting, so you will need to do a little more work to identify relevant programs and examples.

  2. Is there a system of care (comprehensive system of health services, social services, and community supports) in place in your community that a home visiting program can draw upon to support its families?

    Yes → Proceed to Question 3.

    No → Home visiting programs are most effective when they are integrated into a system of health services, social services, and community supports, or a "system of care." This type of system involves several agencies working across systems to provide families with basic needs, medical services, parental supports, and family safety services. For example, a health clinic for low-income families is a part of the "system of care" that must be in place in order for home visitors to be able to refer families for well-child visits.

    If you do not know the answer to this question, or if the answer is no, you can still proceed with the next question on this checklist. Just take note that having a system of care in place is critical to the success of a home visiting program. In Step 1, you will be able to think through exactly which elements of a system of care do exist in your community that you would be able to draw upon for this work.

  3. Is a home visiting community coalition in place to support implementation of the home visiting program within the system of care?

    Coalitions are groups of organizations and individuals who represent different constituencies but share common goals and interests. Your home visiting community coalition will help plan and implement the home visiting program. Having representatives from different agencies in the broader system of care will make your community coalition particularly effective. You might first take a look around your local community for related coalitions that already exist. You could draw upon, or even join, these existing coalitions to support your efforts. These might include:

    • Existing early childhood care and education coalitions. Many states have P-16 or P-20 councils established for collaboration across early learning, K–12, and postsecondary providers. A list of P-16 and P-20 councils for each state is included on the website of the Education Commission of the States: [as of 2/2017].
    • Existing local interagency teams devoted to children and youth services. Check with representatives from the education system, the child welfare department, the department of health, community mental health centers, and other organizations to see if such teams exist in your area.

    Yes → Proceed to Step 1.

    No → It might be that there are no existing coalitions in your community to draw upon for this work. If that is the case, then you will need to put one together. This will ensure that you have all of the most critical perspectives as you continue with this process. We recommend setting up your home visiting community coalition as soon as possible. It would be best to set up this coalition before you start working through Step 1. You may use the Setting Up a Home Visiting Community Coalition Tool provided on the next page.

A community coalition can help you be successful in achieving your goals for home visiting by getting the right people at the table. Ideally, the members of the community coalition will be willing to work throughout the entire home visiting planning, implementation, and evaluation process. You want community coalition members who can help you (Johnson et al., 2009) do the following:

  • Stay connected to the diverse community groups and agencies you will need to engage as you plan and implement your program
  • Gather, analyze, interpret, and make sense of information and data
  • Perceive what is changing in the community around you and determine community needs.

The size of your coalition matters. Too big, and it may be difficult to gather everybody for meetings and have group discussions where everybody is heard. Too small, and it may concentrate the work on too few people, appear to be exclusive, and fail to represent the interests of a diverse stakeholder group. The coalition's work needs to be transparent and well documented so that lessons learned can be shared with other communities.

Tool A. Setting Up a Home Visiting Coalition

You may use Tool A: Setting Up a Home Visiting Community Coalition to help you organize your selections before making your final decisions.

Instructions for using the Setting Up a Home Visiting Coalition Tool:

  1. Customize the list of types of coalition members that you would like to include in the second column of the tool. It is essential to have representation from the following groups in your coalition (University of Kansas, 2012):
  • Stakeholders, which is a broad term to represent those individuals who have a stake in the home visiting program's success. Stakeholders might include
    • parents of young children
    • staff of existing organizations providing services to the children and family in your community, such as child care organizations; hospitals; women, infants, and children (WIC); justice organizations; and mental health service providers.
  • Community leaders, such as clergy or civic and business leaders, who are highly involved in community matters. Getting the buy-in of community leaders may be critical to getting buy-in from the larger community.
  • Political decisionmakers, such as local politicians and their staffers. Because you will need to work with local and state organizations to make your home visiting program a success, having these voices at the table is crucial.
  1. Identify specific individuals that might be able to serve as each type of coalition member. You might identify one, two, or three individuals for each type of coalition member. Write down their name, affiliation, and contact information in the third row.
  2. Each coalition member should bring a different set of connections and resources to the group. In the last column, spell out exactly what those connections and resources are.

Tool A. Setting Up a Home Visiting Coalition
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Planning your coalition's work process

Once you have established a home visiting community coalition, be sure to develop an agreed-upon plan for working together. Keep this simple, but hammer out some important details early in order to keep your process on track. Your plan can include such elements as a meeting schedule, assumptions about roles and responsibilities of the participating individuals, and a desired timeline for your work together. One or two individuals or organizations must be responsible to serve as the lead facilitator(s). The lead facilitator or facilitators are responsible for scheduling the meetings and ensuring that they are executed according to plan. You may want to hire a facilitator to help guide the coalition through the planning process.

When working with your coalition, use GTO-HV as a common framework. The GTO-HV manual is full of tips, tools, forms, and checklists that will help you plan and keep track of your work. Encourage everyone to use the same forms as you work through the various steps. This will make it easier for everyone to work together and communicate more clearly. This will also help you more easily integrate the GTO process into your everyday work. Also, documenting the decisions that are made by taking good meeting notes will build accountability that will assist in the success of the coalition.

Tool B. Completion Calendar

To help you move through the GTO-HV tasks in an organized way, we've provided Tool B: Completion Calendar. The Completion Calendar Tool is designed to help you monitor all of the tasks you'll be working through in the upcoming chapters. The tool can be used differently depending on the coalition's preferences; for example, one person or organization could be responsible for updating it, or the group can review it at each meeting and update it together. We recommend the coalition take time to check in on the calendar regularly and revise the timelines as necessary. Feel free to modify this tool or create an entirely different planning tool that can help you set goals for completion of important tasks.

Instructions for using the Completion Calendar Tool

  1. We have suggested a timeline for each of the tasks, but feel free to select a timeline that feels appropriate to you. This timeline will likely change as you get further into the work, but it is good to set goals for the group.
  2. You may also modify the content on this tool or the ordering of steps, but be sure you only do so after you have carefully read through the manual and understand how the different steps build on one another.
  3. At your first coalition meeting, review this tool and do the following:
    • Revise timeline as necessary
    • Revise tasks as necessary
    • Assign each of the tasks to a coalition member
  4. Continue to revisit this plan at the beginning of each of your coalition meetings.

Tool B. Completion Calendar
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Checklist B. Completion of "Getting Started" Phase

When you finish the "Getting Started" phase, you should have done the following:

  • Developed a basic understanding of GTO-HV.
  • Completed Tool A: Setting Up a Home Visiting Coalition (if necessary).
  • Established a community coalition (if necessary).
  • Recruited a facilitator to guide the GTO-HV planning process (if necessary).
  • Reviewed and modified the Completion Calendar to help estimate how long you expect your process to take.
  • Set up a meeting schedule.
  • Met with the community coalition.

Working through GTO within constraints specified by funders or others

Your coalition might be approaching this work with constraints on the goals you are able to target. These constraints might be due to funders' specifications, or the political climate in your community. If that is the case, you can still work through these steps. For example, you may still want to conduct a community needs and resources assessment in Step 1. By having conducted a needs assessment first, you will be able to understand how any pre-specified goals intersect with the specific needs of your community. Similarly, when filling in the Goals and Desired Outcomes Tool in Step 2, you will simply fill in the goals and desired outcomes that are specified by your funding source or leadership. Your funder might require that you implement a specific home visiting program, or choose from a list of home visiting programs. It is useful to remember that the GTO-HV steps need not always be applied sequentially. In this case, it may be best to visit Step 3 before Step 2, because Step 3 lists program models and their associated outcomes. When you find the program specified by your funder, you can transfer the goals and outcomes for that program to the worksheet in Step 2 that asks for goals and outcomes. In this way, the goals and desired outcomes that you specify in Step 2 will be based both on the needs assessment you conducted in Step 1 and on the goals and outcomes associated with the program model(s) that you will be implementing.

Before moving on to Step 1

Now that you have assessed your community's readiness to implement GTO-HV, it is time to start moving through each of the 10 GTO-HV steps. Step 1 will help you to identify the needs of your community and the resources currently available. No matter where you are in the implementation process, whether you are just beginning, you already have a program in mind, or even if you are already implementing a home visiting program and are hoping to refine it, Step 1 is important. By identifying what is going on in your community related to maternal and child services and outcomes, you will be in a better position to identify ways to best meet the needs of families in the future.