How Universal Home Visiting Models Can Support Newborns and Their Families

A mother holds her sleeping infant's hand.

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No matter a person’s background or where they live, the birth of a baby is a momentous occasion that brings many challenges. All families need support in the days, weeks, and months following a birth. As new mothers are still recovering from childbirth, they also face the challenge of caring for a newborn at a time when financial, mental, and emotional resources are most limited.

During this important transition for parents and infants, additional community and social supports can help families adjust to their new lives and promote healthy child development in the process. A number of evidence-based models have been developed to provide such support, often referred to as “home visiting.”1 Many of these models provide specialized support to parents and children in high-priority families, such as families with low incomes or young parents, or to individuals serving in the military. However, others take a universal approach, supporting all families. One such model is Family Connects, which combines engagement and alignment of community service providers with short-term nurse home visiting beginning in the first month after birth. While many other universal home visiting models exist—including Welcome Baby in Los Angeles County2 and the First Born Program in New Mexico3—Family Connects has been most widely adopted.4

This issue brief explores the positive impacts that universally available family support programs such as Family Connects have on communities by serving all families and connecting those most in need to additional community resources.

What is Family Connects?

Family Connects is an evidence-based voluntary program that “bridges the gap between parents and community resources” and is available to all parents of newborns.5 It employs registered nurses to visit parents in their homes shortly after their baby’s birth. These nurses are trained not only to deliver the model protocols, but also to build trust, offer supportive guidance, and navigate difficult situations in culturally responsive ways. By meeting with every family with a newborn, regardless of income level or background, Family Connects helps boost all parents’ knowledge and confidence around caring for their baby while also linking families who need additional services to community resources based on their individual needs and preferences.6 These services can range from helping a family select a child care arrangement to helping a parent find stable housing or address a substance abuse problem. The services may also include referral to a longer-term home visiting program. The idea is to engineer a system of care around the birth of a child that ultimately has a positive impact on health at a population level; the nurse connects with a family and identifies needs, the nurse connects the family to community resources, and the parents connect with their infants.7

Family Connects’ origins can be traced to 2001, when the Duke Endowment asked the Duke Center for Child and Family Policy to improve community-level outcomes for children in Durham County, North Carolina.8 After convening a broad array of community partners spanning research, health care, and social services, the team agreed that the best way to achieve its goal was to support all families with a newborn through a free, voluntary program. Since its initial 2008 pilot program in Durham, the Family Connects model has been studied through randomized control trials and successfully expanded to more than two dozen communities.9

Universally available family support programs such as Family Connects resemble the health care system’s practice of universal well-baby visits.10 In the United States, most young children attend regular well-baby visits for preventive services such as immunizations and referral to specialists when an issue requires follow-up. Importantly, these regular visits are not triggered by a medical crisis or perceived demographic risk factors such as family structure; instead, they are designed to prevent illness and promote all children’s development and well-being. Similarly, a universal family support program helps families avoid significant challenges, such as severe and unaddressed maternal depression, and promotes families’ ability to flourish. Just as the health care system requires a strong system of referrals and support from specialists, a universal home visiting program works best when there is a strong network of community services available for families.

How does Family Connects work?

Family Connects aims to reach each and every family with a newborn in the community, regardless of income, marital status, or family size. Participants receive one to three in-person meetings, as well as follow-up phone calls during an infant’s first 12 weeks.11 This approach helps keep costs low—between $500 and $700 per infant—and allows programs to reach a large number of families.12 The program is most effective when combined with a robust suite of targeted services so that families who require more intensive assistance can be referred for additional support as needed.

The program rests on three pillars:

  1. Alignment with community agencies: Family Connects staff actively recruit local agencies and community programs that serve families with young children—for example, child care facilities, parent groups, and other home visiting models. Information including program eligibility, service capacity, waitlist times, and evidence of effectiveness is collected and entered into an annotated electronic database. This single portal allows nurses to quickly access information on community resources when they visit families who need additional services such as child care.13
  2. Home visits: Parents are typically greeted by nurses or program staff at the hospital or birthing center, welcoming the new baby into the community and introducing the family to the program. If parents decide to participate—previous studies show that more than 70 percent agree to join—the nurse schedules an in-home visit about three weeks after birth.14 This initial visit lasts between 90 and 120 minutes, during which time the nurse conducts a structured clinical interview and standardized screening to assess the family’s risk levels in key domains such as child care, safety, parental mental health, and health care needs. Nurses score each domain on a scale of 1 to 4, from least to greatest risk.15 Data from a pilot study of Family Connects demonstrated that 94 percent of parents needed support in at least one area.16 After the interview, nurses and parents together develop a course of action, which can include additional visits or phone calls from the nurse, physician follow-up visits, and/or referrals to more intensive services such as targeted home visiting programs.17 This collaborative approach promotes parents’ engagement and empowers them to develop a plan that fits their needs.
  3. Data and monitoring: Family Connects staff maintain an integrated data system that documents their work with all families. Each record includes information on attempts to schedule a home visit; parents’ responses to interview and screener questions; referrals to community services; services received; and parents’ overall satisfaction with the program. To address privacy concerns, all information-sharing requires families’ consent, and staff scrub identifying information from case records when developing summaries about community agencies. This system provides valuable data that allow the community to identify gaps in the services that are available in the community, recruit new programs to fill those gaps, and track the community’s progress toward meeting the needs of all families.18

Why the program is successful

Family Connects has been shown to increase families’ connections to community resources and improve parenting behaviors, such as comforting an infant; it has also been found to improve parents’ mental health, enhance the quality of home environments, reduce infants’ emergency medical care, and increase parents’ utilization of higher-quality child care for their children.19 For example, a study of the Family Connects program in Durham, North Carolina, using a racially diverse sample, found that participating infants had 59 percent fewer visits to the emergency room and two fewer overnight stays in the hospital during their first six months. In addition, participating mothers were 28 percent less likely to have signs of clinical anxiety, and nearly 80 percent of families made a community connection—such as connecting with a local child care program—as a result of participating in Family Connects.20 Preliminary findings also show a reduction in investigations by child protective services.21

Combined, these impacts make investing in a universal program such as Family Connects a smart choice for policymakers who want to maximize the return on investment of public dollars.22 However, the power of a program such as Family Connects is in its combination of targeted, specialized interventions and services within a universal program that reaches the entire community. This makes it more likely that programs will identify hard-to-reach families and connect them to community resources that fit their needs. It is therefore important for policymakers to assess the full scope of services available to support the needs of infants and new parents in their community and to center a universal program within the context of targeted supports that can meet the specific needs of all children and families.

The universal approach expands the scope of the program, removing the potential stigma that could be associated with targeted programs. In Durham, 99 percent of participating families would recommend the program to new mothers,23 and in Oregon, a recent bill to expand Family Connects statewide passed with overwhelming bipartisan support.24 Over time, this increased popular support could also translate to more sustainable funding for programs and greater investments in community resources overall.

Conclusion

As policymakers and advocates seek to give all children and families a strong start in life, a universally available family support model should be part of their agendas. Family Connects provides an example of such a model, and its promising outcomes and potential for cost savings make it broadly appealing to communities ranging from large cities such as Chicago—which recently began a pilot program in four hospitals—to midsize cities such as Durham to small rural communities. It even appeals to states: In June 2019, the Oregon Legislature approved a bill to expand Family Connects throughout the state over the course of several years, becoming the first state in the country to expand home visiting to all families.25

As communities consider how best to serve families with newborns, it is critical to recognize that all families could benefit from additional help. Stakeholders should use the myriad resources available to help communities understand families’ needs, the different models available, the costs and returns on investments, and the potential outcomes of investing early.26 While the results of statewide implementation of Family Connects remain to be seen, the model’s strong track record of improving child outcomes for entire communities is certainly promising.

Cristina Novoa is senior policy analyst for Early Childhood Policy at the Center for American Progress. Simon Workman is the director of Early Childhood Policy at the Center.

The authors would like to thank Steven Jessen-Howard for his assistance with this brief.

Endnotes

  1. National Collaborative for Infants and Toddlers, “Increased Availability of Evidence-Based Home Visiting Models,” available at https://www.thencit.org/measure-impact/select-metrics-for-success/increased-availability-of-evidence-based-home-visiting (last accessed September 2019).
  2. First 5 LA, “Home Visiting Programs,” available at https://www.first5la.org/home-visiting-programs/ (last accessed September 2019).
  3. First Born Program, “About,” available at https://firstbornprogram.org/about/ (last accessed September 2019).
  4. Ron Haskins, Kenneth A. Dodge, and Deborah Daro, “Achieving Broad-Scale Impacts for Social Programs,” The Future of Children (2019): 1-8, available at https://futureofchildren.princeton.edu/sites/futureofchildren/files/media/foc-policy_brief_spring_2019.pdf.
  5. Family Connects, “About,” available at http://www.familyconnects.org/about (last accessed September 2019).
  6. Ibid.
  7. Haskins, Dodge, and Daro, “Achieving Broad-Scale Impacts for Social Programs.”
  8. Family Connects, “Why It Works,” available at http://www.familyconnects.org/evidencebase (last accessed September 2019); Durham Connects and Duke Center for Child and Family Policy, “Right From the Start: The story of Durham Connects” (Durham, NC: 2015), available at https://childandfamilypolicy.duke.edu/wp-content/uploads/2015/02/Durham-Connects_CCFP_FINAL-Online.pdf.
  9. Kenneth A. Dodge and others, “Implementation and Randomized Controlled Trial of Universal Postnatal Nurse Home Visiting,” American Journal of Public Health 104 (2014): S135–S143, available at https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2013.301361; Family Connects, “Why It Works”; Kenneth A. Dodge and W. Benjamin Goodman, “Universal Reach at Birth: Family Connects,” The Future of Children 29 (1) (2019): 41–60, available at https://futureofchildren.princeton.edu/sites/futureofchildren/files/media/foc_vol_29_no_1_0.pdf.
  10. Haskins, Dodge, and Daro, “Achieving Broad-Scale Impacts of Social Programs.”
  11. Dodge and Goodman, “Universal Reach at Birth.”
  12. Ibid.
  13. Ibid.
  14. Ibid. Early randomized control pilot programs and field trials showed that between 77 and 80 percent of families offered the program agreed to participate. Because the program is designed to address a family’s needs holistically, all parents should be present during the initial visit. However, insisting on both parents’ participation led to some mothers’ withdrawal from the program during pilot testing. Nurses are now encouraged to listen to mothers’ preferences and schedule visits to accommodate family situations (e.g., extended stays by relatives) and prior appointments (e.g., standard well-baby visit schedules).
  15. Ibid.
  16. Family Connects, “FAQ,” available at http://www.familyconnects.org/faq (last accessed September 2019).
  17. Family Connects, “About.”
  18. Dodge and Goodman, “Universal Reach at Birth.”
  19. Family Connects, “Why It Works”; Dodge and others, “Implementation and Randomized Controlled Trial of Universal Postnatal Nurse Home Visiting.”
  20. Dodge and others, “Implementation and Randomized Controlled Trial of Universal Postnatal Nurse Home Visiting.”
  21. Dodge and Goodman, “Universal Reach at Birth.”
  22. Mary Ann Barton, “County saves $3 for every $1 spent on ‘Durham Connects’ program,” National Association of Counties, February 19, 2018, available at https://www.naco.org/articles/county-saves-3-every-1-spent-%E2%80%98durham-connects%E2%80%99-program.
  23. Haskins, Dodge, and Daro “Achieving Broad-Scale Impacts for Social Programs”
  24. An Act Relating to Home Visiting, Oregon S.B. 526, 80th Leg., 1st sess. (August 8, 2019), available at https://olis.leg.state.or.us/liz/2019R1/Measures/Overview/SB526; Julie Sabatier, “Oregon Lawmakers Want To Offer Home Visits To All New Parents,” Oregon Public Broadcasting, February 7, 2019, available at https://www.opb.org/radio/programs/thinkoutloud/segment/oregon-home-visits-new-parents-bill/.
  25. Oregon House Democrats, “Legislature Approves New Program Providing Registered Nurse Home Visits for Newborns,” Press release, June 19, 2019 available at https://www.oregonlegislature.gov/housedemocrats/Documents/PRESS%20RELEASE%20Legislature%20Approves%20New%20Program%20Providing%20Registered%20Nurse%20Home%20Visits%20for%20Newborns.pdf.
  26. National Collaborative for Infants and Toddlers, “Implementation of a Universal Family Connection and Referral Strategy,” available at https://www.thencit.org/measure-impact/select-metrics-for-success/implementation-of-a-universal-family-connection-and (last accessed September 2019).