Policymakers Must Fund Home Visiting Programs During COVID-19

A father helps his 1-year-old daughter walk as a family support worker visits the family's home, May 2013, in Virginia.

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Home visitors have always played an important role in the lives of the families they serve by supporting parents through the challenges of raising young children. But during the coronavirus crisis, they are essential for those struggling to navigate the additional stresses and social isolation of the pandemic and consequent economic recession.1 These health and child development professionals seek to understand families’ needs and strengths, and deliver coaching, parental education, and other forms of nonjudgmental support to clients in their homes. Pairing families with these skilled specialists also connects them to services such as food and housing assistance, mental health services, health insurance, and more.2 Despite their critical role, home visiting programs struggle due to insufficient funding. The cost of home visiting services is covered by a mix of federal, state, and local sources, many of which have received inadequate funding for years.3 Even before the pandemic, fewer than 290,000 families—about 3 percent of the 9 million high-priority families—received evidence-based home visiting.4 With state and local governments facing budget cuts, that number could decrease even further if Congress and state legislatures fail to act.

Yet even with limited resources and amid immense challenges, home visitors continue to serve families through virtual visits and other creative solutions. Using testimonies collected by the Association of State and Tribal Home Visiting Initiatives (ASTHVI), this issue brief details how home visitors are helping families during the pandemic.5 As these accounts make clear, home visiting is uniquely situated to help families weather crises because it emphasizes a comprehensive approach to addressing families’ needs and connects families to existing resources. Policymakers at all levels of government must work to stabilize home visiting programs in both the short and long terms in order to ensure families can thrive.

How is home visiting helping families now?

Parenting a young child is difficult, and even in the best circumstances, families need help during their children’s early years. Voluntary, evidence-based home visiting has a proven track record of supporting families’ unique needs during this important period, leading to demonstrated improvements in outcomes including child and maternal health, school readiness, and economic self-sufficiency.6

Although models vary, most programs share a few key ingredients: strong connections to community resources and trusting relationships between home visitors and families. Programs that receive federal funding through the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program are required by law to conduct a needs assessment, a process that requires states and tribal entities to strategize “how to meet the diverse needs of eligible families.”7 Home visiting programs are therefore in the practice of assessing how best to help families and coordinating responsive services.

These traits have allowed programs to quickly adapt how they deliver services while also adjusting their programs to reflect changing demands. In Iowa, for example, the Department of Public Health implemented weekly listening sessions with home visitors and used this information to provide families with current data on necessary topics such as “parenting in a public health emergency” and how to navigate changes in food assistance and unemployment benefits.8 This degree of responsiveness—a key part of home visiting even before the pandemic—is critical in helping programs meet families’ evolving needs.

Outlined below are the three ways that home visitors have leveraged their models’ unique strengths to adjust their services and continue working with families throughout the pandemic.

Feeding families and addressing other basic needs

Home visitors’ knowledge of community resources plays a key role in successfully connecting families to benefit programs, including nutrition assistance and food pantries. As unemployment and economic anxiety increases during the pandemic—especially among families with already limited financial means—these services are more important than ever.9 In Michigan, a home visitor leveraged her relationship with local restaurant owners in order to feed families:10

When the Stay at Home order went into effect in MI, the [restaurant owners] contacted the [home visitor] because they had fresh produce and dairy that would go bad with the closing of the restaurant. … After picking up the food, some of the team worked together at one of the [home visitor’s] homes to sort food … so the food could be distributed to the families most in need.11

Meanwhile in Kentucky, a home visiting program is working with a local nonprofit social service agency to distribute groceries from the agency’s food pantry, assist with rent and utilities, and deliver necessities that were especially scarce12 in the early weeks of the outbreak, including “personal care items and cleaning supplies.”13 Like in Michigan, home visitors leave food and other necessities on families’ doorsteps in order to maintain physical distance while managing to personally connect with families.14

Supporting families’ emotional needs

Home visiting programs often prioritize serving families that lack adequate financial, social, and emotional support, including families with low incomes and young parents.15 As the pandemic destabilizes families’ finances and social connections, home visitors continue to provide a consistent, caring presence in their lives. In Kansas, for example, home visitors have developed a toolkit with strategies that parents and children can use to address anxiety and distributed these resources in both English and Spanish.16

Trusting relationships—a key part of home visiting programs’ success17—are especially important for families that have experienced domestic violence. Addressing violence in the home is a major benchmark of success for home visiting,18 and reports suggest the prevalence of this violence is rising globally in the wake of the pandemic.19 Fortunately, home visitors are well-positioned to support survivors through long-standing relationships. In Texas, for example, one provider has moved its in-person domestic violence support group online, a challenging move that is facilitated by strong relationships between home visitors and parents.20 In New York, some home visitors are connecting early—or calling ahead—with their clients to ensure they are comfortable with scheduled meeting times. This allows home visitors to conduct screenings and provide support when parents feel safe, even if they are still living in abusive, unsafe environments.21

Looking out for mothers’ and babies’ health

The pandemic has been especially difficult for the families of pregnant and postpartum people and newborns. Both infants and pregnant people have weakened immune systems that increase their vulnerability to infection, a fact that can add to a family’s stress.22 Stay-at-home orders also mean that families with pregnant people and newborns also have less access to friends and extended family who would otherwise help. Home visitors must be particularly creative to solve problems related to maternal and infant health while families are practicing physical distancing. Nevertheless, their roles as trusted parent educators, coaches, and liaisons to medical and benefit services help them address these challenges head on by providing advice and helping fill service gaps.

Since the shelter-in-place ordinance in the San Francisco Bay Area was instituted in March, for example, a tribal home visiting program has leveraged the supportive relationships and open communication style established between home visitors and families. The program supported three pregnant women—including two first-time mothers—through healthy deliveries.23 Thanks to the relationships, these home visitors were able to conduct virtual meetings with mothers before and after labor and delivery, a crucial service for tribal communities that struggle to receive medical care at hospitals or clinics.24 These home visitors see their work supporting mothers through pregnancy, delivery, and beyond as “an act of health equity and justice,”25 to address the enormous inequities in maternal and infant health that Native American communities experience.

Before and during the pandemic, home visitors have also facilitated parents’ engagement with medical services, often providing coaching or additional education. One mother in Montana was concerned about poor weight gain for her premature twins, but worried about leaving her house to visit the pediatrician.26 In response to the mother’s anxiety, the home visitor dropped off a sanitized infant scale for the family to use and picked it up and cleaned it afterward. To follow up, the home visitor scheduled a virtual home visiting session to discuss weight gain with the family and contacted the pediatrician to report the babies’ weight and coordinate care. Another home visitor in New York coached a first-time mother as she advocated for herself to receive proper prenatal care, and treatment for a urinary tract infection, in her last trimester.27 Thanks in part to this support, the mother delivered a healthy baby.

What must policymakers do and why?

Despite the support that home visitors provide families, funding for these services is precarious. The MIECHV program—the main federal program focusing only on home visiting—has not had a funding increase since 2013.28 Funding from other federal sources—including the Title V Maternal and Child Health Services Block Grant29 and Temporary Assistance for Needy Families (TANF)30—has also been stagnant. Medicaid, a federal-state partnership that supports home visiting in approximately 20 states,31 has seen serious cuts and restrictions during the Trump administration.32And although states and local governments also supplement federal home visiting dollars with their own funding,33 state governments are facing a 15 percent to 25 percent decrease in revenue due to COVID-19.34

Research strongly suggests that the services home visitors provided before the pandemic—and that they continue to deliver with creativity and dedication—are a smart investment. Cost-benefit analyses suggest that home visiting can yield a return on investment of more than $5 for each $1 invested, through savings to child protection services, K-12 education, and criminal justice.35 To reap these benefits, policymakers should implement the following recommendations.

Stabilize home visiting now and invest in the long term

Congress should pass a one-time, $100 million appropriation for the MIECHV program to allow home visitors to purchase and deliver household necessities and fund training on delivering virtual services. Congress must also allow programs the flexibility to count virtual visits as home visits. To address long-term needs, Congress should double MIECHV funding by 2022 and double the funding set aside for tribal home visiting programs to ensure that programs can continue to support families long after the outbreak subsides.36 The House has already passed these measures; additional funding and flexibility for the MIECHV program were included in the Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act, and the Elijah E. Cummings Lower Drug Costs Now Act, which was passed in December 2019, included a significant investment in MIECHV.37

Increase state investments in home visiting and advocate for federal funding

In the absence of federal action, states that have enacted significant home visiting legislation should continue these programs, as they represent investments in communities’ long term well-being.38 For example, California, which had proposed a $30 million investment in home visiting in January before removing that funding in its June budget agreement, should preserve this investment in the following fiscal year and find other ways to address its budget deficit.39 State policymakers can also advocate with their federal delegations for increased federal funding.

Bolster funding to Medicaid and other benefit programs

Home visiting only works if communities have services to which home visitors can refer families. Congressional, state, and local policymakers must preserve the social safety net and protect funding to programs such as food and housing assistance. Supporting Medicaid is especially important because it represents an important benefit to many families eligible for home visiting and it can be used to pay for some components of home visiting services.40 Congress must substantially increase the share of Medicaid payments borne by the federal government—the Federal Medical Assistance Percentages (FMAP)—to at least 14 percentage points, as in the House-passed HEROES Act.41 In addition, the higher FMAP must be in place until key economic indicators are met, but at least until June 30, 2021, the date included in the HEROES Act. Congress must also keep in place the strong maintenance-of-effort protections that are linked to the current FMAP bump of 6.2 percentage points.42

Conclusion

As the country continues to grapple with the devastating effects of the coronavirus pandemic and economic recession, families will need ongoing assistance to navigate the ensuing financial, social, and psychological challenges. The foundations of many home visiting programs—deep knowledge of community resources, trusting relationships with families, and adaptability to changing needs—make these programs uniquely suited to serve families throughout the pandemic and beyond. Indeed, home visitors have continued to work tirelessly to support families. For this critical work to continue, policymakers at all levels of government must work together to ensure the stability of home visiting in the short and long terms.

Cristina Novoa is a senior policy analyst for Early Childhood Policy at the Center for American Progress.

The author would like to thank the Association of State and Tribal Home Visiting Initiatives; the many reviewers who provided feedback on this piece; and CAP’s Executive, Health, and Art and Editorial teams for their contributions to this issue brief.

To find the latest CAP resources on the coronavirus, visit our coronavirus resource page.

Endnotes

  1. Cristina Novoa, “Home Visiting: A Lifeline During the Pandemic,” Center for American Progress, April 9, 2020, available at https://www.americanprogress.org/issues/early-childhood/news/2020/04/09/482887/home-visiting-lifeline-coronavirus-pandemic/.
  2. Leila Schochet and Rachel Herzfeldt-Kamprath, “Home Visiting 101” (Washington: Center for American Progress, 2016), available at https://www.americanprogress.org/issues/early-childhood/reports/2016/09/16/144349/home-visiting-101/.
  3. Rachel Herzfeldt-Kamprath, Maura Calsyn, and Thomas Huelskoetter, “Medicaid and Home Visiting” (Washington: Center for American Progress, 2017), available at https://www.americanprogress.org/issues/early-childhood/reports/2017/01/25/297160/medicaid-and-home-visiting/. Temporary Assistance for Needy Families is another source of federal dollars, but benefit levels have declined dramatically in most states since TANF’s enactment in 1996. See Ashley Burnside and Ife Floyd, “More States Raising TANF Benefits to Boost Families’ Economic Security” (Washington: Center on Budget and Policy Priorities, 2019), available at https://www.cbpp.org/research/family-income-support/tanf-cash-benefits-have-fallen-by-more-than-20-percent-in-most-states.
  4. “High-priority families” here are defined as pregnant women and families meeting any one of the following targeting criteria: “Families with infants under 12 months, families and pregnant women with income below poverty threshold, pregnant women and mothers under 21 years, single mothers and pregnant women, parents and pregnant women with less than a high school education.” National Home Visiting Resource Center, “2019 Home Visiting Yearbook” (Arlington, VA: James Bell Associates and Washington: Urban Institute, 2019), available at https://nhvrc.org/yearbook/2019-yearbook/.
  5. Association of State and Tribal Home Visiting Initiatives, “Home Visiting Through Coronavirus” (Washington: 2020), available at http://asthvi.org/wp-content/uploads/2020/07/Home-Visiting-Through-Coronavirus-June-2020.pdf.
  6. Schochet and Herzfeldt-Kamprath, “Home Visiting 101.”
  7. Health Resources and Services Administration, “A Guide to Conducting the Maternal, Infant, and Early Childhood Home Visiting Program Statewide Needs Assessment Update” (Rockville, MD: U.S. Department of Health and Human Services, 2019), available at https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthInitiatives/HomeVisiting/needs-assessment-guide.pdf.
  8. Association of State and Tribal Home Visiting Initiatives, “Home Visiting Through Coronavirus,” pp. 32–33.
  9. Novoa, “Home Visiting: A Lifeline During the Pandemic.”
  10. Association of State and Tribal Home Visiting Initiatives, “Home Visiting Through Coronavirus,” pp. 53–61.
  11. Ibid., pp. 53.
  12. Jessica Guynn, “Looking for Lysol spray and Clorox wipes? COVID-19 wiped out disinfectants, but here’s when you can buy again,” USA Today, April 9, 2020, available at https://www.usatoday.com/story/money/2020/04/09/coronavirus-clorox-lysol-shortages-walmart-costco-publix-winco-lowes/2961818001/.
  13. Association of State and Tribal Home Visiting Initiatives, “Home Visiting Through Coronavirus,” pp. 37–38.
  14. Ibid.
  15. Congressional Research Service, “Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program: Background and Funding” (Washington: 2018), available at https://fas.org/sgp/crs/misc/R43930.pdf.
  16. Association of State and Tribal Home Visiting Initiatives, “Home Visiting Through Coronavirus,” pp. 34–36.
  17. Maternal, Infant and Early Childhood Home Visiting Technical Assistance Coordinating Center, “MIECHV Issue Brief on Family Enrollment and Engagement” (Rockville, MD: U.S. Health Resources and Services Administration, 2015), available at https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthInitiatives/HomeVisiting/tafiles/enrollmentandengagement.pdf.
  18. Health Resources and Services Administration, “Maternal, Infant, and Early Childhood Home Visiting Program” (Rockville, MD: U.S. Department of Health and Human Services), available at https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthInitiatives/HomeVisiting/pdf/home-visiting-infographic.pdf (last accessed July 2020).
  19. Amanda Taub, “A New Covid-19 Crisis: Domestic Abuse Rises Worldwide,” The New York Times, April 6, 2020, available at https://www.nytimes.com/2020/04/06/world/coronavirus-domestic-violence.html.
  20. Association of State and Tribal Home Visiting Initiatives, “Home Visiting Through Coronavirus,” pp. 112–114.
  21. Association of State and Tribal Home Visiting Initiatives, “Home Visiting Through Coronavirus,” pp.77–78.
  22. Nina Bai, “What We Know and Don’t Know About Coronavirus and Pregnancy,” University of California San Francisco, April 6, 2020, available at https://www.ucsf.edu/news/2020/04/417091/what-we-know-and-dont-know-about-coronavirus-and-pregnancy.
  23. Association of State and Tribal Home Visiting Initiatives, “Home Visiting Through Coronavirus,” p. 10.
  24. Ibid.
  25. Ibid.
  26. Association of State and Tribal Home Visiting Initiatives, “Home Visiting Through Coronavirus,” pp. 64–69.
  27. Association of State and Tribal Home Visiting Initiatives, “Home Visiting Through Coronavirus,” pp. 77–78.
  28. Congressional Research Service, “Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program: Background and Funding.”
  29. Association of Maternal & Child Health Programs, “Fact Sheet on Title V Maternal and Child Health Services Block Grant Funding” (Washington: 2020), available at http://www.amchp.org/Policy-Advocacy/MCHAdvocacy/Federal%20AffairsandAdvocacy/Documents/AMCHP%20(March%202020)%20FY21%20Fact%20Sheet.pdf.
  30. Congressional Research Service, “Temporary Assistance for Needy Families (TANF) Block Grant: Reponses for Frequently Asked Questions” (Washington: 2019), available at https://fas.org/sgp/crs/misc/RL32760.pdf.
  31. Kay Johnson, “Medicaid Financing for Home Visiting: The State of States’ Approaches” (Hinesburg, VT: Johnson Group Consulting Inc., 2019), available at https://ccf.georgetown.edu/wp-content/uploads/2019/01/Medicaid-and-Home-Visiting.pdf.
  32. Center on Budget and Policy Priorities, “Trump Administration’s Harmful Changes to Medicaid” (Washington: 2010), available at https://www.cbpp.org/research/health/trump-administrations-harmful-changes-to-medicaid.
  33. U.S. Government Accountability Office, “Maternal and Child Home Visiting Program” (Washington: 2019), available at https://www.gao.gov/assets/710/701431.pdf.
  34. National Conference of State Legislatures, “Coronavirus (COVID-19): Revised State Revenue Priorities,” available at https://www.ncsl.org/research/fiscal-policy/coronavirus-covid-19-state-budget-updates-and-revenue-projections637208306.aspx (last accessed July 2020); Alison May, early care and education policy associate at the National Conference of State Legislatures, “State Advocacy in the Time of COVID-19: Protective Investments in Home Visiting,” Ounce of Prevention Advocacy and Policy Community of Practice webinar, June 23, 2020.
  35. National Conference of State Legislatures, “Home Visiting: Improving Outcomes for Children: What Does the Research Say?”, available at https://www.ncsl.org/research/human-services/home-visiting-improving-outcomes-for-children635399078.aspx – :~:text=Cost-benefit analyses show that,retention, and criminal justice expenses (last accessed July 2020).
  36. Novoa, “Home Visiting: A Lifeline During the Pandemic.”
  37. Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act, H.R. 6800, 116 Cong., 2 sess. (May 12, 2020), available at https://www.congress.gov/bill/116th-congress/house-bill/6800; Elijah E. Cummings Lower Drug Costs Now Act, H.R. 3, 116 Cong., 1 sess. (September 19, 2019), available at https://www.congress.gov/bill/116th-congress/house-bill/3/actions?q=%7B%22search%22%3A%5B%22hr+3%22%5D%7D&r=1&s=1.
  38. National Conference of State Legislatures, “Significant Home Visiting Enacted Legislation in States (2008-2018)” available at https://www.ncsl.org/documents/cyf/HV_Enacted_08_18_28330.pdf (last accessed July 2020).
  39. Claudia Boyd-Barrett, “California’s Home Visiting Program Aims to Help the Next Generation Rise from Inequality,” California Health Report, June 26, 2020, available at https://www.calhealthreport.org/2020/06/26/californias-home-visiting-program-aims-to-help-the-next-generation-rise-from-inequality/.
  40. Herzfeldt-Kamprath, Calsyn, and Huelskoetter, “Medicaid and Home Visiting.”
  41. Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act of 2020, H.R. 6800, 116 Cong., 2 sess. (May 12, 2020), available at https://www.congress.gov/bill/116th-congress/house-bill/6800.
  42. Families First Coronavirus Response Act of 2020, H.R. 6201, 116 Cong., 2 sess. (March 11, 2020), available at https://www.congress.gov/bill/116th-congress/house-bill/6201/text.