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Voluntary Home Visiting Data Book: Assessing Need and Access in California

Executive Summary

Voluntary home visiting programs provide critical support to vulnerable children and families in the hopes of setting young children off on a brighter future. Families are paired with trained professionals who provide regular home visits and guidance to parents on a range of topics such as health, early development, and parenting skills.

This report provides county-by-county data on the availability of voluntary home visiting programs in California, as well as several estimates of the need for these programs, in the hopes of providing a helpful tool to policymakers and county-level decision-makers. We highlight five national home visiting models and locally developed models, which capture most children served by home visiting programs in the state.

There are three million children ages birth to five in California and nearly a quarter of them – or over 708,000 children – live in poverty. Using statewide program access and child poverty data, our main findings show high levels of unmet need for home visiting services:

  • About 42,800 California children were served by home visiting programs in 2014. Los Angeles County alone serves nearly half of the children who are receiving home visiting services in California.
  • An overwhelming 94 percent of high-need children in the state do not have access to home visiting programs. In 47 counties, 90 percent or more of children in poverty are not enrolled in a home visiting program.
  • Local models serve the majority of children (58 percent) already enrolled in home visiting programs. Local models operate in 17 counties and reach about 24,600 children.
  • Early Head Start (EHS) is the largest national model serving children and families in California. EHS operates in 42 counties and reaches nearly 8,900 children and pregnant mothers.

The data states plainly that California has yet to prioritize home visiting programs for vulnerable families throughout the state. The vast majority of counties continue to struggle with limited resources and unstable funding to expand these vital services that currently reach only a fraction of high-need families. Bringing these programs to scale requires greater state leadership through committed funding for home visiting, and improved coordination of government agencies and counties.

 

Introduction

The earliest years of a child’s life are the time of the most intense brain growth, and offer an opportunity to build a strong foundation for future learning and emotional strength. Young children living in poverty, however, are disproportionately subject to stress from their home and neighborhood environments that compromise their developmental trajectory and their success in school and beyond.1

Evidence shows that secure relationships with adults buffer children from stressful life events and support children’s growth and development. These factors contribute to children’s resilience, an adaptive response that enables them to cope with adversity.2 Quality early childhood programs have been shown to improve such outcomes for low-income children and families. Children enrolled in quality preschool programs are exposed to stimulating activities and stable, caring adults. In the best of scenarios, these programs offer stability and support to children whose family lives or neighborhoods are chaotic.

But for infants and toddlers, the need for that stability and support is just as great – possibly more so. Due to the high cost of child care3, among other factors, infants and toddlers are much less likely to be in out-of-home care than children ages three to five.Moreover, caring for a new infant or toddler can be physically and emotionally challenging. These challenges can become overwhelming for parents who are geographically isolated, young, low-income, or who lack a support network.

Voluntary home visiting programs seek to provide support to exactly those families in the hopes of setting their children off on a brighter future. These programs provide parents with guidance on developmental stages, and connect families to outside resources that can reduce the pressures of parenting. Trained professionals provide regular home visits and support to parents on a range of topics such as health, early development, and parenting skills. Several home visiting models have been recognized nationally for their promise to support families and deliver long-term benefits to child and parent alike. The Obama Administration has highlighted these programs and provided a federal funding stream to states to create or strengthen programs as part of a larger early learning agenda.5

California has made several large-scale investments in early childhood development and care, most notably through its use of tobacco tax dollars to fund First 5 California and First 5 Commissions in every county. Their purpose is to provide extra supports to ensure that children have access to programs to promote health and learning.6 Given the state’s size, it has a tradition of devolving authority for social service programs to the county level. This allows the counties to shape programs to the needs of their local populations, but also presents challenges to understanding the landscape of services provided across the state as a whole.

This report provides county-by-county data on the availability of voluntary home visiting programs in California, as well as several estimates of the need for these programs, in the hopes of providing a helpful tool to policymakers and county-level decision-makers.

Approach and Data Sources

As discussed in a previous Next Generation issue brief on home visiting programs,7 many voluntary home visiting programs in the state are funded by either the federal Maternal, Infant and Early Childhood Home Visiting (MIECHV) program, or by local First 5 County Commissions. This report offers more concrete data on the availability of those programs, as well as on over 90 home visiting programs offered throughout California by Early Head Start.

To qualify for MIECHV funding, California’s Home Visiting Program (CHVP) conducted a statewide survey in 2010 that identified at-risk communities and examined the quality and capacity of existing home visiting programs.8 This report builds off of that work. It provides updated figures on access to home visiting using 2013 – 2014 data provided by the national program models and First 5 County Commissions. We highlight five national home visiting models and locally developed models, which capture most children served by home visiting programs in California.

CHVP’s Needs Assessment considered many different measurements of need for early interventions, in addition to those required by the MIECHV program, including premature birth, low birth weight infants, infant mortality, poverty, crime, domestic violence, school dropout rates, substance abuse, unemployment, and child maltreatment.9 The report describes the number of risk factors for each county, and concludes that every one of California’s counties is a high-risk community. To indicate which counties should be prioritized for MIECHV funding, however, CHVP considered both the capacity of the county to implement one of the two selected national models, as well as the child poverty rate, which was found to be highly correlated with all other indicators of need: “The poverty indicator was a good proxy measure for identifying at-risk families who are most in need of home visiting services.”10

Based on that reasoning, we also base our calculations of unmet need on county poverty data. In addition, this data book features several other indicators of need, including Medi-Cal births, low birth weight births, the rate of children involved with the Child Protective Services system, and the percent of county residents with high rates of Adverse Childhood Experiences. See Table 1 for more information on these indicators.

Using updated enrollment data provided by home visiting models, we also estimate the level of access to these services. With the exception of locally developed models, the home visiting programs highlighted in this data book are national models that have met the federal Department of Health and Human Services’ (DHHS) criteria for evidence-based home visiting.11 See Table 2 for more information about the access data included in our county snapshots.

Findings: Access and Need for Home Visiting Across California

California is home to a large population of families who would benefit from home visiting programs. There are three million children ages birth to five in California, and nearly a quarter of them – or over 708,000 children – live in poverty. Children who live in poverty are more than twice as likely as affluent children to experience traumatic events like exposure to domestic violence and substance abuse (14 and six percent, respectively).12

Based on the program access data, 42,772 California children were served by home visiting programs in 2014. Using early childhood poverty as a measurement of need, 94 percent of high-need children do not have access to home visiting programs. Using other benchmarks, such as births funded by Medi-Cal, the estimated unmet need for home visiting programs is 83 percent.

There is great variability across counties in the access to home visiting programs for children in need. A few counties have been successful serving a large portion of the target population. El Dorado County, for example, serves 70 percent of its low-income children, according to our estimates. The small counties of Nevada, Plumas and Sierra together serve 52 percent of their low-income children. In 47 counties, however, 90 percent or more of the children in poverty are not touched by a home visiting program.

Los Angeles County is serving nearly half of the children who are receiving home visiting services in the state. Local models in Los Angeles County alone enroll 37 percent (or 15,894 children) of all children served statewide. Los Angeles’s flagship model, Welcome Baby, offers voluntary, universal home visiting services to women who deliver or plan to deliver in 13 participating hospitals. The program is expanding to additional hospitals, and eventually plans to serve 25 percent of all new births in Los Angeles County.

Early Head Start operates in the majority of counties (42 counties total) and is the largest serving national model, reaching 8,854 children (or 21 percent of all children served statewide). In 14 counties, it is the only model serving that community.13 However, the majority of children receiving home visiting services (58 percent) are served by local models, which operate in 17 counties. See Table 3 for more information on the different home visiting models operating across California.

The State of California makes Nurse Family Partnership and Healthy Families America models available to families in 21 counties through its federally-funded California Home Visiting Program (CHVP), administered by the Department of Public Health. According to data reported to the federal Health Resources and Services Administration (HRSA), that program made 39,876 home visits to 2,756 families in fiscal year 2014.14

This set of data may not provide a complete picture of home visiting efforts at the local level with respect to coordination and leveraging of available dollars. For example, we find that Alameda County is serving nine percent of the children who would benefit from these services. However, First 5 Alameda has been resourceful in stretching its dollars to maximize the number of children served with the funds available. It has developed common standards of care, outcomes, and workforce development across all home visiting programs. Hospital Outreach Coordinators identify new mothers who would benefit from one of the several models operating throughout the county and refer them to the provider that is the best fit. Other counties are likely also finding innovative ways to reach the most families with the resources available, which is not captured by the numbers reported in these county snapshots.

Similarly, the federal funding that makes CHVP possible has been used in ways that are not captured by an enumeration of families served. In part, these funds have been used to integrate data systems, coordinate services, and strengthen the network of programs, which allows for greater transparency and understanding of the impacts of those programs.15

Conclusion

This data book provides a county-by-county description of the home visiting system in California. While the estimates of need described here cannot be perfect – some families living in poverty have stronger support networks than others, and may not be ideal candidates for a lengthy intervention – the best evidence available shows that growing up in poverty is predictive of children’s outcomes in adulthood, making childhood poverty the best indicator available.

The data states plainly that California has yet to prioritize home-based services for vulnerable families throughout the state. While counties have demonstrated their willingness to be flexible and creative to meet the needs of the families they serve, the vast majority of counties continue to struggle with limited resources and unstable funding to expand these vital services. As a result, home visiting programs only reach a fraction of high-need families in California. Bringing these programs to scale requires greater state leadership through committed funding for home visiting, and improved coordination of government agencies and counties. Congress’s recent extension of the MIECHV program is helpful to this effort, but insufficient to reach the scale of California children and families who would be strengthened with smart, compassionate programs like home visiting.

 


Notes

1. Gary W. Evans, Jeanne Brooks-Gunn, and Pamela Kato Klebanov, “Stressing Out the Poor: Chronic Physiological Stress and the Income-Achievement Gap,” Community Investments 23 (2) (2011): 22-27.

2. National Scientific Council on the Developing Child, “Supportive Relationships and Active Skill-Building Strengthen the Foundation of Resilience” Working Paper No. 13 (2015).

3. Child Care Aware of America, “Parents and the High Cost of Child Care: 2014 Report” (2014) available at https://www.ncsl.org/documents/cyf/2014_Parents_and_the_High_Cost_of_Child_Care.pdf.

4. Lynn A. Karoly, “The Use of Early Care and Education by California Families” (Santa Monica: RAND Corporation, 2012).

5. The White House, Fact Sheet: President Obama’s Plan for Early Education for all Americans, (Office of the Press Secretary, 2013).

6. First 5 Association of California, “Overview of Proposition 10,” available at http://first5association.org/overview-of-proposition-10/ (last accessed April 2015)

7. Sarah Crow and Hong Van Pham, “Helping Hands: A Review of Home Visiting Programs in California” (San Francisco: Next Generation, 2014).

8. Maternal, Child and Adolescent Health Program, Center for Family Health, California Department of Public Health, “Supplemental Information Request for the Submission of the Statewide Needs Assessment” (2010).

9. California also included seven supplemental indicators in its needs assessment: prenatal care, prenatal substance abuse, maternal depression, birth interval, breastfeeding, children with special needs, and foster care. For more information, see Maternal, Child and Adolescent Health Program, Center for Family Health, California Department of Public Health, “Supplemental Information Request for the Submission of the Statewide Needs Assessment.”

10. Maternal, Child and Adolescent Health Program, Center for Family Health, California Department of Public Health, “Supplemental Information Request for the Submission of the Updated State Plan for a State Home Visiting Program” (2011).

11. For more information on DHHS criteria for evidence-based home visiting models, see “Review Process” available at http://homvee.acf.hhs.gov/ Review-Process/4/Review-Process/19.

12. “Adverse Experiences,” available at http://www.childtrends.org/?indicators=adverse-experiences (last accessed April 2015).

13. The 14 counties where EHS is the only national model present are: Calaveras, Colusa, Del Norte, Glenn, Kings, Marin, Mendocino, Modoc, Plumas, Santa Cruz, Siskiyou, Tulare, Ventura, and Yuba.

14. Health Research and Services Administration, “Home Visiting Program: California” (2015) available at http://mchb.hrsa.gov/programs/homevisiting/states/ca.pdf

15. Stephanie Schmit, Christine Walker, and Rachel Herzfeldt-Kamprath, “An Investment in Our Future: How Federal Home Visiting Funding Provides Critical Support for Parents and Children” (Washington: Center for American Progress and Center for Law and Social Policy, 2015).

16. For more information on 2013 Poverty Thresholds, see “Poverty thresholds” available at http://www.census.gov/hhes/www/poverty/data/threshld/index.html.

17. National Scientific Council on the Developing Child, “The Long Reach of Early Childhood Poverty: Pathways and Impacts.” For more information on early brain development, see the Center on the Developing Child at Harvard University.

18. Nancy E. Reichman, “Low Birth Weight and School Readiness,” Future of Children 15 (1) (2005): 91 – 116.

19. National Scientific Council on the Developing Child, “The Foundations of Lifelong Health Are Built in Early Childhood” Working Paper No. 5 (2010). For more information on the impact of adverse childhood experiences (ACES) on health, see “Adverse Childhood Experiences Study” at http://www.cdc.gov/violenceprevention/acestudy/.

20. For more information on the national home visiting models, see “Model Reports” available at http://homvee.acf.hhs.gov/Models.aspx.

21. The Department of Health and Human Services (DHHS) launched the federal Home Visiting Evidence of Effectiveness (HomVEE) study to review the evidence base of widely-used home visiting models across eight domains: 1) Child Development and School Readiness 2) Child Health 3) Family Economic Self-Sufficiency 4) Linkages and Referrals 5) Maternal Health 6) Positive Parenting Practices 7) Reductions in Child Maltreatment and 8) Reductions in Juvenile Delinquency, Family Violence, and Crime. For more information on the HomVEE study, see Sarah Avellar and others, “Home Visiting Evidence of Effectiveness Review” (Washington: Mathematica Policy Research, 2013).

22. “Program Information Report” available at http://eclkc.ohs.acf.hhs.gov/hslc/data/pir (last accessed April 2015).

23. For San Diego County, HFA data is based on the number of children enrolled in 2013 – 2014. See First 5 Commission of San Diego, “Annual Report FY 2013-14: Improving the lives of children ages 0 through 5” (2014); For Butte County and Yolo County, HFA data are based on current enrollment of families reported in a site survey administered by the HFA national office in March 2014.

24. For more information on the Welcome Baby home visiting program and its outcomes, see “Home Visiting Evaluations” at http://www.first5la.org/index.php?r=site/article&id=3215.

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