Jessie Balmert, Cincinnati Enquirer
WESTWOOD – Jordan Williams, a curly-haired 14-month-old boy, would rather feed his grilled cheese to the family dog than eat it himself.
Jordan’s picky palate was just one of the many topics his mother, 23-year-old Ashley Ohmart, discussed with Mindy Heathcoat Maurer, a professional tasked with giving Ohmart parenting tips and connecting her with resources Ohmart might need as a young, first-time mother.
Ohmart is one of 10,780 families in Ohio that receive such home visits on a regular basis. The goal of these visits: help lower-income women raise children who are healthier, safer and better prepared for school.
Gov. Mike DeWine said he wants to triple the number of families participating in home visits, spending more money on the “grossly underfunded” program. Last year, 130,000 Ohio families were eligible for the voluntary visits, but only 8 percent participated in them.
During Maurer’s visit with Ohmart, the agenda ranged from tips on eating and help navigating the intake process for therapy to suggestions for handling a teething toddler. Well, that and shaking tiny maracas and playing a tambourine with Jordan.
“Do you want to do some dancing?” Maurer, a program manager with Every Child Succeeds, asked Jordan. “You’re a much better dancer than I am.”
State and federal taxpayers foot the bill – about $32.45 million each year, an Ohio health official estimated – for home visits. They are an option for Ohio families living at or below 200 percent of the federal poverty level and facing other factors, such as being a young mother, serving in the military, having a history of abuse and neglect or recovering from addiction. The visits occur from before birth until the child is three years old.
More families eligible for home visits in Ohio
More than 9,800 families received home visits between January 2016 and September 2018. That’s just 6.6 percent of eligible families statewide.
|Rank||County||Percent of eligible families served|
Source: Ohio Department of Health
But expanding home visit programs will require more than taxpayer money. State officials have collected little data on whether home visits are working from Cincinnati to Cleveland and Mansfield to Marion.
Were children healthier because of visits? Did their parents argue less? Were children better prepared for school? Did children services have to intervene to prevent abuse and neglect? Ohio Department of Health officials couldn’t yet say for sure – even though taxpayers have helped pay for home visits for 20-plus years.
Some home visit professionals, like Every Child Succeeds in Cincinnati, kept data on how home visits helped families, but that wasn’t the case everywhere.
A recent audit from the state Office of Budget Management found inconsistencies with how the state monitored home visits, including family assessments completed days or weeks late.
DeWine assembled a 15-member advisory committee to examine Ohio’s home visits and suggest changes by March 1 to include in the state’s two-year budget.
“We’re in a place now where we have the kind of leadership that we haven’t had before,” said Judith Van Ginkel, president of Every Child Succeeds and a member of the committee. “None of this is easy, but at least we’ve begun.”
Do home visits work?
If done properly, home visits can improve the lives of children and mothers. They can help reduce infant mortality – a problem in Ohio, which ranks among the worst in the nation for children living past their first birthdays.
The infant mortality rate among families who received home visits from Cincinnati’s Every Child Succeeds was 4.7 deaths per 1,000 births compared with 12.5 deaths per 1,000 in Cincinnati and 9 deaths per 1,000 births in Hamilton County.
Every Child Succeeds, with the help of Cincinnati Children’s Hospital Medical Center, also tracked how many mothers received more than 10 prenatal care visits (94 percent last fiscal year), how many breastfed for at least a month (62 percent) and how many quit smoking (11 percent).
Ohio could learn from that model. In July, the Ohio Department of Health launched a tool to track 22 measurements of success – everything from postpartum care to safe sleep and child maltreatment. (Ohio lawmakers passed legislation in 2016 to create these benchmarks.)
But it’s too soon to tell whether Ohio’s home visits are hitting any of those marks.
“We really don’t have enough data to do trend analyses,” said Sandy Oxley, chief of maternal, child and family health with the Ohio Department of Health.
More data could show gaps in home visits: where more providers are needed and where home visit officials can market the option better. Every Child Succeeds has OB-GYNs, local pediatricians and even former home visitees to recommend the program. That isn’t the case everywhere.
Does the model work?
Ohio uses three models for home visits approved by the U.S. Department of Health and Human Services as “evidence-based.” The most common model: Healthy Families America.
Healthy Families America has “an odd mix of ratings” on its effectiveness, according to a review by The Chronicle of Social Change, an online publication on child welfare, juvenile justice and other issues. New York officials credit it with reducing the number of infants sent to foster care there, but there’s little evidence it prevents abuse or neglect.
In a health department review, nine studies found direct evidence – through observation, records or self-reporting – that Healthy Families America had a positive impact on child development and school readiness. Thirty-six found no effect. On maternal health, no studies showed direct positive results and 10 showed no effect.
Even if the model is “evidence-based,” how the methods are implemented matters. A 2004 study of home visits in Alaska found parents receiving visits were just as likely to use severe forms of discipline as families who received no intervention. Home visitors often failed to address parental risks and rarely linked families to resources, according to the study.
So is Ohio’s program well-run? The state audit shows room for improvement. It found 43 percent of family assessments were not completed on time (ranging from six to 33 days late.) About 32 percent of family goal plans weren’t finished and 28 percent of environmental safety checklists were not completed.
“(Ohio Department of Health) is unable to efficiently monitor to ensure providers are operating within evidence-based model requirements,” the audit found after detailing flaws with the data system launched in July.
What comes next?
DeWine’s laser-like focus on improving the lives of Ohio’s children includes more home visits like the ones Ohmart and Maurer share. His first budget, expected within a month, will inevitably include more money for them
Van Ginkel, who runs Every Child Succeeds, is excited about the prospect.
But she has some suggestions, too: create a sustainable way to pay for visits, identify gaps where people can’t find a home visit, keep track of outcomes and expand the number of home visitors.
LeeAnne Cornyn, DeWine’s director of Children’s Initiatives, says she hopes the committee will answer some questions: “What are the right metrics and what should we be tracking?”
And Maurer, the home visit manager, suggested patience while waiting for results.
“To do (home visitation) well, it takes time and time and time and communication,” she said. “Our moms want what’s best for their babies, but if all I have time to do is write down a phone number that is not going to get the job done.”
The following is a follow-up to the Enquirer story from Shannon Jones…
I wanted to reach out to you to share some context around the article that you wrote for Cincinnati.com today and provide some thoughts on the state’s ongoing efforts to improve our infant and maternal home visiting services.
When in the Ohio Senate, I wrote and sponsored Senate Bill 332 to elevate home visiting as an infant mortality reduction intervention, among other things. Part of the impetus for the bill, as a result of findings in our Infant Mortality Commission, was our frustration that some home visiting models were implementing their program to fidelity– and others weren’t. This made it extremely difficult to expand programming while ensuring the positive outcomes we wanted. As a result, the bill required that Ohio’s Help Me Grow program only utilize evidence-based or innovative promising home visiting models (as defined by the US Department of Health), established benchmark program domains, and required systemic changes to ensure rigorous data collection and fidelity to the model.
It was out of this law that the Ohio Comprehensive Home Visiting Integrated Data System (OCHIDS), which is being used to collect, monitor, and report outcomes for the state-funded evidence-based home visiting programs, was created. Some might have viewed the recent audit you mention in your article as a punitive action, but I really think it was a proactive next step toward creating a system that allows the state to ensure continuous progress toward rigorous data collection and reporting so that policymakers can focus on the best programs as they seek to expand home visiting services.
The audit only identified two weaknesses:
- State reporting capability to ensure subcontractors are complying with program rules and regulations. ODH agrees and will implement reports by October 2019.
- State completion of on-site reviews of grantees – ODH noted that its staff resources were diverted to a major overhaul of the program rules, requirements, and systems that took effect in July 2018. ODH noted that it implemented its first quality assurance plan for HMG in 2018 and will be back on track by June 2019.
To be clear, this is the system I hoped would be created… one that uses outcomes as a way for policy makers to make decisions about investments. It’s still in its infancy but the department’s proactive review is really a positive step to ensure understanding by everyone of the system we are trying to build. We want a system that improves outcomes rather than a bunch of programs with no accountability to child outcomes.
I think we really need to celebrate that DeWine is on the right track in his approach to expand evidence-based home visiting services. He has clearly identified Every Child Succeeds as a model he wants to emulate and that’s the right move based on their large scale and their ability to produce clear data on critical outcome measures for the families they serve. This program was also in my mind when drafting SB332. Here’s why:
Every Child Succeeds has historically served about 16% of all families receiving evidence-based home visiting services in the State of Ohio. In FY18, 1,419 families were served in Ohio by Every Child Succeeds, the majority of which were African American and single mothers. The outcome measures fastidiously tracked and reported by ECS speak for themselves: 89% of pregnant mothers carrying their children to at least 37 weeks gestational age; at least 97% of kids on target gross motor, fine motor, communication, personal and social, and problem solving skills; and an infant mortality rate nearly half that of the county as a whole (4.7 vs 9.1 deaths per 1,000 live births).
Most astounding is Every Child Succeeds’ ability to achieve an infant mortality rate with no disparity between white and African American babies. In Hamilton County, African American babies are more than twice as likely to die before age one than their white peers (14.3 vs. 6.3 deaths per 1,000 live births). Every Child Succeeds has not only decreased the rate of infant mortality with participating families by 48% compared to Hamilton County’s population as a whole, but has a 67% decrease in rates of African American infant mortality compared to the county. THIS IS HUGE AND IT MUST BE SOMETHING THAT IS EMULATED IN THIS STATE.
As I wrote Senate Bill 332 and throughout my continued work at Groundwork Ohio, this final point is always at the forefront of my mind. The only way we can truly work to reduce racial disparities in outcomes along the lifespan is to start early. As early as possible. And that means doubling down on the interventions we know can work for our most at-risk kids. But to do so means we have to create the system that tracks outcome measures and uses that data for sound decision making. That’s what ODH was doing with that audit.
Dr. Van Ginkel’s comments in your piece were spot on: create a sustainable way to pay for visits, identify gaps where people can’t find a home visit, keep track of outcomes, and expand the number of home visitors. And I would add make sure that the current home visitors are operating the program with fidelity and better target high risk women and infants who are often hard to serve and lack other social supports and would benefit from home visiting.
I’m happy to discuss this further but I thought it important to share the history behind this system — still in its infancy — and the steps that the department has proactively taken to make decisions based on outcomes. You can understand why I viewed this audit as a positive step if you look at it from the broader systems building lens. Trust me, I spent a decade frustrated with ODH and it’s failure to use data in its decision making. It’s only fair that I recognize their new approach — encouraged by SB 332 — when they are really trying to build a robust system that improves outcomes for our most vulnerable children. Still lots of work to do. Really glad the Governor has made this a priority.