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Suggested Citation:"Next Steps." Institute of Medicine. 1999. Revisiting Home Visiting: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/9712.

Forging Linkages to Child Care

In light of modern-day living, especially with recent changes in welfare policy, policymakers and program developers need to rethink how to best reach families. Mothers are more likely than ever to be at work during the day and children are more likely to be in some form of nonparental child care for extensive hours starting in the first year of life. Home visiting programs are beginning to adapt in order to reach families “where they are.” For example, JoAnn Robinson, of the Kempe Prevention Research Center for Family and Child Health, discussed the Clayton Mile-High Program, which began as a home-based program with a small center-based component. However, because of new mandatory work requirements for mothers living in poverty, the babies and mothers that the program was trying to reach were not at home. The mothers were at work and the children were in child care, generally with other family members or friends. The staff redesigned the program to go where the children were -- in child care -- but this presented problems because they had not been invited by the child care providers. This pragmatic response to current family realities appears very promising, although, in addition to the logistical challenges, it raises the question of to whom, in this day and age, should home visiting services be delivered -- the parent, the child care provider, or both.


Where does home visiting go from here? Virtually every speaker at the workshop emphasized the need to use the results of current evaluations to revamp and improve existing programs and to continue evaluating programs as they develop in the years ahead. Olds could have been talking about all home visiting programs when, referring to the Nurse Home Visitation Program, he said “it is always a work in progress [which] needs to be tested as it evolves.” Speakers agreed that the paths of communication between all concerned parties (policymakers, staff, families, researchers, and administrators) need to be kept open, honest, and nonjudgmental, and all of these players need to work together for home visiting to be as effective as possible. Moreover, Gomby and her colleagues advised policymakers and practitioners to “maintain modest expectations for home visiting services” (Gomby et al., 1999). Because home visiting programs will not and cannot serve the needs of all families, other service strategies should be developed and supported to help families and children who do not choose home visiting services.

Home visiting is still evolving, especially insofar as it is extended to address goals other than early maternal health and infant care and is increasingly research driven. Weiss commented that she saw this moment as a great opportunity to build more effective models of home visitation and to build more consistency among home visiting programs. She made a number of suggestions of how to do this:

  1. Build a coherent research agenda that both respects the diversity of goals and approaches in home visitation and yet contributes to a more cumulative understanding of important features that promote effective service delivery and positive outcomes.

Suggested Citation:"Next Steps." Institute of Medicine. 1999. Revisiting Home Visiting: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/9712.
  1. Intersect the research agenda with broader issues of parenting and child development. Evaluation has been disconnected from developmental research; this is a partnership that needs to be developed.

  2. Perform theory-driven evaluation. The need to have informed theory guide the development and evaluation of programs was mentioned by others at the workshop, including Appelbaum, who said, “We will fight endless battles unless we set a common goal of what we have to report on -- on what the shared goals of home visiting are and what we expect out of this strategy.”

  3. Invest in dissemination. Build an institution to facilitate information sharing. Share information on a continual basis to ensure that different home visiting models inform each other and to identify common themes across programs, as well as issues that are unique to specific goals and strategies.

  4. Develop less fragmented approaches to training. It is time to move beyond training modules that are constructed anew and tailored to specific model programs toward greater cross-fertilization and refinement based on what we know now to be the most effective approaches to training home visitors with widely varying backgrounds.

  5. Do not “research, demonstrate, and dilute.” Home visiting programs have tended in the past to get watered down when they are expanded, rendering an effective model program ineffective. The conditions for scaling up need to be fully understood, especially in light of the current policy context. Can a program in one setting apply to other settings? Is implementation compromised when a program is scaled up?

  6. Take a hard look at alternative ways to support parenting and reinforce parenting skills. Home visiting can take the lead in contributing to other approaches.

Home visiting programs might strengthen their effectiveness if they examined and explicitly stated the theory of behavior change on which they are based. In addition, they need to determine if home visiting as a method of service delivery has a specific theory of change that ties all home visiting programs together. In any case, programs need to base their goals and expectations solidly on their theory of change. In fact, it may be best to think of home visiting not as a programmatic model, but rather as a set of principles.

This is an important moment in the history of home visiting. Home visiting programs are under intense scrutiny while simultaneously these programs are being adopted around the country. Although some are concerned that mixed evaluation evidence will prevent policymakers from making additional investments in this strategy, others see it as a catalyst for self-scrutiny and ongoing improvement. As noted by Lisbeth Schorr, of the Harvard Project on Effective Services, recent evidence “provides a marvelous array of tantalizing clues that we can use to improve both programs and policies.” Whatever one’s vantage point, the contemporary challenge is to identify home visiting’s most useful and effective niche among the array of intervention strategies that can be deployed to help young children and families.

Suggested Citation:"Next Steps." Institute of Medicine. 1999. Revisiting Home Visiting: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/9712.
Page 13
Suggested Citation:"Next Steps." Institute of Medicine. 1999. Revisiting Home Visiting: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/9712.
Page 14
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