Introduction Conducted as part of the Massachusetts MIECHV evaluation, this study examined the role of home visitors (HVs) in facilitating families’ connections to early childhood systems of care. The aims of this study were to document the full range of HV behaviors related to service coordination. Methods The study sample was 65 participant cases from five program sites, comprising two home visiting models (HFM and PAT). We coded and analyzed 11,096 home visiting records, focusing on identifying referrals, connections, discon- nections, and supportive behaviors across 20 service areas. Qualitative pattern analyses were conducted on a subsample of records to identify unique pathways from referral to connection. Results HVs discussed an average of 30 different programs with each participant, and overall, only 21% of referrals resulted in a service connection. This rate varied, with some (e.g., housing) requiring much more intensive HV support and yielding far fewer connections. HVs also worked to keep participants engaged once they were connected to a service, often discover- ing challenges in need of attention through monitoring activities. Discussion Home visiting is often thought of as a key entry point into a system of care. Findings from this study confirm this premise, highlighting both the centrality of home visiting in helping families navigate local systems of care, and the insufficiency of these systems to meet family needs. Keywords Home visiting · Service coordination · System of care · Referrals Significance Introduction To date, there have been no comprehensive evaluations Authorized as part of the 2010 Affordable Care Act, the of service coordination within the home visiting context, Maternal, Infant, and Early Childhood Home Visiting pro- particularly regarding the pathways that lead from referral gram (MIECHV) provides federal funds to states and tribal to connection. This study of referral-making and service entities to support evidence-based home visiting services to coordination in the Massachusetts MIECHV home visiting families in at-risk communities. MIECHV has a stated focus program, which details home visitors’ efforts to help partici- on early childhood systems building (Patient Protection and pants navigate services in their local systems of care, begins Affordable Care Act 2010); this recognition that home vis- to address this gap in the literature and point to directions iting is not a panacea, but rather an essential component for further research. in a larger system of care (Daro 2009), acknowledges the challenges of providing services to populations with mul- tiple needs, situated in insufficiently resourced communi - ties. There has been increasing interest in understanding how home visiting programs connect families to services and strengthen local systems of care (Minkovitz et al. 2016; Roberts et al. 1996). While literature investigating home vis- * Jessica Goldberg iting impacts on child and family outcomes is plentiful, far email@example.com less attention has been given to the processes and outcomes Tufts University, 574 Boston Ave., Medford, MA 02155, associated with referral-making in home visiting. Conducted USA Vol:.(1234567890) 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S22–S32 S23 as part of the implementation evaluation of the Massachu- depth, perhaps because EI is legislatively mandated to offer setts (MA) MIECHV program this study is a mixed-methods case management to participants (Peterson 1991). Qualita- process investigation of home visitors’ (HV) role in facilitat- tive investigations of EI parents’ attitudes around referral- ing and maintaining families’ connections to other services making have found that these families expect and value HVs’ in the early childhood system of care. help connecting them to services (Able-Boone et al. 1990; Allen 2007; Mahoney et al. 1990; Roberts et al. 1996). In one of the few studies focusing on service coordination in Background the context of a HV’s workload, Roberts et al. (1996) found that HVs spent 40% of their time integrating services for MA MIECHV delivers home visiting services via four mod- families. els [Early Head Start (EHS), Healthy Families America To our knowledge, there have been no evaluations (HFA), Healthy Families Massachusetts (HFM), and Parents that comprehensively explore how service coordination as Teachers (PAT)], in 17 high-need communities across operates within home visiting programs, particularly regard- MA. MA MIECHV aims to help families across myriad ing the pathways that lead from referral to connection. This domains (e.g., health, positive parenting, child development, study, which details HVs’ efforts to help young mothers economic self-sufficiency), either directly or by connecting navigate services in their local systems of care, begins to families to resources and supports in their communities; the address this gap in the literature. Our operationalization of latter is the focus here. referral-making was informed by the information and refer- Linkage to community resources has long been a stated ral (I&R) services field, which suggests that referrals are component of home visiting programs’ offerings (Duggan more than a one-time event, and emphasizes the importance et al. 1999; Olds and Kitzman 1993; Roberts et al. 1996), of follow-up support activities as part of the referral-mak- and the 2010 MIECHV legislation, which includes coordina- ing processes (AIRS 2016; Gutiérrez 1992; Levinson 2002; tion and referrals to needed services as one of its benchmark Long 1973). The present study documented the full range domains (Adirim and Supplee 2013), brought this aspect of HV behaviors involved in service coordination, including of home visiting into sharper focus. Despite this redoubled behaviors intended to identify needs, connect participants to emphasis, little is known about whether and how home visit- services, and maintain their engagement once connected. ing programs are meeting this service coordination need. As an example, of the 20 home visiting models established as evidence-based (EBHV) by the U.S. Department of Health Methods and Human Services (Avellar et al. 2017), only six consid- ered linkages and referrals in their assessment of program For this mixed methods study, we employed qualitative outcomes (Anisfeld et al. 2004; Dodge et al. 2014; Jacobs methods to code the data and examine pathways from refer- et al. 2015; LeCroy and Krysik 2011; Love et al. 2002; Low- rals to connections, and conducted quantitative analyses of ell et al. 2011; Olds et al. 1986; Silovsky et al. 2011). referrals, HV support behaviors, and service connections. These evaluations focused on two service coordination outcomes: whether a referral was made, and whether a con- Data Source nection to service occurred. Programs with a designated case manager/service coordinator on the home visiting team dem- Our data source was participant case histories drawn from onstrated success connecting families to community services referral, secondary activity, and home visit records con- (EHS, Love et al. 2002; Child First; Lowell et al. 2011), as tained within home visiting programs’ web-based man- did programs with a stated focus on service coordination as agement information system (MIS). HVs use this sys- a key service offering (Family Connects, Dodge et al. 2014; tem to track background information about participants SafeCare Augmented; Silovsky et al. 2011). Findings from (e.g., demographics), service delivery (e.g., the content evaluations of programs without an explicit focus on ser- of home visits, referrals, and other services), goal set- vice coordination are less consistent; while HFA programs ting and attainment, and child and mother assessments. in Kentucky (Williams et al. 2017) and Oregon (Green Referral records included the description of the program et al. 2017) successfully connected families to community to which the family is referred, and the referral outcome. resources, for instance, other state HFAs (e.g., Hawaii, Mas- Secondary activity records described any non-visit sachusetts, Arizona) were found to have no effects on service activities (e.g., dropping off diapers, contacts with other linkage (Duggan et al. 2004; Jacobs et al. 2015; LeCroy and service providers) conducted by the HV with or for the Krysik 2011). participant. Home visiting records included HVs’ narra- Evaluations of early intervention (EI) programs (not con- tive summaries of what was discussed with, or observed sidered EBHV) have examined service coordination in more about, the participant across multiple service areas (e.g., 1 3 S24 Maternal and Child Health Journal (2018) 22 (Suppl 1):S22–S32 housing, child care). We defined a “record” as a single note recorded by a HV in any of these three sources. Samples We used a stratified, weighted sample of 65 participant cases from five demographically diverse program sites compris- ing two home visiting models (HFM and PAT), randomly selecting cases from each site based on program capacity. The records used for this study covered a 4-year period (2012–2016), encompassing participants’ entire duration in the program. Coding As a first step, a team of six coders reviewed all records for the 65 participants in the sample, retaining those contain- ing any mention of community service-related activities. Next, coders organized these codeable records into “service discussions,” or chronologically ordered records within a participant’s case history related to that one specic fi program or service. For example, a discussion may start on one visit with the participant expressing a desire to attend college, and subsequent visits may include the HV and participant com- pleting applications and making calls to admissions offices. The last record in which the college is mentioned by the HV would be considered the “end” of the discussion. Finally, we coded each record in the discussions, using a multi-level scheme capturing all stages of HVs’ facilitation of participants’ linkages to community services, including pre-referral activities (e.g., suggesting a service), referrals (i.e., the initial action taken to link a participant to a ser- vice), referral follow-up activities (e.g., assistance complet- ing applications), service connection, service disconnection, post-connection activities (e.g., satisfaction check-ins), and post-disconnection activities (e.g., attempts to re-engage). Codes also characterized the primary goal of each discussion [i.e., to connect a participant to a service (“linking mode”), or support an existing connection (“maintaining mode”)]. We identified a hierarchy of HV behavior codes, based on the intensity of time and effort required from HVs in provid- ing each type of support, including low-level support (check- ins), moderate support (encouragement/suggestions/advic e; emotional support/cheerleading; information provision), and advanced support (instrumental support; interagency case review) (see Table 1). A detailed coding manual with definitions and examples guided coders. We achieved an interrater reliability rate of 85% based on 20% of the records. Analysis Overall sample statistics are based on data aggregated at the participant level, and statistics for each service area are 1 3 Table 1 Coding scheme: home visitor referral follow-up supports Terms Brief definition Example Low-level support Check-ins Interactions between HVs and participants that are in the Mom used to have Medicaid but it was closed in February. Mom service of tracking and monitoring. HV ask, or participants reapplied and the status is pending volunteer information, about progress toward connecting to a service, concerns about service connection, and actions they must take to become eligible for enrollment Moderate support Encouragement, suggestions, and advice The HV advises or encourages the participant to take an action Mom said she didn’t get a chance to call the adult GED program related to connecting to a service and she will. HV encouraged her to do it ASAP Emotional support/Cheer-leading The HV demonstrates support, gives praise, or provides com- I praised mom for keeping her cool when the DTA case manager fort related to a service that the participant is attempting to told her she was no longer eligible for benefits—we talked connect to about how hard it was for mom to not blow her top Information provision The HV provides the participant with information needed to Mom is in the process of applying for unemployment and asked connect with a service or information about how a service me how to do it. I researched material and went over it with works her Advanced support Instrumental support The HV provides hands-on assistance to the participant (e.g., I help mom fill out the financial application for child support. It helps complete an application, accompanies participant to took up the whole visit appointment) in order to promote service connection Interagency case review Parties from one or more programs, including the home visiting Had meeting with [Child Protection Services] social worker to program, discuss a participant’s case talk about Mom’s service plan for reunification Maternal and Child Health Journal (2018) 22 (Suppl 1):S22–S32 S25 based on records nested within discussions. For the qualita- Distribution of Discussions and Referrals tive component, we used in-depth pattern analyses to create across Service Areas case studies for 20 participants, randomly selected from the larger sample. In this paper we focus largely on the con- Of the 20 service areas we coded for, participants had tent and frequency of HV behaviors that occurred after a discussions pertaining to 13, on average (range 1–20) As referral (rather than the full range of behaviors), and pre- shown in Fig. 1, most participants had at least one discussion sent two case studies that are particularly good illustrations related to medical (95%), early education and care (94%), of the nature of HV-participant interactions around service economic/material assistance (92%), housing (88%), and coordination. food/nutrition services (88%). Even the least common ser- vice areas (i.e., substance abuse, legal aid) were featured in Consent and Approval at least one-fifth of the participants’ records. Participants generally had more than one discussion per Our research team is granted access to the MIS records service area. To understand where participants typically through our ongoing evaluation contract with the home vis- started with respect to each service area (i.e., linking vs. iting program; our research group is named in the informed maintaining mode), we examined their first discussions. consent participants sign when enrolling in MA MIECHV. As shown in Fig. 1, the proportion of initial discussions This research was approved by the Tufts University Institu- that began in linking mode varied widely by service area. tional Review Board. All of the participants who discussed a substance use pro- gram with their HVs, for instance, began these discus- sions in linking mode (i.e., they were not connected to the Results service, but likely needed to be), which was true for only a handful of participants who discussed health insurance In this section we report findings related to: the frequency (i.e., most participants were already connected to health with which HVs document service coordination activities, insurance). and the proportion of activities that are referrals; the distri- Figure 1 also shows the proportion of participants that bution of referrals across service areas; the types of referral had at least one discussion that included a referral. In some follow-up supports HVs offer; and the pathways from refer - of the service areas, such as maternal health, behavioral ral to service connection. health, domestic violence, and substance use, there was tight congruence between the proportions of participants who started a discussion in linking mode and those who Frequency of Discussions Related to Service went on to receive at least one referral, suggesting these Coordination Activities are areas in which participants were specifically looking for referrals and HVs were well placed to provide them. On As seen in Table 2, there was a total of almost 55,000 the other hand, there was little to no overlap between the records across the 65 participants. Of these, around one-fifth two proportions in other service areas, such as child protec- (20.2%, n = 11,096) contained mention of a community ser- tion, and secondary and post-secondary education, areas in vice; approximately 171 records per participant. These code- which participants either may not have wanted/needed refer- able records were organized into, on average, approximately rals, or HVs were unable to provide them for some reason 30 discussions about individual programs per participant, (see Fig. 1). almost a third of which included a referral. HV Post‑referral Follow‑Up Behaviors For a more granular investigation of HV activities fol- lowing referrals, we focused on the most prevalent and/ Table 2 Home visitor records pertaining to community services or salient service areas in our sample: behavioral health, N M SD Range early education and care, economic/material assistance, Total records 54,959 845.52 496.48 41–1986 food/nutrition, housing, and maternal health. With regard Records containing mention of a 11,096 170.70 119.24 1–557 to these service areas, the majority (68%) of HVs’ post- community service referral activities comprised low-level supports (check- Service discussions 1947 29.95 13.99 1–65 ins), and almost a third (32%) were either moderate or Service discussions including a 636 9.78 6.92 0–33 advanced supports; this proportion was similar across referral service areas. 1 3 S26 Maternal and Child Health Journal (2018) 22 (Suppl 1):S22–S32 Fig. 1 For each service area, Participants with at least one discussion proportions of participants who Participants whose first discussion started in linking mode had at least one discussion, had Participants with at least one discussion containing a referral a first discussion beginning in linking mode, and had at least one referral (n = 65) Medical 25 Early Educaon 52 Econ/Material Assistance 53 Housing 53 Food/Nutrion 27 Maternal Health 13 Health Insurance 7 Behavioral Health 36 Early Intervenon 36 Police/Courts 26 Secondary Ed Workforce Development 35 Child Protecon 21 Post-Secondary Ed 24 Family Support Services 26 Adult Basic Ed 24 Domesc Violence 18 Arts/Culture/Recreaon 19 Legal Aid 14 Substance Abuse 13 Moderate and Advanced Supports Proportion of Referrals Ending in Connection Whereas the overall proportion of low-level to moderate/ Overall, 21% of referrals resulted in a connection to the ser- advanced supports did not differ by service area, the distri- vice, with referrals to behavioral health, economic/material bution of moderate and advanced supports revealed consid- assistance, food/nutrition, and maternal health service prov- erable variation (see Table 3). Referrals to food/nutrition and ing more successful than referrals to child care and housing maternal health services were most often followed by mod- (see Table 4). erate supports, whereas referrals to behavioral health, early education and care, economic/material assistance, and hous- ing services were most often followed by advanced supports. 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S22–S32 S27 Table 3 Distribution of Service area Total Moderate supports Advanced supports moderate/advanced supports following home visitor referral, Encour- Emotional Information Instrumental Intera- by service area agement, support/ provision support gency suggestions, cheerlead- case advice ing review n % n % n % n % n % Behavioral health 97 21 22 6 6 8 8 23 24 39 40 Early education 62 16 26 3 5 12 19 23 37 8 13 Econ/material assistance 31 6 19 0 0 2 6 23 74 0 0 Food/nutrition 16 9 56 0 0 4 25 3 19 0 0 Housing 77 11 14 1 1 21 27 42 55 2 3 Maternal health 12 6 50 1 8 1 8 2 17 2 17 Bold type indicates the most common type of moderate/advanced home visitor support following referrals in each service area Table 4 Referrals and connections, by service area each of the six service areas. Referrals to maternal health and food/nutrition services required only moderate effort, Service area Total referrals Connections to and resulted in a relatively high number of connections. service Referrals to behavioral health services and economic/mate- n % of Referrals rial assistance required more intensive follow-up, but yielded Behavioral health 65 18 28 similar rates of connection. Early education and housing also Early education and care 67 7 10 required more advanced effort, but yielded the fewest con- Economic and material assis- 75 20 27 nections (10 and 13%). tance Food and nutrition 33 10 30 In‑Depth Exploration of Service Discussions Housing 88 11 13 Maternal health 21 6 29 Our primary interest for the in-depth analysis of 20 par- Total 349 72 21 ticipants was to generate an understanding of the pathways from referral to connection. While a presentation of findings HV Support Behaviors between Referrals from this study component is beyond the scope of this paper, and Connections we present two of the qualitative case studies, illustrative of HV-participant interactions around service coordina- Figure 2 shows the intensity of HV effort (moderate or tion, and highlighting the range and complexity of the HVs’ advanced support) relative to the success in connecting for roles vis a vis their clients. As background, the participant Fig. 2 Distribution of moderate and advanced supports preced- ing connection to services, by service area 1 3 S28 Maternal and Child Health Journal (2018) 22 (Suppl 1):S22–S32 in the first example (Fig. 3) was enrolled in the program for service areas. In this example the HV and participant talked 2.94 years, during which she received 64 home visits. She about the service—a childcare voucher program—for more had a total of 61 service discussions with her HV, which than 2 years before the participant made a connection. The included eight referrals, and eight connections, across four HV provided instrumental support (e.g., contacting agencies Time Summary of Home Visitor and Participant Interactions Period Home visitor (HV) checked in with themother (MOB) about child care, MOB said father of the baby (FOB) was watching baby at the time, but when FOB gota job she would need childcare. HV referred MOB (gaveher a phone #and explained how vouchers work) to a child care resource center (CCR) where she couldget a childcare voucher to use when the time came. In the meantime, the HV was educating and coaching the mother on how to evaluate childcare centers based on their features, care hours, and other factors. After a couple weeks, MOBreportedhaving trouble reaching anyone at CCR, so HV hadher sign a release so HV couldcall on her behalf. HV also reminded MOB that she wouldneed a written referral from the Department of Transitional Assistance (DTA) to bring to CCR. HV encouraged MOB to keep calling CCR, to get the process started over the phone. MOB told HV Jul-Sep that she had given the informationto DTA but still hadnot heard back from them, or CCR. Both MOB and HV made multiple attempts over the next couple weeks to reach both programs, with no success. HV suggested MOB make an appointment with CCRonline. MOB did this, but didn’t like that thesoonest appointment was a few weeks away, given that her need for childcare had become more pressing, so at the next visit HV and MOB called together and made a new appointment at CCR. MOB missed her appointment at CCR [HV didnot record reason]. MOB did complete some necessary paperwork related to the referral from DTA and with her school. MOB was not able to reach CCR to reschedule. After several attempts, HV reached MOB’s DTA worker to check in about MOB’s paperwork, and also scheduleda new appointment at CCR for MOB. MOB reported that she no longer needed child care because FOB’s momwould watch the baby. [It is implied that MOB does not attend the second scheduled CCR appointment]. MOB reported getting the referral from DTA and said that if she couldstill get the voucher from CCR she woulddo it. HV told her to look on Mass.gov and search for providers where she wanted baby to go (close to her school) so she couldhave a child care center in mind before making an appointment at CCR. Oct-Dec MOB reported to HV that she found a child care center she liked and was ready to make an appointment at CCR. There wasa 2-week delay when MOB misplaced the DTA referral, but then she relocated it and was ready to make an appointment. HV called CCR and made an appointment for MOB. But the week of the appointment, the mother told the home visitor that FOB would not be attending school after all, and they did not need childcare. MOB did not attend her third scheduled CCR appointment. Over the next 1.5 years, MOB pieced together childcare with family members, and HV Jan 2013- periodically reminded MOB that getting on the voucher waitlist is a good idea even in the Jun 2014 absence of immediate childcare needs. MOB finally received a childcare voucher (representing her successful connection to the Jul-Sep service) and wason a waitlist for a child care center she had visited and liked. MOB continuedto talk to HV about the child care centers she hopedto get into. MOB told HV that when MOB called the center two months later to check in, they told her that Oct-Dec she had been mailed a letter saying a spot had opened up and that MOB had declined. MOB told 2014 HV that did not happen, and HV told her to go down to CCR and talk to them about getting back on the list. MOB went to CCR and gotback on the waiting list for a child care slot. She finally gota letter Jan-Mar 2015 offering her a spot, but when she contactedthe center, the spot hadalready been filled. Apr-Jun MOB signed her baby up for Head Start but wastold she hadto wait until the baby turned 3. 2015 When baby turned 3 in June, MOB enrolled him in Head Start, to begin September. Fig. 3 Service discussion example 1: childcare voucher 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S22–S32 S29 and scheduling appointments on the participant’s behalf,); service discussions. Of the thirteen referrals this participant encouragement to continue pursuing the service, persistent received, across nine service areas, nine resulted in a con- checking-in, which seemed to keep the goal of service con- nection. This discussion underscores the diversity of ways nection on the participant’s radar; and reminders to complete in which HVs support young mothers; in this example, the tasks necessary to advance her goal. The HV continued to HV did not make any referrals, and did not play a connecting work with the young woman on accessing child care through role, deferring instead to others to arrange the participant’s multiple setbacks, including missed appointments, admin- housing placements. Rather, the HV focused on supporting istrative complications, and frequent mind-changing on the the participant as she dealt with multiple housing transi- part of the participant. tions, providing instrumental and emotional support such as The second example (Fig. 4)—a discussion about hous- helping the young woman move her belongings, and offer - ing services that lasted more than a year—did not end in ing advice to improve the quality of her living arrangement a connection to the desired service (subsidized apart- experiences. While the HV did not help the participant to ment). This participant was enrolled in the home visiting secure stable, long-term housing during her tenure in the program for 2.23 years, had 46 home visits, and had 48 program, she remained a consistent support while this young Time Summary of Home Visitor and Participant Interactions Period When they begantheir discussion about housing, the mother had recently been relocated from a homeless shelter to a Teen Living Program (TLP). Within a month of settling there she was asked Jul-Sept to leave. HV droveher to the housing authority to drop off an application. MOB was told it wouldbe at least 3-4 months before she couldget an apartment. HV checked in with MOB to see if she hadheard anything from the housing authority. MOB had not, and HV told her to call them to check her status.MOB reported back that she found out she is Oct-Dec still on the waiting list. HV and MOB had a couplediscussions about MOB’s mental health and how she is managing living in the shelter. HV periodically checked in with MOB, and reported that MOB was still on the waiting list for Jan-Mar housing and was “desperate” to get out of the shelter, feeling depressed about living there but trying to keep a positive attitude. MOB reported that hersupport workers from Child Protective Services (CPS)and the shelter both told her it might help with housing to get a job. MOB's shelter worker told her she wasvery close to getting an apartment. The following week, MOB lost custody of her son to CPS and as a result had to move to a temporary shelter. Apr-Jun HV helped MOB move her belongings from her previous to the new shelter. 2014 MOB wasscared because she has heard stories about how violent it wasthere. HV gave MOB recommendations about safety and conflict avoidance while residing there. MOB texted HV to let her know she got a job at Subway and HV told her to let her shelter worker and CPScase manager know. HV talked to MOB’sCPS worker and learnedthat MOB’s unstable housing was a central reason why she had not regained custody of her son. MOB says she has not had a visit with her baby for more than a month. HV and MOB called Jul-Sep CPSworker together to check on the case and to schedule a CPS-supervised visit for HV and MOB for the following week. HV and MOB continued to have conversations about how MOB should deal with the violence at the shelter. HV informed CPSworker that she wouldneed to discontinue services with MOB (the home visiting program allows delivery of services to MOB without custody fora limited period of time). MOB told HV that shefound out shewas at the top of the list to receivehousing but wouldneed Oct-Dec to have a reunification plan from CPSbefore the housing authority couldproceed. HV drove MOB to the CPS office. [This is the last record; we do not know if the mother regained custody of her son, or if she obtained housingafter her discharge from the home visiting program.] Fig. 4 Service discussion example 2: subsidized housing 1 3 S30 Maternal and Child Health Journal (2018) 22 (Suppl 1):S22–S32 mother navigated what was clearly an extremely challenging eligibility requirements, lack of transportation), but they time in her life. also highlight the role HVs play in ameliorating some of the emotional barriers (e.g., participants’ feelings of being disrespected, overwhelmed, defeated) families often Discussion experience during their encounters with the service system (Harris et al. 2016). Results of this study suggest that the processes HVs engage in to connect participants to services are often complex, fol- The Majority of Referrals Do Not End in Service lowing a long and circuitous path with myriad steps involved Connection (including those that involve trying to repair or resolve past challenges), multiple parties participating in the process, On average, only about 20% of HV referrals resulted in a and fairly low success rates. Key conclusions are discussed connection. This seems low; although it is important to note below, followed by research limitations and implications for that we do not have an empirical frame of reference for this the home visiting field. finding. The qualitative analyses illuminated the multiple complications that tended to arise during the pathway from Look Beyond Referrals to Understand HV Eor ff t referral to connection (or lack thereof). The amount of HV effort required to connect participants to services varied by The few home visiting evaluations examining service coor- service area; it took considerably more intensive HV effort dination typically have focused on whether referrals were to connect participants with housing and early education, made (Anisfeld et al. 2004) and/or whether families were for instance, than to maternal health and food/nutrition connected to services (Dodge et al. 2014; Duggan et al. services. These findings map neatly onto the program and 2004; Jacobs et al. 2015; Love et al. 2002; Olds et al. 1986; policy landscape of in which MA MIECHV was operating Silovsky et al. 2011; Williams et al. 2017). Our data, how- at the time. For instance, MA was ranked near the top of the ever, suggest that there are many HV behaviors beyond nation in terms of coverage by health insurance (The Com- referrals that help participants gain access to, and navigate, monwealth Fund 2017), Women, Infants, and Children Food local systems of care. Furthermore, as was illustrated in the and Nutrition Service (WIC) (U.S. Department of Agricul- housing case study, there is a wide range of outcomes— ture, January 2015), and Supplemental Nutrition Assistance other than a connection to a service—that may result from Program (SNAP) (U.S. Department of Agriculture, Febru- these activities, such as an increased ability to problem-solve ary 2014), and near the bottom for housing (National Low or persist in the face of challenges. The home visiting field, Income Housing Coalition 2016) and child care affordability and those to whom the field is accountable, would be well- (Economic Policy Institute 2016). Findings from this study served by a broader understanding of how home visiting are further confirmation that linking participants to needed programs engage in service coordination; simply counting services is contingent on the quality, capacity, and strength “referrals” sheds insufficient light on the role HVs play in of the service systems to which they are being referred. helping participants navigate community systems. Limitations HV Eor ff t Makes a Difference This study, a first attempt at understanding a complicated Moderate and advanced supports, such as instrumental aspect of home visiting service delivery, had several limita- support, encouragement, suggestions, and advice, intera- tions. First, due to our focus on service-related activities, we gency case review, and information provision were essen- do not know what proportion of all HV activities is dedi- tial tools used by HVs to help participants realize con- cated to service coordination. While it may be assumed that nections to services. Through these supports, HVs helped these activities take time away from other activities (e.g., participants navigate complex service requirements, parenting education) that home visiting programs believe to encouraged tenacity in the face of failure and adversity, be important, this is not clear from the data. Future research provided concrete supports that facilitated the application should examine how service coordination fits into HVs’ process, and reminded participants of important deadlines workloads, how service coordination is prioritized by home or appointments. Even in cases when HVs’ support did not visiting programs compared to other goals, and the relative lead to successful service connection, it helped partici- benefits to participants resulting from HVs’ focus on service pants endure the challenges of applying for services, and coordination versus other program goals. Second, there are learn to advocate for themselves. Qualitative findings from limitations associated with using program records as the sole this study suggest the central role HVs can play in navi- data source; HVs vary widely in their ability to consistently gating structural barriers to service access (e.g., changing and thoroughly document services in the MIS, and without 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S22–S32 S31 another primary data source with which to cross-reference coordination strategy in place at the program level, perhaps the data, there was no way to verify their accuracy. Future in the form of a dedicated case manager/service coordinator. studies should include data collected from participants as Findings from this study confirm the inextricability with well, allowing for additional perspectives and better data tri- which HVs are embedded in community systems of care. angulation. Third, the inclusion of only two program models They not only are providing essential direct services to in our study precluded analyses of differential approaches young mothers, but also are working behind the scenes as to service coordination by model; future research should conduits between participants and this system, facilitating examine model-specific variations in referral-related pro- access to services by informing participants about the exist- cesses and outcomes. Finally, the outcome in this study ence and functions of the services, interpreting complicated was service connection, and how it was influenced by HV policies, imparting skills that can be used to pursue needed support activities and contextual factors related to service services in the future, and providing emotional support capacity and events in the participants’ lives. More research throughout. Perhaps the true capacity of HVs to influence is needed to understand whether HVs’ efforts in this area family outcomes is yet to be discovered as a result of the bur- lead to improvements in families’ well-being. den that service coordination represents. Perhaps, also, once the laborious efforts of these frontline staff are more fully Implications and Conclusions understood, it will be easier to identify sustainable program and policy solutions to the challenges of service coordina- Writing about home visiting more than two decades ago, tion within the home visiting context. Weiss noted that “the visitor intent on providing a holis- Acknowledgements This study was conducted with funding from tic and family-focused service often uncovers family needs the Children’s Trust of Massachusetts (MA5014) and Massachusetts beyond those related narrowly to parenting practices or Department of Public Health (DPH), which is the state administra- whatever the single primary focus of the program might tor of the Massachusetts Maternal, Infant, and Early Childhood Home be…” (Weiss 1993). With the advent of MIECHV, and its Visiting Program (MA MIECHV). This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. requirement that HVs regularly screen and refer participants Department of Health and Human Services (HHS) under Grant Num- in areas such as mental health, substance abuse, and domes- ber X10MC29474 Maternal, Infant and Early Childhood Home Visit- tic violence, HVs are increasingly likely to uncover needs for ing Grant Program. All conclusions reached are those of the authors which there simply are not available community services—a alone and do not necessarily represent the views of the funders. reality that is challenging for both the provider and the fam- Open Access This article is distributed under the terms of the Crea- ily (Garg et al. 2016). Findings from this study highlight the tive Commons Attribution 4.0 International License (http://creat iveco lack of concrete resources for families in need, and the con- mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- sequent difficulty experienced by HVs attempting to connect tion, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the these families to services; housing in particular has emerged Creative Commons license, and indicate if changes were made. as a driving unmet need. It is clear that the young women participating in home visiting programs are in profound need of access to a com- munity system of care, and that HVs play a crucial role in References helping these participants navigate this system. On the one hand, HVs are well-positioned to do this kind of work; on Able-Boone, H., Sandall, S. R., Loughry, A., & Frederick, L. L. (1990). 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Maternal and Child Health Journal – Springer Journals
Published: Jun 2, 2018
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