Not all programs that use home visiting have met their objectives. Success depends on a program's design and operation. Well-designed programs share several critical components that enhance their chances of success. Home visiting does not stand alone; much of its success stems from connecting clients to a wider array of community services.

The federal government's home-visiting activities can be better coordi-
nated and focused. The Departments of Health and Human Services
(HHS) and Education provide funding for various home-visiting services
and initiatives. But the knowledge gained through these efforts is not
always shared across agencies and with state and local programs. The
federal government is uniquely situated to strengthen program design
and operation for home visiting by communicating the wealth of prac-
tical knowledge developed at the federal, state, and local levels.

GAO's Analysis

Home Visiting Can Be an
Effective Service Delivery
Strategy

Characteristics That
Strengthen Program
Design and
Implementation

Evaluations of early intervention programs using home visiting demonstrate that these programs can improve both the short- and long-term health and well-being of families and children. Compared to families who were not given these services, home-visited clients had fewer low birthweight babies and reported cases of child abuse and neglect, higher rates of child immunizations, and more age-appropriate child development. Evaluations of home visiting that examined costs have demonstrated its potential to reduce the need for more costly services, such as neonatal intensive care. However, few experimental research initiatives have compared the cost-effectiveness of home visiting to that of other early intervention strategies. (See pp. 29-38.)

Successful programs usually combined home visiting with center-based and other community services adapted to the needs of their target group. Longitudinal studies showed that visited families showed lasting positive effects, including less welfare dependency. (See pp. 31-34.)

Although many early intervention programs using home visiting have succeeded, others have failed to meet their stated objectives. Evaluators have attributed such failures to fundamental problems with program design and operation. (See pp. 39-42.) GAO identified critical design components for developing and managing programs using home visiting that

Executive Summary

Federal Commitment Can
Be Better Coordinated and
Focused

include (1) developing clear objectives and focusing and managing the program in accordance with these objectives; (2) planning service delivery carefully, matching the home visitor's skills and abilities to the services provided; (3) working through an agency with a capacity to deliver or arrange for a wide range of services; and (4) developing strategies for secure funding over time. (See pp. 42-43 and ch. 5.)

HHS and Education support home visiting through both one-time demonstration projects and ongoing funding sources, such as Medicaid (a federal-state medical assistance program for needy people). But federal managers were not always aware of results in other agencies, materials developed through federally funded efforts, or state and local homevisiting efforts. (See pp. 21-23.)

The Federal Interagency Coordinating Council is a multiagency body that attempts to mobilize and focus federal efforts on behalf of handicapped children or those at risk of certain handicapping conditions. The Council is one federal mechanism that can be used to better disseminate information on successful home-visiting efforts and encourage collaboration on joint agency projects. (See pp. 24-25.)

Federal demonstration projects could be better focused to improve program design and fill information voids. Federal managers should emphasize evaluating potential cost savings associated with programs using home visiting and developing strategies to better integrate home visiting into community services, especially beyond federal demonstration periods. (See pp. 21-23 and 55-58.)

The Congress' recent interest in home visiting has focused on maternal and child health initiatives, including newly authorizing home-visiting demonstration projects through the Maternal and Child Health block grant. The Congress considered (but did not pass) legislation to amend the Medicaid statute to explicitly cover physician-prescribed homevisiting services for pregnant women and infants up to age 1. The Congressional Budget Office estimated that the additional federal fiscal year 1990-94 Medicaid costs for this initiative would range from $95 million, if home visiting were made an optional Medicaid service, to $625 million, if mandatory. (See pp. 26-28.)

In view of the demonstrated benefits and cost savings associated with
home visiting as a strategy for providing early intervention services to
improve maternal and child health, the Congress should consider
amending title XIX of the Social Security Act to explicitly establish as
an optional Medicaid service, where prescribed by a physician or other
Medicaid-qualified provider, (1) prenatal and postnatal home-visiting
services for high-risk women and (2) home-visiting services for high-risk
infants at least up to age 1. (See p. 63.)

GAO recommends that the Secretaries of HHS and Education require federally supported programs that use home visiting to incorporate certain critical program design components for developing and managing homevisiting services. (See p. 63.) The Secretary of HHS should specifically incorporate these components into the Maternal and Child Health block grant home-visiting demonstration projects.

GAO further recommends that the Secretaries

make existing materials on home visiting more widely available through established mechanisms, such as agency clearinghouses,

provide technical or other assistance to more systematically evaluate the costs, benefits, and potential cost savings associated with home-visiting services, and

charge the Federal Interagency Coordinating Council with the federal leadership role in coordinating and assisting home-visiting initiatives. (See pp. 63-64.)

HHS and the Department of Education generally concurred with GAO'S conclusions and recommendations. (See pp. 64-66 and apps. III and IV.) Both agreed with the need for more research and evaluation of the costs and benefits of home visiting. Without such data, they expressed reluctance to give priority to home visiting over other early intervention service delivery strategies. Education supported the Council as a focal point for federal home-visiting activities, although HHS believed it to be beyond the scope of the Council's mission. In regard to establishing home visiting as an optional Medicaid service, HHS stated that states essentially have the option now to cover home visiting under a variety of Medicaid categories of service. GAO believes, however, that amending the Medicaid statute to explicitly cover home visiting as an optional service would send a clear message to states about the efficacy of home visiting, especially for high-risk pregnant women and infants.