    [House Hearing, 113 Congress]
    [From the U.S. Government Publishing Office]

                     MATERNAL, INFANT, AND EARLY CHILDHOOD
                         HOME VISITING (MIECHV) PROGRAM

    =======================================================================

                                     HEARING

                                   before the

                        SUBCOMMITTEE ON HUMAN RESOURCES

                                     of the

                          COMMITTEE ON WAYS AND MEANS
                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED THIRTEENTH CONGRESS

                                 SECOND SESSION
                                   __________

                                 APRIL 2, 2014
                                   __________

                                Serial 113-HR11
                                   __________

             Printed for the use of the Committee on Ways and Means

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                             U.S. GOVERNMENT PUBLISHING OFFICE

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    [[Page ii]]

                          COMMITTEE ON WAYS AND MEANS

                         DAVE CAMP, Michigan, Chairman

    SAM JOHNSON, Texas                   SANDER M. LEVIN, Michigan
    KEVIN BRADY, Texas                   CHARLES B. RANGEL, New York
    PAUL RYAN, Wisconsin                 JIM McDERMOTT, Washington
    DEVIN NUNES, California              JOHN LEWIS, Georgia
    PATRICK J. TIBERI, Ohio              RICHARD E. NEAL, Massachusetts
    DAVID G. REICHERT, Washington        XAVIER BECERRA, California
    CHARLES W. BOUSTANY, Jr., Louisiana  LLOYD DOGGETT, Texas
    PETER J. ROSKAM, Illinois            MIKE THOMPSON, California
    JIM GERLACH, Pennsylvania            JOHN B. LARSON, Connecticut
    TOM PRICE, Georgia                   EARL BLUMENAUER, Oregon
    VERN BUCHANAN, Florida               RON KIND, Wisconsin
    ADRIAN SMITH, Nebraska               BILL PASCRELL, Jr., New Jersey
    AARON SCHOCK, Illinois               JOSEPH CROWLEY, New York
    LYNN JENKINS, Kansas                 ALLYSON SCHWARTZ, Pennsylvania
    ERIK PAULSEN, Minnesota              DANNY DAVIS, Illinois
    KENNY MARCHANT, Texas                LINDA SANCHEZ, California
    DIANE BLACK, Tennessee
    TOM REED, New York
    TODD YOUNG, Indiana
    MIKE KELLY, Pennsylvania
    TIM GRIFFIN, Arkansas
    JIM RENACCI, Ohio

            Jennifer M. Safavian, Staff Director and General Counsel

                      Janice Mays, Minority Chief Counsel

                                     ______

                        SUBCOMMITTEE ON HUMAN RESOURCES

                    DAVID G. REICHERT, Washington, Chairman

    TODD YOUNG, Indiana                  LLOYD DOGGETT, Texas
    MIKE KELLY, Pennsylvania             JOHN LEWIS, Georgia
    TIM GRIFFIN, Arkansas                JOSEPH CROWLEY, New York
    JIM RENACCI, Ohio                    DANNY DAVIS, Illinois
    TOM REED, New York
    CHARLES W. BOUSTANY, Jr., Louisiana

    [[Page iii]]

                                C O N T E N T S

                                   __________
                                                                       Page

    Advisory of April 2, 2014 announcing the hearing.................     2

                                   WITNESSES

    Crystal Towne, RN, Nurse-Family Partnership Home Visitor, Yakima
      Valley Memorial Hospital, Testimony............................     8
    Sherene Sucilla, Former Nurse Family Partnership (NFP) program
      participant, Testimony.........................................    16
    Darcy Lowell, CEO, Child First, Testimony........................    22
    Jon Baron, President, Coalition for Evidence-Based Policy,
      Testimony......................................................    34
    Rebecca Kilburn, Senior Economist, RAND Corporation, Testimony...    42

                       MEMBER SUBMISSIONS FOR THE RECORD

    Rep. Danny Davis 1...............................................    58
    Rep. Danny Davis 2...............................................    60
    Rep. Joseph Crowley..............................................    78

                        MEMBER QUESTIONS FOR THE RECORD

    Jon Baron........................................................    81
    Jon Baron Response...............................................    83
    Rebecca Kilburn..................................................    86
    Rebecca Kilburn Response.........................................    88

                        PUBLIC SUBMISSION FOR THE RECORD

    Scott Hippert Parents as Teachers................................    94

    [[Page (1)]]

                     MATERNAL, INFANT, AND EARLY CHILDHOOD
                         HOME VISITING (MIECHV) PROGRAM

                                  ----------

                            WEDNESDAY, APRIL 2, 2014

                 U.S. House of Representatives,
                           Committee on Ways and Means,
                               Subcommittee on Human Resources,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 2:10 p.m. in
    Room 1100 Longworth House Office Building, the Honorable Dave
    Reichert [chairman of the subcommittee] presiding.
        [The advisory of the hearing follows:]

    [[Page 2]]

    HEARING ADVISORY

    FROM THE
    COMMITTEE
     ON WAYS
    AND
    MEANS

                   Chairman Reichert Announces Hearing on the

                     Maternal, Infant, and Early Childhood

                         Home Visiting (MIECHV) Program

    1100 Longworth House Office Building at 2:00 PM

    Washington, Mar 26, 2014

        Congressman Dave Reichert (R-WA), Chairman of the Subcommittee on
    Human Resources of the Committee on Ways and Means, today announced
    that the Subcommittee will hold a hearing on the Federal Maternal,
    Infant, and Early Childhood Home Visiting (MIECHV) program. The hearing
    will take place at 2:00 p.m. on Wednesday, April 2, 2014, in room 1100
    of the Longworth House Office Building.

        In view of the limited time available to hear from witnesses, oral
    testimony at this hearing will be from invited witnesses only.
    Witnesses will include practitioners involved in providing home
    visiting services, a former recipient of these services, and experts on
    the effectiveness of home visiting programs. However, any individual or
    organization not scheduled for an oral appearance may submit a written
    statement for consideration by the Committee and for inclusion in the
    printed record of the hearing.

        In announcing the hearing, Chairman Reichert stated, ``We all know
    it's better to prevent a problem than to try and correct it after
    things have gone wrong. Yet in many cases, the Federal Government does
    just that by only attempting to treat problems instead of focusing on
    prevention. One of the goals of the new federal home visiting program
    is to help families and children before problems arise. With the
    reauthorization of that program pending, it's time to review whether it
    is really making that hoped-for difference. I look forward to hearing
    more about how home visiting programs are working, how we can ensure
    we're investing in what really works, and whether we're getting the
    quality results that at-risk children and families deserve and
    taxpayers expect.''

    BACKGROUND:

        Home visiting programs have operated for many years, delivering
    services to expectant and new mothers designed to improve a variety of
    outcomes and using a mix of public and private resources. One of the
    most successful approaches has involved a trained nurse who visits a
    parent and child in their home on a frequent basis to provide ongoing
    services to the family. However, many different types of home visiting
    programs exist, and these programs may focus on improving child
    development, increasing parenting skills, reducing the likelihood of
    child abuse or neglect, or increasing economic wellbeing.
        Begun in 2010, the Federal Maternal, Infant, and Early Childhood
    Home Visiting program (MIECHV) was designed to strengthen existing
    maternal and child health programs, provide services to improve
    outcomes for families in at-risk communities, and better coordinate
    services in communities. Under the MIECHV program, at-risk communities
    are identified through statewide assessments examining areas with
    concentrations of poor child health outcomes and other difficulties
    such as high poverty, crime, or unemployment. States then specify how
    they will serve these communities using an evidence-based home visiting
    model, and funding is provided based on each state's proportion of
    preschool children in families with income below the poverty level.
    While the bulk of program funding must be used to provide services
    through home visiting models with evidence of effectiveness as
    determined by the Department of Health and Human Services (HHS), up to
    25 percent of total funding can be used to fund promising, but still
    unproven, approaches. Funding for the MIECHV program in FY 2014 is $400
    million. The program's current authorization

    [[Page 3]]

    expires at the end of FY 2014. The Administration's FY 2015 budget
    calls for the program's reauthorization as well as a total of $15
    billion in funding over the next 10 years.

    FOCUS OF THE HEARING:

        This hearing will focus on the MIECHV program, including what is
    known about whether services funded by the program have improved
    outcomes for young children and their parents and how Congress can
    determine whether spending on such services can produce the best
    results for at-risk families.

    DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

        Please Note: Any person(s) and/or organization(s) wishing to submit
    for the hearing record must follow the appropriate link on the hearing
    page of the Committee website and complete the informational forms.
    From the Committee homepage, http://waysandmeans.house.gov/, select
    ``Hearings.'' Select the hearing for which you would like to submit,
    and click on the link entitled, ``Please click here to submit a
    statement or letter for the record.'' Once you have followed the online
    instructions, submit all requested information. Attach your submission
    as a Word document, in compliance with the formatting requirements
    listed below, by April 16, 2014. Finally, please note that due to the
    change in House mail policy, the U.S. Capitol Police will refuse
    sealed-package deliveries to all House Office Buildings. For questions,
    or if you encounter technical problems, please call (202) 225-1721 or
    (202) 225-3625.

    FORMATTING REQUIREMENTS:

        The Committee relies on electronic submissions for printing the
    official hearing record. As always, submissions will be included in the
    record according to the discretion of the Committee. The Committee will
    not alter the content of your submission, but we reserve the right to
    format it according to our guidelines. Any submission provided to the
    Committee by a witness, any supplementary materials submitted for the
    printed record, and any written comments in response to a request for
    written comments must conform to the guidelines listed below. Any
    submission or supplementary item not in compliance with these
    guidelines will not be printed, but will be maintained in the Committee
    files for review and use by the Committee.

        1. All submissions and supplementary materials must be provided in
    Word format and MUST NOT exceed a total of 10 pages, including
    attachments. Witnesses and submitters are advised that the Committee
    relies on electronic submissions for printing the official hearing
    record.

        2. Copies of whole documents submitted as exhibit material will not
    be accepted for printing. Instead, exhibit material should be
    referenced and quoted or paraphrased. All exhibit material not meeting
    these specifications will be maintained in the Committee files for
    review and use by the Committee.

        3. All submissions must include a list of all clients, persons,
    and/or organizations on whose behalf the witness appears. A
    supplemental sheet must accompany each submission listing the name,
    company, address, telephone, and fax numbers of each witness.

        The Committee seeks to make its facilities accessible to persons
    with disabilities. If you are in need of special accommodations, please
    call 202-225-1721 or 202-226-3411 TTD/TTY in advance of the event (four
    business days notice is requested). Questions with regard to special
    accommodation needs in general (including availability of Committee
    materials in alternative formats) may be directed to the Committee as
    noted above.

        Note: All Committee advisories and news releases are available
    online at http://www.waysandmeans.house.gov/.

        Chairman REICHERT. Well, good morning, and welcome to all
    of you, and thank you all for being here to testify, and thank
    you

    [[Page 4]]

    all for coming to listen, and thank I the Members for being
    here today to participate in today's hearing.
        So, today's hearing is on the new federal Maternal, Infant,
    and Early Childhood Home Visiting program. Someone apparently
    thought naming a program MIECHV made sense.
        [Laughter.]
        Chairman REICHERT. But, fortunately, we have the
    pronunciation of this acronym, and it is relatively simple:
    MIECHV Program. So I am going to stick with that, if you guys
    don't mind.
        At its core, this program is designed to improve outcomes
    for children and families who face the greatest risk for abuse
    and neglect and a host of other problems that place too many
    kids far behind on the road of life. Small home visiting
    programs have operated for decades using a mix of federal,
    state, and private funds. But the MIECHV program, when it was
    created in 2010, marked the first time there was dedicated
    federal funding for this purpose.
        Our purpose today is to review what we know about the
    effects of this program, so we can begin thinking about next
    steps. Earlier this week we got a little more time with the
    program's extension through March 20 of 2015. But there is a
    lot to consider here, so it is good that we have a head start.
        For instance, we need to review whether the actual outcomes
    of this program are living up to its promise, in terms of
    producing better outcomes for children and families. We also
    need to think about whether the program's mix of supporting
    proven and promising approaches continues to make sense. And we
    should consider whether this program should continue to have
    100 percent federal funding, especially since some of the
    positive outcomes we hope to see will benefit our state
    partners.
        For my part, I am interested in how we can apply the basic
    discipline of this program, which uses taxpayer funds to
    support what we know works to help children and families. Two
    other government programs today can't say the same thing.
    Fortunately, we have the--a distinguished set of experts to
    help us sort through these questions more thoroughly today, and
    that list includes a service provider and recipient of home
    visitation services from my home state of Washington, so we
    will have an opportunity to ask some real how-does-this-work-
    at-the-ground-level questions.
        We welcome all of our witnesses today, and we look forward
    to their testimony.
        Chairman REICHERT. Mr. Doggett, would you care to make an
    opening statement?
        Mr. DOGGETT. Thank you very much, Mr. Chairman. And I share
    the objectives that you just outlined. We have heard so much
    over the last several years in this Subcommittee about the
    extent of maltreatment and abuse of children across the
    country, and the need to focus more of our resources not just
    on responding to that abuse after it has occurred, but what can
    we do to prevent maltreatment.
        The enactment of this federal home visiting program,
    building on the experience of many local and state initiatives
    that were already existing back in 2010 I think was an
    important step forward. It is an investment in prevention and
    future development of children. I believe there is considerable
    evidence that this is a wise invest

    [[Page 5]]

    ment, though, as some of our witnesses point out, it may be
    difficult to quantify all aspects of the benefits. And this
    cannot be a one-size-fits-all kind of approach, because these
    are families with children in different kinds of positions, and
    we need to adapt the program and look for the most cost-
    effective way to reach the largest number of children.
        It is not surprising that a group representing some 5,000
    law enforcement officers around the country fight crime, invest
    in kids, has recognized that if you have good home visiting
    programs, they will need to visit, as law enforcement officers,
    fewer homes and other places where violence or crime occurs.
        The decision last week of the House to continue this
    program on a temporary extension of one--another year of
    funding into next spring represents some progress. I think we
    need a little more certainty than going from year to year, or
    six months to six months.
        There has been good benefit from this program in the State
    of Texas, in both the City of San Antonio and in the City of
    Austin and the surrounding areas, there have been programs that
    have benefitted from the Nurse Family Partnership, and there
    has been investment from the State of Texas that has been
    important. Between, really, just over the three years of
    MIECHV, the State of Texas has received about $50 million, a
    significant amount of money, but perhaps not that significant,
    compared to the needs that exist there. The money has not been
    spent in a vacuum; the state has worked to try to build a
    network of high-quality programs, and to invest some of its own
    money in these programs.
        The division of monies in MIECHV so that some of it is
    focused on evidence-based--most of it is focused on evidence-
    based programs, important that we have evidence-based programs,
    but that we also continue to look at a few programs that are
    new and innovative, so that we can assure that we are pursuing
    every alternative that would be cost efficient in this area.
        Mr. Chairman, I would explain to the witnesses that at the
    same time this hearing is taking place, the House Budget
    Committee is marking up a resolution that I really think would
    threaten the continuation of home visiting, child abuse
    services generally, and a wide range of social services. So we
    will be having recurrent votes this afternoon there, and I will
    be in and out, with no disrespect to our very diverse and
    experienced panel, so that we raise appropriate issues in the
    course of the budget resolution.
        And I thank you, and yield back.
        Chairman REICHERT. I thank you, Mr. Doggett. And, without
    objection, each Member will have the opportunity to submit a
    written statement and have it included in the record at this
    point.
        And I want to remind our witnesses to please try and limit
    their oral testimony to five minutes. All of your testimony
    will be included in the record.
        Our panel this afternoon is made up of five folks, as
    everyone can see. And our first witness this afternoon is
    Crystal Towne, RN, Nurse-Family Partnership Home Visitor,
    Yakima Valley Memorial Hospital. Welcome.
        Sherene Sucilla, a former Nurse-Family Partnership Program
    participant; Darcy Lowell, CEO, Child First; Jon Baron,
    president,

    [[Page 6]]

    Coalition for Evidence-Based Policy; and Rebecca Kilburn,
    senior economist, RAND Corporation. Welcome to all of you.
        And, Ms. Towne, you are recognized for five minutes.

     STATEMENT OF CRYSTAL TOWNE, RN, NURSE-FAMILY PARTNERSHIP HOME
                VISITOR, YAKIMA VALLEY MEMORIAL HOSPITAL

        Ms. TOWNE. Good afternoon, Chairman Reichert, Ranking
    Member Doggett, and Members of the Subcommittee. Thank you for
    this opportunity to testify on behalf of the Nurse-Family
    Partnership Program in support of evidence-based home visiting.
        I am Crystal Towne, and I am a nurse home visitor for
    Yakima Valley Memorial Hospital in Yakima County, and have been
    a nurse home visitor since 2003. I am here with one of my
    former clients, Sherene Sucilla, who graduated from the Nurse-
    Family Partnership Program two years ago, and is a wonderful
    example of how this innovative program can empower young
    mothers to succeed. I am here in support of the MIECHV program,
    which is currently serving 80,000 families nationwide,
    including our Yakima County NFP program.
        In Washington, NFP is one of several home visiting models
    offered as part of a continuum of services that are supported
    at the state level. A higher percentage of pre-term and low
    birthweight babies, an agriculturally-driven economy, low high
    school graduation rates, and high gang activity in the area
    make NFP a critical element of the county's continuum of
    services.
        As a nurse home visitor, I work with first-time, low-income
    mothers and their families over the course of a little over two
    years. I visit each client in their homes approximately every
    other week, and I have a caseload of no more than 25 clients at
    one time. These visits begin early in pregnancy, and last until
    the child's second birthday. Through these, I empower each
    client to have a healthy pregnancy, improve her child's health
    and development, and set goals to achieve economic self-
    sufficiency. I do this by meeting the mom where she is at at
    the time, not where I would like her to be. In NFP we call this
    a client-centered approach.
        The NFP curriculum guides us to talk about the right issues
    at the right time, such as how can I stay healthy in pregnancy.
    What do I do when I am stressed out? How can I set goals for my
    life? Breastfeeding and infant attachment. The trust I build
    with my clients begins the moment I walk through their door for
    the first time.
        Sometimes my initial visit is filled with laughter and joy.
    But often times, when serving a young client especially, it is
    filled with great insecurity. The things that I hear most often
    are, ``My parents are so angry with me. My boyfriend is no
    longer there for me. My friends don't understand why I won't go
    out to parties any more. I am so lonely.'' I listen to their
    story for the next two-and-a-half years, building on our
    trusting relationship. I listen to clients who experience
    mental illness, intimate partner violence, substance abuse,
    living in poverty, lack of family support, and health
    disparities.
        Sherene is one of hundreds of stories I have had the honor
    to hear. She is a truly amazing woman and I am so proud to have

    [[Page 7]]

    the opportunity to have been her nurse, her counselor, her life
    coach, her confidante, her support system, and, most
    importantly, I am her friend. Every client's story is unique.
    But since she is here with me today, I would like to share my
    experience as Sherene's home visiting nurse.
        On May 6, 2010, I knocked on her front door for the first
    time. I did not know much about her, only that she was 10 weeks
    pregnant, and she had been in several foster care homes
    throughout her youth. During our first encounter, I wanted to
    ask her several questions, but I did not. I listened. I
    wondered how a young woman could appear so happy and speak
    about her goals for her future and her hopes and dreams, but
    have several scars on her arms. We never have talked about
    those scars. It didn't need to be said. I recognized that
    Sherene's smile didn't always come easily. But, despite her
    past and future challenges, Sherene is a truly resilient woman
    who has the hope and the drive to provide a better life for her
    child.
        Since we have ended the program two years later, today
    Sherene has a job she loves. She is self-sufficient. She is
    living in a wonderful home. And she is actively involved in her
    son's life. She has not given up on continuing her dream for
    continuing her education. But sometimes being a great parent
    means postponing some of those personal goals.
        In closing, NFP applauds the subcommittee and the larger
    body of Congress for support of the MIECHV program. Thank you
    again for this opportunity to testify before you today. I
    appreciate it.
        [The prepared statement of Ms. Towne follows:]

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        Chairman REICHERT. Well, thank you, Ms. Towne. And we
    applaud you for your hard work. And we know that you can't do
    this work without becoming a friend to those that you help.
        Ms. TOWNE. Yes.
        Chairman REICHERT. And thank you for having the heart of a
    servant.
        Ms. TOWNE. Thank you.
        Chairman REICHERT. You are welcome. Thank you, Ms. Towne.

    [[Page 14]]

        Ms. Sucilla, you are recognized.

     STATEMENT OF SHERENE SUCILLA, FORMER NURSE FAMILY PARTNERSHIP
                       (NFP) PROGRAM PARTICIPANT

        Ms. SUCILLA. Good afternoon, Chairman Reichert, Ranking
    Member Doggett, and Members of the Subcommittee. Thank you for
    the opportunity to testify on behalf of the Nurse-Family
    Partnership Program in support of evidence-based home visiting
    and the Maternal, Infant, and Early Childhood Home Visiting
    Program. My name is Sherene Sucilla, and I was a client with
    the Nurse-Family Partnership Program delivered by the Yakima
    Valley Memorial Hospital in Yakima, Washington. And I am the
    incredibly proud mother of my son, Andrew, who is now four
    years old.
        As a client, I received regular visits about every other
    week from my NFP nurse home visitor, Crystal Towne, starting
    when I was just a couple of months pregnant, through my son's
    second birthday. I am here on behalf of the mothers like me,
    the children like my son, Andrew, and families like our own, in
    support of home visiting. I am honored to be here today, to get
    to thank you all in person for your commitment to improving the
    health and well-being of children and dedicated funding for
    evidence home-based visiting programs.
        This program has meant so much to me and my family, and I
    know that if every mom could be here today to share their
    experience with you, they would be, because it really is a
    changing experience to be here--to be in this program, excuse
    me.
        I grew up in Yakima, Washington. When I was 12 years old I
    went into foster care and remained there through my 18th
    birthday. In those six years I attended seven high schools,
    which made it very difficult to graduate on time, because I
    didn't go to school in the same district, so the credits didn't
    transfer properly. But I did graduate on time, through a lot of
    hard work. While being in foster care isn't an experience I
    would wish on any child growing up, I would say that that
    experience has shaped who I am today.
        When I was younger, my mom wasn't really a mom. I didn't
    really have a role model for parenting. And so, when I found
    out I was pregnant, I didn't really know what to do. I didn't
    have anything to go off of, and I was really scared, and I was
    in this by myself.
        I heard about the Nurse-Family Partnership Program through
    my doctor's office when I found out I was pregnant. Because I
    was a first-time mom and I met other eligibility requirements,
    they referred me to the Yakima Valley Memorial Hospital NFP
    program and Crystal, and I was set up with an appointment for
    Crystal to come to my home and talk more about the program.
    After our first meeting, I knew that this was the right program
    for me, and I looked forward to our regular home visits.
        At that point I was new to everything when it came to
    parenting. But Crystal was a huge help to me and my family. She
    helped me build confidence and open doors for me to set goals
    for my life, for myself, and for my family. She helped me find
    other services I needed, such as dental care, and she would
    take my blood pressure when I was pregnant, to make sure that I
    was doing okay. And when I had trouble breastfeeding, Crystal
    had a breast pump overnighted to me.

    [[Page 15]]

        And at one point when I was nursing I was afraid that my
    son wasn't getting enough to grow at a healthy rate, but
    Crystal would bring a scale, and we would weigh Andrew every
    week, and she reassured me that he was getting what he needed
    to grow well and according to schedule. That was the first
    major moment for me, where I felt like I was doing a good job,
    that I was a good mother, and that I was getting him what he
    needed. And now, at four years old, I can often say that he is
    the tallest kid in his class.
        I was also nervous about his development. Like every
    parent, you want to make sure that your baby or child is
    keeping up with different milestones, and I didn't know how to
    assess that. But Crystal would bring in questionnaires called
    the Ages and Stages Questionnaire, or ASQ, to assess his
    development at different points in time, and we would know that
    his development was on track.
        I remember throughout the program Crystal would say to me
    that my son Andrew was a very caring person from a very young
    age. He was about 13 months when Crystal first commented on how
    sweet he was. He would give Crystal a hug and actually pat her
    on the back. At the end of each visit she would leave a form
    with lots of different feedback, including highlights from that
    visit, what our next visit would be about, and what I needed to
    do before our next visit. Looking back at one of the forms,
    Crystal mentioned how I was raising such a sweet and loving
    child that his hugs and pats melted her heart.
        Crystal was able to point out to me these different signs
    he was showing of being a very caring human being, even when he
    was just a toddler, and I remember realizing that if I was
    raising a son that loving, I really was doing something right,
    as a parent.
        When I found out I was pregnant, I worked at a barbecue
    stand. When Crystal and I started talking about my future, she
    helped me look into going back to school. Ultimately, I ended
    up getting a job and a great career through steps I took when
    Andrew was younger. I now work in accounts payable for a local
    heating and air conditioning company, and I have been there for
    about a year-and-a-half. And I have great job security, as I am
    the only one in the office doing what I do.
        It has been really special and wonderful to look back at
    all the records that I have while in this program. I have a big
    binder of all the work, the pictures, and activities that we
    did. And it is lovely. I can go back and read all my thoughts
    and feelings from the beginning of my pregnancy to his age of
    two, when he turned two, and that is really special for us, now
    that he is four, we can go back and look at everything.
        I really hope that Congress will continue supporting the
    MIECHV program, which supports great programs like NFP. Thank
    you again for the opportunity to testify today.
        [The prepared statement of Ms. Sucilla follows:]

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        Chairman REICHERT. Great job. Is this your first time
    testifying in front of Congress?
        Ms. SUCILLA. Yes.
        [Laughter.]
        Chairman REICHERT. You didn't even come across nervous.

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        Ms. SUCILLA. I am sweating.
        [Laughter.]
        Chairman REICHERT. So are we. Future congresswoman sitting
    there, I think.
        You know, I just have to make this comment. You did a
    wonderful job, and, Ms. Towne, you did a wonderful job, also.
    And I know it is not easy to come before Congress and testify.
    But the people up here are just regular people, we just happen
    to be sitting in these chairs, elected by the folks that we
    represent. But we all come from backgrounds that you might be
    surprised to hear about.
        You know, I grew up in a home. Ran away from home and from
    domestic violence. And I never became a foster child--by the
    way, we are working on some foster care legislation that can
    help kids stay in school and have those records follow, and
    hopefully stay in one foster home, and hopefully, more than
    anything, get adopted and have a family they can call their
    own. So we are working on all of that. And I am sorry you had
    to go through that, but that just fits into everything that
    this Committee is trying to accomplish. And you are an all-
    star, as far as we are concerned.
        Ms. SUCILLA. Thank you.
        Chairman REICHERT. Yes. Ms. Lowell, you are recognized for
    five minutes. Microphone?
        Ms. LOWELL. Good, okay. Thank you.
        Chairman REICHERT. There you go.

              STATEMENT OF DARCY LOWELL, CEO, CHILD FIRST

        Ms. LOWELL. So, good afternoon. My name is Dr. Darcy
    Lowell, and I am honored to be here to talk to you today. Thank
    you for this opportunity to testify on behalf of Child First
    home visiting and the MIECHV program. And thank you so much for
    your support of the MIECHV extension; it is so needed.
        I am a developmental and behavioral pediatrician, and the
    founder and CEO of Child First. I also serve as an Associate
    Clinical Professor at Yale University School of Medicine.
        Early in my career, I saw the struggles of vulnerable
    children and families firsthand, as they tried to cope with
    trauma and depression, homelessness, and hunger. We needed to
    think about intervention in a very different way, and so Child
    First began. I want to give you a feeling for the kinds of
    families that we work so closely with, and that we serve. And
    here is a little vignette about one of them.
        The Child First mental health clinician met a mother at a
    pediatric visit for her three-year-old daughter, Maria. The
    mother was severely depressed. She had run from her husband
    because of ongoing domestic violence. She and her three
    children lived in an empty apartment without beds or a kitchen
    table. Little Maria was about to be expelled from child care
    for aggressive behavior. Mom worked three jobs, but was still
    way behind in her rent payments, and the family was about to be
    evicted. She was desperately afraid that she would lose her
    children to foster care.
        The care coordinator learned from the family that they had
    been on TANF, but Mom was no longer receiving a check. She, the
    care coordinator, immediately contacted the Department of
    Social Services and found out that the check was being sent to
    her husband

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    in prison. In less than a week, the check was redirected to the
    mother. The family situation improved dramatically. Mom now
    only needed to work one daytime job, and was able to focus on
    her children. The clinician worked psychotherapeutically with
    Mom and Maria together, and also consulted in the preschool.
    Maria's behavior improved markedly. Mom's depression lifted.
    The care coordinator coached Mom as she worked out a schedule
    with the landlord to pay back rent. The life course of this
    family changed dramatically.
        What we know is scientific research on early brain
    development has clearly demonstrated that growing up with
    stresses of poverty, violence, depression, substance abuse, and
    homelessness produce a rise in stress hormones and other
    metabolic chemicals that can severely damage the developing
    brain and other body systems. This may lead to academic
    failure, serious mental health problems, and chronic disease,
    including heart disease, cancer, and diabetes.
        However, it is now scientifically documented that the
    presence of a secure, safe, nurturing relationship between a
    parent and a young child is actually able to protect the
    developing brain from damage. We must, therefore, provide
    intensive intervention at the earliest possible time.
        Child First works with the most challenged families,
    targeting young children under the age of six who suffer from
    behavioral and developmental problems and abuse and neglect. We
    take a two-pronged approach--based on what we now know, what
    the scientific literature tells us--with a team of two
    professionals working in the home.
        First, we must decrease the enormous stress in the
    environment, and help stabilize families. Our care coordinators
    work with our parents to connect them to comprehensive,
    community-based services and supports, like medical services,
    safe housing, early education, and literacy. Through this
    process, our care coordinators build the capacity of our
    parents, and help them to build internal organizational skills
    that enable them to be successful as parents and workers.
        Second, we build the nurturing, responsive, parent-child
    relationship, because that is what protects the developing
    brain, even in the face of adversity. Our mental health
    clinicians use Child-Parent Psychotherapy to heal these two
    generations, while they help parents promote safe environments
    for their children to grow and develop, which makes them so
    ready for school.
        To evaluate our model, we conducted a randomized controlled
    trial with strong, positive results in child language,
    behavior, maternal mental health, and decreased involvement
    with Child Protective Services; and with replication we
    actually have been able to have even better results, with 89
    percent of our families improving in at least one major area.
        Child First has only the capacity at this time to serve
    1,000 children each year in Connecticut, but we know the need
    is enormous. We have replicated through a public-private
    partnership with the Robert Wood Johnson Foundation,
    especially, and our Department of Children and Families. MIECHV
    has been instrumental in allowing us to move to eight new
    cities. This support is so essential.

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        The return on investment is substantial. And though I have
    no time to tell you about it now, I will say that Child First
    only costs about $7,000 a year. And if you have psychiatric
    hospitalization for just three months for one child, it is
    $130,000. There is major savings in multiple sectors.
        I thank the committee most sincerely for your interest and
    efforts in support of the MIECHV home visiting program serving
    vulnerable children and families. Thank you.
        [The prepared statement of Ms. Lowell follows:]

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        Chairman REICHERT. Thank you. Great job.
        Mr. Baron?

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    STATEMENT OF JON BARON, PRESIDENT, COALITION FOR EVIDENCE-BASED
                                 POLICY

        Mr. BARON. Thank you, Chairman Reichert, Members of the
    Subcommittee. I appreciate the opportunity to testify about
    MIECHV on behalf of the Coalition for Evidence-Based Policy.
    The Coalition is a non-profit, non-partisan organization that
    has no affiliation with any programs or program models, and we
    have no financial interest in any of the policy ideas that we
    support.
        We strongly support reauthorization of MIECHV. MIECHV
    represents an important new and bipartisan approach to social
    spending, in that it uses scientific evidence of effectiveness
    as a central factor in determining which activities to fund. As
    a result of this evidence-based approach, MIECHV is funding the
    large-scale implementation of some home visiting program models
    that, as I will discuss in a moment, have been rigorously
    demonstrated to produce major long-term improvement in the life
    outcomes of at-risk children and mothers.
        MIECHV's evidence-based approach is bipartisan in origin.
    The Bush Administration's 2007 pilot, for example, directed HHS
    to ``ensure that states use the funds to support home visiting
    program models that have been shown in well-designed,
    randomized, controlled trials to produce sizeable, sustained
    effects on important child outcomes, such as abuse and
    neglect.'' Randomized trials are considered the most rigorous
    evaluation method.
        Similarly, the full MIECHV program, implemented under the
    Obama Administration, directs HHS to allocate at least 75
    percent of the program's funds to ``evidence-based home
    visiting models,'' and uses a slightly different but still
    rigorous standard to determine what qualifies as evidence-
    based.
        Why does this matter? Because rigorous studies have found
    great variation in the effectiveness of different home visiting
    program models. At one end of the spectrum, for example, is the
    nurse-family partnership, which provides nurse home visitation
    services to low-income, first-time mothers. This model has been
    shown in three well-conducted randomized trials to produce
    major, long-term improvements in participants' life outcomes,
    such as a 20 to 50 percent decrease in child maltreatment and
    hospitalizations, and an 8 percent higher grade point average
    through elementary school for the most at-risk children. And,
    in one trial, a $13,000 reduction in families' use of welfare,
    food stamps, and Medicaid, that more than offset the program's
    cost.
        At the other end of the effectiveness spectrum, for
    example, is the Comprehensive Child Development Program, which
    was a 1990s HHS home visiting program in which trained para-
    professionals provided home visits to families with young
    children, designed to teach parenting skills and connect
    families with community services. This was a well-intentioned
    and a well-implemented program. But when evaluated in a
    rigorous, randomized trial, it unfortunately was found to
    produce no effects on any of the hoped-for outcomes, including
    children's cognitive and social development, child health, and
    parents' economic self-sufficiency.
        More generally, two recent, impartial reviews that examined
    which home visiting models had rigorous evidence of policy-
    important impacts on child maltreatment and other key outcomes
    found

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    several models to be effective or promising, including the two
    that we have heard from today, but a larger number to produce
    no meaningful effects. That pattern is not unique to home
    visitation. In almost every field in which rigorous trials are
    conducted, including medicine, business, and K-12 education,
    the effective interventions are almost always found to be
    outnumbered by interventions producing weak or no impacts.
        What this means is that if MIECHV were to allocate funds
    the usual way, without regard to rigorous evidence, it would
    primarily be funding program models that produce no meaningful
    impacts, and might miss the opportunity to scale up the few
    effective models that can improve people's lives in an
    important way. As I describe in my written testimony, MIECHV's
    evidence-based design has succeeded, in part, in focusing funds
    on the subset of effective models and, for example, is funding
    national implementation of the Nurse-Family Partnership, as
    well as the scale-up of other effective evidence-based models,
    like Child First. We believe this is a very important
    achievement.
        We also suggest a modest legislative revision in my written
    remarks to close a loophole that has allowed some of MIECHV's
    funding to go toward ineffective models. I would be happy to
    discuss this further, if of interest.
        [The prepared statement of Mr. Baron follows:]

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        Chairman REICHERT. Thank you, Mr. Baron.
        Ms. Kilburn, you are recognized for five minutes.

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         STATEMENT OF REBECCA KILBURN, SENIOR ECONOMIST, RAND
                              CORPORATION

        Ms. KILBURN. Chairman Reichert, Ranking Member Doggett, and
    Members of the Subcommittee, thank you for the opportunity to
    testify today about the MIECHV program. My name is Rebecca
    Kilburn, and I am a senior economist at the RAND Corporation.
    My testimony will draw upon a 15-year program of research
    performed at RAND by me and my colleagues.
        We are here today to discuss what we know about whether the
    MIECHV program improves outcomes for children and their
    parents. The Federal Government has sponsored a rigorous study
    of the effects of MIECHV, but initial findings from that study
    will not be available until next year. Absent the results of
    that study, today I will describe currently available research
    that informs MIECHV.
        I am going to discuss two ways that existing research
    findings inform MIECHV. First, I am going to describe research
    related to the rationale for MIECHV. And, second, I am going to
    make recommendations regarding research-supported features of
    MIECHV that raise the likelihood of it achieving its desired
    objectives.
        First, as you have heard, rigorous evaluations have
    demonstrated that a diverse set of home visiting models can
    improve a spectrum of outcomes for children and parents.
    Programs have been able to improve outcomes in the short run
    and the long run, and some, but not all, evidence-based
    programs have found that programs generate government savings
    that more than outweigh the costs. In other words, a growing
    research base has identified evidence-based home visiting
    models, and supports the theory of change underlying MIECHV:
    that scaling up home visiting to large numbers of at-risk
    families has the potential to improve outcomes for children and
    parents; improve population level outcomes, such as reducing
    rates of low birthweight or child maltreatment; and these, in
    turn, should save government money in the long run.
        The primary contribution of MIECHV is to test the idea that
    broadly scaling up home visiting can transform our approach to
    human services.
        Having a research-supported rationale does not imply that
    an initiative will necessarily be effective. The initiative
    must be well structured and well implemented. I will now
    discuss design features of MIECHV that research indicates will
    raise the likelihood of improving outcomes for at-risk
    families.
        Lawmakers should preserve these three existing features of
    MIECHV. First, continuing to concentrate MIECHV funding on
    evidence-based models will make the chances greater that MIECHV
    funds will have their intended impact. Second, drawbacks to
    funding exclusively evidence-based models are that it could
    stifle innovation and prevent us from discovering models that
    may be effective, but have not been evaluated.
        A second feature to preserve are mechanisms in MIECHV that
    circumvent these drawbacks. One is allowing 25 percent of the
    funding to be used for promising models that are being
    evaluated, and the other is funding the MIECHV competitive
    development grants, which allow states to apply for funding, to
    pilot test, and evaluate innovations in home visiting.

    [[Page 41]]

        Third, in order to achieve the best outcomes for children
    and families, it is not only necessary to deliver programs that
    work, but it is also necessary to implement them well. The
    third feature of MIECHV that should be preserved is the
    implementation supports it provides states and other grantees.
    These include training and professional development, plus
    technical assistance that helps states engage in best practices
    in evidence-based program implementation. These best practices
    include conducting needs assessments, identifying goals,
    collecting and reporting outcome data, and engaging in
    continuous quality improvement.
        At the same time that the federal home visiting program has
    expanded, states have also been increasing their funding for
    home visiting. The MIECHV program is partnering with states to
    build state home visiting infrastructure, with the MIECHV
    program leading the drive to integrate best practices into home
    visiting implementation.
        To conclude, there are also a couple of ways that MIECHV
    could be strengthened to further raise the chances of achieving
    the best outcomes for children and families. One is that while
    25 percent of MIECHV funds can be used to deliver promising
    home visiting models, MIECHV currently does not support a path
    by which potentially effective models could undergo evaluation
    that would lead them to be designated as evidence-based. The
    types of evaluations that the MIECHV evidence standards require
    often cost upwards of $1 million, representing a substantial
    barrier to discovering the next evidence-based model.
        Second, MIECHV can better harness the power of performance-
    based accountability, which links performance measures to
    funding or targeted technical assistance. MIECHV currently
    requires states to collect benchmarks related to family
    outcomes, which is a cutting-edge aspect of the program. While
    monitoring outcomes is desirable, there may be opportunities to
    better monitor states' organizational performance, such as
    number of families served, and, importantly, for MIECHV to more
    closely link performance measures to consequences or targeted
    support to generate improvement.
        Thank you for allowing me to appear before you today, and I
    look forward to taking your questions.
        [The prepared statement of Ms. Kilburn follows:]

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        Chairman REICHERT. Well, thank you very much for your
    testimony, Ms. Kilburn. Thank you all for your testimony. And
    we are going to go into the question phase now. We will just
    ask a few questions. It will be easy, don't worry about it.

    [[Page 55]]

        [Laughter.]
        Chairman REICHERT. So, I was a police officer for 33 years
    before I came to Congress. So I just look like I have been here
    for 40 years, but I have only been here 9. I received phone
    calls this past week from sheriffs, from police chiefs from
    Washington State, very much supportive of fighting crime, and
    investing in kids. We get it, because we know if we put the
    money up front, we are going to be saving a lot of money at the
    back end. And that is a hard thing, for people who legislate,
    to really see the long-term, and the long-term goal here. You
    all see it very clearly.
        But we have heard about evidence-based, scientific--I
    think, Mr. Baron, you said scientific evidence and
    effectiveness to decide which programs to fund. And, Ms.
    Kilburn, you talked about design features in three points that
    you made about evidence-based models and funding for evaluation
    and implementation of supporting programs. And what I want to
    try and do is to tie together what you do with what is
    happening, where, as cops would say, where the rubber meets the
    road, where Ms. Towne and Ms. Sucilla are.
        And, you know, what--because you may have never heard about
    implementation supports and things like that, where--no, I
    didn't think so. So you are down here, doing the work. How
    does--so this is for both of you--how does what you are doing
    and what you are going through, how does that get filtered up
    to the folks that are making those decisions and trying to
    figure out what is working and what is not working? What worked
    and--so, just real quickly, what worked in your case? What was
    the--you know, you touched on some of it.
        Ms. SUCILLA. Sorry, I am trying to understand the question,
    I guess.
        Chairman REICHERT. So you are working with Ms. TOWNE.
        Ms. SUCILLA. Yes.
        Chairman REICHERT. And the programs that you got involved
    in that she helped direct you to, what were those programs that
    you saw that really--kind of a light bulb went on as to this
    really is going to work? This program works, or that program.
    If you got sidetracked into a program that you thought, boy,
    this isn't going to work at all.
        Ms. SUCILLA. [No response.]
        Chairman REICHERT. You can help her, if you want to.
        Ms. TOWNE. Are you asking about perhaps she participated in
    programs in addition to Nurse-Family Partnership?
        Chairman REICHERT. Yes. I mean anything that--so she
    finally comes to you, and you give her places where she is
    going, and it is working. How does that get communicated to the
    administrators who are making some decisions as to, you know,
    what programs work, what programs don't work? It is evidence-
    based, right?
        Ms. TOWNE. Correct.
        Chairman REICHERT. So how does that evidence get moved up
    to, filtered up to----
        Ms. TOWNE. Okay. So you are asking specifically about the
    data.
        Chairman REICHERT. Yes.
        Ms. TOWNE. Is that--okay, thank you. I was--okay. At visits
    at various time periods that are structured by the program. So,
    for in

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    stance, in pregnancy, at 36 weeks, at birth, 6 months, 12
    months, 2 years, we collect data from Sherene in the form of
    various questions that are then submitted to the University of
    Colorado for research purposes.
        Chairman REICHERT. Okay.
        Ms. TOWNE. Is that what you are----
        Chairman REICHERT. Yes, yes, sure.
        Ms. Towne [continuing]. Asking? Yes. For--as part of the
    curriculum and part of the model for Nurse-Family Partnership,
    they have outlined very specific questions and data they are
    collecting at different times throughout that two-and-a-half
    year period.
        Chairman REICHERT. Okay.
        Ms. TOWNE. And it is handled through the University of
    Colorado.
        Chairman REICHERT. Do you ever feel like you are working in
    an area where--if a program that is not working, and you are
    able to give feedback data to the--to Denver that this isn't
    really working at the--you know, where the rubber meets the
    road sort of a----
        Ms. TOWNE. [No response.]
        Chairman REICHERT. No?
        Ms. TOWNE. I don't see that, as a home visitor, because the
    beauty of the Nurse-Family Partnership program, again, is that
    it is client-centered. So it is not necessarily myself
    dictating what we discuss throughout each visit. It is really
    looking at the guidelines of suggested topics, but allowing
    Sherene to choose what she feels would be most helpful.
        Chairman REICHERT. Okay, you just hit on the answer, right
    there. She chooses.
        Ms. TOWNE. She absolutely----
        Chairman REICHERT. Yes.
        Ms. TOWNE. Every visit--the way it works in my home
    visiting practice is at the end of every visit we look at what
    options are available to discuss at the next visit. And I guess
    ``available'' isn't maybe the right word. First, Sherene can
    choose. Maybe there is something on her mind that is really not
    a part of the guidelines, and that is okay.
        Chairman REICHERT. Okay.
        Ms. TOWNE. But she can also look at the guidelines and
    topics, and choose one of those.
        Chairman REICHERT. Great. Thank you for your answer. Mr.
    Davis, you are recognized.
        Mr. DAVIS. Thank you very much, Mr. Chairman. And let me
    thank all of our witnesses.
        I have been tremendously impressed with all of your
    testimonies for a number of reasons. And one is that, for all
    of my life, I have been intimately involved with, associated
    with, know people personally, who could make use of this
    program and of these services. And since being in Congress for
    a decade, I have worked with Republican colleagues to advance a
    strong federal investment in home visiting.
        This bipartisan effort drew on research and economic status
    documenting that investing in our youngest citizens yields high
    returns in the form of healthier children and families, and
    taxpayer

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    savings. The voluntary home visiting law was designed as an
    investment in evidence-based prevention.
        In Illinois, 30 percent of children entering out of home
    care for the first time are under the age of 1, slightly higher
    than the national rate. In Chicago, roughly half of those
    babies enter before they are three months old. This pattern is
    generally true, nationwide. These statistics put into context
    the importance of home visiting, which focuses on strengthening
    children and families by supporting pregnant women and parents
    with young children.
        The role of home visiting is particularly important, given
    the recent study reported in JAMA--that is the Journal of the
    American Medical Association--about an increase in infants'
    death, potentially due to the economy. Supporting young
    children and families is critical to preventing harm and
    strengthening children.
        Mr. Chairman, I have got two documents I would like to
    submit for the record.
        Chairman REICHERT. Without objection.
        [The information follows: Mr. Davis 1, Mr. Davis 2]
        [Member Submissions for the Record follows:]

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                               Rep. Danny Davis 1

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                               Rep. Danny Davis 2

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        Mr. DAVIS. I also--well, let me ask you, Ms. Kilburn. You
    mentioned in your testimony that studies--that the Federal
    Government has studies underway, and the data has not all been
    collated and put together, and so there is not a report yet.
    But without that report, would you say that home visiting is
    really an effective way of helping to strengthen and prepare
    children and their families that ultimately will provide them
    with healthier lives, and even save our taxpayers a great deal
    of money?

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        Ms. KILBURN. There is a strong research base that supports
    the idea that these individual programs can improve outcomes
    for children and families. What MIECHV adds to that is allowing
    us, for the first time, to test the concept of scaling that up
    on a large basis in order to see if we can capture those
    effects that were found in individual programs at a community
    or a city or a state level.
        So, there is a lot of evidence to support the basic idea
    behind MIECHV, and now we are really testing if it can achieve
    this transformation in the way we deliver human services so
    that instead of treating things after the fact, we prevent
    them. And so there is a large research basis that supports that
    idea, and we are really testing it right now.
        Mr. DAVIS. And I guess the reason I indicated--I said that
    for all of my life I have been associated--I have lived in low-
    income communities all of my life, growing up, and, of course,
    even today. I used to train community health aides, basically,
    to do home visiting, and basically to make assessments of the
    health needs of individuals in the community who often times
    would not come to the clinics unless they had been prompted a
    little bit, prodded a little bit.
        And I know that there have been people who have said that
    these programs are unnecessary, that they don't really work,
    or, if they do, let the local governments and the state
    governments provide the resources. Are you aware that the
    Federal Government, based upon your research, has been very
    instrumental in making these programs work, and work
    effectively?
        Ms. KILBURN. I don't think we have research evidence on
    MIECHV, per se. But what MIECHV is doing is providing the data
    for us to answer that question. We don't have that right now,
    but the study underway will provide insights into that.
        The reason it is important that the Federal Government does
    this is that, while the individual states have been increasing
    their investments in home visiting, it hasn't been in a
    systematic way that supports evidence-based programming and
    that provides infrastructure support to implement programs
    while also using evidence-based practices in implementation.
        And so, if we allowed the states to do it one by one, we
    wouldn't really know the answer to that question: Does scaling
    this up transform human services? We just have a patchwork or
    sprinkling of different, smaller experiments.
        Chairman REICHERT. Thank you, Mr. Davis.
        Mr. DAVIS. Thank you very much. Mr. Chairman, let me just
    thank you on assembling one of the most outstanding panels I
    think that I have heard testify on this matter. So thank you
    all very much.
        Chairman REICHERT. Thank you.
        Mr. DAVIS. Thank you, sir.
        Chairman REICHERT. Thank you to the staff. Mr. Kelly, you
    are recognized.
        Mr. KELLY. Thank you, Chairman. And I agree with Mr. Davis;
    this is a good panel to have before us.
        One of the things that I have been wondering about--and, of
    course, it seems to me that home visits are critical if we are
    going to continue to support families. And I think one of the
    things that

    [[Page 69]]

    we have seen in our cultural that is causing a greater problem
    is the fact that the nuclear family is now not at the same
    level it used to be.
        Now, some of these programs are working, but there is a lot
    of areas that they are not working. What could we do to change
    that?
        Mr. Baron and Ms. Kilburn, you both had testimony towards
    that. So how do we look at a good return on the investment for
    the American taxpayers that we actually make a difference in
    these peoples' lives?
        And, Ms. Sucilla, I really applaud you for what you have
    been able to do. But that is an example of the success of it.
    So, tell me. What else could we do? What programs aren't
    working? And how would we redirect or redeploy those dollars to
    make sure that there is a better return on it, not just for the
    taxpayers, but also for the people that we are spending the
    time with?
        Mr. BARON. Well, for some of the more effective models,
    like the Nurse-Family Partnership, one of the things that they
    did was they measured long-term impacts for both the people who
    got the program, the program group, and a control group of
    families that did not get the program. They measured their use
    of public assistance over a 12-year period, and found that the
    savings in families' use of public assistance more than offset
    the initial program cost. So, at least for that model, there
    was strong evidence not only of improvement in people's lives,
    but savings to the taxpayer.
        But MIECHV funds, as I mentioned, a diversity of home
    visiting models, some of which have been found in rigorous
    studies not to be as effective. One of the things that could be
    done to shift funds within this program to more effectively
    focus on programs that really make a difference in people's
    lives is to slightly change the evidence standard to make a
    modest but important revision in the evidence standard.
        Right now, the program's standard for ``evidence-based'' is
    that the program model produces statistically significant
    effects. But the standard does not ask whether those effects
    are of policy or practical importance, like reduced use of
    public assistance or reduced child maltreatment rates. That has
    opened a loophole in the program, a modest loophole, allowing
    several models to qualify as evidence-based, solely on the
    basis of statistically significant effects on outcomes that may
    not be particularly important, or effects that may be tiny in
    magnitude. That would be one----
        Mr. KELLY. Okay, but as you look at this, you have data
    that you can look at across the board on different programs.
        Mr. BARON. Yes.
        Mr. KELLY. You have the ability, then, to look at which
    ones are working and which ones aren't working. And I would
    just think that, when you look at that, and you are looking for
    a really good return on the investment, we are talking about
    building a stronger society, and you only can do it through
    building stronger families, which will result in stronger
    communities and a stronger country.
        So, when you look at these, then, how do you separate one
    from the other, say, you know, ``This is one that we see
    working. These other ones aren't doing what they are supposed
    to do.'' Ms. Towne and Ms. Sucilla talked about how that one
    worked for them. And I will just tell you, being a grandfather
    and having eight grand

    [[Page 70]]

    children--two more on the way--I have seen what can happen with
    families that are very supportive, and they get help from the
    outside.
        So, you have the ability to do this, though. You can
    actually compare programs and say, ``This one works, this one
    is not working the way it should,'' and you can redeploy those
    dollars. That is the effort that you are trying to do. Is that
    not correct?
        Mr. BARON. Yes. A very--a straightforward way to do it,
    which is used in many different areas now, increasingly in
    social spending as well as in medicine. A home visiting program
    model generally does not have enough money to serve every
    family that qualifies. So one thing that is often--that is
    sometimes done is to do a randomized control trial, where you
    use a lottery--meaning random assignment--to allocate some
    families to receive the program, and other families, an
    equivalent set who serve as a control group. They get access to
    the usual services in the community.
        And then you track outcomes, important outcomes, over time,
    like rates of child maltreatment for the program group versus
    the control group; families' use of public assistance in the
    program group versus the control group. And the outcomes there
    will tell you which program--in a scientifically----
        Mr. KELLY. Are you able to share that information back and
    forth, then, and actually, you know, come up with a change,
    then, and actually look at this as the best--this is the best
    way to spend those dollars? You can only spend a dollar once,
    so you want to make sure it is spent the right way. So, to get
    the most mileage out of it, you can actually share that data
    and improve these programs.
        Mr. BARON. That can be shared. And, in fact, MIECHV does
    that, it looks at that data, and it allocates--the grants are
    made toward--on the basis of evidence as one of the main
    selection criteria, that kind of evidence. There are ways in
    which that evidence criterion can be strengthened. But, in
    general, the program allocates funds naturally, based on that
    data we were just talking about.
        Mr. KELLY. Okay, all right. Thank you. And just to--so we
    can redeploy these dollars the right way after we have looked
    at this evidence that is conclusive. And you say, ``Listen, we
    don't need to spend money over here. This program is not coming
    up with the results that we need,'' and we can redeploy.
        That is my main concern, because I think too often we
    continue to spend money on programs that aren't effective. And
    we say, ``Well, why do we do this?'' It is because we have
    always done that. That is not the answer. The answer is to
    change it so it benefits families more.
        Mr. BARON. I couldn't agree with you more. That is one of
    the unique features of this program, as opposed to the way
    social spending is often done--social programs are often done--
    that in this case money is allocated on the basis of evidence.
    So, if new findings come in showing a particular model is
    effective, or a particular model is not effective, the funding
    is naturally, through the grant-making process, allocated
    toward the more effective models.
        Mr. KELLY. Okay, good, thank you.

    [[Page 71]]

        Chairman REICHERT. Thank you, Mr. Kelly. I think that is
    the question I was asking, too. Mr. Kelly and I, we are going
    at it at different angles, as to how the information is shared,
    the programs are changed, so that they fit what the star of our
    show today needs.
        So, Mr. Renacci, you are recognized.
        Mr. RENACCI. Thank you. And I want to thank you, Chairman
    Reichert, for holding this hearing, and highlighting the
    importance of using evidence brand models to home visiting
    programs. And I also want to thank the witnesses. This is a
    great panel of witnesses.
        In my home state of Ohio, an estimated 1.8 million Ohioans
    are living below the poverty line. Poverty has increased by
    approximately 58 percent over the last decade, despite a
    stagnant population and a whole host of federal programs
    created to end the cycle of poverty. So I am glad we are here
    today to discuss policies that work.
        Ohio's rate of infant mortality is also ranked the 11th
    worst in the nation, averaging 7.7 deaths per 1,000 births in
    the first year of life. In fact, according to a study conducted
    by researchers at Case Western Reserve University, infant
    mortality exceeds some third-world countries in certain
    neighborhood surrounding the university's circle area in
    Cleveland.
        While I applaud the efforts of home visiting programs that
    have been proven to improve the safety and well-being of
    infants and children, we as a nation cannot continue to
    financially support ineffective programs. As a small business
    owner, when I implemented a particular program, I also wanted
    to ensure that the procedures that I created were effective and
    really meeting certain goals that I created for those
    employees. Businesses--and my business--actually measured our
    programs and used evidence-based models in order to guarantee
    success. And I think the Federal Government should be no
    different.
        As a Member of Congress, I want to protect taxpayer dollars
    from going toward ineffective programs, and redirect them
    toward programs that do what is intended, and lift individuals
    out of poverty. I really hope, together with my friends across
    the aisle, that we can determine what works, what doesn't work,
    and can make--so that government can finally empower
    individuals to become independent and self-sufficient.
        Ms. Towne and Ms. Lowell, both of your programs have been
    shown to increase the safety and well-being of young children.
    For example, I know families who have gone through the Nurse-
    Family Partnership program, have been shown to have fewer child
    injuries, fewer emergency room visits, and less reported child
    abuse and neglect. Families participating in Child First also
    are less likely to be involved with Child Protective Services,
    even after three years. Both of your organizations have had
    some successes. What do you think are really some specific
    factors that have led to these outcomes or successes?
        I will start with you, Ms. TOWNE.
        Ms. TOWNE. Could you repeat the last part of your question,
    please?

    [[Page 72]]

        Mr. RENACCI. Yes. What do you think are some of the
    specific factors that have led to these outcomes or successes
    for both of your programs?
        Ms. TOWNE. That is a complex question. I would say that
    there are many factors of the Nurse-Family Partnership model
    that have led to success. From a home visiting point of view, I
    believe that it is the length of time and the intensity of the
    program that allows me to continue to support a family for two-
    and-a-half years in developing a strong infant bond, a strong
    family--a stronger family unit than when our relationship had
    started is part of what helps.
        Mr. RENACCI. So you are zeroing in on the two-and-a-half
    years, making sure the program--you feel pretty strongly about
    the two-and-a-half year time frame.
        Ms. TOWNE. I feel pretty strongly that a larger length
    period of time, along with the intensity of the visits--we are
    looking at approximately two hours per visit every other week--
    allows quite a bit of time for growth.
        Mr. RENACCI. Ms. Lowell, do you have any----
        Ms. LOWELL. Yes. I think that for us, there are a number of
    factors. One is the intensity of the training for our staff. We
    are working with both bachelor's level care coordinators and
    master's licensed clinicians, as our mental health clinicians
    who go in the home. And we have a training period that lasts a
    year's time (not before they can start; they start after an
    intensive two-week training). But we both have what is called a
    Learning Collaborative, which lasts a year's time, and we have
    our senior clinical consultants working with each new site on a
    weekly basis.
        So, we are really looking at, ``do you have fidelity to the
    model, do you really understand what the work is about, and are
    you doing it well?'' And we also look at implementation
    measures on an ongoing way every single month, and we also look
    at outcomes, at baseline six months and at discharge. So we are
    able to say, ``Do we have a problem here? Are the people who
    are implementing this model doing it really well? Are they
    doing it according to the model fidelity,'' which I think is
    essential.
        The other really important piece about the work itself is
    it is built on relationships and on building relationships. And
    I think that, at least when you talk about the families that we
    serve, which are the most vulnerable, they are the ones who
    have had abuse and neglect, domestic violence, homelessness,
    substance use; these are really difficult families. They don't
    trust easily. And they are not very willing to let new people
    into their lives. And it takes time to build that relationship.
    But when you have built that relationship of trust, you are
    able to make a real difference. These are families who want to
    do the right thing, they want to do the best for their
    children. They are there. But it is a process.
        And so, if you can build that relationship you can work
    with both the parent or care giver and the child
    therapeutically, to understand what are the barriers, what are
    the problems. But it is not so simple. We can't just teach
    them, because that is not enough. They don't learn that
    information. It has to be at a deeper level. And I think, for
    us, with our families, we are so successful with them because
    we do go to that deeper level, and make sure our staff are
    doing it correctly.

    [[Page 73]]

        And one other really important thing I have to say is I
    think that, as was said, that our home visiting models are
    different, and they target different outcomes. And it is really
    important for us to be matching the outcome that the family
    needs and wants with the kind of program that they are getting.
    And I think that we have problems when we have a mismatch
    there, when we have a very vulnerable family, a mom who is
    running from domestic violence, who is severely depressed, and
    someone who is just going to be teaching them things when the
    mom is not available to learn them.
        But, I think that for other moms--that it may be a perfect
    match for them. So we need this continuum of models to work
    together in a system if we are really going to be effective.
        Mr. RENACCI. Thank you, Mr. Chairman.
        Ms. LOWELL. Thank you.
        Chairman REICHERT. Thank you. That was two minutes over
    time, but that was so passionate, there was no way I was going
    to interrupt.
        Ms. LOWELL. Sorry.
        [Laughter.]
        Chairman REICHERT. That was a great answer. Mr. Doggett,
    you are recognized.
        Mr. DOGGETT. Thank you very much. Dr. Lowell, you described
    in your testimony the need here is enormous. What would be the
    impact in your area if the federal funding through MIECHV is
    not continued beyond next spring?
        Ms. LOWELL. Oh, thank you. That is a really important
    question. We have--with our MIECHV funding, we have five new
    sites and three expansion sites, which cover about a third of
    our state Child First programs. So, if the MIECHV funding is
    not continued, there is very high likelihood that those
    programs will be closed. And all of those children and families
    in those areas will not be served.
        Mr. DOGGETT. And you used in your testimony the comparison
    between a $7,000 cost and a $30,000 cost for not relying on
    home visiting to intervene in advance. Would you elaborate on
    that?
        Ms. LOWELL. I think that we are seeing tremendous cost
    savings--at least we did a preliminary cost benefit analysis in
    looking at our data, and we need to do much more. But we know
    that, for instance, if one of our children, many of our
    children have very severe behavioral problems and mental health
    problems if one of those children were to be hospitalized for
    just two months in a psychiatric hospital, it would cost
    $130,000. We know that we are getting great language outcomes.
    If one child needs special education, it is going to cost
    $16,600. If one child goes into foster care--and I have heard
    various costs but we are talking about, potentially, somewhere
    between--depending on the numbers I have seen--$20,000 and
    $80,000 for a child for a year in foster care. And many of our
    families have multiple children.
        For example, we just had a family that I just heard about,
    which we started working with, where Mom was going to be
    evicted. She had six children. Our care coordinator got her
    into a shelter initially, and then got her an apartment with
    low-income housing, and saved six children from going into
    foster care. And the trauma of foster care is very major,
    because that separation is really dif

    [[Page 74]]

    ficult, especially if it is not because there is abuse and
    neglect, but just because the circumstances can't support that
    parent caring for the children.
        So, I also see we are getting other outcomes--we have some
    data on hospitalization and ER visits, which is actually--it is
    very preliminary, but we are talking about a four to sixfold
    decrease in hospitalization and emergency room visits.
        Mr. DOGGETT. Thank you.
        Ms. LOWELL. Thank you.
        Mr. DOGGETT. Thank you very much, and thank you for what
    you are doing there.
        And, Dr. Kilburn, you have made reference, of course, to
    this important study that will come out next year, and the
    blend that is already in the Act to both permit some
    innovation, but to ensure that our dollars are well spent with
    evidence-based programs. Do you believe that that study will
    allow us to focus on more effective programs? Or do you think
    that the study is something that would lead to the elimination
    of the federal program entirely?
        Ms. KILBURN. I think the study will indicate whether this
    scaling up of the individual programs has been accomplished.
    So, were they able to replicate these programs with fidelity,
    and can we provide not just the quantity, but also the quality?
    I think it will also indicate whether, when you scale the
    programs up, you replicate the same outcomes.
        So it is one thing when Darcy is overseeing Child First
    very closely; we are pretty confident that we are going to get
    great results. But when we start having this replicated in
    other states, and Darcy is not directly involved, for example,
    can we achieve the same outcome? So it will provide information
    of that sort.
        Mr. DOGGETT. You believe in the value of home visiting as a
    way of preventing abuse and cost. It is a question more of how
    to do it, rather than whether to do it.
        Ms. KILBURN. That is right.
        Mr. DOGGETT. Is that correct?
        Ms. KILBURN. That is correct.
        Mr. DOGGETT. And, Ms. Towne, I am very impressed by both
    your testimony. But what would be the effect in your area if
    you lose federal funding?
        Ms. TOWNE. Unfortunately, as a home visitor, I am not sure
    that I could really testify to the answer to that, as far as
    funding resources go. I believe it would have a significant
    impact to our families in Yakima County.
        Mr. DOGGETT. I think your testimony--and yours, as well--
    really did bring a human, very human dimension to the
    statistics that we frequently throw around here about how this
    program, this intervention, can really help make a difference
    in lives. And I look forward to your continued involvement, and
    report to the committee on how we can achieve the very most in
    using home visiting as a way to prevent abuse and other costs.
        Thank you so much for the testimony each of you gave.
        Ms. TOWNE. Thank you.
        Chairman REICHERT. Thank you, Mr. Doggett. Mr. Griffin, you
    are recognized.

    [[Page 75]]

        Mr. GRIFFIN. Thank you, Mr. Chairman. Thank you all for
    being here today. Mr. Baron, I wanted to focus a little bit on
    HIPPY USA, which is--although it serves many folks across the
    country, it is based in Little Rock, which is my district,
    second congressional district in Central Arkansas. And HIPPY
    stands for Home Instruction for Parents of Preschool
    Youngsters, HIPPY USA.
        So, they are operating both in rural and urban areas, and I
    wanted to ask you, Mr. Baron, when you are reviewing your
    models for effectiveness, are you seeing any differences
    between the outcomes in rural areas versus urban areas? And, if
    so, what do you attribute those differences to?
        Mr. BARON. It is interesting that there have been
    evaluations of--scientific evaluations of home visiting,
    randomized trials that have been done in both rural and urban
    areas. One of the Nurse-Family Partnership studies was done in
    Upstate New York, in a rural, primarily white population, and
    that study found very large effects, as long as 15 years after
    the study began, for the treatment compared to the control
    group. Big decreases for the children of the mothers, for
    instance, in rates of criminal activity and rates of child
    maltreatment, and so on.
        But some of the other studies have been done, other good
    studies--another Nurse-Family Partnership randomized trial was
    done in Memphis, Tennessee, an urban setting. This study also
    found large effects, but different. The effects may vary for a
    variety of reasons. It might be the women in Upstate New York,
    there was a larger population of smokers than in Memphis. And
    then the third trial was also urban--that was done in Denver.
        What was most impressive about those sets of studies was
    that sizable effects were found across different ethnicities,
    rural versus urban. There were different effects across the
    different studies, but all showed important improvement in
    people's lives. The differing effects could have been because
    the populations were different.
        Mr. GRIFFIN. I think--Ms. Lowell, I think you referred to
    the fact that different programs or different methods are used
    to reach different outcomes. Different families have different
    needs. And I was wondering--and either you, Ms. Lowell, or Mr.
    Baron--when you look at these different programs, are there
    some programs or methods that work in certain areas--urban
    areas, for example--that don't work as well in rural? Have you
    seen anything that would indicate that, or different parts of
    the country?
        Ms. LOWELL. I think that, first of all, it has to do with
    the uniqueness of each family; and that if you really do a good
    assessment, and you really understand what the needs of that
    family are, you are going to be the most successful, because
    you are going to be able to target your intervention
    specifically to the needs of the family.
        As you described so beautifully, it is about what that
    family needs. Now----
        Mr. GRIFFIN. And just to interrupt there, because--so with
    each of the different models or programs or methodologies, that
    flexibility exists. They--with each of them they try to take
    the particular family's circumstances into account, and there
    is a certain flexibility there?

    [[Page 76]]

        Ms. LOWELL. I think that each model does it in their own
    way. But I think that different models have different
    capabilities.
        And, for instance, in Connecticut we work in partnership
    with other home visiting. We have another big home visiting
    program. And so, we often get referrals from that other home
    visiting program, because they have a para-professional model.
    They know, if they are working with a mom who is really
    depressed, or one who has, let's say, domestic violence, that
    they are not really the right model to work with that family.
    So they will refer them to us. And we will do a very close
    transfer, so that we will then take that family, or take a
    family with a child who is having major behavior problems.
        I think that each of us has the same idea, that these are
    very family-focused kinds of interventions. And, in that sense,
    I think that everyone is trying to do that, really trying to
    understand who their families are.
        Mr. GRIFFIN. So there is some degree of nimbleness, if you
    will, to allow for tweaks and changes if--it sounds like,
    through transfers, or what have you--if things aren't working
    exactly as maybe one thought.
        And I am out of time. Thank you, Mr. Chairman.
        Chairman REICHERT. Thank you, Mr. Griffin. Mr. Crowley, you
    are recognized.
        Mr. CROWLEY. Ms. Kilburn, did you want to respond very
    quickly to that?
        Ms. KILBURN. Sure. I just wanted to raise one issue that
    hasn't come up today that I think is relevant, and that is that
    a constraint for implementing these models is the local
    workforce, and this is particularly relevant for rural areas.
        So, if you have a program that needs to deploy mental
    health clinicians, or registered nurses, it is the case that
    many rural areas are designated as health professional shortage
    areas, and you might have selected one of these great programs,
    and have the will to do it, and even have the funding, but you
    don't have the trained personnel to be able to pull it off.
        So, I think particularly in our rural areas, we are
    observing that some of these programs have not been selected,
    and that may be a contributing factor.
        Mr. CROWLEY. I appreciate that. Thank you, Ms. Kilburn.
        Mr. Chairman, reclaiming my time, I am very pleased we are
    having this hearing here today on an effective, evidence-based
    program that has tremendous social benefits down the road.
    Being from New York, I have seen the great work of the Nurse-
    Family Partnership and what it does, and I have been so
    impressed with the results this program has shown over the
    years.
        New York City Nurse-Family Partnership is the largest urban
    program of its kind in the country. It has served more than
    10,500 clients since its creation in 2003, and currently
    serving more than 1,700 clients across all 5 boroughs. These
    dedicated professionals like Ms. Towne are working with New
    York City families to make sure they have the education,
    information, and assistance they need to raise their children
    and become stronger families. And the long-term results are so
    impressive, even beyond what you would expect from the
    immediate assistance provided.

    [[Page 77]]

        Mr. Chairman, I would like to, if I could, offer into the
    record the state profile of the Nurse-Family Partnership of New
    York, if I could.
        Chairman REICHERT. Without objection.
        [The information follows: Mr. Crowley]

    [[Page 78]]

                              Rep. Joseph Crowley

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    [[Page 79]]

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        Mr. CROWLEY. Reductions in child abuse and neglect, better
    educational outcomes for children, a greater likelihood of
    economic stability for the mother, these results are not just
    good for the participants, but also are good for society, as a
    whole.
        Mr. Baron, I know you were here at a previous hearing this
    Subcommittee held, and we discussed the ripple effect we would
    see from cutting or eliminating funding for these types of
    programs. Our budget should focus on long-term priorities, not
    just short-term impacts. That is why I was so pleased that the
    Affordable Care Act started this federal investment and home
    visitation programs, and

    [[Page 80]]

    it is, in fact, an investment in the future health and well-
    being of all families in our country.
        Your testimony references some of the research and
    evidence-based home visiting programs that shows they can lead
    to reductions in child abuse and injuries, improvements in
    educational outcomes for children, and even a reduction in
    needs-tested assistance over the long term for mothers. It is,
    therefore, reasonable to suggest that investment in strong home
    visiting programs will not only protect and help children, but
    also yield major benefits to society, and ultimately to
    taxpayers. Is that not correct?
        Mr. BARON. Yes, that is right. Often there is a claim that
    a social program is so effective that you can improve people's
    lives and save money. Very often, when a rigorous evaluation is
    done, the effects are not quite so promising. The claim doesn't
    pan out.
        But this is a case where, at least for some of the program
    models, like the Nurse-Family Partnership, and perhaps for
    Child First as well, the more effective models, it really does
    look like the evidence shows you can have your cake and eat it,
    too. You can improve people's lives in a very important way,
    over a long period of time, and reduce their use of public
    assistance, so that the government and taxpayer benefits, as
    well.
        Mr. CROWLEY. Win-win. I appreciate that. It is clear that
    this program is making a difference, and we need to maintain
    that federal support.
        I was pleased to see the President and his Administration
    have proposed a long-term extension expansion of this program.
    That is the kind of investment we should be making. Congress
    recently passed a short-term extension of this program, but it
    is clear that more must be done to build upon the success so
    far.
        I look forward to working with my colleagues on both sides.
    I want to commend the chairman for a very bipartisan approach
    to this issue, as well. I really do appreciate that. I hope
    that my colleagues on both sides of the aisle on this Committee
    will work with us to support this program. And, once again, Mr.
    Chairman, thank you for holding the hearing today.
        Chairman REICHERT. Thank you, Mr. Crowley. And, as you can
    see, and as Mr. Crowley said, this is really, truly a
    partnership up here, with Republicans and Democrats all
    appearing to be on the same page, wanting to help those that
    are most vulnerable. And I really--as an old cop--I know I
    mention this quite often, but I am proud to be, you know, an
    old law enforcement officer. But the evidence-based stuff is
    very critical, and you guys are doing an awesome job with that.
        So, congratulations. Congratulations to you, Ms. Sucilla,
    and your success. And, thank you, Ms. Towne, for your hard work
    that you do each and every day. So, we are going to see each
    other again. We will visit again, and continue to work
    together.
        If Members have additional questions for the witnesses,
    they will submit them to you in writing. And we would
    appreciate receiving your responses for the record within two
    weeks. The committee stands adjourned.
        [Whereupon, at 3:30 p.m., the subcommittee was adjourned.]
        [Member Questions for the Record follows:]

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        [Public Submission for the Record follows:]

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                       Scott Hippert Parents as Teachers

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