[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
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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
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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
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MATERNAL, INFANT, AND EARLY CHILDHOOD
HOME VISITING (MIECHV) PROGRAM
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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:]
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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
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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
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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
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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
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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.
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[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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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
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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
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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.
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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.
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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.
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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]
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Rep. Joseph Crowley
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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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Jon Baron
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Rebecca Kilburn
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Rebecca Kilburn Response
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[Public Submission for the Record follows:]
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Scott Hippert Parents as Teachers
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