    [House Hearing, 115 Congress]
    [From the U.S. Government Publishing Office]

                      THE REAUTHORIZATION OF THE 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 FIFTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 MARCH 15, 2017

                                   __________

                              Serial No. 115-HR02

                                   __________

             Printed for the use of the Committee on Ways and Means

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                     U.S. GOVERNMENT PUBLISHING OFFICE

    33-364                  WASHINGTON : 2019

                          COMMITTEE ON WAYS AND MEANS

                          KEVIN BRADY, Texas, Chairman

    SAM JOHNSON, Texas                   RICHARD E. NEAL, Massachusetts
    DEVIN NUNES, California              SANDER M. LEVIN, Michigan
    PATRICK J. TIBERI, Ohio              JOHN LEWIS, Georgia
    DAVID G. REICHERT, Washington        LLOYD DOGGETT, Texas
    PETER J. ROSKAM, Illinois            MIKE THOMPSON, California
    VERN BUCHANAN, Florida               JOHN B. LARSON, Connecticut
    ADRIAN SMITH, Nebraska               EARL BLUMENAUER, Oregon
    LYNN JENKINS, Kansas                 RON KIND, Wisconsin
    ERIK PAULSEN, Minnesota              BILL PASCRELL, JR., New Jersey
    KENNY MARCHANT, Texas                JOSEPH CROWLEY, New York
    DIANE BLACK, Tennessee               DANNY DAVIS, Illinois
    TOM REED, New York                   LINDA SANCHEZ, California
    MIKE KELLY, Pennsylvania             BRIAN HIGGINS, New York
    JIM RENACCI, Ohio                    TERRI SEWELL, Alabama
    PAT MEEHAN, Pennsylvania             SUZAN DELBENE, Washington
    KRISTI NOEM, South Dakota            JUDY CHU, California
    GEORGE HOLDING, North Carolina
    JASON SMITH, Missouri
    TOM RICE, South Carolina
    DAVID SCHWEIKERT, Arizona
    JACKIE WALORSKI, Indiana
    CARLOS CURBELO, Florida
    MIKE BISHOP, Michigan

                         David Stewart, Staff Director

                     Brandon Casey, Minority Chief Counsel

                                     ______

                        SUBCOMMITTEE ON HUMAN RESOURCES

                        ADRIAN SMITH, Nebraska, Chairman

    JASON SMITH, Missouri                DANNY DAVIS, Illinois
    JACKIE WALORSKI, Indiana             LLOYD DOGGETT, Texas
    CARLOS CURBELO, Florida              TERRI SEWELL, Alabama
    MIKE BISHOP, Michigan                JUDY CHU, California
    DAVID G. REICHERT, Washington
    TOM REED, New York

                                C O N T E N T S

                                   __________

                                                                       Page

    Advisory of March 15, 2017, announcing the hearing...............     2

                                   WITNESSES

    Beth Russell, Nurse Home Visitor, Nurse-Family Partnership,
      Lancaster General Health/Penn Medicine, Lancaster, Pennsylvania    10
    Rosa Valentin, Client, Nurse-Family Partnership, Lancaster
      General Health/Penn Medicine, Lancaster, Pennsylvania..........    20
    Eric Bellamy, Home Visiting Manager, Children's Trust of South
      Carolina.......................................................    26
    Diana Mendley Rauner, Ph.D., President, The Ounce of Prevention
      Fund...........................................................    36

                            QUESTIONS FOR THE RECORD

    Questions submitted by The Honorable Tom Reed of New York to Eric
      Bellamy, Home Visiting Manager, Children's Trust of South
      Carolina.......................................................    59
    Questions submitted by The Honorable Danny Davis of Illinois to
      Diana Mendley Rauner, Ph.D., President, The Ounce of Prevention
      Fund...........................................................    62

                           SUBMISSIONS FOR THE RECORD

    Charles Bruner, Ph.D.............................................    66
    American Academy of Pediatrics (AAP).............................    68
    Baby TALK........................................................    74
    Child & Family Research Partnership (CFRP).......................    75
    Children's Home Society of Washington............................    83
    Children's Institute.............................................    84
    Easterseals, Incorporated........................................    86
    Fight Crime: Invest in Kids Council for a Strong America.........    89
    Home Nursing Agency..............................................    91
    Home Visiting Coalition..........................................    95
    Johns Hopkins Center for American Indian Health (JHCAIH).........    99
    National Nurse-Led Care Consortium (NNCC)........................   103
    Nurse-Family Partnership.........................................   108
      Beth Russell...................................................   111
      Virginia Sosnowski, RN, BSN....................................   112
    Parent-Child Home Program (PCHP).................................   113
    Parents as Teachers National Center (PATNC)......................   116
    Partners in Community Outreach (PiCO)............................   122
    Pennsylvania Department of Human Services, Office of Child
      Development and Early Learning (OCDEL).........................   127
    People's Emergency Center (PEC)..................................   137
    Prevent Child Abuse America......................................   139
    Responsible Fatherhood Roundtable................................   145
    Shriver Center, Sargent Shriver National Center on Poverty Law...   149
    The Dads Matter Research Team at the University of Chicago School
      of Social Service Administration and the University of Denver
      School of Social Work..........................................   152
    The Florida Association of Healthy Start Coalitions, Incorporated
      (FAHSC)........................................................   155
    United Way of Miami-Dade.........................................   163
    Voices for Ohio's Children.......................................   164
    Washington State Home Visiting Coalition.........................   171

                      THE REAUTHORIZATION OF THE MATERNAL,

                        INFANT, AND EARLY CHILDHOOD HOME

                           VISITING (MIECHV) PROGRAM

                                  ----------

                           WEDNESDAY, MARCH 15, 2017

                 U.S. House of Representatives,
                           Committee on Ways and Means,
                               Subcommittee on Human Resources,
                                                        Washington, DC.

        The Subcommittee met, pursuant to call, at 10:00 a.m., in
    Room 1100, Longworth House Office Building, Hon. Adrian Smith
    [Chairman of the Subcommittee] presiding.
        [The advisory announcing the hearing follows:]

    ADVISORY

    FROM THE COMMITTEE ON WAYS AND MEANS

                        SUBCOMMITTEE ON HUMAN RESOURCES

                                                    CONTACT: (202) 225-1721
    FOR IMMEDIATE RELEASE
    Wednesday, March 15, 2017
    HR-02

                    Chairman Smith Announces Human Resources

                  Subcommittee Hearing on the Reauthorization

                  of the Maternal, Infant, and Early Childhood

                         Home Visiting (MIECHV) Program

        House Ways and Means Human Resources Subcommittee Chairman Adrian
    Smith (R-NE), announced today that the Subcommittee will hold a hearing
    entitled ``Reauthorization of the Maternal, Infant, and Early Childhood
    Home Visiting (MIECHV) Program'' on Wednesday, March 15, at 10:00 a.m.
    in room 1100 of the Longworth House Office Building. This hearing will
    examine a range of home visiting models, review how States operate and
    fund programs, and highlight how an evidence-based home visiting
    program can produce positive outcomes for children and families.

        In view of the limited time to hear witnesses, oral testimony at
    this hearing will be from invited witnesses only. However, any
    individual or organization may submit a written statement for
    consideration by the Committee and for inclusion in the printed record
    of the hearing.

    DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

        Please Note: Any person(s) and/or organization(s) wishing to submit
    written comments 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 make a submission, and click on the link
    entitled, ``Click here to provide a submission 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 the close of business
    on Wednesday, March 29, 2017. For questions, or if you encounter
    technical problems, please call (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 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 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.

        All submissions and supplementary materials must be submitted in a
    single document via email, provided in Word format and must not exceed
    a total of 10 pages. Witnesses and submitters are advised that the
    Committee relies on electronic submissions for printing the official
    hearing record.

        All submissions must include a list of all clients, persons and/or
    organizations on whose behalf the witness appears. The name, company,
    address, telephone, and fax numbers of each witness must be included in
    the body of the email. Please exclude any personal identifiable
    information in the attached submission.

        Failure to follow the formatting requirements may result in the
    exclusion of a submission. All submissions for the record are final.

        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 TDD/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 at
        http://www.waysandmeans.house.gov/

        Chairman SMITH OF NEBRASKA. The Subcommittee will come to
    order.
        Thank you for joining us here today. Welcome to our Human
    Resources Subcommittee hearing. Today we are here to discuss
    the Maternal, Infant, and Early Childhood Home Visiting
    program, known as MIECHV, which helps support State and local
    efforts to provide voluntary, evidence-based, outcome-focused
    home visiting services to parents and children at risk of
    adverse experiences. The program's objectives include promoting
    school readiness of young children, increasing economic self-
    sufficiency of families, improving prenatal health and birth
    outcomes, and preventing child abuse and neglect.
        This hearing will examine a range of home visiting models,
    review how States operate and fund programs, and highlight how
    an evidence-based home visiting program can produce positive
    outcomes for children and families.
        Federal funding for home visiting was first proposed in
    2004 by Republican Senators Chris Bond and Jim Talent, both
    from Missouri. However, the first Federal funds for evidence-
    based home visiting were provided in fiscal year 2008 after
    Congress agreed to fund President George W. Bush's proposal to
    test this approach and measure the outcomes. The MIECHV program
    was fully authorized in fiscal year 2010 to continue these
    efforts and is now up for reauthorization this year.
        I, like other Members of this Subcommittee, have had the
    opportunity to see firsthand what home visiting looks like in
    my community. Last Monday, I spent time with the Panhandle
    Public Health District's Healthy Families America program,
    which aims to improve the economic success and school readiness
    of vulnerable children and families in three Nebraska counties:
    Scotts Bluff, Morrill, and Box Butte. Dawn, one participant I
    met with on Monday, shared her experience of working with a
    home visitor who helped her find a stable home and a steady
    income in order to provide for her growing family. These are
    the types of outcomes we should be expecting and receiving from
    the use of limited taxpayer resources. Unfortunately, outcomes
    like these are the exception rather than the rule when we look
    around at how we help struggling families.
        New Federal social programs have been evaluated to
    determine if they are working, and almost none have conditioned
    funding on evidence of effectiveness. In our Better Way agenda,
    we proposed measuring how well programs are working so we can
    focus funding on programs which produce real results. When we
    spend limited taxpayer dollars to help those in need, we must
    make sure we are spending money on effective programs. To do
    otherwise is a disservice to both taxpayers as well as
    beneficiaries. MIECHV is one of the only social programs where
    funding is tied to proving evidence.
        For a home visiting model to be funded, an evaluation must
    show the program has demonstrated significant, positive
    outcomes in areas such as reducing child abuse and neglect,
    improving maternal and child health, and improving economic
    self-sufficiency. Many of these approved models are now being
    further studied through a rigorous random assignment evaluation
    to better measure their impact so we know families are
    receiving real help. States have also been held accountable for
    demonstrating positive outcomes for children and families. If
    they don't show improvements in four of six areas specified in
    law, they have to explain how they plan to improve their
    services to get results, which again provide real help to
    struggling families.
        A top priority for this Subcommittee in this Congress
    continues to be ensuring greater opportunity for Americans.
    Last week, I was grateful to learn more about how the Home
    Visiting program empowers Nebraska parents to provide a better
    life for their children, and I look forward to hearing more
    about similar efforts across the country today as we look
    forward to MIECHV reauthorization.
        I now yield to the distinguished Ranking Member, Mr. Davis,
    for the purpose of an opening statement.
        Mr. Davis.
        Mr. DAVIS. Thank you very much, Mr. Chairman. And I want to
    thank you for holding this hearing on evidence-based home
    visiting. I would like to ask unanimous consent to submit a
    group of stories that have--well, not really stories, but
    experiences that have been submitted about families in my
    district, and I would like to submit those for the record.
        Chairman SMITH OF NEBRASKA. Without objection.
        [The submission of Mr. Davis follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. DAVIS. Before I came to Congress, I worked in community
    health centers and saw firsthand how home visits by community
    health workers helped engage people to change behaviors and
    embrace preventative health approaches. I introduced my first
    bipartisan home visiting bill over a decade ago in 2005. And so
    I look forward to continuing this bipartisan work with you and
    other Members of this Committee.
        Frederick Douglass said, ``It is easier to build strong
    children than to repair broken men.'' And I agree. Infants are
    more likely to enter foster care than any other age group,
    twice as likely as 1-year-olds and more than five times as
    likely as 11-year-olds. Several home visiting models, including
    Healthy Families America, which is headquartered in Chicago,
    have proven that home visiting is a tool that can keep these
    children safe at home.
        Children at risk of foster care are not the only ones who
    benefit from home visiting. In my congressional district,
    nearly 60 percent of children 5 and under live in low-income
    families. Some of them are fortunate to be served by the Home
    Instruction for Parents of Preschool Youngsters, our HIPPY
    program, which has a long track record of working with parents
    of all backgrounds to prepare children to succeed at school.
        The Federal Maternal, Infant, and Early Childhood Home
    Visiting program, or MIECHV, did not invent home visiting. My
    home State of Illinois has invested in home visiting for 30
    years, and we are not alone. MIECHV has played a vital role in
    strengthening these State and local efforts. Where home
    visiting did not exist, MIECHV offered the neediest families
    this lifeline for the first time. In States with home visiting,
    like Illinois, MIECHV improved program coordination, reinforced
    the emphasis on proven models, and expanded availability of
    services. In my congressional district, MIECHV directly
    provides home visiting services to 219 additional families and
    has supported innovative pilot projects for homeless families
    and parenting foster youths.
        MIECHV is built on a foundation of decades of research. The
    Department of Health and Human Services has identified 17
    different models that meet its stringent tests for proven
    results. States, territories, and tribes can choose from a
    range of evidence-based models that allow them to target the
    right help to the right families at the right time. Some States
    even transition families from one model to another as children
    grow. In Illinois, MIECHV funds a central intake process to
    make sure families are directed to the most effective models
    for their needs.
        Although home visiting models focus on different aspects of
    child well-being and use visitors with different
    qualifications, they have important commonalities. Home
    visitors form positive relationships with families to help them
    find strength in themselves and in their communities. They link
    families with critical supports like transportation assistance,
    substance abuse, and mental health treatment, child care, and
    economic support, and they measurably improve outcomes for
    children. MIECHV has already made a difference for tens of
    thousands of children and families. And as we continue to
    invest and home visiting models continue to learn from rigorous
    research evaluations, from careful data tracking, from the
    families and communities they serve, and from each other, I
    believe we will be able to do even more to build strong
    children who grow into successful adults.
        So I thank you, Mr. Chairman, and I yield back the balance
    of my time.
        Chairman SMITH OF NEBRASKA. Thank you, Mr. Davis.
        And without objection, other Members' opening statements
    will be made a part of the record.
        I would like to welcome our witnesses here today. Thank you
    for joining us. This is a conversation that I think can help
    many folks, and so, certainly, it is a conversation that we can
    benefit from as we learn more from you.
        I will introduce the panel we have here today. First, we
    have Ms. Beth Russell, nurse home visitor, Lancaster General/
    Penn Medicine. And Ms. Rosa Valentin. She is a client with
    Lancaster General/Penn Medicine. And Mr. Eric Bellamy, home
    visiting manager, Children's Trust of South Carolina. And Ms.
    Diana Rauner, president of The Ounce of Prevention Fund in
    Illinois.
        Witnesses are reminded to limit their oral statements to 5
    minutes. You will see the light there. With the yellow light
    there, you can look to perhaps, as they say, bring it in for a
    landing. And all of your written statements will be included
    in--your full written statements will be included in the
    record.
        Right now, we will begin with Ms. Russell. You may begin
    when you are ready.

      STATEMENT OF BETH RUSSELL, NURSE HOME VISITOR, NURSE-FAMILY
    PARTNERSHIP, LANCASTER GENERAL HEALTH/PENN MEDICINE, LANCASTER,
                              PENNSYLVANIA

        Ms. RUSSELL. Good morning, Chairman Smith, Ranking Member
    Davis, and Members of the Subcommittee. Thank you for the
    opportunity to testify on behalf of Nurse-Family Partnership
    and Lancaster General Health/Penn Medicine in support of
    evidence-based home visiting and the Maternal, Infant, and
    Early Childhood Home Visiting program.
        I am Beth Russell, and I have worked as an NFP nurse home
    visitor for nearly 5 years. I have the privilege of helping new
    mothers become the best moms they can be for their babies. As a
    nurse home visitor, I serve a regular caseload of 25 first-
    time, low-income mothers and their families, including my
    client who is here with me today, Rosa Valentin.
        NFP is a voluntary program that provides regular home
    visits to first-time, low-income mothers by registered nurses,
    beginning early in pregnancy and continuing through the child's
    second year of life. Each woman is partnered with her own free
    personal nurse, a nurse that can be there for her, getting to
    know her during pregnancy, and building trust with her family
    to offer critical support when it is most needed.
        As a nurse home visitor, I serve many kinds of clients.
    Truly, you never know what you will encounter until you meet
    with that mom for the first time. However, in every instance, I
    meet the client where she is, and hopefully I can be a positive
    force for good in her life amidst often stressful situations.
        When I first met Rosa in early 2015, I met a scared, quiet,
    14-year-old with little direction other than that she was 4
    months into an unplanned pregnancy and wanted to do the right
    thing for her baby. She was anxious and unsure if she could be
    a good mom and did not want to give up on her goals to finish
    high school and further her education. Rosa had her whole life
    ahead of her and was still figuring out who she wanted to be.
    Unlike many of my clients, Rosa had supportive parents who
    wanted to help her, but Rosa sought guidance, health advice,
    and one-on-one support as she attempted to navigate becoming a
    parent at such a young age.
        I quickly realized during the first encounter that it would
    take some work to open Rosa up to me, so I took my time to make
    her comfortable. Combine the uncertainty of being pregnant for
    the first time with being a teenager, and Rosa had a lot of
    anxiety she needed to share. ``I needed to vent,'' Rosa would
    say. I was there to listen at each visit and become the person
    Rosa could open up to.
        I had Rosa make a list of her needs and goals and made
    several referrals to get her the right services that she needed
    to complement our visits. I referred her to A Woman's Concern,
    which is a local pregnancy support organization that provides
    education support for parents, and Teen Elect, which helps
    pregnant and parenting students complete their educational
    goals. Rosa was already attending Cyber School, a program that
    allows her to complete her high school diploma primarily
    online. While she had a strong desire to finish, she needed
    confidence to continue, given her pregnancy and impending
    motherhood.
        Rosa had a generally healthy pregnancy, but she struggled
    with the fact that the child's father was not around as much as
    she would have liked and disappointment about not having the
    type of family she would have liked to bring a child into.
    Additionally, routine screening for depression did show that
    Rosa had elevated scores, which prompted conversations about
    counseling. NFP's client-centered approach allowed Rosa to make
    this decision, and while initially she did not want to see a
    counselor, she eventually agreed and now sees how it has helped
    her. Through lots of individual conversation and reflection,
    Rosa was able to get past the things that were holding her back
    and focus on the parent that she wanted to be for her child. I
    also know that our conversations about health and wellness,
    prenatally, postnatal, and for her child, were important to her
    and helped her to be reassured when she was concerned.
        Now 2 years after our first meeting, Rosa is the proud,
    confident parent of 20-month-old Angelica, who is here with us
    today. She is a junior in high school and on track to graduate
    next year. She has also been accepted into a local vocational-
    technical program where she plans to enroll next year.
    Initially, she was interested in cosmetology, but has a growing
    interest in the field of health care. Learning lots of new
    medical terminology over the course of her pregnancy and being
    a mom might have had something to do with that. In addition,
    Angelica continues to be a very healthy child, up to date on
    all well-child visits and immunizations, and has excellent
    developmental scores that reinforce Rosa's positive and
    responsive caregiving.
        In my role as a nurse home visitor, I work with each client
    to help her to establish her education, employment, and life
    course development goals. While Rosa was initially very unsure
    about where this road would take her, she had the sheer will to
    try to make the best of it, and it is that determination, those
    glimmers of achievement along the way, that keep me doing the
    work that I do as a nurse home visitor. I am so proud of her
    progress and her willingness to share her story with you today.
        Rosa's story is just a glimpse of the impact that Nurse-
    Family Partnership has on low-income, first-time parents. Rosa
    is one of over 250,000 that have been partnered with a
    registered nurse through Nurse-Family Partnership. The program
    is backed by over 40 years of evidence, and each visit to a new
    mom's home is tracked to measure the impact we are making in a
    young family's life.
        The MIECHV program is a strong and cost-effective Federal
    policy that is joining States and local agencies to support
    these valuable services to at-risk moms. Without congressional
    action, this program which funds my work and is helping young
    mothers like Rosa and young children like Angelica will expire
    this September. I hope that Congress takes swift action to
    reauthorize the MIECHV program for at least 5 years with the
    increased funding that is needed to reach more families.
        Thank you again, Chairman Smith, Ranking Member Davis, and
    Members of the Subcommittee for the opportunity to testify
    today and for your support of evidence-based home visiting
    programs.
        [The prepared statement of Ms. Russell follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman SMITH OF NEBRASKA. Thank you, Ms. Russell.
        Ms. Valentin, you may begin.

     STATEMENT OF ROSA VALENTIN, CLIENT, NURSE-FAMILY PARTNERSHIP,
    LANCASTER GENERAL HEALTH/PENN MEDICINE, LANCASTER, PENNSYLVANIA

        Ms. VALENTIN. Good morning, Chairman Smith, Ranking Member
    Davis, 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 Rosa Valentin, and I am a client with the Nurse-
    Family Partnership program delivered by Lancaster General
    Health in Lancaster, Pennsylvania. I am the incredibly proud
    mother of my daughter, Angelica, who is 20 months old and here
    with me today.
        As a client, I have received regular visits about every
    other week from my NFP nurse home visitor, Beth Russell,
    starting when I was just 4 months pregnant. I am 16 years old
    and have lived in Lancaster my entire life with my mother and
    father. Two years ago, when I was 14 years old, I found out I
    was pregnant with Angelica. I was in shock. What am I going to
    tell my mother? Thankfully, my mom was supportive of my
    decisions to have the baby, and from the minute I saw her arms,
    legs, and fluttering heartbeat, I knew that I wanted to protect
    her from any harm and do what was best for her.
        I heard about the NFP program through my doctor's office.
    Because I was a first-time mom and met the other eligibility
    requirements, they referred me to Lancaster General Health's
    NFP program and Beth. We set up an appointment for Beth to come
    to my home and talk more about the program. I was shy at first,
    but Beth helped me to start thinking about my goals and
    programs that were available to help me as a teenager. I
    started to look forward to our visits. Up until the point where
    I got pregnant, I had taken care of my little cousins as
    babies, but that was about it.
        On June 23, 2015, at 2:39 p.m., my life changed. My baby
    girl was born weighing 6 pounds, 3 ounces, and measuring 19\1/
    2\ inches long. She had jet-black hair and black eyes. Now I
    had a lot to learn about taking care of my own baby, not to
    mention navigating my own personal challenges. I had
    experienced a lot of disrespect from my peers about my
    pregnancy, and although my mom and dad have always been there
    for me, I didn't have the support of my entire family. And
    although I initially expected Angelica's father to be a part of
    raising her, and I thought we would be together as a family to
    experience her milestones, ultimately he was not in the
    picture. This was very difficult for me, and I struggled to
    move past that, but I had to take care of my baby and reach my
    goals.
        Beth helped me do just that. She has been there for me
    emotionally, sometimes just as a listening ear for venting or
    to provide suggestions on dealing with stressful situations so
    that I can get back to being the mom I needed and wanted to be.
        Angelica is the love of my life. After I brought my baby
    girl home, it seemed like all I wanted to do was spend time
    with her, and there was so much to learn about taking care of a
    new baby. Beth showed me how to bathe her for the first time
    and answered all of my questions about what was going on with
    my baby.
        It was difficult to keep up as a new mom. I was still a
    high school student and started to fall behind on my online
    classes. Beth helped me not to lose sight of my goals for
    school. ``This is what you wanted for yourself,'' she reminds
    me. She helped me to develop a routine for my daughter and find
    time for myself to study. It was exhausting taking care of a
    new baby, but Beth helped me to stay focused. I will go to
    college.
        Beth also helped me find programs to support my parenting
    and educational goals and stick with them. When I initially
    questioned how long I could stick with breastfeeding, she
    encouraged me to set goals and do what I felt was right. My
    initial goal was 6 months, and today, I am still nursing my 20-
    month-old daughter, although trying to wean.
        Like every new mom, I had concerns, and Beth has always
    been there to address them. Beth has also been a resource for
    my mom, who is usually involved with our home visits because
    she helps me take care of Angelica. It has meant so much to me
    to have a nurse at my side, someone who I could trust for
    advice when I was experiencing round ligament pain late in my
    pregnancy and was concerned about the baby, or had cramping
    while breastfeeding. Beth was also very helpful when I was
    worried about Angelica's weight because others thought she was
    too small or if she was learning things at the right pace. Beth
    was always able to reassure me that Angelica was growing well
    and passing her developmental screenings. She also helped me
    understand birth control options after pregnancy, and when I
    was under a lot of stress and needed counseling, Beth helped me
    understand why it was important to talk to somebody.
        What I think is important for me to provide for Angelica is
    consistency. I am trying to follow the four C's of parenting:
    clear, calm, consequences, and consistency, and use encouraging
    words to help her realize what to do instead of what not to do.
    These concepts are all so important for me as my baby grows
    into a toddler. Every day I am so excited for all the new
    things she is learning and showing me. Angelica makes me proud
    every day, and I am so proud to see how much she has learned
    and how much she has grown.
        When I found out I was pregnant, I was a freshman in high
    school. Now here I am with a beautiful blue-eyed, 20-month-old
    little girl, looking forward to my senior year and the Career
    and Technology Center's program for cosmetology. After I
    graduate, I would like to go on to college and graduate school
    and have a career as a prenatal nurse.
        Even though being a mom at times isn't easy, Angelica is my
    motivation to do better, finish school, and have a career. I am
    lucky to say that I had the support to help me along the way. I
    truly hope that Congress will continue supporting the Maternal,
    Infant, and Early Childhood Home Visiting program, which
    supports great programs like Nurse-Family Partnership.
        Thank you, Chairman Smith, Ranking Member Davis, and
    Members of the Subcommittee for the opportunity to testify
    today.
        [The prepared statement of Ms. Valentin follows:]

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        Chairman SMITH OF NEBRASKA. Thank you, Ms. Valentin. Well
    done.
        Mr. Bellamy, please proceed.

     STATEMENT OF ERIC BELLAMY, HOME VISITING MANAGER, CHILDREN'S
                        TRUST OF SOUTH CAROLINA

        Mr. BELLAMY. Good morning. Chairman Smith, Ranking Member
    Davis, and Members, please let me preface with I apologize for
    bringing this crazy weather from South Carolina to DC. But
    thank you for inviting me to represent South Carolina's
    perspective on MIECHV. I represent Children's Trust of South
    Carolina, the agency designated by the Governor to administer
    the State's MIECHV funding.
        Thanks to MIECHV, South Carolina serves families in 39 of
    46 counties. We still have a long way to go in reaching all the
    children and families who could benefit from home visiting. But
    that task would be significantly harder without MIECHV funds,
    specifically the direct services and the underpinnings for
    quality and accountability that MIECHV provides.
        MIECHV funds voluntary, evidence-based home visiting to
    disadvantaged families with young children. Families receiving
    home visiting saw significant improvements in measures such as
    birth outcomes, child development screenings and referrals,
    prevention of child abuse and neglect, school readiness. These
    outcomes and the program's broader success are the results of a
    law that provides State and tribal grantees with a firm
    foundation in evidence-based practice and the flexibility to
    match these practices to individual community needs.
        In 2010, Governor Sanford designated Children's Trust as
    the lead agency to implement and administer the State's MIECHV
    grant. Like other States, we conducted a needs assessment to
    determine which communities were most at risk and which proven
    interventions would best be suited to meet their needs. Our
    needs assessment identified counties with significant
    populations of families at risk for poverty, poor birth
    outcomes, child abuse and neglect, and low school readiness.
    Even in a State the size of South Carolina, no one approach
    meets the needs of all children and families.
        We selected four evidence-based models to meet the needs of
    children and parents: Healthy Steps, Family Check-Up, Healthy
    Families America, and Nurse-Family Partnership. We have since
    added Parents as Teachers, and in 2013, we expanded from 12
    counties to 38 counties. To date, over 6,200 South Carolina
    families have received MIECHV home visits.
        This implementation process illustrates many of the
    strengths of the legislation. States tailor their approach to
    address statewide goals for improving early childhood outcomes.
    States can choose to address prenatal and infant health, child
    abuse and neglect prevention, and/or school readiness goals.
    States can also select any combination of approved models to
    deploy in targeted communities. Each State's home visiting
    network looks a little different. However, every MIECHV program
    is supported by the same evidence base and is held to the same
    requirements that document outcomes and demonstrate continuous
    quality improvement.
        South Carolina can say with confidence and evidence that
    MIECHV continues to make important progress in improving the
    health and economic well-being of our vulnerable families. But
    MIECHV does more than fund direct services to children and
    families. It underpins the statewide foundation on which high-
    quality services depend. South Carolina's MIECHV grant allowed
    us to create the data system that collects and reports
    information on outcomes and provides funding for professional
    development and training for home visitors. These resources are
    available to all home visitors in the State, regardless of how
    their programs are funded.
        Another defining strength of MIECHV is the robust and
    tiered evidence base. MIECHV's rigorous evidence standards give
    State legislators and philanthropies an objective validation
    for investing in home visiting. In South Carolina, we saw a
    significant increase in the philanthropic dollars flowing into
    existing home visiting programs after MIECHV was signed into
    law. While private philanthropy provided modest support for
    home visiting prior to MIECHV, in the years since 2011, we have
    seen an increase in support from organizations such as Duke
    Endowment Foundation, the Blue Cross and Blue Shield
    Foundation, the Boeing Foundation, and other private funders.
        I realize my time is up, though there is much more that I
    could say. If you remember only one thing from South Carolina,
    I hope it is this: MIECHV is evidence-based policy that works
    to empower families, coordinate services, and unify systems.
        I appreciate your time and attention this morning. I will
    be happy to answer any questions you may have. Thank you.
        [The prepared statement of Mr. Bellamy follows:]

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        Chairman SMITH OF NEBRASKA. Thank you, Mr. Bellamy.
        Ms. Rauner.

    STATEMENT OF DIANA MENDLEY RAUNER, PH.D., PRESIDENT, THE OUNCE
                           OF PREVENTION FUND

        Ms. RAUNER. Chairman Smith, Ranking Member Davis, and
    Members of the Subcommittee, thank you for the opportunity to
    testify in connection with your hearing on the reauthorization
    of the Maternal, Infant, and Early Childhood Home Visiting
    program. My name is Diana Rauner and I am here today in my role
    as the President of The Ounce of Prevention Fund, a public-
    private partnership serving children and families from before
    birth through age 5. I am also a developmental psychologist,
    the Co-chair of the Illinois Home Visiting Task Force, and the
    First Lady of the State of Illinois.
        I began my career in investment banking and private equity
    investing, so I know something about return on investment. And
    I came to the field of early childhood because of concerns
    about the huge social and economic costs of educational
    inequities. I chose to focus on early childhood development
    because investments in the first years of life are simply the
    most efficient and effective ways to develop human capital.
    With the right investments, human capital development can
    provide great economic and social gains for individuals and for
    society.
        James Heckman, a Nobel Laureate at the University of
    Chicago, recently said, ``The real measure of child poverty
    isn't money, it's love.'' Voluntary home visiting programs that
    support parents in their critical responsibilities to help
    their children become healthy, successful citizens are the most
    effective human capital investments we can make because they
    compound the positive behavior of parents and children.
        I wish to voice my strong support for the MIECHV program
    and respectfully urge you and your colleagues to reauthorize
    MIECHV. The funding Illinois receives from MIECHV has
    significantly enhanced our State's robust early childhood and
    home visiting systems and is a vital component of our
    infrastructure. Illinois has long valued evidence-based home
    visiting programs as an effective and efficient strategy for
    strengthening expectant and new vulnerable families, by
    increasing children's readiness for school, reducing the risk
    of child abuse and neglect, and improving economic self-
    sufficiency.
        Over the past three decades, Illinois has developed a
    cross-sector statewide home visiting system, serving over
    17,000 families per year, making it a nationally recognized
    model of a State system supporting a variety of evidence-based
    models and innovative practices. Please refer to my written
    testimony which provides a more thorough picture of home
    visiting in Illinois.
        For today's purposes, I would like to elaborate a little on
    what MIECHV funding has allowed us to do in Illinois. We have
    reached more at-risk families. Last year, nearly 1,000
    additional families received more than 12,000 home visits. We
    have improved our home-visiting workforce through infant mental
    health consultation that teams mental health professionals with
    home visitors, and additional training for home visitors,
    regardless of funding, to enhance their understanding of
    critical topics, such as domestic violence, substance abuse,
    and child abuse prevention.
        MIECHV has increased coordination and collaboration across
    funding streams. For example, MIECHV's focus on identifying the
    outcomes that help best support families is something that all
    Illinois funders are now considering in their systems. MIECHV
    has pioneered coordinated intake, which ensures that families
    referred to home visiting are matched with a program and the
    model that best meets their particular needs and that they have
    access to other services as well. This concept of coordinated
    intake introduced through MIECHV has generated such interest
    that several communities not funded directly through MIECHV
    have chosen to develop coordinated intake systems with
    technical assistance from our MIECHV team.
        We have been able to test innovations, including projects
    focused on some of our most vulnerable families, such as
    homeless families and pregnant and parenting youth in care, and
    in randomized control evaluations to examine the effectiveness
    of doula-enhanced home visiting. We hope these innovations will
    be useful to other States as they are proven.
        Decades of research show that high-quality, evidence-based
    home visiting programs produce long-term positive outcomes for
    children and families. Data from Illinois show that home
    visiting services are increasing breastfeeding rates and birth
    intervals between births, particularly among teen parents;
    improving parenting practices; and ensuring that children are
    routinely screened for developmental delays. Research
    demonstrates that these outcomes, while measured in the short-
    term, set children and families on a positive trajectory for
    the long-term. The MIECHV program has increased the focus on
    these outcomes which is raising the bar for all home visiting
    programs in our State.
        In closing, I would like to reiterate my strong support for
    the MIECHV program. MIECHV undergirds and enhances our entire
    home visiting system and improves the lives of at-risk families
    and children in Illinois. It must continue, and I hope you view
    me, The Ounce, and the First Five Years Fund, our project, as a
    resource in that regard.
        Thank you for your time and consideration of my testimony.
    I will be happy to answer your questions.
        [The prepared statement of Ms. Rauner follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman SMITH OF NEBRASKA. Thank you, Ms. Rauner.
        Thank you to all of our witnesses here today. We appreciate
    your insights. They are important for us. So now we will go
    through questions here from myself and the Members.
        I will begin. Mr. Bellamy, in your testimony, you hit on a
    very important point about the program that I think is
    sometimes overlooked, and it is a point about how Federal
    funding programs based on evidence can really support States,
    and even the nonprofit sector, in their efforts to focus on
    what works. In your testimony, you highlight how the MIECHV
    program itself is important, but also that the evidence
    standard is set up and the signal it sent was just as important
    as it identified the models that were shown to be most
    effective. For example, I know once MIECHV-specified programs
    must be evidence-based and show results to receive funding,
    Nebraska, my home State, tied their own State funding to a
    similar standard so now all home visiting in Nebraska is
    evidence-based.
        Can you tell us a bit more about how the evidence standard
    in MIECHV has influenced the State practice in funding home
    visiting?
        Mr. BELLAMY. Yeah. I think the fact that MIECHV has set a
    level of standardization has really influenced how funders look
    at what they will fund around evidence-based practices. We have
    adopted in our South Carolina MIECHV program that we would only
    fund evidence-based programs. And private funders, as well as
    our State, has looked at that standardization authorization for
    those evidence-based programs to really look at setting a
    target and really being able to identify those practices as we
    move forward.
        At this point, funding has not moved in our State as far as
    looking at specific evidence-based practices. We want to build
    a continuum of services in our State around evidence-based
    practices, so we want to continue to really build a systematic
    approach to it.
        Chairman SMITH OF NEBRASKA. In your interactions with other
    States perhaps, have you learned what other States have done,
    or could you point to anything like that perhaps?
        Mr. BELLAMY. Tough for me to say. Well, in conversations
    with my peers in other States, there have been States that have
    identified ways to look at their standardization. They have
    worked with their legislation to really put into action some of
    their standards in evidence-based standardization. It would be
    difficult for me to pinpoint exactly where those States are at
    this time, but, yes, there have been other standardizations
    looked at in how they have adopted those practices.
        Chairman SMITH OF NEBRASKA. Thank you.
        Anyone else on the panel wish to comment? Ms. Rauner.
        Ms. RAUNER. I would just add that one of the ways that
    MIECHV has helped with standardization is in terms of
    standardization of the workforce, common understanding of what
    qualities are necessary across the models for training and
    professional development, ongoing professional development, and
    credentials. And that has, again, raised the standards and
    raised uniformity across programs and across funding streams.
        Chairman SMITH OF NEBRASKA. Thank you.
        Anyone else? If not, that is fine.
        I now recognize the Ranking Member, Mr. Davis, for any
    questions he might have.
        Mr. DAVIS. Thank you very much, Mr. Chairman. And I also
    want to thank all of the witnesses.
        Mr. Bellamy, let me ask you, I don't run into that many men
    in this line of work. What drew you to it, if you would?
        Mr. BELLAMY. To the work that I do?
        Mr. DAVIS. Yes.
        Mr. BELLAMY. That is a very good question, Mr. Davis. You
    know, years ago, I started out in doing teen pregnancy
    prevention work and worked with adolescents in direct services,
    and it really influenced my passion with working with younger
    populations. But, essentially, what it boils down to is the
    fact that I thoroughly believe that early intervention is a
    predictor of some very good things in later years, and I think
    our youngest population is the most vulnerable population, and
    we need to target those strategies, whether it be men, women,
    whatever the case may be. And I am just passionate about what I
    do and the work that I do and, hopefully, I can bring a
    different perspective sometimes from where I sit as a State
    lead.
        Mr. DAVIS. Thank you. Thank you very much.
        Dr. Rauner, it is not every day that I run into a First
    Lady of the State who also has a full-time working job and is
    involved with all kinds of other social service entities.
        The Ounce of Prevention is supporting some innovative home
    visiting programs, especially dealing with pregnant and foster
    youth. How does this work strike you in terms of its benefit to
    society?
        Ms. RAUNER. Well, I personally believe that the development
    of every child's potential is the social justice issue of our
    time. It is an economic challenge and a moral challenge for us
    to ensure that every child can participate in the American
    Dream and in the American economy and as a full citizen of our
    Nation. And, again, research is quite clear that the period of
    the first few years of life has the greatest opportunity for
    setting children on the proper trajectory for development. And,
    again, because it is an intervention that affects both children
    and their parents, it has the opportunity to build and develop
    two lives, and I think that is one of the most powerful pieces
    of this work for me. It certainly drives the work that I have
    been doing for decades.
        Mr. DAVIS. Thank you very much.
        Ms. Valentin, I think you are, indeed, a role model. As a
    former teacher, youth worker, father, grandfather, great-
    grandfather, I used to counsel teenagers, and I think you
    represent the best quality of thinking and decisionmaking that
    I have run into. Could you share with us how your experiences
    have actually assisted you, what you may have done even for
    others?
        Ms. VALENTIN. My experience with this program has been
    amazing. You know, an unplanned pregnancy, a first-time mom,
    any mom, young or older, you know, you just need to have that
    support and need to know certain things. And this program has
    helped me so much with even the littlest things, not so much
    about the child but about me or helping, you know, my family
    and stuff like that. So it has been really helpful, and I hope
    that everybody--I mean, I know if everyone could be here right
    now, they would share their experience, because this is truly
    amazing.
        Mr. DAVIS. Thank you very much. And I yield back, Mr.
    Chairman.
        Chairman SMITH OF NEBRASKA. Thank you, Mr. Davis.
        Mr. Smith from Missouri.
        Mr. SMITH OF MISSOURI. Thank you, Mr. Chairman. And thank
    you to the witnesses for making it here today despite the 2-
    inch winter blizzard that we had up here. Clearly not like
    Missouri and Illinois weather.
        I want to thank the Chairman for holding this important
    hearing on the Maternal, Infant, and Early Childhood Home
    Visiting, or MIECHV, program. Many times the Federal Government
    tries to do too much. Our third President, Thomas Jefferson,
    got it right when he said: ``The government closest to the
    people serves the people best.'' But MIECHV works because it
    offers States like Missouri the flexibility to administer the
    program in the way that best suits their needs.
        MIECHV's flexibility allows Missouri's Governor, Eric
    Greitens, to implement three of his major priorities. He wants
    to improve healthcare access, reduce opiate abuse, and reduce
    infant mortality. By choosing to run the Nurse-Family
    Partnership as part of the program, Governor Greitens is able
    to follow through on his promise to address the high infant
    mortality rates in the Bootheel of Missouri. For example, in my
    district in Pemiscot County in the Bootheel, we have the worst
    health outcomes of any county in Missouri. It is 115 of 115. Of
    course, there are 114 counties in the city of St. Louis, that
    is why it is 115.
        Pemiscot County experiences the highest infant mortality
    rates in all of Missouri. We know that one out of eight mothers
    don't make it to full term when pregnant, and two-thirds of
    infant mortality is due to preterm births. We know that we can
    do a lot better. That is why Missouri's Department of Health
    and Senior Services has begun to administer the Nurse-Family
    Partnership program in Butler, Dunklin, Pemiscot, and Ripley
    Counties in the Bootheel. This targeted approach can help
    reduce infant mortality rates in our most distressed counties.
    Unfortunately, Pemiscot County needs the most help of anywhere
    in the State, but fortunately, because of the MIECHV and by
    working with Governor Greitens, we can improve health outcomes,
    save lives, and reduce costs.
        As an evidence-based program, we know taxpayer dollars are
    being spent in the right place because the Nurse-Family
    Partnership program is shown to decrease preterm births and
    reduce infant mortality.
        Ms. Russell, I would like to learn a little bit more about
    the nuts and bolts of the program. How do you prepare for your
    first visit with a mother?
        Ms. RUSSELL. The Nurse-Family Partnership program is a
    blueprint program, and we do have a curriculum that we follow.
    However, each mom is very different. So, personally, I prepare
    for the first visit by just keeping an open mind, knowing that
    what I walk into in one home might be very different than what
    I walk into in another home. So my priorities across the board
    are always ensuring that she already has prenatal care
    established, and if she does not, ensuring that I can help make
    referrals to get her prenatal care started. And then from there
    we look at some of the--is she utilizing the appropriate
    community resources like she should be? Are they part of the
    WIC program? Do they have food they can eat? And ensuring that
    we will refer to those services as needed.
        Once I am sure that all of her basic needs are met, we can
    start to learn a little bit more about who she is as a person
    and what is important to her. We have, as nurses, outcomes that
    we would like to see as far as keeping everybody healthy and
    safe. But it is also important, and Nurse-Family Partnership
    agrees with this as well, that it is important that we find out
    what the client's heart's desire is and help them reach that as
    well.
        So the first visit is very much getting to know them,
    trying to be as laid back as possible, and letting them share
    with us what they are willing to share, and then building on
    from there in each visit from that point on.
        Mr. SMITH OF MISSOURI. The Nurse-Family Partnership
    requires a 2-year commitment. Why such a duration?
        Ms. RUSSELL. As Rosa can attest to, there are many
    struggles that come up in those first 2 years of parenting.
    Pregnancy in itself is a struggle, and there is a lot to learn
    as far as education to stay healthy and have a healthy baby as
    a result of the pregnancy. And then building on that, infancy
    has its own struggles with learning what your baby needs from
    you and how to respond to those needs in an appropriate way, as
    well as ensuring that the baby is getting access to care and
    immunizations and well-baby visits. And then the toddler years
    also create some more struggles as they are now mobile and they
    are doing different things that their parents aren't sure they
    are supposed to be doing or are safe for them.
        And then from a clinical aspect, the baby's brain grows so
    much in those first 2 years and is almost fully grown at that
    point, so we want to have as many positive influences on the
    baby in those first 2 years as possible.
        Mr. SMITH OF MISSOURI. Thank you, Mr. Chairman. I yield
    back.
        Chairman SMITH OF NEBRASKA. Thank you, Mr. Smith.
        Next is Ms. Chu from California.
        Ms. CHU. Thank you, Mr. Chair.
        In Los Angeles County, we utilize both the Healthy Families
    America and the Nurse-Family Partnership models of home
    visiting. And in 2015, home visitors made over 29,000 home
    visits to around 5,500 parents and children in California. The
    program in my State and in L.A. County has placed an emphasis
    on connecting pregnant women and new mothers with mental health
    services. That is, in my opinion, a fantastic way to leverage
    existing programs aimed at improving mental health and wellness
    for children and families with the unique methods of the home
    visiting program.
        So, Ms. Russell, based on your experiences working with the
    Nurse-Family Partnership model in Pennsylvania, can you
    describe a few ways in which you have relied on a broader array
    of available social services, such as mental health evaluation
    and treatment, to carry out your mission, and do you have
    examples?
        Ms. RUSSELL. Sure. As part of the Nurse-Family Partnership
    program, we do regular incremental screenings for depressive
    and anxiety disorders. So based on those screenings, we can
    refer as necessary. So we do those during pregnancy and then
    continuing through the child's first 2 years of life, on a
    schedule. But we can also do them as needed. So if we come into
    a home and we find that the mother's affect and tone are just
    not quite like they had been before, we can screen as needed,
    which is one thing that is great for us as nurses. We have been
    given those tools in our undergraduate degrees to recognize
    some of the problems that might present if a mother is having
    trouble with her mood but maybe isn't quite ready to recognize
    that in herself, just like Rosa had been through. So through
    those routine screenings and through our basic assessment
    skills that we learn in our undergraduate programs, we are able
    to keep a really close eye on that.
        Unfortunately, in Lancaster, our mental health resources
    are not as strong as we would like them to be. We are able to
    make referrals, but many times they do have to wait for a
    couple of weeks or a couple of months until they can be seen by
    a provider. So in the meantime, we are able to educate on some
    coping mechanisms that they can use in their own home until
    they are able to get into a more structured environment for
    counseling services.
        Ms. CHU. And do you think mental health issues are a
    frequent kind of issue that comes up for pregnant women?
        Ms. RUSSELL. I would say yes. I do feel that they are very,
    very prevalent in our population. Nurse-Family Partnership
    collects data that could give you the real percentages as far
    as that goes, but every day I am working with at least one mom
    who is having trouble with her mood at that current time.
        A general day for me is three to four visits with three to
    four different patients, so that is one a day that is probably
    having some sort of trouble, which is about 25 percent to 50
    percent of my caseload. So it is very prevalent, unfortunately.
        Ms. CHU. And how about substance abuse counseling? Is
    substance abuse an issue that comes up frequently?
        Ms. RUSSELL. Yes. Yes. Substance abuse is also an issue
    that comes up, whether that might be a past history and the
    mother is now no longer using but is working on ways to prevent
    herself from continuing to use, or whether they actually are
    using a substance during their pregnancy.
        So for us as nurses, it is important that we educate on how
    it will not only affect her, but affect her unborn child or if
    she is already parenting, how that will affect that child's
    growth and development as well.
        Ms. CHU. Okay. Ms. Rauner, in placing emphasis on
    connecting pregnant women and new mothers with mental health
    services, States like California try to detect and remediate
    potential issues very early in a child's life. However, data
    from the L.A. County Health Services underscores the challenges
    facing many mothers, which is that nearly one-third of women
    who were recently pregnant or had delivered a baby lacked a
    regular source of health care.
        So how do home visitors help to provide effective early
    intervention for pregnant women and new mothers who do not have
    easy or regular access to health care?
        Ms. RAUNER. Well, certainly, one of our efforts has been to
    connect new mothers to all the services that they need. With
    respect to mental health programs, we also have been able to
    use MIECHV funds to build mental health consultation in for our
    home visitors so that they are actually able to be supportive
    when we don't have access to services.
        But access to early intervention services, to health care
    services, and other connections is a very vital part of what
    the home visitor is doing in any community. And certainly, we
    make that a high priority for all of the models that are in
    place in Illinois.
        Ms. CHU. Okay. I yield back.
        Chairman SMITH OF NEBRASKA. Thank you, Ms. Chu.
        We will move on to Mr. Reichert from Washington State.
        Mr. REICHERT. Thank you, Mr. Chairman.
        First of all, I want to thank the witnesses for being here
    and for the time that it took to put your comments and
    statements together. And I thank the staff. The Democrats and
    the Republicans have people that are sitting back here. They
    put this whole thing together, and I want to congratulate them
    on bringing some excellent witnesses today to testify. It is
    important for us to hear, not only from people like Rosa--if it
    is okay if I call you Rosa--and the experts in the field that
    do the work, but it is so critical to hear from those who are
    the recipients and then those who provide the work, the
    services, like Beth.
        So how many of the witnesses have testified before Congress
    before?
        How many have testified before other members of maybe a
    city council or a county council?
        I knew that Ms. Rauner would raise her hand. She has
    experience in this world.
        You have all done a great job, but I think we really need
    to recognize Rosa's testimony. She is the first 16-year-old to
    testify--I have been here 12 years. I just look like I have
    been here 40. I have been here 12 years, but this is the first
    16-year-old witness, Mr. Chairman, that we have had, and she
    did outstanding. I don't know if it is against the rules or
    not, but we should give her an applause.
        [Applause.]
        The heck with the rules sometimes, right?
        So I wanted to ask Rosa, and you don't have to answer this
    if you don't want to, but why did you choose Angelica for--I
    have kind of maybe a thought on that, but why did you choose
    Angelica for your daughter's name?
        Ms. VALENTIN. Angelica was my grandmother's name, which is
    also my middle name. My middle name is Angelica Marie, so I
    named her Angelica Marie.
        Mr. REICHERT. Okay. I had two choices, but I bet you your
    grandmother was named Angelica and your middle name is Angelica
    because----
        Ms. VALENTIN. Of my grandmother, yes.
        Mr. REICHERT [continuing]. Because you are angels. My
    daughter's name is Angela, and we weren't supposed to have
    children, so we chose Angela because she was our little angel.
    So I am sure you think of Angelica that way, right?
        Ms. VALENTIN. Yes.
        Mr. REICHERT. So what I would like to ask Rosa is just--you
    know, we are having a conversation here. It gets a little
    formal sometimes, but, you know, just from your first contact
    with Beth and how this came about--because the courage it took
    for a 14-year-old to decide to go through with the birth of
    your child, and now here you are today, going to school,
    looking for a nurse's profession in the future, I think is just
    an amazing feat, and it shows so much maturity, but you
    couldn't have done it without Beth and your parents.
        Ms. VALENTIN. Yes.
        Mr. REICHERT. Don't worry about the rest of your family.
    They will get on board eventually. Eric is laughing. I have
    been there. I am the oldest of seven. You know, every now and
    then, they kind of float in and out of your life.
        Just tell me in your own words what the whole thing is all
    about for you. How did it really help you?
        Ms. VALENTIN. I just felt like I needed more support. You
    know, my mom was always there to help me, but she was like, you
    know, this wasn't planned, but we are going to make the best of
    it, and we are going to get you through this no matter what
    bumps come through the road. Like, we are going to get through
    it. You are going to finish school. You are going to be on
    track to finish, and you are going to be a great mom.
        So this program, you know, at first, I was going to Healthy
    Beginnings, but Healthy Beginnings wasn't associated with the
    hospital I was in, the OB-GYN, so I was referred to Nurse-
    Family Partnership. And I am so glad that I was referred to
    Nurse-Family Partnership because it has been, you know, so
    great--I am so grateful to, you know, have this program, have a
    nurse by my side that, you know, can answer any questions and
    stuff like that. So it has been really helpful.
        Mr. REICHERT. Good. Beth, do you want to add something
    quickly to that?
        Ms. RUSSELL. I am just so proud of Rosa. She does not do
    public speaking very well, and one of her goals that she set
    for herself was to try to interact with people more because
    with doing the cyber program, she really doesn't get much
    interaction with people outside of her home, so this is a
    really huge step for her.
        Mr. REICHERT. I mean, you did awesome. Look, at 16 years
    old, I wouldn't have been in your seat. I guarantee you that.
        We get a second round of questions, so I am going to come
    back to the others to just ask some technical questions. But I
    just want to really emphasize the courage it took to move
    forward with your life, the courage it took to be here today. I
    truly would not have been doing what you are doing today. I
    couldn't have done it. And you can't even vote. You might be a
    Congresswoman some day.
        I yield back.
        Chairman SMITH OF NEBRASKA. Or perhaps you have higher
    aspirations.
        Mr. REICHERT. We will make that the first female President
    then.
        Chairman SMITH OF NEBRASKA. There you go. Thank you.
        Ms. Sewell.
        Ms. SEWELL. Thank you, Mr. Chairman.
        I wanted to associate myself with the remarks of my
    colleague. I think that your grace and your courage and your
    maturity is something to be marveled at, Rosa, so thank you for
    being here today.
        Before I begin my questions, I wanted to quickly express my
    desire to make sure that MIECHV is re-funded and reauthorized.
    In my State of Alabama, 5,220 families and 6,280 children
    receive home visiting services. In my district, 12 out of the
    14 counties are eligible to receive MIECHV funds. Moreover, the
    MIECHV funding programs are primarily--are the primary source
    of funding for home visits in Alabama. The Federal funding is.
        My district also has a wide variety of evidence-based
    models, including the Parents as Teachers, Nurse-Family
    Partnership, and the Home Instruction for Parents of Preschool
    Youngsters program. In fact, 86 percent of Alabama families
    receive home visiting services from a model that has been rated
    as evidence-based by HHS.
        For my constituents, many of whom live in underserved rural
    communities, the home visiting services that MIECHV programs
    fund are essential. And as we have learned from the special
    relationship between Beth and Rosa, home visitors also provide
    important emotional support when young parents may feel all
    alone. In Alabama, over 50 percent of the single mothers with
    children under 5 live in poverty. These mothers and their
    children need these kinds of programs.
        I want to thank all the panelists for taking the time to be
    here today.
        And my question I wanted to first address to Mr. Bellamy.
    South Carolina, like Alabama, has both urban and rural
    communities. One of the biggest questions or complaints,
    challenges, that I hear a lot from my constituents that live in
    underserved rural communities is lack of transportation. Can
    you talk to me about how the MIECHV-funded programs are
    administered in your State in rural communities and what are
    some of the challenges, and how your State overcomes those
    challenges?
        Mr. BELLAMY. Yes, ma'am. Many of the same challenges, Ms.
    Sewell, that we have in South Carolina for sure, transportation
    being one of them. The beauty of MIECHV and home visiting is
    meeting families where they are literally. And also, MIECHV has
    also given us an opportunity to expand services into these
    rural communities that really needed it and target those
    families that were most in need, so the needs assessment that
    states that we could really look at where we needed to target
    services. In most of--in South Carolina, most of our State is a
    rural State, so we put in practices and allow the ability for
    programs to be able to have sufficient funding to do home
    visits and travel to outlying counties and work with contiguous
    communities that may be rooted in really a more resource-richer
    community.
        Ms. SEWELL. And I noticed that you guys expanded the number
    of counties that were covered, and that expansion is, I would
    assume that South Carolina like Alabama, most of the funding
    for MIECHV comes from the Federal Government, and our State
    matches maybe, it is sort of a 2 to 1 match. Talk to me about
    how you guys--it seems to be a capacity problem in my State,
    that there are far more eligible families that could benefit
    from MIECHV than are actually reached. In my home county of
    Dallas County, I grew up in Selma, and Selma has 67 percent of
    the families with children under 5 in poverty. But yet 2.9
    percent are actually covered by the MIECHV funding, so there is
    a capacity issue.
        I would like to get you involved, Ms. Rauner, if you could
    talk a little bit about how Illinois addresses the capacity
    issue and making sure that these great programs actually reach
    more families.
        Ms. RAUNER. Yes, thank you. Well, in Illinois, despite many
    years of investment, both from our State Board of Education and
    our State Department of Human Services as well as of course,
    MIECHV, we are still only serving 10 percent of all eligible
    children in our State. And Illinois, as well, is an urban and a
    rural State and has--of our 102 counties, most of them are
    quite rural.
        We have used MIECHV dollars specifically to build community
    collaborations in both urban and in rural States. And we have
    looked through our needs assessment at some of the places that
    are most isolated and, again, have some of the most--the
    highest infant mortality rates. So the MIECHV program has
    allowed us to create community collaborations in those
    communities that bring together the available resources.
        Ms. SEWELL. So you pool funds? Are you pooling funds?
        Ms. RAUNER. Pooling funds, but also making sure that we are
    effectively using all the resources that the community has. And
    to the extent that we find gaps in resources, being able to
    advocate and reach out to other agencies to support those.
        So we have actually connected our MIECHV programs with our
    infant mortality Title V programs. We have been able to use
    some of our child welfare dollars, again, to identify places
    where there are real gaps in services.
        Ms. SEWELL. Thank you.
        Chairman SMITH OF NEBRASKA. Thank you. And now I will begin
    our second round. Fortunately, we have the time resources to
    deal with this, with the second round.
        Ms. Russell, I would like to focus a little bit on your
    insight and, kind of, frontline involvement there. I mean, the
    list is quite long in terms of what can be achieved with these
    effective models of home visiting. And, you know, from
    obviously economic self-sufficiency in a very broad way to
    increased work reduce arrests, less welfare dependence in
    general. Can you, perhaps, highlight or give us more specifics
    on your work in terms of how you might begin providing or
    connecting with a client and what that looks like compared to
    maybe evolving through and in making adjustments along the way
    and the observations that, perhaps, that you have had along the
    way as well?
        Ms. RUSSELL. So in regards to connecting with her and her
    goals for herself, we start that the first day we meet each
    other. It is a very important part of the Nurse-Family
    Partnership program to ensure that we are not only with them
    during these 2\1/2\ years but we have given them the
    information that they need to create their own foundation for
    the future as well. So very early on we do meet, and we talk
    about goals.
        Each time we meet with them, we have an agreement form, and
    they have a little, what we call, a mini goal on there of
    something that they want to accomplish before we see them the
    next time. And sometimes that is a parenting, sometimes that is
    something much larger as far as applying for schooling and
    enrolling in programs like that.
        So we do discuss goals very early on and remind them of
    those goals every time we see each other. Sometimes they come
    to us and they say, oh, I forgot about that, and then we remind
    them kindly, again, that this is important to them. And they
    will very much pull through with what is important to them. And
    that is probably the most beneficial part of Nurse-Family
    Partnership is knowing that they are accomplishing what is
    important to them as well as we are encouraging them to
    accomplish what is also important to them and other parts of
    the program, other importance as well as self-sufficiency in
    the future.
        Chairman SMITH OF NEBRASKA. Okay. And I know that sometimes
    we struggle with wanting accountability in various programs and
    also allowing enough flexibility to spawn innovation, you know,
    a creative approach and so forth. Are there any times when you
    might feel somewhat confined in--with the services you offer
    because of, perhaps, some restrictions or Federal requirements
    or even State requirements?
        Ms. RUSSELL. Yeah. I feel like I can say no to that,
    because the beauty of Nurse-Family Partnership is that we can
    be a little bit flexible with when and where we meet our
    clients. So if it is snowy, and I can't get to her where I need
    to be--our plowing, unfortunately, is not so great--so we might
    see each other a couple of days later, but we can connect by
    phone and have a short interaction by phone if we need to.
        If I have a patient or a family member who is homeless, we
    can meet at a public library or at a park or a cafe. So coming
    to them makes it very flexible for us to be able to meet our
    requirements with how often we are supposed to visit with our
    families, because we can truly meet them wherever our cars will
    allow us to go.
        If there is ever a concern with our clients where maybe
    they are having some difficulties, and they can't physically
    meet with us, again, we are able to have phone encounters as
    well to still check in on them and make sure everything is
    going the way it needs to be, and if they have everything they
    need before we can physically see them again for a true home
    visit.
        Chairman SMITH OF NEBRASKA. And can you say--I think you
    may have said earlier, but can you say a typical number of
    clients you see in a day.
        Ms. RUSSELL. In a day, I try for three to four. Sometimes I
    see more than that, just depending on what they need. But if I
    had perfect control of my schedule, I would see about three to
    four a day, and then we just fill in as needed based on what
    the clients are in need of at that time.
        Chairman SMITH OF NEBRASKA. Okay. Thank you.
        Mr. Davis.
        Mr. DAVIS. Thank you. Thank you, Mr. Chairman.
        And, again, I thank the witnesses.
        Dr. Rauner, let me ask you. Sometimes substance abuse is a
    problem in the home. How does the Ounce of Prevention deal with
    substance abuse issues when you run into them?
        Ms. RAUNER. Well, substance abuse is a major challenge for
    many of the families that we are serving, and one of the most
    important things we can do is train our home visitors to ensure
    that they have the skills necessary to identify, address, and
    refer patients and clients to appropriate services.
        Now, we know that services are sometimes difficult to come
    by. And one of the important things, again, that collaboratives
    allow us to do is begin to look at where the gaps in services
    are and how we begin to advocate for and push for greater
    services to address particularly substance abuse. We know in
    our State that, as in many, that the opioid crisis has really
    changed the dynamics for many of our communities. We also know
    there are many patients who are suffering from mental health
    issues that are, of course, associated with substance abuse.
    And so we are very focused on ensuring that our home visitors
    are appropriately trained and, also, that they are connected to
    a system that can--to which they can refer--they can refer
    clients.
        Mr. DAVIS. And for each one of you, if you could, how do
    you deal with the challenge of getting male involvement or more
    male involvement in the activities?
        Ms. RAUNER. Well, I would just say that one of the benefits
    of home visiting is that it is an opportunity to coach both
    mothers and fathers in their role even when the parents are not
    living together and may not actually be together anymore as a
    couple.
        But one of the things--I tell one story of a family
    actually in, Mr. Davis, in your community, that has been
    benefiting from home visiting services. Again, a mother and a
    father, young individuals who were not together, were not
    living together. The mom living at home and trying to continue
    with her education and get a job, and the dad living in a
    pretty unstable circumstance.
        Over the course of a couple of years of participation in a
    home visiting program, a Healthy Families program, where the
    mom and dad were able to participate in those programs
    together. So he would come over and spend time with the home
    visitor when she would visit the child. They actually--he
    actually decided it was important for him to get his life back
    on track, get back into school and become a caretaker for his
    child. And the couple have decided to get married. He is in
    school. She is employed, and they are getting ready to move
    into their own home. So I think this is an example of how home
    visiting can support parents as they are developing, frankly,
    into adults and making the challenging commitments that they
    need to make to their children and to each other.
        Mr. DAVIS. Thank you.
        Yes.
        Mr. BELLAMY. I think it is--I think fatherhood and male
    involvement is essential to the holistic approach to serving
    families, even though, oftentimes, mothers are the focal point
    and the entry point to many of our programs, we really need to
    continue to look at how we are supporting the entire family
    with our programs.
        You know, oftentimes, as I said, we may have couples or
    families that may be divided and not living together, but we--
    the beauty of MIECHV is that it has allowed for innovation
    within models to really push for the models to look at
    different ways that they can continuously improve the
    initiatives, improve their programming. And fatherhood
    initiatives has been one that has--is building momentum on a
    continuum. And I think as we move forward, it is something that
    many States will look at stronger strategies to involve their
    fatherhood initiatives and local fatherhood initiatives within
    the States to be a part of, again, that holistic approach to
    really bring in the family and being self-sufficient as a
    family.
        Mr. DAVIS. Thank you very much.
        Mr. Chairman, I yield back.
        Chairman SMITH OF NEBRASKA. Thank you, Mr. Davis.
        Mr. Smith from Missouri.
        Mr. SMITH OF MISSOURI. Thank you, Mr. Chairman.
        Ms. Russell, Nurse-Family Partnership is just one service,
    but I am sure you connect your clients with numerous other
    needs. How do you coordinate with these other programs?
        Ms. RUSSELL. In Lancaster, we are very grateful to be under
    the Lancaster General Health and Penn Medicine umbrella, so
    this allows us opportunities to communicate within that
    umbrella to other services that are available to families. But
    we also over some time really built strong relationships with
    other community resources, and we tend to have meetings with
    them on a regular basis to remind each other that all of our
    programs exist and that we should be working together as best
    we can to support our families.
        So we do have as easy as a basic list of resources that are
    available in the area that we can take out to the families, but
    we are also the ones that are making the phone calls and
    sending the faxes to get all that information across to them.
        So we have built some really great connections in our
    community just by meeting each other at different events,
    organizing different coalitions to bring all the resources
    together for our families.
        Mr. SMITH OF MISSOURI. So whenever you, like, coordinate
    some of these programs and services to the families, is there a
    reporting mechanism where they report back to you, or do you
    check back up with them to make sure that those services are
    following through to help assist them, or how does that work?
        Ms. RUSSELL. Yes. If I send a referral somewhere, I do
    request that the referral organization contact me once the
    client has made contact, but then I also will check in with my
    client when I go to the home visit to ensure that they have
    either called that referral source or that they have received a
    call back that they have gotten that service.
        And we do track all of that in our data ETO tracking as
    well so that the main NFP site can see where we are sending
    referrals and what types of referrals we are in most need of.
        Mr. SMITH OF MISSOURI. Thank you.
        And the Nurse-Family Partnership model requires services be
    delivered in a certain way so that they are effective, and the
    MIECHV statute requires programs be operated in the way they
    were designed and studied. What do you do as a nurse visitor to
    ensure fidelity to the model?
        Ms. RUSSELL. So to prepare for each home visit, I will
    first start by reviewing what we had done at our last home
    visit just to see what we had talked about, refresh my memory
    so I don't forget as well, and then build on there.
        So we have multiple different facilitators of educational
    sheets and activities, interaction activities, we can do with
    the family to do things hands-on. And, generally, what we try
    to do is ask the client, the next time I see you, is there
    anything specific you would like to talk about, is kind of how
    we end our visit. And if they are unable to name something, we
    have a choice sheet that they can choose from.
        So that gives us the opportunity to deliver what the
    program is asking us to deliver, because the options that we
    are giving her to talk about are part of that blueprint
    curriculum for Nurse-Family Partnership.
        Mr. SMITH OF MISSOURI. Thank you. I would like to speak to
    Rosa.
        As one of the youngest Members in Congress and the youngest
    Member on this Committee, I am very impressed with you being
    here today. My first touch at ever speaking to anyone in
    government was before my small city council of a town of less
    than 5,000 people, and I was about your age and was fortunate
    enough to be able to still serve that city in Congress now. So
    I can only imagine what your future lies ahead if your first
    venture is to speak before what I believe is the most important
    Committee in Congress.
        I am very impressed, and I look forward to seeing the great
    things that you will accomplish. And I just want to say, I am
    extremely proud and humble to be part of this.
        And Ms. Rauner, as my neighbor to the east, I was highly
    impressed whenever I see a first lady that is a working first
    lady other than--just, you know, career and family, it is both
    a double task. But I would encourage you to meet with our first
    lady, Ms. Sheena Greitens, who is also a working first lady,
    and help mentor her as well. I think you would have a lot in
    common. Thank you for being here.
        Chairman SMITH OF NEBRASKA. Thank you. Well said.
        And Mr. Reichert from Washington State.
        Mr. REICHERT. Thank you, Mr. Chairman.
        Even though Mr. Smith is the youngest, we--you know, he has
    a lot of potential unless more senior Members are, you know,
    trying to work with him. He is coming along nicely.
        You know, I--so I wanted to--so the first question I wanted
    to get to was for Mr. Bellamy.
        Evidence-based, you have all mentioned that. We see that it
    is necessary, you know, from Rosa's testimony also. You know,
    as it applies to how it is used across the State, I think, my
    question: Doesn't it become complicated when you are looking at
    rural versus urban, and then you have to evaluate what services
    to provide? For example, you know, nurses or counselors that,
    sort of, help and how you get that--those resources to those
    different areas needing just different types of services and
    the population is spread out?
        Mr. BELLAMY. Yeah. It can be a little tricky. But, again, I
    think the power in this is being able to identify appropriate
    programs for families and really tailoring those programs and
    interventions that are--that families are going into more
    specific to that family.
        So when we target areas, we look at--you know, when we talk
    about needs assessment, we talk about areas that we want to go.
    We may look at, you know, specific programs that may work well
    there; however, again, the autonomy lies within those local
    implementing agencies. And we want to continuously work with
    them and partner with them to make sure that they have that
    ability to identify appropriate services.
        So, again, in South Carolina, we really wanted to build a
    continuum service, that is why we didn't look at one specific
    model that we wanted to implement across the State or support
    across the State. We wanted to look at prenatally up to age 3,
    up to age 5 and look at the different services that we can
    implement within those communities to help with those services.
        Mr. REICHERT. And that, really, is the important point here
    I think to make is every community is different. And you are in
    those communities, tailor making those services to each
    community is really the key and success.
        I really like what you said, Ms. Rauner, about early
    childhood, the human capital development is absolutely
    critical. I am a 33-year law enforcement career retiree and
    ending up here in Congress. I was a cop in Seattle for 33 years
    ending up as a sheriff and being in homes and working with
    young people my entire career. That human capital is so
    critical.
        Readiness for school, preparing people for the future gives
    hope and opportunity. And that is what is missing in today's
    world, that hope and opportunity, and ending that cycle of, you
    know, just coming from families, and getting into situations
    where it takes away hope. And--which goes back to the
    fatherhood issue.
        You know, if young men don't have hope, they lose
    opportunities. They kind of disappear, and we have to save
    those young people.
        The question I have for you--both of you and Ms. Rauner,
    first, was on the substance abuse issue. I think two or three
    of you mentioned that. What is the most common substance that
    is abused? I know opioids are the biggest problem today, but
    what are some of the others? Alcohol, tobacco, would that be
    some? Is marijuana in that?
        Ms. RAUNER. Yes, I would certainly--I am not sure I have
    the exact data on that. I would certainly say that alcohol, and
    marijuana, and tobacco are some of the biggest--the most
    prevalent. What we also know is that substance abuse is very
    likely and very often associated with depression and mental
    health issues. And so, again, support for the underlying issues
    can, in fact, be an important part of both preventing and
    addressing substance abuse.
        Mr. REICHERT. Yes. Again, I just want to thank all of you
    for being here today and for your testimony. This is such an
    important issue. And you can see from the comments on the dais
    here, you read in the papers and see in the media the lack of
    cooperation that some have described whereas, sort of, the
    state of, you know, separation in some--on some issues. But
    this is one issue where you can see total agreement on this
    panel for both Democrats and Republicans.
        We want to help. We think it is absolutely critical. And I
    thank you all for being here, and especially, again, Rosa.
        And I hope I can see Angelica before--okay--before I leave
    today.
        I yield back, Mr. Chairman.
        Chairman SMITH OF NEBRASKA. Thank you, Mr. Reichert.
        And, again, thank you to our witnesses. And if you don't
    mind, colleagues, we might want to grab a quick photo with our
    witnesses here momentarily.
        But, again, thank you, to all of you, for sharing your
    unique perspectives. And we know that your personal experiences
    and professional expertise are very helpful. I think we have
    Angelica visiting here right now. Very good.
        Please be advised that Members will have 2 weeks to submit
    written questions to be answered later in writing. Those
    questions and your answers will be made part of the formal
    hearing record.
        With that, the Subcommittee stands adjourned.
        [Whereupon, at 10:25 a.m., the Subcommittee was adjourned.]
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