How has New Jersey built a continuum of home visiting services?

Q&A with leadership from the New Jersey Department of Children and Families: Jill Brown, Home Visiting Program Manager, Office of Early Childhood Services; Lenore Scott, Administrator, Office of Early Childhood Services; Sanford Starr, Deputy Director for Family and Community Partnerships1

There is growing recognition that home visiting programs can play vital roles in supporting families of newborns and young children, especially young mothers. This critical time of bonding and child development is life changing but also can be overwhelming, particularly for parents who may be facing challenges in other areas of their lives. Home visitors can help reduce isolation while also empowering parents to care for and support their children in age-appropriate ways. While the specifics of home visiting programs vary, home visitors often provide education and referrals to community-based services, and help parents set goals for themselves and their families. This support has been shown to positively impact families in a number of ways, including reduced child maltreatment, improved child and maternal health, school readiness, and family economic self-sufficiency. Providing an array of effective home visiting services allows parents to participate in the program that best fits their family’s needs. In New Jersey, a long-held commitment to keeping families together was key to building the state’s current network of home visiting programs.

Who were the early champions of New Jersey’s home visiting work?

Long before we joined the agency, home visiting was prioritized by our statewide Prevention Taskforce, which included representatives from advocacy organizations, philanthropy, the United Way, the New Jersey chapter of the American Academy of Pediatrics, and local and state government agencies such as child welfare and juvenile justice, as part of a continuum of services to support families. The taskforce was instrumental in bringing Healthy Families America (Healthy Families), our first home visiting program, to New Jersey in 1995. The group eventually morphed into the Home Visiting Workgroup to look at the successes and challenges of the Healthy Families pilot with the goal of implementing it statewide. Bringing this group of stakeholders together consistently was key to where we are today with home visiting — they were the early champions for this work and helped seed our thinking about prevention work and how we can better support families.

How has your approach to home visiting evolved over the years?

We continue to build and evolve. Whenever new funding is available, we think about how we can take advantage of it and align it with our priorities in this work. We started with Healthy Families, but then we were able to leverage funds from Healthy Start and private foundations to fund a Nurse-Family Partnership site in Trenton. Even though we already had Healthy Families, we wanted to add Nurse-Family Partnership to our continuum of home visiting services because the opportunity to work with first-time moms aligned well with both the available funding and our state’s vision.

In 2006 to 2008, we expanded Nurse-Family Partnership to seven additional sites, as well as piloted Parents as Teachers in two sites, thanks to state funding and a grant from the federal U.S. Department of Health and Human Services, Administration for Children and Families, for the Evidence-Based Home Visiting Models initiative. These were the building blocks for our continuum. Nurse-Family Partnership has a very narrow window of enrollment; Healthy Families has a broader window but one that is still somewhat narrow; and with Parents as Teachers, families are eligible until the child is age 3 or 5, depending on the particular model. We were building our home visiting network at the same time that we were building our early childhood system of care, so it was a perfect fit. Today, Healthy Families, Nurse-Family Partnership, and Parents as Teachers are all available statewide. 

How were you able to scale up these programs to offer them statewide?

Funding was key. With the advent of Maternal, Infant, and Early Childhood Home Visiting (MIECHV) funds, we were able to ramp up our programs to offer them throughout New Jersey. TANF and state dollars are also used to support our home visiting continuum. Our vision is that home visiting will eventually be a universal service, so that every family can have access to the model that best fits their needs. To make that happen, we need a stable source of funding. Right now, these programs are primarily funded through MIECHV, but it’s not sufficient so we are looking at whether we can get a Medicaid waiver to use Medicaid as a payer source for home visiting. That will not solve all our problems, but it will go a long way to help us implement a universal approach. 

What lessons have you learned about implementing home visiting programs?

We subcontract with local providers in each county to implement each home visiting program, and we partner with Prevent Child Abuse New Jersey (PCA-NJ) to provide support to those providers. PCA-NJ is the technical assistance provider for both Healthy Families and Parents as Teachers, and is the state lead for Parents as Teachers. The national office for each program is also a key partner, but it is working with the whole country. We felt it was important to have more localized support, which allows us to be very attentive to model fidelity as well as local needs.

For example, when we developed a plan to implement Parents as Teachers and Nurse-Family Partnership statewide, we worked closely with both the model developers and PCA-NJ. We were a team, each with distinct roles. During the early implementation and Request for Proposal stage, we worked with a diverse group of stakeholders to review proposals and resumes to ensure that the local agencies had the necessary capacity to successfully implement these programs. It was an arduous scoring process, but it was a fair and collaborative one.

Those partnerships — both with the national program office and with PCA-NJ — have been essential to ensuring that each model is implemented to fidelity. Staff are hired for specific models by each local agency and do not work across models, even if an agency provides more than one service. 

It is important to communicate closely with the local implementing agencies, both about our expectations and their needs. We want agencies to be intentional about hiring staff who represent the families served. We include that in their contract and have conversations with them about why. They have to include the demographics of both families and staff in their quarterly reporting. We also want to hear from the agencies about their needs and, when necessary, we adapt accordingly. For example, we reduced the caseload size of Parents as Teachers because we realized that if our goal as a state was to serve families with high needs, then home visitors would need to spend more time with each family to meaningfully address those needs.

How do you know if you are preventing child maltreatment?

Until we are able to provide universal home visiting services, we want to maximize current resources to ensure that families with the most need are able to access the home visiting program that is the best fit for their family. We piloted a central intake system for home visiting services, which is now operational statewide. This intake system is available to anyone, but the majority of referrals come through clinics and hospitals, which use standardized screening and assessment forms to identify families that could benefit from home visiting.

Once families choose to participate in a home visiting program, we collect a variety of data regarding their participation and progress in the program. Every year, we also conduct a data match between the data we collect and the child welfare agency’s data to see if any of the families that received home visiting services also received child welfare services. Looking at the data helps us to see what impact we might be having on preventing child maltreatment, but also to identify families where additional support might be helpful.

As a result, we learned that a lot more families are involved with child protective services (CPS) after enrolling in home visiting than we initially realized. To address that, we recently started a pilot with CPS: for families that do not rise to the level of needing child welfare services but could benefit from home visiting, CPS now provides a warm handoff to an early childhood liaison who can connect families to the most appropriate home visiting program. Families that are involved with CPS and meet eligibility criteria are also welcome to participate in one of the home visiting programs. We believe it is critical to link families to as many preventive services as possible, and home visiting is an essential part of the preventive services spectrum. This is just another example of how we are continuously building and aligning our work.

Can you share any other examples of what “building and aligning” means to you?

We have three statewide models of home visiting but, in the early stages, they were operating in silos. We took a step back and asked: How can we align the programs in a way that makes sense? Rather than having three separate meetings to discuss and collaborate around each of the three models, we decided to bring them together. While that may not seem like a very innovative thing, it was innovative at the time, and sometimes, simple changes can make a big difference. We used these combined meetings to learn from each other and share the challenges we were all facing in working with families with multiple needs. 

We continued to build on that idea and created a statewide home visiting network. We now have regular quarterly meetings with the supervisors of all three models to talk about what is happening across the state. We discuss challenges, best practices that all the models can apply, and continuous quality improvement, including looking at the data and involving meeting participants in the improvement process using Plan-Do-Study-Act (PDSA) cycles. We also provide additional resources and time to discuss model-specific needs and issues. Creating this statewide network and building these relationships between the programs has supported implementation of each model and helped bring the three models into better alignment. Members of the network now reach out to each other, regardless of the particular model they provide, to follow up on PDSA efforts, share information, and provide support. 

What advice would you give to another jurisdiction that wants to develop a home visiting program or network?

Home visiting is all about relationships, and building relationships takes time. You have to build relationships with community members and listen to what families say they want and need. You are introducing something new into the ecosystem, so communication has to be bi-directional. 

Capacity is another essential component — if you are going to implement an evidence-based model, you have to have the capacity to implement to fidelity to get the results that you expect. Implementing three different models in every county is a big lift, but we recognized there is no one-size-fits-all approach. Different families have different needs, and they need different approaches. Having the expertise and bandwidth to implement multiple approaches across the state acknowledges that not all families are the same, and what works well for one family might not work for another.

1 Adapted from interview with Jill Brown, Lenore Scott, and Sanford Starr. November 16, 2020.
2 A small Home Instruction for Parents of Preschool Youngsters program is also available, aligned with Parents as Teachers with a focus on early childhood literacy.