Hearing on the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) ProgramHearing on the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program
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CONTENTS _____________________ WITNESSES Crystal Towne RN, Nurse-Family Partnership Home Visitor, Yakima Valley Memorial Hospital Testimony Sherene Sucilla Former Nurse Family Partnership (NFP) program participant Testimony Darcy Lowell CEO, Child First Testimony Jon Baron President, Coalition for Evidence-Based Policy Testimony Rebecca Kilburn Senior Economist, RAND Corporation Testimony ______________________________________________
Hearing on the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program Wednesday, April 2, 2014
U.S. House of Representatives, Committee on Ways and Means, Washington, D.C. ____________________
The subcommittee met, pursuant to notice, at 2:10 p.m. in Room 1100 Longworth House Office Building, Hon. Dave Reichert [chairman of the subcommittee] presiding. [The advisory of the hearing follows:] _________________________________________________________________ *Chairman Reichert. Well, good morning, and welcome to all of you, and thank you all for being here to testify, and thank you all for coming to listen, and thank I the Members for being here today to participate in today's hearing. So, today's hearing is on the new federal Maternal, Infant, and Early Childhood Home Visiting program. Someone apparently thought naming a program MIECHV made sense. [Laughter.] *Chairman Reichert. But, fortunately, we have the pronunciation of this acronym, and it is relatively simple: MIECHV Program. So I am going to stick with that, if you guys don't mind. At its core, this program is designed to improve outcomes for children and families who face the greatest risk for abuse and neglect and a host of other problems that place too many kids far behind on the road of life. Small home visiting programs have operated for decades using a mix of federal, state, and private funds. But the MIECHV program, when it was created in 2010, marked the first time there was dedicated federal funding for this purpose. Our purpose today is to review what we know about the effects of this program, so we can begin thinking about next steps. Earlier this week we got a little more time with the program's extension through March 20 of 2015. But there is a lot to consider here, so it is good that we have a head start. For instance, we need to review whether the actual outcomes of this program are living up to its promise, in terms of producing better outcomes for children and families. We also need to think about whether the program's mix of supporting proven and promising approaches continues to make sense. And we should consider whether this program should continue to have 100 percent federal funding, especially since some of the positive outcomes we hope to see will benefit our state partners. For my part, I am interested in how we can apply the basic discipline of this program, which uses taxpayer funds to support what we know works to help children and families. Two other government programs today can't say the same thing. Fortunately, we have the ‑‑ a distinguished set of experts to help us sort through these questions more thoroughly today, and that list includes a service provider and recipient of home visitation services from my home state of Washington, so we will have an opportunity to ask some real how‑does‑this‑work‑at‑the-ground‑level questions. We welcome all of our witnesses today, and we look forward to their testimony. *Chairman Reichert. Mr. Doggett, would you care to make an opening statement? *Mr. Doggett. Thank you very much, Mr. Chairman. And I share the objectives that you just outlined. We have heard so much over the last several years in this Subcommittee about the extent of maltreatment and abuse of children across the country, and the need to focus more of our resources not just on responding to that abuse after it has occurred, but what can we do to prevent maltreatment. The enactment of this federal home visiting program, building on the experience of many local and state initiatives that were already existing back in 2010 I think was an important step forward. It is an investment in prevention and future development of children. I believe there is considerable evidence that this is a wise investment, though, as some of our witnesses point out, it may be difficult to quantify all aspects of the benefits. And this cannot be a one‑size‑fits‑all kind of approach, because these are families with children in different kinds of positions, and we need to adapt the program and look for the most cost‑effective way to reach the largest number of children. It is not surprising that a group representing some 5,000 law enforcement officers around the country fight crime, invest in kids, has recognized that if you have good home visiting programs, they will need to visit, as law enforcement officers, fewer homes and other places where violence or crime occurs. The decision last week of the House to continue this program on a temporary extension of one ‑‑ another year of funding into next spring represents some progress. I think we need a little more certainty than going from year to year, or six months to six months. There has been good benefit from this program in the State of Texas, in both the City of San Antonio and in the City of Austin and the surrounding areas, there have been programs that have benefitted from the Nurse Family Partnership, and there has been investment from the State of Texas that has been important. Between, really, just over the three years of MIECHV, the State of Texas has received about $50 million, a significant amount of money, but perhaps not that significant, compared to the needs that exist there. The money has not been spent in a vacuum; the state has worked to try to build a network of high‑quality programs, and to invest some of its own money in these programs. The division of monies in MIECHV so that some of it is focused on evidence‑based ‑‑ most of it is focused on evidence‑based programs, important that we have evidence‑based programs, but that we also continue to look at a few programs that are new and innovative, so that we can assure that we are pursuing every alternative that would be cost efficient in this area. Mr. Chairman, I would explain to the witnesses that at the same time this hearing is taking place, the House Budget Committee is marking up a resolution that I really think would threaten the continuation of home visiting, child abuse services generally, and a wide range of social services. So we will be having recurrent votes this afternoon there, and I will be in and out, with no disrespect to our very diverse and experienced panel, so that we raise appropriate issues in the course of the budget resolution. And I thank you, and yield back. *Chairman Reichert. I thank you, Mr. Doggett. And, without objection, each Member will have the opportunity to submit a written statement and have it included in the record at this point. And I want to remind our witnesses to please try and limit their oral testimony to five minutes. All of your testimony will be included in the record. Our panel this afternoon is made up of five folks, as everyone can see. And our first witness this afternoon is Crystal Towne, RN, Nurse‑Family Partnership Home Visitor, Yakima Valley Memorial Hospital. Welcome. Sherene Sucilla, a former Nurse‑Family Partnership Program participant; Darcy Lowell, CEO, Child First; Jon Baron, president, Coalition for Evidence‑Based Policy; and Rebecca Kilburn, senior economist, RAND Corporation. Welcome to all of you. And, Ms. Towne, you are recognized for five minutes. STATEMENT OF CRYSTAL TOWNE, RN, NURSE‑FAMILY PARTNERSHIP HOME VISITOR, YAKIMA VALLEY MEMORIAL HOSPITAL *Ms. Towne. Good afternoon, Chairman Reichert, Ranking Member Doggett, and members of the subcommittee. Thank you for this opportunity to testify on behalf of the Nurse‑Family Partnership Program in support of evidence‑based home visiting. I am Crystal Towne, and I am a nurse home visitor for Yakima Valley Memorial Hospital in Yakima County, and have been a nurse home visitor since 2003. I am here with one of my former clients, Sherene Sucilla, who graduated from the Nurse‑Family Partnership Program two years ago, and is a wonderful example of how this innovative program can empower young mothers to succeed. I am here in support of the MIECHV program, which is currently serving 80,000 families nationwide, including our Yakima County NFP program. In Washington, NFP is one of several home visiting models offered as part of a continuum of services that are supported at the state level. A higher percentage of pre‑term and low birthweight babies, an agriculturally‑driven economy, low high school graduation rates, and high gang activity in the area make NFP a critical element of the county's continuum of services. As a nurse home visitor, I work with first‑time, low‑income mothers and their families over the course of a little over two years. I visit each client in their homes approximately every other week, and I have a caseload of no more than 25 clients at one time. These visits begin early in pregnancy, and last until the child's second birthday. Through these, I empower each client to have a healthy pregnancy, improve her child's health and development, and set goals to achieve economic self‑sufficiency. I do this by meeting the mom where she is at at the time, not where I would like her to be. In NFP we call this a client‑centered approach. The NFP curriculum guides us to talk about the right issues at the right time, such as how can I stay healthy in pregnancy. What do I do when I am stressed out? How can I set goals for my life? Breastfeeding and infant attachment. The trust I build with my clients begins the moment I walk through their door for the first time. Sometimes my initial visit is filled with laughter and joy. But often times, when serving a young client especially, it is filled with great insecurity. The things that I hear most often are, "My parents are so angry with me. My boyfriend is no longer there for me. My friends don't understand why I won't go out to parties any more. I am so lonely.'' I listen to their story for the next two‑and‑a‑half years, building on our trusting relationship. I listen to clients who experience mental illness, intimate partner violence, substance abuse, living in poverty, lack of family support, and health disparities. Sherene is one of hundreds of stories I have had the honor to hear. She is a truly amazing woman and I am so proud to have the opportunity to have been her nurse, her counselor, her life coach, her confidante, her support system, and, most importantly, I am her friend. Every client's story is unique. But since she is here with me today, I would like to share my experience as Sherene's home visiting nurse. On May 6, 2010, I knocked on her front door for the first time. I did not know much about her, only that she was 10 weeks pregnant, and she had been in several foster care homes throughout her youth. During our first encounter, I wanted to ask her several questions, but I did not. I listened. I wondered how a young woman could appear so happy and speak about her goals for her future and her hopes and dreams, but have several scars on her arms. We never have talked about those scars. It didn't need to be said. I recognized that Sherene's smile didn't always come easily. But, despite her past and future challenges, Sherene is a truly resilient woman who has the hope and the drive to provide a better life for her child. Since we have ended the program two years later, today Sherene has a job she loves. She is self‑sufficient. She is living in a wonderful home. And she is actively involved in her son's life. She has not given up on continuing her dream for continuing her education. But sometimes being a great parent means postponing some of those personal goals. In closing, NFP applauds the subcommittee and the larger body of Congress for support of the MIECHV program. Thank you again for this opportunity to testify before you today. I appreciate it. [The statement of Ms. Towne follows:] *Chairman Reichert. Well, thank you, Ms. Towne. And we applaud you for your hard work. And we know that you can't do this work without becoming a friend to those that you help. *Ms. Towne. Yes. *Chairman Reichert. And thank you for having the heart of a servant. *Ms. Towne. Thank you. *Chairman Reichert. You are welcome. Thank you, Ms. Towne. Ms. Sucilla, you are recognized. STATEMENT OF SHERENE SUCILLA, FORMER NURSE FAMILY PARTNERSHIP (NFP) PROGRAM PARTICIPANT *Ms. Sucilla. Good afternoon, Chairman Reichert, Ranking Member Doggett, and members of the subcommittee. Thank you for the opportunity to testify on behalf of the Nurse‑Family Partnership Program in support of evidence‑based home visiting and the Maternal, Infant, and Early Childhood Home Visiting Program. My name is Sherene Sucilla, and I was a client with the Nurse‑Family Partnership Program delivered by the Yakima Valley Memorial Hospital in Yakima, Washington. And I am the incredibly proud mother of my son, Andrew, who is now four years old. As a client, I received regular visits about every other week from my NFP nurse home visitor, Crystal Towne, starting when I was just a couple of months pregnant, through my son's second birthday. I am here on behalf of the mothers like me, the children like my son, Andrew, and families like our own, in support of home visiting. I am honored to be here today, to get to thank you all in person for your commitment to improving the health and well‑being of children and dedicated funding for evidence home‑based visiting programs. This program has meant so much to me and my family, and I know that if every mom could be here today to share their experience with you, they would be, because it really is a changing experience to be here ‑‑ to be in this program, excuse me. I grew up in Yakima, Washington. When I was 12 years old I went into foster care and remained there through my 18th birthday. In those six years I attended seven high schools, which made it very difficult to graduate on time, because I didn't go to school in the same district, so the credits didn't transfer properly. But I did graduate on time, through a lot of hard work. While being in foster care isn't an experience I would wish on any child growing up, I would say that that experience has shaped who I am today. When I was younger, my mom wasn't really a mom. I didn't really have a role model for parenting. And so, when I found out I was pregnant, I didn't really know what to do. I didn't have anything to go off of, and I was really scared, and I was in this by myself. I heard about the Nurse‑Family Partnership Program through my doctor's office when I found out I was pregnant. Because I was a first‑time mom and I met other eligibility requirements, they referred me to the Yakima Valley Memorial Hospital NFP program and Crystal, and I was set up with an appointment for Crystal to come to my home and talk more about the program. After our first meeting, I knew that this was the right program for me, and I looked forward to our regular home visits. At that point I was new to everything when it came to parenting. But Crystal was a huge help to me and my family. She helped me build confidence and open doors for me to set goals for my life, for myself, and for my family. She helped me find other services I needed, such as dental care, and she would take my blood pressure when I was pregnant, to make sure that I was doing okay. And when I had trouble breastfeeding, Crystal had a breast pump overnighted to me. And at one point when I was nursing I was afraid that my son wasn't getting enough to grow at a healthy rate, but Crystal would bring a scale, and we would weigh Andrew every week, and she reassured me that he was getting what he needed to grow well and according to schedule. That was the first major moment for me, where I felt like I was doing a good job, that I was a good mother, and that I was getting him what he needed. And now, at four years old, I can often say that he is the tallest kid in his class. I was also nervous about his development. Like every parent, you want to make sure that your baby or child is keeping up with different milestones, and I didn't know how to assess that. But Crystal would bring in questionnaires called the Ages and Stages Questionnaire, or ASQ, to assess his development at different points in time, and we would know that his development was on track. I remember throughout the program Crystal would say to me that my son Andrew was a very caring person from a very young age. He was about 13 months when Crystal first commented on how sweet he was. He would give Crystal a hug and actually pat her on the back. At the end of each visit she would leave a form with lots of different feedback, including highlights from that visit, what our next visit would be about, and what I needed to do before our next visit. Looking back at one of the forms, Crystal mentioned how I was raising such a sweet and loving child that his hugs and pats melted her heart. Crystal was able to point out to me these different signs he was showing of being a very caring human being, even when he was just a toddler, and I remember realizing that if I was raising a son that loving, I really was doing something right, as a parent. When I found out I was pregnant, I worked at a barbecue stand. When Crystal and I started talking about my future, she helped me look into going back to school. Ultimately, I ended up getting a job and a great career through steps I took when Andrew was younger. I now work in accounts payable for a local heating and air conditioning company, and I have been there for about a year‑and‑a‑half. And I have great job security, as I am the only one in the office doing what I do. It has been really special and wonderful to look back at all the records that I have while in this program. I have a big binder of all the work, the pictures, and activities that we did. And it is lovely. I can go back and read all my thoughts and feelings from the beginning of my pregnancy to his age of two, when he turned two, and that is really special for us, now that he is four, we can go back and look at everything. I really hope that Congress will continue supporting the MIECHV program, which supports great programs like NFP. Thank you again for the opportunity to testify today. [The statement of Ms. Sucilla follows:] *Chairman Reichert. Great job. Is this your first time testifying in front of Congress? *Ms. Sucilla. Yes. [Laughter.] *Chairman Reichert. You didn't even come across nervous. *Ms. Sucilla. I am sweating. [Laughter.] *Chairman Reichert. So are we. Future congresswoman sitting there, I think. You know, I just have to make this comment. You did a wonderful job, and, Ms. Towne, you did a wonderful job, also. And I know it is not easy to come before Congress and testify. But the people up here are just regular people, we just happen to be sitting in these chairs, elected by the folks that we represent. But we all come from backgrounds that you might be surprised to hear about. You know, I grew up in a home. Ran away from home and from domestic violence. And I never became a foster child ‑‑ by the way, we are working on some foster care legislation that can help kids stay in school and have those records follow, and hopefully stay in one foster home, and hopefully, more than anything, get adopted and have a family they can call their own. So we are working on all of that. And I am sorry you had to go through that, but that just fits into everything that this Committee is trying to accomplish. And you are an all‑star, as far as we are concerned. *Ms. Sucilla. Thank you. *Chairman Reichert. Yes. Ms. Lowell, you are recognized for five minutes. Microphone? *Ms. Lowell. Good, okay. Thank you. *Chairman Reichert. There you go. STATEMENT OF DARCY LOWELL, CEO, CHILD FIRST *Ms. Lowell. So, good afternoon. My name is Dr. Darcy Lowell, and I am honored to be here to talk to you today. Thank you for this opportunity to testify on behalf of Child First home visiting and the MIECHV program. And thank you so much for your support of the MIECHV extension; it is so needed.I am a developmental and behavioral pediatrician, and the founder and CEO of Child First. I also serve as an Associate Clinical Professor at Yale University School of Medicine. Early in my career, I saw the struggles of vulnerable children and families firsthand, as they tried to cope with trauma and depression, homelessness, and hunger. We needed to think about intervention in a very different way, and so Child First began. I want to give you a feeling for the kinds of families that we work so closely with, and that we serve. And here is a little vignette about one of them. The Child First mental health clinician met a mother at a pediatric visit for her three‑year‑old daughter, Maria. The mother was severely depressed. She had run from her husband because of ongoing domestic violence. She and her three children lived in an empty apartment without beds or a kitchen table. Little Maria was about to be expelled from child care for aggressive behavior. Mom worked three jobs, but was still way behind in her rent payments, and the family was about to be evicted. She was desperately afraid that she would lose her children to foster care. The care coordinator learned from the family that they had been on TANF, but Mom was no longer receiving a check. She, the care coordinator, immediately contacted the Department of Social Services and found out that the check was being sent to her husband in prison. In less than a week, the check was redirected to the mother. The family situation improved dramatically. Mom now only needed to work one daytime job, and was able to focus on her children. The clinician worked psychotherapeutically with Mom and Maria together, and also consulted in the preschool. Maria's behavior improved markedly. Mom's depression lifted. The care coordinator coached Mom as she worked out a schedule with the landlord to pay back rent. The life course of this family changed dramatically. What we know is scientific research on early brain development has clearly demonstrated that growing up with stresses of poverty, violence, depression, substance abuse, and homelessness produce a rise in stress hormones and other metabolic chemicals that can severely damage the developing brain and other body systems. This may lead to academic failure, serious mental health problems, and chronic disease, including heart disease, cancer, and diabetes. However, it is now scientifically documented that the presence of a secure, safe, nurturing relationship between a parent and a young child is actually able to protect the developing brain from damage. We must, therefore, provide intensive intervention at the earliest possible time. Child First works with the most challenged families, targeting young children under the age of six who suffer from behavioral and developmental problems and abuse and neglect. We take a two‑pronged approach - based on what we now know, what the scientific literature tells us - with a team of two professionals working in the home. First, we must decrease the enormous stress in the environment, and help stabilize families. Our care coordinators work with our parents to connect them to comprehensive, community‑based services and supports, like medical services, safe housing, early education, and literacy. Through this process, our care coordinators build the capacity of our parents, and help them to build internal organizational skills that enable them to be successful as parents and workers. Second, we build the nurturing, responsive, parent‑child relationship, because that is what protects the developing brain, even in the face of adversity. Our mental health clinicians use Child‑Parent Psychotherapy to heal these two generations, while they help parents promote safe environments for their children to grow and develop, which makes them so ready for school. To evaluate our model, we conducted a randomized controlled trial with strong, positive results in child language, behavior, maternal mental health, and decreased involvement with Child Protective Services; and with replication we actually have been able to have even better results, with 89 percent of our families improving in at least one major area. Child First has only the capacity at this time to serve 1,000 children each year in Connecticut, but we know the need is enormous. We have replicated through a public‑private partnership with the Robert Wood Johnson Foundation, especially, and our Department of Children and Families. MIECHV has been instrumental in allowing us to move to eight new cities. This support is so essential. The return on investment is substantial. And though I have no time to tell you about it now, I will say that Child First only costs about $7,000 a year. And if you have psychiatric hospitalization for just three months for one child, it is $130,000. There is major savings in multiple sectors. I thank the committee most sincerely for your interest and efforts in support of the MIECHV home visiting program serving vulnerable children and families. Thank you. [The statement of Ms. Lowell follows:] *Chairman Reichert. Thank you. Great job. Mr. Baron? STATEMENT OF JON BARON, PRESIDENT, COALITION FOR EVIDENCE‑BASED POLICY *Mr. Baron. Thank you, Chairman Reichert, members of the subcommittee. I appreciate the opportunity to testify about MIECHV on behalf of the Coalition for Evidence‑Based Policy. The Coalition is a non‑profit, non‑partisan organization that has no affiliation with any programs or program models, and we have no financial interest in any of the policy ideas that we support. We strongly support reauthorization of MIECHV. MIECHV represents an important new and bipartisan approach to social spending, in that it uses scientific evidence of effectiveness as a central factor in determining which activities to fund. As a result of this evidence‑based approach, MIECHV is funding the large‑scale implementation of some home visiting program models that, as I will discuss in a moment, have been rigorously demonstrated to produce major long‑term improvement in the life outcomes of at‑risk children and mothers. MIECHV's evidence‑based approach is bipartisan in origin. The Bush Administration's 2007 pilot, for example, directed HHS to "ensure that states use the funds to support home visiting program models that have been shown in well‑designed, randomized, controlled trials to produce sizeable, sustained effects on important child outcomes, such as abuse and neglect.'' Randomized trials are considered the most rigorous evaluation method. Similarly, the full MIECHV program, implemented under the Obama Administration, directs HHS to allocate at least 75 percent of the program's funds to "evidence‑based home visiting models,'' and uses a slightly different but still rigorous standard to determine what qualifies as evidence‑based. Why does this matter? Because rigorous studies have found great variation in the effectiveness of different home visiting program models. At one end of the spectrum, for example, is the nurse‑family partnership, which provides nurse home visitation services to low‑income, first‑time mothers. This model has been shown in three well‑conducted randomized trials to produce major, long‑term improvements in participants' life outcomes, such as a 20 to 50 percent decrease in child maltreatment and hospitalizations,and an 8 percent higher grade point average through elementary school for the most at‑risk children. And, in one trial, a $13,000 reduction in families' use of welfare, food stamps, and Medicaid, that more than offset the program's cost. At the other end of the effectiveness spectrum, for example, is the Comprehensive Child Development Program, which was a 1990s HHS home visiting program in which trained para‑professionals provided home visits to families with young children, designed to teach parenting skills and connect families with community services. This was a well‑intentioned and a well‑implemented program. But when evaluated in a rigorous, randomized trial, it unfortunately was found to produce no effects on any of the hoped‑for outcomes, including children's cognitive and social development, child health, and parents' economic self‑sufficiency. More generally, two recent, impartial reviews that examined which home visiting models had rigorous evidence of policy‑important impacts on child maltreatment and other key outcomes found several models to be effective or promising, including the two that we have heard from today, but a larger number to produce no meaningful effects. That pattern is not unique to home visitation. In almost every field in which rigorous trials are conducted, including medicine, business, and K‑12 education, the effective interventions are almost always found to be outnumbered by interventions producing weak or no impacts. What this means is that if MIECHV were to allocate funds the usual way, without regard to rigorous evidence, it would primarily be funding program models that produce no meaningful impacts, and might miss the opportunity to scale up the few effective models that can improve people's lives in an important way. As I describe in my written testimony, MIECHV's evidence‑based design has succeeded, in part, in focusing funds on the subset of effective models and, for example, is funding national implementation of the Nurse‑Family Partnership, as well as the scale‑up of other effective evidence‑based models, like Child First. We believe this is a very important achievement. We also suggest a modest legislative revision in my written remarks to close a loophole that has allowed some of MIECHV's funding to go toward ineffective models. I would be happy to discuss this further, if of interest. [The statement of Mr. Baron follows:] *Chairman Reichert. Thank you, Mr. Baron. Ms. Kilburn, you are recognized for five minutes. STATEMENT OF REBECCA KILBURN, SENIOR ECONOMIST, RAND CORPORATION *Ms. Kilburn. Chairman Reichert, Ranking Member Doggett, and members of the subcommittee, thank you for the opportunity to testify today about the MIECHV program. My name is Rebecca Kilburn, and I am a senior economist at the RAND Corporation. My testimony will draw upon a 15‑year program of research performed at RAND by me and my colleagues. We are here today to discuss what we know about whether the MIECHV program improves outcomes for children and their parents. The Federal Government has sponsored a rigorous study of the effects of MIECHV, but initial findings from that study will not be available until next year. Absent the results of that study, today I will describe currently available research that informs MIECHV. I am going to discuss two ways that existing research findings inform MIECHV. First, I am going to describe research related to the rationale for MIECHV. And, second, I am going to make recommendations regarding research‑supported features of MIECHV that raise the likelihood of it achieving its desired objectives. First, as you have heard, rigorous evaluations have demonstrated that a diverse set of home visiting models can improve a spectrum of outcomes for children and parents. Programs have been able to improve outcomes in the short run and the long run, and some, but not all, evidence‑based programs have found that programs generate government savings that more than outweigh the costs. In other words, a growing research base has identified evidence‑based home visiting models, and supports the theory of change underlying MIECHV: that scaling up home visiting to large numbers of at‑risk families has the potential to improve outcomes for children and parents; improve population level outcomes, such as reducing rates of low birthweight or child maltreatment; and these, in turn, should save government money in the long run. The primary contribution of MIECHV is to test the idea that broadly scaling up home visiting can transform our approach to human services. Having a research‑supported rationale does not imply that an initiative will necessarily be effective. The initiative must be well structured and well implemented. I will now discuss design features of MIECHV that research indicates will raise the likelihood of improving outcomes for at‑risk families. Lawmakers should preserve these three existing features of MIECHV. First, continuing to concentrate MIECHV funding on evidence‑based models will make the chances greater that MIECHV funds will have their intended impact. Second, drawbacks to funding exclusively evidence‑based models are that it could stifle innovation and prevent us from discovering models that may be effective, but have not been evaluated. A second feature to preserve are mechanisms in MIECHV that circumvent these drawbacks. One is allowing 25 percent of the funding to be used for promising models that are being evaluated, and the other is funding the MIECHV competitive development grants, which allow states to apply for funding, to pilot test, and evaluate innovations in home visiting. Third, in order to achieve the best outcomes for children and families, it is not only necessary to deliver programs that work, but it is also necessary to implement them well. The third feature of MIECHV that should be preserved is the implementation supports it provides states and other grantees. These include training and professional development, plus technical assistance that helps states engage in best practices in evidence‑based program implementation. These best practices include conducting needs assessments, identifying goals, collecting and reporting outcome data, and engaging in continuous quality improvement. At the same time that the federal home visiting program has expanded, states have also been increasing their funding for home visiting. The MIECHV program is partnering with states to build state home visiting infrastructure, with the MIECHV program leading the drive to integrate best practices into home visiting implementation. To conclude, there are also a couple of ways that MIECHV could be strengthened to further raise the chances of achieving the best outcomes for children and families. One is that while 25 percent of MIECHV funds can be used to deliver promising home visiting models, MIECHV currently does not support a path by which potentially effective models could undergo evaluation that would lead them to be designated as evidence‑based. The types of evaluations that the MIECHV evidence standards require often cost upwards of $1 million, representing a substantial barrier to discovering the next evidence‑based model. Second, MIECHV can better harness the power of performance‑based accountability, which links performance measures to funding or targeted technical assistance. MIECHV currently requires states to collect benchmarks related to family outcomes, which is a cutting‑edge aspect of the program. While monitoring outcomes is desirable, there may be opportunities to better monitor states' organizational performance, such as number of families served, and, importantly, for MIECHV to more closely link performance measures to consequences or targeted support to generate improvement. Thank you for allowing me to appear before you today, and I look forward to taking your questions. [The statement of Ms. Kilburn follows:] *Chairman Reichert. Well, thank you very much for your testimony, Ms. Kilburn. Thank you all for your testimony. And we are going to go into the question phase now. We will just ask a few questions. It will be easy, don't worry about it. [Laughter.] *Chairman Reichert. So, I was a police officer for 33 years before I came to Congress. So I just look like I have been here for 40 years, but I have only been here 9. I received phone calls this past week from sheriffs, from police chiefs from Washington State, very much supportive of fighting crime, and investing in kids. We get it, because we know if we put the money up front, we are going to be saving a lot of money at the back end. And that is a hard thing, for people who legislate, to really see the long‑term, and the long‑term goal here. You all see it very clearly. But we have heard about evidence‑based, scientific ‑‑ I think, Mr. Baron, you said scientific evidence and effectiveness to decide which programs to fund. And, Ms. Kilburn, you talked about design features in three points that you made about evidence‑based models and funding for evaluation and implementation of supporting programs. And what I want to try and do is to tie together what you do with what is happening, where, as cops would say, where the rubber meets the road, where Ms. Towne and Ms. Sucilla are. And, you know, what ‑‑ because you may have never heard about implementation supports and things like that, where ‑‑ no, I didn't think so. So you are down here, doing the work. How does ‑‑ so this is for both of you ‑‑ how does what you are doing and what you are going through, how does that get filtered up to the folks that are making those decisions and trying to figure out what is working and what is not working? What worked and ‑‑ so, just real quickly, what worked in your case? What was the ‑‑ you know, you touched on some of it. *Ms. Sucilla. Sorry, I am trying to understand the question, I guess. *Chairman Reichert. So you are working with Ms. Towne. *Ms. Sucilla. Yes. *Chairman Reichert. And the programs that you got involved in that she helped direct you to, what were those programs that you saw that really ‑‑ kind of a light bulb went on as to this really is going to work? This program works, or that program. If you got sidetracked into a program that you thought, boy, this isn't going to work at all. *Ms. Sucilla. [No response.] *Chairman Reichert. You can help her, if you want to. *Ms. Towne. Are you asking about perhaps she participated in programs in addition to Nurse‑Family Partnership? *Chairman Reichert. Yes. I mean anything that ‑‑ so she finally comes to you, and you give her places where she is going, and it is working. How does that get communicated to the administrators who are making some decisions as to, you know, what programs work, what programs don't work? It is evidence‑based, right? *Ms. Towne. Correct. *Chairman Reichert. So how does that evidence get moved up to, filtered up to ‑‑ *Ms. Towne. Okay. So you are asking specifically about the data. *Chairman Reichert. Yes. *Ms. Towne. Is that ‑‑ okay, thank you. I was ‑‑ okay. At visits at various time periods that are structured by the program. So, for instance, in pregnancy, at 36 weeks, at birth, 6 months, 12 months, 2 years, we collect data from Sherene in the form of various questions that are then submitted to the University of Colorado for research purposes. *Chairman Reichert. Okay. *Ms. Towne. Is that what you are ‑‑ *Chairman Reichert. Yes, yes, sure. *Ms. Towne. ‑‑ asking? Yes. For ‑‑ as part of the curriculum and part of the model for Nurse‑Family Partnership, they have outlined very specific questions and data they are collecting at different times throughout that two‑and‑a‑half year period. *Chairman Reichert. Okay. *Ms. Towne. And it is handled through the University of Colorado. *Chairman Reichert. Do you ever feel like you are working in an area where ‑‑ if a program that is not working, and you are able to give feedback data to the ‑‑ to Denver that this isn't really working at the ‑‑ you know, where the rubber meets the road sort of a ‑‑ *Ms. Towne. [No response.] *Chairman Reichert. No? *Ms. Towne. I don't see that, as a home visitor, because the beauty of the Nurse‑Family Partnership program, again, is that it is client‑centered. So it is not necessarily myself dictating what we discuss throughout each visit. It is really looking at the guidelines of suggested topics, but allowing Sherene to choose what she feels would be most helpful. *Chairman Reichert. Okay, you just hit on the answer, right there. She chooses. *Ms. Towne. She absolutely ‑‑ *Chairman Reichert. Yes. *Ms. Towne. Every visit ‑‑ the way it works in my home visiting practice is at the end of every visit we look at what options are available to discuss at the next visit. And I guess "available'' isn't maybe the right word. First, Sherene can choose. Maybe there is something on her mind that is really not a part of the guidelines, and that is okay. *Chairman Reichert. Okay. *Ms. Towne. But she can also look at the guidelines and topics, and choose one of those. *Chairman Reichert. Great. Thank you for your answer. Mr. Davis, you are recognized. *Mr. Davis. Thank you very much, Mr. Chairman. And let me thank all of our witnesses. I have been tremendously impressed with all of your testimonies for a number of reasons. And one is that, for all of my life, I have been intimately involved with, associated with, know people personally, who could make use of this program and of these services. And since being in Congress for a decade, I have worked with Republican colleagues to advance a strong federal investment in home visiting. This bipartisan effort drew on research and economic status documenting that investing in our youngest citizens yields high returns in the form of healthier children and families, and taxpayer savings. The voluntary home visiting law was designed as an investment in evidence‑based prevention. In Illinois, 30 percent of children entering out of home care for the first time are under the age of 1, slightly higher than the national rate. In Chicago, roughly half of those babies enter before they are three months old. This pattern is generally true, nationwide. These statistics put into context the importance of home visiting, which focuses on strengthening children and families by supporting pregnant women and parents with young children. The role of home visiting is particularly important, given the recent study reported in JAMA ‑‑ that is the Journal of the American Medical Association ‑‑ about an increase in infants' death, potentially due to the economy. Supporting young children and families is critical to preventing harm and strengthening children. Mr. Chairman, I have got two documents I would like to submit for the record. *Chairman Reichert. Without objection. [The information follows: Mr. Davis 1, Mr. Davis2] *Mr. Davis. I also ‑‑ well, let me ask you, Ms. Kilburn. You mentioned in your testimony that studies ‑‑ that the Federal Government has studies underway, and the data has not all been collated and put together, and so there is not a report yet. But without that report, would you say that home visiting is really an effective way of helping to strengthen and prepare children and their families that ultimately will provide them with healthier lives, and even save our taxpayers a great deal of money? *Ms. Kilburn. There is a strong research base that supports the idea that these individual programs can improve outcomes for children and families. What MIECHV adds to that is allowing us, for the first time, to test the concept of scaling that up on a large basis in order to see if we can capture those effects that were found in individual programs at a community or a city or a state level. So, there is a lot of evidence to support the basic idea behind MIECHV, and now we are really testing if it can achieve this transformation in the way we deliver human services so that instead of treating things after the fact, we prevent them. And so there is a large research basis that supports that idea, and we are really testing it right now. *Mr. Davis. And I guess the reason I indicated ‑‑ I said that for all of my life I have been associated ‑‑ I have lived in low‑income communities all of my life, growing up, and, of course, even today. I used to train community health aides, basically, to do home visiting, and basically to make assessments of the health needs of individuals in the community who often times would not come to the clinics unless they had been prompted a little bit, prodded a little bit. And I know that there have been people who have said that these programs are unnecessary, that they don't really work, or, if they do, let the local governments and the state governments provide the resources. Are you aware that the Federal Government, based upon your research, has been very instrumental in making these programs work, and work effectively? *Ms. Kilburn. I don't think we have research evidence on MIECHV, per se. But what MIECHV is doing is providing the data for us to answer that question. We don't have that right now, but the study underway will provide insights into that. The reason it is important that the Federal Government does this is that, while the individual states have been increasing their investments in home visiting, it hasn't been in a systematic way that supports evidence‑based programming and that provides infrastructure support to implement programs while also using evidence‑based practices in implementation. And so, if we allowed the states to do it one by one, we wouldn't really know the answer to that question: Does scaling this up transform human services? We just have a patchwork or sprinkling of different, smaller experiments. *Chairman Reichert. Thank you, Mr. Davis. *Mr. Davis. Thank you very much. Mr. Chairman, let me just thank you on assembling one of the most outstanding panels I think that I have heard testify on this matter. So thank you all very much. *Chairman Reichert. Thank you. *Mr. Davis. Thank you, sir. *Chairman Reichert. Thank you to the staff. Mr. Kelly, you are recognized. *Mr. Kelly. Thank you, Chairman. And I agree with Mr. Davis; this is a good panel to have before us. One of the things that I have been wondering about ‑‑ and, of course, it seems to me that home visits are critical if we are going to continue to support families. And I think one of the things that we have seen in our cultural that is causing a greater problem is the fact that the nuclear family is now not at the same level it used to be. Now, some of these programs are working, but there is a lot of areas that they are not working. What could we do to change that? Mr. Baron and Ms. Kilburn, you both had testimony towards that. So how do we look at a good return on the investment for the American taxpayers that we actually make a difference in these peoples' lives? And, Ms. Sucilla, I really applaud you for what you have been able to do. But that is an example of the success of it. So, tell me. What else could we do? What programs aren't working? And how would we redirect or redeploy those dollars to make sure that there is a better return on it, not just for the taxpayers, but also for the people that we are spending the time with? *Mr. Baron. Well, for some of the more effective models, like the Nurse‑Family Partnership, one of the things that they did was they measured long‑term impacts for both the people who got the program, the program group, and a control group of families that did not get the program. They measured their use of public assistance over a 12‑year period, and found that the savings in families’ use of public assistance more than offset the initial program cost. So, at least for that model, there was strong evidence not only of improvement in people's lives, but savings to the taxpayer. But MIECHV funds, as I mentioned, a diversity of home visiting models, some of which have been found in rigorous studies not to be as effective. One of the things that could be done to shift funds within this program to more effectively focus on programs that really make a difference in people's lives is to slightly change the evidence standard to make a modest but important revision in the evidence standard. Right now, the program’s standard for “evidence‑based” is that the program model produces statistically significant effects. But the standard does not ask whether those effects are of policy or practical importance, like reduced use of public assistance or reduced child maltreatment rates. That has opened a loophole in the program, a modest loophole, allowing several models to qualify as evidence‑based, solely on the basis of statistically significant effects on outcomes that may not be particularly important, or effects that may be tiny in magnitude. That would be one ‑‑ *Mr. Kelly. Okay, but as you look at this, you have data that you can look at across the board on different programs. *Mr. Baron. Yes. *Mr. Kelly. You have the ability, then, to look at which ones are working and which ones aren't working. And I would just think that, when you look at that, and you are looking for a really good return on the investment, we are talking about building a stronger society, and you only can do it through building stronger families, which will result in stronger communities and a stronger country. So, when you look at these, then, how do you separate one from the other, say, you know, "This is one that we see working. These other ones aren't doing what they are supposed to do.'' Ms. Towne and Ms. Sucilla talked about how that one worked for them. And I will just tell you, being a grandfather and having eight grandchildren ‑‑ two more on the way ‑‑ I have seen what can happen with families that are very supportive, and they get help from the outside. So, you have the ability to do this, though. You can actually compare programs and say, "This one works, this one is not working the way it should,'' and you can redeploy those dollars. That is the effort that you are trying to do. Is that not correct? *Mr. Baron. Yes. A very ‑‑ a straightforward way to do it, which is used in many different areas now, increasingly in social spending as well as in medicine. A home visiting program model generally does not have enough money to serve every family that qualifies. So one thing that is often ‑‑ that is sometimes done is to do a randomized control trial, where you use a lottery ‑‑ meaning random assignment ‑‑ to allocate some families to receive the program, and other families, an equivalent set who serve as a control group. They get access to the usual services in the community. And then you track outcomes, important outcomes, over time, like rates of child maltreatment for the program group versus the control group; families' use of public assistance in the program group versus the control group. And the outcomes there will tell you which program ‑‑ in a scientifically ‑‑ *Mr. Kelly. Are you able to share that information back and forth, then, and actually, you know, come up with a change, then, and actually look at this as the best ‑‑ this is the best way to spend those dollars? You can only spend a dollar once, so you want to make sure it is spent the right way. So, to get the most mileage out of it, you can actually share that data and improve these programs. *Mr. Baron. That can be shared. And, in fact, MIECHV does that, it looks at that data, and it allocates ‑‑ the grants are made toward ‑‑ on the basis of evidence as one of the main selection criteria, that kind of evidence. There are ways in which that evidence criterion can be strengthened. But, in general, the program allocates funds naturally, based on that data we were just talking about. *Mr. Kelly. Okay, all right. Thank you. And just to ‑‑ so we can redeploy these dollars the right way after we have looked at this evidence that is conclusive. And you say, "Listen, we don't need to spend money over here. This program is not coming up with the results that we need,'' and we can redeploy. That is my main concern, because I think too often we continue to spend money on programs that aren't effective. And we say, "Well, why do we do this?'' It is because we have always done that. That is not the answer. The answer is to change it so it benefits families more. *Mr. Baron. I couldn't agree with you more. That is one of the unique features of this program, as opposed to the way social spending is often done ‑‑ social programs are often done -- that in this case money is allocated on the basis of evidence. So, if new findings come in showing a particular model is effective, or a particular model is not effective, the funding is naturally, through the grant‑making process, allocated toward the more effective models. *Mr. Kelly. Okay, good, thank you. *Chairman Reichert. Thank you, Mr. Kelly. I think that is the question I was asking, too. Mr. Kelly and I, we are going at it at different angles, as to how the information is shared, the programs are changed, so that they fit what the star of our show today needs. So, Mr. Renacci, you are recognized. *Mr. Renacci. Thank you. And I want to thank you, Chairman Reichert, for holding this hearing, and highlighting the importance of using evidence brand models to home visiting programs. And I also want to thank the witnesses. This is a great panel of witnesses. In my home state of Ohio, an estimated 1.8 million Ohioans are living below the poverty line. Poverty has increased by approximately 58 percent over the last decade, despite a stagnant population and a whole host of federal programs created to end the cycle of poverty. So I am glad we are here today to discuss policies that work. Ohio's rate of infant mortality is also ranked the 11th worst in the nation, averaging 7.7 deaths per 1,000 births in the first year of life. In fact, according to a study conducted by researchers at Case Western Reserve University, infant mortality exceeds some third‑world countries in certain neighborhood surrounding the university's circle area in Cleveland. While I applaud the efforts of home visiting programs that have been proven to improve the safety and well‑being of infants and children, we as a nation cannot continue to financially support ineffective programs. As a small business owner, when I implemented a particular program, I also wanted to ensure that the procedures that I created were effective and really meeting certain goals that I created for those employees. Businesses ‑‑ and my business ‑‑ actually measured our programs and used evidence‑based models in order to guarantee success. And I think the Federal Government should be no different. As a Member of Congress, I want to protect taxpayer dollars from going toward ineffective programs, and redirect them toward programs that do what is intended, and lift individuals out of poverty. I really hope, together with my friends across the aisle, that we can determine what works, what doesn't work, and can make ‑‑ so that government can finally empower individuals to become independent and self‑sufficient. Ms. Towne and Ms. Lowell, both of your programs have been shown to increase the safety and well‑being of young children. For example, I know families who have gone through the Nurse‑Family Partnership program, have been shown to have fewer child injuries, fewer emergency room visits, and less reported child abuse and neglect. Families participating in Child First also are less likely to be involved with Child Protective Services, even after three years. Both of your organizations have had some successes. What do you think are really some specific factors that have led to these outcomes or successes? I will start with you, Ms. Towne. *Ms. Towne. Could you repeat the last part of your question, please? *Mr. Renacci. Yes. What do you think are some of the specific factors that have led to these outcomes or successes for both of your programs? *Ms. Towne. That is a complex question. I would say that there are many factors of the Nurse‑Family Partnership model that have led to success. From a home visiting point of view, I believe that it is the length of time and the intensity of the program that allows me to continue to support a family for two‑and‑a‑half years in developing a strong infant bond, a strong family ‑‑ a stronger family unit than when our relationship had started is part of what helps. *Mr. Renacci. So you are zeroing in on the two‑and‑a‑half years, making sure the program ‑‑ you feel pretty strongly about the two‑and‑a‑half year time frame. *Ms. Towne. I feel pretty strongly that a larger length period of time, along with the intensity of the visits ‑‑ we are looking at approximately two hours per visit every other week ‑‑ allows quite a bit of time for growth. *Mr. Renacci. Ms. Lowell, do you have any ‑‑ *Ms. Lowell. Yes. I think that for us, there are a number of factors. One is the intensity of the training for our staff. We are working with both bachelor's level care coordinators and master's licensed clinicians, as our mental health clinicians who go in the home. And we have a training period that lasts a year's time(not before they can start; they start after an intensive two‑week training). But we both have what is called a Learning Collaborative, which lasts a year's time, and we have our senior clinical consultants working with each new site on a weekly basis. So, we are really looking at, “do you have fidelity to the model, do you really understand what the work is about, and are you doing it well?” And we also look at implementation measures on an ongoing way every single month, and we also look at outcomes, at baseline six months and at discharge. So we are able to say, "Do we have a problem here? Are the people who are implementing this model doing it really well? Are they doing it according to the model fidelity,'' which I think is essential. The other really important piece about the work itself is it is built on relationships and on building relationships. And I think that, at least when you talk about the families that we serve, which are the most vulnerable, they are the ones who have had abuse and neglect, domestic violence, homelessness, substance use; these are really difficult families. They don't trust easily. And they are not very willing to let new people into their lives. And it takes time to build that relationship. But when you have built that relationship of trust, you are able to make a real difference. These are families who want to do the right thing, they want to do the best for their children. They are there. But it is a process. And so, if you can build that relationship you can work with both the parent or care giver and the child therapeutically, to understand what are the barriers, what are the problems. But it is not so simple. We can't just teach them, because that is not enough. They don't learn that information. It has to be at a deeper level. And I think, for us, with our families, we are so successful with them because we do go to that deeper level, and make sure our staff are doing it correctly. And one other really important thing I have to say is I think that, as was said, that our home visiting models are different, and they target different outcomes. And it is really important for us to be matching the outcome that the family needs and wants with the kind of program that they are getting. And I think that we have problems when we have a mismatch there, when we have a very vulnerable family, a mom who is running from domestic violence, who is severely depressed, and someone who is just going to be teaching them things when the mom is not available to learn them. But, I think that for other moms ‑‑ that it may be a perfect match for them. So we need this continuum of models to work together in a system if we are really going to be effective. *Mr. Renacci. Thank you, Mr. Chairman. *Ms. Lowell. Thank you. *Chairman Reichert. Thank you. That was two minutes over time, but that was so passionate, there was no way I was going to interrupt. *Ms. Lowell. Sorry. [Laughter.] *Chairman Reichert. That was a great answer. Mr. Doggett, you are recognized. *Mr. Doggett. Thank you very much. Dr. Lowell, you described in your testimony the need here is enormous. What would be the impact in your area if the federal funding through MIECHV is not continued beyond next spring? *Ms. Lowell. Oh, thank you. That is a really important question. We have ‑‑ with our MIECHV funding, we have five new sites and three expansion sites, which cover about a third of our state Child First programs. So, if the MIECHV funding is not continued, there is very high likelihood that those programs will be closed. And all of those children and families in those areas will not be served. *Mr. Doggett. And you used in your testimony the comparison between a $7,000 cost and a $30,000 cost for not relying on home visiting to intervene in advance. Would you elaborate on that? *Ms. Lowell. I think that we are seeing tremendous cost savings ‑‑ at least we did a preliminary cost benefit analysis in looking at our data, and we need to do much more. But we know that, for instance, if one of our children, many of our children have very severe behavioral problems and mental health problems if one of those children were to be hospitalized for just two months in a psychiatric hospital, it would cost $130,000. We know that we are getting great language outcomes. If one child needs special education, it is going to cost $16,600. If one child goes into foster care ‑‑ and I have heard various costs but we are talking about, potentially, somewhere between ‑‑ depending on the numbers I have seen ‑‑ $20,000 and $80,000 for a child for a year in foster care. And many of our families have multiple children. For example, we just had a family that I just heard about, which we started working with, where Mom was going to be evicted. She had six children. Our care coordinator got her into a shelter initially, and then got her an apartment with low‑income housing, and saved six children from going into foster care. And the trauma of foster care is very major, because that separation is really difficult, especially if it is not because there is abuse and neglect, but just because the circumstances can't support that parent caring for the children. So, I also see we are getting other outcomes ‑‑ we have some data on hospitalization and ER visits, which is actually ‑‑ it is very preliminary, but we are talking about a four to sixfold decrease in hospitalization and emergency room visits. *Mr. Doggett. Thank you. *Ms. Lowell. Thank you. *Mr. Doggett. Thank you very much, and thank you for what you are doing there. And, Dr. Kilburn, you have made reference, of course, to this important study that will come out next year, and the blend that is already in the Act to both permit some innovation, but to ensure that our dollars are well spent with evidence‑based programs. Do you believe that that study will allow us to focus on more effective programs? Or do you think that the study is something that would lead to the elimination of the federal program entirely? *Ms. Kilburn. I think the study will indicate whether this scaling up of the individual programs has been accomplished. So, were they able to replicate these programs with fidelity, and can we provide not just the quantity, but also the quality? I think it will also indicate whether, when you scale the programs up, you replicate the same outcomes. So it is one thing when Darcy is overseeing Child First very closely; we are pretty confident that we are going to get great results. But when we start having this replicated in other states, and Darcy is not directly involved, for example, can we achieve the same outcome? So it will provide information of that sort. *Mr. Doggett. You believe in the value of home visiting as a way of preventing abuse and cost. It is a question more of how to do it, rather than whether to do it. *Ms. Kilburn. That is right. *Mr. Doggett. Is that correct? *Ms. Kilburn. That is correct. *Mr. Doggett. And, Ms. Towne, I am very impressed by both your testimony. But what would be the effect in your area if you lose federal funding? *Ms. Towne. Unfortunately, as a home visitor, I am not sure that I could really testify to the answer to that, as far as funding resources go. I believe it would have a significant impact to our families in Yakima County. *Mr. Doggett. I think your testimony ‑‑ and yours, as well ‑‑ really did bring a human, very human dimension to the statistics that we frequently throw around here about how this program, this intervention, can really help make a difference in lives. And I look forward to your continued involvement, and report to the committee on how we can achieve the very most in using home visiting as a way to prevent abuse and other costs. Thank you so much for the testimony each of you gave. *Ms. Towne. Thank you. *Chairman Reichert. Thank you, Mr. Doggett. Mr. Griffin, you are recognized. *Mr. Griffin. Thank you, Mr. Chairman. Thank you all for being here today. Mr. Baron, I wanted to focus a little bit on HIPPY USA, which is ‑‑ although it serves many folks across the country, it is based in Little Rock, which is my district, second congressional district in Central Arkansas. And HIPPY stands for Home Instruction for Parents of Preschool Youngsters, HIPPY USA. So, they are operating both in rural and urban areas, and I wanted to ask you, Mr. Baron, when you are reviewing your models for effectiveness, are you seeing any differences between the outcomes in rural areas versus urban areas? And, if so, what do you attribute those differences to? *Mr. Baron. It is interesting that there have been evaluations of ‑‑ scientific evaluations of home visiting, randomized trials that have been done in both rural and urban areas. One of the Nurse‑Family Partnership studies was done in Upstate New York, in a rural, primarily white population, and that study found very large effects, as long as 15 years after the study began, for the treatment compared to the control group. Big decreases for the children of the mothers, for instance, in rates of criminal activity and rates of child maltreatment, and so on. But some of the other studies have been done, other good studies ‑‑ another Nurse‑Family Partnership randomized trial was done in Memphis, Tennessee, an urban setting. This study also found large effects, but different. The effects may vary for a variety of reasons. It might be the women in Upstate New York, there was a larger population of smokers than in Memphis. And then the third trial was also urban ‑‑ that was done in Denver. What was most impressive about those sets of studies was that sizable effects were found across different ethnicities, rural versus urban. There were different effects across the different studies, but all showed important improvement in people’s lives. The differing effects could have been because the populations were different. *Mr. Griffin. I think ‑‑ Ms. Lowell, I think you referred to the fact that different programs or different methods are used to reach different outcomes. Different families have different needs. And I was wondering ‑‑ and either you, Ms. Lowell, or Mr. Baron ‑‑ when you look at these different programs, are there some programs or methods that work in certain areas ‑‑ urban areas, for example ‑‑ that don't work as well in rural? Have you seen anything that would indicate that, or different parts of the country? *Ms. Lowell. I think that, first of all, it has to do with the uniqueness of each family; and that if you really do a good assessment, and you really understand what the needs of that family are, you are going to be the most successful, because you are going to be able to target your intervention specifically to the needs of the family. As you described so beautifully, it is about what that family needs. Now ‑‑ *Mr. Griffin. And just to interrupt there, because ‑‑ so with each of the different models or programs or methodologies, that flexibility exists. They ‑‑ with each of them they try to take the particular family's circumstances into account, and there is a certain flexibility there? *Ms. Lowell. I think that each model does it in their own way. But I think that different models have different capabilities. And, for instance, in Connecticut we work in partnership with other home visiting. We have another big home visiting program. And so, we often get referrals from that other home visiting program, because they have a para‑professional model. They know, if they are working with a mom who is really depressed, or one who has, let's say, domestic violence, that they are not really the right model to work with that family. So they will refer them to us. And we will do a very close transfer, so that we will then take that family, or take a family with a child who is having major behavior problems. I think that each of us has the same idea, that these are very family‑focused kinds of interventions. And, in that sense, I think that everyone is trying to do that, really trying to understand who their families are. *Mr. Griffin. So there is some degree of nimbleness, if you will, to allow for tweaks and changes if ‑‑ it sounds like, through transfers, or what have you ‑‑ if things aren't working exactly as maybe one thought. And I am out of time. Thank you, Mr. Chairman. *Chairman Reichert. Thank you, Mr. Griffin. Mr. Crowley, you are recognized. *Mr. Crowley. Ms. Kilburn, did you want to respond very quickly to that? *Ms. Kilburn. Sure. I just wanted to raise one issue that hasn't come up today that I think is relevant, and that is that a constraint for implementing these models is the local workforce, and this is particularly relevant for rural areas. So, if you have a program that needs to deploy mental health clinicians, or registered nurses, it is the case that many rural areas are designated as health professional shortage areas, and you might have selected one of these great programs, and have the will to do it, and even have the funding, but you don't have the trained personnel to be able to pull it off. So, I think particularly in our rural areas, we are observing that some of these programs have not been selected, and that may be a contributing factor. *Mr. Crowley. I appreciate that. Thank you, Ms. Kilburn. Mr. Chairman, reclaiming my time, I am very pleased we are having this hearing here today on an effective, evidence‑based program that has tremendous social benefits down the road. Being from New York, I have seen the great work of the Nurse‑Family Partnership and what it does, and I have been so impressed with the results this program has shown over the years. New York City Nurse‑Family Partnership is the largest urban program of its kind in the country. It has served more than 10,500 clients since its creation in 2003, and currently serving more than 1,700 clients across all 5 boroughs. These dedicated professionals like Ms. Towne are working with New York City families to make sure they have the education, information, and assistance they need to raise their children and become stronger families. And the long‑term results are so impressive, even beyond what you would expect from the immediate assistance provided. Mr. Chairman, I would like to, if I could, offer into the record the state profile of the Nurse‑Family Partnership of New York, if I could. *Chairman Reichert. Without objection. [The information follows: Mr. Crowley] *Mr. Crowley. Reductions in child abuse and neglect, better educational outcomes for children, a greater likelihood of economic stability for the mother, these results are not just good for the participants, but also are good for society, as a whole. Mr. Baron, I know you were here at a previous hearing this Subcommittee held, and we discussed the ripple effect we would see from cutting or eliminating funding for these types of programs. Our budget should focus on long‑term priorities, not just short‑term impacts. That is why I was so pleased that the Affordable Care Act started this federal investment and home visitation programs, and it is, in fact, an investment in the future health and well‑being of all families in our country. Your testimony references some of the research and evidence‑based home visiting programs that shows they can lead to reductions in child abuse and injuries, improvements in educational outcomes for children, and even a reduction in needs‑tested assistance over the long term for mothers. It is, therefore, reasonable to suggest that investment in strong home visiting programs will not only protect and help children, but also yield major benefits to society, and ultimately to taxpayers. Is that not correct? *Mr. Baron. Yes, that is right. Often there is a claim that a social program is so effective that you can improve people's lives and save money. Very often, when a rigorous evaluation is done, the effects are not quite so promising. The claim doesn't pan out. But this is a case where, at least for some of the program models, like the Nurse‑Family Partnership, and perhaps for Child First as well, the more effective models, it really does look like the evidence shows you can have your cake and eat it, too. You can improve people's lives in a very important way, over a long period of time, and reduce their use of public assistance, so that the government and taxpayer benefits, as well. *Mr. Crowley. Win‑win. I appreciate that. It is clear that this program is making a difference, and we need to maintain that federal support. I was pleased to see the President and his Administration have proposed a long‑term extension expansion of this program. That is the kind of investment we should be making. Congress recently passed a short‑term extension of this program, but it is clear that more must be done to build upon the success so far. I look forward to working with my colleagues on both sides. I want to commend the chairman for a very bipartisan approach to this issue, as well. I really do appreciate that. I hope that my colleagues on both sides of the aisle on this Committee will work with us to support this program. And, once again, Mr. Chairman, thank you for holding the hearing today. *Chairman Reichert. Thank you, Mr. Crowley. And, as you can see, and as Mr. Crowley said, this is really, truly a partnership up here, with Republicans and Democrats all appearing to be on the same page, wanting to help those that are most vulnerable. And I really ‑‑ as an old cop ‑‑ I know I mention this quite often, but I am proud to be, you know, an old law enforcement officer. But the evidence‑based stuff is very critical, and you guys are doing an awesome job with that. So, congratulations. Congratulations to you, Ms. Sucilla, and your success. And, thank you, Ms. Towne, for your hard work that you do each and every day. So, we are going to see each other again. We will visit again, and continue to work together. If Members have additional questions for the witnesses, they will submit them to you in writing. And we would appreciate receiving your responses for the record within two weeks. The committee stands adjourned. [Whereupon, at 3:30 p.m., the subcommittee was adjourned.] Member Submission For The Record Rep. Danny Davis 1 Rep. Danny Davis 2 Rep. Joseph Crowley Member Questions For The Record Jon Baron Jon Baron Response Rebecca Kilburn Rebecca Kilburn Response Public Submissions For The Record Scott Hippert Parents as Teachers
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