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Definition of home visit

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“Home visit.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/home%20visit. Accessed 23 Jun. 2024.

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• v.2021; 2021

The Practice of Home Visiting by Community Health Nurses as a Primary Healthcare Intervention in a Low-Income Rural Setting: A Descriptive Cross-Sectional Study in the Adaklu District of the Volta Region, Ghana

Kennedy diema konlan.

1 Department of Public Health Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana

2 College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea

Nathaniel Kossi Vivor

Isaac gegefe, imoro a. abdul-rasheed, bertha esinam kornyo, isaac peter kwao, associated data.

The data used to support the findings of this study are included within the article.

Home visit is an integral component of Ghana's PHC delivery system. It is preventive and promotes health practice where health professionals render care to clients in their own environment and provide appropriate healthcare needs and social support services. This study describes the home visit practices in a rural district in the Volta Region of Ghana. Methodology . This descriptive cross-sectional study used 375 households and 11 community health nurses in the Adaklu district. Multistage sampling techniques were used to select 10 communities and study respondents using probability sampling methods. A pretested self-designed questionnaire and an interview guide for household members and community health nurses, respectively, were used for data collection. Quantitative data collected were coded, cleaned, and analysed using Statistical Package for Social Sciences into descriptive statistics, while qualitative data were analysed using the NVivo software. Thematic analysis was engaged that embraces three interrelated stages, namely, data reduction, data display, and data conclusion.

Home visit is a routine responsibility of all CHNs. The factors that influence home visiting were community members' education and attitude, supervision challenges, lack of incentives and lack of basic logistics, uncooperative attitude, community inaccessibility, financial constraint, and limited number of staff. Household members (62.3%) indicated that health workers did not adequately attend to minor ailments as 78% benefited from the service and wished more activities could be added to the home visiting package (24.5%).

There should be tailored training of CHNs on home visits skills so that they could expand the scope of services that can be provided. Also, community-based health workers such as community health volunteers, traditional birth attendants, and community clinic attendants can also be trained to identify and address health problems in the homes.

1. Introduction

Home visit practice is a healthcare service rendered by trained health professionals who visit clients in their own home to assess the home, environment, and family condition in order to provide appropriate healthcare needs and social support services. The home environment is where health is made and can be maintained to enhance or endanger the health of the family because individuals and groups are at risk of exposure to health hazards [ 1 , 2 ]. At home visit, conducted in a familiar environment, the client feels free and relaxed and is able to take part in the activity that the health professional performs [ 1 ]. It is possible to assess the client's situation and give household-specific health education on sanitation, personal hygiene, aged, and child care. The important role the health professional plays during home visits (HV) cannot be overemphasized, and this led Ghana to adopt HV as a cardinal component of its preventive healthcare delivery system. This role is largely conducted by community health nurses (CHN) [ 2 ]. Health education given during HVs is more effective, resulting in behavioural change than those given through other sources such as the mass media [ 3 ].

In the home, the health professionals, mostly CHN monitor the growth, development, and immunization status of children less than 5 years and carry out immunization for defaulters. Care is given to special groups such as the elderly, discharged tuberculosis, and leprosy patients as well as malnourished children [ 1 , 2 ]. It is also possible to carry out contact tracing during HVs [ 2 ]. These services may prevent, delay, or be a substitute for temporary or long-term institutional care [ 4 , 5 ]. HV has potential for bringing health workers into contact with individuals and groups in the community who are at risk for diseases and who make ineffective or little use of preventive health services [ 2 ]. Several factors influence the conduct of HVs. These factors include location of practice, general practitioners age, training status, and the number of older patients on the list and predicts home visiting rate [ 6 ].

The concept of HV has remained in Ghana over the decades, and yet, its very essence is imperative [ 3 ]. In Ghana, home visiting is one of the major activities of CHN. The health visitors, as CHNs were then called, went from house to house, giving education on sanitation and personal hygiene [ 3 ]. These nurses attempt to promote positive health and prevent occurrence of diseases by increasing people's understanding of healthy ways of living and their knowledge of health hazards [ 7 ]. HVs remain fundamental to the successful prevention of deaths associated with women and children under five; yet, there still remain certain gaps in the successful implementation of this innovative intervention in Ghana [ 4 ]. In Sekyere West district in Ashanti Region of Ghana, although nurses had knowledge of home visiting and had a positive opinion of the practice, they could not perform their home visiting tasks or functions up to standard [ 8 ]. Home visiting practice in that district among nurses was found to be very low, even though community members desired more [ 8 ]. The findings indicate that there is a need for HV [ 9 ]. Also identified were several health hazards, such as uncovered refuse containers, open fires, misplaced sharp objects, open defecation, and other unhygienic practices that a proper home visiting regiment can address [ 8 ]. At the service level, lack of publicity about the service, the cost of the service, failure to provide services that meet clients' felt needs, rigid eligibility criteria, inaccessible locations, lack of public transport, limited hours of operation, inflexible appointment systems, lack of affordable child care, poor coordination between services, and not having an outreach capacity were identified as the challenges associated with this kind of service [ 9 – 13 ].

Home visiting is a crucial tool for enhancing family healthcare and the health of every community. Ghana Health Service through home visiting services has supported essential community health actions and address gaps in knowledge and community practices such as reproductive behaviour, nutritional support for pregnant women and young children, recognition of illness, home management of sick children, disease prevention, and care seeking behaviours [ 4 ]. As many interventions are implemented by stakeholders in health to ensure that home visiting practices actually benefit community members, recent studies have not delved into the practices of home visiting in poor rural communities especially in the Volta Region of Ghana. This study assessed the home visiting practices in the Adaklu district (AD) of the Volta Region.

This study assessed the practice of home visiting as a primary healthcare (PHC) intervention in a poor rural district in the Volta Region of Ghana.

2. Methodology

2.1. study design.

This mixed method study employed a descriptive cross-sectional study design as the study involved a one-time interaction with the CHNs and the community members to assess the practice of HVs.

2.2. Study Setting

The AD is one of the districts in the Volta Region of Ghana and has about 40 communities. The district capital and administrative centre is Adaklu Waya. The estimated population of the district was 36391 representing 1.7% of the Volta Region's population before the Oti Region was carved out [ 14 ]. The district is described as a rural district [ 14 ] as no locality has a population above 5000 people. The economically active population (aged 15 and above) represents 67% of the population [ 14 ]. The economically inactive population is in full-time education (55.1%), performed household duties (20.6%), or disabled or too sick to work (4.6%), while the employed population engages in skilled agricultural, forestry, and fishery workers (63.1%), service and sales (12.6%), craft and related trade (14.6%), and 3.4% other professional duties [ 14 ]. The private, informal sector is the largest employer in the district, employing 93.9% [ 14 ]. There are 15 health facilities in the district government health centres [ 4 ], one health centre by Christian Health Association of Ghana, and 10 community health-based planning services (CHPS) of which 5 are functional [ 15 ]. The housing stock is 5629 representing 1.4% of the total number of houses in the Volta Region. The average number of persons per house was 6.5 [ 14 ], and the houses are mostly built with mud bricks [ 15 ]. The most common method of solid waste disposal by households is public dumping in the open space (47.5%). Some households dump solid waste indiscriminately (17.3%), while other households dispose of burning (13.3%) [ 14 ].

2.3. Study Population, Sample, and Sampling Technique

There are about 36391 inhabitants with 6089 households in AD [ 14 ]. This study mainly involved adult members of the household and CHNs from randomly sampled communities in the district. These sampled communities included Abuadi, Anfoe, Ahunda, Dawanu, Goefe, Helekpe, Hlihave, Tsrefe, Waya, and Wumenu. An adult member of the household is a person above the age of 18 years who has the capacity to represent the household. CHN [ 11 ] from the selected communities in the district was recruited. A CHN is a certified health practitioner who combines prevention and promotion health practices, works within the community to improve the overall health of the area, and has a role to play in home visiting.

Estimating for a tolerable error of 5%, with a confidence interval of 95%, and a study population of 6089 households, with a margin of error of 0.05 using Yamane's formula for calculating sample for finite populations, a sample of 375 households were computed. The sample size was increased to 390 to take into consideration the possible effect of nonresponse from participants. Multistage sampling technique was adopted to eventually select study participants. Each community was stratified into four geographical locations: north, south, east, and west with respondents being selected from every second house using a systematic sampling approach. In each household, an adult member of the household responded to the questionnaire.

A whole population sampling method was used to select eleven [ 11 ] CHNs from the specific communities [ 10 ] where the study took place in the district. The CHN that served the 10 selected communities were selected. The numbers selected from each community were Helekpe (18.2%), Waya (18.2%), Anfoe (9.1%), Tsrefe (27.3%) and Wumenu (27.3%). This represented 42.3% of the total CHN community of the district at the time of the study.

2.4. Pretesting

The questionnaire and interview guide were piloted using 30 adult household members and 5 CHNs, respectively, at Klefe CHPS in the Ho municipality. The data collected through the questionnaire were subjected to a reliability test on SPSS (version 22). The pretesting ascertained the respondent's general reaction and particularly, interest in answering the questionnaire. The questionnaire was modified until it produced a Cronbach alpha coefficient of 0.790. It can therefore be concluded that the questionnaire had a high reliability in measuring the objectives of the study. The pretesting helped in identifying ambiguous questions and revising them appropriately. It also helped to structure and estimate the time the respondents used to answer the questionnaires and to respond to the interview.

2.5. Data Collection

Researchers from the University of Health and Allied Sciences School of Nursing and Midwifery were involved in data collection. Five researchers received two days training in data collection, the study tools, and research ethics for social sciences prior to the commencement of data collection. All researchers had a minimum of a bachelor degree in CHN with at least three years' data collection experience.

Respondents were assisted to respond to a questionnaire within their homes. The household questionnaire had four [ 4 ] sections comprising personal details and how HV practice is carried out in the home such as frequency of visit, duration, and activities. Subsequent sections had respondents answer questions on the challenges, benefits, and factors that could promote the HV practice. It took an average of about 15 minutes to complete a single questionnaire.

A semistructured interview guide was used to interview CHNs. This guide was in four sections; the first section was personal details with subsequent sections on practice of home visits, constraints to the practice, the benefits, and promotion factors to HVs. An interview section lasted 20–25 minutes to complete.

2.6. Data Analysis

2.6.1. quantitative data.

Each individual questionnaire was checked for completeness and appropriateness of responses before it was entered into Microsoft Excel, cleaned, and transferred to the Statistical Package for Social Sciences (version 22) for analysis. The data were basically analysed into descriptive statistics of proportions. There were also measures of central tendencies for continuous variables.

2.6.2. Qualitative Data

In data analysis, thematic analysis was engaged that embraces three interrelated stages, namely, data reduction, data display, and data conclusion [ 16 ]. CHNs views were summarised based on the conclusions driven and collated as frequencies and proportions. Guest, Macqueen, and Namey summarised the process of thematic analysis as construing through textual data, identifying data themes, coding the themes, and then interpreting the structure and content of the themes [ 17 ]. In using this scheme, a codebook was first established, discussed, and accepted by the authors. The nodes were then created within NVivo software using the codebook. Line-by-line coding of the various transcripts was performed as either free or tree nodes. Double coding of each transcript was carried out by two of the researchers. Coding comparison query was used to compare the coding, and a kappa coefficient (the measurement of intercoder reliability) was generated to compare the coding that was conducted by the two authors. The matrix coding query was performed to compare the coding against the nodes and attributes using NVivo software that made it possible for the researchers to compare and contrast within-group and between-group responses.

2.7. Ethical Consideration

Ethical clearance was obtained on the 19th September, 2018, from the Research and Scientific Ethics Committee of the Institute of Health Research, University of Health and Allied Sciences (UHAS-REC A.2 [13] 18-19). Permission was sought from the district health authorities, chiefs, and assembly members of each study community. Preliminary to the administration of the questionnaires, an informed consent was obtained as respondents signed/thumb printed a consent form before they were enrolled into the study. Participants could withdraw from the study anytime they wished to do so.

3.1. Household Members' Views regarding Home Visit

The household representatives surveyed (375) had a mean age of 41.24 ± 16.88 years. The majority (26.5%) of household members were aged between 30 and 39 years. Most (75.1%) were females. The majority (97.1%) of people in households were Christians, while 38% was farmers. The majority (69.9%) of household members were married as 47.2% had schooled only up to the JHS level as at the time of this survey as given in Table 1 .

Demographic characteristics of household members.

The majority (73.3%) of adult household members had ever been visited by a health worker for the purpose of conducting HVs as a significant number (26.7%) of household members had never been visited by health workers in the community. Most (52.6%) household members had had their last visit from a health worker during the past month. Within the past three months, some (48.2%) community members were visited only once by a health worker. The majority (93.4%) of community members were usually visited between the time periods of 9am and 2pm as given in Table 2 . The community members contend that home visiting was beneficial to the disease prevention process (65%). The people that need to be visited by CHNs include children under five (25%), malnourished children's homes (14%), children with disabilities (14%), mentally ill people (11%), healthcare service defaulters (22%), people with chronic diseases (9%), and every member of the community (5%).

Practice of home visits in AD (household members).

Most (87.9%) community members were given health education during HVs conducted by the CHN. In describing the nature of health education that is most frequently given by CHNs during HVs, household members indicated fever management (14%), malaria prevention (20%), waste disposal (11%), prevention and management of diarrhoea (22%), nutrition and exclusive breastfeeding (14%), hospital attendance (14%), and prevention of worm infestations (5%). The majority (62.3%) of community members did not receive a minor ailment management during HVs as most (66.5%) of community members received vaccination during HVs by CHNs. Describing the type of minor ailment treatment given during the HV include care of home accidents (13%), management of minor pains (22%), management of fever (45%), and management of diarrhoea (20%). Household members (24.5%) did identify bad timing as a barrier for home visiting, while some (13.1%) did identify the attitude of health workers as a barrier to home visiting. However, most (67.3%) of the household members attributed their dislike for home visiting to the duration of the visit. The majority (95.2%) of household members indicated health workers were friendly. Some household members (78%) indicated they benefited from HVs conducted in their homes. The majority (91.4%) of household members showed that time for home visiting was convenient. Indicating if household members will wish for the conduct of the HV to be a continuous activity of CHNs in their community, the respondents (82%) were affirmative.

3.2. CHNs Views on Home Visit in AD

The mean age of CHNs was 30.44 ± 4.03 years as some (33.3%) were aged 32 years as the modal age. The CHNs (90.9%) were females with the majority (81.8%) being Christians as given in Table 3 .

Demographic characteristics of CHN.

In assessing the home visiting practices of CHNs, the researchers had some thematic areas. These thematic areas that were discussed include but not limited to the concept of HV by CHN, factors that influence the conduct of HVs, ability to visit all homes within CHN catchment area, reasons for conducting or not able to conduct HV, frequency of conducting home visits by CHN, and activities undertaken during HVs. This view that was expressed was simply summarised based on the thematic areas and presented in Table 4 as descriptive statistics related to the CHN conduct of HVs.

Summary of CHNs home visit practice in AD.

3.2.1. Concept of Home Visit by CHN

CHNs have varied descriptions of the concept of HV as it is conducted within the district. The description of HV was basically related to the nature and objective that is associated with the concept. The central concept expressed by participants included a health worker visiting a home in their place of abode or workplace, providing service to the family during this visit, and this service is aimed at preventing disease, promoting health, and maintaining a positive health outcome. These views were summarised when they said

“HVs are a service that we (CHNs) rendered to the client and his family in their own home environment to promote their health and prevent diseases. The central idea is that during the HV, the CHN is able to engage the family in education and services that eventually ensure that diseases are prevented and health is promoted.”

“HV is the art when the CHNs visit community members' homes to provide some basic curative and largely preventive healthcare services to clients within their own homes or workplaces. During this visit, the CHN helps the entire family to live a healthy life and give special attention or care to the vulnerable members of the society.”

“It is the processes when at-risk populations are identified; then, the CHN provides services to this cadre within their own home environment and sometimes workplaces as the case may be. Essentially, the CHN assists the family to adopt positive behaviours that will ensure they live with the vulnerable person in a more comfortable way.”

3.2.2. Factors that Influence the Conduct of Home Visits

The CHNs enumerated a cluster of factors that influence the conduct of HVs within the district. These factors ranged from community members education, attitude, supervision challenges, lack of incentives, and lack of basic logistics to conduct HVs. The uncooperative attitude of community members was identified by CHNs (36.4%) as a barrier to HVs. As they indicate, some community members did not support the continued visit to their homes or did not give them the necessary attention needed for the provision of services.

“Some community members do not understand the importance of HVs in the prevention of disease and for that matter are less receptive to the conduct of HVs. They just do not see the need for the service provider to come to their homes to provide services.”

“The client is the master of his own home; when you get into a home for a HV, the owner should be willing to talk or attend to you. Sometimes, you get into a home and even if you are not offered a seat, or you are just told we are busy, come next time. You know community service is not a paid job, so because the community members do not directly pay for the services we provide, essentially less premium is placed on the activities we conduct.”

“There is some resistance to HVs by some community members. Sometimes, you come to a house and can feel that you are not wanted; meanwhile, the home is part of the home that needs and has to get a HV because of the special needs they have. This is particularly specific in homes that believe that the particular problem is a result of supernatural causes.”

3.2.3. The Ability to Visit All Homes within CHN Catchment Area

The conduct of HVs is a basic responsibility for all CHNs as they remain as an integral part of the PHC delivery system in Ghana. Based on the nature and problems in the community, CHNs strategizes various means that will aid them to provide this essential service efficiently. CHNs (81.8%) are able to visit all homes in the catchment areas during a quarter. Some of the responses included the following:

“We do organise HVs, this is part of our routine schedule. As a community health nurse, to enjoy your work, you will need to organise HVs from time to time.”

“As for the HV, it depends on the strategies a particular CHPS compound is using. Irrespective of the community that one works in, you can always provide full and adequate care and service to the community if you plan well. First, you have to identify the “at need people” then the distance to their homes and put this in your short-term strategic plan for execution.”

“HVs are basic responsibilities of community health nurses, and we ought to execute it. In spite of the challenges, we cannot let those particularly hinder on our ability to conduct our very core mandate.”

Some CHNs were not able to visit all homes in their catchment areas, citing “hard to reach areas” and “Inadequate equipment” as the reasons for not being able to visit all households.

“Sometimes it is the distance to the clients' homes that makes it impossible to visit them. There are some homes if you actually intend to visit them, then you must be willing to spend the whole day doing only that activity.”

“Some clients' problems are such that you will need to have special tools before you visit them. For example, what use will it be to a diabetic client if you visit him/her and you are unable to monitor the blood sugar level or to a hypertension patient, you are not able to check the blood pressure because you do not have the required equipment?”

“To have a successful HV practice, I think the authorities should be willing to provide the basic logistics that will aid us to work. Without this basic logistics, we cannot.”

3.2.4. The Reasons for Conducting or Not Able to Conduct Home Visits

CHNs (72.7%) carried out both routine and special HVs. For those community health nurses who were not able to conduct HVs, several reasons were ascribed. Some of the reasons described included the lack of basic amenities to conduct HVs. The majority (18.2%) of CHNs also did attribute inaccessible geographical areas as a barrier to HV. Also, CHNs (63.6%) identified inadequate logistics and financial constraints as barriers to HV. All of the CHNs report on their activities regarding home visiting to the district health authorities.

“We basically lack the simple logistics that will assist us to conduct HVs. We do not have simple movable equipment like weight scales, thermometers, sphygmomanometers, and stethoscopes.”

“We do not have functionally equipped home visiting bags, so even if we decide to visit the homes, how much help will we be to the client?”

The other reasons included large catchment areas and lack of reliable transportation for the conduct of HVs in the AD.

“The catchment area is quite wide and practically impossible to visit every home. Looking from here to the end of our catchment area is more than 5 kilometers, without a means of transport, one cannot be able to visit all those homes.”

“I remember in those days; community health nurses were given serviceable motor cycles to aid in their movement and especially the conduct of HVs. Today, since our motorbike broke down 5 years ago, it has since not been serviced, yet we are expected to conduct HVs.”

“To conduct home visits, whose money will be used for transportation? The meagre salary I earn? Or the families or beneficiaries of the service have to pay?”

“The number of staff here is woefully inadequate, we are only two people here, how can we do home visiting and who will be left in the facility to conduct the other activities. For this reason, we are not able to conduct HVs.”

CHNs tried to visit the homes at various times depending on the occupation of the significant other of the homes, so that they can provide services in the presence of the significant others. CHNs (63.6%) visit 6–10 homes in a week as 90.9% CHNs conduct HVs in the morning. The reasons given for conducting some HVs in the evenings included the following:

“This place is largely a farming community, most people visit their farms during the mornings, so if you visit the home in the morning, you may not meet the significant others of the vulnerable person to conduct health education.”

“We do HVs because of the clients, so anytime it is possible, we will meet them at home, we conduct the visits at that time. For me, even if the case is that I can only meet the important people regarding the client at night, I visited them at that time. For community health nursing work, it is a 24-hour work and we must be found doing it at all time.”

3.2.5. Frequency of Conducting Home Visits by CHN

Various schedule periods were used based on health facilities for the purpose of HVs. Most (45.5%) conducted HVs three times in a week. CHNs (90.9%) had conducted HVs the week preceding the interview. Indicating that the last time HV was conducted, CHNs conducted a HV at least within the last week:

“HV is a weekly schedule in this facility; for every week, we have a specific person who is assigned to do HV just as all other activities that are conducted in this facility”.

“Yes, last week, we had a number of HVs; we made one routine HV and the other was a scheduled HV from a destitute elderly woman who was accused as a witch by some of her family members.”

Indicating if they sometimes get fatigued for conducting HVs weekly because of the limited number of staff, a community health nurse indicated that,

“I think it is about the plan we have put in place. There are about four people in this facility. We plan our activities that we all conduct HVs. In a month, one may only have one or two HVs, so it is unlikely that you will be fatigued in conducting HVs.”

“Yes, sometimes, it is really tedious, but we cannot let that be a setback. We have a responsibility to execute and we must be doing so to the best of our ability.”

3.2.6. Activities Undertaken during Home Visits

CHNs conducted health education (90.9%), management of minor ailments (54.6%), and vaccination/contact tracing (63.6%) during HVs. Describing if they are able to conduct the management of small ailments and home accidents at home, CHNs were divided in their ability to do this. Those were not able to do so indicated,

“…. And who will pay? Since the introduction of the national health insurance, we are not able to provide management of minor ailments during HVs. In those days, we were supplied with the medicines to use from the district, so we could provide such free services. But with the insurance now in place, we do not get medicine from the district, so whose medicine will you use to conduct such treatment?”

“I think our major goal is on preventive care. We have a lot to do with preventing diseases. Let us leave disease treatment to the clinical people. When we get ailments, we refer them to the next level of care to use their health insurance to access service.”

Identification of cases, defaulter tracing, and health education were identified as benefits and promotion factors of HVs. Identification of cases and defaulter tracing were both mentioned by CHNs as benefits and promotion factors of HVs.

“I think HVs should be continued and encouraged to be able to achieve universal, sustainable PHC coverage for all. Not only do we visit the homes, we also identify vaccination defaulters, tuberculosis treatment defaulters, and prevention of domestic violence against women and children and health education on specific diseases and sometimes we do immunisation.”

“In the home, we have a varied responsibility, treatment of minor ailments, immunization and vaccination, contact tracing, education on prevention of home accidents, etc.” It will be a disservice, therefore, if anyone tries to downplay the importance of HVs in our PHC dispensation.”

“Through HVs, we have provided very essential services that cannot be quantified mathematically, but the community members know the role of the services in their everyday lives. Even the presence of the community health nurse in the home is a factor that promotes girl child education and leads to woman empowerment.”

4. Discussion

This study assessed the home visiting practices in the AD of the Volta Region of Ghana. The concept of home visiting has been enshrined in Ghana's health history and executed by the CHN or public health nurses (PHN). In AD, only CHNs among all the various cadres of health professionals conducted HVs. This was contrary to the practice in the past when both CHN and PHN conducted HVs [ 18 ]. Notwithstanding the limited numbers of CHNs in the district, the majority of households (73.3 %) have a history of visits from a CHN. Home visiting is central in preventive healthcare services, especially among the vulnerable population. In children under five years, it is plausible that nurse home visiting could lead to fewer acute care visits and hospitalization by providing early recognition of and effective intervention for problems such as jaundice, feeding difficulties, and skin and cord care in the home setting [ 19 ]. Home visiting emphasizes prevention, education, and collaboration as core pillars for promoting child, parent, and family well-being [ 20 ].

In Ghana, under the PHC initiative, communities are zoned or subdivided and have a CHN to manage each zone by conducting HVs, including a cluster of responsibilities mainly in the preventive care sectors [ 4 ]. As rightly identified, HV is one of the core mandates of the CHN. Most of the community members who had received more than one visit in a week lived close to the health facilities indicating that there are homes which have never been visited, and CHNs are not able to cover all homes in their catchment areas. Factors that deter the conduct of HVs by CHN ranged from community members' level of education, attitude, supervision challenges, lack of incentives, and lack of basic logistics to conduct HVs. It is imperative that CHNs HVs especially those with newborn children to assess the home environment and provide appropriate care interventions and education as it was reported that 2.8% of 2641 newborns who did not receive a HV were readmitted to the hospital in the first 10 days of life with jaundice and/or dehydration compared with 0.6% of 326 who did receive a HV [ 21 ]. CHNs need to be provided with the right tools including means of transport to reach “hard to reach” communities and homes to provide services.

In rural Ghana such as the AD, community members leave the home to their places of work or farms during the morning sessions and only return home in the evening or late afternoon. HVs (93.4%) were conducted between 9am and 2pm, while some homes (6.6%) were visited between 3pm and 6pm. One problem faced by this timing difference is further expressed when CHNs indicated that they did not meet people at home during HVs. It is important for CHNs to be wary of their safety in client's homes as they show enthusiasm to visit homes at any time, and they could meet significant others. Therefore, to ensure safety, it is important to cooperate with clients and their families [ 22 ] in providing these services especially outside the conventional working hours. The need to use alternative timing of visits is essential as it is known that client participation is required to determine the scope of quality and safety improvement work; in reality, it is difficult for them to participate [ 23 ]. Also, some respondents indicated the time spent during HVs was too short (32.7%), and others (24.5%) wished the CHNs could spend more time with them. Community members have problems they wished could be addressed by the CHNs during HVs, but because of the number of households compared to the limited number of CHNs available, the CHNs could not spend much time during HVs and the respondents were not satisfied with the services rendered. It is likely that services will be better implemented by households if the CHN spends much time with the household and together implements thought health activities. Amonoo-Lartson and De Vries reported that community clinic attendants who spent more time in consultation performed better [ 24 ].

CHNs (8.2%) indicated they could not visit all households that needed the home visiting services in their catchment areas. Home visiting nurses are required to be mindful of the time and environment where they are performing care [ 22 ], so that they can allow for maximum benefit to the community. This notwithstanding, some community members (26.7 %) were not available during the HVs. The determination of suitable time between the CHN and the client is critical in ensuring that a positive relationship is established for their mutual benefit. The interval associated with HVs varied from one community or a health centre to another, and this was planned based on the specific needs of each community or CHPS catchment zone. There is actually no one-size-fits-all approach to home visiting [ 20 ] as several strategies can be adopted in providing services. The number of weeks or months elapsing between the visits ranged from one week to four months. The ministry of Health Ghana per the PHC system encourages CHN to conduct at least one contact tracing and/or HV session within a week within their communities [ 25 ]. All CHNs indicated that in their catchment area, they conducted at least one HV in a week and sometimes even more depending on the exigencies of the time.

Various activities are expected to be conducted by CHNs during HVs. These activities include the provision of basic healthcare services such as prevention of diseases and accidents, disease surveillance, tracing of contacts of infectious disease, tracing of treatment defaulters such as tuberculosis, diabetes mellitus, and hypertension and management of minor ailments at home. Community members (62.3%) did not receive a minor ailment management during HVs. CHNs are expected to be equipped with requisite knowledge, tools, and skills to be able to conduct these services in the homes. Also, the level of care that can be identified as a minor ailment as per the guidelines of the Ministry of Health needs to be specific as community members had varied classification of minor ailments and the level of care to be provided. Home visitors have varying levels of formal education and come from a variety of educational backgrounds marked by different theoretical traditions and content knowledge [ 20 ]. Other jurisdiction HV nurses drew blood for bilirubin checks and set up home phototherapy if indicated; they provided breastfeeding promotion and teaching on feeding techniques and skin and cord care [ 19 ]. Also, CHNs are expected to be able to provide baby friendly home-based nursing care services during a visit to the clients' home. HV nurses should also discuss the schedule of well-baby visits and immunizations [ 19 ] with families.

Important challenges associated with the conduct of HVs were identified as a large catchment area, lack of basic logistics, lack of the reliable transportation system, uncooperative community members, inadequate staff, and “hard to reach” homes due to geographical inaccessibility. Health education, management of minor ailment, and vaccination or contact tracing were the activities carried out in the homes. Home visiting nurses are under pressure to complete a job within an allotted time frame, as determined by the contract or terms of employment [ 22 ]. Time pressure significantly contributes to fatigue and depersonalization, and adjustments to interpersonal relationships with nurse administrators can have notable alleviating effects in relation to burnout caused by time pressure [ 26 ]. CHNs (63.6%) identified inadequate equipment and financial constraints as challenges to HV. Given evidence suggesting that relationship-based practices are the core of successful home visiting [ 27 – 29 ], with a natural harmony between the home visitor and the community members to the home, she renders her services [ 20 ]. A report published by the National Academy of Sciences (1999) also identified staffing, family involvement, language barrier, and cultural diversities as some of the barriers to a HV [ 30 ].

Health education (87.9%) dominated the home visiting activities. Health education helps to provide a safe and supportive environment and also build a strong relationship that leads to long lasting benefits to the entire family [ 5 ]. Face to face teaching in the privacy of the home is an excellent environment for imparting health information [ 31 ]. The CHNs stated that health education, tracing of defaulters, and identification of new cases are the benefits and promotion factors for conducting HVs. This implies that there are other critical aspects of HV that CHNs neglect such as prevention of home accidents and ensuring a safe home environment and care for the aged. Early detection of potential health concerns and developmental delays, prevention of child abuse, and neglect are also other benefits and promotive factors of HV. HV helps to increase parents' knowledge, parent-child interactions, and involvement [ 5 ]. The conduct of HV was not reported among all community members as some community members (22.0%) in the AD indicated their homes have never been visited. This is, however, an improvement over the rate of HVs that was reported in the Assin district in Ghana [ 32 ]. In the Assin district, about 84% of the respondents said they gained benefits from HVs [ 32 ]. In this study, respondents who were visited indicated the CHNs just inspected their weighing card while giving them no feedback. CHNs should implement various interventions to ensure that community members directly benefit from health interventions that are implemented during HVs to reduce the consequences that are usually associated with poor access to healthcare services especially in poor rural communities such as the AD.

5. Conclusion

The activities carried out in the homes were mainly centred on health education, contact tracing, and vaccination. Health workers faced many challenges such as geographical inaccessibility, financial constraints, and insufficient equipment and medications to treat minor ailments. If HV is carried out properly and as often as expected, one would expect the absence of home accidents, child abuse, among others in the homes, and a reduction in hospital admissions.

The need for strengthening HV as a tool for improving household health and addressing home-based management of minor ailment in the district cannot be over emphasized. It is important to forge better intersectoral collaboration at the district level. The District Assembly could assist the District Health Management Team with transport to support HVs. In addition, community-based health workers such as community health volunteers, traditional birth attendants, and community clinic attendants should also be trained to identify and address health problems in the homes to complement that which is already conducted by healthcare professionals.

Acknowledgments

The authors wish to express their profound gratitude to the staff and district health management team of the AD of the Volta Region of Ghana for providing them with the necessary support and assisting in diverse ways to make this study possible. They thank their participants for the frank responses.

Abbreviations

Data availability, conflicts of interest.

The authors declare that they have no conflicts of interest.

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Home Visit: Opening the Doors for Family Health

Chapter 11 Home Visit Opening the Doors for Family Health Claudia M. Smith Chapter Outline Home Visit Definition Purpose Advantages and Disadvantages Nurse–Family Relationships Principles of Nurse–Client Relationship with Family Phases of Relationships Characteristics of Relationships with Families Increasing Nurse–Family Relatedness Fostering a Caring Presence Creating Agreements for Relatedness Increasing Understanding through Communication Skills Reducing Potential Conflicts Matching the Nurse’s Expectations with Reality Clarifying Nursing Responsibilities Managing the Nurse’s Emotions Maintaining Flexibility in Response to Client Reactions Clarifying Confidentiality of Data Promoting Nurse Safety Clarifying the Nurse’s Self-Responsibility Promoting Safe Travel Handling Threats during Home Visits Protecting the Safety of Family Members Managing Time and Equipment Structuring Time Handling Emergencies Promoting Asepsis in the Home Modifying Equipment and Procedures in the Home Postvisit Activities Evaluating and Planning the Next Home Visit Consulting and Collaborating with the Team Making Referrals Legal Documentation The Future of Evidence-Based Home-Visiting Programs Focus Questions Why are home visits conducted? What are the advantages and disadvantages of home visits? How is the nurse–client relationship in a home similar to and different from nurse–client relationships in inpatient settings? How can a nurse’s family focus be maximized during a typical home visit? What promotes safety for community/public health nurses? What happens during a typical home visit? How can client participation be promoted? Key Terms Agreement Collaboration Consultation Empathy Family focus Genuineness Home visit Positive regard Presence Referral Nurses who work in all specialties and with all age groups can practice with a family focus , that is, thinking of the health of each family member and of the entire family per se and considering the effects of the interrelatedness of the family members on health. Because being family focused is a philosophy, it can be practiced in any setting. However, a family’s residence provides a special place for family-focused care. Community/public health nurses have historically sought to promote the well-being of families in the home setting ( Zerwekh, 1990 ). Community/public health nurses seek to promote health; prevent specific illnesses, injuries, and premature death; and reduce human suffering. Through home visits, community/ public health nurses provide opportunities for families to become aware of potential health problems, to receive anticipatory education, and to learn to mobilize resources for health promotion and primary prevention ( Kristjanson & Chalmers, 1991 ; Raatikainen, 1991 ). In clients’ homes, care can be personalized to a family’s coping strategies, problem-solving skills, and environmental resources (see Chapter 13 ). During home visits, community/public health nurses can uncover threats to health that are not evident when family members visit a physician’s office, health clinic, or emergency department ( Olds et al., 1995 ; Zerwekh, 1991 ). For example, during a visit in the home of a young mother, a nursing student observed a toddler playing with a paper cup full of tacks and putting them in his mouth. The student used the opportunity to discuss safety with the mother and persuaded her to keep the tacks on a high shelf. The quality of the home environment predicts the cognitive and social development of an infant ( Engelke & Engelke, 1992 ). Community/public health nurses successfully assist parents in improving relations with their children and in providing safe, stimulating physical environments. All levels of prevention can be addressed during home visits. Research has demonstrated that home visits by nurses during the prenatal and infancy periods prevent developmental and health problems ( Kitzman et al., 2000 ; Norr et al., 2003 ; Olds et al., 1986 ). Olds and colleagues demonstrated that families who received visits had fewer instances of child abuse and neglect, emergency department visits, accidents, and poisonings during the child’s first 2 years of life. These results were true for families of all socioeconomic levels but greater for low-income families. The health outcomes for families who received home visits were better than those of families that received care only in clinics or from private physicians. Furthermore, the favorable results were still apparent 15 years after the birth of the first child ( Olds et al., 1997 ), and the home visits reduced subsequent pregnancies ( Kitzman et al., 1997 ; Olds et al., 1997 ). The U.S. Advisory Board on Abuse and Neglect advocates such home-visiting programs as a means to prevent child abuse and neglect ( U.S. Department of Health and Human Services, 1990 ). Other research shows that home visits by nurses can reduce the incidence of drug-resistant tuberculosis and decrease preventable deaths among infected individuals ( Lewis & Chaisson, 1993 ). This goal is achieved through directly observing medication therapy in the individual’s home, workplace, or school on a daily basis or several times a week (see Chapter 8 ). Several factors have converged to expand opportunities for nursing care to adults and children with illnesses and disabilities in their homes. The American population has aged, chronic diseases are now the major illnesses among older persons, and attempts are being made to limit the rising hospital costs. As the average length of stay in hospitals has decreased since the early 1980s, families have had to care for more adults and children with acute illnesses in their homes. This increased demand for home health care has resulted in more agencies and nurses providing home care to the ill and teaching family members to perform the care (see Chapter 31 ). The degree to which families cope with a member with a chronic illness or disability significantly affects both the individual’s health status and the quality of life for the entire family ( Burns & Gianutsos, 1987 ; Harris, 1995 ; Whyte, 1992 ). Family members may be called on to support an individual family member’s adjustment to a chronic illness as well as take on tasks and roles that the ill member previously performed. This adjustment occurs over time and often takes place in the home. Community/public health nurses can assist families in making these adjustments. Since the late 1960s, deinstitutionalization of mentally ill clients has shifted them from inpatient psychiatric settings to their own homes, group homes, correctional facilities, and the streets (see Chapter 33 ). Nurses in the fields of community mental health and psychiatry began to include the relatives and surrogate family members in providing critical support to enable the person with a psychiatric diagnosis to live at home ( Mohit, 1996 ; Stolee et al., 1996 ). The hospice movement also recognizes the importance of a family focus during the process of a family member’s dying ( American Nurses Association [ANA], 2007a ). Care at home or in a homelike setting is cost effective under many circumstances. As the prevalence of acquired immunodeficiency syndrome (AIDS) increases and the number of older adults continues to increase, providing care in a cost-effective manner is both an ethical and an economic necessity. Nurses in any specialty can practice with a family focus. However, the specific goals and time constraints in each health care service setting affect the degree to which a family focus can be used. A home visit is one type of nurse–client encounter that facilitates a family focus. Home visiting does not guarantee a family focus. Rather, the setting itself and the structure of the encounter provide an opportunity for the nurse to practice with a family focus. A nurse visiting a client in his home listens to the man’s heart while his daughter looks on. Nurses who graduate from a baccalaureate nursing program are expected to have educational experiences that prepare them for beginning practice in community/public health nursing. Family-focused care is an essential element of community/public health nursing. One of the ways to improve the health of populations and communities is to improve the health of families ( ANA, 2007b ). Home visits may be made to any residence: apartments for older adults, group homes, boarding homes, dormitories, domiciliary care facilities, and shelters for the homeless, among others. In these residences, the family may not be related by blood, but, rather, they may be significant others: neighbors, friends, acquaintances, or paid caregivers. Nurses who are educated at the baccalaureate level are one of a few professional and service workers who are formally taught about making home visits. Some social work students, especially those interested in the fields of home health and protective services, also receive similar education. The American Red Cross and the National Home Caring Council have developed training programs for homemakers and home health aides; not all aides have received such extensive training, however. Agricultural and home economic extension workers in the United States and abroad also may make home visits ( Murray, 1968 ; World Health Organization, 1987 ). Home visit Definition A home visit is a purposeful interaction in a home (or residence) directed at promoting and maintaining the health of individuals and the family (or significant others). The service may include supporting a family during a member’s death. Just as a client’s visit to a clinic or outpatient service can be viewed as an encounter between health care professionals and the client, so can a home visit. A major distinction of a home visit is that the health care professional goes to the client rather than the client coming to the health care professional. Purpose Almost any health care service can be accomplished on a home visit. An assumption is that—except in an emergency—the client or family is sufficiently healthy to remain in the community and to manage health care after the nurse leaves the home. The foci of community/public health nursing practice in the home can be categorized under five basic goals: 1.  Promoting support systems that are adequate and effective and encouraging use of health-related resources 2.  Promoting adequate, effective care of a family member who has a specific problem related to illness or disability 3.  Encouraging normal growth and development of family members and the family and educating the family about health promotion and illness prevention 4.  Strengthening family functioning and relatedness 5.  Promoting a healthful environment The five basic goals of community/public health nursing practice with families can be linked to categories of family problems ( Table 11-1 ). A pilot study to identify problems common in community/public health nursing practice settings revealed that problems clustered into four categories: (1) lifestyle and living resources, (2) current health status and deviations, (3) patterns and knowledge of health maintenance, and (4) family dynamics and structure ( Simmons, 1980 ). Home visits are one means by which community/public health nurses can address these problems and achieve goals for family health. Table 11-1 Family Health-Related Problems and Goals Problem * Goal Lifestyle and resources Promote support systems and use of health-related resources Health status deviations Promote adequate, effective family care of a member with an illness or disability Patterns and knowledge of health maintenance Encourage growth and development of family members, health promotion, and illness prevention Promote a healthful environment Family dynamics and structure Strengthen family functioning and relatedness * Problems from Simmons, D. (1980). A classification scheme for client problems in community health nursing (DHHS Pub No. HRA 8016). Hyattsville, MD: U.S. Department of Health and Human Services. Advantages and Disadvantages Advantages of home visits by nurses are numerous. Most of the disadvantages relate to expense and concerns about unpredictable environments ( Box 11-1 ). Box 11-1 Advantages and Disadvantages of Home Visiting Advantages •  Home setting provides more opportunities for individualized care. •  Most people prefer to receive care at home. •  Environmental factors impinging on health, such as housing condition and finances, may be observed and considered more readily. •  Collecting information and understanding lifestyle values are easier in family’s own environment. •  Participation of family members is facilitated. •  Individuals and family members may be more receptive to learning because they are less anxious in their own environments and because the immediacy of needing to know a particular fact or skill becomes more apparent. •  Care to ill family members in the home can reduce overall costs by preventing hospitalizations and shortening the length of time spent in hospitals or other institutions. •  A family focus is facilitated. Disadvantages •  Travel time is costly. •  Home visiting is less efficient for the nurse than working with groups or seeing many clients in an ambulatory site. •  Distractions such as television and noisy children may be more difficult to control. •  Clients may be resistant or fearful of the intimacy of home visits. •  Nurse safety can be an issue. Nurse–family relationships How nurses are assigned to make home visits is both a philosophical and a management issue. Some community/public health nurses are assigned by geographical area or district . The size of the geographical area for home visits varies with the population density. In a densely populated urban area, a nurse might visit in one neighborhood; in a less densely populated area, the nurse might be assigned to visit in an entire county. With geographical assignments, the nurse has the potential to work with the entire population in a district and to handle a broad range of health concerns; the nurse can also become well acquainted with the community’s health and social resources. The potential for a family-focused approach is strengthened because the nurse’s concerns consist of all health issues identified with a specific family or group of families. The nurse remains a clinical generalist, working with people of all ages. Other community/public health nurses are assigned to work with a population aggregate in one or more geopolitical communities. For example, a nurse may work for a categorical program that addresses family planning or adolescent pregnancy, in which case the nurse would visit only families to which the category applies. This type of assignment allows a nurse to work predominantly with a specific interest area (e.g., family planning and pregnancy) or with a specific aggregate (e.g., families with fertile women). Principles of Nurse–Client Relationship with Family Regardless of whether the community/public health nurse is assigned to work with an aggregate or the entire population, several principles strengthen the clarity of purpose: •  By definition, the nurse focuses on the family. •  The health focus can be on the entire spectrum of health needs and all three levels of prevention. •  The family retains autonomy in health-related decisions. •  The nurse is a guest in the family’s home. Family Focus To relate to the family, the community/public health nurse does not have to meet all members of the household personally, although varying the times of visits might allow the nurse to meet family members usually at work or school. Relating to the family requires that the nurse be concerned about the health of each member and about each person’s contribution to the functioning of the family. One family member may be the primary informant; in such instances, the nurse should realize that the information received is being filtered by the person’s perceptions. The community/public health nurse should take the time to introduce herself or himself to each person present and address each person by name. Building trust is an essential foundation for a continued relationship ( Heaman et al., 2007 ; McNaughton, 2000 ; Zerwekh, 1992 ). The nurse should use the clients’ surnames unless they introduce themselves in another way or give permission for the nurse to be less formal. Interacting with as many family members as possible, identifying the family member most responsible for health issues, and acknowledging the family member with the most authority are important. The nurse should ask for an introduction to pets and ask for permission before picking up infants and children unless it is granted nonverbally. A nurse enters the home of a client with a young child. All Levels of Prevention Through assessment, the community/public health nurse attempts to identify what actual and potential problems or concerns exist with each individual and, thematically, within the family (see Chapter 13 ). Issues of health promotion (diet) and specific protection (immunization) may exist, as may undiagnosed medical problems for which referral is necessary for further diagnosis and treatment. Home visits also can be effective in stimulating family members to seek appropriate services such as prenatal care ( Bradley & Martin, 1994 ) and immunizations ( Norr et al., 2003 ). Actual family problems in coping with illness or disability may require direct intervention. Preventing sequelae and maximizing potential may be appropriate for families with a chronically ill member. Health-related problems may appear predominantly in one family member or among several members. A thematic family problem might be related to nutrition. For example, a mother may be anemic, a preschooler may be obese, and a father may not follow a low-fat diet for hypertension. Family Autonomy A few circumstances exist in our society in which the health of the community, or public, is considered to have priority over the right of individual persons or families to do as they wish. In most states, statutes (laws) provide that health care workers, including community/public health nurses, have a right and an obligation to intervene in cases of family abuse and neglect, potential suicide or homicide, and existence of communicable diseases that pose a threat of infection to others. Except for these three basic categories, the family retains the ultimate authority for health-related decisions and actions . In the home setting, family members participate more in their own care. Nursing care in the home is intermittent, not 24 hours a day. When the visit ends, the family takes responsibility for their own health, albeit with varying degrees of interest, commitment, knowledge, and skill. This role is often difficult for beginning community/public health nurses to accept; learning to distinguish the family’s responsibilities from the nurse’s responsibilities involves experience and consideration of laws and ethics. Except in crises, taking over for the family in areas in which they have demonstrated capability is usually inappropriate. For example, if family members typically call the pharmacy to renew medications and make their own medical appointments, beginning to do these things for them is inappropriate for the nurse. Taking over undermines self-esteem, confidence, and success. Nurse as Guest Being a guest as a community/public health nurse in a family’s home does not mean that the relationship is social. The social graces for the community and culture of the family must be considered so that the family is at ease and is not offended. However, the relationship is intended to be therapeutic. For example, many older persons believe that offering something to eat or drink is important as a sign that they are being courteous and hospitable. Because your refusal to share in a glass of iced tea may be taken as an affront, you may opt to accept the tea. However, you certainly have the right to refuse, especially if infectious disease is a concern. Validate with the client that the time of the visit is convenient. If the client fails to offer you a seat, you may ask if there is a place for you and the family to sit and talk. This place may be any room of the house or even outside in good weather. Phases of Relationships Relatedness and communication between the nurse and the client are fundamental to all nursing care. A nurse–client relationship with a family (rather than an individual) is critical to community/public health nursing. The phases of the nurse–client relationship with a family are the same as are those with an individual. Different schemes have been developed for naming phases of relationships. All schemes have (1) a preinitiation or preplanning phase, (2) an initiation or introductory phase, (3) a working phase, and (4) an ending phase (Arnold & Boggs, 2011). Some schemes distinguish a power and control or contractual phase that occurs before the working phase. The initiation phase may take several visits. During this phase, the nurse and the family get to know one another and determine how the family health problems are mutually defined. The more experience the nurse has, the more efficient she or he will become; initially, many community/public health nursing students may require four to six visits to feel comfortable and to clarify their role ( Barton & Brown, 1995 ). The nursing student should keep in mind that the relationship with the family usually involves many encounters over time—home visits, telephone calls, or visits at other ambulatory sites such as clinics. Several encounters may occur during each phase of the relationship ( Figure 11-1 ). Each encounter also has its own phases ( Figure 11-2 ). Figure 11-1 A series of encounters during a relationship. (Redrawn from Smith, C. [1980]. A series of encounters during a relationship [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.) Figure 11-2 Phases of a home visit. (Redrawn from Smith, C. [1980]. Phases of a home visit [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.) Preplanning each telephone call and home visit is helpful. Box 11-2 lists activities in which community/public health nurses usually engage before a home visit. The list can be used as a guide in helping novice community/public health nurses organize previsit activities efficiently. Box 11-2 Planning Before a Home Visit   1.  Have name, address, and telephone number of the family, with directions and a map. 2.  Have telephone number of agency by which supervisor or faculty can be reached. 3.  Have emergency telephone numbers for police, fire, and emergency medical services (EMS) personnel. 4.  Clarify who has referred the family to you and why. 5.  Consider what is usually expected of a nurse in working with a family that has been referred for these health concerns (e.g., postpartum visit), and clarify the purposes of this home visit. 6.  Consider whether any special safety precautions are required. 7.  Have a plan of activities for the home visit time (see Box 11-3 ). 8.  Have equipment needed for hand-washing, physical assessment, and direct care interventions, or verify that client has the equipment in the home. 9.  Take any data assessment or permission forms that are needed. 10.  Have information and teaching aids for health teaching, as appropriate. 11.  Have information about community resources, as appropriate. 12.  Have gasoline in your automobile or money for public transportation. 13.  Leave an itinerary with the agency personnel or faculty. 14.  Approach the visit with self-confidence and caring. The visit begins with a reintroduction and a review of the plan for the day; the nurse must assess what has happened with the family since the last encounter. At this point, the nurse may renegotiate the plan for the visit and implement it. The end of the visit consists of summarizing, preparing for the next encounter, and leave-taking. Box 11-3 describes the community/public health nurse’s typical activities during a home visit. Box 11-3 Nursing Activities During Three Phases of a Home Visit Initiation Phase of Home Visit 1.  Knock on door, and stand where you can be observed if a peephole or window exists. 2.  Identify self as [name], the nurse from [name of agency]. 3.  Ask for the person to whom you were referred or the person with whom the appointment was made. 4.  Observe environment with regard to your own safety. 5.  Introduce yourself to persons who are present and acknowledge them. 6.  Sit where family directs you to sit. 7.  Discuss purpose of visit. On initial visits, discuss services to be provided by agency. 8.  Have permission forms signed to initiate services. This activity may be done later in the home visit if more explanation of services is needed for the family to understand what is being offered. Implementation Phase of Home Visit 9.  Complete health assessment database for the individual client. 10.  On return visits, assess for changes since the last encounter. Explore the degree that family was able to follow up on plans from previous visit. Explore barriers if follow-up did not occur. 11.  Wash hands before and after conducting any physical assessment and direct physical care. 12.  Conduct physical assessment, as appropriate, and perform direct physical care. 13.  Identify household members and their health needs, use of community resources, and environmental hazards. 14.  Explore values, preferences, and clients’ perceptions of needs and concerns. 15.  Conduct health teaching as appropriate, and provide written instructions. Include any safety recommendations. 16.  Discuss any referral, collaboration, or consultation that you recommend. 17.  Provide comfort and counseling, as needed. Termination Phase of Home Visit 18.  Summarize accomplishments of visit. 19.  Clarify family’s plan of care related to potential health emergency appropriate to health problems. 20.  Discuss plan for next home visit and discuss activities to be accomplished in the interim by the community/public health nurse, individual client, and family members. 21.  Leave written identification of yourself and agency, with telephone numbers. Characteristics of Relationships with Families Some differences are worth discussing in nurses’ relationships with families compared with those with individual clients in hospitals. The difference that usually seems most significant to the nurse who is learning to make home visits is the fact that the nurse has less control over the family’s environment and health-related behavior ( McNaughton, 2000 ). The relationship usually extends for a longer period. A more interdependent relationship develops between the community/public health nurse and the family throughout all steps of the nursing process. Families Retain Much Control The family can control the nurse’s entry into the home by explicitly refusing assistance, establishing the time of the visit, or deciding whether to answer the door. Unlike hospitalized clients, family members can just walk away and not be home for the visit. One study of home visits to high-risk pregnant women revealed that younger and more financially distressed women tended to miss more appointments for home visits ( Josten et al., 1995 ). Being rejected by the family is often a concern of nurses who are learning to conduct home visits. As with any relationship, anxiety can exist in relation to meeting new, unknown families. Families may actually have similar feelings about meeting the nurse and may wonder what the nurse will think of them, their lifestyle, and their health care behavior. A helpful practice is to keep your perspective; if the clients are home for your visit, they are at least ambivalent about the meeting! If they are at home to answer the door, they are willing to consider what you have to offer. Most families involved with home care of the ill have requested assistance. Because only a few circumstances exist (as previously discussed) in which nursing care can be forced on families, the nurse can view the home visit as an opportunity to explore voluntarily the possibility of engaging in relationships ( Byrd, 1995 ). The nurse is there to offer services and engage the family in a dialogue about health concerns, barriers, and goals. As with all nurse–client relationships, the nurse’s commitment, authenticity, and caring constitute the art of nursing practice that can make a difference in the lives of families. Just as not all individuals in the hospital are ready or able to use all of the suggestions made to them, families have varying degrees of openness to change. If after discussing the possibilities the family declines either overtly or through its actions, the nurse has provided an opportunity for informed decision making and has no further obligation. Goals of Nursing Care Are Long Term A second major difference in nurse relationships with families is that the goals are usually more long term than are those with individual clients in hospitals. Clients may be in hospice programs for 6 months. A family with a member who has a recent diagnosis of hypertension may take 6 weeks to adjust to medications, diet, and other lifestyle changes. A school-aged child with a diagnosis of attention deficit disorder may take as long as half the school year to show improvement in behavior and learning; sometimes, a year may be required for appropriate classroom placement. For some nurses, this time frame is judged to be slow and tedious. For others, the time frame is seen as an opportunity to know a family in more depth, share life experiences over time, and see results of modifications in nursing care. For nurses who like to know about a broad range of health and nursing issues, relationships with families stimulate this interest. Having had some experience in home visiting is helpful for nurses who work in inpatient settings; it allows them to appreciate the scope and depth of practice of community/public health nurses who make home visits as a part of their regular practice. These experiences can sensitize hospital nurses to the home environments of their clients and can result in better hospital discharge plans and referrals. Because ultimate goals may take a long time to achieve, short-term objectives must be developed to achieve long-term goals. For example, a family needs to be able to plan lower-calorie menus with sufficient nutrients before weight loss is possible; a parent may need to spend time with a child daily before unruly behavior improves. Nursing interventions in a hospital setting become short-term objectives for client learning and mastery in the home setting. In an inpatient setting, giving medications as prescribed is a nursing action. In the home, the spouse giving medications as prescribed becomes a behavioral objective for the family; the related nursing action is teaching. Human progress toward any goal does not usually occur at a steady pace. For example, you may start out bicycling faithfully three times a week and give up abruptly. Similarly, clients may skip an insulin dose or an oral contraceptive. A family may assertively call appropriate community agencies, keep appointments, and stop abruptly. Families can be committed to their own health and well-being and yet not act on their commitment consistently. Recognizing that setbacks and discouragement are a part of life allows the community/public health nurse to be more accepting of reality and have the objectivity to renegotiate goals and plans with families. Box 11-4 includes evidence-based ways to foster goal accomplishment. Box 11-4 Best Practices in Fostering Goal Accomplishment With Families 1.  Share goals explicitly with family. 2.  Divide goals into manageable steps. 3.  Teach the family members to care for themselves. 4.  Do not expect the family to do something all of the time or perfectly. 5.  Be satisfied with small, subtle changes. 6.  Be flexible. Changes are sometimes subtle or small. Success breeds success, at least motivationally. The short-term goals on which everyone has agreed are important to make clear so that the nurse and the family members have a common basis for evaluation. Goals can be set in a logical sequence, in small steps, to increase the chance of success. In an inpatient setting, the skilled nurse notices the subtle changes in client behavior and health status that can warn of further disequilibrium or can signal improvement. Similarly, during a series of home visits, the skilled nurse is aware of slight variations in home management, personal care, and memory that may presage a deteriorating biological or social condition. Nursing Care Is More Interdependent with Families Because families have more control over their health in their own homes and because change is usually gradual, greater emphasis must be placed on mutual goals if the nurse and family are to achieve long-term success. Except in emergency situations, the client determines the priority of issues. A parent may be adamant that obtaining food is more important than obtaining their child’s immunization. A child’s school performance may be of greater concern to a mother than is her own abnormal Papanicolaou (Pap) smear results. Failure of the nurse to address the family’s primary priority may result in the family perceiving that the nurse does not genuinely care. At times, the priority problem is not directly health related, or the solution to a health problem can be handled better by another agency or discipline. In these instances, the empathic nurse can address the family’s stress level, problem-solving ability, and support systems and make appropriate referrals. When the nurse takes time to validate and discuss the primary concern, the relationship is enhanced. Families are sometimes unaware of what they do not know. The nurse must suggest health-related topics that are appropriate for the family situation. For example, a young mother with a healthy newborn may not have thought about how to determine when her baby is ill. A spouse caring for his wife with Alzheimer disease may not know what safety precautions are necessary. Community/public health nurses seek to enhance family competence by sharing their professional knowledge with families and building on the family’s experience ( Reutter & Ford, 1997 ; SmithBattle, 2009 ). Flexibility is a key. Because visits occur over several days to months, other events (e.g., episodic illnesses, a neighbor’s death, community unemployment) can impinge on the original plan. Family members may be rehospitalized and receive totally new medical orders once they are discharged to home. The nurse’s clarity of purpose is essential in identifying and negotiating other health-related priorities after the first concerns have been addressed ( Monsen, Radosevich, Kerr, & Fulkerson, 2011 ). Increasing nurse–family relatedness What promotes a successful home visit? What aspects of the nurse’s presence promote relatedness? What structures provide direction and flexibility? The nursing process provides a general structure, and communication is a primary vehicle through which the nursing process is manifested. The foundation for both the nursing process and communication is relatedness and caring ( ANA, 2003 ; McNaughton, 2005 ; Roach, 1997 ; SmithBattle, 2009 ; Watson, 2002 ; Watson, 2005 ). Fostering a Caring Presence Nursing efforts are not always successful. However, by being concerned about the impact of home visits on the family and by asking questions regarding her or his own motivations, the nurse automatically increases the likelihood that home visits will be of benefit to the family. The nurse is acknowledging that the intention is for the relationship to be meaningful to both the nurse and the family. Building and preserving relationships is a central focus of home visiting and requires significant effort ( Heaman et al., 2007 ; McNaughton, 2000 , 2005 ). The relatedness of nurses in community health with clients is important ( Goldsborough, 1969 ; SmithBattle, 2009 ; Zerwekh, 1992 ). Involvement, essentially, is caring deeply about what is happening and what might happen to a person, then doing something with and for that person. It is reaching out and touching and hearing the inner being of another…. For a nurse–client relationship to become a moving force toward action, the nurse must go beyond obvious nursing needs and try to know the client as a person and include him in planning his nursing care. This means sharing feelings, ideas, beliefs and values with the client…. Without responsibility and commitment to oneself and others…[a person] only exists. It is through interaction and meaningful involvement with others that we move into being human ( Goldsborough, 1969 , pp. 66-68). Mayers (1973, p. 331) observed 16 randomly selected nurses during home visits to 37 families and reported that “regardless of the specific interaction style [of each nurse], the clients of nurses who were client-focused consistently tended to respond with interest, involvement and mutuality.” A client-focused nurse was observed as one who followed client cues, attempted to understand the client’s view of the situation, and included the client in generating solutions. Being related is a contribution that the nurse can make to the family, independent of specific information and technical skills, a contribution that students often underestimate. Although being related is necessary, it is inadequate in itself for high-quality nursing. A community/public health nurse must also be competent. Community/public health nursing also depends on assessment skills, judgment, teaching skills, safe technical skills, and the ability to provide accurate information. As a community/public health nurse’s practice evolves, tension always exists between being related and doing the tasks. In each situation, an opportunity exists to ask, “How can I express my caring and do (perform direct care, teach, refer) what is needed?” Barrett (1982) and Katzman and colleagues (1987) reported on the differences that students actually make in the lives of families. Barrett (1982) demonstrated that postpartum home visits by nursing students reduced costly postpartum emergency department and hospital visits. Katzman and co-workers (1987) considered hundreds of visits per semester made by 80 students in a southwestern state to families with newborns, well children, pregnant women, and members with chronic illnesses. Case examples describe how student enthusiasm and involvement contributed to specific health results. Everything a nurse has learned about relationships is important to recall and transfer to the experience of home visiting. Carl Rogers (1969) identified three characteristics of a helping relationship: positive regard, empathy, and genuineness. These characteristics are relevant in all nurse–client relationships, and they are especially important when relationships are initiated and developed in the less-structured home setting. Presence means being related interpersonally in ways that reveal positive regard, empathy, genuineness, and caring concern. How is it possible to accept a client who keeps a disorderly house or who keeps such a clean house that you feel as if you are contaminating it by being there? How is it possible to have positive feelings about an unmarried mother of three when you and your partner have successfully avoided pregnancy? Having positive regard for a family does not mean giving up your own values and behavior (see Chapter 10 ). Having positive regard for a family that lives differently from the way you do does not mean you need to ignore your past experiences. The latter is impossible. Rather, having positive regard means having the ability to distinguish between the person and her or his behavior. Saying to yourself, “This is a person who keeps a messy house” is different from saying, “This person is a mess!” Positive regard involves recognizing the value of persons because they are human beings. Accept the family, not necessarily the family’s behavior. All behavior is purposeful; and without further information, you cannot determine the meaning of a particular family behavior. Positive regard involves looking for the common human experiences. For example, it is likely that both you and client family members experience awe in the behavior of a newborn and sadness in the face of loss. Empathy is the ability to put yourself in someone else’s shoes and to be able to walk in her or his footsteps so as to understand her or his journey. “Empathy requires sensitivity to another’s experience…including sensing, understanding, and sharing the feelings and needs of the other person, seeing things from the other’s perspective” according to Rogers (cited in Gary & Kavanagh, 1991 , p. 89). Empathy goes beyond self and identity to acknowledge the essence of all persons. It links a characteristic of a helping relationship with spirituality or “a sense of connection to life itself” ( Haber et al., 1987 , p. 78). Empathy is a necessary pathway for our relatedness. However, what does understanding another person’s experience mean? More than emotions are involved. A person’s experience includes the sense that she or he makes of aspects of human existence ( SmithBattle, 2009 ; van Manen, 1990 ). Being understood means that a person is no longer alone ( Arnold, 1996 ). Being understood provides support in the face of stress, illness, disability, pain, grief, and suffering. When a client feels understood in a nurse–client partnership (side-by-side relationship), the client’s experience of being cared for is enhanced ( Beck, 1992 ). To understand another person’s experience, you must be able to imagine being in her or his place, recognize commonalities among persons, and have a secure sense of yourself ( Davis, 1990 ). Being aware of your own values and boundaries is helpful in retaining your identity in your interactions with others. To understand another individual’s experience, you must also be willing to engage in conversation to negotiate mutual definitions of the situation. For example, if you are excited that an older person is recovering function after a stroke, but the person’s spouse sees only the loss of an active travel companion, a mutual definition of the situation does not exist. Empathy will not occur unless you can also understand the spouse’s perspective. As human beings, we all like to perceive that we have some control in our environment, that we have some choice. We avoid being dominated and conned. The nurse’s genuineness facilitates honesty and disclosure, reduces the likelihood that the family will feel betrayed or coerced, and enhances the relationship. Genuineness does not mean that you speak everything that you think. Genuineness means that what you say and do is consistent with your understanding of the situation. The nurse can promote genuine self-expression in others by creating an atmosphere of trust, accepting that each person has a right to self-expression, “actively seeking to understand” others, and assisting them to become aware of and understand themselves ( Goldsborough, 1969 , p. 66). When family members do not believe that being genuine with the nurse is safe, they may tell only what they think the nurse would like to hear. This action makes developing a mutual plan of care much more difficult. The reciprocal side of genuineness is being willing to undertake a journey of self-expression, self-understanding, and growth. Tamara, a recent nursing graduate, wrote about her growing self-responsibility: “Although I felt out of control, I felt very responsible. I took pride in knowing that these families were my families, and I was responsible for their care. I was responsible for their health teaching. This was the first semester where there was no a faculty member around all day long. I feel that this will help me so much as I begin my nursing career. I have truly felt independent and completely responsible for my actions in this clinical experience.” This student, who preferred predictable environments, was able to confront her anxiety and anger in environments in which much was beyond her control. A mother was not interested in the student’s priorities. A family abruptly moved out of the state in the middle of the semester. Nonetheless, the student was able to respond in such circumstances. She became more responsible, and she was able to temper her judgment and work with the mother’s concern. When the family moved, the student experienced frustration and anger that she would not see the “fruits of her labor” and that she would “have to start over” with another family. However, her ability to respond increased because of her commitment to her own growth, relatedness with families, and desire to contribute to the health and well-being of others. In a context of relating with and advocating for the family, the relationship becomes an opportunity for growth in both the nurse’s and the family’s lives ( Glugover, 1987 ). Imagine standing side-by-side with the family, being concerned for their well-being and growth. Now imagine talking to a family face-to-face, attempting to have them do things your way. The first image is a more caring and empathic one. Creating Agreements for Relatedness How can communications be structured to increase the participation of family members? Without the family’s engagement, the community/public health nurse will have few positive effects on the health behavior and health status of the family and its members. Nurses are expert in caring for the ill; in knowing about ways to cope with illness, to promote health, and to protect against specific diseases; and in teaching and supporting family members. Family members are experts in their own health. They know the family health history, they experience their health states, and they are aware of their health-related concerns. Through the nurse–family relationship, a fluid process takes place of matching the family’s perceived needs with the nurse’s perceptions and professional judgments about the family’s needs. Paradoxically, the more skilled the nurse is in forgetting her or his own anxiety about being the good nurse, the more likely the nurse is to listen to the family members, validate their reality, and negotiate an adequate, effective plan of care. One study of home visits revealed that more than half of the goals stated by public health nurses to the researcher could not be detected, even implicitly, during observations of the home visits. Therefore, half the goals were known only to the nurse and were, therefore, not mutual. The more specifically and concretely the goals were stated by the nurse to the researcher, the greater would be the likelihood that the clients understood the nurse’s purposes ( Mayers, 1973 ). To negotiate mutual goals, the client needs to understand the nurse’s purposes. The initial letter, telephone call, or home visit is the time to share your ideas with the family about why you are contacting them. During the first interpersonal encounter by telephone or home visit, explore the family members’ ideas about the purpose of your visits. This phase is essential in establishing a mutually agreed on basis for a series of encounters. As a result of her qualitative research study of maternal-child home visiting, Byrd (2006, p. 271) stated that “people enter…relationships with the expectation of receiving a benefit” that may be information, status, service, or goods. Byrd asserted that it is important for nurses to create client expectations through previsit publicity about (marketing) home-visiting programs. Also it is essential to understand the expectations of the specific persons being visited. Family members may have had previous relationships with community/public health nurses and students. Family members may be able to share such information as what they found to be most helpful, why they are willing to work with a nurse or student again, and what goals they have in mind. Other families who have had no prior experience with community/public health nurses may not have specific expectations. Asking is important. A contract is a specific, structured agreement regarding the process and conditions by which a health-related goal will be sought. In the beginning of most student learning experiences, the agreement usually entails one or more family members continuing to meet with the nursing student for a specific number of visits or weeks. Initially, specific goals and the nurse’s role regarding health promotion and illness prevention may be unclear. (If this role was already clear, undergoing a period of study and orientation would be unnecessary.) Initially, the agreement may be as simple as, “We will meet here at your house next Tuesday at 11:00  AM until around noon to continue to discuss what I can offer related to your family’s health and what you’d like. We can get to know each other better. We can talk more about how the week has gone for you and your family with your new baby.” These statements are the nurse’s oral offer to meet under specific conditions of time and place. The process of mutual discussion is mentioned. The goals remain general and implicit: fostering the family’s developmental task of incorporating an infant and fostering family–nurse relatedness. For the next week’s contract to be complete, the family member or members would have to agree. The most important element initially is whether agreement about being present at a specific time and place can be reached. If 11:00  AM is not workable for the family, would another time during the day when you both are available be mutually agreeable? For families who do not focus as much on the future, a community/public health nurse needs to be more flexible in scheduling the time of each visit. The word contract often implies legally binding agreements. This is not true of nurse–client contracts. Nurses are legally and ethically bound to keep their word in relation to nursing care; clients are not legally bound to keep their agreements. However, establishing a mutual agreement for relating increases the clarity of who will do what, when, where, for what purposes, and under what conditions. Because of some people’s negative response to the word contract, agreement or discussion of responsibilities may be better. An agreement may be oral or written. For some families, written agreements, especially early in the relationship, may be perceived as a threat. For example, a family that has been conned by a household repair scheme may be very suspicious of written agreements. Family members who are not legal citizens may not want to sign an agreement for fear that if it is not kept they will be punished. Do not push for a written agreement if the family is uncomfortable. If you do notice such discomfort, this may be a good opportunity to explore their fears. Written agreements are required when insurance is paying for the care provided by nurses working with home health agencies and to comply with the Health Insurance Portability and Accountability Act (HIPAA). Helgeson and Berg (1985) describe factors affecting the contracting process by studying a small convenience sample of 15 community/public health nursing students and 12 client responses. Of the 11 students who introduced the idea of a contract to clients, all did so between the second and the fourth visits of a 16-week series of visits; 9 students did so orally rather than in writing. No specific time was the best. Eight clients were very receptive to the idea because they liked the idea of establishing goals to work toward and felt the contract would serve as a reminder of their responsibility. The very process of developing a draft agreement to present to families provides the novice practitioner with an increased focus of care, clarity of nurse and family responsibilities and activities, and a basis from which to negotiate modifications in client behaviors ( Helgeson & Berg, 1985 ; Sheridan & Smith, 1975 ). The Home Visiting Evaluation Tool in Figure 11-3 lists nurse behaviors that are appropriate for home visits, especially initial home visits and those early in a series of home visits. Nurses can use this list as a preplanning tool to identify their readiness to conduct a specific home visit. Additionally, students and community/public health nurses have used the tool to evaluate initial home visits and identify their behaviors that were omitted and needed to be included on the second home visits. The tool also has been used jointly as an evaluation tool by nurses and supervisors and students and faculty. Figure 11-3 Home Visiting Evaluation Tool. (From Chichester, M., & Smith, C. [1980]. Home visiting evaluation tool [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.)

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Brief Home Visiting: Improving Outcomes for Children

What is Home Visiting?

Home visiting is a prevention strategy used to support pregnant moms and new parents to promote infant and child health, foster educational development and school readiness, and help prevent child abuse and neglect. Across the country, high-quality home visiting programs offer vital support to parents as they deal with the challenges of raising babies and young children. Participation in these programs is voluntary and families may choose to opt out whenever they want. Home visitors may be trained nurses, social workers or child development specialists. Their visits focus on linking pregnant women with prenatal care, promoting strong parent-child attachment, and coaching parents on learning activities that foster their child’s development and supporting parents’ role as their child’s first and most important teacher. Home visitors also conduct regular screenings to help parents identify possible health and developmental issues.

Legislators can play an important role in establishing effective home visiting policy in their states through legislation that can ensure that the state is investing in evidence-based home visiting models that demonstrate effectiveness, ensure accountability and address quality improvement measures. State legislation can also address home visiting as a critical component in states’ comprehensive early childhood systems.

What Does the Research Say?

Decades of research in neurobiology underscores the importance of children’s early experiences in laying the foundation for their growing brains. The quality of these early experiences shape brain development which impacts future social, cognitive and emotional competence. This research points to the value of parenting during a child’s early years. High-quality home visiting programs can improve outcomes for children and families, particularly those that face added challenges such as teen or single parenthood, maternal depression and lack of social and financial supports.

Rigorous evaluation of high-quality home visiting programs has also shown positive impact on reducing incidences of child abuse and neglect, improvement in birth outcomes such as decreased pre-term births and low-birthweight babies, improved school readiness for children and increased high school graduation rates for mothers participating in the program. Cost-benefit analyses show that high quality home visiting programs offer returns on investment ranging from $1.75 to $5.70 for every dollar spent due to reduced costs of child protection, K-12 special education and grade retention, and criminal justice expenses.

Maternal, Infant and Early Childhood Home Visiting Grant Program

The federal home visiting initiative, the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program, started in 2010 as a provision within the Affordable Care Act, provides states with substantial resources for home visiting. The law appropriated $1.5 billion in funding over the first five years (from FYs 2010-2014) of the program, with continued funding extensions through 2016. In FY 2016, forty-nine states and the District of Columbia, four territories and five non-profit organizations were awarded $344 million. The MIECHV program was reauthorized under the Medicare Access and CHIP Reauthorization Act through September 30, 2017 with appropriations of $400 million for each of the 2016 and 2017 fiscal years. The Bipartisan Budget Act of 2018 ( P.L. 115-123 ) included new MIECHV funding. MIECH was reauthorized for five years at $400 million and includes a new financing model for states. The new model authorizes states to use up to 25% of their grant funds to enter into public-private partnerships called pay-for-success agreements. This financing model requires states to pay only if the private partner delivers improved outcomes. The bill also requires improved state-federal data exchange standards and statewide needs assessments. MIECHV is up for reauthorization, set to expire on Sept. 30, 2022.  

The MIECHV program emphasizes that 75% of the federal funding must go to evidence-based home visiting models, meaning that funding must go to programs that have been verified as having a strong research basis. To date,  19 models  have met this standard. Twenty-five percent of funds can be used to implement and rigorously evaluate models considered to be promising or innovative approaches. These evaluations will add to the research base for effective home visiting programs. In addition, the MIECVH program includes a strong accountability component requiring states to achieve identified benchmarks and outcomes. States must show improvement in the following areas: maternal and newborn health, childhood injury or maltreatment and reduced emergency room visits, school readiness and achievement, crime or domestic violence, and coordination with community resources and support. Programs are being measured and evaluated at the state and federal levels to ensure that the program is being implemented and operated effectively and is achieving desired outcomes.

With the passage of the MIECHV program governors designated state agencies to receive and administer the federal home visiting funds. These designated  state leads provide a useful entry point for legislators who want to engage their state’s home visiting programs.

Advancing State Policy

Evidence-based home visiting can achieve positive outcomes for children and families while creating long-term savings for states.

With the enactment of the MIECHV grant program, state legislatures have played a key role by financing programs and advancing legislation that helps coordinate the variety of state home visiting programs as well as strengthening the quality and accountability of those programs.

During the 2019 and 2021 sessions, Oregon ( SB 526 ) and New Jersey ( SB 690 ), respectively, enacted legislation to implement and maintain a voluntary statewide program to provide universal newborn nurse home visiting services to all families within the state to support healthy child development. strengthen families and provide parenting skills.    

During the 2018 legislative session New Hampshire passed  SB 592  that authorized the use of Temporary Assistance to Needy Families (TANF) funds to expand home visiting and child care services through family resource centers. Requires the development of evidence-based parental assistance programs aimed at reducing child maltreatment and improving parent-child interactions.

In 2016 Rhode Island lawmakers passed the Rhode Island Home Visiting Act ( HB 7034 ) that requires the Department of Health to coordinate the system of early childhood home visiting services; implement a statewide home visiting system that uses evidence-based models proven to improve child and family outcomes; and implement a system to identify and refer families before the child is born or as early after the birth of a child as possible.

In 2013 Texas lawmakers passed the Voluntary Home Visiting Program ( SB 426 ) for pregnant women and families with children under age 6. The bill also established the definitions of and funding for evidence-based and promising programs (75% and 25%, respectively).

Arkansas lawmakers passed  SB 491  (2013) that required the state to implement statewide, voluntary home visiting services to promote prenatal care and healthy births; to use at least 90% of funding toward evidence-based and promising practice models; and to develop protocols for sharing and reporting program data and a uniform contract for providers.

View a list of significant  enacted home visiting legislation from 2008-2021 . You can also visit NCSL’s early care and education database which contains introduced and enacted home visiting legislation for all fifty states and the District of Columbia. State officials face difficult decisions about how to use limited funding to support vulnerable children and families.

Key Questions to Consider

State officials face difficult decisions about how to use limited funding to support vulnerable children and families and how to ensure programs achieve desired results. Evidence-based home visiting programs have the potential to achieve important short- and long-term outcomes.

Several key policy areas are particularly appropriate for legislative consideration:

• Goal-Setting: What are they key outcomes a state seeks to achieve with its home visiting programs? Examples include improving maternal and child health, increasing school readiness and/or reducing child abuse and neglect.
• Evidence-based Home Visiting: Have funded programs demonstrated that they delivered high-quality services and measureable results? Does the state have the capacity to collect data and measure program outcomes? Is the system capable of linking data systems across public health, human services, and education to measure and track short and long-term outcomes?
• Accountability: Do home visiting programs report data on outcomes for families who participate in their programs? Do state and program officials use data to improve the quality and impact of services?
• Effective Governance and Coordination: Do state officials coordinate all their home visiting programs as well as connect them with other early childhood efforts such as preschool, child care, health and mental health?
• Sustainability:  Shifts in federal funding make it likely that states will have to maintain programs with state funding. Does the state have the capacity to maintain the program? Does the state have the information necessary to make difficult funding decisions to make sure limited resources are spent in the most effective way? 

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Two NCSL experts on housing and transportation join the podcast to discuss state efforts to promote transit-oriented development and why states have become so involved in housing legislation, an area long left to cities and counites. 

The Evolution of the Americans With Disabilities Act

The flexibility of the Americans With Disabilities Act of 1990 allows the civil rights law to evolve as more disabilities, such as long COVID-19, are recognized.

Social Media and Children 2024 Legislation

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Why Home Visiting?

The evidence base for home visiting, including its cost effectiveness, is strong and growing. Below are examples of home visiting's demonstrated impact on critical needs and why home visiting is a key service strategy for improving infant, maternal, and family outcomes.

Home visiting has measurable benefits.

By meeting families where they are, home visiting programs have demonstrated short- and long-term impacts on the health, safety, and school-readiness of children; maternal health; and family stability and financial security. Home visitors are able to meet with families in their home and provide culturally competent, individualized needs assessments and services. This results in measured improvements in the following outcomes:

Healthy Babies 

Home visitors work with expectant mothers to access prenatal care and engage in healthy behaviors during and after pregnancy. For example—

• Pregnant participants are more likely to access prenatal care and carry their babies to term.
• Home visiting promotes infant caregiving practices like breastfeeding, which has been associated with positive long-term outcomes related to cognitive development and child health.

Safe Homes and Nurturing Relationships 

Home visitors provide caregivers with knowledge and training to reduce the risk of unintended injuries. For example—

• Home visitors teach caregivers how to “baby proof” their home to prevent accidents that can lead to emergency room visits, disabilities, or even death.
• They also teach caregivers how to engage with children in positive, nurturing ways, thus reducing child maltreatment .

Optimal Early Learning and Long-Term Academic Achievement

Home visitors offer caregivers timely information about child development and the importance of early childhood in establishing the building blocks for life. For example—

• They help caregivers recognize the value of reading and other activities for early learning. This guidance translates to improvements in children’s early language and cognitive development, as well as academic achievements in grades 1 through 3 .

Supported Families

Home visitors make referrals and coordinate services for children and caregivers, including job training and education programs, early care and education services, and— if needed—mental health and domestic violence resources. Research shows that—

• Compared with their counterparts, caregivers enrolled in home visiting have higher monthly incomes, are more likely to be enrolled in school , and are more likely to be employed .

Home visiting is cost effective.

Studies have found a return on investment of $1.80 to $5.70 for every dollar spent on home visiting. This strong return on investment is consistent with established research on other types of early childhood interventions.

Learn more in our Primer and annual Yearbook .

Home Visiting

Stay up to date on the latest home visiting information.

What makes a virtual home visit a visit?

What can count as a home visit during covid.

Phone and video visits can count as a virtual home visit, while texting does not.

Some families have limited access to minutes for phone calls or data for video chats.  Texting can be a very effective way to maintain contact with families can be a powerful way to connect with families during this crisis.  Dr. Bruce Perry talks about the therapeutic value of texting, especially now.  It is important to note that a text conversation, even one of significant length, does not “count” as a home visit.  Despite this, we encourage sites to maintain contact and relationship with families, using whatever methods they find to be effective, whether or not they are able to “count”  these connections as home visits.

Video Visit: YES

Texting: no, phone visit: yes, all contacts are important, home visit or friendly chat what makes a virtual home visit a visit.

Healthy Families America sites are responding to new challenges related to the current COVID-19 pandemic with resilience and are making families a priority despite barriers to services.  Recognizing that families with young children still need support, sites and staff have adapted and are supporting families remotely, often through phone and video calls.  As programs adapt, many are wondering about whether they are still truly doing home visiting at this time.

The Healthy Families America Best Practice Standards are a great resource for sites seeking guidance in this area.  The following is included in the definition of Home Visit in the glossary:

Typically, home visits occur in the home, last a minimum of an hour and the child is present.   Extenuating circumstances may occur where visits take place outside the home, be of slightly shorter duration than an hour, or occur with the child not present. These may be counted as a home visit only if the overall goals of a home visit and some of the focus areas (listed below) have been addressed. Also, in very limited, special situations such as when severe weather, natural disaster or community safety advisory impedes the ability to conduct a home visit with a family, a virtual home visit, via phone (skype, FaceTime or other video technology preferred), can be counted when documented on a home visit record and the goals of a home visit are met including some of the focus areas (below).

Promotion of positive parent-child interaction/attachment:

• Development of healthy relationships with parent(s)
• Support of parental attachment to child(ren)
• Support of parent-child attachment
• Social-emotional relationship
• Support for parent role in promoting and guiding child development
• Parent-child play activities
• Support for parent-child goals, etc.

Promotion of healthy childhood growth & development:

• Child development milestones
• Child health & safety,
• Parenting skills (discipline, weaning, etc.)
• Access to health care (well-child check-ups, immunizations)
• School readiness
• Linkage to appropriate early intervention services

Enhancement of family functioning:

• Trust-building and relationship development
• Strength-based strategies to support family well-being and improved self-sufficiency
• Identifying parental capacity and building on it
• Family goals
• Building protective factors
• Assessment tools
• Coping & problem-solving skills
• Stress management & self-care
• Home management & life skills
• Linkage to appropriate community resources (e.g., food stamps, employment, education)
• Access to health care
• Reduction of challenging issues (e.g., substance abuse, domestic violence)
• Reduction of social isolation
• Crisis management

Supervisors and Family Support Specialists may want to review this definition and the focus areas to ensure that the work that they are doing fits the definition of a home visit.  Additional information about the definition of a home visit, and the use of HFA’s service levels in response to this crisis can be found on the full COVID-19 Guidance for HFA sites page.

What is it that makes a phone call or video chat a home visit?

As sites move forward with phone and video connections with families, they may find that it can be challenging to distinguish a remote home visit from other phone or video calls.  It is possible to have a relatively brief call with a parent and address some of the focus areas above.  Does that mean it was a home visit?

There are many similarities between a regular phone or video contact with a parent and a virtual home visit.  Both are friendly and comfortable, both involve checking in on the well being of the family, both create opportunities for social connection.  With so many similarities, home visitors and supervisors may be wondering how to make sure that what we are doing is home visiting.

How to make sure you are doing home visiting:

Schedule it and call it a visit- Make sure the family knows your intention to make this a visit.  Avoid unscheduled virtual visits when possible.  Scheduling visits allows the FSS and the family to come to agreement about a time when the parent is likely to be available for an extended call and it sets some expectations about what the call will be about.

Be prepared – Hold the family in your mind ahead of the visit. Think about what you know about them, about the child’s developmental status, about their goals and needs.  Be flexible and follow the family’s lead but have a plan in mind as you prepare to start your visit.

Act with intentionality – Bring awareness to your self and your intentions each time you speak or interact with a family during a virtual visit.  Many times, this is what is missing from an informal check-in phone call.  Consider use of Reflective Strategies and other elements of HFA’s trauma-informed approach.

Be fully present-   This can be challenging for HFA staff working from their homes and may require home visitors to be strategic about where they are in their own home during visits.  While on the call or connecting through video, create space in the same way you would do in person: allow for quiet moments, notice feelings, attune to the parent.  Be an active listener: when your mind wanders, use Mindful Self-Regulation to bring yourself back into connection with the family.

Observe Parent Child Interaction and “bring the baby into the call” – Have CHEERS in mind throughout the virtual visit as you observe the interaction between parent and child (keep your virtual tip sheet for CHEERS handy).  When conversation veers away from the child, be intentional about bringing the parent child relationship back into focus.  Ask parents “How is the baby reacting to all of this stress?” or “It sounds like you are feeling isolated- how do your feelings show up in his behaviors?”.  Invite parents to record videos throughout the week of their routines and play with the baby so they can share them with you!  Using video to reflect together on parent strengths is a powerful way to promote attachment and nurturing parenting.

Use your curriculum, community resources and screening tools – Things like sharing parenting curriculum and connecting families to needed community resources will feel familiar to the parents you work with and will help staff and parents distinguish a visit from a regular phone call.  Whenever possible, complete regularly used screening tools such as ASQ-3 and perinatal depression screenings with families during virtual visits.  Continuing “regular” home visit activities can bring a sense of normalcy for staff and families.

When in doubt, support the family- connections with families that don’t fit the definition of a home visit are absolutely valuable.  Families in communities everywhere are facing additional stressors related to increased isolation and economic challenges.  HFA sites should make every effort to connect regularly with families, using whatever modalities are available to the families (including phone calls, texts and even notes and letters).  Dr. Bruce Perry has shared that even 3 minutes of connection can reduce stress and regulate us.

A brief contact with a caring compassionate home visitor can make a difference for a family, whether it is “counted” as a home visit or not.

The predictability and comfort that a safe and healthy relationship with a Family Support Specialist offers to parents is more important than ever right now.  HFA encourages sites to be creative and flexible in serving families with young children in these unprecedented and uncertain times, and we are grateful for the efforts of staff in sites in communities everywhere for the difference they are making in the lives of parents and young children.

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What Makes Home Visiting an Effective Option?

Meeting in a family's home gives home visitors an opportunity to know families intimately. This sets the stage for close, trusting relationships — a critical element in any program designed to support children and their families.

By engaging in a warm, open relationship with parents, home visitors support a strong and secure relationship between the parent and child. Home visitors help parents become more sensitive and responsive to their child. The secure relationship between young children and their families creates the foundation for the development of a healthy brain. The home environment also allows home visitors to support the family in creating rich learning opportunities that build on the family's everyday routines. Home visitors support the family's efforts to provide a safe and healthy environment. Home visitors customize each visit, providing culturally and linguistically responsive services.

The home visiting model allows home visitors to provide services to families with at least one parent or guardian at home with the child or children. Families may choose this option because they want support both for their parenting and for their child's learning and development at home. For example, home visitors are available to families who live in rural communities and who otherwise would not be able to receive services. Home visitors bring services to families whose life circumstances might prevent them from participating in more structured settings or families challenged by transportation. Some programs can be flexible and offer services during nontraditional hours to families who work or go to school.

Every parent and home visitor bring his or her own beliefs, values, and assumptions about child rearing to their interactions with children. Home visiting can provide opportunities to integrate those beliefs and values into the work the home visitor and family do together.

In addition to establishing the relationship with each family during weekly home visits, home visitors provide opportunities to bring all families together twice a month. These group socializations reduce isolation, allow for shared experiences, and connect families to other staff in the program.

Resource Type: Article

National Centers: Early Childhood Development, Teaching and Learning

Program Option: Home-Based Option

Age Group: Infants and Toddlers

Last Updated: September 27, 2023

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Impacts of Home Visiting Programs on Young Children’s School Readiness

Grace Kelley, PhD, Erika Gaylor, PhD, Donna Spiker, PhD SRI International, Center for Education and Human Services, USA January 2022 , 2nd rev. ed.

Introduction

Home visiting programs are designed and implemented to support families in providing an environment that promotes the healthy growth and development of their children. Programs target their services to families and caregivers in order to improve child development, enhance school readiness, and promote positive parent-child interactions. Although programs differ in their approach, populations served and intended outcomes, high-quality home visiting programs can provide child development and family support services that reduce risk and increase protective factors.    Home visiting programs addressing school readiness are most effective when delivered at the community level, through a comprehensive early childhood system that includes the supports and services that ensure a continuum of care for all family members across the early years.  School readiness includes the readiness of the individual child, the school’s readiness to support children, and the ability of the family and community to support early child development, health, and well being. In addition to home visiting services, appropriate referrals to community services, including to preschool programs, offer a low-cost universal approach that increases the chances of early school success. This comprehensive approach to home visiting as a part of a broad early childhood system has been identified as an effective strategy to help close the gap in school readiness and child well-being associated with poverty and early childhood adversity. 1,2 

Home visitation is a type of service-delivery model that can be used to provide many different kinds of interventions to target participants. 3,4 Home visiting programs can vary widely in their goals, clients, providers, activities, schedules and administrative structure. They share some common elements, however. Home visiting programs provide structured services:

• in a home a  ;
• from a trained service provider;
• in order to alter the knowledge, beliefs and/or behaviour of children and caregivers or others in the caregiving environment, and to provide parenting support. 5

Home visits are often structured to provide consistency across participants, providers, and visits and to link program practices with intended outcomes. A visit protocol, a formal curriculum, an individualized service plan, and/or a specific theoretical framework can be the basis for activities that take place during home visits. Services are delivered in the living space of the participating family and within their ongoing daily routines and activities. The providers may be credentialed or certified professionals, paraprofessionals, or volunteers, but typically they have received some form of training in the methods and topical content of the program so that they are able to act as a source of expertise and support for caregivers. 6 Finally, home visiting programs are attempting to achieve some change on the part of participating families—in their understanding (beliefs about child-rearing, knowledge of child development), and/or actions (their manner of interacting with their child or structuring the environment, ability to provide healthy meals, engage in prenatal health care)—or on the part of the child (change in rate of development, health status, etc.). Home visiting also may be used as a way to provide case management, make referrals to existing community services including early intervention for those with delays and disabilities, or bring information to parents or caregivers to support their ability to provide a positive and healthy home environment for their children. 3,4,7

Data about the efficacy of home visiting programs have been accumulating over the past several decades. The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program launched in the U.S. in 2012 and its accompanying national Mother and Infant Home Visiting Program Evaluation (MIHOPE)  (which included 4 models - Early Head Start’s Home-based option, Healthy Families America, Nurse-Family Partnership, and Parents as Teachers), and the Home Visiting Evidence of Effectiveness (HoMVEE) reviews has contributed much new data about program features, implementation, and impacts. 8-12 More of the research has  used randomized controlled trial (RCT) or quasi-experimental designs, with multiple data sources and outcome measures, and longitudinal follow-up. These studies, along with older reviews,  and recent meta-analyses have generally found that home visiting programs produce a limited range of significant effects and that the effects produced are often small. 4,13,14 Nevertheless, a review of seven evidence-based home visiting models showed all seven to have at least one study with positive impacts on child development and school readiness outcomes. 13 Detailed analyses, however, sometimes reveal important program effects. For example, certain subsets of participants may experience long-term positive outcomes on specific variables. 15,16 These results and others suggest that in assessing the efficacy of home visiting programs, it is important to include measures of multiple child and family outcomes at various points in time and to collect enough information about participants to allow for an analysis of the program effects on various types of subgroups. Averaging effects across multiple studies is currently seen as an inadequate approach to understanding what works for whom. 17

Other difficulties when conducting or evaluating research in this area include ensuring the equivalency of the control and experimental groups in randomized controlled trials (RCTs), 18 controlling for participant attrition (which may affect the validity of findings by reducing group equivalence) and missed visits (which may affect validity by reducing program intensity), 19 documenting that the program was fully and accurately implemented, and determining whether the program’s theory of change logically connects program activities with intended outcomes.

Research Context

Because home visiting programs differ in their goals and content, research into their efficacy must be tailored to program-specific goals, practices, and participants. (See also chapter by Korfmacher and coll. ) In general, home visiting programs can be grouped into those seeking medical/physical health outcomes and those seeking parent-child interaction and child development outcomes. The target population may be identified at the level of the caregiver (e.g., teen mothers, low-income families) or the child (e.g., children with disabilities). Some programs may have broad and varied goals, such as improving prenatal and perinatal health, nutrition, safety, and parenting. Other programs may have narrower goals, such as reducing the incidence of child abuse and neglect. Program outcomes may focus on adults or on children; providers frequently cite multiple goals (e.g., improved child development, parent social-emotional support, parent education). 10  

In this chapter, we focus on the effectiveness of home visiting programs in promoting developmental, cognitive, and school readiness outcomes in children. The majority of home visiting services and research have focused on the period prenatally through 2 to 3 years and thus have not measured long-term impacts on school readiness and school achievement, but some of the more recent studies have done follow up into elementary school. However, most of the available studies have examined the impact on these outcomes indirectly through changes in parenting practices and precursors to successful school success (i.e., positive behaviour outcomes including self-regulation and attention).

Key Research Questions

Key research questions include the following:

• What are the short-term and long-term benefits experienced by participating families and their children relative to nonparticipating families, particularly for children’s school readiness skills and parenting to support child development?
• What factors influence participation and nonparticipation in the program?
• Do outcomes differ for different subgroups?

Research Results

Recent advances in program design, evaluation and funding have supported the implementation of home visiting as a practical intervention to improve the health, safety and education of children and families, mitigating the impact of poverty and adverse early childhood experiences. 3 Although program approaches and quality may vary, there are common positive effects found on parenting knowledge, beliefs, and/or behaviour and child cognitive, language, and social-emotional development. In order to achieve the intended outcomes, programs need to have clearly defined interventions and outcome measures, with a process to monitor quality. 20  Recent research has begun to focus on how measures to assess quality can be used to monitor programs and program improvement efforts. 21,22  

A review of seven home visiting program models across 16 studies conducted over a decade ago that included rigorous evaluation components and measured child development and school readiness outcomes concluded positive impacts on young children’s development and behaviour. Six models showed favourable effects on primary outcome measures (e.g., standardized measures of child development outcomes and reduction in behaviour problems). 23 Only studies with outcomes using direct observation, direct assessment, or administrative records were included. More recent reviews also show relatively small effects on developmental outcomes, but authors noted that “modest effect sizes in studies concerning developmental delay can result in important population-level effects given the high proportion of children in low-income families (nearly 20%) meeting criteria for early intervention services”. 3  A rigorous review conducted more recently in 2018 identified 21 home visiting models that met criteria of being an evidence-based model. 11 That review concluded that 12 of the models had evidence for favorable impacts on child development and school readiness outcomes. Recent and continuing research has been focusing on families with infants and toddlers living in poverty who are at higher risk for adverse early childhood experiences (ACES) that can lead to lifelong negative effects on physical and emotional health, and  educational success. 3,24 For example, the Adverse Childhood Experiences study indicates that traumatic experiences in early childhood can have lifelong impacts on physical and mental health. Data from this study indicate that children with 2 or more adverse experiences are more likely to repeat a grade. Home visiting programs can mitigate the effects of toxic stress, enhancing parenting skills and creating more positive early childhood experiences. 24,25 This research points to the importance of targeted home visiting programs to families who are experiencing stress and a recent meta-analysis of home visiting with such families indeed shows decreases in both social-emotional problems and stressful experiences. 26  

Problems identified in earlier reviews completed in the 1990s still plague this field, however, including that many models have limited rigorous research studies. In many of the studies described in previous and more recent reviews and meta-analyses, programs struggled to enroll, engage, and retain families. When program benefits are demonstrated, they usually accrued only to a subset of families originally enrolled in the programs, they rarely occurred for all of a program’s goals, and the benefits were often quite modest in magnitude. 27    The generally small effects on outcomes averaged across studies have led researchers to call for precision home visiting research to look at what works for whom. 17,28 (Also see chapter by Korfmacher and coll .).

Research into the implementation of home visiting programs has documented a common set of difficulties across programs in delivering services as intended. (See also Paulsell chapter ) First, target families may not accept initial enrollment into the program. Two studies that collected data on this aspect of implementation found that one-tenth to one-quarter of families declined invitations to participate in the home visiting program. 29,30 In another study, 20 percent of families that agreed to participate did not begin the program by receiving an initial visit. 19 Second, families may not receive the full number of planned visits. Evaluation of the Nurse Family Partnership model found that families received only half of the scheduled number of visits. 31 Evaluations of the Hawaii Healthy Start and the Parents as Teachers programs found that 42 percent and 38 percent to 56 percent of scheduled visits respectively were actually conducted. 29,32 Even when visits are conducted, the planned curriculum and visit activities may not be presented according to the program model, and families may not follow through with the activities outside of the home visit. 33,34 Recent research has begun to examine how technical assistance and training supports delivered to home visiting program supervisors and home visitors can improve model fidelity. 35 (See Paulsell chapter. )  In a review of home visiting research in the 1990s, Gomby, Culross, and Berman 27 found that between 20 percent and 67 percent of enrolled families left home visitation programs before the scheduled termination date. More recent studies continue to show a persistent problem with families leaving the program and not engaging in visits as intended by program developers. For example, in the MIHOPE evaluation, about 28% of families left MIHOPE home visiting programs within six months, while about 55% were still receiving about two visits per month after a year. 9 With only about half of families remaining after one year, many families were only receiving half of the intended number of visits. 8 Studies of Early Head Start also show that families with the greatest number of risk factors are the most likely to drop out which was also observed in the recent MIHOPE study. 36  

The assumed link between parent behaviour change and improved outcomes for children has received mixed research support. In other words, even when home visitation programs succeed in their goal of changing parent behaviour, these changes do not always appear to produce significantly better child outcomes in the short term, but in some cases appear to have an impact in the long term. 37,38  Examples include a study of the Home Instruction Program for Preschool Youngsters (HIPPY) model with low-income Latino families showing changes in parenting practices and better third-grade math achievement and positive impacts on both math and reading achievement in fifth grade. 39,40 Earlier evaluations of HIPPY found mixed results regarding program effectiveness. In some cohorts, program participants outperformed nonparticipants on measures of school adaptation and achievement through second grade, but these results were not replicated with other cohorts at other sites.

Both older and more recent reviews of home visiting programs described above included only studies using rigorous designs and measurement and a number of models show significant impacts on child development and school readiness outcomes. The Early Head Start model used a RCT design to study the impact of a mixed-model service delivery (i.e., center-based and home-visiting) on developmental outcomes at 2- and 3-year follow-up. Overall, there were small, but significant gains on cognitive development at 3 years, but not 2 years. More recent Early Head Start evaluations find positive impacts at ages 2 and 3 on cognition, language, attention, behaviour problems, and health and on maternal parenting, mental health, and employment outcomes, with better attention and approaches toward learning and fewer behavior problems at age 5 than the control group, but no differences on early school achievement. 41 Nonexperimental follow-up showed, however, that those children who went on to attend preschool after EHS did have better early school achievement. Studies of the Nurse Family Partnership model followed children to 6 years and found significant program effects on language and cognitive functioning as well as fewer behaviour problems in a RCT study. 42 In addition, evaluations of Healthy Families America have shown small, but favourable effects on young children’s development. 43,44  

Home visiting programs focusing on supporting parents’ abilities to promote children’s development explicitly appear to impact children’s development positively. One meta-analysis found that programs that taught parent responsiveness and parenting practices found better cognitive outcomes for children. 4 A meta-analysis of RCTs found that the most pronounced effect for parent-child interactions and maternal sensitivity can be improved in a shorter period of time, where effects of interventions on child development may take longer to emerge. 45 Several studies find longer-term impacts on parenting and associated positive effects for child outcomes. In a RCT of a New York Healthy Families America program, the program reduced first grade retention rates and doubled the number of first graders demonstrating early academic skills for those participating in the program. 2 And at least one recent longitudinal study of Parents as Teachers found positive school achievement and reduced disciplinary problems in early elementary school along with increased scores on parent measures of interactions, knowledge of child development, and family support. 46

Other studies were unable to document program impacts on parenting and home environment factors that are predictive of children’s early learning and development through control group designs. An evaluation of Hawaii’s Healthy Start program found no differences between experimental and control groups in maternal life course (attainment of educational and life goals), substance abuse, partner violence, depressive symptoms, the home as a learning environment, parent-child interaction, parental stress, and child developmental and health measures. 43 However, program participation was associated with a reduction in the number of child abuse cases.   

Other models show mixed impacts. A 1990’s RCT evaluation of the Parents as Teachers (PAT) program also failed to find differences between groups on measures of parenting knowledge and behaviour or child health and development. 32 Small positive differences were found for teen mothers and Latina mothers on some of these measures. However, another RCT study with the Parents as Teachers Born to Learn curriculum did find significant effects on cognitive development and mastery motivation at age 2 for the low socioeconomic families only. 47  Furthermore, a more recent RCT in Switzerland found that children receiving the PAT program had improved adaptive behavior and enhanced language skills at age 3 with the most high-risk children also having reductions in problem behaviours. 48 A randomized controlled trial of Family Check-Up demonstrated favourable impacts on at risk toddlers’ behaviour and positive parenting practices. 49

Randomized controlled trials (RCTs) have also shown that programs are more likely to have positive effects when targeted to the neediest subgroups in a population. For example, in the Nurse Family Partnership model children born to mothers with low psychological resources had better academic achievement in math and reading in first through sixth grade compared to their control peers (i.e., mothers without the intervention with similar characteristics). 50,51 (See also updated information in the Donelan-McCall & Olds chapter ).

The largest RCT of a comprehensive early intervention program for low-birth-weight, premature infants (birth to age three), the Infant Health and Development Program, included a home visiting component along with an educational centre-based program. 52 At age three, intervention group children had significantly better cognitive and behavioural outcomes and improved parent-child interactions. The positive outcomes were most pronounced in the poorest socioeconomic group of children and families and in those who participated in the intervention most fully. In follow-up studies, improvements in cognitive and behavioural development were also found at age 8 and 18 years for those in the heavier weight group. 53 The Chicago Child-Parent  Center Program also combined a structured preschool program with a home visitation component. This program found long-term differences between program participants and matched controls. Participating children had higher rates of high-school completion, lower rates of grade retention and special education placement, and a lower rate of juvenile arrests and impacts lasting into adulthood. 54-56 Another example showing more intensive programming has larger impacts is the Healthy Steps evaluation showing significantly better child language outcomes when the program was initiated prenatally through 24 months. 57 Early Head Start studies cited earlier also show that combining home visiting with later preschool attendance will yield better school readiness impacts than home visiting alone. Finally, there is a need to look at how home visiting could be beneficial for improving school outcomes when combined with a preschool program as in a recent study with families in Head Start programs that found reduced need for educational and mental health services in third grade. 58 These studies suggest that a more intensive intervention involving the child directly may be required for larger effects on school readiness to be seen with home visiting as one part of a more comprehensive approach.

Conclusions

Research on home visitation programs has not been able to show that these programs alone have a strong and consistent effect on participating children and families, but modest effects have been repeatedly reported for children’s early development and behaviour and parenting behaviours and discipline practices. Programs that are designed and implemented with greater rigour seem to provide better results. Home visitation programs also appear to offer greater benefits to certain subgroups of families, such as low-income, single, teen mothers.

These conclusions support recent attention to use of research designs that look at more differentiation of the program models and components to match the needs of the families aimed at improving child development and other outcomes. Precision home visiting uses research to identify what aspects of home visiting work for which families in what circumstance, resulting in programs that target interventions to the needs of particular families. 17  

Future research needs to examine the role of evidence-based home visiting within a more comprehensive system of services across the first five years of life.  It can be an initial cost -effective strategy to build trusting relationships and support early positive parenting that will improve children’s development over the long run because families will have increased likelihood of enrolling their children in preschool programs and use other needed child and family supports. 

Furthermore, efficacy research needs to include longitudinal designs and simultaneously include cost-benefit studies to demonstrate the long-term cost savings that will build public support for both early home visiting programs and a more comprehensive early childhood system. 

The recent Covid-19 pandemic brought to light the disparities and inequities of our early childhood service systems (as well as our later education systems). This state of affairs also has reinforced the benefit of more authentic participatory approaches in research and evaluation to identify what works and for whom.  Research and evaluation that includes various stakeholders, from those who are affected by an issue to those that fund the programs, promises to provide insights and perspectives that can strengthen the impact of home visiting programs. 

Implications

Programs that are successful with families at increased risk for poor child development outcomes tend to be programs that offer a comprehensive focus—targeting families’ multiple needs—and therefore may be more expensive to develop, implement, and maintain. In their current state of development, home visitation programs alone do not appear to represent the low-cost solution to child health and developmental problems that policymakers and the public have hoped for for decades. However, as the field continues to research more precision approaches that match program components to child and family needs, add the needed assistance and professional development supports to ensure model fidelity, and incorporate home visiting programs within a comprehensive early childhood system across the first five years of life, more consistent and positive results for participating target families are to be expected.

For high risk families with multiple challenges and levels of adversity, home visiting programs can serve to encourage families to take advantage of preschool programs available to them and their children and increase their participation in other family support programs during the preschool through 3 rd grade years 59 to further support school readiness outcomes. 

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Williams PG, Lerner MA, Council on Early Childhood, Council on School Health. School Readiness. Pediatrics . 2019;144(2):e20191766.

McKelvey LM, Whiteside-Mansell L, Conners-Burrow NA, Swindle T, Fitzgerald S. Assessing adverse experiences from infancy through early childhood in home visiting programs. Child Abuse and Neglect . 2016;51, 295–302.

van Assen AG, Knot-Dickscheit J, Post WJ, Grietens H. Home-visiting interventions for families with complex and multiple problems: A systematic review and meta-analysis of out-of-home placement and child outcomes. Children and Youth Services Review . 2020;114:104994.

Gomby DS, Culross PL, Behrman RE. Home visiting: Recent program evaluations-analysis and recommendations. Future Child . 1999;9(1):4-26.

Condon EM. Maternal, Infant, and Early Childhood Home Visiting: A Call for a Paradigm Shift in States' Approaches to Funding. Policy, Politics, & Nursing Practice . 2019;20(1):28-40.

Duggan AK, McFarlane EC, Windham AM, Rohde CA, Salkever DS, Fuddy L, Rosenberg LA, Buchbinder SB, Sia CC. Evaluations of Hawaii's Healthy Start Program. Future Child . 1999;9(1):66-90.

Olds DL, Henderson CR, Jr., Kitzman HJ, Eckenrode JJ, Cole RE, Tatelbaum RC. Prenatal and infancy home visitation by nurses: Recent findings. Future Child . 1999;9(1):44-65.

Korfmacher J, Kitzman H, Olds DL. Intervention processes as predictors of outcomes in a preventive home visitation program. Journal of Clinical Child & Adolescent Psychology . 1998;26(1):49-64.

Wagner MM, Clayton SL. The Parents as Teachers Program: Results from two demonstrations. Future Child. 1999;9(1):91-115.

Baker AJL, Piotrkowski CS, Brooks-Gunn J. The Home Instruction Program for Preschool Youngsters (HIPPY). Future Child . 1999;9(1):116-133.

Hebbeler KM, Gerlach-Downie SG. Inside the black box of home visiting: A qualitative analysis of why intended outcomes were not achieved. Early Childhood Research Quarterly . 2002;17:28-51.

Chen W-B, Spiker D, Wei X, Gaylor E, Schachner A, Hudson L. Who gets what? Describing the non‐supervisory training and supports received by home visiting staff members and its relationship with turnover. American Journal of Community Psychology . 2019;63:298-311.

Roggman L, Cook G, Peterson CA, Raikes H. Who drops out of Early Head Start home visiting programs? Early Education & Development . 2009;19:574-579.

Caughy MO, Huang K, Miller T, Genevro JL. The effects of the Healthy Steps for Young Children Program: Results from observations of parenting and child development. Early Childhood Research Quarterly . 2004;19(4):611-630.

Minkovitz CS, Strobino D, Mistry KB, Scharfstein DO, Grason H, Hou W, Ialongo N, Guyer B. Healthy steps for young children: Sustained results at 5.5 years. Pediatrics . 2007;120(3):658-668.

Nievar A, Brown AL, Nathans L, Chen Q, Martinez-Cantu V. Home visiting among inner-city families: Links to early academic achievement. Early Education and Development. 2018;29(8):1115-1128.

Nievar MA, Jacobson A, Chen Q, Johnson U, Dier S. Impact of HIPPY on home learning environments of Latino families. Early Childhood Research Quarterly. 2011;26:268-277.

Love JM, R. C-C, Raikes H, Brooks-Gunn J. What makes a difference: Early Head Start evaluation findings in a developmental context. Monographs of the Society for Research in Child Development . 2013;78((1):vii-viii):1-173.

Olds DL, Kitzman H, Cole R, Robinson J, Sidora K, Luckey DW, Henderson CR Jr, Hanks C, Bondy J, Holmberg J. Effects of nurse home-visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics . 2004;6(6):1550-1559.

Caldera D, Burrell L, Rodriguez K, Crowne SS, Rohde C, Duggan A. Impact of a statewide home visiting program on parenting and on child health and development. Child Abuse and Neglect. 2007;31(8):829-852.

Landsverk J, Carrillo T, Connelly CD, et al. Healthy Families San Diego clinical trial: Technical report. San Diego, CA: The Stuart Foundation, The California Wellness Foundation, State of California Department of Social Services: Office of Child Abuse Prevention; 2002.

Rayce SB, Rasmussen IS, Klest SK, al. e. Effects of parenting interventions for at-risk parents with infants: a systematic review and meta-analyses. BMJ Open 2017.

Lahti M, Evans CBR, Goodman G, Schmidt MC, LeCroy CW. Parents as Teachers (PAT) home-visiting intervention: A path to improved academic outcomes, school behavior, and parenting skills. Children and Youth Services Review. 2019;99:451-460.

Drotar D, Robinson J, Jeavons L, Lester Kirchner H. A randomized, controlled evaluation of early intervention: The Born to Learn curriculum. Child: Care, Health & Development. 2009;35(5):643-649.

Schaub S, Ramseier E, Neuhauser A, Burkhardt SCA, Lanfranchi A. Effects of home-based early intervention on child outcomes: A randomized controlled trial of Parents as Teachers in Switzerland. Early Childhood Research Quarterly. 2019;48:173-185.

Shaw DS, Dishion TJ, Supplee L, Gardner F, Arnds K. Randomized trial of a family-centered approach to the prevention of early conduct problems: 2-year effects of the family check-up in early childhood. Journal of Consulting and Clinical Psychology. 2006;74(1):1-9.

Olds DL, Kitzman H, Hanks C, Cole R, Anson E, Sidora-Arcoleo K, Luckey DW, Henderson CR Jr, Holmberg J, Tutt RA, Stevenson AJ, Bondy J. Effects of nurse home visiting on maternal and child functioning: Age-9 follow-up of a randomized trial. Pediatrics . 2007;120(4):e832-e845.

Kitzman HJ, Olds DL, Cole RE, Hanks CA, Anson EA, Arcoleo KJ, Luckey DW, Knudtson MD, Henderson CR Jr, Holmberg JR. Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatric Adolescent Medicine . 2010;164(5):412-418.

Gross RT, Spiker D, Haynes CW, eds. Helping low birth weight, premature babies . Stanford, CA: Stanford University Press; 1997.

Mallik S, Spiker D. Effective early intervention programs for low birth weight premature infants: Review of the Infant Health and Development Program (IHDP). In: Tremblay RE, Barr RG, Peters RD, eds. Encyclopedia on early childhood development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood Development; 2016.

Reynolds AJ, Temple JA, Robertson DL, Mann EA. Long-term effects of an early childhood intervention on educational achievement and juvenile arrest: A 15-year follow-up of low-income children in public schools. JAMA . 2001;285(18):2339-2346.

Reynolds AJ, Richardson BA, Hayakawa M, Englund MM, Ou S-R. Multi-site expansion of an early childhood intervention and school readiness. Pediatrics . 2016;138(1):1-11.

Reynolds AJ, Temple JA, Ou S-R, Arteaga IA, White BAB. School-based early childhood education and age-28 well-being: Effects by timing, dosage, and subgroups. Science . 2011;333(6040):36-364.

Johnston BD, Huebner CE, Anderson ML, Tyll LT, Thompson RS. Healthy steps in an integrated delivery system: Child and parent outcomes at 30 months. Archives of pediatrics & adolescent medicine. 2006;160(8):793-800.

Bierman KL, Welsh J, Heinrichs BS, Nix RL. Effect of preschool home visiting on school readiness and need for services in elementary school: A randomized clinical trial. JAMA Pediatrics . 2018;172(8):e181029-e181029.

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Note: a Services are brought to the family and settings may include the family’s home, or another mutually agreed upon location such as community center, park, or public library. More recently, due to the pandemic, programs have relied on virtual methods or conducting a home visit remotely via digital devices.   

How to cite this article:

Kelley G, Gaylor E, Spiker D. Impacts of Home Visiting Programs on Young Children’s School Readiness. In: Tremblay RE, Boivin M, Peters RDeV, eds. Spiker D, Gaylor E, topic eds. Encyclopedia on Early Childhood Development [online].  https://www.child-encyclopedia.com/home-visiting/according-experts/impacts-home-visiting-programs-young-childrens-school-readiness . Updated: January 2022. Accessed June 23, 2024.

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BRIAN K. UNWIN, MAJ, MC, USA, AND ANTHONY F. JERANT, M.D.

Am Fam Physician. 1999;60(5):1481-1488

See editorial on page 1337 .

With the advent of effective home health programs, an increasing proportion of medical care is being delivered in patients' homes. Since the time before World War II, direct physician involvement in home health care has been minimal. However, patient preferences and key changes in the health care system are now creating an increased need for physician-conducted home visits. To conduct home visits effectively, physicians must acquire fundamental and well-defined attitudes, knowledge and skills in addition to an inexpensive set of portable equipment. “INHOMESSS” (standing for: i mmobility, n utrition, h ousing, o thers, m edication, e xamination, s afety, s pirituality, s ervices) is an easily remembered mnemonic that provides a framework for the evaluation of a patient's functional status and home environment. Expanded use of the telephone and telemedicine technology may allow busy physicians to conduct time-efficient “virtual” house calls that complement and sometimes replace in-person visits.

In 1990, the American Medical Association (AMA) reported that approximately one half of primary care physicians polled in a national survey indicated that they performed home visits. 1 Although most of the physicians surveyed perceived home visits to be an important service, the majority performed only a few such visits per year. 1 Consistent with these self-reported behaviors are data indicating that only 0.88 percent of Medicare patients receive home visits from physicians. 2 In addition, the Health Care Financing Administration reported charges for only 1.6 million home visits in 1996, an extremely small percentage of the total number of annual physician-patient contacts in the United States. 3 These statistics stand in sharp contrast to medical practice before World War II, at which time about 40 percent of patient-physician encounters were in the home. 4

The low frequency of home visits by physicians is the result of many coincident factors, including deficits in physician compensation for these visits, time constraints, perceived limitations of technologic support, concerns about the risk of litigation, lack of physician training and exposure, and corporate and individual attitudinal biases. Physicians most likely to perform home visits are older generalists in solo practices. Health care providers who have long-established relationships with their patients are also more likely to utilize house calls. Rural practice setting, older patient age and need for terminal care correlate with an increased frequency of home visits. 5

Rationale for Home Visits

Studies suggest that home visits can lead to improved medical care through the discovery of unmet health care needs. 6 – 8 One study found that home assessment of elderly patients with relatively good health status and function resulted in the detection of an average of four new medical problems and up to eight new intervention recommendations per patient. 8 Major problems detected included impotence, gait and balance problems, immunization deficits and hypertension. Significantly, these problems had not been expected based on information obtained from outpatient clinic encounters. Other investigators have demonstrated the effectiveness of home visits in assessing unexpected problems in patient compliance with therapeutic regimens. 9 Finally, specific home-based interventions, such as adjusting the elderly patient's home environment to prevent falls, have also yielded health benefits. 10

Beyond the potential benefit of improved patient care, family physicians who conduct home visits report a higher level of practice satisfaction than those who do not offer this service. 5 Physicians with more positive attitudes about home visits are more likely to have conducted house calls during training. 11 Faculty mentorship and longitudinal exposure in training appear to be important for the development of positive attitudes toward home visits. 5 However, in 1994, only 66 of 123 medical schools offered specific instruction in the role and conduct of home visits. 12 Although 83 percent of the medical schools offered students the opportunity to participate in home visits, only three of the 123 schools required students to make five or more such visits. 12

Home Health Care Industry

Physician home visits have largely been supplanted by the extensive use of home health care services, a $22.3 billion industry that augments a medical system largely comprising facility-based health care providers. 13 The mean annual frequency of home health referrals was 43 per provider in a study published in 1992. 14

Family physicians have authorization and supervision responsibilities for a broad spectrum of skilled services that can be offered in the home. Such services include home health nursing, assistance from home health aides, and physical, occupational and speech therapy. Other health care support services are provided by medical supply companies, respiratory therapists, nutritionists, intravenous therapy services, hospice organizations, respite care services, Meals-on-Wheels volunteers and bereavement support staff. Family physicians also work extensively with social workers, who provide invaluable assistance in coordinating these services.

Thus, effective use of home care services has become a core competency for family physicians. In 1998, the AMA published the second edition of Medical Management of the Home Care Patient: Guidelines for Physicians . 15 The basic physician home care responsibilities outlined in that document are listed in Table 1 . 15

Recent data suggest that many physicians do not have the necessary knowledge and skills to perform these tasks effectively. For example, a survey found that 64 percent of physicians who had signed claims for care plans that were later disallowed had relied on a home health agency to prepare the plan of care, and 60 percent were not aware of the homebound requirement for home services. 16 Thus, increased physician education about home visits seems necessary if the responsibilities and obligations created by the expansion of home health care industry are to be fulfilled.

Types of Home Visits

The four major types of home visits are illness visits, visits to dying patients, home assessment visits and follow-up visits after hospitalization ( Table 2 ) . 17 , 18 The illness home visit involves an assessment of the patient and the provision of care in the setting of acute or chronic illness, often in coordination with one or more home health agencies. Emergency illness visits are infrequent and impractical for the typical office-based physician.

The dying patient home visit is made to provide care to the home-bound patient who has a terminal disease, usually in coordination with a hospice agency. The family physician can provide valuable medical and emotional support to family members before, during and after the death of a patient in the home environment. Family assistance involves evaluating the coping behaviors of survivors and assessing the medical, psychosocial, environmental and financial resources of the remaining family members.

The assessment home visit can also be described as an investigational visit during which the physician evaluates the role of the home environment in the patient's health status. An assessment visit is often made when a patient is suspected of poor compliance or has been making excessive use of health care resources. Medication use can be evaluated in the patient who is taking many drugs (polypharmacy) because of multiple medical problems. Evaluation of the home environment of the “at-risk” patient can reveal evidence of abuse, neglect or social isolation. Patients and family members who are trying to cope with chronic problems such as cognitive impairment or incontinence may particularly benefit from this evaluation. A joint assessment home visit facilitates coordination of the efforts of home health agencies and the physician. Finally, an assessment home visit is invaluable in assessing the need for nursing home placement of a frail elderly patient with uncertain social support.

The hospitalization follow-up home visit is useful when significant life changes have occurred. For example, a home visit after the birth of a new baby provides an excellent opportunity to discuss wellness and prevention issues and to address parental concerns. A home visit after a major illness or surgery can be useful in evaluating the coping behaviors of the patient and family members, as well as the effectiveness of the home health care plan.

Many aspects of physician home care have not been evaluated in the literature. However, it seems likely that properly focused and conducted home visits can enhance home health care delivery, improve patient satisfaction and strengthen the doctor-patient relationship.

Conducting the Home Visit

Equipment and planning.

Most equipment for a home visit can still be carried in the family physician's “black bag” ( Table 3 ) . Some additional items may be acquired from the patient's home.

One of the keys to conducting a successful home visit is to clarify the reason for the visit and carefully plan the agenda. Preplanning allows the physician to gather the necessary equipment and patient education materials before departure. The physician should have a map, the patient's telephone number and directions to the patient's home. The physician, patient and home care team should set a formal appointment time for the visit. Coordinating the house call to allow for the presence of key family members or significant others can enhance communication and satisfaction with care. Finally, confirming the appointment time with all involved parties before departure from the office is a common courtesy to the family as well as a wise time-management strategy.

HOME VISIT CHECKLIST: “INHOMESSS”

The INHOME mnemonic was devised to help family physicians remember the items to be assessed during the home visit directed at a patient's functional status and living environment. 19 This mnemonic can be expanded to “INHOMESSS,” which incorporates investigations of safety issues, spiritual health and home health agencies ( Table 4 ) . 19

Immobility . Evaluation of the patient's functional activities includes assessment of the activities of daily living (bathing, transfer, dressing, toileting, feeding, continence) and the instrumental activities of daily living (using the telephone, administering medications, paying bills, shopping for food, preparing meals, doing housework). The physician can ask the patient to demonstrate elements of the daily routine, such as getting out of bed, performing personal hygiene and leisure activities, and getting in and out of a car. Corrective interventions can be directed at any deficiencies noted. For example, modified pill-bottle caps can be obtained for the patient who has trouble opening medication containers because of a condition such as arthritis.

Nutrition . The physician should assess the patient's current state of nutrition, eating behaviors and food preferences. Permission to look in the refrigerator or cupboard can be obtained by asking open-ended but directed questions. For example, the physician might say, “We have been working hard on your diet to control your diabetes. Would you mind if I look in your refrigerator to see the types of foods you eat?” Improvements in product labeling allow the physician to assess serving sizes and the nutritional value of foods with relative ease. Healthy food preparation techniques can also be reviewed with the patient.

Home Environment . The patient's home environment should allow for privacy, social interaction and both spiritual and emotional comfort and safety. A safe neighborhood with close proximity to services is important for many older patients. The home may reflect pride in the patient's family and past accomplishments and reveal the patient's interests and hobbies. The physician should not make assumptions about social class or material wealth based on the patient's physical environment.

Other People . Having the patient's social support system present at the home visit clarifies the roles and concerns of family members. During routine visits, the physician can assess the availability of emergency help for the patient from family members and friends and can clarify specific issues, such as who is to serve as surrogate for the patient in the event of incapacitation. Discussion of a durable power of attorney and a living will may be more comfortably performed during the home visit than in the usual clinic visit. Evaluation of the caregiver's needs and risk of burnout is critically important.

Medications . To remedy or avoid polypharmacy, the physician must evaluate the type, amount and frequency of medications, and the organization and methods of medication delivery. An inventory of the patient's medicine cabinet can provide clues to previously unidentified drug-drug or drug-food interactions. A home medication review can also allow a direct estimate of patient compliance, uncover evidence of “doctor shopping” and identify the use or abuse of over-the-counter medications and herbal remedies.

Examination . The home visit should include a directed physical examination based on the needs of the patient and the physician's agenda. Practical, function-related examination techniques may include having the patient demonstrate getting on and off the toilet or in and out of the bathtub. The physician can have the patient demonstrate proper technique for the self-monitoring of blood glucose levels. In addition, the physician can weigh the patient and obtain a blood pressure measurement. In-person correlation of home and office measures provides useful information for future telephone and clinic contacts.

Safety . Common home safety issues are listed in Table 5 . The goal of the home safety assessment is to determine whether the patient's environment is comfortable and safe (no unreasonable risk of injury). To raise the subject, the physician should simply state the intention to identify and help modify potential safety hazards. For example, furniture placement or throw rugs may create problems for an elderly patient with gait instability, or the tap water may be so hot that the patient is at risk for scald injury. 20

Spiritual Health . If the home contains religious objects or reading materials, the physician can ask about the influence of spiritual beliefs on the patient's sense of physical and emotional health. This information may provide the impetus, as desired by the patient, for a discussion of spirituality as a coping and healing strategy.

Services . Having members of cooperating home health agencies present for the house call can enhance communication and cooperation among the physician, patient and agencies. Existing orders can be clarified, priorities for future care can be established and other perspectives on the care plan can be solicited. The patient's relationship with home health agency providers can also be assessed.

Elements of the INHOMESSS mnemonic may be used independently, based on the needs of the patient and the physician's agenda. For example, the physician may wish to focus on polypharmacy and safety in a patient with a recent fall, or to assess mobility and the extent of social support in a patient with newly diagnosed Alzheimer's disease. Figure 1 presents the major elements of the home visit in a checklist format that facilitates comprehensive assessment.

INTEGRATING HOME VISITS INTO CLINICAL PRACTICE

Lack of reimbursement and the busy pace of office practice are the reasons commonly cited for not conducting house calls. Poorly organized, sporadic home visits may indeed interfere with clinical practice. Therefore, it is important to develop a systematic approach for planning home visits. 21

Most practices will benefit from using home visits with patients who have difficulty accessing outpatient facilities because of sensory impairment, immobility or transportation problems. Removing such logistically difficult appointments from the clinic schedule and performing them in the home setting may actually enhance clinic functioning. Clustering home visits by geographic location and within defined blocks of time may also improve efficiency. Finally, nurse practitioners and physician assistants can conduct visits as part of a home health care delivery team.

The 1999 Current Procedural Terminology codes and corresponding Medicare reimbursement rates for common types of home visits are listed in Table 6 . 22

Telephone Calls and Telemedicine

Proactive telephone calls are an underutilized method of conducting highly focused and time-efficient “virtual” home visits. 23 Provider-initiated telephone calls can be used to reassure family members after a patient has had an acute illness or has been hospitalized. 23 These calls can also be helpful in reinforcing patient compliance with new medications, following patients with chronic diseases and reducing inappropriate use of primary care clinic or office services. 24

Telemedicine is the use of communication technologies, such as two-way video-conferencing, to provide patient care across distances. A variety of institutions are exploring these technologies as methods of delivering health care in the home. 25 , 26

Final Comment

As fewer patients are admitted to hospitals and hospital stays become ever briefer, the medical complexity of home care will increase, as will the demand for both in-person and “virtual” physician home visits. Physicians interested in obtaining additional information about home care provision can contact the American Academy of Home Care Physicians (P.O. Box 1037, Edgewood, MD 21040; Web address: http://www.aahcp.org/ ).

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How hard is it to buy a home right now? The new NBC News Home Buyer Index measures the market

Why is it so hard to buy a home? Prices have far outpaced middle-class incomes. Mortgage rates are above 7% for the first time since 2002. And 3 out of 10 homes are sold above listing price.

But none of those factors fully captures the variety of challenges buyers nationwide face in the current market. The conditions on the ground can vary widely across state and even county lines.

To better capture how housing market conditions shift at the local level — as comprehensively and in as close to real time as possible —  we’re introducing a new monthly gauge: the NBC News Home Buyer Index.

The Home Buyer Index, which NBC News developed with the guidance of a real estate industry analyst, a bank economist from the Federal Reserve Bank of Atlanta and other experts, is a number on a scale of 0 to 100 representing the difficulty a potential buyer faces trying to buy a home. The higher the index value, the higher the difficulty. 

A low index value, of 10 for example, suggests better purchasing conditions for a buyer — low interest rates, ample homes for sale. Chambers County, Texas, near Houston, is one of the 50 least difficult places to buy in in the country as of May, with low scores on scarcity, cost and competition. 

A high value closer to 90 suggests extremely tough conditions, which can result from intense bidding, high insurance costs or steep jumps in home prices relative to income. Prices are soaring in Coconino County, Arizona, making it one of the 25 most difficult counties to buy a home in as of May. Five years ago it was ranked 300, but the median sale price has increased 81%, nearly twice the national figure.

The index measures difficulty nationwide, as well as on the county level, in the counties where there’s enough homebuying data to make informed assessments.

The national index, presented below, captures the big-picture market and economic conditions that affect homebuying across the U.S.

This index consists of four factors: 

• Cost: How much a home costs relative to incomes and inflation — as well as how related expenses, such as insurance costs, are changing. 
• Competition: How many people are vying for a home — and how aggressive the demand is. This is measured through observations including the percentage of homes sold above list price and the number that went under contract within two weeks of being listed. 
• Scarcity: The number of homes that are on the market — and how many more are expected to enter the market in the coming month.
• Economic instability: Market volatility, unemployment and interest rates — reflecting the broader climate in which home shoppers are weighing their decisions. 

For May, the overall Home Buyer Index nationally was 82.2, down slightly from April and nearly 6 points lower than it was this time one year ago.

Improvements in market competitiveness and the broader economy have eased conditions somewhat within the past year. However, high costs and continued housing shortages have kept overall homebuying difficulty high.

The index updates monthly on the Thursday after the third Saturday of the month. The next update is July 25.

Methodology

The NBC News Home Buyer Index combines real estate and financial data with forecasting techniques to assess market conditions from a buyer’s perspective. 

The perspective is framed as a combination of factors shaping a buyer’s experience of the housing market: cost, scarcity, competition and overall economic instability. 

Each factor is measured by a monthly analysis that takes the following approach: 

• Data is collected from sources including Redfin , the Census Bureau, the Bureau of Labor Statistics and the Federal Reserve Bank of St. Louis. 
• The data is then cleaned, filtered for quality and transformed to address properties that are needed for statistical analysis, including stationarity and seasonality. 
• The data is then brought to a monthly frequency where appropriate, among other steps. 
• The data is scaled to make component variables comparable.
• Finally, the data is combined to generate a single, aggregate measure of homebuyer difficulty. The final output is a single value between 0 and 100, where 0 represents the least difficult market possible and 100 is the most difficult. 

NBC News worked with real estate industry experts to refine the data that would best answer the question ‘How difficult is it to buy a home in the U.S.?’ The experts came from the Federal Reserve Bank of Atlanta, and Redfin.

Caveats to this analysis include variation in data availability at the county level, which is generally tied to market size, which correlates with regional characteristics such as population count. Therefore, systematic gaps affect low-population counties, leading them to be underrepresented.

In addition, recent index values may shift slightly in future releases as final data comes in.

Jasmine Cui is a reporter for NBC News.

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• 17 Jun. 2024 -
• Last updated: 17 Jun. 2024 23:24

NATO collects defence expenditure data from Allies and publishes it on a regular basis. Each Ally’s Ministry of Defence reports current and estimated future defence expenditure according to an agreed definition. The amounts represent payments by a national government that have been or will be made during the course of the fiscal year to meet the needs of its armed forces, those of Allies or of the Alliance. In the figures and tables that follow, NATO also uses economic and demographic information available from the Directorate-General for Economic and Financial Affairs of the European Commission (DG ECFIN) and the Organisation for Economic Co-operation and Development (OECD).

In view of differences between these sources and national GDP forecasts, and also the definition of NATO defence expenditure and national definitions, the figures shown in this report may considerably diverge from those that are referenced by media, published by national authorities or given in national budgets. Equipment expenditure includes expenditure on major equipment as well as on research and development devoted to major equipment. Personnel expenditure includes pensions paid to retirees.

The cut-off date for information used in this report was 12 June 2024. Figures for 2023 and 2024 are estimates.

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Russian warships leave Havana’s port after a 5-day visit to Cuba

A fleet of Russian warships left a port in Cuba on Monday.

The nuclear-powered Russian submarine Kazan leaves the port of Havana, Cuba, Monday, June 17, 2024. A fleet of Russian warships arrived in Cuban waters last week ahead of planned military exercises in the Caribbean. (AP Photo/Ariel Ley)

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The Russian Navy’s Admiral Gorshkov frigate leaves the port of Havana, Cuba, Monday, June 17, 2024. A fleet of Russian warships arrived in Cuban waters last week ahead of planned military exercises in the Caribbean. (AP Photo/Ariel Ley)

HAVANA (AP) — A fleet of Russian warships, including a nuclear-powered submarine , left Havana’s port on Monday after a five-day visit to Cuba following planned military drills in the Atlantic Ocean. The exercise has been seen by some as a show of strength by Moscow against the backdrop of tensions as U.S. and other Western nations support Kyiv in Russia’s war on Ukraine.

The submarine, a frigate, an oil tanker and a rescue tug slowly departed from the port on Monday morning.

It’s unclear what the fleet’s next destination is or where it will dock next in the Caribbean, although U.S. officials said days ago that the vessels could possibly also stop in Venezuela.

Officials with the Biden administration said last week that they were monitoring the vessels and confirmed that they did not pose a threat to the region or indicate a transfer of missiles. Still, the United States docked a submarine , the USS Helena, at its Guantanamo Bay Naval Base in Cuba.

The American naval base, located in the southeastern part of the island about 1,000 kilometers (625 miles) from the capital of Havana, is considered by the Cuban government to be illegally occupied territory.

The nuclear-powered Russian submarine Kazan leaves the port of Havana, Cuba, Monday, June 17, 2024. (AP Photo/Ariel Ley)

Last week, the Russian ships arrived at the port after the Russian Ministry of Defense reported that the fleet successfully conducted military drills in the Atlantic Ocean, simulating a missile attack on targets that could be more than 600 kilometers (375 miles) away.

The fleet, made up of the frigate “Gorshkov,” the nuclear-powered submarine “Kazan,” the tanker “Pashin,” and the tug “Nikolai Chiker,” was received in Havana with a 21-gun salute.

Cuban President Miguel Díaz-Canel visited the frigate on Saturday and interacted with the sailors, according to a post by the president on the social media platform X, formerly known as Twitter.

Meanwhile, Cuban Deputy Foreign Minister Carlos Fernández de Cossío rejected the presence of the American submarine at Guantanamo Base, stating it was unwelcome and uninvited.

A State Department spokesperson said last week that Russia’s port calls in Cuba are “routine naval visits” and do not pose any danger .

On Thursday, a day after arriving, hundreds of people lined up to visit the frigate. The ship was also open to the public on Saturday, which is a common practice when vessels arrive at the port.

Canada’s navy patrol boat Margaret Brooke entered the Havana harbor on Friday.