MAINE MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING EXPANSION PROJECT ABSTRACT

Transcription

1 MAINE MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING EXPANSION PROJECT ABSTRACT Applicant Name: Sheryl Peavey, Director, Early Childhood Initiative, Maine DHHS Address: Office of Child & Family Services, SHS #11, 2 Anthony Avenue, Augusta, ME Contact Phone Numbers: Phone: (207) ; Fax (207) Address: sheryl.peavey@maine.gov Web Address: The Maine Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Expansion Project represents the culmination of years of state and local work towards an accountable, evidence based, data-driven and family-centered home visiting continuum of services. This project will increase direct service capacity, incent community collaboration, amplify program evaluation, and implement purposeful sustainability strategies in a unique, comprehensive and powerful way to benefit Maine s vulnerable families in at-risk communities. Maine's 2010 Home Visiting Needs Assessment, including statewide stakeholder meetings and interviews, pointed to the need for increased coordination not only among different home visiting and home-based programs, but also among with the broader early childhood services system. In particular, there are gaps around serving families with substance abuse and mental health needs, and the data show that needs are increasing: rates of drug-affected babies in Maine have nearly tripled in recent years, rates for opiate treatment admissions have consistently topped other states, and our children experience the highest poverty rates in New England. Serving vulnerable families in our rural state and tribal nations is further complicated by challenges with transportation, travel time, and insufficient workforce skilled in engaging isolated families. The needs assessment also examined service capacity, and Maine has in place a core program upon which to responsibly expand home visiting services and more effectively coordinate state and local resources. The Maine Families Home Visiting program is a network of state-funded programs in every county delivering the evidence-based Parents as Teachers model since Its performance based contracts are guided by rigorous standards of practice and continuous quality improvement. With federal funding, Maine is aligning its existing evaluation and webbased data collection with the federal MIECHV benchmarks and providing the Touchpoints and other specialized multi-disciplinary training so that community partners can more consistently and respectfully serve the families facing substance abuse, co-occurring disorders, and domestic violence issues. The expanded Maine Families program will be integrated into this already existing system and will be evaluated through a partnership with the University of Southern Maine and its epidemiology team. Most importantly, to address sustainability, this project leverages the financial, intellectual and social resources already at play in Maine: a Legislature that diversified home visiting funding in recognition of its centrality within the early childhood system, national experts offering technical assistance for state Medicaid improvements, a history of accountability and finding cost efficiencies, and the successful social marketing strategies of the state s early childhood advisory council, the Maine Children s Growth Council. The thoughtful combination of direct service delivery, community collaboration, evaluation, and sustainability strategies on top of an already proven structure and network offer a compelling model for successful home visiting in all states. Maine MIECHV Expansion Project Abstract HRSA

2 State of Maine Maternal, Infant and Early Childhood Home Visiting (MIECHV) Expansion Project Proposal Narrative TABLE of CONTENTS Introduction...1 Needs Assessment...6 Methodology...9 Work Plan...19 Resolution of Challenges...33 Evaluation and Technical Support Capacity...34 Organizational Information...43 INTRODUCTION Project Purpose Maine s Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Expansion will serve to strengthen, enhance, and expand the state s existing statewide home visiting program, Maine Families, as part of a comprehensive early childhood system. While Maine already has a solid statewide network of Maine Families sites implementing Parents as Teachers (PAT) and following rigorous standards of practice, the state needs additional resources in order to: 1. Reach greater numbers of eligible families (including: those with needs related to substance abuse, mental health, co-occurring disorders, and/or family violence, those in rural areas, and those living in tribal communities). 2. Better serve vulnerable families through enhancement of the PAT program that includes provision of more frequent visits to families who need them; additional training and clinical supervision for home visitors to better prepare them for engaging and assisting families with substance abuse, mental health, co-occurring, and/or family violence issues; and strengthening of coordination and collaboration among local service providers to better serve families in need. For the purposes of this application, these collective efforts are termed the Maine Families Linking Initiative. 3. Increase capacity of all Maine Families sites to participate in data collection and reporting according to federal Benchmark requirements. 4. Strengthen state-level systems collaboration for a coordinated continuum of early childhood services, with home visiting as a sustainable and integral component of that system. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

3 Maine s history of home visiting in a comprehensive early childhood system Maine s proposed program expansion will build on an already existing network of statewide home visiting services. Home visiting began in Maine at the grassroots level in the late 1980 s, resulting in a diverse array of home visiting programs throughout the state. In 1997, the state used General Funds to initiate a pilot home visiting program in six counties. In 2000, the Maine Home Visiting Program was launched so that eligible families in every county could have universal access to home visiting. Initially, communities could choose from one of three models: Healthy Families America, Parents as Teachers, and a homegrown model, Parents are Teachers, Too. In 2007, under a new state administrator, home visiting sites examined the literature, came to consensus on best practices, and, with the state, established shared Standards of Practice. The Touchpoints approach was also adopted, providing a focus on reflective practice and reflective supervision; with the blessing of the Brazelton Touchpoints Center, Maine established a state Touchpoints Coordinator and Home Visiting Training Team. In 2008, Maine selected Parents as Teachers (PAT) as its statewide curriculum. The Maine PAT training team was developed and all staff became Certified Parent Educators. At that time, the state chose to use a single statewide model in order to increase commonality and consistency among program sites and provide a singular basis for performance and quality assurance. Use of a consistent curriculum and parent materials was especially important as families frequently moved from one county to another. PAT was selected because it was a national model that most program sites were already partially invested in. Maine providers preferred PAT because it was regarded as a more strength-based and respectful approach than other models and was a fit with Maine communities and programs' philosophy. In 2010, the state re-branded the network of programs as Maine Families. Today, Maine Families continues to be the core of statewide home visiting services, with trained staff in every county reaching 2,500 families per year. Maine Families sites follow rigorous Standards of Practice that include fidelity to PAT and the use of the Touchpoints approach in reflective practice and reflective supervision. Quality assurance and technical assistance are provided by an in-state team led by the Maine Families Statewide Coordinator. All Maine Families programs share a single web-based data collection system that allows for statewide evaluation and continuous quality improvement. These strategies help to ensure model fidelity, consistency, and coordination of home visiting statewide. The proposed enhanced program will be integrated into this already existing system and will build on our highly trained, highly skilled Maine Families workforce. Maine Families sites work in close collaboration with other home-based programs in the state. The Maine CDC Public Health Nursing program (and its grantees, Community Health Nursing) serves approximately 4,600 families per year statewide. On a local level, Maine Families and home-based nursing programs work closely together to ensure that family needs are met. Because the nurses work with families only for the duration of specific health needs (typically under 6 months), they frequently refer families to the Maine Families program. Maine also has Early Head Start home visiting programs in 10 of 16 counties, serving just under 500 families per year. The Maine Families program operates out of the Department of Health and Human Services Office of Child and Family Services (OCFS), through a collaborative agreement with Maine Center for Disease Control s (CDC) Division of Maternal and Child Health. This administrative structure further helps to promote collaboration and coordination of services. The Maine Families program is administered by Sheryl Peavey, Director of the Early Childhood Initiative within the Office of Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

4 Child and Family Services. Ms. Peavey has guided the development of the Early Childhood Systems Plan since the inception of the Maternal and Child Health Bureau Early Childhood Comprehensive Systems (ECCS) grant in Maine s broader early childhood systems efforts through the ECCS grant have included quality home visiting services as a core component of the state plan since its inception. As the Public Health-Child Welfare Liaison, Ms. Peavey leads the home visiting work and other child maltreatment prevention efforts as a representative of both the Maine OCFS and the Maine CDC. Ms. Peavey is also responsible for staffing and coordination of the Maine Children s Growth Council, which is the state s Early Childhood Advisory Council. Maine s home visiting providers, together with OCFS, the Maine CDC, and the Maine Children s Trust Fund, have been working collaboratively to take steps toward developing a more coordinated state system. Stakeholder meetings have included Maine Families home visiting program managers, Public Health and Community Health Nursing, Early Head Start and Head Start Directors, child protective caseworkers, child welfare leadership, state agency substance abuse representatives and community providers, advocates and others. Open communication has been a hallmark of the early childhood systems work and is key to sustainability, so all relevant home visiting systems documents are available online at the Maine Children s Growth Council website ( As history demonstrates, Maine is committed to implementation of home visiting as part of a comprehensive early childhood system one that emphasizes evidence-based practice, quality assurance, and optimal coordination of services. Maine proposes to use the MIECHV Expansion grant to assist the state in furthering its systems-level work as well as enhancing and expanding direct services provided by Maine Families. State Commitment to Home Visiting As described above, there have been steps taken by the state for more than a decade to have a cohesive and accountable network of home visiting programs in Maine. Until recently, these were supported financially using special revenue from the tobacco settlement, known in Maine as the Fund for Healthy Maine (FHM). Home visiting survived despite annual budget threats from one state agency manager who did not value prevention as a means for social and economic savings for Maine. In 2011, during the transition to a new administration, this manager set in motion a proposal to eliminate all funding for home visiting in the Governor s budget, a move that was resoundingly defeated with bipartisan support in the Legislature and actually propelled the Maine Families program into the spotlight as a model for accountable and effective evidence based programming. The local, state, and even national advocacy for the Maine Families program during the legislative session was possible because of years of early childhood systems work in this state: the maturing social marketing campaign of the Maine Children s Growth Council that heightened public awareness of the architecture of the developing brain; the powerful print/media presence of Maine s chapters of three national, reputable organizations (Fight Crime: Invest in Kids, America s Edge, and Mission Ready); the program s solid evaluation data providing current and historical evidence of improved child outcomes with cost-efficiency; and national and local testimony that engaged legislators and the Executive Branch alike. As a result, Maine Families Home Visiting emerged as a core state investment in primary prevention. Rather than lose all of its funding, the entire $4.6 million was restored, but restored using diversified funding to represent the cross-systems influence of home visiting. Home visiting is now Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

5 supported by state general funds from the Child Care Development Fund (CCDF) match account acknowledging its part in the state CCDF plan, state general funds from foster care, and the Fund for Healthy Maine special revenue. This unprecedented restoration of funding is joined by other state actions demonstrating a solid commitment to home visiting: 1. Governor LePage signed LD 1504, a Resolve to Ensure a Strong Start for Maine's Infants and Toddlers by Extending the Reach of High-quality Home Visitation that aligns state and federal intentions for home visiting and addresses sustainability in state statute; 2. The DHHS Commissioner s Grants Review Committee has stipulated quarterly reports on the progress of implementing the state home visiting plan, demonstrating an interest and level of oversight for home visiting absent in the past; 3. The Maine Children s Growth Council Communications Committee will be focusing its public policy campaign on home visiting in the upcoming biennium, capitalizing on solid partnerships with Fight Crime; America s Edge, and Mission Ready as well as the media generated from the state s MCH New Motherhood Initiative demonstration grant; and 4. The former Director of OCFS has been replaced with new leadership with a track record of collaboration, accountability, and a strong desire to ensure that Maine s youngest children start their lives in healthy, safe, and nurturing communities. Please see our section on Commitment and Sustainability (pp , 32, 49) for more detail about Maine s plans for ongoing high-quality home visiting services. The Problem, The Intervention, The Project Benefit The Problem: While Maine already has a solid statewide network of Maine Families sites implementing Parents as Teachers and following rigorous standards of practice, the state has identified the following needs or gaps: 1. Many eligible families are not being reached (including those with needs related to substance abuse, mental health, co-occurring disorders, and/or family violence, those in rural areas, and those living in tribal communities). 2. Many participants need enhanced services linking them to additional supports. This need is especially urgent for families who are facing challenges with substance abuse, mental health, co-occurring disorders, and/or family violence. 3. Maine Families sites statewide are not yet fully prepared to collect and report according to federal Benchmark requirements. 4. Maine needs increased state-level systems collaboration to build a coordinated continuum of early childhood services with home visiting as a sustainable and integral component. The proposed intervention: To expand and enhance implementation of Maine Families home visiting program by: 1. Increasing Maine Families staffing (trained home visitors) to reach greater numbers of eligible families (including: those with needs related to substance abuse, mental health, cooccurring, and/or family violence, those in rural areas, and those living in tribal communities) 2. Enhancing implementation of PAT model program by implementing a statewide Linking Initiative that includes the following elements: a) Increasing Maine Families staffing and travel budget to provide greater frequency of visits to families who need them, Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

6 b) Providing increased training and clinical supervision for Maine Families home visitors to better prepare them for engaging and assisting families with substance abuse, mental health, co-occurring, and/or family violence issues, c) Offering assistance from consultant/facilitator, supporting local staff time, and supporting shared training opportunities to strengthen local linking efforts to build coordination and collaboration among service providers. 3. Working with the evaluator to develop and maintain statewide and local level data collection, reporting, and analysis according to federal benchmark requirements. 4. Working with the consultant/facilitator and supporting state staff time to build a coordinated continuum of early childhood services statewide while strengthening the long-term sustainability of Maine s home visiting system. The expected benefit: As a result 1. More eligible families will be reached with home visiting. 2. Vulnerable families will be better linked to needed services: a. More families will be able to receive frequency of visits that match their needs. b. Home visiting staff will be better prepared to engage and assist families with substance abuse, mental health, co-occurring, and/or family violence issues. c. Stronger coordination and collaboration among local service providers will ensure that more families receive needed services. 3. Statewide and local level data collection, reporting, and analysis will align with federal Benchmark requirements. 4. Maine will have a more coordinated continuum of early childhood services that includes long-term sustainability of Maine s home visiting system. Maine anticipates that the above results will contribute to measurable health and wellness outcomes for Maine Families participants, including progress in the MIECHV Benchmark categories of Improved Maternal and Newborn Health; Reduction of Child Injuries, Child Abuse, Neglect, or Maltreatment; Improved School Readiness and Achievement (including improvements in Positive Parenting Practices); and Reduction of Domestic Violence. Further, as a longstanding contributor to the State s Maternal and Child Health Block Grant application, the data from this program can help drive state policy and funding changes in a more informed way. Priority elements to be addressed Maine has selected Priority Element 7: To reach families in rural or frontier areas through home visiting programs because it encapsulates the public health and systems improvement priorities that are outlined in our State Plan. The public health challenges facing Maine are largely related to its rural nature. In our 2010 Needs Assessment, home visiting stakeholders in each of Maine s 16 counties reported challenges around engaging isolated, rural families. How this proposal builds on Maine s existing MIECHV program Using its Needs Assessment data, Maine identified two locations as its most at-risk counties as Tier 1 sites, and directed the first wave of MIECHV funding to bolster the direct service capacity and infrastructure for those regions. This proposal will take those changes in a responsible and thoughtful statewide expansion and assist Maine in attaining its goal of reaching more families in rural areas by providing resources to enhance services, increase staffing and travel resources, and increase local collaboration among early childhood providers so that more rural families can be reached, and isolated families can be better engaged. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

7 The Logic Model for Expansion (as related to the existing MIECHV program) Maine s current home visiting program consists of a statewide Maine Families network that is well-established in using the Parents as Teachers model. Our MIECHV Updated State Plan selected two communities, Penquis (Pistataquis/Penobscot Counties) and Washington County, as pilot sites for enhanced Maine Families programming that includes the Linking elements listed above. Maine s proposed MIECHV Expansion will use lessons learned from the pilot communities to implement these enhancements statewide involving state-level partners as well as every local Maine Families site and their local partners to create lasting, systems-level change. Our MIECHV Expansion logic model is provided in Attachment 1. NEEDS ASSESSMENT Selected Communities Maine has selected the entire state as its community to serve with expanded and enhanced implementation of the Maine Families home visiting program. Our 2010 Needs Assessment and 2011 Updated State Plan provided a tiered ranking of Maine s 16 counties based on both risk and readiness; this prioritization was conducted in case of insufficient resources to support enhanced programming statewide. In the event of funding levels that could adequately support statewide implementation, Maine s intent has always been to enhance programming in each of its 16 counties. With only 13,000 to 14,000 babies born across the state every year, and a history of successful statewide implementation of Parents as Teachers, Maine has a unique capacity to implement the proposed expansion on statewide level. In addition, all 16 counties have demonstrated need and readiness to implement the proposed program. Demographic overview o An extremely rural state, Maine has a population of 1.33 million people spread across more than 33,000 square miles roughly the size of all other five New England states put together. o According to 2010 Census data, Maine s population is 95.2% White, 1.2% Black/African American, 1% Asian, 1.3% Latino, 1.6% Multiracial..3% Other, and.6% Native American. o Higher racial diversity can be found in the southern part of the state. Maine s largest city, Portland, has a population of only 66,194, of whom 85% are White. o More than 8,500 Mainers identify as Native American, making up.6% of the state s population and living primarily in the northern part of the state. Maine is home to five American Indian tribal communities: Penobscot Nation, Mi kmaq, Houlton Band of Maliseet, Passamaquoddy at Indian Township, and Passamaquoddy at Sipiyak. Community Needs Maine's 2010 Home Visiting Needs Assessment process was followed by two statewide stakeholder meetings and a series of in-depth one-on-one interviews with stakeholders across the state including local and state-level representatives from Maine Families, Public Health Nursing, Community Health Nursing, and Early Head Start home visiting programs. These meetings clearly pointed to the need for increased coordination not only among different home visiting programs, but also between home visiting and the broader early childhood services structure. In particular, participants emphasized a need to address existing gaps around serving families with substance abuse and mental health needs. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

8 Another common theme was the need to better serve families in rural areas. In our 2010 Needs Assessment and follow-up process, home visiting stakeholders in each of Maine s 16 counties reported challenges surrounding transportation, travel time, and engaging isolated, rural families. Available data points to statewide need in the following priority risk areas: Children in Poverty: Maine has the highest poverty rates in New England. 46,350 Maine children (17.5% of children under age 18, and 21.4% of children under age 5) were living in poverty in Domestic Assault: Statewide, 5,311 domestic assaults were reported to police in 2008 an average rate of 4 reported domestic assaults per 1,000 people. 2 Substantiated Child Maltreatment and Neglect: 3,703 Maine children ages 0-17 were victims of substantiated child maltreatment in 2009, a rate of 13.4 per 1,000 children. 2,654 Maine children were victims of neglect, a rate of 9.6 per 1,000 children. 3 Children in DHHS care or custody: 1,650 Maine children (6% of children statewide) were in state care or custody in 2009 a rate of 6 per 1000 children. 4 High School Drop-out: Total high school graduation rate for Maine public schools was 82.82% for the school year. 5 Infant Mortality: Maine s infant mortality rate is 6.1 per 1,000 births. 6 Substance Abuse: o More than 1 in 5 Mainers (22.1%) ages 12 and older report binge alcohol use, and nearly 1 in 10 (8.3%) report using marijuana in the past month. 7 o Nearly 1 in 20 Mainers (4.2%) report non-medical use of prescription pain relievers an estimated 47,916 people statewide. 8 o Maine has consistently topped other states in opiate treatment admission rates over the last 20 years. 9 o Maine s Drug Affected Baby rates have nearly tripled in recent years, from 201 drug affected babies reported in 2006, to 572 drug affected babies in 2010 a rate of 4 per 100 babies. 10 o Statewide hospital data from 2008 shows that 215 newborns were discharged with drug withdrawal (Neonatal Abstinence Syndrome). 11 Mental Health: More than 1 in 10 Mainers (11.5%) ages suffer from frequent mental distress, with county rates ranging from 9% in York County to 18.9% in Piscataquis County Maine DHHS, Center for Disease Control and Prevention, Office of Data, Research, and Vital Statistics, accessed 3/ Department of Public Safety, Maine State Police, Uniform Crime Reporting Unit, as reported by USM, 8/ Maine Kids Count, 2010; Office of Child and Family Services, Maine Department of Health and Human Services. 4 Maine Kids Count, 2010; Office of Child and Family Services, Maine Department of Health and Human Services retrieved 6/13/11 6 U.S. Census Bureau, American Community Survey; Maine DHHS, Center for Disease Control and Prevention, Office of Data, Research, and Vital as reported by USM 8/ , 2007, 2008 National Survey on Drug Use and Health (NSDUH) 8 ibid 9 Treatment Episode Data Set (TEDS) , page 76. Retrieved on 6/16/2010 from 10 Mandy Milligan, Maine Automated Child Welfare Information System (MACWIS), Maine Office of Child and Family Services 3/15/ USM analysis of 2008 Maine hospital discharge dataset, 8/2010 Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

9 In almost all risk categories, areas with higher population have higher absolute numbers, while rural areas have higher rates. For example, child poverty rates range from 11.9% in Maine s most populated county of Cumberland (6,768 children in poverty) to 29% in Washington County (1,821 children in poverty). This phenomenon further underscores the need for implementation of Maine s enhanced home visiting program on a statewide level, rather than selecting one county over another. In addition, while risk data specific to the tribes is not available because the tribes are in the midst of their public health systems assessments, Maine is committed to exploring need and interest for increasing home visiting services available for the five tribal communities in Aroostook, Penobscot, and Washington Counties. Community Readiness As mentioned in the Introduction, Maine s proposed program expansion will build on an already existing network of statewide home visiting services, the Maine Families program. Maine Families providers are already established in every county, reaching approximately 2,500 families per year. Rigorous evidence-based standards are already in place. Since 2008, all Maine Families sites have been consistently implementing Parents as Teachers and using the Touchpoints approach of reflective practice and reflective supervision. Quality assurance and technical assistance are provided by an in-state team led by the Maine Families Statewide Coordinator. All Maine Families sites share a single web-based data collection system that allows for local and state-wide evaluation and continuous quality improvement. These strategies help to ensure model fidelity, consistency, and coordination of home visiting statewide. The proposed enhanced program will be integrated into this already existing system and will build on our highly trained, highly skilled Maine Families workforce. Through Maine s 2010 Needs Assessment and follow-up meetings (including conversations with Maine Families and Public Health Nursing home visiting administrators statewide), we have determined a high degree of readiness, buy-in, and capacity to implement the enhanced program. The proposed program responds to specific requests around continued commitment to the PAT model and Touchpoints approach, improved clinical support for home visitors, and improved coordination of services among diverse providers. The proposed work plan, which outlines a gradual year-by-year expansion of direct service staff, was developed in close consultation with program sites. The Maine Families State Coordinator spoke with program managers to identify realistically how many staff could be added without compromising fidelity to the PAT model or quality of service. The resulting numbers are based on careful consideration by local providers regarding their own capacity for expansion. In addition, Maine s proposed Linking activities build on the successes and lessons learned from two pilot communities within the state. Washington County s Bridging Project is led by the Community Caring Collaborative (CCC), a coalition of 35 agencies, and is the recipient of a LAUNCH grant from the federal Substance Abuse and Mental Health Services Administration. The Linking model is currently being replicated in the Penquis region (Penobscot/Piscataquis Counties) as part of our MIECHV Updated State Plan, and would be taken statewide as part of the MIECHV Expansion. The success of the model in Washington County and lessons learned 12 BRFSS m US Census 2009 Population Estimates Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

10 from the newly piloted initiative in the Penquis region will further add to Maine s capacity and readiness to expand inter-agency collaboration efforts statewide. Estimated number of families that will be reached by this project The following estimates were developed by gathering feedback from provider sites regarding how fast they could grow and still maintain quality and fidelity: Year 1: Up to 25 new direct service positions and 5 supervisory positions will be added to serve an estimated 700 families per year. Allowing 6 months for hiring, training, and orientation, about half (350 new families) would be served by the end of the first year. Year 2: Up to 15 new positions will be added to serve an estimated 400 families per year. Allowing 6 months for hiring, training, and orientation, about half (200 new families) would be served by the end of the second year. ( =900 families served by MIECHV Expansion in Year 2.) Years 3 & 4: In Year 3, program eligibility will be expanded to include families with children ages 3-5. Up to 15 new positions will be added each year, to serve an estimated 400 families per year. Allowing 6 months for hiring, training, and orientation, about half (200) would be served by the end of the first year. ( =1300 families served by MIECHV Expansion in Year =1700 families served by MIECHV Expansion in Year 4.) How the priority element will reach Maine s desired outcomes for its expansion project Maine has selected Priority Element 7: To reach families in rural or frontier areas through home visiting programs because it encapsulates so many of the public health and systems improvement priorities that are outlined in our State Plan. In our 2010 Needs Assessment, home visiting stakeholders in each of Maine s 16 counties reported challenges around engaging isolated, rural families. The MIECHV Expansion will assist Maine in reaching its goal of reaching more families in rural areas by providing resources to enhance services, increase staffing and travel resources, and increase local collaboration among early childhood providers so that more rural families can be reached, and isolated families can be better engaged. METHODOLOGY Model selection Maine has selected Parents as Teachers as our evidence-based home visiting model. PAT has been offered in some Maine counties since the late 1990 s. Maine has implemented the program statewide since 2008, following rigorous standards of practice to ensure fidelity. We received approval of our MIECHV Expansion implementation plan from the PAT developers in a letter dated 6/22/2011 (see Attachment 8). The letter includes approval of the following proposed enhancements: Continued use of the Touchpoints approach of reflective practice and reflective supervision, and the framework of protective factors. These are all enhancements to the PAT model that Maine has had in place for some time now, and many of these elements have already been incorporated into the PAT model. Provision of additional training and clinical supervision for home visitors to better prepare them for engaging and assisting families with substance abuse, mental health, cooccurring needs, and family violence issues. Resources to allow for greater frequency of home visits to highest-risk families. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

11 Support for strengthening local efforts to build coordination and collaboration among service providers to better serve families in need. Purpose, Goals and Objectives Maine s MIECHV Expansion will serve to strengthen, enhance, and expand the state s existing statewide home visiting program, Maine Families, as part of a comprehensive early childhood system. While Maine already has a solid statewide network of Maine Families sites implementing Parents as Teachers and following rigorous standards of practice, the state needs additional resources in order to: 1. Reach greater numbers of eligible families (including: those with needs related to substance abuse, mental health, co-occurring disorders, and/or family violence, those in rural areas, and those living in tribal communities). 2. Better serve vulnerable families through enhancement of the PAT program that includes provision of more frequent visits to families who need them; additional training and clinical supervision for home visitors to better prepare them for engaging and assisting families with substance abuse, mental health, co-occurring, and/or family violence issues; and strengthening of coordination and collaboration among local service providers to better serve families in need. For the purposes of this application, these collective efforts are termed the Maine Families Linking Initiative. 3. Increase capacity of all Maine Families sites to participate in data collection and reporting according to federal Benchmark requirements. 4. Strengthen state-level systems collaboration to build a coordinated continuum of early childhood services, with home visiting as a sustainable and integral component of that system. The goals and objectives of Maine s MIECHV Expansion, as outlined in our Logic Model in Attachment 1, are as follows: Short term objectives More eligible families served. Increase in participants identified with substance abuse, mental health, co-occurring, and/or family violence issues. Increased enrollment and participation of families living in rural areas and families living on reservations. Maintained PAT program fidelity. Maintained high retention rates for participants. Maintained high rates of participant satisfaction with the program. Maintained high retention rates for staff. Increased staff competency and comfort in addressing issues facing vulnerable families. Increased screening and referrals to needed services. Increased collaboration, formalized agreements, and shared tools/systems among local agencies to better serve vulnerable families. Data collection system enhanced to meet federal requirements. Formalized agreements among state agencies, e.g. program roles within continuum of services, staff competency standards and training plans, and consistent use of data to inform policy and services. Medium term objectives Increased participant knowledge and understanding of maternal and infant health, safety and parenting Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

12 Increased number of vulnerable families who receive needed services (e.g. services for substance abuse, mental health, co-occurring, and/or family violence issues) Benchmarks data routinely submitted to federal government and used for program evaluation Measurable progress in the MIECHV Benchmark: Improved Coordination and Referrals for Community Resources/Supports Documented collaborative initiatives between state agencies to provide a continuum of support to families Public and political will for sustained funding of home visiting programs and infrastructure Long term objectives Measurable progress in the MIECHV Benchmarks and associated constructs: Improved maternal, infant and child health Reduced child maltreatment and injuries Improved school readiness and achievement/positive parenting practices Reduced/prevented domestic violence In addition, the goals and objectives in our MIECHV Expansion logic model are aligned with the Parents as Teachers goals and objectives, outlined below. Parents as Teachers Goals Provide early detection of developmental delays and health issues Increase parent knowledge of early childhood development and improve parenting practices Short Term Intermediate Long Term Increase in healthy pregnancies and improved birth outcomes (when services are delivered prenatally) Early detection of developmental delays and health issues Children will have increased identification and referral to services for possible developmental delays and vision/hearing/ health issues Increase in parent s knowledge of their children s emerging development and age-appropriate child development Parents are knowledgeable about their child s current and emerging language, intellectual, social-emotional, and motor development Parents recognize their child s developmental strengths and possible delays Parents are familiar with key messages about healthy births, attachment, discipline, health, nutrition, safety, sleep, and transitions/routines Improved parenting capacity, parenting practices, and parent-child relationships Parents understand that a child s development influences parenting responses Parents display more literacy and language promoting behaviors Improved child health and development Strong communities, thriving families, and children who are healthy, safe, and ready to succeed Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

13 Parents as Teachers Goals Increase children s school readiness and school success Prevent child abuse and neglect Short Term Intermediate Long Term Parents demonstrate positive parenting skills, including nurturing and responsive parenting behaviors and positive discipline techniques Parents show increased frequency, duration, and quality of parent-child interactions Increased parent involvement in children s care and education Improved family health and functioning Improved quality of home environment Families link with other families and build social connections Parents are more resilient and less stressed Parents are empowered to identify and utilize resources and achieve family and child goals Families are connected to concrete support in times of need Increased school readiness Prevention of child abuse and neglect Details of our evaluation plan are included in the section, Evaluation and Technical Support Capacity on page 34. Strong communities, thriving families, and children who are healthy, safe, and ready to succeed STRENGTH OF EVIDENCE Maine has selected Parents as Teachers (PAT) for four reasons: (1) our state s demonstrated capacity and track record of implementing the program successfully all 16 counties; (2) its fit with community needs and program goals; (3) its strong evidence base; and (4) demonstrated positive outcomes for families in Maine. Each of these points is described in detail below. Maine s experience with PAT: PAT has been an integrated part of Maine home visiting programs for many years. Maine committed to fully adopting PAT for all state-funded Maine Families sites three years ago as our system of home visiting became more coordinated; it was incorporated as a requirement in the Standards of Practice. Maine s statewide network of home visiting providers already have a strong track record of success implementing PAT, a solid administrative infrastructure, and PAT-trained staff in place. A high level of collaboration and coordination already exists among diverse local agencies and providers. Maine has a well-established state-level infrastructure and capacity to support PAT implementation with fidelity, including a centralized online data system and a statewide Quality Assurance and Technical Assistance Specialist to monitor and implement quality assurance standards. Maine has a PAT training team located in-state. Currently, Maine has 100 home visiting staff trained and certified in the PAT model. We completed Foundational retraining for all home visitors and Implementation training for all managers and supervisors this year. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

14 Maine will be able to implement swiftly the activities necessary for implementation, making effective use of federal and state dollars immediately with limited start up costs or time needed. Local conditions and capacities that increase the likelihood of success In addition to Maine s established infrastructure, capacity to implement the program, and promising evaluation outcomes, PAT is a strong fit for Maine for the following reasons: Community needs: The Parents as Teachers Curriculum is designed specifically to support communities with the needs identified in Maine including poverty, high rates of high school dropout, child maltreatment, domestic violence, and substance abuse. The PAT curriculum includes specific modules designed to meet family needs related to low-income, low family or student academic achievement, history of substance abuse or need for substance abuse treatment, history of child abuse or neglect, and families who have experienced child abuse and neglect. Provider buy-in: PAT was selected because it was a national model that most program sites were already partially invested in. Maine providers preferred PAT because it was regarded as a more strength-based, has a more respectful approach than other models, and was a fit with Maine communities and programs' philosophy. Today, as the PAT developers have revamped and updated their curriculum and training, the fit is even stronger. The updated PAT curriculum incorporates a stronger focus on reflective practice and supervision, a curriculum that lends itself to greater individualization for each family and incorporates the Strengthening Families 13 Protective Factors which also aligns with the state s Strengthening Maine Families project working with childcare providers. Family satisfaction: Families consistently report high levels of satisfaction with the program. Each year, Maine Families participants have the opportunity to respond to an anonymous survey about their experiences in the program. In the 2010 survey, 97 percent of the responding families reported they are very satisfied with their home visitor; 97 percent said their home visitor was very well trained; 99 percent reported their home visitor understood their needs and treated them very well; and nearly 100 percent indicated that their home visitor was respectful of their culture or background. Self-reported family outcomes: In addition, the vast majority of surveyed families report positive impacts resulting from their participation in the Maine Families. In the 2010 survey, 92 percent of responding families reported a moderate to great increase in their confidence as a parent; 88 percent reported a moderate to great increase in their knowledge of caring for babies; and 95 percent reported a moderate to great benefit to their children resulting from participation in the program. Fit with Maine goals: Maine s programmatic goals are constructed to match those of our selected evidence-based program model, Parents as Teachers, as outlined above. The four PAT overarching goals are: a) Provide early detection of developmental delays and health issues; b) Increase parent knowledge of early childhood development and improve 13 Strengthening Families is an evidence based approach to child maltreatment that focuses on working with providers of early care and education to improve the protective factors known to mitigate the risk of child abuse and neglect. More information on this national program can be found at the Center for the Study of Social Policy website: and details about Maine s program can be found online at Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

15 parenting practices; c) Increase children s school readiness and school success; and d) Prevent child abuse and neglect. As described above, evaluation of the Maine Families program already demonstrates promising outcomes toward achieving these goals. Fit with Maine theoretical framework: The PAT Theoretical Framework is already integrated throughout the Maine Families Standards of Practice. Maine Families parent educators share research-based information and utilize evidence-based practices by partnering, facilitating, and reflecting with families. Parent educators use the PAT Foundational Curriculum in culturally sensitive ways to deliver services that emphasize a) Parent-child interaction; b) Development-centered parenting; and c) Family well-being. In addition, Maine Families follows these Core Values as outlined by PAT: o The early years of a child s life are critical for optimal development and provide the foundation for success in school and in life. o Parents are their children s first and most influential teachers. o Established and emerging research is the foundation of our curriculum, training, materials and services. o All young children and their families deserve opportunities to succeed, regardless of any demographic, geographic, or economic considerations. o An understanding and appreciation of the history and traditions of diverse cultures is essential in serving families. Evidence of effectiveness There is a solid body of evidence that supports the selection of Parents as Teachers as the evidence-based model of home visiting for Maine. In its review of 16 published evaluations of the Parents as Teachers program, the Home Visiting Evidence of Effectiveness (HomVEE) Study determined favorable impacts in two domains: Child Development and School Readiness, and Positive Parenting Practices. In addition, the 2011 Parents as Teachers Foundational and Model Implementation curriculum and training have been strengthened to incorporate research findings and recommendations. And as we will show, Maine s implementation of the PAT program has had promising outcomes related to physical and emotional health, school readiness, reducing the risk for child abuse/neglect, and increasing family self-sufficiency. Summarized below are the important components about PAT s evidence of effectiveness: study design quality, substantive impact for families served, duration of findings, replication of findings, quality of measures, the presence of null/ambiguous findings, and the independence of the evaluator. 1. Study design quality As a network of home visiting programs, Maine Families is grounded in Parents as Teachers (PAT), one of seven models meeting evidence of effectiveness criteria in the HomVEE review of home visiting program effectiveness. The PAT program model meets the US Department of Health and Human Services (DHHS) criteria for an evidence-based early childhood home visiting service delivery model because there are at least 2 high or moderate quality impact studies using different samples with 1 or more favorable, statistically significant impacts in the same domain. At least 1 of these impacts is from a randomized controlled trial and has been published in a peer-reviewed journal. At least 1 of the favorable impacts from a randomized controlled trial was sustained for at least a year after program enrollment. Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA

16 The following information, excerpted from the HomVEE website 14, provides a summary of study design quality of the research used by HomVEE to review PAT evidence of effectiveness. The HomVEE review identified 49 studies of PAT published between 1979 and Of these, 16 studies were eligible for review: 2 received a high rating; 2 received a moderate rating; 8 received a low rating; and four were additional sources, which overlap with other studies, and were not rated. Across the studies that received a high or moderate rating, four samples were used in the research. The following PAT impact studies were rated high for their randomized control trial design, low attrition, and lack of reassignment or confounding factors: Impact Studies Rated High Citation Design Attrition Baseline Equivalence Reassignment Confounding Factors Drotar, D., Robinson, J., Jeavons, L., & Lester Kirchner, H. (2009). A randomized, controlled evaluation of early intervention: The Born to Learn curriculum. Child: Care, Health & Development, 35(5), Randomized controlled trial Low Not applicable None None Wagner, M., Clayton, S., Gerlach- Downie, S., & McElroy, M. (1999). An evaluation of the northern California Parents as Teachers demonstration. Menlo Park, CA: SRI International. Randomized controlled trial Low Not applicable None None The following Impact Studies were rated moderate. These also used randomized controlled trial, but had high attrition: Impact Studies Rated Moderate Citation Design Attrition Baseline Equivalence Reassignment Confound -ing Factors Wagner, M., & Spiker, D. (2001). Experiences and outcomes for children and families: Multisite Parents as Teachers evaluation. Menlo Park, CA: SRI International. blications/humanpub/patfinal.pdf. Randomized controlled trial High Established on race/ethnicity, SES, and mother s mental health. None None Wagner, M., Cameto, R., & Gerlach-Downie, S. (1996). Intervention in support of adolescent parents and their children: A final report on the Teen Parents as Teachers Demonstration. Menlo Park, CA: SRI International. Randomized controlled trial High Established on race/ethnicity, and SES. Lack of equivalence on baseline contraceptive use and experience with infants. Yes None 2. The substantive impact for the individuals served; Taking into account all of the review results as of January 2010, which include all high- or moderate-quality impact studies for this program model, the HomVee study determined that the PAT program model has 5 favorable impacts and 7 unfavorable or ambiguous impacts. The 14 retrieved 6/17/2010 Maine Maternal, Infant, and Early Childhood Home Visiting Expansion Project: HRSA