by Carlos Cano.

How can a program create opportunities for women, infants, children, and families to thrive independent of their socio-economic status?  In response to this question, in 2010, the United States Congress created the first national home visiting program for women and families expecting a baby and those with young children.  The Obama Administration has implemented this Maternal, Infant, and Early Childhood Home Visiting Program (Home Visiting Program) which offers voluntary, evidence-based home visiting services for at-risk pregnant women and parents with young children up to entry into kindergarten.

The Home Visiting Program builds upon decades of research.  Studies show that home visits by a nurse, social worker, early childhood educator, or other trained community worker during pregnancy and in the first years of a child’s life improve the life course of families. These workers assist by supporting effective parenting, improving maternal and child health, and promoting child development and school readiness.  Research also shows that evidence-based home visiting can provide a positive return on investments in social and economic opportunities through savings in public expenditures devoted to remedial interventions later in life.

Two federal agencies, the Health Resources and Services Administration and the Administration for Children and Families, administer the Home Visiting Program.  States, territories, and tribal entities receive funding and have the flexibility to tailor the program to the needs of their communities.

How can the likelihood be increased that the Home Visiting Program will yield beneficial results as quickly as possible?  A selected group of local agencies participating in the Home Visiting Program sought to address this question. They came together in the spring of 2013 to figure out how to achieve success for families faster.  The agreed-upon strategy: To provide coaching to home visitors, supervisors and administrators at the national, state and local levels in the use of quality improvement tools and methods.  A national quality improvement effort was born: the Home Visiting Collaborative Improvement and Innovation Network or HV CoIIN.

This is the first national collaborative quality improvement effort to promote healthy child development and family well-being in the context of home visiting. Multi-team improvement collaborations have been broadly utilized over the last two decades in health care settings such as hospitals or ambulatory clinics.  The application to community-based preventive programs is novel.

What is an improvement collaborative?

It is a time-limited learning activity (9- 18 months) that brings together a selected group of teams from service agencies to seek improvement in specific topic areas. The topics chosen for improvement in this case are (1) promotion of child development, early detection of delays, and linkage to and receipt of services, (2) initiation and duration of breastfeeding, and (3) alleviation of maternal depression.  These topics are considered “ripe” for improvement, meaning there are evidence-based interventions available to close gaps between what we know works and what is being practiced in frontline services within the community. Thirty-five local agency teams across 12 states are actively seeking to “close the gap” across these topics, forming three learning collaboratives with 10-12 teams per topic area.

The ultimate aim of the HV CoIIN is to reach measurable, specific and ambitious improvement goals in process and outcome measures associated with maternal mental health, breastfeeding and child development. For example, for breastfeeding, one of the ambitious process aims is that 80% of pregnant women in the program who intend to nurse their baby will receive the support they need at the right time. Another “stretch” outcome aim is to increase by 20% from baseline the percent of women who continue to breastfeed at three months post-partum.

How are the three collaboratives in the HV CoIIN supposed to reach these ambitious aims in such a short amount of time?

The project director and the improvement advisor together with expert faculty coach participating teams in the use of quality improvement tools and evidence-based interventions. This intentional support system creates ongoing learning opportunities for teams in the course of face-to-face learning sessions and monthly calls as shown in the following graph.

grafico 1 ENG3

Specifically, the support team guides local agency teams to carry out a series of rapid tests of recommended interventions known to be effective.  Participating teams adapt these “change ideas” to the local context based on the results of tests known as “plan-do-study-act” or PDSA cycles.  The teams submit monthly data reports and tests they have performed. Importantly, all track progress using a shared set of measures.  Data are then aggregated for the entire collaborative:

grafico 2ENG

Left axis: Average % of home visitors trained in infant breastfeeding support across local agencies

Right axis: Average number of home visitors across local agencies

Participants “share seamlessly” and “steal shamelessly” resources and tips on what works best from each other creating a culture where data are used for learning rather than for judging, a culture of continuous quality improvement.

The CoIIN’s final product will be a “play-book” or manual to spread the promising results.  Once their learning disseminates across the United States, more than 700 local implementing agencies funded by the Home Visiting Program stand to benefit from the effort and creativity of the three dozen pioneering local teams.

Taking into consideration the differences in culture, values, and beliefs, would a similar collaborative project benefit home visiting programs in Latin America?  Could the CoIIN “play-book” contribute to good results for women, infants, children and families in other countries?   For the health and wellness of all populations, these are questions worth considering. Share your thoughts in the comments section below or mentioning @BIDgente in Twitter.

Carlos Cano is a Senior Advisor on Quality Improvement at the Maternal and Child Health Bureau in Maryland.

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