Background:

Home visiting programs deliver voluntary services to pregnant women, young children, and families at home and are designed to alleviate the effects of poverty and other risk factors on child development. The Department of Children, Youth, and Families (DCYF) administers the state Home Visiting Services Account (HVSA). The HVSA receives state, federal, and private funding for the provision of home visiting services, including grant funds from the federal Maternal Infant and Early Childhood Home Visiting (MIECHV) program. An advisory committee gives advice regarding research and the distribution of funds from the HVSA. The stated intent of the Legislature is that state funds invested in the HVSA be matched by public-private partnership funds each fiscal year.

In addition to home visiting models funded through the HVSA, local and community-based agencies deliver a number of other home visiting services that are supported with federal, private, or local funding. Each model has its own requirements for provider qualifications, program goals, and the duration or frequency of services for various target populations that can include pregnant women and children up to age 5. A Home Visiting Scan published in 2017 by the DCYF reported 8,852 funded slots were available to families statewide though nine different home visiting program models. In 2017 the Department of Health (DOH) published a home visiting needs assessment estimating the potential need for home visiting services based on certain risk factors and low-income births by county and school locale, as well as by race and ethnicity.

Evidence-Based Home Visiting.

The MIECHV grant funds evidence-based home visiting and requires that grantees demonstrate measurable improvement in at least four of six benchmark domains. The six domains are improvement in maternal and newborn health; reduction in child injuries, abuse, and neglect; improved school readiness and achievement; reduction in crime or domestic violence; improved economic self-sufficiency; and improved coordination and referral for other community resources and supports.

In Washington, the MIECHV grant funds the Nurse-Family Partnership, and Parents as Teachers home visiting services. For federal fiscal year 2018, Washington's MIECHV grant was $10.46 million.

State statute defines evidence-based home visiting as a program or practice that had multiple site random controlled trials across heterogeneous populations demonstrating that the program or practice is effective for the population.

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Summary of Substitute Bill:

Short-Term Universal, Voluntary, Community-Based Home Visiting Program.

Subject to funds appropriated, the DCYF must implement a short-term universal, voluntary, community-based home visiting program (community-based HVP) to be available to all families in up to four demonstration sites. The DCYF must select demonstration sites by October 1, 2019, based on communities with the highest needs and community interest and capacity. The DCYF must begin implementation of services in the demonstration sites by January 1, 2021.

To be eligible for funding, a community-based HVP must:

be an evidence-based or promising practice model selected by the community;
be coordinated with a local resource and referral linkage system;
deliver services using a community-based organization;
be culturally responsive and appropriate to meet the needs of families served;
offer up to three voluntary health-focused visits during the infant's first year to all families in the community;
offer visits in the family's home or another location at times convenient for working families; and
provide for a process that will allow for adaptations necessary to meet the community's needs within the context of the chosen model, including:
- requiring home visits to be led or supervised by a health care professional licensed by the DOH, which may include nurses, midwives, or other relevant health care professionals; and
- allowing for the option of pairing a licensed health care provider with a trusted community partner whenever culturally appropriate.

The initial home visit must focus on the immediate health and safety needs of the child, mother, and family, and if appropriate, provide the family with information and referrals to local community-based resources matched to the family's needs. As appropriate, the community-based HVP must include a process for following up with families to facilitate the family's connection to local service providers.

The DCYF must offer technical assistance to assist communities in the demonstration sites with engagement, planning, and implementation activities including:

facilitating connections between local health jurisdictions, cities, counties, community-based organizations, and early learning coalitions;
developing a family recruitment and outreach plan;
promoting awareness and understanding of the community-based HVP to increase community participation and support;
assessing workforce needs such as training, recruiting, and retaining culturally responsive home visitors who are reflective of community diversity;
identifying or developing a resource and referral linkage system; and
gathering and analyzing data on community-based HVP performance measures and aggregate child and family outcomes.

All personally identifiable data collected under a community-based HVP is confidential. A community-based HVP may only disclose:

aggregate data, without personally identifiable information, to the DCYF for the purposes of program evaluation and outcome reporting; and
with the family's consent, limited family information only for the purpose of referrals to local community-based resources. The community-based HVP must provide the family with the family information to be shared prior to sharing any information as part of a referral.

The DCYF may adopt rules to implement the community-based HVP.

The DCYF must report to the Governor and the Legislature by:

November 1, 2020, a status update on planning and implementation activities in the demonstration sites;
November 1, 2021, an interim evaluation report, an implementation plan and funding model for expanding statewide access to short-term community-based HVPs and possible consideration of the development of a statewide family linkage program for resources and referrals, options for including short-term voluntary home visits as a covered benefit under Medicaid plans, and recommendations for the statewide coordination of short-term universal voluntary home visiting services;
November 1, 2022, in collaboration with the Office of the Insurance Commissioner (OIC) and the Health Benefit Exchange (Exchange), options for including short-term voluntary home visits as a covered benefit under nonMedicaid health plans; and
November 1, 2022, a final report on community-based HVP outcomes.

Funding for the community-based HVP may be deposited into the HVSA. State funds are not required to be matched by public-private partnership funds. The DCYF representation on the advisory committee advising on the distribution of HVSA funds is increased to more than one representative.

Definitions are added for various home visiting services and outdated statutory references are updated.

Substitute Bill Compared to Original Bill:

The substitute bill:

replaces the universal home visiting program for all newborns from birth to 9 months with demonstration sites for the implementation of short-term, universal, voluntary, community-based home visiting during an infant's first year;

removes the requirement that the universal home visiting program be a statewide entitlement by July 1, 2027;
requires the DCYF to select up to four demonstration sites by October 1, 2019, based on communities with the highest needs as well as community interest and capacity and to implement services in the demonstration sites by January 1, 2021;
requires the community to select an evidence-based or promising practice model and requires the model to be reflective of community goals, needs, and diversity;
directs the community-based HVP to:
- be coordinated with a local resource and referral linkage system;
- deliver services using a community-based organization with home visitors who reflect the diversity of the community;
- be culturally responsive and appropriate to meet the family's needs;
- offer visits in the family's home or another location at times convenient for working families;
- offer up to three voluntary, health-focused visits during the infant's first year to all families in the community; and
- focus the initial visit on the immediate health and safety needs of the child, mother, and family, and if appropriate, provide the family with information and referrals to local community-based resources and include a follow-up process for families;
requires the community-based HVP to provide for a process to allow for adaptations necessary to meet the specific needs of local communities within the context of the chosen model, such as:
- requiring home visits to be led or supervised by a health care professional licensed by the DOH; and
- allowing for the option of pairing a licensed health care provider with a trusted community partner whenever culturally appropriate;

requires the DCYF to offer technical assistance to assist communities in the demonstration sites with engagement, planning, and implementation activities as needed;
adds provisions stipulating that all personally identifiable data collected under the program is confidential and limiting how data may be shared and with whom;
adds requirements for the DCYF to report to the Legislature and the Governor by:
- November 1, 2020, a status update on planning and implementation activities in the demonstration sites;
- November 1, 2021, an interim evaluation report; an implementation plan and funding model for expanding statewide access to short-term universal voluntary home visiting programs and possible consideration of the development of a statewide family linkage program for resources and referrals; options for including short-term voluntary home visits as a covered benefit under Medicaid plans; and recommendations for the statewide coordination of short-term universal voluntary home visiting services;
- November 1, 2022, in collaboration with the OIC and the Exchange, options for including short-term voluntary home visits as a covered benefit under non-Medicaid health plans; and
- November 1, 2022, a final report on program outcomes;
modifies language related to how funding is appropriated for community-based HVPs;
adds definitions for "longer-term home visiting" and "promising practice" and revises definitions for the family linkage system and universal home visiting;
removes the requirement for the DCYF to conduct an independent evaluation to measure family and child outcomes;
removes the requirement for the DCYF to develop an implementation plan for universal home visiting;
removes the creation of a statewide family linkage program that provides resources and referrals to all Washington families;
modifies the findings and intent language; and
removes the emergency clause.

Staff Summary of Public Testimony:

(In support) Not all parents have access to resources through a primary care doctor and extended family to give extra support when they bring home a new baby. These services will help identify maternal depression, ensure bonding, healthy eating and breastfeeding at the beginning of life, and will help babies and moms to thrive while targeting the needs of specific communities. Home visitors help parents build confidence in their parenting skills. The guidance of a home visitor can result in long-term better physical health outcomes for children and identify adverse childhood experiences. Families of all incomes can benefit from this voluntary service. Universal services are important to remove any stigma associated with home visiting and to promote equity. The public saves $3 for every $1 invested in home visiting programs. This program is not government surveillance and is voluntary. Allowing adequate time to address nurse workforce issues can be addressed, and the community-based planning processes have already begun. Family linkage programs like Help Me Grow have been used successfully at a limited scale. Perfectly healthy newborns wind up in the emergency room for things that normal newborns do but that parents are afraid of, which is costly and exposes newborns to illnesses in the hospital environment. A contracted provider, not child protective services and not the government, would be the one going into the home.

(Opposed) The language in the bill is concerning for those who value parental rights, including the descriptions applying to all newborns and the statewide entitlement. The terms "voluntary" and "dis-enroll" only appear once. Data collection and privacy is a concern. Home visiting nurses sometimes provide incorrect information that is not culturally representative. Communities should provide services, and this should not be coming from a government mandate. There is no assurance that data collected is kept private and that questionnaires are being stored securely. The state does not know better than parents what children need. A parent's own experience and desires should take precedence.