Lessons Learned on Systems Building from Ohio and Vermont

Originally Published by The Home Visiting-Improvement Action Center Team (HV-ImpACT)

Health Visitor Talking To Mother With Young Baby

This article is based on interviews with Jye Breckenridge, Early Childhood Home Visiting Administrator, Ohio Department of Health; Ann Giombetti, Nurse Home Visiting Program Administrator, Vermont Department of Health; and Janet Kilburn, Child Development Coordinator and Act Early ambassador, Help Me Grow Vermont. Both Ohio and Vermont are engaged in statewide systems building that will help them provide quality home visiting services by coordinating services with other agencies that serve the same at-risk children and families.

Ohio’s Centralized Intake System: The Single Point of Entry for State Early Childhood Programs

Ohio’s home visiting system includes 21 MIECHV-funded programs that operate in 27 communities, and 74 local implementing agencies (LIAs) that operate evidence-based home visiting programs using state funds. In addition, the state has 14 Community Health Worker Model LIAs that focus only on African American infant mortality. Ohio’s state-supported models include Healthy Families America (HFA), Nurse-Family Partnership (NFP), and Parents as Teachers (PAT). County programs implement additional evidence-based models, such as Home Instruction for Parents of Preschool Youngsters (HIPPY).

In early 2017, the state passed legislation that mandated the creation of a Home Visiting Consortium advisory group with the very specific purpose of ensuring that every home visiting program in the state was evidence-based and using best practices. The legislation also mandated exploring other mechanisms to fund evidence-based home visiting. At the same time, the state included home visiting in the State Health Improvement Plan (SHIP) for the first time. One of the key goals in the SHIP was to improve maternal and child health.

This legislation spurred the development of Ohio’s Centralized Intake System, a single point of entry for all home visiting programs, state-supported programs for community health workers, and Part C Early Intervention programs. Prior to the development of this system, each of the 88 communities providing home visiting services had its own intake process and its own enrollment form. This fragmentation made it difficult to set benchmarks or measure progress. Now all home visiting programs, even those funded only locally, will have the opportunity to enroll families using a consistent process that connects families with model services based on each family’s characteristics and the evidence-based models’ eligibility criteria. The goal is to increase enrollment, reduce the number of families on waiting lists, and decrease the waiting time for families once they are on a waiting list. Within the first two months of implementation, the time between making an initial referral and connecting with families decreased by two days.

How the Centralized Intake System Works

The Centralized Intake System enables trained staff members to gather information about primary caregiver demographics, pregnancy, child demographics, and current support services during an intake call. The data is entered into a social determinants screen that weights answers to the questions within the context of census tract data. The system then automatically matches clients to the most appropriate home visiting model based on their responses to the intake questions. For instance, the system will automatically populate Nurse-Family Partnership as the first choice to discuss with a first-time pregnant mother or a mother determined to be at higher risk for infant mortality. Healthy Families America will appear as the first option for new parents with a history of adverse childhood experiences or other social and child developmental concerns. Parent worries about their child’s development or identification of a diagnosed medical condition automatically trigger a referral to Early Intervention; in these cases, the parent can request dual enrolment in both early intervention and home visiting. However, parent choice remains key throughout the process.

Data collected through the system will assign the family a social determinants risk score that will be monitored throughout the duration of home visiting services. The data is also geocoded; that is, the family’s address may be linked to any poor health outcomes that are known to exist in a geographic area. This information can help a home visitor target the content of a home visit.

happy mother read a book to child girlChallenges and Solutions

According to Breckenridge, bringing under one roof all of the independent communities involved was not without its challenges. Many local agencies were passionate about their communities and the job they did, and they were concerned about giving up local control. On the other hand, communities that hadn’t been receiving home visiting referrals welcomed change and embraced the streamlined process.

Breckenridge continues to work at the local level to provide a balanced approach between state and local control. He conducts a weekly town hall webinar, allowing communities to share their concerns and answering their questions. When communities report a best practice that is working well, it is typically adopted at the state level. Breckenridge emphasizes how the program benefits families and communities. Data on referrals sent out weekly, with historical comparisons since 2014, demonstrates the benefits and progress. In addition, he participates in a series of luncheons with local program leaders in each of Ohio’s five regions to elicit feedback and concerns.

Future Directions

In addition to engaging with the home visiting community, Ohio is envisioning its Centralized Intake System as the bridge to collaboration with other statewide partners with overlapping missions. The system gathers data that is of interest not only to home visiting programs but to other programs in the state that are serving the same population. This ability to share relevant, real-time data becomes a point of entry for collaboration with other potential state partners. To broker collaboration with Medicaid, for example, Breckenridge highlighted the state home visiting performance measures that can be tracked to data about managed care. Specifically, the system collects such things as Medicaid numbers, immunization status, postpartum visits, and well-child visits that are aligned with the schedule recommended by the American Academy of Pediatrics. Medicaid representatives were especially interested in the ability to track asthma, maternal depression, and visits to the emergency room and urgent care facilities.

As Ohio continues to explore mutually beneficial intersections with other state agencies, the home visiting program reached an agreement with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to bridge the data systems to provide data matching. The goal is to generate bi-directional referrals to each program when a prospective family is identified. Ohio’s MIECHV team also recently met with the state’s Temporary Assistance to Needy Families (TANF) team to explore direct referrals to home visiting from TANF for all pregnant women who are receiving public assistance. Collaboration with TANF could also reduce duplication of services. For instance, overlapping interests with TANF include parenting education and economic self-sufficiency activities. Other partnerships that are being actively explored include the state’s opioid treatment network, the state’s drug court system, child welfare, Early Head Start, and child care.

Young mother with her toddler son playing outdoors in city.Conclusions

The statewide Home Visiting Coalition was the glue that pulled together Ohio’s Centralized Intake System. The coalition included the director or their designees from all of the early childhood agencies within the state (e.g., education, mental health, jobs, and family services) as well as Medicaid. The coalition also included four state legislators: one from each party of each chamber. The legislation itself was also a key factor. Some of the improvements had been in process but had run into roadblocks. The support of agency leadership and of Ohio’s legislative body were key factors in making the shift to a truly data-driven, evidenced-based statewide system of supports. Ohio’s big dream is for this statewide system to become the true point of access for all things related to early childhood in Ohio, connecting families with needed supports and fostering greater collaboration across state agencies.

Vermont’s Early Childhood Systems

Help Me Grow Promotes Cross-sector Statewide Collaboration

In VermontHelp Me Grow provides a system-building approach to cross-sector, statewide collaboration. Help Me Grow (HMG) promotes the healthy development of children by supporting parents, caregivers, providers, and communities to link children and families to the services and community-based supports they need. The HMG system consists of four core components:

  • Child Health Care Provider Outreach to support early detection and intervention
  • Family and Community Outreach to promote the use of HMG, build collaboration among community providers and services, and bolster healthy development through families
  • Centralized Telephone Access Point for connecting children and their families to services and care coordination
  • Data Collection and Analysis for continuous system improvement

The HMG Vermont (HMG VT) Centralized Telephone Access Point offers a child development information line, staffed by trained HMG child development specialists in partnership with Vermont 2-1-1, a program of the United Way of Vermont. HMG specialists help connect expectant parents and families with children through age 8 to existing resources and services. Parents and caregivers can call, text, or email to ask a question about their child’s development or behavior, find local activities, and seek referrals to specialists and other resources. The HelpMeGrowVT.org website helps parents learn about child development by age, get parenting tips, nurture social and emotional growth, and learn effective ways to manage behavior.

Since 2015, the state’s 1,325 incoming calls to the HMG VT contact center have resulted in 1,076 follow-up calls and 1,760 referrals to basic needs resources, advocacy supports and services, childbirth and parenting education and skills classes, child care, and health and mental health services.

 Vermont’s Children’s Integrated Services (CIS) and Building Bright Futures

Vermont’s Children’s Integrated Services (CIS) co-locates four different early childhood services under the umbrella of the Department for Children and Families: early intervention, specialized child care, nursing and family support, and early childhood and family mental health. CIS was serving children from birth to six before the Maternal, Infant, and Early Childhood Home Visiting program (MIECHV) was implemented in the state. The state then selected Nurse-Family Partnership (NFP) as its model and incorporated the five home health agencies that were funded to provide home visiting services through MIECHV dollars into the statewide system. MIECHV operates in 86 percent of Vermont’s counties.

Each region in the state has a CIS coordinator. Referrals are discussed during weekly meetings so that everyone in the region is aware of where mothers are getting services. For example, families that leave the NFP program before their child turns 2 or who stop engaging in home visits may be connected to another home visiting program through another agency.

HMG VT serves as the safety net for Vermont’s children by providing a one-stop-shop entryway to the coordinated services provided through CIS. HMG VT refers children directly to CIS and can also support children when they are not eligible for IDEA Part C early intervention services, or when their family declines a CIS service. The goal is for children to be connected to the services they need at an early age when the benefit of those services is greatest. In addition, HMG VT’s approach often effectively engages members of families who have had a negative experience with child protective services or who wish to share the concerns they have for their child anonymously.

Building Bright Futures (BBF) is Vermont’s early childhood public-private partnership established by law to monitor the state’s early care, health, and education systems and to advise the administration and legislature on policy and systems improvements. BBF serves as the backbone organization to Vermont’s early childhood system through its 12 active statewide councils and is a key partner to the HMG VT system. It provides family and community outreach, connecting 1,090 partners and 2,021 families in 2017 to date. While membership may vary by region, the goal is to convene education, health, and human service providers; community members; and families with a common goal of meeting the diverse needs of all Vermont’s children.

Lessons Learned

Giombetti and Kilburn shared two important lessons about building statewide systems:

  • Change takes time. Working as a cohesive unit may require individual organizations to share their responsibility. It is crucial to keep the vision of what is best for children and families at the forefront and to help partners see the value of the streamlined and more cost-effective services that result from an integrated system.
  • Leadership matters. Relationships matter. As is so often typical in building collaboration, the close working relationship between two key individuals is a key factor in statewide collaboration. A shared vision and shared belief in the value of home visiting among leaders in two different departments in Vermont helped them align the state’s missions and model collaborative work in the state.


This article was originally published by the Home Visiting-Improvement Action Center Team (HV-ImpACT) at https://hvimpact.wordpress.com/2017/12/20/lessons-learned-on-systems-building-from-ohio-vermont/

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