Rachel Yard and Daniela Lewy, EdLD, MPH*June 25, 2020
Home visiting has long served an essential role in addressing the needs of young children by connecting families to programs, supports, and services. Home visitors — typically nurses, social workers, or community health workers supported by local, state, or federal funding — build relationships that extend beyond parenting and child development. During the COVID-19 pandemic, the need for home visiting — and pivoting to accommodate virtual home visits — is even more critical as families face new or expanding challenges, like domestic violence, substance use, or mental health needs — all issues that surge during crises.
An Increase in Demand
State leaders in New York, Rhode Island, Vermont, and Washington — all participants in Aligning Early Childhood and Medicaid, a national initiative led by the Center for Health Care Strategies with support from the Robert Wood Johnson Foundation — have seen the demand for home visiting increase since the pandemic began in March. Staff initially worried that visits would decline once they shifted to virtual visits, but the opposite has proven true. There has been an uptick in visit frequency, a decline in no-show rates, and previously disengaged families are back in touch with their home visitors. Vermont even has an increase in new enrollments since some families feel less intimidated by an initial phone call or video chat as opposed to an in-person session.
Key Roles of Home Visiting During COVID-19
The increased demand for home visiting validates the value that home visitors provide to families during COVID-19. Below are key roles that virtual home visitors are serving:
1. Meeting basic needs
The demand for basic needs, like diapers, wipes, and food, has skyrocketed. Home visitors are trained to be nimble in supporting parenting practices while simultaneously addressing challenges around food insecurity or housing instability. Staff is connected to local networks and comfortable working in crisis situations. In Rhode Island, staff regularly drop off supplies and ensure that families have food and formula. One home visitor left a bag of food on the doorstep of a young family, reporting that the children “cried with joy” because they finally had food they liked.
2. Providing a sense of normalcy
For single-parent families, the home visitor might be the only adult that they interact with in a given day, providing an emotional break during a time that is even more stressful than usual. Home visitors set up routines in the home, especially when parents are juggling the needs of school-age children, infants, household responsibilities, and employment. In Vermont, one home visitor dropped off pretzel mix to a family, then met them online to make pretzels together virtually while pointing out the developmental learning opportunities. Another home visitor learned that a family could not leave the house because they did not own a car seat. After searching Amazon, local hospitals, and WIC offices, the home visitor was able to get one from a local nonprofit; the mother was overwhelmed with gratitude upon seeing the seat on her stoop.
3. Supporting prenatal care
Prenatal visits are being delayed, rescheduled, or rerouted to new providers because of COVID-19. Furthermore, there is increased fear of giving birth in hospitals. Home visitors play a crucial role in educating families about safe birth plans, advocating for their prenatal visits, and providing support throughout the pregnancy and post-birth. In New York, one first-time mother was in her last month of pregnancy, and mistakenly thought that she did not have to go back to the doctor for four weeks. When the home visitor found out, she reached out to the mother-to-be to clarify and learned that in the meantime she had gone to the emergency department (ED), been diagnosed with a urinary tract infection, and was unable to get the prescription filled. She had since returned home and was experiencing severe back pain. The home visitor coached the woman to return to the ED, get the needed treatment, and see her OB/GYN regularly. The woman has since delivered a healthy baby boy, in part thanks to the home visitor who supported her.
4. Mitigating domestic violence
Domestic violence has increased worldwide during COVID-19 — home visitors are on the frontlines to identify and support families experiencing it. In New York, home visitors are trained to first ask the parent if they are comfortable speaking before continuing with a scheduled session. In one instance, a mother asked to reschedule when her partner would not be home. She was later supported to move to a domestic violence shelter. Home visitors are skilled at navigating these sensitive issues and provide critical support at a time when families are isolated and no one else is conducting in-home visits to recognize the signs of domestic violence.
5. Addressing racial disparities
The U.S. health care system is riddled with racial disparities. A Black woman is 243 percent more likely to die from pregnancy- or childbirth-related causes than a white woman. Additionally, African Americans have the highest infant mortality rate of any racial or ethnic group in the U.S. These outcomes of structural injustices are exacerbated during a pandemic when access to care, information, and support is limited. Home visiting is an evidence-based program recommended to address racial disparities because of its culturally responsive, community-driven approach. Health equity requires that every baby starts life with equal opportunity.
Opportunities to Support Home Visiting During Covid-19
The essential services provided by home visiting are not without challenges. Quickly pivoting to virtual sessions, securing sufficient resources, and reaching vulnerable families require new capabilities. Below are a few of the challenges to home visiting during COVID-19 and how states and providers are partnering to address them:
1. Provide access to technology
While broadband resources have been directed to families of K-12 students to support distance learning, the need for internet access for families with young children is largely being overlooked. One COVID-19 study of over 1,300 home visiting programs found that over half the families did not have access to the internet or a device to have a virtual visit. Advocacy for increased technological capacity for this demographic is underway but did not make it into recent federal legislation through the CARES Act or otherwise. Leaders of home visiting programs also articulated end-of-month challenges when government-issued phones run out of minutes. It is essential to bridge the digital divide to combat structural inequalities. Rhode Island created a guide for residents that details options for temporary free Internet/data allowances during COVID-19. Post-pandemic, technology needs to be embraced beyond a crisis-driven solution, but also as a complement to in-person services during healthy times.
2. Support home visitors
One strength of home visiting is that the staff often come from the same communities as the families they serve and share similar lived experiences. However, during a pandemic, this means that many staff are experiencing similar health hardships, family grief, economic strain, and childcare struggles. Leaders of home visiting programs in Rhode Island expressed the need for reflective practice and supervision during these unprecedented times. They said it has become easier to authentically ask a home visitor about their own personal challenges, and some teams speak less about their caseloads and more about their staff’s social-emotional needs during check-ins.
3. Include fathers
Before the pandemic, fatherhood programs were already limited and under-funded. Now, some of these programs have had to close. Shelter-in-place requirements can also disrupt fragile father-child relationships by preventing opportunities for consistent engagement. Virtual home visits could play a transformative role to include fathers in their child’s development, both during and after the crisis. In Washington, there is a particular focus on how to provide greater support to non-custodial fathers during COVID-19.
Invest and Scale What Works in Home Visiting
Hunger, housing insecurity, racism, and parental struggles have always been urgent issues for many families living in poverty. However, COVID-19 has also destabilized families who were previously secure. People from every walk of life now understand the delicate line that separates comfort from crisis. The visibility of these issues and surge in need compels the government to invest and innovate. Relationships are at the core of any high-quality program, and young children need stable, healthy environments to thrive. This critical moment in history can be used to strengthen programs, policies, and practices that connect America’s most at-risk children and families to resources and opportunities through home visiting.