Making a Difference for Families with Young Children · Making a Difference for Families with Young...

Making a Difference for Families with Young ChildrenThe Intersection of Home Visiting & Mental Health

Vicky Marchand October 2014

californiaPROJECT LAUNCH

ii Making a Difference for Families with Young Children: The Intersection of Home Visiting & Mental Health

Organizations

This work was funded by California Project LAUNCH, a grantee of the federal Project LAUNCH initiative funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). Over the past five years, California Project LAUNCH has aimed to increase the quality and availability of evidence-based programs, improve collaboration among child-serving organizations, and integrate physical and behavioral health services and supports for children and their families. Lessons learned from community-based initiatives will guide state level change and policy improvements. California Project LAUNCH is a partnership between the California Department of Public Health – Maternal, Child and Adolescent Health Program; First 5 Alameda County and WestEd Center for Prevention and Early Intervention.

The Center or the Study of Social Policy (CSSP) is a national, nonprofit organization recognized for its leadership in shaping policy, reforming public systems and building the capacity of communities. For more than 30 years, CSSP has translated research and new ideas into strategies for on-the-ground im-plementation. CSSP works to secure equal opportunities and better futures for all children and families, especially those most often left behind. This issue brief was developed as part of Early Childhood-LINC (Learning and Innovation Network for Communities), an initiative that is co-sponsored by CSSP and the Children’s Services Council of Palm Beach County.

Acknowledgements

Making a Difference for Families with Young Children: The Intersection of Home Visiting and Mental Health was developed by CSSP with the support and assistance of many people. This paper was informed by interviews with key informants – program administrators, researchers, and federal partners – who are developing innovative approaches to strengthening interventions so that families can thrive. The full list of interview participants is provided at the end. Patsy Hampton, California Project LAUNCH Project Director at WestEd Center for Prevention and Early Intervention, provided significant guidance. Becky Karush designed the publication.

Making a Difference for Families with Young Children: The Intersection of Home Visiting & Mental Health@ 2014, Center for the Study of Social Policy

Center for the Study of Social Policy1575 Eye Street, Suite 500 50 Broadway Suite 1504Washington, DC 20005 New York, NY10004202.371.1565 telephone 212.979.2369 telephone202.371.1472 fax 212.995.8756 faxwww.cssp.org

Making a Difference for Families with Young Children: The Intersection of Home Visiting & Mental Health iii

Table of Contents

Introduction Understanding the Unmet Mental Health Needs 1 among Families Receiving Early Childhood Home Visiting

Developing Solutions Approaches to Enhancing Mental Health Services 3

Mental Health Consultation for Home Visiting 6

Enhanced Mental Health Treatment for Families in Home Visiting 8 Integrated Intake 9

Challenges 10

Recommendations 13

References 16

IllustrationsFigure 1 4

Figure 2 5

Figure 3 14

Making a Difference for Families with Young Children: The Intersection of Home Visiting & Mental Health 1

IntroductionEarly childhood home visiting programs face a common struggle to respond to the mental health needs of very young children and their parents. Sites around the country have developed local innovations to increase the skills and knowledge of home visitors and/or to provide timely, responsive mental health treatment services for families. These solutions offer lessons about practices that create service efficiencies and contribute to improved outcomes for families. The next step is to take a systemic approach to building the infrastructure for integrated home visiting and mental health services.

In summer, 2014, California Project LAUNCH engaged the Center for the Study of Social Policy to conduct a national scan of strategies to enhance effective mental health services for families engaged in early childhood home visiting programs. The scan focused on innovations in practice through local efforts to align home visiting and mental health services. This report describes two approaches that address both the needs of families to access timely, effective interventions and the opportunity to build professional knowledge and skills. While there is little research to document the impact of these approaches in home visiting, evidence compiled through practice suggests that

• mental health consultation and• enhanced referral and coordination

contribute to improved outcomes for parents and young children. In addition, this scan highlights an opportunity to develop integrated intake systems that result in a better fit between families and services.

Understanding the Unmet Mental Health Needs among Families Participating in Early Childhood Home Visiting

Reaching Vulnerable Families

Home visiting from pregnancy through early childhood is a strategy for professionals to provide instruction, support, case management, and role modeling for families with very young children. Well-designed and well-implemented home visiting program models have demonstrated improvements in outcomes related to parenting behaviors and skills, children’s health and health care coverage and use, children’s development and school readiness, and family economic self-sufficiency (Boller, 2014).

Home visiting programs have successfully engaged families that face multiple personal and environmental problems that place them at high risk for mental illness. Beyond the challenges of raising young children, these families also face significant stressors, such as being young themselves, having attained limited education, being single and often isolated parents, or having incomes low enough to

2 Making a Difference for Families with Young Children: The Intersection of Home Visiting & Mental Health

qualify for public assistance (Boller, 2014). Many of these parents have experienced abuse or neglect, trauma, and exposure to community violence during their childhood or adolescence (Goodson, 2013).

A significant number of parents, predominantly mothers, engaged in home visiting services, are likely to experience low self-esteem, inadequate social support, and elevated stress which are all associated with mental illness. In populations served by home visiting, the prevalence of maternal depression ranges from 28 – 61 percent (Johnson, 2014). These factors have demonstrated an impact on a parent’s stress level stress and ability to respond to the needs of a very young child. Without effective treatment, maternal depression has been found to contribute to social and emotional impairments in young children, including poor attachment and regulation issues, behavioral problems, delayed language skills, and mood disorders later in life (First Five, 2013).

Revealing Needs of Families without Adequate Follow-up

Home visiting programs, often implemented locally by small non-profit organizations, have encountered a common challenge to serve parents struggling with symptoms of mental illness and to support them in accessing appropriate, affordable treatment services. All evidence-based models of home visiting recommend a standard for universal, periodic mental health screenings, although only a small portion of parents with depressive symptoms receive treatment (Goodman, 2013). Many home visitors do not have adequate training to effectively identify symptoms and provide appropriate referrals. Administrators interviewed suggest that the lack of appropriate treatment services, long wait lists, and past experience in mental health clinics are a significant deterrent for home visitors to identify mental health needs that are likely to remain unaddressed.

A cross-site evaluation of seventeen home visiting programs revealed that programs consistently struggled with client drop-out rates and with difficulty delivering services at the intended intensity. Younger, more economically disadvantaged, single parents were most likely to leave programs early. Home visitors describe mental health issues and family crises as some of the main obstacles that interfere with completing visits (Boller, 2014). In one study of the Hawaii Healthy Start Program, researchers found that home visitors only recognized 14% percent of all mothers with poor mental health (Ammerman, 2010). In other surveys, home visitors identify their own need for better knowledge and skills in working with families to address mental health concerns, and also note the lack of trusted referral options -- both areas for program improvement (First Five, 2013).

Many home visitors do not have adequate training to effectively identify symptoms and provide appropriate referrals.


Still, the relationship developed between home visitors and families offers the opportunity for on-going assessment of mental health needs and supported referrals for treatment when needed. Unlike mandated parent education, early childhood home visiting programs engage participants who accept services based on the quality of their relationship and their belief that the benefits merit their time (Boller. 2014). Home visitors work with families to define goals for all family members and monitor that plan during weekly visits. As one program manager observed, even when parents’ behaviors do not reach the level of clinical concern, home visitors can tell “when something isn’t right” and adjust services or engage specialists to prevent damage that can result from worsening symptoms (California Home Visiting Workgroup (CAHVWG), March, 2014).

Home visiting programs have found that despite the need, only a small number of women get connected to a mental health clinic following a referral. Those that do are not likely to find mental health providers with experience working with families with young children or knowledge about how first line medications impact parenting. The lack of effective referrals and connection to treatment services is documented, but the causes are unclear. An audit of treatment services in California found that women of child-bearing age were the least likely to access mental health services (CAHVWG, Aug. 7, 2014). Home visiting administrators interviewed cited the lack of appropriate services for this population and negative perceptions of mental health treatment as significant obstacles, even when a trusted home visitor provides the referral. They suggested that parents often do not follow up on referrals as a result of stigma, long waiting periods for services, challenging logistics of managing appointments with very young children, and uncomfortable experiences in mental health clinics.

The lack of effective referrals and connection to treatment services is documented, but the causes are unclear. An audit of treatment services in California found that women of child-bearing age were the least likely to access mental health services (CAHVWG, Aug. 7, 2014). Home visiting administrators interviewed cited the lack of appropriate services for this population and negative perceptions of mental health treatment as significant obstacles, even when a trusted home visitor provides the referral. They suggested that parents often do not follow up on referrals as a result of stigma, long waiting periods for services, challenging logistics of managing appointments with very young children, and uncomfortable experiences in mental health clinics.

Developing Solutions

Approaches to Enhancing Mental Health Services

Home visiting programs have collaborated locally to create protocols for better addressing the needs of families who raise concerns related to mental illness. Patterns emerge from this scan of innovative early childhood home visiting programs that can be grouped under two strategies:


• Mental Health Consultation for Home Visiting• Coordinated Mental Health Treatment for Families in Home Visiting

Adapting the “pyramid model” from the Center for Social Emotional Foundations of Early Learning illustrates the portion of the home visiting population targeted by each approach (Figure 1). Each approach provides opportunities for systemic enhancements to both (a) engage families who need specialized care in more effective services and (b) increase the capacity of home visitors and mental health professionals to be responsive to the individualized needs of each family (Figure 2). These approaches may be implemented independently or in combination, depending on local priorities, resources, and expertise.

As the result of consistent, though anecdotal, reports of the benefits of mental health enhancements in home visiting programs, the national offices of the evidence-based home visiting models, including Nurse Family Partnership and Healthy Families America, are exploring how these approaches can function as enhancements without detracting from the fidelity of model implementation. In addition to strengthening operations at the program level, efforts to work across multiple home visiting programs at the community level may contribute to the development of meaningful infrastructure to support new ways of doing business. Multiple programs working together to increase protective factors

FIGURE 1: The Two Mental Health Enhancements Described Focus on Different Components of the Population of Families Engaged in Home Visiting

Adapted from the Center for Social Emotional Foundations of Early Learning Pyramid Model (2014)

Intensive Intervention

Targeted Social & Emotional Strategies &

Supports

High Quality Supportive EnvironmentsNurturing & Responsive Relationships

Enhanced Mental Health Treatment

Mental Health Consultation

}}


associated with the prevention of mental illness and the development of more effective family-driven treatment interventions may achieve desired results at the population level. Alameda County in California is engaged in a “Home Visiting/Family Support System of Care” initiative, which integrates both of the described approaches and is expected to create efficiencies in program management, allowing limited funding to enhance services and have stronger countywide impact (Brief, 2014).

Some agencies and organizations that have worked together to find solutions to the challenges of aligning home visiting and mental health services have focused on how families access services in order to further reduce fragmentation. “Integrated Intake” can lead to further operational efficiencies and may result in a better fit for families and services, particularly since many communities have multiple home visiting programs.

FIGURE 2: Mental Health Enhancements to Home Visiting

kkk MENTAL HEALTH CONSULTATION

Mental health professional hired by or co-located with home visiting program

kkk KEY FUNCTIONS• Consultation to home visitors

• Training for home visitors• Reflective supervision with home visitors

• Case consultation• Building referral relation-ships

• Warm referrals to mental health treatment as appropriate

kkk

BENEFITS

+ professional development+ staff competency & retention+ parent retention in home visiting program; increased satisfaction+ effective referrals+ shape referral network+ triage capacity

kkk

CHALLENGES

• Increased admin. costs

• No impact on capacity & quality of appropriate referrals for treatment

• Can create disparities among home visiting programs

• No payer for non- clinical time

kkk ENHANCED MENTAL HEALTH TREATMENT FOR FAMILIES

Provide effective, home-based treat-ment for families who have concern-ing behaviors or are diagnosed with mental illness

kkk

KEY FUNCTIONS

• Assessment & facilitated referral for services

• Shared case coordination with home visitor

• Specializes in treatment services for families with young children in poor mental health

kkk

BENEFITS

+ no/reduced delay in accessing services+ effective referrals + parent retention in services (can be monitored across programs)+ shifting “leads” over time to respond to family changes/ development+ increased collaboration among programs+ treatment is billable for diagnosed clients

kkk

CHALLENGES

• Agency and system obstacles – separate home resources; data systems, etc.

• Training gap• No support for other family members


Mental Health Consultation for Home Visiting

Building on the demonstrated effectiveness of mental health consultation in child care, a growing number of home visiting programs have added a mental health provider to the management team for their program. Infant and Early Childhood Mental Health Consultation (IECMHC) is a preventative strategy that teams mental health professionals with people who work with young children and their families to improve their social, emotional, and behavioral health and development. IECMHC builds the capacity of providers and families to manage the powerful influence of their relationships and interactions on the development of very young children. (SAMHSA convening, 2014).

The mental health consultant works at multiple levels tailoring services for children and families, addressing professional development of home visitors, and building the capacity of programs and systems around the promotion of mental health and the reduction of mental health problems. The consultant provides some combination of training for home visitors, reflective supervision, assessment and planning for individual families, and referrals to services to address mental health concerns. Although the mental health consultant may not be employed directly by the home visiting program, he or she typically functions as part of the staff, participating in administrative meetings as well as being easily available to home visitors who seek guidance about working with individual families.

Mental health consultation may be an allowable cost for home visiting programs, including those funded by Maternal Infant Early Childhood Home Visiting (MIECHV) Program. However, this enhancement is not a component of core operations related to implementing the evidence based models, so it was not initially a priority until the challenges surfaced for local programs. In response, local programs have accessed Federal, State, and philanthropic funds focused on service integration and infrastructure to forge collaborative approaches and add staff as consultants with a background in supporting women of childbearing age, family support, and parenting and child development as consultants. A review of twelve Project LAUNCH sites in 2013 identified eight home visiting programs using funding from the Substance Abuse and Mental Health Service Administration to implement early childhood mental health consultation (Goodson, 2013).

The authors of this review of LAUNCH sites proposed a pathway that resulted in increased capacity of home visitors, including:

• Increased knowledge about child development, infant and child mental and behavioral health, and parent mental and behavioral health;

• Increased capacity to solve problems with families around mental health related issues;

• Increased knowledge of appropriate follow-up services to address mental health concerns; and

• Reduced job-related stress, including increased sense of support and increased feelings of efficacy with families.


These benefits for home visitors contribute to increased effectiveness in supporting family needs and goals, reduced staff turnover, and increased staff satisfaction. Enhancing these program outcomes leads to improved outcomes for parents and children, including improved maternal mental and physical health, increased protective factors and decreased risk factors for children, and improved child social, emotional, and behavioral health (Goodson, 2013). Their job satisfaction is likely to result in efficiencies related to a more experienced and skilled staff. For example, a survey of home visitors in Alameda County California found that access to a mental health consultant increased their knowledge and skills which in turn improved their relationship with families and changed how they worked with mental health service providers in the community (First Five, 2013).

Experience with this approach also suggests the opportunity for effective prevention of mental illness by addressing environmental stressors and behaviors at a subclinical level. It is important for everyone involved to understand the roles of service providers and how the systems can be supported to work together. Home visitors are not qualified to provide treatment for mental illness, but they can develop the skills to work more effectively with new parents who have experienced abuse or other trauma. In Louisiana, home visitors’ experience with mental health consultation with home visiting led to the development of a 36-hour mental health training which is required for all home visitors statewide. In New York City, a small initiative piloting mental health consultation with Nurse Family Partnership teams is being expanded to train NFP nurses to become Reflective Practice Facilitators to sustain and expand reflective supervision throughout the city (NYC Project LAUNCH, 2014). Illinois has established a mental health consultation certificate which was expanded to home visiting programs in 2013 (ICMHP, 2013).

Home visiting staff in programs with mental health consultation may also develop more specialized triage skills to identify better those families who are suffering from a diagnosable condition and to link parents to the most appropriate treatment services. As home visitors conduct periodic screenings and deepen their relationship with the family, they may learn more about prior trauma or symptoms of mental illness which are interfering with the mother’s parenting or capacity to work towards goals she has defined for herself and her family. As a result, families referred for mental health treatment are more likely to engage in and benefit from appropriate treatment. The mental health consultant can facilitate a “warm hand-off” in which therapists are introduced to mothers and the information collected for assessment may be more nuanced. Improved judgments about which families really need more intensive interventions may result in reducing the demand for severely

Experience with mental health consultation for home visiting suggests the opportunity for effective

prevention of mental illness by addressing environmental stressors and behaviors at a subclinical level..


limited treatment services, help to sustain collaborative efforts and result in reduced life-time costs for services (Johnson, 2014).

Enhanced Mental Health Treatment for Families in Home Visiting

To address the need for more intensive mental health services for some families participating in home visiting, a growing number of communities are focusing on the intersection of the existing mental health system and home visiting programs. This approach emphasizes coordination through three components:

• a quick process for assessment following a screening to identify concerns;• providing treatment services in the family’s home; and• utilizing interventions that focus on the needs of young adults and young

children (i.e. short-term, trauma-informed, cognitive behavioral focus).

Though home visitors and mental health professionals work together closely, staff typically function from their traditional agency or organizational home. Mental health professionals establish regular communication with home visiting programs and provide mental health interventions, sometimes exclusively, for families participating in home visiting with identified mental health concerns.

When a home visitor identifies concerns through administering a depression or anxiety screening or observes worrisome behaviors, she makes a referral and initiates a timely assessment and follow-up protocol. In most cases this approach is used when the public department responsible for mental health care or public health has committed staff to working with families engaged in home visiting. These mental health professionals often have some experience working in the home environment and bring expertise or engage in additional training focusing on the needs of young parents. Though the staff continues to work for different organizations, co-location of staff seems to be an important element to facilitate communication and add the nuanced information which is difficult to capture in written referrals.

In response to the identified need for additional support to work with mothers experiencing significant symptoms of mental illness in Los Angeles County, the Department of Mental Health allocated a licensed clinical social worker to provide home-based therapy. Funded with local Mental Health Services Act funds, these clients do not need to have a mental health diagnosis to access services. According to reports from the Nurse Family Partnership, their experience suggests that short-

To address the need for more intensive mental health services for some families participating in home visiting, a growing number of communities promote collaborations between the existing mental health system and home visiting programs.


term, trauma-informed interventions have effectively reduced the anxiety of moth-ers and allowed them to recognize how their history was interfering with their parenting.

Every Child Succeeds, a home visiting program in Cincinnati, acted a need to respond to:

1. the high prevalence of clinically significant depression in participating mothers; 2. the enormous difficulty experienced by depressed mothers in obtaining

effective treatment in community settings; and 3. the growing literature indicating that depressed mothers have poorer

outcomes in home visiting programs. They developed Moving Beyond Depression, a comprehensive, in-home approach to identifying and treating depressed mothers. It leverages ongoing home visiting to improve engagement of mothers in treatment, is delivered in the home setting, and explicitly creates a collaborative relationship between the therapist and home visitor in order to optimize outcomes. It is culturally sensitive and adaptable, and has been used with racially and ethnically diverse populations (Johnson, 2014).

Integrated Intake

Although not really a mental health enhancement, new relationships between mental health providers and home visitors have promoted other efforts to improve the delivery of services, such as integrating intake practice. Finding and accessing home visiting services often depends on how each program markets itself and factors such as where the baby is delivered or whether a parent accesses WIC or whether the family has a history with the child welfare system. Some communities have established home visiting collaboratives committed to achieving the best fit for each family and supporting parents as decision-makers no matter how they enter the network of services. These communities have taken steps to centralize the intake process, so no matter how families find services, there is a system for doing the initial collection of information about family circumstances and interests.

This collaborative approach may be most impactful in communities with multiple home visiting programs, such as the example in Alameda County, California, which has ten early childhood home visiting programs currently operating. In Palm Beach County, Florida, the Children’s Services Council manages a centralized intake and placement system for a large coalition of early childhood services providers. If a mental health concern is identified at this point, participants can be engaged with home visitors who have more training or have access to mental health consultation or treatment. Giving participants a voice in shaping the services they access reflects principles of trauma-informed practice. Trauma-informed practice acknowledges the power of past experiences as a way to make progress toward recovery and takes a collaborative approach, where healing is led by the client and supported by the service provider. By taking a comprehensive look at family needs and services, the Children’s Services Council identified a need for more intensive home visiting programs for families with mental health concerns and is exploring implementing


the Child First program, an evidence-based home visiting model with an emphasis on mental health services.

Integrated intake requires partnerships among professionals working with young families across programs and may provide the foundation needed to achieve the full potential of collective impact. Home visiting can act as a catalyst for working at the population level and contribute to building the infrastructure and capacity for agreement upon desired results, continuous communication, and shared measurement (Kania, 2011). The Evidence-Based Home Visiting evaluation found that partners reported that the quality of collaboration matters. Building shared infrastructure among service providers (such as fundraising, community awareness and political support, communications, quality improvement and evaluation) contributed to a programs ability to meet model standards, scale-up, and sustain operations (Boller, 2014).

Challenges

Staff leading service integration efforts require a specialized set of skills and abilities. Experience with both consultation and embedded referral systems suggest that the experience and training of mental health staff is critical to the success of the enhancement. Programs have found that experience in home visiting significantly strengthens the credibility of mental health consultants and strengthens their ability to effectively coordinate care. In addition, mental health consultants to early childhood home visiting program may wear many hats including trainer, case supervisor (but not typically formal supervisor), clinician, resource and referral manager, and coalition manager. The Alameda County Public Health Department released a Duty Statement for a Mental Health Specialist which captures the complex skill set needed. Experience in Cincinnati providing training and coaching for mental health professionals to provide Moving Beyond Depression suggests that their comfort with home-based practice and managing the geographic spread of clients are critical to their success (Ammerman interview, 2014).

Collaboration takes time. Case management and mental health treatment have relied heavily on a fee-for-service model that only recognizes and pays for time with clients. These approaches for service integration require substantial consultation to determine the level of therapeutic intervention needed and coordinate care, as well as additional travel time associated with home-based services. Given the time requirements, caseloads are likely to be smaller for mental health professionals working with these mental health enhancements and the financing strategy must cover the time spent outside of the direct services to clients.

Existing data systems do not support efficient communication or tracking impact across service delivery systems. All of the sites interviewed reported ongoing challenges with multiple data systems that make it difficult to collect meaningful data about the impact of mental health enhancement efforts. While staff surveys consistently show an increased sense of efficacy with families, the data collection and reporting requirements for each program are maintained completely


separately and do not facilitate coordination. As professionals reform their practice, it is important for the infrastructure, including data systems, to support new relationships and functions. However, maintaining separate records allows for appropriate confidentiality between professionals which may be important to participants. As Alameda County, California expands its service integration efforts, it is facing this challenge head on with a commitment to the collection of common indicators and benchmarks across home visiting program and the use of data systems that interface with one another to optimize assessment of program outcomes and evaluation of system-wide impact (Brief, 2014).

Research across sites is needed to document the benefits of enhanced mental health approaches. The innovations described in this report resulted from experienced leadership finding solutions to immediate operational challenges informed by research in other fields, such as mental health consultation in early care and education settings. Both the value for staff and the benefits for parents and children are based on anecdotal feedback. As these interventions become more clearly defined and incorporated into the evidence-based home visiting models, they are ripe for research initiatives to document their impact and better understand the mechanisms driving change. Multiple research efforts are in the early stages including an evaluation of the Louisiana initiative and the Home Visiting Research Network, a national initiative to shape and implement a research agenda to guide program quality and test innovations (HRVN, 2013). In addition, there is a growing body of research about effective mental health interventions with this population, such as the Moving Beyond Depression program (Ammerman, 2014).

Existing funding streams create barriers to establishing and sustaining mental health enhancements to home visiting. Local sites have implemented mental health enhancements using varied financing strategies, including MIECHV funding, Medicaid case management reimbursement, child abuse prevention funds, state mental health funds, comprehensive early childhood systems resources, research and other grants, and local tax dollars. When mental illness is diagnosed, Medicaid can pay for treatment services in accordance with the state plan. However, the costs of time and resources needed for collaboration and systems development are likely to be counted as administrative time and require flexible money. Given competition among evidence-based home visiting models, increased cost to the program from mental health enhancements may be used as justification to invest in a less costly model, especially if the increased benefits are not well documented. Also, the burdensome reporting requirements of different funding streams can be a significant disincentive to braiding funds.

Ongoing challenges with multiple, non-compatible data systems and

reporting requirements make it difficult to monitor the impact of

mental health enhancement efforts.


Recommendations• Compile data across home visiting programs to capture the

prevalence of mental health concerns among engaged families and the effectiveness of current referral and support strategies.

• Integrate mental health specialists into home visiting operations to build the capacity of home visitors to effectively identify and address mental health issues among families – parents and children -- engaged in home visiting.

• Support collaborative partnerships between home visiting programs and mental health providers to take advantage of opportunities to increase coordination and enhance referral and treatment services.

• Adopt the Infant-Family Early Childhood Mental Health Personnel Competencies for home visiting mental health consultants. Inventory available training curricula and courses related to maternal and early childhood mental health to promote professional development for home visitors.

• Conduct evaluations of existing mental health enhancements in home visiting programs to build research evidence for the effectiveness of these approaches, particularly on parent and child outcomes.

• Explore opportunities both for program improvement within evidence-based home visiting models and for coordination at the community level working across existing home visiting programs to provide quality choices and individualized placements for vulnerable families.

• Promote policies to establish reliable state and federal funding streams for mental health consultation and coordination with home visiting, such as Mental Health Services Act funds, MIECHV, and MediCal reimbursement.


FIGURE 3Examples of Mental Health Consultation in Home Visiting

Louisiana – Louisiana’s Infant Mental Health Consultation Augmentation for home visiting has led to the development and implementation of a statewide training requirement for all home visitors and the addition of licensed mental health professionals as integral members of home visiting teams. With increased staff knowledge, skills, and confidence, the Nurse Family Partnership has implemented a systematic assessment process with regular client-completed “Mental Health Check Ups” (focusing on depression and anxiety) and a nurse assessment addressing the history of mental health treatment, medications, observations and concerns. This information supports better judgment about when a referral to a mental health specialist or community mental health resources is merited.

Alameda County, California – A mental health clinician was hired with Project LAUNCH funding to work with existing public health home visiting programs to mentor and consult on cases with home visitors, to provide limited direct mental health services, and to make referrals to mental health treatment as appropriate. The mental health consultant has been instrumental in forging partnerships and building infrastructure, including current efforts to build a countywide “Home Visiting/Family Support System of Care.” As the Project LAUNCH grant was ending, county leadership agreed to support this position through the Alameda County Department of Public Health and to hire two additional home visiting mental health specialists.

Illinois – The Early Child Home Visiting Consultation Project is a statewide effort to increase the capacity of home visiting programs to recognize and address the needs of young children and their parents and to develop a well-trained cadre of experienced Infant and Early Childhood Mental Health Consultants. There are six evidence based home visiting models in operation in hundreds of sites throughout the state. Selected sites are awarded $18,000 per year to develop a contract with an early childhood mental health consultant, which generally covers 20 hours per month. The responsibilities of the consultant are defined at the state level and implemented by local programs.

Examples of Enhanced Mental Health Treatment for Families

Los Angeles, California – Guided by a Memorandum of Understanding, the Los Angeles Department of Mental Health assigned a mental health specialist to provide short-term, home-based services to mothers engaged in the Nurse Family Partnership (not subject to restrictive eligibility for traditional DMH services). The mental health specialist performs mental health assessments with families when requested by home visitors and provides brief follow-up preventative mental health interventions as needed. A recent survey found that 90% of the 134 clients seen by the mental health consultant had observable improvements in attitudes and moods. These clients did not need additional referrals for mental health care.

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FIGURE 3 continuedExamples of Enhanced Mental Health Treatment for Families

San Mateo, California – The San Mateo Department of Mental Health (DMH) has assigned two therapists, with experience working with young parents, to work with teen parents engaged in the Nurse Family Partnerships. The bilingual mental health specialists are co-located with the home visitors and participate in staff meetings and regular case coordination for shared clients. When a referral is made, there is no wait to access services and the therapists do home visits. DMH bills for services when clients are covered by MediCal or Healthy Kids.

Cincinnati, Ohio – Every Child Succeeds operates two national models: 10 Healthy Families America sites and one Nurse Family Partnership site. Each month, more than 160 referrals are made to ECS. The Maternal Depression Treatment Program (MDTP) provides In-Home Cognitive Behavior Therapy (IH-CBT), an adapted form of cognitive behavior therapy, to clinically depressed mothers enrolled in Every Child Succeeds. Provided by a trained therapist in the home, IH-CBT helps effectively treat depression, prevent relapse and maximize the impact of home visitation.

New York, New York – The New York City Nurse Family Partnership hired two clinicians to provide mental health support for the programs three sites. Primary responsibilities include training for nurses in mental health and use of assessment tools and supporting nurses as they address the emotional difficulties that arise when dealing with the traumas faced by their families, as well as supporting strategic partnerships with community organizations and alliances with public agencies. With private funding, NFP has hired a clinical social worker to provide individual counseling and support groups for families engaged in NFP.


ReferencesAlameda County Public Health Department. “Mental Health Specialist Duty Statement” December, 2013.

Ammerman, Robert, Frank Putnam, Nicole Bosse, Angelique Teeters, Judith Van Ginkel. (2010) Maternal depression in Home Visiting: A Systematic Review. Aggressive Violent Behavior, 15(3), 191-200.

Ammerman, R.T., Putnam, F.W., Altaye, M., Stevens, J., Teeters, A.R., & Van Ginkel, J.B. (2013). A clinical trial of In-Home CBT for depressed mothers in home visitation. Behavior Therapy.

Ammerman, R.T., Putnam, F.W., Altaye, M., Teeters, A.R., Stevens, J., & Van Ginkel, J.B. (2013).Treatment of depressed mothers in home visiting: Impact on psychological distress and social functioning. Child Abuse & Neglect, 36, 544-554.

Boller, Kimberly, Deborah Daro, Patricia Del Grosso, Russell Cole, Diane Paulsell, Bonnie Hart, Brandon Coffee- Borden, Debra Strong, Heather Zaveri, and Margaret Hargreaves. “Making Replication Work: Building Infrastructure to Implement, Scale-up, and Sustain Evidence-Based Early Childhood Home Visiting Programs with Fidelity.” Children’s Bureau, Administration for Children and Families, U.S. Department of Health and Human Services. June 2014. Contract No.: GS-10F-0050L/HHSP233201 200516G.

Brief “Alameda County’s Home Visiting/Family Support System of Care” January, 2014.

California Project LAUNCH, “Integrating Mental Health Supports into Home Visiting Programs.”

Center for the Study of Social Policy. Strengthening Families. ”Mental Health Consultation,” n.d.

Goodson, B.D., Mackraing, M., Perry, D.F., O’Brian, K, and Gwaltner, M.K. Enhancing Home Visiting With Mental Health Consultation. Pediatrics. 132, S180 – S190. November, 2013.

Home Visiting Research Network. National Home Visiting Research Agenda. 2013. Available at: http://hvrn.org/uploads/3/2/1/0/3210553/home_visiting_research_agenda_2013_10_29_final.pdf

Illinois Children’s Mental Health Partnership. Early Childhood Mental Health Consultation to Home Visiting Programs: Addressing the Unmet Mental Health Needs of Families with Young Children. 2013. http://icmhp.org/icmhppublications/files/ICMHP-HFI-ReportFinal-08-24-13.pdf

Johnson K., Ammerman R.T., and Van Ginkel J.B. Moving Beyond Depression. An Effective Program to Treat Maternal Depression in Home Visiting: Opportunities for States. Every Child Succeeds, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. July, 2014.


Kania, John, and Mark Kramer. “Collective Impact.” Stanford Social Innovation Review (2011): n. pag. www.ssireview.org/articles/entry/collective_impact

NYC Project LAUNCH. “News from NYC Project LAUNCH,” Issue #3, June, 2014.

PEW Charitable Trusts. (January, 2013) Expanding Home Visiting Research: New Measures of Success. Washington, DC. www.pewstates.org/uploadedFiles/ PCS_Assets/2013/HOME_Summit_Brief.pdf

Zero To Three, MIECHV Technical Assistance Coordinating Center Webinar. “Responding to Behavioral Health Needs for Families in Home Visiting through Systems Integration.” February, 25, 2014.

Interviews & WorkgroupsRobert Ammerman, Every Child Succeeds, Cincinnati Children’s Medical Center

Deborah Daro, Chapin Hall Senior Research Fellow, University of Chicago

Lisa Erickson, First Five Alameda County

Anna Gruver, Maternal, Paternal, Child, Adolescent Health Coordinator Alameda County Public Health Department

Lizelle Lirio De Luna, San Mateo Department of Public Health

Kathleen Kilbane, Health Research Services Administration, US Dept of Health and Human Services

Jennifer Oppenheim, Project LAUNCH, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services

Tanya Palmer, Palm Beach County Children’s Services Council

Jeanne Smart, Nurse Family Partnership, Los Angeles Department of Health

David Willis, Health Research Services Administration, US Dept of Health and Human Services

Paula Zeanah, Tulane University & Louisiana’s MIECHV Program

California State Interagency Team for Children, Youth and Families Home Visiting Program Workgroup, May 29, 2014 and August 7, 2014

Substance Abuse and Mental Health Services Administration Expert Convening on Early Childhood Mental Health Consultation, September 11-12, 2014.

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