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National Home Visiting Resource Center

Helping children and families thrive.

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Home Visiting's Reach

Early childhood home visiting helps families meet children’s needs during the critical first 5 years of development. The newly released 2022 Home Visiting Yearbook explores home visiting at the national and state levels.

~17.3 million

pregnant women and families could benefit from home visiting nationally

Building on Strengths: Reaching Unhoused Families With Home Visiting Parent Support Programs

Home visiting is uniquely positioned to reach unhoused families and help them meet basic needs while supporting strong parenting skills and healthy child development. In this video, we learn how Lydia Places offers Parents as Teachers home visiting as part of a comprehensive approach to serving unhoused families.

Stay up to date on the latest home visiting information.

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Steps for Conducting a Home Visit

Establishing Trust and Connection

Meeting the family on its home ground may contribute to their sense of control and active participation in planning and achieving health goals.

Phases/Activities of a Home Visit

Initiation Phase

• Identify source of referral for visit
• Clarify purpose for home visit
• Share information on reason and purpose of visit with family

Pre-Visit Phase

• Initiate contact with mother/family
• Establish shared perception of purpose with mother/family
• Determine mother/family’s willingness for home visit
• Schedule home visit
• Review referral and/or family record

In-Home Phase

• Introduction of self and identity
• Social interaction to establish rapport
• Establish relationship
• Implement educational materials and/or make referrals
• Review visit with family
• Plan for future visits as needed

Post-Visit Phase

• Record visit and plan for next visit
• Follow-up with educational materials and/or referrals

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Direct Service Providers for Children and Families: Information for Home Visitors

How home visitors can protect themselves and their clients from COVID-19 and other diseases that can be spread from person to person.

• Direct Service Providers
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Home-visiting professionals, or home visitors, provide many needed services directly to children and families in their home. These direct service providers can include maternal, infant, early childhood, and early intervention home visitors. They also may be teachers and therapists who provide needed services for infants, children, and teens, including those with disabilities. When in-person services are delivered, they are often done in close and consistent contact with the clients. This means that it is important to use prevention strategies to protect the home visitor and the family from diseases that can be spread from person to person, such as COVID-19, but also flu, colds, and other respiratory or gastrointestinal illnesses. In addition, home visitors are trusted sources of information and support for families, particularly those who experience health inequity . This page provides an overview of how home visitors can protect themselves and their clients during home visits.

Strategies to prevent the spread of COVID-19

With current high uptake of COVID-19 vaccination and high levels of population immunity from both vaccination and infections, the risk of medically significant disease, hospitalization, and death from COVID-19 is greatly reduced for most people. At the same time, we know that some people and communities, such as our oldest citizens, people who are immunocompromised, and people with disabilities, are more likely to get severely ill and face challenging decisions navigating a world with COVID-19.

People who are up to date on COVID-19 vaccines have much lower risk of severe illness and death from COVID-19 than unvaccinated people. However, many home visitors work with children who are not yet eligible for vaccination. When making decisions about preventive behaviors in addition to vaccination, people should consider the COVID-19 Community Level in the county. These levels show the degree of risk (low, medium, high) and describe the prevention strategies that are recommended for each level. Prevention strategies — like staying up to date on vaccines, screening testing, ventilation, and wearing masks — can help limit severe disease and reduce the potential for strain on the healthcare system. For home visitors who work with children, it may not be feasible to use all recommended prevention strategies. Therefore, particularly in communities with medium or high COVID-19 levels, home visitors should use multiple layers of recommended COVID-19 strategies to the extent possible while also following any applicable guidance from regulatory agencies and state and local public health departments.

The following information is a brief overview of strategies that home visitors can use when working with children and families. Detailed information about ways home visitors can protect themselves is in the COVID-19 Guidance for Direct Service Providers (cdc.gov) and in the COVID-19 Guidance for Operating Early Care and Education/Child Care (ECE) Programs (cdc.gov)

Ways home visitors can protect themselves and the families they serve:

1. vaccination.

Vaccination is the leading public health prevention strategy to end the COVID-19 pandemic. COVID-19 vaccines available in the United States are effective at protecting people from getting seriously ill, being hospitalized, and dying from COVID-19. As with vaccines for other diseases, people who are up to date with their COVID-19 vaccines  are best protected.

Home visitors can protect themselves, their own families, and the families they care for by staying up to date with all vaccinations, including COVID-19 vaccines. As trusted professionals who know their families well, home visitors can play a role in helping families learn about the importance of vaccines and about supporting children’s healthy development by keeping up to date on all well visits and preventive screenings, such as screening for developmental delays and lead poisoning. They can help connect the family to a regular primary healthcare provider who provides consistent and supportive health care and serves as the family’s medical home. They can remind families that children should get all routine vaccinations to help protect themselves and others from vaccine-preventable diseases , and that family members who are up to date on all vaccines protect children who are not yet old enough to get all vaccines.

Families who are not up to date with all vaccinations may have questions and concerns about the vaccines. Home visitors can promote vaccines by:

• Encouraging families to connect with a regular primary healthcare provider and stay up-to-date on COVID-19 vaccines.
• Sharing information with parents and caregivers to answer questions and help with any worries and concerns: COVID-19 Vaccines for Children and Teens, Frequently Asked Questions about COVID-19 Vaccination in Children, and Resources to Promote the COVID-19 Vaccine for Children & Teens .
• Using the strategies that health care providers use to help with worries and concerns: Talking with Patients about COVID-19 Vaccination , Frequently Asked Questions about COVID-19 Vaccination .
• Helping families who have worries and fears about needles for themselves and their children: Needle Fears and Phobia – Find Ways to Manage .
• Finding ways to support COVID-19 vaccination in their ECE programs .

2. Ventilation

Improving ventilation is an important COVID-19 prevention strategy that can reduce the number of virus particles in the air. Along with other preventive strategies , bringing fresh outdoor air into a building helps keep virus particles from concentrating inside. Home visitors can improve ventilation or ask families to improve ventilation during the visit by

• Opening multiple doors and windows, if feasible.
• Using child-safe fans to increase the effectiveness of open windows.
• Using the exhaust fan  in the kitchen or bathroom to increase air flow, particularly if opening windows is not possible.
• Using portable HEPA air cleaners .
• Visiting with the child outdoors when possible.

Learn more about encouraging families to improve the ventilation in their home .

3. Hygiene: Respiratory Etiquette, Handwashing, Cleaning, Sanitizing, and Disinfecting

Home visitors can limit the spread of illnesses by following all guidance on cleaning, sanitizing, and disinfecting. During home visits, many activities may involve touching children, and infants and toddlers often need to be held.  For COVID-19 in general, cleaning once a day is usually enough to sufficiently remove potential virus that may be on surfaces. However, in addition to cleaning for COVID-19, home visitors should practice and encourage families to practice respiratory etiquette and recommended procedures for cleaning, sanitizing, and disinfection, such as after diapering, feeding, and exposure to bodily fluids. See more information about cleaning and sanitizing toys .

Home visitors can use the following strategies:

• Use respiratory etiquette, including covering coughs and sneezes and washing hands immediately after blowing the nose, coughing, or sneezing.
• If handwashing is not possible, use hand sanitizer containing at least 60% alcohol. Hand sanitizers should be stored up, away, and out of sight of young children and should be used only with adult supervision for children under 6 years of age or for children with certain disabilities that make it hard for the child to use hand sanitizer safely on their own.
• Avoid touching the eyes while holding, washing, or feeding a child.
• Wear disposable gloves during activities such as dressing, bathing/showering, toileting, feeding. Safely dispose of gloves after use. Wash hands before and after taking off disposable gloves. If gloves are unavailable, wash hands immediately after.
• Change clothes right away if body fluids get on them, whenever possible, and then rewash hands. Launder work uniforms or clothes after each use with the warmest appropriate water setting for the items and dry items completely.
• Wash anywhere that was in contact with a child’s body fluids and follow recommendations on  cleaning and sanitizing toys, other learning tools , and assistive devices, particularly if they were in contact with body fluids.
• Follow recommendations for cleaning and disinfecting the home if someone is sick, or tests positive for COVID-19.

When people ages 2 and older wear a well-fitting mask correctly and consistently, they protect others as well as themselves  from infections that are spread through the air or through respiratory droplets. Consistent and correct mask use is recommended in public settings in communities with high COVID-19 Community Levels, and around people at high risk for severe disease in communities with medium COVID-19 Community Levels. At all COVID-19 Community Levels, people can wear a mask based on personal preference, informed by personal level of risk. People with symptoms of COVID-19, people with a positive COVID-19 test results who are around other people, and people who are quarantining because of a close contact, should wear a mask.

Masks should not be worn by children under age 2. Some older children or adults cannot wear a mask, or cannot safely wear a mask , because of a disability as defined by the Americans with Disabilities Act (ADA) (42 U.S.C. 12101 et seq.).

When choosing a mask , home visitors can consider fit, comfort, and the special needs of the people around them. To facilitate learning and social and emotional development, consider wearing a clear mask or cloth mask with a clear panel when interacting with young children, children learning to speak or read, children learning another language, or when interacting with people who rely on reading lips. Generally, vinyl and non-breathable materials are not recommended for masks . However, for ease of lip-reading, this is an exception to that general guidance.

5. Physical Distancing

It is generally recommended that people maintain a distance of at least 6 feet from persons who are sick with COVID-19. However, maintaining physical distance between a home visitor and their clients is often not feasible during home visiting, especially during certain activities such as physical therapy, feeding, holding/comforting, and among younger children in general. When it is not possible to maintain physical distance in home visiting settings, it is especially important to layer multiple prevention strategies, such as masking indoors, improved ventilation, handwashing, covering coughs and sneezes, and regular cleaning to help reduce COVID-19 transmission risk.

6. Isolation and Quarantine

People who are confirmed to have COVID-19 or are showing symptoms of COVID-19 need to stay home (known as isolation) regardless of their vaccination status. This includes

• People who have a positive viral test  for COVID-19, whether or not they have symptoms .
• People with symptoms  of COVID-19, including people who are awaiting test results or have not been tested. People with symptoms should isolate even if they do not know if they have been in close contact with someone with COVID-19.

People who come into close contact with someone with COVID-19 should quarantine if they have not had confirmed COVID-19 within the last 90 days and are in one of the following groups:

• Infants and young children who are not eligible for vaccination based on age .
• Staff and older children who are not up to date with COVID-19 vaccines (have not received all recommended COVID-19 vaccines, including any booster dose(s) when eligible ).

Home visitors can encourage families to monitor children at home for fever (a temperature of 100.4 ºF (38.0 ºC)  or other signs of illnesses that could be spread to others [PDF – 1 page] , including COVID-19, and adjust visit schedules if needed. Services may be provided virtually during quarantine or isolation if feasible.

Learn more about CDC guidance on COVID-19 Quarantine and Isolation and about making decisions about the length of quarantine and isolation for young children:  Isolation and Quarantine in Early Care and Education (ECE) Programs.

7. Mental Health Support

Taking care of children requires a lot of effort and includes many challenges. CDC provides resources to support the mental health of home visitors and the families they serve, for example:

• Stress and Coping
• How Right Now – Finding What Helps with Emotional Well-Being and Resilience
• Tips for Promoting School Employee Wellness
• Taking Care of Your Emotional Health
• Learn About Children’s Mental Health
• Mental Health
• Occupational Health and Safety
• COVID-19 Guidance for Direct Service Providers
• Vaccinating Children with Disabilities Against COVID-19
• Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program | MCHB (hrsa.gov)
• Home Visiting | The Administration for Children and Families (hhs.gov)
• Health Tips for Home Visitors to Prevent the Spread of Illness (hhs.gov) [PDF – 11 pages]
• COVID-19 Information for Health Centers and Partners | Bureau of Primary Health Care (hrsa.gov)
• “Learn the Signs. Act Early.” 

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Home Visitor’s Online Handbook

All Head Start programs are authorized by the Improving School Readiness through Head Start Act of 2007. The Act describes the general scope and design of Head Start and Early Head Start programs. Section 636 states the purpose of Head Start as promoting the school readiness of low-income children by enhancing their cognitive, social, and emotional development. This takes place in a learning environment that supports children's growth in language, literacy, mathematics, science, social and emotional functioning, creative arts, physical skills, and approaches to learning. It is accomplished through the provision of health, educational, nutritional, social, and other services to low-income children and their families that are determined to be necessary based on family needs. 

The Head Start Program Performance Standards (HSPPS) define the specific regulations for all programs serving infants, toddlers, preschoolers, and pregnant women. They also include the requirements for the home-based program option. As described in the HSPPS, home visits and group socializations are guided by a research- and home-based curriculum that is aligned with the Head Start Early Learning Outcomes Framework: Ages Birth to Five .

The HSPPS are referenced throughout the Home Visitor's Online Handbook to help you become familiar with the unique and comprehensive approach of the Head Start and Early Head Start home-based program option. Your own program will further define this information within its own procedures and protocols. In addition, this handbook relates research on the efficacy of home-based programs, strategies for best practices, video examples for reflection, resources, and wisdom from your colleagues shared in the Voices from the Field video series.

Terminology for the name of the person who conducts home visits in the home-based option varies from program to program. You may be called a home visitor, family advocate, or an infant/toddler educator. In this handbook, we use the term "home visitor." The terms "parent" and "family" are used interchangeably throughout, except where the law and regulations require the work be done with parents. This represents all of the people who may play both a parenting role in a child's life and a partnering role with Head Start and Early Head Start staff. This includes fathers; mothers; expectant parents; grandparents; kith and kin caregivers; lesbian, gay, bisexual, and transgender (LGBT) parents; guardians; teen parents; and families with diverse structures that include multiple co-parenting relationships.

Resource Type: Publication

National Centers: Early Childhood Development, Teaching and Learning

Last Updated: September 27, 2023

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Brief Home Visiting: Improving Outcomes for Children

What is Home Visiting?

Home visiting is a prevention strategy used to support pregnant moms and new parents to promote infant and child health, foster educational development and school readiness, and help prevent child abuse and neglect. Across the country, high-quality home visiting programs offer vital support to parents as they deal with the challenges of raising babies and young children. Participation in these programs is voluntary and families may choose to opt out whenever they want. Home visitors may be trained nurses, social workers or child development specialists. Their visits focus on linking pregnant women with prenatal care, promoting strong parent-child attachment, and coaching parents on learning activities that foster their child’s development and supporting parents’ role as their child’s first and most important teacher. Home visitors also conduct regular screenings to help parents identify possible health and developmental issues.

Legislators can play an important role in establishing effective home visiting policy in their states through legislation that can ensure that the state is investing in evidence-based home visiting models that demonstrate effectiveness, ensure accountability and address quality improvement measures. State legislation can also address home visiting as a critical component in states’ comprehensive early childhood systems.

What Does the Research Say?

Decades of research in neurobiology underscores the importance of children’s early experiences in laying the foundation for their growing brains. The quality of these early experiences shape brain development which impacts future social, cognitive and emotional competence. This research points to the value of parenting during a child’s early years. High-quality home visiting programs can improve outcomes for children and families, particularly those that face added challenges such as teen or single parenthood, maternal depression and lack of social and financial supports.

Rigorous evaluation of high-quality home visiting programs has also shown positive impact on reducing incidences of child abuse and neglect, improvement in birth outcomes such as decreased pre-term births and low-birthweight babies, improved school readiness for children and increased high school graduation rates for mothers participating in the program. Cost-benefit analyses show that high quality home visiting programs offer returns on investment ranging from $1.75 to $5.70 for every dollar spent due to reduced costs of child protection, K-12 special education and grade retention, and criminal justice expenses.

Maternal, Infant and Early Childhood Home Visiting Grant Program

The federal home visiting initiative, the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program, started in 2010 as a provision within the Affordable Care Act, provides states with substantial resources for home visiting. The law appropriated $1.5 billion in funding over the first five years (from FYs 2010-2014) of the program, with continued funding extensions through 2016. In FY 2016, forty-nine states and the District of Columbia, four territories and five non-profit organizations were awarded $344 million. The MIECHV program was reauthorized under the Medicare Access and CHIP Reauthorization Act through September 30, 2017 with appropriations of $400 million for each of the 2016 and 2017 fiscal years. The Bipartisan Budget Act of 2018 ( P.L. 115-123 ) included new MIECHV funding. MIECH was reauthorized for five years at $400 million and includes a new financing model for states. The new model authorizes states to use up to 25% of their grant funds to enter into public-private partnerships called pay-for-success agreements. This financing model requires states to pay only if the private partner delivers improved outcomes. The bill also requires improved state-federal data exchange standards and statewide needs assessments. MIECHV is up for reauthorization, set to expire on Sept. 30, 2022.  

The MIECHV program emphasizes that 75% of the federal funding must go to evidence-based home visiting models, meaning that funding must go to programs that have been verified as having a strong research basis. To date,  19 models  have met this standard. Twenty-five percent of funds can be used to implement and rigorously evaluate models considered to be promising or innovative approaches. These evaluations will add to the research base for effective home visiting programs. In addition, the MIECVH program includes a strong accountability component requiring states to achieve identified benchmarks and outcomes. States must show improvement in the following areas: maternal and newborn health, childhood injury or maltreatment and reduced emergency room visits, school readiness and achievement, crime or domestic violence, and coordination with community resources and support. Programs are being measured and evaluated at the state and federal levels to ensure that the program is being implemented and operated effectively and is achieving desired outcomes.

With the passage of the MIECHV program governors designated state agencies to receive and administer the federal home visiting funds. These designated  state leads provide a useful entry point for legislators who want to engage their state’s home visiting programs.

Advancing State Policy

Evidence-based home visiting can achieve positive outcomes for children and families while creating long-term savings for states.

With the enactment of the MIECHV grant program, state legislatures have played a key role by financing programs and advancing legislation that helps coordinate the variety of state home visiting programs as well as strengthening the quality and accountability of those programs.

During the 2019 and 2021 sessions, Oregon ( SB 526 ) and New Jersey ( SB 690 ), respectively, enacted legislation to implement and maintain a voluntary statewide program to provide universal newborn nurse home visiting services to all families within the state to support healthy child development. strengthen families and provide parenting skills.    

During the 2018 legislative session New Hampshire passed  SB 592  that authorized the use of Temporary Assistance to Needy Families (TANF) funds to expand home visiting and child care services through family resource centers. Requires the development of evidence-based parental assistance programs aimed at reducing child maltreatment and improving parent-child interactions.

In 2016 Rhode Island lawmakers passed the Rhode Island Home Visiting Act ( HB 7034 ) that requires the Department of Health to coordinate the system of early childhood home visiting services; implement a statewide home visiting system that uses evidence-based models proven to improve child and family outcomes; and implement a system to identify and refer families before the child is born or as early after the birth of a child as possible.

In 2013 Texas lawmakers passed the Voluntary Home Visiting Program ( SB 426 ) for pregnant women and families with children under age 6. The bill also established the definitions of and funding for evidence-based and promising programs (75% and 25%, respectively).

Arkansas lawmakers passed  SB 491  (2013) that required the state to implement statewide, voluntary home visiting services to promote prenatal care and healthy births; to use at least 90% of funding toward evidence-based and promising practice models; and to develop protocols for sharing and reporting program data and a uniform contract for providers.

View a list of significant  enacted home visiting legislation from 2008-2021 . You can also visit NCSL’s early care and education database which contains introduced and enacted home visiting legislation for all fifty states and the District of Columbia. State officials face difficult decisions about how to use limited funding to support vulnerable children and families.

Key Questions to Consider

State officials face difficult decisions about how to use limited funding to support vulnerable children and families and how to ensure programs achieve desired results. Evidence-based home visiting programs have the potential to achieve important short- and long-term outcomes.

Several key policy areas are particularly appropriate for legislative consideration:

• Goal-Setting: What are they key outcomes a state seeks to achieve with its home visiting programs? Examples include improving maternal and child health, increasing school readiness and/or reducing child abuse and neglect.
• Evidence-based Home Visiting: Have funded programs demonstrated that they delivered high-quality services and measureable results? Does the state have the capacity to collect data and measure program outcomes? Is the system capable of linking data systems across public health, human services, and education to measure and track short and long-term outcomes?
• Accountability: Do home visiting programs report data on outcomes for families who participate in their programs? Do state and program officials use data to improve the quality and impact of services?
• Effective Governance and Coordination: Do state officials coordinate all their home visiting programs as well as connect them with other early childhood efforts such as preschool, child care, health and mental health?
• Sustainability:  Shifts in federal funding make it likely that states will have to maintain programs with state funding. Does the state have the capacity to maintain the program? Does the state have the information necessary to make difficult funding decisions to make sure limited resources are spent in the most effective way? 

Related Resources

Where is federal early childhood policy heading.

In recent years, the federal government has played a more active role in early childhood care and education through pandemic-era relief funding and new regulations for the Child Care and Development Block Grant and Head Start programs. This article provides an in-depth view of trends in federal policy.

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BRIAN K. UNWIN, MAJ, MC, USA, AND ANTHONY F. JERANT, M.D.

Am Fam Physician. 1999;60(5):1481-1488

See editorial on page 1337 .

With the advent of effective home health programs, an increasing proportion of medical care is being delivered in patients' homes. Since the time before World War II, direct physician involvement in home health care has been minimal. However, patient preferences and key changes in the health care system are now creating an increased need for physician-conducted home visits. To conduct home visits effectively, physicians must acquire fundamental and well-defined attitudes, knowledge and skills in addition to an inexpensive set of portable equipment. “INHOMESSS” (standing for: i mmobility, n utrition, h ousing, o thers, m edication, e xamination, s afety, s pirituality, s ervices) is an easily remembered mnemonic that provides a framework for the evaluation of a patient's functional status and home environment. Expanded use of the telephone and telemedicine technology may allow busy physicians to conduct time-efficient “virtual” house calls that complement and sometimes replace in-person visits.

In 1990, the American Medical Association (AMA) reported that approximately one half of primary care physicians polled in a national survey indicated that they performed home visits. 1 Although most of the physicians surveyed perceived home visits to be an important service, the majority performed only a few such visits per year. 1 Consistent with these self-reported behaviors are data indicating that only 0.88 percent of Medicare patients receive home visits from physicians. 2 In addition, the Health Care Financing Administration reported charges for only 1.6 million home visits in 1996, an extremely small percentage of the total number of annual physician-patient contacts in the United States. 3 These statistics stand in sharp contrast to medical practice before World War II, at which time about 40 percent of patient-physician encounters were in the home. 4

The low frequency of home visits by physicians is the result of many coincident factors, including deficits in physician compensation for these visits, time constraints, perceived limitations of technologic support, concerns about the risk of litigation, lack of physician training and exposure, and corporate and individual attitudinal biases. Physicians most likely to perform home visits are older generalists in solo practices. Health care providers who have long-established relationships with their patients are also more likely to utilize house calls. Rural practice setting, older patient age and need for terminal care correlate with an increased frequency of home visits. 5

Rationale for Home Visits

Studies suggest that home visits can lead to improved medical care through the discovery of unmet health care needs. 6 – 8 One study found that home assessment of elderly patients with relatively good health status and function resulted in the detection of an average of four new medical problems and up to eight new intervention recommendations per patient. 8 Major problems detected included impotence, gait and balance problems, immunization deficits and hypertension. Significantly, these problems had not been expected based on information obtained from outpatient clinic encounters. Other investigators have demonstrated the effectiveness of home visits in assessing unexpected problems in patient compliance with therapeutic regimens. 9 Finally, specific home-based interventions, such as adjusting the elderly patient's home environment to prevent falls, have also yielded health benefits. 10

Beyond the potential benefit of improved patient care, family physicians who conduct home visits report a higher level of practice satisfaction than those who do not offer this service. 5 Physicians with more positive attitudes about home visits are more likely to have conducted house calls during training. 11 Faculty mentorship and longitudinal exposure in training appear to be important for the development of positive attitudes toward home visits. 5 However, in 1994, only 66 of 123 medical schools offered specific instruction in the role and conduct of home visits. 12 Although 83 percent of the medical schools offered students the opportunity to participate in home visits, only three of the 123 schools required students to make five or more such visits. 12

Home Health Care Industry

Physician home visits have largely been supplanted by the extensive use of home health care services, a $22.3 billion industry that augments a medical system largely comprising facility-based health care providers. 13 The mean annual frequency of home health referrals was 43 per provider in a study published in 1992. 14

Family physicians have authorization and supervision responsibilities for a broad spectrum of skilled services that can be offered in the home. Such services include home health nursing, assistance from home health aides, and physical, occupational and speech therapy. Other health care support services are provided by medical supply companies, respiratory therapists, nutritionists, intravenous therapy services, hospice organizations, respite care services, Meals-on-Wheels volunteers and bereavement support staff. Family physicians also work extensively with social workers, who provide invaluable assistance in coordinating these services.

Thus, effective use of home care services has become a core competency for family physicians. In 1998, the AMA published the second edition of Medical Management of the Home Care Patient: Guidelines for Physicians . 15 The basic physician home care responsibilities outlined in that document are listed in Table 1 . 15

Recent data suggest that many physicians do not have the necessary knowledge and skills to perform these tasks effectively. For example, a survey found that 64 percent of physicians who had signed claims for care plans that were later disallowed had relied on a home health agency to prepare the plan of care, and 60 percent were not aware of the homebound requirement for home services. 16 Thus, increased physician education about home visits seems necessary if the responsibilities and obligations created by the expansion of home health care industry are to be fulfilled.

Types of Home Visits

The four major types of home visits are illness visits, visits to dying patients, home assessment visits and follow-up visits after hospitalization ( Table 2 ) . 17 , 18 The illness home visit involves an assessment of the patient and the provision of care in the setting of acute or chronic illness, often in coordination with one or more home health agencies. Emergency illness visits are infrequent and impractical for the typical office-based physician.

The dying patient home visit is made to provide care to the home-bound patient who has a terminal disease, usually in coordination with a hospice agency. The family physician can provide valuable medical and emotional support to family members before, during and after the death of a patient in the home environment. Family assistance involves evaluating the coping behaviors of survivors and assessing the medical, psychosocial, environmental and financial resources of the remaining family members.

The assessment home visit can also be described as an investigational visit during which the physician evaluates the role of the home environment in the patient's health status. An assessment visit is often made when a patient is suspected of poor compliance or has been making excessive use of health care resources. Medication use can be evaluated in the patient who is taking many drugs (polypharmacy) because of multiple medical problems. Evaluation of the home environment of the “at-risk” patient can reveal evidence of abuse, neglect or social isolation. Patients and family members who are trying to cope with chronic problems such as cognitive impairment or incontinence may particularly benefit from this evaluation. A joint assessment home visit facilitates coordination of the efforts of home health agencies and the physician. Finally, an assessment home visit is invaluable in assessing the need for nursing home placement of a frail elderly patient with uncertain social support.

The hospitalization follow-up home visit is useful when significant life changes have occurred. For example, a home visit after the birth of a new baby provides an excellent opportunity to discuss wellness and prevention issues and to address parental concerns. A home visit after a major illness or surgery can be useful in evaluating the coping behaviors of the patient and family members, as well as the effectiveness of the home health care plan.

Many aspects of physician home care have not been evaluated in the literature. However, it seems likely that properly focused and conducted home visits can enhance home health care delivery, improve patient satisfaction and strengthen the doctor-patient relationship.

Conducting the Home Visit

Equipment and planning.

Most equipment for a home visit can still be carried in the family physician's “black bag” ( Table 3 ) . Some additional items may be acquired from the patient's home.

One of the keys to conducting a successful home visit is to clarify the reason for the visit and carefully plan the agenda. Preplanning allows the physician to gather the necessary equipment and patient education materials before departure. The physician should have a map, the patient's telephone number and directions to the patient's home. The physician, patient and home care team should set a formal appointment time for the visit. Coordinating the house call to allow for the presence of key family members or significant others can enhance communication and satisfaction with care. Finally, confirming the appointment time with all involved parties before departure from the office is a common courtesy to the family as well as a wise time-management strategy.

HOME VISIT CHECKLIST: “INHOMESSS”

The INHOME mnemonic was devised to help family physicians remember the items to be assessed during the home visit directed at a patient's functional status and living environment. 19 This mnemonic can be expanded to “INHOMESSS,” which incorporates investigations of safety issues, spiritual health and home health agencies ( Table 4 ) . 19

Immobility . Evaluation of the patient's functional activities includes assessment of the activities of daily living (bathing, transfer, dressing, toileting, feeding, continence) and the instrumental activities of daily living (using the telephone, administering medications, paying bills, shopping for food, preparing meals, doing housework). The physician can ask the patient to demonstrate elements of the daily routine, such as getting out of bed, performing personal hygiene and leisure activities, and getting in and out of a car. Corrective interventions can be directed at any deficiencies noted. For example, modified pill-bottle caps can be obtained for the patient who has trouble opening medication containers because of a condition such as arthritis.

Nutrition . The physician should assess the patient's current state of nutrition, eating behaviors and food preferences. Permission to look in the refrigerator or cupboard can be obtained by asking open-ended but directed questions. For example, the physician might say, “We have been working hard on your diet to control your diabetes. Would you mind if I look in your refrigerator to see the types of foods you eat?” Improvements in product labeling allow the physician to assess serving sizes and the nutritional value of foods with relative ease. Healthy food preparation techniques can also be reviewed with the patient.

Home Environment . The patient's home environment should allow for privacy, social interaction and both spiritual and emotional comfort and safety. A safe neighborhood with close proximity to services is important for many older patients. The home may reflect pride in the patient's family and past accomplishments and reveal the patient's interests and hobbies. The physician should not make assumptions about social class or material wealth based on the patient's physical environment.

Other People . Having the patient's social support system present at the home visit clarifies the roles and concerns of family members. During routine visits, the physician can assess the availability of emergency help for the patient from family members and friends and can clarify specific issues, such as who is to serve as surrogate for the patient in the event of incapacitation. Discussion of a durable power of attorney and a living will may be more comfortably performed during the home visit than in the usual clinic visit. Evaluation of the caregiver's needs and risk of burnout is critically important.

Medications . To remedy or avoid polypharmacy, the physician must evaluate the type, amount and frequency of medications, and the organization and methods of medication delivery. An inventory of the patient's medicine cabinet can provide clues to previously unidentified drug-drug or drug-food interactions. A home medication review can also allow a direct estimate of patient compliance, uncover evidence of “doctor shopping” and identify the use or abuse of over-the-counter medications and herbal remedies.

Examination . The home visit should include a directed physical examination based on the needs of the patient and the physician's agenda. Practical, function-related examination techniques may include having the patient demonstrate getting on and off the toilet or in and out of the bathtub. The physician can have the patient demonstrate proper technique for the self-monitoring of blood glucose levels. In addition, the physician can weigh the patient and obtain a blood pressure measurement. In-person correlation of home and office measures provides useful information for future telephone and clinic contacts.

Safety . Common home safety issues are listed in Table 5 . The goal of the home safety assessment is to determine whether the patient's environment is comfortable and safe (no unreasonable risk of injury). To raise the subject, the physician should simply state the intention to identify and help modify potential safety hazards. For example, furniture placement or throw rugs may create problems for an elderly patient with gait instability, or the tap water may be so hot that the patient is at risk for scald injury. 20

Spiritual Health . If the home contains religious objects or reading materials, the physician can ask about the influence of spiritual beliefs on the patient's sense of physical and emotional health. This information may provide the impetus, as desired by the patient, for a discussion of spirituality as a coping and healing strategy.

Services . Having members of cooperating home health agencies present for the house call can enhance communication and cooperation among the physician, patient and agencies. Existing orders can be clarified, priorities for future care can be established and other perspectives on the care plan can be solicited. The patient's relationship with home health agency providers can also be assessed.

Elements of the INHOMESSS mnemonic may be used independently, based on the needs of the patient and the physician's agenda. For example, the physician may wish to focus on polypharmacy and safety in a patient with a recent fall, or to assess mobility and the extent of social support in a patient with newly diagnosed Alzheimer's disease. Figure 1 presents the major elements of the home visit in a checklist format that facilitates comprehensive assessment.

INTEGRATING HOME VISITS INTO CLINICAL PRACTICE

Lack of reimbursement and the busy pace of office practice are the reasons commonly cited for not conducting house calls. Poorly organized, sporadic home visits may indeed interfere with clinical practice. Therefore, it is important to develop a systematic approach for planning home visits. 21

Most practices will benefit from using home visits with patients who have difficulty accessing outpatient facilities because of sensory impairment, immobility or transportation problems. Removing such logistically difficult appointments from the clinic schedule and performing them in the home setting may actually enhance clinic functioning. Clustering home visits by geographic location and within defined blocks of time may also improve efficiency. Finally, nurse practitioners and physician assistants can conduct visits as part of a home health care delivery team.

The 1999 Current Procedural Terminology codes and corresponding Medicare reimbursement rates for common types of home visits are listed in Table 6 . 22

Telephone Calls and Telemedicine

Proactive telephone calls are an underutilized method of conducting highly focused and time-efficient “virtual” home visits. 23 Provider-initiated telephone calls can be used to reassure family members after a patient has had an acute illness or has been hospitalized. 23 These calls can also be helpful in reinforcing patient compliance with new medications, following patients with chronic diseases and reducing inappropriate use of primary care clinic or office services. 24

Telemedicine is the use of communication technologies, such as two-way video-conferencing, to provide patient care across distances. A variety of institutions are exploring these technologies as methods of delivering health care in the home. 25 , 26

Final Comment

As fewer patients are admitted to hospitals and hospital stays become ever briefer, the medical complexity of home care will increase, as will the demand for both in-person and “virtual” physician home visits. Physicians interested in obtaining additional information about home care provision can contact the American Academy of Home Care Physicians (P.O. Box 1037, Edgewood, MD 21040; Web address: http://www.aahcp.org/ ).

Shut in, but not shut out [Editorial]. Am Med News. 1996;39:47.

Meyer GS, Gibbons RV. House calls to the elderly: a vanishing practice among physicians. N Engl J Med. 1997;337:1815-20.

Boling PA. House calls [Letter]. N Engl J Med. 1998;338:1466.

Starr P. The social transformation of American medicine. New York: Basic Books, 1982:359.

Adelman AM, Fredman L, Knight AL. House call practices: a comparison by specialty. J Fam Pract. 1994;39:39-44.

Arcand M, Williamson J. An evaluation of home visiting of patients by physicians in geriatric medicine. Br Med J. 1981;283:718-20.

Fabacher D, Josephson K, Pietruszka F, Linderborn K, Morley JE, Rubenstein LZ. An in-home preventive assessment program for independent older adults: a randomized controlled trial. J Am Geriatr Soc. 1994;42:630-8.

Ramsdell SW, Swart J, Jackson JE, Renvall M. The yield of a home visit in the assessment of geriatric patients. J Am Geriatr Soc. 1989;37:17-24.

Bernardini J, Piraino B. Compliance in CAPD and CCPD patients as measured by supply inventories during home visits. Am J Kidney Dis. 1998;31:101-7.

Tideiksaar R. Environmental adaptation to preserve balance and prevent falls. Top Geriatr Rehabil. 1990;5:178-84.

Knight AL, Adelman AM, Sobal J. The house call in residency training and its relationship to future practice. Fam Med. 1991;23:57-9.

Steel RK, Musliner M, Boling PA. Medical schools and home care. N Engl J Med. 1994;331:1098-9.

Goldberg AI. Home healthcare: the role of the primary care physician. Compr Ther. 1995;21:633-8.

Boling PA, Keenan JM, Schwartzberg JG, Retchin SM, Olson L, Schneiderman M. Home health agency referrals by internists and family physicians. Am Geriatr Soc. 1992;40:1241-9.

American Medical Association. Medical management of the home care patient: guidelines for physicians. 2d ed. Chicago: The Association, 1998:1–60.

Klein S. Guidance for home care physicians. Am Med News. 1998;41:5-6.

Cauthen DB. The house call in current medical practice. J Fam Pract. 1981;13:209-13.

Scanameo AM, Fillit H. House calls: a practical guide to seeing the patient at home. Geriatrics. 1995;50:33-9.

Knight AL, Adelman AM. The family physician and home care. Am Fam Physician. 1991;44:1733-7.

Huyer DW, Corkum SH. Reducing the incidence of tap-water scalds: strategies for physicians. Can Med Assoc J. 1997;156:841-4.

American Academy of Home Care Physicians. Making house calls a part of your practice. Edgewood, Md.: American Academy of Home Care Physicians, 19981;1–35.

Kirschner CG, ed. Current procedural terminology: CPT. Standard ed. Chicago: American Medical Association, 1999:26–8.

Studdiford JS, Panitch KN, Snyderman DA, Pharr ME. The telephone in primary care. Prim Care. 1996;23:83-102.

Wasson J, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG. Telephone care as a substitute for routine clinic follow-up. JAMA. 1992;267:1788-93.

Jerant AF, Schlachta L, Epperly TD, Barnes-Camp J. Back to the future: the telemedicine house call. Fam Pract Management. 1998;5:18-22.

Johnson B, Wheeler L, Deuser J. Kaiser Permanente Medical Center's pilot tele-home health project. Telemed Today. 1997;5:16-8.

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Knock Knock, Teacher's Here: The Power Of Home Visits

Blake Farmer

Ninety percent of students at Hobgood Elementary in Murfreesboro, Tenn., come from low-income households. Most of the school's teachers don't. And that's a challenge, says principal Tammy Garrett.

"If you only know middle-class families, you may not understand at times why they don't have their homework or why they're tired," Garrett says.

When she became principal four years ago, Garrett decided to get her teachers out of their classrooms — and comfort zones — for an afternoon. Once a year, just before school starts, they board a pair of yellow buses and head for the neighborhoods and apartment complexes where Hobgood students live.

En route, the bus driver describes over the intercom how he picks up 50 children at one complex each morning. The teachers pump themselves up with a chant. After all, they're doing something most people don't enjoy: knocking on doors unannounced.

When the caravan arrives at a cluster of apartments, the teachers fan out and start knocking on doors of known Hobgood families. Some encounters don't get beyond awkward pleasantries and handing over fliers about first-of-the-year festivities. Others yield brief but substantive conversations with parents who might be strangers around school.

Jennifer Mathis has one child still at Hobgood and says she appreciates that the school came to her — since she has a hard time getting to school.

"I don't have a car. I can't drive because my back got broken in two places," she tells a trio of teachers standing in her doorway. "I'm a mom. I can't be there with all of them all the time."

Giving Home Visits A Try

There was a time when a teacher showing up on a student's doorstep meant something bad. But increasingly, home visits have become a tool to spark parental involvement. The National Education Association has encouraged more schools to try it out, and there's this national effort .

One district in Massachusetts just added money to pay teachers for the extra work involved. Traditional schools in Washington, D.C., tried out home visits after privately run charter schools used them to successfully engage parents.

In Murfreesboro, principal Garrett sees the brief visits as mutually beneficial. Parents get to meet their kids' teachers. And teachers get a clearer sense of the challenges many of their students struggle with on a daily basis.

"If a kid doesn't have a place to sleep or they have to share the couch with their siblings at night and there are nine kids with one bedroom or two bedrooms, it's important for them to see that — not to be sympathetic," she says. "It's to empower the teachers to change the lives of the kids."

It's serious business. But Danielle Hernandez, a special education teacher, says it's not the somber experience she'd feared. At one apartment complex, a dozen kids are out riding bikes on their last day of summer break.

"I know that these children, they go through a lot in their lives," Hernandez says. "But they get to have so much fun."

Teachers join in on that fun, borrowing kids' bikes for a cross-parking-lot drag race that generates howls from the adults.

Ashlee Barnes, a fourth-grade teacher at Hobgood, says she's a believer, even if home visits have yet to prove themselves as a difference-maker on standardized testing.

"We become more important in their lives than I think we can ever understand," she says. "I think the sooner you can start a relationship, you're going to see results on their performance in the classroom."

'It Makes Me Want To Cry'

The kids seem to genuinely enjoy the visits, even if they are a reminder that summer is over.

"I am so lucky," says fourth-grader Shelleah Stephens as she's introduced to Barnes, her new teacher. "All the teachers I have had have been so nice. It's great to see you."

Barnes hugs Shelleah, who is barefoot on the sidewalk in front of the unit where she lives with her father, Kenny Phillips. He's standing back, smiling as his daughter shows off her budding social skills.

"It just brings you this joy. It makes me want to cry," Phillips says.

Phillips runs a landscaping business and says long days have kept him from being as involved with his daughter's education as he'd like to be. Seeing this interaction has him a little choked up.

"It's just good to see her grow up and have people around her who care," he says. "Sometimes parents aren't there, man. Sometimes we gotta work. Sometimes we're gone a lot of the time. It's good to see [teachers] come out to the neighborhood like that. I know she's in good hands."

Phillips also grew up in Murfreesboro but says no teacher stopped by his house. He hopes to return the favor by making sure Shelleah finishes all her homework this year.

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The Practice of Home Visiting by Community Health Nurses as a Primary Healthcare Intervention in a Low-Income Rural Setting: A Descriptive Cross-Sectional Study in the Adaklu District of the Volta Region, Ghana

Kennedy diema konlan.

1 Department of Public Health Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana

2 College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea

Nathaniel Kossi Vivor

Isaac gegefe, imoro a. abdul-rasheed, bertha esinam kornyo, isaac peter kwao, associated data.

The data used to support the findings of this study are included within the article.

Home visit is an integral component of Ghana's PHC delivery system. It is preventive and promotes health practice where health professionals render care to clients in their own environment and provide appropriate healthcare needs and social support services. This study describes the home visit practices in a rural district in the Volta Region of Ghana. Methodology . This descriptive cross-sectional study used 375 households and 11 community health nurses in the Adaklu district. Multistage sampling techniques were used to select 10 communities and study respondents using probability sampling methods. A pretested self-designed questionnaire and an interview guide for household members and community health nurses, respectively, were used for data collection. Quantitative data collected were coded, cleaned, and analysed using Statistical Package for Social Sciences into descriptive statistics, while qualitative data were analysed using the NVivo software. Thematic analysis was engaged that embraces three interrelated stages, namely, data reduction, data display, and data conclusion.

Home visit is a routine responsibility of all CHNs. The factors that influence home visiting were community members' education and attitude, supervision challenges, lack of incentives and lack of basic logistics, uncooperative attitude, community inaccessibility, financial constraint, and limited number of staff. Household members (62.3%) indicated that health workers did not adequately attend to minor ailments as 78% benefited from the service and wished more activities could be added to the home visiting package (24.5%).

There should be tailored training of CHNs on home visits skills so that they could expand the scope of services that can be provided. Also, community-based health workers such as community health volunteers, traditional birth attendants, and community clinic attendants can also be trained to identify and address health problems in the homes.

1. Introduction

Home visit practice is a healthcare service rendered by trained health professionals who visit clients in their own home to assess the home, environment, and family condition in order to provide appropriate healthcare needs and social support services. The home environment is where health is made and can be maintained to enhance or endanger the health of the family because individuals and groups are at risk of exposure to health hazards [ 1 , 2 ]. At home visit, conducted in a familiar environment, the client feels free and relaxed and is able to take part in the activity that the health professional performs [ 1 ]. It is possible to assess the client's situation and give household-specific health education on sanitation, personal hygiene, aged, and child care. The important role the health professional plays during home visits (HV) cannot be overemphasized, and this led Ghana to adopt HV as a cardinal component of its preventive healthcare delivery system. This role is largely conducted by community health nurses (CHN) [ 2 ]. Health education given during HVs is more effective, resulting in behavioural change than those given through other sources such as the mass media [ 3 ].

In the home, the health professionals, mostly CHN monitor the growth, development, and immunization status of children less than 5 years and carry out immunization for defaulters. Care is given to special groups such as the elderly, discharged tuberculosis, and leprosy patients as well as malnourished children [ 1 , 2 ]. It is also possible to carry out contact tracing during HVs [ 2 ]. These services may prevent, delay, or be a substitute for temporary or long-term institutional care [ 4 , 5 ]. HV has potential for bringing health workers into contact with individuals and groups in the community who are at risk for diseases and who make ineffective or little use of preventive health services [ 2 ]. Several factors influence the conduct of HVs. These factors include location of practice, general practitioners age, training status, and the number of older patients on the list and predicts home visiting rate [ 6 ].

The concept of HV has remained in Ghana over the decades, and yet, its very essence is imperative [ 3 ]. In Ghana, home visiting is one of the major activities of CHN. The health visitors, as CHNs were then called, went from house to house, giving education on sanitation and personal hygiene [ 3 ]. These nurses attempt to promote positive health and prevent occurrence of diseases by increasing people's understanding of healthy ways of living and their knowledge of health hazards [ 7 ]. HVs remain fundamental to the successful prevention of deaths associated with women and children under five; yet, there still remain certain gaps in the successful implementation of this innovative intervention in Ghana [ 4 ]. In Sekyere West district in Ashanti Region of Ghana, although nurses had knowledge of home visiting and had a positive opinion of the practice, they could not perform their home visiting tasks or functions up to standard [ 8 ]. Home visiting practice in that district among nurses was found to be very low, even though community members desired more [ 8 ]. The findings indicate that there is a need for HV [ 9 ]. Also identified were several health hazards, such as uncovered refuse containers, open fires, misplaced sharp objects, open defecation, and other unhygienic practices that a proper home visiting regiment can address [ 8 ]. At the service level, lack of publicity about the service, the cost of the service, failure to provide services that meet clients' felt needs, rigid eligibility criteria, inaccessible locations, lack of public transport, limited hours of operation, inflexible appointment systems, lack of affordable child care, poor coordination between services, and not having an outreach capacity were identified as the challenges associated with this kind of service [ 9 – 13 ].

Home visiting is a crucial tool for enhancing family healthcare and the health of every community. Ghana Health Service through home visiting services has supported essential community health actions and address gaps in knowledge and community practices such as reproductive behaviour, nutritional support for pregnant women and young children, recognition of illness, home management of sick children, disease prevention, and care seeking behaviours [ 4 ]. As many interventions are implemented by stakeholders in health to ensure that home visiting practices actually benefit community members, recent studies have not delved into the practices of home visiting in poor rural communities especially in the Volta Region of Ghana. This study assessed the home visiting practices in the Adaklu district (AD) of the Volta Region.

This study assessed the practice of home visiting as a primary healthcare (PHC) intervention in a poor rural district in the Volta Region of Ghana.

2. Methodology

2.1. study design.

This mixed method study employed a descriptive cross-sectional study design as the study involved a one-time interaction with the CHNs and the community members to assess the practice of HVs.

2.2. Study Setting

The AD is one of the districts in the Volta Region of Ghana and has about 40 communities. The district capital and administrative centre is Adaklu Waya. The estimated population of the district was 36391 representing 1.7% of the Volta Region's population before the Oti Region was carved out [ 14 ]. The district is described as a rural district [ 14 ] as no locality has a population above 5000 people. The economically active population (aged 15 and above) represents 67% of the population [ 14 ]. The economically inactive population is in full-time education (55.1%), performed household duties (20.6%), or disabled or too sick to work (4.6%), while the employed population engages in skilled agricultural, forestry, and fishery workers (63.1%), service and sales (12.6%), craft and related trade (14.6%), and 3.4% other professional duties [ 14 ]. The private, informal sector is the largest employer in the district, employing 93.9% [ 14 ]. There are 15 health facilities in the district government health centres [ 4 ], one health centre by Christian Health Association of Ghana, and 10 community health-based planning services (CHPS) of which 5 are functional [ 15 ]. The housing stock is 5629 representing 1.4% of the total number of houses in the Volta Region. The average number of persons per house was 6.5 [ 14 ], and the houses are mostly built with mud bricks [ 15 ]. The most common method of solid waste disposal by households is public dumping in the open space (47.5%). Some households dump solid waste indiscriminately (17.3%), while other households dispose of burning (13.3%) [ 14 ].

2.3. Study Population, Sample, and Sampling Technique

There are about 36391 inhabitants with 6089 households in AD [ 14 ]. This study mainly involved adult members of the household and CHNs from randomly sampled communities in the district. These sampled communities included Abuadi, Anfoe, Ahunda, Dawanu, Goefe, Helekpe, Hlihave, Tsrefe, Waya, and Wumenu. An adult member of the household is a person above the age of 18 years who has the capacity to represent the household. CHN [ 11 ] from the selected communities in the district was recruited. A CHN is a certified health practitioner who combines prevention and promotion health practices, works within the community to improve the overall health of the area, and has a role to play in home visiting.

Estimating for a tolerable error of 5%, with a confidence interval of 95%, and a study population of 6089 households, with a margin of error of 0.05 using Yamane's formula for calculating sample for finite populations, a sample of 375 households were computed. The sample size was increased to 390 to take into consideration the possible effect of nonresponse from participants. Multistage sampling technique was adopted to eventually select study participants. Each community was stratified into four geographical locations: north, south, east, and west with respondents being selected from every second house using a systematic sampling approach. In each household, an adult member of the household responded to the questionnaire.

A whole population sampling method was used to select eleven [ 11 ] CHNs from the specific communities [ 10 ] where the study took place in the district. The CHN that served the 10 selected communities were selected. The numbers selected from each community were Helekpe (18.2%), Waya (18.2%), Anfoe (9.1%), Tsrefe (27.3%) and Wumenu (27.3%). This represented 42.3% of the total CHN community of the district at the time of the study.

2.4. Pretesting

The questionnaire and interview guide were piloted using 30 adult household members and 5 CHNs, respectively, at Klefe CHPS in the Ho municipality. The data collected through the questionnaire were subjected to a reliability test on SPSS (version 22). The pretesting ascertained the respondent's general reaction and particularly, interest in answering the questionnaire. The questionnaire was modified until it produced a Cronbach alpha coefficient of 0.790. It can therefore be concluded that the questionnaire had a high reliability in measuring the objectives of the study. The pretesting helped in identifying ambiguous questions and revising them appropriately. It also helped to structure and estimate the time the respondents used to answer the questionnaires and to respond to the interview.

2.5. Data Collection

Researchers from the University of Health and Allied Sciences School of Nursing and Midwifery were involved in data collection. Five researchers received two days training in data collection, the study tools, and research ethics for social sciences prior to the commencement of data collection. All researchers had a minimum of a bachelor degree in CHN with at least three years' data collection experience.

Respondents were assisted to respond to a questionnaire within their homes. The household questionnaire had four [ 4 ] sections comprising personal details and how HV practice is carried out in the home such as frequency of visit, duration, and activities. Subsequent sections had respondents answer questions on the challenges, benefits, and factors that could promote the HV practice. It took an average of about 15 minutes to complete a single questionnaire.

A semistructured interview guide was used to interview CHNs. This guide was in four sections; the first section was personal details with subsequent sections on practice of home visits, constraints to the practice, the benefits, and promotion factors to HVs. An interview section lasted 20–25 minutes to complete.

2.6. Data Analysis

2.6.1. quantitative data.

Each individual questionnaire was checked for completeness and appropriateness of responses before it was entered into Microsoft Excel, cleaned, and transferred to the Statistical Package for Social Sciences (version 22) for analysis. The data were basically analysed into descriptive statistics of proportions. There were also measures of central tendencies for continuous variables.

2.6.2. Qualitative Data

In data analysis, thematic analysis was engaged that embraces three interrelated stages, namely, data reduction, data display, and data conclusion [ 16 ]. CHNs views were summarised based on the conclusions driven and collated as frequencies and proportions. Guest, Macqueen, and Namey summarised the process of thematic analysis as construing through textual data, identifying data themes, coding the themes, and then interpreting the structure and content of the themes [ 17 ]. In using this scheme, a codebook was first established, discussed, and accepted by the authors. The nodes were then created within NVivo software using the codebook. Line-by-line coding of the various transcripts was performed as either free or tree nodes. Double coding of each transcript was carried out by two of the researchers. Coding comparison query was used to compare the coding, and a kappa coefficient (the measurement of intercoder reliability) was generated to compare the coding that was conducted by the two authors. The matrix coding query was performed to compare the coding against the nodes and attributes using NVivo software that made it possible for the researchers to compare and contrast within-group and between-group responses.

2.7. Ethical Consideration

Ethical clearance was obtained on the 19th September, 2018, from the Research and Scientific Ethics Committee of the Institute of Health Research, University of Health and Allied Sciences (UHAS-REC A.2 [13] 18-19). Permission was sought from the district health authorities, chiefs, and assembly members of each study community. Preliminary to the administration of the questionnaires, an informed consent was obtained as respondents signed/thumb printed a consent form before they were enrolled into the study. Participants could withdraw from the study anytime they wished to do so.

3.1. Household Members' Views regarding Home Visit

The household representatives surveyed (375) had a mean age of 41.24 ± 16.88 years. The majority (26.5%) of household members were aged between 30 and 39 years. Most (75.1%) were females. The majority (97.1%) of people in households were Christians, while 38% was farmers. The majority (69.9%) of household members were married as 47.2% had schooled only up to the JHS level as at the time of this survey as given in Table 1 .

Demographic characteristics of household members.

The majority (73.3%) of adult household members had ever been visited by a health worker for the purpose of conducting HVs as a significant number (26.7%) of household members had never been visited by health workers in the community. Most (52.6%) household members had had their last visit from a health worker during the past month. Within the past three months, some (48.2%) community members were visited only once by a health worker. The majority (93.4%) of community members were usually visited between the time periods of 9am and 2pm as given in Table 2 . The community members contend that home visiting was beneficial to the disease prevention process (65%). The people that need to be visited by CHNs include children under five (25%), malnourished children's homes (14%), children with disabilities (14%), mentally ill people (11%), healthcare service defaulters (22%), people with chronic diseases (9%), and every member of the community (5%).

Practice of home visits in AD (household members).

Most (87.9%) community members were given health education during HVs conducted by the CHN. In describing the nature of health education that is most frequently given by CHNs during HVs, household members indicated fever management (14%), malaria prevention (20%), waste disposal (11%), prevention and management of diarrhoea (22%), nutrition and exclusive breastfeeding (14%), hospital attendance (14%), and prevention of worm infestations (5%). The majority (62.3%) of community members did not receive a minor ailment management during HVs as most (66.5%) of community members received vaccination during HVs by CHNs. Describing the type of minor ailment treatment given during the HV include care of home accidents (13%), management of minor pains (22%), management of fever (45%), and management of diarrhoea (20%). Household members (24.5%) did identify bad timing as a barrier for home visiting, while some (13.1%) did identify the attitude of health workers as a barrier to home visiting. However, most (67.3%) of the household members attributed their dislike for home visiting to the duration of the visit. The majority (95.2%) of household members indicated health workers were friendly. Some household members (78%) indicated they benefited from HVs conducted in their homes. The majority (91.4%) of household members showed that time for home visiting was convenient. Indicating if household members will wish for the conduct of the HV to be a continuous activity of CHNs in their community, the respondents (82%) were affirmative.

3.2. CHNs Views on Home Visit in AD

The mean age of CHNs was 30.44 ± 4.03 years as some (33.3%) were aged 32 years as the modal age. The CHNs (90.9%) were females with the majority (81.8%) being Christians as given in Table 3 .

Demographic characteristics of CHN.

In assessing the home visiting practices of CHNs, the researchers had some thematic areas. These thematic areas that were discussed include but not limited to the concept of HV by CHN, factors that influence the conduct of HVs, ability to visit all homes within CHN catchment area, reasons for conducting or not able to conduct HV, frequency of conducting home visits by CHN, and activities undertaken during HVs. This view that was expressed was simply summarised based on the thematic areas and presented in Table 4 as descriptive statistics related to the CHN conduct of HVs.

Summary of CHNs home visit practice in AD.

3.2.1. Concept of Home Visit by CHN

CHNs have varied descriptions of the concept of HV as it is conducted within the district. The description of HV was basically related to the nature and objective that is associated with the concept. The central concept expressed by participants included a health worker visiting a home in their place of abode or workplace, providing service to the family during this visit, and this service is aimed at preventing disease, promoting health, and maintaining a positive health outcome. These views were summarised when they said

“HVs are a service that we (CHNs) rendered to the client and his family in their own home environment to promote their health and prevent diseases. The central idea is that during the HV, the CHN is able to engage the family in education and services that eventually ensure that diseases are prevented and health is promoted.”

“HV is the art when the CHNs visit community members' homes to provide some basic curative and largely preventive healthcare services to clients within their own homes or workplaces. During this visit, the CHN helps the entire family to live a healthy life and give special attention or care to the vulnerable members of the society.”

“It is the processes when at-risk populations are identified; then, the CHN provides services to this cadre within their own home environment and sometimes workplaces as the case may be. Essentially, the CHN assists the family to adopt positive behaviours that will ensure they live with the vulnerable person in a more comfortable way.”

3.2.2. Factors that Influence the Conduct of Home Visits

The CHNs enumerated a cluster of factors that influence the conduct of HVs within the district. These factors ranged from community members education, attitude, supervision challenges, lack of incentives, and lack of basic logistics to conduct HVs. The uncooperative attitude of community members was identified by CHNs (36.4%) as a barrier to HVs. As they indicate, some community members did not support the continued visit to their homes or did not give them the necessary attention needed for the provision of services.

“Some community members do not understand the importance of HVs in the prevention of disease and for that matter are less receptive to the conduct of HVs. They just do not see the need for the service provider to come to their homes to provide services.”

“The client is the master of his own home; when you get into a home for a HV, the owner should be willing to talk or attend to you. Sometimes, you get into a home and even if you are not offered a seat, or you are just told we are busy, come next time. You know community service is not a paid job, so because the community members do not directly pay for the services we provide, essentially less premium is placed on the activities we conduct.”

“There is some resistance to HVs by some community members. Sometimes, you come to a house and can feel that you are not wanted; meanwhile, the home is part of the home that needs and has to get a HV because of the special needs they have. This is particularly specific in homes that believe that the particular problem is a result of supernatural causes.”

3.2.3. The Ability to Visit All Homes within CHN Catchment Area

The conduct of HVs is a basic responsibility for all CHNs as they remain as an integral part of the PHC delivery system in Ghana. Based on the nature and problems in the community, CHNs strategizes various means that will aid them to provide this essential service efficiently. CHNs (81.8%) are able to visit all homes in the catchment areas during a quarter. Some of the responses included the following:

“We do organise HVs, this is part of our routine schedule. As a community health nurse, to enjoy your work, you will need to organise HVs from time to time.”

“As for the HV, it depends on the strategies a particular CHPS compound is using. Irrespective of the community that one works in, you can always provide full and adequate care and service to the community if you plan well. First, you have to identify the “at need people” then the distance to their homes and put this in your short-term strategic plan for execution.”

“HVs are basic responsibilities of community health nurses, and we ought to execute it. In spite of the challenges, we cannot let those particularly hinder on our ability to conduct our very core mandate.”

Some CHNs were not able to visit all homes in their catchment areas, citing “hard to reach areas” and “Inadequate equipment” as the reasons for not being able to visit all households.

“Sometimes it is the distance to the clients' homes that makes it impossible to visit them. There are some homes if you actually intend to visit them, then you must be willing to spend the whole day doing only that activity.”

“Some clients' problems are such that you will need to have special tools before you visit them. For example, what use will it be to a diabetic client if you visit him/her and you are unable to monitor the blood sugar level or to a hypertension patient, you are not able to check the blood pressure because you do not have the required equipment?”

“To have a successful HV practice, I think the authorities should be willing to provide the basic logistics that will aid us to work. Without this basic logistics, we cannot.”

3.2.4. The Reasons for Conducting or Not Able to Conduct Home Visits

CHNs (72.7%) carried out both routine and special HVs. For those community health nurses who were not able to conduct HVs, several reasons were ascribed. Some of the reasons described included the lack of basic amenities to conduct HVs. The majority (18.2%) of CHNs also did attribute inaccessible geographical areas as a barrier to HV. Also, CHNs (63.6%) identified inadequate logistics and financial constraints as barriers to HV. All of the CHNs report on their activities regarding home visiting to the district health authorities.

“We basically lack the simple logistics that will assist us to conduct HVs. We do not have simple movable equipment like weight scales, thermometers, sphygmomanometers, and stethoscopes.”

“We do not have functionally equipped home visiting bags, so even if we decide to visit the homes, how much help will we be to the client?”

The other reasons included large catchment areas and lack of reliable transportation for the conduct of HVs in the AD.

“The catchment area is quite wide and practically impossible to visit every home. Looking from here to the end of our catchment area is more than 5 kilometers, without a means of transport, one cannot be able to visit all those homes.”

“I remember in those days; community health nurses were given serviceable motor cycles to aid in their movement and especially the conduct of HVs. Today, since our motorbike broke down 5 years ago, it has since not been serviced, yet we are expected to conduct HVs.”

“To conduct home visits, whose money will be used for transportation? The meagre salary I earn? Or the families or beneficiaries of the service have to pay?”

“The number of staff here is woefully inadequate, we are only two people here, how can we do home visiting and who will be left in the facility to conduct the other activities. For this reason, we are not able to conduct HVs.”

CHNs tried to visit the homes at various times depending on the occupation of the significant other of the homes, so that they can provide services in the presence of the significant others. CHNs (63.6%) visit 6–10 homes in a week as 90.9% CHNs conduct HVs in the morning. The reasons given for conducting some HVs in the evenings included the following:

“This place is largely a farming community, most people visit their farms during the mornings, so if you visit the home in the morning, you may not meet the significant others of the vulnerable person to conduct health education.”

“We do HVs because of the clients, so anytime it is possible, we will meet them at home, we conduct the visits at that time. For me, even if the case is that I can only meet the important people regarding the client at night, I visited them at that time. For community health nursing work, it is a 24-hour work and we must be found doing it at all time.”

3.2.5. Frequency of Conducting Home Visits by CHN

Various schedule periods were used based on health facilities for the purpose of HVs. Most (45.5%) conducted HVs three times in a week. CHNs (90.9%) had conducted HVs the week preceding the interview. Indicating that the last time HV was conducted, CHNs conducted a HV at least within the last week:

“HV is a weekly schedule in this facility; for every week, we have a specific person who is assigned to do HV just as all other activities that are conducted in this facility”.

“Yes, last week, we had a number of HVs; we made one routine HV and the other was a scheduled HV from a destitute elderly woman who was accused as a witch by some of her family members.”

Indicating if they sometimes get fatigued for conducting HVs weekly because of the limited number of staff, a community health nurse indicated that,

“I think it is about the plan we have put in place. There are about four people in this facility. We plan our activities that we all conduct HVs. In a month, one may only have one or two HVs, so it is unlikely that you will be fatigued in conducting HVs.”

“Yes, sometimes, it is really tedious, but we cannot let that be a setback. We have a responsibility to execute and we must be doing so to the best of our ability.”

3.2.6. Activities Undertaken during Home Visits

CHNs conducted health education (90.9%), management of minor ailments (54.6%), and vaccination/contact tracing (63.6%) during HVs. Describing if they are able to conduct the management of small ailments and home accidents at home, CHNs were divided in their ability to do this. Those were not able to do so indicated,

“…. And who will pay? Since the introduction of the national health insurance, we are not able to provide management of minor ailments during HVs. In those days, we were supplied with the medicines to use from the district, so we could provide such free services. But with the insurance now in place, we do not get medicine from the district, so whose medicine will you use to conduct such treatment?”

“I think our major goal is on preventive care. We have a lot to do with preventing diseases. Let us leave disease treatment to the clinical people. When we get ailments, we refer them to the next level of care to use their health insurance to access service.”

Identification of cases, defaulter tracing, and health education were identified as benefits and promotion factors of HVs. Identification of cases and defaulter tracing were both mentioned by CHNs as benefits and promotion factors of HVs.

“I think HVs should be continued and encouraged to be able to achieve universal, sustainable PHC coverage for all. Not only do we visit the homes, we also identify vaccination defaulters, tuberculosis treatment defaulters, and prevention of domestic violence against women and children and health education on specific diseases and sometimes we do immunisation.”

“In the home, we have a varied responsibility, treatment of minor ailments, immunization and vaccination, contact tracing, education on prevention of home accidents, etc.” It will be a disservice, therefore, if anyone tries to downplay the importance of HVs in our PHC dispensation.”

“Through HVs, we have provided very essential services that cannot be quantified mathematically, but the community members know the role of the services in their everyday lives. Even the presence of the community health nurse in the home is a factor that promotes girl child education and leads to woman empowerment.”

4. Discussion

This study assessed the home visiting practices in the AD of the Volta Region of Ghana. The concept of home visiting has been enshrined in Ghana's health history and executed by the CHN or public health nurses (PHN). In AD, only CHNs among all the various cadres of health professionals conducted HVs. This was contrary to the practice in the past when both CHN and PHN conducted HVs [ 18 ]. Notwithstanding the limited numbers of CHNs in the district, the majority of households (73.3 %) have a history of visits from a CHN. Home visiting is central in preventive healthcare services, especially among the vulnerable population. In children under five years, it is plausible that nurse home visiting could lead to fewer acute care visits and hospitalization by providing early recognition of and effective intervention for problems such as jaundice, feeding difficulties, and skin and cord care in the home setting [ 19 ]. Home visiting emphasizes prevention, education, and collaboration as core pillars for promoting child, parent, and family well-being [ 20 ].

In Ghana, under the PHC initiative, communities are zoned or subdivided and have a CHN to manage each zone by conducting HVs, including a cluster of responsibilities mainly in the preventive care sectors [ 4 ]. As rightly identified, HV is one of the core mandates of the CHN. Most of the community members who had received more than one visit in a week lived close to the health facilities indicating that there are homes which have never been visited, and CHNs are not able to cover all homes in their catchment areas. Factors that deter the conduct of HVs by CHN ranged from community members' level of education, attitude, supervision challenges, lack of incentives, and lack of basic logistics to conduct HVs. It is imperative that CHNs HVs especially those with newborn children to assess the home environment and provide appropriate care interventions and education as it was reported that 2.8% of 2641 newborns who did not receive a HV were readmitted to the hospital in the first 10 days of life with jaundice and/or dehydration compared with 0.6% of 326 who did receive a HV [ 21 ]. CHNs need to be provided with the right tools including means of transport to reach “hard to reach” communities and homes to provide services.

In rural Ghana such as the AD, community members leave the home to their places of work or farms during the morning sessions and only return home in the evening or late afternoon. HVs (93.4%) were conducted between 9am and 2pm, while some homes (6.6%) were visited between 3pm and 6pm. One problem faced by this timing difference is further expressed when CHNs indicated that they did not meet people at home during HVs. It is important for CHNs to be wary of their safety in client's homes as they show enthusiasm to visit homes at any time, and they could meet significant others. Therefore, to ensure safety, it is important to cooperate with clients and their families [ 22 ] in providing these services especially outside the conventional working hours. The need to use alternative timing of visits is essential as it is known that client participation is required to determine the scope of quality and safety improvement work; in reality, it is difficult for them to participate [ 23 ]. Also, some respondents indicated the time spent during HVs was too short (32.7%), and others (24.5%) wished the CHNs could spend more time with them. Community members have problems they wished could be addressed by the CHNs during HVs, but because of the number of households compared to the limited number of CHNs available, the CHNs could not spend much time during HVs and the respondents were not satisfied with the services rendered. It is likely that services will be better implemented by households if the CHN spends much time with the household and together implements thought health activities. Amonoo-Lartson and De Vries reported that community clinic attendants who spent more time in consultation performed better [ 24 ].

CHNs (8.2%) indicated they could not visit all households that needed the home visiting services in their catchment areas. Home visiting nurses are required to be mindful of the time and environment where they are performing care [ 22 ], so that they can allow for maximum benefit to the community. This notwithstanding, some community members (26.7 %) were not available during the HVs. The determination of suitable time between the CHN and the client is critical in ensuring that a positive relationship is established for their mutual benefit. The interval associated with HVs varied from one community or a health centre to another, and this was planned based on the specific needs of each community or CHPS catchment zone. There is actually no one-size-fits-all approach to home visiting [ 20 ] as several strategies can be adopted in providing services. The number of weeks or months elapsing between the visits ranged from one week to four months. The ministry of Health Ghana per the PHC system encourages CHN to conduct at least one contact tracing and/or HV session within a week within their communities [ 25 ]. All CHNs indicated that in their catchment area, they conducted at least one HV in a week and sometimes even more depending on the exigencies of the time.

Various activities are expected to be conducted by CHNs during HVs. These activities include the provision of basic healthcare services such as prevention of diseases and accidents, disease surveillance, tracing of contacts of infectious disease, tracing of treatment defaulters such as tuberculosis, diabetes mellitus, and hypertension and management of minor ailments at home. Community members (62.3%) did not receive a minor ailment management during HVs. CHNs are expected to be equipped with requisite knowledge, tools, and skills to be able to conduct these services in the homes. Also, the level of care that can be identified as a minor ailment as per the guidelines of the Ministry of Health needs to be specific as community members had varied classification of minor ailments and the level of care to be provided. Home visitors have varying levels of formal education and come from a variety of educational backgrounds marked by different theoretical traditions and content knowledge [ 20 ]. Other jurisdiction HV nurses drew blood for bilirubin checks and set up home phototherapy if indicated; they provided breastfeeding promotion and teaching on feeding techniques and skin and cord care [ 19 ]. Also, CHNs are expected to be able to provide baby friendly home-based nursing care services during a visit to the clients' home. HV nurses should also discuss the schedule of well-baby visits and immunizations [ 19 ] with families.

Important challenges associated with the conduct of HVs were identified as a large catchment area, lack of basic logistics, lack of the reliable transportation system, uncooperative community members, inadequate staff, and “hard to reach” homes due to geographical inaccessibility. Health education, management of minor ailment, and vaccination or contact tracing were the activities carried out in the homes. Home visiting nurses are under pressure to complete a job within an allotted time frame, as determined by the contract or terms of employment [ 22 ]. Time pressure significantly contributes to fatigue and depersonalization, and adjustments to interpersonal relationships with nurse administrators can have notable alleviating effects in relation to burnout caused by time pressure [ 26 ]. CHNs (63.6%) identified inadequate equipment and financial constraints as challenges to HV. Given evidence suggesting that relationship-based practices are the core of successful home visiting [ 27 – 29 ], with a natural harmony between the home visitor and the community members to the home, she renders her services [ 20 ]. A report published by the National Academy of Sciences (1999) also identified staffing, family involvement, language barrier, and cultural diversities as some of the barriers to a HV [ 30 ].

Health education (87.9%) dominated the home visiting activities. Health education helps to provide a safe and supportive environment and also build a strong relationship that leads to long lasting benefits to the entire family [ 5 ]. Face to face teaching in the privacy of the home is an excellent environment for imparting health information [ 31 ]. The CHNs stated that health education, tracing of defaulters, and identification of new cases are the benefits and promotion factors for conducting HVs. This implies that there are other critical aspects of HV that CHNs neglect such as prevention of home accidents and ensuring a safe home environment and care for the aged. Early detection of potential health concerns and developmental delays, prevention of child abuse, and neglect are also other benefits and promotive factors of HV. HV helps to increase parents' knowledge, parent-child interactions, and involvement [ 5 ]. The conduct of HV was not reported among all community members as some community members (22.0%) in the AD indicated their homes have never been visited. This is, however, an improvement over the rate of HVs that was reported in the Assin district in Ghana [ 32 ]. In the Assin district, about 84% of the respondents said they gained benefits from HVs [ 32 ]. In this study, respondents who were visited indicated the CHNs just inspected their weighing card while giving them no feedback. CHNs should implement various interventions to ensure that community members directly benefit from health interventions that are implemented during HVs to reduce the consequences that are usually associated with poor access to healthcare services especially in poor rural communities such as the AD.

5. Conclusion

The activities carried out in the homes were mainly centred on health education, contact tracing, and vaccination. Health workers faced many challenges such as geographical inaccessibility, financial constraints, and insufficient equipment and medications to treat minor ailments. If HV is carried out properly and as often as expected, one would expect the absence of home accidents, child abuse, among others in the homes, and a reduction in hospital admissions.

The need for strengthening HV as a tool for improving household health and addressing home-based management of minor ailment in the district cannot be over emphasized. It is important to forge better intersectoral collaboration at the district level. The District Assembly could assist the District Health Management Team with transport to support HVs. In addition, community-based health workers such as community health volunteers, traditional birth attendants, and community clinic attendants should also be trained to identify and address health problems in the homes to complement that which is already conducted by healthcare professionals.

Acknowledgments

The authors wish to express their profound gratitude to the staff and district health management team of the AD of the Volta Region of Ghana for providing them with the necessary support and assisting in diverse ways to make this study possible. They thank their participants for the frank responses.

Abbreviations

Data availability, conflicts of interest.

The authors declare that they have no conflicts of interest.

Home Visits

When is the last time you visited or called a parent or guardian without bad news?

Administrators

How are you equipping teachers to build relationships with families through visits? Learn the benefits of home visits and best practices for how to prepare for and conduct them.

Best Practices

These are some best practices for teachers and administrators concerning home visits:  

• Visits should be voluntary for educators and families, but administrators should seek at least 50 percent participation from a school’s staff.  
• Home visits should always be arranged in advance. It’s helpful for schools to decide if they want educators to visit families once or twice per year and whether that first visit will take place before the school year begins. Some districts also follow up home visits with family dinners at the school to continue deepening school-family ties.  
• If possible, schools should compensate educators for their home-visit work and train them effectively.  
• Educators should visit in teams of two. In some cases, teachers partner with other teachers, social workers or the school nurse to help address a student’s well-being in a more comprehensive manner.  
• It’s important that educators visit a cross-section of students—ideally all of them—rather than target any particular group.  
• The goal of the first home visit is to build relationships. Educators should talk about families’ hopes and aspirations for their students.

Note to teachers: Take extra care when communicating with immigrant families about visiting their homes. Make it clear in advance that you are not from any government immigration agency, such as ICE, and that you will not talk with any such agency. Also, do not ask about immigration status during the visit—or at any other time.

The Benefits

Family engagement contributes to a range of positive student outcomes, including:

• Improved achievement;
• Decreased disciplinary issues;
• Improved parent- or guardian-child and teacher-child relationships.

Different Families, Different Visits

Just as instruction is differentiated, so too are home visits. Depending on the needs of the student and family and the previous history of the teacher-family relationship, a home visit might be:

• A formal conversation on the couch;
• A meal together;
• A guided tour of a home (including favorite toys and hangout spots);
• Walking the family dog in the park or another excursion to an agreed-upon meeting place.

Note: Keep in mind that some families may not be comfortable having guests in their homes and would prefer to meet somewhere else. In this case, you could offer the school or another location as a meeting place.

Story From the Field: Keep Your Eyes On the Speaker

“I once went on a home visit to a trailer home. We sat at the kitchen table, and I was astounded to see a hole around a foot and a half in diameter right in the middle of the kitchen, through which I could see the dirt underneath the trailer. However, as mortified as I was, I thought that it probably was even more mortifying for the mother who so kindly received me. She was probably embarrassed and the least I could do was to keep my eyes on her and focus on our conversation instead of on the material distractions around us. My job is to focus on the human being, not on the dehumanizing conditions many people have to live in.”

—Barbie Garayúa-Tudryn, elementary school counselor and TT Advisory Board member

Home Visit Checklist:

• Participate in home-visit training.
• Call each student’s home, and explain the purpose of the visit.
• Schedule the visit.
• Determine if a translator is needed. The student should not serve as a translator.
• Confirm the day before or the day of the home visit.
• Before the visit, reflect on the reason you’re there in the first place: to build a relationship with the family and collaborate with them for the well-being of the child.
• The visit should be 20-30 minutes long.
• Bring a partner.
• Get to know the family. Find out if they have other children in school.
• Talk about the family’s hopes for their students and share yours.
• Avoid taking notes or bringing paperwork, which can make families feel as if they are being evaluated and can cause nervousness and disengagement.
• If you need to share paperwork, wait 20-30 minutes before delivering it or plan to send it at a later date.
• Ask the family what they need from you, and make a plan to connect again in the future.
• Make a phone call or send a text or note thanking the parents or guardians for the meeting.
• Invite the family to an upcoming event.
• Document the visit, and share takeaways with appropriate stakeholders.
• Follow up with any resource needs that came up during the visit.

To learn more, read “ Meet the Family ” and watch our on-demand webinar Equity Matters: Engaging Families Through Home Visits .

Critical Training Elements for Administrators

Training and preparing for a home visit can be as important as the visit itself. Consider these pointers from the experts when designing professional development for your home-visit program.

• Review logistics , such as how to make contact, how and when to schedule visits, whether and how to record discussions with families, and what to do with the documentation and data.  
• Remind teachers to leave assumptions behind and keep an open mind regarding each family, their culture and their values.  
• Address implicit bias and the impact it can have on what educators or families will perceive during the home visit. To learn more about implicit bias, view our on-demand webinar Equity Matters: Confronting Implicit Bias .  
• Some prior knowledge is essential , such as whether a translator will be necessary (it is not appropriate to use the student as a translator), whether the family has access to a working phone or if the child lives between two households.  
• Coach teachers to establish the purpose for the visit ahead of time. Goals should focus on getting to know the child as a learner and setting the stage for partnership, not on problematic behavior or performance.  
• Model how to talk about both the student and the family. Some families may have significant needs. Connecting them to resources can benefit their child’s learning.

For more information, explore the work of The Parent Teacher Home Visit Project and the Family and Community Engagement Team at Denver Public Schools.

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• Programs & Impact

Important Home Visiting Information During COVID-19

Updated: May 18, 2023

The COVID-19 public health emergency expired as of May 11, 2023. With the end of the public health emergency, specific flexibilities offered for the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program under the Consolidated Appropriations Act, 2021 ( P.L. 116-260 ) have ended. MIECHV awardees may continue to use grant funding for reasonable, allocable, and allowable uses outlined in 42 U.S.C. § 711 (Title V, § 511 of the Social Security Act, as amended) and program guidance. These may include reasonable expenses to support the implementation of virtual or hybrid home visiting services to ensure eligible families can participate in evidence-based home visiting programs. 42 U.S.C. § 711 (Title V, § 511 of the Social Security Act, as amended), which authorizes the MIECHV Program, defines a virtual home visit as “a visit conducted solely by use of electronic information and telecommunications technologies.”

Please note that the end of the public health emergency does not impact allowable uses of funding for MIECHV awards made with American Rescue Plan Act (ARP) funding. HRSA encourages MIECHV awardees to continue to prioritize using ARP award funding to address the immediate and ongoing impacts of the COVID-19 pandemic on children and families.

Jump to: Consolidated Appropriations Act of 2021 American Rescue Plan Act of 2021 FAQs for Home Visiting Grantees

Consolidated Appropriations Act of 2021

On December 27, 2020, the President signed into law the Consolidated Appropriations Act, 2021 ( P.L. 116-260 ). This bill provided new authorities to MIECHV awardees to assist in their response to the COVID-19 public health emergency.

The law allowed awardees to use MIECHV funds during the COVID-19 public health emergency period to:

• Train home visitors in conducting virtual home visits and in emergency preparedness and response planning for families
• Acquire the technological means as needed to conduct and support a virtual home visit for families enrolled in the program
• Provide emergency supplies to families enrolled in the program, regardless of whether the provision of such supplies is within the scope of the approved program, such as diapers, formula, non-perishable food, water, hand soap, and hand sanitizer

The Consolidated Appropriations Act, 2021, specified that the additional authorities are available “during the COVID–19 public health emergency period.” The public health emergency ended on May 11, 2023, so these authorities are no longer available.

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American Rescue Plan Act of 2021

On March 11, 2021, the American Rescue Plan Act of 2021 ( P.L. 117-2 ) (ARP) was signed into law. ARP appropriated $150 million for MIECHV awardees to address the needs of expectant parents and families with young children during the COVID-19 public health emergency. ARP identifies seven categories of required uses of funding, which are service delivery, hazard pay or other staff costs, home visitor training, technology, emergency supplies, diaper bank coordination, and prepaid grocery cards.

The end of the COVID-19 public health emergency does not impact awards made with ARP funding.

On May 10, 2021, HRSA awarded approximately $40 million in funding provided by the American Rescue Plan Act (ARP) to 56 states, territories, and nonprofit organizations currently funded through the MIECHV Program to support home visiting activities that address immediate needs of parents, children, and families related to the COVID-19 public health emergency.

On December 1, 2021, HRSA awarded approximately $81 million in additional ARP funds to continue to support MIECHV recipients in responding to ongoing COVID-19-related needs, including the expansion of services for families residing in at-risk communities as identified in the current approved needs assessment update. The remaining ARP funds will be used to support research, evaluation and technical assistance activities, tribal awards, and competitive innovation awards.

More information on the MIECHV ARP awards, including program guidance and Frequently Asked Questions, is available on the MIECHV Technical Assistance webpage .

FAQs for Home Visiting Grantees

With the end of the covid-19 public health emergency, how can miechv awardees spend formula award funding.

MIECHV awardees may continue to use formula award funding for reasonable, allocable, and allowable uses within the scope of their project. These may include reasonable expenses to support the implementation of virtual or hybrid services to ensure eligible families can participate in evidence-based home visiting programs. 42 U.S.C. § 711 (Title V, § 511 of the Social Security Act, as amended), which authorizes the MIECHV Program, defines a virtual home visit as “a visit conducted solely by use of electronic information and telecommunications technologies.”

MIECHV awardees may reach out to their HRSA Project Officer and Grants Management Specialist with any questions.

With the end of the COVID-19 public health emergency, how can MIECHV awardees continue to support families affected by COVID-19?

HRSA urges awardees to prioritize using American Rescue Plan Act (ARP) award funding to address the immediate and ongoing impacts of the COVID-19 pandemic on children and families, consistent with the seven categories of required uses of funding (Section 9101 of P.L. 117-2 ): service delivery, hazard pay or other staff costs, home visitor training, technology, emergency supplies, diaper bank coordination, and prepaid grocery cards.

Please note that the end of the COVID-19 public health emergency does not impact awards made with ARP funding.

With the end of the COVID-19 public health emergency, can MIECHV award funding support virtual home visiting services?

Yes, MIECHV award funding may continue to support virtual or hybrid home visiting services per Section 511 of the Social Security Act, as amended by the Consolidated Appropriations Act, 2023 ( P.L. 117-328 ). 42 U.S.C. § 711 (Title V, § 511 of the Social Security Act, as amended), which authorizes the MIECHV Program, defines a virtual home visit as “a visit conducted solely by use of electronic information and telecommunications technologies.”

Should well-child telehealth visits be included in performance reporting?

Well-child telehealth visits completed according to the AAP schedule can be included as meeting the numerator criteria for performance measure 4. The AAP has issued guidance on providing well-child care via telehealth during COVID-19 . We recognize that not all providers may offer well-child visits, in person or via telehealth, during this time. Awardees should continue to report on well-child visit completion following directions and information in the Form 2 toolkit (PDF - 1 MB) and FAQs (PDF - 1 MB) .

How should MIECHV awardees report virtual screenings for the purposes of annual performance measurement reporting?

All families screened with a validated tool should be included in the numerator and denominator per the measure definitions (Measure 3, Measure 12, and Measure 14). MIECHV awardees should consult with tool developers to determine appropriateness and criteria for virtual/remote screening. Please note that awardees should not report the number families screened virtually separately; however, awardees may voluntarily provide additional information related to virtual screenings in the comments section. The same information applies for reporting of virtual observations for Measure 10 (Parent-Child Interaction).

Should postpartum telehealth visits be included in Performance Reporting?

Postpartum telehealth visits that meet the criteria defined in Form 2 (PDF - 489 KB) can be included in the numerator for measure 5. The American College of Obstetricians and Gynecologists recommends that women connect with their health care provider to discuss how their postpartum care visits may change during this time, including a shift to telemedicine or telehealth.

Disney Confirms Final Day of Operation for Florida Park in 2024

in Disney Parks , Walt Disney World

Disney has confirmed the last day to visit one of its Florida parks before it closes.

Related: Disney Releases Official and Exclusive Rainbow Items for Gay Days Anaheim

Walt Disney World is home to four incredible theme parks, each featuring a dazzling assortment of rides and attractions for guests to enjoy. Magic Kingdom is home to arguably the best selection of attractions, featuring several iconic dark rides like Peter Pan’s Flight and Pirates of the Caribbean.

There’s plenty of thrilling fun to be found for adrenaline junkies, with Hollywood Studios, EPCOT, and Animal Kingdom all featuring several exhilarating experiences like Guardians of the Galaxy: Cosmic Rewind, Expedition Everest , and the soon-t0-be-extinct DINOSAUR.

The variety of attractions extends to Disney’s two water parks, Typhoon Lagoon and Blizzard Beach, one of which is set to close soon.

Last Day to Visit Typhoon Lagoon

Related: Unexpected Disney Ride Evacuation Reveals Spine-Chilling Surprise

The Walt Disney World Resort has confirmed the last day to visit Typhoon Lagoon in 2024 will be November 3. The water park will close for refurbishment the following day on November 4. Disney’s Blizzard Beach will reopen on November 4.

Since 2020, the Walt Disney World Resort has operated its water parks on a cycle, leaving one open while the other receives maintenance.

This is expected to change in 2025, with Disney unveiling an exciting new deal of guests staying at select Walt Disney World Resort hotels.

Typhoon Lagoon was the second water park to open at the Walt Disney World Resort, opening shortly after Disney’s now-closed River Country in 1989.

Related:  Fox Anchor Sean Hannity Slams Bob Iger, Suggests Disney Doesn’t Want Conservatives in Its Parks

While not one of the four main theme parks, Typhoon Lagoon’s theming is a truly remarkable experience.

Due to a strong storm and the titular ‘typhoon,’ guests see what used to be a pristine paradise has now become an overgrown and messy island, reclaimed by mother nature. Diving gear, stray surfboards, and all sorts of fishing equipment have been strewn out, creating a chaotically beautiful aesthetic.

Guests have the chance to take the plunge on a variety of water slides, as well as take on a daunting surf pool which creates walls of water up to six feet high.

More on Typhoon Lagoon’s wave pool:

Wade into the warm water where gentle waves lap the white sandy beach. Swim out and listen for the thunderous “sonic boom” and the squeals of delighted swimmers as little ripples become big kahunas. Keep watch and feel the excitement build as a cresting wave heads your way—and get ready to paddle! Enjoy an epic body surf ride as you’re propelled to shore. With a continuous set of swells, you’re sure to catch a gnarly wave!

Do you enjoy visiting Walt Disney World’s water parks?

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Kansas Basketball Set to Visit Elite 2025 Five-Star Point Guard

Mathey gibson | sep 17, 2024.

• Kansas Jayhawks

Kansas basketball is making moves on the recruiting trail, setting its sights on one of the nation’s top prospects in the 2025 class, Mikel Brown Jr. Bill Self and an assistant coach are scheduled to visit the elite five-star point guard for an in-home visit on Wednesday, according to Derek Murray of Cerebro Sports.

⭐️⭐️⭐️⭐️⭐️ 2025 Mikel Brown Jr. this week: Today - Kentucky & Louisville in @DMEAcademyMBB . Wednesday - Kansas HC Bill Self + 1 for an in home visit. Thursday - Alabama in @DMEAcademyMBB . pic.twitter.com/QDzm66AtQ6 — Derek Murray (@Derek__Murray) September 17, 2024

Brown, a 6-foot-3 point guard from DME Academy in Florida, is ranked as the No. 7 overall player in the 2025 class by 247Sports. Known for his exceptional court vision, playmaking ability, and scoring touch, Brown has caught the attention of several top programs, including Kansas.

READ: Kansas Target AJ Dybantsa Impresses with 43-Point Game Against Carlos Boozer’s Twins

The Jayhawks initially offered Brown in August 2022, and he followed up with an unofficial visit to the program in October of the same year. Kansas is hoping to get him back on campus for an official visit soon to further solidify their interest.

Brown’s recruitment has been active, with visits to top programs such as Alabama, Ole Miss, and Providence. Most recently, he took a visit to Indiana on September 13, signaling that his decision-making process is heating up as top schools vie for his commitment.

Securing Brown would be a significant win for Kansas, as he’s considered one of the best guards in his class.

Stay tuned to  Kansas Jayhawks On SI for more KU basketball recruiting news.

Kansas On Sports Illustrated Three Reasons Flory Bidunga is a Game-Changer for Kansas Basketball Kansas Basketball Gaining Momentum with Top 2025 Five-Star Prospect Top Kansas Target AJ Dybantsa Remains No. 1 Recruit in 2025 Class Kansas Recruiting: Will Five-Star Forward Koa Peat Consider the Jayhawks?

MATHEY GIBSON

Sean Combs’ new home — a notorious federal jail — has a ‘way of breaking people,’ lawyers say

Sean "Diddy" Combs is used to living in multimillion-dollar mansions. His new home is a notorious federal jail in New York City known for extreme violence and abominable medical care. 

The Metropolitan Detention Center in Brooklyn was the scene of two fatal stabbings in two months over the summer. And in April, MS-13 gang members stabbed an inmate 44 times in a shocking attack that was caught on camera. 

The victim was one of the lucky ones: He survived.

The situation at the Metropolitan Detention Center, known as the MDC, has gotten so bad that judges have refused to send certain nonviolent inmates there.

“Chaos reigns,” U.S. District Judge Gary Brown wrote in a decision last month blasting the conditions at the facility, “along with uncontrolled violence.”

The detention center has housed a number of high-profile inmates in recent years, including Sam Bankman-Fried, R. Kelly and Ghislaine Maxwell. They are kept in a segregated unit outside of the general population. Still, the conditions are horrid across the facility, according to interviews with more than a half-dozen defense lawyers and a review of court documents. 

“I have a client who spent 25 years in federal prison somewhere else, and he’s like, 'Get me the hell out of the MDC,'” defense lawyer Xavier Donaldson said. “It has a way of breaking people.” 

A judge on Tuesday ordered Combs, who has been charged with sex trafficking and racketeering , to be held without bail. Combs’ lawyers appealed , but the ruling was upheld Wednesday. That means he is likely to remain at the MDC until he goes to trial.

The facility came under the spotlight in the winter of 2019 when a power outage left inmates without light or heat for a full week during a brutal cold snap. Conditions for the detainees continued to deteriorate during the Covid-19 pandemic, when they were subjected to 24-hour lockdowns. 

In 2021, the Justice Department shut down the city’s other federal jail, the Metropolitan Correctional Center, two years after disgraced financier Jeffrey Epstein’s death by suicide.

With the most violent federal offenders in New York now housed in the same facility and officials struggling to hire enough corrections officers, the MDC has only become more dangerous, according to defense lawyers and the head of the corrections officers union.

“The agency as a whole has failed to assist MDC Brooklyn with the staffing crisis, hence allowing MDC Brooklyn to fail,” the union head, Rhonda Barnwell, wrote in a memo to Bureau of Prisons officials in June 2023. “What are you waiting for? Another loss of inmate life?”

Her questions proved prophetic. 

First came the stabbing on April 27, which was caught on surveillance cameras. 

The victim was sitting alone at a table when a man sneaked up behind him and pulled out a shiv from his waistband. The man, whom prosecutors identified as an MS-13 gang member, stabbed the victim multiple times. Two other alleged MS-13 members pulled out homemade knives and joined in the attack, according to surveillance video obtained by NBC News.  

It went on for about 37 seconds until a corrections officer showed up in the housing unit, causing the attackers to flee. The unidentified victim sustained about 44 stab wounds to his back, chest, abdomen, right arm and legs, according to federal prosecutors. 

Two shivs were recovered — one 10.5 inches in length, the other 5.5 inches long. The lead attacker was identified as Luis Rivas, who is serving a 40-year sentence for a host of gang-related crimes, including nearly decapitating a 16-year-old boy in Queens, New York.

The stabbing marked the start of a spate of deadly violence. 

On June 7, another inmate, Uriel Whyte, was fatally stabbed in the neck at the MDC, according to the Bureau of Prisons and the chief medical examiner’s office. Less than six weeks later, Edwin Cordero, 36, was stabbed by another inmate. He died July 17 of a stab wound to the chest, according to the medical examiner. 

“Mr. Cordero was a victim of MDC Brooklyn’s deplorable conditions, which are fueled by chronic overcrowding and understaffing,” said his lawyer, Andrew Dalack. “Until the federal government gets its act together to make the conditions at MDC Brooklyn more humane and secure, the solution is simple: Far fewer people should be detained there, period.”   

A spokesman said the Bureau of Prisons "takes seriously addressing the staffing and other challenges at MDC Brooklyn."

"That is why, earlier this year, the director appointed an Urgent Action Team to take a holistic look at the challenges at MDC Brooklyn," the spokesman added. "The team’s work is ongoing, but it has already increased permanent staffing at the institution (including COs and medical staff), addressed over 700 backlogged maintenance requests, and applied a continued focus on the issues raised in two recent judicial decisions."

A series of cases of alleged medical neglect have drawn the ire of judges over the past year. 

An inmate, Terrence Wise, was found to have a mass in his chest in February. But he wasn’t told of the mass or provided any medical care for two months — even after he started coughing up blood, according to court records. He was eventually sent in April to a hospital, where he learned the cancerous mass had nearly doubled in size, according to court documents.

In another case, an inmate endured hours of extreme pain, with the MDC staff ignoring his cries for help, after his appendix burst in April. He was then forced to recover from surgery without pain medication, according to court documents.  

“This is not an anomaly,” U.S. District Judge LaShann DeArcy Hall said at a hearing for the inmate, Jonathan Goulbourne, in May, according to the New York Daily News . "I am tired of hearing the defendants that are held at the MDC are not being provided with the necessary medical treatment."

A statute in the federal court system requires defendants who are out on bail to be remanded to jail after they are convicted. But in January, U.S. District Judge Jesse Furman went so far as to cite the conditions at the MDC as an "exceptional" circumstance that allowed him to leave a defendant on house arrest ahead of imposing a sentence.

Furman cited the facility's “dreadful conditions” and said it has been found to be “egregiously slow in providing necessary medical and mental health treatment to inmates” to justify his decision not to send a man convicted of drug trafficking to the MDC.

Judge Brown offered an even more scathing assessment of the Brooklyn facility in his decision last month in which he vowed to place a convicted fraudster on house arrest if the man were to be placed at the MDC to serve his nine-month sentence.

Brown described the conditions as “dangerous” and “barbaric.” He also noted that each of the five months preceding his opinion was “marred by instances of catastrophic violence at MDC, including two apparent homicides, two gruesome stabbings and an assault so severe that it resulted in a fractured eye socket for the victim.”

“The activities precipitating these attacks are nearly as unthinkable and terrifying as the ensuing injuries: drug debt collection, fights over illegal narcotics, resisting an organized gang robbery, internecine gang disputes and as-yet-unidentified ‘brawls,’" he added in his written opinion.

The lawyer for defendant Daniel Collucci praised Brown.

“He asked a lot of questions, did a lot of research and satisfied himself that that place is a hellhole,” said the lawyer, Richard Kestenbaum.

Rich Schapiro is a reporter for the NBC News Investigative Unit.