Home Visits Set Stage for Health

July-August 2019


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Illustration by: Napal Naps

When Maria Medina moved to Albuquerque, N.M., two years ago to get away from an unsafe domestic environment, she was able to briefly stay with a cousin, but she had no home, no transportation and limited options for food. She was 13 weeks pregnant. She felt afraid and hopeless. Through a collaboration with the Women, Infants, and Children (WIC) program, Maria was referred to CHI St. Joseph's Children's Home Visiting Program. The program's staff visits families, encouraging prenatal care and providing education and resources for parents and babies.

Medina's son, Miguel, initially needed a feeding tube as a medical intervention. The home visiting program linked her to Medicaid, to a government rental assistance program and to food benefits. Her home visitor says she has become a fierce advocate for herself and her son. Miguel, now off his feeding tube, is an energetic toddler.

Medina meets with her home visitor and they discuss child development, strategies for finances, her priorities and the scheduling of health care and other appointments. Mother and son are learning to live healthy lives.

New Mexico's population is plagued by chronic illnesses such as obesity, hypertension, diabetes and congestive heart failure. When CHI St. Joseph's Children strategized how to improve outcomes, our research took us back to the cradle. It seemed that every health challenge we encountered had its roots and solutions in early childhood. Although it has areas of wealth and prosperity, New Mexico also suffers from extreme poverty that has jeopardized the long-term health outcomes of many of its people. In 2018, the U.S. Census ranked the state as having the highest rate of children living in poverty, and today it tops the list for children living with hunger and food insecurity. The Annie E. Casey Foundation Kids Count Report ranked New Mexico 50th in children's well-being. According to Child Trends, the state also was categorized as having the highest rate of people who have experienced adverse childhood experiences (ACEs), or abuse, neglect and other potentially traumatic experiences under the age of 18.

The CHI St. Joseph's Children ministry is supported by an endowment that was created when Catholic Health Initiatives (of which the Sisters of Charity of Cincinnati are a founding member) sold the former St. Joseph Healthcare System in 2002. Our Board reflected on both CHI's mission and the healing work of the Sisters of Charity who arrived in New Mexico in 1865. The Board was challenged by two questions: How do we create the most systemic change to build healthy communities? Through what services could our investment have the greatest return?

The answer was clear: to focus on early childhood development and support for families and their children. CHI St. Joseph's Children employs early childhood educators, known as "home visitors," to meet with first-time parents as they care for their children. The educators help parents understand and recognize developmental milestones, offer ways to interact and play with infants and toddlers to promote connection and learning, and answer questions related to raising a physically, mentally and emotionally healthy child. Whenever possible, home visiting begins during the prenatal stage, teaching parents about infant and toddler health, well-being and school readiness. These visits continue once a week for three years.

We all know young parents need support for the health of their children and for their own well-being. Changes in our society can make this challenging. New parents often live far away from relatives who could provide a family network while the new family is figuring out how to care for an infant. In a dual-income economy, many households have to rely on both parents working outside the home to bring in two salaries.

To illustrate the importance of early intervention with children and their families, we can use the analogy of comparing a child's developing brain to a New Mexico potter making beautiful clay vessels. She takes the clay in her hands and forms a pot, much like building the rapidly developing brain's architecture. But poverty and the conditions often linked to it — like hunger, lack of shelter and lack of health coverage – can poke holes in that wet clay before it has a chance to dry. Later on, when society makes investments in kindergarten through 12th grade education, and tries to pour those investments into the leaking pot, society wonders why the children can't take advantage of those investments. We know if a child arrives at school already behind the standard expectations for that age, she usually stays behind. We know that if we're to improve health outcomes, graduation rates and avoidance of later-life chronic diseases, we must pay attention to those first three years of life.

At a time when health care providers wrestle with the challenges of managing the health of their communities, home visiting has proven to be a valuable approach. In addition to education and support for parents, program representatives link families to the resources they need. Adult participants are supported in making healthy choices and in managing their health in partnership with a medical home. Home visits happen during the time when the greatest potential for changing outcomes exists, as demonstrated by the research of James Heckman, PhD, a University of Chicago professor, a Nobel Memorial Prize winner in economics and an expert in the economics of human development. These skills and partnerships can empower the family for the rest of their lives.

CHI St. Joseph's Children's home visitors are trained to share evidence-based curriculum with families; of equal importance, they learn how to approach each family with values of reverence, integrity, compassion and excellence. They build trust, which is the key component to gaining the family's commitment to the program. This can lead to behavioral changes for the betterment of their lives.

We once had a field representative from a nonprofit funder visit our office, and four families in our home visiting program joined us for lunch. We were gathered around a large table, and a cheerful little 2-1/2 year-old girl was wandering around the room while people enjoyed their conversation. The toddler bumped her head against a too-clean window and ran into the arms of her home visitor, demonstrating the deep level of trust children and families have in their home visitor. At that point, the funder leaned over to me and said, "You're going to get money!"

In a world where our families are challenged to find quality time to raise their children, the home visitor becomes an anchor for them, a cornerstone for commitment to the responsibility given to a family with the birth of their child. Home visitors prepare weekly, individual lesson plans appropriate to the child's age. In delivering these, the home visitor knocks on many doors: strong doors, differently painted doors, secure doors, even tattered cardboard doors. Once, while I was shadowing a home visitor, she and I approached a modest home in an immigrant neighborhood, whose residents call it a colonia. Because of the poverty in which this family lived, their door was a small wooden frame with stapled and duct-taped cardboard; yet behind the door was a family filled with joy and a smiling toddler eager to see her home visitor.

Home visiting is where we connect the dots, where a healthy beginning leads to a long-term healthy life. Recently, a young first-time mother shared with a home visitor how grateful she was that, because of her weekly home visits, she was able to "know her baby." The home visitor, in fact, sometimes functions as a baby whisperer.

This is a simple acknowledgement, something we take for granted, something we believe is happening every day between parents and their children. And yet, like all of us, they are humbled by the arrival of this new little person and initially question their ability to care for their new child.

A significant part of the CHI St. Joseph's Children Home Visiting Program is its Enhanced Referrals. The average family comes to us with five referral needs that include medical coverage, food insecurity and lack of housing. A referral specialist accompanies the home visitor to the home and connects families to needed resources, such as the Supplemental Nutrition Assistance Program (SNAP) and Medicaid. The parent is taught how to advocate for their child, to embrace the fact that they are the primary caregivers and educators of the child. These referral specialists, trained by CHI St. Joseph's Children, meet the needs of the families and create the calm environment so necessary to absorb the curriculum that is delivered.

A recent example of this was when a referral specialist was called to attend a home visit to address the family's food insecurity. The parents of a newborn child were living in an apartment that did not have a functioning refrigerator, which was essential for storing the mother's breast milk for her baby. The referral specialist wrangled with the landlord of the apartment complex and did not leave until a functioning refrigerator was wheeled in.

Our goal is that children reach kindergarten with the health and family capacity necessary to support learning. That goal has drawn us into collaboration with many organizations. Our ministry employees are educated to be culturally sensitive, respectful and effective in providing service for New Mexico's diverse communities. Services are provided throughout seven counties that include Native American pueblos and immigrant colonias. Our home visitors meet with the Native American Pueblo of Acoma, including its village of Acoma Sky City, the oldest inhabited pueblo/village in the United States. Our staff has learned that cultural competence begins with listening, engaging with the community to understand its needs and its values, and how to apply those values in an appropriately delivered curriculum. The importance of cultural competence has led us to hire local staff who have mastered the language of their community. We provide home visiting services in nine languages through the linguistic expertise of the home visitor or by developing a relationship with a translator who attends each weekly home visit.

We sit on the border with Mexico. We find that our challenges go beyond the threat of a border wall, to walls that have been built in people's minds and have limited society's welcome to immigrants and refugees. Our home visitors attend an annual advocacy event at the state capital in Santa Fe called The 1000 Kids March, which we sponsor. I remind our staff, as well as the throngs of families who attend, that our state seal has two eagles, not one: the American Eagle with its wings spread out and the eagle of the Mexican national flag; the American Eagle extends its reach to embrace the Mexican Eagle. In this same way, our home visiting ministry spreads its wing and takes under it the care of the marginalized, the discriminated against and the poor. Living our Catholic Health Initiatives mission of fidelity to the Gospel urges us to emphasize human dignity, with a priority for the poor.

Over time, we've also developed additions to our curriculum, one being our Green Curriculum, which helps young families make changes for sustainable living. As Pope Francis' encyclical letter Laudato Sí has called us to a new reality of embracing mother earth, the mothers and fathers of the young children participating in the home visiting program begin to absorb values of reverence for creation.

Our home visitors encounter wonderful opportunities by sharing in the growth of a family and child. But sometimes, there are stressful situations that can cause burnout. CHI St. Joseph's Children's model is proactive in preventing burnout by supporting its staff through reflective supervision, a collaborative reflection between the home visitor and her supervisor that builds on the home visitor's use of her thoughts, feelings and values. Additionally, staff members participate in "sub-communities" that give employees a time to reflect on organizational core values, thereby creating a community rather than a workforce. This care for the staff is vitally important, and we do not experience the very high turnover rate sometimes seen in social services.

Our program offers universal access to our free services and is targeted to those communities with the greatest needs. The work of our home visitors and referral specialists has produced great results with program participants routinely reporting that:

  • Women receive regular prenatal care
  • Newborns have a healthy birth rate
  • Mothers breastfeed for a minimum of one year
  • Children have regular developmental assessments
  • Children have current immunizations
  • Children have decreased need for emergency room visits
  • Children receive skills that promote school readiness
  • Parents complete high school
  • Families are integrated into the community
  • Families are free from domestic violence
  • Families are free from child neglect, physical, psychological or sexual abuse
  • Parents are free from encounters with the judicial system.
CHI St. Joseph's Children has grown to the be the largest home visiting program in New Mexico, providing 650-700 home visits per week. In order to confirm that our program is effective and benefiting the families we serve, we developed a collaborative Longitudinal Study with the University of New Mexico, following 400 families for 22 years.

The university conducted an implementation review. In this review researchers shadowed our home visitors and conducted surveys of our staff and facilitated focus groups. They concluded that the program follows the requirements and adheres to the model guidelines of the curricula of the First Born Program and Partners for a Healthy Baby. They interviewed our staff and administration; they shadowed our home visitors on their home visits; they studied our electronic files. All of this confirmed that the curricula were being faithfully followed. Further, they determined that the staff and administration understood the curricula and that the home visitors consistently covered topics in a manner appropriate to the particular situation of each family. The results of this review can be found at: http://isr.unm.edu/reports/2015/catholic-health-initiatives-st.-josephs-children-home-visiting-program-implementation-review.

We are now in the third year of the University of New Mexico's Longitudinal Study, and we can confirm the positive outcomes. The university gathered over 29,000 data entries of reported health care visits in the state's medical data bank. For example, in the first year of life children in our program have a 14% greater motor function compared to children who are not in the program and less than a 1% need for visits to the emergency room.

Building on the health care tradition of what was St. Joseph's Hospital in Albuquerque, CHI St. Joseph's Children is approaching a decade of fulfilling its mission for community wellness through its home visiting program. Babies do come with instructions.

ALLEN SÁNCHEZ has served as president of CHI St. Joseph's Children in New Mexico for 11 years.



CHI St. Joseph's Children offers two ways to assist others who may want to replicate our Home Visiting Program. The first is a semi-annual four-day International Study Tour covering every detail of operating a home visiting program. The second is a published manual with step-by-step instructions, related to everything from hiring to training and evaluation. (Please use the weblink below for contact information to request permissions to use the manual.)

The Study Tour introduces participants to the social determinants of health and our nation's epidemic of adverse childhood experiences. Participants include newcomers to home visiting and those looking to achieve higher quality in existing programs. Participants are treated to presentations by scientific experts, researchers, home visitors, and families who are in the program as well as those who have graduated. The University of New Mexico delivers updates of the ongoing 22-year longitudinal study of our program during each Study Tour.

Interactive field trips help participants understand, rather than judge, families. One field trip takes participants to the ancient Pueblo of Acoma, with its famous Sky City. The second field trip takes participants to Santa Fe, the oldest capital in the United States, where they visit world class museums such as the Georgia O'Keeffe Museum and the Museum of International Folk Art. In the third field trip, participants shadow a home visitor as they visit a family expecting their first child or a family raising an infant or toddler.

The next Study Tour is scheduled for Sept. 15-19, 2019. Space is still available, and scholarships are offered. Registration information can be found at www.stjosephnm.org.


Home Visits Set Stage for Health

Copyright © 2019 by the Catholic Health Association of the United States

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