Abstract and Keywords
Home visiting and home-based intervention are two strategies used by social workers when working with individuals or families in direct practice. The basic rationale for home-based work is the benefit to social workers’ assessments and understanding of clients, as well as the benefit of more relevant practice with families who are seen in the setting where difficulties are occurring. Home-based interventions have been shown to be effective in improving health and decreasing family discord. When visiting the home, the social worker has the added responsibility of respecting the privacy of families as a guest in their homes.
When working with individuals and families, many of the problems and risks addressed by social workers occur in the home and its environs. Social workers often conduct home visits to better understand the ecological frameworks and environmental settings in which families live. Home visits can show a family that the social worker respects the difficulties of arranging transportation, child care, and other arrangements necessary to come to the social-work or other social agency. Home visits can also illuminate the relationships, resources, and restrictions families face when trying to make the changes they discuss with their social worker. If a picture is worth a thousand words, home visits provide a full portrait of the family in its daily life.
Formal home-based interventions have been developed and refined to serve many populations: young and first-time parents, parents maltreating their children, children and adults with medical or physical needs, aging adults and their caregivers, and others. Rather than asking clients to come to the social worker’s office, the social worker goes to the home of the client to teach skills of daily living, nutrition, child care and discipline, social networking, and health regimens, as well as the more concrete skills of home maintenance and home and neighborhood safety. Home-based interventions are usually based on curriculum or protocol and follow a standardized model of service compared with the less regimented home visit.
There is a long history of home visits in social-work practice. Early in the inception of settlement social work, social workers were often called “friendly visitors” who would visit the homes of families in their neighborhoods or settlements. These friendly visits would serve many functions: familiarizing families with social workers and social workers with the families in their neighborhood; conducting social assessments of families and their needs; educating families as to the supports that social workers could provide; and, more intrusively, assessing whether families who were using the aid of social workers were also following the attendant requirements of those aids. It was not until the 1970s that social services were separated from financial assistance. In the early 1900s, home visits expanded to school and hospital services as well as to child welfare services.
The use of home visits for prevention and intervention, particularly in child welfare, grew after the passage of the Adoption Assistance and Child Welfare Act of 1980 and the subsequent Family Preservation and Support Services Program (Pub. L. No. 103-66); it was during this period that the first national clearinghouse for home-based services was developed (Nelson & Landsman, 1992). Another boon to home-based services in the 1980s and 1990s, albeit with a different population—very young children with a disability or a risk of developmental delays and their families—was the passage in 1986 of Public Law 99-457, Education of the Handicapped Act Amendments, Part H. In 1997, this was reauthorized as Part C, for children from birth to three years old, of Public Law 105-17, the Individuals with Disabilities Education Act. It provided federal support for the family through home-based interventions to intervene early in children’s lives and prevent or ameliorate the need for special education services later in the child’s life.
By the 21st century, home-based interventions had become firmly established as a part of social-work practice in diverse agency settings that focus on family and individual needs throughout the lifespan, such as early childhood home-based programs, criminal justice programs serving youth and adults, adult mental-health programs, older adult home-health and protective services, and hospice (Allen & Tracy, 2009). For example, the current emphasis on community-based services versus traditional institutional care within adult mental health is consistent with a home-based services approach (Lightburn & Schamess, 2002)and is also supported by the President’s New Freedom Commission on Mental Health (2003) that emphasizes community-based approaches with consumer and family involvement in services.
The recognition of the value of home-based interventions is clear in recent social policy initiatives, most notably the Patient Protection and Affordable Care Act of 2010. An important provision of the Act is funding to expand the availability of evidence-based early childhood home-based intervention programs (Home Visiting Updated State Plan, 2011). Each state must submit its plan for its State Home Visiting program. Most of the funding is reserved for programs found to be evidence based by the government-sponsored Home Visiting Evidence of Effectiveness (HomeVEE) study (see Models of Best Practice in Home-based Intervention below). The objective is to strengthen home-based services and improve outcomes for young children and their families in low-income communities across the nation.
The Role of Home Visiting in Social Work
Doing social work in a client’s or client family’s home provides an insight into the client, family, home, and neighborhood that office work cannot begin to assume. The benefits of working in the client’s home and neighborhood are many:
• The social worker shows respect for the family by coming to them at a time convenient for the family and in a place where they are most comfortable.
• Clients value the professional working relationship with staff that develops in the more personal home versus office setting.
• The number of missed appointments decreases dramatically when it is the social worker who comes to the family on their schedule, rather than the family coming to the social worker’s office between 9 a.m. and 5 p.m.
• The social worker can visually assess and understand the physical environment of the home as well as the surrounding neighborhood––its safety, supports, and services.
• Families who receive services in their own homes are typically more relaxed and receptive to the information, education, and conversation that social workers provide.
• Home-based social work is more effective because it incorporates the naturally occurring events, family members, neighbors, and resources in the home and surroundings. Families do not have to translate skills they learn in the office or lab setting to the different and more complex setting that is their daily environment.
• Social workers who provide home-based services often become advocates for community and social change in the neighborhoods in which they visit, work, and often live.
The Role of Home-based Interventions in Social Work
Home-based interventions are more formal than home visits and are intended to be supportive interactions with families in their own homes to achieve better parenting, better self-care, or other positive outcomes. Such services vary in their intensity and overall focus. Masten and Coatsworth (1998) identify three categories of home-based interventions: process focused to foster a better connection between clients and service settings, resource focused to enhance access to needed services, and risk focused to ameliorate risks from physical, social, or emotional problems. Home-based interventions are shaped by the service delivery systems of which they are a part (for example, education, health, mental health, criminal justice); the source and nature of funding, the reporting and productivity requirements, and the administrative structures all shape the manner in which home-based programs are designed and delivered. Some home-based interventions are delivered solely on their own, but often home-based interventions are coordinated with other office, hospital, or school-based services. In most cases, home-based interventions are delivered in the physical structure in which the client or family reside; however, some programs provide home-based services to people without homes or who are living in temporary or alternate home settings such as shelters, nursing homes, or group homes. As in all social-work interventions, the home-based social worker has the dual roles of helper and mandated reporter of harm or risk of harm; this is managed, as in all formal helping relationships, by clearly explaining responsibilities at the beginning of the treatment relationship.
Models of Best Practice in Home-based Intervention
The most current home-based interventions are teaching models, with a well-defined curriculum, requiring interventionists who are trained in the model and who have the fundamental social-work skills of engagement, respect, and hope. Many of these models are implemented by interdisciplinary teams that often include those with undergraduate or graduate social-work training.
Much of the research to develop best practices for home-based interventions has concentrated on services for young children (birth to age 5) and their families. Thus, many of the evidence-based models of home-based interventions have been developed in the context of serving this population. Therefore, the discussion below focuses first on models for early childhood programs, followed by a briefer discussion of some models in other social-work practice settings.
A key initiative for identifying best practices in early childhood home-based services is the HomeVEE study funded by the U.S. Department of Health and Human Services. This study, ongoing at the time of publication in 2013, follows a number of steps to select and evaluate specific models of home-based interventions (U.S. Department of Health and Human Services, n.d.). These include conducting a broad literature search to prioritize relevant program models that are then rated in terms of the rigor of their evaluation designs, program effectiveness, and implementation details with an attention to potential conflicts of interest. The study criteria for an evidence-based model is that research on the model includes the following: one or more studies of at least moderate quality that yielded statistically significant results in at least two outcome domains or two studies of a least moderate quality that demonstrate statistically significant results for the same one domain. This review process has resulted in a valuable database that currently includes 32 models, 19 (59%) of which are judged as showing positive effects in at least one of eight outcome domains. However, only 13 of the programs (41%) met the study criteria for an evidence-based program, which prioritizes them for funding in state home visiting plans supported by the federal Patient Protection and Affordable Care Act of 2010. These include a diverse array of programs such as Home Instruction for Parents of Preschool Youngsters, which focuses on school readiness for preschoolers; the Early Intervention Program for Adolescent Mothers that targets teen parents of color starting during pregnancy and continuing through the child’s first year; and Healthy Families America, a widely implemented comprehensive program for families that may begin during pregnancy and continue until the child is school age. Two other models supported as evidence based by the HomeVEE study are profiled here to illustrate quality home-based interventions.
A model that has been the focus of a number of research studies since the 1980s to demonstrate longitudinal outcomes is the Nurse–Family Partnership program (Olds et al., 1999). Home visits begin during the prenatal period and continue through the child’s second year, decreasing in frequency over time. Parents who have greater physical and educational needs are visited more frequently. The role of these nurses is to (a) promote improvement in women’s and other family members’ behavior affecting pregnancy outcomes, children’s health and development, and family life course, (b) help women build supportive relationships with family members and friends, and (c) link families with needed health and human services (Olds et al., 1999, p. 49). The HomeVEE study (U.S. Department of Health and Human Services, n.d.) supports this program as effective in seven outcome domains: maternal health; child health; child development and school readiness; reductions in child maltreatment; reductions in juvenile delinquency, family violence, and crime; positive parenting practices; and family economic self-sufficiency. Although this model was specifically developed to be implemented by nurse home visitors, social workers have begun to implement this model within their own services to children and their families. Families who are identified as being at high risk of poor outcomes (because of poor health, child abuse and neglect, uninformed or harmful caregiving, and diminished economic resources) are prime candidates for this holistic home-based intervention.
A second model of home-based intervention, Project SafeCare, is also focused on teaching young or neglectful parents better skills in caring for their children. It has three curriculum elements: health, safety, and parenting (Gerstater, Lutzker, & Wesch, 2002). Unlike the Olds model, this is a brief intervention of 24 weeks, intended for primary use with families identified as having abused or neglected their children. Unlike family preservation models (discussed elsewhere in this compendium), Project SafeCare focuses on these three elements––health, safety, and parenting––and only serves families with young children. There is more emphasis on reducing the risk of child maltreatment through parent training and less emphasis on weekly health-care interventions. (Project SafeCare evolved from Project 12-Ways, which included 12 intervention components.) Over the course of 24 weeks, home visitors teach parents how to care for their children’s health and safety and how to effectively interact with and discipline their children through succinct “packaged” protocols that are readily disseminated, each lasting roughly six weeks, with extra time available in each protocol if needed. Project SafeCare has been studied extensively, although the HomeVEE review only rated one of the studies on this program as meeting its highest criteria for design rigor, a randomized control study of SafeCare+ (included motivational interviewing) implemented in a high-risk rural community in Oklahoma (Silovsky et al., 2011). Based on this study in particular, the HomeVEE study (U.S. Department of Health and Human Services, n.d.) supports this model as providing effective results in reductions in child maltreatment and increased positive parenting practices.
These models exemplify the best of home visiting. Interventions are done in cooperation and collaboration with the families. The interventionists’ visits are scheduled, respectful, helpful, and focused on the tasks at hand. Interventionists use techniques and strategies that have been proven effective and work at the families’ pace, using positive and effective social-work skills that amplify the control and dignity of the family.
Models in Other Social-Work Practice Settings
There are many models that include home-based interventions in other fields of social work practice, which also have been researched to establish an evidence base. Examples include the Home-Based Crisis Intervention program in child or teen mental health (Armstrong, Boothroyd, Evans, & Kuppinger, 2009), Familias Unidas for families of low-income Hispanic teens (Coatsworth, Pantin, & Szapocznik, 2002), and Assertive Community Treatment used with adult mental health (Sullivan, 2009) and adult offender populations (Ashford, Sternbach, & Balaam, 2009). However, many models that target older children, adolescents, and adult populations have not undergone the same rigorous reviews as those discussed above for programs targeting young children and their families. (Additional information on some of the models discussed here as well as on other models can be found through the internet links under Further Reading.)
Challenges and Dilemmas
Home-based interventions as a model of practice are not unique to social work, although this profession has a distinguished and storied past of helping families where they live.
When searching the professional and scholarly literature for the evidence base supporting home-based interventions, one will find sources in nursing, education, and psychology journals as well as in social-work journals. Therefore, the challenge for the social-work profession is to think beyond the boundaries of the profession, to learn from others, and to inform others of the importance of an ecological and holistic perspective when assessing families’ needs throughout the life span. Interdisciplinary approaches that combine the expertise of professionals can only benefit families who have needs that transcend disciplines or the responsibilities of one profession.
Another area of challenge for home-based services comprises issues of funding and administration. Home-based services are not always available in all localities and they tend to be underfunded compared with traditional office or institution based services. On the other hand, home-based programs can also be seen as a cost-effective way to serve hard-to-reach populations. In some agencies, home visitors’ offices are their automobiles, reducing expenses for office space. Administrators face challenges of supervising professionals that spend most of their time in the community, rather than being easily accessible in one agency location.
Another challenge frequently cited for home-based interventions is safety. When intervening with families in their homes, social workers have diminished control over the environment and must be particularly attentive to setting appropriate boundaries with families (Strom-Gottfried, 2009). Studies indicate that risk to professionals varies with the client population with which they work, with some settings, such as child welfare, being particularly vulnerable. Therefore, appropriate training, ongoing supervision, and awareness of appropriate precautions are crucial for home-based social workers (Burry, 2002).
Trends and Directions
As more and more professions see the benefit of working holistically with the family rather than solely focusing on an identified client, be it child, adult, or aging adult, we can expect interventions across the spectrum of helping professions to become multi-client. However, many of these other professions come from a model that is office-based, and these family-centered interventions are offered in the office setting. Home-based interventions have proved that learned behaviors and skills are more efficient, effective, and enduring when they are provided where families live. Social workers can continue to emphasize to colleagues in other professions the importance and efficacy of home-based work.
Service delivery in the home has expanded across many delivery systems and across the life span—from early childhood education programs to end-of-life care (Allen & Tracy, 2009). As home-based services experience an expansion, professional and ethical issues of worker safety, professional identity, and the development of a larger body of evidence-based practice techniques become increasingly important. In addition, the field is in need of home-based practice models with specific target populations, such as new immigrants and military families (Supplee, Paulsell, & Avellar, 2012).
Becoming familiar with families’ own homes and surroundings can inform the assessment and understanding of a family far beyond standard assessment protocols. With appropriate training and supervisory support, social workers are able to respect the boundaries of a family’s privacy while engaging in the collaborative development of well-informed interventions that improve family well-being and outcomes. In a profession that focuses on understanding the ecological and cultural context of the family and using strategies to empower vulnerable populations, it is clear that home-based interventions will continue to be a vital aspect of social-work practice.
Allen, S. F., & Tracy, E. M. (2009). Delivering home-based services: A social work perspective. New York: Columbia University Press.Find this resource:
Armstrong, M., Boothroyd, R., Evans, M. E., & Kuppinger, A. (2009). Child mental health. In S. F. Allen & E. M. Tracy (Eds.), Delivering home-based services: A social work perspective (pp. 160–188). New York: Columbia University Press.Find this resource:
Ashford, J. B., Sternbach, K. O., & Balaam, M. (2009). Criminal Justice, In S. F. Allen & E. M. Tracy (Eds.), Delivering home-based services: A social work perspective (pp. 189–214). New York: Columbia University Press.Find this resource:
Burry, C. L. (2002). Working with potentially violent clients in their homes: What child welfare professionals need to know. The Clinical Supervisor, 21(1), 145–153.Find this resource:
Coatsworth, J., Pantin, H.,& Szapocznik, J. (2002). Familias Unidas: A family-centered ecodevelopmental intervention to reduce risk for problem behavior among Hispanic adolescents. Clinical Child & Family Psychology Review, 5(2), 113–132.Find this resource:
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Silovsky, J. F., Bard, D., Chaffin, M., Hecht, D., Burris, L., Owora, A., et al. (2011). Prevention of child maltreatment in high-risk rural families: A randomized clinical trial with child welfare outcomes. Children & Youth Services Review, 33, 1435–1444.Find this resource:
Strom-Gottfried, K. (2009). Ethical issues and guidelines. In S. F. Allen & E. M. Tracy (Eds.), Delivering home-based services: A social work perspective (pp. 14–33). New York: Columbia University Press.Find this resource:
Sullivan, P. (2009). Adult mental health. In S. F. Allen & E. M. Tracy (Eds.), Delivering home-based services: A social work perspective, (pp. 215–239). New York: Columbia University Press.Find this resource:
Supplee, L., Paulsell, D., & Avellar, S. (2012). What works in home visiting programs. In P. A. Curtis and G. Alexander (Eds.), What works in child welfare (Rev. ed., pp. 39–61). Washington, DC: CWLA Press.Find this resource:
U.S. Department of Health and Human Services. (n.d.). Home Visiting Evidence of Effectiveness. Retrieved from http://homvee.acf.hhs.gov
Assertive Community Treatment Association, http://www.actassociation.org/
Home Visiting Evidence of Effectiveness (HomeVEE) study, http://homvee.acf.hhs.gov
Juniper Gardens Children’s Project at the University of Kansas Lifespan Institute, http://www.jgcp.ku.edu
Multisystemic Therapy for Juvenile Offenders, http://www.mstservices.com
OnLok Lifeways PACE (Program of All-inclusive Care for the Elderly) Program, http://www.onlok.org