Maternal, Infant, and Early Childhood Home Visiting Program

The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program is the primary federal program that focuses exclusively on home visiting. The program seeks to provide and strengthen home visiting services to families residing in at-risk communities, while also improving coordination of supportive services in these communities. Early childhood home visiting is a strategy for delivering services to improve health, well-being, and education outcomes for vulnerable families with young children. Families voluntarily participate and receive periodic home visits from nurses, social workers, and other professionals. Visitors try to build strong, positive relationships with families and provide tailored services such as parenting education, caregiver well-being and child development screenings, and referrals to community supports.

Overview

The MIECHV program is jointly administered by the U.S. Department of Health and Human Services' (HHS') Health Resources and Services Administration (HRSA) and the Administration for Children and Families (ACF). The Patient Protection and Affordable Care Act (P.L. 111-148) established MIECHV under Section 511 of the Social Security Act and appropriated mandatory funding for the program. The authorization and funding have been extended multiple times, most recently for FY2023 through FY2027 by the Jackie Walorski Maternal and Child Home Visiting Reauthorization Act of 2022 (§6101 of the Consolidated Appropriations Act, 2023, P.L. 117-328).

Eligible Entities

The MIECHV program provides funding to the 50 states, District of Columbia, five territories, and tribal entities. Generally, the entity's public health department or social service department is the lead agency that administers the funds. Under the law, HHS may make grants to nonprofit organizations to carry out a home visiting program in a state that did not apply, or receive approval, for a grant. In FY2022, nonprofit organizations were fully or partly administering MIECHV in three states (FL, ND, and WY). As of FY2022, 36 tribal entities had ever received funding.

Participants

Entities provide home visiting services to eligible families who participate voluntarily. An eligible family can be comprised of (1) a pregnant woman and father-to-be, if available; or (2) a parent or primary caregiver of a child from birth to entry into kindergarten (including a qualifying noncustodial parent). Entities must prioritize families who have certain risk factors, such as low income or a history of child abuse and neglect. In FY2022, the MIECHV program served more than 69,000 families, provided over 840,000 home visits, and reached nearly a third of all U.S. counties. Approximately two-thirds of participating families were in poverty, one-in-five reported a history of child abuse and maltreatment, and one-in-ten included a pregnant teen.

Funding

MIECHV's current authorizing law appropriates mandatory funding for the program. The American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) provided additional one-time funding in FY2021 in response to the COVID-19 public health emergency. In certain years, MIECHV funding has been subject to sequestration. From the program's start in FY2010 through FY2022, funding increased the first few years before stabilizing at a pre-sequester funding level of $400 million annually. During this period, HHS used its then statutorily permitted discretion to distribute the bulk of funding through a mix of allocation formulas and, in select years, competitive grants to entities.

The 2022 reauthorization law increased funding and established new procedures for FY2023-FY2027, including separate appropriations for base grants and matching grants (Table 1). From these amounts, funding is reserved for tribal entities (6%); technical assistance (2%); home visiting workforce-related activities (2%); and research, evaluation, and federal administration purposes (3%). HHS traditionally uses its discretion under statute to award tribal funding through competitive cooperative agreements.

Allotments

Under current law, after accounting for the funding reservations and potential effects of sequestration, the remainder of FY2023-FY2027 base and matching grant funding is to be distributed through separate processes to nontribal entities. These entities must meet a maintenance-of-effort requirement to receive any grant funding.

Base grant funding is to be awarded according to a formula that takes into account each entity's share of children under age 5, FY2021 formula grant amounts, and other factors. In practice, the formula adjusts but approximately maintains each entity's share of total annual base grant funding at its share of FY2021 total formula grant funding.

Entities are also eligible for a minimum matching grant amount, and a share of any remaining match funding based on each entity's share of children under age 5 experiencing poverty. Federal matching grants are available subject to a rate of 75% federal funds and 25% nonfederal funds (i.e., $3 in federal funds for every $1 contributed in qualifying nonfederal funds, up to certain limits). There is a reallocation procedure for any unclaimed matching funds.

Entities may expend MIECHV funds through the end of the second succeeding fiscal year after the award. Their administrative costs are generally limited to no more than 10% of funding. Entities may also use up to 25% of their MIECHV grants for a pay-for-outcomes initiative to support home visiting approaches that result in cost savings.

Requirements

The authorizing statute specifies a variety of requirements for entities receiving MIECHV funds (and requires HHS to set similar rules for nonstate entities). Entities have been required to conduct needs assessments to identify service capacity and communities with concentrations of poor child and maternal health, poverty, and other risk factors. Assessments are submitted to HHS with explanations of how identified needs will be addressed. Entities were last required to update these assessments by October 1, 2020.

Entities must also submit an application for funding to HHS that includes various assurances and information, such as how high-risk populations will be served. Entities can only use MIECHV funding to support targeted, intensive home visiting services, and they must comply with several requirements if they wish to support virtual home visits.

Home Visiting Models

The authorizing law directs entities to use a majority of MIECHV funding to implement home visiting models that have shown sufficient evidence of effectiveness based on criteria established by HHS. HRSA has determined that 23 models met the evidence and other statutory criteria for MIECHV implementation as of FY2023. Entities may also use up to 25% of funding to implement and evaluate models that have shown promise of effectiveness (entities must rigorously evaluate such models). In FY2021, states and territories implemented 10 evidence-based models, as well as 3 models under the promising standard (Table 2).

Performance Improvement Benchmarks

The MIECHV statute requires entities to periodically demonstrate improvements among eligible families in what the law refers to as six "benchmark areas." These areas are desired outcomes for participants and relate to health, child maltreatment, academic readiness, crime and safety, economic self-sufficiency, and community referrals. Since FY2017, HHS has used 19 items to measure the performance of each entity (or jurisdiction) across the benchmark areas. For example, 81% of MIECHV caregivers were screened for depression within three months of enrollment or service delivery as of FY2022. Among children enrolled in MIECHV that year, 79% were reported as having a family member who read, told stories, and/or sang with them on a daily basis.

The law requires jurisdictions to show that they are making improvements in at least four out of six benchmark areas. If an entity fails to demonstrate improvements, they must develop and implement a corrective action plan subject to HHS approval or risk grant termination. In FY2020, all state/territory entities met the statutory requirement.

The 2022 reauthorization requires HHS to establish a publicly accessible dashboard for reporting jurisdiction outcomes and other data, as well as an annual report to Congress covering the outcome data and other detailed information on the MIECHV program.

Research and Evaluation

A large body of research suggests that some home visiting models or services can benefit children and their parents. The authorizing law requires HHS to conduct an evaluation of MIECHV. The resulting large-scale random assignment study is known as the Mother and Infant Home Visiting Program Evaluation (MIHOPE). Among other findings, the evaluation has concluded that the home visiting programs primarily served at-risk families, were implemented well, and produced positive effects for families on some outcomes around the time children were 15 months old. Study of longer-term outcomes is ongoing. HHS also sponsors research on other home visiting topics, including model assessment, tribal home visiting, family engagement in services, the home visiting workforce, programs in rural contexts, and efforts to foster family economic well-being.

Technical Assistance

The law directs HHS to provide technical assistance (TA) to entities with regard to home visiting activities and, if applicable, any performance improvement plan or necessary compliance with a requirement regarding virtual home visiting. Entities receive TA from federal staff, model developers, and TA providers supported through HHS contracts or grants. The 2022 reauthorization also requires HHS to consult with eligible entities and analyze, report on, and reduce the paperwork and other burdens on entities associated with administering the MIECHV program.