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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? 

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Related resources, family first state plans and enacted legislation, child support and family law legislation database, child welfare enacted legislation, contact ncsl.

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What do Home Visitors Do?

How Home Visitors Describe What They Do

How Families Describe Supportive Home Visitation Practice

Provide encouragement

• Encourage parents in their parenting roles
• Recognize and build on families’ strengths
• Recognize achievements of familie
• Offer encouragement
• Help us to care for ourselves and find other supports
• Offer positive messages that we are good parents/on the right track

Build trusting relationships

• Build positive relationships with family members
• Use a positive, friendly, non-judgmental approach
• Respect families where they are at
• Be culturally sensitive/responsive
• Honour confidentiality
• Provide a listening ear
• Offer neutrality-someone to discuss difficulties and challenges with
• Build a trusting relationship-know we can count on the home visitor
• Create a relaxed environment that is educational and enjoyable

Make connections

• Connect families with appropriate programs/agencies
• Create supportive groups
• Make referrals to other supports and offer information on community resources

Provide information

• Offer meaningful, culturally relevant information and resources
• Offer learning through role modelling
• Offer information/knowledge about child development to strengthen our parenting skills
• Respond to our questions and concerns
• Provide opportunities for hands-on real learning experiences
• Be aware of potential problems and pointing these out
• Offer specific skills e.g. games and rhymes, how to read to children
• Teach us to problem solve
• Advocate for and with families
• Help families overcome barriers
• Connect with other service providers/organizations

Resource: Exploring Best Practices in Home Visitation, Partners for Best Practice in Home Visitation, Edmonton, Alberta, Canada

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The National Maternal Mental Health Hotline provides free, confidential mental health support. Pregnant people, moms, and new parents can call or text any time, every day.

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• Programs & Impact

Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program

The MIECHV Program helps pregnant people and parents of young children improve health and well-being for themselves and their families. The Program does this by partnering trained home visitors with families to set and achieve goals. This work is part of our Early Childhood Systems programming .

Key summary documents

• Program Brief: Maternal, Infant, and Early Childhood Home Visiting Program (PDF - 320 KB)
• State Fact Sheets
• FY 2022 Home Visiting Infographic (PDF - 208 KB)

How does the Home Visiting Program help families?

Home visitors and families develop strong relationships and trust. They meet regularly to address families’ needs.

The Program aims to:

• Improve the overall health of mothers and children
• Get children ready to succeed in school
• Improve families’ economic well-being
• Connect families to other resources in their community (for example WIC , Medicaid, employment and educational resources, housing support, parenting support classes, and resources on how to stop smoking)

The Program works to prevent:

• Child injuries, abuse, and neglect
• Crime and domestic violence

What happens through home visiting?

Home visitors:

• Support healthy pregnancy habits
• Give advice on things like breastfeeding, making sure babies sleep safely, avoiding accidents with children, and eating well
• Show parents how to be positive and supportive with their children by reading, playing, and praising good behavior
• Encourage talking to babies and teaching them things from a young age
• Work with parents to plan for the future, continue their education, and find jobs and childcare
• Connect families to other services and resources in their community

How does the Program work?

Watch our video that explains this work.

HRSA and the Administration for Children and Families (ACF) fund states, jurisdictions, and tribes to develop and conduct home visiting programs. We provide funds to states and jurisdictions. ACF provides funds to tribes .

These programs must be based on evidence showing that they can meet the needs of families.

How do you ensure these programs work?

We use the Home Visiting Evidence of Effectiveness (HomVEE) review . ACF reviews home visiting program models to ensure they meet families’ needs.

There are 24 home visiting models that meet HomVEE and other eligibility criteria . States, jurisdictions, and tribes can select the best models for their communities.

How do you know how awardees are doing?

Awardees must report on how their program performs. The law requires them to do this across six benchmark areas, which include 19 performance measures (PDF - 137 KB) . They must show that they’ve improved in at least four of the six areas.

Do you offer to help awardees?

Yes. We want our awardees to succeed. Our program officers share their expertise to help improve the quality of the programs .

How is Home Visiting different from the Healthy Start program?

The Home Visiting Program and the Healthy Start program both reach pregnant women and families. But they’re different in terms of both funding and approach.

Funding differences

The Home Visiting Program awards grants to 50 states, the District of Columbia, and five territories to create state-wide networks that support and carry out HHS-approved evidence-based home visiting models.

Healthy Start provides direct funding to local entities . Healthy Start awardees serve communities in which babies die more often than the national average.

The 2023 funding increase for Home Visiting Program is the result of a five-year, bipartisan reauthorization of the Program by Congress. As such, this reauthorization further defines how the Home Visiting Program differs from Healthy Start.

Program differences

While both programs play a vital role in improving maternal and child health, they do so in distinct ways .

The Home Visiting Program:

• Preventing child abuse and neglect
• Promoting positive parenting
• Supporting school readiness
• Allows states to choose evidence-based models that fit their community’s needs

The Healthy Start program:

• Focuses on reducing infant deaths
• Providing both clinical and non-clinical health services
• Offering well-woman, maternity care, and doula services
• Helping with transportation and housing needs

And each program emphasizes different parts of the life course:

• The Healthy Start program focuses on the periods before, during, and after pregnancy.
• While some Home Visiting models focus on the time before birth, many models serve families throughout the early childhood period up until kindergarten.

Additional information

• FY 2022 MIECHV Program Reauthorization
• Demonstrating Improvement in the Maternal, Infant, and Early Childhood Home Visiting Program: A Report to Congress (PDF - 1 MB) (March 2016)

Past funding awards for home visiting programs

• FY 2023 Formula Funding Awards
• FY 2022 Formula Funding Awards
• FY 2021 American Rescue Plan Act Awards
• MIECHV Innovation Awards

Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program Notice of Funding Opportunity (PDF - 685 KB) *

*Note: Persons using assistive technology may not be able to fully access information in this file. For assistance, please email Rachel Herzfeldt-Kamprath or call 301-443-2524 .

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• v.2021; 2021

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.

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Definition of home visit

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Do You Need a Home Watcher? Here’s What One Could Do for You.

Hiring a local to keep an eye on your weekend house can give you peace of mind and keep small problems from becoming big headaches.

By Joanne Kaufman

Leslie Young has a message for new second-home owners: That house of yours isn’t going to look after itself.

Ms. Young, a longtime resident of Cape Elizabeth, Maine, a leafy town on the state’s southern coast, is well acquainted with some part-timers who tend to be on the scene in June, July and August, when the weather is at its best. When they close up their homes on or around Labor Day at the end of their rookie season, they look ahead to next summer, naïvely unaware of the damage that could soon be wrought by strong winds (power outages!), prolonged cold (frozen pipes!) and cracks in the foundation (hi, mice!).

This is where Ms. Young comes in. She is a home watcher, though she prefers the term “home check person.” “My husband and I have renovated two houses,” she said. “I know what to look for.”

For fees that range from $45 (for weekly service) to $51 (for twice-weekly visits), Ms. Young, a retired police officer, does reconnaissance on the exterior and interior of clients’ homes, going back to front and room to room to room to see if anything looks wrong or out of the ordinary. “I give them peace of mind,” she said. “If there’s an alarm at their house and it goes off, I’m just a phone call away.”

The job title is sufficiently vague that home watchers spend considerable time explaining it. They are not caretakers, property managers, house sitters or D.I.Y. experts. Though Ms. Young has been known to tighten latches and fix screens for clients, “I have to draw the line,” she said. “I don’t do A to Z. I don’t pump out basements.”

In the 20 minutes she spends at each property, Ms. Young collects mail, checks the furnace, scans walls for mold, finds the source when there’s a funky odor, makes sure the snowplow guy is doing his job, flushes the toilets and turns on the faucets in the sinks, bathtubs and showers.

“If you don’t run water through the pipes, you could get dry rot,” said Ms. Young, 56, who started her company, Hillway Home Watch, in 2017. She currently has 57 clients, more than half of whom are second-home owners.

When they leave town, some owners “want to turn the thermostat down to the 40s, and I tell them they should keep it at least in the 50s, if not the 60s,” Ms. Young continued. “You need a buffer of warmth in case the furnace breaks down because if the temperature in the house drops enough, the pipes can freeze.”

And a home watcher is not to be confused with a licensed building inspector. “You’re looking for obvious issues,” said Chris Long, 63, a Mohegan Lake, N.Y.-based home watcher (though he prefers the term “home watch professional”) and a former plumber.

“I’m not opening electrical panels,” added Mr. Long, who has three dozen clients. “I’m looking for broken windows and doors.” He monitors properties ranging in size from a 900-square-foot condo to an 8,000-square-foot house, with fees of $50 to $275 per visit.

Mr. Long, like Ms. Young, furnishes clients with a post-check report accompanied by photos. “People love to see pictures of their house,” Ms. Young said.

If there’s a problem, clients hear it fast. “I phone the homeowner and say, ‘This isn’t going to be a good news phone call,’” she said.

“I’ve had a lot of furnaces go down,” Ms. Young continued. “Two winters ago, I went to a house, and the glass had shattered on the all-season sun porch. At first I thought it was an intruder, but then I saw the glass had broken from the inside.” (It turned out the glass was faulty.)

Cameras, remote temperature monitors and systems like Google Nest are all well and good, but they give people a false sense of security, said Jack Luber, the founder and executive director of the National Home Watch Association, a 15-year-old, 600-member organization that provides training, resources and accreditation to people who want to work in the field. (But so far, it’s an unregulated industry. Would-be home watchers don’t need to demonstrate mastery of specific skills, submit to a background check or flash a certificate before they can get a client’s house key or passcode.)

Sensors may alert you to a problem, Mr. Luber said, “but if you’re in New York and the house is in Naples, Fla., what are you going to do about it?” And, he added, “what happens to all those devices when the electricity goes out or batteries die?” Then there’s the fact that video cameras don’t have a sense of smell.

The tools of the trade, according to Mr. Luber, include a high-power flashlight, a hygrometer (for checking relative humidity), a stepladder, a carbon monoxide detector, wasp and insect spray, a fire extinguisher, booties (to avoid tracking dirt into a client’s house), trash bags (for disposing of mouse droppings and dead mice) and masks.

Some home watchers also come equipped with an assortment of lightbulbs and batteries.

David Koster, of Home & Boat Watchdog in Rehoboth Beach, Del., has always been the responsible person of a group. “When my neighbors go out of town, they give me their house key and tell me to hold on to it even after they return,” he said. “I have quite a few keys.” Mr. Koster, 52, a portrait photographer, started his side business watching second homes in 2016 and now has a dozen clients.

Mr. Koster estimates that it takes at least half an hour to get through the two-dozen-plus items on his checklist. He scans roofs for missing shingles; the HVAC system for leaves and ice; walls, from floor to ceiling, for leaks and mold. He also photographs envelopes that appear to contain bills and sends the pictures to the clients for direction. On one notable occasion, he encountered a squatter at the house of a client. “After I confirmed with the owner that no one was supposed to be there, I called the police,” said Mr. Koster, whose fees, based on house size, range from $100 to $300 for a weekly visit.

Some home watchers offer additional services — watering plants, taking clients’ cars out for a spin to keep the tires from going flat, being on site to accept a delivery — for additional fees. “If people are having a kitchen renovation done, I can sign off on the contractor’s work,” Mr. Long said. “I have 47 years’ experience in the building industry, so there’s nothing I haven’t seen.”

The concierge offerings are just a sideline, of course. Job 1 is keeping a steady eye on the house. “Anything can happen in an hour, let alone a month,” Mr. Luber said. “But if there’s a water leak or mold or a pest infestation, we’re going to see it.”

“There might be an insurance claim,” he added. “Hopefully it will be a lot less because we caught the problem at an early stage.”

David Seymour calls for 'reality check' after public service job cut outcry

• 5 hours ago

"The simple number of people being hired doesn't mean you get better results." Credits: Newshub.

ACT leader David Seymour is calling for a 'reality check' after outcry over the latest round of job cuts.   

The Associate Education Minister says they dwindle in comparison to growth across the public service under the previous Government.

More from Newshub

School's out at Porirua College as the Government continues its clean-out of public service workers, which could include members of the school lunches team.   

"We know that Māori and Pasifika students are in the lower-socio-economic groups and school lunches target those groups," said deputy principal John Topp.  

Newshub's also obtained documents showing the Ministry of Education's Te Hurihanganui team, which supports communities to address racism, is also in the firing line. The ministry won't say which roles could go, but changes "have been designed to avoid direct impacts on services to children, teachers and principals/leaders".     

Topp said the education system needs to honour Te Tiriti.  

"If we don't confront our unconscious bias with third-party support, because you can't do it on your own, we are not going to be able to do that," he said.   

But Seymour said: "Having public servants sticking their beaks into how people treat each other has made us a more complicated and divided country."  

As well as 565 jobs at the Ministry of Education, Oranga Tamariki yesterday proposed 447 roles will be lost.  

Labour leader Chris Hipkins said that's about "1000 people in one day alone".   

"That is a lot of people to be potentially losing their jobs."  

But Seymour said there needs to be a "reality check".  

"Everybody is gnashing and wailing about the public service. The reality is, it has grown more in the last six years, much more in fact, than any reduction happening right now."  

According to Public Service Commission data, OT's workforce has grown from 3870 in the second quarter of 2018 to 4904 at the end of last year – a 26 percent increase. It now has about 5100 permanent and fixed-term staff, and removing roughly 450 roles takes it back to where it was mid-last year.

Over at the Ministry of Education, there's been a 55 percent staffing over the past five years. Losing 565 roles would return them to pre-2022 levels.  

"It is justified to spend more money on supporting some of our most vulnerable children. The biggest area of growth at the Ministry of Education has been in areas like learning support," said Hipkins.  

Seymour said: "The simple number of people being hired doesn't mean you get better results."  

The governing parties were elected on a promise to pare back the public service and it sees these jobs cuts as delivering. The opposition argues the bureaucratic boost is in line with the public they serve as the population has grown.   

The public service's grown 32 percent in the past five years. But as a proportion of the total workforce it's only a very slight increase.   

"It hasn't exploded," said Hipkins.   

Seymour said: "It's not always true that because the population increases the size of the public workforce has to increase."

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Home Visitor Safety

You can work with other program administrators and community resources to implement policies, procedures, and strategies that can contribute to home visitors’ and families’ safety in unsafe situations. As you put safety plans and measures in place, keep the following concepts in mind [ 5 ]:

Sometimes situations, such as crises, arise that pose some degree of risk to the safety of family members and home visitors.  The potential for physical harm exists in any emotionally charged crisis. Staff should never overlook or discount that potential.

Home visitors’ skills in handling a potentially dangerous situation shape intervention decisions. Sometimes home visitors find themselves faced with, or caught up in, a family situation that is too complex or too dangerous for them to address directly. At such times, it is critical to recognize that the situation is beyond their intervention abilities and to discuss alternatives with their supervisor.

The best predictor of impending danger is behavior. Safety measures are called for if a family member's current or past behavior includes violent/abusive acts, threats of harm, criminal activities, the use of addictive substances, signs of a serious emotional disorder, or threats of suicide. These measures are needed at several points in the intervention process: before face-to-face visits with the family, during face-to-face visits, and as part of referral and follow-up services.

Home visitors must always be aware of behaviors and situations that signal danger. Some violent incidents may be predicted, but many helping professionals fail to recognize signs of potential violence. Signs of loss of control and impending danger include expressions of anger and hostility. Staff may also sense that a situation is dangerous; know the family has access to guns or other weapons; be aware of violent acts or threats by family friends or relatives; and recognize mounting tension, irritability, agitation, brooding, and/or limit testing in family members.

Home visitors must be and feel safe if they are to support families. Home visitor safety can and must be addressed at many levels. The threat of violence does not occur only in the homes of families or in high-crime neighborhoods, but also in seemingly secure workplaces. Work conditions favorable to violence prevention require action at management, supervisory, and personal levels.

Some general strategies that you may consider include the following:

• Have home visitors work in pairs, particularly when they go to more dangerous neighborhoods. Accompany home visitors, if needed.
• Forge a relationship with the local police department. When police are aware of home visitors’ presence in the community, they may be able to provide protection such as self-defense training and alerts as to potentially hazardous events in the community.
• Provide cell phones, beepers, or other communication devices. Work with finance and other program staff to ensure the budget covers this equipment.
• Involve families in home visitor safety. They often know of potential safety hazards in the neighborhood (e.g., high-crime areas, gang activity) and can inform home visitors of the safest way to travel through the area.
• Work with program administrators and community resources to develop crisis protocols and make sure home visitors are aware of them. Provide opportunities for home visitors to review and practice implementing protocols. Topics may include child abuse/child neglect, substance misuse, violence in the neighborhood, and the presence of a contagious disease.
• Make sure that you or another administrator is “on call” whenever a home visitor is in the field, including after hours and weekends, so that home visitors can get an immediate response when needed.
• Make sure you know home visitors’ schedules. This should include family names and contact information, date and time of visit, and when to expect the home visitor to return. 

In addition, you might encourage home visitors to do the following [ 4 ]:

• Trust their instincts. If they feel something is not right or see something in the home that makes them uncomfortable (e.g., physical or verbal violence, alcohol/drug use, evidence of firearms, or the presence of an acutely intoxicated individual), follow established protocols and leave, if necessary. Encourage home visitors to say to the parent, “Maybe this isn’t a good time for a visit. Let’s reschedule.” Before going on future visits, encourage home visitors to talk with you about how to ensure their safety in the home. Work with home visitors to talk with the parent about the issues that made them feel uncomfortable and to make referrals if needed.
• Wear comfortable shoes.
• Get clear directions to the neighborhood and the home or apartment building, especially for new visits. Take a practice drive to make sure the directions work. Confirm how to enter the home if it is a duplex or apartment.
• Ask families where it is best to park, and park as close to the home as possible. Always park in well-lit areas. If it is not possible for the home visitor to park in a safe place, discuss other options, such as meeting the family in another setting or being driven and picked up by a co-worker.
• Put any important or valuable items in the trunk of the car before arriving for the visit. Avoid carrying and wearing expensive items.
• Contact parents before a visit so they can be on the lookout for the home visitor.
• If no one answers the door, sit in the car or drive around the block rather than wait at the door. Make sure to specify the amount of time home visitors should wait if a family is not home as part of your home visit protocol.
• Make sure home visitors’ cars are in good working order and that there is plenty of gas in the tank.
• Organize belongings so they do not have to take time to search for them. For example, when they leave a home visit, they should have their keys in hand.

4 Rebecca Parlakian and Nancy Seibel, Help Me Grow Home Visitor Curriculum (Cuyahoga County, OH: Help Me Grow of Cuyahoga County, 2005).

5 Head Start Bureau, “Assessing Family Crisis.” Excerpts from Training Guides for the Head Start Learning Community: Supporting Families in Crisis (Washington, DC: Department of Health and Human Services, Administration for Children and Families, Administration for Children, Youth and Families, 2000), https://eclkc.ohs.acf.hhs.gov/mental-health/article/assessing-family-crisis.

Resource Type: Article

National Centers: Early Childhood Development, Teaching and Learning

Program Option: Home-Based Option

Last Updated: May 22, 2023

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Boeing’s CEO search has a new front-runner—and insiders say it could mean a radical change for the $104 billion ailing planemaker

Boeing’s search for a new CEO ranks as the most closely watched succession drama in decades. If the manufacturing icon makes the wrong choice, its airline customers won’t get the planes they desperately need in the years ahead, raising prices and cutting frequency of travel for the 2.2 billion people who fly each year. It’s now clear that the directors’, regulators’, and Wall Street’s view of what the legendary planemaker needs in a new leader has totally changed since the notorious blowout over Portland, Ore., on Jan. 5 exposed manifold flaws in its manufacturing processes and procedures. Last year, the odds strongly favored a veteran insider, and like all its CEOs from the past two decades, not anyone bringing deep experience on the factory floor. Now, the likely choice is a newcomer offering detailed knowledge of how planes get built, a radical change agent determined to restore high-quality production, on-schedule deliveries, and great aerospace expertise, as opposed to financial engineering, job one.

The Alaska Airlines cataclysm upends Boeing’s old succession plan

On March 25, Boeing unveiled a sudden upheaval in its C-suite and boardroom. Its press release that day announced that David Calhoun will step down as CEO at year-end, and that chairman Larry Kellner, former head of Continental Airlines, will depart following the annual meeting on May 16, to be replaced by director Steve Mollenkopf, retired chief of Qualcomm . Stan Deal, the top executive at Boeing Commercial Airplanes, is leaving the company, and Stephanie Pope, the COO, is taking Deal’s old job. It’s Mollenkopf who will lead the search for the next CEO.

Fortune interviewed sources that include past Boeing executives and current and former high-ranking figures in the aerospace industry to get their take on the qualifications needed in a new leader, and the candidates the board is most likely favoring right now. All of them chose to speak on background. On the sudden resignations and shake-up at Boeing Commercial Airplanes, they generally agreed that the board was responding to pressure from both airline customers and the FAA. Four days before the big reshuffling, airline CEOs made the extraordinary request to meet with Kellner sans Calhoun. “When your customers say they want to meet with your chairman, you know they want change at the top,” says one person to whom I spoke, and who added: “The board realized that the FAA can make things harder if today’s leadership stays in place.” Said a second source: “When all these guys at the top are immediately replaced or retire at the first opportunity, it would appear that the FAA had a hand in that.”

Just three weeks before the catastrophe aboard Alaska Airlines Flight 1282, Boeing announced that Pope would ascend to chief operating officer on Jan. 1, making her heir apparent to Calhoun. Pope spent most of her three decades at Boeing in financial jobs, serving as CFO of both Global Services and Commercial Airplanes, and most recently headed Global Services, the unit that supports commercial and industry customers. Pope has proved an expert financial manager in an enterprise that—until the flood of safety issues—focused heavily on shareholder returns. She also apparently did a good job as a general manager. But according to my sources, financial acumen isn’t what’s needed going forward. “I was surprised that after all that happened, Boeing would put a former CFO in the top Commercial Airplanes job,” says one source. Though that move keeps Pope in the running, the people to whom I spoke believe that the board is now leaning heavily toward an outsider with the manufacturing chops to get things right at its giant plants in Renton and Everett, near Seattle, and in North Charleston, S.C.

A probable solution: A great manager who also understands manufacturing, paired with a production hawk who’s all over the factory floor

The big problem the board faces: Running Boeing requires a combination of skills that’s highly unusual, and tough to find in a single leader. “The CEO job at Boeing is so complicated,” explains one industry veteran. “You have all the public-facing and regulatory work to do, all the airline customers around the world, the constituency in Washington. To fill those roles, you need someone with stature and sophistication. And that isn’t always the same person who knows how to build airplanes.” The one obvious candidate blending the two talents is GE Aerospace CEO Larry Culp, who greatly streamlined GE’s manufacturing engine , frequently touring the assembly lines in person and swapping ideas for moving parts faster and safer with welders and machinists. Culp also showed strong diplomatic skills in dealing with Congress and regulators. But Culp has declared he has no interest in leaving the engine-manufacturing business he’s done so much to make highly efficient and profitable.

The best solution for Boeing, say several sources, would probably be a split: naming a CEO who’s a great general manager, and a second-in-command who’s a hard-core, hands-on-the-levers production specialist. At the same time, the generalist CEO needs to be someone who’s headed manufacturing businesses and can delve into the details to tell if the engine’s sound or broken. He or she can’t be someone who believes all the smart thinking only happens in the C-suite, but embraces a mindset where management listens to the folks tightening the screws and fastening the panels. That overall approach would enable the second-in-command to work hand in glove with newly empowered workers and on-site managers so that each step in building these wonderful flying machines only moves forward when all parts and systems from the previous station are complete. That would end the costly, quality-destroying “traveled work” regime that forces workers to rush stations ahead, and install components out of sequence.

Right now, an excellent candidate looks like Dave Gitlin

As of today, the best prospect is probably Carrier Global CEO Dave Gitlin, who’s a Boeing director. The reason: Gitlin’s demonstrated excellence as an overall leader, and his long, broad career in aerospace, including plenty of experience observing what makes for an assembly line that’s an exemplar in quality control. At 54, he’s also the right age. Boeing needs a chief who has a runway of at least seven or eight years; it took decades to undermine its culture, and will require several years to institute a fresh obsession with quality and safety. Plus, it’s best if a single CEO can guide Boeing through the entire process of designing and building a “clean-sheet” successor to the 737 Max.

Gitlin earned a BA from Cornell, a JD from the University of Connecticut School of Law, and an MBA from MIT. He started his career as an attorney at Sundstrand, a manufacturer of electric power systems for the aerospace industry. After Hamilton, a unit of UTC (then United Technologies Corp.) that made airline carburetors, deicing systems, and engine mounts, bought Sundstrand to create its Hamilton Sundstrand unit in 1999, Gitlin moved into operations. At Hamilton Sundstrand, he cycled through six positions, which included overseeing its business with a top customer, engine maker Pratt & Whitney, also part of UTC, and serving as president of auxiliary power, engine, and control systems. In 2012, UTC bought Goodrich Corp., a Charlotte-based maker of nose-to-tail products including landing gear, jet-engine casings, flight controls, and satellite and evacuation systems to create UTC Aerospace Systems. Gitlin led the successful integration, and in 2013 ascended to president and COO of UTC Aerospace Systems.

In 2018, UTC purchased Rockwell Collins, producer of avionics and flight control systems. The $30 billion deal was one of the largest aerospace acquisitions in history. Gitlin rose to COO and president of the entire UTC aerospace unit, newly named Collins Aerospace. But UTC planned to spin off non-aerospace businesses, including its Otis elevator and Carrier heating, ventilation, and AC franchises. UTC named Gitlin as CEO of the soon-to-be independent Carrier Global. According to a former UTC manager I interviewed, the honor was well deserved: “He was so well respected at UTC for being an operating guy. He knew how to make the trains run on time; he was willing to get his fingernails dirty. UTC named him to run Carrier to show that it was putting an expert, smart leader of a manufacturing company in charge.”

At Carrier, Gitlin has assembled one of the best records of any manufacturing CEO in recent years. Since 2020, and despite the hammering from the pandemic, he’s lifted margins from 12.8% to 14.1%, and grown its highly lucrative aftermarkets business in the past two years by 22% to $5.5 billion. He’s also shed the security unit for $5 billion to focus where profitability is highest, in the core heating and refrigeration businesses. Since the spinoff in June 2019, Gitlin has delivered a cumulative 245% total return, or 37% annualized, a record that beats the S&P by 15 points. Under Gitlin, Carrier’s market cap has exploded by over $40 billion to $51 billion.

Landing Gitlin presents potential pitfalls, both for Boeing and on Gitlin’s end

Asked to comment on whether Gitlin is under consideration for the top job, or speak about the succession process, a Boeing spokesperson responded by email, “We don’t have a comment on these topics.” A source close to Carrier says that Gitlin is committed to the company. He now lives in Florida near Carrier’s headquarters in Palm Beach Gardens. My sources say that, as it stands now, Gitlin’s pedigree and record make him the best qualified contender. “He’s a very credible candidate if he wants it,” says a former high-ranking airline executive. There’s a strong possibility that the board will move Boeing’s HQ from Arlington, Va., back to Seattle, where most of the commercial planes, and most of the money, are made. “Seattle is where the headquarters should be,” says one source who was a Boeing customer. Whether Gitlin would be willing to resettle in Seattle is a big unknown.

Boeing, as well as regulators and suppliers, could also have misgivings. Gitlin has been on the Boeing board since late June of 2022, and though it’s a short tenure, that he’s been a director during the time Boeing has made such a wrong turn could undermine his support. “The job he’s got now is really well paid and doesn’t have the same headaches as Boeing,” observes another industry stalwart. Landing Gitlin would also be expensive: It could cost Boeing around $150 million to replace the long-term compensation benefits awarded by Carrier.

Still, neither of those possible drawbacks should stand in his way—if the board is convinced that Gitlin is the right person.

Even so, Gitlin’s not the guy to fix the mechanics on the shop floor. He’ll need a partner to fulfill that absolutely essential second role. The only obvious choice is Pat Shanahan, a manufacturing whiz who camped out at the Everett plant in 2008 to fix the stalled 787 Dreamliner program. In October, he parachuted into Boeing supplier Spirit AeroSystems, to repair the severe gaps in its quality controls. Boeing now plans to purchase Spirit, which it once owned, and hence bring fuselage production in-house. Shanahan also knows Boeing intimately, having worked at the planemaker for 30 years.

The rub: Shanahan will be 62 years old in June. He probably doesn’t have the comforting longevity Gitlin would provide, especially in arguably the highest-pressure production job on the planet. One of my sources sums up the issue: “Getting Gitlin in the top job instead of a pure manufacturing person opens another problem. He’ll need a partner. And as for now, it’s unclear who that could be.”

Another cautionary factor is at play. This will be the most scrutinized CEO search in history. If Gitlin’s the choice, anything in his business history, including possible problems with products at businesses he’s run, will be found and magnified. The same goes for any candidate the board anoints.

According to a manager who still works at Boeing, employees there have just one condition, a reference to three out of Boeing’s past four leaders who came from the house Jack Welch built. “The running joke around the company is,” he quips, “whatever you do, don’t hire another CEO from GE!”

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