Development and implementation of a screen-and-refer approach to addressing maternal depression, substance use, and intimate partner violence in home visiting clients

Highlights

• Fewer HV clients than expected screened positive for maternal depression, substance use, or intimate partner violence risk.

• Home visitors implemented general supportive interventions at higher rates than MI and CM interventions.

• Home visitors identified client and system level impacts on HELP implementation.

• Implementation supports are needed, including coaching, structured supervision, and coordination with the treatment system.

Abstract

Perinatal maternal depression (MD), substance use (SU), and intimate partner violence (IPV) are critical public health concerns with significant negative impacts on child development. Bolstering the capacity of home visiting (HV) programs to address these significant risk factors has potential to improve child and family outcomes. This study presents a description and mixed-methods feasibility evaluation of the “Home Visitation Enhancing Linkages Project (HELP),” a screen-and-refer approach to addressing MD, SU, and IPV within HV aimed at improving risk identification and linkage to treatment among HV clients. HELP was a three-phase intervention that included three evidence-based interventions: screening, motivational interviewing (MI), and case management (CM). This study presents quantitative fidelity data from 21 home visitors reporting on 116 clients in 4 HV programs, as well as qualitative data from structured interviews with 14 home visitors. Nearly all clients were screened and 22% screened positive on at least one risk domain. Rates of MI and CM implementation were lower than expected, however home visitors implemented general supportive interventions at high rates. Home visitor interviews revealed the following factors that may have impacted HELP implementation: client disclosure of risk, barriers to treatment access, systems integration, home visitor role perception, and integration of HELP into the broader HV curriculum. Implications of study findings for the design of future attempts to address maternal risk within HV are discussed.

Introduction

Perinatal substance use (SU), maternal depression (MD), and intimate partner violence (IPV) are critical public health concerns that confer significant risk to maternal and infant health (National Scientific Council on the Developing Child, 2014). While effective treatments exist, rates of access among low-income minority pregnant and postpartum women are distressingly low (Terplan, McNamara, & Chisolm, 2012). Early childhood home visiting (HV) is one of the primary supportive interventions provided to high-risk families during the perinatal period, and thus represents a promising avenue for improving access to treatment for pregnant and postpartum women experiencing SU, MD, and IPV. Due to increased federal investment under the Affordable Care Act (ACA), HV programs currently operate in all 50 states, serve more than 160,000 families annually nationwide, and increasingly serve families with complex behavioral health needs (Health Resources and Services Administration, 2016). In a national sample, 26% of HV clients reported prior binge drinking, 13% reported past illicit drug use, 34% reported clinically significant depression symptoms, and 17% reported past-year physical or psychological IPV (Michalopoulos et al., 2015). Despite the potential of HV to improve access to behavioral health treatment, studies have demonstrated low rates of identification of SU, MD, and IPV and referral to treatment within HV (Dauber et al., 2017, Duggan et al., 2004, Tandon et al., 2005), and more difficult engagement and poorer outcomes for families with complex risk profiles (Azzi-Lessing, 2013, Damashek et al., 2011, Eckenrode et al., 2000).

Several factors may explain this discrepancy between client need and service provision. First, few HV models provide home visitor staff with intensive skills-based training in behavioral health or standardized protocols for addressing client SU, MD, and IPV. Second, the HV workforce comprises a broad spectrum of professionals, many of whom lack the advanced training and clinical skill needed to effectively address complex behavioral health problems (Paulsell, Del Grosso, & Supplee, 2014). Home visitors themselves have reported that they generally feel ill-equipped to effectively address client behavioral health concerns, desire more training and supervision specifically targeted at these issues, and rate inability to connect families with needed services for MH, SU, and IPV as among the most difficult situations encountered in HV (Eddy et al., 2008, Jones-Harden et al., 2010, LeCroy and Whitaker, 2005, Tandon et al., 2008). Lack of home visitor training and skill is compounded by client reluctance to disclose MD, SU, and IPV for fear of child removal and other repercussions, as well as logistical barriers and fragmented service systems making access to treatment difficult (Leis et al., 2011, O'Mahen and Flynn, 2008).

Bolstering HV capacity to address SU, MD, and IPV is critical to improving the continuum of care for high-risk pregnant and postpartum women, with potential for broad impacts on maternal and child health. Moreover, HV represents an ideal context for addressing behavioral health and improving access to needed treatment in this population for several reasons. First, HV programs aim to enroll women prenatally or shortly after birth, providing an opportunity to intervene early to prevent negative child and family outcomes. Relatedly, HV programs are long-term, often providing services into a child's second or third year of life, allowing for greater continuity of care. Second, pregnancy and the postpartum period are times when many women are especially motivated to change behaviors and life circumstances that may negatively impact their baby (Kuo et al., 2013, Lee King et al., 2015). HV programs are inherently voluntary and strength-based, and thus provide a natural framework for capitalizing on this motivation to change. Third, a core component of successful HV services is the strong working relationship built between the home visitor and the client (Schaefer, 2016), which can serve as a foundation for home visitors to assist clients with sensitive topics that they may be reluctant to discuss with other professionals. Finally, HV is broadly aimed at promoting healthy child development through minimizing exposure to adverse events and building parental capacity for responsive caregiving (Minkovitz, O'Neill, & Duggan, 2016). Thus, addressing maternal behavioral health risks that diminish parental capacity fits well within the broader goals of HV and is arguably essential to successfully attaining those goals.

With increased awareness of the need for HV programs to systematically address maternal behavioral health combined with increased funding from the ACA, attempts to improve HV capacity to address maternal behavioral health risks have begun to proliferate. The most well-researched efforts to date have involved the delivery of cognitive behavioral interventions for depression by trained mental health professionals during home visits (Ammerman et al., 2005) or as an adjunct to home visiting (Tandon, Leis, Mendelson, Perry, & Kemp, 2014). Accumulating results from these initiatives are highly promising, suggesting that enhancing HV with research-supported mental health interventions can be effective in reducing client symptoms of depression (Ammerman et al., 2013, McFarlane et al., 2016, Segre et al., 2015, Tandon et al., 2014). However, approaches that integrate psychotherapy into HV require highly trained therapists to provide the intervention, a resource that may be beyond the reach of some state HV systems and local programs. Additionally, existing efforts to integrate behavioral health treatment into HV have focused on a single risk domain, without addressing the high rates of comorbidity among MD, SU, and IPV in the perinatal period (Connelly, Hazen, Baker-Ericzen, Landsverk, & McCue Horwitz, 2013).

Screen-and-refer models, which include screening followed by a brief intervention aimed at linking clients with external treatment providers, represent a potential lower cost strategy for addressing multiple co-occurring behavioral health risks within HV that can complement the more intensive therapeutic approaches described above. The most prominent example of a screen-and-refer approach is the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model originally developed to facilitate linkage to substance use treatment for primary care patients (Substance Abuse and Mental Health Services Administration, 2013). SBIRT has demonstrated notable success in improving access to treatment and reducing alcohol use for adult substance users, including pregnant women, in certain contexts (Agerwala and McCance-Katz, 2012, Aldridge et al., 2017, Babor et al., 2007, Chang et al., 2005, O'Connor and Whaley, 2007), though results are not definitive, particularly for illicit drugs (Hingson & Compton, 2014). While there are no published studies testing SBIRT within HV, this approach has great potential for application within state HV systems for the following reasons. First, by design, screen-and-refer approaches do not necessarily require extensive clinical training or advanced clinical skills, and thus could potentially be effectively delivered by home visitors during routine HV. Second, home visitors already implement standardized assessments as part of their monitoring of child developmental progress, and are beginning to incorporate behavioral health screening in response to federal mandates. Finally, home visitors routinely provide clients with referrals to a range of external care providers, including public assistance agencies, early intervention providers, pediatric and other medical care providers, and behavioral health treatment providers. Thus, the process of linking clients to outside agencies to meet their needs in areas not directly addressed by the HV program is familiar territory for home visitors, and increasing the standardization and systematization of home visitors' screen-and-refer activities regarding maternal behavioral health is potentially feasible.

Screen-and-refer models often include motivational interviewing (MI) and case management (CM) interventions aimed at maximizing the likelihood of a successful referral. The potential applicability of MI for enhancing client engagement and retention in HV as well as for enabling home visitors to more effectively address challenging behavioral health risks has been recognized, and MI training and implementation resources for HV are being developed and tested (University of Maryland Baltimore County, 2016). As this is a newly emerging area in HV, empirical studies are lacking, however the few that exist demonstrate the success of MI for improving engagement and retention in HV (Ingoldsby et al., 2013, Silovsky et al., 2011), but not for decreasing maternal psychosocial risk (Silovsky et al., 2011). Case management in the form of care coordination and referrals to services to meet families' needs in various domains has always been a core component of HV (Minkovitz et al., 2016). Linkages and referrals to community resources is one of the primary outcome domains specified by the federal government for defining evidence-based HV programs, and is also one of the federal HV benchmark outcomes (Administration for Children and Families; HRSA Maternal and Child Health, 2016). Studies have shown that integrating individualized assessment of family needs and care coordination activities aimed at linking families with needed services into HV has resulted in improved rates of receipt of needed services among HV clients in multiple domains (Dodge et al., 2013, Lowell et al., 2011). However, we know of no HV studies to date of an evidence-based case management intervention specifically aimed at linking clients to behavioral health services.

In partnership with state-level administrators, HV staff, and HV training and technical assistance providers, we developed the “Home Visitation Enhancing Linkages Project (HELP).” HELP includes informational and skills-based training in MD, SU, and IPV for home visitors and supervisors, plus integration of evidence-based screening, MI, and CM interventions aimed at improving client linkage to treatment. In contrast to traditional SBIRT models, HELP did not include a specific structured brief intervention to be delivered in a standardized manner to all clients; rather, home visitors were trained in a menu of MI and CM techniques to apply as needed with a particular client. HELP was specifically designed for delivery within routine HV services by the HV workforce. This work is aligned with the national HV research priorities of supporting the development of a competent workforce and strengthening HV effectiveness (Home Visiting Research Network, 2013), and is directly targeted at key HV performance benchmarks required by the federal HV program (HRSA Maternal and Child Health, 2016).

This study presents the HELP development and implementation framework and core intervention components, followed by a mixed-methods evaluation of the feasibility and acceptability of HELP within four home visiting programs implementing the Healthy Families America model. Data were collected during a two-year pilot evaluation of HELP aimed at assessing the initial feasibility of the protocol to inform its refinement for further testing in a larger sample. The following research questions were examined: (1) To what extent were the core HELP interventions implemented with fidelity by home visitors? and (2) What factors influenced successful implementation of HELP? Specific factors examined included home visitor and supervisor readiness to implement evidence-based practices, and home visitor perspectives on risk identification, barriers to treatment access, systems integration, home visitor role definition, and integration of HELP into the broader HV curriculum.