The Evaluation Requirement: FFPSA

The Colorado Title IV-E Prevention Plan also offers some insight as to how the Family First  rigorous evaluation requirement for HFA can be waived, in favor of a CQI process:  

Healthy Families America (HFA): HFA is a practice that has been implemented in one rural county in Colorado since 2016 and served approximately 76 families in CY 2018. A second Colorado county is in the beginning stages of implementing HFA with the goal of serving approximately 40 families. Given the small size of the population served, it is not practical to generate actionable and timely information through a rigorous evaluation such as a quasi-experimental design or randomized controlled trial for HFA. However, the accreditation process offers a foundation for CQI. Thus, Colorado is requesting a waiver of the rigorous evaluation process. HFA has an accreditation process through which site visitors assess adherence to the model. Colorado proposes a CQI process that is focused explicitly on the recommendations by the accreditation team and uses performance management data to track outcomes the intervention is intended to drive. For the county currently implementing HFA, the accreditation site visit took place in October 2019, and the county received the team’s report in January 2020. The CQI process will include quarterly learning calls to: (1) review, strategize, and support progress toward addressing recommendations made by the site team and challenges identified by the sites, and (2) review child safety performance management data that are routinely collected and opportunities to build capacity for routinely collecting and using child and adult well-being data. 

Maryland’s plan also provides an excellent example of how to request a waiver for the evaluation requirement:  

The evidence in favor of the use of HFA as a means of promoting positive family dynamics and reducing the risk of foster care placements in Maryland is compelling enough to warrant a waiver. This request for a waiver of the evaluation requirement for Healthy Families America is based on the following:  

(1) HFA has been shown to be efficacious in a wide variety of geographic locations, suggesting wide applicability, (2) HFA has demonstrated flexibility and favorable outcomes among children of various cultural backgrounds and with underlying problems, suggesting wide applicability, and (3) HFA has demonstrated effectiveness with one or more target populations that shares characteristics with one or more target populations in Maryland.  

HFA is efficacious in a wide variety of geographic locations, suggesting wide applicability. The Clearinghouse identifies a number of well-designed studies demonstrating the efficacy of HFA to cultivate and strengthen nurturing parent-child relationships, promote healthy childhood growth and development, and enhance family functioning by reducing risk and building protective factors in a variety of geographical locations, including Alaska (Duggan, Berlin, Cassidy, Burrell, & Tandon, 2009; Cluxton-Keller et al., 2014), Hawai’i (El-Kamary et al., 2004; Bair Merritt et al., 2010; McFarlane et al., 2013), New York (Rodriguez, Dumont, Mitchell-Herzfeld, Walden, & Greene, 2010; Kirkland & Mitchell-Herzfeld, 2012; Lee, Kirkland, Miranda-Julian, & Greene, 2018), and Oregon (Green, Tarte, Harrison, Nygren, & Sanders, 2014; Green, Sanders, & Tarte, 2017; Green, Sanders, & Tarte, 2018). HFA’s effectiveness in this diverse array of geographic locations indicates the model’s wide applicability and suggests that it will also produce positive outcomes in Maryland.  

A closer analysis of two key studies of HFA further illustrates two different, successful approaches to utilizing HFA to cultivate and strengthen nurturing parent-child relationships, promote healthy childhood growth and development, and enhance family functioning by reducing risk and building protective factors. First, in their study of Healthy Families Oregon, Green et al. (2018) found that HFA participation was associated with fewer gaps in health insurance coverage and with completion of more well-baby visits and immunizations and that the magnitude of the program’s effect grew with longer lengths of participation. Lee et al. (2018) conducted a randomized controlled trial of Healthy Families New York for a subgroup of mothers who had at least one substantiated child protective services report before enrolling in the program. They found that by the child’s seventh birthday, mothers enrolled in HFA were as half as likely as mothers in the control group to have been substantiated for child maltreatment.  

The immense body of literature demonstrating HFA’s efficacy in a variety of geographical locations suggests the intervention would be successful in Maryland, as well.  

HFA has demonstrated flexibility and favorable outcomes among children from various cultural backgrounds and with underlying problems, suggesting wide applicability. In addition to demonstrating favorable outcomes in multiple geographical locations, HFA has been found to be effective for families across a variety of cultural backgrounds and among children with various underlying problems. For example, Barlow et al.’s (2006) study assessing the impact of HFA on pregnant American Indian adolescents demonstrates that mothers in the intervention compared with mothers in the control group had significantly better outcomes, including higher parent knowledge scores and scoring significantly higher on maternal involvement scales. Blair-Merritt et al.’s (2010) work also demonstrates HFA’s treatment effect among mothers who reported instances of intimate partner violence, concluding that those who received HFA services reported lower rates of physical assault victimization and significantly lower rates of perpetration relative to the control group. Lee et al. (2009) found HFA to be effective for families across a variety of cultural backgrounds by demonstrating HFA’s effectiveness in reducing adverse birth outcomes among socially disadvantaged pregnant women, two-thirds of whom were black or Hispanic.  

Based on HFA’s well-established track record producing positive outcomes for children and families with diverse cultural backgrounds and underlying problems, DHS/SSA posits that HFA is widely applicable. Therefore, DHS/SSA believes HFA can be effective across the myriad socio-cultural backgrounds and among children with a range of underlying problems in Maryland.  

HFA has demonstrated effectiveness with one or more target populations that shares characteristics with one or more target populations in Maryland. HFA has been proven effective for improving outcomes in its target population, pregnant and parenting families with young children. This target population also aligns with the characteristics of Maryland’s Family First target population. Family First identifies pregnant and parenting foster youth as a uniquely eligible population for preventative services. Maryland’s administrative data reveal that 83 pregnant and parenting young people were in foster care on June 30, 2018, with 49 dependent children. DHS/SSA believes this number does not account for all youth in foster care who are pregnant or parenting as there is some inconsistency across local departments in reporting this circumstance and how such young people receive parenting supports. Moreover, Maryland’s foster care entry rate is nearly four times as high for children under age one than for children overall. It is clear that HFA’s target population aligns well with the characteristics and needs of the children and families who will be service through Family First in Maryland.”