The Maternal, Infant, and Early Childhood Home Visiting Program in Rural Areas

Featured Speakers

	Jeff Colyer, MD, Chair, National Advisory Committee on Rural Health and Human Services; Former Governor of Kansas
	Kyle Peplinski, Branch Chief, Policy, Data, and Technical Assistance Coordination, Maternal and Child Health Bureau, HRSA
	Michelle Mills, Colorado Rural Health Center

The National Advisory Committee on Rural Health and Human Services met in the Spring of 2023 to assess how the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program is serving rural communities. This webinar will present the findings from the Committee's work and include a discussion of the resulting policy brief and recommendations submitted to the Secretary of Health and Human Services.

Additional Resources

• Maternal, Infant, and Early Childhood Home Visiting Program In Rural America

From This Webinar

• PowerPoint Handout
• Listen to or download an audio version [MP3]

Transcript

Kristine Sande: Hello everyone. I'm Kristine Sande and I'm the program director for the Rural Health Information Hub and I'd like to welcome you to today's webinar featuring the Maternal Infant and Early Childhood Home Visiting (MIECHV) program in rural areas. We are delighted to be hosting this webinar along with the National Advisory Committee on Rural Health and Human Services. Now it is my pleasure to introduce the speakers for today's webinar. First, we'll hear from Jeff Colyer and he is the chair of the National Advisory Committee on Rural Health and Human Services. He is a physician and former governor of Kansas. As governor, he made Kansas the first state to privatize its entire Medicaid program into KanCare, saving $2.5 billion, expanding services and acting as the basis of many other states' programs. A surgeon known for volunteering in 25 war zones from Rwanda to Syria. He provides trauma reconstruction in Kansas City. Originally from Hayes, Governor Colyer has degrees from Georgetown, Cambridge University, and KU Med.

Next we'll hear from Kyle Peplinski and he's the branch chief for policy data and technical assistance coordination for the Division of Home Visiting and Early Childhood Systems within the Maternal and Child Health Bureau at the Health Resources and Services Administration. In this capacity, he is primarily responsible for developing funding opportunities and programmatic guidance, implementing a continuous program of research and evaluation, including performance measurement and developing and overseeing technical assistance and communications materials for the MIECHV program in early childhood systems investments.

Lastly, we'll hear from Michelle Mills, and Michelle is the Chief Executive Officer of the Colorado Rural Health Center, which is the State Office of Rural Health and the Rural Health Association in Colorado. Michelle has over 20 years of experience working with hospitals, clinics, home health agencies, EMS and long-term care facilities and serves on the National Advisory Committee on Rural Health and Human Services. Michelle believes the future of rural health in Colorado can be summed up in one word, community. With that, I'll turn it over to you, Dr. Colyer.

Jeff Colyer: Great. Want to thank everyone for joining us today and I want to thank the staff and the committee for putting this report together and to our friends here at RHIhub for hosting this important event. Thank you all very much and it's been a real honor to serve as the chair of the National Advisory Committee on Rural Health and Human Services, and growing up in western Kansas and a fifth generation Kansan it's so important to me to see many of these programs and their impact that they have on our rural communities. For today's webinar, I'm going to briefly provide some context about the committee and our goals and offer you a high level overview of the topic. Then we'll turn the things over to our other speakers, to Kyle Peplinski who's introduced previously, who manages this program, and then we'll hear from a committee member Michelle Mills who will talk about the findings and the recommendations of the committee. The committee chose to focus on the maternal program because it provides expected parents, infants and young children, health and social supports in numerous counties across the country.

Before we hear from Kyle and Michelle, I want to tell you a little bit about the Committee on Rural Health and Human Services. This is an independent federally-chartered group that has been around for more than 30 years. It is composed of individuals from across the United States with expertise in finance, policy, program management, and a whole range of rural health issues. The committee typically meets two or three times a year to examine health and human service issues of importance to rural areas. For each topic, the committee engages with rural stakeholders and subject matter experts, and we submit a policy brief containing recommendations. This goes directly to the Secretary of HHS, and so you'll find our full policy brief and all the previously submitted briefs on our committee's website.

A little bit about the committee, when I first joined the committee, it did not have a specific vision. Working with the committee, we developed a vision that we wanted to govern our work. The vision is to focus on rural America that emphasizes its rural and diverse communities of healthy people and places to our providers. That's a place where you can access world-class care and human services. Ensure it's the place where we can have the greatest opportunity to live our American dream. We keep this top of mind in all of our work.

As we advance this vision in a variety of ways, we are trying to explore a number of issues such as innovations in rural healthcare, highlighting some of the opportunities to integrate human health services and non-health sectors as well. We also want to recommend public policies that advance the rural community. Then finally, we want to engage in the science and evidence during our deliberations. Let me give you a little background about our topic today on the Maternal Infant and Early Childhood Home Visiting program. The committee met in Bend, Oregon earlier this spring where we engaged with a number of subject matter experts at the federal and state levels and local community stakeholders. We visited the program. The idea of home visiting has been around for over a century, and this program was created as a federal program in the early 2000s. This is the first time the federal government took a more coordinated role in home visiting programs.

Now, home visiting programs generally have three common activities. They first assess family needs, they educate and support parents, and third, they refer families to needed services in their community. The program is designed to serve families during their pregnancy and from childbirth all the way through kindergarten. It targets families who are experiencing some sort of difficulty that presents challenges to raising healthy children. Some of those challenges include being low income, experiencing abuse or overcoming substance abuse, for example. Rural residents fare worse than their urban residents in many of the vulnerabilities that they face, and so this program is especially helpful in rural areas. Many states provide a very robust coverage in them. About 60% of the 1,065 counties served by this program are rural. It reaches about 28% of all of the rural counties in the United States.

During each meeting the committee members, we developed a list of key themes that were the basis of our policy brief. Now a few of these are standing out for us. As a physician, I can tell you that this program was not well-known in the healthcare system. It's not a common word, something that providers don't normally think of firsthand, but it's clear that the program works and would be beneficial for doctors to refer their pregnant patients to and their new parents to it. This lack of awareness of available programs is often a challenge for trying to integrate health and human service programs delivery. Then there are, of course, workforce shortages. And that is a particular challenge for this program. Just like many other health and human service jobs, it's particularly difficult in rural areas. We heard about creative ways that local programs could combine tasks in different programs to help with this problem and use their professional staff.

It was about building pipelines and internship programs that can be created in high schools to help get students interested in these programs as well. Sometimes these programs close, the community may lose its funding because it's no longer a target area because the targeting is based on the state needs assessment. This is a particular challenge for rural programs because their budgets are so limited and so they may not have much cushion as many of the urban programs to keep funding these home visiting services from other sources. This can hurt families that are being helped by a home visitor who may lose a service. We want to recommend to the secretary some help with this problem in particular.

Finally, it's clear that there's paperwork. The burden of paperwork in this program is very high in rural areas, and staff face many conflicting priorities between providing services to family and completing the required paperwork. We have recommendations to the secretary to work with rural and tribal communities to understand this problem better, and to come up with new innovative solutions that help everyone. Now, I'm going to turn this over to Kyle from our Maternal and Child Health Bureau, and after he presents, he'll turn things over to Michelle and then we'll save your questions for the end of her talk. Thank you for joining us. Hey Kyle, thanks for joining us.

Kyle Peplinski: Absolutely. Thank you so much, Governor Colyer. I'm delighted to be here today to discuss an overview for the MIECHV program. As has been mentioned, my name's Kyle Peplinski and I'm the branch chief for policy data and technical assistance coordination in HRSA's Division of Home Visiting and Early Childhood systems. The Maternal Infant and Early Childhood Visiting program, or MIECHV as we call it, funds states and jurisdictions to support the delivery of evidence-based home visiting models and promising approaches within communities that states identify as at risk for poor maternal and child health outcomes, while also improving coordination of early childhood services in those communities. It requires awardees to identify communities that are at risk for poor maternal and child health outcomes based on a statewide needs assessment, and then target services to priority populations within those communities. That includes both rural and underserved communities with families at risk. The MIECHV program was created in 2010 and is administered by the Health Resources and Services Administration in partnership with the Administration for Children and Families and states territories and tribal entities receive funding through the program.

Evidence-based home visiting programs mitigate and prevent poor maternal and child health outcomes. Research also shows that evidence-based home visiting can provide a positive return on investment to society through savings and public expenditures on things like emergency room visits, child protective services engagements, special education, as well as through increased tax revenue from parents' earnings. Home visiting helps prevent child abuse and neglect, supports positive parenting, improves maternal and child health outcomes, promotes child development and school readiness, promotes economic self-sufficiency for families and connects families to other services in their communities. These goals align with the six statutorily defined benchmark areas that make up the key performance areas for which MIECHV programs are required to demonstrate improvement in and for which funds must be used to support evidence-based home visiting programs. Notably eligible families participate voluntarily in home visiting services and families, partner with home visiting health and social service providers to set and achieve goals to improve their own health and wellbeing.

As I've mentioned, home visiting programs funded under MIECHV must prioritize serving certain populations that are defined in the authorizing statute that are listed on this slide, which include low-income families as well as pregnant people under age 21, and a number of other priority populations. As I've mentioned through a statewide needs assessment, states identify target populations taking into account these priority populations and then they're able to select home visiting service delivery models that best meet the needs of the target communities.

What happens during a home visit? During a home visit, a trained professional, which are usually nurses, social workers, early childhood educators or lay professionals, visit families regularly in their homes. Families participate for these programs. They're generally at risk pregnant people or those with young children. During home visits, the home visitors provide families with the tools that they need to thrive, such as information about breastfeeding, safe sleep or preventing childhood injuries. They provide encouragement for early language and development and early learning in the home, and they also connect families to other services and resources in their communities by screening families for various needs.

Recently, the MIECHV program's authorization was extended through the Jackie Willow Scheme Maternal and Child Home Visiting Reauthorization Act of 2022, which was signed into law by the president in late December of last year, so almost a year ago as part of the Consolidated Appropriations Act of 2023. This reauthorization represents the best opportunity in over a decade to expand services to more families across the country who face disproportionate challenges and barriers to achieving optimal health and wellbeing, including rural populations. The MIECHV program was most recently reauthorized with new funding for five years through fiscal year 2027. It allocated additional funding to the program both for base grants and created a new matching grant opportunity for the program that includes a funding increase for all states and territories as compared to what they received in fiscal year 2022. Funding increases over the course of the authorization from $500 million in '23 to up to $800 million in '27.

Additionally, the program has a reservation of appropriations for tribal entities, which was previously set at 3% and now has been doubled to 6%. This significant increase will help meet the needs of tribal entities implementing high quality, culturally relevant and evidence-based home visiting programs in their communities. Additionally, 2% is set aside for technical assistance, 3% of appropriations are set aside for research evaluation and federal administration, and 2% is set aside for workforce supports, including the Jackie Walorski Center for Evidence-based Case Management.

The Tribal MIECHV program, which I just referenced, is administered by the Administration for Children and Families. The goal of that program is to strengthen tribal capacity to support and promote the health and wellbeing of American Indian and Alaskan Native families, expand the evidence-based around home visiting and tribal communities, and support cooperation and linkages between programs that serve native children and their family. As I just mentioned, the program doubled its set aside in funding. Funding went from $12 million to $30 million in FY '23 and that increased funding was able to support 41 tribal grantees as compared with '23 in 2022.

I also mentioned the 2% set aside for workforce support, retention and case management that was included in the reauthorization. This has allowed HRSA to fund the new Institute for Home Visiting Workforce Development and the Jackie Walorski Center for Evidence-based Case Management. As Governor Colyer mentioned, workforce shortages continue to be a significant need in the field and this institute will help with identifying strategies and providing leadership and coordination around some of the workforce challenges that are faced in the home visiting field. They will analyze workforce data to create supply and demand projections for home visiting professionals and create professional development and career advancement strategies in the field.

Then a few other reauthorization highlights. Reauthorization also created a new requirement for an annual report to Congress to share MIECHV program data report on performance technical assistance and program improvements. Also, requires HRSA to create annually updated outcomes dashboards to help Congress and the public track MIECHV's success in improving family outcomes in every state and territory, based on benchmark data. It provides new parameters for the use of evidence-based virtual home visiting services, which really came into the forefront as part of the COVID-19 response in home visiting and also, requires a reduction in administrative burden by at least 15%, which Governor Colyer also mentioned that the paperwork needs for this program.

In fiscal year 2022, the program served all 50 states, DC and five US territories. Among the 56 awardees, which include states and territories, the program served approximately 138,000 parents and children and over 69,000 families and provided over 840,000 home visits, but that only represents an estimated 14% of the more than 488,000 families who are likely eligible and in need of MIECHV services. The MIECHV program only reaches small percentage of all the families who could benefit from home visiting

As has already been mentioned a number of times states are required to conduct needs assessments to identify at-risk communities in their state that they want to target services to, so I won't spend too much time talking about the needs assessment. Here at HRSA, we provide a number of technical assistance resources to our state and territory awardees. Our Technical Assistance Resource Center offers voluntary and individualized technical assistance and tools and resources to awardees. The Technical Assistance Resource Center serves as an integrated unified access point for TA for our awardees, aligning subject matter expertise and comprehensive programmatic, fiscal data performance measurement, evaluation, and continuous quality improvement TA support in one center, and TARC offers universal and targeted supports to strengthen the capacity of our awardees.

Here's a little bit more information about some of our technical assistance offerings for awardees. I will just note a couple of highlights. In 2024, our TA resource center is launching a new community of practice titled Operating Home Visiting Programs in Rural and Frontier Settings. Over a six-month period, participants as part of that community of practice will explore some of the unique considerations awardees face when delivering MIECHV programming in rural and frontier areas and share best practices about how some awardees are overcoming those challenges. Awardees have also participated in individualized TA-related to providing services in tribal communities and rural and frontier communities, as well as conducting community readiness assessments and planning for service expansion.

Then finally, I'll just mention that our programs are also required to participate in quality improvement activities and develop a biannual continuous quality improvement plan. That plan helps awardees assess their CQI efforts, document progress and use lessons learned to support program improvement with a specific focus on improving outcomes for families and children through their activities, which may include better understanding community context and systems in which their programs are operated, better understanding program implementation, improving home visiting staff, recruitment, retention and wellbeing, addressing specific family outcomes or improving family recruitment and retention into home visiting programs.

Then just a couple of challenges. Governor Colyer, also, already mentioned several of these, but some of the challenges that we do see in program implementation, particularly related to the rural context, certainly the lack of primary care providers, maternal and child health providers and human services providers in rural settings. Home visitors often face difficulties providing referrals to these types of services if there are shortages in those communities and families, even if they are referred, are often unable to access those services. Certainly, limited opportunities and challenges related to travel and transportation can be a challenge there, often both families and home visitors are often long distances from each other in rural context and families long distances from other services as well, so lengthier travel is often required for families living in rural areas. Access to technology, particularly related to participation in virtual or hybrid services, which I mentioned really came to the fore as part of the COVID pandemic response, but families without access to WiFi or broadband internet access may have substantial challenges participating in home visiting programs.

We've already talked about staffing shortages a bit, but identifying and hiring highly qualified home visiting professionals are often difficult to find in rural communities. Programs often face long staffing vacancies, vacancies and difficulties in backfilling positions. Challenges related to unemployment, families who are unable to secure jobs, which can contribute to additional burden, including increased stress and health concerns, leaving less time to engage in home visiting if they have young children. Then also, collaborating and coordinating with rural and frontier community assistance agencies can be a helpful strategy for families and home visiting programs. Although, much like home visiting, these agencies can also experience staffing and capacity issues making collaboration difficult. With that, I'm going to turn things over to Michelle and look forward to any questions. Thank you.

Michelle Mills: Great. Thanks so much, Kyle. Appreciate it very much. Just want to say how honored I really am to serve on this committee. Hearing about the MIECHV project and topic was super interesting to me as I really hadn't heard of the program before as Dr. Colyer had mentioned earlier. There's several recommendations that Governor Colyer mentioned earlier that the committee came up with. There's a total of eight, so here are the first four, we've got the additional four. I'm not going to go through each one of these, instead I'll talk a little bit more just about the themes that kind of emerged from our meeting that we had in Oregon and some of the recommendations as a result of this. I encourage you to go look at the full brief, which there's a link to it here in the slides, and it's also available on the committee's webpage.

Flexibility. This was the first theme that really came about is there needs to be some flexibility in the program in order to make it more accessible to rural areas. One of the things that can prove challenging in rural areas is that we can't often meet the requirements that are set aside with the statute of this program rules. In particular, with evidence-based models that aren't developed in rural that we're supposed to try to adopt to rural, so that's challenging. It's challenging because we have fewer resources and sometimes we just don't meet the criteria. For example, we don't maybe have as much staff in terms of registered nurses to be able to meet that criteria. We think that some flexibility for rural around this would be super helpful. We also feel that the needs assessment, which is an essential component in the way that the states decide to implement the model, would be helpful if they would work with State Offices of Rural Health, Rural Health Associations, tribal organizations, and others to help identify where they might have gaps in the needs assessment that is likely available at those entities.

They do have this promising approach. Unfortunately, only 25% of the funding can go towards this promising approach, but we recommend that they develop and evaluate these programs based on rural circumstances. If you allow us the flexibility in rural to be able to develop these promising practices or approaches, then we can develop some more research-related data for the evaluations so we can better meet the criteria for that. Great, so the recommendation really is that we should provide rural specific technical assistance supports for states to implement these promising practices and model enhancements in rural communities. While we definitely recognize as a committee the need to maintain these rigorous evaluation standards for promising practices, but we need to be able to try to pilot the program to create the new evidence models to be able to have more inclusion within the MIECHV program. We really want HHS to consider new ways to support these approaches so that way we can address some of the rural gaps that exist.

The next big area is the requirements for data and administrative burden. The requirements for the data and the reporting and the oversight to participate in these programs, as a committee, we really found like, oh wow, we can't believe how difficult it is for many of the families and the local service providers to really participate in this. One of the things that we heard and discovered was that from a local family caregiver, they are required to fill out multiple forms and sometimes they have to fill out those forms in many duplicates, and also, they have to fill them out on a quarterly basis. Often with this requirement, they have tight timelines. As a caregiver, you don't often have time to fill out this paperwork. In this regard, we really think that the time that HHS thinks that it requires for people to fill this out doesn't often really match with the amount of time and paperwork that it requires to do that.

We definitely think that streamlining this process could be helpful. Would also say that the administrative burden for the grantee as well is difficult also. Often we have lower amount of resources that are available in our rural communities. We don't often have the sufficient amount of staff to be able to provide both all the services that need to be available to our rural families, but also, to complete all these data requirements. We think, again, some streamlining of that process could be very helpful. This essentially says that the secretary should engage with rural and tribal communities to try to understand the most burdensome data and administrative requirements that they encounter, and examine the federal formula grant programs for the best practices and data reporting and oversight, and determine where the administrative procedures can be streamlined to reduce the burdens for local implementing agencies.

I would say additionally, if there could be a breakdown too for rural, versus urban, versus tribal data, this will help with the streamlining of the administrative requirements as well. Continuing on this data administrative burden, the second area of concern for the data in the MIECHV program is the reliance on the data systems that don't always accurately reflect the rural reality. Often, rural facilities don't always have the staff to be able to provide all of these things that they need to provide. Also, just as an example, the American Community Survey administered by the US Census Bureau is often used as the standard for the demographic information to help local officials understand the changes and the challenges occurring in their community. But again, this data only releases non-urban data every five years, and we know that things change more than every five years in rural communities and as compared to urban communities that are updated and the data is refreshed annually.

Given some of those limitations with the national surveys, we also thought it'd be important to incorporate some more rural-specific data in the needs assessment. Like I mentioned earlier, working with tribal organizations, working with rural associations, state offices of rural health, I think can help enhance some of that data. There's often two conflicting priorities, and so HHS really should consider widening that gap for helping with the needs assessment. HHS should require states to consult, which was just what I said, with the State Offices of Rural Health, state and territory, minority health, Indian Health Services, and really other local stakeholders in the preparation of their needs assessment. We just feel like it could be really enhanced if we had a more collaborative approach to that.

Workforce challenges, so not surprising in the program, we also face workforce challenges. We heard as both Kyle and Governor Colyer mentioned that we have trouble retraining staff for this. It can be difficult, obviously, in rural areas more so than in urban areas. Home visitors can have a lasting positive impact on the community, particularly if that home visitor person is local and they really understand and live and work in the community that they serve. The national survey for the home visiting workforce finds that home visitors are generally dissatisfied with their compensation and opportunities for promotion. In turn, prompting qualified and experienced staff to leave for better paying jobs. Many challenges facing workforce recruitment and retention are exasperated in rural areas because rural area tends to have smaller pools of qualified applicants to fill the visiting workforce. I will say this is, in general, our problem and has been one of our problems for workforce in rural for a long time now. I think this could definitely help with further collaboration on how to solve some of these problems.

But the committee did learn and heard some bright spots in some of the other states trying to address these workforce challenges. For example, in Oregon, the universities are encouraging students to stay and work in rural communities through a unique criteria that's features, lived-in experience and credits. Community colleges in Oregon are also designing early childhood classes that are dual language to train the workforce that more accurately reflects the cultural and logistic diversity of the community. I think more states that can do that and again, work in a little bit more collaborative approach with our folks in our rural communities, I think that would help a lot.

The recommendation is that HHS should provide rural-specific workforce training support to home visiting programs by adding rural track within the Institute for Home Visiting Workforce Development at the Jackie Walorski, and I'm sorry if I pronounce that wrong, Center for Evidence-based Case Management. I would also say workforce training working with 3RNET, runs a recruitment and retention program as well, which also receives federal funding and most states work with too can help with that also. Really, those were just some highlights. I did not go through the whole brief or everything about the brief, but here are some links on your slide that you can get to that really highlight the issues that the committee covered for the MIECHV program. We hope really that we can make it easier, raise awareness and make more positive changes.

Kristine Sande: All right, well, thank you all for that great information. The committee's recommendations are for the secretary, but wondering if there are any recommendations for rural healthcare providers in terms of connecting their patients with the program in their local communities? I know Dr. Colyer, you mentioned that sometimes physicians aren't aware of the program, so once they become aware, how do they connect with the program and make sure that their patients can connect with it as well?

Jeff Colyer: Many times these programs are housed in the local community service programs and we really have to work out how to connect those a little bit better to providers that are out there and there's really a large variety of them. Michelle, have you got some examples of where this has worked better for folks?

Michelle Mills: Yeah, so definitely in Oregon there is examples of where things have worked and how programs have worked together. I encourage you to dig a little bit deeper into some of the committee's report to be able to see that. But I would also point out to that in recommendation four where it says that HHS should require states to consult with State Office of Rural Health, state and territory, minority health, Indian Health Services, and really other local stakeholders, even though our recommendation specifically says update it to update the needs assessment, I would say there's a lot of wealth of knowledge that exists within those entities that can dive down into the people who are actually providing the care on a local basis. But like I said, for our office, I was completely unfamiliar with this program until I heard about it back in Oregon and stuff. Raising awareness first with those entities so we can help educate others will be helpful as well.

Kristine Sande: Will part of the workforce recommendations include encouraging programs to hire employees, specifically non-nurse employees. I think you mentioned a couple of different types of providers, but this says specifically such as an MPH in maternal and child health.

Michelle Mills: I think expanding the workforce will be helpful, but also, looking how you can grow your own within the local communities as well. But I think we need to think outside the box. We aren't rolling out enough nurses necessarily to fit the need for this program and/or for all programs in general.

Kyle Peplinski: A number of most home visiting models identify the type of staff that are required for that particular model, and that's where the flexibility of the state to really select the models for the community to really tailor the requirements of the model with the realities of the community. The states have flexibility to ensure that if there are certain types of provider shortages in certain communities, that they're really selecting a model that's going to be successful in that area.

Kristine Sande: Great. Great, so Michelle, how aware do you think rural health folks are of this home visiting program in general?

Michelle Mills: In general, I don't think people are aware of it, which is a part of the problem, right? There's great resources going out and even many are trying to tie their efforts in with the Medicaid program also. I think we could do a bunch better job of educating and making sure there's more awareness.

Kristine Sande: The next question is probably for Kyle, will there be more NOFOs that will be announced in the near future for MIECHV?

Kyle Peplinski: MIECHV has an annual funding process where we, so we do publish a NOFO on an annual basis, usually in the spring, but eligible entities for this program are defined in statute, so they are states, jurisdictions, and tribal entities. We tend to fund the same entities from year-to-year. There's not an open call for new applicants, generally, through the state and territory program. As the tribal program is expanding through its set aside, they do have competitive funding opportunities.

Kristine Sande: Has there ever been any discussion about making a referral to a supportive home visiting program a requirement for all prenatal patients?

Kyle Peplinski: A couple of things. One is MIECHV is required by statute to be a voluntary program, so families have to choose to participate, which is a key hallmark of the program. Now that being said, that wouldn't preclude providing a referral to everyone, but also services have to be targeted and intensive. There are universal home visiting models that do, for example, provide a referral for every family giving birth at a particular birthing hospital or in a certain catchment area, but those are really outside the scope of MIECHV. Some states are funding models like that through other means, either through state funding or have found other ways to fund that type of program, but it's really sort of outside the scope of MIECHV.

Kristine Sande: Is there a way for insurance carriers to partner to help also work to reduce disparities in areas that they look to target?

Kyle Peplinski: A number of states are looking, have successfully leveraged Medicaid as a reimbursement strategy for home visiting services in particular. States really approach that in really unique ways, depending on their state context. There are models for Medicaid reimbursement of home visiting services. I'm less familiar with private insurance opportunities.

Kristine Sande: Can you describe what types of flexibilities that might be requested for implementation in rural areas? Evidence-based models are asked to ensure fidelity to the model that has demonstrated the outcomes desired. What flexibilities might be needed?

Michelle Mills: Yeah, I mean, I think some flexibilities that we touched on are to reduce the amount of evaluation or data collection or administrative burden that is necessary to participate in the program. For example, to have a promising approach, the state could allocate up to 25% of the funding related to that. Maybe they could allocate a little bit more. Maybe the state could provide some technical assistance in helping to meet those kind of time consuming evaluation criteria to make it easier for folks. If you really wanted to think outside the box, I think even if you only have a few families that meet the criteria, it doesn't mean that that's not important. I think if you can expand that out to just be more inclusive for rural communities, that would be helpful. They often have the best solutions because they're forced to have the best solutions to be able to operate. I think if we could just listen to them a little bit more in terms of how can we get to this outcome while meeting certain, obviously, requirements.

Kristine Sande: Then what are some specific examples of other types of trained and credentialed and licensed practitioners that might provide home visits?

Kyle Peplinski: As I mentioned before, most home visiting models define the type of credentials that are needed to implement their specific model. That really ranges from a high school diploma to being a registered nurse or having an MSW. That's really model-specific. I will say there is a trend, I think, in the field in recognizing the value of lived experience in these types of jobs and really trying to recruit home visitors from the communities that they're intended to serve in representing the families that they're hoping to serve.

Kristine Sande: All right, so I don't see any other questions at this point, so I think we will wrap things up. On behalf of RHIhub, I'd like to thank our speakers for the great information that they provided today. Also, would like to thank all of our participants for joining us. The slides used in today's webinar are currently available at https://www.ruralhealthinfo.org/webinars. Thanks so much for joining us and have a great day.