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Definition of home visit

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home visitor

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“Home visit.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/home%20visit. Accessed 26 Mar. 2024.

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Home Visit: Opening the Doors for Family Health

Chapter 11 Home Visit Opening the Doors for Family Health Claudia M. Smith Chapter Outline Home Visit Definition Purpose Advantages and Disadvantages Nurse–Family Relationships Principles of Nurse–Client Relationship with Family Phases of Relationships Characteristics of Relationships with Families Increasing Nurse–Family Relatedness Fostering a Caring Presence Creating Agreements for Relatedness Increasing Understanding through Communication Skills Reducing Potential Conflicts Matching the Nurse’s Expectations with Reality Clarifying Nursing Responsibilities Managing the Nurse’s Emotions Maintaining Flexibility in Response to Client Reactions Clarifying Confidentiality of Data Promoting Nurse Safety Clarifying the Nurse’s Self-Responsibility Promoting Safe Travel Handling Threats during Home Visits Protecting the Safety of Family Members Managing Time and Equipment Structuring Time Handling Emergencies Promoting Asepsis in the Home Modifying Equipment and Procedures in the Home Postvisit Activities Evaluating and Planning the Next Home Visit Consulting and Collaborating with the Team Making Referrals Legal Documentation The Future of Evidence-Based Home-Visiting Programs Focus Questions Why are home visits conducted? What are the advantages and disadvantages of home visits? How is the nurse–client relationship in a home similar to and different from nurse–client relationships in inpatient settings? How can a nurse’s family focus be maximized during a typical home visit? What promotes safety for community/public health nurses? What happens during a typical home visit? How can client participation be promoted? Key Terms Agreement Collaboration Consultation Empathy Family focus Genuineness Home visit Positive regard Presence Referral Nurses who work in all specialties and with all age groups can practice with a family focus , that is, thinking of the health of each family member and of the entire family per se and considering the effects of the interrelatedness of the family members on health. Because being family focused is a philosophy, it can be practiced in any setting. However, a family’s residence provides a special place for family-focused care. Community/public health nurses have historically sought to promote the well-being of families in the home setting ( Zerwekh, 1990 ). Community/public health nurses seek to promote health; prevent specific illnesses, injuries, and premature death; and reduce human suffering. Through home visits, community/ public health nurses provide opportunities for families to become aware of potential health problems, to receive anticipatory education, and to learn to mobilize resources for health promotion and primary prevention ( Kristjanson & Chalmers, 1991 ; Raatikainen, 1991 ). In clients’ homes, care can be personalized to a family’s coping strategies, problem-solving skills, and environmental resources (see Chapter 13 ). During home visits, community/public health nurses can uncover threats to health that are not evident when family members visit a physician’s office, health clinic, or emergency department ( Olds et al., 1995 ; Zerwekh, 1991 ). For example, during a visit in the home of a young mother, a nursing student observed a toddler playing with a paper cup full of tacks and putting them in his mouth. The student used the opportunity to discuss safety with the mother and persuaded her to keep the tacks on a high shelf. The quality of the home environment predicts the cognitive and social development of an infant ( Engelke & Engelke, 1992 ). Community/public health nurses successfully assist parents in improving relations with their children and in providing safe, stimulating physical environments. All levels of prevention can be addressed during home visits. Research has demonstrated that home visits by nurses during the prenatal and infancy periods prevent developmental and health problems ( Kitzman et al., 2000 ; Norr et al., 2003 ; Olds et al., 1986 ). Olds and colleagues demonstrated that families who received visits had fewer instances of child abuse and neglect, emergency department visits, accidents, and poisonings during the child’s first 2 years of life. These results were true for families of all socioeconomic levels but greater for low-income families. The health outcomes for families who received home visits were better than those of families that received care only in clinics or from private physicians. Furthermore, the favorable results were still apparent 15 years after the birth of the first child ( Olds et al., 1997 ), and the home visits reduced subsequent pregnancies ( Kitzman et al., 1997 ; Olds et al., 1997 ). The U.S. Advisory Board on Abuse and Neglect advocates such home-visiting programs as a means to prevent child abuse and neglect ( U.S. Department of Health and Human Services, 1990 ). Other research shows that home visits by nurses can reduce the incidence of drug-resistant tuberculosis and decrease preventable deaths among infected individuals ( Lewis & Chaisson, 1993 ). This goal is achieved through directly observing medication therapy in the individual’s home, workplace, or school on a daily basis or several times a week (see Chapter 8 ). Several factors have converged to expand opportunities for nursing care to adults and children with illnesses and disabilities in their homes. The American population has aged, chronic diseases are now the major illnesses among older persons, and attempts are being made to limit the rising hospital costs. As the average length of stay in hospitals has decreased since the early 1980s, families have had to care for more adults and children with acute illnesses in their homes. This increased demand for home health care has resulted in more agencies and nurses providing home care to the ill and teaching family members to perform the care (see Chapter 31 ). The degree to which families cope with a member with a chronic illness or disability significantly affects both the individual’s health status and the quality of life for the entire family ( Burns & Gianutsos, 1987 ; Harris, 1995 ; Whyte, 1992 ). Family members may be called on to support an individual family member’s adjustment to a chronic illness as well as take on tasks and roles that the ill member previously performed. This adjustment occurs over time and often takes place in the home. Community/public health nurses can assist families in making these adjustments. Since the late 1960s, deinstitutionalization of mentally ill clients has shifted them from inpatient psychiatric settings to their own homes, group homes, correctional facilities, and the streets (see Chapter 33 ). Nurses in the fields of community mental health and psychiatry began to include the relatives and surrogate family members in providing critical support to enable the person with a psychiatric diagnosis to live at home ( Mohit, 1996 ; Stolee et al., 1996 ). The hospice movement also recognizes the importance of a family focus during the process of a family member’s dying ( American Nurses Association [ANA], 2007a ). Care at home or in a homelike setting is cost effective under many circumstances. As the prevalence of acquired immunodeficiency syndrome (AIDS) increases and the number of older adults continues to increase, providing care in a cost-effective manner is both an ethical and an economic necessity. Nurses in any specialty can practice with a family focus. However, the specific goals and time constraints in each health care service setting affect the degree to which a family focus can be used. A home visit is one type of nurse–client encounter that facilitates a family focus. Home visiting does not guarantee a family focus. Rather, the setting itself and the structure of the encounter provide an opportunity for the nurse to practice with a family focus. A nurse visiting a client in his home listens to the man’s heart while his daughter looks on. Nurses who graduate from a baccalaureate nursing program are expected to have educational experiences that prepare them for beginning practice in community/public health nursing. Family-focused care is an essential element of community/public health nursing. One of the ways to improve the health of populations and communities is to improve the health of families ( ANA, 2007b ). Home visits may be made to any residence: apartments for older adults, group homes, boarding homes, dormitories, domiciliary care facilities, and shelters for the homeless, among others. In these residences, the family may not be related by blood, but, rather, they may be significant others: neighbors, friends, acquaintances, or paid caregivers. Nurses who are educated at the baccalaureate level are one of a few professional and service workers who are formally taught about making home visits. Some social work students, especially those interested in the fields of home health and protective services, also receive similar education. The American Red Cross and the National Home Caring Council have developed training programs for homemakers and home health aides; not all aides have received such extensive training, however. Agricultural and home economic extension workers in the United States and abroad also may make home visits ( Murray, 1968 ; World Health Organization, 1987 ). Home visit Definition A home visit is a purposeful interaction in a home (or residence) directed at promoting and maintaining the health of individuals and the family (or significant others). The service may include supporting a family during a member’s death. Just as a client’s visit to a clinic or outpatient service can be viewed as an encounter between health care professionals and the client, so can a home visit. A major distinction of a home visit is that the health care professional goes to the client rather than the client coming to the health care professional. Purpose Almost any health care service can be accomplished on a home visit. An assumption is that—except in an emergency—the client or family is sufficiently healthy to remain in the community and to manage health care after the nurse leaves the home. The foci of community/public health nursing practice in the home can be categorized under five basic goals: 1.  Promoting support systems that are adequate and effective and encouraging use of health-related resources 2.  Promoting adequate, effective care of a family member who has a specific problem related to illness or disability 3.  Encouraging normal growth and development of family members and the family and educating the family about health promotion and illness prevention 4.  Strengthening family functioning and relatedness 5.  Promoting a healthful environment The five basic goals of community/public health nursing practice with families can be linked to categories of family problems ( Table 11-1 ). A pilot study to identify problems common in community/public health nursing practice settings revealed that problems clustered into four categories: (1) lifestyle and living resources, (2) current health status and deviations, (3) patterns and knowledge of health maintenance, and (4) family dynamics and structure ( Simmons, 1980 ). Home visits are one means by which community/public health nurses can address these problems and achieve goals for family health. Table 11-1 Family Health-Related Problems and Goals Problem * Goal Lifestyle and resources Promote support systems and use of health-related resources Health status deviations Promote adequate, effective family care of a member with an illness or disability Patterns and knowledge of health maintenance Encourage growth and development of family members, health promotion, and illness prevention Promote a healthful environment Family dynamics and structure Strengthen family functioning and relatedness * Problems from Simmons, D. (1980). A classification scheme for client problems in community health nursing (DHHS Pub No. HRA 8016). Hyattsville, MD: U.S. Department of Health and Human Services. Advantages and Disadvantages Advantages of home visits by nurses are numerous. Most of the disadvantages relate to expense and concerns about unpredictable environments ( Box 11-1 ). Box 11-1 Advantages and Disadvantages of Home Visiting Advantages •  Home setting provides more opportunities for individualized care. •  Most people prefer to receive care at home. •  Environmental factors impinging on health, such as housing condition and finances, may be observed and considered more readily. •  Collecting information and understanding lifestyle values are easier in family’s own environment. •  Participation of family members is facilitated. •  Individuals and family members may be more receptive to learning because they are less anxious in their own environments and because the immediacy of needing to know a particular fact or skill becomes more apparent. •  Care to ill family members in the home can reduce overall costs by preventing hospitalizations and shortening the length of time spent in hospitals or other institutions. •  A family focus is facilitated. Disadvantages •  Travel time is costly. •  Home visiting is less efficient for the nurse than working with groups or seeing many clients in an ambulatory site. •  Distractions such as television and noisy children may be more difficult to control. •  Clients may be resistant or fearful of the intimacy of home visits. •  Nurse safety can be an issue. Nurse–family relationships How nurses are assigned to make home visits is both a philosophical and a management issue. Some community/public health nurses are assigned by geographical area or district . The size of the geographical area for home visits varies with the population density. In a densely populated urban area, a nurse might visit in one neighborhood; in a less densely populated area, the nurse might be assigned to visit in an entire county. With geographical assignments, the nurse has the potential to work with the entire population in a district and to handle a broad range of health concerns; the nurse can also become well acquainted with the community’s health and social resources. The potential for a family-focused approach is strengthened because the nurse’s concerns consist of all health issues identified with a specific family or group of families. The nurse remains a clinical generalist, working with people of all ages. Other community/public health nurses are assigned to work with a population aggregate in one or more geopolitical communities. For example, a nurse may work for a categorical program that addresses family planning or adolescent pregnancy, in which case the nurse would visit only families to which the category applies. This type of assignment allows a nurse to work predominantly with a specific interest area (e.g., family planning and pregnancy) or with a specific aggregate (e.g., families with fertile women). Principles of Nurse–Client Relationship with Family Regardless of whether the community/public health nurse is assigned to work with an aggregate or the entire population, several principles strengthen the clarity of purpose: •  By definition, the nurse focuses on the family. •  The health focus can be on the entire spectrum of health needs and all three levels of prevention. •  The family retains autonomy in health-related decisions. •  The nurse is a guest in the family’s home. Family Focus To relate to the family, the community/public health nurse does not have to meet all members of the household personally, although varying the times of visits might allow the nurse to meet family members usually at work or school. Relating to the family requires that the nurse be concerned about the health of each member and about each person’s contribution to the functioning of the family. One family member may be the primary informant; in such instances, the nurse should realize that the information received is being filtered by the person’s perceptions. The community/public health nurse should take the time to introduce herself or himself to each person present and address each person by name. Building trust is an essential foundation for a continued relationship ( Heaman et al., 2007 ; McNaughton, 2000 ; Zerwekh, 1992 ). The nurse should use the clients’ surnames unless they introduce themselves in another way or give permission for the nurse to be less formal. Interacting with as many family members as possible, identifying the family member most responsible for health issues, and acknowledging the family member with the most authority are important. The nurse should ask for an introduction to pets and ask for permission before picking up infants and children unless it is granted nonverbally. A nurse enters the home of a client with a young child. All Levels of Prevention Through assessment, the community/public health nurse attempts to identify what actual and potential problems or concerns exist with each individual and, thematically, within the family (see Chapter 13 ). Issues of health promotion (diet) and specific protection (immunization) may exist, as may undiagnosed medical problems for which referral is necessary for further diagnosis and treatment. Home visits also can be effective in stimulating family members to seek appropriate services such as prenatal care ( Bradley & Martin, 1994 ) and immunizations ( Norr et al., 2003 ). Actual family problems in coping with illness or disability may require direct intervention. Preventing sequelae and maximizing potential may be appropriate for families with a chronically ill member. Health-related problems may appear predominantly in one family member or among several members. A thematic family problem might be related to nutrition. For example, a mother may be anemic, a preschooler may be obese, and a father may not follow a low-fat diet for hypertension. Family Autonomy A few circumstances exist in our society in which the health of the community, or public, is considered to have priority over the right of individual persons or families to do as they wish. In most states, statutes (laws) provide that health care workers, including community/public health nurses, have a right and an obligation to intervene in cases of family abuse and neglect, potential suicide or homicide, and existence of communicable diseases that pose a threat of infection to others. Except for these three basic categories, the family retains the ultimate authority for health-related decisions and actions . In the home setting, family members participate more in their own care. Nursing care in the home is intermittent, not 24 hours a day. When the visit ends, the family takes responsibility for their own health, albeit with varying degrees of interest, commitment, knowledge, and skill. This role is often difficult for beginning community/public health nurses to accept; learning to distinguish the family’s responsibilities from the nurse’s responsibilities involves experience and consideration of laws and ethics. Except in crises, taking over for the family in areas in which they have demonstrated capability is usually inappropriate. For example, if family members typically call the pharmacy to renew medications and make their own medical appointments, beginning to do these things for them is inappropriate for the nurse. Taking over undermines self-esteem, confidence, and success. Nurse as Guest Being a guest as a community/public health nurse in a family’s home does not mean that the relationship is social. The social graces for the community and culture of the family must be considered so that the family is at ease and is not offended. However, the relationship is intended to be therapeutic. For example, many older persons believe that offering something to eat or drink is important as a sign that they are being courteous and hospitable. Because your refusal to share in a glass of iced tea may be taken as an affront, you may opt to accept the tea. However, you certainly have the right to refuse, especially if infectious disease is a concern. Validate with the client that the time of the visit is convenient. If the client fails to offer you a seat, you may ask if there is a place for you and the family to sit and talk. This place may be any room of the house or even outside in good weather. Phases of Relationships Relatedness and communication between the nurse and the client are fundamental to all nursing care. A nurse–client relationship with a family (rather than an individual) is critical to community/public health nursing. The phases of the nurse–client relationship with a family are the same as are those with an individual. Different schemes have been developed for naming phases of relationships. All schemes have (1) a preinitiation or preplanning phase, (2) an initiation or introductory phase, (3) a working phase, and (4) an ending phase (Arnold & Boggs, 2011). Some schemes distinguish a power and control or contractual phase that occurs before the working phase. The initiation phase may take several visits. During this phase, the nurse and the family get to know one another and determine how the family health problems are mutually defined. The more experience the nurse has, the more efficient she or he will become; initially, many community/public health nursing students may require four to six visits to feel comfortable and to clarify their role ( Barton & Brown, 1995 ). The nursing student should keep in mind that the relationship with the family usually involves many encounters over time—home visits, telephone calls, or visits at other ambulatory sites such as clinics. Several encounters may occur during each phase of the relationship ( Figure 11-1 ). Each encounter also has its own phases ( Figure 11-2 ). Figure 11-1 A series of encounters during a relationship. (Redrawn from Smith, C. [1980]. A series of encounters during a relationship [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.) Figure 11-2 Phases of a home visit. (Redrawn from Smith, C. [1980]. Phases of a home visit [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.) Preplanning each telephone call and home visit is helpful. Box 11-2 lists activities in which community/public health nurses usually engage before a home visit. The list can be used as a guide in helping novice community/public health nurses organize previsit activities efficiently. Box 11-2 Planning Before a Home Visit   1.  Have name, address, and telephone number of the family, with directions and a map. 2.  Have telephone number of agency by which supervisor or faculty can be reached. 3.  Have emergency telephone numbers for police, fire, and emergency medical services (EMS) personnel. 4.  Clarify who has referred the family to you and why. 5.  Consider what is usually expected of a nurse in working with a family that has been referred for these health concerns (e.g., postpartum visit), and clarify the purposes of this home visit. 6.  Consider whether any special safety precautions are required. 7.  Have a plan of activities for the home visit time (see Box 11-3 ). 8.  Have equipment needed for hand-washing, physical assessment, and direct care interventions, or verify that client has the equipment in the home. 9.  Take any data assessment or permission forms that are needed. 10.  Have information and teaching aids for health teaching, as appropriate. 11.  Have information about community resources, as appropriate. 12.  Have gasoline in your automobile or money for public transportation. 13.  Leave an itinerary with the agency personnel or faculty. 14.  Approach the visit with self-confidence and caring. The visit begins with a reintroduction and a review of the plan for the day; the nurse must assess what has happened with the family since the last encounter. At this point, the nurse may renegotiate the plan for the visit and implement it. The end of the visit consists of summarizing, preparing for the next encounter, and leave-taking. Box 11-3 describes the community/public health nurse’s typical activities during a home visit. Box 11-3 Nursing Activities During Three Phases of a Home Visit Initiation Phase of Home Visit 1.  Knock on door, and stand where you can be observed if a peephole or window exists. 2.  Identify self as [name], the nurse from [name of agency]. 3.  Ask for the person to whom you were referred or the person with whom the appointment was made. 4.  Observe environment with regard to your own safety. 5.  Introduce yourself to persons who are present and acknowledge them. 6.  Sit where family directs you to sit. 7.  Discuss purpose of visit. On initial visits, discuss services to be provided by agency. 8.  Have permission forms signed to initiate services. This activity may be done later in the home visit if more explanation of services is needed for the family to understand what is being offered. Implementation Phase of Home Visit 9.  Complete health assessment database for the individual client. 10.  On return visits, assess for changes since the last encounter. Explore the degree that family was able to follow up on plans from previous visit. Explore barriers if follow-up did not occur. 11.  Wash hands before and after conducting any physical assessment and direct physical care. 12.  Conduct physical assessment, as appropriate, and perform direct physical care. 13.  Identify household members and their health needs, use of community resources, and environmental hazards. 14.  Explore values, preferences, and clients’ perceptions of needs and concerns. 15.  Conduct health teaching as appropriate, and provide written instructions. Include any safety recommendations. 16.  Discuss any referral, collaboration, or consultation that you recommend. 17.  Provide comfort and counseling, as needed. Termination Phase of Home Visit 18.  Summarize accomplishments of visit. 19.  Clarify family’s plan of care related to potential health emergency appropriate to health problems. 20.  Discuss plan for next home visit and discuss activities to be accomplished in the interim by the community/public health nurse, individual client, and family members. 21.  Leave written identification of yourself and agency, with telephone numbers. Characteristics of Relationships with Families Some differences are worth discussing in nurses’ relationships with families compared with those with individual clients in hospitals. The difference that usually seems most significant to the nurse who is learning to make home visits is the fact that the nurse has less control over the family’s environment and health-related behavior ( McNaughton, 2000 ). The relationship usually extends for a longer period. A more interdependent relationship develops between the community/public health nurse and the family throughout all steps of the nursing process. Families Retain Much Control The family can control the nurse’s entry into the home by explicitly refusing assistance, establishing the time of the visit, or deciding whether to answer the door. Unlike hospitalized clients, family members can just walk away and not be home for the visit. One study of home visits to high-risk pregnant women revealed that younger and more financially distressed women tended to miss more appointments for home visits ( Josten et al., 1995 ). Being rejected by the family is often a concern of nurses who are learning to conduct home visits. As with any relationship, anxiety can exist in relation to meeting new, unknown families. Families may actually have similar feelings about meeting the nurse and may wonder what the nurse will think of them, their lifestyle, and their health care behavior. A helpful practice is to keep your perspective; if the clients are home for your visit, they are at least ambivalent about the meeting! If they are at home to answer the door, they are willing to consider what you have to offer. Most families involved with home care of the ill have requested assistance. Because only a few circumstances exist (as previously discussed) in which nursing care can be forced on families, the nurse can view the home visit as an opportunity to explore voluntarily the possibility of engaging in relationships ( Byrd, 1995 ). The nurse is there to offer services and engage the family in a dialogue about health concerns, barriers, and goals. As with all nurse–client relationships, the nurse’s commitment, authenticity, and caring constitute the art of nursing practice that can make a difference in the lives of families. Just as not all individuals in the hospital are ready or able to use all of the suggestions made to them, families have varying degrees of openness to change. If after discussing the possibilities the family declines either overtly or through its actions, the nurse has provided an opportunity for informed decision making and has no further obligation. Goals of Nursing Care Are Long Term A second major difference in nurse relationships with families is that the goals are usually more long term than are those with individual clients in hospitals. Clients may be in hospice programs for 6 months. A family with a member who has a recent diagnosis of hypertension may take 6 weeks to adjust to medications, diet, and other lifestyle changes. A school-aged child with a diagnosis of attention deficit disorder may take as long as half the school year to show improvement in behavior and learning; sometimes, a year may be required for appropriate classroom placement. For some nurses, this time frame is judged to be slow and tedious. For others, the time frame is seen as an opportunity to know a family in more depth, share life experiences over time, and see results of modifications in nursing care. For nurses who like to know about a broad range of health and nursing issues, relationships with families stimulate this interest. Having had some experience in home visiting is helpful for nurses who work in inpatient settings; it allows them to appreciate the scope and depth of practice of community/public health nurses who make home visits as a part of their regular practice. These experiences can sensitize hospital nurses to the home environments of their clients and can result in better hospital discharge plans and referrals. Because ultimate goals may take a long time to achieve, short-term objectives must be developed to achieve long-term goals. For example, a family needs to be able to plan lower-calorie menus with sufficient nutrients before weight loss is possible; a parent may need to spend time with a child daily before unruly behavior improves. Nursing interventions in a hospital setting become short-term objectives for client learning and mastery in the home setting. In an inpatient setting, giving medications as prescribed is a nursing action. In the home, the spouse giving medications as prescribed becomes a behavioral objective for the family; the related nursing action is teaching. Human progress toward any goal does not usually occur at a steady pace. For example, you may start out bicycling faithfully three times a week and give up abruptly. Similarly, clients may skip an insulin dose or an oral contraceptive. A family may assertively call appropriate community agencies, keep appointments, and stop abruptly. Families can be committed to their own health and well-being and yet not act on their commitment consistently. Recognizing that setbacks and discouragement are a part of life allows the community/public health nurse to be more accepting of reality and have the objectivity to renegotiate goals and plans with families. Box 11-4 includes evidence-based ways to foster goal accomplishment. Box 11-4 Best Practices in Fostering Goal Accomplishment With Families 1.  Share goals explicitly with family. 2.  Divide goals into manageable steps. 3.  Teach the family members to care for themselves. 4.  Do not expect the family to do something all of the time or perfectly. 5.  Be satisfied with small, subtle changes. 6.  Be flexible. Changes are sometimes subtle or small. Success breeds success, at least motivationally. The short-term goals on which everyone has agreed are important to make clear so that the nurse and the family members have a common basis for evaluation. Goals can be set in a logical sequence, in small steps, to increase the chance of success. In an inpatient setting, the skilled nurse notices the subtle changes in client behavior and health status that can warn of further disequilibrium or can signal improvement. Similarly, during a series of home visits, the skilled nurse is aware of slight variations in home management, personal care, and memory that may presage a deteriorating biological or social condition. Nursing Care Is More Interdependent with Families Because families have more control over their health in their own homes and because change is usually gradual, greater emphasis must be placed on mutual goals if the nurse and family are to achieve long-term success. Except in emergency situations, the client determines the priority of issues. A parent may be adamant that obtaining food is more important than obtaining their child’s immunization. A child’s school performance may be of greater concern to a mother than is her own abnormal Papanicolaou (Pap) smear results. Failure of the nurse to address the family’s primary priority may result in the family perceiving that the nurse does not genuinely care. At times, the priority problem is not directly health related, or the solution to a health problem can be handled better by another agency or discipline. In these instances, the empathic nurse can address the family’s stress level, problem-solving ability, and support systems and make appropriate referrals. When the nurse takes time to validate and discuss the primary concern, the relationship is enhanced. Families are sometimes unaware of what they do not know. The nurse must suggest health-related topics that are appropriate for the family situation. For example, a young mother with a healthy newborn may not have thought about how to determine when her baby is ill. A spouse caring for his wife with Alzheimer disease may not know what safety precautions are necessary. Community/public health nurses seek to enhance family competence by sharing their professional knowledge with families and building on the family’s experience ( Reutter & Ford, 1997 ; SmithBattle, 2009 ). Flexibility is a key. Because visits occur over several days to months, other events (e.g., episodic illnesses, a neighbor’s death, community unemployment) can impinge on the original plan. Family members may be rehospitalized and receive totally new medical orders once they are discharged to home. The nurse’s clarity of purpose is essential in identifying and negotiating other health-related priorities after the first concerns have been addressed ( Monsen, Radosevich, Kerr, & Fulkerson, 2011 ). Increasing nurse–family relatedness What promotes a successful home visit? What aspects of the nurse’s presence promote relatedness? What structures provide direction and flexibility? The nursing process provides a general structure, and communication is a primary vehicle through which the nursing process is manifested. The foundation for both the nursing process and communication is relatedness and caring ( ANA, 2003 ; McNaughton, 2005 ; Roach, 1997 ; SmithBattle, 2009 ; Watson, 2002 ; Watson, 2005 ). Fostering a Caring Presence Nursing efforts are not always successful. However, by being concerned about the impact of home visits on the family and by asking questions regarding her or his own motivations, the nurse automatically increases the likelihood that home visits will be of benefit to the family. The nurse is acknowledging that the intention is for the relationship to be meaningful to both the nurse and the family. Building and preserving relationships is a central focus of home visiting and requires significant effort ( Heaman et al., 2007 ; McNaughton, 2000 , 2005 ). The relatedness of nurses in community health with clients is important ( Goldsborough, 1969 ; SmithBattle, 2009 ; Zerwekh, 1992 ). Involvement, essentially, is caring deeply about what is happening and what might happen to a person, then doing something with and for that person. It is reaching out and touching and hearing the inner being of another…. For a nurse–client relationship to become a moving force toward action, the nurse must go beyond obvious nursing needs and try to know the client as a person and include him in planning his nursing care. This means sharing feelings, ideas, beliefs and values with the client…. Without responsibility and commitment to oneself and others…[a person] only exists. It is through interaction and meaningful involvement with others that we move into being human ( Goldsborough, 1969 , pp. 66-68). Mayers (1973, p. 331) observed 16 randomly selected nurses during home visits to 37 families and reported that “regardless of the specific interaction style [of each nurse], the clients of nurses who were client-focused consistently tended to respond with interest, involvement and mutuality.” A client-focused nurse was observed as one who followed client cues, attempted to understand the client’s view of the situation, and included the client in generating solutions. Being related is a contribution that the nurse can make to the family, independent of specific information and technical skills, a contribution that students often underestimate. Although being related is necessary, it is inadequate in itself for high-quality nursing. A community/public health nurse must also be competent. Community/public health nursing also depends on assessment skills, judgment, teaching skills, safe technical skills, and the ability to provide accurate information. As a community/public health nurse’s practice evolves, tension always exists between being related and doing the tasks. In each situation, an opportunity exists to ask, “How can I express my caring and do (perform direct care, teach, refer) what is needed?” Barrett (1982) and Katzman and colleagues (1987) reported on the differences that students actually make in the lives of families. Barrett (1982) demonstrated that postpartum home visits by nursing students reduced costly postpartum emergency department and hospital visits. Katzman and co-workers (1987) considered hundreds of visits per semester made by 80 students in a southwestern state to families with newborns, well children, pregnant women, and members with chronic illnesses. Case examples describe how student enthusiasm and involvement contributed to specific health results. Everything a nurse has learned about relationships is important to recall and transfer to the experience of home visiting. Carl Rogers (1969) identified three characteristics of a helping relationship: positive regard, empathy, and genuineness. These characteristics are relevant in all nurse–client relationships, and they are especially important when relationships are initiated and developed in the less-structured home setting. Presence means being related interpersonally in ways that reveal positive regard, empathy, genuineness, and caring concern. How is it possible to accept a client who keeps a disorderly house or who keeps such a clean house that you feel as if you are contaminating it by being there? How is it possible to have positive feelings about an unmarried mother of three when you and your partner have successfully avoided pregnancy? Having positive regard for a family does not mean giving up your own values and behavior (see Chapter 10 ). Having positive regard for a family that lives differently from the way you do does not mean you need to ignore your past experiences. The latter is impossible. Rather, having positive regard means having the ability to distinguish between the person and her or his behavior. Saying to yourself, “This is a person who keeps a messy house” is different from saying, “This person is a mess!” Positive regard involves recognizing the value of persons because they are human beings. Accept the family, not necessarily the family’s behavior. All behavior is purposeful; and without further information, you cannot determine the meaning of a particular family behavior. Positive regard involves looking for the common human experiences. For example, it is likely that both you and client family members experience awe in the behavior of a newborn and sadness in the face of loss. Empathy is the ability to put yourself in someone else’s shoes and to be able to walk in her or his footsteps so as to understand her or his journey. “Empathy requires sensitivity to another’s experience…including sensing, understanding, and sharing the feelings and needs of the other person, seeing things from the other’s perspective” according to Rogers (cited in Gary & Kavanagh, 1991 , p. 89). Empathy goes beyond self and identity to acknowledge the essence of all persons. It links a characteristic of a helping relationship with spirituality or “a sense of connection to life itself” ( Haber et al., 1987 , p. 78). Empathy is a necessary pathway for our relatedness. However, what does understanding another person’s experience mean? More than emotions are involved. A person’s experience includes the sense that she or he makes of aspects of human existence ( SmithBattle, 2009 ; van Manen, 1990 ). Being understood means that a person is no longer alone ( Arnold, 1996 ). Being understood provides support in the face of stress, illness, disability, pain, grief, and suffering. When a client feels understood in a nurse–client partnership (side-by-side relationship), the client’s experience of being cared for is enhanced ( Beck, 1992 ). To understand another person’s experience, you must be able to imagine being in her or his place, recognize commonalities among persons, and have a secure sense of yourself ( Davis, 1990 ). Being aware of your own values and boundaries is helpful in retaining your identity in your interactions with others. To understand another individual’s experience, you must also be willing to engage in conversation to negotiate mutual definitions of the situation. For example, if you are excited that an older person is recovering function after a stroke, but the person’s spouse sees only the loss of an active travel companion, a mutual definition of the situation does not exist. Empathy will not occur unless you can also understand the spouse’s perspective. As human beings, we all like to perceive that we have some control in our environment, that we have some choice. We avoid being dominated and conned. The nurse’s genuineness facilitates honesty and disclosure, reduces the likelihood that the family will feel betrayed or coerced, and enhances the relationship. Genuineness does not mean that you speak everything that you think. Genuineness means that what you say and do is consistent with your understanding of the situation. The nurse can promote genuine self-expression in others by creating an atmosphere of trust, accepting that each person has a right to self-expression, “actively seeking to understand” others, and assisting them to become aware of and understand themselves ( Goldsborough, 1969 , p. 66). When family members do not believe that being genuine with the nurse is safe, they may tell only what they think the nurse would like to hear. This action makes developing a mutual plan of care much more difficult. The reciprocal side of genuineness is being willing to undertake a journey of self-expression, self-understanding, and growth. Tamara, a recent nursing graduate, wrote about her growing self-responsibility: “Although I felt out of control, I felt very responsible. I took pride in knowing that these families were my families, and I was responsible for their care. I was responsible for their health teaching. This was the first semester where there was no a faculty member around all day long. I feel that this will help me so much as I begin my nursing career. I have truly felt independent and completely responsible for my actions in this clinical experience.” This student, who preferred predictable environments, was able to confront her anxiety and anger in environments in which much was beyond her control. A mother was not interested in the student’s priorities. A family abruptly moved out of the state in the middle of the semester. Nonetheless, the student was able to respond in such circumstances. She became more responsible, and she was able to temper her judgment and work with the mother’s concern. When the family moved, the student experienced frustration and anger that she would not see the “fruits of her labor” and that she would “have to start over” with another family. However, her ability to respond increased because of her commitment to her own growth, relatedness with families, and desire to contribute to the health and well-being of others. In a context of relating with and advocating for the family, the relationship becomes an opportunity for growth in both the nurse’s and the family’s lives ( Glugover, 1987 ). Imagine standing side-by-side with the family, being concerned for their well-being and growth. Now imagine talking to a family face-to-face, attempting to have them do things your way. The first image is a more caring and empathic one. Creating Agreements for Relatedness How can communications be structured to increase the participation of family members? Without the family’s engagement, the community/public health nurse will have few positive effects on the health behavior and health status of the family and its members. Nurses are expert in caring for the ill; in knowing about ways to cope with illness, to promote health, and to protect against specific diseases; and in teaching and supporting family members. Family members are experts in their own health. They know the family health history, they experience their health states, and they are aware of their health-related concerns. Through the nurse–family relationship, a fluid process takes place of matching the family’s perceived needs with the nurse’s perceptions and professional judgments about the family’s needs. Paradoxically, the more skilled the nurse is in forgetting her or his own anxiety about being the good nurse, the more likely the nurse is to listen to the family members, validate their reality, and negotiate an adequate, effective plan of care. One study of home visits revealed that more than half of the goals stated by public health nurses to the researcher could not be detected, even implicitly, during observations of the home visits. Therefore, half the goals were known only to the nurse and were, therefore, not mutual. The more specifically and concretely the goals were stated by the nurse to the researcher, the greater would be the likelihood that the clients understood the nurse’s purposes ( Mayers, 1973 ). To negotiate mutual goals, the client needs to understand the nurse’s purposes. The initial letter, telephone call, or home visit is the time to share your ideas with the family about why you are contacting them. During the first interpersonal encounter by telephone or home visit, explore the family members’ ideas about the purpose of your visits. This phase is essential in establishing a mutually agreed on basis for a series of encounters. As a result of her qualitative research study of maternal-child home visiting, Byrd (2006, p. 271) stated that “people enter…relationships with the expectation of receiving a benefit” that may be information, status, service, or goods. Byrd asserted that it is important for nurses to create client expectations through previsit publicity about (marketing) home-visiting programs. Also it is essential to understand the expectations of the specific persons being visited. Family members may have had previous relationships with community/public health nurses and students. Family members may be able to share such information as what they found to be most helpful, why they are willing to work with a nurse or student again, and what goals they have in mind. Other families who have had no prior experience with community/public health nurses may not have specific expectations. Asking is important. A contract is a specific, structured agreement regarding the process and conditions by which a health-related goal will be sought. In the beginning of most student learning experiences, the agreement usually entails one or more family members continuing to meet with the nursing student for a specific number of visits or weeks. Initially, specific goals and the nurse’s role regarding health promotion and illness prevention may be unclear. (If this role was already clear, undergoing a period of study and orientation would be unnecessary.) Initially, the agreement may be as simple as, “We will meet here at your house next Tuesday at 11:00  AM until around noon to continue to discuss what I can offer related to your family’s health and what you’d like. We can get to know each other better. We can talk more about how the week has gone for you and your family with your new baby.” These statements are the nurse’s oral offer to meet under specific conditions of time and place. The process of mutual discussion is mentioned. The goals remain general and implicit: fostering the family’s developmental task of incorporating an infant and fostering family–nurse relatedness. For the next week’s contract to be complete, the family member or members would have to agree. The most important element initially is whether agreement about being present at a specific time and place can be reached. If 11:00  AM is not workable for the family, would another time during the day when you both are available be mutually agreeable? For families who do not focus as much on the future, a community/public health nurse needs to be more flexible in scheduling the time of each visit. The word contract often implies legally binding agreements. This is not true of nurse–client contracts. Nurses are legally and ethically bound to keep their word in relation to nursing care; clients are not legally bound to keep their agreements. However, establishing a mutual agreement for relating increases the clarity of who will do what, when, where, for what purposes, and under what conditions. Because of some people’s negative response to the word contract, agreement or discussion of responsibilities may be better. An agreement may be oral or written. For some families, written agreements, especially early in the relationship, may be perceived as a threat. For example, a family that has been conned by a household repair scheme may be very suspicious of written agreements. Family members who are not legal citizens may not want to sign an agreement for fear that if it is not kept they will be punished. Do not push for a written agreement if the family is uncomfortable. If you do notice such discomfort, this may be a good opportunity to explore their fears. Written agreements are required when insurance is paying for the care provided by nurses working with home health agencies and to comply with the Health Insurance Portability and Accountability Act (HIPAA). Helgeson and Berg (1985) describe factors affecting the contracting process by studying a small convenience sample of 15 community/public health nursing students and 12 client responses. Of the 11 students who introduced the idea of a contract to clients, all did so between the second and the fourth visits of a 16-week series of visits; 9 students did so orally rather than in writing. No specific time was the best. Eight clients were very receptive to the idea because they liked the idea of establishing goals to work toward and felt the contract would serve as a reminder of their responsibility. The very process of developing a draft agreement to present to families provides the novice practitioner with an increased focus of care, clarity of nurse and family responsibilities and activities, and a basis from which to negotiate modifications in client behaviors ( Helgeson & Berg, 1985 ; Sheridan & Smith, 1975 ). The Home Visiting Evaluation Tool in Figure 11-3 lists nurse behaviors that are appropriate for home visits, especially initial home visits and those early in a series of home visits. Nurses can use this list as a preplanning tool to identify their readiness to conduct a specific home visit. Additionally, students and community/public health nurses have used the tool to evaluate initial home visits and identify their behaviors that were omitted and needed to be included on the second home visits. The tool also has been used jointly as an evaluation tool by nurses and supervisors and students and faculty. Figure 11-3 Home Visiting Evaluation Tool. (From Chichester, M., & Smith, C. [1980]. Home visiting evaluation tool [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.)

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Why Home Visiting?

The evidence base for home visiting, including its cost effectiveness, is strong and growing. Below are examples of home visiting's demonstrated impact on critical needs and why home visiting is a key service strategy for improving infant, maternal, and family outcomes.

Home visiting has measurable benefits.

By meeting families where they are, home visiting programs have demonstrated short- and long-term impacts on the health, safety, and school-readiness of children; maternal health; and family stability and financial security. Home visitors are able to meet with families in their home and provide culturally competent, individualized needs assessments and services. This results in measured improvements in the following outcomes:

Healthy Babies 

Home visitors work with expectant mothers to access prenatal care and engage in healthy behaviors during and after pregnancy. For example—

• Pregnant participants are more likely to access prenatal care and carry their babies to term.
• Home visiting promotes infant caregiving practices like breastfeeding, which has been associated with positive long-term outcomes related to cognitive development and child health.

Safe Homes and Nurturing Relationships 

Home visitors provide caregivers with knowledge and training to reduce the risk of unintended injuries. For example—

• Home visitors teach caregivers how to “baby proof” their home to prevent accidents that can lead to emergency room visits, disabilities, or even death.
• They also teach caregivers how to engage with children in positive, nurturing ways, thus reducing child maltreatment .

Optimal Early Learning and Long-Term Academic Achievement

Home visitors offer caregivers timely information about child development and the importance of early childhood in establishing the building blocks for life. For example—

• They help caregivers recognize the value of reading and other activities for early learning. This guidance translates to improvements in children’s early language and cognitive development, as well as academic achievements in grades 1 through 3 .

Supported Families

Home visitors make referrals and coordinate services for children and caregivers, including job training and education programs, early care and education services, and— if needed—mental health and domestic violence resources. Research shows that—

• Compared with their counterparts, caregivers enrolled in home visiting have higher monthly incomes, are more likely to be enrolled in school , and are more likely to be employed .

Home visiting is cost effective.

Studies have found a return on investment of $1.80 to $5.70 for every dollar spent on home visiting. This strong return on investment is consistent with established research on other types of early childhood interventions.

Learn more in our Primer and annual Yearbook .

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History and Development of Home Visiting in the United States

Social justice movements before 1950, the war on poverty and prevention of child maltreatment, expansion of home visiting in recent decades, home visiting outside the united states, poverty, child health, and home visiting, national evaluation and evidence of effectiveness, home visiting and the medical home, recommendations and position statement, community pediatricians, large health systems, managed care organizations, and accountable care organizations, researchers, the aap endorses and promotes the following general policy positions and advocacy strategies:, conclusions.

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• Council on community Pediatrics Executive Committee, 2016–2017
• Council on Early Childhood Executive Committee, 2016–2017
• Committee on Child abuse and Neglect, 2016–2017

Early Childhood Home Visiting

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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James H. Duffee , Alan L. Mendelsohn , Alice A. Kuo , Lori A. Legano , Marian F. Earls , COUNCIL ON COMMUNITY PEDIATRICS , COUNCIL ON EARLY CHILDHOOD , COMMITTEE ON CHILD ABUSE AND NEGLECT , Lance A. Chilton , Patricia J. Flanagan , Kimberley J. Dilley , Andrea E. Green , J. Raul Gutierrez , Virginia A. Keane , Scott D. Krugman , Julie M. Linton , Carla D. McKelvey , Jacqueline L. Nelson , Emalee G. Flaherty , Amy R. Gavril , Sheila M. Idzerda , Antoinette “Toni” Laskey , John M. Leventhal , Jill M. Sells , Elaine Donoghue , Andrew Hashikawa , Terri McFadden , Georgina Peacock , Seth Scholer , Jennifer Takagishi , Douglas Vanderbilt , Patricia G. Williams; Early Childhood Home Visiting. Pediatrics September 2017; 140 (3): e20172150. 10.1542/peds.2017-2150

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High-quality home-visiting services for infants and young children can improve family relationships, advance school readiness, reduce child maltreatment, improve maternal-infant health outcomes, and increase family economic self-sufficiency. The American Academy of Pediatrics supports unwavering federal funding of state home-visiting initiatives, the expansion of evidence-based programs, and a robust, coordinated national evaluation designed to confirm best practices and cost-efficiency. Community home visiting is most effective as a component of a comprehensive early childhood system that actively includes and enhances a family-centered medical home.

Recent advances in program design, evaluation, and funding have stimulated widespread implementation of public health programs that use home visiting as a central service. This policy statement is an update of “The Role of Preschool Home-Visiting Programs in Improving Children’s Developmental and Health Outcomes” (2009) and summarizes salient changes, emphasizes practical recommendations for community pediatricians, and outlines important national priorities intended to improve the health and safety of children, families, and communities. 1 By promoting child development, early literacy, school readiness, informed parenting, and family self-sufficiency, home visiting presents a valuable strategy to buffer the effects of poverty and adverse early childhood experiences that influence lifelong health.

The term “home visiting” refers to an evidence-based strategy in which a professional or paraprofessional renders a service in a community or private home setting. Home visiting also refers to the variety of programs that employ home visitors as a central component of a comprehensive service plan. 2 Early childhood home-visiting programs may be focused on young children, children with special health care needs, parents of young children, or the relationship between children and parents, and they can use a 2-generational strategy to simultaneously address parental and family social and economic challenges. 3  

Home-visiting programs vary widely with regard to target populations and goals. Many successful home-visiting models are directed toward mothers and infants in high-risk groups, such as adolescent mothers and single-parent families. Other models concentrate on specific populations, such as recently incarcerated adolescents, children with special needs, or immigrants. Some programs are designed to identify risk factors, such as environmental hazards and maternal mental health, but others include mentoring, coaching, and other therapeutic interventions. Many employ independently licensed health professionals, but others depend on trained paraprofessionals (including community health workers) drawn from the communities they serve. Community-based care coordination (including housing, transportation, and nutritional support) often are service components. Integration with the family-centered medical home (FCMH) has been a recent focus for program improvement and medical education. 4  

Home visiting began in the United States in the 1880s as an activity of each of 3 social justice movements. Derived from the British models developed a few decades earlier, home visitors were deployed to promote universal kindergarten, improve maternal-infant health through public health nursing, and support impoverished immigrant communities as part of the philanthropic settlement house movement. From the late 19th through the early 20th century, teachers and public health nurses visited communities and families to provide in-home education and health care to urban women and children. These efforts were based on the assumptions still held that education is the most powerful strategy to lift children out of poverty and that the lifelong health of families in immigrant and poor neighborhoods is improved by addressing the social and economic aspects of health and disease. 5  

From the Great Depression through World War II, funding for social initiatives decreased and philanthropic support for home visitors declined. After the relatively prosperous postwar period, renewed interest developed in antipoverty activities, including home visiting, especially in the context of the Civil Rights Movement. In the 1960s, home visiting became an important component of the government’s so-called War on Poverty. Home visiting was and remains integral to programs such as Head Start, although it is applied on a limited basis compared with Early Head Start, for which home visiting is a central service component. A decade later, many home-visiting programs shifted to include case management, intending to help families achieve self-sufficiency and link them to other broad community support services. 6 Improving school readiness, moderating poverty-related social risk determinants, reducing environmental safety hazards, and promoting population-based health remain core goals of contemporary home visiting.

In the last quarter of the 20th century, home visiting gained renewed attention as a strategy for the prevention of child abuse and neglect, promotion of child development, and improvement of parental effectiveness. C. Henry Kempe, MD, called for a home visitor for every pregnant mother and preschool-aged child in his 1978 Abraham Jacobi Memorial Award address. 7 He suggested that integral to every child’s right to comprehensive care is the assignment of a home health visitor to work with the family until each child began school. The visionary pediatrician who developed the concept of the medical home, Cal Sia, MD, reiterated Kempe’s call to action in his 1992 Jacobi Award address 8 based on his experience with Hawaii’s Healthy Start Program, which is an innovative, statewide home-visiting initiative to prevent child abuse and neglect. Another pioneer in modern home visiting, David Olds, PhD, initiated the Nurse-Family Partnership (NFP) with families at risk in Elmira, New York, in 1978. 1  

Before 2009, at least 22 states recognized the critical role of home visitors within statewide systems for at-risk pregnant mothers, infants, and toddlers from birth to 5 years old. States legislated funding for home-visiting programs while insisting on proof of effectiveness, fiscal accountability, and continuous quality improvement. Even during the Great Recession that followed the US financial crisis of 2007 to 2008, some state governments enacted home-visiting legislation to ensure long-term sustainability through innovative financing mechanisms and the strategic allocation of limited public resources.

In 2009, the American Recovery and Reinvestment Act (Public Law Number 111-5) included $2.1 billion for the expansion of Head Start and Early Head Start (including the home-visiting components of Early Head Start) to benefit young children in low-resource communities. The next year, the Patient Protection and Affordable Care Act of 2010 (ACA) (Public Law Number 111-148) designated $1.5 billion, allocated over 5 years, for the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV). The Health Resources and Services Administration currently administers the MIECHV in collaboration with the Administration for Children and Families. The allocations to states, territories, and tribal entities are designed to support the implementation and evaluation of evidence-based home-visiting programs regarding specified goals and objectives. All 50 states, the District of Columbia, and 5 US territories have home-visiting programs. 9 In addition, ACA funding provides support for home-visiting initiatives to serve American Indian and Alaskan native children through the Tribal MIECHV program. 10  

Nineteen home-visiting models have met the criteria of the US Department of Health and Human Services (HHS) for evidence of effectiveness through the Home Visiting Evidence of Effectiveness (HomVEE) review. Supported by federal grants through the MIECHV, states receive funding to implement 1 or more evidence-based models designated eligible by the MIECHV that best meet the needs of particular at-risk communities. The program objectives must improve outcomes that are statutorily defined and must include increased family economic self-sufficiency, improved health indicators (eg, a reduction in health disparities) in target populations, and improved school readiness. After 2013, potential program outcomes were expanded to include reductions in family violence, juvenile delinquency, and child maltreatment. 11 A review of 4 common programs illustrates the range of measurable outcomes. Healthy Families America identifies family self-sufficiency as a principal objective measured by a reduction of dependence on public assistance. 12 Early Head Start and other home-visiting programs focus on the promotion of child development and positive family relationships. NFP is designed to improve prenatal health, maternal life course development, and positive parenting. 13 Parents as Teachers promotes child development and school readiness. 14  

Home visiting for families with young children is an early intervention strategy in many industrialized nations outside of the United States. In several European countries, home health visiting is provided at no cost to the family, participation is voluntary, and the service is embedded in a comprehensive maternal and child health system. 3 While visiting young mothers at home, public health nurses in other countries provide many child health-promotion services that are provided by pediatricians in the United States. For instance, Denmark established home visiting in 1937 after a pilot program showed lower infant mortality rates linked with the services of home visitors. France provides universal prenatal care and home visits by midwives and nurses, who educate families about smoking, nutrition, drug use, housing, and other health-related issues.

The Early Start program in New Zealand targets families with 2 or more risk factors on an 11-point screening measure that includes parent and family functioning. Randomized controlled trials showed improvement in access to health care, lower hospitalization rates for injuries and poisonings, longer enrollment in early childhood education, and more positive and nonpunitive parenting. 15 , 16 The Dutch NFP program, VoorZorg, was found to reduce victimization and perpetration of self-reported intimate partner violence during pregnancy and 2 years after birth among low-educated, pregnant young women, 17 and there were fewer reports of child abuse. At 24 months, measurable improvements were evident in the home environments of participating families, and the children exhibited a significant reduction in internalizing symptoms. 18  

Paraprofessionals (ie, trained but unlicensed lay people) are often employed as home visitors in low-resource areas of the world. In Haiti, for example, community health workers trained by Partners in Health improve the care of those with HIV, multidrug-resistant tuberculosis, and such waterborne illnesses as cholera. In southern Mexico and other areas in Central America, “promotoras de salud,” or community health workers, coordinate with lay midwives to care for expectant mothers in rural, isolated, and other low-resource regions. Promotoras are deployed in many regions in the United States and have been recognized by HHS for their ability to reduce barriers and improve access to culturally informed and linguistically appropriate health care. 19  

More than 1 in 5 young children in the United States live in families with incomes below the federal poverty level, and more than 2 in 5 live at less than twice that level. 20 Living at or below 200% of the federal poverty level places children, 21 especially infants and toddlers, at high risk for adverse early childhood experiences that lead to lifelong detrimental effects on health, education, and vocational success. 22 Home visitors can help families attain economic self-sufficiency by linking them to community support services (such as quality preschool) while encouraging parents to enroll in training opportunities that lead to employment. Although they differ in structure, targeted populations, and intended outcomes, high-quality home-visiting programs deliver family support and child development services that provide a foundation for physical health, academic success, and economic stability in vulnerable families that are at risk for the adverse effects of poverty and other negative social determinants of health.

By applying multigenerational interventions, home visiting may improve child health and family wellbeing in many domains. Individual neuroendocrine-immune function, behavioral allostasis, and relational health are all established in the first 3 years of life, 23 when home visiting is most often applied. 24 The emerging science of toxic stress indicates that poverty and its accompanying problems, such as food insecurity, may disrupt the architecture and function of the developing brain. 25 , 26 Home visitors have the opportunity to assess risk and protective factors in families, identify potential adversity, and intervene at the earliest opportunity. By promoting supportive relationships, reducing parental stress, and increasing the likelihood of positive experiences, home visiting may help avoid the deleterious behavioral and medical health outcomes associated with child poverty. 27 , – 31  

Young mothers in poverty disproportionately suffer moderate to severe symptoms of maternal depression, elevating the risk of poor developmental and educational outcomes for their children. 32 Almost 1 in 4 mothers who are near or below the federal poverty level experience significant depression, but few obtain appropriate treatment. In-home cognitive behavioral therapy is a novel treatment modality for maternal depression that has proved to be effective in early trials. 33 Combining in-home cognitive behavioral therapy with other home-visiting programs, such as Early Head Start, that promote positive parenting and infant development provides a model of 2-generational care that has the potential to mitigate the effects of poverty and improve both family financial stability and school readiness. 34  

Home-visiting programs are most effective when they are components of a community-level, comprehensive early childhood system that reaches families as early as possible with needed services, accommodates children with special needs, respects the cultures of the families in the communities, and ensures continuity of care in a continuum from prenatal life to school entry. 35 , 36 An early childhood system may include safety-net resources (such as supplemental food and subsidies for housing, heating, and child care), adult education, job training, cash assistance, quality child care, early childhood education, and preventive health services. 37 Communicating the strengths and risk factors of individual families to the FCMH may further increase the coordination of care and efficient use of services. 38  

When the MIECHV program was established by the ACA, HHS established the HomVEE review of the research literature on home visiting. 11 Results of that review are used to identify home-visiting service delivery models that meet HHS criteria for evidence of effectiveness because, by statute, at least 75% of the funds available from the ACA are to be used for programs that use service delivery models that are evidence based. The HomVEE conducts a yearly literature search to identify promising studies of home-visiting models. It includes only studies that are considered to meet quality standards on the basis of overall design (only randomized controlled trials or quasiexperimental studies are included) and design-specific criteria. Studies that meet criteria for entry are then assessed for outcomes in the following 8 domains, as defined by HHS:

Child health;

Maternal health;

Child development and school readiness;

Reductions in child maltreatment;

Reductions in juvenile delinquency, family violence, and crime;

Positive parenting practices;

Family economic self-sufficiency; and

Linkages and referrals.

To meet HHS criteria for evidence of effectiveness, home-visiting models must demonstrate favorable outcomes in either 1 study with results in 2 or more domains or 2 studies with significant benefits in the same domain. To be included, study designs must meet evaluation quality standards, and outcomes need to show statistically significant benefits using nonoverlapping analytic samples. As of April 2017, the 18 models that meet these standards (along with 2 programs that do not meet criteria for implementation) with target populations, ages of participants, and outcomes for which there is evidence are listed in Table 1 . 11  

Home-Visiting Programs Meeting HHS Criteria for Evidence of Effectiveness (as of April 2017)

Reference: https://www.mathematica-mpr.com/our-publications-and-findings/publications/home-visiting-evidence-of-effectiveness-review-executive-summary-april-2017 . Descriptions of specific home-visiting programs by state can be accessed at: https://homvee.acf.hhs.gov/models.aspx .

Outcomes: (1) child health; (2) maternal health; (3) child development and school readiness; (4) reductions in child maltreatment; (5) reductions in juvenile delinquency, family violence, and crime; (6) positive parenting practices; (7) family economic self-sufficiency; and (8) linkages and referrals.

A rapidly expanding evidence base documents the benefits of high-quality home-visiting programs, especially when they are integrated in a comprehensive early childhood system of care. 39 Home visiting has been shown to increase children’s readiness for school, promote child health (such as vaccine rates), and enhance parents’ abilities to promote their children’s overall development. There is evidence that home visiting reduces the risk of both child abuse and unintended injury. 16 , 40 Maternal health is improved by more frequent prenatal care, better birth outcomes, and early detection and treatment of depression. 41 Outcome studies have established the effectiveness of home visiting by nurses or community health workers in reducing child maltreatment, 42 improving birth outcomes, 43 and increasing school readiness. 44  

A close examination of the evidence of effectiveness published in 2015 by the HomVEE review provides additional insights about the potential benefits and limitations of current models of home visiting. 11 Of the 44 models assessed in 2015, 19 showed improvements in at least 1 primary outcome measure, and 15 had favorable effects on secondary measures. These results are consistent with both the broad scope of many of the models as well as the likelihood that improvements in 1 domain sometimes lead to benefits in another (eg, positive parenting improving child development). All 19 models that showed positive results had evidence of sustained benefits for at least 1 year after enrollment.

In addition to the 19 models approved in 2015, 8 of the 25 that were not approved had evidence of benefit, perhaps because of stringent criteria for study quality and number. Even among programs showing positive outcomes, there was not a high level of consistency across domains. For example, only 7 of 19 models demonstrated benefits in the same domain across 2 or more studies. Many effect sizes were fairly small (approximately 0.2 SDs) but comparable to those seen in many studies of programs located in other settings (eg, early child education). 45 However, modest effect sizes in studies concerning developmental delay can result in important population-level effects given the high proportion of children in low-income families (nearly 20%) meeting criteria for early intervention services. 46 , 47  

Longitudinal studies within the HomVEE review of the NFP have shown improvements in adolescent mental health, in middle school achievement, over substance use and/or criminality immediately after high school, as well as in overall maternal and child mortality. 48 , – 50 Other studies document the persistence of beneficial outcomes after population-level scaling. A study of Durham Connects (also known as Family Connects) showed more than 80% participation and 84% adherence among all mothers delivering in Durham, North Carolina, during an 18-month period. 51 Researchers in this study, using rigorous methodology, documented important and beneficial effects on child health, including a 59% reduction in emergency medical care, an increase in positive parenting, successful linkages to community services, and improved maternal mental health. In addition, a large-scale study of SafeCare home-based services showed reductions in reports to child protective services after a scale-up of the program in Oklahoma. 52 These beneficial outcomes of rigorous program evaluation counterbalance other studies that found little or no benefit after a scale-up, such as the finding of reduced implementation fidelity and limited benefit after scaling up Hawaii’s Healthy Start Program. 53  

Other studies document the capacity of home visiting to successfully target specific high-risk populations and implement interventions of varying intensity specific to the intended outcome. For example, Computer-Assisted Motivational Intervention, when applied in combination with home visiting, successfully reduced subsequent pregnancies among pregnant teenagers. 54 Other 2-generational interventions, including Family Spirit (which targets American Indian teen-aged mothers) and Family Check-Up (which targets young mothers with depression), improved behavioral problems in infants and young children as well as the mental health of the young mothers. 55 , – 57  

Finally, the outcomes documented by the HomVEE need to be considered in the context of a number of meta-analyses and systematic reviews that have been conducted other than the HomVEE. One of the most cited is a meta-analysis that documented significant benefits across 4 broad domains, including child development, child abuse prevention, childrearing, and maternal life course. 58 Benefits were maximized when specific rather than general populations were targeted, when interventions used professionals versus paraprofessionals, and when interventions were more specifically focused on parental rather than child wellbeing. 59 , – 61  

Integration of home visiting with the medical home expands the multidisciplinary team into the community, enhancing the goals of communication, coordination of care, and comprehensive care. With effective leadership, the pediatric or FCMH may become a community hub that connects early education and child development activities with health promotion to support maximum outcomes for children and families. The Institute for Healthcare Improvement has described the triple aim as improvement of the health of populations, improvement of the quality of care and experience of each patient, and the reduction of per capita cost. The history of home visiting also reveals another triple aim of improving health, preparing children for education, and reducing poverty. An advanced medical home that reaches out to the community by collaborating with or integrating a high-quality home-visiting program has the potential of meeting both sets of triple aims. 62 , 63  

Some important factors that are common among home-visiting programs that are also characteristic of an FCMH include an emphasis on relationships, the provision of culturally informed care, coordination with other community support agencies, an emphasis on strength-based assessments, and collaboration with families to support self-identified goals. Of particular importance is the relationship that develops between the visitor and the family engaging in a natural environment and the consequent improvement in the relationships among family members. 64 As more has been learned about toxic stress and its negative effect on the life trajectory, close and nurturing relationships have emerged as a most important protective factor. The home visitor can extend the support of the medical home into the community and provide an important link for the family to the relationship with a compassionate pediatric practitioner while improving family relational health. 65  

The integration or colocation of home visiting with the medical home presents many opportunities for synergy and collaboration. The joint statement from the Academic Pediatric Association and the American Academy of Pediatrics (AAP) regarding integration of the FCMH with home visiting emphasizes the potential for coordinated anticipatory guidance, improved early detection, and enhanced community involvement. 66 Recommendations in the joint statement include integrated, computerized record systems; the creation of a joint registry; coverage of home visiting by payers, including Medicaid and the Children’s Health Insurance Program; and supporting the evaluation of coordination between an FCMH and home visiting. In a collaborative model, referrals between a pediatric practitioner and the home visitor may constitute a warm handoff (face-to-face introduction), increasing the likelihood that family concerns are communicated and addressed. For example, a home visitor has the opportunity to complete developmental screening with the parent in a child’s natural environment. The results of screening may be communicated to the pediatric practitioner for use and comparison with the developmental assessment during health-promotion visits. A shared chronic condition care plan facilitates common therapeutic goals, linkages to community resources, and follow-up on referrals. Particularly helpful have been home-visiting strategies for children with diabetes or asthma. Researchers have associated home visiting with improvements in symptoms, urgent care use, and family quality of life. 67  

Home visiting may be used effectively as an adjunctive strategy in comprehensive community-based programs serving children. Although not approved for MIECHV funding, Healthy Steps for Young Children is a comprehensive primary-care model that may include on the treatment team a home visitor who supports positive parenting, provides in-home developmental assessment, and links the family more strongly to the medical home. 68 The example of Healthy Steps illustrates the significant potential benefits from improved collaboration between the medical home and community home-visiting programs. These include common documentation, centralized intake services, strength-based assessments, colocation of home visitors in the pediatric practice, and multidisciplinary team meetings convened by the practice. Through these coordinated activities, home visitors are in partnership with the medical home to build parental resilience, promote child development, and support healthy family relationships. 66 , 69 Other models that similarly employ home visiting as an adjunctive strategy, such as the Health Resources and Services Administration’s Bridging the Word Gap Research Network 70 , 71 and the New York City Council’s City’s First Readers program, exemplify systematic linkages among the medical home, home-visiting programs, and other community-based services with early childhood education. 63 , 72  

Because home-visiting models and programs cross many health systems and involve many funding sources, this policy divides recommendations into the following 3 levels: community pediatricians, large health systems, and researchers. The section concludes with AAP-supported federal and state advocacy strategies.

Provide community-based leadership to promote home-visiting services to at-risk young mothers, children, and families;

Be familiar with state and local home-visiting programs and develop the capacity to identify and refer eligible children and pregnant mothers;

Consider opportunities to integrate or colocate home visitors in the FCMH;

Recognize home-visiting programs as an evidence-based method to enhance school readiness and reduce child maltreatment;

Recognize home visiting as a promising strategy to buffer the effects of stress related to the social determinants of health, including poverty; and

Serve as a referral source to home-visiting programs as a strategy to engage families in services and strengthen the connection between home visiting and the medical home.

Develop a continuum of early childhood programs that intersects or integrates with the FCMH;

Ensure that home-visiting programs are culturally responsive, linguistically appropriate, and family centered, emphasizing collaboration and shared decision-making;

Ensure that all home-visiting programs incorporate evidence-based strategies and achieve program fidelity to ensure effectiveness;

Support the use of trained community health workers, especially in lower-resourced, tribal, and immigrant communities; and

Develop training and certification programs for community health workers to ensure quality and fidelity to program expectations.

Improve understanding of how to engage difficult-to-reach and high-risk communities and populations, including immigrant families, families with low literacy and/or health literacy and limited English proficiency, families that are socially isolated, and families living in poverty in evidence-based home-visiting programs;

Improve understanding of how to take successful programs to scale while maintaining fidelity;

Improve understanding of how to optimize links between evidence-based home-visiting programs and the medical home;

Determine the degree to which the medical home and strategies using multidisciplinary and integrated interventions can provide added value to and synergy with evidence-based home-visiting programs;

Determine the degree to which home-visiting programs can augment the medical home in the prevention or mitigation of chronic disease, such as asthma and obesity, and associated morbidities;

Improve understanding of how to tailor the implementation of evidence-based home-visiting programs to diverse populations with heterogeneous strengths and challenges; and

Investigate and establish the cost-effectiveness and return on investment of home-visiting programs as well as program components.

The continuation and expansion of federal funding for evidence-based home-visiting programs;

Public support for the dissemination of home-visiting programs that meet the HomVEE criteria for evidence of effectiveness as well as other programs with early and promising evidence of potential effectiveness;

The establishment of state systems that integrate home-visiting infrastructure (such as data collection and evaluation) into a comprehensive early childhood service system;

Coordination across state agencies and health systems that serve young children to build an efficient and effective infrastructure for home-visiting programs;

The simplification and standardization of referral processes in and among states to improve the coordination of care and integration of home-visiting services with the medical home; and

The inclusion of home-visiting experience in community pediatrics education and exposure by residents and medical students to the evidence of effectiveness of home-visiting models.

The objectives of contemporary home-visiting programs have strong roots in public health, early childhood education, and antipoverty efforts. Home visiting has expanded rapidly in the recent past, with the current generation of programs providing strong evidence of effectiveness in many domains of family life. Rigorous national outcome evaluations substantiate that home-visiting programs are effective in the promotion of healthy family relationships, improvement of overall child development, prevention of child maltreatment, advancement of school readiness, and improvement of maternal physical and mental health. By linking families to opportunities such as employment and continuing education, home visiting increases family economic stability and thereby is a successful antipoverty strategy. Home-visiting programs have shown the most effectiveness when they are components of community-wide, early childhood service systems. With pediatrician leadership, the FCMH can serve as the hub for coordinating community-based, family support programs at the intersection of early education with public health promotion designed to help children avoid the lifelong effects of early childhood adversity.

American Academy of Pediatrcs

Patient Protection and Affordable Care Act

family-centered medical home

US Department of Health and Human Services

Home Visiting Evidence of Effectiveness

Maternal, Infant, and Early Childhood Home Visiting Program

Nurse-Family Partnership

Dr Duffee was intimately involved with the concept, organization, and design during the early phases of writing, he reviewed the contributions of the other authors, consolidated the contributions (along with his own) into the final product, took responsibility for responding to comments and direction from staff and the Board of Directors, and reviewed the references in detail to ensure that the evidence supports the recommendations; and Drs Kuo, Legano, Mendelsohn, and Earls assisted with revisions; and all authors approve the final manuscript as submitted.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

L ead A uthors

James H. Duffee, MD, MPH, FAAP

Alan L. Mendelsohn, MD, FAAP

Alice A. Kuo, MD, PhD, FAAP

Lori Legano, MD, FAAP

Marian F. Earls, MD, MTS, FAAP

Council on c ommunity Pediatrics Executive Committee , 2016–2017

Lance A. Chilton, MD, FAAP, Chairperson

Patricia J. Flanagan MD, FAAP, Vice Chairperson

Kimberley J. Dilley, MD, MPH, FAAP

Andrea E. Green, MD, FAAP

J. Raul Gutierrez, MD, MPH, FAAP

Virginia A. Keane, MD, FAAP

Scott D. Krugman, MD, MS, FAAP

Julie M. Linton, MD, FAAP

Carla D. McKelvey, MD, MPH, FAAP

Jacqueline L. Nelson, MD, FAAP

Jacqueline R. Dougé, MD, MPH, FAAP – Chairperson, Public Health Special Interest Group

Kathleen Rooney-Otero, MD, MPH – Section on Pediatric Trainees

Camille Watson, MS

Council on Early Childhood Executive Committee , 2016– 20 17

Jill M. Sells, MD, FAAP, Chairperson

Elaine Donoghue, MD, FAAP

Marian Earls, MD, FAAP

Andrew Hashikawa, MD, FAAP

Terri McFadden, MD, FAAP

Alan Mendelsohn, MD, FAAP

Georgina Peacock, MD, FAAP

Seth Scholer, MD, FAAP

Jennifer Takagishi, MD, FAAP

Douglas Vanderbilt, MD, FAAP

Patricia Gail Williams, MD, FAAP

Laurel Murphy Hoffmann, MD – Section on Pediatric Trainees

Barbara Sargent, PNP – National Association of Pediatric Nurse Practitioners

Alecia Stephenson – National Association for the Education of Young Children

Dina Lieser, MD, FAAP – Maternal and Child Health Bureau

David Willis, MD, FAAP – Maternal and Child Health Bureau

Rebecca Parlakian, MA – Zero to Three

Lynette Fraga, PhD – Child Care Aware

Charlotte Zia, MPH, CHES

Committee on Child a buse and Neglect , 2016–2017

Emalee G. Flaherty, MD, FAAP

Amy R Gavril, MD, FAAP

Sheila M. Idzerda, MD, FAAP

Antoinette “Toni” Laskey, MD, MPH, MBA, FAAP

Lori A. Legano, MD, FAAP

John M. Leventhal, MD, FAAP

Harriet MacMillan, MD – American Academy of Child and Adolescent Psychiatry

Elaine Stedt, MSW – Department of Health and Human Services Office on Child Abuse and Neglect

Beverly Fortson, PhD – Centers for Disease Control and Prevention

Tammy Hurley

Competing Interests

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• Open access
• Published: 06 December 2021

Effects of home visits on quality of life among older adults: a systematic review protocol

• Yea Lu Tay   ORCID: orcid.org/0000-0002-0150-2075 1 ,
• Nurul Salwana Abu Bakar 1 ,
• Ruzimah Tumiran 1 ,
• Noor Hasidah Ab Rahman 1 ,
• Noor Areefa Ameera Mohd Ma’amor 2 ,
• Weng Keong Yau 3 &
• Zalilah Abdullah 1  

Systematic Reviews volume  10 , Article number:  307 ( 2021 ) Cite this article

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Home visiting services for older adults have been offered for decades to maintain and promote health and independent functioning, thus enhancing quality of life. Previous systematic reviews have provided a mixed picture of the benefits of home visiting programmes in older adults, primarily because of heterogeneity in study designs, targeted populations, and intervention strategies. These reviews may also become out of date; thus, an updated synthesis of relevant studies is warranted. Our objective is to perform a systematic review of recently published primary studies on the effectiveness of multi-professional home visits on quality of life among older adults.

We will perform a comprehensive search for studies investigating the effect of a multi-professional home visit approach on quality of life among older adults. We will conduct the literature search in selected electronic databases and relevant research websites from January 2010 onwards. We will include randomised controlled trials (RCTs), cluster randomised controlled trials (cluster RCTs), and observational studies that enrolled older adults without dementia over 60 years old, along with studies involving multi-professional preventive–promotive home visit approaches not related to recent hospital discharge. We will report our planned review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We will retrieve and record relevant data in a standardised data extraction form and evaluate the quality of the included articles using the Cochrane risk of bias tool and the quality assessment tool for studies with diverse designs (QATSDD). Where appropriate, outcomes will be pooled for meta-analysis using a random-effects model. The main outcomes include quality of life, incidence of falls, depression, dementia, and emergency department admissions.

This review may provide evidence for the effectiveness of home visits in improving older adults’ quality of life. It will potentially benefit health care professionals, policymakers, and researchers by facilitating the design and delivery of interventions related to older generations and improve service delivery in future.

Systematic review registration

PROSPERO CRD42021234531 .

Peer Review reports

Population ageing is a global phenomenon. Most individuals expect to live into their sixties and beyond. The world population of adults aged 60 years and over is expected to nearly double from 12 to 22% between 2015 and 2050 [ 1 ]. In Malaysia, 20% of the total population will be over 65 years old by 2030 [ 2 ]. A recent study indicated that the life expectancy of Malaysian older adults aged 65 years was 79.8 and 82.1 years for males and females, respectively [ 3 ]. Despite the national census statistics defining older adults as those over the age of 65, Malaysia adopted the United Nations’ definition, classifying older adults as those aged 60 years and above for policy development regarding the older adult population [ 4 ]. The older adult population has a multitude of health needs and challenges, along with a deteriorating quality of life (QoL) [ 5 ].

According to the World Health Organization (WHO), QoL refers to “an individual’s perception of life in the context of the culture and value system in which he or she lives and in relation to his or her goals, expectations, standards, and concerns” [ 6 ]. QoL linked to health concepts is defined as the value assigned to the duration of life, modulated by limitations, functional status, perceptions, and social opportunities, which are influenced by diseases, injuries, treatments, and health policies [ 7 ]. QoL is increasingly recognised as a focus for healthcare service delivery in the older adult population. It allows the healthcare providers and policymakers to measure the efficacy of health interventions and evaluate multi-sectoral public policies, which include health, social, community, and policy actions [ 8 ].

Numerous healthcare interventions have been designed and implemented with the goal of maintaining or improving QoL among older adults, and most studies indicate the importance of active ageing. These studies have demonstrated that QoL among older adults can be enhanced through low-cost interventions, such as physical exercise [ 9 , 10 , 11 ]. Besides, older adults utilising the home visiting services were shown to have a better QoL outcome [ 12 , 13 ].

Home visits are defined as visits to an individual’s home by professionals, which may include nurses, social workers, physicians, physiotherapists, occupational therapists, pharmacists and other specialists [ 14 ]. There are five types of home visiting services: palliative, rehabilitative, long-term maintenance, therapeutic, and preventive–promotive home visits [ 15 ]. Preventive–promotive home visiting services have been offered for decades with the goal of maintaining and promoting the health and independent functioning of older adults. In addition, these services aim to reduce admission to hospitals or nursing homes and the associated economic burden [ 16 , 17 ].

Home visits allow health professionals to evaluate possible problems in the living environment of homebound older adults, assess their physical and mental health status, provide older adults with professional support, and refer them to specialist care if needed [ 17 ]. By reducing the risk of functional deterioration, these strategies are primarily structured to enhance the health-related QoL (HRQoL) of older adults, increase the possibility of continued independent living, and delay mortality [ 18 ].

Home visits have been shown to positively affect patient care and provider attitudes as well as increased satisfaction among homebound older adults and providers [ 19 ]. A previous study demonstrated that preventive home visits may have positive effects on QoL of older adults [ 20 ]. However, the variability in the study designs, participants, and outcome measures has made comparisons difficult. Liimata et al. (2019) conducted a randomised controlled trial (RCT) measuring the effects of preventative multidisciplinary home visits on HRQoL of older adults living independently. The team, which consisted of a nurse, a physiotherapist, and a social worker, observed a significantly slower decline of HRQoL in the intervention group, but this effect diminished after the visits ended [ 20 ]. In a separate publication from the same study, preventive home visits resulted in an improved HRQoL without incurring additional healthcare costs [ 21 ]. An effective prevention method aids in supporting quality of life among older adults. In a review on preventive home visits for older adults, Mayo-Wilson et al. (2014) analysed 64 RCTs involving older adults without dementia from database inception until December 2012. The study yielded high-quality evidence for decreasing falls but low-quality evidence for quality of life [ 22 ]. Thus, although an RCT demonstrated promising results on home visits, a review of multiple RCTs failed to observe significant results. In addition, although multi-professional preventive home visit approaches with thorough evaluation and collaboration among healthcare professionals may be more beneficial than home visits by a single professional, few studies have focused on this multi-professional preventive home visit approach [ 20 , 23 , 24 ].

Multi-professional preventive home visit interventions involve coordination between several health care professionals towards shared goals. Effective communication among the team members is crucial when the members work within the boundaries of their expertise and subsequently discuss progress in group sessions [ 25 ]. Previous systematic reviews have provided a mixed picture of the benefits of multi-professional home visiting services for older adults. Stuck et al. [ 26 ] and Touringy et al. [ 14 ] suggested that the multi-professional approach with follow-up visits was effective in identifying the needs of the older adult population. However, Mayo-Wilson et al. [ 22 ] demonstrated the challenges of concluding that preventive home visits result in reliable benefits, primarily due to variability in the study designs, participants, and intervention strategies of the preventive home visits approach.

In Malaysia, home visiting services for the older adult population are delivered by a multidisciplinary team and are primarily provided by the Ministry of Health [ 27 ]. The home visiting services offered in Malaysia include home-based treatment, pharmacy counselling, rehabilitation, and palliative services, which aim to ensure continuity of care at home, reduce hospital readmission, and improve QoL [ 28 , 29 ]. According to the National Health and Morbidity Survey (NHMS) 2018, a national community survey for elderly health in Malaysia, 28.6% of older adults perceived themselves as having poor QoL, 14.1% reported having at least one fall in the 12 months prior to the survey, 8.5% were diagnosed with dementia, and 11.2% were at risk of experiencing depressive symptoms [ 30 ]. Poor QoL in Malaysian older adults was found to be associated with lower education, depression, food insecurity, reduced functional status, and a lack of social support [ 31 ]. Hence, we seek to examine preventive–promotive strategies that specifically prevent or reduce the risk of developing dementia, depression, and falls, with the ultimate aim of improving QoL among the older adult population.

To our knowledge, the most recent systematic review of primary studies examining the multi-professional preventive home visit approach for older adults included studies conducted up to December 2012 [ 22 ]. Because the older adult population is rapidly growing, the number of studies describing the home visit intervention is increasing, and the methodological and reporting quality of these studies is improving. Hence, a comprehensive systematic review which includes recent studies is needed to provide new evidence on the effectiveness of multi-professional preventive–promotive home visits in improving QoL among older adults. This review may serve as a guideline for the healthcare professionals, policymakers, researchers, and institutions in designing and delivering interventions for older adults in future. Aligning health systems with the needs of the older adult population may help to promote healthy ageing in Malaysia in the long term.

This study aims to systematically assess the effect of a multi-professional home visit approach on QoL among older adults.

The present protocol has been registered within the PROSPERO database (registration number CRD42021234531) and is being reported in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement [ 32 , 33 ] (see checklist in Additional file 1).

Eligibility criteria

Types of studies.

Randomised controlled trials (RCTs), cluster randomised controlled trials (cluster RCTs), and observational studies (such as cohort, case-control, and cross-sectional studies) will be included. Quasi-randomised controlled trials (quasi-RCTs), which are often associated with a high risk of bias, and cross-over studies will be excluded. Case reports, guidelines, protocols, and short communication will also be excluded.

We will only include studies examining the older adults without dementia aged 60 years and above who reside in their own homes and receive treatment at primary care outpatient departments. We will exclude studies that involve older adults living in retirement homes or nursing homes.

Types of interventions

We will include studies that aim specifically to assess the following interventions:

Home visits which aim to prevent or reduce risks related to ageing

Home visits which utilise at least two of the following multidimensional approaches: medical, functional, psychosocial, and environmental evaluation of problems and resources, resulting in specific recommendations for solving observed problems and preventing new ones.

Types of outcome measures

Primary outcomes.

We will measure QoL using validated scales such as the WHO QoL Questionnaires, WHOQoL-BREF [ 34 ] and WHOQoL-OLD [ 35 ], the 19-item Control, Autonomy, Self-Realisation and Pleasure (CASP-19) questionnaire [ 36 ], the Older People’s Quality of Life (OPQoL) questionnaire [ 37 ], and the 36-item Short Form Health Survey (SF-36) [ 38 , 39 ].

Secondary outcomes

We will also analyse the effects of home visit interventions on the incidence of falls, depression, dementia, and emergency department admissions.

Exclusion criteria

We will exclude studies that involve follow-up visits for recent hospital discharge and studies targeting people with one specific illness.

Information sources

A comprehensive systematic electronic search will be conducted using these databases: PubMed, Ovid MEDLINE (R), the Cochrane Library, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, ClinicalTrials.gov , the metaRegister of Controlled Trials, the Turning Research into Practice (TRIP) database, Open Grey, High Wire, the National Institute for Health and Care Excellence (NICE), and the National Institutes of Health (NIH). The search will be limited to English language articles published from January 2010 onwards.

In addition, cross-referencing will be performed, whereby the reference lists of articles will be scanned for relevant studies. We will hand-search Malaysian quality initiative or health systems project reports in the libraries of the Institute for Medical Research (IMR), Institute for Health Management (IHM), Institute for Health System Research (IHSR), Institute for Public Health (IPH), and Ministry of Health, Malaysia.

Search strategy

The search strategy will be based on the key components of the research question: population, interventions, and outcomes. It will include a mix of medical subject headings (MeSH) terms and free-text terms in the title and abstract search fields of the databases. The keywords will be related to the participants (e.g., aged, senior, older, elder, and geriatric), home care (e.g., house calls, home visits, and home care), and the outcomes (e.g., quality of life and accidental falls). Examples of the search strategy are presented in Additional file 2.

Selection of studies

Two review authors will examine the titles and abstracts independently and will exclude all irrelevant studies. Two review authors will independently retrieve and screen the full text of potentially relevant articles and identify those that meet the eligibility criteria. These steps will be recorded in an Excel table along with the reasons for study exclusion. To avoid duplication, data will be identified from the main source. Any disagreements that arise will be resolved through discussions with a third author. A PRISMA flow chart showing details of studies included and excluded at each stage of the study selection process will be provided [ 33 ].

Data extraction

Two reviewers will independently retrieve and record data in a data extraction form. Any disagreements will be resolved through discussion with the third reviewer. The data extraction form will include the following variables:

General information: title, first author, publication year, and country

Methods: study design, study duration, sample size, and mean age of the sample

Types of intervention: visitors’ professional group, number of visits, length of visits

Outcome measures:

○ Primary outcome: QoL (characteristics of the scales used to measure QoL)

○ Secondary outcomes: incidence of falls, depression, dementia, and emergency department admissions

Quality assessment

Two reviewers will evaluate the possible risk of bias for each study independently. Any disagreements will be discussed with the third reviewer. We will evaluate the RCT and cluster RCT articles for the methodological quality using the Cochrane risk of bias tool (RoB 2.0) [ 40 ]. We will categorise the risk of bias as low, high, or unclear in each of the following domains: allocation concealment, random sequence generation, blinding of outcome assessment, selective outcome reporting, incomplete outcome data, and other sources of bias.

The quality assessment tool for studies with diverse designs (QATSDD) [ 41 , 42 ] will be utilised to assess mixed-method studies. There are 14 QATSDD evaluative indicators for quantitative studies. Each indicator will be measured on a 4-point Likert scale as follows: 0 (not at all), 1 (very slightly), 2 (moderate), and 3 (complete). The maximum score of this tool is 42. The quality of a study is rated as ‘high’ if the score is over 75%, ‘good’ if it is between 50 and 75%, ‘moderate’ if it is between 25 and 50%, and ‘poor’ if it is below 25%.

Data synthesis and analysis

If the studies are sufficiently homogenous in terms of population, interventions, and outcomes, the results will be pooled, and a meta-analysis using a random-effects model will be conducted. Where possible, dichotomous data will be presented as relative risks (RRs) with 95% confidence intervals (CIs). Continuous data will be expressed as mean differences (MDs) or standardised mean differences (SMDs) (when the outcome is measured using several scales or instruments) with 95% CIs [ 43 ]. If the study characteristics are substantially different, the results will be analysed in the following subgroups, if data are available:

Participant’s age: 60–79, ≥80

Visitors’ professional group

We will interpret the heterogeneity and variability of the included studies in relation to population, interventions, outcomes, and methods. When meta-analysis is attempted, heterogeneity will be evaluated by forest plots to assess whether the CIs overlap. In addition, heterogeneity among the included studies will be measured using the chi-square ( χ 2 ) test and I 2 statistic. A small p value ( p < 0.1) for the χ 2 test and an I 2 of 50% or higher indicate moderate to substantial heterogeneity [ 44 ].

If meta-analysis is not possible, a narrative will be developed to summarise differences. We will present the data in a summary table outlining the content of the included primary studies (the number of participants, study population, description of interventions), as well as the results, conclusions, and quality ranking of studies.

Meta-bias(es)

We will assess publication bias using the Tandem method. If possible, the potential for reporting bias will be further explored using a funnel plot. A linear regression test will be performed to examine the degree of publication bias. Publication bias is significant if the p-value is less than 0.1.

Confidence in cumulative evidence

The quality of the evidence synthesised in this review will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology [ 45 ]. This methodology involves the evaluation of the evidence quality for each outcome across the domains of risk of bias, consistency, directness of evidence, precision of effect estimates, and publication bias, resulting in the following grades for each outcome: high, moderate, low, or very low [ 17 , 46 ].

This review may serve as evidence to support effective interdisciplinary home visits that can improve health-related QoL among older adults. This will potentially benefit policymakers and healthcare managers in planning for an efficient resource utilisation and evidence-based policy designs catered to older adults’ health. Healthcare professionals and implementers will be able to deliver health programmes and interventions suited to the needs of the older adult population. Researchers and other institutions will gain knowledge of multiple health interventions. In addition, recognising international practices will provide information to policymakers regarding strategies to improve quality of care in future.

This review has potential limitations. Our search strategy may miss sources of information available in languages other than the English language. In addition, we anticipate that the review will face challenges due to the heterogeneous nature of the study design, particularly in interventions and outcomes measures, which may limit the interpretability and comparability of results.

Protocol amendments

Any amendments to this protocol in the carrying out of this systematic review will be documented and reported in both the PROSPERO register and any subsequent publications.

Dissemination plans

The findings of this systematic review will be disseminated through publication in peer-reviewed journals and via relevant conferences. In addition, the results will also be shared with potential stakeholders, such as the Ministry of Women, Family and Community Development and the Family Health Development Division under the Ministry of Health Malaysia.

Availability of data and materials

Not applicable.

Abbreviations

Confidence interval

Cluster randomised controlled trials

Health-related quality of life

Medical subject headings

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Quality assessment tool for studies with diverse design

Quality of life

Quasi-randomised controlled trials

Randomised controlled trials

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Acknowledgements

We would like to express our appreciation to the Director General of Health Malaysia for his permission to publish this systematic review protocol. We would also like to thank the Director of the Institute for Health Systems Research, National Institutes of Health Malaysia for her permission to conduct this review.

The authors declare that they have received no specific funding for this work.

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Institute for Health Systems Research, National Institutes of Health, Ministry of Health Malaysia, 40170, Shah Alam, Selangor, Malaysia

Yea Lu Tay, Nurul Salwana Abu Bakar, Ruzimah Tumiran, Noor Hasidah Ab Rahman & Zalilah Abdullah

Institute of Biological Sciences, Faculty of Science, Universiti Malaya, 50603, Kuala Lumpur, Malaysia

Noor Areefa Ameera Mohd Ma’amor

General Medical Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Jalan Pahang, 50586, Kuala Lumpur, Malaysia

Weng Keong Yau

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Contributions

Conceiving the protocol: YLT, NSAB, and ZA. Designing the protocol: YLT and NSAB. Coordinating the protocol: ZA. Designing search strategies: YLT, NSAB, and NAAMM. Writing the protocol: YLT, NSAB, RT, NHAR, and ZA. Providing general advice on the protocol: WKY. The authors read and approved the final manuscript.

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Correspondence to Yea Lu Tay .

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This systematic review protocol was registered with the National Medical Research Register (NMRR-20-1810-56054), Ministry of Health Malaysia. Ethical approval was sought from the Health Medical Research Ethics Committee (MREC), Ministry of Health Malaysia, on 9 September 2020.

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Tay, Y.L., Abu Bakar, N.S., Tumiran, R. et al. Effects of home visits on quality of life among older adults: a systematic review protocol. Syst Rev 10 , 307 (2021). https://doi.org/10.1186/s13643-021-01862-8

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DOI : https://doi.org/10.1186/s13643-021-01862-8

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Home Visits: What Are They and Why Do We Do Them?

So, what exactly is a home visit?  A home visit is basically a play date for the student and his teacher.   The visit is an opportunity for your child to get to know his new teacher on his own turf, so to speak.   In the coming weeks, if your child is new to our Toddler program, your child’s teacher will reach out to you and ask if you would like to have a home visit.   The choice is entirely yours and you are not required to have a home visit.   The home visit is simply one more tool for easing your child’s transition.   The teacher will arrive and her focus will be establishing a bond between her and the child.   She will allow the child to lead the visit, allowing him or her to select where they play and what they do together.   She will stay for about 30-45 minutes.  She may leave a small gift with the child or ask him or her to bring an item to school on the first day, such as a picture of his or her family.  Overall, it is a casual time meant to introduce the child to his teacher and establish bonds of trust.

Now, you might be thinking won’t the teacher and my student have to bond eventually or why only for the Toddler students.  Absolutely your child and his or her teacher will develop a special bond even without a home visit.  But, home visits are an added resource for helping your child with this transition which is uniquely difficult for toddlers.   An infant will not be able to connect a visit in August with the start of school a few weeks later and once their parent has left, infants are easily distractible.  With infants, when the parent is out of sight, they are out of mind (don’t worry they still love you just the same!).  Older children, also benefit from home visits, but they tend to still demonstrate separation anxiety because their displays are more about testing the parents’ reaction than genuine fear. Preschoolers and Elementary students that genuinely feel separation anxiety are able to communicate and comprehend reason at a higher level so teachers are able to engage them in the activities of the room to distract from the separation much faster and with more ease.

The toddler, on the other hand, is in a unique developmental limbo where he or she is capable of deep, complex emotions, but does not have the communication skills to express those feelings or the reasoning abilities to understand the explanations, the time frames, and the obligations that are associated with parents dropping and picking children up for school.  A preschooler understands “I will pick you after nap,” (although they may not accept that).  A toddler does not because they are rooted in the present. They have yet to understand that crying no longer satisfies their desires as it does for infants so.   They want what they want and they want it now!   Additionally, for toddlers, entering school may be the first time that they are away from Mom and Dad or a home environment for an extended period of time.  As such, separation anxiety is often most difficult on toddlers, so we try to give you as many tools as possible to help minimize the stress for your entire family.   Knowing your child is entering a classroom with a teacher who already has a sense of who he or she is and who is not a complete stranger, is not just a relief for the child, but for you as parents as well.  We encourage to take this wonderful opportunity and make the most of it.

Here are some tips and items to keep in mind to make the most of your home visit:

• The visit is entirely about your child
• It is not a time of evaluation. The teacher is not evaluating your home, your family, your parenting, or anything at all.   Similarly, it is not a time for you to evaluate the child or teacher
• It is not a conference between the parent and the teacher. While it will be tempting to ask questions about the program, discuss parental anxieties or point out your child’s capabilities, it is crucial that the child remain the focus of the visit.   If you have such questions, let the teacher know and she will find another time when you can speak privately
• Naturally, parents have anxieties about a new phase in their child’s life and that is OK. However, the home visit (as well as in the first weeks of school), is not a time to show it.  If you are anxious, your child will pick up on it, which will only reinforce and increase his or her anxieties.  Remain positive and excited about school
• Do not stress about the visit. Do not run around cleaning the house or make elaborate snacks.  Try to act as regularly as possible
• The act of inviting the teacher into your home is significant to the child. It unconsciously signals to the child that this is a safe person, a friend, and while a child cannot verbalize this feeling, you are establishing his or her sense of security with this teacher
• Allow the child to plan and lead the visit. It is important for your child to feel in control.  He or she many plan to do one activity and then totally change his or her mind when the teacher arrives.  This is ok.  Go with your child’s flow.
• Don’t worry about planning an elaborate activity.  Blocks, puzzles, games, and/or outdoor play are just fine.  Again, allow your toddler to choose.
• Schedule the visit for a time your child is alert and happy. Avoid meal times, nap times, or too close to bedtime.   A mid-morning or early afternoon visit, usually works best for a toddler
• Try to schedule the visit when other siblings are not present.  If this is not possible, minimize sibling involvement as much as possible.
• Be respectful of the teacher’s time. Do not expect her to stay more than 45 minutes. She is conducting home visits for many students and many visits happen during her personal time
• In the event the home visit does not go well, don’t panic. Some children may not want to engage with the teacher or may get upset.  Such a reaction is perfectly normal.  Do not force the issue.  Instead, have a quick, casual visit between the parents and the teacher.  Seeing you have a friendly exchange is also beneficial.  Just remember to keep it light!
• Most importantly, do not hover or attempt to interfere with the visit. Stay nearby so your child feels safe, but try to participate as little as possible.  Preferably remain within an earshot, but out of sight.  Take the opportunity to treat yourself to some quiet time!

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Lead  Teacher

Ms. Mika comes to us with a wealth of experience and a deep passion for Montessori education. She earned her Early Childhood Credential from the American Montessori Society at the Northern Virginia Montessori Institute. Having started her journey with Montessori during her teen years, Ms. Mika has accumulated over ten years of experience in the field, with six of those years serving as a Lead Teacher

Her love for young children, coupled with her dedication to the Montessori philosophy, makes Ms. Mika an excellent addition to our team. In addition to her educational background, Ms. Mika is passionate about zoology, art, and music. She dedicates her free time to studying arthropods, particularly insects.

Ms. Brianna

Lead Teacher

For the past three years, Ms. Brianna has led toddler classrooms and has found this work to be deeply rewarding. The Montessori pedagogy and beliefs align closely with her teaching mission; to show children they are capable and to give knowledge that will last a lifetime. With a 0-3 Montessori certification and 8-plus years of experience working with children, she is so excited to continue educating young minds. In her free time, Ms. Bri enjoys reading, baking, drawing, and, most of all, making memories with her daughter, who will begin attending The Springs this summer.

Hailing originally from China, Ms. Miko’s journey led her to the United States in 2007 to pursue her studies in accounting at the University of Virginia. Her true passion has always been working with children. For several years, she dedicated herself to serving as a Mandarin interpreter, enriching the lives of others through language and culture. She began her Montessori journey in 2017 as an Infant Montessori Assistant and completed her Infant and Toddler certification in 2020. She has served as a lead Toddler Teacher for the last three years. Beyond her dedication to education, Ms. Miko finds fulfillment in her involvement with her church community. In her free time, she indulges in baking, skillfully crafting delicious creations that bring joy and warmth to those around her.

Ms. Elizabeth

Meet Ms. Elizabeth McCawley, our new Toddler Teacher in Classroom 2! Ms. Elizabeth hails from Barranquilla, Columbia, and has a Technical Degree in Merchandise Marketing from the Institute Tecnicor and has worked in retail for several years. However, her true passion has always remained with children and she loves working with toddlers because each day brings something new. She has been a Montessori Toddler Teacher for two years and has four years of experience working in a Montessori Classroom, both Children’s House and Toddler House. Ms. Elizabeth completed her 0-3 Montessori Diploma from the Prepared Montessorian and is thrilled to be joining The Springs! In her free time, she loves going out dancing, hiking, trying new foods, and visiting museums.

Bio coming soon…

Before and After School Coordinator & PE Teacher

Ms. Peggy was born in New York City and grew up in Queens. She is both a runner and a softball player, having played professionally for the New York Cheetahs. She also played for her college team while majoring in Physical Education.

At the start of her career, Ms. Peggy taught for Millbrook Central School District in New York, but she moved to the DC Metro area over twenty years ago and began working at a Montessori School as a PE Teacher. Ms. Peggy joined The Springs just about one month ago! She is excited to bring PE to all age groups at The Springs! She remains an avid runner, knitter, and voracious reader when she’s not teaching at our school! Ms. Peggy has three adult sons and five grandchildren who know her as Gigi.

Ms. Peggy is at the front desk during aftercare wishing everyone a great evening!

Mrs. Diana Glaukaj

Ms. Diana was born and raised in Albania! She came to the states as an au pair in 2007 for a family of four and completed her Bachelor’s Degree in Information Technology from George Mason simultaneously. Always loving children, Ms. Diana began in the Montessori world as a Children’s House Assistant in 2013 and eventually became an Assistant Head of School for another Montessori School in 2018. Ms. Diana is pursuing her Children’s House Montessori training from the Prepared Montessorian.

Ms. Diana enjoys travel, sports, music, and dancing in her free time and is a mom to her daughter, Jora.

Ms. Ayla Beg

Ms. Ayla was born in Turkey and came to the states at four years old. Settling in New Jersey upon arriving in the states, Ms. Ayla was a stay-at-home mom of four before moving to Virginia and joining a local Montessori school three years ago. Ms. Ayla has been with The Springs since July and loves saying hi to families, operating the phones, and making everyone feel welcome at the front door.

When Ms. Ayla is not greeting and organizing, she enjoys travel, shopping, walks and spending time with her three daughters and one son.

Ms. Elisa Zago

Ms. Elisa is originally from Italy and came to the US for the first time in 2019 as an au pair. Before embarking on this journey, she completed a Bachelor’s Degree in Linguistic and Cultural Mediation from the University of Padova and got a CELTA certificate from Cambridge University. She worked in customer service and communications for almost three years and has a certification in event planning and marketing. She loves languages and speaks Italian, English, Spanish, and French. Ms. Elisa has always loved children and used to lead children’s church programs in her hometown. She joined The Springs’ staff in January 2022 and manages the admission process, social media presence, and planning of school-wide events.

I completed the AMI Montessori Assistance to Infancy training in 2017 and am excited to join The Springs team. I also have a degree in Accounting.

I enjoy traveling, watching movies, exercising, and spending time with my two children in my free time.

Ms. Nikki joined THE SPRINGS in 2016 as an Infant House Assistant Teacher. She then moved to the Toddlers House the following year. She knew she was passionate about Montessori and wanted to be a Lead Teacher at The Springs. Ms.Nikki completed her AMS certification in 2020 and is now embarking on a new challenge as the Toddler House Lead Teacher.

Ms.Nikki has two children of her own who have also attended THE SPRINGS.

Ms.Nikki is excited to welcome each child as her own and is always willing to learn more every day.

I am Ms. Beth, and I joined The Springs in 2014. I hold an AMI diploma from the Montessori Education Center of Arizona and a BS in Sociology from Presbyterian College. I started at a Montessori school in NC.

As a Montessori teacher, I enjoy seeing the children gain skills that will help them in life and carry over into their future. I enjoy teaching in all classroom areas, but the Sensorial area resonates with me, and I hope with the children too.

I enjoy reading, playing tennis, fishing, and spending time with my family.

My name is Deepa Sinha, and if you’ve been around the schools with children in the primary class, you may know me as Ms. Deepa. My teaching journey started when I started tutoring at the age of sixteen and soon realized that teaching was not only my work but my passion. I was introduced to Montessori when one of my kids entered the school, and I just fell in love with its philosophy.

I hold a Bachelor’s degree in Psychology, an American Montessori Society (AMS) Early Childhood Credential, AMS in Lower Elementary, and currently finishing up my AMS in Upper Elementary through CGMS. Additionally, I have extensive experience working as a behavior therapist for children with ADHD, autism, and dyslexia. I have been in the field of Montessori for the past 20 years and as a lead teacher for the last 16 years. I am starting my 6th year at THE SPRINGS. After four years of teaching Early Children House, I embarked on my new journey at THE SPRINGS as an Elementary Lead Teacher.

When I am not working at school, I am busy entertaining my huge extended family and friends with my love of cooking, working out, or hanging around with my family.

Ms. Mary hails from India, a country with a strong Montessori heritage, and has almost 20 years of teaching experience in the US. She has been a Montessori Infant Toddler teacher for nine years. She began her Montessori Infant Toddler career at The Boyd School. She then joined the Montessori School of Chantilly, where she helped start and grow their Infant Toddler program. Chantilly tapped her again to start a second Infant Toddler program upon opening their second school, Montessori School of Gainesville. She has a wealth of experience with the Toddler age group. Ms. Mary joined THE SPRINGS in September 2014 to launch our new Infant-Toddler Program.

Ms. Mary lives with her family in Chantilly. She completed her Montessori Infant and Toddler Certification at the Center for Montessori Teacher Education in North Carolina.

My first introduction to Montessori was in 2001, when I received my Montessori teaching credential from the Toronto Montessori Institute. I’ve continued to grow in my appreciation for teaching in the Montessori way and completed my Master’s Degree in Montessori Education from St. Catherine University in 2018. Language is my passion, and I enjoy opening up children’s curiosity through the perfectly sequenced language curriculum Dr. Montessori created.

I hope to continually inspire children to reach their potential by tapping into their unique strengths and interests, leading and inspiring future educators through my dedication to the practice of teaching. I enjoy traveling, listening to music, and eating delicious food. I am an aspiring writer and am working on finishing my novel in my free time.

Ms. Bianca came to us from Cardinal Montessori in Woodbridge. She was a Lead Lower Elementary Teacher for four years but has been at Cardinal Montessori for the past 15 years. Ms. Bianca has a Bachelor’s Degree in Sociology with a focus in Education and Family Studies from the University of Mary Washington. Ms. Bianca received her Lower Elementary Certification from The Institute for Advanced Montessori Studies.

Ms. Fernanda

Ms. Savannah

Ms. Savannah has a Bachelor’s degree in Psychology from Centre College in Danville, Kentucky. In addition, she has her American Montessori International (AMI) Primary credential from the Montessori Institute of North Texas in Dallas, Texas. From infancy to 5th grade, Ms. Savannah was a Montessori child at Montessori of Roseborough, where she grew up in Mount Dora, Florida. Before solidifying her passion for Montessori pedagogy, Ms. Savannah worked as a toddler assistant in Nashville, Tennessee. She will obtain her Master’s in Education with a concentration in Montessori Education from the University of Hartford this Fall.

Ms. Savannah is beyond excited about what this new year at The Springs has in store for her!

Definition of 'home visit'

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Nursing Home Visit

Description

A nursing home visit is a family- nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities. In performing  home visits, it is essential to prepare a plan of visit to meet the needs of the client and achieve the best results of desired outcomes.

• To give care to the sick, to a postpartum mother and her newborn with the view teach a responsible family member to give the subsequent care.
• To assess the living condition of the patient and his family and their health  practices in order to provide the appropriate health teaching.
• To give health teachings regarding the prevention and control of diseases.
• To establish close relationship between the health agencies and the public for the promotion of health.
• To make use of the inter-referral system and to promote the utilization of community services

The following principles are involved when performing a home visit:

• A home visit must have a purpose or objective.
• Planning for a home visit should make use of all available information about the patient and his family through family records.
• In planning for a home visit, we should consider and give priority to the essential needs if the individual and his family.
• Planning and delivery of care should involve the individual and family.
• The plan should be flexible.

The following guidelines are to be considered regarding the frequency of home visits:

• The physical needs psychological needs and educational needs of the individual and family.
• The acceptance of the family for the services to be rendered, their interest and the willingness to cooperate.
• The policy of a specific agency and the emphasis given towards their health programs.
• Take into account other health agencies and the number of health personnel already involved in the care of a specific family.
• Careful evaluation of past services given to the family and how the family avails of the nursing services.
• The ability of the patient and his family to recognize their own needs, their knowledge of available resources and their ability to make use of their resources for their benefits.
• Greet the patient and introduce yourself.
• State the purpose of the visit
• Observe the patient and determine the health needs.
• Put the bag in a convenient place and then proceed to perform the bag technique .
• Perform the nursing care needed and give health teachings.
• Record all important date, observation and care rendered.
• Make appointment for a return visit.
• Bag Technique
• Primary Health Care in the Philippines

2 thoughts on “Nursing Home Visit”

Thanks alots for the impressive lessons learnt from the principal of community health care and nursing home

Home visit nursing

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Home visits and family engagement.

• Barbara Wasik Barbara Wasik University of North Carolina at Chapel Hill
•  and  Donna Bryant Donna Bryant University at North Carolina at Chapel Hill
• https://doi.org/10.1093/acrefore/9780199975839.013.1237
• Published online: 22 March 2023

The importance of engaging families in home visiting was recognized more than a century ago as M. E. Richmond provided guidelines for involving families in the visiting process. She stressed individualizing services and helping families develop skills that would serve them after the home visiting services ended. During the 20th century, early organized efforts in home visiting in the United States built on methods used in other countries, especially European countries. Although interest fluctuated in the United States during the past century, since 2010 interest has increased due primarily to the passage of the Patient Protection and Affordable Care Act that provided for home visiting services to respond to the needs of children and families in order to improve health and development outcomes for vulnerable children and their families.

Engaging families is essential for a productive home visiting experience requiring thoughtful program activities as well as knowledge and skills on the part of the visitor. Program responsibilities begin with the need to make good employment decisions regarding home visitors and then to provide effective training, supervision, and ongoing professional development. Providing professional training in helping skills such as observation, listening, and ways of asking questions to gain or clarify information is essential to ensure visitors can engage families. Using principles for effective home visiting—including establishing a collaborative relationship with the family; individualizing services; being responsive to family culture, language, and values; and prompting problem-solving skills—can enhance the ability of the visitor to engage the family. Programs can provide opportunities for visitors to enhance their skills in developing relationships with and engaging families. Engaging families is a reciprocal process. Some families will have a positive orientation toward working with visitors to accomplish their own goals and objectives; others may be less willing to engage. Although the program and visitors have the main responsibility for engagement, they will face challenges with some families and may need to seek creative solutions to actively engage.

Just as home visitors need to engage parents in order to facilitate new knowledge and skills, parents need to engage their children to foster development. Recent research identified a set of parent–child interactions that visitors can incorporate to foster parent engagement with young children. These challenges are shared across home visit programs, as well as across cultures and countries, regardless of the professional training of the visitors or the goals and procedures of the programs.

• home visiting
• essential principles
• engaging families
• professional training
• supervision
• parent training
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KEY COMPONENTS IN HOME VISITS

1. Assessment:

• Conduct a thorough assessment of the home environment, including living conditions, safety hazards, and available support systems.

2. Purpose of the Visit:

• Clearly define the purpose of the home visit, whether it is for routine check-ups, health education, medication management, post-discharge follow-up, or addressing specific health concerns.

3. Appointment and Consent:

• Schedule home visits at convenient times for the client and obtain consent for the visit. Respect the client’s privacy and autonomy.

4. Communication:

• Establish effective communication with the client and their family. Listen actively, address concerns, and encourage open dialogue to better understand their needs.

5. Cultural Competence:

• Be culturally competent and respectful of the client’s cultural practices, beliefs, and values. Consider cultural factors when planning and delivering care.

6. Safety Precautions:

• Assess and address safety concerns in the home, including fall risks, fire hazards, and other environmental factors. Provide education on maintaining a safe living space.

7. Medication Management:

• Review medications with the client, ensuring proper administration and understanding. Address any concerns or questions regarding medications.

8. Health Education:

• Provide individualized health education on topics such as chronic disease management, nutrition, hygiene, and preventive care. Use visual aids and written materials as needed.

9. Family Involvement:

• Involve family members or caregivers in the care plan, as appropriate. Consider their support and collaboration in maintaining the client’s health.

10. Health Promotion: – Encourage and facilitate healthy lifestyle choices. Discuss strategies for maintaining or improving health and preventing illness.

11. Assessment of Activities of Daily Living (ADLs): – Evaluate the client’s ability to perform daily activities, such as bathing, dressing, and eating. Provide assistance or make recommendations for improvement as needed.

12. Monitoring and Follow-up: – Establish a plan for ongoing monitoring and follow-up. Determine the frequency of home visits based on the client’s needs and the nature of the healthcare issue.

13. Documentation: – Document the home visit thoroughly, including assessments, interventions, education provided, and any changes in the client’s health status. Maintain accurate and up-to-date records.

14. Collaboration with Other Healthcare Providers: – Collaborate with other healthcare professionals involved in the client’s care, such as physicians, therapists, and social workers. Ensure a coordinated and holistic approach.

15. Respect for Autonomy: – Respect the client’s autonomy and involve them in decision-making regarding their care. Encourage them to express their preferences and goals for health and well-being.

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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.

Coding for E/M home visits changed this year. Here’s what you need to know

CPT has revised codes for at-home evaluation and management (E/M) services as of Jan. 1, 2023. Services to patients in a private residence (e.g., house or apartment) or temporary lodgings (e.g., hotel or shelter) are now combined with services in facilities where only minimal health care is provided (e.g., independent or assisted living) in these code families:

Home or residence E/M services, new patient

• 99341, straightforward medical decision making (MDM) or at least 15 minutes total time,

• 99342, low level MDM or at least 30 minutes total time,

• 99344 (code 99343 has been deleted), moderate level MDM or at least 60 minutes total time, 

• 99345, high level MDM or at least 75 minutes total time.

Home or residence services, established patient   

• 99347, straightforward MDM or at least 20 minutes total time,

• 99348, low level MDM or at least 30 minutes total time,

• 99349, moderate level MDM or at least 40 minutes total time,

• 99350, high level MDM or at least 60 minutes total time. 

Select these codes based on either your level of medical decision making or total time on the date of the encounter , similar to selecting codes for office visits . The E/M codes specific to domiciliary, rest home (e.g., boarding home), or custodial care (99324-99238, 99334-99337, 99339, and 99340) have been deleted, and the above codes should also be used in those settings.

When total time on the date of the encounter exceeds the threshold for code 99345 or 99350 by at least 15 minutes, you can add code 99417 to report prolonged services. The exception to this is for patients with Medicare. For those patients, report prolonged home or residence services to Medicare with code G0318 in addition to 99345 (requires total time ≥140 minutes) or 99350 (requires total time ≥110 minutes). Code G0318 is not limited to time on the date of the encounter, but includes any work within three days prior to the service or within seven days after.

Services provided in facilities where significant medical or psychiatric care is available (e.g., nursing facility, intermediate care facility for persons with intellectual disabilities, or psychiatric residential treatment facility) are reported with codes 99304-99310 .

— Cindy Hughes, CPC, CFPC

Posted on Jan. 19, 2023

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Harris visited an abortion clinic, a first for any president or vice president

Deepa Shivaram

Tamara Keith

Vice President Harris speaks to reporters after her visit to a Planned Parenthood clinic in Saint Paul, Minn. on March 14. Stephen Maturen/AFP via Getty Images hide caption

Vice President Harris speaks to reporters after her visit to a Planned Parenthood clinic in Saint Paul, Minn. on March 14.

Vice President Harris visited an abortion clinic in Minnesota on Thursday — an extraordinary stop meant to signal the importance the Biden campaign is placing on reproductive rights in the 2024 presidential race.

The White House believes this is the first time any U.S. president or vice president has visited a facility that provides abortions along with other reproductive care.

In Wisconsin, Harris marks the 51st anniversary of Roe v. Wade

Harris said she made the visit to draw attention to the "very serious health crisis" facing women who live in states that placed new restrictions on abortion after the Supreme Court overturned Roe v. Wade in 2022 .

"We who have the ability to have a bouquet of microphones in front of us, as I do — I take on, then, the responsibility of uplifting these stories," Harris told reporters.

Harris went to a Planned Parenthood clinic

After the Supreme Court overturned Roe , Minnesota passed a new law guaranteeing the right to abortion. Neighboring states — including North Dakota and South Dakota — passed bans. That has meant more women traveling to Minnesota for the procedure.

Vice President Harris speaks with Dr. Sarah Traxler, chief medical officer of Planned Parenthood North Central States, in Saint Paul, Minn. Stephen Maturen/AFP via Getty Images hide caption

Vice President Harris speaks with Dr. Sarah Traxler, chief medical officer of Planned Parenthood North Central States, in Saint Paul, Minn.

Inside the Planned Parenthood clinic in Saint Paul, Harris met with Dr. Sarah Traxler, the chief medical officer for Planned Parenthood North Central States. The clinic was open during her visit, but reporters were kept in the lobby.

One year after the Dobbs ruling, abortion has changed the political landscape

"I am a proud abortion provider," Traxler told reporters after the tour, calling the vice president's visit a "historic moment."

"Since Roe was overturned, I've cared for patients from everywhere," Traxler said, noting women have come from states as far away as Texas, Alabama, Oklahoma, Missouri, Florida and Wyoming.

Harris emphasized that abortion is health care

About dozen protesters gathered outside for Harris' arrival at the clinic with Democratic Gov. Tim Walz and Rep. Betty McCollum, D-Minn. One sign said "Abortion is not healthcare."

Democrats in North Carolina see abortion rights as a big issue for November

Afterward, Harris emphasized to reporters that the facility provides health care for women. "It is absolutely about health care and reproductive health care. So everyone get ready for the language: 'uterus,'" Harris said. "That part of the body needs a lot of medical care from time to time."

Democrats see abortion as a winning issue for November

Harris' Twin Cities trip was the latest in a series of events she has had around the country highlighting reproductive rights since Roe was overturned. The issue has been a winning one for Democrats in elections that took place in 2022 and 2023, and the party has said they believe it will be on top of voters' minds heading into November.

In the last several weeks, Harris has been to a number of swing states critical for Biden's reelection, like Wisconsin , Michigan and Arizona.

Correction March 13, 2024

An earlier version of this story said the Supreme Court overturned Roe in 2021, instead of 2022.

• 2024 election
• Dobbs v Jackson Women's Health Organization
• Vice President Kamala Harris
• abortion clinics
• reproductive health

India, Pakistan to visit as Australia announce schedule for home summer

The visit of India for a five-match Test series highlights the upcoming Australian home summer.

Australia have released details of their schedule for their upcoming home summer, which includes the visit of Pakistan for six white-ball contests and the eagerly awaited Test series against India.

The five-game Test series against Rohit Sharma's side will commence in Perth on 22 November, with further Tests to be held in Adelaide (day-night), Brisbane, Melbourne and Sydney right up until the start of the New Year.

Australia v India Test schedule:

First Test: November 22-26, Perth Second Test: December 6-10, Adelaide (d/n) Third Test: December 14-18, Brisbane Fourth Test: December 26-30, Melbourne  Fifth Test: January 3-7, Sydney

It will be the first time since the summer of 1991/92 that Australia and India have played a five-match series as part of the Border-Gavaskar Trophy and will provide both teams with a good opportunity to further cement their place in next year's ICC World Test Championship final.

Australia claimed bragging rights when winning the most recent World Test Championship final at The Oval last year, but India have held the coveted Border-Gavaskar trophy since 2017 on the back of consecutive series triumphs away from home.

Cricket Australia CEO Nick Hockley is looking forward to welcoming India to Australian shores later this year and is predicting a tight contest between the evenly matched sides.

“This is one of the most highly anticipated summers of cricket in memory with the eyes of the cricket world focused on the extended Border-Gavaskar Trophy series and the multi-format Women’s Ashes," Hockley said.

“Fittingly, the Border-Gavaskar Trophy has been put on the same footing as The Ashes with a five Test Series for the first time since 1991-92 and we’re confident the schedule will maximise viewership and attendances and there will be a tremendous atmosphere in stadiums across the country."

The visit of Pakistan will commence Australia's home summer, with the Asian side to play three ODIs and three T20Is at the start of November, before the action hots up even further with the Test series against India.

India's women's side will be in Australia at the same time as their male counterparts, with three ODI matches planned to take place at the start of December as part of the women's schedule also announced by Cricket Australia on Tuesday.

Australia will take on New Zealand in three ODIs in September following the Women's T20 World Cup in Bangladesh, before three games against India in Brisbane and Perth from 5 December.

Australia's attention will then turn to the multi-format Women’s Ashes series against England, which consists of three ODIs, three T20Is and a historic day-night Test match at the MCG at the end of January.

Lisa Sthalekar is joined by Clare Connor, Ian Bishop, and Mithali Raj to discuss where women's cricket is currently at and where does it need to go to keep thriving.

Australia v Pakistan white-ball schedule:

First ODI: November 4, Melbourne Second ODI: November 8, Adelaide Third ODI: November 10, Perth First T20I: November 14, Brisbane Second T20I: November 16, Sydney Third T20I: November 18, Hobart

Women's

Australia v New Zealand, T20I series

First T20I: September 19, Mackay Second T20I: September 22, Mackay Third T20I: September 24, Brisbane

Australia v India, ODI series

First ODI: December 5, Brisbane Second ODI: December 8, Brisbane Third ODI: December 11, Perth

Australia v England ODI series

First ODI: January 12, Sydney Second ODI: January 14, Melbourne Third ODI: January 17, Hobart

Australia v England T20I series

First T20I: January 20, Sydney Second T20I: January 23, Canberra Third T20I: January 25, Adelaide

Australia v England Test

Only Test: January 30-February 2, Melbourne (d/n)

Australia players rewarded on latest rankings update

Gardner gains big in ICC Women's ODI Player Rankings

ICC Men’s T20 World Cup 2024 Trophy Tour Begins in New York

18 dead frozen puppies discovered in Oregon home were meant as snake food, officials say

Sheriff's deputies seized 18 dead frozen puppies Friday from a home in rural Oregon that investigators believe were used to feed the homeowner's pet snakes, authorities said.

The Columbia County Sheriff’s Office obtained a search warrant last week for the property north of Portland after the agency was tipped off about a resident freezing litters of puppies for snake food, according to a news release .

The frozen bodies of the 18 puppies investigators found during the search were transported to the Oregon Humane Society to determine how the animals died, the sheriff's office said.

Riley Strain: Preliminary autopsy results reveal death to be 'accidental,' police say

One snake turned over to wildlife department

The search took place Friday at a rural property in Goble, an unincorporated community 40 miles north of Portland.

Investigators also reported finding several snakes at the home, one of which was turned over to the Oregon Department of Fish and Wildlife. It was unclear why just one snake was seized and what has since become of it.

USA TODAY left a message Monday morning with the wildlife department that was not immediately returned.

The humane society also did not immediately return a message to USA TODAY seeking information on whether a cause of death has since been determined.

District attorney to consider charges

The sheriff's office did not announce any arrests in its news release and did not immediately return USA TODAY's message Monday seeking any updates on the investigation.

A spokesperson for the sheriff's office told KOIN that the Columbia County District Attorney Joshua Pond's office is considering charges.

When reached Monday by USA TODAY, Pond said the incident is still being investigated and no charges have yet been filed.

"We are taking this matter very seriously and such behavior simply cannot be allowed or tolerated," Pond said in a statement. "I trust both my office and our local law enforcement to build a case that will effectively prosecute the offender for their actions."

Eric Lagatta covers breaking and trending news for USA TODAY. Reach him at [email protected]

Amazon Is Selling a Foldable Tiny Home That's the Definition of Cozy Living

It can withstand earthquakes and strong winds!

Every item on this page was hand-picked by a House Beautiful editor. We may earn commission on some of the items you choose to buy.

Each oversized package features a steel frame, complete with a hydraulic ceiling, four walls, and a floor. Believe it or not, you don't need to be a construction pro to build this space. With a little bit of elbow grease—and, of course, reading the directions—you can lift the hydraulic ceiling, prop up the walls, and lay down the floor in about 15 minutes. (Yup, that's shorter than an episode of Friends .)

OFFICER OWL Modern Foldable House

We know what you're thinking: A prefab home kit that's so easy to set up must not be built to last, right? Well, not quite. Not only does the Officer Owl Modern Foldable come up with strategically placed windows to provide ample sunlight and air circulation, but the frame itself is fl ame-retardant, waterproof, and thermally insulated. (Not to mention it can withstand grade eight earthquakes and grade 10 winds!) In fact, Officer Owl claims its foldable homes can last up to 25 years.

Since this home has a built-in electrical system complete with LED as well as a fully plumbed kitchen and bathroom, it can be so much more than a tool shed or garage : It can be anything . An office? A gym? An in-law unit for guests to crash at on a whim? Your own home?! Check, check, check, and check. The only downside to Officer Owl's Modern Foldable Home is the price. At $13,450, this tiny home is by no means cheap. However, when you think about the alternative—building a carriage house or extra guest home from scratch—the foldable home suddenly seems worth it.

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