Hawaii's healthy start program of home visiting for at-risk families: evaluation of family identification, family engagement, and service delivery.

OBJECTIVE: To describe family identification, family engagement, and service delivery in a statewide home visiting program for at-risk families of newborns.

SETTING: Six target communities of Hawaii's Healthy Start Program (HSP), which incorporates 1) early identification of at-risk families of newborns via population-based screening and assessment, and 2) paraprofessional home visiting to improve family functioning, promote child health and development, and prevent child maltreatment.

DESIGN: Cross-sectional study: describes early identification process and family characteristics associated with initial enrollment. Longitudinal study: describes home visiting process and characteristics associated with continued participation.

SUBJECTS: Cross-sectional study: civilian births in 6 communities (n = 6553). Longitudinal study: at-risk families in the intervention group of a randomized trial of the HSP (n = 373).

PROCESS: completeness and timeliness of early identification and home visiting activities; family characteristics: sociodemographics, child abuse risk factors, infant biologic risk.

RESULTS: Early identification staff determined risk status for 84% of target families. Families with higher risk scores, young mothers with limited schooling, and families with infants at biologic risk were more likely to enroll in home visiting. Half of those who enrolled were active at 1 year with an average of 22 visits. Families where the father had multiple risk factors and where the mother was substance abusing were more likely to have >/=12 visits; mothers who were unilaterally violent toward the father were less likely. Most families were linked with a medical home; linkage rates for other community resources varied widely by type of service. Half of families overall, but >/=80% of those active at 1 year, received core home visiting services. Performance varied by program site.

CONCLUSIONS: It is challenging to engage and retain at-risk families in home visiting. Service monitoring must be an integral part of operations.