Figures 1 and 2 summarize changes in program engagement outcomes from pre-pandemic (March-December 2019) to pandemic (March-December 2020).
Enrollment and Outreach
At the beginning of the COVID-19 pandemic, sites reported difficulties with conducting community outreach. Previously, WB outreach specialists would hold community events, give presentations at community centers, and work with local healthcare providers to refer families to WB. As the primary methods for getting clients enrolled in WB prenatally, the results of these efforts are reflected in each site’s monthly prenatal enrollment numbers. During the pandemic, nearly all sites reported drops in prenatal enrollment, compared to pre-pandemic. The monthly average number of clients enrolled prenatally decreased by 50.9% during the pandemic (pre-pandemic: 315.2, pandemic: 160.5). Without traditional outreach methods available, outreach specialists had to use novel methods for conducting outreach: through social media, virtual community presentations, and mailed newsletters. Despite some successes using novel recruitment methods, the virtual program created challenges with outreach and recruitment.
Visit Service Type
Prior to March 2020, the vast majority (over 95% on average) of home visits were in-person visits. On March 19, 2020, home visitors suspended in-person home visits due to the pandemic. Sites responded by conducting primarily phone visits for the remainder of March. Virtual home visits using HIPAA-approved video software began in April 2020.
The use of video for home visits increased steadily over time. In April 2020, only about 10% of visits conducted across all sites were done via video; by May, this percentage rose to closer to 30%, and to 44% by June. Starting in July and extending through December 2020, virtual visit completion was consistently over 50% and reached as high as 80% in December 2020.
All WB sites were encouraged to maintain a minimum video completion rate of 75%. The LABBN Technical Assistance Team supported sites in achieving and maintaining this rate through a Virtual Home Visiting Support Response (Bock et al. 2020).
Missed and Completed Visits
At the beginning of the pandemic, the average number of missed visits across sites dropped by roughly 30%. This drop in missed visits was sustained through the months of April and May 2020. During this time, home visiting programs were conducting the majority of home visits via phone versus virtually. WB staff reported that clients were feeling anxious and were looking for guidance and support. Additionally, during this period, LA County was under the strictest Safer-at-Home orders and unemployment rates were at their highest (Employment Development Department 2020). For these reasons, home visitors reported that clients were more apt to answer phone calls.
As businesses in LA County began phased reopening, the number of missed visits rose across all 14 WB sites and remained higher than seen before the onset of the COVID-19 pandemic. Pre-pandemic, the monthly average of missed visits was 1,086 visits; during the pandemic this average rose to 1,148 visits. Program managers reported that clients were under significant stress which was likely a factor in the higher rates of missed visits. Families reported feeling overwhelmed with managing the disruptions in their daily lives; parents were busy assisting children with their virtual schooling and often did not have additional time or devices to use to participate in virtual visits.
Despite the increase in missed visits, the number of completed home visits overall increased during the pandemic. The WB Program Framework encourages home visitors to complete 32–40 visits per month. This completion rate accounts for the time it takes to document the visit notes in the database, and for the time it takes to travel to clients’ homes. Prior to the COVID-19 pandemic, the average monthly visit completion rate across all WB sites was 2,811 visits. During the pandemic, this monthly average rose to 3,138 visits. Many factors influence the number of visits a home visitor can complete each month, and it is unclear exactly what led to the increase in completion rates during the pandemic. However, program managers attributed this increase in part to the fact that virtual home visits made traveling to clients’ homes unnecessary, and WB staff reported being able to complete more visits on average every week with their saved time.
Trends in the average duration of home visits also shifted during the COVID-19 pandemic. Prior to the pandemic, home visits lasted 72.9 min on average. When sites began conducting phone and virtual visits, the average duration of home visits across all WB sites dropped to 54.2 min. The length of a home visit appears to be impacted by delivery method (i.e. phone or video). In March and April, when visits were being conducted primarily by phone, the visits were the shortest; as the percentage of visits conducted via video increased, so too did the average length of visit. During the pandemic, 16% of visits conducted via video were less than 45 min, compared to 28% of phone visits that were less than 45 min. Qualitative data from program managers supports this observation; phone visits made it difficult to establish a personal connection with the client and clients were distracted and less engaged over the phone than they were on video, making them more likely to end the visit quickly.
Life Skills Progression
The Life Skills Progression (LSP) is a summary tool that home visitors use to gather and organize information about families’ competencies obtained from visits, screening tools, and observations of the family. The LSP is not intended to be administered via interview, parent self-report, or during a home visit. Instead, a home visitor scores the LSP items by considering in-depth information about the family that has been collected through referral information, interviews and conversation, observations of family functioning, formal assessments, and selected screening tools. This information is used to develop a profile of family strengths and needs, service plans, and monitor progress in outcomes.
The WB Program Framework requires home visitors to complete the LSP and record the results in the SFDB following the 28–38 week prenatal, 2-week postpartum, and 9-month postpartum home visits. The shift to virtual home visits did not affect the LSP completion rate (% completed out of the total number due). Prior to the pandemic, the average completion rate for all sites was 99.4%. During the pandemic, the average LSP completion rate for all sites was 99.8%.
PHQ-9 and GAD-7
WB home visitors are required to screen clients for prenatal/postpartum depression using the PHQ-9 questionnaire, and for anxiety using the Generalized Anxiety Disorder (GAD-7) questionnaire. According to the WB Program Framework, home visitors are required to administer the PHQ-9 at intake and during at least 95% of all subsequent engagement points. The GAD-7 is required to be administered at the 3rd trimester prenatal visit, the hospital visit, at 2 and 9 months of infant age for 90% of all clients.
Transitioning to virtual visits did not have an effect on the completion of PHQ-9 or the GAD-7 questionnaires. Across all WB sites, the average completion rate (% completed out of the total number due) for the PHQ-9 before the COVID-19 pandemic was 99.2%, and during the pandemic, the average completion rate was 99.0%. Similarly, the GAD-7 average completion rate was 98.7% before, and 98.6% during, the pandemic.
Managers requested support around maintaining client confidentiality and best practices for administering assessments virtually. LABBN provided significant technical assistance to WB program managers to help maintain assessment completion rates during the pandemic through a series of protocols, webinars, and consult sessions.
Overall Program Completion
Overall client completion of the WB program was not negatively affected by the pandemic. Program completion rate is determined by dividing the number of clients that attended the final engagement point visit by the total number of clients enrolled. This measure only includes clients who completed at least one postpartum home visit. The overall program completion rate prior to the COVID-19 pandemic was 68.0%. During the pandemic, the overall program completion rate was 67.4%. This indicates that clients were still engaging with the program during the pandemic to the extent seen prior to COVID-19.