Population Indicators Study:

System and Policy Change Study:

Home Visitation Studies

Family Child Care Homes Study:

Special Needs Child Care Study:

Healthy Start/Medicaid Expansion Study:

System and Policy Change Study:

Home Visitation Studies

Family Child Care Homes Study:

Special Needs Child Care Study:

Healthy Start/Medicaid Expansion Study:

Capacity and Systems Findings:

• In 2.5 years of operation, the ECI reached nearly 83,000 Cuyahoga County children (prenatal through five years of age), and approximately 68% of children born since the start of ECI have received one or more ECI services. Since the start of ECI, Welcome Home visits have been made to over 19,700 new and teen parents, representing 86 percent of all those eligible for the service.
• Since the launch of ECI, 15,441 children, 69% under six months of age, have been referred for Early Start services.
• The Family Child Care Homes program led to the certification of 1,499 new home-based child care providers, a 150% increase since the start of the Initiative, and 74% of these providers received technical support visits.
• The Special Needs Child Care program has delivered technical assistance on behalf or nearly 1,200 children with special needs [based on data from families that consented to participate in the evaluation], trained over 900 providers, and helped more than 250 families through placement assistance.
• From the perspective of a sample of key informants, the Initiative has facilitated a cultural shift among the organizations involved to create a coordinated response to children's needs, established formal, structured collaborations that did not previously exist, facilitated cross-system referrals, and developed new linkages between communitybased agencies and families across the County.
• From the perspective of a sample of key informants, however, some barriers remain, including concerns about long-term political support, long-term funding, and the availability of a sufficient and qualified labor pool.

Outcome Findings:

• Enrollment of children under age 3 in regulated child care increased by 25% since the inception of the ECI, and 76% of 3- and 4- year-olds were enrolled in some type of preschool in 2001, compared to 57% nationally.
• Welcome Home visits provided participants useful information in identifying health and related resources for their children and in offering guidance in basic child care strategies.
• A greater number of Early Start services had modest predictive ability in explaining a participant’s reduced risk for physical abuse and increased sense of competence and comfort in caring for her child.
• Over the three years, family child care provider income increased 58%, on average, and the mean number of children in care increased by 53% (from 3.0 to 4.6 children).
• The receipt of TA and training related to caring for children with special needs was found to be associated with a greater willingness to care for children with special needs.
• Eighty percent of children with special needs whose caregivers received TA remained in their child care placement for six months or more.
• The percent of medically uninsured children under age 6 in Cuyahoga County decreased from 10 percent to 2 percent between 1998 and 2001 (latest data available).
• The proportion of infants enrolled in Medicaid who received a well-baby visit within the first month of life increased from 30% to 43% between 1998 and 2001, and the proportion receiving the intended five visits during the first year of life nearly doubled (from 11% to 21%).

Service Provision and Quality Findings:

• Infants are being served earlier in life as the Initiative progresses, with 63% of infants being served by three months of age in the most recent birth cohorts.
• More children born in 2000 were identified as needing Early Intervention services and were identified at an earlier age than prior to the Initiative.
• Similarly, Early Start home visits are being delivered much earlier in infants’ lives, such that infants referred for service before their 6- month birthday receive an initial home visit within the first month of life.
• Early Start referrals with the highest level of risk are twice as likely to receive an initial home visit and engage in the program as those referrals with fewer presenting problems.
• On average, over a 9-month period Early Start families received 11.3 visits, approximately half the number of intended home visits, comparable to service levels achieved in similar early intervention programs.
• Improving the quality of care in family child care homes proved difficult. Over a 12-month period, the overall quality of care remained poor in a sample of family child care homes. However, the retention of quality was found to be correlated with factors that could be influenced by policymakers: a greater number of technical assistance visits, seeking providers with limited child caregiving experience pre-certification, and fewer children in care.
• During ECI, the percentage of children enrolling in Medicaid during the first month of life increased from 45% to 62%, and the percentage disenrolling within 13 months after initial enrollment decreased from 36% to 25%.

• Three months after receiving their visit, Welcome Home participants report remembering and using the infant care information given to them by the nurse.
• Newborns and their parents are being provided ongoing home visitation services much earlier in the infant’s life than had been true in 1999.
• On average, all new parents, regardless of personal and economic resources, appear to experience a significant loss in their sense of emotional connection and belonging to those in their informal support network and an increase in perceived stress, underscoring the importance of universal support.
• Early Start referrals who present the highest level of risk, as measured by the Child Abuse Potential Inventory (CAP), are twice as likely to receive an initial home visit and engage in the program as those with the lowest CAP scores. However, about one-third of all referrals never receive a home visit.
• The average Early Start participant who received a minimum of 15 visits demonstrated significant improvement in her level of depression, perception of stress, and sense of competence and comfort in caring for her child.
• Retention in Early Start, and consequently more home visits, is far more likely if the participant and home visitor are able to establish a strong relationship based on a mutual understanding of the purpose of Early Start and a mutual respect for what each can bring to the service relationship.
• Enrollment and retention rates varied across Early Start service providers.
• Significant and persistent differences in Early Start service duration and dosage existed between African American and non-African American participants.
• In the first 6 months following enrollment in the study, approximately 6 percent of the total sample and 8 percent of those referred to Early Start were reported for suspected child abuse and neglect.

• A community-wide network of services for young children and their families has been established, and the apparatus of county government has been altered to directly support and coordinate early childhood services.
• More children under age six in Cuyahoga County are receiving needed services at earlier ages than ever before.
• Children and their parents are beginning to show benefits from the services provided through the initiative.
• Efforts to deepen and extend the services, tailor them to individual needs, and assure continuing quality should continue.
• The public and private partners who established this Initiative have maintained their commitment for half a decade and recently recommitted to it, with a new strategic plan that outlines a continued focus on program improvement based on evaluation.

• Need to recognize that there is a great variation in resources, supports, flexibility, and ability to implement program standards among Early Start agencies.
• Need for greater clarity and consistency among Early Start providers in documenting what happens in home visits and the services provided to families.
• Use of peer review and collaboration strategies among Early Start agencies to help enhance quality in documentation and record-keeping.
• Need to consolidate essential data elements to streamline data collection and administrative compliance procedures.
• Need for Early Start to ensure consistent, quality supervision and training because of formal preparation, in-service training, and supervision is not consistent among agencies.
• May need to develop a fine-tuned program model and a reconsider program costs for a more consistent, quality program.
• Need improved linkages to community resources, better collaboration among county service systems, and the development of new public/private partnerships.

• More directed assistance to Early Start agencies in the area of participant recruitment, staff development, and supervision.
• Greater emphasis on strengthening social networks in structuring both Welcome Home and Early Start services.
• Improved linkages among the ECI system, OWF and child protective services.
• Increased thought to the role personal experiences and cultural backgrounds play in defining the participant-worker relationship.

• Develop supplemental approaches to home-based strategies, involving individualized services tailored to caregiver characteristics, to engage (1) more at-risk families, and (2) family child care providers.
• Develop a system to identify and intervene with families with a young child who lacks a consistent source of medical care (i.e., a medical home)
• Promote quality improvement strategies for family child care and home visiting that include attracting qualified and motivated individuals to deliver services
• Continue supports and services for children with special needs
• Continue efforts to expand newborn home visiting beyond first time and teen parents
• Advocate for high quality preschool programs and universal pre-kindergarten programs.