Guidance for HFA sites in response to COVID-19

Parent Survey visits – The Parent Survey can be conducted over the course of two virtual visits, and should be fully documented at the conclusion of the second visit.

Home visits – Sometimes, interruptions or other needs may impact a virtual visit being completed in one session. Or it may be more conducive and supportive to the family to break a virtual visit into two shorter sessions. A virtual home visit may be split into two shorter video or phone calls within the same week. The visit should be fully documented at the conclusion of the second meeting. In order to count as a “completed HV” the 2nd contact must occur. If the 1st one occurs and the 2nd never does, then it is not counted as a completed home visit.

Supervision sessions – Weekly individual supervision can be split into two sessions within the same week. Supervisors will finish documenting the session at the conclusion of the second meeting date, and the combined duration of both sessions will be a minimum of 1.5 hours in duration for .75-1.0 FTE, and 1 hour for .25-.74 FTE staff

The focus of the visit may shift to the immediate needs of the family as they deal with impacts owing to COVID-19, and this is okay. We need to be sure we are helping the family manage this stressor as we do with other stressors, supporting the parent to understand the impact of parental stress on their child(ren), even unborn and newly born babies, and supporting the parent-child relationship in the context of what is happening.

HFA has never mandated the length of a home visit. In the BPS glossary we see: Typically, home visits occur in the home, last a minimum of an hour and the child is present.   Extenuating circumstances may occur where visits take place outside the home, be of slightly shorter duration than an hour, or occur with the child not present.

Things probably look very different in your program right now!  FSSs and FRSs who are used to being out in the field all day suddenly find themselves working from home.  Instead of grabbing curriculum and materials to take on home visits, they are now sitting in front of a screen, trying to connect with families virtually.  It’s a whole new world out there.

Families, too, are dealing with a changing world.  While some families will be eager to visit remotely, others may not have access to the internet, may not have the ability to connect via Facetime or other apps, or may just find it difficult to spend an hour sitting down with you while feeling so stressed.  Their needs may increase at the exact moment that it becomes harder to get those needs met.

Some of your sites may continue with “business as usual”—at least in terms of continuing to enroll new families.  And, for a variety of reasons, other sites may not be able to enroll new families.  If that’s the case for you, here are some different ways to look at serving families:

• If your referral sources close down for a while (e.g., the WIC office or a local medical practice), consider whether you can develop new referral sources during the interim.  If nothing else, most pregnant parents will continue to deliver at a hospital, which could serve as a new or more prominent referral source for your program..  Many hospitals are not allowing birth partners in, so new moms may be delivering alone and then be kept in quarantine for the next 14 days.  So, they might be very eager to hear from you!
• If your staff have fewer scheduled visits, put them in charge of tracking the availability of resources in your community.  Ask them to find out how to access social services (whether in person or online), which parks or libraries are closed, whether food pantries are still open, how to apply for unemployment benefits, etc.
• If your program is not enrolling new families, or has decided to decrease the number of new enrollments related to the COVID-19 pandemic, staff who ordinarily reach out to new referrals to determine eligibility can continue to contact referred families and learn about their needs and strengths.  For sites that determine eligibility using the Parent Survey, FRS staff can continue to complete Parent Surveys as a service to families, and if enrolling in your HFA program is not possible, families can be connected to other supportive services based on their needs.

We are all concerned about the families who are already enrolled in our programs—and rightly so.  At the same time, all those new parents you would ordinarily meet with are still out there waiting for the opportunity to tell their stories to someone who will listen and support them.  They need us now as much as ever!

Work with your agency to determine what constitutes a valid consent (e.g., can parents text you a picture of a signed consent?).  If your agency is bound by HIPAA laws, check here for more information:  https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-covid19/index.html

We know sites are using a variety of mechanisms to obtain family consent. Some online services such as Docusign can be helpful. We also know it is possible to arrange for a contact-less physical drop-off of forms in some instances. We know others have been successful in using text messages and online file sharing to obtain consent.

During this time of COVID-19 restrictions, the Parent Survey can be administered virtually.  Because of the sensitivity of information we ask, the value of observing non-verbal cues, and the timing of the conversation, which occurs during the very early stages of relationship building, having a face-to-face visual can be very important.  However, many staff report they are having success with phone calls because parents can talk while doing other tasks like washing dishes or folding laundry.  In addition, some staff find it easier to bring up sensitive topics because parents cannot see the discomfort evident on staff’s face. Use what works.

It is important to offer to schedule the Parent Survey for a separate day or time, since many parents can’t drop everything to spend an hour on the phone with you without prior planning—and, at the same time, be prepared if the parent is eager to talk right then.  If your agency or program requires consent forms in order to complete the Parent Survey, talk through how this can occur.  Some suggestions include:  using electronic signatures, dropping consents off or sending forms via snail mail and then asking parents to text consent with a photo of the signed form, etc.

It can be harder to build a relationship when you aren’t sitting in the same room together, so consider the following:

• Consider using digital business cards as a way of showing that staff are professionals from legitimate community agencies.
• Take time to check in on how the family is doing. Things are probably more stressful now than in normal times and many parents welcome someone to talk with.
• It may be easier to engage both parents, now that more people are staying at home.  Invite dad or partner to be involved in the call too.
• Pay attention to cues that the parent may not be comfortable and check out your perceptions. Even if you can’t see the parent, you can listen for changes in volume, energy level, background noise, etc.  If someone suddenly starts speaking more quietly, acknowledge what you are noticing and then ask if this is still a good time to talk or if the parent needs to move to another room.
• Be sure to let the family know, throughout the conversation, what information you can share at the end. For example, if they tell you right away that they are running out of food, let them know that you have information on which food banks are still open right now and that you’ll give them that info before you hang up.  That way the family sees immediate benefit to your call.
• Some families may not have enough minutes or cell service to complete the whole Parent Survey in one call. This is one of those times when it may take more than one visit—and the standards allow for that!
• Normally we ask you to provide any information or referrals at the end of the Parent Survey. However, if you need to schedule a second call to complete the conversation, it is okay, at the end of the first call, to give them any referral information you have already promised them, so they are not left waiting.  When you start the second call, check in on those earlier referrals to see if the family has been successful.
• With higher incidences of DV/IPV now that more people are following stay-at-home orders, we want to be very careful not to put anyone at increased risk.  Our priority is to keep families safe.  It is understood that portions of the Parent survey may not be completed until an in-person contact can occur. If this impacts the timing of when a family is determined eligible, this must be documented. All other expectations for documentation of the Parent Survey remain the same.

It may be possible to continue administering regular screenings in remote or virtual visits and possibly even for families on a level such as TR, CO or TO.  Some things to consider when administering “remote” screenings:

• For some families, continuing with regular screenings may bring a feeling of familiarity or normalcy in a time where things are changing quickly. Screenings are a part of our relationships with families and are expected.  In some cases, this may help the family and the FSS feel some consistency and stability.
• To administer a virtual screening involving parent answers, home visitors may read questions to parents over the phone or video.  In some cases, home visitors may be able to take a picture of the blank tool and text it to parents so that they have a copy as well.  It may also be possible to mail a hard copy of the screening tool to the parent ahead of the visit so that they have a hard copy to look at.
• For some families, screenings may be overwhelming or challenging due to their current living situation.  The home may be more crowded than previously, and parents may not be able to find a private place for screenings on sensitive topics such as mental health and domestic violence.
• Reading questions aloud to complete a screening tool over phone or video may present a challenge as well.  Families under stress may lack the concentration and listening skills needed to participate in a screening at times.  The FSS should check in with families about readiness before completing any screening and should be willing to pause the screening if they notice the parent is struggling to participate in the screening.
• Documentation for any screening should include that it was completed on a virtual visit and the modality of the visit (phone, video).

Intervals for administration of ASQs, ASQ-SEs, CCI tools, depression screens and other tools may be missed during this time. Again, note the reason in family file documentation, and administer the tool at the next possible interval (vs what may be current policy). For example, if you miss the 4 month ASQ and policy says the next one due is at 8 months, but you have an opportunity when the COVID-19 crisis resolves to re-establish regular home visits the closest possible ASQ interval should be used rather than waiting until 8 months. See more guidance about specifics on screening tools in the next few bullets.

Sites have had success administering this tool virtually using video functions. In some cases, parents record themselves interacting with their child in a playtime or daily routine for 6-10 minutes and share this video with the FSS.  The FSS can then use this video to complete the ratings for CCI, and also to have a conversation with the parent about what each saw and the strengths that the parent displayed.  It is also possible for the FSS to invite the parent to interact with their child during a video virtual visit, while the FSS quietly observes (as is done for a “normal” CCI).  This tool cannot be completed via a phone visit.  Staff and supervisors should keep in mind that this tool is only required once per year for each child, so they may consider pushing back the completion of this tool to when in-person home visiting resumes.  Sites should put special effort into regular CHEERS observations for families with whom they are not able to complete a CCI Tool.

These developmental screening tools were designed to be parent administered which makes them a great fit for virtual home visiting. Sites may share the appropriate screen with parents at an earlier visit, mail parents a hard copy, or may opt to text them images of the tool itself.  Whenever possible, encourage parents to complete the activities on the tool with their child as part of the visit.

Screening tools that ask parents for potentially sensitive or particularly private information may be more difficult to complete over the phone or through video. Staff should discuss with parents the nature of the screening and ensure that the parent feels they are in a space that private enough to make the administration of the tool safe and comfortable for them.  Parents who are used to responding to the questions on these screenings in writing, might feel less comfortable discussing them out loud.  Sites may opt to drop off or mail hard copies of these screening, but only with parent permission.  Supervisors and home visitors may want to role-play the administration of these tools in supervision and consider each family’s potential reaction to a virtual screening.

• It is permissible per the Best Practice Standards for CHEERS not to be included if the child is not present during the visit. Even with visits by video, it will sometimes be hard to observe Parent-Child Interactions (PCI). We encourage as much CHEERS-related conversation with the parent as possible and offer the following guidance and instruct peers to use contextual decision-making if needed when looking at HV documentation during this time:
  • For all documentation of virtual visits, sites should note the type of visit, including the mechanism (phone, video, app, etc.)
  • Ideally, all CHEERS domains will be documented. When this is not possible, Family Support Specialists (FSS) should capture a minimum of 2.
    • Generally, Expression and Smiles are the easiest to observe and document during phone and video visits.
    • Frequency is not relevant during phone and video visits.
  • CHEERS during virtual visits is not based specifically upon a behavioral observation. Documentation can include facts from the conversation with the parent (such as quotes and what the FSS sees and/or hears during the visit) and parent descriptions of their experiences with their child.
  • The intent is to identify and document the ways that the parent is aware of and interacting with their child as well as to identify specific CHEERS domains the FSS wants to promote and address with the parent to strengthen the parent-child relationship.

• For more help with CHEERS during virtual visits, see additional resources here.

The expectation for all families to have an initial family goal established within 3 months of the first home visit, and an active goal at all times subsequently, may be affected by reduced in-person visits. However, it is possible to “suspend” a current goal and work together with the parent on a new goal that has emerged in response to the current crisis.

While not all videoconferencing and technology tools are HIPAA compliant, HIPAA is relaxing its guidelines during COVID-19. See resources for more info:

• HIPAA Suspension of Penalties: https://www.healthcareittoday.com/2020/03/17/hipaa-penalties-suspended-for-telehealth-during-covid-19-national-emergency/
• HIPAA and tele-intervention information and resources: https://ectacenter.org/topics/disaster/tele-intervention.asp

Families may not have internet or data on their phones to support virtual visits (though if you can help families connect, that is awesome. Here is a list of companies who are offering free internet and other services). Phone calls are still great ways to connect with families, if possible.

Supervision remains crucial as we support our staff during this time. However, at some sites, we know roles may be shifting as staff are required to take on other duties, resulting in lesser amount FTE dedicated to HFA direct services. Therefore supervision may also look different. For frequency and duration requirements, you should reference the intent of Standard 12-1.B.

For all full-time and part-time staff who are .75 FTE to 1.0 FTE, the requirements are 1.5 to 2 hours weekly. For part-time staff who are .25 FTE to .74 FTE, the requirements are 1 hour weekly.  For staff or contractors working less than .25 FTE, supervision may be provided according to occurrence of services.

For example if a full-time home visitor is now required to spend a third of their time working as part of a crisis response team within the organization or any other non HFA direct service role, they now need 1 hour of supervision instead of 1.5 hours. If this is happening at your site, just be sure to keep notes regarding the FTE shift and the start and end date of the shift.

If a significant portion of families are placed on various creative outreach levels, this will impact the content of supervision sessions. Please see guidance in home visiting section (above) about what Creative Outreach Level is appropriate. As a reminder of how level changes impact caseloads:

• • Families placed on Level TO or CO maintain the same case weight as when on the previous active service level.
    • So if a family was on Level 1, and is changed to Level TO or CO, then they will still be maintained at two points each.
    • For families placed on Level TR, family case weight shifts to .5.
    • As a result, if a staff has 20 families which are all placed on Level TR, who they are still responsible for contacting as able, then they will have (.5 * 20) 10 caseload points. 10 case weight points approximates 35% FTE (in accordance with HFA guideline of no more than 30 case weight points per full-time home visitor), and so we would require 1 hour of supervision weekly.
    • If families are moved to TR and then re-assigned to another member of the team, leaving the direct service staff member with between 0 – .25 FTE, then as-needed supervision would occur instead of 1 hour/wk.

As a reminder, HFA allows supervision sessions to be split into 2 contacts per week instead of just one, which may be a good fit for this period where things are changing frequently and staff may have more questions about expectations and site practices.

As it relates to how the content of supervision sessions may change or “what are we supposed to talk about”- here are some suggestions:

• Shadowing virtual visits and using supervision time to reflect on how it went.
• Develop individualized professional development plans with staff.
• Update Service Plans for families experiencing new or significant stress as a result of the situation. Update service plans with strategies specific to family’s new level of service (such as TR) or strategies that would be effective in virtual visits.
• Develop resource lists for community-level supports related to the outbreak.
• Consider impact of the outbreak on Family Goals and opportunities to revisit goals to keep them meaningful and relevant to the current time.
• Reflect on the impact of remote work and reduced family contacts on the FSS/FRS and their experience of the work.
• Role-play virtual visits, including CHEERS observations, use of Reflective Strategies and use of curriculum.
• Attend to work-life balance for staff who are potentially responsible for children now at home who would be in school or if caring for loved ones who are ill.
• Reflecting on family culture and the impact of specific family values and family structures at this time (such as families that value independence, or families with older generations living in the home).
• Review CCI tool ratings for trends and opportunities for inter-rater reliability discussions. (for example, an FSS who consistently rates all families with all 7s- what are the opportunities to learn about PC observations and identifying areas to strengthen?)
• Gathering informal responses from staff related to the program acceptance or retention rates and getting input towards plans to increase these rates.
• Work together with staff to identify ways to maintain an open-door policy when all staff work remotely.

Check out our tips on supporting staff through virtual meetings here!