[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]








                 MATERNAL, INFANT, AND EARLY CHILDHOOD
                     HOME VISITING (MIECHV) PROGRAM

=======================================================================

                                 HEARING

                               before the

                    SUBCOMMITTEE ON HUMAN RESOURCES

                                 of the

                      COMMITTEE ON WAYS AND MEANS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION
                               __________

                             APRIL 2, 2014
                               __________

                            Serial 113-HR11
                               __________

         Printed for the use of the Committee on Ways and Means

 
 
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                      COMMITTEE ON WAYS AND MEANS

                     DAVE CAMP, Michigan, Chairman

SAM JOHNSON, Texas                   SANDER M. LEVIN, Michigan
KEVIN BRADY, Texas                   CHARLES B. RANGEL, New York
PAUL RYAN, Wisconsin                 JIM McDERMOTT, Washington
DEVIN NUNES, California              JOHN LEWIS, Georgia
PATRICK J. TIBERI, Ohio              RICHARD E. NEAL, Massachusetts
DAVID G. REICHERT, Washington        XAVIER BECERRA, California
CHARLES W. BOUSTANY, Jr., Louisiana  LLOYD DOGGETT, Texas
PETER J. ROSKAM, Illinois            MIKE THOMPSON, California
JIM GERLACH, Pennsylvania            JOHN B. LARSON, Connecticut
TOM PRICE, Georgia                   EARL BLUMENAUER, Oregon
VERN BUCHANAN, Florida               RON KIND, Wisconsin
ADRIAN SMITH, Nebraska               BILL PASCRELL, Jr., New Jersey
AARON SCHOCK, Illinois               JOSEPH CROWLEY, New York
LYNN JENKINS, Kansas                 ALLYSON SCHWARTZ, Pennsylvania
ERIK PAULSEN, Minnesota              DANNY DAVIS, Illinois
KENNY MARCHANT, Texas                LINDA SANCHEZ, California
DIANE BLACK, Tennessee
TOM REED, New York
TODD YOUNG, Indiana
MIKE KELLY, Pennsylvania
TIM GRIFFIN, Arkansas
JIM RENACCI, Ohio

        Jennifer M. Safavian, Staff Director and General Counsel

                  Janice Mays, Minority Chief Counsel

                                 ______

                    SUBCOMMITTEE ON HUMAN RESOURCES

                DAVID G. REICHERT, Washington, Chairman

TODD YOUNG, Indiana                  LLOYD DOGGETT, Texas
MIKE KELLY, Pennsylvania             JOHN LEWIS, Georgia
TIM GRIFFIN, Arkansas                JOSEPH CROWLEY, New York
JIM RENACCI, Ohio                    DANNY DAVIS, Illinois
TOM REED, New York
CHARLES W. BOUSTANY, Jr., Louisiana

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                            C O N T E N T S

                               __________
                                                                   Page

Advisory of April 2, 2014 announcing the hearing.................     2

                               WITNESSES

Crystal Towne, RN, Nurse-Family Partnership Home Visitor, Yakima 
  Valley Memorial Hospital, Testimony............................     8
Sherene Sucilla, Former Nurse Family Partnership (NFP) program 
  participant, Testimony.........................................    16
Darcy Lowell, CEO, Child First, Testimony........................    22
Jon Baron, President, Coalition for Evidence-Based Policy, 
  Testimony......................................................    34
Rebecca Kilburn, Senior Economist, RAND Corporation, Testimony...    42

                   MEMBER SUBMISSIONS FOR THE RECORD

Rep. Danny Davis 1...............................................    58
Rep. Danny Davis 2...............................................    60
Rep. Joseph Crowley..............................................    78

                    MEMBER QUESTIONS FOR THE RECORD

Jon Baron........................................................    81
Jon Baron Response...............................................    83
Rebecca Kilburn..................................................    86
Rebecca Kilburn Response.........................................    88

                    PUBLIC SUBMISSION FOR THE RECORD

Scott Hippert Parents as Teachers................................    94

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                 MATERNAL, INFANT, AND EARLY CHILDHOOD
                     HOME VISITING (MIECHV) PROGRAM

                              ----------                              


                        WEDNESDAY, APRIL 2, 2014

             U.S. House of Representatives,
                       Committee on Ways and Means,
                           Subcommittee on Human Resources,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:10 p.m. in 
Room 1100 Longworth House Office Building, the Honorable Dave 
Reichert [chairman of the subcommittee] presiding.
    [The advisory of the hearing follows:]

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HEARING ADVISORY

FROM THE 
COMMITTEE
 ON WAYS 
AND 
MEANS

               Chairman Reichert Announces Hearing on the

                 Maternal, Infant, and Early Childhood

                     Home Visiting (MIECHV) Program

1100 Longworth House Office Building at 2:00 PM

Washington, Mar 26, 2014

    Congressman Dave Reichert (R-WA), Chairman of the Subcommittee on 
Human Resources of the Committee on Ways and Means, today announced 
that the Subcommittee will hold a hearing on the Federal Maternal, 
Infant, and Early Childhood Home Visiting (MIECHV) program. The hearing 
will take place at 2:00 p.m. on Wednesday, April 2, 2014, in room 1100 
of the Longworth House Office Building.
      
    In view of the limited time available to hear from witnesses, oral 
testimony at this hearing will be from invited witnesses only. 
Witnesses will include practitioners involved in providing home 
visiting services, a former recipient of these services, and experts on 
the effectiveness of home visiting programs. However, any individual or 
organization not scheduled for an oral appearance may submit a written 
statement for consideration by the Committee and for inclusion in the 
printed record of the hearing.
      
    In announcing the hearing, Chairman Reichert stated, ``We all know 
it's better to prevent a problem than to try and correct it after 
things have gone wrong. Yet in many cases, the Federal Government does 
just that by only attempting to treat problems instead of focusing on 
prevention. One of the goals of the new federal home visiting program 
is to help families and children before problems arise. With the 
reauthorization of that program pending, it's time to review whether it 
is really making that hoped-for difference. I look forward to hearing 
more about how home visiting programs are working, how we can ensure 
we're investing in what really works, and whether we're getting the 
quality results that at-risk children and families deserve and 
taxpayers expect.''
      

BACKGROUND:

      
    Home visiting programs have operated for many years, delivering 
services to expectant and new mothers designed to improve a variety of 
outcomes and using a mix of public and private resources. One of the 
most successful approaches has involved a trained nurse who visits a 
parent and child in their home on a frequent basis to provide ongoing 
services to the family. However, many different types of home visiting 
programs exist, and these programs may focus on improving child 
development, increasing parenting skills, reducing the likelihood of 
child abuse or neglect, or increasing economic wellbeing.
    Begun in 2010, the Federal Maternal, Infant, and Early Childhood 
Home Visiting program (MIECHV) was designed to strengthen existing 
maternal and child health programs, provide services to improve 
outcomes for families in at-risk communities, and better coordinate 
services in communities. Under the MIECHV program, at-risk communities 
are identified through statewide assessments examining areas with 
concentrations of poor child health outcomes and other difficulties 
such as high poverty, crime, or unemployment. States then specify how 
they will serve these communities using an evidence-based home visiting 
model, and funding is provided based on each state's proportion of 
preschool children in families with income below the poverty level. 
While the bulk of program funding must be used to provide services 
through home visiting models with evidence of effectiveness as 
determined by the Department of Health and Human Services (HHS), up to 
25 percent of total funding can be used to fund promising, but still 
unproven, approaches. Funding for the MIECHV program in FY 2014 is $400 
million. The program's current authorization

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expires at the end of FY 2014. The Administration's FY 2015 budget 
calls for the program's reauthorization as well as a total of $15 
billion in funding over the next 10 years.
      

FOCUS OF THE HEARING:

      
    This hearing will focus on the MIECHV program, including what is 
known about whether services funded by the program have improved 
outcomes for young children and their parents and how Congress can 
determine whether spending on such services can produce the best 
results for at-risk families.
      

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

      
    Please Note: Any person(s) and/or organization(s) wishing to submit 
for the hearing record must follow the appropriate link on the hearing 
page of the Committee website and complete the informational forms. 
From the Committee homepage, http://waysandmeans.house.gov/, select 
``Hearings.'' Select the hearing for which you would like to submit, 
and click on the link entitled, ``Please click here to submit a 
statement or letter for the record.'' Once you have followed the online 
instructions, submit all requested information. Attach your submission 
as a Word document, in compliance with the formatting requirements 
listed below, by April 16, 2014. Finally, please note that due to the 
change in House mail policy, the U.S. Capitol Police will refuse 
sealed-package deliveries to all House Office Buildings. For questions, 
or if you encounter technical problems, please call (202) 225-1721 or 
(202) 225-3625.
      

FORMATTING REQUIREMENTS:

      
    The Committee relies on electronic submissions for printing the 
official hearing record. As always, submissions will be included in the 
record according to the discretion of the Committee. The Committee will 
not alter the content of your submission, but we reserve the right to 
format it according to our guidelines. Any submission provided to the 
Committee by a witness, any supplementary materials submitted for the 
printed record, and any written comments in response to a request for 
written comments must conform to the guidelines listed below. Any 
submission or supplementary item not in compliance with these 
guidelines will not be printed, but will be maintained in the Committee 
files for review and use by the Committee.
      
    1. All submissions and supplementary materials must be provided in 
Word format and MUST NOT exceed a total of 10 pages, including 
attachments. Witnesses and submitters are advised that the Committee 
relies on electronic submissions for printing the official hearing 
record.
      
    2. Copies of whole documents submitted as exhibit material will not 
be accepted for printing. Instead, exhibit material should be 
referenced and quoted or paraphrased. All exhibit material not meeting 
these specifications will be maintained in the Committee files for 
review and use by the Committee.
      
    3. All submissions must include a list of all clients, persons, 
and/or organizations on whose behalf the witness appears. A 
supplemental sheet must accompany each submission listing the name, 
company, address, telephone, and fax numbers of each witness.
      
    The Committee seeks to make its facilities accessible to persons 
with disabilities. If you are in need of special accommodations, please 
call 202-225-1721 or 202-226-3411 TTD/TTY in advance of the event (four 
business days notice is requested). Questions with regard to special 
accommodation needs in general (including availability of Committee 
materials in alternative formats) may be directed to the Committee as 
noted above.
      
    Note: All Committee advisories and news releases are available 
online at http://www.waysandmeans.house.gov/.

                                 

    Chairman REICHERT. Well, good morning, and welcome to all 
of you, and thank you all for being here to testify, and thank 
you

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all for coming to listen, and thank I the Members for being 
here today to participate in today's hearing.
    So, today's hearing is on the new federal Maternal, Infant, 
and Early Childhood Home Visiting program. Someone apparently 
thought naming a program MIECHV made sense.
    [Laughter.]
    Chairman REICHERT. But, fortunately, we have the 
pronunciation of this acronym, and it is relatively simple: 
MIECHV Program. So I am going to stick with that, if you guys 
don't mind.
    At its core, this program is designed to improve outcomes 
for children and families who face the greatest risk for abuse 
and neglect and a host of other problems that place too many 
kids far behind on the road of life. Small home visiting 
programs have operated for decades using a mix of federal, 
state, and private funds. But the MIECHV program, when it was 
created in 2010, marked the first time there was dedicated 
federal funding for this purpose.
    Our purpose today is to review what we know about the 
effects of this program, so we can begin thinking about next 
steps. Earlier this week we got a little more time with the 
program's extension through March 20 of 2015. But there is a 
lot to consider here, so it is good that we have a head start.
    For instance, we need to review whether the actual outcomes 
of this program are living up to its promise, in terms of 
producing better outcomes for children and families. We also 
need to think about whether the program's mix of supporting 
proven and promising approaches continues to make sense. And we 
should consider whether this program should continue to have 
100 percent federal funding, especially since some of the 
positive outcomes we hope to see will benefit our state 
partners.
    For my part, I am interested in how we can apply the basic 
discipline of this program, which uses taxpayer funds to 
support what we know works to help children and families. Two 
other government programs today can't say the same thing. 
Fortunately, we have the--a distinguished set of experts to 
help us sort through these questions more thoroughly today, and 
that list includes a service provider and recipient of home 
visitation services from my home state of Washington, so we 
will have an opportunity to ask some real how-does-this-work-
at-the-ground-level questions.
    We welcome all of our witnesses today, and we look forward 
to their testimony.
    Chairman REICHERT. Mr. Doggett, would you care to make an 
opening statement?
    Mr. DOGGETT. Thank you very much, Mr. Chairman. And I share 
the objectives that you just outlined. We have heard so much 
over the last several years in this Subcommittee about the 
extent of maltreatment and abuse of children across the 
country, and the need to focus more of our resources not just 
on responding to that abuse after it has occurred, but what can 
we do to prevent maltreatment.
    The enactment of this federal home visiting program, 
building on the experience of many local and state initiatives 
that were already existing back in 2010 I think was an 
important step forward. It is an investment in prevention and 
future development of children. I believe there is considerable 
evidence that this is a wise invest

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ment, though, as some of our witnesses point out, it may be 
difficult to quantify all aspects of the benefits. And this 
cannot be a one-size-fits-all kind of approach, because these 
are families with children in different kinds of positions, and 
we need to adapt the program and look for the most cost-
effective way to reach the largest number of children.
    It is not surprising that a group representing some 5,000 
law enforcement officers around the country fight crime, invest 
in kids, has recognized that if you have good home visiting 
programs, they will need to visit, as law enforcement officers, 
fewer homes and other places where violence or crime occurs.
    The decision last week of the House to continue this 
program on a temporary extension of one--another year of 
funding into next spring represents some progress. I think we 
need a little more certainty than going from year to year, or 
six months to six months.
    There has been good benefit from this program in the State 
of Texas, in both the City of San Antonio and in the City of 
Austin and the surrounding areas, there have been programs that 
have benefitted from the Nurse Family Partnership, and there 
has been investment from the State of Texas that has been 
important. Between, really, just over the three years of 
MIECHV, the State of Texas has received about $50 million, a 
significant amount of money, but perhaps not that significant, 
compared to the needs that exist there. The money has not been 
spent in a vacuum; the state has worked to try to build a 
network of high-quality programs, and to invest some of its own 
money in these programs.
    The division of monies in MIECHV so that some of it is 
focused on evidence-based--most of it is focused on evidence-
based programs, important that we have evidence-based programs, 
but that we also continue to look at a few programs that are 
new and innovative, so that we can assure that we are pursuing 
every alternative that would be cost efficient in this area.
    Mr. Chairman, I would explain to the witnesses that at the 
same time this hearing is taking place, the House Budget 
Committee is marking up a resolution that I really think would 
threaten the continuation of home visiting, child abuse 
services generally, and a wide range of social services. So we 
will be having recurrent votes this afternoon there, and I will 
be in and out, with no disrespect to our very diverse and 
experienced panel, so that we raise appropriate issues in the 
course of the budget resolution.
    And I thank you, and yield back.
    Chairman REICHERT. I thank you, Mr. Doggett. And, without 
objection, each Member will have the opportunity to submit a 
written statement and have it included in the record at this 
point.
    And I want to remind our witnesses to please try and limit 
their oral testimony to five minutes. All of your testimony 
will be included in the record.
    Our panel this afternoon is made up of five folks, as 
everyone can see. And our first witness this afternoon is 
Crystal Towne, RN, Nurse-Family Partnership Home Visitor, 
Yakima Valley Memorial Hospital. Welcome.
    Sherene Sucilla, a former Nurse-Family Partnership Program 
participant; Darcy Lowell, CEO, Child First; Jon Baron, 
president,

[[Page 6]]

Coalition for Evidence-Based Policy; and Rebecca Kilburn, 
senior economist, RAND Corporation. Welcome to all of you.
    And, Ms. Towne, you are recognized for five minutes.

 STATEMENT OF CRYSTAL TOWNE, RN, NURSE-FAMILY PARTNERSHIP HOME 
            VISITOR, YAKIMA VALLEY MEMORIAL HOSPITAL

    Ms. TOWNE. Good afternoon, Chairman Reichert, Ranking 
Member Doggett, and Members of the Subcommittee. Thank you for 
this opportunity to testify on behalf of the Nurse-Family 
Partnership Program in support of evidence-based home visiting.
    I am Crystal Towne, and I am a nurse home visitor for 
Yakima Valley Memorial Hospital in Yakima County, and have been 
a nurse home visitor since 2003. I am here with one of my 
former clients, Sherene Sucilla, who graduated from the Nurse-
Family Partnership Program two years ago, and is a wonderful 
example of how this innovative program can empower young 
mothers to succeed. I am here in support of the MIECHV program, 
which is currently serving 80,000 families nationwide, 
including our Yakima County NFP program.
    In Washington, NFP is one of several home visiting models 
offered as part of a continuum of services that are supported 
at the state level. A higher percentage of pre-term and low 
birthweight babies, an agriculturally-driven economy, low high 
school graduation rates, and high gang activity in the area 
make NFP a critical element of the county's continuum of 
services.
    As a nurse home visitor, I work with first-time, low-income 
mothers and their families over the course of a little over two 
years. I visit each client in their homes approximately every 
other week, and I have a caseload of no more than 25 clients at 
one time. These visits begin early in pregnancy, and last until 
the child's second birthday. Through these, I empower each 
client to have a healthy pregnancy, improve her child's health 
and development, and set goals to achieve economic self-
sufficiency. I do this by meeting the mom where she is at at 
the time, not where I would like her to be. In NFP we call this 
a client-centered approach.
    The NFP curriculum guides us to talk about the right issues 
at the right time, such as how can I stay healthy in pregnancy. 
What do I do when I am stressed out? How can I set goals for my 
life? Breastfeeding and infant attachment. The trust I build 
with my clients begins the moment I walk through their door for 
the first time.
    Sometimes my initial visit is filled with laughter and joy. 
But often times, when serving a young client especially, it is 
filled with great insecurity. The things that I hear most often 
are, ``My parents are so angry with me. My boyfriend is no 
longer there for me. My friends don't understand why I won't go 
out to parties any more. I am so lonely.'' I listen to their 
story for the next two-and-a-half years, building on our 
trusting relationship. I listen to clients who experience 
mental illness, intimate partner violence, substance abuse, 
living in poverty, lack of family support, and health 
disparities.
    Sherene is one of hundreds of stories I have had the honor 
to hear. She is a truly amazing woman and I am so proud to have

[[Page 7]]

the opportunity to have been her nurse, her counselor, her life 
coach, her confidante, her support system, and, most 
importantly, I am her friend. Every client's story is unique. 
But since she is here with me today, I would like to share my 
experience as Sherene's home visiting nurse.
    On May 6, 2010, I knocked on her front door for the first 
time. I did not know much about her, only that she was 10 weeks 
pregnant, and she had been in several foster care homes 
throughout her youth. During our first encounter, I wanted to 
ask her several questions, but I did not. I listened. I 
wondered how a young woman could appear so happy and speak 
about her goals for her future and her hopes and dreams, but 
have several scars on her arms. We never have talked about 
those scars. It didn't need to be said. I recognized that 
Sherene's smile didn't always come easily. But, despite her 
past and future challenges, Sherene is a truly resilient woman 
who has the hope and the drive to provide a better life for her 
child.
    Since we have ended the program two years later, today 
Sherene has a job she loves. She is self-sufficient. She is 
living in a wonderful home. And she is actively involved in her 
son's life. She has not given up on continuing her dream for 
continuing her education. But sometimes being a great parent 
means postponing some of those personal goals.
    In closing, NFP applauds the subcommittee and the larger 
body of Congress for support of the MIECHV program. Thank you 
again for this opportunity to testify before you today. I 
appreciate it.
    [The prepared statement of Ms. Towne follows:]

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    Chairman REICHERT. Well, thank you, Ms. Towne. And we 
applaud you for your hard work. And we know that you can't do 
this work without becoming a friend to those that you help.
    Ms. TOWNE. Yes.
    Chairman REICHERT. And thank you for having the heart of a 
servant.
    Ms. TOWNE. Thank you.
    Chairman REICHERT. You are welcome. Thank you, Ms. Towne.

[[Page 14]]

    Ms. Sucilla, you are recognized.

 STATEMENT OF SHERENE SUCILLA, FORMER NURSE FAMILY PARTNERSHIP 
                   (NFP) PROGRAM PARTICIPANT

    Ms. SUCILLA. Good afternoon, Chairman Reichert, Ranking 
Member Doggett, and Members of the Subcommittee. Thank you for 
the opportunity to testify on behalf of the Nurse-Family 
Partnership Program in support of evidence-based home visiting 
and the Maternal, Infant, and Early Childhood Home Visiting 
Program. My name is Sherene Sucilla, and I was a client with 
the Nurse-Family Partnership Program delivered by the Yakima 
Valley Memorial Hospital in Yakima, Washington. And I am the 
incredibly proud mother of my son, Andrew, who is now four 
years old.
    As a client, I received regular visits about every other 
week from my NFP nurse home visitor, Crystal Towne, starting 
when I was just a couple of months pregnant, through my son's 
second birthday. I am here on behalf of the mothers like me, 
the children like my son, Andrew, and families like our own, in 
support of home visiting. I am honored to be here today, to get 
to thank you all in person for your commitment to improving the 
health and well-being of children and dedicated funding for 
evidence home-based visiting programs.
    This program has meant so much to me and my family, and I 
know that if every mom could be here today to share their 
experience with you, they would be, because it really is a 
changing experience to be here--to be in this program, excuse 
me.
    I grew up in Yakima, Washington. When I was 12 years old I 
went into foster care and remained there through my 18th 
birthday. In those six years I attended seven high schools, 
which made it very difficult to graduate on time, because I 
didn't go to school in the same district, so the credits didn't 
transfer properly. But I did graduate on time, through a lot of 
hard work. While being in foster care isn't an experience I 
would wish on any child growing up, I would say that that 
experience has shaped who I am today.
    When I was younger, my mom wasn't really a mom. I didn't 
really have a role model for parenting. And so, when I found 
out I was pregnant, I didn't really know what to do. I didn't 
have anything to go off of, and I was really scared, and I was 
in this by myself.
    I heard about the Nurse-Family Partnership Program through 
my doctor's office when I found out I was pregnant. Because I 
was a first-time mom and I met other eligibility requirements, 
they referred me to the Yakima Valley Memorial Hospital NFP 
program and Crystal, and I was set up with an appointment for 
Crystal to come to my home and talk more about the program. 
After our first meeting, I knew that this was the right program 
for me, and I looked forward to our regular home visits.
    At that point I was new to everything when it came to 
parenting. But Crystal was a huge help to me and my family. She 
helped me build confidence and open doors for me to set goals 
for my life, for myself, and for my family. She helped me find 
other services I needed, such as dental care, and she would 
take my blood pressure when I was pregnant, to make sure that I 
was doing okay. And when I had trouble breastfeeding, Crystal 
had a breast pump overnighted to me.

[[Page 15]]

    And at one point when I was nursing I was afraid that my 
son wasn't getting enough to grow at a healthy rate, but 
Crystal would bring a scale, and we would weigh Andrew every 
week, and she reassured me that he was getting what he needed 
to grow well and according to schedule. That was the first 
major moment for me, where I felt like I was doing a good job, 
that I was a good mother, and that I was getting him what he 
needed. And now, at four years old, I can often say that he is 
the tallest kid in his class.
    I was also nervous about his development. Like every 
parent, you want to make sure that your baby or child is 
keeping up with different milestones, and I didn't know how to 
assess that. But Crystal would bring in questionnaires called 
the Ages and Stages Questionnaire, or ASQ, to assess his 
development at different points in time, and we would know that 
his development was on track.
    I remember throughout the program Crystal would say to me 
that my son Andrew was a very caring person from a very young 
age. He was about 13 months when Crystal first commented on how 
sweet he was. He would give Crystal a hug and actually pat her 
on the back. At the end of each visit she would leave a form 
with lots of different feedback, including highlights from that 
visit, what our next visit would be about, and what I needed to 
do before our next visit. Looking back at one of the forms, 
Crystal mentioned how I was raising such a sweet and loving 
child that his hugs and pats melted her heart.
    Crystal was able to point out to me these different signs 
he was showing of being a very caring human being, even when he 
was just a toddler, and I remember realizing that if I was 
raising a son that loving, I really was doing something right, 
as a parent.
    When I found out I was pregnant, I worked at a barbecue 
stand. When Crystal and I started talking about my future, she 
helped me look into going back to school. Ultimately, I ended 
up getting a job and a great career through steps I took when 
Andrew was younger. I now work in accounts payable for a local 
heating and air conditioning company, and I have been there for 
about a year-and-a-half. And I have great job security, as I am 
the only one in the office doing what I do.
    It has been really special and wonderful to look back at 
all the records that I have while in this program. I have a big 
binder of all the work, the pictures, and activities that we 
did. And it is lovely. I can go back and read all my thoughts 
and feelings from the beginning of my pregnancy to his age of 
two, when he turned two, and that is really special for us, now 
that he is four, we can go back and look at everything.
    I really hope that Congress will continue supporting the 
MIECHV program, which supports great programs like NFP. Thank 
you again for the opportunity to testify today.
    [The prepared statement of Ms. Sucilla follows:]

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    Chairman REICHERT. Great job. Is this your first time 
testifying in front of Congress?
    Ms. SUCILLA. Yes.
    [Laughter.]
    Chairman REICHERT. You didn't even come across nervous.

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    Ms. SUCILLA. I am sweating.
    [Laughter.]
    Chairman REICHERT. So are we. Future congresswoman sitting 
there, I think.
    You know, I just have to make this comment. You did a 
wonderful job, and, Ms. Towne, you did a wonderful job, also. 
And I know it is not easy to come before Congress and testify. 
But the people up here are just regular people, we just happen 
to be sitting in these chairs, elected by the folks that we 
represent. But we all come from backgrounds that you might be 
surprised to hear about.
    You know, I grew up in a home. Ran away from home and from 
domestic violence. And I never became a foster child--by the 
way, we are working on some foster care legislation that can 
help kids stay in school and have those records follow, and 
hopefully stay in one foster home, and hopefully, more than 
anything, get adopted and have a family they can call their 
own. So we are working on all of that. And I am sorry you had 
to go through that, but that just fits into everything that 
this Committee is trying to accomplish. And you are an all-
star, as far as we are concerned.
    Ms. SUCILLA. Thank you.
    Chairman REICHERT. Yes. Ms. Lowell, you are recognized for 
five minutes. Microphone?
    Ms. LOWELL. Good, okay. Thank you.
    Chairman REICHERT. There you go.

          STATEMENT OF DARCY LOWELL, CEO, CHILD FIRST

    Ms. LOWELL. So, good afternoon. My name is Dr. Darcy 
Lowell, and I am honored to be here to talk to you today. Thank 
you for this opportunity to testify on behalf of Child First 
home visiting and the MIECHV program. And thank you so much for 
your support of the MIECHV extension; it is so needed.
    I am a developmental and behavioral pediatrician, and the 
founder and CEO of Child First. I also serve as an Associate 
Clinical Professor at Yale University School of Medicine.
    Early in my career, I saw the struggles of vulnerable 
children and families firsthand, as they tried to cope with 
trauma and depression, homelessness, and hunger. We needed to 
think about intervention in a very different way, and so Child 
First began. I want to give you a feeling for the kinds of 
families that we work so closely with, and that we serve. And 
here is a little vignette about one of them.
    The Child First mental health clinician met a mother at a 
pediatric visit for her three-year-old daughter, Maria. The 
mother was severely depressed. She had run from her husband 
because of ongoing domestic violence. She and her three 
children lived in an empty apartment without beds or a kitchen 
table. Little Maria was about to be expelled from child care 
for aggressive behavior. Mom worked three jobs, but was still 
way behind in her rent payments, and the family was about to be 
evicted. She was desperately afraid that she would lose her 
children to foster care.
    The care coordinator learned from the family that they had 
been on TANF, but Mom was no longer receiving a check. She, the 
care coordinator, immediately contacted the Department of 
Social Services and found out that the check was being sent to 
her husband

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in prison. In less than a week, the check was redirected to the 
mother. The family situation improved dramatically. Mom now 
only needed to work one daytime job, and was able to focus on 
her children. The clinician worked psychotherapeutically with 
Mom and Maria together, and also consulted in the preschool. 
Maria's behavior improved markedly. Mom's depression lifted. 
The care coordinator coached Mom as she worked out a schedule 
with the landlord to pay back rent. The life course of this 
family changed dramatically.
    What we know is scientific research on early brain 
development has clearly demonstrated that growing up with 
stresses of poverty, violence, depression, substance abuse, and 
homelessness produce a rise in stress hormones and other 
metabolic chemicals that can severely damage the developing 
brain and other body systems. This may lead to academic 
failure, serious mental health problems, and chronic disease, 
including heart disease, cancer, and diabetes.
    However, it is now scientifically documented that the 
presence of a secure, safe, nurturing relationship between a 
parent and a young child is actually able to protect the 
developing brain from damage. We must, therefore, provide 
intensive intervention at the earliest possible time.
    Child First works with the most challenged families, 
targeting young children under the age of six who suffer from 
behavioral and developmental problems and abuse and neglect. We 
take a two-pronged approach--based on what we now know, what 
the scientific literature tells us--with a team of two 
professionals working in the home.
    First, we must decrease the enormous stress in the 
environment, and help stabilize families. Our care coordinators 
work with our parents to connect them to comprehensive, 
community-based services and supports, like medical services, 
safe housing, early education, and literacy. Through this 
process, our care coordinators build the capacity of our 
parents, and help them to build internal organizational skills 
that enable them to be successful as parents and workers.
    Second, we build the nurturing, responsive, parent-child 
relationship, because that is what protects the developing 
brain, even in the face of adversity. Our mental health 
clinicians use Child-Parent Psychotherapy to heal these two 
generations, while they help parents promote safe environments 
for their children to grow and develop, which makes them so 
ready for school.
    To evaluate our model, we conducted a randomized controlled 
trial with strong, positive results in child language, 
behavior, maternal mental health, and decreased involvement 
with Child Protective Services; and with replication we 
actually have been able to have even better results, with 89 
percent of our families improving in at least one major area.
    Child First has only the capacity at this time to serve 
1,000 children each year in Connecticut, but we know the need 
is enormous. We have replicated through a public-private 
partnership with the Robert Wood Johnson Foundation, 
especially, and our Department of Children and Families. MIECHV 
has been instrumental in allowing us to move to eight new 
cities. This support is so essential.

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    The return on investment is substantial. And though I have 
no time to tell you about it now, I will say that Child First 
only costs about $7,000 a year. And if you have psychiatric 
hospitalization for just three months for one child, it is 
$130,000. There is major savings in multiple sectors.
    I thank the committee most sincerely for your interest and 
efforts in support of the MIECHV home visiting program serving 
vulnerable children and families. Thank you.
    [The prepared statement of Ms. Lowell follows:]

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    Chairman REICHERT. Thank you. Great job.
    Mr. Baron?

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STATEMENT OF JON BARON, PRESIDENT, COALITION FOR EVIDENCE-BASED 
                             POLICY

    Mr. BARON. Thank you, Chairman Reichert, Members of the 
Subcommittee. I appreciate the opportunity to testify about 
MIECHV on behalf of the Coalition for Evidence-Based Policy. 
The Coalition is a non-profit, non-partisan organization that 
has no affiliation with any programs or program models, and we 
have no financial interest in any of the policy ideas that we 
support.
    We strongly support reauthorization of MIECHV. MIECHV 
represents an important new and bipartisan approach to social 
spending, in that it uses scientific evidence of effectiveness 
as a central factor in determining which activities to fund. As 
a result of this evidence-based approach, MIECHV is funding the 
large-scale implementation of some home visiting program models 
that, as I will discuss in a moment, have been rigorously 
demonstrated to produce major long-term improvement in the life 
outcomes of at-risk children and mothers.
    MIECHV's evidence-based approach is bipartisan in origin. 
The Bush Administration's 2007 pilot, for example, directed HHS 
to ``ensure that states use the funds to support home visiting 
program models that have been shown in well-designed, 
randomized, controlled trials to produce sizeable, sustained 
effects on important child outcomes, such as abuse and 
neglect.'' Randomized trials are considered the most rigorous 
evaluation method.
    Similarly, the full MIECHV program, implemented under the 
Obama Administration, directs HHS to allocate at least 75 
percent of the program's funds to ``evidence-based home 
visiting models,'' and uses a slightly different but still 
rigorous standard to determine what qualifies as evidence-
based.
    Why does this matter? Because rigorous studies have found 
great variation in the effectiveness of different home visiting 
program models. At one end of the spectrum, for example, is the 
nurse-family partnership, which provides nurse home visitation 
services to low-income, first-time mothers. This model has been 
shown in three well-conducted randomized trials to produce 
major, long-term improvements in participants' life outcomes, 
such as a 20 to 50 percent decrease in child maltreatment and 
hospitalizations, and an 8 percent higher grade point average 
through elementary school for the most at-risk children. And, 
in one trial, a $13,000 reduction in families' use of welfare, 
food stamps, and Medicaid, that more than offset the program's 
cost.
    At the other end of the effectiveness spectrum, for 
example, is the Comprehensive Child Development Program, which 
was a 1990s HHS home visiting program in which trained para-
professionals provided home visits to families with young 
children, designed to teach parenting skills and connect 
families with community services. This was a well-intentioned 
and a well-implemented program. But when evaluated in a 
rigorous, randomized trial, it unfortunately was found to 
produce no effects on any of the hoped-for outcomes, including 
children's cognitive and social development, child health, and 
parents' economic self-sufficiency.
    More generally, two recent, impartial reviews that examined 
which home visiting models had rigorous evidence of policy-
important impacts on child maltreatment and other key outcomes 
found

[[Page 33]]

several models to be effective or promising, including the two 
that we have heard from today, but a larger number to produce 
no meaningful effects. That pattern is not unique to home 
visitation. In almost every field in which rigorous trials are 
conducted, including medicine, business, and K-12 education, 
the effective interventions are almost always found to be 
outnumbered by interventions producing weak or no impacts.
    What this means is that if MIECHV were to allocate funds 
the usual way, without regard to rigorous evidence, it would 
primarily be funding program models that produce no meaningful 
impacts, and might miss the opportunity to scale up the few 
effective models that can improve people's lives in an 
important way. As I describe in my written testimony, MIECHV's 
evidence-based design has succeeded, in part, in focusing funds 
on the subset of effective models and, for example, is funding 
national implementation of the Nurse-Family Partnership, as 
well as the scale-up of other effective evidence-based models, 
like Child First. We believe this is a very important 
achievement.
    We also suggest a modest legislative revision in my written 
remarks to close a loophole that has allowed some of MIECHV's 
funding to go toward ineffective models. I would be happy to 
discuss this further, if of interest.
    [The prepared statement of Mr. Baron follows:]

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    Chairman REICHERT. Thank you, Mr. Baron.
    Ms. Kilburn, you are recognized for five minutes.

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     STATEMENT OF REBECCA KILBURN, SENIOR ECONOMIST, RAND 
                          CORPORATION

    Ms. KILBURN. Chairman Reichert, Ranking Member Doggett, and 
Members of the Subcommittee, thank you for the opportunity to 
testify today about the MIECHV program. My name is Rebecca 
Kilburn, and I am a senior economist at the RAND Corporation. 
My testimony will draw upon a 15-year program of research 
performed at RAND by me and my colleagues.
    We are here today to discuss what we know about whether the 
MIECHV program improves outcomes for children and their 
parents. The Federal Government has sponsored a rigorous study 
of the effects of MIECHV, but initial findings from that study 
will not be available until next year. Absent the results of 
that study, today I will describe currently available research 
that informs MIECHV.
    I am going to discuss two ways that existing research 
findings inform MIECHV. First, I am going to describe research 
related to the rationale for MIECHV. And, second, I am going to 
make recommendations regarding research-supported features of 
MIECHV that raise the likelihood of it achieving its desired 
objectives.
    First, as you have heard, rigorous evaluations have 
demonstrated that a diverse set of home visiting models can 
improve a spectrum of outcomes for children and parents. 
Programs have been able to improve outcomes in the short run 
and the long run, and some, but not all, evidence-based 
programs have found that programs generate government savings 
that more than outweigh the costs. In other words, a growing 
research base has identified evidence-based home visiting 
models, and supports the theory of change underlying MIECHV: 
that scaling up home visiting to large numbers of at-risk 
families has the potential to improve outcomes for children and 
parents; improve population level outcomes, such as reducing 
rates of low birthweight or child maltreatment; and these, in 
turn, should save government money in the long run.
    The primary contribution of MIECHV is to test the idea that 
broadly scaling up home visiting can transform our approach to 
human services.
    Having a research-supported rationale does not imply that 
an initiative will necessarily be effective. The initiative 
must be well structured and well implemented. I will now 
discuss design features of MIECHV that research indicates will 
raise the likelihood of improving outcomes for at-risk 
families.
    Lawmakers should preserve these three existing features of 
MIECHV. First, continuing to concentrate MIECHV funding on 
evidence-based models will make the chances greater that MIECHV 
funds will have their intended impact. Second, drawbacks to 
funding exclusively evidence-based models are that it could 
stifle innovation and prevent us from discovering models that 
may be effective, but have not been evaluated.
    A second feature to preserve are mechanisms in MIECHV that 
circumvent these drawbacks. One is allowing 25 percent of the 
funding to be used for promising models that are being 
evaluated, and the other is funding the MIECHV competitive 
development grants, which allow states to apply for funding, to 
pilot test, and evaluate innovations in home visiting.

[[Page 41]]

    Third, in order to achieve the best outcomes for children 
and families, it is not only necessary to deliver programs that 
work, but it is also necessary to implement them well. The 
third feature of MIECHV that should be preserved is the 
implementation supports it provides states and other grantees. 
These include training and professional development, plus 
technical assistance that helps states engage in best practices 
in evidence-based program implementation. These best practices 
include conducting needs assessments, identifying goals, 
collecting and reporting outcome data, and engaging in 
continuous quality improvement.
    At the same time that the federal home visiting program has 
expanded, states have also been increasing their funding for 
home visiting. The MIECHV program is partnering with states to 
build state home visiting infrastructure, with the MIECHV 
program leading the drive to integrate best practices into home 
visiting implementation.
    To conclude, there are also a couple of ways that MIECHV 
could be strengthened to further raise the chances of achieving 
the best outcomes for children and families. One is that while 
25 percent of MIECHV funds can be used to deliver promising 
home visiting models, MIECHV currently does not support a path 
by which potentially effective models could undergo evaluation 
that would lead them to be designated as evidence-based. The 
types of evaluations that the MIECHV evidence standards require 
often cost upwards of $1 million, representing a substantial 
barrier to discovering the next evidence-based model.
    Second, MIECHV can better harness the power of performance-
based accountability, which links performance measures to 
funding or targeted technical assistance. MIECHV currently 
requires states to collect benchmarks related to family 
outcomes, which is a cutting-edge aspect of the program. While 
monitoring outcomes is desirable, there may be opportunities to 
better monitor states' organizational performance, such as 
number of families served, and, importantly, for MIECHV to more 
closely link performance measures to consequences or targeted 
support to generate improvement.
    Thank you for allowing me to appear before you today, and I 
look forward to taking your questions.
    [The prepared statement of Ms. Kilburn follows:]

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    Chairman REICHERT. Well, thank you very much for your 
testimony, Ms. Kilburn. Thank you all for your testimony. And 
we are going to go into the question phase now. We will just 
ask a few questions. It will be easy, don't worry about it.

[[Page 55]]

    [Laughter.]
    Chairman REICHERT. So, I was a police officer for 33 years 
before I came to Congress. So I just look like I have been here 
for 40 years, but I have only been here 9. I received phone 
calls this past week from sheriffs, from police chiefs from 
Washington State, very much supportive of fighting crime, and 
investing in kids. We get it, because we know if we put the 
money up front, we are going to be saving a lot of money at the 
back end. And that is a hard thing, for people who legislate, 
to really see the long-term, and the long-term goal here. You 
all see it very clearly.
    But we have heard about evidence-based, scientific--I 
think, Mr. Baron, you said scientific evidence and 
effectiveness to decide which programs to fund. And, Ms. 
Kilburn, you talked about design features in three points that 
you made about evidence-based models and funding for evaluation 
and implementation of supporting programs. And what I want to 
try and do is to tie together what you do with what is 
happening, where, as cops would say, where the rubber meets the 
road, where Ms. Towne and Ms. Sucilla are.
    And, you know, what--because you may have never heard about 
implementation supports and things like that, where--no, I 
didn't think so. So you are down here, doing the work. How 
does--so this is for both of you--how does what you are doing 
and what you are going through, how does that get filtered up 
to the folks that are making those decisions and trying to 
figure out what is working and what is not working? What worked 
and--so, just real quickly, what worked in your case? What was 
the--you know, you touched on some of it.
    Ms. SUCILLA. Sorry, I am trying to understand the question, 
I guess.
    Chairman REICHERT. So you are working with Ms. TOWNE.
    Ms. SUCILLA. Yes.
    Chairman REICHERT. And the programs that you got involved 
in that she helped direct you to, what were those programs that 
you saw that really--kind of a light bulb went on as to this 
really is going to work? This program works, or that program. 
If you got sidetracked into a program that you thought, boy, 
this isn't going to work at all.
    Ms. SUCILLA. [No response.]
    Chairman REICHERT. You can help her, if you want to.
    Ms. TOWNE. Are you asking about perhaps she participated in 
programs in addition to Nurse-Family Partnership?
    Chairman REICHERT. Yes. I mean anything that--so she 
finally comes to you, and you give her places where she is 
going, and it is working. How does that get communicated to the 
administrators who are making some decisions as to, you know, 
what programs work, what programs don't work? It is evidence-
based, right?
    Ms. TOWNE. Correct.
    Chairman REICHERT. So how does that evidence get moved up 
to, filtered up to----
    Ms. TOWNE. Okay. So you are asking specifically about the 
data.
    Chairman REICHERT. Yes.
    Ms. TOWNE. Is that--okay, thank you. I was--okay. At visits 
at various time periods that are structured by the program. So, 
for in

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stance, in pregnancy, at 36 weeks, at birth, 6 months, 12 
months, 2 years, we collect data from Sherene in the form of 
various questions that are then submitted to the University of 
Colorado for research purposes.
    Chairman REICHERT. Okay.
    Ms. TOWNE. Is that what you are----
    Chairman REICHERT. Yes, yes, sure.
    Ms. Towne [continuing]. Asking? Yes. For--as part of the 
curriculum and part of the model for Nurse-Family Partnership, 
they have outlined very specific questions and data they are 
collecting at different times throughout that two-and-a-half 
year period.
    Chairman REICHERT. Okay.
    Ms. TOWNE. And it is handled through the University of 
Colorado.
    Chairman REICHERT. Do you ever feel like you are working in 
an area where--if a program that is not working, and you are 
able to give feedback data to the--to Denver that this isn't 
really working at the--you know, where the rubber meets the 
road sort of a----
    Ms. TOWNE. [No response.]
    Chairman REICHERT. No?
    Ms. TOWNE. I don't see that, as a home visitor, because the 
beauty of the Nurse-Family Partnership program, again, is that 
it is client-centered. So it is not necessarily myself 
dictating what we discuss throughout each visit. It is really 
looking at the guidelines of suggested topics, but allowing 
Sherene to choose what she feels would be most helpful.
    Chairman REICHERT. Okay, you just hit on the answer, right 
there. She chooses.
    Ms. TOWNE. She absolutely----
    Chairman REICHERT. Yes.
    Ms. TOWNE. Every visit--the way it works in my home 
visiting practice is at the end of every visit we look at what 
options are available to discuss at the next visit. And I guess 
``available'' isn't maybe the right word. First, Sherene can 
choose. Maybe there is something on her mind that is really not 
a part of the guidelines, and that is okay.
    Chairman REICHERT. Okay.
    Ms. TOWNE. But she can also look at the guidelines and 
topics, and choose one of those.
    Chairman REICHERT. Great. Thank you for your answer. Mr. 
Davis, you are recognized.
    Mr. DAVIS. Thank you very much, Mr. Chairman. And let me 
thank all of our witnesses.
    I have been tremendously impressed with all of your 
testimonies for a number of reasons. And one is that, for all 
of my life, I have been intimately involved with, associated 
with, know people personally, who could make use of this 
program and of these services. And since being in Congress for 
a decade, I have worked with Republican colleagues to advance a 
strong federal investment in home visiting.
    This bipartisan effort drew on research and economic status 
documenting that investing in our youngest citizens yields high 
returns in the form of healthier children and families, and 
taxpayer

[[Page 57]]

savings. The voluntary home visiting law was designed as an 
investment in evidence-based prevention.
    In Illinois, 30 percent of children entering out of home 
care for the first time are under the age of 1, slightly higher 
than the national rate. In Chicago, roughly half of those 
babies enter before they are three months old. This pattern is 
generally true, nationwide. These statistics put into context 
the importance of home visiting, which focuses on strengthening 
children and families by supporting pregnant women and parents 
with young children.
    The role of home visiting is particularly important, given 
the recent study reported in JAMA--that is the Journal of the 
American Medical Association--about an increase in infants' 
death, potentially due to the economy. Supporting young 
children and families is critical to preventing harm and 
strengthening children.
    Mr. Chairman, I have got two documents I would like to 
submit for the record.
    Chairman REICHERT. Without objection.
    [The information follows: Mr. Davis 1, Mr. Davis 2]
    [Member Submissions for the Record follows:]

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                           Rep. Danny Davis 1


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                           Rep. Danny Davis 2


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    Mr. DAVIS. I also--well, let me ask you, Ms. Kilburn. You 
mentioned in your testimony that studies--that the Federal 
Government has studies underway, and the data has not all been 
collated and put together, and so there is not a report yet. 
But without that report, would you say that home visiting is 
really an effective way of helping to strengthen and prepare 
children and their families that ultimately will provide them 
with healthier lives, and even save our taxpayers a great deal 
of money?

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    Ms. KILBURN. There is a strong research base that supports 
the idea that these individual programs can improve outcomes 
for children and families. What MIECHV adds to that is allowing 
us, for the first time, to test the concept of scaling that up 
on a large basis in order to see if we can capture those 
effects that were found in individual programs at a community 
or a city or a state level.
    So, there is a lot of evidence to support the basic idea 
behind MIECHV, and now we are really testing if it can achieve 
this transformation in the way we deliver human services so 
that instead of treating things after the fact, we prevent 
them. And so there is a large research basis that supports that 
idea, and we are really testing it right now.
    Mr. DAVIS. And I guess the reason I indicated--I said that 
for all of my life I have been associated--I have lived in low-
income communities all of my life, growing up, and, of course, 
even today. I used to train community health aides, basically, 
to do home visiting, and basically to make assessments of the 
health needs of individuals in the community who often times 
would not come to the clinics unless they had been prompted a 
little bit, prodded a little bit.
    And I know that there have been people who have said that 
these programs are unnecessary, that they don't really work, 
or, if they do, let the local governments and the state 
governments provide the resources. Are you aware that the 
Federal Government, based upon your research, has been very 
instrumental in making these programs work, and work 
effectively?
    Ms. KILBURN. I don't think we have research evidence on 
MIECHV, per se. But what MIECHV is doing is providing the data 
for us to answer that question. We don't have that right now, 
but the study underway will provide insights into that.
    The reason it is important that the Federal Government does 
this is that, while the individual states have been increasing 
their investments in home visiting, it hasn't been in a 
systematic way that supports evidence-based programming and 
that provides infrastructure support to implement programs 
while also using evidence-based practices in implementation.
    And so, if we allowed the states to do it one by one, we 
wouldn't really know the answer to that question: Does scaling 
this up transform human services? We just have a patchwork or 
sprinkling of different, smaller experiments.
    Chairman REICHERT. Thank you, Mr. Davis.
    Mr. DAVIS. Thank you very much. Mr. Chairman, let me just 
thank you on assembling one of the most outstanding panels I 
think that I have heard testify on this matter. So thank you 
all very much.
    Chairman REICHERT. Thank you.
    Mr. DAVIS. Thank you, sir.
    Chairman REICHERT. Thank you to the staff. Mr. Kelly, you 
are recognized.
    Mr. KELLY. Thank you, Chairman. And I agree with Mr. Davis; 
this is a good panel to have before us.
    One of the things that I have been wondering about--and, of 
course, it seems to me that home visits are critical if we are 
going to continue to support families. And I think one of the 
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[[Page 69]]

we have seen in our cultural that is causing a greater problem 
is the fact that the nuclear family is now not at the same 
level it used to be.
    Now, some of these programs are working, but there is a lot 
of areas that they are not working. What could we do to change 
that?
    Mr. Baron and Ms. Kilburn, you both had testimony towards 
that. So how do we look at a good return on the investment for 
the American taxpayers that we actually make a difference in 
these peoples' lives?
    And, Ms. Sucilla, I really applaud you for what you have 
been able to do. But that is an example of the success of it. 
So, tell me. What else could we do? What programs aren't 
working? And how would we redirect or redeploy those dollars to 
make sure that there is a better return on it, not just for the 
taxpayers, but also for the people that we are spending the 
time with?
    Mr. BARON. Well, for some of the more effective models, 
like the Nurse-Family Partnership, one of the things that they 
did was they measured long-term impacts for both the people who 
got the program, the program group, and a control group of 
families that did not get the program. They measured their use 
of public assistance over a 12-year period, and found that the 
savings in families' use of public assistance more than offset 
the initial program cost. So, at least for that model, there 
was strong evidence not only of improvement in people's lives, 
but savings to the taxpayer.
    But MIECHV funds, as I mentioned, a diversity of home 
visiting models, some of which have been found in rigorous 
studies not to be as effective. One of the things that could be 
done to shift funds within this program to more effectively 
focus on programs that really make a difference in people's 
lives is to slightly change the evidence standard to make a 
modest but important revision in the evidence standard.
    Right now, the program's standard for ``evidence-based'' is 
that the program model produces statistically significant 
effects. But the standard does not ask whether those effects 
are of policy or practical importance, like reduced use of 
public assistance or reduced child maltreatment rates. That has 
opened a loophole in the program, a modest loophole, allowing 
several models to qualify as evidence-based, solely on the 
basis of statistically significant effects on outcomes that may 
not be particularly important, or effects that may be tiny in 
magnitude. That would be one----
    Mr. KELLY. Okay, but as you look at this, you have data 
that you can look at across the board on different programs.
    Mr. BARON. Yes.
    Mr. KELLY. You have the ability, then, to look at which 
ones are working and which ones aren't working. And I would 
just think that, when you look at that, and you are looking for 
a really good return on the investment, we are talking about 
building a stronger society, and you only can do it through 
building stronger families, which will result in stronger 
communities and a stronger country.
    So, when you look at these, then, how do you separate one 
from the other, say, you know, ``This is one that we see 
working. These other ones aren't doing what they are supposed 
to do.'' Ms. Towne and Ms. Sucilla talked about how that one 
worked for them. And I will just tell you, being a grandfather 
and having eight grand

[[Page 70]]

children--two more on the way--I have seen what can happen with 
families that are very supportive, and they get help from the 
outside.
    So, you have the ability to do this, though. You can 
actually compare programs and say, ``This one works, this one 
is not working the way it should,'' and you can redeploy those 
dollars. That is the effort that you are trying to do. Is that 
not correct?
    Mr. BARON. Yes. A very--a straightforward way to do it, 
which is used in many different areas now, increasingly in 
social spending as well as in medicine. A home visiting program 
model generally does not have enough money to serve every 
family that qualifies. So one thing that is often--that is 
sometimes done is to do a randomized control trial, where you 
use a lottery--meaning random assignment--to allocate some 
families to receive the program, and other families, an 
equivalent set who serve as a control group. They get access to 
the usual services in the community.
    And then you track outcomes, important outcomes, over time, 
like rates of child maltreatment for the program group versus 
the control group; families' use of public assistance in the 
program group versus the control group. And the outcomes there 
will tell you which program--in a scientifically----
    Mr. KELLY. Are you able to share that information back and 
forth, then, and actually, you know, come up with a change, 
then, and actually look at this as the best--this is the best 
way to spend those dollars? You can only spend a dollar once, 
so you want to make sure it is spent the right way. So, to get 
the most mileage out of it, you can actually share that data 
and improve these programs.
    Mr. BARON. That can be shared. And, in fact, MIECHV does 
that, it looks at that data, and it allocates--the grants are 
made toward--on the basis of evidence as one of the main 
selection criteria, that kind of evidence. There are ways in 
which that evidence criterion can be strengthened. But, in 
general, the program allocates funds naturally, based on that 
data we were just talking about.
    Mr. KELLY. Okay, all right. Thank you. And just to--so we 
can redeploy these dollars the right way after we have looked 
at this evidence that is conclusive. And you say, ``Listen, we 
don't need to spend money over here. This program is not coming 
up with the results that we need,'' and we can redeploy.
    That is my main concern, because I think too often we 
continue to spend money on programs that aren't effective. And 
we say, ``Well, why do we do this?'' It is because we have 
always done that. That is not the answer. The answer is to 
change it so it benefits families more.
    Mr. BARON. I couldn't agree with you more. That is one of 
the unique features of this program, as opposed to the way 
social spending is often done--social programs are often done--
that in this case money is allocated on the basis of evidence. 
So, if new findings come in showing a particular model is 
effective, or a particular model is not effective, the funding 
is naturally, through the grant-making process, allocated 
toward the more effective models.
    Mr. KELLY. Okay, good, thank you.

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    Chairman REICHERT. Thank you, Mr. Kelly. I think that is 
the question I was asking, too. Mr. Kelly and I, we are going 
at it at different angles, as to how the information is shared, 
the programs are changed, so that they fit what the star of our 
show today needs.
    So, Mr. Renacci, you are recognized.
    Mr. RENACCI. Thank you. And I want to thank you, Chairman 
Reichert, for holding this hearing, and highlighting the 
importance of using evidence brand models to home visiting 
programs. And I also want to thank the witnesses. This is a 
great panel of witnesses.
    In my home state of Ohio, an estimated 1.8 million Ohioans 
are living below the poverty line. Poverty has increased by 
approximately 58 percent over the last decade, despite a 
stagnant population and a whole host of federal programs 
created to end the cycle of poverty. So I am glad we are here 
today to discuss policies that work.
    Ohio's rate of infant mortality is also ranked the 11th 
worst in the nation, averaging 7.7 deaths per 1,000 births in 
the first year of life. In fact, according to a study conducted 
by researchers at Case Western Reserve University, infant 
mortality exceeds some third-world countries in certain 
neighborhood surrounding the university's circle area in 
Cleveland.
    While I applaud the efforts of home visiting programs that 
have been proven to improve the safety and well-being of 
infants and children, we as a nation cannot continue to 
financially support ineffective programs. As a small business 
owner, when I implemented a particular program, I also wanted 
to ensure that the procedures that I created were effective and 
really meeting certain goals that I created for those 
employees. Businesses--and my business--actually measured our 
programs and used evidence-based models in order to guarantee 
success. And I think the Federal Government should be no 
different.
    As a Member of Congress, I want to protect taxpayer dollars 
from going toward ineffective programs, and redirect them 
toward programs that do what is intended, and lift individuals 
out of poverty. I really hope, together with my friends across 
the aisle, that we can determine what works, what doesn't work, 
and can make--so that government can finally empower 
individuals to become independent and self-sufficient.
    Ms. Towne and Ms. Lowell, both of your programs have been 
shown to increase the safety and well-being of young children. 
For example, I know families who have gone through the Nurse-
Family Partnership program, have been shown to have fewer child 
injuries, fewer emergency room visits, and less reported child 
abuse and neglect. Families participating in Child First also 
are less likely to be involved with Child Protective Services, 
even after three years. Both of your organizations have had 
some successes. What do you think are really some specific 
factors that have led to these outcomes or successes?
    I will start with you, Ms. TOWNE.
    Ms. TOWNE. Could you repeat the last part of your question, 
please?

[[Page 72]]

    Mr. RENACCI. Yes. What do you think are some of the 
specific factors that have led to these outcomes or successes 
for both of your programs?
    Ms. TOWNE. That is a complex question. I would say that 
there are many factors of the Nurse-Family Partnership model 
that have led to success. From a home visiting point of view, I 
believe that it is the length of time and the intensity of the 
program that allows me to continue to support a family for two-
and-a-half years in developing a strong infant bond, a strong 
family--a stronger family unit than when our relationship had 
started is part of what helps.
    Mr. RENACCI. So you are zeroing in on the two-and-a-half 
years, making sure the program--you feel pretty strongly about 
the two-and-a-half year time frame.
    Ms. TOWNE. I feel pretty strongly that a larger length 
period of time, along with the intensity of the visits--we are 
looking at approximately two hours per visit every other week--
allows quite a bit of time for growth.
    Mr. RENACCI. Ms. Lowell, do you have any----
    Ms. LOWELL. Yes. I think that for us, there are a number of 
factors. One is the intensity of the training for our staff. We 
are working with both bachelor's level care coordinators and 
master's licensed clinicians, as our mental health clinicians 
who go in the home. And we have a training period that lasts a 
year's time (not before they can start; they start after an 
intensive two-week training). But we both have what is called a 
Learning Collaborative, which lasts a year's time, and we have 
our senior clinical consultants working with each new site on a 
weekly basis.
    So, we are really looking at, ``do you have fidelity to the 
model, do you really understand what the work is about, and are 
you doing it well?'' And we also look at implementation 
measures on an ongoing way every single month, and we also look 
at outcomes, at baseline six months and at discharge. So we are 
able to say, ``Do we have a problem here? Are the people who 
are implementing this model doing it really well? Are they 
doing it according to the model fidelity,'' which I think is 
essential.
    The other really important piece about the work itself is 
it is built on relationships and on building relationships. And 
I think that, at least when you talk about the families that we 
serve, which are the most vulnerable, they are the ones who 
have had abuse and neglect, domestic violence, homelessness, 
substance use; these are really difficult families. They don't 
trust easily. And they are not very willing to let new people 
into their lives. And it takes time to build that relationship. 
But when you have built that relationship of trust, you are 
able to make a real difference. These are families who want to 
do the right thing, they want to do the best for their 
children. They are there. But it is a process.
    And so, if you can build that relationship you can work 
with both the parent or care giver and the child 
therapeutically, to understand what are the barriers, what are 
the problems. But it is not so simple. We can't just teach 
them, because that is not enough. They don't learn that 
information. It has to be at a deeper level. And I think, for 
us, with our families, we are so successful with them because 
we do go to that deeper level, and make sure our staff are 
doing it correctly.

[[Page 73]]

    And one other really important thing I have to say is I 
think that, as was said, that our home visiting models are 
different, and they target different outcomes. And it is really 
important for us to be matching the outcome that the family 
needs and wants with the kind of program that they are getting. 
And I think that we have problems when we have a mismatch 
there, when we have a very vulnerable family, a mom who is 
running from domestic violence, who is severely depressed, and 
someone who is just going to be teaching them things when the 
mom is not available to learn them.
    But, I think that for other moms--that it may be a perfect 
match for them. So we need this continuum of models to work 
together in a system if we are really going to be effective.
    Mr. RENACCI. Thank you, Mr. Chairman.
    Ms. LOWELL. Thank you.
    Chairman REICHERT. Thank you. That was two minutes over 
time, but that was so passionate, there was no way I was going 
to interrupt.
    Ms. LOWELL. Sorry.
    [Laughter.]
    Chairman REICHERT. That was a great answer. Mr. Doggett, 
you are recognized.
    Mr. DOGGETT. Thank you very much. Dr. Lowell, you described 
in your testimony the need here is enormous. What would be the 
impact in your area if the federal funding through MIECHV is 
not continued beyond next spring?
    Ms. LOWELL. Oh, thank you. That is a really important 
question. We have--with our MIECHV funding, we have five new 
sites and three expansion sites, which cover about a third of 
our state Child First programs. So, if the MIECHV funding is 
not continued, there is very high likelihood that those 
programs will be closed. And all of those children and families 
in those areas will not be served.
    Mr. DOGGETT. And you used in your testimony the comparison 
between a $7,000 cost and a $30,000 cost for not relying on 
home visiting to intervene in advance. Would you elaborate on 
that?
    Ms. LOWELL. I think that we are seeing tremendous cost 
savings--at least we did a preliminary cost benefit analysis in 
looking at our data, and we need to do much more. But we know 
that, for instance, if one of our children, many of our 
children have very severe behavioral problems and mental health 
problems if one of those children were to be hospitalized for 
just two months in a psychiatric hospital, it would cost 
$130,000. We know that we are getting great language outcomes. 
If one child needs special education, it is going to cost 
$16,600. If one child goes into foster care--and I have heard 
various costs but we are talking about, potentially, somewhere 
between--depending on the numbers I have seen--$20,000 and 
$80,000 for a child for a year in foster care. And many of our 
families have multiple children.
    For example, we just had a family that I just heard about, 
which we started working with, where Mom was going to be 
evicted. She had six children. Our care coordinator got her 
into a shelter initially, and then got her an apartment with 
low-income housing, and saved six children from going into 
foster care. And the trauma of foster care is very major, 
because that separation is really dif

[[Page 74]]

ficult, especially if it is not because there is abuse and 
neglect, but just because the circumstances can't support that 
parent caring for the children.
    So, I also see we are getting other outcomes--we have some 
data on hospitalization and ER visits, which is actually--it is 
very preliminary, but we are talking about a four to sixfold 
decrease in hospitalization and emergency room visits.
    Mr. DOGGETT. Thank you.
    Ms. LOWELL. Thank you.
    Mr. DOGGETT. Thank you very much, and thank you for what 
you are doing there.
    And, Dr. Kilburn, you have made reference, of course, to 
this important study that will come out next year, and the 
blend that is already in the Act to both permit some 
innovation, but to ensure that our dollars are well spent with 
evidence-based programs. Do you believe that that study will 
allow us to focus on more effective programs? Or do you think 
that the study is something that would lead to the elimination 
of the federal program entirely?
    Ms. KILBURN. I think the study will indicate whether this 
scaling up of the individual programs has been accomplished. 
So, were they able to replicate these programs with fidelity, 
and can we provide not just the quantity, but also the quality? 
I think it will also indicate whether, when you scale the 
programs up, you replicate the same outcomes.
    So it is one thing when Darcy is overseeing Child First 
very closely; we are pretty confident that we are going to get 
great results. But when we start having this replicated in 
other states, and Darcy is not directly involved, for example, 
can we achieve the same outcome? So it will provide information 
of that sort.
    Mr. DOGGETT. You believe in the value of home visiting as a 
way of preventing abuse and cost. It is a question more of how 
to do it, rather than whether to do it.
    Ms. KILBURN. That is right.
    Mr. DOGGETT. Is that correct?
    Ms. KILBURN. That is correct.
    Mr. DOGGETT. And, Ms. Towne, I am very impressed by both 
your testimony. But what would be the effect in your area if 
you lose federal funding?
    Ms. TOWNE. Unfortunately, as a home visitor, I am not sure 
that I could really testify to the answer to that, as far as 
funding resources go. I believe it would have a significant 
impact to our families in Yakima County.
    Mr. DOGGETT. I think your testimony--and yours, as well--
really did bring a human, very human dimension to the 
statistics that we frequently throw around here about how this 
program, this intervention, can really help make a difference 
in lives. And I look forward to your continued involvement, and 
report to the committee on how we can achieve the very most in 
using home visiting as a way to prevent abuse and other costs.
    Thank you so much for the testimony each of you gave.
    Ms. TOWNE. Thank you.
    Chairman REICHERT. Thank you, Mr. Doggett. Mr. Griffin, you 
are recognized.

[[Page 75]]

    Mr. GRIFFIN. Thank you, Mr. Chairman. Thank you all for 
being here today. Mr. Baron, I wanted to focus a little bit on 
HIPPY USA, which is--although it serves many folks across the 
country, it is based in Little Rock, which is my district, 
second congressional district in Central Arkansas. And HIPPY 
stands for Home Instruction for Parents of Preschool 
Youngsters, HIPPY USA.
    So, they are operating both in rural and urban areas, and I 
wanted to ask you, Mr. Baron, when you are reviewing your 
models for effectiveness, are you seeing any differences 
between the outcomes in rural areas versus urban areas? And, if 
so, what do you attribute those differences to?
    Mr. BARON. It is interesting that there have been 
evaluations of--scientific evaluations of home visiting, 
randomized trials that have been done in both rural and urban 
areas. One of the Nurse-Family Partnership studies was done in 
Upstate New York, in a rural, primarily white population, and 
that study found very large effects, as long as 15 years after 
the study began, for the treatment compared to the control 
group. Big decreases for the children of the mothers, for 
instance, in rates of criminal activity and rates of child 
maltreatment, and so on.
    But some of the other studies have been done, other good 
studies--another Nurse-Family Partnership randomized trial was 
done in Memphis, Tennessee, an urban setting. This study also 
found large effects, but different. The effects may vary for a 
variety of reasons. It might be the women in Upstate New York, 
there was a larger population of smokers than in Memphis. And 
then the third trial was also urban--that was done in Denver.
    What was most impressive about those sets of studies was 
that sizable effects were found across different ethnicities, 
rural versus urban. There were different effects across the 
different studies, but all showed important improvement in 
people's lives. The differing effects could have been because 
the populations were different.
    Mr. GRIFFIN. I think--Ms. Lowell, I think you referred to 
the fact that different programs or different methods are used 
to reach different outcomes. Different families have different 
needs. And I was wondering--and either you, Ms. Lowell, or Mr. 
Baron--when you look at these different programs, are there 
some programs or methods that work in certain areas--urban 
areas, for example--that don't work as well in rural? Have you 
seen anything that would indicate that, or different parts of 
the country?
    Ms. LOWELL. I think that, first of all, it has to do with 
the uniqueness of each family; and that if you really do a good 
assessment, and you really understand what the needs of that 
family are, you are going to be the most successful, because 
you are going to be able to target your intervention 
specifically to the needs of the family.
    As you described so beautifully, it is about what that 
family needs. Now----
    Mr. GRIFFIN. And just to interrupt there, because--so with 
each of the different models or programs or methodologies, that 
flexibility exists. They--with each of them they try to take 
the particular family's circumstances into account, and there 
is a certain flexibility there?

[[Page 76]]

    Ms. LOWELL. I think that each model does it in their own 
way. But I think that different models have different 
capabilities.
    And, for instance, in Connecticut we work in partnership 
with other home visiting. We have another big home visiting 
program. And so, we often get referrals from that other home 
visiting program, because they have a para-professional model. 
They know, if they are working with a mom who is really 
depressed, or one who has, let's say, domestic violence, that 
they are not really the right model to work with that family. 
So they will refer them to us. And we will do a very close 
transfer, so that we will then take that family, or take a 
family with a child who is having major behavior problems.
    I think that each of us has the same idea, that these are 
very family-focused kinds of interventions. And, in that sense, 
I think that everyone is trying to do that, really trying to 
understand who their families are.
    Mr. GRIFFIN. So there is some degree of nimbleness, if you 
will, to allow for tweaks and changes if--it sounds like, 
through transfers, or what have you--if things aren't working 
exactly as maybe one thought.
    And I am out of time. Thank you, Mr. Chairman.
    Chairman REICHERT. Thank you, Mr. Griffin. Mr. Crowley, you 
are recognized.
    Mr. CROWLEY. Ms. Kilburn, did you want to respond very 
quickly to that?
    Ms. KILBURN. Sure. I just wanted to raise one issue that 
hasn't come up today that I think is relevant, and that is that 
a constraint for implementing these models is the local 
workforce, and this is particularly relevant for rural areas.
    So, if you have a program that needs to deploy mental 
health clinicians, or registered nurses, it is the case that 
many rural areas are designated as health professional shortage 
areas, and you might have selected one of these great programs, 
and have the will to do it, and even have the funding, but you 
don't have the trained personnel to be able to pull it off.
    So, I think particularly in our rural areas, we are 
observing that some of these programs have not been selected, 
and that may be a contributing factor.
    Mr. CROWLEY. I appreciate that. Thank you, Ms. Kilburn.
    Mr. Chairman, reclaiming my time, I am very pleased we are 
having this hearing here today on an effective, evidence-based 
program that has tremendous social benefits down the road. 
Being from New York, I have seen the great work of the Nurse-
Family Partnership and what it does, and I have been so 
impressed with the results this program has shown over the 
years.
    New York City Nurse-Family Partnership is the largest urban 
program of its kind in the country. It has served more than 
10,500 clients since its creation in 2003, and currently 
serving more than 1,700 clients across all 5 boroughs. These 
dedicated professionals like Ms. Towne are working with New 
York City families to make sure they have the education, 
information, and assistance they need to raise their children 
and become stronger families. And the long-term results are so 
impressive, even beyond what you would expect from the 
immediate assistance provided.

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    Mr. Chairman, I would like to, if I could, offer into the 
record the state profile of the Nurse-Family Partnership of New 
York, if I could.
    Chairman REICHERT. Without objection.
    [The information follows: Mr. Crowley]

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                          Rep. Joseph Crowley

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    Mr. CROWLEY. Reductions in child abuse and neglect, better 
educational outcomes for children, a greater likelihood of 
economic stability for the mother, these results are not just 
good for the participants, but also are good for society, as a 
whole.
    Mr. Baron, I know you were here at a previous hearing this 
Subcommittee held, and we discussed the ripple effect we would 
see from cutting or eliminating funding for these types of 
programs. Our budget should focus on long-term priorities, not 
just short-term impacts. That is why I was so pleased that the 
Affordable Care Act started this federal investment and home 
visitation programs, and

[[Page 80]]

it is, in fact, an investment in the future health and well-
being of all families in our country.
    Your testimony references some of the research and 
evidence-based home visiting programs that shows they can lead 
to reductions in child abuse and injuries, improvements in 
educational outcomes for children, and even a reduction in 
needs-tested assistance over the long term for mothers. It is, 
therefore, reasonable to suggest that investment in strong home 
visiting programs will not only protect and help children, but 
also yield major benefits to society, and ultimately to 
taxpayers. Is that not correct?
    Mr. BARON. Yes, that is right. Often there is a claim that 
a social program is so effective that you can improve people's 
lives and save money. Very often, when a rigorous evaluation is 
done, the effects are not quite so promising. The claim doesn't 
pan out.
    But this is a case where, at least for some of the program 
models, like the Nurse-Family Partnership, and perhaps for 
Child First as well, the more effective models, it really does 
look like the evidence shows you can have your cake and eat it, 
too. You can improve people's lives in a very important way, 
over a long period of time, and reduce their use of public 
assistance, so that the government and taxpayer benefits, as 
well.
    Mr. CROWLEY. Win-win. I appreciate that. It is clear that 
this program is making a difference, and we need to maintain 
that federal support.
    I was pleased to see the President and his Administration 
have proposed a long-term extension expansion of this program. 
That is the kind of investment we should be making. Congress 
recently passed a short-term extension of this program, but it 
is clear that more must be done to build upon the success so 
far.
    I look forward to working with my colleagues on both sides. 
I want to commend the chairman for a very bipartisan approach 
to this issue, as well. I really do appreciate that. I hope 
that my colleagues on both sides of the aisle on this Committee 
will work with us to support this program. And, once again, Mr. 
Chairman, thank you for holding the hearing today.
    Chairman REICHERT. Thank you, Mr. Crowley. And, as you can 
see, and as Mr. Crowley said, this is really, truly a 
partnership up here, with Republicans and Democrats all 
appearing to be on the same page, wanting to help those that 
are most vulnerable. And I really--as an old cop--I know I 
mention this quite often, but I am proud to be, you know, an 
old law enforcement officer. But the evidence-based stuff is 
very critical, and you guys are doing an awesome job with that.
    So, congratulations. Congratulations to you, Ms. Sucilla, 
and your success. And, thank you, Ms. Towne, for your hard work 
that you do each and every day. So, we are going to see each 
other again. We will visit again, and continue to work 
together.
    If Members have additional questions for the witnesses, 
they will submit them to you in writing. And we would 
appreciate receiving your responses for the record within two 
weeks. The committee stands adjourned.
    [Whereupon, at 3:30 p.m., the subcommittee was adjourned.]
    [Member Questions for the Record follows:]

                                 

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                               Jon Baron


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                            Rebecca Kilburn






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                        Rebecca Kilburn Response


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    [Public Submission for the Record follows:]

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                   Scott Hippert Parents as Teachers



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