[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]



 
                  THE REAUTHORIZATION OF THE 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 FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 15, 2017

                               __________

                          Serial No. 115-HR02

                               __________

         Printed for the use of the Committee on Ways and Means
         
         
         
         
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]         




                 U.S. GOVERNMENT PUBLISHING OFFICE
                   
33-364                  WASHINGTON : 2019       
 
 
 


                      COMMITTEE ON WAYS AND MEANS

                      KEVIN BRADY, Texas, Chairman

SAM JOHNSON, Texas                   RICHARD E. NEAL, Massachusetts
DEVIN NUNES, California              SANDER M. LEVIN, Michigan
PATRICK J. TIBERI, Ohio              JOHN LEWIS, Georgia
DAVID G. REICHERT, Washington        LLOYD DOGGETT, Texas
PETER J. ROSKAM, Illinois            MIKE THOMPSON, California
VERN BUCHANAN, Florida               JOHN B. LARSON, Connecticut
ADRIAN SMITH, Nebraska               EARL BLUMENAUER, Oregon
LYNN JENKINS, Kansas                 RON KIND, Wisconsin
ERIK PAULSEN, Minnesota              BILL PASCRELL, JR., New Jersey
KENNY MARCHANT, Texas                JOSEPH CROWLEY, New York
DIANE BLACK, Tennessee               DANNY DAVIS, Illinois
TOM REED, New York                   LINDA SANCHEZ, California
MIKE KELLY, Pennsylvania             BRIAN HIGGINS, New York
JIM RENACCI, Ohio                    TERRI SEWELL, Alabama
PAT MEEHAN, Pennsylvania             SUZAN DELBENE, Washington
KRISTI NOEM, South Dakota            JUDY CHU, California
GEORGE HOLDING, North Carolina
JASON SMITH, Missouri
TOM RICE, South Carolina
DAVID SCHWEIKERT, Arizona
JACKIE WALORSKI, Indiana
CARLOS CURBELO, Florida
MIKE BISHOP, Michigan

                     David Stewart, Staff Director

                 Brandon Casey, Minority Chief Counsel

                                 ______

                    SUBCOMMITTEE ON HUMAN RESOURCES

                    ADRIAN SMITH, Nebraska, Chairman

JASON SMITH, Missouri                DANNY DAVIS, Illinois
JACKIE WALORSKI, Indiana             LLOYD DOGGETT, Texas
CARLOS CURBELO, Florida              TERRI SEWELL, Alabama
MIKE BISHOP, Michigan                JUDY CHU, California
DAVID G. REICHERT, Washington
TOM REED, New York


                            C O N T E N T S

                               __________

                                                                   Page

Advisory of March 15, 2017, announcing the hearing...............     2

                               WITNESSES

Beth Russell, Nurse Home Visitor, Nurse-Family Partnership, 
  Lancaster General Health/Penn Medicine, Lancaster, Pennsylvania    10
Rosa Valentin, Client, Nurse-Family Partnership, Lancaster 
  General Health/Penn Medicine, Lancaster, Pennsylvania..........    20
Eric Bellamy, Home Visiting Manager, Children's Trust of South 
  Carolina.......................................................    26
Diana Mendley Rauner, Ph.D., President, The Ounce of Prevention 
  Fund...........................................................    36

                        QUESTIONS FOR THE RECORD

Questions submitted by The Honorable Tom Reed of New York to Eric 
  Bellamy, Home Visiting Manager, Children's Trust of South 
  Carolina.......................................................    59
Questions submitted by The Honorable Danny Davis of Illinois to 
  Diana Mendley Rauner, Ph.D., President, The Ounce of Prevention 
  Fund...........................................................    62

                       SUBMISSIONS FOR THE RECORD

Charles Bruner, Ph.D.............................................    66
American Academy of Pediatrics (AAP).............................    68
Baby TALK........................................................    74
Child & Family Research Partnership (CFRP).......................    75
Children's Home Society of Washington............................    83
Children's Institute.............................................    84
Easterseals, Incorporated........................................    86
Fight Crime: Invest in Kids Council for a Strong America.........    89
Home Nursing Agency..............................................    91
Home Visiting Coalition..........................................    95
Johns Hopkins Center for American Indian Health (JHCAIH).........    99
National Nurse-Led Care Consortium (NNCC)........................   103
Nurse-Family Partnership.........................................   108
  Beth Russell...................................................   111
  Virginia Sosnowski, RN, BSN....................................   112
Parent-Child Home Program (PCHP).................................   113
Parents as Teachers National Center (PATNC)......................   116
Partners in Community Outreach (PiCO)............................   122
Pennsylvania Department of Human Services, Office of Child 
  Development and Early Learning (OCDEL).........................   127
People's Emergency Center (PEC)..................................   137
Prevent Child Abuse America......................................   139
Responsible Fatherhood Roundtable................................   145
Shriver Center, Sargent Shriver National Center on Poverty Law...   149
The Dads Matter Research Team at the University of Chicago School 
  of Social Service Administration and the University of Denver 
  School of Social Work..........................................   152
The Florida Association of Healthy Start Coalitions, Incorporated 
  (FAHSC)........................................................   155
United Way of Miami-Dade.........................................   163
Voices for Ohio's Children.......................................   164
Washington State Home Visiting Coalition.........................   171


                  THE REAUTHORIZATION OF THE MATERNAL,

                    INFANT, AND EARLY CHILDHOOD HOME

                       VISITING (MIECHV) PROGRAM

                              ----------                              


                       WEDNESDAY, MARCH 15, 2017

             U.S. House of Representatives,
                       Committee on Ways and Means,
                           Subcommittee on Human Resources,
                                                    Washington, DC.

    The Subcommittee met, pursuant to call, at 10:00 a.m., in 
Room 1100, Longworth House Office Building, Hon. Adrian Smith 
[Chairman of the Subcommittee] presiding.
    [The advisory announcing the hearing follows:]
    
    

ADVISORY

FROM THE COMMITTEE ON WAYS AND MEANS


                    SUBCOMMITTEE ON HUMAN RESOURCES

                                                CONTACT: (202) 225-1721
FOR IMMEDIATE RELEASE
Wednesday, March 15, 2017
HR-02

                Chairman Smith Announces Human Resources

              Subcommittee Hearing on the Reauthorization

              of the Maternal, Infant, and Early Childhood

                     Home Visiting (MIECHV) Program

    House Ways and Means Human Resources Subcommittee Chairman Adrian 
Smith (R-NE), announced today that the Subcommittee will hold a hearing 
entitled ``Reauthorization of the Maternal, Infant, and Early Childhood 
Home Visiting (MIECHV) Program'' on Wednesday, March 15, at 10:00 a.m. 
in room 1100 of the Longworth House Office Building. This hearing will 
examine a range of home visiting models, review how States operate and 
fund programs, and highlight how an evidence-based home visiting 
program can produce positive outcomes for children and families.
      
    In view of the limited time to hear witnesses, oral testimony at 
this hearing will be from invited witnesses only. However, any 
individual or organization may submit a written statement for 
consideration by the Committee and for inclusion in the printed record 
of the hearing.
      

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

      
    Please Note: Any person(s) and/or organization(s) wishing to submit 
written comments 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 make a submission, and click on the link 
entitled, ``Click here to provide a submission 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 the close of business 
on Wednesday, March 29, 2017. For questions, or if you encounter 
technical problems, please call (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 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 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.
      
    All submissions and supplementary materials must be submitted in a 
single document via email, provided in Word format and must not exceed 
a total of 10 pages. Witnesses and submitters are advised that the 
Committee relies on electronic submissions for printing the official 
hearing record.
      
    All submissions must include a list of all clients, persons and/or 
organizations on whose behalf the witness appears. The name, company, 
address, telephone, and fax numbers of each witness must be included in 
the body of the email. Please exclude any personal identifiable 
information in the attached submission.
      
    Failure to follow the formatting requirements may result in the 
exclusion of a submission. All submissions for the record are final.
      
    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 TDD/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 at
    http://www.waysandmeans.house.gov/

                                 

    Chairman SMITH OF NEBRASKA. The Subcommittee will come to 
order.
    Thank you for joining us here today. Welcome to our Human 
Resources Subcommittee hearing. Today we are here to discuss 
the Maternal, Infant, and Early Childhood Home Visiting 
program, known as MIECHV, which helps support State and local 
efforts to provide voluntary, evidence-based, outcome-focused 
home visiting services to parents and children at risk of 
adverse experiences. The program's objectives include promoting 
school readiness of young children, increasing economic self-
sufficiency of families, improving prenatal health and birth 
outcomes, and preventing child abuse and neglect.
    This hearing will examine a range of home visiting models, 
review how States operate and fund programs, and highlight how 
an evidence-based home visiting program can produce positive 
outcomes for children and families.
    Federal funding for home visiting was first proposed in 
2004 by Republican Senators Chris Bond and Jim Talent, both 
from Missouri. However, the first Federal funds for evidence-
based home visiting were provided in fiscal year 2008 after 
Congress agreed to fund President George W. Bush's proposal to 
test this approach and measure the outcomes. The MIECHV program 
was fully authorized in fiscal year 2010 to continue these 
efforts and is now up for reauthorization this year.
    I, like other Members of this Subcommittee, have had the 
opportunity to see firsthand what home visiting looks like in 
my community. Last Monday, I spent time with the Panhandle 
Public Health District's Healthy Families America program, 
which aims to improve the economic success and school readiness 
of vulnerable children and families in three Nebraska counties: 
Scotts Bluff, Morrill, and Box Butte. Dawn, one participant I 
met with on Monday, shared her experience of working with a 
home visitor who helped her find a stable home and a steady 
income in order to provide for her growing family. These are 
the types of outcomes we should be expecting and receiving from 
the use of limited taxpayer resources. Unfortunately, outcomes 
like these are the exception rather than the rule when we look 
around at how we help struggling families.
    New Federal social programs have been evaluated to 
determine if they are working, and almost none have conditioned 
funding on evidence of effectiveness. In our Better Way agenda, 
we proposed measuring how well programs are working so we can 
focus funding on programs which produce real results. When we 
spend limited taxpayer dollars to help those in need, we must 
make sure we are spending money on effective programs. To do 
otherwise is a disservice to both taxpayers as well as 
beneficiaries. MIECHV is one of the only social programs where 
funding is tied to proving evidence.
    For a home visiting model to be funded, an evaluation must 
show the program has demonstrated significant, positive 
outcomes in areas such as reducing child abuse and neglect, 
improving maternal and child health, and improving economic 
self-sufficiency. Many of these approved models are now being 
further studied through a rigorous random assignment evaluation 
to better measure their impact so we know families are 
receiving real help. States have also been held accountable for 
demonstrating positive outcomes for children and families. If 
they don't show improvements in four of six areas specified in 
law, they have to explain how they plan to improve their 
services to get results, which again provide real help to 
struggling families.
    A top priority for this Subcommittee in this Congress 
continues to be ensuring greater opportunity for Americans. 
Last week, I was grateful to learn more about how the Home 
Visiting program empowers Nebraska parents to provide a better 
life for their children, and I look forward to hearing more 
about similar efforts across the country today as we look 
forward to MIECHV reauthorization.
    I now yield to the distinguished Ranking Member, Mr. Davis, 
for the purpose of an opening statement.
    Mr. Davis.
    Mr. DAVIS. Thank you very much, Mr. Chairman. And I want to 
thank you for holding this hearing on evidence-based home 
visiting. I would like to ask unanimous consent to submit a 
group of stories that have--well, not really stories, but 
experiences that have been submitted about families in my 
district, and I would like to submit those for the record.
    Chairman SMITH OF NEBRASKA. Without objection.
    [The submission of Mr. Davis follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]           

                                 
    Mr. DAVIS. Before I came to Congress, I worked in community 
health centers and saw firsthand how home visits by community 
health workers helped engage people to change behaviors and 
embrace preventative health approaches. I introduced my first 
bipartisan home visiting bill over a decade ago in 2005. And so 
I look forward to continuing this bipartisan work with you and 
other Members of this Committee.
    Frederick Douglass said, ``It is easier to build strong 
children than to repair broken men.'' And I agree. Infants are 
more likely to enter foster care than any other age group, 
twice as likely as 1-year-olds and more than five times as 
likely as 11-year-olds. Several home visiting models, including 
Healthy Families America, which is headquartered in Chicago, 
have proven that home visiting is a tool that can keep these 
children safe at home.
    Children at risk of foster care are not the only ones who 
benefit from home visiting. In my congressional district, 
nearly 60 percent of children 5 and under live in low-income 
families. Some of them are fortunate to be served by the Home 
Instruction for Parents of Preschool Youngsters, our HIPPY 
program, which has a long track record of working with parents 
of all backgrounds to prepare children to succeed at school.
    The Federal Maternal, Infant, and Early Childhood Home 
Visiting program, or MIECHV, did not invent home visiting. My 
home State of Illinois has invested in home visiting for 30 
years, and we are not alone. MIECHV has played a vital role in 
strengthening these State and local efforts. Where home 
visiting did not exist, MIECHV offered the neediest families 
this lifeline for the first time. In States with home visiting, 
like Illinois, MIECHV improved program coordination, reinforced 
the emphasis on proven models, and expanded availability of 
services. In my congressional district, MIECHV directly 
provides home visiting services to 219 additional families and 
has supported innovative pilot projects for homeless families 
and parenting foster youths.
    MIECHV is built on a foundation of decades of research. The 
Department of Health and Human Services has identified 17 
different models that meet its stringent tests for proven 
results. States, territories, and tribes can choose from a 
range of evidence-based models that allow them to target the 
right help to the right families at the right time. Some States 
even transition families from one model to another as children 
grow. In Illinois, MIECHV funds a central intake process to 
make sure families are directed to the most effective models 
for their needs.
    Although home visiting models focus on different aspects of 
child well-being and use visitors with different 
qualifications, they have important commonalities. Home 
visitors form positive relationships with families to help them 
find strength in themselves and in their communities. They link 
families with critical supports like transportation assistance, 
substance abuse, and mental health treatment, child care, and 
economic support, and they measurably improve outcomes for 
children. MIECHV has already made a difference for tens of 
thousands of children and families. And as we continue to 
invest and home visiting models continue to learn from rigorous 
research evaluations, from careful data tracking, from the 
families and communities they serve, and from each other, I 
believe we will be able to do even more to build strong 
children who grow into successful adults.
    So I thank you, Mr. Chairman, and I yield back the balance 
of my time.
    Chairman SMITH OF NEBRASKA. Thank you, Mr. Davis.
    And without objection, other Members' opening statements 
will be made a part of the record.
    I would like to welcome our witnesses here today. Thank you 
for joining us. This is a conversation that I think can help 
many folks, and so, certainly, it is a conversation that we can 
benefit from as we learn more from you.
    I will introduce the panel we have here today. First, we 
have Ms. Beth Russell, nurse home visitor, Lancaster General/
Penn Medicine. And Ms. Rosa Valentin. She is a client with 
Lancaster General/Penn Medicine. And Mr. Eric Bellamy, home 
visiting manager, Children's Trust of South Carolina. And Ms. 
Diana Rauner, president of The Ounce of Prevention Fund in 
Illinois.
    Witnesses are reminded to limit their oral statements to 5 
minutes. You will see the light there. With the yellow light 
there, you can look to perhaps, as they say, bring it in for a 
landing. And all of your written statements will be included 
in--your full written statements will be included in the 
record.
    Right now, we will begin with Ms. Russell. You may begin 
when you are ready.

  STATEMENT OF BETH RUSSELL, NURSE HOME VISITOR, NURSE-FAMILY 
PARTNERSHIP, LANCASTER GENERAL HEALTH/PENN MEDICINE, LANCASTER, 
                          PENNSYLVANIA

    Ms. RUSSELL. Good morning, Chairman Smith, Ranking Member 
Davis, and Members of the Subcommittee. Thank you for the 
opportunity to testify on behalf of Nurse-Family Partnership 
and Lancaster General Health/Penn Medicine in support of 
evidence-based home visiting and the Maternal, Infant, and 
Early Childhood Home Visiting program.
    I am Beth Russell, and I have worked as an NFP nurse home 
visitor for nearly 5 years. I have the privilege of helping new 
mothers become the best moms they can be for their babies. As a 
nurse home visitor, I serve a regular caseload of 25 first-
time, low-income mothers and their families, including my 
client who is here with me today, Rosa Valentin.
    NFP is a voluntary program that provides regular home 
visits to first-time, low-income mothers by registered nurses, 
beginning early in pregnancy and continuing through the child's 
second year of life. Each woman is partnered with her own free 
personal nurse, a nurse that can be there for her, getting to 
know her during pregnancy, and building trust with her family 
to offer critical support when it is most needed.
    As a nurse home visitor, I serve many kinds of clients. 
Truly, you never know what you will encounter until you meet 
with that mom for the first time. However, in every instance, I 
meet the client where she is, and hopefully I can be a positive 
force for good in her life amidst often stressful situations.
    When I first met Rosa in early 2015, I met a scared, quiet, 
14-year-old with little direction other than that she was 4 
months into an unplanned pregnancy and wanted to do the right 
thing for her baby. She was anxious and unsure if she could be 
a good mom and did not want to give up on her goals to finish 
high school and further her education. Rosa had her whole life 
ahead of her and was still figuring out who she wanted to be. 
Unlike many of my clients, Rosa had supportive parents who 
wanted to help her, but Rosa sought guidance, health advice, 
and one-on-one support as she attempted to navigate becoming a 
parent at such a young age.
    I quickly realized during the first encounter that it would 
take some work to open Rosa up to me, so I took my time to make 
her comfortable. Combine the uncertainty of being pregnant for 
the first time with being a teenager, and Rosa had a lot of 
anxiety she needed to share. ``I needed to vent,'' Rosa would 
say. I was there to listen at each visit and become the person 
Rosa could open up to.
    I had Rosa make a list of her needs and goals and made 
several referrals to get her the right services that she needed 
to complement our visits. I referred her to A Woman's Concern, 
which is a local pregnancy support organization that provides 
education support for parents, and Teen Elect, which helps 
pregnant and parenting students complete their educational 
goals. Rosa was already attending Cyber School, a program that 
allows her to complete her high school diploma primarily 
online. While she had a strong desire to finish, she needed 
confidence to continue, given her pregnancy and impending 
motherhood.
    Rosa had a generally healthy pregnancy, but she struggled 
with the fact that the child's father was not around as much as 
she would have liked and disappointment about not having the 
type of family she would have liked to bring a child into. 
Additionally, routine screening for depression did show that 
Rosa had elevated scores, which prompted conversations about 
counseling. NFP's client-centered approach allowed Rosa to make 
this decision, and while initially she did not want to see a 
counselor, she eventually agreed and now sees how it has helped 
her. Through lots of individual conversation and reflection, 
Rosa was able to get past the things that were holding her back 
and focus on the parent that she wanted to be for her child. I 
also know that our conversations about health and wellness, 
prenatally, postnatal, and for her child, were important to her 
and helped her to be reassured when she was concerned.
    Now 2 years after our first meeting, Rosa is the proud, 
confident parent of 20-month-old Angelica, who is here with us 
today. She is a junior in high school and on track to graduate 
next year. She has also been accepted into a local vocational-
technical program where she plans to enroll next year. 
Initially, she was interested in cosmetology, but has a growing 
interest in the field of health care. Learning lots of new 
medical terminology over the course of her pregnancy and being 
a mom might have had something to do with that. In addition, 
Angelica continues to be a very healthy child, up to date on 
all well-child visits and immunizations, and has excellent 
developmental scores that reinforce Rosa's positive and 
responsive caregiving.
    In my role as a nurse home visitor, I work with each client 
to help her to establish her education, employment, and life 
course development goals. While Rosa was initially very unsure 
about where this road would take her, she had the sheer will to 
try to make the best of it, and it is that determination, those 
glimmers of achievement along the way, that keep me doing the 
work that I do as a nurse home visitor. I am so proud of her 
progress and her willingness to share her story with you today.
    Rosa's story is just a glimpse of the impact that Nurse-
Family Partnership has on low-income, first-time parents. Rosa 
is one of over 250,000 that have been partnered with a 
registered nurse through Nurse-Family Partnership. The program 
is backed by over 40 years of evidence, and each visit to a new 
mom's home is tracked to measure the impact we are making in a 
young family's life.
    The MIECHV program is a strong and cost-effective Federal 
policy that is joining States and local agencies to support 
these valuable services to at-risk moms. Without congressional 
action, this program which funds my work and is helping young 
mothers like Rosa and young children like Angelica will expire 
this September. I hope that Congress takes swift action to 
reauthorize the MIECHV program for at least 5 years with the 
increased funding that is needed to reach more families.
    Thank you again, Chairman Smith, Ranking Member Davis, and 
Members of the Subcommittee for the opportunity to testify 
today and for your support of evidence-based home visiting 
programs.
    [The prepared statement of Ms. Russell follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    Chairman SMITH OF NEBRASKA. Thank you, Ms. Russell.
    Ms. Valentin, you may begin.

 STATEMENT OF ROSA VALENTIN, CLIENT, NURSE-FAMILY PARTNERSHIP, 
LANCASTER GENERAL HEALTH/PENN MEDICINE, LANCASTER, PENNSYLVANIA

    Ms. VALENTIN. Good morning, Chairman Smith, Ranking Member 
Davis, 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 Rosa Valentin, and I am a client with the Nurse-
Family Partnership program delivered by Lancaster General 
Health in Lancaster, Pennsylvania. I am the incredibly proud 
mother of my daughter, Angelica, who is 20 months old and here 
with me today.
    As a client, I have received regular visits about every 
other week from my NFP nurse home visitor, Beth Russell, 
starting when I was just 4 months pregnant. I am 16 years old 
and have lived in Lancaster my entire life with my mother and 
father. Two years ago, when I was 14 years old, I found out I 
was pregnant with Angelica. I was in shock. What am I going to 
tell my mother? Thankfully, my mom was supportive of my 
decisions to have the baby, and from the minute I saw her arms, 
legs, and fluttering heartbeat, I knew that I wanted to protect 
her from any harm and do what was best for her.
    I heard about the NFP program through my doctor's office. 
Because I was a first-time mom and met the other eligibility 
requirements, they referred me to Lancaster General Health's 
NFP program and Beth. We set up an appointment for Beth to come 
to my home and talk more about the program. I was shy at first, 
but Beth helped me to start thinking about my goals and 
programs that were available to help me as a teenager. I 
started to look forward to our visits. Up until the point where 
I got pregnant, I had taken care of my little cousins as 
babies, but that was about it.
    On June 23, 2015, at 2:39 p.m., my life changed. My baby 
girl was born weighing 6 pounds, 3 ounces, and measuring 19\1/
2\ inches long. She had jet-black hair and black eyes. Now I 
had a lot to learn about taking care of my own baby, not to 
mention navigating my own personal challenges. I had 
experienced a lot of disrespect from my peers about my 
pregnancy, and although my mom and dad have always been there 
for me, I didn't have the support of my entire family. And 
although I initially expected Angelica's father to be a part of 
raising her, and I thought we would be together as a family to 
experience her milestones, ultimately he was not in the 
picture. This was very difficult for me, and I struggled to 
move past that, but I had to take care of my baby and reach my 
goals.
    Beth helped me do just that. She has been there for me 
emotionally, sometimes just as a listening ear for venting or 
to provide suggestions on dealing with stressful situations so 
that I can get back to being the mom I needed and wanted to be.
    Angelica is the love of my life. After I brought my baby 
girl home, it seemed like all I wanted to do was spend time 
with her, and there was so much to learn about taking care of a 
new baby. Beth showed me how to bathe her for the first time 
and answered all of my questions about what was going on with 
my baby.
    It was difficult to keep up as a new mom. I was still a 
high school student and started to fall behind on my online 
classes. Beth helped me not to lose sight of my goals for 
school. ``This is what you wanted for yourself,'' she reminds 
me. She helped me to develop a routine for my daughter and find 
time for myself to study. It was exhausting taking care of a 
new baby, but Beth helped me to stay focused. I will go to 
college.
    Beth also helped me find programs to support my parenting 
and educational goals and stick with them. When I initially 
questioned how long I could stick with breastfeeding, she 
encouraged me to set goals and do what I felt was right. My 
initial goal was 6 months, and today, I am still nursing my 20-
month-old daughter, although trying to wean.
    Like every new mom, I had concerns, and Beth has always 
been there to address them. Beth has also been a resource for 
my mom, who is usually involved with our home visits because 
she helps me take care of Angelica. It has meant so much to me 
to have a nurse at my side, someone who I could trust for 
advice when I was experiencing round ligament pain late in my 
pregnancy and was concerned about the baby, or had cramping 
while breastfeeding. Beth was also very helpful when I was 
worried about Angelica's weight because others thought she was 
too small or if she was learning things at the right pace. Beth 
was always able to reassure me that Angelica was growing well 
and passing her developmental screenings. She also helped me 
understand birth control options after pregnancy, and when I 
was under a lot of stress and needed counseling, Beth helped me 
understand why it was important to talk to somebody.
    What I think is important for me to provide for Angelica is 
consistency. I am trying to follow the four C's of parenting: 
clear, calm, consequences, and consistency, and use encouraging 
words to help her realize what to do instead of what not to do. 
These concepts are all so important for me as my baby grows 
into a toddler. Every day I am so excited for all the new 
things she is learning and showing me. Angelica makes me proud 
every day, and I am so proud to see how much she has learned 
and how much she has grown.
    When I found out I was pregnant, I was a freshman in high 
school. Now here I am with a beautiful blue-eyed, 20-month-old 
little girl, looking forward to my senior year and the Career 
and Technology Center's program for cosmetology. After I 
graduate, I would like to go on to college and graduate school 
and have a career as a prenatal nurse.
    Even though being a mom at times isn't easy, Angelica is my 
motivation to do better, finish school, and have a career. I am 
lucky to say that I had the support to help me along the way. I 
truly hope that Congress will continue supporting the Maternal, 
Infant, and Early Childhood Home Visiting program, which 
supports great programs like Nurse-Family Partnership.
    Thank you, Chairman Smith, Ranking Member Davis, and 
Members of the Subcommittee for the opportunity to testify 
today.
    [The prepared statement of Ms. Valentin follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]      
    

                                 
    Chairman SMITH OF NEBRASKA. Thank you, Ms. Valentin. Well 
done.
    Mr. Bellamy, please proceed.

 STATEMENT OF ERIC BELLAMY, HOME VISITING MANAGER, CHILDREN'S 
                    TRUST OF SOUTH CAROLINA

    Mr. BELLAMY. Good morning. Chairman Smith, Ranking Member 
Davis, and Members, please let me preface with I apologize for 
bringing this crazy weather from South Carolina to DC. But 
thank you for inviting me to represent South Carolina's 
perspective on MIECHV. I represent Children's Trust of South 
Carolina, the agency designated by the Governor to administer 
the State's MIECHV funding.
    Thanks to MIECHV, South Carolina serves families in 39 of 
46 counties. We still have a long way to go in reaching all the 
children and families who could benefit from home visiting. But 
that task would be significantly harder without MIECHV funds, 
specifically the direct services and the underpinnings for 
quality and accountability that MIECHV provides.
    MIECHV funds voluntary, evidence-based home visiting to 
disadvantaged families with young children. Families receiving 
home visiting saw significant improvements in measures such as 
birth outcomes, child development screenings and referrals, 
prevention of child abuse and neglect, school readiness. These 
outcomes and the program's broader success are the results of a 
law that provides State and tribal grantees with a firm 
foundation in evidence-based practice and the flexibility to 
match these practices to individual community needs.
    In 2010, Governor Sanford designated Children's Trust as 
the lead agency to implement and administer the State's MIECHV 
grant. Like other States, we conducted a needs assessment to 
determine which communities were most at risk and which proven 
interventions would best be suited to meet their needs. Our 
needs assessment identified counties with significant 
populations of families at risk for poverty, poor birth 
outcomes, child abuse and neglect, and low school readiness. 
Even in a State the size of South Carolina, no one approach 
meets the needs of all children and families.
    We selected four evidence-based models to meet the needs of 
children and parents: Healthy Steps, Family Check-Up, Healthy 
Families America, and Nurse-Family Partnership. We have since 
added Parents as Teachers, and in 2013, we expanded from 12 
counties to 38 counties. To date, over 6,200 South Carolina 
families have received MIECHV home visits.
    This implementation process illustrates many of the 
strengths of the legislation. States tailor their approach to 
address statewide goals for improving early childhood outcomes. 
States can choose to address prenatal and infant health, child 
abuse and neglect prevention, and/or school readiness goals. 
States can also select any combination of approved models to 
deploy in targeted communities. Each State's home visiting 
network looks a little different. However, every MIECHV program 
is supported by the same evidence base and is held to the same 
requirements that document outcomes and demonstrate continuous 
quality improvement.
    South Carolina can say with confidence and evidence that 
MIECHV continues to make important progress in improving the 
health and economic well-being of our vulnerable families. But 
MIECHV does more than fund direct services to children and 
families. It underpins the statewide foundation on which high-
quality services depend. South Carolina's MIECHV grant allowed 
us to create the data system that collects and reports 
information on outcomes and provides funding for professional 
development and training for home visitors. These resources are 
available to all home visitors in the State, regardless of how 
their programs are funded.
    Another defining strength of MIECHV is the robust and 
tiered evidence base. MIECHV's rigorous evidence standards give 
State legislators and philanthropies an objective validation 
for investing in home visiting. In South Carolina, we saw a 
significant increase in the philanthropic dollars flowing into 
existing home visiting programs after MIECHV was signed into 
law. While private philanthropy provided modest support for 
home visiting prior to MIECHV, in the years since 2011, we have 
seen an increase in support from organizations such as Duke 
Endowment Foundation, the Blue Cross and Blue Shield 
Foundation, the Boeing Foundation, and other private funders.
    I realize my time is up, though there is much more that I 
could say. If you remember only one thing from South Carolina, 
I hope it is this: MIECHV is evidence-based policy that works 
to empower families, coordinate services, and unify systems.
    I appreciate your time and attention this morning. I will 
be happy to answer any questions you may have. Thank you.
    [The prepared statement of Mr. Bellamy follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    Chairman SMITH OF NEBRASKA. Thank you, Mr. Bellamy.
    Ms. Rauner.

STATEMENT OF DIANA MENDLEY RAUNER, PH.D., PRESIDENT, THE OUNCE 
                       OF PREVENTION FUND

    Ms. RAUNER. Chairman Smith, Ranking Member Davis, and 
Members of the Subcommittee, thank you for the opportunity to 
testify in connection with your hearing on the reauthorization 
of the Maternal, Infant, and Early Childhood Home Visiting 
program. My name is Diana Rauner and I am here today in my role 
as the President of The Ounce of Prevention Fund, a public-
private partnership serving children and families from before 
birth through age 5. I am also a developmental psychologist, 
the Co-chair of the Illinois Home Visiting Task Force, and the 
First Lady of the State of Illinois.
    I began my career in investment banking and private equity 
investing, so I know something about return on investment. And 
I came to the field of early childhood because of concerns 
about the huge social and economic costs of educational 
inequities. I chose to focus on early childhood development 
because investments in the first years of life are simply the 
most efficient and effective ways to develop human capital. 
With the right investments, human capital development can 
provide great economic and social gains for individuals and for 
society.
    James Heckman, a Nobel Laureate at the University of 
Chicago, recently said, ``The real measure of child poverty 
isn't money, it's love.'' Voluntary home visiting programs that 
support parents in their critical responsibilities to help 
their children become healthy, successful citizens are the most 
effective human capital investments we can make because they 
compound the positive behavior of parents and children.
    I wish to voice my strong support for the MIECHV program 
and respectfully urge you and your colleagues to reauthorize 
MIECHV. The funding Illinois receives from MIECHV has 
significantly enhanced our State's robust early childhood and 
home visiting systems and is a vital component of our 
infrastructure. Illinois has long valued evidence-based home 
visiting programs as an effective and efficient strategy for 
strengthening expectant and new vulnerable families, by 
increasing children's readiness for school, reducing the risk 
of child abuse and neglect, and improving economic self-
sufficiency.
    Over the past three decades, Illinois has developed a 
cross-sector statewide home visiting system, serving over 
17,000 families per year, making it a nationally recognized 
model of a State system supporting a variety of evidence-based 
models and innovative practices. Please refer to my written 
testimony which provides a more thorough picture of home 
visiting in Illinois.
    For today's purposes, I would like to elaborate a little on 
what MIECHV funding has allowed us to do in Illinois. We have 
reached more at-risk families. Last year, nearly 1,000 
additional families received more than 12,000 home visits. We 
have improved our home-visiting workforce through infant mental 
health consultation that teams mental health professionals with 
home visitors, and additional training for home visitors, 
regardless of funding, to enhance their understanding of 
critical topics, such as domestic violence, substance abuse, 
and child abuse prevention.
    MIECHV has increased coordination and collaboration across 
funding streams. For example, MIECHV's focus on identifying the 
outcomes that help best support families is something that all 
Illinois funders are now considering in their systems. MIECHV 
has pioneered coordinated intake, which ensures that families 
referred to home visiting are matched with a program and the 
model that best meets their particular needs and that they have 
access to other services as well. This concept of coordinated 
intake introduced through MIECHV has generated such interest 
that several communities not funded directly through MIECHV 
have chosen to develop coordinated intake systems with 
technical assistance from our MIECHV team.
    We have been able to test innovations, including projects 
focused on some of our most vulnerable families, such as 
homeless families and pregnant and parenting youth in care, and 
in randomized control evaluations to examine the effectiveness 
of doula-enhanced home visiting. We hope these innovations will 
be useful to other States as they are proven.
    Decades of research show that high-quality, evidence-based 
home visiting programs produce long-term positive outcomes for 
children and families. Data from Illinois show that home 
visiting services are increasing breastfeeding rates and birth 
intervals between births, particularly among teen parents; 
improving parenting practices; and ensuring that children are 
routinely screened for developmental delays. Research 
demonstrates that these outcomes, while measured in the short-
term, set children and families on a positive trajectory for 
the long-term. The MIECHV program has increased the focus on 
these outcomes which is raising the bar for all home visiting 
programs in our State.
    In closing, I would like to reiterate my strong support for 
the MIECHV program. MIECHV undergirds and enhances our entire 
home visiting system and improves the lives of at-risk families 
and children in Illinois. It must continue, and I hope you view 
me, The Ounce, and the First Five Years Fund, our project, as a 
resource in that regard.
    Thank you for your time and consideration of my testimony. 
I will be happy to answer your questions.
    [The prepared statement of Ms. Rauner follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    Chairman SMITH OF NEBRASKA. Thank you, Ms. Rauner.
    Thank you to all of our witnesses here today. We appreciate 
your insights. They are important for us. So now we will go 
through questions here from myself and the Members.
    I will begin. Mr. Bellamy, in your testimony, you hit on a 
very important point about the program that I think is 
sometimes overlooked, and it is a point about how Federal 
funding programs based on evidence can really support States, 
and even the nonprofit sector, in their efforts to focus on 
what works. In your testimony, you highlight how the MIECHV 
program itself is important, but also that the evidence 
standard is set up and the signal it sent was just as important 
as it identified the models that were shown to be most 
effective. For example, I know once MIECHV-specified programs 
must be evidence-based and show results to receive funding, 
Nebraska, my home State, tied their own State funding to a 
similar standard so now all home visiting in Nebraska is 
evidence-based.
    Can you tell us a bit more about how the evidence standard 
in MIECHV has influenced the State practice in funding home 
visiting?
    Mr. BELLAMY. Yeah. I think the fact that MIECHV has set a 
level of standardization has really influenced how funders look 
at what they will fund around evidence-based practices. We have 
adopted in our South Carolina MIECHV program that we would only 
fund evidence-based programs. And private funders, as well as 
our State, has looked at that standardization authorization for 
those evidence-based programs to really look at setting a 
target and really being able to identify those practices as we 
move forward.
    At this point, funding has not moved in our State as far as 
looking at specific evidence-based practices. We want to build 
a continuum of services in our State around evidence-based 
practices, so we want to continue to really build a systematic 
approach to it.
    Chairman SMITH OF NEBRASKA. In your interactions with other 
States perhaps, have you learned what other States have done, 
or could you point to anything like that perhaps?
    Mr. BELLAMY. Tough for me to say. Well, in conversations 
with my peers in other States, there have been States that have 
identified ways to look at their standardization. They have 
worked with their legislation to really put into action some of 
their standards in evidence-based standardization. It would be 
difficult for me to pinpoint exactly where those States are at 
this time, but, yes, there have been other standardizations 
looked at in how they have adopted those practices.
    Chairman SMITH OF NEBRASKA. Thank you.
    Anyone else on the panel wish to comment? Ms. Rauner.
    Ms. RAUNER. I would just add that one of the ways that 
MIECHV has helped with standardization is in terms of 
standardization of the workforce, common understanding of what 
qualities are necessary across the models for training and 
professional development, ongoing professional development, and 
credentials. And that has, again, raised the standards and 
raised uniformity across programs and across funding streams.
    Chairman SMITH OF NEBRASKA. Thank you.
    Anyone else? If not, that is fine.
    I now recognize the Ranking Member, Mr. Davis, for any 
questions he might have.
    Mr. DAVIS. Thank you very much, Mr. Chairman. And I also 
want to thank all of the witnesses.
    Mr. Bellamy, let me ask you, I don't run into that many men 
in this line of work. What drew you to it, if you would?
    Mr. BELLAMY. To the work that I do?
    Mr. DAVIS. Yes.
    Mr. BELLAMY. That is a very good question, Mr. Davis. You 
know, years ago, I started out in doing teen pregnancy 
prevention work and worked with adolescents in direct services, 
and it really influenced my passion with working with younger 
populations. But, essentially, what it boils down to is the 
fact that I thoroughly believe that early intervention is a 
predictor of some very good things in later years, and I think 
our youngest population is the most vulnerable population, and 
we need to target those strategies, whether it be men, women, 
whatever the case may be. And I am just passionate about what I 
do and the work that I do and, hopefully, I can bring a 
different perspective sometimes from where I sit as a State 
lead.
    Mr. DAVIS. Thank you. Thank you very much.
    Dr. Rauner, it is not every day that I run into a First 
Lady of the State who also has a full-time working job and is 
involved with all kinds of other social service entities.
    The Ounce of Prevention is supporting some innovative home 
visiting programs, especially dealing with pregnant and foster 
youth. How does this work strike you in terms of its benefit to 
society?
    Ms. RAUNER. Well, I personally believe that the development 
of every child's potential is the social justice issue of our 
time. It is an economic challenge and a moral challenge for us 
to ensure that every child can participate in the American 
Dream and in the American economy and as a full citizen of our 
Nation. And, again, research is quite clear that the period of 
the first few years of life has the greatest opportunity for 
setting children on the proper trajectory for development. And, 
again, because it is an intervention that affects both children 
and their parents, it has the opportunity to build and develop 
two lives, and I think that is one of the most powerful pieces 
of this work for me. It certainly drives the work that I have 
been doing for decades.
    Mr. DAVIS. Thank you very much.
    Ms. Valentin, I think you are, indeed, a role model. As a 
former teacher, youth worker, father, grandfather, great-
grandfather, I used to counsel teenagers, and I think you 
represent the best quality of thinking and decisionmaking that 
I have run into. Could you share with us how your experiences 
have actually assisted you, what you may have done even for 
others?
    Ms. VALENTIN. My experience with this program has been 
amazing. You know, an unplanned pregnancy, a first-time mom, 
any mom, young or older, you know, you just need to have that 
support and need to know certain things. And this program has 
helped me so much with even the littlest things, not so much 
about the child but about me or helping, you know, my family 
and stuff like that. So it has been really helpful, and I hope 
that everybody--I mean, I know if everyone could be here right 
now, they would share their experience, because this is truly 
amazing.
    Mr. DAVIS. Thank you very much. And I yield back, Mr. 
Chairman.
    Chairman SMITH OF NEBRASKA. Thank you, Mr. Davis.
    Mr. Smith from Missouri.
    Mr. SMITH OF MISSOURI. Thank you, Mr. Chairman. And thank 
you to the witnesses for making it here today despite the 2-
inch winter blizzard that we had up here. Clearly not like 
Missouri and Illinois weather.
    I want to thank the Chairman for holding this important 
hearing on the Maternal, Infant, and Early Childhood Home 
Visiting, or MIECHV, program. Many times the Federal Government 
tries to do too much. Our third President, Thomas Jefferson, 
got it right when he said: ``The government closest to the 
people serves the people best.'' But MIECHV works because it 
offers States like Missouri the flexibility to administer the 
program in the way that best suits their needs.
    MIECHV's flexibility allows Missouri's Governor, Eric 
Greitens, to implement three of his major priorities. He wants 
to improve healthcare access, reduce opiate abuse, and reduce 
infant mortality. By choosing to run the Nurse-Family 
Partnership as part of the program, Governor Greitens is able 
to follow through on his promise to address the high infant 
mortality rates in the Bootheel of Missouri. For example, in my 
district in Pemiscot County in the Bootheel, we have the worst 
health outcomes of any county in Missouri. It is 115 of 115. Of 
course, there are 114 counties in the city of St. Louis, that 
is why it is 115.
    Pemiscot County experiences the highest infant mortality 
rates in all of Missouri. We know that one out of eight mothers 
don't make it to full term when pregnant, and two-thirds of 
infant mortality is due to preterm births. We know that we can 
do a lot better. That is why Missouri's Department of Health 
and Senior Services has begun to administer the Nurse-Family 
Partnership program in Butler, Dunklin, Pemiscot, and Ripley 
Counties in the Bootheel. This targeted approach can help 
reduce infant mortality rates in our most distressed counties. 
Unfortunately, Pemiscot County needs the most help of anywhere 
in the State, but fortunately, because of the MIECHV and by 
working with Governor Greitens, we can improve health outcomes, 
save lives, and reduce costs.
    As an evidence-based program, we know taxpayer dollars are 
being spent in the right place because the Nurse-Family 
Partnership program is shown to decrease preterm births and 
reduce infant mortality.
    Ms. Russell, I would like to learn a little bit more about 
the nuts and bolts of the program. How do you prepare for your 
first visit with a mother?
    Ms. RUSSELL. The Nurse-Family Partnership program is a 
blueprint program, and we do have a curriculum that we follow. 
However, each mom is very different. So, personally, I prepare 
for the first visit by just keeping an open mind, knowing that 
what I walk into in one home might be very different than what 
I walk into in another home. So my priorities across the board 
are always ensuring that she already has prenatal care 
established, and if she does not, ensuring that I can help make 
referrals to get her prenatal care started. And then from there 
we look at some of the--is she utilizing the appropriate 
community resources like she should be? Are they part of the 
WIC program? Do they have food they can eat? And ensuring that 
we will refer to those services as needed.
    Once I am sure that all of her basic needs are met, we can 
start to learn a little bit more about who she is as a person 
and what is important to her. We have, as nurses, outcomes that 
we would like to see as far as keeping everybody healthy and 
safe. But it is also important, and Nurse-Family Partnership 
agrees with this as well, that it is important that we find out 
what the client's heart's desire is and help them reach that as 
well.
    So the first visit is very much getting to know them, 
trying to be as laid back as possible, and letting them share 
with us what they are willing to share, and then building on 
from there in each visit from that point on.
    Mr. SMITH OF MISSOURI. The Nurse-Family Partnership 
requires a 2-year commitment. Why such a duration?
    Ms. RUSSELL. As Rosa can attest to, there are many 
struggles that come up in those first 2 years of parenting. 
Pregnancy in itself is a struggle, and there is a lot to learn 
as far as education to stay healthy and have a healthy baby as 
a result of the pregnancy. And then building on that, infancy 
has its own struggles with learning what your baby needs from 
you and how to respond to those needs in an appropriate way, as 
well as ensuring that the baby is getting access to care and 
immunizations and well-baby visits. And then the toddler years 
also create some more struggles as they are now mobile and they 
are doing different things that their parents aren't sure they 
are supposed to be doing or are safe for them.
    And then from a clinical aspect, the baby's brain grows so 
much in those first 2 years and is almost fully grown at that 
point, so we want to have as many positive influences on the 
baby in those first 2 years as possible.
    Mr. SMITH OF MISSOURI. Thank you, Mr. Chairman. I yield 
back.
    Chairman SMITH OF NEBRASKA. Thank you, Mr. Smith.
    Next is Ms. Chu from California.
    Ms. CHU. Thank you, Mr. Chair.
    In Los Angeles County, we utilize both the Healthy Families 
America and the Nurse-Family Partnership models of home 
visiting. And in 2015, home visitors made over 29,000 home 
visits to around 5,500 parents and children in California. The 
program in my State and in L.A. County has placed an emphasis 
on connecting pregnant women and new mothers with mental health 
services. That is, in my opinion, a fantastic way to leverage 
existing programs aimed at improving mental health and wellness 
for children and families with the unique methods of the home 
visiting program.
    So, Ms. Russell, based on your experiences working with the 
Nurse-Family Partnership model in Pennsylvania, can you 
describe a few ways in which you have relied on a broader array 
of available social services, such as mental health evaluation 
and treatment, to carry out your mission, and do you have 
examples?
    Ms. RUSSELL. Sure. As part of the Nurse-Family Partnership 
program, we do regular incremental screenings for depressive 
and anxiety disorders. So based on those screenings, we can 
refer as necessary. So we do those during pregnancy and then 
continuing through the child's first 2 years of life, on a 
schedule. But we can also do them as needed. So if we come into 
a home and we find that the mother's affect and tone are just 
not quite like they had been before, we can screen as needed, 
which is one thing that is great for us as nurses. We have been 
given those tools in our undergraduate degrees to recognize 
some of the problems that might present if a mother is having 
trouble with her mood but maybe isn't quite ready to recognize 
that in herself, just like Rosa had been through. So through 
those routine screenings and through our basic assessment 
skills that we learn in our undergraduate programs, we are able 
to keep a really close eye on that.
    Unfortunately, in Lancaster, our mental health resources 
are not as strong as we would like them to be. We are able to 
make referrals, but many times they do have to wait for a 
couple of weeks or a couple of months until they can be seen by 
a provider. So in the meantime, we are able to educate on some 
coping mechanisms that they can use in their own home until 
they are able to get into a more structured environment for 
counseling services.
    Ms. CHU. And do you think mental health issues are a 
frequent kind of issue that comes up for pregnant women?
    Ms. RUSSELL. I would say yes. I do feel that they are very, 
very prevalent in our population. Nurse-Family Partnership 
collects data that could give you the real percentages as far 
as that goes, but every day I am working with at least one mom 
who is having trouble with her mood at that current time.
    A general day for me is three to four visits with three to 
four different patients, so that is one a day that is probably 
having some sort of trouble, which is about 25 percent to 50 
percent of my caseload. So it is very prevalent, unfortunately.
    Ms. CHU. And how about substance abuse counseling? Is 
substance abuse an issue that comes up frequently?
    Ms. RUSSELL. Yes. Yes. Substance abuse is also an issue 
that comes up, whether that might be a past history and the 
mother is now no longer using but is working on ways to prevent 
herself from continuing to use, or whether they actually are 
using a substance during their pregnancy.
    So for us as nurses, it is important that we educate on how 
it will not only affect her, but affect her unborn child or if 
she is already parenting, how that will affect that child's 
growth and development as well.
    Ms. CHU. Okay. Ms. Rauner, in placing emphasis on 
connecting pregnant women and new mothers with mental health 
services, States like California try to detect and remediate 
potential issues very early in a child's life. However, data 
from the L.A. County Health Services underscores the challenges 
facing many mothers, which is that nearly one-third of women 
who were recently pregnant or had delivered a baby lacked a 
regular source of health care.
    So how do home visitors help to provide effective early 
intervention for pregnant women and new mothers who do not have 
easy or regular access to health care?
    Ms. RAUNER. Well, certainly, one of our efforts has been to 
connect new mothers to all the services that they need. With 
respect to mental health programs, we also have been able to 
use MIECHV funds to build mental health consultation in for our 
home visitors so that they are actually able to be supportive 
when we don't have access to services.
    But access to early intervention services, to health care 
services, and other connections is a very vital part of what 
the home visitor is doing in any community. And certainly, we 
make that a high priority for all of the models that are in 
place in Illinois.
    Ms. CHU. Okay. I yield back.
    Chairman SMITH OF NEBRASKA. Thank you, Ms. Chu.
    We will move on to Mr. Reichert from Washington State.
    Mr. REICHERT. Thank you, Mr. Chairman.
    First of all, I want to thank the witnesses for being here 
and for the time that it took to put your comments and 
statements together. And I thank the staff. The Democrats and 
the Republicans have people that are sitting back here. They 
put this whole thing together, and I want to congratulate them 
on bringing some excellent witnesses today to testify. It is 
important for us to hear, not only from people like Rosa--if it 
is okay if I call you Rosa--and the experts in the field that 
do the work, but it is so critical to hear from those who are 
the recipients and then those who provide the work, the 
services, like Beth.
    So how many of the witnesses have testified before Congress 
before?
    How many have testified before other members of maybe a 
city council or a county council?
    I knew that Ms. Rauner would raise her hand. She has 
experience in this world.
    You have all done a great job, but I think we really need 
to recognize Rosa's testimony. She is the first 16-year-old to 
testify--I have been here 12 years. I just look like I have 
been here 40. I have been here 12 years, but this is the first 
16-year-old witness, Mr. Chairman, that we have had, and she 
did outstanding. I don't know if it is against the rules or 
not, but we should give her an applause.
    [Applause.]
    The heck with the rules sometimes, right?
    So I wanted to ask Rosa, and you don't have to answer this 
if you don't want to, but why did you choose Angelica for--I 
have kind of maybe a thought on that, but why did you choose 
Angelica for your daughter's name?
    Ms. VALENTIN. Angelica was my grandmother's name, which is 
also my middle name. My middle name is Angelica Marie, so I 
named her Angelica Marie.
    Mr. REICHERT. Okay. I had two choices, but I bet you your 
grandmother was named Angelica and your middle name is Angelica 
because----
    Ms. VALENTIN. Of my grandmother, yes.
    Mr. REICHERT [continuing]. Because you are angels. My 
daughter's name is Angela, and we weren't supposed to have 
children, so we chose Angela because she was our little angel. 
So I am sure you think of Angelica that way, right?
    Ms. VALENTIN. Yes.
    Mr. REICHERT. So what I would like to ask Rosa is just--you 
know, we are having a conversation here. It gets a little 
formal sometimes, but, you know, just from your first contact 
with Beth and how this came about--because the courage it took 
for a 14-year-old to decide to go through with the birth of 
your child, and now here you are today, going to school, 
looking for a nurse's profession in the future, I think is just 
an amazing feat, and it shows so much maturity, but you 
couldn't have done it without Beth and your parents.
    Ms. VALENTIN. Yes.
    Mr. REICHERT. Don't worry about the rest of your family. 
They will get on board eventually. Eric is laughing. I have 
been there. I am the oldest of seven. You know, every now and 
then, they kind of float in and out of your life.
    Just tell me in your own words what the whole thing is all 
about for you. How did it really help you?
    Ms. VALENTIN. I just felt like I needed more support. You 
know, my mom was always there to help me, but she was like, you 
know, this wasn't planned, but we are going to make the best of 
it, and we are going to get you through this no matter what 
bumps come through the road. Like, we are going to get through 
it. You are going to finish school. You are going to be on 
track to finish, and you are going to be a great mom.
    So this program, you know, at first, I was going to Healthy 
Beginnings, but Healthy Beginnings wasn't associated with the 
hospital I was in, the OB-GYN, so I was referred to Nurse-
Family Partnership. And I am so glad that I was referred to 
Nurse-Family Partnership because it has been, you know, so 
great--I am so grateful to, you know, have this program, have a 
nurse by my side that, you know, can answer any questions and 
stuff like that. So it has been really helpful.
    Mr. REICHERT. Good. Beth, do you want to add something 
quickly to that?
    Ms. RUSSELL. I am just so proud of Rosa. She does not do 
public speaking very well, and one of her goals that she set 
for herself was to try to interact with people more because 
with doing the cyber program, she really doesn't get much 
interaction with people outside of her home, so this is a 
really huge step for her.
    Mr. REICHERT. I mean, you did awesome. Look, at 16 years 
old, I wouldn't have been in your seat. I guarantee you that.
    We get a second round of questions, so I am going to come 
back to the others to just ask some technical questions. But I 
just want to really emphasize the courage it took to move 
forward with your life, the courage it took to be here today. I 
truly would not have been doing what you are doing today. I 
couldn't have done it. And you can't even vote. You might be a 
Congresswoman some day.
    I yield back.
    Chairman SMITH OF NEBRASKA. Or perhaps you have higher 
aspirations.
    Mr. REICHERT. We will make that the first female President 
then.
    Chairman SMITH OF NEBRASKA. There you go. Thank you.
    Ms. Sewell.
    Ms. SEWELL. Thank you, Mr. Chairman.
    I wanted to associate myself with the remarks of my 
colleague. I think that your grace and your courage and your 
maturity is something to be marveled at, Rosa, so thank you for 
being here today.
    Before I begin my questions, I wanted to quickly express my 
desire to make sure that MIECHV is re-funded and reauthorized. 
In my State of Alabama, 5,220 families and 6,280 children 
receive home visiting services. In my district, 12 out of the 
14 counties are eligible to receive MIECHV funds. Moreover, the 
MIECHV funding programs are primarily--are the primary source 
of funding for home visits in Alabama. The Federal funding is.
    My district also has a wide variety of evidence-based 
models, including the Parents as Teachers, Nurse-Family 
Partnership, and the Home Instruction for Parents of Preschool 
Youngsters program. In fact, 86 percent of Alabama families 
receive home visiting services from a model that has been rated 
as evidence-based by HHS.
    For my constituents, many of whom live in underserved rural 
communities, the home visiting services that MIECHV programs 
fund are essential. And as we have learned from the special 
relationship between Beth and Rosa, home visitors also provide 
important emotional support when young parents may feel all 
alone. In Alabama, over 50 percent of the single mothers with 
children under 5 live in poverty. These mothers and their 
children need these kinds of programs.
    I want to thank all the panelists for taking the time to be 
here today.
    And my question I wanted to first address to Mr. Bellamy. 
South Carolina, like Alabama, has both urban and rural 
communities. One of the biggest questions or complaints, 
challenges, that I hear a lot from my constituents that live in 
underserved rural communities is lack of transportation. Can 
you talk to me about how the MIECHV-funded programs are 
administered in your State in rural communities and what are 
some of the challenges, and how your State overcomes those 
challenges?
    Mr. BELLAMY. Yes, ma'am. Many of the same challenges, Ms. 
Sewell, that we have in South Carolina for sure, transportation 
being one of them. The beauty of MIECHV and home visiting is 
meeting families where they are literally. And also, MIECHV has 
also given us an opportunity to expand services into these 
rural communities that really needed it and target those 
families that were most in need, so the needs assessment that 
states that we could really look at where we needed to target 
services. In most of--in South Carolina, most of our State is a 
rural State, so we put in practices and allow the ability for 
programs to be able to have sufficient funding to do home 
visits and travel to outlying counties and work with contiguous 
communities that may be rooted in really a more resource-richer 
community.
    Ms. SEWELL. And I noticed that you guys expanded the number 
of counties that were covered, and that expansion is, I would 
assume that South Carolina like Alabama, most of the funding 
for MIECHV comes from the Federal Government, and our State 
matches maybe, it is sort of a 2 to 1 match. Talk to me about 
how you guys--it seems to be a capacity problem in my State, 
that there are far more eligible families that could benefit 
from MIECHV than are actually reached. In my home county of 
Dallas County, I grew up in Selma, and Selma has 67 percent of 
the families with children under 5 in poverty. But yet 2.9 
percent are actually covered by the MIECHV funding, so there is 
a capacity issue.
    I would like to get you involved, Ms. Rauner, if you could 
talk a little bit about how Illinois addresses the capacity 
issue and making sure that these great programs actually reach 
more families.
    Ms. RAUNER. Yes, thank you. Well, in Illinois, despite many 
years of investment, both from our State Board of Education and 
our State Department of Human Services as well as of course, 
MIECHV, we are still only serving 10 percent of all eligible 
children in our State. And Illinois, as well, is an urban and a 
rural State and has--of our 102 counties, most of them are 
quite rural.
    We have used MIECHV dollars specifically to build community 
collaborations in both urban and in rural States. And we have 
looked through our needs assessment at some of the places that 
are most isolated and, again, have some of the most--the 
highest infant mortality rates. So the MIECHV program has 
allowed us to create community collaborations in those 
communities that bring together the available resources.
    Ms. SEWELL. So you pool funds? Are you pooling funds?
    Ms. RAUNER. Pooling funds, but also making sure that we are 
effectively using all the resources that the community has. And 
to the extent that we find gaps in resources, being able to 
advocate and reach out to other agencies to support those.
    So we have actually connected our MIECHV programs with our 
infant mortality Title V programs. We have been able to use 
some of our child welfare dollars, again, to identify places 
where there are real gaps in services.
    Ms. SEWELL. Thank you.
    Chairman SMITH OF NEBRASKA. Thank you. And now I will begin 
our second round. Fortunately, we have the time resources to 
deal with this, with the second round.
    Ms. Russell, I would like to focus a little bit on your 
insight and, kind of, frontline involvement there. I mean, the 
list is quite long in terms of what can be achieved with these 
effective models of home visiting. And, you know, from 
obviously economic self-sufficiency in a very broad way to 
increased work reduce arrests, less welfare dependence in 
general. Can you, perhaps, highlight or give us more specifics 
on your work in terms of how you might begin providing or 
connecting with a client and what that looks like compared to 
maybe evolving through and in making adjustments along the way 
and the observations that, perhaps, that you have had along the 
way as well?
    Ms. RUSSELL. So in regards to connecting with her and her 
goals for herself, we start that the first day we meet each 
other. It is a very important part of the Nurse-Family 
Partnership program to ensure that we are not only with them 
during these 2\1/2\ years but we have given them the 
information that they need to create their own foundation for 
the future as well. So very early on we do meet, and we talk 
about goals.
    Each time we meet with them, we have an agreement form, and 
they have a little, what we call, a mini goal on there of 
something that they want to accomplish before we see them the 
next time. And sometimes that is a parenting, sometimes that is 
something much larger as far as applying for schooling and 
enrolling in programs like that.
    So we do discuss goals very early on and remind them of 
those goals every time we see each other. Sometimes they come 
to us and they say, oh, I forgot about that, and then we remind 
them kindly, again, that this is important to them. And they 
will very much pull through with what is important to them. And 
that is probably the most beneficial part of Nurse-Family 
Partnership is knowing that they are accomplishing what is 
important to them as well as we are encouraging them to 
accomplish what is also important to them and other parts of 
the program, other importance as well as self-sufficiency in 
the future.
    Chairman SMITH OF NEBRASKA. Okay. And I know that sometimes 
we struggle with wanting accountability in various programs and 
also allowing enough flexibility to spawn innovation, you know, 
a creative approach and so forth. Are there any times when you 
might feel somewhat confined in--with the services you offer 
because of, perhaps, some restrictions or Federal requirements 
or even State requirements?
    Ms. RUSSELL. Yeah. I feel like I can say no to that, 
because the beauty of Nurse-Family Partnership is that we can 
be a little bit flexible with when and where we meet our 
clients. So if it is snowy, and I can't get to her where I need 
to be--our plowing, unfortunately, is not so great--so we might 
see each other a couple of days later, but we can connect by 
phone and have a short interaction by phone if we need to.
    If I have a patient or a family member who is homeless, we 
can meet at a public library or at a park or a cafe. So coming 
to them makes it very flexible for us to be able to meet our 
requirements with how often we are supposed to visit with our 
families, because we can truly meet them wherever our cars will 
allow us to go.
    If there is ever a concern with our clients where maybe 
they are having some difficulties, and they can't physically 
meet with us, again, we are able to have phone encounters as 
well to still check in on them and make sure everything is 
going the way it needs to be, and if they have everything they 
need before we can physically see them again for a true home 
visit.
    Chairman SMITH OF NEBRASKA. And can you say--I think you 
may have said earlier, but can you say a typical number of 
clients you see in a day.
    Ms. RUSSELL. In a day, I try for three to four. Sometimes I 
see more than that, just depending on what they need. But if I 
had perfect control of my schedule, I would see about three to 
four a day, and then we just fill in as needed based on what 
the clients are in need of at that time.
    Chairman SMITH OF NEBRASKA. Okay. Thank you.
    Mr. Davis.
    Mr. DAVIS. Thank you. Thank you, Mr. Chairman.
    And, again, I thank the witnesses.
    Dr. Rauner, let me ask you. Sometimes substance abuse is a 
problem in the home. How does the Ounce of Prevention deal with 
substance abuse issues when you run into them?
    Ms. RAUNER. Well, substance abuse is a major challenge for 
many of the families that we are serving, and one of the most 
important things we can do is train our home visitors to ensure 
that they have the skills necessary to identify, address, and 
refer patients and clients to appropriate services.
    Now, we know that services are sometimes difficult to come 
by. And one of the important things, again, that collaboratives 
allow us to do is begin to look at where the gaps in services 
are and how we begin to advocate for and push for greater 
services to address particularly substance abuse. We know in 
our State that, as in many, that the opioid crisis has really 
changed the dynamics for many of our communities. We also know 
there are many patients who are suffering from mental health 
issues that are, of course, associated with substance abuse. 
And so we are very focused on ensuring that our home visitors 
are appropriately trained and, also, that they are connected to 
a system that can--to which they can refer--they can refer 
clients.
    Mr. DAVIS. And for each one of you, if you could, how do 
you deal with the challenge of getting male involvement or more 
male involvement in the activities?
    Ms. RAUNER. Well, I would just say that one of the benefits 
of home visiting is that it is an opportunity to coach both 
mothers and fathers in their role even when the parents are not 
living together and may not actually be together anymore as a 
couple.
    But one of the things--I tell one story of a family 
actually in, Mr. Davis, in your community, that has been 
benefiting from home visiting services. Again, a mother and a 
father, young individuals who were not together, were not 
living together. The mom living at home and trying to continue 
with her education and get a job, and the dad living in a 
pretty unstable circumstance.
    Over the course of a couple of years of participation in a 
home visiting program, a Healthy Families program, where the 
mom and dad were able to participate in those programs 
together. So he would come over and spend time with the home 
visitor when she would visit the child. They actually--he 
actually decided it was important for him to get his life back 
on track, get back into school and become a caretaker for his 
child. And the couple have decided to get married. He is in 
school. She is employed, and they are getting ready to move 
into their own home. So I think this is an example of how home 
visiting can support parents as they are developing, frankly, 
into adults and making the challenging commitments that they 
need to make to their children and to each other.
    Mr. DAVIS. Thank you.
    Yes.
    Mr. BELLAMY. I think it is--I think fatherhood and male 
involvement is essential to the holistic approach to serving 
families, even though, oftentimes, mothers are the focal point 
and the entry point to many of our programs, we really need to 
continue to look at how we are supporting the entire family 
with our programs.
    You know, oftentimes, as I said, we may have couples or 
families that may be divided and not living together, but we--
the beauty of MIECHV is that it has allowed for innovation 
within models to really push for the models to look at 
different ways that they can continuously improve the 
initiatives, improve their programming. And fatherhood 
initiatives has been one that has--is building momentum on a 
continuum. And I think as we move forward, it is something that 
many States will look at stronger strategies to involve their 
fatherhood initiatives and local fatherhood initiatives within 
the States to be a part of, again, that holistic approach to 
really bring in the family and being self-sufficient as a 
family.
    Mr. DAVIS. Thank you very much.
    Mr. Chairman, I yield back.
    Chairman SMITH OF NEBRASKA. Thank you, Mr. Davis.
    Mr. Smith from Missouri.
    Mr. SMITH OF MISSOURI. Thank you, Mr. Chairman.
    Ms. Russell, Nurse-Family Partnership is just one service, 
but I am sure you connect your clients with numerous other 
needs. How do you coordinate with these other programs?
    Ms. RUSSELL. In Lancaster, we are very grateful to be under 
the Lancaster General Health and Penn Medicine umbrella, so 
this allows us opportunities to communicate within that 
umbrella to other services that are available to families. But 
we also over some time really built strong relationships with 
other community resources, and we tend to have meetings with 
them on a regular basis to remind each other that all of our 
programs exist and that we should be working together as best 
we can to support our families.
    So we do have as easy as a basic list of resources that are 
available in the area that we can take out to the families, but 
we are also the ones that are making the phone calls and 
sending the faxes to get all that information across to them.
    So we have built some really great connections in our 
community just by meeting each other at different events, 
organizing different coalitions to bring all the resources 
together for our families.
    Mr. SMITH OF MISSOURI. So whenever you, like, coordinate 
some of these programs and services to the families, is there a 
reporting mechanism where they report back to you, or do you 
check back up with them to make sure that those services are 
following through to help assist them, or how does that work?
    Ms. RUSSELL. Yes. If I send a referral somewhere, I do 
request that the referral organization contact me once the 
client has made contact, but then I also will check in with my 
client when I go to the home visit to ensure that they have 
either called that referral source or that they have received a 
call back that they have gotten that service.
    And we do track all of that in our data ETO tracking as 
well so that the main NFP site can see where we are sending 
referrals and what types of referrals we are in most need of.
    Mr. SMITH OF MISSOURI. Thank you.
    And the Nurse-Family Partnership model requires services be 
delivered in a certain way so that they are effective, and the 
MIECHV statute requires programs be operated in the way they 
were designed and studied. What do you do as a nurse visitor to 
ensure fidelity to the model?
    Ms. RUSSELL. So to prepare for each home visit, I will 
first start by reviewing what we had done at our last home 
visit just to see what we had talked about, refresh my memory 
so I don't forget as well, and then build on there.
    So we have multiple different facilitators of educational 
sheets and activities, interaction activities, we can do with 
the family to do things hands-on. And, generally, what we try 
to do is ask the client, the next time I see you, is there 
anything specific you would like to talk about, is kind of how 
we end our visit. And if they are unable to name something, we 
have a choice sheet that they can choose from.
    So that gives us the opportunity to deliver what the 
program is asking us to deliver, because the options that we 
are giving her to talk about are part of that blueprint 
curriculum for Nurse-Family Partnership.
    Mr. SMITH OF MISSOURI. Thank you. I would like to speak to 
Rosa.
    As one of the youngest Members in Congress and the youngest 
Member on this Committee, I am very impressed with you being 
here today. My first touch at ever speaking to anyone in 
government was before my small city council of a town of less 
than 5,000 people, and I was about your age and was fortunate 
enough to be able to still serve that city in Congress now. So 
I can only imagine what your future lies ahead if your first 
venture is to speak before what I believe is the most important 
Committee in Congress.
    I am very impressed, and I look forward to seeing the great 
things that you will accomplish. And I just want to say, I am 
extremely proud and humble to be part of this.
    And Ms. Rauner, as my neighbor to the east, I was highly 
impressed whenever I see a first lady that is a working first 
lady other than--just, you know, career and family, it is both 
a double task. But I would encourage you to meet with our first 
lady, Ms. Sheena Greitens, who is also a working first lady, 
and help mentor her as well. I think you would have a lot in 
common. Thank you for being here.
    Chairman SMITH OF NEBRASKA. Thank you. Well said.
    And Mr. Reichert from Washington State.
    Mr. REICHERT. Thank you, Mr. Chairman.
    Even though Mr. Smith is the youngest, we--you know, he has 
a lot of potential unless more senior Members are, you know, 
trying to work with him. He is coming along nicely.
    You know, I--so I wanted to--so the first question I wanted 
to get to was for Mr. Bellamy.
    Evidence-based, you have all mentioned that. We see that it 
is necessary, you know, from Rosa's testimony also. You know, 
as it applies to how it is used across the State, I think, my 
question: Doesn't it become complicated when you are looking at 
rural versus urban, and then you have to evaluate what services 
to provide? For example, you know, nurses or counselors that, 
sort of, help and how you get that--those resources to those 
different areas needing just different types of services and 
the population is spread out?
    Mr. BELLAMY. Yeah. It can be a little tricky. But, again, I 
think the power in this is being able to identify appropriate 
programs for families and really tailoring those programs and 
interventions that are--that families are going into more 
specific to that family.
    So when we target areas, we look at--you know, when we talk 
about needs assessment, we talk about areas that we want to go. 
We may look at, you know, specific programs that may work well 
there; however, again, the autonomy lies within those local 
implementing agencies. And we want to continuously work with 
them and partner with them to make sure that they have that 
ability to identify appropriate services.
    So, again, in South Carolina, we really wanted to build a 
continuum service, that is why we didn't look at one specific 
model that we wanted to implement across the State or support 
across the State. We wanted to look at prenatally up to age 3, 
up to age 5 and look at the different services that we can 
implement within those communities to help with those services.
    Mr. REICHERT. And that, really, is the important point here 
I think to make is every community is different. And you are in 
those communities, tailor making those services to each 
community is really the key and success.
    I really like what you said, Ms. Rauner, about early 
childhood, the human capital development is absolutely 
critical. I am a 33-year law enforcement career retiree and 
ending up here in Congress. I was a cop in Seattle for 33 years 
ending up as a sheriff and being in homes and working with 
young people my entire career. That human capital is so 
critical.
    Readiness for school, preparing people for the future gives 
hope and opportunity. And that is what is missing in today's 
world, that hope and opportunity, and ending that cycle of, you 
know, just coming from families, and getting into situations 
where it takes away hope. And--which goes back to the 
fatherhood issue.
    You know, if young men don't have hope, they lose 
opportunities. They kind of disappear, and we have to save 
those young people.
    The question I have for you--both of you and Ms. Rauner, 
first, was on the substance abuse issue. I think two or three 
of you mentioned that. What is the most common substance that 
is abused? I know opioids are the biggest problem today, but 
what are some of the others? Alcohol, tobacco, would that be 
some? Is marijuana in that?
    Ms. RAUNER. Yes, I would certainly--I am not sure I have 
the exact data on that. I would certainly say that alcohol, and 
marijuana, and tobacco are some of the biggest--the most 
prevalent. What we also know is that substance abuse is very 
likely and very often associated with depression and mental 
health issues. And so, again, support for the underlying issues 
can, in fact, be an important part of both preventing and 
addressing substance abuse.
    Mr. REICHERT. Yes. Again, I just want to thank all of you 
for being here today and for your testimony. This is such an 
important issue. And you can see from the comments on the dais 
here, you read in the papers and see in the media the lack of 
cooperation that some have described whereas, sort of, the 
state of, you know, separation in some--on some issues. But 
this is one issue where you can see total agreement on this 
panel for both Democrats and Republicans.
    We want to help. We think it is absolutely critical. And I 
thank you all for being here, and especially, again, Rosa.
    And I hope I can see Angelica before--okay--before I leave 
today.
    I yield back, Mr. Chairman.
    Chairman SMITH OF NEBRASKA. Thank you, Mr. Reichert.
    And, again, thank you to our witnesses. And if you don't 
mind, colleagues, we might want to grab a quick photo with our 
witnesses here momentarily.
    But, again, thank you, to all of you, for sharing your 
unique perspectives. And we know that your personal experiences 
and professional expertise are very helpful. I think we have 
Angelica visiting here right now. Very good.
    Please be advised that Members will have 2 weeks to submit 
written questions to be answered later in writing. Those 
questions and your answers will be made part of the formal 
hearing record.
    With that, the Subcommittee stands adjourned.
    [Whereupon, at 10:25 a.m., the Subcommittee was adjourned.]
    [Questions for the Record follow:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    

    

    [Submissions for the Record follow:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]