Outreach Plan

In addition to locating resources, it is imperative that Home Visitors provide education and outreach to other organizations within the community. This is to strengthen their understanding of the MCH Home Visitor’s role in addressing the health and safety of families, both prenatally and after delivery up to one year. In some rural and frontier counties without these key partners, outreach should be to partners in neighboring counties and surrounding areas where prenatal and postpartum women receive services and/or deliver.

Each local home visiting program will develop a written outreach plan to be included in the annual MCH grant application and made a part of the local policy and procedure manual. The plan will include conducting internal and external outreach and promotion of home visiting services to recruit and engage participants.

Internal Outreach

Outreach to programs delivering services to prenatal and postpartum women, including but not limited to:

  • WIC
  • Family Planning
  • Special Health Care Needs
  • Teen Pregnancy Targeted Case Management
  • Pregnancy Maintenance Initiative
  • Community-based Primary Care

External Outreach

Outreach to local programs including, but not limited to:

  • Obstetricians
  • Hospitals
  • Community health providers
  • Social service programs
  • Early education partners
  • Local coalitions/coordinating councils

Go Beyond Brochures and Flyers

Outreach methods should be creative and may include letters explaining services, meetings with referral organizations, participation in local coalitions, media promotion (radio, TV, social/online, billboards), health fairs and other community events.

Local Coordinaton

The following lists are not comprehensive and may not apply to every locality, but are a good starting point for community and regional resources that can help Home Visitors address the health and safety needs of families.

Possible Health Department Services

  • Maternal and Infant/Child Health services (M&I/MCH)
  • Special Health Care Needs (SHCN) Services
  • Women, Infants and Children (WIC) Nutrition services
  • Reproductive Health/Family Planning services
  • Immunization services and education
  • Child Care (technical assistance and referral)
  • Tobacco/smoking education, screening and cessation counseling
  • Developmental screening [find information and resources at https://helpmegrowks.org/
  • Well Infant/Child/Adolescent visit (screenings and health assessment)
  • Chronic disease risk reduction

Other Community Contacts

  • Long-term Home Visiting Programs such as Parents as Teachers, Healthy Families America, Early Head Start, Nurse-Family Partnership
  • Department for Children and Families (DCF)
  • Head Start
  • Hospitals
  • Private physicians serving pregnant woman and infants
  • Community medical and dental health centers
  • School nurses and administrators
  • Licensed Child Care providers
  • Information and referral services
  • Faith-based organizations
  • Early Childhood Educators, Special Education Infant-Toddler Services (tiny-K)
  • Retail businesses
  • Transportation partners
  • Food pantries/shelters
  • Domestic Violence services
  • Health Coalitions
  • Foundations
  • County Extension offices

Community Collaboration

In every locality, opportunity exists for building cooperative relationships and maximizing time and resources. Every community has varying organizations and services available to assist families on many levels through different approaches. Partnering with other community programs can help Home Visitors more efficiently serve clients avoid duplication of services.


Home Visitors have a unique relationship with the families they serve, and parents often confide in them about private matters. A family has the right to expect that what is seen and heard in the home will be kept in the strictest confidence.

Written Materials

  • Written material must be kept confidential, including the home visitor’s working file and central file in the office.
  • Staff should never leave confidential records out in the open, including in a vehicle.
  • When documenting, staff should write only what is necessary and factual. Subjective information, assumptions, and opinions should not be included.
  • Parents have the right to read any and all portions of their files, so staff should always be thoughtful and professional in documentation.

Verbal Conversations

Anytime home visitors discuss a family with other Home Visitors, program staff, or agencies, it should only be for the purposes of assisting the family or child.

Health Information All sharing of health information must conform to the Health Insurance Portability and Accountability Act (HIPAA) and agency policy. See HIPAA for more information.

Documentation and Data Collection

Documentation of home visits is to be done in a timely, objective, and accurate manner, and must be maintained in a secure file location. Each agency should have policies and procedures in writing that address documentation and maintenance of the client records.

Appropriate Record Maintenance

For information on information management and patient-integrated records, consult the American Medical Association’s Code of Medical Ethics Opinion 3.3.1.

Timing and Professionalism

Thorough and objective documentation of a home visit should occur within 24 hours following the visit and will be a part of the permanent client record. Home Visitors must be professional and objective in their writing, keeping in mind that records could be subpoenaed in court. Documentation needs to focus on what is seen and heard, not assumed conclusions of the home visitor.

Specific Visit Data

Data obtained from Home Visitors assists MCH grantees in demonstrating progress being made toward meeting the National Performance Measures (NPM) and State Performance Measures (SPM) for the Title V MCH program.

Data collected for home visiting services includes, but is not limited to, the following:

  • Where services were provided (setting)
  • What education was provided
  • What referrals were provided and completed
  • Number of mothers served prenatal and postnatal
  • Number of children and other family members impacted through visits
  • Number of visits made overall

Grantees must capture all required client demographics and service/encounter data via the web-based shared measurement system, DAISEY (Data Application and Integration Solutions for the Early Years), and this must be entered/submitted no later than the 10th of each month.

Client-level data is captured on the following DAISEY forms:

  • Adult Profile
  • Child Profile (only if infant visit is included in the service)
  • Program Visit Form (Adult or Child)
  • MCH Service Form
  • Referral Form

NOTE: Services provided to the infant or child are not documented as home visiting services. If the infant or child requires services, these should be documented by the professional staff that conducts their assessment and intervention. Visits can be completed by a Home Visitor and professional staff on the same day or at the same visit, as these services are not duplicated and are not provided by the same level of practitioner.


Home Visitors will often consult with their Supervisor to initiate a referral if one of the following is needed:

  • More intensive form of home visiting
  • Assessment by a nurse, doctor, mental health clinician, and/or licensed addictions counselor
  • Home visits beyond the infant’s first birthday

Considerations when Referring

Home Visitors should:

  • Understand their role within the larger community’s continuum of care
  • Focus on warm handoffs whenever possible (meeting with the family and the referring organization to support acceptance of the service and engagement)
  • Follow-up with the family and/or service provider after a referral has been made
  • Take advantage of electronic systems whenever possible to minimize effort and increase coordination
  • Use signed consents to share specific information about the family with other providers as appropriate. (Consents must be documented and maintained in the client file, and will be reviewed during monitoring visits.)
  • Communicate with other home visiting providers to coordinate services and avoid duplication of services
  • Utilize 1-800-CHILDREN by phone or free mobile app for free 24/7 statewide referral to services. Hotline assistance is available in either English or Spanish (www.1800childrenks.org)

Long-Term Program Referral

Every effort should be made to refer and transition enrolled families to long-term home visiting programs as needed (Healthy Families America, Parents as Teachers, Early Head Start, and Infant Toddler Services – tiny-k). 

Parent Education and Curriculum

Local MCH Home Visiting programs must have a base curriculum (standard MCH topics to be covered with each family) used for each visit to provide consistency regarding education topics, resources provided, and anticipatory guidance. The base curriculum can be individualized as needed depending on the mother’s pregnancy stage, infant’s developmental age, parents’ special health or life needs, and any infant health or developmental concerns.

The materials selected must be approved by the Home Visiting Supervisor prior to use and should align with the most current standards and evidence-based or evidence-informed education and practice, whenever possible.

Educational Material Topics

  • Birth Plans
  • Car Seat Safety/Installation
  • Child Care Search/Selection
  • Child Development/Screening
  • Community Resources
  • Domestic Violence
  • Father Involvement
  • Health Care Coverage
  • Immunizations
  • Infant Care
  • Infant Feeding (breast/formula)
  • Injury Prevention/Safety
  • Labor/Childbirth
  • Oral Health (screening/care)
  • Prenatal Risk/Exposures
  • Prenatal/Postpartum Risk Screening
  • Perinatal Mood and Anxiety Disorders
  • Medical Home
  • Reproductive Health/Family Planning
  • Safe Haven for Newborns
  • Safe Sleep
  • Siblings (support, relationships)
  • Smoking Cessation
  • Substance Use/Abuse
  • Well Child/Well Woman
  • Work (returning to work)

Curriculum Assistance

Educational materials will be reviewed during monitoring visits, but programs can request support from the MCH Program Contact as necessary if they need guidance around content and/or sources.

Frequency and Duration

The Home Visitor, Supervisor, and family will work together to determine the appropriate number of visits, schedule, timing, and termination or transition from the program. General guidelines exist, but there is flexibility based on identified family needs.


MCH Home Visiting services usually include a minimum of one (1) visit and may be as many as four (4) visits during the prenatal postnatal periods.

Regularly scheduled visits are typically conducted monthly in accordance with standard protocol. This does not prevent an additional visit as necessary to respond to an urgent need related to safety or basic needs, (e.g. food, shelter, utilities), or a crisis situation (e.g., domestic violence, depression, substance use). 

Number of follow-up visits scheduled will depend on level of risk/need, and other community services to which the mother/family is or is not referred and linked.


Typical home visits should last approximately one (1) hour, and Home Visitors should plan to provide a manageable amount of information for that time frame. Occasionally, a visit may need more or less time, considering the circumstances or family situation. The focus of the family might be on other priorities or urgent matters that must be addressed with care. If it is not a situation in which the home visitor can assist at that time, it is okay to end the visit and reschedule to compile appropriate resources or make referrals. 
Services should continue as long as deemed appropriate through ongoing assessment of the family up until the infant’s first birthday (12 months), at which time visits should terminate. Families continuing to need/benefit from home visiting should be transitioned into a longer term, more intensive program where available. If there is no other program to refer within the community, contact the KDHE MCH program consultant for guidance.


Although a majority of visits will occur in the mother’s home, Home Visitors will want to be sure to consider convenience, safety, and maximum impact when determining the best setting.

Comfort for Family

It is important to meet the woman/mother when and where it’s most convenient for her and her support person, whenever possible. A family may not be comfortable meeting in the home or it may not as convenient as other locations they may already be visiting.

Possible alternate locations include:

  • Clinic (MCH, WIC, Primary Care)
  • Hospital or Women’s Center
  • Community Setting

Telephone Calls

It is expected that there will be follow up conversations between the home visitor and family that will take place by telephone, but official “visits” should never take place by phone. Further, phone discussions do not count as “visits” for the purposes of recording/reporting service numbers.


Every grantee agency providing home visiting services should have a well-understood and practiced safety policy. Valuable and effective visits require careful and systematic planning, and local programs should take appropriate precautions to assure the health and safety of both the families served and the MCH workforce. Prior to making home visits, home visitors and staff should make sure they are following the prevention basics provided in the COVID-19 resource, Guidance for Workers Who Visit Homes. Virtual home visits are allowed for health and safety, but should be utilized only upon request of the family. It is preferred to conduct home visits in a face-to-face environment, and the allowance of virtual options is temporary in response to the COVID-19 public health pandemic.