Amended in Assembly May 13, 2015

Amended in Assembly April 21, 2015

Amended in Assembly April 6, 2015

California Legislature—2015–16 Regular Session

Assembly Bill No. 50

Introduced by Assembly Member Mullin

December 1, 2014

An act to begin delete amend Section 123492 of the Health and Safety Code, end delete begin insert add Section 14148.25 to the Welfare and Institutions Code, end insert relating to perinatal care.

LEGISLATIVE COUNSEL’S DIGEST

AB 50, as amended, Mullin. begin delete Nurse-Family Partnership. end delete begin insert Medi-Cal: evidence end insert begin insert -based home visiting programs. end insert

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services, including perinatal services for pregnant women.

Existing law establishes the Nurse-Family Partnership program, which is administered by the State Department of Public Health, to provide grants for voluntary nurse home visiting programs for expectant first-time mothers, their children, and their families. Under existing law, a county is required to satisfy specified requirements in order to be eligible to receive a grant.

This bill would require the State Department of begin delete Public Health to additionally develop a grant application and award grants to counties for other evidence-based home visiting programs, and would require the department, end delete begin insert Health Care Services, end insert in consultation with begin delete stakeholders and the State Department of Health Care Services, end delete begin insert stakeholders, end insert to develop and implement a plan on or before January 1, 2017, to ensure that begin delete Nurse-Family Partnership and other end delete evidence-based begin delete nurse end delete home visiting programs are offered and provided to Medi-Cal eligible pregnant begin delete women. end delete begin insert and parenting women, end insert begin insert and would require the department, on or before January 1, 2022, and every 5 years thereafter, to report to the Legislature, as specified. The bill would also require the department, in developing the plan, to consider, among other things, establishing Medi-Cal coverage for evidence-based end insert begin insert home visiting program services and incentives for providers to offer those services. end insert

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

SECTION 1.  

The Legislature finds and declares all of the
following:

(a) According to United States Census Bureau, California has
a poverty rate of 23.5 percent, the highest rate of any state in the
country.

(b) Children born into poverty are at higher risk of health and
developmental disparities, including, but not limited to, premature
birth, low birth weight, infant mortality, crime, domestic violence,
developmental delays, dropping out of high school, substance
abuse, unemployment, and child abuse and neglect.

(c) In 2014, the Legislature passed Assembly Concurrent
Resolution No. 155 by Assembly Member Raul Bocanegra,
recognizing that research over the last two decades in the evolving
fields of neuroscience, molecular biology, public health, genomics,
and epigenetics reveals that experiences in the first few years of
life build changes into the biology of the human body that, in turn,
influence the person’s physical and mental health over his or her
lifetime.

(d) On May 3, 2012, Governor Edmund G, Brown Jr. issued
Executive Order B-19-12, establishing the “Let’s Get Healthy
California Task Force” to develop a 10-year plan for improving
the health of Californians, controlling health care costs, promoting
personal responsibility for individual health, and advancing health
equity.”

(e) The task force identified several priorities, including a subset
for “Healthy Beginnings,” which include reducing infant deaths,
increasing vaccination rates, reducing childhood trauma, and
reducing adolescent tobacco use.

(f) The final report of the task force states “the challenge going
forward is to identify evidence-based interventions and quicken
the pace of uptake across the state,” in order to meet the ambitious
goals in the Governor’s directive.

begin insert

(g) Voluntary evidence-based home visiting programs, such as
Nurse-Family Partnership, Healthy Families America, Early Head
Start (Home-Based Program Option), Parents as Teachers, and
Home Instruction for Parents of Preschool Youngsters, strengthen
the critical parent-child relationship and connect families with
information and resources during the pivotal time from pregnancy
to five years of age. Extensive research has shown that
evidence-based home visiting programs serving pregnant and
parenting mothers, prenatal to the child turning five years of age,
increase family self-sufficiency, positive parenting practices, child
literacy and school readiness, and maternal and child health.

end insert begin insert

(h) Voluntary evidence-based home visiting program models
the prenatal to five years of age range from low to high intensity,
reflecting the broad spectrum of family needs that home visiting
can impact. Many experts hail home visiting program diversity as
essential to providing parents with choices and ensuring that
programs are well matched with local needs and strengths, as well
as responsive to the diverse needs of California’s children and
families.

end insert begin delete

(g)

end delete

begin insert (i) end insert  In 2013, more than 248,000 Medi-Cal beneficiaries gave
birth to a child. Because Medi-Cal covers half of all births in the
state, this has increased costs for taxpayers. Medi-Cal expansion
has resulted in an 18 percent increase in Medi-Cal enrollment to
a total of 11.3 million, and enrollment is expected to exceed 12
million in 2015.

begin delete

(h)

end delete

begin insert (j) end insert  The California Health and Human Services Agency recently
submitted its State Health Care Innovation Plan, including the
Maternity Care initiative, which addresses issues of high costs in
maternity care, to the federal Center for Medicare and Medicaid
Innovation. Child deliveries and related expenses, including
high-risk births, rank among the top 10 begin delete high cost end delete begin insert high-cost end insert episodes
of health care, and in the last 15 years, California has seen a
continual rise in maternal mortality.

begin delete

(i)

end delete

begin insert (k) end insert  The cost of health care specifically related to high-risk
pregnancies, neonatal intensive-care unit (NICU) services, toxic
stress, and emergency room visits has increased and is projected
to continue to rise. Average health care costs for women were 25
percent more than men primarily due to higher costs of health care
during childbearing years.

begin delete

(j) The Nurse-Family Partnership is a voluntary, evidence-based,
prevention program that partners low-income, pregnant women
having their first child with a registered nurse who provides home
visits from early in pregnancy until the child’s second birthday.

(k) With more than 37 years of evidence from randomized,
controlled trials, the Nurse-Family Partnership has demonstrated
sustained improvements in maternal health, child health and
development, and the economic stability of families.

(l) The Nurse-Family Partnership has consistently demonstrated
reductions in preterm births and preventable maternal mortality
via controlled trial and longitudinal follow-ups over two decades.

(m) Randomized, controlled trials have also demonstrated that
the use of Nurse-Family Partnership nurse home visitors increases
positive outcomes during the prenatal period and the first two years
of life compared to the use of paraprofessionals.

(n) Research has shown that the Nurse-Family Partnership can
reduce smoking during pregnancy, complications of pregnancy,
preterm births, closely spaced subsequent births, and childhood
injuries resulting in costly emergency department use and
hospitalizations. The Nurse-Family Partnership also can improve
childhood immunization rates and compliance with well child visit
schedules. As a result of families benefiting from Nurse-Family
Partnership, there has been cost savings to federal, state, and local
governments with respect to programs and services, including
Medicaid, the Supplemental Nutrition Assistance Program (SNAP),
and the Temporary Assistance for Needy Families (TANF)
program.

(o) By enrolling recipients no later than 28 weeks of gestation,
the Nurse-Family Partnership maximizes the impact on prenatal
care, birth outcomes, and critical early brain development of
infants.

(p) The Nurse-Family Partnership’s evidence base and benefits
to society are well documented and validated by independent
analyses.

end delete begin insert

(l) With more than three decades of evidence from randomized,
controlled trials and rigorous followup evaluation studies,
evidence-based home visiting programs have demonstrated
sustained improvements in maternal health, child health, positive
parenting practices, child development and school readiness,
reductions in child maltreatment, family economic self-sufficiency,
linkages and referrals, and reductions in family violence.

end insert begin insert

(m) Evidence-based home visiting programs have specifically
demonstrated reductions in preterm births, preventable maternal
mortality, smoking during pregnancy, complications of pregnancy,
closely spaced subsequent births, childhood injuries resulting in
costly emergency department use and hospitalizations, improved
childhood immunization rates, compliance with well child visit
schedules, lower body mass index rates, higher birth weights, and
improved family well-being, including increased family health
literacy, and parent self-help development. As a result of families
benefiting from evidence-based home visiting, there has been cost
savings to federal, state, and local governments with respect to
programs and services, including Medicaid, the Supplemental
Nutrition Assistance Program (SNAP), and the Temporary
Assistance for Needy Families (TANF) program.

end insert begin delete

(q)

end delete

begin insert (n) end insert  The begin delete Nurse-Family Partnership’s end delete strong evidence of
effectiveness and predictable return on investment demonstrate
that begin delete this end delete evidence-based begin delete intervention end delete begin insert home visiting programs end insert
should be brought to scale in California to improve maternal and
child health outcomes and help reduce health care costs for
generations to come.

begin delete

(r) Twenty-one California counties currently operate a
Nurse-Family Partnership program providing services to 4,000
residents. Only a fraction of the 100,000 potentially eligible
recipients annually are receiving these highly beneficial and
cost-effective services.

(s) However, if California were to provide these services to
significantly more eligible first-time mothers, the state could see
population-wide health and economic benefits that would carry
over to future generations.

end delete begin insert

(o) By supporting families from the start, voluntary
evidence-based home visiting programs serving families from
prenatal to five years of age provide a foundation for subsequent
early childhood programs and family support efforts to build upon,
and can help ensure that families are well-equipped to raise
California’s next generation of productive, healthy, and successful
adults.

end insert begin delete

(t)

end delete

begin insert (p) end insert  Therefore, it is the intent of the Legislature to develop a
means to leverage public and private dollars to substantially expand
the scale of begin delete the Nurse-Family Partnership and other end delete evidence-based
begin delete nurse end delete home visiting begin insert programs end insert throughout California, beginning
with communities and populations with the greatest need.

begin delete

SEC. 2.  

Section 123492 of the Health and Safety Code is
amended to read:

123492.  

(a) The department shall develop a grant application
and award grants on a competitive basis to counties for the startup,
continuation, and expansion of the Nurse-Family Partnership
program established pursuant to Section 123491 and other
evidence-based home visiting programs. To be eligible to receive
a grant for purposes of that section, a county shall agree to do all
of the following:

(1) Serve through the program only pregnant, low-income
women who have had no previous live births. Notwithstanding
subdivision (b) of Section 123485, women who are juvenile
offenders or who are clients of the juvenile system shall be deemed
eligible for services under the program.

(2) Enroll women in the program while they are still pregnant,
before the 28th week of gestation, and preferably before the 16th
week of gestation, and continue those women in the program
through the first two years of the child’s life.

(3) Use as home visitors only registered nurses who have been
licensed in the state.

(4) Have nurse home visitors undergo training according to the
program and follow the home visit guidelines developed by the
Nurse-Family Partnership program.

(5) Have nurse home visitors specially trained in prenatal care
and early child development.

(6) Have nurse home visitors follow a visit schedule keyed to
the developmental stages of pregnancy and early childhood.

(7) Ensure that, to the extent possible, services shall be rendered
in a culturally and linguistically competent manner.

(8) Limit a nurse home visitor’s caseload to no more than 25
active families at any given time.

(9) Provide for every eight nurse home visitors a full-time nurse
supervisor who holds at least a bachelor’s degree in nursing and
has substantial experience in community health nursing.

(10) Have nurse home visitors and nurse supervisors trained in
effective home visitation techniques by qualified trainers.

(11) Have nurse home visitors and nurse supervisors trained in
the method of assessing early infant development and parent-child
interaction in a manner consistent with the program.

(12) Provide data on operations, results, and expenditures in the
formats and with the frequencies specified by the department.

(13) Collaborate with other home visiting and family support
programs in the community to avoid duplication of services and
complement and integrate with existing services to the extent
practicable.

(14) Demonstrate that adoption of the Nurse-Family Partnership
program is supported by a local governmental or
government-affiliated community planning board, decisionmaking
board, or advisory body responsible for assuring the availability
of effective, coordinated services for families and children in the
community.

(15) Provide cash or in-kind matching funds in the amount of
100 percent of the grant award.

(16) Prohibit the use of moneys received for the program as a
match for grants currently administered by the department.

(b) The department shall, in consultation with stakeholders and
the State Department of Health Care Services, develop and
implement a plan on or before January 1, 2017, to ensure that
Nurse-Family Partnership and other evidence-based nurse home
visiting programs are offered and provided to all Medi-Cal eligible
pregnant women.

end delete

begin insert

begin insert SEC. 2. end insert   

end insert

begin insert Section 14148.25 is added to the end insert begin insert Health and Safety
Code end insert begin insert , to read: end insert

begin insert

begin insert 14148.25. end insert   

(a) The department shall, in consultation with
stakeholders, develop and implement a plan on or before January
1, 2017, to ensure that evidence-based home visiting programs
are offered and provided to all Medi-Cal eligible pregnant and
parenting women. The department shall consider all of the
following in developing the plan:

(1) Establishing Medi-Cal coverage for evidence-based home
visiting program services.

(2) Incentives for providers to offer evidence-based home visiting
program services.

(3) Other mechanisms to fund evidence-based home visiting
program services.

(4) Identifying among evidence-based home visiting programs
those with established evidence to improve health outcomes, the
experience of care, and cost savings to the health care system.

(b) (1) The department shall, on or before January 1, 2022,
and every five years thereafter, report to the Legislature on
implementation progress and the effectiveness of evidence-based
home visiting services in improving maternal and child health
outcomes, the experience of care, and cost savings to the Medi-Cal
program and the state.

(2) A report to be submitted pursuant to paragraph (1) shall be
submitted in compliance with Section 9795 of the Government
Code.

(c) For the purposes of this section, the following definitions
shall apply:

(1) “Evidence-based program” means a program that is based
on scientific evidence demonstrating that the program model is
effective. An evidence-based program shall be reviewed on site
and compared to program model standards by the model developer
or the developer’s designee at least every five years to ensure that
the program continues to maintain fidelity with the program model.
The program model shall have had demonstrated and replicated
significant and sustained positive outcomes that have been in one
or more well-designed and rigorous randomized controlled
research designs, and the evaluation results shall have been
published in a peer-reviewed journal.

(2) “Evidence-based home visiting program” means a program
or initiative that does all of the following:

(A) Meets, on or before April 1, 2015, the United States
Department of Health and Human Services Maternal, Infant, and
Early Childhood Home Visiting (MIECHV) criteria, as described
in Section 511(d)(3)(A)(i)(l) of Title V of the Social Security Act
(42 U.S.C. Sec. 711).

(B) Contains home visiting as a primary service delivery strategy
by providers satisfying home visiting program requirements to
provide services to families with a pregnant or parenting woman
who is eligible for medical assistance.

(C) Offers services on a voluntary basis to pregnant women,
expectant fathers, and parents and caregivers of children from
prenatal to five years of age.

(D) Targets participant outcomes that include all of the
following:

(i) Improved maternal and child health.

(ii) Prevention of child injuries, child abuse or maltreatment,
and reduction of emergency department visits.

(iii) Improvements in school readiness and achievement.

(iv) Reduction in crime or domestic violence.

(v) Improvements in family economic self-sufficiency.

(vi) Improvements in coordination of, and referrals to, other
community resources and support.

(vii) Improvements in parenting skills related to child
development.

end insert