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Paper

Cross national implementation of the HomebuildersĀ® Model: Experiences, challenges and outcomes

abstract

Background and program description. Over the past two decades there has been a growing interest in strengthening families and preventing out of home placement in the U.S. and other countries. Homebuilders® is an intensive in-home family treatment program designed to keep children safe and prevent out-of-home placement and reunify children from foster care, group care, psychiatric or correctional institutions. Families referred to Homebuilders have children (birth-18) in imminent danger of placement, or children in placement who cannot be reunified without intensive services. The presenting problems include abuse, neglect, family conflict, delinquency, substance abuse, and/or mental illness. The Homebuilders model is a "holistic" approach, and involves crisis intervention, counselling, skill building, research-based cognitive and behavioural interventions, motivational strategies, and addressing basic needs. Services are provided in the families' homes for 4-6 weeks, with 40 or more hours of face-to-face contact. Homebuilders therapists work with 2-3 families at a time and are available 24 hours a day, 7 days a week, meeting at times convenient to families, when and where the problems occur. The Institute for Family Development, a NGO based in Washington State (U.S.) is the parent agency of Homebuilders. Programs based on Homebuilders operate throughout the U.S. and in 9 countries.

Homebuilders implementation in three European countries. In 1993, the Dutch government commissioned the development of Homebuilders programs (known in the Netherlands as "Families First") and program implementers and evaluators from the Netherlands Institute of Care and Welfare (Nizw) and the Paedologisch Instituut were commissioned to implement the program in 4 experimental sites. The program has expanded to 15 agencies and has served over 9,000 families.

"Crisishup ann Huis" (Homebuilders program in Flanders) started in 1997 with a team of 2.5 family workers and 2 part-time supervisors. In 2007 there were 5 program sites. Recently the Flemish government made the decision to include the program as a standard service in all Flemish regions. It is anticipated there will be 10 program sites throughout the regions by 2009.

In 1999, the first Homebuilders program in the UK (called "Families First"), serving families with children birth-18, was established in Lincolnshire and Hull by NCH, the Children's Charity, with funding from city councils. Programs in Tower Hamlets, London (for adolescents) and in Wales (for caregivers misusing drugs/alcohol) were later established. Although the programs demonstrated high success rates, changes in the UK central government policies, which focused funding on prevention/early intervention resulted in the loss of funding and closure of programs in Lincolnshire in 2003 and in Hull in 2007.

Evaluation of the Homebuilders program in the U.S. and Europe. In 2006 a "meta analysis" of all rigorous evaluations of "Intensive Family Preservation Services" was conducted by the Washington State Institute for Public Policy. The studies in this analysis were either randomized control trials or well-controlled quasi-experimental studies, and were "sorted" based on the adherence and "fidelity" to the Homebuilders model. This is the first analysis of model adherence, fidelity and outcome, and showed that when the results from all 14 studies were combined, the programs produced no significant effect on out-of-home placements. After sorting for "fidelity" to the Homebuilders model, the analysis found, "the programs with demonstrated fidelity to Homebuilders, showed a significant reduction in out-of-home placement... and also significantly reduced subsequent official reports of child abuse and neglect. Non-Homebuilders programs had no significant effects on these official reports." (Wsipp, 2006). The analysis concluded that programs adhering closely to the Homebuilders model significantly reduce out-of-home placements and subsequent abuse and neglect, and are estimated to produce $2.54 of benefits for each $1 spent. Programs with low fidelity to the model produced no significant effect on placement and no cost benefit.

Evaluations in the Netherlands, Belgium and the UK also have found high rates of placement prevention and positive changes in family functioning. An implementation study in the Netherlands found that one year after treatment, 76% of the 250 children in the program remained living at home, and behavioural problems and parental stress decreased significantly (Veermam et al., 2003). A study of 146 families in Flanders also found positive changes in parental perceptions of problems, parental stress and child behaviour problems (Van Puyenbroeck et al., 2007). This study, which used a pretest, post-test and follow-up design, measured changes reported on four instruments: Parent-Child Interaction Questionnaire, revised (PACHQ-R); Nijmeegse Ouderlijke Stress Index, a Dutch version of the Parenting Stress Index; Nimegen Questionnaire on Childrearing Situations (NQCS); and the Strengths and Difficulties Questionnaire (SDQ). At the end of the intervention and at follow-up, significant differences (p<.05 or p<.01) were reported in items related to parental stress and perceptions of problems (e.g., greater resilience, fewer parental problems, improvements in "getting along with the child") and children's behaviour (e.g., decreases in conduct problems, total problems, and emotional symptoms). Evaluations of the Hull program in the U.K. found that of the 105 children receiving services, 3 were placed out of home during or immediately after intervention and six month later, no other children were placed (Andrews, 2004, 2007).

Implications for practice and future research. The cross-national implementation of the Homebuilders model provides opportunities to examine critical issues related to the implementation of evidenced based programs across countries. These issues include: governmental support and strategies for program implementation, evaluation, quality assurance and maintenance; funding processes and systems; child and family outcomes; model adaptations/changes; and the impact on national policies and practices. Future cross-national research that utilizes the same fidelity and outcome measures would likely produce valuable information and knowledge about the transfer of program models across countries.

Key references

Andrews, P. (2004). The heart of the family. Community Care, 34-35.

Andrews, P. (2007). The Homebuilders model in England. Unpublished paper.

Van Puyenbroeck, H., Loots, G., Grieten. H, & Jacquet, W. (2007). Crisishulp aan Huis Vlaanderen: Een uitkomstondervoek. Tijdschrift voor Orthopedagogiek, 46, 78-89.

Veerman, J. W., De Kemp, R. A., Ten Brink, L. T., Slot, N. W., & Scholte, E. M. (2003). The implementation of Families First in the Netherlands: A one year follow-up. Child Psychiatry and Human Development, 33(3), 227-243.

Washington State Institute for Public Policy. (2006). Intensive family preservation programs: Program fidelity influences effectiveness. www.wsipp.wa.gov.

Contacts: Shelley Leavitt, Institute for Family Development, 34004 16th Ave. South, Suite 200, Federal Way, Washington 98003, USA, E-mail: sleavitt@institutefamily.org, Phone 253-874-3630.

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