Based on what we learned about the science and our community context, we opened the doors to a new Southwest Ohio/Northern Kentucky program called ECS in March 1999. Our hope was to connect with first-time moms who were most often poor, unmarried, young, victims or witnesses of violence, living in disinvested communities, and having had inadequate health care before and during pregnancy.

The foundation for ECS was laid by private-sector and public-sector community leaders who showed the courage and compassion to step forward and contribute their time, talent, and resources. They had the clout and the influence to engage others, and to issue a call to action. They built upon the knowledge that what happened to our children from birth to three not only had the potential to give them an optimal start but also to affect their lives for years to come. They believed that every child deserves access to opportunities that better their lives.

Our board and community leaders helped us develop a program based on the best available science and evidence, then held us accountable for continuing on that path to achieve results. Critically, we kept a focus on foundational, early relationships between parents and their young children. We ensured that home visitors had the training and tools to support parents’ efforts to provide safe, stable, and nurturing homes. We used community leaders and volunteers to make the larger context more supportive for families. We followed the research and harnessed new tools to ensure our communities and families had the best support.

How It Began

The most accurate answer to “How was ECS created?” is that we were able to rely on relationships with people in our community who understood the compelling and well-documented need to focus on early brain development in young children. They were people with the kind of influence that inspired change and knew how to make it happen. Our relationships ranged from the business world to nonprofits, from funders to policy makers, and from families to the community.

Let’s begin with the role of John Pepper, whom I have often called the grandfather of ECS. In 1996, he approached our regional United Way board, including John C. Haller, regional president of PNC Bank, and Richard Aft, president of the United Way, then known as the United Way and Community Chest. Pepper, an ardent United Way volunteer and donor, suggested to board members that they consider asking the United Way to lead an initiative to ensure that children from birth to three, especially infants in high-risk and low-resourced situations, had the opportunity to get the best possible start in life. He stressed the effort would benefit not only the children and their families but the entire community.

The clear and compelling evidence led Pepper to ask community leaders, business leaders, and funders these provocative questions: “What is it about this opportunity that you don’t understand? Why are programs so balkanized? Why is funding skewed in the wrong direction? Why are seemingly like-minded people unable to advocate effectively for causes both authentic and documented? Why doesn’t policy and funding follow science?” Pepper, as the CEO of Proctor & Gamble (P&G) with headquarters in Southwest Ohio, had the clout to challenge community leaders and funders to create new programming that would concentrate on our youngest children. This programming would put into practice what science was telling us, that the foundation of a successful society is built in early childhood and that all our children and their families deserve the best possible start in life.

Pepper found fertile ground at United Way. A Blue Ribbon Task Force was formed, a community steering committee was assembled, community partners including Cincinnati Children’s and the Community Action Agency were enlisted, a business plan was written, and, after working for 18 intensive months, ECS was born.

Blue Ribbon Task Force on Focus

By 1996, efforts to expand early childhood programming were underway across the country in response to new guidance about brain development in young children and the Carnegie Starting Points Initiative (Carnegie Corporation of New York 1994). Beyond those receiving direct support from the initiative, state leaders, including those in Ohio, were making new commitments and investments to advance early childhood programs and systems. In parallel, Cincinnati-area leaders were responding in unique ways.

In August of 1996, Haller guided formation of a United Way Blue Ribbon Task Force on Focus. The group was charged with doing three things: 1) identify all other community organizations that would be part of a system or a continuum of services for young children; 2) discover what data were available in the community to support creation of an inclusive, comprehensive early childhood database; and 3) highlight the gaps in the system. The task-force work was summarized in a set of conclusions and recommendations that became a report delivered to the United Way board. The task force distilled input from across the community and determined that the birth-to-three population was the most underserved and was thus the best area to focus on.

Basically, the task force affirmed that the needs of the children in our service area were acute. No system was in place to address those needs, services were largely uncoordinated, and no one was in charge. David R. Walker, formerly vice president and comptroller at P&G and later president of the ECS board, speaking for the task force, built upon an adage from W. Edward Deming and advanced by P&G. Walker characterized it this way: “It has been said that every system is perfectly designed to produce the results it achieves. Our current approach to children’s services produces unacceptable results. The Task Force sees no evidence that is changing.”

Outcome measurements were sporadic and unclear, leadership was inconsistent or missing, and, although the United Way was just one part of the collaboration, it had key leadership and relationship strengths. The task force recommended that the United Way make children an area of special focus, insisting upon collaboration among partners, including governments, parents, schools, hospitals, churches, agencies, and communities.

Importantly, in its comment about focus, the task force recognized that concentrating on the needs of children involved many players and issues. They acknowledged that not everything could be addressed in the short term, nor would the broader and consequential societal issues, primarily poverty, be adequately addressed. However, the report continued, “Our choice is to start with a core focus on children and to use the ongoing breadth of United Way and other providers to address those broader issues.”

Following investigation of research and practice locally and nationally, evidence-based home visiting was chosen as the first strategy to address the challenge of giving all children the opportunity for the best-possible start in life. Home visiting studies from a number of researchers told us that many pregnant women and families with young children could benefit from a regular schedule of home visits, sound curriculum to support parents, ways to measure progress, and respect for the family itself. Studies suggested we could use home visiting to support and foster foundational early relationships between young children and their caregivers. The home visitor, of course, was key to success.

While evidence-based home visiting seemed like a programmatic solution, the issue of service fragmentation and lack of an early childhood system remained of concern. The task force report emphatically recommended that the United Way board assume a stronger leadership role to address gaps in services for children and to improve coordination among existing programs created to serve them. They acknowledged that the leadership role would be neither comfortable nor easy. There were challenges and risks involved in making a concentrated, major new programmatic investment. However, the task force argued, unless there was improvement in service delivery and coordination, the current disjointed system would continue to produce the same inadequate results. To achieve better results, a more aggressive role was mandatory. David R. Walker provided additional guidance, highlighting the major issues:

1. United Way must be willing to make a major multi-year commitment of time and resources, including a full-time person at the vice-president level, a share of other staff, and funds for the research effort. Walker estimated that cost to be about 1% of the United Way budget during the startup year. Over the next years, United Way would have to raise significant money because, as one task member said, “If we are serious about making a breakthrough intervention in children’s services, it would be a mistake to assume that we can get significantly different results without a significant investment.”
2. Finding solutions for fundamental systemic problems focused on early childhood and challenged families presents a conundrum no one has ever really solved. Solutions are complex and risk of failure is high. Having modest goals is essential. The community—from parents to grassroots activists to government agencies—will want more rapid change and progress than it is possible to produce. Educating the community about the size and fundamental nature of the issues is key.
3. The outcomes of the task force were more than another United Way initiative and should be a separate entity, not an in-house operation of the United Way. Creating an independent 501(c)(3) nonprofit was the way to structure this new community organization. The United Way board would approve this idea, and ECS was set up in this way, with its own board and independent structure.
4. We must have a compelling business case and plan; and must enroll the key leaders. Asking business and individual donors for additional resources and volunteer time is crucial, because we are planning an initiative both bold and expensive.
5. Collaboration among community partners (governments, schools, unions, agencies, health-care facilities) must be attended to early and often. It is crucial for success, yet in many cases, this work will be seen as threatening to existing programs and current spending patterns. Collaboration is possible and absolutely essential for success, but it will take major effort to work through these issues both privately and publicly.
6. When one area is chosen as a “focus,” the question always arises regarding what else will be diminished as one area is lifted up. This must be sensitively managed so as not to create a zero-sum game! For an organization like United Way, this is especially sensitive with substantial relationships with 140 agencies and boards, all representing real needs in our community. Those issues must be addressed given that resources are finite while needs are infinite.

The task force recommended that the United Way concentrate on supporting programming for children from the prenatal period to age 18, and financially support the work that would be required to create and implement the programs. They were aware that large-scale social-service programs could not be sustained on the shoulders of philanthropy alone and that public-sector advocacy would be required to obtain the essential public-sector portion of the money. They acknowledged, however, that the private money raised by organizations like the United Way was essential to pay for research activities and administrative tasks typically not covered in public-sector budgets. We saw this as inspired understanding. We were aware as we began to plan and then implement ECS that virtually the only funds that we had for administrative and research/evaluation activities would come from the United Way and other philanthropic donors. The public monies we were able to secure would only pay for the home visits themselves. As the program grew, this gap widened, even though we were sometimes able to use grant funds when we successfully competed for those monies.

At this point, we had what I call a prosaic problem. We needed a name that was memorable, action-oriented, and reflective of our work. We needed to stop referring to what we were working on as the “Task Force on Focus Report.” We needed to make it real for us and for those we wanted to enlist to support us. So far, nothing had fit. And our marketing and public relations advisors had not come up with anything that met our needs. One day, David R. Walker, the “numbers guy,” unexpectedly said three words out loud—Every Child Succeeds—and we knew immediately that they were right. They reflected our focus, were action oriented, and were memorable.

We had given voice to those words as a team, but it was Walker who provided the headline. Critics have said, “You know that every child won’t succeed, so why are you saying that they will?” We had to answer that. We—and our families—were aspirational. We knew that families who came to us would do well. Internally, we have speculated that the name should have been Every Mom Succeeds, because if moms don’t thrive, children’s opportunities are diminished. This is a legitimate and relevant position. But as of this writing, the name has not changed, even though many offers were made over the years.

With the name came acknowledgement that ECS was more than just a vague idea. The mandate from the task force was to develop a program to turn its ideas into action, and that became our challenge.

That role was delegated to a newly created steering committee charged to gather information, evaluate best strategies across the country, ensure that the effectiveness of the strategies was grounded in good data, and guarantee that what was being proposed clearly reflected what our community wanted for its children. Additionally, the task force called for the steering committee to outline a best-practice continuum of service over the lives of the children so that gaps in the system would be visible. The goal, of course, was to work toward designing a continuum of services for young children in our community so that they would be healthy and would live with caring families in a community that sees their welfare as a priority. Recognizing the difficulties and accepting the challenge, the United Way board voted to commit the resources that would be required for the steering committee to begin its assignment to bring ECS to life.

Blue Ribbon Task Force Phase One Report

The Phase One Report, as presented to the United Way board in October 1997, emphasized taking on a larger leadership role in children’s services, committing a larger share of United Way resources toward the needs of children. A statement adopted four months later in January 1998 by the ECS steering committee (which included future board members and other community leaders who would guide this work over the coming years), reflected the task-force recommendations, stating:

John Haller emphasized that the Phase One Report encouraged the United Way to take a major leadership role for program deployment and implementation; and that programming rely not only on new science related to brain development during infancy, but also adoption of an evidence-based home visiting approach that research showed could save infant lives and reduce cases of child abuse. The task force leaders emphasized an enduring truth—the key to success of a program is in good execution. Program success is always tied to effective implementation, not only design. Plans come alive through good leadership, teamwork, and conscientious attention to detail.

The Phase One Report delineated best practices throughout the country and the more than two-dozen Southwest Ohio and Northern Kentucky community focus-group sessions that were held to better understand what the communities themselves viewed as high priorities for their children. Close to 400 community residents attended, representing families, business, faith, human services, health, and neighborhood organizations. Together, the task force and the focus groups determined which program strategies had the best evidence of success and which ones most closely aligned with community interest.

It is instructive to look at what we identified as the key opportunity areas to present to the community groups because, taken together, the 14 discrete but closely interwoven factors shown below are the ones that influence the growth and development of our children; underscore the problem; and substantiate the need for a network of services. Home visiting was not then, and is not now, an end in itself, but rather, it should be part of a system or a set of interlocking services relatively easy for families to navigate and driven by what users of the services let us know that they need.

Not one of the following opportunity areas stands in isolation—trying to choose among them or to create a priority list becomes a Hobson’s choice, because each area is important, and there is not one right answer. We worked with the community representatives to condense the 14 opportunity areas into four. What happened over the next years—and not unexpectedly—is that programming emerged around all 14, but unfortunately, rarely in a coordinated way. The 14 opportunity areas are:

1. Transform schools to be responsive community resources.
2. Strengthen community cohesiveness and ability to better support families.
3. Provide family support and parenting information to all parents of young children.
4. Develop community resource and recreation centers.
5. Provide health education that promotes positive outcomes.
6. Increase access to affordable quality childcare and early childhood education.
7. Increase access to health care for working poor families.
8. Ensure that children and youth have opportunities to interact with adults.
9. Promote health and development of children from prenatal to three years.
10. Enhance children’s access to healthy, nutritious meals.
11. Strengthen support of teen parents and their children.
12. Connect families to neighborhood assets and people.
13. Promote safe environments for children.
14. Increase economic resources available to families.

Community Leaders Advance the Case for Action

When John Pepper went to the United Way with his challenge to create programming for children birth-to-three years of age, he had some unexpected help from The Cincinnati Enquirer. On February 1, 1998, under the banner front-page headline, “Despite Efforts, Children’s Plight Virtually Unchanged,” the newspaper printed its “Everybody’s Four-Year Report Card” as evidence of the plight of children in our community. While there is nothing that establishes a direct relationship between the Enquirer article and approval by the United Way board to support new programming for young children, the timing was propitious. The piece seemed to alert the community to the poor condition of our children, particularly those of color, and recognition that existing programs were not sufficient. Perhaps—and this is more intuition than provable fact—the piece set the stage for what the United Way was able to initiate with urging from Pepper, Haller, and others. Unfortunately, the report card was not continued, and the effort to create a periodic assessment to provide community-wide visible accountability, transparency, and sustainability for programs serving children foundered.

By the end of 1998, we were able to make the case that investing in prevention in early childhood can produce quantifiable results. We also had created an organization to deliver home visiting services to families facing higher economic and social risks. Our public messaging included six key points:

1. Optimal child development begins with a healthy birth.
2. Birth to three is the most active period of brain development.
3. Toxic stress in early childhood has disruptive impacts.
4. Parental support mediates the deleterious effects of poverty.
5. Maternal depression impacts child development.
6. Investment in early childhood yields a strong return.

This messaging, along with its strong advocates, were compelling, and engaged our local funding community. The United Way board was persuaded, and the organization initially committed $750,000 in 1999, with consideration for up to $3 million from the 1999 community campaign to create an evidence-based program. It would be focused on our youngest children and their families with the understanding—and I use that word most deliberately here—that the foundation for what comes later for these children would be built in the first three years of their lives, the first 1,000 days.

Michael Fisher, then president and CEO of Cincinnati Children’s and formerly CEO of the Cincinnati USA Regional Chamber of Commerce, was closely involved in that initial campaign. He pledged and successfully increased the number of Tocqueville Society members, people who donated $10,000 to the United Way, from 100 to 200. This raised an additional $1 million for ECS. Four years later, he and his wife, Suzette, co-chaired the entire United Way campaign. He remembers that on the very first day the campaign was launched, Michael and Suzette went on a home visit to better understand the challenges our moms were facing. They sat on the floor, talked with the mom, and watched how the home visitor, the mom, and the baby learned together. He said they developed a clearer understanding of why raising money to support the first 1,000 days of life mattered. This strategy of having funders and leaders experience firsthand the family experience in ECS proved invaluable again and again.

It was into this environment that what became the ECS program was born, with its passionate leaders who witnessed the families we served and who also made a vigorous commitment to being data driven, evidence based, and quality focused. From the beginning, we combined community leaders and families in this endeavor.

For more than 20 years, that commitment from the United Way and our other two founding partners, Cincinnati Children’s and the Cincinnati-Hamilton County Community Action Agency, was unwavering. Local leaders, funders, staff, families, and the community understood that if the foundation is not properly laid for children in the earliest days and hours of life, amelioration later is more expensive and less effective. Most important, it denies children their right to an optimal start. Prevention is a good investment.

Writing the Business Plan

I was selected to chair the steering committee to write the business plan. I would serve with our P&G-loaned business executive, Frank P. Smith, assigned by Pepper to work with us for one year. Margaret Clark, the United Way director of women’s and children’s services, rounded out the leadership team for the work going forward.

Smith was an outstanding choice. He brought strong management skills, a sense of humor, and a focus on brevity and action. He was tall and lanky, with a Tennessee drawl. He had a sign above his desk that I have replicated numerous times. It read:

The six phases of a project:

1. Enthusiasm
2. Disillusionment
3. Panic and hysteria
4. Hunt for the guilty
5. Punishment for the innocent
6. Reward for the uninvolved

It was Smith, with an entire career in the for-profit world, who truly set the stage for our ECS business orientation. We were able, in the early and formative months, to put solid systems in place, and adopt effective principles for execution that guided the work.

Margaret Clark came to ECS from an 11-year career at United Way. She had a background as director of a Montessori program, a firm understanding of what communities needed, and a solid grasp of how to enlist their help. She had many long-standing relationships in the community, and she was trusted, insightful, and collaborative.

The ultimate decision to focus on evidence-based home visiting was recommended because home visiting was seen as the most promising strategy to create a comprehensive approach for our challenged families and their young children. By offering a dedicated professional home visitor to a family, the services could be tailored to the needs of the individual family while embracing what else was available in the community. The professional home visitor could follow our established curriculum, identify specific needs of the family, and determine—to the extent possible—what would work best for them. This kind of individualized and focused work, now often termed precision home visiting, allows the frequency and type of services to be linked more closely with the family by identifying their personal needs and goals.

What the Phase One Report called for—engaging the community, using best practices, and following the sound business principles and entrepreneurial actions described throughout this book—is exactly what happened over the first 20 years as the ECS program was deployed across our community’s nine counties in Southwest Ohio and Northern Kentucky.

Ironically, the evidence-based home visiting strategy was meant to be the first of the opportunity areas to be addressed. The leaders hoped that other programming would emerge to focus on the rest of the 14 opportunity areas, and move to more unified, connected services for early childhood. ECS has evolved over 20 years into an outstanding example of a collaborative, blending the interests and the work of the founding partners, board, provider agencies, home visitors, and staff. However, with a few limited exceptions, the continuum of services that were envisioned has not materialized. But, as we will explore further, there are glimmers of hope, changes are occurring in the community, and there is reason for optimism.

Enlisting the Founding Partners

A crucial step in launching ECS was to elicit support and participation from the three partners that the steering committee identified as essential to success: the United Way of Greater Cincinnati, Cincinnati Children’s, and the CAA. Together, these three organizations were understood to be credible leaders—committed to tracking and measuring results with the means to develop and expand successful strategies, and support growth with the requisite public policy network. All three had significant respect in the community and were beginning to work more actively at the neighborhood level.

United Way of Greater Cincinnati

Through the Blue Ribbon Task Force on Focus and the steering committee, the United Way can certainly be credited with generating the strong proposal for change and, over the months, highlighting the concept of more cooperative thinking, improved transparency, and focus on effectiveness. They had agreed, at the board level, that the recommendation from the task force described a courageous path forward that was sorely needed.

United Way brought access to business contributions through their annual fundraising campaign and a sizable commitment of private-sector dollars. The organization was in fact the original ECS private-sector funding partner and, over the last 20 years, continued that commitment. However, and this is an important point, the United Way financial support was not guaranteed. With more than 100 other grantees and partners, the potential for large and sustained financial commitment to one organization was unprecedented. What was allocated each year was based on the success of the annual fundraising campaign, the availability of funds, and the priorities established by the United Way board.

It was with United Way dollars, other grants, and private-sector contributions that ECS was been able to 1) provide the match required to draw down additional public dollars, leveraging both sources of funding; 2) buttress the research/measurement component that has led to more than $14 million in grants over ECS’s two decades; and 3) allow the development of program enhancements including the maternal-depression treatment program; home-visit planning guides; community engagement; and improved parenting and early literacy activities. The United Way monies have not grown exponentially, although the amounts have been stable and sizable. With United Way support, ECS maintained an enviable private and public-sector funding mix (typically 60/40)—subject to the results of the annual United Way funding campaign and vagaries in the availability and stress upon public-sector budgets.

What was especially consequential was that United Way policies and funding continued to emphasize the significance of programs targeting the first 1,000 days of life and the recognition that what happens in those early hours and days lays the foundation for so much that follows. However, there is no legal requirement for the United Way to continue to fund ECS, or indeed any of United Way’s approximately 135 affiliated agencies. The level of funding and other funding decisions are made by the United Way board, typically on an annual basis.

Cincinnati Children’s

Next was Cincinnati Children’s, which was then and continues to be one of the premier children’s hospitals in the world. When we gained support from Cincinnati Children’s, we received, by affiliation, the imprimatur of quality medical care and good science—and as I have often said, credibility before we had earned it. It is easy to say that now, because over the years, we earned our name, but in the beginning, none of us was sure we could do what we promised. We said, and firmly believed, that we would deliver, but it was the prominence of Cincinnati Children’s; the well-deserved acknowledgment of the quality of their operation; their fine science and emphasis on outcomes, professionalism, and belief in the value of community health that allowed us to flourish as more than just another aspiring nonprofit.

But one could logically ask, “How did this happen?” Cincinnati Children’s is frequently approached by individuals and groups who know what we knew about the value of recognition from them. Having the Cincinnati Children’s stamp of approval was part of our success.

How did we get it? The first and most-influential contact was made by John Haller and Richard Aft, who scheduled an appointment in spring 1997 with James M. Anderson, then president of Cincinnati Children’s, and Lee Ault Carter, president of the board of Cincinnati Children’s and later an ECS Steering Committee member.

Both Haller and Aft, representing the United Way, were able to provide compelling documentation regarding the effectiveness that evidence-based home visiting had demonstrated over nearly 20 years of pilot studies and trials—most notably by David Olds, who founded the Nurse-Family Partnership and did seminal work in the home visiting field. In many ways, all of us in home visiting today stand on his shoulders. What Haller and Aft were proposing was to rigorously deliver an evidence-based home visiting program in greater Cincinnati derived largely from the Olds research.

Both Anderson and Carter had been affiliated with Cincinnati Children’s for decades, and they had been active United Way volunteers and funders. They frequently articulated their belief that a hospital needs to be there when a child is sick or injured, but a hospital also has a commitment to community health, in other words, to keep children out of the hospital. So when Haller and Aft met with Anderson and Carter at Cincinnati Children’s to propose a partnership to address the needs of moms and their young children, the response was enthusiastic and positive, but not without stipulations. Anderson and Carter emphasized two conditions—service delivery must be of the highest quality, and strong evaluation must be in place. Before any final decision was made about Children’s backing ECS, hospital leaders needed to be assured that what Haller and Aft were proposing was sound. Anderson and Carter also needed to confer with Thomas F. Boat, MD, chair of the department of pediatrics at the University of Cincinnati Medical Center and chair of the Cincinnati Children’s Research Foundation. Boat, nationally recognized for his clinical and policy expertise, and active in the prestigious National Academies of Sciences, Engineering, and Medicine, would be key to the decision.

When consulted, Boat recommended that Cincinnati Children’s join, but with a caveat. He reiterated that the program be supported with strong research and evaluation to monitor program operation and to uncover information about the effectiveness of home visiting as a strategy for improving outcomes for families. Not unexpectedly, it was Boat’s advice that allowed the embryonic ECS to favorably lobby the United Way to provide funds so that Frank W. Putnam, MD, and Robert T. Ammerman, PhD, two outstanding scientists, could be brought to Cincinnati to join the ECS staff to create the requisite research and measurement infrastructure; to collect and analyze data; and to guide research and evaluation activities. This would provide the bedrock ECS needed and would be the bedrock over the next 20 years. It has been fundamental to our evolution as a strong organization that can document its outcomes, its operation, and its effectiveness.

In October 1999, Putnam and I were asked to present to the Cincinnati Children’s board about the progress of the ECS initiative. They always look for accountability, and we were positioned to respond. I presented the program itself—the intrinsic value of our prevention model, our 1,200 stakeholders (organizations and individuals engaged in our work), and the business plan that was our roadmap—while Putnam explained that our research was designed to be what our P&G friends called actionable. The Cincinnati Children’s board was pleased and gave us a green light. What we proposed was bold. We needed smart, insightful, demanding partners. Cincinnati Children’s was right there with us.

The plan was built upon decades of research regarding the effectiveness of home visiting for changing the outcomes of mothers, children, and families. It turned the science into action. ECS would not just provide an evidence-based home visiting model, we would demonstrate its effectiveness for families and communities in greater Cincinnati.

Cincinnati-Hamilton County Community Action Agency (CAA)

The third significant organization approached for partnership was the CAA, which had deep roots in the community and was viewed by residents as an essential advocate for its interests. Thus, CAA acceptance of the proposal for investment in home visiting would signal wider community connection. CAA was led by Gwen Robinson, an emphatic and eloquent spokesperson whose participation was essential for success. CAA reflected the ECS commitment to community engagement and to inclusion, equity, and diversity. Their involvement was germane to gaining acceptance in the community that would translate into referrals for the program, enthusiasm, and legitimacy for what our home visiting strategy could do for families. Robinson understood and, along with her CAA commitment to partnership, became an ECS provider, offering the wealth of services and contacts from CAA to ECS families. CAA provided training, amplified our work community-wide, and brought the voice of the community to all our deliberations.

But there is another CAA story that needs to be told, because it validates what a community-focused agency in partnership with a prestigious health institution and known funder can bring to an enterprise such as the one that we were proposing. The story emphasizes the potential for change when community leaders concentrate resources and pull together.

What became a highlight in our history began in 2004 when I read an article by Paul Tough in The New York Times Magazine (June 20, 2004, Section 6, Page 44). Tough focused on Geoffrey Canada and his amazing transformational work with the 24-block Harlem Children’s Zone in New York City, viewed as a national model for place-based innovation. Canada himself was recognized as a model for all of us, having raised considerable private dollars and, with Mayor Michael Bloomberg, identified a circumscribed area in Harlem where challenged families and their children could have access to a variety of services that provided what a child needed for an optimal start, beginning with The Baby College and continuing with parenting workshops, preschool, charter schools, and child-oriented health programs.

Anderson invited me to speak to a small group of African American leaders from the Avondale neighborhood that is home to Cincinnati Children’s. Anderson met with these leaders on a regular basis and wanted them to hear about the opportunities for their families with ECS. I used the astonishing Harlem Children’s Zone as an example of what was possible.

The logical question from the group was, “Why not here?” That set us on a course that became highly rewarding. Robinson was my partner in this enterprise, and together we met with Reverend Clarence Wallace, head of the Carmel Presbyterian Church on Reading Road in Avondale. Wallace became one of our best advocates, making his church available as a central location, enlisting his church members as volunteers, engaging other members of the clergy, and welcoming Geoffrey Canada to Carmel when he came to launch our Avondale program. That was a memorable day. Canada is a compelling speaker with much success to report. The church was filled with community leaders eager to ensure that our work in Avondale would be successful. Under the leadership of Carter and Thomas G. Cody, then a senior executive at Federated Department Stores, we raised an additional $1 million to enhance services for Avondale families.

Anita Brentley, our tireless and creative ECS outreach coordinator, brilliantly led the staff work. It was an exciting and fruitful endeavor as we engaged over 85% of eligible community moms during our three-year involvement. Other outcomes were important and substantial: program retention improved, moms accepted more visits, prenatal enrollment increased, and wait times for the initial home visit decreased. We all learned what could be achieved with greater focus on equity, authentic community engagement that provided enthusiasm, and a sincere belief in what is possible when people work together. Our community leaders—Reverend Wallace and Gwen Robinson—were partners who ensured our success. Brentley was the heart and soul of this effort, bringing critical community connections and knowledge of families to our staff team.

ECS Community Board of Trustees

We carefully selected board members to bring the capacity and skills that we needed to augment paid staff. Our board was never ceremonial. Rather, its members worked through our committee structure or as individuals to offer the guidance that we needed. We sought board members who had a demonstrated interest in our work.

When queried, one potential board member told us that she wanted to create her own legacy, rather than to be part of ours. We appreciated her candor and chose someone else, because we needed to be able to look to our board for ideas about how best to navigate the crowded, competitive public arenas in the birth-to-three category; clearly identify our unique contributions; look for new sources of support; and improve awareness about ECS in the community. We wanted board members who reflected the Pepper call for “one team, one dream.”

Unlike some boards, we did not require a financial contribution from board members. Rather, we asked them to lend us their experience and their time—in law, public policy, marketing, accounting, program operation, and science—to assist in decision-making. And we have always been mindful of the value of having a board that represents an array of perspectives and expertise, knowledgeable people willing to offer opinions and engage in dialogue.

Legal Structure

With three strong partnerships secured, we turned to creating the legal structure that was needed to go forward. We applied for and received designation as a 501(c)(3) nonprofit organization, with three founders: United Way, Cincinnati Children’s, and CAA. We employed legal counsel skilled in the creation of nonprofits to write our ECS Inc. Code of Regulations that specified how we would operate; how board members and officers would be chosen; and what the role of the three founding partners would be. We executed a contract with Cincinnati Children’s to be the managing partner of the three. Our administrative staff and later a few nurse-home visitors would be employees of Cincinnati Children’s.

We issued a community-wide request for proposals (RFP) asking agencies interested in being part of our new initiative to respond. We chose 14 of the 18 proposals submitted and executed contracts with them to employ the ECS home visitors but to operate under the direction of ECS, through the terms of our contractual agreement. We considered hiring all the home visitors ourselves but rejected the concept for two reasons. First, we wanted to maintain maximum neighborhood involvement. Second, we believed that having administrative responsibilities at the agency or Cincinnati Children’s level, rather than housed in a community-based organization, reduced duplication in the system. We have occasionally made small changes to our Code of Regulations, contracts with the provider agencies, and with Cincinnati Children’s, but we operate basically as we did in March 1999 when we opened our doors to families.

Opening Our Doors

By October 1998, we were ready to turn planning and policy into action. We had a business plan, a legal structure, a funding partner with access to business contributions, and a sizable commitment of private-sector dollars. We had a science partner with world-class measurement, research, and evaluation experience and a community partner in contact with people who needed and wanted our services.

We had a compelling name and a logo that made our mission visual—a mother with her arms raised, a baby, and stars. The logo employed purple, teal, and gold.

Cincinnati Children’s had identified an Oklahoma woman who had the credentials for leadership to be president of the new organization. She visited with us twice in Cincinnati, but late in the process informed us that she had a family emergency and would not be able to come. What to do? We were ready to begin but did not have a senior executive. During a short but important conversation with Boat, he and I discussed next steps. With only a few seconds of forethought, I bluntly asked, “Why not me?” He seemed surprised but apparently saw me as a reasonable option, as I had chaired the steering committee; been involved with Cincinnati Children’s and children’s issues for many years; and had a history of advocacy and project management. Boat agreed that Cincinnati Children’s could hire me to be the president of ECS. If he were asked today, I think and hope that he would see it as a good decision.

We had an ambitious list of critical tasks that needed to be completed to begin enrolling families. That list of our 10 broad focus areas became our work plan to ensure that we were on target for a program launch by March 1999. We were singularly concentrated on these assignments:

1. Contract development with more than a dozen organizations, including the states of Ohio and Kentucky
2. Evaluation protocols for program operation and outcomes
3. Funding and fiscal management for internal operations, budgets, legal, and IRS requirements
4. Marketing to create community awareness, and enroll moms
5. Identification to develop and delineate roles and assignments
6. Provider council (now lead agency) formation to begin engagement and collaboration
7. Staff hiring, determining which services would be provided by partners, and where consultants were needed
8. Structure to inventory referral sources, set up proper training, determine best program elements, neighborhood and agency assignments
9. RFPs for agencies to discover which ones wanted to operate the Nurse-Family Partnership and the Healthy Families America models
10. Outcome assessments and information systems to describe primary and secondary outcomes; and the computer hardware, software, personnel, and facilities for home-visit coordination and training

Cincinnati Children’s gave us office space and access to accounting, budgeting, marketing, legal, and business-development services. We were initially housed in a clinical lab that was waiting for the arrival of a prominent scientist. Our first secretary stayed only two weeks, because she was concerned about the visible shower systems along the halls of the research building that would mitigate any potential contamination event in one of the labs.

We soon moved from the lab to a shared space with Putnam and the Mayerson Center for Safe and Healthy Children, an identification and treatment center for victims of child abuse. Putnam and I saw our ECS prevention approach and the Mayerson identification and treatment program as synergistic.

But when space became available in a new but small building several blocks away, still on the Cincinnati Children’s campus, we moved again. The new location, only two blocks from the main hospital, proved to be ideal for us, because our families, home visitors, board, and community partners who met with us frequently found that coming to the smaller, more-accessible building offered convenient parking, accessibility for strollers, and a real footprint in the community of Avondale.

So we got to work––Putnam, Ammerman, Clark, and I—to launch the new venture. Clark and I shared a desk with a tape down the center to keep our papers separated.

Organizationally, we implemented the work plan that we completed in January 1999. Committee assignments included marketing, contracts, budgets, hospital screening, public relations, data collection and assessment, program audits, and, critically, we announced our new carefully chosen board engaged to lead the new 501(c)(3).

As president of ECS, my commitments included fundraising, government relations, marketing, scientific advisement, research, and managing evaluations. Clark, as director of operations, was not only responsible for program implementation but also writing grants and preparing reports––more than 50 of them each year. She had help, of course, from our business director and measurement team, but she was the one who compiled the information and delivered it to the funder or the state or the federal government in a timely manner.

As we set out to promote ECS to the community, we explained it this way: ECS is a regional, voluntary program to help first-time parents in their most important job; to ensure an optimal start for their children. We identified our three founding partners, service area, and outcomes we expected to achieve: reduced child abuse and neglect, improved pregnancy outcomes, reduced infant mortality, and enhanced family functioning. We explained what services and supports ECS would provide for an eligible family, how to enroll, and how the program would work, beginning with referral, agency assignment, family contact, and length of service. We promised transparency.

We received outstanding media coverage based on what we intuited to be acknowledgment for the critical need for our service and confidence that our organization could accomplish what we promised to do. We could not afford expensive media buys, so we relied upon personal media contacts. In those days in greater Cincinnati, most media organizations had health care reporters. Part of our work was encouraging reporters to let people know that ECS was open for business, and we were eager to enroll high-risk pregnant women and new moms who met the qualifications in our service area.

We had to dispel fears that our home visitors were there to remove babies to child protective services or to judge a lifestyle. Repeatedly, we emphasized that we were there to offer professional guidance and to help moms be the best moms they could be in order to give their children an optimal start. And, in truth, this is where the magic of home visiting occurs—where a strong, supportive relationship between a mom and her home visitor creates just the right environment for the baby. People frequently asked about fathers and where they fit. We encouraged two-person parenting when possible. With about 14% of our families, dads were eager and enthusiastic. We celebrated one parent, two parents, and extended families; however the family defined itself and whatever worked to ensure that the little ones got what they needed.

Within the first few months, we received 1,700 referrals—and they just kept coming. In 1999, we enrolled 799 families during the first 10 months we were operational. For comparison, the number of new families enrolled in 2020 was 1,870. Balancing program growth with program quality has been a key concern for everything from training modules for home visitors, to contact with referral sources, to data collection and analysis, and financial planning.

One of the ECS provider agencies, Beech Acres Parenting Center, coordinated our training for home visitors and supervisors, using what was offered by the state and home visiting models but augmenting that with modules for learning that we deemed important. We kept track of training hours for each individual home visitor and required 90 hours of training in year one. Moreover, we urged the agencies to select managers who could motivate their home visitors to work as a team, to communicate well, and to think strategically and tactically.

ECS Provider Agencies

The three founding partners, steering committee members, and our working team recognized that what we were proposing was bold, and there could be repercussions from other community organizations feeling vulnerable as a new, large initiative was forming. Some organizations might see us as competition. We were especially careful when we issued the community-wide RFP for agency participation, and we made sure that our public presentation—and, over time, our implementation—was inclusive, clear, and honest. Trust was and is a key element for success. Having communities engaged and being able to build with them to deliver new services while weaving in their understanding of their community narratives were fundamental. We not only needed community support but also provider agencies eager to deliver evidence-based home visiting to families in their neighborhoods. Our goal was to enhance the existing relationships among the community agencies and their families, not to supplant them.

When 18 agencies responded to our RFP, and we selected 14 from across the region for contract negotiations, we knew that we had crossed the first of many implementation hurdles. In February 1999, Aft thanked Pepper for making ECS possible and reported that “the set-up time for this multi-agency effort is going much more quickly than projects typically go in our community.”

From the corporate perspective, Pepper responded by urging us to create a timeline for enrollment and to establish a means for getting an early measurement of results. He added that, “I continue to believe that this is the single most important and promising initiative that I have seen to make a ‘big difference’ for at-risk youth and their families. I am delighted to see the progress being made, but I would push . . . push . . . push.”

When we later discussed our sign-up process with the agencies, a few told us that they were initially afraid of losing their identity when they joined, because they thought that with our large medical-center partner, the involvement of smaller organizations would be minimized—that they would become invisible. They also expressed concern about ECS reporting requirements and the data-collection component. Resistance to our data-collection requirements was strong. The agencies viewed data collection as time taken from families and even perhaps an unnecessary, burdensome part of the visit. But they had agreed, with their contracts, to provide data using a variety of forms and inventories assembled by our research staff. Slowly, the home visitors began to see the value in the work and, to their credit, became in many cases our biggest advocates.

Later, after ECS had been operational for some months, we had gratifying news. Rather than finding the data collection onerous and time-consuming, the home visitors were pleased to have more information about their families so that they could serve them better, and they reported feeling more competent.

In the beginning, and before we were able to use the eECS data-collection platform we developed with the University of Cincinnati, everything was done manually. Home visitors and agencies completed their forms and delivered them to our office. An employee remembers walking to our UC data office through the tunnels at Cincinnati Children’s to deliver the paper data forms. She called it “sneaker mail.”

The relationship between our ECS administrative group, provider agencies, and Cincinnati Children’s proved beneficial in several substantial ways. Most notably, we had opportunities for enhanced training in motivational interviewing, quality improvement, early childhood development, literacy, and maternal-depression treatment. We were bolstered by the credibility that came through affiliation with a major medical and research center. We learned how to integrate quality improvement (QI) strategies into our daily work, and importantly, to do our work better. Home visitors reported that moms frequently expressed confidence in ECS, because it was part of Cincinnati Children’s. They joined ECS, and stayed with us. We were continually reminded that a central organization must add value to engage community-based organizations in such an arrangement.

We prepared a contract manual for provider agencies to accompany their ECS provider agreement. The contract manual was written to detail how the complex ECS program would operate to achieve high-quality care across all provider agencies and would ensure that our evaluation instruments would be used consistently. There were two audiences for the manual: 1) current providers and staff, so that they would have a single source for guidelines and philosophical approaches; and 2) those new to the program who needed an introduction.

To me, the preparation of this manual was emblematic of how we endeavored to be inclusive and thoughtful as we fostered this new alliance with strong community-based organizations. We needed to engender successful relationships based on good contracts and trust. Everything we were doing was new, from the people to the processes, and if we were going to achieve the outcomes we promised, and serve the families as we intended, consistency, transparency, and reliability had to be part of our daily work. We were careful all along to maintain the unique identity of each agency while emphasizing the unifying principle that ECS brings to the enterprise.

Administrative Structure

We described our rather-complicated structure as centralized management but decentralized service delivery. This model was reflected in our monthly meetings for all the agencies. To me, the meetings exemplified a well-executed collaborative. Administered by Clark, ECS senior program director, these monthly meetings were held faithfully for more than 20 years. Information was shared transparently; ideas and problems discussed openly; offers for collaboration were frequent. Not once during those 20-plus years was there a serious argument; rather, disagreements were addressed and solutions found.

On occasion, we brought in experts to help us, such as Kay Johnson of Johnson Group Consulting for the national scope and improved understanding of funding opportunities, and the firm of Deloitte Touche for management guidance. Interns from Yale University, University of Michigan Ross School of Business, and the University of Cincinnati Institute for Health Policy and Health Services Research helped with the eECS data platform, our public opinion surveys, and strategic community guidance; and used graduate-student projects to address specific questions.

An example is graduate student Alex Lee’s 2010 report to determine whether ECS mothers were making the necessary medical appointments for their babies during the first week of life (Are Mothers Establishing Medical Home Visiting During the First Weeks of Life?). Unexpectedly, the research provided a crucial piece of information that influenced how we communicated with moms going forward. When queried about why the number of physician appointments were low, moms told him they often would hang up before making appointments, because they were on hold too long and didn’t want to use their valuable phone minutes. This applied to more than just communication with medical offices; it applied to all the communication home visitors had with families.

We also used public relations and marketing consultants, groups such as the Cincinnati Children’s Innovation Ventures group to help us better understand our ethnography and to conduct program evaluation. In addition, we had fundraising consultants, most notably Ignite Philanthropy in Cincinnati, a group familiar both with our work and our community.

A note here about nonprofit administration. As small and midsize nonprofits endeavor to keep their operating costs as low as possible, people frequently are not hired to fill organizational needs—fundraising, business development, marketing, government relations, research, evaluation infrastructure, and grant writing. In turn, one of two things happens. Either people within the organization take on additional responsibilities, adding new work to already busy schedules; or people are hired as freelancers, temporary workers, or consultants. Too often, the temporary worker comes to the work with inadequate knowledge of the organization, or the work is assigned internally to a staff member who may or may not be skilled in that area.

ECS itself is an effective collaborative and a good example of how a group of different organizations can commit to a common purpose, and work together. The elements are good leadership, focus, transparency, proper incentives, and productive communication. Any of the ECS agency partners could have delivered a home visiting program independently, but ECS added significant value, and together we were stronger. We paid careful attention and kept good records for everything from training modules for home visitors, to contacts with referral sources, to data collection and analysis, to home visitor performance, to financial planning. The operating strategy and the tools were introduced to ECS early in the development process, largely by our business partners.

Essentially, we always kept a Pepper admonition in mind: “Do not hold meetings where nothing happens, and nothing gets done.” I submit that for our dedicated staff, our volunteers, and community leaders, their willingness to engage with us and to stay with us was buttressed by knowing that we would not waste their time, and we would focus.

Trust Matters

Underlying all of this, of course, is trust—trust that leadership will do what is promised, trust that the agencies will be consulted and considered in all decision-making, trust that each agency, indeed each staff member and each family, will be treated with respect.

As part of our due diligence, representatives from the United Way, Cincinnati Children’s, and Beech Acres, our training partner, met in July 1997 with Karen Bankston, RN, professor emerita at the University of Cincinnati College of Nursing, to seek guidance regarding how to best establish a collaborative that would deliver on its promises to: 1) acknowledge tension between and among agencies, and address issues as quickly as possible; 2) put aside institutional egos; and 3) respect all parties. Following Bankston’s guidance, that is what we did. I cannot say that every day and every meeting was smooth, but I can say without hesitation that ECS was effective and supportive. It wasn’t as if we didn’t have problems to face. Rather, the difference has been in the way we faced them—beginning with looking at reality.

Whether it was a concern from one provider agency or many, one home visitor or the entire cohort, one state or two, funding or training, we have always sought to surface issues, and look at them squarely. We have never ignored the truth—often at our own expense. We supported our work force. It has not been easy. It required a bit of bravery, solid ground for evidence, and a willingness to speak truth to power.

Several years ago, we approached a nearly fatal stress point when our provider agencies were anxious about the amount of their reimbursement from us and if ECS as an entity was viable. They told us they were barely breaking even financially. We understood that they weren’t being paid enough, yet we did not have additional public or private money to distribute. They questioned whether the benefits from their ECS affiliation justified staying in the collaborative and whether they couldn’t do just as well on their own. We had several contentious meetings and numerous side conversations with agencies threatening to leave ECS and work on their own.

Rescue came in the form of a new leader of our largest provider agency. After his first meeting, John Banchy, CEO of The Children’s Home of Cincinnati (now Best Point Education & Behavioral Health), wrote a short note to me saying, in effect, that we were stronger together than apart and that he was willing, bravely as someone new to the group, to take that stance, and ask others to join him. He elaborated on the benefits of our common operation and successes and, through conversation, slowly drew others to his point of view. Elements such as data collection and QI, shared training opportunities, and other centralized support were of value to the provider agencies. The words we had often used were more effective with this audience when they heard them from another provider and director. He came to the nonprofit world from the private sector, and he recognized reality when he saw it.

As I reflect on my decades of experience with ECS, one of the comments that has made me feel most proud came from a provider-agency manager who told me she was so pleased to work with ECS, because she knew that we would always “have their back and stand up for them as needs arose.” That certainly was my plan, though on execution, it was not always easy. Having your colleagues’ back is, to my mind, what leadership is all about.

Lessons

This is what we learned in terms of home visiting, specifically:

1. Home visiting is an effective, two-generation service for families in our community. We built upon the research done in other places and adapted the work to fit what local families wanted and needed. At ECS, we were fortunate to have a strong research-and-evaluation component for our work (for more about the ECS approach to measurement and research, see Chapter 7), but we always knew that our primary purpose was to ensure that children have the best possible start in life, and one of the best ways to do that is to provide coaching and support for their parents. Aiming to serve very young children alone, without addressing the needs of the family overall, is not as effective during the period from prenatal to age three.
2. Early relationships matter. Research tells us that early relationships between parents and infants are a foundation for lifelong health and well-being. Home visiting services can help to reduce the stresses—poverty, racism, community violence, mental health conditions, inadequate housing, and so forth—that inhibit these foundational relationships, and help parents provide safe, stable, and nurturing environments.
3. Home-visitor skills and competence are key. Whether a nurse, social worker, or early childhood specialist, a home visitor needs training and skills in how to build trust, support families, and serve in a culturally responsive and respectful manner. As the COVID-19 pandemic unfolded, the role of the home visitor, which had always been important, became a lifeline. They became trusted friends, links to a larger group with similar interests and needs. Our families embraced the concept, joined the program in record numbers, and accepted many more visits during the pandemic years.
4. Community connections and social support are critical to the service design. The parents that participated in our voluntary home visiting services were typically young, poor, and socially isolated. Home visitors offered coaching and support in the home, as well as ways to link to other services and social supports. Whether the parent gained the benefit of a mom’s group, nutrition services, job training, or other services, the resource-and-referral aspect of home visiting was as important as what happened within the visits.
5. Home visiting programs must give greater attention to what works best for whom. Among all families having babies, many could benefit from a few visits, and an estimated one-quarter have risks or needs that could be addressed through intensive evidence-based home visiting models such as that provided by ECS. Overall, at least 10% have more extensive needs calling for interventions to address risks such as serious mental health conditions, substance use, family violence, or homelessness. For example, Moving Beyond Depression™ sought to augment home visiting. One size does not fit all.

As important as what ECS did is how we did it. We were fortunate to have outstanding mentors and willing community partners joining with us from a variety of backgrounds (e.g., business, religion, human services, and health sectors). Many of these people are quoted in this book, but, on the day he retired, James Anderson—for 12 years CEO of Cincinnati Children’s and a lawyer and successful businessman—presented what for me should be the guiding principles for ECS and other mission-driven nonprofits:

• Be the very best that we can be.
• Don’t get caught in the details. Consider the long term. Are we doing the right thing?
• Count on your workers and your associates.
• Be optimistic and see ambiguity as opportunity.
• Be credible and brave.
• Do what matters.
• Be stronger under fire.
• Like and respect people.
• Be what you are.

For other nonprofits, the lessons from the ECS startup, administrative design, funding structure, and strategic partnerships are as follows:

1. Keep mission and people top of mind. Amplify the reason to believe. Nonprofits should be mission-driven organizations, striving to take action to advance their goals.
2. Clearly define the problem to be solved, as well as killer issues to help the organization keep focus during times when they are lean or flush with resources. Knowing where you are aiming and what barriers you are likely to encounter is critical.
3. Emphasize the positive, using strength-based approaches. Aim to fix problems and community challenges rather than focusing on fixing people.
4. Listen to the voice of the people. Focus on equity, transparency, and accountability. Engage in codesign, including those who receive the services, when determining which services should be delivered and how that will happen.
5. Use good communication at all levels to support the work. Give reliable feedback internally to board and staff, and externally to community stakeholders. Launch educational, marketing, and public relations campaigns that generate demand for service rather than telling people what they need.
6. Work toward community consensus and collaboration. Engage community and business leadership for expertise and support—strategic, comprehensive, systemic.
7. Create a board that is not merely ceremonial, manage it effectively, and take advantage of the strengths that its members bring to you. Encourage their questions, discussion, and input on solutions.
8. Know that the quality of implementation determines ultimate success. Deliver on your promises. Identify the most compelling measures that will, in the next one-to-two years, validate you are achieving the results you promised, or if not, why not. Agree on measures, outcomes, and expectations—and then hold everyone accountable.