ECS became a nationally recognized voluntary home visiting program designed to support optimal physical, social, and emotional development for mothers, infants, and toddlers who face elevated economic and social risks. Operating regionally in Southwest Ohio and Northern Kentucky, the program uses a two-generational approach focused on parental support and education, resulting in children living in safe, stable, and nurturing environments and families moving toward independence and economic self-sufficiency. The work has been guided by the ECS mission, vision, and values since our doors opened in March 1999 and continues today.

The Essence of ECS

Officially, the carefully prepared mission, vision, and values statements describe ECS, but to understand us better, one needs more context than what is reflected in those words alone. Who are we really? A sound investment? A program with results? How are we different from other good programs? Hearing from people who receive the service and those who provide it to families is how to truly understand what we are.

In 2004, to celebrate our fifth anniversary, we held a large community luncheon celebrating those who parent children. We sought community nominations and selected families to honor, who had been nominated by the community for special recognition. Among them were one family with three children affected by autism spectrum disorder and another in which the mother was an ECS graduate, a teen mom who, with the help and encouragement of her home visitor, graduated from high school with honors, lived independently, and had a job at Walmart. She was described by her home visitor as a “terrific parent to an energetic, smart and thriving two-year old son.”

The luncheon keynote was delivered by then-Ohio Governor Robert Taft. A video was presented by human rights activist and writer Kerry Kennedy. The 600-person capacity audience overflowed the room. The message was: “Parenting matters. Really matters! What ECS is doing is valuable and is working.” We were propelled by our belief that everyone wants to be a good parent and that positive reinforcement and celebration leads to stronger families and children.

ECS was founded on the premise that babies need to feel loved and protected. Families need to be listened to, understood, and respected. Fostering social connectedness helps. Early relationships affect people throughout their lives. Mothers with high self-esteem and self-agency are better able to parent and achieve their goals.

We assumed: Parents are the child’s first and most important teachers, and everyone wants to be a good parent. By volunteering to join ECS, mothers, fathers, and children would develop the tools needed for success. We could create a model that would work here and in other communities.

We promised: Our families and our community that we would make a difference—and we delivered.

We ended most of our communications with the words, “With your help and ours, every child succeeds.” Inspired by our families and the promise we made to them, we highlighted nine key words as themes in all our presentations: evidence-based, focused, collaborative, regional, public-private, power-of-prevention, business-oriented, accountable, and outcomes-driven.

This was how we described ourselves both internally and externally. ECS moms, home visitors, and community partners saw how we added value in the broader landscape of programs for at-risk pregnant women and young children in greater Cincinnati.

What happened when a family was engaged with ECS was reflected most compellingly by a young boy who had graduated from ECS and was in grammar school. He nervously brought home a letter from his teacher for his mother. The teacher wrote to compliment his work—his response to his mother was: “Of course I am doing well in school because, after all, you allowed me to be an ECS child.”

For families, ECS provided support and resources and helped them to overcome barriers to success. By connecting with a trusted, experienced home visitor, families can be the best they can be and fulfill life goals for parents and children.

Avondale moms wrote their own mission statement, saying, “Starting prenatally, we want healthy, happy babies. We want to become resourceful and instill goals and values in our children’s lives that will carry them into adulthood.”

The board believed that the ECS program produced results. Its strength lies in the families who join and thereby create a better start for their children. These are families who face challenges that most of us will never know.

Looking Back on ECS Design and Implementation

The positive impact we had on thousands of lives, improving the well-being of women, children, and families, was largely due to rigorous implementation of effective home visiting practices, supported by following a carefully crafted business model that included quality improvement activities, performance monitoring, research and evaluation, community connections and a public-private funding mix. We’ve learned that this is a common recipe for long-term success in nonprofit organizations.

Although ECS was not unique in its ability to coordinate multiple stakeholders, operate several models of home visiting, deliver high-quality service, and verify outcomes, we were in many ways first among equals, and we were lauded for our operational strength and our ability to generate a return on investment for funders. RAND Corporation research shows that well-designed early childhood interventions generate a return for society of $2–4 per dollar invested (Cannon 2018; Kilburn et al. 2008; Karoly et al. 2005; Karoly et al. 1998).

The ECS governance and management structure had an unusual but effective framework that included three of Cincinnati’s most influential organizations as founding partners: Cincinnati Children’s, United Way, and CAA. Cincinnati Children’s was the managing partner. Provider contracts were executed with established Ohio and Northern Kentucky community organizations that hired the home visitors and provided the direct service. Provider activity was centralized through the contracts to assure consistent high quality and effective implementation and data collection. The agencies, selected through a request for proposal process, were those that had firm and respected footprints in their communities. I termed our structure “centralized management and decentralized service delivery.” Home visitors were hired and services delivered through contracts with nine provider agencies in seven counties across Northern Kentucky and Southwest Ohio—agencies with firm and respected community footprints. The contracts assured consistent high quality and effective implementation. These nongovernmental community-based agencies were grounded in their communities, drew from the local workforce, and served the neighborhoods that surrounded them.

Since 1999, ECS has served approximately 28,000 high-risk families (56,000 parents and children). We made more than 700,000 home visits, meeting approximately 20% of the need for the service among people in our region who qualified under our program criteria—single, low-income, younger than 18, and/or with inadequate (late) or no prenatal care. Many had a history of trauma. According to the 2020 ECS annual report, 45% of the families served were African American/Black, 32% were White, 13% were Hispanic/Latinx, and 10% were of other or unidentified race/ethnicity. The majority of those served were families of color, facing the challenges of structural racism in their daily lives (Every Child Succeeds Report to the Community, 2020).

An evidence-based curriculum tailored for each family was delivered by approximately 80 professional, well-trained home visitors who met with the family two-to-four times per month. We went beyond the basics of the evidence-based home visiting models being delivered by contracting agencies. The expanded ECS home visitor-friendly curricula included elements of the Ohio Help Me Grow program, which is funded by the federal Maternal, Infant and Early Childhood Home Visiting (MIECHV) program and state general funds. The Kentucky Health Access Nurturing Development Services (HANDS) home visiting program was funded through Medicaid and tobacco-settlement proceeds. ECS delivered five federally approved evidence-based models: Healthy Families America (HFA), Nurse-Family Partnership (NFP), Safe Care (Silovisky et al. 2022), Early Head Start (Chazan-Cohen et al. 2019; Jones Harden et al. 2012; Love et al. 2002), and Kentucky HANDS (Williams et al. 2017). The Parents As Teachers (PAT) model was used as part of the curriculum only (Drotar et al. 2009; Wagner and Spiker 2001). ECS also relied upon service improvement and augmentation initiatives, age-focused family success priorities, and program enhancements that included but were not limited to evidence-based treatment for maternal depression, children’s executive function, early literacy, smoking cessation, and home safety.

Data from each visit were collected and became part of the Maternal and Child Health Data Hub at Cincinnati Children’s. Outcomes and performance metrics were documented and used to continually improve the program and to support robust research and evaluation activity.

The annual program budget ranged from $7–9 million annually. Close to 60% of ECS funding came from public sources and 40% was secured privately. The annual cost per family per year was approximately $3,500.

We understood and advocated for home visiting as only one part of a continuum of services for mothers and babies. We saw home visiting as a tactic toward a larger goal for the child and the family. Home visiting, we believed, was not an end in itself. Home visitors helped families achieve their goals both through direct support and referrals to other services (e.g., nutrition, housing, mental health, education, and employment). Again, community context matters.

Cookies Never Hurt

Early on in the development and implementation of ECS, as we were thinking about how to generate more referrals from pediatric offices, I asked my husband, a busy pediatrician, what would capture his attention at the end of a long and typically stressful day. He had a one-word answer: “cookies.” So we went to work. One of our provider agencies, The Children’s Home, had made wonderful chocolate chip cookies for events (actually they were the best chocolate chip cookies I have ever eaten and I never learned their secret recipe). The agency was willing to sell the cookies to us for a reasonable price. We found small cookie boxes that looked like houses, put on an ECS sticker, and filled the boxes with two dozen of The Children’s Home chocolate chip cookies. We hand-delivered the cookies to pediatric practices to ensure that they stayed fresh and that we had a chance to interact with people in the office. Referrals from pediatric providers to home visiting and goodwill both went up. Eventually, we provided cookies to anyone who had helped us either with referrals or something else related to helping families. It was, without doubt, our most successful marketing initiative. And, happily, as we filled the little box houses, there were always cookies left over for us too.

Volunteers Added Value

For years, we operated a warehouse where nearly 1,500 Parent Aid bags were assembled each month. Most items were donated items for baby and mother. The bags always included an age-appropriate book for the child. Home visitors delivered one bag each month for each family. The home visitor, with her special bag, was welcomed with enthusiasm. Our home visitors let us know that even the babies began to recognize the gift bags, lighting up when they saw them or even reaching for their new books as soon as the visitor got in the door.

Often the books we provided were the only books in the home, and there was a well-stocked home library by the end of year three. Moms were glad to have something for themselves too—a little makeup, body lotion, special soaps.

Our diverse cadre of volunteers was drawn from the community, especially the faith-based organizations, our board members, friends of ECS, and our colleagues. More than 50 volunteers managed the warehouse, putting in many hours of work to find the items for the bags, assemble the bags, and deliver them to the agencies. We had funds to employ one paid volunteer coordinator. Eventually, we could not afford the warehouse rent and the coordinator salary and this popular, worthy project ended.

Family retention is always an issue in a long-term, intensive program like ECS. Committing oneself and one’s family for weekly and/or monthly visits for a three-year period can be daunting. The program must have value to the family. Mothers told us that the monthly bags we provided were valuable to them. They viewed the bags as special gifts, and we endeavored to present them that way. Along with the age-appropriate book for the child, we made sure that the bags themselves had items of high quality, were well designed and useful for the mothers themselves. We made them as appealing as possible. Special bags came on certain occasions: birthdays, celebrations, holidays, any time that we could help these women feel valued and proud of what they were doing for themselves and their children. We wanted to celebrate their successes.

While the Parent Aid Bag program was operational, we distributed 130,000 bags and nearly 100,000 books. We gratefully accepted over 15,000 volunteer hours and presented workshops for at least 150 corporate events where, under the guidance of our volunteer coordinator, the employees made things to include in the bags: woven blankets, handmade toys, and small assemblies of items so that the mother and child could make toys together from easily accessible items in the home, such as paper-towel tubes, plastic bottles with lids, magazines, yarn.

Our commitment to early literacy and recognizing the importance of having books in the home led two of our key longtime volunteers and board members, Mary Ellen Cody and Digi Schueler, to create the Bringing Books to Babes fundraising campaign to ensure that even when the families could no longer receive the bags, at least they would have the books. Over 10 years, these two caring and effective volunteers raised more than $400,000 to ensure that all ECS families would receive an age-appropriate book each month.

In the early years, we had birthday events sponsored by P&G at the Cincinnati Zoo, learning opportunities at the Underground Railroad Freedom Center and annual Mother’s Day parties—large, raucous, warm events with hundreds of moms, babies, and friends—creating stroller gridlock. We had gifts for moms and events that awarded prizes. The days at the Cincinnati Museum Center were especially memorable, as each family received an annual pass for free repeat visits to the Children’s Museum.

When I asked Angie Coyle, my administrative assistant at that time, what she remembered most about her years with ECS, this is how she described one Mother’s Day at Cincinnati Children’s: “The place was standing room only. We were over capacity and cramped but when I looked out and saw the mothers and the babies in that auditorium that day, it made me very proud that I was part of the ECS family. I knew then that ECS was a unique and special program.” We had over 500 families in attendance that day. And the next year the event at the Cincinnati Museum Center was even bigger and better, with 800 mothers and babies.

Lessons

I asked our staff to let me know how they would describe ECS. Our referral coordinator, Theresa Popelar, powerfully spoke for all of us when she described how she saw the heart of the program, the magic of this work. Beyond our specific mission, her words reflect what so many nonprofit organizations hope to have: more people reached with meaningful and effective services, more basic needs met, more healing of trauma, dedicated staff and volunteers, partnerships with families, and more people with positive outcomes and lifelong success: