Public Comment

February 5, 2024
Carole Johnson
Administrator
Health Resources and Services Administration
U.S. Department of Health and Human Services
5600 Fishers Lane | Rockville, MD | 20857

Re: Proposed Information Collection Activity: Assessing the Use of Coaching to Promote Positive
Caregiver-Child Interactions in Home Visiting
Dear Administrator Johnson,
The National Service Office (NSO) for Nurse-Family Partnership® (NFP) and Child First appreciates the
opportunity to respond to the Health Resources and Services Administration’s (the Department’s) proposed
study to examine the use of coaching to promote caregiver-child interactions and positive caregiving skills
(88 FR84342, published 12/5/2023). The NSO shares the Department’s commitment to identify and study
practices implemented in response to the COVID–19 public health emergency that support evidence-based
practice and have the potential to enhance home visiting programming. The NSO has reviewed the proposed
study instruments and makes the following recommendations.
Overall, our main concern is the Department’s approach in trying to isolate “coaching” and measure its
effectiveness. First, our programs, like most home visiting programs, are built upon client-centered
principles. NFP nurses and Child First Clinicians adapt their approaches to each family differently,
depending on the families’ needs and desires. Our home visitors utilize clinical decision-making, which may
include the provider’s assessment of the caregiver’s skills and needs (this relates to a behavioral concept of
“graduated guidance,” and working from the least restrictive intervention to most restrictive to support
errorless teaching methods). This framework is specifically behavioral – therefore, the study needs to also
understand the theoretical underpinnings of whatever model the home visitor may be using. Some may use
these strategies, but for others, who are using a different clinical approaches/EBP approach, it may not make
sense. Trying to account for all the ways that home visitors interact with clients under one umbrella term of
“coaching” will not provide the results the Departments seeks to gain through this work. The instruments
describe coaching as an isolated activity. Home visitors weave elements of “coaching” into their everyday
practice. It would be hard to parse out the effects of just one element of a very complex and deeply personal
interaction with a family.
The questions put forward by the Department for this study will likely not yield the intended results of
understanding how home visitors coach or model caregiver-child interaction. NFP nurses, like most home
visitors, already use a variety of styles of coaching and modeling dependent on the needs of the families.
When responding to the questionnaires, we do not feel a home visitor would be able to isolate specific
elements of their practice in any meaningful way to inform this work. Furthermore, we do not feel that
“coaching” would resonate with families. Again, coaching and modeling are seamlessly built into our
models, and not definitive parts of a families’ experience. Asking a family about “coaching” they received

1900 Grant St. | 4th Floor | Denver, CO | 80203
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from their home visitor would be difficult for them to do. If the Department chooses to keep this language in
the questionnaire for families, we recommend adding examples.
We also suggest that the Department consider how the word “coaching” will be interpreted by home visitors
and families. Throughout the questionnaire, coaching connotes a sense that there is a right and a wrong way
of doing things without providing options. As previously stated, our home visiting programs provide families
with the options to pursue what is best for their lives. Coaching may even evoke a sense of authority over
another. Different terminology, such as “scaffolding,” “skill-building,” or “teaching” are words that may
resonate more with nurses, clinicians, and early childhood professionals. Questions such as “did you run into
any issues when your home visitor was coaching you” demonstrates how the terminology could lead a family
and the home visitor into thinking that there was a right and a wrong way, and that they did something wrong
during their own home visiting experience. It is especially important to consider language when introducing
this to families.
From a research standpoint, the tools created, and the methods described by Mathematica seem sound.
Overall, we believe that, with some minor changes, this study may yield useful information for us at the NSO
and our partners and affiliates. COVID gave us a unique opportunity to implement innovative strategies and
it would be a shame if we did not learn from all of that. We can see utility in understanding more about
experiences with all three components of this study and the resulting recommendations for supportive
strategies. The only specific piece of feedback from a design perspective is that the protocols lacked
information on obtaining informed consent. We urge the Department to explicitly inform families that their
participation or lack of participation will not affect the home visiting services they receive. Finally, we
encourage the Department to consider how many home visits are occurring virtually. Most NFP and Child
First visits have returned to in-person, so many of the questions and therefore intended research results may
not be as relevant as they once were.
Thank you for your consideration of these comments and your continued work to bring quality programs to
families in need.
Regards,

Charlotte Min-Harris
President and CEO
National Service Office for Nurse-Family Partnership and Child First
1900 Grant St. | 4th Floor | Denver, CO | 80203

1900 Grant St. | 4th Floor | Denver, CO | 80203
(303) 327-4240 | FAX: (303) 327-4260 | TOLL FREE: (866) 864-5226
www.nursefamilypartnership.org | www.childfirst.org