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Service Delivery Innovation Profile

Nurse Home Visits Improve Birth Outcomes, Other Health and Social Indicators for Low-Income, First-Time Mothers and Their Children


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Snapshot

Summary

The Nurse–Family Partnership program, which operates in more than 500 counties in 43 States, US Virgin Islands, and 6 tribal nations, consists of a series of home visits conducted by nurses to low-income, first-time mothers during pregnancy and throughout the child's first 2 years of life. These visits are designed to engage these mothers in health activities that help improve their pregnancy outcomes and their child's health and development. Studies have found that the program yields lasting improvements in a variety of maternal, child health, and social indicators. Several financial analyses have found that the program generates substantial cost savings and a positive return on investment.

Evidence Rating (What is this?)

Strong: The evidence consists of three separate randomized controlled trials, long-term followup with participants in these studies, and several analyses of the economic impact of the program.
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Developing Organizations

Nurse-Family Partnership
Denver, COend do

Date First Implemented

1996
The Nurse–Family Partnership program components were first developed in the 1970s; these components were formalized and replicated as the Nurse–Family Partnership program in 1996.begin pp

Patient Population

Vulnerable Populations > Children; Gender > Female; Age > Fetus; Vulnerable Populations > Impoverished; Age > Infant (1-23 months); Vulnerable Populations > Womenend pp

Problem Addressed

Low-income, pregnant women often do not receive adequate prenatal care, leading to poor outcomes. In addition, first-time mothers in low-income communities may require education about how to care for themselves and their children and how to access health care and other services in the community.
  • Lack of adequate prenatal care, leading to poor outcomes: Low-income women often do not receive adequate prenatal care or may initiate prenatal care late in their pregnancy.1 Barriers to pursuing prenatal care include the inability to find a physician willing to accept uninsured patients and transportation difficulties. The lack of adequate prenatal care in low-income women leads to a greater risk of poor birth outcomes.2 In addition, unhealthy behaviors during pregnancy (e.g., smoking, poor dietary choices) may be difficult to change without support.
  • Lack of adequate parenting help, leading to negative consequences: Once their babies are born, low-income women, especially young first-time mothers, may need help learning how to care for their children and developing parenting skills. However, low-income women often do not seek such help. One survey found that, while a majority of low-income women agreed that most parents need parenting help or advice, they were less likely to seek help than were mothers with higher incomes.3 Frustrations with daily life can affect the ability of low-income women to supportively parent their children, with negative consequences. For example, one study found that harsh parenting among low-income women was associated with poorer child adjustment at school and poorer academic achievement.4 Other studies have shown that supportive parenting (e.g., displaying more warmth and sensitivity and encouraging cognitive stimulation) leads to better developmental achievement and cognitive performance.5
  • Lack of access to health care services: Many low-income families do not access needed health care, even if they have insurance coverage.6 This failure to access care contributes to poor health outcomes among low-income women and children.
  • Synergistic interaction that compounds the problem: Poor birth outcomes, challenges in parenting, and poverty can interact synergistically to create deeper, more complex problems for these families over time.

What They Did

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Description of the Innovative Activity

The Nurse–Family Partnership program consists of a series of home visits conducted by nurses to low-income, first-time mothers during pregnancy and through the child's first 2 years of life. These visits are designed to engage these mothers in health activities that help them to improve their pregnancy outcomes, enhance their child's health and development, and focus on their life goals. Key elements of the program include the following:
  • Target population: The program serves low-income women and adolescents who are pregnant for the first time. Participants tend to be young (average age of 18 years), with a racial mix that reflects that of the community in which the program is implemented.
  • Referrals: Referral sources also vary by community, but typically include Women, Infants and Children programs, obstetrics/gynecology clinics, family planning offices, school nurses (for teen pregnancies), physician practices, and word of mouth.
  • Visit schedule: The visit schedule is flexible based on the needs of the mother and child but typically includes weekly visits during early pregnancy followed by visits every other week until the birth, weekly visits for the first 6 weeks after the birth, and then visits every other week and then monthly from 21 months of age until "graduation" from the program when the child reaches 2 years. Participants are eligible to receive approximately 14 home visits from nurses during pregnancy, 28 visits during infancy, and 22 visits during the toddler years.
  • Visit content: Nurses use visit-by-visit guidelines as they build a relationship with the client and determine her priorities. In general, nurses uses motivational interviewing techniques to encourage behavioral change, covering the following topics:
    • Pregnancy: Visits ideally begin by the 16th week of pregnancy. Visits during pregnancy emphasize pregnancy health and well-being, nutrition, diet, exercise, prenatal care, family support during pregnancy, and anticipatory guidance for parenthood.
    • Infancy: Visits during infancy emphasize the parental role as caregiver in nurturing the attachment with the infant, proper pediatric care and immunizations, reading infant cues and responses to signals of comfort and discomfort, ensuring home safety, and recognizing early signs of illness and appropriate response.
    • Toddlerhood: During toddlerhood, visits focus on life planning and goal setting (e.g., how to finish school and hold a job while being a good parent); toddler safety; appropriate discipline; encouragement of toddler autonomy; development of the child's listening, communication, and vocabulary skills; development of the mother's coping skills and stress management; and development of a support system within the extended family and in the community.
  • Care coordination and referrals for medical care: Throughout the relationship, nurses ensure that clients have a medical home and are accessing care appropriately. Although the visits do not substitute for office-based medical care, nurses may provide assessment and guidance within the scope of their licenses (e.g., taking the mother's blood pressure, weighing the baby) and then suggest appropriate followup medical care.

Context of the Innovation

David Olds, PhD, and his colleagues at the University of Rochester first developed a home visitation program for low-income, first-time pregnant women in the 1970s. With funding from several organizations, including the Robert Wood Johnson Foundation and the National Institutes of Health, Dr. Olds, who later became affiliated with the University of Colorado, conducted a series of three randomized controlled trials in 1977, 1988, and 1994, which indicated that the program was very effective in improving a range of important child and maternal health and developmental outcomes.

Because the randomized controlled trials suggested that the program was worthy of national replication, the Nurse–Family Partnership National Service Office, a nonprofit organization, was developed to lead replication efforts providing materials and consultation to ensure that professionals and organizations around the country can implement and sustain the program effectively in their own communities. The Nurse–Family Partnership National Service Office in Denver provides support to would-be adopters by helping local communities identify funding sources; providing guidance on recruitment and hiring; and offering nurse education, consulting services, and a Web-based evaluation system to track performance indicators. Organizations adopting the Nurse–Family Partnership program include city and county public health departments, federally qualified health centers, hospital systems, and community-based organizations such as family support centers and child development centers.

Did It Work?

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Results

The Nurse-Family Partnership program has been tested in three separate randomized controlled trials (RCTs) that have found lasting improvements in a variety of maternal and child health and social indicators for program participants. Several subsequent financial analyses have found that the program generates substantial cost savings and a positive return on investment (ROI).
  • Better pregnancy outcomes: Compared with a control group, the intervention group experienced a 79-percent reduction in preterm deliveries for women who smoke, a 35-percent reduction in prenatal hypertensive disorders, and a decrease in cigarette smoking among pregnant women.7
  • Increases in intervals between first and second births: Compared with a control group, program participants had a 28-month greater interval between the birth of the first and second child and 31-percent fewer closely spaced pregnancies (defined as pregnancies less than 6 months apart).7
  • Reductions in childhood injuries: Compared with a control group, program participants experienced 39-percent fewer injuries among children, including a 56-percent reduction in emergency department (ED) visits for accidents and poisonings among children from birth to 2 years.7
  • Reduction in child abuse: Compared with a control group, program participants had a 48-percent lower rate of child abuse.7
  • Other social benefits: Other study findings show that the program was associated with increases in women's employment, reductions in families' use of welfare and food stamps, and increases in children's readiness for school (improvements in language, cognition, and behavioral control).7
  • Enduring gains: Followup studies of participants in the three randomized controlled trials over a 10- to 15-year period found that the program has had an enduring positive impact on mothers and children, as described below7:
    • Lasting benefits for mothers: Compared with control groups, program mothers had fewer subsequent pregnancies and longer intervals between the births of their first and second child, had fewer cumulative subsequent births per year, had longer relationships with their current partners, used less welfare, were arrested and convicted less often, and spent less time in jail.
    • Lasting benefits for children: Compared with control groups, program children experienced less child abuse and neglect, had higher intelligent quotient and language scores, had fewer mental health problems and other behaviors likely to compromise their adjustment to elementary school, had better grade point averages and achievement test scores in math and reading in grades 1 to 3, and had lower mortality rates through age 9 years. The reduced risk of mortality is due to fewer deaths from potentially preventable causes, including preterm deliveries, sudden infant death syndrome, and injuries.
  • Significant cost savings and a positive ROI: Several financial analyses have shown significant cost savings, positive ROI, and economic benefits from the program.
    • Cost savings: The New York City Department of Health and Mental Hygiene estimated the following cost savings to the city per 100 families served by the Nurse–Family Partnership: $29,500 due to a reduction in pregnancy-induced hypertension; $38,500 due to a reduction in child abuse and neglect cases; $11,584 due to a reduction in ED visits; and $133,000 to $440,000 due to a decline in language delays at 21 months.8 The Pacific Institute for Research & Evaluation estimates that the program reduced Food Stamp costs by 11 percent and Medicaid costs by 9 percent in Memphis.9
    • Positive ROI: The Washington State Institute for Public Policy found that the Nurse–Family Partnership generated a $2.88 return per dollar invested. A RAND Corporation analysis estimated that the program was associated with a $5.70 return per dollar invested.8 The Prevention Research Center for the Promotion of Human Development at the Pennsylvania State University found that the program generated a $3.59 return per dollar invested in Pennsylvania.10
    • Estimated average economic benefit: The Prevention Research Center for the Promotion of Human Development at the Pennsylvania State University estimated an average economic benefit of $4,782,976 per community served, based on the program's significant likelihood to reduce crime, reliance on public assistance, substance abuse, and child abuse rates and to increase test scores, high school graduation rates, and employment opportunities. The estimated potential economic benefit statewide amounts to $119,574,400 from the 25 programs that serve 3,200 families across the State.10
  • Additional analyses under way: Studies are currently under way to evaluate the program's effectiveness in several other countries and to gauge the impact of program enhancements designed to address the needs of women experiencing interpersonal violence and to increase program participation. Studies to develop strategies to increase client participation and retention and analyses are being conducted in partnership with the Children's Hospital of Philadelphia to examine differences in implementation and outcomes across communities implementing the model in Pennsylvania.

Evidence Rating (What is this?)

Strong: The evidence consists of three separate randomized controlled trials, long-term followup with participants in these studies, and several analyses of the economic impact of the program.

How They Did It

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Planning and Development Process

Key steps in the local planning and development process include the following:
  • Data-driven assessment of need: Interested parties can request program materials to help them determine whether implementing the program makes sense in their own communities. These materials pose pertinent questions and suggest statistical analyses (e.g., identifying child abuse rates, crime, unemployment, and health problems) to inform decisionmaking.
  • Review of existing services: Interested parties perform a thorough assessment of currently available services for low-income women and children to determine how the program could fit into that continuum.
  • Creation of task force to select program host: Based on the assessment of existing services, interested parties set up a planning task force with representatives of the various organizations (hospitals, public health departments, women's clinics, community organizations) that might host or support the program. This task force then decides which agency would be the best host for the program.
  • Feasibility assessment: The selected agency performs a feasibility assessment during which it considers its ability to staff and finance the program, including whether it can serve enough women to be viable.
  • Determination of referral sources and outreach methods: Using program materials, the agency designs a referral and outreach process to ensure that qualified women hear about the program.
  • Development of implementation plan: The agency develops an implementation plan that incorporates processes for identifying sustainable sources of funds, hiring and training staff, ensuring client identification and outreach, and managing the program with fidelity to the model.
  • Hiring: The agency hires nurses and a nursing supervisor. The Nurse–Family Partnership National Program Office offers sample job descriptions and interviewing guidance.
  • Initial and ongoing training: Nurses and their supervisors participate in a 9-month comprehensive training program to learn how to conduct the in-home visits. The training incorporates a combination of a self-study workbook, Web-based training activities, and two onsite training sessions at the Nurse–Family Partnership National Service Office in Denver. Ongoing education and training occurs for both new nurse home visitors and supervisors hired to implement the program. Supervisors receive ongoing consultation to help them develop strong skills with respect to reflective supervision, along with coaching from experienced program consultants.

Resources Used and Skills Needed

  • Staffing: Each full-time nurse can serve approximately 25 families. Nurses have a bachelor of science in nursing, and, as noted, receive additional training from the program. Nurses should be good at assessing clients' needs and interests, teaching clients the skills necessary to access needed services, and encouraging clients to become advocates for their own health and that of their families. Nurse supervisors require a master's degree in nursing. The supervisor-to-nurse ratio is 1:8.
  • Costs: The program costs approximately $4,500 per family per year; this per-family cost varies widely (from about $2,900 to $6,500 per year) depending on the geographic location and organizational host for the program. There is no cost for program materials provided by the National Service Office.
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Funding Sources

Medicaid; Local funding sources; State funding sources; The Maternal and Infant Early Childhood Home Visitation Program
Local sites are responsible for securing their own funding for the program. The most common sources of funding include Medicaid, State and county government general funds, Maternal-Child Health Title V Block Grants, Temporary Assistance for Needy Families funds, child abuse prevention funds, and juvenile justice and mental health agency funds.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Obtain buy-in from senior leadership: Ensure that senior leadership of the host agency sees the program as a fit with the agency's mission.
  • Perform community assessment: Before implementing the program, thoroughly assess the services that already exist in the community and determine whether the program would be a valuable addition within this broader continuum of services.
  • Ensure sufficient initial enrollment: Enrollment of at least 100 families fosters long-term viability.
  • Take a broad view of outcomes: The program can have a broad impact on the community in arenas beyond traditional health outcomes.

Sustaining This Innovation

  • Ensure ongoing funding to meet demand: To secure sustained funding, operational and political "champions" can promote the value of the Nurse–Family Partnership within the community.
  • Support nurses who make home visits: Organizations adopting the program should be committed to supporting the nurses who make home visits. Because the work is stressful and can lead to burnout, sponsoring agencies should be sensitive to the emotional challenges of this type of relationship-intensive work. Sponsors should provide active, ongoing support to the nurses (e.g., by offering formal opportunities for nurses to come together to share suggestions on managing difficult cases).
  • Maintain education and coaching: Effective staff supervision is a key driver of long-term success. As a result, the Nurse–Family Partnership National Office has intensified its education and coaching of local nurse supervisors.
  • Track results on ongoing basis: Positive results can be used to build community support for continuing the program.

Spreading This Innovation

The program has been implemented in more than 500 counties, 43 states, US Virgin Islands, and six tribal nations.

More Information

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Contact the Innovator

Erika Bantz
Director Program Development
Nurse-Family Partnership National Service Office
1900 Grant Street, Suite 400
Denver, CO 80203-4304
(866) 864-5226
E-mail: erika.bantz@nursefamilypartnership.org

Innovator Disclosures

Ms. Bantz has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Information about Nurse-Family Partnership is available at the organization's Web site: http://www.nursefamilypartnership.org

Olds DL, Kitzman H, Hanks C, et al. Effects of nurse home visiting on maternal and child functioning: age-9 follow-up of a randomized trial. Pediatrics. 2007;120(4):e832-45. [PubMed]

Olds DL, Henderson CR Jr, Kitzman H. Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life? Pediatrics. 1994;93(1):89-98. [PubMed]

Olds DL, Eckenrode J, Henderson CR Jr, et al. Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA. 1997;278(8):637-43. [PubMed]

Kitzman H, Olds DL, Henderson CR, Jr, et al. Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial. JAMA. 1997;278(8):644-52. [PubMed]

Olds DL, Kitzman H, Cole R, et al. Effects of nurse home-visiting on maternal life course and child development: age 6 follow-up results of a randomized trial. Pediatrics. 2004;114(6):1550-9. [PubMed]

Olds DL. Prenatal and infancy home visiting by nurses: from randomized trials to community replication. Prev Sci. 2002;3(3):153-72. [PubMed]

Footnotes

1 Althaus F. Prenatal care use and birth outcomes of low-income women improve after Medicaid expansion in Florida. Family Planning Perspectives. Jul/Aug 1998. Available at: http://connection.ebscohost.com/c/articles/949401/prenatal-care-use-birth-outcomes-low-income-women-improve-after-medicaid-expansion-florida.
2 Aved BM, Irwin MM, Cummings LS, et al. Barriers to prenatal care for low-income women. West J Med. 1993;158(5):493-8. [PubMed]
3 Keller J, McDade K. Attitudes of low-income parents toward seeking help with parenting: implications for practice. Child Welfare. 2000;79(3):285-312. [PubMed]
4 Shumow L, Vandell DL, Posner JK. Harsh, firm, and permissive parenting in low-income families. J Fam Issues. 1998;19(5):483-507. Available at: http://jfi.sagepub.com/cgi/reprint/19/5/483.
5 Family resources, parenting quality influence children's early cognitive development [Web site]. Bio-Medicine. July 14, 2008. Available at: http://www.bio-medicine.org/medicine-news-1/Family-resources--parenting-quality-
influence-childrens-early-cognitive-development-23994-1/.
6 DeVoe JE, Baez A, Angier H, et al. Insurance + access does not equal health care: typology of barriers to health care access for low-income families. Ann Fam Med. 2007;5(6):511-8. [PubMed]
7 Nurse–Family Partnership Web site. 2008. Available at: http://www.nursefamilypartnership.org/.
8 Nurse–Family Partnership National Program Office. "Nurse-Family Partnership--Effective and Affordable--What's Not to Like About It?" January, 2008.
9 Miller TR. Estimated Medicaid costs and offsetting Federal cost-savings of Nurse–Family Partnership. Pacific Institute for Research & Evaluation. May 6, 2009.
10 Jones D, Bumbarger BK, Greenberg MT, et al. The economic return on PCCD's investment in research-based programs: a cost-benefit assessment of delinquency prevention in Pennsylvania. The Prevention Research Center for the Promotion of Human Development. The Pennsylvania State University. March 2008. Available at: http://prevention.psu.edu/pubs/docs/PCCD_Report2.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
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Original publication: September 01, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 07, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 21, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.