|By the Innovations Exchange Team, based on an interview with Peggy Hill , MS, Chief Strategic Relations Officer, Nurse-Family Partnership National Service Office, Denver, CO|
Innovations Exchange: Can you briefly describe the Nurse-Family Partnership program and the key elements of the program model?
Peggy Hill: The partnership, which operates in 392 counties in 32 states as of March 2011, is an evidence-based home visitation program conducted by nurses that targets low-income first-time mothers.1 The program is designed to improve pregnancy outcomes and child health and development by improving the mother’s prenatal health, caregiving skills, and economic self-sufficiency. Nurses help the women develop a vision for their futures, plan future pregnancies, stay in school, and find employment.2
The program model consists of 18 elements that describe the target population, and the process, frequency, and structure for conducting home visits as well as the surrounding community supports that are critical to the program’s effectiveness and sustainability.
David Olds, PhD, a professor and researcher at the University of Rochester in New York, developed the model in 1977. The model of home visitation by nurses was rigorously tested over 30 years in three research locations representing semirural and urban settings with white, African-American and Hispanic families in the United States. In 1996, Dr. Olds saw sufficient longitudinal evidence of the program’s effectiveness to justify public funding.
What supports were needed to spread the model?
Dr. Olds knew he would need to create a series of resources and consultative supports to enable new practitioners around the country—in this case, teams of nurses—to learn how to deliver the model program in diverse families and settings.
The opportunity came following the initiation of Dr. Olds’ third randomized controlled trial in Denver, CO, beginning in 1993. The Colorado Trust provided significant funding for the study, with the additional expectation that lessons learned would benefit others throughout the state and beyond. Dr. Olds accepted an invitation to join the faculty of the University of Colorado Health Sciences Center in Denver and established the Prevention Research Center for Family and Child Health in the Department of Pediatrics. Beginning in 1996, his team of researchers and nurses created a system of support for program replication that included a clear articulation of the program model’s key elements, well-specified home visit guidelines, and education specific to the model for nurse home visitors learning to implement the program model with families in other communities. Dr. Olds and his colleagues also developed training for the supervisors of nurse home visitors to learn how to conduct reflective supervision and function as coaches for their nurses as they developed their skills.
The most critical support was a nationally led quality improvement data system that is still used today by every local agency implementing the Nurse-Family Partnership (NFP). The agencies gather data on key aspects of program implementation and outcomes that help them determine if they are conducting the program well and achieving outcomes that are comparable with those achieved in the randomized controlled trials. They use that data locally to monitor and improve their practice, and we use it nationally to inform ongoing development and refinement of the model and our consulting practice.
Dr. Olds had great foresight to think about scaling up and spreading the program beyond the university walls. Can you elaborate on his thought process?
Dr. Olds was unique in that he had an activist heart and wanted to ensure that his research had an impact on society. He realized the only way to make real public health impact was to see the program model operating in high-risk neighborhoods with large number of the families it was designed to serve. So he knew that if the program produced reliable, positive effects, he eventually had to move the model into practice.
Dr. Olds also realized that many research-based programs become diluted when implemented and scaled in the real world. As a result, they lose their effectiveness. Dr. Olds and his colleagues established a national nonprofit organization in 2005 to ensure that partner organizations that wanted to implement the program were committed to the discipline of careful implementation of the model so that its fundamental effectiveness would not be lost while adapting it to diverse communities and organizations.
What type of staffing was needed to move the program model into community practice?
Dr. Olds had superb research skills, but he recognized that he lacked expertise in marketing and communications, politics, and policy, which are necessary skills to move the model into practice and sustain it. He hired me in 1996 to work with his team of researchers and nurses at the University of Colorado because I had experience with program development, health and human service systems, and politics and policy, and could help create some of the resources necessary for successful replication. There were also approximately 10 other team members with nursing and child development expertise who devoted a percentage of their time to carefully crafting home visit guidelines, initial nursing education processes, and implementing a 1.0 version of the evaluation system that would be used by local implementing agencies Once we received additional grant funding, we hired staff full-time to work on the national replication effort.
Were the supports tested in the field before scaling up to the current program?
After creating a rudimentary system of implementation supports at the Prevention Research Center, we pilot tested the program and our support system nationally in six communities so we could evaluate the implementation of the model by new nursing teams and local agencies. It was like building a bicycle while we were riding it because we were figuring out how to help sites implement the program while doing it. Based on their feedback, we revised our guidance for program planning and startup and continued to improve our nursing education process. We also needed a 2.0 version of our data system, which was expensive and took a while to refine. By 2001, we had a good, basic system of supports established, which we continued to improve upon with feedback from our partners in states and local communities.
What were your main funding sources?
By about 2000, the interest in implementing the program was outstripping our human and financial resources. Our program replication team was receiving inquiries from state and local health departments, a few foundations, and members of state legislatures who were frustrated with not having solutions to ongoing problems. To meet our growing capacity needs, our team at the Prevention Research Center applied for and received multiyear grants from major foundations such as The Robert Wood Johnson Foundation and the Edna McConnell Clark Foundation. That funding enabled us to move the program more quickly into practice and work on the second and third generation of supports.
Why did Dr. Olds create a not-for-profit to be the national office for the Nurse Family Partnership program?
Dr. Olds realized that the university, with its primary mission of research and teaching, was not well suited to community-based program development on a national scale. Nor could we freely engage in the necessary political advocacy, fundraising, and other administrative functions in a way that was efficient and rapidly responsive to the needs of our local partners. Dr. Olds and his colleagues sought consultation from David Racine (Replication and Program Strategies, Inc.) and the Bridgespan Group to inform a business plan that included identifying the characteristics an organization needed to be fundamentally service oriented, and could expand the program nationally while preserving its quality and maintaining its high performance. The Edna McConnell Clark Foundation was instrumental in supporting this transition planning with both guidance and financing.
In 2005, a newly formed board of directors incorporated a nonprofit organization to house the NFP and its national leadership. This became the Nurse-Family Partnership National Service Office located in Denver, CO. Most of the staff involved in program replication transferred from the university to the new office. Dr. Olds remained with the university with a clear, separate focus on ongoing research, while the new nonprofit focused on the mission of taking the NFP program to scale with quality. The two organizations remained connected through a legal Memorandum of Understanding that gives the National Service Office the sole license to replicate the program, while Dr. Olds and the university retain the right to define the model and continue its development through careful ongoing research.
The national office provides several services to local communities including program development, nursing education and consulting, evaluation and quality support, marketing and communications, and public policy and government affairs. As we obtained additional funding, we implemented components of the plan for scale, which included staffing the functions we knew were necessary to assure quality and expand the number of local programs operating nationally. For example, a grant from the Kellogg Foundation supported expanded marketing and communications efforts as well as policy work in states. Their support allowed us to expand our marketing resources for local implementing agencies and help pay for the addition of program developers in particular regions.
How many staff support the program nationally and what backgrounds do they have?
We now have approximately 70 staff nationally serving in a various roles. The program developers, nurse educators, nurse consultants, and program quality coordinators are the four types of consultants who work with local agencies from our national service office. In addition, our national office has a small marketing and communications staff, an information technology group, policy and government affairs staff, and a small executive leadership team. The nurse home visitors and nurse supervisors are employed by the local implementing agencies that serve families directly.
The program developers come from different backgrounds including nursing, social work, policy, and health care administration but they all have experience with developing and managing community services/programs and advocacy. They conduct outreach to state and community leaders, educate them about the model, assess and plan for implementation, and advocate for sustainability.
The nurse educators prepare registered nurses and supervisors to deliver the program using a competency model of instruction that builds on their professional education and experience. NFP nurse consultants are assigned regionally to provide ongoing clinical consultation to supervisors and state or local administrators on everyday nursing practice and program management issues as they relate to conducting the NFP model.
The program quality coordinators monitor and evaluate the data that nurses collect on each visit and support our nurse consultants and local supervisors in using use data system reports to do continuous quality improvement. We track a small set of readily observable markers of program implementation including the time nurses spend during their visits on the major domains of family functioning, and critical outcomes of the program including birth outcomes and length of stay in the program. We also use those reports at the state and national level to inform the focus of our consulting, develop new resources for critical areas in need of improvement, and educate stakeholders about the program’s performance and value. We’ve enhanced and improved our quality improvement data system and reporting capacity to make those data and reports relevant to practice and useful for program management purposes.
We later added government affairs staff and consultants to our payroll so they can advocate on behalf of our local partners for increased funding. Many of our implementing agencies are public health departments that lack the freedom and capacity to do that essential work.
It can take a long time to impact public health policies; but persistence pays off. A multiyear team effort between our government affairs and program development staff, local programs, mothers in the program who wanted to share their stories, a coalition of other home visiting programs, and a small amount of paid lobbyist time, was successful in getting $1.5 billion included in the Affordable Care Act to be used over 5 years by states to implement evidence-based home visitation programs designed to serve high-risk families and communities.
What is the motivation for nurses and local organizations to use your program services?
They come to us because the NFP has strong evidence that it works and improves health outcomes. People often have been struggling with poor outcomes for pregnant women and children for decades and want better results. They are more open to adhering to the program model and its core values because they recognize that a more disciplined, carefully structured model with theoretical foundations and change theory can provide more reliable outcomes. They also recognize that reliable performance requires an investment in high quality program implementation and ongoing performance monitoring. We can make all of that relatively easy because of the package of resources and services we offer.
Who are your partner agencies that implement your program model?
Most of our partners are health system–based. Eighty percent of implementing agencies are public health departments operating in cities and counties; 15% are hospitals or clinics like Federally Qualified Health Centers and a small percentage are nonprofit organizations that provide health and social services to families and want to include NFP in their array of programs.
Increasingly, state health departments or comparable agencies are engaged with us and local agencies as a funder. We also work with state agencies to help finance and sustain local program operations.
What type of agreement do partnering agencies enter with you?
We enter a contractual relationship with each agency that implements the program. Elements of the contract outline our mutual accountabilities, including their agreement to implement the model as described and use the data system for quality improvement, maintain an adequate budget for program operation, and purchase the basic resources that enable proper program implementation. It’s essentially an ongoing partnership in which we both learn from each other.
Can you elaborate on your current funding streams?
The main funding stream is the fees (approximately 5% of a local operating budget) that our local implementing agencies pay us for the education, evaluation, and consultation services we provide. This revenue helps underwrite costs for us to provide replication and support services. We also receive some funding from Medicaid, Maternal and Child Health Services Block Grant (Title V), juvenile justice funds, and Temporary Assistance for Needy Families (TANF).3
We currently serve 23,000 women and need to serve 100,000 women to cover our operating expenses. Our current operating budget runs about $8 million, and we are continually seeking operational efficiencies to reduce the cost of doing business while we maintain high quality, high value services. As long as we provide that high level of service to our contracting partners, we assume they will continue to pay us this small slice, which will sustain our organization.
Until we reach that long-term target goal, we continue to pursue and receive grants from foundations and individuals to offset the difference between earned revenue and our operating expenses. Our business plan assumes that even at scale, we will need to raise roughly $2 million in grants and gifts annually.
Although we don’t receive direct funding from the $1.5 billion in federal funding included in the health care reform bill, securing that funding was a major goal of our national office to help state and local implementing agencies serving families with NFP. We worked with other home visitation program partners to secure this $1.5 billion, 5-year commitment to evidence-based home visitation programs during pregnancy into early childhood, and under the law, there are currently seven program models that qualify for funding in high-need communities targeted by states.
What home visitation programs do you work with?
We work with other effective programs to plan for integrated program implementation using multiple models at the community level. In any community, there are families with a wide range of needs that arise at different periods of time in family development. No one model or approach or set of resources alone can meet those needs. We think it serves families and communities well when the leaders of health and human service systems work together to plan a continuum of supports for those in greatest need. We continue to work on a national and local level with a number of other well-known home visitation programs, including Healthy Families America, the Parent Child Home Program, HIPPY, Parents As Teachers, Early Head Start, Healthy Start, and Healthy Steps for Young Children.
Do you think you’re financially safe?
We never assume or take for granted that we will have continuous funding. However, we have weathered the last few years of state/national funding crises because of the success our local sites have achieved and because together, we have been able to provide solid performance and outcome data to convey the value of the program to state and local decisionmakers. The additional independent research we have that demonstrates the economic return on investment from costs averted through effective prevention by NFP has also been extremely helpful. The next 2 years will be extremely difficult as states continue to struggle to balance their budgets, and we know there will be intense pressure on every health and human services program.
You have data on cost savings, which is great. When did you realize the importance of collecting this data?
In the early 1990s, Dr. Olds hired an economist to begin to monetize savings that accrued because mothers participating in the program and their children had better health, were safer, and families were doing better economically. We were able to identify which government agencies experienced cost savings and talk with them about the rationale for helping to pay for the program. The program paid for itself by the time children born into the program were school-age; but over time, for every dollar spent on nurse visitation, RAND estimated $5.70 would be saved for every dollar invested to offer the program.4
What literature and experts guided your thinking during the scaleup and spread of your program?
Early on, we were guided by a consultant named David Racine, who was the principal in an organization known then as Replication and Program Strategies, Inc. His firm merged with Public/Private Ventures, a research and consulting organization based in Philadelphia that continued to be instrumental in shaping our thinking.
More recently, we have benefited from the work and consultative assistance of the National Implementation Research Network (NIRN) at the University of North Carolina. Drs. Dean Fixsen and Karen Blase published a monograph in 20085 that was a primer on critical functions for implementing research-based programs in community practice. This paper helped us reflect on what we were doing right and what we needed to strengthen, especially during the last 5 years. We hired Dr. Blase as a consultant as we were preparing to take the program to greater scale.
As a result, we changed the focus of our program performance measures from observing primarily structural aspects of program implementation (e.g., demographics of women enrolled, gestational age at enrollment, length and frequency of visits, total length of enrollment) to intervention process skills, meaning the quality of nursing practice actually experienced by women enrolled in the program. Their consultation helped us focus more intensively on supervisors and recrafting their roles to serve as coaches to nurse home visitors. Building supervisors’ skills and confidence as the main source of ongoing professional development for their team of nurse home visitors placed the capacity for ongoing learning closer to the families themselves, and recognized that as adults, we generally get better at something through guided practice, not by just talking about it in advance.
What tips or advice would you give innovators who want to spread their work to other organizations?
It’s important to conduct a careful assessment of the complexity of the innovation itself and determine what practitioners and organizations need to know and do to be successful in practicing the innovation. So the design of infrastructure and resources needed to take the innovation to scale should start at that level. The conceptual model that NIRN uses based on the work of Fixsen and Blase does a good job of covering the important questions to ask, including whether the model is well defined enough so people know what they have to do, what education and coaching do practitioners need, what data should be collected for quality assurance, and what system changes may be needed to have a well-functioning program.
Another key lesson we learned is that financing and politics are critical to sustaining the program. I suggest determining early on how potential adopters will finance and sustain implementation of the innovation once it's clear that the model program works and can be replicated in other places.
How can the Innovations Exchange be useful to organizations in the scaleup and spread process?
By serving as the conduit of information about the innovation, the Innovations Exchange can get the word out to practitioner or policy networks. What helped the NFP over a decade were the relationships we built with professional associations whose members were interested in our work and were successful in adopting our program. Examples include the Association of Maternal and Child Health Programs, the National Association of City and County Health Officials, and the Association of State and Territorial Health Officers. We might share information by exhibiting or presenting at their national conferences, or join with a member of the association who had implemented the NFP and present a hosted webinar about the program and its results for association members nationally.
So, the Innovations Exchange could play an important role as convener or supporter of information-sharing in potential adopter groups. Another role could be as a governmental source or hub for best practice and research information about the emerging field of implementation science. The Innovations Exchange could elevate the visibility of that emerging body of evidence, which is still relatively obscure although growing in its sophistication and breadth.
About Peggy Hill, MS
Peggy Hill develops external partnerships and relationships to promote long-term business interests between the National Service Office and agency administrators, associations, managed care agencies, and other national influencers in health care and human services. She has more than 20 years of experience at community-based programs that improve family and child health and prevent child abuse. She was instrumental in laying the groundwork for early replication of the Nurse-Family Partnership. Peggy earned a master’s degree in counseling from Purdue University with a focus on social change and community systems of care.