HomeMy WebLinkAbout20012581.tiff (\ in
Invest
Kids
August 31, 2001
The Honorable Glen Vaad
Weld County Commissioner
915 10th Street
PO Box 758
Greeley, CO 80632
Dear Commissioner Vaad:
I hope your summer has been wonderful!
I wanted to update you on the statewide progress of the Nurse-Family
Partnership, since our last letter to you. As of July 1, 2001, the program is up and
running in 38 Colorado counties, including, of course, yours!
I have endosed a report that I thought might be of interest to you. The topic of
the report is bringing research to practice. It describes the evolution of the Nurse-
Family Partnership from a proven research model to a broadly disseminated program
that is currently serving over 1000 Colorado families (with the enrollment growing
rapidly, by the day). The report was commissioned by The Colorado Trust, who funded
the Nurse-Family Partnership's third scientifically controlled research trial, in Denver.
The Trust also funds the majority of Invest in Kids'work with communities to implement
the program with fidelity to the proven model.
I wanted to share this report with you because your leadership and support in
getting the program started in Weld County were invaluable!
Please let me know if you have any questions after reading through the enclosed
report, or if you would like any further information. Otherwise, I hope the remainder of
your summer is enjoyable and thank you again for your continued support for the
Nurse-Family Partnership!
Sincerely, ,
nnifer V. Atler
ecutive Director
Enclosure
Ce nse/II get/Olaf
9- /D D/ pe: 2001-2581
1905 Sherman Street, Suite 225 • Denver, Colorado 80203 • 303.839.1808 Voice • 303.839.1695 FAX • www.iik.org
r. t )µ n.
Fes_ '
BRINGING RESEARCH TO SCALE:
THE NURSE-FAMILY
PARTNERSHIP PROGRAM
Prepared for The Colorado Trust
Written by Kaia Gallagher,Ph.D.
Director of Evaluation
Center for Research Strategies,LLC
June 2001
e _„,„„:777
Mission
The mission of The Colorado Trust is to promote and enhance the health and well-being of the
people of Colorado.To fulfill its mission,the foundation supports innovative projects,conducts
studies,develops services and provides education to produce long-lasting benefits for all
Coloradans.Within the framework of human development,The Colorado Trust advances
accessible and affordable health care programs and the strengthening of families.
The Colorado Trust
1600 Sherman Street
Denver,CO 80203-1604
303-837-1200
Toll free 888-847-9140
Fax 303-839-9034
wwwcoloradotrustorg
"The Colorado Trust"is registered as a trademark in the U.S. Patent and Trademark Office.
Copyright June 2001.The Colorado Trust.All rights reserved.
'�'�.. L^SG« NURSE-FAMILY PARTNERSHIP PROGRAM
CONTENTS
Introduction
Bringing Research to Scale 1
The Program Model 3
Program Components that Maximize Client Outcomes 3
Research and Implementation Costs Associated with the Nurse-Family Partnership Program 6
Program Advocacy 9
Translating Program Models into Community Settings 9
Legislative Advocacy 13
The Role of State Legislators in Sustaining Effective Program Models 13
Conclusion 15
Appendix A 18
Experts Interviewed 18
Appendix B
19
Components of the Nurse-Family Partnership Program that Contribute to its Effectiveness 19
Risk Factors Addressed by Nurse-Family Partnership Program 19
Theories that Guide the Nurse-Family Partnership Program in Terms of Behavior Changes 19
Theoretical Foundations of the Nurse-Family Partnership Program for Pregnant Women
and Parents of Young Women 20
Incorporating the Three Theories into the Program's Design 22
Measuring the Effect of the Program 23
Summary 25
References 27
NURSE•FAMILY PARTNERSHIP PROGRAM
BRINGING RESEARCH TO SCALE:
THE NURSE-FAMILY PARTNERSHIP PROGRAM
INTRODUCTION
Bringing Research to Scale
The search for effective programs—those capable of producing clear client outcomes—has
never been more pressing. Inventories of programs that are proven to work in the fields of
maternal and child health have been compiled by the U.S. Surgeon General, I the American
Academy of Pediatrics,2 the RAND Corporation,;university research centers*and individ-
ual academic researchers. 5 Each of these inventories laud the Nurse-Family Partnership
(NFP) program (also known as Dr.David Olds'Nurse Home Visitation program) as an
effective,research-based program that should be replicated in varied community settings.
The national replication of this model is being conducted by the National Center for
Children,Families and Communities.
This paper looks at how The Colorado Trust (The Trust),a private grantmaking founda-
tion, helped to bring the NFP program to scale in Colorado. In 1993,building on the
strong results of two randomized controlled trials conducted by Dr. Olds—one in
Elmira,New York, and the other in Memphis,Tennessee—The Trust provided funding
to Dr. Olds and the Kempe Prevention Research Center for Family and Child Health at
the University of Colorado Health Sciences Center (now known as the National Center
for Children,Families and Communities) for a third nurse home visitation randomized
controlled trial to be conducted in Denver,Colorado. In 1999, Invest in Kids,now a
501(c)3 nonprofit organization,was funded by The Trust to help bring the NFP program
to Colorado communities. Invest in Kids was created in 1996 by a group of Denver
attorneys who sought to discover and promote scientifically-based programs designed to
improve the lives of Colorado's children.
At the outset,The Trust was particularly interested in determining how this research-
based program with effective results could be sustained on a broad scale once foundation
support ended. Many creative ventures require the design of mock-up models or ideal-
ized versions of products, technologies or systems that then are tested in controlled
settings before they are introduced to a broader market. In the social sciences field, large-
scale experiments are rarely conducted due to the expense and length of time required to
mount these programs successfully. Even less common are examples of successful
research programs for which community-scale versions have been developed.
For hinders,government agencies and social service agencies,the task of selecting effec-
tive programs entails identifying well-evaluated programs that have demonstrated
convincing client outcomes and determining the extent to which these programs can be
successfully implemented in local communities. The NFP program meets both of these
criteria.The program is now being implemented throughout Colorado and in 23 other
states. According to experts in home visitation programs who were interviewed for this
paper (see Appendix A for a listing of the experts), the experience in bringing the NFP
model to scale in Colorado has been successful due to several factors:
NURSE-FAMILY PARTNERSHIP PROGRAM .' ,' .t•5&o;�4 Va;+" -IE':fe. 1
• The strength of the NFP model and its ability to produce results
• The effective organizing work of a local advocacy group, Invest in Kids
• The willingness of a respected legislator (State Senator Norma Anderson) to
advocate for the program in the Colorado legislature
• The availability of funds to support the program's dissemination as afforded
through Colorado's portion of the settlement proceeds from the U.S. civil case
against major tobacco companies I (tobacco settlement).
As a foundation,The Colorado Trust enabled many of these key players to work together
effectively. To solidify the research base for nurse home visitation,The Trust funded the
third replication of the NFP program in Denver. This program sought to demonstrate
that the model was appropriate to a Colorado milieu with an added component—deter-
mining the effectiveness of nurses conducting the visits as compared to paraprofessionals.
Support from The Trust also helped to underwrite the development of the core curricu-
lum and home visit guideline materials, as well as financing the advocacy work of Invest
in Kids in promoting the development of the NFP programs throughout Colorado.
1. In 1999,16 states agreed to a civil settlement with the four biggest tobacco companies under which
they would collectively receive$2O6 billion over a 25-year period.The funds resolve remaining state
claims related to the health costs of treating sick cigarette smokers.In exchange for payment starting in
the year 2000,the participating states have agreed to drop any future lawsuits related to smoking-related
costs incurred by the states.In the first year of funding(1999),$33 million from Colorado's tobacco
settlement award was placed in a trust fund.
2 ^' j A NURSE•FAMILY PARTNERSHIP PROGRAM
THE PROGRAM MODEL
Program Components that Maximize Client Outcomes
The Nurse-Family Partnership program has been relatively easy to "sell" to communities,
service-providing agencies and government officials in Colorado because of its positive
results. The three separate randomized controlled trials—conducted in Elmira,New
York; Memphis,Tennessee; and Denver, Colorado—have shown that clients who receive
nurse home visitation services experience the following positive outcomes:
• Improvements in women's prenatal health, such as reductions in hypertensive
disorders and in the use of cigarettes
■ Reductions in children's health-care visits for injuries
• Fewer unintended subsequent pregnancies, and increases in the interval between
first and second births
• Increases in women's employment coupled with reductions in the use of welfare k MATERNAL LIFE-
and food stamps. 6 fi COURSE refers to the
paths a mother may take in
Even more dramatic are the results from the 15 year follow-up with the original her life and the impact of
participants in the Elmira,New York, randomized clinical controlled trial. The follow-up these choices on her and
her children.This includes
showed that program participants had experienced: such things as the mother's
• Seventy-nine percent reduction in child abuse and neglect age when her first child is
• Forty-four percent reduction in maternal behavioral problems caused by the born,the number of chil-
mothers' use of alcohol and drugs dren born to her,the
• Sixty-nine percent fewer arrests among the mothers amount of time between
• Fifty-four percent fewer arrests and 69%fewer convictions among the 15-year-olds children born to her,the
• Fifty-eight percent fewer sexual partners among the 15-year-olds mother's educational
■ Twenty-eight percent fewer cigarettes smoked and 51% fewer days consuming
riences and any depend-
attainment,her work expe-
alcohol among the 15-year-olds
ence on welfare,whether
• Four dollars saved in improved client outcomes for every program dollar invested. 6 she is married or receives
support from the children's
Since the Memphis,Tennessee,and Denver, Colorado, studies were conducted more father,and any criminal
recently,long-term follow-up data are not yet available.To date, results obtained confirm involvement by the mother
that the NFP program has produced statistically significant effects in the areas of or her friends and family.
women's prenatal health,infant health and development, and maternal
life-course (see sidebar).
The ability of the Nurse-Family Partnership program to produce these results can be
attributed to several key components in the program's design: the frequency with which
visits are carried out, the use of nurses as home visitors and the content of the home
visits themselves,as outlined below. A more detailed description of the program,its
theoretical foundation,program design and assessment procedures is provided in
Appendix B, at the end of this report.
NURSE-FAMILY PARTNERSHIP PROGRAM L 1�:� Y Wo�a¢�a;IAi-g 3
'
Linking Theoretical Concepts into a Program Design 7
Frequency of visitation • Changes with stage of pregnancy and early child
development
• Can be adapted to the mother's needs
• Scheduled every one to two weeks until the child is two
years old
• Visits last an average of 75 minutes
Nurses as home visitors • Nurses have formal training in women's and children's
health
• Nurses are competent to handle complex clinical
situations
• Nurses are credible in the eyes of the family,increasing
the nurses'influence and therefore the clinical influence
of the program
Outline of program content ■ Detailed program guidelines link nurse visits to long-
term project goals,in particular improving pregnancy
outcomes,child health and family economic self-
sufficiency
• Program content is organized developmentally to reflect
challenges at different stages of pregnancy and the child's
life
• Assessments are made of maternal,child and family
functioning,interventions selected depending on the
assessment results
• Significant others(husband,boyfriend,mother)are
encouraged to participate in the home visits
• Visits may be held at night or on weekends to encour-
age involvement of others
As a model,the NFP program offers a well-designed and conceptually grounded
approach to promoting positive changes in clients. The importance of the components
listed above have been supported by a rigorous research program that has measured client
progress toward program goals, and has shown positive outcomes in different communi-
ties and with varied client groups.
Seven steps are recognized by program staff as the process by which generalized support
for a research model is created,as listed on the following page.
4 i h '.vw+� ^;[+„A < '.' NURSE-FAMILY PARTNERSHIP PROGRAM
Steps in Developing a Successful Research-based Model 8
Ground'-in theoretical literature to identify clinically effective methods to
reduce the specific risks for,poor outcomes
2. Target the program to those most at-risk
3. Provide comprehensive,intensive services structured to produce behavior
•
ge
4. Deliver these services through competent,well-supervised home visitors with
a limited caseload
�x N
5� Design sound research and evaluation
6. Test programs across multiple domains and within different cultural groups
1. .Allow suf{tlient-timeto`.iElen long-term ogram-,outcomes
The logic model below summarizes the client risk factors addressed by the NFP model and
the complex interrelationships of these factors.This well-articulated theory of change,
combined with 25 years of implementation experience,helps explain the program's success
with implementing positive changes in participating mothers and children.
Prenatal Child/
Health- Adolescent
Related Functioning
Behaviors -School failure
-Antisocial
behavior
Chil
Dysftncdonal Neiuo __► -Substance
-
abuse
Categiving a developmental
Impairment
Maternal Life -Emotional
Course behavior
dysregulation
- Closely spaced -Cognitive
....•••„...3/416„. unplanned impairment
pregnancy
-Welfare •
dependence Negative
-Substance
peers
abuse
NURSE-FAMILY PARTNERSHIP PROGRAMM.S.° r !IS".0 ..a s.is>-a 5
Research and Implementation Costs Associated with the NFP Program •
As detailed above, the strengths of the Nurse-Family Partnership program include target-
ing specific behaviors and conditions associated with poor outcomes, employing a clearly
defined model of change grounded in theory and linked to specific types of anticipated
client change.As an intervention effort, nurse home visitation also has 25 years of delib-
erate research protocols that have been sufficiently funded to support three large-scale
clinical controlled trials.The specific features of the three randomized controlled trials
are listed below.
Research Documenting the Effects of
the Nurse-Family Partnership Program
Location of the Number of women Focus of the research Length of the trial
clinical trial enrolled
Elmira,NY 400 Caucasian families;mostly 1977-present
low-income and single parent ongoing
Memphis,TN 1,139 African-American families; 1987-present;primarily low-income and ongoing
single parent
Denver,CO 735 Large sample of Mexican- 1994-present;
American families; ongoing
differences resulting from
the use of community lay
visitors versus nurses
Data collection related to client outcomes is ongoing,with assessments recently
completed of the now 15 year old children born during the 1977 Elmira,New York, trial.
In addition to the clients enrolled during these trials who continue to be tracked,the
National Center for Children,Families and Communities maintains a data bank with
assessment results from approximately 17,000 clients who have received or continue to
receive home visits across the country. (All communities that agreed to implement the
Nurse-Family Parmership program participate in ongoing program evaluation by provid-
ing data on key aspects of program implementation and benchmark outcomes for clients
to whom homc visits are provided.)
Since the inception of this program in the late 1970;a wide range of governmental and
private funding sources have supported the research through which the program's
outcomes have been documented (see chart on page 7).The Colorado Trust's support
began in 1993 with an initial investment of $7 million to support the randomized con-
trolled trial conducted in Denver, and an additional$1.7 million grant to finance the corn-
munity organizing and advocacy efforts of Invest in Kids.
6 F.,r3 „9• iF NURSE.FAMILT PARTNERSHIP PROGRAM
After the Denver research trial, six communities implemented the NFP programs using
surplus funds from the federal Temporary Assistance for Needy Families (TANF) pro-
gram, city and county funding and other local sources of revenue. With the infusion of
the tobacco settlement funds, the NFP program will be serving an additional 14 sites
covering 38 counties (as of July 2001),with more communities creating NFP programs
in the coming years.
Funding Sources for the Nurse Home Visitation
Randomized Clinical Controlled Trials, 1977-2000
Bureau of Maternal and Child Health Research
Carnegie Corporation of New York
The Colorado Trust
Hearst Foundation
National Center for Nursing Research
National Institute for Child Health and Development
National Institute of Mental Health
Pew Charitable Trusts
The Robert Wood Johnson Foundation
The Smith Richardson Foundation
U.S Administration for Children and Families
U.S.Department of Health and Human Services,Office of
the Assistant Secretary for Planning and Evaluation
William T.Grant Foundation
Despite the clear-cut results that properly implemented NFP programs can produce for
some people, the costs of these efforts sometimes overshadow their benefits.The
National Center for Families, Children and Communities estimates that providing nurse
home visitation services,including program start-up,staff training,operations and pro-
gram evaluation, to 100 families on average costs approximately$300,000 each year. How
has Colorado been so successful in helping people focus on the strong results of the pro-
gram and establishing so many local programs?Much of the credit must go to the advo-
cacy and community organizing efforts of Invest in Kids.
NORSE•FAMILY PARTNERSHIP PROGRAM ^ �4 �^'-Yy4 ym}Ag�4,�J-�g 7
PROGRAM ADVOCACY
Translating Program Models into Community Settings
In Colorado, successfully bringing the Nurse-Family Partnership research to scale required
the assistance of an organization that could bridge the gap between a community's start-
ing point and the requirements of implementing this model program. Invest in Kids, a
501(c)3 nonprofit organization,was established to identify,promote and help implement
high quality research-based programs for low-income kids from the prenatal period
through age four. Invest in Kids leaders believe that implementing a research-based pro-
gram requires choosing one with proven results and then building community commit-
ment to establish and maintain that program. In those communities where NFP programs
have been developed, the Invest in Kids staff has recruited stakeholder groups from key
community sector and a wide variety of backgrounds.As shown in the chart below,some
groups were more involved than others at the various stages of the program's development.
Stakeholders Represented in Capacity-Building Groups
in 13 Colorado Communities
Stakeholder category Phase of involvement
Initial phase: Ongoing Support
First three to phase:six phase:
six months months advisory
through board
funding
Health department directors 92% 85% 85%
Human services department directors 77% 77% 77%
Public health nurses 100% 100% 100%
Elected officials 77% 85% 15%
Existing nurse home visitation programs 54% 85% 77%
Other youth agencies(schools,childcare 15% 54% 85%
providers,Head Start,child advocacy
groups)
Other health providers(hospitals,communi- 15% 77% 54%
ty health centers and nurse midwives)
City officials,law enforcement,judicial 15% 69% 62%
Business leaders 15% 31% 31%
NU RSEFAMILY PAR TN ER SNIP PROGRAM I��HS B{a;;b ta`s�¢:iH,::Ad 9
The Invest in Kids staff found that combining these stakeholders into a committed coali-
tion fully supportive of an NFP program typically requires numerous phone calls, face-to-
face meetings and community forums. The chart below shows the community contacts
the Invest in Kids staff initiated in the 13 Colorado communities now implementing NFP
programs.
Community Contacts/meetings Committed to Establishing
Nurse-Family Partnership Program in 13 Communities
over a Two-Year Period During 1999-2001
Type of meeting Mean number of meetings
INITIAL CONTACTS: Introducing the program 2 per community
COORDINATION: Determining how the program would 1.8 per community
meet community needs and coordinate with
existing programs
FUNDING: Identifying and securing program funding 1.8 per community
ONGOING SUPPORT: Technical assistance,quality 3.6 per community
improvement
TOTAL ALL MEETINGS 9 per community
In a two-year period between 1999 and 2001, the Invest in Kids staff completed:
• 120 community meetings, or an average of nine per community in the 13
communities in which a Nurse-Family Partnership program was established
• 364 to 481 phone calls for meeting set-up and follow through
• 80 one-on-one meetings with state legislators in their districts.
1O .&:I '. h�- �=*"I'�al. te'^ 4.k7=-94 NURSE-FAMILY PARTNERSHIP PROGRAM
Invest in Kids leaders believe that the following program elements need to be in place to
support NFP programs over the long term.
Creating broad-based r \
Finding sustainable
support in each F 8
funding sources
community
\\*.%%., }
COMPONENTS OF AN
EFFECTIVE
ADVOCACY PROGRAM
a
Building on and
Involving key local coordinating with
leaders in program existing programs
development offering services to the
p target population
While community interest in the Nurse-Family Partnership program tends to be high,
finding an adequate and ongoing source of funding has presented a challenge to many
candidate communities. The Invest in Kids staff determined early in its advocacy cfforts
that more stable,long-term funding support for these programs had to be found.The
prospect of securing funds from Colorado's portion of the tobacco settlement became a
possibility in 1998 when the availability of these funds was first announced.A task force,
headed by the Colorado state attorney general,developed some initial recommendations
for Senator Anderson,who introduced a bill in the Colorado Senate that included pro-
posed funding for nurse home visitation programs during the 1999 legislative session.
Because of the many interest groups vying for a share of the tobacco settlement's$2.9
billion dollars,the legislature was unable to reach agreement during the 1999 session.
After no compromise was reached in 1999 regarding the distribution of the tobacco
settlement dollars, the Invest in Kids staff met throughout the legislature's off-season
with 80 legislators to educate them regarding the merits of the NFP program.Because
the strongest opposition to the program came from those who viewed the program as
NURSE-FAMILY PARTNERSHIP PROGRAM ilin
l .. m • . +-s
i 7i.• y. 11
contributing to government intrusion, the Invest in Kids staff pointed to the success of
the NFP program in increasing the rates of marriage, decreasing the rates of abortion
and, most importantly, reducing the cost of social service programs while working with
the established values of families.These one-on-one educational efforts put the NFP pro-
gram in a strong position to be considered for a portion of Colorado's tobacco settlement
funds during the 2000 session. Additionally, the skilled leadership of Senator Anderson,
combined with the hard work of several other key legislators, proved to be critical in
determining the amount of funding allocated over time to the NFP program relative to
other funding options, such as roads and education. Another important factor that
encouraged the legislature to underwrite the development of a statewide NFP program
was the willingness of the Colorado Department of Public Health and Environment to
act as the grantmaking and management agency for this program.
12 ; . 'z -t NURSE•FAMILY PARTNERSHIP PROGRAM
LEGISLATIVE ADVOCACY
The Role of State Legislators in Sustaining Effective Program Models
Despite ever-increasing evidence regarding the effectiveness of prevention programs, few
have been successfully sold to the Colorado Legislature as worthy of ongoing
funding support. Historically, Colorado has been particularly leery about using state dol-
lars to support social service programs. In 1996, the Tabor Amendment—a taxpayers'
bill of rights—passed limiting the overall growth in state funding for any government
program to 6%per year. Given these spending limitation preferences, Colorado's legisla-
tive environment was not likely to be immediately receptive to a relatively expensive serv-
ice delivery program, regardless of how effective it may be.
Senator Norma Anderson,a state legislator from Jefferson County, Colorado,was willing
to champion the NFP program. A highly respected, 15-year veteran in the Colorado
Legislature, Senator Anderson has been an advocate for many women's and children's
issues. For Senator Anderson,the NFP program was appealing because of its strong
evidence base of positive results. She said,
"I think legislators strongly believe in prevention care (for nurse home visitation), the
outcomes, the results and the long-term savings—that is what swayed them. When
you talk about a 60% reduction in juvenile delinquency,that's pretty astounding . .
Nurse home visitation has the research to prove that(Dr. Olds) program works."
Recognizing the high level of competition for the tobacco settlement funds, Senator
Anderson worked tirelessly to ensure that a portion of the settlement funds would be
allocated to the NFP program.
During the 2000 legislative session, the advocacy efforts of Invest in Kids and Senator
Anderson paid off,and the NFP program became one of the major beneficiaries of the
plan by which the tobacco settlement dollars will be allocated.The final allocation of
funds to this program was a compromise, but one that nonetheless funded the NFP pro-
gram for the next 25 years. In addition to the immediate funds made available to the pro-
gram, Senator Anderson was able to allot a large portion of the annual payment into a
trust fund, the interest from which will allow community-level NFP programs to be
funded well beyond the next 25 years.9 As shown in the table on the next page, the
increases in funding are incremental, allowing the program to expand at a manageable
rate of growth.To further support the NFP programs,negotiations are currently under-
way to secure Medicaid matching funds for NFP programs.
NURSE•PAMILY PARTNERSHIP PROGRAM . II etY v.,. $,, 1 13
Allocation of Tobacco Settlement Funds to
Nurse-Family Partnership Programs in Colorado
Year Percent of settlement funds Estimated dollars available
allocated to NFP programs through the settlement funds
2000-2001 3% $2.3 million
2001-2002 5% $4.1 million
2002-2003 7% $6.8 million
2003-2004 9% $8.8 million
2004-2005 11% $9 million
2005-2006 13% $10.6 million
2006-2007 15% $12.3 million
2007-2008 17% $14 million
2008-2026 19%per year $16 to$17.8 million (estimated)
Given this level of support,Invest in Kids expects that Colorado will be able to fund an
average of two to four additional NFP program sites per year, each serving roughly 100
clients. Invest in Kids estimates that these programs will each be staffed by four full-time
nurses, a half-time nurse supervisor and additional support staff.
14 ^ " 174/,r3°4 NURSE•FAMILY PARTNERSHIP PROGRAM
CONCLUSION
Bringing Research to Scale
As a foundation,The Colorado Trust has had an ongoing commitment to funding effective
program models that can demonstrate results and continue once foundation support is no
longer available.In the early 1990s,The Trust decided that the early promise of the nurse
home visitation program in Elmira,New York,coupled with the emerging successful replica-
tion in Memphis,Tennessee,warranted the recruitment of Dr. David Olds,Associate
Professor of Pediatrics at the University of Rochester and developer of the NFP program,to
initiate such a program in Colorado.This third randomized controlled trial in Colorado sought
to examine the relative value of using nurses versus paraprofessionals for the home visitations.
With positive results emerging in the late 1990s from the Denver,Colorado, trial,The Trust
decided to provide support for Invest in Kids.This Colorado-based advocacy and community
development organization was developed to serve as an adjunct to Dr. Olds'National Center
for Children,Families and Communities,which was focusing on the national dissemination of
the NFP model.To the credit of the National Center,much of the material needed for pro-
gram dissemination in Colorado already was available when Invest in Kids began its work:
• Program outcomes had been convincingly replicated across three community loca-
tions with different target client populations since 1977 (see chart on page 6).
• The content of the program had been fully developed in terms of visit-by-visit
guidelines and training requirements,and associated materials had been tested in
various settings.
• The implementation requirements,in terms of staff recruitment,program
administration and ongoing program support,had been fully documented.
The ultimate success of Invest in Kids in facilitating the implementation of NFP
programs across Colorado also can be attributed to the fortuitous availability of funding
through Colorado's portion of the tobacco settlement and the leadership of Senator
Anderson in ensuring that a portion of these funds was allocated toward the NFP program.
The partnering necessary to bring the NFP model to scale in Colorado took place over seven
years, from the original funding of the Denver trial by The Colorado Trust in 1993 to the
decision to allocate tobacco settlement dollars to the NH'program in 2000.As chronicled in
this paper,each partner in the process had a critical and interdependent tole,one in which the
various players complemented and reinforced their capacities in disseminating this model
across a wide variety of Colorado communities.
The experience of bringing the NFP model to scale in Colorado suggests that the following
factors are part of the formula for success:
• Adequate initial funding for demonstration research and advocacy(as provided by
The Colorado Trust)
• Strength of the NFP model in terms of having demonstrated outcomes and well-
specified protocols for dissemination and replication as developed by the
National Center for Children, Families and Communities
• Efficacy of a community-oriented advocacy group (e.g., Invest in Kids)willing to
NURSE•FAMILV PARTNERSHIP PROGRAMEli /1 �"✓•J�m;a3 Yv`.ri Z�16>_®� 15
create broad-scale and ongoing community support for NFP programs and to
educate legislators about the program
• Willingness of a lead state agency (e.g., the Colorado Department of Public
Health and Environment) to administer the distribution of the tobacco settlement
funds and to award competitive contracts to community-based NFP programs
• Availability of additional dollars (e.g., tobacco settlement funds) that allows
legislators to fund NFP programs without taking funds from other programs or
needing to increase revenues
• Support and commitment of a legislative leader (e.g.,Colorado State Senator
Norma Anderson) willing to promote the NFP programs.
At a program level, staff from the National Center for Children, Families and
Communities have outlined further steps they have taken to promote the widespread dis-
semination of NFP programs in Colorado and other states.
/ Communicating the key..\ (Developing home visit
elements of the model and guidelines for use in
its likely different community
components in non- settings -
technical language
/
/ \ ( Developing an effec-
Defining the program's ` rive training and professional
operating requirements, development system in-
costs and standards for corporating effective adult
quality learning principles and
providing ongoing
/ Challenges of troubleshooting and
-. Taking a consultation
/
Research-based c
Finding an appropriate Model to Scale 9 Developing a clinical
balance between program information system to
fidelity and local monitor program quality and
adaptation to assure outcomes
program effectiveness
.. Pre izanon aannd�community to` (Lung -scale,sustain\
able financial support for
support and sustain a model
effective programs that can
program over time,including contribute to their long-term
strategies for client recruit-
stability
ment and linkages with ty
other health and
social services / J
16 rnNIIRSE.FAMILY PARTNERSHIP PROGRAM
•
The lessons of this experience underscore the complexity of bringing research to scale and
explain,in part,why so few programs have been able to do so.Yet, the success of the
Nurse-Family Partnership program in becoming an institutionalized part of the Colorado
health and human services landscape offers promise that other evidence-based programs
also can be brought to scale and implemented more broadly in local community settings.
NURSE-FAMILY PARTNERSHIP PROGRAM L. , ea, °4*'.pietas 8� 17
APPENDIX A •
Experts interviewed
Colorado State Senator Norma Anderson
Jennifer V. Ader,J.D.
Executive Director
Invest in Kids
Peggy Hill,M.S.
Associate Director
Prevention Research Center for Family and Child Health
University of Colorado Health Sciences Center
David Olds, Ph.D.
Professor of Pediatrics and Director
Prevention Research Center for Family and Child Health
University of Colorado Health Sciences Center
18 - Let�',' NURSE•FAMILY PARTNERSHIP PROGRAM
APPENDIX B
COMPONENTS OF THE NURSE-FAMILY PARTNERSHIP
PROGRAM THAT CONTRIBUTE TO ITS EFFECTIVENESS
Risk Factors Addressed by NFP Program
Many of the preconditions that put women at risk for poor birth and parenting out-
comes have been found to be interrelated. Mothers who give birth at closely spaced inter-
vals tend to be at risk for welfare dependency. Their children are more likely to be born
at a low birth weight and to exhibit early on-set antisocial behavior. In addition, environ-
mental factors such as unemployment and poor housing create stressful household situa-
tions that have been associated with higher rates of child abuse and neglect. By identify-
ing the modifiable risk factors associated with poor birth and parenting outcomes, the
Nurse-Family Partnership program seeks to maximize the chances that improvements
can be realized.The chart below synthesizes the various risk situations toward which the
NFP program directs its efforts.
Modifiable Risk Factors by Problem Area tR
Low birthweight, Child abuse;neglect Welfare dependence Early on-set
preterm delivery and injuries to and compromised antisocial behavior
and neurodevel- children maternal life-course
opmental development
impairment
Use of tobacco Mother's psychological Families where par- Neuropsychological
immaturity and mental ents are teenagers, deficits,in part related
Use of alcohol and health problems unmarried and poor to poor prenatal
other substances health conditions
Environmental factors Women who have
Inadequate weight that create stressful rapid,successive and Dysfunctional care-
gain,inadequate household situations subsequenct pregnan- giving
diet,inadequate des
prenatal care,unat- A history of punitive, Compromised mater-
tended obstetric rejective,abusive or Women who have lit- nal life-course(e.g,
complications neglectful parenting de control over their large family size,
life circumstances and closely spaced ch l-
Challenges parents face contraceptive prac- dren,parental criminal
when their young chil- tices,and limited involvement and wet-
dren have compromised visions for their own fare dependence
neurodevelopmenral personal development
functioning in the areas of educa-
tion and work
Theories That Guide the Nurse-Family Partnership Program in Terms of
Behavior Change
The Nurse-Family Partnership program uses three theories of human development and
change to target the ways in which a mother's behavior can be modified,namely the self-effi-
cacy,human attachment and human ecology theories.The strength of the NFP program
rests with the translation of these theoretical building blocks into program elements that are
ItAre
NURSE-FAMILY PARTNERSHIP PROGRAM Lt444 �� .A) .n',;%.Ye,mnzaa$:.-Ari t9
part of the nurse home visit guidelines. Examples of these theoretical translations are
summarized in detail on the following tables. In brief, some of the key theoretical compo-
nents that have been incorporated into the home visiting model are as follows:
• Since individuals are more likely to have a sense of mastery when they have experi-
enced success,the Nurse-Family Partnership program helps women set small achiev-
able objectives for behavior changes that strengthen their confidence that they can
cope with similar problems in the future.
• Because many women seek help from caregivers during times of stress,the nurse
home visitors use the opportunity of a mother's first pregnancy to create empa-
thetic relationships that help to model positive caring relationships.
• The nature of the mother-child relationship is dependent on the quality of the moth-
er's relationships with others in her immediate environment hence,the Nurse-Family
Partnership program encourages improved relationships with partners and other fam-
ily members.
Theoretical Foundations of the Nurse-Family Partnership Program for
Pregnant Women and Parents of Young Children
Self-Efficacy Theory tl
Theory components Application within the model
Differences in motivation and behavior are a Role modeling is encouraged through the
function of individuals'beliefs about the development of warm,caring relationships
connection between their efforts and their between the visitor and her client.
desired results.
Individuals understand that certain behaviors The education component of the NFP
lead to given outcomes program was designed to bring women's
outcome expectations into alignment with
the best evidence available about the
influence of specific behaviors and
conditions on maternal and child health.
Efficacy expectations are individuals'belief The Nurse-Family Partnership program
that they can successfully carry out the helps women to set small,achievable
behavior required to produce the desired objectives for behavioral change that,if
outcome. accomplished,are designed to strengthen
their confidence in coping with similar
problems in the future
Four sources of information affect individu- Women are encouraged to carry out desired
als'efficacy expectations: behaviors.
1)Performance accomplishments Problem-solving skills are explicitly taught,
2)Vicarious experience with visitors helping women to anticipate
•
3)Verbal persuasion common problems and to devise methods
4)Emotional arousal of coping with those problems
Individuals'sense of mastery is raised with
perceived successes and lowered with failures
20 NURSE-FAMILY PARTNERSHIP PROGRAM
Human Attachment Theory 12
Theory components Application within the model
Human beings have developed a repertoire Sensitive,responsive and engaged caregiving is
of behaviors that promote interactions encouraged in the early years of the child's
between caregivers and their infants. life.
Sensitive and effective responses to those
communications promote secure infant Parents are given information to correctly
attachment read and respond to infant cues through
parent-infant curricula.
Caregivers'levels of responsivity to their Parents are encouraged to review their own
children can be traced to caregivers'own childhood histories and make proactive choic-
childrearing histories and attachment-related es about how they will care for their own chil-
experiences. dren.
Humans are biologically predisposed to seek The Nurse-Family Partnership model encour-
proximity to specific caregivers in times of ages visitors to develop an empathetic rela-
stress,illness or fatigue in order to promote tionship with the mother and other family
survival. Individuals who do not receive members where possible.
consistent and responsive caregiving devel-
making BY efforts to maintain a consistently
op mistrusting views of others.
supportive relationship with parents,the visitor
shows the parent that positive,caring relation-
ships are possible.
The helping relationship becomes a corrective
emotional experience for parents who experi-
enced neglectful and abusive relationships in
their own childhoods.
NURSE-FAMILY PARTNERSHIP PROGRAM _ A $.;gip 21
Human Ecology Theory 13
Theory components Application within the model
The Nurse-Family Partnership program DEVELOPMENT OF PARENTING
emphasizes the development of parents SKILLS:
because their behavior constitutes the most Women selected with no previous live births;
powerful and potentially alterable influence they undergo a major ecological or role tran-
on a developing child,particularly given par- sition(e.g.,the mother's first pregnancy).
ents'control over their children's prenatal
environment,their face-to-face interaction Program initiated during pregnancy and the
with their children postnatally and their early years of a child's life when parents are
influence on the family's home environment. learning the parental role.
Skills obtained during the care of the first
child would carry over to subsequent
children. •
Attention given to the evaluation and
improvement of the material and social envi-
ronment of the family.
One of the central hypotheses of the INFORMAL SOCIAL SUPPORT:
human ecology theory is that the capacity of The capacity of women to improve their
the parent-child relationship to function health-related behaviors is influenced by their
effectively as a context for development levels of informal support for adaptive
depends on the nature of other relation- change.
ships that the parents may have.
Visitors encourage family members and
friends to support the mother's attempts to
improve her health-related behaviors.
Visitors encourage improved relationships
with partners and other family members.
Emphasis on the importance of social con- USE SERVICES IN THEIR
texts as influences on human development COMMUNITIES:
Visitors assess family needs and help them
make use of other needed services to reduce
situational stresses.
Access to primary care providers is developed.
Knowledge of maternal and child health
indicators is promoted.
Visitors also contribute to the improvement
of the health and human services system in
the communities where they work.
Incorporating the Three Theories into the Program's Design
The preceding sections have detailed the overall structure of the Nurse-Family
Partnership model and the ways in which program components are designed to produce
improved client outcomes.Through the extensive research conducted on this model,
attention also has been given to the intensity, duration and scope of the services offered,
as detailed on the chart on the next page.
22 2gsa<,ala NURSE-FAMILY PARTNERSHIP PROGRAM
Linking Theoretical Concepts into a Program Design 14
Frequency of visitation • Changes with stage of pregnancy and early child
development
• Can be adapted to the mother's needs
• Scheduled every one to two weeks until the child is two
years old
• Visits last an average of 75 minutes
Nurses as home visitors • Nurses have formal training in women's and children's
health
• Nurses are competent to handle complex clinical
situations
• Nurses are credible in the eyes of the family,increasing
the nurses'influence and therefore the clinical influence
of the program
Outline of program content ■ Detailed program guidelines link nurse visits to long-
term project goals,in particular improving pregnancy
outcomes,child health and family economic self-
sufficiency
• Program content is organized developmentally to reflect
challenges at different stages of pregnancy and the child's
life
• Assessments are made of maternal,child and family
functioning;interventions selected depending on the
assessment results
• Significant others(husband,boyfriend,mother)are
encouraged to participate in the home visits
• Visits may be held at night or on weekends to encour-
age involvement of others
Measuring the Effects of the Program
During the three randomized controlled trials,the specificity with which the program
goals were defined also were matched by careful measurement instruments designed to
detect the program's effects. Each of the three randomized controlled trials was devel-
oped to continue to test and refine the program's effectiveness. In addition to maternal
and child assessments conducted by independent data gatherers (not the home visitor),
secondary records were reviewed,including birth certificate information,pediatric and
hospital records and welfare files. Currently, the Nurse-Family Partnership programs in
Colorado and the other 23 states are also being monitored through less intensive evalua-
tion protocols that assess program implementation and maternal and child functioning.
NURSE-FAMILY PARTNERSHIP PROGRAM karnj A ; ___miym;;j9aLFg-II:rq 23
Location of Special study factors Assessment tools utilized
study
Elmira,NY • Investigators heavily involved in pro- • Assessments conducted at registration,at end of
gram implementation pregnancy,at months six,ten,22,24,34,46 and 38 of
• Same nurses worked with families for the child's life,and at the child's 15th birthday
the duration of the program • Self-reports by clients of cigarette,marijuana and
• Community had the highest rates of alcohol use
reported and confirmed cases of child • Chemical test to determine any tobacco use by moth-
abuse/neglect in the state when the er during pregnancy
study began • Obstetrical,newborn and pediatric medical record
• Community had the worst economic reviews
conditions among all Standard • Child protective service record reviews
Metropolitan Statistical Areas in the • Tests on children for mental development and IQ
country ■ Observations of the home environment
• Women were recruited at less than 26 ■ Maternal reports of subsequent pregnancies,partner
weeks gestation relationships,continuing education and work
■ Aid to Families with Dependent Children(AFDC)
record reviews
• Maternal reports of arrests and convictions
• Adolescent reports of arrests and convictions
Memphis,TN • Investigators were less involved in pro- • Assessments conducted at registration,at 28 and 36
gram administration weeks prior to birth,and postpartum at months six,
• The program experienced high nursing 12 and 24
turnover ■ Self-reports by clients of cigarette,marijuana and
• Program able to reduce dysfunctional alcohol use
care of children and improve maternal • Obstetrical,newborn and pediatric medical record
life course,but its impact on improve- reviews
meet of pregnancy outcomes was • Tests on children for mental development
equivocal • Observations of the home environment
• Absence of effect on pre-term delivery • Maternal reports of subsequent pregnancies,partner
may be related to lower rates of cigarette relationships,continuing education and work
smoking among African-Americans • AFDC record reviews
Denver,CO • Designed to examine the effectiveness • Assessments conducted at registration,at weeks 36 of
of paraprofessional versus nurse home pregnancy,and at months six,12,15,21 and 24 of
visiting as a means of improving the child's life.
prenatal health behaviors • Self-reports by clients of cigarette,marijuana,and
• Clients recruited included a much larger alcohol use
proportion larger representation by • Chemical test to determine any tobacco or drug use
Mexican-American women than in by mother during pregnancy
Elmira or Memphis • Obstetrical,newborn and child medical record
reviews
It Tests on children for language and mental develop-
ment
■ Observations of infants'emotional responsiveness
• Observations of the home environment
• Maternal'Torts of subsequent pregnancies,partner
relationships,continuing education and work
■ AFDC record reviews
24 III *' !'1° 3 t °1' NURSE-FAMILY PARTNERSHIP PROGRAM
SUMMARY
As summarized in the overall report and these appendices, the Nurse-Family Partnership
program is constructed to address very specific types of behavior change in participating
mothers. These behavioral changes have beneficial impacts on the participating clients'lives
and those of their children. More than 20 years of experience have confirmed that it is not
sufficient to expect these types of changes unless:
• The NFP program targets people who are at risk for poor outcomes.
• The program targets specific risks and protective factors thought to affect maternal and
child health outcomes.
• The nurse home visit guidelines incorporate specific targets for behavior change that
reinforce the strengths of individual clients.
• The focus of the nurse home visits lies in building on the individual strengths of clients.
• The visit schedule is sufficiently long in duration to promote sustained behavior
improvements.
• The visits are conducted by trained nurse home visitors who understand how to
promote behavior change.
The NFP program requires a two-and-a-half year commitment on the part of the participating
clients,but the results demonstrate the value of this type of long-term visitor/client contact.
For many of the mothers who have participated in the NFP program,the relationships they
have developed with their nurse home visitors are the among the first sustained,caring relation-
ships they have experienced.It is the strength of these relationships that form the foundation
on which subsequent improvements in the clients'lives are built.
In light of this extensive discussion of what the NFP program sets out to achieve,it also is
instructive to note what is does not do.While the NFP program focuses on training mothers
and fathers to become better parents and to relate to their young children,the program does
not provide direct health services. Moreover,improvements in the economic situations of their
clients are promoted by coaching clients toward school completion,planning subsequent preg-
nancies and finding and keeping adequate employment It also is important to note that despite
the evidence of client benefits 15 years after the program,the actual contacts between the visi-
tors and their assigned mothers do not formally continue after the child's second birthday.
The Nurse-Family Partnership program represents a prototype for how effective prevention
programs work In comparison with many single-focus programs,this program uses a focused
intervention to encourage changes in the behavior of women at a critical juncture in their own
lives and the lives of their children.The birth of a child,particularly a first child,presents a
unique and life-altering opportunity for mothers to understand and respond to their children's
needs and to nurture their optimal early development.These changes can have lifelong conse-
quences for the mothers and their children.
At its essence,the Nurse-Family Partnership program seeks to enhance the earliest bond
between mothers and their children,a relationship that influences the child's health,social
behavior and physical well-being. These changes improve the mother's welfare as well,increas-
ing her sense of self-esteem and competency and ultimately leading to more general improve-
ments in her own life.What better investment in the future can be made than to provide a firm
foundation for mothers and their children to improve their relationship with one another as a
basis for allowing each to become more productive and healthy citizens?
NURSE-FAMILY PARTNERSHIP PROGRAM '' 1
25
REFERENCES
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Health Services and the National Institute of Health, National Institute of
Mental Health.
2. American Academy of Pediatrics. The role of home-visitation programs in
improving health outcomes for children and families (RE9734). Pediatrics.
1998;101:486-489.
3. RAND,The Promising Practices Network,http://wwwpromisingpractices.net
4. Center for the Study and Prevention of Violence,The University of Colorado at
Boulder, http://www.colorado.edu/cspv/blueprints/model
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8. Hill P. Family in-home support in early childhood: bridging the gap between
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9. Ibid.
10. Olds DL,Henderson C, Kitzman H,et al. Prenatal and infancy home visitation
by nurses: a program of research. In Rovee-Collier C,Lipsitt L,Hayne H, eds.
Advances in Infancy Research. Stamford, Connecticut Ablex Publishing
Corporation; 1998:Vol 12: 79-130.
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Pgcbological View. 1997; 84:191-215.
12. Bowlby J.Attachment and Loss: Volume 1.Attachment. New York,New York:Basic
Books;1969.
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Design. Boston, Massachusetts: Harvard University Press; 1973.
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by nurses: a program of research. In Rovee-Collier C,Lipsitt L, Hayne H,
eds.Advances in Infancy Research. Stamford, Connecticut Ablex Publishing
Corporation; 1998: Vol 12: 103-104.
28 a 'k=5Pira NURSE`FAMILY PARTNERSHIP PROGRAM
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