AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
SHERRY HAY: --who were court ordered. But they signed a consent, so that’s considered voluntary. The sites have chosen to--that we have now, interpret that a little differently. Some of them don’t take any court-ordered. But we’re dealing with that now as we get to the implementation phase of the research. It’s a program that makes sense to the parents. It makes sense because we’re in their home, like the other home visitation programs. We’re in their context, and we start from where they are in their lives. It has solid clinical underpinnings. In other words, its nurses go into the home. Having been from a State Board of Nursing, I know they ought to have a minimum level of competency. They’re licensed, and if that competency is not there, it is indeed regulated. And then our educational program builds on that educational level. So we know there’s a basic level on which to build upon, although the nurses come from a variety of backgrounds. And sometimes that makes it difficult for the trainee. It’s been identified, and I’ll discuss this later, the most cost-effective program of its kind, and it’s obviously been rigorously tested for those of you who are familiar with it, you know that David Olsen’s research team have invested almost 30 years. This is David’s life work. And he is not done.
The families served are low income, pregnant women. They have to be first-time parents, which according to our Fidelity model right now means no previous live births. They’re usually teens. The average age in our states right now is 19. Some are 10; some are 30, or a little older even. We have some nurses who like the older ones, some nurses who like the teens. And they’re usually unmarried. The three goals of the program are to improve pregnancy outcomes. And this occurs when the nurses go in and they talk to them about nutrition, help them quit smoking. At least during the pregnancy. It is not a smoking cessation program. It has never claimed to be. It’s to reduce the smoking as much as possible. Especially during pregnancy. They talk to them about nutrition. They certainly work with them, with substance abuse, which as we all know, is really difficult. And many of these moms also have dual diagnosis of course. And we’re just learning that.
Improved child health and development. And again, that is teaching in relation to parenting skills, and improvement in parents’ economic self-sufficiency. And that refers to getting these models to, if they’ve dropped out of high school, to go back to high school, get their GED, go on to college. We have many graduates, quite frankly, who have gone on to college, never had any dreams of going to college, and they are now nurses. So that’s pretty exciting for us. And the basic elements of the nurse family partnership—in other words, some of the model elements—is that the visits begin during pregnancy. And they began no later than 28 weeks. We have a few states that passed state statute while it was still in the research phase or coming out of the University in the Fidelity. You know, nobody was watching what the legislation was going on to get the funding. So we have a few states that have said no. It can be after 28 weeks. And we’re dealing with that and how to bring that into line as we work with the Fidelity issues in quality improvement and then work with the state statutes.
By most part, all programs get the moms in by 28 weeks. The goal is to get them in by 16 weeks. The nurses visit for over two and a half years. They follow visit guidelines. There’s content, but it is not a cookie cutter approach. They are licensed healthcare professionals. Consequently, they must individualize the care and pay attention to the content. Those visits also describe the number of visits that are made. And some of the information is based on the trials. There is research going on now with allowing more flexibility with the visits. But basically, the visits are based on the premise that when the mom is new into the program, the nurse has to establish a relationship so it’s intense. Depending on when she comes in, 16 weeks versus 27 weeks, the visits are weekly until delivery. Or almost until delivery. And then they back, if they came in at 16 weeks—I’m kind of messing this up a little bit, they come in at 16 weeks, then it might start going monthly prior to the delivery. Then at delivery, after delivery, it intensifies again, to weekly. And that’s because that’s a time when moms, what we’re learning is, you know, they’re tired. All of a sudden they think they understand everything. They call for their families to help them; they don’t want people coming into their home. So the nurse intensifies the relationship in working with the mom, and then they go to monthly and then every other month until the child is two. The nurses have thorough continuing nursing education in the NFP Program. As I said, it’s built upon nursing’s basic education. It’s got a theoretical framework, so it isn’t simply training. It isn’t simply talking about the models. Right now a lot of that is onsite. They come to Denver. Sometimes our trainers go out to the regions, depending on how many new nurses there are at one time. We’re working towards making that more blended learning and changing that process. We have a business plan that’s supposed to increase the number of moms served threefold by 2010. So we are changing our processes, compared to how it was done in the research trials. As I mentioned, they have powerful relationships with the families, so powerful that certainly we have to spend a lot of time talking to the nurses about the termination process and boundaries. And their supervisors help with that. They focus on the client goals and their strong scientific underpinnings, which I will tell you about the research.
So a lot of people say, why nurses? Well, as I mentioned, they’re licensed healthcare professionals. They come in with a minimum set of competencies, they know healthcare. This is a health-care model as well, although it has implications for juvenile justice, substance abuse, and a lot of things, really. Nurses have a high level of professional trust. They are continually rated number one. Somehow they have not been associated with psychiatry or neurology, or, you know, some of these things that patients are a little leery of being seen walking into the office, or child abuse. They have expertise in establishing therapeutic relationships that ought to be part of their basic education. As well, their education should provide them with information on how to establish community relationships. It is a stated, and in Memphis trials and Denver trials, they were all baccalaureate-prepared nurses. The recommendation is a minimum of a baccalaureate degree.
As you know, in this nursing shortage, that does not all work. It’s based on the premise that we know there are differentiated competencies that are recognized in this country, and our State Boards of Nursing are recognizing those differentiations more and more, even though there’s one license. It’s just like the medical practice. One license, but not all docs do the same thing. There’s also a lack of stigma related to nursing care, and that has to do with the, relates to the trust issue. The three theories underpinning the program include self-efficacy theory. And that’s basically saying, you can have some control over your life. And the nurses work with the clients by helping them make small changes. A little bit at a time, and pointing out how successful they have been. They use solution-focused approach.
Another theory—I’m not going to go into the theories in depth—is the human ecology theory, which again is consistent with nursing theory. It says context matters. Your physical, emotional, social. So the nurses under-use that to underpin their approach. And all three of these go together. It’s none of them used separately.
And then of course, attachment theory, which if you were here, I think it was Sunday; there were wonderful presentations on attachment theory out of Louisiana. And that’s the relationship between the mom and the baby, or the caregiver and the baby, I should say, because it’s not always the mom. This is just for you to ponder. It basically is another way of saying that the program intervenes in health-related behaviors, care giving, and a maternal life course is what it’s called in the model. But that’s the whole issue of spacing pregnancies, welfare dependents, and substance abuse. Here are the clinical trials. Over the years, as you can see, it is nearly 30 years. David continues to do longitudinal studies on the children, and I think he’s headed towards the children of the children in Elmira. In addition, he’s working with the replication research. He started in Elmira in 1977, and then he wanted to test it on a different group, so he went to Memphis. And then he went to Denver where he remains today at the University of Colorado Health Sciences Center. He’s in the Department of Pediatrics, and the research team is also located there, in addition to the School of Nursing. Some of the faculty are part of that research team.
And I’m going to go into each of these trials briefly now. But before I do that, I want to tell you about the consistent results across all the trials. So that’s Elmira, Memphis, Denver. Consistent across the trials is improvement in women’s prenatal health, reduction in children’s injuries, fewer subsequent pregnancies, greater intervals between those pregnancies and births, increases in fathers’ involvement. Increases in employment on the part of the mother, and I think he’s studying the kids too. He’ll be able to do that soon. Reductions in welfare and food stamps, improvements in school readiness as a more recent finding.
So Elmira. During the study he found a 80% reduction in child maltreatment, and a 56% reduction in emergency room visits. Then he went and studied the mothers 15 years after the trials, and he found out that their arrests were 61% lower. They saw a decrease of 72% in convictions and a decrease in the number of days in jail by 98%. And then he looked at those kids, and he found out that the kids had a 48% decrease in abuse and neglect, they had fewer arrests, 59%, and adjudications as PINS. I had to double-check that. I’m not from juvenile justice. So I don’t know you all know what that is. It’s kids that tend to be runaway, and they’re having trouble, and then they can call in, the parents can, and get help, and it’s more of a probation setting, and the courts can provide some guidance. There’s probably more of you in here that might know about that than me and can help answer any questions. Okay, the Memphis design. So he went from Elmira, that was rather rural, urban setting, to Memphis. So that was one of his goals.
The other goal was to test it with a different cultural population. And this population was predominantly African-American. And he had replicated in enduring infects in Memphis. He had 28% fewer cases of pregnancy induced hypertension. Well, with that population, that might show up more frequently than it did in Elmira. He had 39% fewer injury encounters. Thirty-one percent fewer closely spaced pregnancies; 50% fewer subsequent therapeutic abortions. I was thinking, “Well, maybe South Dakota should know about this.” Thirty percent fewer subsequent admissions to neonatal intensive care units. Three point six four fewer months of welfare use. And he found a 32% increase in the father’s presence in the whole household, and sometimes the nurses had very mixed feelings about that. So I guess it depends on how you look at it, but 50% increase in marriage, and that’s sometimes the same feeling.
The growing effects on child development, for the Memphis, he studied the kids at six years—and this is his most recent research. He did find out the NFP kids had higher IQs. They had better language development, less dis-regulation, and fewer mental health problems. And I think it’s like December, 2000, for Journal of Pediatrics that that article is in. The articles are just stack high over 30 years as you can imagine. So then he goes to Denver. He says, “Okay, it worked there. I got good results. Now let’s see what happens when I go to another area.” And besides, I think the University of Colorado recruited him. And this was predominantly a Mexican-American population. And this is also where he compared paraprofessionals to nurses. And the reason he did that is people continually kept saying, “Oh, the program is just way too expensive. Can’t you just do this with non-nurses?” Because it is nursing salaries that indeed drives the program costs. So, he went ahead and tried that. He compared paraprofessionals to a control group and a group of nurses. They were all randomly assigned. They were all volunteers to be in the program, and the paraprofessionals had twice as much supervision as the nurses and they had the same training. A training that existed at that time. And what he found was the problem is with the paraprofessionals, there were virtually no effects. There were some, slightly some affects on some things, but even with all things the same, the nurses got more significant outcomes than the paraprofessionals. So his thinking was that, you know, it’s very expensive to get no outcome. So he stayed with the nurses. He particularly saw a drastic decrease in the amount of smoking with the nurses. But in general this pattern held throughout.
So now I want to talk to you a little bit about the economics because I kind of ended with the cost issues there. If you turn to the sheet with the yellow on it, I’m going to be talking about the study on the front just briefly. And then on the back you will see some other studies that have been done, or sites, or and states are starting to look at issues. And if you were in the session with the economist and another session here, they talked about the Rand Corporation study. And David always wants to point out to people, yes that was done before welfare reform. So, a little uneasy about still using the same numbers. What I’m going to talk about is the Washington state study on the front of the handout here. And what Washington did, as the legislature asked for their economic policy department to look at all programs that basically would reduce crime, lower substance abuse, improve educational outcomes, and decrease pregnancy, suicide, child abuse, and domestic violence. So then they divided those, so they went to the literature, they reviewed everything, they applied their economic models, there’s detailed, and I think it’s referenced on here, article on how they did all that. And then they divided into home visitation. I think it was mental health and correction kind of programs. Well, in home health, David was quite pleased and he says he did not bribe them but the Nurse Family Partnership actually saved $17,000 in social costs per family.
Now when we say social costs, then, we’re not talking about, they didn’t look at the number of preemies that were, the decreased number in prematurity, the decreased number in low birth weight, which you know, those in healthcare, is unfortunate. New York City has looked at some of the physical costs. Now they projected those costs. And New York City, based on their economic findings, now plans to go to 60,000 moms out of the New York City Health Department. They got a horrendous grant, or a very large grant from the Robin Hood Foundation. I think they got nearly $9 million for New York City. Now I want to tell you about what happened. So we have the research team, David is in the University. Edna McConnell Clark, the Doris Duke Foundation, and the Pick Our Foundation have all funded this, but a predominant amount of money has come from the Etta McConnell Clark Foundation. And as part of their money, they helped NFP; when it was in the University, develop a business plan. The recommendation of that business plan was that to proactively get this program out to more moms, it needed to come out of the university, it needed to separate from the research. Therefore in November of 2004, some of us moved out of the University for the purpose of replication. We’re located down the street from the University of Colorado, over here somewhere, on the side there. And David, Dr. Ruth O’Brien, and the research team, remains at the University. It is the purpose of the National Office, or the National Service Center—we’re not quite decided on the name yet—to proactively replicate the program. And that’s what we’re doing now. When we moved out of the University, and we still are, we’re serving, we’re in 20 states. We serve 20,000 families annually.
Texas, it says it’s imminent, well, that one is going to be unique. They’re going to open a nurse family partnership in the YWCA in Dallas. And they’re just about ready to start hiring nurses. Arizona is, we’ve had a lot of interest in Arizona. As I said, New York is going full speed ahead in New York City. Also other areas of the state of New York. New Jersey had an RFP out, they got a new commissioner, they were going to open 10 new sites and the new commissioner is just reevaluating everything right now in terms of programs. So, the other thing we’re doing is we’re putting developers in regions of the country. We are currently hiring developers for the Midwest. Then we plan on going more to the Southeast.
Public private ventures, if you saw Jerry Somerville present on Sunday, they covered the Northeast states for us, and then the national office has the quality improvement, the training, and the clinical information system, which I will describe to you. Our job is to, as I said, help sites, new sites get started, and we provide the technical assistance. The education right now is in Denver. The nurses in the office also provide clinical consultation. The other thing, we just had a reengineering project and met with numerous sites, and we learned that the new sites have totally different needs than our very mature sites. For instance, Oklahoma, Louisiana, Colorado, and Pennsylvania were some of the first initiatives. They’re state initiatives. They cover almost every county. They have personnel at the state level that provide guidance. So we have people in the office that provide similar guidance when it’s just a few sites in the state or one site in the state. And what we learned is when they get more mature, their questions and their support needs move to clinical consultation. So it switches from our developers helping them to the nurses in the office helping.
Most of our states in the state of New York have clinical nurse consultants that help the supervisors. And by the way, there is one supervisor per every four nurses, and it’s recommended that the supervisor have a master’s degree. I didn’t mention that. We have the program guidelines and we have the clinical information system. It probably should be called a clinical monitoring system. It is the research base that was used during the trials, essentially the same. But all of our nurses fill out the clinical forms, that data, according to a contract with the National Service Center, goes back to that clinical information base, and the sites get annual reports on how they’re doing. It’s compared to the national data, it’s compared to the research data, and they can use it to compare it to their local data. So that is part the program. We’re starting the quality improvement program, and we’re on our way with being a service center. We know that the characteristic of strong sites is clinical excellence. It does matter who we hire. That’s important, and if you read the implementation research, sometimes after the research process, that gets diluted. We are intent on not letting that get diluted, and if we can’t get all baccalaureate nurses, we will figure out how to fill in the gap analysis. We’re working, or gaps in the knowledge for some of the other nurses. Or if they’ve been in acute care for 20 years, you have to retool them back into community health. It’s important that the sites have solid funding. We help get that. Most sites have TANF, Medicaid, and private foundation funding. We certainly are partnership oriented with public/private. It’s important that sites have broad community support. It’s grassroots to get a NFP site going. You have to have strong relationships with other agencies because you depend on those agencies for a referral and support. You have to have visibility. Most of our sites are in a newspaper constantly. And NFP was supposed to be on Nightline Tuesday night. It supposed to be Thursday night now. I think South Dakota bumped them. And they will be in Louisiana. You need that visibility. We want to assure that the sites, and they need to implement it with Fidelity to the model, and they work closely with the national office.
NFP I will say has been recognized in blueprints, which is the group of evidence based programs that get together. They are sponsoring a conference next week in Denver. If any of you are there, please come and see us. We’re not far at all from that conference. The Justice Department, Substance Abuse, HHS, President’s Commission on Mental Health, the White House Policy Conference, David was on NPR, which had us get a flurry of calls, mostly from nurses saying, “How do I work there?” And do you have one in my state? And recently it was written up in The New Yorker and it was referred to as the Swamp Nurse, where Kate Boo went to Louisiana before Katrina. She knew nothing about Katrina going to hit when she started writing, and that was in I think September’s or October’s New Yorker. So that’s it. And I thank you, and then any questions you have, I’d be happy to answer them when everyone else is done. Now I’m going to try to help her get (inaudible). I’ll try to help you get slides.