How is Family Connects providing every infant in Travis County, Texas, a healthy start to life?

Welcoming a new baby into the home is a time of great joy for parents, but it also can feel overwhelming, filled with seemingly unending questions and concerns. Having the right support systems in place during this time is essential to build a solid foundation for the child’s future health and development. Home visiting programs can provide that support and build that foundation.

Home visiting programs match new parents and/or new parents-to-be with trained professionals who provide information and support. A number of these programs start during pregnancy and continue through a child’s first few years. The majority target families that have been identified as at-risk for abuse and neglect. However, data from a universal home visiting program show that 95% of all families report needing additional support and would welcome assistance and guidance as they move through this life-changing transition.

The Austin/Travis County Success By 6 Coalition, a group of early childhood stakeholders, wants to ensure that every child has the best possible start to life and enters school ready to succeed. Recognizing that a universal approach to prevention is key to reducing child abuse and neglect, the coalition sought support to implement an evidence-based universal home visiting model, Family Connects. Through the work of a handful of champions and strong partnerships across the state, the program was piloted in 2018 in two rural and two urban counties, including Travis County, which serves Austin and the surrounding area.

Austin has always had a robust continuum of community-based home visiting services, such as Nurse-Family Partnership, Parents as Teachers, and Healthy Families. These programs target at-risk parents and, accordingly, only reached about 8% to 9% of the population. The vision for Family Connects Texas, however, is that every family in Travis County with a newborn will have an opportunity to receive an in-home visit from a nurse and be directly linked to additional community resources if needed.1

Family Connects Texas is overseen by the Prevention and Early Intervention program of the Texas Department of Family and Protective Services, and is funded through the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program. To demonstrate to the public that Family Connects serves all families with newborns, United Way for Greater Austin, the program administrator, partnered with Austin Public Health.

The impact

Family Connects Texas is based on Durham Connects, a replicable universal home visiting model. Research on Durham Connects shows that the program is effective at keeping children safe. Two randomized control trials, the results of which have been published in Pediatrics and the American Journal of Public Health, found that participation in Durham Connects led to more than a 50% reduction in overall emergency medical care across the first 12 months of a child’s life. Mothers in the Durham Connects program reported more community connections, increased positive parenting behaviors, and lower rates of anxiety than mothers in the control group. Researchers also found increased participation in higher quality out-of-home child care and enhanced home environments for families that participated in Durham Connects.

Durham Connects’ Return on Investment 
By reducing emergency room care costs, The Center for Child and Family Policy at Duke University estimates that for cities averaging 3,187 births per year, an annual investment of $2.2 million in nurse home visiting would yield community healthcare cost savings of about $6.7 million in the first six months of life, or $3 saved for every $1 spent.

Serving all families

St. David’s South Austin Medical Center became the first hospital to offer Family Connects Texas in Travis County. For each family who delivers a baby at St. David’s, a program support specialist comes to the room with a congratulatory gift, describes the program to the new mother (and partner, if present), and schedules a visit by a registered nurse to the family’s home for when the baby is about 3 weeks old.

The three-week timeframe is key. This is often the time that the mother’s support network is not as present and she is experiencing being on her own for the first time. Adjustments in the timing of the visit are made for babies who spend additional time in the hospital, are in foster care or adopted, or meet other criteria. The scheduling of the visit can occur at the hospital or a community clinic, and the day before the visit, the nurse texts the mother a reminder.

During that first two-hour visit, the nurse home visitor talks with the family to gauge the health of the family and any additional services that would support the parents and baby. Partners are highly encouraged to participate in the visit.

The nurse home visitor spends time with the family in a friendly and supportive dialogue while at the same time assessing and rating the family and support environment using the Family Support Matrix. This matrix helps the nurse look at 12 factors within four domains — Support for Health Care, Support for a Safe Home, Support for Caring for an Infant, and Support for Parents — all known to be associated with maternal and child health and well-being.

The nurse rates each of the 12 factors as: (1) no risk/needs at this time, supportive guidance provided; (2) needs and concerns addressed by education and demonstration during visit; (3) family issues best addressed by linkage with community resources; and (4) urgent need(s) requiring immediate intervention. The nurse then shares relevant resources and discusses topics such as safe sleep practices, breastfeeding or the schedule for the mother’s and baby’s upcoming medical appointments.

If an assessment indicates a risk or need with a score of three, the nurse connects parents to the right community resources. In cases of mild risk, nurses may provide immediate physical resources such as food, diapers, and bus tokens; or information about other home visiting programs, mental health services, public assistance programs or primary health care providers.

In making referrals, nurses use a searchable database of local agencies, created and regularly updated by local Family Connects Texas program staff. Any follow up by the home visiting nurse is intended to support a smooth transition between one community resource to the next. The role of the nurse home visitor is one of simplifying entry and ease of access into the right community resources, not to become a case manager. The role of Family Connects is clear: Nurses identify the specific needs of the parents, make the warm hand off to the appropriate service providers to meet those needs, and then close the feedback loop with providers.

A second or third follow-up visit by the nurse home visitor may be necessary, depending on the results of the assessment. Approximately 30% of families receive a second or third visit. One month following case closure, the nurse calls families to determine whether they connected with the referred agency, are receiving services, and have any additional needs, as well as to asks them to rate their satisfaction with the program.

A community feedback loop

Family Connects Texas goes beyond the nurse visits, sharing all of the aggregate data it collects with the community to inform decisions about capacity and program infrastructure building. Tailoring resources to a family’s needs not only builds a bridge to community-based family support services, it also creates a quick feedback loop of community-specific data to illustrate emerging issues and trends. Tracking this data makes it possible for the community to act quickly in response to a new challenge and initiate community-wide changes that benefit all families. For example, communities have worked on car seat distribution and a community campaign for safe sleep practices as a result of the data collected from Family Connects.

The program administrators are developing a more robust community referral tool, in partnership with 211 Texas, a free helpline that provides up-to-date information on human services programs in Texas. The goal is to create “truly closed-loop referrals” in which providers sign agreements and are able to log into the system to acknowledge that they’ve connected with the family, as well as to add notes and share updated information.

Each community that implements Family Connects Texas is required to engage a group of social service agencies, health care providers and other recipients of these referrals into a community advisory board. This group meets regularly to analyze data and share information about identified family needs, any changes to the resources available to families, and problem-solve to fill the gaps in services that might be identified.

Family Connects collects a comprehensive amount of information on the families. Nurses complete detailed documentation from each visit: information on maternal health, infant health, home environment, material needs, screening results, and parenting difficulties/parent-child relationship.

If family scored a three in any of the assessment areas, the program tracks referrals to community partners and that data informs the conversation between nurse and family during the follow-up call after case closure. The nurses also send a report to the pediatrician for every baby.

Implementation considerations

The first Family Connects Texas home visits in Travis County began in September 2018, serving 2,000 infants in that first year. The next hospital begins serving families in 2020. Some of the lessons learned in the first year of implementation include:

Staffing up

To get up and running, Family Connects Texas first needed to hire nursing staff for the program. They experienced challenges in recruiting and finding the right staff, as this is a nontraditional role for nurses who need to be comfortable going into homes in all communities, making clinical judgments independently, and working to improve the health of both mother and baby, as well as engaging fathers. “The role is part nursing, part social work,” said Shalyn Bravens, United Way Director of Family Connects Texas. Some of the early hires were not a good fit, resulting in initial high turnover. In addition, some experienced nurses in the community were not willing to take the risk of signing onto a new program or were not aware of this new program. To remedy this challenge, a nursing supervisor has been hired to address recruitment, and the number of qualified and interested nurses has increased significantly.

Partnerships with hospitals

Another challenge was the length of time it took to finalize an agreement with St. David’s Hospital. Moving the contract through each of the parties’ respective legal processes took a significant amount of time, such that there were about two months where the nursing staff were on board but unable to serve families. Through the prolonged contracting process, the existing relationship of trust between the medical director at the Department of Public Health and the chief medical officer at St. David’s helped define the hospital’s commitment and participation.

There is an additional consent process at St. David’s hospital that must be adhered to, on top of the program’s consent forms. Prior to childbirth when patients register for delivery, parents must sign a consent form for the program support specialist to even enter the hospital room. Consequently, the program has less control over how many families receive the consent form, how it’s presented to the family and how any language barriers are addressed. Bravens suggests that there needs to be sufficient time set aside to cultivate strong, active relationships with the hospitals. “There’s no secret, no formula. Every hospital is different and every relationship is different. With every new hospital, it will take a significant amount of time to develop a real partnership.”

Cultural responsiveness

Family Connects prioritizes culturally responsive services and language accessibility. The program seeks to hire nurses that are reflective of the communities that St. David’s Hospital serves, although it has been a challenge to hire bilingual nurses. Currently, there is only one bilingual nurse out of six total nurses. To mitigate the impact of their lack of bilingual nurses, a language access plan was developed — interpreters have been hired and a language line is used when necessary. As the program expands to other hospitals, Family Connects will continue to recruit and hire more nurses who speak languages reflective of the families they are visiting.

Moving Forward

Travis County has a plan to serve all Travis County mothers who deliver a baby by 2028, depending on available funding. As with many prevention programs, funding is an issue that requires a creative and resourceful approach. Prevention programs are often the first to be cut because they are not deemed essential. For universal prevention programs, it is that much more of a challenge. The MIECHV federal dollars provided the seed money to pilot Family Connects Texas, and the St. David’s Foundation is funding the remainder of the roll out in Travis County. Episcopal Health Foundation has provided two years of additional funding to create a sustainability plan that identifies revenue streams and which hospitals are ripe for partnership across the state. The Prevention and Early Intervention program will continue to provide the majority of state dollars.

Program staff are also exploring other funding streams such as private insurance, hospital funding and city or county dollars, with the acknowledgement that revenue streams will always need to be braided and getting the right mix will be a challenge. In addition, the passage of the 2018 Family First Prevention Services Act — which allows child welfare agencies to draw down federal Title IV-E funds for evidence-based preventive services for children, parents and relative caregivers to prevent foster care placement, offers an unprecedented opportunity for the Texas Department of Family and Protective Services to secure federal dollars to support prevention programs such as Family Connects.

1 Based on conversations with Shalyn Bravens, United Way director of Family Connects Texas, United Way for Greater Austin, and Hope Hunt, nurse supervisor for Austin Public Health on May 2, 2019.