What are some considerations when implementing Nurse-Family Partnership?
Throughout pregnancy and in the early months of their child’s life, first-time mothers understandably have many questions about their own health as well as the health of their child. For some, home visiting programs provide opportunities to receive answers to those questions, and increase the support, tools, and knowledge that mothers need to successfully navigate pregnancy and the first few years of parenthood. While the specifics of home visiting programs can vary in terms of content, target audience, and intensity, all include regular visits from a professional or paraprofessional focused on building parenting skills. Home visiting programs have a strong evidence base for increasing positive outcomes for families and have been shown to decrease child maltreatment, support healthy child development, increase economic independence, and increase positive parenting practices.
Overview
Nurse-Family Partnership (NFP) is an evidence-based home visiting program that is highly effective in supporting first-time mothers. Mothers who participate in NFP do so on a voluntary basis early in their pregnancy and must meet specific income requirements. Once a mother is enrolled, registered nurses begin home visits during the pregnancy and continue until the child reaches 2 years old. This specific model is unique in several ways: women are engaged at a point in their lives when they are particularly receptive to and interested in support; the home visitor is a nurse, who has inherent credibility; and a long-lasting relationship between the mother and her NFP nurse is created. Combining their medical background with their NFP training, nurses focus on nurturing health-related behaviors, parenting skills, competent caregiving, and supportive relationships, with the goal of improving pregnancy outcomes including full-term births and healthy birth weight, as well as the child’s health, development, and safety. Nurses also assist mothers in setting and achieving educational and career goals.
While nurses are encouraged to use their professional judgment regarding the frequency of interaction with mothers, visits typically occur weekly for the first month of enrollment and then bi-weekly until the child is born. After birth, visits occur weekly for the first six weeks and continue bi-weekly until the child is 20 months old. When the child is between 20 months and 24 months, visits occur monthly.
Though Nurse-Family Partnership (NFP) traditionally is offered in the home, visits occurred virtually during the COVID-19 pandemic, with the NFP National Service Office adapting its approaches so services would not be interrupted. The office provided technology to mothers who needed it and developed a COVID-19 response webpage to disseminate information and connect mothers to resources.
Evidence of impact
NFP has a long history of research examining outcomes for mothers enrolled in the program. In 1977, 1990, and 1994, NFP initiated large, longitudinal, randomized controlled trials to establish program effectiveness and improve service delivery. One study found, women who participated in NFP, when compared to services as usual, were less likely to be identified as perpetrators of child abuse and neglect during the 15 years following their enrollment. In addition, these mothers were less likely to be arrested for crimes.
Another study found that NFP was effective in reducing preventable deaths among children whose mothers participated in the program, as compared to a control group. Data gathered from a subset of the population enrolled in the study also revealed that mothers who received home visiting services from a nurse used less in public benefits (SNAP, TANF, and Medicaid, for example). Each one of these studies had significant populations of white, Black, and Latina mothers, demonstrating the effectiveness for NFP across different races/ethnicities.
The Title IV-E Prevention Services Clearinghouse has rated NFP as “well-supported” as an intervention for “in-home parent skill-based programs and services,” which gives jurisdictions the option to use Title IV-E funds for NFP to prevent foster care placement. NFP is also rated as effective by the U.S. Department of Health and Human Services’ Home Visiting Evidence of Effectiveness Review and as “well-supported by the research” by the California Evidence-Based Clearinghouse for Child Welfare.
The NFP National Service Office continues to gather and analyze data from its many partner organizations, allowing substantial opportunities to track outcomes and initiate continuous quality improvement efforts. NFP also relies on the experience of participants to both improve and expand the program, particularly through a parent ambassadors program, which leverages the personal experience and expertise of mothers who have participated in NFP to increase awareness and advocate for NFP at the local, state, and national levels.
National scale and spread
Established in 2004, the NFP National Service Office oversees the majority of the NFP programs nationwide, and is involved in the implementation process from the moment an application is submitted to as long as NFP is active in the jurisdiction.1 The office works closely with applicants to develop an effective roadmap that details how to deliver NFP, helping the jurisdiction focus on families with the most need, develop clear target outcomes, and secure the involvement of the community. The office collects data regarding enrollment characteristics and outcomes throughout the life of the project to ensure NFP continues to be replicated properly and achieves target outcomes.
It also works directly with six different tribes, in both rural and urban settings, and about 3% of mothers involved with NFP are American Indian/Alaska Native. In partnership with select tribal communities, the National Service Office expanded eligibility to allow the NFP model to enroll mothers past the 28-week point in their pregnancy, and to be delivered to mothers pregnant with their second child. Informed by the initial tribal work, the office developed a study across 31 sites in 12 states, serving over 1,000 families. Results from the study, which concluded in January 2021, were promising.2 Tribes and the sites that participated in the study will continue to serve mothers past 28 weeks of pregnancy and mothers pregnant with their second child, and the National Service Office has expanded this initiative to Ohio and Florida. The office also plans to partner with the Prevention Research Center at the University of Colorado to conduct a randomized control trial to study the impact the NFP model could have on this expanded population. The National Service Office remains committed to improving the ways that NFP supports communities affected by adversity and economic inequality, in particular Black and American Indian/Alaska Native communities.
Jurisdictional examples
Experiences in New Jersey and Colorado offer important insights and lessons to other jurisdictions considering NFP as part of their array of upstream support for families.
New Jersey
NFP is just one piece of the New Jersey Department of Children and Families’ (DCF) home visiting service continuum.3 Primarily supported through Maternal, Infant, and Early Childhood Home Visiting funds, the agency offers multiple home visiting programs geared toward parents with children in specific age ranges. By implementing NFP, DCF was able to work with first-time mothers prior to the birth of their child, aligning with their vision of a statewide home visiting network that serves families at every stage of their parenthood journey.
DCF operates a centralized intake and referral system for all of its home visiting programs. Referrals are received from various clinical settings and sent to the local agencies and organizations with which DCF subcontracts. This allows each agency to hire the home visitors who hail from and reflect the community they are serving. Many of the local agencies operate more than one home visiting program, so when the referral is received, agency staff review the needs of the family next to multiple program eligibility criteria to determine which program would be most appropriate. Program staff then contact the family to determine the interest in enrolling.
One community agency providing NFP is the Partnership for Maternal & Child Health of Northern New Jersey (‘Partnership’). The agency started implementing NFP in 2007, with support from the NFP National Service Office. The program started small with four nurses and one part-time supervisor. Since then, it has grown to serve four counties with two teams (each team has eight nurses and one supervisor). The National Service Office provides training for the nurses and a training consultant who works directly with the supervisors.
One early lesson learned by the Partnership was the importance of hiring the right nurse. Since nurses begin working with mothers prior to the birth of their child and continue until the child turns 2, there often is a close, trusting, and supportive relationship formed between the mother and the nurse. If the nurse leaves, it may negatively impact the mother, who may not want to continue services. As a result, the goal is to hire nurses who will stay with NFP for a minimum of three years. Early in implementation, the Partnership also discovered that having a part-time supervisor was not adequate to meet the needs of the nursing staff. Six months after launching, the Partnership was able to secure additional funding to make the position full-time.
The Partnership has found that the “right nurse” is one who really enjoys this type of nursing, is from the local area, and is familiar with the resources that are unique to each community. The Partnership often recruits for nurses with language proficiencies and cultural heritage that match the backgrounds of the mothers they serve. While the National Service Office requires NFP nurses to have a Bachelor of Science degree in nursing, the nurses’ fit with the position really is about dedication to the NFP mission and supporting families through home visiting, being comfortable in different homes, and having an engaging personality. Since the position is grant-funded, the nurses also must have the willingness to accept compensation that may be less than they would earn in a hospital setting. As a result, some NFP nurses are early in their career, while others are more experienced nurses toward the end of their career who are seeking more time-flexibility and freedom in their work.
Just in Time
When Christian Mallon went to her local health department to sign up for Medicaid, the representative she spoke to recommended she participate in NFP. Within days, she was matched with a nurse who taught her all about pregnancy and childbirth — “the best nurse,” Christian said. From the beginning, the nurse’s presence did not feel intrusive to Christian. The nurse was welcoming, happy, and bubbly, and Christian was grateful she was there. Christian’s son was constantly sick during his first three months of life. The nurse stuck beside Christian throughout the ordeal. When her nurse arrived for the three-month visit, she knew something was wrong and encouraged Christian to get a second opinion, despite her pediatrician insisting that her son was fine. The next day her son had emergency surgery for a rare condition. The doctors who performed the surgery said that had the condition gone undiscovered much longer, her son would not be alive. After the surgery, the nurse continued to visit, providing Christian with advice and information about baby and toddler milestones. She helped Christian set goals for her family’s future and, after years of hard work, Christian achieved her goal of becoming a homeowner. Her son is currently a happy, healthy 7-year-old and Christian credits her NFP nurse with saving his life. “NFP is a great support system and they teach you so much,” she says.
Colorado
NFP was implemented in Colorado prior to the creation of the National Service Office.4 As a result, Colorado’s Department of Human Services (DHS) does not work directly with the office, but instead relies on Invest in Kids, a Colorado-based nonprofit, as an intermediary. Invest in Kids secured original funding for NFP through the federal tobacco master settlement agreement and since these funds flow through the state, DHS acts as the fiscal agent while Invest in Kids oversees the program. Invest in Kids oversees the program in partnership with the National Service Office and a university partner.
In Colorado, NFP is offered to mothers across the state. Invest in Kids partners with experts in each community, such as public health departments, federally qualified health centers, places of worship homeless shelters, and other home visiting programs at the regional and county level. Through this outreach, Invest in Kids identify eligible women that could benefit from NFP services.
Recruiting and retaining nurses to do home visits can be a challenge. Similar to the experience in New Jersey, Invest in Kids has found that hiring nurses who reflect the populations being served and partnering with local community agencies are two essential elements of NFP implementation and sustainability. Invest in Kids focuses on building a workforce that embraces a supportive nursing culture, creating a system where NFP nurses meet with their peers and supervisors to debrief after their home visits. The system allows nurses to receive support, advice on professional boundaries, and help with planning services that meet the needs of the mother, all while maintaining fidelity to NFP.
NFP prides itself on treating mothers as individuals, and staff at each local agency do their best to match the nurse to the needs of each mother. To do so, NFP recognizes that local agencies may need to make certain cultural adaptations to their approaches based on the populations served. In parts of Colorado with large Latinx populations, local agencies strive to hire Spanish-speaking and Latinx nurses. If a Spanish-speaking nurse is not available, a translator is provided and written materials are translated into Spanish. In a rural part of Colorado that has a small but significant Somali population, Invest in Kids is adapting NFP to meet the needs of Somali mothers by working with the local community. Invest in Kids also has developed partnerships with local universities to grow its nursing staff, especially nurses from diverse backgrounds.
Invest in Kids’ operational approach ultimately is to engage mothers as soon as possible, approaching them in a way that promotes partnership and allows them to see the non-judgmental nature of the program. In the agency’s experience, this approach is key to engaging mothers in a therapeutic relationship. By serving alongside mothers, nurses support them to find their strengths and build their confidence. Additionally, by developing a trusting relationship with a nursing professional, NFP hopes to nurture in mothers the confidence to successfully interact with other professionals they encounter in the future.
1 Unless otherwise noted, the information on the Nurse-Family Partnership National Service Office was gleaned from personal correspondence with: Sarah McGee, policy and government affairs, and other office leadership, on Dec. 9, 2020, Dec. 18, 2020, and March 1, 2022.
2 Tung GJ, Williams V*, Franco C, Lopez C, Knudson MD, Gehring W, Mazzuca WG, Arestides C, Olds DL, Allison MA. Adapting nurse-family partnership to serve multiparous mothers: A formative study. Oral presentation at the 2021 American Public Health Association Annual Research Meeting
3 Unless otherwise noted, the information on Nurse-Family Partnership in New Jersey was gleaned from personal correspondence with: Jill Brown, home visiting program manager, Office of Early Childhood Services; Lenore Scott, administrator, Office of Early Childhood Services; and Sanford Starr, deputy director for family and community partnerships; New Jersey Department of Children and Families on Nov. 16, 2020; and Liliana Pinete, chief operating officer, Partnership for Maternal and Child Health of Northern New Jersey on Jan. 29, 2021.
4 Unless otherwise noted, the information on Nurse-Family Partnership in Colorado was gleaned from personal correspondence with: Michelle Neal, program director, Nurse-Family Partnership Invest In Kids on Nov. 19, 2020; and Christian Mallon, Colorado Nurse-Family Partnership participant, on Dec. 1, 2020.