NURSE - FAMILY PARTNERSHIP
Program Overview
The first program Invest in Kids identified and chose to advocate throughout Colorado was Nurse-Family Partnership (also known as the Nurse Home Visitor Program). Invest in Kids chose this model because it has been shown to produce truly life changing outcomes for families through scientifically controlled, randomized trials, over 30 years. The program’s remarkable results have been the subject of numerous articles published in the Journal of the American Medical Association and other peer reviewed journals.
Conceived by Dr. David Olds and his colleagues in the 1970s, Nurse-Family Partnership sends specially trained nurses on weekly or bi-weekly visits to low-income, first-time mothers starting as early as possible in pregnancy and continuing until their children's second birthdays. Under this voluntary program, nurses help mothers improve their health and nutrition during pregnancy, learn effective early parenting skills, and reach goals like completing school and finding employment.
The program has visit by visit guidelines that provide for a client-centered approach that uses solution focused techniques with the goal of achieving enduring behavioral changes. The intervention centers around six program domains: personal health, environmental health, life course development, maternal role, family and friends and health and human services. It is the focus on these domains that enables the clients to achieve the program goals: to improve pregnancy outcomes, promote child health and development and impact parental life course development.
Research Trials
A cornerstone of Nurse-Family Partnership is the extensive research on the model conducted over the last three decades. Randomized controlled trials were conducted with three diverse populations beginning in Elmira, New York, 1977; in Memphis, Tennessee, 1988; and Denver, Colorado, 1994. All three trials targeted first-time, low-income mothers. Follow-up research continues today, studying the long-term outcomes for mothers and children in the three trials.
The program effects that have the strongest evidentiary foundations are those that have been found in at least two of the three trials. They are listed below:
Consistent Program Effects1
- Improved prenatal health
- Fewer childhood injuries
- Fewer subsequent pregnancies
- Increased intervals between births
- Increased maternal employment
- Improved school readiness for children born to mothers with low psychological resources
Employing new and improved statistical analysis methods, Dr. Olds and his research team at the Prevention Research Center have been involved in an extensive reanalysis of certain outcomes from the 15-year follow-up of the Elmira trial of Nurse-Family Partnership. An updated summary of the findings is given below:
Positive Program Effects Found in First Trial at Child Age 15:
Benefits to Mothers
- 61% fewer arrests
- 72% fewer convictions
- 98% fewer days in jail2
Benefits to Children at Child Age 15
- 48% reduction in child abuse and neglect
- 59% reduction in arrests
- 90% reduction in adjudications as PINS (person in need of supervision) for incorrigible behavior³
Whereas the original analysis indicated that program effects were limited to the higher risk portions of the sample (where the mother was unmarried and from a low-income family at registration), the reanalysis indicates that the benefits of the program on the outcomes listed above are present for the entire nurse-visited sample, irrespective of risk. Many of the program-control differences remain larger for the higher risk families, but the significance of the program effects now holds for the entire sample.
Earlier reported impacts of the Elmira program on `maternal behavioral problems due to substance abuse' and number of times the teens ran away are no longer statistically significant in the new analysis. Program effects on `conviction rates among 15-year old children' and `number of sex partners among 15-year old children' are more accurately characterized as trends.
Dr. Olds and his research team are to be commended for their integrity in continually subjecting their work and earlier findings to the highest scientific standards and state-of-the-art statistical analysis.
About the Research
A randomized trial is the most rigorous research method for measuring the effectiveness of an intervention. This is the type of study that the FDA requires of new drugs or medical devices to determine their effectiveness and safety before they are made available to the public. Because of their cost and complexity, these kinds of trials are not often used to evaluate complex health and human services.
In addition, important data are continuously collected from Nurse-Family Partnership replication sites through the web-based Clinical Information System (CIS). These data are analyzed and returned to local Nurse-Family Partnership implementing agencies to provide them with evidence of their progress toward NFP's three goals. (Nurse-Family Partnership National Service Office)
1 Effects observed in at least two of three trials (Elmira, Memphis and Denver).
2 Impact on days in jail is highly significant, but the number cases that involved jail-time is small, so the magnitude of program effect is difficult to estimate with precision
3 Based upon family-court records of 116 children who remained in study-community for 13-year period following end of program.
Program Costs and Benefits
The Nurse-Family Partnership program costs approximately $4,500 per family per year to fund, and can range from $2,914 to $6,463 per family per year. Nurses' salaries are the primary driver that affects variability of cost, with highest costs typically found in urban centers on either coast and in hospital-base programs. Communities choose to invest in Nurse-Family Partnership because it's a wise investment that can yield substantial, quantifiable benefits in the long term--to parents, their children and the communities in which they live
Summary of Independent Cost-Benefit Studies
A RAND Corporation 2005 analysis found a net benefit to society of $34,148 (in 2003 dollars) per family served, with the bulk of the savings accruing to government, equating to a $5.07 return for every dollar invested in Nurse-Family Partnership. The analysis also found that for the higher-risk families participating in the first trial in Elmira, New York, the community recovered the costs of the program by the time the child reached age four, with additional savings continuing throughout the lives of both mother and child.
In a 2004 study by the Washington State Institute for Public Policy, Nurse-Family Partnership ranked highest in terms of cost return among pre-K, child welfare, youth development, mentoring, youth substance prevention and teen pregnancy prevention programs at $2.88 benefit per dollar of cost.
In a 2004 report, the New York City Department of Health and Mental Hygiene projected the expect cost savings to New York City for every 100 families served by Nurse-Family Partnership. Projected cost savings estimates were based on the elimination of public health costs that would not be needed as the Nurse-Family Partnership program achieves its intended positive effects. Projected costs savings include:
- 50% decrease in language delays at 21 months resulting in a savings of $133,000-$440,000
- 50% reduction in child abuse and neglect among children from birth to two years, resulting in a savings of $38,500
- 29% reduction in subsequent births within two years after the birth of the first child and a 14% increase in time between first and second births, reducing risk of premature delivery and saving $80,933 for every premature birth that was prevented (Benefits and Costs, Nurse-Family Partnership National Service Office).
Facilitating Implementation
Invest in Kids acts as a catalyst and resource for communities interested in implementing Nurse-Family Partnership. By convening meetings and making presentations to community groups, Invest in Kids supports local leaders who have chosen to bring the program to their community to identify a strong implementing agency and assess where the program fits on their continuum of services. By collaborating with other programs, communities can maximize service offerings for Colorado’s most vulnerable children.
Invest in Kids assists each implementing agency in building a broad based coalition at the local level, whose involvement helps support a successful high-quality implementation of the program. Once a site is funded, Invest in Kids provides technical assistance to support program implementation and on-going program success.
Promoting Sustainability
Invest in Kids knew that the success of its efforts to bring the Nurse-Family Partnership to as many eligible families as wanted to participate depended on long-term, sustainable funding for the program. Consequently, Invest in Kids worked with Colorado legislators and helped convey the importance and effectiveness of the program to them. As a result of Invest in Kids’ work, a passionate and committed sponsor, former State Senator Norma Anderson, and the hard work of several other interested parties and legislators, the Colorado General Assembly passed the Nurse Home Visitor Act (the "Act") in the 2000 legislative session. The Act allocated Colorado’s share of the proceeds from the Master Settlement Agreement negotiated between the States’ Attorneys General and the tobacco industry.
The Act allocates 3% (or roughly $2.3 million) of the tobacco settlement proceeds in fiscal year 2000-2001 to local communities to fund the implementation of the Nurse-Family Partnership. According to the Act, the Nurse-Family Partnership receives additional funding each subsequent fiscal year until it receives 19% (roughly $19 million) in 2014-2015. After that, the program will continue to receive 19% per year in perpetuity. At that point, this voluntary program will be available to thousands of low-income, first-time mothers and their families. Currently the program is serving over 2,600 families in 52 of Colorado's 64 counties.
According to the Act, The Colorado Department of Public Health and Environment (CDPHE) administers the program. Local communities must apply to the CDPHE and compete for funds to implement the program. CDPHE works closely with the National Nurse-Family Partnership, Dr. David Olds and Invest in Kids to oversee the program's implementation in Colorado. The Nurse-Family Partnership National Service Office also oversees the dissemination of the program throughout the country and ensures that the program is implemented with fidelity to the original model (training, guidelines, computer system, evaluation and reporting mechanisms). Nationally, the Nurse-Family Partnership is serving families in 329 counties across 25 states.
