10 Nurse Family Partnership.ppt - University of Vermontkappatau/images/10 Nurse Family Partnership.pdf · implemented with fidelity 9. ... The Nurse-Family Partnership model was developed

Vermont Department of Health

The Nurse Family Partnership: Vermont’s experience in p

implementing an evidenced based nurse home visitation programp g

Sally Kerschner, RN, MSN November 2, 2012


Key Program Personnel Sally Kerschner, RN, MSN, Vermont

Department of Health, Division of MCH Deb Coutu, RN, VDH, Division of MCH Susan Shepard, RN, MSN, Dept for Children p p

and Families, Child Development Division Dr. Breena Homes, VDH, Director, Division of

MCH Contact: 802-652-4179

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Overview of Maternal Infant Early Childhood Home Visitation ProgramHome Visitation Program

Funding from the federal Affordable Care Act (March, 2010) as a response to the goal of improving the h lth d i l lf f f ili d hildhealth and social welfare of families and children living in at-risk communities

First series of funds awarded to the states July 2010Fi d i d h i i i First grants were designed to support home visiting needs assessment and planning process for a Maternal, Infant, and Child Home Visiting programV t f d bli h lth h i iti Vermont performed a public health home visiting needs assessment September 2010

Vermont submitted a State Plan in June, 2011

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Vermont began the program in July, 2011


National Perspective: National Governor’s Association Issue Brief March 2011Association Issue Brief March 2011

Early childhood is critical time for cognitive, social, and behavioral development

Home visitation programs are an important component of early childhood systems

States and communities have a variety of home yvisitation systems, however states “lack a coordinated strategy to maximize the impact of such public investments” S i ff d ith t l i i Services are offered without a common plan or vision or do not rely on data to guide planning and funding decisions

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Vermont’s Public Health Needs Assessment ProcessAssessment Process

Conducted a community needs assessment according to the public health process Contractedaccording to the public health process. Contracted with JSI, Inc. for the formal assessment.

Assessed both population needs and also capacity of services to respond to community needs.

Use of population data and also qualitative methods such as survey of community agencies and keysuch as survey of community agencies and key informant interviews with physicians, leaders of health and human service agencies.

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Results of the 2010 Needs Assessment

Quantitative ranking of Vermont counties considered at-risk based on criteria such asconsidered at risk based on criteria such as poverty, crime, infant morality, domestic violence, school drop out rates, etc.

Qualitative data results. This assessment provided data for planning

t h t h i it ti d l ld bas to what home visitation model would be most useful for Vermont and to determine the order of counties for implementation.

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Qualitative Data Results: Key Informants

Stressed the high costs of full implementation of home visiting programs.

Concern about ongoing workforce training and maintaining staffing levels.

Desire for uniformity and consistency of the programs, yet needing flexibilityneeding flexibility.

Need for coordination of the programs in the community. Understanding of program dosage and intensity.

C b t th f t f th h i it Concern about the safety of the home visitors. Desire for identifiable outcomes and strong evaluation. Vermont’s overall themes similar to national findings (NGA

report)

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report)


MIECHV: Evidenced Based Home Visitation Key concept of the MIECHV vision States required to design a program using one or more evidenced

based home visitation models aimed at addressing the particular risks in the targeted communities and the needs of the families living in thosein the targeted communities and the needs of the families living in those communities.

States must choose an evidenced based model or can use up to 25% of their funds to support a “promising practice”

Models are designated as “evidenced based” after rigorous review ofModels are designated as evidenced based after rigorous review of such factors as quality of research studies, results of impact studies, evidence of effectiveness.

Process described on website of “Home Visiting Evidence of Effectiveness” www.homevee.acf.hhs.govg

As of June, 2011, there were 7 nationally approved models. As of 2012, there are 13. Examples being Head Start, Parents as Teachers, Healthy Families America and Nurse Family Partnership.

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Vermont's Evidenced Based Model: Nurse Family PartnershipNurse Family Partnership

Vermont's needs assessment indicated a lack of health related preventive home visitation services pstatewide for pregnant women and infants/toddlers.

Qualitative data indicated a concern for health outcomes for Vermont's families and childrenoutcomes for Vermont s families and children

Vermont leaders selected the Nurse Family Partnership to implement for the MIECHV programEl t f thi h b d i V t Elements of this program have been used in Vermont for several years, but the full model has never been implemented with fidelity

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Overview of Nurse Family Partnership

Nurse-Family Partnership® (NFP) is an evidence based, community health program that helps , y p g ptransform the lives of vulnerable mothers pregnant with their first child. Each mother served by the program is partnered with a registered nurse early in p g p g yher pregnancy and receives ongoing nurse home visits that continue through her child’s second birthday. Independent research proves that y p pcommunities benefit from this relationship — every dollar invested in Nurse-Family Partnership can yield up to five dollars in return.

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up to five dollars in return.


Nurse Family Partnership

The Nurse-Family Partnership model was developed more than 30 years ago when its founder, Dr. David y g ,Olds, began the first of three randomized, controlled trials in Elmira, New York. His vision and commitment were a result of his early experience working in an y p ginner city day care center. He saw the need for care early in a young mother’s pregnancy and through the first two years of her child’s life if social problems like y pchild abuse and neglect were to be reduced.

NFP has been implemented in over 42 states/tribes

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NFP: Research Base via RCT

Improved Pregnancy Outcomes: Reduction in preterm delivery, greater intervals between first and p y, gsecond births.

Improved Child and Development: reduction in criminal activity reduction in child injuries increase incriminal activity, reduction in child injuries, increase in school readiness.

Increase in Economic Self-Sufficiency: increase in workforce participation reduction in welfare useworkforce participation, reduction in welfare use, increase in father involvement, reduction in criminal activity

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“Done well, it could be among the best money the government spends. Investments in early childhood g p ydevelopment produce big payoffs for society. But there’s an important concern: home visiting programs are not all effective. When carefully studied, only a y , yfew have been shown to reduce the physical abuse and neglect of children. Among the programs that meet the government’s standard for funding, there g g,are large variations in evidence of impact. Policy makers and proponents of home visiting would do well to pay attention to the specific elements in the p y pNurse-Family Partnership’s model that account for its success.” - David Bornstein, “The Power of Nursing,” The New York Times, May 16, 2012

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e e o es, ay 6, 0


Implementation Matters: Durlack and DuPreAm J Community Psychology 2008Am J Community Psychology, 2008

Complex phases of diffusion: dissemination, adoption implementation sustainabilityadoption, implementation, sustainability

Assessment of implementation is essential for knowing what aspects of the interventionknowing what aspects of the intervention were delivered and if delivered correctly.

Effective implementation is associated with Effective implementation is associated with better outcomes

Finding the right mix of fidelity and adaptation14

Finding the right mix of fidelity and adaptation


Overview of Vermont Community Based Systems for Children and FamiliesSystems for Children and Families

Examples of key community based programs: home health agencies, Head Start, Mental Health Agencies, Parent Child Centers

Children's Integrated Services: Coordination and gservices for pregnant women and families with young children in each community.

CIS serves to allocate funds locally via bundledCIS serves to allocate funds locally via bundled services reimbursement.

NFP is intentionally placed as a service within this referral and coordination system

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referral and coordination system.


NFP Implementation Tasks/Considerations

Hire VDH program coordinator Analyze potential referral numbers Assess Home Health Agency capacity in at-risk communities Create MOU/Contracts between NFP/VDH/HHA Advertising and hiring of nursing staff g g g Staff training at NFP headquarters in Colorado Outreach to referral sources: WIC, OB’s and CIS Create benchmarks/data systemsy Coordination with Federal project officers/federal requirements Coordination with NFP and NFP requirements

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Elements of NFP Model: Clients

1. Client participates voluntarily in the NFP program2. Client is a first time mother3. Client meets low income criteria at intake4. Client is enrolled early in pregnancy and receives first

home visit no later than 28th week EGAhome visit no later than 28 week EGA5. Client is visited one home visitor to one first time

mother/family6 Client is visited in her home6. Client is visited in her home 7. Client is visited thought out her pregnancy and for the

first two years of her child’s life.

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Elements of the NFP Model: Nurses and SupervisorsNurses and Supervisors

8. NHV and nurse supervisors are registered nurses with a minimum of a BSN

9. NHV and Nurse supervisors complete core educational sessions at the national offices and deliver the intervention with fidelity to the NFP model

10 NHV apply the NFP visit guidelines individualizing them to the10. NHV apply the NFP visit guidelines, individualizing them to the strengths and challenges of each family

11. NHV apply the NFP theoretical framework, emphasizing Self-Efficacy, Human Ecology, and Attachment TheoryEfficacy, Human Ecology, and Attachment Theory

12. A full time NHV carries a caseload of no more than 25 active clients.

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Implementation of NFP VDH home visiting needs assessment guides planning for first counties to begin

the program: Franklin County, NEK, Lamoille County. Begin planning Fall/Winter 2011 and officially begin the program April 2012.

Rutland County begin planning Fall 2012Rutland County begin planning Fall, 2012. Consider “community readiness” in addition to county rankings, such as home

health agencies who are able to comply with NFP model and implement the program.

Work with area home health agencies and NFP to arrange for adequate i lcoverage in a rural area.

MOU between agencies to allow for proper coverage: Lamoille and Franklin HHA create an implementation plan for NFP approval in order to receive

approval to begin recruitment. NHV and Nursing Supervisors need to attend mandatory trainings in Denver NHV and Nursing Supervisors need to attend mandatory trainings in Denver,

CO before begin enrolling and visiting families. Working with NFP, such as nurse ratios, MOU between HHA, etc

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Implementation of NFP Franklin County Home Health Agency covers

Franklin County. Began enrolling families July, 2012. Franklin County Home Health Agency covers

Lamoille County, with formal letter of agreement with Lamoille Home Health Agency.

Caledonia Home Health Care and Hospice covers th N th E t Ki d f C l d i E dthe North East Kingdom of Caledonia, Essex and Orleans Counties. Began enrolling families July, 2012

Rutland Visiting Nurse Association covers Rutland d B i t C ti d ill b i lliand Bennington Counties and will begin enrolling

families in January 2013.

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Nurse Client Ratios and Planning

NFP model requires one Nurse Home Visitor to 25 families

“Half time” NFP supervisor for every four NHV or a full time supervisor for every eight NHV

Created pattern of staffing between HHA’s so as to Created pattern of staffing between HHA s so as to accommodate best NHV ratio in a rurally populated areaM di id d t V t id t b fi t bi th b Medicaid data: Vermont residents by first birth by delivery: total of 1139 in 2011. Assume we can reach 50 % of eligible families with 25% acceptance rate.

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g p


NFP and CQI

Quality is defined as the degree to which implementation and nursing interventionsimplementation and nursing interventions meet model fidelity and improve health outcomes.outcomes.

Priority areas of clinical interaction, program implementation, outcome achievementp ,

Involves research, CQI, Evaluation

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NFP and CQI: Tools and ReportsClient Interaction Nursing Practice Assessment Client Survey Nurse Supervisor Assessment Program Implementation Critical Structural Elements Assessment Annual Plan Fidelity Report y p Nurse Consultant Assessment Administrative Task Completion Outcome Achievement Pregnancy OutcomesPregnancy Outcomes Maternal Outcomes Child Health and Development Outcomes NFP MIECHV Benchmark Report

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6 Benchmarks for Measurement and Evaluation – Required for Federal Funding

1. Improved Maternal and Child Health p2. Child injuries, child abuse, neglect or maltreatment

and reduction of ED visits3 Improvements in School Readiness and Achievement3. Improvements in School Readiness and Achievement4. Domestic violence 5. Family economic self sufficiency 6 Coordination and Referrals for other community6. Coordination and Referrals for other community

resources and supports Total of 35 constructs

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Benchmark: Improved Maternal and Child Health: Example of Constructsand Child Health: Example of Constructs

Screening for maternal depression using Patient Health Questionnaire (PHQ-9 - valid (measure for depression severity)

Breastfeeding: Increase % of postpartum gwomen enrolled in the program who breastfeed for a minimum of four weeks

% Children enrolled in the program who receive 4 or more well-child visits in their first 3 th f lif

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3 months of life


MIECHV Development Grant Received September 2012

Enable expansion of program within the existing regions and the inclusion of two more regions.

Ideally we will cover all counties in Vermont except Ideally we will cover all counties in Vermont except for Addison and Chittenden, which had the lowest scores for “at risk” community.

Funding is being sought for full state coverage with MIECHV funds and other sources Req ired research component of the de elopment Required research component of the development grant will explore “recruitment and retention” of clients to the program

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MIECHV Development Grant Evaluation ComponentEvaluation Component

Draft Hypothesis: The way in which women are referred and enrolled to NFP influencesare referred and enrolled to NFP influences engagement.

Draft Hypothesis: The first visit establishes a ypsense of trust and respect that the client perceives as useful and will improve retentionD ft H th i P ti i t h Draft Hypothesis: Participants who are engaged in NFP perceive that the program has structure and flexibility to meet their

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yneeds.


MIECHV Development Grant Evaluation Component Data CollectionEvaluation Component Data Collection

Focus groups of women who are program participantsparticipants

Contact with clients who declined participationparticipation

Key Informant Interviews of NHV Key Informant Interviews of community Key Informant Interviews of community

professionals who refer clients to NFP

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NFP Current Research Projects

Ongoing research trials to evaluate NFP impact on maternal life course and outcomesimpact on maternal life course and outcomes for firstborn children

“Risk” classification of families in order to provide individualized interventions.

Interpersonal Violence curriculum being d l d d t t ddeveloped and tested

NFP nurses provide hormonal contraceptive to clients during home visits

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to clients during home visits


Summary of MIECHV in Vermont Affordable Care Act supports evidenced based home

visitation for improving the health and welfare of pregnant women and young children.

Public Health Needs Assessment indicated need for a health based, nurse implemented home visitation program statewide. Evidenced based program of Nurse Family Partnership is chosenPartnership is chosen.

Program implemented in three regions as of Fall 2012. Funding being sought to implement program statewide. Key benchmarks being measured for fidelity and outcomes Key benchmarks being measured for fidelity and outcomes. Research project on client recruitment and retention.

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Resources/Links For more information

VDH: www.healthvermont.gov CIS: www.dcf.vermont.gov/cdd/cis NFP: www.nursefamilyparternship.org Pew: www.pewstates.org/projects/home-

visiting-campaign DOHVE:

www.mdrc.org/dohve/dohve_resources.html

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Documents

10 Nurse Family Partnership.ppt - University of Vermontkappatau/images/10 Nurse Family Partnership.pdf · implemented with fidelity 9. ... The Nurse-Family Partnership model was developed