By Katie Kerwin McCrimmon
A program incubated in Denver to help mothers and babies thrive through intensive nurse visits is now growing across the country thanks to a $1.5 billion shot in the arm from the Affordable Care Act.
The Nurse-Family Partnership, a national program based in Denver, now serves more than 22,000 families in 32 states. That number is expected to rise as additional funds flow to every state to fund home-visitation models like the one pioneered by Dr. David Olds, director of the Prevention Research Center for the University of Colorado School of Medicine.
More than 30 years of research in New York, Tennessee and Colorado have shown that investing in long-term nurse visitation programs for first-time, low-income mothers results in better outcomes for both mothers and babies. Olds and other researchers have found dramatic reductions in child abuse and neglect, fewer childhood injuries, improved prenatal health, fewer subsequent pregnancies, increased maternal employment and improved school readiness.
“It’s a significant step forward for children and families to have this new federal maternal infant and early childhood home-visiting program,’’ said Dr. Libby Doggett, director of the Pew Center on the States’ Home Visiting Campaign, a division of the Pew Charitable Trusts in Washington, D.C.
“What’s particularly significant about this is it’s focused on evidence-based policies. Everybody wants to do good things for children and families. In our rush to do that, we sometimes put money out without really knowing…how it’s going to make a difference,” she said.
The Pew Center seeks to provide states with data on programs that work so they can spend scarce dollars well.
“We know this is a highly impactful intervention,” she said. “The data-driven policies and investments in high quality parent education start positive chain reactions that result in stronger families. It’s hard to change adult behavior. This is one of the most effective ways to do it.”
The Nurse-Family Partnership is one of seven programs authorized under the Affordable Care Act for use in the majority of the new visitation programs. It’s the most highly rated.
“The evidence is clear that some are better than others,” said Doggett.
While Doggett said the outcomes are strongest for the Nurse-Family Program, some other programs — including Parents as Teachers and Healthy Families — are more widely available.
The Colorado Connection
- Dr. David Olds pioneered his concept for a nurse-home visitation program in Elmira New York in 1977. Read more.
- Randomized controlled trials showed the program worked to improve outcomes for low-income white families.
- In 1988, Olds tests program among a population that included more African American families in Memphis, Tenn.
- In 1993, The Colorado Trust invited Olds to speak to its board. Olds was looking for a place to test his program among Hispanic families.
- Olds, who was then living in New York, estimated it would take four years to raise funds for the next phase of his research. The Trust took just four months to give Olds $7 million.
- Olds moved to Denver and in 1994 launched his Denver trial. Read more.
- Denver trial show nurse home visits are much more effective than those conducted by paraprofessionals. Nearly half of the 735 Denver mothers were Hispanic.
- Denver results published in Pediatrics in 2002 and in 2004: Denver follow up results – age 4.
- Colorado expansion: in the mid-1990s, a group of Colorado lawyers led by Bob Hill and Bill Rosser created Invest in Kids with support from The Colorado Trust to “scale up” Olds’ program throughout the state. Altogether, The Trust has given about $11 million to support research, evaluation and implementation of the Nurse-Family Partnership in Colorado, including grants to Invest in Kids.
- Colorado lawmakers pass the Nurse Home Visitors Act in 2001, allocating $75 million over 10 years from tobacco settlement funds.
- In 2003, the Nurse-Family Partnership incorporates with national offices in Denver to expand visitation programs across the country.
- The Affordable Care Act, passed in 2010 includes $1.5 billion to strengthen families through visitation programs.
Pew’s Home Visiting Campaign has created a state inventory of home visiting programs. That analysis shows that 46 states are now spending $1.4 billion on various home visiting programs. All 50 states have applied for their share of the new $1.5 billion in federal funds, meaning that spending could double across the country over the next five years.
A voluntary program, the Nurse-Family Partnership, pairs first-time mothers with trained nurses who visit them in their homes to provide support, medical advice and behavioral guidance during weekly and semi-weekly visits from pregnancy through the baby’s second birthday.
A 2005 RAND Corp. study found that the Nurse-Family Partnership has a big bang for the buck. On average, the cost to help each mother and baby for 2 ½ years from pregnancy through the child’s second birthday is about $4,500. Nationwide, it ranges from $2,900 to about $6,500. For every dollar spent on high-risk mothers, the program saved $5.70.
A separate 2004 study by the Washington State Institute for Public Policy found that the Nurse-Family Partnership ranked best for return on investment and keeping kids out of the public welfare system. The study evaluated a wide range of programs from pregnancy and teen substance abuse prevention to preschool programs and found that the Nurse-Family Partnership saved $3 for every dollar spent.
“The reason Congress passed (the home visiting section) of the Affordable Care Act is because of the strong evidence from the Nurse Family Partnership that these investments produce returns in both health and development, and reduced costs,” said Dr. David Olds, who pioneered the research that has led to nurse visitation programs across the country.
Even more poignant than the economic benefits are the countless stories of babies and mothers who are thriving thanks to the close bonds they form with their nurse partners.
‘Moms need to be sober’
Take Rita Erickson, for example. Now 30, she was just out of jail, homeless and addicted to meth and alcohol when she learned she was pregnant.
Erickson told her probation officer that she didn’t know anyone who was sober, and begged for help kicking her 12-year habit. The officer connected her with the Nurse-Family Partnership and got her into a drug rehab program. Erickson said she was looking for motivation and support to quit and stopped using drugs and alcohol early in her pregnancy. Her nurse visited her in rehab and as she struggled to build a new life afterwards.
“For a while I didn’t have anywhere to live. She was chasing me around town trying to do visits,’’ Erickson said. “She was very positive. She gave me lots of encouragement: ‘You’re making the right choice by not talking to the dad. You’re doing the right thing. Stay positive.’ ”
Erickson’s former boyfriend continues to be in and out of jail and she ultimately had to get a restraining order to keep him away from their daughter.
She says she’s never been able to count on her own mother.
“It’s been my whole life. She leaves me and she comes back.”
Erickson’s nurse, Valerie Carberry, became the constant female force in her life. Erickson was afraid to give birth and Carberry helped her understand birthing options and prepare. After Erickson’s daughter was born nearly three years ago, Carberry helped her learn to breastfeed and got her a breast pump.
With each new stage of development, Carberry was there to give support, information and guidance.
Today Danika is nearly 3 and is already speaking in full sentences, counting to 10 in English and Spanish and knows her colors and shapes.
“We read every night,’’ Erickson said. “She likes to read to me. We have books and games and a project box so she can do crafts any time she wants.”
Erickson is also thriving. She and her daughter now live in their own apartment. Erickson is studying business at Red Rocks Community College and hopes to go on to Regis University and someday get her MBA. Recently, she was one of just two students at Red Rocks and a handful around the state to receive the prestigious Phi Theta Kappa All-Colorado Academic Team award for 2011.
The Nurse-Family Partnership taught her a critical lesson.
“It’s important for moms to be sober. If they don’t pass that on to their kids, we’ll have generations of drug addicts or alcoholics,” she said.
Demand outpaces funding – Colorado program turns away thousands
In Colorado, the Nurse-Family Partnership is available to mothers in 50 of the state’s 64 counties, said Lisa Merlino, executive director of Invest in Kids, the group that implements the nurse visitation program in Colorado.
Funds in Colorado currently come from the tobacco settlement trust fund. This year, the fund will pump $13.4 million in nurse visitation throughout the state. The funds have been ramping up since 2000, starting at $2 million that year and slated to grown to $19 million by 2015.
So far, nearly 13,000 women in Colorado have benefited from the program.
“There’s a tremendous impact that we have seen from pregnancy to infancy to toddlerhood,” Merlino said.
But there are also long waiting lists. Since the program involves such deep and long relationships between the mothers and nurses, the program cannot begin to serve everyone who would qualify.
In 2009, for example, the Tri-County Health Department in the Denver area turned away 1,300 referrals to the program. Most are young, poor, unmarried and have no GED or high school diploma. On average, the mothers are 18 and on Medicaid.
Statewide, the program is able to serve about 2,640 mothers a year. “We’re seeing a very small percentage of the eligible population,” Merlino said.
That’s where federal funds from the Affordable Care Act could help the program grow.
In Colorado, the governor’s staff is leading the efforts to create a state plan and apply for the new federal grants. The minimum for which Colorado should qualify will be about $1.8 million. The funds step up over time.
Visitation advocates, like Merlino, are hoping that the federal government awards funds based on a competitive model, like the Race to the Top funding in education, rather than a straight per capita formula.
“We feel very confident that based on the historic work of Invest in Kids and the success of local departments of health that we can put forth a very competitive proposal,” Merlino said.
Colorado has one of the most advanced and widespread home visitation programs in the country. Pew’s national inventory shows that Colorado is spending far more than the national average in this area: $270 per low-income child per year compared with $170 per child nationally.
The Nurse-Family Partnership model is also expected to be popular as states ramp up their visitation programs both because of its 30-year track record of research and because it is the only federally-authorized program that begins when mothers are pregnant.
Merlino said it’s tremendously gratifying to watch graduate after graduate do well and to know that their children will do better in school, stay out of jail and ultimately will better nurture and support their own children.
“The vast majority of savings come when you keep kids out of the juvenile system at 15,” Merlino said.
The clinical trials continue to evaluate the long-term benefits to both mothers and children in Colorado, Tennessee and New York.
The short-term benefits are also dramatic.
“We have healthier birth outcomes and significantly higher immunization and breastfeeding rates. Because of all of this rich data, we know this saves us money in real time.
“The program is based on self-efficacy and empowering women for life. It’s not just a short term fix,” Merlino said. “We watch the women succeed and sail.”