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
Vermont Department of Health
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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Vermont Department of Health
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
Vermont Department of Health
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 Department of Health
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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Vermont Department of Health
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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p
Vermont Department of Health
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)
Vermont Department of Health
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 Department of Health
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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Vermont Department of Health
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.
Vermont Department of Health
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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Vermont Department of Health
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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Vermont Department of Health
“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
Vermont Department of Health
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
Vermont Department of Health
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.
Vermont Department of Health
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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Vermont Department of Health
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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Vermont Department of Health
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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Vermont Department of Health
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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Vermont Department of Health
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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Vermont Department of Health
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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Vermont Department of Health
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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Vermont Department of Health
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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Vermont Department of Health
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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Vermont Department of Health
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
Vermont Department of Health
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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Vermont Department of Health
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.
Vermont Department of Health
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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Vermont Department of Health
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
Vermont Department of Health
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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Vermont Department of Health
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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