New Research Bolsters Model for Preventing Infant Mortality

Announcer (00:00)
The following is an encore presentation of conversations on healthcare.

Mark Masselli (00:09)
Americans consistently rate nurses as the most trusted profession in the country. That's probably accounts for
some of the success of Nurse Family Partnership. NFP has been growing its community health program across
the country that focuses on first time moms and their babies.

Sharon Sprinkle (00:26)
It begins in pregnancy before the 28th week of pregnancy and goes up until the child turns age two. There is no
financial cost to this. However, there is a commitment to being available for in-person visits that began early in
pregnancy and goes up until the child turns age two.

Margaret Flinter (00:42)
Sharon Sprinkle is a registered nurse and the co-director of nursing Practice for Nurse Family Partnership. Jenny
Harper is a Washington veteran and Government Affairs Director for Nurse Family Partnership.

Jenny Harper (00:58)
We continue to have different evaluations done. We're, you know, continuing to innovate the program and the
model and look at how we can best serve families and communities, you know, many years later. And so, you
know, we have continued research coming out on different aspects of the program.

Margaret (01:11)
This Is Conversations on Healthcare.

Mark (01:22)
Sharon Sprinkle and Jenny Harper with the Nurse Family Partnership. Welcome to Conversations on
Healthcare.

Sharon (01:30)
Thank you.

Jenny (01:31)
Thanks for having Us.

Mark (01:32)
Absolutely. Sharon, maybe we start with you. I suspect there are some in our audience who yearned for the old
days when doctors made house calls, but Nurse Family Partnership is in that spirit. I think NFP focuses on
helping first time parents succeed right. In their homes. I'm wondering if you could just share with our audience
how it works.

Sharon (01:56)
Sure. Absolutely. Happy to do that. As you know, you said, mentioned it a couple of times that Nurse Family
Partnership is an evidence-based community health program with over 45 years of research showing significant
improvements in the health and lives of first-time moms and their children affected by social and economic
inequality. How do we do that? We do that by aiming for three overarching goals, which is to improve
pregnancy outcomes by partnering moms with nurses to focus on improving their health-related behaviors, such
as cessation of smoking and improving their diets, going to their prenatal visits. A second goal of ours is to
improve child health and development by assisting parents to understand normal child growth and development
so that they can provide healthy and competent care. And the third goal is to improve economic self-sufficiency
of a family by supporting the client to create a vision for what she wants her future to be either completing
school or continuing in work. So nurses meet families in the home where the action is where they live to be able
to provide support to achieve these three overarching goals.

Mark (03:06)
Sure. And that's so great. Tell me, is there a, is it, is this free? Is there any income eligibility? And, and I
understand this continues in into the child's, is it second birthdate?

Sharon (03:19)
It is. It begins in pregnancy before the 28th week of pregnancy and goes up until the child turns age two. There
is no financial cost to this. However, there is a commitment to being available for in-person visits that began
early in pregnancy and goes up until the child turns age two. We focus on economically disadvantaged families.
We use the term low income, and that we use Medicaid as a proxy in terms of, of determining eligibility. So not
only eligibility in the terms of income, but other social factors that can impede healthy pregnancies, such as the,
such as, such as age, such as, education such as substance abuse. All of those things that are add that can
adversely impact a healthy outcome, those overlapping adversities that get in the way of healthy pregnancies
and, healthy showering.

Margaret (04:19)
Well, Jenny, David Olds is the person considered the visionary founder of Nurse Family Partnership, and I
understand that he got his inspiration after working at a daycare center. Share the founding story of your
organization with us.

Jenny (04:34)
Absolutely. So Dr. David Olds had graduated from Johns Hopkins and he was working at a daycare in the inner
city, and he was working with kids who, you know, were experiencing a lot of those overlapping adversities that
Sharon was talking about. And, you know, seeing the impacts that were already happening on those kids at that
point. And so he thought, how can we move as far upstream as possible to really provide this, you know,
prevention and intervention for these families? And so that led him to designing Nurse Family Partnership and
beginning in that prenatal period, to, you know, to, to get to those families as soon as possible. and so originally
there was, there were trials done in Elmira, New York, in Memphis, Tennessee, and in Denver, Colorado to, you
know, test the model and to look at how it was, you know, achieving the results that he thought it could. And so
those, trials were really successful and in 1996 began implementing the program more widely across the
country. And today, nurse Family Partnership is in 40 states plus dc, US Virgin Islands, and a number of tribal
communities.

Margaret (05:37)
And was David Olds a just recent grad, teacher, clinician? What did he bring to this that allowed him to have
these insights?

Jenny (05;47)
Yeah, he, I mean, he, he's, his, his background is in pediatrics. He's currently a professor of pediatrics. so that's,
that's what he really brought to it.

Margaret (05:55)
I see.

Mark (05:56)
Jenny, I wanna pull the thread on, the trials that happened, but also, the Nurse Family Partnership program has
been independently reviewed and evaluated. Were that part of the trial or were they separate? it, I'm wondering
if you could just take us through the findings that led experts to say this home visiting program really works.

Jenny (06:17)
Great question. And there's been a lot of different, independent review, I would say over the years. the trials in
particular had, you know, specific outcomes that they were looking at. and, you know, I think some of the main
outcomes that we talk about from that were reductions in child abuse and neglect reductions in ER visits due to
accidents in poisoning, re reductions in speech delays, reductions in behavioral problems, increases in months
employed, and then re reductions in arrests of the mother as well as of the children. And so those were some of
the main outcomes that I think really led to the, you know, then trying to bring this, this more widely. Since
then, there's been a lot of additional, look at things like, the, like the cost, like the return on investment, looking
at how, you know, the program, you know, dollars invested in the program have return on investment. So we
continue to have different evaluations done. We're, you know, continuing to innovate the program and the
model and look at how we can best serve families and communities, you know, many years later. And so, you
know, we have continued research coming out on different aspects of the program.

Mark (07:29)
I would think the, return on investment would be important to Medicaid partners and others across the country.
And, how successful has it been for you?

Jenny (07:41)
It's been very successful. you know, I think it's always hard to get those exact, numbers sometimes that I think
policymakers always wanna have. But, we've begun really expanding Medicaid financing for home visiting
programs over the last, you know, many years now. And looking at how we can find those billing pathways in
states. And it looks very different state by state. but we know a lot of those costs associated with, you know, a
child being in the NICU for an extended amount of time, or a child having an ER visit or some really high dollar
costs, you know, to the Medicaid program. And so we know when we can have avoidance of those, or
reductions in those that, you know, the program does have a really strong return on investment.

Margaret (08:22)
Well, let me ask a question really, to either of you, I, I haven't heard, within our discussion so far, whether there
is a screening qualifier threshold for risk factors, social circumstances, adverse social determinants of health that
lead one to be referred. Is it a referral process because, someone has determined that there are concerns or more
risk? Is it really open to anybody in a community? Tell us about that.

Sharon (08:50)
So that's a, that's a great question Margaret, and thank you for asking it. we support network partners across the
40 states and the District of Columbia and tribal communities that Jenny mentioned, and it's at the network
partner level where the referral is generated from to, to, to nurse family Partnership. And the, the characteristics,
overlapping characteristics that I mentioned earlier were age, educational level, substance abuse issue, substance
misuse, or abuse issues, as well as other overlapping adversities we're we look for, we ask our network partners
to look for three or more of those overlapping adversities and social determinants of health that you mentioned,
because research has found that those are the families that are gonna benefit, get the greatest benefit from NFP
intervention when you have three or more of those overlapping, characteristics. We recently just refined our
criteria, our recruitment criteria in terms of providing 13 different characteristics that referral sources should
look for, screened for before referring to Nurse Family Partnership.

Mark (10:02)
Sharon, let me ask a follow up to that. Is it that a mom goes through the, third party agency or can they sign up
on their own? And, and I'm wondering just in general, how you deal with, you know, individuals perhaps
reluctance to sign up. What are your strategies around that? But first of all, the pathway from, if there's a mom
listening in now, is this, is this a direct or is there a third party, player here that they'd, sign up with?

Sharon (10:37)
It's usually a third-party provider; however, they can sign up directly. Most referrals at the local level come
through, obstetricians come through, WIC come through various social service agencies that our moms typically
go to for support, or NFP moms or, or mom that's pregnant typically goes to for support looking for resources
such as Medicaid. WIC. Obstetricians, word of mouth from a current or past NFP participant. So those are the,
is a pathway to NFP.

Mark (11:11)
So those are the independent groups you work with. A WIC program might be the, somebody who would be
your strategic partner?

Sharon (11:20)
Absolutely.

Mark (11:21)
Oh, that's great.

Sharon (11:22)
Shelters as well as shelters. Any, any, any agency that support homeless individuals can refer as well.

Margaret (11:32)
Well, it seems like there's a, another, outcome that I've read about, that I found very fascinating, which is that
82% of the parents engaged in this, program who received the benefit, see an increase in the, sort of their
months of employment throughout this, I think pregnancy and early childhood, period, which of course is a help
in terms of, financial, stability for the family. I don't think the nurses are doing employment counseling, so I'm
curious, what do you, with all of your expertise, what do you think is connected to that particular outcome?
What's the, what's the connection there?

Sharon (12:13)
So one of the core tenets of Nurse Family Partnership is really meeting the family where they are and helping
that person identify what we call the client's heart's desire. So if the client's heart's desire is to seek employment,
we work with the nurse, work with the client to explore what excites the client about employment, what type of
employment is the client look for, and then they work to cap together to create that vision that the client has
created in their mind in terms of what they wanna do with employment and or education.

Mark (12:51)
Boy… go ahead.

Sharon (12:52)
So it’s a partnership. It’s a partnership in helping move forward, workforce employment.

Mark (13:00)
You know, one to, to both of you, Sharon and Jenny, what an exciting program and to lead with nurses is so
important. All but all of a sudden the pandemic rolls around and we have lost a hundred thousand nurses. We
have this huge shortage that's happening in the country. It must have caused an enormous amount of gyrations
within your organization. I'm wondering how you dealt with that and are there, other players that community
health workers, peer counselors or others that, you've tested with that might be, equally effective? though
obviously nurses are, the foundation of the program, but given all the changes that have happened societally,
what's happening in terms of the organization internally as you're trying to adjust to these changes?

Sharon (13:56)
Great question. I'll start, and Jenny, please, please chime in. We see Nurse Family Partnership as part of a
continuum of care as it relates to early childhood development and prenatal care. I think we were uniquely
positioned during the pandemic because telehealth has been a part of NFP intervention since 2017. So it was
easy for us to pivot to telehealth because it was already a part of the model. We took that framework or our
experience in delivering the model through telehealth made some revisions in terms of recruitment efforts as
well as delivering the model virtually.

Jenny (14:39)
Yeah, I would add in just the, the workforce shortage has been an issue certainly for us. And, you know, one of
the things that we know is when our families have the best outcomes from going through the program, it's
because they have that same nurse for the duration of the program. So, you know, it's really important to retain,
you know, the nurses that are in the program. We also see nurses leave the hospital setting to come work for
Nurse Family Partnership or to work for the network partners who are implementing Nurse Family Partnership.
you know, because they're able to use the full scope of their clinical practice and work with these families for
this duration of time and really see that benefit. another issue has, you know, been the, the compensation
certainly, and, you know, when there's a lot of competing, you know, jobs for nurses, it's been a priority for us to
try to increase the funding in a number of these programs that support nurse family partnerships so that, you
know, compensation can be addressed as well.

Margaret (15:32)
Well, I, I have so many questions for you, but let me, just ask this one that's been on my mind certainly since
you were founded 45 years ago, the needs of, of mothers and, their, their children have been, in front and center
of many discussions, but certainly in the last couple of years, it's been about maternal mortality and it's been
about maternal mortality, particularly in the, within the childbirth period and the year afterwards, and
particularly among our African American, population. And I'm, I'm curious, with all the effort that's been
brought to bear on that, has that led to a renewed, focus on nurse family partnerships and the kind of
empowerment work that you do in, in making sure that women, have the tools to speak up for themselves and to
communicate their needs and, their concerns?

Sharon (16:26)
I would say absolutely. Agency is really important in helping clients voice their concerns and also supporting
clients around health literacy, as well as helping expecting parents to understand the signs and symptoms of
preterm labor or any adverse symptoms that they may have. Part of what we do is use our nursing knowledge
around maternal child health is issues to help educate the client so that they in turn can be better advocates for
themselves as they navigate the health and human services arena.

Mark (17:08)
You know, I'd be interested in sort of the finance model behind the program, and just remind me, are all of the
encounters done by telehealth? Are there any face-to-face encounters?

Jenny (17:22)
We're almost entirely back at, at face-to-face.

Mark (17:24)
Okay. You are now back. Okay.

Jenny (17:27)
Some things are done via telehealth, it provides some flexibility certain, certainly particularly when we're
serving families in maybe rural areas or through inclement weather right. Type situations. But, in, in general,
we're back in person.

Mark (17:39)
And then is that the main source of revenue or are there grants supporting the work that you're doing as well?

Jenny (17:48)
The, the way that we're structured is, so we're a part of the National Service Office, so we're, you know, where
the model is housed. we are helping to provide, you know, support and funding and training and technical
assistance and all that. But the program is implemented through what we call our network partners. and those
can range from a federally qualified health center to a county public health agency to a hospital system. And
they're the ones who are, you know, having the funding for the program. And that can be a variety of different
funding streams. You know, largely that's, funding from the maternal infant Early Childhood Home visiting
program or MCV as it's known, which is a federal program that grants money to states to implement home
visiting programs. also a lot of Medicaid financing. There's a lot of state line items supporting home visiting,
sometimes specifically NFP across the country. And we also have funding support from, philanthropic
supporters as well.

Mark (18:41)
So, Medicaid, is it approved in all states for a Medicaid encounter?

Jenny (18:46)
No. So the way Medicaid works right now is essentially Medicaid can support some components of the Nurse
Family Partnership program, but not holistically the whole program. And so, you know, more of the clinical
pieces as opposed to some of the, you know, care coordination side of it. and so state by state, it looks very
different. States have found very sometimes creative ways to finance home visiting services through Medicaid, a
lot of times using waivers, using, using targeted case management, and then have different reimbursement rates
set up per visit. There's a lot of, you know, challenges sometimes that it only begins, you know, pain, pain
reimbursement once the child's born, or you know, before the child is born or up until the child is born. So, you
know, we're looking at how we can streamline that better. But right now, I would say there's about 20, you
know, just over 20 states where there's a Medicaid billing pathway that covers some portion of the nursing
program.

Mark (19:40)
Is there, is there a best practice state you'd like to point to and say, “Hey, everybody should follow this state,” or
what? there,

Jenny (19:47)
There's a few out there. I mean, Alabama is a state that's really done a lot to, you know, have a really, a really
nice reimbursement rate that covers more or less, you know, the fully burden cost of the program. Idaho is
another state that's done a lot in the past few years and is working on kind of getting all of the different
components of it. Right. Pennsylvania's a state that's done a lot with, with, Medicaid financing. Ohio actually is
another state that's really expanded our family partnership through Medicaid. So there's a lot out there. but
there's a lot of work to be done still.

Margaret (20:22)
Well, Sharon, Jenny just mentioned a number of programs and, they fit together. it seems like maybe under
Nurse Family Partnership, but I'd be curious if you could tell us a little bit about the Child First Program. It's a

program we've certainly heard about in our, area of the country. I understand it's, maybe more oriented towards,
mental health, behavioral health services, but tell us what Child First is and how the Nurses of Nurse Family
Partnership would work together with Child First, or is it an either or?

Jenny (20:53)
It’s… so, they're two distinct programs. They're both evidence-based home visiting programs. child First is
much more on the mental and behavioral health side. So they're programs that are both, you know, considered
eligible for the maternal infant early childhood Home visiting program, and can receive funding through a lot of
the same types of sources, but what Child First does. so it's a distinct program from Nurse Family Partnership.
So it's not being administered by Nurse Family Partnership Nurses. so in, in Child First Case, you've got a
master's level mental health clinician as well as a care coordinator working with the family, that can begin
anywhere from prenatal, through the child's, sixth birthday. And a lot of times that team is working with that
family for the duration of about nine months to a year. that can, you know, vary. a lot of times it's a more
intensive duration of meeting the family sometimes several times a week. it provides child parent psychotherapy
as part of the intervention. and it's really, you know, similarly to Nurse Family Partnership, it's looking at the
holistic needs of the family, right? It's, it's not just kind of the clinical side, it's also really getting into those
social determinants of health. but yes, a lot of times it's really focused on children who've experienced adverse
childhood experiences, families who've experienced trauma, and providing that support to, you know, build,
resilient, you know, strong relationships between that child and the caregiver. Great. So I should also add Child
First is in seven states currently. it was developed in Connecticut, and about three years ago, child First came on
board with Nurse Family Partnership. So we have this overarching national office that supports both programs.
and what we're trying to do is help Child First grow and have a similar footprint to Nurse Family Partnership
moving forward. There are some states where we are, you know, working to co-locate Nurse Family Partnership
and Child First Programs. There might be families that, you know, would benefit from receiving Nurse Family
Partnership services and then moving on to Child First Services. it's gonna look different, but we wanna have
kind of a variety of programs and interventions that can support families and, you know, having the right
program for the right family at the right time.

Mark (23:01)
Well, we're proud that we're in Connecticut and have a great deal of experience with Child First. It's such a
remarkable program. As, as is the, nurse Family program as well. Sharon, I wanna, ask you to tell us about the
importance of moms advocating for themselves and others like them. How is that occurring through your, parent
ambassador program? And maybe tell our listeners what the results are that you're seeing so far.

Sharon (23:30)
We have a wonderful Parent Ambassador program that is led by a former NFP client. They receive trainings and
education on how to advocate for themselves and for Nurse Family Partnership. They've gone to Capitol Hill
several times. They meet frequently to talk about issues Around advocacy. And it's working wonderfully. I can't
speak more highly of it. It's a great way of giving back. They really understand US Fought Family Partnership
because they are, they were former participants in the program. So they know how it works, they know how it
feels. They understand the relationship that the nurse and the client has. They understand the need for funding to
sustain NFP and who better to speak to the benefits of NFP other than someone who has actually received the
services of NFP. And any parent ambassador will tell you that the nurse and the relationship with the nurse
made the difference in terms of where they are today. Some parent ambassadors will tell you that the nurse
literally saved their lives. Hmm. It is a component of the program that was long overdue and has returned, made
a huge return on investment, since it, since it was inducted into nurse funding partnership accepted into nurse
funding partnership.

Margaret (25:04)
Well, Jenny, we recently talked to the Chief Medical, advisor at the Bipartisan Policy Center. And, it strikes,
me, this is very much, in line with what you're saying, that, home visiting programs for MOS and Babies might
be one of the few nonpartisan issues that we have going in the country these days. They seem to attract support
on both sides of the aisle. And, and I wonder if that really is still true. Do you find this funding, you know,
issues always being present, but do you find this generally to be a truly bipartisan issue that people recognize the
need for these programs?

Jenny (25:39)
It really is. And, you know, even over the past couple decades as partisanship has, you know, been more
rampant, you know, nurse Family Partnership and home visiting programs in general have continued to enjoy a
strong amount of bipartisan support. You know, I think everything from the way the MIECHV program was

structured, you know, makes a lot of sense to people on both sides of the aisle. It has those components of, you
know, really just strong, funding that has a lot of, you know, evidence and rigor to it. So we know that, you
know, those dollars are gonna be invested in what works. and you know, I think people have just seen the
impact of what these programs have done in their own communities. And that's, and like, like Sharon said, when
we bring our parent ambassadors and other, you know, program advocates to the Hill, people understand the
value of it. And, you know, some people might see it more as, we like this for the maternal health aspects,
aspects of it. Some people might see it more as we like it for the economic mobility aspects of it, but there's
really something for everyone. And we had a recent, at the end of the last Congress, there was a bipartisan
reauthorization of the MIECHV program, and it had overwhelming support at a time that was really challenging
to get legislation through. It had overwhelming support.

Sharon (26:48)
And if I could just add, investing, investing in home visiting is investing in a brighter future for America, I
believe.

Mark (26:56)
Well, you're, I think you're both spot on in terms of building bipartisan support. it's a program that helps, all
Americans across the country, no matter where, where you live or, or your political, persuasions. But sure. I
want to focus in on the moms, who might be listening in close with this quote from, your founder, David Olds.
He, he says, there's magic window during pregnancy, a time when the desire to be a good mother and raise a
healthy and happy child creates motivation to overcome incredible obstacles, including poverty with the help of
well-educated nurses. And I'm just thinking about the mom who might be listening to the conversation. What's
the first step to bring NFP to their community?

Sharon (27:42)
So bringing NFP to a community involves community support. It involves an organization deciding that they
wanna bring NFP to their community. That's where it begins. Utilizing the Healthy Human Services arena as a
referral source is the pathway to get to NFP. Moms by themselves can go out if they're paying ambassadors or
have received NFP services and ask about NFP, why don't you have NFP in our community? They can reach out
to their legislators to ask, where's NFP in our community? We need NFP in our community.

Mark (28:22)
Well, you know, community health centers, federally qualified health centers all across America, the majority of
their boards are patients and moms. so there's a lot of power, in the voices of moms, whether they're through
their community action program, their WIC program, their community health center program. you're absolutely
right. there, those, those voices will be heard when they speak up.

Margaret (28:47)
Sharon Sprinkle and Jenny Harper with Nurse Family Partnership, thank you for your inspiring work and thanks
to our audience for being here. Be sure to subscribe to our videos on YouTube, find us on Facebook and X with
our account name, CHC Radio. And as always, you can go online to CHC radio.com to sign up for email
updates and also share your thoughts and your comments about this program. Sharon and Jenny, thank you so
much for being here, and best of luck to you.

Jenny (29:14)
Thank you.

Sharon (29:14)
My pleasure. Thank you.

Margaret (29:19)
This copyrighted program is produced by conversations on healthcare and cannot be reproduced or remitted in
whole or in part without the express written consent from Community Health Center, Inc. The views expressed
by guests are their own, and they do not necessarily reflect the opinion of conversations on healthcare or its
affiliated entities.