professor of pediatrics, nursing, and public health university of colorado nurse family partnership...

Professor of Pediatrics, Nursing, and Public

Health

University of ColoradoUniversity of Colorado

NurseFamily Partnership

David Olds, PhD

November 13, 2014

Baltimore, 1970

NURSE FAMILY PARTNERSHIP

• Prenatal and infancy home visiting by nurses

• Focused on low-income mothers with no previous live births

• Clarity in goals, objectives, and methods

• Activates and supports parents’ instincts to protect their children

• Strengths-based

NURSE FAMILY PARTNERSHIP’STHREE GOALS

1. Improve pregnancy outcomes

2. Improve child health and development

3. Improve parents’ health and economic self-sufficiency

TRIALS OF PROGRAM

• Low-income whites

• Semi-rural

• Low-income blacks

• Urban

• Large portion of Latino families

• Nurse versus paraprofessional visitors

Elmira, NY1977

N = 400

Memphis, TN1987

N = 1,138 and N=743

Denver, CO1994

N = 735

CONSISTENT RESULTS ACROSS TRIALS

Prenatal health

Children’s injuries Children’s language and school readiness

(low resource mothers)

Children’s behavioral problems

Children’s depression/anxiety

Children’s substance use Maternal Impairment due to substance use

Short inter-birth intervals

Maternal employment

Welfare & food stamp use

Indicated Cases of Child Abuse and Neglect0 to 15 Years - Elmira

*P= .03 JAMA, 1997;278:637-643

Number of Life-Time ArrestsElmira Youth - Age 19

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Comparison Nurse

P=.02, IR = 0.49 Arch Pediatr Adolesc Med 164(1) 9-15

Memphis DesignMemphis Design

Urban Setting Sample (N = 1138 for prenatal and N = 743 for

postnatal)

92% African American 98% Unmarried 85% < Federal Poverty Index 64% < 19 years at intake 2.4 SD above mean neighborhood adversity

Services Treatment 1N=166

Treatment 2N=514

Treatment 3N=230

Treatment 4N=228

Transportation for prenatal care

 X

 X

 X

 X

Screening and referral for children

   X

   X

Prenatal/neonatal home visiting

 X

 X

Infant and toddler home visiting

       X

Services Provided in Each Treatment ConditionMemphis

Memphis Program Effects on Childhood Injuries (0 - 2 Years)

23% Reduction in Health-Care Encounters for Injuries & Ingestions

80% Reduction in Days Hospitalized for Injuries & Ingestions

JAMA 1997; 278: 644-652.

Nurse

Simultaneous Region of TreatmentDifferences (p < 0.05)

Comparison

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

60 110 120 13080 90 10070

Mothers’ Psychological Resources

No

. Day

s H

osp

ital

i ze d

wi t

h In

juri

e s/ In

ge s

tio

ns

Diagnosis for Hospitalization in which Injuries and Ingestions Were Detected

Nurse-Visited (n=204)

Age Length(in months) of Stay

Burns (10 & 20 to face) 12.0 2 Coin Ingestion 12.1 1 Ingestion of Iron Medication 20.4 4

JAMA 1997; 278: 644-652.

Diagnosis for Hospitalization in which Injuries and Ingestions Were Detected - Comparison (n=453)

Age Length (in months) of Stay

Head Trauma 2.4 1 Fractured Fibula/Congenital Syphilis 2.4 12 Strangulated Hemia with Delay in Seeking Care/ Burns (10 to lips) 3.5 15 Bilateral Subdural Hematoma 4.9 19 Fractured Skull 5.2 5 Bilateral Subdural Hematoma (Unresolved)/ Aseptic Meningitis - 2nd hospitalization 5.3 4 Fractured Skull 7.8 3 Coin Ingestion 10.9 2 Child Abuse Neglect Suspected 14.6 2 Fractured Tibia 14.8 2 Burns (20 face/neck) 15.1 5 Burns (20 & 30 bilateral leg) 19.6 4 Gastroenteritis/Head Trauma 20.0 3 Burns (splinting/grafting) - 2nd hospitalization 20.1 6 Finger Injury/Osteomyelitis 23.0 6

Reading & Math Achievement – Age 12Reading & Math Achievement – Age 12(Born to Low-Resource Mothers)(Born to Low-Resource Mothers)

p=.009, Effect Size = 0.25 Arch Pediatr Adoles Med, 164(5) 412-418

Percent of Children Who Used Tobacco, Alcohol, or Marijuana (Last 30 Days)

Memphis – Child Age 12

P = .04 OR = 0.31 Arch Pediatr Adoles Med, 164(5) 412-418

Percent of Children with Depression- Anxiety – Child Age 12

P = .04 OR = 0.63 Arch Pediatr Adoles Med, 164(5) 412-418

Copyright restrictions may apply.

control groups over timeTotal Discounted Government Spending (2006 US dollars) after Birth of First Child for Food Stamps, Medicaid, & AFDC/TANF

All mothers assigned to treatments 1- 4 All children assigned to treatments 2 & 4

National Death Index Review

Survival plots for intervention and control mothers – all causes of

death

(T1+T2 vs. T3 p=.007; T1+T2 vs. T4 p=.19; T1+T2 vs. T3+T4 p=.008) JAMAPEDIATRICS.2014.472.pages E1-E7.July 7, 2014

Control (T1 and T2)

Nurse-Visited Prenatal/Postpartum (T3)

Nurse-Visited Prenatal/Infancy/Toddler (T4)

Surv

ival

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Follow-up time since randomization (years)

0 2 4 6 8 10 12 14 16 18 20 22

* Sudden Infant Death Syndrome, injury, homicide (T2 vs. T4 p=.02) JAMAPEDIATRICS.2014.472.pages E1-E7.July 7, 2014

Survival plots for intervention and control children - preventable causes

of death*

Control (T2)

Nurse-Visited Prenatal/Infancy/Toddler (T4)

Sur

viva

l - P

reve

ntab

le C

ause

s

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Follow-up time since birth (years)

0 2 4 6 8 10 12 14 16 18 20 22

Tip of the Iceberg Health Disparities

• Cardiovascular disease

• Type-2 Diabetes

• Depression

• Cognitive decline

Pattern of Denver Program Effects

Maternaland

ChildFunctioning

Comparison Para Nurse

Washington State Institute for Public Policy Economic Analysis (2011)

Nurse Family Partnership produced

large return on investment:

– Implementation costs $9,421– Benefits $30,325 – Return on investment $20,904

Coalition for Evidence-Based Policy

• Committed to reducing waste by identifying interventions that meet high evidentiary standards

• “Top Tier” interventions– Well designed and conducted randomized controlled trials– Replicated findings – Community settings– Sizable and sustained effects– Outcomes of clear public health, educational or social

significance

Support Organizational and Community Capacity

Education and Consultation

Program Guidelines

Information System

Assessing Program Performance

Continuous Improvement

FROM SCIENCE TO PRACTICE

27

Nurse-Family Partnership is a growing, national program

43 States that NFP serves

Number of counties NFP is serving

Where we work

551

Tribal agencies are denoted by Band

Map does not include program in U.S. Virgin Islands

© Copyright 2014 Nurse-Family Partnership. All rights reserved.

Research Focused on Improving Program Model and Implementation

• Participant retention and completed home visits

• Intimate partner violence

• New method to observe & promote caregiver-child interaction

• Maternal depression and anxiety

• Development of STAR (Strength and Risk) framework to guide program implementation

Pediatrics 2013; 132; S110

International Replication• No presumptions

• Adaptation

• Pre-test and small-scale trial

• Larger trial

• Faithful replication of adapted program

• International work:– UK – England, Scotland, Northern Ireland– Australia – aboriginal families– Netherlands– Canada – ON and BC– American Indians & Alaskan Natives

Model Development

Original Trials

Trial 1

Trial 2

Trial 3

Articulate Essential Model Elements

Develop/Test Model Innovations

Studies of Implementation

Process

International Replication

Adapt and Test Original Model

US Community Replication

Community Preparation

Ed/Coachingof Nurses

Performance Monitoring

Continuous Quality Improvement