This post is part three in a 10-part series on care model innovation.
We left off last week with Don Berwick’s list of features common to care models that create health. These included reconnecting personal health to relationships, and impacting the whole person, not just the “disease.” These are the crux of Nurse-Family Partnership (NFP), the first of four evidence-based models I will examine in the “Care Models That Work” segment of this series.
NFP is a voluntary home visiting program for low-income, first-time moms. A public health nurse is paired with each woman and visits her regularly during pregnancy and until the child’s second birthday. Visits include some standardized assessments and interventions, but are largely woman-directed. What matters to the woman is what the woman and the nurse will work on together, whether that’s improving her diet or accessing job training for her return to work after childbirth. The model was developed in the 1970’s and refined and studied throughout the 80’s and 90’s, and has been replicated broadly since 1996. NFP programs are now established in 558 counties, enrolling over 30,000 women and families at any given time. The program is also being replicated internationally, including in the UK, Canada, and the Netherlands.
Health through relationship
Berwick’s assertion that health creation happens in the context of interpersonal interactions is truly a hallmark of NFP. The program puts strong emphasis on the stable, trusting relationship between the nurse and the woman as the foundation of NFP’s effectiveness. This relationship provides support, safety, and accountability as the women set and make progress toward health and parenting goals.
While the relationship between the nurse and the woman has benefits in its own right, it also provides a temporary model for a relationship that is both paramount and permanent: that between the woman and her infant. The program acknowledges the significant impact of the parenting relationship on the health and wellbeing of the child, and draws heavily on attachment theory to help women form nurturing bonds with their babies and learn pragmatic parenting skills.
Taking the long view
The program acknowledges that pregnancy is not a condition to be “managed,” but rather a powerful inflection point in the life course of a woman and a family. I began to get a sense of NFP’s long view when I followed links to a study earlier this year reporting reduced maternal and child death with NFP.
As someone who routinely analyzes maternity research, my frame of reference was our vital statistics concepts of mortality: infant mortality is death within the first year; maternal death occurs during or within 42 days of pregnancy. To be sure, these are important public health measures, but if you look at it from the family’s perspective, the death of a mother or child is devastating no matter when it happens, and it has ripple effects through a family and community. So the NFP researchers looked at death at any time during the child’s upbringing, and the findings are remarkable. In a 20-year follow-up from one of the original NFP randomized controlled trials, they found:
- 1.6% of children in the control group (without nurse home visiting) died of preventable causes like SIDS, homicide, or accidental injury while none of the nurse-visited children died.
- Mothers were three times more likely to die of any cause and seven times more likely to die of homicide, suicide, accidental injury, or drug overdose if they did not receive nurse home visitation.
Here we see the tip of the iceberg of what Berwick was referring to in the outcomes research from the salutogenesis movement. When we take a public health view of pregnancy, we realize that the typical measures of maternity care effectiveness – cesarean rates, Apgar scores, number of prenatal visits, and so on – are grossly inadequate for describing either the pathogenetic or the salutogenetic potential of pregnancy.
Pregnancy, by definition, alters a family. And if family dynamics affect health and wellbeing (which, of course, they do), we need to broaden our scope and lengthen our view. NFP researchers have done just that, and in addition to the mortality outcomes above, randomized, controlled trials have shown:
- better pregnancy outcomes
- fewer closely spaced subsequent pregnancies
- less child abuse and neglect
- fewer child injuries
- improved school readiness
- reduced use of welfare and other government assistance
- higher employment rates for the mothers
- increased presence of fathers and partner stability
When Nirav Shah, former commissioner of the NY State Medicaid Program, visited Yale School of Management this fall, he referred to implementing Nurse-Family Partnership as a no-brainer with a 5x return on investment. It is one of the programs that has helped New York save a projected $4 billion while adding over 150,000 people to the state’s Medicaid program. But not every state has had this a-ha moment or figured out the right mechanism to finance NFP even in the face of clear evidence. As a result, fundraising is still a major activity for NFP implementing agencies.
Later in this project, I will be exploring this disconnect. Why do we have a healthcare system that doesn’t have a clear mechanism to fund an intervention that saves 5 dollars for every dollar spent, all while improving the health of people and communities and solving some of our most vexing public health problems? How can new payment models that reward value and accountability help?