Nurse Family Partnership (NFP) is a voluntary evidenced-based community health program that provides ongoing home visits (from pregnancy through age 2 of the child) from a registered nurse to low-income, first time mothers to provide the care and support they need to have a healthy pregnancy, be a responsible and caring parent, and to become more economically self-sufficient. A nurse visits the women approximately weekly and bi-monthly during their pregnancy and after birth, and then monthly visits during the first two years of their children’s lives. The program is a two-generation intervention and improves outcomes for both the mother and the child. NFP produces very strong outcomes for very high risk, low-income populations.

Economic analyses performed by the Washington State Institute for Public Policy, the Brookings Institute and the Rand Corporation determined that NFP provides a return on investment for taxpayers of $2.37 to $5.70 (high-risk population) per $1 invested in the program.

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Nurse Family Partnership

Proven Outcomes

National outcomes associated with NFP, verified through independently evaluated randomized controlled trials, include long term family improvements in health, child welfare, education and self-sufficiency. When brought to scale, NFP can achieve:

• 23% reduction in smoking during pregnancy
• 26% reduction in pregnancy-induced hypertension
• 18% reduction in first pre-term births
• 58% reduction in infant deaths
• 30% reduction in second teen births
• 37% reduction in childhood injuries treated in emergency departments up to age 2
• 30% reduction in child maltreatment
• 38% reduction in language delay of the child by age 2
• 45% reduction in crimes and arrests, ages 11-17
• 51% reduction in alcohol, tobacco and marijuana use, ages 12-15
• 15% reduction in TANF and Food Stamp payments
• 9% reduction in Medicaid costs through age 1

Locally, Salt Lake County has a small NFP program. In 2012, 10.68% of the comparable Medicaid clients had a preterm delivery, compared to 7.5% of NFP clients, a reduction in incidence of 30%. Preterm babies require expensive medical services and a 30% reduction in incidence results in significant cost savings to Medicaid. In addition, the following outcomes for the mother have been documented in Salt Lake County:

• 52.5% increase in employment of clients younger than 18 after starting the program
• 18.9% increase in employment of clients 18 and older after starting the program
• 40% decrease in maternal smoking
• 50% reduction in reported incidence of domestic violence during pregnancy

Government Cost Savings and Avoidance

The outcomes listed above produce significant cost savings in Medicaid, Criminal Justice, Child Welfare, Food Stamps and TANF. Based on national data, Medicaid is the largest recipient of cost savings per family served (55% of cost savings accrue to Medicaid).

Nurse Family Partnership in Utah

The Office of Home Visiting in the Utah Department of Health received $1,097,713 in federal funding through the Maternal, Infant and Early Childhood Home Visiting (MIECHV) Program for Fiscal Year 2013. Of that, $300,000 was allocated to Nurse Family Partnership to serve 75 families in Salt Lake County (the remaining $700,000 was allocated to Parents as Teachers (PAT) - a home-visiting school readiness program). The average cost per family per year for NFP is $4,000. In 2012 (the most recent data available), 4,867 mothers were eligible for NFP statewide. Based on this, an investment of $19,468,000 would be necessary to serve all eligible families.

Recommendation

Voices for Utah Children recommends an ongoing state appropriation of $2,000,000 per year for Nurse Family Partnership, to serve 500 high risk, low-income first time mother statewide. To date, 21 states have appropriated state funds for NFP and/or home visitation.

More Information

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A Two Generation Strategy: Right from the Start

This is the second in a series of issue briefs focused on two-generation strategies to reduce poverty supported by Ascend: the Aspen Institute.

The first issue brief in this series is available here:

A Two-Generation Approach to Ending Poverty in Utah

Full Text

Children raised in poverty are likely to be poor as adults. Breaking the cycle of intergenerational poverty necessitates a two-generation approach that meets the needs of vulnerable children and their parents together. Evidenced-based and effective interventions which promote a healthy pregnancy and lifestyle, effective parenting, parental education and training, self-sufficiency and early education can improve the economic prospects for the family, reduce child maltreatment and toxic stress, and improve long term educational and life outcomes for the child.

A two-generation, multi-intervention strategy for single, first-time pregnant women in poverty is being developed by Salt Lake County. The three proposed interventions are:
• Nurse Family Partnership
• Education and training for the mother, and
• Two years of high quality preschool for the child beginning at 3 years of age

This combination of interventions is intended to improve the health of the mother and baby, reduce toxic stress, improve child welfare, economic self-sufficiency and the long term life prospects of the child.

COLLABORATION AND INNOVATION

Salt Lake County, the largest in Utah with a population of 1,032,2261, is planning to expand access to the Nurse Family Partnership (NFP). According to the County, approximately 1,100-1,500 women meet the eligibility requirements for NFP. However, only 100 women are currently being served.

Nurse Family Partnership is an evidenced-based community health program that provides ongoing home visits from pregnancy through age 2 of the child by a registered nurse to low-income, first time mothers to provide the care and support that they need to have a healthy pregnancy, be a responsible and caring parent, and to become more economically self-sufficient. Outcomes associated with NFP include long-term family improvements in health, child welfare, education and self-sufficiency.

More than 35 years of evidence from randomized, controlled trials prove this maternal health program’s effectiveness guiding low-income, first-time moms and their children to successful futures. By developing strong family foundations, the Nurse Family Partnership establishes better, safer, and stronger communities for generations to come.

NFP assists clients in returning to their local high school, alternative high school (which usually offers childcare services), or obtaining a GED. They help them with their college applications and suggest ways to finance schooling either through scholarships or PELL grants. NFP also works with the Utah Department of Workforce Services (DWS) Education and Training programs. The nurses encourage their clients to utilize programs which assist financially with completion of a high school diploma, GED, or ESL. NFP encourages participants to use DWS career planning services, take advantage of DWS financial incentives for setting and achieving educational goals, as well as assistance with childcare while
completing their education.

To supplement the education and training referrals performed by NFP, Salt Lake County plans to collaborate with the public libraries to offer Career Online High School to NFP participants in order to promote higher educational attainment and economic self-sufficiency. Career Online High School offers students the opportunity to earn an accredited high school diploma while learning real-world career skills. An accredited, private online school district, Career Online High School is specifically designed to re-engage adults into the education system and prepare them for entry into post-secondary education or the workforce. It is committed to preparing students for careers and post-secondary career education by delivering high-quality, supportive, and career-based online education. Career Online High School gives students the opportunity to earn an accredited high school diploma and credentialed career certificate. Students graduate with the tools to take the next step in their careers or career-education.

COLLABORATION BETWEEN SALT LAKE COUNTY AND THE DEPARTMENT OF WORKFORCE SERVICES

Salt Lake County and DWS will partner to expand access to Nurse Family Partnership, as well as education, training and employment opportunities for the participants. Through the intergenerational poverty focus of DWS, eligible women in Salt Lake County and those classified as living in “intergenerational poverty” will be the target population for the expansion. Additionally, DWS is interested in using Temporary Assistance for Needy Families (TANF) funds to increase access to NFP for this population.

FINANCING STRATEGY

Currently, funding for NFP in Salt Lake County is provided by County funds, Title V-Maternal and the Child Health Block Grant, a grant from the Department of Child and Family Services through the Community-Based Child Abuse Prevention (CBCAP) federal funding, and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) Program created by the Patient Protection and Affordable Care Act of 2010.

To fund the expansion of NFP, Salt Lake County is exploring a blended funding strategy utilizing County funds, federal TANF funds through the collaboration with DWS, and investor funds through an innovative strategy called “Pay-for-Success” or social impact financing.

Under a “Pay-for-Success” financing model, there is an arrangement between one or more government agencies and an external organization where the government specifies the outcomes and promises to pay the external organization a pre-agreed amount if it is able to achieve the outcomes.3 Private commercial and philanthropic investors provide the upfront capital through the external organization to expand services for proven interventions with effective track records that either achieve desired outcomes and/or reduce the cost of later services to government. Outcome measures, such as reduction in preterm births and the spacing of second births, as well as reductions in other areas such as child maltreatment and criminal justice, in the case of NFP, are established and agreed upon by the parties. If the performance measures are achieved, the County would pay back the investors with interest. However, if the outcomes are not achieved, the investors may lose all or some of their investment. Several states, including North Carolina and New York State, and local jurisdictions, such as San Francisco, are exploring the expansion of NFP through social impact financing.

Salt Lake County participated in a proof of concept Results-Based Financing contract (a local term for Pay for Success) for high quality preschool in Utah for the 2013-2014 school year. Six hundred children who were identified as economically disadvantaged were funded through a Pay-for-Success contract. Goldman Sachs Bank and J.B. Pritzker provided the upfront investment. The United Way of Salt Lake and Salt Lake County provided the funds to repay the investors based on the performance metric of reducing the number of children funded through the contract who will need special education services in k-6. The project was announced during the Clinton Global Initiative Conference in June 2013. It is the first social impact loan in the U.S. to finance preschool.

THE PAY FOR PERFORMANCE ACT

On July 30, 2014, U.S. Senator Orrin Hatch (R-Utah), Ranking Member of the Senate Finance Committee and Senator Michael Bennet (D-Colorado), member of the Senate Finance Committee, introduced the Pay-For-Performance Act. The legislation is a companion bill to the Young-Delaney Social Impact Bond Act in the House of Representatives. The Pay-for-Performance Act directs resources to states and local communities to support innovative public-private partnerships to tackle social and public health challenges, while ensuring a smarter, more efficient use of tax dollars.

“The Pay-for-Performance Act gives policymakers a critical, evidence-based strategy for dealing with major societal challenges. By connecting the tools of impact investing to a ‘what works’ approach, this bill takes us one step closer to a smarter, leaner, results focused government. Senators Bennet and Hatch should be commended for providing a bi-partisan, national blueprint for cross sector investments in the outcomes our communities and country need.” Melody C. Barnes, former Director, White House Domestic Policy Council.

CONCLUSION

Although every birth is a major event and every child warrants special attention, home visiting for first time, low-income expectant mothers and their infants is especially beneficial because it provides information and support early in family formation and improves a woman’s ability to effectively parent. Combining home visitation with additional educational and improved employment opportunities leverages positive outcomes for both the mother and the child.

Additionally, implementing or expanding home visiting programs may reduce costs and increase the efficiency of care delivery for managed care organizations (MCO’s) and other health insurance providers. Evidence based home visiting programs have been shown to reduce health care costs by preventing complications in pregnancy, reducing injuries and maltreatment, enhancing maternal and child health through prevention and early detection and promoting efficient use of the health care system.

Two-generation approaches such as Nurse Family Partnership that include providing education and training for mothers are examples of strategies to meet the needs of vulnerable children and their parents.

Voices for Utah Children is proud to be a part of the Aspen Institute Ascend Network. The goal of the
Aspen Institute Ascend Network is to mobilize empowered two-generation organizations and leaders
to influence policy and practice changes that increase economic security, educational success, social
capital, and health and well-being for children, parents, and their families.
Learn more at http://ascend.aspeninstitute.org/network