Every day in communities across the nation, nurses touch the lives of highly stressed and marginalized women and their children. Nurses in inpatient settings, neighborhood clinics, schools, and public health agencies provide nursing care to those who are buffeted by the winds of poverty. These nurses often serve as the peace corps of our nation's health care system; they are courageous, tenacious, and creative-and their efforts are often poorly funded.
Why has the public maternal and child health care system not been better funded? There are services that are intensive enough- and of sufficient duration-to contend with the conditions and circumstances that compromise health in low-income communities, but research on these programs is sorely lacking. One program that has been studied is the Nurse-Family Partnership (NFP), a preventive care intervention in which nurses visit the homes of low-income women who are pregnant for the first time and continue to visit until the child is two years of age. The intervention, which is described in more detail elsewhere in this issue, has yielded favorable outcomes in several areas of maternal and child health and development (see pages 60 and 69).
City, county, and state health officials countrywide are looking closely at the NFP as a tool for improving the health, well-being, and economic self-sufficiency of low-income families expecting their first children.
THE BUSINESS CASE FOR THE NFP
Independent evaluation of the program's economic outcomes has moved the program into wider practice. The RAND Corporation,1 the Washington State Institute for Public Policy,2 and the Brookings Institution3 have all given the program an econometric thumbs-up; estimates of the economic return (to the government and society) for every dollar invested range from $2.88 to $5.70. The return is higher when the program is targeted to higher-risk mothers, who tend to gain more from the nurse home visits than do more advantaged women. And once policymakers and public health leaders learn about the program and review the evidence for it, very few question its value.
NFP services cost roughly $4,500 per family served, and each family is offered home visits for two and a half years. Our experience with the NFP has shown that it's impractical to develop an NFP program in a locality unless at least 100 women can be enrolled in a year. The operating budget, then, is about $450,000 to $500,000 a year- depending on local nursing salaries.
Most of the public money saved as a result of the NFP's services is from costs of emergency and hospital services, public welfare, social services, juvenile justice, and corrections. The cost per family is a steal compared with the costs of other highvalue services, such as highquality center-based child care, residential foster care, or prison.
It's far less expensive than many mental health interventions, repeated high-risk pregnancies, or hospitalizations related to child abuse and neglect. In fact, the economic analyses indicate that when it serves low-income, first-time mothers (many of whom are in their teens and single), the program pays for itself by the time the children reach four years of age. The rub, as they say, is funding it within a beleaguered health services system.
Thinking outside the box
Funding sources vary from state to state and come from very different places. Currently, the NFP works with partners at the state and local levels to find the necessary money-which sometimes requires some creativity.
For example, in Louisiana the Office of Public Health has been working with the governor's Children's Cabinet office to expand the program beyond what Medicaid reimbursement can cover. In Colorado the NFP is available nearly statewide as a result of a legislative commitment allocating tobacco settlement funds administered by the Colorado Department of Public Health and Environment in conjunction with Medicaid reimbursement. In Texas, with help from the lieutenant governor's office and leaders on both sides of the legislative aisle, a combination of funding from Temporary Assistance for Needy Families, Medicaid, and state general revenue is being proposed, along with some local public or private matching dollars, to implement the NFP in as many as 10 cities in 2008. And to establish NFP services in four or five counties in North Carolina next year, a unique public-private partnership is bringing together the Duke Endowment, the Kate B. Reynolds Charitable Trust, the North Carolina Partnership for Children, Prevent Child Abuse North Carolina, and several public agencies that share a commitment to child abuse prevention. (For more information on possible sources of funding, contact the NFP's National Service Office at http://www.nursefamilypartnership.org.)
WHAT THE CRITICS ARE SAYING
For years, public health agencies have absorbed the costs of NFP implementation in many communities (although many others benefit and ought to be brought to the table as fiscal stakeholders). And many people have asked why public health agencies should bear the entire burden. Although there is increasing evidence of the NFP's favorable cost-benefit ratio, other questions have been raised about whether to implement the NFP, and these can create barriers to funding.
"Too much government." Some people are concerned that home visitation represents a dangerous intrusion of government into family life. The NFP is entirely voluntary, however, and prospective clients are usually very enthusiastic about having their "own nurse" come and provide support, information, and guidance during their pregnancies and while their babies are young. It's possible that clients might feel vulnerable or a sense of intrusion when services are provided in the home, but nurses' professional education and the NFP-specific education in client-centered and strengthsfocused practice mitigate that risk significantly. Basic nursing education and licensure laws require that nurses understand the ethical obligations and legal responsibilities inherent in their therapeutic relationships with clients and their families, regardless of the service setting. And ultimately, it's the client who opens the door. If nurses fail to earn the trust of the families they visit, they will not be welcomed back.
"Home visitation doesn't work." It has also been contended that research shows that home visitation doesn't work. But a problem lies in the definition of the term: "home visitation" covers a lot of territory, and the various existing programs have deep differences in staffing, intensity, target populations, and intervention methods. Two recent Cochrane analyses revealed that because of tremendous variance across home visit programs, metaanalysis could not yet yield a recommendation of one home visitation program over another.4, 5 Consequently, any investor in health and social services would be well advised to examine the evidence of a program's effectiveness, paying particular attention to areas that are of most concern to the community. For example, it would be important not to tout the NFP as a school dropout prevention initiative since there is no evidence that the program affects dropout rates. Similarly, the NFP's effectiveness has been repeatedly documented in the context of first-time, lowincome mothers, but not with families who already have children (for more information on the evidence regarding the NFP and patient outcomes, see "The Nurse-Family Partnership," page 60). Other programs that deliver services in the home may or may not achieve the results a community is seeking, but a careful reading of the evidence is warranted.
"Professionals cost too much." It has also been suggested that programs that employ professionals as home visitors are just too expensive. However, close comparison will show that the cost of professionally-staffed home visitation programs is often comparable to that of programs staffed by paraprofessionals if the programs offer similar levels of intensity, supervision, and training, especially when the cost of more frequent staff turnover is considered.6 Recognizing the reality of budget constraints, we encourage policymakers to appreciate both that an investment is required to achieve significant outcomes and that, as a Harvard report on early-childhood intervention states, "return on investment is more important than up-front costs."6
Policymakers may also find it difficult to justify a service that reaches relatively few families. But according to the evidence available today, the NFP is policymakers' best option. The more superficial interventions that are characteristic of high-caseload programs aren't going to remedy the problem. Producing a genuine reduction in complex, serious health and social problems requires complex, intensive, serious programmatic interventions. The key is to find ways to sustainably finance programs that work on a scale sufficient to make a broad, lasting impact. And more and more, states and cities are doing just that, successfully.
The bottom line is that while it may take some time to develop the kind of strategic, evidencebased policy and collaborative financing that typically supports the NFP in states and major cities, such financing is feasible and can work on a larger scale. It's necessary to have a vision for improving access to higher-quality services for low-income women and children and the political will to make it a reality. We encourage policymakers to look at the cost of the intransigent problems their communities and states are living with. The cost of not investing in effective preventive intervention can be outrageously high, in both economic and human terms.
ACTION IN CONGRESS
To support state and local efforts to identify sustainable public funding, the NFP is pursuing federal strategies that complement our local initiatives. For example, in the 110th Congress, the president's fiscal year 2008 budget request included $10.3 million to the Administration for Children and Families for evidence-based nurse home visitation programs. This funding would provide five-year, time-limited competitive grants to states and local entities for existing or new programs, including the NFP. While the funds would provide timelimited support to approximately 15 programs, the NFP is simultaneously working to develop sustainable funding through the Healthy Children and Families Act of 2007 (S 1052; HR 3024), which gives states the option to include evidence-based nurse home visitation services to first-time, low-income pregnant women and their children as part of Medicaid and the State Children's Health Insurance Program. The act was sponsored in the Senate by Ken Salazar (D-CO), Arlen Specter (R-PA), and Richard Durbin (D-IL) and in the House by, among others, Diana DeGette (D-CO) and Lois Capps, RN (D-CA), cochairperson of the Congressional Nursing Caucus. As we pursue targeted federal and state initiatives to develop sustainable funding for evidencebased nurse home visitation services, and work with traditional and unexpected partners to achieve success, the NFP is finding that the political will exists to translate into reality a vision of better health care access and opportunity for disadvantaged families.
Nurses in action. Nurses have never been short of the passion and commitment needed to transform the quality, availability, and accessibility of health care, particularly for those most disadvantaged by poverty. Many of the improvements in our care of patients have come through the vigilance and advocacy of nurses who understand that women and children in poverty are marginalized and who have the courage to communicate the human and economic consequences of that marginalization to those in power. Politically savvy leaders in every community in this country are weary of seeing the stream of ill and wounded children in poverty grow ever wider.
The NFP is eager to join hands with nurses and their communities to do its part in helping to improve the lives of low-income, first-time parents and their children, who are most at risk in this country.
For more information on the NFP, visit http://www.nursefamilypartnership.org or contact Peggy Hill, director of Program Development, at (303) 327-4270 or [email protected].
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