It’s a sadly familiar story, one that is playing out in hundreds of communities across the nation: Sonoma County is hitting rough financial times. Demand for government services, particularly those related to law enforcement, has risen steadily over the last decade, while revenues have plummeted. Criminal justice services now consume more than half the county’s discretionary general fund, with no relief in sight. One grim sign of the times: the county’s single largest capital expenditure in the coming years is a proposed expansion of its adult detention facilities, with a price tag of up to $300 million.
The prevalence of substance abuse and mental illness in the prison population is striking. An estimated 70% of local inmates have drug and alcohol problems that underlie their criminal behavior, and 17% have significant mental health issues. These are expensive problems to treat, and when the price of economic support and welfare to inmates’ families is added in, the true scope of the problem becomes clear. Criminal justice costs are crippling other government functions.
In 2007, faced with a sobering Strategic Plan report, the county Board of Supervisors began weighing their options. They could “stay the course,” but simply slashing budgets and reallocating resources from other departments would only lead to an even deeper fiscal hole in the future. So in addition to belt-tightening measures the Board formed an Upstream Team to search for proven, long-term, evidence-based strategies that could ultimately decrease the demand for criminal justice dollars. What could be done “upstream” today, they asked, that could pay dividends in the coming “downstream” years?
It’s here that the County’s criminal justice needs coincided with the goals of First 5 Sonoma County, the Prop 10-funded organization dedicated to ensuring that all children enter school ready to achieve their greatest potential. Why that particular goal? “Because school readiness,” says Jennie Tasheff, executive director of First 5 Sonoma County, “is a proxy goal for optimal child development.” And optimizing child development is a proven way to decrease future criminal justice costs.
Working independently, the Board of Supervisors and First 5 reviewed dozens of programs. One stood out to both groups as a model of evidence-based preventive practice: Nurse-Family Partnership (NFP), a home-visit program with a long track record of remarkable success with high-risk, first-time mothers and their babies. Seeing the program as both a proven boost to school readiness and a means to reduce future criminal justice costs, First 5 committed $5.2 million over five years to fund NFP in Sonoma County.
NFP is the brainchild of David Olds, PhD, professor of pediatrics, psychiatry and preventive medicine at the University of Colorado. On graduation from Johns Hopkins in 1970 with a degree in social and behavioral sciences, Olds landed a job in an inner-city Baltimore day care center. Dissatisfied with being a “glorified babysitter,” as he put it, Olds soon introduced a new curriculum, inviting parents to discuss child behavior and home-based stimulation activities.
Though he made progress with some families, Olds soon concluded that his work at the center was a futile form of daily triage. Many of the center’s children had already suffered serious, even irreparable emotional damage from in utero drug exposure, abuse and neglect. If any intervention was going to help children born into such high-risk families, Olds reasoned, it would have to come at a much earlier time, ideally well before birth.
So Olds went back to school, to Cornell this time, and earned a PhD in developmental psychology. In 1977, working with a nonprofit developmental screening and referral agency in Elmira, NY, Olds launched his first study. It contained all the elements of today’s NFP, which centers on home visits by well-trained nurses to first-time, high-risk parents, beginning early in pregnancy. Olds sought to achieve three major goals: improving pregnancy outcomes, improving child health and development, and improving the mother’s life course.
Elmira was a troubled city in the late 1970s. The incidences of premature birth, infant mortality and child abuse were among the highest in New York state, making Elmira an ideal testing ground for NFP. Olds selected 400 families from a population that was mainly white, rural and hovering at the poverty level. Half the families were randomly assigned to receive nurse-visitation services, while the other half, who were offered transportation to and from prenatal and well-child appointments but no nurse visits, served as a control group.
Weekly visits began in the mother’s first trimester, followed by visits every other week during the rest of the pregnancy. After birth the nurse resumed weekly visits for six weeks, then continued at a biweekly pace until the child’s 21st month. The family next received monthly visits until the child’s second birthday, at which time the program ended. At each visit the nurses gave the mothers (and fathers, if they were available) NFP-developed information and detailed guidelines for care, allowing the mother’s concerns and questions to guide the session.
Recruitment for the trial opened in 1978 and closed in 1981. The first report on the trial was published in 1986, and even at that early date the findings were remarkably positive. The incidence of child abuse or neglect was reduced five-fold in the families who received nurse visits. Maternal smoking decreased by 25%, and preterm births among mothers who continued to smoke dropped by 75%.
These and other results convinced Olds that his model worked, at least in a white, rural community, but he felt the need to test his theories in other populations. Turning down federal funds from the Carter administration, which wanted to tinker with NFP by substituting paraprofessionals for registered nurses, Olds looked around for other communities to study. In 1984, after considering every major city in the United States, he selected Memphis, which was particularly attractive because of its centralized system of prenatal care registration for poor women, most of whom were black. The city also had a neighborhood-based network of clinics for prenatal and pediatric care, and nearly all of its poor women delivered their babies in a single hospital.
The Memphis study was much larger than the Elmira one, with nearly 2,000 women enrolled. The early results, though, were just as striking. Mothers who received nurse visits had 23% fewer pregnancy-induced hypertensive disorders than those in the control group; nurse-visited children had 80% fewer hospital days for injuries or poisonings; and mothers in the nurse-visited group had 23% fewer pregnancies by their first child’s second birthday.
Now that NFP had proved its worth in two different communities, many interested observers suggested the time was right to expand the program across the country. But Olds demurred. NFP worked in rural white and inner-city black populations, but would it work in a Hispanic community as well? In the mid-1990s, Olds launched a study of Hispanic women in Denver.
The model again produced striking, measurable improvement in the health of the nurse-visited mothers and children. In addition, by employing paraprofessionals in one arm of the study, Olds proved that registered nurses were critical to achieving best outcomes. Since then, Olds has revisited the mothers and children he studied in all three sites and found that the benefits of NFP continue to accrue long after the visits stop. The study children were significantly less likely than those in the control groups to have had brushes with the law at age 15, for example, and were more likely to be succeeding in school.
Expansion of NFP finally began in 1996, first to Dayton, Ohio, and to several counties in Wyoming. The U.S. Justice Department then offered its help, providing seed money from an anti-gang initiative to start the program in Oakland, Fresno, Los Angeles, St. Louis, Oklahoma City and Clearwater, Florida. At each site, the benefits of nurse home visits were obvious within a couple of years of startup. Politicians and child health advocates soon caught wind of the success of NFP. Over the next decade, grants totaling millions of dollars helped the program become established in dozens of communities.
Today NFP serves more than 20,000 families in 31 states. The current business plan calls for growth to 34,000 families and 38 states in the near future—an expansion that will require significant resources at a time when local and state budgets are shrinking. Success depends on political support of an initiative whose returns will only be fully realized years down the road, certainly well beyond the next election cycle. That is a daunting task in a country that, to paraphrase Thomas Jefferson, often chooses prisons over schools.
Yet Olds remains a self-described “happy warrior,” soldiering on in tough economic times. “This is what we can really stand behind,” he says with enthusiasm, when asked to describe NFP’s success. “It reduces injuries to children. It helps families plan future pregnancies and create better spacing between the birth of the first and second children. It helps women find employment. It helps improve prenatal health. It improves children’s school readiness.”
Olds’ research now takes him to Colombia, Spain, Russia, and other nations interested in NFP. Recent developments in Washington, DC, also give him reason for optimism here at home.
“Nurse-Family Partnership is the kind of investment we as a society should be making,” says Dr. Mary Maddux-González, Sonoma County Public Health Officer. She points to the program’s impressive results as “upstream thinking” that will pay off in the years ahead. That payoff can be striking: a 2005 study by the RAND Corporation found that every dollar invested in NFP yields as much as five dollars in savings by reducing demand for future government services. In the Elmira study, for example, the cost of the program with higher-risk families was recovered by the time the children reached four years of age, with additional savings continuing to accrue after that.
The recently enacted Patient Protection and Affordable Care Act includes federal dollars for effective home visiting programs. “There is money available for evidence-based prevention programs that provide lifelong impact, and NFP clearly works,” Maddux-González observes. “You have skilled, caring adults working with young, at-risk mothers, educating them, encouraging them, and telling them they can do it. And they do.”
Sonoma County is now one of only 13 California communities in which NFP is up and running. In July, four experienced local public health nurses traveled to Denver for an intensive, week-long training in the NFP model. One of them, Beverley Green, PHN, has been an admirer of Olds and his work for a long time. “Everything I’ve done in nursing has always seemed to lead me to the next step,” she says, and NFP seems a natural part of that progression.
NFP, Green points out, is different from traditional public health nursing: “In field nursing we meet clients at a challenging time in their lives, when all sorts of things are already going on and changing behavior can be difficult. In NFP we start the visits early in pregnancy, when there’s a great opportunity to build a strong relationship.”
Green gives an example of one such relationship. She and one of her clients, a young woman in her early second trimester, decided together to make healthy meal planning the focus of a particular visit. Using materials and exercises provided by NFP, Green helped the woman develop a plan for shopping, budgeting and preparing the kinds of meals that would optimize her own health and that of her baby.
Such low-key early visits lay the foundation for tougher work ahead. As the weeks pass and trust deepens between Green and the women she follows, she will explore her clients’ willingness to change behaviors like smoking, drug use and domestic violence. The ongoing relationship between nurse and client makes all the difference in NFP’s success, as evidenced by this quote from NFP’s guidelines for nurses: “We sometimes refer to the relationship and your ability to use yourself in a therapeutic way as the ‘secret ingredient.’”
Even though NFP has just arrived in Sonoma County, enrollment is growing as pregnant women are referred from primary and prenatal care providers, and from WIC nutrition clinics. No babies have arrived yet, but Green looks forward to meeting her next generation of tiny clients, whom she will follow until their second birthdays.
In the meantime, Green and other nurses are working hard to recruit young, pregnant, at-risk women for NFP, a gold-standard, evidence-based program that will benefit young mothers, their babies, and Sonoma County.
For more information on enrolling patients in the Nurse-Family Partnership, contact Monica Teixido, PHN, at 707-565-4536 or firstname.lastname@example.org.
1. Sonoma County Upstream Investments Report to the Board of Supervisors (January 2010).
2. Olds DL, et al, “Preventing child abuse and neglect: a randomized trial of nurse home visitation,” Pediatrics. 78:65-78 (1986).
3. Olds DL, et al, “Improving the delivery of prenatal care and outcomes of pregnancy,” Pediatrics, 77:16-28 (1986).
4. Kitzman H, et al, “Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing,” JAMA, 278:644-652 (1997).
5. Olds DL, et al, “Home visiting by paraprofessionals and by nurses,” Pediatrics, 110:486-496 (2002).
6. Olds DL, et al, “Long-term effects of nurse home visitation on children's criminal and antisocial behavior,” JAMA, 280:1238-1244 (1998).
7. Goodman A, “The story of David Olds and the Nurse Home Visiting Program: Grants Results Special Report,” Robert Wood Johnson Foundation (2006).
8. Karoly LA, et al, “Early childhood interventions: proven results, future promise,” RAND Corporation (2005).
Dr. Sloan, a pediatrician at Kaiser Santa Rosa, serves on the SCMA Editorial Board.