How nurses’ home visits help families—and why they’re needed everywhere
A Capita Conversation with Chris Bishop
Chris Bishop is the executive director of regional expansion for the Nurse-Family Partnership (NFP) National Service Office, a nonprofit organization based in Denver that supports replication of the Nurse-Family Partnership® community health program. NFP works by having specially trained nurses regularly visit young, first-time moms-to-be, starting early in the pregnancy, and continuing through the child’s second birthday. NFP has reached nearly more than 309,000 families nationally since the program’s replication began in 1996 and is still growing. Multiple academic studies show the model clearly works to improve an array of outcomes for young children and their families, including improved maternal and child health outcomes, child-development outcomes, increased family economic self-sufficiency, and more.
NFP programs across the country are funded by blended public and private sources. In South Carolina, where Capita is based, the program has expanded into thousands more homes thanks to the world’s first “Pay for Success” public-private partnership involving a maternal-child health program for this explicit purpose. We spoke with Bishop about this intersection innovation, the approach, what he’s learned, and the future of supporting children and families in the U.S. and around the world.
Capita: What does the Nurse-Family Partnership do?
Chris Bishop: Nurse-Family Partnership (or NFP) is a community health program that pairs registered nurses with first-time expectant mothers prenatally through the child’s second birthday. Nurses visit program participants in their homes to provide support and guidance as they strive to be the most caring, competent, and tenacious caregivers they can be.
Our program is all about intervening early in the lives of the women and girls who are interested in NFP, and so our goal is to enroll them before the 28th week of pregnancy. Our program impacts the health and well-being of mom and her baby – a two-generation change. The data shows us that the time when NFP is involved in a mother and baby’s lives is the most critical period of brain development for the child, when they’re developing all of their senses. The brain is developing at the fastest rate. So, if mom is smoking, or mom is using drugs, or mom is in a very challenging high-stress relationship… toxic stress-ors… All of that that mom is feeling, the baby is feeling it, too. That means the baby’s going to enter the world having been impacted by this stress.
So, Nurse-Family Partnership is an intervention that gets involved early to help shape that path… nurses working with mom and the father of the baby to be able to keep reinforcing here’s how you want to have a healthy pregnancy, here’s how to interact with that child when she’s born, here’s how you want to understand the baby’s cues… help mom and dad just be attuned to what this little person is trying to tell them. The goals of the NFP program are to improve pregnancy outcomes, improve child health and development outcomes, and improve family economic self-sufficiency.
Capita: How did you get into this kind of work? What attracted you to the Nurse Family Partnership, and why is home visiting important?
CB: I fell into the work of NFP. The mission resonated with me. It was a community-based intervention. Nurses are going into local community to impact change. My background is not in maternal-child health. I was doing local grassroots level community development, community organizing, advocacy work (in Durham, North Carolina) and really was looking for something at a larger scale. I’m now in my ninth year at NFP. Now I manage a team responsible for program growth and impact and also sustainability of our program in Texas, Florida, North Carolina, and South Carolina.
Home visiting is so important, because home visitors are out there on the front lines so to speak. They’re going into communities across this country to support families and provide services where there have been very difficult and challenging situations. NFP home visitors are serving families in neighborhoods that face lots of challenging issues, from neighborhood infrastructure, dilapidated housing, limited or lack of childcare and after-school programs. It’s really rewarding to see families thrive as they participate in NFP.
We need to be doing more home visiting and want to serve more families, and so we’re trying to figure out how we expand our partnerships with other programs and organizations. Personally, I think it’s important to create a continuum of work all the way from the prenatal period until kids are 5 years old or even up to 8 years old. (Right now, the NFP program runs prenatal through age 2.) There’s certainly a lot more families who could benefit, like in South Carolina, who we are not yet serving. And we need to evolve our model so that we’re maybe not just serving moms with one child but maybe moms with multiple kids.
“Personally, I think it’s important to create a continuum of work all the way from the prenatal period until kids are 5 years old or even up to 8 years old. (Right now, the NFP program runs prenatal through age 2.) There’s certainly a lot more families who could benefit, like in South Carolina, who we are not yet serving. And we need to evolve our model so that we’re maybe not just serving moms with one child but maybe moms with multiple kids.”
Capita: How does home visiting help young mothers? What are you learning from this strategy?
CB: A lot of our moms, they’re caught in generational cycles of both poverty and teen pregnancy. Our work really helps to break those cycles. You have a nurse that’s creating that bond with the mom and saying, ‘I’m here to support you at this amazing, important time and milestone in your life.’ I’ve met so many NFP participants who have never had a role model before meeting their nurse home visitor. The NFP nurse really helps that mom to create life course goals around education and workforce participation to help her family succeed.
One of the things that I appreciate about NFP nurses is that they go into so many different homes and communities, and they receive women and families as they are without judgment. They are true professionals who want to help that mom and that family be the best caregivers they can be. In doing so, we’re often helping them expand their view of ‘here’s what I could be.’ Part of the program is not only to improve pregnancy outcomes, but one of our goals is helping families to become more economically self-sufficient.
The nurses, they are medical professionals, but they’re also tapping into a lot of resources they know and are connected to in their communities. In South Carolina, we’re working with hospitals and the public health sector and others. All their networks are in their local communities. They are constantly asking, ‘Who are the people and the institutions that I know who could help this family succeed?’
In a lot of the situations our nurses are in, they’re helping women and girls who are in unstable situations. They’re in households that are overcrowded. The housing situation is really unstable for a lot of people. It can be overcrowded, it can be unsafe, it can be an environmental hazard (for the baby). She (the nurse) is there to be able to provide linkages to those resources. The nurse is empowering that mom to make that call. The nurse is not doing it for them. A lot of times, those resources are through people on our community advisory boards. Generally, there’s a good sense of who the people are you can tap into. Our nurses are local in their communities. They’re employed by our partners in the field. They know people and organizations around them.
Capita: What are your challenges in this work?
CB: Finding qualified nurses who are going to want to do this kind of program. It’s a rewarding program, and in most areas the pay and the benefits are competitive. But in some communities where nurses are working, there might be other nursing positions that for other reasons appeal to them. It’s finding the right fit of nurse who wants to do this kind of community-health work. One of the requirements is they need to be a bachelor’s degree-prepared nurse.
Another challenge is finding the dollars to sustain the scale of this work in order to make a dramatic impact. We’re coming to the end of funding for our expansion in South Carolina. We’re working to sustain what we’ve built through this project. Then we will begin to evaluate, to measure the impact of what we agreed to deliver for the project over a couple of years. It officially gets wrapped up in the spring of 2022. The state Medicaid office is a tremendous partner on so many levels, including as a ready-made referral pipeline. The enrollment for our expansion project and evaluation in South Carolina ends on March 31 of this year. In other states, it can look very different.
Capita: How do you address the challenge of serving young mothers while also dealing with issues of race and class?
CB: It’s got to be an ongoing effort. That’s one thing I appreciate about the Nurse-Family Partnership national office. We’re really trying to provide that ongoing education and support to local partners to be effective. Internally within the national office, we are committed to addressing issues of institutional racism and implicit bias, health equity and equality. We try to address these issues in different ways: through professional development opportunities and community initiatives. We’re also trying to make sure our team and our extended teams are having these conversations about these important, crucial issues. All of these issues are impacting the families that we serve, so if we’re not talking about violence impacting communities, for example, and why that is (then we aren’t getting to the heart of the matter).
We also want to be relevant and be connected to work that’s happening on a broader scale. You’ve got to be able to incorporate what you’ve learned into the day to day work of a nurse supervisor and home visitor. We have case conferences where teams brainstorm together: How do we try to support the family better, or handle this situation differently? We have our national symposium, where annually we’re trying to bring in relevant speakers, to expand our imagination about pressing issues not only we’re dealing with but also from a community perspective, like having a keynote speaker or workshop leaders on maternal morbidity and mortality, or economic mobility, or other related topics to what we do day-to-day. These are some of the most pressing issues that we’re talking about.
Our focus is, how do we improve the health and well-being of families, including breaking the cycles of poverty?
“We also want to be relevant and be connected to work that’s happening on a broader scale. You’ve got to be able to incorporate what you’ve learned into the day to day work of a nurse supervisor and home visitor. ”
Capita: What’s new at Nurse Family Partnership?
CB: Over the last four years or so, we’ve focused on really getting more customer feedback. Our primary customer is the mom who is in the program. We ask them, what do you want from NFP? We put some of what we learned into motion with two programs last year.
One is a parent ambassador program. It’s a competitive process, selecting a small group of NFP graduates across the country. It’s like an internship or fellowship for couple of years. We are really investing in them to build their skills and abilities to be better advocates for the NFP program. They can certainly transfer (what they learn) to other (job, family, and civic) opportunities. We’ve had our very first group of ambassadors who are wrapping up their year. It’s really exciting. They’re out and about, speaking directly to moms, speaking to funding groups, speaking to elected leaders, involved in advocacy for our program, telling why it works and its impact on their lives.
The second thing is our alumni network. We’re trying to build a network of NFP grads for a variety of purposes. Our moms were wanting to be more connected after they got out of the program. I know that with my own kids and my wife going down to our neighborhood park, she’s built kind of that moms’ support group at the park. The graduates from our program don’t necessarily have that luxury. This is an opportunity to connect with others around them. Hopefully it’ll also generate the possibility where they can be a cadre of local leaders in their communities. That’s one of the biggest areas we could still work on, to help moms continue to grow their networks and for us to stay connected with our graduates.
Capita: What does the future look like for this work?
CB: Last year, with Hopelab in California, we created an app that nurses use with moms called Goal Mama. Technology is big part of their professional lives now. It’s a way for nurses and moms in the program to stay connected and to set some goals between visits. Anything we can do to nurture that thinking on the part of moms. Focus on the little things, because the little things are going add up to big things. Still, technology can make people feel engaged and connected, but it’s not a substitute for face to face relationships.
Hopefully, what this work looks like 20, 30 years down the road: One, it’s informed by the data we collect. We know it works; we know what we need to invest. We need to influence elected leaders at all levels, private foundation leaders, and businesses to be able to invest more in NFP specifically and home visiting globally. We’ve got to use the data to invest in what works. We’ve got to be creative in what it takes in bringing these programs to scale. It takes a tremendous amount of coordination and communication to be able to collaborate at this level, but it’s so worth it. Hopefully, we’ll have made great strides in how we partner together with others. There’s a lot of people in need, and we just need to think creatively about how to do that.
Second, how do we be more flexible on our model in particular? We are currently focusing on first time women and girls in poverty. How do we figure out a way to get our model to moms with multiple kids? NFP serves only first-time moms, but there are other home visiting programs that serve parents and moms with multiple kids. We’ve got to figure out how to be effective in that space, as well, because there’s a lot of families that can benefit from our approach. It’s not just about growth, it’s about impact.
Photos courtesy of Nurse-Family Partnership.