Roxanne White

By Jordan Smith

In the late 1990s, Roxane White was working with homeless teenagers in Colorado. One of the young women she worked with was pregnant, still working on the street some, homeless, and a teenager. Nobody really wanted to help her because she was just too tough. White, now the President and CEO of Nurse-Family Partnership (NFP), comments that these women are exactly the kind of women that NFP wants to help. NFP provides high-risk low-income first-time mothers with a trained nurse to help her through her pregnancy and the child’s first two years of life. NFP emphasizes data-driven outcomes resulting in an extensive database tracking families’ key metrics. Measuring these outcomes has opened up new avenues for NFP to further their model and reach a greater population. In order to rapidly scale-up a program that is proven to work, NFP is pursuing the first U.S. maternal and child health Pay for Success project.

A Model That Works

NFP, whose national service office is located in Denver, Colorado, was established as a nonprofit in 2003 to replicate the NFP program, developed through 37 years of randomized controlled research trials, across the United States. Dr. David Olds, Professor of Pediatrics, Psychiatry, and Preventive Medicine at the University of Colorado Denver was inspired to create the NFP program after working at an inner-city day care center in the early 1970s and realizing that low-income children need assistance much earlier in their young lives.

In 1977, Dr. Olds began conducting randomized controlled research trials to test his theories. Three different populations in three different parts of the country took part in these early research trials. Results showed a remarkable improvement in the life of the mothers and their children. Only when he was satisfied that the program was ready did he began partnering with various entities in communities from around the U.S. to establish the program.

“This program is my baby,” Dr. Olds tells Woodrow McCutchen of The Edna McConnell Clark Foundation, a supporter of NFP since 2002, “It’s my life’s work. I am so excited that you are willing to invest in us and help us scale this intervention throughout the country. It’s the best thing that could ever happen. But I need to let you know something. If there’s any inkling that in scaling this program, we will compromise the scientific integrity of the evidence, I will pull the rug out from under it.”

To uphold the scientific integrity of the program and keep the emphasis on data-driven programs, NFP has implemented longitudinal studies measuring both the short-term and long-term outcomes of the program. NFP partners an eligible mom with a registered nurse who assists the mother with prenatal and childcare development from early-on in the pregnancy until the child reaches two years of age. Through these partnerships, the program is able to successfully reduce child abuse and neglect by 48%, emergency room visits by 56%, child arrests at age 15 by 59%, behavioral and intellectual problems at age 6 by 67%, and hypertensive disorders of pregnancy by 35%.

Successfully implemented in 43 states, 6 tribal entities, and the U.S. Virgin Islands, NFP is only able to expand through the 250 implementing agencies, or the local agencies that NFP partners with in each community. These local agencies are a source of information about community needs and also a point of entry for eligible families. Moms go to a variety of places for information and the care they need—from the local hospital to a Planned Parenthood—so it’s necessary for NFP to partner with various entities within a local community to reach those moms.

White attributes NFP’s success to the quality of their program: “We use a very highly trained workforce to deliver the model because it’s complicated and requires a nurse and the skills that a nurse has. The flexibility to work with an individual community—what does that community need and where does that community connect with a mom—combined with a very well tested model makes for a nice intersection and a nice dynamic.”

Pay For Success

Despite their wide-spread success, however, NFP is only reaching 2-3% of eligible families. NFP is working to rapidly scale its program to reach a larger population of eligible mothers by launching Pay for Success projects—a public-private partnership funding model.

The first Pay for Success project, also known as a Social Impact Bond, will target high-risk areas in New York State through a public contract with the State. This contract agrees to reimburse private investors  once the program has been established and there is evidence of its success. Initial capital will support start-up costs, helping NFP enroll eligible mothers in New York City and Long Island, but will not be reimbursed. Expanding upon existing NFP programs, NFP hopes to enroll an additional 2,000 low-income women in four years.

Additional Pay for Success projects are being discussed for at-risk areas in South Carolina, the goal being to enroll an additional 4,000 eligible mothers, and in Michigan, for an additional 2,000 eligible mothers.

White says that the biggest challenge NFP has is really just getting the resources to scale-up their program. Pay for Success projects are a savvy way to scale-up their program fast. It is an incredibly complicated project, due to the players involved, but there’s huge potential for success.

McCutchen comments, “Thanks to the outcomes and cost benefits it has demonstrated over three decades, NFP is emerging as one of the premier and sought-after candidates for states interested in Pay for Success agreements. I firmly believe that NFP is potentially one of the most effective solutions we have to the problem of multi-generational poverty, and I’m intrigued to see how Pay for Success agreements can help it realize that potential.”

Nurse-Family Partnership works to empower first-time mothers living in poverty to successfully change their lives and the lives of their children through evidence-based nurse home visiting. To find your local NFP program, see this map.

Jordan Smith is a recent graduate of NC State, holding her Master’s degree in English with a concentration in Rhetoric and Composition