community-wide newborn home visiting: a …...2016/11/15 · at the birth of a child. • providing...

SummitonQualityinHomeVisitingPrograms

Community-WideNewbornHomeVisiting:AParadigmShift

KarenO’Donnell,PhDBenGoodman,PhDRobertMurphy,PhD

Center for Child &

Family Health

Duke Center for Child and Family Policy

Durham County Health

Department

ØThewhatandwhyoftheFamilyConnectsnursehomevisitingmodel?

ØProgramcomponentsØCommunityalignmentØThehomevisit(s)ØTheevidence

ØInteractiveDiscussion

PRESENTATIONAGENDA

• TheDukeEndowmenthad interestandten-yearcommitmenttoreducecommunitylevelsofchildmaltreatment.

• Requirementsfor aresponse• Replicablemodelbasedindevelopmentalscience• Rigorousevaluationofimpact• Communityrateofmaltreatment/childwell-beingastheprimaryoutcomes

• Plan• Formulateamodelbasedonstudyofchildandfamilyriskandneeds.• Pilotinterventions;developtheFamilyConnectsmodel.• Testthepublichealthapproachthrougharandomizedcontrolledtrial.• Replicateanddisseminatethemodel.

THECHALLENGETOHAVECOMMUNITYIMPACT

• Connect witheveryfamilyshortlyafterbirth.

• Connect familywithcommunityservicesandresourcesbasedonindividuallyidentifiedneedsandfamilywishes.

• Sothatnewparentsconnect withtheirinfanttowardbetterhealthandchilddevelopment.

THEFAMILYCONNECTSPROGRAM

• Everyfamilyisvulnerableandhasquestionsandneedsatthebirthofachild.

• Providingservicestoall families(whochoosetoparticipate)istheonlyroutetocommunity-levelchange.

• Community-wideeffortsdonotreplaceintensivetargetedhomevisitingprograms,buttheyidentifywhatfamiliesactuallyneedandwantfromlocalresources.

• ProgramslikeFamilyConnectsprovideanindividualized,non-stigmatizingentryintoacommunitysystemofcare.

COMMUNITY-WIDESERVICEISAPARADIGMATICSHIFT

• Everyfamilyiseligible.• Providingservicestoallfamilies(whochoose toparticipate)istheonlyroutetocommunity-levelchange.• Community-wideeffortsdonotreplacemoreintensivetargetedhomevisitingprograms.Theyidentifywhatindividualfamiliesactuallyneedandwant.• Whenfamiliesgetwhattheyneed,nomoreandnoless,thecommunityavoidsadditionalcostsforidentificationandoutreach.• So,FamilyConnectsisnotonlyascreening/intakebecauseoftheindividualizedassessmentandinterventionsprovided.Itisalsonotthelongertermintensiveprogramthatsomefamiliesneed.

HOWDOESFAMILYCONNECTSHAPPEN?

COREPROGRAMCOMPONENTS

CommunityAlignment

Data&Monitoring

HomeVisiting

THECOMMUNITYSYSTEMOFCARE:CONTEXTFORFAMILYCONNECTS

TheCommunityAlignmentcomponentidentifies:

• Existingservicesthatprovideforchildandfamilyneeds,rangingfromhousing,tomentalhealthservices,toearlychildhoodintervention,andothers.

• Servicedeliverygapsforfeedbacktolocalstakeholders.

• Keystakeholders,includingparents,toinformaboutthelocalcontextandtosupportexpandedprogramreach.Therelationshipisbidirectionalandongoing.

THECOMMUNITYSYSTEMOFCARE:THECONTEXTFORFAMILYCONNECTS

Communityresourcesandservices…• Affecteveryleveloftheprogram;• Assistingarneringbuy-infromalllevelsandallstakeholders;• Serveasacatalystson“activating”thecommunityforchange;and• Identifycommunitycapacity,infrastructure,andgapsinneededservicesinsystematicway.

COMMUNITYALIGNMENTCOLLABORATION

• Communityleveloutcomesareonlyasgoodastheagenciestowhichfamiliesarereferred.

• It’simportanttobeawareoftheorganizations’infrastructure,strengths,andchallenges.

• Theresultcanbetheidentificationofathresholdatwhichorganizationsaremovingtoimprovecommunitycapacity.

READINESSOFCOMMUNITYPROVIDERS

ForInteractiveDiscussionThoughtsaboutcreatinganeffectivecommunityalignment

THENURSEHOMEVISIT(S)

• Engagement&schedulingthehomevisit(s)

• Theintegratedhomevisit(IHV;~2Hours)atapproximately3weekspostdischarge

• Follow-upvisits(0-2total)andtelephonecallsasneededforfurtherassessment,facilitatinglinkagetocommunityservices,andfamilysupport

• Post-visitcontact(PVC)1monthaftercaseclosure• Confirmationofconnectionstocommunityresources

NURSINGINTERVETIONS

• Sharethejoy!

• UsetheFamilySupportMatrix fortheassessmentof12factorspredictiveofchildandfamilywell-being.

• Performphysicalassessments:Maternalpostpartumandnewborn.

• Respondtoimmediateparentquestionsandconcerns• Feeding,weightgain,sleep,crying…

THECOREOFFAMILYCONNECTS:THEINTEGRATEDHOMEVISIT

ALSO

• Providesupportiveandanticipatoryguidance.

• Planlinkageswithcommunityresourcesasneededanddesired.

• Followadetailedprotocol(manual)presentedinafriendlyandinformalmannerbythenursehomevisitorusingahighinferencemethodology.

SUPPORTFORHEALTHCARE1. MaternalHealth2. InfantHealth3. HealthCarePlans

SUPPORTFORINFANTCARE4. ChildCarePlans5. Parent-ChildRelationship6. ManagementofInfant

Crying

SUPPORTFORASAFEHOME7.MaterialSupports8. Family& CommunitySafety9. HistoryofParenting

Difficulties

SUPPORTFORPARENT10. ParentWellBeing11. SubstanceUse12. ParentEmotionalSupport

DOMAINSANDFACTORSFORTHEFAMILYSUPPORTMATRIX

SupportforHealthCare SupportforaSafeHome- OB/PrimaryCareProvider - DSSSocialWorker- Pediatrician/FamilyPractice - LocalHousingAuthority- CareCoordinationforChildren - DomesticViolenceShelter(CaseManagement)

- LactationSupport

SupportforCaringforInfant SupportforParent(s)- CCSA(ChildCareServices) - MentalHealthServices- HealthyFamilies - SubstanceAbuseTreatment- EarlyHeadStart - MotherSupportGroups- CareCoordinationforChildren(CaseManagement)

EXAMPLESOFCOMMONCOMMUNITYREFERRALS

Metric # Total Assessments Goal Overall Fidelity /

Reliability

Fidelity to IHV Protocol Overall Fidelity = 75%

Inter-Rater Agreement for Risk Assessment

Overall Agreement = 75%

• Weeklycaseconferences– supervisoryandpeersupervision§ Allfamilieswithinitialhomevisitsfrompreviousweekarereviewed.

• Quarterlydyadichomevisits:Nursevisitor+supervisingnurse§ Fidelitytotheprotocol– adherenceto63itemFidelityChecklist§ RaterreliabilityforthescoringoftheFamilySupportMatrix§ Clinicalsupervisionforthevisit

• Post-visitconnections– didfamiliesgetwhattheyneededandwanted?

QUALITYASSURANCEFORHOMEVISITING

PARENTPERSPECTIVESONFAMILYCONNECTS

forInteractiveDiscussionWheredoesFamilyConnectsfitintheschemeofscreeningversusintensivelongtermhomevisitingprograms?

PROGRAMMONITORING,EVIDENCEBASE,ANDDISSEMINATION

ØDOCUMENTATIONinJAVA-4Database• ElectronicMedicalRecord(EMR)• Reportingonprogramimplementation• Billingforhomevisitingservices(whenapplicable)

HOWDOESFAMILYCONNECTSUSETHEINFORMATIONGATHERED?

ØMONITORImplementation• HomeVisitScheduling&CompletionRates• FidelitytotheHomeVisitProtocol• Inter-raterReliabilityontheFamilySupportMatrix• FamilyRiskFactors• Follow-UpVisitRates• CommunityReferral&ConnectionRates• Family-ConsumerSatisfaction

HOWDOESFAMILYCONNECTSUSETHEINFORMATION?

COMMUNITYALIGNMENTforLong-TermFamilySupport

Family Risk

Rates

Community Capacity to

Support Family Needs

HOWDOESFAMILYCONNECTSUSETHEINFORMATION?

• FirstRCT:July,2009– December,2010(Durham,NC)• All4,777residentbirthsattwocountyhospitals

• Even-oddbirthdaterandomization

• SecondRCT:January,2014– June2014(Durham,NC)• All967residentbirthsatacademictertiaryhospital• 2nd countyhospitalexcludedduetohospitalpolicychanges

• Even-oddbirthdaterandomization

FAMILYCONNECTSRANDOMIZEDCONTROLLEDTRIALS(RCTs)

1st RCTImplementation:• 69%programcompletionrate(penetration)• 83%nurseadherencetohomevisitingprotocol(fidelity)• 61%ofnursereferralsresultedinsuccessfulcommunityconnection.• 99%ofparticipatingmotherswouldrecommendtheprogramtoanothernewmother.

2ND RCTImplementation:• 64%programcompletionrate(penetration)• 90%nurseadherencetohomevisitingprotocol(fidelity)• 79%ofnursereferralsresultedinsuccessfulcommunityconnection.• Family-consumersatisfactionnotassessedin2nd RCT

RCTIMPLEMENTATIONRESULTSINDURHAM,NC

RCTIimpactevaluation:• Random,representativesample(n=549)offamiliesrecruitedfrompublicbirthrecordsforindependentevaluationbeginningatinfantage6months

Resultsatinfantage6months• Comparedtocontrolgroupfamilies,interventionfamilieshad:

• ↑connectionstocommunityservices/resources

• ↑mother-reportedpositiveparentingbehaviors

• ↑mothersensitive/responsiveparenting(blindedobserver-rated)

• ↑safetyandqualityofhomeenvironments(blindedobserver-rated)

• ↑childcarequalityforinfantsincenter-basedchildcare

• ↓mother-reportedanxiety

IMPACTEVALUATIONRESULTSDURHAM,NC

Dodgeetal.(2014).AmericanJournalofPublicHealth

Resultsatinfantage12monthsfromaggregatehospitalrecords

• 50%lesstotalinfantemergencymedicalcare(ERvisits+overnightsinhospital)


0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

0 1 2 3 4 5 6 7 8 9 10 11 12

TotalCum

ulativeEm

ergencyCa

reEpisode

s

InfantAgeinMonths

ControlFamilies

DCFamilies

Intervention effect is 31% more reduction˅-----------------------------------------------˅

Intervention effect is 59% reduction˅------------------------------------------------˅

Dodgeetal.(2013).Pediatrics

Each$1.00inprogramcosts

$3.17insavingsthrough24months

throughreducedchildemergencymedicalcarebillingcosts.



0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

Control DurhamConnects

AverageNumberofCPSAssessmentsPerChild

Interventioneffectis36%reduction

DSSReportsofChildProtectiveServicesInvestigationsforChildMaltreatmentthoughAge48Months

RCTIIimpactevaluation:• Representativesubsample(n=367)offamiliesrecruitedfrompublicbirthrecordsforindependentevaluationatinfantage6months

Preliminaryresultsatinfantage6months• Comparedtocontrolgroupfamilies,interventionfamilieshad:

• ↑connectionstocommunityservices/resources

• ↓mother-reportedmentalhealthproblems• ↓motheranxiety

• ↓motherdepressivesymptoms

• mother-reportedpositiveparentingbehaviors

• childcarequalityforinfantsincenter-basedchildcare


• FamilyConnectsiscertifiedasanevidence-basedhomevisitingmodelbytheU.S.DepartmentofHealthandHumanServices(HomVEE /MIECHV)andiseligibleforMIECHVfunding.

• FamilyConnectscanbesupportedbydiversemeans.• Countyandstategovernments• Federalgrants(e.g.,RacetotheTop)• Foundationgrants• For-profithealthsystems

• FamilyConnectsoperatesindiversesettings.• Countyhealthdepartments• Hospitalsystems

FAMILYCONNECTSDISSEMINATION

• MIECHV• Medicaid

reimbursement• Donors

• Communitynonprofits

ActiveSites PendingSites PossibleFutureSites

FAMILYCONNECTSPROGRAMDISSEMINATION

forInteractiveDiscussionWhatdoesittaketoimplementFamilyConnects?

LEADINVESTIGATORS: KenDodge,Ph.D.RobertMurphy,Ph.D.

[email protected]@duke.edu

PROGRAMCO-DIRECTORS:KarenO’Donnell,Ph.D.BenGoodman,Ph.D.

[email protected]@duke.edu

TRAININGANDDISSEMINATIONSPECIALIST:AshleyAlvord,[email protected]

CONTACTUS

community-wide newborn home visiting: a …...2016/11/15 · at the birth of a child. • providing...

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