Showing posts with label NursingHSR. Show all posts
Showing posts with label NursingHSR. Show all posts

Tuesday, June 11, 2013

Why the Nurse-Family Partnership Model is a Work in Progress

http://www.rwjf.org/en/blogs/human-capital-blog/2012/05/improving-on-success-why-the-nurse-family-partnership-model-is-a-work-in-progress.html

Improving on Success: Why the Nurse-Family Partnership Model is a Work in Progress

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David Olds, PhD, is founder of the Nurse-Family Partnership, a Robert Wood Johnson Foundation 40th Anniversary Force Multiplier that provides maternal and early childhood health programs for at-risk, first-time mothers. He is a professor of pediatrics at the University of Colorado School of Medicine, where he directs the Prevention Research Center for Family and Child Health.
When I finished my undergraduate degree in Baltimore in 1970, I went to work at an inner-city day care center, hoping that I might help poor preschoolers get off to a great start and have a better chance of succeeding in school and becoming productive, healthy citizens. But I soon realized that for many children in my classroom, it was already too little, too late. One little boy had been exposed to alcohol during pregnancy and was pretty profoundly developmentally compromised—he couldn’t communicate with words. Other children were being abused or neglected, so it was clear to me that parents’ prenatal health and parenting behaviors were part of the solution for low-income children.
I would have been out of touch, however, to think that all that was needed was for parents to do a better job of caring for their children. Our center was in a poor, inner-city neighborhood, where poverty, crime and a lack of adequate housing were undeniable influences for families. It was clear that parents wanted the best for their children, but their own personal histories and the social and material stressors weighing on them often made it really hard for them to protect themselves and their children. And this was happening in countless communities across the country.
After leaving that day care center and finishing graduate school, my colleagues and I developed what’s today known as the Nurse-Family Partnership® program in Elmira, New York in 1977. I developed this program in the context of a randomized, controlled trial because I didn’t want to just promote a program because our team happened to develop it; I wanted to know whether it would really help vulnerable children and families. I felt a responsibility to know, in the most disciplined fashion possible, whether or not it was effective. The findings from the Elmira trial were extremely promising, but before offering it for public investment, we decided to replicate the Elmira trial in two additional scientifically controlled trials with different populations living in different contexts throughout the US.
Today, we have an extensively tested model operating in 40 states in 432 counties nationwide. Early on in the national replication process, we created a nonprofit to manage the program’s national expansion and ensure that it was replicated with fidelity to the model we’d tested in our original trials. We recognized, however, that the program would have to be adapted to families’ individual needs in order to be meaningful to them, to elicit their engagement, and to bring about the changes needed to support maternal and child health.
Today, the Nurse-Family Partnership (NFP) serves more than 22,000 families a year in the United States. Nurses make home visits to young, low-income mothers, providing guidance and support for first-time parents before and after their babies are born. NFP improves the health of babies, as well as the health and financial well-being of mothers. They are better parents and more prepared for the challenges of raising children, have fewer subsequent pregnancies, longer intervals between births, increased employment and improved school readiness.
We think of the program itself as a work in progress, though.
For instance, we know that our nurses don’t have the resources they need to address intimate partner violence in homes. Violence is all too frequently occurring, and is dangerous and stressful for both parents and children. With that in mind, a team led by Harriet MacMillan, MD, MSc, FRCPC, and Susan Jack, BScN, PhD, are now testing an approach in randomized, controlled trials to help NFP nurses address intimate partner violence more effectively.
We strive to ensure that NFP has both clinical and scientific integrity. It has to reliably engage populations, and bring about adaptive behavioral change in key aspects of maternal and child health. We tap into parents’ instinct to protect their children, and support it in a clinically sophisticated way that motivates parents to do well by their children. At the same time, we try our best not to overstate NFP benefits; we face head on when things aren’t going as well as we’d like, and we develop and test new innovations in the NFP model to improve its impact.
At the Prevention Research Center for Family and Child Health (PRC) at the University of Colorado, we continue to follow the participants from our original trial to measure the long-term effects of NFP on health and behavioral functioning. As illustrated by the work on intimate partner violence, PRC organizes programs of research to improve the basic model and its replication. And the NFP continues to grow both in the US and abroad. We’ve partnered, for example, with governments in England, Scotland, Ireland, Canada, the Netherlands and Australia to adapt and test the program in those settings.
As we expand NFP to more and more populations, we are constantly focused on improving the basic model and our efforts to replicate it with quality.
Read more about the Nurse-Family Partnership.
Read an online commentary about the Nurse-Family Partnership on the New York Times Opinionator.

Swamp Nurse

http://newamerica.net/node/8122

Swamp Nurse

  • New America Foundation
    February 6, 2006 |
    What's the best hope for the first child of a poor mother?
    Click here to read this full article.
    Swamp Nurse
    In the swamps of Louisiana, late autumn marks the end of the hurricane and the sugarcane seasons -- a time for removing plywood from windows and burning residues of harvest in the fields. Then begins the season of crayfish and, nine months having passed since the revelry of Mardi Gras, a season of newborn Cajuns. Among the yield of infants in the autumn of 2004 was a boy named Daigan James Plaisance Theriot, and, on the morning of Daigan's thirtieth day of life, he was seated next to a bag of raw chickens in the back of an Oldsmobile Cutlass. His mother, a teen-ager named Alexis, was in front, squeezed between her younger sister and her sister's latest beau, a heavily tattooed man who had just been released from maximum-security prison. The car came down a road that begins with a bayou and ends in dented trailers, and stopped at a small wooden house.
    When Alexis's sister leaned into the back seat to fetch the poultry, the young man, grinning, slipped a hand down the back of her jeans. Alexis stared at the couple for a moment, then pushed them aside to pick up Daigan. Alexis's hair was long and streaked with pink, and her face was a knot of frustration. As Daigan began to cry, she crossed the yard denouncing in absentia his father, whom she called Big Head: "If I see him, I will hurt him -- Big Head asking for it now." When she reached the porch, which was crammed with auto parts and porcelain toilets, she fell silent, then forced a smile. Amid the fixtures stood a tall black nurse.
    The nurse, Luwana Marts, holds one of the stranger jobs in the Louisiana state bureaucracy: she is a professional nurturer in a program called the Nurse-Family Partnership, which attempts to improve the prospects of destitute babies. A few months earlier, Alexis, eighteen and pregnant, had arrived at a local government office seeking Medicaid for her impending delivery. She ended up with both the Medicaid and Luwana. As a rule, Cajun families don't welcome government intervention, especially when it occurs inside their homes, involves their infants, and means the presence of a dark-skinned person. To some parents, Alexis among them, Luwana was a spy in the house of maternity, and so she now and again had to lie in wait for reluctant beneficiaries.
    Alexis maneuvered herself and Daigan past the toilets, from which cacti had started to grow, and pushed open the front door with her hip. She entered a combined living room, dining room, kitchen, laundry, and storage facility that was home to five people, a dying cockatoo named Tweety, and multitudes of flat silver bugs. Luwana followed Alexis, Daigan, little sister, and boyfriend inside. That morning, feeling the onset of flu symptoms, Luwana had decided to avoid contact with the infants she called her "little darlings." In the field, though, calculations of risk were subject to change. She dropped her satchel, slathered her hands with Purell disinfectant, and reached out. Alexis handed over Daigan and wrapped her arms tightly around herself. "So, tell me," the nurse began with practiced tranquility as she scanned a body in a playsuit for damage. "Not the happiest day of your life?"
    Alexis and nineteen other girls in Luwana's caseload call her their "nurse-visitor," a term whose genteel ring seldom comports with the details of her job. She is one of eight nurses, all mothers themselves, who work the parishes of Terrebonne and Lafourche, persuading poor first-time mothers-to-be to accept assistance. The Nurse-Family Partnership model is currently being tried in Louisiana and nineteen other states on the basis of promising preliminary results -- results achieved in the face of the nurses' preposterously difficult assignment. In regular visits until a baby is two years old, they try to address, simultaneously, the continual crises of poverty and the class -- transcending anxiety of new maternity: this creature is inexplicable to me. Despite its ambition, the program is rooted in a pessimistic view of the future that awaits an American child born poor -- a sense that the schools, day-care centers, and other institutions available to him may do little to nurture his talents. Shrewder, then, to insulate him by an exercise of uncommon intrusion: building for him, inside his home, a better parent.
    Thus, no matter how chaotic the scene -- no matter that Alexis's sister had taken a break from hacking chicken parts by the kitchen sink in order to satisfy the ex-inmate's sexual needs in the next room-Luwana's first task is to create an aura of momentousness around the new baby. As she moves through a household, giving advice about routine building, breast-feeding, and storing shotguns out of reach, she attempts to win over not just a young mother but a typically unwieldy cast of supporting players, from the baby's father to the great-grandmother getting high in a tent behind the house. What Luwana tells each family may seem, on the face of it, fiction: that in this infant enormous possibilities inhere. But such fictions can be strategic, especially in cultures in which the act of becoming a mother is honored far more than what the mother subsequently does for her child.
    Alexis, who wore a tight red T-shirt, would have been striking even without the pink improvements she'd made to her caramel-colored hair, and since fifth grade, when she'd lost interest in schoolwork, most of her opportunities had come from men who'd taken note of her looks. Lately, she'd been wishing that she'd had a longer, simpler childhood, but, in the childhood that she had, full hips and breasts and lips had served her well. They served her less well now. To Luwana's questions about Daigan's feeding schedule, she responded monosyllabically while studying her manicured fingers. She'd received the manicure, plus some blue balloons and a chocolate-chip cake, on what she called the "heartful" occasion of Daigan's birth. The days preceding his arrival had not been happy. Alexis lived with her mother and father, a grocery clerk and a construction worker who were in constant conflict. When Alexis was eight months pregnant, the fights grew so fierce that she fled the household altogether. Her recent return testified less to domestic reconciliation than to the impact that a squalling baby has on the sleepover invitations a girl receives.
    As Luwana tried to draw Alexis out, the phone rang, and Alexis covered her ears. "I'm guessing this is Daigan's dad who keeps on calling," Luwana said, after the third round of unanswered rings. Alexis met her eyes for an instant, then burst into tears. "O.K., now," the nurse said, "spell it out for Miss Luwana." Between sniffles, the proximate cause of distress became clear. Daigan's father, a sturdy twenty-six-year-old named James, worked on a tugboat on the Mississippi River. That weekend, he would be returning to shore and expected to have sex with Alexis, though she was not healed from childbirth, nor was she using contraception.
    "No way!" Luwana said. "Keep your legs closed: embed that in your brain. Tell him to keep his hands to himself. And if you can't stand up for yourself, stand up for Daigan. You've got a lot of work ahead, giving him what he needs. Look around, Alexis. You need another baby in this picture?"
    "No," Alexis said dully. Then she brightened: "Miss Luwana, maybe you can write me an excuse note, like for gym?"
    Luwana's church friends smiled knowingly when they learned that she worked for the state. They pictured cubicles, potted plants, and cushy hours. She seldom corrected this impression, nor did she say that some mornings, driving her six-year-old Maxima toward some difficult case, she wanted to turn north and spend the rest of her working life in more high-minded quarters. But Luwana's efforts were invigorated by the fact that twenty years ago she was herself a poor, pregnant teen-ager in these swamps. "I know now that there were government programs on the books designed to help girls in my situation, but back then, especially if you were black, you didn't hear about them," she said. She is now thirty-eight, with two sons and a husband who has spent most of his working life in a mill that makes paper cups. It took her fourteen years, between child-rearing and stints as a nurse's aide, to earn a bachelor's degree in nursing. Her state job pays thirty-five thousand dollars a year, half of what she'd make in the emergency room of a private hospital. "Oh, I have my material longings -- every so often I'll throw a pity party for the house I'll never have," she said. "But quite a few of us nurses are working, you could say, in the context of our own memories."
    "How he doing?" Alexis asked uneasily, as Luwana's fingers explored Daigan's soft spot.
    "You're the mama," Luwana responded. "You tell me."
    "He's got a big head like his father," Alexis said under her breath. Then she rallied: "He's not as cranky as he was. And one thing I learned already is how he cries different when he's hungry than when he's wet." Luwana bestowed on Alexis a dazzling smile that she had thus far reserved for Daigan. "Making that distinction is important," she said. "You're listening to him, and in his own way he's explaining what he needs. Pretty soon now he'll be making other sounds, and when he does you'll want to make that noise right back. He'll babble, and then you'll talk to him, and that's how you'll develop his language. Now, what you may also find, around five to eight weeks, is that he'll be crying even more -- it's a normal part of his development, but it can also stress out the mom, so we'll want to be prepared for it. The main thing will be keeping calm. And if you just can't keep calm -- if you find yourself getting all worked up and frustrated -- well, then what?"
    "Put him down? So I don't hurt him, shake him, make him brain-dead?"
    "Put him down and . . . ?" Luwana drilled her girls hard on this particular point.
    "Call someone who isn't upset? Let the baby be, and get help."
    Luwana turned to Daigan and clapped. "See, your mama is getting it," she said, using the high-frequency tones that babies hear best. "She's surely going to figure you out."
    There was a trick that Luwana relied on to stave off dejection: imagining how a given scene would unfold if she weren't in it. In Alexis's case -- one that, in terms of degree of difficulty, fell roughly in the middle of her caseload -- she knew that slight improvements had already been made. At Luwana's urging, Alexis had stopped drinking and smoking when she was pregnant and had kept her prenatal appointments. So she wasn't incapable of changing her life on Daigan's behalf; the odds were just long.
    Sitting cross-legged on the floor now, Luwana sang "Clementine" and made faces at Daigan, and for a moment Alexis studied this demonstration of engagement with her child. But then her gaze drifted over to her sister and the ex-con, who had emerged from the bedroom to chop the rest of the chicken. The young man, whose tattoos included white supremacist ones, put on mirrored sunglasses for this task, a fashion choice that made Alexis giggle. Luwana's primary subject that day was infant attachment, a topic she tailored to fit Alexis's limited attention span. "A funny thing about the axe murderers," she said casually. "Usually something missing in the love link." And, indeed, axe-murdering seemed to register with both Alexis and the former prisoner, who set down his knife and came over. "I need to hear, too -- mines is horrible," he said. "We whup him but since he turned two he don't do nothing we say, probably 'cause his mama on drugs and sleeping around and getting locked up -- well, she's a whore."
    "You hit a two-year-old?" Luwana asked, her eyes narrowing. "You teach him how to fight and are surprised when he turns around, starts fighting you?" She then fixed her stare on Alexis, who began examining the brown linoleum floor.
    "The love link," Luwana began again. Now the room was still. "It's a cycle. When there's no safe base for the baby -- when you're not meeting his basic needs, satisfying his hunger, keeping him out of harm's way -- there will be no trust, no foundation for love. And that's when you might just get the axe murderer. Maybe sometimes we have a baby and expect that baby to comfort us? Well, sorry, it works the other way around. It's on you now to comfort him, earn his trust, because that's how Daigan is going to learn how to love."
    Infant-development strategies, like other forms of social capital, are perversely distributed in America-fetishized in places where babies are fundamentally secure and likely to prosper, undervalued in places where babies are not. The nurse-visiting program aims, in a fashion, at equalization. The territory that Luwana and her colleagues cover begins an hour's drive southwest of New Orleans, down fog-prone highways lined with cypress trees which lead to the Gulf of Mexico. On the shoulders, turkey vultures pause, flicking mud from their wings. Mississippi River sediment shaped this marshy delta, to which eighteenth-century French Acadians, expelled by the British from Nova Scotia, laid a claim not hotly contested. The terrain now occupied by the exiles' descendants is muggy, heavily wooded, and visited so often by hurricanes that Katrina, which made landfall near here, failed to register as a main event. Residents have another, steadier battle with nature, because they've built their lives on one of the fastest-sinking landmasses on earth.
    The social demographics are almost as fragile. Louisiana literacy rates are among the nation's lowest; infant mortality and child-poverty rates -- thirty per cent of all children are poor -- are among the very highest; and almost half of all births are to single mothers. Historically, the swamp region's topography isolated it from the rest of the state, but drawbridges and thoroughfares have been erected in recent years, and cane fields now give way to Wal-Marts. Still, idiosyncratic child-rearing beliefs endure: a baby will become constipated if held by a menstruating woman; formula is healthier than breast milk; giving an infant a haircut before his first birthday will stunt his growth and hurt his brain.
    The cases that Luwana and her fellow-nurses take typically begin with a referral from a public-health or prenatal clinic: a form indicating the age and address of an expectant mother and the baby's due date. Occasionally, a nurse shows up at the given address to find a mother-to-be converting Sudafed to methamphetamine on a hot plate. Other times, a pregnant girl's father is hostile because he's the probable father of his daughter's child. But the nurse's typical commission is to work with what she finds. And while Luwana believes that some aspects of mothering are instinctual, what she teaches is more like applied science. Her tools include a polystyrene demonstration baby named Dionne, picture books, a raft of developmental checklists, and, above all, her trade's bleak knowledge: babies can get used to almost anything -- as many of those babies' mothers had.
    The Nurse-Family Partnership program began twenty-eight years ago as the obsession of a developmental psychologist named David Olds. He is fifty-seven years old, with clear blue eyes and a tendency to fidget not unlike that of Luwana's adolescent mothers. He grew up in a working-class household and as a young man taught in an inner-city day-care center, an experience that led him to suspect that by age four or five some children are already gravely damaged. In the nineteen seventies, after earning a Ph.D. at Cornell under the late child psychologist Urie Bronfenbrenner, he began working with colleagues to translate this grim view into an elaborate scheme of prevention. At the time, scientific knowledge about early brain development and the importance of a child's first years of learning was more limited than it is now. But for Olds, who has one biological child and two adopted children, intuition as much as evidence suggested that the rescue effort should begin before birth, and unfold in the setting where an infant would spend most of his time. As for what sort of person a low-income young woman might trust inside her home, he and his colleagues settled on nurses, who in poor communities have high status and medical expertise that many pregnant women want. In 1978, Olds used a federal grant to test his idea in Elmira, an economically depressed, mostly white community in New York's Southern Tier, which had the highest rates of child abuse and neglect in the state.
    "Some policymakers look for cure-alls, which this isn't," said Olds, who continues to study his protocol's effects as the director of the Prevention Research Center for Family and Child Health, at the University of Colorado, in Denver. "We keep refining how we do this as the nurses report back on their experiences, because there's still a lot that we don't know -- for instance, how best to help mothers who are battered or mentally ill." Nonetheless, when he conducted random-assignment evaluations (among the most strenuous tests of a social program's effect) to gauge how the Elmira mothers and children were faring at the completion of the program, he found more improvement than he had expected. One of his chief concerns had been child abuse, and it turned out that children whose mothers had finished the nurse-visiting program were far less likely to be abused or injured than their counterparts in a control group. He also discovered that by the time the nurse-visited children were four, their mothers were more likely to be employed, off public assistance, and in stable relationships with their partners. Evaluations of two subsequent pilot programs-with primarily black families in Memphis and a racially diverse group in Denver-showed less dramatic results against control groups but suggested additional possibilities. By age six, for instance, the nurse-visited Memphis children had larger vocabularies, fewer mental-health problems, and slightly higher I.Q.s. In all three sites, the mothers had fewer subsequent children and longer spaces between them. An economic analysis of the Olds experiment commissioned by the state of Washington concluded that the approach -- which currently costs around four thousand dollars per year per family -- was cost-effective as well, because the children aided by the nurses had required fewer expensive social services such as foster care and hospitalization.
    The early optimism surrounding programs meant to help poor children is often dispelled by the rigorous assessments that come later. Children may make startling intellectual and functional gains in the hothouse of a model program -- say, a preschool run by skilled and idealistic teachers -- but those gains tend to vanish when the children move on to their communities' less hospitable institutions. This phenomenon, known as "fade-out," is one of the great frustrations of antipoverty policy, and I was first drawn to Olds's work because his long-term findings seemed to defy the regressive trend. By the time the Elmira children turned fifteen, they were still demonstrably better off than their control group peers. For instance, they'd been arrested far fewer times, one of several findings that inspired the U.S. Department of Justice to cite Olds's infant intervention program as a model for the prevention of juvenile crime. I wondered, however, about the objectivity of the Olds studies, since, regardless of acceptance by peer-reviewed publications like the Journal of the American Medical Association, he is essentially grading his own work. When I raised specific questions about the long-term outcomes in Elmira, Olds decided to recalculate his data using seven different evaluation methodologies, grasping that such a test might undercut his life's work. He later reported that some of the original findings -- for instance, those about Elmira teen-agers drinking and running away less than their counterparts -- weren't holding up under a preliminary analysis. He was so dismayed by these results that he seemed oblivious of the fact that other evidence of the improved futures of nurse-visited children and their mothers was now about as solid as findings can be when the subject is social policy's impact on human behavior.
    The nurse-visitor approach makes some liberals uneasy, because they fear that its focus on good parenting will undermine the fight for decent schools, quality day care, and other institutional supports for poor children. Libertarians recoil at a government-funded program that meddles in private lives, and child-welfare advocates have been frustrated by Olds's restraint. In their view, a "scientifically proven" approach like nurse visiting could have attracted bipartisan support and been widely implemented years ago, if its creator had more emphatically promoted it.
    Olds's cautiousness is based not just on a sense of personal fallibility but on what he considers the faltering of Head Start in the late sixties and seventies. A rapid, politically driven expansion inflated public expectation while diluting program standards; by the eighties, conservative policymakers were using Head Start's modest results to justify the rejection of other government antipoverty programs. Olds wants his protocol to expand incrementally, as he fine-tunes it. Currently, thanks to a hodgepodge of public and private funders, nurse visitors in places as diverse as Los Angeles, Fargo, Allentown, Tulsa, and Bedford Stuyvesant serve an annual twenty thousand of the United States' 2.5 million low-income children under the age of two.
    Louisiana, where I decided to watch Olds's ideas at work over the course of a year, is one of nurse-visiting's most difficult settings. Legislators there have been sufficiently impressed with the program to more than double its size in four years, with the help of federal Medicaid dollars. But, in a state where nurses often run out of breath when recounting the disadvantages of their clients ("The mom I'm working with now is a sixteen-year-old unmedicated, bipolar rape victim and crack-addicted prostitute with a pattern of threatening to kill her social worker, who recently abandoned her baby at her ex-boyfriend's sister's, and who has an attempted murder charge in another situation -- well, I think I've got all the risk factors," a colleague of Luwana's said one day), nurse-visiting is unlikely to be mistaken for a cure-all.
    In the bayou, every schoolchild knows that a shrimp's heart is in its head, and that now it's cheaper to buy that shrimp from China. So last winter, in a neighborhood called Upper Little Caillou, people who once worked on the water were trawling for a service sector niche. On homemade signs in yards, the inventory of salable goods continually evolved: "Shrimp/Alterations/Vinyl Blinds"; "Turtle Meat, Adult Novelties & Bail Bonds." Maggie Lander, a seventeen-year-old client of Luwana's, was among the residents hawking what she imagined rich people might want, such as her mother's cache of Harlequin novels. In the interest of clarity of message, though, the front of her home bore just one sign -- "No smoking" -- on behalf of her one-year-old daughter.
    In a few years, Maggie figured, her daughter would perceive the deficiencies of her home, as Maggie did -- understanding, for instance, that a sheet stapled to the ceiling wasn't what people usually meant by an interior wall. But she chose to believe what Luwana had told her: that babies didn't care about the surface of things. Their standards were deeper, Maggie believed, than those of some grownups she knew.
    In addition to selling secondhand goods, Maggie worked for a janitorial service. She has a lisp, a vulpine face, and auburn hair that she parts down the middle and often lets fall over her eyes. When Luwana came around, though, Maggie tucked the strands behind her ears, revealing the sallow beauty of a Victorian consumptive. For a half-Mexican, halfNative American schoolmate named Jose Hernandez, the sexual attraction had been intense. It wasn't entirely an accident when, after a year and a half of courtship, she got pregnant.
    In the bayou region, which is traditionally Catholic, no doctors admit to performing abortions. Home remedies, though, are highly evolved: blue cohosh root, a belly flop from bed to floor, the placenta-rupturing magic of cocaine. ("Is the baby shaking yet?" practitioners of this late-stage strategy asked when they entered the local emergency room; they knew the drill better than the doctors did.) But most pregnancies here were not terminated; as Maggie's mother liked to say, "God doesn't make mistakes." Maggie concurred with this theory. Still, when Luwana first appeared on her broken front porch, she was relieved to have a fresh pair of eyes on her life.
    David Olds and his researchers like findings that can be quantified, and Luwana has learned to report her experiences accordingly. The forms she filled out, however, didn't always capture the extent of a family's despair. The first time she'd come to Maggie's house, she had found an intelligent, underfed tenth grader in her second trimester who was sick with untreated hepatitis B and was also trying to care for her mother, who was bedridden and weighed eighty-two pounds. "I was in another world then, wanting to die," Maggie's mother, whose name is Tammy, recalled. "I'd been played the fool by a man I thought wanted a wife." Though mother and daughter shared malnourishment, depression, and very close quarters, they seemed to exist in separate spheres.
    One afternoon before Christmas, the effects of Luwana's yearlong campaign against hopelessness were easy to see. The baby, whose name is Maia, was an exuberant babbler, with a paunch so magisterial that her patchwork jeans were left unbuttoned. Maggie's mother was rounder, too, thanks to antidepressants, and she was working alongside Maggie at the cleaning company. Maggie was buoyed by her recent engagement to Jose, whom Maia plainly adored. He had moved into the house shortly before his daughter's birth, and he, Maggie, and Maia now occupied a sweltering room in the rafters.
    As Maggie discussed her low-budget wedding plans with Luwana, she bounced her dark-skinned daughter gently, while her fingers traced shapes on the baby's thigh. Maggie had become a diligent student of child-development technique, reading aloud so often from the parenting handouts Luwana had given her that she got on Jose's nerves. "She's, 'Listen to this on early brain development,' and I'm like 'O.K., I was here when Luwana went over it, I know,' " he said. "But she has to memorize this stuff." Luwana, of course, found the habit agreeable, and privately gave Maggie her highest praise: "The girl's an overcomer." But, in the swamps, a massively improved life is not the same as a good one.
    Maggie was now weak from the interferon that Luwana pressed her to take for her hepatitis. Maggie didn't know whether she had caught the disease from the twenty-five-year-old to whom she lost her virginity, at age thirteen, or whether she had been born with it. But the combined pressures of infirmity and maternity had led her to a decision with which Luwana took strong issue: dropping out of school after Maia was born.
    "I'm just trying to see that we're taking logical steps here," the nurse said gently. A fiercer iteration of her argument -- that bearing a child as an unmarried teen-ager and failing to finish high school were matchless predictors of lifetime poverty -- had just brought tears to Maggie's eyes. "You have too much to lose, and I know you don't want to clean houses all your life. Remember when I met you? It was one of the first things you said -- how adamant you were about finishing?"
    "I will go back, Miss Luwana, I promise," Maggie replied. "It's just now, with my job and Maia doing so many new things -- I don't know. . . ." Luwana's concern with diplomas, career plans, and jobs with benefits wasn't shared by many people Maggie knew. In a sinking region, land and housing came cheap, and dinner could be yanked from the brown water, so uneducated people could in fact "work the odd one," "do for themselves," and get by.
    Luwana, like many of her clients, is good at suppressing emotion. Among her cases were a young mother who had attempted suicide in her third trimester, two others who'd been violently abused, and one who was paraplegic and mentally disabled. Maggie's case troubled the nurse differently. She saw in the girl something of her younger self -- "You know, that caged bird singing" -- and feared the potential was going to be lost.
    "I mean, I'm not going to be just some dropout," Maggie promised Luwana now, gathering conviction. She reminded the nurse of a pact she'd made with Jose, who worked nights with her on the cleaning crew and spent his days in high school. He'd get his diploma while she took care of Maia, then it would be her turn for school.
    "So he's going to be the main one keeping Maia, is that what you're saying?" Luwana said skeptically. "You're going to trust him with her next year when you don't trust him now -- when he doesn't wake up when she's crying?" In the year that Luwana and Maggie had spent together, Luwana had grown alert to the girl's romantic habits of mind.
    When Maggie and Jose cleaned houses for lawyers and car dealers, Jose enjoyed discoveries of drug stashes and signs of affairs. "Wife large," he'd say with a broken-toothed smile, brandishing a find. "Panties behind the trash can in the bathroom, petite." Maggie preferred to dwell on other evidence. "I like dirty kitchens more than the fancy spotless ones," she said, "because in the dirty ones you can picture the homey wife and the father and kids all eating together and talking like a family." She hoped to replicate this scenario with Jose and Maia.
    "Let's see," she said one day of the family life she had personally experienced. "In the last few years, we stayed in that trailer park we couldn't afford, then the little blue house we couldn't afford, either -- had to give it back. Then a trailer park, then my auntie's trailer when we couldn't afford the trailer, then back to the trailer park, then straight to a little bitty camper behind my aunt's trailer -- now, that was tiny, you walk in the door, there's a mattress and a table and that's it. Then we moved in with my uncle, then with my mom's boyfriend, then back to the trailer park, then back to the boyfriend, then back to my uncle, and then here."
    Luwana had bettered her own circumstances with the help of caring teachers and strong parents, neither of which Maggie seemed to have. Her father, an illiterate as well as an addict, beat her mother when Maggie was young, and then his neck was broken in a car wreck. Afterward, he got sober, found religion, and separated from Tammy. Both parents are devoted to Maggie, but their leverage is minimal. "I hear Luwana saying to Maggie, 'It's not about you, you're making decisions for your daughter now,' " Tammy once said, "and I can almost see it on the tip of Maggie's tongue, 'But you didn't, Mom. You didn't look out for me.' " Tammy thought often about a day, shortly before Maggie got pregnant, when her daughter told her she was suicidal. "I didn't want to hear it," Tammy said. "I just wanted to believe that Maggie was the one thing in my lousy life I'd done right." Now Maggie considered Maia one thing that she was doing right.

    N.Y.C. Nurses Aid Low-Income First-Time Mothers

    http://www.nytimes.com/2012/12/16/nyregion/nyc-nurses-aid-low-income-first-time-mothers.html?pagewanted=all&_r=0

    For Mothers at Risk, Someone to Lean On

    N.Y.C. Nurses Aid Low-Income First-Time Mothers

    Ángel Franco/The New York Times
    VISITING Susan Spadafora, center, a nurse, met recently with Rose Mendoza and her son, Mason, in the Bronx.
    The tattoo below Joanne Schmidt’s right ear says “Jesus” in Hebrew. On the back of her neck, under a short crop of dyed red hair, is a second tattoo that says “Bad Girl” in Chinese.

    “That was from my earlier period,” she said.

    On a drizzly December afternoon, Ms. Schmidt was in the Throgs Neck section of the Bronx to visit Elizabeth De la Rosa, who is 19 years old, single and was about as pregnant as a person can be. On this day, which happened to be the date her baby was due, Ms. De la Rosa was living in her mother’s apartment, a surprise to Ms. Schmidt, 37, who had been visiting her since early in the pregnancy — sometimes at a homeless shelter, sometimes at Ms. De la Rosa’s aunt’s. Ms. De la Rosa and her mother had a history of bitter arguments, which had landed the daughter in counseling at age 14.
    “I must say,” Ms. Schmidt said mildly, “I’m glad that you and your mom are getting along.”
    “We don’t fight when I’m at my aunt’s,” Ms. De la Rosa said.
    “Did your mother ask you to move back?” Ms. Schmidt asked.
    “My sister did.”
    As the two talked, Ms. De la Rosa’s mother watched television in her bedroom. There were many things to discuss:
    How was Ms. De la Rosa feeling? (Impatient.) Did she have headaches or blurry vision? (Headaches.) Did she tell her doctor? (Yes.) Was she still planning to get a job and find her own place? (First she wanted to get her high school equivalency diploma.) Did she need a referral? Did she have a day care plan? Was she considering any schooling beyond the G.E.D.? How long did she plan to breast-feed?
    Discussion circled back to her relationship with her mother. Ms. Schmidt, who did not get along with her own mother, nodded sympathetically and recorded Ms. De la Rosa’s answers on printed sheets that she kept in a thick folder.
    Afterward, in her government-owned Prius, Ms. Schmidt confided that she was worried. “What happens when this baby’s born and her mom tells her she’s doing something wrong? Elizabeth says she doesn’t want it to get physical, but that it can get physical. She’s very strong-willed. I’m going to ride it out.”
    Her face showed her further concern: In a home with physical violence, little money or resources, with a nonsupportive father, what sort of life prospects would Ms. De la Rosa’s baby have?
    “I know these girls because I come from the same background as they do,” Ms. Schmidt said, adding that of the young women she visited, Ms. De la Rosa had one of the more stable home situations. “There were a few times when I found myself on the streets,” Ms. Schmidt said — “no apartment, I was cut off of welfare, living from place to place. I lived out of my car for a while. With my son.
    “So my story is very much these girls’ story. And it just takes one person, one person, to just say, ‘You are worth it. You’re not a terrible person for the mistakes and the things you’ve done in the past. You may have gone through whatever, but there’s a way out.’ ”
    She did not need to say that for her clients, 15 at any time, she intended to be that one person.
    Joanne Schmidt is a nurse for the New York City Department of Health and Mental Hygiene, in a program called the Nurse-Family Partnership, which matches specially trained nurses with low-income first-time mothers, starting during pregnancy; they meet at the mother’s home every week or two until the child’s second birthday. She is also a daughter of the soul singer Sam Moore, of Sam and Dave — a quick-eyed woman with freckles and a Rochester accent that adds a Midwestern flavor to mild oaths like “jeez Louise” or “shut the front door.”
    Raised mostly by her maternal grandmother and aunt, she was not told until age 8 who her father was, or why she looked different from her German relatives.
    After high school, she said, “that’s kind of when my life went — ” she made a screeching sound like a rocket veering out of control. “I didn’t realize I was following my mother.” For years she was by her description a “groupie” on the hip-hop scene; now she is a Christian, a PTA president, a mother to a 16-year-old and a partner with his father. And a nurse.
    Her unit takes the hard cases: mothers in foster care, homeless shelters or Rikers Island.
    The program, which was started in upstate New York in the 1970s and has been adopted in 42 states, is one of the rare public initiatives that have shown consistent and rigorously tested benefits for the mothers and children, as well as significant savings for taxpayers.
    In different studies on different demographic groups, women in the program have had fewer premature deliveries, smoked less during pregnancy, spent less time on public assistance, waited longer to have subsequent children, had fewer arrests and convictions, and maintained longer contact with their baby’s fathers. Their children have had fewer language delays and reported less abuse and neglect, slightly higher I.Q. scores, fewer arrests and convictions by age 19, and less depression and anxiety.
    A 2011 study of New York City’s Nurse-Family Partnership program, which currently has 91 nurses serving 1,940 families, projected that by the time a child in the program turns 12, the city, state and federal governments will have saved a combined $27,895, with additional savings thereafter — more than twice the program’s cost per child. The study was conducted by the Pacific Institute for Research and Evaluation using data from the Nurse-Family Partnership’s research at three locations, then extrapolated to New York.
    This fall, I attended a dozen home visits, all in the Bronx, with five nurses — three from the Visiting Nurse Service of New York, which contracts with the city to provide service in the Bronx, and two, including Ms. Schmidt, with the health department’s Targeted Citywide Initiative, which tackles the most at-risk cases. The nurses’ styles and backgrounds varied; the families’ needs and challenges even more so. Each mother participated voluntarily and at no cost.
    The problems were many: violence on the street, abuse in the women’s past, illness, anger, obesity, insecure housing or financial circumstances. Most of the women had the poor luck to have been born in poverty. Like their middle-class counterparts, none came into the world knowing how to raise a baby.
    At the Andrew Jackson Houses in the South Bronx, Rose Mendoza and her nurse, Susan Spadafora, were discussing Ms. Mendoza’s plans for the next week. She had a doctor’s appointment for her son, Mason, who is about 17 months old, and an appointment to get an assessment from her psychiatrist, so she could receive counseling for her longstanding temper problems. Previous attempts to get this assessment had failed, often ending with Ms. Mendoza in a tantrum.
    “If she’s not there,” Ms. Mendoza said of the psychiatrist, “I’m going to be mean.”
    “You don’t have to be mean,” Ms. Spadafora said. She commended Ms. Mendoza, 26, for her progress in controlling her temper since the baby’s birth.
    “She’s always late,” Ms. Mendoza said. “And I get frustrated to have to wait.”
    Patiently, Ms. Spadafora, 52, who works for the Visiting Nurse Service of New York, walked her client through steps they had discussed for dealing with unresponsive clinic staff members without blowing up. Several times, the nurse has gone along on appointments to demonstrate ways to ask questions and elicit better treatment. Part of her work, she said, lies in modeling good habits.
    “Susan’s changed a lot for me,” said Ms. Mendoza, who dyes her hair flaming red and has a gold stud by the corner of her mouth. “A lot. Like how to deal with things, how to think before you speak. Don’t just blurt it out.”
    Most of Ms. Mendoza’s friends had children as teenagers, but she did not become pregnant until she was 24, with her long-term boyfriend, David. They both left high school in their senior years.
    Hers was not an easy pregnancy. Ms. Mendoza weighed as much as 380 pounds and had diabetes and dangerously high blood pressure. Early tests showed that she was pregnant with triplets. One died in the womb, then a second. The third fetus and Ms. Mendoza were both in danger of not surviving.
    On a late-November morning, Mason stared alertly at the action around him and babbled. He ambled from one part of the apartment to another.
    Ms. Mendoza’s goal is to move out. Two people have been killed in the building since Ms. Spadafora started visiting, including one man who was shot in the daytime; Ms. Mendoza heard him screaming on the sidewalk at the pain, waiting for an ambulance that arrived too late.
    During two visits I attended, Ms. Mendoza was adamant that she was going to get her G.E.D., study to become a pastry chef, apply for housing, get an apartment with David — “he’s a great father,” she said — and begin a new life with her new family. But she has been making such plans since pregnancy, Ms. Spadafora said.
    “She seems to put roadblocks in front of herself,” the nurse said. “She’s registered for six or seven G.E.D. review courses. Always the obstacles seem real, but she can exaggerate them. Success can be as scary as failure. There’ll be more expectations if she gets a degree.”
    Like other nurses I talked to, Ms. Spadafora finds herself trying to counteract certain practices of the babies’ grandmothers — like putting cereal in a baby bottle, which can lead to overfeeding. “Everybody wants a fat baby,” Debra Rivera-Oquendo, who works for the Visiting Nurse Service of New York, told me.
    Though childhood obesity is not high on the national Nurse-Family Partnership agenda, it is a major concern in New York and especially in the Mendoza household, where obesity and diabetes are rampant. At 295 pounds, Ms. Mendoza was greatly slimmed down but still no waif. Her mother, who is also obese and diabetic, pushed back against the nurse.
    “We’re trying to make tiny breakthroughs with the baby,” Ms. Spadafora said. “I’ll ask, ‘What things did your mother do that might have contributed to your obesity?’ She knows what her mother did wrong, and doesn’t want to do that with the baby. Rose is doing better with the baby than with herself.”
    The visiting nurse program, though, is not for everyone. It makes demands on both nurses and clients, not least the demand for data, which means constant reporting and paperwork.
    More than half of the mothers drop out before their child turns 2 — some because they successfully move into work or school, but others because they lose interest. In the original trials, 60 percent of mothers finished the program, but the rate fell to 42 percent as the program expanded — another impetus for more data-gathering.
    For Joanne Schmidt, whose team has a far lower graduation rate because of the mothers’ challenges going in, each patient who drops out becomes an unsolved mystery.
    “I wonder what happens to some of them,” she said. “I wonder if they went to school. I wonder if they’re out of jail. I try hard not to take it personal. They have their own life to live, and I made it through on my own with no help. A lot of these girls are tough. They know how to use their resources.
    “It sounds cold, but I have to remember that this is my role. I can’t save the world. If someone drops, you wrestle with that for a second, then it’s, ‘all right, got to pick up the next client.’ That’s part of being a nurse, knowing you’re going to have clients that die on you. You have babies that die, you have clients that die. It’s sad to see, but it’s part of why you do what you do, and part of the reason everyone can’t be a nurse.”
    The Monday after Ms. Schmidt’s visit to Ms. De la Rosa, the baby had still not arrived. The nurse was hoping the birth would fall on her own birthday, Dec. 12. She needed some good news. One of her patients, a 5-month-old boy born a month early, was in the hospital with respiratory syncytial virus, or RSV, an illness that can be fatal to premature infants. Another patient, who was born two months prematurely, was sick and not receiving treatment.
    The two families were lined up back-to-back on her Monday morning schedule, along with a mother and her 3-month-old son who were living at Inwood House, transitional housing for homeless youths who are pregnant or have children. The mother, Nicola Brown, 19, said she had been physically and emotionally abused as a child, and verbally abused by the baby’s father.
    Ms. Brown was the day’s first appointment, and she had good news: in part thanks to Ms. Schmidt, she had finished her training to become a home health aide. This after getting her G.E.D. in August.
    Ms. Schmidt beamed at her. “Do you feel proud of yourself?” she said. “You should.”
    Ms. Brown said she wanted to work for a while, then go to nursing school. She was seeing a mental health clinician because of lingering effects of her past abuse, she said.
    Ms. Schmidt was her second nurse in the program. She had not gotten along with the first, whom she described as loud and obnoxious. “Joanne has an upbeat personality, and it’s easy to trust her,” she said, adding that she did not easily trust people.
    The meeting was the easiest part of Ms. Schmidt’s day. At the next appointment, in the Eastchester neighborhood, Natasha Pennant and her boyfriend, Aaron Pelzer, had a sick child, a new apartment, problems with Medicaid and stress from Ms. Pennant’s mother, who recently had shoulder surgery, and who relied on her daughter for help raising four foster children. Their daughter, Azalea, was born at 30 weeks, weighing one pound, 14 ounces.
    “I feel everything is on me,” Ms. Pennant said. “With my mom and Azalea, and trying to find a steady job.” She was too busy with her mother to reapply for Medicaid, she said. Without the coverage, she did not have money to take her daughter to the pediatrician.
    Ms. Schmidt asked how she was coping with the stress.
    “Honestly, I’m going back to smoking,” Ms. Pennant said. Mr. Pelzer, who is trying to start a mobile app business, sat nervously by her side.
    “When you smoke, where do you smoke?” Ms. Schmidt asked.
    Ms. Pennant told a story about Ms. Schmidt’s visiting her in the hospital just after Azalea was born. For two days, Ms. Pennant was unable to go to her daughter in the neonatal intensive care unit because of a pounding headache, which the floor doctors were not treating. Ms. Schmidt pushed the nurses on the floor to have a doctor look into it. Finally, a doctor said that the pain was a side effect of spinal anesthesia and prescribed treatment. Ms. Pennant was able to see and hold her child.
    “It was all because of Joanne,” she said.
    Now Ms. Schmidt urged the couple to take Azalea to the pediatrician or the emergency room ASAP. “They cannot refuse to see you based on your inability to pay.” Because Azalea had been premature, Ms. Schmidt feared RSV, and was especially worried about delaying treatment. “I just went through this with someone, and the outcome is not going well,” she said.
    The last visit of the day was the hardest: At Montefiore Medical Center’s Wakefield campus, a weary Stephanie Velez-Rivera, 23, lay with her son, Elisha, on her chest, trying to ease his weak cough. After eight days in the hospital and a week of illness before, he had lost half a pound and wasn’t eating or sleeping. The night before, he had rolled off his mother while she slept and onto the floor; in the morning, she said, the medical staff had interrogated her as if she had dropped her baby.
    Now she worried that when her husband learned of the baby’s fall, he would be upset with her. During Ms. Schmidt’s last visit, Ms. Velez-Rivera’s husband had rejected a suggestion of couples counseling.
    Ms. Schmidt did not criticize the husband. “His personality isn’t able to handle some of the things you can,” she said.
    “He gets stressed out,” Ms. Velez-Rivera said.
    Ms. Velez-Rivera, who has sickle-cell anemia, said that she had been raised in an abusive home, “physically, emotionally, verbally,” and that she was determined to make a better home for Elisha; the boy’s needs, she said, came before hers or her husband’s.
    Ms. Schmidt had no easy answers. The child was very sick, the marriage was fraught, the mother was pushed beyond exhaustion — and still it was not too early to discuss birth control, so Ms. Velez-Rivera would not become pregnant again right away. The nurse promised to bring information at their next visit, and to check back in a few days.
    Ms. Schmidt’s birthday came and went without Ms. De la Rosa delivering her baby. Instead of celebrating, the nurse went to a holiday party for the mothers and babies in the program. She asked her clients not to mention her birthday, saying the party was for them, not her.
    By week’s end everything was still up in the air. Ms. De la Rosa’s doctor said he would wait until Dec. 18 before inducing labor. Ms. Velez-Rivera was fighting to keep Elisha in the hospital, saying he was still not eating well enough to be safely discharged.
    Ms. Schmidt put away her work cellphone for the weekend, then picked up a message anyway.
    “All my girls have a lot going on,” she said. “That’s their everyday life. I know that they’ll be O.K., and that the decisions they make will become the road they have to take.”
    She took a deep breath. “I have to hang up my cape at some point,” she said. “You let it go, then you pick it back up.”
     
    Ángel Franco/The New York Times
    Joanne Schmidt checked Natasha Pennant’s daughter, Azalea, who weighed less than two pounds at birth.
    Ángel Franco/The New York Times
    Ms. Schmidt and Elizabeth De la Rosa, on what was supposed to be her due date.
    Ángel Franco/The New York Times
    JOY A Christmas party for nurses and clients in East Harlem.

    The Power of Nursing

    http://opinionator.blogs.nytimes.com/2012/05/16/the-power-of-nursing/

    The Power of Nursing



    Fixes
    Fixes looks at solutions to social problems and why they work.

    In 2010, 5.9 million children were reported as abused or neglected in the United States. If you were a policy maker and you knew of a program that could cut this figure in half, what would you do? What if you could reduce the number of babies or toddlers hospitalized for accidents or poisonings by more than half? Or provide a 5 to 7 point I.Q. boost to children born to the most vulnerable mothers?
    Well, there is a way. These and other striking results have been documented in studies of a program called the Nurse-Family Partnership, or NFP, which arranges for registered nurses to make regular home visits to first-time low-income or vulnerable mothers, starting early in their pregnancies and continuing until their child is 2.
    We tend to think of social change as more of an art than a science. “What’s unique about Nurse-Family Partnership is that the program was studied in what’s considered the strongest study design, and it showed sizable, sustained effects on important life outcomes which were replicated across different populations,” explained Jon Baron, president of the Coalition for Evidence-Based Policy, a nonpartisan group. “This is very unusual. There are probably only about ten programs across all areas of social policy that currently meet that standard.”

    What that means, notes Baron, is that if policy makers replicate the program faithfully they can be confident that it will change people’s lives in meaningful ways — improving child and maternal health, promoting positive parenting, children’s school readiness and families’ economic self-sufficiency, and reducing juvenile delinquency and crime.
    NFP is not a new idea — it’s almost 40 years old — but after decades of study the program, which has assisted 151,000 families, has the potential for broader impact, thanks to the Affordable Care Act’s Maternal, Infant, and Early Childhood Home Visiting Program, which provides $1.5 billion for states to expand such programs.
    Done well, it could be among the best money the government spends. Investments in early childhood development produce big payoffs for society. (A 2005 RAND study estimated that NFP provided $5.70 in benefits to society for every dollar spent.) But there’s an important concern: home visiting programs are not all effective. When carefully studied, only a few have been shown to reduce the physical abuse and neglect of children. Among the programs that meet the government’s standard for funding, there are large variations in evidence of impact (pdf). Policy makers and proponents of home visiting would do well to pay attention to the specific elements in the Nurse-Family Partnership’s model that account for its success.
    NFP was founded by David Olds, who directs the Prevention Research Center for Family and Child Health at the University of Colorado Health Sciences Center. Early in his career, Olds worked in a day care center in Baltimore because he believed that quality preschool attention would help disadvantaged children succeed in life. What he began to see was that, for some kids, it was already too late to make big gains. If children had been abused or neglected or exposed to domestic violence, or if their mothers had abused drugs, alcohol or tobacco while pregnant, their brains could have been damaged in ways that limited the children’s abilities to control impulses, sustain attention or develop language.
    A nurse with the Nurse-Family Partnership on a visit with a client.Courtesy of Nurse-Family PartnershipA nurse with the Nurse-Family Partnership on a visit with a client.
    Olds developed NFP in the early 1970s. He conducted his first large study in 1977, in Elmira, N.Y., a semi-rural, mostly white, community with one of the highest poverty rates in the state. The program produced strong results. Follow-up studies would reveal that, by age 19, the youths whose mothers received visits from nurses two decades earlier, were 58 percent less likely to have been convicted of a crime. In the 1980s and 1990s, Olds spread the work to Memphis and Denver and subjected the program to more randomized study with populations of urban blacks and Hispanics. The results continued to be impressive. In 1996, NFP began wider replication; the model is now being implemented by health and social service providers in 40 states.
    As Olds published his results, the idea gained momentum, but the imitations did not remain faithful to NFP’s approach. “People adopted all kinds of home visiting models and used our evidence to make claims,” he recalled. In the early 1990s, for example, the federal government, inspired in part by NFP, began a $240 million program to train paraprofessionals, rather than nurses, to make home visits to low-income families with young children. NFP also experimented in Denver, using paraprofessionals (trained from the communities they served) in place of nurses for a subset of families.
    In both cases, paraprofessionals didn’t get the same results. When it came to improving children’s health and development, maternal health, and mothers’ life success, the nurses were far more effective. In the federal program, paraprofessionals produced no effects on children’s health or development or their parents’ economic self-sufficiency.
    What’s special about nurses? For one thing, trust. In public opinion polls, nurses are consistently rated as the most honest and ethical professionals by a large margin. But there were other reasons nurses were effective. Pregnant women are concerned about their bodies and their babies. Is the baby developing well? What can I do for my back pain? What should I be eating? What birthing options are available? Those are questions mothers wanted to ask nurses, which was why they were motivated to keep up the visits, especially mothers who were pregnant for the first time.
    Nurses had more influence encouraging mothers to delay subsequent pregnancies, Olds explained. They could identify emerging complications more promptly, and they were more successful at getting mothers to stop or reduce smoking, drug or alcohol use. This is vital. Prenatal exposure to neurotoxicants is associated with intellectual and emotional deficits. It can also make babies more irritable, which increases risks of abuse. (A mother who was abused herself is more likely to misinterpret an inconsolable baby’s crying as “bad behavior.”)
    “A lot of the young mothers have had some pretty terrible early life experiences,” says Olds. “It’s not uncommon for them to have been abused by partners or never have had support and care from a mother. Their lives haven’t been filled with much success and hope. If you ask them what they want for themselves, it’s not uncommon for them to say, ‘What do you mean?’”
    A big part of NFP’s work is helping them answer this question.
    Consider the relationship between Rita Erickson and Valerie Carberry. Rita had had a methadone addiction for 12 years and was living from place to place in Lakewood, Colo. She found out she was pregnant; a parole officer told her about NFP. “I’d burned bridges with my family,” Rita told me. “I was running around with the wrong people. I didn’t have anyone I could ask about being pregnant.” In the early months, Valerie had to chase her around town, Rita recalled. “I was worried she might say, ‘This is too much hassle. Come back when you have your act together.’ But she stuck with me.”
    Over the next two years, they embarked on a journey together. “I had a zillion questions,” Rita recalled. “I was really nervous at first. I had lived most of my adult life as a drug addict. I didn’t know how to take care of myself.” On visits, they discussed everything: prenatal care, nutrition, exercise, delivery options. After Rita’s daughter, Danika, was born, they focused on things like how to recognize feeding and disengagement cues, remembering to sleep when the baby sleeps, how to manage child care so Rita could go back to school. For Rita, what made the biggest impression was hearing about how a baby’s brain develops — how vital it was to talk and read a lot to Danika, and to use “love and logic” so she develops empathy. Once Valerie explained that when babies are touching their hands, they’re discovering that they have two. “To me that was really amazing,” Rita said.
    This month, Rita is graduating from Red Rocks Community College with an associate degree in business administration. She’s going to transfer to Regis University to do a bachelors degree. Her faculty selected her as outstanding graduate based on leadership and academic achievement — and she was asked to lead the graduation procession and give one of the commencement speeches. Danika is thriving, Rita said. Recently, she came home from preschool and announced: “Mommy, I didn’t have a good day at school today because I made some bad decisions and you wouldn’t be proud of me.” (She had pushed another child on the playground.) As for the NFP, Rita says that it helped her recover from her own bad decisions. When Valerie came along, she needed help badly. “I didn’t care about my life. I didn’t care about anything. I never ever thought I would have ended up where I am today.”

    “When a woman becomes pregnant whether she’s 14 or 40, there’s this window of opportunity,” explained Valerie, who has been a nurse for 28 years and hasworked with more than 150 mothers in NFP over the past seven. “They want to do what’s right. They want to change bad behaviors, tobacco, alcohol, using a seat belt, anything. As nurses, we’re able to come in and become part of their lives at that point in time. It’s a golden moment. But you have to be persistent. And you have to be open and nonjudgmental.”
    Beyond the match between nurses and first-time moms, there are multiple factors that make NFP work. (NFP has identified 18 key elements for faithful replication.) The dosage has to be right: Nurses may make 50 or 60 visits over two and a half years. The culture is vital: It must be non-judgmental and respectful, focusing on helping mothers define their own goals and take steps towards them. The curriculum should be rigorous, covering dozens of topics — from prenatal care to home safety to emotional preparation to parenting to the mother’s continuing education. Nurses need good training, close supervision and support, and opportunities to reflect with others about difficult cases. And, above all, data tracking makes it possible to understand on a timely basis when things are working and when they are not.
    With the government making such a large investment in home visiting, it’s crucial for programs to get the details right. Otherwise, society will end up with a mixed bag of results, and advocates will have a hard time making the case for continued support. That would be a terrible loss. “When a baby realizes that its needs will be responded to and it can positively influence its own world,” says Olds, “that creates on the baby’s part a sense of efficacy — a sense that I matter.” It’s hard to imagine higher stakes.
    Join Fixes on Facebook and follow updates on twitter.com/nytimesfixes.

    David Bornstein
    David Bornstein is the author of “How to Change the World,” which has been published in 20 languages, and “The Price of a Dream: The Story of the Grameen Bank,” and is co-author of “Social Entrepreneurship: What Everyone Needs to Know.” He is the founder of dowser.org, a media site that reports on social innovation.

    Friday, June 7, 2013

    Lower Mortality In Magnet Hospitals

    Finding value in nursing

    Medical Care:
    doi: 10.1097/MLR.0b013e3182726cc5
    Original Articles

    Lower Mortality in Magnet Hospitals


    McHugh, Matthew D. PhD, JD, MPH, RN*; Kelly, Lesly A. PhD, RN; Smith, Herbert L. PhD; Wu, Evan S. BA§; Vanak, Jill M. MSN, RN§; Aiken, Linda H. PhD, RN§


    Supplemental Author Material

    Collapse Box

    Abstract

    Background: Although there is evidence that hospitals recognized for nursing excellence—Magnet hospitals—are successful in attracting and retaining nurses, it is uncertain whether Magnet recognition is associated with better patient outcomes than non-Magnets, and if so why.
    Objectives: To determine whether Magnet hospitals have lower risk-adjusted mortality and failure-to-rescue compared with non-Magnet hospitals, and to determine the most likely explanations.
    Method and Study Design: Analysis of linked patient, nurse, and hospital data on 56 Magnet and 508 non-Magnet hospitals. Logistic regression models were used to estimate differences in the odds of mortality and failure-to-rescue for surgical patients treated in Magnet versus non-Magnet hospitals, and to determine the extent to which differences in outcomes can be explained by nursing after accounting for patient and hospital differences.
    Results: Magnet hospitals had significantly better work environments and higher proportions of nurses with bachelor’s degrees and specialty certification. These nursing factors explained much of the Magnet hospital effect on patient outcomes. However, patients treated in Magnet hospitals had 14% lower odds of mortality (odds ratio 0.86; 95% confidence interval, 0.76–0.98; P=0.02) and 12% lower odds of failure-to-rescue (odds ratio 0.88; 95% confidence interval, 0.77–1.01; P=0.07) while controlling for nursing factors as well as hospital and patient differences.
    Conclusions: The lower mortality we find in Magnet hospitals is largely attributable to measured nursing characteristics but there is a mortality advantage above and beyond what we could measure. Magnet recognition identifies existing quality and stimulates further positive organizational behavior that improves patient outcomes.

    Thursday, June 6, 2013

    Future of Getting Paid to Be Healthy

    http://www.theatlantic.com/health/archive/2013/06/the-future-of-getting-paid-to-be-healthy/276461/?goback=%2Egde_140698_member_247288366

    The Future of Getting Paid to Be Healthy

    Pairing financial incentives and workplace wellness programs, employers can save money, and employees can make it.
     

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    (Fabrizio Bensch / Reuters)
    When a 2014 portion of the Affordable Care Act comes into effect, employers will be able to use financial rewards and penalties to encourage healthier behaviors. Last week the Obama administration released its final rules regarding these employer-based wellness programs.
    Still, critics are concerned that an annual premium adjustment isn't likely to change behavior, and will just end up penalizing those with poorer health.
    The difference between the Bronze and Gold tiers can make a difference of as much as $2,400 per year for a family of four.
    According to Dr. Kevin Volpp, director of the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, it isn't as simple as just paying someone for doing the right thing. People tend to respond to immediate, short-term rewards (e.g. the satisfaction of eating one more piece of pizza) more readily than to delayed consequences (weight gain). The science of "behavioral economics" has found that when people are offered immediate incentives and penalties to do the healthy thing, they are more likely to make the right decision, sort of like having a swear jar for healthy living.
    But not all incentives are created equal, and some behaviors are harder to change (e.g. quitting smoking) than others (taking your kid for a routine check up). The impact of an incentive depends a lot on how it is framed, and the context in which it's offered.
    People also respond differently to rewards and penalties. Volpp studies how different types, sizes, and frequencies of incentives impact people's behavior.
    In one study, Volpp and colleagues teamed up with General Electric to develop financial incentives to get employees to quit smoking. All smokers received information about smoking-cessation programs, but half were chosen at random to also receive financial incentives. In the financial incentive group, smokers were given $100 for completing a smoking-cessation informational program, $250 for quitting smoking within six months of joining the study, and $400 if they were still not smoking six months after they quit.
    The smokers in the incentive group were three times more likely to join a smoking-cessation program, and three times more likely to quit smoking than those who were not offered financial rewards. But when GE rolled these financial incentives to quit smoking to the rest of their workforce, employees complained about rewarding smokers to do something they should be doing anyway. From their perspective, GE turned the program into a penalty rather than reward program.
    "If you make it all about rewarding smokers, you'll predictably get the reaction, 'No, we shouldn't be rewarding smokers, we should penalize them,'" Volpp said. But we already are paying for the health consequences of other people smoking, eating poorly or not exercising. According to him, the response to the financial incentive might have been different if GE had done a better job of explaining to its workforce that getting employees to quit smoking would also save money for everyone else.
    Volpp also cautioned that you have to be careful about overusing penalties if you are trying to help people improve their health. Penalties can create distrust and drive unhealthy behaviors underground, making them that much harder to tackle.
    ***
    King County, Washington, was one of the first local governments to use rewards and penalties to encourage healthier behaviors. A decade ago, the county panicked as health care costs were growing at a pace of 15 percent every year. Then-executive Ron Sims convened a task force that included physicians, health care policy and legal experts, economists and labor and business leaders to develop a strategy to address health care costs from the perspective of both patients and the employers paying for their coverage.
    Sims told the Seattle Times at the time, "I refuse to sit back and allow the county and its employees to be victims of these seemingly uncontrollable cost increases. Further, I refuse to accept there are only two choices: reducing benefits to our employees and their families, or paying crippling annual increases. Tweaking the edges of the problem will no longer work."
    Out of the task force's recommendations was borne Healthy Incentives -- a voluntary wellness program for its employees and their families. While everyone receives the same medical benefits coverage, their out-of-pocket costs (deductibles and co-pays) vary according to their level of participation in the Healthy Incentives program. Those who choose not to participate receive a Bronze status, with the highest out-of-pocket costs. To attain a Gold status, with the lowest out-of-pocket costs, you need to complete a health risk assessment and complete a personal wellness plan. The individual action plans might include texting in a log of healthy activities, joining Weight Watchers at Work, attending YMCA classes to learn how to prevent diabetes through nutrition and exercise, or working with a Quit for Life coach on the phone to quit smoking. The difference between the Bronze and Gold tiers can make a difference of as much as $2,400 per year for a family of four.
    When she started working for King County three years ago, Lynn Argento was automatically enrolled in the Gold tier after completing her health risk assessment. Failing to complete her personal wellness plan, Argento got bumped down to the Silver level the following year. "It was an eye opener in terms of the differences that I was paying for my deductible and co-pays," she said. "It was a big reminder that my wellness activities had a significant financial connection to what I was paying out-of-pocket." But Argento wasn't upset with King County. She was disappointed in herself. "It was pretty clearly laid out to me. I knew what I needed to do, and I didn't follow through on it," she said.
    Argento resolved to earn back her status. She runs on a treadmill during her lunch breaks at a worksite activity center, where employees can also attend yoga, tai chi, Zumba and kickboxing classes. Argento's husband is now also on her plan, which means that he too has to participate in wellness activities to earn Gold status. Argento has noticed not only the financial but also health benefits of her wellness activities. "I have a lot more stamina," she said. "I often have to sprint for a bus because I'm running late, and now I can do that without wanting to pass out when I get to the bus."
    Argento also used to miss a couple days of work or leave the office early each month due to migraines, but the frequency of her migraines has gone down significantly since she started eating regular, healthier meals to complement her training schedule. And the Healthy Incentives program has been self-reinforcing. Argento and her co-workers talk about work-life balance and making space for wellness during the workday.
    During the first five years of the program, 38 percent of obese participants lost at least 5 percent of their body weight, and almost a quarter lost at least 10 percent. Smoking rates dropped from 12 percent to 7 percent, which is lower than both national and state averages. Between 2007 and 2011 King County saved $14.6 million due to the improved health of its employees and their families. According to Brooke Bascom with the Healthy Incentives program, "It is so much better than cutting people off and making health care inaccessible. We give them the support they need to make changes."
    The state of Oregon, like King County, saw a need to reign in its health care costs, having spent $1.6 billion on costs related to obesity alone in 2006. The Oregon Educators Benefit Board and Oregon Public Employee's Benefit Board, which provide health insurance coverage to the state's teachers and public employees, have also used financial incentives to encourage healthier behaviors. During the first year of the program, they charged employees $17.50 per month if they failed to take a baseline health risk assessment and follow through on recommendations. 70 percent of employees completed their health assessment and took the suggested health actions. With a switch the following year to a reward of $17.50 per month per person for participation and a $100 higher deductible per person for those not participating, 7 percent more employees completed wellness recommendations. Through a combination of these financial incentives and a partnership with Weight Watchers, rates of obesity decreased from 28 percent to 22 percent among the state's teachers between 2009 and 2012, at a time when rates of obesity were increasing among the general population.
    Employers' interest in using worksite wellness and incentive programs is expanding rapidly, but not all have the resources to develop their own, so some outsource to companies like The Vitality Group, which relies on behavioral economics to structure programs. Vitality might track your gym visits, activity using pedometers and accelerometers and attendance at Weight Watchers meetings, and in exchange you earn redeemable points that can be used to purchase items -- movie tickets, iTunes gift certificates, hotel stays -- from the Vitality Mall. Your behaviors also earn you points towards your Vitality Status. The higher your Vitality Status, the more prizes you are entitled to win.
    Vitality recently partnered with Walmart to offer members a 5 percent credit on purchases of healthy foods that can be used towards future purchases at Walmart -- another immediate reward for a healthy action. But one of Vitality's greatest successes in the U. S. was in partnership with Alcon Labs, which involved not just the incentive program, but creation of a comprehensive wellness program.
    A key feature of this program were "Vitality Champs," employees who volunteered to be trained to lead and encourage their co-workers in wellness activities and to organize events, ranging from 5K run/walks to mobile mammography screening to flu shot campaigns. And those people are the key to these programs. We are influenced by the people around us, and when there's a culture of health in the workplace, we are more likely to do the healthy thing ourselves.
    "Incentive programs are not wellness programs," said Dr. Ronald Goetzel, Director of Emory University's Institute for Health and Productivity Research and President and CEO of The Health Project. "That can be a component, when done smartly, of a comprehensive program, but if that's all your program is going to be, you're going to fail miserably, and people are going to be resentful," he explained. According to Goetzel -- who has studied worksite wellness programs at large corporations such as Dow Chemical and Johnson & Johnson, and is being funded by the Centers for Disease Control and Prevention to study best practices in the field -- incentive programs can help get people excited about health and keep them on track, but ultimately people's habits will only change if they are given the resources to change them and if the workplace norms and environments change.
    Without the other pieces to facilitate behavior change -- healthy cafeterias, opportunities to exercise, flexible work hours, supportive leadership and middle managers, and health risk assessments and coaching -- incentive programs will only penalize, not change, those who are least healthy.