Spotlight on the Safety Net

When 20-year-old Mahogany found out she was pregnant, she didn't know what to expect from pregnancy or childbirth, or how to take care of a baby. Nurse Stephanie, a Nurse-Family Partnership home visiting nurse, helped Mahogany prepare for the birth of her baby, Josiah. After Josiah's birth, nurse Stephanie helped Mahogany with breastfeeding, and when Mahogany and Josiah were displaced from their home after Hurricane Matthew, Stephanie and Nurse-Family Partnership helped Mahogany with new baby items and continued support while the family found a new home [1].

For new parents, pregnancy and the early days with a baby can be filled with questions and uncertainty about how to best care for the baby and mother, how to adjust life and routines, and how to learn new skills to ensure the family is stable and healthy. While family and friends can be a great source of support for new parents, many families find that additional support and assistance from health and human services professionals can be incredibly valuable.

Research has long shown the positive impact of home visiting programs on children and families. These programs, which generally focus on home visits to expecting and new parents, provide medical, parenting, and social support and have been shown to reduce child maltreatment and improve infant and maternal health for participating families [2]. Programs in which nurses or other health care professionals visit parents and children in their homes to assess child and maternal health and offer support can also reduce parental stress, improve families' economic self-sufficiency, and decrease medical costs for families [2]. According to Donna White, deputy director and vice president of North Carolina Partnership for Children, the 2-generation approach of home visiting programs is “proven to improve parent and child outcomes such as breastfeeding, use of emergency room for health issues, spacing of repeat pregnancies, positive parent-child interactions, and school readiness” (written communication, Donna White, Deputy Director and Vice President, North Carolina Partnership for Children, to Michelle Ries, NCIOM, September 7, 2019). In addition, evidence-based early home visiting programs show a financial return on investment; some programs report a return of up to $5.70 for every $1 invested to serve the highest-risk families [3].

Nurse-Family Partnership (NFP) is a highly successful, evidence-based home visiting model currently implemented in 25 North Carolina counties [4]. April Harley, executive director of North Carolina's Nurse-Family Partnership, says of the program, “NFP serves women in poverty pregnant with their first child, from pregnancy until their child turns 2. The main goals of the NFP are to improve pregnancy and child health and development outcomes, improve family economic self-sufficiency, and break the cycles of intergenerational poverty” (written communication, April Harley, Executive Director, NC Nurse-Family Partnership, to Michelle Ries, NCIOM, September 5, 2019). Recent analyses have shown that NFP services resulted in lower Medicaid and SNAP enrollment, with a reduction of 8.5% in Medicaid costs from birth to age 18 and a reduction of 9.6% in SNAP from birth to age 12 [3].

Established in 2008 as a universal home visiting program to improve child health outcomes and prevent child maltreatment, another safety net for new families, Family Connects (originally known as Durham Connects), serves all parents of newborn babies, regardless of income, with no-cost postpartum home visits [5, 6]. Benefits of participating in Family Connects include improved maternal mental health, 50% reductions in child emergency care, and higher-quality parenting behaviors [6, 7]. Family Connects also reports cost savings of $3.02 in emergency medical care costs for each $1 invested [4]. Family Connects currently operates in Durham, Forsyth, and Guilford counties in North Carolina, as well as in counties in 9 other states [8].

Despite the success of NFP and Family Connects in North Carolina, many gaps remain in provision of services and funding for home visiting programs. Of these gaps, White says the main challenges include, “finding and retaining qualified home visitors and assuring staff have the supports they need to provide high-quality services. Services are not well known by families, and they are not well coordinated to maximize resources and best meet the needs of families in communities.”

In July 2018, NC Medicaid launched 2 pilot home visiting initiatives using Medicaid funds. The Cleveland County pilot uses the Nurse-Family Partnership model and Johnston County uses a hybrid model focused on high-risk pregnancies. The North Carolina Department of Health and Human Services has estimated the per-visit cost to Medicaid at $83.72, for a total projected expense in Cleveland County of $251,160, and $92,090 in Johnston County [9]. Results of the pilot will be reported back to the North Carolina legislature [9]. NC Medicaid will also be providing coverage of home visiting programs and services through the Healthy Opportunities pilot program. Starting in 2020, NC Medicaid will serve 2 to 4 Healthy Opportunities regions of the state, with the aim of assessing how using Medicaid funding for evidence-based interventions, including home visiting, will improve health outcomes and reduce costs [10].

A recent study by researchers at the Jordan Institute for Families at the University of North Carolina at Chapel Hill assessed the current landscape and developed a comprehensive assessment of North Carolina home visiting programs. The assessment included recommendations for a statewide home visiting leadership structure and strategic plan to include new funding streams, support of the home visiting workforce, continued assessment of community capacity for specific models, and improved service coordination [11].

In early 2019, a group of early childhood experts, home visiting program staff, state agency representatives, and others—under the joint leadership of NC Partnership for Children, Jordan Institute for Families, North Carolina Department of Health and Human Services Division of Public Health, and early childhood philanthropy leaders—convened to develop a statewide plan that addresses recommendations from the Jordan Institute study and creates a “family-centered, coordinated system (to ensure that) high-quality home visiting services can be scaled up to be accessible and offered in an equitable manner” [12]. Cyndi Soter O'Neil, senior policy advisor at ChildTrust Foundation and co-chair of the home visiting systems planning process, describes the process: “Bringing together so many of the players in home visiting creates a tremendous opportunity to build on what's happening in the state and thoughtfully craft a system that can better reach the families it seeks to serve. By leveraging private investments alongside state and federal funds, North Carolina can make real strides toward meeting families' needs” (written communication, Cyndi Soter O'Neil, Senior Policy Advisor, ChildTrust Foundation, to Michelle Ries, NCIOM, September 4, 2019).

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