# Nurse-Family Partnership (NFP)

The Nurse-Family Partnership (NFP) is a Gold Medal organization. We believe that NFP improves the lives of the children and mothers it serves. Note: we believe that the NFP has only a long-term need for additional donations (i.e., new donations to NFP will go to long-term growth and sustainability), and potential donors should take this into account (more). More information:
The Nurse-Family Partnership supports programs offering home visits (from trained registered nurses) to low-income, first-time mothers. Nurses advise mothers on prenatal health, child care, and personal life management (including birth spacing and employment counseling). The program has been the subject of several formal, rigorous evaluations that imply measurable impacts on both mothers (particularly on how long they go between births) and children (particular cognitive and behavioral measures). NFP stands above any other developed-world organization we know of in terms of its commitment to replicating a proven model. We estimate the cost of the full 2.4-year program as ranging from $10,000-$12,000 per family. We do not have the data to say how often the program makes a significant difference in a particular child's life, but across large numbers of children, a statistical difference is noticeable.

## What do they do?

The NFP model consists of having trained registered nurses visit low-income, first-time mothers – starting with weekly visits early in pregnancy, and progressing toward monthly visits until the child's second birthday – attempting to help with prenatal health (nutrition; reducing alcohol/tobacco/drug use during pregnancy; obtaining prenatal care), child care (creating a safe and supportive home environment), and personal life management (birth spacing as well as taking steps toward education and employment). A summary of topics covered, as well as frequency of visits, is available at the Home Visit Experience page on NFP's website. NFP's national office primarily provides a consulting (as opposed to funding) role, partnering with regional organizations in order to carry out its model. Attachment B-13 lays out the national office's activities, along with the associated 2007 expenses (which we cite below as a proportion of the organization's total expenses):
• Program development (19%): helping regional organizations raise funding.
• Nursing practice (12%): training and supporting participating nurses.
• Program quality support (28%): ongoing evaluation and consultation with regional programs.
• Federal policy & program finance (5%): advocacy for more government funding of programs on the NFP model.
• Other (37%): marketing, administrative and management costs; a small amount of direct funding for regional programs.
NFP notes that individuals or communities interested in learning more about the feasibility of starting NFP for families in your city should call NFP at 1-800-864-5226.

## Does it work?

The primary evidence for the NFP model's effectiveness consists of three different studies - each of which has been reported on several times - in which low-income mothers were (or were not) assigned nurses based on lottery, and then researchers followed both those who did and did not receive nurse visits, collecting a broad range of data. We find the evidence from these studies to provide a compelling case that the model in question - a model that NFP's national office exists specifically to replicate - likely improves later life outcomes for children, across a variety of regions and population profiles. A thorough literature review of home visitation programs (see Gomby 2005 Pg 2) points to NFP as a standout among such programs in terms of the methodological strength and encouraging implications of its studies.

### Formal studies of the NFP model

The first trial of the NFP model, in Elmira County, NY, followed families for 15 years after birth and found statistically significant effects on children's disciplinary records (though few differences in their reported behavior, such as sex and drug use) (Olds 1998 Pg 1241). The second, in Memphis, has so far published 3-, 6-, and 9-year follow-ups (and found the children of visited mothers with low economic and psychological resources to have superior scores on a variety of tests including vocabulary, arithmetic, and a mental processing composite at age 6 (Olds and Kitzman 2004 Pg 1554, 1556) and higher GPA and academic achievement at age 9 (Olds 2007 Pg 838). The third, in Denver, published the results of its 4-year follow-up in 2004, and found the children of visited mothers with low economic and psychological resources to have superior scores on a variety of tests including language and behavioral adaptation in testing (Olds, Robinson and Pettitt 2004 Pg 1565-1566). We compiled a summary of the main results in this table. Other studies of home-visit programs have found much weaker results; the hypothesis we have seen advanced in the literature is that NFP is distinctive partly for its insistence that registered nurses conduct the visits (Gomby 2005 Pg 40). The Denver study of NFP provides preliminary direct evidence for this, by not only comparing NFP to "no treatment," but also looking at an "in-between" option in which an NFP-like program was carried out by paraprofessionals rather than registered nurses (Olds, Robinson and Pettitt Pg 1563). While both appeared to have some positive effects on both mothers and children, paraprofessional effects were reported to be about half as large (Olds 2002 Pg 492-493). On one hand, it is important to emphasize that the effects found by these studies are often small in aggregate. In many cases, the studies look at many variables and find a few pointing strongly in the direction of the treated group, with the remaining variables showing no statistically significant differences. On the other hand, we feel it is impressive to see even these effects given the nature of the evaluations: examining the impact of a relatively low-intensity program, anywhere from 2 to 15 years after program ends, on a variety of different populations.

### Replication

There is reason for caution in extrapolating from the results of these studies to the expected impact of the NFP program as a whole; the question is how well regional programs, working with the national office's help, can replicate the most important aspects of the program. We cannot be fully confident about the quality of replication, but are cautiously optimistic for the following reasons:
• NFP's national office was established with direct involvement from David Olds, the lead researcher on all of the above studies, specifically to replicate the program under discussion (see NFP's website).
• The national office has clear, measurable criteria for adherence to the program, including the requirement that registered nurses carry out the program according to the (proprietary) NFP curriculum. (Unfortunately, Attachment B-14, which gives a good sense of these criteria, is currently confidential; a brief overview is available at this page on NFP's website.)
• The national office appears thorough in its data collection, although it unfortunately keeps much of this information confidential. We were sent a sample report (Attachment B-12, not cleared for public release) with both national aggregate data and data for an anonymous local agency on demographics; attrition; implementation (number and content of visits); and a broad range of outcomes (maternal smoking/alcohol consumption, life situation, measures of children's development, etc.) NFP has told us that a similar data set, at least at the national level, may be cleared for public release by September 2008; in the meantime, it has cleared Attachments B-17 and B-18 for public release, though these do not include as much data as the confidential Attachment B-12.
• As shown in the studies above, empirical evidence for the model's effectiveness holds across very different populations.

## Costs

NFP puts the cost of the program at a total of $10,000 per family, for the complete 2.4-year program (Attachment B-8). Its sample startup budget is around$500,000 per year for 100 families (this sample budget, Attachment B-15, is unfortunately not yet cleared for public release), which implies a total cost of about $12,000 for the full program. Note that most of these costs are paid by the individual agencies. The role of the national organization is to provide training, support, and oversight, and its costs are negligible next to regional costs: around$10 million (Attachment D-1) to serve the implementing agencies, which together serve 14,800 enrolled families as of 5/31/2008 (Attachment C-1 Pg 2).

## The Organization

Financials. The following data is from NFP's IRS Form 990s (available via the National Center for Charitable Statistics).
YearRevenues (in thousands)Expenses (in thousands)
2004$2,035$1,439
2005$5,562$3,162
2006$2,251$5,594
2007$12,797$6,840
200821,757$9,396 We tried to get an idea of the assets NFP holds by looking at their Form 990 for 2008 (PDF). On 9/30/2008 (the end of NFP's fiscal year), NFP held$18,812,508 in assets. This is reasonable in relation to that year's expenditures (\$9,396,000). For more, see our perspective on this financial metric. Board of directors. Half of NFP's 13-member board of directors come from high-level positions in the private sector. The remaining directors have a mix of academia, not-for-profit, and public sector backgrounds.

## Conclusions

The NFP model has been shown to positively affect the lives of participating mothers and their children in several rigorous studies, and grants to the national NFP organization are directed towards replicating this proven program. This organization stands out from any other we have examined, in any cause, for its clarity of strategy, commitment to replicating what is proven, and ability to continue learning about what works (both through ongoing randomized trials and through the data collected from all its sites). We would like to see NFP share more of its materials publicly, but we nonetheless strongly recommend it as a proven and scalable early childhood intervention.

### Elmira Trial

• Olds DL, Henderson CR Jr, Kitzman H. Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life? Pediatrics. 1994 Jan;93(1):89-98.
• Olds DL, Eckenrode J, Henderson CR Jr, Kitzman H, Powers J, Cole R, Sidora K, Morris P, Pettitt LM, Luckey D. Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA. 1997 Aug 27;278(8):637-43.
• Olds D, Henderson CR Jr, Cole R, Eckenrode J, Kitzman H, Luckey D, Pettitt L, Sidora K, Morris P, Powers J. Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA. 1998 Oct 14;280(14):1238-44. Available online.

### Memphis Trial

• Kitzman H, Olds DL, Henderson CR Jr, Hanks C, Cole R, Tatelbaum R, McConnochie KM, Sidora K, Luckey DW, Shaver D, Engelhardt K, James D, Barnard K. Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial. JAMA. 1997 Aug 27;278(8):644-52.
• Kitzman H, Olds DL, Sidora K, Henderson CR Jr, Hanks C, Cole R, Luckey DW, Bondy J, Cole K, Glazner J. Enduring effects of nurse home visitation on maternal life course: a 3-year follow-up of a randomized trial. JAMA. 2000 Apr 19;283(15):1983-9. Available online.
• Olds DL, Kitzman H, Cole R, Robinson J, Sidora K, Luckey DW, Henderson CR Jr, Hanks C, Bondy J, Holmberg J. Effects of nurse home-visiting on maternal life course and child development: age 6 follow-up results of a randomized trial. Pediatrics. 2004 Dec;114(6):1550-9. Available online.
• Olds DL, Kitzman H, Hanks C, Cole R, Anson E, Sidora-Arcoleo K, Luckey DW, Henderson CRJ, Holmberg J, Tutt RA, et al. Effects of nurse home visiting on maternal and child functioning: age-nine follow-up of a randomized trial. Pediatrics 2007;120(4):832-45. Available online.

### Denver Trial

• Olds DL, Robinson J, O'Brien R, Luckey DW, Pettitt LM, Henderson CR Jr, Ng RK, Sheff KL, Korfmacher J, Hiatt S, Talmi A. Home visiting by paraprofessionals and by nurses: a randomized, controlled trial. Pediatrics. 2002 Sep;110(3):486-96. Available online.
• Olds DL, Robinson J, Pettitt L, Luckey DW, Holmberg J, Ng RK, Isacks K, Sheff K, Henderson CR Jr. Effects of home visits by paraprofessionals and by nurses: age 4 follow-up results of a randomized trial. Pediatrics. 2004 Dec;114(6):1560-8. Available online.

### Misc.

• Gomby D. Home visitation 2005: outcomes for children and parents. Committee for Economic Development, Invest in Kids Working Group. 2005 Jul. Available online.

## Attachments

### A. Application and response

• Attachment B-1: Gomby 2005 Literature Review
• Attachment B-2: Kitzman 2000 Memphis Paper
• Attachment B-3: Kitzman 2003 Memphis Paper
• Attachment B-4: Olds 1998 Elmira Paper
• Attachment B-5: Olds 2002 Denver Paper
• Attachment B-6: Olds 2004 Denver Paper
• Attachment B-7: Olds 2007 Memphis Paper
• Attachment B-8: Cost-Benefit Analysis
• Attachment B-9: Data Collection and Reporting Summary (currently classified as confidential by NFP; may later be released)
• Attachment B-10: Brief History of NFP
• Attachment B-11: Numbers and Locations of Nurse Visits 2003 - 2007 (currently classified as confidential by NFP; may later be released)
• Attachment B-12: Sample Quarterly Nurse Visit Data Tables (currently classified as confidential by NFP; may later be released)
• Attachment B-13: National Office Program Descriptions and Budgets
• Attachment B-14: Example Implementing Agency Evaluation Report (currently classified as confidential by NFP; may later be released)
• Attachment B-15: 2008 Sample Budget for Implementing Agency (currently classified as confidential by NFP; may later be released)
• Attachment B-16: Description of Implementing Agency Costs (currently classified as confidential by NFP; may later be released)
• Attachment B-17: Sample Report I
• Attachment B-18: Sample Report II
• Attachment B-19: Public statement on NFP Curriculum