INTRODUCTION TO THE MODEL: CONSIDERATIONS FOR DISSEMINATION

INTRODUCTION TO THE MODEL: CONSIDERATIONS FOR DISSEMINATION

Thank you for your interest in the Family Connects nurse home visiting program. We provide here a brief description of the program background and our approach to dissemination. Please review the description with your community collaborators. If there is interest and funding available for implementing and sustaining the program as well as training and certification as Family Connects, please contact us. We will discuss together what is needed in your community to address your local goals, funding, and timeline. Family Connects parents say: We were referred to Family Connects by our pediatrician We love our nurse, she was very friendly. She provided support, listened, and gave suggestions. She was very knowledgeable and came with resources and she was a phone call away. Family Connects is a wonderful program for anyone. [The visit] was a lot more personal you are more comfortable [in your own home] and you feel like you can ask any sort of question, which is different than when you re in a clinical setting. Family Connects is such an important service to our community. Reaching out to new parents, especially first-time moms and their babies, is like providing a lifeline in some cases to feel supported and not alone in the community. Contacts: Karen O Donnell, Ph.D., kod@duke.edu, Co-Director, Family Connects, CCFH Ben Goodman, Ph.D., ben.goodman@duke.edu, Co-Director, Family Connects, CCFP Ashley Alvord, MPH, ashley.alvord@duke.edu, Training and Dissemination Specialist Jeff Quinn, MPH, jquinn@duke.edu, Director of Community Outreach Center for Child and Family Health (CCFH) and Center for Child and Family Policy (CCFP) Duke University, Durham, North Carolina 2015 Family Connects July 2015 Family Connects Introduction 2

I. THE FAMILY CONNECTS PROGRAM Introduction Family Connects is a model for a community-based program to support new parents in caring for their newborn(s), to offer physical assessments of the mother and the baby, to address questions about caring for the newborn, to discuss parents needs at this happy and vulnerable time, and to help them access community services or resources that match their needs. Family Connects also works to identify family resources that are critical but not available in the community, with the goal of working toward increasing needed services locally. The aim of the Family Connects home visit is to engage with the family and, with the family, to celebrate the new arrival. We acknowledge that caring for a newborn can be a joyful but also challenging job involving parents losing sleep, having unanswered questions about their own health or that of the baby, and needing support for their new role. We know that each community has both formal and informal services and resources that a parent may not know about or may not know how to contact. We use the Family Connects program to connect to the family and to link family members to resources that support this period of new parenting. Program Background and Logic Model The Family Connects model was developed within the context of the Durham Family Initiative, funded by the Duke Endowment in 2002, with the primary goal of reducing community rates of child maltreatment (K. Dodge, Principle Investigator). The program centers on a theory-driven and evidence-based assessment of child and family strengths and needs, provided in an informal and family-friendly manner. The community-wide Family Connects approach is designed as an addition to or alternative to two- and threeyear long home visiting programs targeting families with specific risk factors. The universal approach is critical to promoting child and family well-being as a means of facilitating community-wide change. The goal of universal, rather than targeted, engagement is that a high percentage of participating families is essential for the program to be successful in promoting community level change. The underlying assumption is that all families with newborns need support, education, recommendations, and access to community services and resources. Family Connects has a rigorous approach to the evaluation of program performance, fidelity to the home visit protocol, community penetration, and benefits for family recipients. July 2015 Family Connects Introduction 3

The logic model below (see Figure 1) depicts the Family Connects theory of change for infants and families. Nurse home visits and assessments facilitate increased connections to matched community resources and services. Increased connections to the community, in turn, promote family functioning child and family well-being over time. Figure 1. The Family Connects Logic Model Family Assessment The program is linked to a high inference assessment of family strengths, risks, and needs. The nurse visitor engages with the family in a friendly and supportive dialogue while assessing and rating 12 factors within four domains (see Figure 2). These factors are known to be associated with maternal and child health and well-being and, when identified, provide opportunities for prevention and intervention. The Family Support Matrix is the tool used to addresses family health needs, childcare and the parent-child relationship, household needs and safety, and parenting support. The home visitor rates each of the 12 factors as: (1) no risk/needs at this time, supportive guidance provided; July 2015 Family Connects Introduction 4

(2) needs and concerns addressed by education and demonstration during visit; (3) family issues best addressed by linkage with community resources; and (4) urgent need(s) requiring immediate intervention. Figure 2. Domains and Factors in the Family Support Matrix Assessment Support for Health Care Factor 1-Maternal Health Factor 2-Infant Health Factor 3-Health Care Plans Support for Caring for the Infant Factor 4-Child Care Plans Factor 5-Parent and Child Relationship Factor 6-Management of Infant Crying Support for a Safe Home Factor 7-Household Safety/Material Supports Factor 8-Family and Community Safety Factor 9-History with Parenting Difficulties Support for Parents Factor 10-Maternal Wellbeing Factor 11-Substance Abuse Factor 12-Maternal Emotional Support July 2015 Family Connects Introduction 5

Each of the twelve factors comes with a set of queries for the visiting nurse to use during the assessment, as needed, and supportive guidance to deliver for each domain/factor (see Figure 3 for example). Figure 3. Example of a Factor with Queries and Supportive Guidance Factor 4. Goal for Child Care Plans Parent has a plan for child care, including emergencies, respite care, and day care as needed. Queries Who helps you take care of (baby s name) now? Over the next year what are your plans for work or school? Supportive Guidance: 4.1 Having a plan about what to do when something comes up last minute is important. Having some of these details worked out as preventative measures will relieve your stress when the unexpected happens. Over the next year what are your plans for child care? If you needed a babysitter now, is there anyone you trust to take care of him/her? What if you had an emergency and had to leave your home to go to the doctor or something, is there someone you would call on to take care of the baby? (If not, try to help make a plan for such emergencies.) If you just needed to get away, such as go to the grocery store alone for a change, is there someone else you feel good about leaving your baby with? II. CRITICAL COMPONENTS OF THE FAMILY CONNECTS PROGRAM The Family Connects approach has a number of program components, some of which are essential for communities to replicate the model. The key components are listed and described below as those needed for implementation to be distinguished those activities that may be selected as auxiliary to the program. These critical components are necessary for replicating the model as an evidence-based program derived from the evaluation studies of Durham Connects, the Family Connects model in Durham, North Carolina. Other program components may be included in dissemination locations as important options, auxiliary resources, or those that address specific local needs. Critical (essential) components for the Family Connects model with comments from the Durham, North Carolina experience: The Family Connects program is community-based with community ownership, and it is seen as part of the continuum of care for newborns and their parents in the community. July 2015 Family Connects Introduction 6

Lessons Learned: Family Connects in Durham The original project in Durham was developed by Duke University s Center for Child and Family Policy, the Center for Child & Family Health, and the Durham County Department of Public Health in collaboration with community leaders: Durham s Department of Social Services, the Durham County Commissioners, and the Duke University Medical Center, Departments of Obstetrics and Pediatrics. These community leaders signed a memorandum of agreement to align community resources with identified birth-family needs. The program became a part of the local system of care in close liaison with birthing hospitals and pediatric primary care, and all families of Durham County resident newborns are entitled to the program. Family Connects home visitors are Registered Nurses, providing health and psychosocial assessments of newborn, mother, and family. Nurse visitors are trained to provide systematic education in response to parent queries and nurse observation in areas of possible difficulties in adapting to the newborn (e.g., breastfeeding, support for baby blues, and others). The program is designed for universal community coverage in order to promote community-wide change for families. All families with newborns in a catchment area are eligible, whether region, state, city, or neighborhood. Lessons Learned: Universal Implementation By providing funds for community implementation of evidence-based home visiting programs, the Patient Protection and Affordable Care Act of 2010 heightened the need for programs implemented at scale in community settings. Although evidence supports the positive impact of home visiting programs targeted to high-risk groups, when these programs are implemented with small study samples, scaling up of the programs can result in declined participation and retention rates, decreased implementation fidelity, and demands for adequate community resources that exceed community capacity. Family Connects is a short-term, universal, and relatively inexpensive postnatal nurse home visiting program designed to provide brief child health and parenting assessment and intervention and connections with community resources based on individualized assessments of family needs. This brief universal program addresses many family needs that would not necessarily be identified by a program that targets demographic risk factors only. All families need support at this vulnerable time, but not all families need the two to three years of weekly services. During the initial randomized controlled trial of Family Connects in Durham program, 94% of families seen were assessed to have one or more needs for specific education, July 2015 Family Connects Introduction 7

recommendations, or community services. All families benefit from the supportive guidance provided by Family Connects nurses. The Integrated Home Visit includes a systematic assessment (Family Support Matrix) of family strengths, risks, and needs. Anticipatory and supportive guidance for families are spelled out in the protocol and provided by home visitors at all visits (e.g., back-to-sleep, the benefits of tummy time). The family and nurse plan together for individualized connections to and recommendations for community resources and services. As indicated clinically, the initial home visit can have one or more follow up visits/telephone calls to complete the assessments, allow for more direct intervention, and to ensure linkage to local services and resources. The goal of follow up is to support the community resource linkage but not to become case management. In addition to the clinical follow up, a brief contact by phone or mailed survey is made regarding client satisfaction and successful linkage to referrals at one month after the case is closed. Available community resources are compiled in a web based format and/or printed directory and updated regularly. Regular review should include understanding capacity and accessibility of community resources and identifying gaps in services. Lessons Learned: Community Services for Those Who Need Them The Family Connects model does not replace more intensive two- and three-year home visiting programs for those families that need and choose them, such as Healthy Families America and Nurse Family Partnership. Rather, the short-term home visits serve as a universal screening and triage approach to ensure optimal matching and follow-through of families with other community services. In this way, families have access to what they need and to the programs and services to which they agree. Only families with identified needs for more intense and more expensive programs receive them, resulting in cost efficient programming and service utilization for the community as a whole. A direct link between Family Connects and the local Department of Social Services is essential to facilitate the family s access to and knowledge about eligible benefits, such as Medicaid eligibility, SNAP benefits (food stamps), and others. Systematic quality assurance includes: home visit protocol adherence, accurate assessment of family risks and needs, inter-rater reliability in rating the Family Support July 2015 Family Connects Introduction 8

Matrix, successful connections with needed resources in the community, and consumer satisfaction. Documentation of the home visit(s) and contacts with families and community services related to family needs in an electronic medical record is required for the medical record and for performance and outcome reports. The clinical team has weekly individual supervision from the Nursing Director and/or team meetings for peer review. Optional or auxiliary components recommended and may include: Scheduling the initial home visit at the birth hospital(s) is the preferred method in order to accomplish universal service delivery. Other options may have to be explored for differences in hospitals and communities. In a community with few formal resources, identifying informal resources by examining local standards of care through interviews of clients and stakeholders may be helpful. Referrals to these resources should be documented with outcomes reported back to agencies to strengthen community systems. A Community Advisory Board that includes consumers and community resources/stakeholders is strongly advised. Electronic documentation of 1) program penetration of the targeted community and 2) child and family outcomes, can be used to assist with marketing the program, creating a locally sustainable model, and fundraising. Lessons Learned: Evaluation of Family Connects in Durham Family Connects in Durham was piloted at the population level prior to evaluation by a randomized controlled trial (RCT) (1 July 2009 31 December 2010). Findings from the RCT are found in journal articles referenced in Appendix B. Any Family Connects program will develop its own approach to formative and summative evaluation, both of which are needed for ongoing and sustainable quality improvement. Using administrative and/or individually collected data about child and family outcomes may also assist in claiming funding for local program sustainability. For the 18 month trial, Dodge and colleagues (2013) reported a community participation rate of 69% for families of eligible newborns, and nurses maintained an average of 84% fidelity to the Family Connects home visit protocol. By age 6 months, those eligible for the program had more family community connections, July 2015 Family Connects Introduction 9

better positive parenting behavior, lower rates of maternal anxiety, higher quality home environments, and decreased emergency medical care for the infants, which resulted in estimated healthcare savings of $3.02 for every $1.00 in program costs. The evaluation of Family Connects in Durham at infant age 12 and 24 months indicated continued cost avoidance for child emergency care (i.e., emergency department, urgent care, inpatient hospitalization). Summary of Program Steps There are several connecting steps, involved in Family Connects; they are: 1) A nurse visitor, program support worker, or member of the hospital staff visits all new parents in the hospital after delivery to describe the program and to schedule an initial home visit with a Family Connects nurse. All residents in the program service area are eligible. Any community may explore alternate and combined methods for scheduling the home visit, including scheduling over the phone, a website for selfreferral, working with medical care practices, and advertising. 2) The nurse home visitor conducts the initial home visit, referred to here as the Integrated Home Visit (IHV). The visit is designed for the home visiting nurse to make a connection with the family, assess health and psychosocial wellbeing, respond to a range of questions about postpartum and newborn care, and plan for connections in the community to provide support for the family. 3) One or two follow up home visits or telephone contacts for families are scheduled, as needed, to provide further education, assessment, and/or to help secure family connections to community resources and supports identified during the initial visit. 4) Nurse visitors make appropriate contacts as needed to link the family to community organizations. At times, the work involves researching what is available in the community for a specific family need. 5) A follow up telephone call (the Post-Visit Connection, or PVC) is completed one month after the nurse closes the case. A staff member discusses the visit with the parent and evaluates the success of referrals to community services as well as consumer satisfaction. If the client cannot be reached by phone, a written survey may be sent by mail. 6) The information gathered from the PVC will provide the program with information about the effectiveness of the visit and the referrals that were made. In addition, gaps in services are identified and enable the program to provide feedback to community partners. July 2015 Family Connects Introduction 10

The overall goal of Family Connects is to provide high-quality home visits with connection to community resources, thus promoting community-level change for families and children by increasing the community s capacity to meet their needs. III. THE ROLE OF FIDELITY AND QUALITY ASSURANCE Family Connects aims to be a universal home visiting program for all newborns in a designated geographic area and to be disseminated to other cities and other states. In order to continue to show implementation success and outcomes effectiveness, it is important that all clinical providers participate in monthly or quarterly assessments of adherence to the home visit protocol and the testing inter-rater reliability on rating on the Family Support Matrix. Fidelity to the protocol is assessed by dyadic visits during which a supervisor (or peer) participates by checking off critical items required for the IHV (using a Fidelity Checklist). The goal is at least 75% adherence to the visit protocol, which provides information about percentage of adherence and also a forum for learning and growth in conducting the visit. We have learned that peer feedback and recommendations are very helpful in creating a culture of openness and competency. After the visit, both visitors complete the Family Support Matrix, and inter-rater agreement is calculated. As a part of quality assurance, there are quarterly audits of important protocol items, for example, information required for Medicaid billing. IV. DISSEMINATION AND REPLICATION OF THE EVIDENCE-BASED MODEL Family Connects dissemination follows the training models in use at the Center for Child & Family Heath in Durham, North Carolina, including Learning Communities, Learning Collaboratives, and/or a cascading model of implementation of the evidence-based protocol. Recipients will receive a range of input from the Durham-based team, depending on community readiness and needs. All critical components of the Family Connects model must be incorporated into the new site in order to be considered a Family Connects (evidence-based) program. Additionally, in securing funding for Family Connects program implementation, consideration should be given to costs associated with the initial training, consultation, and travel required to replicate the model and to sustain the services. The Learning and Mentoring Model for Family Connects Dissemination An extensive body of implementation research emphasizes that the best results for disseminating evidence-based practices are achieved when several key elements are included: 1) interactive learning sessions; 2) action periods between learning sessions for guided learning and practice of new skills; 3) consistent use of a manual for intervention, case-based consultation, mentoring, performance and fidelity monitoring; and 4) leadership and July 2015 Family Connects Introduction 11

organizational support for the new practice. In a Learning and Mentoring model (O Donnell et al., 2012; Chamberlin et al., 2012; Chamberlin et al., 2008), the cascading knowledge and mentoring from external experts to local experts has several benefits for programs adopting the evidence-based practice. For Family Connects, advantages of this dissemination model include: Preserves best practices as the Family Connects model reaches larger audiences; Limits the need for external experts to conduct larger-scale local training sessions, systematically replacing external experts with local leadership; Promotes local ownership and expertise toward sustainability; Provides a monitoring structure for new programs to adopt standards to be certified as a Family Connects program; and Continues support for ongoing certification as a Family Connects evidence based program. An effective dissemination involves a flexible and iterative process with didactic sessions, collaborative learning activities, and mentored action periods described briefly below. Summary of Implementation Steps Step 1: Readiness Assessment Assist the local program in assessing current staffing, the local organization, and community readiness. The results of initial conference calls and written queries help build a model for community needs and a preliminary budget. Step 2: Program Installation Train in model development and implementation and set up database for program documentation and reporting. Step 3: Initial Implementation Action period by local providers implementing the Family Connects model. Nurses receive local supervision on all home visits, to include fidelity and reliability checks. This period includes regularly scheduled communication with the Durhambased team. Step 4: On-site Assessment and Certification Observation and review by the Durham team will be scheduled following the Initial Implementation period. Step 5: Full Operation The program enters the second action period, including regular consultation with the Durham team. Full data collection and reporting should be in place for review by the Durham team. Step 6: On-site Review Following 6-12 months of full operation, with timing determined by the Durham and local teams, an on site audit will occur. July 2015 Family Connects Introduction 12

Continuing yearly audits: Consultation will occur regularly to confirm the adherent implementation of the Family Connects model and to assess all critical program components. Each third year, there will be an on-site audit for continued certification. V. REFERENCES Alonso-Marsden, S., Dodge, K.A., O Donnell, K.J., Murphy, R.A., Sato, J.M., & Christopoulos, C. (2013). Family risk as a predictor of initial engagement and follow-through in a universal nurse home visiting program to prevent child maltreatment. Child Abuse & Neglect, 37, 555-565. Chamberlain, P., Price, J., Reid, J., & Landsverk, J. (2008). Cascading implementation of a foster and kinship parent intervention. Child Welfare, 87(5), 27-48. Chamberlain, P., Roberts, R., Jones, H., Marsenich, L., Sosna, T., & Price, J. M. (2012). Three collaborative models for scaling up evidence-based practices. Administration and Policy in Mental Health, 39(4), 278-90. Dodge, K.A., Goodman, W.B., Murphy, R.A., O Donnell, K., Sato, J., & Guptill, S. (2013). Implementation and randomized controlled trial evaluation of universal postnatal nurse home visiting. American Journal of Public Health. Available online at: http://ajph.aphapublications.org/doi/pdf/10.2105/ajph.2013.301361 Dodge, K.A., Goodman, W.B., Murphy, R.A., O Donnell, K., & Sato, J. (2013). Randomized controlled trial evaluation of universal postnatal nurse home visiting: Impacts on child emergency medical care at age 12-months [Special Issue]. Pediatrics, 132, S140-S146. Available online at http://pediatrics.aappublications.org/content/132/supplement_2/s140.long Dodge, K.A., Goodman, W.B., Murphy, R.A., O Donnell, K., Sato, J. (2013). Toward population impact from home visiting. Zero to Three, 33, 17-23. O Donnell, K., Nyangara, F., Murphy, R., Cannon, M., & Nyberg, B. (2008, Revised 2014). Child Status Index Manual. Chapel Hill, NC: Measure Evaluation. July 2015 Family Connects Introduction 13