Improving Child and Family Well-Being in the Durham, North Carolina Community Universal Nurse Home Visiting: Maltreatment Prevention and More Jeannine Sato, Program Director NC Child Fatality Task Force Intentional Death Committee September 23, 2013 Contact Information: j.sato@duke.edu Historical Comparison of Maltreatment in Durham 1
The Rationale for Universal Home Visiting: A Model of Child Maltreatment Prevention Connect with Families Identify Family Strengths & Needs Support Families with Social and Medical Resources as Needed Child & Family Well-being Improved Reaching Families: Home Visiting Home visiting is a widespread early-intervention strategy for most industrialized nations other than the U.S. Free, voluntary, and embedded in a comprehensive child and maternal health system In the U.S., the most popular home visiting programs provide long-term, intensive services for high-risk, first-time mothers 2
Public Health Approach to Home Visiting: Durham Connects I. Connect with every mother (and father) at birth; assess unique family risks (and needs) II. Connect family with matched community resources based on identified risk III. So that parents can connect with their infant DURHAM CONNECTS OVERVIEW Target population All Durham County, NC residents Approximately 3,200 births eligible per year Voluntary completion of program is ~70% Staff characteristics Home visitors are RNs w/public health/child-mat exp. Home visiting MSW employed by DSS partner. Program support workers complete post-visit calls and assist with scheduling. Feedback loops between DC RNs, doctors and referral agencies. 3
Overview DURHAM CONNECTS OVERVIEW CONT. Recruitment & Scheduling In hospital, typically within 24 hours of birth Families missed in hospital contacted by phone Integrated Home Visit (~1-2 Hours) Conduct newborn and mother health assessments Conduct informal but systematic assessment of family strengths and needs (Family Support Matrix); motivational interviewing Standardized screeners for highest risk areas (DV, Sub, PPD) Provide direct intervention to all families through teachings Facilitate connections to matched community agencies for identified risk Overview DURHAM CONNECTS OVERVIEW Follow-Up Visits (0-2 Total) Follow-up visits or calls made as needed to conduct additional assessment and to ensure community connections Post-Visits Call (PVC) Calls made to families 4 weeks after case closure Ensure connects made to community resources Identify new concerns / needs for additional resources Track referral outcomes 4
THE DURHAM CONNECTS RISK ASSESSMENT MODEL Assessment is based in a family friendly, informal home visit that is congratulatory, supportive, educational, and individualized. Implemented with a manualized protocol for fidelity and reliability from nurse to nurse, visit to visit. 12 Empirically Derived Maltreatment Risk Factors In 4 Domains Health 1. Parent Health 2. Infant Health and Safety 3. Health Care Plans Care of Infant 4. Child Care Plans 5. Parent-Child Relationship 6. Management of Infant Crying 5
12 Empirically Derived Maltreatment Risk Factors In 4 Domains Safe Home 7. Household/Material Supports 8. Family & Community Violence 9. History of Parenting Difficulties Parent Support 10. Parent Well-Being 11. Substance Abuse 12. Parent Emotional Support Family Examples: Mother with 1 st baby born at term with many questions about breast feeding, pumping, food intake. Has set up child care. Mother, however, got teary eyed when describing difficult birth, initial Apgar of 1, cord round neck, meconium aspiration, resulting in important supportive counseling during visit. Needed postpartum appt. scheduled. Baby looked great, gaining weight. Family has no insurance or resources; referred to social worker. 1 st time mother, 19 yo with long history of depression, but did not want treatment, nurse educated about baby blues and resources, if desired. Grandmother seen as very supportive; referral to Healthy Families Durham accepted. 22 yo mother with very fussy baby- consultation about feeding and PURPLE crying. Planned follow up with primary care for mother with concerns about her blood pressure, which continues out of normal range. Mother of 2 nd baby, has services in place, has housing, high risk for depression, 4 days ago smoked weed, breast feeding, smokes cigarettes in house. History of fights in pregnancy, had to go to hospital when he broke her nose. Active CPS case. DC nurse will make an additional CPS report and try to facilitate mother referring herself to the Family Care Program. 6
Durham Connects RCT Durham Connects implemented as a randomized controlled trial study (RCT) Intent to treat design (Only 70% of intervention group actually received DC) 18-Month Trial (July 2009 - December 2010) All 4,777 Durham County births included Even Birth Date Families Durham Connects Eligible (n = 2,327) Odd Birth Date Families Received Services as Usual (n = 2,450) 7
Cummulative Emergency Episodes General Findings Parent satisfaction surveys 99% positive. Results at age 6 months: More community connections More positive parenting behaviors More father involvement Higher quality child care usage Less clinical anxiety for mother Results at age 12 months: 18% fewer ER visits (Control Mean=.83 ;DC Mean=.68) 85% fewer hospital overnights (Control Mean=.74 ;DC Mean=.11) Infant Emergency Medical Care 1.8 Mean Cumulative Number of Emergency Care Episodes Birth Age 12 Months 1.6 1.4 1.2 1 0.8 Control Families DC Families 0.6 0.4 0.2 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Infant Age in Months 8
RCT Medicaid Savings Estimated Health Care Costs for Medicaid / S-CHIP for Current Sample: All Families: (164 ER Visits * $423) + (150 Overnights * $3,722) = $69,372 + 558,300= $627,672 Control Families: (92 ER Visits * $423) + (139 Overnights * $3,722) = $38,916 + $517,358= $556,274 DC Families: (72 ER Visits * $423) + (11 Overnights * 3,722) = $30,456 + $40,942= $71,398 DC Reduced Medicaid/S-CHIP Spending on Emergency Care at Age 6-Months by 87.2% DC Reduced Private Insurance spending on Emergency Care at Age 6-Months by 56.2% Preliminary Evaluation Findings Return on Investment Cost-Benefit Analyses for Total Emergency Medical Care suggests $3.02 in savings for each $1.00 in cost For Durham County, $2,230,900 for DC would yield $6,737,318 in health care savings 9
Dissemination Northeast Connects - Race to the Top Early Learning Challenge Transformation Zone 4 year grant. Four rural NC counties: Beaufort, Bertie, Chowan and Hyde Capacity building began in 2011-12. NEC slated to launch 2014. Leadership: Duke University/The Center for Child & Family Health NC Division of Public Health NC Early Childhood Advisory Council National Implementation Research Network ECU Local county leaders. ACKNOWLEDGEMENTS Funding The Duke Endowment * Durham County * Oak Foundation Collaborations Center for Child and Family Policy, Duke University Kenneth Dodge Center for Child & Family Health Robert Murphy, Karen O Donnell, Paula Wright (Clinical Services Director) Durham Connects Nurses Durham County Health Department Sue Guptill, Gayle Harris, Hattie Wood Special thanks to all the new parents and their infants who welcomed us into their homes and taught us what they needed. 10