In this segment, Roxane White describes the mission of the Nurse-Family Partnership, which is to help transform the lives of vulnerable first-time moms and their babies. Roxane outlines how the organization creates a culture of success through mutual motivation. Through ongoing home visits from registered nurses, low-income, first-time moms receive the care and support they need to have a healthy pregnancy, provide responsible and competent care for their children, and become more economically self-sufficient.
The following is conversation between Roxane White, President and CEO of Nurse- Family Partnership, and Denver Frederick, host of The Business of Giving, on AM 970 The Answer in New York City.
Denver: Over the last several months, we’ve had on the show the CEOs of the organizations that rate charities–from Charity Navigator to GreatNonprofits. And if you visited their websites to check on how they rated the Nurse-Family Partnership, you would see that it’s been awarded the maximum number of plaudits and stars. And here to tell you why that is the case, is the President and CEO of the Nurse-Family Partnership, Roxane White. Good evening, Roxane, and welcome to The Business of Giving.
Roxane: Thank you so much. It’s delightful to be here!
Denver: Tell us about the Nurse-Family Partnership (NFP)–what the central mission and purposes of the organization are.
Roxane: Well, what we do is really pretty basic and simple in many ways. We work with moms who are low-income, and we go into the home before they deliver their baby. We help them deliver a healthy baby; we support the mom to raise a healthy child, and then we help Mom get back on track as well.
Denver: Let me ask you this: What compelled you to take the CEO job at the Nurse-Family Partnership? I know you’ve been a tireless advocate for fighting homelessness and supporting youth. Most recently, you served as the Chief of Staff for the governor of Colorado. What inspired you to take on this job?
Roxane: My first encounter with the Nurse-Family Partnership was when I was working with street kids. I had a young mom who was ready to get off the street, and she was becoming a mom. And I called Nurse-Family Partnership, and I was like: “Yeah, right. Nobody really wants a street kid.” And they took her! They helped her, and she turned her life around. The second time I was working in child welfare, and I was at an autopsy of a young person who had died. Family had failed: the foster family had failed; government, sure as Hell, can’t raise kids. So, I was asking our staff, “What can we do?” They said, “There’s a program that can reduce child abuse by over 48% and has a track record of doing that.” And we started working with Nurse-Family Partnership and got much better outcomes for families.
And then when I was Chief of Staff for the governor of Colorado, we were looking at what the heck do we do about Medicaid costs that were completely out of control! And we brought in Nurse-Family Partnership as a way to reduce the cost to taxpayers of delivering unhealthy babies.
Denver: They made quite an impression on you. Let’s walk through the process a little bit. Give us a picture of the typical mother you serve–her age, education, race, marital status– things like that.
Roxane: All of our moms are low-income, and all of our moms are at risk for a high-risk pregnancy. So they’re identified by their docs, by pregnancy testing places, by community advocates who say: “Hey, we got a mom here that’s going to deliver a baby.” Often, they are young moms; they may be teen moms. We don’t take any moms generally under the age of 14–but from 14 until about 30. There are moms who are at risk of having a baby born into the ICU unit, a baby being born unhealthy, a mom who’s not prepared to be a mom. So, our most vulnerable moms are the most expensive moms in terms of that delivery. And then we go into the home, and we start working with her. We’re in the home at least every other week, if not more often before she delivers the baby, to help her deliver a baby on time, at a healthy birth weight.
Denver: Let me pick up on that teen mom issue– that has always been a big question. Are we making any progress in this country, Roxanne, in getting teen mom birth rates down?
Roxane: We are making huge progress in this country. And one of the things we know is most important when we are working with these moms– is to delay the next birth. Because we know that what we need to help moms do.. is to develop assets. We’ve got to get them back to school; we gotta get them back to work. And so, not only are we making progress in people not having babies… and getting through school… and getting a job before they have a baby… But when these moms have had a first baby, we’re helping them delay the second baby– which has everything to do with their future, and the child’s future.
Denver: Well, let’s talk about these visits. When do they begin? I know they last until the child turns two years old.
Roxane: We have to be in the home by 28 weeks of pregnancy…
Roxane: …in order to help make certain that we have a healthy baby born. We can have a mom come in earlier than that. Then we work with the mom up until the baby is two-and-a-half years old…with plenty of time to help Mom get career education, school, job back on track, help her find good quality, early childhood education. And then to really attach to that child and learn how to be a good mom. Some moms don’t know how to read to their children and do it in an interactive way… that really does the most for brain development, for example. Moms will see things going wrong with their kids and not understand what’s happening. That’s when we have a nurse who helps look at things like: Do we need to have this child screened for autism? Do we have a developmental issue, or do we have a parenting challenge?
Denver: Do families generally get assigned one nurse? Or, are those nurses rotated in and out with the family?
Roxane: It’s generally one mom and one nurse. But each nurse has 25 moms that she works with at any point in time. Unless that nurse says: “You know what? You need a nurse that has a particular specialty.” So, in the case of a Down Syndrome baby, or an autism baby, or a mom that has been using heroin… We might bring in another nurse with more specialty in that area. But we really try to keep that consistent nurse, so that the family develops trust, and she also sees what’s happening over time.
Denver: That makes an awful lot of sense. Are fathers ever in the picture? Are they around? Or, is this pretty much strictly a relationship between the nurse, the mom and her baby?
Roxane: We absolutely work with fathers, but we don’t have the ability oftentimes to have those fathers in the scene and present. So, one of the things we do is help Mom try to identify the father, reconnect with the father… and see if there are any resources that are safe and helpful there.
Denver: I would imagine that if a registered nurse was coming to my house for two and a half years or so… every two weeks, I would grow pretty accustomed to that and look forward to it. How is it when that relationship ends? I mean, it can be a sweet sorrow as they move on. How is the adjustment… for one and all?
Roxane: Towards the last year and a half, we’re only in the home once a month, or we decrease the amount of visits. Moms know that it is going to end. And generally what we’re trying to do, is get moms to make a referral of a friend, so that they feel like they have done something really successful. We also have graduations. For many of our moms, it’s the first time they will have graduated for something.
Denver: That’s great.
Roxane: And it’s fascinating to watch them put NFP Graduate on a resume, because they’ve accomplished something. And what we say to them is: “We want this to be your first graduation… if it’s your first graduation… but you’re gonna do more graduations!”
Denver: For sure! I know that one of your guiding principles is to create positive change for both generations–for the mom and the baby. Are you unique in this regard? How do you go about trying to maintain that balance?
Roxane: It’s amazing… because Dr. David Olds– who founded the program– has been studying these moms and babies now for more than 40 years to see: What is the long-term impact? Can you really get two-generation change? And one of the things he’s found is that: 18 years after we have been in the home–only with this intervention–the moms are 72% less likely to have been arrested.
Denver: That’s a nice number.
Roxane: Well, that’s because mom went back to work.
Roxane: Right? That’s because Mom went to school; that’s because Mom developed some assets. So, she sees a different pathway out. We have immediate results for our young people, including a 59% reduction in arrests when the child is aged 15. Again, long-term outcomes! And what do we know about arrests? We know that it’s related to: Was the child able to succeed in school? Were they able to read by third grade? We have significant outcomes every step along the way. But it’s really fascinating to see that you really can change moms– and her pathway– and you can change the kid’s pathway.
… because Dr. David Olds– who founded the program– has been studying these moms and babies now for more than 40 years to see: What is the long-term impact? Can you really get two-generation change? And one of the things he’s found is that: 18 years after we have been in the home–only with this intervention–the moms are 72% less likely to have been arrested.
Denver: And, actually, I think they help one another. You talked about something called mutual motivation. What is that?
Roxane: It really is that you start to create a culture of success. We see parents who have their children back in early childhood education and understand that there’s a difference between just leaving the child with… whomever you’re gonna leave them with… and early childhood education. And we see the parents start to understand that as well: There’s a difference between a job and a career track. Doing that parallel process with mom and baby…particularly for our younger moms that may have never had that conversation before in their lives…
Denver: It’s interesting, as the baby does better, the mom will do better. And as the mom does better, the baby will do better.
Roxane: There are families where we have a tough starting conversation… No mom has a child that she hopes ends up in prison. But we have conversations with Mom that if something doesn’t change, it doesn’t look good for her child and her unborn baby.
Denver: Honest conversations.
Roxane: Honest conversations. Real conversations, and “we can change that with you… if you want to. And we can change the prognosis for you and for your baby. It’s gonna take a hell of a lot of hard work, but we’re gonna help you do that work.”
Denver: I know the cost of the program is going to vary depending on what part of the country you’re in. But by and large, on average, what is the cost of a program for a nurse visiting a family for 64 visits or so, over the course of two and a half years?
Roxane: It’s around $9,000 over the course of two years. What’s important to understand about that is that the RAND Corporation has found that for every dollar invested, there’s an average return to the taxpayers of $5.60. Ted Miller just did a follow-up study on that– looking at just the cost in Medicaid, and in health care, and to assess taxpayers– and it was over $6.60.
Denver: That’s fantastic! And I know it is sometimes suggested that you could get this cost down a bit if you did not use registered nurses. But you believe that they are worth their weight in gold. Why is that the case?
Roxane: I’m not a nurse; let me start there and explain to you: I’m a social worker and a minister in my background. So, I’m in the home with the mom, and there’s a baby that has burned its hand. And the nurse is looking at the burn… and the mom’s explanation for the burn…and it’s starting to make some sense. And it looks like it was accident; the baby grabbed a really hot curling iron. But the nurse is able to look at the hand, due some triage with Mom, and we avoid an emergency room visit.
In another example, I’m in a home with the mom that has clearly relapsed and is using substances again. And as a social worker, I’m thinking: “Oh crud, we’re gonna have to get Child Protective Services involved. We’re going to have to do these things. Mom keeps saying she hasn’t relapsed.” The nurse says to the mom: “Let me take your vitals.” She takes the vitals for the mom and then she says: “Honey, your eyes are dilated; your heart’s racing. I know you’re saying nothing’s going on, but your body says something’s going on.” And at the end of the visit, we have mom cooperating with child welfare; we have everybody involved. We have a safe baby, and we have mom headed back the way she needs to … because the nurse used her medical knowledge to help the mom. Because pre-term birth babies born into ICU are skyrocketing, as are the Medicaid costs in this country, and their overall healthcare costs in this country. Nurses are critical for delivering a healthy baby, avoiding emergency rooms, helping Mom know what to do to get to a full-term pregnancy.
Real conversations, and “we can change that with you… if you want to. And we can change the prognosis for you and for your baby. It’s gonna take a hell of a lot of hard work, but we’re gonna help you do that work.
Denver: Interesting! You touched on this before, Roxanne, but the Nurse-Family Partnership–you’re the gold standard, you’re the royalty when it comes to having an evidence-based community health program… How did this get baked into the DNA of NFP?
Roxane: So the founder Dr. David Olds did not go out into the community with this program until he had studied it for more than 20 years in terms of outcomes. And so it is only after really looking at comparison populations in a community…controlling for everything else that was happening in a community…Did Nurse-Family Partnership make the difference in terms of the baby’s future and the mom’s future? And only after he was able to prove that it did over time, did he bring the model into the field.
Denver: You’ve touched on a couple of the outcomes already, Roxanne… Give us a few more of the results you’ve been able to get with this program.
Roxane: A 56% reduction in emergency room visits. Now, think about that for a minute. I worked for a time in government, and I was really tired of government funding things that didn’t work and our dollars being wasted, right? 72% fewer convictions of moms later…as I talked about. An immediate 11% reduction in moms’ use of public assistance within a year.
Denver: Instant payback!
Roxane: Instant payback.
Denver: That’s great. When you look at the number of new moms who are at high risk in this country right now, what percentage of them are getting the benefit of a home-visiting program?
Roxane: Well, we are in 43 states and about 33,000 families’ homes each day. We know we could go to 100,000– and really start to meet the needs of taxpayers and meet the needs of families.
Denver: So there’s a lot more work to be done...
Roxane: There’s more work to be done.
Denver: That’s the tip of the iceberg. Tell us about the fundings…I know that there’s been a $ 1.5 Billion dollar fund that has been established called the Maternal Infant And Early Childhood Home Visiting Program. Tell us about that.
Roxane: So, this is actually one of those times when government really worked for us as taxpayers. It was the first time that the government established that the only programs that would be funded were evidence-based programs. And if you couldn’t prove your outcomes, it didn’t matter how much we liked your name, or how much we thought it was a “feel good” program. There’s no “feel good” in these programs as a starting base; it’s evidence-based. And so that has allowed more families to be served across the country.
There are several home visitation programs. We are the one that works specifically with the highest risk babies, with nurses in the homes. And there are other programs that work more on education and other aspects. So, we try to get the right program into the right family at the right time.
Denver: Fantastic! Picking up on that notion, NFP announced a landmark “Pay for Success” project in South Carolina. Tell us what Pay for Success is… and about the partnership that you have formed with Governor Nikki Haley in the state of South Carolina.
Roxane: So Governor Haley is a leading governor in terms of outcomes and paying for outcomes. What she established was “Pay for Success.” So if we are not successful in South Carolina, government doesn’t pay us. Novel concept, right? Can we all say “Amen!”
It was the first time that the government established that the only programs that would be funded were evidence-based programs. And if you couldn’t prove your outcomes, it didn’t matter how much we liked your name, or how much we thought it was a “feel good” program. There’s no “feel good” in these programs as a starting base; it’s evidence-based.
Roxane: And so it has allowed us to expand to more than 3,000 new moms, and make certain that a very rigorous evaluation is done with those moms…vs. moms who are not in the program in South Carolina. Then the government will only pay, over the course of the time, as outcomes are proven.
Denver: You really believe in Pay for Success outcomes and that government should pay for those kinds of programs. Why is that the case?
Roxane: Whether you call it “Pay for Success,” or whether you call it “good government” or you call it “outcomes in government,” my experience running a human service department, and as Chief of Staff for a governor, is that oftentimes nonprofits and other for-profit entities have really good advocates. As a result, things that get funded are not always outcome-focused; they’re not always changing things in our community. And I believe we should invest in things where we, as taxpayers, get a return on our money that is long-term change.
Denver: Tough to close down programs for some reason, even though they should be closed down. I was speaking to Jacob Harold, the CEO of Guidestar, and he was saying that the dirty little secret here in the nonprofit sector is that actually some nonprofits are better than other nonprofits… And I think there’s a sense in this country that they’re all deserving because they’re trying to do good work and try to help people. But the fact of the matter is, some are a lot more deserving than others. I think the sooner people realize that, I think the more we’re going to get for our charitable and our government tax dollar.
Roxane: I completely agree with you, and I think it is the challenge that will help us establish confidence again that our government is doing the right thing.
Denver: Very good. We love to close with a story on The Business of Giving, and you have thousands and thousands of them. So give us one of a mom and her baby who really benefited from the Nurse-Family Partnership.
Roxane: So I’ll tell you a story of this amazing young woman, Oyuni. And Oyuni started out life pretty tough. She came from a background that didn’t help her in terms of her own skill set and development. She was living on the streets– as is happening across the country with so many of our young people–she started using heroin. And we all know heroin is a pretty addictive drug, and so, she was on the streets when she found herself pregnant. She’d already made a decision that she was going to have a baby. And fortunately she started looking for some support and assistance, and she connected to Nurse-Family Partnership and got a referral to us.
The nurse started working with her. Often we still work with moms who are in shelters or living on the streets, or our nurses in some communities are out under bridges. So wherever these moms are…we connected with her. She started understanding things like reading to the baby in the womb–which doesn’t sound like a big thing to a lot of people. But what are we doing there? We’re helping Mom develop focus; we’re helping mom think about her own reading skills. And then we’re helping her have quiet downtime and think about the baby she’s about to deliver.
And I believe we should invest in things where we, as taxpayers, get a return on our money that is long-term change.
Roxane: After she delivered the baby, she had some pretty severe depression. A key time for a former addict to relapse, right? Because, what do we know happens with things like depression… is that one of the places to go… is to go back to…
Denver: Where you were, yeah.
Roxane: …the substance abuse. So we continue to work with her there. She ended up breastfeeding her baby; she got support around her depression. What she says over and over is, she didn’t feel judged by the nurse. And that is a critical point– it’s different to tell a nurse that you’ve been a heroin addict than it is to tell a social worker. A nurse addresses it from a medical perspective. Our nurse just didn’t give up, and kept going into the home, working with her… When needed, they called Child Protective Services together and said she needed to get back into treatment; we need to get the baby safe. They worked on plans– instead of having this baby end up in child welfare… again very, very expensive long-term… helping the mom get back to work…having a career path. And she now has a two-year-old son and is doing quite well. And if you want to hear her entire story, it is on Story Corps.
Denver: Fantastic! Well for people to learn more about the work of NFP, or to financially support the work you do— so you can go visit more moms and babies– where do they go? And what will they find?
Roxane: So we’d be delighted to have people join us by going to givetonfp.org. Pretty simple: givetonfp.org. There you can help us turn around a mom and a baby’s life and invest in something where there will be real results.
Denver: Well, Roxanne White, the president and CEO of the Nurse-Family Partnership– Thank you for coming by this evening. An ounce of prevention is truly worth a pound of cure, maybe more. And the Nurse-Family Partnership has the scales to prove it! It was a real pleasure having you on the show, Roxanne.
Roxane: A delight! Thank you so much.
The Business of Giving can be heard every Sunday evening between 6 and 7 PM Eastern on AM 970 The Answer in New York and on I Heart Radio. You can follow us at bizofgive on twitter and at facebook.com/businessofgiving.