Nurse-Family Partnership (NFP)

In a nutshell:

What do they do? The Nurse Family Partnership supports programs offering home visits (from trained registered nurses) to low-income, first-time mothers. Nurses advise the mothers on prenatal health, child care, and personal life management (including birth spacing and employment counseling).

Does it work? Yes. 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.

What do you get for your dollar? We estimate the cost of the full 2.75-year program as ranging from $10,000-$14,000 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.

The Details:

Table of Contents

What do they do?

The NFP model consists of having trained registered nurses visit low-income, single 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 [[Program descriptions]] 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. The national office collects extremely thorough and detailed data from its implementing programs, which it then compares to benchmarks, monitoring compliance and providing advice; see Attachment [[example of monitoring]] for a sample review.
  • 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.

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. This opinion is confirmed by a literature review of home visitation programs (see Attachment B-1 Pg 2), which 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) (Attachment B-4 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 (Attachment B-3 Pgs 1554, 1556) and higher GPA and academic achievement at age 9 (Attachment B-7 Pg 838). The third, in Denver, published the results of its 4-year followup 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 (Attachment B-6 Pg 1565-1566). We complied a summary of all results in this table.

Other studies of similar 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 (Attachment B-1 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 (Attachment B-6 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 (Attachment B-5 Pgs 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 are 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 ([[History]]).
  • The national office has clear, measurable criteria for adherence to the program (see [[Fidelity attachment]]), including the requirement that registered nurses carry out the program according to the (proprietary) NFP curriculum.
  • The national office is extremely thorough in its data collection. It records information from each regional partner on demographics; attrition; implementation (number and content of visits); and a broad range of outcomes (maternal smoking/alcohol consumption, life situation, children’s test scores, etc.) ([[Data collection example]]). It provided us with a sample report containing all of this data, and national aggregates; it was not able to provide us site-by-site data due to confidentiality issues ([[Data collection examples]]).
  • As shown in the studies above, empirical evidence for the model's effectiveness holds across very different populations.

Costs

NFP’s website puts the cost of the program at a total of $10,000 per family, for the complete 2.75-year program ([[Attachment C-1 Pg 1]]). Its sample startup budget ([[Attachment D-1]]) is around $500,000 per year for 100 families, which implies a total cost of about $14,000 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 for 75,000 families next year ([[Attachment D-2]]).

The Organization

Financials. The following data is from NFP's 2003-2005 IRS Form 990s (available via GuideStar) and Attachment D-2.

Year Revenues (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
2008 (exp) $11,114 $9,951

The financials we were sent do not include statements of assets, so we tried to get an idea of how much NFP holds by looking at the Form 990 for 2006, the last one we have access to. At that time, NFP held $495,381 in assets. This is low in relation to that particular year's expenditures ($5,594,000); however, we don't think that such a low level of assets is characteristic of the organization, given that this number was calculated during a period of growth in which expenses were out-pacing revenues.

We further expect that the NFP's assets have since increased. Since NFP is a not-for-profit, its projected $7,120,000 in surplus revenues for 2007 and 2008 (see table above) must be held in assets. Even assuming high levels of depreciation in the organization's assets, we should be safe in assuming that NFP currently holds at least $3,420,000 (50% of its 2007 expenditures) in assets, and will hold at least $4,975,500 (50% of its 2008 expenditures) in assets by the end of 2008.

Board of directors. Half of NFP's ten 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 highly recommend it as a proven and scalable early childhood intervention.

Attachments:

A. Application and response:

B. Program related attachments:

C. Organization related attachments:

D. Financials: