fy14 hvsa evidence based funding opportunity...fy14 hvsa evidence based funding opportunity i....

Review Group Reviewers Applicant EBHV Model Request Amount

Funding Use Age Group Geo Area Served

Rural / Urban

Race/Ethnicity Served Est. Children (Request)

Cost Per Child (Request)

Children Served (Program)

Cost Per Child (Program)

Kitsap Public Health District

Nurse‐Family Partnership (NFP)

$ 51,823.20 Expansion 0 to 3 Years Western Washington\Kitsap County

Urban American Indian/Alaskan Native Non‐HispanicAsian Non‐HispanicBlack Non‐HispanicHispanicMultiple Races Non‐HispanicWhite Non Hispanic

12 $ 4,318.60 48 $ 10,511.00

Clark Public Health


$ 50,000.00 Critical Sustainability

0 to 3 Years Western Washington\Clark County

Urban Black Non‐HispanicHispanicMultiple Races Non‐Hispanic

12 $ 4,167.00 80 $ 8,519.00

Thurston County Public Health and Social Services



0 to 3 Years Western Washington\Thurston County

Rural American Indian/Alaskan Native Non‐HispanicAsian Non‐HispanicBlack Non‐HispanicHispanicMultiple Races Non‐HispanicPacific Islander Non‐HispanicWhite Non Hispanic

10 $ 5,000.00 108 $ 3,847.00

Palouse Industries (Boost Collaborative)

Parents as Teachers (PAT)


0 to 3 Years Eastern Washington\Whitman County

Rural Asian Non‐HispanicMultiple Races Non‐HispanicWhite Non‐Hispanic

18 $ 3,035.38 19 $ 3,035.38

Community Youth Services

Parents as Teachers (PAT)


0 to 3 Years Western Washington\Thurston County

Both American Indian/Alaskan Native Non‐HispanicHispanicMultiple Races Non‐HispanicWhite Non‐Hispanic

45 $ 2,716.00 50 $ 1,929.00

Snohomish County

Early Head Start $ 104,567.00 Critical Sustainability

0 to 3 Years Western Washington\Snohomish County

Both HispanicWhite Non‐Hispanic

82 $ 1,275.21 82 $ 13,063.00

Group 1Laura Wells Ellen

Silverman Saadia Hamid

Group 2

Nicole Rose Shannon Blood Isidro Rodriguez Alex O'Reilly

FY14 HVSA EVIDENCE BASED FUNDING OPPORTUNITY

I. ORGANIZATIONAL INFORMATION ORGANIZATIONAL INFORMATION Organization Name: Kitsap Public Health District City: Bremerton State: WA Zip Code: 98337 Tax ID: 421689063 DUNS #: 169167202 Full-Time Equivalents (FTEs): 89.98 Organization Budget: $9,832,014.00 Organization Fiscal Year-End: December 31 Sources of Income %:

Government: Federal (18%) Government: State (21%) Government: County (32%) Government: City (1%) Private: Fees/Earned Income (28%) Other Description:

LEAD APPLICANT CONTACT INFORMATION

Chief Executive Information Name: Mr. Scott Daniels Title: Administrator Home Visiting Manager Information: Name: Mrs. Katie Eilers Email: [email protected] SUBCONTRACTOR ORGANIZATION 1 Organization Name Physical Address SUBCONTRACTOR ORGANIZATION 2 Organization Name Physical Address SUBCONTRACTOR ORGANIZATION 3 Organization Name Physical Address

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II. PROJECT OVERVIEW

HOME VISITING MODEL INFORMATION

Select the home visiting model you are implementing with the HVSA funds. Nurse-Family Partnership (NFP) If you selected “Other,” please provide the name of the model/program: Indicate how long your organization has been operating this home visiting program for which you are requesting funding: 1-2 Years Has your organization ever been previously funded through the Home Visiting Services Account or the Council for Children & Families to implement the home visiting model selected above? Yes COMMUNITIES SERVED Select the county you will serve with this funding. Western Washington\Kitsap County

Within the selected county, what specific geographic area will you serve? the entire county Is this county/geographic area ranked in the Washington State Home Visiting Needs Assessment? No What number is the geographic area ranked in the Washington State Home Visiting Needs Assessment? 33.00 Is the county you are serving with this request primarily urban, rural or both? Urban (100%) Age Group Served 0 to 3 Years Race/Ethnicity: American Indian/Alaskan Native Non-Hispanic Asian Non-Hispanic Black Non-Hispanic Hispanic Multiple Races Non-Hispanic White Non-Hispanic Risk Factors: Disparities, multiple indicators

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Infant mortality Low birth weight births Poverty Premature births Underserved HVSA FUNDING REQUEST INFORMATION HVSA FUNDING REQUEST Request Amount: $51,823.20 The amount requested for the estimated numbers served represents which of the following use of funds. Expansion If requesting funds for “Critical Sustainability” or “Critical Sustainability and expansion,” indicate the funding source and amount of funds you will be replacing in your program. Provide the proposed numbers your organization will serve through HVSA Funding.

Children: 12 Parent(s)/Caregiver(s): 12 Families: 12

Cost per Child Served by HVSA Funding: $4,318.60 PROGRAM INFORMATION Total Home Visiting Program Budget: $504,545.00 Total Number of Children Your Organization will serve through the Home Visiting Program: 48 Cost per Child Served by the Program: $10,511.00 Percentage of Effort Represented by HVSA Funding: 28 List the primary funders of your home visiting program. Subcontracted amount through Thrive By Five HVSA funding; Department of Health Local Community Dollars Fund; Healthy Start Kitsap. Healthy Start Kitsap is a local not-for profit organization dedicated to preventing child abuse and neglect, with KPHD's NFP program at the top of the their funding priority list.

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PROJECT ABSTRACT Create a narrative description of your project, addressing the following information:

• Name of Organization • Home Visiting Model • Proposed Outcomes • Target Population • Curriculum Used in Service Delivery • Activities (Frequency, intensity, and duration of each activity as outlined in the logic model) • Model Enhancements (Additional activities that have been added to address the unique needs in your

community) • Staff Administering Services (Position Titles and FTEs) • Number of unduplicated families, parents, and children to be served annually by the whole program and

the Number of unduplicated families, parents, and children supported by HVSA funding

Kitsap Public Health District (KPHD) utilizes the Nurse Family Partnership model to serve low-income pregnant women of Kitsap County. Since its inception in July of 2012, KPHD has made marked progress in fidelity measure compliance and improvement in maternal and child health indicators. The program targets low-income first time mothers, including pregnant adolescents and minorities. KPHD's proposed outcomes focus on healthy newborns who grow and develop appropriately and have safe and competent parents. Among other measures, the program aims to address specific needs of Kitsap County, including improving breastfeeding initiation rates, reducing low birth weight births, promoting initiation of prenatal care in the first trimester, and reducing perinatal substance abuse. The curriculum follows the NFP manual and is structured around model elements. From the mid-pregnancy period until the child's second birthday, trained nurses visit families biweekly for approximately 1.25 hours per visit. The specially-trained nurses follow the NFP guidelines and provide education and support to improve maternal and child health outcomes. Educational topics covered will include smoking cessation; safe discipline methods; parental emotional well-being; cognitive, emotional, and physical childhood developmental markers; creating educational plans; and enhancing the learning environment for children through positive parent interactions. Support activities include encouraging compliance with prenatal and well-child visits. Model enhancements include routine screening of Adverse Childhood Experiences (ACEs). The staff member administering services will be a 0.5FTE trained registered nurse. The program will serve 48 unduplicated families; 12 of which are supported by the requested HVSA funding.

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III. COMMUNITY PROFILE

COMMUNITY NEED

Using the Washington State Home Visiting Needs Assessment and local community data, describe the needs in your community. Explain how the home visiting model you are implementing directly addresses those needs, providing clear examples of how community need is matched to the core components of the model. Describe the process your program used to select the model and determine if your community, organization, and program could successfully implement the model.

Kitsap County has only 395 square miles of land area but is the third most densely populated county in Washington State. The population estimate for 2013 is just over a quarter million (254,000), with 67% living in unincorporated areas. There are four incorporated city centers, of which the largest is Bremerton (population 37,850). Two tribes, the Port Gamble S'Klallam and Suquamish, are located in the northern portion of the county. In the mid- and southern portions of the county, there are two naval bases and the Puget Sound Naval Shipyard; the active military population, the civilian population working for the federal government, and the families of these employees have a large influence on the economy and on social and health services. There are five school districts in Kitsap - Bainbridge Island, Bremerton, Central Kitsap, North Kitsap and South Kitsap. Bremerton School District is typically the area with the worst socioeconomic status indicators- highest poverty, highest proportion of students receiving Free and Reduced Lunch, highest proportion of single parent households, highest proportion of residents receiving public assistance, lowest median income, etc. Many of the lowest-income pregnant women are living in Bremerton. In addition to Bremerton, there are other pockets of poverty in our county, but these tend to be masked when looking at county-level data due to the positive economic impacts of the military and neighboring Seattle/Tacoma areas. There are large disparities in health and well-being status across our county due to the large disparities in socioeconomic factors. Kitsap has about 3,000 resident births per year; in 2012, 935 of those were to women receiving services through the military. The majority of military moms are married and compared to civilian moms have dramatically lower rates of smoking and higher rates of high school education. Of Kitsap civilian women giving birth, at least 42% are low-income; in 2012, this was 860 births. A total of 47% of these low-income births occurred to women living in Bremerton, 26% to women living in South Kitsap, 16% to women living in North Kitsap, 9% to women living in Central Kitsap and 2% to women living in Bainbridge Island. Of the 860 low-income women, 63% were unmarried, 22% did not have a high school education, 23% smoked during pregnancy, 12% did not breastfeed at birth, and 7% had low birth weight babies. In the 2011 WA State Department of Health Home Visiting Needs Assessment (WAHVNA), Kitsap had higher rates than the state average for infant mortality, DSHS clients reporting substance use and late/no prenatal care. In the 2013 Maternal Child Health Block Grant Needs Assessment which local health departments completed for the state, Kitsap was statistically worse than the state on the following measures: women smoking during pregnancy, breastfeeding initiation, 1st trimester prenatal care initiation, children age 19-35 months with complete immunizations, children age 6-8 years with dental caries, and children enrolled in Medicaid. Additionally, late or no prenatal care and low birth weight have statistically increased over time.

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Kitsap Public Health District initiated Nurse Family Partnership in July 2012 and has a current caseload of 23 with 1.0 visiting nurse FTE, with 26 potential clients on a waitlist. As an enhancement to the program, NFP Home Visitor's began implementing Adverse Childhood Experiences (ACE) screening with their clients when possible. Of the 22 clients who have been screened, the average number of ACEs per client is 5.1 and 73% have three or more ACEs. Nurses work with clients after the screening to help clients find motivation for change, discover and build resilience, and inspire decisions to protect their children from having ACEs. As demonstrated by the risk indicators above, in Kitsap County there are areas of concern which NFP helps to address. These include child maltreatment and domestic violence through ACEs screening and discussion; poverty and disparities, particularly geographically; and low birth weight births. NFP expansion in Kitsap County is necessary due to demonstrated immediate need within the community, as evidenced by our waiting list. To date, program outcomes indicate that NFP core components have had a marked impact in addressing community needs. For example 100% of clients in the program initiated breastfeeding. Of the 15.4% of clients who were smoking at intake, none (0%) were smoking at 36 weeks. EXISTING REFERRAL RESOURCES List up to ten organizations to which you refer home visiting participants for additional resources, and indicate the primary services they deliver.

Organization Name

Primary Services

(Maltreatment Prevention, Child Welfare, DV Prevention, Early Childhood Development, Education, Health, Mental Health, Substance Abuse)

1. Harrison Medical Center Health

2. Kitsap Mental Health Mental Health , Substance Abuse

3. WIC Early Childhood Development , Health

4. Holly Ridge Neurodevelopmental Center

Early Childhood Development

5. Early Head Start Education

6. CPS Child Maltreatment Prevention

7. DSHS Child Welfare

8. Salvation Army Child Welfare , Health

9. YWCA Alive Domestic Violence Prevention

10. Penninsula Health Services Health

Describe any community plan for coordination among existing resources in the county. KPHD formally collaborates with a wide variety of existing resources in the county through several venues, including the Kitsap Community Health Priorities, the ACES Partnership, and the Olympic-Kitsap

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Peninsulas Early Learning Coalition. Providers represented in these groups include early head start and head start, community action consortiums, health care providers, home visitors, educators, early learning specialists, and public health professionals. KPHD works with providers in these consortiums to ensure cross-referral of existing and potential NFP client families for services. KPHD participates in monthly Olympic-Kitsap Penninsulas Early Learning Coalition meetings to share experiences and advocate for early learning interventions, including NFP, in our counties. Based on the information above, and your understanding of the community served, list referral resources that are needed to support families residing in the county, but which are not currently available. Infant mental health resources Mental health providers specializing in perinatal mental health issues Obstetric/Gynecology providers in the City of Bremerton Limited Spanish-speaking providers, including lactation services Limited housing options for families living in sub-standard conditions Describe all existing mechanisms for screening, identifying and referring families and children to home visiting programs in the community. NFP referrals are made directly to the program at KPHD by phone or fax from community resources, including DSHS, WIC, health care providers, schools, family planning clinics, and the District's own Maternity Support Systems referrals. Referrals are screened for program eligibility based on: 1) income status (DSHS First Steps eligible), 2) whether the candidate is a first time mother, 3) whether the pregnant mother is under 28 weeks of gestation, and 4) resident of Kitsap County. Once these criteria are met, priority is given to mothers who are at the earliest gestation and with highest risk factors. KPHD maintains a waiting list of eligible candidates. Pregnant mothers who do not meet the eligibility criteria for NFP are often referred to Early Head Start home visitation.

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HVSA Logic Model Organization Name: Kitsap Public Health District Home Visiting Model: Nurse-Family Partnership Date: November 16, 2013

RESOURCES ACTIVITIES OUTPUTS

FIDELITY MEASURES CONSTRUCTS BENCHMARKS

Target Population: low income, first-time pregnant women residing in Kitsap County Target Geographic Area: Kitsap County Staffing: BSN nurses Home Visiting Curriculum Used: NFP visit guidelines PIPE parenting education Funding Sources: Kitsap Public Health District Health Start Kitsap Data System(s): ETO CHAMP Nightingale Notes EHR

1: Staffing 1.1: Add 0.5 FTE nurse home visitor

2: Training 2.1: NFP staff will participate in initial and ongoing training and education as required by NFP NSO 2.2: NFP supervisor will participate in ongoing training, education, and consultation as required to support quality, fidelity, and specific population needs. 3. Outreach/Recruitment

3.1: Existing caseload will be increased by 12 families

3.2: Maintain outreach and referral plan to reach target population and maintain caseload

3.3: Monitor effectiveness of outreach plan

1.1: Existing staff is increased by 0.5 FTE Nurse Home Visitor( NHVs 2.1: NFP Supervisor and NHVs will participate in DANCE education and other program updates when scheduled. 2.2: NFP Supervisor will participate in: - 1 monthly Supervisor Community of Practice call -1 quarterly Supervisor Community of Practice meeting - annual 3 day National Education Symposium in Denver -monthly individual consultation calls with state nurse consultant

3.1: Each FTE NHV will maintain a caseload of 25 clients 3.2: Supervisor will have a written plan for cultivating relationships with referral sources and community partners including in-person contacts, follow-up visits and/or letters and/or calls, and community

Measure 1 Nurse home visitors and supervisors are registered nurses with a minimum of a Bachelor's degree in nursing. Measure 2 Nurse home visitors and nurse supervisors complete core educational sessions required by the Nurse-Family Partnership National Service Office and deliver the intervention with fidelity to the NFP Model. Measure 3 Client meets low-income criteria at intake as defined by program. Measure 4 Client is enrolled in the program early in her pregnancy and receives her first home visit by no later than the end of the 28th week of pregnancy. Measure 5 Client is visited throughout her pregnancy and the first two years of her child’s life in accordance with the current Nurse-Family Partnership Guidelines.

1. Prenatal Care 2. Parental Use of alcohol,

tobacco, or illicit drugs 3. Preconception Care 4. Inter-birth Intervals 5. Screening for maternal

depressive symptoms 6. Breastfeeding 7. Well-child Visits 8. Maternal and Child

Health Issues 9. Visits for children to the

emergency department from all causes

10. Visits for children to the emergency department from all causes

11. Information provided or training of participants on prevention of child injuries topics such as safe sleeping, shaken baby syndrome, or traumatic brain injury

12. Incidence of child injuries requiring medical treatment

13. Reported suspected maltreatment for children in the program

14. Reported substantiated maltreatment

15. First-time victims of maltreatment for children in the program.

16. Parent support for

children’s learning and

Improved Maternal and Newborn Health CAN and Reduction of ER Visits Improvements in School

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4: Home Visits

4.1: Provide home visits for first time, low-income pregnant women, mothers and infants

4.2: New clients will be enrolled before 28 weeks of pregnancy and receive visits according to NFP guidelines

4.3: Content of home visits will be aligned with NFP guidelines

5: Supervision

5.1: Staff who provide home visits will receive individual reflective supervision

5.2: All staff will participate in reflective case conferences

6: Continuous Quality Improvement 6.1: Supervisors and nurse home visitors will review and utilize their data 6.2: Data is used for quality and fidelity monitoring and improvement

presentations. 3.3: Supervisor will use ETO data on enrollment by referral source to monitor effectiveness and adapt plan.

4.1: 12 clients will each receive 1-3 home visits per month according to the NFP standard and/or flexible visit guidelines 4.2: 12 clients enrolled by 28 weeks of pregnancy, 45 % enrolled by 16 weeks of pregnancy. Quarterly average completed to expected visit ratio will be: Pregnancy completers : 65% Infancy completers: 55 % Toddler completers: 60 % 4.3: The quarterly average Maternal Role Domain will be: Pregnancy: 23-25% Infancy: 45-50% Toddler: 40-45%

5.1: Supervisor will provide individual, 60" reflective supervision sessions 3 times per month for each NHV 5.2 Reflective case conferences are held twice a month for 1.5 -2 hours.

6.1 Supervisors will review ETO quarterly reports with NHVs and SNC and use this data to create the Annual Plan. 6.2 Supervisor and SNC

Measure 6 A full-time nurse home visitor carries a caseload of no more than 25 active clients. Measure 7 A full-time nurse supervisor provides supervision to no more than eight individual nurse home visitors. Measure 8 Nurse home visitors and nurse supervisors collect data as specified by the Nurse-Family Partnership National Service Office and use NFP reports to guide their practice, assess and guide program implementation, inform clinical supervision, enhance program quality and demonstrate program fidelity.

development 17. Parent knowledge of

child development and of their child’s developmental progress

18. Parenting behaviors and parent-child relationships

19. Parent emotional well-being or parenting stress

20. Child’s communication, language, and emergent literacy

21. Child’s general cognitive skills

22. Child’s positive approaches to learning including attention

23. Child’s social behavior, emotion regulation, and emotional well-being

24. Child’s physical health and development

25. Screening for domestic

violence 26. Referrals for domestic

violence services for families with identified need

27. Safety plan completed for families with identified need

28. Household income and

benefits 29. Maternal Employment

or Education 30. Health Insurance Status 31. Number of families

identified for necessary services

32. Number of families that required services and received a referral to available community resources

Readiness and Achievement Domestic Violence Family Economic Self-Sufficiency Coordination and Referral

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review Annual Plan quarterly.

33. MOUs or other formal agreements with other social service agencies in the community

34. Information sharing Number of completed referrals

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V. IMPLEMENTATION CAPACITY ORGANIZATIONAL CAPACITY Provide the mission of your organization and describe how your home visiting program advances the mission. The mission of KPHD is to prevent disease and protect and promote the health of all persons in Kitsap County. We are founded on five guiding principles: prevention, partnerships, effectiveness, equity and quality. The NFP home visitation program directly advances our mission to prevent adverse conditions contributing to disease, including low birth weight, perinatal substance use, and untreated post-partum depression. The program is founded on efficient collaboration with a network of service providers to promote holistic health of mother and baby and equity in access to quality mental, physical and psychosocial services.

Describe the structure and management of your organization. How does it facilitate effective program implementation? Describe any opportunities for better alignment between administrative infrastructure and program implementation. KPHD is governed by a Public Health Board consisting of Kitsap County Commissioners and local mayors and council members of County cities. The District is directed by a Medical Officer and Administrator, with department directors under their guidance. The Director of Community Health and her Assistant Director provide program guidance and coordinate clinical supervision for the home visitation programs. In order to better align our administrative infrastructure and program implementation, we have established a new position for 2014 of Supervisor of Parent-Child Health programming. This position will serve as a strong link between public health nursing staff and the administration. Describe your organization's track record of success managing complex, multi-year grants. KPHD receives grant funding from federal, state, city, and private foundations. Grants range from simple one-time unrestricted funding donations, to highly regulated, complex multi-year grants. KPHD has sophisticated fiscal and programmatic oversight systems in place to manage the operational and reporting requirements of a wide variety of funders. Finance and program staff have extensive experience in grant implementation and coordination. Organizations in Washington are implementing home visiting services in very diverse communities. Describe how your organization supports culturally competent service delivery through policy and practice. The Kitsap Public Health District is committed to a workforce that is culturally and linguistically competent, and takes deliberate action to ensure that the populations we serve have meaningful access and an equal opportunity to participate in our services, activities, programs, and employment. Our personnel and service practices adhere to internal policies and procedures which promote cultural and linguistic competence, and all staff undergo specified training in these topics. It is a priority of the agency to be able to offer all services to people of any cultural and linguistic background. Describe your organization's plan for sustaining home visiting services. Home visitation programming strongly aligns with KPHD's mission and core values. The department has historically invested local community development dollars to form a significant percentage of home visitation program costs. KPHD not only intends to continue this investment, but has also established strategic partnerships with potential donors, including the local not-for-profit philanthropic organization

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Kitsap Healthy Start, whose mission to prevent child abuse and neglect closely aligns with the goal of the NFP program. Kitsap Healthy Start has identified Kitsap County's NFP programs as its top funding priority for 2014-2017. PARTICIPANT OUTREACH, ASSESSMENTS, AND TIMELINE TO REACH MAXIMUM CASELOAD Describe your plan to enroll the populations you propose to serve. Include information on how clients are referred, engaged, recruited, and/or enrolled into your program. (Provide examples of community-based organizations and local agencies that refer children and families to your program as well as the frequency and duration of outreach.) NFP referrals are made directly to the program at KPHD by phone or fax from community resources, including DSHS, WIC, health care providers, schools, family planning clinics, and the District's own Maternity Support Systems program. Referrals are screened for program eligibility based on: 1) income status (DSHS First Steps eligible), 2) whether the candidate is a first time mother, 3) whether the pregnant mother is under 28 weeks of gestation, and 4) resident of Kitsap County. Once these criteria are met, priority is given to mothers who are at the earliest gestation and with highest risk factors. NFP nurses have visited provider offices, WIC locations, local high schools, churches and OESD to recruit potential clients, though currently KPHD has a waiting list of 26 eligible pregnant mothers so outreach activities have been curtailed. In the coming year, nurses plan to expand their outreach to include CPS. Does your home visiting program currently engage families and children in the child welfare system? If so, in what ways? To date, KPHD has not had clients involved in the child welfare system. What strategies or activities are included in your home visiting plan for engaging families and children in the child welfare system going forward? KPHD NFP Home Visitors have planned to extend outreach in 2014 to the local Children's Administration and CPS, to ensure they are aware of NFP services. This is particularly critical to solicit referrals of pregnant teenagers in the foster care system, who can especially benefit from the NFP program. All home visitation nurses are trained mandated reporters, and aware of the need for referral and follow up with child welfare. Are individualized assessments of enrolled participant families conducted? Yes If YES, describe how referral to services are provided in accordance with those individual assessments Our intake assessment provides guidance on a wide range of issues, including needs related to medical care, lactation services, education, housing, substance abuse recovery, domestic violence, and mental health services. Referrals to services are made based on this assessment. RN's administer the Edinburgh Depression Screening postpartum and refer to mental health providers as needed. Following delivery, RN's utilize several assessment tools, including the ASQ, the ASQ-SE, and the HOME Inventory to identify developmental and environmental needs of the child. Referrals include Holly Ridge Birth to Three program, medical providers, Early Head Start, and Kitsap Community Resources for housing services. Provide an estimated timeline to reach maximum caseload.

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KPHD will draw immediately from its current wait list of NFP eligible clients. We estimate that the 0.5 FTE Home Visitor would expand her caseload by one to two clients per month, ensuring that she reaches full caseload within three to four months. HOME VISITING MODEL NATIONAL TRAINING, TECHNICAL ASSISTANCE, AND SUPPORT Present a plan for working with the national model developer and Washington State Model Lead. Include the frequency and duration of the current support available from both the national model and the Washington State Lead for: a) initial and ongoing training and professional development, and b) initial and ongoing technical assistance and support. NFP program implementation requires each nurse home visitor and nurse supervisor to complete NFP core nursing education in order to implement the program with fidelity. As KPHD has already identified an existing NFP nurse to fill this position, this nurse home visitor will have completed the on-site training at the Denver NSO. Nurse supervisor competency for this expansion has already been met. Technical assistance is provided by Quen Zorrah, the Washington State NFP consultant, and Lauren Platt, the NFP Program Developer. Monthly phone consultations are scheduled with Ms. Zorrah to review data, program implementation, team needs and goals. Other technical support is provided through the Washington State Consortium Nurse Supervisors' group through monthly phone conferences and the Washington State NFP consortium annual meeting, where nurse home visitors and supervisors meet for education and collaboration. Ongoing regional NFP collaboration occurs at regional NFP Partners meeting with representatives from Jefferson, Kitsap, Clallam, Pierce, Grays Harbor and Mason Counties and the Port Gamble S'Klallam Tribe and NFP representatives Quen Zorrah and Lauren Platt. STAFF SELECTION, TRAINING, AND RETENTION STAFF SELECTION List the qualifications (education, credentials, experience, etc.) and skills recommended and/or required for home visitors by the home visiting model/program. Indicate if qualifications include cultural competency and language accessibility recommendations or requirements. One of the model elements of NFP is that nurse home visitors are registered professional nurses with a minimum of a Bachelor's degree in nursing. Other qualifications necessary to implement the program include experience in public health nursing, home visiting, and maternal and child health nursing. Experience working with diverse cultural groups, including Hispanic and Native American cultures are desired qualifications to serve families living in poverty in Kitsap County. The identified staff to fill the proposed NFP HV position is highly qualified for the position, as she currently serves as a part-time NFP nurse with KPHD. If your program requires any additional staffing qualifications beyond those required by the developer, list and describe those qualifications. Do you have adequate staffing capacity (both in terms of FTEs and alignment with identified service population) to implement your home visiting program as described in the proposal? Yes

If YES, briefly describe the existing staffing as it relates to the client volume and the unique needs of the population served.

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KPHD is prepared to immediately expand our caseload. Currently, we have two 0.5FTE fully-trained NFP BSN RN's serving as home visitors. One of these home visitors, Nancy Acosta, will expand her position to become a 1.0 FTE NFP HV should funding become available. Supervision is and will continue to be subcontracted to the Jefferson County Nurse Supervisor, Yuko Umedo. Lori Werdall, trained administrative assistant who currently manages NFP ETO reporting, will continue to serve this program.

If NO, please describe the recruitment plan and the timeline for recruiting and hiring staff. What is the timeline for obtaining all necessary training for new staff to implement the home visiting model? We will fill the 0.5 FTE position with already-trained NFP nurse, Nancy Acosta. Implementation can begin immediately upon receipt of funding.

ORGANIZATIONAL STAFF TRAINING

List all initial and ongoing professional development activities provided by the implementing organization(s). KPHD will guide, monitor and support professional development activities, including completion of NFP core training (if needed) and attendance at NFP-related education and support such as WA State NFP consortium annual meetings and NFP regional team meetings. Nurses will receive the required training to implement the NFP DANCE in 2014. Additional ongoing training topics will include ACEs screening, depression screening, domestic violence, attachment theory, substance abuse, mental health issues, and life course perspective. Does your program provide any training to staff beyond that required by the model/program developer, including any racial equity and/or cultural competency training? If so, describe. KPHD provides several training opportunities for staff that go beyond program requirements. Topics of trainings include reducing bias in health care delivery and hiring practices, the affordable care act and its influence on families served, the importance of the perinatal period in the life course perspective of health, and collective impact.

STAFF RETENTION

What mechanisms are in place to retain all staff in the program(s)? Clinical supervision is closely provided to staff to ensure balance of work/caseload, client acuity, and support. Individual and team meetings are held to provide reflective support and mentoring. Nurses are encouraged to enhance their nursing practice through continuing education and to share and exchange new ideas to improve practices. NFP staff are integrated into the larger parent-child health department, and share in lifelong learning with their colleague public health nurses. Humor, enthusiasm and respect are regularly shared and help build team resiliency. CLINICAL SUPERVISION AND REFLECTIVE PRACTICE What training is provided to support clinical supervision/reflective practice? An important core element of the NFP model is the provision of clinical and reflective supervision for the nurse home visitor and the nurse supervisor. This component reflects a parallel process within many levels of relationships in NFP: the relationship between the client and her child, between the client and the nurse, between the nurse and nurse supervisor and between the nurse supervisor and NFP nurse

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consultant. The nurse home visitors and nurse supervisor complete core education on motivational interviewing and reflective practice. Nurse supervisors receive additional training on reflective supervision in NFP supervisor education and also receive supervision from NFP nurse consultants. Are there currently individuals on staff/in your community who are providing this supervision? Yes If YES, what is the frequency and duration of the supervision provided? Home visitors have weekly, individual,1hour reflective supervision with nurse supervisor. Team case conferences & meetings of 1hour held on alternating weeks each month. Joint home visits between the nurse and nurse supervisor are held every four months. If NO, please describe the recruitment plan and the timeline for recruiting and hiring supervisors.

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VI. FIDELITY AND QUALITY ASSURANCE MONITORING, ASSESSING, AND SUPPORTING IMPLEMENTATION WITH FIDELITY AND ONGOING QUALITY ASSURANCE How does the home visiting program(s) participate in fidelity monitoring and/or quality assurance through the national model developer and Washington State Model Lead? The KPHD NFP program has participated in fidelity monitoring and quality assurance for the past year when the NFP model was implemented. KPHD has maintained fidelity to the program defined by the NFP Model Elements. KPHD will follow the 18 specific fidelity criteria to best ensure the NFP program goals of improved pregnancy outcomes, improved child health and development and improved maternal life course development. Bachelors prepared nurse home visitors and supervisors complete the core education program in order to deliver services to nulliparous, low income women with fidelity to the NFP model. Data is collected at specific times during the service episode, entered into the ETO data collection software, and reviewed to monitor quality of the program. Data can be organized, as in the quarterly summary reports, to monitor fidelity to the model elements and assess areas for organizational or operational changes as needed. What additional monitoring, assessing, and supporting implementation with fidelity and quality assurance does the home visiting program participate in? (i.e. if currently receiving technical assistance from HVSA please describe) The Washington State NFP Nursing Consultant, Quen Zorrah, provides monthly consultation with the nurse supervisor to review program implementation and supervision. She provides supervision and assistance as needed to the site nurse supervisor, Yuko Umedo, and regularly reviews data to look at fidelity to the program and helps assess areas of or in need of improvement. Ms. Zorrah works with KPHD to develop an annual plan with goals to improve program implementation. Does your organization conduct fidelity tracking or quality assurance on its own? If YES, please describe. QA is conducted through 1) Family Health Team/ Maternal Child Health (MCH) chart audits, 2) monthly case conference on MCH clients, 3) inter-rater reliability practices, 4) analysis of client outcomes by tracking changes in knowledge, behavior, and status, and 5) epidemiologic review of data collected for funder requirements. KPHD's Quality Assurance committee meets monthly to discuss inter-rater reliability and chart review results, and to make improvements to quality assurance tracking mechanisms. Identify two to three model-specific fidelity measures and describe challenges to maintaining quality and fidelity when implementing in the proposed service area with the identified population. In regard to fidelity model #4, KPHD's entire NFP caseload has been enrolled prior to 28 weeks. Our most recent data indicates that 33% of NFP clients are enrolled prior to 16 weeks, which falls short of the goal that 50% of participants being enrolled by this time. Our referral process contributes to the lag time in enrollment. Currently, DSHS provides referrals of low-income pregnant women to our Maternity Support Services program, which then conducts eligibility screening for all referrals. Pregnant mothers who qualify for NFP are then referred to NFP staff. We are currently evaluating the feasibility of DSHS referrals coming directly to NFP staff. Additionally, because we have a waiting list of eligible pregnant clients, we have potential clients pass the 16 week mark before a slot opens for them in the caseload. The addition of a 0.5 FTE NFP nurse would help alleviate this problem.

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In reference to Fidelity measure 10, NFP nurses continue to share lessons learned and receive new information on NFP theory and practice, tools, and skills through case conferences and reflective supervision sessions. HV's are continuing to develop their skills in meeting apportioned time requirements across domains and in motivational interviewing. Describe all enhancements that are currently being made by the home visiting program(s). NFP HV's are utilizing the Adverse Childhood Experiences (ACEs) assessment tool to help inform their care of the client, particularly in relation to empowering the client to become more trauma and resiliency-informed, and to intentionally develop protective factors in the family. Care planning stemming from the ACES assessment aim to interrupt intergenerational transmission of ACEs, including prevention of child abuse and neglect, and promotion of positive parenting skills. What is the average rate of attrition for program participants? What is your plan to reduce attrition? Since its inception in July of 2012, 28 clients have enrolled in the NFP program. Two (2) have moved out of the County, three (3) have been lost to follow-up, and one (1) refused services part-way through the program. The rate of attrition for the program has been 21%. In order to prevent and reduce attrition, HV's are particularly focusing on three of the Client-centered principles that improve long-term client engagement in the process - "the client is the expert in her life" and "follow the client's heart's desire." Additionally, HV's have begun to embrace Dr. Old's retention research that allows for alternative schedules in visits. Several clients have expressed difficulty in maintaining the prescribed visitation schedule, but are enthusiastic about alternative schedule options.

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VII. FIDELITY AND QUALITY ASSURANCE CONTINUED EVALUATION, DATA MANAGEMENT, AND CONTINUOUS QUALITY IMPROVEMENT

Does the national home visiting model have a database that program(s) implementing the home visiting model are using? Yes If YES, does the lead organization, and subcontractor organizations implementing the home visiting program, use the national model database? KPHD's NFP program will use the NFP NSO ETO (Efforts to Outcomes) system for data management.

Measurement Tool Frequency Administered

1. NFP form Home Visit every visit 2. NFP form Demographics pregnancy intake, infancy 6 mo, 12 mo, toddler 18

mo, 24 mo 3. NFP form Mental Health Assessment first visit 4. NFP form Use of Government & Community

Services first visit, postpartum visit, infancy 6 mo, 12 mo, toddler 18 mo, 24 mo

5. NFP form Health Habits pregnancy 3rd or 4th visit, pregnancy 36 wks, infancy 12 mo

6. NFP form Relationship Assessment pregnancy 3rd or 4th visit, pregnancy 36 wks, infancy 12 mo

7. NFP form Infant Health Birth postpartum first visit 8. NFP form Infant Health Care Infancy 6 mo, 12 mo, toddler 24 mo 9. Patient Health Questionnaire - 9, depression

screen Pregnancy 36 wks, Postpartum 1-4 wks, Infancy 4-6 mo, Infancy 12 mo

10. Ages and Stages Questionnaire (ASQ, developmental screening)

Infancy 4 mo, 10 mo, 14 mo, 20 mo

11. Ages and Stages Questionnaire, Social-emotional (ASQ-SE) social emotional developmental screening

Infancy 6 mo, 12 mo, 18 mo, 24 mo

12. HOME Inventory Infancy 6 mo, Toddler 18 mo 13. 14. 15. 16. 17. 18. 19. 20.

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If NO, how does the lead organization, and any subcontractor organizations implementing the home visiting program, track data? Are there other data systems being used? Yes, KPHD will continue to use the NFP ETO system. Who is responsible for collecting the data? The nurses collect client data at designated times during the service period. The nurse supervisor is responsible for data collection and input for data from both nurse home visitor data and team supervision data. Who is responsible for data input? A designated and trained administrative assistant is responsible for entering data collected by the nurse home visitor. The nurse supervisor is able to input team supervision data into ETO. Who analyzes and reports the data? The nurse supervisor and NFP nurse consultant analyze data to review and improve program implementation. Data analysis support is provided by the KPHD Epidemiologist, Beth Lipton. The Boards of Health and funding partners receive annual reports from KPHD NFP. Once analyzed, how is the data used for continuous quality improvement? The KPHD epidemiologist conducts analysis and identifies gaps and needs in the targeted population for future service recommendations and quality improvement. Quarterly, using a plan-do-study-act cycle method, the analyzed program data is compared to performance benchmarks established by NFP and the federal Maternal, Infant Early Childhood Home Visiting Program. The NFP team then develops a quality improvement plan targeting the areas not meeting or exceeding the performance benchmarks. The quality improvement plan is implemented and evaluated for effectiveness every quarter. The quality improvement plan is revised as needed to assure that performance benchmarks are met or exceeded.

PERFORMANCE SNAPSHOT

Please see the attached:

1) Fidelity Summary 2) Tools and Measures Summary

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Fidelity Summary Document Since inception of the Nurse Family Partnership (NFP) program at Kitsap Public Health District (KPHD) in July 2012, the organization has demonstrated a high level of fidelity to the eighteen model elements of the NFP program. The program is reaching its demographic and caseload targets, adheres to client visitation stipulations, has met staffing training and educational requirements, follows supervision guidelines, and contains the structural and fiscal dedication required to operate the program according to the NFP framework.

Specific examples of fidelity relate to model elements 2 and 3, which indicate that clients should be first-time, low-income mothers. All (100%) of KPHD’s participants are first-time mothers, ranging in ages between 17 and 25 years, with the median age of 20. All (100%) of clients are low-income, with 90% of program referrals originating from the Department of Social and Human Services.

A significant strength of the program relates to model element 17, which mandates a

Community Advisory Board be in place to support and promote program quality and sustainability. KPHD is pleased to have formed a partnership with Healthy Start Kitsap (HSK), a 501(c)3 non –profit organization. HSK was formed in 2003 by several community leaders concerned about breaking the multi-generational cycle of abuse. Based on the evidence that the NFP model comprises a cost-effective, evidence based approach to child abuse and neglect prevention, the HSK Board of Directors has committed to provide administrative and fiscal support to KPHD’s NFP program. HSK offers guidance on program quality enhancement and promotes the program to the larger community to solicit support and funding. HSK’s support, combined with commitment by KPHD to contribute local community development funds to the NFP program, play a critical role in the program’s sustainability and evidence of the value the community places on child abuse and neglect prevention.

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Tools and Measures Summary Document Kitsap Public Health Districts (KPHD) began its Nurse Family Partnership (NFP) program in July 2012, so outcomes data are limited by the relatively short duration of the program to date. KPHD utilizes needs assessment and health disparities data to help guide development of priority outcome measures for the NFP program. According to the 2011 WA State Department of Health Home Visiting Needs Assessment (WAHVNA), Kitsap had higher rates than the state average for DSHS clients reporting substance use. The 2013 Maternal and Child Health Block Grant (MCHBG) Needs Assessment indicated that Kitsap County was statistically worse than the state on women smoking during pregnancy. Since the beginning of the program in July of 2012, 17.6% (n=3) of clients reported smoking at intake. NFP Home Visitors educated clients on the negative impact of smoking on the fetus and provided resources for smoking cessation. At 36 weeks of gestation, the program saw a 67% (n=2) reduction in maternal smoking during pregnancy, exceeding the NFP relative change objective of a 20% reduction.

The MCHBG Needs Assessment also reported that Kitsap County was statistically worse than the state on breastfeeding initiation, with 12% of women not initiating breastfeeding at birth. Among KPHD clients, only 6% (n=1) of clients did not initiate breastfeeding at birth. Additionally, at 6 months of age, three of five (60%) clients were still breastfeeding, exceeding the state average of 28.9% breastfeeding prevalence at that age of infancy.

When assessed using the Omaha System problem classifications, all (100%) of our

clients had one or more problems identified, with low income a common problem to everyone. Clients had an average of 3.4 problems. Within the Omaha System, outcomes of public health nursing interventions to address identified problems are rated on a Likert scale of 1-5 in the areas of client knowledge (K), behavior (B), and status (S). Ninety-three percent (n=26) of our NFP clients have achieved a statistically significant improvement in knowledge, behavior, and status for all problems combined. Additionally, we have seen a statistically significant increase by problem and rating area as follows: knowledge improved related to substance abuse, and knowledge and status improved for mental health (p-value = 0.5).

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HOME VISITING MODEL: Nurse Family Partnership

Period: January 1 - December 31, 2014

Line ItemFY14 HVSA Award

Comments/Justification

(List individual positions, types of expenses on lines below each line item) Provide descriptions and formulas for each line item expense.

A. Personnel $47,112.00

Salaries and Wages (Salaries and Wages for (individual classifications, benefits and taxes, etc.)

0.5 FTE Home Visitor $47,112.00 salary and benefits for 0.5 FTE Home Visitor

B. Staff Recruitment, Training, Retention, etc. $0.00

C. Travel $0.00

D. Equipment (Purchase, rent, maintenance) $0.00

E. Supplies (Postage, Printing, Publication, etc.) $0.00

F. Occupancy (Rent, utilities, etc.) $0.00

G.Contracted/Professional Services (Subcontracts, Consulting, Printing, etc.) $0.00

H. Evaluation Stipend (for Cohorts 3 and 6 ONLY) $0.00

I. Travel Stipend (forThrive mandatory trainings) $0.00

J. Indirect Charges if not included above $4,711.00 10% indirect charge to cover administrative costs

K. TOTAL $51,823.00

Kitsap Public Health District

Item heading. Formulas automatically total up and across in yellow field for each line item.

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I. ORGANIZATIONAL INFORMATION ORGANIZATIONAL INFORMATION Organization Name: Clark Public Health City: Vancouver, WA State: WA Zip Code: 98666-8825 Tax ID: 916001299 DUNS #: 030783757 Full-Time Equivalents (FTEs): 75.15 Organization Budget: $9,937,107.00 Organization Fiscal Year-End: 12/31/2013 Sources of Income %:

Government: Federal (24%) Government: State (23%) Government: County (22%) Private: Fees/Earned Income (30%) Private: Foundations and Corporations (1%) Other Description:


Chief Executive Information Name: Dr. Alan Melnick Title: Health Officer - Director Home Visiting Manager Information: Name: Ms Pat Shaw SUBCONTRACTOR ORGANIZATION 1 Organization Name Physical Address SUBCONTRACTOR ORGANIZATION 2 Organization Name Physical Address SUBCONTRACTOR ORGANIZATION 3 Organization Name Physical Address

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Select the home visiting model you are implementing with the HVSA funds. Nurse-Family Partnership (NFP) If you selected “Other,” please provide the name of the model/program: Indicate how long your organization has been operating this home visiting program for which you are requesting funding: More Than 5 Years Has your organization ever been previously funded through the Home Visiting Services Account or the Council for Children & Families to implement the home visiting model selected above? No COMMUNITIES SERVED Select the county you will serve with this funding. Western Washington\Clark County

Within the selected county, what specific geographic area will you serve? Central Vancouver Is this county/geographic area ranked in the Washington State Home Visiting Needs Assessment? No What number is the geographic area ranked in the Washington State Home Visiting Needs Assessment? 21.00 Is the county you are serving with this request primarily urban, rural or both? Urban (100%) Age Group Served 0 to 3 Years Race/Ethnicity: Black Non-Hispanic Hispanic Multiple Races Non-Hispanic Risk Factors: Involvement in the Child Welfare System Child maltreatment Disparities, multiple indicators

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Domestic violence High school dropout rates Low birth weight births Non-English Speaking Poor school readiness statistics Poverty Premature births Underserved HVSA FUNDING REQUEST INFORMATION HVSA FUNDING REQUEST Request Amount: $50,000.00 The amount requested for the estimated numbers served represents which of the following use of funds. Critical Sustainability If requesting funds for “Critical Sustainability” or “Critical Sustainability and expansion,” indicate the funding source and amount of funds you will be replacing in your program. Current funding source: Clark County general fund. HVSA funds will replace $50,000 of general fund support. Provide the proposed numbers your organization will serve through HVSA Funding.


Cost per Child Served by HVSA Funding: $4,167.00 PROGRAM INFORMATION Total Home Visiting Program Budget: $681,527.00 Total Number of Children Your Organization will serve through the Home Visiting Program: 80 Cost per Child Served by the Program: $8,519.00 Percentage of Effort Represented by HVSA Funding: 7 List the primary funders of your home visiting program. Clark County - General Fund Contribution Centers for Medicare & Medicaid Services - Federal Medicaid Centers for Medicare & Medicaid Services - Medicaid Adminstrative Match

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PROJECT ABSTRACT Create a narrative description of your project, addressing the following information:




Clark County Public Health has provided Nurse Family Partnership (NFP) since 2007, with a target population of low income, first-time pregnant women, enrolling before 28 weeks gestation. NFP's relationship-based model and curriculum is known to improve pregnancy outcomes, improve child health and development, and empower women/families to become economically self-sufficient. The home-visiting model includes weekly visits for the first four weeks and every other week until baby is born. Postpartum visits are weekly for the first six weeks and every other week until baby is 21 months. From 21-24 months visits are monthly. To meet the needs of an individual family, the nurse home visitor may adjust frequency of visits. HVSA funds will support NFP in central Vancouver, particularly Hispanic women, African American, or women of mixed race. Central Vancouver has the highest proportion in Clark County of: low income residents, minority ethnic groups, women who smoke during pregnancy, births to women with a high school diploma or less, and births to unmarried mothers. NFP will serve 80 un-duplicated pregnant/parenting families and 80 infants-toddlers in 2014, with NFP for twelve of those families supported by HVSA funding. Client caseload will be maintained as new clients are enrolled. Current NFP program staffing levels will be maintained: Supervisor 0.75 FTE; four Nurses at 0.8 FTE each; Office Assistant at 0.45 FTE. The team convenes weekly for trainings/case-conferences; nurses each have weekly reflective supervision. An outreach and recruitment plan will be utilized and reviewed monthly. No enhancements are added to Clark's NFP program.

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COMMUNITY NEED


Clark County Public Health (CCPH) is applying for Thrive funding to support critical sustainability of Nurse Family Partnership (NFP) in Clark County, specifically in the central Vancouver area. Clark County is the 5th most populous county in Washington, with a 2013 population of 435,500 (WA Office of Financial Management). Vancouver, the largest city in Clark County with a population of 163,200 (April, 2012, City of Vancouver website), has a densely populated, high-need, centrally located urban area. In the spring of 2011, as a result of a comprehensive, county-wide assessment of health risks and disparities to identify high-risk communities, a detailed neighborhood selection process was implemented for the Partnerships for Healthy Neighborhoods project (a collaborative effort lead by CCPH Chronic Disease Prevention program staff). Priority areas were identified using indicators related to chronic disease, school readiness, birth outcomes, safety, and demographics. Another sub-county area assessment was conducted for the Community Transformation Grant, for which a combination of factors including population density, poverty and health risk factors such as obesity and smoking rates were evaluated. The selected neighborhoods, located in central Vancouver, are home to the highest proportion of low income residents as well as minority ethnic groups. The following indicators from Central Vancouver and Clark County Birth Outcome Indicators* Table are significant: Significant to the population served by NFP (first time pregnant teens/women, low-income and enrolled prior to 28th week of pregnancy): Indicator Central Vancouver** Clark County Percent of births to women with a high school diploma or less 54% 13% Percent of births to unmarried women 44% 30% Percent of births to women who obtained prenatal care in the first trimester 70% 78% Percent of birth to women who smoked during pregnancy 18% 13% Percent of women who were overweight or obese before becoming pregnant 54% 23% *Data Sources: 2011 MCH Data Book, WA Dept. of Health; 2011 WA State Home Visiting Needs Assessment; 2012 SELF Early Learning Indicator Summary Tables; Vancouver School District data from 2011. **Central Vancouver includes zip codes 98661, with parts of 98662, 98663 and 98664 In addition, the WA State Home Visiting Needs Assessment shows that, compared to WA State, Clark County has a higher unemployment and higher domestic violence rate. Clark County Public Health has successfully provided NFP in Clark County since 2007. The program was implemented because it was at the forefront of community health programs supporting maternal and

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child health and has been shown through research to "deliver multi-generational outcomes that benefit communities and reduce the costs of long-term social service programs" (NFP Overview, NFP National Service Office). The following outcomes have been shown through at least one of the NFP research trials: • 48% reduction in child abuse and neglect • 56% reduction in emergency room visits for accidents and poisonings • 59% reduction in arrests at child age 15 • 67% reduction in behavioral and intellectual problems at child age six and • 35% fewer hypertensive disorders of pregnancy CCPH's NFP program is well established and highly valued by the clients served, by CCPH leadership, and by community partners. There has been stable staffing of NFP nurses, and positive client feedback, since the program began. CCPH's specialty trained nurses are uniquely qualified to address the needs of low income pregnant women, who often struggle with the impacts of poverty, abuse, low-educational attainment, and poor health. The women NFP serves tend to experience barriers such as: lack of knowledge about how to obtain health care coverage or a health care provider; language and cultural differences; lack of transportation; homelessness; isolation and lack of support. NFP improves pregnancy outcomes by helping at-risk women engage in preventive health practices that include: • seeing a prenatal care provider • improving their diet • reducing their use of cigarettes, alcohol and other substances NFP Improves child health and development by helping parents to: • provide responsible, nurturing and competent care • develop a vision for their future • continue their education • find work • become economically self-sufficient NFP is a relationship-based model, and utilizes registered nurses who are perceived as trusted and competent professionals, fostering a powerful bond between nurse and mother. CCPH's NFP nurses and supervisor are well connected in the community and work to assure coordinated efforts to serve low income pregnant and parenting families. Nurses assist clients in accessing resources to further their education, gain employment skills, address behavioral health issues and stop smoking. Health teaching is a key part of NFP, a comprehensive program that is client-centered and strengths-based.

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EXISTING REFERRAL RESOURCES List up to ten organizations to which you refer home visiting participants for additional resources, and indicate the primary services they deliver.

Organization Name

Primary Services


1. SeaMar: WIC (Women, Infants and Children Supplemental Nutrition Program

Health

2. YWCA Domestic Violence Prevention

3. ESD 112 (Educational Service District)

Early Childhood Development , Education

4. Columbia River Mental Health Mental Health

5. Division of Children and Family Services / Child Protective Services

Child Maltreatment Prevention , Child Welfare

6. DSHS (Dept. of Social and Health Services)

Health

7. ABCD (Access to Baby and Child Dentistry)

Health

8. Vancouver and Evergreen School Districts' Teen Parent Programs

Education

9. Lifeline Connections Substance Abuse

10. Sante Mama Lactation Support Health

Describe any community plan for coordination among existing resources in the county. 1. Enhanced coordination between the First Steps/Maternity Support Services Program (offered by SeaMar Community Health Center) and Nurse Family Partnership in order to assure reciprocity of referrals and coordination of services. 2. Expansion of the Teen and Young Parent Community Collaborative (a stakeholder group of representatives from agencies/schools working with pregnant and parenting teens/women), to include broader representation such as faith-based community and hospital family birth center social workers. Based on the information above, and your understanding of the community served, list referral resources that are needed to support families residing in the county, but which are not currently available. -In-Person Assisters to help clients access Medicaid; managed care plans -Mental / Behavioral health services for non-English speaking clients; teens

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-Affordable childcare; childcare during "off hours"---weekends; evenings; early AM. -Access to no-cost/low-cost safety devices such as smoke alarms and window guards, as well as safe cribs -A "relief nursery" to serve as a drop-in center for parents who have an urgent childcare need. -Teen parent programs in outlying school districts and/or transportation to existing programs Describe all existing mechanisms for screening, identifying and referring families and children to home visiting programs in the community. There are a range of entry points and a "no wrong door" approach to helping pregnant and parenting families in Clark County access services. Through outreach and participation in many community collaboratives, there is a broad awareness of programs serving young families. Examples include: Home Visitor Forums; Community Health Access Resource Group (CHARG); Ready Families (a sub-group of SELF---Support for Early Learning and Families); Clark County Interagency Coordinating Council and the Teen and Young Parent Community Collaborative. The following agencies/programs are represented on these community groups: Nurse Family Partnership, Pregnancy Partners, Library, WIC, DSHS, Housing; Head Start / Early Head Start, healthcare providers, teen-parent programs, Medicaid Managed Care Plans, Early Support for Infants and Families program (ESIT); Child Protective Services; legal and juvenile justice system.

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HVSA Logic Model Organization Name: Clark County Public Health Home Visiting Model: Nurse-Family Partnership Date: November 8, 2013



Target Population: Low income, first-time pregnant women living in central Vancouver, with priority given to women of minority ethnic groups, specifically Hispanic, African American and mixed race. Target Geographic Area: Central Vancouver Staffing: Public Health Nurses Home Visiting Curriculum Used: NFP visit guidelines Partners in Parenting Education (PIPE) Funding Sources: -Clark County: General

1: Staffing 1.1: Maintain existing staff

2: Training 2.1: NFP staff will participate in initial and ongoing training and education as required by NFP National Service Office. 2.2: NFP supervisor will participate in ongoing training, education, and consultation as required to support quality, fidelity, and specific population needs. 3. Outreach/Recruitment 3.1: Existing caseloads will be maintained 3.2: Maintain outreach and referral plan to reach target

1.1: Maintain existing staff: 0.475 FTE Nurse Home Visitors (NHVs) 2.1: NFP Supervisor and NHVs will participate in Dyadic Assessment of Naturalistic Caregiver-Child Experiences (DANCE) education and other program updates when scheduled. 2.2: NFP Supervisor will participate in: - 1 monthly Supervisor Community of Practice call -1 quarterly Supervisor Community of Practice meeting - annual 3 day National Education Symposium in Denver -monthly individual consultation calls with state nurse consultant

3.1: The 0.475 FTE NHV

Measure 1 Nurse home visitors and supervisors are registered nurses with a minimum of a Bachelor's degree in nursing. Measure 2 Nurse home visitors and nurse supervisors complete core educational sessions required by the Nurse-Family Partnership National Service Office and deliver the intervention with fidelity to the NFP Model. Measure 3 Client meets low-income criteria at intake as defined by program. Measure 4 Client is enrolled in the program early in her pregnancy and receives her first home visit by no later than the end of the 28th week of

1. Prenatal Care 2. Parental Use of

alcohol, tobacco, or illicit drugs

3. Preconception Care 4. Inter-birth Intervals 5. Screening for

maternal depressive symptoms

6. Breastfeeding 7. Well-child Visits 8. Maternal and Child

Health Issues 9. Visits for children to

the emergency department from all causes




13. Reported suspected maltreatment for children in the

Improved Maternal and Newborn Health Child Abuse and Neglect; Reduction of ER Visits

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Fund Contribution; -Centers for Medicare & Medicaid Services: Federal Medicaid; -Centers for Medicare & Medicaid Services: Medicaid Administrative Match Data System(s): NFP National Service Office: Efforts to Outcomes (ETO); Clark County Public Health: Insight

population and maintain caseload 3.3: Monitor effectiveness of outreach plan 4: Home Visits 4.1: Provide home visits for first time, low-income pregnant women, mothers and infants 4.2: New clients will be enrolled before 28 weeks of pregnancy and receive visits according to NFP guidelines 4.3: Content of home visits will be aligned with NFP guidelines 5: Supervision 5.1: Staff who provide home visits

will maintain a caseload of 12 clients with the HVSA funding. 3.2: Supervisor will have a written plan for cultivating relationships with referral sources and community partners including in-person contacts, follow-up visits and/or letters and/or calls, and community presentations. 3.3: Supervisor will use ETO data on enrollment by referral source to monitor effectiveness and adapt plan. 4.1: 12 clients (with HVSA funds) will each receive, on average, two home visits per month according to the NFP standard and/or flexible visit guidelines 4.2: 12 clients enrolled by 28 weeks of pregnancy; 60% enrolled by 16 weeks of pregnancy. Quarterly average completed to expected visit ratio will be: Pregnancy completers: 90% Infancy completers: 90% Toddler completers: 90% 4.3: The quarterly average Maternal Role Domain will be:

Pregnancy: 23-25% Infancy: 45-50%

pregnancy. Measure 5 Client is visited throughout her pregnancy and the first two years of her child’s life in accordance with the current Nurse-Family Partnership Guidelines. Measure 6 A full-time nurse home visitor carries a caseload of no more than 25 active clients. Measure 7 A full-time nurse supervisor provides supervision to no more than eight individual nurse home visitors. Measure 8 Nurse home visitors and nurse supervisors collect data as specified by the Nurse-Family Partnership National Service Office and use NFP reports to guide their practice, assess and guide program implementation, inform clinical supervision, enhance program quality and demonstrate program fidelity.

program 14. Reported

substantiated maltreatment


16. Parent support for children’s learning and development

17. Parent knowledge of child development and of their child’s developmental progress








25. Screening for domestic violence

26. Referrals for domestic violence services for

Improvements in School Readiness and Achievement Domestic Violence

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will receive individual reflective supervision 5.2: All staff will participate in reflective case conferences 6: Continuous Quality Improvement 6.1: Supervisors and nurse home visitors will review and utilize their data 6.2: Data is used for quality and fidelity monitoring and improvement

Toddler: 40-45%

5.1: Supervisor will provide individual, 60 minute reflective supervision sessions three times per month for each NHV 5.2 Reflective case conferences are held twice a month for 1.5 -2 hours. 6.1 Supervisors will review ETO quarterly reports with NHVs and State Nurse Consultant (SNC) and use this data to create the Annual Plan. 6.2 Supervisor and SNC review Annual Plan quarterly.

families with identified need


28. Household income and benefits

29. Maternal Employment or Education

30. Health Insurance Status

31. Number of families identified for necessary services

32. Number of families that required services and received a referral to available community resources


34. Information sharing 35. Number of

completed referrals

Family Economic Self-Sufficiency Coordination and Referral

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V. IMPLEMENTATION CAPACITY ORGANIZATIONAL CAPACITY Provide the mission of your organization and describe how your home visiting program advances the mission. A. Mission Clark County Public Health (CCPH) is a county department overseen by the Board of Health, which is comprised of three county commissioners. The mission of CCPH is to prevent disease and injury; promote healthier food choices; protect food, water, and air; and prepare for emergencies. The vision of CCPH is active, healthy families and people of all ages, abilities, and cultures living, playing, and working in thriving communities. We value: o Prevention of disease and promotion of health; o Collaboration with community partners o Data-driven, science-based services that ensure effective public health interventions. o Social justice and diversity o Customer service and accountability o Skilled and innovative employees B. Experience providing home visiting CCPH has been delivering nurse home visiting services for over 60 years to the maternal-child health (MCH) population. While services have changed over the years, the focus has remained on health and well-being of mothers (families) and children. Currently, we offer limited Nurse Family Partnership services and care coordination for medically fragile children. C. Additional program services As an organization, we have provided public health services since August 3, 1945. We served Southwest Washington, Cowlitz, Skamania and Klickitat counties from 1971 until 1997 when Klickitat County formed its own health department. In 2002, Clark County became a County department, no longer serving Skamania and Cowlitz counties. D. History of successful compliance with a grant agreement or contract Our Financial Management System (FMS) allows us to allocate revenue and expenditures by funding source, program, project, and activity. The Department is able to manage a range of grants and contracts successfully. We have never had audit findings; audit files are available upon request. The Department has a proven ability to work closely with funders to fulfill grant deliverables and reporting needs. hg F. Plans for continued funding

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CCPH has maintained the NFP program since September of 2007. Clark County Commissioners have provided generous funding for the program. Receiving grant revenue will show that there is state support for this program and could help to leverage funds in the future. Clark County Public Health's Mission is: "Your Good Health", and the vision of "active, healthy families and people of all ages, abilities, and cultures living, learning, working, and playing in thriving communities". We believe that "through partnerships we will influence conditions that promote good health for everyone because good health occurs when family and community environments provide all of us the opportunity for a healthy start and healthy choices where we live, learn, work, play, and worship". NFP promotes healthy starts and is part of the strategic initiative: Increase opportunities for every child to have a healthy start.

Describe the structure and management of your organization. How does it facilitate effective program implementation? Describe any opportunities for better alignment between administrative infrastructure and program implementation. Clark County Public Health has a leadership team that works closely with the eight program managers. The Leadership Team includes a director (who is also the county Health Officer), the Chief Operations Officer, Chief Administration Officer and Chief Performance Officer. A Public Health Advisory Council meets monthly. The leadership team has frequent communication with the county administrator and the three County Commissioners who make up the Board of Health. Public Health presents "public health in action" stories to the Board of Health monthly, the goal being to educate them about the public health department's role, and programs such as NFP. Describe your organization's track record of success managing complex, multi-year grants. Clark County Public Health has a long history of managing federal, state and local grants from government and private funders. Programs supported by grants include HIV Prevention, HIV Case Management, Communicable Disease, Children with Special Health Care Needs, and Chronic Disease Prevention. Our department has a grants manager who assists program managers with tracking grant/program deliverables. Work plans are developed to guide the projects/activities in order to achieve desired outcomes. Monthly and quarterly performance reporting by staff and managers helps the leadership team be aware of the status of meeting grant deliverables. Organizations in Washington are implementing home visiting services in very diverse communities. Describe how your organization supports culturally competent service delivery through policy and practice. All-staff diversity trainings occur every one to two years, with staff also seeking out such training on their own. For example, an NFP nurse attended a conference addressing the disparity in breastfeeding rates among different ethnic groups. Our values include recognition that everyone's health matters equally, and that services and solutions must be accessible, affordable, and appropriate for all. As vigilant stewards of the public's trust, we provide services that are responsive and accountable to the community's needs. A well-trained, dedicated, creative and diverse workforce is the foundation of our ability to assess and address the health of the community. Describe your organization's plan for sustaining home visiting services. We will continue to educate the Clark County Board of Health, and the Public Health Advisory Board, about NFP's proven short and long term impacts and the return on investment associated with NFP. We will maintain an NFP advisory board that is part of the Teen and Young Parent Community Collaborative. We will assure communication with health care providers and other community partners who make

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referrals to NFP, with goals of coordinated care for our mutual clients and stable referrals sources that are available to advocate for the benefits of NFP to their clients. PARTICIPANT OUTREACH, ASSESSMENTS, AND TIMELINE TO REACH MAXIMUM CASELOAD Describe your plan to enroll the populations you propose to serve. Include information on how clients are referred, engaged, recruited, and/or enrolled into your program. (Provide examples of community-based organizations and local agencies that refer children and families to your program as well as the frequency and duration of outreach.) Long term partnerships have been a key factor to a steady flow of referrals to Clark County Public Health's NFP program. Referrals come from Clark County's two largest school districts, Vancouver and Evergreen, both of which have teen parent programs called GRADS (Graduation, Reality and Dual-Role Skills); prenatal care providers; hospital social workers; and the Medicaid managed care plans. Referrals to NFP also come from Sea Mar, a Federally Qualified Health Center, which oversees the WIC program and Maternity Support Services, as well as from our own patient navigator program called Pregnancy Partners, that assists low-income teens/women in accessing medical coverage and a prenatal care provider. Outreach includes distribution of NFP referral forms, brochures and posters to offices/businesses where women of childbearing age congregate; presentations to child welfare, juvenile and adult probation officers, Columbia United Providers (a physician group that serves Medicaid clients), a community collaborative called CHARG (Community Health Access Resource Group) and to school nurses and counselors. Outreach includes inviting representatives from local organizations, such as Partners in Careers, or the YWCA Domestic Violence program to attend our NFP team meeting for mutual sharing about programs/services. Outreach activities are tracked as they are carried out throughout the year. Referrals are received by fax, phone call or mail. Nurses take turns triaging and calling new referrals to offer NFP. Letters and an NFP brochure are sent to clients not reached by phone. Feedback is given to referring doctor or agency about outcome of the referral. Does your home visiting program currently engage families and children in the child welfare system? If so, in what ways? There are currently five NFP clients on the nurses' caseload that are in foster care or have a relative as a guardian. Child protection workers refer pregnant teens to NFP. As mandatory reporters, the NFP nurses, on occasion, make referrals to Child Protective Services (CPS). The NFP nurse works closely with CPS staff to assure coordination of services in order to help the family obtain their goals. Nurses are often invited to Family Team Decision Making meetings, convened by the CPS worker. The nurses recently attended a CPS staff meeting to share about NFP. What strategies or activities are included in your home visiting plan for engaging families and children in the child welfare system going forward? Ongoing coordination of services when we share mutual clients, including attending wrap-around / Family Team Decision Making meetings. Meeting with each other's staff at least one time per year to share about each other's services, referral processes, etc. Attending community collaboratives that include child welfare staff. Are individualized assessments of enrolled participant families conducted? Yes If YES, describe how referral to services are provided in accordance with those individual assessments

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Assessments include the Edinburgh Postnatal Depression Screen. Referrals are made to medical and behavioral health providers for treatment of depression and other mental health concerns. Another assessment is the Ages and Stages Questionnaire, administered by the NFP nurse during the child's first and second year of life. If the screening identifies any potential concerns, the parent is referred to ESIT (Early Support for Infants and Toddlers) where further developmental assessments can be arranged at no cost to the parent. NFP nurses also screen for domestic violence, referring clients to the YWCA where there are advocates that can assist the client. Provide an estimated timeline to reach maximum caseload. Our nurses each work 0.8 FTE, and currently have caseloads that are at, or near, the goal of 18 to 20 clients (pro-rated from the NFP guideline of 23 to 25 clients per 1.0 FTE). We have a steady flow of referrals, making it easier to keep NFP caseloads up. HOME VISITING MODEL NATIONAL TRAINING, TECHNICAL ASSISTANCE, AND SUPPORT Present a plan for working with the national model developer and Washington State Model Lead. Include the frequency and duration of the current support available from both the national model and the Washington State Lead for: a) initial and ongoing training and professional development, and b) initial and ongoing technical assistance and support. NFP has a structured training plan for nurse home visitors, nurse supervisors and NFP implementing agency administrators. Training takes place in Denver, CO, at NFP headquarters, as well as remotely by webinar. Most years, in the spring, a training symposium is held in Denver for NFP supervisors. There are NFP nurse consultants in each region of the United States. Washington State has its own nurse consultant, Quen Zorrah, who is employed by Thrive by Five. She works with local implementing agencies, including Clark County Public Health, to assure fidelity to the NFP model. Quen convenes NFP nurse supervisors from around the state in what are called "community of practice" calls monthly, and in-person quarterly. Topics for these calls and meetings have included Reflective Supervision, the impact of adverse childhood experiences on early brain development, and screening for peri-natal mood disorders (maternal depression). There are also opportunities for sharing and updating each other about our programs. We learn from each other about continuing education opportunities, or books that are relevant to the NFP program. We support each other through challenges facing our organizations such as budget shortfalls, and share ideals about advocating for NFP in our communities and with policy makers / funders. STAFF SELECTION, TRAINING, AND RETENTION STAFF SELECTION List the qualifications (education, credentials, experience, etc.) and skills recommended and/or required for home visitors by the home visiting model/program. Indicate if qualifications include cultural competency and language accessibility recommendations or requirements. Nurse Family Partnership, and Clark County Public Health (CCPH) require registered nurses with bachelor's degrees (BSN) to provide NFP services. Nurses attend and participate in all core NFP education sessions before they initiate home visits. This training assists nurses to know what is expected of them, allows them to understand how to deliver the program with fidelity and orients them to the NFP program philosophy and materials. Cultural competency is central to the NFP training and to the values and policies of Clark County Public Health. Bi-lingual capability is encouraged.

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If your program requires any additional staffing qualifications beyond those required by the developer, list and describe those qualifications. Clark County Public Health has an orientation plan which introduces Home Visitors to the department mission, structure, and policies. Staff develop individualized development and training plans each year as part of the Review process. Clark County Public Health values staff development highly and includes $350.00 per employee for this activity each year. Annual Performance Review and Evaluation which includes home visit observations provides an opportunity for feedback. Team meetings have a training component at least two times/month. One of our NFP nurses has her certification in Public Health Nursing through PHN Ready, and another is working on hers. Do you have adequate staffing capacity (both in terms of FTEs and alignment with identified service population) to implement your home visiting program as described in the proposal? Yes

If YES, briefly describe the existing staffing as it relates to the client volume and the unique needs of the population served. Staffing: four public health nurses, each working at 0.8 FTE. Each nurse carries a caseload of 18 to 20 clients (in keeping with the ratio set by the National Service Office of 25 clients per 1.0 FTE). Clients referred to our NFP program tend to be higher risk (three 13 year olds are on nurses' caseloads currently), and often have mental health needs or special health conditions such as Type 1 diabetes. Health care providers are one of our main sources of referrals and we believe it is because of their confidence in referring their patients to registered nurses.

If NO, please describe the recruitment plan and the timeline for recruiting and hiring staff. What is the timeline for obtaining all necessary training for new staff to implement the home visiting model? When new staff are hired, they would be scheduled for the next available NFP on-site training at the NFP headquarters in Denver, CO. The nurse would be given time to complete the on-line portion of NFP training that is required before and after attending on-site training. The nurse would shadow the experienced NFP nurses on home visits, complete our agency orientation and, ideally, would meet with the state nurse consultant within a month of being hired. Typically a new nurse would be able to begin seeing clients on her own within two months of being hired.


List all initial and ongoing professional development activities provided by the implementing organization(s). Training in Motivational Interviewing; Adverse Childhood Experiences (ACEs) and Trauma Informed Care; opportunity to participate in online P.H. nurse certification course called PHN Ready (strongly encouraged but not yet required). Staff develop individualized development and training plans each

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year as part of the Review process. Clark County Public Health values staff development highly and includes $350.00 per employee for this activity each year. Does your organization provide any training to staff beyond that required by the model/program developer, including any racial equity and/or cultural competency training? If so, describe. Yes--- diversity/cultural competency trainings are part of yearly all-staff trainings. Staff are also encouraged to use their training hours/funds to attend such training. For example, one of the NFP nurses recently attended a conference related to disparities in breastfeeding rates among different ethnic/racial groups. Clark County Public Health prides itself in having a "health equity" view in all of its programs, and encourages all employees to look at the publics' health and social needs through a health equity "lens".

STAFF RETENTION

What mechanisms are in place to retain all staff in the program(s)? Public Health Nursing Staff are union represented and receive benefit and wage packages comparable with public agencies throughout the state. The NFP model is also designed with staff retention in mind. The weekly required reflective supervision between the supervisor and nurse contributes to a supportive relationship and the opportunity to problem solve or recognize successes in a timely manner. The culture of Clark County Public Health also contributes to staff retention. Nurses are highly valued for their knowledge, skill, demeanor and passion for the clients they serve. CLINICAL SUPERVISION AND REFLECTIVE PRACTICE What training is provided to support clinical supervision/reflective practice? The NFP on-site training for supervisors includes training in reflective supervision. The WA state nurse consultant has made reflective supervision a priority topic during the monthly supervisor calls as well as at the quarterly in-person meetings. The supervisors read a book "together" on reflective supervision, discussing the chapters during our meetings. Clark's NFP supervisor has made improving reflective supervision skills one of her priority goals for 2014. Are there currently individuals on staff/in your community who are providing this supervision? Yes If YES, what is the frequency and duration of the supervision provided? The NFP nurse supervisor provides weekly reflective supervision. In addition, it is a goal of Clark's team to engage a licensed mental health clinician to provide two to four hours of clinical supervision/case consultation each month. If NO, please describe the recruitment plan and the timeline for recruiting and hiring supervisors.

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VI. FIDELITY AND QUALITY ASSURANCE MONITORING, ASSESSING, AND SUPPORTING IMPLEMENTATION WITH FIDELITY AND ONGOING QUALITY ASSURANCE How does the home visiting program(s) participate in fidelity monitoring and/or quality assurance through the national model developer and Washington State Model Lead? Clark's Team of four Bachelor of Science (BSN) registered nurses carries out the NFP program based on NFP's 18 Model Elements. Examples include Model Element Number 12: nurses don't exceed maximum caseload of 25 clients per full time equivalent (pro-rated to 20 clients for 0.8 FTE); and Model Element Number 14: weekly individual clinical supervision for each nurse; weekly team meetings for training and/or case conferencing. Supervisor and NFP state nurse consultant review quarterly reports from NFP National Service Office (NSO), which include local, state, and national NFP data. Supervisor then provides feedback to nurses about how the Clark team is doing in relation to state, nation and NFP-NSO benchmarks/goals. Nurse supervisor participates in monthly one-on-one conference calls with NFP state nurse consultant; monthly community of practice conference calls, convened by state nurse consultant, with NFP supervisors from around WA state, as well as quarterly in-person nurse supervisor meetings. What additional monitoring, assessing, and supporting implementation with fidelity and quality assurance does the home visiting program participate in? (i.e. if currently receiving technical assistance from HVSA please describe) Internal monthly and quarterly data reporting as part of Clark County Public Health's performance management / quality assurance system. Nurse supervisor looks at: number of clients served, number of hours of client contact, total completed visits, number of clients enrolled in NFP, number of babies (of NFP moms), percent of babies breastfeeding at six months of age, percent of children with up to date immunizations at age two, and number of clients who graduate from NFP. Monitoring and quality assurance is also done through home visit observation, weekly reflective supervision with nurses, and weekly team meetings. Does your organization conduct fidelity tracking or quality assurance on its own? If YES, please describe. Yes, as stated above, through internal performance management system which includes monthly and quarterly program reporting and yearly NFP performance "snapshots". The information is useful to Clark County Public Health's Leadership Team, providing them with data that can be shared with community partners and policy makers. Identify two to three model-specific fidelity measures and describe challenges to maintaining quality and fidelity when implementing in the proposed service area with the identified population. Clark consistently meets Model Element #4: clients enroll in NFP prior to 28 weeks gestation. NFP set an objective of 60% or greater enroll by the 16th week of pregnancy. Clark's rate is 32.5% (WA 44.1%; national 44.8%). Early engagement allows the nurse to assess areas such as tobacco use, provide education and refer to community resources. Central Vancouver is known to have greater rates of poverty, domestic violence, low education levels and tobacco use. It is imperative that Clark has a consistent outreach plan for central Vancouver and contacts women referred to NFP in a timely manner.

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Model Element #18, assuring data is accurately entered into the NFP-ETO database in a timely manner, is an ongoing challenge. Clark's NFP nurses carry high acuity caseloads, with clients experiencing many life challenges such as homelessness or domestic violence. The nurses work hard to balance addressing their clients' needs with timely paperwork submission. Demographics of central Vancouver indicate that nurses are likely to have higher acuity clients from that area. Clark's NFP program is moving towards an electronic medical record which will improve timing of data entry. Until then, system improvements to address timely documentation and submission of paperwork is a priority. Describe all enhancements that are currently being made by the home visiting program(s). There are no model enhancements being used at this time. What is the average rate of attrition for program participants? What is your plan to reduce attrition? The 2013, Quarter Three NFP data report shows cumulative average rate of attrition for Clark's NFP program to be: • 13% in pregnancy (WA 9.5%; National 15.4%; NFP objective is 10% or less) • 30.7% in infancy (WA 24.9%; National 33.3%; NFP objective is 20% or less) • 21.3% in toddlerhood (WA 23.2%; National 18.2%; NFP objective is 10% or less) Client engagement and retention is a continual theme in weekly reflective supervision meetings as well as during team meetings. The team plans to take advantage of training materials available on the NFP website, and the NFP supervisor will review plans for reducing attrition rate with the NFP state nurse consultant as part of monthly consultation calls.

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Does the national home visiting model have a database that program(s) implementing the home visiting model are using? Yes If YES, does the lead organization, and subcontractor organizations implementing the home visiting program, use the national model database? Yes; Efforts to Outcomes (ETO), a holistic approach to quality assurance and improvement to help NFP sites achieve program implementation as designed, fidelity to NFP model and targeted outcomes. Home visit data is entered into ETO database; NFP supervisors can then pull data from the Reporting Portal.


1. Demographics Pregnancy Intake, Infancy 6 and 12 months, Toddler 18 and 24 months.

2. Maternal Health Assessment Pregnancy Intake 3. Health Habits (Mother) Pregnancy Intake, Pregnancy 36 weeks, Infancy 12

months 4. Use of Government and Community Services Pregnancy Intake, Infant's birth, 6,12, 18 and 24

months 5. Relationship Assessment Pregnancy Intake, Pregnancy 36 weeks, Infancy12

months 6. Infant Birth Form First infant home visit 7. Infant Health Care Infant age 6, 12, 18 and 24 months. 8. Home visit encounter form Every home visit or attempted home visit 9. Patient Health Questionnaire Pregnancy Intake, Pregnancy 36 weeks, Infant 1-8

weeks, 4-6 months and 12 months 10. Ages and Stages Questionaire (ASQ-3) 4, 10, 14 and 20 months of age 11. Ages and Stages Questionnaire, Social-

Emotional 6, 12, 18 and 24 months of age

12. Edinburgh Postnatal Depression Scale Intake, Pregnancy 36 weeks, Infancy 1-8 weeks, 4-6 months and 12 months.

13. (see below) 14. HOME Inventory Infancy 6 months, Toddler 18 months 15. Joint Visit Observation form Baseline, 4 months, 8 months, then annual 16. 17. 18. 19. 20.

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If NO, how does the lead organization, and any subcontractor organizations implementing the home visiting program, track data? Are there other data systems being used? Who is responsible for collecting the data? The NFP nurses collect the data on NFP-ETO forms during home visits. Example of data being tracked: the timing of developmental screenings (Ages and Stages Questionnaires) administered by nurses to the infants/toddlers of the NFP mothers on the nurse's caseload. Who is responsible for data input? The NFP Office Assistant, Jan Schmalenberger. Who analyzes and reports the data? NFP NSO compiles some of the data and provides quarterly reports that compare our local data with WA data. Clark NFP Supervisor, Pat Shaw, can pull timely reports from the ETO website. The WA NFP nurse consultant, Quen Zorrah, also has access to the data. Once analyzed, how is the data used for continuous quality improvement? NFP supervisor and State nurse consultant review quarterly data reports together. Supervisor shares data with NFP team so that they can see how their activities and outcomes compare with rest of state. Team is made aware of strengths and areas that can use improvement. The nurse consultant's suggestions are considered when team is problem solving about how to improve outcomes. Example: Clark County, and especially central Vancouver, has a higher maternal smoking rate than WA state. Nurses reviewed their tobacco interventions, participated in Motivational Interviewing training and worked with a nurse intern to develop "Stages of Change" cards for use when talking to clients about their readiness to quit tobacco use. Quit Kits were assembled, to be given to clients as a tool to help them achieve their goal of reducing and, ideally quitting, tobacco use. In addition, clients are told about smoking cessation classes and WA State Quit Line.

PERFORMANCE SNAPSHOT



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Clark Fidelity Summary

Clark County Public Health is dedicated to the Nurse Family Partnership (NFP) program being delivered with fidelity to the model. Departmental supports are in place to assure program supervisors interpret and utilize data in the most useful way possible. Performance goals and measures are identified with input from the NFP team. Quarterly reports from the NFP National Service Office, and monthly calls with the NFP state nurse consultant, help the NFP supervisor identify where the team is strong in meeting fidelity measures and where improvement is needed. The supervisor then shares that information with the nurses.

Clark’s program is strong in meeting fidelity measures, called Model Elements, in the following areas:

NFP Model Element # 10: “Nurse Home visitors, using professional knowledge, judgment and skill, apply the NFP Visit-to-Visit Guidelines, individualizing them to the strengths and challenges of each family and apportioning time across defined program domains.”

Clark’s NFP team is made up of four experienced public health nurses who actively seek out knowledge and new skills. They are a strong team and supportive of one another’s success. The nurses share ideas formally as part of team meetings, and informally in the office space they share. An example is when one of the nurses, Joan, shared how she uses the NFP curriculum drawings depicting different stages of readiness to change. Joan had turned the drawings into individual, laminated “stages of change” cards. She demonstrated for the team how she uses the cards as a tool when helping her clients identify their readiness to adopt more healthful behaviors, such as quitting smoking. This led to a project for a public health student intern who made a set of cards for each nurse. She first listed motivational interviewing-style phrases on the back that can be prompts for the nurse when talking with her client.

Related to Model Element #10 is the percent of time nurses spend addressing subject areas, or domains, with their clients. The NFP domains are: Personal Health, Environmental Health, Life Course, Maternal Role, Friends and Family, and Health and Human Services. Each domain is intended to be emphasized a certain percentage of time during pregnancy, infancy and toddlerhood. NFP Quarterly data reports indicate Clark’s program is within, or close to, the range recommended for delivering program content in each of the domains.

NFP Model Element #11: “Nurse home visitors apply the theoretical framework that underpins the program, emphasizing Self-Efficacy, Human Ecology and Attachment theories, through current clinical methods”.

Clark’s team of public health nurses have a great deal of expertise in human development and the impact early life experiences can have on the clients they serve. NFP, and the field of Public Health, emphasizes a holistic approach to work with individuals and families. Considering the client’s environment and how they interface with the community is key to providing client centered interventions.

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Clark Tools and Measures Summary

Performance data provided by NFP Quarterly Reports is useful to sites implementing NFP. The report includes comparative data, listing Clark County, Washington State, and National NFP performance statistics. Cumulative data, spanning the six years CCPH has provided NFP, shows strengths in the following areas: “Education Status over Time for Clients without a High School Diploma/GED”: Clark has a higher rate of school enrollment for NFP moms at time of intake, and at six, 12, 18 and 24 months postpartum, when compared to both WA State and National NFP data. Example: at 24 months, 36.7% of Clark’s NFP moms are enrolled in school compared to WA State at 22.6% and National at 19.7%.

The successful school enrollment rate is attributed to strong community support for teen parents continuing their education. The two largest school districts in Clark County have teen parent programs called GRADS (Graduation, Reality and Dual-Role Skills). Referrals are made between GRADS and the NFP program. NFP nurses work closely with the school nurses and/or case managers in the GRADS program. There is strong representation of GRADS staff at the bi-monthly stakeholder meetings---the Teen and Young Parent Community Collaborative.

“Cumulative-Subsequent Pregnancy at six, 12, 18 and 24 Months Postpartum”: At 12, 18 and 24 months, Clark’s percent of NFP clients experiencing a subsequent pregnancy is lower than the WA State and National rates. At six months, Clark, at 4.8%, is in line with WA State (4.6%); the National percent at six months is 3.7%. An example of data beyond six months: at 18 months postpartum, 12.2% of Clark NFP clients have had a subsequent pregnancy, with WA State at 21.8% and National at 21.9%.

Pregnancy planning is emphasized by the NFP program. When women are able to space their pregnancies, they are more likely to finish school and learn job skills. Overall, women enrolled in NFP tend to have fewer subsequent babies overall. Clark’s nurses have family planning teaching kits they take to the client’s home. Clients are encouraged to see their health care provider for their birth control needs. Recent research conducted by Oregon Health and Sciences University, with participation by Clark’s NFP nurses, is looking at the potential benefit of NFP nurses offering some forms of birth control in the home for clients who have barriers to accessing birth control at clinical sites.

“Cumulative (administration of) Ages and Stages Questionnaire (ASQ)”: The infants/toddlers of NFP clients are screened for developmental delays, using the standardized Ages and Stages Questionnaire, at four, ten, 14 and 20 months, following NFP guidelines. Clark’s rate of screening is higher than WA State and National rates. An example is at 20 months, 92.5% of Clark toddlers were screened for developmental delays, compared to 68.3% at WA State level and 82.3% National level. The goal of early and frequent developmental screening is to ensure infants/children with potential delays are identified as early as possible so they can be referred to early intervention services. Clark’s NFP program has a close working relationship with the local Early Support for Infants and Toddlers (ESIT) program which is the entry point for early intervention services for children age 0 to three years of age. Public Health staff participates in community coalitions that are looking at improving rates of routine developmental screening, including the development of a “road-map” for early intervention services that is nearly finalized so that it can be distributed in the community.

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HOME VISITING MODEL: Nurse Family PartnershipPeriod: 1/01/14--12/31/14






Rowland, Barbara, Public Health Nurse $23,983.00 Actual projected personnel costs. This respresents 0.2375 FTEDaphne Beck, Public Health Nurse $20,872.00 Actual projected personnel costs. This respresents 0.2375 FTE

The public health nurses (PHN's) listed will focus on enrolling into NFP a minimum of 12 pregnant teens / women living in central Vancouver, a geographic area that has been identified as having more females of childbearing age at risk for poor health / birth outcomes. PHN's will use the NFP curriculum/guidelines during homevisits that occur two to four times / month until the child turns two y/o.


C. Travel $600.00Local Mileage/Staff Travel $600.00 Projected actual travel costs (local mileage) @ $50 per month.

NFP is a home visiting model. PHN's drive their personal vehicles to and from home visits and are reimbursed for mileage at rate of 0.565 cents/mile.







J. Indirect Charges if not included above $4,545.00Indirect Costs $4,545.00 Indirect costs budgeted at grant maximum allowable of 10%. Agency Federally

Negotiated Indirect Rate (FNIR) at 34.4% for 2013.K. TOTAL $50,000.00

Clark County Public Health


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November 18, 2013 Thrive by Five Washington 1111 Third Avenue #210 Seattle, WA 98101 Re: State Fiscal Year 2014 Home Visiting Services Account Evidence-Based Funding Opportunity Dear Grants Manager: As chair of the Clark County Public Health Advisory Council (CCPHAC), I am writing in support of Clark County Public Health’s (CCPH) application for Home Visiting Services Account Evidence-Based Funding to sustain funding for the Nurse-Family Partnership (NFP) program. The NFP is an evidence-based home visiting program for low-income, first-time mothers that improves pregnancy outcomes, child health and development, and economic self-sufficiency for the family. The CCPHAC was created to identify public health priorities and advise the Clark County Board of Health on improving the health of the citizens of Clark County. Healthy children and healthy communities were identified by the council as overall umbrella priorities for improving our community’s health. Promoting the health and well-being of women before birth through pregnancy and beyond is critical for ensuring healthy births and healthy children. Public health can most effectively improve the health of populations through evidence-based health interventions using a public health systems approach. CCPH has been hit by severe budget cuts in the past few years, which means that the NFP program is extremely vulnerable. NFP is funded largely with county general fund dollars. It is not a mandatory program, nor is funding leveraged by matching dollars. If county revenues are decreased as a result of falling sales tax revenues, or state legislative actions, NFP is one of the few programs CCPH can cut. It is critical that the program receive diversified funding if it is to be sustained in the county budget. The NFP program is evidenced-based, high-intensity, long-term, and relationship-based, and it is a vital component of the continuum of services to families with children in Clark County. We strongly support CCPH’s application for funding to continue this very important work in our community. Sincerely,

Laurie Lebowsky, Chair Clark County Public Health Advisory Council

Advisory Council 1601 East Fourth Plain

P.O. Box 9825 Vancouver, WA 98666-8825

(360) 397-8000

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I. ORGANIZATIONAL INFORMATION ORGANIZATIONAL INFORMATION Organization Name: Thurston County Public Health and Social Services City: Olympia State: WA Zip Code: 98506 Physical Address: Tax ID: 916001375 DUNS #: 126801914 Full-Time Equivalents (FTEs): 65.50 Organization Budget: $8,659,348.00 Organization Fiscal Year-End: 12/31/13 Sources of Income %:

Government: Federal (12%) Government: State (20%) Government: County (14%) Private: Fees/Earned Income (50%) Other (4%) Other Description: Treatment Sales Tax


Chief Executive Information Name: Mr. Don Sloma Title: Director Home Visiting Manager Information: Name: Ms Gretchen Thaller SUBCONTRACTOR ORGANIZATION 1 Organization Name Physical Address SUBCONTRACTOR ORGANIZATION 2 Organization Name Physical Address SUBCONTRACTOR ORGANIZATION 3 Organization Name Physical Address

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Select the home visiting model you are implementing with the HVSA funds. Nurse-Family Partnership (NFP) If you selected “Other,” please provide the name of the model/program: Indicate how long your organization has been operating this home visiting program for which you are requesting funding: More Than 5 Years Has your organization ever been previously funded through the Home Visiting Services Account or the Council for Children & Families to implement the home visiting model selected above? Yes COMMUNITIES SERVED Select the county you will serve with this funding. Western Washington\Thurston County

Within the selected county, what specific geographic area will you serve? All of Thurston County Is this county/geographic area ranked in the Washington State Home Visiting Needs Assessment? No What number is the geographic area ranked in the Washington State Home Visiting Needs Assessment? 99.00 Is the county you are serving with this request primarily urban, rural or both? Rural (53%) Urban (47%) Age Group Served 0 to 3 Years Race/Ethnicity: American Indian/Alaskan Native Non-Hispanic Asian Non-Hispanic Black Non-Hispanic Hispanic Multiple Races Non-Hispanic Pacific Islander Non-Hispanic White Non-Hispanic

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Risk Factors: Involvement in the Child Welfare System Child maltreatment Disparities, multiple indicators High school dropout rates Low birth weight births Poor school readiness statistics Poverty Premature births Underserved HVSA FUNDING REQUEST INFORMATION HVSA FUNDING REQUEST Request Amount: $50,000.00 The amount requested for the estimated numbers served represents which of the following use of funds. Critical Sustainability If requesting funds for “Critical Sustainability” or “Critical Sustainability and expansion,” indicate the funding source and amount of funds you will be replacing in your program. Expected reductions of $50,000 in Medicaid Administrative Match funding in 2014 will be replaced with the funds requested through this grant. Provide the proposed numbers your organization will serve through HVSA Funding.


Cost per Child Served by HVSA Funding: $5,000.00 PROGRAM INFORMATION Total Home Visiting Program Budget: $777,116.00 Total Number of Children Your Organization will serve through the Home Visiting Program: 108 Cost per Child Served by the Program: $3,847.00 Percentage of Effort Represented by HVSA Funding: 6 List the primary funders of your home visiting program. Thrive by Five

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1/10th of 1% sales tax MCH Block Grant County General Funds Medicaid (Medicaid Administrative Match) PROJECT ABSTRACT Create a narrative description of your project, addressing the following information:




The Thurston County NFP program targets young, low-income first time mothers and their child until the child's 2nd birthday. The purpose of the evidence-based home visiting program is to improve pregnancy outcomes, improve parenting skills, improve healthy child development and parent/child attachment as well as promote school readiness for families at risk of child abuse, neglect, and poor educational outcomes. One specially trained nurse will maintain a caseload of 22-25 clients and approximately 28 per year. The nurse will provide home visits utilizing the NFP facilitators and guidelines to deliver weekly visits during the first 4 weeks of program enrollment and the first 6 weeks postpartum. Otherwise visits will be bi-monthly until the child is 21 months of age at which time the visits become monthly until the program ends at the child's 2nd birthday. Families graduating at their child's 2nd birthday will have received approximately 38 visits, each 60-90 minutes in length. The NFP staff includes 3.9 nursing FTE's, .5 FTE supervisor and .5 FTE program assistant. One nurse serves approximately 25 women and 20-22 children annually. The program as a whole serves 127 families including 94 children per year.

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COMMUNITY NEED


Thurston County has urban and rural areas varying greatly in risks and needs. Pockets within the County, often associated with extreme poverty, have health risks for children as high as or higher than anywhere in the state. In 2002, a Home Visitation Task Force created a plan for Thurston County, and identified NFP to serve high-risk, young, first-time moms. As a result, Thurston County NFP has been serving clients since 2004. Our most urgent community need is to reduce toxic stress in children growing up here. Estimates for adverse childhood experiences (ACEs) show that 32% of county adults experienced high ACEs (three or more) during childhood compared to 28% for Washington State as a whole. High ACE scores increase risk for poor health outcomes such as depression, substance abuse and adolescent pregnancy. In 2011, Thurston County ranked eighth among Washington counties in rate of high ACE scores. Child abuse, one of the most toxic experiences for a developing child, Increased by 31% between 2008 and 2011, from 1,166 to 1,529 child abuse victims reported to CPS. Local data shows that 22% of children with three or more ACEs are involved with CPS and 92% are receiving state economic assistance. NFP addresses the risk of intergenerational transmission of ACEs and toxic stress in two important ways. Through the nurse's teaching, encouragement and role modeling, 1) Mothers learn the importance of parenting skills not only for the baby's physical health, cognitive development, and social-emotional growth, but also for protecting the infant from the toxic stress that interrupts healthy growth and development of her infant. 2) NFP nurses teach and encourage skill development so clients learn how to parent and how to protect their infant from the toxic stress. Thurston County also needs to reduce the poverty level of families with children living in our communities. Clients referred into NFP come from areas of the county with the highest poverty rates and the highest birth rates. An example is the rural city of Yelm where about 10% of our current referrals reside. Yelm has a large presence of military residents and 13% of Yelm residents live in poverty -- the 2nd highest poverty rate in the county. Yelm also has the highest birth rate for women age 15 to 24 (76 per 1000 in Yelm vs 55 per 1,000 countywide). The city of Lacey and its environs contribute another 26% of current referrals. This area has the highest elementary school free/reduced meal eligibility in the county (Lydia Hawk = 73% of students) and a very high birth rate for women age 15-24 (66 per 1,000). Education through high school and beyond is an important means to lift a family out of poverty. Yet completion of education in rural and high-poverty areas of the county is a concern: Taking Thurston County as a whole, 15% of female high school students do not graduate on time; 3% drop out of school in 11th grade and 6% in 12th grade. In rural areas of the county, the educational outcomes are starker with 34% of Tenino and 22% of Yelm female students not graduating on time. Our NFP program maintains partnerships with schools, and is effective in keeping pregnant and parenting students working toward educational attainment and employment. Since 2010, 18% of participants enrolled in NFP were referred by a school. NFP nurses encourage clients and link them with

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resources to complete high school, attain a GED, or enroll in community college. They also encourage them to think about and plan for the future they envision for themselves and their children. They are successful: at 24 months 40.8% of the clients without a GED or HS diploma at intake completed their diploma/GED. According to national data, NFP clients worked 82% more than women that were not in NFP through their child's 4th birthday. Finally, birth outcomes in Thurston County are placed at risk by two issues: Potential racial factors and high smoking rates in young, reproductive age women. Through the support of NFP, we strive to address the needs of our minority racial populations; 9.6% of our caseload is multiracial. Thurston County also has high rates of smoking during pregnancy, especially in the demographic groups served by NFP, posing another risk for poor birth outcomes. Women ages 15 to 24 years have smoking rates ranging from 33% to almost 200% of statewide rates. Education and encouragement to reduce smoking has resulted in a 24% reduction in smoking by Thurston County NFP clients during their pregnancy. EXISTING REFERRAL RESOURCES List up to ten organizations to which you refer home visiting participants for additional resources, and indicate the primary services they deliver.

Organization Name

Primary Services


1. Seamar WIC Health

2. St. Peters Family Medicine Health , Mental Health

3. Parent to Parent Early Childhood Development , Education

4. Behavioral Health Resources Education , Mental Health , Substance Abuse

5. Safe Place Child Maltreatment Prevention , Domestic Violence Prevention

6. Seamar Community Health Health , Mental Health

7. South Puget Sound Community College

Early Childhood Development , Education

8. Crisis Nursery Child Maltreatment Prevention

9. Department of Social and Health Services

Child Maltreatment Prevention , Child Welfare , Health , Mental Health , Substance Abuse

10. Community Youth Services Education

Describe any community plan for coordination among existing resources in the county. In 2002, Thurston County Home Visitation Task Force published recommendations for implementing home visitation services. A continuum was described ranging from low risk (Parents as Teachers) to high risk (Nurse Family Partnership). The highest risk families that meet NFP criteria should be encouraged to participate in NFP by all service providers. Coordinating referrals to best meet the need of the client is

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essential. We do that through the Mother-Baby Coalition where Thurston County NFP, St.Peters Adolescent OB clinic and the local MSS agency currently participate to improve coordination. Our coalition continues to build by inviting other community organizations such as housing, family support centers, and Department of Social and Health Services to join in the efforts to improve coordination between the resources within our county. Based on the information above, and your understanding of the community served, list referral resources that are needed to support families residing in the county, but which are not currently available. Housing, mental health and health care services are limited in our community. If their parents do not provide it, vulnerable teen moms are often without safe, adequate housing. Limited mental health resources are overwhelmed by a community faced with an increasingly higher level of acuity, clearly identifying the need for more resources. The need for health care providers serving Medicaid clients is evident as many families are forced to use the emergency department. Describe all existing mechanisms for screening, identifying and referring families and children to home visiting programs in the community. Currently, the home visitation programs each have their own mechanisms in place for receiving referrals. However, we currently have a memorandum in place with the other agencies in our community agreeing that we will refer any client that does not meet NFP criteria to their program and they will refer first time, young, low-income mothers to NFP. An additional memorandum will be needed with CYS for PAT if funded. Our community Mother-Baby coalition continues to work hard to improve referral systems to ensure all families receive the services available. The program does act as a central referral place for home visiting for First Steps and NFP to eliminate confusion for referring agencies. We send all clients not eligible to the other home visiting agencies.

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HVSA Logic Model Organization Name: Home Visiting Model: Nurse-Family Partnership Date: July 1, 2013



Target Population: low income, first-time pregnant women in Thurston County. Target Geographic Area: Thurston County Staffing: .5 FTE trained Public Health Nurse,.5 FTE Supervisor w/ county organization supported by administration and technical support staff. Home Visiting Curriculum Used: NFP visit guidelines PIPE parenting education Funding Sources: Thrive by Five 1/10 of 1% sales Tax (TST) County General Fund MCH Block Grant

1: Staffing 1.1: Maintain existing staff

2: Training 2.1: NFP staff will participate in initial and ongoing training and education as required by NFP NSO 2.2: NFP supervisor will participate in ongoing training, education, and consultation as required to support quality, fidelity, and specific population needs. 3. Outreach/Recruitment • 3.1: Existing caseloads will be

maintained • 3.2: Maintain outreach and referral

plan to reach target population and maintain caseload

• 3.3: Monitor effectiveness of outreach plan

1.1: Maintain existing staff: .5 FTE Nurse Home Visitor 2.1: NFP Supervisor and NHVs will participate in DANCE education and other program updates when scheduled . 2.2: NFP Supervisor will participate in: - 1 monthly Supervisor Community of Practice call -1 quarterly Supervisor Community of Practice meeting - annual 3 day National Education Symposium in Denver -monthly individual consultation calls with state nurse consultant

3.1: Each FTE NHV will maintain a caseload of 12 clients. 3.2: Supervisor will have a written plan for cultivating relationships with referral sources and community partners including in-person contacts, follow-up visits and/or letters and/or calls, and community presentations.

Measure 1 Nurse home visitors and supervisors are registered nurses with a minimum of a Bachelor's degree in nursing. Measure 2 Nurse home visitors and nurse supervisors complete core educational sessions required by the Nurse-Family Partnership National Service Office and deliver the intervention with fidelity to the NFP Model. Measure 3 Client meets low-income criteria at intake as defined by program. Measure 4 Client is enrolled in the program early in her pregnancy and receives her first home visit by no later than the end of the 28th week of pregnancy. Measure 5 Client is visited throughout her pregnancy and the first two years of her child’s life in accordance with the current Nurse-Family Partnership Guidelines.

1. Prenatal Care 2. Parental Use of alcohol,

tobacco, or illicit drugs 3. Preconception Care 4. Inter-birth Intervals 5. Screening for maternal

depressive symptoms 6. Breastfeeding 7. Well-child Visits 8. Maternal and Child

Health Issues 9. Visits for children to the

emergency department from all causes




13. Reported suspected maltreatment for children in the program

14. Reported substantiated maltreatment


16. Parent support for

Improved Maternal and Newborn Health CAN and Reduction of ER Visits

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Data System(s): ETO

4: Home Visits • 4.1: Provide home visits for first

time, low-income pregnant women, mothers and infants

• 4.2: New clients will be enrolled before 28 weeks of pregnancy and receive visits according to NFP guidelines

• 4.3: Content of home visits will be aligned with NFP guidelines

5: Supervision • 5.1: Staff who provide home visits

will receive individual reflective supervision

• 5.2: All staff will participate in reflective case conferences

6: Continuous Quality Improvement 6.1: Supervisors and nurse home visitors will review and utilize their

3.3: Supervisor will use ETO data on enrollment by referral source to monitor effectiveness and adapt plan.

4.1: 12 clients will each receive 1-3 home visits per month according to the NFP standard and/or flexible visit guidelines 4.2: 12 clients enrolled by 28 weeks of pregnancy, 40% enrolled by 16 weeks of pregnancy.

Quarterly average completed to expected visit ratio will be: Pregnancy completers : 72 % Infancy completers : 65% Toddler completers: 65%

4.3: The quarterly average Maternal Role Domain will be:

Pregnancy: 23-25% Infancy: 45-50% Toddler: 40-45%

5.1: Supervisor will provide individual, 60" reflective supervision sessions 3 times per month for each NHV 5.2 Reflective case conferences are held twice a month for 1.5 -2 hours. 6.1 Supervisors willreview ETO quarterly reports with NHVs and SNC and use this data to create the Annual Plan. 6.2 Supervisor and SNC review Annual Plan quarterly.

Measure 6 A full-time nurse home visitor carries a caseload of no more than 25 active clients. Measure 7 A full-time nurse supervisor provides supervision to no more than eight individual nurse home visitors. Measure 8 Nurse home visitors and nurse supervisors collect data as specified by the Nurse-Family Partnership National Service Office and use NFP reports to guide their practice, assess and guide program implementation, inform clinical supervision, enhance program quality and demonstrate program fidelity.

children’s learning and development

17. Parent knowledge of child development and of their child’s developmental progress








25. Screening for domestic

violence 26. Referrals for domestic

violence services for families with identified need


28. Household income and

benefits 29. Maternal Employment

or Education 30. Health Insurance Status 31. Number of families

identified for necessary services

32. Number of families that required services and

Improvements in School Readiness and Achievement Domestic Violence Family Economic Self-Sufficiency Coordination and Referral

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data 6.2: Data is used for quality and fidelity monitoring and improvement

received a referral to available community resources


34. Information sharing Number of completed referrals

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V. IMPLEMENTATION CAPACITY ORGANIZATIONAL CAPACITY Provide the mission of your organization and describe how your home visiting program advances the mission. The mission of the Thurston County Public Health and Social Services Department is to make a positive, significant and measurable difference in the environmental, physical and mental health, safety and well being of our community. Our department has implemented home visitation programs to include Children with Special Health Care Needs, Early Intervention Program and First Steps for over 30 years. In 2004 we began to implement NFP and have been successful with delivering this with fidelity to the model and compliance to all funding agreements and sources. The NFP program is well supported by the county commissioners, the Director and many community organizations including schools, justice entities and many health care providers to name a few. At this time there is support for continued funding from the Treatment Sales Tax that emphasizes efforts for programs addressing mental health, chemical dependency and reducing criminal involvement for populations. NFP is the only preventive program at this time receiving funding from this source. The mission of the Thurston County Public Health and Social Services Department is to make a positive, significant and measurable difference in the environmental, physical and mental health, safety and well being of our community. Our department has implemented home visitation programs for over 30 years. In 2004 we implemented NFP and have been successful with delivering this with fidelity to the model and compliance to all funding agreements and sources. The NFP program is well supported by the county commissioners, the Director and many community organizations including schools, justice entities and many health care providers to name a few.

Describe the structure and management of your organization. How does it facilitate effective program implementation? Describe any opportunities for better alignment between administrative infrastructure and program implementation. Our NFP program is located in the Public Health and Social Services Department of Thurston County, under the direction of the 3-member Board of County Commissioners who also serve as the Board of Health. Two major benefits to NFP arise from this organizational structure: 1) County commissioners see benefit from investing in prevention efforts like NFP that can reduce costs of the corrections system, the largest component of the county budget; and 2) Since county social services are co-located with public health, we have opportunities for cross-collaboration with mental health, chemical dependency and housing services needed by many NFP clients. Describe your organization's track record of success managing complex, multi-year grants. Our department has successfully delivered home visitation programs (including Children with Special Health Care Needs, Early Intervention, First Steps and NFP) for over 30 years. These and other programs are funded through grants to the department totaling approximately $2,244,104 in 2013. Our success in managing grants reflects an organizational commitment to meeting the deliverables of the grant, achieving community health goals, and absolute fidelity to good accounting practice.

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Organizations in Washington are implementing home visiting services in very diverse communities. Describe how your organization supports culturally competent service delivery through policy and practice. The department has policies in place that support culturally competent service delivery through cultural competency trainings and a commitment to a diverse staff reflecting the population that we serve. Home visitors recognize the importance of understanding a client's culture and how culture may impact pregnancy, parenting, and life aspirations. They are trained in and skilled at motivational interviewing. This allows them to incorporate cultural differences as needed by an individual client to achieve health outcomes. Supervised reflection, case conferencing and creating goals with a client all utilize a client- and culturally-centered approach. Describe your organization's plan for sustaining home visiting services. None of the funds for our NFP program is a dedicated resource that we can count on from year-to-year. Health reform, however, gives us hope that Medicaid could help stabilize and expand our NFP program. New ROI studies show that Medicaid can recover full costs of paying for NFP before the child's 18th birthday, so we are working with the HCA and the NFP NSO to expand Medicaid funding for NFP. Proven outcomes of NFP can advance proposed innovations such as a pay-for-performance reimbursement system; an integration of medical and social services; and intensive case management. PARTICIPANT OUTREACH, ASSESSMENTS, AND TIMELINE TO REACH MAXIMUM CASELOAD Describe your plan to enroll the populations you propose to serve. Include information on how clients are referred, engaged, recruited, and/or enrolled into your program. (Provide examples of community-based organizations and local agencies that refer children and families to your program as well as the frequency and duration of outreach.) Our current outreach is so successful that we have had a waiting list for over the last year. We have established good relationships with many organizations in our community that also serve the at-risk population that the NFP program serves. These referral sources include WIC, schools, health care offices, and other community partners. Our NFP team members are all strong advocates for the program and clients and will use the opportunity when seeing a client at a school or clinic to educate and collaborate with the site regarding NFP services. Building these partnerships is critical to the referral process. Additionally, we continue to meet with health care providers, WIC clinics, tribal public health departments and multiple other agencies to increase and maintain a steady flow of referrals. We have and will continue to schedule at least 1-2 outreach meetings per month with established or new referring agencies. Does your home visiting program currently engage families and children in the child welfare system? If so, in what ways? Yes, the NFP program at our department does engage families and children that are currently or have been in the child welfare system. We receive referrals for teen moms that are currently or have been in foster care in the past. We have worked to form a collaborative partnership with caseworkers and supervisors at CPS by ensuring they are knowledgeable about NFP, through our Mother Baby Coalition and by our nurses being active with participating in any team services for clients. What strategies or activities are included in your home visiting plan for engaging families and children in the child welfare system going forward? We continue to work hard to collaborate and partner with clients and case workers involved in the child welfare system recognizing the strengths and importance of each of our roles in improving the

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environment and success of parenting. Referrals that indicate a pregnant mom who is in the child welfare system or has been in the past are prioritized in our program. Our nurses are skilled in working with high risk populations and utilize a client centered approach to form a partnership with the client. Motivational interviewing is a critical component to the success of this therapeutic relationship. Many teens that have been in foster care struggle to trust others so the consistent, reliable relationship is very important between the client and nurse home visitor. The nurse is an advocate, support and trusted person that uses a strength based approach with the mom. Are individualized assessments of enrolled participant families conducted? Yes If YES, describe how referral to services are provided in accordance with those individual assessments The NFP nursing team uses the Omaha surveillance charting to complete individual assessments with clients. This will indicate the client's knowledge, behavior and status related to health targets and assist the nurse in making the appropriate referrals. Nurses also use a number of assessments including depression, anxiety and relationship safety screenings to determine needed referrals. Finally, the NFP nurse's are skilled in assessing the ongoing need for additional referrals to resources and existing barriers to these for clients. Provide an estimated timeline to reach maximum caseload. The NFP National Service Office recommends that a new nurse at an established site add at least 4-5 clients per month. All current NFP staff are at full caseload except our newest nurse who will be building caseload over the coming months in accordance with the NSO recommendations. HOME VISITING MODEL NATIONAL TRAINING, TECHNICAL ASSISTANCE, AND SUPPORT Present a plan for working with the national model developer and Washington State Model Lead. Include the frequency and duration of the current support available from both the national model and the Washington State Lead for: a) initial and ongoing training and professional development, and b) initial and ongoing technical assistance and support. Currently the supervisor has one hour phone calls each month with the State Nurse Consultant from Thrive. Training, staff support, reflection on output and outcome data, quality assurance, quality improvement, and community relations are topics often addressed. As the past year has presented multiple significant threats to funding, the supervisor, our division director and our department director have had many calls and meetings with our State Nurse Consultant and Program Developer to address the funding risks as well as to problem solve the need for secure funding. The National Service office offers ongoing technical support and assistance. STAFF SELECTION, TRAINING, AND RETENTION STAFF SELECTION List the qualifications (education, credentials, experience, etc.) and skills recommended and/or required for home visitors by the home visiting model/program. Indicate if qualifications include cultural competency and language accessibility recommendations or requirements. The NFP nurse is required to hold a Bachelor of Science in Nursing degree. This is a Community Health Nurse II position in the agency, which also requires the nurse to be Bachelors prepared. We seek

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applicants for home visiting positions that have experience working with the diverse Maternal Child populations that we serve. If your program requires any additional staffing qualifications beyond those required by the developer, list and describe those qualifications. Do you have adequate staffing capacity (both in terms of FTEs and alignment with identified service population) to implement your home visiting program as described in the proposal? Yes

If YES, briefly describe the existing staffing as it relates to the client volume and the unique needs of the population served. We have adequate staffing capacity to implement our program but not to meet the needs of all of the referrals. We have had an ongoing wait list for more than the past year causing us to enroll many clients past our goal of 16 weeks but before 28 weeks. We have had to send at least 27 referrals on as we were not able to assign them to a home visitor before the client was 28 weeks pregnant. We continue to look for funding to expand so we can meet the referral needs of the community.

If NO, please describe the recruitment plan and the timeline for recruiting and hiring staff. What is the timeline for obtaining all necessary training for new staff to implement the home visiting model? All NFP staff, except for our recent replacement hire, are currently trained as required from the National Service Office. The team will complete any further training required or seen as important to the delivery of the program as offered. Our replacement hire is currently completing the initial NSO training. In the event of new staff joining the team they will receive training per NSO protocol.


List all initial and ongoing professional development activities provided by the implementing organization(s). Initial and ongoing professional development includes motivational interviewing, inter-rater reliability for Omaha charting, temperament, Nightingale Notes electronic health record, mental health tools, team meeting education modules and safe driving. Does your organization provide any training to staff beyond that required by the model/program developer, including any racial equity and/or cultural competency training? If so, describe. Our department provides cultural competency, harassment prevention, CPR, communication, safe driving, Our home visiting team continues with motivational interviewing and ACES training. We have also had training in mental health/positive psychology, team meeting modules, Omaha charting, safety, collective impact, promoting maternal mental health and successful communication.

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STAFF RETENTION

What mechanisms are in place to retain all staff in the program(s)? The mechanisms in place to aid in staff retention include competitive pay/benefits, reflective supervision, a supportive team, continued learning and flexible scheduling. NFP training emphasizes focusing on one's strengths and using this to aid in the professional development. We continue to work closely as a team to improve electronic charting and other efficiencies, so that home visitors can focus on personal growth and client success to improve their satisfaction with their NFP role. CLINICAL SUPERVISION AND REFLECTIVE PRACTICE What training is provided to support clinical supervision/reflective practice? The NSO provides webinars for supervisors, monthly calls with the State Nurse Consultant and a 3 day NFP supervisors training. Additionally, the supervisor participates in monthly state supervisor calls in which reflective practice skills are often addressed. Within the last year, supervisors have had continuing education in this area through a monthly reading exercise and additional training at a quarterly supervisor meeting. Finally, the calls with the nurse consultant provide a reflection time for the supervisor to discuss successes, challenges with staff or other program delivery issues. The nurse consultant is an invaluable resource available for problem solving and planning for ongoing program development. Are there currently individuals on staff/in your community who are providing this supervision? Yes If YES, what is the frequency and duration of the supervision provided? Currently the program supervisor meets individually with NFP staff weekly for one hour of reflective supervision. The supervisor and each nurse work as partners to make this a time that is useful and growth-fostering for the home visitor. If NO, please describe the recruitment plan and the timeline for recruiting and hiring supervisors.

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VI. FIDELITY AND QUALITY ASSURANCE MONITORING, ASSESSING, AND SUPPORTING IMPLEMENTATION WITH FIDELITY AND ONGOING QUALITY ASSURANCE How does the home visiting program(s) participate in fidelity monitoring and/or quality assurance through the national model developer and Washington State Model Lead? The NFP model has built-in assurance that the program maintains fidelity and quality assurance. Data in some form is collected in all interactions with clients, whether it is the time spent on domains in the home visit, relationship safety or an infant health care assessment. This data is entered into the National Service Office data system and is accessible both by reports that the site can run any time and by quarterly reports. The quarterly reports share National, state and individualized site rates. All nurses are specially trained in the NFP program and in data collection in order to provide consistency in program delivery and documentation. The supervisor regularly reviews and reflects on data with the SNC as well as the team. We utilize our data to reflect on our practice, what's going well and where can we make a greater impact. What additional monitoring, assessing, and supporting implementation with fidelity and quality assurance does the home visiting program participate in? (i.e. if currently receiving technical assistance from HVSA please describe) We have additional data and program information that is collected for program funders as well as for Department quality assurance and improvement. Some of the data includes the number of women with mental health concerns, the number of referrals, graduation rate and the number of referrals to mental health/chemical dependency programs for clients. The program logic model with HVSA cohort 4 assesses and monitors fidelity measures such as voluntary enrollment, gestational age at enrollment, staff training and reflective supervision. These are critical to program fidelity and a valuable measurement in the program delivery. Does your organization conduct fidelity tracking or quality assurance on its own? If YES, please describe. Our organization does collect information that helps us to assure quality delivery of the program. Some of this includes the number of visits delivered and attempted by nurses. As we reflect and improve on this it allows us to ensure the dosage of program delivery therefore improving the likelihood of positive outcomes for families. In addition to this we also review the length of time of the client visits, ensuring that visits are in alignment with the National and State averages. Identify two to three model-specific fidelity measures and describe challenges to maintaining quality and fidelity when implementing in the proposed service area with the identified population. 1) Enrolling early in pregnancy: Clients who start NFP home visits early in their pregnancies have more time to build a relationship with their nurse, to learn how to keep themselves healthy during pregnancy, and to prepare for parenting the newborn. We have worked in a number of ways to make sure clients are referred in as early as possible. School nurses and WIC programs are two resources for early referrals. However, The ongoing wait list that we have had for the past year is effecting these numbers. We get the referral early but we must wait until there is availability in a nurse's caseload. 2)Attempted vs. Completed visits: One of the challenges with program delivery can be the age of the population that we work with. Young mothers are often overwhelmed by appointments, school, lack of support and concerns such as mental health or drug/alcohol use. Their unpredictable lives can make it

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challenging for them to follow through with scheduled home visits. The nurses must be engaging with the client while also being flexible and creative with scheduling to help improve the number of home visits delivered as well as the attrition in the program. Describe all enhancements that are currently being made by the home visiting program(s). We are not currently doing any enhancements. What is the average rate of attrition for program participants? What is your plan to reduce attrition? Our quarterly NSO report reflects cumulative attrition for pregnancy of 10.1%, infancy 21.4% and toddler 21.2%. These have increased slightly since December, 2012. Contributing factors include: 1) Clients moving from the area due to housing shortages or lack of other needed services; accounts for 40% of early discharge. Many of these clients are transferred to another NFP site. 2) The resignation of a home visitor in July causing a loss of 40% of her caseload. When transitioning clients between staff, we anticipate 50% or more clients will opt out of NFP. We work with our State Nurse Consultant to utilize recent research on attrition and tools to reduce it in the areas we can control such as "unable to locate". This involves bi-annual motivational interviewing trainings, working to offer flexible scheduling with families and utilizing strategies such as re-contracting with clients at different phases of the program.

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Does the national home visiting model have a database that program(s) implementing the home visiting model are using? Yes If YES, does the lead organization, and subcontractor organizations implementing the home visiting program, use the national model database? Yes, we utilize the Efforts To Outcomes (ETO) database which is the National Service Office database. The database provides valuable information assuring quality about program delivery, fidelity, outcomes and the population served. If NO, how does the lead organization, and any subcontractor organizations implementing the home visiting program, track data? Are there other data systems being used?


1. Maternal Health Assessment Enrollment 2. Demographics Enrollment, 6 months, 12 months, 18 months, 24

months. 3. PHQ-9 Depression screening Enrollment, 36 weeks, 1-8 weeks infancy, 4-6

months infancy, 12 months, 18 months, 24 months 4. Use of Government and Community Services Enrollment, 1-2 weeks infancy, 6 months, 12

months, 18 months, 24 months. 5. Healthy Habits Visit 2-4, 36 weeks. 12 months. 6. Relationship Assessment Visit 2-4, 36 weeks, 12 months. 7. Infant Birth Form Visit 1 infancy. 8. NCAST Feeding Scale 1-8 weeks infancy, 12 months. 9. NCAST Teaching Scale 7 months infancy, 22-24 months. 10. ASQ Developmental Screening 4 months, 10 months, 14 months, 20 months. 11. ASQ-SE Developmental Screening 6 months, 12 months, 18 months, 22-24 months. 12. Infant Health Care 6 months, 12 months, 18 months, 24 months. 13. 14. Knowledge, Behavior and Status Omaha

Charting Beginning and end of each program phase.

15. Global Assessment of Functioning Enrollment then every 6 months 16. GAD 7- Anxiety screening Enrollment then every 6 months. 17. ACES Enrollment 18. HOME Inventory 12 months, 18 months 19. 20.

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Who is responsible for collecting the data? The home visiting nurses are specially trained and responsible for collecting the data on their home visits. Who is responsible for data input? The program assistant for the NFP team is responsible for data input. The nurses are also trained in data input should it be necessary. Who analyzes and reports the data? The supervisor of the NFP team analyzes and reports on the data to the organization, funding sources and also the team. Team members use the data to reflect on their practice, recognizing their strengths and areas to improve. Once analyzed, how is the data used for continuous quality improvement? The NFP team and organization are continuously striving for quality. We use the ETO reports, data collected for funding sources and NFP quarterly reports to reflect on program outcomes identifying the strengths and weaknesses of these. The data is insightful as to areas that we are doing well with clients and areas that have room for growth and improvement. This opportunity allows for professional growth individually and as a team. PERFORMANCE SNAPSHOT



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Fidelity to the NFP model is critical to the success of the program. Early enrollment is one of the most important elements of fidelity, because it affects the dosage of NFP services delivered during the pregnancy phase. We continue to meet the fidelity measure of all clients being enrolled into the program by 28 weeks. This is essential to the client and nurse being able to maximize the program content and have a positive effect on building a strong therapeutic relationship and birth outcomes.

Over the last several years, we have put effort into increasing the number of clients enrolled by 16 weeks gestational age through outreach to community partners to encourage referrals earlier in pregnancy. Our ongoing waitlist, however, has made it difficult to find an immediate place for those new referrals. During the period of 10/1/11 to 9/30/12, our early enrollment rate was 66%. From 10/1/12 to 9/30/13, we have seen this rate decline to 38%. We are now receiving many referrals early in pregnancy, but unfortunately, clients are too often past 16 weeks by the time a nurse has an opening on her caseload. In fact, in the last year 27 referrals have “aged out” of the possibility of enrolling in services at all. Instead, they have been referred on to a non-evidenced based HV program (MSS) as they were past 28 weeks by the time there was an opening. Our inability to serve newly referred clients quickly makes it difficult to meet the goal of 60% enrollment by 16 weeks.

The NFP model also requires that clients participate in the program voluntarily. The 2013 fidelity report indicates that we are fully aligned with this element of fidelity. Voluntary participation is critical to the success of the visits for the family. Services are designed to build self-efficacy. The client is empowered when she participates voluntarily and is invested in the work that she does with her NFP nurse.

Finally, we continue efforts to decrease the attrition rate during pregnancy.

Fidelity Indicator Thurston County NFP 09/2013

Thurston County NFP 03/2012

Thurston County NFP 09/2011

WA State Total

National Total

NFP Objective

Attrition in pregnancy 10.1% 9.1% 7.6% 9.5% 15.4% <10% Attrition can be attributed to several factors, only some of which are in our control. Half of the clients leaving the program during pregnancy have moved to another area, often because of housing issues; clients who move are transferred to another NFP site if possible. Attrition also results from other challenges faced by the young, high-risk population we serve. We have worked with our State Nurse Consultant to utilize research by Dr. Olds showing how to decrease attrition rates through flexible scheduling and skilled motivational interviewing. Our nurses are all trained in motivational interviewing, and we require biannual updates to this training. We continue look for creative ways to meet the flexible scheduling needs of our clients.

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The aggregated data related to the Thurston County NFP site clearly shows strengths of the program and areas that we strive to improve. We have chosen two performance measures -- reducing the number of premature/low birth weight babies and increasing the rate of breastfeeding initiation and duration -- that improve the long-term health of our community and families.

Data from the NSO quarterly reports indicate a continued reduction in the number of Low Birth Weight (LBW) infants born related to the mother’s race/ethnicity as well as the client age. In March 2012, the total cumulative program rate of LBW births was 6.1% with Hispanics and Native American clients having the highest number of LBW babies born. The total rate of LBW babies based on race/ethnicity has since dropped to 5.5% as of September, 2013. This rate is below the state average of 7.5% and the national average of 9.8%. We have also seen a reduction in preterm births to 5% as of September, 2013. NFP clients begin pregnancy with a number of risk factors for LBW: alcohol/drug use, domestic violence, chronic mental health concerns and often a lack of prenatal care. The nurses focus referrals and client education on controlling these risk factors where they exist. They also work with clients to take steps towards healthy self care. Continued efforts towards early enrollment aid in more effective control of risk factors for LBW as well.

Thurston County NSO data also show changes in rate of NFP mothers initiating breastfeeding. Breastfeeding initiation has increased from 97.6% in March, 2012 to 98.1% as of September, 2013. Our initiation rates remain well above national averages. While we have seen success initiating breastfeeding, we continue to encourage moms to continue to breastfeed for a longer duration. Between 2011 and September, 2013 we have exceeded the national average rate but have remained just under the state average at 6, 12, 18 and 24 month’s breastfeeding duration.

Initiation 6 months 12 months 18 months 24 months 2011 98% 34% 19% 8.7% 4.7%% 2012 97.6% 32% 20% 8% 5% 2013 98.1% 33% 19.1% 9.4% NA%

To promote breastfeeding duration, nurses work with clients to ensure breastfeeding satisfaction and to problem-solve barriers to success. The young clients may face difficulties in continuing breastfeeding due to their own developmental tasks and social demands. School, work and friends often compete with ongoing breastfeeding. NFP nurses continue to educate and support the client in continued breastfeeding for ongoing health benefits.

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HOME VISITING MODEL: Nurse Family Partnership

Period: 01/01/14-12/31/14






Home Visitor $45,455.00 .40 FTE


C. Travel $0.00







J. Indirect Charges if not included above $4,545 $4,545 Indirect @ 10%

K. TOTAL $50,000

Thurston County Public Health & Social Services


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November 17, 2013

Thrive by Five Washington Seattle Tower, 8th floor 1218 3rd Avenue Seattle, WA 98104 To Whom It May Concern: Regarding: Thurston County Health Department grant proposal to support the Nurse Family Partnership Program I am writing in support of Thurston County’s grant application. I am a local pediatrician who’s patients have benefited from this program in our community. I am also a past president of the Washington Chapter of the American Academy of Pediatrics and have seen the benefits of nurse home visiting programs across our state. I am also currently working on a Community Based Children’s Wellness Initiative with the Health Care Authority and Medicaid managed care companies. This program will be an important piece of our initiative. Our local NFP nurses benefit my patients and their families by teaching healthy child development, enhancing parenting skills, improving the quality of parent-child interactions, and promoting school readiness activities for families at-risk for child abuse and neglect and poor educational outcomes. Our NFP program has shown a 58% reduction in the experience of violence, 98% initiation rate for breastfeeding, 96.6% of patients up to date with immunizations at 24 months, and they have a 24% reduction in smoking during pregnancy. Additionally they have a 5% rate of prematurity compared to our county at large with 11%. I have seen the NFP nurses support early literacy, family skill and strength building, and focus on resiliency and enhanced parenting confidence in these families. I am a firm believer that the NFP program has been a key to the success and positive outcomes for many of these families. Several of the families that I care for are teen parents and the NFP program has supported their education and has helped the new parents support their own children’s early learning. Supporting this program is vital to our community. Sincerely,

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