Brief Description of Local Health Department

Tri-County Health Department (TCHD) serves over 1.5 million people in Adams, Arapahoe and Douglas Counties located in the Denver, Colorado metro region. The agency offers over 60 programs/services from 11 offices in this 3,000 square mile area. The agency's jurisdiction includes 26 municipalities and 3 unincorporated counties, 15 school districts with more than 360 public schools, 12 acute care hospitals, 3 Federally Qualified Healthcare Centers with multiple facilities, 3 community mental health service providers and one Regional Accountability Entity- Colorado Access.

TCHD was established in 1948. It is the largest local public health department in Colorado and the only one that serves three diverse counties.^[1] The population of each county is unique and varied.  Adams County’s 2019 demographics showed the highest percentage of white Hispanic families at 40.4% while the largest population of African American families reside in Arapahoe County (10.5%).  Douglas County is less diverse with 83% identifying as white, non-Hispanic. Poverty is a concern in Adams County with rates of 6.5% and in Arapahoe County at 5.6% .  Close to one-third of youth in these two counties experience poor mental health and 17-18% report having suicide ideation. Between 2010 and 2018, median monthly rent increased 52.2-56.6% and median annual household income increased only 33.0-34.2%.  Top public health concerns in these three jurisdictions include mental health, access to health, food and housing. All of these have a profound impact on child abuse and neglect.

Description of the Public Health Issue

Child maltreatment is the mental, physical and sexual abuse or neglect of children under the age of eighteen. Risk factors such as poverty, interpersonal violence, mental illness and substance abuse contribute to this issue. It is an individual, family, community and system level trauma that impacts all of society.

The World Health Organization describes the generational consequences of child abuse and neglect as a “global problem with serious lifelong consequences” and ... “Beyond the health, social and educational consequences of child maltreatment, there is an economic impact, including costs of hospitalization, mental health treatment, child welfare, and longer-term health costs.”^[2]   Major studies document the link between trauma experienced in childhood and adult obesity, depression and heart disease.

Goals and Objectives of the Nurse Support Program

Established in the early 2000s, Tri-County Health Department and Adams County built the Nurse Support Program concept with two goals in mind:  support families in times of need and decrease the need for Child Welfare intervention.  Since then, the program has grown to include agreements with Arapahoe County and Douglas County.  The purpose of the nurse home visitation programs is to help stabilize low to moderate risk families in crisis situations who are referred by County Human Services divisions in Adams, Arapahoe and Douglas Counties.

Activities in the Nurse Support Program

Nurse home visitors help families maintain family integrity, improve family dynamics, facilitate positive behavior change during bi-weekly nurse home visits.  They perform nursing assessments, offer client centered education and provide community-based quality referrals. These public health nurses teach educational community classes that strengthen families and increase active participation in healthcare, school, work and health related practices.  In their practice, TCHD nurse home visitors apply the Strengthening Families Protective Factors Framework Five Protective Factors, validated assessment tools such as the Ages and Stages Questionnaire and PHQ 9 along with public health expertise to assure the safety and wellbeing of the family. 

Results, Outcomes and Success of the Nurse Support Program

The Nurse Support Program has continued to grow and expand in practice since inception. The addition of new agreements with partner human services has been major milestones. In 2013, the Omaha System of Documentation was implemented to measure nursing intervention impact.  The Omaha System is a research-based, comprehensive and standardized charting method that documents client care and client impact. The Omaha System measures increases in knowledge and behavior in relationship to interventions. Results from a comprehensive Omaha System analysis in 2017 and 2018 demonstrated statistically significant increases in rating for knowledge, behavior across clients enrolled in Adams and Arapahoe County Nurse Support Programs.  According to the increase in ratings, clients increased understanding of growth and development milestones and in some manner, impacted the behavior in that family.  In relationship to child abuse and neglect, this can be show up as an infant that was referred to the Nurse Support Program for failure to thrive who is now gaining weight appropriately or a family who suffers from a mental health disorder engaging in family therapy as well as newly learned parenting skills that focus on positive instead of negative behaviors.  All of these interventions work to strengthen families and decrease the need for child protection intervention. 

Health Equity and the Nurse Support Program

The Nurse Support Program integrates health equity concepts in practice and guiding principles.  Beginning with Bachelor’s prepared registered nurses, the program intentionally trains staff to recognize implicit bias and expand their understanding of poverty and trauma.  Training includes learning how to conduct comprehensive family assessments that uncovers socio-economic, behavioral and medical challenges. Finally, the Strengthening Families Protective Factors Framework^[3] is applied to the intervention to assure a strengths-based approach to increase positive reinforcement of healthy behaviors.

Public Health Impact

Child maltreatment is recognized as a generational public health concern.  Growing knowledge of prevention strategies to address adverse childhood experiences indicates that early intervention through a strengths-based program can have a generational influence on traumatized individuals, families and communities. The Nurse Support Program has established a strong public health and human services partnership with sustainable impact. 

Websites for Tri-County Health Department and the Nurse Support Program

www.tchd.org

https://www.tchd.org/424/Nurse-Support-Program-Home-Visiting

^[1] Source:  Tri-County Health Department website www.tchd.org

^[2] Source: World Health Organization  https://www.who.int/news-room/fact-sheets/detail/child-maltreatment.

^[3] Source:  Center for the Study of Social Policy  https://cssp.org/our-work/projects/protective-factors-framework/

Statement of the Problem

Child abuse and neglect is a complex and concerning problem across the nation and in Colorado. According to the CDC “at least 1 in 7 children have experienced child abuse and/or neglect in the past year, and this is likely an underestimate.” ¹ Colorado trends are also alarming. Data from the 2018 Kids Count Data Center ² report a rate of 9.5/1000 Colorado kids with substantiated cases of abuse and neglect. This is of concern due a growing link to child fatality. Colorado Child Fatality Review Teams found in 2019³ that 50-75% of families experiencing fatal or egregious incidents involving child abuse and neglect were either currently involved or had past involvement in Child Protection Services.

There is increasing evidence that there is additional concern for children of color in the child protection system. Higher numbers of children of color are reported for child maltreatment, in foster care, and in the Juvenile Justice System. ⁴  When African American children are removed from their homes, they are assessed by the child welfare system to have lower risk than white children removed from their homes despite higher mortality rates for Black children (43.8 deaths per 100,000 in foster care versus 34.1 deaths per 100,000 in the general population), compared to the risk of all kids in foster care (35.4 per 100,000 vs 25 per 100,000 in the general population outside of foster care).  Latinx children also face increasing numbers of reports and child protection involvement versus stable numbers for while children.⁵  This suggests that systemic racism may play a role in a potentially biased child protection system.  

Families who have experienced generational child maltreatment and who have been referred to the child welfare system benefit from well-designed nurse home visitation programs that provide nonbiased support and education.  The Nurse Support Program works to empower families, increase self-sufficiency and ultimately to reduce the incidence of child maltreatment.

Target Population and Demographics

The target population of the Nurse Support Program are families who are referred from local human services agencies and community partners that work with high risk families. Eligible participants include pregnant and parenting people experiencing poverty, and families in crisis due to substance use, interpersonal violence and reported cases of child or adult maltreatment.  The Nurse Support Program and partners at local human services have developed referral criteria to maximize limited program capacity and to target the highest risk referrals.

According to available program data, the demographics of the program participants who were enrolled in 2018 in Adams and Arapahoe County were

●       61% White,

●       20% Black, and

●       35% Hispanic. 

Compared to Adams and Arapahoe county demographics⁶  in that same time period, county residents were

●       Adams 51.3% and Arapahoe 62.6% White,

●       Adams 3% and Arapahoe 10.3% Black, and

●       Adams 41% and Arapahoe 20% Hispanic.

White families represented the majority of Nurse Support enrollees along with a higher percentage of Black families receiving services in 2018 versus the general population. Comparison of program enrollees versus families involved with human services is not available for this application, however, this represents an opportunity for a cross-agency quality improvement project.  In addition, much can be learned from a trending analysis of TCHD data when capacity to explore 2019 and 2020 data is greater. 

What is the Reach of the Program?

The volume of potential Nurse Support Program participants is significantly higher than program capacity. County human services child and adult protection caseworkers and Temporary Assistance to Needy Families (TANF) caseworkers are able to refer eligible women and families to the Nurse Support Programs when the family or client meets contractual requirements. These requirements were constructed to assure the highest risk families, such as those with children aged 5 and under, those with medical concerns and those whose families are experiencing trauma are prioritized.

One source of referrals are families who have been reported to the county hotline for adult or child maltreatment. In 2019, Arapahoe County alone received more than 13,000 reports into the child maltreatment hotline. ⁷  Arapahoe County’s Nurse Support agreement that year included 6 public health nurses to partner with caseworkers.  These caseworkers referred 1,399 families to TCHD.  The program was able to complete services for 666 (48%) of referrals. 

Adams County received 11,310 calls into the hotline in 2019 and referred 56 families to this county’s much smaller 1.5 FTE (full time equivalent) public health nurse program that provides nursing intervention for 4-6 months. This staff provided services to 46 (82%) clients that year.  

Another source of referral into the Nurse Support Program are those families seeking TANF. In Adams County, 13,473 families applied for TANF funds in 2019. The 3.5 FTE Nurse Support Program contract received 160 referrals and was able to provide case management to 112 (70%) in this ongoing program that aims to see families until the infant’s first birthday.

How does the Nurse Support Program Address Health Inequities?

The principles and concepts of health equity are woven deeply into the practice of the Nurse Support Program. The program purposefully addresses this ideal through training of staff, utilizing comprehensive assessment tools and incorporating a foundational framework into program activities. 

Equity is a core training topic for all Nurse Support Program staff.  The comprehensive new hire training manual requires staff to explore socio-economic barriers that contribute to poor health status, health disparities and toxic stress.  Some examples of training topics and materials include:

• Poverty: Bridges out of Poverty^8, Spent
• Implicit Bias: multiple sources including the Harvard Study
• Racism: A Precious Loss^10,
• Adverse Childhood Events and
• Trauma informed care.

Each of these training modules, webinars and documentaries increases the nurse home visitor’s knowledge and awareness of socio-economic barriers to equity in health and prosperity. In addition, the program facilitates monthly learning sessions often with experts from the community to continuously provide relevant education for nursing staff.  Each staff is also provided a yearly stipend to spend on ongoing education.

Nursing assessments are the next step to assuring principles of equity are applied into practice. In the Nurse Support program, each is designed to evaluate and explore the individual needs of the participants. When complete, the participant and the nurse can explore potential resources or identified education needs and establish client-centered goals.  The assessments also provide valuable data for the county and Nurse Support Program leadership to understand new and emerging challenges the community may be facing.

For example, the 2018 Annual¹¹ report revealed that the majority of participants had a high school degree or less and the main concerns included income, mental health, domestic violence and concerns around safety.  Information like this prompts Nurse Support Program leadership to provide staff education to build a non-biased, well prepared workforce that are proficient using tools like the SBIRT (Screening, Brief Intervention, and Referral to Treatment) to assess for substance use, the HITS and Danger Assessment to assess for safety, and the PHQ-2 and PHQ-9 to assess mental health status.  In addition to these evidence-based tools, the program also assesses participants for social determinants of health like income, housing and environment, insurance and access to medical care. Additionally, the nursing assessment utilizes the two-question screening tool recommended by the American Academy of Pediatrics¹²  to identify and address food insecurity.

Lastly, the Strengthening Family Framework is incorporated into the practice of the Nurse Support Program to standardize the approach of intervention. The Framework directs the nurse and client to focus on more positive, and less negative behaviors to promote resilience in parents. It inspires families to recognize areas of strength to build upon¹³, areas such as increasing social connectedness, knowledge of growth and development and the socio-emotional competence of children.  The framework empowers parents to understand their ability to provide a safe, healthy and strong family. Coupled with the concepts of evidence-based Motivational Interviewing¹⁴, the Nurse Support Program is able to provide equitable nursing intervention with well supported, equity minded constructs.

These three components, intensive and mindful training of public health nursing staff, comprehensive nursing assessments and integration of holistic models support the aim of the Nurse Support Program’s mission for equity in Adams, Arapahoe and Douglas County. 

Innovation and the Nurse Support Program

The Nurse Support Program is a unique contractual partnership between public health and human services.  The partnership was the first of its kind for the Denver Metro area and originated in Adams County in 1998.  Program founders sought to develop a new and inclusive nurse home visitation program regardless of financial status, insurance or family size. This was heavily influenced by nurse home visitation programs that were limited in eligibility requirements such as pregnancy status, Medicaid enrollment or first-time motherhood. In contrast, the Nurse Support Program founders developed a shared plan of intervention that fulfilled the desires of the county to decrease the need for welfare assistance and public health aims to improve community health.  Today, this consistent collaboration and flexibility in programming continues to assure that partner goals are achieved to decrease the incidence of child maltreatment in TCHD jurisdictions.   

 Is the Nurse Support Program Evidence-Based?

The Nurse Support Program has not achieved evidence-based status.  Although the program has documented efficacy, utilizes evidence-based assessments and an evidence informed framework, the capacity of TCHD and program staff has prohibited opportunities to explore publication.  Establishing evidence-based designation is an active goal of the program and in 2020, TCHD engaged partnerships with local and national academic institutions to research and ultimately publish Nurse Support Program data and evidence. 

¹Source:  Center for Disease Control and Prevention https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html

²Source 2018 Kids Count Data Center https://datacenter.kidscount.org/data/tables/445-child-abuse-rate-per-1000#detailed/2/any/false/37,871,870,573,869,36,868,867,133,38/any/1104

³Source: 2019 CFRT Report  https://drive.google.com/file/d/1IkEt1f-GfRJQGSdmb8DBjWYonszMyX8K/view

⁴Source: Child Welfare Information Gateway https://www.childwelfare.gov/topics/systemwide/cultural/disproportionality/causes/

⁵Source:  Infectious Diseases in Children https://www.healio.com/news/pediatrics/20200424/children-in-foster-care-42-more-likely-to-die-than-children-in-general-population

⁶Source:  TCHD Health Reports and Factsheets https://data-tchdgis.opendata.arcgis.com/

⁷Source:  Not One More Child Arapahoe County https://www.arapahoegov.com/1387/Not-One-More-Child-in-Arapahoe-County

⁸Source: Bridges out of Poverty https://www.nemcsa.org/services/bridges-out-of-poverty-education.html#:~:text=The%20Bridges%20Out%20of%20Poverty%20Training%20is%20designed%20to%20develop,hidden%20rules%20of%20our%20upbringing.

9Source:  Spent https://www.nemcsa.org/services/bridges-out-of-poverty-education.html#:~:text=The%20Bridges%20Out%20of%20Poverty%20Training%20is%20designed%20to%20develop,hidden%20rules%20of%20our%20upbringing.

10Source: Colorado  PBS https://video.rmpbs.org/video/race-colorado-precious-loss1/

¹¹Source:  Internal, 2018 Nurse Support Program Annual Report, Tri-County Health Department

¹²Source:  American Academy of Pediatrics Food Insecurity Toolkit https://frac.org/aaptoolkit

¹³Source:  Center for the Study of Social Policy https://cssp.org/our-work/projects/protective-factors-framework/

¹⁴Source: Excellence in Motivational Interviewing https://motivationalinterviewing.org/understanding-motivational-interviewing

Goals of the Nurse Support Program

The Nurse Support Program vision is for optimal health for the communities of Adams, Arapahoe and Douglas Counties by reducing trauma and the impacts of trauma. It is the mission of the program to provide a holistic assessment of individuals and families, advocate for equity in our communities by connecting clients to the support systems and resources they need to achieve optimal health. Both were instrumental in designing the goals of the Nurse Support Program.

In collaboration with Adams, Arapahoe and Douglas County Human Services the program has developed goals to address the needs of both agencies. These goals blend public health vision, public health nurse practice standards and human service organization objectives. The goals of the Nurse Support Program are to:

1.Provide comprehensive assessment of child/adult abuse and neglect allegations,

2.Build resilience in individuals and families through resource referral, education and support, 

3.Reduce the risk and impact of traumatic events by encouraging healthy social, physical and emotional development,

4.Support healthy adult/child engagement and growth with evidence-based practices and assessments and

5. Strengthen families to ensure the safety and well-being of every child. 

What steps were taken to implement the Nurse Support Program?

The concept of the first Nurse Support Program at Tri-County Health Department (TCHD) in the late 1990’s was a community effort in recognition of the need to establish a nurse home visitation program for mothers with more than one child.  The Adams County Department of Human Services Director and county District Attorney at that time were instrumental in identifying and authorizing funding for the new program with creative use of prevention funding from the Department.   Adams County Mental Health Center (now known as Community Reach Center), TCHD and other local leaders brainstormed innovative ideas on structure for the new program.

By the mid-2010s, TCHD was engaged in partnership with the three counties, and had established contractual agreements in Adams and Arapahoe County.  Each county had their own version of the program that included partnerships with child protection and child welfare assistance.  In these formative years, the practice of the program and management at TCHD was fragmented and independent according to individual counties. This worked well, however, there was potential for greater knowledge and resource sharing across the agency. That recognition precipitated the unification of the practice of the Nurse Support Program in 2016.  This move assured standard delivery of program services, program oversight, and quality improvement strategies across all three counties despite multiple contractual agreements and human service funding sources. 

What was the Role of the Local Health Department in Planning and Implementation?

The role of the health department in the partnership began as a collaborative partner that was willing to explore innovative solutions to an identified gap in services.  This first step was founded on an existing, mindful relationship between local service agencies.  It was important in the early stages and continues to this day to be cognizant and respectful of each agency's overall goals and objectives in this multidisciplinary model.  With this in mind, TCHD’s role was to design a nurse home visitation program in the beginning that

●       incorporated goals of the human service department,

●       was grounded on flexible and evidence-based nursing assessments and client education, and,

●       established a solid infrastructure that supported the work of home visitation.

Later, as the program grew, leadership developed and integrated

●       evaluation strategies to assess efficacy and,

●       incorporated the Strengthening Families Protective Factors theoretical framework to guide how the programs were delivered.

What does the Nurse Support Program do to foster collaboration with community stakeholders?

The child maltreatment and welfare arena have many stakeholders that focus efforts on abuse and neglect. Local and state agencies including the behavioral health providers, early childhood providers, school districts and state public health departments all play important roles in the prevention of child maltreatment and are natural partners of TCHD. The Nurse Support Program, as part of the local health department, intentionally participates in community collaboration for several reasons. This community work fosters increased stakeholder collaboration while the public health nurse expertise and intimate knowledge of the struggles of the community provides a bridge for coalitions that work to address trauma. For example, Nurse Support nurses participate in local Early Childhood Partnership workgroups and advisory committees. They regularly attend local Review, Evaluate and Direct (RED) teams at the county human service departments which evaluate incoming reports of child maltreatment, adding a nursing perspective to decision making in the child welfare arena. They co-chair and attend local Collaborative Management Programs (Colorado House Bill 04-1451).  The program staff also coordinate and participate in Child Maltreatment Prevention workgroups, local and State Child Fatality Review Teams and Colorado State Maternal Mortality Review Team. These outreaching efforts engage community stakeholders and increase community awareness of the Nurse Support Program.

What does the Nurse Support Program do to ensure equitable collaboration with target populations?   

The scope of the Nurse Support Program utilizes the concepts of nursing practice and public health principles to ensure equitable partnership at the program level while meeting the client where they are at. Enrollees in the Nurse Support Program are engaged with comprehensive assessments to determine needs.  These assessments explore social determinants of health factors, healthy and risky health behaviors, interpersonal violence, and mental health status.  Adults, pregnant women and infants receive basic nursing assessments such as blood pressure and infants are weighed at standard intervals. Each assessment is client centered, bringing an opportunity to build the nurse/client relationship, engage in positive health education and space to identify strengths that are present in the family. Goal setting is a shared activity between client and nurse to encourage self-sufficiency and future growth. 

Nurses work to authentically engage families living in poverty and experiencing high life stress.  Nurse Support Program staff are specifically trained in skills that will enhance their ability to engage in authentic relationship with clients. Examples of the evidence-based or evidence-informed skills and tools used include:

●       Motivational Interviewing:  a style of nurse/client interaction that encourages change,

●       Trauma Informed Care:  nurses are offered a local secondary trauma resiliency training and utilize the NEAR (Neuroscience, Epigenetics, ACEs, and Resilience) @ Home^[1] tool kit that coaches home visitors how to address adverse childhood experiences (ACEs) with families in a supportive multi-generational approach,

●       SBIRT: Screening, Brief Intervention, and Referral to Treatment, an evidence-based approach to assessing substance use,

●       Interpersonal Violence:  tools to assess current experiences and risk including the HURT, INSULT, THREATEN, and SCREAM (HITS) Tool for Intimate Partner Violence Screening^[2], and the Danger Assessment^[3] to help determine the level of danger an abused woman has of being killed by her intimate partner and,

●       One Key Question (OKQ)^[4]:  a research-informed model for standardized assessing pregnancy readiness to support family planning goals and encourage healthy child spacing.

The Nurse Support Program incorporates other approaches to assure equitable practice. Clients enrolled in the program are invited to complete regularly scheduled surveys to assess their level of satisfaction with the program. Questions include how the client felt respected, how much their parenting confidence increased, and asks in what ways could the program be improved.

Similarly, contract meetings with each county invites a continuous feedback loop for program leaders to assess efficacy and programming.  Information gleaned from these sources informs the Nurse Support Program’s progress in providing quality, client-centered care. 

Start Up Cost and Cost of Doing Business

Initially, the Adams County Department of Human Services provided the startup funding for the Nurse Support Program in the late 1990s.  The agreement was to provide fiscal support for a team of public health nurses to provide home visits and the budget consisted of funding for salaries.  Lessons learned since then provide a more accurate account of actual program costs.

In 2020, the Nurse Support Program is funded exclusively through the local public health and human services contracts.  Actual program costs include cost per nursing full time equivalent (FTE), cost of administrative and supervisory support, mileage, technology, training and supplies. With TCHD’s infrastructure, there is in-kind cost sharing that is realized in management, data collection and reporting and indirect costs. 

In totality, the Nurse Support Program has a budget exceeding $2,000,000 in fiscal year 2019/2020.  County contracts and budgets range from the largest 8.5 FTE contract to smaller 1.0 FTE agreements.  A comprehensive budget for 2020 per public health nurse is approximately:

●       1.0 FTE Public Health Nurse: $82,000

●       0.25 FTE Business Support: $25,000

●       0.10 FTE Nursing Supervisor: $9,000

●       0.05 FTE Program Manager:  $6,000

●       Cell Phone per year:  $500

●       Mileage:  $3,500

●       Supplies:  $1,000

●       Training for Public Health Nurse:  $500

●       Indirect on Salaries: $12,300

Total Cost of TCHD base expenses and fees for a 12-month period = $140,000. 

While the program is funded through human services sources, TCHD shares costs in several budget areas. First, county contracts are charged a low indirect rate (10%) that is well below the usual federal percentages that fluctuate around 30%.  Second, administration and managerial oversight is underrepresented, demonstrating the benefits from a large organizational structure that had greater capacity for data management, collection and analysis. Lastly, the cost of oversight can be lessened with added public health nurse FTEs (supervisors can effectively oversee up to 8 FTE), making supervision and management costs less per FTE. 

^[1] Source: Start Early https://startearly.org/where-we-work/washington/nearathome/

^[2] Source: HITS Danger Assessment http://www.ctcadv.org/files/4615/6657/9227/HPO_HITS_Screening_Tool_8.19.pdf

^[3] Source:  National Resource for Domestic Violence https://vawnet.org/material/danger-assessment

^[4] Source:  Power to Decide https://powertodecide.org/one-key-question

Evaluation of the Nurse Support Program

The Nurse Support Program is dedicated to consistent quality improvement which includes evaluation of program processes and program outcomes. It is important that this information is accessible for contract fidelity and for program credibility.  The goals of the Nurse Support Program are to provide comprehensive assessment of child/adult abuse and neglect allegations, build resilience in individuals and families through resource referral, education and support, reduce the risk and impact of traumatic events by encouraging healthy social, physical and emotional development, support healthy adult/child engagement and growth with evidence-based practices and assessments and strengthen families to ensure the safety and well-being of every child. 

TCHD tracks primary data or process data including number of referrals, number of enrollees, demographic descriptions of participants, number of contacts, and description of resource referrals to report back to contractors. In addition, TCHD also monitors progress through an agency-wide Performance Management dashboard for internal accountability. Secondary data or outcome data measures the efficacy of the nursing intervention of the program using the Omaha System of Documentation. These data are collected internally and results are shared in annual reporting when possible. Data analysis of the Omaha System information is an internal collaborative effort that draws on the expertise of epidemiology staff in the Planning and Information Management Division of TCHD. The Nurse Support Program has annual reports for years 2017 and 2018 and is the intent of the program to provide a 2019 and 2020 report once COVID-19 pandemic responsibilities have eased. 

What did we find out? Process Outcome Data

Process outcome data are documented in TCHD’s client electronic database and spreadsheets to monitor enrollment, reasons for referral and to problem solve gaps in services as necessary. Enrollment, home visits and number of referrals into the program are one method of monitoring the Nurse Support Program.  During the years 2017-2019, all programs across two counties enrolled more than 3200 program participants.  These participants received approximately 7,000 home visits. In total the program received more than 6,000 referrals from the community, TANF and human services partners. Across two counties the program realized a 53% engagement rate which is exemplary considering that participation in the Nurse Support Program is voluntary and offered during times of crisis and trauma. 

Example of Process Changes due to Evaluation Measures

Process data like these help the Nurse Support Program and partner human service departments to evaluate targeted program and referral practices to make administrative decisions regarding performance measures and adjust as needed. In Arapahoe county, this data has informed and precipitated change for a 2015- 2018 Nurse Support activity that focused on one to two client contacts to provide resources and referral for families with non-founded protection reports.  This activity was found to be highly unsuccessful in that families were not willing to engage with nursing outreach.  The rate of engagement in 2018 was 38% with only 186 home visits for 493 referrals.  With this information, the decision was made to suspend that activity in the Fall of 2018. This type of data clearly provides information for contract and scope of work negotiation but they do not often reflect the practice outcomes or objectives of the Nurse Support Program.   

Outcome Evaluation: How the Nurse Support Program Efficacy is Measured and Analyzed

Starting in 2012, the Nurse Support Program implemented the Omaha System to measure nursing intervention outcomes. It is a research-based, comprehensive classification system that is used worldwide to evaluate patient and community outcomes. It is designed to enhance and standardize practice, documentation, and information management. It is intended for use across the continuum of care for individuals, families, and communities who represent all ages, geographic locations, medical diagnoses, socio-economic ranges, spiritual beliefs, ethnicity, and cultural values. The Omaha System of Documentation^[1] consists of three interrelated, reliable and valid components: The Problem Classification Scheme, the Intervention Scheme and the Problem Rating Scale for Outcomes. These three components provide a way to document client needs and strengths, describe interventions carried out by practitioners and measure the resulting client outcomes. It is designed to generate meaningful data following documentation of client care.

How is the Omaha System Applied to the Nurse Support Program?

The Omaha System is applied to the Nurse Support Program documentation when clients are enrolled and receive four or more home visits.  In this time frame, nurses document client problems, interventions and outcomes throughout the course of providing client care. Clients are given a rating at the first home visit within three categories for each identified problem; these three categories are Knowledge (K), Behavior (B) and Status (S). The KBS ratings are given on a scale of 1 to 5 with “1” denoting the highest severity in that area and problem, and “5” denoting the lowest severity in that area and problem. In essence, client progress can be documented as pre and post intervention. The goal of the nursing intervention is to increase the score over time indicating a lessening of the severity of the identified problem. Once a client is closed/discharged from the program, the problems and their associated outcomes are tracked within TCHD’s database that includes demographic and client information. Analysis of the Omaha System data is performed in partnership of TCHD’s Nursing and Planning and Information Management Divisions. 

Results

Omaha System data was analyzed in 2013, 2017 and 2018 for clients enrolled in Nurse Support Program ongoing programs and who received four or more home visits.  Overall, these three years demonstrated statistical significance in pre and post nursing intervention KBS ratings. Omaha data also provides a glimpse into the challenges of the average client during these years as the majority of clients were documented to have problems in parenting, income, mental health and substance use categories. 

In 2013, 119 clients were evaluated using the Omaha System.  Income and parenting concerns were the top problems identified by program nurses with 83.2% (99/119) and 60.5% (72/119) of families experiencing either lack of resources or lack of knowledge. Measurement of KBS ratings for each category demonstrated that families improved their knowledge, behavior and status after Nurse Support education, support and referrals. For example, the KBS rating system demonstrated that the 99 participants for whom income was identified as a deficit increased their knowledge of financial support from an average rating of 2.4 to a statistically significant rating of 2.95 (p<0.0001).  When all identified problems were combined, the Nurse Support Program Omaha System analysis demonstrated statistically significant improvement in all three areas (KBS) increasing average initial ratings in Knowledge from 2.46 to a last rating of 3.01, Behavior at intake of 2.72 to last rating of 3.18 and increase of Status from 2.71 to 3.04 (p<0.0001)^[2]. 

Omaha System data was analyzed in Adams and Arapahoe County in 2017 and 2018. Again, data indicated improvements in client understanding, actions and situation.  In 2018, Adams and Arapahoe County Omaha data was combined to demonstrate statistically significant change in KBS in the top five most frequently identified problems existing for clients:  growth and development, caretaking and parenting, income, mental health and substance use.  That year data revealed a combined average rating increase in Knowledge from 2.96 at intake to a last rating of 3.33, Behavior from 3.45 to 3.74 and improvement in Status from 3.65 to 3.85 (p<0.0001 with statistical significance at p<0.05).[3] 

The Omaha System is providing the Nurse Support Program with definable evidence for efficacy and the opportunity to establish evidence-based status. To that end, the program has engaged both the University of Minnesota and Colorado State University to evaluate data from TCHD and the local department of human services to determine impact in re-referrals to the departments with the intent to publish the results.  This, and the reassurance of Omaha System documentation will do much to establish the practice of the Nurse Support Program and invite future funding. 

^[1] Source:  The Omaha System http://www.omahasystem.org/overview.html

^[2] Source:  Internal TCHD Report MOF Omaha Report

[3] Source:  Internal Nurse Support Program 2017, 2018 Report

Lessons Learned in the Practice of the Nurse Support Program

The Nurse Support Program at TCHD has learned much in twenty years. The program itself has seen considerable changes in supervision, training expectations and program evaluation.

Effective supervision of nurse home visitors is one area that the Nurse Support Program recognized early on as a vital component to healthy leadership and staff.  Learning from TCHD’s Nurse Family Partnership, the Nurse Support Program implemented the evidence-based model of Reflective Supervision^[1] for staff oversight. This style of supervision creates a supportive culture for staff and empowers supervisors with inquiry techniques to increase mindful responses in lieu of reactive responses to difficult situations. This technique works well to diffuse the chronic stress of working with families in crisis. While Reflective Supervision is an effective tool to explore complex client cases, it became increasingly clear that supervisors and staff often needed additional support to understand client’s mental health challenges. Leadership in the program have long valued mental health consultation and through community and interdivisional partnership agreements, the public health nurses receive additional Reflective Supervision in a bi-monthly group format facilitated by a licensed mental health provider.  In this safe space the nurses can reflect on challenging cases and explore strategies to increase their own awareness and resiliency.  

Training a well-prepared and stable nursing workforce is another example of lessons learned in the Nurse Support Program.  This home visitation, public health nursing practice demands a high level of understanding of the intense impacts of poverty, mental health illness, substance use, violence and trauma on children and families. Public health nurses working in a home visitation setting need a consistent training regime that develops empathy, reinforces nursing knowledge and empowers them to provide appropriate nursing intervention. However, in the initial years of the program, new hire and ongoing training was not clearly defined and leadership was isolated by county resulting in differing practices in onboarding across the counties. When the Nurse Support Program leadership began to function as a unified, cross-county team in 2016, one of the first projects was to develop an inclusive New Hire Orientation Manual. Today, this comprehensive training guide is used to educate and foster greater understanding of the socio-economic challenges of program participants and to increase the knowledge of the nurse home visitor in key areas like childhood growth and development, interpersonal violence and substance use. It is a relevant document for all three counties and staff working with clients in child welfare and child protection and a vital component to the standardization of the knowledge base of the Nurse Support Program workforce. 

Lastly, the importance of rigorous evaluation is a lesson learned for the Nurse Support Program.  New programming is an exciting endeavor and nurses are ideal thinkers who, by training and education, are collaborative and inventive. Public health nurses are holistic visionaries that understand the social, economic and generational challenges of a community. Current leadership have learned that it would have been advantageous to have integrated evaluation measures in the formative years. Analysis of early data may have led to earlier adoption of a classification practice like the Omaha System and perhaps greater opportunity to establish efficacy in meeting the mutual goals of TCHD and human services departments.  In context of the difference of the Nurse Support Program in early 2000 versus 2020, it is understandable that the need for establishing the program as an evidence-based practice was not seen as urgent as it is in 2020.  Other factors influenced the lack of evaluation development including targeted evaluation capacity, expertise and funding.  Hindsight clearly indicates that this is a critical step for program establishment and for developing a highly functioning program out of strong public health nursing practice. The Nurse Support Program as since fully endorsed evidenced-based practice which will allow the program continue to grow, support families and prevent child abuse into the future.

Lessons Learned in Partner Collaboration

Today’s Nurse Support Program has the benefit of twenty years of a well-established relationship with the Adams, Arapahoe and Douglas County human services departments. Having a strong relationship has been important in many arenas, especially when negotiating contracts and funding. 

The importance of negotiating an all-inclusive and sustainable budget is an important lesson learned from the Nurse Support Program. Early budgets presented in contract negotiations did realize the true cost of a public health nurse but a general amount that was projected to support one full time equivalent.  Year-end budget reconciliations revealed that while salary and fringe benefits were accounted for, supervision, training, technology and incidentals such as mileage and cell phones were not.  Program leaders learned to proactively develop budgets to include the actual cost of providing a program, not merely the cost of an employee. Through solid relationships with human services, the Nurse Support Program has great fiscal support for sustainable budgeting. 

Cost Benefit Analysis

The Nurse Support Program at TCHD has not participated in a cost/benefit analysis.  This could be a potential research project to establish the program as an evidence-based practice. 

Stakeholder Commitment

The commitment of the Nurse Support Program partners is promising as evidenced by program growth in 2020.  Douglas County, in early winter, contracted the Nurse Support Program for 1.0 FTE and Adams County expanded to include an additional 3.0 FTEs in the fall.  All three counties participate in regular quarterly or monthly contract meetings with TCHD Nurse Support Program leadership, provide charting space for nurses between home visits and engage in open communication between staff and caseworkers. To improve cross-agency communication, TCHD nurses are invited to human service team meetings and trainings throughout the year. All in all, the counties have demonstrated their commitment by investing many resources and growing the partnership with TCHD for more than twenty years.

Sustainability Plans

The sustainability of the Nurse Support Program is encouraging. The Nurse Support program is funded by human services who use federal, state and county sources designated for prevention.  These agencies use a blend of funds to contract with TCHD.  For example, Federal Title IV-E of the Social Security Act funds the Nurse Support Program services for clients that are referred by county TANF (Temporary Assistance to Needy Families) programs. Other Nurse Support Program participants who are involved in child or adult protection are funded by the creative use of Child Welfare’s state Core Services Programming.  Each county has been able to utilize their flexibility in how to appropriate the funds according to guidelines set forth by the Department of Human Services to finance the Nurse Support Program. 

Looking to the future, the implementation of the Families First Prevention Act will necessitate more innovative thinking around funding the Nurse Support Program.  The Nurse Support Program is currently engaged in several research projects to demonstrate efficacy and to ultimately apply for the Title IV-E Prevention Services Clearinghouse designation as a promising practice.  This will not only increase the Nurse Support Program’s establishment as an evidence-based program, but will increase the probability that the program will continue funding. Colorado is also in statewide discussions to explore ways to utilize Medicaid billing and Families First funding for grassroot programs like the Nurse Support. All are opportunities for TCHD’s innovative Nurse Support Program to grow in years to come. 

^[1] Source:  Zero to Three Reflective Supervision https://www.zerotothree.org/resources/407-reflective-supervision