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Providing Family Planning Services During Maternal Child Health Field Visits to Enhance Family Services and Improve Outcomes for Mother and Child

State: FL Type: Promising Practice Year: 2019

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Florida Department of Health in Pinellas
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Providing Family Planning Services During Maternal Child Health Field Visits to Enhance Family Services and Improve Outcomes for Mother and Child

The Florida County of Pinellas has a population of approximately 970,637 residents as of 2017, with 52% female and 82.7% White, 11.1% Black, and 9.7% Hispanic. Situated on 608 square miles, only 274 of which are land, Pinellas County is the most densely populated county in Florida, with a density of 3,292/sq. mi. The Florida Department of Health in Pinellas County (FDOH in Pinellas) was established in 1936 and maintains public health jurisdiction over Pinellas County. FDOH in Pinellas is one of 67 County Health Departments and operates under the auspices of Department of Health, Florida's state agency dedicated to protecting, promoting, and improving the health of all people in Florida. FDOH in Pinellas serves Pinellas County with more than 700 employees in six health department locations throughout the county. FDOH in Pinellas is divided into six divisions that provide a wide range of public health services including infectious disease control, health promotion, chronic disease prevention, environmental health monitoring, disaster preparedness and response, as well as personal health services, including home visiting and clinic services.

FDOH in Pinellas has two home visiting programs that currently offer nursing services: Healthy Families, and Nurse Family Partnership. The Nurse-Family Partnership (NFP) is a home visiting-based program intended to promote well-being of first-time, low-income mothers and their children. Nurses provide parenting education, referrals to community resources, and promote family enrichment beginning in pregnancy prior to 28 weeks gestation through the child's second birthday. Goals for the program include improving pregnancy outcomes, child health and development, and family economic self-sufficiency. FDOH in Pinellas has offered NFP since 2011. The Healthy Families program is modeled after the highly successful Hawaii Healthy Start program and part of a National Network of Healthy Families America (HFA) sites. This intensive home visiting and family support program has been in operation since 1992.The program offers enhanced services provided by specialty staff including nurses, mental health counselors, father services specialists, and resource specialists that assist families until the child reaches kindergarten age. The program was designed to promote positive parenting, enhance child health and development and prevent child abuse and neglect.

While the structure and goals of both programs vary, both share a focus on positive parenting, creating a home environment that fosters child development, and improved health outcomes through pregnancy and early childhood. One factor in achieving these goals is healthy interpregnancy intervals. Short interpregnancy intervals (less than 24 months) are associated with adverse birth outcomes, such as low birth weight and premature/preterm birth, increased parental stress levels about parenting, and increased risk for post-partum depression.  By integrating family planning services into home visits, nurses encourage longer interpregnancy intervals by providing family planning counseling and supplies.

Healthy Families and Nurse Family Partnership both have nurses that are cross-trained to provide not just family planning counseling, but provide in-home assessments and hormonal birth control supplies, utilizing the Providing Quality Family Planning Services Recommendations of CDC and the U.S. Office of Population Affairs”.  Nurses receive Title X trainings, including Putting the QFP into Practice”, and are trained on state policies and local protocols. Under protocol, the nurses assess clients and match them with appropriate family planning methods. Through the state issuance program, the nurses can provide starter packs for birth control supplies such as combined oral contraceptives, progestin-only pills, and DMPA injections. The nurses have telephonic access to a physician for orders not covered under protocol.

Healthy Families nurses started providing family planning visits in the field in 1997, and Nurse Family Partnership has provided these services since 2017. Healthy Families Florida set a goal that 80% percent of mothers enrolled in the project will not have a subsequent pregnancy within two years of the target child's birth. Healthy Families Pinellas has achieved 100% in this measure during 2017-2018. Nurse Family Partnership set a goal that at least 25% of all NFP Moms have 24 months between pregnancies. Pinellas County's NFP has had 40% of mothers with at least 24 months interpregnancy interval in 2017-2018. While there is still low participation in family planning services in the Pinellas NFP, the impact on health for the women participating is noticeable.  With increase interpregnancy intervals, these women have more time to focus on developing healthy relationships and bonding with their children and decrease the likelihood of adverse pregnancy outcomes when they decide to have another child.

The website for FHOH in Pinellas is http://pinellas.floridahealth.gov/

Interpregnancy intervals of less than 24 months from birth to pregnancy increase risks for adverse birth outcomes such as low birth weight and premature/preterm birth, increased parental stress levels about parenting, and increased risk for post-partum depression. In Pinellas County, 38.5% (1,898) of births have an interpregnancy interval of less than 18 months. This is higher than the rate of 34.8% for the state of Florida. The Nurse Family Partnership target population consists of low-income first time mothers and Healthy Families' target population is vulnerable families at risk for abuse and neglect. Currently, Nurse Family Partnership serves approximately 150 families and Healthy Families serves approximately 747 families. While some MCH clients receive birth control through their medical homes, 6% of NFP clients receive family planning services in the field and 16.7% of Healthy Families clients receive family planning services in the field.

This model of care improves on NFP and Healthy Families home visiting models by integrating family planning services into the home visit in lieu of referrals and linkages. Traditionally, clients enrolled in Maternal Child Health Services have only benefited from counseling on family planning topics during field visits. Utilizing cross-trained nurses to provide not only counseling but also assessment and supplies in the field ensures access to care for many of these low socioeconomic status clients by helping them overcome barriers to service, including but not limited to: lack of transportation, lack of access to affordable services, and psychosocial barriers.

This practice reflects a creative use of existing strategies generally utilized outside of the United States. Some Medicaid programs do offer family planning home visiting programs, and most MCH home visiting models offer family planning counseling, referrals, and linkages. However, evidence- based programs have successfully increased the use of effective or higher birth control methods in their target populations by combining family planning services with other services for the family such as maternal child health visits and child immunizations (i.e., Pathfinder International and the Evidence to Action Project Conducting Home Visits and Providing Counseling and Contraceptive Services to Young Women, Including First-Time Mothers in Akwa Ibom, Nigeria – A Supplemental training module for Community Health Extension Workers. Watertown, MA: Pathfinder International, 2016” and Meeting Postpartum Women's Family Planning Needs Through Integrated Family Planning and Immunization Services: Results of a Cluster-Randomized Controlled Trial in Rwanda” Lisa S Dulli, Marga Eichleay, Kate Rademacher, Steve Sortijas, Théophile NsengiyumvaGlob Health Sci Pract. 2016 Mar; 4(1): 73–86.).   

Goals and objectives of the practice of providing family planning services/supplies in the field are to increase use of effective or higher methods of birth control in women enrolled in maternal child health home visiting programs to encourage longer interpregnancy intervals. Maternal Child Health home visiting nurses were cross-trained in Title X/Quality Family Planning practices and protocols were developed/adapted to allow nurses autonomy to provide birth control in the field.  In 2017, Nurse Family Partnership nurses received approximately twelve hours of on-line training for Title X and Putting the QFP into Practice” and twelve hours of classroom instruction on birth control methods, state technical assistance guidelines, and local protocols. The nurses also received several hours of preceptorship from MCH nurses already providing family planning in the field and on-going telephonic support from physicians, APRNs, and seasoned family planning nurses.  These nurses were expected to start providing the practice within 3 months of receiving initial training.

Start-up costs are estimated as approximately $1, 689 per nurse for training hours and supplies, including emergency kits for field visits.

  • 40 hours at $23.00/hr for training
  • 16 hours at $23.00/hr for preceptorship
  • 12 hours at $23.00/hour for in-house trainer
  • $120 in supplies including epinephrine, diphenhydramine, etc. for emergency kits

Implementing the practice requires participation and cooperation between different programs and divisions within the health department. The Medical Services Division provides physician back-up for the MCH nurses, the Community Health and Performance Management Division provides training and quality assurance, and nurse preceptorships are arranged between the Nurse Family Partnership and Healthy Families programs in the Maternal Child Health Division. Without cooperation between programs and divisions, these nurses would not have the support needed to execute the practice in the field.

The Florida Department of Health in Pinellas Nurse Family Partnership is funded by the Juvenile Welfare Board (JWB).  JWB is a high-performing, data-driven organization established by a Special Act of the Florida Legislature (Chapter 119, FL Statutes) to strengthen the lives of children and families in Pinellas County. As a countywide special taxing district, JWB is responsible for directing the community's investments to give children the best opportunities to lead healthy, successful, and satisfying lives.  For example, in 2017, JWB invested $53 million and worked collectively with 89 community programs and 51 nonprofit agencies to strengthen the lives of 68,000 children and families last year. 

FDOH in Pinellas' Healthy Families program collaborates with the Healthy Start Coalition of Pinellas, Juvenile Welfare Board of Pinellas County, The Ounce of Prevention Fund of Florida, and Health Resources and Services Administration (HRSA) for support and funding. Healthy Families Pinellas also maintains partnerships with Bayfront Health, Morton Plant Mease Hospital, and Suncoast Center.  Without these robust collaborations and partnerships, MCH programs at the FDOH in Pinellas may receive less funding, requiring higher case-loads for each registered nurse and limit the nurses' ability to provide integrated services in the field.

Many of our clients take advantage of the family planning services offered by their home visiting nurse.  This practice supports Florida Department of health in Pinellas' goal of reducing the number of births with an interpregnancy interval of less than 24 months. Analysis of available data suggests that there may be a correlation between offering family planning services in the field and increased interpregnancy intervals in clients participating in FDOH in Pinellas home visiting programs. Program managers, supervisors, and workers believe that many more MCH clients would have additional children much earlier if family planning services were not offered in the field.

In Pinellas County 38.5% of births have interpregnancy intervals of less than 18 months compared with the state rate of 34.8%. Healthy Families Florida set a goal that 80% of mothers enrolled in the project will not have a subsequent pregnancy within two years of the target child's birth. Healthy Families Pinellas has achieved 100% in this measure during 2017-2018. Nurse Family Partnership set a goal that at least 25% of all NFP mothers have 24 months between pregnancies. Pinellas County's NFP, in its first year providing family planning in the field, had 40% of mothers with at least 24 months interpregnancy interval in 2017-2018. Women enrolled in MCH services in Pinellas County exceed interpregnancy interval performance measures for their programs, while the overall population in Pinellas county has a high rate of short interpregnancy intervals. Healthy Families Pinellas exceeds Healthy Families Florida performance measures with a rate of 100% compared to the rate of 98% for Healthy Families Florida participants overall.

Data Sources:

FL HEALTH Charts: http://www.flhealthcharts.com/charts/DataViewer/BirthViewer/BirthViewer.aspx?cid=0610

Healthy Families Service Activity (7/1/2017-06/30/2018): Participant Outcomes Required by HFF

Efforts to Outcomes (Nurse Family Partnership database) 2017/18 NFP Performance Measure Outcomes. 

Internal service audits of HMS (Health Management System) electronic health records

Informal survey of Healthy Families managers/supervisors/workers

No modifications have been made to the practice of providing family planning services to MCH clients in the field based on this informal analysis. However, plans include developing internal monitoring and measures for interpregnancy intervals for women receiving combined services.

Recently, DOH in Pinellas experienced the retirement of trained nurses providing combined Family Planning /MCH services in the field, effectively causing a brain drain” and loss of institutional knowledge of how these services were provided. While the practice of providing services from different programs in the field is fiscally sustainable, more human resources are needed to ensure cross-training programs are available for registered nurses entering home visiting programs. This involves open communication between programs and divisions within the health department to facilitate sharing of knowledge, practices, and ideas to maintain and improve quality services. Plans for sustainability include regular process and protocol reviews and quarterly family planning meetings for all MCH nurses regardless of their program assignments to share and build knowledge across programs.

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