Running Head: CARE COORDINATION MODEL 1

Care Coordination Model

Johanna Bareman and Monica Lawson

Bonnie Blachly MN, RN

Western Washington University

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Care Coordination Model

The Nurse-Family Partnership (NFP) is a community-based program that serves first time

mothers and connects them with a nurse. The nurse follows these mothers through their

pregnancy until their child is 2 years of age. This unique program is evidence based and has been

shown to improve both mother and child outcomes (Nurse-Family Partnership, 2014). The basic

criteria that the client must meet to qualify for assistance are she has to be a first time mother in

28th week of pregnancy (no later), low income, and live in an area serviced by NFP. Each NFP

program has the ability to add restrictions based on population needs in specific areas. The NFP

program does not follow a traditional care model, because the type of care coordination used is

tailored to the specific patients needs and social situation. This flexible care model allows for

autonomy for the nurse, making the care provided highly individualized based on specific

patients needs. Although it does not follow a traditional care coordination model, the NFP

works to keep care consistent across the stages of pregnancy and postpartum by educating first

time, low income mothers, and connecting them to whatever resources they may need (Nurse-

Family Partnership, 2011).

NFP uses a strengths and risks (STAR) framework to assess the mother and child. This is

a very detailed oriented assessment tool which helps the nurse build a care plan for the mother

and baby in order to ensure successful pregnancy outcomes, improve child health and

development, and increase financial independence. The nurse follows guidelines each visit

within reason, the program allows a great deal of autonomy. The first visit includes an

orientation to the program where the expecting mother is given a binder with information of

resources and education about her pregnancy and the nurse discusses the purpose and structure of

the program. Each subsequent visit is tailored to the clients needs and developmental mile

markers of the child. The home visits happen weekly for the first 3 weeks in the prenatal period
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and six weeks after the child is born. The goal is to taper home visits down to once a month

when the child is 18 months old. Of course, each individual client may have needs that require

more frequent visits and this is up to the nurses discretion (Nurse-Family Partnership, 2014).

The nurse-family partnership is based off continual evidence, which includes over 37

years of studies using randomized controlled trials. It began in the early 1970s when David

Olds, Ph.D. created a home nursing program for first time mothers and began studying the

effects of this program. He conducted three separate randomized control trials in three different

populations over three decades. Since that time there have been 14 additional studies on the

effects of NFP. It was found that the program has been known to reduce preterm birth by 79%,

which improves the overall pregnancy outcome. NFP has lasting effects for children as well as it

reduces childhood arrests at age 15 by 59%, childhood injuries by 39%, emergency visits for

accidents or poisoning by 56%, and childhood abuse and neglect by 48%. Many mothers after

completing the program showed more financial independence by exhibiting 32% fewer

unintended pregnancies, an increase in months of employment by 82%, months of welfare usage

reduced by 20%, increased involvement of father of child by 68%, and 61% less arrests of

mother. The NFP continues to be a topic of research to provide first time mothers with the best

available support (Nurse-Family Partnership, 2014).

The NFP only allows those who are enrolled by 28 weeks gestation to be a part of their

program. This means if they are 29 weeks when they find out about the program, they cannot

enroll, despite the fact they may really benefit from a program like this. Some might argue that

doing this makes the program to exclusive, thus leaving one part of the population underserved

and in need. However, evidence backs the importance of enrolling in the program by 28 weeks

gestation. In order to make the program successful, nurses have to capitalize on the time they

have to educate these first time mothers (Nurse-Family Partnership, 2014). When these expectant
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mothers enroll in the program early, it allows for time for the nurse to establish a relationship

with the client before the child is born, and to discuss prenatal health. Prenatal health has a direct

impact on the childs development and birth outcomes, leading to more success in the program.

If the program allowed women to enroll at any stage in their pregnancy, they could miss out on

this key time for education, which is crucial for the maternal health and their childs

development.

The NFP strives to promote independence in the lives of first time, low income mothers.

For this reason, every client uses a different care model. Nurses consistently follow these

mothers through their pregnancy, until their child is 2 years of age. They provide individual

referrals, as needed to keep care consistent and highly specific to the needs of the mother and her

child. The NFP ultimately serves to promote independence in these families, foster positive

mother and child relationships, and monitor the childs development to connect them with

resources that would enable them to thrive.

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References

Nurse-Family Partnership. (2017). Model elements. Retrieved July 18, 2017, from

http://www.nursefamilypartnership.org/Communities/Model-elements

Nurse-Family Partnership. (2014). Proven effective through extensive research. Retrieved

July 18th 2017, from http://www.nursefamilypartnership.org/proven-results