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Background Aligning delivery and financing systems across sectors to create broader systems of care can improve the health and well-being of families experiencing adversities. We aimed to identify structural and relational factors for best practices to achieve successful cross-sector collaboration among home visiting programs in the United States. Materials and methods We used a multiple case study approach to identify best practices for successful cross-sector collaboration between home visitors and other community service providers. We selected five diverse exemplary cases with cross-sector collaboration with variation in implementing agency type and geographic location. Cases were selected using a positive deviance approach based on strong coordination and integration with different community service provider types identified from previous survey data. We conducted in-depth qualitative interviews with home visiting staff, community providers, and clients with a total of 76 interviews conducted from 2021 to 2022. We wrote memos to synthesize themes within each case through data triangulation using interview data, documents, and site visit observations. We compared themes across the five cases to create a cross-case synthesis of best practices for successful cross-sector collaboration. Results Across the five cases, relational factors including leadership from all levels, champions across sectors, and shared goals between community providers were key factors for successful collaboration. Interpersonal relationships, coupled with the desire and capacity to engage, facilitated effective coordination to address families’ needs. At the structural level, shared data systems, written agreements, and co-location enabled care coordination activities. Community Advisory Boards provided a venue for developing partnerships, relationship-building, resource-sharing, and increasing awareness of home visiting. Conclusions We identified key elements of successful cross-sector collaboration across five case studies where home visitors coordinate care frequently and/or are structurally integrated with a range of providers. These learnings will inform future interventions to improve home visiting collaboration with other community providers to create a system of care to enhance family well-being.

Prevention programs like Nurse-Family Partnership® (NFP) must enroll and retain clients of the intended population to maximize program impact. NFP is an evidence-based nurse home visitation program shown in randomized trials to improve maternal and child health and life course outcomes for first-time parents experiencing economic adversity, particularly for mothers with limited psychological resources. The purpose of this study was to understand enrollment and engagement experiences of mothers with previous live births referred to NFP in a formative study of the program for this population, but did not enroll or dropped out before program graduation. We used a grounded theory approach and purposively selected three NFP sites with variation in enrollment rates. We conducted telephone interviews with 23 mothers who were either referred to NFP and declined enrollment or former clients who dropped out before graduation. All interviews were conducted in English, recorded, transcribed, and validated. We developed an iterative codebook with multiple coders to analyze our data in NVivo11 and wrote thematic memos to synthesize data across study sites. Mothers described experiencing overlapping risk factors including physical and behavioral health conditions, child welfare involvement, and housing insecurity. Mothers from all sites discussed how they were referred to the NFP program, their experience of the enrollment process, reasons for enrolling or not enrolling, and reasons for dropping out after initial enrollment. Key themes that influenced mothers’ decision-making were: perceptions of program value, not needing the program, their living situation or being too busy as a deterrence, and past experiences including a distrust of health care. Reasons for attrition were related to no longer needing the service, being assigned a new nurse, being too tired postpartum, and moving out of the service area. One way to support home visiting nurses in family enrollment and engagement is to build their professional capacity to implement trauma-informed strategies given mothers’ life experiences.

Background Clinical guidelines in the United States (U.S.) recommend a patient-centered approach to healthcare for pregnant people with substance use disorders (SUD); however, pregnant people with SUD often describe experiencing stigmatization and shame when seeking prenatal care. We explored the perspectives of pregnant and parenting people engaged with SUD treatment regarding their experiences with healthcare providers during the perinatal period to improve guidance for patient-centered care. Materials and methods Using an adapted phenomenological approach, we conducted in-depth interviews with 22 pregnant and parenting people recruited from inpatient or outpatient substance use treatment centers in the U.S. state of Colorado. We developed an interview guide to explore participants’ experiences during pregnancy, childbirth, and postpartum. We audio recorded, transcribed, and validated interviews for analyses. A codebook was developed using an iterative process. Three coders analyzed the data and synthesized data into thematic memos. Results Participants reported challenges within the healthcare system, including barriers to receiving services, connection to or education on resources, challenges in and reasons for sharing their history of substance use with healthcare providers, provider reactions to this information, and the impact of providers’ response to knowing about their substance use history. Participants described shame regarding their substance use but also a strong desire to ensure the health of their infants. This desire motivated them to share their history of substance use with healthcare providers. When participants perceived nonjudgmental and empathetic responses, they reported feeling pride and empowerment. Participants who reported judgmental responses from providers stated that it made them less likely to share and engage with other healthcare providers in the future. Conclusion The perspectives and experiences of people engaged in SUD treatment can inform the implementation of clinical guidelines for patient-centered care for pregnant and parenting people in perinatal healthcare settings. Learnings from this study addresses ongoing challenges to compassionate care during this critical window, leading to disengagement of patients. Support through connection of resources can be helpful for ongoing recovery. Recommendations are made to establish trust through transparency and non-judgmental care and to reinforce receipt of appropriate healthcare services.

BackgroundEvidence-based home visiting programs are designed to improve maternal child health. Nurse-Family Partnership (NFP) is a model evidence-based home visiting program, shown to improve pregnancy outcomes, child development, and economic self-sufficiency for first-time mothers and their families experiencing social and economic adversities, enrolling them early in pregnancy. Recently, NFP has expanded its services to multiparous women (previous live births) and enrolling women past 28 weeks gestation (late registrants) in selected agencies in Florida since 2021.ObjectiveTo study the process and impacts of expanding NFP to expanded populations (multiparous and/or late registrants), we convened a diverse Advisory Committee to guide the NFP expansion evaluation in Florida.MethodsThis study employed a modified e-Delphi method with three rounds of data collection, to engage diverse partners to identify process and impact outcomes for the NFP expansion evaluation.ResultsChild maltreatment was identified as the highest priority outcome. Process outcomes included program reach, client enrollment, and client engagement, while impact outcomes included maternal physical health, maternal mental health and substance use, birth outcomes, and breastfeeding practices. The Advisory Committee further identified potential data sources to measure these outcomes.Conclusions for PracticeIdentifying and selecting key process and impact outcomes using a community-engaged process is necessary to ensure equal buy-in from all partners and to inform rigorous program evaluation. This study showed that using methods such as e-Delphi is feasible and effective for achieving thoughtful and rigorous decision-making, even in times of uncertainty like the COVID-19 pandemic.SignificanceWhat is Already Known on this Subject? Home visiting programs range widely in terms of goals, scope, intended population, and evidence base, but are increasingly recognized as a unique and impactful resource for improving maternal child health. The expansion of these programs to new intended populations must be evaluated to ensure that the original program as designed remains effective.What this Study adds? We highlight a systematic process used to identify and select key process and impact outcomes, through a community-engaged process to inform rigorous program evaluation in the context of perinatal and early childhood home visiting program. We demonstrated that effective transdisciplinary engagement, collaboration, and decision-making is feasible in a remote environment.

The study aimed to examine the association between cross-sector collaboration in Nurse-Family Partnership (NFP), a model home visiting program, and participant retention. We used the 2018 NFP Collaboration Survey that measured agency-level collaboration, operationalized as relational coordination and structural integration, among nine community provider types (including obstetrics care, substance use treatment, child welfare). This dataset was linked to 2014–2018 NFP program implementation data (n = 36,900). We used random-intercept models with nurse-level random effects to examine the associations between provider-specific collaborations and participant retention adjusting for client, nurse, and agency characteristics. The adjusted models suggest that stronger relational coordination between nurses and substance use treatment providers (OR:1.177, 95% CI: 1.09–1.26) and greater structural integration with child welfare (OR: 1.062, CI: 1.04–1.09) were positively associated with participant retention at birth. Stronger structural integration between other home visiting programs and supplemental nutrition for women, infants, and children was negatively associated with participant retention at birth (OR: 0.985, CI: 0.97–0.99). Structural integration with child welfare remained significantly associated with participant retention at 12-month postpartum (OR: 1.032, CI: 1.01–1.05). In terms of client-level characteristics, clients who were unmarried, African-American, or visited by nurses who ceased NFP employment prior to their infant’s birth were more likely to drop out of the NFP program. Older clients and high school graduates were more likely to remain in NFP. Visits by a nurse with a master’s degree, agency rurality, and healthcare systems that implement the program were associated with participant retention. Cross-sector collaboration in a home visiting setting that bridges healthcare and addresses social determinants of health has potential to improve participant retention. This study sets the groundwork for future research to explore the implications of collaborative activities between preventive services and community providers.

Statement of the Problem: Pregnant women living in poverty are at risk for adverse pregnancy outcomes. Children born to women living in poverty are also at greatest risk for poor health and development. Nurse-Family Partnership (NFP) has been proven to address these problems related to pregnancy and child development. Home-visiting programs like NFP must coordinate with other community services across sectors to be most effective, but little research has examined the effect of cross-sector collaboration on program outcomes.Objectives: This dissertation aimed to characterize the nature and extent of collaboration between NFP nurses and cross-sector providers including healthcare and social services. We also explored the association between collaboration and program outcomes, including client retention, client smoking cessation and childhood injury.Methods: We used a sequential mixed-methods approach, first exploring collaboration across selected NFP sites using adapted grounded theory. Next, we used qualitative findings to develop a survey and measure collaboration across NFP sites in the United States. We integrated survey measures of collaboration (relational coordination and structural integration) with national NFP Implementation Data to assess the relationship between collaboration and program outcomes using a random effects model.Results: Most interview participants perceived collaboration to be important when serving clients with complex needs, but variation exists in the degree of collaboration with different providers. Factors that contribute to effective collaboration include: leadership commitment; provider champions; mission congruence; shared value; structural facilitators; and referral partnerships. Survey results confirmed qualitative findings that collaboration varies by provider type and community. The strongest relational coordination occurred with the Special Supplemental nutrition program for Women, Infants & Children (WIC), early intervention and obstetrics, and the least with housing resources. NFP sites were most integrated with WIC and least with housing resources. Random effect models suggest that coordination and integration with providers, in particular coordination with substance use treatment providers and parenting programs, may improve client retention.Conclusion and Significance: This dissertation describes NFP collaboration with cross-sector providers and found collaboration to improve certain program outcomes. Integration of these findings into NFP program development and nursing practice will maximize nurse productivity to serve vulnerable families.