Speakers
Margaret McConnell, PhD
Associate Professor
Department of Global Health and Population
Harvard T.H. Chan School of Public Health
Keywords
Randomized controlled trial
Key Points
- This trial took place in South Carolina at a time when Medicare was thinking about how to improve outcomes and if expanding home nursing services could improve health outcomes. The trial was part of a “Pay for Success” contract that enabled the state to promise funds for further expansion conditional on positive evidence of impact from the randomized trial. The home visit services were covered through a Medicaid waiver that allowed the Nurse Family Partnership (NFP) to serve about 4,000 people over 4 years (up to 40 visits at home).
- The Nurse Family Partnership (NFP) delivered bi-weekly home visits with a registered nurse for the first 2 years of the child’s life and targeted first-time, low-income pregnant people. The types of services NFP nurses provide include health assessments, such as prenatal health assessment, monitoring weight and blood pressure; screening for depression, anxiety, intimate partner violence; referrals to health care providers and community resources; educational content; and psychosocial support.
- This was a randomized controlled trial that enrolled 5,670 mothers into the evaluation between 2016 and 2020, with 2/3 allocated to the intervention group. The control group received standard of care in South Carolina. To be eligible, patients needed to be first-time mothers aged 15 and older who met the income-eligibility criteria for Medicaid and were no more than 28-weeks gestation at enrollment.
- The primary evaluation question for the trial was what is the impact of NFP on health outcomes when delivered at scale? The primary outcome was a composite of at least one of small for gestational age, or low birth weight, or preterm birth or perinatal mortality. Secondary outcomes included neonatal outcomes and maternal outcomes.
- There also were primary outcomes related to 2-year outcomes. The primary outcomes were a composite of at least one of health care encounter or mortality from major injury or concern for abuse or neglect and birth interval of less than 21 months. The study will be able to follow longer-term outcomes observed following moms and babies for up to 30 years, including health care utilization, timing of subsequent pregnancies, use of social services, criminal justice involvement, educational outcomes and economic opportunity.
- 98% of participants enrolled in the treatment group received at least one visit from NFP. Visits were mostly spent on personal health and maternal role topics. The median home visit length was 65 minutes. Some referrals were made for general services (25%) and health care (23%). The median number of visits is 9.
- There was not much of a difference in birth outcomes between the nurse home visit and control groups. There were substantial adverse outcomes (26% for the full sample control group) and large racial disparities. There was no impact on primary or secondary outcomes and no improvement in outcomes for any subgroup
Discussion Themes
-The program itself was disappointed but the state would much rather know that the program is not working. With birth outcomes there is not a large stable of interventions that do work and that address racial inequities. It’s hard to use existing literature to figure out what to do next.
–Is there a loss to follow up due to families moving out of state? We are largely looking at state data but are thinking about federal data that we can access. We are working to see if we can set up agreements with North Carolina and Georgia to capture the majority of migration from South Carolina.
Tags
#pctGR, @Collaboratory1