The Story of David Olds and the Nurse Home Visiting Program

The Storyof David Olds and the Nurse Home Visiting Program

Grants Results Special ReportWritten by Andy GoodmanJuly 2006

Table of Contents

M is for the Model 3

More Than a Visit 4

Gestating the Model 6

Putting the Model to the Test 9

Elmira, N.Y. 10

Memphis, Tenn. 12

Denver, Colo. 14

Roll Out 15

Growing the Program 18

Appendix 20

© 2006 Robert Wood Johnson Foundation.

� The Story of David Olds and the Nurse Home Visiting Program

M is for the Model Motherhood,inspirationofmythandsong,canbeparticularlydauntingforlow-income,first-timemothers.In1977,DavidOlds,Ph.D.,begandevelopinganursehome-visitationmodeldesignedtohelptheseyoungwomentakebettercareofthemselvesandtheirbabies.Nearly30yearslater,withsupportfromtheRobertWoodJohnsonFoundationandothers,the“OldsModel”hasblossomedintotheNurse-FamilyPartnership,anonprofitorganizationservingmorethan20,000mothersin20statesacrosstheUnitedStates.Today,despitedecadesofevidenceconfirmingtheefficacyoftheprogram,aswellasrecognitionatthehighestlevels,Oldscontinuestorefinehismodel,stilldedicatedtohelpingmothersprovidethemanythingstheirchildrenneed.

David Olds, Ph.D.Founder, Professor of Pediatrics, Psychiatry and Preventive Medicine

University of Colorado


More Than a Visit Onthisclear,crispJanuarymorning,thevisitwillhappeninsideanondescriptsplit-levelhomewithanAmericanflagdisplayedoutside.Thehouseisoneofdozensinadevelopmentthathassprunguplikesomanyothersontheonce-grassyplainsofColorado,bringingwithitnewroadslinedwithafamiliarassortmentofbig-boxstoresandfast-foodoutlets.Ifyoueverwonderedwhatsprawllookslike,justdrivenorthfromDenvertoWestminster(population100,000andgrowing)andyouwillgetagoodpicture.

JulieWilber,aregisterednursebasedatSt.AnthonyCentralHospitalinDenver,hasjustmadethis15-minutedrivetovisitherclient,Leah,the28-yearoldmotherofLance,whorecentlyturnedone.Dressedinasweater,sleevelessdownvestandcorduroypants,Juliecouldeasilybemistakenforafriendorrelativeassheringsthedoorbell,buttheclipboard,stackofnotes,andstethoscopepokingoutofherbagsuggestthereismoretothevisitthananeighborlychat.JuliehasbeenmeetingregularlywithLeahsinceJune2004,whenLeahwas12weekspregnant,andthefriendshipthathasdevelopedovertheensuingmonthsisevidentthemomentthedooropensandthewomenhug.

LeahescortsJulieupstairs,openingtheplasticsafety-gatetothelivingroomandapologizingforthemess,anapologyJuliewavesoff.She’samom,too,andknowsexactlywhatit’slike.Juliesitscross-leggedonthecarpetedfloor,Leahtakesapositionacrossfromherleaningagainstacouch,andLancetoddlesaround,between,andoverbothofthemastheytalk.DressedinablueandorangeDenverBroncosT-shirtandjeans,andwearinganirrepressiblesmile,Lanceisthejust-walking,not-yet-talkingdefinitionof“allboy.”Julie’sbaghasbeenonthefloorbesideherlessthanaminutebeforeLancehasherstethoscopeinhishands.“He’sintoeverything,”Leahsaysapologeticallyasshereachestotakethestethoscopefromherson.Anotherknowingsmileandno-worrieswavefromJulie.

AfterabriefdiscussionofLance’sdiet—turkeysticksandChefBoyardeeravioliarethenewestadditions—Julieshiftstheconversationtothesubjectmatterforthisvisit,topicscarefullychosentocoincidewithLance’sdevelopment.Takingacoupleofbluepagesoutofherbag,shetellsLeahthatitisveryimportantforhertotakesometimeandhonorthefactthatshehassuccessfullyguidedLancethroughthefirstyearofhislife.JulieencouragesLeahtoanswerthequestionsinatwo-page“Mom’sMemo,”whichwillhelpherreflectonheraccomplishmentssofar.Asamplequestionfromthememo:“Whatwasitlikethefirsttimebabysmiledatyou?”LeahtakesthepagesandpromisestofillthemoutbeforeJulie’snextvisit.

Julie’ssecondsubjectis“emotionalrefueling,”makingsurethatLeah“takestimeformesoIcantakecareofhim,”asentencethatJuliebeginsandLeahfinishes,thoughit’sobviousfromLeah’swrysmilethatthisismucheasiersaidthandone.LeahexpressesanxietyaboutnotgettinganythingaccomplishedaroundthehousewhensheisbusyfollowingLancearound.“IfIdon’tdothechores,”shetellsJulie,“Ifeellike,‘WhatdidIdoallday?’”WhenLeahmentionsTravis,herhusbandofeightyears,itisevidentthatshe’snottheonlyoneaskingthisquestion,sothereisdefinitelysometensionaroundthispoint.

JuliegivesLeahajournalandaskshertospendsometimewritingaboutherexperiencesandfeelings.ShetossesoutahandfulofideastohelpLeahgetstarted.Listfivethingsyoulikeaboutyourself.Pickthreepeopleyouadmireandexplainwhy.Writehowyoufeelaboutyourmotheringskills.Leah’sbrowfurrowsatthissuggestion,andJulieimmediatelypicksupthecue.“I’mveryconfidentaboutyouasamother,”shesays.


Leahlooksatherwide-eyed.“Really?”sheasksasanumberoffeelingsplayacrossherface—self-doubt,relief,gratitude.Juliesmilesandnods,andinthatmomentyoucanalmostfeelherconfidenceflowingdirectlyintoLeah.Thevisitwillcontinuefortheremainderofthescheduledhour,Juliewillworkherwaythroughtheprescribedtopicsuntilit’sevidentthatLanceisreadyforhismiddaynap,butinasensetheday’sworkwasdoneinthatoneexchange.

JulieWilberregularlyvisits22clientsthroughtheNurse-FamilyPartnership,andinmanyways,Leahisexceptionalamongthem.Sheismarriedwhenmostothersarenot;sheisacollegegraduatewhenmostothershavebarelymadeitthroughhighschool;andherfamily’sincome(fromTravis’full-timejobasanautomechanicandherpart-timeworkasawaitress),whilemodest,ishigherthanmost.

WhatpassedbetweenthesetwowomenonabriskJanuarymorning,though,isemblematicoftheprogram,anditisoneofthedrivingforcesbehinditssuccess.WhileJulieWilber,registerednurse,wasprovidingherclientwithinformationandprofessionaladviceinthismeticulouslyscheduledandscriptedhomevisit,JuliewasgivingLeahconfidenceandhope.Itisthatscientificandthatsimple.Andmostimportantofall,itworks.


Gestating the Model “Givemealeverlongenoughandafulcrumonwhichtoplaceit,”saidArchimedes,“andIshallmovetheworld.”Threedecadesago,DavidOldsdecidedtosethisleverundertheweightyinstitutionofmotherhood,andhehasbeenlaboringeversincetoelevatetheparentingskillsofvulnerableyoungwomenacrosstheUnitedStates.Helpthembecomehealthier,strongermothers,histheorygoes,andtheywillraisehealthier,strongerchildren—strongenoughtomovetheworldinabetterdirectionontheirown.

Oldswouldprobablyblanchatsuchadescriptionofhismodel—it’sbothtoosweepingandtoosimplifiedatthesametime,anditomitshistwofavoritewords:evidencebased.Inhealthcarecircles,heiswellknownforhisscrupulousdevotiontodata,andwhenhespeaks,hemeasureshiswordsjustascarefully.Atthesame

time,Oldsissomeonewhoflatoutloveshisjob(heisprofessorofpediatrics,psychiatryandpreventivemedicineattheUniversityofColorado),andthisgivesthe57-yearold“manofscience”analmostboyishquality,especiallywhenhetalksabouthismodel.

WhenothershavewrittenthehistoryofOlds’home-visitationmodel,theyusuallybegininElmira,N.Y.,whereitwastestedforthefirsttimein1977.TheinspirationforwhatwouldbecomeOldslife’swork,however,canbefoundinOhio.BorninAshtabulain1948,OldsmovedtoConneaut,Ohio,thefollowingyearandlivedinthesamehouseuntilhegraduatedfromhighschool.Althoughheacknowledgesthathisfather,Bob,hadadrinkingproblemandchangedjobsfrequently,Oldshasfondmemoriesoftheseearlyyears—untilheturned11.Inthatyear,hisparentsweredivorced,hisfathermovedtoFlorida,andhisgrandmother,whohadlivedwiththefamily,passedaway.Hisdevotedmotherworkedinafactory,providingforandcaringforOldsandhissisterthroughouttheirchildhood.

Lookingbackonthattime,Oldsseesaturningpoint.“IknewthatIwantedtodosomethingtohelppeople,”hesays,eventhoughthe11-year-oldDavidmaynothavefullyunderstoodwhy.Inhighschool,Oldsstartedtothinkaboutcareersinjournalism,medicineoreventheclergy.“IhadromanticvisionsofgoingofftoIndiaorsomeexoticplace,”heconfesseswithaself-deprecatingchortle.In1965,heappliedtoJohnsHopkinsUniversityandwasacceptedwithascholarshiptopursueafive-yearB.S./M.S.programininternationalrelationssponsoredbytheSchoolforAdvancedInternationalStudies.Hestartedtheprogramin1966.

Byhissophomoreyear,however,Olds’interestininternationalstudieshadwaned.Hisdesire“tohelppeople”wasmovingmuchclosertohome,literally.Hestartedsigningupforcoursesindevelopmentalpsychologywithafocusonearlyinfantattachment.“IthinkthereisapartofmethathasalwayswantedtorecapturethatsenseIhadofahappyfamilyinmyearliestyears,”Oldssays.Whenheofficiallychangedhismajortosocialandbehavioralsciences,heforfeitedtheremainderofhisscholarshipandhadtotakeapart-timejobcuttinggrassforthecityofBaltimoretopayhistuition.Clearly,thiswasnotaneasydecisiontomake,butOldshadnodoubtitwastherightone.

Long-Term Impact

New data from the 15-year follow-up in Elmira, N.Y., shows positive effects on nurse-visited families more than a dozen years after the visits were concluded. Some of the metrics of success (from pregnancy through child age 15) include:

56 percent fewer doctor and hospital visits due to childhood injuries through child age 2.25 percent reduction in cigarette smoking by mothers during pregnancy.48 percent less incidence of child abuse and neglect through child age 15. 69 percent fewer convictions of nurse-visited children at age 15.83 percent increase in workforce participation by low-income, unmarried mothers by the time their child is 4 years old.

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AftergraduationfromHopkinsin1970,helandedhisfirstfull-timejobattheUnionSquareDayCareCenter,threecrampedroomsinthebasementofachurchinWestBaltimore.Thecenterservedchildrenages3to5,withroughly15to18kidsinaroom,supervisedbyateacherandanassistant.Oldswastheyoungestteacheronthestaff,whichhadamixofveteranteachers,recentgraduatesandeverythinginbetween.OneofhisclosestfriendsonthestaffwasanAfrican-AmericanwomannamedPocahontasWilkinson,orPokieasherfellowteacherscalledher.(“Youhavetoremember,wecameoutoftheSixties,”Oldssayswithasmile.)Hisexperiencesthere,thoughbrief,wouldplayasignificantroleinpropellinghimtowardshislife’swork.

Rightfromthestart,Oldssays,hehadthesensethatsomeofhiscolleagueswereapproachingtheirwork“asglorifiedbaby-sitting,withnotalotofaspirationsforthekidsortheirparents.”Mostoftheactivitiesatthecenterwerepureplay.“Iwantedthekidstohavefun,butwantedtocreatemorecognitivestimulationandstructureforthekids,”hesays,sohebroughtinanewcurriculum,thePerryPre-Schoolprogram,whichhehadlearnedaboutwhileatHopkinsandwhichwasbeingtestedinMichigan.Healsostartedinvitingparentstocomeintohisclassroomduringnaptimesohecoulddiscusstheirchild’sbehavioratschoolandtalkaboutactivitiestheparentscouldtryathome.

Whilehiscolleagueslookedonskeptically,Oldsfelthewasmakingprogresswithhisnewapproach,butacoupleofincidentsofferedpainfulremindersofhowmuchworkstilllayahead.Oldsrecallsoneblue-eyed,blond4-year-oldboywhowasbeingcaredforbyhisgrandmother.Thechild,whoOldsdescribesas“afragileboywithasweetdisposition,”communicatedonlywithbarksandgrunts.Inclassroommeetingswiththegrandmother,Oldslearnedthattheboy’sspeechwassoseverelydelayedbecausehismotherwasadrugaddictandalcoholic,andhadbeenusingthroughoutherpregnancy.

Bobbie,another4-year-oldwiththickglassesandapartiallycrossedeye,wasalwaysrestlessatnaptime,Oldssays.“Hewouldberollingaround,halfoutofhiscotmostofthetime.”Ononeoccasion,OldsandPokietriedtotalkwithBobbieaboutthisproblem,andtheboyfiredbackastringofexpletivesthatstunnedhisteachers.EventuallyBobbiecalmeddown,anditwasonlythenthatOldsdiscoveredwhyhisyoungchargewassorestless:athome,Bobbiewouldwethimselfwhenhetooknaps,andhismotherwouldbeathimaspunishment.Bobbiecouldnotfallasleepbecausehewastooafraidthesamethingwasgoingtohappenhere.

Oldsbegantodevelopasensethathisworkatthecenterwasfutile.Formanyofthechildreninhisclassroom,irreparabledamagehadalreadybeendone.ThebestOldscoulddothereonaday-to-daybasiswastriage.Thelaissez-faireattitudeofsomeofhiscolleaguesfurtherreinforcedhisfeelingthatthesystemwasnotinclinedtoexpectmoreoftheseinner-citykids.AndeventhoughhewastakingmorecoursesinstatisticsandearlydevelopmentatHopkinswhileworking,Oldsfeltthathedidnothavetheknowledgenecessarytotakethisunderstandinganddosomethingmeaningfulwithit.Hehadtogobacktoschool.

Whilestillworkingatthecenter,OldsstartedtoreadbooksbyUrieBronfenbrenner,aprofessoratCornellUniversitywhowroteabout“humanecology”—thenetworksthatformamongparents,educatorsandotherstoprovidecareforchildren.HewrotelettersinlonghandchallengingBronfenbrenneronhistheories,andtohissurpriseBronfenbrennerwroteback.ThescholarlycorrespondenceeventuallyyieldedaninvitationforOldstoattendoneoftheprofessor’slectures

A visiting nurse, mother and toddler visit a park.


inWashington.“He’sthereasonIdecidedtogotoCornell,”saysOlds,whoenteredtheSchoolofHumanEcologyin1972.

WhileOlds’workattheUnionSquareDayCareCenterultimatelydrovehimbacktoschool,thehands-onexperienceinthosecrampedbasementclassroomsalsomadehimimpatientwithapurelyacademiclife.“IalmostdroppedoutofCornell,”hesays,butBronfenbrenner,whowasOlds’mentorbythispoint,counseledhimtostayandgetthePh.D.indevelopmentalpsychologythatOldswasworkingtowards.Sohestayedput,butin1975,Oldstookapart-timejobatComprehensiveInterdisciplinaryDevelopmentalServices(betterknownbyitsunfortunateacronym,CIDS)wherehecouldworkmorecloselywithchildren.

BasedinElmira,N.Y.,CIDSconductedprogramsintendedtopreventhealthanddevelopmentalproblemsinyoungchildrenbyprovidingthemwithscreeningservicesandthenreferringthemforfurtherevaluationandtreatment.Oldssaysthathe“doubtedjusthoweffectivethatkindofservicemightbeandrecognizedimmediatelythattheirprogramwasnotsetuptodeliverreallyrigorousscientificresults,”andthisprovidedevenmoreincentivetodevelopaprogramofhisown.JohnShannon,executivedirectorofCIDS,gavehimthego-aheadtodevelopapreventiveprogramthatcouldbestudiedrigorously.Forsometime,Oldshadbeenthinkingaboutahomevisitationprogram,butnowhefeltcertainthatheknewalltheelementsthathadtobepresenttoensureapositiveimpact:

Theprogramhadtoworkwithfirst-time parents,becausethiswouldprovidethebestchanceofpromotingpositivebehaviorsbeforenegativeoneshadtakenhold.

Theprogramhadtobeconductedin the home,becausethiswaswherethevastmajorityofparentingoccurs,andbecauseitwouldnotrelyonparentstravelingtoaprogramsite.(Olds’experienceinBaltimorespokeloudlyhere:theparentswhoneededthemosthelphadbeentheleastlikelytoshowupforhisparentgroupmeetings.)

Theprogramwouldrelyonnurses as in-home visitors,becausethemotherswouldtrustthemtoknowaboutpregnancyandthecareofbabies,andpreferthemtodoctors,andbecausemuchofthenecessarytrainingfornurseswouldalreadybeinplace.

Thevisits would begin during pregnancy,becausenegativeinfluencesontheprenatalenvironmentcanhavelong-termandpossiblyirreversibleeffectsafterbirth.Startingatthispointwouldalsohelpbuildabondbetweenthevisitingnurseandtheparentsbeforeallthepressureofcaringforanewbornbegins.(“Wedidn’twanttostigmatizethemothersandmakethemfeel,‘You’reherebecauseI’mnotgoingtobeagoodparent,’”Oldsadds.)

Theprogramwouldhavethreemajorgoals:

Toimprovepregnancyoutcomesbyimprovingwomen’sprenatalhealth.

Toimprovechildhealthanddevelopmentbyreducingtheamountofdysfunctionalcaregivingforinfants.

Toimprovethemothers’lifecoursebyhelpingthemdevelopavisionfortheirfutures,planfuturepregnancies,stayinschoolandfindemployment.

ThebasicelementsoftheOldsModelwereinplace.Theyoungmanwhowatchedhisfamilyfallapartatage11,andwhosetoutonapath“tohelppeople,”nowhadaplantodojustthat.

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Putting the Model to the Test Before1975wasout,OldssubmittedaproposaltotheOfficeofMaternalandChildHealthoftheU.S.PublicHealthServicetoconductarandomizedcontroltrialinthecityofElmira.Itwasrejected,whichisnotuncommonforfirst-timeapplicants,sohemadesomemodificationsandtriedagain,thistimeattheOfficeofChildDevelopmentatwhatwasthencalledtheDepartmentofHealth,EducationandWelfare(HEW).OfficialsatHEWacceptedtheproposalandoffered$1.5milliontoconductafive-yearstudyinElmira.Oldsturnedthemoneydown.

“Iwasabletomapthisout,”herecallstodaywithatouchofembarrassment,“butIdidn’treallyknowhowtoactuallyputitalltogether.”Howwouldthenursesbetrained?Whatcurriculumwouldtheyuse?Oldsknewthequestionstoask,buthewasconcernedthathewouldnotbeabletopulltogethertheanswersquicklyenoughtoconductatrialthatwouldproducemeaningfulresults.

AfterwithdrawinghisproposalfromHEW,heturnedforhelpfromadvisersattheUniversityofRochester,whichhadaprograminchildhealththatOldsrespected.

AdvisersatRochesterhelpedhimconceiveanewproposalthatincludedanentireyearupfrontforplanning,aswellasasmallerpilotstudythatwouldgivethemodelasix-monthtestrunbeforeawiderstudywaslaunched.

OldscallshisdecisiontorejecttheHEWofferandretoolhisproposal“thesmartestdecisionIevermadeinmylife.”HewentbacktotheofficeattheU.S.PublicHealthServicethathadrejectedhisfirstproposalandpresentedhisnewplan.Officialsthererespondedwithenoughmoneytofundthefirsttwoyearsoftheplanaswellasapromisetoconsideradditionalsupportuponareviewoftheresults.

Thistime,Oldsenthusiasticallyacceptedtheofferandpreparedtolaunchthefirsttestofhismodel.

Twoyearslater,theRobertWoodJohnsonFoundationwouldmakeagranttosupportcontinuationoftheElmirastudy.RubyHearn,theprogramofficerresponsibleforthisinitialgrant,hadbeenworkingwithofficialswithintheCarterAdministrationtofindaprogramthatcouldpositivelyinfluencematernalandchildhealth.WhenshewenttoElmiraforapreliminarysitevisitandacloserlookatOlds’home-visitationmodel,shemetOldsforthefirsttime.“Iwassurprisedathowyounghewastobetakingonsuchanambitiousproject,”shesaystoday,“buthewasveryimpressive.”

Oldsconfessestosomesurprisehimself.“Iwasastonished,”hesays,”thatamajorfoundationwouldtakeachanceonayoungpersonwhohadnotrackrecordandwhowasnotaffiliatedwithamajoruniversity.ThatinitialJohnsongrantwasagod-sendthatsolidifiedeverythingwehavedonesince.”

A visiting nurse goes over the visit’s topics with a new mother.

10 The Story of David Olds and the Nurse Home Visiting Program

Elmira, N.Y.

Bythelate1970s,ElmiraandthesurroundingtownsinChemungCountyhadbeensufferingfromhighunemploymentforsometime.Theincidenceofprematurebirth,infantmortalityandchildabuseatthetimewereamongthehighestinthestateofNewYork,makingtheregionaparticularly(ifsadly)appropriatetestinggroundforOlds’model.Forthestudy,400familieswereselectedfromapopulationthatwaspredominantlywhite,ruralandhoveringaroundthepovertylevel.Outofthisgroup,abouthalfwererandomlyassignedtonurse-visitationservicesandtherestwereassignedtoacontrolgroupthatwouldreceivetransportationforprenatalandwell-childcareandtheCIDSscreeningservicesforchildren,butnonursevisits.

Thiskindofstudymethodisnecessarytorigorouslycomparetheeffectsoftheprogramonthechildrenandmothersreceivingthehome-visitservicestothosechildrenandmotherswhoreceivedtheoptimumthatthecommunitycurrentlymightofferthroughexistingresources.Moreover,byprovidingsomeservicestothecontrolgroup,thestudyprovidesaconservativetestofthenurse-visitingmodel.

Forwomeninthestudywhowouldreceivenursevisits,theprogramwouldbeginduringpregnancy,ideallywithinthefirsttrimester.Duringthefirstmonthofvisits,registerednurseswouldcheckinweeklywiththeirclients,primarilytobuildaleveloftrust—anessentialelementiftheyoungmotherswereexpectedtoheedthenurses’advice,especiallyintimesofcrisis.Fortherestofthepregnancy,visitswouldbescheduledeveryotherweek.

Oncethebabywasborn,nurseswouldresumeweeklyvisitsandcontinueatthisfrequencythroughthenextsixweeks,oftenatryingadjustmentperiodforanyyoungfamily.Afterthis,visitswouldreturntoanevery-other-weekbasisuntilthebaby’s21stmonth,whentheywouldbescheduledmonthly.Theprogramofficiallyendsatthebaby’ssecondbirthday.Foreveryphase—pregnancy,infancyandtoddler—nurseshaddetailedguidelinesforthecaretheyweretogiveandtheinformationtheyweretoprovidetotheyoungmothers(andfatherswheneverpossible)inthestudy.

WhiletheElmiratrialbeganenrollingwomenin1978,therecruitmentwould

notenduntil1981.Andofcourseittookanothertwoandahalfyearstocompletethestudyandgatherthedatafollowingregistrationofthelastparticipant.Thefirstreportonthetrialwasnotpublisheduntil1986,buttheearlyfindingswereremarkable.Withintwoyearsfollowingthebirthofthefirstchild,theElmirastudystartedtogenerateresultsthatshowednursevisitswerehavingthedesiredpositiveimpact.Forexample:

Inthegroupoflow-income,unmarriedteenmotherswhodidnotreceivenursevisits,theincidenceofchildneglectorabusewas19percent.Insharpcontrast,amonglow-income,unmarriedteenmotherswhodidreceivevisits,theincidencewas4percent.

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A visiting nurse uses a doll to show a new mother techniques for caring for her child.


Nurse-visitedmotherswhoweresmokerssmoked25percentfewercigarettesoverthecourseoftheirpregnancythandidsmokersinthecontrolgroup.

Nurse-visitedmotherswhosmokedcigarettesalsohad75percentfewerpre-termdeliveriesthandidwomeninthecontrolgroupwhosmoked.

YearsbeforethesefindingswerepublishedtheseearlypromisesofsuccessbegantoattractattentionoutsideElmira.In1979,Oldssays,hewascontactedbyrepresentativesoftheCarterAdministrationwhowereinterestedinreplicatingtheprogram.Whilethelureoffederalsupporthadtobestrong,Oldsdemurred.

Unlikehispreviousrejectionofgovernmentfunds,however,hisconcernswerenotwithhisownabilitytoadministerawellconstructedprogram.Lookingtoreducecosts,administrationofficialswerealreadysuggestingmodificationsintheprogram—e.g.,usingparaprofessionalsinsteadofregisterednursesforthehomevisits—andOldswasnotreadytotinkerwithadesignthat,tohismind,stillrequiredmorethoroughtesting.

Thiswouldnotbethelasttimethat“fidelitytothemodel”wouldbeaguidingprincipleinOlds’work.

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What the Numbers Cannot Say

While the data from the Elmira study confirm the positive impact the nurses had on the lives of the women and children they visited, it may inadvertently paint a picture that is as clean and neat as a computer printout. Rarely was this the case, and there is no more dramatic example of how raw the picture could be than the story of Bonnie, an Elmira mother, and Stacy, the nurse who visited her. (While names have been changed to protect the privacy of the individuals in this story, the details are based on an actual case.)

Bonnie was 17, and her “home” was a dirt-floor basement apartment that was infested with roaches. She drank, smoked, was frequently in trouble with the law, but most important of all, she was pregnant. Stacy, a registered nurse who began visiting regularly with Bonnie, asked her if she would consider stopping smoking. “This baby’s taken everything else away from me,” Bonnie spat back referring to her swollen belly. “It’s not going to take my cigarettes.” She threatened to slap the nurse across the face, and given that she had already broken her mother’s ribs in a fight, it was not a threat to be taken lightly.

Bonnie had been tortured as a child and had cruelly mistreated babies entrusted to her for baby-sitting jobs, and while this might have appeared as one more indication that she would be a disaster as a mother, it actually turned out to be her saving grace. During one visit, she broke down and confessed, “I’m afraid I’m going to do that to my own baby—especially if it’s a crier,” and

for the first time Stacy felt that she could help—because when Bonnie revealed her fear, it was a cry for help.

During pregnancy, before the baby was even on the scene, Stacy asked Bonnie whom she would call for help if, when she returned home with her baby after delivery, the baby was crying inconsolably at night. Bonnie had no idea. After some probing by Stacy, Bonnie said a neighborhood “grandma” (not really related) would help. Stacy asked Bonnie to write down this woman’s phone number and tape it up on the wall so she would be prepared when she needed help, and she suggested some other strategies to help Bonnie cope with situations that she was worried about.

Bonnie’s baby was born prematurely, but she dutifully visited her child in intensive care every day. When the baby was discharged from the hospital, Bonnie moved in with the neighborhood “grandma” rather than return to her basement apartment so the baby could be raised in a safer environment. Even the baby’s father, who had been absent until this time, started participating in the home visits, and became deeply invested in his child. Bonnie and her boyfriend managed the care of their child remarkably well in spite of overwhelming odds against them. Today, her child has graduated from high school and avoided many of the difficulties experienced by her mother. Had Stacy not become a part of Bonnie’s life, such a happy ending is difficult, if not impossible to picture. It is also an outcome that numbers alone cannot describe.


Memphis, Tenn.

WhiletheresultsinElmirawereencouraging,Oldsandhisteamwerenotreadytoassumethatsuccessinawhite,ruralregionwouldautomaticallybeduplicatedinurbansettingsandincommunitiesofcolor.AstheNewYorktestdatacontinuedtobuildacaseforthemodel,Oldsassembledateamtoidentifythebestlocationforasecondstudyworkingwithinner-city,African-Americanfamilies.

Beginningin1984,theteamconsideredeverymajormetropolitanUnitedStatescitywithapopulationof250,000ormore.EnormouscitiessuchasNewYork,LosAngelesandChicagowerequicklyruledoutbecausetheirverysizecreatedtoomanycomplicationsfromthestandpointofcoordinatingresearchwithintheheathcaredeliverysystem.Forawhile,itappearedthatPhiladelphiawouldbethebestsite,butthentheteamtookacloserlookatMemphis.

LikeElmirainthelate1970s,Memphisinthemid-1980swasacitywithconsiderableroomforimprovementinthefieldofinfantandmaternalcare.Ratesofinfantmortalityandmorbiditywereamongthehighestinthenation.Ratesofpre-termdeliveryandincidencesofunusuallylow-birthweightbabiesequaledthoseoflargercities.

Itwouldbeanotherfactor,however,thatwouldultimatelyswingthebalanceinMemphis’direction.Fortheinner-city,low-incomewomenwhowouldbeprimecandidatesforthestudy,Oldssays,“asingleclinicmanagedregistrationforprenatalcare.Womeneitherremainedatthatclinicorwerereferredtoneighborhoodhealthcentersfortheircare—andtheyalldeliveredinthesamehospital.”

Forpediatriccare,allchildreninlow-incomefamilieswereseeninthesamesystemofneighborhoodhealthcentersandallchildrenweretakentoLaBonheurChildren’shospitalforemergencycareandhospitalizations.Whereresearchmanagementwasconcerned,theteamthatwouldsupervisethestudycouldhardlyhaveaskedforbetterconditions.

Ofthe$7millionneededtofundthestudy,theRobertWoodJohnsonFoundationcontributedroughlyhalf.Eightotherfundingsources1combinedtocovertherestofthebudget.Olds’teamidentified1,139African-Americanwomenforthetestoftheprenatalphaseoftheprogramand743tobefollowedafterdeliveryforthetestoftheinfantandtoddlerphase,againwithfamiliesrandomlyassignedtotheprogramortoacontrolgroup.Forthepostnatalphaseofthestudy,twiceasmanywomenwereassignedtothecontrolgroupasthenurse-visitedconditiontoreducecostsoftheresearch.

By1991,thenextstudyofnursehomevisitingwasunderway.WhilethestudyoftheprogramrolledoutinMemphis,OldsremainedinNewYork,monitoringnewdatafromElmiraanddraftingaproposalforadditionalresearchthatwouldtakeanotherlookatfamiliesintheElmirastudywhenthechildrenreachedage15.(In1992,theNationalInstituteofMentalHealthwouldacceptOlds’proposalandprovidethefunding.)

1 NationalInstituteforNursingResearch(NationalInstitutesofHealth)BureauofMaternalandChildHealth,(DepartmentofHealthandHumanServices—DHHS)AdministrationforChildrenandFamilies(DHHS)OfficeoftheAssistantSecretaryforPlanningandEvaluation(DHHS)NationalCenterforChildAbuseandNeglect(DHHS)TheCarnegieCorporationThePewCharitableTrustsTheW.T.GrantFoundation

1� The Story of David Olds and the Nurse Home Visiting Program

EarlyresultsfromtheMemphistrialswereaspromisingastheElmiradata.

Nurse-visitedwomenhad23percentfewerhypertensivedisordersinpregnancythandidwomeninthecontrolgroup.

Nurse-visitedchildrenhad80percentfewerdaysofhospitalizationforinjuriesoringestionsinthefirsttwoyearsoflifeascomparedtothecontrolgroupchildren.

Mothersinthehome-visitedgrouphad23percentfewerpregnanciesbythefirstchild’ssecondbirthday,andwhereasecondpregnancyoccurred,therewasgreaterspacingbetweenthefirstandsecondpregnanciescomparedtowomeninthecontrolgroup.

Onceagain,Oldsreports,hereceivedinquiriesaboutreplicatingtheprograminseveralothercommunities.Givensuchstrongindicationsthatthemodel’ssuccesswasnottiedtoaparticularraceorgeographicsetting,itmayhaveappearedtomanyinterestedobserversthatthemomentforexpansionhadarrived.

ButnottoDavidOlds.Fromhisperspective,therewerestillsignificantquestionstobeaddressed.ElsewhereintheUnitedStates,thereweresimilarhome-visitingprogramsthatusedparaprofessionalsinsteadofregisterednurses.Oldshadalreadyheardsuggestionsthatthisapproachwouldbeaneffectivewaytoreducetheprogram’scost.Butcouldanyonebecertainthatparaprofessionalswouldbringthesameskillsandgeneratethesameleveloftrustasregisterednurses?AndeventhoughpositiveresultswithCaucasiansandAfricanAmericanswereencouraging,thisstillleftoutalargeportionoftheU.S.population:Hispanics.

Backthen,inthemid-1990s,justashewouldin2006,Oldspreferredtomoveslowly,deliberatelyandalwayswithfidelitytothemodel.Expansionwouldhavetowait.Therewasmoretestingtodo.

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Mothers are grateful for the assistance they receive from visiting nurses.


Denver, Colo.

InJanuary1993,theColoradoTrustinvitedOldstospeaktoitsboardofdirectorsabouthishome-visitingmodel.AfterOldssharedthelatestfiguresfromElmiraandMemphis,hewasaskedwhereheintendedtofieldhisnextstudy.Thelocationwasstillupintheair,Oldstoldthem,butthepurposeofthethirdstudywasclear:Oldswantedtoputtheparaprofessionals-versus-nursesquestiontoarigorousscientifictest.Theboardaskedhowmuchsuchastudywouldcost.Oldsestimated$7millionandaddedthatitwouldprobablytakeanotherfouryearstoraisethesefunds.

TheColoradoTrustcamebackwiththemoneyinfourmonths,andthestudyOldsenvisionedhadfoundahomeinDenver.(OldshimselfalsomadeDenverhishome,relocatingin1993fromRochester,N.Y.)

ThebasicformatwouldbesimilartoElmiraandMemphis,butwithtwosignificantdifferences.InColorado,notonlywouldtherebeacontrolgroup(receivingnovisits)andaregisterednurse-visitedgroup,therealsowouldbeagroupvisitedbyparaprofessionals—caregiverswhowereexpectedtohaveahighschooleducationbutnobachelor’sdegreeoranycollegepreparationrelatedtothetasksathand.ThestudywouldalsobeOlds’firstchancetotesthismodelwithHispanics,whowereheavilyrepresentedintheDenvermetroarea.

ByJune1995,Olds’teamhadrandomlyassigned735first-timemothersintoroughlyequalgroups—control,paraprofessional-visitedandnurse-visited.Nearlyhalf(46percent)wereHispanic.Amodelfoundedontheprinciplethatregisterednurseswerebestqualifiedtoconducthomevisitswasreadyforitsthirdandperhapsmostcrucialtest.

Overthepasttwodecades,thenumberofhome-visitingprogramshadproliferated,andtheuseofparaprofessionalswasgrowingrapidly.(In1999,thejournalThe Future of Childrenwouldestimatethatasmanyashalfamillionchildrenwereenrolledinsixlarge-scalehome-visitingprograms,andfiveoftheseusedparaprofessionals.TheOldsModelwasthesixth.)

TheresultsoftheDenverstudy,publishedinPediatricsin2002,confirmedOlds’suspicions.Whennurse-visitedmothersandchildrenwerecomparedtotheircounterpartsintheunvisitedcontrolgroup,therewereimportantdifferences.

Nurse-visitedmothersweremorelikelytoentertheworkforce.

Theyhadfewerpregnanciesbeforethefirstchild’ssecondbirthday.

Nurse-visitedchildrenborntomotherswhoweremorepsychologicallyvulnerablehadbetterlanguagedevelopmentandabilitytocontroltheirbehavioratages2and4.

Incontrast,whenparaprofessional-visitedmotherswerecomparedwiththecontrolgroup,therewerevirtuallynodifferences.Thesevisitedmothersinteractedbetterwiththeirchildrenandshowedsomereportedreductioninpsychologicaldistress,butthosewereessentiallytheonlymeasurableimprovements.

Havingputthreelarge-scaletestsintothefield,investedmillionsofdollarsinresearch,anddevotednearly20yearstoscrutinizingthedata,DavidOldswasfinallyreadytoconsidermorerapidandwidespreaddeploymentofhismodel.Hewouldnothavetowaitlong.

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Roll Out In1991,theU.S.JusticeDepartmentlaunched“OperationWeedandSeed,”anationwideinitiativetoattackgangactivity,drugabuseandviolentcrimeattheirroots.Subsequently,inhertenureasU.S.attorneygeneral,JanetRenowasveryinterestedinthepreventionsideofhermission,andgiventhetrackrecordtheOldsModelwasbuildingforfosteringstronger,healthierfamilies,Reno’sdepartmentsawanopportunityforlong-termprevention.In1996,officialsfromJusticeapproachedOldsandproposedanexpansiontosixmorecities:LosAngeles;Fresno,Calif.;Oakland,Calif.;Clearwater,Fla.;St.Louis;andOklahomaCity.

Clearly,suchrapidgrowthwouldbeanexpensiveenterprise,buttheJusticeDepartmentwasnotofferingfundinganywherenearthescaleoftheColoradoTrust.Instead,thedepartmentproposedallocating$25,000percityasseedmoney.Thesefunds,thedepartmentbelieved,wouldattractlocalorganizationsthatcouldleveragethemintothemoniesnecessarytoadministeranursehome-visitingprogram.Proceedingrequiredaleapoffaith—notexactlycharacteristicofOldstodate—butheapprovedoftheplan.

Above and Beyond

The services nurses perform in the Nurse-Family Partnership have been carefully defined over the years thanks to the constant refinement of the Olds Model. But there are some things the model just never planned on. (Once again, names have been changed to protect the privacy of program participants.)

In Greensboro, N.C., Sherry, a registered nurse, was home-visiting a particularly young client named Alice. One of seven children, Alice had become pregnant as a teenager and at 14 was caring for her baby while still living at home. Not even old enough to drive, Alice needed someone to take her almost every time she had to transport her baby.

When nobody from her family was available to drive her to a WIC Program (a supplemental nutrition program for Women, Infants and Children) appointment one morning, Alice called Sherry to ask for a ride. Seeing it as an opportunity to spend some more time with her client, Sherry agreed.

In the car on the way to the appointment, Sherry asked how things were going, expecting little more than a perfunctory “Fine,” but Alice had startling news: her house had no power. “For how long?” Sherry asked. “A week,” Alice replied, not overly upset.

Sherry, on the other hand, instantly saw a host of problems and started asking questions rapid-fire: “How have you been eating? How have you been doing your

homework? When will the power go back on?” To the last question Alice could offer only an uncertain shrug.

After dropping Alice at her WIC appointment, Sherry found a phone and placed a call to the local Department of Social Services. Sorry, a voice at the other end of the line said, we can not see you today.

Miffed but not yet out of options, Sherry placed her next call to the House of Refuge, a community nonprofit that assists low-income families who run into difficulty paying for food and vital services. Better luck here: the nonprofit was glad to help, but they could only cover half of the outstanding electric bill.

Fortunately, Sherry had one more card up her sleeve. She called Project Homestead, another nonprofit with services similar to the House of Refuge. They committed to cover the other half. When Sherry returned Alice to her house, she let Alice tell her father that the power would be restored the next day.

Up until this point, Alice’s father never had much to say to Sherry—having a teenage mother in his home along with six other children had not made him more agreeable, and accommodating this frequent visitor, no matter how well-intentioned, was just more hubbub. But he could not let this moment pass unremarked. “A lot of people say they will help you,” he said to Sherry, “but you’re the one that really did.”


“Iwasokaywiththis,”Oldsexplains,“becauseitforcedonlycommittedorganizationstogetinvolved.”Andsoin1996thewheelsstartedturningtorolloutthenursehome-visitingmodelinCalifornia,Florida,MissouriandOklahoma.

In2006,theprogramwasoperatingineverycountyinOklahomaanda2005evaluationoftheprogramtherefoundthattherateofinfantmortalityamongmothershavingfirstbabiesintheprogramislessthanhalftherateamongotherfirst-timemothers,inspiteofthefactthatmothersinthenurse-homevisitingprogramareyounger,poorerandmorelikelytobeunmarried.

Ataboutthesametime—1996—saysOlds,“agroupoflawyerswalkedthroughmydoorandsaid‘We’reheretohelpyou.’”ThegroupwasledbyBillRosser,anadvocateforthedisadvantaged,andBobHill,bothprominentColoradoattorneyswhowereinterestedinchildren’sissues.ThegrouphadbeenlookingforprogramsthatbenefitedchildrenthattheycouldbringtoColoradoand“scaleup.”ItwasinNewYorkthattheylearnedofaprogramthatwasalreadydeliveringresultsintheirownbackyard—Olds’program.

TheconversationsthatbeganinOlds’officeledtotheformationofanewnonprofit,InvestinKids,aswellasaninitiativetodivertmoniesfromthe

state’spieceofthenationaltobaccosettlementagreementtofundreplicationofOlds’programinColorado.By2000,thesefundstotaled$19millionperyear,andtwoyearsafterthat,nursehomevisitswereunderwayinmorethan30countiesacrossthestateofColorado.

WhileplanswerepercolatinginColorado,asimilarstorywasbeingwritteninPennsylvania.ThenGovernorTomRidgeandhiswife,Michele,wereinterestedinfindingprogramsthatwouldpreventcrimeanddelinquency.ClayYeager,whowasexecutivedirectorofthePennsylvaniaGovernor’sCommunityPartnershipforSafeChildren,wasassignedthetaskofbringingsuchprogramstotheKeystoneState.

YeagerhadalreadyheardabouttheimpressiveresultsyieldedbytheOldsModelandheinvitedOldstomakeapresentation.Using$20millioninfederalTANF(TemporaryAssistanceforNeedyFamilies)funds,Yeagerhelpedimplementthenursehome-visitingprogramin20communitiesacrossPennsylvania.

In1999,theRobertWoodJohnsonFoundationawardeda$10-milliongranttosupportaplannedsix-yearnationalrolloutthatestablishedthegoalofreaching100communitiesand10,000families.“It’sbecauseofDavid’sfocus,persistenceandstandards,”saysSeniorProgramOfficerJeaneAnnGrisso,M.D.,whenaskedtoexplainwhytheFoundationwaswillingtocommitsuchalargelevelofsupport.“Heinventedthephrase‘fidelitytothemodel.’Whenwebegantofundhimforreplicationanddissemination,heinsistedthatcloseattentionbepaidtotheintensityandfrequencyofvisits,thequalityofnursetraining,andthequalityofcaredelivery.”Oneyearlater,ColoradopassedtheNurseHomeVisitorsAct,allocating$75millionover10yearstosupporttheprograminthatstatealone.

A visiting nurse joins a mother and daughter on an outing.


Withsuchsignificantsumsnowearmarkedforreplication,newchallengesemerged—toattractandtrainnewstaff,toensurequalityineachnewsite,andtofindefficienciesandeconomiesofscaleforaprogramrunninginhundredsofsitessimultaneously.

Tomeetthesechallenges,theNurse-FamilyPartnership(NFP)wasincorporatedin2003,andanationalofficewasestablishedinDenver.Thenonprofitorganizationassumedresponsibilityforqualitycontrol,trainingnurses,monitoringexistingprogramsandensuringaccuracyinreportingandcoordinatingthedevelopmentofadditionalsites.Itreceivedstart-upfundingcapitalfromtheEdnaMcConnellClarkFoundation.

Bytheendof2005,NFPwasoperatingin20states,serving20,000families,andplanstomorethantripletheprogram’spresenceinNewJerseywerealreadyonthedrawingboard.

“TheFoundation’smajorinvestmentin1999,”Oldsexplains,“propelledourgrowingmomentumbyensuringthattheirearlierinvestmentwouldyieldreturnsinfuturepublicinvestmentsintheNFPandinsavinglives.”

A happy family can be one result of the Nurse Home Visiting Program.


Growing the Program ClayYeager,whohelpedbringtheprogramtoPennsylvaniainthelate1990s,wasnamedpresidentandCEOofNFPin2005.WhileDavidOldscontinuestorefinethemodelthroughresearch,thechallengeofgrowingtheorganizationhasbeenhandedtoYeager,anditisnotasmallone.

Nurse-FamilyPartnershipismarketingits“product”usingabusinessapproachtoreplication,accordingtoYeager.SeeitsWebsiteformoreinformationonnewdevelopments.Thecurrentbusinessplancallsforgrowthto38statesby2010(fromthecurrent20)andexpandingNFP’sserviceto34,000families(from20,000).Thiswillentailhiringandtrainingnearly1,200additionalnursesandhelpingnewsitesfindmorethan$80milliontooperatealltheprograms.

Atatimewhengovernmentofficialsatalllevelsarecuttingfundingforsocialservices,nobodyneedstoremindYeagerhowmuchheisswimmingagainstthetide.Thesteadybarrageofdepressingheadlinesdoesnotparticularlytroublehim,however,becauseYeagerbelieveshisrealbattleiswithamuchlargerfoe:along-standingbiasburieddeeplywithintheAmericanpsyche.“Ifgiventhechoicebetweenprisonandschools,”heexplains,“Americanswillalwayschooseprisons.”

Thepessimisticwordsarenothisown,havingbeenutteredlongagobyThomasJefferson.Andtheydonotpaintaprettypictureforanonprofitexecutivewhomusthelpattracttensofmillionsofdollarsforpreventionwhenpunishmentremainsanationalpriority.

ButYeagerremainsahappywarriorbecauseheknowshewillnotbefightingthisbattlealone,andhisstrongestallyisunwaveringinhiscommitmenttopreventionasourmostpowerfulstrategy.“Ihaveworkedwithmanyresearchers,academicsandscientists,”Yeagersays,“butDavidOldsisinaclassofhisown.”

AndwhereisOldstoday?Asthisisbeingwritteninearly2006,heisinBogotá,Colombia,talkingtogovernmentofficialsandrepresentativesoftheColombianPediatricSocietyaboutthepossibilityoftestinghisnursehome-visitingmodelyetagain.HehasreceivedsimilarinquiresfromofficialsinAustralia,

Canada,Germany,Holland,Israel,RussiaandSpain.Alloftheattentionandinteresthasnotalteredhismodusoperandi,however,whichremainsdeliberate,cautiousandalwayswithfidelitytothemodel.

Evennow,witha15-yearlongitudinalstudyfurtherconfirmingthesuccessinElmira,recognitionatthehighestlevelsofgovernment,andhighprofilecoveragebyCBSNews,theNew York Times,theWall Street JournalandmostrecentlyafeaturedessayintheNew Yorker,Oldsstillspeaksmodestlyabouttheworkthathasconsumedthebetterpartofhislife.

Plaudits

In its 1994 report, Blueprints for Violence Prevention, the Office of Juvenile Justice and Delinquency Prevention (within the U.S. Department of Justice), evaluated 600 programs to identify those that most contributed to violence prevention. The Nurse-Family Partnership was one of 11 programs cited by the report for its exemplary effectiveness.

In July 2003, the President’s New Freedom Commission on Mental Health issued a report entitled, Achieving the Promise: Transforming Mental Health Care in America. The report identified the Nurse-Family Partnership as a “model program” for “intervening early to prevent mental health problems.”

A RAND Corp. study, Early Childhood Interventions: Proven Results, Future Promise, released in January 2006, identified Nurse-Family Partnership as an early childhood program that “can return more to society in benefits than [it] costs.” (Another RAND study conducted in 1998 estimated that, over time, the Elmira program would save as much as $4 in government spending for every $1 in program costs.)

http://www.nursefamilypartnership.org/


“Thisiswhatwecanreallystandbehind,”hesaysofhismodel,speakingasifabatteryoflawyersisstandingnearby,poisedtojumpontheslightestinaccuracy.“Itreducesinjuriestochildren.Ithelpsfamiliesplanfuturepregnanciesandcreatebetterspacingbetweenthebirthofthefirstandsecondchildren.Ithelpswomenfindemployment.Ithelpsimproveprenatalhealth.Itimproveschildren’sschoolreadiness.”

Reasonablycertainthathehasenumeratedthemeritsofhismodelwithoutoverstatingthecase,Oldsfoldshisarmsandsmiles.Itisthesmileofamanwhohasamassedaremarkablebodyofwork,butwhoisbynomeanscontenttorestonhislaurels.Notwhentherearestillsomanyquestionstobeanswered.WillitworkinSouthAmerica?InEurope?Everywhere?

Thelongleverisstillinplace,andOldsisnotfinishedpressingonit.


Appendix Thefollowingindividualswereinterviewedforthisstory:

DavidOlds,Founder,ProfessorofPediatrics,PsychiatryandPreventiveMedicine,UniversityofColorado

AnnJones,FormerNationalDirector

NanButler,ActingVicePresidentofExternalAffairs

MattBuhr-Vogl,SeniorSiteDeveloper

PatMoritz,BoardofTrustees

SandyDunlap,VicePresidentofFinance

IreneBindrich,NurseEducator,2000–06

PatUris,VicePresidentofPrograms

SharonSprinkle,ProgramDirectorforNFPinGuilfordCounty,N.C.

EvelineHunt,NFPNurseSupervisor,Detroit,Mich.

ClayYeager,PresidentandChiefExecutiveOfficer

RubyHearn,Ph.D.,FormerVicePresident,RWJF(retired)

JeaneAnneGrisso,M.D.,SeniorProgramOfficer,RWJF

WadeHorn,AssistantSecretaryforChildrenandFamilies,U.S.DepartmentofHealthandHumanServices

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Documents

The Story of David Olds and the Nurse Home Visiting Program