Implementation Plan Guidance
SMALL TEAM GUIDANCE
AGENCY PROFILE
POPULATION CHARACTERISTICS
SERVICE AREA
OTHER HOME VISITING PROGRAMS
CAPACITY TO IMPLEMENT WITH FIDELITY
NURSE RECRUITMENT & HIRING
CLIENT REFERRAL SYSTEM AND ENROLLMENT PROCESS
TIMELINE FOR IMPLEMENTATION
SMALL TEAM GUIDANCE
The usual minimum team size for NFP agencies is 4 full-time equivalent (FTE) nurse home visitors and a supervisor, available at least half-time, with each nurse having a caseload of 25 clients per FTE, and each team serving 100 families. The National Service Office (NSO) will consider approving teams serving a minimum of 50 families.
Consideration for a small team is given for communities facing social and economic inequality that are underserved and do not have a first-time birth rate to support an NFP team serving more than 50 clients. Consideration may also be given when an organization feels NFP offers the best intervention for meeting specific community and/or population needs, yet funding opportunities limit a larger team size.
Each team must have at least 2 FTE nurse home visitors and a 0.5 FTE supervisor. All nurses must work at least a minimum of 0.5 FTE (20 hours per week), be prepared for the challenges of small team implementation and be able to meet the requirements detailed below.
CHALLENGES FOR SMALL TEAMS
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LIMITED RESOURCES
- NFP teams benefit from having a group of nurses practicing together and each lending their individual clinical expertise. Team members also provide emotional and practical support to each other in this highly challenging work. A smaller number of people from whom to draw both support and clinical expertise presents a substantial challenge to building model expertise. Moreover, NFP teams should anticipate and plan for how they will continue to serve enrolled clients when faced with staff turnover, vacations, and extended leave.
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DATA AND REPORTS
- Network partners that begin with less than the minimum 4 nurse team can access reports from Microsoft ® Power Business Intelligence website utilizing the NFP applications. However, there are noticeable differences when the reports are produced for a small-sized implementation. Often a table is blank because many tables or graphs in the reports are broken down by month, age, etc. In these smaller increments, small-sized implementations may not have adequate enrollees to generate data.
- Small sample sizes will also produce reports with misleading percentages. For example, when four of eight clients have given birth to a baby with a low birth weight, it results in a 50% low birth weight rate. Although technically accurate, the percentage is magnified with a small sample size, and, in effect, becomes meaningless. It is important to use caution when interpreting statistics based on small samples. For smaller implementations it may be more beneficial to focus on the numbers instead of percentages.
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INCREASED COST OF SERVING CLIENTS
- Some small team implementations serve families dispersed across large, mostly rural, geographic areas. NFP teams serving these areas often incur increased mileage costs and may be limited in the number of clients they are able to visit per day due to extended travel times. Additional medical supplies and program materials (e.g. PIPE, baby scale, etc.) will need to be purchased for teams where the nurse home visitors do not disperse from a central location on a daily basis.
RECOMMENDATIONS FOR SMALL TEAMS
- Network partners benefit from participating in Communities of Practice. Network partners are encouraged to participate in a Community of Practice whenever the subject matter is relevant and supportive to their NFP implementation. Further, Nursing Practice Managers assist in connecting you with peers across the network to expand the support network for your implementation
- The NSO highly recommends securing enough funds for the supervisor and team for travel to and communication with an existing NFP network partner, in order to shadow team meetings, case conferences, and client visits. The budget should also reflect increased mileage costs and additional program supplies needed, if applicable, for nurse home visitors dispersed across a large area.
REQUIREMENTS FOR SMALL TEAMS
- Each team must have a minimum of 2 FTE nurse home visitors and a half-time nurse supervisor. The supervisor must work a minimum of 20 hours per week in the NFP Nurse Supervisor role and may be assigned to no more than 3 clients if limited to 20 hours per week in the role. It is anticipated that in the absence of a nurse home visitor due to leave, termination, etc., the supervisor will temporarily see additional clients.
- Network partners are expected to enroll 25 clients per full-time FTE nurse home visitor.
Agency Profile
Use of Interpreters
- If your agency plans to use interpreters on an as-needed basis, keep in mind that unless they are already employees of your agency, contracting out for these services may be quite costly and should be included as part of the budget. Untrained language interpreters may not know enough vocabulary in their weaker language to communicate what the client or nurse said. They may omit part of what the client or nurse said, add their own ideas and/or change what was said. Trained interpreters know not to add, omit or change any part of the message. Without bilingual nurses, it is difficult to serve clients who do not speak English. It is always best to have a nurse who speaks the client’s language; however, many people are overconfident in their ability to speak a second language. They may use the wrong words when trying to communicate with the client. They may misunderstand what the client has said. It takes years to master a second language proficiently to have a substantive conversation such as the ones that occur in the many 1 to 1½ hour visits involved for Nurse-Family Partnership.
- A national telephonic interpreting company can provide certified interpreters. In-person trained interpreters are more costly, but usually are preferable to telephonic interpreters. Part of the in-person interpreter training is to interpret without taking over the nurse’s role and to not add, omit or change any part of the message. However, a trained telephonic interpreter is almost always preferable to an untrained in-person interpreter.
- Many sites find they are able to enroll clients when the client has immigrated with the family, attends school and has learned English. The client may need to translate for their family and their partner of the baby, but they can engage in useful dialogue and relationship-building with the nurse. If clients in your agency’s target market do not speak English, you will need to recruit nurses with appropriate language proficiency. Never assume family members are interpreting for one another accurately. They may have personal reasons for misrepresenting what was stated.
Established Need & Population Characteristics
Population Characteristics
- Determine your agency’s definition of “low income” for the purposes of NFP eligibility. Remember NFP shows the greatest benefits among those who experience the most societal and economical barriers. Most often, implementing agencies align their definition of “low-income” with existing eligibility guidelines for pregnant parents in programs such as WIC, Medicaid, or TANF.
- Avoid creating a situation where NFP nurses must verify income of prospective program participants. It can be a difficult and time-consuming process, which does not lend itself to establishing a warm, empathic relational environment to invite a first time parent to participate in home visits. It can discourage clients from enrolling and requires time from NFP nurse home visitors that could be more productively spent delivering services to clients. Instead, establish a simple proxy such as Medicaid or WIC eligibility for the poverty index.
Service Area
- Define clear geographic boundaries for referrals and program availability. Most agencies do this by considering variables such as geography, locations in which need is concentrated, existing agency or governmental unit service boundaries if they exist, distance, driving time, and the number of eligible clients (first-time, low-income, pregnant parents) in a given area. Be sure to carefully estimate distance and driving time during the hours nurses will work. Ensure the travel time is not so extensive as to prohibit nurses from being able to realistically visit 3-4 clients per day. You will need to be sure you can recruit and enroll enough first time parents to fill your initial nursing team’s caseload within 9 months of staff completing NFP Education Unit 2.
Other Home Visiting Programs in Service Area
- Learn as much as you can about each program already in place. Gather a list of referral programs/agencies and contact the agencies for information and to discuss with their leadership staff why you see the need or benefit of NFP. Determine how NFP might add to the continuum of existing services. Find out if the other program leaders perceive NFP as a helpful addition or as competition. Seek to understand their concerns and discuss how to resolve those concerns. Invite them to participate on your community advisory board to assure ongoing dialogue and good coordination. Some important issues to address include:
- Are multiple programs trying to reach and enroll pregnant parents in the same service area? If so, can you segment referrals so that referrals are directed to the program that best fits their needs (First-time, high-risk pregnant parents to NFP; low-risk, multiparous, past 28 weeks pregnant to other home visiting programs)?
- Can you work out an arrangement where you will refer to one another to make sure all pregnant parents who need support get it in a timely way?
- Are there concerns about funding issues?
- Many communities planning to implement NFP engage the leaders of all other programs in developing a ‘Continuum of Services Map.’ If you develop a ‘Continuum of Services Map,’ identify which programs target all pregnant parents and which are specific to particular populations. Completing a “SWOT” analysis (Strengths, Weaknesses, Opportunities, and Threats) can be helpful in this effort. Once the service continuum is defined, determine where NFP fits in it.
Organization Capability
- There are many ways to configure an efficient Nurse-Family Partnership program. The best set-up for each agency is dependent upon the nature of the community served, the logistical challenges nurse home visitors are likely to encounter, and the resources shared with other programs in the host agency. However, the minimum requirements for each agency are:
- One computer for the supervisor
- One computer for the data entry/support staff
- One computer for each nurse home visitor
- To meet their program responsibilities, the nurse supervisor and administrative assistant need access to computers during all work hours.
- The administrative assistant requires secure medical records storage and adequate space for equipment. This position also requires highly-organized and accessible resource materials sets used by nurse home visitors.
- Cell phones are an essential element to ensure the efficiency and safety of nurse home visitors.
- Supervisors must also have a cell phone in order to be accessible to nurse home visitors in the field.
- The team needs access to conference room space for team meetings and case conferences.
- Space for confidential one-to-one reflective supervision sessions.
- To best take advantage of the features of our data collection system and web based supports, the NSO strongly recommends laptops and tablets for nurses. Benefits of using laptops and tablets include access to additional learning tools in the home, and the ability to schedule appointments with clients within the core data collection system (not guaranteed for 3rd party systems).
Nursing Practice & Support
Nurse Recruitment & Hiring
- To get more detailed information on the nursing workforce in your community, contact your State Board of Nursing. Your State Board of Nursing can provide information on the distribution of Associate’s-, diploma-, Bachelor’s- and Master’s-prepared nurses in the state. As you consider your agency’s recruitment plan, please consider this: feedback from existing agencies, and direct observation of new site “start-ups,” suggests it is better when the supervisor hires the staff. While it might be faster to hire the whole staff at once, it puts the supervisor at a disadvantage. The supervisor needs to be able to vet the staff, find the right mix, and make decisions about who will become part of the team.
- Nursing salaries tend to be higher in larger cities and on the east and west coast. They tend to be higher in hospitals than in health departments. Although clinic salaries are generally lower, you may need to meet the average hospital salary in order to effectively recruit and retain well-qualified nurses. Nurses are very interested in working for Nurse-Family Partnership programs. If it is a good fit, nurses love the work and stay for a long time. However, when the salary is considerably lower than the local market, nurses sometimes have to leave for financial reasons.
- Sometimes nurses accept lower salaries because they want a “retirement job” or a job that does not involve evening/weekend work. This is not an effective profile in Nurse-Family Partnership. NFP nurses work after hours, sometimes on weekends. It is difficult, challenging, yet very rewarding work requiring nurses who are skilled, open to learning and highly committed.
- Your Human Resources department and nurse executives can help you establish an appropriate job classification level for NFP nurses. The level should reflect the independent and highly-skilled nature of the job. Some agencies classify the nursing staff as “advanced nurses” by appropriately addressing their Human Resources definitions for that role (for example PHN-3 versus PHN-1). It may take considerable time to negotiate definitions and role descriptions to satisfy the requirements justifying the classification and salary level. Some agencies have established higher pay grades by addressing the BSN requirement, need for relevant experience, and hazard pay due to the challenges of the neighborhoods and homes visited. Some have been able to increase pay for certification in specific areas.
- Your NFP Network Development Specialist can provide you with resources that will assist you in planning for interviewing and hiring, including: sample job descriptions, desired skills and sample interview questions.
- A nurse with excellent administrative skills should be chosen as the new NFP supervisor. But, however essential those administrative skills are when starting a new program, it is only part of what makes a successful NFP supervisor. A Nurse-Family Partnership Nurse Supervisor must also be inspired by and advocate for an evidence-based prevention program that is truly client-centered. The supervisor must be able to listen to and value the opinions and expertise of the staff. The supervisor must be skilled in helping nurses reflect on their practice. Successful NFP supervisors can support the nurses’ growing self-efficacy and competence. The supervisor must understand the theories central to NFP and be able to assist nurses in integrating the theories. Not all nurses are a good fit. Nurses who do not embrace the culture and values of NFP will not be successful or happy working in the program.
Nursing Education, Practice and Caseloads
- Model Element #13 defines the agency commitments regarding the nurse supervisor workload. The first year of implementation is intense. The maximum number of nurse home visitors a full-time supervisor may carry in NFP is eight. Even full-time nurse supervisors who start with only four nurses found their time was overfull in the first year. A full-time nurse supervisor with eight nurses dedicates 18 to 20 hours per week to building clinical competence and providing support to the nurse home visitors. This includes;
- One case conference or team meeting each week (one to three hours plus planning time)
- One hour of reflection time with each nurse each week (eight hours plus ½ hour each for preparation, documentation and follow-up)
- Networking and building community advisory board
- Supervisors have additional administrative duties such as meetings, committees and managing operations and reports. These responsibilities keep a full-time supervisor very busy.
- Model Element #12 describes agency agreements regarding nurse home visitors’ caseloads. Nurses in NFP do best when they work at or very close to full-time, because they can best build competency in the model by spending significant time becoming familiar with the model and then practicing it with multiple clients. Enrolling large percentages of special populations to caseloads can require additional supports for nurse home visitors. A nurse who acquires an especially high-needs or complex family may need additional time to assess, refer and settle some of the client issues. Consider what additional supports your nurses and agency will need to respond to the needs of these clients. Are there specific community resources they will need? Are there experts or consultants with whom you will want to engage? How will nurses be supported to manage their caseloads? How will you support nurses with complex caseloads to prevent burnout?
Community Linkages
Client Referral System and Enrollment Process
- Many NFP implementing agencies target a particular group of clients. This may be mandated by funding sources or by a community need. You may choose to work more with clients early in pregnancy, with the lowest incomes, or from specific zip codes of residence. As you consider planning for a steady stream of clients, how will you balance your organization’s mission to target a smaller population? Will there be enough? Will the target population need a different approach? Are there other agencies that could assist you in accessing this population?
- If you plan to recruit pregnant parents from populations that may be difficult to reach and/or enroll, how will you gain access to them? Will you need to make special efforts, use special staff, establish different marketing approaches, etc. to establish these referrals? Special populations can be especially hesitant to enroll. Engaging with, and gaining support from, individuals who are already trusted and established in the target population, can have a great impact on pregnant parents choosing to enroll in the program. You may need large numbers of referrals, especially in the beginning, until your NFP program has established “word-of-mouth” credibility.
Timeline for Implementation
- Consider the following dependencies when completing your agency’s Implementation Timeline:
- Plan on a minimum of three weeks to receive feedback and ‘ready to implement” status on your agency’s Implementation Plan. Your Network Development Specialist can provide you with more specifics on the timeline of the review, which includes NSO staff review, questions to the agency on sections that are unclear or incomplete, and a follow- up discussion with the reviewers to go through any final questions or clarifications.
- Staff recruitment and hiring will generally take a minimum of four weeks. It often takes much more time, depending on agency and community factors.
- At least three weeks prior to attending face-to-face education in Denver, staff should register for NFP Unit 2 Education and reserve flights and lodging.
- Staff should be given a minimum of 30 hours to complete the self-study unit prior to attending Unit 2 Education.
- Staff should receive their agency’s orientation before attending education in Denver.
- Staff should begin educating referral sources about the NFP program, identifying resources for families, and complete basic program set-up prior to attending education in Denver.
- Staff may begin conducting enrollment visits with clients only after completion of Unit 2.
- Nurse home visitors should reach a full caseload of at 25 or more active families within 9 months of completing Unit 2.