Good Care Collaborative
Nurse-Family Partnership Site Visit at the Visiting Nurses Association
Red Bank, NJ
April 11, 2014, 10:00 am – 12:00 pm
Meeting Minutes
Attendees
John Monahan Greater Trenton Behavioral Health, Ev Liebman AARP NJ, Laurie McCabe Senator
Vitale’s Office, Kate Greenwood Seton Hall Law, Tara Ragone Seton Hall Law, Andrew Kitchenman NJ
Spotlight, Nell Quest Rutgers University, Jackie Ruocco Pepper Hamilton, Dr. Robert Morgan DCF,
Arlene Patrick UnitedHealthCare, Hanna Mori Senator Booker, Crystal McDonald PICO NJ, Mark
Humowiecki CCHP, Shabnam Salih CCHP, Natassia Rozario CCHP, Elizabeth Buck CCHP, MK Kleva
CCHP, Carter Wilson CCHP, Alexandra Junn CCHP, Emma Tucher CCHP, Jim Lloyd CCHP, Kimberly
Druist NFP, Georgette Caldwell NFP, Denise Andino NFP, Mary Schwartz, Frances Juachon NFP,
Adriana Gonzalez NFP, Raquel Matos NFP, Sandra McKinley NFP, Patricia Nitchman NFP
, Mary
Remhoff NFP, Colleen Nelson NFP, Lisa Reyes NFP, Dr. Steven Landers NFP
Agenda
1. Welcome, GCC Introduction and Attendee Introductions
a. Mark Humowiecki
2. Welcome to VNA
a. Dr. Steven Landers
3. VNA and NFP Organizational Overview
a. Colleen Nelson and Lisa Reyes
4. NFP Model Overview
a. Kim Druist and Denise Andino
5. NFP Client Story
6. NFP Client Activity Role Play
7. NFP Nurses Q and A
8. Group Discussion
a. Mark Humowiecki
Beginning GCC NFP Site Visit (10:08 am)
Mark began introductions. Attendees introduced themselves/their organizations. Mark gave an
introduction on the Good Care Collaborative, explaining GCC is coalition of stakeholders dedicated to
the conversation about what consumers/governments are paying for in healthcare, with special
attention to vulnerable populations. He also talked about a Politico.com article on government and the
value of spending on health care.
NFP overview
Organizers and leaders from NFP gave an overview of the NFP model, as well as information about the
program in states outside New Jersey. NFP is a program for first time vulnerable mothers. It is a patient
centered program that fully wraps around the patient and provides education, information, care
coordination and connections to social services.
NFP shared a client story. They then had a mock NFP nurse case conference, in which nurses give
each other suggestions after one nurse shares story of a client. NFP then showed a PIPE (Partners in
Parent Education) activity (role play).
Q&A
Parents come to NFP from high schools, the community at large, clinics, personal referrals, WIC and
other government programs, and early intervention programs. Many clients also come from just talking
to women and handing out cards.
The statewide capacity of NFP is to serve 1500. They are currently serving about 1000.
Is the care being integrated with the patient’s provider?
ASQ scores are sent directly to providers; however, building trust with patients and raising confidence
of moms is an additional piece.
NFP is currently looking at how to integrate community programs, referrals, other programs, etc.
NFP leadership explained that they’re more “cabinet makers” than they are “general carpenters,”
meaning that their nurses have a specialized skill set for moms and moms to be. The priority is not to
replace the “cabinet makers” of NFP with general contractors who cannot offer this specialized care.
Case conferences take place biweekly as a team. NFP nurses alternate each week between team
meetings and case conferences. There is a cycle so that each nurse has the opportunity to share
stories and gather ideas for care from other nurses. The nurses’ supervisor meets with each nurse
weekly.
This evidence-based model has a demonstrated benefit — executing and adapting the model is
essential. Ensuring experts are in every role is key to high performance.
How does NFP keep fidelity to this model? Supervisors receive reports on activities to make sure
progress is happening with each client.
NFP is only beginning digital reporting and record keeping. A “fidelity report” looks at the 18 different
key measures of the model and serves as outcome tracking, comparing each client to national/goal
numbers. One important thing to consider with these is that each client is not the same as the people
who participated in the Randomized Controlled Trial on NFP. Professionals at NFP work toward
problem-solving for people whose situations may fall outside the norm, tracking outcomes, keeping true
to the model, having good staff, and keeping attention to anomalies (and be flexible with them/creating
specialized solutions).
Rigorous research in Colorado studies the model and it continues to be innovative and adaptive, while
still research-based and strong.
The audience was very interested in learning that NFP is reimbursed through Medicaid payments in
other states across the country. In NJ, NFP has shown that their program returns $5 in savings for
every $1 spent.
Breakout Sessions
Participants broke into small groups comprised of members of different organizations. Discussion
questions included what made NFP a model of “good care,” what lessons from the meeting could be
brought back to participants’ organizations, and lessons from the day that would be a positive addition
to health reform in New Jersey.
Groups highlighted that NFP strengths include the fact that it is an evidence based program, they have
strong outreach efforts and that they develop and hold dear patient and provider trust and relationship.
Groups also brought up the question of how to pay for good, integrated care.
The next GCC Site Visit will be at Henry J. Austin’s Ryan White HIV clinic in Trenton, NJ on
Friday, May 21st, 10:00 am to 12:00 pm.