Investment that pays

YAKIMA – Like a tiny tornado, Andrew Taylor rumbled through the playground and into the parking lot of a small apartment complex here. The 15-month-old ducked under a parked truck and grabbed an empty cola cup.

“Doesn’t that kind of worry you?” Crystal Towne, a public health nurse, asked Taylor’s 19-year-old mother, Ramona, as they sat at a picnic table nearby. “I wish they had a gate around the playground. It worries me that he can get out into the parking lot or the street that easily.”

Ramona Taylor walked over and picked up her son, balancing the boy on her hip.

“It seems like he knows he has no medical insurance,” Ramona Taylor said, laughing. “He’ll do crazy things like stand up on the table.”

Yakima County has a vested interest in the development of Andrew Taylor. By Andrew’s second birthday, the county will have spent about $5,500 on the toddler through an intensive program known as the Nurse-Family Partnership. The program, which sends public health nurses into the homes of poor, first-time mothers, has been recognized as one of the nation’s most effective child welfare programs.

It’s also one of its most expensive.

But those upfront costs are a good investment, researchers say. For every dollar invested in the program, taxpayers receive $5.70 in future savings, according to a 2005 report by the RAND Corporation. Program participants were more likely to hold steady jobs and less likely to become involved with the criminal justice system or rely on welfare.

“It’s a very expensive program, but the studies show the expense pays off,” said Joan Sharp, executive director of the Washington Council for the Prevention of Child Abuse and Neglect (WCPCAN), a legislatively mandated state board that evaluated the program. “The core of that program is the relationship between the nurse home visitor and the family.”

Despite the praise, the program doesn’t exist in Spokane; county staff proposed launching the program two years ago but were unable to secure funding.

The program’s absence raises uncomfortable questions about how much money governments are willing to spend on preventing child abuse and neglect – even when investing in the most rigorously tested programs.

“Do we spend the money now, or do we spend it later? That’s the philosophic dilemma for our society,” said Dr. Kim Thorburn, the county’s former health officer. “We seem to like to pull the child out of the well rather than capping the well and preventing the child from falling in.”

What the program does

The limitation of the Nurse-Family program may also be its key: It focuses only on low-income, first-time mothers.

Beginning in pregnancy, trained public health nurses conduct weekly visits with each mother, helping them with everything from doctor visits to what foods to eat and how to quit smoking. The program, which receives referrals from health-care professionals and social services agencies, is offered voluntarily to the families.

“Some of the women who need it the most may reject it,” said Marilyn Van Oostrum, supervisor of the Yakima program. “You can’t invest this kind of money if they aren’t in a place where they are ready to make those changes in their lives.”

Since the late 1970s, the Nurse-Family Partnership has demonstrated that intensive intervention by professionals into the lives of young mothers can dramatically improve the lives of the children. The program has dramatically lowered the number of verified reports of child abuse and neglect in the study homes; mothers are far less likely to be arrested; and children are less likely to end up in juvenile detention centers.

Encouraged by the national studies, Yakima secured a $3 million federal grant to start the program in 2003. Compared with other programs around the state, Yakima’s $550,000 annual budget is frugal. At the state’s seven other Nurse-Family programs – all in Western Washington – the per-family cost exceeds $9,000. That’s about twice the cost in Yakima.

The four nurses in the Yakima program serve a total of 100 families for three years – from pregnancy until the child turns 2 years old.

Results have begun to trickle in. Not only do the children in the Yakima program have fewer visits to hospital emergency rooms, they are less likely to be in homes with domestic violence and more likely to benefit from breast-feeding and immunizations.

For Towne and the other Yakima nurses, the job entails both professional and personal tasks. She makes cupcakes for birthdays. She praises and encourages the young mothers. She teaches them how to play with their children.

Earlier this month, she sat at a table with Andrew and Ramona Taylor, hiding blocks under a sweatshirt for Andrew to uncover.

“Do you see the look on his face when you cheerlead him?” she said to Ramona Taylor. “He’s got the biggest smile.”

Not all families in Yakima are fortunate enough to have a public health nurse help them adapt to the challenges of parenting.

In the city and the outlying farmland, poverty continues to be a problem. Nearly 80 percent of the babies born in Yakima are eligible for Medicaid, the state-federal insurance program for poor families, officials say; that’s about twice the national average.

Every year, about 1,000 new babies are eligible for the program – far more than the nurses can handle.

“We would like to serve 200 first-time moms,” Van Oostrum said. “That would make a significant impact in Yakima County.”

Potential cost for Spokane

Two years ago, the Spokane Regional Health District estimated that it would cost between $500,000 and $750,000 a year to hire four to six nurses. Each nurse would work intensively with between 20 and 25 Medicaid-eligible families for the first three years of the child’s life.

“We would love to see it here,” said Marilyn Walli, program manager for Spokane’s First Steps program, which also works with at-risk children. “It easily pays for itself. But it’s a funding issue.”

In Olympia, legislators have allocated $3.5 million for home visits.

Elaine Conley, director of nursing for the health district, said her staff is continuing to search for alternative funding sources, including private foundations.

“We’re going to have to get very innovative I think,” Conley said. “Public health does not have sufficient funding to really be able to afford the startup and maintenance of the program.”

As envisioned by the health district, the Nurse-Family program in Spokane would work in conjunction with First Steps, as it does in Yakima. The goal would be to significantly increase the number of public health nurses working with families.

“If I had my druthers, every family in this community that has a first baby would have a public health nurse to help with that first baby,” said Cathy Fritz, a public health nurse with the Spokane Regional Health District. “It would be a community norm.”

But it’s not fail-safe.

Last month, Adriana Lytle was enrolled in the First Steps program. As part of the program, a nurse from a private agency – Family Home Care and Hospice Corp. – visited the Lytles’ north Spokane apartment on March 10.

Court documents indicate that Jonathan Lytle told police he took his 4-year-old daughter, Summer, on a car ride while a nurse visited Adriana Lytle and her 8-month-old son, Jonny. Summer died later that day. She suffered “extensive injuries” before her death, police said.

Nurses are required by law to report signs of child abuse and neglect – if they learn of it.

Both First Steps and the Nurse-Family Partnership must be part of a broader support system for children and families, said WCPCAN’s Sharp.

“We see the Nurse-Family Partnership as one of a number of research-based programs,” Sharp said. “They have had the benefit of millions of dollars of research that show the cost-effectiveness. But it needs to be one part on the menu of options in the community.”