One Home Visit at a Time, Public Health Nurses Emphasize Prevention
April 5, 2013 – Once a week for the past two years, Sarah Braxton – a public health nurse employed by Multnomah County's Nurse-Family Partnership – has checked in for an hour long appointment with Jasmine Tavera-Ruelas, a college student and first-time mother living in East Portland.
Braxton brings disposable diapers and books from the Multnomah County's Raising a Reader Program – they're rotated out on a regular basis – and she checks in with Tavera-Ruelas about how her 17-month-old son, Steven, is faring.
“He's not eating as well as he used to. He's getting picky,” Tavera-Ruelas tells Braxton. She also says she and her partner are still working on weaning him from the bottle – he would still rather have milk in a bottle than a sippy cup, she said – and getting him to sleep through the night since he sometimes wakes up crying and very upset.
“They get nightmares, just like we do. They just need to be reassured,” Braxton says, but he may be having night terrors as well. He's also not as talkative as he was a few months ago, instead grabbing for or pointing to things he wants, rather than asking for them.
That may be a cause for concern, Braxton says, but is more likely a normal, temporary delay since he's learning English and Spanish at the same time – which might slow him down for awhile but help his brain develop in the long run. It can also just be a sign that his brain is working on a different aspect of development right now, she says.
Tavera-Ruelas said she found out about the Nurse Family Partnership, the program Braxton is involved with, when she first became pregnant with Steven. The program reaches out to first-time mothers who are referred by other services. Tavera-Ruelas said she heard about it both through the Women, Infants and Children nutrition assistance program and through Kaiser Permanente, which was her insurer when she first became pregnant.
Registered nurses who are part of the nurse-family partnership start consulting with women in the early stages of their pregnancy and continue to meet with them until the child is two years old. Tavera-Ruelas, who is studying criminal justice and hopes to become a police officer, says the program has taught her a lot about the stages of a child's development, both during pregnancy and after. Braxton says Steven really struggled with his health in the first few months of his life, and she was worried about him – but now he's a healthy, normal toddler.
But Steven's individual development isn't Braxton's only focus. She also helps Tavera-Ruelas navigate the health system – her insurance coverage lapsed after she moved and some enrollment correspondence from the Oregon Health Plan was lost in the mail. The last person she spoke to at the OHP office was new on the job and told her she couldn't enroll, she says, so Braxton offers to make a call on her behalf. Tavera-Ruelas also says she would like to re-enroll with Kaiser, since that's where she received her prenatal care and where Steven has received care most of his life, but right now just wants to get Steven covered again.
The importance of a clean, safe home environment is also a cornerstone of the program: “I try to do an environmental assessment every time I come,” Braxton says.
Tavera-Ruelas had problems with mold in her last home, and she tells Braxton the kitchen sink in her new house isn't working, and that the dishwasher is full of water. Because she's had bad interactions with landlords in the past, she's reluctant to call her new one and ask him to come fix it, so Braxton offers to call on her behalf – but puts the landlord on speaker phone so Tavera-Ruelas can participate in the call.
“A lot of clients feel so hopeless,” Braxton said. Advocating for them – but also helping them advocate for themselves – is a big part of the job.
The county health department is the only Nurse-Family Partnership provider in Multnomah County, but it's a nationwide program backed by 30 years worth of research, according to Jessica Guernsey, maternal child health director of the Multnomah County Health Department. Research shows that frequent home visits improve health outcomes for children. Most of the research published on the Nurse-Family Partnership website focuses on reducing the prevalence of neglect and child abuse among first-time, low-income mothers, but researchers have also noted that receiving routine home visits from nurses changes the course of women's lives for the better, with a 35% reduction in pregnancy-induced cases of hypertension and a 79% reduction in preterm delivery among women who smoke.
Those outcomes alone can save the healthcare system hundreds of thousands of dollars, but the return on investment can be seen in other sectors as well. An analysis by the RAND Corporation found that for every dollar invested in NFP programs, communities may see up to a $5.70 return due to savings in social and criminal justice expenditures, as well as medical costs.
Braxton is among 30 public health nurses employed by the county, though NFP is only one of the public health nursing programs sponsored by the county. It also employs general field nurses to work with young families, including refugee families, the healthy birth initiative, the healthy start program and the Oregon care coordination program (CaCoon) that assists families with young children with special health needs, such as developmental delays or disabilities that require special medical and parenting services.
“It's a very unique piece of work that bridges the clinic to the home,” Guernsey said.
This story is the first in a series on the role of public health nurses. To contact reporter Christen McCurdy, write to [email protected].