One of the most vexing dilemmas for community health funders and policy-makers is the difficulty in bringing promising interventions at the community level to a larger scale. The literature is resplendent with 40 or 50 years of excellent research, in all public health disciplines, suggesting specific practices designed to improve both individual and community health status. It is discouraging for public health professionals to see that local, state and national policies often don’t match the best of what is learned in the field. Explanations for this often include the elements of cost, tradition and political will. Yet there is something less tangible going on here, too — the challenge in focusing the interests and practices of stakeholders around a single intervention.

The Nurse-Family Partnership (NFP) is the most studied of the many maternal and child health home visitation programs designed to improve pregnancy outcomes, child health and development, and the educational and economic achievements of first time, low-income mothers. The program is staffed by bachelors-prepared nurses, most often working out of local health departments. The implementation of NFP differs from other programs in its intensity (up to 40 home visits) and delivery of protocols. Three case-controlled studies with demographically different populations have proven NFP to be a very effective intervention for this population. The national NFP office in Colorado is currently providing technical assistance, training and data collection for sites in almost 30 states.

Public and private funders in North Carolina have long been proponents of strong maternal and child health programs. The North Carolina Department of Public Health is a longtime supporter of a number of home visitation programs. The North Carolina Partnership for Children oversees a statewide network of local partnerships working on everything from improving the quality and availability of childcare to piloting innovative best practices parenting programs. Prevent Child Abuse North Carolina has been instrumental in providing leadership and recommendations coming out of a statewide task force on child abuse prevention. Two private funders, The Duke Endowment (TDE) and the Kate B. Reynolds Charitable Trust (KBR) are deeply engaged in the funding of individual programs promising to drive better outcomes for low-income children and their families.

Even with a strong legacy of developing and supporting maternal and child health programs, there was little history of stakeholders intentionally working together to join in a best practices intervention. Some of the participants had experience with NFP from other states or from a previous, limited attempt in North Carolina many years before. NFP had been identified by a coalition of early childhood support organizations as a proven intervention that deserved support, and North Carolina already had a successful NFP site in Guilford County. Although there was a consensus that NFP would be a strong program to rally around, the on-the-ground development of NFP needed to be a flexible learning process for everyone involved.

The process began with the private funders, TDE and KBR, agreeing to fund Prevent Child Abuse North Carolina to do site-specific developmental work in anticipation of a formal application to the national NFP office. A new regional NFP developer from the national office joined the team. The entire group of stakeholders then met to develop an initial list of 15 counties/regions that could meet the caseload criteria for NFP and had a history of leading community-based work. Concurrently, private and public funders made funding commitments that leveraged local dollars, making it possible for multiple sites around the state to be selected in the first funding round.

A monthly conference call was convened for the stakeholder group to work on both specific implementation issues (allowable budget items, consistency on local match dollars, equitable salaries) and policy/advocacy issues, like the need to have funded sites throughout all parts of the state. The process culminated with the certification of six sites, representing eight counties. The state of North Carolina is funding two sites, and TDE and KBR are sharing the costs of three sites. The initial commitment is for seven years for each site, assuming continued availability of funds. A second round is planned for spring 2009 with the hope that additional rural, very low-income communities will be ready for funding. The Duke Endowment is now leading a similar effort in South Carolina.

After almost two years of hard work, the stakeholders can reflect upon the groundwork that has been laid not just for future NFP sites, but also for increasing dissemination of best practices models statewide. The stakeholders have a heightened respect for why this type of intentional work is not yet the norm. We also know that we would have never gotten this far without the multiple layers of leadership and engagement from all of our partners.