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Improving the NurseFamily Partnership in Community

Practice
AUTHORS: David Olds, PhD,a Nancy Donelan-McCall, PhD,a
abstract Ruth OBrien, RN, PhD,b Harriet MacMillan, MD,c Susan
Jack, RN, PhD,c Thomas Jenkins, MSW,d Wallace P. Dunlap
BACKGROUND: Evidence-based preventive interventions are rarely nal III, MBA,d Molly OFallon, MS,d Elly Yost, MSN, PNP,d Bill
products. They have reached a stage of development that warrant Thorland, PhD,d Francesca Pinto, MPH,a Mariarosa
public investment but require additional research and development Gasbarro, MA,a Pilar Baca, MSN,a Alan Melnick, MD,e
to strengthen their effects. The Nurse-Family Partnership (NFP), and Linda Beeber, RN, PhDf
a program of nurse home visiting, is grounded in ndings from aDepartment of Pediatrics, bCollege of Nursing, University of

replicated randomized controlled trials. Colorado, Aurora, Colorado; cHamilton, School of Nursing,
McMaster University, Hamilton, Ontario, Canada; dNurse-Family
OBJECTIVE: Evidence-based programs require replication in accor- Partnership National Service Ofce, Denver, Colorado;
eDepartment of Family Medicine, Oregon Health Sciences
dance with the models tested in the original randomized controlled
University, Portland, Oregon; and fSchool of Nursing, University of
trials in order to achieve impacts comparable to those found in those North Carolina, Chapel Hill, North Carolina
trials, and yet they must be changed in order to improve their impacts,
KEY WORDS
given that interventions require continuous improvement. This article continuous quality improvement, home visiting, maternal and
provides a framework and illustrations of work our team members child health, practice-based research
have developed to address this tension. ABBREVIATIONS
CUUniversity of Colorado
METHODS: Because the NFP is delivered in communities outside of re- DANCEDyadic Assessment of Naturalistic CaregiverChild
search contexts, we used quantitative and qualitative research to iden- Experiences
tify challenges with the NFP program model and its implementation, as IPVintimate partner violence
NSONational Service Ofce
well as promising approaches for addressing them.
NFPNurse-Family Partnership
RESULTS: We describe a framework used to address these issues and PRCPrevention Research Center for Family and Child Health
illustrate its use in improving nurses skills in retaining participants,
reducing closely spaced subsequent pregnancies, responding to in- (Continued on last page)
timate partner violence, observing and promoting caregivers care of
their children, addressing parents mental health problems, classify-
ing families risks and strengths as a guide for program implemen-
tation, and collaborating with indigenous health organizations to
adapt and evaluate the program for their populations. We identify
common challenges encountered in conducting research in practice
settings and translating ndings from these studies into ongoing
program implementation.
CONCLUSIONS: The conduct of research focused on quality improve-
ment, model improvement, and implementation in NFP practice set-
tings is challenging, but feasible, and holds promise for improving
the impact of the NFP. Pediatrics 2013;132:S110S117

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The Nurse-Family Partnership (NFP), a great deal of emphasis is placed on deliver the program, ensuring delity to
a home visiting program for families delivering the program with delity to the the program model through sites
beginning in pregnancy and continuing model tested in the original trials.1,10,11 We contractual agreement to conduct the
through child age 2 years, focuses on need, however, to discover even better program with adherence to 18 model
low-income mothers bearing their rst ways of formulating the NFP model and elements (eg, client and nurse char-
children. The nurses aim to improve the its delivery. This focus on improving the acteristics, nurse education in the NFP
outcomes of pregnancy, child health and NFP is consistent with the growing em- model, site supports needed for quality
development, and maternal life-course phasis on improving health care by us- implementation).13 This contract gives
by helping mothers improve their pre- ing methods that are appropriately sites access to public policy support,
natal health, by supporting parentsearly rigorous given the nature of the issue marketing and communications ser-
care of their children, and by supporting being addressed.12 vices, nurse education and consulta-
mothers with subsequent pregnancy It is important to note that we refrained tion, NFP Visit-to-Visit Guidelines, an
planning, education, and work in ways from offering the program for public in- intranet service that links sites and
that are consistent with parents values vestment until we had determined, nurses delivering the program, the NFP
and aspirations. Nurses address social through replicated trials, that we could Web-based information system, and sup-
and material conditions in the home that reproduce the program and its effects port for quality improvement.
support or undermine mothers and through nurse education and consulta- Revenue generated by the NFP NSOs
childrens health and coordinate their tion in varied settings.1,10,11 We estab- services is used to support NFP core
work with ofce-based staff.1 lished a nonprot organization in the functions, including support for improving
The NFP is based on 3 decades of ran- United States, the NFP National Service the program model13 through research
domized controlled trials, with consistent Ofce (NSO), to support quality replica- orchestrated by the Prevention Research
and enduring effects on maternal and tion of the program. The NFP NSO focuses Center for Family and Child Health (PRC) in
child health.27 Families in the control on ensuring that community and orga- the Department of Pediatrics at the CU
groups of these trials were provided free nizational conditions support effective School of Medicine. The funds channeled
transportation for prenatal and well- development of the program, that nurses back to the PRC catalyze research to im-
child care and referral of children with are educated and guided well in its de- prove the underlying program model and
developmental needs to other health and livery, that a uniform Web-based in- its implementation system. Program
human services in their communities; formation system is used to monitor its implementation and continuous quality
therefore, the NFP benets estimated in performance, and that this information is improvement are housed in the NFP NSO,
these trials have to be understood as used to improve its implementation.10,11 and research on model improvements is
being above and beyond whatever good It is also important to understand the housed at the PRC. Quality of program
is derived from facilitated access to business arrangements that underpin implementation depends critically, in our
ofce-based care and other community the NFP and its replication. The Uni- view, on the clarity and coherence of the
services for children. model itself, which affects nursesabilities
versity of Colorado (CU) owns the in-
to grasp its fundamental features and
The results of these trials27 have served tellectual property on which the NFP is
embrace improvements. These functions
as the primary evidentiary foundation based, and it must approve alterations
involve considerable collaboration among
for the Maternal, Infant, and Early to the NFP model and Visit-to-Visit
the NFP NSO, NFP-implementing agencies,
Childhood Home Visitation Program Guidelines. CU provides NFP NSO with
the PRC, and investigators based outside
supported by the US federal govern- a royalty-free license to replicate the
of CU using the types of information, re-
ment.8 Today, the NFP is operating in program. Growth capital has been
search, and improvement activities shown
.440 counties throughout the United invested in the NFP NSO by 7 foundations
in Fig 1.
States, serving .26 000 families per (Edna McConnell Clark, Robert Wood
year.9 Signicant efforts are underway Johnson, Bill and Melinda Gates,
to adapt, test, and replicate the program Kellogg, JPB, Kresge, and Robertson) to SOURCES OF INFORMATION
in the United Kingdom, Canada, and expand the program in the United GUIDING IMPROVEMENT
the Netherlands, and to adapt and eval- States, with the expectation that the NSO Data from the original trials; sites
uate it in partnership with indigenous-led eventually will become self-sustaining performance metrics, nurses, fam-
health services in Australia, Alaska, through revenues it generates from ilies, and other stakeholders; program
and American Indian tribes. As the pro- the services it provides to sites. The NFP evaluations; and updated standards
gram is expanded to new communities, NSO develops contracts with sites to of care are reviewed by a standing

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FIGURE 1
Sources of information, types of research, and targets for improving the NFP in community practice.

committee composed of representa- identify aspects of the program and its adjustments to improve implementation
tives of the NSO and PRC who evaluate delivery that need to be strengthened. and outcomes. The NFP NSO also has
the data and make preliminary deci- Our response to the review of these data developed a framework for quality im-
sions about the most sensible approach often leads to 1 of 3 types of improve- provement that species separate imple-
to improving outcomes while ensuring ment research and targeted activities, mentation standards for program sites
delity to NFPs evidentiary foundations. which are described in the following through all phases of their development
The results of program evaluations de- sections. and operation.
serve particular attention. A series of Moreover, at periodic intervals, we re-
retrospective cohort studies, using pro- TYPES OF IMPROVEMENT view and update the NFP Visit-to-Visit
pensity matching, have been used to RESEARCH AND TARGETS OF Guidelines to ensure that their con-
evaluate NFPs impact in Pennsylvania14,15 IMPROVEMENTS tent aligns with practice standards
and Oklahoma.16 Quasi-experimental eval- promoted by the American College of
uations such as these are limited in Continuous Quality Improvement
Obstetrics and Gynecology, the Ameri-
the extent to which selection biases can NFP NSO generates regular reports for can Academy of Pediatrics, and the
be controlled and must be interpreted sites that compare features of imple- American Nurses Association.9
with great caution. We give particular mentation and maternal and child health
attention to these propensity-matching with national averages and results of the Implementation Research
evaluations in guiding quality improve- original trials. Administrators, super- We conducted analyses of quantitative
ment efforts, however, because they visors, and nurses use these reports and and qualitative data at the level of the
include matched control groups and results of program evaluations to reect entire implementation system with the
outcomes on all registered NFP clients on their performance and to devise goal of gaining insights to improve its
in community settings. This method improvements in practices. Performance performance. Most, but not all, of these
brings added rigor to our efforts to is monitored over time as teams make analyses are conducted by the NSO or

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PRC. The results of this work can lead to research. We start with an effort to un- and making iterative adjustments to the
quality improvement efforts at the level derstand program challenges (review- innovation. Once we have condence that
of the NFP system (eg, simultaneous ing implementation data, conducting it is feasible and promising, we usually
adjustments to site developmentsupport focus groups and key informant inter- conduct quasi-experimental or experi-
and nurse education) or to additional views with stakeholders [nurses, super- mental trials of those innovations that
work leading to Model Improvement visors, clients, agency administrators]), represent fundamental model changes
Research (as described in the following and we review the scientic literature to or that will require new resources. When
section). System analyses are multilevel inform potential solutions. we develop an innovation that sub-
and focus on organizational factors atthe We use these ndings to formulate initial stitutes 1 component of the model for
levels of sites or states or within the NFP innovations in the model. It is crucial that another (such as our substitution of
NSO that support or impede effective preliminary model modications align a new measure for nurses assessment
delivery of the program. Our multilevel, with current NFP practice and theory and support of parents care of their
mixed methods study of participant re- because compatibility and complexity of children [described later in the article]),
tention, described here, illustrates this innovations affect the degree to which we simply replace the old with the new,
approach.17 they are incorporated into practice.18 as long as the new element is consistent
Modications must be feasible for with the NFPs theories and model ele-
Model Improvement Research nurses to accommodate and must res- ments9,13 and the evidence indicates that
Figure 2 summarizes the steps we fol- onate with program participants. We it is superior and costs no more to im-
low in conducting model improvement address these issues through piloting plement.

FIGURE 2
Steps in developing innovations in the NFP model.

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Finally, once a new model component visits on helping parents care compe- presence of emerging IPV that is
has been developed and found to im- tently for their children as nurses did in designed to align with NFPs underlying
prove implementation or outcomes, we the original trials. Through surveys and theories and operating procedures. This
integrate this innovation into practice. interviews with nurses and supervisors, curriculum is now being tested in a 15-
This step may require changes in site we found that the original tool nurses site randomized controlled trial with
development activities, nurse educa- used to observe qualities of caregiver funding from the Centers for Disease
tion and consultation, the NFP Web- child interaction was hard to learn and Control and Prevention.23
based information system, and quality that it insufciently guided clinical
improvement benchmarks. implementation of the program. Dr Improving NFP Nurses Resources for
We present next examples of studies we Donelan-McCall has been leading a pro- Improving Pregnancy Planning
have undertaken aimed at model im- gram of research to address this issue Although the NFP has produced consis-
provement. through development of a new obser- tent effects on delaying subsequent
vation tool called the Dyadic Assessment pregnancies,1,3,5 an outcome of consid-
Increasing Participant Retention and of Naturalistic CaregiverChild Experi- erable public health importance,24,25
Completed Home Visits ences (DANCE) and clinical pathways analyses of NFP nurses records suggest
called DANCE STEPS that integrate DANCE that there is room for improvement.26
We found that nurses in community rep-
into the existing parenting content of the Dr Melnick, Teresa Gipson, and Marni
lication sites in the United States were not
program.20 Storey have been leading a randomized
retaining families as well as nurses did in
the original trials, and that there was We did not conduct a trial of DANCE trial of an innovation in the NFP program
signicant variation in retention among because it was designed to replace an that gives nurses the resources to dis-
sites.17 Using qualitative analyses, we existing tool in the program. We con- tribute hormonal contraception to NFP
found that sites with the lowest levels of ducted studies to ensure that DANCE had mothers during home visits.27 If effec-
retention employed nurses who used adequate predictive validity and re- tive, we will expand nurses roles to
more directive, prescriptive approaches liability, superior clinical utility, and that include distribution of hormonal con-
to working with clients and that those with it could be implemented in a cost- traception, which will be challenging
the highest rates of retention employed effective way relative to the old tool. in some settings. Recent legislation in
nurses who adapted the program more DANCE and DANCE STEPS are now in- California allows nurses to dispense
completely to clients needs. Although the tegrated into nurses NFP education, and hormonal contraception,28 illustrating how
program is designed to be adapted to nurses in all existing sites are being favorable policies support the NFP and its
each familys needs,9 we developed an in- educated in DANCE and DANCE STEPS innovations.
tervention that gave more explicit control with funding from the JPB Foundation.
of visit frequency and content to families. Development of a System for
We tested this modication rst in a 16- Improving Nurses Resources in Classifying Families Risks and
site quasi-experimental pilot study19 and Addressing Intimate Partner Violence Strengths
then in a 26-site randomized trial. Given In the rst trial of the NFP, we found that NFP nurses are required to oversee no
consistent, promising results from these its impact on state-veried rates of child more than 25 families, the maximum
trials, we changed program guidelines, abuse and neglect through child age 15 allowed in the original trials. Because
nurse education, and site consultation to years was attenuated in households nurses in the rst 2 trials indicated that
promote more exible collaboration be- with moderate to high levels of intimate they could not serve all of their caseloads
tween nurses and families to meet fami- partner violence (IPV).1,21 Although with the required number of visits, we
lies needs regarding visit frequency, there was some evidence that NFP re- encouraged them to follow the regular
content, and location of visits. duced IPV in the third trial,5 that nding visit schedule with higher-risk families
has not yet been replicated. Moreover, and topayfewervisitstothosewith fewer
Improving Nurses Observation of nurses in many sites reported that the needs.29 With funding from the Annie
CaregiverChild Interaction and program was decient in guiding them E. Casey Foundation, we are working with
Promotion of Parenting to address this problem, and there 5 NFP sites to develop a more rigorous
In analyses of program implementation were no evidence-based methods for method of classifying families risks and
data, we discovered that nurses in preventing or addressing IPV.22 Dr strengths, which will provide more ex-
community replication sites were not MacMillan and Dr Jack developed a new plicit guidance to nurses and super-
spending as much time during home intervention for NFP nurses to use in the visors in adjusting their frequency of

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visits, with the goal of improving pro- and previous births often have unique reviews proposed studies from the
gram effectiveness and efciency. concerns, challenges, and aspirations standpoint of site readiness.
that must be reected in the evolving NFP
Improving Nurses Resources in program materials. Serving multiparous Need to Set Research Priorities
Addressing Maternal Depression and women represents such a signicant and Coordinate Studies
Anxiety departure from the existing NFP pro-
It is crucial that studies be prioritized,
Nurses in community settings have gram that we will tread cautiously to well planned, and coordinated. Because
requested more support in addressing ensure that the adapted program is resources for research are limited, it is
parents mental health; we therefore experienced as deeply helpful to mul- important that these resources be
developed a set of mental health tiparous indigenous women. If serving marshaled in ways that ensure there
screening tools for NFP nurses to use, multiparous women in these populations are sufcient numbers of participants,
and we piloted these tools in New York seems effective, we eventually may con- nurses, and sites to meet sampling
City and Los Angeles County. Many sider applying this learning to serve requirements and that study goals align
nurses felt that they had a better un- multiparous women in majority cultures. with nurses priorities.
derstanding of mental disorders after
this training but reported that few CHALLENGES IN THE CONDUCT OF Translating New Findings Back Into
mental health services were available SITE-BASED MODEL the NFP Program
in their communities, and even when IMPROVEMENT WORK Everytimeanewinnovationisintroduced,
services were available, their clients
In conducting these programs of re- it creates reverberations throughout the
used them infrequently.30 Dr Beeber,
search, we have encountered a number program implementation system that
has recently joined our team to develop
of challenges that impede the conduct cost money and time. Site development
mental health tools that are consistent
of practice-based research. procedures may need to be changed,
with the NFP model and which can be
nurse education and consultation upgra-
implemented by nurses with limited
Participation in Research by ded, the NFP information system adapted,
burden.
Nurses and Local Administrators Is and new performance benchmarks and
Burdensome continuous quality improvement proce-
Adapting the NFP to Indigenous dures established.
Cultures and Serving Multiparous The kind of research described here
Women often leads to nurses having less time
for clinical work. The NFP NSO has Human Subjects Review
We are working with indigenous health
established a committee (Research and A number of studies described here
services serving Australian Aboriginal
Publications Communications Commit- have required extended times for
and Torres Strait Islander populations,
tee) to review and approve proposed obtaining institutional review board
Alaska Native people, and American In-
studies from the standpoint of burdens approval. This has increased overall
dian populations. In doing so, we are
created by such studies. research costs, and, in some cases, led
addressing 2 fundamental questions:
to reductions in resources for data
What will it take to adapt core elements of
Not All Sites Are Ready for collection and analysis. Some of these
the NFP to address the needs and aspi-
Research challenges are likely to be mitigated as
rations of these more culturally distinct
new Human Subjects procedures are
populations, and what would be needed Some sitesare notreadytoparticipate in
approved by the US Ofce for Human
to adapt the program to serve indigenous the kinds of studies outlined here. Par-
Research Protections.31
women who have had previous live ticipation in research is especially chal-
births? The adaptation to local cultures lenging when organizations are rst
and needs involves changes in the look learning to implement the NFP model, Funding and Human Infrastructure
and feel of the NFP program materials, have additional site-level requirements, The work we have described requires
and potentially deeper adjustments to or are experiencing stafng or orga- funding for key positions (human in-
program content and nurses ways of nizational transitions. Under these frastructure) to support data gathering,
building collaborations with families and circumstances, it is likely that either the analysis, and the translation of ndings
communities. The changes required to program or research will be dis- back into core functions such as site de-
serve multiparous women are signi- continued. The Research and Pub- velopment, nurse education, and consul-
cant because women with other children lications Communications Committee tation. Some of this work is supported by

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revenues generated from sites purchase CONCLUSIONS implementation and the model itself. Our
of services from the NSO. Realizing the For the NFP to achieve its full potential for experience indicates that such work is
potential of this approach, however, will affectingmaternalandchildhealth,itmust challenging but feasible, and holds con-
require additional investments in research continue to evolve through systematic siderable promise for improving the lives
and implementation infrastructure. quality improvement and research on of vulnerable children and families.

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(Continued from rst page)


Dr Olds helped conceptualize this work and drafted the initial manuscript; and Dr Donelan-McCall, Dr OBrien, Dr MacMillan, Dr Jack, Mr Jenkins, Mr Dunlap, Ms
Yost, Ms OFallon, Dr Thorland, Ms Gasbarro, Ms Pinto, Ms Baca, Dr Melnick, and Dr Beeber helped conceptualize the manuscript and helped draft particular
sections. Drs Olds and Donelan-McCall oversaw the editing; all authors helped edit the manuscript. All authors approved the nal manuscript as submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2013-1021I
doi:10.1542/peds.2013-1021I
Accepted for publication Aug 26, 2013
Address correspondence to David Olds, PhD, Prevention Research Center for Family and Child Health, University of Colorado Department of Pediatrics, 13121 East
17th Ave, MS 8410, Aurora, CO 80045. E-mail: david.olds@ucdenver.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Olds directs the PRC at the University of Colorado, which has a contract with the NFP NSO to support research aimed at improving the
NFP program model and its implementation. This contract has covered parts of the salaries of Dr Olds, Ms Gasbarro, Ms Baca, and Ms Pinto. Dr Olds also has
received funding from the WT Grant Foundation to conduct research aimed at improving NFP participant retention. Dr Donelan-McCall is the Principal Investigator
and Director of the DANCE Program at the University of Colorado. To support this work, she has received funding from John and Marci Fox to develop DANCE and
has partnered with the NFP NSO on a grant from the JPB Foundation to implement DANCE in US NFP community practice settings. Part of her salary is covered by
the scope of work included in this grant. Drs Jack and MacMillan have received funding from the Centers for Disease Control and Prevention to develop and test an
innovation in the NFP model to address intimate partner violence. Mr Jenkins, Mr Dunlap, Ms OFallon, Ms Yost, and Dr Thorland are employees of the NFP NSO. Dr
Melnick has received funding from an anonymous donor to conduct research on supporting nurses dispensing hormonal contraception to NFP clients. Dr Beeber
has received funding from the NFP NSO and NFP sites in North Carolina, South Carolina, and Pennsylvania for providing training to NFP nurses in infant and
parental mental health. Dr OBrien has indicated she has no nancial relationships relevant to this article to disclose.
FUNDING: Funding was received from the WT Grant Foundation (grant 12120), Centers for Disease Control and Prevention (grant 5R49E001170-02), Childrens
Hospital Foundation (Gift from John and Marci Fox), Robert Wood Johnson Foundation (grants 62870 and 9904518), Edna McConnell Clark Foundation (grant 07010),
Bill and Melinda Gates Foundation (grant 49107), W.K. Kellogg Foundation (grant P3008922), Kresge Foundation (grant 237909), Picower Foundation, JPB Foundation,
The Childrens Hospital Research InstituteColorado Clinical and Translational Science Institute (National Institutes of Health National Center for Research
Resources 5 UL1 RR025780), The David and Lucile Packard Foundation (Grant# 99-8142). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: Dr Olds was the principle architect of the NFP program model and has been the Principal Investigator on 3 of the original
randomized controlled trials of the program. He has an interest in seeing the NFP succeed in improving maternal and child health in community practice. Dr
Donelan-McCall has led a program of research designed to improve NFP nurses work with clients to promote competent caregiving. She has an interest in seeing
the NFP succeed in improving maternal and child health in community practice. Dr MacMillan is a co-principal investigator on the Centers for Disease Control and
Preventionfunded study to develop and evaluate the intimate partner violence intervention for the NFP; she is also a co-principal investigator of a study to
evaluate the NFP within the Canadian context. Dr Jack is a co-investigator on a qualitative case study to develop the NFP intimate partner violence intervention, on
the randomized controlled trial to evaluate this component of the NFP program, and on a separate randomized controlled trial of the NFP in Canada; she is also
a co-principal investigator of a study to evaluate the NFP within the Canadian context. As employees of the NFP, Mr Jenkins, Mr Dunlap, Ms OFallon, Ms Yost, and Dr
Thorland have an interest in seeing the NFP succeed. The other authors have indicated they have no potential conicts of interest to disclose.

PEDIATRICS Volume 132, Supplement 2, November 2013 S117


Downloaded from http://pediatrics.aappublications.org/ by guest on December 6, 2017
Improving the NurseFamily Partnership in Community Practice
David Olds, Nancy Donelan-McCall, Ruth O'Brien, Harriet MacMillan, Susan Jack,
Thomas Jenkins, Wallace P. Dunlap III, Molly O'Fallon, Elly Yost, Bill Thorland,
Francesca Pinto, Mariarosa Gasbarro, Pilar Baca, Alan Melnick and Linda Beeber
Pediatrics 2013;132;S110
DOI: 10.1542/peds.2013-1021I

Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/132/Supplement_2/S110
References This article cites 18 articles, 3 of which you can access for free at:
http://pediatrics.aappublications.org/content/132/Supplement_2/S110
.full#ref-list-1
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright 2013 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .

Downloaded from http://pediatrics.aappublications.org/ by guest on December 6, 2017


Improving the NurseFamily Partnership in Community Practice
David Olds, Nancy Donelan-McCall, Ruth O'Brien, Harriet MacMillan, Susan Jack,
Thomas Jenkins, Wallace P. Dunlap III, Molly O'Fallon, Elly Yost, Bill Thorland,
Francesca Pinto, Mariarosa Gasbarro, Pilar Baca, Alan Melnick and Linda Beeber
Pediatrics 2013;132;S110
DOI: 10.1542/peds.2013-1021I

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/132/Supplement_2/S110

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright 2013 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .

Downloaded from http://pediatrics.aappublications.org/ by guest on December 6, 2017