With a single nurse dispatched to Maine’s rural outposts in 1923, the state launched what would become a key effort to stop infants from dying: public health nursing.

Almost 100 years later, Maine faces similar health challenges. Rural areas still have limited health services, and the state has seen a rise in infant mortality.

Unlike in 1923, public health nursing is no longer the only available service in Maine that sends a trained professional into a new or expectant mother’s home to offer parent coaching and, sometimes, basic health services. Three such programs operate in Maine today, each with different specialties and target populations. But the latest available data show they reach only 28 percent of new Maine parents.

Research has shown home visits reduce the likelihood of pregnancy complications, infant deaths, family violence and child maltreatment. They also contribute to improved parenting practices and school readiness.

That’s why Congress and the Obama administration made a $400 million-per-year federal investment in home visiting services through the Affordable Care Act. And it’s why, in 2011, the Maine Department of Health and Human Services applied for a special federal award to expand home visiting services statewide. Maine won a four-year, $5.7 million grant as a result; it was one of just nine states to receive an expansion award.

With $5.7 million, the state’s plan was to reach 72 percent more parents and babies through Maine Families, which has evolved over the past two decades to become Maine’s largest home visiting program. Maine’s plan also relied on improved collaboration among existing home visiting services and closer connections with a variety of other early childhood services in order to ensure high-need families received the services they needed.

“The thoughtful combination of direct service delivery, community collaboration, evaluation, and sustainability strategies on top of an already proven structure and network offer a compelling model for successful home visiting in all states,” read the grant application, led by Sheryl Peavey, then the director of Maine DHHS’ Early Childhood Initiative and now the chief operating officer of the Maine Center for Disease Control and Prevention, a part of DHHS.

But in the five years since Maine received $5.7 million to expand home visiting, the expansion hasn’t happened and the collaborative spirit hasn’t materialized.

— The latest available data show Maine’s home visitors aren’t reaching more families.

— Key efforts highlighted in the grant application to simplify how families are referred to home visiting have largely stalled.

— Plus, home visiting and early childhood programs in some parts of the state report that competition for referrals has intensified with time and that cooperation has fallen by the wayside.

“The whole point is to expand the services that are going to serve this state well going forward,” said Karen Heck, senior program officer with the Bingham Program in Augusta, a charitable endowment that funds efforts aimed at improving Maine’s health. “We continue to be disappointed that collaboration doesn’t occur and that the families who need services are the losers in the short term, and the state is the loser in the long term.”

Maine Families served 2,368 families in 2011 and just 25 more — 2,393 — in 2014, according to the KIDS Count database.

By the end of the third year of the grant, Maine DHHS had estimated that home visitors would have served an additional 1,300 families.

A spokesman for the Maine CDC didn’t respond to requests for comment from the BDN regarding the state’s home visiting programs and collaboration among them.

Short on coordination

Part of the state’s plan for the $5.7 million home visiting expansion grant was to ensure that families received referrals to the correct home visiting service based on their particular needs, that the referral process became simpler, and that longstanding confusion surrounding referrals ended.

As public health nursing has become limited to families with special medical needs and as the LePage administration has allowed the program to shrink by half, Maine Families has taken nursing’s place as the state’s universally available home visiting program. The program sends about 125 certified parent educators into families’ homes across the state. Those home visitors can offer parent education but not medical services.

Early Head Start — which is funded by the federal government without state management — offers home visits and other services to low-income families living at or below the federal poverty level. Early Head Start home visits are typically more frequent and occur over a longer timespan than visits through Maine Families, but they’re not available across the state.

“There’s a need for both kinds of services at different times,” Ted Hensley, who resigned in March as director of Maine’s public health nursing program, said of nursing and home visiting. “We were working on making sure that there was optimal coordination between the groups.”

The mechanism to bring about that coordination among home visiting services with a limited history of working together was CradleME, a referral system developed by public health nursing and Maine Families staff that used algorithms to determine the right referral based on a family’s needs.

“If there’s only a single program, you’ve missed the richness and resources that other programs can offer,” said Nell Tharpe, who led the effort for public health nursing during her time as the program’s maternal and child health consultant, from 2012 until January 2015. “That’s what’s great about collaboration. You maximize every resource for the benefit of those you serve.”

CradleME started as a pilot project in 2013 involving Eastern Maine Medical Center, Maine Families, public health nursing and the city of Bangor’s public health department, which holds a Maine CDC contract to provide maternal and child health nursing visits within city limits.

No longer would a hospital or doctor’s office have to decide on the right program; a health-care provider would make a single referral, and the destination would be decided in Augusta based on predetermined clinical factors.

“I felt it was a project that all other states would want to follow up with,” Hensley said, “that they would want to do the same thing that we were doing in order to be able to coordinate and effectively and efficiently get people served by the best partners.”

CradleME’s designers set up the system to refer parents to Maine Families home visiting when they needed only support for settling into parenting. Those with medical needs were to receive a referral to public health nursing. Some parents with health and social needs would receive referrals to both programs. Early Head Start didn’t participate in the pilot project.

The program got off to a promising start in its pilot phase in the fall of 2013. Referrals were about evenly split between public health nursing and Maine Families. Previously, the overwhelming majority of referrals went to public health nursing. What’s more, a greater percentage of families offered home visiting services accepted them, according to a state report on CradleME’s first phase. The partnering programs and EMMC all offered positive reviews.

The next steps included developing an electronic — instead of paper-based — referral system, refining the scoring system, incorporating prenatal referrals and preparing for statewide implementation.

‘Dead in the water’

According to Hensley and other former public health nursing employees, the model is now “dead in the water” even if CradleME still exists in name. It has strayed far from the timeline its designers set out for it in 2013 and 2014, and it’s strayed far from the criteria it initially used to refer parents to the appropriate home visiting service.

The original timeline was to figure out expansion plans at the end of 2014. Five months later, in May 2015, state CDC leaders said their plan was to “accelerate” the initiative, rolling out CradleME statewide within three months, according to a presentation Maine CDC leadership and Peavey, then the strategic reform coordinator in Health and Human Services Commissioner Mary Mayhew’s office, made to public health nursing managers on May 5, 2015.

But CradleME still hasn’t moved beyond the pilot phase and Eastern Maine Medical Center.

Plus, Hensley said, staff in Mayhew’s office continued to insist on adjustments to the criteria CradleME used to refer new parents to public health nurses. Originally, clinically trained nursing staff had developed the criteria for nursing referrals, he said. The new adjustments — which Maine CDC officials have issued on multiple occasions since November 2015 — narrowed the criteria by which parents are referred to public health nursing services, limiting the number of mothers and babies who receive visits from a nurse.

“It’s like a bus driver telling a doctor how to practice,” Hensley said. “These are non-clinicians. They essentially held up the whole process based on their desire for us not to be providing services that we deemed were appropriate.”

CradleME is behind schedule on a number of measures. EMMC continues to fax in paper referral forms. A fall rollout of electronic referrals is possible, said Pam LaHaye, the statewide coordinator for Maine Families. (The Maine Children’s Trust, which took over Maine Families oversight from the state earlier this year through a no-bid contract, will receive $105,000 over the next two-and-a-half-years to pay for CradleME maintenance.)

Meanwhile, under CradleME, EMMC doesn’t know what happens to patients once the hospital faxes in referrals, said Mark Moran, a licensed social worker who leads EMMC’s family service and support team. Ensuring that such information would be communicated was one of the project’s initial goals.

“They’re still getting serviced by someone, but I’m not sure the high-risk families are really getting the service that they need if the workforce isn’t adequate to provide that,” Moran said, referring to low numbers of public health nurses.

Beyond CradleME

The effects of increasingly narrow criteria for public health nursing referrals haven’t been limited to the CradleME pilot project and its participants.

Bangor Public Health is one of a handful of agencies around the state that hold Maine CDC contracts to provide maternal and child health nursing services in specific geographic areas. The contracts are funded through the federal Maternal and Child Health Block Grant, which brings about $3 million to Maine each year.

The city of Portland holds a contract similar to Bangor’s to deliver nursing services within city limits. Outside of Portland, the agency MaineHealth Care at Home provides maternal and child health nursing home visits in York and Cumberland counties. Androscoggin Home Care and Hospice holds the nursing contract for Lewiston and Auburn.

Those agencies all saw the number of families and children referred to them plummet at the start of the year when the Maine CDC started handling all referrals itself, instead of allowing the agencies to continue receiving referrals and handling them directly.

“The lack of adequate communication, planning and coordination with contracted providers and referral sources have resulted in a steady decline in referrals for all participating agencies and has left many patients without a safety net,” the agencies wrote in a letter to Mayhew on June 29.

The state’s 2011 federal grant application spoke of “creating improved referral systems” among Maine Families, health-care providers, public health nursing and the agencies around the state that hold maternal and child health nursing contracts.

But as the state took over nursing referrals, the new process resulted in delays, said Mia Millefoglie, grant manager for the maternal and child health program at MaineHealth Care at Home.

Meanwhile, hospitals and doctors’ offices continued to send referrals directly to the nursing agencies, which the agencies then had to fax to the Maine CDC in Augusta. The reason behind all of the changes, Millefoglie said, is that the state has chosen to use the money it receives through the federal Maternal and Child Health Block Grant for moms and babies with acute health needs. The grant traditionally paid for nursing services for all moms and babies who requested them.

“With all the confusion, we have all faced a tremendous decline in referrals, which is alarming, and now we’re faced with rebuilding,” Millefoglie said. “The state has refocused its efforts in terms of this grant on those with higher-acuity needs. That’s a shift, and that’s a shift we need to work through.”

In the interim, the Maine CDC has returned to allowing the local nursing agencies to handle their own referrals.

“We had been very concerned that if we went through the state process that we might have very sick mothers and children fall through the cracks,” Millefoglie said.

Competition continues

While the 2011 home visiting expansion grant emphasized collaboration among home visiting and early childhood services, program operators report an atmosphere of competition that has generally intensified in recent years.

Around the time the state received its federal award, Heck, of the Bingham Program, offered her organization’s services to improve collaboration among Maine Families and Early Head Start. She facilitated a meeting that brought together staff from the state and both programs.

Since then, however, “it’s only gotten worse,” Heck said.

The state’s public health nursing program has shrunk by half, and the state no longer has a Head Start State Collaboration Office. The office’s role was to ensure that the federally funded Head Start was integrated into the state’s full range of early childhood services.

The collaboration office closed last September after the LePage administration didn’t apply for the federal funds that paid for it. Maine is the only state in the nation that lacks such an office.

“We continue to be disappointed [by] this kind of focus on one program,” Heck said, referring to an emphasis from state officials on Maine Families.

A July 2015 report from Maine’s Head Start collaboration office highlighted this frustration shared by Head Start directors across the state.

Families can sometimes start with Maine Families and receive an Early Head Start referral. If an Early Head Start classroom program has available spots, Maine Families can alert eligible families so they can enroll their children. But 36.4 percent of Maine Head Start directors said it was “extremely difficult” to “establish linkages” with their local Maine Families program. Some 54.5 percent said it was “somewhat difficult” to do the same with public health nursing. (The report highlighted the most common response from Head Start directors.)

“[Early Head Start] home visiting and Maine Families have wonderful services to offer families,” wrote one Head Start director. “It is too bad that a competition approach exists for the two programs.”

“Our work with Maine Families has changed dramatically over the last two years,” wrote another director. “We have gone from a program that worked in complete partnership to having no relationship at all. Information leads us to believe that direction from the State level has influenced this change and the result has been that local Maine Families programs are not working cooperatively with Head Start and [Early Head Start] programs.”

LaHaye, the statewide Maine Families coordinator, didn’t return a follow-up phone call from the BDN regarding collaboration with other early childhood services.

Hensley reported a similar sentiment from public health nursing.

“Some of them worked very closely with our nurses and got along very well professionally, and many Maine Families workers were absolutely quick to recognize and refer to nursing when nursing was needed,” he said. “In other parts of the state, there was more of a competition for clients.”

Maine Focus is a journalism and community engagement initiative at the Bangor Daily News.

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