Coordination of family's care in an evidence-based nurse home visiting program

Interprofessional care coordination within evidence-based prevention programs like Nurse-Family Partnership® (NFP) is necessary to meet family needs and maximize program impact. This study aimed to describe the coordination of families' care in the NFP home visiting context. We used an adapted grounded theory approach and purposively sampled seven NFP sites. We conducted telephone interviews with 95 participants: 51 NFP staff (54%), 39 healthcare providers (41%), and 5 social service providers (5%). All interviews were recorded, transcribed, validated, and analyzed in NVivo11. Many community providers in all sites described their knowledge of the characteristics of the NFP intervention, including the strength of its evidence to achieve outcomes. Care coordination was dynamic and changed over time based on client needs and staff willingness to work together. Effective care coordination in the NFP context from the provider perspective is driven by shared knowledge, integrated systems, mission alignment, and individual champions who value the program.