Deona Scott was 24 and in her final semester at Charleston Southern University in South Carolina when she found out she was pregnant. She turned to Medicaid for maternity health coverage, and learned about a free program for first-time mothers that could connect her with a nurse to answer questions about pregnancy and caring for her baby.
The nurse would come to her home throughout her pregnancy and for two years after her child's birth.
"My mouth dropped," Scott says. "I was like, 'Thank you, thank you — I can't not take this program.' "
Now Scott works full time for the same branch of Nurse-Family Partnership that helped her, a local affiliate of the national program. She spreads the word about the program to pregnant teenagers and other young women in South Carolina who may be feeling just as scared and unprepared as she felt before her son Phoenix was born. He's now 3.
Scott's job is part of a private-public initiative that is expected to ultimately increase the number of young women in the state that Nurse-Family Partnership serves by 3,200. The expansion, which started last year, was designed in accordance with the nonprofit pay-for-success approach: It ties South Carolina's contribution to the payment for social services to measurable outcomes.
This is the first pay-for-success program to be run statewide in any state. Before the expansion, the program served about 1,000 first-time mothers in South Carolina.
Initially, the expansion is being funded with a total of $30 million from private donors and the federal Medicaid program.
Philanthropists, including the Duke Endowment, the Boeing Co. and the BlueCross BlueShield of South Carolina Foundation, pledged $17 million upfront to allow Nurse-Family Partnership to expand its services.
In addition, the federal Centers for Medicare & Medicaid Services approved a waiver that allows the project to be reimbursed by Medicaid. This will allow approximately $13 million in Medicaid reimbursement (jointly funded by the federal government and the state) to go to service providers over the course of the project.
And after the first few years, the state will contribute as much as another $7.5 million (in total) in "success payments" to help keep the program going over years four and five — but only if the partnership achieves specified results.
The outcomes to be measured include reducing the number of preterm births, reducing hospitalizations of the young children, and reducing emergency department visits related to injuries.
Also, the program will need to show an increase in the spacing between births and an increase in the number of moms served in high-poverty areas. In South Carolina, more than a quarter of children live in poverty, and a majority of babies are born to low-income mothers who qualify for Medicaid.
The expansion will allow the partnership to focus on pregnant teenagers and young women with less formal education, who are at higher risk for complications, says Chris Bishop, executive director of Nurse-Family Partnership in South Carolina.
"It's a massive investment to help us grow and to serve more families, and to innovate," Bishop says. For example, the program is trying telehealth visits "to keep moms engaged and stay in touch, and keep them in the program while they go off and become great moms."
Having someone like Scott doing grass-roots outreach is a new strategy, too, Bishop says, noting that his organization traditionally relied on referrals from other groups.
Nationally, Nurse-Family Partnership has been operating for more than 30 years. During that time, dozens of studies and clinical trials have found it improves pregnancy outcomes, reduces the likelihood of child abuse and neglect and enhances school readiness, among other things.
Scott, for example, says that until she started talking with her nurse, Lindsay Odell, she had no plans to breast-feed her baby. "I thought that was old-school," Scott says, but Odell's advice helped change her mind.
She also credits Odell with helping her organize child care and other details so she could complete her bachelor's degree in kinesiology. She graduated at the end of 2015, and is now married and five months pregnant with her second child.
Nurse-Family Partnership and other similar organizations receive federal funding through the Maternal, Infant and Early Childhood Home Visiting program. Congress bundled its nearly $400 million in funding with the appropriation for the Children's Health Insurance Program two years ago, but that money will dry up on Sept. 30. Traditionally a bipartisan program, it's expected to be reauthorized for funding by Congress in the next budget; in fact advocates of the program are requesting an increase to $800 million over five years.
Efforts like South Carolina's pay-for-success project can play an important role in expanding services, says Karen Howard, vice president of early childhood policy at First Focus, a nonprofit advocacy group.
"Many of the programs in the states are relatively small programs," she says, "and because of funding can't always go deep and saturate the community."
Continued federal funding is key, she adds. "What we really want is secure and dedicated funding. "We need to serve more families."