Amended in Assembly April 6, 2015

California Legislature—2015–16 Regular Session

Assembly Bill No. 50

Introduced by Assembly Member Mullin

December 1, 2014

An act to begin delete amend Section 123492 of the Health and Safety Code, end delete begin insert add Section 14148.25 to the Welfare and Institutions Code, end insert relating to perinatal care.

LEGISLATIVE COUNSEL’S DIGEST

AB 50, as amended, Mullin. begin delete Nurse-Family Partnership. end delete begin insert Medi-Cal: nurse home visiting programs. end insert

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Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services, including perinatal services for pregnant women.

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Existing law establishes the Nurse-Family Partnership program, which is administered by the State Department of Public Health, to provide grants for voluntary nurse home visiting programs for expectant first-time mothers, their children, and their families. Under existing law, a county is required to satisfy specified requirements in order to be eligible to receive a grant.

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This bill would declare the intent of the Legislature to develop a means to leverage public and private dollars to substantially expand the scale of the Nurse-Family Partnership in California, in accordance with specified findings. The bill would revise the requirements relating to the award and use of Nurse-Family Partnership grants, including eliminating a requirement for nurse home visitors and supervisors to receive certain training in effective home visitation techniques.

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This bill would require the State Department of Health Care Services, in consultation with stakeholders, to develop and implement a plan on or before January 1, 2017, to ensure that Nurse-Family Partnership and other evidence-based nurse home visiting programs are offered and provided to Medi-Cal eligible pregnant women, and would require the department, on or before January 1, 2022, and every 5 years thereafter, to report to the Legislature, as specified. The bill would also require the department, in developing the plan, to consider, among other things, establishing Medi-Cal coverage for evidence-based nurse home visiting program services and incentives for providers to offer those services.

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Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

SECTION 1.  

The Legislature finds and declares all of the
following:

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(a) According to United States Census Bureau, California has
a poverty rate of 23.5 percent, the highest rate of any state in the
country.

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(b) Children born into poverty are at higher risk of health and
developmental disparities, including, but not limited to, premature
birth, low birth weight, infant mortality, crime, domestic violence,
developmental delays, dropping out of high school, substance
abuse, unemployment, and child abuse and neglect.

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(a)

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begin insert (c) end insert  In 2014, the Legislature passed Assembly Concurrent
Resolution No. 155 by Assembly Member Raul Bocanegra,
recognizing that research over the last two decades in the evolving
fields of neuroscience, molecular biology, public health, genomics,
and epigenetics reveals that experiences in the first few years of
life build changes into the biology of the human body begin delete which end delete begin insert that end insert ,
in turn, influence the person’s physical and mental health over his
or her lifetime.

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(b)

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begin insert (d) end insert  On May 3, 2012, Governor Edmund G, Brown Jr. issued
Executive Order B-19-12, establishing the “Let’s Get Healthy
California Task Force” to develop a 10-year plan for improving
the health of Californians, controlling health care costs, promoting
personal responsibility for individual health, and advancing health
equity.”

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(c)

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begin insert (e) end insert  The task force identified several priorities, including a subset
for “Healthy Beginnings,” which include reducing infant deaths,
increasing vaccination rates, reducing childhood trauma, and
reducing adolescent tobacco use.

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(d)

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begin insert (f) end insert  The final report of the task force states “the challenge going
forward is to identify evidence-based interventions and quicken
the pace of uptake across the state,” in order to meet the ambitious
goals in the Governor’s directive.

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(e) In addition to reducing healthcare costs, the Nurse-Family
Partnership has demonstrated proven outcomes addressing factors
that contribute to toxic stress and made measurable progress
towards many of the goals identified by the task force.

(f) The Nurse-Family Partnership is an evidence-based,
community health program that improves pregnancy outcomes,
improves child health and development, and improves economic
self-sufficiency.

(g) Multiple peer-reviewed, randomized, controlled trials and
longitudinal followup studies have clearly demonstrated the
efficacy of the Nurse-Family Partnership programs, through
significant sustained results, in achieving these goals.

(h) The Nurse-Family Partnership provides lifelong health and
economic benefits to both mothers and children served by the
program.

(i) These lifelong benefits have the potential to achieve
substantial savings to federal, state, and local governments with
respect to programs and services, including Medicaid, Child
Protective Services, law enforcement, special education, the
Supplemental Nutrition Assistance Program (SNAP), and
Temporary Assistance for Needy Families (TANF) program,
among others. These savings far exceed the costs of implementing
the Nurse-Family Partnership program.

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(g) In 2013, more than 248,000 Medi-Cal beneficiaries gave
birth to a child. Because Medi-Cal covers half of all births in the
state, this has increased costs for taxpayers. Medi-Cal expansion
has resulted in an 18 percent increase in Medi-Cal enrollment to
a total of 11.3 million, and enrollment is to exceed 12 million in
2015.

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(h) The California Health and Human Services Agency recently
submitted its State Health Care Innovation Plan, including the
Maternity Care initiative, which addresses issues of high costs in
maternity care, to the Center for Medicare and Medicaid
Innovation. Child deliveries and related expenses, including
high-risk births, rank among the top 10 high cost episodes of health
care, and in the last 15 years, California has seen a continual rise
in maternal mortality.

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(i) The cost of health care specifically related to high-risk
pregnancies, neonatal intensive-care unit (NICU) services, toxic
stress, and emergency room visits has increased and is projected
to continue to rise. Average health care costs for women were 25
percent more than men primarily due to higher costs of health
care during childbearing years.

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(j) The Nurse-Family Partnership is a voluntary,
evidence-based, prevention program that partners low-income,
pregnant women having their first child with a registered nurse
who provides home visits from early in pregnancy until the child’s
second birthday.

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(k) With more than 37 years of evidence from randomized,
controlled trials, the Nurse-Family Partnership has demonstrated
sustained improvements in maternal health, child health and
development, and the economic stability of families.

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(l) The Nurse-Family Partnership has consistently demonstrated
reductions in preterm births and preventable maternal mortality
via controlled trial and longitudinal follow-ups over two decades.

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(m) Randomized, controlled trials have also demonstrated that
the use of Nurse-Family Partnership nurse home visitors increases
positive outcomes during the prenatal period and the first two
years of life compared to the use of paraprofessionals.

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(n) Research has shown that the Nurse-Family Partnership can
reduce smoking during pregnancy, complications of pregnancy,
preterm births, closely spaced subsequent births, and childhood
injuries resulting in costly emergency department use and
hospitalizations. The Nurse-Family Partnership also can improve
childhood immunization rates and compliance with well child visit
schedules. As a result of families benefiting from Nurse-Family
Partnership , there has been cost savings to federal, state, and
local governments with respect to programs and services, including
Medicaid, the Supplemental Nutrition Assistance Program (SNAP),
and the Temporary Assistance for Needy Families (TANF)
program.

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(o) By enrolling recipients no later than 28 weeks of gestation,
the Nurse-Family Partnership maximizes the impact on prenatal
care, birth outcomes, and critical early brain development of
infants.

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(p) The Nurse-Family Partnership’s evidence base and benefits
to society are well documented and validated by independent
analyses.

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(q) The Nurse-Family Partnership’s strong evidence of
effectiveness and predictable return on investment demonstrate
that this evidence-based intervention should be brought to scale
in California to improve maternal and child health outcomes and
help reduce health care costs for generations to come.

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(j)

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begin insert (r) end insert  Twenty-one California counties currently operate a
Nurse-Family Partnership begin delete program. end delete begin insert program providing services
to 4,000 residents. end insert Only a fraction of begin insert the 100,000 end insert potentially
eligible recipients begin insert annually end insert are receiving these highly beneficial
and cost-effective services.

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(k)

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begin insert (s) end insert  However, if California were to provide these services to
significantly more eligible first-time mothers, the state could see
population-wide health and economic benefits that would carry
over to future generations.

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(l)

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begin insert (t) end insert  Therefore, it is the intent of the Legislature to develop a
means to leverage public and private dollars to substantially expand
the scale of the Nurse-Family Partnership begin delete in end delete begin insert and other
evidence-based nurse home visiting throughout end insert California,
beginning with begin delete regions end delete begin insert communities end insert and populations with the
greatest need.

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SEC. 2.  

Section 123492 of the Health and Safety Code is
amended to read:

123492.  

The department shall develop a grant application and
award grants on a competitive basis to counties for the startup,
continuation, and expansion of the program established pursuant
to Section 123491. To be eligible to receive a grant for purposes
of that section, a county shall agree to do all of the following:

(a) Serve through the program only pregnant, low-income
women who have had no previous live births. Notwithstanding
subdivision (b) of Section 123485, women who are juvenile
offenders or who are clients of the juvenile system, with no history
of prior live births, shall be deemed eligible for services under the
program.

(b) Enroll women in the program while they are still pregnant,
before the 28th week of gestation, and preferably before the 16th
week of gestation, and continue those women in the program
through the first two years of the child’s life.

(c) Use as home visitors only registered nurses who have been
licensed in the state.

(d) Have nurse home visitors undergo training according to the
program and follow the home visit guidelines developed by the
Nurse-Family Partnership program.

(e) Have nurse home visitors specially trained in the
Nurse-Family Partnership guidelines for prenatal care and early
child development.

(f) Have nurse home visitors follow a visit schedule keyed to
the developmental stages of pregnancy and early childhood.

(g) Ensure that, to the extent possible, services shall be rendered
in a culturally and linguistically competent manner.

(h) Limit a nurse home visitor’s caseload to no more than 25
active families at any given time.

(i) For every eight nurse home visitors, provide a full-time nurse
supervisor who holds at least a bachelor’s degree in nursing and
has substantial experience in community health nursing.

(j) Have nurse home visitors and nurse supervisors trained in
the method of assessing early infant development and parent-child
interaction in a manner consistent with the program.

(k) Provide data on operations, results, and expenditures in the
formats and with the frequencies specified by the department.

(l) Collaborate with other home visiting and family support
programs in the community to avoid duplication of services and
complement and integrate with existing services to the extent
practicable.

(m) Demonstrate that adoption of the Nurse-Family Partnership
program is supported by a local governmental or
government-affiliated community planning board, decisionmaking
board, or advisory body responsible for assuring the availability
of effective, coordinated services for families and children in the
community.

(n) Provide cash or in-kind matching funds in the amount of
100 percent of the grant award.

(o) Prohibit the use of moneys received for the program as a
match for grants currently administered by the department.

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begin insert SEC. 2. end insert   

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begin insert Section 14148.25 is added to the end insert begin insert Welfare and
Institutions Code end insert begin insert , end insert immediately following Section 14148.2 begin insert , to read: end insert

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begin insert 14148.25. end insert   

(a) The department shall, in consultation with
stakeholders, develop and implement a plan on or before January
1, 2017, to ensure that Nurse-Family Partnership and other
evidence-based nurse home visiting programs are offered and
provided to all Medi-Cal eligible pregnant women. The department
shall consider all of the following in developing the plan:

(1) Establishing Medi-Cal coverage for evidence-based nurse
home visiting program services.

(2) Incentives for providers to offer evidence-based nurse home
visiting program services.

(3) Other mechanisms to fund evidence-based nurse home
visiting program services.

(b) (1) The department shall, on or before January 1, 2022, and
every five years thereafter, report to the Legislature on
implementation progress and the effectiveness of evidence-based
nurse home visiting services in improving maternal and child
health outcomes, the experience of care, and cost savings to the
Medi-Cal program and the state.

(2) A report to be submitted pursuant to paragraph (1) shall be
submitted in compliance with Section 9795 of the Government
Code.

(c) For the purposes of this section, the following definitions
shall apply:

(1) “Evidence-based program” means a program that is based
on scientific evidence demonstrating that the program model is
effective. An evidence-based program shall be reviewed on site
and compared to program model standards by the model developer
or the developer’s designee at least every five years to ensure that
the program continues to maintain fidelity with the program model.
The program model shall have had demonstrated and replicated
significant and sustained positive outcomes that have been in one
or more well-designed and rigorous randomized controlled
research designs, and the evaluation results shall have been
published in a peer-reviewed journal.

(2) “Nurse home visiting program” means a program or
initiative that does all of the following:

(A) Contains home visiting as a primary service delivery strategy
by registered nurses to families with a pregnant woman who is
eligible for medical assistance.

(B) Offers services on a voluntary basis to pregnant women,
expectant fathers, and parents and caregivers of children from
prenatal to two years old; and

(C) Targets participant outcomes that include all of the
following:

(i) Improved maternal and child health.

(ii) Prevention of child injuries, child abuse or maltreatment,
and reduction of emergency department visits.

(iii) Improvements in school readiness and achievement.

(iv) Reduction in crime or domestic violence.

(v) Improvements in family economic self-sufficiency.

(vi) Improvements in coordination of, and referrals to, other
community resources and support.

(vii) Improvements in parenting skills related to child
development.

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