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Family Connects

Meets DHHS criteria for an evidenced based model

Model Overview

Last Updated

July 2016


Theoretical Model

The model aims to bring families, community agencies, and health care providers together through nurse home visits to ensure that all families have the support and resources they need to promote the well-being of their newborns. The program uses a triage model of care, providing one to three home visits to every family living within a defined service area, typically when the infant is 2 to 12 weeks old. Families with identified needs can receive further support, including additional home visits, telephone contacts, and connections to community resources for longer-term services.


Model Components

Family Connects is a manualized intervention that provides one to three home visits from a registered nurse to all families with newborns living in a specified service area. During the initial home visit, the nurse conducts a physical health assessment of the mother and newborn, provides guidance on topics that are common to all families (such as infant feeding and safe sleeping practices), and assesses family risks and needs. The risk and needs assessment covers 12 factors in 4 domains associated with mother and infant health and well-being (domains and factors are listed in Assessment Tools).

If an assessment indicates a risk or need, nurses directly support families or connect them to community resources, typically through additional home visits and/or telephone contacts. In cases of mild risk, nurses may provide direct support, such as feeding assistance. If a family’s risk is more significant, the nurse collaborates with the family to connect them to desired community services and supports. Supports may include intensive, targeted home visiting programs such as Healthy Families America or Early Head Start, mental health services, public assistance programs, or primary health care providers. Nurses use a searchable database of local agencies, created by local program staff, in making referrals.

One month following case closure, a staff member (the nurse home visitor or another staff member) calls families to determine whether the family contacted the referred agency(ies), is receiving services, has any additional needs, and was satisfied with the program.


Target Population

The intervention is available to all families with newborns residing within a defined service area. The program targets families with newborns ages 2 to 12 weeks but may reach families earlier or later (up to age 6 months) when special needs are present (for instance, if an infant had been admitted for neonatal intensive care). Sites must have a recruitment plan to reach all eligible families in their defined community area, which could be a city, county, or other geographic area.


Where to Find Out More

Ashley Alvord and Jacquelyn Mroz, Training Specialists
Family Connects
1121 W. Chapel Hill Street
Suite 100
Durham, NC 27701