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Family Connects

Meets HHS criteria for an evidenced based model

Model Overview

Last Updated

April 2018


Theoretical Model

The model aims to bring families, community agencies, and health care providers together through nurse home visits to provide all families with the support and resources they need to promote the well-being of their newborns. The model 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 defined service area. During the initial home visit, the nurse conducts a physical health assessment of the mother and newborn, provides supportive guidance on topics that are common to all families (such as infant feeding and safe sleeping practices), and conducts a systematic assessment of 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, 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 they connected with the referred agency(ies), are receiving services, have any additional needs, and were satisfied with the program.


Target Population

The intervention is available to all families with newborns residing within a defined service area, which could be a region, county, city, neighborhood, or other geographic area. The model targets families with newborns ages 2 to 12 weeks but may reach families earlier or later (up to when the child is 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 families with newborns in their defined service area.


Where to Find Out More

Ashley Alvord, Director of Training and Dissemination
Family Connects
Center for Child and Family Policy
Duke University
2024 W. Main St., Bay C, Box 90539
Durham, NC 27708-0539