South Carolina Nurse Family Partnership Pay for Success Project

South Carolina Nurse Family Partnership Pay for

Success Project

Sarah Allin

I. Executive Summary

In January 2016, South Carolina launched a pay

for success (PFS) project to connect low-income

mothers and their children with nurse home

visiting services. South Carolina’s Department of

Health and Human Services (SCDHHS) used the

pay for success contract to deliver preventive

services to first-time mothers in the state’s

Medicaid program with the goal of improving

the health outcomes of mothers and their babies.

Through the South Carolina Nurse-Family

Partnership project (SC NFP), South Carolina

provides nurse home visiting services to

approximately 4,000 mothers over a six-year

period. Mothers who enroll in Nurse-Family

Partnership services receive individualized home

visits from trained nurses from early in their

pregnancy until their child’s second birthday.

The SC NFP project employed several innovative

techniques to expand and evaluate preventive

services:

1. The use of a ‘pilot period’ to test

changes in program enrollment and

data transfer.

The SC NFP project led to changes in how

mothers were screened for and enrolled in NFP

home visiting services in South Carolina. A

three-month pilot period allowed (1) nurses to

practice new enrollment protocols, (2)

evaluators to make adjustments to the consent

and information gathering process, and (3)

project partners to establish data agreements

and protocols for sharing data.

2. The development of a PFS outcome

metric focused on enrolling high-risk

mothers.

NFP and the nine implementing agencies (IAs)

in the SC NFP project have served South

Carolina mothers as far back as 2009. To

incentivize IAs to enroll more at-risk mothers,

SCDHHS and project partners set a target for

the percentage of enrollees living in low-income

zip codes (poverty rates above 15 percent). If at

least 65 percent of mothers in the SC NFP

project live in these low-income zip codes at the

time of enrollment, SCDHHS pays a per

participant success payment.

3. State-Federal Partnership

It has been challenging for state governments to

establish pay for success projects in health policy

because the joint state-federal funding of

Medicaid implies that much of the benefits of

such projects will flow to the federal

government, even if the federal government does

not fully share in the project’s implementation

costs. SCDHHS received a 1915(b) waiver from

the Centers for Medicare and Medicaid Services

to allow NFP to bill Medicaid . The waiver also

expands the number of home visits billable to

South Carolina Medicaid for each mother-child

pairing from two to a maximum of forty. This

project was feasible only because the waiver

allows the federal government to pay for a

portion of the project’s costs, just as it would for

other Medicaid-funded services.

4. Combination of Fee-for-Service and

Pay for Success

In this project, the contemporaneous per-visit

Medicaid payments are covering

approximately45 percent of the project budget,

and investor contributions are covering the

remaining 55 percent. This mix of fee-for-

service and pay for success is an extremely

promising model for leveraging investor dollars

to improve service delivery for a much larger

total amount of services.

5. The incorporation of philanthropic

investment and rollover of success

payments.

Philanthropic investors contributed $17 million

to fund upfront operations of the SC NFP

project. Real-time Medicaid billing under the

1915(b) waiver covers the remaining $13.5

million in operational costs. In the hope of

cultivating a path to long-term, sustainable

funding of NFP in South Carolina, the investors

are rolling over any success payments into

ongoing NFP operations in the state.

6. The incorporation of a randomized

controlled trial (RCT) and a long-term

evaluation.

Nationally, NFP has participated in several

rigorous evaluations of their model; however,

South Carolina has limited evidence on the

effects of services for their state’s current

residents. The Abdul Latif Jameel Poverty

Action Lab (J-PAL) designed a RCT to provide

rigorous evidence on the effects of NFP, and the

results of the RCT will be used to calculate PFS

success payments. Beyond the PFS contract

period, J-PAL is also conducting a

comprehensive, long-term evaluation of NFP’s

impact on mothers and children, an approach

not usually pursued in PFS projects because of

the focus on short-term benefits in mapping

success metrics and payments. In South

Carolina, partners are taking advantage of the

state’s integrated data system and the work

already done to set up an RCT to build evidence

on the benefits NFP may generate for families in

health, economic security, and criminal justice

outcomes beyond the traditional PFS

measurement period.

II. Timeline for Developing the SC NFP

Project

Building Knowledge and Assessing Feasibility

of Pay for Success

South Carolina’s process for learning more about

pay for success projects began in 2012 when the

Institute for Child Success (ICS) -- a policy and

research organization focused on child

development and well-being nationally --

convened a pay for success working group in the

state. With the support of ICS, the working

group began to focus on the potential of pay for

success as a tool for improving health outcomes

for low-income mothers and children in the

state. In 2013, ICS released a report assessing

the suitability of early childhood home visiting

models for PFS financing. The assessment

particularly focused on Nurse-Family

Partnership (NFP), a national model for home

visiting already operating in the state. ICS

determined that the evidence base for NFP and

the potential benefits to residents and the state

of South Carolina made the model a strong

candidate for PFS.

During the feasibility assessment period, staff

from within South Carolina state government

and ICS began engaging with the Harvard

Kennedy School Government Performance Lab

(GPL) to integrate the GPL’s technical expertise

on PFS into their discussions.

The GPL provides pro bono technical assistance

to state and local governments interested in

pursuing Pay for Success projects. The GPL

awarded assistance to South Carolina in the

spring of 2013 and the lab’s full-time fellow

began working on site at SCDHHS in June 2013.

Procurement Process and Negotiations Kickoff

With the ICS feasibility assessment completed,

SCDHHS released a Request for Information

(RFI) on interventions aimed at “controlling

costs and improving health and other outcomes

of mothers and newborns in South Carolina’s

Medicaid program.

” From the RFI responses,

South Carolina continued to refine its goals and

interests in improving child and maternal health

outcomes for Medicaid beneficiaries. After a

thorough internal review of RFI responses and

the existing evidence on home visitation and

other prenatal and early childhood programs,

SCDHHS began developing a Pay for Success

Contract to expand NFP services throughout the

state. Negotiations between SCDHHS and NFP,

who received advisory services from Social

Finance, began in March of 2014. Negotiations

to set a target population, outcomes of interest,

and success payment structure progressed

through the fall of 2015.

Applying for a Medicaid 1915(b) waiver

Throughout the negotiations, partners began

searching for innovative approaches to financing

the Pay for Success effort and, aside from more

traditional philanthropic and private investment

channels, started looking into the potential of

billing a portion of the NFP home visits directly

to Medicaid. SCDHHS searched for a path that

would keep the incentive structure of success

payments important to the Pay for Success

model in place, while also offsetting some of the

costs through fee-for-service billing that would

be contemporary with the delivery of services.

After extended discussions with the federal

government, SCDHHS determined that a

1915(b) waiver from the Centers for Medicare

and Medicaid Services (CMS) offered the most

practical path to allow NFP to bill for a portion

of the home visits upfront in a way that limited

the state’s financial exposure and preserved the

integrity of the project’s evaluation. SCDHHS

submitted the waiver application in June 2015,

and CMS approved the waiver in December

2015.

Pilot Period and Full Service Launch

The SC NFP project contract was executed in

December 2015, and the project was officially

announced in February 2016 at the South

Carolina state capitol. The contract specified

that full-scale service delivery of NFP would

launch in April 2016. With the support of the

Laura and John Arnold Foundation and The

Duke Endowment, project partners also set up a

“pilot period” to test out procedures for enrolling

moms in the Pay for Success project from

January through March of 2016 -- ahead of the

full launch in April.

Following the April 2016 launch, 4,000 mothers

will be enrolled to receive services over the next

four years.

iii

Each mother will receive home

visits beginning around the end of her first

trimester of pregnancy and lasting for as long as

she desires up until her child’s second birthday.

J-PAL will track the PFS outcomes of each

mother and child for two years after the birth of

the child, meaning the total enrollment, service

delivery period, and tracking timeline will take

place over six years. Success payments will be

calculated at two different points – in year five

and year six of the project.

III. Determining the Target Population

for NFP Services

The launch of the NFP SC project in April 2016

was not the beginning of Nurse Family

Partnership service delivery in South Carolina.

Through philanthropic support and U.S.

Department of Health and Human Services

Maternal Infant Early Child Home Visiting

(MIECHV) funds, Nurse Family Partnership

began delivering home visiting services to South

Carolina moms in 2009.

In South Carolina and in other jurisdictions,

NFP focuses on serving low-income, first time

mothers with specially trained Nurse Home

Visitors through their model. NFP Nurse Home

Visitors connect with mothers before their

twenty-eighth week of pregnancy and begin

delivering regular home visits up until the child’s

second birthday. NFP tries to maintain the

nurse-mother relationship by keeping a

consistent pairing throughout the mother’s time

receiving NFP services. The frequency of visits

adjusts as the mother transitions from prenatal

to postpartum and into the early childhood

phases of pregnancy and motherhood. In the SC

NFP project, partners estimated moms would

receive approximately forty home visits if they

continue until their child’s second birthday.

Determining which Moms to Target with

Services

The SC NFP project continued focusing on a

population similar to that served by NFP in the

state since 2009 – first-time, low-income moms

at no more than twenty-eight weeks gestation.

SCDHHS also made Medicaid eligibility and

enrollment a condition of enrolling in the

project. Finally, SCDHHS wanted a path for NFP

to serve those mothers most at-risk and who

might not otherwise connect with home visiting

services. To do this, project partners looked for

ways to focus on high poverty areas, and

ultimately agreed on an additional layer of

enrollment targets for zip codes with high

concentrations of poverty.

Evidence on the Effectiveness of NFP Services

Previous evaluations of NFP demonstrated that

the home visiting model could result in reduced

child injuries, increased spacing between

subsequent births, improved prenatal health for

mothers, and additional improvements in child

well-being.

The existing evidence from previous

evaluations provided critical information to

project partners as they put together the SC NFP

project. SCDHHS saw great value in

implementing their own rigorous evaluation of

NFP services in the state given that the previous

evaluations covered other geographic areas

(New York, Tennessee, and Colorado) and took

place in previous decades. It also allowed

SCDHHS to assess the impact of NFP’s efforts to

reduce service delivery costs by as much as 25

percent over the six years of the project.

IV. PFS Outcome Metrics

The SC NFP project plans to evaluate NFP’s

service delivery in the state using four success

outcomes: reduction in child injury rates,

reduction in pre-term births, increase in healthy

birth intervals, and enrollment of moms from

low-income zip codes. The first three outcomes

focus on the health benefits to mothers and

children served by NFP’s nine IAs, while the

fourth – enrollment in low-income zip codes –

aims to incentivize IAs to expand the reach of

their service delivery to high-need communities.

J-PAL will track, evaluate and report on

outcomes through a randomized controlled trial.

Child injury: Measured through Medicaid billing

claims, a child injury is any emergency

department visit caused by acute injury in the

child’s first 24 months of life. A series of

diagnosis and billing codes were mutually

agreed upon by partners to reflect acute child

injury events.

Preterm birth: Obtained from vital statistics

birth records, preterm births are any live births

with a gestation period of less than 37 completed

weeks.

Healthy birth intervals: Obtained from vital

statistics birth records, healthy birth intervals

monitor if mothers have subsequent live births

within 24 months of the first recorded birth.

Coverage in low-income zip codes: Obtained

from the study enrollment survey, low-income

zip codes are those with household poverty rates

above 15 percent according to U.S. Census

Bureau data from 2012. NFP aims to enroll at

least 65 percent of mothers in the project from

these low-income zip codes.

V. Evaluating Pay for Success Outcomes

Once SCDHHS and NFP decided on the

outcomes for determining success, they needed a

plan for reliably evaluating NFP services.

Partners also determined:

 Which and how many moms would be

eligible for services;

 How moms would enter into the project

and receive home visiting services;

 How NFP, SCDHHS and other partners

would share data and monitor success of

the project in real time; and

 How J-PAL would evaluate the four

outcome metrics.

Randomized Evaluation

Although the SC NFP project expands home

visiting to 4,000 mothers, there are still more

mothers across South Carolina who would like to

receive NFP’s services. South Carolina felt that

using a lottery system to assign slots in NFP

would be the fairest way to allocate the 4,000

openings. The oversubscription for NFP also

meant that an opportunity existed to use a

randomized controlled trial, the gold standard in

evaluation design, to evaluate NFP services and

determine whether NFP met the project’s

success outcomes.In particular, the RCT

approach makes it possible to rigorously

determine the impact of the NFP services by

comparing results for those offered NFP slots to

those who are not offered slots. SCDHHS’s

Director was insistent on using the RCT

approach.

Operational Planning

Following the selection of the RCT approach,

partners created clear protocols for enrolling

moms in home visiting services and monitoring

their success. To start, eligibility criteria were set

for moms enrolling in the NFP project. Mothers

have to be (1) less than twenty-eight weeks

pregnant, (2) have no previous live births, and

(3) be Medicaid eligible and have applied for

Medicaid in South Carolina. Mothers also review

information about the NFP program and consent

to participate in the project.

Enrollment Targets

Over four years of project enrollment, NFP aims

to enroll 4,000 moms in NFP nurse home

visiting services across the nine IAs. Project

partners agreed to a randomization ratio of 2:1,

meaning that for every two mothers enrolled in

the treatment group for NFP services, the lottery

assigns one mother to the control group, so that

their outcomes can be compared over time. This

means NFP is responsible for recruiting a total

of 6,000 moms for the NFP project, with 4,000

of those moms offered NFP home visiting

services.

Enrollment Protocols

To increase engagement with the mother and

increase the personal nature of enrollment, NFP

nurses themselves -- rather than other trained

staff -- enroll each mom in the SC NFP project.

For each NFP nurse, J-PAL provides intensive

training on how to collect baseline information

on each mother, how to explain the SC NFP

project and NFP services, and how to obtain

In total, 3,200 of the moms receiving NFP will be billable

under the 1915(b) waiver from CMS. The remaining mothers

will have their services covered by the federal MIECHV

program. The additional MIECHV mothers will be included

in the evaluation sample, but SCDHHS will only make

success payments on the subset of mothers funded by the

1915(b) waiver.

informed consent as approved by Harvard

University’s Internal Review Board.

Nurses are also trained to use a J-PAL tablet

which has the software for the lottery

assignment of the mom into the treatment or

control group. Each new NFP nurse practices the

consent, randomization and enrollment process

prior to conducting an enrollment visit with a

mom, and new nurses shadow veteran nurses for

the first few site visits. All information collected

in the tablets at enrollment is sent directly and

securely to J-PAL for long-term monitoring. If a

mom is enrolled in the treatment group, nurses

can then begin conducting regular home visits

with the mother.

Pilot Period to Test New Enrollment Procedures

The SC NFP project enrollment protocols

differed considerably from the previous way the

implementing agencies enrolled moms in NFP

services in South Carolina. To give each IA time

to practice the new procedures, project partners

sought funding for a three-month “pilot period”

in the beginning of 2016.

Funded by the Laura and John Arnold

Foundation, the pilot period aimed to enroll 100

moms in the SC NFP project using the new

protocols – with at least ten moms enrolled by

each implementing agency. The pilot period also

gave NFP sufficient time to hire the additional

nursing and outreach staff who would be needed

to expand NFP services, and gave other project

partners – SCDHHS, NFP and J-PAL – much

needed time to get final data agreements and

data transfer procedures in place for the project.

Each of these tasks ultimately will prove critical

to collecting and transferring key information

necessary for the evaluation.

VI. Payment Schedule

In total, SCDHHS set aside $7.5 million for

success payments achieved by NFP throughout

the project, in addition to the funds allocated

through the Medicaid 1915(b) waiver for real

time billing for services. Philanthropic investors

agreed prior to project launch that any success

payments made by SCDHHS would be

reinvested into NFP service delivery in South

Carolina. There are two payment points when

outcomes are evaluated and success payments

Katherine Baicker, the JPAL principle investigator on the

project, was a Harvard professor at the time.

are determined. The first payment point marks

distribution of any success payments earned on

the Preterm Birth metric and the Coverage in

Low-Income Zip Codes metric. The first

payment point occurs five years after the launch

of service delivery, in April 2021.

The second payment point marks distribution of

any success payments associated with the

Healthy Birth Interval metric and the Child

Injury metric. The second payment point is

scheduled for six years from the launch of

services, in April 2022. J-PAL will provide

impact estimates for all outcomes using results

of the PFS evaluation.

Calculating Success Payments by Outcome

Metric

Two components make up the success payment

for the Preterm Birth, Healthy Birth Interval,

and Child Injury metrics – a variable component

and a fixed component. The outcome metrics

used in this project measure only a subset of the

benefits that are likely to arise from improved

child and maternal health. For example, the

project directly measures the reduction in child

injuries but does not also measure the reduced

usage of child welfare system resources that

almost certainly will arise in association with the

reduction in child injuries. The project parties

agreed that for directly measured benefits,

payments would be paid for any improvements

in outcomes for the treatment group relative to

the control group, with no minimum

improvement required. This is the variable

component of the payments. However, for

payments for associated benefits that are not

directly measured, the payment schedule is more

conservative, and payments occur only if a

minimum threshold is reached. These are

referred to as the “fixed component” of

payments. As part of the negotiations that

concluded the transaction, it was agreed that

there would be a lower threshold to receive an

initial fixed payment, and a higher threshold for

the full fixed payment.

The relationship between the variable

component and fixed component can be

illustrated using the preterm birth metric. The

variable component of each metric’s payment is

not conditional on meeting a minimum

threshold. In the case of the Preterm Birth

Metric, SCDHHS will pay $29,514 for each

preterm birth avoided based on the impact

estimates generated by the PFS evaluation. The

payment is calculated by multiplying project

participants x control group mean x impact

estimate for pre-term birth, so if there were 100

project participants, the pre-term birth rate was

20 percent among the control group, and the

preterm birth impact estimate was -15 percent,

then the calculation for the variable component

would be as follows:

100 participants x 20% preterm birth rate X 15%

preterm birth impact X $29,514 = $88,542

The fixed component of each metric’s payment is

contingent on whether NFP reaches a success

threshold. For example, in the case of the

Preterm Birth Metric, SCDHHS will pay the first

tier of the fixed component of the metric’s

success payment only if NFP reduces the

Preterm Birth rate of treatment group members

by at least 13.5 percent. In the example above If

NFP reduces the Preterm Birth rate by 15

percent (which not only exceeds the 13.5 percent

threshold but achieves the 15 percent threshold

as well), SCDHHS will pay a success payment of

$551 for each mother enrolled in NFP services.

The success payment for the fixed component

would be:

100 participants x $551 = $55,100

Table 1 details the two different components of

each success payment that will be made

throughout the project. For each payment

period, the success payment will be calculated

using the rates below. SCDHHS will then deduct

its share of expenditures on NFP home visits

under the Medicaid waiver in that period from

the total for a final success payment amount.

SCDHHS will make up to $7.5 million in success

payments throughout the course of the project.

VII. Key Entities in the Formation of

the SC NFP Project

Nurse-Family Partnership’s nine implementing

agencies have the responsibility for providing

4,000 moms with home visiting services over

the next six years. However, setting up a pay for

success project to deliver services on such a wide

scale took the work of many entities, some of

which have been previously mentioned. This

section provides a brief summary describing

each entity and their contribution to the SC NFP

project.

Service Provider: Nurse-Family

Partnership

NFP Local Implementing Agencies: Nine

entities across South Carolina deliver home

visiting services to mothers and children in the

SC NFP project including: three hospitals, one

federally qualified health center, one rural health

clinic, and four South Carolina Department of

Health and Environmental Control (DHEC)

sites.

Outcome Metric

Price Per Outcome (no

threshold)

Success Threshold

for Fixed Payment

Fixed Payment if Success

Threshold is Met (per

participant)

Preterm Birth

$29,514 per preterm

birth avoided

>=13.5%

$331

>=15%

$551

Healthy Birth

Interval

$2,437 per closely

spaced birth avoided

>=18%

$331

>=20%

$551

Child Injury

$141 per child injury

avoided

>=23.4%

$331

>=26%

$551

Coverage in Low-

Income Zip Code

65%

$551

Table1: Components of Each SC NFP Success Payment by Outcome Metric

NFP National Service Office: NFP is a national

model for nurse home visiting. Local agencies –

hospitals, home health agencies, federally

qualified health centers, health clinics – can

receive training on the NFP approach and

provide NFP services. The National Service

Office and its staff contributed heavily to the

operational planning and contract formation for

the SC NFP project and are continuing to

provide support to the nine implementing

agencies throughout project implementation.

Government Agency: South Carolina

Department of Health and Human

Services

SCDHHS administers the Medicaid program for

the state of South Carolina. The agency

spearheaded the state’s interest in pay for

success and the process of applying to CMS for a

1915(b) waiver. In this project, SCDHHS

provides referrals to NFP of newly enrolled

Medicaid mothers, oversees billing and

reporting associated with the 1915(b) Medicaid

waiver, and is the payer of up to $7.5 million in

success payments.

PFS Trust Fund Administrator:

Children’s Trust of South Carolina

The Children’s Trust of South Carolina is a state-

chartered 501(c)3 non-profit organization

focused on prevention efforts that keep South

Carolina’s children safe. The Children’s Trust

has the capacity to receive and hold (1) capital

calls from philanthropic investors for NFP

operations and (2) $7.5 million allocated from

SCDHHS for future success payments.

Children’s Trust of South Carolina will also

calculate and distribute success payments based

on J-PAL’s evaluation results.

Evaluator: Abdul Latif Jameel Poverty

Action Lab (J-PAL)

Based at MIT, J-PAL seeks to reduce poverty by

ensuring that policy is informed by rigorous

evidence. J-PAL designed the randomized

controlled trial evaluation for the SC NFP

project, facilitated Harvard IRB approval of the

evaluation design, and trained nurses and staff

in enrollment protocols. J-PAL continues to

monitor project enrollment and operations to

implement a high-quality randomized controlled

trial. Outside of the PFS project, J-PAL will also

track long-term outcomes associated with SC

NFP with the goal of generating broader lessons

on the impacts of home visiting on the long-term

wellbeing of mothers and children.

Project Manager: Social Finance US

Social Finance is a 501(c)3 organization focused

on mobilizing capital to drive social progress.

Social Finance assisted in cultivating investment

for the Pay for Success effort and informed the

planning and contract negotiation process on

behalf of the Nurse-Family Partnership and

investors. Social Finance convenes and serves on

the SC NFP Operations Committee – alongside

SCDHHS, NFP and HKS GPL – which regularly

meets to monitor project progress.

Philanthropic Investors: Blue Cross Blue

Shield of SC Foundation; Boeing

Foundation; The Duke Endowment;

Greenville County SC First Steps: Laura

and John Arnold Foundation; New

Partnership for Youth LLC

A combination of national, regional and local

philanthropies contributed more than $17

million in capital to fund the upfront costs and

pilot of the SC NFP project. Several of these

foundations have previously funded NFP’s

services in South Carolina, and all investors

agreed to rollover any success payments made

by SCDHHS into on-going NFP operations in

South Carolina.

Government Side Technical Assistance:

Harvard Kennedy School Government

Performance Lab

HKS GPL conducts research on how

governments can improve the results they

achieve for their citizens. HKS GPL provided pro

bono technical assistance to SCDHHS

throughout the project including: data analysis

for feasibility and population targeting,

literature review of potential interventions,

assistance in applying for the 1915(b) waiver,

cost-benefit analysis, financial modeling,

support in contract negotiations, and general

project management. HKS GPL continues to be

involved with the project through their role on

the SC NFP Operations Committee.

VIII. Investment Structure/Funding

In the SC NFP project, philanthropic investors

committed $17 million to fund NFP operations,

including outreach and service delivery, along

with evaluator and intermediary services.

Investor capital is inserted into the project every

six months according to a schedule laid out in

the PFS contract. In addition to the investors’

capital commitments, a portion of each home

visit – up to forty visits per mother -- is directly

billable to South Carolina’s Medicaid program

because of flexibility granted through a 1915(b)

waiver from the Centers for Medicare and

Medicaid Services (CMS).

Together, these

sources of funding set up a PFS project with (1)

substantial success payments to incentivize

performance and (2) direct billing for a portion

of service costs.

Billing and the Medicaid 1915(b) Waiver

Under existing coverage, all new mothers in

South Carolina’s Medicaid program are eligible

for two postpartum home visits. SCDHHS’s

1915(b) waiver allows NFP to bill Medicaid for

an expanded number of home visits over the

five-year waiver period from the start of 2016 to

the end of 2020. The waiver also allows NFP to

bill South Carolina Medicaid at a higher rate for

the more robust services associated with home

visits. The waiver applies only to the NFP model

and the nine implementing agencies

participating in the SC NFP project.

As with all states, Medicaid expenditures are

split between a federal and state share. South

Carolina pays 29 percent of the Medicaid

distribution for each home visit, while the

federal government pays 71 percent. SCDHHS

estimates that approximately $13 million will be

spent in total through direct Medicaid billing to

support the SC NFP project.

MIECHV-Funded Services

Approximately 3,200 moms in the treatment

group will have a portion of their service costs

billable to Medicaid. An additional 800 moms

funded by the federal MIECHV program are

included in the SC NFP project evaluation – for

a total of 4,000 moms. MIECHV-funded moms

are not billable to the waiver or eligible for

success payments. SC NFP partners made the

decision to include additional MIECHV-funded

moms in the project to ease the enrollment

process for NFP services and increase the scale

and precision of the SC NFP evaluation.

Rollover of Success Payments and Service

Delivery Costs

SCDHHS will make success payment of up to

$7.5 million depending on the extent to which

the project achieves its outcome metrics.

Philanthropic investors contributing the upfront

capital for project operations agreed to rollover

any success payments back into the operations

of NFP in South Carolina. As investors look for a

path to sustainably funding NFP services in the

long-run, the SC NFP pay for success contract

also stipulates that NFP will implement

strategies to reduce service delivery costs by 25

percent by the conclusion of the SC NFP project.

IX. Conclusion

The SC NFP project’s aim of connecting 4,000

low-income mothers and their children with

nurse home visiting services is no small task.

The effort requires careful planning and

continual monitoring by NFP, SCDHHS, J-PAL,

Social Finance, investors and HKS GPL. Because

of its scale and scope, the project also offers

many unique components for state and local

leaders looking for opportunities to scale the

delivery of preventive services and rigorously

evaluate their benefits to residents, whether

through pay for success or other avenues.

The Government Performance Lab is grateful

for support from Bloomberg Philanthropies, the

Corporation for National and Community

Service Social Innovation Fund, the Dunham

Fund, the Laura and John Arnold Foundation,

the Pritzker Children’s Initiative, and the

Harvard Kennedy School Government

Performance Lab.

Golden, Megan. 2013. “Using Pay for Success Financing to

Improve Outcomes for South Carolina’s Children: Results of

a Feasibility Study.” Institute for Child Success.

https://www.instituteforchildsuccess.org/publication/using

payforsuccessfinancingtoimproveoutcomes-south-carolinas-

children-results-feasibility-study/

https://www.scdhhs.gov/sites/default/files/Social_Impact

_Bond_RFI_%231.pdf

iii

A total of ~6,000 moms will be enrolled in the overall

project for evaluation purposes, and 4,000 of those will be

placed in the treatment group to receive NFP services. See

Section V, “Evaluating Pay for Success Outcomes”.

Home Visiting Evidence of Effectiveness. “Nurse Family

Partnership: Evidence of Program Model Effectiveness. ”U.S.

Department of Health and Human Services. May 2016.

http://homvee.acf.hhs.gov/Model/1/Nurse-Family-

Partnership--NFP--sup---sup-/14/1.

South Carolina Department of Health and Human Services.

2015. “Section 1915(b) Waiver Proposal For MCO, PIHP,

PAHP, PCCM Programs And FFS Selective Contracting

Programs.” December 2015.

https://www.medicaid.gov/Medicaid-CHIP-Program-

Information/By-Topics/Waivers/Downloads/SC_Enhanced-

Prenatal-Postpartum-Home-Visitation-Managed-Care.pdf.

“Gov. Nikki Haley Announces Landmark ‘Pay For Success’

Project To Improve Maternal And Child Health, Strengthen

State Government Accountability.” South Carolina

Department of Health and Human Services. 26 February

2016. https://www.scdhhs.gov/press-release/gov-nikki-

haley-announces-landmark-%E2%80%9Cpay-

success%E2%80%9D-project-improve-maternal-and-child.