Dusk falls over Miami’s Liberty City neighborhood as Chante Washington-Oates, B.S.N. ’07, a McKnight Doctoral fellow and Ph.D. in nursing candidate at the University of Miami School of Nursing and Health Studies (SOHNS), pulls her car up in front of a small, wood-frame house with a cheerful, diminutive garden. She’s here to visit “Beverly,” 1 a young mother who has been living with her parents and teenage sister since completing an inpatient rehabilitation program for addiction to opioid painkillers. In recovery for the past four months, Beverly is struggling to find a job, housing, childcare for her toddler and preschooler, and help for chronic back pain from a fall she suffered two years ago.
Five miles south in Little Havana, nurse Marlene Mora sits at a kitchen table in a modest apartment with 36-year-old “Violeta,” who has struggled with major depression for the past 12 years. After a recent job loss, Violeta sank into a deep depression, drinking heavily and unable to get out of bed or care for her children. Alarmed, her 12-year-old daughter, Jimena, confided in a teacher. Authorities placed the four children with relatives, and now, three months later, Violeta must clear a daunting set of hurdles before the family can be reunited.
Washington-Oates and Mora are nurse interventionists for the Healthy Home randomized research study, funded by the National Institutes of Health/ National Institute of Minority Health and Health Disparities.2 It is a partnership between the SONHS’ Center of Excellence for Health Disparities Research: El Centro and Banyan Health Systems, a community-based provider that offers integrated substance abuse, mental health, and primary health care.
It is the nurses’ job to help moms like Beverly and Violeta who are in recovery. The nurses support the mothers in navigating the complex landscape of family, social, financial, and health-related factors that place them at high risk for relapse, and link them to supportive community resources that can address their needs. “We’re navigators and connectors,” says Washington-Oates. “When I think of Healthy Home, I picture a bridge. We’re the bridge that helps connect family members to each other and to the resources they need.”
Healthy Home is an adaptation of Structural Ecosystems Therapy (SET), a family intervention for minority women that has been shown to reduce drug relapse and psychological symptoms in mothers and their children. SET identifies and builds on a woman’s strengths and helps improve the way she engages and interacts with her environment – from her children and other family members to the multiple health care, educational, employment, legal, and other settings and systems that are critical to her recovery and to her children’s well-being.
“Like SET, Healthy Home focuses on improving relationships within the family and between the family and care providers, but Healthy Home differs from SET because nurses, not family therapists, visit the homes,” says SONHS professor and associate dean for research Victoria Behar Mitrani, A.B. ’80, Ph.D. ’87, who serves as principal investigator of the Healthy Home research study. “It also adds a health assessment, education, and warm handoff referral component that can best be delivered by nurses.”
A unique role for nurses
Because nurses are holistic, family centered, and knowledgeable about home-based care, they’re uniquely prepared to implement the adapted SET model through Healthy Home. “Healthy Home builds onto nurses’ toolkits by teaching them how to intervene in the family to strengthen family support for the mother’s self-care and parenting so she can better care for herself and her children, as well as how to strengthen connections with health and recovery providers,” says Mitrani.
Nurses are a perfect match for Healthy Home because they’re a trusted, safe, and familiar presence in the lives of the families and communities they’re visiting. “Nurses are viewed as nonthreatening,” says Washington-Oates. “People see us as there to take care of them, not judge them.” “I always wear my uniform, and I’m regarded with respect when I have to enter an unsafe neighborhood, and when I arrive at the home,” adds Mora.
It may also be easier for nurses to overcome mistrust and the barriers the mothers have learned to erect to protect themselves than it is for interventionists from other disciplines. “These are moms who feel stigmatized and marginalized,” Mitrani explains. “Many are at risk of having their children removed from the home, and they’re living in a situation of constant stress. But we’re already finding that, compared to the SET studies where a family therapist was going to the home, the nurse-as-interventionist Healthy Home model is better accepted by the mother.”
Healthy Home supports and supplements the mothers’ existing substance abuse and mental health treatment. Most of the mothers are Banyan patients, and the Healthy Home nurses work closely with the mothers’ Banyan care providers to ensure they are keeping their appointments and maintaining their recovery. “A unique feature of Healthy Home is that we’re the eyes and ears for the therapists who can’t go to the home,” says Washington-Oates. “We can help the therapist understand the barriers the mother faces at home, such as transportation problems, which prevent her from keeping appointments or following through on her treatment plan.”
From Homestead to Hialeah, venturing into unsafe neighborhoods and taking South Florida’s weather, traffic, and distances in stride, the Healthy Home nurses visit the mothers every two weeks over a four-month period. In the living room at Beverly’s home, Washington-Oates takes her vital signs and goes over her medical history. Washington-Oates gains the family’s trust as she gently and respectfully guides a discussion of the family’s goals and needs with Beverly, her parents, Marla and Walter, and her sister, Lilian. By identifying and reinforcing existing strengths and enlisting the entire family as supports for Beverly, Washington-Oates hopes to reduce the tendency to blame Beverly for her addictive behaviors and the resistance to allowing her to care for the children.
By the end of the session, plans are in place for Beverly to improve her employment prospects by completing her GED. She’ll begin attending a pain management and support group at a local clinic. And Marla has been recruited to support her daughter Beverly’s efforts to be a better mom; this week, Beverly will take her children to a nearby playground, and she’ll take charge of their bedtime routine. “We come up with a customized plan to build on mom’s strengths, and to address family interactions that aren’t helping and that place her at higher risk for relapse,” explains Washington-Oates.
During her home intervention visit, Mora is struck by Violeta’s profound isolation from any supportive family or friends, and her chain smoking. Their intent is to have one of Violeta’s neighbors who’s been kind to her provide assistance, but, for now, Mora will serve as her primary support, checking in daily with a phone call. They develop an action plan for Violeta to meet the requirements to regain custody of her children: parenting classes, successful supervised visitation, and Alcoholics Anonymous meetings. They outline the steps Violeta can take to start seeking employment. Violeta commits to her own self-care and recovery by agreeing to begin a smoking cessation program, to take her medications every day, and to call Mora immediately if she feels herself becoming despondent.
“Most of the moms are taking care of their kids conscientiously and want to be better parents,” says Mitrani. “In fact, their children are their greatest motivation for staying in recovery. But we’re finding that the greater the responsibility for taking care of her children—especially if the children have health or behavioral issues—the less likely she is to take care of herself, placing her at greater risk for relapse or health problems.”
“We remind her that she has to take care of herself so she can be an effective parent,” adds Washington-Oates. “She may be feeling like she’s not capable or not worth it. She may have had family members and agencies give up on her. But we’re not giving up on her.”
A comprehensive approach
The nurses meet weekly as a team with Enrique Sanchez, a psychotherapist at Banyan who serves as mental health clinical supervisor, to discuss each case. Together, they develop a plan that is tailored to each family, and identify resources to meet their needs. Mitrani attends the clinical meetings as well, to help keep the nurses faithful to the Healthy Home research model.
“Dr. Mitrani is the heartbeat of Healthy Home,” says Washington-Oates. “She fosters a team that values everyone’s contributions and professional growth. She’s an extraordinary mentor who wants you to succeed.”
The nurses are equally enthusiastic about the role that Banyan plays in this community-academic partnership. “I always feel supported going out into the community, knowing I can call Enrique any time if I have any concerns,” adds Mora. “I know the team has my back.”
“Banyan sincerely wants to serve health disparity populations and to improve their quality of life,” says Washington-Oates. “They have a comprehensive approach that addresses social challenges, and their integrative services model allows mom to get substance abuse and mental health services, as well as primary care, for herself and her kids in one place.”
In the end, the nurses gain as much as they give, learning new skills and realizing new insights.
“The key to Healthy Home’s success is the trusting bond that’s forged between mom and nurse,” says Mora. “I learned that if they trust you, they’ll tell you the truth about their lives—and only then will you be able to help them.”
“Despite the overwhelming challenges these moms are confronting, I learned they’re capable of thriving,” adds Washington-Oates. “They’re embarking on difficult but wonderful journeys to improve their lives and the lives of their children.”
1The case studies and names used in this article are fictitious and based on composite cases, and do not describe any specific study participant.
2Funding for this program was made possible by NIH/NIMHD Grant No. P60MD002266. The views expressed in this article do not necessarily reflect the official policies of the Department of Health and Human Services or the U.S. Government.
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