National Performance Measure #7.2: Rate of hospitalization for non-fatal injury per 100,000 adolescents aged 10‑19

 

Evidence-Based or Informed Strategy Measure: Percent of high school students who wear seatbelts

 

Objectives:

 

• By June of 2022, increase seatbelt usage in the 15 high schools participating in the Teen Driving Project by 10 percentage points over the baseline of 70% to 80% on the observational study

• By June of 2022, schools in the state will have implemented the NH Concussion Law and/or will have written policies with at least 95% having a return to play policy and at least 70% having a “return to learn” policy

 

Strategies:

 

• Use of peer groups within schools to increase seatbelt usage and overall teen driving safety culture
• Increase parental participation and understanding of teen driving issues
• Analyze concussion policies within school systems and make recommendations for potential change

 

 

Non-fatal injuries present a significant burden to the health care system, particularly to urgent care facilities and emergency departments (ED). Unintentional injuries accounted for the majority of all injury-related visits, which are often seen among both children and young adults. One of the age groups with the highest hospitalization rate is the 10‑14 age group.

 

The rate of non-fatal injury inpatient (IP) hospital discharges in NH residents aged 10‑19 years has shown a decreasing trend. The data provided in the graph below is from an updated dataset for IP discharges between 2016 and 2018. The counts for these years in earlier charts may not match these numbers because of corrections and additions made to the dataset.

 

The year 2016 is the new baseline for inpatient and emergency department data because it uses only ICD 10 coding. If the current data trend continues, projections show a potential 88% decrease[1] in the rate of non-fatal injury in the 10‑19-year-old age group by 2026.

 

  Data Source: NH Hospital Discharge Data, NH DHHS

 

The focus areas selected to decrease hospitalizations for non-fatal injury in NH’s adolescent population (ages 10‑19) included motor vehicle safety, concussion prevention and response, and suicide prevention. The primary focus was adolescent driver safety, which intersected with the second focus area, concussion prevention and response. The third focus area is teen suicide prevention.

 

The following graphs and analysis address National Outcome Measures (NOM) #15, #16.1, #16.2, and #16.3 and how they intersect with National Performance Measure (NPM) #7.

 

NOM#15 Child Mortality

 

The child mortality rate for NH residents, 1‑9 years old, has not shown a statistically significant change between 2008 and 2020.  

 

  Data Source: NH Vital Records, Population Data Denominator from CDC WONDER

 

Calendar year 2020 in the death certificate data is provisional, as it may be incomplete for NH residents who died out-of-state. Denominator data for 2020 is not available on CDC WONDER, so the rate was calculated using a three-year population average over the past three years.

 

According to CDC WISQARS (Web-based Injury Statistics Query and Reporting System) data, unintentional injury is the leading cause of death in this age group. The main cause of unintentional injury was drowning. In previous years, the leading cause of death was motor vehicle crash (MV). MCH works closely with the Injury Prevention Center at Dartmouth (IPC) regarding child passenger safety. In 2014, RSA 265:107a was passed to strengthen child passenger safety by more clearly defining the age and size requirements for car seat use, booster seats and seatbelts for children age 18 years and younger.

 

 

Five Leading Causes of Death, NH Residents, Ages 1‑9 Years, 2010‑2019

Data Source: WISQARS, National Center for Health Statistics (NCHS), National Vital Statistics System,

accessed 5/16/2021.

Note: For leading cause categories in this State-level chart, counts of less than 10 deaths have been suppressed (---).

 

 

The second and third leading causes of death in children are cancer and congenital anomalies, followed by homicide at number four. Injury deaths to children are addressed in the Child Fatality Review Committee (CFRC). This committee meets every other month and develops recommendations for the prevention of such deaths through policy, program, systems and educational changes. These recommendations are published in the biennial Child Fatality Review Report.[2] In 2018, the CFRC stopped meeting pending review of the confidentiality rules and policies related to the non-public sessions where detailed information on cases is shared. New legislation (SB118) related to the CFRC passed into law in July 2019[3] and the CFRC meetings have resumed under the auspices of the DPHS, specifically MCH and not the Attorney General’s Office. In late 2019 and 2020, the CFRC received special permission to meet in a virtual format, rather than in-person, due to COVID‑19 restrictions.

 

NOM#16.1 Adolescent Mortality

 

Adolescent mortality has not shown a statistically significant change between 2008 and 2020. Annual counts of adolescent deaths range from 33 to 51 per year. According to the CDC WISQARS, the 10‑19-year-old age group's leading overall cause of death is unintentional injuries, with motor vehicle traffic being the number one injury-related cause. MCH selected adolescent driver safety as a primary focus area for programmatic activities. The second leading cause of adolescent death is suicide, so this issue was also addressed.

 

Data Source: NH Vital Records, Population Data Denominator from CDC WONDER

 

Data year 2020 in the death certificate data is provisional, as it may be incomplete for NH residents who died out-of-state. Denominator data for 2020 is not available on CDC WONDER, so the rate was calculated using a three-year population average over the past three years.

 

Five Leading Causes of Death, NH Residents, Ages 10‑19 Years, 2010‑2019

Data Source: WISQARS, National Center for Health Statistics (NCHS), National Vital Statistics System, accessed 5/16/2021.

Note: For leading cause categories in this State-level chart, counts of less than 10 deaths have been suppressed (--).

 

 

NOM#16.2 Adolescent motor vehicle death

 

Motor vehicle (MV) crashes continue to be the number one cause of death for adolescents and new drivers. According to New Hampshire Driving Towards Zero, speed and inexperience of novice drivers are the major causes of fatal crashes among teens as reported by the NH Division of Motor Vehicle’s Division of Motor Vehicle Fatal Accident Reporting System.[4] Adolescent motor vehicle death rates for NH residents 15‑19 years old have not changed significantly between 2008 and 2019. Counting the deaths from year to year shows very few events and will not generate stable or statistically significant rates. The graph below includes all motor vehicle crash deaths: occupants, including drivers and passengers, who were injured in MV crashes. These data exclude motorcyclists, pedestrians, pedal cyclists, and ATV crashes. This exclusion was made because NH’s prevention efforts focus on teen drivers and passengers. On average between 2008 and 2020, approximately three adolescents aged 15‑19 died per year in MV crashes who were occupants of a motor vehicle.

 

  Data Source: NH Vital Records, Population Data Denominator from CDC WONDER

 

 

ESM#7.2.1 Seatbelt Use: Percent of high school students who wear seatbelts (as a driver or passenger)

 

The 2019 NH Youth Risk Behavior Survey (YRBS) indicates that 94.4% of respondents “Sometimes, most of the time, or always wore a seat belt (when riding in a car driven by someone else).” This percent has increased from 72.4% when it was first assessed in 1993. The percentage of students who rarely or never wear a seat belt when driving (among students who drive a car) has decreased from 8.3% in 2013, to 7.7% in 2015, 6.3% in 2017, and down to 4.8% in 2019. The percent of students reporting that they are texting and driving has decreased from 48% when the question was first asked in 2013, to 42% in 2017, but increased to 44% in 2019. A "Hands-Free" law was passed in 2015 that forbids the use of hand-held devices by drivers except in the case of an emergency.

 

 

  Source: US and NH YRBS

 

 

 

Adolescent Driver Safety Programmatic Activities

 

Objective: 

• By June of 2022, increase drivers’ seatbelt usage in the 15 high schools participating in the Teen Driving Project from the baseline of 87.7% to 92.0% on the observational assessment of school parking lots.
• By June of 2022, increase passengers’ seatbelt usage in the 15 high schools participating in the Teen Driving Project from the baseline of 77.9% to 82.0% on the observational assessment of school parking lots.

 

The seatbelt observational study conducted in the spring of 2019 showed that 87.7% of teen drivers and 77.9% of teen passengers were wearing seatbelts. When driver and passenger calculations were averaged, this produced an overall 82.8% seatbelt usage. Unfortunately, observational assessments were not conducted Fall 2019 to Spring 2021 largely due to the COVID‑19 pandemic halting in-person activities. During the period directly prior to the pandemic, many schools were highly focused on completing mandates from the Department of Education related to suicide prevention, vaping prevention, and opioid use prevention. Additionally, many schools are reluctant to complete assessments. Concerns about school district data privacy and the non-academic survey mandate as well as logistics were all issues preventing data collection. Approval must be given by the administration for observations to be conducted and information regarding the date and time must be kept from students so the data is accurate for an average day.

 

Strategies:

 

• Use of peer groups within schools to increase seatbelt usage and overall teen driving safety culture
• Increase parental participation and understanding of teen driving issues

 

Systems Building

 

MCH staff continued to support efforts regarding novice adolescent driving safety. MCH contracts with the Injury Prevention Center (IPC) at Children’s Hospital at Dartmouth-Hitchcock to fund (through state and CDC Preventive Health and Health Services Block Grant funds) a one day per week Traffic Safety Coordinator; MCH and the Division of Highway Safety jointly fund this position. The Traffic Safety Coordinator facilitates the Buckle Up NH committee, which was combined with the Teen Driving Committee. Part of this work includes the NH Teen Driving Program (NHTDP).

 

The NHTDP’s primary goals include assisting adolescents in understanding the true risks associated with their driving experience and educating parents and participating community members in understanding these risks. The program also attempts to change the “driving culture” for NH’s adolescents by using a peer-to-peer evidence-based[5] strategy, which deems driving distracted, impaired driving, speeding and nonuse of seat belts socially unacceptable. During the 2020‑2021 academic year, the Teen Driver Program interacted with schools throughout the state to provide resources as needed.

 

Observational surveys of seat belt and electronic device use are collected at participating high schools at the start of the program implementation year and periodically as interventions (educational programs, school seat belt challenges, etc.) are facilitated. Statewide YRBS data is collected and reviewed every other year as a program outcome measure.

 

Of the 15 schools participating in the NHTDP peer-to-peer program, eight (8) provided observational studies starting in the fall of 2016, spring and fall of 2017, spring and fall of 2018, and Spring 2019. The results are as follows:

 

 

 

COVID‑19

 

Fall 2019: only one school reported data: No Device Use 0.0%, Driver Belt Usage 88.8%, Passenger Belt Usage 79.4%.

 

Spring 2020: No data collected due to schools practicing remote learning during the COVID‑19 pandemic.

 

Fall 2020: No data collected due to schools practicing remote learning during the COVID‑19 pandemic.

 

Spring 2021: No data collected due to schools practicing remote learning during the COVID‑19 pandemic.

 

Overall, seatbelt usage increased among drivers and passengers; hand-held device use remained relatively low. Even with only eight (8) or fewer of the 15 schools providing data collected from fall 2016 through spring 2019, there is enough data to show changes during the past two (2) schools years.

 

During the 2020‑2021 school year, there was a decrease of interest in schools and the safety program, due to a number of factors surrounding the COVID‑19 pandemic. After legislation was put into place disallowing nonacademic surveys in schools, the observations were changed to assessments to comply with the new law. The Teen Driver Program continues to put high value on Observational Assessments and strongly encourages all schools that are partnered with the program to conduct them. As a major part of assessing program effectiveness, consideration is being given to making Observational Assessments mandatory for participation with the Teen Driver Program while addressing school district concerns.

 

Due to COVID‑19, most NH schools were participating in some form of restricted learning with remote options throughout the school year. Frequently, schools and students were required to be remote due to potential COVID‑19 exposures. With schools facing continued uncertainty about in-person activities and restrictions on who was allowed into the buildings, focus was placed on social media outreach, the National Highway Traffic Safety Administration (NHTSA) calendar events, and providing electronic educational resources. Despite opportunities to reach teens in the State changing in format, the education remained the same, encouraging students to buckle up, to never drive distracted, and to always be a good passenger. In cooperation with the Buckle Up NH Coalition, the NH Teen Driver Safety Program is holding a social media contest for students to submit a 15‑second video commercial focused on distracted driving prevention, with prizes available for the winner. The winner will be selected in June 2021.

 

In 2020, the Traffic Safety Coordinator hosted and supported a virtual Traffic Safety webinar series in December with four sessions focusing on; Teen Driving, Speeding, Impairment, and Vehicle Technologies. It was planned in collaboration with AAA Northern New England and the NH Office of Highway Safety. The sessions were each attended by an average of over 100 traffic safety partners and law enforcement officers.

 

The series received an average of four out of five on the evaluation, which is positive feedback from attendees. In addition to the evaluation, many attendees provided feedback on sessions and what they are hoping to see as part of conferences in the future as well as what was successful/not on the virtual platform.

 

The MCH section and the IPC continue to look for ways to enhance parental awareness of highway safety issues as well as school staff who can foster the adoption of better habits behind the wheel. The online toolbox at the NH Teen Driver Program website was developed to provide resources to schools and parents. Any parent or school leader looking for resources to guide their teens to make good choices behind the wheel can find information that will be updated throughout the year.

 

The teen driver program collaborated in a newly created group called the Distracted Driving Task force. The program’s participation in the group allowed for the collaborative development of resources with the intention to disseminate to the 15 high schools working with the program. Due to COVID‑19, the information was moved to a digital format and sent out to 20 high schools across the State as a pilot to test the on-line program. In addition to the Teen Driver and Buckle Up NH programs, the NH Insurance Department, NH Office of Highway Safety, AAA Northern New England, AT&T, UNH, and the Community Alliance for Teen Safety were a part of the group. Metrics from the digital format could not be retrieved based on the type of hosting platform, so its value is based on its ease of dissemination. Many of the schools that received the information were excited about the opportunities it provided. Because of the pandemic, the in-person activities involved were not an option at that time. As many in-person events begin to occur again, the Distracted Driving Task Force is continuing to evaluate how to best utilize this resource.

 

The MCH section and the IPC staff continue to look for ways to provide more and better educational experiences for teen drivers and members of the community. To assist with this, the staff participated in various community-related activities, as well as promoted messaging through social media platforms and program websites when events were canceled due to COVID‑19.

 

During April 2019, the National Highway Traffic Safety Administration conducted an occupant protection assessment for NH, which resulted in a strong recommendation to enhance the current seat belt law to include all ages—the current law only requires seatbelts for children up to age 18. The recommendations cited a need to convene the Seat Belts For All group to discuss future legislative efforts for an adult seat belt law. The group included members from each State agency, community groups, IPC Staff, State Police, EMT’s, nurses, physicians, and AAA of Northern New England. Previously there have only been bills to introduce an entirely new seat belt law related to adult use. It was critical for the Teen Driver program to be a part of this group because many high school teens turning 18 during their senior year are being affected. During the legislative session 2019‑2020, there were two bills to enhance the law, one in the Senate and one in the house. Due to the COVID‑19 pandemic, the NH Legislature shut down, and then returned to only review essential bills. Both bills were tabled. In next year’s legislative session, these bills will be reintroduced with the same sponsors and supporters.

 

MCH Specific Activities

 

The MCH’s Injury Prevention Program (IPP) continues working with the Buckle Up / NH Teen Driver Committee, comprised of multiple state agencies and organizations; these are now working towards the implementation of the New Hampshire Violence and Injury Prevention Plan 2020‑2025, which has a component on traffic safety and adolescent drivers. The Committee is working towards educating more adolescent drivers across the state through collaboration and prevention efforts. In addition, the MCH IPP Manager and the IPC Traffic Safety Coordinator both sit on the Governor’s Traffic Safety Commission, which meets to address traffic safety concerns in NH. The Injury Prevention Program Manager sits on this commission as the DHHS Commissioner’s designee. The Traffic Safety Coordinator is currently vacant. The name of this position will be changed to Transportation Safety Coordinator.

 

Concussion

 

Concussion in adolescents can be a result of a non-fatal motor vehicle crash, a sports injury, or a fall. The effects of a concussion can be long-lasting and vary in severity. Cognitive abilities are affected after a concussion, and the brain needs time to rest and heal. NH has a law regarding return to playing sports after a concussion. MCH is working with the Brain Injury Association of NH (BIANH) to amend this law (SB584) to include “return to learn.”[6] This bill was passed the Senate and House and was signed into law by the Governor in June 2020.

 

Objective: By June of 2019, 85% of schools in the state will have implemented the NH Concussion Law and/or will have written policies with at least 95% having a return to play policy and at least 50% having a “return to learn” policy.

 

Strategy: Analyze concussion policies within school systems and make recommendations for potential change.

 

Data Analysis

In NH, the annual death count for traumatic brain injury (TBI) in ages 10‑19 is low. Years 2016 to 2019 were aggregated in the table below. Suicide by firearm was the top cause of TBI deaths and motor vehicle crash was the third. Over the last 10 years, there have been no deaths due to concussion in this age group.

 

 

NH TBI Death Counts, Age 10-19 years, 2016-2020

Data Source: NH Vital Records

Cause Description	Total	Percent
Suicide-Firearm	17	45%
Other Land Transport Crash	11	29%
MV Crash	5	13%
Fall	2	5%
Homicide-Firearm	1	3%
Pedestrian vs MV	1	3%
Blunt Force Trauma	1	3%
Grand Total	38	100%

 

 

 

Inpatient (IP) discharge rates for TBI for ages 10‑19 showed no statistically significant changes between 2016 and 2018. There were 112 IP discharges between 2016 and 2018.

 

 

Emergency Department (ED) discharge rates for this age group significantly decreased between 2016 and 2018.

 

The number of cases seen in the hospital as inpatients (IP) or in the Emergency Department (ED) are not a complete count; some children are seen in urgent care facilities or a doctor’s office, and some do not receive medical attention at all.

 

Percentage of concussions showed a similar pattern. Concussion cases comprised 42% to 44% of the TBI cases seen in the ED, and 67% to 79% of the TBI cases seen in the IP between 2016 and 2018. (See tables below.)

 

The most common causes of non-fatal TBI in children ages 10‑19 years in NH are: 1) Struck by or Against, 2) Falls, and 3) MV Crashes. Combining the non-fatal cases of TBI due to MV crash with the number of deaths due to MV crash shows the importance of adolescent driver safety programming.

 

In 2018, there were 898 ED discharges for NH residents age 10‑19 with a concussion, with an average cost per patient of $3,170. These numbers do not include students who may have had a concussion and sought care in a doctor’s office without going to the hospital. IP care for more serious cases of concussion, often including additional injuries or complications, numbered 18 in 2016 at an average cost per patient of $81,571. In 2018, among ages 10‑19, there were 2,020 children discharged from the emergency department with TBI (including concussion and other head injuries) at an average cost per patient of $2,988. TBI IP care in 2018 for this age group had 27 discharges at an average cost per patient of $73,156.

 

Data Source: NH Hospital Discharge Data, NH DHHS

Note:  these figures may differ from previous reports due to improvements in the data set in recent years.

 

There has been increased education regarding the seriousness of concussion in response to the “Return to Play” law (RSA 200:49-52). This law, enacted in 2012 and revised in 2014, calls for the immediate removal of any student-athlete from play if a concussion is suspected. The law requires medical clearance and written authorization from a health care provider trained in the evaluation and management of concussions as well as parental written permission for return to play.[7] The MCH’s IPP has been working with the Brain Injury Association of NH (BIANH) to assess the implementation and effectiveness of NH’s school return to play concussion law.

 

A recent article featured in the Morbidity and Mortality Weekly Report (MMWR)Weekly[8] reported a decline of children ages 17 years and under seen in the emergency department (ED) for contact sports-related traumatic brain injuries, including concussions. Between 2010 and 2016, about 45% of the 283,000 childhood traumatic TBI in the US were sports and recreation related (SRR). When reviewing data from 2012-2018, researchers found that ED visits for sport-related TBI declined 32% during this period, and “the reduction in the latter part of the study period was predominantly the result of a decline in ED visits related to football SRR-TBIs.”

 

“The rate of football-related TBI ED visits in children aged 5‑17 years declined 39% from 118.8 in 2013 to 72.4 in 2018, after increasing approximately 200% from 2001 (38.7) to 2013 (118.8).”[9] Evidence shows that restrictions in tackling techniques (shoulder-style tackling) and “the amount and frequency of full-contact drills during practice” might reduce the risk of concussion by 33% and TBI by 42%. Increasing public health efforts to reduce contact sports injuries could continue to lower the rate TBI ED visits.

 

Trends in rates per 100,000 of ED visits for nonfatal sports and recreation–related TBIs among persons aged ≤17 years, by type of activity and contact level in the United States, 2001–2018

Data Source:  National Electronic Injury Surveillance System–All Injury Program

 

Trends in rates of ED visits for the three most common contact sports associated with nonfatal sports and recreation–related TBI among persons aged 5–17 years, 2001-2018, United States

Data Source: National Electronic Injury Surveillance System–All Injury Program

 

Systems Building/MCH Specific Activities

 

Many of the causes of TBI are predictable and preventable. Prevention includes:

 

• Wearing a seat belt whenever driving or riding in a motor vehicle.
• Never driving while under the influence of alcohol or drugs.
• Wearing a helmet while riding a bicycle, skateboard, motorcycle, snowmobile, or all-terrain vehicle; also wearing head protection when batting or running bases, skiing, and skating, riding a horse, or playing a contact sport.
• Installing safety features in the home, such as handrails on stairways, non-slip mats in the bathtub, grab bars in the bathroom, window guards, and safety gates on the top and bottom of stairs (especially when young children are around) to limit falls.

 

Between July 2020 and March 2021, the BIANH made progress in amending and strengthening the NH school concussion law to include a new focus on the impact of concussion on learning and recommendations that schools have a return-to-learn plan. BIANH secured bi-partisan legislative sponsors for SB584. As the House reopened in late May 2020, the chair of the House Education Committee indicated that the concussion bill was a priority for the Committee. SB584 is different from all other states in that it provides for BIANH and the NH Department of Education to draft model return to lean policies and implementation protocols for NH schools. Concussion stakeholders statewide will thus have a leading role in this process. A team of stakeholder has been meeting regularly for the past six months. The team members include leadership from the NH Department of Education (DOE), School Nurses Association, classroom teachers and special education staff. This team has been reviewing other state models of best practices that can be adapted for use in NH. Most recently, the team reviewed information provided by the stakeholder team in Maine on the Maine DOE website, after which NH would like to model NH’s program.

 

The high school staff survey was not completed during the 2019‑2020 school year, and may not be done in 2020-2021 due to the COVID‑19 restrictions placing NH schools being in remote learning, and sporting activities being curtailed. NH high school staff including coaches, school nurses, and administrators were surveyed about return to play and learn policies in 2016 and 2018. The surveys were conducted by both online survey and phone call follow-up. In comparison to 2016, the 2018 results showed the following:

 

• High schools with a concussion policy on return-to-play: increased from 73% to 86%.
• High schools with return-to-learn policies: increased from 59% to 86%.
• High schools indicating there are no exceptions to their policy: increased from 33% to 47%.

 

In the 2018 survey, reasons given as to why schools do not have a return-to-learn policy included:

 

• They have protocols and not formal policies.
• Doctors’ orders are an important component of the decision-making process and can carry more weight than policy. (This is a very important issue for future consideration in making sure policies are implemented consistently.)

 

Concussion Chalk Talk is a program that assists schools with their concussion management policies and procedures. As with return to play, a concussed student needs a stepwise progression of healing to go back to the classroom. Concussion Chalk Talk assists participating schools with understanding the academic accommodations necessary for a concussed student. In the 2018/19 school year, 16 schools participated. Many of the schools are now including funds from their budget to help support this initiative, but not at the level needed to sustain the program. The program includes the formation of a Concussion Management Team (CMT), consisting of key personnel both inside and outside the school. A highlight of the program is the presence of a neuropsychologist on the CMT, who visits the school to consult on challenging cases and to answer questions.

 

Due to the COVID‑19 causing school closures, there is no update for Chalk Talk for the 2019‑2020 school year. The grant that was funding this is done, but the program has continued to be sustained after the grant period with funding from several school districts’ budgets. These schools found the support and resources from Chalk Talk to be outstanding. BIANH has also continued with the annual school surveys about what each school is doing in this area, but because of COVID last year, this was on hold. Implementation of Chalk Talk, and the school surveys should resume at the beginning of the next school year in Fall 2021.

 

The NH “return to learn” methodology is comprised of:

 

• Enhanced behavioral management in the acute phase of concussion
• Enhanced communication between all parties, both inside and outside the school
• Ongoing consultation with sports neuropsychology team at Geisel School of Medicine/Dartmouth Hitchcock Medical Center
• Daily education and monitoring of concussed students regarding behaviors and symptoms
• Feedback from teachers and parents daily to understand the level of recovery
• Assurance of a graduated return to academics and classroom functioning
• Provision of a supervised space within the school for symptomatic students

 

When students become concussed, parents contact school personnel (nursing staff, attendance office, school counselor, etc.). The initial contact person will inform the CMT Leader, who will in turn make contact with parents to provide an overview of the program. The “return to learn” schedule is as follows:

 

1. Student rests at home for approximately the first 48 hours post-injury.
2. Student returns to school as soon as they meet attendance criteria.
3. Student checks in with Assistant CMT Leader to perform a symptom checklist and optimally a Behavioral Assessment (BA).
4. Results of the BA and symptoms determine next steps and the day's schedule.
5. Student attends class if able to do so; if symptoms arise, they return to the Chalk Talk Room where they can first rest and then engage in activities that are less cognitively taxing.
6. Periodic check-ins throughout the day with the CMT Assistant if symptoms arise.
7. Plan for the evening.
8. If the student has not met expected progress in terms of symptom reduction, neuropsychologist advises CMT regarding referrals to specialists.

 

An electronic survey followed up by phone interviews on Chalk-Talk was facilitated in 2018; 27 high schools were sampled for telephone interviews. Respondents reported that are still some barriers to overcome, including:

 

• Staff concern about being responsible for the “diagnosis” of the student (in fact, they only report observations of Better or Worse)
• Handling the non-compliant student/family
• Handling “abusers of the system”
• Communicating with parents who don’t have email/computer access
• Parents who "opt-out" of Chalk Talk because they and their athletes want the athletes to return to the playing field sooner

 

In early 2019, key stakeholders met with the Commissioner of the Department of Education (DOE) about strengthening supports for schools, especially training teachers regarding academic accommodations for students with a concussion as well as for students with more severe TBI. The BIANH suggested that NH take an in-depth look at the BrainSTEPS program used by Pennsylvania and Colorado, which is now viewed nationally as a model program. A stakeholder retreat meeting was held in June 2019, to collect input on goals, strategies, target audiences, barriers and challenges, opportunities and triggering events, next steps, and evaluation. Upon compilation of these, recommendations will be drafted and shared with the Commissioner. The key recommendation was to pursue passage of legislation SB584, which has passed and signed by the Governor in 2020. With the passage of SB584, the stakeholder team continues to meet with the goal is to develop specific recommendations for the DOE Commissioner to recommend to local school districts. No deadline has been established for completing this work at this time.

 

NOM#16.3 Adolescent suicide

 

Adolescent suicide death rates for NH residents 15‑19 years old have not changed significantly between 2016 and 2020, even with the steep decline between 2018 and 2019. The suicide death rate for 2020 was 12.3, which is more in line with the trend in previous years. While annual counts are low and may not be statistically significant, the death of any child is significant and the underlying causes need to be addressed. According to the CDC WISQARS, suicide is the second leading cause of death in the 10‑19 year-old age group. The most common lethal means of suicide are suffocation, firearms, and poisoning.

 

  Data Source: NH Vital Records, Population Data Denominator from CDC WONDER

 

 

Leading Causes of Death and Violent Death, NH Residents, Ages 15‑19 Years, 2010‑2019

Rank	All Causes of Death	All Injury Deaths	All Unintentional Injury Deaths	All Violent Injury Deaths
1	Unintentional injury 127	Unintentional MV Traffic 82	Unintentional MV Traffic 82	Suicide, Suffocation 38
2	Suicide 85	Suicide, Suffocation 38	Unintentional Poisoning 28	Suicide, Firearm 37
3	Malignant Neoplasms 21	Suicide, Firearm 37	Unintentional Fall --	Suicide, Poisoning --
4	Heart Disease 11	Unintentional Poisoning 28	Unintentional Stuck by or Against --	Homicide, Firearm --
5	Two Tied --	Suicide, Poisoning --	Unintentional Suffocation --	Two Tied --

Data Source: WISQARS, National Center for Health Statistics (NCHS), National Vital Statistics System, accessed 5/16/2021. 

Note: counts of less than 10 deaths have been suppressed (--).

 

 

Systems Building

 

MCH has a representative on the Suicide Prevention Council (SPC). The mission of the State SPC is to reduce the incidence of suicide in NH by accomplishing the goals of the NH Suicide Prevention Plan, which are to:

 

• Raise public and professional awareness of suicide prevention;
• Address the mental health and substance abuse needs of all residents;
• Address the needs of those affected by suicide; and
• Promote policy change.[10]

 

The MCH section IPP, in cooperation with the IPC, hosted a two day virtual Suicide Prevention Conference on November 12 and 13, 2020. The first ever virtual conference had 180 attendees on Day 1 and 300 attendees on Day 2. Sponsorships of the conference helped offset costs. In the coming year, the conference is continuing with two days in early November both to be held virtually.

 

The SPC Communications Subcommittee guided the writing of five articles in the NH news media related to suicide. The topics were all stories with a positive twist: peer counseling; funding for suicide prevention in the biennium budget; attempt survivor stories; best practice interventions that are working; and the State of Mental Health in America report highlighting NH’s access to care.

 

The MCH IPP has been awarded the National Violent Death Reporting System (NVDRS) grant from CDC since 2014. In addition to collecting demographic data on homicides, suicides, and firearm deaths, the data abstractor also reviews police reports, medical examiner records, and toxicology reports to develop a narrative on the circumstances that lead to violent deaths. The MCH IPP collaborates with the Department of Justice, Office of Chief Medical Examiner on the grant. The first full year data set is for 2015. This data set was released by CDC in the summer of 2018. NH-NVDRS data was included in the 2017, 2018, and 2019 Annual Suicide Reports. In the 2019 report, the NH NVDRS data was integrated throughout the report rather than placed in a separate section.  This reduced duplication of information and improved readability.

 

 

 

Work Plan Accomplishments in 2019 (2019-2020 school year)

 

 

 

 

 

*   *   *   *   *   *   *

 

 

 

National Performance Measure #10: Percent of adolescents, aged 12‑17, with a preventive medical visit in the past year.

 

Evidence Based or Informed Strategy Measure: Percentage of adolescents aged 12‑21 at NH Maternal and Child Health (MCH) contracted health centers who have at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.

 

Objectives: Increase the percentage of adolescents aged 12‑21 who have had a preventive medical visit at the MCH funded Community Health Centers (CHCs) from a baseline of 53% in SFY19 to 64% by 2025.

 

Strategies:

 

1.               Build partnerships by:

• networking with other State Adolescent Health Coordinators
• collaborating with public and private partners through the NH Pediatric Improvement Partnership
• statewide contracting with CHCs and provision of oversight on Primary Care Services
• establishing mechanisms to inform the public about adolescent preventive services via social media

 

2. Enhance capacity of CHCs to improve access and quality of adolescent services by:

• establishing performance measures that align with national guidelines and promote Bright Futures recommendations
• ensuring contracted CHCs utilize Quality Improvement (QI) processess to increase the percentage of adolescents who have a preventive medical visit
• collecting and analyzing Performance Measure outcome data from CHCs
• providing data results and feedback to CHCs for comparison
• providing education, resources, QI support and technical assistance

 

3. Increase MCH section staff who include adolescent health in their job responsibilities:

• In 2020, the MCH section sought to establish a new position (Child/Adolescent Health Coordinator) to support programmatic initiatives to improve child and adolescent well-being.  This position was not able to be posted in 2020 due to state hiring freeze related to COVID‑19.  This position is anticipated to be posted in 2021 and will be 100% funded by Title V.

Although adolescence is in general a healthy period of life, this time is marked by major physical, psychological and social development. As adolescents transition toward adulthood, they frequently initiate risky behaviors that may negatively impact their health including unsafe sexual activity, unsafe driving, and the use of substances (tobacco, alcohol, and illegal drugs). The NH MCH section strives to improve the health, safety and well-being of NH’s adolescents and young adults by administering targeted programs including the Injury Prevention Program, Family Planning Program, Home Visiting Program, Comprehensive Family Support Program and Pediatric Mental Health Care Access Program.

 

The MCH section understands the issues affecting adolescent health and is well positioned to utilize staff expertise to maintain collaborations with state and local partners for the purposes of promoting adolescent health. MCH remains committed to ensure adolescent access to health care and preventive services, which support adolescents’ ability to adopt or maintain healthy habits and behaviors and avoid health‐damaging behaviors by implementing following:

 

• Engaging stakeholders and building partnerships to leverage collaborative efforts to support adolescent health;
• Promoting Title V priorities and adolescent well-visits via contracted mechanisms for services for health care and family support services;
• Enhancing the capacity of MCH-funded Community Health Centers (CHCs) to improve access and quality of adolescent/young adult services;
• Providing positive adolescent health messages to the public.

 

NH Adolescent Health

 

According to the 2018-2019 National Survey of Children’s Health (NSCH), 92% of NH’s children, ages 0‑17, are in excellent or very good health.[11] The health of NH’s adolescents and young adults has been positively influenced by a high immunization rate and low teen birth rate and negatively influenced by tobacco, alcohol, drug use and unsafe behaviors.

 

 

 

Vaccination Coverage

 

For years, NH has ensured universal immunization coverage of all children 18 years of age and younger regardless of insurance status. As a result, NH demonstrates high vaccination rates among children and adolescents. These rates will be monitored closely to identify and address gaps in routine vaccination resulting from the COVID‑19 pandemic. 

 

 

Teen Birth

 

NH continues to maintain one of the lowest teen birth rates in the nation. According, to the most recent data available from the CDC, NH’s teen birth rate is less than seven (7) per 1000 females 15‑19 years old.[12]

 

 

NH MCH contributes to this success by overseeing two adolescent pregnancy prevention projects (funded by the Administration of Children & Families) which operate in areas of the State that have the highest teen birth rate, ensuring access to primary care and family planning services. In addition, Title V staff work alongside Title X staff to ensure that health care agencies funded by either or both programs are providing the highest level of comprehensive care for adolescents. Program staff also promote public awareness of adolescent sexual health by contributing to social media posts.

 

 

 

NH Adolescent Health Risk

 

NH adolescent health continues to be at risk due to the use of tobacco, alcohol and drugs as well as unsafe driving and sexual behaviors. The graphic below illustrates a snapshot of tobacco/alcohol/drug and sexual behaviors among NH high school students from the 2019 NH Youth Risk Behavior Survey (YRBS).[13] MCH along with DPHS colleagues strategically align program initiatives and messaging to address adolescent risks. (Please refer to the NPM7 narrative for more discussion of adolescent safety risks and injury prevention).

 

 

 

 

 

 

 

 

 

 

 

Tobacco Use

 

According to the NH YRBS 2019, 35% of high school youth report having used tobacco products in the 30 days prior to taking the survey. The survey also shows electronic vapor product (e.g. e-cigarettes) use among youth increasing since the 2017 NH YRBS, with 50% reporting ever used and 34% reporting current use. Electronic vaping (ever use) was highest among Hispanic students (58%).[14]

 

In 2020, the State of NH raised the legal age required to purchase cigarettes and other tobacco products to age 21.

 

 

Alcohol Consumption

 

Alcohol use is prevalent across NH. Currently, NH’s total alcohol consumption is estimated at 4.76 gallons per person. This volume is significantly higher than the less than 2.1 gallons per person per year goal established by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which puts NH as the highest ranking state for highest level of alcohol consumption.[15]

 

The 2019 NH YRBS indicates that 27% of high school students currently drink alcohol (29% of females and 25% of males). Eleven percent (11%) of students reported having had their first drink of alcohol before the age of 13. Alcohol consumption by Hispanic students is higher than the overall percentage at 31%, while Black students reported less than the overall percentage, at 16%.

 

 

 

Sexual Risk

 

NH YRBS 2019 data indicate that 39% of NH high school students have ever had sexual intercourse. Although the majority (87%) of NH high school students receive some basic sexual health education, some students were at risk for STI and/or pregnancy, as 19.6% reported using alcohol and/or drugs before the last sexual intercourse, 45% did not use a condom, and 7% did not use contraception at last intercourse.[16]

 

 

Drug Use

 

Drug use, especially the use of opioids, has become a serious national crisis affecting the social and economic welfare of NH. According to the National Survey on Drug Use and Health (NSDUH), NH ranks among the highest in the country for illicit drug use among 18 to 25 year olds.[17] According to the CDC, NH was among the top six states with the highest rate of opioid-involved deaths in 2018 (35.8 per 100,000 total population).[18] In 2019 NH improved this state ranking to ninth place, with 32 deaths per 100,000 total population).[19]

 

Although ranked poorly for drug use, NH has seen some indication of decreased prescription drug use and overdose deaths. Per the 2019 NH YRBS, the percentage of NH high school students who have ever taken prescription drugs without a doctor’s prescription has decreased from 20.4% in 2009 to 10% in 2019.[20] 

 

 

According to the NH Medical Examiner’s office, NH drug overdose deaths decreased from 415 to 402 from 2019‑2020. In 2020, the age group with the largest number of opioid related ED visits was 20‑29 which represented 24% of all opioid related ED visits, followed by 30‑39 with 22%.[21] These rates will be monitored closely to identify and address unfavorable trends in drug use associated with the COVID‑19 pandemic. 

 

 

NH is addressing the drug crisis by implementing a comprehensive response that includes prevention, treatment, and recovery services in every region of the State. The strategies to combat this epidemic start with expanding resources for treatment and recovery, support for law enforcement, and enhancing prevention efforts. NH has implemented provider trainings and updated rules for prescribers, which include assessing the need for opioids, the risk for abuse, and providing education to patients. Due to the drug epidemic, all MCH-contracted CHCs are expected to screen for drug and alcohol abuse as part of primary care services. Although mechanisms are in place for CHCs to refer individuals with substance use disorder (SUD) for treatment, outpatient and residential substance abuse treatment for adolescents remains limited.

 

The State of NH continues to increase infrastructure to support Children’s Behavioral Health. In 2016, the Bureau of Children’s Behavioral Health was established within the DHHS Division of Behavioral Health. This Bureau works alongside the Bureau of Mental Health Services, the Bureau of Drug and Alcohol Services, and the State’s behavioral health facilities to unify the delivery of mental health and substance use disorder services. In 2019, the MCH section established a new Pediatric Mental Health Care Access Program (PMHCAP), to increase NH pediatricians’ and primary care providers’ capacity to address behavioral health needs of children 0‑21 years of age (refer to Cross Cutting Domain for more information on PMHCAP). The NH PMHCAP Program Coordinator has strengthened the MCH connection to the Bureau of Children’s Behavioral health to expand pediatric behavioral health services and resources for NH’s children, families, and health care providers.

 

Adolescent Well-Visits

 

The adolescent preventive medical visit is an ideal opportunity to improve adolescent biopsychosocial health by screening for adolescent health risks, addressing health concerns and providing referral and counseling to influence behaviors. According to the 2019 National Survey of Children's Health (NSCH) survey, the State of NH has a higher percentage of adolescents ages 12‑17 who have had a preventive medical visit than the national average, at 91.0% vs 79.6%.[22]

 

 

These figures from the NSCH are slightly higher than figures obtained through the YRBS measure, where 80% of NH high school students saw a doctor or nurse for a check-up or physical exam when they were not sick or injured during the 12 months before the survey.[23] 

 

However, when reviewing data that includes older individuals to age 21, the percentage of preventive visits decreases significantly to 62.4% according to NH Medicaid.[24] This along with anecdotal information from NH health care providers suggests that younger children/adolescents are more likely to complete annual preventive visits in comparison to young adults. Keeping this in mind, NH MCH encourages efforts to improve health literacy among young adults.

 

 

 

 

 

 

 

 

 

 

National Outcome Measures (NOMS) influenced by the Adolescent well visit

 

• NOM16.1 adolescent mortality: During well-care visits, health care providers deliver preventive services, assess health and safety behaviors, and provide age-appropriate anticipatory guidance (such as helmet use, protection against violence, firearm safety, and use of protective gear during sports) to encourage safe and healthy lifestyles. These activities seek to reduce adolescent mortality by supporting the adolescent to adopt healthy habits, prevent disease, manage chronic conditions and reduce unsafe behaviors.

 

• NOM16.2 adolescent motor vehicle mortality: During well-care visits, health care providers screen for alcohol and drug use (using validated tools such as Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) and provide age appropriate anticipatory guidance to encourage safe driving habits (following speed limits, seat belt use, no texting). These activities seek to reduce adolescent motor vehicle mortality by supporting the adolescent to reduce unsafe driving behaviors.

 

• NOM16.3 adolescent suicide: During well-care visits, health providers screen for depression and suicide risk using validated tools such as the Patient Health Questionnaire (PHQ) 2 and PHQ‑9. If adolescents screen positive, clinicians then provide treatment of depression and referral to mental health providers. These activities seek to reduce suicide by identifying at risk adolescents and establishing protective interventions as needed.

 

• NOM18 mental health treatment: During well-care visits, health providers screen for mental health conditions such as depression, anxiety and if positive, provide appropriate treatment/follow up/referral for mental health services. These activities ensure that adolescents with mental health conditions receive appropriate treatment or counseling.

 

• NOM19 health status: During well-care visits, health care providers identify/address social determinants of health, deliver preventive services, assess health and safety, and provide age appropriate anticipatory guidance. These activities seek to improve the overall health status of adolescents by connecting adolescents with tangible resources (transportation, health insurance, WIC, food pantry, fuel assistance, etc.) to address social determinants of health and support adolescent well-being.

 

• NOM20 obesity: During well-care visits, health care providers assess BMI, nutrition/ physical activity and provide anticipatory guidance to promote healthy eating and active living. For obese adolescents, providers ensure follow-up or referral for further counseling of nutrition/physical activity. These activities seek to reduce obesity among adolescents.

 

• NOM22.2 Influenza vaccination, NOM22.3 HPV vaccination, NOM22.4 Tdap vaccination, NOM22.5 Meningococcal vaccination: During well-care visits, health care providers provide preventive services, which include immunization and education about vaccine preventable diseases. These activities seek to improve rates of all CDC recommended vaccinations including, those for influenza, HPV, Tdap and meningitis.

 

• NOM23 teen birth: During well-care visits, health care providers assess sexual health and behaviors, provide anticipatory guidance and discuss family planning methods. Contraceptive services are made available confidentially and at no cost through NH Title X family planning clinics. These activities seek to prevent teen pregnancy.

 

 

MCH Section Current Activities

 

In SFY20, NH MCH and NH Medicaid were contacted for interview by the National Alliance (NA) to Advance Adolescent Health as NH Medicaid was among the top six highest performing states for adolescent well-care performance. Input from this interview was incorporated in the NA publication “Summary of Factors Influencing Adolescent Well-Care Performance Top-Performing State Medicaid Programs”.[25]

 

Collaborative projects with key stakeholders:

 

MCH staff promote Title V and adolescent health activities by engaging stakeholders, and participating in committees and task force work groups. One such stakeholder participation is the NH Pediatric Improvement Partnership (NH PIP). For example, the MCH QI/QA nurse consultant, epidemiologist and program administrator are members of the NH PIP steering committee. NH PIP is a state-level multi-disciplinary collaborative of private and public partners dedicated to improving child health care quality through the use of systems and measurement-based quality improvement processes. In 2017, NH MCH collaborated with NH PIP to participate in the second cohort of the Adolescent and Young Adult Health, Collaborative Improvement and Innovation Network (AYAH CoIIN), sponsored by the Adolescent and Young Adult Health National Resource Center (AYA-NRC). The objective of MCH participation in this 18-month CoIIN, which concluded in September 2018, was to leverage existing relationships with the NH PIP to further advance evidence-informed strategies for improving access to preventive care services for both adolescents and young adults and the quality of visits for preventive health services statewide. Overall, this project was successful and strengthened the MCH and NH PIP collaboration. 

 

As a result of NH’s participation in the AYAH CoIIN, the publication “Adolescent & Young Adult Health Care in New Hampshire: A Guide to Understanding Consent & Confidentiality Law” was developed by the Center for Adolescent Health & the Law and published in March 2019.[26] Following publication MHC and NH PIP broadly disseminated this document to NH stakeholders through emails and meetings. In addition, the NH PIP in collaboration with the New Hampshire Pediatric Society and the NH Academy for Family Physicians is obtaining a final legal review by the Center for Adolescent Health & the Law on consent reporting for children under 18 years of age. Once this document is obtained a NH‑specific toolkit will be created to include this document along with other AYAH CoIIN publications (NH School Board recommended policy for adolescent well care visits, LGTBQ Resource pamphlet and Guide to Understanding Consent & Confidentiality Law”).

 

Currently, NH MCH contracts with family planning and primary care health centers to increase statewide access to well-care visits as these provide an opportunity for youth to receive recommended preventive services. MCH staff provides contract monitoring and oversight of all contracted vendors.

 

MCH section staff ensure primary care agencies follow National Standards of Care, such as Bright Futures/American Academy of Pediatrics; accordingly, adolescents receive age-appropriate anticipatory guidance and are routinely screened for nutrition, physical activity, depression, substance use (tobacco, alcohol and drug), sexual behavior, violence, and safety. For family planning services, MCH staff ensure that contracted agencies obtain a health history and screen for substance use (tobacco, alcohol and drug), sexual behavior, violence, and safety (coercion, intimate partner violence). As family-planning (FP) is sometimes the only source of care, FP providers are also expected to promote overall health by providing preconception counseling (regardless of pregnancy intention) for the following:

 

• medical history that influences reproductive outcome
• intimate partner violence
• alcohol, tobacco and other drug use
• immunizations
• depression
• high/low Body Mass Index (BMI)
• blood pressure control
• diabetes
• referral to services such as primary care, SUD treatment and behavioral health services as indicated.

 

Maternal & Child Health (MCH) Contracted Community Health Centers (CHCs)

 

For over 25 years, MCH has utilized Title V funding to contract agencies to support primary care and primary care for the homeless services. Through this contracting, MCH has successfully engaged with CHCs across the state to ensure access and quality of primary care, including integration of behavioral health services. MCH provides agency oversight and ensures accountability by specifying reporting requirements and conducting site visits. Primary care contracted agencies are expected to provide services consistent with Bright Futures/National Guidelines and are required to submit performance outcome data to MCH.

 

Coordinators’ Meetings

 

Twice per year, the MCH QA/QI nurse coordinates and presents at the Primary Care Coordinators’ meetings as an opportunity to meet face-to -face with staff from all contracted CHCs to provide them with information, resources, and technical support. Agency representatives for these meetings include agency directors/clinical managers and quality improvement staff members. During SFY20, one coordinators meeting was held (fall 2019), the second meeting was deferred due to the COVID‑19 pandemic. 

 

November 2019 Coordinators Meeting Presentations included:

• Heart Disease, Stroke and Diabetes
  • Basic geographic mortality patterns of heart disease, stroke, and diabetes
    • in the US and NH
  • Unique characteristics of heart disease, stroke, and diabetes among women
  • Prevention and Management of diabetes, heart disease and stroke
• Quality Improvement:
  • Review of AAP Bright Futures recommendations related to chronic disease prevention
  • Selected PC performance measures: Obesity (BMI Screening and Intervention), Tobacco Screening and Intervention, hypertension control
• NH Tobacco Prevention and Cessation Program’s new adolescent tobacco cessation program “My Life, My Quit”.

 

An additional Primary Care Meeting was held in January 2020 to conduct Title V Needs Assessment Activities with CHC Directors.  The purpose of this meeting was to:

• Facilitate discussions about the unmet needs of NH’s women, children and families;
• Solicit NH stakeholders’ input related to NH Title V priorities as part of the NH Title V Needs Assessment;
• Exchange information about how Title V program resources are utilized and evaluated.

 

Quality Assurance:

 

MCH collects CHC data on 13 primary care services performance measures. Six (6) of these measures assess preventive care for adolescents including:

 

• Body Mass Index (BMI) documentation and education related to nutrition and physical activity for children 3‑17 years
• Body Mass Index (BMI) documentation and follow up for patients if their BMI is out of range (18 years and over)
• Depression screening (12 years and over)
• Tobacco screening and cessation for tobacco users (12 years and over)
• Screening Brief Intervention and Referral to Treatment (SBIRT) for substance misuse (18 years and over)
• Adolescent annual well-care visit (ages12‑21 years). 

 

For the adolescent well-care visit, MCH’s historical data over the past five years demonstrates rates ranging from 50-60% among CHCs.

 

 

In SFY20, the program did see a decrease to 49% for the reporting period July 1, 2019 to June 30, 2020. This decrease has largely been attributed to fewer visits following the emergence of COVID‑19 in addition to challenges in data extraction and reporting from one CHC. These rates will be monitored closely to identify and address gaps in preventive resulting from the COVID‑19 pandemic. As adolescent preventive services are frequently missed outside of the well-care visit, MCH anticipates focused efforts to support improvement of this measure outcome, including promotion of virtual telehealth visits and catch-up in-person visits.

 

Over the last several years, NH MCH has been shifting focus from quality assurance (QA) toward quality improvement (QI). As such, NH MCH is revising the work that is being done with contracted CHCs to provide greater QI support and to require greater accountability for performance outcomes including:

 

• Providing education, support and resources to further promote adolescent health
• Collecting/analyzing performance measure data twice per year rather than annually
• Requiring all contract agencies to develop an adolescent visit QI project
• Requiring all contract agencies to review/revise an adolescent QI workplan annually
• Providing feedback to contracted agencies about performance (clinical services documented in medical record, workplan activities and performance measure/data outcomes)

 

Data collection

 

Aware that some agencies only reviewed their agency data when reporting was due to the State, MCH encouraged agencies to review their own data more frequently (at least quarterly). Current MCH revised Primary Care contracts require CHCs to submit MCH performance measure data to the State twice per year.

 

MCH staff (QI/QA nurse consultant) collects and analyzes CHC performance measure data. Following data analysis the MCH QI/QA nurse consultant reviews data results with MCH staff (Child Health nurse consultant and MCH program administrator) for internal discussion. The MCH QI/QA nurse consultant then disseminates all-agency data and graphs and provides recommendations for improvement activities to CHCs. MCH encourages CHCs to review all-agency data to understand how they compare to other MCH-contracted agencies and to consider incorporating MCH QI recommendations.

 

Site Visits

 

Although site visits were deferred in 2020 due to COVID‑19, typically each contracted CHC receives a site visit every two-year contract period to monitor adherence to contract requirements, provide an opportunity to for MCH staff to better understand agency services (especially services that address social determinants of health, i.e. enabling services), and provide technical assistance on agency performance and quality improvement. 

 

During site visits, chart audits are conducted for adolescents aged 11‑21 to promote Bright Futures Guidelines. The site visit and audit findings have prompted discussions about the significance of an annual well-care visits for the AYAH population and how to reduce missed opportunities for health care providers to screen, counsel and provide preventive intervention for key areas including:

 

• Mental and behavioral health
• Tobacco and substance use
• Violence and injury prevention
• Sexual behavior
• Nutritional health

 

 

MCH currently requires MCH-contracted CHCs to submit annual Quality Improvement (QI) Work Plans to describe agency Adolescent QI initiatives. Prior to this requirement, MCH allowed each agency to self-select their QI project topic as long as it related to the Primary Care contract scope of services. As only two (2) out of the 13 contracted CHCs self-selected the adolescent visit, MCH revised contract language to require an adolescent health QI workplan as a mechanism to ensure local effort for the SFY18-19 contract period. In 2020, 100% of contracted CHCs submitted two-year Adolescent Visit QI workplans. The most recent submission of these workplans occurred following the close of SFY20 to allow data and narrative information to be updated in the outcome sections to reflect the work that was done during the year (see below SYF20/21 QI Work Plan as an example).

 

 

 

 

 

 

MCH continues to encourage CHCs to monitor their performance measure data at least quarterly and to implement improvement activities throughout the year.

 

As SFY20 performance measure outcome data for the adolescent well-care visit demonstrate, outcomes are variable among contracted CHCs (range of 22% to 69%) as illustrated by the graph below. MCH continues to encourage CHCs to monitor their performance measure data at least quarterly and to implement improvement activities throughout the year. In addition, MCH will continue to offer additional QI support (by phone, email and/or in person) to lower performing agencies and any agency requesting assistance.

 

 

 

By reviewing QI workplans MCH staff are able to glean insight to the challenges experienced by CHCs including:

 

• Inability to schedule next annual visit while adolescent is in the office due to system only allowing for scheduling of appointments up to six months in advance;
• Inability to capture patients who have received an annual visit elsewhere;
• Inaccuracy of EMR data reporting.

 

In addition to the above described challenges included in QI workplans, MCH staff have also determined, during site visit chart audits, that CHCs are rendering appropriate clinical care, including consistent provision of recommended Bright Futures preventive services, on visits other than well-child visits. Although following AAP recommendation, some CHCs may appear to be low performers for this measure as the measure specification and EMR data extraction systems will not count children who have received recommended services outside of the well-child visit. 

 

 

COVID‑19 Impact

 

Since the onset of the pandemic, a significant drop in well-child visits has resulted in delays in vaccinations, delays in appropriate screenings and referrals and delays in anticipatory guidance to assure optimal health. Pediatricians rapidly adapted to provide appropriate elements of well exams through telehealth when clinically warranted, and also implemented measures to provide in-person care as safely as possible. While outpatient visits to adult primary care physicians have rebounded to near pre-pandemic levels, pediatric visits and immunization rates have been slower to recover.

 

In response to the pandemic, MCH staff collaborated with the University of New Hampshire to conduct a four-session ECHO (Extension for Community Health Outcomes) series titled “Telehealth for Special Populations During COVID‑19 and Beyond”. This series, partially funded by the HRSA Pediatric Mental Health Care Access Program, was held in May 2020, and targeted primary care practices, community-based social services organizations, mental health and behavioral health practices, family and peer recovery and support organizations to support efforts in:

 

• promoting best practices for efficient and effective telephonic/telehealth care visits;
• linking clients/patients to local and web-supported services and resources to accommodate care barriers;
• developing a sustainable model to support current care needs.

 

This series was attended by 92 providers from organizations providing Behavioral/Mental Health, Peer/Family Support, Pediatric/Primary Care, Social Services, SUD treatment, or were connected to State/Local Public Health Agency Networks. Forty-nine percent (6/14) of CHCs contracted by MCHS for Primary Care/Primary Care for the Homeless Services participated in this ECHO series. 

 

 

Social Messaging

 

A 2018 Pew Research Center survey of nearly 750 13‑17 year olds found that 45% are online almost constantly and 97% use a social media platform, such as YouTube, Facebook, Instagram or Snapchat.[27] On average, adolescents aged 13‑18 years old spend over seven (7) hours a day using online media (video, music, gaming, and social media). Those aged 10‑12 years old are spending four (4) hours a day using online media.[28]

 

In 2017, the use of social media became available to MCH through the DPHS to promote healthy lifestyles, preventive screenings and overall health awareness. In 2018, DPHS launched its Instagram account. In addition to promoting health awareness and health education, the goal of using Instagram is to reach youth, as 76% of American teens (13‑17 years old) use Instagram.[29] As adolescents are spending more and more time using social media, reaching youth through online avenues has been leveraged as an approach to behavioral change. 

 

The following messages are other examples of 2020 postings:

 

 

 

 

 

[1] https://www.percentage-change-calculator.com/calculate.php

[2] NH Department of Health and Human Services, Child Fatality Review Report, https://www.dhhs.nh.gov/dphs/bchs/mch/cfrc/documents/child-fatality-review-report-2020.pdf

[3] SB118, http://gencourt.state.nh.us/bill_Status/billText.aspx?sy=2019&id=943&txtFormat=pdf&v=current

[4] Krysten Godfrey Maddocks,  Parenting NH, “Know the rules of the road for teen drivers,” July 22, 2019, https://www.parentingnh.com/know-the-rules-of-the-road-for-teen-drivers/, as read on 6/19/2020.

[5] Fischer, P. (2019, March). Peer-to-peer teen traffic safety program guide (Report No. DOT HS 812 631). Washington, DC: National Highway Traffic Safety Administration.

[6] SB584, http://gencourt.state.nh.us/bill_status/Results.aspx?q=1&txtbillnumber=SB%20584&txtsessionyear=2020

[7] https://www.accesssportsmed.com/news/governor-lynch-signs-nh-concussion-bill-into-law/

[8] Waltzman D, Womack LS, Thomas KE, Sarmiento K., “Trends in Emergency Department Visits for Contact Sports–Related Traumatic Brain Injuries Among Children - United States, 2001–2018.” MMWR Morb Mortal Wkly Rep 2020; 69:870–874. https://www.cdc.gov/mmwr/volumes/69/wr/mm6927a4.htm, viewed on 5/19/2021.

[9] Ibid.

[10] NH NAMI, NH Suicide Prevention 2017 Annual Report, https://theconnectprogram.org/wp-content/uploads/2018/11/2017_annual_suicide_report_-_10-30-2018.pdf, accessed 5/18/2019

[11] Child and Adolescent Health Measurement Initiative. 2018-2019 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved 03/08/2021 from www.childhealthdata.org.

[12] Centers for Disease Control and Prevention (CDC), National Center for Health Statistics.  Retrieved 04/30/21 from https://www.cdc.gov/nchs/pressroom/sosmap/teen-births/teenbirths.htm.

[13] New Hampshire Department of Education website.  Retrieved 05/01/21 from https://www.education.nh.gov/sites/g/files/ehbemt326/files/files/inline-documents/2019nhhgraphs.pdf.

[14] New Hampshire Department of Education website.  Retrieved 05/01/21 from https://www.education.nh.gov/sites/g/files/ehbemt326/files/files/inline-documents/2019nhhgraphs.pdf.

[15] National Institute on Alcohol Abuse and Alcoholism (NIAAA). Retrieved 05/01/21 from [https://worldpopulationreview.com/states/alcohol-consumption-by-state/.

[16] New Hampshire Department of Education website.  Retrieved 05/01/21 from https://www.education.nh.gov/sites/g/files/ehbemt326/files/files/inline-documents/2019nhhgraphs.pdf.

[17] Anyone, Anytime. Facts about NH’s heroin, fentanyl, & other opioid crisis. Retrieved 05/01/21 from https://www.nhshp.org/resources/Documents/Opioid%20Crisis%20FACTSheet_FINAL.pdf.

[18] Centers for Disease Control and Prevention, National Center for Health Statistics.  Retrieved 05/01/21 from https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm.

[19] Centers for Disease Control and Prevention, National Center for Health Statistics.  Retrieved 05/01/21 from https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm.

[20] New Hampshire Department of Education website.  Retrieved 05/01/21] from https://www.education.nh.gov/sites/g/files/ehbemt326/files/files/inline-documents/2019nhhgraphs.pdf.

[21] New Hampshire Drug Monitoring Initiative, 2020 Overview Report. Retrieved 05/01/21 from https://www.dhhs.nh.gov/dcbcs/bdas/documents/dmi-2020-overview.pdf

[22] Child and Adolescent Health Measurement Initiative. 2019 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved 05/01//21 from www.childhealthdata.org.

[23] New Hampshire Department of Education website.  Retrieved 05/01/21 from https://www.education.nh.gov/sites/g/files/ehbemt326/files/files/inline-documents/2019nhhgraphs.pdf.

[24] NH Department of Health and Human Services. Bureau of Program Quality. Retrieved 05/01/21 from http://medicaidquality.nh.gov.

[25] Summary of Factors Influencing Adolescent Well-Care Performance Top-Performing State Medicaid Programs. Retrieved [04/30/21] from [https://www.thenationalalliance.org/publications/2020/1/3/summary-of-factors-influencing-adolescent-well-care-performance-in-top-performing-state-medicaid-programs]

[26] Adolescent & Young Adult Health Care in New Hampshire: A Guide to Understanding Consent & Confidentiality Law. Retrieved [04/30/21] from [http://nahic.ucsf.edu/resource_center/confidentiality-guides/]

[27] Anderson M, Jiang J. Pew Research Center. 2018. Retrieved 04/30/21 from https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/.

[28] The Common Sense Census: Media Use by Tweens and Teens 2019. Retrieved 04/30/21 from https://www.commonsensemedia.org/sites/default/files/uploads/research/2019-census-8-to-18-key-findings-updated.pdf.

[29] New survey: Snapchat and Instagram are most popular social media platforms among American teens.  Retrieved 04/30/21 from https://www.sciencedaily.com/releases/2017/04/170421113306.htm.