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 2019, 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 2019, 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
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. Emergency department visits for unintentional injuries are often seen among both children and young adults; one of the age groups with the highest hospitalization rate is the 10 to 14 age group.
The rate of non-fatal injury inpatient (IP) hospital discharges in NH residents aged 10 to 19 years has shown a decreasing trend. The data provided in the graph below is from an updated dataset for IP discharges between 2012 and 2016. The total counts are larger than in previous years’ charts because of corrections and additions made to the dataset.
In 2015, coding changed from the ICD9 to the ICD10 version. As hospitals changed over to the new coding system during the fourth quarter of 2015, it is likely that miscoding may have occurred and/or some data was missing, which may account at least in part for the apparent sharp drop in the rate between 2014 and 2015/2016.
As new years of data become available, 2016 will be the new baseline, using only ICD10 coding. If the current data trend continues, projections show a potential 86% decrease in the rate of non-fatal injury in the 10 to 19 year old age group by 2025.
Data source: NH Hospital Discharge data, NH DHHS
The focus areas selected to decrease hospitalizations for non-fatal injury in the NH 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, 16.2, 16.2, and 16.3 and how they intersect with National Performance Measure (NPM) #7.
NOM15 Child Mortality
The child mortality rate for NH residents, one through nine years old, has not shown a statistically significant change between 2008 and 2017.
Data Source: NH Vital Records, Population Data Denominator from CDC WONDER
Data year 2018 in the Death Certificate data is provisional, as it may be incomplete for NH residents who died out of state. Denominator data for 2018 is not available on CDC WONDER, so the rate could not be calculated for that year. (Note: Rates based on few than 20 events are unstable. Use with caution.)
According to the Center for Disease Control and Prevention (CDC) WISQARS (Web-based Injury Statistics Query and Reporting System) data, unintentional injury is the leading cause of death in this age group. The top cause of unintentional injury death 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.
Leading causes of death, ages 1-9 years, 2008-2017
Data Source: WISQARS, National Center for Health Statistics (NCHS), National Vital Statistics System, accessed 5/20/2019.
Note: 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. Child homicides 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.[1] 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 (SB218) related to the CFRC passed in the NH Senate in April 2019. Currently, this bill is on the calendar for the NH House of Representatives.[2] After the bill becomes law, the CFRC will reconvene.
NOM16.1 Adolescent Mortality
Adolescent mortality has not shown a statistically significant change between 2008 and 2017. Annual counts of adolescent deaths range from 33 to 49 per year. According the CDC WISQARS, the 10 to 19 year old age group’s leading overall cause of death is unintentional injuries, with motor vehicle traffic being the number one specific cause. This is why MCH selected Adolescent Driver Safety as 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 2018 in the Death Certificate data is provisional, as it may be incomplete for NH residents who died out of state. Denominator data for 2018 is not available on CDC WONDER, so the rate could not be calculated for that year.
Leading causes of death, ages 10-19, 2008-2017
Data Source: WISQARS, National Center for Health Statistics (NCHS), National Vital Statistics System, accessed 5/20/2019. Note: counts of less than 10 deaths have been suppressed (---).
NOM16.2 Adolescent motor vehicle death
Motor vehicle (MV) crashes continue to be the number one cause of death for adolescents and new drivers. Speed and the inexperience of novice drivers are the major causes of fatal crashes among adolescents in NH. Adolescent motor vehicle death rates for NH residents 15 through 19 years old have not changed significantly between 2008 and 2017. The graph below includes all motor vehicle crash deaths: MV Occupants, Motorcyclists, Pedestrians or Pedal Cyclists injured in MV Crash. On average between 2008 and 2017, approximately four adolescents age 15 to 19 who died per year in MV crashes were occupants of a motor vehicle. Of those four, about two per year were drivers at the time of the crash.
Data Source: NH Vital Records, Population Data Denominator from CDC WONDER
Data year 2018 in the Death Certificate data is provisional, as it may be incomplete for NH residents who died out of state. Denominator data for 2018 is not available on CDC WONDER, so the rate could not be calculated for that year. (Note: Rates based on few than 20 events are unstable. Use with caution.)
ESM7.2.1 Seatbelt Use: Percent of high school students who wear seatbelts
The 2017 NH Youth Risk Behavior Survey (YRBS) indicates that of the respondents, 93.1% “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. If the current trend continues, by 2023 some 98.2% of students may report using their seatbelts. 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. 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 2020, increase seatbelt usage in the 15 high schools participating in the Teen Driving Project from the baseline of 75% to 85% on the observational assessment of school parking lots.
The seatbelt observational study conducted in the spring of 2018 showed that 86.9% of teen drivers and 83.5% of teen passengers were wearing seatbelts.
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
Systems Building
MCH staff in the Injury Prevention Program (IPP) continued to support efforts regarding novice adolescent driving safety. MCH contracts with the Injury Prevention Center at Dartmouth (IPC) to fund (through state and CDC Preventive Health and Health Services Block Grant funds) a one day per week Highway Safety Specialist. MCH and the Division of Highway Safety jointly fund this position. The Highway Safety Specialist facilitates, with a MCH co-chair, the NH Teen Driving Committee, which was combined with the Statewide Buckle Up Coalition to serve all ages. Part of this work includes the NH Teen Driving Project (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 making it socially unacceptable, through peer-to-peer evidence-based education, for them to drive while distracted or impaired, to speed or to not wear their seat belts.
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. YRBS school specific survey data is collected and reviewed every other year and schools with low seat belt usage are targeted.
Of the 15 schools participating in the NHTDP peer-to-peer program, only eight provided observational studies in both the fall and spring of 2016, 2017 and 2018. These data are collected by counting the number of cars leaving the school’s parking lot. The results are as follows:
Overall, seatbelt usage increased among drivers and passengers; hand-held device use remained relatively low. With only eight of the 15 schools providing both spring and fall data, there is enough data to show changes during the past two schools years, but more data is needed to attain statistical significance.
MCH 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. Some examples of events attended by students, parents, and teachers include the National Highway Safety Conference Lifesavers 2018, where the IPC Highway Safety Specialist was a speaker; the New Hampshire Traffic Safety Conference, where the IPC staff did a presentation; and the New England Pedestrian Safety Summit located in Rhode Island.
The online toolbox at the NH Teen Driver Program website was developed to provide resources to schools that were unable to participate in the Adolescent Driver Safety Program. Any school leader looking for resources to guide their teens into make good choices behind the wheel can find information that will be updated throughout the year.
Teen Driver Safety and Buckle Up NH informational displays were shared at community events such as:
- The Safe Kids 500 Bike Rally, which was held at the NH Motor Speedway with hundreds of parents attending;
- The Derry Fest with an attendance of over 2,000 people including parents and teens;
- The National Night Out events at Goffstown and Gilford with hundreds of children, teens and parents; and
- The Derry Safety Day Touch a Truck event with over 1500 attendees.
MHC and IPC staff continue to look for ways to provide more and better educational experiences for teen drivers and for members of the community. To assist with this, MCH and IPC staff participated in teen driving collaborative efforts hosted by the Children’s Safety Network for the past three years. The collaborative provided training in project planning and evaluation that was applied to the NH Teen Driver Safety program.
In the fall of 2018, funds from AT&T that were awarded to the Teen Driver Program were utilized for a teen-focused event on distracted driving. The event brought in guest speakers Jacy Good and her husband Steve Johnson who discussed the crash that Jacy’s family was involved in on her graduation day. The event was attended by 150 teens from 14 different high schools, who rated it 4.9 out of 5 on the post-event evaluation. The program will continue to identify relevant topic areas and events to get the message across to the target audience.
The program’s successes also resulted in IPC staff being asked to speak at this year’s Lifesaver’s Conference about New Hampshire’s Teen Driving Program. This opportunity provided a platform to inform other states, assisting them in the promotion of their teen driver programs, and it facilitated a mutual exchange of information that will enable NH to further enhance Teen Driver Safety efforts.
Occupant Protection and Teen Driving priorities are included in the revised DOT Strategic Highway Safety Plan. The Highway Safety Specialist and her assistant worked with approximately 15 high schools. Two examples of their work are detailed below.
The Belmont High School Healthy Choices Event occurred for the third consecutive year. After the event in the second year, the school leaders nominated the teen driver program coordinator to be recognized for her role in organizing this event for the school with the New Hampshire College and University Council. She received one of the 2019 Champion Awards. Belmont is the only school in the state that shuts down for a half day for this event, which allows students to focus on behaviors that can cause crashes. These behaviors include impairment, distraction and seat belt usage. In addition, school leaders include other relevant topics that they consider timely and significant. The event in 2019 included a panel of various businesses that talked with students about the various choices they make now and how these can affect their futures, including career choices.
Sadie Raymond is the mother of a teen, Corbin, who was almost killed in a crash in July of 2018 in NH. Ms. Raymond spoke with students at John Stark Regional High School, telling the story of how she almost lost her son because his friend, another teen, was driving but going at an excessive speed and lost control of the vehicle. She explained her son’s injuries as well as his extensive recovery over the last 10 months. Corbin joined his mother during the presentation so the students also were able to see how far he has come in his recovery from the crash.
Students from John Stark’s Leadership group took the teen driver program’s previously created “Room to Live” presentation and included observational data from their school parking lot. The “Room to Live” presentation was built to educate its listeners about the importance of buckling up and how a car is built to keep you safe as long as seat belts are used.
NH’s bill HB1259 for an adult seat belt law was unsuccessful in 2017; however moving forward in 2019/2020 there is discussion about introducing an enhancement to the current primary belt law that goes up to age 18, to include all ages. The Seat Belts 4 All group has convened 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. The strategy to enhance the current law is under review by State agencies to determine whether they will support or stay neutral during the upcoming legislative session.
After 24 years of conducting the Seat Belt Challenge the same way, IPC staff are completely redesigning it. The redesign will be implemented in the spring of 2019. Formerly, students dashed around a car jumping into seats, buckling and unbuckling seatbelts as fast as possible. Concerns arose from participating school administrators that this activity in itself might lead to injury, and it was not the best representation for using seatbelts when driving or riding in a vehicle. The new program will be more educational and less physical, and will allow more schools to participate. The program selected is the national program ThinkFast® Interactive. This new program is in the development stages and an evaluation will be conducted after the event occurs.
MCH Specific Activities
MCH’s IPP continues working with the NH Driving Towards Zero Coalition (the Coalition). The Coalition, comprised of multiple State agencies and organizations, is now working towards the implementation of the New Hampshire Strategic Highway Safety Plan, 2017-2021, which has a component focusing on adolescents. The Coalition is working towards both strengthening and understanding the State’s Graduated Drivers Licensing (GDL) laws, which involve stepped licensing of novice drivers; GDL has been proven effective in reducing the number of crashes and fatalities. All 50 states have some GDL components in place. The MCH IPP Manager and the IPC Highway Safety Specialist both sit on the Governor’s Highway Safety Council.
Concussion
Concussion in adolescents can be a result of a non-fatal motor vehicle crash, a sports injury, or a fall. The effects of 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. New Hampshire has a law regarding return to playing sports after a concussion. MCH is working with the Brain Injury Association of NH (BAINH) to amend this law to include “return to learn.” The earliest that the law can be amended in order to strengthen it will be in the 2020 legislative session, since this will not be a state budget year and the focus will be on policy priorities.
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 to 19 is low. Years 2006 to 2017 were aggregated in the table below, which shows the selected causes of TBI deaths in NH adolescents. Motor vehicle crash is clearly the top cause of TBI deaths. Over the last 10 years, there have been no deaths due to concussion in this age group.
NH TBI death counts 2006-2017
Data Source: NH Vital Records
Inpatient (IP) discharge rates for TBI for ages 10 to 19 showed no statistically significant changes between 2012 and 2016. There were 191 IP cases between 2012 and 2016.
Emergency Department (ED) discharge rates for this age group significantly decreased in 2015, and then increased again in 2016. This may be due to coding error during the change from ICD9 coding to ICD10 in 2015. There were 9,492 ED visits between 2012 and 2016.
The number of cases seen in the hospital IP and ED are not a complete count; some children are seen in urgent care facilities or a doctor’s office, and some minimize their injuries and do not receive medical attention at all.
Rates of concussion showed a similar pattern. Concussion cases comprised 42% of the TBI cases seen in the IP, and 48% of the TBI cases seen in the ED between 2012 and 2016. (See tables below.)
The most common causes of non-fatal TBI in children ages 10-19 years in NH are falls, sports injuries, and motor vehicle 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 2016, there were 874 ED discharges for NH residents age 10 to 19 with concussion, with an average cost per patient of $3,235. 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 14 in 2016 at an average cost per patient of $51,971. In 2016, among ages 10 to 19, there were 1,684 children discharged from the emergency department with TBI (including concussion and other head injuries) at an average cost per patient of $2,830. TBI IP care in 2016 for this age group had 39 discharges at an average cost per patient of $92,800.
Figure 1Data 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.[3]
This law needs stronger language about “return to learn” and the need for schools to have “best practice” policy, modeled after that of other states. States are just beginning to include this in their statutes but at this point most do not, the emphasis being on return to play. NH was one of the few states to have received a HRSA grant to help schools implement “return to learn” policies and classroom accommodations, so NH has considerable experience and will be an important player in establishing consensus over what should be included in “return to learn” legislation.
Systems Building/MCH Specific Activities
Many of the causes of TBI are predictable and preventable. Prevention includes:
- Wearing a seat belt every time when 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.
MCH’s IPP has been working with the Brain Injury Association of NH (BIANH) to assess the implementation and effectiveness of NH’s school concussion law, RSA 200:49-52. The primary objective continues to be the determination of which specific elements of the law have been implemented, as well as the establishment of a concussion policy concerning return to play and the distribution of information to both students and parents. Another objective was to determine what parts of the law are difficult to implement, and whether MCH and the BIANH could assist in decreasing barriers.
A survey was sent to all NH high schools in early 2016. There were 122 respondents, a 13% response rate. Respondents included school nurses (74%), athletic directors/trainers (22%), and school principals (4%). Key findings included:
- 96% of athletic directors/trainers report having a school policy versus 73% of all others (66% of school nurses)
- Only 64% of respondents reported having a “return to learn” policy (57% of school nurses)
- A majority of respondents have a baseline concussion testing program
- 33% of all respondents say the policy is followed with absolutely no exceptions, ranging from 76% of athletic directors/trainers to 21% of nurses
- The top two (2) reasons concussion policies are not being followed consistently are that students do not truly describe how they are feeling and a lack of communication between parents, students, teachers and coaches
- The top two (2) sources for all respondents for information on concussions are "professional conferences" (78%) and "subject matter expert organizations" (42%); the "CDC" is cited more frequently (21%) than the "Brain Injury Association of NH" (5%)
- Only slightly more than one-fifth of all respondents (22%) say they have ever contacted the BIANH to get information on concussions; of those, the top two (2) most frequently cited behaviors by all respondents are “visit the website/download information about concussions” (35%) or “attend a workshop sponsored by BIANH” (24%)
- Seventy-two percent (72%) of respondents were aware of the law and 66% of those said they would likely support strengthening it
- Only 5% of all respondents said they are not likely to support strengthening the law and pointed to several reasons, including “consider each on a case-by case basis,” “already strict enough,” “should cover more than sports injuries,” and “State shouldn’t be involved.”
In 2018, another high school survey was completed. In this new survey, 100% of respondents were school nurses. They were contacted 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 new 2018 survey, reasons given as to why school 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.)
Recommendations were brought to the Injury Prevention Advisory Council’s Policy Subcommittee in the fall of 2016 to discuss any potential additional actions. At that time, legislative elections were being held and it was decided to postpone any legislative policy action.
In 2018, a new statewide stakeholder retreat was hosted by BIANH. In discussions about future legislation to strengthen the law, the consensus was to wait until the 2020 legislative session.
BIANH hired intern in 2016 to:
- identify all of the Return to Play (RTP) laws in other states;
- identify states with strong RTP laws (schools in a few states were contacted, and it was discovered that application of their state’s RTP laws is inconsistent; most schools were using the law as a guideline);
- review various state laws to identify best practices; and
- identify model state laws that NH can follow in strengthening the concussion law in NH.
The information collected by the intern identified best practices related to Return to Learn and Return to Play (RTL/TRP) Laws in Oregon, Pennsylvania, and Colorado. The legislation from these states will be used to guide the strengthening of NH’s RTL/RTP Law.
The intern was subsequently hired to work at BIANH, to answer the help line and make outreach calls to people who have requested help, information, and resources related to TBI.
In 2016, DHHS’s Bureau of Development Services, the Acquired Brain Disorder Program, received HRSA funding (with the help of a committee that included MCH staff) to facilitate a “return to learn” program in NH schools entitled Concussion Chalk-Talk. Funding was subcontracted with the BIANH under the guidance of an advisory committee including MCH staff. Title V funding to the BIANH is now being braided with this funding to include policy assessment and development as referenced above.
NH's HRSA/ACL concussion grant ended in 2018 (the TBI program is transitioning from HRSA to the Administration for Community Living, ACL). In the 2018/2019 school year, BIANH invested over $100,000 of its general funds to maintain this effort without grant funding and continue supporting participating schools and the DHMC concussion clinical team. In January 2020, if awarded, at grant from ACL will continue this work.
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 are participating. Many of the schools are now including funds from their own 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.
The NH “return to learn” methodology is comprised of:
- Enhanced behavioral management in the acute phase of concussion by designing a structured schedule within the school setting
- Enhanced communication between all parties, both inside and outside the school, to provide consistency and avoid conflicting sources of information
- Ongoing consultation with sports neuropsychology team at Geisel School of Medicine/Dartmouth Hitchcock Medical Center, including in-person visits to school to consult on challenging cases and perform additional neuropsychological testing if necessary
- Daily education and monitoring of concussed students regarding behaviors and symptoms
- Feedback from teachers and parents on a daily basis to understand the level of recovery across environments
- Assurance of a graduated return to academics and classroom functioning based on readiness and tolerance of cognitive activities
- Provision of a supervised space within the school for symptomatic students to engage in academic replacement activities while they recover
When students become concussed, parents should 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:
- Student rests at home for approximately the first 48 hours post-injury.
- Student returns to school as soon as they meet attendance criteria.
- Student checks in with Assistant CMT Leader to perform a symptom checklist and optimally a Behavioral Assessment (BA).
- Results of the BA and symptoms determine next steps and creation of the day’s schedule.
- 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.
- Periodic check-ins throughout the day with the CMT Assistant if symptoms arise. These check ins will quickly diminish during a 2-5 day window.
- Plan for the evening.
- If 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 February and March of 2017 and presented to the Injury Prevention Advisory Council in May of 2017. Special education staff at schools were also included, as were school nurses, athletic directors/trainers and principals. In 2018, 27 high schools were sampled for telephone interviews.
Respondents overall were pleased with the program:
“I would absolutely recommend the Chalk Talk program. Having a program forces everyone to be more sensitive to concussions. All schools should have a Chalk Talk “return to learn” policy so kids can be appropriately rested as they recover.”
“We have done training with faculty. Many times faculty say, ‘the kid seems fine’ because they look fine…it is not as obvious as a broken leg. Even those not in sports that have experienced a concussion will be referred to the trainer and we put them in the protocol. The trainer works with the guidance counselor and makes sure there is communication with the teachers. Now with Chalk Talk, we will have a protocol for returning to the classroom.”[4]
Respondents reported that are still some barriers to overcome, including:
- Staff concern about being responsible for the “diagnosis” of the student (in reality, they only report Better or Worse observations)
- 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
Results on following policies mirrored that of non-Concussion Chalk Talk school staff members surveyed in the beginning of 2016, indicating that little change occurred between 2016 and 2018, with the same barriers being identified.
A majority (86%) of all respondents say they would support a “return to learn” policy as a way to strengthen NH’s concussion law. Similarly, almost three-fourths (71%) of special education teachers say they would support revised legislation that would address “return to learn.”
“After experiencing a concussion, the brain needs time to heal. Computer time and reading activities should be minimized during the healing process. Students’ memory may be impacted because of the concussion. Teachers need to be aware of these issues and ensure that precautions are taken during the healing process.”[5]
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 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.
Following up on the meeting with the DOE Commissioner, a stakeholder retreat meeting was held on June 10, 2019. The focus was on improving schools’ ability to better support students with mild (concussion) to severe brain injury. A facilitator at the retreat compiled comments related to: goals, strategies, target audiences, barriers and challenges, opportunities and triggering events, next steps, and evaluation. After the stakeholders have reviewed the notes from the facilitator, provided edits and comments, recommendations will be drafted that will be shared with the Commissioner when they are finalized.
NOM16.3 Adolescent suicide
Adolescent suicide death rates for NH residents 15 through 19 years old have not changed significantly between 2007 and 2017. Yet the number of cases have doubled from 6 in 2015 to 11 in 2016 and 12 in 2017—while these low numbers may not be statistically significant, the death of any child is significant and the underlying causes need to be addressed. According the CDC WISQARS, suicide is the second leading cause of death in the 10 to 19 year old age group. The most common lethal means of suicide are firearms, suffocation, and poisoning.
Data Source: NH Vital Records, Population Data Denominator from CDC WONDER
Data year 2018 in the Death Certificate data is provisional, as it may be incomplete for NH residents who died out of state. Denominator data for 2018 is not available on CDC WONDER, so the rate could not be calculated for that year. (Note: Rates based on fewer than 20 events are unstable. Use with caution.)
Causes of death and violent death, ages 15-19, 2008-2017
Data Source: WISQARS, National Center for Health Statistics (NCHS), National Vital Statistics System, accessed 5/20/2019.
Note: counts of less than 10 deaths have been suppressed (---)
MCH hosts a 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.[6]
“A major accomplishment of the council in 2016 was the revision of the NH Suicide Prevention Plan (2017-2020), which is available online. A key addition to the revised Plan is the concept of a Zero Suicide approach to prevention in the state. This concept was built into the overall goals of the Plan, as well as the goals of the individual SPC subcommittees. More information about Zero Suicide is available online. The State Suicide Prevention Plan is not a static document and will continue to evolve over time to incorporate promising concepts and initiatives, such as Zero Suicide, that may help prevent suicides in the state.”[7]
MCH in cooperation with the National Alliance on Mental Health in NH (NAMI NH) produces an annual Suicide Prevention Report (available online) as well as the State Suicide Prevention Plan.
The goals of NH’s Suicide Prevention Plan 2017-2020 are the following:
- Promote awareness that suicide in NH is a public health problem that is generally preventable.
- Reduce the stigma associated with obtaining mental health, substance misuse and suicide prevention services.
- Improve and expand suicide surveillance systems.
- Collaborate with partners and implement training for recognition of at-risk behavior among the law enforcement community.
- Educate the public to improve recognition of at-risk behaviors and the use of effective interventions. Promote training to personnel that are directly involved with veterans, service members and/or their families who exhibit high risk, worrisome behaviors.
- Coordinate delivery of informational material to the community and treatment sites or resources on potentially suicidal veterans, service members and/or their families.
- Provide subject matter expertise to the NH Legislature regarding the public health impact of suicide.
- Support survivors of suicide loss through the implementation of support and education programs for family, friends, and associates of people who died by suicide.
- Promote Zero Suicide in collaboration with all other subcommittees of the State Suicide Prevention Council.[8]
“The Youth Suicide Prevention Assembly (YSPA) is dedicated to reducing the occurrence of suicide and suicidal behaviors among NH's youth and young adults up to 24 years old. This is accomplished through a coordinated approach to providing communities with current information regarding best practices in prevention, intervention, and post-event strategies and by promoting hope and safety in our communities and organizations. YSPA is an ad hoc committee of individuals and organizations that meet monthly to review the most recent youth suicide deaths and attempts, in order to develop strategies for preventing them. Over the years, YSPA and its partners have been involved with a wide range of suicide prevention efforts in the state including:
- Collecting and analyzing timely data on suicide deaths and attempts;
- Collaborating on an annual educational conference;
- Creating the original NH Suicide Prevention Plan; and
- Identifying the need for statewide protocols and training, which were developed through NAMI NH into the Connect Program.”[9]
The MCH IPP has been awarded the National Violent Death Reporting System (NVDRS) grant from CDC since 2014. This grant’s purpose is to collect more than 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 back to the state in the summer of 2018 so in-depth analysis could begin on the violent death circumstances. NH-NVDRS data was included in the 2017 Annual Suicide Report.
* * * * * * *
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 & 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 50% in SFY16 to 64% by 2020
Strategies:
- Build partnerships by:
- networking with other State Adolescent Health Coordinators
- collaborating with public and private partners through NH Pediatric Improvement Partnership
- participating in the Adolescent and Young Adult Health (AYAH) CoIIN Cohort
- 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:
- establishing a new position within MCH to support the development of the NH Pediatric Mental Health Care Access Program (funded by HRSA and Title V) for adolescent behavioral health. This position is 80% funded by HRSA and 20% by Title V.
- recruiting to fill the Family Planning Program Health Promotion Advisor position for adolescent reproductive and related health. This position was previously funded only by Title X and upon hire will be partially 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 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 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 impacting 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
- Participating as a key member of the NH state team for the Adolescent and Young Adult Health Collaborative Improvement and Innovation Network AYAH CoIIN Cohort
- 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 2017 National Survey of Children’s Health (NSCH), 90% of NH’s children, ages 0-17, are in excellent or very good health.[10] 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.
Source: 2017 National Survey of Children’s Health
Vaccination Coverage
In NH, all children through the age of 18 years can receive all recommended immunizations at no cost. As a result, NH has a strong history of attaining high vaccination rates for children and adolescents.
The NH Immunization Program recently received five (5) awards at the National Immunization Conference including: “Outstanding progress toward the Healthy People 2020 targets for each of the four vaccines among adolescents aged 13-17” and “Outstanding progress toward the HP 2020 target of 70% for influenza vaccination coverage among children 6 months-17 years during the 2016-17 season.”
Data Source: National Immunization Survey-Teen 2017; https://www.cdc.gov/mmwr/volumes/67/wr/mm6733a1.htm
Teen Birth
NH has attained one of the lowest teen birth rates in the nation. Currently (2017 data), this rate is 8.4 per 1000 females 15-19 years old.[11] 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 2017 NH Youth Risk Behavior Survey (YRBS).[12] (Please refer to the NPM7 narrative in this report for more discussion of adolescent safety risks).
Source: NH YRBS, 2017
Tobacco Use
According to the NH YRBS 2017, 24% 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 becoming more common, with 41% reporting ever use and 23% reporting current use. Electronic vaping (ever use) was highest among Hispanic students (57%).[13]
Alcohol Consumption
Alcohol use is prevalent across NH. In 2016, NH’s total alcohol consumption was >2.31 gallons per person, which puts NH among the 30 states with the highest level of alcohol consumption.[14]
The 2017 NH YRBS indicates that 30% of high school students currently drink alcohol (31% of females and 29% of males). Eleven percent (11%) of students reported having their first drink of alcohol before the age of 13. Alcohol consumption by Hispanic students is higher than the overall percentage at 39%, while Black students reported slightly less than the overall percentage (28%).
Sexual Risk
NH YRBS 2017 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 21% reported using alcohol and/or drugs before the last sexual intercourse, 40% did not use a condom and 7% did not use contraception at last intercourse.[15]
Drug Use
Drug use, especially the use of opioids, has become a serious national crisis that affects 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.[16] According to the CDC, NH is among the top five states with the highest rate of opioid-involved deaths, with more than 450 NH residents dying as result of a drug overdose in 2017. According to the NH Medical Examiner’s office 87% of these deaths resulted from the use of opioids and 19% of victims were 20-29 years of age.[17]
NH is dealing with 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 have started 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.
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 2018, the MCH section was awarded HRSA funding to establish 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. The NH PMHCAP will connect with 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 2017 NSCH survey, the state of NH has a higher percentage of adolescents aged 12-17 who have had a preventive medical visit than the national average, at 90.2% vs 82.2%.[18]
Source: Data Resource Center for Child & Adolescent Health (NSCH)
However, data from NH Medicaid suggests that well-care visits are less likely to occur after age 17 as the percentage of individuals having well-care visits decreases to 66% when this age group is expanded to include young adults up to age 21.[19]
As adolescents (12-17 year olds) and young adults (18-21 years of age) are less likely to have annual visits during the stage of their life in which they are developing health habits and more likely to engage in high risk behavior, MCH has selected the percentage of adolescents aged 12-17 (NPM) and the percentage of adolescents aged 12-21 (ESM) having an annual well-care visit as a priority area for this five-year reporting cycle.
MCH contracts with family planning and primary care health centers to increase state-wide 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
- blood pressure control
- diabetes
- referral to services such as primary care, SUD treatment and behavioral health services as indicated.
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). 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 2018, MCH strategy to improve adolescent health and increase adolescent well-care visits was to educate and collaborate with stakeholders, promote adolescent health and QI among MCH-contracted partners, participate in the second cohort of the Adolescent and Young Adult (AYA) Collaborative Improvement and Innovation Network (CoIIN), and develop opportunities for public awareness.
AYAH CoIIN
MCH staff also promote Title V and adolescent health activities by participation in the NH Pediatric Improvement Partnership (NH PIP). 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. The MCH QI/QA nurse consultant and program administrator are members of the NH PIP steering committee. In 2018, NH MCH participation 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) ended due to the conclusion of the project period. The objective of MCH participation in this 18-month CoIIN 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.
AYAH CoIIN Project Overview
The NH AYAH CoIIN team completed the following strategies to improve access to and quality of AYAH preventive care visits in NH.
- MCH Workforce Development: NH AYAH team members had the opportunity to increase skills and knowledge through participation in three monthly AYAH CoIIN National Strategy Team (NST) webinars: 1) access and utilization of preventive services; 2) quality of preventive services (MCH QA/QI Nurse); and 3) state and system level policies and practices. The MCH QA/QI nurse participated in the quality of preventive services calls and received information from the other two webinar sessions from participating colleagues.
- Influencing state system policies: Input from the NH PIP steering committee was obtained to identify policies that impact adolescent annual well care visits. As local providers 1) voiced concerns over challenges associated with current school policies and 2) believed there was potential to make positive change in adolescent well-care through evolution of such policies, the NH team decided to review school administrative unit (SAU) policies on adolescent comprehensive physical exams (including sports physicals) for students of two (2) SAUs for the purpose of developing a policy that would promote adolescent well care visits. Through this review and in consultation with AYAH learning collaborative colleagues, the team developed a policy with model language geared to SAU superintendents to encourage annual preventive care visits within the youth’s medical home. The recommended policy was disseminated to the NH School Board Association for school superintendents’ review and consideration. In addition to the school policies this project allowed the facilitated review of NH adolescent confidentiality laws and drafting of “Adolescent & Young Adult Health Care in New Hampshire: A Guide to Understanding Consent & Confidentiality Laws “ by the Center for Adolescent Health & the Law, Chapel Hill, NC.[20] Note: This guide was published and disseminated by MCH staff for sharing statewide in 2019.
- Improving youth satisfaction with clinic setting: The NH CoIIN team engaged MCH -contracted CHCs to solicit participation in the AYAH CoIIN for the purposes of piloting youth patient satisfaction surveys and hosting youth-led assessments of their clinics for youth friendliness. The AYAH team trained youth representatives in how to tour a clinic to assess youth friendliness and completed one (1) clinic tour as practice. Following training, the youth representatives completed clinic tours of each participating CHC and provided the results of the assessments to the NH AYAH team. The participating CHCs submitted data and youth patient satisfaction survey responses. The AYAH team including the youth representatives met virtually with the CHCs to share results and provide feedback (see dashboard below for example) to the agencies as part of improvement planning.
- Training and Technical Assessment: Based on assessment findings, participating CHCs and the CoIIN team identified confidentiality as a primary topic area for follow-up training and technical assistance. In-person confidentiality training was provided to the CHCs by a board-certified adolescent medicine physician in 2018. The assessment also identified a secondary topic related to care of Lesbian Gay Bisexual Transgender (LGBT) youth as an area where training would be beneficial. As providing in-person training on two topics was not feasible within the AYAH CoIIN project period, the NH AYAH CoIIN team developed a resource list and created a brochure (with input from LGTBQ+ youth) for use by providers and LGTBQ+ Youth & Families (see brochure below). To respond to the CHCs training request, the MCH section forwarded to all MCH-contracted CHCs a recorded four-part webinar from the American Academy of Pediatrics, Section on Lesbian Gay Bisexual Transgender Health and Wellness, designed to educate health care providers on caring for transgender youth.
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.
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 (ages 12-21 years).
For the adolescent well-care visit, MCH’s historical data (see graph below) demonstrate a decrease in performance outcome from 62% in 2015 to 50% in 2016. However, the decrease is likely due to a change in the performance measure target group to those 12-21 years of age, as younger children (age 10-11) who are more likely to receive annual exams were no longer included. As adolescent preventive services are frequently missed outside of the well-care visit, MCH directed efforts to support this measure contributing to an increase in performance outcome from 50% in 2016 to 58% in 2018.
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) and in 2015 MCH revised Primary Care contracts to require CHCs to submit MCH performance measure data to the state twice per year starting in SFY16. 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
Each contracted CHC receives a site visit every two-year contract period to provide support and monitor adherence to contract requirements. Over this past contract cycle the MCH team has changed the format of site visits to allow greater opportunity to understand agency services (especially services that address social determinants of health, i.e. enabling services), as well as performance and quality improvement efforts.
Chart audits are being 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
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.
In 2018, the spring meeting was deferred as the MCH section was in process of procuring Primary Care contracts during this time. The focus of the fall meeting in November 2018 was adolescent health. During this meeting the following occurred:
- The Title X program manager provided information about a new MCH/State Lab collaboration: the family planning program is piloting an initiative to pay for STD testing (chlamydia, gonorrhea, Hepatitis C and HIV) for Title X eligible clients in order to expand STD testing in light of increasing STD rates.
- “QI” presentation was made by the MCH QA/QI Nurse to disseminate individualized reports to provide historical data for each agency to compare their own agency’s performance vs. the performance of all contracted agencies. The QA/QI Nurse specifically reviewed outcomes for adolescent well care visit, depression screening and follow-up and SBIRT. MCH and agency staff discussed opportunities for improvement.
- “Got Transitions, Six Core Elements of Health Care Transition” presentation was made by the Medical Home Project Director of Family Voices. During this presentation, participants discussed opportunities to support youth and address transition within the adolescent preventive care visit. CHC staff were encouraged to review their agency’s adolescent-to-adult care transition policy to determine if the agency has a policy and if so: 1) are staff educated about the policy; 2) is the policy posted for patients/families to view; and 3) is the policy discussed with youth and families as part of an adolescent visit.
- “Adolescent and Young Adult Health AYAH CoIIN” presentation was made by the MCH QA/QI Nurse along with two (2) contracted agencies that participated in the project to assess clinic youth friendliness. AYAH CoIIN outcomes were presented including: Youth led clinic survey results, AYAH satisfaction survey results, recommended SAU school health policy and the new LGTBQ+ Youth and Families Resource Guide. The LGTBQ+ resource guide is electronically available and was printed by the MCH section and distributed to CHCs during this meeting and is encouraged to be shared with other stakeholders.
MCH also required MCH-contracted CHCs to submit annual Quality Improvement (QI) Work Plans to describe agency QI project activities. Prior to SFY18 all MCH-contracted CHCs were required to submit QI work plans, but 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 2018, 100% of contracted CHCs had an Adolescent Visit QI Work Plan on file with MCH. These workplans are updated following the close of each SFY to include data and narrative information in the outcome sections to reflect the work that was done during the year (see below QI Work Plan for example).
MCH continues to encourage CHCs to monitor their performance measure data at least quarterly and to implement improvement activities throughout the year.
As SFY18 performance measure outcome data for the adolescent well-care visit demonstrate, outcomes are variable among contracted CHCs (range of 27% to 75%) and MCH continues to offer additional QI support (by phone, email and/or in person) to lower performing agencies and any agency requesting assistance.
Social Messaging
In 2017, the use of social media was made available to MCH through the DPHS to promote healthy lifestyles, preventive screenings and overall health awareness. As adolescents are spending more and more time using online media, reaching youth through online avenues has become a priority. On average, adolescents aged 13-18 years old spend nearly nine hours a day using online media (video, music, gaming, and social media). Those aged 10-12 years old are spending 6 hours a day using online media.[21]
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 (source: https://www.sciencedaily.com/releases/2017/04/170421113306.htm). This platform will be essential in increasing adolescent awareness of the importance of adolescent wellness visits and for the promotion of healthy behaviors. Social media platforms have provided MCH an opportunity to place health messages where youth gather and share information. Currently, MCH is creating and posting adolescent health awareness messages (examples below) on three social media accounts (Facebook, Instagram, and Twitter).
* * * * * * *
[1] NH Department of Health and Human Services, Child Fatality Review Report, https://www.doj.nh.gov/criminal/victim-assistance/documents/child-fatality-report-2017.pdf
[2] SB218, http://gencourt.state.nh.us/bill_Status/billText.aspx?sy=2019&id=943&txtFormat=pdf&v=current
[3] https://www.accesssportsmed.com/news/governor-lynch-signs-nh-concussion-bill-into-law/
[4] Schnell, R. (2017). Presentation to the Injury Prevention Advisory Council on Concussion Chalk Talk.
[5] Ibid.
[6] 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
[7] NH Suicide Prevention Council, NH Suicide Prevention Plan, 2017-2020 https://www.dhhs.nh.gov/dphs/bchs/spc, assessed on 6-18-2018
[8] Ibid.
[9] 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
[10] Child and Adolescent Health Measurement Initiative. 2017 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA MCHB). Retrieved [05/20/19] from www.childhealthdata.org. CAHMI: www.cahmi.org.
[11] Centers for Disease Control and Prevention (CDC), National Center for Health Statistics website. Retrieved [05/20/19] from https://www.cdc.gov/nchs/pressroom/sosmap/teen-births/teenbirths.htm.
[12] New Hampshire Department of Education website. Retrieved [05/30/18] from https://www.education.nh.gov/instruction/school_health/hiv_data.htm
[13] ibid
[14] National Institute on Alcohol Abuse and Alcoholism (NIAAA). Surveillance Report #110. Apparent per capita alcohol consumption: national, state, and regional trends, 1977-2016. Retrieved [05/14/18] from https://pubs.niaaa.nih.gov/publications/surveillance110/CONS16.htm.
[15] Ibid.
[16] Anyone, Anytime. Facts about NH’s heroin, fentanyl, & other opioid crisis. Retrieved [05/14/19] from https://www.nhshp.org/resources/Documents/Opioid%20Crisis%20FACTSheet_FINAL.pdf.
[17] NH Medical Examiner’s Office, 2018 Drug Death Data. Retrieved [05/20/19] from
https://www.dhhs.nh.gov/dcbcs/bdas/documents/dmi-2018-overview.pdf
[18] Child and Adolescent Health Measurement Initiative. 2017 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA MCHB). Retrieved [05/20/19] from www.childhealthdata.org. CAHMI: www.cahmi.org.
[19] NH Department of Health and Human Services. Office of Quality Assurance and Improvement. Retrieved [05/20/19] from http://medicaidquality.nh.gov.
[20] http://nahic.ucsf.edu/resource_center/confidentiality-guides/
[21] USATODAY Published 10:54 a.m. ET Nov. 3, 2015. Retrieved [5/09/18] from https://www.usatoday.com/story/news/nation/2015/11/03/teens-spend-more-time-media-each-day-than-sleeping-survey-finds/75088256).
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