State Performance Measure #1: Percentage of MCH-contracted Community Health Centers who have met or exceeded the target(s) indicated on their NH DHHS, MCH Enabling Services (ES) workplan.

 

Objective: Increase the percentage of MCH contracted CHCs who have met or exceeded the target(s) indicated on their NH DHHS, MCH Enabling Services workplan from the 2020 baseline of 33% (5 of 15) to 75% in 2025.

 

Strategies:

 

• MCH requires all CHCs to submit a two-year ES work plan as a contract deliverable within 30 days of each contract period. MCH will review ES work plans and provide feedback/technical assistance as needed to ensure agencies have included specific, measurable, achievable, realistic and, timely (or time-bound) SMART objectives/goals.
• At the end of each State Fiscal Year (SFY), MCH will review ES work plans’ outcome sections to determine the percentage of CHCs attaining their target(s).
• At the end of each SFY, MCH will review and provide feedback/technical assistance as needed on the plan for improvement section(s) of CHCs not meeting their target(s).

 

Background: For more than 25 years, the NH MCH section has used Title V funding and state general funds to support a network of safety-net CHCs to provide access to health services for low-income and uninsured individuals and families. In 2021, 12% of the 112, 389 individuals served by the Title V CHCs were uninsured. While this percentage has decreased with the advent in 2014 of the Affordable Care Act (ACA) and NH’s expanded Medicaid initiatives, there remains an uninsured population that is served by the health centers (range 4-22%).[1] 

 

Historically, Title V funding was used to provide reimbursement of the cost of care for uninsured individuals. However, to better align with the Maternal and Child Health Pyramid of Health Services, MCH has encouraged its contracted CHCs to not only support the costs associated with caring for uninsured populations, but also to support infrastructure-building services (planning, policy development, coordination, quality assurance, standards development, monitoring, training, applied research, systems of care, and information systems). This has been accomplished by expanding contract scope of services to include Enabling Services and Quality Improvement (QI) activities. Accountability for all MCH-contracted services has been maintained by MCH through monitoring performance via site visits and reporting requirements.

 

This performance measure directly addresses two priorities identified in the five year needs assessment, “Increase the focus of Title V on the Social Determinants of Health and the resolution of barriers impacting the health of the MCH population” and “Improving access to needed healthcare services for all MCH populations”. 

 

Enabling Services

Enabling Services (ES) are non-clinical services that support the delivery of basic primary care and preventive services by addressing factors such as geographic, linguistic, cultural and socioeconomic barriers. Those ES that are not currently reimbursed by any health payor are supported by MCH funding to enhance CHCs’ capacity to “do the work” needed to care for their patient population. ES positively contribute to care, improve quality of services, support health equity and reduce health care costs. The following are the types and outcomes of all of the enabling services from the Title V funded CHCs this past year.

 

 

A total of six out of 14 CHCs met all of their enabling work plan goals for a total of 43%. Eighty six percent of the CHCs met at least one of their enabling work plan goals. However, each agency should have had at least two enabling service workplans and that did not happen. Some had only one and some had three.

 

The MCH section allows each CHC the flexibility to self-select the type of ES to be provided based on the unique needs of their own community. The following example from one MCH funded CHC health center illustrates the increased screening with respect to social determinants of health, particularly with respect to transportation barriers.

 

Screening for social determinants of health and the resulting interventions was intermingled into almost all of the enabling services work plans. Another CHC has health insurance enrollment as their enabling work plan. Three of the Title V funded CHCs had an enabling service workplan on utilizing community health workers and patient navigators in helping to access insurance. A story from the CHC is as follows:

 

“About three months ago before Christmas time, a female patient came to the Nashua Soup Kitchen Mobile Health unit with her daughter looking to be seen for her arm pain. The daughter was very concerned because her mother also needed labs, x-rays and a possible surgery for other health issues, not related to the arm pain. The daughter said the patient hadn’t addressed these issues because she did not have insurance, due to her recent change of immigration status. The patient had only been in the United States for one year, with her Permanent Resident card, and because of this the patient did not qualify for Medicaid. The patient’s daughter expressed these concerns to a community health worker (CHW), who then asked if she had time to check the Marketplace for insurance, as it was open enrollment time. The daughter agreed and they went through the process together, and when they finished with the application, the patient was approved for an excellent insurance plan with zero copays and zero dollars for the monthly payment. The patient qualified for the Premium Tax Credit that covered the whole amount of the monthly cost- in other words for free. The patient and the daughter where so happy and grateful, and they both got so emotional. Our Title V funded CHW never thought that helping a patient acquire health insurance would mean so much. The next Wednesday the patient and her daughter came back to the van and the daughter expressed again how grateful she was that we could help her mother with insurance. That same week the patient did all her labs, x-rays for her arm and she is seeing a specialist for her other health issues.”[2]

 

Title V funded CHCs have been on the forefront of utilizing Community Health Workers in the State. This past year, MCH was fortunate enough through the American Rescue Plan Act (ARPA) and pandemic workforce funds, to create a Community Engagement Specialist position whose function is to bring together all the work that is happening with CHWs together in the State, including contracts for CHW training, supporting facilitation of the NH Community Health Worker Coalition and increasing the number of CHWs utilized in all settings to benefit the MCH population.

 

Care coordination across different spectrums was another focus of Title V funded CHCs. CHCs often provide personal stories along with their outcome reports. One of these relates the success one particular CHC had with one particular prenatal patient. 

 

“A patient presented to our prenatal program well into her third trimester of pregnancy, homeless and stressed out. Having relocated to the Nashua area a few weeks before, she and her 4 year old daughter were staying at an acquaintance’s apartment. However, they could only remain there for the next month, which meant that she had limited time to find another place to live before she’d deliver. She had the support of her children’s father, but he lived separately. Neither of them was employed, and they were quickly running out of their savings, so their financial situation was difficult. Food was scarce, and the patient had to walk everywhere because she did not have a car. As part of our social services program, our Title V funded Care Coordinator worked closely with the patient throughout the remainder of her pregnancy, providing ongoing emotional support and referrals to community resources. And by the time her new baby arrived, the entire family had already moved in to a transitional shelter. They were accessing local food pantries and participating in programs, such as WIC and home visiting. The patient was also able to benefit from our internal taxi voucher program for her medical appointments, as well as, her daughter’s specialty appointments out of town. The patient is definitely more relaxed and content these days. She is very grateful that she was able to find, not only the quality medical care that she and her family needed, but also the assistance in connecting with the supports and services to improve their overall lives.”[3]

 

Systems Building

MCH staff monitored contract deliverables to ensure that services are being provided in accordance with the scope of services.

 

Budget/Budget Narrative: On an annual basis, MCH reviews and approves individual agency budgets and budget narratives, which are electronically submitted by CHCs. This activity provides MCH an opportunity to understand how CHCs anticipate they will expend their funds and is one mechanism MCH uses to ensure fiscal accountability. Agency budgets and budget justifications are submitted as part of agencies’ Request for Proposal applications and reviewed for approval with a request to revise if indicated by MCH staff. Fiscal accountability is monitored by monthly review/authorization of CHC invoices by the DHHS fiscal team and MCH staff.

 

ES Work plans: On an annual basis, MCH reviews and approves individual agency ES work plans, which are electronically submitted by CHCs. From the MCH perspective, the ES work plans are a key mechanism for CHCs to communicate with MCH about the work that is being done. The ES work plan describes each individual agency’s project goals, objectives, inputs/resources, planned activities and evaluation methods. This allows an opportunity for MCH staff to provide the CHC feedback and request revision when needed. At the end of each state fiscal year (SFY), CHCs are then required to report annual outcomes by completing the “Work Plan Performance Outcome Section.” This section prompts CHCs to: 1) revisit their work plans; 2) indicate if their agency targets/objectives were met; 3) evaluate the effectiveness of their activities; and 4) communicate any revisions to their work plan (improvement plan, required if targets are not met) as indicated. Once completed, outcomes have been submitted to MCH’s QI and Clinical Services Program for review and provide feedback as part of continuous QI. 

 

Data Collection and Analysis on Performance Measures: MCH staff work in collaboration with other DHHS programs including the Chronic Disease Prevention and Screening Section, the Bureau of Drug and Alcohol Services (BDAS), Tobacco Prevention and Cessation Program for input on performance measures before each funding cycle. Care is taken to align the measures, which in general reflect health outcomes specific to the MCH population, with standard federal and state performance indicators such as those from the Healthcare Effectiveness Data and Information Set (HEDIS), the National Quality Forum (NQF), the Uniform Data System (UDS) as well as HRSA’s specific to Title V. The performance measures for the CHCs for SFY 20 and 21 were the following:

 

Key:

HEDIS – Healthcare Effectiveness Data and Information Set

NQF – National Quality Forum

NH MCH – New Hampshire Maternal & Child Health section

Title V – Federal Maternal and Child Health Services Block Grant

UDS – Uniform Data System

 

At the beginning of each SFY, MCH’s Quality Improvement and Clinical Services program requests that the CHCs set and submit their individual agency’s target for each performance measure. Performance measure outcome data is reported to MCH twice per year (January and July) via spreadsheets known as “Data Trend Tables” (DTT). DTT forms are updated by MCH’s QI and Clinical Services’ program staff and forwarded to contracted agencies with instructions for completion, 30 days prior to due date. Completed DTTs are then reviewed and analyzed and compared with past data to monitor individual agency and all-agency performance outcome trends. Lower performing agencies and performance measures showing lack of improvement across all agencies are selected for QI activities. Additional individual QI support is provided by MCH staff as needed.

 

Site Visits: In the past, MCH staff have conducted site visits at each Title V funded CHC at least once per each two year contract cycle to maintain relationships with CHC staff, observe how funds are utilized, review and discuss agency-specific data, work plan(s) and QI project(s), address agency identified needs, conduct chart reviews as needed (to assess if following Bright Futures Guidelines) and monitor program compliance. This has been put on hold during the COVID‑19 pandemic. However, staff have continued to provide technical support through individual virtual conference calls and semi-annual PC Coordinators’ meetings with all of the CHC contractors.

 

Overall, the CHCs funded by MCH have moderately high to high QI capacity. Most agencies have embedded QI into their organization’s culture and support QI activities by incorporating the following:

 

• Designating a QI team led by a full time Quality Assurance Manager
• Setting an expectation that all staff members will participate in one (1) to two (2) QI projects each year and allocating hours (limited) for staff members of any discipline to participate in QI projects
• Including QI participation on staff annual performance review
• Allocating IT support to automatically generate data reports, which allow the QI team to analyze data monthly/quarterly.

At this time nine (9) of 15 MCH Primary Care contracted agencies contract for clinical and administrative system infrastructure support with a Health Center Controlled Network known as the “Community Health Access Network” (CHAN). CHAN provides a computer network system, which integrates electronic medical records (EMR), practice management and accounting systems. As CHAN is responsible for writing these agencies’ data queries, the MCH QI and Clinical Services Administrator has established contact with a specific CHAN staff member to discuss issues related to performance measure data collection, i.e. feasibility of collecting particular data, how to align MCH performance measures with other federally required measures, etc. Through CHAN, data reporting and analytical functions have been automated allowing CHAN-affiliated QI staff the ability to generate real time data displays.

 

Transformation of the CHC scope of services and new Request for Proposals: In the fall of 2021, revisions were made to the scope of services and the performance measures for the CHCs to even further target efforts in improving access to integrated primary care (including prenatal and behavioral health services) to the MCH target population of women, infants and children. Performance measures for a new scope of services were included in a Request for Proposals (RFP) RFP-2022-DPHS-19-PRIMA: Maternal and Child Health Care in the Integrated Primary Care Setting | New Hampshire Department of Health and Human Services (nh.gov) that was released at the beginning of calendar year 2022. Proposals were reviewed March of 2022 and were allocated funding utilizing a new formula, which took into account proposal scoring (proposals had to score a minimum of 70 to be funded), number of MCH clients/patients in each category and need of the MCH population served (percent uninsured, percent on Medicaid, etc.). The Governor and his Executive Council approved the contracts in the middle of June 2022.

 

As part of the RFP revisions, the scope of services was revised to put an increased emphasis on Social Determinants of Health (SDOH) screenings and follow-up to align with the Title V State Performance Measure. Title V funded CHCs are now required to have at least two ES workplans, with one focusing on SDOH screening and follow-up. In addition, organizations were required to select a second ES focused initiative, and were given a ‘menu’ of potential ES options to choose from, including, but not limited to:

 

• Increasing rates of developmental screenings and/or implementing visits with Child Development Specialist.
• Increasing number of postpartum women who have lactation support.
• Increasing referrals to home visiting for qualifying children.
• Initiating the Plan of Safe/Supportive Care during the prenatal period for pregnant women with Substance Use Disorder.
• Implementing the ACEs (Adverse Childhood Experiences) screening in the child/adolescent population.
• Providing targeted outreach to homeless women, children and adolescents.
• Providing an Injury Prevention Initiative for infants, children and adolescents such as safe sleep and/or suicide prevention.
• Implementing a project involving a Community Health Worker targeted to the population of women, infants, and/or children.
• Implementing a program or service aimed to increase behavioral health integration for women and children within the medical practice that may include, but is not limited to:
  • Psychiatric teleconsultation; and/or
  • Educational/training opportunities for treating women and children with mental health concerns.

 

Performance measures were revised to include a developmental screening measure, a Screening, Brief Intervention and Referral to Treatment (SBIRT) measure focused on the adolescent population and lead screening measures that were in line with state legislation that mandates lead testing at both one and two years of age. The following are the revised performance measures for SFY23 and 24:

 

 

Funded CHCs were required to submit two QI workplans, the first being the adolescent well-visit measure to align with the Title V Performance Measure as well as one performance measure of their choice.

 

 

*  *  *  *  *  *  *

 

State Performance Measure #3

Percent of enrolled pediatric primary care providers that received pediatric mental health teleconsultation from the Pediatric Mentral Health Care Access (PMHCA) Program.

 

Objective: Increase the percentage of enrolled providers who  receive Pediatric Mental Health Care Teleconsultation in the NH Pediatric Mental Health Care Access (PMHCA) Program from a baseline of 23% in 2020 to 41% in 2026.

 

Strategies:

• Provide NH pediatric primary care providers with additional training on the assessment and treatment of children with mental health concerns by:
  • Development of a Pediatric Mental Health Project ECHO series facilitated by the NH Pediatric Mental Health Team faculty of local subject matter experts.
  • Recruitment of pediatric primary care practices across NH to participate in the Pediatric Mental Health Project ECHO, targeting those in rural/underserved areas.

 

• Provide teleconsultation opportunities as needed for primary care providers with the PMHCA pediatric mental health team faculty members by:
  • Promotion of the Teleconsultation opportunities for participating pediatric primary care practices with the NH Pediatric Mental Health Team faculty.

 

• Continuation of teleconsultation services by:
  • Increased NH pediatric primary care physician satisfaction with using teleconsultation as a way to build their knowledge and confidence in treating children with mental health conditions
  • Development of a plan for program sustainability

 

Background

New Hampshire Children’s Mental Health

 

According to the 2020 National Survey of Children’s Health (NSCH) results, New Hampshire has been ranked as having the highest rate of children ages 3-17 years-old with at least one or more reported mental, emotional, developmental, or behavioral health problem, at 30%, which is significantly higher than the national average of 23%.[4] This ranking has also worsened from NH having the second highest rate in the 2018-2019 NSCH results to now the highest rate nationally[5].

[6]

 

Additionally, a recent analysis of claims data of NH children on Medicaid and commercial insurance has found that overall, 24% of children on Medicaid and 17% of children on commercial insurance have a documented mental health condition for which they had received treatment for during 2019. An analysis comparing 2019 claims to 2020 will likely be forthcoming and will shine light on the impact that the COVID‑19 pandemic had on children’s mental health across the state.

 

[7]

 

Furthermore, the latest Youth Risk Behavior Survey Data Summary and Trends Report (2019), shows that youth mental health and suicidality rates are trending in the wrong direction. Of the students surveyed, 37% reported experiencing persistent feelings of sadness or hopelessness, compared to 26% surveyed in 2009. For those experiencing these depressive symptoms, 16% made a suicide plan compared to only 11% in 2009. This data was collected in 2019, pre-pandemic, so we may suppose that these numbers are actually higher now and will likely see this in the next YRBS results.

 

[8]

In order to get a more current and accurate look at youth mental health during the COVID‑19 pandemic, there was a recent survey administered entitled the Adolescent Behaviors and Experiences Survey (ABES), which was conducted by the CDC from January-June 2021 which assessed student behaviors and experiences during the pandemic. Results found that 44% of adolescents surveyed reported experiencing persistent feelings of sadness or hopelessness almost every day for two weeks or more in a row to where they stopped doing some usual activities. Even more concerning is that 20%, or 1 in 5 students surveyed, reported that they had seriously considered attempting suicide within the last 12 months. [9] To address these growing concerns, in December 2021 the U.S. Surgeon General Dr. Vivek Murthy issued a Surgeon General’s Advisory for Protecting Youth Mental Health to highlight the urgent need to address the nation’s youth mental health crisis.[10]

 

[11]

 

Compounding the youth mental health crisis, much of New Hampshire continues to experience a mental health professional shortage.[12] Additionally, the American Academy of Child and Adolescent Psychiatrists has found that half (five out of ten) of the NH’s counties were determined to be insufficient in their number of child and adolescent psychiatrists (CAPs) and two of NH’s counties had none at all.

[13]

Moreover, the NH Mental Health Practitioner (MHP) Licensure Survey conducted in 2018-2019 by the NH Division of Public Health Services’ Health Professions Data Center found that only 25% of mental health practices were located in rural public health regions which is where they are needed most in order to increase access for the underserved NH residents that live in the more rural areas of the state.

[14]

 

National Outcome Measures (NOMS) influenced by children’s access to mental health treatment

NOM 18 - Mental health treatment or counseling, age 3-17 years: According to the 2020 National Survey of Children’s Health, only 50% of NH children age 3-17 years old with a mental health disorder received mental health treatment or counseling in the past year (see graphic below), while the national average was 52%.[15] This is, however, an improvement from the previous 2018-2019 NSCH results that showed only 47% of NH children received mental health treatment for their condition.[16]

 

 

According to the National Alliance on Mental Illness NH (NAMI NH), as of April 15th 2022, there were a total of 19 children waiting in local Emergency Departments for inpatient psychiatric beds.[17] Comparing this to the previous year on April 1st 2021, there were 16 children waiting for a bed. [18] This number has remained relatively stable likely due in part to the continued efforts to divert people from emergency departments through increasing behavioral health integration into primary care, particularly in Community Health Centers that are being supported in part with Title V funding.

 

Also important to note is the roll-out of the NH Rapid Response Access Point that occurred in January 2022, which is a 24/7 service where NH residents can speak to a trained mental health professional via phone, text, or chat when in crisis. In order to alleviate the Emergency Room boarding crisis of people waiting for psychiatric evaluations, the local community mental health centers now have mobile crisis response teams that will go out to the individual in crisis to assess the need for potential hospitalization rather than the previous model of advising those in crisis to go to their local Emergency Room for assessment. Beginning in July of 2022, anyone looking to contact the Rapid Response Access Point will simply be able to dial 9-8-8 to access these crisis supports.

[19]

 

The rising rates of children with mental health disorders along with only about half of those children receiving mental health treatment continues to demonstrate the necessity of programs aimed at increasing children’s access to mental health care in New Hampshire. One of the recommendations recently provided by the newly established Surgeon General’s Advisory for Protecting Youth Mental Health (2021) is to,

 

“Support integration of screening and treatment into primary care. For example, continue expanding Pediatric Mental Health Care Access programs, which give primary care providers teleconsultations, training, technical assistance, and care coordination to support diagnosis, treatment, and referral for children with mental health and substance use needs. (p.36)”[20]

 

To address this, the NH Maternal and Child Health (MCH) Section’s Pediatric Mental Health Care Access (PMHCA) HRSA grant continues to fund the NH Mental Health Care Access in Pediatrics (NH MCAP) Program which is a collaboration with the University of New Hampshire Institute for Health Policy and Practice that aims to integrate behavioral health services into pediatric primary care. The NH MCAP Program utilizes a pediatric mental health team of subject matter experts that is comprised of specialists in the field who provide education, support, and consultation to primary care providers using the Project ECHO telemontoring model. The integrated nature of the program works to enable enrolled providers to feel more confident and knowledgeable in conducting early identification and treatment of children with mental health conditions.

Through participation in NH MCAP, enrolled providers can increase their ability to screen and treat children’s mental health issues within their primary care setting which allows children to receive the mental health care where and when it is needed most. Through integrating these behavioral health services into the primary care setting, significantly fewer children will be referred out and put on long wait lists to access treatment. Behavioral health integration will also expand early intervention for mental illnesses which continues to be a major component of NH’s 10‑Year Mental Health Plan.

[21]

In order to address the NH 10 Year Mental Health Plan’s established goal of “improving the recruitment, retention, and quality of the mental health workforce,” MCH is continuing its Title V funded contract with the New Hampshire-Vermont Recruitment Center of Bi‑State Primary Care Association (Bi‑State Recruitment Center) for recruitment of behavioral health professionals (defined as psychiatrists, clinical or counseling psychologists, psychiatric nurse practitioners, masters prepared social workers, mental health counselors, family therapists, and licensed alcohol and drug counselors). Recent data from the Bi‑State Recruitment Center has identified 33 vacancies (5 psychiatrists, 9 psychiatric nurse practitioners, and 19 behavioral health counselors) that they are actively recruiting for statewide as of May 2022.

[22]

In addition to the 33 behavioral health provider vacancies that the Bi‑State Recruitment Center is actively recruiting for, the NH Community Behavioral Health Association (CBHA) who has been collecting data on NH’s ten Community Mental Health Center (CMHC) vacancies since 2015, reported that in January 2022 that there were a total of 400 behavioral health professional vacancies among CMHC’s across the state. This vacancy rate has almost doubled since the previous year.

[23]

 

Systems Building

To address this need for increased access to mental health care for NH children, MCH’s NH Pediatric Mental Health Care Access (PMHCA) Program continues to work to increase pediatric primary care provider knowledge and confidence in identifying, screening, and treating pediatric patients with mental health concerns. In 2019, through contract with the University of New Hampshire Institute for Health Policy and Practice (UNH IHPP) the NH Mental Health Care Access in Pediatrics (NH MCAP) Program was created to:

 

• Develop and facilitate three Pediatric Mental Health Project ECHO cohorts over the course of the five-year PMHCA grant period
• Offer individual provider-to-provider teleconsultations from the ECHO Pediatric Mental Health Team of subject matter experts
• Create a referral directory of NH pediatric mental health services and supports, which is to be updated and redistributed annually to enrolled participants

 

The NH MCAP Program is utilizing the Project ECHO (Extension for Community Health Outcomes) model which is an evidenced based all-teach all-learn method developed by the University of New Mexico and is practiced in the US and internationally. UNH is the only Project ECHO hub in NH that is focusing on children’s behavioral health. The NH MCAP Project ECHO sessions connect participating practices/primary care providers via web-based conference technology to participate in a 20‑minute didactic presentation from established pediatric mental health faculty experts on set curriculum objectives. After the didactic training, a participant then presents a case study and receives feedback and recommendations from both the pediatric mental health faculty members of subject matter experts and also from peers at the other participating pediatric primary care practices.

 

There has been a new NH MCAP Project ECHO cohort each year which has taken place from February through November. Each cohort has one ECHO session per month during that time period (10 sessions total) and each cohort has a unique curriculum based on a different children’s mental health topic. The first cohort took place in 2020 and focused on Pediatric Depression and Anxiety, the second cohort occurred in 2021 and focused on Pediatric ADHD and Trauma, and the third cohort that is currently taking place in 2022 is focusing on Promoting Child and Family Resilience and Healing in a Pandemic. Curriculum topics for the didactic trainings in this cohort include:

 

• Pandemic impact, brief interventions, and relational health
• Building Family Relational Health
• Community supports to reduce family stressors and promote relational health
• Use of Occupational Therapy to address mental health and build relational health
• Anxiety: use of “common elements” and “common factors” to deliver a brief intervention
• Depression: use of “common elements” and “common factors” to deliver a brief intervention
• Difficult/Disruptive behaviors in young/school age children: brief interventions to support self-regulation, coping, and communication as well as linkage to supports
• Eating disorders (Part 1): Types of eating disorders, epidemiology, pandemic impact, and screening
• Eating Disorders (Part 2): Evidence-based treatments and linkage to supports  for common eating disorders
• Special populations: CYSHN, BIPOC, LGBTQ, grandparent as parents, foster children, building therapeutic relationship and population-specific resources

 

 

To measure impact on enrolled providers’ change in knowledge and confidence in treating children with mental health concerns as a result of participating in the NH MCAP Project ECHO cohorts, the providers are required to complete both a pre-cohort and post-cohort survey which asks them to rate their perceived knowledge and confidence in various children’s mental health treatment competencies. The knowledge related questions are rated on the Likert scale: 1 - Not knowledgeable, 2 – Slightly knowledgeable, 3- Fairly Knowledgeable, 4 –Knowledgeable, and 5 – Very Knowledgeable. The confidence related questions are rated on the Likert scale: 1 – Completely lacking confidence, 2 – Somewhat lacking confidence, 3 – Neither lacking confidence nor confident, 4 – Somewhat confident, and 5 – Completely confident.

 

All of the questions answered by the enrolled providers in the last cohort (cohort 2 in 2021) showed an increase in both knowledge and confidence. An example of one of the knowledge related questions is, “How knowledgeable are you about screening for and diagnosing mental/behavioral conditions co-occurring with trauma such as anxiety and depression?” The pre-cohort participant averaged rating was 3.05 (“Fairly knowledgeable”), and upon completion of the cohort the average for this question went up by 1.12 points to 4.17 (“Knowledgeable”) on the post-cohort survey.

 

An example of one of the confidence related questions is, “How confident are you about screening for and diagnosing ADHD in children and adolescents?” The pre-cohort survey average for this question was 3.5 (“Neither lacking confidence nor confident”) and the post-cohort survey average went up by 0.83 points to 4.33 (“Somewhat confident”).

 

 

Enrolled providers also have the opportunity to request teleconsultations as needed throughout the cohort with the pediatric mental health team faculty subject matter expert(s) of their choice to continue improving their skills in the assessment and treatment of children with mental health concerns. Over the course of the second Project ECHO cohort in 2021, the NH MCAP Program had a teleconsultation utilization rate of 31.6% with 12 teleconsults provided to unique providers among the 38 providers enrolled in the program. With the goal of increasing utilization to 41% by 2026, it is important to continue increasing the pediatric primary care providers’ satisfaction and comfort level with using teleconsultation as a way to build their knowledge and confidence in treating children with mental health conditions. Program staff have continued to utilize many strategies to improve the teleconsultation utilization rate, which have included:

 

• Sending reminder emails twice per month suggesting utilizing teleconsults as well as during each ECHO session
• Offering a free NH MCAP glass water bottle for a provider’s first teleconsult
• Implementing “faculty highlights” during ECHO sessions to spotlight each faculty subject matter expert and the different questions they can help participants with during teleconsults.
• Surveying participants regarding barriers in utilizing teleconsults
• Following up with each case presenter and encouraging them to utilize the faculty expertise to address any unresolved or newly developed aspects of their case.

 

 

Although the teleconsultation process was changed during the summer of 2021 based on provider feedback from twice per month open office hours to an as needed model where the subject matter expert will respond to a teleconsult request and schedule the teleconsult within 48 hours, the increase in utilization was not as much as expected. Program staff have found that often times enrolled providers will say that they would like to utilize a teleconsult but then do not have the time to follow-through or to coordinate with the subject matter experts a scheduled time for the teleconsult that works for them both. As we know, providers are stretched thin now more than ever which causes them to be short on time and often over-scheduled. Perhaps if NH MCAP was able to utilize a hotline type teleconsult model where providers can call and speak to the subject matter expert right then when it is needed, this would be most time efficient and user friendly for the providers. However, program staff and the subject matter experts do not have the capacity to provide this type of model under the current program budget. If additional funding is received beyond the end of this grant period in September of 2023, the NH PMHCA Program will use this knowledge to create a plan to adjust to this model that has worked in other states’ PMHCA programs.

 

In addition to the program activities listed above, NH MCAP was also able to leverage unused travel funds to develop and facilitate an additional learning opportunity/webinar titled “Improving Clinical Communication for Student Mental Health” which explored issues and on-the-ground experiences for supporting clinic-school-family communication within the regulatory frameworks of the health (HIPAA) and educational (FERPA) systems. Webinar panelists included NH pediatric primary care clinicians, school nurses/administrators, a family advocate, and legal/policy expert.

 

Bi-State Primary Care Recruitment Center

Although the original state performance measure #3, “the percent of behavioral health professionals recruited,” has been retired as of this year, MCH is continuing its Title V funded contract with the New Hampshire Vermont Recruitment Center of Bi‑State Primary Association (Bi‑State Recruitment Center) for behavioral health professional recruitment. To address behavioral health provider vacancies, in 2021 the Recruitment Center had reached or sourced 254 candidates.

 

From January 1, 2021 to December 31, 2021, 41% or 104 of the 254 sourced contacts became “active” with the Recruitment Center. From an active status, an individual is then referred for matching to the recruiting agency for potential interviews, etc. Out of the 104 active contacts, 101 were referred to employers. Five professionals secured positions: one psychiatric nurse practitioner, one social worker, and three mental health counselors.[24] The following table outlines the variety of behavioral health professionals sourced, activated/matched, referred and recruited.

 

 

During the past year, the Recruitment Center has used a combination of strategies in its recruitment efforts which include:

 

• Participating in multiple virtual career fairs with residency programs nationwide through their CareerMD Regional Access
• Presenting at the National Association of Socal Workers (NASW) NH 2022 Annual Conference
• Referring candidates to client organizations through the 3RNet Auto Referral feature
• Listing on PracticeLink online job board and candidate database
• Recruiting at the NH Behavioral Health Summit 2021
• Presenting for Mental Health Counselor students at Rivier University, Nashua, NH
• Presenting for Mental Health Counselor students at Plymouth State University, Plymouth, NH
• Listing advertisements in the National Association of Social Workers quarterly newsletters for NH, Massachusetts and Connecticut

 

In addition, Bi‑State continues to work to inform agencies that hire mental health treatment providers of recruitment center (RC) services and provide technical assistance to organizations and regions, inclusive of Integrated Delivery Networks (IDNs), with recruitment needs for mental health providers. For exmaple:

 

• RC staff conducted a Zoom session with a community health center as they hired a new HR Director. The purpose of the meeting was to re-introduce their services and provide technical assistance regarding salary information. The RC followed up with information on salary averages for LCSWs, CMHCs, and other master’s level behavioral health providers to an FQHC.
• Reached out to all Premium Promotional contacts several times to provide support and inquire about behavioral health recruiting needs. Many sites continued with their recruitment efforts during the pandemic. The RC has continued to promote their organizations and their job openings in social media, job postings and when attending virtual events.
• Reached out to all Contingency and Premium Promotional clients to keep abreast of updates relating to federal loan repayment programs.
• The RC conducted outreach to psychiatrist nurse practitioners, mental health clinicians, psychiatrists, and psychologists who expressed interest in NH opportunities through the website Indeed.com. Each clinician was provided information about opportunities located at sites that have openings listed with the RC.
• Shared information and web links with an FQHC regarding salary data for master’s level clinicians and psychiatric nurse practitioners.

 

The recruitment center continues to update the comprehensive resource library on its website that includes key resources to help facilities stay current on the ever-evolving COVID‑19 related policies and procedures, as well as available funding sources to enable them to continue to provide services. Updates are emailed to health centers in a weekly bulletin.

 

MCH Specific Activities

In addition to the project activities within the PMHCA grant, the PMHCA Program Coordinator (leveraged to a full FTE with Title V funding) continues to collaborate and create linkages with other departments and organizations through engaging in various stakeholder and other state agency committees to further the improvement of NH children’s mental health initiative. These include:

 

• The NH Department of Education and the Bureau for Children’s Behavioral Health’s System of Care Advisory Council

Meets bimonthly with the mission to promote, align, and continuously improve System of Care Principles and values into every relevant initiative, support system, service of child welfare, juvenile justice, behavioral health, education, primary care, first responders, public health, and community providers at the family, organization, community, regional, and state levels.

• NH Children’s System of Care Technical Assistance Center Leadership Advisory Team

Meets bimonthly to support the establishment of a resource center for children’s behavioral health that is available statewide and acts as a clearinghouse for information and resources on evidence-based practices for children receiving mental health services.

• The Building Futures Together Leadership Team

Meets bi-monthly to support the grant funded Building Futures together program which will prepare 98 paraprofessionals in healthcare and school settings to provide specialized enhanced care coordination to children, youth and their caregivers whose parents are impacted by substance use disorders (SUD).

• NH PIP Steering Committee

Meets quarterly to work on promoting awareness of and interest in pediatric care quality measurement, projects, and resources, and is made up of a diverse group of stakeholders from around the State.

• Watch Me Grow Steering Committee

Meets monthly to help guide the NH Watch Me Grow developmental screening system.

 

Social Messaging

The PMHCA Program Coordinator continues to contribute to the DPHS/MCH social media presence by creating posts that highlight the need for increased access to mental health care for NH children that explain the presence and purpose of the NH MCAP Program, and that increase viewer knowledge on mental health statistics and resources.

 

 

 

 

[1] NH DHHS, Maternal & Child Health Section: Uniform Data Set Table, 2021

[2] MCH Staff (2022). Documented from ES Workplan Outcome.

[3] Ibid.

[4]Child and Adolescent Health Measurement Initiative. 2020 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 [5/3/2022] from [www.childhealthdata.org].

[5] 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 [5/3/2022] from [www.childhealthdata.org].

[6]Child and Adolescent Health Measurement Initiative. 2020 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 [5/3/2022] from [www.childhealthdata.org].

[7] Tutko H, Porter J, Shessler E, Swanson B, Plante E-L, Costello A. NH Children and Teens Experiencing Mental Health Disorders: An Analysis of 2019 Health Care Claims Data. Concord, NH: University of New Hampshire; 2022.

[8] Youth Risk Behavior Surveillance System (YRBSS). Youth Risk Behavior Survey Data Summary & Trends Report 2009-2019, accessed on 5/10/2022. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBSDataSummaryTrendsReport2019-508.pdf

[9] Jones SE, Ethier KA, Hertz M, et al. Mental Health, Suicidality, and Connectedness Among High School Students During the COVID-19 Pandemic — Adolescent Behaviors and Experiences Survey, United States, January–June 2021. MMWR Suppl 2022;71(Suppl-3):16–21. Retrieved May 4, 2022, from https://www.cdc.gov/mmwr/volumes/71/su/su7103a1.htm?s_cid=su7103a1_w

[10] Office of the Surgeon General, Protecting Youth Mental Health. The U.S. Surgeon General’s Advisory. (n.d.). Retrieved May 5, 2022, from https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf.

[11] Jones SE, Ethier KA, Hertz M, et al. Mental Health, Suicidality, and Connectedness Among High School Students During the COVID-19 Pandemic — Adolescent Behaviors and Experiences Survey, United States, January–June 2021. MMWR Suppl 2022;71(Suppl-3):16–21. Retrieved May 4, 2022, from https://www.cdc.gov/mmwr/volumes/71/su/su7103a1.htm?s_cid=su7103a1_w

[12] New Hampshire's mental health professional shortage areas - November 2021. (n.d.). Retrieved April 18, 2022, from https://www.dhhs.nh.gov/dphs/bchs/rhpc/documents/nhmhpsa-mentalhealth.pdf

[13]AACAP. (n.d.). Workforce maps by State. Retrieved May 9, 2022, from https://www.aacap.org/app_themes/aacap/docs/Advocacy/federal_and_state_initiatives/workforce/individual_state_maps/New%20Hampshire%20workforce%20map.pdf 

[14] Hernandez, D. (n.d.). Practice Location. NH DHHS Workbook: 2018-19 MHP workforce data report. Retrieved May 13, 2022, from https://dashboard.nh.gov/t/DHHS/views/2018‑19MHPWorkforceDataReport/Distribution?%3Aembed=y&%3Aiid=1&%3AisGuestRedirectFromVizportal=y

[15] Child and Adolescent Health Measurement Initiative. 2020 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 [5/3/2022] from [www.childhealthdata.org].

[16] 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 [5/3/2022] from [www.childhealthdata.org].

[17] NAMI NH (2022, April 15). Today, 19 children and 15 adults are waiting for inpatient psychiatric beds. If folks are experiencing anxiety, depression, thoughts of suicide. [Status update] Facebook. https://www.facebook.com/naminh1

[18] NAMI NH (2021, April 1). Today, 16 children and 41 adults are waiting for inpatient psychiatric beds.

If folks are experiencing anxiety, depression, thoughts of suicide. [Status update] Facebook. https://www.facebook.com/naminh1

[19] Beacon of New Hampshire. (n.d.). New Hampshire Rapid Response Access Point. Individuals/Families. Retrieved May 5, 2022, from https://www.nh988.com/individuals-families/

[20] Office of the Surgeon General, Protecting Youth Mental Health. The U.S. Surgeon General’s Advisory. (n.d.). Retrieved May 5, 2022, from https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf

[21] NH Department of Health and Human Services (2019). New Hampshire 10-Year Mental Health Plan January 2019. Retrieved on 4/20/22 from https://www.dhhs.nh.gov/dcbcs/bbh/documents/10-year-mh-plan.pdf

[22] Bi-State Primary Care Recruitment Center (2022). Personal communication with Workforce Recruitment Project Coordinator on 5/6/22.

[23] Jay Couture, N. H. B. F. 28. (2022, February 28). Commentary: The workforce problem is a mental health problem. New Hampshire Bulletin. Retrieved May 6, 2022, from https://newhampshirebulletin.com/2022/02/28/commentary-the-workforce-problem-is-a-mental-health-problem/

[24] Bi-State Primary Care Recruitment Center (2022). Personal communication with Workforce Recruitment Project Coordinator on 5/6/22.