State Performance Measure #1:

Retiring Measure (2015-2020):  Percentage of MCH-contracted Community Health Centers (CHCs) with Enabling Services (ES) work plan on file with DHHS/MCH

 

Objective: Increase the percentage of MCH contracted CHCs with an ES workplan on file with DHHS from the 2015 baseline of 60% (9 of 15) to 90% by October 2018.

 

Strategies:

 

• MCH will require CHCs to submit an ES work plan as a contract deliverable
• MCH will review completed ES work plans and provide feedback/technical assistance as needed to ensure activities are within the scope of services

 

New Measure (2020-2025): 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 primary care (PC), primary care for the homeless (PC-H) and prenatal services for low-income and uninsured individuals and families. In 2019, 14% of the 122,895 individuals served by the NH 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 7-25%).[1]  Note: The rate of uninsured is anticipated to increase in 2020 as a result of high unemployment rates experienced during the COVID-19 pandemic. It is critical to maintain this safety-net system of providers, as they are an essential source of care regardless of individual’s insurance status or ability to pay. 

 

 

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.

 

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 influence care by improving the quality of services, supporting health equity and reducing health care costs. The following are examples of the type of enabling services currently being provided by CHCs:

 

• Case management
• Benefit counseling
• Insurance eligibility and enrollment assistance
• Health education and supportive counseling
• Interpretation
• Outreach
• Transportation
• Education of patients and the community regarding the availability and appropriate use of health services

 

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 from one health center illustrates how MCH-contracted CHCs utilize funding for the provision of ES and the impact their ES services have had on families.

 

“The Health Care for the Homeless (HCH) Program of the City of Manchester Health Department, based at Catholic Medical Center, braids state and federal funds to employ two full-time staff members who significantly enhance enabling services. HCH employs a Health Educator who also functions as an Outreach Worker and as an Enrollment Specialist (salaries and benefits covered 5% by state and 95% by federal) and an RN who also does Care Coordination (salaries and benefits covered 10% by state and 90% by federal).

 

State funding provides HCH with greater capacity to reach and assist people experiencing homelessness, including men, women, and families. In response to the COVID-19 pandemic, HCH has collaborated with other agencies and has significantly expanded street outreach efforts. This has ensured that those who are experiencing unsheltered homelessness are kept informed of the most recent CDC guidelines, offered health education, assisted with health insurance enrollment and maintaining benefits, and connected with supportive services in the community. Case management also continues to be an integral part of the HCH patient visit, responsive to the patient’s social determinants of health and unique medical and behavioral health needs. State support of the salaries and benefits of these staff members is essential; without it, the multi-faceted needs that enabling services address would be neglected.

 

We are able to wrap around families who are in need of a myriad of community referrals and have barriers related to their social determinants of health. We are able to coordinate care with other housing agencies to quickly and effectively assist them in filling out housing applications and help them gather documents needed to obtain medical care, food resources, and get into their own apartment. We support families in fostering independence by providing budgeting resources, psychoeducation, and empowerment. We help families who experience homelessness gather their basic needs and get connected with parent education and both formal or informal wrap-around services and mental health treatment. We meet families where they are at to support them in filling out paperwork and getting them connected to services that will help them thrive.”

Source:  NH DHHS, MCH Section, email correspondence, 2019

 

Systems Building

 

MCH monitors contract deliverables to ensure that services are being provided in accordance with PC and PC-H services, scope of services, Exhibit A as follows:

 

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 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.

 

The following is an example of one CHCs staff list and excerpt of narrative used to justify MCH funding for the support of three (3) interpreters that was reviewed by MCH staff in 2019. The full narrative for each below staff member has been submitted and is not included for brevity.

 

 

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” (see below). 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, the MCH staff (QA/QI Nurse Consultant, Title V Program Administrator and Child Health Nurse Consultant) will review and provide feedback to as part of continuous QI. 

 

As the ES work plan is of critical importance to MCH’s understanding of how funds are being spent, MCH staff revised contract language starting in SFY18 to require the submission of an ES work plan, rather than leave it optional. Because of this change requiring an ES work plan as a contract deliverable, MCH increased the percentage of contracted CHCs that have an ES work plan on file with MCH from 60% in SFY16-17 to 100% for SFY18-19. As this measure has been maintained at 100%, MCH staff developed a new measure for 2020-2025, “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”. SFY19 workplans were reviewed to establish baseline data for this newly developed measure, which is 33% (5 of 15 have currently met or exceeded their ES targets). This new measure will expand MCH’s capacity to maintain CHC accountability by ensuring that CHCs establish Specific, Measurable, Attainable, Realistic, Timely (SMART) goals/objectives and are encouraged to progress toward demonstrated improvement.

 

In 2019, MCH received/reviewed the workplan outcome section from 100% of MCH contracted CHCs and provided feedback for performance improvement. An example of one agency’s ES work plan has been included below to demonstrate the agency’s use of funding to support early access to prenatal care.

 

 

Site Visits

 

MCH conducts a site visit during each contract period to allow an opportunity to meet face-to-face with the staff of each CHC to exchange information (hear about services and provide feedback). During site visits MCH conducts chart audits and reviews performance measure outcomes, ES work plans and budgets in person with CHC staff. The site visit interactions serve as further demonstration of agency accountability through in-person observation of how ES are being implemented and how funds are utilized. Site visits were deferred in 2019 to MCH-contracted CHCs due to staff assignment to other duties, such as establishing a new Pediatric Mental Health Care Access Program, and covering staff vacancies (Newborn Screening Program). MCH staff anticipates the resumption of site visits to occur in 2020-2021.

 

Ongoing MCH Specific Activities

 

MCH monitors program accountability and quality through the following activities:

 

• Contracting Process: Agencies who respond to a Request for Proposal have their proposal reviewed by MCH staff and DHHS Contracting Unit. This process allows MCH to ensure that agencies demonstrate capacity to fulfill contracted Primary Care and Preventive Services prior to the awarding of MCH funds. 
• Primary Care Services, Scope of Services: This contract document is developed by MCH staff (Program Administrator, Program Evaluation Specialist, QI/QA Nurse Consultant, Child Health Nurse Consultant) prior to each two (2) year contract cycle to clearly communicate Primary Care contracted services and reporting requirements (Work plans, Outcome Reports, Data Trend Tables, Uniform Data Set Tables, Perinatal Client Data Form). The Scope of Services document is made available to agencies in advance, prior to applying for funding. 
• Fiscal Monitoring: MCH and the DHHS Audit Team monitor all sub-recipient activities and financial management in accordance with OMB Circular A-133 compliance requirements for sub-recipients of federal awards. MCH staff ensures fiscal responsibility by reviewing contracted agency budget, budget justification, sources of revenue and program staff list annually. MCH staff ensures that work plan inputs/resources are accounted for in agency’s financial documents. MCH staff communicates budget discrepancies to contracted agencies for reconciliation. 
• Performance Measures: MCH staff works in collaboration with other DHHS programs including Chronic Disease Prevention and Screening Section, Bureau of Drug and Alcohol Services (BDAS), Tobacco Prevention and Cessation Program, to develop performance measures for MCH-contracted agencies prior to each two (2) year Primary Care contract cycle. As the majority of Primary Care contracted agencies continue to receive funding, MCH elicits input from contracted agencies by reviewing proposed performance measures and definitions prior to implementing the measures for the next contract cycle. MCH staff review agency feedback and revise performance measures as needed (e.g. to better align with a comparable measure for which agencies are federally required to collect data). MCH has implemented the below Primary Care Performance Measures for SFY18-19. In 2019, these measures were maintained for SFY20. 

 

NH Maternal & Child Health Section Primary Care Performance Measures SFY20-21   Percent of infants who are ever breastfed (Title V NPM #4) Percent of children three (3) years of age who had two or more capillary or venous lead blood tests for lead poisoning by their third birthday (NH MCH) Percent of adolescents 12 to 21 years of age, who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year (HEDIS) Percent of patients aged 12 and older screened for clinical depression using an age         appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen  (NQF 0418, UDS) Percent of women who are screened for clinical depression during any visit up to 12 weeks following delivery using an appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen (NH MCH) Percent of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside of normal parameters, a follow-up plan is documented  (NQF 0421, UDS) Percent of patients aged 3-17 who had evidence of BMI percentile documentation AND who had documentation of counseling for nutrition AND who had documentation of counseling for physical activity during the measurement year (UDS) Percent of patients aged 18 years and older who were screened for tobacco use at least once during the measurement year or prior year AND who received cessation counseling intervention and/or pharmacotherapy if identified as a tobacco user (UDS) Percent of pregnant women who are screened for tobacco use during each trimester AND who received tobacco cessation counseling intervention if identified as a tobacco user (NH MCH) Percent of patients aged 18-85 years who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHG) during the measurement year (NQF 0018) Percent of patients aged 65 years and older who were screened for fall risk at least once within 12 months (NH MCH) Percent of patients aged 18 years and older who were screened for substance use, using a formal valid screening tool, during an annual physical AND if positive, received a brief intervention or referral to services (NH MCH) Percent of patients aged 18 years and older who were screened for substance use, using a formal valid screening tool, during any medical visit AND if positive, received a brief intervention or referral to services (NH MCH) Percent of pregnant women who were screened, using a formal valid screening tool, for substance use, during every trimester they are enrolled in the prenatal program AND if positive, received a brief intervention or referral to services (NH MCH)   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

 Source: NH DHHS, Maternal & Child Health section, 2019

 

• Data Collection and Analysis: At the beginning of each state fiscal year, the MCH QA/QI Nurse Consultant requests contracted agencies to 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 the QA/QI Nurse Consultant and forwarded to contracted agencies with instructions for completion, 30 days prior to due date. Completed DTTs are then reviewed and analyzed by the QI/QA Nurse Consultant, 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 from the MCH QA/QI Nurse Consultant is provided as needed.
• Site Visits: MCH staff conduct site visits at each Primary Care contracted agency at least once per each two (2) year contract cycle to: maintain relationships with CHC staff, observe how MCH funds are utilized, review and discuss agency-specific data, work plan(s) and QI project(s), address agency-identified needs, provide individual agency support, conduct chart reviews (to assess if following Bright Futures Guidelines) and monitor program compliance.
• Technical Assistance (TA) and Support: MCH staff provide technical support via conference calls, site visits, and semi-annual PC Coordinators’ meetings. For example, presentations about Adverse Childhood Experiences (ACEs) were made during the Spring 2019 Primary Care Coordinators’ meeting. This provided an opportunity for the MCH QA/QI nurse consultant to lead conversations about how the ES work that is being done by CHCs addresses Social Determinants of Health, decreases family stress, improves family resiliency and reduce ACEs.
• Education: MCH staff disseminate information, resources and provide education via phone, emails and face-to-face interactions (meetings and site visits).
• Individualized Agency Support: MCH staff foster relationships with contracted agency staff and are available to provide assistance to the contract agency staff as needed via phone and email.
• Quality Improvement: The MCH QA/QI Nurse Consultant collaborates with Primary Care contracted agencies to build capacity and staff QI skills via email, phone and face-to-face interactions (meetings and site visits). The level of support provided by the MCH QA/QI Nurse is determined by the degree of agency QI capacity and need.

 

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 QA/QI Nurse Consultant 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.

 

*   *   *   *   *   *   *

 

Retiring State Performance Measure #3: Percent of behavioral health professionals recruited (number of sourced contacts that became “active”/number of reached or “sourced” contacts)

 

Objective: Increase the recruitment of behavioral health professionals by five percentage points over five years, from a baseline of 21% (in 2017) to 26% (in 2021).

 

Strategies:

• Assess the current behavioral health workforce
• Determine the factors that recruit and retain workforce
• Establish a vacancy tracking system with employers
• Establish relationships with professional training programs for pipeline development
• Social marketing, to attract behavioral health professionals
• Policy: Supporting the State Loan Repayment Program for behavioral health professionals and changing credentialing requirements

 

New State Performance Measure #3a: Percent of pediatric mental health teleconsultation utilization by NH pediatric primary care providers who are enrolled in the newly established Pediatric Mentral Health Care Acess (PMHCA) Program.

 

Objective: Increase the percent of pediatric of pediatric mental health teleconsultation from a baseline of 25% in 2020 to 75% utilization in 2025.

 

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 open office hours for Teleconsultation opportunities 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 upon completion of the HRSA grant period 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 following the end of the PMHCA grant award period.

 

Background

New Hampshire Children’s Mental Health

According to the latest NH Youth Risk Behavior Survey (YRBS) 2019 results,[2] NH adolescents are experiencing an increase in the percentage who feel sad, hopeless, or helpless almost every day for two or more weeks in a row, which caused them to stop doing usual activities within the last 12 months, from 28% in 2018 to 33.6% in 2019. There has also been an increase in the percentage students who seriously considered attempting suicide in the last twelve months, from 16.1% in 2018 to 18.4% in 2019 and an increase in the percentage who attempted suicide in the last 12 months, from 5.9% in 2018 to 7% in 2019.[3]

 

NH DHHS released its newest 10-Year Mental Health Plan[4] in January 2019, which for the first time focused heavily on improving children’s mental health. There are key goals and action items that directly relate to MCH’s PMHCA Program. The first is through intervening “upstream” to prevent the emergence or halt the progression of mental illness by expanding early intervention, which is expected to improve as a result of the PMHCA Program increasing pediatric primary care providers’ knowledge and confidence in screening and treating children’s’ mental health disorders within their own practice when feasible.

 

 

Along with the prevention and early intervention goal and strategies, the 10-Year Mental Health Plan also has a goal to increase support among those with mental health conditions effectively within their home communities with integrating behavioral health into primary care as a key strategy.

 

 

Integration of behavioral health into primary care settings improves health outcomes for both children and adults. Considering that much of NH is experiencing mental health professional shortages,[5],[6] patients can wait weeks, if not months for an intake with a mental health provider once referred. Reports have also shown workforce shortages and high staff turnover, as extreme as one in five per year for children’s providers.[7]

 

According to the 2017-2018 National Survey of Children’s Health, NH ranks as having the 6th highest rate in the US of children ages 3-17 years having at least one mental, emotional, or behavioral problem, at 26.4%.[8]

 

According to that same survey, only 51.3% of NH children ages 3-17 years-old with a mental health disorder received mental health treatment or counseling in the past year.

 

Data from the MCH’s Title V funded contract with the New Hampshire Vermont Recruitment Center of Bi-State Primary Association (Recruitment Center) for their behavioral health professional recruitment (defined as psychiatrists; clinical or counseling psychologists; nurse practitioners; masters prepared social workers, mental health counselors, and family therapists; licensed alcohol and drug counselors; and masters prepared licensed alcohol and drug counselors) identified 112 vacancies statewide as of June 1, 2020.

 

[9]

Upon recommendation from the 10-Year Mental Health Plan, additional state funds were put into the State Fiscal Years 20 and 21 budget for contracts put out into the communities for increased funds for community mental health centers and additional mobile behavioral health crisis response units. That along with the behavioral health/primary care integration, particularly in Community Health Centers/FQHCs that is being supported in part with Title V funding, has helped to make the week of March 31st of 2020 the first time in eight (8) years that no one in a mental health crisis was waiting in an emergency department for an inpatient psychiatric bed.[10] Neither an adult nor a child, was waiting. The number of people waiting for inpatient behavioral or mental health admissions in emergency departments is usually indicative of a need for enhanced community supports and crisis response. “No one waiting” has not continued consistently since then, but the very fact that it happened at all and does so after such a long period of time, has shown that the efforts in the community have been effective in diverting people from emergency departments and hospitalization.

 

Systems Building

In October 2018, the NH DHHS Division of Public Health Services, Maternal and Child Health Section (MCH) was awarded a five year HRSA Pediatric Mental Health Care Access Program (PMHCA) grant to address barriers to mental health care for NH children. This program aims to increase NH pediatricians’ and primary care providers’ capacity to address behavioral health needs of NH children 0-21 years of age. For the first time, the NH MCH section is able to leverage Title V funds (20%) in conjunction with the HRSA PMHCA grant (80%) to create a designated program and full time 1.0 FTE housed within MCH addressing children’s access to mental health treatment. By increasing the capacity of primary care physicians to both screen and treat patients’ mental health conditions within their practice, the NH PMHCA Program helps to decrease the amount of children that become lost in the referral system and increase those who can get access to the mental health treatment where and when they need it.

 

One of the key activities of the PMHCA program has been the establishment of a Pediatric Mental Health Project ECHO through a partnership with the University of New Hampshire’s Institute for Health Policy and Practice (UNH IHPP). Project ECHO (Extension for Community Health Outcomes) is a trademarked, evidenced-based all-teach all-learn method developed at the University of New Mexico and practiced widely in the US and internationally. UNH is one of two Project ECHO “Hubs” for NH and the only one focusing on efforts related to behavioral health in children. Project ECHO sessions use web-based conferencing technology to bring participants together from their clinic sites with just an internet connection and a computer with a camera. During ECHO sessions, practices participate in a 15-20 minute didactic presentation from established faculty experts on set curriculum objectives and they also present a case study and receive feedback and recommendations from both the expert pediatric mental health faculty members and their peers at the other participating pediatric primary care practices.

 

Over the course of the last year, MCH has worked diligently to create the infrastructure needed to get the PMHCA program up and running, which included: creation of a PMHCA Program Coordinator position within MCH, contract development and obtaining state approval with the subcontractor UNH IHPP, and receiving state fiscal and G&C approval to accept and expend the HRSA funding. These state processes took ten months to complete, but once all was approved, the program was able to hit the ground running in August of 2019 to begin implementing its set work plan. Within the next six months, all pediatric mental health faculty experts were recruited, the first ECHO cohort curriculum was developed, all pediatric primary care practice slots were recruited, and the first pediatric mental health Project ECHO cohort started on March 10, 2020.

 

Considering the longer than expected length of time to get the Project ECHO piece up and running with an approved contract with the UNH IHPP, the past nine months have been very productive with little to no setbacks, which has allowed a quick start-up of the first of the three pediatric cohorts. The current cohort consists of 16 pediatric primary care practices throughout the state of NH who are engaged in the PMHCA Project ECHO community of learning and consultation. Each cohort consists of a one hour-and-a-half session per month for ten months. Bi-weekly tele-consult hours are available with the pediatric mental health team faculty so participating practices have the opportunity to sign up when needed. Topics being covered in the didactic presentations in the first PMHCA Project ECHO cohort include:

 

• Making Sense of Behavior
• Practice flow: screening, referral and closed loop follow up
• Depression in Children and Adolescents: Implications, Screening and Diagnosing
• Treating Depression: Strategies, Planning and Pharmacology
• Anxiety in Children and Adolescents: Implications, Screening and Diagnosing
• Treating Anxiety: Strategies, Planning and Pharmacology
• Suicidality
• Parent and Family Support
• Staff training and competencies
• Working with External Partners

 

In addition to the learning opportunities presented within these didactic presentations and case studies, enrolled providers will also have multiple opportunities throughout each month to request a teleconsultation with the faculty expert(s) of their choice to continue improving their skills in the assessment and treatment of children with mental health concerns. Within the next year (2020-2021) the PMHCA Program will be establishing its baseline for the teleconsultation utilization rate among pediatric primary care providers enrolled in the program. As the first Project ECHO and Teleconsultation cohort just began two months ago, program staff will assess teleconsultation needs and barriers to better understand how to best promote this valuable service.

 

The NH PMHCA Program has also been able to leverage funds to develop a new condensed four session ECHO program to respond quickly to the unique needs of pediatric and family practices and other service providers in the state in light of the COVID-19 pandemic. This ECHO project focuses on implementing and effectively utilizing telehealth with special populations, including children and youth. Prior to the COVID-19 pandemic, telehealth was not a popular platform used by many practices in NH, mainly due to poor health insurance reimbursement among NH insurers. Now that billing and reimbursement laws have been loosened to allow providers to bill for telehealth, it is possible that major changes will be coming in the future that will allow for providers to continue providing healthcare via telehealth platforms. In this new ECHO project there are four sessions, with didactic topics including: An Introduction to Telehealth, Addressing Mental/Behavioral Health, Challenges and Solutions, and The Future of Telehealth, occurring every other week that started on May 13th 2020.

All together there were 93 individuals that registered for the new ECHO series, from the following organizations:

 

• 13 Behavioral/Mental Health Organization

• Five Peer/Family Support Organization

• 30 Primary Care Practices

• 16 Social Service Organizations

• Seven State/Local Public Health Agency/Networks

 

Bi-State Primary Care Recruitment Center

As stated previously, there are 112 vacancies for behavioral health providers in the State as of June 1st, 2020. [11] The retiring state performance measure (although the contract with the Recruitment Center is continuing) is the percent of behavioral health professionals recruited, which is defined as the number of “active” contacts divided by the number of reached or sourced contacts. A reached or sourced contact is someone who the Recruitment Center has communicated with (electronically, in-person, etc.) who has expressed an interest in working in the state of NH. A contact is considered “active” if that person has actually followed-up and sent a resume and additional personalized information to seek a position. To address these vacancies, since July of 2019, the Recruitment Center has reached or sourced 380 candidates.

 

Nineteen percent, or 74, of the 380 sourced contacts became “active” with the Recruitment Center since July of 2018. From an active status, an individual is then referred for matching to the recruiting agency for potential interviews, etc. The 74 active contacts became matched with 66 job opportunities (some matched to multiple opportunities). Two professionals secured positions; one MLADC and one psychiatrist, both in medically underserved areas (MPSAs). This year’s percentage of sourced candidates that became active did not meet this year’s objective of 26%. However, sourced candidates were up 60%; but, matched candidates were down 9%. This has been an extremely unusual year when many recruitment strategies became virtual because of the COVID‑19 pandemic. The following table outlines the variety of behavioral health professionals sourced, activated/matched, referred and recruited.

 

[12]

 

Typically, the Recruitment Center uses a mixture of the following strategies in its recruitment efforts.

 

• Hosting a current vacancy map on the Recruitment Center’s website (http://bistaterecruitmentcenter.org/)

• Participating in recruitment events such as fairs, virtual events, exhibits, meetings and conferences.
• Subscriptions to web based job hosting sites such as 3RNet and other clinician job search engines and databases.
• Presentations to students enrolled in educational and training programs related to behavioral health.
• Posting of on-line and print advertisements that appear in professional journals and online concurrently.

 

The Recruitment Center is particularly focused on establishing relationships with training programs in the state/region for pipeline development. Research shows that where one does an end degree training program (e.g. residency, fellowship, internship, etc.) is more predictive of future practice location than is graduate or medical school.[13] Data from the most recent physician survey from the Rural Health and Primary Care Section show that the top five (5) residencies where the most recently graduated practicing physicians trained were almost all New England/New York.[14] This data is a key resource in recruitment initiatives. Some highlights of the past year’s recruiting efforts with training programs, were:

 

• Presentation series to Psychiatric Physician Residency Program at Dartmouth Hitchcock Medical Center on topics such as job searching techniques and National Health Service Corps loan repayment programs.
• Post Masters’ Psychiatric Nurse Practitioner Program at Rivier University enrolled in Medication Assisted Treatment (MAT) waiver certification. Presentations on job searching techniques and placements in NH. Similar presentations are done with the clinical mental health counseling students at Rivier.
• Program series is done biannually to the family nurse practitioner students at UNH similar to all of the series above.

 

All programs done since early March of 2020 were done virtually. All students interested were kept informed of NH opportunities and incentive resources through the Recruitment Center’s quarterly E-newsletter.

 

The National Rural Recruitment and Retention Network (3RNet) continues to be a significant tool for the Recruitment Center employer sites to identify qualified candidates, with premium sites now able to receive auto-referrals directly from 3RNet. Recruitment Center staff serve on the board of the 3RNet. In this capacity, they work with 3RNet to create best practices. Bi-State’s Recruitment Center has been invited to co-host the 2021 3RNet Annual Conference. In addition, Bi-State sponsored the 3RNet 2019 Recruitment for Retention Academy so that all NH healthcare organizations could participate in the six-part webinar series at no cost. The series ran October through December of 2019 and covered topics on recruitment planning, generating candidates, finding the right candidate fit, recruiting with incentive programs, and special consideration for recruiting mental health providers. New Hampshire participants included three critical access hospitals, five FQHCs, two community mental health centers and two community service organizations that are part of an IDN.

 

Recruitment Center staff shared expertise and provided technical assistance at numerous behavioral health workforce development meetings and forums. Involvement included:

 

• Regular participation in DISRIP IDN Workforce Taskforce meetings;
• Participation in the NH Children’s Behavioral Health Workforce Development Network meetings, including a 45-minute presentation on “Strategies for Attracting, Recruiting and Retaining Clinicians.”
• The Recruitment Center Director was a panelist at the policy caucus, focused on workforce, for the NH Center for Non-Profits;
• The Recruitment Center hosted an exhibit booth at the NH Behavioral Health Summit to promote its services with potential employers and candidates among the almost 600 attendees.

 

Due to event cancellations because of the COVID‑19 pandemic, Recruitment Center staff were unable to attend several conferences, including three National Association of Social Workers conferences (MA, CT, and NH). Recruitment Center staff evaluated planned recruiting strategies and pivoted outreach efforts that allowed candidate engagement without direct personal contact. This included expanding advertising efforts targeting social workers; increasing online job postings and database and resume searches targeting master’s level behavioral health clinicians, psychiatric nurse practitioners and psychiatrists; and the addition of participating in several virtual events targeting psychiatrists, psychiatric nurse practitioners and addiction counselors. Lessons learned and results of these efforts will be evaluated and assessed for determining outreach strategies for the coming year.

 

MCH Specific Activities

Engagement in Stakeholder and State Agency Committees

In addition to the project activities within the PMHCA grant, the PMHCA Program Coordinator has also been actively engaged 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.
• Creating Connections NH Interagency Council 
  • Meets bimonthly to support Creating Connections NH which is 4-year grant that is developing a continuum of care for adolescents and transition-aged youth with Substance Misuse and co-occurring Mental Health.
• Watch Me Grow Steering Committee
  • Meets monthly to help guide the NH Watch Me Grow developmental screening system.
• Autism Council
  • Meets bi-monthly to consider recommendations, identify priority issues, and assist state agencies in attracting resources for initiatives aligned with the Recommendations of the 2008 Commission on Autism Spectrum Disorders and the 2016 State Plan - Growing Supports and Services for Autism and other Related Developmental Disabilities.
• 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.
• SPARK NH Policy Committee 
  • Meets monthly to coordinate the development and implementation of a comprehensive strategic plan for early childhood in NH and collaborates with state agency and policy leaders to identify and support changes in policy regarding expectant families and children from birth through third grade and their families.

 

These groups allow the PMHCA Program Coordinator to collaborate and create linkages with other departments and organizations working together to enhance mental health services for NH children. The PMHCA Program Coordinator has also become a Certified Youth Mental Health First Aid Instructor and has instructed Youth Mental Health First Aid courses in NH teaching both teachers and other community members the signs and symptoms of mental health problems arising in youth and how to support them in receiving help.

 

Social Messaging

 

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

 

  

 

 

[1] NH DHHS, Maternal & Child Health Section: Uniform Data Set Table, 2019

[2] Youth Risk Behavior Surveillance System (YRBSS). 2019 Youth Risk Behavior Surveillance data query, accessed on 05/15/20. http://www.cdc.gov/yrbss.

[3] Ibid.

[4] NH Department of Health and Human Services (2019). New Hampshire 10-Year Mental Health Plan January 2019. Retrieved on 05/11/20 from https://www.dhhs.nh.gov/dcbcs/bbh/documents/10-year-mh-plan.pdf.

[5] New Hampshire's Mental Health Professional Shortage Area Designations. (2017, October). NH DHHS, Division of Public Health Services, Rural Health and Primary Care Section. Retrieved f on 07/26/2020 from https://www.dhhs.nh.gov/dphs/bchs/rhpc/documents/nhmhpsa-mentalhealth-2017.pdf

[6] Children’s Behavioral Health Collaborative. Improving Child and Community Health: Addressing Workforce Challenges in Our Community Mental Health Centers.  Retrieved on 07/26/2020 from http://www.endowmentforhealth.org/uploads/resources/id107/CMHC_Workforce_Full_Report_2016.pdf.

[7] Ibid.

[8] Child and Adolescent Health Measurement Initiative. 2017-2018 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health. Department of Health and Human Services, Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA MCHB). Retrieved 05/13/2020 from www.childhealthdata.org.

[9] Bi-State Primary Care Recruitment Center (2020). Personal communication with Director on 07/17/2020.

[10] National Alliance on Mental Illness (2020). ED Wait Resources. Retrieved on 07/29/2020 from https://www.naminh.org/find-support/erwait/.

[11] Bi-State Primary Care Recruitment Center (2020). Personal communication with Director on 07/17/2020.

[12] Ibid.

[13]  NH Health Professions Data Center (2019). 2018 Physician Workforce Data Report. Retrieved on 08/02/2020 from https://public.tableau.com/profile/danielle.weiss#!/vizhome/2018PhysicianWorkforceReport/TableofContents.

[14] Ibid.