The New Hampshire (NH) Title V program is a partnership of the US Department of Health and Human Services, Health Resources and Services Administration (HRSA) with the New Hampshire Department of Health and Human Services’ Maternal and Child Health (MCH) section, and the Bureau for Family Centered Services (BFCS), which administers programs for Children and Youth with Special Health Care Needs (CYSHCN). Together, these entities support core Title V public health functions including direct, enabling, population-based, and infrastructure-building services in maternal and child health including CYSHCN.

Title V’s programming focus comes from MCH and CYSHCN populations’ priority needs. A comprehensive five-year needs assessment was conducted in 2019-2020. Following an extensive data review, specific input from the public and stakeholders, as well as a capacity assessment, a list of priority issues emerged to form the basis of programming through 2025. Ongoing needs assessments are carried out routinely each year (e.g. focus groups, client satisfaction surveys, stakeholder workgroup meetings) to assure that programming remains consistent with needs, and to date the list of priorities established in 2020 are unchanged:

Priority need #1: Improve access to needed healthcare services for all populations.

NPM#10: Percent of adolescents, ages 12‑17 with a preventive medical visit in the past year.

Domain: Adolescent Health; and

NPM#12: Percent of adolescents with and without special health care needs, ages 12‑17 who received services necessary to make transitions to adult health care

Priority need #2: Decrease the use and abuse of alcohol, tobacco and other substances among pregnant women.

NPM#14.1: Percent of women who smoke during pregnancy

Priority need #3: Increase the focus of Title V on the Social Determinants of Health and the resolution of barriers impacting the health of the MCH population.

SPM#1: Percentage of MCH-contracted Community Health Centers who meet or exceed the target of their Enabling Services workplan

Priority need #4: Improve access to mental health services for children, adolescents and women in the perinatal period.

SPM#3: Percentage of enrolled pediatric primary care providers who received pediatric mental health teleconsultations from the Pediatric Mental Health Acre Access (PMHCA) Program

Priority need #5: Decrease unintentional injury in children ages 0‑21.

NPM#5: Percent of infants: a) placed to sleep on their back; b) placed to sleep on a separate approved sleep surface; c) placed to sleep without soft objects or loose bedding

NPM#7.2: Rate of hospitalization for non-fatal injury per 100,000 adolescents ages 10‑19

Priority need #6: Increase family support and access to trained respite and childcare providers.

SPM#2: Percentage of children and youth with special health care needs enrolled in BFCS services who report access to respite care

Priority need #7: Improve access to standardized developmental screening, assessment and follow-up for children and adolescents.

NPM#6: Percent of children, ages 9‑35 months, receiving a developmental screening using a parent-completed screening tool in the past year.

Specific strategies aiming to improve these performance measures are delineated in each population domain, in the State Action Plan table.

Roughly, 48% of Title V’s workforce has been in their position within DHHS for less than ten years and 63% of MCH and 47% of BFCS staff are under the age of 50. DHHS itself has rebranded itself with a new website (Welcome | New Hampshire Department of Health and Human Services (nh.gov)), hired a new Director of Human Resources and have put the recruitment of qualified staff on the top of their priority list. In addition, and for the first time in many decades, the Governor has approved a 10% across the board increase in salaries for all State personnel. This is dependent upon legislative approval by the end of June 2023.

NH’s Title V works with professional training pipelines in the State and their job boards, such as the increasing number of NH based colleges and universities awarding degrees in public health and the numerous schools of nursing. In direct response to the workforce shortage, particularly in health related fields, many new programs have been established within New Hampshire. These include an MD residency program in rural health/primary care at one of Title V’s contracted community health centers and a new MSN to be a Primary Care Family Nurse Practitioner at UNH (funded by HRSA’s Advanced Nursing Education Workforce grant). Title V contracted agencies often serve as the training sites and clinical proctors for many of these programs.

MCH and the BFCS also work with interns from many different programs, such as the HRSA funded Leadership Education in Neurodevelopmental and Related Disabilities (LEND; on whose advisory board Title V leadership sit) at UNH, CDC’s Public Health Associate and Fellow Programs, and summer graduate school interns set up through AMCHP and most in-state colleges and universities.

In both BFCS and MCH, staff are required to complete the MCH Navigator Self-Assessment to help inform professional development plans. Yearly staff evaluations include an assessment of the previous year’s learning as well as the development of an annual plan.

Professional training in the past year has focused on accessing and obtaining Race, Ethnicity, Ancestry and Disability (REALD) and Sexual Orientation and Gender Identity (SOGI) data; collecting REAL and SOGI data is vital to tracking variations in health outcomes and reducing health disparities/inequities. A pilot project has revealed differences between the large birthing hospitals’ discharge data and birth certificate worksheet data, as well as disparities in birth outcomes themselves. The second professional training focus is on increasing family engagement and incorporating people with lived experience into all of NH Title V’s work. This is also the subject matter for a technical assistance request.

All staff participate in DHHS required annual trainings including Computer Use Policy Training, CPR (for nurses), and Security and Safety in the Workplace.

This past year, MCH had an opportunity to involve families in policy advocacy around SB105, which originally allowed for an opt-out for information on the birth worksheets, then an elimination of most of the data. This would have had a negative impact on many MCH and other DHHS programs that utilize this data, like newborn screening, to cross check and make sure that every baby was screened and out of ranges can be called out in a timely manner. In April of 2023, three families and a person living with mucopolysaccharidosis type I (MPS1) testified to the Executive Departments and Administration House Committee against SB 105 (after it had passed the Senate in its original format). The families testified on the importance of newborn screening and the timeliness of getting results. The delay in calling out of ranges would have potentially delayed treatment for these families (after the disorder may have already inflicted damage). The person living with MPSI talked about how early treatment is so important and the difference it would have made in his life. Other people with MPSI were not as fortunate as he has been, because they were diagnosed later in life and have significantly more chronic medical conditions. It was his testimony and that of the other families that really had an impact on the House Committee. This is known because of the legislators’ questions and comments. The legislators amended the bill to take out the exclusion of the birth worksheet, the Senate agreed and the Governor has signed it into law

There has been a concerted effort to define and provide training for new members, particularly family or those with lived experience, on each of Title V’s advisory committees. Considerations include the committee’s function (oversight, advice giving, operations, policy management or all of the above), the roles of committee members and an opportunity to be compensated for this role. There has also been an increase this past year in including compensation for family involvement in budgets over the span of MCH programs.

As of summer 2023, MCH will have 7.2 FTEs whose sole responsibility is the management and analysis of different types of MCH data. Of those FTEs, 4.2 are specific to a certain data set, such as PRAMS, the National Violent Death Reporting System (NVDRS) and the State Unintentional Drug Overdose Reporting System (SUDORS). However, all FTEs in MCH have a role in working with data, whether through its collection, making a determination of what the data reveals or in its dissemination to stakeholders and the public to guide surveillance and/or prevention activities. MCH now has a full 1.0 FTE Epidemiologist (as opposed to 0.8 for 20 plus years) under contract with the University of New Hampshire, Institute for Health Policy and Practice, Department of Health Management and Policy. Dr. Carolyn Nyamasege has a background as a field researcher in maternal and child health issues, working both with the University of Tsukuba in Japan and the African Population and Health Research Center in Kenya

The current SSDI five‑year project cycle is in the first year of a new cycle. The goals of which now include: (1) strengthening the capacity to collect, analyze, and utilize reliable data for the Title V MCH Block Grant to assure data-driven programming; (2) strengthening access to and linkage of key MCH datasets to inform Title V MCH Block grant programming and policy development; (3) enhancing the development, integration, and tracking of health equity and social determinants of health (SDOH) metrics to inform MCH programming; and (4) developing systems and enhancing data capacity for timely MCH data collection, analysis, reporting and visualization to inform rapid state program and policy action including for emergencies and emerging issues/threats.

DPHS also has a Bureau of Health Statistics and Data Management (BHSDM), who are the formal DPHS liaison with Vital Records as well as the stewards of survey data and surveillance systems such as the hospital discharge data (emergency room and inpatient), the Behavioral Risk Factor Surveillance System and the Youth Risk Behavior Surveillance System (shared with the Department of Education). The BHSDM facilitates QA on many of the public data requests MCH receives & prepares and serves as a backup for most of MCH’s data staff. BHSDM also stewards the portal https://wisdom.dhhs.nh.gov/wisdom/#main, aggregating health and social services data and producing customized reports, maps and time trend analysis on hundreds of health related indicators at the town, county and state level. Data may be used to identify trends, develop program initiatives, strengthen research, aid grant writing and support policy changes.

In preparation for involvement in the revision of the State Emergency Operations Plan, identified Title V staff (leads, MCH Epidemiologist, Newborn Screening, CSHCN Clinical Program Manager, etc.) have been reviewing the Association of Maternal and Child Health Programs’ (AMCHP) checklist in the document Public Health Emergency Preparedness and Response Checklist for Maternal and Infant Health [1]. NH’s Title V program already is able to check “yes” to a subset of questions in the document related to public health emergencies such as “During the next three years, will your jurisdiction assess emergency preparedness among postpartum women using the Pregnancy Risk Assessment Monitoring System (PRAMS)?” and “Are lists of key jurisdictional MCH partners, stakeholders, and/or social networks updated annually to reflect current contact information?” [2] All of NH’s Title V staff are also trained annually (virtually) in emergency response protocol and systems.

Title V in NH does not work in a vacuum. The success of its programs has to do with integral partnerships, both funded and non-funded, with governmental partners as well as community-based agencies. Leveraging federal and state program resources contributes to the delivery capacity of NH’s State Title V.

This past year, MCH’s Home Visiting Program, for the very first time, collaborated with NH DHHS’s Division for Children, Youth and Families (DCYF) on a joint request for proposals and a contract award process enlarging the scope of the current use of Healthy Families America (HFA) to include HFA’s Child Welfare Protocol Services. This will enable services to another 195 families statewide with children under age two, specifically referred by DCYF.

MCH began work with both the Southern NH Area Health Education Center (SNHAHEC) and the North Country Health Consortium (NCHC-the Northern part of the state’s AHEC) on the topic of community health worker (CHW) education, support of the current and expanding CHW infrastructure and utilization within the State’s healthcare and social services system. NH’s CHWs job responsibilities are different dependent upon the agency for whom they work. However, all improve access to social determinants of health needs through resource navigation. In June of 2022, MCH was able to hire a new position, a Community Engagement Specialist, with leveraged COVID 19 pandemic funds. This position has worked in tandem with SNHAHEC and NCHC along with others to help increase CHW staffing, training and. In particular, MCH’s Community Engagement Specialist established a monthly CHW Community of Practice meeting whose format consists of one or two presentations on various social and health topics and then dedicated time to share strategies, success stories, ask questions and network with one another. Three of the Title V funded CHCs utilize a portion of their funding for a CHW (all three related to maternal health, breastfeeding, etc.)

Another state partnership with great importance to MCH’s work is with the Bi-State Primary Care Association (Bi-State). Bi-State provides training and technical assistance to FQHCs and FQHC Look-Alikes (8/10 Title V funded CHCs) to improve programmatic, clinical, operation and financial performance. MCH’s Quality Improvement and Clinical Services Program meets monthly with Bi-State as well as with DPHS’s Rural Health and Primary Care Section to discuss State Performance Measure #1, “MCH contracted CHCs that have met or exceeded the target indicated on their enabling services workplans” and leveraged Title V funds for Bi-State’s Recruitment Center contract, of which the focus is on behavioral health. Bi-State is also the conduit for funding to their agencies for CHW support and expansion, with the primary purpose of addressing health disparities and social determinants of health within the health care setting.

On a national level, MCH works very closely with the National Center for Fatality Review and Prevention (the Center). In addition to providing technical assistance on fatality review processes, the Center does QI on the SUID and SDY case data that is entered into its child death registry. This enables MCH to facilitate analyses on the data, leading to a better understanding of how and why infants and children die in the State and catalyzes actions to prevent other deaths.

A web-based presence like social media is becoming widely used by the MCH section as it can promote programming and inform on health policies. BFCS provides Title V funding to NH Family Voices (NHFV) to utilize and promote social media efforts for CSHCN and their families. Using social media enables Title V as a whole to disseminate messages in real time to inform about immediate health risks, but also to share healthy lifestyle and prevention strategies. Title V and its contracted agencies can use social media to disseminate time-sensitive health information, and can circulate information that encourages behavior change. Using social media can also stimulate the involvement of the public through comments and conversation. 

In preparation for the 2024-2025 Title V needs assessment and in response to suggestions from last year’s Block Grant review, a technical assistance request is being made to learn about Community Participatory Action Research methods. In this case, to include these methods during the five year needs assessment to elicit meaningful and inclusive stories from maternal and child health populations, especially from traditionally marginalized groups in NH such as people of color, people with low incomes, immigrants, people who live in the most rural parts of the state, judicially involved woman and children, the underinsured, and people with disabilities.

BFCS will explore the Blueprint for Change: Guiding Principles for a System of Services for CYSHCN and their families.  Beginning with a lunch & learn, September 2023, the National Center for CYSHCN will assist NH with ways to utilize the national framework to advance the vision for CYSHCN to thrive in a well-functioning system.   

[1] Public-Health-Emergency-Preparedness-and-Response-Checklist-for-Maternal-and-Infant-Health.pdf (amchp.org) retrieved on 07/01/23.

[2] Ibid.