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 NH Department of Health and Human Services’ Maternal and Child Health (MCH) section, and the Bureau for Family Centered Services (BFCS) which oversees programs for Children and Youth with Special Health Care Needs (CYSHCN). Together, these local entities support core Title V public health functions including direct, enabling, population-based, and infrastructure-building services in maternal and child health including CYSHCN, focused on family planning and teen pregnancy prevention; primary care; perinatal health; early childhood systems and home visiting; adolescent health; injury prevention; newborn screening and early intervention; as well as surveillance and information translation and dissemination. All services have continued at least modified operations, despite the COVID‑19 pandemic.

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. Additional information, data and stakeholder/public input are also gathered continuously within the scope of work of each Title V program, and fresh information is given full consideration, notably at the start of every new year in the project cycle.

Participating groups in the needs assessment process were diverse and included, among others: Watch Me Grow; Spark NH (Governor’s former early childhood advisory council); Office of the Child Advocate; Newborn Screening Advisory Council; Medical Home Advisory Committee; Autism Council; NH Pediatric Improvement Partnership; Early Hearing Detection and Intervention Advisory Board; NH Office of Health Equity; MCH and BFCS contractors and Community Health Center Directors; Legislative Commission on Primary Care Workforce; NH Citizens Health Initiative; City of Manchester Healthcare for the Homeless Program; WIC Nutrition Program; Planned Parenthood of Northern New England; Dartmouth-Hitchcock Medical Center Patient/Family Advisory; Council for Youth with Chronic Conditions; State and Regional Family Support Councils; School Nurse Association; DOE Office of Student Wellness; and Medicaid Managed Care Organizations (MCOs).

An in-house report on health equity among the pregnant population (utilizing PRAMS 2013-2017 data) examined disparities among subgroups. The greatest number of disparities were found to be based on differences in income, education, and age; but a significant number of disparities were also based on nativity (US-born vs. foreign-born), race/ethnicity, and residence (urban vs. rural, as well as specific county or city). Similar disparities were found in the federally available data when disagregated by these characteristics.

Based on the entirety of the information gathered from the sources above, Title V staff established the following list of priorities to steer programming in the next five-year period (through 2025), and selected National Performance Measures (NPMs) or created State Performance Measures (SPMs) for implementation, to address these needs:

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

Domain: Children with Special Health Care Needs

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

Domain: Women/Maternal Health

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

Domain: Cross-cutting/Systems-building

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

Domain: Cross-cutting/Systems-building

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

Domain: Perinatal/Infant Health

and

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

Domain: Adolescent Health

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

Domain: Children with Special Health Care Needs

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.

Domain: Child Health

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

Access to services continues to be an underlying theme of the work done under Title V, including to meet priority need #3 which singles out social determinants of health as the focal point of access to services. Many Title V contracted agencies utilize their funding to maintain family and community health services when no other resources can be employed. Title V funding decisions are based on gap assessments founded on discussions of the State’s health care system as well as the needs assessment process which looks at health outcomes. Grant funds go towards agency staffing infrastructure as well as services.

During the past year, the COVID‑19 pandemic has loomed large for NH’s Title V staff, with the State’s prioritization of time and funding being given to the COVID response. In addition to a nine-month hiring freeze, the Governor issued 25 Executive Orders and 90 Emergency Orders in response to the pandemic. These ranged from allowing all legislated committees (some facilitated by Title V staff) to meet virtually, to extending telehealth, to allowing schools to function remotely. Title V staff has participated in the DHHS Coordinated Response Team, worked with the DPHS Bureau of Infectious Disease surveilling pregnant moms with COVID, made daily as-needed calls to monitor the concerns of contracted agencies and their clients, realigned contractual funds to better reflect the costs of the pandemic, and gained expertise in telehealth issues, among many other duties.

MCH works closely with the 12 Community Health Centers (CHCs) receiving Title V funds (some through multiple contracts) for their mission to provide accessible and affordable comprehensive primary care and perinatal services. These funds are the payor of last resort for the very small percentage of women and children not insured, and mostly go to enabling services such as case management, transportation and interpretation services, that are not reimbursed elsewhere. A portion of every contract is dedicated to quality improvement projects such as getting adolescents into annual care; increasing the number of pregnant women receiving tobacco cessation services; and increasing the usage of highly effective contraceptive methods.

Title V funds are also braided and leveraged with those from the Division of Children, Youth and Families and the Division of Housing and Economic Security to support the eight Comprehensive Family Support Services program agencies, which provide home visiting and parenting education for families with children under 21.

Using Title V, the Bureau of Family-Centered Services (BFCS) supports seven contracts. These focus primarily on systems access, infrastructure development and improvement, and a small percentage goes for direct services. Support to the system of care includes statewide programming for Community-based Health Care Coordination; a Child Development Clinic Network which consists of an autism clinic and four locations for interdisciplinary diagnostic evaluation services to children 0-6 years of age suspected of or at risk for altered developmental progress; a comprehensive Complex Care Network that incorporates interdisciplinary clinics and specialty consultation to providers serving CYSHCN that is child specific or that addresses more general questions; and Comprehensive Nutrition and Feeding/Swallowing Consultation Networks which offer community-based consultation and intervention services utilizing a home visiting framework.

NH Title V staff and its contractors lead by calling attention to emerging issues, thinking strategically, facilitating analysis, and educating on best practices. Title V looks for gaps and tries to fill them, in alignment with priority areas. Title V also has the role of convener as well as participant in many statewide groups such as advisory committees for Newborn Screening, Birth Conditions, PRAMS, and Early Hearing Screening (all led by MCH staff); mortality review groups such as Maternal Mortality Review Committee, Sudden Unexpected Infant Death, Sudden Death in Youth and Child Fatality (also led by MCH staff), as well as workgroups such as the Perinatal Substance Exposure Task Force, and the NH Pediatric Improvement Partnership from the University of New Hampshire (UNH).

Title V staff from both MCH and BFCS have been involved in a variety of statewide collaborative projects focused on family engagement, such as the Early Childhood Regional-State Systems Building Workgroup, the DHHS/Department of Education Family Engagement Workgroup, and staff will be participating in a technical assistance institute later in 2021 for contractors and families on “Building Effective Parent/Practitioner Collaboration.”

NH DHHS leads the implementation of several of the emergency service functions (ESFs) of the State Emergency Operations Plan (SEOP). ESF 8, which focuses on health and medical support, is led by the newly formed (since the onset of the COVID‑19 pandemic) Bureau of Emergency Response, Preparedness and Recovery (BERPR) within the Division of Public Health Services (DPHS) in the DHHS. DPHS’s BERPR created a specific COVID‑19 incident management team (IMT), which includes Title V staff, and is planning a public health specific IMT, which will also include Title V staff.

The Division of Long Term Supports and Services (DLTSS), which houses the BFCS, had developed a Continuation of Operations Plan (COOP) in 2018. The CYSHCN Director is responsible for coordinating the DLTSS COOP and response activities, and managing incidents to include oversight of the COOP Response, repair/restoration of the primary facility or transition/construction of a new facility, as well as provision of executive level guidance and decision-making throughout any Continuity Event.

An Intra-Agency Agreement (IAA) between NH Title V custodians (MCH and BFCS) and the Division of Medicaid Services sets out the framework and conditions for joint planning, coordination and improvement of programs under Title V MCH and Title XIX Medicaid, including the assignment of a seat for MCH on the Medicaid Medical Care Advisory Committee. The IAA outlines and codifies:

• Collaboration on the development and implementation of quality health standards;
• Improvement in referral processes and access to and utilization of health services;
• Implementation of processes for making intra-agency decisions and coordination of policies;
• Reduction of duplicative services and implementation of innovative solutions to health care issues;
• Assurance of compliance with federal and state statutes;
• Promotion of joint planning, monitoring and evaluation of a health care system for the Title V MCH and Title XIX Medicaid populations.

The IAA reaffirms the commitment to have Title V funded agencies identify, enroll and re-enroll Medicaid-eligible clients and to refer those clients to appropriate services. Many CHCs utilize

Title V funds for sustaining or increasing staff capacity to assist with client insurance needs, since up to one half of clients coming to their agencies for the first time are uninsured, and other federal funding for patient navigators has greatly diminished.

Recruitment and retention of qualified Title V program staff is an ongoing challenge. Establishing a new position can take up to a year or more. Even for positions vacated, it can take several months to post on the State’s large job website. Title V as whole also works with professional training pipelines in the State and their job boards, and accepts interns from many programs, such as the HRSA funded Leadership Education in Neurodevelopmental and Related Disabilities (LEND) at UNH, or CDC’s Public Health Associate and Fellow Programs.

In this second year of the five-year project cycle, NH Title V is requesting technical assistance (TA) for the following:

(1) facilitation of three virtual half-day trainings on anti-racism and equity, to be led by Emerald Anderson-Ford of Communities Reaching for Equity and Diversity, who has facilitated sessions with multiple programs within DHHS/DPHS and is recommended by DHHS’s Office of Health Equity; the trainings would encompass exploration of the concept of identities, histories of socialization, white dominant culture norms, and the beliefs and biases held by the participants.

(2) provision of a half-day webinar on screening tools for SDOH within health care settings, in order to include a performance measure for Title V funded CHCs on assessing and referring clients with respect to the SDOH; from the National Association of Community Health Centers, who developed the Protocol for Responding to And Assessing Risk and Experiences (PRAPARE), or the American Academy of Family Physicians, developers of EveryOne Project.

(3) a two-day workshop and 10 hours of follow-up electronic consultation, from the DaSy Center, a national technical assistance center funded by the US Department of Education, which works with states to support early intervention systems; to promote enhanced collaboration between the MCH newborn screening staff and BFCS staff in their joint interactions, notably for the Birth Conditions Program and Early Hearing Detection and Intervention. Staff from DaSY Center could orient DHHS staff on privacy requirements under IDEA, FERPA, and HIPAA; they would facilitate (including a collaborative rewrite if necessary) the data sharing agreement between MCH and BFCS from a draft to a signed agreement.

(4) BFCS has been faced with current vendors’ costs exceeding the available funding. BFCS has consulted the NASHP Standards for Health Care Coordination for a framework within which to improve the quality of health care coordination, and will convene an advisory group of staff, families and stakeholders to consider program redesign. Technical assistance is requested to bring in expertise from other states who have made similar consolidations and moved from direct service delivery to consultative models that support community-based services.