Ongoing needs assessment activities are diverse and often implemented on an ongoing basis; examples of needs assessment include the following examples:

• The Special Medical Services (SMS) conducts a biennial satisfaction and needs assessment survey; contract agencies complete annual reports which include barriers, trends and needs assessment; one contract agency, Child Health Services, of the Manchester Community Health Center provides Family Satisfaction and Nutrition surveys to inform needs assessment.
• The Pregnancy Risk Assessment Monitoring System (PRAMS) has added a 13-question supplement to the standard questionnaire, to assess the use of pain medications including opioids during pregnancy.
• The Family Planning Program (FPP) sub-grantees collect confidential client satisfaction surveys; analysis of social outreach efforts using Facebook and Instagram provides the number of unique users who were reached.
• The Injury Prevention Program (IPP) makes use of post-conference evaluations from the annual Teen Driver Safety Event and Suicide Prevention Conference, as well as participant input at the Quarterly Injury Prevention Advisory Committee (IPAC), the Quarterly Brain and Spinal Cord Injury Council meetings, and Quarterly Buckle-up NH/Teen Driver Safety meetings.
• The Maternal, Infant. and Early Childhood Home Visiting Program (MIECHV) completed an update to their 2010 foundational needs assessment which identifies communities with elevated risk due to higher incidence of factors such as premature birth, low-birth weight, and infant mortality; it also assesses the quality and capacity of existing programs, or the gaps in early childhood home visiting, as well as the state’s capacity for providing substance misuse treatment and counseling services to individuals and families in need of treatment and services.
• The Early Hearing Detection and Intervention (EHDI) program implemented focus groups and surveys with the audiologists who conduct diagnostic testing; findings from the evaluation will be addressed through the quality improvement committee.
• Members of the Maternal Mortality Review Committee (MMRC) abstract medical records of maternal deaths; in cases of postpartum overdose deaths, the MMRC Coordinator has begun requesting pediatric records, as allowed in the legislation, in order to have a more comprehensive view of the woman’s situation.

MCH and SMS continue to explore ways to institutionalize the needs assessment process; this could include a permanent online survey instrument on the DHHS website, updated periodically to garner input on time-sensitive issues, as well as provisions written into the contracts of Title V-funded community health centers and other contractors to more systematically assess the needs of the population in their catchment area, in addition to their standard customer satisfaction surveys. Other needs assessment processes are already institutionalized, with information routinely gathered from advisory councils, steering committees, and Community Health Centers, representing stakeholders and clients statewide.

Changes in the health status of the state’s MCH population are sometimes positive, but there still remains room for improvement, especially among sub-populations (geographic, socio-economic, etc.). Health updates include:

• The percentage of FPP clients receiving preconception health services has increased overall from 56% in SFY14 to 89% in SFY19; there is still a need for improvement among the NH FPP Title X network (without Planned Parenthood), which has only 65% of clients receiving preconception care at these clinic sites.
• The utilization of LARCs (long-acting reversible contraceptives) among women aged 15-44 years of age has increased from 15% in SFY14 to 22% in SFY17 and 28% in SF18; among teens 15-19 utilization has gone from 7% in SFY14 to 17% in SFY17 and then 13.7% in SFY18.
• The practice of vaping or Juuling in increasing; NH teens can acquire these products on the internet, even though the state prohibits purchases by anyone under 18; the Juul device contains as much nicotine as a full pack of cigarettes.
• The Home Visiting needs assessment has identified the following needs: getting help to find services in general, dental care, behavioral health, information on a healthy pregnancy, housing, employment, food, cash assistance.
• In 2017, there were ten cases of Sudden Unexpected Infant Death (SUID); in four of the cases there was a known history of drug abuse by the primary care giver; three of the four abused opioids, and in two of the four cases there was also a known history of drug abuse by the secondary caregiver. In 2018, there were six SUID cases, and no documented drug abuse by the caretakers (as of 2019/04/09).
• SMS’ Nutrition Program providers report that the number of infants being followed for neonatal abstinence syndrome (NAS) has increased. This is currently based on anecdotal information from the Nutrition and Feeding & Swallowing Program Leads; changes have been made to the data system to better capture this information going forward.
• In June 2018 two (2) of the State’s 19 birthing hospitals closed their labor and delivery units, leaving coverage gaps in those regions of the state. There is a plan to continue to provide prenatal care in those communities, but delivering a baby requires families to travel, making access more difficult.
• New Hampshire was recently recognized by the CDC for outstanding achievement in vaccination coverage rates, specifically: Outstanding Progress toward Health People 2020 targets for each of four vaccines among adolescents aged 13-17 years; Outstanding Progress toward the Healthy People 2020 target of 70% for influenza vaccination coverage among children ages six months to 17 years during the 2017-2018 flu season; and Outstanding Accomplishment in achieving pneumococcal vaccination coverage of over 80% among adults aged 65 years and over during 2017.

National outcome data show that:

An in-house report on Health Equity among pregnant women (utilizing PRAMS 2013-2017 data) showed that characteristics with the greatest number of inequities were income (%FPL), education and age: 15 of 16 indicators showed a disparity according to income, 14 of 16 showed a disparity by education, and 10 of 16 showed a disparity by age.

Five indicators had disparities by nativity, with the foreign-born women reporting lower prevalences of starting PNC in the first trimester, smoking before pregnancy, and drinking alcohol before pregnancy, and higher prevalences of ever breastfeeding and breastfeeding at least eight weeks.

Disparities by race/ethnicity showed that, compared with White non-Hispanic women, Black non-Hispanic women had significantly more unintended pregnancies, less often started prenatal care in the first trimester, less often had their teeth cleaned before or during pregnancy, less often drank alcohol before pregnancy, more often had a postpartum checkup. Asian non-Hispanic women less often had a preterm birth, less often started prenatal care in the first trimester, less often drank alcohol before pregnancy, more often breastfed eight weeks or longer, less often had a postpartum checkup. Hispanic women less often had their teeth cleaned in the 12 months before pregnancy, and less often breastfed eight weeks or longer.

There were no statistical differences from the statewide prevalences according to urban or rural residence, although there were three instances where the urban and the rural prevalences were significantly different from each other (smoking before pregnancy, smoking during pregnancy, postpartum checkup).

Disparities by county or city were numerous and can be summarized by reporting that two counties had significantly better findings than the statewide average, while three counties and the city of Manchester fared significantly worse that the statewide average.

Changes in state capacity

Family Planning (FP) contract agencies continue to expand mental health, substance misuse, and preconception health services for clients; when services are not available internally, agencies have established referral linkages for these services.

The EHDI program is working with audiologists to expand diagnostic center capacity.

NH Family Voices (NHFA) reports that access to Applied Behavior Analysis (ABA) remains problematic for families; with delays in provider enrollment and decreased numbers providing home-based vs. center-based services; the Autism Council has been working on these issues.

Prior to closing at the end of February 2019, the firm ATech Services had been providing assistive technology to aid approximately 900 individuals with disabilities in NH; services have been transferred to DHHS and families will need to work with the insurance providers and DHHS staff to find other providers.

In June 2018, the NH Legislature passed legislation (SB 549) for the Plan of Safe Care, for the care of infants affected by prenatal drug or fetal alcohol exposure. The Perinatal Exposure Task Force (including three MCH staff) continues to refine the plan template, to make it comprehensive and easier to use, and in compliance with NH RSA 132 – Protection for Maternity and Infancy.

Proposed changes in Title X rules would negatively impact the MCH population; there would likely be fewer participating Title X clinics, former/potential clients would forgo care due to decreased accessibility or affordability, or seek care elsewhere, placing additional burden on an already stressed system (e.g. hospital ER, Convenience Care, CHCs).

With the abatement of the Zika virus threat, NH has re-instituted the Birth Conditions Program, to identify any birth defects as outlined by the National Birth Defects Prevention Network (NBDPN). This new program has been integrated into the MCH Newborn surveillance group.

NH’s 10-year Mental Health Plan (2019) now includes a focus on expanding early childhood supports and includes a home visiting component, in contrast to the 2008 Plan and the Community Mental Health Agreement (CHMA) signed in 2014, which took into account only the needs of the adult population.

MCH is also developing a Pediatric Mental Health Care Access Program to expand the state’s capacity to address the access and availability of pediatric mental health care.

Changes in organizational structure and leadership

The MCH section is now working under a new Bureau chief (Sai Cherala, M.D.), a new Deputy Director of the Division of Public Health (Tricia Tilley, formerly the MCH Administrator), as well as a new Associate Commissioner of Human Services and Behavioral Health (Christine Tappan, who has a background in the prevention of child maltreatment) and a new Associate Commissioner of Population Health (Ann Landry, who has a background in Medicaid).

MCH section is recruiting for two positions as of this writing: a Child Health Nurse Consultant, and a Newborn Screening Program Specialist. New members of the MCH staff include the Opioid Overdose Surveillance Coordinator, the Community Collaborations Program Manager, the Pediatric Mental Health Care Access Coordinator, the Infant Surveillance Program Coordinator, and the Family Planning Health Promotion Advisor.

As of March 2019, the Bureau of Special Medical Services has a new Director of the Division of Long Term Supports and Services who was previously the Deputy Director for NH Medicaid. In addition, SMS has been successful in filling vacant positions and currently has only one unfilled position that will be reclassified to better meet CYSCHN program needs.

There is a broad range of partnerships and ongoing collaborations inside and outside NH DHHS; these collaborations are active at many different levels, from technical guidance to program implementation. Some of the collaborating entities include (these were not cited in previous yearly applications):

Emerging issues

The legalization of recreational marijuana was passed by the NH House in April 2019. The bill will go to the NH Senate for approval, but the Governor has promised to veto it, and there is not enough support in the House to override a veto. Currently, ten states have legalized recreational marijuana, including the neighboring states of Maine, Vermont, and Massachusetts. Medical marijuana became available for qualifying patients in NH in 2013 (RSA 126-X). The Therapeutic Cannabis Program (TCP) is housed within the Division of Public Health Services, thus facilitating collaboration between the TCP and MCH staff.

There is continued concern about the state’s rate of suicide (up 48.3% since 1999, according to the CDC), which is significantly higher than the national average. There is also recent concern regarding youth suicide – the 2017 NH Youth Risk Behavior Survey (YRBS) shows that 11.5% of males and 20.6% of females in high school seriously considered attempting suicide in the previous year. Addressing this issue will involve many stakeholders and support from the Suicide Prevention Council. There are several initiatives underway such as broad implementation of NAMI NH’s Connect Program training and a “Zero Suicide” focus for health care organizations that will lend support to these efforts, which are being funded by the state, grant funds and private partnerships. This issue is also complicated by the opioid crisis in NH, which has had devastating effects on many youth and their families.

There is currently a hepatitis A outbreak in the state. There have been 84 cases of infection (with one death) identified since November 2018, compared to an average of 6-7 cases annually (range of 1-10), over the past five years. DHHS increased outreach when the CDC first reported a hepatitis outbreak in the US, before cases appeared in NH; health providers were encouraged to push vaccines, especially among vulnerable populations. The new diagnoses have occurred in eight of ten counties, predominantly in the southern (most populous) part of the state, with one ‘hotspot’ county. Outreach efforts are utilizing social media as well as mass mailings. There is no vaccine registry in NH, which increases the difficulty of following up which individuals receive the standard two-dose regimen, and which ones receive only one dose.

Workforce capacity for Home Nursing services continues to be identified by families as a significant area of need. NH has begun implementation of varied activities recommended by the commission to study the shortage of nurses and other skilled health care workers for home health care services and post-acute care services. These activities include a Medicaid reimbursement rate increase and the creation of a workgroup whose efforts are focused on addressing the impact of long wait times for criminal record checks on workforce recruitment and hiring.

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