Recruitment and retention of a qualified Title V program staff

The COVID 19 pandemic changed the new “normal” for the Title V workforce in NH. Staff have re-evaluated their work life balance and the expectation is that DHHS would change in return. In the last year, no less than five relatively new Title V staff resigned and no less than five additional brand new staff were hired within both parts of Title V. Roughly 48% of Title V’s workforce has been in their position within DHHS for less than ten years and 63% 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.

Also at a Department level, Organization Development and Training Services (ODTS) has expanded their offerings. This includes a Supervisor Certificate Program, which focuses on topics such as managing change and authority and using the employee assistance program as a management tool. Several Title V employees have taken advantage of this as well as a new Supervisor Round Table, which is a bi-weekly Zoom session hosted by ODTS and focusing on professional development topics specific to leadership and supervision. This is in addition to supporting membership in a wide variety of national and statewide professional groups (e.g. AMCHP) and tuition reimbursement.

As the largest state agency, NH DHHS, along with the Department of Administrative Services, Division of Personnel initiated a process of migrating all DHHS (and eventually every State position) into the National Standard Occupational Classification (SOC) system, with effective implementation planned for July 1, 2023. The intent of the SOC is to align DHHS positions, including all Title V personnel) with a nationally accepted standard for position classification. This transition is intended to make recruitment more efficient and positions more appealing to job seekers who are familiar with SOC, as well as create clarity of roles and functions through tighter job specifications and application requirements. SOC creates better uniformity across roles, in job function and educational and skills requirements, allowing NH to target and evaluate potential members of its Title V team more efficiently. This classification modernization may also be paired with improved process and standards for pay adjustments and promotion within titles allowing the State to better retain qualified staff and create clearer career trajectories without having to go through the current, long and inefficient system of re-classification.

Almost all Title V staff worked from a “home” office during the COVID 19 pandemic (with the exception of MCH management and newborn screening). During this time, staff accommodated and changed their workflow to become just as efficacious and efficient at home. Staff began to expect some sort of mix of home/office as the State emergency declaration ended in June of 2021. In response to that overall feeling, DHHS went through several iterations of a telework policy until a final Department-wide one was developed this past year. Every staff person must have a telework policy in place (all Title V staff do) which requires at least four days out of a ten-day working period in the office. Although some MCH staff primarily work in the office setting, the majority adhere to the four in office/six out of office pay period (two weeks). Most BFCS staff work at least three days in the office and two days remote, each week, with a requirement to attend a monthly in-person all staff meeting.  Although reflecting the flexibility needs of most staff, a few left MCH this past year simply because they could not telework full time.

As with the telework policy, some partner meetings, particularly those legislatively mandated have to meet either all in person (e.g. child fatality) or a quorum in person and the rest joining virtually (e.g. newborn screening, maternal mortality). Other legislatively mandated meetings, including the CYCC and Council on Autism Spectrum Disorders, continue to meet virtually, which yields greater participation from families with CSHCN. Virtual meetings have become the norm in 2023. DHHS utilizes the TEAMS platform and both MCH and the BFCS have use highly specialized audio/visual equipment (Surface HUB 2S) for joint in person/virtual meeting. Thus, on any given day, Title V has a reduced in-office FTE count dedicated to the implementation of its many programs.

At the time of this writing, MCH has 29 positions (25 FTEs including a contracted 1.0 FTE Epidemiologist and three part-time staffers for an additional 1.8 FTEs). There is also an additional unfunded, part-time position ‘on the books’ for future planning efforts. Title V funds are utilized in full or part for 14 positions. Positions have also developed to encompass more of the activities related to the performance measures and ESMs, such as the full-time Perinatal Nurse Coordinator, the Pediatric Mental Health Care Access Program Manager and the Child-Adolescent Clinical Nurse Consultant, broadening the availability of staff dedicated to core Title V services. Several grants have remained level-funded and have not kept up with personnel cost of living and salary increases, necessitating the leveraging of Title V funds in order to maintain full-time positions. Braiding of Federal grant and State general funding supports is crucial for an effective Title V workforce. MCH currently has seven programmatic units (with changes in some unit titles from last year): Data/Decision Support; Infant Surveillance; Injury Prevention; Home Visiting; Sexual and Reproductive Health, Quality Improvement and MCH Clinical Services; and Family Support and Community Engagement.

The last year has brought many changes, successes and struggles for all of NH’s Title V regarding personnel. Key MCH management positions (Home Visiting, Sexual and Reproductive Health and Quality Improvement and MCH Clinical Services) were vacated and filled by in-house employees, which was helpful for transitioning and onboarding. In order to address this, the often difficult reclassification process (to a higher labor grade with added responsibilities) was utilized. Within a labor grade are nine steps that an employee, upon a satisfactory annual evaluation, can move through, albeit at a very slow pace. Reclassifying is a professional development path that enables the current workforce to grow within the context of Title V and not have to seek alternative employment elsewhere. There is currently no promotion if job duties or expertise increase unless a position is reclassified. Reclassifying a position to a higher labor grade is particularly difficult with many forms needing to be filled out, having the finances necessary, and going through both DHHS’s Human Resources Division, the State’s Department of Administrative Services, Division of Personnel and with the final say coming from Governor and Executive Council (G&C). That all being said, five of the seven (two had already been re-classed several years before) MCH unit leads were successfully re-classed from a Program Manager at labor grade 25 to an Administrator 1 at labor grade 27. The Pediatric Mental Health Care Access Program Coordinator at a labor grade 23 was reclassified to a Program Manager at labor grade 25. However, MCH still has two lingering re-classification requests that have been in the que for close to a year. It is hoped that with the institution of the SOC job classification system (previously described), employees will not have to rely on reclassification but as of now, that mechanism is still in place.

That success was counteracted by several additional resignations, including the MCH Perinatal Nurse Coordinator, a position that has “flipped” three times over the same amount of years. Tools utilized to address these vacancies included using COVID and ARPA grant funding for position listing advertisements on LinkedIn and other similar platforms. This gave Title V the ability to set parameters (e.g., demographics, job skills) to help increase the listing’s visibility. Many of NH’s Title V vacant positions are filled through “word of mouth” through current staff whose colleagues and friends want a change of pace since the COVID 19 pandemic.

In the past year, MCH has taken oversight over DPHS’s involvement and contracts with respect to community health workers. Funded initially by a CDC COVID Health Equity Grant, a 1.0 FTE Community Engagement was added to the MCH roster under the Family Support and Community Engagement Unit.  Funding has since been leveraged with the Federal Children’s Bureau Community Collaborations grant. This work involves funding agencies to directly employ community health workers as well as to two agencies to facilitate statewide training, a monthly learning collaborative and work on possible state certification within the next couple of years. A large percentage of community health workers in NH are specifically involved with maternal and child health. In fact, some of the Title V funding for the MCH in the Integrated Primary Care Setting contracts with the Community Health Centers fund full time equivalents for community health workers, particularly in the enabling work plans.

As of July 1st, 2023 (at the start of the next State biennium budget), MCH will be absorbing three additional FTEs, two data analysts funded by the CDC’s Opioid Data to Action/National Violent Death Reporting System grants who will sit in Injury Prevention and a family resource center program manager underneath Family Support and Community Engagement. The data analysts historically have been employees of the Office of the Medical Examiner. The Family Resource Center Program Manager joins MCH from the Division of Economic Stability, Family Assistance Program. This position will bring Family Resource Center contracts as well as a contract for the NH Children’s Trust, the State’s chapter of Prevent Child Abuse America. In preparation for this and to lay the groundwork for the end of the Block Grant five year cycle when the MCH Administrator/Section Chief, Data Scientist and Program Evaluation Specialist are all scheduled to retire as well as a needs assessment completed, MCH staff has been engaged in a strategic planning process (which started the Fall of 2022). This has included, but has not been limited to, a review (and potentially a rewrite) of all job descriptions/responsibilities, contractors and their performance measures and fiscal planning. The MCH Administrator/Title V Director has also led two mandatory “Title V/MCH Block Grant 101 and 102” sessions for staff with the premise that even though it doesn’t fund all 29 positions, it is still the foundation for all of what MCH does. Many staff also do not realize the complexity of the grant writing (even for those that have oversight for and write sections about individual domains).

The Bureau for Family Centered Services (BFCS) has 18 positions (17 FT and one part time .26 FTE). Program areas including family support for children with chronic conditions, funded by the Social Services Block Grant; Family Centered Early Supports and Services Part C Early Intervention, funded by the Office of Special Education; Family Support for individuals with Developmental/Intellectual Disabilities, funded with state general funds; and Title V activities for CSHCN. Currently, there are 11 FT and 1 PT positions funded by Title V.

As is the case in NH and across the country, unemployment rates are low and recruitment and hiring remain challenging.  Like MCH, BFCS experienced turnover throughout the past year. With several promotions and transfers, it is encouraging that the workforce continues to grow internally with an eye on succession planning.  

Three newly upgraded Nurse Consultants are slowly adapting to their new roles, transitioning from health care coordination work, which will be provided through community-based contracts beginning July 1, 2023, to a consultation role. The Clinical Program Assistant II hired in June 2022, left the Bureau after only nine months following a promotion to the Program Integrity Unit of the Commissioner’s Office. This position was quickly posted and a new hire is scheduled to begin June 16, 2023. The Bureau was successful in completing a direct hire of a part time Evaluation Specialist, Erica Proto, RN, July 1, 2022, who works closely with the Data Coordinator and program leadership on ongoing needs assessment and performance management activities.  The Financial Eligibility Specialist left state service in August 2022 to pursue a 100% remote position after only four months in her position. Fortunately, BFCS was successful in hiring Jamie Hill, formerly from the Department of Safety, who has demonstrated her adaptability and excellence in developing procedures since starting in October 2022. Also in the early fall of 2022, the former Clinical Program Manager opted to transfer into one of the vacant Nurse Consultant positions. Following a brief recruitment period, Cynthia Beattie, RN, was hired as the new Clinical Program Manager in October 2022. Cindi’s responsibilities are focused on developing the Nurse Consultant program along with contract management for the Nutrition, Feeding & Swallowing and Specialty Services for CSHCN contracts. Early in 2023, the Data Coordinator transferred to the Department of Education and the former Systems of Care for CSHCN Program Specialist, Erika Downie, was promoted to the vacant position in May. She brings a wealth of experience about family-centeredness and systems of care, which will be valuable as she leads the Bureau’s ongoing needs assessment activities. This created a second vacancy that is currently in recruitment and interviews are being held with several strong candidates. 

The Family Centered Early Supports and Services (FCESS) Part C program was successful in creating a new full time Program Assistant II position following nearly three years of unsuccessful recruitment for a part time Program Assistant I.  The newly hired individual will start June 16, 2023. Like MCH, BFCS submitted a reclassification request that has been on hold, due to the new SOC.  This will upgrade the current Public Health Program Manager (LG 26) to a Program Planning and Review Specialist (LG 28), which will align her with other DLTSS positions with similar responsibilities.   

Innovations in staffing structures, including key partnerships that enhance the capacity of Title V to meet its goals and objectives and support training of the State Title V workforce (i.e., partnerships with academic institutions, other training providers, student internships, etc.).

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. As a 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. A current intern in home visiting is working on developmental screening in non-English speaking households and some of the challenges experienced by families using interpretation services for screening. Infant surveillance has an intern working on SUID/SDY by creating narratives for some of the case reviews, redesigning the grief packets and consent forms and entering data into the child death review database. 

Title V also has a seat on the Advisory Board of Boston University’s (BU) School of Public Health’s Center of Excellence in MCH Education, Science, and Practice as well as access to all the training from Boston Children’s Hospital Leadership Education in Adolescent Health program. The Division of Public Health Services (under which MCH sits) has a partnership with the Dartmouth Institute for Health Policy and Clinical Practice whereby Dartmouth significantly covers the cost for an MPH.

MCH’s Injury Prevention programmatic unit received data analysis help from the CDC Foundation in the form of a 0.5 FTE who through an MOU has been able to work on a special project on opioid misuse in the homeless population.

Assessment of training and professional development needs for new and seasoned Title V program staff and family leaders

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. As was stated previously, current Title V staff vary greatly in terms of years’ experience

Professional training, for the most part, seemed to fall into two different topical subjects this past year. The first was a repeat of past years and still a persistent training need, 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 done by the MCH Epidemiologist both revealed differences between the large birthing hospitals’ discharge and birth certificate worksheet data as well as disparities themselves in birth outcomes. NH DHHS recently hired a new Office of Health Equity Director (after almost a four year vacancy) and it is hoped that with this, additional in-house (and to Title V stakeholders and contractors) training can continue to be facilitated. 

The second focus was a continued interest and emphasis on family engagement. The MCH Home Visiting Program participated in the AMCHP Family Engagement Community of Practice. Several of MCH’s programs have participated in this over the years. In addition, there is a heightened interest on incorporating people with lived experience into all of NH Title V’s work. This is the subject matter for one of the technical assistance requests for this upcoming year. There has been an increase in the last several years of groups made up of the populations Title V serves such as the Young Adult Advisory Council and the Perinatal Community Advisory Council.

Staff participated in their individual annual grantee and partnership meetings virtually. Several MCH staff presented posters and sessions at AMCHP, CityMatch, the Annual Association of Public Health Laboratories (APHL) Newborn Screening Conference, the Northeast Epidemiology Conference, and the annual DCYF conference including

• Care for Pregnant and Postpartum People with Substance Use Disorder: Implementing a Postpartum Naloxone Distribution Program in New Hampshire
• Causes of Maternal Mortality in New Hampshire and Interventions/Recommendations for Prevention
• Intervening for Perinatal SUD and Mental Health Concerns: Optimizing the Role of Perinatal Providers
• Maximizing Infant Surveillance
• Adverse Childhood Experiences (ACEs), Adult Health Behaviors and Adult Health Outcomes using Behavioral Risk Factor Surveillance System data with ACES questions funded by MCH (every five years).

The CSHCN Director, Clinical Program Manager and a Nurse Consultant completed NH DHHS Medicaid Academy through the Center for Health Care Strategies. The program designed to increase leadership capacity for the Department, participants engaged in projects identified by Leadership to advise and promote initiatives to address gaps.

All Department staff are required to complete the following trainings offered by the Department, upon hire and/or annually:

• CPR (for nurses)
• Computer Use Policy training (annually)
• Cyber Security Training – Information Security & Compliance Awareness and Respect in the Workplace (within three months of hire and annually)
• Diversity and Cultural Competence, Civilian Response to Active Shooter Events (CRASE), and Fostering a Culture of Respect  (within one year of hire)
• Domestic Violence in the Workplace, Sexual Harassment Policy Review Training and Confidentiality (as part of the annual evaluation process)
• Secure Email Training (within the first month of hire)

Title V staff participated in additional professional training opportunities in this past year including, but not limited to the following:

• 10th Annual Strengthening Families Summit
• 23rd Annual Chronic Illness and Disability Conference: Transition from Pediatric to Adult-Based Care
• Advancing Systems of Services for CYSHCN
• AMCHP mentoring program: Next Generation MCH Leaders cohort (had to apply and be accepted)
• Boston Children’s Hospital Grand Rounds Metabolism Clinic Presentations
• Catalyst Center’s Child Tax Credit, Financing Cafés
• Healthy Families America Peer Reviewer Training
• HRSA-NETRC 2022 Telehealth Tuesday: The Role of Telehealth in Expanding Access to Health Care and Social Services, with a Focus on Pediatric Behavioral Health
• IDEA Fiscal Forum
• NH Telehealth Alliance: A Turning Point in State & Federal Policies
• NH Transition Community of Practice Annual Summit
• National Birth Defects Prevention Network Data Standards and Guidelines Committee. MCH staff co-chairs the Standards Development and Evaluation Workgroup as well as sitting on the Surveillance Guidelines Manual Workgroup;
• Providing Culturally Responsive Reproductive Health Care, ASTHO
• State of NH Tableau Analytics Summit
• Title V Guidance Revision Listening Session

NH Title V staff also participated in the newly formed AMCHP led “Title V Block Grant Coordinators Quarterly Networking calls.” Along with the Region 1 AMCHP facilitated quarterly calls, the Block Grant Coordinators calls have been very informative with different states sharing the grant writing and implementation process. Two MCH staff participated in a several month collaborative learning project on community health workers.

MCH positions that have responsibility over program budgets meet twice a month with DPHS fiscal colleagues and the BFCS Leadership Team meets monthly with their financial manager. MCH and BFCS management and fiscal staff meet quarterly to monitor Title V expenditures. The Title V budget and its 30‑30‑10 requirements, among others, is complicated and takes a while to gain enough competence to manage it effectively.

Current and anticipated training needs of key MCH partners (external to the Title V program), as relevant

All of the programs within Title V offer professional training to stakeholders, in particular those agencies that are contracted or are in daily contact (e.g. labor and delivery units, pediatric offices, etc.) For example, MCH’s Family Support and Community Engagement, Quality Improvement and Clinical Services and Home Visiting programs all collaborated with the WIC/Nutrition Services at DPHS to offer a series focused on the support of breast feeding to clients. Many contractor staff attended for this four-day interactive workshop. Breastfeeding was chosen as the quality improvement/enabling service topic for six out of ten Title V funded health centers this past year. In addition, breastfeeding support and education is mandated with Home Visiting and within the family support contracts.  

Another example is MCH’s Pediatric Mental Health Care Access Program Project ECHO cohort titled Promoting Child and Family Resilience and Healing in a Pandemic conducted one 1.5-hour session per month for ten months. These sessions connected participating practices/primary care providers via web-based conference technology to participate in a 20‑minute didactic presentation from established pediatric mental health faculty experts on set curriculum objectives. After the didactic training, a participant then presents a case study and receives feedback and recommendations from both the pediatric mental health faculty members of subject matter experts and from peers at the other participating pediatric primary care practices.