Ongoing needs assessment activities and findings, including family engagement
Needs assessment is an ongoing activity, implemented in many different ways. It includes the typical review and compilation of data and information from various reports and resources produced by stakeholder groups, such as, but not limited to,
Monthly NH DPHS Medicaid Care Management Summary Reports;
NH Child and Teen Mental Health: An Analysis and Comparison of 2019-2020 Healthcare Claims Data;
NH Council for Youth with Chronic Conditions 2022 Families’ Needs Assessment;
NH State Profile for Women’s Health (Kaiser Family Foundation);
The 2022 Kids Count New Hampshire Profile;
The 2022 NH Child Advocate Annual Report;
The 2022 NH Kids Count Data Book;
The 2023 NH Breastfeeding Report;
The Child Health and Development Institute’s Policy Brief on Children’s Behavioral Health;
The Council for Thriving Children’s ‘Understanding the NH Birth through Five System: A Needs Assessment;
The Dartmouth Hitchcock ‘Community Health Needs Assessment | FY2022;
The NH Baseline Needs Assessment Report;
The NH Center for Justice and Equity Demographic Profiles of NH;
The State of Childhood Obesity (November 2022);
The State Data Chartbook (The Catalyst Center);
The Status of Women in NH, 2023; and
The UVN Center of Rural Addiction’s NH Baseline Needs Assessment Feb. 2022.
Online resources utilized for national and state-specific data include query tools for the
- CDC’s National Health and Nutrition Examination Survey (NHANES),
- the Youth Risk Behavior Surveillance System (YRBS),
- the Behavioral Risk Factor Surveillance System (BRFSS),
- SAMHSA’s Behavioral Health Barometer, and
- the National Survey of Children’s Health (NSCH) data portal (the Data Resource Center).
HRSA MCHB’s Federally Available Data (FAD) document and accompanying data tables are also a rich source of information on the state-specific status of performance and outcome measures, with the presentation of stratified data over many years, allowing for the discernment of trends in the State and comparisons with other states or the national averages or trends.
Regular meetings held by multiple stakeholder working groups discussed the needs of the population especially in response to the COVID pandemic and resulting modifications of services. Both MCH-funded Community Health Centers and BFCS-funded contract agencies conduct and report on results from annual family surveys, which continue to provide an important snapshot of real-time health needs and concerns of local families.
Within NH DHHS, the Community Collaboration grant’s Family Advisory Council informs services to families. Within the Health Disparities grant, monthly Community of Practice meetings with CHWs provide information and feedback to DHHS. Key informant interviews and video story telling to help inform engagement for pregnancy through age three and substance use disorder (SUD) were implemented within MCH’s Family Support and Community Engagement Program.
The Newborn Screening Program provides birth hospitals a quarterly timeliness report, to track unsatisfactory specimens and inform on the reasons why. The SUID/SDY Program hosted a parent town hall to gather information of why families do not always practice safe sleep. The Birth Conditions Program (BCP) engages a program advisory committee, comprised of stakeholders including parents of children with birth defects.
The NH Mental Health Care Access in Pediatrics (NH MCAP) program utilizes provider satisfaction surveys and an advisory board to solicit feedback on programmatic needs, didactic curriculum, and effectiveness. Families with lived experience are engaged in both the NH MCAP advisory committee as well as the upcoming Project ECHO cohort on Early Childhood Mental Health. One of the faculty members who will be serving as a subject matter expert for this cohort is a parent who has had a child in the mental health care system.
Under the auspices of the Injury Prevention Program (IPP), the Teen Driver Safety (TDS) peer lead groups, based at local high schools, engage teens to be leaders in cultural changes toward motor vehicle safety in their communities. The TDS is partnering with the IPP at the University of Vermont Medical Center to design a teen-led Drive Safe Curriculum around distracted driving. The program will allow students to customize the curriculum and have ownership over their presentation.
The HFA NH Home Visiting Program agencies collect family satisfaction surveys on a yearly basis. All agencies are required to have advisory boards that include a mix of participants with skills, strengths, community knowledge, and cultural diversity, to focus on data-driven quality improvement (QI) to improve services. Family engagement continues to be a priority; in this year’s Continuing QI update, a goal is to increase engagement of participants and stakeholders in improving specific performance measures on maternal depression screening/referral and safe sleep.
The Child and Adolescent Coordinator continues to use data from the YRBS, the NSCH, the Adolescent Behaviors and Experience Survey, and the NH DHHS Immunization program (TeenVaxView) to inform and promote best practices in the care and support of the child and adolescent population.
The Maternal Mortality Review (MMR) Coordinator utilizes data and information acquired from the Division of Vital Records Administration (DVRA), the Medical Examiner’s office, Medicaid, hospitals, as well as informant interviews, including decedents’ family members.
Since FY2020, BFCS has sought input about gaps in a variety of ways including surveys, stakeholder meetings, and family councils. BFCS conducts bi-annual site visits to community-based agencies providing family support services to CSHCN, which includes meeting with Regional Family Councils; in these meetings, youth (CSHCN ages 18‑21), parents and other caregivers share their experiences with systems of care and challenges they face in navigating the system.
As a member of the NH Council for Youth with Chronic Conditions (CYCC), BFCS was an active member of the advisory group, which provided feedback and assisted with dissemination and recruitment for each of the needs assessment activities. Key findings from CYCC report will inform the BFCS survey and the 2025 Title V Needs Assessment.
Throughout the quality improvement initiative (known as the BFCS Redesign), stakeholder input was gathered through informational meetings with families and service providers including representatives from health care, specialty services, community-based social service agencies, the development disability system and insurers.
Efforts to operationalize needs assessment
For all programs, data is collected from participating agencies on at least a yearly basis, and usually on a quarterly calendar. This information includes progress on work plans, process or outcome measures, as well as barriers encountered or outreach activities implemented. Some data, such as for birth conditions, contributes to pooled national data. All data is reviewed with a lens assuring that diversity, equity and inclusion is an important aspect of all programs, and that the needs of sub-groups such as youth will be addressed.
The NH MCAP Program conducts yearly needs assessments of each Project ECHO cohort of enrolled pediatric primary care providers to determine topics of interest for the next year’s training efforts as well as pre and post cohort surveys on perceived changes in knowledge and confidence of treating children with mental health concerns to measure program impact.
The Injury Prevention Center has established a program performance management system using the framework of Results Based Accountability (RBA). RBA helps to define a contribution relationship that injury prevention programs have on population level data. IPC programs write quarterly progress reports using the RBA format, for internal review and sharing with external stakeholders.
The work of MCH’s Perinatal Nurse Coordinator who is also the Coordinator of the Maternal Mortality Review Committee includes weekly collaborative meetings with other MCH staff as well as partner agencies, notably the Northern New England Perinatal Quality Improvement Network (NNEPQIN) and the national Alliance for Innovation on Maternal Health.
The most recent MIECHV (home visiting) needs assessment update utilized parent/caregiver surveys, a PhotoVoice Project, and a home visitor survey, which were analyzed to determine if there were any possible disproportionate impacts by large municipalities on country-level data; it was determined that there was enough need in every NH county to justify services being offered statewide.
A key finding of the MIECHV Needs Assessment was the need to support families with substance-exposed infants (SEI). A pilot project was developed to support families of SEI in connecting with family support and strengthening programs through partnership with providers of these programs, child protection, and prenatal care and birthing hospital staff. A toolkit was developed based on the lessons learned from this pilot. Contracts developed by DPHS and DCYF, with additional support from the Health Disparity Grant and the Governor’s Commission on the Prevention of Alcohol and other drugs, have been recently approved; this will continue to focus support with strategies to connect families with SEI to home visiting services.
To operationalize NHs Title V Needs Assessment work, BFCS assesses the training needs of staff through annual surveys and monthly meetings with contract agencies’ staff. All programs are required to report on their own annual satisfaction survey results, as part of their annual reporting requirements. Monthly meetings provide opportunity for peer-to-peer discussion that often identifies needs from the sharing of experiences.
NH’s MCH and CSHCN Directors recently met, together with their teams, to discuss a plan for 2025 that will be comprehensive and look not only at individual and family experiences, but also at the needs of the professionals who work with the population served by Title V.
Noted changes in health status and needs
There have been no drastic changes in the health status of needs of the maternal and child population in NH. The programs under the purview of the MCH Title V Block Grant continue to serve their respective populations as outlined in their work plans. Often there is a focus on individuals who are low-income, uninsured or underinsured.
The Birth Conditions Program notes that birth defects cause one in every five deaths in infants nationwide. The overall annual prevalence for birth defects in infants born in NH is approximately 3%, and around one in six infant deaths is due to a birth defect.[1]
The Injury Prevention Program notes that injury remains the leading cause of death for children and teens in the US. Leading causes of child unintentional injury include motor vehicle crashes, suffocation, drowning, poisoning, fires, and falls.[2]
Children’s mental health continues to be affected by the COVID-19 pandemic. The Surgeon General’s Advisory on youth mental health remains in place; it recommends supporting the integration of screening and treatment into primary care. The Pediatric Mental Health Care Access Program grant continues to fund the NH Mental Health Care Access in Pediatrics (NH MCAP) Program, which aims to integrate behavioral health services into pediatric primary care through utilizing the Project ECHO model, to provide training and teleconsultation to pediatric primary care providers on how to best treat youth with mental health concerns within the primary care setting. In February 2023, the NH MCAP Program launched its fourth Project ECHO cohort, focusing on Early Childhood (0‑5) Mental Health.
Childhood well-care visits and immunizations were affected by the COIVD pandemic, and rates have not yet recovered. The national goal of Healthy People 2030 for Well-care visits for children and adolescents is 75%. In NH, contracted care agencies report percentages ranging from 34-77%.
The State of Childhood Obesity – New Hampshire report states that among 10-17 year olds, the rate of obesity has gone from 8.5% in 2016 to 13.5% in 2019‑20. In January 2023, over 425,000 NH residents, including over 150,000 children, lived in households that reported having insufficient food. In 2021, NH enrolled only half of the population eligible for SNAP (Supplement Nutrition Assistance Program), with wide variations by county.
The use of vaping products among teens as reported by the 2021Youth Risk Behavior Survey (YRBS) was 18% overall, with a wide gender disparity: 15% of males reported using vapor product in the past 30 days, compared to 21% of females. Given the risks associated with vaping as outlined in the CDC’s Quick Facts on the Risks of E-cigarettes, vaping remains of concern, particularly among girls.
The perinatal population has faced the closing of birthing units and the consequent reduction of service availability and professional staff. Women with Substance Use Disorder (SUD) and mental health diagnoses experience stigma resulting in disparities in health care. In NH, over half of maternal deaths are related to SUD and/or mental health issues. The need for a validated screening tool for SUD and Mental Health is critical, and must include a system in place for referrals to treatment.
Health challenges faced by the families served by HFA‑NH home visiting included:
- SUD - 49% of primary or secondary caregivers indicated a history of substance use (SUD);
- 32% of enrollees reported a history of child abuse, neglect, or involvement with the child welfare system; there is a growing partnership between NH DCYF and the HFA programs, working to enroll high risk families into preventive home visiting services;
- 36% of enrollees reported that someone in the house was a user of tobacco products.
Noted changes in program capacity or systems of care
The Family Planning Program has noted that all sub-recipient agencies, like many health care organizations across NH, have experienced some of their highest rates of staff turnover in the last year, and continue to experience higher than normal staff vacancy rates. A high number of new staff and vacancies impact service delivery; it also affects staff professional growth, as the ability to attend professional development opportunities is limited in order to prioritize patient care.
The transition to an Electronic Medical Record (EMR) system and electronic reporting by nearly all family planning sub-recipient agencies will facilitate the collection and reporting of data.
The Birth Conditions Program staff is supporting surveillance activities for pregnancies impacted by COIVD, in cooperation with the Bureau of Infectious Disease Control. Data collection is experiencing mixed levels of effort from birth hospitals, due to ongoing staffing shifts and shortages.
The Injury Prevention Center added a Data Specialist position in 2022 that will assist in reviewing data for the state injury trends. The Injury Prevention Program is short one staff member.
NH MIECHV agencies report 53 staff changes during the 24-month period 2020‑2022. Local implementing agencies (LIAs) report that while they pay competitively within the field of family support, the level of risk in this type of work often means that only people who are already passionate about prevention and supporting families will apply or remain in their position. Additionally, the program has seen several staff leave to stay home to meet their own family needs, or transfer to other human services programs. NH MIECHV continues to evaluate opportunities for improvement in its staff recruitment and retention efforts, and plans to participate in the 2023 HV COIIN, which will focus on staff recruitment and retention in order to support LIAs in this area.
In the Adolescent Health domain, it is noted that many Community partners including contracted FQHC’s/Community Health Centers continue to face workforce shortages creating delays in receiving care. The increased use of telehealth since the pandemic has permitted more patients to receive needed healthcare. One of MCH’s contracted agencies providing school based care has been able to increase both medical and mental health services with the addition of grant funding from MCH and the CDC.
BFCS has also observed workforce issues including the loss of the Data Coordinator in January and the Clinical Program Assistant in March of 2023. Recruitment is ongoing for both positions. Agencies serving families with CSHCN continue to report difficulties filling positions; in part due to the low unemployment rates combined with the high housing costs in NH. Families in need of in-home supports and private duty nursing are unable to find help, which adds to the stress of caregiving.
Partnerships and collaborations with other entities that serve the MCH population
New Hampshire has an extensive history and experience with partnerships and collaborations, in part because NH is a small state with limited financial, programmatic and human resources, which creates a need to get buy-in and assistance from groups and agencies throughout the State. In addition, in a small state there is considerable overlap of membership in various stakeholder groups, which promotes collaboration and networking. A sample of partnership groups that include participants from NH Title V staff include the following:
- Alliance for Innovation on Maternal Health (AIM) and the Northern New England Perinatal Quality Improvement Network (NNEPQIN): provide educational webinars and implement AIM safety bundles at maternity hospitals; assist with record abstraction and other support services for the MMR Committee;
- Bi-State Primary Care Association: educational and technical assistance on perinatal healthcare and salary support for CHWs in NH Federally Qualified Health Centers (FQHCs)
- Buckle Up NH/Teen Driver Safety: A gathering for traffic safety professionals and others interested in youth motor vehicle safety.
- Injury Prevention Center (IPC): DHHS contracts with the IPC to provide meeting facilitation and prevention activities related to teen driver safety, traumatic brain injury prevention, child maltreatment prevention, suicide prevention, and older adult fall prevention, and other injury prevention activities.
- National Birth Defects Prevention Network: The BCP participates in the Guidelines and Standards Committee and within that committee holds a co-chair position on the Standards Development and Evaluation workgroup and participates in the Surveillance Guidance Manual workgroup to assure the program aligns with national objectives for participation in pooled national data;
- NH Children’s Trust (NHCT) is a contractor for the Community Collaboration program; they subcontract with Family Resource Centers to pay for CHWs in those centers;
- NH Council for Youth with Chronic Conditions educates and informs policy-makers and stakeholders of the unique challenges facing CSHCN.
- NH Early Childhood Integration Team: monthly collaborative meetings with other DHHS family-serving programs and quarterly collaborative meetings with NH Department of Education staff to support collaboration and coordination of efforts;
- NH DCYF and NH MIECHV have implemented a pilot project related to substance-exposed infants; additionally, over the last year, there has been collaboration to develop a joint contract for home visiting services, expanding to encompass the HFA Child welfare protocols, which expand services to DCYF-referred families with children up to 24 months of age;
- NH Medicaid Quality: to assure quality in Medicaid services, including shared pediatric quality indicators and recommendations for improvement;
- NH Suicide Prevention Council: A gathering of high-level stakeholders to discuss activities related to suicide prevention; NH MCH is particularly focused on teen risk factors and joint initiatives to prevent adolescent and young adult suicides;
- North Country Health Consortium is working to improve CHW trainings statewide as well as to establish CHW certification in the state so CHW services can be reimbursed by Medicaid;
- Regional Public Health Networks have CHWs working in their networks to help address Social Determinants of Health;
- Safe Kids New Hampshire: A gathering of stakeholder to discuss activities related to prevention of childhood injuries; Safe Kids International sets up an annual conference and Safe Kids-NH, with the IPC, sets up an annual bike rally event;
- State Plan to Improve Nutrition Equity: to improve nutrition equity and create initiatives to reduce childhood obesity and increase utilization of food access programs;
- State Universities—the Family Planning Program (FPP) connects regularly with UNH Durham and Colby-Sawyer College to provide sexual health supplies, education, program information, and to attend campus tabling events throughout the year;
- The Bureau for Children’s Behavioral Health’s System of Care Advisory Council, whose mission is 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;
- Watch Me Grow (NH’s Help Me Grow affiliate): to assist in creating a centralized access point for child and family referrals to community resources.
Changes in organization structure and leadership
Lori Weaver, previously the Deputy Commission of DHHS, was identified as the Interim Commissioner following the resignation of Commissioner Lori Shibinette in December 2022.
The MCH section has a new Bureau Chief, Lissa Sirois, who was formerly the Administrator of the Nutrition program. There was a transition to a new MCH Epidemiologist in 2022.
NH’s Birth Conditions Coordinator has undertaken a co-chair position in 2022 of the NBDPN’s Standards Development and Evaluation workgroup, which is now under the Functional Committee, Guidelines and Standards.
MCH’s Clinical Services Program Manager left her position in March 2022; that position has now been filled by the former Coordinator of the Pediatric Mental Health Care Access Program (PMHCA).
A new Perinatal Nurse Coordinator/Maternal Mortality Review Coordinator joined MCH in December 2022.
The NH Personal Responsibility Education Program, managed by the Family Planning Program (FPP) has ended, as the contracts were not approved by the NH Executive Council in 2022. The FPP Administrator resigned in January 2023; that position has now been filled. The Adolescent Health nurse has taken on some clinical duties including on-site QA reviews.
The Injury Prevention Program is short one staff member; the Injury Prevention Center added a Data Specialist position in 2022 to assist in reviewing data for the state injury prevention plan trends.
In the Home Visiting Program, the program Administrator left her position at the end of February 2023. Significant staff turnover has also been noted in the field.
The Senior Program Director of New Hampshire Children’s Trust (a key partner) left her position in March 2023. Contracts for Comprehensive Family Support Services (CFSS)/home visiting and NH Children’s Trust are moving to DPHS from the Division of Economic and Housing Stability.
NH Family Voices experienced substantial turnover and difficulties competing in the labor market to fill positions.
Reorganization of BFCS continued throughout FY2022, in preparation for the launch of the new Health Care Coordination programs in July 2023. Three nurse health care coordinators were reclassified as Registered Nurse Consultants, with responsibilities to provide consultation services to community-based and health agencies in the development and organization of care coordination services for CSHCN and their families.
One Health Care Coordinator has become a CSHCN Program Coordinator who will coordinate and participate in the development, training and planning of CSHCN Program initiatives, systems, policies and procedures, to improve statewide access to quality health care for CSHCN.
The greatest change in BFCS will be the implementation of ten regional community-based contracts for Health Care Coordination that will incorporate the family support component previously provided by the Partners in Health program. This redesign will address one of the most frequently identified concern of families by giving the Health Care Coordinators the flexibility to meet family support needs without referring to a separate program.
Emerging issues and capacity and resources to address them
Emerging public health issues are varied and have highly consequential impacts on the lives of NH residents. One of these is the end of the COVID-19 Public Health Emergency (PHE), which has resulted in the termination of some Medicaid coverage and SNAP benefits. At the same time, consumer costs for food, gas, electricity, rent, and child care all have increased and are not coming down with the end of the PHE. These changes will pose substantial burden on NH residents, who will find it hard to adjust and still get their needs met.
For families served by MCH, its contractors and the BFCS, the unwinding of the COVID-19 Medicaid Continuous Eligibility Protection is most concerning. In partnership with Medicaid and the Bureau of Family Assistance, Title V has been informing all of the families they and their contractors work with to watch for “yellow letter” notices which provide redetermination dates, and encourages them to prepare for their re-determination date in order to continue coverage. Along with social media, print and television campaigns share information about options for those no longer eligible.
Among children and youth aged 0-19 in the US, COVID‑19 is ranked first in deaths caused by infectious or respiratory diseases, and COVID‑19 deaths constituted 2% of all causes of death in this age group.[3] This is a significant disease burden, and pharmaceutical as well as non-pharmaceutical interventions continue to be important to limit transmission of the virus and to mitigate severe disease.
Insufficient availability of childcare continues to be an issue. With the end of the PHE and more people returning to work at their place of employment, demand for childcare is rising, but the child care workforce is not increasing.
Closings of birthing units in hospitals and birthing centers throughout the State, coupled with the shortage of perinatal healthcare workforce creates a lack of health access, education and resources for the perinatal population. Insufficient access to Substance Use and Mental Health treatment continues to be a crucial perinatal emerging health issue within NH.
Substance use disorder is an ongoing issue. The treatment system in NH consists of services including outpatient, intensive outpatient, partial hospitalization, residential, withdrawal management, as well as peer and non-peer recovery support services. Many of these are paid by public and/or private insurance, as well as funding from DHHS.
Child and pediatric obesity is an ongoing issue. In the US, nearly 1 in 5 children have obesity, which places them at risk of developing heart disease and type 2 diabetes; they are also more likely to suffer from anxiety, depression, and low self-esteem.[4] Addressing obesity is a challenge for parents, because it entails lifestyle changes for the entire family.
Sexually transmitted infections (STIs) increased during the pandemic and are continuing to rise, in part due to pandemic-related barriers to testing and treatment. Despite a rise in STIs, there is a decrease in condom use. Untreated STIs can lead to infertility and adverse maternal and newborn health outcomes. NH has some capacity and resources to address this, through the further promotion of free condoms and HIV testing kits from the Bureau of Infectious Disease’s HIV funding; also through the promotion of “pop-up” HIV/STD testing at community centers, universities, etc.; referrals for treatment could be made for anyone who tests positive, and free condoms should be offered at these sites.
Previously contracted family planning agencies have been unable to get their contracts approved by the NH Executive Council. With the reversal of Roe v. Wade, which established a constitutional right to pregnancy termination, it is now up to each state to establish laws on this. New Hampshire law has maintained the status quo, though various groups continuously work towards reducing access to reproductive and sexual health services, leaving a sense of uncertainly regarding the future availability of services in the State.
Lack of a behavioral health workforce, which creates a lack of access to mental health care for children, continues to be a crucial health issue within NH; NH PMHCA is addressing this through providing training and teleconsultation opportunities to providers to treat children with mental health concerns within the primary care setting.
[1] https://www.nbdpn.org/docs/BDStateProfile-New_Hampshire.pdf; accessed 2/28/2023.
[2] https://www.cdc.gov/injury/features/child-injury/index.html; accessed 2/28/2023.
[3] https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2800816; accessed 3/6/2023.
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