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 produced by stakeholder groups, such as, but not limited to, the 2020-21 NH Child Advocate Annual Report, the 2021 Kids Count New Hampshire Profile, the 2021 NH Breastfeeding Report, the NH Baseline Needs Assessment (identifying current and future substance use disorder treatment needs and barriers, and COVID‑19 impacts), NH DHHS’ Closing the Cliff Effect progress report, monthly DPHS NH Medicaid Care Management Summary Reports, the Kaiser Family Foundations’ State Profiles for Women’s Health, and the NH Women’s Foundation’s 2021 report: The Status of Girls in NH.

 

Online resources for national and state-specific data include CDC’s NHANES, YRBS or BRFSS survey query tools, SAMHSA’s Behavioral Health Barometer, or the National Survey of Children’s Health’s 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 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 normal services, hours of operation, or availability of appointments. The MCH-funded Community Health Centers’ annual family surveys continue to provide an important snapshot of real-time health needs and concerns of local families.

 

Within the NH DHHS MCH section, the Family Planning (FP) Program collects family planning encounter data and annual client satisfaction surveys to assess and record the performance of all sub-recipient agencies. The FP program’s Advisory Committee, composed of individuals matching the demographics of the clientele, including some actual clients is involved with all assessments of performance and the addressing of barriers experienced by clients in accessing high quality family planning services.

 

In the Home Visiting (HV) program, family satisfaction surveys are collected on a yearly basis.

There has been an emphasis on supporting family engagement in continuous quality improvement (CQI) efforts, and goals have been developed to increase engagement of participants and stakeholders in improving specific performance measures on maternal depression screening/referral and safe sleep, while continuing to allow agencies to select other CQI projects that are particularly salient for their community.

 

In the most recent MIECHV Needs Assessment update a key finding was the need to support families with substance exposed infants (SEI). A pilot project was developed to support families in connecting with programs through partnership with providers of these programs, as well as child protection, and prenatal and birthing hospital staff. A toolkit was developed to support spreading the lessons learned from this pilot. Existing contracts with agencies are being amended to include additional funds to support agencies to implement strategies from the toolkit.

 

The NH Mental Health Care Access in Pediatrics (NH MCAP) program utilizes data collection, program evaluation, provider satisfaction surveys, and its advisory board to solicit feedback regarding programmatic needs and effectiveness. NH MCAP’s advisory committee, composed of commercial and Medicaid insurers, American Academy of Pediatrics (AAP) NH chapter, Children’s Hospital at Dartmouth, NH Department of Education, UNH Institute of Health Policy and Practice, UNH School of Nursing, and NH Family Voices, recommends topics and the didactic curriculum.

 

The high school based Teen Driver Safety peer groups, facilitated by the Injury Prevention Center (IPC) at Dartmouth Health Children’s, engage other teens to be leaders in cultural change regarding motor vehicle safety at their schools and in their communities.

 

The Birth Conditions Program (BCP) engages a program advisory committee, which includes a parent of children with birth defects. 

 

In preparing the performance measures for the Title V funded MCH in the Primary Care Setting RFP, the Clinical Services Program Manager consulted with other NH DHHS sections, such as the Tobacco Prevention and Cessation Program, Chronic Disease Prevention and Screening, the Lead Poisoning Prevention Program, as well as with committees such as Watch Me Grow, the Pediatric Improvement Partnership, and the Perinatal Substance Exposure Task Force. These efforts helped ensure that the performance measures for the upcoming contract would reflect some of the state priorities for the MCH population, such as developmental screenings, lead screening for both one and two year olds, as well as SUD screenings focused on the adolescent and prenatal population.

 

The Child & Adolescent Nurse Coordinator utilizes data from CDC’s Youth Risk Behavioral Survey to assess emerging concerns among NH children and youth. These include increased depression and suicide as well as the higher rates among NH youth (compared to the US) of vaping/smoking and marijuana use, and bullying. The use of a Youth Advisory Council has been an integral part of the Youth Homeless demonstration program.

 

In 2021, NH was awarded the CDC COVID‑19 Health Disparities Grant. As part of this work, DPHS/MCH has engaged in two new contracting activities: (1) adding funds and scope to the BFCS contract with NH Family Voices and an (2) Request for Application (RFA) for Early Childhood Comprehensive Systems, to implement additional activities in the scope for family services that will engage family voices and increase family participation in Title V through additional focus group work on barriers to care due to COVID or other reasons. The RFA will enhance training with health care providers on the Plan of Safe Care, which is one of our ESMs. The selected vendor will engage in needs and gap analysis for the P-3 population and substance exposure, as well as make policy and funding recommendations. The vendor is asked to leverage existing needs assessments and gap analysis to avoid duplicating efforts. Families, family support programs and other partners will be engaged in the process.

 

The CSHCN Director represents DHHS on the Council for Youth with Chronic Conditions (CYCC), which was established by NH law (RSA 126-J) to promote the organized assessment of the needs of youth with chronic conditions and their families. In 2022, the CYCC entered into a contract with the JSI Research and Training Institute, Inc. (JSI) to complete a statewide, qualitative needs assessment to identify the unmet needs of CSHCN. Strategies will include development of an advisory group and methods for stakeholder engagement. A Caregiver Survey has been widely distributed, including in non-English languages, to assist with the robust dissemination plan. Key informant interviews and caregiver focus groups will support and give context to the data collected from the survey. The results will inform the next CSHCN Survey/Needs Assessment, planned for FY2024 for the Title V Block Grant application in 2025.

 

NHFV routinely uses a number of methods to capture feedback, as well as advisory input. As a primary partner for BFCS’ family engagement work, NHFV convenes issue-specific efforts (e.g. developmental screening access, private duty nursing) utilizing focus groups and key informant interviews to gather information.

 

Family and caregivers of CYSHCN are involved in the needs assessment process in different ways. Sub-recipients are required to conduct a yearly family satisfaction survey of those served during the previous year. The survey asks participants to identify needs and comment on whether or not they were met. Results are reported to BFCS as part of each agency’s annual report.

 

Efforts to operationalize needs assessment

 

To make needs assessment an ongoing process, the FP program utilizes quarterly data reports, semi-annual reports for data and program updates, outreach reports, and data trend tables. The HV program has utilized a parent/caregiver survey, a PhotoVoice Project, and a Home Visitor survey. The Maternal Mortality (MM) program relies on informant interviews to gather suggestions for changes that could be made in maternal mental health, obstetrical, and hospital care; these in turn help the MM Review Committee formulate recommendations. NH MCAP (implemented in NH SPM3) conducts yearly needs assessments of each Project ECHO cohort as well as pre and post cohort surveys on knowledge and confidence in treating children with mental health concerns to measure program impact.

 

The SUID/SDY Program and the NH Safe Sleep workgroup (part of NH’s NPM5) will be using the data and feedback from the virtual events hosted for families to develop safe sleep materials targeted to new and expecting families. Both the NBS and EHDI program use the data that is collected to improve outcomes for infants who need further testing.

 

Historically, BFCS conducts a bi-annual Satisfaction Survey/Needs Assessment (SSNA) of individuals and families enrolled in its programs/services. The last SSNA was done in 2018, due to the COVD‑19 Public Health Emergency and subsequent hiring freeze in 2019-2020. Leadership acknowledge lack of capacity to conduct the next survey. To address this need, the BFCS Data Analyst will participate in the 2022 Training Course in MCH Epidemiology; she will focus on needs assessment and gap analysis.

 

Additionally, annual needs assessment activities include satisfaction surveys, which are requested from all BFCS program participants. Results are compiled and submitted to BFCS as part of annual reporting each July. BFCS training needs assessments are conducted frequently, by program managers and partners, to identify annual training plans such as those for use of the ASQ for development screening. 

 

Noted changes in health status and needs

 

The needs of the MCH population in NH, as everywhere, have been impacted by the COVID pandemic and the measures taken for its mitigation or containment. Those measures are being scaled back, but their impact is still being felt. Service sites were closed or operated with reduced hours, at reduced capacity. Telework was improvised and televisits were instituted with no prior opportunity to coach users on how it all worked. Face-to-face visits became the exception, often used only in situations of high-need or urgency, thus pre-empting much routine, preventive care. The population is re-adapting to a new normal with fewer restrictions, but creating new routines is a work in progress, and in-person events often have reduced attendance, perhaps due to ongoing site-specific recommendations of social distancing and mask wearing, compared to pre-pandemic times.

 

COVID aside, MCH population needs have not changed greatly, as reflected in the list of priority needs retained for this project cycle from the previous project cycle. There remains an emphasis on access to services, which is addressed by the selection of NPM 6 (access to developmental screening), NPM 10 (preventive medical visit for adolescents), NPM 12 (adolescents’ transition to adult health care), ESM 14.1.1 (the Plan of Safe Care for birthing women), SPM 1 (enabling services to reduce SDoH barriers), SPM 2 (access to respite services for families of CYSHCN), and SPM 3 (access to pediatric mental health teleconsults). Primary health care providers are noting that many children are behind on routine physicals, routine screenings (such as developmental screenings) as well as vaccinations. In addition, children and adolescents are struggling with behavioral health issues at higher rates than pre-pandemic.

 

Children’s mental health continues to be considerably affected by COVID‑19. In December 2021, a Surgeon General’s Advisory was issued to highlight the urgent need to address the nation’s youth mental health crisis. This advisory provided recommendations that individuals, families, community organizations, governments, and others can take to improve the mental health of children, adolescents and young adults. One of those was to “Support integration of screening and treatment into primary care. For example, continue expanding Pediatric Mental Health Care Access programs, which give primary care providers teleconsultations, training, technical assistance, and care coordination to support diagnosis, treatment, and referral for children with mental health and substance use needs. NH’s Mental Health Care Access in Pediatrics (NH MCAP) Program 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 best to treat youth with mental health concerns within the primary care setting.

 

Based on a preliminary analysis of MIECHV Outcome Measure reporting for 10/1/20-9/30/21, it appears that among the program beneficiaries there was an increase in preterm births, a reduction in breastfeeding, depression screening, well child visits, and postpartum care visits, and an increase in tobacco cessation referrals from the previous year. There also appeared to be a decline in the use of safe sleep practices and an increase in investigated cases of child maltreatment, although this could be due to increased referrals of families with child welfare investigated cases to the HFA program,. Increases in parent-child interaction screenings and developmental screenings were observed, along with increased intimate partner violence (IPV) screening. Decreases in primary caregiver education, continuity of insurance coverage, and referrals for maternal depression measures also occurred.

 

For CYSHCN, the pandemic interfered with outpatient therapies, home care, availability of medical appointments and respite. As the number of NAS infants continues to climb, BFCS’ Nutrition, Feeding & Swallowing consultants report increasing complexity and struggle to reach all those in need. Medically complex children are finding fewer options for care and providers are less available. BFCS providers also note that families are seeking financial support with transportation, utilities and rent.

 

Noted changes in program capacity or systems of care

 

The entire healthcare system in the State is struggling with staffing related shortages and vacancies. This is impacting health centers and their ability to provide full, comprehensive services to patients. Many agencies have not been able to expand hours or appointment availability since the pandemic due to short staffing. In addition, many healthcare agencies have been hesitant to take on new or expanded initiatives due to staffing shortages.

 

Workforce shortages continue to impact access for some services for CYSHCN and their families. The nursing shortage continues and BFCS has found it nearly impossible to fill vacant positions. Pediatric providers are scarcer and which often means that families have to travel greater distances for services. There is also a shortage of pediatric mental health providers and wait lists are very long. Recently Tufts Children’s Hospital announced the closing of its pediatric hospital, July 1, 2022. The impact on service delivery for NH residents is yet unknown.

 

The FP program is trying to expand to telehealth services among the network of FP agencies. Telehealth services were available in 2020 but many of the agencies have moved back to the model of in-person visits with very little telehealth. Telehealth services have the ability to decrease barriers to care (e.g., transportation, child care) and may help address staffing capacity at clinic locations by making appointments more flexible, at non-traditional times. By increasing telehealth services, the FP program hopes to augment the number of clients served and further expand services statewide.

 

There has been significant turnover of HV staff at the local agency level. There was an opportunity to increase funds for service delivery through MIECHV American Rescue Plan (ARP) funding; however, due to staff shortages, it was not possible to increase access to families in a significant way.

 

NH is experiencing a shortage of mental health/substance use disorder (SUD) providers. The majority of maternal deaths occur in the postpartum period, and the majority of those deaths are related to SUD overdose. NH needs adequate mental health/SUD providers available to provide care and have more care coordinators to provide closed-loop referrals and follow-up.

 

In March 2022, the NBS program hired a part time position for long-term follow up. This position will be responsible for monitoring infants who need further testing to determine if a genetic disorder is present, and for providing resources to connect families and providers with the Bureau of Family Centered Services.

 

MCH is working to address the shortage of mental/behavioral health professionals and consequent reduction of adolescent well visits and immunizations by designing an RFA to increase access to care by providing mental/behavioral health services in the school setting.

 

BFCS is aware of the growing need for developmental pediatricians, pediatric neurologists, psychiatrists and other qualified professionals to evaluate children for autism spectrum disorder in NH. The Title V supported Child Development Clinic (CDC) reported a wait list that became increasingly difficult to manage, as there were simply not enough clinicians available. CDC implemented a triage process to identify those children in most need and collaborated with Complex Care Network for appropriate referrals. Children with developmental concerns who are suspected of having autism need accurate diagnoses. Ruling out autism is just as important as making an autism diagnosis, as appropriate treatment and remediation often begins at diagnosis. The BFCS is investigating what and where the gaps exist, who are other critical partners and how can workflow be changed to build a better system for service delivery.

 

Program staff turnover continues to be high and positions are harder to fill. Salary levels for those working in direct care and family support are often insufficient to find affordable housing options in the state.  

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 external groups and agencies throughout the State. In addition, in a small state there is considerable overlap of membership on 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 Quality Improvement Network (NNEPQIN), to provide educational webinars and implement AIM Safety Bundles at maternity hospitals.
• Building Futures Together Leadership Team, to support the Building Futures Together program which prepares paraprofessionals in healthcare and school settings to provide specialized enhanced care coordination to children, youth and their caregivers whose parents are impacted by opioid use disorders (OUD) and other substance use disorders (SUD).
• Council for Youth with Chronic Conditions (CYCC), to promote assessment of the needs of children with chronic conditions and their families. The CYCC also advises and collaborates with DHHS, DOE and the insurance department for policy and program development and to enhance community-based family supports that meet the unique needs of the populations.
• Early Childhood Integration Team (ECIT), to support data driven policy and program coordination, integration, and development, while increasing performance and resource accountability across the ECCE system. Members coordinate locally with child care, schools, Public Health Networks, and community based agencies like FRCs.
• Governor’s Perinatal Substance Abuse Task Force, especially around the work of the Plan of Safe Care (POSC).
• LEND Advisory Committee, which reviews programming and planning for NH-ME LEND to prepare leaders to work in the field of MCH and improve the lives of children with neurodevelopmental disabilities and their families.
• Massachusetts College of Pharmacy and Health Sciences (MCPHS) places nursing students/interns with BFCS to learn about the types of services available for CYSHCN.
• Medicaid partnership, which is critical to MCH/BFCS. Together individuals provide ideas and feedback for MCO performance measures for Medicaid’s 11 priority measures for this year; including increasing BMI and nutrition referrals to combat childhood obesity, and increasing adolescent immunizations including HPV. BFCS provides training and technical assistance to MCOs relative to caring for CYSHCN, consultation to providers, and policy review.
• NH Children’s Health Foundation collaborates with the FP program on a contraceptive access initiative to address adverse childhood experiences.
• NH Department of Education and the Bureau for Children’s Behavioral Health’s System of Care Advisory Council, which promotes, aligns, and continuously improves 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.
• NH Pediatric Improvement Partnership (PIP) Steering Committee, to work on promoting awareness of and interest in pediatric care quality measurement, projects, and resources, and is made up of a diverse group of stakeholders from around the state.
• NH Transition Community of Practice, which shares resources and problem-solves barriers and issues related to transition to the adult service system.
• Office of the Chief Medical Examiner (OCME), to identify all resident SUID and SDY cases using Centers for Disease Control and Prevention (CDC) guidance
• State Family Support Council, to exchange, share and distribute information to each regional council; provide an avenue for arbitration and mediation conflict resolution between Area Agencies and regional councils; and provide information and feedback on issues and concerns for regional councils to DHHS/BFCS and the Bureau of Developmental Services (BDS)
• University of NH Institute on Disability (UNH IOD) partners with DHHS in areas including Charting the Life Course (CtLC) Community of Practice, to promote family-centered approaches to working with families, and NH Acts Early project using LTSAE funding to support developmental screening activities.
• Watch Me Grow Steering Committee is comprised of partners that make up the developmental screening system in NH.
• Youth Homeless Demonstration Program (designed to reduce the number of youth experiencing homelessness) works to assure that assistance with Health Navigation for youths experiencing homelessness is a priority.

Changes in organization structure and leadership

 

Within NH DHHS, the Director of the Division of Public Health Services (which houses MCH) retired and a new Director was promoted with within. More recently, the Chief of the Bureau of Population Health and Community Services (overseeing MCH) has taken another position out of state, and the position is currently vacant. In addition, the MCH Epidemiologist, after over a decade with MCH, resigned his position; a new Ph.D. level epidemiologist has been hired and began on boarding in May 2022.

 

Multiple changes for the FP program included the departure of the MCH nurse consultant and the MCH epidemiologist. There were also leadership changes in two of the FP program’s sub-recipient agencies, and in facilitator staff.

 

Likewise, the HV program saw several key changes. The HRSA project officer supporting the MIECHV program changed. In-house, a new full-time HV CQI Specialist position was created and filled. There was also significant turnover among Supervisors, Program Managers, Nurses, Family Resource Specialists, and Family Support Specialists within several local implementing agencies (LIAs).

 

The NH MCAP program welcomed a new supervisor in June 2021, in the Clinical Services Program Manager, but that person resigned in March 2022. Also, there was a change of a key collaborator from the UNH Institute for Health Policy and Practice.

 

Within MCH, a new Child and Adolescent Nurse Coordinator was hired in September 2021; this is a new position in MCH. A new PRAMS Coordinator began working in November 2021 (after a 15‑month vacancy) and a new Newborn Screening Program Specialist was hired in March 2022.

 

The Division of Long Term Supports and Services Director retired in June 2021 and a former, semi-retired Associate Commissioner returned to provide interim leadership for nearly a year; a new Director was hired in early 2022.

 

One of the founders and co-Directors of NH Family Voices, retired and new staff are onboarding to redistribute the workload and implement new projects. 

 

Since December 2021, BFCS has seen four staff retirements and recruitment is underway to fill.

 

BFCS sub-recipients have witnessed first-hand the phenomenon known as the “great resignation”. Several vacancies exist in community-based agencies and they have been difficult to fill.

 

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 access to family planning services. The likelihood of Roe v. Wade being overturned has paved the way for states across the nation, including NH, to enact legislation to restrict access to services. New Hampshire has seen this with the dis-approval of three contracts due to agencies’ offering of services outside their Title X Family Planning project. The three agencies were among the top performers for family planning services in the FP program. MCH hands are tied in the face of legislated mandates.

 

Another area of concern is access to broadband internet for clients who live in rural areas. Not having access to broadband has led to a delay or halt in agencies’ ability to serve their clients through telehealth, especially during the COVID emergency. Access to telehealth could also mitigate the effects of staff shortages among providers, but the primary beneficiaries would be the population seeking services and no longer needing to drive long distances. MCH and partners are supportive of legislation and policy to expand broadband for all NH residents.

 

NH has among the highest rates of alcohol consumption in the country. The most current YRBS data reported that 27% of high school youth drink alcohol, with rates highest among those of color (31% for Hispanic youth). NH’s Personal Responsibility Education Program (PREP) provides evidence-based, age-appropriate education geared towards the development of social and emotional skills young people need to have healthy relationships, to make responsible decisions, and for positive youth development. PREP can address this issue by including education on alcohol consumption, and the program could be expanded to areas of the State where a higher percentage of Hispanic youth reside.

 

STI/STDs increased during the pandemic due to limited access to testing (and subsequent treatment). Untreated STIs/STDs can lead to infertility and adverse maternal and newborn outcomes. MCH will continue to promote the availability of free condoms and HIV self-testing kits made available by the Bureau of Infectious Disease Controls’ HIV section funding. MCH will also continue to partner with the NH Public Health Laboratories to offer free STD/HIV testing to family planning clients, who are eligible, and enrolled in the NH Title X project.

 

The Family Planning Program, within MCH, has also started a condom distribution project which provides free condoms within two food establishment bathrooms. The condoms include a QR code on the wrapper, which allows patrons to scan with mobile phones to find available family planning services, including STD testing and treatment. The food establishments are located near universities and populations of young people. The program anticipates expanding this project in 2022-2023.

 

The State of NH continues, as before the pandemic, to struggle with the issues of mental illness and substance use disorder statewide. Lack of mental health and SUD providers is impacting care globally, and lack of mental health care for children is a major component of this issue. The MCH section is currently drafting an RFA for primary care providers who are interested in creating/expanding access to school-based health services (primary care and/or behavioral health) in the school setting, for students in grades K-12.

 

The lack of pediatric providers, nurses and personal care staff continues to be an obstacle for families with and without CSHCN. There continues to be a shortage of in-home care providers as well, which prevents families from accessing these services and getting respite breaks. Travel to specialty pediatric hospitals is always challenging, as there are great distances to cover. Recent increases in gas prices will further compound this challenge for families who often need to travel into other states for specialty care providers. Families report a rise in behavioral health needs in children – with insufficient capacity to address them.