Demographics, Geography, Economy and Urbanization: New Hampshire (NH) is one of the oldest states in the country; it was originally a land grant in 1623 and became a state in 1775. NH’s population of 1.36 million live in 9,351 mostly forested (81%[1]) square miles bordered by Canada on the north and by Massachusetts on the south. On the east is the Atlantic Ocean and Maine and on the west is Vermont.
With its 1,300 lakes and ponds, 40,000 miles of river and 18 miles of seashore NH is the 45th largest state at 190 miles long and 70 miles wide. The state’s landscape lends itself to many different types of outdoor recreation. However, that same topography lends itself to difficult driving and long distances between places, particularly in the winter months.
With its ten counties, approximately 47% of the population and 84% of the landmass in NH is considered rural; most of the land area lies north and west of the capital Concord. The three (3) most urban or metro areas are Manchester, Nashua and Concord, all located in the state’s southern tier where the majority (53%) of the population lives. The state’s population is primarily white (94%), but its residents of color are increasing.[2] Rising as well is the 5.9% of the state’s population born outside of the United States, with a 10.5% growth just between 2010 and 2014.[3]
New Hampshire is a rapidly aging state. Approximately 18% of the state is 65 and older compared with 16% nationally.[4] The state routinely is amongst the top five for the highest percentage of its population enrolled in Medicare.[5]
New Hampshire’s Title V Program consists of the Maternal and Child Health Section (MCH) located in the Bureau of Population Health and Community Services in the Division of Public Health Services (DPHS), and the Bureau of Special Medical Services (SMS) located in the Division of Long Term Supports and Services (DLTSS). Many factors guide its efforts.
Both DPHS and DLTSS reside within the New Hampshire Department of Health and Human Services (DHHS), the state’s largest agency made up of approximately 10,000 employees and the bulk of the state’s budget (with Medicaid being the most costly line item). A Commissioner oversees the NH DHHS, appointed by the Governor for what typically is a four-year term. Both MCH and SMS are physically located in the capital city of Concord. However, much of their Title V work takes place in funded agencies across the state in the form of community health centers, specialty health clinics, human services agencies that provide home visiting and the like. The Title V Program focuses on the ever-changing landscape of the state in which it serves.
New Hampshire has the largest bicameral legislature in the English-speaking world,[6] with 24 Senators and 400 Representatives, and operates under a unique Governor and Council (G&C) system. Five Executive Councilors, each representing 1/5 of the population are elected separately from the Governor, though for the same two-year term. All state departments and agencies must seek approval of both receipt and expenditure of state and federal funds, budgetary transfers within the department and all contracts with a value of $25,000 or more. The current Governor of NH is Christopher Sununu, who started serving his second term in 2019 and is a Republican. Title V policy and funding is heavily influenced by both the Legislature and G&C.
Unique strengths and challenges that impact the health status: Historically, New Hampshire has often been in the top tier in rankings of its overall well-being and in the social determinants of health.[7],[8],[9],[10],[11],[12] Scores are based on a composite index of metrics that give a snapshot of the health of a population or its health care, such as rates of infant and maternal mortality (both of which NH scores well on). The State also scores high because some of its key social determinants of health such as economic stability, quality of education and public safety
generally are good. The unemployment rate (2.4%)[14] is well below and the median household income/per capita personal income ($71,305/$61,045) well above that of the United States as a whole.[15],[16] Part of that is due to consistently having a more educated workforce, above the national average for more than a quarter century.[17],[18] New Hampshire also has a relatively small incidence of violent crime, both personal and property, making it rank again in the top ten across the country.[19]
New Hampshire’s poverty rate is 7.7%.[20] The rates vary across the state with numbers increasing the further away from the more population dense areas in the South, close to the Massachusetts state line. Geographic poverty disparities are greatest among children with
about one in five children in Coos County (the Northernmost and only county significantly different than all the others) and one in 17 estimated to be living poverty in Rockingham County (the most heavily populated and in the South). [21] Differences also exist among age, racial/ethnic groups and family composition.[22]
Federal poverty rates are based on food costs, not housing nor child-care. Housing costs are high in NH while the supply is not sufficient. With a median price of $280,000, buying a home is beyond the means of homebuyers with less than $90,000 to $100,000 of income.[23] In the rental market, rents have risen faster than incomes and the vacancy rate is 2% compared to the national average of 5%.[24] In addition, for renter households, the percent of total household income housing necessitates is 47%, much greater than the recommended 30%.[25]
Childcare is also costly. Research estimates that 6.2% of NH families with young children are below the poverty level. If they did not pay for out-of-pocket for child-care, roughly half of these families would not be poor.[26]
Components of the state’s systems of care: New Hampshire’s Title V population is served by its 26 acute care hospitals. Thirteen of the 26 are designated as critical access hospitals, which have 25 beds or less and are the smaller, rural systems. Five specialty hospitals provide psychiatric and rehabilitative care with 498 beds. Dartmouth Hitchcock is the largest medical system in the state with its flagship hospital having the only Level 1 designated trauma classification.
New Hampshire has a highly concentrated health care delivery system. Acute care hospital systems are more than just inpatient and emergency room services. Many of NH’s hospitals have evolved to include the majority of the medical and primary care practices in the state as well as ownership of ambulatory surgery centers, health centers, assisted or skilled nursing care facilities and home care and hospice. This has resulted in the hospital sector having among the highest employment and income numbers in the state.
There are also 11 Federally Qualified Health Centers (FQHCs), one FQHC look-alike and 14 Rural Health Clinics (RHCs), most of which are hospital-affiliated. Through MCH, Title V helps to support the efforts of all of the FQHCs, the FQHC look-alike, one RHC and a hospital affiliated community health center.
Of particular concern to the MCH population is the closure of nine-hospital labor and delivery units in the past 16 years, two within 2018 alone. As of July 15, 2018, there are only 17 hospital birthing units and three non-hospital birthing centers in NH. Only six (6) of the critical access hospitals now offer obstetrical services presenting a distance issue.
This is not unique to NH. Obstetrical services have high fixed costs and low reimbursement rates.[28] Small volume hospitals (like critical access) in NH typically have a higher percentage of patients that give birth paid for by Medicaid (up to 62%).[29]
Over the last decade, Medicaid has consistently paid for approximately one quarter of all NH births. [30]
Research has shown there is a reason to be concerned with closures precipitating increases in births that occurred in hospitals without obstetric services (higher for counties not adjacent to urban areas), increases in out-of-hospital births (including those that occurred in homes and freestanding birth centers) and decreased outpatient prenatal care.[32]
MCH and its partner, the Northern New England Perinatal Quality Improvement Network (NNEPQIN) are collaborating with a team of investigators from the Urban Institute on a three year Robert Wood Johnson interdisciplinary research project entitled, “Maternity Ward Closures in Rural New Hampshire: Investigating the Causes, Consequences and Strategies for Mitigating Adverse Effects”. The MCH Epidemiologist is acting as a formal mentor the research group and is providing expertise in specific NH datasets. The team is using a mixed methods approach. A research plan, data requests and a stakeholder meeting was held during the first year. Over the next two years, the team will facilitate key informant interviews, focus groups with pregnant and postpartum women, and a rigorous analysis of NH birth records and hospital discharge data since 2000. The results of the research will provide critical information for providers and policymakers focused on maintaining access to high quality maternity care services for a rural population.
As with the population of NH in general, the health care workforce is aging. In a 2019 report from the NH Health Professions Data Center, male physicians make up over 80% of the workforce 50 years and older. While 30% of the current available physician capacity (by FTE) is expected to decrease in five year. [33] Title V is working with colleagues such as DHHS’s Office of Rural Health and Primary Care with participation in activities such as the Legislative Commission on Primary Care Workforce Issues.
Financing of services for the MCH population: NH Medicaid utilizes a managed care model for medical services as of 2013. There are currently two managed care organizations (MCOs), Well Sense and New Hampshire Healthy Families.
This past year, Medicaid Care Management, NH’s Medicaid managed care program developed a Request for Proposals (RFP) with a brand new scope of service. Input on the RFP was gathered from across the state through community listening sessions and was released in August of 2018. MCH and SMS staff were part of the process and participated in the development of the RFP, as well as the proposal review and scope of service development. Examples of Title V input include the required list of pediatric specialists for network adequacy, the requisite inclusion of the social determinants of health in the initial health risk assessment and a focus on medical homes. On March 26, 2019, the Governor and his Executive Council approved three insurance plans to serve as recipients of Medicaid Care Management beginning September 1, 2019. Two, NH Healthy Families and Well Sense are already MCOs providing services for enrolled clients. One, AmeriHealth Caritas, will be a new MCO provider.
This year, participants in NH’s Medicaid expansion program, which was a choice of plans on the federal Marketplace called the Premium Assistance Program switched on January 1, 2019 to managed care with a choice of the current MCOs. Called the Granite Advantage Health Care Program, it utilizes a demonstration waiver including a work and community engagement requirement, approved by CMS 1115 Waiver in May of 2018. Those who are not medically frail or otherwise exempt must engage in certain work, public service or educational activities for 100 hours a month after 75 days or more of enrollment in a Granite Advantage Program MCO. Reporting began on June 1, 2019. The enrollee must also remain under 138% of the Federal Poverty Level to remain eligible for coverage.
The Granite Advantage Health Care Program, like those few states who also received CMS waivers for their work requirements, created a lot of political debate. This program, approved by the NH legislature, will extend Medicaid expansion through 2023. Statistics show that most nonelderly adults that have health coverage under Medicaid expansion are already working or face significant barriers to work. [34] Among those who are not working, most are in fair/poor health or report illness or disability, caregiving responsibilities, or going to school as reasons for not working.[35] Many of these reasons would likely qualify as exemptions from work requirement policies. However, research on current Medicaid clients who lose coverage report that they do so for failure to return or provide the necessary documentation, (whether or not they work) which may be a huge challenge for older adults and people with disabilities. The disenrollment and coverage losses in other states provide no indication that the same thing will not happen in New Hampshire.[36] States may also not use federal funds to address work barriers; NH has responded with a partnership between DHHS and NH Employment Security establishing a pilot work program called Granite Workforce.
Health care advocates have involved Title V by supporting legislation that would add additional general funds to the contractual line item for MCH; thereby increasing funds for CHCs whose clients may lose eligibility for Medicaid expansion due to the work requirement. This effort was not successful.
As of the end of April 2019, approximately 178,012 New Hampshire residents, nearly 13% of the state’s population, were on Medicaid, including 50,291 people who were added to the rolls with Medicaid expansion.[37] Children continue to make up the greatest proportion of the NH Medicaid roster with the expansion population second.
The State also operates a partnership health insurance exchange with the Federal government (https://www.nh.gov/insurance/consumers/mp_plans.htm), with the Department of Insurance having control over plan management and consumer assistance functions on the federal Marketplace. There are three (3) medical carriers with 17 plans for individuals and 12 for small groups, having all 26 acute care hospitals in-network for the enrollment period, which started in November 2018.
The legislature also changed the way the state’s share of the Medicaid expansion funding is generated. In July 2017, the federal government identified concerns with the NH HPP’s reliance on donations from providers to fund the non-federal share and indicated NH may be out of compliance. Thus, starting in calendar year 2019, in addition to insurance premiums and high-risk pool assessments, the non-federal share will be paid for out of revenue transferred from the Alcohol Abuse Prevention and Treatment Fund (which will in turn be replaced by DHHS or other federal funds). [39]
Many of these changes have helped to address financial barriers to care. Over the past five (5) years, the rate of the uninsured in NH has gone down 6% to approximately 6.8% in 2017.[41], [42] However, the issue of the uninsured or underinsured remains. For the MCH population, in 2017, most children under the age of 18 were insured (97%). Yet 12% of the 18-34 population remain uninsured, the highest of any age category. The rural percentage of the uninsured continues to remain higher at 11%. A survey of Title V funded CHCs found that in 2018, between 10 to 50% of their patients were uninsured at the first encounter or visit. [43] UDS data of the same agencies report from 2018 that between seven and 30% of the patient population were still uninsured at the last visit.[44] This past year was the last that the Bi-State Primary Care Association had a federally funded patient navigator grant. They did a closer look at the uninsured in the state with data from a variety of sources including the U.S. DHHS Office of the Assistant Secretary for Planning and Evaluation, Small Area Health Insurance from the U.S. Census Bureau, NH Employment Security County Profiles, the Henry Kaiser Family Foundation, Enroll America Research and Maps, and the Uniform Data System (UDS). The data revealed at that time, and there is nothing to indicate that it has changed currently, that there are pockets of the still uninsured in places such as Northern Coos County, in age groups such as young adults, the justice-involved population; consumers needing substance use disorder treatment and mental health services; low income women; individuals living in low income housing and immigrants.[45]
Medicaid is in the fourth of a five-year 1115 CMS waiver for the Delivery System Reform Incentive Payment program (DSRIP) to expand behavioral health care capacity; promote integration of physical and behavioral healthcare and improve care transitions that are implicated by behavioral health needs for the Medicaid population. Funds support seven (7) Integrated Delivery Networks (IDNs) across the state that are made up of medical, behavioral health, substance use disorder and social service providers (including all of MCH’s Title V funded CHCs). The intent is to provide support for delivery system transformation, rather than to cover the costs of specific services rendered by providers and move 50% of the managed care payments to Alternative Payment models by the end of the waiver cycle, December 2020.
All seven IDNs are working on selected community and statewide projects based on an initial needs assessment and emphasizing the topical areas previously mentioned. This includes the focus on utilizing care transition teams (e.g. inpatient (or emergency department) to outpatient; correctional facility to community, etc.) and enhanced care coordination, two (2) areas in which both MCH and SMS are heavily invested, through both staff time and contractual work. Title V funded agencies involved in their local IDNs have been able to braid funding and develop interagency care coordination teams based on shared care plans, secured messaging exchanges and event notification services (admission, discharge and transfer). This includes the eventual adoption of a standardized comprehensive assessment and closed loop referral process. All of this has been slow to develop and is time consuming for the IDNs due to privacy and cost issues, but if successful, will perhaps be the most effective output of the 1115 waiver benefitting the Title V population. IDNs that are further along in this process report initial decreases in emergency department visits and credit that due to appropriate care coordination.
The statewide 1115 project on increasing the behavioral health workforce complements Title V’s efforts towards State Performance Measure #1, which seeks to increase behavioral health capacity for children and pregnant women through its work with the State Loan Repayment Program, the Legislative Commission on Primary Care Workforce Issues, the Recruitment Center of Bi-State Primary Care Association (Bi-State) and the Children’s Behavioral Health Collaborative Workforce Development Network. Several IDNs are offering recruitment incentives, scholarships and their own loan repayment funding. Most are working with Bi-State on developing a collaborative social marketing campaign to attract behavioral health workers to the State.
A second 1115 statewide waiver project supports the integration of behavioral health and primary care. Once again, IDN affiliated CHCs have leveraged this funding to allow for progress already initiated many years ago and continued currently by funding from Title V. Most of the Title V funded CHCs have also been able to expand their Medication Assisted Treatment programs for substance affected perinatal patients due to IDN involvement.
All of the IDNs are currently completing the transition from process-based incentive payments to those that are performance based on the achievement of pre-determined metrics. It is particularly gratifying that three of the IDN performance metrics mirror State Performance Measures #1 (increasing behavioral health capacity) and #2 (decreasing unnecessary emergency department visits) as well as National Performance #10 (adolescent wellness visits). The DSRIP program is beginning to have an impact on Title V populations within the state. Next year’s Title V needs assessment will hopefully determine just how and if Title V funding should or could be readjusted to fill in the gaps and leverage funding to the best ability possible.
Another health issue of particular concern to the MCH population is the high rate of opioid overdoses and deaths plaguing the state for more than a decade and severely straining the health care system as a whole. In 2017, NH had a drug overdose rate of 37.0 compared with a national rate of 21.7.[46] The mortality rate has increased significantly since 2010.
For the MCH population, this has been particularly tragic. One of the leading causes of maternal mortality in the state is accidental drug overdose.[48] MCH’s surveillance tool, the Pregnancy Risk Assessment Monitoring System (PRAMS), released a report entitled “Perinatal substance use among New Hampshire Women, 2013 -2017”[49] in December of 2018. It found that the prevalence of perinatal use of tobacco and marijuana was higher in those with less educational attainment, young and with less income.[50] Use decreased during pregnancy, but for some it resumed after giving birth. [51] MCH’s PRAMS recently added opioid use questions to the 2019 surveys.
MCH is the lead on the CDC’s Overdose to Action grant, which will fund several opioid overdose surveillance and prevention strategies over the next three years. One of the surveillance strategies will provide funds for the continued development and operation of the Comprehensive Opioid Response Business Intelligence (CORbi) to standardize and simplify data dissemination. The CORbi electronic dashboard will enhance multiple data sources into geospatial and other displays, and provide performance tracking on the impact of services delivered over time.
There continues to be an increase in infants born with neonatal abstinence syndrome (NAS). In the ten years from 2005 to 2015, the number of infants diagnosed with NAS increased fivefold from 52 to 269.[52] NH has seen a significant increase in the number of accepted referrals for child abuse and neglect assessment in which substance misuse was involved. The numbers increased from 4,007 to 5,491 referrals in the period from 2014-2018. In 2018, 64% of the cases opened with a substance abuse risk factor and 45% of the total number of cases had founded substance abuse.[53]
Title V staff are participants and support several clinical interventions in the State designed to connect pregnant and postpartum women with substance use disorder to treatment. These initiatives include: Partnership for Academic Clinical Telepractice: Medication Assisted Treatment (MAT), a Project ECHOTM based collaboration to expand access to MAT through telehealth services; additional Project ECHO™ efforts to spread best practices on topics related to addiction, such as clinical management, compassion fatigue, and stigmatization; [54] and efforts required by the current and upcoming MCO contracts to prevent the exposure of babies to substances through care management and support. All Title V contracted CHCs have integrated the evidence based Screening, Brief Intervention and Referral to Treatment (SBIRT) as part of their primary care contracts and many are providing MAT services The State has significantly expanded both outpatient and residential substance misuse treatment through additional emergency funding through all branches of the Federal Department of Health and Human Services.
Title V staff have also been involved for the last several years with statewide colleagues on the Perinatal Substance Exposure Task Force, designed and are in initial implementation of a Plan of Safe Care[55], to be developed collaboratively by the new mother and her health care providers. For the last two years, NH has been collecting drug exposure to its situational surveillance fields on the birth certificate. MCH then aggregates the data received and submits the number de-identified to satisfy the federal CARA/CAPTA notification requirements. MCH is working with Vital Records to potentially make those fields a permanent part of the birth certificate worksheets. Mandatory reporting is required under NH RSA 169-C:29 whenever anyone has a reason to suspect child abuse and/or neglect. The fact an infant is born with prenatal exposure to drugs and/or alcohol does not itself require a mandatory report.
In January of 2019, NH DHHS released its “10-Year Mental Health Plan” (the plan). [56] Several Title V staff were involved in six multi-disciplinary workgroups organized around the continuum of care (prevention, outpatient, etc.), taking the results of research and statewide focus groups and then developing feasible strategies and recommendations. The plan, for the first time, provides a focus on children as well as the prevention of suicide. NH’s suicide rates were up 48.3% from 1999-2016, third behind Vermont and North Dakota.[57] MCH has played a pivotal role in suicide prevention with its staff co-founding the Youth Suicide Prevention Assembly more than 20 years ago and its leadership positions on the current NH Suicide Prevention Council. Title V funds have enabled the integration of behavioral health and primary care, a strategy that is highlighted in the plan. MCH and its funded colleagues helped to pioneer this concept over a decade ago and continue to do so today.
MCH section was awarded HRSA funding to establish a new Pediatric Mental Health Care Access Program (PMHCAP), to increase NH pediatricians’ and primary care providers’ capacity to address behavioral health needs of children 0-21 years of age. The NH PMHCAP will be working with the University of New Hampshire’s Citizens Health Initiative utilizing Project ECHOTM as their implementation strategy.
Statutes and other regulations that have passed or are in process within the last year and have relevance to the Title V program: MCH staff along with DPHS and DHHS colleagues provided input and language for Senate Bill 118, recently approved and waiting for signature from the Governor. The bill establishes a child fatality committee, and its affiliated protections, along with ones addressing SUID and SDY, within DHHS. Oversight will reside within MCH who currently chairs the SUID and SDY review committees. MCH staff sat on the old child fatality review, which was brought into existence several decades ago by Governor’s Executive Order (and enabled the creation of both SUID and SDY). Recently, there was legal determination that the Executive Order did not provide enough privacy guarantees for information shared at review meetings. Thus, DHHS requested this bill to ensure the viability of the three fatality review groups. MCH is currently recruiting for a Child Health Nurse Consultant, who will have the responsibility of the child fatality review (the Infant Surveillance Coordinator oversees SUID and SDY).
The newborn screening and newborn hearing screening rules He-P 3008 were revised and approved late September 2018. Amongst other changes, the new rules include the addition of Critical Congenital Heart Defects (CCHD) to the newborn screening panel, allowing for its surveillance by MCH.
House Bill 631 will establish a Deaf Child's Bill of Rights and an Advisory Council on the education of deaf children. The council will include a representative from EHDI and SMS and will be charged with establishing a mechanism to identify the needs of children who are deaf/hard of hearing and to conduct ongoing assessment of the populations service needs.
RSA 318:47-1 enables pharmacists to dispense hormonal contraceptives pursuant to a standing order entered into by a health care provider. The MCH Quality Assurance/Quality Improvement Nurse Consultant has been involved with the Board of Pharmacy in developing the law’s accompanying rules, soon to be voted upon for the last time in the rule process, which will include a model statewide protocol, pharmacist training and the content of a client information sheet.
A plan of safe care for an infant identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure is now mandated by RSA 132:10-e. Situational surveillance fields on the birth certificate collect information on substance misuse. The plan of safe care must be submitted to DHHS only if the infant is thought to be abused or neglected.
Senate Bill 592 from the 2018 Legislative Session enabled $500,000 be allotted to the Division of Children, Youth and Families for parental assistance programs, which were later determined to be the Community Collaborations Project in conjunction with MCH. These funds are leveraged with the Federal Children’s Bureau dollars for three communities in their implementation of programs to reduce child maltreatment.
Senate Bill 274 will legislate Medicaid payment for home visiting of all types. Currently, in order to be Medicaid reimbursable, families had to fall into the guidelines developed by the old Home Visiting NH model, first time moms under the age of 21. Agencies also had to be Title V contracted (as in the CFSS agencies). This would negate all of those requirements.
* * * * * * *
[1] Division of Forests and Lands, New Hampshire Department of Natural and Cultural Resources. Retrieved on 05/26/2019 from https://www.nhdfl.org/reports/forest-statistics.
[2] United States Census Bureau (2019). Quick Facts New Hampshire. Retrieved on 05/26/2019 from https://www.census.gov/quickfacts/fact/table/NH/POP815217#POP815217.
[3] New American Economy (2016). The Contributions of New Americans in New Hampshire. Retrieved on 09/05/2019 from http://www.newamericaneconomy.org/wp-content/uploads/2017/02/nae-nh-report.pdf
[4] United States Census Bureau (2019). Quick Facts New Hampshire. Retrieved on 05/26/2019 from https://www.census.gov/quickfacts/fact/table/NH/POP815217#POP815217.
[5] Kaiser Family Foundation (2018). Medicare Beneficiaries as a Percent of Total Population. Retrieved on 06/14/19 from https://www.kff.org/medicare/state-indicator/medicare-beneficiaries-as-of-total-pop/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
[6] Citizens Count New Hampshire (2019) Retrieved on 05/26/2019 from http://www.lfda.org/issues/legislative-process.
[7] Commonwealth Fund, (2019). 2019 Scorecard on State Health System Performance. Retrieved on 06/12/19 from https://scorecard.commonwealthfund.org/.
7 Annie E. Casey Foundation (2018). 2018 Kids Count Data Book: State Trends In Child Well-Being. Retrieved on 06/06/2019 from https://www.aecf.org/m/databook/2018KC_profiles_NH.pdf.
8 United Health Foundation (2018), America’s Health Rankings. Retrieved on 06/07/2019 from https://assets.americashealthrankings.org/app/uploads/2018ahrannual_020419.pdf.
[10] United Health Foundation (2019), America’s Health Rankings, Senior Report. Retrieved on 06/07/2019 from https://assets.americashealthrankings.org/app/uploads/ahr-senior-report_2019_final.pdf.
[11] McCann, A. (2019). Best and Worst States to Have a Baby. Retrieved on 06/07/2019 from https://wallethub.com/edu/best-and-worst-states-to-have-a-baby/6513/#methodology.
[12] U.S. News and World Report (2019). Best States 2019. Retrieved on 06/07/2019 from https://www.usnews.com/news/best-states/new-hampshire.
[13] Annie E. Casey Foundation (2018). 2018 Kids Count Data Book: State Trends In Child Well-Being. Retrieved on 06/06/2019 from https://www.aecf.org/m/databook/2018KC_profiles_NH.pdf.
[14] New Hampshire Employment Security (2019). New Hampshire Economic Conditions: June 2019. Retrieved on 06/10/19 from https://www.nhes.nh.gov/elmi/products/documents/ec-0619.pdf.
[15] New Hampshire Employment Security (2019). Per Capita Personal Income, 2018. Retrieved on 06/10/29 from https://www.nhes.nh.gov/elmi/products/chartroom/documents/chart18.pdf.
[16] United States Census (2019). American Fact Finder. Retrieved on 06/11/19 from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_17_5YR_S1903&prodType=table.
[17] U.S. News and World Report (2019). Education Rankings, Measuring How Well States Are Educating Their Children. Retrieved on 06/11/19 from https://www.usnews.com/news/best-states/rankings/education..
[18] WalletHub (2018). States with the Best and Worst School Systems. Retrieved on 06/11/19 from https://wallethub.com/edu/states-with-the-best-schools/5335/.
[19] U.S. News and World Report (2019). The Ten Safest States in America. Retrieved on 06/11/19 from https://www.usnews.com/news/best-states/slideshows/10-safest-states-in-america.
[20] United States Census Bureau (2019). Quick Facts New Hampshire. Retrieved on 06/11/19 from https://www.census.gov/quickfacts/fact/table/NH/PST045218.
[21] New Hampshire Fiscal Policy Institute (2018). New Hampshire’s Numbers: Disparities Between Counties and Populations Persist: 2013-2017. Retrieved on 06/12/19 from http://nhfpi.org/research/state-economy/new-hampshires-numbers-disparities-between-counties-and-populations-persisted-in-2013-2017.html.
[22] Ibid.
[23] New Hampshire Housing Finance Authority (2019). Market Update April 2019. Retrieved on 06/14/19 from https://www.nhhfa.org/assets/pdf/Presentations/Market_Update_Manchester_C_of_C_4-23-19.pdf.
[24] Ibid.
[25] New Hampshire Fiscal Policy Institute (2019). New Hampshire’s State Budget and Families in the Post-Recession Economy. Retrieved on 06/14/2019 from http://nhfpi.org/wp-content/uploads/2019/02/New-Hampshire’s-State-Budget-and-Families-in-the-Post-Recession-Economy_Web_Version.pdf.
[26] Ibid.
[27] NH Hospital Association (2019). Map of Hospitals. Retrieved on 06/06/2019 from https://nhha.org/images/2018_Hospital_Map_logo.jpg.
[28] Kozhimannil, K. et al. Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States. JAMA. 201; 319(12):1239-1247.doi:10.1001/jama2018.1830.
[29] Medicaid Claims Data/Vital Records Data analyzed by MCH, 06/17/2019.
[30] Ibid.
[31] Ibid.
[32] Kozhimannil, K. et al. Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States. JAMA. 201; 319(12):1239-1247.doi:10.1001/jama2018.1830.
[33] Weiss, Danielle (2019). 2018 Physician Workforce Data Report. Retrieved on 06/14/19 from https://public.tableau.com/profile/danielle.weiss#!/vizhome/2018PhysicianWorkforceReport/TableofContents.
[34] Kaiser Family Foundation (2019). Implications of a Medicaid Work Requirement: National Estimates of Potential Coverage Losses. Retrieved on 06/09/19 at https://www.kff.org/medicaid/issue-brief/implications-of-a-medicaid-work-requirement-national-estimates-of-potential-coverage-losses/.
[35] Ibid.
[36] New Hampshire Fiscal Policy Institute (2019). Medicaid Work Requirements and Coverage Losses. Retrieved on 06/09/19 from http://nhfpi.org/research/health-policy/medicaid-work-requirements-and-coverage-losses.html.
[37] NHHS, Office of Quality Assurance and Improvement (2019). New Hampshire Medicaid Enrollment, Demographic Trends and Geography, April 2019. Retrieved on 06/08/19 from https://www.dhhs.nh.gov/ombp/medicaid/documents/medicaid-enrollment-05022019.pdf.
[38] Ibid.
[39] New Hampshire Fiscal Policy Institute (2018). Medicaid Expansion in New Hampshire and the State Senate’s Proposed Changes. Retrieved on 06/09/2019 from http://nhfpi.org/research/health-policy/medicaid-expansion-in-new-hampshire-and-the-state-senates-proposed-changes.html
[40] Ibid.
[41] Kaiser Family Foundation (2018). Health Insurance Coverage of the Total Population. Retrieved on 06/08/19 from https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22desc%22%7D.
[42] Hodder, L. and Porter, J. (2017). Covering the Care: Health Insurance Coverage in New Hampshire. Institute for Health Policy and Practice. Retrieved on 06/07/2019 from https://scholars.unh.edu/cgi/viewcontent.cgi?article=1344&context=law_facpub.
[43] Personal Communication with MCH Quality Assurance/Quality Improvement Nurse Consultant, 06/09/2019.
[44] Ibid.
[45] Personal Communication with staff at Bi-State Primary Care on 06/09/19.
[46] Centers for Disease Control and Prevention (2019). Drug Overdose Mortality by State. Retrieved on 06/14/19 from https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm.
[47] New Hampshire Drug Monitoring Initiative, New Hampshire Information and Analysis Center (2019). April 2019 Report. Retrieved on 06/15/19 from https://www.dhhs.nh.gov/dcbcs/bdas/documents/dmi-april-2019.pdf.
[48] Division of Public Health Services (2019). Annual Report on Maternal Mortality to the New Hampshire Health and Human Services Oversight Committee, Annual Report 2019.
[49] Maternal and Child Health, PRAMS (2018). Perinatal substance use among New Hampshire Women, 2013-2017. Retrieved on 06/14/19 at https://www.dhhs.nh.gov/dphs/bchs/mch/prams/documents/perinatal-substance-use.pdf.
[50] Ibid.
[51] Ibid.
[52] Smith, Kristin (2017). University of New Hampshire Carsey Institute. As Opioid Use Climbs, Neonatal Abstinence Syndrome Rises in New Hampshire. Retrieved on 06/14/2019 from https://scholars.unh.edu/cgi/viewcontent.cgi?article=1330&context=carsey.
[53] DCYF, Statewide Automated Child Welfare Information System, NH Bridges, June 2019.
[54] UNH PACT MAT ECHO 2019
[55] NH Governor’s Commission on Alcohol and Other Drugs, Perinatal Substance Misuse Task Force (2019). Plans of Safe Care. Retrieved on 06/19/19 from https://nhcenterforexcellence.org/governors-commission/perinatal-substance-exposure-task-force/plans-of-safe-care-posc/.
[56] NH DHHS (2019). New Hampshire Ten-Year Mental Health Plan. Retrieved on 06/19/19 from https://www.dhhs.nh.gov/dcbcs/bbh/documents/10-year-mh-plan.pdf.
[57] Stone DM, Simon TR, Fowler KA, et al. Vital Signs: Trends in State Suicide Rates — United States, 1999–2016 and Circumstances Contributing to Suicide — 27 States, 2015. MMWR Morb Mortal Wkly Rep 2018; 67:617–624. DOI: http://dx.doi.org/10.15585/mmwr.mm6722a1.
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