Demographics, Geography, Economy, Urbanization and Government: 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 1.38 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, as well as disparities in broadband access with 10% of households not having an internet service subscription.

 

With its 10 counties, approximately 37% 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 most urban or metro areas are Manchester, Nashua and Concord, all located in the state’s southern tier where the majority of the population lives.

 

NH’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 for Family Centered Services (BFCS), located in the Division of Long Term Supports and Services (DLTSS). Many factors guide its efforts.

 

Both DPHS and DLTSS reside within the NH 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 BFCS are physically located in the capital city of Concord. However, much of the Title V work takes place in funded agencies across the State in the form of community health centers, specialty health clinics and human services agencies that provide home visiting and the like.

 

NH has the largest bicameral legislature in the English-speaking world, 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 for both receipt and expenditure of state and federal funds, budgetary transfers within the department and all contracts with a value of $10,000 or more. There is also a Joint Legislative Fiscal Committee. This group of both Senators and Representatives has to accept and give the approval to expend any new or additional funding in between the preparation and approval of the two year biennium budget.

 

Christopher T. Sununu, Republican, is the 82nd Governor of the State and is currently serving his third term, running for election for a fourth this November of 2022. All of the positions in the Legislature and the Executive Council are also up for election this fall. Title V policy and funding is heavily influenced by both the Legislature (particularly the Joint Legislative Fiscal Committee) and G&C.

 

Last year’s legislative session and G&C meetings were busy for Title V staff who between MCH and BFCS have a substantial amount of contracts. This is in addition to the substantial amount of House and Senate bills that span a wide range of issues affecting the MCH population from immunization through family planning. Title V staff are asked to provide input through a bill’s fiscal detail sheet and through written and in-person testimony. The upcoming year will be spent in the preparation and deliberation of the State Fiscal Years 24/25 biennium budget. The work begins the summer of 2022 with Title V staff developing budgets for every separate accounting unit and preparing justification for any state, general funds.  

 

Over the decade from 2010 to 2020, the population of NH increased by approximately 4.6%. The 2021 population was estimated at 1,388,992 residents, an increase of 11,107 from the previous year. This was the largest one-year increase in New Hampshire’s population since 2002.[2] As part of that, there was a 7% increase in the number of births those same years, 2020 to 2021 (from 11,837 to 12,674). This was the largest percentage increase in annual births in the country.[3] Most population growth since 2010 has been the result of positive net migration. Different hypotheses abound, but the general consensus is that during the COVID pandemic, people in general looked to the State as a safer place to live with its lower population density. Realtors noted that prior to the pandemic, approximately 10% of buyers were from out of state but jumped to 35% during 2020.[4] Other reports (vital records data, etc.)[5] remark that more highly educated couples in their thirties chose to use the opportunities afforded by remote work to start a family. It will be interesting to see if both the migration trend and the birth uptick continue in future years. 

 

The actual population of the State of New Hampshire is primarily non-Hispanic white (89% and fourth highest in the US), but its residents of color (Asian, 3%; Black, 2%; Hispanic, 4%; Two or more races, 2% and Other at less than 1%) are increasing.[6] Diversity is geographically uneven in NH. Many square miles of the State are uniformly white, while the more urban part in southern NH is more diverse as is the Hanover/Lebanon area in the Upper Valley and a few areas of the Seacoast.[7]

 

 

 

 

 

 

[8]	Looking at it by age, children under 18 make up the greatest diversity in the State with approximately 20% in that age group identifying as Non-White in 2020.[9]

 

 

For the last five years, there were more deaths in NH than births. The COVID‑19 pandemic’s mortality was particularly felt in the older adult population.

[10]

 

 

In the last decade, the number of children in NH under 18 declined close to 11%. This same decline was seen in the U.S. but at a much smaller percent. Even with the high percentage increase in number of births in 2021, NH has the lowest number of children per household in the country at 1.73 children.[11] In comparison, adults over the age of 65 increased by more than 40%.[12] The State routinely is among the top five for the highest percentage of its population enrolled in Medicare.[13] As a result, the State’s older population will more than double over the next 20 years. As with its diversity numbers, older populations are not represented evenly within the State: the percentage of the population of older adults is greatest in the North Country, while the biggest number of older adults live in the Southern part, which is the most populated.

 

Prior to and even during the pandemic, NH has often been ranked in the top tier of overall well-being and in many of the social determinants of health.[14],[15],[16] 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 Title V measures such as a low adolescent birth rate (5.44% in 2021 in NH compared to 15.4% in the US)[17] or in the or high pediatric immunization rate in the school aged population (93% children fully up to date in grades K-12).[18] The State also scores high because some of its key social determinants of health such as economic stability, quality of education and public safety in general are good.

 

[19]

 

NH is a low-revenue, low-expenditure state. Its revenue structure is distinctive in that the State lacks a broad-based personal income or sales tax, and its biggest single source of revenue is local property taxes. The funding of NH’s school districts is largely at the local level through property taxes, which has led to disparities across the State in property poor districts. The largest tax revenue for the State level are those on business, tobacco, rooms and meals, real estate transactions and from the State enterprises selling liquor and lottery tickets. 

 

NH has a diverse mix of industries which usually makes its economy more resilient than that of states that are dependent on fewer. The State’s jobs are most heavily concentrated in retail, health care, government, and manufacturing with the lowest minimum wage in New England at $7.25 an hour. NH’s unemployment rate, pre-pandemic, was usually well below that of the U.S. as a whole (hovering around 2 to 2.5 % for over a decade). Part of that is due to consistently having a more educated workforce. However, with the advent of the COVID‑19 pandemic, NH, like the rest the country, experienced a significant increase in its incidence of new and sustained unemployment claims. However, also like the rest of the country, NH’s current unemployment rate has bounced back to even lower than before the pandemic at 1.8% as of May 2022. [20]

 

NH typically has one of the lowest poverty rates in the country, most recently at 8.1% in 2021, an increase from 7.4% in 2020.[21] This varies across counties, with Coos and Sullivan having higher rates as the following map shows:

 

[22]

 

 

The COVID‑19 pandemic has accentuated these differences, creating and accentuating the State’s vulnerable populations. There are clearly racial, family and living situation disparities in poverty level as well as median income within the State. Single female-headed families face higher levels of poverty and a lower median income ($41,605 compared to $80,175) regardless of their identified race, ethnicity, number of children, education level, work status, or home ownership status compared to all families.

 

[23]

 

Many of the changes that have happened within the past several years have particularly affected the Title V population, as with the higher poverty rates in female headed households with young children. During the height of the pandemic, one out of three families with children received food assistance, receiving some form of public food assistance or benefits including picking up meals from schools, participating in free and reduced-price school breakfast and lunch programs or receiving benefits through the pandemic EBT program.[24] And the situation in the State does not seem to be getting any easier. A greater number than usual of families with childcare demands have risen just as capacity and costs have increased; rental costs have risen faster than overall consumer inflation. Close to half of low income families (less than $35,000 per year) have rental costs of over half their income. This has put conflicting pressures on families to make difficult decisions about the financial viability of participating or not in the workforce. In the last week of April, first week of May 2022, approximately 33% of NH adults surveyed felt it “was somewhat or very difficult to pay for usual household expenses in the past seven days” and this has only been increasing.[25]  

 

Components of the state’s systems of care and Title V populations: NH’s Title V population includes a slightly increasing number of CYSHCN. According to the National Survey of Children’s Health (NSCH) from 2016 to 2020, the percentage of children whose parent identifies them as having special health care needs based on the CYSHCN Screener has increased from 20.5% in 2016-2017 to 24.2% in 2019-2020[26].

 

 

 

As the number of Autism Spectrum Disorder (ASD) diagnoses reported to the NH ASD Registry increased through 2018, they began to decrease with the onset of the COVID‑19 Emergency.

 

The number of child development clinics available to assess, evaluation, and diagnose children with suspected developmental delay continues to decrease since the availability of developmental pediatricians in NH remains very limited. According to the Title V-funded Child Development Clinic Network’s 2021 Annual Report. “Highly qualified psychologists, particularly those familiar with developmental differences in very young children have limited availability. Applied Behavioral Analysis (ABA) services are limited and constantly changing. Wait lists are long and availability varies greatly by region.”[27] Few service providers offer ABA in the home setting, making it difficult for children to learn daily living skills in their home and for parents to learn strategies to interact and teach their children. There is evidence that training parents to support developmental skill-building is helpful. Few providers offer interpreters for families, making it nearly impossible for families to have equal access to services for young children with autism. “Child psychiatry, particularly for children having Medicaid, is also limited. Securing experienced behavioral health providers for children and parent counseling for challenging behavior is also difficult for families, complicated by waitlists at the community mental health centers.”[28]

 

NH’s Part C services for infants and toddlers under the age of three years with a development delay, known as Family Centered Early Supports and Services (FCESS), sits within BFCS organizationally. The Part C office indicated significant changes to the numbers of children receiving early intervention services throughout the COVID pandemic. After three consecutive years of decreasing enrollment, FY2022 reached beyond the 2018 enrollment numbers as new families learned about the benefits associated with early supports and services. 

 

 

 

While the workforce shortage has affected most, if not all, professions, the lack of nurses and Direct Service Providers (DSPs) continues to be of great concern for families with CSHCN who rely on these individuals to keep their medically complex children at home and in the community.

 

NH’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 576 beds. Dartmouth Health (DH), which recently changed its name from Dartmouth Hitchcock Medical Center, is the largest medical system in the State with its flagship hospital in Lebanon having the only Level 1 designated trauma classification. It also offers the State’s only comprehensive, full-service children’s hospital, a Level II designated pediatric trauma center, the Children’s Hospital at DH. Three hospitals in Boston are the closest Level I designated pediatric trauma centers to almost all locations in the State. A few pediatric subspecialties are also sometimes only found in Boston, which is particularly critical for Title V programs such as newborn screening and follow up.

 

[29]

 

NH 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 including rural health clinics, assisted or skilled nursing care facilities and home care and hospice. As payment models shift from volume to value, hospitals are working to advance population health efforts within their institutions and improve the health of the communities they serve.[30] In the past three years, most of the hospitals in the State have also merged and affiliated with one another and across stateliness, joining hospital and health care systems in Maine, Vermont and Massachusetts and even on a national level. Only three of the 26 acute care hospitals have not been the subject of recent merger activity (Cottage, Speare and Valley Regional). Thus narrowing the healthcare delivery system to a handful of players. This past May of 2022, the Attorney General’s Charitable Trust Unit came out in opposition of the latest merger proposal between DH and GraniteOne Health, two of four of the State’s largest Health Systems, primarily because of the lack of competition and protection for the consumer.[31] This puts any future mergers into question.

 

There are 10 Federally Qualified Health Centers (FQHCs), one FQHC look-alike and 15 Rural Health Clinics (RHCs), all but two them critical access hospital-affiliated. They provide services at 63 sites. During the past year, one FQHC in the northernmost town of Colebrook closed, Indian River Health Center. However, one RHC took its place and it is thought that both an existing FQHC and a RHC in nearby towns will establish satellite sites, all three in the one town. Through MCH, Title V helps to support the efforts of the majority of the FQHCs, the FQHC look-alike and one RHC.

 

NH DHHS also supports mental health services regionally through a network of ten designated Community Mental Health Centers. There are also designated receiving facilities that provide 24/7 care, five for adults and one for children. In the past year, NH DHHS bought Hampstead Hospital, a 116-bed acute care facility for children with the intention of turning it into a residential and treatment hospital for children and young adults, increasing pediatric psychiatric beds, in the upcoming years. This past year also saw the implementation of DHHS’ Rapid Response, which provided mental health crisis services via phone, text and chat for children, youth and adults in NH who may be experiencing a mental health or substance misuse crisis. It is available 24/7 and can also newly deploy mobile crisis teams around the State.

 

With the COVID 19 pandemic, all health systems have had many systemic changes, with a significant difference in the way of managing their care and a tremendous roller coaster in financial resources. There are still many federal grant opportunities specific to recovering from the COVID‑19 pandemic for the State’s healthcare system, particularly for FQHCs.

 

NH also has a network of 13 regional Public Health Networks (established in 2013 through emergency planning and drug and alcohol prevention funds) which seek to integrate multiple public health initiatives and services into a common network of community stakeholders for communities with comparable public health issues and priorities in order to improve health outcomes specific to these regions. These Public Health Networks took the lead along with DPHS in the State’s response to the COVID‑19 pandemic.

 

A State Health Assessment (SHA) and State Health Improvement Plan (SHIP) Advisory Council was initially established in July 2020 in New Hampshire with the expectation that a SHA would reach completion in fall 2021 and a SHIP would be produced by August 2022. Due to the COVID‑19 pandemic, progress on the SHA-SHIP process was delayed with the existing council representation of the State of New Hampshire involved in the major public health emergency and unable to provide guidance to the council. New legislation was enacted on May 17, 2021 which amended previous language to read that the SHA would describe the status of health and well-being in New Hampshire, access to critical healthcare services including maternity care, the cost of healthcare and insurance coverage, and the fiscal stability and sustainability of critical services to ensure sufficient and equitable access throughout the state; utilize input from state and local level stakeholders obtained through public forums; identify disparities in social determinants that may impact health, health outcomes, and access to care; map health care service delivery, utilization, inter-entity collaboration, and identification of gaps or redundancies’ describe the role of state agencies in supporting the public health system in New Hampshire; utilize existing data and plan for future data to support statewide and local planning; identify priorities for the state health improvement plan.

 

SHIP language was also revised with the legislation and now reads: The state health improvement plan shall guide the department in assessing, planning, implementing, and monitoring improvement in the health and well-being of New Hampshire’s population; the state health improvement plan shall focus on strategies to: improve health outcomes and reduce inequities; and strengthen public health and human service delivery systems; the state health improvement plan shall identify priorities and evidence-based practices, integrate services, and leverage resources across the state. The new legislation gave the SHA a deadline of May 2022, with a deadline of May 2023 for the SHIP.

 

Additional delays have been experienced since this legislation was enacted, such that the SHA is anticipated for August 2022 and the SHIP for May 2023. A website is under construction to display the SHA and will also host the SHIP when it is complete.

 

A particular concern to the MCH population is the closure of ten labor and delivery hospital units ten over the past two decades leaving 16 birth hospitals and four birthing centers. Only six of the critical access hospitals now offer obstetrical services presenting a distance issue. Obstetrical services have high fixed costs and low reimbursement rates. Weekly for the past several years. Title V staff confer with their Alliance on Innovation in Maternal Health (AIM) partners, the Northern New England Perinatal Quality Improvement Network (NNEPQIN) on these such issues. Small volume hospitals typically have a higher percentage of patients that give birth paid for by Medicaid (up to 59% as shown in the figure  below), which typically pays for a quarter of NH’s births in a year.  

[32]

 

A legislative response saw the passing of an omnibus House Bill (HB) 1661[33] increase the Medicaid reimbursement rate for facility based birth services provided at hospitals by 25%, in the aggregate, based on the rate in effect as of June 30, 2022.The DHHS Commissioner has the discretion to implement the reimbursement increase to adjust for access risk geographically; provided that no critical or non-critical access hospital receives less than a 20% increase. In conjunction, Senate Bill (SB) 408[34] increased the Medicaid facility fee reimbursement schedule for freestanding birthing centers. A legislative effort to extend Medicaid coverage through at least one year postpartum failed.

 

Other initiatives going on in the State to address birthing unit closures include Dartmouth Health’s (NNEPQIN’s parent organization) two-year long HRSA Rural Northern Border Regional Planning grant creating the North Country Maternity Network (NCMN), which is a collaboration of agencies in rural Northern NH and adjacent border communities that “strive to better understand the needs, gaps, and opportunities in maternity care, including prenatal, labor and delivery, and postnatal care to help shape strategies to better serve the needs of pregnant and parenting people of the North Country, while also improving financial sustainability of these services”.[35] Title V staff are on the NCMN’s Executive Steering Committee.

 

A project focusing on increasing education to both emergency medical services and non-labor and delivery hospitals on unplanned births is taking place with NNEPQIN and the State’s Department of Safety, Bureau of Emergency Medical Services. MCH is monitoring unplanned births which occur if the birthing person gave birth at home unintentionally, gave birth during transport to a hospital with a labor and delivery unit or gave birth in a hospital without a labor and delivery unit. This group is also looking to correlate these unplanned location births with weather patterns, outcomes, characteristics of the mom (parity, gestational age, etc.), and driving distance to a birth hospital from residence.

 

The data associated with labor and delivery closures such as an increase in low risk cesareans or a decrease in the amount of prenatal visits suggest that this is occurring.

 

[36]

 

There is a significant difference in low risk cesareans between 2015 and 2020. There was also a significant difference between 2019 and 2020 when looking at birth certificate data with respect to entry into care during the first trimester from 86.6% to 85.8%.[37] Both of these are issues Title V staff and their partners are delving into.

 

NH Title V staff are also involved with addressing the statewide shortage of health care professionals, exacerbated by the pandemic and a rapidly increasing aging of the population. Title V is working with colleagues at DHHS’s Office of Rural Health and Primary Care with participation in activities such as the Legislative Commission on Primary Care Workforce Issues and the NH Health Professions Data Center. Several of the Title V funded community health centers are also involved as placements for family practice, psychiatry and pediatric residencies with one even implementing a full residency program in Family Practice that opened with pandemic federal funds. In March of 2022, Giving Care: A Strategic Plan to Expand and Support New Hampshire’s Health Care Workforce[38] came out under the auspices of the NH Endowment for Health. This plan outlines a detailed, long-term outline towards increasing and retaining the healthcare workforce in NH.

 

Financing of services for the MCH population: NH Medicaid utilizes a managed care model for medical services with three insurance plans, NH Healthy Families, Well Sense and AmeriHealth Caritas. Medicaid participation increased significantly during the pandemic,

 

 

[39]

 

with 41% of the enrollees at the end of May 2022 being children and with one percent being pregnant women with low incomes.[40] Approximately 17% of NH’s population is currently on Medicaid. In SFY22 and SFY23, Medicaid provided an across the board 3.1% increase in reimbursement fees, an approximate $60 million in total. This was the first Medicaid rate increase in NH in decades. In addition, an adult Medicaid dental benefit was just passed into law in June 2022, the first time in NH’s history.[41]

 

The State also operates a partnership health insurance exchange with the federal government (https://www.nh.gov/insurance/consumers/documents/2021-plan-comparison-tool.pdf), with the Department of Insurance having control over plan management and consumer assistance functions on the federal Marketplace. The total percent (all ages) uninsured in NH was approximately 6.3% for all ages in 2021 with it increasing to 7.5% under the age of 65.[42]

 

Currently of most concern is that thousands of Medicaid enrollees face potential disenrollment when the federal public health emergency declaration associated with the COVID‑19 pandemic ends. Since then, those on Medicaid have not had to renew every year. It is thought that the public health emergency will likely be extended through at least October 2022, if not longer. However, NH Medicaid in collaboration with UNH’s Institute on Health Policy and Practice, have initiated a “pink letter” campaign, which was both a mass mailing and a social media campaign to help enrollees maintain their coverage or find alternative health insurance options.[43] Many of the Title V funded CHCs support patient navigators specifically for the purpose of helping patients sign up for health insurance and connect with many other community resources. BFCS Health Care and Family Support Coordinators work closely with Medicaid and with families with CSHCN to assure Medicaid applications do not lapse. Throughout the pandemic, coordinators encouraged and assisted families with updating eligibility paperwork, regardless of the requirement, in an effort to avoid the cliff effect once the public health emergency ends.

 

Challenges that impact the health status: The deferral of preventive care; the increase of substance misuse, and food insecurity all increased in the State because of the COVID‑19 pandemic. However, numbers have been returning slowly over the past year to pre-pandemic times. Almost all of the Title V funded agencies now are back to facilitating in-person visits. Interestingly, a comparison of pandemic statistics from one year ago to present day, 

 

July 2022

[44]

 

August 2021

[45]

reveals not necessarily a decrease in cases (although at the present time, cases may be undercounted with the number of home tests available), but a decline in the severity of the cases which require hospitalizations and an increase in the percentage of NH’s population that are fully vaccinated as well as having only one dose. Another difference within the last 12 months is that vaccinations for children and adolescents have become FDA-approved and available with vaccines for children six months to five years old recently becoming accessible in June of 2022.

 

Title V staff have all been involved in the COVID‑19 pandemic response, helping to keep an ear to the ground on the needs of contractors as well as surveilling pregnant woman who are COVID positive and their delivered infants. Current pandemic work primarily has been on helping immunization efforts, including messaging, in the MCH and CYSHCN populations. As of July 1, 2021, all NH state-managed fixed vaccination/National Guard-run sites closed, and Title V funded community health centers are vaccinating patients in regular office visits to offer the COVID‑19 vaccine in a similar way to how patients access other common vaccines. Families have been encouraged to see their children’s primary health care provider for vaccinations. This is especially true for those with CYSHCN.

 

The Title V population’s health care and social service providers in the State have had to alter their methods of providing care. Specialized outreach will continue to make sure families did not forego routine care (i.e. child immunizations, treatment of chronic diseases, dental care, early supports and services and well-child visits). This has been accommodated through the expansion of hours, the ramp-up of telehealth visits, mobile health vans, increased transportation vouchers and on-call 24/7 health care by phone support. Community health centers and home visiting agencies mitigate the impact of food insecurity on the State’s children and families by maintaining food pantries, delivering food to individuals experiencing homelessness and children usually supported by the free and reduced school lunch and breakfast programs. Health care and family support coordinators worked in collaboration with stakeholders, suppliers and Medicaid to assure families with CSHCN were able to obtain necessary supplies, medication and formula.

 

Telehealth has had a rapid expansion in NH aided by Medicaid and other insurers’ reductions of limitations. Telehealth has advanced health equity through its reduction of geographical barriers to care, particularly in behavioral health. Several community health centers have documented that for the very first time they are seeing a 0% no-show rate for behavioral health.[46] Patients have also shared that telehealth means they do not miss as much time from work.[47] For these reasons and many more, health care providers including the health centers are making changes in their offices to accommodate for telehealth as the way of the future. MCH is also a member of the NH Telehealth Alliance along with DPHS’s Primary Care and Rural Health Section; its sole mission is to support better access and more cost effective benefits of telehealth.

 

Although 99% of the population has access to broadband internet service, speed is the issue that creates a digital divide. Millions of dollars have come into NH in the past two years specifically for broadband. NH is beginning the regulatory process to set standards and rules to create an infrastructure of fiber optic cable that can provide higher speeds, particularly in rural regions.

 

NH’s opioid overdoses and deaths have been plaguing the State for more than a decade and severely strains the health care system as a whole. Although the rate has been going down, provisionally 27.66 per 100,000 in 2021, this epidemic is particularly tragic for the MCH population.

 

[48]

 

One of the leading causes of maternal mortality in the State is accidental drug overdose.[49] Poisoning, mostly due to opioids, has overtaken car crashes, as the leading cause of death due to unintentional injuries particularly in the adolescent and young adult population (unintentional injuries, primarily poisoning due to opioids, continue to be the leading cause of death for all NH residents ages one through 44).[50], [51]

 

MCH is the lead on the CDC’s Overdose to Action grant, which funds several opioid overdose surveillance and prevention strategies including the collection of real-time emergency department overdoses; the collection and dissemination of data related to overdose deaths; the development of overdose surveillance systems such as the Opioid Overdose Dashboard; the enhancement of the State’s Prescription Drug Monitoring Program; the provision of care navigators to help families connect to services when children are separated from their parents due to parental substance use disorder; the provision of education about syringe services to reduce harm, and the education of health care providers and support health care systems related to best practices around prescribing opioid medications.

 

MCH also facilitates both NH’s Maternal Mortality Review Committee and its Child Fatality Review Committee. Many case reviews in both committees (the majority in maternal mortality which reviews all deaths, unlike child fatality which picks representative cases) result in recommendations specifically related to overdose prevention such as the provision of naloxone if warranted. For the last five years, MCH has been collecting drug exposure data on its situational surveillance fields on the birth certificate. Now, the questions are permanent parts on the birth certificate work sheets, are aggregated, de-identified and submitted to DHHS’s Division of Children, Youth and Families (DCYF; the State’s Child Protection Agency) for its federal CARA/CAPTA notification requirements. The fact that an infant is born with prenatal exposure to drugs and/or alcohol does not itself require a mandatory report.

 

Title V staff also work in coordination with statewide colleagues on the Perinatal Substance Exposure Task Force as well as NNEPQIN on encouraging the completion of the Plan of Safe Care, developed by a pregnant person and health care and social service providers when substance misuse is present (this has been a recommendation of both maternal mortality and child fatality review committees).[52] MCH and NNEPQIN in their co-sponsorship of NH as an AIM State, have been spearheading efforts within perinatal care of both SUD screening and treatment if necessary, and the dispensation of naloxone as part of implementing the AIM patient safety bundle, “Care for Pregnant and Postpartum People with Substance Use Disorder.” [53]

 

Other issues Title V staff have their eye on are the increasing population of children who are obese in the State. There were significant differences between baseline years and the last survey for both WIC and the National Survey of Children’s Health (2014/2018 and 2016/2020 respectively).[54] Early indications also show that pregnant people are accessing prenatal care later in their pregnancy, which is not the norm in NH. Whether this is due to the COVID‑19 pandemic or the closure of labor and delivery units as discussed previously, or not, there was a large and significant decrease between 2019 and 2020.[55] In the upcoming year, Title V staff will be focusing on maternal morbidity and any rural/ethnicity/race disparities. 

 

Statutes and other regulations that have passed or are in process within the last year and have relevance to the Title V program: RSA 132:10-a was altered as of November 2021, The Newborn Screening Program (NBS) is self-funded through the cost of individual filter papers, purchased by each of the birth hospitals. This addition to the law will enable hospitals to get reimbursed through Medicaid and other insurers for those costs, which they had not been before. MCH’s NBS is also in the process of revising its Administrative Rule He-P 3008, He-P 3000 (state.nh.us) to accurately reflect its current operations and procedures as well as ensure that definitive diagnostic results on infants who screen positive are reported in a timely manner.

 

There were many vaccine bills in the legislature this past year, most with a potentially negative effect, in particular HB 1606 which passed both bodies and was signed into law as of July 1st, 2022, making the State Vaccine Registry an opt‑in, thus decreasing its usefulness. Similarly, HB 1639 would have made the Youth Risk Behavior Survey (YRBS) opt in. This would have diminished the numbers of students participating in an important survey used by not only Title V staff, but the entire State to gauge the behaviors of adolescents. Unlike the vaccine bill, it was not passed due mostly to the support of advocates in the State. Title V staff wrote testimony for the DPHS legislative liaison to present.

 

[1] Division of Forests and Lands, New Hampshire Department of Natural and Cultural Resources. Retrieved on 07/03/22 from https://www.nh.gov/nhdfl/reports/forest-statistics.htm.

[2] NH Employment Security (2022). Vital Signs 2022: Economic and Social Indicators for New Hampshire 2016-2020. Retrieved on 07/15/22 from vs-2022-final.pdf (nh.gov).

[3] Vital Records Data analyzed by MCH, 07/15/22.

[4] NH Employment Security (2022). Vital Signs 2022: Economic and Social Indicators for New Hampshire 2016-2020. Retrieved on 07/15/22 from vs-2022-final.pdf (nh.gov).

[5] Vital Records Data analyzed by MCH, 07/15/22.

[6] U.S. Census Bureau (2022). Quick Facts New Hampshire. Retrieved on 07/16/22 from https://www.census.gov/quickfacts/NH.

[7] NH Department of Health and Human Services (2022). Wisdom Data Portal. Retrieved on 07/16/22 from NH DHHS Data Portal.

[8] Ibid.

[9] University of NH, Carsey School of Public Policy (2021). Modest Population Gains, but Growing Diversity in New Hampshire with Children at the Vanguard. Retrieved on 07/16/22 from https://carsey.unh.edu/publication/modest-population-gains-but-growing-diversity-in-new-hampshire-with-children-in-vanguard.

[10] NH Employment Security (2022). Vital Signs 2022: Economic and Social Indicators for New Hampshire 2016-2020. Retrieved on 07/15/22 from vs-2022-final.pdf (nh.gov).

[11] Centers for Disease Control and Prevention (2022). Behavioral Risk Factor Surveillance System. Retrieved on 07/16/22 from https://nccd.cdc.gov/BRFSSPrevalence

[12] NH Employment Security (2022). Vital Signs 2022: Economic and Social Indicators for New Hampshire 2016-2020. Retrieved on 07/15/22 from vs-2022-final.pdf (nh.gov).

[13] Kaiser Family Foundation (2021). Medicare Advantage in 2021: Enrollment Update and Key Trends. Retrieved on 07/16/22 from https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2021-enrollment-update-and-key-trends/.              

14 United Health Foundation (2022), America’s Health Rankings 2021 Annual Report. Retrieved on 07/18/2022 from America's Health Rankings 2021 Annual Report (unitedhealthgroup.com).

[15] U.S. News and World Report (2022). Best States 2022. Retrieved on 07/17/2022 from https://www.usnews.com/news/best-states/new-hampshire.

[16] Annie E. Casey Foundation (2022). 2021 Kids Count Data Book: State Trends In Child Well-Being. Retrieved on 07/18/2022 from 2021 KIDS COUNT Data Book - The Annie E. Casey Foundation (aecf.org).

[17] Vital Records Data analyzed by MCH, 07/15/22.

[18] DHHS, (2022). Annual School Immunization Report 2021-2022 Bureau of Infectious Disease Control NH Immunization Program. Retrieved on 07/24/2022 from surveyresults-2022.pdf (nh.gov).

[19] https://assets.aecf.org/m/resourcedoc/aecf-2022kidscountdatabook-2022.pdf

[20] NH Employment Security (2022). Local Area Unemployment Statistics, May 2022 (updated 06/23/22).Retrieved on 07\/20/2022 from laus-current.pdf (nh.gov).

[21] United Health Foundation (2022), America’s Health Rankings 2021 Annual Report. Retrieved on 07/18/2022 from Explore Social and Economic Factors in New Hampshire | 2021 Annual Report | AHR (americashealthrankings.org).

[22] NH Department of Health and Human Services (2022). Wisdom Data Portal. Retrieved on 07/16/22 from NH DHHS Data Portal.

[23] NH Fiscal Policy Institute (2022). Financial Vulnerability in New Hampshire. Retrieved on 07/209/2022 from https://nhfpi.org/assets/2022/06/NHFPI-Financial-Vulnerability-in-New-Hampshire-6.20.22.pdf.

[24] NH Employment Security (2022). Vital Signs 2022: Economic and Social Indicators for New Hampshire 2016-2020. Retrieved on 07/15/22 from vs-2022-final.pdf (nh.gov).

[25] Ibid.

[26] Child and Adolescent Health Measurement Initiative. 2019-2020 NSCH data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, HRSA, MCHB. Retrieved 08/04/22 from www.childhealthdata.org.

[27] Smith, J., LaFleur, L., Clark, J., & McLean, P. (2021). SMS Title V CDC Annual Report.

[28] Ibid.

[29] NH Hospital Association (2022). Map of Hospitals. Retrieved on 07/20/2022 from 4154 NHHA_MAP_without-logo_03-31-2020.

[30] NH DHHS (2021). NH Statewide Primary Care Needs Assessment. Retrieved on 07/21/2022 from https://www.dhhs.nh.gov/dphs/bchs/rhpc/documents/pc-needsassesssment2021.pdf.

[31] NH Department of Justice, Charitable Trusts Unit (2022). Proposed Acquisition Transaction Involving GraniteOne Health, Dartmouth Hitchcock Health and Related Organizations. Retrieved on 07/21/2022 from https://www.doj.nh.gov/charitable-trusts/documents/graniteone-dartmouth-health-report.pdf.

[32] Vital Records Data analyzed by MCH, 07/15/22.

[33] General Court of NH (2022). Retrieved on 07/21/2022 from http://www.gencourt.state.nh.us/bill_status/billinfo.aspx?id=1606&inflect=2

[34] General Court of NH (2022). Retrieved on 07/21/2022 from http://www.gencourt.state.nh.us/bill_status/billinfo.aspx?id=2184&inflect=2.

[35] North Country Maternity Network (2022). Retrieved on 07/24/2022 from (20+) North Country Maternity Network | Facebook

[36] HRSA (2022). Federally Available Data Resource Document.

[37] Ibid.

[38] Endowment for Health (2022). Giving Care: A Strategic Plan to Expand and Support New Hampshire’s Health Care Workforce. Retrieved on 07/21/2022 from Giving-Care-A-Strategic-Plan-to-Expand-Support-NHs-Health-Care-Workforce.pdf (endowment-assets.nyc3.digitaloceanspaces.com).

[39] NH Fiscal Policy Institute (2022). Thousands of Granite Staters Risk Losing Medicaid Health Coverage at the End of the Public Health Emergency. Retrieved on 07/21/2022 from Thousands of Granite Staters Risk Losing Medicaid Health Coverage at the End of the Public Health Emergency - New Hampshire Fiscal Policy Institute (nhfpi.org).

[40] Ibid.

[41] Bi-State Primary Care Association (2022). NH Primary Care Sourcebook 2021. Retrieved on 07/22/2022 from PowerPoint Presentation (bistatepca.org).

[42] U.S. Census Bureau (2022). Quick Facts New Hampshire. Retrieved on 07/16/2022 from https://www.census.gov/quickfacts/NH.

[43] NH Fiscal Policy Institute (2022). Thousands of Granite Staters Risk Losing Medicaid Health Coverage at the End of the Public Health Emergency. Retrieved on 07/21/2022 from Thousands of Granite Staters Risk Losing Medicaid Health Coverage at the End of the Public Health Emergency - New Hampshire Fiscal Policy Institute (nhfpi.org).

[44] NH DHHS (2022). COVID-19 New Hampshire retrieved on 07/23/2022 from Welcome | NH COVID-19 Response.

[45] Ibid.

[46] Ibid.

[47] Ibid.

50 NH Drug Monitoring Initiative (2022). May 2022 Report. Retrieved on 07/23/2022 from dmi-may2022.pdf (nh.gov).

[49] DPHS (2022). Annual Report on Maternal Mortality to the NH Health and Human Services Oversight Committee, Annual Report 2021.

[50] DHHS, MCH (2022); Child Fatality Review Committee 2021. Retrieved on 07/24/2022 from child-fatality-review-report-2021.pdf (nh.gov).

[51] CDC, WISQARS (2022). Leading Causes of Death Reports, 1981-2020. Retrieved on 07/24/2022 from WISQARS Leading Causes of Death Reports (cdc.gov)

[52] Center for Excellence on Addiction (2022). Plan of Safe Care. Retrieved on 07/24/2022 from Plans of Safe Care (POSC) - Center for Excellence on Addiction (nhcenterforexcellence.org)

[53] Alliance for Innovation on Maternal Health (2022). Care for Pregnant and Postpartum People with SUD. Retrieved on 07/24/2022 from Care for Pregnant and Postpartum People with Substance Use Disorder | AIM Program (Previously Council on Patient Safety) (safehealthcareforeverywoman.org).

[54] HRSA (2022). Federally Available Data Resource Document.

[55] Ibid.