State Performance Measure #1: Percentage of Enabling Services (ES) work plans that have been met or exceeded on an annual basis. The numerator is the number of primary care agency ES work plans that have met or exceeded their target on an annual basis. The denominator is the total number of ES work plans.

Objective: Increase the percentage of ES work plans that have met or exceeded their target(s) to 75% in 2025.

Strategies:

• MCH requires all contracted primary care agencies to submit a two-year ES work plan as a contract deliverable within 30 days of the beginning of a contract period. 
• MCH staff routinely review ES work plans and provide feedback/technical assistance as needed to ensure agencies have included specific, measurable, achievable, realistic and, timely (or time-bound) SMART objectives/goals and a target for each State Fiscal Year (SFY).
• Monthly calls will continue between the MCH QI/Clinical Staff and primary care agency QI staff to share updates, need for technical assistance, etc.
• Learning communities and communities of practice on specific ES topics will be set up and implemented as needed.
• Updates to the ES work plans will be formally submitted twice per year, in January and July. At this point, MCH will review ES work plan outcome sections to determine how many have reached their target. If the target was not attained, feedback/technical assistance will be provided and the CHCs will need to submit a revised plan.

Systems Building

Based on the latest five-year needs assessment in 2020, NH MCH added a new Title V priority to “Increase the focus of Title V on the Social Determinants of Health and the resolution of barriers impacting the health of the MCH population.” Therefore, the new MCH in the Integrated Primary Care Setting contracts require that each funded Community Health Center (CHC) submit two Enabling Services (ES) work plans each two-year contract period with one of the two needing to focus on increasing screening and referrals for Social Determinants of Health (SDOH) among the MCH client population. These funded agencies must also submit work plan updates and outcomes every six months, the first update being due at the end of January (for reporting period 7/1-12/31) and the second due at the end of July (for 1/1-6/30). Below are the ES work plan topics for each agency for the contract period 7/1/22 through 6/30/24.

Since many of these ES work plan topics overlap, the MCH Quality Improvement and Clinical Services team are working on developing additional training opportunities and communities of practice to bring the CHCs together to fine tune their workflows and overcome barriers in order to achieve their work plan goals. For example, in a recent MCH in the Integrated Primary Care Setting All Primary Care Coordinators Meeting, one topic area in particular that was discussed was how to increase adolescent well child visits. One of the CHCs was able to share through the group discussion what workflows and processes were proving successful for them. A QI contact list of each CHC was sent out to enable the sharing of lessons learned between funded health centers.

Additionally, MCH staff are currently working to revise the CHC contract scope of services to align with the Title V guidance and performance measures due to be released in January of 2024 and in preparation for the next NH MCH needs assessment happening 2024-2025. The updating of this scope of services will place more emphasis on the prenatal population and ensuring that health centers are increasing access to prenatal care throughout the state.

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State Performance Measure #3: Percent of enrolled pediatric primary care providers that received pediatric mental health teleconsultation from the Pediatric Mentral Health Care Access (PMHCA) Program.

Objective: Increase the percentage of enrolled providers who receive Pediatric Mental Health Care Teleconsultation in the NH Pediatric Mental Health Care Access (PMHCA) Program from a baseline of 23% in 2020 to 50% in 2026.

Strategies:

• Provide NH pediatric primary care providers with additional training on the assessment and treatment of children with mental health concerns by:
  • Development of a Pediatric Mental Health Project ECHO series facilitated by the NH Pediatric Mental Health Team faculty of local subject matter experts.
  • Recruitment of pediatric primary care practices across NH to participate in the Pediatric Mental Health Project ECHO, targeting those in rural/underserved areas.

• Provide teleconsultation opportunities as needed for primary care providers with the PMHCA pediatric mental health team faculty members by:
  • Promotion of the Teleconsultation opportunities for participating pediatric primary care practices with the NH Pediatric Mental Health Team faculty.

• Continuation of Teleconsultation services by:
  • Increased NH pediatric primary care physician satisfaction with using Teleconsultation as a way to build their knowledge and confidence in treating children with mental health conditions.
  • Development of a plan for program sustainability

Systems Building

As MCH’s Pediatric Mental Health Care Access (PMHCA) Program HRSA grant funding is due to end on September 29, 2023, program staff recently submitted the PMHCA competing continuation grant application which will begin September 30, 2023 and fund the program for an additional three years. This grant will allow MCH to continue to fund the NH Mental Health Care Access in Pediatrics (NH MCAP) project, which is a collaboration with the University of New Hampshire Institute for Health Policy and Practice that aims to integrate behavioral health services into pediatric primary care. The NH MCAP pediatric mental health team of subject matter experts is comprised of specialists in the field (child psychiatrist, clinical mental health counselor, psychiatric nurse practitioner, pharmacist, occupational therapist, care coordinator, and family engagement specialist) who provide education, support, and teleconsultation to primary care providers using the Project ECHO telemontoring model. The integrated nature of the program works to enable enrolled providers to feel more confident and knowledgeable in conducting early identification and treatment of children with mental health conditions.

In addition to the Project ECHO training/telementoring sessions, enrolled providers also have the opportunity to receive teleconsultations as needed throughout the cohort with the pediatric mental health team faculty subject matter expert(s) of their choice to continue improving their skills in the assessment and treatment of children with mental health concerns. Since teleconsult utilization in 2022 was 45.9%, the state performance measure objective of increasing utilization to 41% by 2026 will now be adjusted to 50% by 2026. As program staff are planning and preparing the work plan for the next three year PMHCA grant, much thought is going into ways to streamline the teleconsult process to make it less of a time burden for primary care providers. Also being built into the work plan and budget are more funding for marketing the teleconsult service better to enrolled providers.

A recent polling of the program’s enrolled providers during one of the latest ECHO sessions showed that a majority of providers that do not utilize teleconsults either because the process to request one is too cumbersome or it does not come to mind when a teleconsult would be needed for a patient. Improved workflow/teleconsult request process and more efforts on marketing and education around when a teleconsult would be beneficial are top priorities for this new PMHCA funding to begin this fall.

Bi-State Primary Care Recruitment Center

In effort to continue the recruitment, retention, and quality of the NH mental health workforce, MCH will continue its Title V funding of the Bi‑State Recruitment Center for their recruitment of behavioral health providers throughout the State. Behavioral health providers are defined as psychiatrists; clinical or counseling psychologists; nurse practitioners; masters prepared social workers, mental health counselors and family therapists; licensed alcohol and drug counselors; and masters prepared licensed alcohol and drug counselors. Some of the anticipated activities of the recruitment center for the next year include, but are not limited to:

• The provision of technical assistance to organizations and agencies with recruitment needs for behavioral health providers on the techniques of recruitment and retention and the measures critical for securing candidates.
• The engagement and encouragement of agencies to post behavioral health provider/clinician vacancies through the Recruitment Center. These vacancies will be tracked as a means to identify vacancy, recruitment and turnover trends and determine effective tactics for successful outreach, recruitment and retention. These trends will be shared with MCH and other key stakeholders as appropriate.
• The carrying out of efforts to fill the vacancies with the target audience of behavioral health providers using targeted marketing.

The Recruitment Center also provides MCH with quarterly statistics on the recruitment of behavioral health providers as tracked by its electronic vacancy tracking system and measured by:

• The number of contacts with behavioral health professionals broken out by provider type. This includes the number sourced, the number who have become active and the number of professionals who then match with interviews.
• The number of behavioral health professionals recruited to and who obtained employment within NH, again broken out by agency and provider type.
• The number and type of behavioral health provider who declined placement and the reason(s) for declining.

MCH Specific Activities

In order to assist the MCH Title V funded primary care agencies in achieving improved depression screening rates in patients aged 12 and older from their 2022 baseline rate of 59%, MCH’s Quality Improvement and Clinical Services team will continue meeting with each agency monthly. These monthly meetings allow MCH to check-in and provide technical assistance for this measure as well as their other performance measures and Quality Improvement/Enabling Services work plans. Furthermore, MCH plans to have two “MCH in the Integrated Primary Care Setting All Primary Care Coordinators Meetings” each year with QI and Clinical Staff from each contracted agency to provide additional training and quality improvement activities. For example, at the last meeting MCH had the director of the NH DHHS Bureau for Children’s Behavioral Health come to present on the work they are doing and the various new services/initiatives that are now available and the process of how to make successful referrals. Behavioral health will be a consistent topic of discussion at both the monthly individual agency meetings as well as the biannual all primary care coordinators meetings.

Additionally, MCH’s CDC Public Health Crisis Response: Workforce Development (WFD) for COVID-19 funding was recently awarded a no cost extension by the CDC. This will allow the School Based Health Services contracted primary care agency who was not able to spend down all of their funds due to a statewide workforce shortage; continue their work in their school based health centers during this next 2023-2024 school year.

With the intention of continuing to collaborate and create linkages with other departments and organizations, the PMHCA Program Manager will continue engaging in various stakeholder and other state agency committees to further the improvement of NH children’s mental health initiative. These include:

• The NH Pediatric Improvement Partnership Steering Committee
• The NH Bureau for Children’s Behavioral Health’s System of Care Advisory Council
• The NH Watch Me Grow Developmental Screening Steering Committee
• NH Children’s System of Care Technical Assistance Center Leadership Advisory Team
• The NH Association for Infant Mental Health

Through involvement in these committees and the partnerships formed, the Pediatric Mental Health Program Manager (leveraged to a full FTE with Title V funding) will continue to work to promote awareness of and interest in the NH Mental Health Care Access in Pediatrics (NH MCAP) Program. Additionally, the need for behavioral health integration in pediatrics, current children’s mental health resources, as well as NH system of care initiatives and updates.