New Hampshire’s Title V is located within two distinct areas of the Department of Health and Human Services (DHHS). The Maternal and Child Health Section (MCH) resides in the Bureau of Population Health and Community Health Services within the Division of Public Health Services (DPHS). The Bureau for Family Centered Services (BFCS) sits within the Division of Long Term Supports and Services (DLTSS). However, despite their placements in different organizational divisions, both MCH and the BFCS share the same DHHS mission in joining communities and families in providing opportunities for citizens to achieve health and independence. This is done by “meeting the health  and basic human needs of NH citizens, particularly those most vulnerable.”[1] This reflects the national mission of “providing a foundation for family and community health across the State and in assuring access to the delivery of quality health care services for mother, infants and children, including CYSHCN.” Building upon this, NH’s Title V staff and programs have no one definitive framework, rather taking a generalized life course approach focusing on all people, acknowledging that people live within families and communities, have a trajectory of experiences which build one upon the other, leading to self-determination, social capital, economic sufficiency, and community inclusion.[2] Everything is looked at with an equity lens.

The Title V Director is the Administrator/Section Chief of Maternal and Child Health. The CSHCN Director is the Bureau Chief of Family Centered Services. Both have worked in the maternal and child health fields for over sixty years combined. MCH and BFCS have historically worked together for decades. Their relationship is based on a signed agreement granting the BFCS 39.6% of the approximately $1.9 million in Title V funding with MCH receiving the other 60.4%.

DHHS is led by a Governor and Executive Council (G&C) appointed Commissioner, who at this time, is an interim with over two decades within the agency. The DPHS’s Director comes from a background well acquainted with Title V in that she previously served as the MCH Administrator for over ten years. The DLTSS’s Director is an experienced Social Worker with a long history of working within the health care industry. All have a deep knowledge of and most importantly show great support for Title V and its activities within the State.

The Republican Governor Christopher Sununu was re-elected in November of 2022 for his fourth term (of two years). Rounding out the State’s government is one of the world’s largest bicameral, citizen-led legislatures at 424 members (400 representatives, 24 senators; currently both Republican controlled although by a slim margin) and the G&C, a body of five elected Councilors (currently four Republicans and one Democrat; unchanged in the 2022 election) who approve all State contracts and expenditures over the amount of ten thousand dollars. There is also a legislated Senate/House Fiscal Committee, which accepts and agrees to expend any outside (e.g. Federal) dollars within a biennium budget period and a Senate/House Health and Human Services Oversight committee, which is presented numerous Title V reports from legislated committees such as newborn screening, maternal mortality, child fatality, and the Council for Youth with Chronic Conditions. A good portion of at least a day or two per week of any Title V staff person’s day is spent writing and editing items such as a G&C letter explaining the contents of a contract in layman’s terms, putting together a written justification of the necessity and health benefits of accepting a federal grant (including carryovers) for the Fiscal Committee or putting together a literature review of best practices and financial costs for a legislative study request (the step before a piece of legislation becomes a bill). Thus, in NH, the government and politics has an oversize role in the daily functioning of Title V.

This was experienced particularly in the last year when the G&C did not approve two community agency contracts for an adolescent pregnancy prevention program (in the two areas of the State with the highest adolescent birth rate) entitled the State Personal Responsibility Education Program (PREP) out of the Administration on Children, Youth and Families. Although a small grant in terms of money, MCH had participated in PREP since its inception over a decade ago. Unfortunately, after several months of meetings, the Executive Council continued to reject the contracts, forcing MCH to withdraw from the Federal program. MCH’s Reproductive and Sexual Health Program, while not funded by Title V, is an integral part of the Section’s functioning.

Title V staff drafted State Fiscal Year 24/25 budget proposals (07/1/23‑06/30/25) during the spring and summer of 2022. The Governor presented his version of the budget to the legislature in February and it is currently with the Senate after having passed the House. A committee of conference between the House and the Senate will result in a budget bill for the Governor to sign before the end of the State Fiscal Year on June 30th. All Title V staff are on‑call during this time, particularly the management staff, when Directors and the Commissioner can require information for legislators debating the budget with a five-minute turnaround time. Title V requires a general state fund match of $2,872,257. Between MCH and the BFCS, the match is usually not a problem and currently looks stable. However, there is always uncertainty until the process is completed and the budget is approved. For the first time, MCH is also supporting a state general fund match consistent with the upcoming requirements of HRSA’s Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. This in turn has generated many questions, particularly about home visiting.

During the last year, the COVID‑19 pandemic was still a part of the professional and personal lives of NH’s Title V staff. However, prioritization of responsibilities has somewhat returned to pre-pandemic functioning. MCH is still working with the COVID‑19 vaccination efforts across the State (which has shifted from large events to collaboration with primary care providers and pediatricians), continues working with the DPHS Bureau of Infectious Disease surveilling pregnant moms with COVID (this has taken on an even larger focus, with the first maternal death due to COVID being in the review que for the maternal mortality committee), making calls to monitor the concerns of contracted agencies and their clients, realigning contractual funds to better reflect the costs of the pandemic, assisting families in need of personal protective equipment and gaining expertise in telehealth issues. Title V staff played, and continue to play, an integral role in the COVID‑19 pandemic response. Although buildings are now open, all of the Title V staff now take advantage of the new teleworking policy, which mandates attendance in the office buildings at least four times in a ten-day working period.

With that as a backdrop, NH Title V programs, particularly those administered by MCH,  benefitted from several of the additional American Rescue Plan Act (ARPA) funded projects as well as the large overall COVID grant sent to DHHS. ARPA funds have been primarily utilized for material goods needed by families, diapers, transportation, etc. while the large COVID grants have gone to initiating new programming and support for staff retention in community-based agencies. That being said, Title V staff are currently working with their colleagues across DHHS in helping families whether it be through the Medicaid transition (re-signing up for Medicaid if now currently qualified) and the SNAP loss of benefits.

MCH, in particular, benefited from the CDC’s large Health Equity COVID and Workforce grants to DPHS. Through it, in the last year, MCH’s Family Support and Community Health has been able to add another 1.0 FTE dedicated to the growth and expansion of community health workers in the State. This melded perfectly with the rest of MCH’s Title V vision as well as enabled contracts with several area health education centers who train and lead a statewide Community Health Worker Taskforce. Again, within this past year, MCH’s Quality Improvement and Clinical Services has been able to utilize some of the funding to contract with a CHC implementing behavioral health in the State’s largest school system as well as starting two new school based health clinics in elementary schools. Both of these programs will hopefully continue within NH’s Title V sphere into the future.

Forty-one percent of MCH’s workforce has been in their position within DHHS for less than ten years and 63% are under the age of 50. MCH has 29 positions (25 FTEs including a contracted 1.0 FTE Epidemiologist and three part-time staffers for an additional 1.8 FTEs). At the start of the NH State Fiscal Year 24 biennium (July 1, 2023), MCH will be adding 2.0 FTEs for the Injury Prevention Program, primarily working on the National Violent Death Reporting System (NVDRS) and the State Unintentional Overdose Reporting System (SUDORS). These positions were originally with the Medical Examiner’s Office. Three additional full time equivalents will be added to the Family Support and Community Health Program (formerly Community Engagement) to work on the state’s family resource centers (also all coming to MCH). In preparation for that and to lay the groundwork for late calendar year 2024 when the MCH Administrator/Section Chief and Program Specialist retire, the MCH management staff has been engaged in a two year strategic planning process (which started the Fall of 2022).

Over the last several years in MCH, positions have been set up to encompass more of the activities related to the performance measures and ESMs, such as the full-time Perinatal Coordinator and the Child-Adolescent Clinical Coordinator, broadening the availability of staff dedicated to core Title V services. MCH currently has seven programmatic units: Data/Decision Support; Infant Surveillance; Injury Prevention; Home Visiting; Quality Improvement and Clinical Services; Women’s Health; and Family Support and Community Health (formerly Community Engagement).

Much of Title V funding is blended and braided to support staff and contracts that implement strategies consistent with the Block Grant’s Five Year State Action Plan. Within MCH, Title V leverages funding for 11 FTEs. Several grants have remained level-funded and have not kept up with personnel cost of living and salary increases, necessitating the leveraging in order to maintain full-time positions. Braiding of Federal grant and State general funding is crucial for an effective Title V workforce. In MCH, the Administrator/Section Chief, Executive Secretary and MCH Program Specialist are cost allocated across all of MCH’s Federal grants and state general funds. Title V funds, in some part, all of the Quality Improvement and MCH Clinical Services unit, which includes the Child-Adolescent Health Nurse Consultant, the Perinatal Coordinator, the Pediatric Mental Health Care/Access Program Coordinator, and the QI/QA and Clinical Services Program Administrator. This last position, among other responsibilities, oversees the evaluation of all programming and makes specific recommendations and required actions to meet the goals of the Title V National and State Performance Measures (NPM and SPM).

Title V also funds a portion of the MCH Injury Prevention Program Administrator and the Injury Surveillance Coordinator who seek to reduce morbidity and mortality due to intentional and unintentional injuries. This team oversees contracts with the NH Coalition for Domestic and Sexual Violence, the Injury Prevention Center at Dartmouth Health (Title V funded) and the Northern New England Poison Center.

Leveraged Title V funds also support MCH’s Data Scientist/SSDI Project Director, Birth Conditions Program/Early Hearing Screening Follow-Up Coordinator, Infant Surveillance Program Coordinator, Newborn Screening Program Administrator and all of the Quality Improvement and Clinical Services’ team of four.

MCH utilizes part of its Title V funding for a PhD-level public health epidemiologist from the University of New Hampshire (UNH), conducting analyses of state and national data sets related to maternal and child health. This is the first year of MCH’s full time epidemiologist who has settled in very well after coming to the State fresh off a three-year period of post-doctoral work in maternal and child health epidemiology at the University of Tsukuba in Japan. She, in conjunction with MCH’s Data Scientist/SSDI Project Director, oversees and leads MCH’s Data/Decision program unit along with several data analysts in other MCH programmatic units.

MCH is looked upon as the “keeper and assessor” of all data related to maternal and child health. This is one of the core public health functions supported by Title V. The MCH Epidemiologist leads the State in assessing data for the Alliance in Innovation in Maternal Health (AIM). Work on this includes, but is not limited to, the efforts on implementing AIM’s patient safety bundle, “Care for Pregnant and Postpartum People with Substance Use Disorder”[3] with colleagues at the Northern New England Perinatal Quality Improvement Network (NNEPQIN) at Dartmouth Health (DH) that addresses NPM#1. In addition, the MCH Epidemiologist has created many slide decks on maternal health in the State that have been utilized for presentations to the Governor and his Executive Council, at State and National meetings, for testimony to the legislature on bills such as extending Medicaid through the first year postpartum and most recently as the basis for an upcoming MCH/NNEPQIN publication which will be entitled “Maternal Health in New Hampshire, 2023”.

Title V funds the birth conditions piece of the Birth Conditions Program/Early Hearing Screening Follow-Up Coordinator. NH’s Birth Conditions Program, which restarted in 2018 after a six year hiatus, will be coming out with two years of aggregated data in the upcoming year. This has been a work in progress as the staff person needed to rewrite the Administrative Rules, renegotiate chart access in all of NH’s birthing hospitals and restart a data abstraction process. It will be interesting to see where this data leads NH’s Title V.

Five of the seven MCH Block Grant State Action Plan priorities highlight access to services: needed healthcare, mental health services, family support, social determinants of health and developmental screening. Title V sees itself as the “enhancer” or “enabler” of access to quality health care services of all kinds for the MCH population, including CYSHCN. Title V funding decisions are made based on gap assessments founded on discussions of the State’s health care system and the needs assessment process, which looks at health outcomes as well as process measures. This is revisited every year. For example, MCH’s Quality Improvement and Clinical Services programmatic unit consisting of the Perinatal Coordinator, Pediatric Mental Health Care Program Manager, Child/Adolescent Health Nurse Consultant and the Program Administrator use the data provided by their colleagues and MCH contractors to assess the quality of the maternal and child health in the State and then lead or participate in innovative and evidence based or informed approaches to address issues.

A new effort this past year has been the inclusion of a social determinants of health (SDOH) screening performance measure and work plan mandated in all of the new “MCH in the Integrated Primary Care” contracts with ten statewide community health centers (CHCs) supported by Title V. These agencies’ mission is to provide accessible and affordable comprehensive primary care and perinatal services, with a focus on reproductive age women and children. Funds are the payer of last resort for the very small percentage of women and children who are not insured, and mainly go to enabling services such as case management, transportation and interpretation services, that are not reimbursed elsewhere.

The successful implementation of the CHCs’ enabling services workplans address SPM#1, Percentage of MCH-contracted Community Health Centers that have met or exceeded the target indicated on their NH DHHS/MCH Enabling Services workplan. One of the two required enabling workplans must focus on the initiation and implementation of a screening for SDOH within the electronic medical record, using a tool such as PRAPARE.[4] The measure also includes the need for follow up documentation. The ten agencies are all at different levels, some looking for a screening tool, others working on tracking of referrals for any positive screening item (mostly within a closed-loop system), and others having facilitated this for several years now.

Another portion of every CHC contract is dedicated to quality improvement projects such as getting adolescents into annual care; increasing the number of pregnant women receiving tobacco cessation services; and increasing the usage of highly effective contraceptive methods. The QI projects all address the NPMs in some way. MCH’s QI and Clinical Services team, all with “boots on the ground” clinical experience, guide the agencies by tracking 14 health outcome performance measures (such as postpartum depression and mental health screening and SBIRT (SUD screening, brief intervention and referral to treatment) with adolescents).

NH Title V staff and its contractors lead by calling attention to emerging issues, thinking strategically, facilitating analysis, and educating on best practices. Title V looks for gaps and tries to fill them, in alignment with priority areas. MCH continues to work in tandem with the State’s Vital Records (overseen by the Secretary of State) and continues to collect birth certificate data including drug exposure, naloxone discussions and Plans of Safe Care questions. This addresses a NH Title V priority area, the need to decrease the use and abuse of alcohol, tobacco and other substances among pregnant women.

Title V also has the role of convener as well as participant in many statewide groups such as advisory committees, for example: Newborn Screening, Birth Conditions, PRAMS, and Early Hearing Screening (all led by MCH staff); mortality review groups such as Maternal Mortality, Sudden Unexpected Infant Death, Sudden Death in Youth and Child Fatality (also all led by MCH staff); as well as legislatively enacted Councils such as the NH Council on Autism Spectrum Disorders (MCH and BFCS), the Perinatal Substance Exposure Collaborative (no longer a part of the Governor’s Commission on Alcohol and other Drugs), the NH Pediatric Improvement Partnership out of the University of New Hampshire (MCH and BFCS),  the Transition Community of Practice (BFCS), the Charting the Life Course (CtLC) Community of Practice (BFCS) and the Council for Youth with Chronic Conditions (BFCS). In addition, BFCS’ Part C Early Supports and Services staff, lead the Interagency Coordinating Council.

BFCS administers a variety of services including specialized networks for nutrition, feeding, and swallowing and children with medical complexities; child development evaluations; health care coordination; Family Centered Early Supports and Services (NH’s Part C program for infants and toddlers with developmental delays), and Family Support for CSHCN and individuals with developmental disabilities across the lifespan. In addition, BFCS provides systems of care leadership for developmental screening initiatives and supports information and referral through NH Family Voices (NHFV). BFCS has 18 positions that provide leadership, administer, manage and implement programs and services for children with special health care needs and their families. Title V services for CSHCN are organized in accordance with the Standards for Systems of Care for Children and Youth with Special Health Care Needs Version 2.0. Title V funds the following BFCS positions: the CSHCN Director/Bureau Chief, Data Coordinator, Evaluation Specialist, Systems of Care Specialist, Clinical Program Manager, three Nurse Consultants (two of whom were former health care coordinators), one CSHCN Program Coordinator, one Eligibility Technician, and two administrative support staff.

Of these 18 positions, three are vacant as of 4/6/2023. For the first time in more than five (5) years, there are no pending retirements. Due to a high vacancy rate during COVID, the average length of state service among BFCS staff is just over six years. However, the combined number of years in state service, addressing the needs of children and families, is more than 93 years. Operational changes to meet the shifting programmatic needs are addressed, as positions become vacant and subsequently reclassified.

BFCS also employs a Family Support Administrator who provides oversight for the Part C Early Supports and Services program, Child Development, and Family Support for individuals with developmental disabilities, and is funded with state general funds. Her staff includes the Part C Early Supports and Services Coordinator, a Program Specialist, and a Program Assistant (vacant), all funded by the US Department of Education, Office of Special Education Programs (OSEP) Part C grant. The Partners in Health Program Manager and Program Assistant are funded by the Social Services Block Grant (SSBG) under the Service Category of Special Services for Persons with Developmental or Physical Disabilities. This team will be joined by the CSHCN Program Coordinator and the Eligibility Technician to provide oversight and technical assistance to the community-based health care coordination (HCC) programs beginning July 1, 2023; as the former Partners in Health family support program is phased out. Services provided under this program have been incorporated into HCC.

BFCS supports seven Title V-funded contracts. These contracts primarily focus on systems access, infrastructure development and improvement, and a small percentage for direct services. The support to the system of care includes statewide programming for three contracts. The first is a Child Development Clinic Network, which consists of an autism clinic and four locations for interdisciplinary diagnostic evaluation services to children 0-6 years of age suspected of or at risk for altered developmental progress. Next is a comprehensive Complex Care Network that incorporates interdisciplinary clinics and specialty consultation to providers serving CSHCN that is child specific or that addresses questions that are more general. Third is a Comprehensive Nutrition and Feeding/Swallowing (F/S) Consultation Network, which offers community-based consultation and intervention services utilizing a home visiting method of service delivery. BFCS also uses Title V funds to support training to potential providers, in addition to direct service to program recipients.

BFCS funds two contracts with the New Hampshire Coalition for Citizens with Disabilities Inc. d/b/a/ Parent Information Center. Led by NH Family Voices, the first supports and enhances the State’s Family-to-Family programming to assist families with CSHCN to navigate the system of care, maintain a virtual resource center on their website, assist family advisories/councils, and provide a comprehensive lending library. Additional funding is braided into the contract from the Child Development and Head Start Collaboration office for coordination of the Birth through 8 Early Childhood Care and Education Advisory (B‑8) Team and to support Watch Me Grow developmental screening system activities (NPM#6). Lastly, funding is included from MCH for family engagement work with the B‑8 Team. The second contract, also led by NHFV, is specific to supporting NH’s work on NPM#12, Youth Health Care Transition. BFCS is currently in the procurement process for ten (10) regional community contracts to provide Health Care Coordination for CSHNC and their families with funding from Title V and SSBG which, among other things, will provide information about and access to respite services (SPM#2). 

BFCS braids funding to pursue collaborative efforts including one with DHHS’s Bureau of Developmental Services (BDS) for a contract that enhances access for CSHCN to Psychiatry Services, limited to one-time direct assessment, consultation, and short-term condition/ medication management.

[1] Retrieved from Mission & Principles | New Hampshire Department of Health and Human Services (nh.gov) on 03/05/2023.

[2] Retrieved from LifeCourse Framework – LifeCourse Nexus (lifecoursetools.com) on 03/05/2023.

[3] Retrieved from Care for Pregnant and Postpartum People with Substance Use Disorder | AIM (saferbirth.org) on 03/05/2023.

[4] Retrieved from The PRAPARE Screening Tool - PRAPARE on 03/05/2023.