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). Other programs within this Bureau include Chronic Disease, WIC and Tobacco Prevention and Cessation. The Bureau for Family Centered Services (BFCS; formerly Special Medical Services) sits within the Division of Long Term Supports and Services (DLTSS). Other bureaus within this Division include Developmental Services and Elderly and Adult Services. However, despite their internal placements,  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 needs of NH citizens;
• Meeting the basic human needs of NH citizens;
• Providing treatment and support services to those who have unique needs including disabilities, mental illness, special health care needs or substance abuse problems and
• Protecting and caring for NH’s most vulnerable citizens.”[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 of the Maternal and Child Health Section. Her colleague is the Bureau Chief of Family Centered Services, which includes CYSHCN. MCH and the BFCS have historically worked together for decades. In fact, close to thirty years ago, they resided in the same DHHS Division. Their relationship is based on a signed agreement granting the BFCS 41% (out of the required 30%) of the $1.9 million in Title V funding with MCH receiving the other 59%.

DHHS is led by a Commissioner who is a nurse with a long background in health facility management. Both DPHS and the DLTSS have had recent retirements of their respective Directors in the past year. Fortunately for both Divisions, new Directors were appointed with many years of experience. The new DPHS Director comes from a background well acquainted with Title V in that she previously served as the MCH Administrator for close to ten years. The new DLTSS Director is coming out of retirement, having served DHHS in many roles, including as Associate Commissioner for Human Services for over thirty years. Both have an understanding, deep knowledge of and most importantly share great support for Title V and its activities within the State.

During the last year, the COVID‑19 pandemic was looming large for NH’s Title V staff. Prioritization of time and funding had been (and still is) given to the response. On any given day, NH’s Title V had a reduced FTE count. This was in large part because approximately 90% were (and still are, some days) working remotely, attending to childcare and helping with remote school work, as well as dealing with other changes in the home-life balance. Some staff, particularly those with clinical backgrounds, were pulled to work for a varying amount of time on the pandemic response, primarily as contact tracers and data analysts. There was renovation of the space housing MCH personnel during the past year, as well as the use of the majority of the renovated space for National Guard deployed to DPHS for contact tracing and immunization efforts. For MCH, this meant that only a small group of staff could work in the office.

Title V went through many professional and personal issues, with some staff and their family members contracting COVID‑19, some making life decisions and choosing to retire or leave State service and all battling with isolation and change.

The Governor issued 25 Executive Orders and 90 Emergency Orders over the last year and a half due to the pandemic. These ranged from allowing all legislated committees (some of which Title V staff facilitate) to meet virtually, to extending telehealth and the ability of schools to function remotely. Since the COVID‑19 vaccine became available, the situation is slowly improving, although as of June 21, 2021, this is the current situation:

[3]

[4]

At the time of writing, approximately 50% of the population over 12 is vaccinated with the trend going up slowly. The Governor has ordered all schools to reopen and re-opened State buildings to the public, both in May of 2021, and his emergency orders all ended the middle of June. The National Guard has vacated most of the MCH space and Title V staff have been trickling back to the office. However, unlike before the pandemic, the majority of Title V staff are now working a hybrid schedule, alternating between teleworking and being in the office.

Throughout the COVID‑19 pandemic, all Title V staff worked tirelessly to ensure the health and well-being of the State’s MCH population, including CYSHCN. From participation in the DHHS Coordinated Response Team, working with the DPHS Bureau of Infectious Disease surveilling pregnant moms with COVID, making daily calls to monitor the concerns of contracted agencies and their clients, realigmomh contractual funds to better reflect the costs of the pandemic and gaining expertise in telehealth issues among many other duties, Title V staff played, and continue to play, their part in the COVID‑19 pandemic response.

Within this past year and mostly due to the pandemic, DHHS and State administrative tasks took a longer time from start to finish. The DHHS Executive Leadership Team, including Directors and Deputies of both DPHS and DLTSS (whose signatures and approval are needed for certain tasks and on all contracts) have also spent much time addressing and directing the COVID‑19 pandemic response. New projects and innovative ideas were deferred throughout the public health emergency. This was accentuated by the Governor’s nine month hiring freeze and waiver process (to bypass the freeze for essential positions) which delayed Title V’s recruitment of vacant positions. The Executive Council (which provides final approval for most contracts, MOUs, etc.), the Senate and most legislative committees, including the Health and Human Services Oversight Committee, met less frequently and until recently, did so virtually. This year’s House of Representatives, however, did meet in person at large venue locations.

The State Legislature was also involved in the months long biennium budget process for State Fiscal Years 22 and 23 (starting 7/1/21). Title V staff were very much involved, particularly at the beginning step (Fall of 2020), when the full DHHS budget is developed. Title V requires a general state fund match , which currently is $2,872,257. Between MCH and the BFCS, the match is usually not a problem. However, for the last decade, these general funds have been reduced. The Governor signed the budget at the end of June 2021. MCH’s general funds for Title V activities has decreased by two million dollars since 2010. BFCS general funds for Title V activities was reduced by 20% in the 22-23 biennium budget. This creates a level of fiscal insecurity during each budget session.

MCH has grown  substantially in the past decade. Seventy percent of Title V’s workforce has been in their position within DHHS for less than ten years and 65% are under the age of 50. MCH has increased its grant portfolio significantly in the last decade to include funding sources such as the CDC’s Pregnancy Risk Assessment Monitoring Systems (PRAMS), ERASE Maternal Mortality, and the National Violent Death Reporting System, as well as the Children’s Bureau’s Community Collaboration to Strengthen and Preserve Families, and HRSA’s Pediatric Mental Health Care Access Program. Due to the staff vacancies resulting from the hiring freeze, BFCS was unable to pursue new opportunities in the past year.

Much of Title V funding is braided to support staff and into contracts to implement strategies consistent with the MCH Block Grant’s Five Year State Action Plan.

MCH has 28 positions (23 FTEs, a contracted 0.8 FTE Epidemiologist, and three part-time staffers for an additional 1.8 FTEs). There is an additional unfunded, part-time position “on the books,” for future planning efforts. Title V funds 14 of the positions in part, three in full, which is an increase from last year (strategically done during action planning). Positions have also developed to encompass more of the activities related to the performance measures and ESMs, such as the full-time Perinatal Coordinator (pregnant women and substance misuse performance measure), the Infant Surveillance Program Coordinator (safe sleep performance measure), the Pediatric Mental Health Care Access Coordinator (cross cutting behavioral health state measure) and the Child/Adolescent Health Clinical Coordinator (adolescent well visit performance measure, currently vacant), broadening the availability of staff dedicated to core Title V services. Several grants have remained level-funded and have not kept up with personnel cost of living and salary increases, necessitating the leveraging with Title V in order to maintain full-time positions. Braiding of federal grant and state general funding supports is crucial for an effective Title V workforce. MCH currently has seven programmatic units, each led by staff who are part of the MCH management team: Data/Decision Support; Infant Surveillance; Injury Prevention; Quality Improvement and Clinical Services; Home Visiting; Women’s Health; and Early Childhood Systems. Only the latter two are not funded in some way by Title V, although all MCH staff have the same overall objectives.

Title V funds in whole or part the following positions in MCH: Administrator (through cost allocation), Child/Adolescent Health Nurse Consultant (currently vacant), MCH Program Specialist, Data Scientist/SSDI Project Investigator, Birth Conditions Program/Early Hearing Screening Follow-Up Coordinator, Executive Secretary, Infant Surveillance Program Coordinator, Newborn Screening Program Manager, Perinatal Coordinator, Pediatric Mental Health Care/Access Program Coordinator, Newborn Screening Program Manager and the QI/QA and Clinical Services Program Manager. This last position 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. Title V also funds a portion of the Injury Prevention Program Manager and the Injury Surveillance Coordinator ,who seek to reduce morbidity and mortality due to intentional and unintentional injuries and oversee the contracts with the Brain Injury Association (Title V funded), the NH Coalition for Domestic and Sexual Violence, the Injury Prevention Center and the Northern New England Poison Center.

MCH utilizes part of its Title V funding for a PhD level public health epidemiologist from the University of New Hampshire, who has worked with Title V for close to two decades, conducting analyses of state and national data sets related to maternal and child health. He, in conjunction with the MCH’s Data Scientist/SSDI Project Investigator, oversee and lead MCH’s Data/Decision program unit along with several data analysts in other programmatic units such as Injury Prevention, Home Visiting and QI and Clinical Services.

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 that are supported by Title V. As an example, the Injury Prevention Program recently completed its “State of New Hampshire, Violence and Injury Prevention Five Year Plan (State Injury Plan).”[5] Title V supported the Injury Surveillance Coordinator in retrieving. analyzing and presenting core injury data such as hospital discharges, YRBS and vital records data such as births and deaths. This data was utilized as the foundation of the State Injury Plan and also became part of the Title V needs assessment which led to NH choosing National Performance Measure #7 rate of hospitalization for non-fatal injury per 100,000 adolescents ages 10-19. The Injury Surveillance Coordinator also works with the Infant Surveillance Program Coordinator in gathering the data to look at efforts related to another of NH’s chosen measures, NPM #5, all around infant safe sleep.

Another example of the core assessment function is the MCH Data Scientists/SSDI Project Investigator’s work with the PRAMS data and in the past year has released several data briefs including “Overview of the Impact of Pregnancy Intention on Maternal Behaviors During and After Pregnancy, 2013-2018.”[6] Pregnancy intention (not intended) was shown to be correlated with higher percentages of unhealthy behaviors such as incidence of smoking during pregnancy and postpartum, as well as later entrance into prenatal care.

The MCH Epidemiologist leads the State in assessing data for its role in the Alliance in Innovation in Maternal Health (AIM), as well as chairs the Vital Records Improvement Fund Advisory Committee and sits on the biannual Vital Records Birth Quality Committee, of which he is an active member.

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. For example, MCH’s Quality Improvement and Clinical Services programmatic unit (consisting of the Perinatal Coordinator, Pediatric Mental Health Care/Access Program Coordinator and Child/Adolescent Health Nurse Consultant lead by the QI/QA and Clinical Services Program Manager) use the data provided by their colleagues and Title V 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. This is reflected in the work around workforce and the shortage of pediatric mental health practitioners. The Pediatric Mental Health Care/Access Program Coordinator leads a Project ECHO centering on pediatric psychiatric providers engaging a group of primary care providers on best practices. This MCH staff member also facilitates a Title V funded contract with the Bi-State Recruitment Center specifically geared towards increasing staffing in mental health shortage areas. 

MCH’s Quality Improvement and Clinical Services programmatic unit works closely with the 12 community health centers (CHCs) receiving Title V funds (some through multiple contracts) in their mission to provide accessible and affordable comprehensive primary care and perinatal services. Funds are the last payer of 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. A portion of every 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/QA and Clinical Services Program Manager, the Child/Adolescent Health Nurse Consultant and the Perinatal Coordinator, all nurses with close to sixty years combined of “boots on the ground” clinical experience, guide the agencies by tracking health outcome performance measures (such as the frequency of the adolescent well visit) and helping to design effective programs addressing the social determinants of health, which are often barriers to care.

Title V funds are also braided and leveraged with those from the Division of Children, Youth and Families and the Division of Housing and Economic Security to support the eight Comprehensive Family Support Services Program agencies, which provide home visiting  and parenting education for families with children under 21. The contract is in its first year with increasing responsibilities (e.g. having to become a Family Resource Center of Quality) and funding sources (resources for kinship care for children affected by substance use disorders of their parents). MCH’s Home Visiting and Early Childhood Systems programmatic units’ staff work on almost a daily basis with these contractors, particularly during the COVID‑19 pandemic, responding to community needs and barriers, in supporting a healthy maternal and child health population.

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. For example, using the birth certificate’s two situational surveillance questions related to substance use exposure (and leading into the Plan of Safe Care), MCH identified a birthing hospital with a large percentage of affected newborns. A partnership was initiated across DHHS, enabling these newborns to get connected immediately upon birth with the MCH sponsored home visiting agency in the birthing hospital’s catchment area. This project showed increased enrollment into the evidence based Healthy Families America model, which is led by MCH’s Home Visiting programmatic unit.

MCH, working in tandem with Vital Records this past year was also able to get the drug exposed questions asked as situational surveillance, into the core data set on the birth certificate. One of the two questions in the birth certificate’s situational surveillance slots now focuses on naloxone distribution in postpartum mothers with SUD. This topic was also recently added to the Plan of Safe Care, whose efforts MCH is an integral part of, and it addresses NH’s selected NPM#14 on smoking during pregnancy (addressing 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 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 Task Force (a subcommittee 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), and the Council for Youth with Chronic Conditions (BFCS). In addition BFCS leads the Interagency Coordinating Council and Caregiver Integration Team workgroup and participates in the Transition Community of Practice (COP) and the Charting the Life Course CoP. The CSHCN Director is a member of the National Advisory Committee for the Catalyst Center’s work on Improving Coverage and Financing of Care for Children and Youth with Special Health Care Needs.

BFCS has 19 positions which provide leadership, administration for and management and implementation of 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. BFCS uses Title V funds in whole or part for the following positions: the CSHCN Director/Bureau Chief, Data Analyst/Coordinator, Program Data Specialist (part time-vacant), CSHCN Systems of Care Specialist, Clinical Program Manager, three nurse health care coordinators (one vacant), two Health Care Coordinators (one part time), a Financial Eligibility Technician, and two administrative support staff.

In addition, BFCS employs a Family Support Administrator who provides oversight for the Part C Early Supports and Services program 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, Program Specialist III (vacant), and Program Assistant (part time – vacant), who are 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 under the Service Category of Special Services for Persons with Developmental or Physical Disabilities, with the goal of preventing or reducing inappropriate institutional care by providing community-based care, home-based care, or other forms of less intensive care. 

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: (1) 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; (2) a comprehensive Complex Care Network that incorporates interdisciplinary clinics and specialty consultation to providers serving CSHCN that is child specific or that addresses more general questions; and (3) Comprehensive Nutrition and Feeding/Swallowing Consultation Network, which offers community-based consultation and intervention services utilizing a home visiting method of service delivery..

BFCS also 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 SSBG to support the Partners in Health Training services and from the Child Development and Head Start Collaboration office for coordination of the Birth through 8 Early Childhood Care and Education Advisory Team. The second contract, also led by NHFV, is specific to supporting NH’s work on Title V NPM#12, Youth Health Care Transition. In addition to the five Health Care Coordinators employed by BFCS, a community contract, Health Care Coordination, provides five additional coordinators to ensure state-wide coverage for families with CSHCN.

BFCS braids funding to work on 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. BFCS is the lead agency for Watch Me Grow (WMG) activities within DHHS. As such, the Systems of Care Specialist facilitates the coordinating steering committee, which includes representatives from state agencies and public and private organizations, to foster a comprehensive developmental screening, referral, evaluation, diagnosis, treatment and services system. A new contract with Brookes Publishing is being developed to ensure all NH’s privacy and security conditions are met with the WMG partners’ use of the ASQ Online Management system.

[1] Retrieved from https://www.dhhs.nh.gov/about/mission.htm on 06/21/21.

[2] Retrieved from https://www.lifecoursetools.com/lifecourse-library/lifecourse-framework/ on 06/21/21.

[3] Retrieved from https://www.covid19.nh.gov/ on 06/28/21.

[4] Retrieved from https://www.covid19.nh.gov/dashboard/vaccination on 06/28/21.

[5] Retrieved from https://www.dhhs.nh.gov/dphs/bchs/mch/documents/nh-vip-plan-2020-2025.pdf on 07/03/21.

[6] Retrieved from https://www.dhhs.nh.gov/dphs/bchs/mch/prams/documents/pregnancy-intention-db.pdf on 07/03/21.