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). BFCS is made up of three units that integrate services to meet the needs of CSHCN and their families. These are Special Medical Services, 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. 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 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. 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 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 Governor appointed Commissioner who is a nurse with a long background in health facility management. 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 new DLTSS 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 is in his second year of a third two-year term with intention to run for re-election in November 2022. 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) and the Governor’s Executive Council, a body of five elected Councilors (currently four Republican and one Democrat) 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 Governor and Executive Council 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.

Currently, NH is near the end of the first year of a biennium budget. Programmatically, Title V staff will be drafting State Fiscal Year 24/25 budget proposals (07/1/23-06/30/25) during the spring and summer of 2022. Division Directors then move budgets to the Department level before they are sent to the Governor for consideration. The State Legislature (all seats are up for re-election in November 2022) will begin its involvement at the start of the session in January 2023. Title V requires a general state fund match of $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. This creates a level of fiscal insecurity during each budget session.

During the last year, the COVID‑19 pandemic was still very much a part of NH’s Title V staff’s professional and personal lives. Prioritization of time and funding was and continues to be given to the response. Some staff, particularly those with clinical backgrounds, were asked to help with the large variety (large scale events; fixed sites, etc.) of COVID‑19 vaccination efforts across the State, from participation in the DHHS Coordinated Response Team, working with the DPHS Bureau of Infectious Disease surveilling pregnant moms with COVID, 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 with CSHCN in need of personal protective equipment and gaining expertise in telehealth issues, among many other duties, Title V staff played, and continue to play, an integral role in the COVID‑19 pandemic response.

COVID statistics for NH are fairly similar to other New England states with the exception of its immunization percentage, which is lower. Like elsewhere, the number of those with severe disease, hospitalizations and deaths fortunately keeps decreasing.

[3]

[4]

The Governor opened State buildings to the public in May of 2021 and the rest of his emergency orders expired the following month. There are no current mask mandates anywhere in the State, with the exception of inside a direct contact health care facility. Although buildings are now open, nothing is as it was before the pandemic, with the majority of Title V staff continuing to work a hybrid schedule, alternating between teleworking and being in the office.

MCH has grown substantially in the past decade juxtaposed to also having retained a long term workforce. Forty-one percent of Title V’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). There is also an additional unfunded, part-time position ‘on the books’ for future planning efforts. Positions have also developed 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 Community Engagement Programs (formerly Early Childhood Systems).

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.

Within MCH, Title V funds two FTEs in full, three FTEs are cost allocated and 10 FTEs have leveraged support. 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. In MCH, the Administrator, Executive Secretary and MCH Program Specialist are cost allocated across all of MCH’s Federal grants and state general funds. Title V funds all of the Quality Improvement and MCH Clinical Services unit in full or in part which includes the Child-Adolescent Health Nurse Consultant (fully Title V funded), the Perinatal Coordinator, the Pediatric Mental Health Care/Access Program Coordinator, and the QI/QA and Clinical Services Program Manager. 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 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 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 and Newborn Screening Program Manager.

MCH utilizes part of its Title V funding for a PhD level public health epidemiologist from the University of New Hampshire (UNH), who has worked with Title V for over two decades, conducting analyses of state and national data sets related to maternal and child health. He, in conjunction with MCH’s Data Scientist/SSDI Project Director, 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. Recently, the longtime MCH Epidemiologist left his position to work as a full-time consultant, necessitating the year long search for another Epidemiologist within the context of the UNH contract. The new MCH Epidemiologist started in May of 2022, freshly off a three year period of post-doctoral work in maternal and child health epidemiology at the University of Tsukuba in Japan. This is an exciting period for NH’s MCH as the MCH Epidemiologist will be working a full FTE (as opposed to the 0.8 FTE worked by the former MCH Epidemiologist) as well as initiating what hopefully will be a long term career in the field.

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 completed and did its first annual data update of the “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 as well as its evaluation and also became part of the Title V needs assessment which led to NH choosing NPM #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, around infant safe sleep. The contracted Injury Prevention Center at Dartmouth Health and the Brain Injury Association then take MCH’s data analysis and utilize it to implement statewide evidence based programming and evaluation addressing unintentional injuries in adolescents. 

Another example of the core assessment function is the MCH Data Scientists/SSDI Project Director’s work with the PRAMS data. In the past year, she has released several data briefs including “Vaping / Smoking / Marijuana, 2016-2019.”[6] This brief reports that vaping has increased the number of persons giving birth who are exposed to nicotine; before pregnancy from 14% who smoked cigarettes only, to 22% who did either or both, smoking and vaping; and during pregnancy, from 8% who smoked cigarettes only to 10% who did either or both, smoking and vaping. It also reported that vaping in the two years before pregnancy was significantly associated with low birth weight. The conclusion was that dual use of substances is widespread, even during pregnancy, when dual use ranged from nearly 6% of marijuana users who also vaped, to nearly 12% of smokers who also vaped, to 37% of smokers who also used marijuana. All of this directly impacts Title V’s efforts on NPM#1, Percent of Women Who Smoke During Pregnancy.

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 months. 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 an abstraction process. It will be interesting to see where this data leads NH’s Title V.

The former and current MCH Epidemiologists lead the State in assessing data for the Alliance in Innovation in Maternal Health (AIM). Work on this, which includes many efforts on implementing AIM’s patient safety bundle, “Care for Pregnant and Postpartum People with Substance Use Disorder”[7] with colleagues at the Northern New England Perinatal Quality Improvement Network (NNEPQIN) at Dartmouth Health also addresses NPM#1. 

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/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 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 worked tirelessly this past year to write and release the Request for Proposals entitled “MCH in the Primary Care Setting” as well as closely review the 10 proposals received. Currently those 10 community health centers (CHCs) are and will be receiving Title V funds in their mission to provide accessible and affordable comprehensive primary care and perinatal services, with a focus on reproductive age women and children. 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. 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. Another 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 projects all address the NPMs in some way. The QI/QA and Clinical Services Program Manager, the Child/Adolescent Health Nurse Consultant and the Perinatal Coordinator, all nurses with “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 breastfeeding initiation and duration) and helping to design effective programs to both screen and address the social determinants of health, which are often barriers to care.

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 continued 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 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 participates in the Transition Community of Practice (CoP) and the Charting the Life Course CoP.

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 Analyst, Evaluation Specialist (formerly the Program Data Specialist - part time), Systems of Care Specialist, Clinical Program Manager, one Nurse Consultant (formerly a health care coordinator), two nurse health care coordinators, one Health Care Coordinator, one 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, a Program Specialist, and a Program Assistant (part time – 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 (vacant) 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 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 uses Title V funds to support training to potential providers, in addition to direct service to patients. Early in 2022, the contractor for Comprehensive Nutrition and Feeding/ Swallowing Consultation Network notified BFCS that the subcontract they held for F/S Consultation would end June 30, 2022. The community-based agency is in the process of reorganizing how these services will continue in the new fiscal year. In addition, BFCS was recently informed that the former F/S Program Coordinator will begin providing F/S services at a local hospital. This newly created position will increase NH’s capacity for specialty feeding and swallowing services as a result of Title V work to identify and address gaps in access.

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. In a recent contract amendment, two additional activities were added to the scope of services. The first is in collaboration with MCH for family engagement work with the B‑8 Council and the other is in collaboration with the Bureau of Child Development and Head Start to support Watch Me Grow developmental screening system activities (NPM#6). The second contract, also led by NHFV, is specific to supporting NH’s work on NPM#12, Youth Health Care Transition. In addition to the three Health Care Coordinators employed by BFCS, a community contract, Health Care Coordination, provides five additional coordinators to ensure statewide coverage.

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 addressing NPM#6.

[1] Retrieved from https://www.dhhs.nh.gov/about/mission.htm on 04/27/22.

[2] Retrieved from https://www.lifecoursetools.com/lifecourse-library/lifecourse-framework/ on 04/27/22.

[3] Retrieved from Welcome | NH COVID-19 Response on 05/09/2022.

[4] Retrieved from Vaccination | NH COVID-19 Response on 05/09/2022.

[5] Retrieved from https://www.dhhs.nh.gov/dphs/bchs/mch/documents/nh-vip-plan-2020-2025.pdf on 05/10/2022.

[6] Retrieved from prams-datasummary-2020.pdf (nh.gov) on 05/10/2022.

[7] Retrieved from Care for Pregnant and Postpartum People with Substance Use Disorder | AIM Program (Previously Council on Patient Safety) (safehealthcareforeverywoman.org) on 05/10/22.