Ongoing needs assessment activities and findings, including family engagement

 

Needs assessment is an ongoing activity, implemented in many different guises. It includes the typical review and compilation of data and information from various reports produced by stakeholder groups, such as the NH Council for Thriving Children, the 2020 databook from the NH Division of Children, Youth, and Families, or Vital Signs 2020 (a yearbook of economic and social indicators for New Hampshire), as well as national and state-specific data that can be found online such as CDC’s NHANES, YRBS or BRFSS survey query tools, SAMHSA’s Behavioral Health Barometer, or the National Survey of Children’s Health’s data portal (the Data Resource Center). The Federally Available Data (FAD) document and accompanying data tables provided by HRSA are also a rich source of information on performance and outcome measures, with the presentation of stratified data over many years, allowing for the discernment of trends in the State and comparisons with other states or the national averages or trends.

 

Weekly meetings were held by multiple stakeholder working groups, to ascertain and discuss the needs of the population especially in response to the COVID pandemic and resulting shutdowns or curtailment of normal services, hours of operation, or availability of appointments. The MCH-funded Community Health Centers’ annual family surveys continue to provide an important snapshot of real-time health needs and concerns of local families, both routine and COVID-related.

 

Within the NH DHHS Maternal and Child Health section, the Family Planning Program (FPP) collects family planning encounter data and annual customer satisfaction surveys to assess and record the performance of all sub-recipient agencies. The FPP Advisory Committee, composed of individuals matching the demographics of the clientele, including some actual clients, is involved with all assessments of performance and the addressing of barriers experienced by clients in accessing high quality family planning services.

 

In the Home Visiting (HV) program, a session during last year’s spring learning exchange explored ways to engage the family voice in CQI efforts with continued reflections on how to build capacity, to include a past or current program participant on a CQI team, or other concrete steps to tap into the less formal and more organic input that families provide, which can positively shape the ways that services are carried out. The Healthy Families America (HFA) model used by the HV program also encourages the presence of current of past participants on all agency advisory boards.

 

The birth conditions program (BCP) engages a program advisory committee, which includes a parent of children with birth defects. The Early Hearing Detection and Intervention (EHDI) program and the Newborn Screening (bloodspot) program hold biannual QI meetings, which may include the participation of families; the EHDI program meetings include participation of parents associated with NH Hands and Voices, all of whom have a child who is deaf or hard of hearing, and/or are deaf or hard of hearing themselves.

 

The NH Mental Health Care Access in Pediatrics (NH MCAP) program utilizes data collection, program evaluation, provider satisfaction surveys, and its advisory board to solicit feedback regarding programmatic needs and effectiveness. The NH Pediatric Improvement Partnership (NHPIP) Steering Committee serves as the advisory committee for NH MCAP;NHPIP is a state-level multi-disciplinary collaborative of private and public partners dedicated to improving health care quality for all NH children through the use of systems and measurement-based quality improvement processes. The roster includes a diverse array of stakeholders, including commercial and Medicaid insurers, American Academy of Pediatrics (AAP) NH chapter, Children’s Hospital at Dartmouth, NH Department of Education, UNH Institute of Health Policy and Practice, UNH School of Nursing, and NH Family Voices.

 

The high school based Teen Driver Safety peer groups, facilitated by the Injury Prevention Center (IPC), engage other teens to be leaders in cultural change regarding motor vehicle safety at their schools and in their communities.

 

The Community Collaborations project utilizes population health mapping to graphically identify areas of need utilizing various NH datasets, some of which are not typically used by MCH programs, including: juvenile justice data, child protection data, police department data, as well as points of interest from open street maps, such as bars, supermarkets, libraries, parks, places of worship, etc.

 

Stakeholder interviews conducted by Watch Me Grow identified barriers to completing developmental screenings that included the impact of State emergency orders on classrooms and home visiting, as well as prioritization of families experiencing urgent needs. NH Family Voices invited families to share their issues during the COVID Public Health Emergency using a dedicated email address posted on the NHFV.org website. Additional information from families gathered through social media sites managed by NHFV was shared with BFCS during bi-weekly virtual meetings.

 

The NH Rural Health Primary Care needs assessment (report completed in March 2021) reported numerous findings pertinent for Title V/Maternal and Child Health, viewed through a geographic lens of rural/urban differences.

 

As a whole, New Hampshire has the lowest rate of poverty (<200%) in the country at 20.1%. However, this figure belies the significant income disparities that exist between rural and non-rural regions of the State. The low income population is about 40% larger in rural regions than non-rural regions (25% and 18%, respectively). Limited English Proficiency (LEP) is found to represent only 1% of the overall population; this has not changed in the last four years.

 

Just over 14% of NH residents are enrolled in Medicaid. The Affordable Care Act and New Hampshire’s expansion of Medicaid in 2013-2014 brought a 42% increase in Medicaid/Children’s Health Insurance Program enrollment from 2013-2018.[i] This reduced uninsurance from 9.3% in 2014, to 7.7% in 2018—a 17.2% reduction. However, the rural rate of uninsurance is higher at 9.9% compared to 6.9% in non-rural areas.

 

Rural hospitals make up 17 of the State’s 26 acute care hospitals. Rural hospitals provide essential emergency department services, inpatient care, long-term care, and care coordination services to residents who otherwise would not have access to these. Populations served in rural hospitals tend to be older, poorer, are more likely to have chronic diseases and depend on public programs for healthcare coverage. Thirteen of the 26 acute care hospitals are Critical Access Hospitals (CAH).

 

In the Critical Access Hospitals (CAHs), low volume of births and staffing challenges for labor and delivery units raise concerns about financial feasibility of continuing these community services as well as questions about the quality of care that can be provided. Between 2003 and 2017, eight CAHs closed their labor and delivery units citing both of these difficulties. In 2017 NH DPHS started to examine the maternity care deserts that were developing. Data was examined to try determine why particular hospitals were more vulnerable to closure when some were mid-volume in the year that they closed their unit. Looking at the payer mix, it was found that hospitals where higher volumes of births were covered by Medicaid (typically around 60% or more) were more likely to have closed their units. RHPC’s Rural Health Manager and DPHS Maternal and Child Health Section have begun meeting with representatives from the Northern New England Perinatal Quality Improvement Network (NNEPQIN) and NH Medicaid to ensure these essential community services remain available.

 

Noted changes in health status and needs

 

The needs of the MCH population in New Hampshire, as everywhere, have been impacted by the COVID pandemic and the measures taken for its mitigation or containment. Service sites were closed or operating with reduced hours, at reduced capacity. Telework was improvised and televisits were instituted with no prior opportunity to coach users on how it all worked. Face-to-face visits became the exception, often used only in situations of high-need or urgency, thus pre-empting much routine, preventive care.

 

COVID aside, MCH population needs have not changed greatly, as reflected in the list of priority needs retained for this project cycle from the previous project cycle. There remains an emphasis on access to services, which is addressed by the selection of NPM 6 (access to developmental screening), NPM 10 (preventive medical visit for adolescents), NPM 12 (adolescents’ transition to adult health care), ESM 14.1.1 (the Plan of Safe Care for birthing women), SPM 1 (enabling services to reduce SDoH barriers), SPM 2 (access to respite services for families of CYSHCN), and SPM 3 (access to pediatric mental health teleconsults). The challenge remains in finding new and better ways to reduce barriers and thus improve accessibility.

 

In primary care, COVID-related measures resulted in reduced visits of all kinds, particularly pediatric well visits including immunizations. A positive change was the increase in telehealth availability and utilization, including the ability for service providers to be paid for telehealth services, and an increase in the types of providers allowing telehealth, as well as changes (liberalization) in payment policies overall.

 

The needs of Family Planning clientele were affected in 2020 with the closure of sub-recipient clinics due to the COVID‑19 pandemic. The agencies moved to telehealth visits whenever possible to ensure continued services; limited hours of operation were also maintained for those clients who needed to see a provider in‑person. Sexually transmitted infections (STIs) are still on the rise, and efforts have been made to address testing needs of clients, even with limited clinic hours of operation. An increase in abnormal pap test screenings has been noted; clinic staff have expressed the belief that this is due to the reduced clinic hours during the pandemic, which resulted in the screening of relatively fewer low-risk and more high-risk clients.

 

The most notable change noted by Home Visiting was the impact on families of a lack of access to technology, which affected negatively the access to schooling for older children, the ability to engage virtually in home visiting services, mental health services, and virtual health appointments.

 

Children’s mental health has been drastically affected by the COVID‑19 pandemic. Demand for children’s mental health services has been far greater than the capacity of mental health providers throughout the State, thus increasing the importance of the NH MCAP Program.

 

Noted changes in program capacity or systems of care

 

The hiring freeze imposed by the Governor due to the pandemic caused a shift in duties and a taking on of additional tasks by nearly all of the MCH and BFCS staff, many of whom are now showing signs of fatigue; filling vacant positions will be a priority in the coming year.

 

BFCS vacancies prevented quality improvement work as staff focused on priority needs. Inability to provide in-person services had a negative impact on families’ relationships with coordinators and their ability to maintain home nursing and respite. 

 

The Family Planning program experienced a decrease in the number of clients served this year due to COVID‑19. The pandemic also led to staff shortages at sub-recipient clinics, resulting in some administrative staff needing to take on both administrative and clinical work. Site visit audits in 2020 by program staff were cancelled due to the pandemic, as program staff did not have the capacity or experience to do virtual site visit reviews. The program has increased its email communications to meet this challenge and now has a family planning quarterly newsletter for all sub-recipient agencies’ staff.

 

There have been minor capacity changes in the Birth Conditions program related to the COVID pandemic. The program currently employs one public health nurse coordinator position at 0.70 FTE. During the COVID pandemic, this position dedicated three hours per week to support surveillance activities of pregnancies impacted by COVID, in cooperation with the Bureau of Infections Disease Control. Record abstraction and data collection continued during this time though furloughs at the hospital level hindered their ability to fulfill BCP requests for access to records, resulting in a few months’ delay for some facilities. The Newborn Screening program manager and the MCH epidemiologist continue to support the Birth Conditions Coordinator position, in grant writing and management, as well as data analysis and reporting.

 

The MIECHV program which struggled to meet 85% capacity for years is now at over 100% capacity.

 

Due to the COVID pandemic, hearing diagnostic centers shut down for a period of time, which affected the timeliness of diagnostic appointments for some infants. Also, families who were receiving early intervention services had to switch to a telehealth model, which is less than ideal.

 

NH MCAP Program capacity has remained unchanged; as the program is designed to be conducted virtually, it did not skip a beat when most services pivoted to virtual platforms as a result of the COVID pandemic.

 

Partnerships and collaborations with other entities that serve the MCH population

 

New Hampshire has an extensive history and experience with partnerships and collaborations, in part because NH is a small state with limited financial, programmatic and human resources, which creates a need to get buy-in and assistance from external groups and agencies throughout the State. Also, in a small state there is considerable overlap of membership on various stakeholder groups, which promotes collaboration and networking. A sample of partnership groups that include participants from NH Title V staff include the following:

 

• UNH Health & Wellness – increasing awareness of available family planning services within the State for youth
• Council for Youth with Chronic Conditions – collaboration on the implementation and analysis of a qualitative needs assessment of CHSCN in NH
• NH DHHS Early Childhood Integration Team (ECIT) – a component of the Governor’s Council on Thriving Children seeking to connect and increase collaboration among DHHS programs serving families with children up to age eight
• NH DPHS Equity Council – supported the production of an equity toolkit and evaluated content of social media and DPHS newsletters that highlight equity
• The New Hampshire COVID Equity Task Force – a collective of over 50 individuals and organizations across NH representing multiple sectors and communities; formed to address issues of equity arising from the COVID‑19 pandemic and response, and to provide guidance and advocacy on behalf of communities of concern in NH
• Family Support NH – collaboration for training of health care and family support coordinators in the Standards of Quality for Family Support
• NH Pre-School Development Grant – data collection and funding of the Centralized Access Point for Watch Me Grow
• NH Division of Economic and Housing Supports/Bureau of Child Development and Head Start Collaboration – braided funding with BFCS to support Watch Me Grow Coordination and Facilitation
• NH Perinatal Substance Exposure Taskforce – works to identify, clarify, and inform the Governor’s Commission on issues related to perinatal substance exposure, including ways to lessen barriers faced by pregnant women when seeking quality healthcare; aligning state policy and activities with best medical practices for pregnant and newly parenting women and their children; and increasing public awareness about the dangers of exposure to prescription and illicit drugs, alcohol and other substances during pregnancy
• NH Alliance for Innovation on Maternal Health (AIM) and Erase Maternal Mortality – work to reduce preventable maternal mortality and severe morbidity, and promote respectful care for all birthing persons and eliminate disparities in perinatal outcomes
• NH Department of Education and The Bureau for Children’s Behavioral Health’s System of Care Advisory Council – to promote, align, and continuously improve System of Care Principles and values into every relevant initiative, support system, service of child welfare, juvenile justice, behavioral health, education, primary care, first responders, public health, and community providers at the family, organization, community, regional, and state levels
• NH Pediatric Improvement Partnership (PIP) Steering Committee – to promote awareness of and interest in pediatric care quality measurement, projects, and resources
• Injury Prevention Center (IPC) - to provide meeting facilitation and prevention activities related to teen driver safety, traumatic brain injury prevention, child maltreatment prevention, suicide prevention, older adult fall prevention, and other injury prevention activities
• Suicide Prevention Council – a gathering of stakeholders to discuss activities related to suicide prevention; there are multiple subcommittees
• Medicaid Part C (early intervention) collaborates with EHDI on sharing of data on infants’ enrollment into early intervention services

 

The SUID (Sudden Unintended Infant Death) program collaborated with the Division for Children, Youth, and Families (DCYF), the Bureau of Program Quality (BPQ) and the Division of Quality Assurance and Improvement (DQAI) on a LEAN project. The primary function of the project was to evaluate and review the workflow utilized by the three divisions as it relates to child fatality reviews. Process mapping, fishbone (cause and effect diagram) and PICK charts (a Lean Six Sigma tool for organizing process improvement ideas and categorizing them) were utilized to determine areas for collaboration, improvement for case reviews, and streamlining internal processes.

 

The Community Collaborations project establishes an integrated continuum of family support with community-based services such as mental health, substance misuse treatment, economic supports, home visiting, and educational programs in order to prevent child abuse and neglect, adverse childhood experiences and ultimately reduce the number of children entering foster care.

 

Efforts to operationalize needs assessment

 

The Family Planning program is moving to the new FPAR 2.0 system (go-live date is January 1, 2022) through OPA; this system will collect encounter level data and provide the program with more information, especially on behaviors, which will help the program make any necessary shifts to meet the needs of its clients. The family planning sub-recipient agencies already collect information on behaviors (e.g. mental health and substance use) but this has been kept in the medical record and not shared.

 

NH MCAP conducts yearly needs assessments of each Project ECHO cohort as well as pre and post cohort surveys on knowledge and confidence in treating children with mental health concerns, to measure impacts as well as needs to be addressed with future cohorts.

 

In the Home Visiting, EHDI, and Birth Conditions programs, the ongoing representation of participant families promotes their voices being heard on a regular basis and eliminates the need to ask for their input as a separate ‘needs assessment’ activity.

 

While BFCS was unable to conduct the 2020 bi-annual needs assessment due to COVID-related staffing issues, a plan is underway to begin planning for the 2022 survey in the fall of 2021. The recent hiring of a Data Analyst will support a more robust survey than has been done in the past. In addition, the Council for Youth with Chronic Conditions (CYCC) is conducting a needs assessment in FY2022 which will help inform planning and point to areas that need further exploration.

 

Changes in organization structure and leadership

 

Due to the extensive focus on CQI at the awardee level, the Home Visiting programs has implemented a shift to support greater staffing allocation for CQI, with the development of a full time Home Visiting CQI Specialist.

 

The Infant Surveillance program filled a new Program Specialist position and the Newborn Screening (bloodspot) program has hired a full-time Program Coordinator and a part-time Program Specialist.

 

The SUID program hired a full-time program coordinator.

 

The Pregnancy Risk Assessment Monitoring System (PRAMS) project’s Coordinator position has been vacant since August 2020; recruitment and interviews are ongoing. The lengthy duration of the vacancy is in part due to the hiring freeze that was implemented during the early days of the COVID response.

 

In March 2021, the NH MCAP Project Director Anne Marie Mercuri resigned from her position with MCH. Effective 3/12/21, the NH MCAP Program Coordinator Erica Tenney took on the Project Director role.

 

The CSHCN Director completed her first full year as such in February 2021. 

 

Erika Downie was promoted into the position of Systems of Care Coordinator and State Coordinator of Watch Me Grow at the end of June 2020.

 

A new Data Analyst position was posted for recruitment once the hiring freeze was lifted and Subha Kandasamy joined the BFCS team April 2021.

 

Kathleen Gray, the former Part C Coordinator accepted the promotion to Family Support Administrator as of May 2021, filling a 19‑month vacancy. In this role she will oversee the Family Centered Early Supports and Services Part C Coordinator and work closely with the Bureau for Developmental Services on family support services provided by the Area Agencies. 

 

The Clinical Program Manager for the BFCS has been on an extended medical leave since October 2020. Other staff have been prioritizing and sharing her duties related to management of the Health Care Coordination and Complex Care Programs and as liaison to the Child Development Clinic, Nutrition and Feeding & Swallowing Programs.

 

The DLTSS Director is retiring June 30, 2021; an interim Director was recently named. The new Associate Commissioner will fill the vacancy overseeing DLTSS beginning in July 2021.

 

Emerging issues and capacity and resources to address them

 

In view of the national increase in STIs, and particularly syphilis, the Family Planning program is concentrating on the importance of testing for all STIs and reducing barriers to STI testing across the network. Program staff continue to partner with the NH DHHS STD program to coordinate prevention efforts.

 

Worldwide as well as in NH, unintended pregnancies are expected to be higher than normal due to the strict COVID‑19 lockdown measures that were taken during 2020. The lockdown inhibited the ability of individuals to get contraceptive supplies. The Family Planning program has shared information on social media about mail-order contraception, and about the program’s family planning clinics that are providing telehealth and/or in-person appointments for contraceptive services.

 

The COVID‑19 pandemic highlighted societal inequities through higher rates of infections, hospitalizations, and deaths in BIPOC (Black, Indigenous, People of Color) communities. When the schools turned to remote learning, communities with higher racial diversity had less access to in-person learning or the technology necessary for remote learning, possibly perpetuating or increasing already existing divides in education. COVID‑19 has also impacted mental health, substance use, IPV, and has increased isolation. A significant trend seen specifically with home visiting data, which will likely have long term impacts, was children missing their well child visits when their providers shut down last spring.

 

The EHDI Program established a level 2 diagnostic appointment for infants who had a unilateral ‘did not pass’ on the final (second) hearing screening. This is not a best practice, but with the closing of diagnostic centers during the pandemic, wait times exceeded the national recommendation of diagnosis by three months of age. The program piloted this project with a new diagnostic facility. With good success, the program rolled out the level 2 appointments to other diagnostic centers.

 

A lack of access to mental health care for children remains a crucial emerging health issue, which the NH MCAP program (through PMHCA funding from HRSA) is designed to address by training providers to treat children with mental health concerns within the primary care setting. Data from the first Project ECHO cohort will be available in this reporting year.

 

For the Injury Prevention Program, in-person events such as the bike rally were cancelled due to the COVID‑19 pandemic. When possible, injury prevention-related conferences were offered in a virtual format, but conferences that had been scheduled early in the pandemic period were cancelled. Monthly and quarterly partner meetings were quickly switched to virtual formats with attendance actually improving in some groups.

 

Watch Me Grow is working to implement a Centralized Access Point and the ASQ Online Management System to enable families to complete screenings online from home. This system will not only meet the need for virtual resources identified during COVID, but will increase access to screenings state wide by providing another “doorway” for families to connect to services.

 

During the FY 2022 contracting process, it became clear that the cost of continuing with “business as usual” through the four community-based contracts for Health Care Coordination, Child Development, Complex Care, and Nutrition, Feeding & Swallowing (NFS) would exceed the available funds. BFCS was able to negotiate the terms of the NFS contract to focus on fewer children with more significant needs, for two years, and is requesting that the Governor and Executive Council approve an extension for the three remaining contracts to provide time to consider ways to redesign existing services into a more cost‑effective model based on the National Care Coordination Standards for CSHCN, October 2020, and that incorporate components of the Partners in Health family support program funded by the Social Services Block Grant (SSBG). Stakeholder engagement will be part of the process as will further examination of the Title V Needs Assessment results from 2020 and analysis of the CYCC needs assessment and the Bureau’s own survey in 2022. 

 

 

 

 

 

[i] Health Insurance & Health Reform Authority. “New Hampshire and the ACA’s Medicaid Expansion.” October 1, 2020. Accessed on March 23, 2021 at https://www.healthinsurance.org/new-hampshire-medicaid/.