Insight

Access to Timely Mental Health Care in New Hampshire is at a Crisis Point

--By Ken Norton, Executive Director, NAMI-NH

    One in five people have a mental illness and most can be treated effectively by their primary care provider and without the need for hospitalization.  Most people who receive treatment function well in their families and at their jobs. However, like other serious medical conditions, mental illness in its most severe form can be difficult to treat and potentially life threatening.

    According to a recent poll*,  an overwhelming public majority -- 92% -- believe that mental health services are fundamental for overall health.  Yet despite this, and a strong evidence base of effective treatment and programs, access to mental health care is a significant problem in New Hampshire and nationally. 

    Mental health services in New Hampshire have deteriorated to a crisis point where our community mental health centers have substantial waiting lists for outpatient appointments and where our most vulnerable adults and children who need inpatient admission are being boarded in Emergency Departments for days without proper treatment.  On Monday Feb 4, 2013 there were 18 children and 26 adults waiting in emergency departments for an inpatient psychiatric bed.  This practice is wrong medically, legally, ethically, morally and economically. 

    It is medically wrong because people don’t receive timely treatment to reduce their suffering and promote speedy recovery.  It is also medically wrong because it delays treatment for people with other medical conditions who need emergency treatment.  For people being involuntarily admitted, it is legally wrong because NH law establishes due process and other legal protections which are currently being ignored.  It is ethically wrong because it places medical providers in the untenable position of failing to uphold the standard of care to “do no harm.”   It is morally wrong because we don’t categorically deny treatment to patients with heart disease, diabetes or any other medical condition.  And it is economically wrong because emergency departments are one of the most costly hospital services.  People could receive more effective and less costly
treatment in other settings.

    New Hampshire once had a proud tradition of caring for people with mental illness and during the 1990’s our state was rated number one in the US for our mental health service delivery system.  Resolution of the current crisis will mean rebuilding comprehensive community supports for people with mental illness.  We also must do a better job of providing treatment for substance use disorders which often co-occur with mental illness.   

    As a state and as a society we need to recognize and treat mental illness for what research has demonstrated it is – a medical condition.  We need to end discriminatory insurance and other practices that limit access to necessary treatment.   We know the best outcomes occur when health care providers promote early detection and treatment and utilize an integrated model of care that addresses mental and physical wellness together.  Lastly, if we are to be successful in getting timely and effective treatment for people with mental illness we need to examine and change our attitudes and how media portray mental illness.  We have overcome the shame, fear and stigma that surrounded other medical conditions like cancer and HIV/AIDS, we can and we must do the same with mental illness. 

 *2006 U.S. poll by Parade and Research America

Building a Health Care Workforce That Reflects Our Increasing Diversity

                                           

--by Kelly Laflamme, EH Program Director

    The U.S. Census recently released population projections for our nation and predicted that the U.S. will become a “nation of plurality.” By the end of this decade, no single racial or ethnic group will constitute a majority of children under 18. This matches what we learned earlier this year when, for the first time in U.S. history, the Census reported there were more births to minorities than to whites in the U.S.

    As goes the nation, so goes New .Hampshire. According a report from UNH’s Carsey Institute, in the last decade racial and ethnic minorities produced 50% of the state’s population gain. While racial and ethnic minorities comprised nearly 8% of the state’s population in 2010, among children, minorities were over 12% of the population. This is why the Endowment for Health and our partners in the New Hampshire Health and Equity Partnership (NH HEP) are engaged in research, dialogue, training and planning with health-related and health care organizations to ensure our systems are culturally appropriate and that no one experiences unfair challenges to health based on their language, race or ethnicity.

    We’ve long been invested in building the state’s ability to bridge language differences. But ensuring everyone has an equal opportunity to be healthy will take more than an interpreter. We are leading conversations about the importance of creating a health care workforce that reflects the diversity of our residents. Through funding from the Robert Wood Johnson Foundation, we’ve created the NH Nursing Diversity Pipeline. The Office of Minority Health and Refugee Affairs partnered with us to train ethnic community health workers and design health education modules for immigrants and refugees, who are unfamiliar with our health care system. And a diverse collaborative is now benefiting from nearly $100,000 in technical assistance from Harvard Pilgrim Health Care Foundation’s Culture InSight program to help institutions of higher learning, health care providers and decision makers to be better prepared to recruit, train and employ a more diverse health care workforce in our future.

    There is much more work ahead of us, but the good news is that we started this work long before the Census released its report and NH is increasingly ready to embrace the change ahead.

Taking the Long View: The Connection Between Health and The Economy

--By Steve Rowe, Endowment for Health President

 

It was a pleasure presenting at the Nashua Chamber of Commerce last week alongside Dartmouth-Hitchcock CEO Dr. Jim Weinstein and NH Department of Health and Human Services Commissioner Nick Toumpas.

Dr. Weinstein emphasized that our current health care system is weighted toward costly medical procedures, many of which are unnecessary.  Commissioner Toumpas highlighted the rising costs of health care services under the state’s Medicaid program.  We all agreed that our current health care system places too much emphasis on treating health problems and too little on preventing them.

My remarks to the business leaders in attendance went beyond the obvious need to improve our health care system.  I emphasized the need to take the long view when thinking of health and the need to focus more attention on the social and economic determinants of health - the conditions in which people are born, grow, live and work.  I also emphasized that the future health of New Hampshire people will determine, to a large extent, the health of our state’s economy.

We need only look at New Hampshire’s changing demographics to realize that it’s in everyone’s interest to advance the health of Granite Staters in the broadest sense.

First, we are aging in place.  New Hampshire’s population is among the oldest in the nation.  This presents multiple challenges for everything from clinical health care and long-term care to transportation.

Second, New Hampshire has one of the lowest birth rates in the country.  Indeed, only about 13,500 babies will be born in the state this year – about 37 a day.  More than 4,000 of these new babies will be born into low-income families.  Moreover, current demographic patterns indicate that the number of babies born into low-income families will increase in the future. 

Third, in-migration of educated and skilled workers has declined.  In the past, the state has seen a steady influx of highly educated and skilled young and middle-aged adults.  This trend has stopped.

These changing demographic patterns reveal the need to focus more attention and resources upstream – particularly to those families and children most at risk.  Trajectories for lifelong health outcomes and learning are set early.  That’s why early childhood investments have such high economic returns. 

We can no longer sit back and expect highly educated and skilled workers in fields such as science, technology, engineering and math to show up at our company doors looking for employment.   Here, in the aging Granite State, we will have to grow our own healthy, smart and innovative workers.  And, with our low birth rate, we won’t have many to work with.  That’s why every child matters.  Not just some or most, but every single one.   

The quality of New Hampshire’s economy will depend on the quality of its workforce.  It’s as simple as that. That’s why one of the most important actions that business leaders can take is to encourage public policymakers to focus much more attention and resources upstream.  Short term planning and budgeting won’t work.  Neither will isolated investments.  We must start connecting the “cause and effect dots” over a longer time period.  The future health of the New Hampshire economy depends on it.

 

Faster Alone, Farther Together

--Steve Rowe, Endowment for Health President

The Endowment for Health program directors and I are fresh from the Collective Impact conference in Waterville Valley earlier this month.  This was an invigorating four days participating with organizations from all over New England.  We gathered to talk about how we can accomplish more together.  Quite simply, collective impact is an approach that helps diverse organizations come together to solve complex social problems.

The saying, “faster alone, farther together,” really resonates with me.  Taking the time to build a common vision and to mobilize around important issues is essential.  Certainly, the Endowment for Health cannot do its work without a wide array of community partners.  So the notion of working even more closely to pursue mutual goals in a coordinated, structured and collaborative approach has me energized and optimistic about our future together in New Hampshire.

Since my arrival at the Endowment a few months ago, my focus has really been to meet with people – the staff, the board, our community partners and others throughout the State of New Hampshire to LISTEN and LEARN -- to get to know about New Hampshire and its people and the changing needs in these difficult economic times.

All of this information will feed into the Endowment’s strategic planning process, now underway, as we create a roadmap for the future based on how New Hampshire is changing and evolving.  We expect to share this new roadmap with all of you early this coming spring.

I am excited to continue exploring how our new direction will dovetail with yours.  It’s about working better with our existing partners and establishing ties with new partners as well – including the public and nonprofit sectors, business, government and foundations.  Though our missions may vary, oftentimes we share common purpose around large social issues.  We have an opportunity to find that “sweet spot” where our work collectively moves us forward and makes life better for our fellow Granite Staters.

I’m impressed with the fact that most everyone I’ve met since arriving in New Hampshire truly appreciates the importance of good health.  It’s much more than just keeping people from getting sick.  Good health is essential to the realization of human potential and it’s critical for our individual and collective well-being.  Good health is also absolutely necessary to sustain a high quality of life and strong economy in New Hampshire.

While it’s true there are a great many challenges facing the health of New Hampshire's people, there are just as many opportunities.   Our job is to work together to leverage our collective impact to take advantage of those opportunities.  I know we’ll do just that.

A New Hampshire High School Finds a Better Way to Reach Kids With Emotional and Behavioral Challenges

 --by JoAnne Malloy, Ph.D. and Dan Habib

 In 2006, Somersworth High School had one of the highest dropout rates in the state, and discipline issues were rampant. The school was under intense pressure to improve academic outcomes and improve the school culture and climate. At the same time, the NH Department of Education started up a grant called APEX, providing training and support for high schools to implement an evidence-based framework called Positive Behavioral Interventions and Support (PBIS).

    Positive Behavioral Interventions and Supports is not a program; instead, it provides a structure for organizing of the school environment that emphasizes positive interactions between students and teachers, focuses on teaching pro-social behaviors, ensures consistency of discipline, and helps the school staff to clearly identify students who are struggling with behavior or emotional challenges.

    Over the next 3 years, Somersworth High School worked with our staff at the Institute on Disability and formed a leadership team that developed a clear and concise outline of the behaviors that were expected of students, and made it clear how discipline problems were to be addressed. The school also developed a group of specialists who worked on behavior plans for students who were struggling.

    For those students who were failing multiple classes, constantly truant, or had other major problems that put them at risk of dropping out of school, Somersworth implemented RENEW, a student-led planning model that has helped hundreds of young people with emotional and behavioral challenges. The results were dramatic: by 2010, Somersworth reduced its dropout rate by 75%, and behavior problems were reduced by 65%.

    

Kelsey Carroll could have been the poster child for Somersworth High School’s challenges. Diagnosed with ADHD and carrying the emotional scars of homelessness and substance abuse, as well as the actual scars of repeated self-mutilation, Kelsey was volatile, disruptive and, by her own admission, “not a nice person” to be around. As a freshman, she didn’t earn a single academic credit, but she did get suspended for dealing drugs. The new documentary film 'Who Cares About Kelsey?' is the story of Kelsey's participation in RENEW and her transformation from a defiant and disruptive “problem student” to a motivated and self-confident young woman.

    Along the way, critical figures in her personal and educational life shape her coming of age and play important roles in an education revolution that's about empowering – not overpowering – youth with emotional and behavioral disabilities. The film project includes a 75-minute feature-length film plus nine mini- films documenting the lives of students with emotional/behavioral challenges. The project also includes extensive educational materials and a national outreach/engagement campaign.

    The Who Cares About Kelsey? Project vividly captures innovative educational approaches that help these students to succeed—while improving the overall school culture and climate.

    Supported by a Theme Implementation Grant from the Endowment for Health, the film premiered in screenings and discussions at schools, theatres and community centers across New Hampshire in the spring of 2012. More events are planned for the fall. The Educational DVD will be freely distributed to hundreds of schools, non-profits and family groups across NH as part of the grant. For more information on RENEW or Who Cares About Kelsey?, go to www.iod.unh.edu/Projects/renew/ or www.whocaresaboutkelsey.com.

JoAnne Malloy, Ph.D., is Project Director and Clinical Assistant Professor, Institute on Disability at the University of New Hampshire

Dan Habib is Filmmaker in Residence at the Institute on Disability at the University of New Hampshire

The Supreme Court Ruling is Good News for New Hampshire

--by Mary Vallier-Kaplan, Interim President, Endowment for Health

    Solid solutions are on the way for millions of Americans who are currently uninsured – 134,000 of them right here in New Hampshire.  And for those of us already fortunate enough to have insurance, we can look forward to even higher-quality, more affordable care in the years to come.

    The Supreme Court has upheld the Affordable Care Act as constitutional.  At least from a legal standpoint, if not from a political one, the ruling clears the way for full implementation of the law.  Now it’s time to turn the page and put the debate to rest. 

    This should offer considerable peace of mind and security for families and small businesses who struggle to access and afford health care in our state.  They can take some comfort in knowing that the law designed to protect them has been validated.  With it, a higher level of economic security can be expected:  The days of going bankrupt to pay for medical care are seriously numbered.

    And what of all this talk of the individual mandate as being a tax?  That only applies to those who choose not to buy health insurance. 

    For the 85% of Americans already insured, nothing will change – they won’t be affected at all.  For those who do not yet have insurance, a health insurance exchange will offer affordable, reliable health insurance options.

    But let’s not lose sight of this important truth:  Most Americans want to buy health insurance, but many have had trouble accessing it, and when they do, often cannot afford skyrocketing premiums and deductibles.

    Now we have clarity and a clear path forward to change all that.  New Hampshire health-care providers already have been planning to implement the Affordable Care Act, and patients have been anticipating it.

    Popular provisions of the Act will remain unchanged, such as extended coverage for young adults up to age 26, so they can remain on their parents’ plan, as well as consumer protections, expanded preventive care services, and more affordable drug coverage.

    We need to get on with it.  We have work to do.

    We now must prepare for additional expanded coverage and the establishment of a federally facilitated health insurance exchange in New Hampshire.  The exchange will help to lower the cost of health insurance in our state – the most expensive in the country for a family plan (current average annual cost of $15,204).

    A health insurance exchange is like a virtual marketplace.  It will provide individuals and small businesses with easy-to-understand, apples-to-apples comparisons of health insurance plans.

    Certainly, the Court’s ruling on the Medicaid expansion, designed to offer coverage to our most vulnerable citizens, is the biggest question mark at this point.  We most assuredly will hear heated policy debates in every state, including New Hampshire.   The Court ruled that the federal government cannot withdraw current Medicaid funding if the state elects not to implement the law’s new Medicaid program expansion, now deemed optional for states.

    We know that the “devil is in the details” to implement far-reaching health reforms.  The Supreme Court ruling is certainly a major milestone in that process and ensures that the basic roadmap doesn’t change. There is more to do to ensure that our most vulnerable populations benefit from the law as the ACA intended.  There will continue to be some curves in the road.  But we’ve started the engine, our hands are firmly on the wheel and we know our destination.  The Endowment for Health will continue to support everyone in New Hampshire, including providers, businesses and government, to successfully implement this important change on behalf of all Granite Staters.

 

NH Health & Equity Partnership Applauds Affordable Care Act Initiatives

--By Peter Janelle, Chair, Health & Equity Partnership

The NH Health & Equity Partnership recently celebrated the two-year anniversary of the Affordable Care Act and all that it has done – and will do – to create healthier communities here in New Hampshire.

Understanding and fighting unnecessary and avoidable differences in health between social groups is paramount to creating healthier communities, and it is a singular focus of the Affordable Care Act. On March 23, the day of the second anniversary of the law, new requirements now in place for any ongoing or new Federal health programs to collect and report racial, ethnic, gender, language and disability status data.

By collecting this information, health leaders will be better able to understand and take measures to reduce persistent health disparities, while also reducing the health burden on our society. Not surprisingly, experts have come to realize that by addressing the health concerns of the most vulnerable populations, health improves for all populations.

In New Hampshire, many health care organizations have already begun collecting this data and have quickly realized its benefits. The Manchester Community Health Center is one of those organizations, and collecting the data helped officials there to realize that Spanish-speaking patients were receiving flu shots at a lower rate than their other patients.

"We clearly needed to improve our communication with our Spanish-speaking patients about flu shots," said Kris McCracken, director of operations, "and toward that end, we worked with one of our Spanish-speaking doctors to create an out-going reminder call in Spanish. This one small change increased phone calls from patients requesting the shots, thereby improving immunization rates."

Collecting and reviewing health data helped them to recognize – and then address – improvements that could be made. Doing so actually boosted the health of their patients, and this is but one facility; imagine health care organizations all across the state and country working in a similar fashion to improve patient health.

"The more ambitious and potentially transformative provisions of the health care reform law seek to better align public health and medicine by bringing prevention and population-based strategies into clinical care," said Dr. William Kassler, Chief Medical Officer for the New England Region of CMS and immediate past president of the New Hampshire Medical Society. "Capturing demographic data on our patients allows us to assess how our patients are diagnosed and treated. Are health outcomes better for one ethnic group or language group compared to another? With good data there are many things that we can do as physicians to better care for our patients and for the betterment of public health."

The Affordable Care Act is moving our nation and our state towards better health in other ways too. Consider that the Affordable Care Act already has increased funding to Community Health Centers, which is extremely important as those centers provide care to underserved individuals and communities. Medicaid income eligibility will soon be expanded to cover more children and adults, and the law already offers subsidies in the form of tax credits to increase affordability of coverage for small businesses.

Furthermore, consumer protections are greatly increased under the health reform law, so that by the year 2014, no individual with a pre-existing condition will be denied coverage or charged a higher premium, simply because they have a pre-existing condition.

All the significant ways in which the Affordable Care Act takes action to reduce health disparities is important to The NH Health & Equity Partnership, a public-private coalition of individuals and organizations whose vision is for everyone in New Hampshire to have a fair opportunity to live a long, healthy life.

The many benefits already implemented along with this new health reform milestone – the collecting and reporting of data related to racial, ethnic, gender, language and disability status – will go a long way to ensuring that every New Hampshire family has this opportunity.

 

Learning Starts at Home

--by Cordell Johnston, EH Board Chairman 

During my time on the Endowment for Health board, I have been impressed by how seriously the organization takes evaluation and continuous improvement. As stewards of the resources of this foundation, we have an obligation to do so.

 In late 2011, the Endowment for Health once again contracted with a national consulting firm, the Center for Effective Philanthropy (CEP), to conduct a survey of our current grantees. CEP had conducted similar surveys for us in 2004 and 2007. In 2011, for the first time, we also engaged CEP to conduct a survey of our external stakeholders—those in the healthcare, media, business, education, advocacy, service, and government sectors. These two groups are critical partners in helping us to realize our mission to improve the health and reduce the burden of illness of the people of New Hampshire. These surveys explore the same themes: what the Endowment does well and what it can do better. Because CEP conducts these surveys for foundations across the country, they also enable us to compare our performance against other health conversion and national foundations.

As always with CEP’s surveys, we learned many things. From grantees, we heard that we continue to be valued for our work to advance knowledge and affect public policy, as well as our impact on grantees’ fields and communities. Our relationships with our grantees are strong: we rate in the top 20 percent of foundations nationwide relative to our interactions with and treatment of grantees. We provide more “assistance beyond the grant check” to our grantees than over 90% of foundations, and the helpfulness of this assistance is rated very highly. We need to do more, however, to support our grantees in their ability to sustain the work we fund after our grant funding ends.

 

No Data, No Problem.

--by Kelly Laflamme, EH Program Director

    When I moved to New Hampshire several years ago, someone said to me, “We don’t have racism in New Hampshire – there just aren’t enough people of color here.”  I was stunned by the simplistic analysis of what I see as a terrifically complex issue.

    Likewise, when we look broadly at data and statistics for health and well-being among New Hampshire residents – we see a stunningly simple picture.  New Hampshire is the 2nd healthiest state in the country.  Our state has the lowest child poverty rate in the country.  But for those of us who care deeply about the most vulnerable members of our communities, we know that aggregates and averages hide the reality of homelessness, hunger, disproportionate disease burden and premature death for some folks in our state.

    This week we celebrate the 2^nd anniversary of the passage of the Affordable Care Act, historic legislation with potential to move our country and our state towards a healthier tomorrow.  On this anniversary new requirements for the collection and reporting of data -- standardizing how race, ethnicity, language, gender and disability data are collected – go into effect.  

    Bill Walker, founding director of the State’s Office of Minority Health, often reminded health leaders of the reality, “No data—no problem.”  In other words, we only know what the data we collect, report and read tell us.  So if we don’t collect data that help us to reveal differences in health they won’t exist.  Yet they do.  For example, national data show us differences such higher infant mortality for babies born to African-American women even when income and education are equal.   Locally, a community health center used electronic health records to identify lower flu immunization rates among their Spanish-speaking patients.  

    Collection of this data is a crucial step in enabling health care providers and policy makers to identify where and for whom differences in health status exist.  With the right data, we can identify the problems and move forward on the more important tasks of implementing targeted solutions.  Only then will we live up to our ranking as the 2^nd healthiest state in the nation. Only then will we improve the quality of health care for all and offer all people in our state an equal chance at health. 

 

 

Welcoming New Hampshire: Weaving Cultures, Building Community

--By Eva Castillo-Turgeon, NH Alliance for Immigrants and Refugees   

    For immigrants, the process of adapting to a new culture, language and community can be very difficult. Such is the case of immigrants that come to New Hampshire. I have heard some describe the process as "like moving to another planet, where everything is different, where you feel like an alien".

    On the other hand, it is also difficult for the receiving community. They find it hard to communicate and to identify with new arrivals. Many people have mixed feelings about the changing faces in their neighborhoods and others are not sure where to start to develop a sense of connection.

   How are newcomers supposed to integrate if they are not feeling welcomed? And how is the receiving community going to welcome all these new faces if they feel anxious and apprehensive about their presence in their towns? Interaction and dialogue between members of the immigrant and the receiving communities is the key to promote mutual respect and acceptance. These in turn will allow for successful integration.

   Welcoming America works to help strangers become neighbors in the communities that receive those immigrants. In their words, "Welcoming America focuses on the communities where new immigrants have made their homes, helping neighbors build relationships built on trust and understanding". The initiative started in Tennessee in 2007, as result of tensions due to the arrival of refugees in the town of Shelbyville and the lack of communication and understanding between the cultures. The model has proven to be successful in breaking down barriers and promoting understanding. It has been replicated in 19 states including New Hampshire.

   The Welcoming New Hampshire initiative was brought to the state in 2011 by NH Alliance for Immigrants and Refugees (NHAIR), with collaboration of a strong group of community leaders and organizations. We have built a local coalition of native-born and immigrant voices to counteract misconceptions and focus on integration.

   The recent incidents in Concord highlight the need for more communication and positive interaction between different segments of the community and immigrants. As the face of the state becomes more diverse, people need to come together and share their feelings and concerns. Welcoming New Hampshire strives to promote dialogue between immigrant and receiving communities.

 The Welcoming initiative creates a safe space where respectful dialogue can take place; where all members are allowed to express their beliefs free of judgment, and where questions are asked from a position of curiosity.

 We recognize that building trust begins by sharing one's ideas. By exploring our common values we build a connection and develop common goals that will result in a stronger, more welcoming community.

   To find more information about Welcoming America visit their website at www.welcomingamerica.org and become a member of friends of welcoming.

   To become involved in the Welcoming New Hampshire initiative or to find more information about it contact: Eva Castillo at Ecastillo@miracoalition.org or call (603) 661-2873.

Visit the Welcoming NH page on Facebook for announcements and events.

 The New Hampshire Alliance of Immigrants and Refugees(NH-AIR), a program-agency of the Massachusetts Immigrant and Refugee Advocacy Coalition (MIRA), is the only organization in New Hampshire  with the mission of promoting the rights and integration of immigrants and refugees-statewide. The organization serves the state’s foreign-born residents with policy analysis and advocacy, institutional organizing, and training and leadership development. NH-AIR educates and civically engages immigrants and refugees to build their social capital -- as voters and leaders advocating for public policy change that ensures the civil and human rights of all NH residents.