Medical Homes in New Hampshire

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»Related Grant Initiatives	»Educational Initiatives
»Partners in the State	»Screening Initiatives

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Medical Home Initiatives
This section provides information on state medical home initiatives/programs. States that are a part of the mentorship network will have a "Promise to the State" which outlines how they will achieve ensuring that all children have a medical home by 2010. This is based on the Healthy People 2010 goals which is a 10 year action plan to achieve and measure success for all CSHCN.

New Hampshire Medical Home Contact:

Name: Judith Bumbalo
Bureau Chief, Office of Program Operations Special Medical Services
Contact: Phone: (603) 271-0546 | Email: jbumbalo@dhhs.state.nh.us

New Hampshire Medical Home Grants
MCHB Medical Home Grant: Beyond the Medical Home: Cultivating Communities of Support for CSHCN Abstract
Contact Person: Jeanne McAllister, RN, MS, MHA
Phone: (603) 547-3311 (Ext 510) | E-mail: Jeanne.McAllister@crotchedmountain.org
Project Period: 4 years from July 1, 2004 to June 30, 2008
Purpose: In partnership with the NH Bureau of Special Medical Services (Title V), NH Family Voices, and the NH chapters of the American Academies of Pediatrics and Family Physicians. Beyond the Medical Home (BMH) will extend previous CMHI efforts by improving transitions to adult services and by establishing effective methods of communication and coordination among families, community-based organizations and the Medical Home. Two Medical Home practice networks, one in Concord (NH) and one located within NH’s Seacoast Region will address three critical needs: 1) expansion of Medical Home access within practice networks; 2) creation of transitions to adult services by inclusion of family medicine practices with a QI focus on transition; and 3) implementation of effective family and interagency coordination and communication strategies.

MCHB Medical Home Grant: The Rural Medical Home Expansion Project Abstract
Project Period: March 31, 2001 to March 30, 2004
Purpose: Support statewide development of community-based medical homes for Children with Special Health Care Needs (CSHCNs) by surveying and informing pediatric practices in VT and NH about the medical home concept and providing them access to a continuous improvement process involving partnerships with parents, linkages to community resources, and new Medicaid reimbursement.

Medical Home and Transitions Champions Incentive Grant
Goal: To develop strategies, methods, and protocols that will improve the process of health care transition.
For more information contact: Kathy Higgins Cahill, MS, ARNP
Health Care Transition Project Coordinator Special Medical Services NH
Phone: (603) 271-4510 | Email: kcahill@dhhs.state.nh.us | Incentive Award FAQs

Medical Home Implementation Resources and Tools
Center for Medical Home Improvement: www.medicalhomeimprovement.org
New Location: Crotched Mountain Foundation - 1 Verney Drive - Greenfield, NH 03047

The mission of the Center for Medical Home Improvement (CMHI) is to establish and support networks of parent/professional teams to improve the quality of primary care medical homes for children and youth with special health care needs and their families.

CMHI efforts have included a successive series of Medical Home development efforts with practices in New Hampshire, Vermont, Maine and across the country including three Medical Home projects, validation of Medical Home measurement tools, and leadership for the national Medical Home Learning Collaborative offered in collaboration with the National Initiative for Children’s Health Care Quality (NICHQ).

The Medical Home Project for Children with Special Health Care Needs
A state contract from Special Medical Services, the Title V program has
been awarded to The Center for Medical Home Improvement to commence as of
October 2007. It is entitled "The Medical Home Project for Children with
special Health Care Needs". The focus for the contract will include the
following activities: statewide medical home planning; development of a
Medical Home network and registry; creation of policy regarding medical
home development; and provision of technical assistance to medical
practices working on the development medical homes.

Related Grant Initiatives
This section provides information on current state grants that are working on medical home initiatives. This includes the grant abstract as well as key contacts for the grant.

Partners in Chronic Care at the Hood Center for Children and Families
Provides training for office based care coordination that involves conducting family meetings with the health team in the office and collaborating with the insurer case manager.

This program is an MCHB financing grant (submitted as "Partners Enhancing Managed Care Expansion"). The purpose of the project is to apply a new structured primary care based model of Enhanced Care Coordination(ECC) as a case management insurance benefit for CSHCN. This model has been shown to work for health providers, insurers, and families and to reduce health costs. The ECC model is family centered, and is designed to provide comprehensive care coordination in the primary care setting where the insurer case manager collaborates closely with the practice & other community & specialty care players to meet the full range of needs of families with complex health conditions.

The goal of this program is to develop statewide and community level supports and training and then disseminate this comprehensive care coordination approach through private and public insurers for CSHCN in pediatric practices in NH and then ME. Following evaluation of these expansion efforts, the partners will focus on revising and sustaining these services in pediatric practices. At the health plan level this project utilizes the information that results from this comprehensive partnership to assist the quality assurance units in both Anthem Blue Cross Blue Shield and Cigna in implementing ongoing quality assessment and quality improvement initiatives to improve the care given to all CSHCN.Grant Abstract

For more information on this training, please contact program manager Beth Pearson at Elizabeth.Pearson@dartmouth.edu

Healthy Tomorrows Partnership for Children Grants 2005-2010
Good Beginnings Home Visiting Network Expansion Project
Valley Regional Healthcare, Inc. Claremont, NH
Purpose: The goals of this project are to promote healthy pregnancy and birth outcomes; to promote a healthy, safe and nurturing environment for children; and to enhance the families’ life course and development. The target population for this project is uninsured families who do not have access to the full array of preventive healthcare services available to others in our community. Click here for more information on this project.

For more information on the Healthy Tomorrows Grant Program click here. For more information on this HTPCP project, please e-mail your name, address, telephone, and fax numbers with your specific request to healthyt@aap.org.

Partners in the State
This section provides information on who in the state (individuals and agencies) are working together to create medical homes for children.

American Academy of Pediatrics (AAP) Chapter: www.nhps.org/default.htm

American Academy of Family Physicians (AAFP) Chapter: www.nhafp.org/

Title V CSHCN Program - Special Medical Services: www.dhhs.state.nh.us/DHHS/SPECIALMEDSRVCS/default.htm

Title V Block Grant to States
Title V of the Social Security Act is one of the largest Federal block grant programs. It leads the nation in ensuring the health of all mothers, infants, children, adolescents, and children with special health care needs (CSHCN). Title V is administered by the Maternal and Child Health Bureau (MCHB) as part of the Health Resources and Services Administration, U.S. Department of Health and Human Services.

Title V and Children with Special Health Care Needs
MCHB Objective: Support development and implementation of comprehensive, culturally competent, coordinated systems of care for the estimated 18 million U.S. children who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally.

Early Hearing Detection & Intervention (EHDI) Contact(s):
State EHDI programs promote universal newborn hearing screening, develop effective tracking and follow-up as a part of the public health system, promote appropriate and timely diagnosis of the hearing loss, prompt enrollment in appropriate Early Intervention, link newborns to a medical home and strive to eliminate geographic and financial barriers to service access.

Name: Ruth Fox; RN, MS
Contact: Phone: 603-271-1037 | Fax: 603-271-4519 | E-mail: rfox@dhhs.state.nh.us

Family-Centered Early Supports and Services/Part C Coordinator:
The Program for Infants and Toddlers with Disabilities (Part C of IDEA) is a federal grant program that assists states in operating a comprehensive statewide program of early intervention services for infants and toddlers with disabilities, ages birth through age 2 years, and their families.

Name: Carolyn Stiles, Part C Coordinator/Program Specialist
Contact: Phone: (603) 271-5122 | Fax: (603) 271-5166 | Email: cstiles@dhhs.state.nh.us
Web Site: nhdds.org/programs/famchild/earlysupports/

Section 619/ Preschool Grants Program of the Individuals with Disabilities Education Act (IDEA). This program provides free appropriate public education (FAPE) for children, ages 3 through 5 years, with disabilities:

Name: Ruth Littlefield, 619 Coordinator
Contact: Phone: (603) 271-2178 | Fax: (603) 271-1953
Email: rlittlefield@ed.state.nh.us
Website: www.ed.state.nh.us/education/doe/organization/instruction/bose.htm

State Interagency Coordinating Council (ICC) Chairs: The ICC advises appropriate agencies on the unmet needs in early childhood special education and early intervention programs for children with disabilities, assists in the development and implementation of policies that constitute a statewide system, and assists all appropriate agencies in achieving full participation, coordination, and cooperation for implementation of statewide system.

Name: Deborah Bennis, ICC Chair
Contact: Phone: (603) 679-1453 | Email: bennistrio@aol.com

Resources/Documents
The Medical Home Index (MHI) - Developed by the Center for Medical Home Improvement: www.medicalhomeimprovement.org/outcomes.htm
The Medical Home Index (MHI) is a validated self-assessment and classification tool designed to translate the broad indicators defining the medical home (accessible, family-centered, comprehensive, coordinated, etc.) into observable, tangible behaviors and processes of care within any office setting. It is a way of measuring and quantifying the "medical homeness" of a primary care practice. The MHI is based on the premise that "medical home" is an evolutionary process rather than a fully realized status for most practice settings. The MHI measures a practice's progress in this process. The companion Medical Home Family Index is also included on this site.

State Waiver Information: www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/08_WavMap.asp
Waivers are the result of a process that allows state Medicaid agencies to apply for and receive permission from HCFA to provide services not otherwise covered by Medicaid and/or to do so in ways not described by the Social Security Act. Most Medicaid managed care programs require Waivers. The Waivers, which can differ greatly, are known by their numbers (1115, 1119), or as home-and community-based, or as Katie Beckett Waivers.

Educational Initiatives
This section provides information on training initiatives on the medical home. Some states will discuss their outreach projects in relation to physicians, families, and the community.

No information is currently available for this category.

Screening Initiatives
This section provides information on surveillance and screening initiatives in the state.

State Newborn Screening & Genetics Programs: genes-r-us.uthscsa.edu/resources.htm

• State Newborn Screening Program Links
• State Genetics Program Links
• Regional Genetics and Newborn Screening Collaborative Links
• Newborn Screening State Contact Fact Sheet

Funding Opportunities
Partnership for Effective Nonprofits Offers Grant Program for Organizations in New Hampshire and Maine
Deadline: February 15 and July 14, 2006

The purpose of the Partnership for Effective Nonprofits, a joint initiative of the Foundation for Seacoast Health, the Piscataqua Region of New Hampshire Charitable Foundation, and the United Way of the Greater Seacoast, with additional support from the Fuller Foundation, is to coordinate resources to strengthen management and improve the sustainability of community-based nonprofit organizations in southeastern New Hampshire and southern York County, Maine.

For the 2006 program, proposals can be submitted online using the Greater Seacoast United Way electronic grant system. Complete details and links to the system will be posted at the PEN Web site by December 15, 2005.

See the Web site for complete program guidelines, including further information on geographic eligibility, and details on previously funded projects at: http://fconline.fdncenter.org/pnd/5002100/partnership

State Resources on the Internet

Note: The information provided on the state pages was submitted by the state medical home teams.As this is not an exhaustive list, please let us know if you have additions for your state resource page. You can contact us at: medical home@aap.org.

Last Updated November 8, 2006