The Turning Point Initiative – Planting the Seed

New Hampshire was awarded a two-year planning grant in 1997 through Turning Point: Collaborating for a New Century in Public Health, a program of the Robert Wood Johnson (RWJ) and W.K. Kellogg Foundations. New Hampshire was one of fourteen states originally awarded a grant to transform and strengthen the public health infrastructure in the United States so that states and local communities, and their public health agencies, could respond to the challenge of protecting and improving the public’s health in the 21st century.

Beginning in 2004, over 250 representatives from state public health agencies, hospitals, health centers, networks and coalitions, schools and academic institutions, businesses, non-profit agencies, the legislature, civic organizations, faith organizations, and foundations met to develop a Public Health Improvement Action Plan for the State of New Hampshire, which outlined priority action areas for the improvement of public health capacity.

The recommendations contained in the Public Health Improvement Action Plan include policy and operational changes intended to address systemic limitations that were serving as barriers to optimal health improvement. A major finding of the assessment was the lack of an established local public health system. In most of New Hampshire’s 234 cities and towns, the only local public health resource is a health officer, often employed as a building inspector, with no formal education or training in public health. Thus, police, fire, school nurses, and nonprofit health and human service providers fulfill roles typically assigned to local public health officials in other states. Unfortunately, at the time no formal mechanism existed for coordinating the delivery of public health services at the local level among these diverse public health stakeholders.

A key recommendation of the planning process was the development of community level public health capacity to protect and promote the public’s health.

The Public Health Networks – Bearing Fruit

In response to the Turning Point initiative, the State of New Hampshire began funding community public health partnerships in 2000 to develop models for improving local public health. These partnerships involved a wide variety of stakeholders in the communities working together to address complex public health issues. Four local agencies were funded in 2001 with funds provided by the Robert Wood Johnson Foundation to host what were then known as Public Health Networks. These four Public Health Networks covered 39 towns and cities, representing 15% of the State’s population.

Following the tragic events of September 11, 2001 and the anthrax attacks along the east coast, Congress appropriated funds through the Public Health Threats and Emergencies Act to improve the readiness of public health agencies throughout the nation to respond to a bioterrorism attack and other public health emergencies. The New Hampshire Department of Health and Human Services recognized the importance of a strong state and regional public health infrastructure to effectively perform essential public health functions needed to respond to a public health emergency. Priority was given to appropriating a portion of the funding awarded to New Hampshire to expand the Public Health Networks to cover additional communities. With the funding provided by the Centers for Disease Control and Prevention (CDC), all of the Public Health Networks were tasked with local public health infrastructure development, focusing on  emergency preparedness planning.  Beginning in 2006, the State funded Public Health Networks that served all 234 of New Hampshire’s cities and towns.

In 2007, it was recognized that maintaining Public Health Networks focused almost exclusively on emergency preparedness would be challenging and that other important public health capabilities were not being adequately addressed from a statewide perspective. A Public Health Regionalization Initiative Task Force was convened with the goal of developing a sustainable performance-based public health delivery system which could, over time, provide all 10 Essential Public Health Services  throughout New Hampshire. The task force envisioned a public health system based on national accreditation standards and linked to government. There was consensus that the state would retain certain functions, such as infectious disease investigation and laboratory services, and that core staffing and infrastructure was needed regionally to deliver essential public health services through the Public Health Networks.

In 2009-2010, each Public Health Network and their partners conducted an assessment of the regional public health system to gauge improvements since the beginning of the Turning Point Initiative. Three assessments were done in each region: an assessment to identify regional public health assets and the capacity to provide the Essential Services; a governance assessment to gather information on potential governance structures for regional public health and determine the level of readiness in each region to take on this function; and a financial assessment of local and regional public health financial resources. A final report, Creating a Regional Public Health System in New Hampshire: Results of Assessments to Inform the Planning Process, was published in 2011. 

The Strategic Prevention Framework

In 2004, New Hampshire was awarded a Substance Abuse and Mental Health Services Administration federal grant to reduce alcohol, tobacco, and other drug problems in New Hampshire communities by building a prevention infrastructure and capacity that are culturally competent and sustainable. Thus, the Strategic Planning Framework initiative was launched.  This model is based on data and is outcome driven consisting of five steps:  assessment, capacity, planning, implementation, and evaluation.

To ensure a comprehensive prevention infrastructure, a regional delivery system was design to reduce gaps and duplication of services, and to ensure the strategic planning model was being implemented across all communities.  During the regional design period, school districts and SAUs, community health, rural public health, and hospital service areas were considered when configuring the regions. Forums were held around the state for community and provider input and feedback.  In 2007, ten Regional Networks were developed. These Regional Networks were required to build a Community Prevention Coalition infrastructure that supported the facilitation of the Strategic Planning Model process

This Regional Network process involved key strategies, including a community level assessment that identified risk, protective factors that influenced substance misuse and abuse, resources and capacities, and readiness to implement a community-developed prevention plan aimed to address the state’s priorities of reducing consequences and consumption of alcohol, tobacco, and other drugs.

In 2013, this regional and strategic planning model framework continued to be based on a public health approach, facilitating activities such as health assessment, capacity building, implementation, and adoption of evidence-based practices, policies, and programs within six community sectors: business, health/medical, safety/law enforcement, education, government, and community and family supports.  This is being accomplished with coordination among multiple public health programs to achieve outcome-based prevention of the misuse of alcohol and other drugs.

The Regionalization Initiative – Coming to Maturity

One of the four priority recommendations from the Public Health Regionalization Initiative, which included substance misuse prevention partners, was that, “A regional public health system in New Hampshire should be built upon existing Public Health Networks (PHNs) and the infrastructure that has been established, recognizing the unique characteristics and structures of various regions.” with a specific sub-recommendation that, “DPHS and the Bureau of Drug and Alcohol Services (BDAS) should continue to work to align their respective regional initiatives to create efficiencies, eliminate duplication, and build upon the strengths of the two systems.”  Over the past several years, DPHS has increased the range of programs delivered through the PHNs and encouraged other funders to leverage these networks and utilize the geographic regions established by the DPHS when appropriate.

This recommendation was also consistent with the “Transformation Initiative” established by the Commissioner of NH DHHS.  This initiative seeks to align programs and services within DHHS and its contracted partners to increase the effectiveness of services being provided while reducing the administrative burden and, where feasible, costs for both DHHS and its partners.  Because both DPHS and the Division of Community Based Care Services (DCBCS) were funding services regionally that are based on a public health approach to improving health, the Regional Network and Public Health Network programs were identified as being amenable to alignment.

In early 2013, DPHS and BDAS issued a joint Request for Proposals (RFP) for Regional Public Health Network Services.  This RFP established a strategic partnership to align multiple public health priorities into one integrated system. The partnership aims to increase efficiency through single contracts with 13 agencies to serve as the host entity for a Regional Public Health Network (RPHN).  The purpose of the RPHNs is to integrate multiple public health initiatives and services into a common network of community stakeholders. The RPHNs include every community in the state.