In the past, not having an Asthma Action Plan filled out and sent back to the school might not have had a direct detrimental effect. However, in New Hampshire the difference between an asthmatic patient with a current Asthma Action Plan on file and one without is now the difference between a patient who can access emergency medication at school and one who cannot.
In 2016, RSA 200:54-57 (Bronchodilators, Spacers, and Nebulizers in Schools) was passed by the NH State Legislature.Prior to this passage, students with asthma could self-carry their inhaler at school if they had a prescription on file with the school nurse.However, if they forgot their inhaler and had an asthma attack, the school nurse was not authorized to provide them with a bronchodilator.This meant that many students were being taken by ambulance to the hospital – a practice that incurs high cost, causes the student to miss valuable classroom time, diverts the school nurse’s attention from other students in need, and delays access to rescue medication, putting students at risk.
RSA 200:53-57 allows the following measures to be taken: 1) a school board to approve the obtainment and storage of emergency bronchodilator medication at the school 2) A licensed physician to prescribe a stock amount of medication for the school district 3) a licensed pharmacist to fill a prescription for stock medication 4) the school nurse or other school personnel, after receiving a New Hampshire School Nurse Association training, to administer emergency medication during an asthma attack to students with a current (annually updated) Asthma Action Plan and parental permission on file.
The New Hampshire Asthma Control Program, as part of the New Hampshire Asthma Collaborative, has designed an Asthma Action Plan with ease of use in mind. This Asthma Action Plan, available free of charge, is a triplicate form (one copy for your office, for the family, and for the school) that has a signature for yourself, the school nurse, and the parent.In addition to an Asthma Action Plan, this document serves as physician’s orders that can be acted upon, as well as a release of information between your office and the school. This form was designed with consultation from the New Hampshire School Nurse Association, the American Lung Association in Maine and New Hampshire, and other clinical professionals.To request hard copies of Asthma Action Plans, please email firstname.lastname@example.org.To access a printable version, click here.The Asthma Control Program is also piloting a low-literacy Asthma Action Plan that will eventually be available for wide-spread use.
The New Hampshire Asthma Control Program has been working to educate schools and parents about the importance, and potentially life-saving impact, of Asthma Action Plans. With New Hampshire’s legislative changes, the role that Asthma Action Plans play in supporting asthmatic students is even greater, and we appreciate the partnership of physicians in this effort.In New Hampshire, Asthma Action Plans are no longer just a supplemental document, and truly can give patients better access to care.
The New Hampshire WIC Nutrition Program supports breastfeeding for WIC recipients in the state. Breastfeeding information from New Hampshire WIC program and the CDC is available for download.Each WIC agency in New Hampshire has a Breastfeeding Coordinator and Alternate Contact.Each WIC clinic has a peer counselor program to help support WIC mothers with breastfeeding.The peer counselors provide support to mothers via telephone and at clinic visits and can loan electric and manual breast pumps to mothers meeting breastfeeding criteria.To find the peer counselor coordinator in your area, use the link above.
LaLeche League is a group of women with a long history of peer support for breastfeeding mothers using group meetings. Their website lists LaLeche league group meetings in various parts of the state.They also have a conference every 1-2 years in the Maine/New Hampshire area.
ZIPMilkis a non-profit organization (based in Massachusetts) that provides information about breastfeeding support resources to health care professionals and mothers.It has sections on resources by location (including the state of New Hampshire and zip codes) and topics.You can find breastfeeding support for mothers in your area.If you would like to list your office or a breastfeeding support person in your office you can be added to the list.
The Academy of Breastfeeding Medicine is an organization for physicians in any specialty with an interest in breastfeeding. They have an annual meeting, and have produced evidenced based protocols for the care of the mother/baby breastfeeding couple.They have more than 20 protocols including the following:
Model Hospital Breastfeeding Policy,
Human Milk Storage,
Breastfeeding the Late Preterm Infant and,
more than 15 other topics.
To access the protocols go to the link above, click on resources and protocols and then the English bubble.
American Academy of Pediatrics, Section of Breastfeeding
The Section of Breastfeeding of the American Academy of Pediatrics website is resource for pediatricians on breastfeeding. It includes the policy statements on Breastfeeding and Human Milk, Breastfeeding Friendly Pediatric Office and other related policies and clinical reports.It also has the Breastfeeding Curriculum for Residency programs in Pediatrics and Family Medicine and a guide for coding for breastfeeding related visits (under resources at the link below).
Bella Breastfeeding in an on-line free breastfeeding education course for physicians, residents, nurse practitioners, physician assistants, advanced practice clinical nurses and other providers. It was developed by Bobbi Phillip MD and funded through the W.K.Kellogg Foundation to meets the requirements for 3 hours of physician education for the Baby Friendly Hospital Initiative physician training. If physicians want CME credit, there is a cost. It could also be used for resident training. It covers the following topic areas:
Benefits of exclusive breastfeeding,
Physiology of lactation,
How the provider’s specific field of practice impacts lactation,
How to find safe medications for use during lactation, and
Who the provider can refer a mother to for help.
To access the course, use the link above. You then have register to access the course and search under Bella Breastfeeding.
The Carolina Global Breastfeeding Institute is part of the University of North Carolina Gillings School of Global Public Health at the University of North Carolina. They have information for to support breastfeeding in communities, child care settings, and handouts on many topics including responsive infant feeding.
Center for Disease Control and Prevention (CDC) Breastfeeding Section
This section of the CDC website has information about breastfeeding including breastfeeding statistics (national and state), guidelines for breastfeeding, resources, special situations including maternal infections such as influenza, Lyme disease and others, toxins, and other frequently aked questions. Some sections have patient education handouts.
The Office of Women’s Health has a section on breastfeeding including making the decision to breastfeed, learning to breastfeeding, breastfeeding challenges, pumping and storing breast milk, breastfeeding out of the home, and resources.
LactMed is the free National Library of Medicine searchable database on the use of medications while breastfeeding. Most breastfeeding specialists use this as one of their primary resources for answering questions about the use of maternal medications while breastfeeding.There is also a free LactMed app under the resources tab.
The United Breastfeeding Committee is a multisectoral national breastfeeding committee comprised of representatives from relevant government departments, non-governmental organizations, and health professional associations to coordinate national breastfeeding initiatives. The USBC’s mission is work collaboratively for policy and practices that support breastfeeding across the United States. They have a free weekly on-line newsletter which shares information to help support breastfeeding for mothers and infants.
Lawrence RA and Lawrence RM. Breastfeeding , A Guide for the Medical Profession 7 ed.2011.ElSevier/Mosby.This is the classic breastfeeding textbook for physicians.
Shandler RJ, Krebs NF, and Mass SB. Breastfeeding Handbook for Physicians 2 ed.2014.American Academy of Pediatrics and American College of Obstetricians and Gynecologists.
Hale TW and Rowe HE. Medications & Mothers’ Milk 2017.Springer Publisher Co.
Bunik M. Breastfeeding Telephone Triage and Advice, 3rd Edition.2019.American Academy
Meek JY. New Mother’s Guide to Breastfeeding, 3rd Edition.2017.American Academy of Pediatrics
NH PEDIATRIC IMPROVEMENT PARTNERSHIP
The NH Pediatric Improvement Partnership (NHPIP) is a diverse group of stakeholders, including pediatric primary care, academic, public health, insurance (commercial and Medicaid), and child/family-centered organization stakeholders whose collective mission is to improve child health in NH through the use of measurement-based quality improvement (QI) processes in primary care settings. NH PIP began in 2012, and has identified three focus areas for its initial QI work: behavioral/mental health, developmental screening, and oral health. The Institute for Health Policy and Practice at the University of New Hampshire serves as the institutional home for the NH PIP, with Medical Director leadership from the Geisel School of Medicine at Dartmouth. NHPIP started its first QI project on developmental screening in fall 2014 (offering Maintenance of Certification and CME credit) with 4 NH pediatric primary care clinics. Interested in learning more about the work of the NH PIP, including how to become involved in a future QI project? --- Go to www.nhpip.org.
Augmentative and Alternative Forms of Communication
For children with severe expressive communication disorders, augmentative and alternative communication (AAC) can improve their ability to interact with others in everyday settings. AAC promotes wider social interaction by offering different functions from supporting existing speech to providing an alternative for verbal communication. Individuals with autism, cerebral palsy, genetic syndromes, cognitive impairments, hearing impairments, and head injuries use AAC to enhance their communication abilities.1
Depending on a child’s needs, AAC can be applied through the means of unaided and aided forms of communication. Unaided forms of ACC require children to use their bodies to communicate and include sign language, gestures and facial expressions.2 Aided forms of ACC involve the use of equipment/devices to communicate and are categorized by low tech and high tech options.3
AAC was originally the last type of intervention recommended for children with communication disorders.4 Older devices were limited in function because they exclusively helped children with their expressive communication to better convey their wants and needs. Today, there is an increased recognition that AAC devices can also be used to improve children’s receptive communication abilities by helping them receive and understand messages from others.
Examples of AAC features:
Speech output using text displays that allow two people to exchange information
Picture board touch screens that use images and symbols
Spelling and word detection
Internet to access information
Multimedia components for videos and photos
Texting and cell phone features
Social media to connect with others5
Mobile technology has made AAC more accessible to families with phones and tablets, because these devices are light and portable, less costly and are widely used in society. Although these technologies are easily accessible, it is important for children to receive a referral and formal evaluation for AAC software and devices. A speech and language pathologist will choose a program that uses the best language concepts, organization and layout, selection of target concepts and support for a child’s needs.
Obtaining a referral and arranging funding and training for an aided AAC device can be complicated for any family. Primary care providers can facilitate this process by:
Identifying communication issues early and making timely referrals – pediatric clinics often offer free developmental screenings6
Coordinating the AAC assessment with other therapeutic services the child is currently receiving
Supporting funding of AAC devices and services by providing “medical necessity” letters to funding sources7
Working with a team of educational and therapy professionals to monitor the effectiveness of the chosen AAC device
Assisting parents in conversations with school staff and child care staff to ensure that AAC devices are being used effectively in both school and home settings
Children with suspected communication issues should always be referred for an additional evaluation. Early detection and treatment can help children reach their fullest potential.
 Information for AAC Users. American Speech-Language-Hearing Association. ASHA Homepage. www.asha.org. Accessed 22 Apr 2015.
 Communication Services and Supports for Individuals with Severe Disabilities: FAQS. American Speech-Language-Hearing Association. ASHA Homepage. www.asha.org. Accessed 17 Dec 2014.
 Assistive Devices for People with Hearing, Voice, Speech, or Language Disorders. National Institute on Deafness and Other Communication Disorders. NIDCD Homepage. www.NIDCD.nih.gov. Accessed 17 Dec 2014.
 Romski, M.A, & Sevcik, R.A. Augmentatie communication and early intervention: Myths and realities. Infants & Young Children. 2005; 18: 174-185.
 Light J, McNaughton D. The Changing Face of Augmentative and Alternative Communication: Past, Present, and Future Challenges. Augmentative and Alternative Communication. 2012; 28(4): 197-204.
 Desch L, Gaebler-Spira D. Prescribing assistive-technology systems: focus on children with impaired communication. Pediatrics. 2008; 121(6): 1271-1280.
 Funding for Service Delivery: FAQS. American Speech-Language-Hearing Association. ASHA Homepage. www.asha.org. Accessed 21 Aug 2014.
Pathways.org is a 501(c) 3 not-for-profit organization dedicated to empowering parents and health professionals with FREE tools and resources to maximize children’s motor, sensory, and communication development. All materials are created under the direction of the esteemed Pathways.org Medical Roundtable. Our video library contains 40+ free videos to encourage the early detection and intervention of developmental delays.
On July 1, 2009, Harvard Pilgrim Health Care (HPHC) became the insurance partner for the NH Healthy Kids Silver Program (SCHIP). This program covers 9000 NH children under the age of 19 who do not qualify for Medicaid (Healthy Kids Gold) because they are above those income guidelines. Most of the children come from families with working parents who do not have access to employer based health plans or who are self employed. Since the original Healthy Kids legislation passed the NH Legislature in 1993 Healthy Kids Silver has covered over 60,000 children who otherwise would not have had access to health insurance and has reduced the percentage of uninsured children in NH from 21% to around 7%.
Blue Cross of NH which became Anthem has been a valued partner with Healthy Kids since the program started but the contract for the next 2 years has now been awarded to Harvard Pilgrim in a competitive bidding process. Several meetings have been held with staff at HPHC to discuss preventive programs for children. Harvard Pilgrim has developed a web page for New Hampshire Healthy Kids pediatricians and family practitioners that provides up-to-date information about their disease and care management programs, behavioral health and wellness programs. The link is www.harvardpilgrim.org/nhhkproviders. Examples from the website include Harvard Pilgrim’s extensive array of tools and resources for asthma available through the website as well as resources for childhood obesity, including the CATCH recreation programs in New Hampshire that promote positive physical activity and healthy eating. In addition, immunization reminders are sent both to patients and to providers about childhood and adolescent immunizations to improve immunization rates. All of Harvard Pilgrim's patient education materials are on the website and can be downloaded for our patients. For behavioral health services, Harvard Pilgrim Health Care (HPHC) has had a contract with United Behavioral Health since 2004. This is not a “carve out” but a “partnership” as care managers from HPHC
and United work together on cases. The behavioral network in NH includes 450 clinicians who see kids plus 35 child psychiatrists and 21 nurse practitioners. Some examples of behavioral health diagnoses and HPHC resources include:
1)Eating disorders – There are about 100 clinicians listed in NH that have expertise in eating disorders on the HPHC list. United Behavioral Health manages the eating disorders patients and matches them with appropriate in or out patient resources either in state or beyond.
2)ADHD – The parents of newly diagnosed patients are mailed a packet of information about ADHD. Follow up visits are tracked (linked with medication prescriptions) and frequent follow up visits are encouraged for quality of care.
3)Screening – Code 96110 can be used and is reimbursed for depression screening (any legitimate screen) as well as Vanderbilt screening for ADHD and developmental screening. Documentation needs to be made in the medical record about the screening.
4)Behavioral health referrals and phone consultations – United Behavioral Health encourages primary care physicians to refer patients needing behavioral health services by calling UBH’s referral line, 1-888-777-4742.In addition, providers who have questions about medication choice or general management of patients with behavioral diagnoses can call the physician consultation service at 800 292-2922. This is a national service that employs clinicians including many child psychiatrists who are available to speak directly with PCPs and help with management and medication questions.
NH Healthy Kids Silver Program looks forward to partnering with HPHC and NH pediatricians are strongly encouraged to use their web site as a resource for valuable patient and referral information. Patients can also access extensive health and wellness information from the web site as well, www.harvardpilgrim.org. Discussions are also underway to utilize teen friendly communication tools in the future. Please call NH Healthy Kids if you have questions or want to give feedback about the new partnership.
MemorialHospital, SpeareMemorialHospital, ValleyRegionalHospital, and
-Promoting the 5 E’s- Excitement, Enthusiasm, Energy, Exercise, and Education At home, school, and in the community
Granite State FitKids is an interactive health awareness program specifically designed for the 4th grade level.The core of the program is a set of seven lessons, called “The Body Workshops”, discussing the various body systems - cardiovascular, respiratory, gastrointestinal, muscular, skeletal, and nervous.In addition, three of the lessons focus on the effects of tobacco and the benefits of good nutrition and regular physical activity.These lessons are approximately 45-60 minutes each and complement the existing health education curriculum. Charles T. Cappetta, MD -a pediatrician at Dartmouth Hitchcock Nashua- instructs the seven lessons, with the assistance of Mr. Bones, and various health care/educational professionals.
The curriculum uses a variety of educational strategies, including lecture, group discussions, and interactive student activities such as games and projects. Extension of the learning environment is reinforced by fun, easy to do homework assignments and weekly communication to parents and family members. Adjunct school staff members such as the physical education, art, computer, and music teachers are also involved in providing corresponding supportive information and activities in their own classrooms during the 7 weeks of the program.
Having taught > 15,000 students since its inception in 1997, the expansion of the Granite State FitKids program has grown from 3 schools and teaching over 200 children in Nashua, to now 36+ schools and 15 communities in NH and MA and teaching over 2700 4th graders in 2008-2009. It was established as a 501c3-child health promotion organization in July 2000 and is registered as a Charitable Trust in NH with a 5 member Board of Governors made up of local hospital/school/parent and health care leaders.
In May 2005, Granite State FitKids was nationally recognized and honored as a “Silver Award” winner in The Cooper Institute (Dallas, Texas) Children’s Healthy Bodies Initiative which identified programs (150 programs were reviewed) with the greatest potential to help reduce the epidemic of childhood obesity.
In April 2006, Granite State FitKids had the distinct honor of being selected as only 1 of 7 programs from the United States included in the CDC/WHO publication, “Best Practices for Physical Activity Promotion around the World” which highlights various efforts from over 20 countries to deal with the epidemic of overweight and obesity and physical inactivity.
In April 2007, Granite State FitKids was listed as a “Classroom curriculum energizer” in the NH Foundation for Healthy Communities release; Recommendations from the New Hampshire Childhood Obesity Expert Panel-Preventing Childhood Obesity: Promoting physical activity and healthy eating.
If you would like more information about this program, please contact:
CMHI (Center for Medical Home Improvement) is an organization affiliated with Crotched Mountain (http://www.cmf.org/) founded in 1993 by Dr. W. Carl Cooley, Medical Director and Ms. Jeanne W. McAllister, B.S.N., M.S., M.H.A., Director.
The mission of the Center for Medical Home Improvement (CMHI) is to promote high quality primary care in the medical home and secure health policy changes critical to the future of primary care.
CMHI Staff (from left to right): Lori Keehl-Markowitz , W. Carl Cooley , Jeanne W. McAllister, Lora Council, and Leah Reed
What Is a Medical Home?
Medical Home represents the standard of excellence for pediatric and adult primary care in the 21st Century.
CMHI defines the medical home as a community-based primary care setting which provides and coordinates high quality, planned, family-centered: health promotion, acute illness care and chronic condition management.
CMHI seeks and uses local and national resources to:
build and spread awareness of the medical home model of primary care
develop supports for primary care practices to improve their "medical homeness"
use tools and guidance to coach and provide technical assistance for individual practices to entire networks
seek to align state and national efforts towards a comprehensive investment in the future of primary care
For more information click link to CMHI's website: www.medicalhomeimprovement.org. CMHI's website provides e-library of resources supporting practices, patients, families, consumers, and researchers to learn, build, and/or improve their medical home.
The Center for Medical Home Improvement (CMHI) is based at Crotched Mountain, and is directed by Jeanne W. McAllister, RN, MS, MHA.
Its mission is to improve the quality of primary medical carefor children and youth with special health care needs and their families by establishing and supporting networks of parent/professional teams. A "medical home" is a process of care offered by primary care providers in partnership with families of children with special health care needs (CSHCN).
The CMHI web site includes many resources available to families and medical professionals including: a medical home improvement kit; medical home measurements; a parent partner guide; current events; and profiles of medical home improvement teams.