Fresh Takes: A State Where Everyone Belongs
- Endowment for Health
- Feb 1, 2024
- 7 min read
Updated: 19 hours ago
Spring 2024
Kim Firth: Building Equitable Health Systems
New Hampshire is better when all our children thrive, and our children thrive when they have strong communities, healthy families, and policies that support them.
This year’s data update from the New Hampshire Child Well-Being Data Hub indicates that our state is on the right track, and indicators reveal low child poverty rates, high rates of insured children, and good maternal health. But when these indicators are separated by income, race/ethnicity, or geography, a problem emerges: inequity, often exacerbated due to a lack of funding for affordable housing, healthcare, economic support, and food programs. These are symptoms of larger causes: generational poverty, lack of educational and economic development opportunities, and structural racism. Though overall indicators show that New Hampshire is a great place to grow up, the inequity is in the details – and the details tell us that many Granite State families are struggling.
Our children are struggling, too. The national child and adolescent mental health emergency, declared by the American Academy of Pediatrics and other national associations, has not bypassed the Granite State. A leading cause of death for New Hampshire youth ages 10-24 is suicide. Studies show that girls, children from communities of color, LGBTQ+ youth, and youth with disabilities are disproportionately affected by mental health challenges. And even if families can overcome long waiting lists for services and the cost of care, there is no guarantee that they will receive mental health care that is culturally relevant. The inequities built into our policies and systems are leaving some of our kids behind.
To create a more equitable mental health care system, we need to adopt solutions that center the experiences, perspectives, needs, and strengths of children, youth, and families – especially those who face significant behavioral health inequities. And we need to recognize and address the interconnected nature of the challenges that New Hampshire families face.
New Hampshire organizations are working to build solutions, and to provide an immeasurable amount of hope. There is hope because so many are working so hard to ensure equitable mental healthcare access for youth. There is hope because young people are using their creativity to create powerful art addressing mental health stigma. There is hope because New Hampshire is investing in our children’s system of care. Now, more than ever, children’s mental health care in New Hampshire is better coordinated across systems, and the array of mental health care services is more robust, especially for children with the most acute needs.
And there is hope because we are not done yet.
To address the workforce shortage in our community mental health system, we need smart investments in loan repayment and programs that build up a pipeline of diverse talent. We need to address low insurance reimbursement rates, which limit providers who take insurance and keep mental health professionals’ salaries artificially low.
To connect families to care, we need to address affordability and waiting lists, and implement more robust culturally responsive care.
And we are on our way. The New Hampshire Health Assessment and Improvement Plan promotes approaches that eliminate inequities and reduce disparities. Its four tenets – access to opportunity, community, health status and outcomes, and social connectedness – address the interconnected nature of these challenges.
We all have a role to play in addressing the children’s mental health crisis in the Granite State, and in promoting a more equitable system of care that works better for everyone. New Hampshire is better when all our kids can thrive – and that takes all of us.
Please read on to discover We Are Here, a project to learn from youth and family members from historically marginalized communities, and the providers that serve them. Also, check out the resource section for training opportunities, information about the 6th Annual Magnify Voices Expressive Arts Contest, and other ways you can take action.
Heidi Cloutier: We Are Here
For this edition of Fresh Takes, we spoke with Heidi Cloutier at the UNH Institute on Disability to talk about the We Are Here video project. The project amplifies the voices of those who have experienced challenges accessing behavioral health services in New Hampshire.
Tell us about the We Are Here project.
A healthy childcare industry benefits all of us. Parents who have access to affordable childcare can go into the labor force, if they choose. Less financial stress and more household income benefits families and our economy. Currently, we need more people in the workforce: There are about two jobs available for every one person in New Hampshire’s labor force. If parents can’t go into the labor force, that limits the hiring pool available to businesses. Limited business growth impacts the overall economy. Finally, and possibly most importantly, high-quality early care and education is important for the healthy growth and development of our youngest Granite Staters. Positive early care and education can help buffer against adverse early experiences and have long-term positive impacts that benefit both individuals and society overall.
What does the distribution for these videos look like? Who has been using them?
We first hosted a screening with the interview subjects to get their feedback before we released the videos. That helped ensure that participants were comfortable with the final edit and felt well represented. Then we began sharing the videos at various behavioral health conferences in New Hampshire and regionally. We reached a large number of behavioral health providers, direct service professionals and administrators in community mental health, substance use treatment, or school counseling. The majority of individuals requesting access to the material will view it for their own professional development. The videos are also being used in academic settings including human development and family studies courses, social work curriculum, trauma graduate certificates and the mental health graduate program.
What has the response to the videos been?
The videos offer challenging feedback about how the system can fail certain populations. We had some initial pushback from some participants – some providers expressed frustration about their limited power to improve systemic barriers and discrimination. Direct service providers don’t always feel like they can influence larger policy issues. We've facilitated discussions about what individual providers can do to advocate for strong policies to support language and communication access, or outreach and recruitment of all populations, and not screen some individuals out because they might be harder to coordinate language and communication access for, for example. Providers and patients often have the same goals around culturally competent care. But when we're operating with limited resources, sadly, decisions about data collection and outreach to historically marginalized communities are often not prioritized.
What can providers do with the resources they have to help facilitate that systems-level change? And what can they do on an individual level?
Video participants said they want their providers treat them with dignity and respect. That doesn’t take systems change. Some of our failures stem from not recognizing our own privilege, or not recognizing differences – especially at the pace that providers are expected to operate, and the caseloads that they’re expected to manage. There are so many barriers to accessing care, and having conversations – with administrators, with boards, with decision makers and policymakers – is key. We need to better understand the factors that harm youth and families, and advocate for better language and communication access. Flexibility and choice within the system is also an issue. Many families have multiple jobs and responsibilities. They must often rearrange their entire work or childcare schedule to get to a behavioral healthcare appointment. And if they can't access that care because of communication issues, or feel that their provider doesn’t understand their experience or their identity, that can be off-putting – and lead to someone not following through with care.
What’s an example of systems-level change that individuals and organizations need to work to address?
Limited resources is a big problem. Each of us individually, and within our organizations, and within our systems, make choices about what to prioritize – with our schedules, with our time, with what's important to us, with our funding. It's true that our behavioral health systems are operating with limited resources, and that our providers should be paid more. But if we truly care about access and equity, we have to prioritize funding for it so we can serve individuals who need care.
What are we making progress on – what’s going well?
Individual providers are beginning to understand the complexity of culture, and we’re seeing great progress in providers recognizing their own implicit biases. We need to understand that we all have implicit biases and that those biases can discourage someone from getting care. As we learn more about individuals’ experiences, we have a better understanding about what culturally responsive care looks like. My role is to help students and new professionals understand the complexities of why someone would not want to engage in care. And I think that the younger generation is much more aware of culture, and aware of how to create inclusive environments, and they’re bringing that into the world and changing our workforce. Organizations are recognizing the importance of language and communication access. They’re changing how they use data to identify disproportionate outcomes for patients they’re serving. They’re more aware of the need to partner with patients in designing their care. We’re starting to see a shift away from tokenism – from having individuals with lived experience on governing boards just to check a box – and instead partnering and recruiting more diverse experience in the workforce.
Is there anything else that you want to mention either about the project itself, or about access in general in New Hampshire?
Given the demands of the workforce, it's challenging for organizations to develop and implement plans to engage underserved communities. We talk a lot about how to engage people who face barriers to accessing mental health care and substance use treatment and support. It takes a lot of work to go out and meet with faith leaders and community leaders, and people who work in our behavioral health systems don’t necessarily have the time and resources to do so. And those who do so are doing it outside of their normal work hours, and they’re burning out.
How can people access the We Are Here videos?
We have a link directly on the Institute on Disability website, where folks can complete a short survey about who they are and how they intend to use the videos, and then gain access. By listening to the stories highlighted in the videos, individuals and organizations can increase their cultural competence and take steps toward strengthening the behavioral health system in New Hampshire.