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Bar Journal - March 1, 2003

Access to Care in New Hampshire's North Country

New Hampshire's North Country is part of the Northern Forest, a landmass that stretches across the northernmost reaches of New York, Vermont, New Hampshire and Maine, and is an area geographically distinct from the rest of New Hampshire. Generally speaking the North Country is composed of Northern Grafton County and all of Coos County and is bordered by Vermont, Maine, and Canada, with an inner-state line of demarcation running through Franconia Notch, Crawford Notch and Pinkham Notch.

Most of the health and human services and retail businesses in the region are located in the towns of Littleton, Haverhill, Lancaster, Colebrook and Berlin. These communities range in population from 2,321 in Colebrook to 10,331 in Berlin, the largest North Country town. The total population of the area is 55,732 (US Census 2000). For the purposes of health care delivery, the communities are grouped into New Hampshire Department of Health and Human Services (NH DHHS) designated Healthcare Service Areas (HSA) identified by these five larger towns where healthcare facilities are located.


The North Country is noted for its spectacular vistas and mountainous terrain lending immense beauty to the region but creating economic and geographic barriers. These barriers significantly affect the quality of life for many North Country residents. Population density in the North Country region is approximately 32 persons per square mile compared to a population density of 132 persons per square mile for the state as a whole. Little public transportation exists for those traveling into and out of the area and none exists between communities. The same winter weather that attracts skiers, snowboarders and others looking for winter activities makes the roads treacherous to navigate for long periods each year.

These barriers affect more than just the roads. According to 2000 Census figures, the area lost almost five percent of its population between 1990 and 2000. Data from NH DHHS reflect a median family income for Coos County families that is 30 percent lower than the state as a whole. Moreover, almost 20 percent of North Country residents are Medicaid recipients compared with just over 11 percent statewide. Unemployment is higher; and fewer people have access to employer-supported health insurance. While 71 percent of New Hampshire employers provide health insurance for their employees, only 57 percent of North Country businesses provide such benefits. Data on access to health insurance brings to mind issues relating to access to health care services in general; and here the North Country suffers as well. Again citing NH DHHS data, almost 25 percent of the North Country population under the age of 65 has indicated that they are not confident of access to health care compared with 19 percent statewide. In addition, this same population indicates higher than state average numbers with no usual source of health care and no contact with a physician and/or a dentist within the past year.

Lack of access to health care usually means that the health status of the population in question is not as good as that of a population that does not suffer from such barriers. Data regarding the actual health status of the North Country population is hard to come by. The best measures of access relate to what are called "Ambulatory Care Sensitive Conditions." These are conditions that are less likely to require inpatient hospitalization if timely and appropriate primary care is received. The assumption here is that higher than average rates for inpatient admissions for these conditions could indicate that the service area population does not have timely and appropriate access to primary care and are forced to access the health care delivery system through hospital emergency departments or to wait until the condition requires inpatient hospitalization. Almost 11 percent of North Country inpatient admissions are for Ambulatory Sensitive Conditions compared to a state average of just over seven percent. The unavoidable conclusion from reviewing these data is that for a sizeable number of North Country residents, access to adequate primary care is not always available.


These somewhat dire statistics generally described the status of the North Country population last year when two events took place almost simultaneously - one enormously demoralizing and one exciting - that would affect future access to health care by this same population. The first was a rapidly deteriorating financial situation affecting the two pulp and paper mills in Berlin and Gorham. The second was a decision by the Endowment for Health to support an initiative to improve North Country access to health care proposed by the North Country Health Consortium to be called North Country Cares.

On September 10, 2001, following months of financial uncertainty for workers and vendors, Pulp and Paper of America, a subsidiary of American Tissue, declared bankruptcy and shut the doors of the largest employer in Coos County. The pulp and paper mills were based in the Berlin area, but the effects of the shutdown reached down to the loggers, machine shops, jobbers and even restaurants and retail establishments throughout Coos and Northern Grafton Counties. The mills had employed 850 people and labor market analysis suggested that an additional 600-1000 workers in other areas were also affected.

Along with the loss of jobs came the loss of health and dental insurance coverage, including prescription coverage. Claims made by the Androscoggin Valley Hospital and private practitioners to the existing Pulp and Paper of America insurance carrier had not been paid for months. The communities then learned that the company did not sent payments to the insurance company that laid off workers had contributed through COBRA, the federal "safety net" insurance program for workers in transition. In addition, Crown Vantage, the former owners of the mill complex, declared bankruptcy in August 2001 leaving 350 retired mill workers without insurance coverage.


During this time a group of community members began meeting to address the many health and social service needs caused by the shutdown of the mills. Close to thirty people including representatives from mental health, welfare, legal assistance, credit counseling, United Way, the Union, business, the clergy, Coos County Family Health Services (CCFHS) and the Family Resource Center began meeting weekly to sort out the challenges and begin to assign activities to meet the immediate needs. The group became known as the Concerned Community Providers (CCP). CCP identified access to health insurance and prescription drugs as a top priority, along with maintaining mortgage and utility payments and a clear and easy process for connecting people to the right services.

In early November CCP, in partnership with the Union, sponsored a workshop on insurance options for laid off workers. Representatives from the NH Healthy Kids Program and the Deputy Director of the NH Department of Insurance provided an overview and then stayed to meet individually with workers to hear their stories and connect them with resources. One worker, who had been paralyzed in a diving accident 20 years ago, required prescriptions costing $3,000/month; another retiree had a heart condition that required surgery; all were frantic about the future for themselves and their families.


As the community was reeling from the shutdown of the pulp and paper mill Berlin/Gorham Area health and human service providers began meeting in October 2001, to develop a joint community needs assessment in preparation for filing a Community Benefit Plan with the State of New Hampshire Attorney General's office.

Each health care charitable trust in New Hampshire must complete or update a community needs assessment every three years. Berlin/Gorham area health and human services providers decided to develop a collaborative community needs assessment and community benefit plan that would focus the attention of all the area's providers on common needs in the area. The North Country Health Consortium (NCHC) was asked to facilitate the process with the Executive Directors and CEOs of Androscoggin Valley Home Care Services, Androscoggin Valley Mental Health and Developmental Services, Androscoggin Valley Hospital & Mountain Health Services, Coos County Family Health Services, The Family Resource Center, St. Vincent de Paul Nursing Home, and the United Way of Northern New Hampshire assisting in completing the needs assessment.

The Community Needs Assessment was conducted from December 2001-January 2002 and consisted of key informant interviews, a community survey and demographic and health status data analyses. Representatives from participating health care charitable trusts interviewed key community leaders and attended meetings of school board members and other school representatives, law enforcement, business and economic development, health and human service workers, community board members of health and human service organizations, and municipal government. A total of 130 key leaders from the Berlin/Gorham area participated.

Community input was also elicited through a survey tool developed to assess the broader health and wellness needs of the community. Surveys were distributed to participating health care agencies, social service agencies, faith based organizations and municipalities. A press release was printed in the local weekly newspaper announcing the survey, indicating where surveys could be obtained.

Results of the needs assessment showed the most pressing issues facing the community according to community leaders were a lack of health insurance, a lack of services for the growing elderly population, a lack of dental health services and a lack of preventive health programs. Com munity residents listed unemployment and a lack of opportunities for youth as major concerns.

The provider group developed a collaborative community benefit plan that included working closely with the North Country Health Consortium to support implementation of North Country Cares, a community-wide sliding fee scale and care coordination program, to meet the needs of the uninsured and underinsured populations in the Berlin-Gorham area.


North Country Cares embodies a concept known as care coordination that, simply put, is the integration of available services to address the health and social service needs of the population targeted for assistance. A cornerstone of such a system is entry through any point on the continuum. Additional characteristics include assuring access to appropriate levels of care, monitoring referral and follow up as the patient moves through the care continuum and integrated access to social/human services to address the physical and psychological needs of the whole patient.

In response to the specter of the mill closings, the Consortium proposed in its request for funding to the Endowment for Health to pilot North Country Cares in the Berlin/Gorham health care service area. The Endowment agreed and North Country Cares was on its way to becoming a reality.

Consortium members from the Berlin/Gorham Area came together to form the North Country Cares Berlin Team including representatives from Coos County Family Health Services, Androscoggin Valley Hospital, Androscoggin Valley Home Services, Tri-County Community Action Program (CAP) and Androscoggin Valley Mental Health and Developmental Services. During the course of its work, the Team was expanded to include area clinicians, the NH DHHS District Office and the Berlin/Gorham Family Resource Center.

Target populations of care coordination initiatives usually focus on the management of specific diseases, the provision of care for a population with specific income characteristics or some combination of the two. After reviewing the latest socio-economic data on the area population and keeping in mind the emerging needs of the area population soon to be unemployed, the group decided to focus its initial efforts on the development of a sliding fee scale which would provide access to primary health care and some specialty care based on income criteria. After further discussions, the group agreed that for the first year eligibility for North Country Cares would be limited to those residents of the Berlin/Gorham area whose income was at or below 200 percent of 2001 Federal Poverty Guidelines.

Another important component of the work plan involves the screening of all clients for eligibility for local, state and/or federal programs that provide some reimburse ment for services. The Berlin Team began its work late in 2001 anticipating that North Country Cares could be seeing clients sometime during the summer of 2002.

On July 25, 2002, Dr. James Squires, President of the Endowment for Health, Dr. John Robinson, medical director of Anthem Blue Cross and Blue Shield and Martha McLeod, Executive Director of the North Country Heath Consortium lead a ribbon cutting ceremony to open the North Country Cares office in Berlin.

Much to the surprise of NCC staff, potential clients began seeking services the next day. In fact, the response to the opening of North Country Cares has been overwhelming. Between the opening at the end of July and the middle of October, NCC staff has interviewed almost 100 potential clients and have deemed over 50 eligible for North Country Cares. Clients determined to be eligible receive a card, much like an enrollment card issued by a health insurance company, for their use when accessing health care in the Berlin/Gorham area.

In addition to NCC services, all female applicants have been referred to "Let No Woman Be Overlooked" breast and cervical cancer screening program funded by the NH Office of Community and Public Health and all children have been referred to NH Healthy Kids program. Moreover, NCC staff has been able to access a variety of programs and funding sources for area residents who have presented with a variety of other access issues. NCC staff have secured local Lions Club funding for a client who needed cataract surgery, assisted a client and his/her primary care provider to access financial assistance for care at a tertiary care facility, assisted a new business owner who was looking for ways to provide affordable health insurance to employees - and even making home or hospital bedside visits to potential clients when needed.

The two following North Country Cares case studies highlight the need and the response of the community. Ben, a man in his 40s (the names have been changed to protect the confidentiality of individuals in the community) works at a seasonal business that makes health insurance available only to full time employees. As a part-time employee, Ben is not eligible for health insurance coverage. Three prescription medications a day (two for allergies and one for a stomach disorder) cost well over $200 a month. Faced with limited resources, Ben made the tough decision to stop taking the allergy medicines his primary care provider prescribed. He could only afford to take the prescription for his chronic stomach ailment. Then he heard about North Country Cares (NCC) from some friends. Ben met with Elaine Belanger, the NCC Community Care Coordinator. Elaine assessed Ben's situation and found that his prescription medications were available for little or no cost from the drug manufacturer through a special program for people of low to moderate income. Now Ben can afford to take all of his medications and, above all, he is healthy and able to work. When discussing NCC Ben simply says, "They've been absolutely wonderful".

Then there is Jane, a 40ish mother of two. Jane's family lost their health insurance when her husband's employer left town. Jane's husband is lucky. He found full time employment and his new employer will provide him with health insurance beginning in December. Jane and the children were not so lucky. Although Jane works nearly 40 hours per week, her job is classified as part-time. Jane must work eight more months (for a total of 2 years) before she qualifies for health insurance with her employer. Jane came to North Country Cares to find out what help might be available for insurance for their two children and to bridge the gap she and her husband face before they qualify for employer sponsored health insurance. At NCC Jane was helped to enroll her (adolescent) son in New Hampshire Healthy Kids, a State sponsored health insurance program for income eligible children up to age 19. Because of their low to moderate combined incomes, Jane, her husband and their college-aged daughter were found eligible for the NCC Community Health Care Benefit. Their daughter recently saw the doctor for a throat infection. They paid a small fee for the office visit and will pay only a portion of the costs for lab tests, based on their income. This mom summed up her thoughts about NCC saying, "we really appreciate the helping hand and the peace of mind that comes from knowing our family has a safety net to fall back on if we get sick in the months before we have health insurance again".

North Country Cares Community Benefit Health Care is not insurance, nor is it intended to take the place of employer sponsored health insurance or health insurance from any other source. The NCC Community Benefit Health Care program is possible because Berlin-Gorham area health care providers who participate in NCC agree to offer discounted services to individuals who meet income eligibility criteria. Eligibility is based on economic need, as determined by NCC program guidelines. NCC Community Benefit Health Care is the last resort for providing access to health care for individuals in the community who do not have health insurance, do not qualify for public assistance and are of low to moderate income with few resources.

The North Country Health Consortium, with financial support from the Endowment for Health, plans to expand North Country Cares into other parts of the North Country during the next several years. The specific components of the program may differ from those selected in Berlin and will be determined by the demographics and health status indicators of the target population in each area as well as the ability of the area's rural providers to meet the need.

The key to the long-term success of North Country Cares or any other care coordination initiative is to find ways to make it self-sustaining. This is also the most difficult component of such a project to design and implement, especially in an area with geographic and economic barriers to access to overcome. When reviewing successful care coordination projects in other rural areas two fundamentals relating to sustainability are replicated time and time again. These essentials are 1) changing state Medicaid reimbursement to pay for care coordination and 2) documenting dollars saved through appropriate use of facilities and services which can be turned into dollars to support and sustain the project. The Consortium plans to pursue both of these initiatives to insure that North Country Cares is around to provide service to the North Country community for years to come.


Coos County Family Health Services began working with the NH Charitable Foundation, Anthem Blue Cross Blue Shield and the State of NH to develop a reduced cost prescription drug program for its clients. Through this combination of efforts and with support from CCP, CCFHS was able to put together close to $100,000 in funds to start up the Section 340b reduced cost drug program. With technical assistance and support from the North Country Health Consortium, CCFHS offered access to reduced cost prescriptions July 2002.

Working under contract with a local pharmacy, the CCFHS 340b program has saved their patients an average of 67% on the cost of medications. CCFHS also increased access to medications by utilizing free samples and indigent drug programs and have distributed medications worth over $535,000 to patients in the first 9 months of 2002, a $200,000 increase over the previous year.


As a result of a presentation to the New England Rural Health Round Table by Berlin/Gorham Area providers on the plight of the area and the resultant community collaboration, the Concerned Community Providers were offered an opportunity by the National Association of Counties to bring national consultants on health care reform to the region. The Community Health Leadership Network provided technical assistance to providers from the Berlin/Gorham Area to organize a two-day event that brought together legislative and state policy makers, municipal leaders, business leaders, health care practitioners, faith-based organizations, health and human service providers and community representatives to discuss increasing access to health care. As a result of these efforts, the community has energized to address the issue of health care access. The community is now organizing around an effort to approach the State Legislature to consider a State sponsored adult health insurance program similar to New Hampshire Healthy Kids.


Health and human providers in the Berlin/Gorham Area have joined in a regional effort to improve access to oral health services. The Berlin Area Dental Task Force has joined with the Grafton County Dental Task Force and representatives from Colebrook and Lancaster to develop a strategic plan for increasing oral health services in the region. The group was successful in acquiring a planning grant from the Endowment for Health to hire a consultant to assist in this project.


The crisis in the community caused by the shutdown of the pulp and paper mills created the impetus for forming the Concerned Community Providers. Through this process, the members of the group gained a deeper understanding of the issues facing the community and a clear ability to create mechanisms for addressing those issues. Even though the mill has reopened, the Concerned Community Providers continues to meet to follow through with some of the long term challenges such as improved access to health care for the uninsured and under insured. This broad based community group understands the economic cost to the community for poor health care access and the stress to the healthcare infrastructure when reimbursement rates are low and private insurance unaffordable. CCP applauded the introduction of North Country Cares as a way of beginning to meet the significant health care challenges faced by the North Country.

The next step for the Berlin/Gorham community is to improve health care access based on a model such as that implemented in Muskegon, Michigan. Access Health of Muskegon brings individuals, area business and area health care providers together to develop a private public partnership that relies on contributions from employers, employees and public funding sources to meet the need of uninsured residents ( Small to mid-sized businesses that have not been players in the health coverage field for at least a year, and whose employees make $10 or less an hour, contribute $40-50/month per employee, the employee contributes a similar amount. The community providers match the contribution by providing a community-wide sliding fee scale thus directing additional money to the area's health care delivery system to meet the needs of the uninsured population.

The not-for-profit safety-net providers are virtually the only health care providers in the North Country. The safety-net providers consist of community health centers, rural health clinics, critical access hospitals and rural hospitals. Few private practices exist and these are primarily - specialty services - such as radiology. The payer mix for the safety-net providers has a much higher percentage of Medicare and Medicaid enrollees compared to the rest of the state (as high as 70% compared to average of 40% in the southern part of the state). This indicates an already overburdened health care system that has no place to shift the un-reimbursed costs of public programs. The North Country residents and health care providers are threatened by the area's reliance on publicly funded programs and yet there are few regional or State resources to bring to the table. Discussions in the NH Legislature indicate a desire to decrease costs in the State's Medicaid program, perhaps with a change in eligibility to the NH Healthy Kids program or reducing payments to providers. Both options would have a profound impact on an area whose population relies on publicly funded health coverage and whose providers are already contributing more than they have available.

The population is chronically underserved - with shortages of primary care providers, oral health providers, and mental health providers - and has the triple federal designations to prove it-Health Professional Shortage Area (HPSA), Dental Health Professional Shortage Area (DHPSA), Mental Health Professional Shortage Area (MHPSA). Adults wait 3-6 months to receive mental health services. Parents drive their Medicaid eligible children to a dental clinic in northern VT to find care. Rural health and community health clinics utilize the J-1 Visa program in order to find trained clinicians to work in their clinics.

New Hampshire's North Country is a natural resource-rich area that is the playground for residents of Southern New Hampshire and other parts of New England and the United States and around the world. Northern New Hampshire residents are the stewards of this unique natural resource. The stewardship does not pay well. The burden of health care for the region's residents should be shared by those who share in the North Country's abundance of natural resources.

In the face of these challenges the impetus for creating better access to health care has come from a grassroots effort of local citizens and non-profit agencies. The Concerned Community Providers and the agencies involved in North Country Cares have identified the need and come together as a focused group to address the need. This group is committed to improving the health of North Country residents and preserving the integrity of the local health care delivery system. These organizations and individuals will be looking for the commitment of our State leaders and Legislators in developing a viable long-term solution that ensures essential health care services are available to all residents without regard to the geographic area they reside.


Concerned Community Providers (CCP)- Representatives from mental health, welfare, legal assistance, credit counseling, United Way, the Union, business, the clergy, Coos County Family Health Services (CCFHS) and the Family Resource Center began meeting weekly to address the many health and social services needs caused by the shutdown of the Berlin mills.

Berlin Area Health Consortium (BAHC)-Began in 1995 by the leading Berlin/Gorham Area health and human service providers as a forum to carry out strategic planning.

North Country Health Consortium (NCHC) began in 1997 as a rural health network. NCHC's membership includes five hospitals, two community health centers, home health agencies, and the community mental health and community action programs serving northern New Hampshire. NCHC's mission is to be a vehicle for collaboration among the region's health and human service providers.


Catherine McDowell is the Executive Director of the Family Resource Center and Chair of the Concerned Community Providers. She has worked in the health and social service field in the North Country for the last 25 years.

Adele Woods, MS, is the CEO of Coos County Family Health Services, a federally qualified health center located in Berlin, the current President of North Country Health Consortium and the immediate past chair of the Berlin Area Health Consortium.

Katharine Terrie is the Care Coordination Program Manager at North Country Health Consortium and has spent the last 25 years working on improved access to health care for residents of rural areas in West Virginia, Ohio and New Hampshire.

Martha McLeod, MOE, RD, is the Executive Director of the North Country Health Consortium and Chairperson of the NH Rural Development Council. Martha has worked in the field of community and public health in New Hampshire since 1986.

Mary Ruppert, RN, BSN, is a health care consultant in Littleton, NH. Mary has worked in the home care industry for 20 years and the past President of the Home Care Association of New Hampshire.


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