community needs assessment

Running Head: 2014 COMMUNITY NEEDS ASSESSMENT 1

2014 Community Needs Assessment of the Greater Seacoast Area

Caitlyn Cannone

Michelle Constant

Lyndsey Cote

Laura Sichling

Jill Stowe

The University of New Hampshire

2014 COMMUNITY NEEDS ASSESSMENT

Preplanning

Back in September, our group chose to perform a community needs assessment in the

greater seacoast area. Group members include Caitlyn Cannone, Michelle Constant, Lyndsey

Cote, Laura Sichling, and Jillian Stowe. Performing a community needs assessment allowed us

to focus on a variety of health issues, rather than just one. We were tasked with updating the

existing needs assessment for the seacoast area, which included the following topics of focus:

access to care, mental health, transportation, dental care, and housing and homelessness. Our

group was also asked to add a new portion to the needs assessment regarding the oncology

services offered in the area. As previously mentioned, the population of focus was the entire

greater seacoast area. The following provides more in depth information regarding the

population:

Demographics

The Greater Seacoast area includes twenty- one towns throughout Rockingham, Strafford and

York Counties. The towns included are as follows:

Rockingham Portsmouth Exeter Greenland

Hampton Stratham New Castle

Rye Newmarket

Seabrook North Hampton

Strafford Dover Durham Rochester

Somersworth Farmington Barrington

2


York York Berwick South Berwick

Eliot Kittery

Population

Rockingham County has a population of 299,134 people.1 89,515 residents reside in the

southeastern corner of the county that is included in the Greater Seacoast service area.1 The

population of Rockingham County in its entirety rose by one percent (1.3%) between 2010 and

2013. New Hampshire increased at a rate of 0.5% between 2010 and 2013.1 Rockingham

County’s population is projected to increase at a rate of twenty-two (22.4%) in the years between

2000 and 2030.1

Strafford Country has a population of 124,593 people.1 101,505 residents in Strafford

County are included in the Greater Seacoast service area.1 The population of Strafford County

has grown one percent (1.2%) between 2010 and 2013, which is faster than the rate statewide.

Strafford County’s population is projected to increase twenty-two percent (22.8%) by the year

2030.1

York County, Maine has a population of 199,431 people.1 Only 42,689 residents in York

County are included in the Greater Seacoast service area.1 York county’s population grew one

percent (1.2%) between 2010 and 2013.1

Public Health Agency

Our group was able to complete the community needs assessment with the help of

Portsmouth Regional Hospital. The mission statement of the hospital reads, “To serve our

community with innovative care delivered with compassion and a commitment to excellence”

(portsmouthhospital.com). To fulfill this mission, the hospital must know which areas are

lacking in services so that the needs of their patients can be addressed. Portsmouth Regional

3


Hospital is located at 333 Borthwick Avenue in Portsmouth, NH and services “the people and

communities of the Seacoast region and Northern New England” (portsmotuhhospital.com).

This hospital is part of HCA, Hospital Corporation of America. HCA is an American for- profit

organization that operates 162 hospitals across the United States. Because Portsmouth Regional

Hospital is an HCA owned hospital, there are strict rules and regulations that they must abide by.

Our group was very lucky to have the help of our field agent, Gregory Dalzell. Gregory Dalzell

is the Administrative Director of Oncology Services at Portsmouth Regional Hospital. He was

able to provide guidance and information about oncology services in the region. He was always

available for questions that our group had, and he was also able to connect us with other people

to contact for further research.

Assessment and Analysis

Literature Review

In the process of conducting our community needs assessment, we relied on a large

number of sources to gather the information necessary. Through the use of those resources, we

were able to formulate the 2014 Greater Seacoast Needs Assessment with the most current and

up-to-date information pertaining to the seacoast region. Our findings and literature revealed a

great number of findings regarding the seacoast’s needs. The chapters addressed included:

access to care, mental health, dental care, transportation, housing, and oncology. Through the

use of various types of literature and resources, we were able to fully conduct our needs

assessment and identify our findings.

Access to Care

Resources revealed a large amount of pertinent information regarding access to care in

the seacoast region. The information is divided into four subsections: primary care, children,

4


adults, and seniors.

Primary Care

Evidence shows that access to primary care is associated with better, more appropriate

healthcare, better health, and lower health costs. However, there are considerably less primary

care physicians in the U.S. than other industrialized countries, with a ratio of one-third to one-

half1. The high rates of specialist providers have been shown to be associated with higher, more

costly, and perhaps unnecessary utilization rates in healthcare.

Having adequate primary care physicians available is essential so that people can receive

preventative and primary care when needed. Between Rockingham and Strafford Counties,

access to a primary care physician is roughly 1,300:1 (Rockingham 1,311, Strafford 1,346),

which is slightly worse than the national average.5 The 90th percentile and national average is

roughly 1,050 persons to 1 primary care physician.5 York County is slightly better with a ratio of

1,271:1.5 While there appear to be an abundance and ample choices for primary care providers in

the area, barriers to accessing primary care still remain. According to the 2013 Exeter Hospital

Community Needs Assessment, the UNH Telephone Survey revealed that ninety-five percent

(95.0%) of the population in the area reports having a primary care provider.6 Of those ninety-

five percent (95.0%), eighty-nine percent (89.0%) reported their health status as good, very good,

or excellent.6 Meanwhile, access to the care remains a problem due to high co-payments, lack of

insurance or insufficient coverage.6 Transportation also remains a barrier. This shows that while

access to a primary care is attainable in the seacoast region, barriers still remain to use those

resources appropriately. While access to critical care remains a concern for the greater seacoast

region, children and elderly, the two highest populations of vulnerability should take greater

focus.

5


Children

New Hampshire has one of the lowest rates in the country for uninsured children. Health

insurance is incredibly crucial for children; it ensures that they have access to appropriate

necessary care, including preventative services.

Research shows that uninsured children are more likely to suffer due to inadequate health

interventions, lack of usual care, and have worse health outcomes as a result of no primary

access. In fact, recent statistics show that 1 in 11 children, 7.2 million, remained uninsured in

20127. The growing implementation of public health related insurance programs has helped to

gain insurance for children. Since the implementation of Children’s Health Insurance Program

(CHIP) in 1997, children who are uninsured has dropped forty percent (40.0%)7. Enrollment in

government provided programs has also increased, due to both growing public awareness and

decreased familial incomes. However, the full enrollment of eligible children in government

provided programs has not been reached. Nearly seventy percent (68.9%) of eligible children are

not enrolled in Medicaid or CHIP, according to 2009 statistics.7 According to 2012 statistics

from the Child Defense Fund, eighty-seven percent (87.1%) of children living in New

Hampshire were enrolled in Medicaid and CHIP.7 However, recent research shows that the type

of insurance coverage that you have can contribute to the quality of care that you receive. In

fact, according to a study released in 2011, twenty-two percent (22.0%) of children are less likely

to receive comprehensive primary care than those covered by private insurance.8 With only five

percent (5.4%) of children in NH uninsured, the amount of children not receiving quality care

does not pose grave threat.7

Adults

While the amount of uninsured children in NH is one of the lowest in the nation, the

6


number of uninsured adults remains on the rise. According to a Health Insurance Coverage

Report, an estimated fourteen percent (14.6%) of adults lack health insurance coverage9.

Although the number reflected is not overwhelming, many other individuals experience a gap in

coverage that is usually not recognized. The number of individuals with a gap in coverage is

rising dramatically. According to Gallup-Healthways Well-Being Index, the percentage of

uninsured adults in NH is the highest in the Northeast10. The number of uninsured adults varies

throughout the state, as reported between counties. According to the 2010 BRFSS, Strafford

County uninsured rate (12.1%) is higher than the state’s (as reported by the BRFSS as 11.3%),

and Rockingham County had one of the lowest in the state (7.7%)11.

The number of individuals with comprehensive health insurance provides for a

measurement of health care access. One of the most prevalent barriers identified in the 2013

Exeter Needs Assessment was the cost of health insurance and deductibles.6 According to the

2008 assessment, forty-nine percent (49.0%) of respondents to the UNH Telephone Survey

reported that they did not have insurance because they could not afford it.12 This correlates

directly with the fact that New Hampshire has some of the most expensive health care costs in

the country.13 In 2008, eighteen percent (18.0%) of the state’s economy was spent on personal

healthcare, doctors’ visits, hospitalizations, medicines, and more, according to the NH Center

for Public Policy.14 However, pricing of interventions is highly dependent on where the person

seeks heath care treatment.14 There is a seventy-one percent (71.0%) differential in pricing

between the least expensive hospital and most expensive hospital in New Hampshire.11 Speare

Memorial Hospital in Plymouth, NH was noted as nineteen percent (19.0%) below the average of

NH healthcare costs, while Exeter Hospital was fifty-two percent (52.0%) above the average.13

With the increasing amount of economic costs and price disparities, the gap is broadening

7


in health care coverage, leading to furthermore unobtainable health care access. These increased

costs are absorbed through out of pocket health care costs and higher premiums. According to

the 2008 UNH Telephone Survey, sixty-five percent (65.0%) of respondents spend more than

twenty-five dollars per month on healthcare, while twenty-six percent (26%) report spending

more than one hundred dollars.12 Meanwhile, national family based premiums for job-based

health insurance increased seventy-eight percent (78.3%) between 2007 and 2009.15

Several Organizations in the Seacoast region work together to bridge the gap in health

care. Ninety-one percent (91.0%) of seacoast respondents reported having no problem accessing

health care in the area.12 Meanwhile, only fifty-four percent (54.0%) knew of a place to get health

care without insurance.12 Of those respondents, they listed the Emergency Room services or

hospitals, Lamprey Health Care, SeaCare, and Families First.12 Thirty-eight percent (38.0%)

gave other responses than those listed above.12

With today’s economy, access to care without health insurance is in high demand. The

heightened demand also results in increased burden on hospitals. It is seven times more likely

that uninsured adults will consider the emergency room their usual source of care.12 That being

said, thirty-three percent (33%) of seacoast respondents who visited the ER in the past twelve

months considered visiting their primary doctor first.12

Providers who offer services to uninsured individuals are currently absorbing much of the

costs. National studies show that the majority of uninsured adults are actually eligible for

publicly provided services, but have barriers to accessing them.16 These barriers include, but are

not limited to knowledge of the programs available, eligibility criteria, time to complete the

application, renewal process, cost of premiums for incomes above poverty level, and language.16

In New Hampshire, the greatest barrier to Medicaid enrollment is the eligibility requirements.

8


New Hampshire has one of the lowest eligibility limits for parents. Even with the strict

requirements, NH Medicaid enrollment has increased eight percent (8.3%) between 2009 and

201017. It is expected that the trend will continue to increase in the coming years.

Seniors

The ability of the elderly to access healthcare will continue to become more difficult as

health care becomes more expensive and the population continues to grow older. Being that the

elderly have the highest rate of hospital admissions and ER visits, it is especially crucial that

access to health care is available. According to the UNH Telephone Survey ninety-six percent

(96.0%) of seacoast residents over the age of sixty had a primary care provider.12 The majority of

those have been seeing their provider consistently over ten years. Ninety-six percent (96.0%)

reported seeing their primary care provider in the past 12 months12. With new health care

reforms, Medicare health coverage does not guarantee elderly patients access to health care

services. This also does not guarantee them to see their current provider, which thus could

negatively affect patient relationships. Each year more and more health care providers are opting

out of Medicare and Medicaid, making it harder to obtain a primary care provider. With the

rates of reimbursement, payment delays, and increases in operating costs, providers are finding it

harder to financially sustain their practices.

The Seacoast area has an ample amount of care providers servicing the area. The

providers in the area may be considerably underutilized. The largest barrier to accessing health

care is not finding access, but actually the patient’s lack of personal insurance. With a lack of

insurance and heightened medical costs, people in the Seacoast area are relying less and less on

the use of primary care providers. This in turn has increased the number of Emergency Room

(ER) visits, which are a result of patients’ lack of primary care providers because of the out of

9


pocket costs. With the number of providers in the Seacoast Region sufficient to service the area,

and the use of those services readily accessible, ensuring the residents of the region have

insurance and the ability to use those services is especially important.

Mental Health

The literature also revealed many important developments in mental health in the

seacoast region. This section, like access to care, is also divided into many subsections to create

specifically organized material.

The Greater Seacoast 2011 Community Needs Assessment noted that New Hampshire is

in immense need of a comprehensive, integrated and coordinated system regarding mental health

concerns18. As of 2014, this fact remains unchanged. Most reports have not been updated since

the 2011 needs assessment; however, it is known that mental illness and health is still an area in

the health care system of New Hampshire that must be reassessed.

The national occurrence of adults with a diagnosable mental health condition still stands

at twenty-six percent (26.0%), as cited in the last needs assessment.19 If this is true for New

Hampshire as well, than over 250,000 adults living in the state would be in this category.19

According to the National Alliance on Mental Illness (NAMI), in 2010 there were approximately

43,000 adults and 14,000 children living with serious mental health conditions in New

Hampshire20. Furthermore, NAMI has found that only twenty-one percent (21.0%) of adults in

the state living with a mental illness are able to access the public mental health system20. Mental

illnesses are disorders of the brain and environment which can cause life changing disabilities

when untreated2. With such high prevalence and such low accessibility rates for mental health in

New Hampshire, one can clearly understand the dire need for increased mental health care

facilities and treatment centers.

10


The 2011 Greater Seacoast Needs Assessment cited several risk factors for mental illness

including income, employment status and age. NH policy upon which these risk factors were

cited is still the most current21. It is clear that low socioeconomic status is the greatest risk factor

for mental illness. Nationally, about twenty-one percent (21.0%) of children of low

socioeconomic status aged 6-17 have mental health conditions. 21 Unemployment may put

individuals at risk for exacerbating or bringing forth a mental illness. The increased stress, along

with lack of accessibility to treatment facilities, may increase ones risk for mental illness. 21

Unemployed men are three times more likely than employed men to develop a mental illness.

Alongside this idea, unemployed men are twice as likely as unemployed women to have poor

mental health. 21 These facts speak to the idea that not only does job status affect ones risk for

mental health, but also gender. One other point brought forth by the 2011 Needs Assessment

relates to age. Half of all lifetime cases of mental illness begin by age 14, and seventy-five

percent (75.0%) begin by age 24.22 However, it is also expected for the amount of mental illness

in the older adult population to double in the coming decades.23 With an early onset and

increasing rate of diagnosable disorders in older adults, the prevalence of mental illness seems to

be unstoppable.

Availability

The availability of mental health resources has not significantly changed since the 2011

Needs Assessment. Several points from the past assessment are important to recall. As

explained above, there is a significant need for an increased psychiatric workforce in New

Hampshire. In 2009, NH ranked lowest in Northern New England for child mental health

providers.24 The seacoast region specifically is experiencing a shortage of psychiatrists.2 Based

on survey results, primary care providers have reported that they do not feel they have adequate

11


training to care for mental health patients.2 However, parents reported that they will turn to their

child’s primary care providers first for mental health issues.24 With insufficient resources in the

state, individuals are unsure of where to turn for mental health needs, resulting in insufficient

care.

Facilities in the greater seacoast region are limited. Portsmouth Regional Hospital has

the Behavioral Health Unit, which is available as an inpatient facility for patients 15 years of age

and above. The hospital has recently added several new beds due to increased demand25.

However, the need is still immense. The Seacoast Mental Health Center is designated as one of

the state’s community mental health centers.26 The facility is mandated to provide evaluation to

individuals of all ages, regardless of their ability to pay for the service.26 This facility provides an

array of psychiatric and supportive services for clients.26 In the area there is also Community

Partners, who provide mental health services to individuals of all ages.27 For the older adult

population, Frisbee Memorial Hospital in Rochester has and inpatient and outpatient Geriatric

Psychiatry unit, dedicated to the mental health treatment of the elderly.28 The Greater Seacoast

area is comprised of sections of three different counties, Rockingham, Strafford, and York, and

contains over 235,000 residents. With such a great demand, the few facilities available are

insufficient to meet the growing demand of mental health needs.

Increasing Demand

According to a report addressing the critical mental health needs in NH, there are several

reasons why the state is increasingly challenged to service the growing mental health needs.29

These factors include population increases, decreased Medicaid funding, lack of inpatient

facilities, increasing homelessness, increased hospital stays, and psychiatric services shortage.29

12


As an initial thought, the population of NH is growing, and with a growing overall

population, comes a growing number of mental health patients. According to the 2005 state

population projections, NH will host over 1,500,000 residents by 2020.30 According to NAMI

NH, one in five older adults suffers from diagnosable psychiatric illness.23 The amount of older

adults with a mental illness is expected to more than double in the coming decades.23 Also,

services for children are at an increased demand.21 Approximately 56,000 children in NH suffer

from a diagnosable mental health condition. Not only is the current prevalence high in children,

but also the at risk children. Approximately one quarter of all children in New Hampshire has

experienced a traumatic event and almost 10,000 have a serious emotional disturbance; both of

which put these individuals at increased risk for developing a serious mental health disorder.21

With a growing overall population, alongside a growing mental health and at risk population, the

need for more facilities and resources is tremendous.

The second possible factor in regard to increasing mental health needs in NH relates to

Medicaid. Over the past 15 years, the Medicaid spending for individuals with persistent mental

health needs has gone down, while the cost of providing the services required has increased.29 If

this trend were to continue, than there would be less ability to build additional mental health

resources, with a growing patient population. If patients are under treated or completely

untreated, than their illnesses may become more severe, putting pressure on other state resources,

such as law enforcement agencies, emergency rooms, the court systems and county jails.29

Approximately thirty-eight percent (38.0%) of all Medicaid mental health expenditures were

provided to adults over 60 years of age.19 If the population of older adults with mental illness is

to increase, as described above, than increased Medicaid funding will be required to fulfill the

need. As lawmakers continue to cut budgets for mental health resources, individuals will have

13


no place to access affordable mental health services.29 Mental illnesses will remain prevalent in

the area, but without access to affordable facilities and resources, their severity may increase.

Pressure on other state facilities and resources, such as emergency rooms, only adds more of a

load to the system and becomes more costly, overall.29 There needs to be an affordable way for

these individuals to access the treatment they require, especially when considering that a great

number of mental health patients are at a low socioeconomic status, as discussed above.

As of late, the inpatient and residential alternatives for mental health treatment have been

declining in NH, as well as nationally, over the past 20 years.29 There are approximately 7,000

adults in NH with persistent mental illness, and very few in patient or residential options for

these individuals.29 As of the 2008 report, there are only 186 inpatient beds dedicated to mental

health concerns across the state and only 203 residential group home beds available.29 There is

currently only one hospital-based designated receiving facility, with only 8 beds available. In

addition, the number of Acute Psychiatric Residential Treatment Program beds decreased from

52 to currently 1629. With three different psychiatric units having closed within the last ten

years, and the increasing mental health prevalence, this is a huge barrier to treatment. The only

facility in the Greater Seacoast area with an inpatient mental health treatment facility is

Portsmouth Regional Hospital, hosting the Behavioral Health Unit.25 This unit has added a few

more beds for mental health patients, however the demand is still enormous compared to the

supply.

One other factor addresses the issue of mental health and homelessness. Individuals with

mental health conditions who rely on Social Security as their main income cannot afford housing

in most cases, leading to housing instability or homelessness.29 The challenges of mental illness

alongside a lack of housing can lead to significant impairment and greater difficulty in accessing

14


supports or services.31 This can lead to increased hospitalizations and of longer durations.31 As of

the 2008 report, there is a six- year wait for individuals with mental illness to receive federally

funded housing assistance.29 Even if one is to gain funding, it is difficult for these individuals to

find willing landlords in their price range.29 With all of these factors combined, New Hampshire

Hospital has become a harbor for these individuals. There is already a need for inpatient

facilities in the state, longer duration of stays in these facilities only adds to this barrier to care.

New Hampshire Hospital is not the only facility to handle the increased duration of stay

for mental health patients; other hospitals that admit these patients have been enduring the same

effects.29 These patients have multiple barriers to discharge including high level of treatment

needs, legal risks, scarcity of community resources, and lack of residential and housing

availability.29 Also, a subset of the mental health population may take part in high-risk behavior

if discharged without proper ongoing treatment planned.29 With so many factors and barriers to

care for these individuals, the only safe place for them at the time may be the hospital setting,

leading to increased duration of stay.

A final factor regarding the increased mental health care demand addresses the shortage

of psychiatric treatment. There are approximately 200 psychiatrists in NH, which is only about

1.3 per 10,000 residents.29 If one assumes that the national average of adults with mental illness

of twenty-six percent (26.0%) applies to New Hampshire, than it is clear that there is an

inadequate amount of psychiatrists to meet the demand. On top of the lack of psychiatrists, there

is a complete turnover of psychiatric staff about every five years.29 Mental illness is complex and

often requires lifelong treatment. If patients are required to give their complete history to new

physicians every five years, their care may suffer, possibly resulting in worse prognoses.29

Chronic mental illnesses require consistent treatment and care teams dedicated to the long term

15


health of the patients. If these individuals are given new health care providers every few years,

consistent care cannot be expected. With a lack of good health care support, patient prognoses

will suffer, only adding to the cascade of increased needs.

Depression

The World Health Organization (WHO) describes depression as the leading cause of

disability worldwide, affecting over 350 million people throughout the world.32 About 15 million

Americans are affected by major depression, which is about eight percent (8.0%) of the U.S.

population of individuals over the age of 1833. Depression is often untreated; in the U.S. eighty-

percent (80.0%) of individuals diagnosed with this disease are not receiving any treatment33.

However, depression is one of the most treatable illnesses, with eighty to ninety percent (80-

90%) of patients experiencing relief from their depression when treated. When untreated,

depression can cause a decrease in quality of life, impairment in social and occupational

functioning, suffering, and increased health care costs along with an increased rate of chronic

medical conditions.34 It is known that depression weakens the immune system, putting these

individuals at risk for other medical illnesses. In conjunction with this idea, residents of New

Hampshire suffering from depression were found to be more likely to smoke and not exercise,

when compared to those of the general population24. With added health risks on top of their

mental illness, these individuals are at high risk for other medical diseases. If a patient cannot

access care to treat their primary disorder than receiving care for secondary conditions only adds

another barrier to care.

In the U.S., there are several trends to note when understanding depression. Women are

more likely to develop depression over men33. When regarding race/ethnicity, the non-Hispanic

black population had a higher prevalence rate of depression over non-Hispanic white persons34.

16


The highest rates of depression occur in those aged 40-59 years old, compared to any other age

group.34 The prevalence of depression in New Hampshire is also higher in individuals with lower

education and adults who are out of work or unable to work.2 Poverty status can also affect

depression; individuals who fall below the poverty line have higher rates than those above it.34

This statement is accurate for New Hampshire specifically, as well; individuals with incomes

below $35,000 reported greater difficulty in paying for medical care. Eighteen percent (18.0%)

of adults in New Hampshire indicated that they would not be able to afford medical care.24

Families and persons in low socioeconomic status may be forced to choose between providing

necessities for life, or paying for mental health care. With the increase cost of care, it may not

seem efficient to these individuals to use their limited income on prescriptions or therapy for

their mental health needs.

The 2006 New Hampshire BRFSS report cited in the 2011 Greater Seacoast Needs

Assessment is still the more current source of information regarding depression prevalence in

New Hampshire. At this time it was estimated that 60,000 NH adults suffer from current

depression, accounting for about seven percent (6.8%) of the population35. Approximately

seventeen percent (17.2%) of New Hampshire adults reported having been diagnosed with

depression at one point in time by a health care provider.35

In regard to the counties in the greater seacoast region of New Hampshire, the 2006 NH

BRFSS is also the most current source of data. The report found that fifteen percent (15.1%) of

adults in Rockingham County and nearly twenty-one percent (20.8%) of adults in Strafford

County were diagnosed with depression at some point by a health care provider.35 The rate of

depression in York County was reported to be at eighteen percent (18.0%), compared to the

Maine overall depression rate of nearly fifteen percent (14.9%)36. Even more astonishing in

17


York County is that twenty-four percent (24.0%) of adults reported having been diagnosed with

depression at one point in their life; this rate is higher than the state average, twenty-two percent

(22.1%), as well.36

Depression can be costly to the system as well. Between 2003 and 2007 mental illness

related conditions ranked in the highest reasons for both inpatient and emergency department

admissions. Over the years, mental illness related admissions have increased in New

Hampshire.2

Children

Children are at an increased risk for developing depression, especially when other risk

factors, such as low socioeconomic status, are prevalent. Overall mental health disorders affect

approximately twenty percent (20.0%) of NH children ages 5-19 years3. In 2009, depression was

reported in New Hampshire high school aged students at a rate of twenty-five percent (25.0%)3.

The highest rates of depression across the lifespan occur between the ages of 15 and 24.21

Depression can be extremely harmful to a child’s growth and development.

Assessing depression in children can be very difficult. Language barriers and

developmental milestones must be understood in order to best communicate with this patient

population. The children may also be resistant to admitting feelings of depression, for the fear of

being a burden on the family. Depression also puts children at an increased risk for other

harmful behaviors, such as substance abuse and an increased risk of suicide.21 With an extreme

lack of child psychiatrists in the greater seacoast region, this patient population is at high risk for

serious mental illness and worsening condition. As described above, parents are unsure of where

to turn for care of children, which may result in inadequate or absent mental health resources

being provided for the child. With such a high prevalence rate of depression in children in New

18


Hampshire, it is important to be aware of the risks associated with this diagnosis and the lack of

appropriate care available for this patient population.

Suicide

As of 2012, suicide was the fifteenth leading cause of death worldwide, accounting for

one percent (1.4%) of all deaths37. With statistics such as these, suicide has become a major

global concern37. It is also a main concern in New Hampshire specifically. According to the

2013 NH Suicide Prevention Plan, there are several trends related to suicide rates locally. It was

the second leading cause of death among 15-29 year olds world wide.38 Between the years of

2004-2013, 188 NH residents aged 10-24 lost their lives due to suicide.38 It is the second leading

cause of death for those aged between 15-34 years of age in NH.38 The total deaths by suicide in

2013 alone were 182 deaths, with the majority occurring in the 45-64 year old age group38. With

regard to gender, male deaths by suicide outnumber female deaths by nearly four to one39. It is

curious to note here that females, however, have hospitalizations related to self-inflicting injuries

at almost two times the rate of males. This may be due to the fact that males tend to use more

lethal methods of suicide38.

On average in NH, 156 residents will die due to suicide, 185 will be hospitalized due to

suicide attempts, and 945 will be treated in emergency departments due to self-inflicted

injuries38. The NH Suicide prevention plan notes that suicidal behaviors, including attempts and

completed deaths, are a significant cause of inpatient hospitalization, emergency and outpatient

treatment38. This can be very costly, amounting to approximately $16.8 million in acute health

care costs38. This amount does not include outpatient services post discharge. The cost of care

after suicide attempts could be drastically reduced with more preventative supports and

resources. As described above, mental illness is highly prevalent in the greater seacoast region.

19


A major risk factor for suicide is a history of mental illness. Without available care to treat these

mental illnesses, they could worsen and result in patients attempting suicide. The dramatic rates

of suicide and extreme health care costs should prompt officials to push for greater mental health

resources for the greater seacoast population.

The leading suicide methods both in New Hampshire and nationally are

hanging/asphyxiation and firearm wounds38. In New Hampshire, the majority of violent deaths

are suicides2. Suicides outnumber homicides by over eight to one in the state, between the years

of 2004 and 200838.

Specifically to the greater seacoast area, suicide has become a major issue. From 2007-

2013, the crude suicide death rate across all ages for Rockingham County was approximately ten

percent (10.0%) and approximately twelve percent (12.0%) for Strafford County. Compared to

the rest of the state, these rates are low; however, they are higher than the national average,

calling them into concern38. The Emergency Department discharge rates for self-inflicted

injuries are greater in the Strafford County, compared to that of the Rockingham County2. The

emergency department discharge rates are as follow, twenty-one percent (20.8%) for Strafford

County, ten percent (10.3%) for Rockingham County, and twelve (12.3%) for NH overall40. It is

clear that the issue of self-injurious behavior and suicide rates in Strafford County are of serious

concern at this time.

Suicide and suicide attempts affect a great number of people. For each suicide death,

family and close friends are at a higher risk for self-inflicting injuries or suicide themselves.

There are approximately six individuals for each person who has been killed due to suicide.

With a high rate of suicide already on board, health care professionals cannot ignore all of these

other individuals who are now at risk for the same fate.

20


Substance Abuse

Substances harmful to the body may put the user at risk for harm and addiction.

Addiction is similar to other disease, in that it is preventable, treatable, changes, and can last a

lifetime if untreated41. Addiction is a disease of the brain and can be detrimental to human life if

it becomes serious enough41. There are approximately 22 million Americans that suffer from

drug use and addiction41.

The 2011 State Health Profile found that nearly six percent (5.5%) of NH adults reported

heavy drinking, which is similar to the national rate2. Heavy drinking appeared to be most

common in the young adult male population2. In 2009, sixteen percent (16.0%) of adults in New

Hampshire reported binge drinking at least once in the past month. This rate is also similar to

the national average2. The alcohol abuse and dependence rates of NH adults remain among the

highest in the nation. The rate for youth aged 12-17 was eight percent (8.0%) and for 18 to 25

year olds the rate was 23%3. This rate is of great concern due to its constant increase.

Adolescents are susceptible to peer pressure and the mimicking of behaviors. Seeing parents and

friends indulging in excessive amounts of alcohol may put them at risk for the same behaviors.

Alcohol abuse at young age can be extremely harmful to the brain and development41. Health

care providers must be aware of the high prevalence of alcohol abuse in youth and take

preventative measures so further harm does not occur.

Approximately ten percent (10.0%) of adults in New Hampshire used illicit drugs in the

past month, according to the SAMSHA survey2. This rate is substantially higher than the

national average of eight percent (8.0%). Adults aged 18-25 years were most often the illicit

drug users2. As of 2010, treatment capacity for substance abuse exists for less than ten percent

(10.0%) of the need3. Also, youth who need substance abuse treatment are among the lowest

21


cared for in New Hampshire3. The Portsmouth Regional Hospital Behavioral Health Unit has an

inpatient facility that treats addiction and substance abuse, but only for patients 15 years of age

and older25. There is no child inpatient facility in the Greater Seacoast Region.

All together, there is a lack of child psychiatrists, no inpatient child facility, and a

growing problem of substance abuse in adolescents in New Hampshire. Without stopping the

problem early on, addiction may occur and be troublesome for this population throughout their

lifetime. The effects on emergency rooms and law enforcement services will be burdened

heavily by the drastic effects of drug use.

Dental Care

Lack of dental care can be extremely detrimental to health. With the use of outside

literature and resources, we were able to discover where there were health disparities in dental

care in the seacoast region.

In order for America to have good overall health, dental care is essential. Unfortunately

many people today do not have access to or cannot afford to see a dentist. Recent studies show

that there are 108 million Americans do not have dental coverage42. Currently, the US spends

about $64 billion every year on dental care and government programs pay only four percent

(4.0%) of that42. Vulnerable populations face many barriers to accessing the dental care they

need such as expensive costs, lack of insurance, shortages of dentists and hygienists, language

and cultural barriers and gaps in information about dental services.

Dental insurance is one of the main factors that influence access and utilization of oral

health care. New Hampshire is no different from the rest of the country when it comes to dental

coverage. In New Hampshire, eighty-nine percent (89.0%) of residents have health insurance,

which is one of the best percentages in America43. Health insurance however, does not include

22


dental for most of these residents. Medicare in New Hampshire and Maine does not include

dental coverage. It will not cover routine checkups, cleanings or pay for fillings. Medicare also

will never pay for dentures44. There are around 137,000 New Hampshire residents are on

Medicaid, which is about ten percent (10.0%) of the state45. In New Hampshire, Medicaid also

does not cover dental treatments unless it is for emergency treatment46.

Throughout New Hampshire, there are 14 federally qualified community health centers.

While many of the services focus on those who are low income and uninsured, anyone can

contact them for help, and no one is turned away. Individuals of all income levels and

backgrounds can get free or low cost dental care from the centers located across New Hampshire,

including Exeter and Portsmouth. These facilities help those without insurance throughout the

seacoast, afford the care they need47.

Lack of access to dental facilities in individuals can result in delayed diagnosis, untreated

oral diseases and chronic conditions. According to a survey done by the New Hampshire Oral

Health Program, twenty- two (22.0%) of residents said they have had problems getting dental

care when they need it. Of those who had a problem, seventy-five (75.0%) were because they

could not afford it, eighteen percent (18.0%) were fearful of the dentist, seventeen (17.0%)

couldn’t get an appointment, twelve (12.0%) did not have transportation and two percent (2.0%)

had a dental provider that was not handicapped accessible. In New Hampshire, forty percent

(40.0%) of older adults have not had a cleaning or visited a dental office in the past year. Of the

older adults surveyed, sixty-two (62.0%) reported that they do not have dental insurance48.

Older adults have a difficult time paying for their dental care including dentures and not having

dental coverage makes this even more difficult.

23


Declining numbers of dentists and practices may become a problem in New Hampshire in

the future. Currently in New Hampshire, the majority of dentists are located in the Seacoast

area. Between the two counties, Strafford has twenty- four (24.0%) of dentists and Rockingham

only has eight percent (8.0%). Dental care will be changing in the future. By 2020, the amount of

dentists is expected to decline by fourteen percent (14.0%)49. A shortage of available dentists

could be very detrimental to New Hampshire’s dental health. With transportation being an issue

for many Seacoast residents, if the dentist they typically go to retires or is let go for budget cuts,

many NH residents will not be able to travel to other dentist offices for care.

The New Hampshire Dental Society released an update in 2014 on the old “Something to

Smile About” program from 2010, entitled “More to Smile About.” This update includes the

improvements that New Hampshire has done in dental care in the past four years. In 2010, New

Hampshire’s primary goal was to increase education regarding preventative oral health. Since

most dental heath problems are preventable, the NH dental society has been working hard to

educate people about how dental health affects overall health. Since 2010, this program has been

used to promote preventive initiatives such as sealants, the use of school-based programs to

screen young children early in life, and water fluoridation. Sealants, in young children, are one of

the most effective ways to prevent tooth decay and cavities. As of 2014, NH is one of the five

states in the country that received a grade A in sealants. New Hampshire now has sealant

programs in over seventy- five (75.0%) of its high-risk schools. These are schools where more

than fifty percent (50.0%) of the students participate in federal free and reduced-price lunch

programs, and are thus considered to have some of the most at risk children. These school based

dental programs have made a large improvement on the oral health in New Hampshire. As the

number of kids who have received sealants increased, the number of children with decay history

24


and untreated decay has decreased. In 2013, 45 New Hampshire dentists participated in a

program called Give Kids a Smile Day. In the Seacoast area alone, cleanings, fillings, and

educational screenings were provided to patients at a value of over $10,000. New Hampshire has

also increased their amount of dental providers. New Hampshire now has 64.4 dentists per

100,000 residents. This is higher than the national average of approximately 59 dentists per

100,000 people. This ranks New Hampshire 15th in the country for ratio of provider to

population.50

New Hampshire’s public school systems have helped to create opportunities for students

to receive the care they need. Back in 2009, there were 21 – school based programs for

preventative dental care. These programs served 37,424 students and were implemented in 168

schools, which was fifty-three (53.0%) of the total elementary schools across the state.1 Since

then, New Hampshire’s school-based programs have continued to increase. Many public schools

have a working hygienist that provides care to the students or use the Mobile Dental Van that

provides care to students who cannot receive help outside of school due to financial reasons or

lack of access. The Greater Derry Oral Health Collaborative Corporation (GDOHCC) has been

working since before 1993 to instill more programs in New Hampshire schools to promote dental

care. Today, the GDOHCC dentists and hygienists use the best available evidence and best

practices from other school-based programs to develop their clinical preventive practice models.

The people working for this corporation have strong connections to the school nurses in New

Hampshire. They collaborate with them to find out which students are likely to need our services

and work hard to get permission forms for their treatment. Hygienists come to the school and

teach the students about brushing their teeth, use fluoride varnish and sealants to maintain

students’ oral health by preventing decay and provide interim temporary restoration (ITR), which

25


are fillings for small cavities, to the students who have teeth decay. New Legislation was passed

in early 2012 to create a new member of the dental workforce: the Certified Public Health Dental

Hygienist (CPHDH), who will be able to place ITR without excavation and take X-rays in

addition to other services already permitted under public health supervision. This has greatly

improved the effectiveness of ITR. In the past, students who needed fillings would need to wait

until the dentist was present to receive them, some students would be absent or forget their forms

on the day the dentist was present and could not receive the care. Now, a specially trained

hygienist can complete all the work on one day and prevent this from happening. Medicaid only

covers about twenty- five (25.0%) of the student population served; most lack dental insurance.

Programs like GDOHCC require considerable grant funds and contributions to operate.51

New Hampshire has made a lot of progress in the past 4 years when it comes to dental

care. Educational programs have put New Hampshire ahead of many other states when it comes

to preventative dental measures. Dental coverage remains a problem for most Americans,

including residents in the Seacoast area of NH. Since dental is not covered by Medicare and is

only covered in Medicaid when it is a medical emergency, many people are left without the

ability to pay for dental cleanings let along any dental problems that arise. Transportation

remains a major problem in the Seacoast area and this hinders the accessibility to many facilities.

Housing

The housing chapter of the needs assessment revealed many concerns regarding areas of

improvement, through the use of the literature. Outside resources helped us to discover the most

up-to-date information, to further formulate recommendations.

The Greater Seacoast area is perhaps one of the most desirable areas to inhabit within the

states of New Hampshire and Maine. This can be attributed to financial securities, such as low

26


unemployment rates and a steady economy, and also to the scenic beauty of the area. The

desirability of this region has remained constant over the past few decades, as has the increase in

demand in the housing market. The New Hampshire housing market peaked in 2005, when the

median price for a single-family home was $270,000. Following this economic high, the market

saw four consecutive years of a decreasing market. Since 2009, the state has been witnessing a

“normalization” of the market.52 Between 2008-2012, the median household income of the New

Hampshire Seacoast area was $68,238 per year, and the average value of an owner- occupied

housing unit between 2008-2012 was $256,25053. This is 3.76 times the average household

income. In 2013 the median home price in York County was $210,000, which is 3.9 times the

average household income of $54,18054. According to the Maine State Housing Authority, it

would take a household income of $59,666 to afford the median home price55, which is ten

percent (10.1%) more than the average household income. However, despite the financial

obstacles, homeownership rates remain higher than the national average of sixty- five and a half

percent (65.5%). From 2008-2012 the homeownership rate in Strafford County was almost

sixty- seven percent (66.8%). This is a three percent (3.6%) increase since 2000. Rockingham

County had a seventy- seven percent (77.3%) home ownership rate in 201256, which is a two

percent (2.2%) increase since 2000. The home ownership rate in 2012 was seventy-three percent

(73.1%) in York county.53

From 2006 to 2008, subprime mortgages more than doubled nationally. Sub prime

mortgages allowed individuals with low credit scores to buy a home. From 2005-2010, the state

of New Hampshire saw an increase in foreclosures from 462 in 2005 to 3,953 in 201057. This is

a seven hundred and fifty-five percent (755%) increase in five years. Since 2010, New

Hampshire foreclosures have been in decline, and the housing market has begun to stabilize.

27


The Seacoast area is home to many renters. This is in part due to the high median cost of

a home in the Seacoast area. In Rockingham County, twenty-four percent (24.0%) of the

population rents living space58. Nearly thirty-six percent (36.0%) of the population in Strafford

County rents living space59 and in York County twenty-seven percent (27.0%) of the population

rents living space60. Data from 2009 reveals that the median contract rent in Rockingham

County is $920, which is higher than the state average of $825. Strafford County has a median

rent of $798. The average rent in York County, Maine is $747, higher than the state average of

$626. Much of the population struggles to meet ends meet with high rental costs such as these.

According to the New Hampshire housing Finance Authority, housing is considered affordable if

it costs thirty percent (30.0%) or less of a household gross income. As of 2013, an average two-

bedroom apartment in the state of NH cost $1,076 per month.61 For a single parent that makes

minimum wage and works 40 hours a week, gross income is $15,080 per year, if he/she worked

52 weeks a year. If a two bedroom apartment was to be considered “affordable housing” for this

individual, he or she would have to work 2.9 jobs 40 hours per week, which is not possible.

Approximately 55,000 NH renters pay more than thirty percent (30.0%) of their income for

housing. Fifty percent (50.0%) of these people pay more than fifty percent of their income

towards housing3. These statistics highlight the need for affordable housing options in the

seacoast. HUD, The U.S. department of Housing and Urban Development Public Housing

Program provides affordable rental housing to eligible low-income families. There are many

criteria that must be met to be eligible. The U.S. Department of Housing and Urban

Development generally gives New Hampshire approximately $200 million each year62.

However, the state is still facing a crisis in finding funds to help all those in need of low-income

housing. As of September of 2013, the Portsmouth Housing Authority reported nearly 360

28


individuals on their waiting list alone in need of low- income housing. Crossroads House in

Portsmouth, NH stated that their 96 beds are full every night of the week because of the inability

of people to afford rent. Further cuts to publically funded programs would mean longer waits for

those already on the wait lists, and increases in people on the waiting lists. The state of Maine,

the MaineHousing’s Section 8 Housing Choice Voucher program provides eligible renters with a

subsidized portion of their monthly rent63. The need for low-income housing options is dire in

the seacoast region. Without low-income housing options, these individuals become homeless.

Homelessness

With such difficulties finding affordable housing or low-income housing, many

individuals and families find themselves without a home. Some factors that attribute to

homelessness are job loss, divorce, illness, and low wages. As of September 2014, New

Hampshire ranks 7th overall for lowest unemployment rates at four percent (4.3%). Overall,

unemployment has been trending downward in the seacoast area. In 2012 Strafford County had

an unemployment rate of five percent (5.4%). As of September of 2014, the unemployment rate

is three percent (3.7%). Similarly, Rockingham County has seen a decrease in unemployment

from five percent (5.9%) to four percent (4.4%) from 2012 until September 2014. Similar trends

are occurring in Maine. York county unemployment rates decreased from seven percent (7.2%)

to five percent (5.8%) from 2012 to September of 2014. Despite the decreasing trend in

unemployment, there is an increase in the number of homeless individuals. The New Hampshire

Department of Health and Human Services Bureau of Homeless and Housing identified 2,576

homeless people in New Hampshire in 2013. This is a five percent (5.0%) increase from 2012

when 2,438 homeless individuals were identified.61

29


The State of New Hampshire Administrative Rules define homelessness as an individual

or family that lacks a fixed, regular, and adequate nighttime residence or a family or individual

who has a primary nighttime residence that is a shelter, transitional housing, an institute that

provides temporary residence for individuals intended to be institutionalized, or a private or

public place that is not designated for sleeping accommodations of human beings64. Other

factors that can contribute to homelessness are mental health disorders, physical disabilities,

poverty, and tragedy. In 2013, the average length of stay in an emergency shelter was 58 days.

This is almost a fourteen percent (14.0%) increase from 2008, in which the average length of

stay was 51 days. Nearly thirty-six percent (36.0%) of sheltered individuals in NH were

identified as temporarily doubled up or couch surfing. This means that these people do not meet

the definition for homeless that is provided by the HUD. Therefore they are not eligible to

receive aide in finding low- income housing, although they are homeless in the sense that they do

not have a permanent nighttime residence. For individuals who make thirty percent (30.0%) of

the area median income, affordable rent would be approximately $535 per month. In the

seacoast area this only accounts for one percent (1.1%) of available housing in the area.

In 2013, there were 4,732 individuals sheltered in both emergency and transitional

housing in the state of New Hampshire. Of these sheltered, 3,110 were adults. There were 689

families made up of 720 adults and 902 children. In January of 2014, the state performed a

Point-in-Time Count. At this time in Rockingham County there were 126 individuals in shelters,

42 unsheltered individuals, and 97 individuals temporarily doubled up. In Strafford County at

this time, there were 59 sheltered individuals, 15 unsheltered individuals, and 25 individuals

temporarily doubled up61. With so many individuals struggling to find a roof to put over their

head, we need to look to the available resources to help these people.

30


Crossroads House in Portsmouth, NH provides emergency shelter to those who have no

place else to go. In 2013, Crossroads House served 469 people. This is a twenty-one and a half

percent (21.5%) increase in individuals since the previous year. However, the length of time

those individuals stayed at Crossroads House decreased by eighteen percent (18.0%). The main

goal of this facility to find permanent housing for those they serve. In 2013, eighty percent

(80.0%) of the families and forty-two percent (42,0%) of the individuals in the transitional

housing program moved into permanent housing65. There is a true lack of transitional housing in

the seacoast region. Based upon the statistics from Crossroads House, it is clear that there is a

real benefit for the individuals in the transitional housing program, as many of them were place

in permanent housing. Because there is a lack of funding for housing programs in New

Hampshire there are not enough transitional housing options.

Between July 1, 2013 and June 30, 2014, Crossroads House reported that forty-nine

percent (49.0%) of adults reported a history of substance abuse and/ or mental illness.65 Also, of

the 4,732 people sheltered in New Hampshire in 2013, 1,284 individuals had known mental

illness, 397 had known alcohol abuse, 366 had other substance abuse problems, and 148

individuals had a combined mental illness and substance abuse problem.61 This evidence outlines

the close ties of mental illness, substance abuse, and homelessness. Mental illness and substance

abuse must be addressed to help improve homelessness in the state.

Homeless Youth

Nearly nineteen percent (19.0%) of all individuals sheltered in New Hampshire in 2013

were children. The McKinney-Vento to Homeless Assistance Act of 2001 ensured that all

education agencies in New Hampshire have a homeless education liaison. Each year these

liaisons identify homeless youth in the school system, and work with the children to ensure they

31


are getting the education they deserve despite their living situation. Approximately 444 children

were identified in 2013 in seacoast NH as being homeless. School breakfast programs have been

implemented in many schools who students from many low-income families. School dinner

programs have also begun tin some schools to ensure children get balanced meals even when

they don’t have a roof over their head. In 2013, the number of families that utilized shelters

deceased by eighteen percent (18.0%). From July 1, 2013- June 30, 2014, Crossroads House in

Portsmouth, NH served 32 families with 53 children. Resources need to be aimed at aiding

homeless children so that the cycle can end and these children do not grow up to be homeless

adults.

Transportation

Transportation remains the largest barrier to healthcare in the seacoast region. With the

use of outside resources, we were able to get a better definition of how large the barrier was to

accessing healthcare, as a result of a lack of transportation.

Access to public transportation remains an issue in New Hampshire. Public transportation

services are essential to allow for travel to and from school, jobs, doctors appointments and

grocery stores. It is essential for patients with chronic illnesses such as dialysis or cancer, as well

as the elderly and disabled. New Hampshire lacks connectivity between its public transportation

sources, which has made it near impossible for members of the more rural communities without

private transportation the ability to get around.

New Hampshire has a great lack of public transportation services. In 2000, only 0.6% of

New Hampshire residents used public transportation services for their commute to work.66 New

Hampshire ranks 42nd in the nation in state spending for public transportation6. New Hampshire

is not home to a subway system and there are currently four public bus routes in the cities of

32


Manchester, Nashua, and Portsmouth. Durham, NH is also home to one of the more commonly

used bus systems—Wildcat Transit—which services mainly students, but the general public has

access with a small fee of $1.50 per ride67. Appendix A shows a map of all public transportation

services and their routes offered in the state of New Hampshire. Of the 21 cities and towns in the

greater seacoast area, only 11 are serviced by public transportation (Portsmouth, Exeter,

Stratham, Newmarket, Dover, Somersworth, Durham, Farmington, Rochester, Berwick, ME, and

Kittery, ME). Along these routes, the bus makes an average of five stops. These buses on

average run hourly, some routes are limited to only a few stops each day. Some buses are only

available M-F running on average from 6am to 6pm68. In the states 234 cities and towns,

scheduled bus services are available in less than 306. Nine town included in the greater seacoast

region are not included in the transportation systems (Hampton, Rye, Seabrook, North Hampton,

Greenland, Newcastle, Barrington, York, ME, Eliot, ME, and South Berwick, ME). The

residents in these towns may find it difficult, inopportune, or impossible to commute using the

public transportation services.

According to the United States Census Bureau, The mean travel time to work in New

Hampshire is 26.2 minutes53. The larger cities in the greater seacoast area include Portsmouth,

Dover, Newington and Exeter. A majority of employment opportunities are located in these

towns, yet the housing in those areas are not affordable. The average number of people per

household is 2.47, with a median household income of $64, 925.53 The average U.S. household

spends seventeen percent (17.6%) of their annual expenses.69 With vehicle and fuel prices ever

on the rise, the cost of commuting is an issue with many households, but New Hampshire has

such a poor public transportation that a majority of travelers do not have an alternate method of

travel.70

33


According to the Alliance for Community Transportation 2009 Survey, twenty-one

percent (21.0%) Americans over the age of 64 did not drive. Of that twenty one percent, 3.6

million Americans age 65 and older do not leave home due to their lack of transportation. In one

study conducted by the University of New Hampshire telephone survey, eighty-six percent

(86.0%) of adults over age 60 still drive. Nineteen percent (19.0%) of older adults are driven by

family or friends, and of the eighty-six percent who do drive, nineteen percent of people are

concerned about losing their ability to drive.6 In 2008, more than twenty-five percent (25.0%) of

residents in the state of New Hampshire do not drive due to poor health, disability, or simply do

not have a license and thirteen percent (13.0%) of disabled and elderly seacoast residents lack

consistent access to reliable mode of transportation.6 New Hampshire’s public bus services are

lacking, but in recent years there are more transportation services that are available for the

disabled, elderly and other people who lack transportation for various reasons. These programs

are limited to only allow certain citizens; for example, the Transportation Assistance for Seacoast

Citizens71 provides transportation for “citizens age 55 or older and citizens with medical issues

that prevent them from driving71.” The Alliance for Community Transportation72 is a coalition of

more than 20 agencies that have come together to expand the accessibility to transportation

services73. The Community Rides program through ACT finds various transportation services

available depending on location and ride type needed.72 Although these resources may be helpful,

they may not be affordable or accessible to some members of the population.

In 2010, New Hampshire has come up with a plan to change the state of the

transportation system in the state. The 2010 NH Long Range Transportation Plan has little

information on the plan to improve the state of public transportation in New Hampshire. The

state has limited funding for public transportation services. The Para transit services, which

34


provide door-to-door, usually appointment based services for the elderly or disabled. This aspect

of public transportation is very restricted on how the funds provided can be spent74. In recent

years, there has been a congressional push for the expansion of a commuter rail service in New

Hampshire. In 2013, the NH Executive Council approved a study that would look at the

feasibility of this transportation option with a $3.6 million budget.75 If the project moves

forward, an estimated $250-300 million will be needed to construct and operate the rail systems.

This rail system would not greatly benefit the seacoast region, as it would extend transit along

the Merrimack River from Nashua to Concord.75 The biggest setback to expansion of the public

transportation services in the greater seacoast region is government and private funding.

Oncology

With the use of not only literature, but also first-hand experience, we were able to gather

information on oncology across the seacoast region. The literature revealed pros and cons of all

the different available facilities in the region. With the interviews and literature, disparities

could be identified.

There are four major hospitals that service the Greater Seacoast area. These hospitals

include Portsmouth Regional Hospital, Frisbee Memorial Hospital, Exeter Hospital, and

Wentworth Douglass Hospital. All four of these facilities provide cancer care in a variety of

services. The areas that were examined were radiation services, oncology services, available

transportation options to each facility, supportive services, and holistic approaches to care.

Information regarding these facilities was obtained from face to face meetings at Portsmouth

Regional Hospital, Wentworth Douglass Hospital, and Frisbee Memorial Hospital, as well as

information taken from the hospital websites. Information regarding Exeter Hospital was taken

35


exclusively from the hospital website as Exeter Hospital was unresponsive to many attempts to

contact the facility.

Radiation Services

The majority of the hospitals in the area offer radiation services on site. Wentworth

Douglass prides themselves on their advanced and up to date radiation technologies. Offered

technologies include three-dimensional, conformal treatment planning, High Dose Rate

Brachytherapy (HDR), Partial Breast Irradiation, Intensity Modulated Radiation Therapy

(IMRT), Stereotactic Radio Surgery (SRS), and Stereotactic Radio Therapy (SRT). These

treatment options allow their patients to receive radiation closer to home and avoid extensive

travel. Frisbee Memorial Hospital also utilizes these services through a partnership with

Wentworth Douglass Hospital. Radiation is offered to all Frisbee patients at the Wentworth

Douglass campus. Exeter Hospital also offers radiation on site. The therapies offered are Breast

Intraoperative Radiation Therapy, CT Simulation, Partial Breast Irradiation, Image Guided

Radiation Therapy, Intensity Modulated Radiation Therapy, and Intraoperative Radiation

Therapy (IORT). Portsmouth Regional Hospital also offers a variety of radiation therapies. At

this facility patients can receive stereotactic radiosurgery (SRS), stereotactic body radiotherapy

(SBRT), brachytherapy, image-guided radiation therapy (IGRT), intensity modulated radiation

therapy (IMRT), accelerated partial breast irradiation (APBI), high-dose rate (HDR) radiation

treatment. With many hospitals in the seacoast area offering technologically advanced

treatments, oncology patients have the ability to receive treatment close to home.

Chemotherapy Services

Oncology patients in the Greater Seacoast Area have many options in regards to chemotherapy

treatment. Wentworth Douglass Hospital, Exeter Hospital, and Portsmouth Regional Hospital all

36


offer their patients an outpatient infusion center. The 18 bay Infusion Unit at Wentworth

Douglass includes “private patient waiting areas, designated spaces for an oncology pharmacy,

nutrition and social work services. Each treatment bay has a reclining chair, television, DVD and

seating for visitors. The infusion room has Wi-Fi and laptops are available for patient use.

Adjacent to the infusion room is an outdoor healing garden. (Wentworth Douglass website).

Frisbee Memorial Hospital offers both oral and intravenous chemotherapy in their nine treatment

chairs. Patients also receive laptops and cable TV to pass the time during their infusion

treatment. Exeter Hospital provides 13 treatment areas for patients receiving infusions. Each

patient also receives a heated reclining chair for comfort during treatment. In addition to the

treatment areas, Exeter has 3 private day suites for long- term infusion treatment. Like

Wentworth Douglass, Exeter has an oncology specific lab and pharmacy. Portsmouth Regional

Hospital offers an outpatient infusion center to their oncology patients as well. Chemotherapy

options at the infusion center include Intravenous, oral, Intramuscular, Intrathecal, Subcutaneous,

and Intra-arterial. During treatments, patients are given a private room, free Wi-Fi connection,

personal flat screen TVs, heated recliner chairs, and a library of books and resources to access.

Transportation

Transportation has proven to be a large issue for oncology patients receiving treatment in

the Greater Seacoast Area. Although contact was not established with Exeter Hospital,

according to the 2013 Needs Assessment conducted by Exeter Hospital, “transportation remains

the second largest barrier to treatment behind inadequate insurance.”6 The Assessment went on

to say that, “transportations is also challenging for patients with health needs such as cancer who

require ongoing appointments.”6 Transportation is a particular issue among the elderly and

disabled populations. Wentworth Douglass Hospital and Frisbee Memorial Hospital both utilize

37


the Care- Van service. For a patient to qualify for this service, he or she unable to provide his or

her own transportation and have no other regular, reliable and appropriate means of

transportation, either public or private such as by bus, family members or friends. An issue with

this service is that it only operates from 8-4:30 Monday through Friday. This means that n

appointment cannot be scheduled earlier than 9:00 am and the Care- Van leaves the hospital no

later that 4:00 pm. This service is subject to cancellation when there is inclement weather, and

drive- ways and walkways must be cleared. This can be an issue for disabled and elderly

patients. The Frisbee Care- Van only services Rochester, Barrington, Milton, Somersworth, and

Farmington. The Wentworth Douglass Care- Van gives priority to patients in Dover,

Somersworth, and Rollinsford. Patients in other towns may be able to obtain the service

depending upon how busy the day is. This service is a great option, but only for those who are

able to obtain the service. At Portsmouth Regional Hospital, the Road to Recovery Program is

offered. This service provides transportation to and from the hospital through volunteers who

donate their time and cars. This is an outside service that serves Portsmouth Regional. The

Wentworth Connections is another option. It is collaborative effort between the city of

Portsmouth and The Mark Wentworth Home. Patients must apply for this service. The cost is

$30 for 20 rides if the patient’s monthly income is less than $1011.76. If the patient’s income is

greater than $1011.76, then the cost is $50 for 20 rides.

Supportive Services

The hospitals serving the Greater Seacoast Area offer many supportive services to

oncology patients. Wentworth Douglass Hospital offers a prostate cancer support group, a newly

diagnosed breast cancer support group, and a breast cancer survivor support group. A Look

good…Feel Better group is also offered at the facility as well as “The children and Family grief

38


services program.” There is an “Exercise Works for Cancer Recovery” class, which promotes

exercise to aide healing. Wentworth Home Care and Hospice and Palliative Care are also

options available for patients. Many of these programs are also offered at Portsmouth Regional

Hospital. Multiple breast cancer support groups, including Stage IV and Look Good...Feel Better

are offered at PRH. Support groups for gynecologic and prostate cancers, options for

reconstructive surgery, and access to participation in clinical trials. Behavioral health services

are also offered, which can be a huge benefit for the patient. The behavioral services include

psychosocial evaluation and five complimentary counseling sessions while you receive active

treatment. An option for patients who are having a difficult time coping with skin changes is

Brighter Days complimentary bi-monthly skin care workshop. In addition, nutrition counseling

and spiritual care are readily available. There is a Wig Bank with free fittings and hats and

scarves for all patients interested. Exeter Hospital offers counseling, VNA referral, exercise

programs, nutritional consults, oncology rehab, and a creative arts program. Some of the support

groups offered include the “Women’s perspective” support group and “Coping with Cancer”

support group. The Look Good…Feel Better programs is also available, as well as palliative

care services. Frisbee also offers Palliative Care services and Hospice care options. The

survivorship program is very popular for patients at Frisbee, which helps patient adapt to life

after cancer. Supportive services are plentiful in the seacoast region for oncology patients.

Holistic Approach to Care

It is important to incorporate a holistic approach to cancer care to help the patient heal.

There are many adjunct therapies that can be used in combination with chemotherapy and

radiation to aide in the treatment of the patient. Portsmouth Regional Hospital offers a variety of

therapies such as acupuncture, biofeedback, healing circle (meditation group), massage,

39


reflexology, reiki, nutrition connection, a bridge to healing group, a relaxation hotline, spiritual

care, yoga, meditation and exercise class. Wentworth Douglass also offers many therapies

including clinical aromatherapy, medical acupuncture, pet visitation, reiki, massage, “Sail

through Surgery” (class which helps with guided imagery, relaxing music for surgery), and

guided imagery. At Exeter Hospital patients are offered massage therapy, acupuncture, pet

visitation, and spiritual care. Reiki is also available for Frisbee’s oncology patients.

With the use of an abundance of outside resources, we were able to fully create the 2014

Greater Seacoast Needs Assessment. There were many things that were found to be plentiful and

easily accessible, however there were still many barriers present.

Barriers

Few barriers arose during the creation of the 2014 Greater Seacoast Needs Assessment.

One of the largest barriers and only barriers we had was accessing hospitals and gathering

facilities’ resources. Exeter Hospital was not welcoming to our outreach regarding the

assessment and did not allow us to view their Oncology facility. This provided a huge barrier for

us. Because the new and specific information added to the updated research study was based on

oncology, it made it difficult to holistically review all the facilities with the denied access from

Exeter. Although this proved to be a barrier, we were able to overcome it as best as we could.

Utilizing the public resources on Exeter Hospital’s Oncology page, we were able to gather

information about the unit that we would have gotten through an interview and tour. Although

this is not the most practical way for gathering information and not the preferred method, we

were able to make do with what we had. Other barriers were simply making initial contact with

the hospitals. It took an immense amount of time to establish contact with certain facilities. We

overcame this simply by working on other aspects of the study during the time we waited.

40


Although the barriers were present, they were minimal, and we found ways to overcome them

and formulate the study.

Summary of Interviews:

Once we formulated a plan for our research assignment, we relied on many contacts to

help us along the way. Greg, our contact from PRH, who coordinated the project for us, was

very helpful each step of the way. Because it was his project, specifically, we were able to rely

on him for help achieving directly what he wanted for the research study. With the use of emails

and meetings with Greg, weekly group meetings, and the help of interested community members

and stakeholders, we were able to conduct the 2014 Greater Seacoast Needs Assessment.

Greg was able to help us formulate our plan for the project and tell us specifically how

we should conduct each step of the assessment. We relied on him for information regarding

what he wanted. Weekly emails with Greg helped us to make sure we were focused and

achieving what was needed for the research project. Our initial meeting with Greg revealed the

significance of the project to us and what it was necessary to conduct the assessment. He

discussed resources for conducting the assessment with us and provided us with information for

stakeholders. He also provided us with a contact nurse at Portsmouth’s Oncology department for

any questions we may have throughout the process of creating the needs assessment’s Oncology

chapter. Greg provided us with the necessary resources and information to conduct the needs

assessment at its full potential.

As a group, we met weekly to discuss the new developments and the plan for conducting

the research study. Because we were able to split the majority of the work, we were able to work

independently, and come together as a group weekly and discuss new developments that we had

come across within the research study. We also were able to discuss barriers and help each other

41


through them. We were well organized and coordinated. We also served as great resources for

one another. Because we had a group email open at all hours of the day, we were able to

communicate openly whenever necessary. As a group, we discussed each hospital’s oncology

departments’ resources and new developments as we updated the previous needs assessment.

Together, we created the 2014 Greater Seacoast Needs Assessment.

Members of the community, although less frequently, did show interest in our research

study. The Portsmouth High School nurse expressed interest, specifically in the project. We

were able to gather information about the area through speaking with her. We were also able to

gain opinions on what could be improved in the seacoast region, as well. The Seacoast Public

Health Emergency Coordinator also showed interest in our needs assessment. Having the

opportunity to speak with stakeholders in the community was specifically important for us for

gaining insight into the community’s needs.

We also had the opportunity to visit three of the four hospitals that service the seacoast

area. By acquiring contacts within those facilities, we were able to conduct interviews with each

Oncology Department’s coordinators. Through the interviews, we were able to appropriately

assess the resources available to members of the community. We were also able to see the

facilities first-hand to provide a better description of the units in the needs assessments. Going to

the hospitals allowed us to truly assess the resources. Because we did this on an individual basis

(each of us visited a different facility), we were able to compare and contrast from an unbiased

stand point; we did not have any views of any other facilities that could obstruct our views of

other facilities. We were able to tour Portsmouth, Frisbee, and Wentworth Douglass’ oncology

units. Unfortunately, Exeter Hospital was unwilling to respond to our outreaches regarding the

needs assessment. We were able to use their websites information to assess their resources.

42


Current Concerns:

The 2014 Greater Seacoast Community Needs Assessment revealed constructive

information about the area. After assessing the information, general findings revealed many

current concerns. The concerns formulated regarding the seacoasts needs addressed access to

care, mental health, dental care, transportation, housing, and oncology. The current concerns for

the seacoast community are constructive criticism as a means of quality improvement.

Access to care continues to be a growing problem in the Greater Seacoast Area.

Although there are an ample amount of primary care providers servicing the area, community

access of these resources remains a barrier. This is partly due to lack of transportation, but more

commonly, lack of insurance. There are not enough transportation services that come at low

costs to accommodate the financially unstable population of the Greater Seacoast Area. There

are also not enough health care resources for uninsured individuals to access. With the high

costs of co-payments and treatments, people lacking insurance tend to shy away from accessing

it. Without transportation services and services that aid uninsured individuals, members of the

Greater Seacoast Area will continue to not access the care that they need.

Mental health continues to be a growing problem in the Greater Seacoast Area.

Individuals affected with mental health conditions have difficulty accessing care, leading to

increased severity of disease, further burdening other services including hospitals and law

enforcement, which only further potentiates the problem. The area lacks sufficient services to

accommodate the growing needs of the area. There are not enough in-patient facilities, assistive

programs, or child psychiatrists to provide care to the large population of mental health patients.

Between the lack of ample Medicaid funding for psychiatric services and the high turnover rate

of psychiatrists and mental health providers, patients are not able to get the treatment needed to

43


stabilize their conditions. Without funding for more mental health services, adequate psychiatric

care and preventative and surveillance methods, the problem will continue to amplify.

New Hampshire’s dental care has improved immensely in the last four years. School

based dental programs have helped thousands of New Hampshire’s kids who cannot afford or

cannot access dental care to receive the help they need. Sealants, fillings and cleanings have been

offered in most schools, including the Seacoast area. Dental insurance remains a big issue in the

New Hampshire area, preventing many residents from receiving the care they need.

The status of transportation in New Hampshire has not noticeably improved in the last

several years. Public transportation continues to be an issue in the greater seacoast area. It poses

an obstacle to several members living in the rural areas of the seacoast. There are several

resources for the elderly, patients with disabilities, and/or chronic illness to have rides arranged,

but they may come at a price that is steeper than that of the public transit system of buses and

trolleys. There are plans in place to improve the transportation status of New Hampshire by

2030.

Homelessness in New Hampshire is an apparent problem. In the seacoast area, the

homeless population often appears “invisible.” Just because these individuals are not always

obvious, this does not mean they are not there. Overall, it appears that the seacoast needs more

low income housing options. Many people are forced into homelessness because there are not

enough affordable homes or apartments in the area. With more affordable options, many people

may be able to avoid falling into the homeless category. In addition, the greater seacoast area

could greatly benefit from more transitional housing options. Statistics have proven that many

individuals that enter transitional housing end up in a permanent housing situation. Improving

44


these issues is not as simple as identifying them as lack of funding is a huge barrier to fixing the

homelessness and housing problem.

The greater seacoast area has many technologically advanced options for oncology

treatment. Both chemotherapy and radiation are plentiful in the area. All of the hospitals in the

area also offer a variety of support groups and services to aide the oncology patient through their

treatment process. Holistic approaches to care are also offered at each facility. Massage, reiki,

acupuncture, and aromatherapy are common adjunct therapies to chemo and radiation. The

largest area that is lacking in the oncology field is transportation. Cancer treatment is very time

consuming, as the patient often needs to be at the hospital for treatment many days a week. A

lack of transportation is a huge barrier to receiving treatment, especially for the elderly and

disabled population. The transportation options available are not always reliable and can be

cancelled due to weather. These services also have parameters regarding when appointments can

be made and may carry an additional charge. Transportation is the number one barrier that can

be improved in oncology care.

The current concerns regarding the needs of the seacoast region can be used

constructively to improve the quality of the region’s resources. With the concerns addressed,

health outcomes will be increased, overall.

Planning Intervention

For this project, the intervention we decided on was to present the updated Community

Needs Assessment to the Cancer Care Committee at Portsmouth Regional Hospital. A

PowerPoint presentation was put together to highlight the important pieces of information we

planned on delivering to our audience. Our field agent, Greg Dalzell set up the time and group

we would be presenting to. There were no costs involved in the implementation of the

45


intervention, besides the cost of gas to physically get to the hospital. In order for the intervention

to be carried out, the room we were presenting in required access to computers, a projector, and

the USB drive that contained our presentation. As a group, we discussed potential questions the

audience may have, and how we planned to answer them if they came up.

We planned to give recommendations on where the needs were not being met to the

highest standards. The biggest area in need of adjustment was found to be transportation. This

issue is a fairly significant one, and lack of funding for transportation programs is a potential

barrier for improving the quality of the need for improved transportation in the greater seacoast

community.

Implementation

Implementing our intervention was essentially presenting our needs assessment at

Portsmouth Regional Hospital. In order to be prepared to do this, we needed to first create our

updated needs assessment. Once we successfully updated the assessment and added an oncology

needs section, we prepared for our presentation. An image of title page and table of contents of

our assessment can be seen in Appendix A.

We were scheduled to present our needs assessment at Portsmouth Regional Hospital on

December 4th. Our audience was the Cancer Care Committee and we were allotted 15 minutes to

present our findings at the beginning of their meeting. The schedule for this meeting can be

viewed at Appendix B. We each presented the section that we updated and then divided up the

oncology section into five areas so we could each present a part of it. When we got to the

radiation section of the presentation, we encountered a slight hiccup. The information from

Portsmouth Regional Hospital was retrieved from the hospital’s website however, the manner

that the information was presented was misinterpreted by one of the surgeons in the audience. He

46


inquired about this in the middle of the presentation, and claimed we had incorrect information.

We explained that we had retrieved all of our information from reliable sources so would look

into it and get back to him. Later that day, we reviewed the facts from the website and submitted

a formal addendum about the confusion that will be reviewed at their next meeting.

When the presentation was complete we asked if anyone had any other questions. We

were asked where the funding for new transportation should come from and how we planned to

implement the changes we suggested. This was a tricky question because we were well aware the

funding for the changes like these is not readily available. We explained that we are mindful of

many different programs and plans are all fighting for the same government funds. We answered

the questions to the best of our abilities and by submitting the formal addendum, we were able to

remain professional during an unexpected event.

Evaluation

Our overarching goal from this day was present the current issues and where the seacoast

is lacking to this group and we did this successfully. The needs assessment identified many

health issues in the area, including those related to access to care, mental health, dental, housing

and homelessness, and transportation. Oncology services appeared to be available to persons in

the area; however, access to these services regarding transportation and cost still is an issue.

Overall, the audience appeared very appreciative of our work on the needs assessment.

We were prepared for a broader audience, with backgrounds in health fields other than oncology.

If this were the case, than our presentation as a whole may have been more beneficial to this

group. This is because we covered our entire needs assessment rather than just the oncology

portion that these audience members may have been more interested in. If we had known more

about the audience in advance, our preparation for this presentation may have been different.

47


We could have provided a presentation with more emphasis on oncology needs in the area and

less information regarding the other chapters in our needs assessment. It is beneficial for health

care providers to be aware of all the needs we identified in our project; however, given the time

restraint of this presentation, our focus could have leaned more towards just oncology.

We were assigned to update the past needs assessment in 2011 and to add a separate

section on oncology services. We provided health care providers with a full, in depth analysis of

the health care needs in the greater seacoast area. We answered questions regarding what

services were available in the area, what were needed, and possible causes for different health

concerns. When reading the assessment health care providers will have information regarding

resources in the area, including transportation and access to facilities, availability of different

health care resources/facilities, and what areas of health care need additional support in this area.

We used the presentation at Portsmouth Regional Hospital as our intervention. Some

questions during the presentation arose about oncology services provided in the area. There was

some miscommunication between audience members, the information we provided and the

information shown on external resources (i.e. brochures, websites, etc.). Others had questions

about what our recommendations would be to help accommodate with the issues we presented.

We had already thought through this question and were ready with answers for these

participants. One member was also interested in transportation for patients seeking oncology

services. There are a number of transportation options available, but a new question that arose

was whether or not these patients were utilizing transportation resources and what could be done

in addition. It was good to see that our needs assessment was being used to not only inform, but

was also being analyzed to better the health care system in the area.

48


The one change to our intervention that may be most beneficial would be to have a

second or larger presentation to a broader audience. A large portion of our needs assessment had

to do with issues other than oncology, and health care providers in other fields, such as public

health workers, social workers, primary care providers, etc. could have benefited from it. If we

had a larger audience to present our findings to than more health care providers could have been

informed which may initiate changes to be made. We also had a time restraint on our

presentation and had to be very brief with our findings. Having more time to present our

research would have given the audience a more detailed understanding of the health care needs

in the area. Overall, the intervention appeared to be beneficial and has stimulated new questions.

Our objective was to inform providers of health care needs in the area; the needs assessment did

exactly this.

49


References

1. New Hampshire. (n.d.) Retrieved October 29, 2014, from U.S. Census Bureau: http://quickfacts.census.gov/qfd/states/33/33015.html.

2. New Hampshire Department of Health and Human Services. (2011). 2011 New Hampshire state public profile. Retrieved from http://www.dhhs.nh.gov/dphs/documents/2011statehealthprofile.pdf.

3. New Hampshire. N. (2010). Title V Community Needs Assessment. NH. 4. Star field, B. (2005). The Primary Solution. Retrieved 2014 from

bostonreview.net/BR30.6/starfield.php 5. County Health Rankings. (2014). New Hampshire Rankings. Retrieved October 29, 2014,

from County Health Rankings: www.countyhealthrankings.org. 6. Exeter Health Resources. (2013). Exeter Community Needs Assessment. Seacoast.7. Children’s Defense Fund. (n.d.). Retrieved October 29, 2014, from Children’s Defense

Fund: http:// http://www.childrensdefense.org/policy-priorities/childrens-health/uninsured-children/.

8. Anderson, C. (2011, Aug.). In Comprehensive primary care lags for kids with public health insurance, study says. Retrieved October 29, 2014, from: http://www.healthcarepayernews.com/content/comprehensive-primary-care-lags-kids-public-health-insurance-study-says#.VFFZrocaKXN.

9. Kiernan, J. (n.d.). Retrieved October 29, 2014, from WalletHub 2014 Reports: Health Insurance Coverage: http://wallethub.com/edu/rates-of-uninsured-by-state-before-after-obamacare/4800/.

10. Gallup-Healthways Well-Being Index survey. State of the States: Midyear 2009. (August 19, 2009). Retrieved October 29, 2014 from http://www.gallup.com/poll/122387/uninsured-highest-percentage-texas-lowest-mass.aspx.

11. 2010 New Hampshire 2010 BRFSS. 12. Exeter Health Resources. (2008). Exeter Community Needs Assessment. Seacoast. 13. Miller, p. (2009, Apr.). The Price of Healthcare in New Hampshire Affects Us All. 14. Norton, S. & Delay, D. (2008). Driving the Economy: Health Care in New Hampshire. 15. Families USA. (2009, Mar.) Americans at Risk: One In Three Uninsured. Retrieved

October 29, 2014. 16. Kenney, Genevieve, PhD. (November 2009). Uninsured and Eligible for Public

Coverage: Underlying Causes and Policy Solutions. In Expert Voices: National Institute for Health Care Management (NIHCM) Foundation. Retrieved October 29, 2014 from http://nihcm.org/pdf/EV-Kenney_FINAL.pdf.

17. Department of Health and Human Services. (2011). 2011 New Hampshire state healthprofile.

18. Seilder, B., Noble, A., Villanova, A., Smith, E., Wogan, J., & Berg, C. (2011). The Greater Seacoast 2011 Community Needs Assessment.

50


19. Tappin, R., Norton, S. (August 2008). Mental health and adults: aging will drive the system. New Hampshire Center for Public Policy.

20. National Alliance on Mental Illness. (2010). State statistics: new hampshire.21. Tappin, R., Norton S., (2007, September). Children’s mental health in new hampshire.

New Hampshire Center for Public Policy22. Department of Health and Human Services, National Institute of Mental Health (2008).

Mental illness expects heavy toll, beginning in youth.23. National Alliance on Mental Health, NH. (2008). Mental health, mental illness, health

aging24. Antal, P. (2009, October). New hampshire’s prescription for mental health care.25. Portsmouth Regional Hospital (2014). Behavioral Health. Retrieved from

http://portsmouthhospital.com/service/behavioral-health26. Seacoast Mental Health Center (2014). Founded in 1963…27. Community Partners (2014). Behavioral health and developmental services of strafford

county.28. Frisbie Memorial Hospital. (2014). Geriatric psychiatry – inpatient. Retrieved from

http://www.frisbiehospital.com/services/hospital-services/geriatric-psychiatry/inpatient.aspx

29. NH DHHS, NH HBBH, & The Community Behavioral Health Association. (August, 2008). Addressing the critical mental health needs of NH’s citizens: A strategy for restoration.

30. U.S. Census Bureau (2005). Interim state population projections.31. Corrigan, P.W., K.T. Muesser, et al. (2008). Principles and practice of psychiatric

rehabilitation. New York, Guilford Press.32. World Health Organization. (2014). Depression, a hidden burden. Retrieved from

http://www.who.int/mental_health/management/depression/flyer_depression_2012.pdf33. Public Broadcasting Service (2008). Depression out of the shadows statistics.34. Center for Disease Control and Prevention. (2008, September). Depression in the united

states household population 2005-2006. 35. Behavioral Risk Factor Surveillance System. (2008, April). Depression and anxiety

disorders among nh adults 2006-issue brief.36. UNE: Center for community and Public Health (2010). Onemaine community needs

assessment37. World Health Organization. (2014). Preventing suicide a global imperative. Retrieved

from http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf?ua=138. New Hampshire Department of Health and Human Services (2013). State suicide

prevention plan.39. Centers for Disease Control and Prevention (2011). Web-based injury statistics query

and reporting system.40. 2008 Community Needs Assessment Summary Report (2008). United way of the greater

seacoast.

51


41. Dewey, W. (2008). Friends of NIDA42. Oral Health. (2011, January 1). Retrieved October 20, 2014, from

http://www.hrsa.gov/publichealth/clinical/oralhealth/43. Health Insurance New Hampshire. (2014, January 1). Retrieved October 25, 2014, from

http://www.healthcare.org/new-hampshire44. Medicare Interactive. (1 January 2013). Does medicare ever cover dental services.

Retrieved from http://www.medicareinteractive.org/page2.php?topic=counselor&page=script&script_id=1591

45. Jan, T. (2013, July 21). New hampshire residents left in limbo. Retrieved from http://www.bostonglobe.com/news/politics/2013/07/20/new-hampshire-residents-left-limbo-legislature-blocks-medicaid-expansion/SShvWrRhkCeFu4KNkStOFM/story.html

46. McGinn-Shapiro, M. (2008). Medicaid coverage of adult dental services. State Heath Policy. Retrieved from www.nashp.org/sites/default/files/Adult Dental Monitor.pdf

47. New Hampshire Free Dental Clinics. (2013, January 1). Retrieved October 15, 2014, from http://www.needhelppayingbills.com/html/new_hampshire_community_dental.html

48. Horsch, K. (2010). New Hampshire Senior Center Dental Survey Results. New Hampshire Department of Health and Human Services Division of Public Health Services. Retrieved October 15, 2014, from http://www.dhhs.nh.gov/dphs/bchs/rhpc/oral/documents/seniorcentersurveyreport.pdf

49. Exeter Health Resources (2008). Exeter Community Needs Assessment Seacoast. 50. More to Smile About2014. (2014). The New Hampshire Dental Society’s Plan for Better

Oral Health. Retrieved October 28, 2014, from www.nhds.org/pdf/more_to_smile_about.pdf

51. Majeski, J. (2013). School-Based Dental Hygiene. 20-21. Retrieved October 22, 2014, from www.futuresmiles.net/201_Access_Mag.pdf

52. New Hampshire Real Estate Market Statistics from the NHAR. (n.d.). New Hampshire Real Estate Market Statistics from the NHAR. Retrieved October 20, 2014, from http://www.nhar.org/market-statistics/

53. United States Census Bureau. (n.d.). New Hampshire QuickFacts from the US Census Bureau. Retrieved September 27, 2014, from http://quickfacts.census.gov/qfd/states/33000.html

54. United States Census Bureau. (n.d.). York County QuickFacts from the US Census Bureau. Retrieved October 20, 2014, from http://quickfacts.census.gov/qfd/states/23/23031.html

55. 2013 Housing Facts for Portsmouth, NH-ME MA Housing Market. (n.d.). mainehousing.org. Retrieved October 20, 2014, from http://www.mainehousing.org/docs/default-source/housing-facts/portsmouthnhlma2013.pdf?sfvrsn=5

56. HUD's Public Housing Program/U.S. Department of Housing and Urban Development (HUD). (n.d.). HUD's Public Housing Program/U.S. Department of Housing and Urban

52

http://www.mainehousing.org/docs/default-source/housing-facts/portsmouthnhlma2013.pdf?sfvrsn=5

http://www.mainehousing.org/docs/default-source/housing-facts/portsmouthnhlma2013.pdf?sfvrsn=5

http://quickfacts.census.gov/qfd/states/23/23031.html

http://quickfacts.census.gov/qfd/states/33000.html

http://www.nhar.org/market-statistics/


Development (HUD). Retrieved October 23, 2014, from http://portal.hud.gov/hudportal/HUD?src=/topics/rental_assistance/phprog

57. Foreclosure and Housing Market Update - 9/3/2014. (2014, September 3). Foreclosure and Housing Market Update - 9/3/2014. Retrieved October 23, 2014, from http://www.nhhfa.org/data-planning/foreclosure/ForeclosureUpdate_09-03-14.html

58. Rockingham County, New Hampshire (NH). (n.d.). Rockingham County, New Hampshire detailed profile. Retrieved October 23, 2014, from http://www.city-data.com/county/Rockingham_County-NH.html

59. Strafford County, New Hampshire (NH). (n.d.). Strafford County, New Hampshire detailed profile. Retrieved October 23, 2014, from http://www.city-data.com/county/Strafford_County-NH.html

60. York County, Maine (ME). (n.d.). York County, Maine detailed profile. Retrieved October 23, 2014, from http://www.city-data.com/county/York_County-ME.html

61. Bureau of Homeless and Housing Services. (n.d.). Homelessness in New Hampshire A Report. Homelessness in New Hampshire A Report. Retrieved September 29, 2014, from http://www.dhhs.state.nh.us/dcbcs/bhhs/documents/2013-bhhs-report.pdf

62. McMahon, C. (2014, September 5). Budget cuts sting N.H. housing advocates. seacoastonline.com. Retrieved October 23, 2014, from http://www.seacoastonline.com/article/20130905/News/309050410

63. Rental Program Details. (n.d.). Rental Program Details. Retrieved October 23, 2014, from http://www.mainehousing.org/programs-services/rental/rentaldetail/housing-choice-vouchers

64. Homelessness | Bureau of Homeless and Housing Services | New Hampshire Department of Health and Human Services. (n.d.). Homelessness | Bureau of Homeless and Housing Services | New Hampshire Department of Health and Human Services. Retrieved September 30, 2014, from http://www.dhhs.state.nh.us/dcbcs/bhhs/homelessness.htm

65. Crossroads House. (n.d.). Crossroads House. Retrieved September 30, 2014, from http://www.crossroadshouse.org/

66. U.S. Department of Transportation. (2000). New Hampshire transportation profile. Retrieved from https://www.rita.dot.gov/bts/sites/rita.dot.gov.bts/files/publications/state_transportation_statistics/new_hampshire/pdf/entire.pdf

67. UTS | Wildcat Transit | Home. (n.d.). Retrieved from http://www.unh.edu/transportation/wildcat/

68. Coast : Schedules & Maps. (n.d.). Retrieved October 2, 2014, from http://www.coastbus.org/default/schedules_maps.html

69. Makofsky, N. (n.d.). The Average American Household Budget - Budgeting Money. Retrieved from http://budgeting.thenest.com/average-american-household-budget-4385.html

70. NH Department of Transportation. (2005). New Hampshire Long Range Transportation Plan. Concord, NH

53

http://www.crossroadshouse.org/

http://www.dhhs.state.nh.us/dcbcs/bhhs/homelessness.htm

http://www.dhhs.state.nh.us/dcbcs/bhhs/documents/2013-bhhs-report.pdf

http://portal.hud.gov/hudportal/HUD?src=/topics/rental_assistance/phprog


71. TASC - Transportation Assistance for Seacoast Citizens | NH Transportation | NH Seniors. (n.d.). Retrieved from http://www.tasc-rides.org/

72. ACT : Home. (n.d.). Retrieved from http://www.communityrides.org/default.html73. Davis, C., Miftari, C., Salamone, A., Weise, W., & Marx, J. (2009, May 18). The alliance

for community transportation 2009 survey. Retrieved from http://www.nh.gov/dot/programs/scc/documents/ACT-UNHSurveyFinalReport.pdf

74. New Hampshire Department of Transportation. (2010). NH long range transportation plan. Retrieved from http://www.nh.gov/dot/org/projectdevelopment/planning/documents/CompleteLRTP083110.pdf

75. Solomon, D., & New Hampshire Union Leader. (2013, February 2). Executive Council approves $3.6 million rail study | New Hampshire Politics. Retrieved from http://www.unionleader.com/article/20130206/NEWS06/130209387

Appendix A:

54


Appendix A (continued)

55


Appendix B

56


Appendix B (continued)

57

2014 COMMUNITY NEEDS ASSESSMENT 58

community needs assessment

Documents