Community Needs Assessment

Running Head: 2014 COMMUNITY NEEDS ASSESSMENT
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
Strafford
Portsmouth
Exeter
Greenland
Hampton
Stratham
New Castle
Rye
Newmarket
Seabrook
North Hampton
Dover
Durham
Rochester
Somersworth
Farmington
Barrington

York
York
Berwick
Eliot
Kittery
South Berwick
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
Countys 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 Countys 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 countys 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
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 seacoasts 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,
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 onehalf1. 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 ninetyfive 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.
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 Childrens 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
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 states (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 states 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
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 todays 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.
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 patients 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
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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.
11
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
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training to care for mental health patients.2 However, parents reported that they will turn to their
childs 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 states 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
13
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
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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
supports or services.31 This can lead to increased hospitalizations and of longer durations.31 As of
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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
health of the patients. If these individuals are given new health care providers every few years,
16
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. eightypercent (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 (8090%) 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.
The highest rates of depression occur in those aged 40-59 years old, compared to any other age
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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 York
County is that twenty-four percent (24.0%) of adults reported having been diagnosed with
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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 childs 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
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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.
20
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 20072013, 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.
21
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
22
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
23
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%)
couldnt 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.
24
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 Hampshires 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
Hampshires 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
25
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 Hampshires 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 Hampshires 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
26
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
27
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.
28
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 twobedroom 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
29
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 MaineHousings 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
30
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.
31
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
32
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 dont 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
33
Manchester, Nashua, and Portsmouth. Durham, NH is also home to one of the more commonly
used bus systemsWildcat Transitwhich 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
34
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 Hampshires 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
35
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
36
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
37
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 the Care-
38
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 patients monthly income
is less than $1011.76. If the patients 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
goodFeel Better group is also offered at the facility as well as The children and Family grief
39
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 Womens perspective support group and Coping with Cancer support
group. The Look GoodFeel 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,
40
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 Frisbees 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 Hospitals 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.
41
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 Portsmouths Oncology department for
any questions we may have throughout the process of creating the needs assessments 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
42
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 hospitals 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 communitys 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 Departments 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.
43
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 copayments 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
44
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 Hampshires dental care has improved immensely in the last four years. School
based dental programs have helped thousands of New Hampshires 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
45
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 regions 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
46
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 hospitals website however, the manner
that the information was presented was misinterpreted by one of the surgeons in the audience. He
47
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. We
48
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.
49
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.
50
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http://www.unionleader.com/article/20130206/NEWS06/130209387
Appendix A:
Appendix A (continued)
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Appendix B
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Appendix B (continued)
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Community Needs Assessment

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Running Head: 2014 COMMUNITY NEEDS ASSESSMENT

2014 Community Needs Assessment of the Greater Seacoast Area

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

adults, and seniors.

2014 COMMUNITY NEEDS ASSESSMENT

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2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

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

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

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

2014 COMMUNITY NEEDS ASSESSMENT

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

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

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

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

74. New Hampshire Department of Transportation. (2010). NH long range transportation

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT

2014 COMMUNITY NEEDS ASSESSMENT