New Hampshire Site Visit November 2001

About Caring Community Network of the Twin Rivers

Caring Community Network of the Twin Rivers (CCNTR) is a nonprofit organization established in 1996. The Network is active in a tricounty area that includes 12 towns in central New Hampshire. CCNTR member agencies include a wide range of local social services organizations (ranging from shelters, to elder care, drug abuse, and the Women with Infants and Children Program), a regional hospital, the chamber of commerce, a regional nursing association, a mental health service provider, schools, an affordable housing provider, a visiting nurse association, and a clergy association. The CCNTR board consists of 24 members; half of the members are community representatives, and the remainder represent different agencies.

CCNTR's Mission, Goals, and Objectives

CCNTR has been a participant in the Turning Point Program, which is funded by the W. K. Kellogg and Robert Wood Johnson Foundations, and directed by the National Association of County and City Health Officials with assistance from the University of Washington School of Public Health. CCNTR is one of three Turning Point project sites in the state of New Hampshire, but it is somewhat unique compared with the other projects in the state and projects in other states, as it works on the creation of local public health capacity in an area with limited public health staffing and infrastructure.

CCNTR has six main objectives, including: (1) improving access to health and mental health care; (2) establishing programs to lower youth risk behaviors related to substance abuse and other issues; (3) health promotion and disease prevention; (4) community/public health improvement; (5) increasing social capital, engagement in community health, and development; and (6) supporting the basic needs of individuals and families. There has been some progress in both planning and implementing activities in most areas. In 1998, for instance, CCNTR conducted a large-scale community needs assessment that revealed youth risk behaviors as a major issue, especially because teens do not have many available activities or opportunities for after-school and extracurricular entertainment. As a result, the community and CCNTR developed three strategies for addressing risk behaviors. The first two, which have already been funded and initiated in several communities, include school-based prevention curricula and structured after-school (3:00 to 7:00 p.m.) programs. The third strategy, not yet funded at the time of the site visit, is the alignment of community attitudes to enable recognition of risk and the involvement of adults in community wide prevention activities.

Public Health Infrastructure: Existing and Needed Capacity

As in most states, the public health infrastructure in New Hampshire has experienced certain difficulties. In New Hampshire, these stem from fragmentation, a lack of coordination between the state and local levels, limited resources, and other factors (Rhein et al., 2001). This means that effective communication, sharing of information, and the standardization of functions, services, and roles can be difficult to accomplish. Local public health entities function under separate and often dissimilar town ordinances. There is one public health laboratory for the entire state, and surveillance functions are covered by individual hospitals, at least in the Twin Rivers area. Unlike localities where there are health departments, a public health infrastructure, adequate facilities, and many public health workers to help facilitate and support community health improvement efforts, the Twin Rivers area does not have an easily visible public health presence. There is no official agency building, and the health officers (one in each town) are mostly semivolunteers who have other full-time jobs (e.g., a firefighter, a plumber, and a city legislator) in addition to their public health responsibilities. The services provided across the region are thus fragmented and reactive, as well as lacking in uniformity, because of local differences in policies and procedures. The collection of public health information, such as the collection of data by the state, has been recognized as one of the areas in need of improvement. For example, people at the local level have charged that the data collected by the state may skew or entirely miss the needs of small, heterogeneous local communities.

CCNTR used the state Turning Point project grant to assist local health officers in ensuring the three core public health functions are performed, and to join existing public health efforts with community resources to accomplish more in improving and assuring the health of the population in the area. CCNTR is working on the development of a public health system of governance that would help to shape local public health policy, interface with the state about policy and service delivery issues, and deliver and assure public health services (such as assessment and surveillance). The Caring Community Network has been conducting assessment of a range of basic health indicators, such as adolescent pregnancy, immunization levels, and school-based administration of Behavioral Risk Factor Surveillance System questionnaires. Furthermore, CCNTR carries out formal and informal community needs assessment activities, identifies local strengths and assets that can be used to respond to the identified needs, and also maintains a "big picture" of state policy and other issues that have impact on the local level. CCNTR has also worked with the state to change state policies about data collection (e.g. going beyond county data and collecting data in a way that recognizes the heterogeneity of health data across towns) and means for making data available to local levels (e.g., through the Internet). CCNTR's mission is to work with communities to plan and develop an integrated health and human service delivery system that optimally addresses regional social and health problems, such as an underfunded and fragmented public health system, barriers to accessing services, high-risk behaviors, and many unmet basic needs (e.g., for shelter, food, and transportation).

CCNTR embraces a broad and inclusive definition of public health that includes attention to social issues from a low level of community engagement in collective development and change to the mental health and the social needs of youth. The point, according to a CCNTR partner, is to include "things we all do for work and play" in order to engage "as many people as possible in improving community health." As a result of a perspective that is expansive, flexible, and truly interested in the community's expressed needs, CCNTR supported the community's first area of priority: the development of a multipurpose trails/greenways system that could provide a place for recreational activities and that could provide a safe and environmentally friendly alternative for pedestrian and bike traffic. Being responsive to community needs also ensured the interest and involvement of a wide cross-section of community members who felt that they could rally around an issue critical to them rather than being obliged to accept an issue determined by outside "experts." Other accomplishments of CCNTR have included the redevelopment of the old city hall/opera house in recognition of the economic and social potential of cultural education and the importance of the arts to nurturing the community and developing creative and artistic skills in young people. An important dimension of CCNTR's work has been its consistent emphasis on communicating with and providing feedback to the community.

Site Visit Discussion

Because of the limited nature of the public health infrastructure of the Twin Rivers area, CCNTR, local health officers, and the community have creatively assembled a public health system that draws on the locally available public health expertise that is available but also capitalizes on community resources and skills. The committee heard about the potential implications posed by this specific scenario to national-level attempts to standardize local public health infrastructures and credentialing public health workers. Although the Twin Rivers community leaders present at the site visit expressed a clear vision of quality public health services, they expressed some concern that credentialing and other efforts to formalize local public health services may impair rather than help local work. Although not having a "real" health department may be perceived as a problem in some ways, one participant in the site visit stated that they consider themselves "lucky" that they have no existing infrastructure to "undo" to make it correspond to actual community needs. Workers and community representatives at the site visit noted that they have a great deal of flexibility and the ability to respond to needs in a manner that is unencumbered by the potential rigidity and resistance to change of more formal, highly bureaucratic structures.

CCNTR members further stated that they would prefer something more basic than credentialing to ensure standardization and quality. Having standards for health officers is important, they noted, but a formal credential may not be a good idea given their local situation and the already diverse professional backgrounds of existing health officers. Site visit participants would also like to see continuing education available in areas where the infrastructure is underdeveloped and more focus on Internet-based tools. This highlights the potential of distance education and other emerging technologies for the purpose of continuing education and capacity building. Even so, there are some local limitations in terms of technical capacity (e.g., the low level of availability of T1 or DSL connections to the Internet), as well as logistical issues, such as the absence of a central office where public health officers may check in regularly.

For more information about Caring Community Network of Twin Rivers, visit and http://www.

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