Program and Service 11SEPT2019

A GUIDE TO PROGRAMS AND SERVICES

A GUIDE TO PROGRAMS AND SERVICES

2019-2020 9/11/2019 3:38:23 PM

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Welcome to Amoskeag Health

A message from
our President
& CEO

At Amoskeag Health, we are proud to serve over 14,600 patients
annually across four locations in Manchester. Primary care patients
of Amoskeag Health have access to 60+ services in-house including
behavioral health and specialty care. We provide exceptional
care that is accessible to all regardless of income and
insurance coverage.

We promote wellness by empowering our patients through
education and by removing barriers so our patients can achieve and
maintain their best possible health. By fostering an environment of
respect, integrity, and caring, we ensure all patients and their families
are treated equally with dignity and courtesy. Amoskeag Health
works alongside its community partners to provide patients with the
tools they need to thrive and succeed.

Kris McCracken 9/11/2019 3:38:24 PM
President and CEO

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Table of Contents

Amoskeag Health is a 501(c)(3) non-profit Federally Qualified Health
Center providing comprehensive health care including preventive,
wellness, acute, and chronic care for all ages. Amoskeag Health
integrates access to specialty care, behavioral health, and patient
education resources through the Wrap-Around Care Model to help
patients with all important matters that may affect good health.

This documents details the integrated care offered at Amoskeag Health.

Primary Health Care for All......................................................................................... 4-5
Behavioral Health...........................................................................................................6-7
Specialty Care................................................................................................................ 8-9
Wrap-Around Services..............................................................................................10-11
Patient Education.......................................................................................................12-13
Community Collaboration........................................................................................14-15

Program and Service 2019JUL30.indd 3 MISSION
To improve the health and
well-being of our patients
and the communities we serve
by providing exceptional
care and services that are

accessible to all

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Primary Care

Adult Primary Care
Amoskeag Health provides comprehensive, team-
based primary, integrated (physical and behavioral)
care focused on quality and safety. Patient Centered
Medical Home is a model for achieving primary
care excellence by providing care in partnership with
patients and their families to ensure decisions respect
patients’ wants, needs and preferences and that
patients have the education and support they need to
make decisions and participate in their own care.

Pediatric Care
Pediatric care is offered at all
Amoskeag Health locations.
Pediatric care is focused on the
whole child (newborn to 20
years old) for their wellness care,
immunizations, and development
of physical and emotional growth.

Adolescent Care & Teen Clinic 9/11/2019 3:38:30 PM
Adolescent care is offered at all Amoskeag
Health locations. It is focused on the unique
health situations for patients between 12
and 20 years old including screenings for
depression and anxiety, substance use
screenings, information and guidance about
appropriate diet and exercise as well as
ensuring that immunizations are up to date.
Based at The Dr. Selma Deitch Center for
Children & Teens, the Teen Clinic offers a
full range of primary care services to teens
from 14-20 years old including confidential
reproductive health services with counseling
for sexual orientation and identity, pregnancy
testing, and testing and treatment for sexually
transmitted infections (STIs).

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Gynecology Services
Amoskeag Health offers Gynecologic Care for healthy female reproductive systems
including pap smears, breast exams, STD and STI testing and treatment, and pregnancy
testing at all locations. Amoskeag Health offers colposcopy (cervical examination) and
LEEP (Loop Electrosurgical Excision Procedures) at our 145 Hollis Street location.

Prenatal Care
At Amoskeag Health, Prenatal Care is a group effort that involves initial screenings
by a team that includes social workers, counselors, nutritionists, and prenatal nurses.
All prenatal patients are seen primarily by a Nurse Midwife but have the opportunity
to meet with all of the medical providers on the prenatal care team. Patients who
are considered high risk are seen at our Tarrytown location by an Obstetrician from
the Bedford Commons OB/GYN group. If a patient delivers vaginally, then one
of our family practice physicians or our nurse-midwife attends the delivery at Elliot
Hospital. If a patient requires a C-section or abdominal delivery, a Bedford Commons
Obstetrician performs that surgery at Elliot Hospital.

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Behavioral Health

Behavioral Health Consultants
Amoskeag Health provides brief behavioral health intervention services for our
patients during their scheduled appointments. These interventions are conducted by a
Behavioral Health Consultant (BHC) to target mental health, substance misuse, and
crisis-related issues. BHCs are available during business hours for immediate brief
15-20 minute targeted interventions.

Mental Health Therapy (Traditional)
Amoskeag Health provides 40-60 minute mental health therapy sessions, on a weekly
or bi-weekly basis, for our patients who are struggling and want to make changes
in their life.

Pediatric Behavioral Health
Amoskeag Health’s Pediatric
Behavioral Health team offers
counseling care to children,
adolescents, and young adult
patients from birth to age 20.
Behavioral Health Consultants
(BHCs) provide a range of
services including brief
supportive check-ins during
medical visits, short-term
counseling, and referrals to
mental health care providers
in the community.

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Substance Use Counseling
Amoskeag Health provides assessment and counseling sessions, ongoing weekly or
bi-weekly, for patients struggling with substance use.

Medication Assisted Treatment
Amoskeag Health offers Medication Assisted Treatment for opiate use and alcohol
misuse disorder. Amoskeag Health uses Suboxone and Vivitrol medications to
support recovery.

Perinatal Substance Use Disorder (SUD)
Amoskeag Health provides care for patients who are pregnant or may become
pregnant and are using substances. Pregnant patients receive free pregnancy testing,
counseling, prenatal and primary care, medication assisted treatment, contraception
options, nutrition education, breastfeeding support, Medicaid enrollment assistance,
and case management.

Psychiatric Nurse Practitioner
Amoskeag Health employs a Psychiatric Nurse Practitioner to provide psychiatric
medication assistance to any patient deemed appropriate for this service. Common
mental health issues treated at Amoskeag Health include anxiety, depression, and
mood disorders. Once patients are stabilized on their medication regimen, they
are transferred back to their Primary Care Providers.

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Specialty Care

Special Medical Programs (SMP)
Special Medical Programs at Amoskeag Health facilitates New Hampshire’s Title V
program, Special Medical Services, for children with special health care needs. SMP
administers health programs and services for children, aged birth to 21 years, who
have or are at risk for a chronic medical condition, disability, or special health care
need. SMP provides leadership in building and promoting community-based systems of
care and services that are family centered, comprehensive, coordinated and culturally
competent. SMP’s efforts to help children and youth with special health care needs
includes health care coordination, child development clinics, treatment for complex
medical needs and services for feeding and swallowing difficulties.

Preventive Cancer Screening Programs
(Breast Cancer, Cervical Cancer, Colorectal Cancer)
Amoskeag Health has a full-time Community Health Worker (CHW) who works with
patients that are due to receive preventive cervical, breast and/or colorectal cancer
screenings. The CHW assists patients who are unsure about being screened or
patients who are experiencing barriers to care such as difficulties with transportation,
interpretation, or costs of services. Amoskeag Health is also a Breast and Cervical
Cancer Program (BCCP) screening site for the State of NH providing free breast and
cervical cancer screening to eligible patients. We have a nurse who assists patients
that may be eligible to receive free breast and cervical cancer screenings if they are
uninsured. An Amoskeag Health Nurse provides education, support, and assistance to
navigate through the program’s options. The cancer screening program is supported
by funding from the State of NH’s Department of Health and Human Services BCCP
Program and Dartmouth Hitchcock’s NH Colorectal Cancer Screening Program.

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Comprehensive Eye Care
Amoskeag Health offers all patients 5 years and older the opportunity to see an
Optometrist for a variety of eye problems at our eye care center located at The Dr.
Selma Deitch Center for Children & Teens. Amoskeag Health Optometry prescribes
glasses for those patients who have visual acuity issues, performs routine annual eye
screenings for diabetic patients and addresses acute ocular issues such as red eyes
or ocular pain. Some patients under 18 years of age qualify for free eye glasses.

Dental Program: Referrals and Services
Amoskeag Health provides dental assistance for primary care patients who do not
have dental insurance. We have a limited amount of funding to offer restorative dental
services to low income, eligible patients through a direct referral to Easterseals Oral
Health Center for patients with pain, infection, bleeding, or trauma. Upon the referral
of the Medical Provider, Amoskeag Health will coordinate an appointment for you at
Easterseals for a cleaning, x-rays, and a consultation for a treatment plan.

Podiatry Services
Amoskeag Health employs a Podiatrist to
provide foot care to any Amoskeag Health
patient. The Podiatrist performs regular
services such as diabetic foot care as well as
management of common podiatry problems
such as ingrown toenails, bunions, callouses,
infections, and other issues.

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Wrap-Around Care at Amoskeag Health

Language Interpretation & Translation
Amoskeag Health provides high quality, professional language assistance to patients
through Staff Interpreters, Video Remote Interpreting (VRI), and over the phone interpreter
services that are available for patients during appointments.
Communication Services for Deaf and Hard-of-Hearing people:
Amoskeag Health serves Deaf and Hard-of-Hearing patients through:

• Registry of Interpreters for the Deaf (RID) certified sign language interpreters
• Written communication and visual aids (Patient Portal online access)
• Adaptive equipment such as Video Remote Interpreters (iPads)
Emergency Food and Clothing
Amoskeag Health maintains food pantries located at every location to provide
emergency groceries to families in need. At 1245 Elm Street, we also have an emergency
clothing closet for families with infants and children in need of clothing.
Women Infant and Children (WIC) Nutrition Program
The WIC Program provides nutrition education, healthy foods, breastfeeding support
and referrals to other community programs for pregnant women, new mothers, and their
children. Amoskeag Health offers monthly on-site enrollment for WIC eligible patients for
their convenience as well as referrals to the Manchester office of Southern NH Services.
Insurance Enrollment
Amoskeag Health offers Marketplace health insurance application assistance
appointments for eligible patients. Our goal is to assist all eligible patients to apply for
Marketplace through Healthcare.gov and receive medical insurance with possible
subsidies and tax credits.
Community Health Workers
Community Health Workers (CHWs) work directly with patients who experience a higher
prevalence of health disparities in four chronic disease states: diabetes, hypertension,
pediatric obesity, and high risk.
Title X Family Planning Services
Title X Family Planning Services play a critical role in ensuring access to a broad range
of family planning and preventive health services. Effective methods of family planning
services are offered, including abstinence counseling, preconception counseling, STD/
HIV screening, and contraception, including hormonal methods, barrier methods, fertility
awareness-based methods, and/or permanent sterilization.
Refugee Services
Amoskeag Health partners with the Manchester Health Department and the State of NH’s
Office of Minority Health and Refugee Affairs to assist with the preventive health care and
primary health care of refugees resettling in Manchester and the surrounding towns. The
program ensures that refugees have access to primary health care, appropriate medical
screenings, vaccinations, health education, case management, and interpreter services.

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Family Support & Case Management
Case Managers at Amoskeag Health work on teams with Medical Providers to provide
family support services. Case Managers meet with all individuals and families to assess their
needs and provide resources and crisis intervention due to domestic violence, homelessness
or lack of food. Case Managers help with applying for Fuel Assistance, TANF, or other
assistance programs. Families with more complicated needs receive ongoing case
management services. Case Managers at Amoskeag Health help families find enrichment
opportunities for their kids including summer camp, tickets to community events, access to
sports or music classes and more.
Prescription Refill Assistance
Amoskeag Health has a number of programs to assist patients with getting their
medication(s):

• Medication Assistance Program (MAP): Amoskeag Health has a full-time
Medication Refill Coordinator who manages refills of patient medication and
also enrolls patients who have no prescription coverage/insurance into MAP
programs.

• Amoskeag Health 340B Formulary: This program is available at the three
Walgreens locations in Manchester and Hooksett. Patients must have an
Amoskeag Health discount card that is not expired to show eligibility for the
Amoskeag Health 340B Formulary. This program is limited to the medications listed
on the formulary.

Free Legal Advice Clinic
A collaborative program of Amoskeag Health and NH Legal Assistance provides
integrated legal and medical services for Amoskeag Health patients who need legal
assistance with public benefits (TANF, food stamps, Medicaid, unemployment, Social
Security); public housing/section 8; conditions issues in rental housing (including private
housing); housing discrimination; and school discipline/special education.
Sliding Fee Scale
Amoskeag Health offers services on a sliding fee scale that has five levels of adjusted fees
based on patient household size and income. Uninsured or underinsured patients who
qualify for the sliding fee scale will be issued a Medical Assistance Card to receive a
discount for charges incurred at all Amoskeag Health locations.
Appointment Transportation
Amoskeag Health offers transportation coordination services for qualifying patients. Our
Transportation Coordinator works with patients to identify transportation options for medical
visits when transportation assistance is needed.
Medicaid Assistance
Amoskeag Health assists with applications for Medicaid benefits for children and prenatal
patients and consumers.

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Patient Education

Cooking Classes
Amoskeag Health offers cooking classes for
children and adults. Preschool cooking classes
for ages three to five are designed to help
kids identify, try, and enjoy fruits, vegetables,
whole grains, low-fat dairy and healthy fats.
Adult cooking classes are for any parents of
Amoskeag Health patients. The lessons are
designed to teach a low-cost, healthy dinner
recipe that can be replicated at home.

Nutrition
Nutrition services are offered for adults
and children with a licensed Dietician
or Nutritionist. Counseling is offered
for obesity and weight loss support,
diabetes care, hypertension and
hyperlipidemia (high level of fats in
the blood), prenatal nutrition services,
Women Infants Children enrollment
services, and prenatal and post-partum
lactation services. Preventive and
proactive nutrition approaches are
taken to help patients of all ages
improve their overall health.

Family Literacy 9/11/2019 3:38:32 PM
Amoskeag Health provides adults
with a stress-free environment in
which to improve their English,
study for the GED, or prepare for
the US citizenship test. Child care
is provided during class where
children can receive help with
homework or play educational
games. Amoskeag Health also
strives to get books to all
pediatric patients.

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Child Birthing Classes
Occurring on a monthly basis, Amoskeag
Health hosts child birthing classes for
pregnant patients and their partners.

Diabetes Education
Amoskeag Health provides prediabetes
and diabetes education with a Certified
Diabetic Educator and Nutritionist who
explain the diagnosis, blood glucose
monitoring and targets, causes of high
and low blood glucose levels, meal
planning, exercise and weight management, medication options and reducing the risk
of complications. A monthly Diabetes Support Group helps participants engage in their
diabetes health management and allows them to discuss any barriers or questions with their
peers and participating health care staff.

Million Hearts Hypertension (High Blood Pressure) Program
Amoskeag Health partnered with several organizations in 2014-2015 to initiate the Million
Hearts program. The program involves several components, including staff training and a
standardized algorithm for medication management with hypertensive patients (patients with
high blood pressure). Partner agencies include:

•YMCA for reduced fee memberships. (Any patient of Amoskeag Health with
hypertension can be referred to the YMCA to receive a reduced fee membership
($10/month) to improve their health through exercise);

•Catholic Medical Center Parish Nurse or Manchester Health Department, during
their open hours patients can receive free blood pressure check;

•Amoskeag Health has wallet cards available in English and Spanish for patients who
are pre-hypertensive (prevention) and with hypertension (management).

Breastfeeding Education
An Amoskeag Health Lactation Counselor reviews
health benefits of breastfeeding, addresses myths
associated with breastfeeding, discusses characteristics
of breast milk vs. formula, feeding cues, positioning,
supply and demand, barriers to breastfeeding with
all pregnant patients and reviews their options.
Medicaid patients may receive a referral for an
electric breast pump.

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Community Based Collaboration

Adverse Childhood Experience
Response Team (ACERT)
The Adverse Childhood Experience Response Team
(ACERT) is a team of providers dedicated to reducing
the effects on children who are exposed to violence and
crime, specifically addressing prevention and intervention
of adverse childhood experiences.* Through a targeted
approach to identify families and children in need, ACERT
works in conjunction with First Responder agencies by
deploying a small team comprised of a crisis services
advocate, family advocate, and police officer to speak to
the family directly on the effects of trauma while helping

children get connected to appropriate programs and services in the community.

*Visit CDC.gov for more information

LAUNCH Manchester
LAUNCH (Linking Actions for Unmet Needs in Children’s Health) Manchester
promotes positive behavioral health for NH’s families and young children through
8 years of age by building strong social and emotional skills in children as well as
promoting positive physical and cognitive development by employing a growing cross-
sector team focused on several priority areas: 1. Improving access to high-quality early
education and care; 2. Empowering families; 3. Identifying and mitigating the effects
of Adverse Childhood Experiences; and 4. Improving access to health, behavioral
health, and specialized medical services. LAUNCH Manchester uses evidence-based
strategies and the expertise of community leadership serving children and families.

Manchester Community Schools Project
The Manchester Community Schools Behavioral
Health Counselor (BHC) is responsible for providing
direct mental health counseling and behavioral
support to students including classroom observation,
full mental health assessments with treatment and a
behavior plan and support to school staff and families
through ongoing implementation of trauma-informed
schools. A trauma-informed school is ready to
address students who express, through behavior,
their need for support.

Personal Responsibility Education Program (PREP)
Amoskeag Health delivers the evidence-based curriculum “Get Real” to adolescents

ages 14-19 to reduce pregnancy, sexually transmitted infections and increase healthy

relationships and positive adolescent development.

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Healthy Start Nurse Home Visiting Program
Pregnant patients at Amoskeag Health can receive home visits from a Registered
Nurse during their pregnancies and after their babies are born. Participants receive
“healthy baby” rewards. The rewards include a “healthy start” diaper bag and a
$50 diapers.com gift card.

Adolescent Preventive Services (APS)
The Adolescent Behavioral Health Consultant (BHC) provides weekly, mental health
counseling and case management services to adolescents enrolled in the Adolescent
Preventive Services Program, a collaboration between the Manchester School District
and Amoskeag Health. The goal of these services is to provide interventions that
enhance the overall physical, emotional and educational well-being of program
participants as well as to provide opportunities for participants to build strong and
meaningful connections with their families, schools, and communities. The Adolescent
BHC works closely with the other Adolescent BHCs, the clinic based BHCs and other
Amoskeag Health staff as well as the school personnel at the various schools.

Youth Enrichment Program
Amoskeag Health brings mental health counselors to local afterschool programs
through this Granite United Way funded project. Middle-school youth attending
Boys and Girls Club of Manchester, Granite YMCA, Girls Inc., and other community
programs can access counseling support on-site at their enrolled program.

ProHealth Integrated Care
Located at 1555 Elm Street, The Mental Health Center of Greater Manchester in
collaboration with Amoskeag Health have created a partnership allowing mental
health center patients access to primary health care. The goal of this collaboration is
to improve the well-being of participating patients through the complete integration of
mental and physical health at one co-located site.

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Where quality and compassion meet family and community

145 Hollis Street Manchester, NH 03101

603-626-9500 amoskeaghealth.org

Amoskeag Health Amoskeag Health @AmoskeagHealth

Manchester Community Health Center dba Amoskeag Health receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or
health-related claims, including medical malpractice claims, for itself and its covered individuals. Primary care, preventive care, outreach and enabling services at Amoskeag Health
are supported in part by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the Health Center Cluster grant
number H80CS00571. This grant provides approximately 19.1% of total revenue.

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