Living Well Cross Site Evaluation New Hampshire Living Well Grantee Profile 1

Living Well 2020 

Cross-Site Evaluation

NEW HAMPSHIRE

Living Well Grantee Profile
Living Well Cross Site Evaluation New Hampshire Living Well Grantee Profile 2

The University of New Hampshire Institute on Disability (UNH IOD) received the five-year Living Well grant in 2017.

I. Grant Background

A. Grant Context and Purpose

Between 1998 and 2016, the number of people with intellectual and developmental disabilities (I/DD) living in facility 

settings decreased 39 percent, while the number of people in small group settings of four to six people increased 80 

percent. During the same period, the number of people with I/DD living in their own home increased 126 percent, and 

the number of people living in a host or foster home increased by 132 percent.1

 People with I/DD who live in home and 

community-based service (HCBS) settings are more likely than people with I/DD living in institutional settings to make 

their own choices, have friends who are not paid staff, and have a paid job in the community.2

 Despite these positive 

outcomes, variations in access to and quality of HCBS across the country can put the well-being of people with I/DD living 

in their communities at risk. A recent series of Office of Inspector General (OIG) reports identified significant gaps in the 

reporting of and response to critical incidents in group homes.3

To address these pressing needs, the Administration for Community Living (ACL)4

 issued Living Well-Model Approaches 

for Enhancing the Quality, Effectiveness and Monitoring of HCBS for Individuals with I/DD (Living Well) grants, with two 

key goals:

• Increase community integration and independence of individuals with I/DD; and 

• Improve the quality of HCBS.

ACL awarded eight five-year grants across two cohorts to identify, develop, and evaluate model approaches which address 

two interrelated core components by incorporating eight key features. ACL administers Living Well grants through the 

Projects of National Significance (PNS) program. Funded under Subtitle E in the Developmental Disabilities Assistance 

and Bill of Rights Act (DD Act), PNS create and enhance opportunities for people with developmental disabilities (DD) to 

contribute fully in all aspects of community life. Further, PNS support the development of national and state policies that 

promote independence, integration, and inclusion in community life.

In 2020, the COVID-19 pandemic exacerbated many of the challenges faced by individuals with I/DD living in HCBS 

settings and the systems that support them, including concerns about health and safety, abuse and neglect, and social 

isolation. While the COVID-19 pandemic was not anticipated when ACL awarded Living Well grants, the public health 

crisis magnified gaps in effective systems of community monitoring for individuals with I/DD and provided opportunities 

for grantees to rapidly respond to local and state needs.

B. Two Core Components

Grantees address two core components with their Living Well model(s). 

• Community Monitoring: Development and implementation of a coordinated system utilizing multiple community 

and state level partners for monitoring the safety, health, and well-being of individuals with intellectual and 

developmental disabilities living in a variety of community settings. The purpose is to identify and eliminate the risk 

1 Larson, S.A., Eschenbacher, H.J., Anderson, L.L., Taylor, B., Pettingell, S., Hewitt, A., Sowers, M., & Bourne, M.L. (2018). In-home and residential 

long-term supports and services for persons with intellectual or developmental disabilities: Status and trends through 2016. Minneapolis: University of 

Minnesota, Research and Training Center on Community Living, Institute on Community Integration.

2 Human Services Research Institute (HSRI) and National Association of State Directors of Developmental Disabilities Services (NASDDDS). (2019). 

National Core Indicators In-Person Survey: 2017-2018 Final Report.

3 Office of Inspector General, Department of Health and Human Services. (2016). Massachusetts did not comply with federal and state requirements 

for critical incidents involving developmentally disabled Medicaid beneficiaries.

4 The Administration on Intellectual and Developmental Disabilities (AIDD) oversaw the Living Well grants when they were awarded in 2017 and 

2018. The Administration on Disabilities (AoD) now provides oversight to the grants within ACL.
Living Well Cross Site Evaluation New Hampshire Living Well Grantee Profile 3

factors for tracking, redressing and preventing abuse, neglect and 

exploitation in community settings;

• Community Capacity Building: Application of evidence 

based practices and innovative strategies focusing on 

improving services that support people with developmental 

disabilities living in the community or those moving to the 

community from a more restrictive setting; access to and quality 

of community services through capacity building and scaling 

of evidence based and other promising practices; reducing and 

mitigating the incidence of and risk factors for abuse and neglect; 

and supporting empowerment, self-determination, self-advocacy, 

and an individual’s independence, autonomy and right to live alongside their non-disabled neighbors.5

Community 

Monitoring

Community 

Capacity 

Building

Exhibit 1. Core Components 

of Living Well Models

5 Living Well-Model Approaches for Enhancing the Quality, Effectiveness and Monitoring of Home and Community Based Services for Individuals 

with Developmental Disabilities; HHS-2017-ACL-AOD-DNIQ-0221. https://acl.gov/grants/living-well-model-approaches-enhancing-qualityeffectiveness-and-monitoring-home-and-1

C. Eight Key Features

Grantees incorporate eight key features into their Living Well models.

Exhibit 2. Eight Key Features of Living Well Models 

Partnerships

Initiation and coordination 

of partnerships or coalitions 

with local and state-level 

organizations, agencies, and 

other relevant stakeholders, 

including at least one-self 

advocacy organization, in 

the design, implementation, 

and replication of grantee 

activities

Meaningful and 

active engagement 

with self-advocates 

and families

Continuous, meaningful, 

and active engagement of 

self-advocates and family 

members throughout the 

life cycle and in all stages of 

the project

Evidence based 

practices for service 

improvements

Use of evidence based and 

innovative strategies to (1) 

improve access to and quality 

of community services, 

(2) reduce and mitigate 

abuse and neglect, and (3) 

support empowerment, 

self-determination, and selfadvocacy

Building capacity 

of DSPs and HCBS 

providers

Prevention-based tools 

and technical assistance 

to address common 

needs, such as changing 

the ‘culture of abuse and 

neglect’ in HCBS settings 

and transferring knowledge 

of positive behavior

Reducing abuse 

and neglect through 

community monitoring

Collection, analysis, and 

dissemination of data to 

develop and implement 

coordinated community 

monitoring that builds 

on existing local or 

state infrastructure and 

partnerships

Addressing health 

and safety with data 

tools

Data tools and evidence 

based practices for 

monitoring high-risk 

individuals and addressing 

reoccurring issues of health 

and safety concerns

Program and 

outcome evaluation

Process and outcome 

evaluation to analyze 

delivery and impact of 

project activities

Sustainability

Assurance of organizational, 

financial, and/or community 

stability to continue and 

refine grantee work
Living Well Cross Site Evaluation New Hampshire Living Well Grantee Profile 4

D. Grantees and Partnerships

ACL awarded grants in two cohorts, with the first cohort of three grantees beginning in September 2017. The second 

cohort of five grantees began their five-year grants in September 2018. 

Exhibit 3. Living Well State Grantees by Cohort

Cohort 1

University of Georgia 

Institute on Human 

Development

University of New 

Hampshire Institute on 

Disability

Virginia Commonwealth 

University Partnership for 

People with Disabilities

Cohort 2

Alaska Governor’s Council 

on Disabilities and Special 

Education

University of Idaho Center 

on Disabilities and 

Human Development

Indiana Family 

and Social Services 

Administration

University of 

Missouri-Kansas City 

Institute for Human 

Development

Wisconsin Board for 

People with 

Developmental Disabilities

The grant requires partnerships among, at minimum:

• One Protection and Advocacy System, State Developmental Disabilities Council, or University Center for 

Excellence in Developmental Disabilities; and, 

• At least one state agency (state I/DD agency, state Medicaid agency, self-advocacy organization, consumercontrolled organizations, or family-led organizations). Additional partnerships are strongly encouraged.

II. Grantee Information

The UNH IOD was established in 1987 and is the state’s University Center for Excellence in Developmental Disabilities 

Education, Research, and Service. The UNH IOD builds local, state, and national capacity to serve the needs of people with 

disabilities and their families through research, academic, service, and dissemination initiatives. These initiatives focus on 

various areas, including assistive technology, community living and employment, inclusive early care and education, and 

health and genetics.

New Hampshire’s IOD is involved in related projects that address disability topics across the lifespan. These include the 

New Hampshire Disability and Public Health Project, which aims to improve the health and quality of life of people 

with disabilities in the state; Inclusive Communities, a project focused on promoting acceptance and inclusion of people 

with disabilities in schools and communities through documentary film; and Disability Statistics and Demographics 

Rehabilitation Research and Training Center, a center that works to alleviate gaps between producers and end users of 

disability statistics in order to support better data collection, more effective programs, and better lives for people with 

disabilities.
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III. Grantee Partnerships

The UNH IOD partners with key stakeholders on their Living Well grant (collectively, the New Hampshire Living Well 

team) including, but not limited to, the Council on Developmental Disabilities, the New Hampshire Department of Health 

and Human Services Bureau of Developmental Services, Easter Seals New Hampshire, and the Disability Rights Center.

IV. State Context

Variations in access to quality home and community-based services (HCBS) occur, in part, due to varying demographic, 

economic, political, and historical factors in each state. Key contextual factors are described here to better understand 

IOD’s external conditions for their Living Well model. The COVID-19 pandemic rapidly evolved during the 2019-2020 

evaluation cycle with significant impact on the delivery of HCBS and the health and safety of individuals with intellectual 

and developmental disabilities (I/DD). The pandemic response influenced both how and the extent to which grantees 

implemented grant activities as planned and the local and state context in which the grant is being implemented. 

In January 2020, New Hampshire’s Department of Health and Human Services (DHHS) confirmed a new commissioner. 

The New Hampshire Living Well team met with the new UNH IOD director and the DHHS Director of Long-Term 

Services and Supports to ensure that the Living Well grant continues to support the quality efforts of DHHS as well as the 

new commissioner. 

New Hampshire DHHS is implementing a corrective action plan based on the HCBS settings rule for conflict-free case 

management, which is now called conflict-free service provision. The Living Well grant has supported the state’s efforts to 

implement measures necessary to meet the conflict free requirement, as well as meeting compliance with the final settings 

rule. As a result, the New Hampshire Living Well team, with input from stakeholders, identified additional changes that 

need to be made to the state’s Service Agreement template which is on the Health Risk Screening (HRS) platform. Revisions 

to the Service Agreement and supporting documentation will include documentation of HCBS expectations and allow for 

ongoing monitoring of the settings requirements. Alterations to the use of the HRS platform will support the state’s efforts 

towards conflict-free service provision by including access to multiple providers for each individual’s record. 
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V. Model and Objectives

The New Hampshire Developmental Services Quality Council provides leadership for the consistent review and 

improvement of the quality of DD within the system. The Quality Council acts as an advisory group to the New Hampshire 

Living Well project, titled the New Hampshire Quality Framework. 

The objectives of the New Hampshire Quality Framework are as follows: 

1. Self-advocates, family members, DD network members, and other stakeholders will actively engage in the full 

implementation of the project.

2. The New Hampshire Quality Framework will demonstrate a comprehensive system to improve services for 

individuals living in the community.

3. Direct support professionals (DSPs) and other HCBS providers will demonstrate improved competencies to improve 

access to and quality of HCBS services to individuals in the community.

4. The community monitoring system in New Hampshire will demonstrate an increase in tools, training and other 

strategies to address all types of abuse, neglect, and exploitation.

5. DSPs and other HCBS providers will demonstrate increased understanding and follow through on health issues and 

the supports needed.

6. The project evaluation process will measure and report on activity progress, barriers, and areas of improvement.

7. The New Hampshire Quality Framework will demonstrate a sustainability plan that reflects organizational, financial, 

and community sustainability.

The New Hampshire Living Well team is supporting the way that providers across the state collect and analyze data. The team 

strategically leverages their strong, long-lasting partnerships across the state to implement evidence based practices to improve 

the health and safety of individuals with disabilities. The New Hampshire Living Well team encourages collaboration within 

the state, and their involvement of other partners in the development of trainings and key activities have resulted in vetted and 

effective resources.
Living Well Cross Site Evaluation New Hampshire Living Well Grantee Profile 7

VI. Key Activities by Core Components

A. Community Monitoring

Community Monitoring includes efforts to develop a comprehensive system to monitor the health and well-being of 

individuals with I/DD living in a variety of home and community-based settings. The following are key activities reported 

by the New Hampshire Living Well team during this evaluation period with the main goal of addressing this core 

component: 

Key Activity: Expand and Refine Data Collection using the HRS Platform 

• As part of the effort to continue to improve the community monitoring system in New Hampshire and move from 

paper-based to electronic data collection and documentation methods, the New Hampshire Living Well team 

partnered with Health Risk Screening, Inc. to expand the system based on a comprehensive review and crosswalk of 

data collection requirements. Through this partnership, the team identified changes needed for the HRS platform, 

which hosts the Health Risk Screening Tool (HRST), the New Hampshire Service Agreement, the Supports Intensity 

Scale, the Planning Process Acknowledge Form, the Service Agreement Amendment Form, and the Quarterly 

Satisfaction Surveys. The regulations in New Hampshire require there to be quarterly satisfaction check-ins with 

individuals with disabilities, family members, and guardians. These surveys were originally paper-based, but will be 

hosted on the HRS platform.

• The New Hampshire Living Well team updated the service agreement used by providers in the region to collect data 

on regulatory requirements, waiver sub-assurances, file review audits, and home and community-based services 

compliance. To achieve this, the New Hampshire Living Well team obtained feedback from service coordinator 

supervisors, certification and licensing, New Hampshire Living Well team, and the Bureau of Developmental Services 

to ensure each stakeholder’s needs are addressed. The HRS platform is used statewide for the Person-Centered 

Planning documentation and HRST. The additional information/forms that will be captured in the HRS platform will 

support regional and statewide quality monitoring efforts.

• The HRST is used to detect health risks and destabilization early. The HRST assigns scores to 22 health and 

behavioral-related rating items. The total points result in a Health Care Level (HCL) with an associated degree of 

health risk. HCLs can range from 1 through 6; Level 1 being the lowest risk for health concerns and Level 6 being 

the highest risk for health care concerns. The HRST diagnoses are auto-populated into the service agreement to 

avoid duplication of effort for service coordinators and to eliminate errors. This is especially helpful when filling 

out information for those with dual diagnoses. The HRST also has a referral section that includes assessments of 

risk, communication, behavioral health, and assistive technology. The HRS helps to ensure that health conditions 

are not overlooked by an individual’s team by capturing health related data on a regular basis. The Living Well grant 

is supporting the state’s enhancement of the managed care organizations (MCOs) role by notifying them when an 

individual’s Health Care Level is 3 or above. The MCO will then take advanced measures to work with the individual 

and their team to address health care issues, ultimately preventing the Health Care Level from increasing. 

B. Community Capacity Building

Community Capacity Building includes efforts to increase the skills and knowledge of all individuals, families, and service 

providers in the HCBS system. The following are key activities reported by the New Hampshire Living Well team during 

this evaluation period with the main goal of addressing this core component:

Key Activity: Accelerate and Conduct 

Medication Administration Training 

• In New Hampshire, the original medication administration training for direct support professionals was eight hours 

long, only available in English, and had not been updated in twelve years. It was recognized that the lack of updated 

information and inconsistency in presentation (use of the DVD) impacted DSP success. As the New Hampshire team 

recognized that a large portion of the staff administering medication did not speak English as their first language, 
Living Well Cross Site Evaluation New Hampshire Living Well Grantee Profile 8

the New Hampshire Living Well team updated and translated the training to the three top languages spoken by staff, 

Spanish, Dzongkha, and Nepalese.

• In support of DHHS during the pandemic, the New Hampshire Living Well team was able to provide DHHS with the 

almost completed (missing the video demonstration components) medication administration training to put onto the 

Relias online training platform. This allowed for ongoing medication administration to occur during the pandemic 

when it was not possible to hold in-person trainings. The training allowed for medication administration to continue 

and for staff and home providers to receive initial or re-authorization training during the epidemic.

• The videos that will be included in the training will cover various aspects of medication administration. Topics 

covered by the videos include how to interact with individuals that do not wish to take their medication, as well 

as demonstrations of how to administer certain medications. Furthermore, the training had embedded evaluation 

questions throughout the training to measure the impact of the training on medication administration practices. If 

this training continues to be successful, it will result in the reduction of staff that lose their medication administration 

privileges and will improve the longevity of DSPs and home providers. 

VII. Analysis and Conclusion

A. Contextual Factors

The New Hampshire Living Well team utilizes their strong and long-lasting partnerships with self-advocates, direct 

support professionals, state agencies, providers, families, and advocacy organizations to improve the supports and services 

for people with disabilities within the state. As New Hampshire is a small state, they are able to work collaboratively 

with stakeholders and maintain strong buy-in for their initiatives. Additionally, New Hampshire responded to issues of 

cultural diversity that sometimes impact how DSPs deliver supports and participate in the workforce. In response, the 

New Hampshire Living Well team actively considers cultural and linguistic diversity across activities to enhance DSP 

employment, retention, and delivery of supports to ensure optimal performance in the service delivery system.

B. Model Design

The New Hampshire Living Well team actively engages stakeholders and individuals with disabilities in the development 

and implementation of all project activities. Through the Quality Framework, the team addresses numerous barriers in 

data collection system to improve community monitoring efforts within the state. By regularly surveying and coordinating 

with direct support professionals, the New Hampshire Living Well team is able to build capacity through the development 

of resources that build the competencies of DSPs.

C. Key Activities

The reliance on paper-based data collection and the lack of a standardized reporting and monitoring system within the 

state led the New Hampshire Living Well team to adopt the HRS platform to support data collection. By moving to an 

electronic-based platform, the team is improving data collection and streamlining crucial elements of the community 

monitoring system for all stakeholders. The New Hampshire Living Well team’s inclusion of stakeholders throughout 

the development of the platform both strengthens existing partnerships and ensures the final product is relevant, 

appropriate, and best serves the needs of the community. Having one platform used across the system will result in more 

comprehensive, up-to-date data collection that can be easily accessed to run reports and identify trends.

The medication administration training was born out of the New Hampshire Living Well team’s realization that the 

DSPs most likely to lose their medication administration privileges are those whose primary language is not English. 

Additionally, the state was interested in updating the way in which the training was offered due to the age of the video 

and its’ content. The action taken to update the medication administration training to make it more accessible will help 

improve the retention of the staff in the workforce and make entering the workforce easier for new employees. Hosting the 

medication administration training online ensures accessibility of the resource beyond the lifespan of the grant, in addition 

to the components of the live, in-person training being distributed throughout the state.