Transformative Ideas for NH's Healthcare System

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Margo Sullivan has spent her career helping people live safely and independently in their own homes. In Coös County, residents rely on Margo and her team each day for support that allows them to maintain dignity, stability, and quality of life.

“I remember a time when people had what they needed,” Margo said. “They were happy, stable, and able to thrive.”

Over the years, she has seen the healthcare safety net weaken, particularly in rural communities. Services are harder to access, eligibility rules are more restrictive, and people who depend on in-home care face growing barriers to staying housed and healthy.

“The people who really need resources to live independently are being challenged the most,” Margo said. “It’s easier to fall off service rolls and much harder to get back on.”

Her experience reflects a broader reality across New Hampshire: workforce shortages, rising costs, and policy changes are straining healthcare providers and limiting access to care, especially in rural areas.

Workforce Shortages Limit Access to Care

Across the state, the lack of trained healthcare workers is one of the most significant challenges providers face. Staffing gaps create ripple effects throughout the system, reducing service availability and driving up costs.

“Significant workforce shortages continue to affect the healthcare sector across the state, with challenges particularly acute in rural communities,” said Maureen Znoj, Senior Director of HealthForce NH. “Rural health systems face persistent staffing gaps and limited provider availability.”

As Executive Director of Androscoggin Valley Home Care Services (AVHCS) in Berlin, Margo experiences these challenges daily. AVHCS supports older adults and people with disabilities so they can remain in their homes rather than moving into institutional care. For the approximately 300 clients AVHCS serves across Coös County, home care is often a lifeline.

“It’s about supporting all the different pieces of a person’s life with respect,” Margo said.

Founded 50 years ago to serve the Berlin and Gorham communities, AVHCS has expanded countywide to meet growing demand. But like many providers, it struggles to recruit and retain Licensed Nursing Assistants (LNAs), limiting how many people can receive care.

Innovation as a Path Forward

HealthForce NH was created to drive coordinated strategies that attract people to healthcare careers and expand the state’s workforce. In 2024, HealthForce NH launched the Innovation Challenge, a competition designed to catalyze creative, scalable solutions. The top proposals receive funding to move from concept to implementation.

Margo immediately recognized the opportunity to address AVHCS’s most pressing challenge.

Her proposal, the Inter-Disciplinary Elite Aides (IDEA) project, envisions a shared, regional pool of LNAs who could work across multiple healthcare organizations. Through a shared online scheduling system, LNAs would be able to choose flexible shifts across participating providers, while organizations could fill open slots even when permanent positions remain unfilled.

The IDEA project is designed as a triple win: healthcare workers gain flexibility and choice, providers gain staffing support, and communities gain more reliable access to care.

As the first-place Innovation Challenge winner, AVHCS received start-up funding to begin developing the technology, training, legal, and employment frameworks required to launch the project.

“The complexity was mind-bending,” Margo said. “But the hardest problems are often where the real opportunity is.”

Progress has been slower than anticipated. What initially appeared to be a simple workforce shortage revealed deeper structural challenges tied to reimbursement, funding, and shifting healthcare priorities. Still, the project continues to move forward with a focus on long-term, sustainable solutions rather than quick fixes.

Medicaid Changes Add New Pressure

Workforce challenges are now intersecting with anticipated Medicaid policy changes, creating additional uncertainty for providers across New Hampshire.

Medicaid plays a critical role in the healthcare safety net, serving older adults, people with disabilities, and families with low incomes. Many AVHCS clients receive services through the Medicaid-funded Choices for Independence program, which enables eligible residents to remain in their homes instead of entering assisted living or nursing facilities.

While changes will be phased in and the full impact is not yet known, providers expect some residents to lose coverage and many organizations to face financial shortfalls.

“Honestly, we’re bracing for everything,” Margo said.

Federal Investment Creates Opportunity

To help rural states respond to these pressures, Congress created the Rural Healthcare Transformation Program to support innovation and strengthen healthcare delivery systems.

In a major boost for New Hampshire, the state was awarded $204 million through the 2026 Federal Rural Healthcare Transformation program—the largest award of any New England state. The funding will support workforce development, technology, and new models of care designed to expand access in rural communities.

“This represents a powerful opportunity for our state to reimagine how healthcare is delivered,” said Peter Ames, Executive Director of the Foundation for Healthy Communities. “As we navigate Medicaid changes, these funds will help build partnerships and develop innovative solutions that strengthen care for rural residents.”

The New Hampshire Department of Health and Human Services led a collaborative application process involving providers, partners, and community members statewide—an approach that mirrors the coordination needed for lasting system change.

Healthcare and New Hampshire’s Future

Healthcare is essential not only to individual well-being, but to New Hampshire’s economic strength. When people are healthy, they can work, care for their families, and contribute to their communities.

By investing in workforce innovation, supporting providers, and leveraging historic federal resources, New Hampshire has the opportunity to build a healthcare system that is accessible, affordable, and responsive to people of all ages and abilities.

Together, we can create a healthier and more prosperous New Hampshire—one where everyone has the opportunity to thrive.

NH Possible is building a movement to make this vision a reality. Join us! Sign up for the NH Possible newsletter to stay up-to-date and learn how you can contribute to progress.