Background
Alabama is the thirtieth largest state and is sometimes called the Yellowhammer State, after the state bird. It is bordered by Tennessee to the north, Georgia to the east, Mississippi to the west, and Florida and the Gulf of Mexico to the south. Montgomery is the state capital and the location of the Central Office of ADPH. The largest urban areas in Alabama are the cities of Birmingham, Mobile, Montgomery, and Huntsville. Birmingham is the largest city in the state and the location of UAB Hospital which has one of the state’s level one trauma hospitals. Mobile is the state’s port city and the third largest metropolitan area. It considers itself the cultural center of the Gulf Coast and the birthplace of America's original Mardi Gras. Huntsville, the fourth largest city, has experienced exponential growth in the last 10 years because of its national defense installations and high-technology industries. Huntsville considers itself the star of Alabama. As such, it has become a star in the fight for better community health through the creation of Healthy Huntsville. This effort focuses on the core concepts of nutrition and exercise to encourage our residents to embrace healthy lifestyles.
The state of Alabama is divided into eight Public Health Districts and each Public Health District Office is overseen by a District Health Officer or District Administrator. District Offices manage CHDs in 66 of Alabama’s 67 counties. CHD staff work to preserve, protect, and enhance the general health and environment of the community by:
- Providing health assessment information to the community.
- Providing leadership in public health policy.
- Assuring access to quality health services and information, preventing disease, and enforcing health regulations.
ADPH operates on a mission to promote, protect, and improve Alabama’s health with a focus on heathy people and healthy communities. In 2019, ADPH leadership released a 5-year strategic plan. The plan focuses on five main areas and goals which are outlined below:
Health Outcome Improvement
Goal: Improve specific health outcomes or health disparities so that Alabama is a healthier place to live and work
Financial Sustainability
Goal: Increase available funds in order to continue to promote, protect, and improve the health of Alabamaians
Workforce Development
Goal: Strengthen the performance and capacity of the ADPH workforce so that the ability to serve our customers increases
Organizational Adaptability
Goal: Adapt to changes in the health care environment so that programs and processes are increasingly effective and efficient
Data Driven Decision Making
Goal: Become data-driven in analysis and decision making so that leaders and programs make informed decisions
An additional part of this plan was to assemble teams to concentrate on five special projects. For 2019, those projects were as follows:
1. Improve Pregnancy Outcomes
2. Increase Participation Rates in Obesity and Chronic Disease Prevention Programs
3. Increase Reimbursement for Services Provided in 2018 and 2019
4. Establish a More Unified Workforce
5. Increase the Number of Initiatives Reporting in InsightVision (ADPH's performance management dashboard)
In 2021, the ADPH Office of Health Equity and Minority Health was established. Its mission is to bring vision and imagination through a multisector frame to achieve equity in health, an established priority area for the department. The Office of Minority Health has developed a 2-year blueprint for elevating health equity as a priority. Utilizing reliable data to identify communities at highest risk of health disparities and inequities, the new office and its partners seek to deliver intentional strategies that will build health equity into daily practices. Strategies as reported in the ADPH 2021 Annual Report are as follows:
- Increase/improve data collection and reporting for populations experiencing a disproportionate burden of COVID-19.
- Build, leverage, and expand infrastructure support for COVID-19 prevention and control among populations at higher risk and underserved.
- Mobilize partners and collaborators to advance health equity and address social determinants of health as they relate to COVID-19 health disparities among populations at higher risk and underserved.
The State of Alabama CSHCN Program is administered by CRS, a division of ADRS. CRS’ mission embodies the principles of comprehensive, community-based, and family-centered care. The mission of CRS is to enable children and youth with special health care needs and adults with hemophilia to achieve their maximum potential within a community-based, culturally competent, family-centered, comprehensive, coordinated system of services. Coordinated health services are delivered via 14 community-based clinics across 8 service districts.
SELECTED CHANGES IN ALABAMA'S POPULATION /ECONOMIC ENVIRONMENT AND POVERTY LEVELS/TRENDS IN NUMBERS OF ALABAMA TITLE V-SERVED PERSONS
Total Population
Based upon the Annual Estimates of the Resident Population produced by the U.S. Census Bureau, the estimated population for the state, as of July 1, 2019, was 4,903,185 according to data retrieved on March 25, 2022. This figure exceeds the 2018 estimate, of 4,887,681, by 15,504 persons.
0-24 Year-Old Residents
Of data available from the year 2019, there were 1,538,530 (or 31.4 percent) of the Alabama population, from the age of 0-24 according to the U.S. Census Bureau. The age group breakdown for this calculation was as follows: Under 5 years was approximately 6.0 percent (294,357); 5-9 years was approximately 6.1 percent (297,968); 10-14 years was approximately 6.3 percent (310,498); 15-19 years was approximately 6.4 percent (313,615), and 20-24 years was approximately 6.6 percent (322,092). Of the total population, approximately 4.6 percent of Alabama’s population was of Hispanic Origin and approximately 95.4 percent was Not of Hispanic Origin.
Live Births
According to numbers retrieved March 25, 2022, from the National Center for Health Statistics website, in 2020, there were a total of 57,647 live births to Alabama residents-a slight decrease (approximately 1.7 percent) from the 58,615 live births in 2019 for the state. There were 5,233 (approximately 9.1 percent) live births to mothers of Hispanic origin in the same year. Of the mothers who were non-Hispanic, approximately 56.7 percent were white; 30.8 percent were black; 1.5 percent were Asian; 0.2 percent were American Indian or Alaska Native and approximately 0.07 percent were Native Hawaiian or Other Pacific Islander.
Below are charts of additional vital statistics data.
Vital Statistics, 2020
Source: ADPH 2021 Annual Report
Alabama’s Leading Causes of Death, 2020
Source ADPH 2021 Annual Report
ECONOMIC ENVIRONMENT AND POVERTY LEVELS
Per the U.S. Census Bureau, 2019 American Community Survey Poverty Status In The Past 12 Months, for the year 2019, an estimated 739,108 or 15 percent of Alabamians were below the poverty level.
TRENDS IN NUMBERS OF ALABAMA TITLE V-SERVED PERSONS
Per guidance on the completion of Forms 5a and 5b, the methods used for calculating the entries have changed; thus, data reported in this application/annual report will not be directly comparable to previous years. From our annual report year 2020, there were 1,014 pregnant women; 31,385 infants less than one year of age; 12,092 CSHCN; and 50,969 “Others” served under Title V.
CRS continually participates in community awareness and outreach activities in order to educate individuals about services for CYSHCN and their families. The following figures represent CYSHCN and families who received services directly from CRS. Specifically, in FY 2018, CRS served 10,784 CYSHCN, an increase of 4.8 percent over FY 2017. In FY 2019, CRS served 11,772 CYSHCN, an increase of 9.15 percent over FY 2018. In FY 2020, CRS served 12,091 a slight increase of 2.7 percent over FY 2019. The 2019 increase is attributed to expansion of Augmentative Communication Clinics to serve children with severe expressive language disorder, opening the Craniofacial Orthodontia Clinic to all payor sources, and additional hearing clinics.
In FY 2021, CRS served 12,833 CYSHCN, an increase of 6.13 percent over FY 2020. The 2021 increase is attributed to clinics resuming operations after the brief shutdown in FY 2020 due to COVID-19 and is in line with normal growth. CRS staff reached approximately 52,149 CYSHCN and their families via incoming toll-free calls, information and referrals, Parent and Youth Connection Facebook pages, ADRS/CRS website, outreach activities, health fairs, transition expositions, local hearing screenings, and FVA activities.
Issues important to understanding the health needs of the state's population include the health care environment, selected changes in the state’s population, the number of state Title V-served individuals, strategic and funding issues, and special challenges in delivery of services to CYSHCN. Also key to understanding the health needs of the state's Title V populations are salient findings from the current 5-Year Statewide Needs Assessment and priority MCH needs based on these findings which are discussed further in this MCH report/application.
The Health Care Environment
Changes that have occurred in Alabama's health care environment have caused a shift in the provision of direct medical services from CHDs to private providers. This shift has been especially evident with respect to the provision of services to pregnant women, children, and youth. Because the shift continues to affect ADPH's role in providing services, salient history concerning the health care environment is summarized here.
Medicaid Maternity Care
The FY23 General Fund budget includes $8.5 million dedicated to Alabama Medicaid Agency (Medicaid) funded postpartum care to assist in reducing maternal mortality rates. The extension of Medicaid coverage for new mothers provides them access to life-saving health care for 12 months post-delivery. This represents a significant change from the current coverage access period, which is only 60 days after childbirth. Public data shows that Alabama holds the nation’s third worst maternal death rate, with nearly 40 mothers dying within a year after delivery.
Patient 1st and Case Management/Care Coordination
Through an agreement with Medicaid, ADPH continues to provide case management services to those infants who do not pass the newborn screenings in the hospital and those children with an elevated lead level. In FY 2021, ADPH provided case management services to 1,727 infants who did not pass the Newborn Screening or Newborn Hearing Screening at birth and 494 children with an elevated lead level. FY 2021 ended with 7 full-time equivalents (FTEs) providing services to the identified infants and children.
Collaboration between CRS and Medicaid
The Medicaid Commissioner has emphasized children's issues as an Agency priority and specific Medicaid staff members are assigned to work with CRS. Meetings between Medicaid and CRS are held quarterly to discuss any issues or concerns regarding services provided to Medicaid recipients with special health care needs. If issues arise outside the quarterly meetings, the CRS Medicaid liaison will contact Medicaid to discuss. In addition, CRS staff, including SPC, participate on advisory committees and work groups associated with various Medicaid initiatives.
In order to ensure consistent quality, statewide standards of care, and access to community-based clinical services, Medicaid and CRS have negotiated a list of approved multidisciplinary clinics. CRS operates these clinics within Medicaid’s Children's Specialty Clinic Services program requirements, which includes the required practitioners credentialed in accordance with Medicaid Administrative Code. CRS clinics employ physicians, nurses, social workers, physical therapists, audiologists, nutritionists, occupational therapists, and speech language pathologists. CRS works with Medicaid to add new specialty clinics or modify existing clinics as needed.
Throughout the COVID pandemic, CRS has continued to work closely with Alabama Medicaid to discuss the needs of therapists and Medicaid recipients, both in and out of ADRS, to maintain a continuum of service delivery for all recipients in the state. Medicaid communicated with CRS program specialists regarding therapeutic codes and service delivery options to ensure all Medicaid recipients could be served appropriately. Medicaid has continued to recognize the need for covering speech, occupational, and physical therapy services via telemedicine visits which allows CRS to continue providing services during the pandemic to families that would have otherwise been unable to receive needed services.
CRS is a direct provider with Medicaid for audiological services, hearing aids, and related supplies, thereby providing better coordination of these services for Medicaid-eligible CRS clients. CRS reviews all statewide requests to Medicaid for augmentative communication devices (ACDs) and houses all Medicaid prior authorization requests for ACDs.
CRS is the only provider of medically necessary orthodontia for Medicaid recipients. CRS works closely with Medicaid’s Dental Director regarding coverage for medically necessary orthodontia services. During the pandemic CRS worked with orthodontists at UAB School of Dentistry to approve teledentistry codes to ensure clients in active orthodontia were still followed by their orthodontist for their plan of care to prevent patient abandonment.
CRS has an ongoing collaboration with Medicaid to meet Health Insurance Portability and Accountability Act (HIPAA) standards for privacy and billing. CRS staff have access to Medicaid eligibility data for confirming coverage as outlined in the Provider Agreement between Medicaid and ADRS.
Medicaid Family Planning Waiver and Related Issues
The 1115(a) Family Planning Waiver Proposal, submitted by ADPH and Medicaid to the Health Care Financing Administration (HCFA) in FY 1999, was implemented in October 2000 (HCFA became CMS). This waiver, called Plan First, expanded Medicaid eligibility for family planning services to 133 percent of Federal Poverty Level (FPL) for women ages 19-55 years of age. The Plan First Family Planning Program includes coverage for women ages 19 to 55 up to 141 percent of FPL and coverage for men age 21 and older with incomes up to 141 percent of FPL for vasectomies only. A standard income disregard of 5 percent of the FPL is applied if the individual is not eligible for coverage due to excess income. In November 2016, Medicaid submitted a waiver amendment to add care coordination for males enrolled in Plan First to receive vasectomies and vasectomy-related services.
UAB evaluates the implementation of Plan First. The evaluation determines progress on six goals: enrolling 80 percent of eligible women under age 40, maintaining a high level of awareness of the Plan First program among enrollees, increasing utilization of Plan First services by enrollees to 70 percent, increasing the portion of Plan First enrollees who receive smoking cessation services to 85 percent, maintaining birth rates among Plan First participants, and making sterilization services available to income-eligible men over age 21. According to the Plan First Market Analysis report, the Alabama Family Planning Program provides services to approximately 33 percent of all Plan First enrollees statewide. The evaluation determined the program paid for itself by reducing costs associated with births and noted participants with the lowest birth rates are those who received risk assessments or care coordination and those who use Title X Family Planning services. The waiver has been extended through September 2022. Medicaid has consistently expanded services with each renewal, most recently adding care coordination services for males seeking sterilization services.
The State Children's Health Insurance Program
CHIP was added to the Social Security Act by the Balanced Budget Act of 1997. Alabama was the first state in the nation to have a federally approved CHIP. Alabama's CHIP program is the result of a partnership between ADPH, Medicaid, and the former Alabama Child Caring Foundation. Alabama’s CHIP is administered through ADPH's Bureau of Children's Health Insurance. CHIP provides comprehensive health coverage to eligible children through a separate program known as ALL Kids. As a result of provisions in the Affordable Care Act, in addition to the ALL Kids program, CHIP also funds two groups of Medicaid eligible children (MCHIP). Persons eligible for Medicaid are not eligible for ALL Kids. Medicaid and ALL Kids continue to collaborate on the application process.
The bureau continues to work collaboratively with Medicaid to make enhancements to the dual eligibility enrollment system. This collaboration will ensure a streamlined application process that is easy for applicants to navigate. At the end of FY 2021, there were 186,344 children enrolled in CHIP with 74,173 enrolled in ALL Kids and 112,171 enrolled in MCHIP.
CHIP also developed the ALL Babies Program. ALL Babies is a collaborative effort pilot program between CHIP and FHS, with a focus on pregnant women in Montgomery, Macon, and Russell counties. Medical insurance coverage is provided to women who are not eligible for insurance allowing for access to prenatal care. FHS provides case management services to the women and their infants to ensure prenatal appointments are kept, a family planning method is selected, and the post-partum appointment is kept. Education is also provided on a variety of topics including but not limited to: early elective deliveries, safe-sleep, and breast feeding. Case management services are also provided for the infant until the first birthday. The purpose is to provide continued support to the mom and encourage all well-child appointments and immunizations are up to date. Once the infant is close to the first birthday, education is provided on the importance of a dental home and making the first dental appointment. FY 2021 ended with two FTEs providing case management services to the eligible population.
CRS Services to Certain Medicare Enrollees
In FY 2021, CRS served 47 clients with Medicare benefits. All clients were adults with bleeding disorders. CRS assisted clients with Medicare coverage to select the health plan option that best addressed their needs and helped them locate Medicare pharmacies for factor treatment of bleeding disorders. In FY 2021, CRS paid insurance premiums for 16 clients with bleeding disorders.
Special Challenges in Delivery of Services to CYSHCN
CRS staff members continue to ensure CYSHCN and their families receive high quality services in their local communities while identifying resources for families to address the ongoing impacts of COVID-19. These impacts include compromised learning as a result of virtual school, challenges related to returning to in person learning, disruption to health care due to hesitancy to seek in person care, along with social and economic impacts. CRS care coordinators continue to link CYSHCN and their families to resources that may mitigate some of the long-term effects of the pandemic.
CRS staff maintained safety practices, including wearing PPE, utilizing screening procedures, managing waiting areas, and limiting the number of individuals that could accompany the child to clinic. Parents and caregivers have provided feedback that these measures increased their confidence in bringing their CYSHCN to CRS offices. Our mission has always been to provide quality clinical services to CYSHCN and their families, and we are continuing to meet their needs.
CRS has continued utilizing CMS/Medicaid's lessened restrictions on telemedicine visits to ensure CYSHCN receive quality care. Evaluation and medical telemedicine clinics developed at the start of the pandemic continue to deliver multidisciplinary clinical services to families when applicable. These clinics include Adult Hemophilia, Pediatric Hemophilia, Augmentative Communication & Technology, Cystic Fibrosis, Feeding, Neurology, Seizure, and Seating/Positioning/Mobility Clinic. CRS audiologists have the capability to perform remote hearing aid programming as needed.
In addition to the ongoing COVID-19 crisis, CRS faced continued challenges in rural areas. The state is largely rural, with greater population concentrations surrounding three larger urban areas (Mobile, Birmingham, and Huntsville). In rural areas, more risk factors exist that could potentially increase the percentage of CYSHCN in the general child population, such as higher poverty levels and lower education levels. According to the U.S. Department of Agriculture Economic Research Service the poverty rate in rural Alabama is 18.5 percent,compared with 14.8 percent in urban areas of the state, and 18.8 percent of the rural population has not completed high school. In 2019, 21.9 percent of Alabama’s children ages 0-17 lived in poverty.
Comprehensively meeting the needs of CYSHCN in rural areas is even more difficult due to transportation barriers and limited access to providers with specialized experience in treating complicated health issues. Specialists and allied health professionals with pediatric experience are mainly located in the larger urban areas, necessitating travel to access them. In general, the state has poor public transportation systems. Though private programs exist in some areas and reimbursement for transportation is provided through various sources (including Medicaid and CRS), the state lacks the infrastructure to meet transportation needs in all locations. Thus, CRS continues to have an integral direct service role in the state's system of care for CYSHCN through its 14 community-based offices. Via the provision of multidisciplinary medical specialty and evaluation clinics, care coordination, and family support throughout the state, more CYSHCN have access to care in their home communities. Public/private partnerships, including agreements with the state's two tertiary-level pediatric hospitals, enable CRS to bridge gaps in the system of care, thereby increasing the state's capacity to address the health, social, and educational needs of Alabama's CYSHCN.
Health Care Coverage and Healthcare Provider Access
Oral Health
Alabama is on the verge of a dental provider crisis. From the early 1970s until the early 1980s, federal dollars provided a means to enlarge the UAB School of Dentistry and accept more students – about 169 during those 10 years. When funding stopped, and larger numbers of dentists were graduating, the accepted class size was reduced back to the original size of 57 per year. Those excess graduates from the 70s and 80s began to reach retirement age around 2015, leading to a decrease in the number of dentists in the state that Alabama is still experiencing today. Additionally, an increase in the number of out of state students has resulted in less retention of graduates in the state. The following is a summary of the demographics of Alabama dentists:
- Alabama has the worst dentist to population ratio in the country
- Greene and Clay counties have no dentist
- Coosa county has one dentist who provides dental services only 2 days per week
- Lowndes county has a Federally Qualified Health Center that has rotating dental staff from neighboring Montgomery County. The clinic is open 4 days per week
- There are 2,095 practicing dentists in Alabama and 26 percent (557) are over age 60+
Age and number of dentists available are part of the contributing factors which lead to access to care issues Alabama presently faces. In an effort to increase the number of dentists in Alabama, the UAB School of Dentistry—the only dental school in the state—increased its enrollment to 84 students in 2021. Of the more than 1,500 applicants in 2022, 84 entered the freshman class. Of those admitted, 17 percent were the first in their family to attend college; 70 percent were from Alabama; 56 percent were female; 24 percent were minorities; and 21 percent were from a rural zip code.
ADPH Office of Telehealth
Telehealth is a statewide program with 65 county health departments equipped with telehealth carts. Collaborating with 15 healthcare agencies, ADPH staff facilitate services such as nephrology, neurology, cardiology, behavioral health, and HIV follow-up. Telehealth staff work with special partners, such as the Alabama Lions Sight Association, Jacksonville State University’s Nurse Practitioner Program, and UAB’s Living Donor Program in order to reach patients in rural communities. The telehealth equipment is also utilized by ADPH staff for meetings and training events.
The telehealth office manages several grants that provide for the deployment of carts, specialty equipment, and funding for CHD staff to operate the equipment during the telehealth appointments. ADPH continues to improve and increase the opportunities to use the telehealth carts by expanding the network of partners and upgrading equipment.
In response to the COVID-19 pandemic, Telehealth program staff worked with ADPH administration and a local vendor to establish the alcovidvaccine.gov website for vaccine appointment scheduling. During the pandemic, the telehealth equipment was utilized for staff training and meetings to accommodate social distancing and reduce travel costs for the department.
Primary Care and Rural Health
The Office of Primary Care and Rural Health (OPCRH) administers programs to improve healthcare access and quality in rural and medically underserved communities. As reported in ADPH’s 2021 Annual Report, 63 of Alabama’s 67 counties have areas designated as being medically underserved. These underserved areas have a high prevalence of healthcare issues, including chronic diseases such as diabetes, hypertension, heart disease, and other challenges such as a high rate of substance abuse. OPCRH employs several programs and works closely with partners such as the Alabama Rural Health Association, Alabama Hospital Association, Alabama Primary Health Care Association, and departmental bureaus to address these health issues. Some of the major initiatives in OPCRH are recruitment and retention of healthcare professionals and technical assistance to support 42 small, rural hospitals and health providers in transitioning to a new value-based healthcare system.
OPCRH utilizes a national, web-based recruitment system called National Rural Recruitment and Retention Network to recruit into medically underserved areas. During FY 2021, approximately 1,543 primary care practitioners were referred to rural hospitals and clinics in Alabama. Another recruitment program is the National Health Service Corps (NHSC), which has both scholarship and loan repayment components.
NHSC covers a wide array of health professionals such as physicians, dentists, nurses, and behavioral health professionals. Currently, there are 131 Alabama participants in NHSC. These programs are supplemented by a J-1 visa waiver program, which enables placement of foreign trained physicians in return for 3 years of service in medically underserved areas. Currently, there are 72 healthcare providers delivering medical care to rural and medically underserved Alabamians under the J-1 visa waiver program. OPCRH assists communities in establishing Centers for Medicare and Medicaid services-certified rural health clinics. Over the past year, 15 new rural health clinics were established, for a current total of 147.
OPCRH collaborates with various entities to address workforce issues essential to improving the health of Alabama residents. One such initiative is the partnership with the UAB Heersink School of Medicine - Huntsville Regional Medical Campus to develop a rational service area plan designed to identify workforce shortage areas more accurately for federal designation. These areas determine eligibility for certain federal grants as well as eligibility for NHSC and the J-1 visa waiver program. Alabama’s 42 small, rural hospitals are also assisted under federal grants administered by OCPRH which target improvement of operational efficiency, quality, and hospital sustainability.
COVID-19 presented many financial and operational challenges to Alabama’s rural hospitals, including heavy reductions in patient appointments and elective surgeries, as well as an unprecedented level of hospital staff turnover. To build on efforts that HRSA began in 2020, to provide funding to hospitals through the Coronavirus Aid, Relief, and Economic Security Act, HRSA provided a second wave of funding through the American Rescue Plan. These funds target COVID-19 testing and mitigation efforts. OPCRH continues to work closely with the Alabama Hospital Association to provide relief and support to Alabama’s small rural hospitals.
To Top
Narrative Search