Demographics, Geography, Economy, and Urbanization

 

Tennessee spans approximately 500 miles east to west, 110 miles north to south, and is bordered by 8 other states.  The state, comprised of 95 counties, is geographically, politically, and constitutionally divided into three Grand Divisions:  East, Middle, and West.  East Tennessee, comprised of 35 counties, is characterized by mountains and rugged terrain.  This region contains Knoxville and Chattanooga (the 3rd and 4th largest cities in the state) as well as the "Tri-Cities" of Bristol, Johnson City, and Kingsport located in the extreme northeastern most part of the state near the boarders to Virginia and North Carolina.  Middle Tennessee consists of 39 counties, has the largest land area, and is characterized by rolling hills and fertile stream valleys.  Middle Tennessee is the least densely populated of the three Grand Divisions, yet houses the state’s capitol and largest city.  West Tennessee, bordered by the Mississippi River on the west and the Tennessee River on the east, contains 21 counties.  This region has the smallest land area and is the least populous of the three Grand Divisions, yet contains the second most populous city in the state – Memphis.  Outside greater Memphis, the region is mostly agricultural.

 

Tennessee’s population is estimated to be 6.9 million.  Compared to the United States, Tennessee is less racially and ethnically diverse with a smaller foreign born and non-native English-speaking population.  The state has slightly higher rates of homeownership and health insurance coverage.  However, the state sees slightly worse rates of high school graduates, employment, and poverty.  The tables below compare Tennessee to the US as a whole on many different factors.[1]

 

 

 

 

 

Distressed Tennessee counties rank among the 10 percent most economically distressed counties in the nation. Each year, the Appalachian Regional Commission (ARC) prepares an index of county economic status for every county in the United States. Economic status designations are identified through a composite measure of each county's three-year average unemployment rate, per capita market income, and poverty rate. Based on these indicators, each county is then categorized as distressed, at-risk, transitional, competitive or attainment. As state FY 2023, there were 10 distressed, and 32 at-risk counties in Tennessee, representing an increase of 1 distressed and 2 at-risk counties from 2022. 

 

Health Status of Tennessee’s MCH Population

 

While the 2021 Annual Report for America’s Health Rankings did not include overall state health rankings out of shared understanding that the country continues to face ongoing challenges due to the COVID-19 pandemic, individual measures were still ranked.

 

Unfortunately, Tennessee ranks poorly on several key MCH, chronic disease, and social determinants of health indicators. From 2020 to 2021, the following indicators remained unchanged or declined:

 

• Childhood immunizations (41st)
• Child poverty (41st)
• Mental distress (45th)
• Multiple chronic conditions (46th)
• Premature death (46th)
• Smoking (46th)
• Teen births (41st)
• Violent crime (48th)

 

However, the state celebrates improvements in the rankings of several key MCH, chronic disease, and social determinants of health indicators, including:

 

• Low birthweight (38th)
• Obesity (38th)
• Physical distress (36th)
• Physical inactivity (30th)
• Preventable Hospitalizations (36th)

 

Additionally, the state continued to rank well on a couple of MCH, chronic disease, and social determinants of health indicators, including:

 

• High school graduation (6th)
• Excessive drinking (9th)

 

Likewise, the Health of Women and Children Report 2021, a sub report of America’s Health Rankings Report, did not include overall state rankings due to the on-going challenges related to the COVID-19 pandemic; however, rankings were still made available for individual measures. The report highlighted an 11% reduction in the percent of women ages 18-44 who report living in poverty between 2018 and 2019, a 32% reduction in the rate of teen births between 2013 and 2019, a 61% increase in the percent of women ages 14-44 who report drinking excessively between 2014-2015 and 2018-2019, and a 33% increase in the rate of drug related deaths among women ages 20-44 between 2014-2016 and 2017-2019.[2]

 

State Health Agency Roles, Responsibilities, and Priorities

 

Tennessee’s MCH initiatives are administered by the Tennessee Department of Health (TDH), the cabinet-level public health agency.  The mission of TDH is to protect, promote, and improve the health and prosperity of people in Tennessee.  The Department has a strategic plan that focuses on prevention and access to health and healthcare services. TDH is currently prioritizing four prevention initiatives:  tobacco use, youth obesity, substance misuse, and adverse childhood experiences (ACEs).

 

Within TDH, the MCH/Title V Program is administered by the Division of Family Health and Wellness (FHW).  This Division manages the Department’s portfolio of programs and initiatives related to Maternal and Child Health, Chronic Disease Prevention and Health Promotion, and Supplemental Nutrition. FHW is responsible for programmatic implementation of core public health services within local health departments (ie. family planning, breast and cervical cancer screening, Children's Special Services, WIC) in addition to health promotion activities (tobacco prevention, lead prevention and case follow up, etc.) as well as management of programs external to the department such as Evidence Based Home Visiting and expanding systems capacity for priorities spanning from perinatal care to diabetes prevention programs.

 

Public health efforts in Tennessee have long been focused on the MCH population.  All of the current TDH priorities relate to the MCH population, and TDH is committed to improving the health and well-being of the MCH population across the life course.

 

State Systems of Care for Underserved and Vulnerable Populations

 

As of June 2022, Tennessee has 15 Critical Access Hospitals designated to preserve access to local primary and emergency health services.  These hospitals are located in rural counties with less healthy populations that demonstrate higher rates of obesity, diabetes, preventable hospitalizations, cardiovascular deaths and cancer deaths as compared to state and national benchmarks.  Additionally, these hospitals are located in rural counties with fewer physicians and with a higher proportion of patients who live in poverty and a higher Medicaid population.  They have 25 beds or less and are more than 35 miles from the next nearest hospital.

 

As of June 2022, 94 of Tennessee’s 95 counties are federally designated as either whole or partial-county Health Professional Shortage Areas (HPSAs) for Primary Care (based on either the low-income population or geography).  This is up from 90 counties in June 2020.  Eighty-eight of the state’s 95 counties are designated as federal Dental HPSAs and all 95 counties are designated as federal Mental Health HPSAs.  Ninety-one of the state’s 95 counties are designated as either whole or partial-county Medically Underserved Areas (MUA).  TDH facilitates state funding for Federally Qualified Health Centers as well as Faith and Charitable Care Centers has strong relationships with both the Tennessee Primary Care Association (FQHCs) and Tennessee Charitable Care Network (faith-based clinics) which has facilitated grants and population health planning among the entities.

 

The distribution of primary care providers varies across the state.  A map with health resource shortage areas for obstetrics and pediatrics can be found in the Supporting Documents section.  As of July 2022, TDH Division of Health Licensure and Regulation[3]:

 

 

The most pressing primary care workforce shortages in Tennessee are in the field of obstetrics. According to the most recent Uninsured Adult Healthcare Safety Net Report, among the 95 Tennessee counties, ten (11%) have no obstetric providers, three have patient: obstetric provider ratios greater than 15,000:1, and 27 have ratios greater than 4000:1. 

There are 58 birthing facilities and two birth centers in Tennessee. This is down from 68 in 2016.[4] In 2018, 60 Tennessee birth facilities participated in the Center for Disease Control and Prevention’s Levels of Care Assessment tool. For maternal care, there were 5 facilities (8%) assessed as < Level I, 27 (45%) as Level I, 19 (32%) as Level II, 2 (3%) as Level III, and 7 (12%) as Level 4. TDH coordinates the Tennessee Regional Perinatal Centers, which contain five regional centers throughout out the state to assure statewide infrastructure to provide high-risk obstetric and infant care through direct clinical care and consultation (available 24/7), education for community hospitals and providers, and technical assistance to state agencies. In FY2021, 101,852 consultations were performed by perinatal center staff and 7132.5 hours of education were provided throughout the state.

 

Since 2012, there have been 11 obstetric closures, including three full hospital closures and seven obstetric facility closures (Figure 1); of these eleven closures, seven have occurred in rural counties. Of Tennessee counties, 57 (60%) do not have a birthing facility.

 

TDH works closely with TennCare, the state's Medicaid agency. TennCare provides health care for approximately 1.3 million Tennesseans and operates with an annual budget of approximately $12 billion. TennCare members are primarily low-income pregnant women, children and individuals who are elderly or have a disability. TennCare covers approximately 20 percent of the state’s population, 50 percent of the state’s births, and 50 percent of the state’s children.  TennCare is a critical and valuable partner in serving Tennessee’s MCH population. 10 More description of this agency and the partnership between the agencies is found in the description of the Health Care Delivery System in the State Action Plan Narrative Overview.

 

Children's Special Services (CSS, Tennessee’s state MCH/Title V CYSHCN program) is a critical gap-filling program supported by federal and state MCH funds. It serves as both a payor of last resort for Children and Youth with Special Health Care Needs as well as a care coordination entity for these families. Founded in 1919, CSS is governed by state code. While CSS is core to CYSHCN services in Tennessee, CYSHCN priorities for this vulnerable population expand beyond the program to include broad family and stakeholder engagement particularly in the areas of pediatric to adult transition and patient centered medical home, as determined by the state needs assessment. CYSHCN staff have also coordinated some efforts at behavioral health integration, though this has largely taken place within health care delivery facilities, particularly FQHCs and safety net mental health centers.

 

State Statutes and Other Regulations Impacting MCH/Title V

 

Numerous state laws and regulations impact the operation of MCH/Title V program services in Tennessee.  Many of the laws provide TDH authority to operate programs such as Family Planning, CSS, evidence-based home visiting, fetal infant mortality review (FIMR), child fatality review (CFR), maternal mortality review or teen pregnancy prevention. Child fatality review and, more recently, maternal mortality review legislation provide funding and legal authority to enhance data gathering to inform action.

 

Some state laws mandate specific activities or services related to the MCH population.  For example, laws mandate that infants receive screening for metabolic/genetic conditions, critical congenital heart disease, and congenital hearing loss.  Others mandate coverage for services such as hearing screening or hearing aids.

 

Other laws provide basic protections for the MCH population. These include Tennessee’s child passenger restraint law (which was the first such law passed in the nation), as well as laws which require prophylactic eye antibiotics for infants, prohibit female genital mutilation, require schools to test for lead in water, and prohibit smoking in most public places.

 

Several laws establish committees that advise TDH on specific programs or services.  These include the Children’s Special Services Advisory Committee (services for children and youth with special health care needs), Perinatal Advisory Committee (perinatal regionalization), and the Genetics Advisory Committee (newborn screening and follow-up).

 

In addition to laws passed by the General Assembly, many programs and services related to the MCH population operate under rules and regulations promulgated by the TDH and approved by the Attorney General, Secretary of State, and Government Operations Committee of the General Assembly. Often these rules contain more detailed information on program operations than the law that established a particular program or service. Examples include rules related to newborn screening, operation of the CSS program, and operation of the child safety fund (funding from child safety seat violations used to fund purchase of additional child safety seats for distribution in local communities).

 

Several new MCH-related laws were passed during the 2022 legislative session:

 

Narcan Standing Order Legislation

 

Public Chapter 749 allows licensed healthcare workers to prescribe, directly or through standing order, naloxone or other similarly acting and equally safe drugs approved by the FDA to an organization or municipal or county entity, including but not limited to a recovery organization, hospital, school, or county jail. This public chapter also allows an individual or entity under a standing order to receive and store an opioid antagonist and provide an opioid antagonist directly or indirectly to an individual. Additionally, this public chapter authorizes a first responder acting under a standing order to receive and store an opioid antagonist and to provide an opioid antagonist to an individual at risk of experiencing a drug-related overdose or to a family member friend or other individual in a position to assist an at-risk individual. This public chapter includes “unresponsiveness, decreased level of consciousness, and respiratory depression” to be included within the definition of drug related overdose. Effective on July 1, 2022.

 

Smokeless Nicotine Products

 

Public Chapter 810 makes it unlawful for the sale or distribution of smokeless nicotine products to individuals under 21 years old and unlawful for individuals under 21 years old to purchase or possesses smokeless nicotine products. For the purposes of this public chapter, smokeless nicotine product means nicotine that is in the form of a solid, gel, gum, or paste that is intended for human consumption or placement in the oral cavity for absorption into the human body by any means other than inhalation. Smokeless nicotine does not include tobacco or tobacco products or nicotine replacement therapy products.

Effective as of April 8, 2022.

 

Telehealth Reimbursement

 

Public Chapter 766 extends the ability for healthcare providers to receive reimbursement for healthcare services provided during a telehealth encounter. This public chapter also clarifies that a healthcare provider acting within the scope of a valid license is not prohibited from delivering services through telehealth. Lastly, this public chapter adds that the requirement of an in-person encounter between the healthcare services provider, the provider’s practice group, or the healthcare system and patient within sixteen months prior to the interactive visit is tolled for the duration of a state of emergency declared by the Governor provided that healthcare services provider or patient, or both, are located in the geographical area covered by the state of emergency. Effective as of April 1, 2022 and applies to insurance policies or contracts issued, entered into, renewed, or amended on or after that date.

 

A list of MCH-related laws is included in the Supporting Documents section.

[1] Data Profiles. Tennessee 2020. https://data.census.gov/cedsci/profile?g=0400000US47

[2] America’s Health Rankings.  2021 Health of Women and Children Report.  https://assets.americashealthrankings.org/app/uploads/hwc2021-report.pdf

[3] Tennessee Department of Health.  Division of Health Disparities.  Healthcare Provider Census.

[4] Tennessee Department of Health, Division of Vital Records and Statistics, Office of Health Statistics.  Birth Statistical System