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 Nashville, 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 6.7 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]

Health Status of Tennessee’s MCH Population

In 2019, according to America’s Health Rankings, Tennessee ranked 44th in the nation for overall health.[2]  Historically Tennessee has ranked in the bottom ten states for this overall measure.  Unfortunately the state ranks poorly on several key MCH population indicators, including:

• Low birthweight (41st)
• Children in poverty (42nd)
• Infant mortality (43rd)

However, the state also ranks well on a few MCH indicators including:

• Excessive drinking (8th)
• High school graduation (3rd)
• Pertussis case rate (13th)

Based on America's Women and Children Report, a sub report of America’s Health Rankings Report, Tennessee ranked in the lowest quintile at 41st overall in 2019.  When the population is broken down into women, infants, and children, slight improvements are observed.  Although infants still rank in the lowest quintile at 46th, women and children saw a slight ranking improvement to the second to lowest quintile at 35th and 30th respectively.[3]

State Health Agency Roles, Responsibilities, and Priorities

Tennessee’s MCH initiatives are housed within 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, obesity, substance abuse, and ACEs.

Within TDH, MCH/Title V 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 95 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 Departmental priorities relate to the MCH population, and the Department is committed to improving the health and well-being of the MCH population across the life course.

The Department is also broadly focusing on primary prevention—preventing disease before it ever occurs.  Introduced in 2017, all 95 counties have developed, implemented, and evaluated primary prevention plans.  The Primary Prevention Plans are a component of the County Performance Plan.  The TDH Primary Prevention Plans are developed by all staff and partners to focus on community based prevention activities.  The goal is to implement local policy, systems and environmental changes that positively influence population health.  The Primary Prevention Planning Process allows for a consistent and measurable format, and also allows for innovation from the local health department to address community needs.  The majority of the plans focus on obesity, tobacco-free environments, physical activity, substance misuse, and immunizations. Over the past year, county prevention plans are now being informed by the county health assessment process which is being rolled out across the state.

In addition to programmatic and policy efforts on these other public health topics, the Department has undertaken a major commitment to performance excellence using the Baldrige framework.  The department supported Baldrige Examiner training for 132 LHD employees in the course of six years through TNCPE. The examiners then formed an internal Baldrige Advisory Group to promote enterprise-wide efforts to diffuse quality improvements into LHDs and other TDH services and programs. This quality atmosphere supported program implementation and, in turn, examples of processes and outcomes supported individuals’ involvement in the departmental improvement drive. As a result, there was substantial growth in county and program-level applications for TNCPE awards. To date, the total number of TNCPE awards recognizing the work of departments, offices or programs include:

• 82 Interest Recognition Awards
• 40 Commitment Awards
• 6 Achievement Awards

TNCPE named 17 organizations as 2018 Award winners representing outstanding achievement in the following industry sectors: health care, manufacturing, service, education, government and nonprofit.

Of those recognized, the Tennessee Department of Health, eight county health departments and five offices received an award at the 26th Annual Excellence in Tennessee Awards Banquet. TDH was recognized by TNCPE for the second time with a Level 3: Achievement Award – our first was in 2016. In addition, 7 individual counties, a regional office, and five divisions/offices were recognized with awards.

State Systems of Care for Underserved and Vulnerable Populations

As of July 2020, Tennessee has 16 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 July 2020, 90 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 89 counties in May 2017.  All but two of the state’s 95 counties are designated as federal Dental HPSAs and all but four counties are designated as federal Mental Health HPSAs.  Ninety 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 as has strong relationships with both the Tennessee Primacy 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.  This section also includes the annual Safety Net report as well as the assessment of rural health for the state as required by the Governor’s Executive order #1, both of which highlight MCH needs and state support for these efforts. As of July 2020, the following counts of full-time or part-time, actively licensed providers were available through the TDH Division of Health Licensure and Regulation[4]:

There are 60 birthing hospitals and centers in Tennessee (hospitals/centers with >50 deliveries/year).  This is down from 68 in 2016.[5] There are five regional perinatal centers, and TDH works closely with these networks of hospitals to implement measures to assure care and delivery at the appropriate level of care.

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.

The Children's Special Services (CSS) 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 services in Tennessee.  Many of the laws provide Departmental authority to operate programs such as Family Planning, Children’s Special Services (CSS, Tennessee’s state MCH/Title V CYSHCN program), evidence-based home visiting, fetal infant mortality review (FIMR), child fatality review (CFR), 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 Department of Health 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).

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

[1] Data Profiles. Tennessee 2018. https://data.census.gov/cedsci/profile?g=0400000US47&hidePreview=true&tid=ACSDP1Y2018.DP02&vintage=2018

[2] America’ Health Rankings. 2019.  https://www.americashealthrankings.org/explore/annual/state/ALL

[3] America’s Health Rankings.  2019 Health of Women and Children Report.  https://www.americashealthrankings.org/learn/reports/2019-health-of-women-and-children-report/findings-state-rankings

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

[5] Tennessee Department of Health, Division of Policy, Planning, and Assessment, Office of Health Statistics.  Birth Statistical System, 2013-2017 Nashville, TN