Population Demographics
Utah is geographically the thirteenth largest state and is a largely rural and frontier state. Thirty-six percent of the State’s population resides in a single county, Salt Lake County, which comprises one percent of the State’s land mass. Utah has 5 urban, 11 rural, and 13 frontier counties. Utah's 2020 average population density is 39.7 persons per square mile, compared to 93.8 persons per square mile nationally. Sixty-three percent of Utah’s lands are under federal ownership, with 24% privately owned, 8.5% by the State and 4.5% by Utah’s tribal governments.
On April 26, 2021, The Census Office announced the 2020 Census findings: https://www.census.gov/data/tables/time-series/dec/popchange-data-text.html. In their press release, Utah was noted to be the fastest-growing state since the 2010 Census, with an increase of 18.4%. According to the U.S. Census Office, Utah’s population increased to 3,271,616.
According to the report “Diversity in Utah, Race, Ethnicity and Sex”, Utah ranks as the 34th most racially/ethnically diverse state in the nation with 22.3% of the population being of non-White race or Hispanic ethnicity. Utah’s younger population is more diverse than older age groups.
Population estimates for 2019 detail Utah’s racial/ethnic populations:
Diversity in Utah Race, Ethnicity, and Sex: https://gardner.utah.edu/wp-content/uploads/DiversityDataBook-May2021.pdf?x71849
Utah Population by Age and Sex
Diversity in Utah Race, Ethnicity, and Sex: https://gardner.utah.edu/wp-content/uploads/DiversityDataBook-May2021.pdf?x71849
The 2020 Census results also show that while Utah’s population increased by 18.4%, growth was concentrated among racial and ethnic minorities. Utah’s Native Hawaiian/Pacific Islander population grew the most between 2010 and 2020 at 50.4%, followed by Asians (45.5%), Black/African Americans (36.8%), Hispanic/Latinos (37.6%), American Indian/Alaska Natives (26.5%), and Whites (8.1%).
The latest information on religious affiliation in Utah comes from the 2020 Behavioral Risk Factor Surveillance Survey (BRFSS), which reports that 52.2% of Utahns are members of the Church of Jesus Christ of Latter Day Saints (LDS). Utah is the world headquarters of the LDS church. Other Christian faiths (Protestant and Catholic) make up 10.9% of Utah’s population. Thirty-seven percent of Utahn’s identify as some another religion and less than 1% report no religion. Religious entities are invited to advisory committees and their input is sought out and valued.
There are eight sovereign tribal governments within Utah: Confederated Tribes of the Goshute Reservation, Navajo Nation, Northwestern Band of Shoshone Nation, Paiute Indian Tribe of Utah, San Juan Southern Paiute, Skull Valley Band of Goshute, Ute Mountain Ute Tribe, and Ute Indian Tribe. Census data shows the largest tribal communities indigenous to Utah are the Navajo Nation, Ute Indian Tribe, and Paiute Indian Tribe of Utah.
Utah has resettled over 21,501 refugees since 1998 and ranks 24th in refugee arrivals. Recent data shows that the number of refugee arrivals in Utah declined from a high in 2016 of 1,555 to 261 in 2020. Of those arrivals in 2020, 43.7% were female. Children under 18 years old comprise 53% of the refugees arriving in Utah since 2015. Refugees in Utah arrive from countries all over the world, but since 2016 most arrive from African countries (52%), followed by South and Central Asian countries (14%), the Near East (North Africa and Middle Eastern countries) (13%), and Latin American and East Asian/Pacific countries (both at 10%).
In 2020, life expectancy at birth was 77.1 years for males and 80.9 years for females in Utah, compared to 74.5 for US males and 80.2 US females. Utahns under the age of 25 make up 41.1% of Utah’s population, compared to 32.1% for the U.S. overall. The younger age structure of the Utah population results in the lowest median age in the nation at 31.2 years, compared to 38.5 years for the U.S. as a whole.
Utah’s Births
Utah’s 2020 general fertility rate currently ranks 5th highest in the nation. Utah’s fertility rate was 64.1 live births per 1,000 women in 2020 compared to 56.0 nationally. Utah continues to have the highest birth rate in the U.S. (14.1 Utah vs.10.9 U.S.). Utah’s birth numbers declined for the fifth consecutive year with 45,724 live births to Utah residents in 2020.
Utah Births by Race/Ethnicity, 2020
Utah’s birth outcomes are generally favorable, yet disparities emerge when examined by race and ethnicity:
Utah's Economy
The Office of Labor Statistics notes that the 2021 unemployment rate in Utah was 2.7 compared to 5.3 for the nation. The 2016-2020 American Community Survey (ACS) estimates for median household income put Utah's $74,197 above the U.S. at $64,994. Utah's households are also large, resulting in a significantly lower per capita income ($30,986 vs. $35,384). There is also large variation in median income when broken out by race and ethnicity:
According to the 2016-2020 ACS 5-Year estimates, the percentage of individuals with incomes below the federal poverty level is 9.1% in Utah vs. 12.8% in the U.S. Poverty rates also range widely, depending on the county of residence. Poverty rates in 2020 were lowest in Morgan County (3.7%) and highest in San Juan County (18.6%), with a statewide mean of 7.3%. The 2019-2020 National Survey of Children’s Health finds that 8.9% of families had a household income below 100% FPL, compared to 18.4% nationally.
Health Insurance
In 2019, BRFSS data estimated that 8.6% of Utahns were uninsured. Uninsured rates for Utah children ages 0-18 decreased as well during this time.
Rates of uninsured vary by race/ethnicity:
Utah BRFSS data from 2019 estimates that 4.8% of children below 18 years were without health insurance. The 2019-2020 National Survey of Children’s Health has higher estimates of no insurance among this group, at 8.6%.
Education
Based on the 2016-2020 ACS, Utah had a higher percentage of residents with a high school diploma, at 93.0% vs. 88.5% nationally among those aged 25 years and older. Utah’s population age 25 years and older with a Bachelor's degree is higher than the U.S. (22.5% vs 19.8%) and similar to the U.S. for those with graduate degrees (12.7% vs 11.7%). According to the 2020 Kids Count report, Utah has a higher percentage of children ages 3-4 who are not in school compared to the nation (56% vs 52%). Utah is doing better than the national average for the proportion of fourth graders not proficient in reading (60% vs. 66%). The National Education Association reports Utah having the second-lowest per-student expenditure at $7,951, compared to the national average of $15,120.
Household and Family
Utah has the largest household size in the country at 3.1 persons per household compared to 2.6 nationally. Utah’s average family size is also larger than the U.S. (3.6 vs 3.2). The percentage of Utah family households with one or more persons under the age of 18 is higher at 40.2% vs. 30.7% nationally.
Children and Adolescents
National Survey of Children’s Health data from 2019-2020 illustrate many areas where Utah’s children differ from the national average:
*Interpret with caution - estimate may be unreliable due to small sample size
The 2019 Youth Risk Behavior Survey (YRBS) illustrates differences between Utah high school youth and those in the nation: Utah youth were significantly more likely to report that they carried a weapon in the past 30 days (21.5% vs. 13.2%) and were more likely to report having carried a weapon onto school property (6.9% vs. 2.8%). Utah youth were significantly more likely to report having experienced sexual violence (14.3% vs. 10.8%). Utah youth were less likely than their U.S. peers to report any form of tobacco or alcohol use, but were just as likely to report illicit drug use.
Children with Special Health Care Needs (CSHCN)
Data from the 2019-2020 National Survey of Children’s Health (NSCH) found 24.3% of Utah children have one or more functional difficulties and 15.8% of Utah children have special health care needs. Utah’s percentage of children with special health care needs ranks fourth lowest in the nation. The 2019-2020 NSCH data provides important information on Utah’s CSHCN population and their parents:
Autism Spectrum Disorders (ASD) Prevalence Estimates Statewide
The Utah Registry of Autism and Developmental Disabilities (URADD), identifies Autism Spectrum Disorder using a community medical diagnosis and/or autism special education eligibility to indicate a prevalence estimate of 2.2% for individuals aged 0 to 16 years old. Of interest is the population that is four years of age, in which the estimated prevalence has dropped from 1.2% in 2012 to 0.9% in 2018. As Utah’s overall prevalence estimate has risen, attempts to diagnose children with ASD earlier have not been successful. In 2021, the Autism Systems Development Program (ASDP) developed marketing and educational materials to encourage earlier diagnosis and worked with Help Me Grow Utah (HMG) and early intervention programs to implement the M-CHAT and STAT screeners. In 2021, HMG screened 140 children for ASD and referred 103 of those children to appropriate services. In the past, ASD prevalence estimates in Utah have focused on Salt Lake, Davis, and Tooele Counties.
In an effort to better understand ASD state-wide, URADD produced ASD prevalence estimates for the entire state based on a medical diagnosis of ASD. Autism prevalence estimates in urban and rural areas are similar, however, frontier locations are lower than expected.
Utah Title V Capacity
The Department of Health and Human Service’s and Utah's Title V unified vision is “The Department of Health and Human Services will advocate for, support, and serve all individuals and communities in Utah. We will ensure all Utahns have fair and equitable opportunities to live safe and healthy lives. We will achieve this through effective policy and a seamless system of services and programs.''
Utah Code 26-10-1 through 26-10-7 provides statutory authority for Title V. Two Offices within the Division of Family Health (DFH) collaborate to serve mothers, infants, teens, children and children with special health care needs: Maternal and Child Health (MCH) and Children with Special Health Care Needs (CSHCN). The Office of Health Promotion and Prevention in the Division of Population Health, also collaborates and contributes to the Title V work.
Title V staff work to identify the needs of underserved women, children, and children with special health care needs to prioritize allocation of resources. Staff weigh factors that limit access to, or availability of, services across the state in partnership with community organizations and other interested parties. Staff develop plans and interventions to support health needs. Division staff review and analyze MCH/CSHCN data and educate the public through marketing and educational sessions, as well as producing reports, fact sheets, abstracts, and articles in peer reviewed journals with UDOH staff as authors.
In 2019-2020, MCH/CSHCN staff, in partnership with the University of Utah Division of Public Health, conducted a comprehensive statewide needs assessment to determine the priority focus for the upcoming five years. A copy of the full Needs Assessment Report can be found here: 2020 Utah MCH_CSHCN Needs Assessment.pdf.
Using results from a detailed review of Utah data and the statewide Needs Assessment, Domain Leaders met and identified priority areas, associated National and State Performance measures (NPM/SPM) and Evidence Based Strategy Measures (ESM). For this annual report, state priorities have not changed based on community needs. Designated MCH/CSHCN program staff are assigned responsibility for one or more National/State Performance measures. Additional goals and objectives are developed by each program as issues arise. Regular meetings are held to evaluate, re-assess and change strategies and/or amend program plans as needed. The Block Grant annual report and application process provides an opportunity for each program to review its accomplishments and to amend plans as needed based on its achievement of the assigned measures. For a more comprehensive description of Title V programs, please see Appendix A.
Data capacity is strong and focused around the Division of Data, Systems and Evaluation (DDSE), which serves as the central point for state health data. DDSE includes four Offices: Vital Records and Statistics, Informatics and Data Systems, Information Privacy and Security, and Research and Evaluation. The DDSE oversees the Internet-based query system for health data (http://ibis.health.utah.gov/), providing access to more than 100 different indicators, as well as to data sets such as birth and death files, BRFSS, Pregnancy Risk Assessment Monitoring System (PRAMS), Youth Risk Behavior Surveillance System, hospital and emergency department data, hospital performance data, population estimates, and the Utah Cancer Registry. The DDSE also conducts the Behavioral Risk Factor Surveillance System. The DDSE is responsible for health plan surveys and reporting plan performance annually, as well as inpatient, ambulatory, and emergency room data. The DFH has strong working relationships with the DDSE. The MCH/CSHCN Offices collaborate across the Department to ensure integrated use of data and population assessment.
Utah’s Strengths and Challenges
Strengths
Utah’s Title V programs have many attributes which contribute to enhancing communities' health and wellness statewide. Utah has strong collaboration efforts with stakeholders and values and incorporates the advice of our partners to develop, implement, and evaluate programs for women, children, and families. The State of Utah has created a hybrid work model which includes both telework and in-person options. Utah continues to find success by being able to conduct our MCH/CSHCN work with stakeholders, the public, and populations we serve through virtual meetings and service provision.
Utah MCH/CSHCN staff are resilient and respond when called on. A specific example this past year was when the Omicron variant was surging in the state. Testing sites were overwhelmed with long wait times for testing. A call went out to all UDOH staff to assist at testing sites. Dozens of staff stepped up and assisted testing sites with registrations, vehicle movement through the long lines, swabbing (if trained) and distributing home testing kits.
Another example happened when there was a shortage of substitute teachers in the school systems. Governor Cox asked all State Employees to consider substitute teaching in respective school districts to relieve the burden. With many regular staff out sick, the need was great. Many MCH/CSHCN staff stepped up and answered the call to be a temporary substitute teacher in their respective school districts.
Utah has been able to react quickly to gather needed information. The Utah PRAMS survey was able to add supplemental questions related to the COVID-19 pandemic and COVID-19 vaccinations during pregnancy. This data was important for the Title V program to understand how pregnant women were impacted by the pandemic.
Baby Watch Early Intervention
The biggest change for Utah's early intervention service delivery during the COVID-19 pandemic was the implementation of tele-intervention. Although many providers and families were very skeptical about using tele-intervention, we all learned that there are actually benefits to this type of service provision, including the following:
As Part C Early Intervention is provided through a family coaching model, we found that providers became better "coaches" during tele-intervention sessions. They developed strong skills that supported the parent(s) in providing interventions for their child during daily routines and activities.
Parents became more empowered as they learned that they are capable of supporting their child's growth and development. In some instances, it was less stressful for parents to receive tele-intervention vs having someone come into their home. Services were still able to be delivered even if the provider or family member was not feeling well.
Service delivery can be more efficient by decreasing travel time and allowing more time for providers to deliver services to more children during their work day. Both providers and families were able to increase their skills using technology.
In addition to the positive experiences, we also learned that although most parents were happy with virtual services overall, they also feel that virtual services are most beneficial as a compliment to what can be provided during an in-person service.
Early Hearing & Detection Intervention (EHDI)
Utah EHDI addressed the COVID-19 pandemic head-on with immediate action.
1) Rapid outreach was conducted to all of the newborn hearing screening (NBHS) programs statewide to determine what the state shutdown would mean to their programs at their hospitals and clinics; some conveyed that NBHS or its follow-up would not be accomplished. Within a few days of the state shutting down, the Utah EHDI program sent out a document, "Newborn Hearing Screening and COVID-19 Guidance" to all stakeholders and providers that serve newborns and infants. This document immediately set forth that NBHS and its appropriate follow-up is considered an essential service and should be completed to the safest extent possible, and that all obligations, laws, and UDOH policies regarding NBHS and all related follow-up remain in place.
2) Several video conferences were held over the ensuing months with NBHS programs to document any forced changes in protocols due to the pandemic and their effects. In order to maintain documentation of COVID-19 affecting NBHS, a "COVID-19" note was created in the Utah EHDI database, HiTrack, in order to make note of COVID positive moms and neonates and track families who did not receive services or timely follow-up due to COVID. These video conferences served as a platform for programs to share concerns that had arisen and brainstorm ideas for improvement with each other. This constant communication was key in ensuring the best possible services for our infants and families.
3) The EHDI Follow-Up Coordinator also completed a needs assessment with families she spoke to while contacting them during the pandemic in the course of conducting EHDI follow-up. During the pandemic, in 2020, 99.93% of newborns in Utah were screened for hearing; in 2021, 99.95%.
Integrated Services Program (ISP)
The COVID pandemic and the accompanying fears of travel and face to face encounters has pushed the healthcare and service delivery systems into a more readily available and accessible telehealth environment. As such, both providers and families have been encouraged to pursue telehealth as a viable alternative to the traditional visit. Staff felt that often services like developmental screenings, evaluations, and diagnoses are easier and better via telehealth because children are in their natural environment. ISP has heard success stories from parents indicating that telehealth has allowed them to have appointments at times that more readily fit their schedules, without the added burden of travel costs and missing school and work.
While telehealth works very well in a wide range of patient encounters, it is NOT the solution for every situation. Some well child visits are not well suited to telehealth as both the hands-on physical evaluation AND subsequent scheduled immunizations cannot be completed virtually. For behavioral health evaluations, some children cannot or will not participate virtually, therefore, live visits become the only option. Our pediatric psychologist had to adapt her face-to-face skill set to telehealth testing and evaluation. This required a lot of re-training, adaptation, and practice to gain confidence in both reliability and validity of test results. Given the time frame to adapt her skill set, the psychologist was unable to test children remotely for almost six months.
Our "Lending Library", which includes Chromebooks and hotspot technology. We’ve learned that a hotspot is only as good as the wireless/broadband signal in the area. If families reside where there are no or very few cell towers, then a hotspot may not be the best option. In these cases, we have encouraged families and patients to schedule appointments with the local health department (LHD), school, or library and use their wireless or wired connection to the internet. Most of these locations can provide a private room where the family may conduct the telehealth visit to remain HIPAA-compliant. Our care coordinators have helped to coordinate these arrangements between family, service provider, and the school, library, or LHD.
Challenges
The geographic distribution of the State's population continues to present significant challenges for those delivering and accessing health care services, particularly in rural and frontier areas. Long travel distances and a shortage of nearby hospital facilities and providers, particularly specialists, mean many residents must travel hundreds of miles for care. Many may be reluctant, if not unwilling, to utilize certain services in their communities, such as family planning, mental health, and telehealth, because of concern for confidentiality and anonymity, as well as cultural beliefs in seeking these services.
The UDOH continued as the statewide lead on the COVID-19 pandemic and employees across all sections of the department participated in areas of pandemic safety, education, in-person testing, setting up vaccination clinics, and research and media information presentations. Our executive leadership have worked tirelessly to address community, legislative, and safety needs while acknowledging the efforts of the entire UDOH team.
Face-to-face service provision during the pandemic continues to create challenges due to the variety of safety measures to be considered to reduce transmission of the virus and protect the service providers and population/families we serve. A recent report published by the program highlights the challenges and successes of providing tele-audiology in rural and frontier counties in Utah: https://ibis.health.utah.gov/ibisph-view/pdf/opha/publication/hsu/2022/02_Tele-ABR.pdf#HSU
For the CSHCN population, the COVID-19 pandemic has caused significant adaptations in everyday routines due to school closures, online learning, virtual health, lack of therapy and in-home services, and financial hardships. Additionally, the pandemic has raised stress and anxiety in both parents and children, tension in relationships, fear of a CSHCN or family member contracting the virus, and finding ways to manage caregiving. Utah is creating a “new'' normal service delivery system, i.e. allowing the past to be the past and being open and creative in developing new modern strategies for service and work processes.
A significant change is the UDOH and the Department of Human Services merged to form a new Department of Health and Human Services (DHHS), effective July 1, 2022. The Bureaus of MCH and CSHCN are co-located, and have been renamed “Offices”, in the new Division of Family Health (this change is reflected throughout the narrative of this document). This restructuring involved a building move for MCH/CSHCN staff in April 2022. The consolidation has created changes in organizational structure, processes, policies, logos, and eventually, websites. One example is the legislature passed a requirement for human resources to implement which changes a schedule B (a "career service" designation) to an AX (an "at-will" designation) classification for supervisory positions. These changes have created stress for supervisors as there is concern for loss of employment protections and the long term consequences are unknown. Fortunately, within MCH/CSHCN, we have maintained employees, although some have been offered new leadership opportunities within the Department. This created turnover of employees, challenges with workloads, timeliness of rehiring, orienting, and stabilizing new employees. MCH/CSHCN team members are being positive and creatively engaging to improve the system with the new Department changes.
Addressing the Needs of a Diverse Population
The Department has endeavored to include data on subpopulations in an attempt to better quantify the issues faced by various groups. The Office of Health Equity (OHE) works to document and address existing and emerging health disparities among historically and systematically disadvantaged populations. The OHE produced the Health Equity Framework: https://healthequity.utah.gov/health-equity-in-utah/#framework which outlines how structural and social determinants of health impact health equity and quality of life. It guides the vision that Utah’s public health, health care, and social systems should be adequate and accessible for all Utahns. The OHE assists the Department in identifying priorities and needs of specific key populations in the state through quantitative and qualitative data reporting, assessing the adequacy of race/ethnicity data from common public health data sources and recommending improvements and guidelines, informing communities about efforts and activities, and developing tools and guidance to promote cultural and linguistic appropriateness for programs.
The OHE works to build Utah’s public health infrastructure to advance health equity at the state and local levels. It supports the establishment of health equity offices across Utah’s LHDs and provides training to Department and LHD staff on health equity practices and equity, diversity, inclusion, and access. The OHE also works closely with community health workers (CHWs) to create programs and systems, like the COVID Community Partnership (CCP) project, to integrate CHWs in Department efforts. Efforts also include building internal and external infrastructures to support and expand the capacities of the CHW workforce. The OHE developed the It Takes a Village: Giving our babies the best chance (ITAV) project. ITAV is a community education and engagement series to raise awareness about maternal and infant health. It uses a thorough anthropological approach with a cultural framework, which mirrors the Pacific way of life and borrows from traditional Pacific systems for resolving community problems. Additionally, The Embrace Project Study (Embrace) is a community-based participatory research study extending ITAV practices and principles to improve maternal mortality and morbidity and diabetes and gestational diabetes health disparities among Native Hawaiian/Pacific Islander women. Title V program and the OHE work together to identify opportunities to collaborate to address MCH needs among diverse populations.
The Department works with the Office of American Indian/Alaska Natives Health and Family Services (AI/AN). This Office facilitates meetings with the Utah Indian Health Advisory Board (UIHAB). The purpose of this Board is to reaffirm the unique legal status of Tribal governments through the formal 'government to government' relationship and Tribal Consultation. The board provides leadership to develop collaborative efforts between and among Tribes, Tribal organizations, the Urban Indian Organization, the Indian Health Services (IHS), the Department, and other public and private agencies addressing the health and public health of AI/AN living on and off the reservation. In addition to these roles, the Board works with Utah's Executive and Legislative leadership promoting strategies to improve health outcomes. The mission of this Office is to raise the health status of Utah's AI/AN population to that of Utah's general population.
Public Health System
MCH/CSHCN services are provided in various settings, including medical homes/private providers, LHDs, community health centers that serve the homeless and migrant workers, and a number of free clinics. There remains a great need for CSHCN services around the state. The CSHCN Office, in collaboration with its stakeholders, continues to research resources, make community connections, refer, and brainstorm ideas for a more comprehensive and accessible service delivery system. During the past year, service needs have grown and the CSHCN Office and stakeholders continue to discuss strategies to meet the current health needs of this population.
Utah's public health system comprises the Department and 13 LHDs. The UDOH and three LHDs are accredited by the Public Health Accreditation Board. Approximately half of the LHDs are multi-county districts covering large geographic areas. Many include both rural and frontier areas within their service region.
Contracts with the LHDs include developing SMART objectives for Title V measures. The specific objectives vary by district and include postpartum depression education/screening, breastfeeding, family planning, home visiting, oral health/sealants, vision/hearing screening for children. All 13 LHDs have the same developmental screening objective. Four rural LHDs are receiving funding for a CSHCN Care Coordinator and coordinate with the Integrated Services Program.
Systems of Care
To meet the needs of underserved populations, there are many systems which collaborate to increase seamless services for Utah’s population. One such system is the Community Health Centers (CHCs) throughout the state and the Wasatch Homeless Clinic in Salt Lake City who provide primary care to underinsured and uninsured MCH populations. Utah has thirteen CHCs who operate 56 clinics throughout the state. The Association for Utah Community Health, the state's primary care association, works to promote the development of new or expansion of existing community health centers in Utah.
The Department provides primary care through the Health Clinic of Utah (HCU), which is located in Salt Lake City. The medical clinic is staffed with a multidisciplinary team. The clinic provides high quality medical care at the lowest cost to clients. HCU accepts most forms of insurance including; Medicaid, the Children’s Health Insurance Program (CHIP), and Medicare. Among the patients seen in the clinic in FY2020 36% had Medicaid and 26% were uninsured. In addition to regular clinical services, the HCU provides immunizations and health screenings for newly resettled refugees and provides medical screenings for children in protective service care in multiple counties.
The Indian Health System in Utah consists of one IHS outpatient facility, four Tribal and Tribal Organization operated facilities, and one Urban Indian Organization located in Salt Lake City. Not all reservation communities have a health care facility nearby. While some Tribal programs operate health care facilities, travel time for services can be 3-4 hours each way. When accessing this system, appointments are not always the norm; it is first come first serve. This can be problematic if you live a significant distance and arrive later in the day, running the risk of not being seen and may be asked to return the next day. The Indian Health System is primarily dependent on federal funding. Each year, Congress appropriates funding for the IHS. This system is chronically underfunded, operating below the level of need. Most of the Indian Health System facilities do not provide specialty care or dialysis and will refer patients to specialists outside of the system or refer them to the closest IHS Area Office or IHS hospital, which can be located in a different state.
Hospital Systems in Utah
The hospital healthcare system for MCH/CSHCN populations is well developed in Utah, with several large Maternal-Fetal Medicine Centers, 10 self-designated Level III NICUs, and two tertiary children's hospitals (Primary Children's Hospital and Shriners Hospital). Utah currently has 46 delivering hospitals across the state, four hospital systems, and one medical school/facility. All but 12 hospitals are part of the four hospital systems, which provides Utah a unique opportunity to build strong collaborations. Of Utah's hospital systems, the largest is Intermountain Healthcare. Intermountain has a national reputation for excellent quality improvement efforts and is a valuable resource for the state. The University of Utah Hospital is a teaching medical school providing tertiary care and services. Other hospitals are owned by several different hospital systems such as MountainStar, Steward and LifePoint or are independently owned.
Utah has 13 Critical Access Hospitals throughout the state:
Telehealth Capacity
Telehealth capacity is expanding in Utah. The 2021 America’s Health Rankings Report notes that Utah has the third highest percentage of households with high-speed internet, with a rate of 93.3%. Utah has a small number of infant-pediatric audiologists, all of whom reside on the Wasatch Front or in the St. George area. Oftentimes, these babies become lost-to-follow-up due to lack of access to specialists, travel costs, inability to take time off from work, costs of testing, etc. To reduce barriers to early diagnosis after failing newborn hearing screening, the Utah Early Hearing Detection and Intervention (EHDI) program purchased auditory brainstem response equipment to provide diagnostic tele-audiology services for rural/frontier communities. In 2020-2021, EHDI expanded the rural tele-audiology service.
Tele-audiology services are hosted at the CSHCN Office with three pediatric audiologists on staff and a nurse or trained facilitator at the remote sites. During the pandemic, audiologists worked from their homes to provide the services. The facilitator provides direct face-to-face contact with the family and child. The nurse connects the electrodes to the baby and stays with the family throughout evaluation testing, while the audiologist remotely accesses the computer to run the testing. The testing is considered diagnostic and if a child is identified as deaf or hard of hearing, the CSHCN Office helps the family with the next steps in the EHDI process, including referrals to early intervention, parent-to-parent support, and referrals to medical providers.
The Department funds the University of Utah (UofU) for perinatal mental health screening and counseling via telehealth. The project is now working with five of Utah’s rural LHDs to screen women for postpartum depression symptoms using the Edinburgh postnatal depression scale tool, refer women who need support, and provide online support groups and counseling using telehealth.
This past year, Utah has continued to utilize a hybrid work model of telework, virtual healthcare, and in-person services. We have found keeping communications open, providing online support, and direct services have been invaluable during the past year.
Clinical Workforce Availability
The ratio of physicians to persons in a population is an indication of the adequacy of the health system and the access to care for persons in that population. According to the United Health Foundation’s 2021 Annual Report on America’s Health Rankings, Utah ranks 49th in the number of Primary Care providers with 194.3 providers per 100,000 population (compared to 252.3 nationally). The ratio of dental care (59.7 per 100,000) and mental health care (367.3 per 100,000) providers for Utah ranks 26th and 14th respectively. The Utah Office of Primary Care & Rural Health 2021 Health Needs Assessment report also finds that the distribution of providers who practice in rural communities is uneven. With 21.5% of the State’s population living in rural areas, only 11% of primary care provides practice in rural areas. There are similar disparities for dental and mental health care providers.
Population and Provider Distribution Between Urban and Rural Areas
In 2018, the latest data available, the primary care physician to civilian ratio per LHD varied from a low of 1.7 in Tooele LHD to a high of 12.9 in Summit County LHD. While there are primary care physicians at the LHD level, three counties do not have any primary care physicians, resulting in geographic disparities within LHDs.
Primary Care: Family Physicians Primary Care: Obstetrics/Gynecology
Primary Care: Pediatricians Primary Care: Dentists
The Integrated Services Program (ISP) contracts with four LHDs within the State. These four LHDs provide care coordination and clinical coordination for direct care services to the CSHCN population residing within their counties. This model creates a regional “hub” or main point of contact for local families of CSHCN through which they may be referred to for support, specialists, and services that may benefit their child. Over 72% of the referrals for either care coordination, direct clinical services, or both were related to autism spectrum disorder. The CSHCN specialty and subspecialty pediatric providers are mostly located along the Wasatch Front, including the state's tertiary pediatric care centers. There is one comprehensive women and children’s health center located in the southern part of the state, serving a five-county rural area. The location of most pediatric specialists and subspecialists in the most populous areas of the state present a problem for provider access for special needs children in rural Utah. Several counties have no pediatricians or sub-specialists, meaning families must drive long distances to access care for their children. In most cases, there is limited additional itinerant coverage from the private sector for these large geographic areas. In rural counties, health care is often provided to children through family practice physicians, LHDs, or community health centers.
Families continue to face formidable barriers in accessing services and coordinating care for their children with special health care needs. Access to pediatric specialists and subspecialists is adequate if you live along the Wasatch Front (although long waiting lists exist to see practitioners), but for those living in rural/frontier areas of the state, families must drive long distances to access the same services. In 2021-2022, we provided services through a hybrid model that includes both virtual and in-person services. The program has found this modality has allowed the ISP providers to be more flexible on appointment times and they have met in the evenings with families after the work day. Additionally, it has cut travel time and costs allowing for more service time.
Utah’s Public Behavioral Health System
Utah's public behavioral health systems have a similar structure to public health. Utah's Department of Human Services contracts with local county governments who are designated as local mental health authorities and local substance abuse authorities to provide prevention, treatment, and recovery services. There are 13 local authorities that deliver services throughout the state, several are co-located with the LHD.
Utah Medicaid
Utah’s Medicaid program is administered through the Department. The Medicaid program provides vital support to MCH/CSHCN populations throughout the State. Utah Medicaid contracts with managed care entities to provide medical services to Medicaid members. Utah Medicaid has two types of managed care entities that are relevant: Accountable Care Organizations (ACO) and Utah Medicaid Integrated Care (UMIC). Members enrolled through Adult Expansion living in Davis, Salt Lake, Utah, Washington, or Weber counties must choose a UMIC plan. Non-expansion members living in Box Elder, Cache, Davis, Iron, Morgan, Rich, Salt Lake, Summit, Tooele, Utah, Wasatch, Washington, or Weber counties must choose an ACO. Members that live in other counties have the option to choose an ACO or the Fee for Service Network.
Each ACO or UMIC plan is responsible for covering all medically necessary services for their enrolled Medicaid members. Medicaid pays a monthly capitated rate for each Medicaid member enrolled in an ACO or UMIC plan. Each ACO or UMIC plan is allowed to offer more benefits and potentially fewer restrictions than Utah’s State Plan benefits, however they are not allowed to provide less benefits. The ACO or UMIC plan must specify services which require prior authorization and the conditions for authorization.
Members enrolled in an ACO or UMIC plan must receive all services through a provider in that plan’s network. The provider is paid by the managed care entity. Members enrolled in the Fee for Service Network may use any willing Utah Medicaid provider; Fee for Service providers are paid directly by the State.
The CSHCN Office is designated by Medicaid to provide the following services to children with special health care needs: case management, explaining benefits including eligibility and services, and referral assistance.
On December 23, 2019, the Centers for Medicare and Medicaid Services (CMS) authorized the UDOH to implement full Medicaid expansion, as authorized under the Affordable Care Act, for the State of Utah. More than 110,000 Utah adults have enrolled under the expansion program as of May 2022. Adults ages 19-64 are eligible with household incomes up to 138% of the Federal Poverty Level. Enrollment in Medicaid continues year round and is not limited to an annual enrollment period.
Under a program titled the Utah Premium Partnership, the state allows newly eligible adults to enroll in an employer-sponsored health plan if they have access to one. Under this program, Medicaid will then cover the individual’s monthly premium and other out-of-pocket expenses like copays and deductibles up to a monthly maximum.
During the Public Health Emergency (PHE) due to the COVID-19 pandemic, Medicaid has sustained a Maintenance of Effort (MOE) requirement for eligibility. From March 2020 until the end of the PHE, all Medicaid cases are kept open unless a member moves out of state, requests closure, or dies. This has led to an approximate 40% increase in enrollment numbers. Closures will increase as the PHE ends and normal eligibility reviews begin again.
Overview/Conclusion
The directors of Title V/MCH and CSHCN work with employees at the state and local levels as well as with strategic partners to implement programs and services of the Title V Block Grants three federally defined populations. The Title V/MCH and CSHCN Directors and staff use data, needs assessments, capacity surveys and historical experience to make determinations for program capacity, development and funding with the goals to improve access and services throughout Utah.
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