Overview of the State
Nebraska is a state that covers a large geographic area, but has a smaller population base, much of which is located in the eastern half of the state. Measuring 387 miles across with a total area of approximately 77,000 square miles, almost 20% larger than all of New England, much of the land is utilized in the state’s large agricultural sector. 45.8% of the state’s population reside in the population centers of Omaha and Lincoln in the east, which represent Metropolitan Statistical Areas (MSA) with populations larger than 50,000. In contrast, 34 of the 93 counties statewide are considered to be frontier, which is variously defined as an area with low population density (6 or fewer persons per square mile), residing a large distance from a population center or specific service, requiring long travel time to reach a population center or service, having low availability of paved roads, and/or experiencing seasonal changes in access to services.
Nebraska has also been experiencing shifts in the demographic composition of the state over the 2000 to 2019 time period, according to the U.S. Census, which includes an overall aging of the population as well as an increasing diversity. Statewide, 16.2% of the population is 65 and over, however in 66 counties that number exceeds 20%. In terms of increased diversity, Nebraska has seen its minority population grow 97% during the same time period – which represents 21.8% of the total population. These demographic shifts can have significant implications for healthcare delivery, creating a need to focus on services that are relevant to an older population as well as those that are culturally and linguistically appropriate.
In addition to providing services that are culturally and linguistically appropriate overall, health care providers should be aware of the specific minority populations that exist in their areas in order to provide quality care and to address existing health disparities. While this is a standard of care that all providers should adhere to, there is an increased stress on providers in the eastern part of the state, where an average population increase of over 28% between 2000 and 2019 has occurred. Migration of the younger population (18 to 45 years) from parts of western Nebraska has primarily affected the Douglas, Sarpy (City of Omaha), and Lancaster (City of Lincoln) counties. For some minority populations – notably African Americans at 87% – these are the counties where most of the population is located.
Within its minority populations, Nebraska has seen the largest increase in the Hispanic American population, which has more than doubled from 94,425 in 2000 to 219,645 in 2019 (132.6% increase) according to the U.S. Census estimates. Hispanic Americans now comprise 11.4% of the state's population. Asian and Pacific Islander populations grew during 2000 to 2019 by 136%; and the African American population has grown by 44%.
Similarly, the Native American population in Nebraska has increased by 87.3% during the same time period. Four federally recognized Native American Tribes are headquartered in Nebraska - the Santee Sioux, Omaha, Winnebago, and Ponca. Though many Native Americans live on reservations, the majority does not. The urban areas of Omaha and Lincoln account for more than 36% of the state’s Native American population, although they make up only a small proportion of these counties' total populations. A sizable number of Native Americans also reside in the northwestern part of Nebraska adjoining the Pine Ridge Reservation in South Dakota. Among the reservations situated in Nebraska, the Winnebago Tribe and Omaha Tribe in northeastern Thurston County account for 22% of Nebraska's Native American population. An additional 3% reside at the Santee Sioux Nation in Knox County. The Ponca Tribe operates within a designated service area covering 15 counties in Nebraska, South Dakota, and Iowa. Tribal offices are established in four Nebraska locations, and a fifth in Iowa. The Iowa and the Sac and Fox Indian Reservations on the Nebraska-Kansas border account for about 1% of Nebraska's Native American's total population.
Health disparities exist in Nebraska, and unfortunately impact many issues relevant to maternal and child health. Though African Americans make up only 5% of the Nebraska population, they have a significantly disproportionate share of health burden and poor outcomes. According to the DHHS Office of Health Disparities and Health Equity 2020 Nebraska Health Disparities Report, the infant mortality rate (expressed as per 1,000 live births) among African Americans was 13.4, compared to that among the White population at 5.8. Additionally, the obesity rate for African Americans was 36.5 compared to a rate of 29.1 for the White population, and they are 0.8 times more likely to have a depressive disorder than Whites. American Indians in Nebraska (1.4% of the NE population) have a 2.7 times higher rate of inadequate prenatal care, are 1.4 times more likely to have a depressive disorder, and have a 5.3 times higher incidence of sexually transmitted disease as compared to Whites.
An additional challenge unique to 2020 has been, of course, the COVID19 pandemic. As schools and day-cares closed, working parents were forced to either transition to a remote work environment (while simultaneously caring for their school-age children) or stop working entirely. Various businesses had to close, continuing the ripple of lay-offs, furloughs, and decrease in work for many Nebraskans. Isolation and distancing recommendations have kept people apart and cut off from their usual social networks and supports.
Specific to the maternal and child population in Nebraska, programs saw immediate effects. Calls to the Child Abuse and Neglect hotline decreased significantly, raising concerns about vulnerable children, especially in homes where caregivers might be financially and mentally stressed. Home visitation stopped for a time before continuing remotely. WIC clinics quickly shifted to offering services remotely, with the help of federal waiver of requirements, and fortunately were able to continue offering benefits. The number of immunizations in Nebraska dropped dramatically as compared to the same time in the previous year, partially due to clinic closures and partially to parent concern over visiting clinics
Due to the sudden job losses and the downturn in the economy, Economic Assistance applications increased by 30% in the first month of the pandemic and have stayed at higher than normal rates of requests with a record high in August of 2020. SNAP issued emergency allotments for the months of March, April, May, June, and July.
Pandemic Electronic Benefit Transfer (P-EBT) was introduced to help meet the needs of food insecure children eligible for the free/reduced school lunch program that were not able to access the food due to school closures and remote learning. Child care providers are setting up virtual learning areas for children to attend remote learning while parents are at work.
CARES act funding brought supplemental payments to households for heating/cooling costs through the Low-Income Household Energy Assistance Program; stabilization and incentive to reopen grants for child care providers; as well as additional funding for food banks, homelessness agencies, and community action agencies.
While most Economic Assistance programs were seeing record high requests, others were underutilized such as the Lifespan Respite program due to families feeling uncomfortable with providers coming into their homes/going to out to the community with providers.
Nebraska Title V took advantage of the circumstances that combined a Needs Assessment, request for public input, and a pandemic together, and adapted our survey to include questions regarding the impact of the pandemic on communities generally as well as on population domains specifically. Responses received are shared throughout this Application as emerging issues for further consideration.
One portion of access to care – the ability to obtain health insurance coverage – will improve in Nebraska in 2020. Medicaid expansion – called Heritage Health Adult (HHA) - was approved via a ballot measure in the fall of 2018, with the result that up to 90,000 Nebraskans could be eligible for benefits beginning October 1, 2020 when expansion is implemented. The Medicaid program underwent integration beginning in 2017, offering enrollees a single plan combining physical health, behavioral health, and pharmacy benefits in an integrated health care program. While HHA is expected to have different tiers of coverage depending on enrollees’ individual circumstances, the plans are still integrating health care services to allow for a medical home.
The ability to physically access care remains a challenge for this rural, low-population state. Rural areas have difficulty recruiting and retaining providers and health care professionals, and also in supporting facilities such as hospitals or other comprehensive care centers. These challenges have resulted in a proliferation of shortage areas throughout the state. The NDHHS Office of Rural Health tracks state-designated shortage areas by discipline, in April 2019 64 counties out of 93 had this designation for the Family Practice discipline, and 85 full counties had this designation along with portions of those surrounding Lancaster and Douglas counties for the OB/GYN discipline. A similar situation exists for the Psychiatry and Mental Health disciplines, with the majority of Nebraska’s 93 counties state-designated shortage areas - only 3 full counties and a portion of those surrounding were not designated as of April 2019.
To address these shortage areas, there are facilities located in federal shortage areas that specifically address providing affordable and accessible primary and public health care services, including 142 Medicare-certified Rural Health Clinics (RHC), eight Federally Qualified Health Centers (FQHC), and eight Indian Health Service (IHS) funded clinics. The network of local public health departments covering all 93 counties in the state is an additional source of public health capacity for Nebraska.
The population of children and youth with special health care needs (CYSHCN) in Nebraska is especially vulnerable, as they often face confounding challenges and barriers. By creating a partnership between the Medically Handicapped Children’s Program and the Munroe-Meyer Institute (MMI) within the University of Nebraska Medical Center (UNMC), NDHHS has created a network of clinics across the state that provide a range of services for individuals with disabilities. In addition, the partnership has created a system of care for CYSHCN by ensuring that a strong referral network is in place, that services are covered by insurance as much as possible, and by training and supporting parent resource coordinators as family support. However, it should be noted that not every child with complex medical needs is eligible for services and supports through the Medically Handicapped Children’s Program.
Alongside this physical network of clinics, NDHHS Title V has many strengths to assist its work to facilitate the ongoing engagement which is needed to address these daunting challenges – particularly with experienced staff and a strong administrative foundation. This expertise asserts itself as Title V undergoes statewide, systems-level work such as engaging partners, ensuring quality improvement, and/or developing system supports. The success in these activities is a testament to the leadership that Title V staff have consistently demonstrated for years.
Administratively, Nebraska Title V takes advantage of having co-leads who are housed in separate Divisions. Nebraska Title V is jointly administered by the Title V MCH Director and the Children and Youth with Special Health Care Needs (CYSHCN) Director. The Unit Administrator for the Lifespan Health Services Unit within the Division of Public Health is designated as the Title V MCH Director. The CYSHCN Director role lies with the Economic Assistance Policy Administrator II within the Division of Children and Family Services (CFS), Economic Assistance Unit (also within NDHHS). Having state co-leads in two divisions extends the reach of Title V activities, expands the amount of available state support, and increases the staff expertise available to the program overall. This framework helps to ensure that Title V priorities are fully aligned with those of the larger state agency and of other statewide efforts.
The MCH Director oversees multiple programs, many of which align directly with the mission of Title V, including: Newborn Screening, WIC, Immunizations, MIECHV, Reproductive Health, Every Woman Matters, Women’s Health Initiatives, and more. Likewise, the CYSHCN Director is responsible for numerous program areas, including the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF), Child Care and Development Fund (CCDF), the Medically Handicapped Children’s Program (MHCP), and more. Additional key staff in both Public Health and CFS assist with implementing the Title V MCH Block Grant. These are the Maternal Child Adolescent School Health (MCASH) team, the MCH Epidemiology team, a Federal Grants Administrator, the Disabled Persons Program Administrator, and the MHCP Program Coordinator.
Solidifying this operational approach is an Intra-Agency Protocol between the Divisions of CFS, PH, and Medicaid and Long-Term Care. While the agreement is statutorily required, it also provides a means to formalize the long-standing relationships between the Divisions by describing shared and individual responsibilities of each Division.
Another part of the administrative framework for Nebraska Title V work are the statutes pertaining to the broad authority to carry out maternal and child health services in the state, which are found in Chapter 71, sections 2201-2208 which originated in 1935. Additional related authorities include the statute requiring a Birth Defects Registry (found in 71-645 through 71-648), Child Maternal Death Review (found in 71-3404 through 71-3411), the Childhood Vaccine Act (found in 71-526 through 71-530), metabolic screening and associated responsibilities (found in 71-519 through 71-524), newborn hearing screening (found in 71-4734 through 71-4744), WIC (found in 71-2227), and the Women’s Health Initiative program (found in 71-701 through 71-707). The statutes pertaining to the Medically Handicapped Children’s Program are found in Chapter 43, section 522, Chapter 68, section 309, and Chapter 68, section 717 with the associated NDHHS regulations are found in Title 467.
NDHHS Title V additionally relies on established relationships with key stakeholders to ensure that the public health and direct care infrastructures have CLAS and health equity standards in place to inform how staff interact with clients, and that services are offered in a family-centered, comprehensive way. These relationships are enhanced by the technical expertise that Title V offers to others. The programmatic staff within Title V offer a significant output of high quality continuing education and professional development activities every year for professionals statewide. During COVID, transition to virtual platforms for educational delivery has gone relatively smoothly. While training participants are frequently licensed health professionals, particularly nurses, training opportunities also are delivered to youth-serving professionals and home visitors. Additionally, Title V participates in developing new roles for MCH workers, such as home visitors, parent resource coordinators, and the TOP ® educators working in positive youth development. Title V staff supports development and proficiency of the school nurse workforce as well as providers in birthing hospitals and clinics. In addition to peer-approved continuing education events for health professionals, Title V facilitates Communities of Practice (with tribal health on maternal and perinatal health topics; with stakeholders interested in data-driven decision-making).
In the area of data collection and analysis, Nebraska has an experienced MCH Epidemiology team who work with MCH data regularly and maintain a deep understanding of health indicators. Examples of the collaborative contributions of these staff include: building data linkage between the Medicaid Claims and Vital Statistics data, providing learning opportunities and technical assistance to colleagues, and participating on Division- and Department-wide workgroups on data governance, collection, and release policies and procedures. Nebraska is particularly excited to have a CDC assignee joining the Office of MCH Epidemiology, which will deepen the expertise and capacity available to the state.
Nebraska takes a strategic approach to align the priorities of the state agency with those identified by stakeholders as it implements Title V activities. This alignment ensures that broader influences on Title V activities are in line with the five year Needs Assessment and existing strengths, knowledge, and resources of Title V staff and staff in other program areas. Priorities of the state agency include the NDHHS Business Plan, the NE State Health Improvement Plan (SHIP), and the Division of Public Health Strategic Plan.
The 2017-2021 SHIP resulted from an initial State Health Assessment followed by a public process to select five priorities, which ultimately reflect similarities between the SHIP and Title V state priorities. SHIP priorities are:
• Nebraska will have an integrated health system that values public health as an essential partner
• Nebraska will have a coordinated system of care to address depression and suicide
• Nebraskans will have decreased rates of obesity
• Nebraskans will experience improved utilization and access to healthcare services
• Nebraskans will experience health equity and decreased health disparities
While the SHIP is a statewide plan involving all parties involved in or affected by public health, the Strategic Plan is internal and for the Division alone. The Division of Public Health 2017-2021 Strategic Plan contains priorities around data, culture and communication, planning and performance, equity, policies, and workforce. These plans, along with the five year Needs Assessment findings, serve as a cornerstone for the development of the Action Plan for the state Title V program – and indeed, a reflection of the above priorities can clearly be seen in the strategies and objectives that govern the past and future work of the Title V MCH Block Grant.
With issues around health disparities, medical shortage areas, a shifting demographic, and health care access, Nebraska certainly has challenges to improving the health of Nebraska’s maternal and child population. However, as discussed above, there is a solid framework in place to address these issues. The blend of experienced staff, technical expertise, long-term relationships with stakeholders, and statute and general fund availability make up an infrastructure that is in place to support Nebraska’s priorities and vulnerable populations. This existing infrastructure provides fertile ground for Title V funds to enhance efforts and bring additional resources to this important work. Through a framework of assessment, inclusive planning, and regular evaluation Nebraska Title V seeks to promote systems change that will directly benefit families, and ultimately improve the health of the maternal and child population in Nebraska.
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