This section puts into context the Title V Maternal and Child Health (MCH) program within the State's health care delivery environment. The overview provides an understanding of the State Health Agency's current priorities/initiatives and the Title V role.

Overview & Authority: The Kansas Department of Health and Environment (KDHE) is responsible for administration of programs carried out with allotments under Title V. The Title V MCH Services Block Grant program is administered by the Bureau of Family Health (BFH) in the Division of Public Health. The mission of the Bureau is to “provide leadership to enhance the health of Kansas women and children through partnerships with families and communities.” KDHE convenes the Kansas Maternal and Child Health Council and contracts with local public health departments (independent entities) and Federally Qualified Health Centers (FQHCs) across the state to ensure provision of MCH services within a coordinated, family-centered system. Kansas statutes do not mandate comprehensive services for MCH populations except for Children with Special Health Care Needs (CSHCN). Pursuant to K.S.A. 65-5a01, a "child with special health care needs” means a person under 21 years of age who has a disease, defect or condition which may hinder normal physical growth and development." Statutes and regulations detail program requirements related to direct health services, in which individuals ages 0-21 with eligible medical conditions and all ages with conditions diagnosed through the state's newborn screening program are served. Kansas provides direct services for state mandated conditions, and the program provides non-direct services through community partnerships to the broader CSHCN population, as defined by MCHB/HRSA, with support and guidance from the Special Health Services Family Advisory Council (SHS-FAC).

Geography/Demography: Kansas, spanning 82,278 sq. miles, is divided into 105 counties with 628 cities.1 The U.S. Census Bureau estimates there are approximately 2,913,123 residents living in the state in 2017. Kansas has a unique geographic layout that ranges from urban to frontier counties. Within each of its regions there are few populous cities intermixed with multiple rural areas. For example, the South-Central region includes Wichita with a population of 390,591. Within that same region also lies Pratt with a population of 6,748. This is a good example of Kansas’ diversity where rural communities are influenced by mid-sized cities and mid-sized cities are influenced by rural communities. This diversity provides challenges to service delivery, but also an opportunity for sharing resources.2

Population Density & Peer Groups (Urban, Semi-Urban, Densely-Settled Rural, Rural, and Frontier): The population density of Kansas was 35.6 inhabitants per square mile in 2017, a 10.9% increase from 32.01 persons per square mile in 1998. For comparison, the population density of the U.S. increased from 72.4 to 92.2 persons per square mile from 1998 to 2017, a 27.3% increase. In 2017, 36 of the state’s 105 counties had population densities of less than 6.0 persons per square mile. The most sparsely populated county was Greeley, with a density of 1.6 persons per square mile. The most densely populated county was Johnson, with 1,248.8 persons per square mile. Kansas counties are assigned to peer groups based on population density. Several Kansas counties were re-categorized from one population-density peer group to another, to reflect population shifts indicated by the 2010 U.S. Census. During the 2013-2017 period, the population of the urban peer group increased by 2.9%, while the frontier, rural, densely-settled rural, and semi-urban peer groups decreased by 3.7%, 2.8%, 1.8%, and 1.7%, respectively.2

Population Growth/Change: The percent increase in the Kansas total population from 1998-2017 was 10.8%, including a 12.4% increase for Kansas males and a 9.3% increase for Kansas females. Kansas increased in population from 2,907,289 residents in 2016 to 2,913,123 residents in 2017, a 0.2% increase. Douglas, Pottawatomie, and Johnson counties had the largest relative increases in population from 2013 to 2017 with percent changes of 5.7, 5.4, and 4.3 respectively. Morton, Lane, Geary, Clark and Comanche counties had the largest relative decreases in population, with changes of 12.8%, 9.4%. 9.4%, 8.6%, and 8.4% respectively.2 In 2017, there were an estimated 38,059 infants living in Kansas or about 1.3% of the total Kansas population (2,913,123). Women of reproductive age 15-44 accounted for 19.2% (558,606) of the Kansas population.2 In 2017, there were 842,020 children and adolescents aged 1-21 years living in Kansas, which represents 28.9% of the Kansas population.3 Among families with children under 18, 29.3% are single-parent families versus married-couple families (70.7%).4 According to the 2016-2017 National Survey of Children’s Health, 20.7% of Kansas children aged 0 to 17 (est. 147,776 children) were identified as having special health care needs. Males (22.1%) were more likely to have a special health care need than females (19.2%).5

Age: The median age of Kansans in 2017 was 36.6 years, a 4.0% increase from the median age of 35.2 in 1998. The median ages of Kansas males and females in 2017 were 35.4 and 37.9 respectively. Shifts in the Kansas population distribution by age from 1998 to 2017 included a decrease in the 35-44 age group of 17.4%. This decrease, and increases of 5.2% in residents 45-54 years of age, 75.6% in residents 55-64 years of age, and 43.3% in residents 65-74 years of age reflected the aging of the baby boomers. Furthermore, there were 6.0%, 2.8%, 6.9%, 10.7%, and 10.8% increases in the 0-4, 5-14, 15-24, 25-34, and 75 and over age-groups respectively.2 The prevalence of children with special health care needs within the child population increase with age, from 18.4% of 0-5, 20.8% of 6-11, and 22.8% of 12-17.3 The higher prevalence of special health care needs among older children is likely attributable to conditions that are not diagnosed or that do not develop until later in childhood.

Race/Ethnicity: According to the 2017 Census Bureau estimates, 75.9% of Kansans were non-Hispanic white and 5.8% were non-Hispanic black. Hispanics made up 11.9% of Kansas’ population.2 The race and ethnicity composition of women aged 15-44 (i.e., of childbearing age) was estimated at 71.9% non-Hispanic white, 6.2% non-Hispanic black, 0.9% non-Hispanic Native American or Alaska Native, 4.3% non-Hispanic Asian and Pacific Islander, 2.8% non-Hispanic multiple race, and 13.9% Hispanic (any race).2 The Kansas population, like that of the nation, is becoming more racially and ethnically diverse. About one-third (30.8%) of Kansas children and adolescents (1-21 years) belong to a racial or ethnic minority. Across the age groups, about one-third (31.4%) of young children (1-5 years) are part of a racial/ethnic minority versus about three in 10 (29.2%) young adults (20-21 years). About 16.1% of Kansans age 15-21 are Hispanic, compared to 18.6% of young children.3 The prevalence of special health care needs varied only a small amount by child’s race and ethnicity with Kansas Hispanic children (19.0%) having a slightly lower prevalence than non-Hispanic white children (19.8%).5

Diversity/Languages: According to the 2013-2017 American Community Survey, in Kansas, 2.5% of the households met the definition of being limited English speaking compared to 4.5% of U.S. households. In Kansas, the prevalence of limited English speaking in households varies by language spoken at home. Limited English speaking among households speaking Spanish was 23.4%, other Indo-European languages 11.3%, Asian and Pacific Island languages 26.3%, and other languages 17.2%.6 Among people at least five years old living in Kansas in 2013-2017, 11.5% spoke a language other than English at home. Of those speaking a language other than English at home, 66.2% spoke Spanish and 33.8% spoke some other language; 39.4% reported that they did not speak English “very well.” Notable is a change in Spanish speaking population in Kansas, which has been steadily increasing. The increase mirrors similar trends at the national level. Ninety-three percent (93.0%) of the people living in Kansas in 2013-2017 were native residents of the United States. About 59.0% of these residents were living in the state in which they were born. About 7.0% of the people living in Kansas in 2013-2017 were foreign born. Of the foreign-born population, 37.3% were naturalized U.S. citizens, and 80.8% entered the country before the year 2010. About 19.2% of the foreign born entered the country in 2010 or later. Foreign born residents of Kansas come from different parts of the world.4 

Education: Kansas compares favorably with the U.S. average in terms of educational attainment with a 90.5% of the population with a high school education or higher compared with 87.3% for the U.S. About thirty-two percent (32.3%) of Kansans have a bachelor's degree or higher compared with 30.9% for the U.S.4

Income/Poverty: For 2017, the federal poverty level was $25,094 for a family of four.7 Children living in families with incomes below the federal poverty level are referred to as poor. Research suggests that, on average, families need an income of about twice the federal poverty threshold to meet their most basic needs.8 In 2017, based on the Small Area Income and Poverty Estimates (SAIPE), compared to the U.S. population, a lower percentage of Kansans lived in households with incomes below the federal poverty level (11.9% vs. 13.4% for the U.S.) and also a lower percentage of children under age 18 lived in households with incomes below the federal poverty level (14.7% vs. 18.4% for the U.S.). During the past 5 years (2013-2017), Kansas experienced a significant decrease in the poverty rate for children under age 18 but in 2017 there was a slight bump from the previous year. A decrease was seen in the United States without the bump from 2016 to 2017.9 In 2017, an estimated 102,858 Kansas children under 18 years of age were living in poverty. Five counties accounted for over half of all Kansas children (51,736 children; 50.3%) in poverty: Sedgwick (23,239), Wyandotte (11,185), Johnson (8,349), Shawnee (6,365), and Douglas (2,598). However, the rural southeastern portion of the state has many counties with high concentrations of children in poverty as well. In 2017, the percent of Kansas’ families living below the federal poverty level (8.5%) was lower than the U.S. (10.5%).10 Poverty was more common in Kansas families headed by single females with children in the household, regardless of race or ethnicity. In 2017, the Kansas percent of female headed households with related children under 18 years living below federal poverty level (37.0%) was slightly below the U.S. percent (38.7%).10 According to the 2016-2017 National Survey of Children’s Health, Kansas children living at or below poverty had an increased prevalence of special health care needs. Nearly one-half (47.5%) of children with special health care needs lived in families with incomes less than 200% of the federal poverty level.3 

The health of the economy plays a major role in the health status of the state’s MCH population as well as the delivery of MCH services. The economy in Kansas has been recovering since the economic downturn suffered during the most recent nationwide recession. The statewide GPD has been rising steadily since 2010 including a 1.9% increase from 2017 to 2018. GDP, which measures the total economic output of a given area, increased in 10 out of the 11 major industries in Kansas, with declines in the agricultural GDP causing the natural resources and mining GDP to decline as well. The median annual wage in Kansas currently stands at $35,950 which is 69% of the national average. There was a 3.2% increase in personal income from 2017 to 2018 in all components except for farm income, which decreased by 36.7% The three top occupation titles in Kansas include “Office and Administrative Support” with an annual mean wage of $35,580, followed closely by “Food Preparation and Serving” with an annual mean wage of $21,740 and “sales and related occupations” with an annual mean wage of $39,430. While the unemployment rate is the lowest in our state’s history at 3.4% many of those jobs are low paying which makes it difficult for many individuals and families to meet their basic needs. Those households most disproportionately affected are female-headed households, blacks, Hispanics, people living with a disability, and unskilled recent immigrants. Even though the Kansas unemployment rate is at its lowest in state history, nearly 50,000 open jobs are available. Moving the low-income population into the workforce is a protective factor for today’s families.

Health Insurance Coverage: Data from the Small Area Health Insurance Estimates (SAHIE) show that the percentage of Kansas children under 19 years old without health insurance decreased from 6.2% in 2013 to 5.2% in 2017, a 16.1% decrease. After a low of 4.5% in 2016, there was a slight increase in the uninsured population under age 19 in 2017 (5.2%).11 The U.S. percentage also decreased from 7.5% in 2013 to 5.0% in 2017. In 2017, nearly half (49.3%) of all uninsured Kansas children under age 19 lived in the four largest population centers: Sedgwick County (Wichita), Johnson and Wyandotte counties (Kansas City metropolitan area), Shawnee County (Topeka), and Douglas County (Lawrence). However, the southwestern part of the state, a largely Hispanic populated area where presumably many are not KanCare (Medicaid or CHIP) eligible, has many counties with high concentrations of uninsured children under age 19. The southeastern portion of the state (Kansas Ozarks), on the other hand, has a cluster of counties with high concentrations of children in poverty, as stated above, but the children are less likely to be uninsured than those in the southwestern part of the state. According to the 2016-2017 National Survey of Children’s Health, in Kansas, 97.7% of CSHCN were reported to have some type of insurance at the time of the survey: 48.6% had private coverage, 41.7% had public coverage, 7.4% had both, and 2.3% had no insurance.5

Primary Care Access & Workforce: In 2017, the supply of family and general practitioners per 100,000 population (23.3) was significantly lower in Kansas than the national average (38.8). So was the supply of obstetricians/ gynecologists (1.7), compared to the national average (5.8). The 2017 estimate for the supply of pediatricians in Kansas was not released/not available. (Individual occupational employment and wage estimates may be withheld from publication for a number of reasons, including failure to meet the Bureau of Labor Statistics quality standards or the need to protect the confidentiality of their survey respondents.) In 2016, the supply of pediatricians (8.9) in Kansas was slightly higher compared to the national average (8.3), although the difference was not statistically significant.12 KDHE recognizes that while there are needs across the state, there are also unique needs in different areas of the state. Access to care has been recognized as a challenge for the maternal and child health population living in both geographic domains for different reasons. For example, women in rural areas face barriers accessing transportation and getting to providers who may be unavailable in their area. Whereas, women in more densely populated areas, have a wider availability of services yet may not have time off work or the insurance needed to receive services. The CSHCN population often experiences reduced access due to the lack of pediatric specialists in the state, in addition to the other barriers mentioned. In fact, 31.5% of CSHCN families reported that they had trouble getting specialist care versus 18.4% of non-CSHCN families.5 Overall, KDHE has recognized that programs and providers are an important part of the landscape and the unique needs of the Kansas MCH population are being addressed throughout the state. The Bureau has been and will continue to be committed to working with local partners to address those unique needs, and to build on the successes at the local and regional levels in improving maternal and child health.

Estimates derived from national prevalence and 2017 US Census data suggest at least 157,151 or 21.9% of Kansas children have experienced a mental disorder, and around 34,888 or 4.9% of Kansas children meet the criteria for severe impairment. Over 65% of Kansas youth with major depression do not receive mental health treatment, and only 26.5% of Kansas youth with severe depression receive consistent treatment. Largely rural, Kansas faces severe shortages of medical providers across the state, particularly mental health professionals. Ninety-nine of the 105 counties in Kansas are designated as mental health professional shortage areas, or mental health HPSAs. This shortage leaves more than 70% of Kansas children with unmet mental health needs.13

Due to the shortage of providers, ensuring adequate access to mental health services for Kansas youth will require an innovative approach that increases capacity across a range of medical settings and offers new avenues for care. Kansas is home to more than 700,000 children, all of whom should have access to integrated healthcare. Such integration would require primary care providers, including pediatricians, family practice physicians and non-physician primary care providers (PCPs), have the ability to screen, diagnose, and treat children and adolescents with uncomplicated mental illness, such as anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD). A reformed model of care would also require the establishment of an expert pediatric mental health care team to provide training, consultation, and support services to PCPs.

Kansas Tribes: KDHE has been working over the last several years to develop a working relationship with the four Kansas tribes (Iowa Tribe of Kansas and Nebraska, Prairie Band Potawatomi Nation, Sac & Fox Tribe, and Kickapoo Tribe) (1.0% of the Kansas population). As a result of improved communication and established trust with KDHE, the Kansas Tribal Health Summit took place for several years. The purpose of the annual Summit was to bring together Kansas Tribes and leadership from KDHE. A partnership building meeting is scheduled for November 2019 with the tribes so KDHE public health leaders, including the Title V Director, can learn more about the concerns they have related to the health of their communities. The Kansas Maternal Mortality Review Committee has tribal representation, and the Native-American population is considered for all MCH efforts and initiatives as appropriate, considering the small population and lack of information available through Vital Statistics. As stated in the Women & Maternal Health section, the MCH program is planning to partner with the March of Dimes to launch The Coming of the Blessing (comingoftheblessing.com) by 2020, starting with the Kickapoo Tribe in response to their request for support and initiatives to improve access to prenatal care and birth outcomes. The Kansas Special Health Care Needs program (KS-SHCN) partnered with faculty with the Leadership Education in Neurodevelopmental Disabilities (LEND) program at the University of Kansas Medical Center to conduct the Northeast Kansas Tribal Developmental Disabilities Needs Assessment. The primary objectives were to: assess the needs of young Native American children with intellectual and developmental disabilities (I/DD) in northeast Kansas; identify sociocultural barriers that influence access to special care and developmental services; evaluate the cultural responsiveness of disability and developmental services; and foster partnerships between tribal communities, state, and academic agencies. More information can be found on this Assessment in the CYSHCN domain report.

Heath Equity and Social Determinants of Health (SDoH)/Disparities: According to the 2018 KIDS COUNT Data Book, Kansas ranked 13th for overall child well-being, 8th in economic well-being, 21st in education, 18th in health, and 23rd in the family and community. The annual KIDS Count Data Book uses 16 indicators to rank each state across four domains - economic well-being, education, health, and family and community - that represent what children need the most to thrive. Comparing 2017 and 2013, Kansas saw an increase in the percentage of fourth graders not proficient in reading (from 62% in 2013 to 63% in 2017) and experienced a five percent rise in eighth graders not proficient in math (from 60% in 2013 to 65% in 2017). Kansas saw a decline in the percentage of 3- to 4-year-olds not attending school, from 56% in 2011-2013 to 53% in 2015-2017. The percentage of children under age 18 living in families where no parent has regular, full-time employment increased from 20% (est. 45,000 children) in 2016 to 21% (est. 146,000) in 2017. This is slightly higher than the five-year low for Kansas in 2016 and a 6% drop since 2010 (27%, 199,000). However, the percentage of children living in high-poverty areas dropped from 8% (est. 56,000) in 2008-2012 to 7% (est. 51,000) in 2013-2017.14,15 

When looking at outcomes such as infant mortality, preterm birth and smoking during pregnancy rates, we see consistent trends based on race/ethnicity (particularly non-Hispanic black and non-Hispanic white) and socioeconomic factors (particularly Medicaid vs. non-Medicaid) in Kansas. Factors include:

• Race/Ethnicity
• Insurance Type
• Education Level
• Federal Poverty Level
• Special Health Care Needs

These variables are all tied together. For example, people with lower education levels are more likely to live in poverty.

To address disparities, we have taken the following action steps to improve health equity and eliminate disparities:

• Using data to determine where to pilot/target programming, based on disparities (e.g., Smoking Cessation pilot sites chosen from the counties with the highest smoking rates)
• Increasing access to prenatal education and service access in communities with demonstrated disparities (Kansas Perinatal Community Collaboratives/Becoming a Mom®)
• Providing culturally appropriate prenatal education (bi-lingual curriculum and instructors)
  • Currently accommodate for the Hispanic population (curriculum in Spanish and program forms also translated)
  • In conversation with the March of Dimes to launch The Coming of the Blessing (comingoftheblessing.com) by 2020 (related to the current state action plan) to target the Native American population.
• Assessing the need for health coverage, transportation, housing, food, education, etc.
• Implementing nontraditional community-level outreach (minority and at-risk)
• Assuring gap-filling services for those without insurance/access
  • Expediting Medicaid eligibility for prenatal care coverage
  • Expanding the Optum/Alere Health partnership to increase availability of 17P for Medicaid-covered pregnant women in the service area (Kansas City)
• Screening for social determinants through local MCH programs
  • Need tool or screening questions to integrate into existing programs/services
• Working with the agency-appointed staff person to coordinate/advance minority health and health equity strategies (utilizing the CoIIN SDoH network framework and resources)
• Expanding the Community Baby Shower model focused on safe sleep to integrate smoking cessation and breastfeeding education and referral to services on site; partnering with managed care organizations (MCOs) to align efforts
• Implementing a centralized, web-based data sharing system (DAISEY) that allows for monitoring outcomes and quality improvement along MCH programs; assessing ongoing if local programs are serving those most in need, in line with the Title V purpose
• Supporting development among the MCH workforce through provision of healthy equity and SDoH trainings to the Special Health Services Family Advisory and Maternal and Child Health Councils.

State Health Agency Priorities & Initiatives - Title V Roles & Responsibilities: Kansas is a state that values young children and families. Over the past decade, significant investments have been made in building a collaborative environment and in supporting at-risk communities to improve child and family health and well-being. The Kansas Department of Health and Environment, Bureau of Family Health has been a leader in these efforts. The Bureau/Title V Program plays a key role with the following:

Infant Mortality Reduction: Kansas Title V is a lead partner in convening and facilitating efforts to reduce infant mortality and eliminate disparities in maternal and infant health. Over the past several years, the Title V program has invested in comprehensive approaches prenatal care and education, tobacco/smoking cessation (before, during, after pregnancy), and pre/early term birth.  From concept to reality, the state has worked to integrate initiatives into existing systems to provide the mechanism to achieve current success and future expansion of successful programs. There were 217 infant deaths in 2017 in Kansas, a decrease of 2.7% from 223 infant deaths in 2016, though the infant mortality rate slightly increased from 5.9 infant deaths per 1,000 live births in 2016 to 6.0 in 2017. This meets the Healthy People 2020 target of 6.0 for infant deaths. The infant death rate for non-Hispanic white mothers in 2017 was 4.7, a decrease of 9.6% from 5.2 in 2016. The rate for non-Hispanic black mothers in 2017 was 11.8, a decrease of 22.4% from 15.2 in 2016. The rate for Hispanic mothers in 2017 was 7.2, an increase of 41.2% from 5.1 in 2016. Infant death rates for non-Hispanic black mothers have consistently remained higher than those of non-Hispanic white and Hispanic mothers for the past twenty years (1998-2017). Rates for Hispanic mothers have sometime been higher and sometimes lower than those for non-Hispanic white mothers.2

Special Health Care Needs Program (KS-SHCN): Kansas Law mandates health care services for CYSHCN pursuant to K.S.A. 65-5a01, based on medical and financial eligibility. The KS-SHCN program vision spans far beyond the mandate for services and aims to assess and address needs of all children, youth, and families. KS-SHCN continues to expand the focus of the program to address the needs of families through collaboration, systems integration, and increased statewide capacity. Utilizing quality improvement and evaluation, the program strives for sustainable and systemic changes for the CYSHCN population. The completion of the Kansas State Plan for CYSHCN in 2018 provides opportunity to further engage with partners in ways to improve the system of care, collaborate more effectively and efficiently, and consider the current needs of families across the state with CYSHCN in the upcoming 5-Year Needs Assessment. In addition, the creation of Supporting You, a peer-to-peer support network, and the focus on integration of the National Standards of Quality for Family Strengthening and Support will greatly compliment the direction the KS-SHCN program is heading, focusing on population health, systems of care, and policy improvements.

State Systems Development Initiative (SSDI): The SSDI project provides data capacity and support to the Title V program and specifically aims to: 1) build and expand MCH data capacity, allowing for informed decision making and resource allocation to support effective, efficient and quality programming; 2) advance the development and utilization of linked information systems between key MCH datasets, including minimum/Core dataset for the Kansas Title V MCH program; and 3) support surveillance systems development to address data needs related to emerging MCH issues,  for example, establishing maternal mortality review committee and conducting ongoing surveillance of pregnancy-related deaths.

Aid to Local Funding/Statewide MCH Network: When funds are allocated to external programs, the Bureau maintains contracts for the use of funds to outline the nature of the work in support of MCH priorities. Services are delivered in compliance with Title V legislation and in accordance with the KS MCH Manual: http://www.kdheks.gov/c-f/downloads/SFY19_Kansas_MCH_Service_Manual.pdf. The manual provides background on the Title V MCH Block Grant legislation/authority, KS MCH program principles, and service guidance and offers a vast appendix of resources related to practice and national performance measures.

The process with local agencies begins with the development of Grant Application Guidance and Reporting Materials annually in December. Materials are available by mid-January to local agencies applying for Title V funding. The review process informs funding recommendations and involves external reviewers applying guidance and a scoring matrix, a funding formula based on poverty and population by county/target area, and willingness/ability to comply with grant requirements. Detailed client and service data is required to be collected, aggregate progress reports and affidavits of expenditures are required quarterly, and site visits are conducted to verify compliance with funding requirements and progress. More information about the MCH Aid to Local Program is available online through the Kansas Grants Management System (KGMS) site: https://khap2.kdhe.state.ks.us/KGMS/Default.aspx.

Aid to Local contract documents and the list of 2019 MCH grantees are attached as supporting documents. The maps indicate SHCN regions and satellite office lead counties. This information is updated annually in July to reflect new state fiscal year grantees. A map of 2020 MCH grantees/local agencies is provided in supporting documents and in other sections of the grant application.