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, 12 rural, and 12 frontier counties. Utah's 2018 average population density is 37.2 persons per square mile, compared to 93.8 persons per square mile nationally. Sixty-seven percent of Utah’s lands are under federal ownership, with 22% privately owned, 7% by the State and 4% by Utah’s tribes.

 

 

Utah’s 2019 population was estimated at 3,205,958. From 7/1/18 to 6/30/19, Utah’s population grew by 1.7 percent, an increase of 44,853 people.  According to the Census Bureau, Utah’s 2019 growth was the fourth highest in the nation, behind other intermountain-west states Idaho, Nevada, and Arizona. 

 

Population estimates for 2018 detail Utah’s racial/ethnic populations:

 

According to a 2014 survey by the Pew Foundation, the predominant religion in Utah is the Church of Jesus Christ of Latter Day Saints (LDS), and Utah is the world headquarters of the church. The Pew Foundation reports that 55% of Utahns are of the LDS faith. Eighteen percent are of other Christian faiths (Protestant, Catholic, Jehovah’s Witness), four percent are of non-Christian faiths (Jewish, Muslim, Buddhist, Hindu), 22% are unaffiliated (agnostic or atheist) and 1% are undecided. Religious entities are invited to advisory committees and their input is sought out and valued. While these efforts occur, challenges arise with different systems and policies with each denomination.

 

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. Close to one-third of Utah’s American Indian population speak a language other than English at home. After English, Navajo is the fourth-most spoken language in Utah.

 

Utah has resettled over 15,000 refugees since 1995 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 539 in 2018.  Of those arrivals in 2018, 51.4% were female. Most refugees in Utah arrive from the Democratic Republic of the Congo, Somalia, Iraq, and Burma. 

 

In 2018, life expectancy at birth was 77.5 years for males and 81.2 years for females in Utah. The median age of Utah's population is 31 years, versus 37.9 in the U.S., making Utah the state youngest in the nation. The 2014-2018 American Community Survey (ACS) estimates note that 40.7% of Utah’s population is under the age of 25, compared with 32.3% nationwide.

Utah’s Births

 

Until 2017, Utah had claimed the highest general fertility rate in the nation. Utah’s 2018 general fertility rate now ranks 4th highest in the nation. Utah’s fertility rate was 68.4 live births per 1,000 women in 2018 compared to 59.1 nationally. Utah continues to have the highest birth rate in the U.S. (14.9 Utah vs.11.6 U.S.). Utah’s birth numbers declined for the fourth consecutive year with 47,211 live births to Utah residents in 2018.

 

Maternal Race/Ethnicity	Number of Births	Percent of Births
American Indian/Alaskan Native	478	1.0
Asian	1,121	2.4
Black/African American	662	1.4
Hispanic/Latina	8,101	17.2
Native Hawaiian/Pacific Islander	430	0.9
Two or more races	259	0.5
White, Non-Hispanic	34,636	73.4
Unknown	1,524	3.2

 

Overall, Utah’s birth outcomes are generally favorable. However, disparities emerge when examined by race and ethnicity:

 

Maternal Race/Ethnicity	Preterm Birth*	Low Birthweight*	Cesarean Section*	Infant Mortality**	Teen Births*
American Indian/ Alaskan Native	8.2%	7.3%	25.9%	2.6/1,000	32.8/1,000
Asian	9.2%	9.5%	26.4%	7.6/1,000	5.2/1,000
Black/African American	11.6%	10.4%	29.4%	9.4/1,000	27.8/1,000
Hispanic/Latina	11.2%	8.6%	24.6%	5.6/1,000	32.9/1,000
Native Hawaiian/ Pacific Islander	13.3%	7.9%	33.7%	10.0/1,000	15.0/1,000
Two or more races	10.4%	6.2%	23.6%	***	2.6/1,000
White, Non-Hispanic	8.8%	6.6%	21.4%	4.6/1,000	9.7/1,000
Unknown	11.4%	9.8%	27.1%	16.8/1,000
Statewide	9.4%	7.2%	22.6%	5.3/1,000	14.1/1,000
*2018 Vital Records data, ** 2015-2018 linked birth-death data,  ***Data suppressed due to small numbers

 

Utah's Economy

 

The Bureau of Labor Statistics notes that the 2018 unemployment rate in Utah was 3.0 compared to 3.9 for the nation. The 2014-2018 ACS estimates for median household income put Utah's $68,374 above the U.S. at $60,293. However, Utah's households are also large, resulting in a significantly lower per capita income ($28,239 vs. $32,621). There is also large variation in median income when broken out by race and ethnicity: 

 

Race/Ethnicity	Median Income (2014-2018 American Community Survey)
American Indian/Alaskan Native	$41,942
Asian	$70,759
Black/African American	$42,739
Hispanic	$49,787
Pacific Islander/Native Hawaiian	$64,594
White Non-Hispanic	$71,859

 

According to the 2014-2018 ACS 5-Year estimates, the percentage of individuals with incomes below the federal poverty level is 9.0% in Utah vs. 11.8% in the U.S. Poverty rates also range widely, depending on county of residence. Poverty rates in 2018 were lowest in Morgan County (4.0%) and highest in San Juan County (22.6%), with a statewide mean of 9.1%. The National Survey of Children’s Health finds that 12.6% of families had a household income at or below 100% FPL, compared to 19.7% nationally.

 

Health Insurance

 

In 2018, data from the Behavioral Risk Factor Surveillance System (BRFSS) estimated that 9.5% of Utahns were uninsured.

 

Rates of uninsured fell for all age groups except 19-26 and 35-49. Rates of uninsured decreased significantly for those living between 0-138% of the Federal Poverty Level (FPL). Rates of uninsured vary by race/ethnicity:

 

Race/Ethnicity	No Insurance
American Indian/Alaskan Native	22.0%
Asian	14.2%
Black/African American	22.2%
Hispanic	42.5%
Pacific Islander/Native Hawaiian	24.6%
White Non-Hispanic	10.9%

 

Insurance rates also decreased for children ages 0-17 living at or below 138% FPL. Utah BRFSS estimated that 5.7% of children below 18 years were without health insurance. The 2018 National Survey of Children’s Health has higher estimates of no insurance among this group, at 8.3%.

 

Education

 

Based on the 2014-2018 ACS, Utah had a higher percentage of residents with a high school diploma, at 92.0% vs. 87.7% nationally among those aged 25 years and older. Utah’s population 25 years and older with a Bachelor's degree is higher than the U.S. (22.0% vs 19.4%) and similar to the U.S. for those with graduate degrees (11.3% vs 12.1%). According to the 2019 Kids Count report, Utah has a higher percentage of children ages 3-4 who are not in school compared to the nation (57% vs 52%). Utah is doing better than the national average for the proportion of fourth graders not proficient in reading (59% vs. 65%). The National Education Association reports Utah having the second-lowest per-student expenditure at $7,187, compared to the national average of $12,602.

 

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 percent of Utah family households with one or more persons under the age of 18 is higher at 40.3% vs. 30.3% nationally.

 

Children and Adolescents

 

National Survey of Children’s Health data from 2018 illustrate many areas where Utah’s children differ:
 

	Utah %	U.S. %
Race/Ethnicity   Hispanic   White Non-Hispanic   Black Non-Hispanic   Asian Non-Hispanic   Other Non-Hispanic	17.6 73.2 0.3 2.7 6.2	25.2 50.5 13.4 4.8 6.1
Primary language spoken in home   English   Non-English	89.8 10.2	84.9 15.1
Highest Education in Household   Less than High School   High School   Some College   College Graduate	8.6 11.8 21.4 58.2	10.0 19.1 22.0 48.9
Family Structure   Two parent, currently married   Two parent, not currently married   Single parent   Other family type	78.3 2.5 16.9 2.2	62.7 8.5 22.8 6.0
Not insured at time of NCHS survey	8.3	6.6
Current insurance not adequate	30.2	26.0
2 or more adverse childhood events	17.3	17.8

 

The 2017 Youth Risk Behavior Survey illustrates differences between Utah youth and those in the nation: Utah youth were significantly more likely to report that they carried a weapon in the past 30 days (24.0% vs. 15.7) and were more likely to report having carried a weapon onto school property (7.1% vs. 3.8%). Utah youth were significantly more likely to report having experienced sexual violence (17.6% vs. 9.7%). Utah youth report higher rates of seriously considering suicide attempt (21.6% vs. 17.2%) 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.

 

The County Health Ranking and  Roadmaps report reveals that the percentage of children who are eligible for free or reduced price lunch vary from 13% in Morgan County (north) to 100% in San Juan County (south). For children residing in Utah, there are noted disparities by county of residence.

 

Children with Special Health Care Needs (CSHCN)

 

Data from the 2018 National Survey of Children’s Health (NSCH) found 17.4% of Utah children have one or more functional difficulties and 16.8% of Utah children have special health care needs. Utah’s percentage of children with special health care needs ranks sixth lowest in the nation.

 

2017-2018 NSCH data shows that Utah’s rate of children ages 3-17 diagnosed with autism is 2.1% and is lower than the U.S. rate of 2.9%. The 2018 National Survey of Children’s Health data provides important information on Utah’s CSHCN population and their parents:

 

	Utah %	U.S. %
Race/Ethnicity   Hispanic   White Non-Hispanic   Black Non-Hispanic   Asian Non-Hispanic   Other Non-Hispanic	19.4 73.4 0.0 3.2 3.9	20.0 53.7 16.6 3.1 6.6
Household Income   0-99%  FPL   100-199% FPL   200-399% FPL   400% or greater FPL	23.5 22.4 28.6 25.4	23.1 23.5 23.8 29.7
One or More Current or Lifelong Health Conditions	21.4	23.0
Not insured at time of NCHS survey	9.9	4.0
Current insurance not adequate	37.8	32.5
Currently uninsured or had periods without coverage in past 12 months	10.4	9.2
Child has coordinated, ongoing, comprehensive care in a medical home	36.9	42.1
Problems paying for child’s medical or health care bills in past 12 months	23.9	16.4
Family member cut back hours, stopped working, or both	17.8	19.8

 

 

Attention Deficit Hyperactivity Disorder (ADHD) Prevalence Estimates

 

Nationally, the prevalence of ADHD relies on the National Survey of Children’s Health (NSCH).

In 2016, an estimated 6.1 million U.S. children 2–17 years of age (9.4%) had ever received an ADHD diagnosis.

 

For the first time, Utah has been able to develop a prevalence estimate of ADHD through the Utah Registry of Autism and Developmental Disabilities (URADD).  Identification of ADHD was based on a community medical ADHD diagnosis (ICD-9: 314.00, 314.01 and ICD-10: F90.0, F90.1, F90.2, F90.8, and F90.9).

 

Percent of children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) in Utah (2018)
Birth Year	Count	Percentage
2012 (6-year-olds)	768 of 50,305	1.5%
2011 (7-year-olds)	1,131 of 51,662	2.2%
2010 (8-year-olds)	1,499 of 52,672	2.8%
2007 (11-year-olds)	1,086 of 54,129	2.0%
2006 (12-year-olds)	1,687 of 53,185	3.2%
2005 (13-year-olds)	1,932 of 52,831	3.7%
Data Source: The Utah Registry of Autism and Developmental Disabilities and the UDOH Public Health Indicator Based Information System (IBIS)

 

Utah Title V Capacity

 

The Department of Health’s and Utah's Title V unified vision is “A place where all people can enjoy the best health possible, where all can live, grow and thrive in healthy and safe communities.'' The Utah Department of Health (UDOH) is accredited by the Public Health Accreditation Board (PHAB) and continues to work on maintaining this credential.

Utah Code 26-10-1 through 26-10-7 provides statutory authority for Title V. Two bureaus within the Division of Family Health and Preparedness (DFHP) 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 Bureau of Health Promotion in the Division of Disease Control and Prevention, also collaborates and contributes to the Title V work.

 

Title V staff work to identify the needs of underserved mothers, 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, produce reports, fact sheets, abstracts, and articles in peer reviewed journals with UDOH staff as authors.

 

Over the past two years, 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. The detailed Needs Assessment Report is found later in this document. 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).   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.

 

UDOH data capacity is very strong and focused around the Center for Health Data (CHD), which serves as the central point for state health data. CHD includes the Office of Vital Records and Statistics, the Office of Public Health Assessment (OPHA), the Office of Health Care Statistics (OHCS), and the Office of Public Health Informatics (OPHI). The CHD 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 (YRBSS), hospital and emergency department data, hospital performance data, population estimates, and the Utah Cancer Registry. The OPHA also conducts the Behavioral Risk Factor Surveillance System (BRFSS). The OHCS is responsible for health plan surveys and reporting plan performance annually, as well as inpatient, ambulatory, and emergency room data. The DFHP has strong working relationships with the CHD. The MCH/CSHCN Bureau’s collaborate across the UDOH to ensure integrated use of data and population assessment.

 

The Utah Department of Health (UDOH) conducts a Utah Healthcare Safety Net bi-annual meeting. The meeting involves 50+ stakeholders vested in MCH/CSHCN and provides insight into legislative issues affecting healthcare and community resources and facilitates networking and collaborations with State advocates and organizations throughout the State.

 

Utah’s Strengths and Challenges

 

Strengths

 

Utah’s strengths include being one of the healthiest states in the Nation. The 2019 America’s Health Rankings rank Utah as the fifth healthiest U.S. state. Utah’s low rates of smoking, alcohol consumption, and obesity contribute to a healthier population. The Health Rankings Report notes that Utah’s rate of children in poverty is the lowest in the nation. Utah’s data capacity and utilization is high, which allows us to act quickly on emerging issues and make data driven decisions. Utah’s Title V programs use social media for health education and are using technology to engage families and partners. Utah has strong collaboration efforts with stakeholders and utilizes the advice of our peers to develop, implement, and evaluate programs for women, children, and families. The State was well prepared when the COVID-19 pandemic hit, as it had already been pilot testing telework and telehealth services. This past year, the Governor’s initiative was to get 30% of the State workforce teleworking. As such, we were rapidly able to move employees to a work from home environment. Utah has also been working on expanding telehealth capacity to address teleservice needs, protections and requirements for MCH/CSHCN populations.

 

Challenges

 

The geographic distribution of the state's population presents 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. Telehealth technology also poses barriers with lack of technology lines, services and equipment in both rural and frontier areas.

 

The America’s Health Ranking Reports lists Utah’s health challenges as having a low rate of primary care physicians, low immunization coverage among children, and large differences in health status by high school education.

Reorganization of the UDOH and DFHP continued this year. Some of the major transitions which occurred in this grant period: the CSHCN Bureau moved from the 44 North Mario Capecchi location after 40 plus years of occupation at this location to join the DFHP at the Highland Drive location (including ISP moving back to the CSHCN Bureau); both the Security and Privacy Officer and the Division Deputy Director, left employment in the Division. Due to the COVID-19 outbreak, on April 1, 2020, Governor Herbert appointed both temporary Executive Director, General Jefferson Burton and temporary Chief Deputy, Richard Saunders to support the current leadership of Joseph Miner, M.D., Marc Babitz, M.D., and Nathan Checketts. The variety of reorganizational changes has increased the turnover of employees that has created challenges with workloads, timeliness of rehiring, orienting and stabilizing new employees. On August 3, 2020, the UDOH announced another administrative change. General Burton left employment to pursue a Senate seat opening and Richard Saunders moved into Interim Executive Director to support current leadership. Dr. Miner will now serve as the Chief Medical Advisory to the UDOH and to the Executive Office of the Governor through the end of the year.

There remains a great need for services for children with special health care needs around the state. The CSHCN Bureau in collaboration with its stakeholders continue to research resources, make community connections, refer and brainstorm ideas for a more comprehensive and accessible service delivery system. During the current pandemic, this need has grown and posed a leadership challenge while maintaining competency, relevancy and quality.

 

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 Disparities (OHD) addresses disparities that may occur among populations whether they be defined by race, ethnicity, etc. The OHD assists the UDOH in identifying priorities and needs of specific key populations in the state, assessing the adequacy of ethnic data from common public health data sources and recommending improvements, informing ethnic communities about efforts and activities, and developing guidelines for cultural effectiveness for UDOH programs. In 2018, the OHD published “The Utah Health Improvement Index”. This report measures social determinants of health and inequities and creates an index for each of Utah’s 99 small geographic areas. The report presents index groupings from low to very high. The OHD works closely with Title V programs to identify opportunities to work together to address MCH needs.

 

The​ UDOH works closely with the Office of American Indian/Alaska Natives (AI/AN) Health Affairs. This office facilitates meeting 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 UDOH 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, including those for children and youth with special health care needs, are provided in various settings, including medical homes/private providers, local health departments, community health centers that serve the homeless and migrant workers, and a number of free clinics.

 

Utah's public health system comprises the UDOH and 13 Local Health Departments (LHD). The Utah Department of Health 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.

 

The LHDs have SMART Objectives for Services for Women and Children, which are part of their contract and work plans. The specific objectives vary by district. For Services for Women objectives include - postpartum depression education/screening, breastfeeding, family planning, home visiting, etc. For Services for Children objectives include oral health/sealants, vision/hearing screening, etc. All 13 LHDs have the same Developmental Screening objective - NPM6. Four rural LHDs are receiving funding for a CSHCN Care Coordinator and coordinate with the Integrated Services Program.

 

Systems of Care

 

The UDOH has created a safety net group of community providers who meet regularly to share their resources, coordinate services, and identify ongoing community needs. Community Health Centers (CHCs) throughout the state and the Wasatch Homeless Clinic in Salt Lake City 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.

 

For many years, the UDOH provided primary care through the Health Clinics of Utah (HCU), which has locations in Salt Lake, Ogden, and Provo and plays a key role for the UDOH and Utah’s Safety Net of providers. Medical clinics are staffed with a multidisciplinary team. The clinics provide 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), Primary Care Network (PCN), and Medicare. Among the patients seen in these clinics in FY2018, 47% had Medicaid/Medicare, and 13% were uninsured. In addition to regular clinical services, the HCU provides immunizations and health screenings for newly resettled refugees in Salt Lake and Weber counties and provides medical screenings for children in protective service care in multiple counties. Due to COVID-19 and resulting legislative budget reductions, all three clinics will be closing in the next couple of months.

 

The Indian Health System in Utah consists of one IHS outpatient facility, 3 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 in that community. 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 at approximately 54% of 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. Sometimes this can be 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 three hospital systems, which provides Utah a unique opportunity to build strong collaborations. Of Utah's hospital systems, the largest is Intermountain Healthcare hospitals. 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.

 

Telehealth Capacity

 

Telehealth capacity is expanding in Utah. To reduce barriers to early diagnosis, Utah Early Hearing Detection Intervention (EHDI) purchased auditory brainstem response equipment to provide tele-audiology services for rural communities. This equipment was placed in Blanding and Richfield, Utah. In 2018-2019, EHDI expanded the rural tele-audiology service. 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 barriers of access to specialists, travel costs, inability to take time off from work, costs of testing, etc. In June 2020, the EHDI Program purchased 32 Otoacoustic Emission (OAE) equipment for local health departments and midwives who needed equipment. They are setting up education sessions for use of the new equipment. This will ensure providers can offer this service statewide and EHDI data remains updated and timely follow up can occur.

 

Tele-audiology services are hosted at the CSHCN Bureau with two pediatric audiologists on staff and a nurse at the remote site. The nurse 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 takes over 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 Bureau 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 UDOH funds the University of Utah (UofU) for perinatal mental health screening and counseling via telehealth. The project is now working with four of Utah’s rural health departments to screen women for postpartum depression symptoms using the Edinburgh postnatal depression scale tool, refer women who need support, and provide on-line support groups and counseling using telehealth.

 

Telehealth platforms are also being used to deliver educational programs. Project ECHO (Extension for Community Health-Care Outcomes), housed at the UofU, is a platform that can deliver education and interactivity through telemedicine. This platform is used to coordinate statewide implementation of maternal safety bundles, saving travel costs and facilitating greater participation.

 

Starting in July 2019, the DFHP was requested by the Governor to support his initiative to implement and pilot teleworking.  The Division over the past year transitioned many programs to telework. Some direct care service programs had not transitioned due to privacy and security concerns with patient care. Then in March 2020, when Utah started to experience the COVID-19 pandemic, telehealth became a quick methodology to implement. Due to previous experience with teleworking, both the MCH/CSHCN Bureaus were able to convert to a telehealth platform to provide continuity of care throughout Utah. National standards and changes allowed Utah to implement face-to-face services by telehealth. Proudly we made the transition within two weeks while ensuring guidelines were written to direct our services to occur in a safe, private and confidential manner. Virtual services cannot replace a face-to-face connection and services but we have found keeping communications open, providing online support and services have been invaluable during this time of crisis. We project this immediate transition has provided an opportunity for the future in offering virtual services when the individuals we serve do not have access or the ability to have a visit in person.

 

Clinical Workforce Availability

 

The Utah Medical Association (UMA) reported 9,990 licensed physicians in 2015. Of the total number of licensed physicians, 6,035 (60.4%) reported providing services in the state. This provides a ratio of 198 patient care providers per 100,000 population, compared to a national average of 265.5/100,000. The County Health Rankings and Roadmaps Report notes that the ratio of population to primary care physicians is 1,730:1 statewide, but ranges from 740:1 in Grand County to 10,080:1 in Emery County. The report also notes that seven of Utah’s counties had negative trends in this measure. High population to provider ratios can also be seen among dentists and mental health care providers. Among dentists, the statewide ratio is 1,470:1 and among mental health care providers, the ratio is 300:1.

 

A report from the Office of Primary and Rural Health at the UDOH noted that the distribution of healthcare providers is disproportionate to where the population resides in the state. In Utah, 21% of the population lives in rural areas, but only 11% of primary care providers, 9% of mental health providers, and 16% of dental providers work there.

 

From July 1, 2017 to present, the Integrated Services Program (ISP) has contracted 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, which are the University of Utah, Primary Children's Hospital and Shriners Hospital for Children. 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 presents 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, local health departments 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. The story is different for those living in rural/frontier areas of the state where families must drive long distances to access the same services.

 

Utah’s Public Behavioral Health System

 

Utah's public behavioral health systems have a similar structure as 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 local health department.

 

Utah Medicaid

 

Utah’s Medicaid program is administered through the UDOH. The Medicaid program is an advocate for supporting MCH/CSHCN populations throughout the State. Utah Medicaid contracts with health plans, or Accountable Care Organizations (ACO), to provide medical services to Medicaid members. 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 is responsible to provide enrolled Medicaid members with all medical services covered by Medicaid. Medicaid typically pays a monthly fee for each Medicaid member enrolled in an ACO. Each ACO may offer more benefits and/or fewer restrictions than the Medicaid scope of benefits. The ACO must specify services which require prior authorization and the conditions for authorization.

Members enrolled in an ACO must receive all services through a provider on that ACO’s network. The provider is paid by the ACO. Members enrolled in the Fee for Service Network may use any Utah Medicaid provider. The provider is paid by Medicaid.

 

The CHSCN Bureau is designated by Medicaid to provide and/or oversee the following services to children with special health care needs: case management, explaining benefits, eligibility and services, and referral and assistance.

On December 23, 2019, the Centers for Medicare and Medicaid Services (CMS) authorized the Utah Department of Health to implement a full Medicaid expansion in the state. It is estimated that up to 120,000 Utah adults are eligible for the expansion program. The state requires newly eligible adults to enroll in their employer-sponsored health plan if one is available. Medicaid will then cover the individual’s monthly premium and other out-of-pocket expenses like copays and deductibles.

 

Full Medicaid expansion took effect in Utah as of January 2020. Adults ages 19-64 are now eligible with household incomes up to 138% of the FPL. Enrollment in Medicaid continues year round and is not limited to an annual enrollment period. A self-sufficiency/work requirement was established, but has been currently suspended due to the COVID pandemic.

 

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 assessment, capacity surveys and historical experience to make determinations for program capacity, development and funding distribution.