State Overview

1. Geography

Nevada is the most mountainous state in the U.S with over 150 named ranges and has several mountain peaks exceeding 11,000 feet. The state has a unique topography, with vast distances separating frontier, rural, and urban communities. With a land mass of approximately 110,000 square miles, Nevada is the 7th largest state in the United States (U.S.). The State Demographer’s Office indicates Nevada has three urban counties (Carson City, Clark, and Washoe), three rural counties (Douglas, Lyon, and Storey), and eleven counties designated as frontier (Churchill, Elko, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Mineral, Nye, Pershing and White Pine). The three rural counties (Douglas, Lyon, and Storey) also meet “micropolitan” classification due to their proximity to the urban (metropolitan) counties (Carson City, Clark and Washoe). 

Figure 1. Map of Nevada with Counties

The distance between Washoe and Clark counties is 448 miles (approximately 7.5 hours by car), between Washoe and Elko counties is 290 miles (approximately 4.5 hours), and between Elko and Clark counties is 433 miles (approximately 7.5 hours by car). Residents in the rural and frontier counties are spread across 95,421 square miles or 86.9% of the state’s land mass. Population density ranges from 379 people per square mile in Carson City to 0.22 people per square mile in Esmeralda County. Approximately 90% of Nevada land is publicly owned and administered by federal, state, and Tribal entities, with the remaining 10% privately owned.

Figure 2. Map of Nevada with Cities

2.  Population 

In 2018, the Nevada State Demographer’s Office and the U.S. Census Bureau estimate Nevada’s population as just over 3 million, 3,034,392. Between 2010 and 2018, Nevada had the seventh-highest percentage growth in the nation (12.4%%), according to the US Census Bureau. While Nevada’s population continues to grow, some rural and frontier counties lose population annually. The most densely populated area in the state is Clark County with 73.6% (2,251,175) of all Nevada residents. The population in the rural and frontier counties ranges from approximately 969 (Esmeralda County) to 56,075 residents (Carson City). In 2018, the child population (Nevadans under 18 years old) made up 22.9% of the population, which is similar to the US (22.4%). 

The U.S. Census Bureau also indicates Nevada is an ethnically diverse state, with over 28.8% of the state’s population in 2018 documented as Hispanic Origin of Any Race. In comparison, Nevada’s population is 74.6% White alone, 9.8% Black alone, 8.8% Asian alone, 1.7% Native American or Alaskan alone, 0.8% Hawaiian and Other Pacific Islander alone, and 4.3 % two or more races (https://www.census.gov/quickfacts/nv).

According to the most recent Kid’s Count Data Center (2016) approximately 37% of Nevada’s children are from non-U.S. national families and of these children, 72% are from Latin America. These numbers have been holding steady over the last 5 years. 

Health concerns for Nevada’s diverse maternal, child, and adolescent health (MCAH) population include physical, reproductive, behavioral, mental, psychosocial, chronic disease concerns, and care of children and youth with special health care needs (CYSHCN). Language barriers, cultural differences, access to insurance, and service availability can influence the use of clinics, hospitals, doctors and other health care services. Title V MCH-funded partners provide bilingual referrals and resources to community events and health fairs. Along with providing printed materials, personnel link diverse populations to specific programs providing culturally informed services. 

3.  Public Health System/Organizational Structure

Governor Steve Sisolak is Nevada’s Governor, currently serving the first year of a 4-year term.  The Nevada Department of Health and Human Services (DHHS) is the largest of the State’s departments and reports directly to the Governor.  The Director of DHHS, Richard Whitley, is Governor-appointed and was appointed by Nevada’s former governor, Brian Sandoval. DHHS is comprised of five divisions, with multiple programs under the DHHS Director. The divisions include the Division of Public and Behavioral Health (DPBH), Aging and Disability Services Division (ADSD), Division of Child and Family Services (DCFS), Division of Health Care Financing and Policy (DHCFP), and Division of Welfare and Supportive Services (DWSS).

Nevada has 3 counties with their own health authority: Carson City Health and Human Services (Carson City), Washoe County Health District (Washoe County) and Southern Nevada Health District (Clark County). The rural and frontier counties: Humboldt, Elko, Pershing, Lander, Eureka, White Pine, Churchill, Mineral, Esmeralda, Nye and Lincoln counties do not have their own health authority, so the State of Nevada Office of Public Health Informatics and Epidemiology serve as the health authority for those counties. Additionally, some of the rural and frontier counties have or are forming their own boards of health. The State of Nevada, Community Health Services has community health nursing clinics and behavioral health clinics in various rural and frontier counties to provide family planning services, related preventative health services, public health and infectious disease services.

DHHS programs helping to promote Title V MCH priorities in Nevada include: Nevada 2-1-1, Office of Consumer Health Assistance, Nevada Governor's Council on Developmental Disabilities, the Office of Health Information Technology (HIT), Individuals with Disabilities Education Act (IDEA) Part C Office, Nevada Early Intervention Services (NEIS), the Office of Minority Health and Equity, Tribal Liaisons (DHHS and DBPH partner with 27 Tribes across Nevada through a Tribal Consultation Process Agreement to strengthen ties and relationships with Tribal Governments), Primary Care Office (PCO addresses access to health care and identifies workforce shortage areas), Oral Health (initiatives focusing on pregnant women, infants, and young children), Community Health Nurses (rural communities), Office of Public Health Informatics and Epidemiology (OPHIE), Office of Analytics, Substance Abuse Prevention Treatment Agency (SAPTA), Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) the Division of Child and Family Services (DCFS), Chronic Disease Prevention and Health Promotion (CDPHP), Community Health Workers Program (CHW), WIC, and the Immunization Program (IZ).

Nevada Revised Statute (NRS) Chapter 442 (http://www.leg.state.nv.us/NRS/NRS-442.html) details Title V MCH public health authority of DPBH. The DPBH Interim Administrator is Lisa Sherych and Bureau Chief is Beth Handler, MPH. The Bureau of Child, Family and Community Wellness (CFCW) within the Community Services Branch is led by Bureau Chief Candice McDaniel, MS. She is also the MCH Title V Director and oversees WIC, IZ, CDPHP and MCAH. The MCAH Section is led by CYSHCN Director, Vickie Ives, MA.  MCAH programs include: Maternal, Infant, and Early Childhood Home Visiting (MIECHV); Teen Pregnancy Prevention (TPP), including Personal Responsibility Education Program (PREP) and Abstinence Education Grant Program (AEGP); Pregnancy Risk Assessment Monitoring System (PRAMS); Rape Prevention and Education (RPE); Early Hearing Detection and Intervention (EHDI); and the Title V MCH Program.  The MCAH Section addresses health and social issues among the populations served by coordinating efforts with Nevada DHHS programs, local health authorities (LHAs), public and private partners, MCH Coalitions, Community Coalitions, Family Resource Centers, Federally Qualified Health Centers (FQHC), stakeholders, and regional hospitals.

The MCAH Section includes the Title V MCH Program, led by Christina Turner, who administers Title V MCH activities. Title V MCH Program fiscal staff includes two partially funded Management Analyst and a part time Accounting Assistant. Title V MCH staff and programs include:

• The CYSHCN Program Coordinator who cooperates with partners, to promote the NCMHP, serve family and self-advocates for CYSHCN, provide services and supports for CYSHCN, health education, and training for families and health professionals. Examples include the University of Nevada, Reno (UNR) Craniofacial Clinic, Children’s Cabinet Technical Assistance Center on Social Emotional Interventions (TACSEI), Family TIES, transition activities for older CYSHCN, and Nevada Center for Excellence in Disabilities.
• The Title V MCH Epidemiologist is responsible for MCH data needs in annual reporting and the five-year needs assessment. In addition, the epidemiologist analyzes data and writes reports for federal, state, and local use.
• The Rape Prevention and Education (RPE) Coordinator collaborates with partners to prevent sexual violence and intimate partner violence among youth and young adults ages 12 through 24 years old. Funding for the RPE Coordinator position and related prevention activities is provided through the Title V MCH Block Grant (0.25 FTE), Preventive Health and Health Services Block Grant set-aside, and the Centers for Disease Control and Prevention (CDC).
• The Adolescent Health and Wellness Coordinator collaborates with community partners on improving access to health insurance, increasing utilization of adolescent well visits and general health and wellness services, increasing daily physical activity, and school-based health center Medicaid certification promotion.
• The Maternal and Infant Health Coordinator collaborates with diverse community partners on a variety of pre-and post-interconception care initiatives, including substance use prevention, Safe Haven, breastfeeding promotion, injury prevention, perinatal quality collaborations, perinatal mood and anxiety disorders, safe sleep, Child Death Review, and Fetal and Infant Mortality Review (FIMR). 

Nevada’s Title V MCH activities occur at the local, regional and statewide levels, and MCH cooperates with programs and sections within DPBH supporting women of child-bearing age, infants, children, CYSHCN, adolescents, and their families. Examples of Title V MCH-funded partners administering programs congruent with the priorities indicated in the 5-year plan, include:

• Children’s Cabinet TACSEI provides technical assistance and facilitates parent involvement in social emotional Pyramid Model activities.
• FamilyTIES serves CYSHCN and supports families and health professionals who work on their behalf. They provide advocacy, education, training, and other supports including a toll-free hotline.
• FIMR Program in Washoe County evaluates elements impacting the health of the mother, as well as fetal and infant birth outcomes to reduce fetal and infant mortality.
• Money Management/Nevada 2-1-1 provides information and referral via www.nv211.org, a toll-free phone number, text support, as well as hosting the Title V MCH toll free line, supporting the NCMHP resource sections, and educating women on the priority status of pregnant women at Substance Abuse Prevention and Treatment Agency (SAPTA) funded treatment centers.
• Immunize Nevada supports training/workforce development, including the statewide Nevada Health Conference with trainings to build topical MCH knowledge.
• Local Health Authorities (LHA) provide outreach, care coordination, health education, health services access information, and support to improve public health.
• March of Dimes supports training of healthcare professionals and advocates, as well as providing Title V MCH with educational materials focusing on pre/interconception, including birth spacing, smoking cessation, and reducing early elective deliveries. 
• Nevada Broadcasters Association provides airtime and support for the Sober Moms Healthy Babies (SMHB), PRAMS, Safe Sleep and marijuana in pregnancy media campaigns. DP Video supports adolescent physical activity, tobacco quit line and SMHB social media campaign.
• Nevada PRAMS partner is the University of Nevada, Reno (UNR).
• Specific activities and initiatives focused on pregnancy, prenatal, and early childhood health including websites (e.g., sobermomshealthybabies.org and text4baby) and promotion of safe sleep and developmental screenings.
• Statewide MCH Coalition supports website maintenance, communication, advocacy across public and private health entities in Nevada, maternal mental health trainings, and planning with partners for meeting community needs of diverse populations.
• UNR Nevada Center for Excellence in Disabilities provides training on leadership, advocacy, and the medical home for parents of CYSHCN.
• Urban Lotus provides trauma-informed yoga to at-risk youth.

Program management and fiscal staff meet weekly to discuss and coordinate all Title V MCH activities across Nevada, while program personnel meet weekly to discuss the status of funded programs. Program and fiscal goals, potential barriers, training needs and technical assistance are all topics for discussion and action. New activities are considered as funding allows. Title V MCH Program personnel work with community partners to determine the scope of work and budget needed for community-level activities on an annual basis. This includes annual site visits monitoring program deliverables and fiscal processes and monthly calls. 

Culturally and Linguistically Appropriate Services (CLAS) Standards

Title V MCH-funded programs provide outreach and culturally informed services. Training on cultural competence topics is a valuable component to the success of the Title V MCH Program and is offered to case managers, nurses, and others. Licensed personnel provide Culturally and Linguistically Appropriate Services (CLAS) and all non-licensed, para-professionals, including CHWs, Home Visitors and support staff, access CLAS training, and related training. 

Title V MCH works with partners in remote areas to increase the number of sufficiently trained staff in the rural/frontier areas of Nevada. The Title V MCH Program, including funded partners, works with diverse communities across Nevada, including other partners/stakeholders who have a great understanding of the communities in which they live. Partners offer language and translation assistance, either through local community organizations, or over the phone. Several have personnel with language skills who can provide language assistance and translation. 

Title V MCH provides bilingual information and media to serve Spanish language speakers. Nevada State Purchasing provides additional assistance with the capacity to work with diverse entities who provide translation assistance, and can aid with translation of documents.

Family TIES, a Title V MCH funded Family Voices partner, provides interpretation and translation at the University of Nevada, Reno, Craniofacial Clinic. Title V MCH also funds a CHW in Elko County, and works with a hospital in southern Nevada to hire Promatores to serve Spanish-speaking populations. Information and materials disseminated by these partners are required to be culturally appropriate. Internal translation support is provided by MCAH staff members.

MCAH staff received training related to equity and diversity over the past year and participated in webinars and trainings related to: diversity, CLAS, intergenerational trauma, minority health and wellness, tribal partnerships, social determinants of health and health literacy. The Title V MCH Program works with community stakeholders to expand the MCH presence across populations to address gaps, and service scope to engage all state communities. The Title V MCH Program collects accurate demographic information shared across all funded community partners.

4.  Healthcare

The Patient Protection and Affordable Care Act (ACA) and Medicaid expansion continue to have a positive effect in Nevada. The percent of children, ages 0 through 17, without health insurance from 2012-2017 was 16.6%, 13.9%, 9.7%, 7.6%, 6.1% and 7.1% in 2017. The percent of uninsured children has been decreasing over the last 5 years. Nevada will continue to monitor insurance enrollment data. The Title V MCH Program will also review PRAMS data. 

Nevada Medicaid is administered through the Division of Health Care Financing and Policy (DHCFP), with enrollment administered by the Division of Welfare and Supportive Services (DWSS) for Nevada Check Up (Nevada’s Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Program) and Medicaid. Both Fee for Service (FFS) and Managed Care Organizations (MCOs) operate in the state. Rural areas are served by FFS providers and the urban areas of Clark and Washoe counties are served by four contracted MCO providers. 

As of January 2019, according to Medicaid Children’s Health Insurance Program (CHIP) enrollment (Medicaid.gov) an estimated 635,194 individuals were enrolled in Medicaid and Nevada CHIP, compared to September 2013 in which 332,560 were enrolled. These estimated numbers demonstrate continued growth, a net increase of 91%, in Nevada’s Medicaid population from the previous calendar years (https://www.medicaid.gov/medicaid/by-state/stateprofile.html?state=nevada).

Nevada continues to monitor and promote the utilization of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screenings among Medicaid-eligible children under the age of 21. Healthy Kids, the Nevada EPSDT Program, reimburses for well-child visits for all children enrolled in Nevada Medicaid and Nevada Check Up. Outreach to providers and families to encourage EPSDT screenings is a continuing effort for the DHCFP and MCH. Continued collaboration between DHCFP and Title V MCH includes education and outreach to promote available preventive benefits and EPSDT screenings, particularly as they relate to maternal, child, and infant health (http://dhcfp.nv.gov/Pgms/CPT/EPSDT/).

The Title V MCH Program is instrumental in advancing the Healthy Kids Program, by funding parent education materials, which encourage Bright Futures recommended preventive health services for infants, children, and adolescents and provide information on enrollment in Nevada’s Medicaid Program. Title V MCH has also developed a growth chart based on the Bright Futures recommended preventive pediatric health care visits. The growth chart includes important milestones, outlined by the Bright Futures guidelines. Title V MCH partners also receive these materials to disseminate to their clients. In addition, a one-page version of the growth chart is included in the Protect and Immunize Nevada’s Kids PINK packets; across the state, hospitals distribute these materials to all new parents after the birth of a child. Title V MCH also funds other Bright Futures materials, including the Bright Futures tool and resource kit, and health care professional pocket guide, which are provided to partners statewide. MCH provides data related to MCH quality measures to DHCFP annually.

Title V MCH also partnered with DHCFP and National Academy for State Health Policy (NASHP) on a learning network regarding medically complex children and on Maternal and Infant Health Initiative (MIHI) efforts.

Uninsured Nevadans continue to have difficulty with access to providers; however, Access to Healthcare Network (AHN) offers a medical discount program for members, who pay a membership fee to access the discounted provider network and case management. Participating network providers receive a timely, yet reduced, payment. People unable to pay for their healthcare needs can access limited financial assistance. The Mexican Consulate in Las Vegas provides information relating to insurance for non-U.S. nationals.  FQHCs in Nevada provide sliding scale fees for health care, irrespective of citizenship status.

Free health care is provided through the University of Nevada, Reno, School of Medicine (UNSOM) Student Outreach Clinic operated by medical students. The clinic is operated in cooperation with the Family Medicine Center and UNSOM and made possible by faculty and community physicians who donate their time. Services include general and acute medical care, gynecological exams, immunizations, and discounted laboratory services. Currently, there are five separate clinics run by the Student Outreach Clinic (General, Geriatric, Dermatology, Pediatric, and Women's). A new obstetrics and gynecology (OB/GYN) Department at UNR Medical School will provide education for medical students OB/GYN. 

The organization Volunteers in Medicine provides free medical care in southern Nevada. The University of Nevada Las Vegas (UNLV) School of Medicine clinical practice provides Southern Nevadans with access to a full range of academic medicine faculty physicians delivering clinical patient-focused and collaborative services. The UNLV clinics are open to the public. Rural Access Networks (RAN) events provide oral health and immunizations at no cost.

5.  Employment

According to the Bureau of Labor and Statistics, there are approximately 1.48 million Nevadans in the work force as of April 2019; the unemployment rate was 4.0% compared to the national average of 3.6%. The traditional industries in Nevada include: tourism, gaming and hospitality; logistics and operations; and agriculture. Other industries including: manufacturing; information technology; aerospace and defense; energy and health care have all experienced growth and helped stimulate the economy according to the Nevada Governor’s Office of Economic Development.  Mining has experienced a decrease in the number of jobs but has seen an increase in wages (http://www.diversifynevada.com/key-industries).

The Kids Count Data Center data for 2017 reports the statewide median income of households with children was $63,000; an increase from $58,500 in 2016.

The American Community Survey (ACS) indicates there were approximately 19,360 children who had at least one parent unemployed, and 79,947 with at least one parent not in the labor force during 2017.  

6.  Housing

Market forces continue to create a squeeze on the affordable end of the rental market, increasing rates of rent burden for lower income households. According to the National Low-Income Housing Coalition, the Fair Market Rent (FMR) in Nevada for a two-bedroom apartment is $966. For a renter to afford this level of rent and utilities, without paying more than 30% of income on housing, a household must earn $3,222 monthly or $38,660 annually. The estimated hourly mean renter wage is $16.84 at which they can afford rent of $876 (https://reports.nlihc.org/sites/default/files/oor/files/reports/state/OOR_2018_NV.pdf).

7.  Income

The Kaiser Family Foundation measures state economic distress: housing foreclosures, changes in unemployment, and food stamp participation. In 2015, Nevada ranked number one in economic distress; however, in 2016, Nevada improved to 19th due to reductions in economic distress indicators. Nevada faced no recent budget shortfalls.

The median household income for Nevada increased from $55,180 in 2016 to $58,003 in 2017 according to ACS.  At the same time, the U.S. median household income increased from $57,617 to $60,336.  According to County Health Rankings and Roadmaps, “Income inequality helps measure gaps in household earnings.”  Income inequality is measured as the ratio of household income at the 80th percentile to income at the 20th percentile. In Nevada, the ratio is 4.3 overall and ranges from 2.8 (Story County) to 10.1 (Eureka County) (http://www.countyhealthrankings.org/app/nevada/2019/measure/factors/44/map).

Nevada’s urban areas struggle with an unusually high cost of living relative to low wages and insecure work associated with service industry tourism economies. The poverty level in rural and urban areas is comparable; however, accessing medical and health care services is severely limited in rural and frontier counties due to geographic access barriers, as well as difficulties in recruiting and retaining providers. This translates into low rates of routine preventive health services, such as recommended EPSDT screening and related childhood immunizations, and decreased access to preconception health services, including the screening and management of chronic conditions, counseling to achieve a healthy weight, and smoking cessation.

8. Policy/Legislature

The 79th Nevada Legislative Session concluded June 6, 2017. Tax allocations were set in relation to the legalization of recreational marijuana and marijuana is available both recreationally and medically in Nevada.  Title V MCH worked in partnership with the Department of Taxation to post warnings in relation to use in pregnancy and child injury prevention in all state marajuana dispensaries, in English and Spanish, as well as placement in consumer-facing publications. Title V MCH launched a marijuana use in pregnancy public service announcement (PSA) in partnership with SAPTA.

Chapter 442 of Nevada Revised Statutes (NRS) codifies statutes related to Title V MCH. NRS 442.133 provides the membership and terms of the Maternal and Child Health Advisory Board (MCHAB). The MCHAB is comprised of nine members appointed to two-year terms by the State Board of Health, with two legislators appointed by the Legislative Counsel. MCHAB is staffed by the Title V MCH Program Manager and an Administrative Assistant III. MCHAB advises the DBPH Administrator on objectives related to primary care, infant mortality, preventing fetal alcohol syndrome and substance use by pregnant women, and increasing immunizations. The Advisory Board meets at least quarterly.

Key legislation from the 79th Legislative Session was promoted statewide with Title V MCH-drafted summary sheets and sharing information with MCH partners including:

Assembly Bill (AB) 340: The Director of DHHS appointed a committee to research opportunities to improve access to diapers and diapering supplies for recipients of public assistance and other low-income families. The prior Title V MCH Manager served on the Committee.

Senate Bill (SB) 253: The Nevada Pregnant Workers’ Fairness Act provides protections to female employees and applicants for employment who are affected by a condition of the employee or applicant relating to pregnancy, childbirth, or a related medical condition, and aligns Nevada law with federal requirements.

SB 325, authorized children less than 19 years of age lawfully residing in the U.S to enroll in Nevada Medicaid and Nevada CHIRPA programs. Previously, a five-year waiting period was necessary for lawfully residing qualified non-citizen children; this is no longer the case in Nevada.

MCAH and the Title V MCH Program worked in close partnership with DCFS and SAPTA to support efforts to align and implement federal and state legislative changes to the Infant Plan of Safe Care and are active in Infant Plan of Care efforts as a key stakeholder.

The 80th Legislative Session ended on June 3, 2019, but a key piece of legislation passed was AB 169 which establishes a Maternal Mortality Review Committee and protections for the Committee.  Title V MCH will be sharing information relating to MCH populations from legislation passed in the session with partners statewide, particularly in relation to any changes to the CHIP and Medicaid programs which broaden allowable billing codes or reimbursement and creation of a Diapering Committee and Family Planning account on NBS free changes.