Population Demographics

 

Geographically, Utah is the 13th largest state consisting of primarily rural and frontier land. Utah has 5 urban, 12 rural, and 12 frontier counties (figure 2). In 2020, Utah's average population density was 39.7 persons per square mile, compared to 93.8 persons per square mile nationally. While geographically the state is largely rural and frontier, 89.8% of the population lives in the 5 urban counties that make up the Wasatch Front, with 36% residing in Salt Lake County. Sixty-three percent of Utah’s lands are under federal ownership, with 24% privately owned, 8.5% by the state and 4.5% by tribal governments. According to the U.S. Census Office, Utah’s population increased to 3,271,616 in 2020, an 18.4% increase since 2010, making Utah the fastest-growing state in the nation.

 

Figure 2. Classification of Utah’s counties as urban, rural, and frontier

 

Between 2000 and 2020, natural increase (births minus deaths) accounted for 66% of population growth compared to migration. However, between 2021-2022, this long-term trend reversed with only 39% of growth coming from natural increase and 61% coming from migration.

 

Figure 3. Utah components of population change

 

 

According to the report “Diversity in Utah, Race, Ethnicity and Sex”, Utah ranks as the 34th most racially/ethnically diverse state in the nation with 22.3% of the population being of non-White race or Hispanic ethnicity. Utah’s younger population is more diverse than older age groups (Figure 4).

 

Figure 4. Age groups by race and ethnicity, 2022

 

Utah’s population increased by 18.4% between the 2010 and 2020 Census with growth being concentrated among racial and ethnic minorities. Utah’s Native Hawaiian/Pacific Islander population grew the most between 2010 and 2020 at 50.4%, followed by Asians (45.5%), Black/African Americans (36.8%), Hispanic/Latinos (37.6%), American Indian/Alaska Natives (26.5%), and Whites (8.1%). This trend is expected to continue with racial and ethnic minorities projected to make up 35% of the total population by 2060 (Figure 5).

 

Figure 5. Utah estimated population shares by race and ethnicity, 2060

 

Religious attendance is more common in Utah than any other state in the country with 53% of adults attending worship services at least weekly. Data on religious affiliation in Utah comes from the 2022 Behavioral Risk Factor Surveillance Survey (BRFSS), which reports that 47.7% of Utahns are members of the Church of Jesus Christ of Latter-day Saints (LDS). Utah is home to the world headquarters for the LDS church. Other Christian faiths (Protestant and Catholic) make up 12.1% of Utah’s population. Forty-percent of Utahns identify as some other religion and less than 1% report no religion.

 

There are 8 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. Figure 6 provides a map of Utah Tribal lands.

 

Figure 6. Map of Utah tribal lands

 

 

 

Utah has resettled more than 25,000 refugee cases since 1995 and ranks in the top 25 for refugee arrivals in the U.S. Of arrivals in 2023, 48.5% were female and 42.2% were younger than the age of 18. While refugees in Utah arrive from countries all over the world, in 2023, most have arrived from African countries, followed by South and Central Asian countries, and Latin American countries.

 

In 2022, life expectancy at birth was 77.6 years for males and 81.4 years for females in Utah, compared to 74.8 for U.S. males and 80.2 U.S. females. Utahns under the age of 25 make up 39.6% of Utah’s population, compared to 31% of the U.S. overall. The younger age structure of the Utah population results in the lowest median age in the nation at 31.8 years, compared to 39.0 years for the entire U.S.

 

Utah’s births

 

While Utah’s fertility rate remains high, it has been declining, mirroring national trends. Utah’s 2022 general fertility rate ranked seventh highest in the nation, a drop from the fifth highest in 2021 and the highest in 2014. Utah’s 2022 general fertility rate was 61.3 live births per 1,000 women compared to 59.7 nationally. Utah continued to have the highest birth rate in the U.S. in 2022 (13.5 Utah vs.11.0 U.S.). In 2022, there were 45,774 live births to Utah residents, slightly lower than the average number of births since 2018 (46,452).

 

Figure 7. Utah’s general fertility rate (live births per 1,000 women aged 15-44), 2014-2022

 

Figure 8. Utah births by race/ethnicity, 2022

 

 

Figure 8 illustrates the 2022 Utah births by race and ethnicity. Mothers identifying as Hispanic or as non-Hispanic Native Hawaiian/Pacific Islander delivered a greater proportion of births in 2022 compared to previous years. Hispanic women delivered 19.5% of all births in 2022 – an increase from 17.3% in 2018-2021; and non-Hispanic Native Hawaiian/Pacific Islander women delivered 1.6% of births in 2022 – a nearly 80% increase from 0.9% in 2018-2020. Utah Vital Records also show an increase in the proportion of birthing mothers who identify as multiple races (from 2.4% to 3.0%, 2018-2021 vs. 2022) concurrent with a decrease in those whose race is unknown (from 2.4% to 1.3%, 2018-2021 vs. 2022), indicating a more complete and specific collection of birth data.

 

Table 1. Birth outcomes by race/ethnicity, 2022
 

Maternal race/ethnicity✝	Preterm birth	Fetal mortality rate (per 1,000)#	Cesarean section	Infant mortality rate (per 1,000)§	Adolescent birth rate (per 1,000)^
American Indian / Alaska Native	13.9%	10.0	*28.9%	*7.4	24.2
Asian	10.1%	3.3	27.9%	4.0	7.3
Black/African American	12.2%	15.5	29.4%	7.7	14.2
Hispanic/Latino	10.0%	5.9	26.2%	5.7	35.6
Native Hawaiian/Pacific Islander	12.1%	5.6	26.5%	7.6	5.2
Two or more races	*10.5%	3.6	26.0%	6.6	5.8
White	8.9%	5.4	22.8%	4.6	7.3
Additional races	9.8%	0.0	*24.1%	**	NA
Unknown	9.8%	10.1	25.8%	5.4	NA
State	9.4%	5.6	23.9%	4.9	11.9

✝ All categories are non-Hispanic except Hispanic/Latino.

# Fetal mortality refers to a fetus of 20 weeks gestation or more that is not born alive. Fetal mortality rate is the total fetal deaths per 1,000 live births plus fetal deaths.

§ Infant mortality refers to the death of an infant born alive within the first year of life. Infant mortality rate is the total infant deaths per 1,000 live births.

^ Adolescent birth is the proportion of live births delivered by females younger than age 20.

*Interpret with caution. The estimate has a coefficient of variation > 30% and is therefore deemed unreliable by Utah Department of Health and Human Services standards.

**The estimate has been suppressed because the relative standard error (RSE) is greater than 50% or RSE can't be determined, or the observed number of events is very small and not appropriate for publication.

 

More infants are born preterm to American Indian/Alaska Native (13.9%), Black (12.2%), and Native Hawaiian/Pacific Islander (12.1%) mothers compared to the state overall (9.4%). Black/African American mothers were nearly three times more likely to experience a fetal death than the state average (15.5 vs. 5.6 fetal deaths per 1,000 live births). The fetal mortality rate was also much higher for AI/AN (10.0) compared to the state overall (5.6). Mothers from these racial groups are also more likely to grieve an infant death than other mothers in Utah; with an infant mortality rate of 7.7 per 1,000 Black infants, 7.6 per 1,000 Native Hawaiian/Pacific Islander infants, and 7.4 per 1,000 American Indian/Alaska Native infants; compared to the state rate of 4.9 per 1,000. Females ages 10-19 who identify as Hispanic or non-Hispanic AI/AN are more likely to have an adolescent birth, at a respective rate of 35.6 and 24.2 per 1,000 females, compared to the state rate of 11.9 per 1,000. Finally, Black mothers are more likely to deliver by cesarean (29.4% of deliveries) compared to the state overall (23.9%).

 

The proportion of Utah births that occur in an out-of-hospital setting is increasing (see Figure 9). In 2022, 4.2% of Utah births occurred in an out-of-hospital setting.

 

 

 

Figure 9. Out-of-hospital births in Utah, 2017-2022

Utah's economy

 

The Office of Labor Statistics noted that the 2023 annual average unemployment rate in Utah was 2.6 compared to 3.6 nationally. The 2018-2022 American Community Survey (ACS) estimates for median household income put Utah's $86,833 above the U.S. at $75,141. However, there is a large variation in median household income when broken down by race and ethnicity, as shown in Figure 10.

 

Approximately 3.5% of Utah households are also headed by single women with children younger than 18 years and the median household income for female householders with children younger than 18 is significantly lower than the state average ($42,496). As Utah’s households are large, there is also a significantly lower per capita income in Utah ($38,514) compared to the U.S. ($41,804) in 2022.

 

Figure 10. Median household income by race and ethnicity, ACS, 2018-2022

 

According to the 2018-2022 ACS 5-year estimates, the percentage of individuals with income below the federal poverty level (FPL) is 8.5% in Utah vs. 12.5% in the U.S. poverty rates range widely between counties of residence. In 2021, poverty rates were lowest in Morgan County (4.5%) and highest in San Juan County (26.8%), with a statewide mean of 10.2%. The poverty rate for children younger than 18 is 8.8% for Utah, compared to 16.7% nationally.

 

Health insurance

 

In 2022, BRFSS data estimated that 8.8% of adult Utahns were uninsured, continuing a decreasing trend over the past several years (See Figure 11). However, there is variation in insurance status by race and ethnicity. Figure 12 illustrates Asian adults being the least likely to be uninsured (3.8%) followed by White adults (6.4%). Pacific Islander, Black, American Indian/Alaska Native, and Hispanic adults all have higher uninsured rates compared to the Utah average. Uninsured rates for Utah children ages 0-17 have been gradually increasing since 2016 (see Figure 13) and are slightly higher than the national average.

 

Figure 11. Percentage of adult Utahns without health insurance, BRFSS, 2013-2022

 

Figure 12. Utah uninsured rates for adults by race and ethnicity, BRFSS, 2021-2022

Note: Health insurance is defined as including private coverage, Medicaid, Medicare, and other government programs. Age-adjusted. No comparable U.S. average is provided.
 

*Use caution when interpreting. Estimates have a coefficient of variation greater than 30% and less than or equal to 50% and are therefore deemed unreliable by Utah Department of Health and Human Services standards.
 

Figure 13. Percentage of children (ages 0-17) without health insurance, Utah vs. U.S., NSCH, 2016-2022

 

Education

 

Based on the 2018-2022 ACS, Utah had a higher percentage of residents with a high school diploma (93.2%) compared to what is seen nationally (89.1%) among those aged 25 years and older. A higher percentage of Utahns aged 25 and older obtained a Bachelor's degree or higher (36.1%) compared to the U.S. (34.3%). Although the proportion of Utahns with a graduate degree (12.2%) is somewhat lower compared to the U.S. (13.4%). According to the Kids Count report, Utah has a higher percentage of children ages 3-4 who are not in school compared to the nation (58% vs 54%). While still high, the proportion of fourth graders who are not proficient in reading is lower in Utah (63%) as compared to the national average (68%). The June 2022 National Education Association Report lists Utah as having the second lowest per-student expenditure at $8,968, compared to the national average of $14,360.

 

Household and family

 

Family households make up 80.7% of all households in Utah (compared to 72.8% U.S.). Utah has the largest household size in the country with 3.04 persons per household compared to 2.57 nationally. Utah’s average family size is also larger than the U.S. (3.53 vs 3.18), and the percentage of households with one or more persons younger than 18 is higher in Utah (39.2%) than nationally (30.2%).

 

Children and adolescents

 

Table 2 uses NSCH data from 2021-2022 to illustrate many areas where Utah’s children differ from the national average.

 

Table 2. Demographic characteristics of children ages 0-17, Utah and U.S., NSCH 2021-2022

 

*Interpret with caution - estimate may be unreliable due to small sample size

 

The 2021 Youth Risk Behavior Survey (YRBS) illustrates differences between Utah high school youth and those in the nation. Compared to national estimates, Utah youth were significantly more likely to report texting or emailing while driving (47.0% vs. 36.1%), but less likely to report driving after drinking alcohol (1.0% vs 4.6%). Utah youth were also more likely to report having carried a weapon onto school property (8.0% vs. 3.1%). Utah youth were also significantly more likely to report having experienced sexual violence (14.8% vs. 11.0%). Utah youth were less likely than their U.S. peers to report any form of tobacco (9.5% vs. 18.7%), alcohol use (8.1% vs. 22.7%), or to ever misuse prescription pain medication (8.2% vs. 12.2%).

 

Children with Special Health Care Needs (CSHCN)

 

Data from the 2021-2022 NSCH found that 24.6% of Utah children have one or more functional difficulties and 16.1% of Utah children have special health care needs. Utah’s percentage of children with special health care needs ranks 7th lowest in the nation. The 2021-2022 NSCH data provides important information on Utah’s CSHCN population and their parents in Table 3.

Compared to their non-CSHCN counterparts, CSHCN in Utah were more likely to experience one or more current or lifelong health conditions (CSHCN 90.0% vs. non-CSHCN 36.5%) and to not have received needed health care (CSHCN 11.2% vs. non-CSHCN 2.5%). Their families were also more likely to have problems paying for medical bills and health care in the past 12 months (CSHCN 21.2% vs. non-CSHCN 7.8%). Families of CSHCN were also likely to report cutting back on hours or stopping working due to the child’s health (CSHCN 14.7% vs. non-CSHCN 4.5%), and to report food insecurity (CSHCN 5.8% vs non-CSHCN 2.7%). Utah CSHCN families seem to be doing better compared to U.S. CSHCN when it comes to children receiving coordinated, ongoing, and comprehensive care in a medical home (UT CSHCN 49.4% vs U.S. CSHCN 40.7%). Utah CSHCN adolescents tend to be less likely to receive transition services than their U.S. CSHCN peers (UT CSHCN 16.3% vs U.S. CSHCN 22.1%). These findings reflect broader U.S. conditions for CSHCN and their families.

Table 3. Comparison of Utah and U.S. child demographics and other select characteristics by CSHCN and Non-CSHCN, NSCH, 2021-2022

 

Comparison of Utah and U.S. child demographics by CSHCN and Non-CSHCN
	Utah Non- CSHCN (%)	Utah CSHCN (%)	U.S. Non- CSHCN (%)	U.S. CSHCN (%)
Race/ethnicity
Hispanic	19.5	16.6	27.3	23.4
White Non-Hispanic	71.4	75.7	48.4	51.2
Black Non-Hispanic	0.9**	1.4*	12.2	15.4
Other Non-Hispanic	8.3	6.3	12.1	9.9
Household income
0-99% FPL	9.8	8.8	18.5	19.8
100-199% FPL	20.1	17.4	19.7	21.7
200-399% FPL	39.8	41.1	28.6	28.0
400% or greater FPL	30.3	32.7	33.2	30.4
One or more current or lifelong health indicators	36.5	90.0	38.8	91.6
Current insurance is not adequate	27.9	45.9	24.3	33.5
Did not receive needed health care	2.5	11.2	2.1	8.5
Child has coordinated, ongoing, and comprehensive care in a medical home	54.7	49.4	47.4	40.7
Problems paying for child's medical or health care bills in the past 12 months	7.8	21.2	6.7	14.4
Family members cut back hours, stopped working, or both due to the child's health	4.5	14.7	4.7	18.1
Sometimes or often could not afford to eat	2.7*	5.8*	3.9	7.1
Child receives needed transition to adult health care services, age 12-17 years	11.0	16.3	16.2	22.1
** Indicates the total number of respondents is less than the criteria set by MCHB
* Please interpret with caution Estimate has a 95% confidence interval width exceeding 20 percentage points or 1.2 times the estimate and may not be reliable

 

 

Autism spectrum disorders prevalence estimates statewide

The Utah Registry of Autism and Developmental Disabilities (URADD) uses a passive, population-based system to identify persons with autism spectrum disorder (ASD) based on a community medical diagnosis of ASD and/or an autism special education eligibility. As previously reported, early identification of ASD in Utah continues to be lower than expected.

In Utah, 1 in 40 8-year-olds in Salt Lake, Davis, and Tooele counties were identified with ASD. Only about 1 in 79 4-year-olds in the same counties were identified. For every two children identified with ASD who were age 4, there was one child who was suspected but not confirmed to have ASD. This is lower than national estimates, indicating that fewer Utah children are being diagnosed early.

To further explore these trends, URADD investigated ASD prevalence estimates statewide throughout childhood, ages 4 through 16 (see Figure 14).

Figure 14. Utah Registry of Autism and Developmental Disabilities (URADD) prevalence estimates for urban, rural, and frontier children ages 4-16, 2020

These disparities are likely due to the lack of diagnostic services available for children and youth in rural and frontier communities, and a lack of proper screening protocols for ASD, as recommended by the American Academy of Pediatrics. In 2022, URADD estimates that only 43% of 4-year-old children who were later diagnosed with ASD were screened for ASD using an M-CHAT R/F.

As an essential first step, the Autism Systems Development Program (ASDP) developed marketing and educational materials to encourage earlier diagnosis and worked with Help Me Grow Utah (HMG) and early intervention programs to implement the M-CHAT screener. In 2023, HMG screened 92 children for ASD and referred 232 children to appropriate services. Moving forward, additional steps need to be taken in working with diagnosis partners to help diagnose children at a younger age.

Utah Title V capacity

 

The DHHS and Utah's Title V unified vision is “The Department of Health and Human Services will advocate for, support, and serve all individuals and communities in Utah. We will ensure all Utahns have fair and equitable opportunities to live safe and healthy lives. We will achieve this through effective policy and a seamless system of services and programs.''

With the 2022 merger into the Utah Department of Health and Human Services, the Utah statute was recodified in the 2023 Legislative Session. Statutes supporting Title V efforts are now woven into Section 26B, Health and Human Services Code, Chapters 4 (Health Care - Delivery and Access) and 7 (Public Health and Prevention). Offices within the Division of Family Health (DFH) - Maternal and Child Health (MCH), Children with Special Health Care Needs (CSHCN), and the Office of Early Childhood (OEC) - collaborate to serve mothers, infants, adolescents, children, and children with special health care needs. Other DHHS programs that collaborate and contribute to the Title V work include the Office of Health Promotion and Prevention in the Division of Population Health and the Oral Health Program in the Office of Primary Care and Rural Health.

 

Title V staff work to identify the needs of underserved women, children, and children with special health care needs to prioritize the 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 data and educate the public through marketing and educational sessions, as well as producing reports, fact sheets, abstracts, and articles in peer-reviewed journals with DHHS staff as authors.

 

In 2019-2020, MCH/CSHCN staff, in partnership with the University of Utah Division of Public Health, conducted a comprehensive statewide needs assessment to determine the priority focus for the upcoming five years. A copy of the entire needs assessment report can be provided upon request. Work is currently underway to prepare an updated needs assessment report for 2025.

 

Using results from a detailed review of Utah data and the statewide needs assessment, domain leaders met and identified priority areas, associated NPM/SPMs, and ESMs. For this annual report, state priorities have not changed based on community needs, but one SPM was discontinued. 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 needs arise. Regular meetings are held to evaluate, reassess, and change strategies and/or amend program plans as needed. The Block Grant annual report and application process provides an opportunity for each program to review its accomplishments and to amend plans as needed based on its achievement of the assigned measures. For a more comprehensive description of Title V programs, please see Appendix A.

 

Data capacity is strong and focused around the Division of Data, Systems and Evaluation (DDSE), which serves as the central point for state health data. DDSE includes 4 offices: Vital Records and Statistics, Informatics and Data Systems, Information Privacy and Security, and Research and Evaluation. DDSE oversees the Internet-based query system for health data (http://ibis.health.utah.gov/), providing access to more than 100 different indicators, as well as to data sets such as birth and death files, Behavioral Risk Factor Surveillance System (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. DDSE also conducts the BRFSS. DDSE is responsible for health plan surveys and reporting plan performance annually, as well as inpatient, ambulatory, and emergency room data. DFH has strong working relationships with DDSE. The MCH/CSHCN Offices collaborate across the department to ensure integrated use of data and population assessment.

 

Utah’s Strengths and Challenges

 

Strengths

 

Utah’s Title V programs have many attributes that contribute to enhancing communities' health and wellness statewide. Utah has strong collaboration efforts with stakeholders and values and incorporates the advice of our partners to develop, implement, and evaluate programs for women, children, and families. Utah continues to find success by conducting our MCH/CSHCN work with stakeholders, the public, and the populations we serve through both in-person and virtual meetings and service provision.

Challenges

The geographic distribution of the state's population continues to present significant challenges for those delivering and accessing health care services, particularly in rural and frontier areas. Long travel distances and a shortage of nearby hospital facilities and providers, particularly specialists, means 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 holding cultural beliefs that impact seeking these services.

Addressing the needs of a diverse population

 

The department has endeavored to include data on subpopulations in an attempt to better quantify the issues faced by various groups. The Office of Health Equity (OHE) produced the Health Equity Pathways Framework that outlines how structural and social determinants of health impact health equity and quality of life in Utah. It guides the vision that Utah’s public health, health care, and social systems should be adequate and accessible for all Utahns. OHE assists the department in identifying priorities and needs of populations experiencing health disparities in the state through quantitative and qualitative data reporting, assessing the adequacy of race/ethnicity data from common public health data sources and recommending improvements and guidelines, informing communities about efforts and activities, and developing tools and guidance to promote cultural and linguistic appropriateness for programs.

OHE works to build Utah’s public health infrastructure to advance health equity at the state and local level. OHE also works closely with community health workers (CHWs) to create programs and systems, like the COVID Community Partnership (CCP) project, to integrate CHWs into department efforts. Efforts also include building internal and external infrastructures to support and expand the capacities of the CHW workforce. OHE developed the It Takes a Village: Giving our babies the best chance (ITAV) project. ITAV is a community education and engagement series to raise awareness about maternal and infant health. It uses a thoroughly anthropological approach with a cultural framework, which mirrors the Pacific way of life and borrows from traditional Pacific systems for resolving community problems. Additionally, the Embrace Project Study (Embrace) is a community-based participatory research study extending ITAV practices and principles to improve maternal mortality and morbidity and diabetes and gestational diabetes health disparities among Native Hawaiian/Pacific Islander women. Title V programs and OHE work together to identify opportunities to collaborate to address MCH needs among diverse populations.

The department works with the Office of American Indian/Alaska Native Health and Family Services. The mission of this office is to raise the health status of Utah's American Indian/Alaska Native (AI/AN) population to that of Utah's general population. This office facilitates meetings with the Utah Indian Health Advisory Board (UIHAB). The purpose of this board is to reaffirm the unique legal status of Tribal governments through the formal 'government to government' relationship and Tribal Consultation. UIHAB provides leadership to develop collaborative efforts between and among Tribes, the Indian Health System which includes the Indian Health Service (IHS), tribally owned and operated organizations, and the Urban Indian Center (referred to collectively as the I/T/U), the Department of Health and Human Services, 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 to promote strategies to improve health outcomes.

 

The I/T/U in Utah consists of two Indian Health Service (IHS) service units, five tribally owned and operated facilities, and one Urban Indian organization located in Salt Lake City. Not all reservation communities have a health care facility nearby. While some Tribal programs operate health care facilities, travel time for services can be 3-4 hours each way. When accessing this system, appointments are not always the norm; it is first come first serve. This can be problematic if an individual lives a significant distance or arrives later in the day, running the risk of not being seen and potentially asked to return the next day. The IHS is primarily dependent on federal funding. Each year, Congress appropriates funding for the IHS. This system is chronically underfunded, operating below the level of need. Most of the IHS facilities do not provide specialty care or dialysis and will refer patients to specialists outside of the system or to the closest IHS area office or IHS hospital, which can be located in a different state.

 

Figure 15. Diagram of the components of the Indian Health System

 

Public health system

 

MCH/CSHCN services are provided in various settings, including medical homes/private providers, LHDs, community health centers, and a number of free clinics. There remains a great need for CSHCN services around the state. The CSHCN office, in collaboration with its stakeholders, continues to research resources, establish community connections, refer to services, and brainstorm ideas for a more comprehensive and accessible service delivery system. During the past year, service needs have grown and the CSHCN office and stakeholders continue to discuss strategies to meet the current health needs of this population.

 

Utah's public health system comprises the Department and 13 LHDs (see Figure 16). DHHS and 4 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.

 

Figure 16. Utah’s local health departments

 

Contracts with LHDs include developing SMART objectives for Title V measures. The specific objectives vary by district and include postpartum depression education/screening, breastfeeding, family planning, home visiting, oral health/sealants, and vision/hearing screening for children. All 13 LHDs have the same developmental screening objective. Four rural LHDs are receiving funding for a CSHCN care coordinator and coordinate with the Integrated Services Program. Additionally, 7 LHDs are participating in the Preschool Development Grant to provide care coordination to those aged 0-8 years within their population.

 

Systems of care

 

To meet the needs of underserved populations, there are many systems that collaborate to increase seamless services for Utah’s population. One such system is the community health centers (CHCs) throughout the state and the Wasatch Homeless Clinic in Salt Lake City that provides primary care to underinsured and uninsured MCH populations. Utah has 14 CHCs that operate 69 clinics throughout the state. In 2022, these health centers served 134,762 adults and 46,466 children. Of the 4,260 prenatal patients, 74% had their first prenatal care visit within their first trimester, as reported in the Association for Utah Community Health (AUCH) report 2022/23 Utah Health Center Overview. The AUCH, the state's primary care association, works to promote the development of new or expansion of existing community health centers in Utah. Figure 17 provides a map of CHCs and clinics across the state.

 

Figure 17. Map of Utah community health centers and clinics

 

 

The department provided primary care through the Health Clinic of Utah (HCU), which was located in Salt Lake City. This clinic closed in May 2023. The clinic location now houses the University of Utah Population Health Center. This new clinic provides primary care services through a student-run primary care clinic, offering physicals, immunizations, diabetes care, cancer screenings, etc. New American Services for refugees provides health screenings and medical care for newly arrived refugees, and an intensive outpatient clinic provides long-term medical and mental health care tailored to the individual needs of patients. The Integrated Services Program recently established a care coordination program for Afghan refugees for families who have children 0-8 years old. The care coordination is being provided through funding from the Utah Division of Workforce Services.

 

Hospital systems in Utah

 

The hospital system for MCH/CSHCN populations is well developed in Utah, with several large maternal-fetal medicine centers, 10 self-designated Level III NICUs, and three tertiary children's hospitals. Utah currently has 46 delivering hospitals across the state, four hospital systems, one University medical school/facility, and one college of osteopathic medicine. All but 12 hospitals are part of the four hospital systems, which provides Utah with a unique opportunity to build strong collaborations. Of Utah's hospital systems, the largest is Intermountain Health. 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 hospital systems such as MountainStar, Centura (CommonSpirit) Health, and LifePoint, or are independently owned. As shown in Figure 18, Utah has 13 critical access hospitals throughout the state.

 

Figure 18. Map of Utah’s critical access hospitals

 

 

 

 

Telehealth Capacity

 

Telehealth capacity is expanding in Utah. The 2023 America’s Health Rankings Report notes that 95.3% of Utah households have high-speed internet, the 2nd highest in the nation. Utah has a small number of infant-pediatric audiologists, all of whom reside on the Wasatch Front or in the St. George area. Oftentimes, these babies become lost-to-follow-up due to lack of access to specialists, travel costs, inability to take time off from work, costs of testing, etc. To reduce barriers to early diagnosis after failing newborn hearing screening, the Utah Early Hearing Detection and Intervention (EHDI) program purchased auditory brainstem response equipment to provide infant diagnostic tele-audiology services for rural/frontier communities. There are now seven tele-audiology sites across Utah.

 

Tele-audiology services are hosted at the CSHCN office with three pediatric audiologists on staff and a nurse or trained facilitator at the remote sites. The facilitator provides direct face-to-face contact with the family and infant. The nurse connects the electrodes to the infant and stays with the family throughout the evaluation, while the audiologist remotely accesses the computer to conduct the testing. If the testing reveals that the infant is deaf or hard of hearing, the CSHCN staff helps the family with the next steps in the EHDI process, including referrals to early intervention, parent-to-parent support, and to medical providers.

 

The department allocates funds to the University of Utah for perinatal mental health screening and counseling via telehealth. The project is now working with five of Utah’s rural LHDs to screen women for postpartum depression symptoms using the Edinburgh Postnatal Depression Scale tool, refer women who request support, and provide online support groups and counseling using telehealth.

 

Clinical workforce availability

 

The ratio of physicians to persons in a population is an indication of the adequacy of the health system and the access to care for persons in that population. According to the United Health Foundation’s 2023 Annual Report on America’s Health Rankings, Utah ranks 47th in the number of primary care providers, with 184.3 providers per 100,000 population (compared to 232.0 nationally). The ratio of dental care (60.8 per 100,000) and mental health care (402.1 per 100,000) providers for Utah ranks 26th and 14th, respectively. The Utah Office of Primary Care and Rural Health 2021 Health Needs Assessment report (latest available) found that the distribution of providers who practice in rural communities is disproportionate to where the population resides.

 

Table 4. Population and provider distribution between urban and rural areas

 

	Urban	Rural
Population distribution	78.5%	21.5%
Primary care provider distribution	89.0%	11.0%
Dental provider distribution	84.0%	16.0%
Mental health provider distribution	91.0%	9.0%

 

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 along the Wasatch Front, although long wait lists exist to see practitioners; but for those living in rural/frontier areas of the state, families must drive long distances to access the same services. In 2023, ISP provided services through a hybrid model that includes both virtual and in-person services. ISP has found this modality allows ISP providers to be more flexible on appointment times, with the ability to meet with families in the evening after the workday, or occasionally, even on Saturdays. Additionally, it has cut travel time and costs, subsequently allowing for more service time.

 

The Integrated Services Program (ISP) contracts with four rural LHDs to provide care coordination and clinical coordination for direct care services to the CSHCN population residing within their service delivery areas. This model creates a regional “hub” or main point of contact for local families of CSHCN through which they may be referred for support, specialists, and services that may benefit their child, which frequently are not readily available in their local communities, as the CSHCN specialty and subspecialty pediatric providers, including the state's tertiary pediatric care centers, are mostly located along the Wasatch Front. There is one comprehensive women and children’s health center located in the southern part of the state, serving a five-county rural area. Many rural counties have no pediatricians or sub-specialists, meaning families must drive long distances to access care for their children. In most cases, there is limited additional itinerant coverage from the private sector for these large geographic areas. In rural counties, health care is often provided to children through family practice physicians, LHDs, or community health centers.

 

Since 2018, the number of autism spectrum disorder (ASD) evaluation providers and Applied Behavior Analysis (ABA) providers has slowly increased (see Figure 19). Although the number of ASD providers has increased, the discrepancy between services in urban, rural, and frontier counties remains substantial. While 91% of ABA providers serve urban counties, 27% serve rural counties and only 16% serve frontier counties, with many rural and frontier communities don’t have access to an ASD assessment or ABA.

 

Figure 19. Utah autism spectrum disorder provider Counts, 2018 - 2024

The ISP has built a professional relationship with an ASD service agency out of Vernal (Uintah County, northeastern Utah) who has agreed to travel to Price (Carbon County, central eastern Utah) quarterly to perform autism diagnostic evaluations. The CSHCN care coordinator at the LHD in Price arranges the schedule, reaches out to the care coordinators in the LHDs in San Juan County and Central Utah, and then the three coordinate to schedule children in need of ASD evaluations who reside in their areas. The ISP nurse practitioner travels to Price to provide support and follow-up for the diagnostic team, the care coordinators, and the families. On a recent two-day clinic, 14 children were evaluated and, within a month, received a diagnostic report. Post diagnosis, the care coordinators work with the nurse practitioner and the families to ensure families are connected to supports and services recommended in the diagnostic report that may include ABA therapy (where available) and educational interventions. This is one small way CSHCN is working to help alleviate the long wait times for diagnosis.

 

Utah’s public behavioral health system

 

Utah's public behavioral health systems have a similar structure to public health agencies. Contracts are created with local county governments who are designated as local mental health and substance abuse authorities to provide prevention, treatment, and recovery services. There are 13 local authorities that deliver services throughout the state, and several are co-located with the LHD.

 

Utah Medicaid

 

Utah’s Medicaid program is administered through the department. The Medicaid program provides vital support to MCH/CSHCN populations throughout the state. Utah Medicaid contracts with managed care entities to provide medical services to Medicaid members. Utah Medicaid has two types of managed care entities that are accountable for providing physical health benefits: accountable care organizations (ACO) and Utah Medicaid Integrated Care (UMIC). Members enrolled through adult expansion living in Davis, Salt Lake, Utah, Washington, or Weber counties must choose a UMIC plan. Non-expansion members living in Box Elder, Cache, Davis, Iron, Morgan, Rich, Salt Lake, Summit, Tooele, Utah, Wasatch, Washington, or Weber counties must choose an ACO. Members who live in other counties have the option to choose an ACO or the fee-for-service network.

Each ACO or UMIC plan is responsible for covering all medically necessary services for their enrolled Medicaid members. Medicaid pays a monthly capitated rate for each Medicaid member enrolled in an ACO or UMIC plan. Each ACO or UMIC plan is allowed to offer more benefits and potentially fewer restrictions than Utah’s State Plan benefits, however, they are not allowed to provide fewer benefits. The ACO or UMIC plan must specify services that require prior authorization and the conditions for authorization.

Members enrolled in an ACO or UMIC plan must receive all services through a provider in that plan’s network. The provider is paid by the managed care entity. Members enrolled in the fee-for-service network may use any willing Utah Medicaid provider; fee-for-service providers are paid directly by the state.
 

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. The Title V/MCH and CSHCN directors and staff use data, needs assessments, capacity surveys, and historical experience to make determinations for program capacity, development, and funding to improve access and services throughout Utah.