Overview of the State

Nebraska is a state that covers a large geographic area, but has a smaller population base, much of which is located in the eastern half of the state.  Measuring 387 miles across with a total area of approximately 77,000 square miles, almost 20% larger than all of New England, much of the land is utilized in the state’s large agricultural sector,  45.8% of the state’s population reside in the population centers of Omaha and Lincoln in the east, which represent Metropolitan Statistical Areas (MSA) with populations larger than 50,000.  In contrast, 34 of the 93 counties statewide are considered to be frontier, which is variously defined as an area with low population density (6 or fewer persons per square mile), residing a large distance from a population center or specific service, requiring long travel time to reach a population center or service, having low availability of paved roads, and/or experiencing seasonal changes in access to services.

Nebraska has also been experiencing shifts in the demographic make-up of the state over the 2000 to 2018 time period, according to the U.S. Census, which includes an overall aging of the population as well as an increasing diversity.  Statewide, 15.7% of the population is 65 and over, however in 63 counties that number exceeds 20% and is projected to grow to 56% by 2020.  In terms of increased diversity, NE has seen its minority population grow 91% during the same time period – which represents 21.5% of the total population.  These demographic shifts can have significant implications for healthcare delivery, creating a need to focus on services that are relevant to an older population as well as those that are culturally and linguistically appropriate.

In addition to providing services that are culturally and linguistically appropriate overall, health care providers should be aware of the specific minority populations that exist in their areas to be prepared for their unique needs and to address existing health disparities.  While this is a standard of care that all providers should adhere to, there is an increased stress on providers in the eastern part of the state, where an average population increase of over 26% between 2000 and 2018 has occurred.  Migration of the younger population (18 to 45 years) from western parts of NE has primarily affected the Douglas, Sarpy (Omaha), and Lancaster (Lincoln) counties.  For some minority populations – notably African Americans at 87% – these are the counties where most of the population is located. 

Within its minority populations, Nebraska has seen the largest increase in the Hispanic American population, which has more than doubled from 94,425 in 2000 to 215,872 in 2018 (128.6% increase) according to the U.S. Census estimates. Hispanic Americans now comprise 11.2% of the state's population.  Asian and Pacific Islander populations grew during 2000 to 2018 by 132%; and the African American population has grown by 41%. 

Similarly, the Native American population in NE has increased by 83.3% during the same time period.  Four federally recognized Native American Tribes are headquartered in Nebraska - the Santee Sioux, Omaha, Winnebago, and Ponca. Though many of Nebraska's Native Americans live on reservations, the majority does not. The urban areas of Omaha and Lincoln account for more than 35% of the state's Native American population, although they make up only a small proportion of these counties' total populations. A sizable number of Native Americans also reside in the northwestern part of NE adjoining the Pine Ridge Reservation in South Dakota. Among the state's reservations, the Winnebago and Omaha reservations in Thurston County account for 22% of Nebraska's Native American population.  An additional 3% reside at the Santee Sioux Indian Reservation in Knox County. The Iowa and the Sac and Fox Indian Reservations on the Nebraska-Kansas border account for about 1% of Nebraska's Native American's total population. 

Health disparities exist in Nebraska, and unfortunately are present in many issues relevant to maternal and child health. Though African Americans make up only 5% of the Nebraska population, they have a significantly disproportionate share of health burden and poor outcomes.  According to the DHHS Vital Records, in 2016, the infant mortality rate (expressed as per 1,000 live births) among African Americans was 12.29, compared to that among the White population at 4.37 (approximately 2.4 times higher rate).  Additionally, the preterm birth rate for African Americans was 13.35 compared to a rate of 8.99 for the White population, and they are 1.5 times more likely to be obese and have a 15.5 times higher incidence of sexually transmitted disease as compared to whites.  American Indians in NE have a 3 times higher rate of inadequate prenatal care, are 4 times more likely to have severe anxiety/depression, and have a 4.4 times higher incidence of sexually transmitted disease as compared to whites. 

Nebraskans traditionally look out for one another, and care for their neighbors.  This strength manifests itself during times of challenge as a means to overcome barriers as much as possible.  NDHHS Title V has many strengths to assist its work in facilitating the ongoing, systematic engagement which is needed to address these daunting challenges – a major one being the experienced staff within the program.  This expertise asserts itself as Title V undergoes statewide, systems-level work such as engaging partners, ensuring quality improvement, and/or developing system supports make up the core work of Title V.  The success in these activities represents the leadership that Title V staff have consistently demonstrated for years. 

In addition to its experienced staff, NDHHS Title V has established relationships with key stakeholders to ensure that the public health and direct care infrastructures have CLAS and health equity standards in place to inform how staff interact with clients, and that services are offered in a family-centered, comprehensive way. 

Another strength of Nebraska Title V is in the capacity to offer technical expertise to others.  In the area of data collection and analysis, Nebraska has an experienced MCH Epidemiology team who work with MCH data regularly and maintain a deep understanding of health indicators.  Examples of the collaborative contributions of these staff include: building data linkage between the Medicaid Claims and Vital Statistics data, providing learning opportunities and technical assistance to colleagues, and participating on Division- and Department-wide workgroups on data governance, collection, and release policies and procedures.

The programmatic staff within Title V work to assure a competent workforce in Nebraska by offering professional education activities to health workers statewide.  Nebraska Title V has a significant output of high quality continuing education and professional development activities every year for these professionals, and virtually all are developed with collaborative planning committees.  Examples include the “Recharge for Resilience” conference, led by the N-MIECHV Program; the annual Current Practices of Maternal Behavioral Health Conference, Healthy Youth Nebraska, statewide School Health Conference led by the MCAH program; certified and approved training events for TOP® (Teen Outreach Program) and Healthy Families America providers.  Additional regular speaking engagements by staff from the Immunization, Reproductive Health, and the MCAH programs are also delivered statewide on topics including safe sleep, breastfeeding, adverse childhood experiences, school health screening, diabetes management, and more.  With professional nurses in the Title V program, most to all continuing education events provide the value-add of being peer-reviewed and approved for contact hours for health professionals. 

Nebraska Title V takes advantage of having co-leads who are housed in separate Divisions.  Nebraska Title V is jointly administered by the Title V Director and the Children and Youth with Special Health Care Needs (CYSHCN) Director.  The Unit Administrator for the Lifespan Health Services Unit within the Division of Public Health is designated as the Title V MCH Director.  The CYSHCN Director role lies with the Economic Assistance Policy Administrator II within the Division of Children and Family Services (CFS), Economic Assistance Unit (also within NDHHS).  Having state co-leads in two divisions extends the reach of Title V activities, expands the amount of available state support, and increases the staff expertise available to the program overall.  This framework helps to ensure that Title V priorities are fully aligned with those of the larger state agency and of other statewide efforts. 

The MCH Director oversees multiple programs, many of which align directly with the mission of Title V, including: Newborn Screening, WIC, Immunizations, MIECHV, Reproductive Health, Every Woman Matters, Women’s Health Initiatives, and more.  Likewise, the CYSHCN Director is responsible for numerous program areas, including the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF), Child Care and Development Fund (CCDF), the Medically Handicapped Children’s Program (MHCP), and more.  Additional key staff in both Public Health and CFS assist with implementing the Title V Block Grant.  These are the Maternal Child Adolescent Health (MCAH) team, the MCH Epidemiology team, a Federal Grants administrator, the Disabled Persons Program Administrator, and the MHCP Program Coordinator.

Solidifying this operational approach is an Intra-Agency Protocol between the Divisions of CFS, PH, and Medicaid and Long-Term Care.  While the agreement is statutorily required, it also provides a means to formalize the long-standing relationships between the Divisions by describing shared and individual responsibilities of each Division. The current agreement is due to be updated, pending a new Director for PH.

Another part of the administrative framework for Nebraska Title V work are the statutes pertaining to the broad authority to carry out maternal and child health services in the state, which are found in Chapter 71, sections 2201-2208 which originated in 1935. Additional related authorities include the statute requiring a Birth Defects Registry (found in 71-645 through 71-648), Child Maternal Death Review (found in 71-3404 through 71-3411), the Childhood Vaccine Act (found in 71-526 through 71-530), metabolic screening and associated responsibilities (found in 71-519 through 71-524), newborn hearing screening (found in 71-4734 through 71-4744), WIC (found in 71-2227), and the Women’s Health Initiative program (found in 71-701 through 71-707). The statutes pertaining to the Medically Handicapped Children’s Program are found in Chapter 43, section 522, Chapter 68, section 309, and Chapter 68, section 717 with the associated NDHHS regulations are found in Title 467.

 Nebraska takes a strategic approach to align the priorities of the state agency with those identified by stakeholders as it implements Title V activities.  This alignment ensures that broader influences on Title V activities are in line with the five year Needs Assessment and existing strengths, knowledge, and resources of Title V staff and staff in other program areas. Priorities of the state agency include the NDHHS Business Plan, the NE State Health Improvement Plan (SHIP), and the Division of Public Health Strategic Plan.

NDHHS is finishing up its third annual Business Plan, which identifies 20 priorities that strategically align with the Governor’s priorities, and will ultimately improve services and effectively manage resources.  These priorities are grouped under five categories that span the work of the Department:

• Integrating Services and Partnerships

• Promoting Independence through Community-Based Services

• Focusing on Prevention to Change Lives

• Leveraging Technology to Increase Effectiveness

• Increasing Operating Efficiencies and Improvements

The 2017-2021 SHIP resulted from an initial State Health Assessment followed by a public process to select five priorities, which ultimately reflect similarities between the SHIP and Title V state priorities.  SHIP priorities are:

• Nebraska will have an integrated health system that values public health as an essential partner

• Nebraska will have a coordinated system of care to address depression and suicide

• Nebraskans will have decreased rates of obesity

• Nebraskans will experience improved utilization and access to healthcare services

• Nebraskans will experience health equity and decreased health disparities

While the SHIP is a statewide plan involving all parties involved in or affected by public health, the Strategic Plan is internal and for the Division alone.  The Division of Public Health 2017-2021 Strategic Plan contains priorities around data, culture and communication, planning and performance, equity, policies, and workforce.  These plans, along with the five year Needs Assessment findings, serve as a cornerstone for the development of the Action Plan for the state Title V program – and indeed, a reflection of the above priorities can clearly be seen in the strategies and objectives that govern the past and future work of the Title V Block Grant. 

The systems of care present in NE to meet the needs of underserved and vulnerable populations includes a health care infrastructure that is based upon the low population density in much of the state.  Rural areas have difficulty recruiting and retaining providers and health care professionals, and also in supporting facilities such as hospitals or other comprehensive care centers.  These challenges have resulted in a proliferation of shortage areas throughout the state.  The NDHHS Office of Rural Health tracks the federally-designated Health Professional Shortage Areas (HPSA) as well as state-designated shortage areas by discipline.  As of January 2019, nine full counties were federal HPSA for both the primary care and OB-GYN disciplines.  There are far more counties identified as state-designated shortage areas; in April 2019 64 counties out of 93 had this designation for the Family Practice discipline, and 85 full counties had this designation along with portions of those surrounding Lancaster and Douglas counties for the OB/GYN discipline.  A similar situation exists for the Psychiatry and Mental Health disciplines, with the majority of Nebraska’s 93 counties state-designated shortage areas - only 3 full counties and a portion of those surrounding were not designated as of April 2019.

To address these shortage areas, there are facilities located in federal shortage areas that specifically address providing affordable and accessible primary health care services, such as Medicare-certified Rural Health Clinics (RHC), Community and Migrant Health Centers (CHC), and Indian Health Service funded clinics.  As of February 2018, there were 141 RHC, 7 CHC, and 8 IHS funded clinics, which have a main focus on assisting underserved areas.

The population of children and youth with special health care needs (CYSHCN) in NE is especially vulnerable, as they often face confounding challenges and barriers.  By creating a partnership between the Medically Handicapped Children’s Program and the Munroe-Meyer Institute (MMI) within the University of Nebraska Medical Center (UNMC), NDHHS has created a network of clinics across the state that provide a range of services for individuals with disabilities.  In addition, the partnership has created a system of care for CYSHCN by ensuring that a strong referral network is in place, that services are covered by insurance as much as possible, and by training and supporting parent resource coordinators as family support.  However, it should be noted that not every child with complex medical needs is eligible for services and supports through the Medically Handicapped Children’s Program. 

Another component of Nebraska’s systems of care involves the shift towards patient-centered medical home practice which has been ongoing in Nebraska for a number of years.  A major development in this direction occurred in January 2017 with the creation of Heritage Health, a NDHHS Division of Medicaid & Long-Term Care approach to administering Medicaid benefits which offers enrollees a single plan combining physical health, behavioral health, and pharmacy benefits in an integrated health care program.  In addition to integrating services, Heritage Health managed care plans offer “value-added services” – services that are available to clients but not traditionally covered by Medicaid.  Many of these value-added services benefit the MCH population, such as baby showers and diaper days for expecting moms; breast pumps and other rewards for new moms meeting all well-child and post-partum visits; and supplemental transportation to appointments.  The update to this changing landscape is that Medicaid expansion was approved via a ballot measure in the fall of 2018, with the result that up to 90,000 Nebraskans could potentially be eligible for benefits once the expansion is implemented.

In 2018, NDHHS was awarded funds from HRSA to implement a Pediatric Mental Health Care Access (PMHCA) project.  This project has two main components, a clinical demonstration component and a systems level integration component.  The clinical demonstration component involves a subaward to the UNMC MMI to assist with integrating mental health consultation into primary care clinics in a network of clinics statewide.  The systems component seeks integration of the program goals and objectives with systems of care, providers, stakeholders, and families/consumers concerned with improving mental and behavioral health care access for children, youth, and families.  There is strong alignment of priorities between Title V and the PMHCA project, which ensures synergy as the project is launched.

With issues around health disparities, medical shortage areas, a shifting demographic, and health care access, Nebraska certainly has challenges to improving the health of Nebraska’s maternal and child population.  However, as discussed above, there is a solid framework in place to address these issues.  The blend of experienced staff, technical expertise, long-term relationships with stakeholders, and statute and general fund availability make up an infrastructure that is in place to support Nebraska’s priorities and vulnerable populations.  This existing infrastructure provides fertile ground for Title V funds to enhance efforts and bring additional resources to this important work.  Through a framework of assessment, inclusive planning, and regular evaluation Nebraska Title V seeks to promote systems change that will directly benefit families, and ultimately improve the health of the maternal and child population in Nebraska.