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, 11 rural, and 13 frontier counties. Utah's 2020 average population density is 38.5 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.

 

 

 

On April 26, 2021, The Census Bureau announced the 2020 Census findings (https://www.census.gov/data/tables/time-series/dec/popchange-data-text.html). In their press release, Utah was noted to be the fastest-growing state since the 2010 Census, with an increase of 18.4%. According to the U.S. Census Bureau, Utah’s population increased to 3,271,616.

 

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.

 

Population estimates for 2019 detail Utah’s racial/ethnic populations:

Diversity in Utah Race, Ethnicity, and Sex: https://gardner.utah.edu/wp-content/uploads/DiversityDataBook-May2021.pdf?x71849

 

Utah Population by Age and Sex

Diversity in Utah Race, Ethnicity, and Sex: https://gardner.utah.edu/wp-content/uploads/DiversityDataBook-May2021.pdf?x71849

 

 

The latest information on religious affiliation in Utah comes from a 2014 survey by the Pew Foundation. The Pew Foundation reports that 55% of Utahns are members of the Church of Jesus Christ of Latter Day Saints and Utah is the world headquarters of the church. 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.

 

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 speaks 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 550 in 2018, but increased to 585 in 2019. Of those arrivals in 2019, 51.2% were female. Most refugees in Utah arrive from the Democratic Republic of the Congo, Somalia, Iraq, and Burma.

 

In 2019, life expectancy at birth was 78.5 years for males and 82.0 years for females in Utah. The median age of Utah's population is 31.2 years, versus 38.5 in the U.S., making Utah the youngest state in the nation. The 2015-2019 American Community Survey (ACS) estimates note that 41.1% of Utah’s population is under the age of 25, compared with 32.1% nationwide.

 

Utah’s Births

 

Until 2017, Utah had claimed the highest general fertility rate in the nation. Utah’s 2019 general fertility rate currently ranks 4th highest in the nation, behind Alaska, North Dakota and South Dakota. Utah’s fertility rate was 66.7 live births per 1,000 women in 2019 compared to 58.3 nationally. Utah continues to have the highest birth rate in the U.S. (14.6 Utah vs.11.4 U.S.). Utah’s birth numbers declined for the fifth consecutive year with 46,832 live births to Utah residents in 2019.

 

Maternal Race/Ethnicity	Number of Births	Percent of Births
American Indian/Alaskan Native	390	0.8
Asian	1,083	2.3
Black/African American	732	1.6
Hispanic/Latina	8,061	17.2
Native Hawaiian/Pacific Islander	410	0.9
Two or more races	247	0.5
White, Non-Hispanic	33,640	71.8
Unknown	2,269	4.9

 

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**	Adolescent Births*
American Indian/ Alaskan Native	11.5%	4.6%	28.2%	2.2/1,000	30.0/1,000
Asian	10.3%	9.3%	28.2%	5.4/1,000	4.7/1,000
Black/African American	13.0%	13.1%	30.1%	5.4/1,000	21.4/1,000
Hispanic/Latina	10.4%	8.5%	25.7%	6.0/1,000	28.4/1,000
Native Hawaiian/ Pacific Islander	14.2%	10.0%	31.2%	11.6/1,000	11.2/1,000
Two or more races	13.8%	6.1%	20.6%	***	2.8/1,000
White, Non-Hispanic	9.3%	6.7%	21.8%	4.5/1,000	7.7/1,000
Unknown	10.9%	7.5%	24.3%	20.8/1,000
Statewide	9.7%	7.2%	23.0%	5.3/1,000	12.0/1,000
*2019 Vital Records data, ** 2016-2019 linked birth-death data, ***Data suppressed due to small numbers

 

Utah's Economy

 

The Bureau of Labor Statistics notes that the 2019 unemployment rate in Utah was 2.6 compared to 3.7 for the nation. The 2015-2019 ACS estimates for median household income put Utah's $71,621 above the U.S. at $62,843. However, Utah's households are also large, resulting in a significantly lower per capita income ($31,771 vs. $35,672). There is also large variation in median income when broken out by race and ethnicity:

 

Race/Ethnicity	Median Income (2015-2019 American Community Survey)
American Indian/Alaskan Native	$45,957
Asian	$73,139
Black/African American	$41,752
Hispanic	$53,547
Pacific Islander/Native Hawaiian	$66,391
White Non-Hispanic	$75,227

 

According to the 2015-2019 ACS 5-Year estimates, the percentage of individuals with incomes below the federal poverty level is 9.8% in Utah vs. 13.4% in the U.S. Poverty rates also range widely, depending on the county of residence. Poverty rates in 2019 were lowest in Morgan County (4.0%) and highest in San Juan County (21.9%), with a statewide mean of 8.8%. The 2018-2019 National Survey of Children’s Health finds that 11.1% of families had a household income below 100% FPL, compared to 19.4% nationally.

 

Health Insurance

 

In 2019, data from the Behavioral Risk Factor Surveillance System (BRFSS) estimated that 8.6% of Utahns were uninsured.

 

 

Uninsured rates for Utah children ages 0-18 decreased as well during this time.
 

 

Rates of uninsured vary by race/ethnicity:

 

Race/Ethnicity	No Insurance
American Indian/Alaskan Native	18.5%
Asian	8.1%
Black/African American	32.3%
Hispanic	29.8%
Pacific Islander/Native Hawaiian	17.6%
White Non-Hispanic	9.7%

 

 

Utah BRFSS data from 2019 estimates that 4.8% of children below 18 years were without health insurance. The 2019 National Survey of Children’s Health has higher estimates of no insurance among this group, at 7.8%.

 

Education

 

Based on the 2015-2019 ACS, Utah had a higher percentage of residents with a high school diploma, at 92.3% vs. 88.0% nationally among those aged 25 years and older. Utah’s population age 25 years and older with a Bachelor's degree is higher than the U.S. (22.5% vs 19.8%) and similar to the U.S. for those with graduate degrees (11.5% vs 12.4%). According to the 2020 Kids Count report, Utah has a higher percentage of children ages 3-4 who are not in school compared to the nation (56% vs 52%). Utah is doing better than the national average for the proportion of fourth graders not proficient in reading (60% vs. 66%). The National Education Association reports Utah having the second-lowest per-student expenditure at $7,247, compared to the national average of $12,978.

 

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 40.8% vs. 31.0% nationally.

 

Children and Adolescents

 

National Survey of Children’s Health data from 2019 illustrate many areas where Utah’s children differ from the national average:
 

	Utah %	U.S. %
Race/Ethnicity Hispanic   White Non-Hispanic   Black Non-Hispanic   Asian Non-Hispanic   Other Non-Hispanic	18.0 72.1 0.9* 1.5* 7.4	25.6 50.2 13.3 4.5 6.3
Primary language spoken in home   English   Non-English	94.5 5.5*	86.3 13.7
Highest Education in Household   Less than High School   High School   Some College   College Graduate	4.6* 13.4 20.3 61.7	9.2 18.9 21.8 50.1
Family Structure   Two parent, currently married   Two parent, not currently married   Single parent   Grandparent household   Other family type	79.7 4.8* 12.0 1.4 2.0*	65.0 8.8 20.5 3.8 1.9
Not insured at time of NCHS survey	7.8	6.7
Current insurance not adequate	30.0	27.9
2 or more adverse childhood events	17.6	18.7

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

 

The 2019 Youth Risk Behavior Survey illustrates differences between Utah high school youth and those in the nation: Utah youth were significantly more likely to report that they carried a weapon in the past 30 days (21.5% vs. 13.2%) and were more likely to report having carried a weapon onto school property (6.9% vs. 2.8%). Utah youth were significantly more likely to report having experienced sexual violence (14.3% vs. 10.8%). 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 Schools Workgroup in the Bureau of Health Promotion at UDOH recently published a report detailing the findings from the latest YRBS conducted in 2019 (https://choosehealth.utah.gov/documents/pdfs/yrbs_2019.pdf). This report highlights important data on student health, safety, and lifestyle factors such as physical activity and nutrition, tobacco use, violence and injury prevention, and asthma. Key findings of the report:

• One in three students reported eating breakfast every day (30.9%)
• More than 1 of every 5 students seriously considered attempting suicide (22.3%)
• Nearly 1 in 5 Utah high school students were bullied on school property in the past 12 months (18.4%)
• More than 1 in 10 students reported using tobacco products including e-cigarettes or vape in the past 30 days (11.1% of males; 10.4% of females)
• 8.7% of Utah high school students have a current asthma diagnosis

 

The County Health Ranking and Roadmaps report reveals that the percentage of children who are eligible for free or reduced price lunch varies from 13% in Morgan County (north) to 100% in San Juan County (south).

 

Children with Special Health Care Needs (CSHCN)

 

Data from the 2019 National Survey of Children’s Health (NSCH) found 18.4% of Utah children have one or more functional difficulties and 15.6% of Utah children have special health care needs. Utah’s percentage of children with special health care needs ranks third lowest in the nation.

 

The Utah Registry of Autism and Developmental Disabilities (URADD), identifies Autism Spectrum Disorder using a community medical diagnosis and/or autism special education eligibility to indicate a prevalence estimate of 2% for individuals aged 0 to 16 years old. Of interest is the 4 years old population, prevalence is 1.2% which demonstrates Utah is diagnosing late. This year, the Autism Systems Development Program (ASDP) developed marketing and educational materials to encourage earlier diagnosis and worked with Help Me Grow Utah and early intervention programs to implement the M-CHAT and STAT screeners. The 2018 CDC Autism rates for URADD/UT-ADDM are embargoed until publication.

 

The 2019 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   Other Non-Hispanic	18.0 72.1 0.9* 9.0	25.6 50.2 13.3 10.9
Household Income   0-99% FPL   100-199% FPL   200-399% FPL   400% or greater FPL	6.7* 27.9* 40.4* 25.1	22.7 21.2 26.8 29.3
One or More Current or Lifelong Health Conditions	91.0	91.8
Current insurance not adequate	37.9	34.9
Consistent health insurance coverage in past 12 months	94.6*	93.6
Child has coordinated, ongoing, comprehensive care in a medical home	56.5*	42.4
Problems paying for child’s medical or health care bills in past 12 months	22.2*	18.2
Family member cut back hours, stopped working, or both due to child’s health	15.8*	19.2

*Interpret with caution - estimate may be unreliable due to small sample size
** Sample size too small to include Asian race category

 

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.

 

In Utah, we have 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, F90.9).

 

Percent of children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) in Utah (2020)
Birth Year	Count	Percentage
2012 (8-year-olds)	768 of 50,605	1.5%
2011 (9-year-olds)	1,131 of 51,995	2.2%
2010 (10-year-olds)	1,499 of 52,913	2.8%
2008 (12-year-olds)	771 of 54,086	1.4%
2007 (13-year-olds)	1,086 of 54,402	2%
2006 (14-year-olds)	1,687 of 53,503	3.2%
2005 (15-year-olds)	1,932 of 53,158	3.6%
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 women, 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, as well as producing reports, fact sheets, abstracts, and articles in peer reviewed journals with UDOH 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 full Needs Assessment Report can be found here.

 

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 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 Bureaus collaborate across the UDOH to ensure integrated use of data and population assessment. There is a Department Peer Analyst network that meets monthly for collaboration and learning events.

 

The Utah Department of Health (UDOH) conducts a Utah Healthcare Safety Net bi-annual meeting. The meeting involves more than 50 stakeholders vested in MCH/CSHCN. They provide insight into legislative issues affecting healthcare, community resources, facilitate networking, and collaborate with State advocates and organizations throughout the State.

 

Utah’s Strengths and Challenges

 

Strengths

 

Utah’s Title V programs have many attributes which contribute to enhancing communities' health and wellness statewide. Utah has strong collaboration efforts with stakeholders and values and incorporates the advice of our peers to develop, implement, and evaluate programs for women, children, and families. The State was  prepared when the COVID-19 pandemic hit, as it had already been pilot testing telework and telehealth services. This past year, all employees worked from the home environment and continued working on expanding telehealth capacity to address teleservice needs, protections and requirements for MCH/CSHCN populations. Utah found success by being able to continue our MCH/CSHCN work with stakeholders, the public and populations we serve by being available and present for virtual meetings and service provision. We also made ourselves available on a limited need basis for face-to-face meetings when safety procedure measures were put into effect. Lastly, a huge strength during the pandemic is the resilience of our employees. The MCH/CSHCN Bureau’s leadership focused on personal/family health first which then allowed team members to continue to dedicate, contribute and be innovative with meaningful service provision.

 

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.

 

Face-to-face service provision during the pandemic continues to create challenges due to the variety of safety measures to be considered to reduce transmission of the virus and protect the service providers and population/families we serve. Telehealth technology also poses barriers with lack of technology lines, services and equipment in both rural and frontier areas, although we have made efforts to reduce these barriers during the pandemic. This past year Utah applied for and were granted Telehealth Cares Act funding. We created a lending library for Chrome Books and hot spots in addition to distributing audiology equipment throughout the State at the local health departments to provide virtual audiology services.

 

The pandemic for the CSHCN population has caused significant adaptions in everyday routines due to school closures, online learning, virtual health, lack of therapy and in-home services and financial hardships. Additionally, the pandemic has raised stress and anxiety in both parents and children, tension in relationships, fear of a CSHCN or family member contracting the virus and finding ways to manage caregiving. Finding the “new normal” has been challenging as schools and daycares have closed or have had limited capacity, limits of access to health care delivery and developing new strategies for service and work processes are continuing effort areas for improvement. Creating a “new” normal service delivery system. Allowing the past to be the past and being open and creative in developing new modern strategies for service and work processes.

Major changes and reorganization of the UDOH and DFHP happened in 2020 and have continued into 2021. The DFHP Division moved from the Highland building to the main UDOH Cannon building. The majority of employees transitioned from in person working to virtual service provision as a result of COVID-19 and following the Governor's mission to have 80% of State employees work from home.

The variety of reorganizational changes has increased the turnover of employees and has created challenges with workloads, timeliness of rehiring, orienting and stabilizing new employees. The biggest challenge to our overall system is the leadership and structural changes that occurred throughout the fiscal year. This creates stress, strain and extra work beyond the normal position related duties on employees and the system. In addition, during the 2021 legislative session, it was determined to combine the Utah Department of Health and the Department of Human Services within the state to form a Department of Health and Human Services (DHHS), and reassess programs and their placement. This  may bring challenges which the MCH/CSHCN Title V programs have to navigate.

Many changes also occurred at the Local Health Department (LHD) level during the past year, in part due to COVID-19. Eight of thirteen local health departments had transitions in leadership. Six of the eight who left employment retired, and two changed health departments. Two of the new LHD Health Officers are women. These are significant changes that will impact public health in the state for many years to come.

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, continues to research resources, make community connections, refer and brainstorm ideas for a more comprehensive and accessible service delivery system. During the current pandemic service needs have grown and the CSHCN Bureau and stakeholders continue to discuss strategies to meet the current health needs of this population.

The last challenge we will discuss is with the priority of addressing the COVID-19 pandemic. The UDOH has been the statewide lead on the COVID-19 pandemic and employees across all sections of the department participated in areas of pandemic safety, education, in- person testing, setting up vaccination clinics, research and media information presentations. Our executive leadership have worked tireless hours to address community, legislative, safety needs while acknowledging the efforts of the entire UDOH team. The UDOH Public Information Office was stretched to capacity addressing COVID-19 in the state, and had limited time for other requests.

 

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 race/ethnicity data from common public health data sources and recommending improvements, informing  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.

 

UDOH works with the Office of American Indian/Alaska Natives (AI/AN) Health Affairs. 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. 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. 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.

 

The UDOH provides primary care through the Health Clinic of Utah (HCU), which is located in Salt Lake and plays a key role for the UDOH and Utah’s Safety Net of providers. The medical clinic is staffed with a multidisciplinary team. The clinic provides 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 the clinic in FY2019, 36.7% had Medicaid and 17.3% were uninsured. In addition to regular clinical services, the HCU provides immunizations and health screenings for newly resettled refugees and provides medical screenings for children in protective service care in multiple counties. Over the years, the HCU has reduced services. Since last year, the HCU went from three locations to one.

 

The Indian Health System in Utah consists of one IHS outpatient facility, three 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 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 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, which can be located in a different state.

 

In 2019, staff with the Utah Department of Health Office of Health Disparities (OHD) conducted a qualitative study to evaluate one of its programs and to better understand challenges faced by Utah urban underserved communities in establishing a primary care provider. Thirty-five people from the neighborhood of Glendale (SLC) and the city of South Salt Lake participated in six focus groups. Represented were American-born, first-generation immigrants, refugees, single mothers, single grandparents, married couples, individuals experiencing homelessness, diverse races/ethnicities, etc. In this process, it was learned that access to health care is just one aspect of the multifaceted issue of inequity. These systematic barriers and problems must be addressed in order to improve the health of our communities.

 

Key takeaways from the study are as follows:

1. Cost is the main barrier: Most participants live paycheck to paycheck and do not have access to disposable income. Access to health care is perceived as a commodity not as a priority.

2. Understanding a complicated system: Participants linked the term primary care provider (PCP) with having health insurance. Although participants were fulfilling their primary care needs at free clinics, they did not perceive them to be their PCP.

3. Trust: There was a lack of trust in the health care system in general; many lacked trust in the care they receive at free clinics.

4. Stress: Financial concerns, challenging family situations, and rearing children under stressful circumstances take precedence and do not leave space or time for thinking about health.

 

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. 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.

 

Utah has 13 Critical Access Hospitals throughout the state:

 

 

 

Telehealth Capacity

 

Telehealth capacity is expanding in Utah. The 2020 America’s Health Rankings Report notes that Utah has the highest percentage of households with high-speed internet, with a rate of 92.9%. 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 2019-2020, 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 lack 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. During the pandemic, audiologists worked from their homes to provide the services. 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 accesses 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 five of Utah’s rural LHDs 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.

 

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 via telehealth. Within two weeks of the pandemic shut-down, the transition to telehealth was in place, all 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 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. The Utah Office of Primary Care & Rural Health reports that the number of active physicians per 10,000 civilian population in Utah is lower than in the U.S. (23.1 vs 29.2, 2015 data).

 

 

In 2017, the latest data available, the primary care physician to civilian ratio varied from a low of 1.7 in Tooele County to a high of 13.3 in Grand County. 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.

 

Primary Care: Family Physicians   Primary Care: Obstetrics/Gynecology

 

Primary Care: Pediatricians   Primary Care: Dentists

 

For the past four years, 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 present 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), but for those living in rural/frontier areas of the state, families must drive long distances to access the same services. The pandemic has adapted this service provision in that the ISP has not traveled to provide face-to-face service provision for over the past year, but adapted and utilized telehealth to meet families with their children for assessments, follow up and prescribing when practitioners are not available. The program has found this modality has allowed the ISP providers to be more flexible on appointment times and they have met in the evenings with families after the work day. Additionally, it has cut travel time and costs allowing for more service time.

 

Utah’s Public Behavioral Health System

 

Utah's public behavioral health systems have a similar structure to 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 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 relevant: 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 that 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 fee 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 less benefits. The ACO or UMIC plan must specify services which 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

 

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

On December 23, 2019, the Centers for Medicare and Medicaid Services (CMS) authorized the Utah Department of Health to implement full Medicaid expansion, as authorized under the Affordable Care Act, for the State of Utah. More than 90,000 Utah adults have enrolled under the expansion program as of June 2021. 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.

 

Under a program titled the Utah Premium Partnership, the state requires newly eligible adults to enroll in an employer-sponsored health plan if they have access to one. Under this program, Medicaid will then cover the individual’s monthly premium and other out-of-pocket expenses like copays and deductibles.

 

 

 

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 assessments, capacity surveys and historical experience to make determinations for program capacity, development and funding with the goals to improve access and services throughout Utah.