Population Demographics

Utah is geographically the thirteenth largest state and is a largely rural and frontier state. Thirty-seven percent of the State’s population resides in a single county, Salt Lake County, which comprises one percent of the State’s land mass. Utah has 5 urban, 12 rural, and 12 frontier counties. Utah's average population density is 35.9 persons per square mile, compared to 91.0 persons per square mile nationally. Sixty-seven percent of Utah’s lands are under federal ownership, with 22% privately owned, 7% by the State and 4% by Utah’s tribes.

 

 

Utah’s 2018 population was estimated at 3,161,105. From 7/1/17 to 6/30/18, Utah’s population grew by 1.9 percent, an increase of 59,292 people. Most growth comes from migration to the State.

 

Historically, Utah has claimed the highest general fertility rate in the nation, however in 2017, Utah’s fertility rate fell below that of both North and South Dakota. Utah’s fertility rate was 72.0 live births per 1,000 women in 2017 compared to 60.3 nationally. Utah continued to have the highest birth rate in the U.S. (15.8 Utah vs.11.8 U.S.). Utah’s birth numbers declined for the third consecutive year with 48,578 live births to Utah residents in 2017.

 

Population estimates for 2017 detail Utah’s racial/ethnic populations:


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

 

There are eight sovereign tribal governments within Utah: Confederated Tribes of the Goshute Reservation, Navajo Nation, Northwestern Band of Shoshone Nation, Paiute Indian Tribe of Utah, San Juan Southern Paiute, Skull Valley Band of Goshute, Ute Mountain Ute Tribe, and Ute Indian Tribe. Census data shows the largest tribal communities indigenous to Utah are the Navajo Nation, Ute Indian Tribe, and Paiute Indian Tribe of Utah. Close to one-third of Utah’s American Indian population speak a language other than English at home. After English, Navajo is the fourth-most spoken language in Utah.

 

In Utah, life expectancy at birth was 78.0 years for males and 81.8 years for females in 2017. The median age of Utah's population is 30.5 years, versus 37.8 in the U.S., ranking the state youngest in the nation. The 2013-2017 American Community Survey (ACS) estimates note that 41.8% of Utah’s population is under the age of 24, compared with 32.7% nationwide.

 

Utah's Economy

The Bureau of Labor Statistics notes that the 2017 unemployment rate in Utah was 3.3 compared to 4.4 for the nation. Utah's median household income, $65,325, was higher compared to the U.S. at $57,652. However, Utah's households are also large, resulting in a significantly lower per capita income ($26,907 vs. $31,177). There is also variation by race with the median income ranging from $67,070 for white Utahns to $40,536 for Black Utahns. According to the 2013-2017 ACS 5-Year estimates, the percentage of individuals with incomes below the federal poverty level is 11.0% in Utah vs. 14.6% in the U.S. For children living in poverty, Utah’s 12.5% is below the national average of 20.3%. Poverty rates also range widely, depending on county of residence. 2017 poverty rates are lowest in Morgan County (4.1%) and highest in San Juan County (25.9%), with a statewide mean of 9.7%.

 

Health Insurance

The rates of no health insurance coverage declined from 2013-2016, regardless of data source. However, rates of no insurance increased in 2017. Estimates of no health insurance coverage among adults in 2017 were slightly higher in the BRFSS (9.8%) than the ACS (9.2%), but both rates are now higher than the U.S. rate of 8.6% (ACS).

Education

Based on the 2013-2017 ACS, Utah had a higher percentage of residents with a high school diploma, at 91.8% vs. 87.3% nationally among those aged 25 years and older. Utah’s population 25 years and older with a Bachelor's degree is higher than the U.S. (21.5% vs 19.1%) and similar to the U.S. for those with graduate degrees (11.0% vs 11.8%). According to the 2018 Kids Count report, Utah has a higher percentage of children ages 3-4 who are not in school compared to the nation (58% vs 52%). Utah is doing better than the national average for the proportion of fourth graders not proficient in reading (59% vs. 65%). The National Education Association reports Utah having the second-lowest per-student expenditure at $7,187, compared to the national average of $12,602.

 

Household and Family

Utah has the largest household size in the country at 3.1 persons per household compared to 2.6 nationally. The percent of Utah family households with children is also higher at 39.5% vs. 28.8% nationally.
 

2016 National Survey of Children’s Health data illustrate many areas where Utah’s children differ:
 

Children with Special Health Care Needs (CSHCN)

Data from the 2017 National Survey of Children’s Health (NSCH) found 19.4% of Utah children have one or more functional difficulties, an increase from 15.5% in 2016. The NSCH data also found that 15.6% of Utah children have a special health care needs, ranking Utah as the sixth lowest in the nation.

 

2016-2017 NSCH data shows that Utah’s rate of children ages 3-17 diagnosed with autism is 2.5% and is very similar to the U.S. rate of 2.8%. Utah’s percentage of children diagnosed with autism at 5 years or older is higher than the U.S. (35.9% vs 31.5%). NSCH data also finds that children in Utah with autism are more often diagnosed by a psychologist or psychiatrist (55.5%) than the U.S. (39.1%).

 

 

 

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 also collaborates and contributes to the Title V work.

 

Title V staff work to identify the needs of underserved mothers, children, and children with special health care needs to prioritize allocation of resources. Staff weigh factors that limit access to, or availability of, services across the state in partnership with community organizations and other interested parties. Staff develop plans and interventions to support health needs. Division staff review and analyze MCH/CSHCN data and educate the public through marketing and educational sessions, produce reports, fact sheets, abstracts, and articles in peer reviewed journals with UDOH staff as authors.

 

Each program which addresses the health of mothers and children has a specific plan identifying goals, objectives and activities. The FHP Division has been in the process of reviewing, updating and improving all Bureau and Programs missions and strategic plans to ensure they are meaningful and useful to the individuals we serve. Program staff within DFHP are assigned responsibility for one or more National/State Performance measures. For programs outside of the Division, each is assigned responsibility for the related measures in their program plans. Additional goals and objectives are developed by each program as issues arise. Annually, each program reviews the previous year's accomplishments, as well as strategies and needs for the future. Based on these discussions, program managers 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.

 

The Bureau of Maternal and Child Health oversees eight programs that focus on improving the health of MCH populations; Maternal and Infant Health; Integrated Services (care coordination, transition, medical home, and direct evaluative and diagnostic clinical services); Family and Youth Outreach (Adolescent/Child, Oral Health, Mother to Baby Utah); Office of Home Visiting (MIECHV); Early Childhood Utah (ECU) which includes the Early Childhood Integrated Data System (ECIDS); Women Infants and Children (WIC) Program; and the Data Resources Program. The MCH Bureau also oversees 13 local health department contracts for services to mothers, children and adolescents.

 

The CSHCN Bureau oversees fourteen programs that focus on improving the statewide system of care for CSHCN and their families: Autism Systems Development Program; Baby Watch Early Intervention Program; Child Health Advanced Records Management (CHARM); Critical Congenital Heart Defect Screening; Children’s Hearing Aid Program (CHAP); Cytomegalovirus Public Education and Testing (CMV); Early Hearing Detection and Intervention (EHDI); Fostering Healthy Children Program; Kurt Oscarson Children’s Organ Transplant Fund; Organ Donations; Technology Dependent Waiver Program (contract from Medicaid to administer program ended 2/1/19, program combined with other waiver programs within Medicaid); Utah Birth Defects Network (including Zika Surveillance Intervention and Referral Program); and Utah Family Voices.The CSHCN Bureau improves the quality of life for families and children with special health care needs by monitoring occurrence, early screening, education, care coordination, transition and intervention to reach optimal health. For a more comprehensive description of Title V programs, please see Appendix A.

 

The CSHCN Bureau programs strive to coordinate care for the children and families served throughout the State. The Bureau has internal communication methods to encourage care coordination and transition for the populations served, monthly meetings, data sharing agreements, CHARM and shared resources to create a system which flows smoothly for Bureau employees. The Bureau also has external partnerships with other State agencies which are working toward reducing redundancies, creating data sharing agreements, utilizing CHARM, quarterly meetings and working towards utilizing the cHIE electronic record in sharing records in a one stop shared resource. Internally within the DFHP, the Integrated Services Program (ISP) collaborates with the CSHCN Bureau and shares an electronic record called CaduRx which allows sharing of patient records in one system to ensure clear communication and follow through methods to reduce loss to follow up.             

 

The DFHP collaborates across the UDOH to ensure integrated use of data and population assessment. UDOH data capacity is very strong and focused around the Center for Health Data (CHD), which serves as the central point for state health data. CHD includes the Office of Vital Records and Statistics, the Office of Public Health Assessment (OPHA), the Office of Health Care Statistics (OHCS), and the Office of Public Health Informatics (OPHI). The CHD oversees data collection via the Behavioral Risk Factor Surveillance System (BRFSS) and the development of an 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 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 Utah Department of Health (UDOH) conducts a Utah Healthcare Safety Net bi-annual meeting. The meeting involves 50+ stakeholders vested in MCH and CSHCN and provides insight into legislative issues affecting healthcare and community resources and facilitates networking and collaborations with State advocates and organizations throughout the State.

 

Utah’s Strengths and Challenges

 

Strengths

Utah’s strengths include being one of the healthiest states in the Nation. The 2018 America’s Health Rankings rank Utah as the fifth healthiest U.S. state. Utah’s low rates of smoking, alcohol consumption, and obesity contribute to a healthier population. Utah’s data capacity and utilization is high, which allows us to act quickly on emerging issues and make data driven decisions. Utah’s Title V programs use social media for health education and are using technology to engage families and partners. Utah has strong collaboration efforts with stakeholders and utilizes the advice of our peers to develop, implement, and evaluate programs for women, children, and families.

 

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 or mental health, because of concern for confidentiality and anonymity, as well as cultural beliefs in seeking these services in a very small town.

 

Health challenges among Utah’s population include high rates of drug related deaths, primary care provider shortages, and low rates of childhood immunizations and lower than average public health spending.

 

Reorganization of the DFHP continued this year. A second major transition occurred in this grant period was the DFHP moving from six Bureaus to four. The Bureau of Child Development was dissolved and its three programs were split between MCH, CSHCN, and Health Facilities Licensing. Also, the DFHP moved the Health Clinics of Utah under executive leadership and the Patient Safety Director/IRB Chair was relocated to the Center for Health Data. The variety of reorganizational changes has increased the turn-over of employees which has created challenges with workloads, timeliness of rehiring, orienting and stabilizing new employees.

 

There remains a great need for services for children with special health care needs around the state. The CSHCN Bureau and ISP continue to research resources, make community connections, refer and brainstorm ideas for a more comprehensive and accessible service delivery system.

 

A challenge and opportunity arose in the month of May in which one of the largest counties, Weber, had its early intervention school district discontinue its contract June 30, 2019. The program is being transitioned in house and will be developed and managed within the CSHCN Bureau, Baby Watch Early Intervention Program. The opportunity provides for identifying inefficiencies in the early intervention system and ensuring top quality and compliance with regulations. We were able to hire almost all of the employees from the school district who provided the early intervention services which created minimal inconsistencies in service provision. Additionally, the location of the center is co-located in the same building in Ogden as the Clinics of Utah which will allow for referrals and collaboration, including coordination with ISP 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 Disparities (OHD) addresses disparities that may occur among populations whether they be defined by race, ethnicity, etc. The OHD assists the UDOH in identifying priorities and needs of specific key populations in the state, assessing the adequacy of ethnic data from common public health data sources and recommending improvements, informing ethnic communities about efforts and activities, and developing guidelines for cultural effectiveness for UDOH programs. In 2018, the OHD published “The Utah Health Improvement Index”. This report measures social determinants of health and inequities and creates an index for each of Utah’s 99 small geographic areas. The report presents index groupings from low to very high. The OHD works closely with Title V programs to identify opportunities to work together to address MCH needs.

 

The​ UDOH works closely with the Office of American Indian/Alaska Natives (AI/AN) Health Affairs. This office facilitates meeting with the Utah Indian Health Advisory Board​ (UIHAB). The purpose of this Board is to reaffirm the unique legal status of Tribal governments through the formal 'government to government' relationship and Tribal Consultation. The board​ provides leadership to develop collaborative efforts between and among Tribes, Tribal organizations, the Urban Indian Organization, the Indian Health Services (IHS), the UDOH and other public and private agencies addressing the health and public health of AI/AN living on and off the reservation. In addition to these roles, the Board works with Utah's Executive and Legislative leadership promoting strategies to improve health outcomes.​ The mission of this Office is to raise the health status of Utah's AI/AN population to that of Utah's general population. ​

 

Public Health System

MCH 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 is comprised of the UDOH and 13 Local Health Departments (LHD), 3 of which are PHAB accredited. Approximately half of the LHDs are multi-county districts covering large geographic areas. Many include both rural and frontier areas within their service region.

 

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

 

Systems of Care

The UDOH has created a safety net group of community providers who meet regularly to share their resources, coordinate services, and identify ongoing community needs. Community Health Centers (CHCs) throughout the state and the Wasatch Homeless Clinic in Salt Lake City provide primary care to underinsured and uninsured MCH populations. Utah has thirteen CHCs, with many having multiple clinic sites. 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 Clinics of Utah (HCU), which has locations in Salt Lake, Ogden, and Provo and plays a key role for the UDOH and Utah’s Safety Net of providers. Medical clinics are staffed with a multidisciplinary team. The clinics provide high quality medical care at the lowest cost to clients. HCU accepts most forms of insurance including; Medicaid, the Children’s Health Insurance Program (CHIP), Primary Care Network (PCN), and Medicare. Among the patients seen in these clinics in FY2017, 62% had Medicaid/Medicare, and 13% were uninsured. In addition to regular clinical services, the HCU provide immunization and health screenings for newly resettled refugees in Salt Lake and Weber counties and provide medical screenings for children in protective service care in multiple counties.

 

The Indian Health System in Utah consists of one IHS outpatient facility, 3 Tribal and Tribal Organization operated facilities, and one Urban Indian Organization located in Salt Lake City. Not all reservation communities have a health care facility in that community. While some Tribal programs operate health care facilities, travel time for services can be 3-4 hours each way. When accessing this system, appointments are not always the norm; it is first come first serve. This can be problematic if you live a significant distance and arrive later in the day, running the risk of not being seen and may be asked to return the next day. The Indian Health System is primarily dependent on federal funding. Each year, Congress appropriates funding for the IHS. This system is chronically underfunded, operating at approximately 54% of the level of need. Most of the Indian Health System facilities do not provide specialty care or dialysis and will refer patients to specialists outside of the system or refer them to the closest IHS Area Office or IHS hospital. Sometimes this can be in a different state.

 

Hospital Systems in Utah

The hospital healthcare system for MCH 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. Utah's hospital system is comprised largely of the Intermountain Healthcare hospitals. Intermountain has a national reputation for excellent quality improvement efforts and is a valuable resource for the state. The University of Utah Hospital is a teaching medical school providing tertiary care and services. Other hospitals are owned by several different hospital systems such as MountainStar, Steward and LifePoint or are independently owned.

 

Telehealth Capacity

Telehealth capacity is expanding in Utah. To reduce barriers to early diagnosis, Utah Early Hearing Detection Intervention (EHDI) purchased auditory brainstem response equipment to provide tele-audiology services for rural communities. This equipment was placed in Blanding and Richfield, Utah. In 2018-2019, EHDI has been expanding the rural tele-audiology service. Utah has a small number of infant-pediatric audiologists, all of whom reside on the Wasatch Front or in the St. George area. Oftentimes, these babies become lost-to-follow-up due to barriers of access to specialists, travel costs, inability to take time off from work, costs of testing, etc.

 

Tele-audiology services are hosted at the CSHCN Bureau with two pediatric audiologists on staff and a nurse at the remote site. The nurse provides direct face-to-face contact with the family and child. The nurse connects the electrodes to the baby and stays with the family throughout evaluation testing, while the audiologist remotely takes over the computer to run the testing. The testing is considered diagnostic and if a child is identified as deaf or hard of hearing, the CSHCN Bureau helps the family with the next steps in the EHDI process, including referrals to early intervention, parent-to-parent support, and referrals to medical providers.

 

In 2017, the UDOH awarded a pilot grant to the University of Utah (UofU) for perinatal mental health screening and counseling via telehealth. The project is now working with four of Utah’s rural health departments to screen women for postpartum depression symptoms using the Edinburgh postnatal depression scale tool, refer women who need support, and provide on-line support groups and counseling using telehealth.

 

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

 

Clinical Workforce Availability

The Utah Medical Association (UMA) reported 9,990 licensed physicians in 2015. Of the total number of licensed physicians, 6,035 (60.4%) reported providing services in the state. This provides a ratio of 198 patient care providers per 100,000 population, compared to a national average of 265.5/100,000. Family Medicine specialists are the largest group with 954 providers, followed by 445 general pediatricians, 312 OB/GYNs, 141 pediatric subspecialists, and 58 OB/GYN sub-specialists. The UMA report notes among practicing physicians, there has been a decrease in the proportion who spend 50% or more of their time in direct patient care or teaching and the number reporting a full practice that cannot accept new patients increased slightly since 2010.

 

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

 

The UDOH collaborates with the UofU School of Medicine to encourage educating new medical students of the needs and opportunities in serving the MCH/CSHCN population to increase capacity.

 

From July 1, 2017 to present, the Integrated Services Program (ISP) has contracted with four LHDs within the State. These four LHDs provide care coordination and clinical coordination for direct care services to the CSHCN population residing within their counties. This model creates a regional “hub” or main point of contact for local families of CSHCN through which they may be referred to supports, specialists, and services that may benefit their child. Over 72% of the referrals for either care coordination, direct clinical services, or both were related to autism spectrum disorder. The CSHCN specialty and subspecialty pediatric providers are mostly located along the Wasatch Front, including the state's tertiary pediatric care centers, which are the University of Utah, Primary Children's Hospital and Shriners Hospital for Children. There is one comprehensive women and children’s health center located in the southern part of the state, serving a five-county rural area. The location of most pediatric specialists and subspecialists in the most populous areas of the state presents a problem for provider access for special needs children in rural Utah. Several counties have no pediatricians or sub-specialists, meaning families must drive long distances to access care for their children. In most cases, there is limited additional itinerant coverage from the private sector for these large geographic areas. In rural counties, health care is often provided to children through family practice physicians, local health departments or community health centers.

 

Families continue to face formidable barriers in accessing services and coordinating care for their children with special health care needs. Access to pediatric specialists and subspecialists is adequate if you live along the Wasatch Front, although long waiting lists exist to see practitioners. The story is different for those living in rural/frontier areas of the state where families must drive long distances to access the same services.

 

Utah Medicaid

Utah’s Medicaid program is administered through the UDOH. The Medicaid program is an advocate for supporting MCH/CSHCN populations throughout the State. Utah Medicaid contracts with health plans, or Accountable Care Organizations (ACO), to provide medical services to Medicaid members. Members living in Box Elder, Cache, Davis, Iron, Morgan, Rich, Salt Lake, Summit, Tooele, Utah, Wasatch, Washington, or Weber counties must choose an ACO. Members that live in other counties have the option to choose an ACO or the Fee for Service Network.

Each ACO is responsible to provide enrolled Medicaid members with all medical services covered by Medicaid. Medicaid typically pays a monthly fee for each Medicaid member enrolled in an ACO. Each ACO may offer more benefits and/or fewer restrictions than the Medicaid scope of benefits. The ACO must specify services which require prior authorization and the conditions for authorization.

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

 

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

 

Overview/Conclusion

The directors of Title V/MCH and CSHCN work with employees at the state and local levels as well as with strategic partners to implement programs and services of the Title V Block Grants three federally defined populations.

 

The Title V/MCH and CSHCN Directors and staff use data, needs assessment, capacity surveys and historical experience to make determinations for program capacity, development and funding distribution.