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.   46.2% 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 composition of the state over the 20-year time period 2000 to 2020, according to the U.S. Census, which includes an overall aging of the population as well as an increasing diversity.  Statewide, 16.5% of the population is 65 and over, however in 70 counties that number exceeds 20%.  In terms of increased diversity, Nebraska has seen its minority population grow 97% during the same time period – which represents 22.2% 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 in order to provide quality care 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 minority population increase of over 29.6% in the 20-year span 2000 to 2020 has occurred.  Migration of the younger population (18 to 45 years) from parts of western Nebraska has primarily affected the counties of Douglas, Sarpy (City of Omaha), and Lancaster (City of Lincoln).  For some minority populations – notably African Americans at 88.5% – these three counties are home to the majority of the Nebraska population. 

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 225,592 in 2020 (138.6% increase) according to the U.S. Census estimates. Hispanic Americans now comprise 11.6% of the state's population.  Asian and Pacific Islander populations grew by 138% and the African American population saw a 46% increase in the 20-year period 2000 to 2020. 

Similarly, the Native American population in Nebraska has increased by 97.7% during the same time period.  Four federally-recognized Native American Tribes are headquartered in Nebraska - the Santee Sioux, Omaha, Winnebago, and Ponca. Though many Native Americans live on reservations, the majority does not. The urban areas of Omaha and Lincoln account for more than 34.8% 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 Nebraska adjoining the Pine Ridge Reservation in South Dakota. Among the reservations situated in Nebraska, the Winnebago Tribe and Omaha Tribe in northeastern Thurston County account for 22% of Nebraska's Native American population.  An additional 3% reside at the Santee Sioux Nation in Knox County. The Ponca Tribe operates within a designated service area covering 15 counties in Nebraska, South Dakota, and Iowa.  Tribal offices are established in four Nebraska locations, and a fifth in Iowa.  The Iowa and the Sac and Fox Indian Reservations on the Nebraska-Kansas border account for about 1% of Nebraska's total Native American population. 

Health disparities exist in Nebraska, and unfortunately impact 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 Office of Health Disparities and Health Equity 2020 Nebraska Health Disparities Report, the infant mortality rate (expressed as per 1,000 live births) among African Americans was 13.4, compared to that among the White population at 5.8.  Additionally, the obesity rate for African Americans was 36.5 compared to a rate of 29.1 for the White population, and they are 0.8 times more likely to have a depressive disorder than Whites.  American Indians in Nebraska (1.4% of the NE population) have a 2.7 times higher rate of inadequate prenatal care, are 1.4 times more likely to have a depressive disorder, and have a 5.3 times higher incidence of sexually transmitted disease as compared to Whites.

The ability to physically access care remains a challenge for this primarily rural, low-population 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 state-designated shortage areas by discipline. In April 2019, 64 counties out of 93 had this designation for the Family Practice discipline.  For the OB/GYN discipline, the entirety of 85 counties had this designation along with portions of counties surrounding Lancaster and Douglas counties.  A similar situation exists for the Psychiatry and Mental Health disciplines, with the majority of Nebraska’s 93 counties designated as shortage areas - only 3 counties (and a portion of the counties surrounding them) were not considered a shortage area as of April 2019.

Facilities located in federal shortage areas provide affordable and accessible primary and public health care services, including 142 Medicare-certified Rural Health Clinics (RHC), eight Federally Qualified Health Centers (FQHC), eight Indian Health Service (IHS) funded clinics and local public health departments.  These facilities not only address access issues, but also make up the safety net healthcare system in Nebraska; serving the 8.3% of Nebraskans who do not have health insurance as well as other vulnerable groups.  Expectations are that more Nebraskans will have coverage moving forward.  Medicaid expansion, called Heritage Health Adult (HHA), was implemented October 1, 2020 with a tiered system of benefits as a demonstration project.  Beginning June 1, 2021 the tiered system is removed so that all enrollees will receive equal benefits coverage effective October 1, 2021.  The additional step to remove requirements for participation in wellness, personal responsibility, and community engagement activities should further incentivize Nebraskans to enroll.

Medicaid also helps to ensure that integrated services are offered to Nebraskans.  Beginning in 2017, Medicaid offered enrollees a single plan combining physical health, behavioral health, and pharmacy benefits in an integrated health care program – a practice that has continued throughout recent changes to the overall program.  Since Community Health Centers and many private providers connected to larger health systems serve both private pay and Medicaid patients, integration of health services is not unique to Medicaid enrollees.   

Nebraska's System of Care (NeSOC) began in 2013 and continues to maximize services provided by Divisions of DHHS as well as other system partners.  NeSOC is not a program but rather a different way of doing business. It is youth-guided, family-driven, trauma-informed, and culturally responsive to improve outcomes for children and youth with mental and behavioral health challenges and their families.  NeSOC serves children and youth ages 0-19 and their families. This includes children and youth who are experiencing mental and/or behavioral health challenges. Nebraska’s SOC is active in all six Behavioral Health regions in Nebraska. Each region hosts a local system of care, but across the state the NeSOC shares common philosophies in the approach to care. One of the services provided is Crisis Services as a behavioral health resource for schools.  Crisis Services provide an evidence-based continuum of services that are provided to individuals experiencing a psychiatric crisis. Another example of the services provided is the Youth Mobile Crisis Response (YMCR). The YMCR is a free resource for families and youth of any age who are experiencing a behavioral health crisis anywhere in the state. YMCR therapists are available 24/7 through the Nebraska Family Helpline and help is provided in the community, home, or through video consultation within one hour of the call.  Currently, services are either funded as applicable through DHHS Division of Behavioral Health or Medicaid.

The population of children and youth with special health care needs (CYSHCN) in Nebraska is especially vulnerable, as they often face confounding challenges and barriers.  By creating a partnership between the DHHS Medically Handicapped Children’s Program and the Munroe-Meyer Institute (MMI) within the University of Nebraska Medical Center (UNMC), a network of clinics exists across the state to 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. 

An additional component of the CYSHCN health care system is how newborns and infants are screened for metabolic diseases and hearing issues.  100% of Nebraska’s birthing facilities collect a bloodspot sample and send to the screening laboratory for analysis; those facilities also conduct hearing screenings consistent with state statutes governing standard of care for newborns.  These timely screenings ensure that debilitating and sometimes deadly conditions are identified and, if possible, treated to prevent negative health effects or developmental delays.  Staff at these facilities also undertake parent education regarding the screening and potential necessary follow up care.  Staff with the Newborn Screening programs also conduct follow up on screened infants to ensure that any additional screening, testing, or connection to care occurs – a process that can often involve healthcare staff, data, and communication with families.

As tele-health continues to advance throughout Nebraska – with the COVID pandemic a large driver of uptake – it is important to call out the tele-audiology framework that was initiated by the NE Early Hearing Detection and Intervention (EHDI) program.  For those families in western NE with a newborn who did not pass the hearing screen, a follow up  re-screen or diagnostic hearing test can be conducted via tele-audiology with the University of Nebraska-Lincoln’s Barkley Speech Language and Hearing Clinic.  Appointments are conducted using end-to-end encryption via Zoom HIPAA-compliant conferencing. The testing is completed by a Doctor of Audiology in Lincoln, with a Teacher of the Deaf and Hard of Hearing as a trained facilitator at the test site.  

NDHHS Title V has many strengths to facilitate the ongoing engagement needed to address the daunting challenges faced by CYSHCN and their families – particularly with experienced staff and a strong administrative foundation.  This expertise asserts itself across all MCH populations as Title V undergoes statewide, systems-level work such as engaging partners, ensuring quality improvement, and/or developing system supports.  The success in these activities is a testament to the leadership that Title V staff have consistently demonstrated for years. 

Administratively, 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 MCH 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), Programs and Services Unit.  Having state co-leads in two Divisions of NDHHS extends the reach of Title V activities, expands the amount of available state support, and extends the staff expertise on the Title V Team.  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, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Immunizations, Maternal, Infant, and Early Childhood Home Visiting (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 lead the Title V MCH Block Grant and partner with stakeholders statewide.  These are the Maternal Child Adolescent School Health (MCASH) 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.

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, found in Nebraska Revised Statutes (Neb. Rev. Stat.) §§71-2201 to 71-2208. 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 Neb. Rev. Stat. §43-522, §68-309, and §68-717 with the associated NDHHS regulations found in Title 467 Chapters 1 through 7.

NDHHS Title V additionally relies on 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.  These relationships are enhanced by the technical expertise that Title V offers to others.  The programmatic staff within Title V offer a significant output of high quality continuing education and professional development activities every year for professionals statewide.  While training participants are frequently licensed health professionals, particularly nurses, training opportunities also are delivered to youth-serving professionals and home visitors. Additionally, Title V participates in developing new roles for MCH workers, such as home visitors, parent resource coordinators, and the TOP ® educators working in positive youth development. Title V staff supports development and proficiency of the school nurse workforce as well as providers in birthing hospitals and clinics. 

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 linkages between separate datasets, 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. Nebraska is particularly excited to have a CDC assignee with the Office of MCH Epidemiology, which has already deepened the expertise and capacity available to the state.

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.