National Indian Health Board Exploring Tribal Public Health Accreditation Aleena M. Hernandez, MPH Red Star Innovations, LLC September 15, 2010

Overview Historical Basis of Indian Health Tribal Management of Health Programs NIHB’s Exploring Tribal Public Health Accreditation project PHAB/NIHB Tribal Think Tank Recommendations Next Steps

Promises to Keep: Public Health Policy for American Indians and Alaska Natives in the 21 st Century Dixon M, Roubideaux Y American Public Health Association, 2001

American Indians and Alaska Natives 564 Federally-recognized Tribes in 35 States 1 Sovereign Nations Distinct culture, language and traditions Live on trust land and in urban areas Economic Diversity Tribal Membership 1 Indian Health Service Website

2000 Census AI/AN alone2.5 million (0.9%) AI/AN in combination with 1.6 million one or more other races Total AI/AN 4.1 million (1.5%) Reported a specific tribal affiliation74% IHS Service Population1.5 million

Historical Basis of Indian Health Pre-Contact/Tradition Medicine Impact of European Settlement Constitution/Supreme Court/Treaties/Legislation - Sovereignty - Federal Trust Responsibility - Government to Government Relationship

Significant Policy/Legislation Affecting Indian Health  1800’s – Responsibility of the War Department  Indian Removal  Indian Removal Act of 1830  1836 – Medical services for land cessions  BIA/Department of Interior  Dawes Act – General Allotment Act 1887  Reservation land divided into allotments  Ban on traditional practices  Introduction of boarding schools

Significant Policy/Legislation Affecting Indian Health  Indian Reorganization Act 1934  Termination Program of the 1950’s  The Transfer Act of 1954 – Transferred health services from the BIA to PHS  Indian Health Service established

Indian Health Service  Under the US Department of Health and Human Services  Comprehensive, primary health care system and some public health services Only agency to provide direct medical care  Trust Responsibility: Members of federally recognized tribes  Divided into 12 Service Areas

Per Capita Health Expenditures Indian Health Service (2005)$2,130 Bureau of Prisons (2005 estimate)$3,986 In California and New Mexico over $4000 Veterans Administration (2002)$4,653 US General Population (2003)$5,670 Department of Health and Human Services, Source published January 2006www.dhhs.gov

Tribal Management of Health Programs The Indian Self-Determination and Educational Assistance Act 1975 P.L Tribes can manage their health programs - Title I: CONTRACT part or all of the services - Title V: COMPACT entire health programs - Funding issues: shares, contract support costs

Putting Tribal Public Health Into Context for Accreditation  Direct service and 638 (contract/compact) tribes  Geographic location (IHS Area, Rural/Urban)  Landbase versus non-landbase tribes, checkerboard  Single tribe applicant versus consortium of tribes  Health Department Size  Level of Public Health Activity  Multi-jurisdictional overlap and relations

National Indian Health Board Exploring Tribal Public Health Accreditation

Exploring Tribal Public Health Accreditation  National Indian Health Board involvement  Grant: Robert Wood Johnson Foundation 2008  Purpose: to assess the feasibility of the promotion of voluntary public health accreditation and public health standards in Indian Country

Exploring Tribal Public Health Accreditation  Objectives of NIHB Project:  Establish an Advisory Panel  Review past accreditation efforts in Indian country  Explore/Discuss the potential for voluntary public health accreditation in Indian country  Benefits, challenges, barriers, ideas…  Gather recommendations from Indian country  Process, resources needed, potential partnerships  Produce a Strategic Plan

Call for Input Results  Positive response to concept of public health accreditation – broader than just health services  Interest in tribes having a leadership role  Opportunity to recognize the excellence in public health across Indian Country  Challenges include the diversity of public health delivery in Indian country, time, capacity and cost to seek accreditation, multiple entities involved

Strategic Plan Recommendations  Provide ongoing education/awareness to Tribes  Provide training, Technical Assistance, preparation, and readiness assessments relevant to tribal context  Consider Tribal version of Standards and Measures  Explore PHAB’s role in strengthening relationships among tribal, local, and state HDs  Convene regional roundtables  Facilitate a “Tribal Think Tank” to address relations

Public Health Accreditation Board National Indian Health Board Tribal Think Tank December 16, 2009 Tucson, Arizona

TRIBAL THINK TANK 17 Participants Representing  Tribal Beta Test Sites  NIHB Tribal Public Health Accreditation Advisory Board Members  Tribal Health Directors/Administrators  PHAB Staff/Board Members  RWJF

Tribal Think Tank Objectives Based on NIHB Advisory Board Recommendations:  Identify and discuss strategies to ensure ongoing Tribal input into the accreditation process  Identify strategies for PHAB to strengthen Tribal/State relations in accreditation  Explore the adaptation of the PHAB Public Health Accreditation Standards and Measures to create a Tribal version

Strategies: Involving Tribes  Convene local, regional and national meetings  Provide outreach and education to tribes  Hire/contract individuals with experience in tribal public health systems (culturally competence)  Identify opportunities for communication and collaboration among tribal, local and state health department

Accreditation Incentives  Potential to identify model Tribal Public Health Systems  Opportunity to strengthen tribal public health infrastructure  Improve the quality of care  Build credibility and  Strengthens a tribe’s ability to advocate for health Cost Issues – funding is needed to support tribal infrastructure development, technical assistance, and capacity building.

Tribe/State Relations  Government to Government relationship  Overlapping Jurisdictions  Responsibility and Authority  Federal transfer of responsibility and funding for public health functions to states

Tribal Consultation  1994 – Bill Clinton introduced Tribal Consultation Policy  Facilitates formal government to government relations  Requires federal executive departments and agencies to consult with tribes prior to making decisions that would affect them  November 2009, President Barack Obama convened all tribal leaders in Tribal Consultation

Strategies: Tribe/State Relations  Conduct regional/national roundtables with tribal, local, and state health departments  Use the Beta Test to develop a “Model Partnership for Accreditation”  Provide education about tribal public health systems to local and state health departments  Utilize the accreditation process/documents to encourage coordination and collaboration among tribal, local and state health departments

Next Steps – In Progress  Conduct outreach to tribes at the regional and national level  Convene tribal, local and state health departments to dialogue about partnership and accreditation  Utilize input from the Tribal Beta Test Sites to identify lessons learned and to inform future work  Develop tribal version of the Standards, Measures and documentation

PHAB – Tribal Standards Workgroup  Conducted a call for Workgroup volunteers in July  People with knowledge and understanding of Tribal Public Health Systems  Workgroup volunteers selected in August  Includes members of original Standards and Measures Workgroup  1 st Workgroup meeting to be held in conjunction with NIHB Annual Consumer Conference  Scheduled to be completed in March 2011

2010 NIHB Tribal Public Health Profile  Assess readiness for public health accreditation  Provide a baseline to measure growth and change in tribal public health capacity  Prioritize development and resource allocations  Advocate for resources and policy on behalf of Tribes and public health  Identify technical assistance and quality improvement needs

Tribal Standards Workgroup Tribal Representatives  Michael Allison, MPH  Donald Vesper, REHS,MPH  Loren Sekayumptewa, MSW  Debra Smith, RN, PHN, MSN  JT Petherick, JD, MPH  Annette James, RN  Gary Quinn, MSW  Glenda Davis Standards Development WG  Jane Smilie  Barbara Worgess, MPH  Steve Ronk, MPH  Torney Smith, MSHE

Profile Participants Tribal Health Organizations  Tribal Health Departments  Indian Health Service Units (Hospitals, clinics, and satellites)  Indian Health Boards or Intertribal Councils with Tribal Epidemiology Centers  Urban Indian Health Centers

Profile Highlights: Assessment  44% conducted community health assessment in the past 3 years  47% of Tribal Health Departments; 46% percent of IHS Facilities: 60% Area Indian Health Boards and 74 % of Urban Indian Health Centers have data sharing agreements with state health departments  66% evaluate public health activities and/or services

Profile Highlights: Policy Development  Regulatory activities are provided primarily by the Tribal Health Departments or IHS in tribal communities  Less than 40% receive funding from their state health agency through the CDC public health preparedness cooperative agreement.  Over 40% have a research policy or ordinance for reviewing and approving health research.

Profile Highlights: Assurance  59 % serve populations that travel 50 miles or more to access their services  83% help enroll eligible individuals into public benefit programs, such as Medicaid/Medicare.  Collaborative relationships with other Tribal Health Organizations were most frequently rated effective or highly effective

Profile in Summary  Tribes are providing a wide range of public health activities across domains  Further exploration is needed to understand:  Tribal public health performance  Readiness for public health accreditation  Technical assistance and quality improvement needs 

RWJF – PHSSR Grant 2010  RWJF Grant: Public Health Systems and Services Research  Partnership with Nat’l Opinion Research Center (NORC)  Enhance data analysis and conduct initial comparison to state and local health departments  Gather additional qualitative data  Recommend future data collection enhancements to produce a profile for harmonization with State and Local Profiles (ASTHO and NACCHO)

Thank You Aimee Centivany, MPH National Indian Health Board Aleena M. Hernandez, MPH Red Star Innovations, LLC