1. Identifying Programs, Services, Functions, and Activities Self Governance 101 Training May 10, 2016 Carolyn Crowder Crown Consulting & Management & NSHC Self Governance Liason Dakota Event Center Aberdeen, South Dakota

2.  System Conversion from Federal to Tribal  Tribal Assumption of Programs, Services, Functions & Activities (PSFA’s)  Identifying Programs, Services, Functions, and Activities (PSFAs)  Identifying ISDEAA 106(a)(1) program funding in Federal Contracts (P/RC, services, etc.)  Best Practices from other Tribes/Tribal Health Organizations

3.  Tribal Vision & Mission for Future Generations  Provide quality & safe care and impact Improved Tribal Health Outcomes  Wholistic Approach – considering whole community including economic, housing, social, education, community infrastructure, etc.  Desire to own & improve management of our Health System  Local Governance & Close to Home Consultation & Accountability (Not bound by federal constraints)  Flexibility to Redesign & Reprogram Funding to address Local Health Priorities & Needs (i.e. move from PRC to Direct Care, shift funding priorities from year-to-year, develop new programs)  Recurring Base Funds & Lump Sum Payments  Interest Earnings, Savings, & Carry Over Ability  Start up & Contract Support Costs  Federal Benefits: Federal Supply Sources, Federal Torts Claims Coverage

4.  Ability to Leverage other Resources  Funding:  Tribal  BIA  HRSA,  Federal & State Grants/Contracts  3 rd Party Revenues  Foundation Funding  Local Fundraising  Loans/Bonds & other private financing options  Access non-IHS Health Care Systems:  Inter-Tribal & Indigenous Global Health Collaboratives/Coalitions  State & Local Health Authorities  Private-sector provider agreements & networks/associations  other Federal agencies, including HRSA, VA, NIH, SAMSHA, SBA  “http://www.nativeonestop.gov/ Rural Health non-profit organizations

5.  Understand and analyze program/service information (PSFA’s) and associated financial information (Tribal Shares) to make informed decisions:  Understand funding distribution for all levels of IHS  Understand purpose and description of scope of service for PSFA’s benefiting Tribe  Analyze which PSFA’s to assume (100% or portion), withhold, buy-back, or are retained as inherent federal functions by the IHS  Consider Tribal readiness, priorities, and alternate delivery models: option to negotiate PSFA’s into FA’s at later date

6.  Analyze management capacity & infrastructure changes:  Affect on Funding & Budget  Legal & Compliance issues  Overhead management systems changes i.e. HR, Finance, Supervisory oversight levels  Changes in delivery of care models (sub-regional, decentralized, etc.)  Assess Implementation strategies:  Performance goals & measures, personnel & recruitment, vendor contracts, business office practices, training needs, evaluation models  Plan out transitional strategies  Community/Staff Communication Plan & Input  Schedule & Timelines  Facility & Infrastructure Development Plan

7.  ISDEAA 106(a)(1) & (2) program funding

9.  Headquarters Tribal Shares: Proportionate share of IHS- wide PSFAs benefiting each Tribe  Macro level calculation  Area Tribal Shares: Proportionate share of Area Office PSFAs benefiting each Tribe  Local Tribal Shares: identified as historical level of funding directly benefit each Tribe

13.  Most HQ PFSA’s calculates $ share for all 567 Tribes based in user counts  92% of total HQ Funds are calculated on a per user basis for all Tribes  8% of total HQ Funds are set aside for small tribes (less than 2,500 users), calculated on a sliding scale that diminishes as approach 2,500 users  Intended to address economy of scale issues (Minimum $$ requirement)

14.  HQ PSFA tables do not correspond to Organizational structure of staff  HQ staff may divide work time to various PSFA  Shares are protected, even if HQ reorganizes  IHS cannot eliminate PSFA prior to contracting/compacting  Office of Finance & Accounting create HQ tables  Other HQ offices are responsible for carrying out PSFA & descriptions in PSFA Manual

16.  What is population to be served with funding available? (i.e. Tribal Shares & leveraging other existing grants, 3 rd party revenues, etc.)  How easy or hard will it be to restructure management of organization to provide service?  How does this fit in with our local health priorities and ability to impact long-term improvement outcomes?  What opportunities and/or challenges does this provide the Tribe? (i.e. new revenues, ACA/IHCIA expansion opportunities, administrative burdens/barriers)  Can this be phased-in at a later time?

18.  PSFA Manuals: Area-specific & HQ  Additional PSFA Descriptions i.e. Recruitment  Workload Reports i.e. Primary Care Provider visits by type; unduplicated user counts; specific services benefiting the Tribe  Revenue Reports: 3 rd party collections  Staffing & Organizational information including description of IHS program staff functions  Other reports requested by Tribe

20. Changing Health Delivery, One Tribe at a Time…… “I am committed to making sustainable changes to ensure that we are providing quality health care to the patients we serve, not only in the Great Plains but throughout the country. I fully support our treaty obligations and our responsibility to provide access to health care in direct-service facilities and through Tribal and Urban centers.”