National Indian Health Board

Exploring Tribal Public Health Accreditation

Aleena M. Hernandez, MPH Red Star Innovations, LLC January 21, 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 www.ihs.gov

2000 Census

• AI/AN alone • AI/AN in combination with one or more other races • Total AI/AN 2.5 million (0.9%) 1.6 million • • Reported a specific tribal affiliation IHS Service Population 4.1 million (1.5%) 74% 1.5 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  1849 - 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  1955 - 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, www.dhhs.gov

, Source published January 2006

Tribal Management of Health Programs

The Indian Self-Determination and Educational Assistance Act 1975 P.L. 93-638 • 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  Tribe, Health Department Size  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

Key Recommendations

 Ensure ongoing Tribal Input and Engagement  Involve key stakeholders within Tribal Public Health Systems  Adapt the standards, measures, and documentation for tribal health departments.

 Provide opportunities for tribe, local and state health departments to convene, communicate and coordinate

Next Steps

 Formalize a process for adapting tribal versions of the Standards, Measures and documentation  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

Thank You

Aimee Centivany, MPH National Indian Health Board [email protected]

Aleena M. Hernandez, MPH Red Star Innovations, LLC [email protected]