Onyemaechi Nweke: Good afternoon, and welcome to the Equity in All Policies webinar series.
Today's webinar is sponsored by the Federal Interagency Health Equity Team, which is part
of the National Partnership for Action to End Health Disparities, and in acronym world
that is the NPA for short.
The NPA is a national platform for convening stakeholders who are committed to action to
address health inequities.
My name is Onyemaechi Nweke, and I will serve as your call moderator for today's event alongside
my esteemed colleague from the Office of Minority Health, Dr. Alexis Bakos.
These webinars offer a platform for practitioners at all levels to share current practices and
innovative strategies that they apply in their work for promoting equitable outcomes in health
and the social determinants of health.
Today's webinar is going to feature one of our partners, the National Indian Health Board,
and the webinar will actually touch on some of the exciting work that they have done to
support their partnership under the NPA.
Now, given that their work uses funding from the Office of Minority Health, I do want to
clarify that the views that they will share on this webinar do not represent the views
of the Office of Minority Health.
They are simply reporting based on their experience and the work that they do.
In particular, the work that you will hear about today features some preliminary environmental
scan that they have done in support of public health accreditation in Indian country.
Accreditation happens to be something that we've heard about with more of this happening
around the country, both at the state and local level, in recent times.
It is an important process for public health departments because it strives to advance
the quality and performance of public health departments, and it lends a strategic, comprehensive
and more accountable approach to managing wellbeing and health in our communities.
Our panelists today are definitely going to highlight the state of accreditation in Indian
country, and in the process of doing so, they will identify and talk about challenges and
opportunities.
Specifically you will hear about the findings from the environmental scan, which was focused
on the state of public health accreditation within tribal communities, and then they will
exemplify some of the work that is going on within tribal public health departments using
an approach that was done by one of their tribal public health departments.
Before we start, I do have a few short housekeeping announcements for you.
The main presentation will last about 40 minutes, maximum 45.
You have opportunities to ask questions of the presenters, but you will have to post
your questions in what we call the Question-and-Answer window or screen.
Any questions related to the webinar will be read out not during the webinar but after
the presentation—not during the presentation, excuse me, but after the presentation, and
that will be during the question-and-answer session.
The presenters will be able to respond at that time.
However, if you have some technical difficulties and you have questions about your technical
difficulties that you would like to share with the individuals who are managing this
call, please do post them in Question-and-Answer window.
Hopefully the difficulties do not extend to your ability to use the Question-and-Answer
window.
Those questions will be answered in real time.
Now, if you don't have the Q&A window open on your screen now, I recommend that you look
on the console at the bottom of your computer screen.
There is an icon labeled Q&A.
Click on it, and it should open up your screen.
You can minimize your screen so that you can see the actual presentation, but it's best
to leave it open.
Now, finally we are going to send you some questions at the end of the presentation but
before the Q&A questions.
They will be posted to you, so you'll see a popup on your screen during the Q&A session.
This is all about feedback regarding the presentation you have heard.
We definitely appreciate your feedback.
We want to hear back from you about the contents of the webinar as well as the presentation.
So, once you see that popup, we encourage you to begin to answer the questions as we
go through the questions and answers you have posted.
It should not take more than three or four minutes to complete this set of questions
that you will receive.
If you don't see the popup, if you don't see the window open up after the presenters are
done with their presentation, I encourage you to click on the icon which is labeled
Survey.
And it's on the console also at the bottom of your screen.
So again, the questions, responding to the questions should not take more than three
to four minutes, but the input we do receive from you is very valuable, and we use it to
continue to determine what kind of content to bring on this platform.
So without much ado, I will hand off to my colleague, Dr. Bakos, who will now introduce
the speakers.
Alexis Bakos: Hello there, and thank you very much, Onyemaechi.
First of all, my name is Dr. Alexis Bakos, and I'm a senior advisor to the Deputy Assistant
Secretary for Minority Health, and I'm also currently the acting director of the Division
of Policy and Data at the Office of Minority Health.
I'm very pleased to introduce our panel of esteemed speakers.
Our first speaker today is Ms. Karrie Joseph, who is the public health programs manager
with the National Indian Health Board, or NIHB, where she currently works with the Tribal
Accreditation Initiative and the Tribal Leaders Diabetes Committee project.
Ms. Joseph joined NIHB in March of 2015 and brings more than 13 years of experience in
public health.
She earned a BA in anthropology and an MPH in health promotion and education from the
University of South Carolina.
Prior to joining NIHB, she had the honor and privilege of working with native communities
in North Dakota at Fort Berthold and in Cherokee, North Carolina, with the Eastern band of Cherokee
Indians.
Our second speaker is Carrie Sampson, who is the assistant administrator at Yellowhawk
Tribal Health Center on the Confederated Tribes of the Umatilla Indian Reservation.
In this capacity, she oversees organizational strategic planning, continuously works towards
addressing the community's top health priorities through policy initiatives and program planning,
leads the organization's path to public health accreditation and is a constant voice for
tribal health programs and services to tribal leadership.
She also is actively involved on regional and national levels on issues affecting public
health in tribal communities.
Prior to working at Yellowhawk, Ms. Sampson spent several years as the sexual assault
prevention project manager at the Northwest Portland Area Indian Health Board, coordinated
Treaty 7 First Nations health data for the Alberta First Nations Information Government
Center in Canada, and served as the youth Healing to Wellness program coordinator at
the Blackfeet nation in Browning, Montana.
Ms. Sampson began her career as a licensed practical nurse and later graduated with a
BS in community health education from Portland State University.
Currently she is working towards an MS in health care management for Oregon Health and
Science University.
I'd like to start the presentation and turn the session over to Ms. Joseph.
Thank you very much.
Karrie Joseph: Thank you so much.
Good afternoon or morning, depending on where you are in the country.
I'd like to first thank the host, the Federal Interagency Health Equity Team, for inviting
us to present in this webinar series, and also thank my co-presenter, Carrie Sampson,
who will be sharing her knowledge from the forefront of health equity work in tribal
communities.
I'd also like to thank the OMH, National Partnership for Action to End Health Disparities, for
their support and partnership with the National Indian Health Board.
A bit about the National Indian Health Board.
We're a 501(c)(3) charitable organization created by the tribes over 40 years ago to
advocate for improved health for American Indian and Alaskan natives.
NIHB is the only national organization of its kind.
We serve all 567 federally recognized tribes and advocate on all issues related to health
and public health in Indian country.
We're going to do a quick poll just to see who's on the line.
It should have just popped up, and you can scroll through and just choose which best
describes your organization.
As you click on that, it will go to wherever it goes in outer space, and we'll check the
results in a second.
You have to scroll down and hit the Submit.
All right.
Hopefully everyone's had a chance to choose one of those.
Just looking at who's on the call, we have some tribal health departments, some state
health departments, some national non-profits, federal agencies and private organizations.
Looks like we have a pretty equal span over here.
And some academia.
So, welcome.
We have another question.
Has your organization begun discussions around public health accreditation?
Yes, no, and "n/a" would refer to if maybe your organization's not eligible to apply
for public health accreditation.
All right.
Okay, 37% yes, 3% no and 67% where there's not eligibility.
Thank you for participating in the polls.
Just to go over the objectives of this webinar, one is to provide a background on the landscape
of public health in Indian country; two is to discuss the findings of an environmental
scan on the state of public health accreditation and health equity within tribal communities,
and three, share one tribe's approach to using public health accreditation activities to
achieve health equity within its community.
To start out, I want to start with some slides and background to orient you to tribal public
health.
We really can't talk about health equity today without having some understanding about the
history of health care and public health for Native Americans.
There are four points I'd like to emphasize, and I'm going to go into these a little deeper,
but number one is that health services are not free to American Indian/Alaskan Natives;
two, tribal nations are sovereign; three, tribes experience inequities in participation
and representation in public health systems infrastructure; four, the contributions to
the nation's health made by the Indian health service and tribal health departments is significant.
So let's start with number one, health services are not free to American Indian/Alaskan Natives.
They've essentially been prepaid.
As with most if not all indigenous people prior to European contact, Native Americans
had complex traditions, cultural practices, social organizations, forms of government,
education, spirituality that all inter-relatedly worked together to ensure the health and survival
of the people.
This health and balance was intrinsically tied to the land that Native Americans lived
on, hunted, fished, gathered and, for some tribes, farmed.
European contact in North America brought devastation to the indigenous tribes by way
of sickness, disease and warfare that decimated the population and drove Indians from their
land.
This was followed by US expansion westward, and federal policies that forced relocation,
forced people onto reservations, forced assimilation, broke treaties, sold Indian land.
It's a wonder that tribal nations were able to survive at all.
However, they have survived and they're over two million strong.
The US government has what is called a federal trust responsibility to provide health services
to American Indian/Alaskan Natives.
The federal trust responsibility came about through numerous treaties, Supreme Court cases,
legislative acts and executive orders.
Through the trust responsibility, the federal government took on a duty to provide health
care and other benefits to the tribes across Indian country.
While there are agencies that have been set up to fulfill this duty, like the Indian Health
Service, today this duty has not been fulfilled
IHS was established in 1955, and the responsibility of Indian health was transferred to this agency.
IHS is funded at approximately 56% of its need with the vast majority of that funding
going to health care for individuals rather than to population health, which as we know
is the focus of public health.
Two, tribal nations are sovereign.
What does that mean?
That basically means self-rule.
Sovereignty refers to the inherent right of tribal nations to govern themselves.
Tribal sovereignty is recognized and protected by the US Constitution, legal precedent and
treaties.
In the context of public health, tribes have inherent authority as sovereign nations to
protect and promote the health and welfare of their citizens, using methods most relevant
for their communities.
Let me note that tribal citizens are also citizens of the United States as well as the
individual states in which they live and are entitled to all the same rights.
Tribes have a government-to-government relationship with the United States.
There's a myth that Indian nations were conquered, so therefore, they should assume the role
of a conquered nation and succumb to the conqueror's government.
I'd like to read a quote from a paper called "Myths and Realities of Tribal Sovereignty:
The Law and Economics of Indian Self-Rule" by Joseph Kalt and Joseph Singer.
The reality is that few tribes in the U.S. were conquered in military campaigns.
Most, but not all, tribes entered treaties with the United States.
This was particularly true of those that engaged in military combat with the U.S.
The very act of treating is a nation-to-nation form of intergovernmental interaction.
. . . This is the current policy of the United States, and has been so for forty years—to
recognize tribes' sovereignty and to ensure its continued existence.
This policy is based on promises made by the United States in its 250 treaties with Indian
nations and is based on recognition of tribes' sovereignty embedded in the U.S. Constitution.
An important piece of more recent legislation is the Indian Self-Determination and Education
Assistance Act of 1975, or Public Law 93-638, which allows tribes rather than the federal
government to deliver IHS-funded services to their own communities.
This allows tribal control over what services and how services are delivered and how that
will best meet the needs of their people.
So what does that look like for a tribal public health system?
Some but not all tribes may have contracted some services or contracted all services from
the Indian Health Service, and those services are determined by individual tribes so health
and public health can be organized and governed quite differently from tribe to tribe.
This graphic here, this big web, it's a little misleading as the functions of public health
and tribal communities may not be so explicit as to have a, quote-unquote, tribal public
health agency named as such.
In fact, this is probably rare.
As public health and health care are fairly integrated in tribal health systems, the functions
of public health may be disbursed among several organizations or programs such as community
health, environmental health programs, tribal epidemiology centers, urban Indian health
centers and such.
Local and state public health agencies often have a role in a tribal public health system.
Again, it varies from tribe to tribe and place to place.
Number three, tribes experience inequities in participation and representation in US
public health system infrastructure.
This is by lack of comparable funding opportunities or by mere omission.
Funding that supports infrastructure is often not available or acceptable to tribes.
One example is the CDC block grant funding which is received by all 50 states and eight
US territories but only two tribes, and that's out of 567.
CDC does offer tribal-specific funding in terms of grants, such as the Good Health and
Wellness in Indian Country grant, and also supports our NIHB tribal accreditation support
initiative, which has been a really successful program.
We hope it will continue.
But what we hear from tribes what is needed is equal, consistent, sustained infrastructure
funding.
Sometimes funding is funneled to select states and locals first who already exhibit some
level of success, with the intention of creating models for others to follow.
This is typical in funding, and funding can be tricky.
Of course, you want your grantees to be successful, but this practice can perpetuate the structure
that those who already have a higher capacity will have more opportunities to advance, leaving
those with less capacity further behind.
Tribes have been providing many essential public health services to tribal communities
but are largely not recognized.
One example of this is the 2016 document released by the Office of the Assistant Secretary of
Health from Health and Human Services called "Public Health 3.0: A Blueprint for the Future
of Public Health."
Touted as a new model and a new area of broadened public health practice, it focuses on infrastructure
and the social determinants of health and repeatedly calls upon local and state health
departments to lead this new era.
But the recognition of the mere existence of tribal public health is absent from this
document.
Where is the term "tribal health public agency"?
It's only mentioned once in the entire document, and that's in the description of Public Health
1.0, the time period from the 19th century through much of the 20th century.
So somewhere between Public Health 1.0 and 3.0, tribal public health apparently fell
off the radar of HHS.
The term "tribal entities" is used once, and that is last in a long list of "other sectors
that have not traditionally worked in public health."
So my question is, How can we as a nation have complete infrastructure when vital components
are left out of the plan?
We need to also talk about limited data, the red box on the screen.
This is a very big issue for tribes.
Without day, tribes are unable to demonstrate the need not only for more tribal public health
resources but just being counted.
Some of the data challenges faced by Native Americans is that there's a lack of tribal-specific
data.
We have great data sets for counties and states, but tribes are not counted in the same way,
and having comparable data is often non-existent.
In addition, data classifications such as American Indian and Alaskan Native may be
inaccurate, depending how and who reports it.
There's also low numbers for American Indian/Alaskan Natives is a challenge and often results in
American Indians and Alaskan Natives being left out of statistics.
In our data-dependent world, if you don't show up in the data, you don't exist.
Just today I was reading an article about health equity and chronic disease, and the
statistics reference the risk of being diagnosed with diabetes and reference African Americans,
high rates for Hispanics, high rates for Pacific Islanders and Native Hawaiians.
There was no mention at all of the risk for American Indian/Alaskan Natives.
We know that American Indian/Alaskan Natives have the highest risk of being diagnosed with
diabetes, as you can see from the CDC National Diabetes statistics report, but you wouldn't
know that from that article.
So just want to thank you to CDC for looking to other data sets and bringing those together
to present a complete picture of this devastating disease.
You often have to look at more than one source.
My fourth point, the contributions to the nation's health made by IHS and tribal health
departments is significant.
Considering American Indian/Alaskan Native populations suffer from some of the worst
health experience in the nation, including lower life expectancy, the highest death rates
from diabetes, suicides, several types of cancer, cirrhosis of the liver, motor vehicle
accidents, to name a few, and in terms of the social determinants itself, they're less
likely to graduate high school.
They have lower socioeconomic status and are more likely to live in poverty.
Considering these factors along with the infrastructure challenges described earlier, the work of
health care and public health for this population is an enormous challenge.
But the contributions are significant.
As reported by the Indian Health Service, 15 out of 24 of the government performance
results at targets were met in 2016.
That includes cardiovascular disease screening, dental sealants, tobacco cessation, depression
screening, domestic violence screening and childhood weight control.
Another example is the special diabetes program for Indians, a treatment and prevention program,
has been in existence for 20 years.
During this time, kidney failure from diabetes has decreased 54 percent, more than any other
race or ethnicity.
This means less people are needing dialysis, which is a huge health and cost savings to
the country.
One of the signature characteristics of this program is that it's community directed.
As one tribal leader commented, "SDPI honors the treaty."
He stated that "when American Indians and Alaskan Natives are the priority, things get
better."
Let me add that the SDPI program is not part of the IHS budget.
It is a separate funding authorized by Congress, and it expires on September 30 of this year,
in about one month.
Congress needs to act soon to keep this life-saving program alive and in the country.
Okay, let's shift a little bit and talk about public health accreditation.
Public health accreditation is defined as the measurement of a health department's public
health performance in systems against a set of national standards based on the 10 essential
services of public health.
It's voluntary, and it is administered and managed by the Public Health Accreditation
Board.
The public health accreditation in Indian country, what does that look like?
So far to date, one tribe has received accreditation, as compared to 26 states and 152 local health
departments.
Four tribes are currently in line in the system for accreditation and review.
We do know that in many ways, tribes are engaging in public health accreditation activities
such as conducting community health assessments, strategic planning, workforce development
and quality improvement, but the goal of these activities may or may not be accreditation.
NIHB and tribes have been involved in public health accreditation since the inception.
There are tribal-specific measures that were originally vetted by tribes, and that's in
the standards and measures.
And through the work of the Tribal Public Health Accreditation Advisory Board, which
has been in existence since 2008, just currently has gone through the standards and measures
and made recommendations to PHAB on how those could be more relevant to tribal communities.
A supplement is being drafted and piloted to further assist tribes in using the standards
and measures.
NIHB through the support of the CDC offers small awards to tribes through the Tribal
Accreditation Support initiative.
We have funded 15 tribes to date, and our assessment shows that there's an increase
in readiness for our grantees to apply for public health accreditation, so helping tribes
move along to get closer to achieving accreditation.
We currently have a request for applications open right now.
The deadline's September 1, and the link is www.nihb.org/tribalasi/.
So what does accreditation mean to tribal public health?
A lot of the similar benefits to other health departments.
Responsibility, credibility and visibility.
It means performance feedback and quality improvement.
It means valuable partnerships are made and sustained.
It means health disparities are reduced as folks are getting the same high quality level
services as other health departments.
And then for tribes, there's an element of sovereignty for tribes, as well as what we
hear from the health departments we work with: staff pride.
I want to start pulling this together a little bit and move on to our NIHB environmental
scans.
This was made possible through CDC and Office of Minority Health Funding to develop a training
curriculum on strategic planning for health equity.
The purpose is to provide insight on how tribes are using the prerequisites of public health
accreditation as a vehicle to advance health equity within their own communities, and one
of the goals is a white paper that's going to provide guidance and recommendations to
funders on how they can more effectively structure funding requirements to support opportunities
that will enable tribes to advance health equity through public health accreditation.
The prerequisites we're talking about are three documents that need to be in place prior
to applying for public health accreditation, and that is the community health assessment,
the community health improvement plan and a health department strategic plan.
We focused our scan on these documents, as many tribes have engaged in these processes
whether in the context of public health accreditation or not.
The reach of our environmental scan, we had input from Indian country.
That was gleaned from several sources, from key informant interviews and focus groups
and surveys, input from individual tribes, area Indian health boards, tribal epidemiology
centers.
We had a pretty broad reach across the nation.
Although the context for the scan was public health accreditation, the input received was
much broader, and I will be presenting the findings in that broader context.
My next few slides are really the results and the recommendations to funders and to
others.
Basically, funders need to, one, better understand tribes, tribal structures, historical trauma,
health conditions and factors that impact the social determinants of health.
Funders need to use language that is familiar to tribes.
What we heard is that the jargon of health equity and the social determinants of health
may not be the jargon espoused by tribal communities.
When asking about health equity work in tribal communities, I've often gotten maybe a blank
look or responses like, "I feel like everything I do all day every day is health equity work.
Why are you even asking me this?"
The concept of health equity is not a new concept for tribes.
Health equity can be described as a traditional value of many Native American groups.
Similarly with the social determinants of health, that may not be the jargon but linking
health to social and environmental conditions is well understood.
You may hear people talk about clean water, sanitation, pest control, good education,
safe roads, economic growth.
Funders should also fund capacity building such as grant writing, data collection, training
to build local expertise and collaborations.
Note that the items that are asterisked in red indicate recommendations from the scan
that also align with the PHAB standards and measures.
For example, data collection is a large part of several domains in the PHAB standards,
meaning the health department is expected to collect primary and secondary data both
quantitative and qualitative, interpret data as well as use data for planning.
So when funders include these aspects in their funding opportunities, there's an add-in opportunity
to support accreditation activities.
It's also recommended that funders rethink their proposal goals and objectives.
Are these tribally driven?
Did the tribes set the goals and objectives, or can the tribes set the goals and objectives?
Reviewing proposal review practices.
Okay, that sounds a little strange, but basically for funders when you're reviewing proposals,
is everyone looked at the same?
Is it fair that entities with perhaps a low capacity for grant writing compete against
universities, professional grant writers, organizations that have a higher capacity?
Is there a possibility to have a separate stream of funding for tribes to alleviate
these inequities in these resources such as lack of data, grant-writing resources, small
versus large tribes?
More recommendations to funders.
They should fund components of the accident process that result in outcomes that are important
to tribes.
Also should fund programs that support an integrated approach.
For example, multiple tribal departments such as education, transportation and environment.
Fund programs that change poverty in tribal communities.
Fund health equity models that shift the focus from individuals first, then to the community,
to the community first and then individuals.
And then also fund programs that are culturally aligned with the needs of the respective tribal
communities.
Just a couple recommendations to government agencies.
I think we've all said this/ heard this.
Pool funding across agencies to address common interests, so working on that whole silo bit.
Improve partnerships and collaborations at all levels of government.
Recommendations to the Indian Health Service in particular has mainly to do with data,
so working with tribes to provide timely tribal-specific health data back to them.
Link the Indian Health Service data with other federal data sets to improve knowledge of
health conditions.
Create more data parity between tribes and IHS.
We have a few recommendations to tribes as well.
Incorporate a health-in-all-policies approach when you're making policy.
Allocate resources for infrastructure to support accreditation.
Ensure leadership is invested, present and engaged in health and advisory boards active
in addressing social determinants of health.
Leadership has been identified as key, especially when it comes to accreditation.
Create tribal codes to address public health needs specific to the community.
Become educated on the roles and responsibilities of public health and its place in the tribal
health care system.
Educate tribal members on wellness and equity.
And then support state and federal legislation that impacts conditions affecting health equity
in tribal communities.
So, that concludes the information we gathered through the environmental scan, and I know
I went through that very quickly.
Another aspect of this project was developing a curriculum for health departments to engage
in strategic planning specifically with a health equity lens.
We presented aspects of this curriculum in webinars, at conferences, created a template
that's currently on the NIHB website in the Tool section on the tribal ASI page.
One of our tribal partners, Yellowhawk Tribal Health Center in Mission, Oregon, was the
recipient of one of the NIHB in-person trainings.
So with that, I'm going to turn the presentation over to Carrie Sampson.
Carrie Sampson: Good afternoon.
Hello, everyone.
As mentioned, my name is Carrie Sampson, and I'm an enrolled member of the Confederated
Tribes of the Umatilla Indian Reservation.
I actually have a new role here.
I'm the quality director at Yellowhawk Tribal Health Center.
Over the last year, we have been working closely with the National Indian Health Board on the
accreditation support initiative and, as Karrie mentioned, the health equity concept, specifically
to our strategic planning.
Our vision and mission at Yellowhawk Tribal Health Center, our vision is our tribal community
will achieve optimal health through a culture of wellness.
Our mission is to empower our tribal community with opportunities to learn and experience
healthy lifestyles.
Just a snapshot of our community and our organization.
Since 1996, we compacted from the Indian Health Service and became 100% owned and governed
by our tribe, the Confederated Tribes of the Umatilla Indian Reservation.
Since this graphic has been developed, there are actually a few updates to these numbers.
Our employee base has grown to over 150 employees.
The additional numbers here are just to provide you with a snapshot of our organization from
population served, patient volume and active funding.
Yellowhawk Tribal Health Center is actually located 10 miles from a town called Pendleton,
Oregon.
We are in rural northeastern Oregon and located at the base of the Blue Mountains.
The red indicates our reservation boundaries.
We are located in only one county, Umatilla County, indicated in yellow; however, our
service population area consists of two counties, Umatilla and Union County.
Our funding from IHS is actually based on the number of American Indians and Alaskan
Natives residing in those two counties, also known as our CHSDA or our Contract Health
Service Delivery Area.
The Confederated Tribes of the Umatilla Indian Reservation is actually a union of three tribes:
the Cayuse, Umatilla, and Walla Walla.
We have nearly 2,965 tribal members.
That number adjusts very frequently, so it could be a little higher, it could be a little
lower from the time I repeat this number.
And our reservation is located on 172,000 acres, about 273 square miles.
I would say roughly half of our tribal members actually live on the reservation or in the
close surrounding area.
Before European contact, the members of the Cayuse, Umatilla and Walla Walla were actually
8,000 members strong.
Until the early 1900s, our ancestors moved in a yearly cycle from hunting camps to fishing
spots along the Columbia River to celebration and trading camps.
However, in 1855, the Cayuse, Umatilla and Walla Walla tribes and the US government negotiated
a treaty in which 6.4 million acres were ceded in exchange for a reservation homeland of
250,000 acres.
As a result of federal legislation in the late 1800s, that size was reduced even further
to 172,000 acres.
I just wanted to also give you some specific language that was actually in our treaty that
addresses why we actually receive IHS and government funds to initiate health care on
our reservation.
I'm just going to read a couple of quotes from our treaty.
In addition to the articles advanced the Indians at the time of signing this treaty, the United
States agree to expend the sum of fifty thousand dollars during the first and second years
after its ratification, for the erection of buildings on the reservation, fencing and
opening farms, for the purchase of teams, farming implements, clothing, and provisions,
for medicines and tools, for the payment of employees, and for subsisting the Indians
the first year after their removal.
Another quote directly from our treaty of 1855,
In addition to the consideration above specified, the United States agree to erect, at suitable
points on the reservation, one saw-mill, and one flouring-mill, a building suitable for
a hospital, two school-houses, one blacksmith shop, one building for wagon and plough maker
and one carpenter and joiner shop, one dwelling for each, two millers, one farmer, one superintendent
of farming operations, two school-teachers, one blacksmith.
So really, from our treaty, you can hear just a couple words here that specify a hospital,
medicine and one doctor.
I just wanted to provide a little bit of background as to what was stated in our treaty and how
that concept is being initiated today through the funding of IHS.
Moving along, I want to talk a little bit about why Yellowhawk decided to begin inching
our way towards public health accreditation.
I would say that it was an early decision from our leadership to make this a priority.
They saw immediate benefits in our tribe becoming accredited.
Local health departments were becoming accredited.
And really, I would say we're competitive.
We want to be able to say that we are reaching the highest standards possible and we can
compare to the state health departments, county health departments.
Just because of our limited resources, that shouldn't—we're going to push forward and
persevere and try to meet all the same standards and measures as all of those health departments
are.
We kind of did a trial run back in 2011 with a community health assessment, which is a
prerequisite of public health accreditation before you can even apply.
The results of that 2011 community health assessment, we only received 139 community
health assessment responses, so not necessarily enough to really consider our population as
a whole.
But in 2015, we did the process again, and we received over 427 responses, and those,
again, are specific to American Indian/Alaskan Native responses.
The questionnaire itself was 115 health-related questions, and they were administered to our
American Indians and Alaskan Natives that were 18 and older residing within Umatilla
County.
In addition to that, we really tried to find a way to engage our community and provide
a snapshot of our trend.
Really this data was telling a story about our community specifically.
So we created this easy-to-read tool to, again, help our community understand what our snapshot
was and really how we compare to the county, state and national numbers.
After we received the data, we organized up to 25 different community health assessment
forums and focus groups to make sure that every single community member had the opportunity
to receive the feedback and the data from our community health assessment.
We organized two large community gatherings, a community health gathering, and then CTUIR,
which is the acronym for our tribe, community health improvement sessions.
Really what we were trying to do by disseminating that data and getting it out to our community
was to get the feedback and begin prioritizing our top health needs.
Through that process, we did prioritize really our top health concerns for our community
that we want to address in our community health improvement plan.
Number one was obesity.
Based on our community health assessment results, over 80% of our population was either overweight
or obese.
Our second priority was diabetes.
Again, closely related to our obesity category.
Number three, drug use.
Number four, alcohol use.
And number five was mental health.
Once we prioritized our health priorities, we decided that we really needed to break
it down, and so we held several focus groups, one on obesity, one on diabetes, one on drug
and alcohol use and one on mental health, and really tried to engage the community to
really participate in one of those focus groups and help us identify ways that we could address
these issues and what the root causes of these issues were and brainstorming solutions.
Over 50 of our community members participated in those health discussion sessions, and really
this framework helped guide the process of our community health improvement plan.
This next slide here really identifies the step-by-step process that we've gone through
to get to our community health improvement plan, which I would like to note, we're still
not completed with it but we've been really working diligently at ensuring we're getting
the feedback we need to make this community health improvement plan not necessarily Yellowhawk's
health improvement plan but that all entities of the tribe and all tribal members are involved
in this process.
We did initiate another survey.
After having all of our focus groups analyzed, we decided to do another survey to have our
community again help us identify ways to address the goals and objectives of our community
health improvement plan.
Through that survey process, we received actually over 240 responses from our community members,
which in the big picture for other communities, that may not sound like a lot, but for a smaller
tribal community, we were really proud of that number.
We used a Survey Monkey tool, but we also set up in different areas around the community
to get this feedback.
We have actually gotten to the point of putting the feedback into tables, and so as you can
see here, this is—I'm sorry, it's a little blurry, now that I see it on my screen.
Our first priority was obesity, and so through the survey process, our community members
helped us prioritize our number one, two and three goals to address obesity.
And then on the right column, the second column, you'll see that they also helped us prioritize
our objectives that we are going to fulfill to hopefully reach that goal.
This community health improvement plan is really a tool for us to use over the next
three to five years to, again, address our top health priorities really the best way
we can.
And it's not just Yellowhawk Tribal Health Center addressing our health priorities.
We're getting to the point where we're pulling in different entities of the tribe to help
us address our health priorities to, again, meet the needs of our communities.
This is the second half of the table that addresses number three, drug and alcohol use
priority, and number four, our mental health priority.
As I go through these, I just want to, again, elaborate.
I don't know how much background everyone on this call has on public health accreditation,
but through this process, these are prerequisites that we and all the health departments have
to complete before we're even able to apply for public health accreditation.
Through this process, we really learned what valuable information we learned by going through
these prerequisites and really understand PHAB makes that a requirement.
We've been learning so much about our community through this process.
As Karrie mentioned, they came here to Yellowhawk and facilitated a strategic planning session
for us as we were inching into our next strategic plan, our 2017-2018 strategic plan.
This session was called Integration of Social Determinants of Health Framework and Equity
Lens.
Using a SWOT exercise and ensuring that we were equitable in the objectives that we included
in our strategic plan, they brought this framework called SMART-E. Not only do we want to make
them Specific, Measurable, Attainable, Realistic and Timely, but the SMART-E piece was the
important part, which was Equitable.
Again, using different exercises we identified our organization's top priorities: integration,
workforce development, community engagement, quality, transition, health community and
sustainability.
I'm sorry if I'm going pretty fast.
We're at nine minutes I think, getting close to the end of the webinar, so I'm just going
to try to go through this fairly quickly.
We really tried to, again, tie our strategic plan to the information that was coming out
of our community health assessment and ensure that not only through our community health
improvement plan are we addressing our top health priorities but us as a tribal health
organization are addressing our top health priorities through our strategic planning
process.
This is just a snapshot that we shared with the community of Yellowhawk's strategic plan.
It's a really easy-to-ready overview of what Yellowhawk's strategy is over the next three
years.
Another piece to our process of becoming public health accredited, or getting to the point
of applying for accreditation, is really also helping our community understand what public
health accreditation is.
I've developed this little brochuring tool.
This is sort of the back side of the brochure, and the next page here—I'll move forward—is
the inside of the brochure.
Just a really simple brochure to help our community members understand that Yellowhawk
is pursuing public health accreditation.
These are the reasons why, and this is also the strategic plan that Yellowhawk is going
to implement to get us to that point.
I did want to highlight in this presentation our community engagement piece because I feel
like that has been the most important part of this process is engaging our community
members to get their feedback.
We're learning every day from our people, from our community, from our elders.
We need to do an excellent job as an organization to engage them and help them understand all
the things we're doing to address their health needs.
It was actually--as you saw in a previous slide, was one of our top health priorities,
and I just wanted to talk a little bit about the importance of it and some of the tools
we're doing, just different newsletters.
We've tried to revamp our branding and local process.
We just feel like this is a super important area, and in order to get to public health
accreditation and meet the public health needs of our community, we need to listen and learn
from our community members.
This final slide that I have here is really something that's really intimate and special
to us, and that is that we are opening a new tribal health center in the next few months,
actually.
The building is up.
It's actually been a process that's been 11 years in the making.
We felt like our current building, we're very siloed and segregated because it's grown so
much, we've had to add different outstation buildings.
And so, moving into a new facility is really a way that we feel like we're going to bring
that patient-centeredness, bring this back to a community gathering space, to not only
address the health needs of our community but connect with our community and make it
more than just a health center.
So, I just wanted to provide you all with a glimpse of our new health center that we're
extremely proud of.
I feel like maybe outside communities would not feel so much pride in opening a new clinic,
but I would say that our organization and our community has taken a lot of pride and
ownership in this facility, and we feel like this is just another way that we are enhancing
our ability to meet the needs of our tribal population and bring it to that patient-centeredness
and provide the best health care in Indian country that we possibly can.
I just wanted to share our process and our experience through public health accreditation
and really the different ways that we are listening and engaging our community's feedback
to move forward and bring public health in Indian country to homes.
Thank you.
I appreciate everyone that has taken the time to join our webinar today, and with that,
I will ask our moderator to do the question and answers.
Thank you.
Onyemaechi Nweke: Thank you so much for your presentation and listening to the two Carries.
We have Carrie Sampson, who just finished speaking, and Karrie Joseph, who spoke earlier.
I really appreciate the breadth and depth of information that you've covered today.
We only have about three minutes left, and maybe we can go over by two minutes because
I know that folks in the audience have questions.
So we're just going to go ahead and start taking questions.
While we do that, I would encourage people to please look at the questions, the survey
questions, that have popped up on your screen and answer those questions while we go through
the different Q&As.
The way this will proceed is I will ask a question.
Between myself and Dr. Bakos, we will ask the questions, and then our panelists will
respond to the questions.
If you have any additional questions, you can post them there, but since we have very
little time left, I doubt we'll be able to get through all the questions we have here.
So we have a question from someone from the Winslow Indian Health—I'm sorry, I can't
see the whole thing, but we have a question here, and the question is—are we still on?
Okay.
The question is, With reference to accreditation of tribes, how are individual service areas
considered?
Especially with a 638 facility.
I'm not sure what the last part means, but I'll let Carrie Sampson and Karrie Joseph,
see if they can explain what they mean by the 638.
It seems like coded words that you would understand.
Karrie Joseph: Yeah, this is Karrie Joseph.
638 refers to the Indian Self-Determination Act that we talked about, I talked about earlier,
that allows—and that's a common term.
If someone says, "Oh, we have a 638 facility," that means that the tribe has taken over the
operations of that facility from the Indian Health Service.
So that's one of the ways tribes can have health services provided.
Generally—and I know Navajo Nation is big and there's many service units or health care
facilities on the Navajo Nation, but when it comes to public health accreditation, it's
not the same as AAAC or health care facility accreditation.
It's not the facility itself that gets accredited; it's the entire public health system.
So it wouldn't be individual facilities getting accredited.
You'd be accrediting the public health system, and that's generally done through the tribe,
their Department of Health.
Onyemaechi Nweke: Okay.
There's one more question.
You talked about—you said earlier during your presentation—and this is Karrie Joseph—that
based on assessments, you have observed an increase in readiness of tribal public health
departments for accreditation.
Can you provide us with some insights on how you define readiness?
What do you mention as readiness?
Because I think that's an issue that's relevant not only to tribal public health departments
but local public health departments as well.
Karrie Joseph: Sure.
We have adapted the evidence-based community readiness assessment, which is a tool developed
probably over two decades ago, maybe at Colorado State.
It's an evidence-based tool that is used to find how ready is a community to take on whatever
issue it is, if it's substance abuse or opiode epidemic or anything like that.
We have adapted that tool for accreditation, so we have what's called an accreditation
readiness assessment.
And we look at six dimensions of that, so we'll look at—there's a question, a qualitative
sort of interview, and then the questions get scored over dimensions such as leadership,
community knowledge, what are the efforts that you're doing, how much does the staff
know about what you're doing, what do the staff feel, what's the climate of taking on
that issue, in this case accreditation.
In a nutshell, that's how we do that.
We've adapted the community readiness model.
Onyemaechi Nweke: Thank you.
We have 4:01 PM.
Alexis, do you have a question for them?
Would you like to ask a question?
Alexis Bakos: I definitely do.
One of the questions I have is for either one of our speakers.
One of your recommendations is funding of components of the accreditation process that
result in outcomes that are valued by tribes.
What outcomes do you believe are important to tribes, and what components of accreditation
influence these outcomes and how?
Karrie Joseph: I'll let—Carrie Sampson, if you want to give your perspective on that.
If not, I can answer that.
Onyemaechi Nweke: Are you
on mute?
Carrie Sampson: Yeah, sorry, I was just talking.
I said I was reading the Q&As on the webinar here.
Could you repeat that question real quickly?
Onyemaechi Nweke: Sure.
Definitely.
One of your recommendations is funding of components of the accreditation process that
result in outcomes that are valued by tribes.
What outcomes are important to tribes, and what components of accreditation influence
these outcomes and how?
Carrie Sampson: I would say the important components to us really as an organization
and making it a priority to fund public health accreditation and continued work is that we
see that it's valuable.
Again, that we uphold the same standards as other state and local health departments and
are providing a high-quality tribal public health program that is specific and meets
the specific needs of our community.
We're identifying those specific needs of our community by reaching out and engaging
our community and asking them to help us understand really the benefits of doing this, and through
the process we've started several new initiatives such as our community gardens, our different
challenges that we're offering, fitness challenges that we offer through our community.
We've initiated a health-in-all-policies framework and presented that to our tribal board.
So I'd say that these are impactful things that we're doing as a tribal health program,
and we see its value already and its impact on our community and the positive response
that we get from our community on these different practices and really these new health programs
and activities that we're doing.
I don't know if I answered—your question was kind of two parts, I know.
Sorry, I was a little long, but I just wanted to let you know some of the activities that
we've offered our community since beginning this process have really enhanced people's
access to new things.
Alexis Bakos: Thank you.
Thank you very much.
We have one more I think question.
Maechi, do you want me to read the one from—I think that's Health Insight?
Onyemaechi Nweke: Yes, please, go ahead.
Alexis Bakos: How did your work merge, if at all, with the area office?
We're from Phoenix, Arizona, and we cover five service units locally and 25 across the
nation.
How do you interweave this work with their aims?
Karrie Joseph: This is Karrie.
I'm not sure I understand which work the question is referring to.
Do you think it's talking about the work of NIHB?
Alexis Bakos: I have a feeling that—Health Insight, I'm not really sure if you can refine
your question a bit.
Is this in response to the work that Ms. Sampson has spoken about?
Onyemaechi Nweke: I suspect that—because I know that there are—does NIHB have area
offices?
Karrie Joseph: No, we work with the area Indian Health Board.
We don't have area offices.
Onyemaechi Nweke: Okay.
I wonder if that's what the person is referring to, the area Indian Health Board.
Alexis Bakos: He's saying yes.
Karrie Joseph: Okay.
Well, the NIHB as an organization, our board of directors, we have one elected tribal leader
from every IHS area, and there's 12 of those in the nation.
And each of the IHS areas, not all but most of them have an area Indian Health Board that
is a non-federal government group.
Those boards, although we serve all 567 tribes in terms of communication, we generally work
through the area Indian Health Boards.
I think that's sort of organizationally, so with that communication and networking and
monthly meetings, we get guidance from the area Indian Health Boards and what's going
on in that area and what is needed by the tribes or what are some of the issues.
And in turn, the area Indian Health Boards help us network information that's going on
here and in Washington, DC, and among the other area Indian Health Boards, or other
areas, I should say.
Onyemaechi Nweke: Thank you.
I think that helped to answer his question.
Okay.
So, I think we're at 4:08.
We have people who have dropped off already.
I want to again thank the panelists for being with us today, and I also want to thank you
for the great work that you are doing with tribes and tribal public health departments.
It's work that's very much needed.
If you haven't filled out the survey, you still have a couple of seconds to do it.
In any case, I'd like to also thank my colleagues, my co-moderator, Dr. Alexis Bakos, and I want
to say that a recording of today's webinar will be available on the registration website
usually within seven to 10 business days.
You will have access to the webinar at that page for about 90 days, and beyond the 90
days the recordings will be archived on the Federal Interagency Health Equity Team's webpage,
and that webpage is minorityhealth.hhs.gov/npa.
Without much ado, thank you very much, again, for participating in this webinar.
We'll connect with you again the next time we host a webinar, which should be sometime
soon.
Thanks, everyone.
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