National Indian Health Board Exploring Tribal Public Health Accreditation

1. National Indian Health BoardExploring Tribal Public Health Accreditation Aleena M. Hernandez, MPH Red Star Innovations, LLC January 21, 2010

2. 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

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

4. American Indians and Alaska Natives • 564 Federally-recognized Tribes in 35 States1 • 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

5. AI/AN alone 2.5 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 affiliation 74% IHS Service Population 1.5 million 2000 Census

6. 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

7. 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

8. 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

9. 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

11. 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

12. 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

13. 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

14. National Indian Health Board Exploring Tribal Public Health Accreditation

15. 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

16. 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

17. 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

18. 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

19. Public Health Accreditation BoardNational Indian Health Board Tribal Think Tank December 16, 2009 Tucson, Arizona

20. 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

21. 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

22. 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

23. 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.

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

25. 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

26. 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

27. 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

28. 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

29. Thank You Aimee Centivany, MPH National Indian Health Board acentivany@nihb.org Aleena M. Hernandez, MPH Red Star Innovations, LLC aleenamh@redstar1.org