Editor’s Note: This article is a compilation of information obtained while attending a few of the meetings on healthcare options and opportunities being considered by the Salt River Pima-Maricopa Indian Community for its members.
The Salt River Pima-Maricopa Indian Community (SRPMIC) has been exploring, reviewing and analyzing a wide range of options and opportunities to address the growing healthcare needs of its people and to plan for a sustainable future for the tribal Community. Health and wellness of the Community is extremely important, and some of the points to be considered include impacts associated with the implementation of the Affordable Care Act, the governmental budget issues associated with Indian Health Service (IHS) funding, and the health disparities of Native Americans, which are disproportionally higher than other populations, are focal points to be considered in addressing health care for SRPMIC.
SRPMIC Vice-President Martin Harvier said, “We need to explore options. This includes looking at Public Law 93-638 compacting [to manage our health care funds] to provide services that [our] people need, and that IHS cannot provide or don’t provide right now.” Harvier said, “If there are opportunities to provide services [that will] impact our members in a good way, then I think this is something we really need to sit down and think about as a Council.”
He added, “We need to talk about what direction we should go. Are we going to continue to go in the same direction as we are now, utilizing direct services [funded and operated through the Phoenix Area IHS office]? … Currently, the Community is [partnering] with our Salt River Clinic staff to support and provide [additional healthcare] services that are paid for by tribal funds [and tribal grants]. Right now as a tribe we are able to provide funding to do this, but in the future, as things change, [we need to look at new ways].”
A review of healthcare organizations will need to consider several key components associated with operation aspects of health care systems, such as an efficient electronic healthcare records system; viable billing, accounting and revenue cycle systems other than the current IHS Resource and Patient Management System (RPMS); as well as the development of healthcare provider and staffing contracts, employment provisions, operational accreditation requirements, refinement of policies and procedures at all levels of operations, and much more.
The task may sound overwhelming; however, many tribes have successfully taken over the operation and management of their healthcare systems, whereby tribes can engage in tribal self-determination contracts, self-governance compacts, and establish funding agreements with IHS. The provisions mandated by Congress in P.L. 638 reflect the main tenets of the nation-to-nation relationship between the United States and the American Indian tribes and Alaskan Natives throughout the country.
Current Status of Healthcare at SRPMIC
Currently, healthcare delivery for SRPMIC tribal members is primarily provided through the Salt River Clinic, located within the boundaries of the Community. The unit is an outpatient (ambulatory) clinic offering general medical care, podiatry, women’s health and pediatric care provided by three physicians on staff along with other visiting physicians. In addition, the clinic provides pharmacy services, dental services, prevention and intervention services, and wellness programs such as diabetes-focused services, community health and public health services, and more. The tribe has contracted to provide behavioral health and mental health services which are operated at other sites outside of the clinic
The clinic opened in 1987 in conjunction with IHS and the SRPMIC to meet the immediate needs of the tribal members in the area, with the notion that additional health services would be provided through the Phoenix Indian Medical Center (PIMC). The Salt River Clinic is an extension of the Phoenix Indian medical Center and as such is an entity of the Phoenix Area Indian Health Service (PAIHS), whose Phoenix Service unit provides IHS direct care to SRPMIC tribal members.
Over the years, the ability to provide additional health services has been hindered by the availability of IHS funds and the space capacity of the current facility, which has created challenges that have impacted the delivery of health services in the Community. In response over the years, SRPMIC has supported critical positions within the Salt River Clinic as a commitment to the health of their members.
Over the last 12 months, very visible challenges have occurred that have impacted the Salt River Clinic, which included the physical structure of the facility; flooding within the building as a result of rainstorms and interruption of phone and data lines provided by IHS, to name a few. Upgrading and/or renovating the clinic’s facilities is a must to meet increased patient demand as well as comply with updated building codes, meet healthcare regulatory requirements, provide efficient means to manage utilities at the facility, and more.
All of these incidents and demands have impacted care being provided to tribal members of the SRPMIC.
Different Models of Indian Healthcare Delivery System
During August, SRPMIC leadership, along with the director and assistant directors of the Health & Human Services Department, traveled to visit three distinct tribal communities that utilize different types of healthcare systems to provide care and services to their tribal members.
The SRPMIC contingent was seeking information to help the Community determine the value and viability of utilizing the mandates stated in Title I and V of P.L. 93-638 to become full owners in the delivery of healthcare to tribal members and other Native Americans from federally recognized tribes and nations.
Harvier summarized his goal for making the visits: “I would like to see how other tribes run their [healthcare] organizations and how they benefit from running their own healthcare organizations. I think healthcare is going to be very beneficial to us as a tribe, as far as [generating] funding and [capturing] revenues from people who utilize different insurances [or payer sources]. The ability to gain additional funding will enhance what we are currently providing or [allow us] to provide new services that we need.”
The following summary highlights characteristics of each healthcare system that was visited.
The Jamestown Family Health Center (JFHC)
The Jamestown Family Health Center (JFHC), owned and operated by the Jamestown S’Klallam Tribe in Sequim, Washington, provides primary healthcare services to anyone in the area, including non-tribal members as part of the tribe’s Department of Health and Human Services. A full day of meetings with healthcare executives at JFHC gave the SRPMIC contingency valuable information on the model of healthcare used to delivery services and the emphasis placed the operational aspects of the business, like revenue management and their tribal member benefits program.
Their delivery of care has some unique aspects to their operations. The S’Klallam Tribe uses a patient-centered medical home model that utilizes segmented care delivery pods for different specialties to coordinate care and patient-care teams to deliver and communicate care. A unique aspect is that their reception system for incoming calls (their call center) is located in a separate room, away from the patient appointment and walk-in counter. This allows for limited interruptions and more privacy of phone calls. It also allows staff to continually make calls and follow up with patients throughout the day to ensure scheduled appointments are kept and enhance communication of important information.
Another key point concerning the Jamestown Family Health Center is that they are not a direct-funded clinic through the IHS, therefore they cannot provide free services to tribal members. The tribal healthcare system provides services to tribal and non-tribal people in the Jamestown area, as long as they have qualified insurance. The tribe purchases insurance for each tribal member who does not qualify for Medicare or Medicaid so their services are covered at the health center. The purchase is through their purchased referred care (contract care) dollars
Enrollment of the S’Klallam Tribe (their “tribal citizens”) is just under 600 people. Many tribal members are age 50 and older, so many of them qualify for Medicare coverage. Many tribal members younger than 65 have their care covered through Medicaid. Currently, the Jamestown Family Health Clinic has 9,510 active patients, with 2,000 people enrolled in 2015. Through August of 2015 the health center had logged about 54,000 patient visits.
The IHS funds that the tribe receives are utilized to fund their specific tribal member services, like diabetes programs, community health representatives, patient advocates, wellness initiatives for its members, as well as costs of certain ACA insurances, and more.
Southcentral Foundation (SCF)
The Southcentral Foundation (SCF) is an Alaska Native nonprofit healthcare organization established by the tribal authority of Cook Inlet Region, Inc. in 1982 to improve the health and social conditions of Alaska Native people, enhance culture, and empower individuals and families to take control of their lives. In 1998, SCF began a process to assume management of programs at the Anchorage Native Primary Care Center and in 1999 became co-owner and co-manager of the Alaska Native Medical Center, along with the Alaska Native Tribal Health Consortium (a consortium of 15 Alaska Native organizations). Before this, all healthcare services were provided by IHS.
Southcentral Foundation provides a full range of health care and wellness services to over 65,000 Alaska Native and American Indian peoples whose coverage area stretches 107,400 square miles across south central Alaska. Primary, dental, optometry and elder care, as well as other health-related services, are provided. Other services include substance-abuse treatment, transitional living, adolescent residential mental health, home health, complementary medicine, traditional healing and youth internships.
Southcentral Foundation operates similar to other P.L. 638 contracted facilities by utilizing federal (IHS and Medicare) and state government funding (Medicaid), private foundations and third-party billing, which amounts to an organization that has an annualized budget of around $290 million and 1,873 employees, many of whom are Alaska Native.
The meetings with SCF spanned about a day and half, which included a review of their business model and how their Native history is applied to their business operations, operational practices, including coordinated care teams and unique patient care departments that meet patient needs. SCF provided examples of how human resources and the business development and training areas support and help drive initiatives at SCF.
Every presenter from SCF emphasized their focus on their Nuka System of Care, which includes an understanding of how healthcare is really about human beings. Southcentral Foundation wants patients to know they are customers and owners of the business, hence the reason they call their patients “customer-owners.”
Another significant point is the focus on understanding and knowing “the relationship” providers and staff must have and must build with their patients. Their customer-owners have the most control over their health outcomes—they decide when to pick up their medication, customer-owners decide what to eat and drink, and have control over many aspects of their life that effect their care.
The business operations focus on their mission, “Working together with the Native Community to achieve wellness through health and related services,” and their vision, “A Native Community that enjoys physical, mental, emotional and spiritual wellness.” Every service offered falls within this framework.
Case in point, the primary care delivery system applies an integrated care team model that many health organizations see as best practice and are working to implement. The unique aspects of SFC include their primary care pods are set up with a focus on patients (“customer-owners”); the work flow is more parallel in design and not provider-driven; in additional to standard treatment rooms, there are consultation rooms that are more set up for comfort and discussion; there are large central integrated team pod areas in each clinic that includes medical assistants, RN’s, Nurse Case Managers, Case management support, behavioral health and Pharmacist access at all times, along with the medical provider. In this office/pod setting the doctor’s work area (desk) is next to all the other staff, which allow for easy access to ask questions, get answers, get authorizations and address immediate patient needs.
SCF utilizes an elder council and other patient feedback methods to gain information on their performance and to get input on how to continually improve care. For example, the input from these groups required SCF to change certain systems to provide same-day access to a primary care provider, expand integration of care, monitor culturally appropriate care, improve wait times and much more. During their visit, the SRPMIC contingency were exposed to many aspects of the Nuka System of Care, which provided a well-rounded review of business philosophies and best practices of an Alaska Native health system that has been in operation for more than 15 years.
The Chief Andrew Isaac Health Center (CAIHC)
The SRPMIC contingent also visited the Chief Andrew Isaac Health Center in Fairbanks, Alaska, which opened in 2012. Operated by the Tanana Chiefs Conference, the health center provides an array of outpatient (ambulatory) services that include diabetes care, immunizations, obstetric care, orthopedics, pediatrics, radiology, women’s health, dental, vision, prevention, substance-use rehabilitation, patient advocacy, pharmacy, community health aides, and a community health center. Violet Mitchell-Enos stated, “The Chief Andrew Isaac Health Center has some very interesting features; the unique behavioral health treatment [mode] incorporated native camps, and most important they are able to produce measurable outcomes to this type of behavioral treatment.” They had a Community Health Aide, who are trained providers for the outlying villages. The Aides who function as a step down from a Physician’s Assistant. The Community is very interested in learning more about this project.
SRPMIC Assistant Community Manager Lena Jackson-Eckert stated, “I’m glad [SRPMIC] is looking at different organizations. I’m glad we have [health services staff] who are willing to think outside of the box and look for better ways [to deliver healthcare] and not rely on IHS as the only way to provide services … We have an opportunity to make some changes, with the help and support of our community.”
The SRPMIC will continue to review other tribal healthcare organizations to gain the breadth of knowledge needed to make an informed decision on the future of healthcare at SRPMIC. This endeavor will include meeting with Community members and their family to share information and gather their input as tribal leadership moves forward to craft a healthcare system for the Community.
Details on the progress of the health care future at SRPMIC, including timelines and construction proposals will be forthcoming in upcoming issues of Au-Authm Action News, or through the utilization of other communication methods.