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National Indian Health Board
Exploring Tribal Public Health Accreditation
Aleena M. Hernandez, MPHRed Star Innovations, LLC
September 15, 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 21st Century
Dixon M, Roubideaux YAmerican Public Health Association, 2001
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
2000 Census
• 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
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, checkerboardSingle tribe applicant versus consortium of tribesHealth Department Size Level of Public Health ActivityMulti-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 PanelReview past accreditation efforts in Indian countryExplore/Discuss the potential for voluntary public health
accreditation in Indian countryBenefits, challenges, barriers, ideas…
Gather recommendations from Indian countryProcess, 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 HDsConvene regional roundtablesFacilitate a “Tribal Think Tank” to address relations
Public Health Accreditation BoardNational 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 ObjectivesBased 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 relationshipOverlapping JurisdictionsResponsibility and AuthorityFederal transfer of responsibility and
funding for public health functions to states
Tribal Consultation
1994 – Bill Clinton introduced Tribal Consultation PolicyFacilitates formal government to government relationsRequires 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
Next Steps – In Progress 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 Develop tribal version of the Standards, Measures
and documentation
PHAB – Tribal Standards Workgroup Conducted a call for Workgroup volunteers in July
People with knowledge and understanding of Tribal Public Health Systems
Workgroup volunteers selected in August Includes members of original Standards and Measures
Workgroup 1st Workgroup meeting to be held in conjunction with
NIHB Annual Consumer Conference Scheduled to be completed in March 2011
2010 NIHB Tribal Public Health Profile Assess readiness for public health accreditation Provide a baseline to measure growth and change in
tribal public health capacity Prioritize development and resource allocations Advocate for resources and policy on behalf of
Tribes and public health Identify technical assistance and quality
improvement needs
Tribal Standards WorkgroupTribal Representatives
Michael Allison, MPH Donald Vesper, REHS,MPH Loren Sekayumptewa, MSW Debra Smith, RN, PHN, MSN JT Petherick, JD, MPH Annette James, RN Gary Quinn, MSW Glenda Davis
Standards Development WG Jane Smilie Barbara Worgess, MPH Steve Ronk, MPH Torney Smith, MSHE
Profile Participants
Tribal Health Organizations Tribal Health Departments Indian Health Service Units (Hospitals, clinics,
and satellites) Indian Health Boards or Intertribal Councils with
Tribal Epidemiology Centers Urban Indian Health Centers
Profile Highlights: Assessment 44% conducted community health assessment in the
past 3 years 47% of Tribal Health Departments; 46% percent of
IHS Facilities: 60% Area Indian Health Boards and 74 % of Urban Indian Health Centers have data sharing agreements with state health departments
66% evaluate public health activities and/or services
Profile Highlights: Policy Development
Regulatory activities are provided primarily by the Tribal Health Departments or IHS in tribal communities
Less than 40% receive funding from their state health agency through the CDC public health preparedness cooperative agreement.
Over 40% have a research policy or ordinance for reviewing and approving health research.
Profile Highlights: Assurance
59 % serve populations that travel 50 miles or more to access their services
83% help enroll eligible individuals into public benefit programs, such as Medicaid/Medicare.
Collaborative relationships with other Tribal Health Organizations were most frequently rated effective or highly effective
Profile in Summary
Tribes are providing a wide range of public health activities across domains
Further exploration is needed to understand:Tribal public health performance Readiness for public health accreditationTechnical assistance and quality improvement needs
http://nihb.org/docs/07012010/NIHB_HealthProfile%202010.pdf
RWJF – PHSSR Grant 2010 RWJF Grant: Public Health Systems and Services Research
Partnership with Nat’l Opinion Research Center (NORC) Enhance data analysis and conduct initial comparison to state
and local health departments Gather additional qualitative data Recommend future data collection enhancements to produce a
profile for harmonization with State and Local Profiles (ASTHO and NACCHO)
Thank You
Aimee Centivany, MPH
National Indian Health Board
Aleena M. Hernandez, MPH
Red Star Innovations, LLC
