INTRODUCTION

1. The Olympic Regional Tribal-Public Health Collaboration and Mutual Aid Agreement and Operation Plan: Challenges and Solutions

2. INTRODUCTION • Who I am: • Susan Ferguson • Facilitator for the Olympic Regional Tribal-Public Health Collaboration and MAA and Operation Plan • Contact Information: • Phone: 206-909-0613 • Email: sferguson222@msn.com

3. The Presentation THE OLYMPIC REGIONAL MAA AND OPERATION PLAN: HISTORY OF THE TRIBAL-LHJ MAA DEVELOPMENT PROCESS STATUS OF AGREEMENT TODAY OPERATION PLAN DEVELOPMENT AND IMPLEMENTATION

4. OLYMPIC REGIONAL TRIBAL-PUBLIC HEALTH MAA • Seven tribes and three LHJs located in close proximity on the Olympic Peninsula: • Hoh Tribe • Jamestown S’Klallam Tribe • Lower Elwha Klallam Tribe • Makah Tribe • Port Gamble S’Klallam Tribe • Quileute Tribe • Suquamish Tribe • Kitsap County Health District • Clallam County Health Department • Jefferson County Health Department

5. Olympic Regional Tribal-Public Health Mutual Aid Agreement • Kitsap LHO Dr. Scott Lindquist and Jefferson/Clallam LHO Dr. Tom Locke proposed and supported project • Tribes expressed desire to explore MAA, support and interest • DOH agreed to support work, both for facilitation and some tribal and public health support. Neutral facilitator does not represent any party or DOH and DOH not a party to the agreement • Preexisting conditions: • Interdependent region of state • Strong existing relationship between LHJs and Tribes • Recognized need for coordinated public health response

6. FIRST STEPS • Initial meeting of Scott Lindquist, Tom Locke, Jessica Guidry (Region 2 PHEPR Coordinator) and facilitator to discuss project • Identify appropriate tribal chairpersons and medical directors to contact; Consult with American Indian Health Commission • Initial letter of invitation to chairpersons explaining idea: • Government to government proposed agreement • Work group cannot bind governments • May or may not come to agreement

7. Respect for the Sovereignty of the Tribal Nations • Important to start the process understanding government to government principles • Letter of introduction and invitation was sent from Drs. Lindquist and Locke to the tribal chairpersons with a cc to the medical directors • Letter asked the chairpersons to appoint a representative to the meetings • Tribes selected medical directors, executive directors, public safety/emergency response coordinators, and a community health nurse

8. First Meeting Purpose • To get to know one another • To establish parameters of agreement: decision to have agreement be for these seven tribes and three LHJs, not open statewide but perhaps useful as model for others • To decide scope of proposed agreement: decision to cover emergency mutual aid, some day to day public health operations, communicable disease control and isolation and quarantine • To select three model MAAs to create “Starting Points for Discussion” document • To schedule all meeting dates and locations

9. Models Selected • CDC Menu of Suggested Provisions • LHJ Inter-Jurisdictional Mutual Aid Agreement • Lummi Nation/Whatcom County Health Department draft MAA, deals with isolation and quarantine issues • Portions of 1996 draft MAA prepared by Dr. Locke related to day to day public health operations

10. Underlying Background • Recognition that public health related issues arise everywhere, including on tribal lands; example, substantial exposure • Most tribes have not adopted comprehensive public health codes. Most don’t have persons functioning as local health officers, with related legal authority • Providers in health clinics are not public health practitioners and have a different perspective

11. Definitions • In all MAAs, definitions are extremely important! • Work group defined: • “Tribal Lands” to include land within tribal reservation boundary, tribal and member trust lands, settlement agreements lands and lands under control of the tribal government, or its agents. • “People on Tribal Lands” to include members of the Tribe, members of other tribes that live on tribal lands, and all other people on Tribal Lands (employees, residents, etc). • “Mutual Aid” to mean assistance requested or provided during a public health emergency or disaster, or related to day to day public health services, communicable disease outbreak, isolation and quarantine, or other public health service.

12. PARTICIPATION AGREEMENT EFFECTIVENESS IMPLEMENTATION Agreement effective upon signing by any one LHJ and any one tribe Remains in effect until such time a party gives written notice of withdrawal Termination by one party does not affect continued agreement operation so long as one LHJ and one tribe remain parties Expressed desire to help one another but no legal duty to provide mutual aid All actions voluntary and in each party’s sole discretion A party must take into consideration whether giving aid will unreasonably diminish its capacity to provide basic public health services to its own jurisdiction

13. Worker Registration/Liability • Each party agreed to take all actions necessary to qualify and maintain qualification of its own personnel, employees or volunteers as emergency workers under RCW 38.52 and WAC 118-04 • Party requesting aid responsible to seek issuance of mission number from state EMD • Parties may condition their willingness to respond and continuance of their response on issuance of a mission number and compliance with RCW 38.52 and WAC 118-04 • To extent local, state or federal governments do not provide complete waiver, immunity, indemnification, reimbursement, or other payment related to liability, each party legally responsible for own liability.

14. COMMAND AND CONTROL • This provision recognizes need for qualified and experienced person to function in LHO role and the need for laws to govern the response • The issue: how do sovereign governments that function alongside one another want to address their responsibilities related to disease that crosses the borders? • Without tribal public health codes, persons on staff with public health expertise, or the need (or budgets) to create full time public health departments, some tribes have authority and responsibility to deal with issues that affect public health, but not the public health infrastructure

15. Option Two CREATION OF TWO OPTIONS Option One Party tribal government will exercise own public health authority Parties understand that ability or willingness of Party HD to respond within the tribal jurisdiction may be limited Party TG may still seek technical assistance from the Party HD Party TG may grant Party HD in its closest geographical proximity permission to exercise public health authority Either Party HD or Party TG may refuse, decline, withdraw or rescind the grant of authority at any time

16. What Laws Would Apply? • Issue: Without a tribal public health code that addresses the specific event, how does a responding LHJ public health nurse or doctor know what public health laws apply on tribal lands or to people on tribal lands during the response? • Tribe may choose to adopt federal, state or local law as tribal code temporarily to address the specific public health threat. • Specific details implementing this provision were developed by the work group for inclusion in the Operation Plan

17. SOME WASHINGTON LAWS THAT A TRIBE MIGHT ELECT TO INVOKE • TUBERCULOSIS CONTROL • SEXUALLY TRANSMITTED DISEASE CONTROL • SUBSTANTIAL EXPOSURE TO BODILY FLUIDS • COMMUNICABLE DISEASE CONTROL • ISOLATION AND QUARANTINE • BIOMEDICAL WASTES • EMERGENCY RESPONSE

18. IF TRIBE HAS ADOPTED TRIBAL PUBLIC HEALTH CODE • If a Party TG has adopted a public health code that addresses the specific public health response, then the Party HD exercises the grant of authority in conformance with tribal, as well as the adopted or applicable federal, state or local public health laws. • If there is a conflict between or among the legal requirements, the Party HD may decline to accept, or withdraw its acceptance of, the authority

19. Dispute Resolution • Issue: How do the parties resolve disputes between them, and what effect does tribal sovereign immunity have on the process? • The attorney representing the Suquamish Tribe proposed dispute resolution through direct discussions, mediation, and binding arbitration. • Arbitration award enforceable by Tribal Court or Federal or State Court • Tribal limited waiver of sovereign immunity granted solely for purpose of dispute resolution and as limited by process set forth in agreement. • This proposal was accepted by the work group.

20. Outcome • All governments considered the MAA over summer 2009 • Attorney reviews, as well as reviews by insurance providers, admin committees, tribal councils, BOH and BOCC • LHOs were asked to make presentations to some Tribal Councils in fall 2009 • All governments signed the agreement as of January 2010 • First agreement of its kind: Groundbreaking work • Dedicated, diligent work group

21. OPERATION PLAN DEVELOPMENT • Work group formed including representatives from all MAA participating governments • Meetings March through August 2010, and an additional teleconference in September 2010 • Five attorneys representing tribes and LHJs attended several meetings, reviewed the Plan and participated in preparation of BOH and Tribal Council Resolutions

22. FIRST STEPS • At the same time that the parties are determining the scope of the emergency, that is, whether it is low, moderate or high level of severity, they must also think about what laws will apply and whether the tribal government wants to exercise its own tribal public health authority or offer to grant authority to the health department or district.

23. The Process of Offering and Accepting the Grant of Authority Boards of health TRIBAL COUNCILS Tribal Councils decide at the time of the emergency whether they want to grant public health authority to the health department or district. A model tribal council resolution is attached as an appendix to the Plan for use at the time of the emergency. • Boards of Health are considering resolutions now that authorize health officers to make the initial decision to accept or deny a tribal offer of grant of authority. These resolutions will be attached to the Plan as appendices.

24. TRIBAL RESOLUTIONS • Party HDs and TGs consult re: whether tribal code has been adopted and what specific laws the Tribal Council may choose to adopt temporarily to respond to the emergency. The parties also consult regarding the appropriate duration of law adoption given nature of emergency.

25. NEXT STEPS • If Tribal Council adopts the resolution, a certified copy is given to health department/district. • Health Officer decides whether to accept the tribal grant of public health authority. • If accepted, tribe informs enrolled members and other People on Tribal Lands of the adoption of the resolution, its scope and duration. • Health Officer seeks affirmation by BOH at next meeting, but previous actions taken valid regardless of whether affirm. • Health Officer and Tribal Governments may rescind or withdraw the tribal grant of authority at any time. • If needed, tribe may extend duration of resolution.

26. Authorized Representatives • The Plan provides that Authorized representatives, those people who are authorized to make or agree to requests for assistance (or know how to contact the decision-maker in the emergency) are listed on the Washington SECURES website.

27. Three levels of Activation • Low level, moderate level or severe level • Parties consult to determine level • Example of low level is training or technical assistance • For low level, parties can decide whether to seek a mission number

28. MODERATE LEVEL • Example: an event that impacts a single health department or tribe • The parties’ emergency operation plans must be activated • The parties must operate under the incident command system • The parties must seek and obtain a mission number from the state EMD (health departments or districts seek them through their county departments of emergency management; tribes can seek them directly)

29. High Severity or Complexity • Disaster impacts multiple jurisdictions or causes significant impacts that overwhelm response structure of a Party HD or TG

30. Distinction between low/moderate events and high severity events • In events of low or moderate severity, the parties can request assistance directly from one another, take the necessary steps set forth in the Plan, and then complete the resource request form • In events of high severity, a single coordination and receiving point for all mutual aid requests may be established, called the Local Mutual Aid Team (LMAT)

31. LMAT ACTIVATION • LMAT activated following conference call with Party HD and TG representatives and DOH to assess incident and need • LMAT staffed by one or two Party HD or TG personnel • LMAT activated under mission number • LMAT receives requests for aid and matches resources to needs • May use form in Appendix 5

32. RESOURCE REQUEST FORM: THREE STAGE PROCESS • Contacts made by ARs or designees • Form is in Appendix 4 • Part 1: Filled out by Requesting Party HD or TG (The Request) • Part 2: Filled out by Assisting Party HD or TG (The Response) • Part 3: Filled out by Requesting Party HD or TG(The Acceptance) • Must complete form fully before departure of Assistance, if possible, or unless electronically or logistically impossible to do so

33. LOGISTICAL DETAILS COVERED • Staging and deployment • Deployment briefing contents • Worker registration • Demobilization • License/Credential Requirements • Reimbursement • Recordkeeping

34. Plan Appendices • Appendices 1A and B: Definitions; Acronyms • Appendices 1C,D and E: BOH Resolutions • Appendix 1F: Partial List of Laws • Appendix 1G: Model Tribal Resolution • Appendix 2A: LMAT Responsibilities

35. PLAN APPENDICES • Appendix 2B: Requesting Party HD Mobilization Process Checklist • Appendix 2C: Assisting Party HD Mobilization Process Checklist • Appendix 2D: Assisting Party HD’s Demobilization Process Checklist • Appendix 3: Authorized Representatives (now on SECURES) • Appendix 4: Resource Request Form • Appendix 5: Mutual Aid Resource Tracking Form

36. TRAINING • The health departments and tribes are now scheduling training sessions in anticipation of participation in a statewide exercise in 2011.

37. Contact Information • Susan Ferguson • Phone: 206-909-0613 • Email: sferguson222@msn.com

38. QUESTIONS?

39. Thank you!