Regional Referral Centers: “Improving Access to Specialty Care”

1. Regional Referral Centers:“Improving Access to Specialty Care” Portland Area Facilities Advisory Committee (PAFAC)

2. Presentation Outline • PAFAC Charge & Recommendation • Benefits of a regional referral center in Portland Area • Guiding Principles • Pilot Study overview and findings • Address questions/concerns on moving forward

3. PAFAC Charge • …to provide recommendations to the Director, PAIHS, on issues related to healthcare facilities and staffing. • Initial Task: Make recommendations to allow regional healthcare facilities and Area-wide medical centers to be ranked under the revised IHS Healthcare Facilities Construction Priority System (HFCPS).

4. The PAFAC’s Recommendation • Fund a “Demonstration Project” or projects • A multi-tribal specialty care referral facility • At least one in the Portland Area • The 1st of 3 to be built in the Portland Area • To include planning, design, construction, and staffing of regional referral center(s) that will provide secondary care referral services to Portland Area Tribes.* *NPAIHB passed Resolution No. 10-01-04 on 10/22/09

5. What is a Regional Referral Specialty Center? A healthcare facility that provides culturally sensitive access to specialty care through referrals from primary care facilities operated by the participating tribes.

6. Benefits of a Regional Referral Center • Decrease dependence on CHS resulting in cost savings • Increase access to all levels of specialty care • More timely access to care • Reduce waiting period for contract health • Culturally-relevant healthcare • Primary Care remains at, and is best delivered at the local level

7. Why this approach? INNOVATION, CHANGE.. The Demonstration Project would • Provide improved access to more comprehensive care for dispersed Tribal populations. • Have a “specialty care” focus that compliments community-based primary care. • Be based on multi-tribal partnerships. • Make use of telemedicine when possible. “…in order for us to get the support that is so desperately needed, we need to demonstrate a willingness to change and improve.” -- Dr. Yvette Roubideaux, Director Indian Health Service Open Letter to Tribal Leaders, June 2, 2009

8. The Influence of Portland Area Tribes Portland Tribes: • Have a unique ability to collaborate • Share common goal: provide culturally-sensitive care to patients • This sense of partnership guided the Master Planning Process of 2005. • These attributes carry over to the PAFAC and their recommendations.

9. Partnerships Portland Area Tribes = Collective Power Examples of successful partnerships that have resulted in better services for users: • Healing Lodge of the Seven Nations • SDPI Consortiums (i.e., Southern Oregon) • Northwest Washington Indian Health Board • Northwest Portland Area Indian Health Board

10. Guiding Principles Such a facility will bring new resources: • Additional services on a direct care basis. • Current local resources and services remain unchanged. • Full consultation among all involved Tribes before any advancement of the facility. • Governance will be with the consent of the governed – the participating Tribes. • Concept will be self-sufficient (revenue-stream) • Range and scope of services provided will be determined based on the need of the participating Tribes and communities. • Size, staffing, location, other pertinent aspects

11. Why a Demonstration Project? • Current IHS healthcare resources do not fully address the needs of small, geographically dispersed Tribes. • CHS is inadequate. • Small, isolated populations do not justify direct service Specialty Care. • Current IHS methodologies for healthcare facilities construction funding are inequitable. • Areas that service predominantly small Tribes have been left out.

12. Terminology of the Pilot Study • CHSDA – Counties defined all or in part as the Contract Health Service Delivery Area for a particular Tribe. • Primary Service Area (PSA) – A group of communities and its population for which, at a minimum primary care is planned and resourced. • User Population – The number of Active Registrants in the healthcare system that have used the system in the last 3 years. • Workload – The number of annual Indian patient visits for primary care and/or specialty care at a service unit or Tribal clinic.

13. Pilot Study Findings Portland Area Regional Specialty Care Referral Centers must: • Rely on existing Primary Care at Tribal clinics and service units • Be near a population center that supports hospitals • For recruitment/retention of high skilled Specialists • Be near a transportation hub • Facilitate Tribes’ access to the facility • Demonstrate prelim. planning criteria for use by IHS • Sufficient to adapt the IHS facility planning process • Determine facility workload and size • Travel Distance • Alternate Resources

14. 30+ Hospitals 8 Universities/colleges 1 Major Medical School SeaTac International Airport I-5 Corridor 8 Hospitals 5 Universities/colleges Spokane International Airport I-90 Corridor 15+ Hospitals 8 Universities/colleges 1 Major Medical School Portland International Airport I-5 Corridor

15. Cardiology Orthopedic procedures Endo/Colonoscopy Rheumatology Dermatology ENT Pulmonology GYN “Scope” Surgery Possible Referral Services • Final range of services for the Referral Center will be determined during planning phase • **These services would be provided on a direct care basis within IHS system instead of utilizing CHS resources.

16. Why Telemedicine? • Improved Access • It brings healthcare to patients in remote location • Cost Efficiencies • Better management of chronic diseases • Shared health professional staffing • Reduces/eliminates travel • Fewer or shorter hospital stays • Improved Care • Reduces travel and related stress to patients

17. Specialty/Primary Care Education/Information Continuing Education Education Seminars Peer-to-peer support Telemedicine • Dermatology • Ophthalmology • Mental Health • Cardiology • Pathology • Imaging • Radiology • Pathology • Cardiology • Remote Monitoring • Blood Glucose • EKG • Final range of services for the Referral Center will be determined during planning phase

18. Initial Task Timeline • January 2008 • Initial charge/task from Director, PAIHS • February – April 2008 • Develop Pilot Study Concept • November 2008 • Met w/ IHS Director Bob McSwain • Pilot Study approved and funded by IHS • March – October 2009 • Pilot Study contract finalized - Mar • First Draft Pilot Study completed - Aug • NPAIHB Supporting Resolution passed - Oct 22, 2009 • Pilot Study Final Report completed - Oct 30, 2009

19. Initial Task Timeline • November 2009 • Met with IHS Director Dr. Roubideaux • March – Sept 2010 • Tribal-IHS Director listening Session - Mar • PAFAC participated • PAFAC sent follow-up letter - Aug • requested $300K for initial planning • ATNI supporting resolution passed - Sept • January 2011 • Follow-up letter on planning funds to IHS Director • April 2011 • Tribal Leader - PAFAC Forum, Ocean Shores, WA

20. Why a Demonstration Project Now? • IHS HQ acknowledgement • The current system does not address all healthcare needs • Smaller individual Tribes ≠ Specialty Care • IHS Priorities for innovation and increased access to care • National focus on healthcare reform and Affordable Care Act • Other Areas are eager to act on regional referral concept. (California, Nashville, Bemidji, Oklahoma)

21. PAFAC Membership - 2012

22. “Health Care Funding for Pacific Northwest Tribes Is Seriously Inadequate IHS funding is appropriated annually at the discretion of Congress and is not adequate to meet the health care need of Native American people. This ongoing funding deficit is a major factor in cancer-related and other disparities experienced by Native populations. The Institute of Medicine (IOM) has stated that closing the gap on health disparities for this population will require a national recommitment; especially in the form of increased Federal funding that would allow patients timely access to specialty care.”1 1Facing Cancer in Indian Country: The Yakama Nation and Pacific Northwest Tribes; President’s Cancer Panel, 2002 Report; U. S. Department of Health and Human Services, National Institute of Health, National Cancer Institute

23. Discussion? For more information visit the NPAIHB web site under “Indian Health Policy” page http://www.npaihb.org/policy/portland_area_facilities_advisory_committee/