TRIBAL PERSPECTIVES ON QUALITY IMPROVEMENT AND ACCREDITATION

1. TRIBAL PERSPECTIVES ON QUALITY IMPROVEMENT AND ACCREDITATION Aleena M. Hernandez, MPH, Red Star Innovations Rachel Ford, MPH, NW Portland Area Indian Health Board Nancy Young, Institute for Wisconsin’s Health, Inc.

2. TRIBAL PERSPECTIVES ON QUALITY IMPROVEMENT AND ACCREDITATION National Network Of Public Health Institutes – Open Forum June 19, 2012 Aleena M. Hernandez, MPH, Red Star Innovations Rachel Ford, MPH, NW Portland Area Indian Health Board Nancy Young, Institute for Wisconsin’s Health, Inc.

3. Welcome and Introductions

4. Objectives • Provide an overview of the historical basis of Indian health and Tribal health departments • Share work that has been done nationally to inform accreditation and prepare tribes • Share regional approaches to build capacity and prepare Tribes for accreditation • Discuss opportunities, challenges and future directions

5. Tribal Sovereignty • Tribes are inherently sovereign • Government-to-Government relationship established through: • Treaties • U.S. Constitution • Federal legislation • Court decisions

6. TRIBES • 566 Federally-recognized Tribes in 35 States • Sovereign; individually governed • Distinct culture, language and traditions • Landbase and non-landbase; checkerboard • Tribal membership • Economic diversity • Unique history

7. American Indians and Alaska Natives2010 Census • AI/AN alone 2.5 million (1%) • AI/AN in combination with 2.5 million one or more other races • Total AI/AN 5 million (1.6%) • IHS User Population (registered) 2.5 million • IHS User Population (active) 1.5 million

8. States with Largest AI/AN Populations Total Number of AI/AN • California • Oklahoma • Arizona • Texas • New Mexico Percent Population • Alaska • Oklahoma • New Mexico & South Dakota • Montana

10. Historical Basis for Indian Health

11. 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

12. 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

13. Federal Trust Responsibility • Established by treaties/court decisions/legislation • Land and resources were ceded to the U.S government by treaty, forced removal or other means • Provided, in exchange, with health, education, social services, housing and other services

14. Indian Health Service • Under the US Department of Health and Human Services • Comprehensive, primary health care system and some public health services • Only federal agency to provide direct medical care • 12 Service Areas

16. 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

17. Tribal Public Health Systems

18. Key Stakeholders Tribal Public Health Systems Assuring the conditions for community (population) health

19. 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 • Tribes supplement contract services with other public health services

20. Indian Health Boards/Inter Tribal Councils • 1970’s Tribes began to form organizations to advocate on behalf of their collective interests • Governed by the highest elected official of member tribes • National, IHS Service Area, State, Region, other commonalities • Tribal Epidemiology Centers funded by CDC and IHS

21. Unique Context for Tribal Accreditation • Tribal sovereignty; government-to-government relationships • Land base and non-landbase; checkerboard • Tribal Program Management or Direct IHS service • Multi-jurisdictional relations with local and state health departments to address health needs • Wide variation in public health activities, structures, partnerships

22. Preparation for Tribal Accreditation • Accreditation Readiness Workshops • Accreditation 101 – process and benefits • Self-Assessment using WIQI/IWHI Tool • 3 Prerequisites • Quality Improvement Trainings • Role of public health law and tribal health code development • Accreditation Roundtables • Facilitation and technical assistance with prerequisites

23. Common Challenges • Defining the “Tribal Health Department” • Tribal clinics and public health services • 638 Programs and the role of IHS • Health and Human Services • Defining public health • Infrastructure and resources to prepare for accreditation • Tribal law and policy; enforcement • Data collection, management; surveillance

24. Common Opportunities • Strengthen self-determination • It’s about the health of our communities • Improve health services and public health performance • Improve communication and coordination • Standards and measures provide guidance • Establish Tribe as a “public health authority”