The Confederated Tribes of the (2015)

Tribal code

Ask Donna

What actually matters in this document.

Text

The Confederated Tribes of the

Warm Springs Reservation of Oregon

and

The Indian Health Service

Annual Health System Report

for the

Warm Springs Indian Reservation

November 3, 2016

2016 Edition

Reporting Information through 2015

2015 Annual Health System Report

Table of Contents

Executive Summary…………………………………………………………....1

SECTIONS

Section 1: Overview of Health Delivery System.………….…………5

Section 2: Customers…………………..………………………….….9

Section 3: Services……………..……………………………………35

Section 4: Resources Availability and Use……………..…………...85

Section 5: Evaluation ………………………………………………115

EXECUTIVE SUMMARY

This Annual Health System Report includes information about the community members

served by the health system at Warm Springs, the services provided and resources

utilized during 2015 and prior years. It is published in response to requirements set

forth within the Joint Comprehensive Plan for the Delivery of Health Services to the

Warm Springs Indian Reservation. In adopting the plan, and the requirements for this

report, the Tribal Council recognized that good and reliable information is needed as a

foundation for developing sound policy and for setting priorities and designing effective

programs to serve the Warm Springs community. The report is also considered an

important tool to communicate information, to the community, about its health status,

and the services and resources available to provide health services. It is designed to

respond to questions put forth by the health plan.

•

How do we best know and focus on our customers?

How do we design and deliver high quality responsive health services?

How do we deploy and maximize resources toward a healthier community?

How do we maintain and forge strategic alliances and relationships that augment

and support the overall effort?

How do we assemble and report information to support informed decision

making?

How do we evaluate our progress and our effectiveness?

The health plan sets forth requirements for this report and assigns responsibility to the

Warm Springs Joint Health Commission to direct its publishing and improvement. The

Commission took formal action adopting the format and content of this report, and

recommending information collection efforts to improve it in the future.

The Commission is responsible under the plan…”to adopt coordinated health program

priorities, strategies and action plans each year, and monitor their progress”. Initial

efforts have focused on addressing program deliverables, including reporting, as well as

those reported herein. To guide priorities, the Commission has adopted a strategic

wellness and prevention approach aimed at the following outcomes.

1. Each child has had the advantage of knowledgeable care, concern and safety

during its mother’s pregnancy to ensure that child is born with maximum health

and brain development.

2. Each child, during its critical first years of life, has optimal experience with

primary caregivers who are educated and motivated to ensure a healthy happy

start to life.

3. Each child’s experience in early childhood education includes all appropriate

tools upon which to build a healthy happy life.

4. Each school age child is engaged in a system of age specific learning and

incentives for healthy lifestyle and strong interpersonal skills as a platform for a

bright future.

5. Each child having formative and environment related issues has access to a

support and treatment system to ensure that he/she can maximize life

experience and potential.

6. Each young adult at reproduction age already has substantial knowledge of

choices and recognizes his/her obligation to future generations. (Understand

vital information about brain and character development)

7. Each minor that chooses poorly finds peers, family, local government, health

system and community that are willing to provide positive pressure toward

healthy behavior, including the productive use of leisure.

8. Young adults find a community, government and health system to support

healthy lifestyles, education about child development, etc. They also find

plentiful support and opportunities for education and employment.

9. The community, government and health system coordinate with other institutions

to endure availability of healthy events, including cultural and recreational events

that promote community, pride and belonging. Incentives are available for

individual and family improvement.

10. The community is provided high quality information about health status, health

care available, health risks and opportunities for health improvement.

11. The community, government and health system have created dis-incentives for

minors and adults who engage in continued destructive lifestyles, while at the

same time providing the broadest possible support for those who wish to change.

(Explore opportunities for community based detox, aftercare housing and other

needed support.)

12. The Tribe as an employer and government provides incentives and support for

healthy lifestyles. (Health Education, environmental considerations, wellness

activities – on job recreation/exercise opportunities, etc.)

13. Focused attention and resources toward elders to ensure that the system

supports best possible health status and life experience.

Promotion of

opportunities for younger generations to learn from and engage elders.

14. Community members experience a health system that has its customers as its

primary focus in providing access to needed services.

15. Members of the Tribe occupy a large number of the professional provider

positions within the health care delivery system.

This report indicates that the community faces significant health challenges. Overall,

members suffer at great deal from chronic disease and accidents, with a high number of

deaths attributable to chronic liver disease and cirrhosis, diabetes and accidents. It also

reveals that longevity at Warm Springs falls well behind that of the general public, as

well as the American Indian population in the United States. While high relative to other

populations, premature deaths, infant mortality and childhood deaths have decreased

significantly. Diabetes which has been a long standing problem has shown some

improvement in recent years with fewer individuals diagnosed and those afflicted have

better blood sugar control.

Recent studies put Warm Springs children at an

unacceptable level of adverse risk factors. High levels of risk factors are observed

throughout the community, but personal choices underlie the cause of many illnesses

and injuries. Reducing risks and charting a path to better health must be a very high

priority for the health system and the community. (Refer to Section 2 – Customers)

Efforts to address accessibility to the health system have been a major theme in recent

years. Extended hours and community outreach through the community health

programs have been in place for several years. In 2014 the system initiated a mobile

clinic to serve outlying areas. Indications are that it has been well received. Clinic

physicians no longer see patients at the hospital, which increases their availability at the

health center. Efforts are underway to improve mental health and substance programs,

as well as health education. These programs play a vital role in addressing identified

health risks to the community. Efforts to improve the maternal and child health picture

in the community have resulted in higher immunization rates, lower teen pregnancy

rates and the development of “baby college”, an educational program to prepare young

parents to provide a safe and healthy environment toward a solid start for our most

vulnerable members of the community. (Refer to Section 3 – Services)

Resources available through federal appropriations to the Indian Health Service have

trended upward. The national deficit is expected to limit increases in the coming years

The system will rely on alternate resources from Medicare, Medicaid and Insurance, as

well as grants for maintenance and growth. Emphasis placed on billing is timely as

access to alternate resources under the Affordable Care Act has improved dramatically.

The Tribal programs are expected to consolidate all billing related functions to improve

collection capabilities in 2015. The Purchased & Referred Care Program has been

positively impacted by the additional alternate resource availability leading to savings

that can improve care and reserve resources towards higher cost years in the future,

while maintaining the current priority levels. (Refer to Section 4 – Resources)

The Indian Health Service has adopted Government Performance and Results Act

(GPRA) measures to provide for evaluation of services. Accreditation reviews by

outside bodies that are skilled and evaluation the quality of operations are also

conducted. These reports point to high quality in services provided and highlight a high

degree of patient satisfaction with services received. (Refer to Section 5 – Evaluation)

The Commission anticipates the ability to report cost vs. value of services. Information

on most recent years has not been made available. Such information is not easily

obtained from existing Indian Health Service financial systems. Further effort will be

needed to improve the timeliness and consistency of such information. To respond to

the health plan goal of maximizing resources, it is important to measure efficiency in

utilizing resources.

Overall, the report reflects increased information that is now being maintained and

reported. Efforts are underway to continually improve the ability to collect, maintain and

utilize information to guide management of the system and the future development of

health priorities, strategies and action plans to address community needs.

SECTION 1

Overview of Health Delivery System

The Warm Springs health delivery system is comprised of ambulatory care, community

health services, community counseling services and emergency medical transport

(ambulance). Purchased/Referred Care resources (Managed Care) are utilized to

purchase outside services for eligible Indians. The majority of outside services involve

hospital and specialty care not offered by the health delivery system in Warm Springs.

The health delivery system is operated in part by the Confederated Tribes, and in part

by the Indian Health Service (IHS). Programs being operated by the system are

discussed and depicted in this section, and reflect the connections between Tribal and

Indian Health Service operations and purchased care.

In 2009 the Confederated Tribes and the Indian Health Service entered into a

Memorandum of Understanding, creating the Warm Springs Joint Health Commission to

oversee the ongoing development of the health care system and the implementation of

the Joint Comprehensive Plan for the Delivery of Health Services to the Warm Springs

Indian Reservation.

The Tribal Health and Welfare Committee retain its role as liaison addressing

community member access and concerns to the health system and Tribal Council. It

also maintains a role in addressing regional and national health care issues and

developments.

The health care system is confronted with all of the complexities of the national health

care system, including inability of federal and state governments, industry and

individuals to keep up with the rising cost of health care. The demographics of the

nation reflect an aging population, demonstrating longer life expectancy. This creates

increasing demand on the system as the older population uses a proportionally higher

share of the overall health care systems. This national demographic is also present in

the Warm Springs community, in that the local population also reflects increasing

portions of the total population in the older age groups.

Advances in technology and new therapies create additional demand, and while more

effective against disease, bring a much higher price tag. The U.S. system continues to

be based on curative care, with only a modest proportion devoted to prevention.

At Warm Springs, there has been recognition of the need to improve health status and

wellness.

Resources have been channeled to health promotion and disease

prevention. There has long been recognition that the community can’t “cure” its way to

good health. One major advantage to the partnership forged with the Indian Health

Service, over that of other communities, is the ability to coordinate all health system

efforts to better serve and educate the community.

Although the Tribes’ plan calls for a shift from curative to a more preventive orientation,

the payoff is a long term proposition. Therefore the design of programs and the

allocation of resources must be carefully examined to ascertain the most effective

approaches. This report has been mandated to ensure evaluation and measurement of

progress.

Rural health care is challenged around the nation with distance to hospitals and other

providers, and difficulty in recruiting the health professions needed in a community.

Warm Springs is similarly challenged and recruitment and retention is a major focus.

Attracting and maintaining highly qualified and committed health professionals is

essential.

Throughout the years, the Tribe has contracted various portions of the Indian Health

Service financed community health programs, mental health and alcohol and substance

abuse programs, completing that transition in 2008. The Tribe has also appropriated

tribal resources and sought and received grants to enhance the health system, in

addition to providing health insurance for Tribal employees.

The financial vitality of the delivery system has been primarily dependent upon federal

appropriations and, to a lesser extent, collections. In an environment that suggests very

limited increases in federal resources in the coming years, the system will increase its

level of dependence on collections and efficiency of operations.

It is anticipated that there will be grants available from federal, state and foundation

sources, for which there will be heavy competition. The health system will need to be

able to clearly articulate its needs and proposed solutions, all of which will rely on good

record keeping and reporting.

The outline on the following page reflects the major health programs and functions as

they are currently operated.

SECTION 2

Customers

How do we best know and focus on our customers?

This section describes our customer base in terms of demographics (age profile, tribal

affiliation, community of residence, alternative resource eligibility, etc.) It also provides

a historical picture of picture of the Tribe’s vital statistics (births, deaths, age of death

and cause). The major diseases in the community and major health risks are also

identified and quantified. This information helps to determine not only the present

conditions, but also the trends that affect the delivery of health services.

Summary and Highlights

The demographic profile of the customers of the Warm Springs Health Programs

remains very stable in terms of the number of patients, age breakdown, residence and

tribal affiliation (Figures 2-1, 2-2, 2-3 and 2-4). This stability is an important asset as

programs continue to plan services, deploy resources and evaluate.

One of the most positive trends affecting the customers of service is the availability of

Alternate Resources (Figure 2-5). From 2012-2015, the number of patients with

Alternate Resources has increased by 1,032 (31% improvement). Medicaid only

eligibility increased by an astonishing 69% over that same period. Duel eligibility for

Medicaid and Private Insurance increased by 41%. This has resulted in not only a

significant increase in the potential for billable services, but significant reduction of

expenditures of the Purchased/Referred Care (PRC) Program which is operated by the

Tribe through a Contract with Indian Health Service (IHS).

The Vital Statistics of the Tribal Members have improved dramatically over the last few

years. Infant and child mortality rates have declined significantly over the past three

years. The average age of death for the Warm Springs population continues to rise, but

overall it is still negatively impacted by deaths early in life. The rate of progress at

Warm Springs is however noteworthy. Since 1987, the life expectancy at Warm Springs

has increased by 17.5 years whereas in the U.S. All Races population has increased by

3.9 years over that same period of time. This is the ultimate indicator of an improving

health status. (Figures 2-9, 2-10)

Leading causes of death in the 3 year period (Figure 2-11) were Cirrhosis, Accidents

and Diabetes. These were the same leading causes in the previous 3 years. Each of

these conditions is amenable to prevention efforts, but the individual is ultimately

responsible for necessary behavior modification. While there has been significant

improvement in accidental deaths as a result of Seat Belt Laws, too many accidental

deaths are still occurring. Alcohol Abuse and Hepatitis C are major contributors to

Cirrhosis Deaths. Diabetes is not only a leading cause of death but a contributor to

related heart disease or kidney failure.

There has been remarkable progress with respect to the number of high risk teen

pregnancies. From 1996 through 2011, there were a total of 178 births averaging

twenty per year to mothers nineteen and younger, which represented 24% of all births in

those years. From 2012 through 2015, there were 36 births (9 per year) to that group of

mothers, which represents 10% of total births. (Figure 2-6)

Recent student wellness surveys indicate that children of the Warm Springs community

have lived with an unacceptable level of adverse risk factors. A community wide effort

is needed to reverse this dangerous trend. Multidisciplinary teams, including the health

system are working on this issue.

The number of patients listed as active on the Diabetes Register was 402 in 2014 and

2015. The patients with controlled blood sugar improved to 62% from 54% in 2012

(Figure 2-4). There were 16 patients in 2015 on dialysis. The number of dialysis

patients has been on the rise since 2011.

In 2015 there was an alarming increase in the number of hospitalizations for the Warm

Springs patients (524 admissions vs. 342 in the previous year). That represents over a

50% increase and that increase occurred in practically every category. Hospital days

increased even more dramatically (1,837 vs. 1,051 in 2014). The cost per day at

Madras also increased by nearly 30%. Fortunately, a large share of the hospitalizations

were covered by alternate resources; resulting in a 58% cost reduction for the PRC

program. Last year would have been a catastrophic year financially, if PRC did not

have the level of alternate resources that were employed. The importance of alternate

resource utilization became very evident when spikes in hospitalization occur as was

the case in 2015.

There is no recent available data on the health risk factors of the community (Figure 219). Another Behavioral Risk Factor Survey is being planned so that comparisons can

be made to the study completed 10 years ago. It is suspected that the community is

making good progress with many high risk factors. A follow-up study would help

determine the effectiveness of the health promotion effort and identify areas that need

additional emphasis.

Customers That Use the Services

Purpose: To identify the number of new registered patients, the active clinic patients,

the official IHS user population, and the corresponding trends for each category.

Relevance: New registered patients are those who have not previously accessed

services, including newborns, new eligible residents, and eligible visitors who presented

themselves for service. This is one factor in growth of the service population. Active

clinic patients are those who have actually utilized the service within a three year period.

This is another indication of the growth of the service population. The IHS official user

population excludes users residing in other services areas, and is used for resource

allocation purposes.

Warm Springs Health and Wellness Center

Year

8000

New

Registrations

Active Clinic

Patients

User

Population

2001

417

6048

5057

2002

471

6302

5375

2003

449

6478

5402

2004

409

6558

5471

2005

346

6612

5564

2006

368

6685

5634

2007

328

6612

5229

2008

370

6703

5298

2009

320

6665

5454

2010

333

6692

5628

2011

2012

2013

2014

2015

338

304

323

278

198

6672

6680

6651

6595

5669

5649

5772

5737

Active Clinic Patients

6444

User Population

7000

6000

5000

4000

3000

2000

1000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Figure 2-1

Customers That Use the Services, Continued

Interpretation: Between 2001 and 2015, new patient registrations have decreased by

approximately 42%. During that timeframe, new patient registrations peaked in 2008 at

370. Over the past two years, there has been a swift decline in new patients; this is

most likely due to the Affordable Care Act. In 2015, new patient registrations reached

their lowest point since tracking started in 2001 at 198 registrations. In this 15 year time

span, the user population has increased from 5,057 to 5,737 (12%) and the population

of active clinic patients has increased by 8%. The user population and active clinic

population have followed the same trends over time averaging a change within 1% in

either direction. 2007 had the most significant value change; a decrease of 7.2% for the

active user population.

Customers Served by Year

Purpose: To identify our patients by community of residence, tribal affiliation and the

associated trends.

Relevance: While services are generally planned and financed for those who reside on

or near the reservation (service area), a significant number reside outside the service

area. Changes in the make-up of visits can impact access and resources.

Patients Served by Fiscal Year

By Community of Residence

2012

2013

2014

2015

Chg(14-15)

Warm Springs Indian Reservation

3,536

3,630

3,679

3,741

Madras/Redmond/Bend

1,266

1,263

1,234

1,162

(72)

Maupin/The Dalles/Hood River

Portland/Salem

104

110

Other Oregon

427

443

428

427

(1)

Outside Oregon

200

185

195

194

(1)

TOTAL

5,626

5,716

5,697

5,689

(8)

By Tribal Affiliation

2012

2013

2014

2015

Chg(14-15)

Warm Springs Member

3,955

4,048

4,038

3,670

(368)

Other Oregon Tribes

218

225

219

175

(44)

1,364

1,350

1,352

1,756

404

5,626

5,716

5,697

5,689

(8)

All Other Tribes

Non-Indians

TOTAL

Figure 2-2

Interpretation: Trends have remained stable from 2012 to 2015 with approximately

66% of our patients being Warm Springs Tribal Members (WSTM) and approximately

65% of our patients residing on the Warm Springs Indian Reservation (WSIR):

• 2008 – 68% WSTM; 64.1% residing on the WSIR.

• 2010 – 69.1% WSTM; 65% residing on the WSIR.

• 2012 – 70.3% WSTM; 62.7% residing on the WSIR.

• 2015 – 66% WSTM; 65% residing on the WSIR.

From 2012 to 2014 there was a small increase in patients who are WSTM. In 2015,

there was a slight decrease of WSTM of 9%, but an increase of 1% that live on the

Reservation. Between 2012 and 2015, there was an increase of approximately 6% of

patients who reside on the WSIR. As of 2015, over 86% of patients resided on the

WSIR or in the Madras/Redmond/Bend areas.

Age of Enrolled Members of the Confederated Tribes of Warm Springs

(CTWS)

Purpose: The relationship exists between the IHS and the CTWS, under the Treaty of

1855 and federal law, in whose absence there would be no service area. Tribal age

profile is displayed to support planning.

Relevance: Resource deployment is guided by differences in demands placed on the

system for services by differing age groups.

2011 Census Data and 2015 CTWS Population

14.00%

12.00%

Age Group as a % of Total Population

Age Group as a % of Total Indians

Age Group as a % of Total CTWS Population

10.00%

8.00%

6.00%

4.00%

2.00%

0.00%

2015 CTWS Population

14.00%

12.00%

10.00%

8.00%

6.00%

4.00%

2.00%

0.00%

Figure 2-3

Age of Enrolled Members of the Confederated Tribes of Warm Springs

(CTWS), Continued

Interpretation: The CTWS population has a higher percentage of its population in

younger age groups and fewer persons in older age groups than the U.S. general and

Native American populations.

Age of Patients

Purpose: To display the age profile of patients who utilize the services over several

different periods.

Relevance: Different age groups place different types of demands on the health

system for services, and require different strategies. Trends advise planning for such

strategies as well as resource allocation.

Patients by Age Group

FY 2000

Patients

Age Group

2012

Patients

2013

Patients

2014

Patients

2015

Patients

0-4

543

699

588

618

566

5-9

460

545

532

562

540

10-19

1,367

968

984

981

1,017

20-29

971

1,082

1,025

963

905

30-39

912

725

700

714

722

40-49

738

699

659

643

622

50-59

440

633

615

579

627

60-69

204

449

424

441

460

70-79

180

166

180

194

80+

TOTAL, Patients

5,773

6,042

5,756

5,738

5,707

1,600

Patients by Age Group

1,400

1,200

FY 2000

1,000

FY 2012

800

FY 2013

600

FY 2014

400

FY 2015

200

0-4

5-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

80+

Figure 2-4

Interpretation: The total number of patients seen in 2015 closely approximates the

number of patients seen back in the year 2000. However, patients over 50 years of age

increased by 71%. All other age groups have declined with the exception of the 0-9 age

group which has increased slightly.

Alternate Resource Eligibility

Purpose: To identify the availability of alternate resources for active patients and the

corresponding trends. Active patients are displayed by billable and non-billable

categories.

Relevance: The composition of our patient population with respect to alternate

resources measured for two reasons; 1) Purchased/Referred Care (PRC), as payer of

last resort, is directly impacted by alternate resource availability, and 2) the ability to

collect for services directly impacts total collections, which in turn are a significant

financing source for the health delivery system.

Active Patients by Eligibility

Billable

FY 2012

FY 2013

FY 2014

FY 2015

Medicaid Only

1,455

1,637

2,264

2,487

Private Insurance Only

1,263

1,313

1,109

853

Medicare A Only

Medicare B Only

Medicare Part A & B Only

138

126

142

139

Medicare Part D

200

217

230

249

Medicaid & Medicare

Medicaid & Private Ins.

736

663

1,119

1,067

Medicare & Private Ins.

142

159

150

136

Medicaid, Medicare, & PI

4,008

4,179

5,085

5,252

Total

Non-Billable

224

254

No Alternate Resource

Tribal Employee Self-Insurance

2,276

2,277

1,926

1,626

Total

2,500

2,329

1,993

1,880

Total Patients

6,508

7,078

7,132

Figure 2-5

Interpretation: From 2012 to 2015 the number of patients with Alternate Resources

has increased by 1,244 or 31%. Medicaid Only eligibility increased by an astonishing

1,032 or 71% over that same period. The duel eligibility of Medicaid & Private

Insurance increased by 45%.

Those with no Alternate Resources designated

decreased by 29%. Medicare numbers were fairly stable.

This presents a very positive picture of a population and a staff who have worked

together to take full advantage of the expansion of Medicaid and the Affordable Care

Act. It will pay dividends in terms of collections and ensure the viability of the PRC

Program that is administered by the Tribe.

Tribal Member Births by Age of Mother

Purpose: To identify the changing trend in the age of mothers at the time of childbirth.

Relevance:

Tracking total births is important for planning services and education

efforts. Age of mother also identifies high risk patients that may require additional or

special services.

Warm Springs Births by Age of Mother

Calendar

Age

Year*

14 & under

Age

15-19

Age

20-24

Age

25-29

Age

30-34

Age

35-44

Total

Births

108

111

104

1996

1997

1998

1999

2000

2008

2009

2010

2011

2012

2013

2014

2015

Total

214

366

293

168

1115

% of Total

0.0%

19.2%

32.8%

26.3%

15.1%

6.6%

100.0%

Figure 2-6

Figure 2-7

Tribal Member Births by Age of Mother, Continued

Interpretation: From 1996 through 2011 there were a total of 178 births to mothers 19

and younger, which was 24% of all births during that time period. From 2012 through

2015, there were a total of 36 births to that group of mothers which represents 10% of

all births during that particular period. That means the high risk pregnancies have been

lowered considerable in a relatively short time. The total births in 2015 were 89, which

is only 2 greater that births that occurred in 2014. (Figures 2-6, 2-7)

Birth Rate Comparison

Purpose: To compare the Warm Springs birth rate to that of the State of Oregon

Relevance: This information tracks the trend of birth rates.

Figure 2-8

Interpretation: Past reports reflected a substantially higher birth rate in Warm Springs

than the general Oregon population. The difference reduced by the 2000 report but has

remained fairly consistent since then with a slight decrease noted in 2012 – 2014 to an

average of 17 live births per 1,000 population.

The statistics for the 2015 Birth Rate Comparison will be finalized through the State of

Oregon Vital Statistics Department in August 2016 and will be reflected in the next

annual report.

Average Age of Death, Crude Death Rate and Years of Productive Life

Lost

Purpose: To record and display the number of deaths each year and to relate this to

the Tribal population to produce a rate. A year of productive life lost is a measure of

premature death. Average age of death advises life expectancy of the population.

Relevance: Understanding the trends along with causation is important to understand

how programs can impact on the outcomes, as well as forecasting changing needs as

the population ages.

Average Age of Death

Crude Death Rates, Years of Productive Life Lost

Number of Deaths

1994-1996

19971999

20002002

20032005

20062008

20092011

20122014

2015

111

103

121

155

117

Crude Death Rate

502

482

608

524

605

774

587

683

Years of Productive Life Lost

1,889

1,877

1,794

2,141

1,906

2,898

1,594

442

Figure 2-9

Interpretation: This report reflects a significant loss of life at earlier ages than is

reflected in the general U.S. population, where the average life expectancy was 78.8 in

2014. The average age at death continues to increase. Deaths early in life continue to

have a disproportionately high impact on the local population, but the impact is

decreasing. Since 1987 the life expectancy in the US, all races population, has

increased 3.9 years compared to 17.5 years in the local population.

Child Mortality Rates

Purpose: To identify the trends in infant and child mortality.

Relevance: Infant and child mortality is a major factor in determining the health of a

community and is helpful in designing intervention strategies to reduce incidence.

Native populations have historically been concerned with high incidence of child

mortality. Emphasis has been placed on this issue and resources increased to address

it.

Child Mortality

3 year Avg

Infant: Less

Infant Death

than 1 year

Rate*

Child:

Ages

1-12

3 year Avg

Death Rate +

Teen:

Ages

13-17

3 year Avg

Death Rate +

11.9

1995-1997

47.7

1998-2000

22.7

2001-2003

15.9

2004-2006

10.1

15.1

2007-2009

36.8

17.4

4.4

2010-2012

16.6

8.6

12.9

2013-2015

6.5

5.1

5.2

Leading Cause of Death 2003-2015

Infant:

Cause 1:

Cause 2:

Cause 3:

Child:

Cause 1:

Teen:

Cause 1:

Accidents

Congenital Malformations, Deformations and Chromosomal Abnormalities

Sudden Infant Death Syndrome

Disorders related to length of gestation and fetal malnutrition.

Accidents

Homicide

Accidents

Cause 2:

Malignant neoplasms

Cause 3

Intentional Self Harm (suicide)

Figure 2-10

Child Mortality Rates, Continued

Interpretation: This report reflects the changing nature of infant mortality in the past

decade. In 1987-88, there were four deaths due to sudden infant death syndrome

(SIDS). In the last decade, there have only been 2 deaths due to SIDS. Despite the

decline in SIDS, infant deaths have been increasing, primarily due to accidental death

and birth defects. Since 2010, we are seeing this trend reverse.

The vast majority of childhood and teen deaths in the past two decades are due to

accidental death. The majority of accidental deaths were due to motor vehicle

accidents, though accidental firearm deaths and toxicity from alcohol and inhalants also

contributed in teens. There has been a steady decline in childhood deaths since 1995.

Cause of Death

Purpose: To identify trends in the leading causes of death over time.

Relevance: The health system needs to be constantly aware of the leading causes of

death, and in particular premature death, in order to design and implement effective

health promotion and prevention efforts.

The Five Principal Causes of Death

(Warm Springs 2015 , IHS 2013, US 2014)

Cause 1

Cause 2

Cause 3

Cause 4

Cause 5

Warm Springs

Indian Health Service

U.S.

Accidents

Malignant Neoplasms

Chronic Liver Disease & Cirrhosis*

Diseases of the heart *

Sepsis

*-Tied

Diseases of the heart

Malignant neoplasms

Accidents

Diabetes mellitus

Chronic liver diseas and cirrhosis

Diseases of the heart

Malignant neoplasms

Chronic lower respiratory diseases

Accidents

Cerebrovascular diseases

Trends in the Leading Causes of Death (3-yr average), Warm Springs, 1994-2015

Figure 2-11

Interpretation: Accidental deaths had been the leading cause of death since the

1950’s. Rates of accidental death are gradually declining. Since 2001, the rates of

motor vehicle accidents have decreased significantly, likely due to the passage of the

Tribal Seat-Belt Law.

Cause of Death, Continued

Rates of death related to cirrhosis, cancer and stroke are climbing. Cirrhosis had been

the leading cause of death in 2011, but in 2012 showed a decline. Death from cirrhosis

remains more common among the Warm Springs people than for other Americans.

Cirrhosis is also a major contributor to early death. Alcohol abuse and Hepatitis C

infection are the major contributors to this disease.

Diabetes is a growing concern. The majority of patients with diabetes died from related

heart disease or kidney failure. This remains an area that needs emphasis for our local

population. We can combat this through healthier diets and increased physical activity,

reducing the number of overweight and obese people in our community.

Prevalence of Major Chronic Diseases

Purpose: To highlight the prevalence of chronic disease by major condition.

Relevance: This information is vital to understanding the extent of each condition and

the development of effective responses. Chronic diseases account for 70% of all

deaths in the United States. The medical care costs of people with chronic diseases

account for more than 75% of the nation’s medical care costs. Chronic diseases

account for one-third of the years of potential life lost before age 65.

Patients Identified with

Chronic Disease in 2012 - 2015

Condition

FY 2012

FY 2013

FY 2014

FY 2015

Diabetes

605

622

627

631

Ischemic Heart Disease (IHD)

100

104

108

109

Hypertension 18-85 w/HTN DX

503

510

512

495

Asthma

286

272

276

225

Prediabetes/Metabolic Syndrome

904

881

515**

428

Rheumatoid Arthritis

Figure 2-12

** Prediabetes not available in CRS v15.1 so used iCare which has a slightly different logic

Interpretation:

Diabetes, Ischemic Heart Disease, Hypertension, Asthma and

Rheumatoid Arthritis have shown a slight increase over the past year while Prediabetes

continues to show a downward trend over the past two years. The continued decreased

prevalence of Prediabetes/metabolic syndrome likely reflects the efforts made by the

Diabetes Prevention Program (DPP) to identify and engage people at risk for diabetes

over the past several years. We have engaged in community education and events to

promote personal health activities in order to prevent chronic diseases. It is important to

continue providing resources to more effectively engage all people in identifying lifestyle

factors that contribute to chronic disease and to provide support for self health

management.

Data for previous years of Rheumatoid Patients is not easily obtained because it lists

patients that are no longer living also. This list shows the current Active Workload of

Rheumatoid Arthritis Patients.

Customer Diabetes Profile

Purpose: To identify the number of patients active in the Diabetes Registry by year,

along with the number of patients who maintained acceptable control of their blood

glucose levels during the past year.

Relevance: Detection of diabetes and control of blood glucose levels are essential to

managing the progression of the disease and delaying or preventing the resulting

damage to the health of the individual. Monitoring this group of patients, counseling and

educational efforts can be a great impact on the health status of the patient and future

health care costs of caring for patients with diabetes.

Warm Springs Diabetes Profile 2009-2015

(Control of HgbA1)

500

450

400

350

300

250

200

150

100

2009

2010

2011

2012

2013

2014

Patients with Controlled Blood Sugar (HgbA1c<7)

2015

Patients with Controlled Blood Sugar (HgbA1c<8)

Number of Active Patients on the Diabetes Registry

Figure 2-13

Customer Diabetes Profile, Continued

Warm Springs Diabetes Profile 2009-2015

(Control of HgbA1)

80%

70%

60%

% 50%

40%

30%

20%

2009

2010

2011

% of patients with HgbA1c <7.0

2012

2013

2014

2015

% of patients with HgbA1c <8.0

Figure 2-14

Interpretation: The number of patients in the diabetes registry remained at 402. In

order to be active in the Diabetes Registry, patients need to have made at least one visit

for the purpose of improving their diabetes. Patients receiving their primary care with a

provider outside of WSHWC (i.e. VA or private physician) are not included as active in

the diabetes registry. Ideal control of HgbA1c (<7%) decreased between 2014 and

2015 from 47.8% to 43% for active registry patients. In 2012, IHS changed the goal of

good HgbA1c from <7% to <8% based on national changes in standards of care.

Based upon the new standard, good HgbA1c control (<8%) decreased from 70.9% in

2014 to 63% in 2015.

Hospitalization of Customers

Purpose: To ensure that the health system is aware of hospitalization rates and

causes and the associated trends.

Relevance: Hospitalization is a measure of morbidity pointing to serious breakdowns in

individual health status, and is a major consumer of health resources. The health

system needs to respond to the causes of hospitalization and its financial impact.

Purchased/Referred Care Financed Hospitalization

2013 - 2015

Inpatient Indicators

Total Admissions

Average Length of Stay

Total Hospital Days

Average Daily Patient Load

Emergency Room Visits

2013

2014

2015

185

3.61

667

1.83

1,146

118

4.09

483

1.32

773

159

4.50

715

1.96

540

Purchased/Referred Care Hospitalizations and Those Paid by Other Resources

Warm Springs Patients by Primary Diagnosis

2013

# of

2014

# of

2015

# of

Number of

% of

Hosp. Days

Admits

Number of

Hospital

Days

% of

Hosptial

Days

18.7%

Condition

Admits

Obstetrics

107

216

115

231

135

25.8%

344

Motor Vehicle Accidents

0.6%

0.4%

Other Accidents/Injuries

120

10.1%

292

15.9%

Cancer

0.2%

0.1%

Heart and Circulatory

6.9%

141

7.7%

Respiratory

193

112

16.8%

340

18.5%

Renal

5.0%

3.8%

Digestive

133

115

11.5%

153

8.3%

Infectious Disease

205

143

10.3%

300

16.3%

Hosp. Days Admits

Diabetes

1.7%

1.5%

Substance Abuse

3.1%

2.1%

Mental Health

1.7%

1.4%

All Other

6.5%

5.2%

TOTALS

349

1,101

342

1,051

524

100%

1,837

100%

Figure 2-15

Interpretation: These two tables (Figure 2-15) describe the hospitalization experience

in two different ways.

The first table describes the cases for which the

Purchased/Referred Care (PRC) Program provided payment. The second table is all

Hospitalization of Customers, Continued

inclusive covering cases that were paid by the PRC plus all other cases that were

financed by other alternate resources.

The Purchased/Referred Care Caseload (first table)

•

The number of hospital admissions increased by 41 (26%) from the experience

of the prior year.

The Average Length of Stay increased by 0.41 (9%) from the prior year.

The Total number of hospital days increased by 232 (32%) from the previous

year.

The total number of Emergency Room Visits decreased by 233 (30%) from the

previous year.

The above statistics in hospital admissions, average length of stay and total hospital

days represent a reversal of the improving pattern of PRC financed hospitalization.

These spikes in hospitalization will occur from time to time which is why a healthy

reserve is necessary to maintain. It is fortunate to this program that Medicare Like

Rates are in place so that the cost per day offset the increase in hospital days.

In 2015, 73% of the total admissions were financed by the Oregon Health Plan

(Medicaid) and other Alternate Resources, which compares very favorably with the prior

year when 66% of admissions were covered by others.

This performance resulted in the lowest exposure to the highest cost item in the Health

Service Budget. This is nearly a $2.5 million dollar decrease from costs experienced in

2010-2012. (See detail in the Resource Section of this report).

Total Hospitalization Caseload regardless of payment source (second table)

This table identifies Total Admissions and the associated number of hospital days for

the last three years by category. For the latest year, the breakdown also includes the

percentages within each category.

The actual number of admissions for patients in 2015 regardless of payment source

increased from the prior year (524 vs. 342; a 53% increase). Overall hospital days

increased from 1051 to 1837 (75%).

The PRC Program covered 30% of hospital admissions and 39% of hospital days in

2015. In the previous year (2014), 34% of all admissions and 46% of hospital days

were covered. This is also a significant factor in reducing financial obligations for

hospital care.

The total admissions and days by category help us understand which conditions are the

sources of hospitalizations. As in 2014, the number of obstetrical cases led in both total

admissions (26% - 2015) and days (19% - 2015).

Hospitals Utilized and Expenditures

Purpose: To determine the extent of hospitalization at the various facilities within the

areas. This data includes only cases that PRC has spent resources.

Relevance: While this represents an incomplete picture of total hospitalization, it does

highlight where PRC resources are being expended.

Hospitals Utilized

2015

Admissions

Hospital

Days

St. Charles-Madras

St. Charles-Redmond

St. Charles-Bend

Legacy Emanual

All Other

296

378

$315,836

$8,149

$51,312

$32,441

$20,258

Totals

159

715

$427,996

Hospital

Total Cost $

Total Cost per Day

Cost per Day

$1,067.01

$254.66

$135.75

$4,055.16

$20,258.22

$598.60

Figure 2-16

Interpretation: This table reflects the total cost of hospitalizations PRC paid for in

2015, and the number of admissions and hospital days that comprised this cost at the

three major hospitals utilized. St. Charles-Madras accounts for 74% of the total hospital

costs, compared to 27% last year, with St. Charles-Bend accounting for 12%, compared

to 20% last year.

When comparing 2015 to 2014, an increase of 41 occurred in the number of hospital

admissions financed by the PRC was noted. There was also a corresponding increase

of 232 in the number of hospital days covered by the PRC.

The cost per day figures report above can be somewhat misleading. The cost per day

can reflect some admissions that are partially paid by another resource. In the future

efforts will be made to try to separate admissions, so only those cases that are fully paid

by PRC are used to compute cost per day.

The effective use of alternate resources has decreased PRC’s expenditures and the

Medicaid Expansion, implemented in 2014, has created cost savings. Since the

inception of Medicare Like Rates and Medicaid Expansion, PRC has seen dramatic

savings and believes that this trend has reached a plateau and steady savings for the

program will continue to be seen, which in turn shall benefit future health delivery cost.

Resources are still vulnerable due to unusually high rates of hospitalization as was the

case in 2015.

Emergency Room Utilization

Purpose: Patient utilization of Emergency Room represents a high cost element of

PRC. It is important to monitor utilization to determine how best to reduce the budget

impact.

Relevance: Understanding the volume, cause and timing of Emergency Room Visits

will provide insight as to what strategies might be employed to reduce usage.

EMERGENCY ROOM VISITS

Allergic Reaction

Cardiovascular

Cellulititis/Infections (impetigo)

Chronic Conditions

Communicable Disease

Dental

Dermatology (includes spider bites)

Drug/Alcohol

ENT (ear, nose, throat)

Eyes

Headaches

MEDS Only/ Dressing Changes

Miscellaneous

NeurologyEUROLOGY

OB-GYN

Orthopedic (musculoskeletal)

Pulmonary

Psychiatric (Mental Health)

Snake Bite

Trauma

Assault

Gunshots

Lacerations/Burns/Contusions

MVA

Poisons (ingested/breathed)

Sexual Assault

Drowning

Other

Triage Only

Viral Syndrome

Vascular (blood) - anemia/hem

TOTALS

COST (As Of 4/22/16)

COST PER VISIT

2012

2013

2014

2015

106

187

134

201

131

159

1,109

1,239

773

540

$739,859

$667

$880,062

$710

$227,272

$294

$256,999

$476

Figure 2-17

Emergency Room Utilization, Continued

Interpretation: The ER cost for the years 2014 and 2015, show that from 2013 to 2014

there was a decrease of $416 per visit to $294. This is a 241% decrease. From 2014

to 2015 there was an increase of $182 per visit to $476. This is a 62% increase. This

large increase seems to be from diagnosis of injury rather than increased medical costs.

The 2014 reversal in cost is still trending into 2015 as Medicaid Expansion has reduced

costs exponentially. Since January 1, 2014, costs have significantly decreased by

$652,790, a 74% decrease. Continuing into 2015, those costs maintained with savings

over 2013 at $623,063, a 71% decrease.

PRC was unable to capture data for patients presenting to the ER as OHP patients.

Thus, it is important to note the above totals for ER visits include some, but not all, visits

for which PRC is not responsible (i.e. OHP), while the “COST” is the total amount paid

by PRC for ER claims.

EMERGENCY ROOM VISITS - TIMES / DAYS

0800-2000,weekdays (8:00am-8:00pm)

2000-2400, weekdays (8:00pm-midnight)

2400-0800, weekdays (midnight-8:00am)

0800-1600, sat, sun (8:00am-4:00pm)

1600-2400, fri, sat, sun (4:00pm-midnight)

2400-0800, sat, sun, mon (midn-8:00am)

TOTALS

2012

2013

2014

2015

490

226

136

113

500

267

154

130

114

298

175

188

152

1,109

1,239

773

540

Figure 2-18

Interpretation: Emergency care is a critical component of the overall healthcare

system. However, there has been a national trend towards increased utilization of

emergency room services provided for what would be more appropriately cared for in an

ambulatory care setting. Locally, that trend exhibits itself by increased utilization of St.

Charles – Madras ER when the IHS Clinic would be much more appropriate. These

statistics support that trend in the past four years, with ER visits on weekdays between

0800-2000 hours ranging within a narrow margin from a low of 188 in 2015 to a high of

500 in 2013, with this year’s total of 188 below the four year average of 369.

Major Community Health Risk Factors

Purpose: To highlight community health risk factor surveys most recently identified

through behavioral risk factor surveys conducted in 2006.

Relevance: Behavioral risk factor survey is a scientific method of quantifying risks.

The prevention orientation of the program requires on-going examination and program

and strategy adjustments which relate to changes identified.

Health Risks Most Recently Identified:

•

Estimated % of Population Affected*

Motor Vehicle Accidents

Tobacco Use

Alcohol and other Drug Use

Overweight/Obesity

Hypertension

Diabetes

High Cholesterol

Arthritis

Mental Health / Suicidal thought

Abuse (various)

Unintentional Injury

Perceived Health Status: Poor

Perceived Health Status: Fair

45.0%

44.0%

45.0%

75.0%

24.5%

18.6%

21.7%

26.4%

14.0%

30.0%

71.1%

4.4%

29.1%

Figure 2-19

* 2006 – Behavioral Risk Factor Survey

Interpretation: All of the most prevalent risks identified can be reduced through

lifestyle changes and other personal choices. Improvement in health status can be

expected through reducing these risk factors.

Improving the health status of the Warm Springs Community and containing costs

associated with our health services is dependent upon reducing the health risks

described above. Repeating this survey should be considered so that we may measure

progress in reducing risk factors. Also it would be helpful to know how the Warm

Springs Community compared to other Northwest Tribes who have also been surveyed.

SECTION 3

Services

How do we design and deliver high quality responsive health services?

The comprehensive health plan anticipates an ongoing review of services being

provided and other information that will aid in understanding the deployment of

resources to provide them. Workload measures aid in understanding how patients are

accessing the health system.

This section describes the workload associated with each of the health care

components. The workload is a function of patient demand and available staff. The

information is useful to determine staffing priorities and what adjustments need to be

made to better provide more access to services. The efficiency of various services can

also be evaluated. For example, how well does the workload conform to the priorities

identified by the Health Commission? How effective and efficient has been the

extension of clinic hours? How has the outpatient work load changed since August 15,

2013, when the doctors transitioned out of inpatient coverage at St. Charles Hospital –

Madras.

It has been a long standing goal of the Confederated Tribes of Warm Springs (CTWS)

Tribal Council that the Warm Springs Community be a healthy community. The Warm

Springs Health & Wellness Center (WSH&WC) fully supports the Tribes’ goal and

believe that the best way to help meet this goal is by focusing on the care provided at

the WSH&WC and more importantly to work in partnership with each patient to improve

their health.

Areas of Focus that Supports Improved Patient Care:

• Since summer of 2013, the WSH&WC has been working with the Community

Health Nurses to provide health care throughout the community in the Mobile

Health Clinic.

• Along with community partners, a review will be conducted of the professional

staff needs and necessary changes will be made.

• With focus on care provided at the WSH&WC, it is anticipated that there will

be increased access to provider appointments each day.

• The service unit will continue to work closely with the St. Charles Hospital –

Madras to ensure that our community patient needs are met.

A significant portion of program information has not been maintained for items to be

reported. New reporting mandates are being implemented to assure that the needed

information will be available to future reports.

Summary and Highlights

In an effort to improve accessibility to outpatient care, there have been a number of

changes made. A new Medical Mobile Unit (MMU) had its first full year of operation. In

2015 the MMU provided 464 medical visits, 578 dental visits and 9 community health

visits (Figure 3-38). It is anticipated that this workload will continue to increase as the

community gets more familiar with the operation schedule. The WSH&WC continues to

offer extended hours (196 days in 2015), but the workload remains stubbornly low at 2.1

patients per hour. (Figure 3-1)

Now that physicians no longer provide care to patients in the hospital, it was assumed

that physician workload at the clinic would increase. That, however, was not the case in

2015 as both physician and mid-level practitioner visits actually declined. (Figure 3-1)

Productivity of clinicians is a complicated issue but it is important to examine all the

related factors so that the situation can be improved. Some of the factors that may

impact patient visits include: excess administrative requirements, the appointment

system and patient compliance, support staff in terms of number and skill set, facility

restrictions, Mobile Unit impact and of course, patient demand may be falling off.

Physicians choose their profession to “see patients”. It appears as though they are

absorbing a great deal of work that may be related, but is detracting from their primary

responsibility. This situation is not unique to Warm Springs, as studies from the Journal

of Medical Economics indicate patient visits per week per family practice provider have

dropped from 99 to 89 in the period 2013-2014. These calculated rates are much lower

(2183 average visits per physician per year divided by 46 available weeks = 47 patients

per week). (Figure 3-1)

During 2015, the Podiatry Program was without a Podiatrist for the majority of the year,

thus the workload presented (Figure 3-2) included only a month of operations. This

important program now has hired a Podiatrist and continues to have a Nurse/CMA;

therefore it is resuming full time operation.

In 2015 the Dental Program experienced its best year in terms of patient visits. Both

Dental and Hygienist visits were up 18% over the previous year. The total number of

identified problems that were treated was also up 20%. (Figure 3-3)

The Optometry Program had another banner year in terms of patient visits (44%

increase) despite a 20% missed appointment rate. (Figure 3-7)

Pharmacy filled 77,177 prescriptions in 2015, which is less than a 1% increase over the

previous year. The average cost of a prescription increased nearly 15% (Figure 3-4).

The staffing also increased in 2015 as therapy management services, adult

immunizations and additional consulting services expanded.

Community Health Nursing visits increased by 26% in 2015 but the number of services

declined by 29% (Figure 3-9). With an average of 10 visits per day for a staff of three

brings into question the productivity and expectations of the program.

The Maternal Child Health Program identified 89 births in 2015 of which 79 were Tribal

Members. A total of 43 (48%) were determined to be high-risk pregnancies and 39

high-risk infants were closely followed (Figure 3-10). The management of high-risk

cases is having a very positive impact and a key component responding to the strategic

principles set out by the Health Commission.

The Community Health Representatives Program visits declined by 44% in 2015.

Several components of service, which were previously reported, did not indicate any

activity. This is another program that needs to look at their services and productivity.

(Figure 3-12)

The Diabetes Program experienced a decline in visits during 2015. There was a Nurse

Practitioner vacancy for nearly half of the year, which negatively impacted the workload

figures (Figure 3-13). Diabetes remains a very high priority across all health programs

and progress is occurring.

The Mental Health Program is in transition as it experienced a retirement, three

resignations and the loss of the part-time psychiatrist. This resulted in a loss of critical

services and a corresponding reduction in revenue. This is a great need that requires

more attention. Despite these handicaps, the program increased its preventive services

by three fold. (Figure 3-17)

The Alcohol & Substance Abuse Program also lost a number of seasoned counselors

between 2014-2015, which resulted in a decrease in visits and days of service (Figure

3-18). The Health Commission is well aware of the seriousness of these problems and

the inadequacy of the response. There is a need for an improved information system

and more talented staffing in all areas of Behavioral Health.

The Ambulance Service experienced a small decline in ambulance calls but an increase

in the number of patients transported. A total of 93% of the calls and transports were

for Tribal Members and Dependents. Calls with a Substance Abuse Factor accounted

for 211 calls, which was a substantial increase from the previous year.

The Purchased/Referred Care Program experienced an outstanding year attributed to a

very effective pursuit of alternate resources. The number of obligations processed was

a new low of 6,206. More importantly the funds obligated were also at a new low of

$2,094,865 which was $630,000 less than last year and $3.3 million less than 2013

(Figure 3-8). It is remarkable that this occurred despite a significant increase in hospital

days in 2015.

KWSO and Spilyay Newspaper both continue their very appreciated support of all the

Health Programs. KWSO broadcasted 15,266 Public Service Announcements (PSA)

pertaining to health matters. The Spilyay continued their great support with 232 articles

and 428 announcements. These are both extremely valuable allies in efforts to improve

the health status of the community.

Medical Services

Purpose: To identify the Medical Program workload directly associated with patient

contacts by provider category for each year and the associated trends.

Relevance: Workload measures are useful to describe overall program growth, plan

resources – particularly personnel requirements.

Medical Department

FY2012

FY2013

FY2014

FY2015

Medical Visits by Provider

Physicians

Mid Level Practitioners

Nursing Staff

11,459

3,920

3,961

10,057

5,297

4,249

8,600

5,933

4,357

7,639

4,837

6,063

Total Medical Visits

19,340

19,603

18,890

18,539

Workload Factors

Clinic Days

Average Visits Per Clinic Day

250

Total FTE's In Medical Department

Physician FTE's

Mid-Level Practitioner FTE's

Avg Annual Visits Per FTE

Avg Annual Visits Per Physician FTE

Avg Annual Visits Per Mid-Level FTE

5.0

879

2,292

1,960

4.0

2.5

891

2,514

2,119

4.0

2.5

900

2,150

2,373

3.5

2.5

883

2,183

1,935

Extended Hours of Service

Days of Late Clinic

Hours of Service (M-Th, 7pm)

Visits

Visits Per Hour of Service

202

404

902

2.2

114

228

741

3.3

201

402

851

2.1

196

392

831

2.1

Hospital Patient Count

Hospital Visit Count

Average Hospital visits per patient

Average Hospital patients per day

Average Hospital visits per day

381

1,654

4.3

1.0

4.5

325

1,378

4.2

0.9

3.8

N/A

Mid Level Practitioners

Nursing Staff

Physicians

14,000

12,000

Number

of Visits

10,000

8,000

6,000

4,000

2,000

FY2012

FY2013

FY2014

FY2015

Figure 3-1

Medical Services, Continued

Interpretation: The number of medical clinic visits in 2015 totaled 18,539 or an

average of 74 visits per clinic day (250 days open). The breakdown by provider of care

was as follows: physicians 41%, mid-level practitioners 26% and nursing staff 33%.

Each physician provided an average of 1,909 visits. This was lower than anticipated as

the physicians transitioned out of hospital service in August 2013. The number of visits

serviced by mid-level practitioners also declined in 2015.

The Clinical Director and Quality Improvement Supervisor are looking into a better way

to capture the data to more thoroughly show the day to day workload/responsibilities of

all providers.

Quality of care is dependent upon spending an adequate amount of time with patients

so that may be factor in the lower number of visits. The recent addition of a Medical

Mobile Unit (MMU) may also play into why there was a lower rate of visits.

IN 2015, the clinic was open late 196 days for extended hours from 5pm to 7pm. During

those times, the late clinic averaged 2.1 medical visits per hour.

The physicians transitioned out of hospital service August 15, 2013.

presented represents only 10.5 months of FY 2013.

The data

Podiatry Program

Purpose: To identify the Podiatry Program workload directly associated with patient

contacts by provider category for each year and the associated trends.

Relevance: Workload measures are useful to describe overall program growth, plan

resources – particularly personnel requirements.

Podiatry Department

FY2012

Podiatry Visits

Physican Visits

Nurse/CMA visits

Missed Appointment Rate

Workload Factors

Physican Clinic Days

Average Visits per Clinic Day

Nurse/CMA Clinic Days*

Average Visits per Clinic Day

Nature of Visits

PT visit with Diabetes

PT visit with Open Wound

Comprehensive or Annual DM Ft Exam

Office Procedure Performed

OR Case

Hospital Patient

Other Visit Reasons

Total Podiatry Visits (Some patient visits include multiple problems)

FY2013

FY2014

FY2015

1,608

1,751

1,976

154

224

21%

24%

23%

143

155

615

223

105

376

808

297

108

464

886

359

133

508

220

503

433

469

1,685

1,824

1,987

Figure 3-2

Interpretation: For the majority of 2015, there was not a Podiatrist to provide needed

services in Warm Springs. A new Podiatrist was hired late in the year, thus the huge

drop in visits from 2014 to 2015. There were also coding issues that will be corrected

for the 2016 report. The newly hired Podiatrist and Nurse/CMA will continue to reduce

the “No Show” rate.

Dental Services

Purpose: To identify the Dental Program workload by provider category. For each

year, to determine the impact of broken appointments, to identify the categories of care

provided.

Relevance: Workload measures are useful to describe overall program growth and

plan resources – particularly personnel requirements. Broken appointments represent a

loss of resource capability and waste of health resources. The categories of care

describe the patient service needs.

Dental Department

FY2012

FY2013

FY2014

FY2015

Dental Visits by Provider

Dentist Visits

Hygienist Visits

4,657

713

4,558

818

4,203

899

4,955

1,062

Total Dental Visits

5,370

5,376

5,102

6,017

Missed Appointments

No Shows (Broken Appointments)

Broken Appointments vs Total Visits

265

664

11%

956

16%

631

Workload Factors

Clinic Days

Average Visits Per Clinic Day

250 249(snow day)

250

Total FTE's

Average Annual Visits Per FTE

413

448

425

547

Categories of Care

Preventive

Restorative including Crowns

Dentures including Bridges

Surgical

Orthodontic

Endodontic

Diagnostic

6,950

2,856

115

985

324

6,749

7,295

2,888

169

1,106

251

6,700

8,030

2,556

826

270

7,111

10,692

2,451

1,063

244

8,191

Total Identified Problems Treated

17,987

19,193

18,885

22,697

Figure 3-3

Interpretation: For FY 2015, Broken Appointments decreased by 20%; a quick call list

and list of employees that are in need of exams are utilized, which has helped keep

chairs full. Visits to Dental Providers are up 18% in both categories. The Total of

Identified Problems that has been treated is up 20% from 2014.

Pharmacy Services

Purpose: To identify the Pharmacy Program workload.

Relevance: Workload measures are useful to describe overall program growth and

plan resources – both personnel and drug cost.

Pharmacy

Previous Previous

Year (%) 3 years (%)

FY2012

FY2013

FY2014

FY2015

New Prescriptions

Refills

53980

27211

53415

26125

50464

26479

50609

26568

0.3

-3.8

-0.1

Total Prescriptions

81,191

79,540

76,943

77,177

0.3

-2.6

Workload Factors

Clinic Days

Avg Prescriptions per Clinic Day

Visits to the Pharmacy

Prescriptions per Pharmacy Visit

Total FTE's

Avg Annual Prescriptions Per FTE

250

325

33,688

2.41

6.0

13,532

253

314

33,622

2.36

6.8

11,697

251

306

33,975

2.26

6.8

11,315

250

309

32,848

2.35

8.25

9,354

-0.4

1.0

-3.3

4.0

21.3

-17.3

-0.5

-1.9

-2.7

0.3

26.6

-23.2

868,828

11.25

Prescriptions Filled

Pharmaceuticals

Total Expenses

Avg Cost Per Perscription

Rx for Patients outside Service Area

784,700

9.66

Unavailable

791,276

9.95

Unavailable

753,909

9.79

Unavailable

Figure 3-4

Interpretation: Workload in FY 2014 as compared to FY 2015 remains stable to the

previous three years in the number of prescriptions filled (down 2.6%). The number of

prescriptions per FTE decreased by 17.3% from the previous year, and decreased

23.2% from the previous three years. The decrease in the number of prescription per

FTE is related to increased FTE (from 6.8 to 8.25). Drug costs as compared to the

previous year have increased, primarily due to the inclusion of Enbrel (etanercept).

Average cost per prescription has therefore increased. The average number of

prescriptions filled per day remains consistent for the last five years. Pharmacy staff

continue to manage patients in four pharmacy-based clinics as well as provide

medication therapy management services and adult immunizations over this period of

time. Pharmacy works closely with Tribal Programs including Community Health

Nursing, High Lookee Lodge, Warm Springs Corrections, Community Counseling

Center and the Senior Program to provide drug information, education on proper drug

storage and administration.

Diagnostic Services

Purpose: To identify the workload associated with the diagnostic services (X-Ray and

Medical Laboratory).

Relevance: Workload measures are useful to describe the overall program growth and

plan resources for personnel and supplies necessary.

Diagnostic Services - X-Ray

FY2012

FY2013

FY2014

FY2015

Total X-Ray Exams

1,649

1,711

1,713

1,378

Workload Factors

Clinic Days

Average Exams per Clinic Day

Total Patients

Average Exam per Patient

Total PCPV's

Average Exams per PCPV

Total FTE's

Exams per FTE

250

6.60

1,468

1.12

14,980

0.11

1,649

250

6.84

1,493

1.15

16,568

0.10

1,711

251

6.82

1,606

1.07

15,757

0.11

1,713

250

5.51

1,249

1.10

13,041

0.11

1,378

Imaging Exams

Figure 3-5

Interpretation: Between 2014 and 2015, there was a 20% decrease in X-ray images

performed at the clinic. This decrease was due to not having a Podiatrist on staff from

11/25/2014 to 9/30/2015. Throughout that time span there was an average of 5.5 X-ray

images per day completed. The average patient visits per patient have been

consistently around 1.1 over the past four years.

Diagnostic Services, Continued

Diagnostic Services - Medical Laboratory

FY 2014

**3/31/15-9/30/15

**FY 2015

FY2012

FY2013

Medical Lab Tests

Tests collected in the Lab

Tests collected outside the Lab

Tests performed off-site

77,797

3,407

6,422

76,743

3,173

5,473

59,257

12,570

19,332 *

N/A

6,065

Total Lab Tests Ordered

87,626

85,389

71,827

N/A

Workload Factors

Clinic Days

Tests Ordered per Clinic Day

Total Primary Care Provider Visits

Average Tests per Visit

Total FTE's

Tests per FTE

250

351

15,379

5.7

5.0

17,525

250

342

16,568

5.2

5.0

17,078

250

287

15,757

4.6

5.0

14,365

250

116

13,041

0.5

4-4.5?

7,224

25,707

55,936

831

5,152

19,491

60,491

939

4,468

7,981

39,610

1,752

3,152

Category of Tests Ordered

Hematology

Chemistry

Bacteriology

Urinalysis

Sub total:

Quest

St. Charles Hospital

Oregon State Laboratory

Total Referred Procedures (send Outs)

Total Lab Tests Ordered

87,626

85,389

1,696

8,120

1,993

11,885

3,392

16,240

152

3,986

23,770

470

19,332

5,125

154

940

6,219

71,827

36,208

Figure 3-6

*Tests performed Off-Site are not counted in the Medical Lab Tests Total.

**Data collected for 6 months, there was a purge on 3/29/15, so a full year was not available.

6 month data was multiplied by two (2) to get the Fiscal Year report.

Interpretation: Due to multiple RPMS Laboratory Patches, the data for workload has

changed and is most likely counting different matrixes then in the past. A new way to

find meaningful matrixes and sources is being looked at.

Optometry Services

Purpose: To identify the Optometry Program workload for each year. To determine

the impact of broken appointments per year. To identify the categories of care

provided.

Relevance: Workload measures are useful to describe the overall program growth and

plan resources accordingly. Broken appointments represent a loss of resource

capability and a waste of health resources.

Optometry Department

FY2012

FY2013

FY2014

FY2015

Optometry Visits

Clinic Visits

1,663

1,941

2,912

4,190

16%

18%

22%

20%

220

2.0

Refractions

821

832

1,034

1,141

Diabetic Eye Exam

308

309

266

308

143

Missed Appointment Rate

Workload Factors

Clinic Days

Average Visits per Clinic Day

Total FTE's

Nature of Visits

Contact Lens Visit

Medical Visit

Early Childhood Education Visits

Glasses Repair/Adjustment

372

338

732

639

Other

363

814

1,518

Figure 3-7

Interpretation: The Optometry department continues to see an increase in the number

of patient visits from year to year, even without the full time placement of a fourth year

Optometry student. The Optometry Student Program is in the process of being reestablished.

The rate of patients who did not keep appointments is slightly down from the past year;

if walk-in numbers are used to counter for the no shows, then the Missed Appointment

Rate is only 9%.

The number of diabetic patients seen in the clinic is up one from last year.

The number of patients seen in most all categories has increased over the years except

for staff levels, which remain at two.

Purchased and Referred Care

Purpose: To identify workload of the Purchased/Referred Care (PRC).

Relevance: To assure effective processing and management of resources.

Purchased and Referred Care

Staffing & Other Workload

FTEs

Number of Obligations

Funds Obligated

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

8,190

6,120

5,022

7,162

9,136

9,757

9,099

8,667

8,861

6,930

6,206

$4,905,541

$5,049,015

$3,447,919

$3,881,990

$4,953,270

$5,185,344

$4,999,277

$5,521,545

$5,376,701

$2,726,209

$2,094,865

Figure 3-8

Interpretation: The Number of Obligations/Funds Obligated reflects the implementation

of Priority I’s in 2005 and the elimination of specialty clinics in 2006; thus, the decrease

seen from 2005 through 2007. The Tribal Council passed a Resolution funding some

non-Priority I healthcare implemented late 2007, and 2008 and 2009 reflected increased

healthcare coverage funded via “carve-outs” from PRC reserves accumulated through

Medicare-Like Rate savings; thus the increase seen from 2007 through 2010. 2010

marked the expansion of Priority I’s back to full coverage of Priority I-IV’s. Significant

personnel time was involved in the implementation of Medicare-Like Rates

reimbursement, but was time well spent as exhibited by the documented savings found

in Figure 4-12. The implementation of Medicaid Expansion on 1/1/14 had a significant

impact, resulting in the 22% decrease in Number of Obligations from 2013.

This era of healthcare transformation, with the implementation of Coordinated Care

Organizations (CCO’s) in 2013, preparing for implementation of the Federal Health

Insurance Exchange for potential 2013 October enrollment, and, more importantly,

January 2014 Medicaid Expansion, has greatly increased the complexity of PRC

processes. New complexities are emerging with changes in the Medicaid system to the

potential of Federal Medical Assistance Percentages (FMAP).

Community Health Nursing Services

Purpose: To identify the workload associated with the Community Health Nursing

Program.

Relevance: Workload measures are needed to assess program growth, personnel

requirements and efficiency.

Services Provided by Category

2012

2013

2014

Prenatal

Post Partum

Well Child

Immunization

Diabetes

Cardiovascular

Mental Health

Sexually Transmitted Infections

Family Planning

Phone Contact/Follow-ups

Other Activity

1,274

1,380

135

213

614

Total Services Provided

2015

145

213

219

898

1,137

202

201

261

1,537

206

203

313

726

2,336

2,897

3,516

2,496

742

666

1,408

250

5.6

1.8

782

892

1,039

1,931

250

7.7

2.0

966

1,100

886

1,986

250

7.9

3.0

662

1,729

767

2,496

250

10.0

3.0

832

983

Visits by Location

Out of Clinic Visits

Clinic Visits

Total Community Health Nurse Visits

Total Days of Service

Average Visits Per Day

Total FTE's

Average Visits per FTE per year

Figure 3-9

Interpretation: The Community Health Nursing Program was fully staffed for 8 months

of 2015 with 3 full-time nurses. They provided services in a variety of community areas

including Warm Springs Corrections, Child Protection Services Group Home, Warm

Springs K-8 Academy along with home and clinic visits.

The goals for the program, that was started in 2014, are to reduce hospital

readmissions and provide a network of services to support the community members to

return back to optimum health after a serious illness have been achieved.

Community Health Nursing Services, Continued

The top 10 leading Purposes of Visit managed through the Community Health Nursing

Program include (highest to lowest):

•

Vaccinations

Corrections Care

Health Counseling/Surveillance

Sexually Transmitted Infections

Contraception

Routine Child Health

Protective Care Visits

Pregnancy Testing

Diabetes Care/Follow up

Laboratory testing/Blood Draws

Other activities includes case review/coordination, education provided, screening and

physician ordered treatments.

Maternal and Child Health (MCH) Program

Purpose: Maternal Child Health (MCH) data is collected to identify the number of

births and those to tribal members. It is also used to determine the number of high risk

pregnancies and high risk infants. Data is also used to determine the workload and

needs of the program.

Relevance: The Maternal Child Health (MCH) Program workload is directly related to

the number of pregnancies and births managed each year as well as those identified as

high risk. High risk clients require more intensive services.

Maternal and Child Health (MCH)

2012

Total number of births

Total number of births (Tribal members)

Number of high risk pregnancies

Number of high risk infants identified*

Prenatal Home Visits

Post-Partum Home Visits

Other Home/Office Visits

Number of Hospital Visits

Number of Birthing Classes

Total Number of Participants

Infant Immunization level**

2013

2014

2015

143

565

115

157

104

150

399

181

327

162

218

300

141

84.4%

83.5%

90.7%

85.0%

Figure 3-10

*Born pre-mature, low birth w eight, congenital defects, multiple births, transferred infant to

high-level care facility, exposure en uteri to toxins such as drugs, alcohol, tobacco and infants

born in facilities other than St. Charles-Madras.

**Infant Immunization Level figures - Source: GPRA Report Figures on Children 19-35 months of age.

MCH Case Management Data

120

100

104

Total number of births managed by MCH

Number of high risk pregnancies

2012

2013

2014

2015

Figure 3-11

Maternal and Child Health (MCH), Continued

Interpretation: In 2015, the birth rate for the MCH Program decreased to 89 deliveries

case managed by the program, 79 of which were to Tribal Member mothers. 43% of the

pregnancies required intensive services due to their high risk status.

High risk status includes: Medical risk factors, tobacco, illicit drug or alcohol use, poor

social situation and/or domestic violence, late or no prenatal care, and maternal age

(<18 or >35).

Total number of births reflects all births that were case managed by the MCH nurse and

eligible for care under IHS standards.

Community Health Representative

Purpose:

To identify the caseload and workload by category for the Community

Health Representative (CHR) program.

Relevance: The CHR Program is an important liaison between the health delivery

system and the community. As priorities shift within the health system the CHR

program priorities should shift as well.

Community Health Representative

2012

2013

2014

2015

Caseload by category:

- Transports

- Patient Care

- Case Findings/Screening

- Monitoring Patient

- Case Management

- Health Education

- Other

274

412

428

284

109

445

467

1395

634

1364

677

638

119

126

156

Total Client Encounters

1,984

2,099

2,124

1,471

250

7.9

3.0

661

250

8.4

3.4

617

250

8.5

4.0

531

250

5.9

4.0

368

Total Days of Service

Average Number of Encounters per Day

Total FTE's

Average Number of Encounters per FTE per Year

Figure 3-12

Interpretation: In 2015, the CHR Program remained consistent in the amount of

patient transport requests with the previous year.

For most of 2015, the program provided dialysis transportation five days per week for 26 clients per trip. In the fall of 2015, dialysis services began to be provided locally in the

Madras area which offers more convenient scheduling for patients. This decreased

dialysis transportation services to three days a week with an early and late drop-off for

1-10 patients.

Diabetes Program Services

Purpose: To identify the workload by category associated with the diabetes program.

Relevance: Diabetes Mellitus remains a continuing challenge to the health of the

Warm Springs population. Continued monitoring of the clinical resources dedicated to

improving the health of patients with diabetes is necessary to determine if community

needs are being adequately addressed.

Diabetes Program

FY2012

FY2013

FY2014

FY2015

Diabetes Program Visits

Clinician Clinical Visits

Community Encounters

4,156

1,531

4,729

1,752

5,254

2,414

4,316

1,997

Total Visits

5,687

6,481

7,668

6,313

Workload Factors

Clinic Days

Average Clinical Visits per Clinic Day

Total Clinical FTE's

Average Clinical Visits Per FTE

250

16.6

4.0

1,039

250

18.9

4.0

1,182

250

21.0

4.0

1,314

250

17.3

3.5

1,233

Categories of Service

Diabetes Clinical Encounters

Diabetes Case Management Encounters

Diabetes Community Education Contacts

Diabetes Screening Community Contacts

1,922

2,334

559

972

2,630

2,099

1,559

193

2,868

2,386

2,083

331

2,429

1,887

1,997

Patients in Dialysis

Number of Patients

Figure 3-13

Interpretation: The Warm Springs Diabetes Program Nurse Practitioner position was

vacant until June 2015. Staff includes the Program Coordinator, Nurse Practitioner, RN,

Certified Diabetes Educator and Administrative Assistant. Major educational events for

2015 included Diabetes Awareness Day Conference, Heart Smart Dinner, Pi-Ume-Sha

Health Fair, Senior Center Diabetes Support Group Dinners, Youth Support Group,

Food Demo and Support Group. H.O.P.E. (Healthy Outcomes Promoted by Education)

diabetes education program is accredited by the American Association of Diabetic

Educators through July 2016. Community screening for Diabetes prevention education

has been transitioned to Diabetes Prevention Program Staff to increase the number of

clinical appointments in the Diabetes Program. Monthly Diabetes Group Visits and

Diabetes Mobile Clinic Visits are included in the clinician clinical visit statistics.

Women and Infant Children (WIC)

Purpose: To identify the caseload for the Women and Infant Children (WIC) program.

Relevance: The growth of the WIC program reflects on many other health services

and there is a need for coordination.

Women and Infant Children (WIC)

2012

2013

2014

2015

Infants and children under 5 years of age

550

534

482

470

Pregnant, breastfeeding and postpartum women

211

187

192

181

761

721

674

651

Total number of Women, Infants and Children served

Figure 3-14

Interpretation: The number of Women, Infants and Children served by the WIC

Program remained relatively stable for the past 4 years with the exception of 2014 and

2015. In those years, Warm Springs noted a decline in women/children seeking WIC

services. This is not a unique issue for Warm Springs, WIC sites throughout the state

are experiencing the same trend. State benchmarks for program participation have

been adjusted lower for almost every WIC site for 2015.

Other interesting facts for 2015, 98% of new mothers start out breastfeeding and 39% of

the families served are working families. Both of these rated increased in 2015.

Community Health Education Program

Purpose: To identify the activities and the associated number of participants involved.

Relevance: There is a need to measure the workload and level of community

participation for all prevention activities.

Number of Participants

2015

Program

Health Education Team

No. of Educational Encounters

Direct Time Spent Educating

No. of Participants

No. of PSA's generated

No. of Newspaper Articles

80.5

1815

General Health

My Future My Choice; 5 Sessions (Sexuality Education)

Girlz Club (8-11 year olds); Hygiene, Leadership, Wellness

Million Hearts Campaign

Great American Smokeout

Wellness of Warm Springs; 10/12 Classes

Pi-Ume-Sha Health Fair

Heart Smart Dinner

Employment and Life Skills Training

120

100

525

450

150

100

Alcohol and Drug Prevention

FASD Awareness Day

3D Project

included in WOWS

Cultural Prevention

Craft Classes

Jewlery Making

8 classes

9 classes

General Prevention

Trunk or Treat

275

HIV/AIDS

World Aids Day

Figure 3-15

Community Health Education Program, Continued

EDUCATION TOPICS

Nutrition

Bullying

Alcohol Awareness

Water Safety/

Skin Cancer

Tobacco Prevention

Self Discovery

28%

Cultural as

Prevention

51%

Leadership Skills

Figure 3-16

Interpretation: In 2015, the Community Health Education Program was able to

participate in many onetime events such as the Great American Smoke Out and the PiUme-Sha Health Fair as well as many ongoing classes such as Wellness of Warm

Springs and Soaring Butterflies/Warrior Spirit. The topics of education were wide

ranging from the Art of Storytelling to alcohol awareness and leadership skills.

Mental Health

Purpose:

category.

To identify the caseload and the number of visits by age and service

Relevance: Understanding patient demand and workload is necessary to determine

appropriate resources and staffing. Mental Health service provision has become a

valued resource for the Tribes and for the Warm Springs Community. Additionally, it

has become a significant source of legitimate revenue.

Mental Health

2012

Visits & Clients Served

Number of Adult and Child Visits

Number of Clinic Days

Average Visits per Clinic Day

Total Visits

Categories of Service

Crisis Management Visits

Jail

Total

Service Hours

Client Contact Hours

Prevention Services

Soaring Butterflies/Warrior Spirit

Positive Indian Parenting Participants (5)

Elvis Birthday Bash

MSPI Madras High School Presentations

QPR Trainings (5)

Sock-Hop Event

All Night Lock-In

He-He Butte Prevention Camp

Oregon Native Youth Survey

Halloween Party

Prevention Basics Power Point

Christmas Light Parade & Event

Spring Into Action (Prev. Coalition)

Penny Carnival

Rez Olympics

Street Dance

GONA Training

ASIST Workshop

MSPI & Child Initiative Against Violence

THRIVE

Rick Schimmel Motovational Speaker

Holiday Gift Making

Soaring Butterflies/Warrior Spirit Planing Meetings (10)

Soaring Butterflies/Warrior Spirit Event at Museum

Soaring Butterfly Year End Camp

Community Clean Up Project

Protecting Your Child

Drugasors Prevention Classes

Drugasours at Jamboree

Survivors of Suicide Conference

Spring Break Prevention classes at Recreation

WOW Lunch Meth Presentation

Total Prevention Services Attendance

2013

2014

2015

3,012

2,539

1,494

1,274

244

1,274

204

270

204

270

219

313

193

386

3,216

3,703

500

100

1,635

300

22 NA

100

600

178

1,601

2,016

100

300

600

200

1,318

982

33 *

n/a

100

n/a

600

n/a

500

n/a

250

200

217

3,394

* (with 15 graduates)

Figure 3-17

Mental Health, Continued

Interpretation: The 2015 calendar year has been a time of continued transition for the

mental health program. A reduction of mental health counselors/therapists was

experienced including the retirement of a .6 FTE and three full-time employees that left

this program. Two of those positions were filled after vacancies occurred. Community

Counseling Center also lost the part-time psychiatrist that was contracted. This resulted

in the loss of critical services that could be provided to the Community and a reduction

in revenue.

Note that despite the challenges, the number of total crisis visits provided in 2015 is

nearly double the number of crisis responses in 2012.

Alcohol & Substance Abuse

Purpose: To identify the extent of the substance abuse problem and the workload

response by activity age group of patient. To determine collection effectiveness (visits

billed and collected by alternate resource).

Relevance: Substance abuse issues are prevalent in the community. Evaluation of

A&D treatment is essential to see what is working and not working in our treatment

program.

Alcohol and Substance Abuse

2012

Encounters - Outpatient Treatment

Number of Visits

Number of Clinic Days

Average Visits per Clinic Day

Relapse Anger Resolution Grp (Quarterly)

Jail Groups

2,501

254

334

2013

1,793

251

425

2014

2015

1,567

252

375

Service Hours

1,495

244

1,871

Aftercare

Healing from Grief & Trauma - 1 day conf.

Recovery Month Dinner

A&D Prev B-Ball "And 1" (Street Ball tour) all ages

Community Grief/Trauma Gathering (2 workshops)

Healing Family Circle Conference

Winter Nights Round Dance

Spirit Fest Friday Night Dinner

White Bison Recovery Event

100

n/a

400

200

Total

655

Figure 3-18

Interpretation: Co-morbidity exists when events, situations or dynamics occur at the

same time. For instance, the majority of substance abusing individuals also experience

some form of associated mental health issue(s). Often times, co-morbid factors include

loss, grief, trauma (sometimes from decades earlier) and family of origin conflicts. It is

often difficult to accurately determine which problem area is the primary issue; in these

statistics much effort has been made to avoid duplication of numbers and to most

accurately identify the primary area of concern in each client’s life.

The number included under “Encounters” for the jail groups is the total number of

inmates that participated in non-crisis group services. The 2015 total is down

specifically due to difficulties of staff getting into the jail to conduct groups. Those

issues have been resolved. For calendar year 2016, there have been regular groups

held with relatively large attendance in both men’s and women’s groups.

Alcohol & Substance Abuse, Continued

It is also important to note that Community Counseling Center lost four of the seasoned

substance abuse counselors between 2014 and 2015. Two interns were hired and

have been in a training capacity and those employees typically carry a smaller caseload

while they are in a training capacity. The other two positions remain open and hopefully

will be filled in the near future.

Adolescent Aftercare

Purpose: Collect data related to the Adolescent Aftercare Program to track the

services available for youth, adolescents and adults to determine if the activities

available provide the best services to clients.

Relevance: Data helps to evaluate the program and determine that necessary services

are being provided to community members.

Adolescent Aftercare

2012

2013

2014

2015

Outpatient Visits

128

Prevention Youth Dance

236

116

Teen Craft Night

n/a

Rez Head Youth Conference

n/a

Baseball Camp

Suicide Prevention Camp

n/a

Healing Wounded Spirits Camp

n/a

Winter Youth Conference

n/a

Movie Nights

416

384

480

421

Wii Bowling

112

n/a

Hoop Camp

Madras Bowling

Wellness walk

204

224

147

All Night Sobriety Party

n/a

Kids Bingo

196

159

Red Road to Recovery/Boys Circle

Tribal Youth Leadership

Respect Club

Jude Schimel Hoop Camp

160

Sobriety Pow Wow

150

Total

1,187

1,251

1,533

1430

Figure 3-19

Adolescent Outreach, Continued

Interpretation: The aftercare program provides services including healthy alternatives

to social activities in a group setting. In addition, one on one services that can help

individuals build coping skills and resilience services are provided to clients leaving

treatment. Through this program additional support is provided to program participants

who are in danger of relapsing with positive, supportive interactions of others. Services

are also provided to clients returning from residential treatment facilities to help them

successfully transition back into their community.

Community Health & Prevention Resource Center

Purpose: Track the number of people using resources, and the number and type of

resources used, to determine program usage and community need.

Relevance: These numbers help to determine the state of this program, how it’s being

used, where it can be improved and where focus is needed.

Community Health & Prevention Resource Center

Resource Center Usage

Number of patrons that checked out materials

Number of materials checked out

2012

2013

2014

2015

486

339

300

280

1,358

949

792

810

Health related materials checked out

Native American materials checked out

215

160

156

120

Circulations*

3,015

1,679

1,438

1,372

Number of visits

9,351

8,936

11,147

9,601

378

144

123

230

197

159

Patron cards issued

Graphic Design Requests

Posters/Banners printed

Figure 3-20

*A circular occurs whenever an item is loaned out (checked out or renewed).

When the number of circulations exceeds the number of items checked out, some items some items were

checked out more than once.

Interpretation: 280 people checked out material from the Community Health &

Prevention Resource Center (CHRC) in 2015, continuing a downward trend. Although

fewer people borrowed from the CHRC in 2015, they borrowed more on average (2.9

items/person) than in previous years. CHRC issued the most patron cards since 2011,

and had its second highest number of visits. Overdue/lost items continue to be an issue

and are a contributing factor in the declining circulations and number of borrowers.

People with lost/overdue items are prohibited from borrowing any more items until they

return or pay for their items. On a positive note, the fact that people who are able to

check out items have been checking out more on average, and the fact that almost

twice the amount of patron cards were issued as last year, indicates that the selection of

materials is relevant and useful.

Social Services

Purpose: To appropriately identify the needs of the community and apply and direct

the various resources associated with the programs administered by the Tribal Social

Service Program which consists of the Energy Assistance Program, Medical Gas

Voucher Program, Disabilities and Social Security Assistance and Commodity Food

Program.

Relevance: The Social Services Program serves some of the community’s most

vulnerable members. Monitoring these services and their impact is very important.

Social Services

2012

2013

2014

2015

Housing & Energy Assistance

Number of Clients Served

248

Total Vouchers Processed

292

318

248

292

202

86,131

87,346

94,843

114,429

Number of Clients Served

458

336

420

946

Total Vouchers Processed

458

336

420

946

Total $ Value of Vouchers*

12,200

9,709

12,480

27,785

New Clients pursuing claims for SSI/SSDI

105

Number of clients currently checking on

Number of Clients inquiring about Retirement Benefits

Number of Clients that have been denied

Number of Clients that just filed their 1st Appeal

Number of Clients that are in the middle of Appeal

Number of Clients in Court Hearings

Number of Families Served

259

278

Number of Individuals Served

494

749

166

197

137

174

Total $ Value of Vouchers

Medical Travel

Disability

Survivorship/widow benefits

Commodities

Number of Warm Springs Tribal Members**

Figure 3-21

**For 2012 & 2013 Tribal Member data was not recorded.

Interpretation: The Low Income Housing Energy Assistance Program (LIHEAP)

served 44 more client households with assistance. In addition, the program also

distributed 40 cooling fans, 40 heaters and 36 homes received weatherization kits.

Medical Travel funded 525 more clients in 2015 with assistance to Medical

appointments. This program serves all Indian Health Service eligible clients with no

priority levels currently in place.

Social Services, Continued

Clients seeking services through the Disabilities Coordinator continue to fluctuate based

on need. The Disabilities Coordinator has increased home visits as well as outreach

and is working closer with the Senior Disability clients.

The Commodities Program increased its participation level from 137 to 174 in 2015. A

tracking system is being used to count the actual number of individual households, as

well as the actual number of individuals in each household, for the entire year – not

counting the same households and participants every month.

Ambulance Services

Purpose: To identify the workload by category of incident. To identify the effectiveness

of the collection effort (patients with alternate resources, total billed, total collected).

Relevance: Ambulance services are expensive but necessary in the Warm Springs

community. Understanding the causes of these transports can signal needed health

promotion campaigns (i.e. seat belt use). Patients serviced by alternate resource

measures collection potential of this enterprise.

Ambulance Activity Summary

SUMMARY OF AMBULANCE ACTIVITY

Calls

Patients Transported

2014

2015

Calls w/Substance Factor

2014

2015

Reason for Call

2014

2015

Motor Vehicle Accident

Other Accident

Assault and Battery

Suicides/Attempts

Corrections

379

385

128

Pediatric

222

280

Cardiac

149

Respiratory

148

137

Other Illness

134

145

1,208

1,187

382

419

135

211

Total

TRIBAL AFFILIATION RELATED TO CALLS

Reason for Call

Members and Dependents

Calls Dispatched

2014

2015

Patients Transported

2014

2015

Calls w/Substance Factor

2014

2015

1,625

1,714

623

702

227

344

Other Eligible Indian

Non Tribal

126

156

1,751

1,870

671

760

229

354

Total

Figure 3-22

Interpretation: Between 2014 and 2015, there really was no significant difference in

the reasons for calls. In 2015, a new form was used to calculate the number of alcohol

related Motor Vehicle Calls (MVCs), which has lead a better actual count of alcohol

related calls and therefore has raised the count significantly for Motor Vehicle Accidents

(MVAs).

Ambulance Services, Continued

Nearly 93% of the calls were for Tribal Members and Dependents in 2015. Nearly 93%

of patients transported were also Tribal Members and Dependents.

Almost 8% of our transports were for motor vehicle accidents. Assault and Battery,

Suicides/Attempts and Corrections were the reasons for 19% of transports. Pediatric

transports were nearly 18%.

Most of the transports were for Cardiac, Respiratory and Other Illnesses (55%).

Culture and Heritage Language Program

Purpose: Cultural and Heritage provides language and cultural education opportunities

for Warm Springs Tribal and community members.

Relevance: Providing Cultural and Language Education opportunities gives Tribal

members an understanding of the history, traditions, and sovereign rights reserved in its

treaty with the Unites States government. Tracking this data is important for planning

and implementing outreach efforts and developing relevant materials.

Teaching Opportunities

Figure 3-23

1200

Number of Students

1000

800

600

400

200

Figure 3-24

Culture and Heritage Language Program, Continued

Interpretation:

The fall is the busiest time of year for the Culture and Heritage program. Staff attends

several community events. The largest way for the program to share its knowledge is

through dances, language and history that it shares with local schools and the Warm

Springs community. These opportunities allow for information distribution via language

materials for home that will help support the effort to reach out to school age children.

The number of classes is steady throughout the year. September is when several

classes are offered at the same time. This includes:

•

Autni Ichishkin Sapsikwat (pre-school)

Autni Ichishkin Sapsikwat (k-8)

Out-of-school classes (morning and pm)

Leadership Conference Opportunities

Language Bowl Classes (prep for annual event)

Rites of Passage

Traditional and Spiritual Events

Contributing to this number is outreach presentations to non-member communities that

request our services including:

•

Local school districts

Mt Hood Cultural Presentation

Community colleges, universities and other higher education institutions

Museums

KWSO

Purpose: KWSO is a non-commercial radio station with programming focused on

meeting the needs of the Warm Springs Community. Information and Education is

offered through on-air live calendar reads, pre-recorded public service announcements,

in local news stories and in locally produced news magazine segments.

Relevance: Public Service Announcements are categorized for the purpose of

identifying our broadcast efforts to the Guidance from Joint Health Commission

strategies. KWSO supports the work of the Health & Human Services Programs in

Warm Springs by utilizing media to promote health related events and activities plus

providing health education and information about services.

KWSO

2014

PSAs by Category

Health Education

Community Event

Health Insurance

Mental Health Education

Health Related Event

Diabetes Education

Violence Prevention

FASD Awareness

Child Development/Parenting

Cultural Event

Child Mental Health

Youth Education

Child Abuse Prevention

Child Health

Youth Health Related Event

Youth Opportunity Information

School Related Event

Elder Event

Mental Health Event

Youth Employment

Safety

Veteran Support

Veteran Event

Disabilities

Education

2015

2,718

1,988

1,405

1,263

1,261

825

822

732

709

467

374

319

312

2,110

2,231

680

1,959

1,543

1,360

538

715

557

1,044

282

376

419

263

446

121

128

156

115

291

124

118

13,850

15,266

Figure 3-25

KWSO, Continued

2015 PSA Campaigns by Topic

Veteran Event

Safety

Mental Health Event

School Related Event

Youth Health Related Event

Child Abuse Prevention

Child Mental Health

Child Development/Parenting

Violence Prevention

Health Related Event

Health Insurance

Health Education

500

1,000

1,500

2,000

2,500

Figure 3-26

Interpretation: This data is focused on the Public Service Announcements (PSAs)

broadcast that were categorized to tie in with the Guidance for Joint Health Commission

strategies. This represents only a portion of all PSAs broadcast. The top health related

PSA campaigns focused on: Health Education; Mental Health; Diabetes Education;

Child Mental Health; Child Development/Parenting and Health Insurance.

Overall –“Events” (which included: Community Events; Health Related Events; Cultural

Events; School Related Events; Elder Events; and Mental Health Events) was the

strategy most often broadcast in the Public Service Announcements.

“Health Education” across a broad range of topics was the strategy second most often

broadcast.

A total of 15,266 PSAs (60 seconds or less) were broadcast – that were health related

and relevant to the Joint Health Commission strategies.

That is a value of $305,320 (at $20/spot).

Spilyay Tymoo Newspaper

Purpose: To publish a comprehensive and informative newspaper devoted to the

health and wellbeing of the Warm Springs Tribal Community.

Relevance: The Spilyay Tymoo strives to advance the health and wellness programs

and opportunities available to Tribal Members.

Spilyay Tymoo

2015

2014

Article/Announcement Category

Article

Announcements

Article

Announcements

Child Development/FASD

Early Childhood/Child Development

Youth Fitness

Youth Mental Health

Youth Health Education

Youth Support

Education & Job Opportunity Events

Health Services Information

Tribe's Health Education & Health Support

Elders

Health System

104

Total # of Articles/Announcements

241

408

232

428

Figure 3-27

Spilyay Tymoo Health Related Publications

2015

Health System

Elders

Tribe's Health Education & Health Support

Health Services Information

Education & Job Opportunity Events

Youth Support

Youth Health Education

Youth Mental Health

Youth Fitness

Early Childhood/Child Development

Child Development/FASD

Announcements

Series4

Series3

Series2

100

120

Articles

Figure 3-28

Spilyay Tymoo Newspaper, Continued

Interpretation: The Spilyay Tymoo publishes a newspaper every two weeks. Every

issue includes Health Education, Information about Available Health Services or details

about local events. These all tie to the Guidance for Joint Health Commission

strategies.

Vocational Rehabilitation

Purpose: To track the caseload of pending and eligible Vocational Rehabilitation (VR)

consumers/clients.

Relevance: The tracking of case load data allows for the determination of the success

rates of consumers/clients from initial contact until their case is closed. Ultimately, this

data is reported to the Tribe, Joint Health Commission and the main funding source for

this program to determine if VR is fulfilling the annual programmatic goals for the

number of consumers served under an Individual Plan of Employment (IPE) and the

number of cases closed due to being successfully rehabilitated. This data is both a

reflection of the consumer’s participation level and the programmatic service delivery

effectiveness.

Vocational Rehabilitation

FY2013*

Orientations

Intakes

Files Closed

New Cases Opened

Mo. Average Pending Eligibity

FY2015*

FY2014*

145

174

Figure 3-29

*Vocational Rehabilitation uses a Fiscal Year (October – September) for data collection.

Interpretation: Consumer/Client data: Attendance at VR Orientations (Warm Springs,

Madras and Portland) was 174, compared to 145 and 59 in the previous years. Intakes

and Files Closed, also increased. New Cases Opened decreased and there was little

change in the number of Individuals Pending Eligibility each month. The data guides

VR to areas within the case management system that may need to be addressed by the

VR team. An example of this would be determining the effectiveness of the program

outreach by the number of attendees at orientations; tracking the ability of staff to

secure medical documentation as a measure of eligibility determination; tracking the

eligible consumer’s files that are closed “successfully rehabilitated” or closed “other”

status. An electronic database of eligible clients is also utilized to break data down

further.

A majority of consumers have dual diagnosis, the most common being alcohol/drug

dependency with related psychological social issues such as depression, anxiety, Post

Traumatic Stress Disorder (PTSD), and medical issues; such as Diabetes Type II,

renal/kidney disease, obesity, arthritis, hypertension/high blood pressure, hearing and

vision impairments. The rehabilitation process generally takes 12-18 months for most

consumers.

Vocational Rehabilitation, Continued

The data also provides “Consumer Self Sufficiency” and “Community Collaboration”

indicators. These indicators assist in determining the level of cooperation of the health,

human, social and economic service providers that serve common consumers/clients.

“Comparable Benefits” are services contributed to IPE’s by the consumer or other

service providers. In 2015, while the program was not actively tracking Comparable

Benefits, $5,544 were recorded. This number will increase substantially in 2016, as the

program will actively be tracking Comparable Benefits for all consumers, to demonstrate

the services leveraged through IPE’s. Comparable Benefits is also a measure of

consumer self sufficiency, as consumers seek out other services and personally

contribute to their IPE employment plans.

Other relevant training, education and employment data: In 2015, the target number to

achieve an employment outcome was 25. The actual number of clients to achieve

successful employment outcome was 14; all working full time and 0 were self-employed.

This was 64% of the target goal and a 56% increase from 2014. A total of 47 clients

served under an IPE. The total number whose employment resulted in earnings was

38, with an average of $360/week at the time of being determined eligible. The average

earnings at the time of achieving/completing the program was $536/week with 10 still

employed 3 months and 8 still employed six months after completing the program. In

2015, 11 consumers were enrolled in an educational training program, primarily in Bend

and Portland. One client attained a post secondary degree and two started GED

programs.

High Lookee Lodge Adult Living Facility (HLL)

Purpose:

High Lookee Lodge (HLL) Assisted Living Facility (ALF) provides

individualized services to elder and disabled adults who are in need of assistance with

daily living, with an emphasis on a home like and cultural living environment. These

services are provided within the guidelines established by the State of Oregon License

as an ALF.

Relevance: HLL provides care to elder and disable adults who are no longer capable

of living on their own. Serviced provided include but are not limited to medication

distribution, meals, assistance with dressing, laundry, setting up appointments and

providing rides to appointments. Provide assistance to residents that helps maintain

their independence with assistance in areas as needed.

High Lookee Lodge

2012

2013

2014

2015

Private

Resident

Pay Medicaid Count

Private

Pay

Medicaid

Resident

Count

Private

Pay

Medicaid

Resident

Count

Private

Pay

Medicaid

Resident

Count

January

February

March

April

May

June

July

August

September

October

November

December

Avg Number

of Residents

Figure 3-30

Interpretation: In 2015, HLL averaged 20 patients per month. The ALF is able to

house 36 total residents. In addition to the patients that receive Medicaid, HLL

averages 4 private pay residents per month.

Children’s Protective Services

Purpose: Children’s Protective Services (CPS) works to empower parents, families

and community members through support, accountability and cultural teachings to give

all children an optimal chance in life. CPS provides prevention and intervention

services to families in need so that the family system has the opportunity to learn the

necessary skills to keep the family safe and together.

Relevance: Program statistics allow CPS to evaluate the effectiveness of the

program’s response and resolution to Child Abuse and Neglect referrals as well as tailor

services to meet the unique needs of each child and family that enters the CPS system.

Children's Protective Services

FY2013

FY2014

FY2015

Visits/Contact

Total Number of Services Provided to Children

5,116

Total Number of At-Risk Children

4,879

325

389

Total Number of Child Abuse/Neglect

379

476

402

Children Placed in Emergency Shelter

129

207

Average Length of Time in Emergency Shelter prior to being placed (days)

120

Average time in Foster Care (days)

270

285

Figure 3-31

Interpretation: The statistical information provided represents the ongoing need for

protective care services, intervention and prevention as the amount of children served in

2015 remains significant.

The average time in Foster Care days is an indicator of the amount of time children

remain in protective care prior to reunification or alternative permanency is achieved. In

2015, the average time was 285 days which is significantly longer than the program

goal of 180 days. There are several contributing factors for CPS not achieving this goal

including issues with staff vacancies, lack of family involvement with becoming certified

as relative foster care providers, lack of general Tribal foster homes on the Reservation

and reunification with parents have not occurred in a consistent and timely manner.

Family Preservation

Purpose: The goal of the Family Preservation (FP) program is to enable families to

properly care for their children, while maintaining the safety of the child in the home. FP

assists families in coping with problems that interfere with successful parenting, and

helps families to find and use resources, and support. This program is not designated to

“fix” everything in the family but to help the family learn the skills necessary to provide a

safe and caring environment for the child.

Family Preservation objectives are:

1. To protect the child from further harm within his or her own home

2. To strengthen and maintain client families

3. To help families recognize and enhance their own strengths

4. To prevent family breakup

5. To prevent further removal of children who have been reunified with their own

families

6. To reduce client dependency on social services by promoting family self

sufficiency.

Relevance: The programs data collected allow FP to evaluate the strengths and

weakness in the program. The data allows FP to make necessary changes for overall

improvement showing the amount of clients that are being seen before they are in

danger of child removal.

Family Preservation Program

FY2015*

Visits/Contact

Total Number of Children Served (not counting CPS monitor)

Children Also Receiving Counseling/Social Worker Services

Total Number of Families Served

Total Number of Children transferred into CPS

Total Number of Children served in-home to prevent Placement disruption

131

Figure 3-32

* Data from June to December 2015 only.

Interpretation: The data above is from the Months June through December due to

program change. Family Preservation was originally a part of Warm Springs Child

Protective Services but in June, Family Preservation transferred into Warm Springs

Community Health Services. Family Preservation works with the family rather than

focusing just on the child. The program’s caseloads are per family rather than per child.

Children who have been transferred from Family Preservation into Child Protective

Services are either due to: Court Orders, family’s unwillingness to work with FP, strong

drug or alcohol relapse, or child in need of supervision. Family Preservation works in

collaboration with Community Health Clinical Social Worker.

Tribal Day Care Program

Purpose: The Tribal Day Care Program provides child care services to children ages 6

weeks to 12 years of age. Children are provided a clean, healthy, safe-learning

environment as well as age-appropriate curriculum to educate them in early learning

and health-related curriculum. Day Care Staff participate in healthy learning activities

provided through community departments, social events, and healthy gross motor

activities.

Relevance: The data being collected is used to track medical exclusions as well as

child injuries and if they were a transport or a non-transport to Indian Health Services.

Dental screenings are provided to those children whose parents give authorization.

These screenings help in the prevention or detection of cavities in young children. All

enrolled children’s immunizations are tracked via the Alert System in order to make sure

all enrolled children are current on immunizations.

Tribal Day Care

Visits/Contact

Dental Screenings

Medical Exclusions

Injuries/Accidents:

Transport

Non-Transport

Head Lice Exclusions

Immunizations

Ages & Stages Questionnaire

FY2014

FY2015

127

102

112

Figure 3-33

Interpretation: In 2015, there was an increase in Medical Exclusions due to

Respiratory Syncytial Virus (RSV) and other viruses. Injuries/Accidents increased from

108 to 119 with 94% of these incidents not being severe enough that the child needed

to be transported for medical care.

This data reflects the number of dental screenings, Ages & Stages Questionnaires

(ASQ’s), medical & head lice exclusions, and injuries/accidents and whether they were

a transport or non-transport to Indian Health Services (IHS). This data also reflects that

Tribal Day Care meets State requirements as far as all enrolled children having

completed their immunizations before the exclusion day in March of every year.

Community Wellness Center

Purpose: To provide safe and properly supervised community/youth activities which

enhance the physical, health, social, educational, cultural and leadership well-being of

our community’s youth and families.

Relevance: Work load measures are needed to assess program growth, community

activities and community benefit as well as personnel requirements for the Community

Wellness Center (CWC).

Community Wellness Center

FY2014

FY2015

Youth and Community Activity

Recreation Field Trips (incl. Chaperones)

Sports/Athletic Program Attendance (all)

Game Room Attendance

Snack Attack

After Shool Programs/Community Activities

437

49,872

2,333

4,071

9,426

368

35,739

2,614

3,186

9,363

Total Program Participation

66,139

51,270

Signed Weight Room Waivers

402

428

Summary of Activity

Figure 3-34

Interpretation: The CWC continued to serve large numbers of community members

through the programs in 2015, the majority of which were in the Sports/Athletics

programs. After School Programs/Community Activities also had strong participation

numbers as did the “snack attack” program which provided a healthy afterschool snack

option for youth.

Some of the major activities provided in 2015 included: Youth field trips, Arts & Crafts,

Board Games, Halloween Activities, popcorn and movie, holiday craft projects,

carnivals, parades, Christmas Bazaar, community yard sales, Christmas activities, and

Penny Carnival.

Medical Social Worker (MSW)

Purpose: To identify the workload associated with the Medical Social Worker (MSW).

Relevance: Workload measures are needed to assess program growth, personnel

requirements and efficiency.

Medical Social Worker

2015

Patients Seen

Chart Reviews

Telephone

Ambulatory Visits

149

129

132

Total Days of Service

Average Visits Per Day

Total FTE's

Average Visits per FTE per year

250

0.53

132

Figure 3-35

Interpretation: The MSW provides many types of services including mental health

counseling for individuals and families. Classes are offered on Negative Thinking for

the Diabetes Prevention Program. The MSW is a member of the Fetal Alcohol

Spectrum Disorder Coalition. A close relationship is maintained with the Family

Preservation Program to provide social work services and teach Conscious Discipline to

families.

The Top Ten Purposes of Visits managed by the MSW include:

•

Administrative Encounter

Family Circumstances

Counseling

Economic Problem

Posttraumatic Stress Disorder (PTSD)

Other Specified

Inadequate Housing

Psychological Stress

Family Health Problems

Medical Mobile Unit (MMU)

Purpose: To provide an overall summary of the use of the Medical Mobile Unit (MMU)

in the community.

Relevance: The MMU travels to different areas of the reservation to deliver primary

medical and dental services.

Medical Mobile Unit

2015

Location

Sidwalter

Seekseequa

Administration Building

Campus

Community Center

Senior Center

ECE

Corrections

WSK8 (Dental)

Agency (specific location unknown)

Fire Management (Physicals)

Visits

Figure 3-36

Figure 3-37

Medical Mobile Unit (MMU), Continued

Mobile Medical Unit Patient Visits

2015

Department

Visits

No Shows

Walkins

I.H.S Medical

I.H.S Dental

Community Health

464

578

73 (16%)

48 (10%)

Figure 3-38

Figure 3-39

Interpretation: The MMU is scheduled for primary care clinics on Tuesdays. Once a

month it is scheduled for outlying areas. Dental screenings are provided at the Warm

Springs K-8 Academy for a couple weeks in the fall and spring. The MMU is also used

for specialty clinics such as annual physicals for children starting Head Start or for fire

fighters working with Fire Management. It was anticipated that the MMU would be used

for flu shot clinics but due to changes in scheduled events and difficulty with

connectivity, it was decided not to use the MMU.

Summary of Grants (Their Purpose etc.)

Purpose: Education and assistance for Native Americans to pursue optimal health.

Relevance: Grants enable programs to offer a multitude of services including: health

education, presentations, cooking classes and community interaction to the Warm

Springs Community.

Special Diabetes Prevention for Indians Grant (Tribe): Heightened community

awareness regarding diabetes risk reduction strategies, physical activity education and

family involvement in fitness activities. The SDPI Wellness Program co-sponsors

multiple diabetes/physical fitness activities and events throughout the grant year.

Target youth ages 6-12 who are at-risk for diabetes. Provide funding and incentives for

youth sports-related activities and sports camps in the community to provide exercise

opportunities for Tribal youth.

Maternal Child Health (MCH): Provide high quality, Tribal Best practices home visiting

based services to pregnant women and families with young children aged birth to

kindergarten. One Tribal Best Practice that has been supported since 1995 is Back to

Boards, which teaches how to complete baby boards for the infants first year, receiving

instruction and education on the dangers of tobacco, drugs and alcohol use of the fetus.

State Women, Infants and Children (WIC): Provides nutrition education, one on one

nutritional consultants and assistance to purchase nutritious foods and formula for

pregnant/nursing mothers and children up to age 5.

State Tobacco Prevention: Utilize the same principles stated in A&D Prevention and to

provide on-going projects that concentrate on promoting policy such as having smoke

free buildings, events and worksites.

Alcohol & Drug Prevention: Provide prevention services targeting populations by

following the continuum of care model (universal, selective and indicated) and the six

Center Substance Abuse Prevention strategies (information dissemination, education,

alternative activities, community base, environmental/policy and early identification and

referral).

Coordinated Tribal Assistance Solicitation: Provides expanded A&D services and

specialized treatment for sex offenders.

Domestic Violence: This is a project that is coordinated with Victims of Crime and

Prosecution. Provides expanded A&D services and specialized treatment for domestic

violence victims.

Juvenile Crime Prevention: Substance Abuse Counselor/Part time position will screen

youth and identify early indicators of problem behaviors and provide case management.

Strategic Prevention Framework/Partners For Success (SPF/PFS): The SPF/PFS is a

community-wide program that requires a high level of communication, collaboration, and

involvement on the part of those involved. The SPF-PFS initiative allows Warm Springs

SPF/PFS to plan and implement strategies to prevent substance abuse in the

Summary of Grants (Their Purpose etc.), Continued

community. The program is responsible for assessment, capacity building, planning,

implementing, and evaluating activities associated with the PFS priorities.

Mental Health Initiative: Following 3 programs:

• Mental Health Promotion and Prevention: Transformational Change using

Conscious Discipline (CD). Folds mental health promotion and prevention into

existing tribal prevention system so departments can identify early indications of

problems and foster mental health.

• Jail Diversion: Wellbriety Program (Tribal jail Diversion). Expands services to

keep people with mental illness and other behavior problems from unnecessary

incarceration in local jails.

• System of Care and Wraparound: Warm Springs Family Preservation Program.

Increase the availability of wraparound services, providing intensive care

coordination for family and children with emotional and behavioral disorders.

USDA Commodity Warehouse: Provide food to low income/disabled households on the

Reservation.

NARA Youth Suicide Prevention): This grant operated off of a scope of work agreed

upon annually with our funders, NARA. The main focus is with youth encouragement of

self-worth and family values. Hosting community events that provide family activities

and developing the Tribal Youth Council.

Influenza Pandemic: Provide policy guidance within the emergency preparedness plan

for fast response with all disease prevention and treatment. Follow the same process

indicated with Alcohol & Drug Prevention above.

Vocational Rehabilitation: Helps Native Americans with disabilities find, obtain, maintain

or become promoted in employment.

Meth/Suicide Prevention (MSPI): Develop the Health and Human Service Infrastructure

to address suicide prevention, intervention and post/vension and to educate community

members & provider partners.

Interpretation: Grants provide needed services that compliment base dollars we

receive through our 638 annual funding agreement and base dollars received by the

State of Oregon. Programs are tracked within the Annual Health Report, mandated

grant reports and collectively have shown reductions in numerous areas. The Wellbriety

program has diverted 33 cases that would have had to face fines or jail time; they are

receiving treatment as a diversion. Back to Boards has reduced SIDS, and other health

problems, which are complicated to prove since, true prevention means the

consequence of poor chooses does not occur. More than 500 youth and community

members have been trained locally with QPR (question, persuade and refer) again

reducing suicide attempts.

SECTION 4

Resource Availability and Use

How do we deploy and maximize resources toward a healthier community?

This section provides an overview of all the resources that have been devoted to the

provision of health care including Indian Health Service, State of Oregon, awarded

grants and those resources allocated by the Warm Springs Tribe. The resources are

compared to the national medical inflation factors to determine our status. The

information also identifies expenditures by program. Detailed history of collected

revenue is captured by year and by program. Since almost one quarter of all health care

resources is absorbed by Managed Care, it is important that the system continue to

monitor total costs and unit costs of all those services that are purchased. The staffing

levels of each program are identified and further reviewed to determine the extent of

tribal member employees. An accounting of carryover funds and reserves is also

maintained.

The vast majority of the resources that are provided annually are associated with

ongoing programs and services, leaving only limited resources to add new services or

address special needs. Implementing the comprehensive health plan anticipates a

careful examination of resources and careful priority setting for available resources.

This section highlights the available resources for the past several years, as well as the

spending patterns.

Resources that are not expended in a given year are, for the most part, available to the

subsequent year. Some, but not all, may be available to re-allocate to other purposes.

This section also indicates that federal funding has lagged medical inflation for many

years. Purchasing power is diminished when this happens. Increases in 2009 and

2010 have helped to close this gap. However, the federal budget deficit will place

pressure on federal budgets for many years to come.

Summary and Highlights

Overall funding of the Health System in 2015 remained at the same level as the

previous year (just over $28 million).

While the total resources from the Indian Health Service declined by 3%, the recurring

funding actually increased by 4.2% in 2015, benefiting the health service portion of the

budget. (Figure 4-1)

Indian Health Service collections increased by $250,000 or 5.5%. The Tribal collections

decreased slightly from the previous years experience due to a change in billing policy.

In previous years, the biller would bill for a year back. In 2014, the biller caught up with

all past billing and they are now current. The 2015 collection amount should be a more

standard amount received from now on. There was a substantial increase in collections

by Community Health Nursing (nearly tripling from the 2014 level). Together the Indian

Health Service and Tribe collected $6.5 million (a record high). (Figure 4-1)

The resources through appropriations in 2015 increased by 4.2% which is a little above

the medical inflation rate reported. This was much better than what was experienced in

2013 and 2014.

The actual expenditures for health services declined by $2.6 million in 2015. (Figure 43). The declines are explained in the text of this chart. Purchased/Referred Care,

Facilities, Health Administration, Pharmacy and Podiatry were the areas with the most

notable declines.

Purchased/Referred Care had another banner year in terms of resource utilization,

primarily due to the effective use of alternate resources and the medicare negotiated

hospital rates. This is despite a large increase in admissions and hospital days that

occurred in 2015.

A substantial increase in grant funding brought the total to nearly $5 million over the

past four years.

Health System Funding by Major Source

Purpose: To provide a complete picture of all funding available to the overall health

system to serve the community.

Relevance: The Health Programs rely on funding from several sources, many of which

the health system has little control. While the historical viewpoint is important, the

current funding is most useful for addressing planning and priorities.

Health System Funding by Major Source

2012

2013

2014

2015

17,348,813

16,135,780

16,248,026

16,927,090

510,231

603,603

1,236,741

81,181

17,859,044

16,739,383

17,484,767

17,008,271

2,522,740

2,630,125

3,876,758

4,093,398

Medicare

Private Insurance

99,349

503,833

265,122

420,342

285,257

361,643

302,669

377,431

Total IHS Collections

3,125,922

3,315,589

4,523,658

4,773,498

Ambulance

146,086

358,739

329,823

386,582

Community Counseling

567,466

944,058

1,196,976

658,195

Community Health

398,428

462,844

228,950

680,023

Total Tribal Collections

1,111,980

1,765,641

1,755,749

1,724,799

Grant Awards

1,650,982

2,133,838

1,114,664

1,511,893

Tribal Employee Group Insurance (Est)

1,901,827

2,231,557

3,091,229

2,648,623

Tribal Appropriations

1,682,649

396,905

477,754

547,417

Indian Health Service

Recurring Funding

Non-Recurring Funding

Total IHS Funding

Collections IHS

Medicaid

Collections Tribe

Total

$27,332,404 $26,582,913 $28,447,821 $28,214,501

Figure 4-1

Interpretation: The funding trends have been positive over the past 4 years, although

there was some erosion of funding in 2013 as a result of the sequester.

While the total resources from IHS declined by 3%, it is worth noting that the recurring

funding actually increased by 4.2% in 2015 over the previous year benefitting the

operational budget.

Health System Funding by Major Source, Continued

IHS collections increased by $250,000 or 5.5% in 2015 and established another new

record. Tribal collections decreased slightly from the previous year’s experience. A

huge decline (50%) in the collections of the Community Counseling (decrease of

$538,781) was experienced in 2015 and that situation must be corrected. On the other

hand, the Community Health Nursing Program increased its collections by $451,073 or

nearly tripling its total. The ambulance program increased collections by 1% from the

prior year.

Grant awards increased by $397,229 from the previous year. Tribal appropriations

increased by $69,663 over that same period. Tribal Employee Group Health

expenditures were estimated at $2,648,623, which represents a decrease of $442,606.

The overall total Health Program Funding for 2015 was slightly less than in 2014. The

decrease was somewhat less than 1%. Without the decrease in non-recurring funding

experienced in 2015, actual health services money increased slightly.

Base Health System Funding Versus Inflation

Purpose: To identify the historical Indian Health Service recurring funding base and to

compare it with medical inflation.

Relevance: Measuring the purchasing power of ongoing resources is vital to

addressing resource allocation and priorities. While there are numerous other resources

the Indian Health Service recurring funding base represents the only source derived

directly from the federal obligation that is adjusted for inflation.

Annual IHS

Base Funding

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Base

Increase

9,570,435

9,955,164

10,428,865

10,716,132

11,102,601

11,836,295

11,914,200

12,072,614

12,454,591

12,833,003

13,340,464

13,995,065

16,174,897

16,284,305

17,348,813

16,135,780

16,248,026

16,927,090

1.0%

4.0%

4.8%

2.8%

3.6%

6.6%

0.7%

1.3%

3.2%

3.0%

4.0%

4.9%

15.6%

0.7%

6.5%

-7.0%

0.7%

4.2%

Medical

Inflation

2.9%

3.5%

4.1%

4.6%

4.7%

4.0%

4.4%

4.2%

4.0%

4.4%

3.7%

3.2%

3.4%

3.0%

3.7%

2.5%

3.0%

2.6%

Growth of $1 from 1998

$2.50

$2.00

$1.50

Growth of $1 of Inflation

$1.00

Growth of $1 of IHS Base

$0.50

$0.00

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Figure 4-2

Base Health System Funding Versus Inflation, Continued

Interpretation: Funding increases provided by the Congress in 2009, 10 and 12

addressed deficiencies in bringing the funding in line with inflation. The national budget

sequester in 2013 stripped funding, thereby reducing the benefits realized from those

increases. The reductions were restored in 2014. Funding has just kept pace with

inflation but does not account for population growth over the past 15 years.

Health System Spending by Program

Purpose: To report actual outlays by each program as well as overall carryover and

savings.

Relevance: Important to understand, plan and adjust resource allocation to meet the

changing health system priorities.

Clinical Services

Medical

Dental

Optometry

Pharmacy

Podiatry

Medical Lab

X-Ray

Diabetes - Clinic

Community Health

Community Health Dept.

Health Education

WIC Program

Diabetes Grant (Tribal)

Environmental Health

Public Health Nursing

Community Center

Community Counseling

Mental Health

Adolescent Aftercare

Vocational Rehabilitation/Social Sv

Prevention Projects

Administrative Support

Facilities

Security

Medical Records

Health Administration

Business Office

Quality Assurance

Data Systems

Indirect Costs

Other

Managed Care

Ambulance

Quarters

Clinic Equipment

Total

2012

2013

2014

2015

2,229,705

1,217,056

287,891

1,122,677

107,033

749,719

2,875,284

1,217,823

240,219

1,492,054

101,993

640,333

797,546

680,280

2,653,814

1,314,421

221,051

1,631,774

344,842

775,851

111,181

483,737

2,747,835

1,341,744

195,204

1,224,359

171,583

860,922

92,431

462,312

415,384

221,757

64,620

142,075

56,113

941,253

214,402

364,932

299,954

63,190

193,268

46,624

644,482

293,289

277,899

816,638

40,020

184,296

94,400

650,440

174,291

198,781

743,194

53,856

165,049

94,090

820,840

258,955

1,055,718

321,245

79,931

552,314

337,782

1,164,795

197,119

85,647

411,200

423,370

480,416

442,326

130,052

66,509

419,615

380,237

737,596

136,649

91,332

132,230

986,419

22,891

263,269

1,071,288

1,264,624

947,236

106,017

269,888

1,314,107

1,007,004

462,821

107,336

492,258

394,679

1,291,843

646,238

110,678

482,681

1,335,157

473,883

24,280

393,689

1,379,464

557,516

141,251

478,445

1,190,811

5,566,489

1,071,369

123,740

5,836,686

300,000

51,865

3,048,409

325,021

176,684

2,160,842

337,353

23,204,464

19,957,095

20,196,251

18,114,356

67,621

Figure 4-3

Health System Spending by Program, Continued

Interpretation: From 2014 to 2015 the overall spending on total health services has

decreased by $2,615,821 (13%). Most of the decrease is easily explained.

The expenditures in Managed Care were nearly $900,000 less than the previous year

and are a reflection of the effective use of alternate resources and the Medicare rates

now available for hospitalizations.

The reduction in spending for the Pharmacy Program was primarily because of two

factors: Intermittent Pharmacy costs were down by $58,000 and more importantly drug

costs dropped by $336,000. This was attributed to one of the top ten expensive

medications now being available as a generic drug. It is anticipated that in 2016, drug

costs will again rise due to an additional expensive drug (etanercept) being added to the

formulary.

Podiatry expenditures declined by $174,000 in 2015. This was mainly due to the

vacancy created when the Podiatrist retired. It took several months to recruit a new

Podiatrist.

Most of the other programs and activities had expenditures that were in line with the

previous years. Vacancies can account somewhat for the variances in most of the other

categories.

Clinic Billing

Purpose: To identify visits billed, revenue collected and source by year.

Relevance: To identify trends and determine action of program considerations to

improve billed revenues.

2012

Visits Billed

Medical

Dental

Pharmacy

Optometry

All Other

Total Visits Billed

Collections

Medical

Dental

Pharmacy

Optometry

All Other

Total Collected

Source

Medicaid

Medicare

Private Insurance

Other (Workmen's Comp, VA, etc)

2013

2014

2015

10,208

2,190

22,189

387

3,275

10,320

2,296

21,159

467

2,232

12,179

3,308

25,771

689

2,469

11,743

3,333

30,223

1,021

2,389

38,249

36,474

44,416

48,709

2012

2013

2014

2015

2,213,237 $

395,382

535,153

75,514

205,794

2,465,486 $

414,088

480,071

107,595

189,182

3,081,135 $

734,752

617,569

98,224

116,865

2,998,233

609,708

956,958

138,160

104,653

3,425,080 $

3,656,422 $

4,648,545 $

4,807,712

2012

2013

2014

2015

2,624,016

268,149

506,060

26,855

2,908,078

277,127

449,167

22,050

3,923,674

291,374

390,379

43,118

4,093,398

302,669

377,431

34,214

Figure 4-4

Interpretations: Total Medical visits billed have increased by 13% over the last 4

years with an average of 11,113 visits a year. Pharmacy visits has increased by 27%

over the last four years, with a 15% increase in the last year. Total visits billed have

increased 21.5% since 2012 then, with a 9% increase in the last year. The largest area

of billing growth was in Pharmacy.

In 2015, Medical billed out for 11,743 visits and received $2,998,233 (an average of

$255 a visit). Medicaid accounted for approximately 85% of collections, Medicare

around 6.3% and Private Insurance makes up 8%.

Tribal Billing

Purpose: To identify visits billed collected revenue and source by year.

Relevance: To identify trends and determine action of program considerations to

improve billed revenues.

2012

Incidents/Visits Billed

Ambulance

Alcohol & Substance/

Mental Health

Community Health

Other

Total Incidents/Visits Billed

Collections

Ambulance

Alcohol & Substance/

Mental Health

Community Health

Other

Total Collected

Source

Medicaid

Medicare

Private Insurance

Workers Comp

Other

2013

2014

2015

594

1,896

636

2,938

690

3,532

854

1,888 *

2,075

1,502

839

1,943

4,565

5,076

5,061

4,685

2012

2013

146,086

2014

2015

358,739

329,823

377,077

567,466

398,428

944,058

462,830

1,196,976

228,950

657,265

680,022

$ 1,111,980

$ 1,765,627

$ 1,755,749

$ 1,714,364

2012

2013

2014

2015

1,000,140

1,099

98,325

9,980

2,437

1,519,144

112,256

115,964

11,317

6,946

1,548,191

77,849

110,224

15,013

4,472

1,508,888

93,580

101,439

4,092

Figure 4-5

Interpretation: Since 2010, when the Tribe added Billing Staff, Collections have

continued to increase even though there was a small decrease from 2014-2015. In

2015 collections saw a decrease of $41,385 from the previous year. The big decline in

Community Counseling was due to a change in Policy and Procedures.

Ambulance Financial Summary

Purpose: To identify cost and sources of revenue for ambulance operations and to

identify trends in collections.

Relevance:

Provides information needed for decisions regarding financing of

ambulance operations.

OUTLAYS AND FUNDING

2014

Outlays

Allocated Salaries and Benefits

Medical Supplies

Other Supplies & Expenses

Vehicle Expenses

Equipment

Vehicle & Equip. Depreciation

2015

255,258

16,786

13,930

38,583

463

5,795

Total

Average Direct Cost Per Transport

330,816

255,602

19,848

19,764

40,963

1,176

5,795

343,148

479 $

402

Figure 4-6

Funding Source

Indian Health Service (PL 93-638)

Collections

Warm Springs Tribe - Direct Appropriation

Interpretations: The collections for ambulance services increased by $47,254 or 14%

in 2015. At the same time the expenses also increased by $12,332 or 4%. The cost of

Medical Supplies and Vehicle maintenance accounted for this increase. The average

cost per transfer decreased by $77 or 16%.

Contract Health Services – Funding

Purpose: To compare annual CHS base funding to medical inflation and to report on all

CHS Funding.

Relevance: Identifies gap between medical inflation and funding.

CHS Annual

Funding

Base

N/R &

Deferred

Services

78,547

CHEF

Base

Increase

Total

Medical

Inflation

1998

2,716,800

193,567

2,988,914

1.8%

3.2%

1999

2,798,596

23,857

2,822,453

3.0%

3.7%

2000

2,997,244

259,696

3,256,940

7.1%

4.9%

2001

2,997,244

431,485

115,450

3,544,179

0.0%

5.2%

2002

2,997,244

436,886

71,117

3,505,247

0.0%

6.0%

2003

3,511,606

32,831

166,859

3,711,296

17.2%

5.2%

2004

3,538,505

180,023

479,118

4,197,646

0.8%

5.0%

2005

3,665,746

90,206

155,406

3,911,358

3.6%

4.6%

2006

3,807,490

97,119

239,859

4,144,468

3.9%

4.6%

2007

3,947,624

79,971

397,960

4,425,555

3.7%

5.4%

2008

4,148,016

470,258

4,618,274

5.1%

5.2%

2009

4,522,779

422,971

4,945,750

9.0%

4.6%

2010

5,409,429

243,152

867,507

6,520,088

19.6%

4.9%

2011

5,414,309

206,376

675,421

6,296,106

0.1%

4.3%

2012

5,838,361

255,088

6,095,461

7.8%

3.1%

2013

5,545,485

315,168

6,019,539

-5.0%

3.0%

2014

6,027,353

325,025

6,354,392

8.7%

3.1%

2015

6,289,399

36,896

6,328,310

4.3%

2.6%

156,873

Growth of $1 from 1998 - 2015

$2.50

$2.00

$1.50

$1.00

Growth of $1 of Inflation

Growth of $1 of CHS

$0.50

$0.00

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Note: Medical Inflation is the average of U.S. Department of Lab or, Bureau of Lab or Statistics

Medical Services (50% Professional Services and 50% Hospital Services).

Figure 4-7

Contract Health Services – Funding, Continued

Interpretations: Funding increases provided by the Congress in 2009, 10 and 12

addressed deficiencies in bringing the funding in line with inflation, but the sequester in

2013 stripped funding, thereby reducing the benefits realized from those increases.

Funding has just kept pace with inflation but does not account for population growth

over the past 15 years.

Purchased/Referred Care - Spending

Purpose:

To provide a report of major categories of spending for the

Purchased/Referred Care (PRC) program.

Relevance: Purchased care represents a significant portion of the health care resource.

Understanding the nature of costs is important to policy and priority decisions.

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

In-Patient

OutPatient

Emergency

1,662,882

1,781,146

2,575,549

1,828,048

1,729,514

2,030,516

2,214,036

1,863,629

1,956,174

2,109,445

819,201

427,996

1,927,564

2,261,024

1,684,794

1,115,067

1,487,726

1,915,341

1,976,500

2,003,106

2,091,392

1,981,981

1,115,817

773,800

88,150

467,070

553,401

440,908

507,249

790,176

778,472

794,683

739,859

879,032

267,291

256,999

Dental

358,298

169,229

65,901

38,592

52,544

90,704

72,569

170,874

179,203

161,423

177,025

203,861

Vision

4,416

3,640

2,483

3,424

5,611

7,154

12,486

11,100

14,592

18,402

19,744

Pharmacy

Supplies

81,942

137,381

110,504

5,915

17,373

18,620

25,384

34,497

21,908

32,833

45,493

36,403

92,879

80,571

58,866

10,093

82,811

102,421

118,159

144,001

179,056

114,451

150,146

156,306

Total

4,216,131

4,900,061

5,049,015

3,441,106

3,880,641

4,953,389

5,192,274

5,023,276

5,178,692

5,293,757

2,593,375 *

1,875,109 *

Warm Springs Contract Health Services

8,000,000

7,000,000

Amounts

6,000,000

5,000,000

4,000,000

3,000,000

2,000,000

1,000,000

2004

2005

2006

2007

2008

2009

2010

Year

Funding Available

2011

2012

2013

2014

2015

Outlays

Figure 4-8

*There are Obligations for Services that have not been finalized. Final payment amounts will vary.

*There is an additional $995 Obligated but not yet paid for 2014.

*There is an additional $216,756 Obligated but not yet paid for 2015.

Purchased/Referred Care – Spending, Continued

Interpretation: Illustrates fluctuations in PRC total costs, as well as seven components

of that total cost, over twelve years.

Even with the implementation of Priority I’s in July 2005, costs appeared to peak in

2006.

The implementation of the Medicare-Like Rates in July 2007 had a huge positive impact

as costs fell by roughly $600-700K for both In-Patient and Out-Patient. The rise in OutPatient in 2008, 2009 and 2010 is the result of the $500K Tribal Council Resolution

(2008), $500K carryover “carve-out” from reserves (2009), $250K carryover “carve-out”

from reserves (2010), and relaxation of Priority I’s in April 2010. Priorities II, III and IV

have been authorized since then, with the resulting yearly peak costs of $5,296,757 in

2013. However, with $216,756 Obligated but not yet Paid for 2015, added to the

$1,875,109 paid for 2015, the projected $2,091,865 2015 PRC Healthcare Costs are

19% less than 2014.

Since Medicaid Expansion came into effect at the beginning of 2014, PRC healthcare

costs have receded by 65%. While the opportunity is present, Purchased/Referred

Care may explore other Specialty Clinics to improve the health of the community.

Purchased/Referred Care – Utilization and Unit Cost

Purpose: To identify the total cost and unit cost for Hospitalization and Emergency

Room services purchased through the Purchased/Referred Care (PRC) Program.

Relevance: PRC funds are limited and managed on a priority basis. Patterns of

utilization and costs must be monitored to support resource decisions and program

priorities.

2014

2015

Units

Total Cost

Cost per

Unit

Units

Total Cost

Cost per

Unit

Hospital Days

483

$693,170

1,435

715

$427,996

599

Emergency Room Visits

773

$227,272

294

540

$256,999

476

Figure 4-9

Interpretation: This table reflects the units, total cost and cost per unit for both

Hospital Days and Emergency Room Visits that PRC paid only a small percentage of

the actual costs. Other alternate resources picked up the majority of the costs.

Although there was a 68% increase in Hospital Days from 2014 to 2015, there was an

even greater 58% decrease in Hospital Cost per Unit for this same period of time.

There was a 30% decrease in Emergency Room Visits from 2014 to 2015, but an

increase of 62% for Emergency Room Cost per unit.

While the data in the table indicates the Cost per Unit for Hospital Days in 2015 was

$599, more detailed admissions information is found in Figure 2-16 for the two major

hospitals that serve the community.

100

Deferred Services

Purpose: To identify the number of cases and estimated costs for recommended care

that could not be purchased under current circumstances.

Relevance: It is important that the program maintain a record of these cases and track

progress.

2015

Priorities*

Cases Deferred

Estimated Cost

Priority 1

Priority 2

Priority 3

2,400

Priority 4

2,400

500,000.00

Figure 4-10

Interpretation: PRC was fortunate from 1995 through 2005 to cover Priorities I-IV with

its current year’s budget supplemented by carryover dollars when necessary, and thus

fortunately did not have a Deferred Services list. From the implementation of Priority I

coverage only in July 2005, PRC kept a Deferred Services list defined as those services

in Priorities II-IV that PRC had covered the preceding 10 years but no longer could

cover due to Priority I coverage only.

In April 2010, PRC was able to expand coverage beyond Priority I’s to Priority II-IV

coverage once again. PRC was able to cover Priority I-IV throughout 2011 & 2013, and

had minimal “Deferred Services” as defined as those which PRC had covered pre-2005.

The data above was based on numbers compiled by the PRC Case Manager in

conjunction with the Portland Area Office (PAO) Contract Health Services (CHS)

Manager for a report requested by PAO last year.

For Dental, PRC covers emergent conditions such as abscesses and Priority I

situations, in addition to dentals and partials. PRC will cover dentures and partials

automatically for an elder, but per approval through the PRC Review Team, PRC will

cover a patient in any age group determined on a case by case basis. PRC is also

covering more procedures this year based on dental recommendation and PRC review.

Examples: a) teeth that are not able to be extracted by IHS dentist due to difficulty of

extraction; b) a patient elderly, or fragile in health, may be referred to an Oral Surgeon

for extractions; c) elderly patients may be sent to dentist that specializes in mini posts to

secure their dentures; d) “spacers” for children’s teeth cared for by a pediatric dental

surgeon; e) an anomaly that could possibly be a cancerous situation will be sent out to

101

Deferred Services, Continued

an Oral Surgeon for complete evaluation. Working with IHS dental, PRC emphasis has

been towards Elders and the children of the Reservation. A pediatric dental surgeon

performs about two dental restorations a week at SCMC-Bend.

The approximate cost for dental services that were deferred is about $300,000. There

were an estimated 400 dental cases deferred in 2015.

For Pharmacy, PRC covers only emergent conditions, in addition to anti-rejection drugs,

chemotherapy, anti-coagulant after heart surgery, or knee and hip replacement surgery.

PRC also pays for high cost drugs for a one month period of time to allow a patient to

get into a program sponsored by the pharmaceutical companies that will assume the

cost after the initial month. This “bridge” will ease the high cost for the patient who may

not be able to pay for that medication themselves, but are in critical need of that

medication. Some of those medications have cost as much as $9,000 for one month.

The approximate cost for pharmacy that was deferred is $200,000. There were an

estimated 2000 scripts @ 170 per month average deferred.

Both Dental and Pharmacy were determined by estimating from pre-2005 when MCP

was able to cover more Pharmacy and Dental, and both are higher than last year due to

the increase in population and need, as well as a decrease in drugs in IHS formulary.

Priority I: Emergent/Acutely Urgent Care Services: i.e. immediate threat to life or limb.

Priority II: Preventive Care Services: i.e. Screening Mammograms

Priority II: Primary & Secondary Care Services: i.e. Specialty Consultations

Priority IV: Chronic Tertiary & Extended Care Services: i.e. Hip/Knee Replacement

102

CHS – Catastrophic Health Emergency Fund (CHEF)

Purpose: To identify the numbers of cases qualifying for Catastrophic Health

Emergency Fund (CHEF) reimbursement, the funding request, the received and the

shortfall for each year.

Relevance: Catastrophic cases have a huge impact on the Managed Care budget. All

must be aware of these high cost cases as they develop since they affect overall

service priorities and impact reserves of the program.

Total CHEF Total CHEF

Total CHEF

Threshold Funds Due MCP

Current

Year

RECEIVED

Following

Year

Shortfall

YEAR

Obligation

2006

1,388,591

25,000

788,591

336,978

240,802

577,780

2007

521,458

25,000

346,458

157,158

138,617

295,775

50,683

2008

1,008,323

25,000

633,323

331,651

187,833

519,484

113,839

2009*

996,036

25,000

521,036

235,139

374,375

609,514

(88,478)

2010

1,900,122

25,000

1,050,122

493,132

301,223

794,355

255,767

2011

1,650,223

25,000

775,223

374,198

154,381

528,579

246,644

2012

1,444,760

25,000

694,760

100,707

172,839

273,546

421,214

2013

1,272,006

25,000

572,006

149,087

242,717

391,804

180,202

2014

650,624

25,000

425,624

375,550

49,032

424,582

1,042

2015

272,088

25,000

188,596

62,570

64,135

126,705

61,891

$ 11,784,390

221

Totals

Cases

CHEF

Total

210,811

6,354,797 $ 2,733,030 $ 1,925,954 $ 4,658,984 $ 1,695,813

Figure 4-11

* 2009 $91,274 was received on a very high cost CHEF case. Several months, later, upon

appeal, OHP retroactively covered the patient for DOS including CHEF costs. This money was

paid back to IHS via future Budget Mod Amendment Adjustment.

Interpretations: The IHS Catastrophic Health Emergency Fund (CHEF) exists to

reimburse for high cost cases that exceeds a given threshold, thus limiting financial risk

to that threshold until the CHEF is exhausted for a given year. $25k has been the

threshold for the last 9 years.

The CTWS PRC operates on a calendar year fiscal year. However, the IHS operates

on an October – September fiscal year. Historically, the IHS CHEF was exhausted

about May or June, and was then replenished in October. Thus, a prime reason for a

shortfall in reimbursement is that a CHEF case occurred after the funds were exhausted

for that year. Then, when the new CHEF year starts in October, reimbursement for a

CHEF case falling the last three months of the year usually will not take place until the

following year. Using 2015 as an example, 12 CHEF cases resulted in $188,596 due

CTWS PRC; $62,570 was reimbursed in 2015, and $64,135 has been reimbursed so far

in 2016.

103

CHS – Catastrophic Health Emergency Fund, Continued

Timely application for CHEF is very important, and the PRC Case Manager places

highest priority on this process. Receipt of CHEF can have a significant impact in

helping to offset expenditures for high cost cases. Application for CHEF is competitive

across IHS. Due to a larger budgeted CHEF allocation by IHS, combined with

implementation of Medicare Like Rates (MLR) nationwide, the CHEF has the potential

to last longer than May/June. An additional significant major impact in 2014 was

Medicaid Expansion effective 1/1/14. Not since 2007, the year MLR took effect, has the

number of CHEF cases been measured in single digits. Of the $188,596 due to PRC

$126,705 of the 12 CHEF cases in 2015 has been reimbursed by IHS.

In the ten years from 2006-2015, there was a total of 221 cases qualifying for CHEF

reimbursements of $6,354,797. Total reimbursement of $4,658,984 was received from

IHS, leaving a shortfall of $1.7 million to be absorbed by the PRC program in addition to

the $5,429,593 initially paid out to meet the threshold.

104

Medicare-Like Rate (MLR) Savings

Purpose: Illustrate the significance of the savings resulting from implementation of the

Medicare-Like Rates Legislation effective mid-2007.

Relevance: Savings resulting from implementation of Medicare-Like Rates are the

prime reason MCP has been able to relax Priority I’s and expand coverage to paying for

many Priority II-IV referrals.

2012

2013

2014

2015

St. Charles - Madras

Inpatient

942,724

542,778

197,225

105,808

Outpatient

1,109,233

1,019,541

783,786

479,276

Mixed

57,508

35,705

53,710

109,537

Total

$2,109,465

$1,598,024

$1,034,721

$694,622

Inpatient

15,482

14,916

5,136

Outpatient

Other CAH & Surgery Centers

14,651

28,930

26,788

7,800

Mixed

Total

$30,133

$43,846

$26,788

$12,935

Inpatient

1,534,274

1,761,944

978,753

240,655

Outpatient

440,190

473,532

329,322

149,851

Hospitals that Bill on DRG Rates

Mixed

22,312

13,108

46,205

Total

$1,996,776

$2,248,584

$1,308,075

$436,711

$4,136,374

$3,890,454

$2,369,584

$1,144,268

TOTAL MLR SAVINGS

Figure 4-12

Interpretation: After exhausting $1M in reserves three years in a row (2004-2006), and

beginning in 2007 with only $500k in reserves, the huge positive effect of Medicare-Like

Rates (MLR) cannot be overemphasized.

The Federal Medicare-Like Rates legislation basically states that any Indian Health

Services Purchased/Referred Care (PRC) or Tribally contracted plan which operates

PRC locally may reimburse a Medicare contracted hospital no more that the total

reimbursement the hospital would have received from Medicare.

MLR became effective 7/5/07 which resulted in significant savings for PRC. Savings

resulting from MLR implementation 7 ½ years ago not only was responsible for halting

the erosion of PRC reserves, but allowed PRC to add non-Priority I services through

105

Medicare-Like Rate (MLR) Savings, Continued

specified “carve-out” of $500k under strict criteria in 2009. After a $250k “carve-out” to

begin 2010, the decision was made effective April 1, 2010 to cover Priority II, III & IV

under Committee Review and methodical implementation. I.H.S. physicians and Health

& Welfare Committee were consulted and they gave input on services to add back. As

seen in the table on the previous page, MLR savings have resulted in $15.1 million to

PRC and thus potential healthcare referrals over the last four years.

PRC closely monitors expenditures and is ready to make adjustments if needed. The

goal is to carefully implement authorization and payment for additional services (II, III,

and IV) without trying to implement “too much” and having to then “restrict again”. The

PRC currently pays for most all specialty Priority I-IV referrals it did prior to

implementation of Priority I coverage in 2005.

This is all made possible through PRC taking advantage of the MLR legislation which

has resulted in the significant savings realized from MLR documented above.

However, it is noted the Total MLR Savings decreased by $1,225,316 (48%) from

$2,369,584 (2014) to $1,144,268 (2015). This 48% decrease was consistent across all

three categories: 33% - St. Charles-Madras (Critical Access Hospital reimbursement);

52% - Other CAH & Surgery Centers; 67% - Hospitals reimbursed on Diagnostic

Related Groups (including St. Charles Bend/Redmond). The Diagnostic Related

Groups (DRG) showed the most significant decrease of the three categories.

The $1,144,268 Total MLR Savings in 2015 is extremely positive for the reasons

mentioned above. The MLR Savings are dependent on the Medicare reimbursement

determined by the Centers for Medicare & Medicaid Services (CMS), PRC has to be

prepared to react and adjust depending on future impact of CMS decisions.

106

Grants Received

Purpose: To monitor the availability and funding levels of grants received to support

the health care system.

Relevance: Grants represent an important part of the health care system’s financing,

and are frequently targeted at key risk factors and national priorities. Numerous grants

finance ongoing staff and programs at Warm Springs.

Grant Names

Grant Amount

Diabetes Grant (Tribe)

State Women, Infants, and Children (WIC)

Woman's Wellness Conference

CHET Dental Project

Senior Fitness Enhancement

Tobacco Pilot Site

State Tobacco Prevention

USDA Commodity Warehouse

State Alcohol & Drug

State Alcohol Prevention

State Mental Health

State Youth Suicide Prevention

Influenza Pandemic

Vocational Rehablilitation

Meth Prevention Project

Total

Grant Expenditures

Diabetes Grant (Tribe)

State Women, Infants, and Children (WIC)

Woman's Wellness Conference Grant

CHET Dental Project Grant

Senior Fitness Enhancement Grant

Tobacco Pilot Site Grant

State Tobacco Prevention Grant

USDA Commodity Warehouse Grant

State Alcohol & Drug Grant

State Alcohol Prevention Grant

State Mental Health Grant

State Youth Suicide Prevention Grant

Influenza Pandemic

Vocational Rehabilitation Grant

Meth Prevention Project Grant

Total

2012

2013

2014

2015

193,268 $

78,355

510,846 $

79,391

519,818 $

80,842

193,268

75,497

73,821

39,918

125,000

73,821

79,636

72,902

78,636

66,616

85,175

62,500

362,466

152,500

506,432

381,733

26,000

232,742

$ 1,150,837 $ 1,168,660 $ 1,114,664 $ 1,079,488

129,719 $

84,061

83,549 $

23,200

157,600 $

44,874

78,024

25,614

54,516

71,905

172,187

79,897

144,006

25,094

3,219

266,919

13,813

24,746

17,440

54,396

78,465

23,690

85,175

341,263

$ 1,045,336 $

149,015 $

676,598 $

212,503

Figure 4-13

107

Grants Received, Continued

Interpretation: The above listing of active grants offers a historical glimpse of the

awards received and their associated expenditures. Grants can be awarded at various

times of the year and some cover periods of time which exceed a single year time

frame. It is therefore difficult to draw conclusions without understanding the details of a

specific grant. The list however presents an inventory of our grant activity which has

totaled nearly $5 million over the past 4 years. This represents a significant

enhancement of our available resources. Grants can fill important holes in our

comprehensive health program especially when federal appropriations are limited.

108

Staffing

Purpose: To provide an overall summary of personnel devoted to healthcare, and the

number of Warm Springs t

This text is long and has been trimmed here. Open the source document for the complete record.

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.