The Confederated Tribes of the (2015)

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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

February 9, 2016

2015 Edition

Reporting Information through 2014

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……………..……………………………………37

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

Section 5: Evaluation ………………………………………………117

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 2014 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 (IHS)

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

years and the system will rely more 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 IHS 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 of Warm

Springs, 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 IHS 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 United States (US)

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 IHS, 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 subsequent

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 IHS 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, reporting and data.

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

they are currently operated.

Warm Springs Health Delivery System

INDIAN HEALTH

SERVICES

•

TRIBAL HEALTH

SERVICES

Medical Outpatient

Off Site Hospital Services

Dental

Optometry

Podiatry

Pharmacy

SDPI Diabetes prevention

Demonstration Project

(Competitive Grant 2004)

Diagnostic Lab & X-Ray

Administrative Support

Model Diabetes Site of

Excellence Program

JOINT RUN

SERVICES

SDPI Community

Directed Grant

Amputation

Prevention

Program

•

Health Education

Maternal & Child Health

Community Health Representatives

SDPI Community Directed Grant

Nutrition

Public Health Nursing

Medical Social Services

Environmental Health

Mental Health

Alcohol/Substance Abuse

Ambulance

Administrative & Support

Other Grants

MANAGED CARE

Traditional

Healers

andand

Healers

Spiritual

Advisors

PURCHASED CARE

PRIVATE / REGIONAL PROVIDERS

•

Hospitalization

Inpatient Physician

Special Physicians

Adromed Diagnostic

Emergency Room

Nursing Home

Assisted Living

•

Prosthetics

Medical Equipment

Eyeglasses

Hearing Aids

Specialty Dental Care

Physical Therapy

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

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

Alternate Resources (Figure 2-5). From 2012-2014 the number of patients with

Alternate Resources have increased by 27%. The increase in billable services had a

major impact on reducing the expenditures of the Purchased/Referred Care Program

which is operated by the Tribe through a Contract with IHS.

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

years. Years of Productive Life Lost (YPLL, which is a measure of premature deaths) is

the lowest ever recorded at Warm Springs. The number for the latest three year period

(2012-2014) was nearly half of the experience recorded in the prior three year period

(2009-2011) (Figure 2-9). Corresponding infant mortality and early childhood deaths

have decreased significantly (Figure 2-10).

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

Accidents and Diabetes. These were the same leading causes in the previous three

years. Each of these conditions is amenable to prevention efforts, but the individual is

ultimately responsible for necessary behavior modification.

Teen pregnancies have averaged 20 per year from 1996-2011. Over the latest period

(2012-2014) these high-risk pregnancies substantially declined to an average of 8 per

year (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 on the Diabetes Register has declined from a high of 460

in 2012 to 402 in 2014. Also the patients with controlled blood sugar have improved to

70.9% from 54% in 2012. This is a very positive trend that has a major impact on the

future health status of the population (Figure 2-4). The number of dialysis patients is

still on the rise and has gone from 12 patients in 2011 to 19 patients in 2014.

Although our overall hospitalization admissions remained fairly stable (342 vs. 349) over

the last two years, the number of hospital days decreased by 5%. Over 33% of our

admissions and 22% of our hospital days were for Obstetrics (Figure 2-15). There were

87 births in 2014, 70 of which were Tribal Members.

There is no recent available data on the health risk factors of the community (Figure 219). Another Behavioral Risk Factor Survey is needed to make comparisons to the

study done ten 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

338

304

323

278

6672

6680

6651

6595

5669

5649

5772

5737

Active Clinic Patients

User Population

7000

6000

5000

4000

3000

2000

1000

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

Figure 2-1

Customers That Use the Services, Continued

Interpretation: Between 2001 and 2014, new patient registrations have decreased by

approximately 33%. During that timeframe, new patient registrations peaked in 2002 at

471, an increase of 54 patients from the previous year. In 2014, new patient

registrations decreased to their lowest point 278 registrations. In that fourteen-year time

span, the user population has increased from 5,057 to 5,737 (13%) and the population

of active clinic patients has increased by 9%. The user population and active clinic

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

either direction. New patient registrations in 2007 had the most significant value change

with 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

2011

2012

2013

2014

Chg(13-14)

Warm Springs Indian Reservation

3,690

3,536

3,630

3,679

Madras/Redmond/Bend

1,190

1,266

1,263

1,234

(29)

Maupin/The Dalles/Hood River

(8)

Portland/Salem

104

110

(26)

Other Oregon

440

427

443

428

(15)

Outside Oregon

181

200

185

195

TOTAL

5,680

5,626

5,716

5,697

(19)

By Tribal Affiliation

2011

2012

2013

2014

Chg(13-14)

Warm Springs Member

3,990

3,955

4,048

4,038

(10)

Other Oregon Tribes

219

218

225

219

(6)

1,377

1,364

1,350

1,352

(5)

5,680

5,626

5,716

5,697

(19)

All Other Tribes

Non-Indians

TOTAL

Figure 2-2

Interpretation: Trends have remained stable from 2011 to 2014 with approximately

two-thirds of our patients being Warm Springs Tribal Members and approximately twothirds of our patients residing on the Warm Springs Indian Reservation:

• 2011 – 70.25% Warm Springs Tribal Members; 64.96% residing on Reservation.

• 2012 – 70.3% Warm Springs Tribal Members; 62.7% residing on Reservation.

• 2013 – 70.82% Warm Springs Tribal Members; 63.51% residing on Reservation.

• 2014 – 70.88% Warm Springs Tribal Members; 64.58% residing on Reservation.

In the years, 2013 and 2014, there was a small increase in patients who are Warm

Springs Tribal Members over the 2011 and 2012 patient counts. There was a slight

decrease in patients who are members of Other Oregon Tribes or who have no tribal

affiliation. Patients that are members of All Other Tribes seen an increase of 2.

Between 2011 and 2014, there was a decrease of approximately 1% of patients who

reside on the Warm Springs Indian Reservation. As of 2014, 86% of our patients

resided either on the Reservation or in the Madras/Redmond/Bend area.

Age of Enrolled Members of the Confederated Tribes of Warm Springs

Purpose: The relationship exists between the IHS and the Confederated Tribes of

Warm Springs (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 2014 CTWS Population

12.00%

10.00%

Age Group as a % of Total Population

Age Group as a % of Total Indians

Age Group as a % of Total CTWS Population

8.00%

6.00%

4.00%

2.00%

0.00%

Note: Age Group as a % of Total Indians was an estimate from Census for 2010 at time of Report.

2014 CTWS Population

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, 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 US 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

Age Group

FY 2000

Patients

2011

Patients

2012

Patients

2013

Patients

2014

Patients

0-4

543

677

699

588

618

5-9

460

551

545

532

562

10-19

1,367

1,094

968

984

981

20-29

971

1,077

1,082

1,025

963

30-39

912

719

725

700

714

40-49

738

693

699

659

643

50-59

440

615

633

615

579

60-69

204

397

449

424

441

70-79

168

180

166

180

80+

TOTAL, Patients

5,773

6,053

6,042

5,756

5,738

1,600

1,400

1,200

1,000

800

600

400

200

0-4

5-9

FY 2000

10-19

20-29

FY 2011

30-39

40-49

FY 2012

50-59

60-69

FY 2013

70-79

80+

FY 2014

Figure 2-4

Interpretation: The graph reflects that the number of individuals in the over 40 age

group has grown in proportion to the younger age groups over the past several years.

Note: The major upwards adjustment in total patients bears further study and analysis.

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) Managed Care, 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 2011

FY 2012

FY 2013

FY 2014

Medicaid Only

1,181

1,455

1,637

2,264

Private Insurance Only

1,269

1,263

1,313

1,109

Medicare A Only

Medicare B Only

Medicare Part A & B Only

139

138

126

142

Medicare Part D

189

200

217

230

Medicaid & Medicare

Medicaid & Private Ins.

842

736

663

1,119

Medicare & Private Ins.

141

142

159

150

Medicaid, Medicare, & PI

3,829

4,008

4,179

5,085

278

224

No Alternate Resource

2,492

2,276

2,277

1,926

Total

2,770

2,500

2,329

1,993

Total Patients

6,599

6,508

7,078

Total

Non-Billable

Tribal Employee Self-Insurance

Figure 2-5

Interpretation: Over the past four years the number of patients with billable alternate

resources has increased by 33%. Those with Tribal insurance (non-billable) have seen

a significant drop of 76% since 2011. Those with no alternate resources have

decreased by 23%. The increase in patients with alternate resources is due in part to

an aging population becoming eligible for Medicare as well as Medicaid expansion.

Staff works aggressively to ensure that all patients get enrolled in any outside benefits

that they may be eligible for.

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

Total

203

346

261

146

1026

% of Total

0.0%

19.8%

33.7%

25.4%

14.2%

6.8%

100.0%

Figure 2-6

120

Warm Springs Births by Age of Mother

111

104

Number of Births

100

86 86 87

2010

2011

2012

2013

2014

14 &

under

15-19

20-24

25-29

30-34

Age of Mother

35-44

Total

Births

Figure 2-7

Tribal Member Births by Age of Mother, Continued

Interpretation: Information reported through 2000 reflected a large portion of births to

very young mothers. From 2008 to present, total births to the 15-19 year old age range

has continued to trend downward. There were 85 deliveries with two sets of twins for a

total of 87 births.

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.

Crude Birth Rate

Warm Springs and State of Oregon

Live Births per 1,000 population

Rate

1989-1990

1999-2000

2008-2009

2010-2011

2012-2013

Years

Warm Springs

State of Oregon

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.

The statistics for the 2014 Birth Rate Comparison will be finalized through the State of

Oregon Vital Statistics Department in August 2015 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

19941996

19971999

20002002

20032005

20062008

20092011

20122014

Number of Deaths

111

103

121

155

117

Crude Death Rate

502

482

608

524

605

774

587

Years of Productive Life Lost

1,889

1,877

1,794

2,141

1,906

2,898

1,594

Figure 2-9

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

reflected in the general US population, where the average life expectancy was 78.7 in

2011. In 2013-2014, crude death rates remain lower than in the US, but the average

age at death continues to increase and was the highest in over two decades. Deaths

early in life continue to have a disproportionately high impact on the local population,

but the impact is decreasing.

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

Infant:

3 year Avg

Less than Infant Death

Rate*

1 year

Child:

Ages

1-12

3 year Avg

Death Rate +

Teen:

Ages

13-17

3 year Avg

Death Rate +

1995-1997

47.7

11.9

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

2013-2014

9.6

7.5

* Deaths per 1,000 live births + Deaths per 100,000 population

Leading Cause of Death 2003-2014

Infant:

Cause 1:

Cause 2:

Cause 3:

Accidents

Congenital Malformations, Deformations and Chromosomal Abnormalities

Sudden Infant Death Syndrome

Disorders related to length of gestation and fetal malnutrition.

Child:

Cause 1:

Accidents

Teen:

Cause 1:

Cause 2:

Accidents

Malignant neoplasms

Figure 2-10

Child Mortality Rates, Continued

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

decade. In the years 1987-88, there were 4 deaths due to sudden infant death

syndrome (SIDS) and 6 deaths from SIDS from 1991-2007. Since 2007, there have

been no SIDS deaths. Despite the decline in SIDS, infant deaths have occurred from

accidental death and birth defects. From 2008 to 2011 there were 4 deaths from

positional asphyxia due to incorrect cradle board use. With community education this

trend is reversing with no deaths from this since 2011.

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 2014 , IHS 2012-2014, US 2013)

Cause 1

Cause 2

Cause 3

Cause 4

Cause 5

Warm Springs

Indian Health Service

U.S.

Chronic liver disease and cirrhosis*

Diabetes mellitus*

Accidents

Malignant neoplasms

Diseases of the heart

*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, 1994-2014

Figure 2-11

Cause of Death, Continued

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

1950’s but over the decades, gradually declining. Since 2001, the rates of motor

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

Seat-Belt Law.

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 and can be combated through healthier diets, increased physical activity,

and 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 US. 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 onethird of the years of potential life lost before age 65.

Patients Identified with

Chronic Disease in 2011 - 2014

FY 2011

FY 2012

FY 2013

FY 2014

Diabetes

600

605

622

627

Ischemic Heart Disease (IHD)

100

104

108

Hypertension 18-85 w/HTN DX

500

503

510

512

Asthma

256

286

272

276

Prediabetes/Metabolic Syndrome

970

904

881

515**

Rheumatoid Arthritis

Condition

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

SDPI Program to identify and engage people at risk for diabetes over the past several

years. Community education and events have been used 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.

HEALTHY INDIVIDUALS CREATE A HEALTHY COMMUNITY

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 2008-2014

(Control of HgbA1)

500

450

400

350

300

250

200

150

100

2008

2009

2010

2011

2012

2013

Patients with Controlled Blood Sugar (HgbA1c<7)

2014

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 2008-2014

(Control of HgbA1)

80%

70%

60%

% 50%

40%

30%

20%

2008

2009

2010

2011

% of patients with HgbA1c <7.0

2012

2013

2014

% of patients with HgbA1c <8.0

Figure 2-14

Interpretation: The number of patients in the diabetes registry decreased from 423 in

2013 to 402 in 2014. 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 Warm Springs Health and

Wellness Center (i.e. Veterans Affairs or private physician) are not included as active in

the diabetes registry. Ideal control of HgbA1c (<7%) increased from 47.0% to 47.8%

between 2013 and 2014 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%) improved significantly from

65.6% to 70.9% from 2013 to 2014.

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.

Managed Care Financed Hospitalization

2012 - 2014

Inpatient Indicators

Total Admissions

Average Length of Stay

Total Hospital Days

Average Daily Patient Load

Emergency Room Visits

2012

2013

2014

220

3.88

854

2.34

1,097

185

3.61

667

1.83

1,146

118

4.09

483

1.32

773

Managed Care Hospitalizations and Those Paid by Other Resources

Warm Springs Patients by Primary Diagnosis

2014

Number of

% of

Number of

% of

Condition

Admissions

Hospital Days

Hosptial Days

Obstetrics

115

33.6%

231

22.0%

Motor Vehicle Accidents

0.6%

0.2%

Other Accidents/Injuries

5.0%

9.2%

Cancer

2.0%

4.0%

Heart and Circulatory

7.0%

8.8%

Respiratory

11.7%

112

10.7%

Renal

4.7%

6.6%

Digestive

12.9%

115

10.9%

13.6%

Infectious Disease

10.5%

143

Diabetes

2.0%

3.9%

Substance Abuse

3.8%

Mental Health

2.3%

1.3%

All Other

3.8%

5.0%

TOTALS

342

100%

1,051

100%

Figure 2-15

Hospitalization of Customers Continued

Interpretation: The two tables (Figure 2-15) on the previous page describe our

hospitalization experience in two different ways. The first table describes the cases for

which the Managed Care Program (MCP) provided payment. The second table is all

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

financed by other alternate resources.

The Managed Care Caseload (first table)

•

The number of hospital admissions declined by 67 (36%) from the experience of

the prior year.

The Average Length of Stay declined by 0.48 (13 %) from the prior year.

The Total number of Hospital Days declined by 184 (28%) from the previous

year.

The Total Number of Emergency Room Visits decreased by 373 (33%) from the

previous year.

The above declines in hospital admissions, average length of stay and emergency room

visits can all be directly attributed to the Medicaid Expansion which was effective

January 1, 2014. In 2014, 66% of our total admissions were financed by the Oregon

Health Plan (OHP) also known as Medicaid. This increased significantly from 47% in

2013.

Total Hospitalization Caseload regardless of payment source (second table)

The actual number of admissions for patients in 2014 regardless of payment source

decreased from the prior year (342 vs. 349 or 2%). Overall hospital days decreased

from 1101 to 1051 (5%). In 2014 the MCP covered 34% of hospital admissions and

46% of hospital days. This was an improvement over 2013 when the MCP covered

53% of hospital admissions and 61% of hospital days.

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

sources of our hospitalizations. As in 2013, the number of obstetrical cases led in both

total admissions (34% - 2014) and days (22% - 2014).

Hospitals Utilized and Expenditures

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

areas. This data includes only cases the MCP has spent resources.

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

highlights where MCP resources are being expended.

Hospitals Utilized

2014

Admissions

Hospital

Days

St. Charles-Madras

St. Charles-Redmond

St. Charles-Bend

Providence Portland

All Other

231

199

$190,112

$11,345

$139,540

$346,313

$5,860

Totals

118

483

$693,170

Hospital

Total Cost $

Total Cost per Day

Cost per Day

$823.00

$1,134.50

$701.21

$17,315.65

$254.78

$1,435.13

Figure 2-16

Interpretation: This table reflects the total cost of hospitalization MCP paid for in 2014,

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

major hospitals utilized. St. Charles-Madras accounts for 27% of the total hospital

costs, compared to 56% last year, with St. Charles-Bend accounting for 20%, compared

to 32% last year.

However, it is worth noting that costs were skewed this year by a very unique high cost

oncology case treated at Providence Portland. If this outlier was subtracted, then St.

Charles – Madras would have accounted for 55% (compared to 56% last year), and St.

Charles – Bend would have accounted for 40% (32% last year). Both of these results

are much closer to the historical average for each.

When comparing 2014 to 2013, a decrease of 67 in the number of hospital admissions

financed by the MCP was noted. There was also a corresponding decrease of 184 in

the number of hospital days covered by the MCP. In addition, there was a very

significant decrease of $1,093,009 (61%) in overall hospital expenditures for the MCP in

2014. There was a significant 46% decrease of $1,242 in Total Cost per Day from 2013

($2,678) to 2014 ($1,435).

A substantial decrease in Medicare-Like Rate

Reimbursement to St. Charles-Madras (“Critical Access Hospital”) was largely

responsible for the Total Cost per Day decrease.

Hospitals Utilized and Expenditures, Continued

The Average Cost per Day for St. Charles-Madras decreased by $2,367 (74%) over

2013, while the Average Cost per Day for St. Charles-Bend decreased by $1,571

(69%).

The effective use of alternate resources decreases the MCP’s expenditures on

hospitalizations. For example, last year 47% of total admissions financed primarily by

the OHP. Medicaid Expansion in 2014 increased this to 66%. Medicaid Expansion

effective January 1, 2014, was largely responsible for the significant decreases in Costs

seen above. Very significant cost savings attributable to Medicaid Expansion will be

noted repeatedly in future figures in this Report.

Emergency Room Utilization

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

of Managed Care. It is important to monitor utilization to determine how best to reduce

the budget impact.

Relevance: Understanding the volume, cause and timing of ER Visits will provide

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

EMERGENCY ROOM VISITS

ALLERGIC REACT

CARDIOVASCULAR

CELLULITIS/INFECTIONS (impetigo)

CHRONIC CONDIT.

COMMUNICABLE DISEASE

DENTAL

DERMATOLOGY (includes spider bites)

DRUG/ALCOHOL

ENT (ear, nose, throat)

EYES

HEADACHES

MEDS ONLY / DRESSING CHGS

MISCELLANEOUS

NEUROLOGY

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

2009

2010

2011

2012

2013

2014

111

116

121

199

136

140

102

125

209

106

120

129

169

104

106

187

134

201

217

106

131

159

1,441

1,485

1,297

1,109

1,239

773

COST (As Of 4/2/15) $790,176 $778,472 $794,683 $739,859 $880,062 $227,272

$548

$524

$613

$667

$710

$294

COST PER VISIT

Note: The above data is for St. Charles - Madras ER care at other hospitals is an extremely small portion of the whole.

MVAs are not counted in the total, and since 2010 assaults have not been counted in the total; however, the principal

diagnosis is counted. As an example, because this is a Diagnosis chart, pt may have been in an MVA and may have

a broken leg, and would thus be counted in the orthopedic category.

Figure 2-17

Emergency Room Utilization, Continued

Interpretation: After two consecutive years of decreases in ER visits (188 decrease

from 2010-2011 and a 200 decrease from 2011-2012), there was a 12% increase from

2012-2013 of 130 ER visits. However, ER cost per visit has increased each of these

three years (albeit by a smaller % increase each year), from $524 in 2010, to $613

(17%) in 2011, to $667 (9%) in 2012, to $710 (6%) in 2013.

The trend was reversed in 2014! Due primarily to Medicaid Expansion which started

January 1, 2014, cost significantly decreased by $652,790 (74% decrease).

The MCP 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 MCP is not responsible (i.e. OHP), while the “COST” is the total amount paid

by MCP 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

2009

2010

2011

2012

2013

2014

445

210

151

221

311

103

471

237

169

182

330

474

233

112

225

185

490

226

136

113

500

267

154

130

114

298

175

1,441

1,485

1,297

1,109

1,239

773

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 ER

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 five years, with ER visits on weekdays between 0800-2000 hours

ranging within a narrow margin from a low of 445 in 2009 to a high of 481 in 2012, with

2014’s total of 459 below the five year average of 466.

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 CTWS Tribal Council that the Warm Springs

Community be a healthy community. The Warm Springs Health and Wellness Center

(WSHWC) fully supports the Tribes’ goal and we believe we can best help meet this

goal by focusing on the care provided at the WSHWC 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 WSHWC has been working with the Community

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

Health Clinic.

• Along with community partners, the WSHWC will review the professional staff

needs and make necessary changes.

• With focus on care provided, anticipated increased access to provider

appointments each day.

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

Madras to ensure that 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. In October 2014 a new Mobile Clinic began service to the Community.

There seems to be a good acceptance of this service but accurate utilization statistics

will not be available until next year’s report. Extended hours of clinic operations

continue, but the associated workload has remained stubbornly low. Now that the clinic

physicians no longer see patients in the hospital, it does increase their availability at the

Health & Wellness Center during normal hours.

Because of a very stable population, a fairly stable workload is reported for most of the

acute care services.

The Medical, Dental, Pharmacy, Laboratory and X-Ray

Departments have experienced very little change in workload over the past four years.

On the other hand, the preventive clinical activities have grown considerably in concert

with the priorities of increasing health promotion/prevention. Over the last two years

Podiatry workload increased by 13%, Optometry by 50% and the Diabetes Program by

13%.

Infant immunization levels are now back over 90%. The Maternal Child and Health

Program continues to follow all pregnancies, particularly the high-risk group. Of the 87

deliveries, 65% were considered moderate or high risk.

The health system initiated a new program referred to as “Baby College” which is an

educational program to assist new mothers to support healthy child development.

Mental Health and Alcohol Services had disappointing results in 2014. There is

obviously a mismatch between the extent of the problems and the level of service

utilized. Is this a demand problem, an accessibility problem, a staffing problem or a

data problem? There is an awareness the data must be improved to better understand

the problem (Figure 3-17, Figure 3-18).

The Family Preservation Program, established in 2014 provided services to 146

children, 137 of which avoided protective care and were able to continue living in their

home, with supportive measures.

Purchased/Referred Care had a fantastic year in 2014, attributable to an increase in

availability of Alternate Resources. There was a significant decrease in expenditures

and as a result an impressive increase in savings over that period of time. The

Affordable Care Act together with the application of Medicare Like Rates and a very

vigilant management have all contributed to this very positive development.

Purchased/Referred Care financed hospital admissions declined by 36% from 20132014. The average length of stay was 13% less than the prior year. Hospital Days paid

by Purchased/Referred Care declined by 28%. Emergency Room visits financed

decreased by 33% from the previous year.

Ambulance calls dispatched increased from 1477 in 2013 to 1751 in 2014, an increase

of 19%. Patients transported increased slightly from 626 to 671. The number of calls

with Substance Abuse as a factor increased from 96 to 227 which represent an

alarming increase of 136% (Figure 3-22).

KWSO 91.9FM has become a great partner in the health education process. There

were 13,850 health related public service announcements in 2014. Spilyay Tymoo has

also been supportive with 241 articles and 408 announcements that were health related.

Included in the 2014 report are a number of services and programs not previously

represented. The information will be further developed to see if it does represent the

appropriate measures of utilization and services. It will be more meaningful when

comparisons are made over time.

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. Two issues that must be decided

relate to future hospital inpatient care and extended hours of operation.

Medical Department

FY2011

FY2012

FY2013

FY2014

Medical Visits by Provider

Physicians

Mid Level Practitioners

Nursing Staff

11,579

4,591

4,785

11,459

3,920

3,961

10,057

5,297

4,249

8,600

5,933

4,357

Total Medical Visits

20,955

19,340

19,603

18,890

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

5.5

998

2,105

2,296

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

Extended Hours of Service

Days of Late Clinic

Hours of Service (M-Th, 7pm)

Visits

Visits Per Hour of Service

202

404

869

2.2

202

404

902

2.2

114

228

741

3.3

201

402

851

2.1

Hospital Patient Count

Hospital Visit Count

Average Hospital visits per patient

Average Hospital patients per day

Average Hospital visits per day

476

2,107

4.4

1.3

5.8

381

1,654

4.3

1.0

4.5

325

1,378

4.2

0.9

3.8

Mid Level Practitioners

Nursing Staff

Physicians

14,000

N/A

12,000

Number

of Visits

10,000

8,000

6,000

4,000

2,000

FY2011

FY2012

FY2013

FY2014

Figure 3-1

Medical Services, Continued

Interpretation: From 2011 to 2014, the medical department averaged 19,697 medical

visits per year. Of those visits 10,424 were physician visits, 4,514 were seen by midlevel providers and 4,338 were nursing visits. The average number of visits per day

was 80 over a 250 day time-span. There was an average of 21.5 Full Time Employees

(FTEs) in the medical department including five physicians and two mid-level providers.

Each FTE physician had an average of 2,265 visits per year and each FTE mid-level

provider had an average of 2,187 visits per year. FTE physicians had approximately

3.5% more visits per year than mid-level providers.

There was an average of 180 days when the clinic was open late for extended hours

from 2011-2014 and during those times the late clinic averaged 2.1 medical visits per

hour.

Podiatry Program

Purpose: The practice of podiatry is to preserve human movement. We only get one

pair of feet and we have to keep them healthy in order to carry us through our life’s

journey. In each of the podiatry program service areas, we aimed during 2014 to teach

each person to “Walk Well” at the highest level of ambulatory ability; given each

person’s physical potential, whether impaired or not.

Relevance: There is an old saying “if your feet hurt, everything hurts” and perhaps

even suffers is likely true to one degree or another; therefore it is relevant to provide

excellent and up-to-date podiatric medicine, foot and ankle surgery, as well as wound

care. The Podiatry Program provides age appropriate extremity education so that lower

extremity health and wellness becomes a proactive and preventative art practiced by

patients. Some patients already demonstrate these preventative measures and the

program does their best to educate all clients on proper foot care so that their travels

can be as problem-free as possible.

Podiatry Department

FY2011

Podiatry Visits

Clinic Visits

Missed Appointment Rate

Workload Factors

Clinic Days

Average Visits per Clinic Day

Average Visits per Year

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)

FY2012

FY2013

FY2014

1,753

18%

1,608

21%

1,751

24%

1,976

23%

170

143

155

813

313

489

473

615

223

105

376

808

297

108

464

886

359

133

508

503

433

469

1,753

1,685

1,824

1,987

Figure 3-2

Interpretation: Education, patient training and patients’ decisions to change take time

so pure numbers of patients seen don’t tell the complete story. Again this year (2014)

more people were getting better about Diabetes Mellitus (DM) foot care prevention

resulting in less numbers of serious foot infections and wounds. Increased numbers of

patients were treated, even with procedures in the clinic rather than in the hospital

setting.

Dental Services

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

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

care provided.

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

plan resources in particular 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

FY2011

FY2012

FY2013

FY2014

Dental Visits by Provider

Dentist Visits

Hygienist Visits

4,342

758

4,657

713

4,558

818

4,203

899

Total Dental Visits

5,100

5,370

5,376

5,102

Missed Appointments

No Shows (Broken Appointments)

Broken Appointments vs Total Visits

408

265

664

956

Workload Factors

Clinic Days

Average Visits Per Clinic Day

250

250 249(snow day)

250

Total FTE's

Average Annual Visits Per FTE

443

413

448

350

Categories of Care

Preventive

Restorative including Crowns

Dentures including Bridges

Surgical

Orthodontic

Endodontic

Diagnostic

6,524

2,558

134

1,067

304

8,920

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

Total Identified Problems Treated

19,513

17,987

19,193

18,885

Figure 3-3

Interpretation: In 2014, Broken Appointments were still around 20%, which appears to

be average. The Dental Services program maintains call lists and lists of employees

that are in need of exams that can be pulled from, which has helped keep chairs full.

Dr. Ashton’s part time position was replaced with a full time Dentist. Two new Dental

Assistants will be added soon.

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

FY2011

Prescriptions Filled

FY2013

FY2012

FY2014

New Prescriptions

54,672

Refills

28,360

53980

27211

53415

26125

50464

26479

83,032

81,191

79,540

76,943

Clinic Days

251

250

253

251

Avg Prescriptions per Clinic Day

331

325

314

306

34,567

33,688

33,622

33,975

2.40

2.41

2.36

2.26

Total Prescriptions

Workload Factors

Visits to the Pharmacy

Prescriptions per Pharmacy Visit

Total FTE's

Avg Annual Prescriptions Per FTE

6.8

6.0

6.8

12,211

13,532

11,697

11,315

Pharmaceuticals

Total Expenses

Avg Cost Per Perscription

796,241

9.59 $

Rx for Patients outside Service Area

784,700

9.66 $

Unavailable

791,276

753,909

9.95 $

9.79

Unavailable

Figure 3-4

Interpretation: Workload in 2014 as compared to 2013 was down 4% in the number of

prescriptions filled. The number of prescriptions per FTE also decreased by about 4%.

However, for the first nine months of 2014, the pharmacy was understaffed by one full

FTE pharmacist. Additionally, training of new staff (resident and technician) may have

contributed to decreased prescriptions per FTE.

The decrease in the number of prescriptions per FTE is related to increased FTE (from

6.0 to 6.8) as well as the decrease in total prescription number. The total number of

prescriptions has steadily decreased compared to four years ago.

Drug costs as compared to 2013 remain stable. Average cost per prescription has also

remained stable. These changes likely reflect fluctuations in drug costs as well as

changes and additions to the formulary. Drug costs will continue to fluctuate as existing

formulary drugs are becoming available generically at lower costs, as well as newer,

more expensive agents being added to the formulary.

Pharmacy Services, Continued

The average number of prescriptions filled per day remains consistent for the last four

years. We 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, despite continued lack of staff. Pharmacy works closely with Tribal

programs including Community Health Nursing, High Lookee Lodge and Warm Springs

Corrections.

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

FY2011

FY2012

FY2013

FY2014

Total X-Ray Exams

1,645

1,649

1,711

1,713

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

6.58

1,556

1.06

15,839

0.10

1,645

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

Imaging Exams

Figure 3-5

Interpretation: Between 2011 and 2014, there was an average of 1,680 X-ray images

completed each year. Throughout that time span, there was an average of 7 X-ray

images per day completed. An average of 1,531 patients received approximately 1.10

visits each between 2011 and 2014.

Diagnostic Services, Continued

Diagnostic Services - Medical Laboratory

FY 2014

FY2011

FY2012

FY2013

Medical Lab Tests

Tests collected in the Lab

Tests collected outside the Lab

Tests performed off-site

85,069

3,407

6,561

77,797

3,407

6,422

76,743

3,173

5,473

59,257

12,570

19,332 *

Total Lab Tests Ordered

95,037

87,626

85,389

71,827

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

380

16,170

5.9

5.0

19,007

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

Category of Tests Ordered

Hematology

Chemistry

Bacteriology

Urinalysis

Referred Procedures (send Outs)

25,707

63,347

831

5,152

25,707

55,936

831

5,152

19,491

60,491

939

4,468

7,981

39,610

1,752

3,152

19,332

Total Lab Tests Ordered

95,037

87,626

85,389

71,827

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

Figure 3-6

Interpretation: Due to spacing issues in EHR, data was purged from the Electronic

Lab package. Data is not lost but stored in another electronic PCC file. Pulling data

from this file is very tedious. When a new Lab Manager is hired, Management will

discuss with the new Manager the best way to pull and maintain Lab workload data.

The 2013 and 2014 numbers vary due to the purging of data.

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

FY2011

FY2013

FY2012

FY2014

Optometry Visits

Clinic Visits

Missed Appointment Rate

1,973

1,663

1,941

2,912

22%

16%

18%

22%

220

Workload Factors

Clinic Days

Average Visits per Clinic Day

2.0

Refractions

795

821

832

1,034

Diabetic Eye Exam

264

308

309

266

Contact Lens Visit

Medical Visit

Early Childhood Education Visits

Glasses Repair/Adjustment

350

372

338

732

Other

488

363

814

Total FTE's

Nature of Visits

Figure 3-7

Interpretation: The Optometry department saw a significant increase in the number of

patient visits this past year even without the services of a full time replacement of a

fourth year Optometry student. Dr. Dziuk has increased the number of appointment

slots available in a day.

The rate of patients who do not keep appointments is up slightly over the past year.

The number of diabetic patients seen in the clinic is down slightly from last year.

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

for staff levels, which remain at 2.

Purchased and Referred Care

Purpose: To identify workload of the Managed Care Program (MCP).

Relevance: To assure effective processing and management of resources.

Purchased and Referred Care

FTEs

Number of Obligations

Funds Obligated

2005

8,190

$4,905,541

2006

6,120

$5,049,015

2007

5,022

$3,447,919

2008

7,162

$3,881,990

2009

9,136

$4,953,270

2010

9,757

$5,185,344

2011

9,099

$4,999,277

2012

8,667

$5,521,545

2013

8,861

$5,376,701

2014

6,930

$2,726,209

Staffing & Other Workload

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 MCP reserves accumulated through

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

2010 there was an 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 January 1, 2014 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 Oregon health

insurance exchange (Cover Oregon) for potential 2013 October enrollment, and, more

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

MCP processes.

Community Health Nursing Services

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

(CHN) Program.

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

requirements and efficiency.

Services Provided by Category

2011

2013

2012

2014

Prenatal

Post Partum

1,274

1,380

1,137

Well Child

Immunization

1,034

Diabetes

Cardiovascular

Mental Health

Sexually Transmitted Infections

145

202

Family Planning

135

213

201

Phone Contact/Follow-ups

545

213

219

261

Other Activity

594

614

898

1,537

2,339

2,336

2,897

3,516

1,046

742

892

1,100

748

666

1,039

886

1,794

1,408

1,931

1,986

Total Days of Service

250

Average Visits Per Day

7.2

5.6

7.7

7.9

Total FTE's

2.0

1.8

2.0

3.0

Average Visits per FTE per year

897

782

966

662

Total Services Provided

Visits by Location

Out of Clinic Visits

Clinic Visits

Total Community Health Nurse Visits

Figure 3-9

Interpretation: The CHN Program was fully staffed for eight months of 2014 with three

full-time nurses. The third nurse was hired to implement a new program to case

manage patients being discharged from the regional hospitals who are not eligible for

Home Health/Hospice Services. The goals for this new program are to reduce hospital

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

to return back to optimum health after a serious illness.

Community Health Nursing Services, Continued

The top 10 leading Purposes of Visit managed through the CHN 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 activity includes case review/coordination, education provided, screening and

physician ordered treatments.

Maternal and Child Health Program

Purpose: To identify the number of births and those to tribal members. To determine

the number of high risk pregnancies and high risk infants. To identify the workload of

the program.

Relevance: The Maternal and Children Health (MCH) Program workload is directly

related to 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)

2011

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

2012

111

104

150

399

181

327

162

84.4%

83.5%

90.7%

90.9%

2014

143

565

115

157

116

196

Infant Immunization level**

2013

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

111

100

104

Total number of births managed

by MCH RN

Number of high risk pregnancies

2011

2012

2013

2014

Figure 3-11

Maternal and Child Health Continued

Interpretation: In 2014, the birth rate for the MCH Program decreased to 87 deliveries

case managed by the program, 70 of which were to Tribal Member mothers. Sixty-five

percent of the deliveries were categorized as either moderate or high risk which is a

very concerning issue for our community. Forty-three percent 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

2011

2012

2013

2014

Caseload by category:

- Transports

- Patient Care

- Case Findings/Screening

- Monitoring Patient

- Case Management

- Health Education

- Other

164

592

532

425

312

500

274

412

428

284

109

445

467

1395

634

1364

119

126

Total Client Encounters

2,567

1,984

2,099

2,124

Total Days of Service

Average Number of Encounters per Day

Total FTE's

Average Number of Encounters per FTE per Year

250

10.3

3.0

856

250

7.9

3.0

661

250

8.4

3.4

617

250

8.5

4.0

531

Figure 3-12

Interpretation: In 2014, the CHR Program once again had an increase in the amount

of patient transport requests over the previous year. A new CHR was added in 2013 to

accommodate the increased transportation load as well as the increasing numbers of

dialysis clients. Currently the program provides dialysis transportation 5 days per week

for 2-6 clients per trip. In 2015, dialysis services will be provided locally in the Madras

area which will offer more convenient scheduling for our clients and more transportation

options for families.

The average number of client encounters per CHR per day has remained fairly

consistent for the past three years even with the addition of a new CHR in 2013.

Unfortunately, in 2014, more of the CHR’s times were spent providing transportation

services and less on direct client care due to the increase in transportation requests.

Diabetes Program Services

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

Relevance: Diabetes Mellitus (DM) 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

FY2011

FY2012

FY2013

FY2014

Diabetes Program Visits

Clinician Clinical Visits

Community Encounters

1,931

2,032

4,156

1,531

4,729

1,752

5,254

2,083

Total Visits

3,963

5,687

6,481

7,337

250

15.8

5.0

793

250

16.6

4.0

1,039

250

18.9

4.0

1,182

250

21.0

4.0

1,314

985

2,032

1,922

2,334

559

972

2,630

2,099

1,559

193

2,868

2,386

2,083

331

Workload Factors

Clinic Days

Average Clinical Visits per Clinic Day

Total Clinical FTE's

Average Clinical Visits Per FTE

Categories of Service

Diabetes Clinical Encounters

Diabetes Case Management Encounters

Diabetes Community Education Contacts

Diabetes Screening Community Contacts

Patients in Dialysis

Number of Patients

Figure 3-13

Interpretation: The Warm Springs Diabetes Program was fully staffed during 2014.

Staff included the Program Coordinator, Nurse Practitioner, RN, Certified Diabetes

Educator and Administrative Assistant.

Major educational events included Diabetes Awareness Day Conference, Heart Smart

Dinner, Honor Seniors Day, Pi-Ume-Sha Health Fair, Senior Center Diabetes Support

Group Dinners, Youth Support Group, Food Demo & Support Group and Culture Camp.

The H.O.P.E. (Healthy Outcomes Promoted by Education) diabetes education program

is accredited by the American Association of Diabetic Educators through 2016.

Diabetes Program Services, Continued

Community screening for diabetes and diabetes prevention education has been

transitioned to Diabetes Prevention Program Staff except for a few special events to

increase the number of clinical appointments in Diabetes Program.

Monthly Diabetes Group Visits and Diabetes Mobile Clinic Visits are included in the

clinician clinical visit statistics.

Women and Infant Children

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)

2011

2012

2013

2014

Infants and children under 5 years of age

550

534

482

Pregnant, breastfeeding and postpartum women

232

211

187

192

782

761

721

674

Total number of Women, Infants and Children served

Figure 3-14

Interpretation: The number of Women, Infants and Children served by our program

remained relatively stable for the past four years with the exception of 2014 where

Warm Springs noted a decline in women/children seeking WIC services. This site is not

unique as 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 2014: 87% of our new mothers start out breastfeeding and

38% of the families we serve are working families. Both of these rates experienced a

decline in 2014 over previous years.

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

2014

Program

Health Education Team

No. of Educational Encounters

Direct Time Spent Educating

No. of Participants

No. of PSA's generated

No. of Newspaper Articles

129 hours

2667

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

101

230

723

Alcohol and Drug Prevention

FASD Awareness Day

3D Project

Cultural Prevention

Craft Classes

Jewlery Making

5 classes

General Prevention

Trunk or Treat

HIV/AIDS

World Aids Day

Figure 3-16

Community Health Education Program, Continued

Health Education