# The Confederated Tribes of the (2015) > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3Aa22f941bf26d50d9 ## Record - **Collection:** Tribal code - **Document type:** Tribal code ## 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 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 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. 2 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 3 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. 4 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 5 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. 6 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 Traditional Healers andand Healers Spiritual Spiritual Advisors Advisors PURCHASED CARE PRIVATE / REGIONAL PROVIDERS • • • • • • • Hospitalization Inpatient Physician Special Physicians Adromed Diagnostic Emergency Room Nursing Home Assisted Living • • • • • • 7 Prosthetics Medical Equipment Eyeglasses Hearing Aids Specialty Dental Care Physical Therapy 8 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. 9 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. 10 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 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Figure 2-1 11 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. 12 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 49 Madras/Redmond/Bend 1,190 1,266 1,263 1,234 (29) Maupin/The Dalles/Hood River 85 93 85 77 (8) Portland/Salem 94 104 110 84 (26) Other Oregon 440 427 443 428 (15) Outside Oregon 181 200 185 195 10 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 2 94 89 93 88 (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. 13 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 14 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. 15 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 98 168 180 166 180 80+ 40 62 62 63 57 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 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. 16 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 28 33 29 29 Medicare A Only Medicare B Only - - - - Medicare Part A & B Only 139 138 126 142 Medicare Part D 189 200 217 230 Medicaid & Medicare 30 35 28 35 Medicaid & Private Ins. 842 736 663 1,119 Medicare & Private Ins. 141 142 159 150 Medicaid, Medicare, & PI 10 6 7 7 3,829 4,008 4,179 5,085 278 224 52 67 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 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. 17 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 20 27 23 19 20 39 28 27 41 33 40 29 17 16 14 18 17 21 18 22 31 24 33 30 7 9 12 14 9 10 13 11 16 14 17 14 7 5 7 2 6 7 7 5 6 8 4 6 73 77 70 75 68 108 81 86 111 86 104 87 1996 1997 1998 1999 2000 2008 2009 2010 2011 2012 2013 2014 0 0 0 0 0 0 0 22 20 14 22 16 30 16 21 17 7 10 8 Total 0 203 346 261 146 70 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 80 2010 2011 60 2012 40 2013 2014 20 0 14 & under 15-19 20-24 25-29 30-34 Age of Mother 35-44 Total Births Figure 2-7 18 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. 19 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 35 30 25 20 15 10 5 0 31 14 1989-1990 18 20 14 1999-2000 13 2008-2009 20 12 2010-2011 18 12 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. 20 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 60 55 50 45 40 35 30 Crude Death Rates, Years of Productive Life Lost 19941996 19971999 20002002 20032005 20062008 20092011 20122014 Number of Deaths 83 84 111 103 121 155 117 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. 21 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 1 8 47.7 2 11.9 1998-2000 3 4 22.7 3 17 2001-2003 3 3 15.9 3 15.9 2004-2006 4 2 10.1 3 15.1 2007-2009 8 36.8 4 17.4 1 4.4 2010-2012 5 16.6 2 8.6 3 12.9 2013-2014 2 9.6 1 7.5 0 0 * 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 22 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. 23 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 24 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. 25 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) 88 100 104 108 Hypertension 18-85 w/HTN DX 500 503 510 512 Asthma 256 286 272 276 Prediabetes/Metabolic Syndrome 970 904 881 515** Rheumatoid Arthritis 79 81 76 78 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. 26 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 50 0 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 27 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. 28 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 Admissions Hospital Days Hosptial Days Obstetrics 115 33.6% 231 22.0% Motor Vehicle Accidents 2 0.6% 2 0.2% Other Accidents/Injuries 17 5.0% 97 9.2% Cancer 7 2.0% 42 4.0% Heart and Circulatory 24 7.0% 92 8.8% Respiratory 40 11.7% 112 10.7% Renal 16 4.7% 69 6.6% Digestive 44 12.9% 115 10.9% 13.6% Infectious Disease 36 10.5% 143 Diabetes 7 2.0% 41 3.9% Substance Abuse 13 3.8% 40 3.8% Mental Health 8 2.3% 14 1.3% All Other 13 3.8% 53 5.0% TOTALS 342 100% 1,051 100% Figure 2-15 29 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). 30 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 74 3 33 4 4 231 10 199 20 23 $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. 31 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. 32 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 GI GU 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 7 67 49 37 2 15 22 111 116 11 121 75 44 2 78 34 14 199 136 23 1 3 73 67 26 5 29 16 140 102 23 125 96 50 5 61 39 17 209 106 24 0 11 53 76 42 13 19 45 69 120 15 129 77 48 7 32 41 17 169 104 30 0 14 49 78 31 12 30 19 59 85 7 106 80 35 4 28 12 9 187 70 20 0 10 80 83 31 22 23 18 76 79 11 134 73 29 2 46 14 22 201 78 19 1 10 45 47 19 4 25 10 30 43 8 82 56 14 1 29 21 15 99 89 10 1 17 1 201 15 2 0 0 5 43 8 36 1 217 12 10 2 0 2 9 10 18 20 1 106 19 4 0 0 42 2 18 7 22 1 131 22 10 1 0 18 0 13 0 13 1 159 11 10 1 0 6 0 9 1 3 0 90 4 0 1 0 1 0 23 0 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 33 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 96 474 233 112 225 185 68 490 226 60 136 84 113 500 267 74 154 130 114 298 175 31 82 90 97 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. 34 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. 35 36 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. 37 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. 38 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 39 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. 40 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 84 250 77 250 78 250 76 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 21 5.5 2 998 2,105 2,296 22 5.0 2 879 2,292 1,960 22 4.0 2.5 891 2,514 2,119 21 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 2 2 Mid Level Practitioners Nursing Staff Physicians 14,000 N/A N/A N/A 12,000 Number of Visits 10,000 8,000 6,000 4,000 2,000 FY2011 FY2012 FY2013 FY2014 Figure 3-1 41 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. 42 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 10 143 11 143 12 155 13 813 313 97 489 10 64 473 615 223 105 376 4 19 808 297 108 464 15 87 886 359 133 508 9 2 503 433 469 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. 43 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 8% 265 5% 664 8% 956 5% Workload Factors Clinic Days Average Visits Per Clinic Day 250 20 250 249(snow day) 21 22 250 20 Total FTE's Average Annual Visits Per FTE 12 443 13 413 12 448 12 350 Categories of Care Preventive Restorative including Crowns Dentures including Bridges Surgical Orthodontic Endodontic Diagnostic 6,524 2,558 134 1,067 6 304 8,920 6,950 2,856 115 985 8 324 6,749 7,295 2,888 169 1,106 27 251 6,700 8,030 2,556 85 826 7 270 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. 44 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 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 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. 45 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. 46 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 1,645 250 6.60 1,468 1.12 14,980 0.11 1 1,649 250 6.84 1,493 1.15 16,568 0.10 1 1,711 251 6.82 1,606 1.07 15,757 0.11 1 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. 47 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. 48 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% 220 220 220 220 Workload Factors Clinic Days Average Visits per Clinic Day 9 8 9 13 2.0 2.0 2.0 2.0 Refractions 795 821 832 1,034 Diabetic Eye Exam 264 308 309 266 Contact Lens Visit 45 56 39 66 Medical Visit - - - Early Childhood Education Visits 31 53 60 - Glasses Repair/Adjustment 350 372 338 732 Other 488 53 363 814 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. 49 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 7 8,190 $4,905,541 2006 7 6,120 $5,049,015 2007 7 5,022 $3,447,919 2008 7 7,162 $3,881,990 2009 7 9,136 $4,953,270 2010 7 9,757 $5,185,344 2011 7 9,099 $4,999,277 2012 8 8,667 $5,521,545 2013 8 8,861 $5,376,701 2014 7 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. 50 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 29 - - - Post Partum - - - - 34 42 58 1,274 1,380 1,137 Well Child Immunization 1,034 Diabetes 12 Cardiovascular 48 Mental Health 60 Sexually Transmitted Infections 42 66 145 202 Family Planning 95 135 213 201 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 250 250 250 250 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. 51 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. 52 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 82 33 39 52 150 399 72 43 181 87 70 37 36 80 91 327 57 43 162 84.4% 83.5% 90.7% 87 90.9% 2014 86 72 43 43 56 143 565 115 45 157 44 32 116 196 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 87 86 80 60 Total number of births managed by MCH RN 44 43 37 33 40 Number of high risk pregnancies 20 0 2011 2012 2013 2014 Figure 3-11 53 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. 54 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 42 500 274 412 428 284 109 32 445 467 1395 52 45 21 634 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. 55 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 12 13 17 19 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. 56 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. 57 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 550 550 534 482 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. 58 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 71 129 hours 2667 13 11 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 32 22 50 230 723 21 Alcohol and Drug Prevention FASD Awareness Day 3D Project 61 60 Cultural Prevention Craft Classes Jewlery Making 5 classes 34 General Prevention Trunk or Treat HIV/AIDS World Aids Day 8 Figure 3-16 59 Community Health Education Program, Continued Health Education TOP 10 Educational Topics FASD Sexual Health HIV/AIDS Cancer; Breast, Cervical Melanoma Skin Cancer Stroke/Heart Health Diabetes prevention Winter Safety Smoking Cessation Alcohol Prevention Interpretation: In 2014, the reporting methods for the Community Health Education Program changed. We began tracking the number of educational encounters, the number of participants and amount of direct time spent educating. The number of educational encounters reflects classes that the Community Health Educators directly sponsored or provided health education at as well as participation in major events such as the Pi-Ume-Sha Health Fair. Also noted in the graphic are the Top 10 Educational Topics delivered to community members in 2014. 60 Mental Health Purpose: To identify the caseload and number of visits by age and service category. To determine the efficiency of operations by comparing clinic contact hours to available FTE hours. Relevance: Understanding patient demand and workload is necessary to determine appropriate resources and staffing. Mental health has potential to increase billing. Mental Health 2011 Visits & Clients Served Number of Adult Visits Number of Children Visits Total Visits Categories of Service Crisis Management Visits Jail Total 2012 2013 2014 1,268 1,515 2,783 * * 3,012 2,539 1,494 224 204 270 224 204 270 219 94 313 NA 299 97 103 115 62 105 43 24 500 5 1,400 200 NA 48 70 0 3 30 0 61 24 500 60 500 49 80 50 60 100 1,635 300 48 NA 46 3 83 98 22 NA 100 NA 600 NA 178 48 75 NA 1,601 * 3,216 3,703 Prevention Services Soaring Butterflies/Warrior Spirit Positive Indian Parenting (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 W.S. Christmas Fun Party Spring Into Action (Prev. Coalition) Penny Carnival Rez Olympics Street Dance GONA Training Total Prevention Services Attendance 2,953 53 0 100 300 600 200 65 1,318 Service Hours Client Contact Hours *Total FTE Hours 2,275 Figure 3-17 61 Mental Health, Continued Interpretation: Oregon Web Infrastructure for Treatment Services (OWITS) Electronic Health Records does not allow separation of age categories, but our Program is researching a different Electronic Health Record Program, that will be more category and user friendly for reporting. 62 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 our community. Evaluation of Alcohol and Substance Abuse (A&D) treatment is essential to see what is working and not working in our treatment program. Alcohol and Substance Abuse 2011 2012 2013 2014 Encounters - Outpatient Treatment Number of Visits Number of Clinic Days 2,899 2,501 1,793 1,567 239 254 251 252 Average Visits per Clinic Day 12 9 8 6 Relapse Anger Resolution Grp (Quarterly) 33 28 25 5 Jail Groups (estimate) 250 334 425 375 Healing from Grief & Trauma - 1 day conf. 57 40 87 23 Recovery Month Dinner n/a 100 100 100 A&D Prev B-Ball "And 1" (Street Ball tour) all ages 250 NA 36 - Community Grief/Trauma Gathering (2 workshops) 80 NA 50 23 Healing Family Circle Conference 40 NA NA - 2,899 2,501 1,793 1,567 Aftercare Categories of Service Alcohol Abuse Figure 3-18 Interpretation: The program will continue to build on grief and trauma work as they are co morbid conditions with substance use. 63 Adolescent Outreach Purpose: Initiate, conduct and coordinate children’s outreach program which includes substance abuse, suicide and mental health prevention activities, with an emphasis on adolescent suicide prevention with other Tribal, State and Federal agencies. Relevance: An integrated children’s aftercare treatment program which includes suicide, substance abuse and mental health prevention programs in coordination with other Tribal work groups and committees. Initiate and conduct aftercare prevention activities, document and report prevention activities to Program Director. Develop and conduct aftercare program in coordination with prevention programs, with an emphasis on adolescent prevention within the Warm Springs community. Adolescent Aftercare 2011 Outpatient Visits 2012 NA 2013 2014 30 43 Prevention Youth Dance 72 236 Teen Craft Night 32 45 Rez Head Youth Conference 34 - Baseball Camp 31 36 Suicide Prevention Camp 50 68 38 18 Healing Wounded Spirits Camp n/a 46 NA - Winter Youth Conference n/a n/a NA - Movie Nights 319 416 384 480 Wii Bowling n/a 112 NA - Hoop Camp 144 73 36 89 Madras Bowling 83 88 79 96 Wellness walk 81 84 204 224 All Night Sobriety Party 160 n/a n/a - Kids Bingo 76 26 196 159 Red Road to Recovery/Boys Circle 93 0 93 61 Tribal Youth Leadership Total 24 24 22 46 1,030 1,187 1,251 1,533 Figure 3-19 64 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 to build coping skills and resilience. Services are provided also to clients returning from a treatment setting to help them readjust. Through this program additional support is provided to youth who are in danger of relapsing without the positive interactions provided through the aftercare program. Services are also provided to clients returning from a Residential Treatment setting to help readjust with transition back into Family and Community. The Native American Rehabilitation Association (NARA) Youth Residential Treatment plans to provide an aftercare outreach program to Oregon Tribes to assist youth with transition back into their communities and home. The structure is still in Program Planning, in which NARA was chosen as lead treatment center to develop this youth treatment center. 65 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 us determine the state of our program, how it’s being used, where we can improve and where we need to focus. Community Health & Prevention Resource Center 2014 Resource Center Usage Patrons that checked out materials Materials checked out Health related materials checked out Native American materials checked out Circulations* Number of visits Patron cards issued 2011 2012 2013 2014 248 733 46 139 1,424 3,833 505 486 1,358 80 215 3,015 9,351 378 339 949 81 160 1,679 8,936 144 300 792 30 156 1,438 11,147 123 199 197 99 66 Graphic Design Requests Posters/Banners printed *A circulation occurs whenever an item is loaned out (checked out or renewed). When the number of circulations exceeds the number of items checked out, that means some items were checked out or renewed more than once. Figure 3-20 Interpretation: In 2014, there was a continued decrease in the number of people who checked out materials as well as a decrease of the number of materials they checked out. Three hundred people checked out an average of 2.6 books and renewed them at an average of 1.8 times in 2014. This is compared to 339 people who checked out an average of 2.8 books and renewing them 1.8 times in 2013. The main reason for the continual decline is that people aren’t returning their overdue materials. This reduces the overall quality and selection available for other people to check out. While 123 new patrons were added in 2014, this did not offset the 500 plus people who had not returned their library materials by the end of 2014. One exception to the general decline was the notable 24.7% increase in the number of visits in 2014 over 2013. This increase is due to heavy public computer usage. 66 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 2011 2012 2013 2014 Housing & Energy Assistance Number of Clients Served 248 292 Total Vouchers Processed 248 292 Total $ Value of Vouchers 84,443 86,131 87,346 94,843 Number of Clients Served 789 458 336 420 Total Vouchers Processed 789 458 336 420 Total $ Value of Vouchers 20,211 12,200 9,709 12,480 Medical Travel Disability New Clients pursuing claims for SSI/SSDI 92 78 67 105 Number of clients currently checking on 28 16 10 12 Survivorship/widow benefits Number of Clients inquiring about Retirement Benefits 21 24 20 32 Number of Clients that have been denied 77 36 23 28 Number of Clients that just filed their 1st Appeal 49 20 15 15 Number of Clients that are in the middle of Appeal 54 33 17 24 Number of Clients in Court Hearings 16 8 20 16 259 278 75 Number of Individuals Served 301 494 749 166 Number of Warm Springs Tribal Members* 516 Commodities Number of Families Served 137 Figure 3-21 *For 2012 & 2013, Tribal Member data was not kept. It will be in the 2014 report. The 2014 figures are a true reflection of the actual number of people served. Interpretation: In 2014, the LIHEAP Energy Assistance Program served 44 more client households with assistance than 2013. This program also distributed 30 cooling fans, 20 heaters and 40 homes received weatherization kits. Medical Travel funded 84 more clients this year with assistance to getting to Medical appointments. In 2014, the program started using the priority one system developed by IHS and mid-year lifted the priority one system due to receiving additional funding. 67 Social Services, Continued Clients seeking services through the Disabilities Coordinator services have increased substantially with the Coordinator doing more home visits and outreach. The Commodities Program has increased its participation level. The numbers have changed drastically due to staffing change and how numbers are calculated. A tracking system was set up to count the actual number of individual households served the entire year and actual number of individuals in each household for the entire year not counting the same households and participants every month. 68 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 (e.g. seat belt use). Patients serviced by alternate resource measures collection potential of this enterprise. Ambulance Activity Summary SUMMARY OF AMBULANCE ACTIVITY Calls Patients Transported 2013 2014 Calls w/Substance Factor 2013 2014 Reason for Call 2013 2014 Motor Vehicle Accident 47 88 27 30 3 4 Other Accident - - - - 0 - Assault and Battery 43 66 14 21 12 21 Suicides/Attempts 2 22 0 13 2 8 Corrections 173 379 30 40 39 75 Pediatric 108 222 33 67 2 5 Cardiac 76 149 69 69 6 11 Respiratory 38 148 34 82 0 2 Other Illness 610 134 306 60 58 9 1,097 1,208 513 382 122 135 Total TRIBAL AFFILIATION RELATED TO CALLS Reason for Call Members and Dependents Calls Dispatched 2013 2014 Patients Transported 2013 2014 Calls w/Substance Factor 2013 2014 1,373 1,625 580 623 96 227 Other Eligible Indian 0 0 0 0 0 0 Non Tribal 104 126 46 48 45 2 1,477 1,751 626 671 141 229 Total Figure 3-22 Interpretation: The number of calls received in 2014 increased by 10% over the previous year. The number of patients transported decreased by 26% over that same period. The calls where substance abuse was a factor increased from 122 to 135. 69 Ambulance Services, Continued Nearly 93% of the calls were for Tribal Members and Dependents in 2014. 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%). 70 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 the 1855 treaty with the US government. Tracking this data is important for planning and implementing outreach efforts and developing relevant materials. Figure 3-23 Figure 3-24 71 Culture and Heritage Language Program, Continued Interpretation: September is the busiest month for outreach with the attendance of staff to several community events. The largest draw is the invitation to the back-to-school barbeque. This opportunity allows Culture and Heritage to reach nearly all the Tribal members students enrolled in 509J school district and/or boarding schools to provide information on classes offered (community and out of school efforts). These opportunities also allow for information distribution via language materials for home to support our school age children effort. The numbers of classes offered are steady throughout the year. September is when several classes were offered at the same time. This includes: • • • • • • • • Autni Ichishkin Sapsikwat (pre-school) Autni Ichishkin Sapsikwat (k-8) Out-of-school classes (morning and afternoon) Ittitamasha (math tutoring) College Success (middle school outreach) Leadership conferences (OIEA) Language Bowl Classes (prep for annual event) Rites of Passage Over the course of the year, non-member communities request outreach presentations and services. These communities include: • • • • Local school districts Mt Hood Cultural Presentation Community colleges, universities and other higher education institutions Museums 72 KWSO 91.9 FM Purpose: KWSO 91.9 FM is a non-commercial radio station with programming focused on meeting the needs of the Warm Springs Community. The radio station broadcasts Information and Education, Cultural and Language Education and music through on-air live calendar reads, pre-recorded PSAs, local news stories and locally produced news magazine segments. The station reaches 50,000 people in all of Jefferson County and into Wasco, Crook and Deschutes Counties with a primary focus on the residents of the Warm Springs Indian Reservation. Relevance: Public Service Announcements (PSA’s) are categorized for the purpose of identifying our broadcast efforts to the Guidance from Joint Health Commission strategies. KWSO 91.9 FM 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 Educaiton 2,718 Community Event 1,988 Health Insurance 1,405 Mental Health Education 1,263 Health Related Event 1,261 Violence Prevention 825 FASD Awareness 822 Child Development/Parenting 732 Cultural Event 709 Child Mental Health 467 Youth Education 374 Child Abuse Prevention 319 Child Health 312 School Related Event 291 Elder Event 124 Mental Health Event 118 Youth Employment 82 Education 40 13,850 Figure 3-25 73 KWSO, Continued 2014 PSA Campaigns by Topic Sexual Assault Health Info (Cancer, Cold/Flu, Diabetes,… Ages & Stages Child Abuse Prevention Dangerous Decibels Managed Care FASD Awareness Flu FASD Awareness Bullying Drug & Alcohol Awareness Positive Indian Parenting Gambling Diabetes Prevention For the Health of … Affordable Heath Care 0 200 400 600 800 1000 1200 Figure 3-26 Interpretation: This data is focuses on the PSAs broadcasted 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 Insurance; Diabetes Awareness; Gambling; Parenting/Child Development; Drug & Alcohol Awareness; Bullying’ FASD Awareness (prenatal thru elders); Child Abuse Prevention; Sexual Assault Awareness; and Health Education. Overall, “Events” were the topic most often broadcast in the PSAs. These included: Community Events; Health Related Events; Cultural Events; School Related Events; Elder Events; and Mental Health Events) “Health Education” across a broad range of topics was the strategy second most often broadcast. A total of 13,850 PSAs (60 seconds or less) were broadcast that were health related and relevant to the Joint Health Commission strategies representing a value of $277,000 ($20 per spot). 74 KWSO, Continued In August of 2014, KWSO 91.9 FM re-launched their website (www.kwso.org) and saw significant growth in website visits and engagement. The first website report was compiled in September and during that month, the website had 663 users (user who has had at lease one session with the selected data range, includes both new and returning) who engaged in 942 sessions (period of time a user is engaged on the website). In October, users increased to 875 users engaging in 1,269 sessions and in November the website had 1,563 users engaging in 2,787 sessions. December had the largest engagement of the first 3 months of the website launch with 1,856 users engaging in 3,430 sessions. Over the first three months of the website re-launch, traffic and engagement with the site have increased significantly and demonstrates that the public turns to KWSO 91.9 FM for Information and Education, Cultural and Language Education, music and timely information. 75 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. The publication is delivered every two weeks to 1200 Post Office boxes in the Warm Springs community and 1,200 are delivered to Tribal Members and other subscribers off the reservation. An additional 300 are left at the Tribal Administration Building. Spilyay Tymoo 2014 Article/Announcement Category Article Announcements Child Development/FASD 1 5 Early Childhood/Child Development 6 26 Youth Fitness 78 104 Youth Mental Health 13 26 Youth Health Education 20 26 Youth Support 13 13 Education & Job Opportunity Events 26 52 Health Services Information 26 52 Tribe's Health Education & Health Support 26 52 Elders 13 26 Health System Total # of Health Related Articles/Announcements 19 241 26 408 Figure 3-27 76 Spilyay Tymoo Newspaper, Continued Spilyay Tymoo Health Related Publications 2014 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 0 20 Announcements 40 60 80 100 120 Articles Figure 3-28 Interpretation: The semimonthly publication includes Health Education, Information about Available Health Services or details about local events. These all tie to the Guidance for Joint Health Commission strategies. 77 Vocational Rehabilitation Purpose: To track the caseload of pending and eligible Vocational Rehabilitation (VR) consumers/clients. Relevance: Tracking the case load helps the program to determine the success rates of consumers/clients from their initial contact until their cases are closed. This data is reported to the Joint Health Commission and funders to determine if the program is fulfilling the annual programmatic goals for number of consumers served under an Individual Plan of Employment (IPE) and the number of cases successfully rehabilitated. Reflective of VR program standards are “consumer informed choice” and service delivery effectiveness. Vocational Rehabilitation FY2013 FY2014 Orientations 59 145 Intakes 26 61 Files Closed 34 13 New Cases Opened 19 44 Mo. Average Pending Eligibity 3 11 Figure 3-29 Interpretation: Consumer/Client attendance at VR Orientations more than doubled in 2014 from 59 in 2013 to 145. The total number served was 90 and the actual number served with an IPE was 109 well ahead of the program target. The 121% increase is a significant program improvement from 2013, where only 20% of the goal was met. In 2014, 3 consumers enrolled in an educational training program. One attained a post secondary degree, 1 attained a post secondary certificate, 1 consumer is successfully moving into 2015 to complete their educational goal. This is compared to 2013, where 1 client was enrolled and 1 person completed a GED. The data tells helps the program to determine if there are areas within the case management system that need to be addressed by the VR team. For example, the program can determine the effectiveness of outreach efforts by the attendance of 78 Vocational Rehabilitation, Continued Orientations, tracking effectiveness of securing medical documentation as a measure of eligibility determination, and tracking the eligible consumer’s files that are closed successfully rehabilitated, or closed “other” status. The program also has an electronic database that is used for all eligible clients that breaks data down further. A majority of consumers have dual diagnosis, the most common being alcohol/drug dependency, with related psychological social diagnosis, such as depression, anxiety, PTSD, and medical diagnosis; such as diabetes, renal/kidney disease, obesity, arthritis, hypertension/high blood pressure, hearing and vision impairments. The rehabilitation process generally takes 12-18 months for most consumers. The data is also a Community Collaboration indicator, of health, human and social service providers who serve common consumers/clients. 79 High Lookee Lodge Adult Living Facility Purpose: High Lookee Lodge (HLL) Adult 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 ALF guidelines established by the State of Oregon licensing requirements. . Relevance: High Lookee Lodge provides care to elder and disabled adults who are no longer capable of living on their own. Services 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 January Resident Count Private Pay Medicaid Resident Count 18 4 14 21 2013 2014 Private Resident Pay Medicaid Count Private Pay Medicaid 5 16 7 14 21 February 19 4 15 21 6 15 20 5 15 March 19 5 14 22 6 16 21 5 16 April 19 5 14 22 7 15 21 5 16 May 19 5 14 24 6 18 20 5 15 June 18 5 13 25 6 19 20 5 15 July 20 5 15 24 7 17 20 5 15 August 19 5 14 24 7 17 19 5 14 September 21 6 15 22 7 15 19 6 13 October 20 6 14 22 7 15 17 5 12 November 20 6 14 20 6 14 17 4 13 December 20 6 14 20 5 15 18 4 14 Avg Number of Residents 19 22 19 Figure 3-30 Interpretation: High Lookee Lodge currently provides service to 20 residents. The average for 2014 was 19. There is room for 36 total residents in the facility. We provide service to an average of 5 private pay residents and the remainder are Medicaid eligible. 80 Children’s Protective Services Purpose: Children’s Protective Services (CPS) empowers parents, families and community members through support, accountability and cultural teachings to give all children an optimal start in life. CPS provides prevention and intervention services to families in need so that the family system has the opportunity to learn the skills needed to keep the family safe and together. Relevance: Program statistics allow Children’s Protective Services to evaluate the effectiveness of their response and resolution to Child Abuse and Neglect referrals as well as tailor their services to meet the unique needs of each child and family who enters the system. Children's Protective Services Visits/Contact Total Number of Services Provided to Children Total Number of At-Risk Children Total Number of Child Abuse/Neglect Children Placed in Emergency Shelter Ave Length of Time in Emergency Shelter prior to being placed (days) Ave time in Foster Care (days) FY2013 FY2014 379 129 5,116 325 476 97 90 270 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 2014 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 2014, the average time was 270 days which is much longer than our goal of 180 days. There are several contributing factors preventing CPS for achieving that goal for this reporting year including staff vacancies, foster care certification and records management. All of these issues have since been resolved. Of significant note, the Family Preservation Program was established in 2014 and of the 146 children that received services from the that program, 137 avoided protective care and were able to continue living in the home with a parent or guardian while the safety issues were being addressed and resolved in a supportive manner. 81 Tribal Day Care Program Purpose: The Tribal Day Care Program provides child care services to children ages 6 weeks to 12 years of age. The program provide a clean, healthy, safe-learning environment to children as well as utilize an age-appropriate curriculum to teach children in early learning and health-related curriculum. Attendees 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 IHS. Dental screenings are provided to those children whose parents give us 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 FY2014 Visits/Contact Dental Screenings Medical Exclusions Injuries/Accidents: Transport Non-Transport Head Lice Exclusions Immunizations Ages & Stages Questionnaire 60 80 6 102 56 1 60 Figure 3-32 Interpretation: 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 we meet State requirements as far as all enrolled children having completed their immunizations before the exclusion day in March of every year. 82 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, community benefit and personnel requirements for the Community Wellness Center. Community Wellness Center FY2014 Summary of Activity 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 Total Program Participation 66,139 Signed Weight Room Waivers 402 Figure 3-33 Interpretation: The Community Wellness Center continued to serve large numbers of community members through the programs in 2014, the majority of which were in the sports and athletics programs. After school programs and community events also had strong participation numbers as did the “snack attack” program which provided a healthy afterschool snack option for youth. 83 Summary/Purpose of Grants Purpose: Education and assistance for Native Americans. 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): Offers group activities and renal clinics for the education, prevention and treatment of Diabetes. Maternal Child Health (MCH): 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: On-going project that concentrates on promoting policy such as having smoke free buildings, events and worksites. Alcohol & Drug Prevention: USDA Commodity Warehouse: Provide food to low income/disabled households on the Reservation. State Youth Suicide Prevention: Youth encouragement of self-worth and family values. Hosts community events that provide family activities. Influenza Pandemic: Vocational Rehabilitation: Helps Native Americans with disabilities find, obtain, maintain or become promoted in employment. Meth/Suicide Prevention (MSPI): Provides education and resistance education through Health Fairs, Prevention Conference and various community events. Interpretation: 84 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 IHS, 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 demostrates 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. 85 Summary and Highlights Recurring Indian Health Service funding remains about the same as it was in 2011. An increase realized in 2012 was reversed with the national sequestration in 2013 and was not restored in 2014. A significant change in recurring appropriations to the Indian Health Service is not anticipated in the coming years. (Figure 4-1). On a brighter note, collections by the Indian Health Service and the Tribal Programs have significantly increased in the past few years with more members eligible for alternate resources. Total IHS are up more than 50% from 2011, having topped $4.5 million. Tribal collections have nearly doubled over the same period, and efforts are underway to consolidate all billing activities to assure resources are captured. Collections are vital to providing support for the health system in the future. (Figure 4-1). Expenditures and workload are impacted by vacancies. Recruiting health professionals will always be challenging. Several programs saw significant turnover and vacancies, which affected workload and strategic priorities. The Contract Health Service program has been significantly impacted by increases in appropriations to both the local program and the national catastrophic health emergency fund (CHEF). In addition, being able to pay hospitals at Medicare Like Rates and the improvements in alternate resources have saved the program significant resources. These factors have allowed the program to build savings and extend priorities, while be able to maintain healthy reserves against high cost years in the future. The Purchased/Referred Care had its best year in 2014, primarily attributable to an increase in availability of Alternate Resources. Consequently, 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 2013-2014. 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. If this trend continues, it would greatly impact the health program. 86 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 2011 2012 2013 2014 Recurring Funding 16,284,305 17,348,813 16,135,780 16,248,026 Non-Recurring Funding 1,538,649 510,231 603,603 1,236,741 Total IHS Funding 17,822,954 17,859,044 16,739,383 17,484,767 Indian Health Service Collections IHS Medicaid 2,400,000 2,522,740 2,630,125 3,876,758 Medicare Private Insurance 201,700 428,600 99,349 503,833 265,122 420,342 285,257 361,643 Total IHS Collections 3,030,300 3,125,922 3,315,589 4,523,658 Ambulance 171,068 146,086 358,739 329,823 Community Counseling 537,996 567,466 944,058 1,196,976 Community Health 266,563 398,428 462,844 228,950 Total Tribal Collections 975,627 1,111,980 1,765,641 1,755,749 Grant Awards 1,513,100 1,650,982 2,133,838 1,114,664 Tribal Employee Group Insurance (Est) 1,554,753 1,901,827 2,231,557 3,091,229 Tribal Appropriations 1,761,800 1,682,649 396,905 477,754 Collections Tribe Total $26,658,534 $27,332,404 $26,582,913 $28,447,821 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. The recurring FY 2014 IHS base funding increased by a $112,245 (1%) from the previous year. The non-recurring funding for 2014 increased by a little over 87 Health System Funding by Major Source, Continued $633,138 (51%). IHS collections continued their upward trend while tribal collections saw a slight decrease. IHS program collections increased by $1,208,069 or 27% in 2014. Tribal program collections decreased by over $9,892 or -1% in 2014. Most of the Tribal program’s decrease was attributed to Community Health Program collections which saw a decrease of $233,894. Community Counseling continued to increase collections by over $252,918. Ambulance Service collections also saw a slight decrease of $28,916 in 2014. It is essential that all programs continue to emphasize collections to maintain and enhance services. Grant awards decreased by $1,019,174 from the previous year. Tribal appropriations declined by $80,849 over the same period. Tribal Employee Group Health expenditures were estimated at $3,091,229, which represents an increase of $859,672 or 28%. The over total Health Program Funding for 2014 was $28,447,821 which represents an increase of 7% when compared to 2013. 88 Base Health System Funding Versus Inflation Purpose: To identify the historical IHS 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 IHS 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 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 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% 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% Growth of $1 from 1998 $2.00 $1.80 $1.60 $1.40 $1.20 $1.00 Growth of $1 [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3Aa22f941bf26d50d9. Public record. Not legal advice.