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The Confederated Tribes of the

Warm Springs Reservation of Oregon

and

The Indian Health Service

Annual Health System Report

for the

Warm Springs Indian Reservation

December 31, 2016

Reporting Information through 2016

2017 Annual Health System Report

Table of Contents

Executive Summary…………………………………………………………....3

SECTIONS

Section 2: Customers…………………..………………………….…11

Section 3: Services……………..……………………………………40

Section 4: Resources Availability and Use……………..…………...94

Section 5: Evaluation ………………………………………………124

EXECUTIVE SUMMARY

This Annual Health System Report includes information about the community members

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

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

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

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

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

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

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

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

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

respond to questions put forth by the health plan.



How do we best know and focus on our customers?

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

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

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

and support the overall effort?

How do we assemble and report information to support informed decision

making?

How do we evaluate our progress and our effectiveness?

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

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

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

recommending information collection efforts to improve it in the future.

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

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

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

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

wellness and prevention approach aimed at the following outcomes.

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

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

and brain development.

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

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

start to life.

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

tools upon which to build a healthy happy life.

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

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

bright future.

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

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

experience and potential.

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

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

vital information about brain and character development)

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

system and community that are willing to provide positive pressure toward

healthy behavior, including the productive use of leisure.

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

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

plentiful support and opportunities for education and employment.

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

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

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

individual and family improvement.

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

care available, health risks and opportunities for health improvement.

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

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

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

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

needed support.)

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

healthy lifestyles. (Health Education, environmental considerations, wellness

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

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

supports best possible health status and life experience.

Promotion of

opportunities for younger generations to learn from and engage elders.

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

primary focus in providing access to needed services.

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

positions within the health care delivery system.

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

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

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

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

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

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

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

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

better blood sugar control. Recent studies put Warm Springs children at an

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

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

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

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

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

years. Extended hours and community outreach through the community health

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

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

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

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

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

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

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

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

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

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

Resources available through federal appropriations to the Indian Health Service have

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

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

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

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

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

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

positively impacted by the additional alternate resource availability leading to savings

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

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

The Indian Health Service has adopted Government Performance and Results Act

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

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

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

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

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

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

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

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

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

utilizing resources.

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

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

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

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

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SECTION 1

Overview of Health Delivery System

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

health services, community counseling services and emergency medical transport

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

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

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

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

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

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

Indian Health Service operations and purchased care.

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

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

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

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

Indian Reservation.

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

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

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

developments.

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

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

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

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

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

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

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

portions of the total population in the older age groups.

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

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

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

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

wellness.

Resources have been channeled to health promotion and disease

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

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

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

efforts to better serve and educate the community.

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

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

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

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

progress.

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

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

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

Attracting and maintaining highly qualified and committed health professionals is

essential.

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

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

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

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

addition to providing health insurance for Tribal employees.

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

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

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

level of dependence on collections and efficiency of operations.

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

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

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

record keeping and reporting.

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

they are currently operated.

SECTION 2

Customers

How do we best know and focus on our customers?

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

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

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

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

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

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

Summary and Highlights

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

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

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

programs continue to plan services, deploy resources and evaluate.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

responsible for necessary behavior modification. While there has been significant

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

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

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

related heart disease or kidney failure.

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

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

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

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

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

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

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

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

system are working on this issue.

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

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

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

patients has been on the rise since 2011.

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

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

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

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

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

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

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

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

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

the case in 2015.

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

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

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

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

additional emphasis.

Customers That Use the Services

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

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

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

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

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

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

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

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

allocation purposes.

Warm Springs Health and Wellness Center

8000

Year

New

Registrations

Active Clinic

Patients

User

Population

2001

417

6048

5057

2002

471

6302

5375

2003

449

6478

5402

2004

409

6558

5471

2005

346

6612

5564

2006

368

6685

5634

2007

328

6612

5229

2008

370

6703

5298

2009

320

6665

5454

2010

333

6692

5628

2011

2012

2013

2014

2015

2016

338

304

323

278

198

252

6672

6680

6651

6595

5669

5649

5772

5737

5806

5959

Active Clinic Patients

6444

6402

User Population

7000

6000

5000

4000

3000

2000

1000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Figure 2-1

Customers That Use the Services, Continued

Interpretation: Between 2006 and 2016, new patient registrations peaked in 2008 at

370. In the previous two years, there had been a swift decline of new patients; this is

most likely due to the Affordable Care Act. In 2016, there was a rise in registration

numbers of 20% over 2015. In that sixteen year time span, the user population has

increased from 5,057 to 5,959 (15%) and the population of active clinic patients has

increased by 5%. The user population and the active clinic population have followed

the same trends over time, averaging a change within 1% in either direction. The year

2007 had the most significant value change; a decrease of 7.2% for the active user

population.

Customers Served by Year

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

associated trends.

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

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

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

Patients Served by Fiscal Year

By Community of Residence

2013

2014

2015

2016

Chg(15-16)

Warm Springs Indian Reservation

3,630

3,679

3,741

3,617

(124)

Madras/Redmond/Bend

1,263

1,234

1,162

1,051

(111)

Maupin/The Dalles/Hood River

(21)

Portland/Salem

110

103

Other Oregon

443

428

427

388

(39)

Outside Oregon

185

195

194

160

(34)

TOTAL

5,716

5,697

5,689

5,378

(311)

By Tribal Affiliation

2013

2014

2015

2016

Chg(15-16)

Warm Springs Member

4,048

4,038

3,670

4,006

336

Other Oregon Tribes

All Other Tribes

Non-Indians

TOTAL

225

219

175

207

1,350

1,352

1,756

1,078

(678)

(1)

5,716

5,697

5,689

5,378

(311)

Figure 2-2

Interpretation: Warm Springs Tribal Members (WSTM) served increased over 2015 by

5% in 2016 along with an increase of 2% of patients that reside on the Warm Springs

Indian Reservation (WSIR)

 2013 – 70.8% WSTM; 63.5% residing on the WSIR.

 2014 – 70.6% WSTM; 64.3% residing on the WSIR.

 2015 – 64.2% WSTM; 65.4% residing on the WSIR.

 2016 – 70.0% WSTM; 63.3% residing on the WSIR.

As of 2016, over 86% of patients reside either on the reservation or in the

Madras/Redmond/Bend area.

Age of Enrolled Members of the Confederated Tribes of Warm Springs

(CTWS)

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

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

profile is displayed to support planning.

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

system for services by differing age groups.

2011 Census Data and 2016 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%

2016 CTWS Population

12.00%

10.00%

8.00%

6.00%

4.00%

2.00%

0.00%

Figure 2-3

Age of Enrolled Members of the Confederated Tribes of Warm Springs

(CTWS), Continued

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

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

Native American populations.

Age of Patients

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

different periods.

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

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

strategies as well as resource allocation.

Patients by Age Group

Age Group

FY 2000

Patients

2013

Patients

2014

Patients

2015

Patients

2016

Patients

0-4

543

588

618

566

525

5-9

460

532

562

540

513

10-19

1,367

984

981

1,017

983

20-29

971

1,025

963

905

884

30-39

912

700

714

722

753

40-49

738

659

643

622

617

50-59

440

615

579

627

609

60-69

204

424

441

460

471

70-79

166

180

194

209

80+

TOTAL, Patients

5,773

5,756

5,738

5,707

5,620

1,600

Patients by Age Group

1,400

1,200

FY 2000

1,000

FY 2013

800

FY 2014

600

FY 2015

400

FY 2016

200

0-4

5-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

80+

Figure 2-4

Age of Patients Continued

Interpretation: The total number of patients over 50 years of age has increased by

72% since 2000. All other age groups have continued to decline with the exception of

the 0-9 age group which continues to increase slightly.

Alternate Resource Eligibility

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

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

categories.

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

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

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

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

financing source for the health delivery system.

Active Patients by Eligibility

Billable

FY 2013

FY 2014

FY 2015

FY 2016

Medicaid Only

1,637

2,264

2,487

2,609

Private Insurance Only

1,313

1,109

853

833

Medicare A Only

Medicare B Only

Medicare Part A & B Only

126

142

139

128

Medicare Part D

217

230

249

263

Medicaid & Medicare

Medicaid & Private Ins.

663

1,119

1,067

889

Medicare & Private Ins.

159

150

136

148

Medicaid, Medicare, & PI

4,179

5,085

4,998

4,940

Total

Non-Billable

Tribal Employee Self-Insurance

254

191

No Alternate Resource

2,277

1,926

1,626

1,491

Total

2,329

1,993

1,880

1,682

Total Patients

6,508

7,078

6,878

6,622

Figure 2-5

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

resources has increased by 15%. Those with Tribal insurance (non-billable) has

trended downwards. Those with no alternate resources have dropped dramatically from

2013 as a result. The increase in patients with alternate resources is due, in part, to an

aging population becoming eligible for Medicare as well as the Medicaid Expansion and

the Affordable Care Act. Staff work aggressively to ensure that all patients get enrolled

in any outside benefits that they may be eligible for.

Tribal Member Births by Age of Mother

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

Relevance:

Tracking total births is important for planning services and education

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

special services.

Warm Springs Births by Age of Mother

Calendar

Age

Year*

14 & under

Age

15-19

Age

20-24

Age

25-29

Age

30-34

Age

35-44

Total

Births

108

111

104

1996

1997

1998

1999

2000

2008

2009

2010

2011

2012

2013

2014

2015

2016

Total

222

397

330

178

1212

% of Total

0.1%

18.3%

32.8%

27.2%

14.7%

6.9%

99.9%

Figure 2-6

Figure 2-7

Tribal Member Births by Age of Mother, Continued

Percent of Births to Moms Age 15-19

35%

30%

29.30% 29.40%

27.80%

26%

25%

24.40%

20%

19.80%

15.50%

15%

12.40%

10%

9.60%

9.20%

8.20%

8.10%

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Figure 2-8

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/hold steady. The number of mothers delivering in the

35-44 age group was the highest since reporting stated in 1996. These older mothers

are considered high risk for complications during pregnancy and birth. Teen mothers

are considered high risk as well and also require more intense case management by the

Maternal Child Health Nurse.

Birth Rate Comparison

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

Relevance: This information tracks the trend of birth rates.

Crude Birth Rate

Warm Springs and State of Oregon

Live Births per 1,000 population

Rate

1989-1990

1999-2000

2008-2009

2010-2011

2012-2013

2014

2015

Years

Warm Springs

State of Oregon

Figure 2-9

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 2012-2016 to 16

live births per 1,000 population.

The statistics for the 2016 Birth Rate Comparison will be finalized through the State of

Oregon Vital Statistics Department in August 2017 and will be reflected in the next

annual report.

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

Lost

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

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

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

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

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

the population ages.

Average Age of Death

61.5

59.7

56.6 56.7 56.7

53.2

54.1

52.6 53

53.3

51.4

52.9

52.7

50.2

49.1

48.2

47.1

46.2

43.4

41.3

45.3

44.2

43.2

40.6

40.3

Figure 2-10

Crude Death Rates, Years of Productive Life Lost

Number of Deaths

Crude Death Rate

Years of Productive Life Lost

19941996

19971999

20002002

20032005

20062008

20092011

20122014

20152016

502

1,889

482

1,877

111

608

1,794

103

524

2,141

121

605

1,906

155

774

2,898

117

587

1,594

670

903

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

Lost, Continued

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

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

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

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

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

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

Child Mortality Rates

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

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

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

Native populations have historically been concerned with high incidence of child

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

it.

Child Mortality

Infant: Less

than 1 year

3 year Avg

Infant Death

Rate*

Child:

Ages

1-12

3 year Avg

Death Rate +

Teen:

Ages

13-17

3 year Avg

Death Rate +

1995-1997

47.7

11.9

1998-2000

22.7

2001-2003

15.9

2004-2006

10.1

15.1

2007-2009

36.8

17.4

4.4

2010-2012

16.6

8.6

12.9

2013-2015

6.5

5.1

5.2

2016

15.6

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

Figure 2-11

Leading Cause of Death 2003-2016

Infant:

Cause 1:

Cause 2:

Cause 3:

Child:

Cause 1:

Cause 2

Accidents

Congenital Malformations, Deformations and Chromosomal Abnormalities

Sudden Infant Death Syndrome

Disorders related to length of gestation and fetal malnutrition.

Accidents

Homicide

influenza/pnuemonia

Teen:

Cause 1:

Accidents

Cause 2:

Malignant neoplasms

Cause 3

Intentional Self Harm (suicide)

Congenital Malformation

Figure 2-12

Child Mortality Rates, Continued

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

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

(SIDS). In the twenty years of data shown, there have only been four deaths due to

SIDS. From 2008 to 2011, the Warm Springs community experienced an increase in

infant deaths (94)

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 form alcohol and inhalants also

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

Cause of Death

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

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

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

health promotion and prevention efforts.

The Five Principal Causes of Death (Warm Springs 2016, IHS 2013, US 2014)

Warm Springs

Indian Health Service

U.S.

Diseases of the heart

Diabetes mellitus

Accidents *

Malignant Neoplasm*

Chronic liver disease and cirrhosis*

Diseases of the heart

Malignant neoplasms

Accidents

Diabetes mellitus

Chronic liver disease and cirrhosis

Diseases of the heart

Malignant neoplasms

Chronic lower respiratory diseases

Accidents

Cerebrovascular diseases

* Tied

Trends in the Leading Causes of Death (3-yr average), Warm Springs, 1994-2016

Figure 2-13

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

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

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

Tribal Seat-Belt Law.

Cause of Death, Continued

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

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

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

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

infection are the major contributors to this disease.

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

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

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

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

Prevalence of Major Chronic Diseases

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

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

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

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

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

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

Patients Identified with

Chronic Disease in 2013 - 2016

FY 2013

FY 2014

FY 2015

FY 2016

Diabetes

622

627

631

642

Coronary Heart Disease (CHD)

104

108

109

115

Hypertension 18-85 w/HTN DX

510

512

495

508

Asthma

272

276

216

205

Prediabetes/Metabolic Syndrome

881

515*

428*

381*

Rheumatoid Arthritis

Condition

Figure 2-14

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

Interpretation: Diabetes, Ischemic Heart Disease and Rheumatoid Arthritis have

shown a slight increase over the past year while Asthma, Hypertension and Prediabetes

have shown a downward trend over the past two years. The continued decreased

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

Special Diabetes Program for Indians (SDPI) to identify and engage people at risk for

diabetes over the past several years. SDPI has engaged the community in education

and events to promote personal health activities in order to prevent chronic diseases. It

is important to continue providing resources to more effectively engage all people in

identifying lifestyle factors that contribute to chronic disease and to provide support for

self health management.

Customer Diabetes Profile

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

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

glucose levels during the past year.

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

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

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

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

health care costs of caring for patients with diabetes.

Warm Springs Diabetes Profile 2009-2015

(Control of HgbA1)

500

450

400

350

300

250

200

150

100

2010

2011

2012

2013

Patients with Controlled Blood Sugar (HgbA1c<7)

2014

2015

2016

Patients with Controlled Blood Sugar (HgbA1c<8)

Number of Active Patients on the Diabetes Registry

Figure 2-15

Warm Springs Diabetes Profile 2008-2015

(Control of HgbA1)

100%

90%

80%

70%

% 60%

50%

40%

30%

20%

2011

2012

2013

% of patients with HgbA1c <7.0

2014

2015

2016

% of patients with HgbA1c <8.0

Figure 2-16

Customer Diabetes Profile, Continued

Interpretation: In 2016, the Diabetes Registry terms for status in the registry were

reviewed to ensure a fair representation of the patients. This was partially done due to

new supervision in the department and also in noticing the discrepancy in data. The

data compared to Government Performance and Results Act (GPRA) measures, as well

as the total number of patients with diabetes, looks like it decreased in 2012. The policy

for a patient being “active” status and “inactive” status in the registry is now more clearly

defined. There are now more patients listed as active on the registry than in the past

year(s) and this also effects the total patients in good control. This does not necessarily

mean that patient’s lab results have gotten worse, though it does show that data is

being reported differently. These end results for the year should be more comparable

and similar to GPRA.

Hospitalization of Customers

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

causes and the associated trends.

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

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

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

Purchased/Referred Care Financed Hospitalization

2014 - 2016

Inpatient Indicators

Total Admissions

Average Length of Stay

Total Hospital Days

Average Daily Patient Load

Emergency Room Visits

2014

2015

2016

118

4.09

483

1.32

773

159

4.50

715

1.96

540

242

4.29

1039

2.85

526

Figure 2-17

Purchased/Referred Care Hospitalizations and Those Paid by Other Resources

Warm Springs Patients by Primary Diagnosis

2016

Condition

Number of

% of

Number of

% of

Admissions

Hospital Days

Hosptial Days

Obstetrics

Motor Vehicle Accidents

Other Accidents/Injuries

Cancer

Heart and Circulatory

Respiratory

Renal

Digestive

Infectious Disease

Diabetes

Substance Abuse

Mental Health

All Other

150

33.5%

0.2%

9.2%

0.7%

5.6%

15.0%

5.4%

10.5%

8.9%

2.2%

2.0%

2.5%

4.5%

390

141

243

117

178

169

25.8%

0.1%

9.3%

0.4%

5.8%

16.1%

7.8%

11.8%

11.2%

1.6%

0.9%

4.2%

5.0%

TOTALS

448

100%

1,509

100%

Figure 2-18

Hospitalization of Customers, Continued

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

in two different ways.

The first table describes the cases for which the

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

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

financed by other alternate resources.

The Purchased/Referred Care Caseload (first table)



The number of hospital admissions increased by 83 (34%) from the experience

of the prior year.

The Average Length of Stay decreased by 0.21 (5%) from the prior year.

The Total number of hospital days increased by 324 (31%) from the previous

year.

The total number of Emergency Room Visits decreased by 14 (3%) from the

previous year.

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

room visits can be directly attributed to Medicaid Expansion which was effective

January 1, 2014.

Total Hospitalization Caseload regardless of payment source (second table)

The actual number of admissions for patients in 2016 regardless of payment source

decreased from the prior year (448 vs 524; 17%). Overall hospital days decreased from

1837 to 1509 (22%). In 2016, PRC covered 54% of hospital admissions and 35% of

hospital days. The coverage by PRC for admissions increased by 24%; however,

hospital days covered by PRC decreased by 11%.

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

source of hospitalizations. Obstetrical cases, once again, leads in both total admissions

(33.5%) and days (26%).

Hospitals Utilized and Expenditures

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

areas. This data includes only cases for which Purchases/Referred Care (PRC) has

spent resources.

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

highlight where PRC resources are being expended.

Hospitals Utilized

2016

Admissions

Hospital

Days

St. Charles-Madras

St. Charles-Redmond

St. Charles-Bend

OHSU

All Other**

154

201

711

$235,518

$10,797

$148,954

$71,536

Totals

242

1039

$466,805

Hospital

Total Cost $

Total Cost per Day

Cost per Day

$1,171.73

$134.96

$209.50

$2,980.66

$0.00

$449.28

** These two admissions at other hospitals were paid by OHP

Figure 2-19

Interpretation: This table reflects the total cost of hospitalization PRC paid for in 2016,

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

major hospitals utilized. St. Charles-Madras accounts for 50% of the total hospital

costs, compared to 74% last year, with St. Charles-Bend accounting for 32%, compared

to 12% last year. St. Charles-Redmond only being 2%.

When comparing 2016 to 2015, an increase of 83 hospital admissions financed by the

PRC was noted. There was also a corresponding increase of 324 in the number of

hospital days covered by Purchased/Referred Care.

The Average Cost per Day for St. Charles-Madras increased by $105 (9%) over 2015,

while the Average Cost per Day for St. Charles-Bend increased by $74 (35%).

With Medicaid Expansion coming effective in 2014, there was a significant savings over

the past few years. Those savings have now leveled out and PRC is in a median zone

of cost per stay on hospitalization.

Emergency Room Utilization

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

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

impact.

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

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

EMERGENCY ROOM VISITS

Allergic Reaction

Cardiovascular

Cellulitis/Infections (impetigo)

Chronic Conditions

Communicable Disease

Dental

Dermatology (includes spider bites)

Drug/Alcohol

ENT (ear, nose, throat)

Eyes

Headaches

Meds Only/Dressing Changes

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

2011

2012

2013

2014

2015

2016

120

129

169

104

106

187

134

201

106

131

159

1,297

1,109

1,239

773

540

526

COST (As Of 4/13/17) $794,683 $739,859 $880,062 $227,272 $256,999 $307,818

$613

$667

$710

$294

$476

$585

COST PER VISIT

Figure 2-20

Emergency Room Utilization, Continued

Interpretation: Since 2011, emergency room visits have reduced by 61%. This is

mainly due to Medicaid Expansion. All categories have seen a reduction through the

emergency room that PRC is obligated for.

The ER cost per visit for the years 2015 and 2016 show that from 2014 to 2015 an

increase of $182 per visit to $476. This is a 62% increase. From 2015 to 2016, there

was an increase of $107 per visit to $583. This is an 18% increase. This increase

could be attributed to diagnosis of injury as well as a slight increase in medical costs.

It appears that Medicaid Expansion is leveling out now and cost are stabilizing to a

norm. The years 2014 and 2015 seen dramatic reductions in costs compared to prior

years. 2016 shows an increase of 16% in actual cost, which cannot be attributed to any

particular diagnosis.

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

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

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

paid by PRC for ER claims. PRC has a good relationship with ST. Charles Medical

Systems and may be able to provide visits statistics in future annual reports.

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

2011

2012

2013

2014

2015

2016

474

233

112

225

185

490

226

136

113

500

267

154

130

114

298

175

188

152

254

117

1,297

1,109

1,239

773

540

526

Figure 2-21

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

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

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

ambulatory care settings. 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 several years, with ER visits on weekdays

between 8:00am and 8:00pm ranging within a narrow margin from a low of 188 in 2015

to a high of 500 in 2013, with this year’s total of 254 slightly below the five year average

of 346.

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 2-22

* 2006 – Behavioral Risk Factor Survey

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

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

expected through reducing these risk factors.

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

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

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

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

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

SECTION 3

Services

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

The comprehensive health plan anticipates an ongoing review of services being

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

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

accessing the health system.

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

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

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

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

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

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

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

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

Madras.

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

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

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

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

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

their health.

Areas of Focus that Supports Improved Patient Care:

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

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

Health Clinic.

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

staff needs and necessary changes will be made.

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

be increased access to provider appointments each day.

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

Madras to ensure that our community patient needs are met.

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

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

information will be available to future reports.

Summary and Highlights

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

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

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

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

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

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

patients per hour. (Figure 3-1)

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

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

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

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

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

impact patient visits include: excess administrative requirements, the appointment

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

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

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

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

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

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

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

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

per week). (Figure 3-1)

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

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

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

therefore it is resuming full time operation.

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

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

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

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

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

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

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

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

immunizations and additional consulting services expanded.

Summary and Highlights Continued

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

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

brings into question the productivity and expectations of the program.

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

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

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

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

principles set out by the Health Commission.

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

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

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

(Figure 3-12)

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

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

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

and progress is occurring.

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

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

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

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

by three fold. (Figure 3-17)

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

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

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

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

and more talented staffing in all areas of Behavioral Health.

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

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

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

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

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

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

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

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

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

days in 2015.

Summary and Highlights Continued

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

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

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

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

the health status of the community.

Medical Services

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

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

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

resources – particularly personnel requirements. Two issues that must be decided

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

Medical Department

FY2013

FY2014

FY2015

FY2016

Medical Visits by Provider

Physicians

Mid Level Practitioners

Nursing Staff

10,057

5,297

4,249

8,600

5,933

4,357

7,639

4,837

6,063

7,373

4,002

5,460

Total Medical Visits

19,603

18,890

18,539

16,835

Workload Factors

Clinic Days

Average Visits Per Clinic Day

250

224

Total FTE's In Medical Department

Physician FTE's

Mid-Level Practitioner FTE's

Avg Annual Visits Per Physician FTE

Avg Annual Visits Per Mid-Level FTE

4.0

2.5

2,514

2,119

4.0

2.5

2,150

2,373

3.5

3.0

2,183

1,612

3.2

2.3

2,304

1,740

Extended Hours of Service

Days of Late Clinic

Hours of Service (M-Th, 7pm)

Visits

Visits Per Hour of Service

114

228

741

3.3

201

402

851

2.1

196

392

831

2.1

149

2.7

Mid Level Practitioners

Nursing Staff

Physicians

12,000

10,000

Number

of Visits

8,000

6,000

4,000

2,000

FY2013

FY2014

FY2015

FY2016

Figure 3-1

Interpretation: From 2012 to 2016, the Medical department averaged 16,000 medical

visits per year. The average number of visits per day was 75. There was an average of

216 FTEs in the medical department including 3.2 physicians and 2.3 mid-level

providers in FY 2016. Each FTE physician had an average of 2304 visits per year and

each FTE mid-level provider had an average of 1740 visits per year.

In FY 2016, the clinic was open late 28 days for extended hours from 5pm to 7pm.

During those times, the late clinic averaged 2.7 medical visits per hour.

Podiatry Program

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

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

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

resources – particularly personnel requirements.

Podiatry Department

FY2012

Podiatry Visits

Physican Visits

Nurse/CMA visits

Missed Appointment Rate

Workload Factors

Physican Clinic Days

Average Visits per Clinic Day

Nurse/CMA Clinic Days*

Average Visits per Clinic Day

Nature of Visits

PT visit with Diabetes

PT visit with Open Wound

Comprehensive or Annual DM Ft Exam

Office Procedure Performed

OR Case

Hospital Patient

Other Visit Reasons

Total Podiatry Visits (So me patient visits include multiple pro blems)

FY2013

FY2014

FY2015

1,608

1,751

1,976

21%

24%

23%

143

155

615

223

105

376

808

297

108

464

886

359

133

508

220

503

433

469

1,685

1,824

1,987

154

224

Figure 3-2

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

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

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

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

the “No Show” rate.

Dental Services

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

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

provided.

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

plan resources – particularly personnel requirements. Broken appointments represent a

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

describe the patient service needs.

Dental Department

FY2013

FY2014

FY2015

FY2016

Dental Visits by Provider

Dentist Visits

Hygienist Visits

4,558

818

4,203

899

4,955

1,062

4,703

971

Total Dental Visits

5,376

5,102

6,017

5,674

664

11%

956

16%

631

842

13%

Workload Factors

Clinic Days

Average Visits Per Clinic Day

249(snow day)

250

247

Total FTE's

Average Annual Visits Per FTE

448

425

547

473

Categories of Care

Preventive

Restorative including Crowns

Dentures including Bridges

Surgical

Orthodontic

Endodontic

Diagnostic

7,295

2,888

169

1,106

251

6,700

8,030

2,556

826

270

7,111

10,692

2,451

1,063

244

8,191

8,771

2,364

1,108

188

7,878

Total Identified Problems Treated

19,193

18,885

22,697

20,375

Missed Appointments

No Shows (Broken Appointments)

Broken Appointments vs Total Visits

Figure 3-3

Interpretation: Dental visits in FY 2016 have held relatively steady even with the

fluctuations in dental staff. Broken appointments have increased since FY 2015. In

response to this, staff has created a short notice list to try and fill those appointments.

Pharmacy Services

Purpose: To identify the Pharmacy Program workload.

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

plan resources – both personnel and drug cost.

Pharmacy

Previous Previous

Year (%) 3 years (%)

FY2013

FY2014

FY2015

FY2016

New Prescriptions

Refills

53415

26125

50464

26479

50609

26568

46474

28516

-7.9

7.7

-11.7

7.2

Total Prescriptions

79,540

76,943

77,177

74,990

-2.5

-5.3

Workload Factors

Clinic Days

Avg Prescriptions per Clinic Day

Visits to the Pharmacy

Prescriptions per Pharmacy Visit

Total FTE's

Avg Annual Prescriptions Per FTE

253

314

33,622

2.36

6.8

11,697

251

306

33,975

2.26

6.8

11,315

250

309

32,848

2.35

8.25

9,354

252

298

33,092

2.27

7.0

10,712

0.4

-2.6

0.4

2.9

-5.3

0.3

-5.4

-2.0

-3.1

7.4

-12.1

841,676

11.22

Prescriptions Filled

Pharmaceuticals

Total Expenses

Avg Cost Per Perscription

Rx for Patients outside Service Area

791,276

9.95

Unavailable

753,909

9.79

Unavailable

868,828

11.25

Unavailable

Figure 3-4

Interpretation: Workload in FY 2016 has decreased from the previous three years in

the number of prescriptions filled (down 5.3%). The number of prescriptions per FTE

decreased by 5.3% from the previous year, and decreased 12.1% from the previous

three years. The decrease in the number of prescriptions per FTE has only slightly

decreased (from 8.25 to 7.0). Drug costs as compared to the previous year have

decreased but remained relatively stable. Average cost per prescription has remained

stable. The average number of prescriptions filled per day remains consistent for the

last four years. Staff continued to manage patients in four pharmacy-based clinics as

well as provide medication therapy management services and adult immunizations over

this period of time. Pharmacy works closely with Tribal programs including Community

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

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

drug storage and administration.

Diagnostic Services

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

Medical Laboratory).

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

plan resources for personnel and supplies necessary.

Diagnostic Services - X-Ray

FY2013

FY2014

FY2015

FY2016

Total X-Ray Exams

1,711

1,713

1,378

1,409

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

6.84

1,493

1.15

16,568

0.10

1,711

251

6.82

1,606

1.07

15,757

0.11

1,713

250

5.51

1,249

1.10

13,041

0.11

1,378

199

7.08

1,253

1.10

13,665

0.10

1,409

Imaging Exams

Figure 3-5

Interpretation: From 2015 to 2016, the number of X-ray images performed has

remained steady. An increase from 5.4 X-Ray images per day in FY 15 to 7 per day in

FY 16 may be due to having a podiatrist on board and a decrease in the number of days

X-Ray was staffed. Staff is currently being sought to fill the permanent fulltime

Radiology Technologist and an Intermittent Radiology Technologist.

Diagnostic Services, Continued

Diagnostic Services - Medical Laboratory

FY2013

FY 2014

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

**FY 2015

FY 2016

Medical Lab Tests

Tests collected in the Lab

Tests collected outside the Lab

Tests performed off-site

76,743

3,173

5,473

59,257

12,570

19,332 *

N/A

6,065

N/A

Total Lab Tests Ordered

85,389

71,827

N/A

Workload Factors

Clinic Days

Tests Ordered per Clinic Day

Total Primary Care Provider Visits

Average Tests per Visit

Total FTE's

Tests per FTE

250

342

16,568

5.2

5.0

17,078

250

287

15,757

4.6

5.0

14,365

250

116

13,041

0.5

4-4.5?

7,224

250

114

13,665

2.1

4.5

6,320

19,491

60,491

939

4,468

7,981

39,610

1,752

3,152

1,696

8,120

1,993

11,885

3,392

16,240

152

3,986

23,770

3,238

13,999

N/A

3,751

20,988

470

19,332

5,125

154

940

6,219

6,259

147

1,044

7,450

71,827

36,208

28,438

Category of Tests Ordered

Hematology

Chemistry

Bacteriology

Urinalysis

Sub total:

Quest

St. Charles Hospital

Oregon State Laboratory

Total Referred Procedures (send Outs)

Total Lab Tests Ordered

85,389

Figure 3-6

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

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

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

*** Bacteriology testing was ceased due to volume and cost effectiveness. Currently testing is

being referred to Quest and St. Charles Hospital.

Interpretation: For FY 2015 and FY 2016, data is not able to be collected for Medical

Laboratory Data for tests collected in the laboratory and outside the laboratory along

with tests performed off site.

Due to low volume and high cost, Bacteriological testing was discontinued and patients

needing this test are referred to Quest and St. Charles Hospital.

FY 2016 numbers are a bit lower than FY 15 which may be due to few providers.

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

FY2013

Optometry Visits

Clinic Visits

Missed Appointment Rate

FY2014

FY2015

FY2016

1,941

18%

2,912

22%

4,190

20%

4,201

22%

Workload Factors

Clinic Days

Average Visits per Clinic Day

Total FTE's

220

2.0

220

2.0

220

2.0

220

2.0

Nature of Visits

Refractions

Diabetic Eye Exam

Contact Lens Visit

Medical Visit

Early Childhood Education Visits

Glasses Repair/Adjustment

Other-dispensing/vision screenings

832

309

338

363

1,034

266

732

814

1,141

308

143

936

252

107

639

1,518

127

668

1,478

Figure 3-7

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

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

fourth year Optometry student. Staff is working to re-establish the fourth year

Optometry Student Program.

The rate of patients that do not keep appointments is up slightly from the previous year.

Recognizing this, the staff has changed how appointments are made to try decreasing

the number of broken appointments. There has been significant Walk-In numbers that

could be used to bring the No Show rate down to only 9%. The number of diabetic

patients seen in clinic is down from last year.

The number of patients seen in most categories has stayed similar over the last years

except for staff levels, which remain at 2.

Optometry Services Continued

The decreases in services can mainly be attributed to the provider being on extended

medical leave from January 21 to April 5, 2016.

Purchased and Referred Care

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

Relevance: To assure effective processing and management of resources.

Purchased and Referred Care

Staffing & Other Workload

FTEs

Number of Obligations

Funds Obligated

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

5,022

7,162

9,136

9,757

9,099

8,667

8,861

6,930

6,206

5,851

$3,447,919

$3,881,990

$4,953,270

$5,185,344

$4,999,277

$5,521,545

$5,736,701

$2,726,209

$2,094,865

$2,529,494

Figure 3-8

Interpretation: The Tribal Council passed a Resolution funding some non-Priority I

healthcare implemented in last 2007, and 2008 and 2009 reflected increased healthcare

coverage funded via “carve-outs” from PRC reserves accumulated through MedicareLike Rate savings; thus the increase seen from 2007 through 2010. The year 2010

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

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

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

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

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

increase in funds obligated in 2016 from 2015 is due to PRC having brought in specialty

clinics for the first time since 2006. These clinics include rheumatology, ear/nose/throat

and physical therapy, to name a few.

This era of healthcare transformation with the implementation of Coordinated Care

Organizations (CCOs) in 2013, the implementation of the Federal Health insurance

exchange and, more importantly, January 2014 Medicaid Expansion has greatly

increased the complexity of PRC processes. New complexities are emerging with

changes in the Medicaid system to the potential of Federal Medicaid Assistance

Percentages (FMAP) for referred health services form PRC. FMAP could provide

resources for the Tribal Health System to expand tribal coverage of some health

services.

Community Health Nursing Services

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

Program.

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

requirements and efficiency.

Services Provided by Category

2013

2014

Prenatal

Post Partum

Well Child

Immunization

Diabetes

Cardiovascular

Mental Health

Sexually Transmitted Infections

Family Planning

Phone Contact/Follow-ups

Other Activity

1,380

145

213

219

898

1,137

202

201

261

1,537

Total Services Provided

2,897

892

1,039

1,931

250

7.7

2.0

966

2015

2016

206

203

313

726

878

149

191

116

716

3,516

2,496

2,224

1,100

886

1,986

250

7.9

3.0

662

1,729

767

2,496

250

10.0

3.0

832

1,412

746

2,158

250

8.6

2.5

863

983

Visits by Location

Out of Clinic Visits

Clinic Visits

Total Community Health Nurse Visits

Total Days of Service

Average Visits Per Day

Total FTE's

Average Visits per FTE per year

Figure 3-9

Interpretation: Due to a position transfer and extended medical leave, the Community

Health Nursing (CHN) Program was fully staffed for only three months of 2016 with

three full-time nurses. They provide services in a variety of community areas including

Warm Springs Corrections, Child Protective Services, Group Home, Warm Springs K-8

Academy along with home and clinic visits.

Community Health Nursing Services, Continued

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

Program include (highest to lowest):



Vaccinations

Health Counseling

Laboratory testing/Blood Draws

Contraception

Routine Child Health

Pregnancy Testing

Sexually Transmitted Infections

Protective Care Visits

Major Depressive Disorder

Low Back Pain

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

physician ordered treatments.

Maternal and Child Health (MCH) Program

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

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

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

needs of the program.

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

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

high risk. High risk clients require more intensive services.

Maternal and Child Health (MCH)

2013

Total number of births

Total number of births (Tribal members)

Number of high risk pregnancies

Number of high risk infants identified*

Prenatal Home Visits

Post-Partum Home Visits

Other Home/Office Visits

Number of Hospital Visits

Number of Birthing Classes

Total Number of Participants

Infant Immunization level**

2014

2015

2016

104

150

399

181

327

162

218

300

141

135

384

108

162

83.5%

90.7%

85.0%

70.0%

Figure 3-10

*Born pre-mature, low birth weight, congenital defects, multiple births, transferred infant to high- level care

facility, expose 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.

Maternal and Child Health (MCH), Continued

MCH Case Management Data

120

104

100

2013

2014

2015

2016

Total number of births managed by MCH RN

Number of high risk pregnancies

Figure 3-11

Interpretation: In 2016, the birth rate for the MCH program increased from last year

with 97 deliveries case managed by the program, 68 of which were to Tribal Member

mothers. Out of these pregnancies, 47% required intensive service due to their high

risk status.

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

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

(<18 or >35).

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

eligible for care under IHS standards.

Community Health Representative

Purpose:

To identify the caseload and workload by category for the Community

Health Representative (CHR) program.

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

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

program priorities should shift as well.

Community Health Representative

2013

Caseload by category:

- Transports

- Patient Care

- Case Findings/Screening

- Monitoring Patient

- Case Management

- Health Education

- Other

Total Client Encounters

Total Days of Service

Average Number of Encounters per Day

Total FTE's

Average Number of Encounters per FTE per Year

2014

2015

2016

467

1395

634

1364

677

638

1220

774

119

126

156

181

2,099

2,124

1,471

2,175

250

8.4

3.4

617

250

8.5

4.0

531

250

5.9

4.0

368

250

8.7

4.0

544

Figure 3-12

Interpretation: In 2016, the CHR program had an increase in the number of patient

transport requests from the previous years.

During 2016, the program provided dialysis transportation five days per week for 2-6

clients per trip. Dialysis services continue to be provided locally in the Madras area

which offers more convenient scheduling for CHR clients. There is an early and late

drop off which is covered by two drivers.

Diabetes Program Services

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

Relevance: Diabetes is considered a Global epidemic according to the World Health

Organization. Native Americans are at increased risk according to the American

Diabetes Association. The mission of the Diabetes Program is to help improve the

Health of individuals and the community with a focus on diabetes and the complications

of diabetes. Staff aspire to be a source of support to the individual and community to

learn to prevent diabetes and support self-management of diabetes.

Diabetes Program

FY2015 FY 2016

Diabetes Program Ambulatory Visits

Family Nurse Practitioner (FNP)

Registered Nurse

Diabetes Educator/Registered Nurse

Estimated Average FNP Ambulatory visits

Estimated days patients seen by FNP

701

382

579

7.7

1208

686

616

7.8

154

Other catagories of Service

Chart Reviews/Case management total

Telecommunications

Community Education Contacts

Community Screening

1887

557

1997

1064

2379

835

1495

913

Patients in Dialysis

Number of Patients

Figure 3-13

1. Statistics for Ambulatory Visits is different than past years and included one year back for

comparison. Electronic Health Record records visits by provider and by if it is Ambulatory, Chart

Review or Telecommunication.

2. RN assists Family Nurse Practitioner (FNP) and there is no Nurse Assistant as in Medical

Department. RN does not see as many patients independently. Educator does at times provide

leave coverage for RN.

3. Estimated Average FNP Ambulatory visits includes estimated days employee actually seeing

patients. In FY 2015 there were two different FNP employees and have to estimate days in clinic.

4. FNP generally in a week is scheduled for patients 3.5 days and 52 weeks/ye. FY 2015 had an

FNP approximately 6 months. FY 2016, FNP saw patients for approximately 10 months.

5. Case management is done on all patients diagnosed with diabetes and a chart review note is

done. This is done by the three clinical employees and the Coordinator.

Diabetes Program Services Continued

Interpretation: The Warm Springs Diabetes Program Nurse Practitioner position was

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

Certified Diabetes Educator and Administrative Assistant. Major educational events for

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

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

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

diabetes education program is accredited by the American Association of Diabetic

Educators through July 2016. Community screening for Diabetes prevention education

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

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

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

Women and Infant Children (WIC)

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

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

and there is a need for coordination.

Women and Infant Children (WIC)

2013

2014

2015

2016

Infants and children under 5 years of age

534

482

470

466

Pregnant, breastfeeding and postpartum women

187

192

181

183

721

674

651

649

Total number of Women, Infants and Children served

Figure 3-14

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

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

2015 where Warm Springs noted a decline in women/children seeking WIC services.

The Warm Springs WIC site is not unique with this issue as WIC sites throughout the

state are experiencing the same trend. Outreach methods are being made to decrease

barriers to access.

Other interesting facts for 2016, 98% of new mothers start out breastfeeding and 44% of

the families served are working families.

Community Health Education Program

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

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

participation for all prevention activities.

Number of Participants

2015

Program

Health Education Team

No. of Educational Encounters

Direct Time Spent Educating

No. of Participants

No. of PSA's generated

No. of Newspaper Articles

80.5

1815

General Health

My Future My Choice; 5 Sessions (Sexuality Education)

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

Million Hearts Campaign

Great American Smokeout

Wellness of Warm Springs; 10/12 Classes

Pi-Ume-Sha Health Fair

Heart Smart Dinner

Employment and Life Skills Training

120

100

525

450

150

100

Alcohol and Drug Prevention

FASD Awareness Day

3D Project

included in WOWS

Cultural Prevention

Craft Classes

Jewlery Making

8 classes

9 classes

General Prevention

Trunk or Treat

275

HIV/AIDS

World Aids Day

Figure 3-15

Community Health Education Program, Continued

Nutrition

EDUCATION TOPICS

Bullying

Alcohol Awareness

Water Safety/

Skin Cancer

Tobacco Prevention

Self Discovery

28%

Cultural as

Prevention

51%

Leadership Skills

Figure 3-16

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

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

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

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

Mental Health

Purpose: To identify the caseload of clients by appointments and service category.

Relevance: To determine the projected need in providing appropriate Mental Health

services to the Warm Springs Tribal Community relating to client staff ratios and care

delivery. This significant resource also provides additional revenue, essential to the

overall stability and wellness of our people.

Mental Health

2012

Visits & Clients Served

Number of Adult and Child Visits

Number of Clinic Days

Average Visits per Clinic Day

Total Visits

Categories of Service

Crisis Management Visits

Jail

Total

Service Hours

Client Contact Hours

Prevention Services

Soaring Butterflies/Warrior Spirit

Positive Indian Parenting Participants (5)

Elvis Birthday Bash

MSPI Madras High School Presentations

QPR Trainings (5)

Sock-Hop Event

All Night Lock-In

He-He Butte Prevention Camp

Oregon Native Youth Survey

Halloween Party

Prevention Basics Power Point

Christmas Light Parade & Event

Spring Into Action (Prev. Coalition)

Penny Carnival

Rez Olympics

Street Dance

GONA Training

ASIST Workshop

MSPI & Child Initiative Against Violence

THRIVE

Rick Schimmel Motovational Speaker

Holiday Gift Making

Soaring Butterflies/Warrior Spirit Planing Meetings (10)

Soaring Butterflies/Warrior Spirit Event at Museum

Soaring Butterfly Year End Camp

Community Clean Up Project

Protecting Your Child

Drugasors Prevention Classes

Drugasours at Jamboree

Survivors of Suicide Conference

Spring Break Prevention classes at Recreation

WOW Lunch Meth Presentation

Total Prevention Services Attendance

2013

2014

2015

3,012

2,539

1,494

1,274

244

1,274

204

270

204

270

219

313

193

386

3,216

3,703

500

100

1,635

300

22 NA

100

600

178

1,601

2,016

100

300

600

200

1,318

982

33 *

n/a

100

n/a

600

n/a

500

n/a

250

200

217

3,394

* (with 15 graduates)

Figure 3-17

Mental Health, Continued

Interpretation: the 2016 calendar year has seen staffing challenges. Two Mental

Health therapist positions are vacant to date and being advertised. The Behavioral

Health Center is still in need of filling the part-time contracted psychiatrist position.

These vacancies will also affect the number of services provided to clients in 2017 until

staff is hired.

Alcohol & Substance Abuse

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

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

billed and collected by alternate resource).

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

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

program.

Alcohol and Substance Abuse

2012

Encounters - Outpatient Treatment

Number of Visits

Number of Clinic Days

Average Visits per Clinic Day

Relapse Anger Resolution Grp (Quarterly)

Jail Groups

2,501

254

334

2013

1,793

251

425

2014

1,567

252

375

Service Hours

2015

1,495

244

1,871

Aftercare

Healing from Grief & Trauma - 1 day conf.

Recovery Month Dinner

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

Community Grief/Trauma Gathering (2 workshops)

Healing Family Circle Conference

Winter Nights Round Dance

Spirit Fest Friday Night Dinner

White Bison Recovery Event

100

n/a

400

200

Total

655

Figure 3-18

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

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

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

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

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

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

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

Alcohol & Substance Abuse, Continued

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

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

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

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

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

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

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

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

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

will be filled in the near future.

Adolescent Aftercare

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

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

available provide the best services to clients.

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

are being provided to community members.

Adolescent Aftercare

2012

2013

2014

2015

Outpatient Visits

128

Prevention Youth Dance

236

116

Teen Craft Night

n/a

Rez Head Youth Conference

n/a

Baseball Camp

n/a

Healing Wounded Spirits Camp

n/a

Winter Youth Conference

n/a

Movie Nights

416

384

480

421

Wii Bowling

112

n/a

Hoop Camp

Madras Bowling

Wellness walk

204

224

147

All Night Sobriety Party

n/a

Kids Bingo

196

159

Red Road to Recovery/Boys Circle

Tribal Youth Leadership

Suicide Prevention Camp

Respect Club

Jude Schimel Hoop Camp

160

Sobriety Pow Wow

150

Total

1,187

1,251

1,533

1430

Figure 3-19

Interpretation: The aftercare program provides services including healthy alternatives

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

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

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

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

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

successfully transition back into their community.

Community Health & Prevention Resource Center

Purpose: Track the number and type of resources being used, and how many people

use them.

Relevance: To ensure that the resources provided are useful, relevant and being

utilized by the community. These numbers are a general reflection of how successful

the needs of the community are being met.

Community Health & Prevention Resource Center

2013

2014

2015

2016

Number of patrons that checked out materials

339

300

280

260

Number of materials checked out

949

792

810

835

Resource Center Usage

Health related materials checked out

Native American materials checked out

160

156

120

113

Circulations*

1,679

1,438

1,372

1,414

Number of visits

8,936

11,147

9,601

9,022

144

123

230

118

159

1,720

Patron cards issued

Graphic Design Requests

Posters/Documents printed

Figure 3-20

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

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

checked out more than once.

Interpretation: Although fewer people borrowed materials in 2016, they tended to

borrow more. People checked out three items on average, which is higher than

previous years. Graphic Design Requests were up significantly, in which 1720 posters

and documents were printed for Tribal departments.

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

2013

2014

2015

2016

Housing & Energy Assistance

Number of Clients Served

248

292

318

333

Total Vouchers Processed

248

292

202

208

Total $ Value of Vouchers

87,346

94,843

114,429

93,779

Number of Clients Served

336

420

946

1,581

Total Vouchers Processed

336

420

946

1,581

Total $ Value of Vouchers*

9,709

12,480

27,785

30,270

New Clients pursuing claims for SSI/SSDI

105

Number of clients currently checking on

Number of Clients inquiring about Retirement Benefits

Number of Clients that have been denied

Number of Clients that just filed their 1st Appeal

Number of Clients that are in the middle of Appeal

Number of Clients in Court Hearings

Number of Families Served

278

Number of Individuals Served

749

166

197

199

137

174

185

Medical Travel

Disability

Survivorship/widow benefits

Commodities

Number of Warm Springs Tribal Members**

Figure 3-21

** 2013 Tribal Member data was not recorded.

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

moved into the Family Resource Center to better serve and assist the community. With

the relocation there was an increase of 15 additional households served. The winter of

2016 showed many challenges for the wood vendors. These challenges were primarily

environmental, yet after evaluation weaknesses were identified that were strengthened

in this area.

Social Services, Continued

Medical Travel served 635 more clients in 2016 with assistance to Medical

appointments. This service was based on no priorities and all patients were referred

through the Indian Health Service.

Disabilities Coordinator fluctuates on based on need. After the relocation to the Family

Resource Center, community outreach and consistency there was an increase in

community members accessing services.

The Commodities Program increased its participation in 2016 from 174 to 185. A

tracking system is used to count the actual number of individual households served.

This allows for the tracking of individuals in a household for the entire year without any

duplication. Through this system, Commodities staff is able to evaluate services

provided on a monthly, quarterly and annual basis to address issues, concerns or

changes.

Ambulance Services

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

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

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

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

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

measures collection potential of this enterprise.

Ambulance Activity Summary

SUMMARY OF AMBULANCE ACTIVITY

Calls

Patients Transported

2014

2015

Calls w/Substance Factor

2014

2015

Reason for Call

2014

2015

Motor Vehicle Accident

Other Accident

Assault and Battery

Suicides/Attempts

Corrections

379

385

128

Pediatric

222

280

Cardiac

149

Respiratory

148

137

Other Illness

134

145

1,208

1,187

382

419

135

211

Total

TRIBAL AFFILIATION RELATED TO CALLS

Reason for Call

Members and Dependents

Calls Dispatched

2014

2015

Patients Transported

2014

2015

Calls w/Substance Factor

2014

2015

1,625

1,714

623

702

227

344

Other Eligible Indian

Non Tribal

126

156

1,751

1,870

671

760

229

354

Total

Figure 3-22

Ambulance Services, Continued

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

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

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

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

(MVAs).

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

of patients transported were also Tribal Members and Dependents.

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

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

transports were nearly 18%.

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

Culture and Heritage Language Program

Purpose: Cultural and Heritage provides language and cultural education opportunities

for Warm Springs Tribal and community members.

Relevance: Providing Cultural and Language Education opportunities gives Tribal

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

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

and implementing outreach efforts and developing relevant materials.

Figure 3-23

Figure 3-24

Culture and Heritage Language Program, Continued

Interpretation:

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

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

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

Springs community. These opportunities allow for information distribution via language

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

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

classes are offered at the same time. This includes:



Autni Ichishkin Sapsikwat (pre-school)

Autni Ichishkin Sapsikwat (k-8)

Out-of-school classes (morning and pm)

Leadership Conference Opportunities

Language Bowl Classes (prep for annual event)

Rites of Passage

Traditional and Spiritual Events

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

request our services including:



Local school districts

Mt Hood Cultural Presentation

Community colleges, universities and other higher education institutions

Museums

KWSO

Purpose: KWSO is a public radio station licensed to the Confederated Tribes of Warm

Springs. Programming includes content around health education, the promotion of a

healthy lifestyle and dissemination of information about health related events &

opportunities. Information is shared on-air in live calendar reads, pre-recorded public

service announcements, in local news stories and in locally produced news magazine

segments. Information is also shared online at www.kwso.org plus KWSO’s pages for

Facebook, Twitter, SoundCloud and YouTube.

Relevance: KWSO is within the Tribes’ Health & Human Services Branch and provides

their programs with media support to disseminate information about health related

events, health education and information about services.

KWSO

2014

PSAs by Category

2015

2016

Combined Categories for 2016:

Mental Health, Health, Events & Opportunities*

Community Events/Opportunities**

Parenting Education***

Violence Prevention/Awareness?

Education Information/Opportunity??

Health Education

Health Insurance

Mental Health Education

Health Related Event

Diabetes Education/Awareness

Violence Prevention

FASD Awareness

Child Development/Parenting

Cultural Event

Child Mental Health

Youth Education

Child Abuse Prevention

Child Health

Youth Health Related Event

Youth Opportunity Information

School Related Event

Elder Event

Mental Health Event

Youth Employment

Safety

Veteran Events/Opportunities

Disabilities

Education

Community Health/Fitness Events

Holiday Events (Easter, 4th, Halloween, etc)

Voting/Elections

Child Health Education 5-2-1-0 Campaign

Adult Education Opportunities

Literacy Events

Environmental Event

Diversity

Natural Resources Education Event

Enterprise Events

2,034 *

1,354 **

1,440 ***

848 ?

757 ??

1,988

2,231

2,718

1,405

1,263

1,261

2,110

680

1,959

1,543

1,360

538

3,912

459

715

557

1,044

1,436

307

825

822

732

709

467

374

319

312

291

124

118

282

376

419

263

446

121

128

156

115

185

111

330

430

11,862

13,035

764

670

346

325

288

169

152

16,321

Figure 3-25

KWSO, Continued

2016 PSA Campaigns by Topic

Enterprise Events

Natural Resources Education Event

Diversity

Environmental Event

Literacy Events

Adult Education Opportunities

Child Health Education 5-2-1-0 Campaign

Voting/Elections

Holiday Events (Easter, 4th, Halloween, etc)

Community Health/Fitness Events

Education

Disabilities

Veteran Events/Opportunities

Safety

Youth Employment

Mental Health Event

Elder Event

School Related Event

Youth Opportunity Information

Youth Health Related Event

Child Health

Child Abuse Prevention

Youth Education

Child Mental Health

Cultural Event

Child Development/Parenting

FASD Awareness

Violence Prevention

Diabetes Education/Awareness

Health Related Event

Mental Health Education

Health Insurance

Health Education

1,000

2,000

3,000

4,000

5,000

Figure 3-26

Interpretation: Guidance for Joint Health Commission Priorities/Strategies. This

represents only a portion of all Public Service Announcements (PSA) broadcasted. The

top health related PSA campaigns focused on: Health & Mental Health Education &

Events, Youth Opportunities, Parenting Education, Community Events & Prevention

(Violence/Drugs/Alcohol/Tobacco).

Overall Health/Mental Health Education and

Events/Opportunities were the strategies most often broadcast in PSAs.

A total of 16,321 PSAs (60 seconds or less) were broadcast – that were health related

and relevant to the Joint Health Commission’s Priorities/Strategies.

That is a value of $326,420 (at $20/spot).

Spilyay Tymoo Newspaper

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

health and wellbeing of the Warm Springs Tribal Community.

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

and opportunities available to Tribal Members.

Spilyay Tymoo

2015

Article/Announcement Category

2016

Article

Announcements

Article

Announcements

Child Development/FASD

Early Childhood/Child Development

Youth Fitness

Youth Mental Health

Youth Health Education

Youth Support

Education & Job Opportunity Events

Health Services Information

Tribe's Health Education & Health Support

Elders

Health System

104

109

124

Total # of Articles/Announcements

232

428

246

452

Figure 3-27

Spilyay Tymoo Health Related Publications

2016

Health System

Elders

Tribe's Health Education & Health Support

Health Services Information

Education & Job Opportunity Events

Youth Support

Youth Health Education

Youth Mental Health

Youth Fitness

Early Childhood/Child Development

Child Development/FASD

Announcements

Series4

Series3

Series2

100

120

Articles

Figure 3-28

140

Spilyay Tymoo Newspaper, Continued

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

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

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

strategies.

Vocational Rehabilitation

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

consumers/clients.

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

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

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

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

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

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

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

effectiveness.

Vocational Rehabilitation

FY2013

Orientations

Intakes

Files Closed

New Cases Opened

Mo. Average Pending Eligibity

FY2014

145

FY2015

FY2016

174

161

Figure 3-29

Interpretation: Attendance at VR Orientations (Warm Springs, Madras and Portland)

was 161, compared to 174 and 145 in previous years. Although Intakes and Files

Closed slightly decreased; some of the consumers opened and closed more than one

time within the grant year. New Cases Opened increased – and taking longer to write

and implement the employment plan. The average number of individual Pending

Eligibility each month is seven.

The data tells the Program if there are areas within case the case management system

that need to be addressed by the VR team. For example, the effectiveness of program

outreach is determined by the number, who attends orientations, and the effectiveness

to secure medical documentation, as a measure of eligibility determination, and tracking

of the eligible consumer’s files that are closed successfully rehabilitated or closed

“other” status. Staff also uses an electronic database that is used for all eligible clients

that breaks data down further, which is not always accurate, thus staff reviews the

counselors’ monthly statistics reports.

Vocational Rehabilitation Continued

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

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

Traumatic Stress Disorder P.T.S.D., bi-polar and schizophrenia and schizo-affective

disorder. Other medical issues such as: Diabetes Type II, renal/kidney disease,

obesity, arthritis, hypertension/high blood pressure, hearing and vision impairments.

The rehabilitation process takes 12-18 months for most consumers. There are

consumers who were able to start work, receive their needed cost services and be

closed successful within 4-5 months.

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

Indicators. Staff can determine the levels of cooperation of health, human, social and

economic service providers who serve common consumers/clients. In 2016, the

program began tracking “Comparable Benefits” for Medicaid eligible consumers. The

Purchased & Referred Care Program stated in a report that the monthly billing rate for

Comparable Benefits is $350. Comparable Benefits are services contributed to I.P.E.s

by the consumer or other service providers. This is used as a measure of consumer

self sufficiency, as they seek out other services and personally contribute to their I.P.E.

High Lookee Lodge Adult Living Facility (HLL)

Purpose:

High Lookee Lodge (HLL) Assisted Living Facility (ALF) provides

individualized services to elder and disabled adults who are in need of assistance with

daily living, with an emphasis on a home like and cultural living environment. These

services are provided within the guidelines established by the State of Oregon License

as an ALF.

Relevance: HLL provides care to elder and disable adults who are no longer capable

of living on their own. Serviced provided include but are not limited to medication

distribution, meals, assistance with dressing, laundry, setting up appointments and

providing rides to appointments. Provide assistance to residents that helps maintain

their independence with assistance in areas as needed.

High Lookee Lodge

Resident

Count

2013

2014

Private

Resident

Pay Medicaid Count

Private

Pay

Medicaid

Resident

Count

Private

Pay

Medicaid

Resident

Count

Private

Pay

Medicaid

2015

2016

January

February

March

April

May

June

July

August

September

October

November

December

Avg Number

of Residents

Figure 3-30

Interpretation: The average monthly client count for 2016 was 20. There is room for

36 total residents in the facility. On average, there are four private pay residents with

the remainder being Medicaid eligible.

Children’s Protective Services

Purpose: Children’s Protective Services (CPS) works to empower parents, families

and community members through support, accountability and cultural teachings to give

all children an optimal chance in life. CPS provides prevention and intervention

services to families in need so that the family system has the opportunity to learn the

necessary skills to keep the family safe and together.

Relevance: Program statistics allow CPS to evaluate the effectiveness of the

program’s response and resolution to Child Abuse and Neglect referrals as well as tailor

services to meet the unique needs of each child and family that enters the CPS system.

Children's Protective Services

FY2013

FY2014

FY2015

Visits/Contact

Total Number of Services Provided to Children

Total Number of At-Risk Children

5,116

4,879

325

389

Total Number of Child Abuse/Neglect

379

476

402

Children Placed in Emergency Shelter

129

207

Average Length of Time in Emergency Shelter prior to being placed (days)

120

Average time in Foster Care (days)

270

285

Figure 3-31

Interpretation: The statistical information provided represents the ongoing need for

protective care services, intervention and prevention as the amount of children served in

2015 remains significant.

The average time in Foster Care days is an indicator of the amount of time children

remain in protective care prior to reunification or alternative permanency is achieved. In

2015, the average time was 285 days which is significantly longer than the program

goal of 180 days. There are several contributing factors for CPS not achieving this goal

including issues with staff vacancies, lack of family involvement with becoming certified

as relative foster care providers, lack of general Tribal foster homes on the Reservation

and reunification with parents have not occurred in a consistent and timely manner.

Family Preservation

Purpose: Family Preservations’ (FP) goal is to support families to properly care for

their children, while maintaining the safety of the child in the home. FP assists families

in coping with problems that interfere with successful parenting and helps families to

find resources and support. Family Preservation is not designated to “fix” everything in

the family but to help them learn the skills necessary to provide a safe and caring

environment for the child.

To best serve Warm Springs families, FP focuses on a variety of prevention and

intervention methods, and on occasion, post-vention services when exiting the Child

Welfare system.

Relevance: The programs data collected allow FP to evaluate the strengths and

weakness in the program. The data allows FP to make necessary changes for overall

improvement showing the amount of clients that are being seen before they are in

danger of child removal.

Figure 3-32

Interpretation

This data shows that families were given the opportunity to work with the program under

a number of circumstances. The program’s data are per family rather than per child. Of

the 43 families, nearly one in four families worked with the program on a volunteered

basis, and less than half were court ordered and/or referred to the program.

Children who have been transferred from Family Preservation into CPS are either due

to: Court orders; family’s unwillingness to work with FP; strong drug and/or alcohol

relapse; child in need of supervision. This program works in collaboration with

Community Health Social Worker.

Tribal Day Care Program

Purpose: The Tribal Day Care Program provides child care services to children ages 6

weeks to 12 years of age. Children are provided a clean, healthy, safe-learning

environment as well as age-appropriate curriculum to educate them in early learning

and health-related curriculum. Day Care Staff participate in healthy learning activities

provided through community departments, social events, and healthy gross motor

activities.

Relevance: The data being collected is used to track medical exclusions as well as

child injuries and if they were a transport or a non-transport to Indian Health Services.

Dental screenings are provided to those children whose parents give authorization.

These screenings help in the prevention or detection of cavities in young children. All

enrolled children’s immunizations are tracked via the Alert System in order to make sure

all enrolled children are current on immunizations.

Tribal Day Care

Visits/Contact

Dental Screenings

Medical Exclusions

Injuries/Accidents:

Transport

Non-Transport

Head Lice Exclusions

Immunizations

Ages & Stages Questionnaire

FY2014

FY2015

FY2016

127

136

102

112

199

Figure 3-33

Interpretation: In 2016, there was an increase in Medical Exclusions due to a center

wide breakout of Hand, Foot and Mouth disease as well as individual cases of Scabies,

the Flu and some Respiratory Syncytial Virus (RSV). Injuries/Accidents increased from

112 to 199 with 99% of these incidents not being severe enough that the child needed

to be transported for medical care. This increase is not that more children had

accidents; it is most probably due to increased documentation, keeping classrooms at

full capacity of enrollment and changes in staffing.

This data reflects the number of dental screenings, Ages & Stages Questionnaires

(ASQ’s), medical & head lice exclusions, and injuries/accidents and whether they were

a transport or non-transport to Indian Health Services (IHS). This data also reflects that

Tribal Day Care meets State requirements as far as all enrolled children having

completed their immunizations before the exclusion day in March of every year.

Community Wellness Center

Purpose: To provide safe and properly supervised community/youth activities which

enhance the physical, health, social, educational, cultural and leadership well-being of

our community’s youth and families.

Relevance: Work load measures are needed to assess program growth, community

activities and community benefit as well as personnel requirements for the Community

Wellness Center (CWC).

Community Wellness Center

FY2014

FY2015

FY2016

Youth and Community Activity

Recreation Field Trips (incl. Chaperones)

Sports/Athletic Program Attendance (all)

Game Room Attendance

Snack Attack

After Shool Programs/Community Activities

437

49,872

2,333

4,071

9,426

368

35,739

2,614

3,186

9,363

330

22,039

2,250

3,426

10,294

Total Program Participation

66,139

51,270

38,339

Signed Weight Room Waivers

402

428

360

Summary of Activity

Figure 3-34

Interpretation: The CWC continued to serve a large number of community members

throughout 2016. The majority were in sports/athletics programs. After school

programs and community events also had a strong number of participants. The “Snack

Attack” program was also successful with providing youth with an after school option.

Some of the major activities included: Youth Field Trips; Arts and Crafts; board games;

quilting; Reawakening; Halloween activities; popcorn and movie nights; Tribal Member

Youth Art Show; holiday craft projects; carnivals; parades; Christmas Bazaar;

community yard sales; Christmas activities; Penny Carnival; sweetheart activities; Mad

Hatter Party; art camp; Kids Jamboree Day; Jesuit High School Exchange Sports

Camps; Native Lacrosse (Burns, Umatilla).

Medical Social Worker (MSW)

Purpose: To identify the workload associated with the Medical Social Worker (MSW).

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

requirements and efficiency.

Medical Social Worker

2015

2016

Patients Seen

Chart Reviews

Telephone

Ambulatory Visits

149

129

132

241

251

234

Total Days of Service

Average Visits Per Day

Total FTE's

Average Visits per FTE per year

250

0.53

132

250

0.94

117

Figure 3-35

Interpretation: The Medical Social Workers provide many types of services including

mental health counseling for individuals and families along with classes to teach life

skills such as parenting and emotion recognition. In February of 2016, a second

Medical Social Worker was added to focus on integrating behavioral health in the

Medical Clinic. The MSWs work closely with Family Preservation Programs providing

social work service and teaching Conscious Discipline for the families. They also work

closely with the Behavioral Health Center and medical providers at IHS. In addition,

one MSW is a member of the Child Advocacy Team for forensic interviewing.

The Top Ten Purposes of Visits managed by the MSW include:



Other Specified Counseling

Major Depressive Disorder

Problem related to housing and economic circumstances

Disruption of family

Counseling unspecified

Post-traumatic stress disorder

Administrative exams

Problem related to life management difficulty

Person encountering health services to consult on behalf of another

person

Other stressful life events affecting family and household

Medical Mobile Unit (MMU)

Purpose: To provide an overall summary of the use of the Medical Mobile Unit (MMU)

in the community.

Relevance: The MMU travels to different areas of the reservation to deliver primary

medical and dental services.

Medical Mobile Unit

2016

Visits

Location

2015

Sidwalter

Seekseequa

Simnasho

Administration Building

Campus

Community Center

Senior Center

ECE

Corrections

WSK8 (Dental)

Agency (specific location unknown)

Fire Management (Physicals)

2016

Figure 3-36

2016 Visits: Department Community

Health

I.HS. Medical

37%

IH.S Dental

62%

I.HS. Medical

IH.S Dental

Figure 3-37

Community Health

Medical Mobile Unit (MMU), Continued

2016

Visits

No Shows

Walkins

I.HS. Medical 367

IH.S Dental

606

Community Health

44 (12%)

16 (4%)

Figure 3-38

Interpretation: The MMU is scheduled for primary care clinics on Tuesdays. Once a

month it is scheduled for outlying areas. Dental screenings are provided at the Warm

Springs K-8 Academy for a couple weeks in the fall and spring. The MMU is also used

for specialty clinics such as annual physicals for children starting Head Start or for fire

fighters working with Fire Management. In the Fall, the MMU is used as a Flu shot

clinic.

Summary of Grants (Their Purpose etc.)

Purpose: Education and assistance for Native Americans to pursue optimal health.

Relevance: Grants enable programs to offer a multitude of services including: health

education, presentations, cooking classes and community interaction to the Warm

Springs Community.

Special Diabetes Prevention for Indians Grant (Tribe): Heightened community

awareness regarding diabetes risk reduction strategies, physical activity education and

family involvement in fitness activities. The SDPI Wellness Program co-sponsors

multiple diabetes/physical fitness activities and events throughout the grant year.

Target youth ages 6-12 who are at-risk for diabetes. Provide funding and incentives for

youth sports-related activities and sports camps in the community to provide exercise

opportunities for Tribal youth.

Maternal Child Health (MCH): Provide high quality, Tribal Best practices home visiting

based services to pregnant women and families with young children aged birth to

kindergarten. One Tribal Best Practice that has been supported since 1995 is Back to

Boards, which teaches how to complete baby boards for the infants first year, receiving

instruction and education on the dangers of tobacco, drugs and alcohol use of the fetus.

State Women, Infants and Children (WIC): Provides nutrition education, one on one

nutritional consultants and assistance to purchase nutritious foods and formula for

pregnant/nursing mothers and children up to age 5.

State Tobacco Prevention: Utilize the same principles stated in A&D Prevention and to

provide on-going projects that concentrate on promoting policy such as having smoke

free buildings, events and worksites.

Alcohol & Drug Prevention: Provide prevention services targeting populations by

following the continuum of care model (universal, selective and indicated) and the six

Center Substance Abuse Prevention strategies (information dissemination, education,

alternative activities, community base, environmental/policy and early identification and

referral).

Coordinated Tribal Assistance Solicitation: Provides expanded A&D services and

specialized treatment for sex offenders.

Domestic Violence: This is a project that is coordinated with Victims of Crime and

Prosecution. Provides expanded A&D services and specialized treatment for domestic

violence victims.

Juvenile Crime Prevention: Substance Abuse Counselor/Part time position will screen

youth and identify early indicators of problem behaviors and provide case management.

Summary of Grants (Their Purpose etc.), Continued

Strategic Prevention Framework/Partners For Success (SPF/PFS): The SPF/PFS is a

community-wide program that requires a high level of communication, collaboration, and

involvement on the part of those involved. The SPF-PFS initiative allows Warm Springs

SPF/PFS to plan and implement strategies to prevent substance abuse in the

community. The program is responsible for assessment, capacity building, planning,

implementing, and evaluating activities associated with the PFS priorities.

Mental Health Initiative: Following 3 programs:

 Mental Health Promotion and Prevention: Transformational Change using Conscious

Discipline (CD). Folds mental health promotion and prevention into existing tribal

prevention system so departments can identify early indications of problems and foster

mental health.

 Jail Diversion: Wellbriety Program (Tribal jail Diversion). Expands services to keep

people with mental illness and other behavior problems from unnecessary incarceration

in local jails.

 System of Care and Wraparound: Warm Springs Family Preservation Program.

Increase the availability of wraparound services, providing intensive care coordination

for family and children with emotional and behavioral disorders.

USDA Commodity Warehouse: Provide food to low income/disabled households on the

Reservation.

NARA Youth Suicide Prevention): This grant operated off of a scope of work agreed

upon annually with our funders, NARA. The main focus is with youth encouragement of

self-worth and family values. Hosting community events that provide family activities

and developing the Tribal Youth Council.

Influenza Pandemic: Provide policy guidance within the emergency preparedness plan

for fast response with all disease prevention and treatment. Follow the same process

indicated with Alcohol & Drug Prevention above.

Vocational Rehabilitation: Helps Native Americans with disabilities find, obtain, maintain

or become promoted in employment.

Meth/Suicide Prevention (MSPI): Develop the Health and Human Service Infrastructure

to address suicide prevention, intervention and post/vension and to educate community

members & provider partners.

Summary of Grants (Their Purpose etc.), Continued

Interpretation: Grants provide needed services that compliment base dollars we

receive through our 638 annual funding agreement and base dollars received by the

State of Oregon. Programs are tracked within the Annual Health Report, mandated

grant reports and collectively have shown reductions in numerous areas. The Wellbriety

program has diverted 33 cases that would have had to face fines or jail time; they are

receiving treatment as a diversion. Back to Boards has reduced SIDS, and other health

problems, which are complicated to prove since, true prevention means the

consequence of poor chooses does not occur. More than 500 youth and community

members have been trained locally with QPR (question, persuade and refer) again

reducing suicide attempts.

SECTION 4

Resource Availability and Use

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

This section provides an overview of all the resources that have been devoted to the

provision of health care including Indian Health Service, State of Oregon, awarded

grants and those resources allocated by the Warm Springs Tribe. The resources are

compared to the national medical inflation factors to determine our status. The

information also identifies expenditures by program. Detailed history of collected

revenue is captured by year and by program. Since almost one quarter of all health care

resources is absorbed by Managed Care, it is important that the system continue to

monitor total costs and unit costs of all those services that are purchased. The staffing

levels of each program are identified and further reviewed to determine the extent of

tribal member employees. An accounting of carryover funds and reserves is also

maintained.

The vast majority of the resources that are provided annually are associated with

ongoing programs and services, leaving only limited resources to add new services or

address special needs. Implementing the comprehensive health plan anticipates a

careful examination of resources and careful priority setting for available resources.

This section highlights the available resources for the past several years, as well as the

spending patterns.

Resources that are not expended in a given year are, for the most part, available to the

subsequent year. Some, but not all, may be available to re-allocate to other purposes.

This section also indicates that federal funding has lagged medical inflation for many

years. Purchasing power is diminished when this happens. Increases in 2009 and

2010 have helped to close this gap. However, the federal budget deficit will place

pressure on federal budgets for many years to come.

Summary and Highlights

Overall funding of the Health System in 2015 remained at the same level as the

previous year (just over $28 million).

While the total resources from the Indian Health Service declined by 3%, the recurring

funding actually increased by 4.2% in 2015, benefiting the health service portion of the

budget. (Figure 4-1)

Indian Health Service collections increased by $250,000 or 5.5%. The Tribal collections

decreased slightly from the previous years experience due to a change in billing policy.

In previous years, the biller would bill for a year back. In 2014, the biller caught up with

all past billing and they are now current. The 2015 collection amount should be a more

standard amount received from now on. There was a substantial increase in collections

by Community Health Nursing (nearly tripling from the 2014 level). Together the Indian

Health Service and Tribe collected $6.5 million (a record high). (Figure 4-1)

The resources through appropriations in 2015 increased by 4.2% which is a little above

the medical inflation rate reported. This was much better than what was experienced in

2013 and 2014.

The actual expenditures for health services declined by $2.6 million in 2015. (Figure 43). The declines are explained in the text of this chart. Purchased/Referred Care,

Facilities, Health Administration, Pharmacy and Podiatry were the areas with the most

notable declines.

Purchased/Referred Care had another banner year in terms of resource utilization,

primarily due to the effective use of alternate resources and the medicare negotiated

hospital rates. This is despite a large increase in admissions and hospital days that

occurred in 2015.

A substantial increase in grant funding brought the total to nearly $5 million over the

past four years.

Health System Funding by Major Source

Purpose: To provide a complete picture of all funding available to the overall health

system to serve the community.

Relevance: The Health Programs rely on funding from several sources, many of which

the health system has little control. While the historical viewpoint is important, the

current funding is most useful for addressing planning and priorities.

Health System Funding by Major Source

2012

2013

2014

2015

17,348,813

16,135,780

16,248,026

16,927,090

510,231

603,603

1,236,741

81,181

17,859,044

16,739,383

17,484,767

17,008,271

Indian Health Service

Recurring Funding

Non-Recurring Funding

Total IHS Funding

Collections IHS

Medicaid

2,522,740

2,630,125

3,876,758

4,093,398

Medicare

Private Insurance

99,349

503,833

265,122

420,342

285,257

361,643

302,669

377,431

Total IHS Collections

3,125,922

3,315,589

4,523,658

4,773,498

Ambulance

146,086

358,739

329,823

386,582

Community Counseling

567,466

944,058

1,196,976

658,195

Community Health

398,428

462,844

228,950

680,023

Total Tribal Collections

1,111,980

1,765,641

1,755,749

1,724,799

Grant Awards

1,650,982

2,133,838

1,114,664

1,511,893

Tribal Employee Group Insurance (Est)

1,901,827

2,231,557

3,091,229

2,648,623

Tribal Appropriations

1,682,649

396,905

477,754

547,417

Collections Tribe

Total

$27,332,404 $26,582,913 $28,447,821 $28,214,501

Figure 4-1

Interpretation: The funding trends have been positive over the past 4 years, although

there was some erosion of funding in 2013 as a result of the sequester.

While the total resources from IHS declined by 3%, it is worth noting that the recurring

funding actually increased by 4.2% in 2015 over the previous year benefitting the

operational budget.

Health System Funding by Major Source, Continued

IHS collections increased by $250,000 or 5.5% in 2015 and established another new

record. Tribal collections decreased slightly from the previous year’s experience. A

huge decline (50%) in the collections of the Community Counseling (decrease of

$538,781) was experienced in 2015 and that situation must be corrected. On the other

hand, the Community Health Nursing Program increased its collections by $451,073 or

nearly tripling its total. The ambulance program increased collections by 1% from the

prior year.

Grant awards increased by $397,229 from the previous year. Tribal appropriations

increased by $69,663 over that same period. Tribal Employee Group Health

expenditures were estimated at $2,648,623, which represents a decrease of $442,606.

The overall total Health Program Funding for 2015 was slightly less than in 2014. The

decrease was somewhat less than 1%. Without the decrease in non-recurring funding

experienced in 2015, actual health services money increased slightly.

Base Health System Funding Versus Inflation

Purpose: To identify the historical Indian Health Service recurring funding base and to

compare it with medical inflation.

Relevance: Measuring the purchasing power of ongoing resources is vital to

addressing resource allocation and priorities. While there are numerous other resources

the Indian Health Service recurring funding base represents the only source derived

directly from the federal obligation that is adjusted for inflation.

Annual IHS

Base Funding

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Base

Increase

9,570,435

9,955,164

10,428,865

10,716,132

11,102,601

11,836,295

11,914,200

12,072,614

12,454,591

12,833,003

13,340,464

13,995,065

16,174,897

16,284,305

17,348,813

16,135,780

16,248,026

16,927,090

1.0%

4.0%

4.8%

2.8%

3.6%

6.6%

0.7%

1.3%

3.2%

3.0%

4.0%

4.9%

15.6%

0.7%

6.5%

-7.0%

0.7%

4.2%

Medical

Inflation

2.9%

3.5%

4.1%

4.6%

4.7%

4.0%

4.4%

4.2%

4.0%

4.4%

3.7%

3.2%

3.4%

3.0%

3.7%

2.5%

3.0%

2.6%

Growth of $1 from 1998

$2.50

$2.00

$1.50

Growth of $1 of Inflation

$1.00

Growth of $1 of IHS Base

$0.50

$0.00

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Figure 4-2

Base Health System Funding Versus Inflation, Continued

Interpretation: Funding increases provided by the Congress in 2009, 10 and 12

addressed deficiencies in bringing the funding in line with inflation. The national budget

sequester in 2013 stripped funding, thereby reducing the benefits realized from those

increases. The reductions were restored in 2014. Funding has just kept pace with

inflation but does not account for population growth over the past 15 years.

Health System Spending by Program

Purpose: To report actual outlays by each program as well as overall carryover and

savings.

Relevance: Important to understand, plan and adjust resource allocation to meet the

changing health system priorities.

Clinical Services

Medical

Dental

Optometry

Pharmacy

Podiatry

Medical Lab

X-Ray

Diabetes - Clinic

Community Health

Community Health Dept.

Health Education

WIC Program

Diabetes Grant (Tribal)

Environmental Health

Public Health Nursing

Community Center

Community Counseling

Mental Health

Adolescent Aftercare

Vocational Rehabilitation/Social Svs

Prevention Projects

Administrative Support

Facilities

Security

Medical Records

Health Administration

Business Office

Quality Assurance

Data Systems

Indirect Costs

Other

Managed Care

Ambulance

Quarters

Clinic Equipment

Total

2012

2013

2014

2015

2,229,705

1,217,056

287,891

1,122,677

107,033

749,719

2,875,284

1,217,823

240,219

1,492,054

101,993

640,333

797,546

680,280

2,653,814

1,314,421

221,051

1,631,774

344,842

775,851

111,181

483,737

2,747,835

1,341,744

195,204

1,224,359

171,583

860,922

92,431

462,312

415,384

221,757

64,620

142,075

56,113

941,253

214,402

364,932

299,954

63,190

193,268

46,624

644,482

293,289

277,899

816,638

40,020

184,296

94,400

650,440

174,291

198,781

743,194

53,856

165,049

94,090

820,840

258,955

1,055,718

321,245

79,931

552,314

337,782

1,164,795

197,119

85,647

411,200

423,370

480,416

442,326

130,052

66,509

419,615

380,237

737,596

136,649

91,332

132,230

986,419

22,891

263,269

1,071,288

1,264,624

947,236

106,017

269,888

1,314,107

1,007,004

462,821

107,336

492,258

394,679

1,291,843

646,238

110,678

482,681

1,335,157

473,883

24,280

393,689

1,379,464

557,516

141,251

478,445

1,190,811

5,566,489

1,071,369

123,740

5,836,686

300,000

51,865

3,048,409

325,021

176,684

2,160,842

337,353

23,204,464

19,957,095

20,196,251

18,114,356

67,621

Figure 4-3

100

Health System Spending by Program, Continued

Interpretation: From 2014 to 2015 the overall spending on total health services has

decreased by $2,615,821 (13%). Most of the decrease is easily explained.

The expenditures in Managed Care were nearly $900,000 less than the previous year

and are a reflection of the effective use of alternate resources and the Medicare rates

now available for hospitalizations.

The reduction in spending for the Pharmacy Program was primarily because of two

factors: Intermittent Pharmacy costs were down by $58,000 and more importantly drug

costs dropped by $336,000. This was attributed to one of the top ten expensive

medications now being available as a generic drug. It is anticipated that in 2016, drug

costs will again rise due to an additional expensive drug (etanercept) being added to the

formulary.

Podiatry expenditures declined by $174,000 in 2015. This was mainly due to the

vacancy created when the Podiatrist retired. It took several months to recruit a new

Podiatrist.

Most of the other programs and activities had expenditures that were in line with the

previous years. Vacancies can account somewhat for the variances in most of the other

categories.

101

Clinic Billing

Purpose: To identify visits billed, revenue collected and source by year.

Relevance: To identify trends and determine action of program considerations to

improve billed revenues.

2013

Visits Billed

Medical

Dental

Pharmacy

Optometry

All Other

Total Visits Billed

Collections

Medical

Dental

Pharmacy

Optometry

All Other

Total Collected

Source

Medicaid

Medicare

Private Insurance

Other (Workmen's Comp, VA, etc)

2014

2015

2016

10,320

2,296

21,159

467

2,232

12,179

3,308

25,771

689

2,469

11,743

3,333

30,223

1,021

2,389

12,062

3,620

31,850

958

2,272

36,474

44,416

48,709

50,762

2013

2014

2015

2016

2,465,486 $

414,088

480,071

107,595

189,182

3,081,135 $

734,752

617,569

98,224

116,865

2,998,233 $

609,708

956,958

138,160

104,653

3,137,776

839,803

1,457,802

153,133

83,030

3,656,422 $

4,648,545 $

4,807,712 $

5,671,543

2013

2014

2015

2016

2,908,078

277,127

449,167

22,050

3,923,674

291,374

390,379

43,118

4,093,398

302,669

377,431

34,214

4,906,998

309,642

428,927

25,977

Figure 4-4

Interpretations: Total Medical visits billed have increased by 17% over the last 4

years with an average of 11,576 visits a year. Pharmacy visits has increased by 51%

over the last four years, with a 5% increase in the last year. Total visits billed have

increased 39% since 2013 then, with a 4% increase in the last year. For the last three

years, the largest area of billing growth was in Pharmacy.

Since 2013, Pharmacy visits billed has increased by 51% and their collections by

203%. This is due to the Medicaid Expansion Act. Over this same time frame,

Medicaid Collections as a whole has increased by 69%.

In 2015, Medicaid accounted for approximately 87% of collections, Medicare 5% and

Private Insurance makes up 8%.

102

Tribal Billing

Purpose: To identify visits billed collected revenue and source by year.

Relevance: To identify trends and determine action of program considerations to

improve billed revenues.

2013

Incidents/Visits Billed

Ambulance

Alcohol & Substance

Mental Health

Community Health

Other

Total Incidents/Visits Billed

2014

636

2,938

690

3,532 *

Total Collected

1,502

839

5,076

5,061

4,685

358,739

944,058 **

462,830

$ 1,765,627

793

1,148

659

2,898

5,498

2014

2015

2016

329,823

377,077

398,438

1,196,976 **

228,950

657,265

680,022

728,506 ***

1,066,358

$ 1,755,749

$ 1,714,364

$ 2,193,302

2014

2015

2016

1,548,191

77,849

110,224

15,013

4,472

1,337,288

1,884,756

29,990

37,530

1,247

2013

Source

Medicaid

Medicare

Private Insurance

Workers Comp

Other

2016

854

1,061 *

827 *

1,943

2013

Collections

Ambulance

Alcohol & Substance/

Mental Health

Community Health

Other

2015

1,519,144

112,256

115,964

11,317

6,946

Figure 4-5

Interpretation: Since 2010, when the Tribe added Billing Staff, Collections have

continued to increase even though there was a small decrease from 2014-2015. In

2016 collections increased by $478,938 (28%) from the previous year.

Alcohol & Substance/Mental Health collections are down due to provider vacancies.

103

Ambulance Financial Summary

Purpose: To identify cost and sources of revenue for ambulance operations and to

identify trends in collections.

Relevance:

Provides information needed for decisions regarding financing of

ambulance operations.

Interpretations: The collections for ambulance services increased by $47,254 or 14%

in 2015. At the same time the expenses also increased by $12,332 or 4%. The cost of

Medical Supplies and Vehicle maintenance accounted for this increase. The average

cost per transfer decreased by $77 or 16%.

104

Contract Health Services – Funding

Purpose: To compare annual CHS base funding to medical inflation and to report on all

CHS Funding.

Relevance: Identifies gap between medical inflation and funding.

CHS Annual

Funding

Base

N/R &

Deferred

Services

78,547

CHEF

Base

Increase

Total

Medical

Inflation

1998

2,716,800

193,567

2,988,914

1.8%

3.2%

1999

2,798,596

23,857

2,822,453

3.0%

3.7%

2000

2,997,244

259,696

3,256,940

7.1%

4.9%

2001

2,997,244

431,485

115,450

3,544,179

0.0%

5.2%

2002

2,997,244

436,886

71,117

3,505,247

0.0%

6.0%

2003

3,511,606

32,831

166,859

3,711,296

17.2%

5.2%

2004

3,538,505

180,023

479,118

4,197,646

0.8%

5.0%

2005

3,665,746

90,206

155,406

3,911,358

3.6%

4.6%

2006

3,807,490

97,119

239,859

4,144,468

3.9%

4.6%

2007

3,947,624

79,971

397,960

4,425,555

3.7%

5.4%

2008

4,148,016

470,258

4,618,274

5.1%

5.2%

2009

4,522,779

422,971

4,945,750

9.0%

4.6%

2010

5,409,429

243,152

867,507

6,520,088

19.6%

4.9%

2011

5,414,309

206,376

675,421

6,296,106

0.1%

4.3%

2012

5,838,361

255,088

6,095,461

7.8%

3.1%

2013

5,545,485

315,168

6,019,539

-5.0%

3.0%

2014

6,027,353

325,025

6,354,392

8.7%

3.1%

2015

6,289,399

36,896

6,328,310

4.3%

2.6%

156,873

Growth of $1 from 1998 - 2015

$2.50

$2.00

$1.50

$1.00

Growth of $1 of Inflation

Growth of $1 of CHS

$0.50

$0.00

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Note: Medical Inflation is the average of U.S. Department of Lab or, Bureau of Lab or Statistics

Medical Services (50% Professional Services and 50% Hospital Services).

Figure 4-7

105

Contract Health Services – Funding, Continued

Interpretations: Funding increases provided by the Congress in 2009, 10 and 12

addressed deficiencies in bringing the funding in line with inflation, but the sequester in

2013 stripped funding, thereby reducing the benefits realized from those

increases. Funding has just kept pace with inflation but does not account for population

growth over the past 15 years.

106

Purchased/Referred Care - Spending

Purpose:

To provide a report of major categories of spending for the

Purchased/Referred Care (PRC) program.

Relevance: Purchased care represents a significant portion of the health care resource.

Understanding the nature of costs is important to policy and priority decisions.

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

In-Patient

OutPatient

Emergency

2,575,549

1,828,048

1,729,514

2,030,516

2,214,036

1,863,629

1,956,174

2,109,445

819,201

427,996

502,873

1,684,794

1,115,067

1,487,726

1,915,341

1,976,500

2,003,106

2,091,392

1,981,981

1,115,817

773,800

1,052,714

553,401

440,908

507,249

790,176

778,472

794,683

739,859

879,032

267,291

256,999

307,818

Dental

Vision

65,901

38,592

52,544

90,704

72,569

170,874

179,203

161,423

177,025

203,861

264,877

2,483

3,424

5,611

7,154

12,486

11,100

14,592

18,402

19,744

23,363

Pharmacy

Supplies

110,504

5,915

17,373

18,620

25,384

34,497

21,908

32,833

45,493

36,403

23,533

58,866

10,093

82,811

102,421

118,159

144,001

179,056

114,451

150,146

156,306

175,828

Total

5,049,015

3,441,106

3,880,641

4,953,389

5,192,274

5,023,276

5,178,692

5,293,757

2,593,375 *

1,875,109 *

2,351,006 *

Warm Springs Contract Health Services

8,000,000

7,000,000

Amounts

6,000,000

5,000,000

4,000,000

3,000,000

2,000,000

1,000,000

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Year

Funding Available

Outlays

Figure 4-8

*There are Obligations for Services that have not been finalized. Final payment amounts will vary.

* There is an additional $31,482 Obligated, but not yet paid for 2015.

* There is an additional $193.892 Obligated, but not yet paid for 2016.

107

Purchased/Referred Care – Spending, Continued

Interpretation: Illustrates fluctuations in PRC total costs, as well as seven components

of that total cost, over twelve years.

Even with the implementation of Priority I’s in July 2005, costs appeared to peak in

2006.

The implementation of Medicare-Like Rates in July 2007 had a huge positive impact as

costs fell by roughly $600-$700K for both In-Patient and Out-Patient. The rise in OutPatient in 2008, 2009 and 2010 is the result of the $500K Tribal Council Resolution

(2008), $500K carryover “carve-out” from reserves (2009), $250K carryover “carve-out”

from reserves (2010)and relaxation of Priority I’s in April 2010. Priorities II, III and IV

have been authorized since then, with the resulting yearly peak costs of %5,308,971 in

2013. There is $193,892 obligated but not yet paid for in 2016, added to the $2,351,006

paid for in 2016, the projected $2,544,898,2016 PRC Healthcare Costs are 7% more

than 2015.

108

Purchased/Referred Care – Utilization and Unit Cost

Purpose: To identify the total cost and unit cost for Hospitalization and Emergency

Room services purchased through the Purchased/Referred Care (PRC) Program.

Relevance: PRC funds are limited and managed on a priority basis. Patterns of

utilization and costs must be monitored to support resource decisions and program

priorities.

2015

2016

Units

Total Cost

Cost per

Unit

Units

Total Cost

Cost per

Unit

Hospital Days

715

$427,996

599

1039

$466,805

449

Emergency Room Visits

540

$256,999

476

526

$306,418

583

Figure 4-9

Interpretation: This table reflects the units, total cost and cost per unit for both

Hospital Days and Emergency Room Visits that PRC paid for. Although there was a

31% increase in Hospital days from 2015 to 2016, there was an even greater 25%

decrease in Hospital Cost per Unit for this same period of time.

There was a 3% decrease in Emergency Room Visits from 2015 to 2016, but an

increase of 16% for Emergency Room Cost per Unit.

While the data in the table indicates the Cost per Unit for Hospital Days in 2016 was

$449, more detailed admissions information is found in Figure 2-16 for the two major

hospitals that serve the community.

109

Deferred Services

Purpose: To identify the number of cases and estimated costs for recommended care

that could not be purchased under current circumstances.

Relevance: It is important that the program maintain a record of these cases and track

progress.

2016

Priorities*

Cases Deferred

Estimated Cost

Priority 1

Priority 2

Priority 3

2,435

Priority 4

520,000.00

280

56,000.00

2716

576,000.00

Figure 4-10

Definitions of Priorities is below.

Interpretation: PRC was fortunate from 1995 through 2005 to cover Priorities I-IV with

its current year’s budget supplemented by carryover dollars when necessary, and thus

fortunately did not have a Deferred Services list. From the implementation of Priority I

coverage only in July 2005, PRC kept a Deferred Services list defined as those services

in Priorities II-IV that PRC had covered the preceding 10 years but no longer could

cover due to Priority I coverage only.

In April 2010, PRC was able to expand coverage beyond Priority I’s to Priority II-IV

coverage once again. PRC was able to cover Priority I-IV from 2013 to 2016 with

minimal “Deferred Services” as defined as those which PRC covered pre-2005. The

data above was based on numbers compiled by the PRC Case Manager for a report

requested by PAO in 2015, then revised for this year’s unmet needs.

For Dental, PRC covers emergent conditions such as abscesses and Priority I

situations, in addition to dentures and partials. PRC will cover dentures and partials

automatically for an elder; approval is required by the PRC Review Team for any other

age group and is determined on a case by case basis. PRC is also covered more

procedures in 2016 based on dental recommendation and PRC review. Examples: a)

teeth that are not able to be extracted by IHS dentist due to difficulty of extraction; b) a

patient elderly, or fragile in health, may be referred to an Oral Surgeon for extractions;

110

Deferred Services, Continued

c) elderly patients may be sent to dentist that specializes in mini posts to secure their

dentures; d) “spacers:” for children’s teeth cared for by the IHS Pediatric Dentist; e) an

anomaly that could possibly be a cancerous situation will be sent out to an Oral

Surgeon for complete evaluation. Working with IHS Dental, PRC emphasis has been

towards Elders and the children of the Reservation. The IHS Pediatric Dental Surgeon

performs about two dental restorations a week at St. Charles Medical Center, Bend.

Purchased/Referred Care has also brought in two Dental Specialists to assist the Dental

Program in Warm Springs. An Oral Surgeon and an Endodontist that comes in once or

twice a week to help take care of patients in need of their type of specialized treatment.

PRC has also contracted with a General Dentist to help the program on a day to day

basis when they have the need. PRC has started to pay for crowns and bridges on

patients that are in need.

The approximate cost for dental services that are deferred in 2016 was about $320,000.

There were approximately 435 dental cases deferred.

For Pharmacy, PRC covers only emergent conditions, in addition to anti-rejection drugs,

chemotherapy, anti-coagulant after heart surgery, or knee and hip replacement surgery.

PRC also pays for high cost drugs for a one month period of time to allow a patient to

get into a program sponsored by the pharmaceutical companies that will assume the

cost after the initial month. This “bridge” will ease the high cost for the patient who may

not be able to pay for that medication themselves, but are in critical need of that

medication. Some of those medications have cost as much as $9,000 for one month.

The approximate cost for pharmacy that was deferred is $200,000. There were an

estimated 2000 scripts @ 170 per month average deferred.

Both Dental and Pharmacy were determined by estimating from pre-2005 when PRC

was able to cover more Pharmacy and Dental, and both are higher than last year due to

the increase in population and need, as well as a decrease in drugs in IHS formulary.

Eye glasses are covered for students, diabetics and elders. All others have to purchase

their own at this time. PRC has figured that there is a need for approximately 280 for

all others. That may be a low estimate. At the cost to PRC of $200.00 per pair, there is

about $56,000 for unmet need of glasses.

Priority I: Emergent/Acutely Urgent Care Services: i.e. immediate threat to life or limb.

Priority II: Preventive Care Services: i.e. Screening Mammograms

Priority II: Primary & Secondary Care Services: i.e. Specialty Consultations

Priority IV: Chronic Tertiary & Extended Care Services: i.e. Hip/Knee Replacement

111

HS – Catastrophic Health Emergency Fund (CHEF)

Purpose: To identify the numbers of cases qualifying for Catastrophic Health

Emergency Fund (CHEF) reimbursement, the funding request, the received and the

shortfall for each year.

Relevance: Catastrophic cases have a huge impact on the Managed Care budget. All

must be aware of these high cost cases as they develop since they affect overall

service priorities and impact reserves of the program.

Total CHEF Total CHEF

YEAR

2006

2007

2008

2009*

2010

2011

2012

2013

2014

2015

2016

Obligation

Cases

1,388,591

521,458

1,008,323

996,036

1,900,122

1,650,223

1,444,760

1,272,006

650,624

272,088

416,816

Totals $ 11,521,047

214

CHEF

Total CHEF

Threshold Funds Due MCP

25,000

788,591

346,458

633,323

521,036

1,050,122

775,223

694,760

572,006

425,624

188,596

281,653

Current

Year

336,978

157,158

331,651

235,139

493,132

374,198

100,707

149,087

375,550

62,570

132,314

RECEIVED

Following

Year

240,802

138,617

187,833

374,375

301,223

154,381

172,839

242,717

49,032

64,135

56,110

Shortfall

Total

577,780

295,775

519,484

609,514

794,355

528,579

273,546

391,804

424,582

126,705

188,424

210,811

50,683

113,839

(88,478)

255,767

246,644

421,214

180,202

1,042

61,891

93,229

6,277,391 $ 2,748,484 $ 1,982,064 $ 4,730,548 $ 1,546,843

Figure 4-11

* 2009 $91,274 was received on a very high cost CHEF case. Several months, later, upon

appeal, OHP retroactively covered the patient for DOS including CHEF costs. This money was

paid back to IHS via future Budget Mod Amendment Adjustment.

Interpretations: The IHS Catastrophic Health Emergency Fund (CHEF) exists to

reimburse for high cost cases that exceeds a given threshold, thus limiting financial risk

to that threshold until the CHEF is exhausted for a given year. $25k has been the

threshold for the last 10 years.

The CTWS PRC operates on a calendar year fiscal year. However, the IHS operates

on an October – September fiscal year. Historically, the IHS CHEF was exhausted

about May or June, and was then replenished in October. Thus, a prime reason for a

shortfall in reimbursement is that a CHEF case occurred after the funds were exhausted

for that year. Then, when the new CHEF year starts in October, reimbursement for a

CHEF case falling the last three months of the year usually will not take place until the

following year. Using 2016 as an example, six CHEF cases resulted in $281,653 due

CTWS PRC; $132,314 was reimbursed in 2016, and $56,110 has been reimbursed as

of May 2017.

112

CHS – Catastrophic Health Emergency Fund, Continued

Timely application for CHEF is very important, and the PRC Case Manager places

highest priority on this process. Receipt of CHEF can have a significant impact in

helping to offset expenditures for high cost cases. Application for CHEF is competitive

across IHS. Due to a larger budgeted CHEF allocation by IHS, combined with

implementation of Medicare Like Rates (MLR) nationwide, the CHEF has the potential

to last longer than May/June. An additional significant major impact in 2014 was

Medicaid Expansion effective 1/1/14. Not since 2007, the year MLR took effect, has the

number of CHEF cases been measured in single digits. Of the $281,653 due to PRC

$188,424 of the six CHEF cases in 2016 has been reimbursed by IHS.

113

Medicare-Like Rate (MLR) Savings

Purpose: Illustrate the significance of the savings resulting from implementation of the

Medicare-Like Rates Legislation effective mid-2007.

Relevance: Savings resulting from implementation of Medicare-Like Rates are the

prime reason MCP has been able to relax Priority I’s and expand coverage to paying for

many Priority II-IV referrals.

2012

2013

2014

2015

2016

St. Charles - Madras

Inpatient

942,724

542,778

197,225

105,808

116,201

Outpatient

1,109,233

1,019,541

783,786

479,276

401,413

Mixed

57,508

35,705

53,710

109,537

57,059

Total

$2,109,465

$1,598,024

$1,034,721

$694,622

$574,673

Inpatient

15,482

14,916

5,136

595

Outpatient

14,651

28,930

26,788

7,800

1,900

Other CAH & Surgery Centers

Mixed

Total

$30,133

$43,846

$26,788

$12,935

$2,495

Inpatient

1,534,274

1,761,944

978,753

240,655

536,068

Outpatient

440,190

473,532

329,322

149,851

525,227

Mixed

22,312

13,108

46,205

60,760

Total

$1,996,776

$2,248,584

$1,308,075

$436,711

$1,122,055

$4,136,374

$3,890,454

$2,369,584

$1,144,268

$1,699,223

Hospitals that Bill on DRG Rates

TOTAL MLR SAVINGS

Figure 4-12

Interpretation: After exhausting $1M in reserves three years in a row (2004-2006), and

beginning in 2007 with only $500k in reserves, the huge positive effect of Medicare-Like

Rates (MLR) cannot be overemphasized.

The Federal Medicare-Like Rates legislation basically states that any Indian Health

Services Purchased/Referred Care (PRC) or Tribally contracted plan which operates

PRC locally may reimburse a Medicare contracted hospital no more that the total

reimbursement the hospital would have received from Medicare.

MLR became effective 7/5/07 which resulted in significant savings for PRC. Savings

resulting from MLR implementation 7 ½ years ago not only was responsible for halting

the erosion of PRC reserves, but allowed PRC to add non-Priority I services through

114

Medicare-Like Rate (MLR) Savings, Continued

specified “carve-out” of $500k under strict criteria in 2009. After a $250k “carve-out” to

begin 2010, the decision was made effective April 1, 2010 to cover Priority II, III & IV

under Committee Review and methodical implementation. I.H.S. physicians and Health

& Welfare Committee were consulted and they gave input on services to add back. As

seen in the table on the previous page, MLR savings have resulted in $12.9 million to

PRC and thus potential healthcare referrals over the last five years.

PRC closely monitors expenditures and is ready to make adjustments if needed. The

goal is to carefully implement authorization and payment for additional services (II, III,

and IV) without trying to implement “too much” and having to then “restrict again”. The

PRC currently pays for most all specialty Priority I-IV referrals it did prior to

implementation of Priority I coverage in 2005.

This is all made possible through PRC taking advantage of the MLR legislation which

has resulted in the significant savings realized from MLR documented above.

115

Grants Received

Purpose: To monitor the availability and funding levels of grants received to support

the health care system.

Relevance: Grants represent an important part of the health care system’s financing,

and are frequently targeted at key risk factors and national priorities. Numerous grants

finance ongoing staff and programs at Warm Springs.

Grant Names

Grant Amount

Diabetes Grant (Tribe)

State Women, Infants, and Children (WIC)

Woman's Wellness Conference

CHET Dental Project

Senior Fitness Enhancement

Tobacco Pilot Site

State Tobacco Prevention

USDA Commodity Warehouse

State Alcohol & Drug

State Alcohol Prevention

State Mental Health

State Youth Suicide Prevention

Influenza Pandemic

Vocational Rehablilitation

Meth Prevention Project

Total

Grant Expenditures

Diabetes Grant (Tribe)

State Women, Infants, and Children (WIC)

Woman's Wellness Conference Grant

CHET Dental Project Grant

Senior Fitness Enhancement Grant

Tobacco Pilot Site Grant

State Tobacco Prevention Grant

USDA Commodity Warehouse Grant

State Alcohol & Drug Grant

State Alcohol Prevention Grant

State Mental Health Grant

State Youth Suicide Prevention Grant

Influenza Pandemic

Vocational Rehabilitation Grant

Meth Prevention Project Grant

Total

2012

2013

2014

2015

193,268 $

78,355

510,846 $

79,391

519,818 $

80,842

193,268

75,497

73,821

39,918

125,000

73,821

79,636

72,902

78,636

66,616

85,175

62,500

362,466

152,500

506,432

381,733

26,000

232,742

$ 1,150,837 $ 1,168,660 $ 1,114,664 $ 1,079,488

129,719 $

84,061

83,549 $

23,200

157,600 $

44,874

78,024

25,614

54,516

71,905

172,187

79,897

144,006

25,094

3,219

266,919

13,813

24,746

17,440

54,396

78,465

23,690

85,175

341,263

$ 1,045,336 $

149,015 $

676,598 $

212,503

Figure 4-13

116

Grants Received, Continued

Interpretation: The above listing of active grants offers a historical glimpse of the

awards received and their associated expenditures. Grants can be awarded at various

times of the year and some cover periods of time which exceed a single year time

frame. It is therefore difficult to draw conclusions without understanding the details of a

specific grant. The list however presents an inventory of our grant activity which has

totaled nearly $5 million over the past 4 years. This represents a significant

enhancement of our available resources. Grants can fill important holes in our

comprehensive health program especially when federal appropriations are limited.

117

Staffing

Purpose: To provide an overall summary of personnel devoted to healthcare, and the

number of Warm Springs tribal members employed in the system.

Relevance: Staffing represents the single largest use of health resources. Tracking the

number of enrolled members reports against a key objective of the health plan.

2000 FTE

Tribal

Clinical Services

Medical

Dental

Optometry

Pharmacy

Medical Records

Medical Lab

X-Ray

Diabetes - Clinic

Community Health

Community Health Dept.

Health Education

CHET

Com. Health Resource Center

Maternal Child Health

Early Intervention Services

Community Health Rep.

WIC Program

Wellness Coordinator

Diabetes Grant (Tribal)

SDPI Grant (IHS)

Environmental Health

Community Health Nursing

Nutrition

Medical Social Work

Physical Therapy

Senior Wellness Center

Community Wellness Center

Community Counseling

Mental Health

Alcohol & Substance Abuse

Prevention

Administrative Support

Facilities

Security

Health Administration

Personnel

Procurement

Business Office

Data Systems

Transportation

Quality Assurance

Registration

Other

Managed Care

Ambulance

JV/JHC

Total

2016 FTE

IHS

Total Tribal

26.0

15.0

2.0

6.0

9.0

4.0

3.0

4.0

26.0

15.0

2.0

6.0

9.0

4.0

3.0

4.0

IHS

2.0

1.0

4.0

2.0

1.0

3.0

1.0

3.0

2.0

4.0

3.0

4.0

3.5

1.0

6.0

3.0

1.0

2.0

6.0

3.0

4.5

1.0

Total Tribal

3.0

1.0

2.0

11.0

2.0

14.0

2.0

1.0

6.0

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