# The Confederated Tribes of the (2016) > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3Add2b825c2323fb03 ## Record - **Collection:** Tribal code - **Document type:** Tribal code ## Text The Confederated Tribes of the Warm Springs Reservation of Oregon and The Indian Health Service Annual Health System Report for the Warm Springs Indian Reservation 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 2 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. 3 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. 4 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 5 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. 6 This page left intentionally blank 7 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 8 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. 9 10 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. 11 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. 12 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. 13 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 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Figure 2-1 14 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. 15 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 85 77 80 59 (21) Portland/Salem 110 84 85 103 18 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 32 1,350 1,352 1,756 1,078 (678) 93 88 88 87 (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. 16 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 17 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. 18 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 98 166 180 194 209 80+ 40 63 57 54 56 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 0-4 5-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+ Figure 2-4 19 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. 20 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 29 29 27 23 Medicare A Only Medicare B Only - - - - Medicare Part A & B Only 126 142 139 128 Medicare Part D 217 230 249 263 Medicaid & Medicare 28 35 33 39 Medicaid & Private Ins. 663 1,119 1,067 889 Medicare & Private Ins. 159 150 136 148 Medicaid, Medicare, & PI 7 7 7 8 4,179 5,085 4,998 4,940 Total Non-Billable Tribal Employee Self-Insurance 52 67 254 191 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. 21 Tribal Member Births by Age of Mother Purpose: To identify the changing trend in the age of mothers at the time of childbirth. Relevance: Tracking total births is important for planning services and education efforts. Age of mother also identifies high risk patients that may require additional or special services. Warm Springs Births by Age of Mother Calendar Age Year* 14 & under Age 15-19 Age 20-24 Age 25-29 Age 30-34 Age 35-44 Total Births 20 27 23 19 20 39 28 27 41 33 40 29 20 31 17 16 14 18 17 21 18 22 31 24 33 30 32 37 7 9 12 14 9 10 13 11 16 14 17 14 22 10 7 5 7 2 6 7 7 5 6 8 4 6 4 10 73 77 70 75 68 108 81 86 111 86 104 87 89 97 1996 1997 1998 1999 2000 2008 2009 2010 2011 2012 2013 2014 2015 2016 0 0 0 0 0 0 0 0 1 22 20 14 22 16 30 16 21 17 7 10 8 11 8 Total 1 222 397 330 178 84 1212 % of Total 0.1% 18.3% 32.8% 27.2% 14.7% 6.9% 99.9% Figure 2-6 Figure 2-7 22 Tribal Member Births by Age of Mother, Continued Percent of Births to Moms Age 15-19 35% 30% 30% 29.30% 29.40% 27.80% 26% 25% 24.40% 20% 20% 19.80% 15.50% 15% 12.40% 10% 9.60% 9.20% 8.20% 8.10% 5% 0% 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. 23 Birth Rate Comparison Purpose: To compare the Warm Springs birth rate to that of the State of Oregon Relevance: This information tracks the trend of birth rates. Crude Birth Rate Warm Springs and State of Oregon Live Births per 1,000 population Rate 35 30 25 20 15 10 5 31 14 18 14 20 20 13 12 18 12 17 12 16 11 0 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. 24 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 65 61.5 60 59.7 56.6 56.7 56.7 55 53.2 54.1 52.6 53 53.3 52 51.4 52.9 52.7 50.2 50 49.1 48.2 47.1 46.2 45 44 43.4 41.3 40 45.3 44.2 43.2 40.6 40.3 35 30 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 83 502 1,889 84 482 1,877 111 608 1,794 103 524 2,141 121 605 1,906 155 774 2,898 117 587 1,594 86 670 903 25 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. 26 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 1 8 47.7 2 11.9 1998-2000 3 4 22.7 3 17 2001-2003 3 3 15.9 3 15.9 2004-2006 4 2 10.1 3 15.1 2007-2009 8 36.8 4 17.4 1 4.4 2010-2012 5 16.6 2 8.6 3 12.9 2013-2015 2 6.5 1 5.1 1 5.2 2016 0 0 1 15.6 1 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 27 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. 28 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) 1 2 3 4 5 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. 29 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. 30 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 76 78 88 73 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. 31 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 50 0 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 32 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. 33 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 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 1 41 3 25 67 24 47 40 10 9 11 20 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 1 141 6 87 243 117 178 169 24 13 64 76 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 34 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%). 35 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** 51 33 154 2 2 201 80 711 24 23 $235,518 $10,797 $148,954 $71,536 $0 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. 36 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 GI GU 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 11 53 76 42 13 19 45 69 120 15 129 77 48 7 32 41 17 169 104 30 0 14 49 78 31 12 30 19 59 85 7 106 80 35 4 28 12 9 187 70 20 0 10 80 83 31 22 23 18 76 79 11 134 73 29 2 46 14 22 201 78 19 1 10 45 47 19 4 25 10 30 43 8 82 56 14 1 29 21 15 99 89 10 1 8 43 35 20 2 8 4 15 30 5 68 28 28 0 22 11 12 72 33 4 1 1 20 1 106 19 4 0 0 42 2 18 7 22 1 131 22 10 1 0 18 0 13 0 13 1 159 11 10 1 0 6 0 9 1 3 0 90 4 0 1 0 1 0 23 0 8 35 22 24 4 11 12 15 33 6 57 43 12 0 27 17 13 72 45 8 0 1 0 1 47 0 4 0 0 0 0 23 0 1,297 1,109 1,239 773 540 526 0 52 2 0 0 0 0 22 0 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 37 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 68 490 226 60 136 84 113 500 267 74 154 130 114 298 175 31 82 90 97 188 152 32 51 46 71 254 117 14 41 37 63 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. 38 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. 39 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. 40 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. 41 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. 42 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. 43 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. 44 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 78 250 76 250 74 224 75 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 22 4.0 2.5 2,514 2,119 21 4.0 2.5 2,150 2,373 21 3.5 3.0 2,183 1,612 16 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 28 56 149 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 45 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. 46 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 11 143 12 155 13 28 6 90 2 615 223 105 376 4 19 808 297 108 464 15 87 886 359 133 508 9 2 220 503 433 469 1,685 1,824 1,987 154 224 2 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. 47 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 9% 842 13% Workload Factors Clinic Days Average Visits Per Clinic Day 249(snow day) 22 250 20 250 24 247 23 Total FTE's Average Annual Visits Per FTE 12 448 12 425 11 547 12 473 Categories of Care Preventive Restorative including Crowns Dentures including Bridges Surgical Orthodontic Endodontic Diagnostic 7,295 2,888 169 1,106 27 251 6,700 8,030 2,556 85 826 7 270 7,111 10,692 2,451 44 1,063 12 244 8,191 8,771 2,364 66 1,108 0 188 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. 48 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 -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 $ $ 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. 49 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 1,711 251 6.82 1,606 1.07 15,757 0.11 1 1,713 250 5.51 1,249 1.10 13,041 0.11 1 1,378 199 7.08 1,253 1.10 13,665 0.10 1 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. 50 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 N/A 6,065 N/A N/A Total Lab Tests Ordered 85,389 71,827 N/A 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 76 1,993 11,885 3,392 16,240 152 3,986 23,770 3,238 13,999 N/A 3,751 20,988 77 470 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. 51 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 9 2.0 220 13 2.0 220 19 2.0 220 19 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 39 60 338 363 1,034 266 66 732 814 1,141 308 143 936 252 107 86 639 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. 52 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. 53 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 7 7 7 7 7 8 8 7 7 8 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. 54 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 42 1,380 145 213 219 898 58 1,137 12 48 60 202 201 261 1,537 Total Services Provided 2,897 892 1,039 1,931 250 7.7 2.0 966 2015 2016 206 203 313 726 8 1 50 878 43 63 9 149 191 116 716 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 42 983 23 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. 55 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. 56 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 82 33 39 52 150 399 72 43 181 87 70 37 36 80 91 327 57 43 162 89 79 43 39 218 64 300 39 43 141 97 68 46 47 8 135 384 108 52 162 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. 57 Maternal and Child Health (MCH), Continued MCH Case Management Data 120 104 97 100 89 87 80 60 43 40 33 46 37 20 0 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. 58 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 52 45 21 634 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. 59 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 91 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 16 13 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. 60 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. 61 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. 62 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 58 80.5 1815 4 4 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 30 100 65 525 450 150 100 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 63 Community Health Education Program, Continued Nutrition 2% EDUCATION TOPICS Bullying 5% Alcohol Awareness 3% Water Safety/ Skin Cancer 2% Tobacco Prevention 2% Self Discovery 28% Cultural as Prevention 51% Leadership Skills 7% 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. 64 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 5 1,274 204 270 204 270 219 94 313 193 193 386 3,216 3,703 NA 48 70 0 3 30 0 61 24 500 60 500 49 80 50 60 100 1,635 300 48 NA 46 3 83 98 22 NA 100 NA 600 NA 178 48 75 NA 1,601 2,016 53 0 100 300 600 200 65 - 1,318 982 33 * n/a n/a 100 n/a n/a n/a n/a 600 n/a 500 n/a n/a n/a n/a n/a 32 85 3 250 30 50 75 40 40 60 75 200 15 217 7 3,394 * (with 15 graduates) Figure 3-17 65 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. 66 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 9 28 334 2013 1,793 251 8 25 425 2014 1,567 252 6 5 375 Service Hours 2015 1,495 244 6 20 81 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 40 100 NA NA NA 87 100 36 50 NA 23 100 23 - 15 n/a n/a n/a n/a 400 200 40 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. 67 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. 68 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 30 43 128 Prevention Youth Dance 72 236 116 Teen Craft Night 32 45 n/a Rez Head Youth Conference 34 - n/a Baseball Camp 31 36 28 68 38 18 n/a Healing Wounded Spirits Camp 46 NA - n/a Winter Youth Conference n/a NA - n/a Movie Nights 416 384 480 421 Wii Bowling 112 NA - n/a Hoop Camp 73 36 89 49 Madras Bowling 88 79 96 75 Wellness walk 84 204 224 147 All Night Sobriety Party n/a n/a - n/a Kids Bingo 26 196 159 52 Red Road to Recovery/Boys Circle 0 93 61 44 Tribal Youth Leadership 24 22 46 38 Suicide Prevention Camp Respect Club 22 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. 69 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 81 30 27 53 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 99 66 159 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. 70 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 67 105 95 69 Number of clients currently checking on 10 12 19 13 Number of Clients inquiring about Retirement Benefits 20 32 40 24 Number of Clients that have been denied 23 28 35 17 Number of Clients that just filed their 1st Appeal 15 15 30 19 Number of Clients that are in the middle of Appeal 17 24 27 2 Number of Clients in Court Hearings 20 16 16 0 Number of Families Served 278 75 87 92 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. 71 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. 72 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 88 77 30 35 4 19 Other Accident - - - - - - Assault and Battery 66 48 21 11 21 20 Suicides/Attempts 22 17 13 15 8 8 Corrections 379 385 40 49 75 128 Pediatric 222 280 67 91 5 1 Cardiac 149 98 69 71 11 5 Respiratory 148 137 82 73 2 14 Other Illness 134 145 60 74 9 16 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 0 0 0 0 0 0 Non Tribal 126 156 48 58 2 10 1,751 1,870 671 760 229 354 Total Figure 3-22 73 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%). 74 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 75 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 76 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 82 282 376 419 263 446 121 128 156 115 185 38 111 330 28 430 40 11,862 13,035 764 670 346 325 288 169 152 86 44 31 16,321 Figure 3-25 77 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). 78 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 5 88 6 26 26 13 26 13 13 16 13 30 104 30 13 52 26 52 52 26 30 5 109 5 24 28 16 23 10 9 17 15 31 124 27 16 48 24 52 55 28 32 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 0 Announcements 20 Series4 40 Series3 60 Series2 80 100 120 Articles Figure 3-28 79 140 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. 80 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 59 26 34 19 3 FY2014 145 61 13 44 11 FY2015 FY2016 174 85 36 34 12 161 75 25 50 7 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. 81 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. 82 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 21 7 14 21 5 16 17 4 9 19 4 15 February 21 6 15 20 5 15 19 4 14 21 4 17 March 22 6 16 21 5 16 18 4 14 22 4 18 April 22 7 15 21 5 16 18 4 14 21 5 16 May 24 6 18 20 5 15 18 4 14 19 4 15 June 25 6 19 20 5 15 18 4 14 20 4 16 July 24 7 17 20 5 15 18 4 14 22 4 18 August 24 7 17 19 5 14 21 4 17 20 4 16 September 22 7 15 19 6 13 21 4 17 17 4 13 October 22 7 15 17 5 12 22 4 18 18 4 14 November 20 6 14 17 4 13 22 4 18 20 5 15 December 20 5 15 18 4 14 22 4 18 18 5 13 Avg Number of Residents 22 19 20 20 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. 83 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 97 207 Average Length of Time in Emergency Shelter prior to being placed (days) 90 120 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. 84 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. 85 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 60 80 70 127 39 136 6 102 56 1 60 7 112 72 0 44 2 199 69 0 60 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. 86 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). 87 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 15 129 132 241 24 251 234 Total Days of Service Average Visits Per Day Total FTE's Average Visits per FTE per year 250 0.53 1 132 250 0.94 2 117 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 88 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 10 2 Sidwalter Seekseequa Simnasho Administration Building Campus Community Center Senior Center ECE Corrections WSK8 (Dental) Agency (specific location unknown) Fire Management (Physicals) 4 4 8 4 3 1 40 4 2 2016 4 1 4 0 11 8 11 3 0 29 0 3 Figure 3-36 2016 Visits: Department Community Health 1% I.HS. Medical 37% IH.S Dental 62% I.HS. Medical IH.S Dental Figure 3-37 Community Health 89 Medical Mobile Unit (MMU), Continued 2016 Visits No Shows Walkins I.HS. Medical 367 IH.S Dental 606 Community Health 10 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. 90 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 [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Aconfederated_warm_springs%3Add2b825c2323fb03. Public record. Not legal advice.