ATR SUSTAINABILITY: A TRIBAL PERSPECTIVE

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Technical Instructions You may ask a question at any time during the Webinar by typing it into the Questions field below the slide presentation and then pressing Enter. Most questions will be addressed at the end of the presentation. Today s slides, as well as additional resource materials, are available in the Downloads area to the left of the slide presentation.

Today s Speakers Michael Bird Chairman, Kewa Pueblo Health Corporation; Past President, American Public Health Association Judith Alger Project Director, Alaska Southcentral Foundation, Access to Recovery

SUSTAINABILITY: A TRIBAL PERSPECTIVE Michael Bird ATR

THE CURRENT LANDSCAPE AND IMPACT ON THE PROVISION OF BEHAVIORIAL HEALTH SERVICES

THE PATIENT PROTECTION AND AFFORDABLE CARE ACT: IMPACT ON TRIBES The Patient Protection and Affordable Care Act (ACA) became law on March 23, 2010. ACA provides an opportunity for millions of uninsured Americans to have health insurance, including American Indians/Alaska Natives (AI/ANs). ACA permanently reauthorizes the Indian Health Care Improvement Act and strengthens Indian health. Indian Health Service (IHS), Tribal, and urban Indian clinics will be able to bill for services and increase revenue to the Tribe, clinic, and community when AI/ANs enroll in health insurance. AI/AN can receive special benefits under ACA.

MARKETPLACES Each State has established a Health Insurance Marketplace State-Based Marketplace Federally Facilitated Marketplace Federal-State Partnership Hybrid (e.g., State operates SHOP only) The Marketplace allows individuals (and families) to shop for health insurance plans and compare prices and benefits. The Marketplace provides one-stop shopping. A single application determines eligibility for Medicaid, Children s Health Insurance Program (CHIP), and Marketplace Health Insurance plans.

ACA AND AI/AN Two definitions of Indian under ACA: Enrolled members of federally recognized Tribes or Alaska Native Claims Settlement Act (ANCSA) corporations Individuals eligible for services from an Indian health care provider (IHS, Tribal, or urban Indian clinic) Enrolled members of federally recognized Tribes or ANCSA corporations Eligible for zero and limited cost-sharing plan variations Eligible for a special monthly enrollment period (after March 31, 2014) Eligible to apply for exemption from the tax penalty for not having health insurance by March 31, 2014 Individuals eligible for services from an Indian health care provider Eligible to apply for exemption from tax penalty for not having health insurance by March 31, 2014.

APPLICATION PROCESS Apply: Online By mail By phone In person Enrollment assister IHS, tribal or urban Indian clinic All Marketplaces have enrollment assisters: Referred to as navigators, certified application counselors, or another name. www.localhelp.healthcare.gov The applicant may also designate an authorized representative to act on behalf of the applicant.

MARKETPLACE ENROLLMENT BY AI/AN Enrolled members of federally recognized Tribes or ANCSA corporations Can enroll in health insurance after March 31, 2014 Must submit documentation reflecting membership status Individuals eligible for Indian health care provider services Open enrollment closes for these individuals on March 31, 2014. The next enrollment period is October 1, 2014. Tribal advocates have been advocating for the ACA definition of Indian to be like the Medicaid definition of Indian. Medicaid s definition includes both categories. A fix would mean that individuals eligible for Indian health care provider services would have the same benefits as enrolled members cost-sharing protections and monthly enrollment.

MEDICAID EXPANSION In States expanding Medicaid, many AI/AN will be eligible to enroll in Medicaid. Minnesota only Covers individuals up to 138% Federal Poverty Line (FPL), including single adults In States not expanding Medicaid, there will be a coverage gap for low-income AI/AN. Includes Alaska, Kansas, Nebraska, and South Dakota No coverage for individuals who do not qualify for traditional Medicaid Tax credits are only available to purchase insurance if between 100% to 400% FPL, not below 100% FPL. (Medicaid was supposed to cover this group.) Many adults will have no affordable coverage option.

MARKETPLACE PLAN BENEFITS The Marketplace application process determines an individual s or family s eligibility for tax credits (subsidies) based on income. Income determination = modified adjusted gross income Subsidies are paid directly to the insurance company and reduce the monthly premium paid by the individual or family. Eligibility for tax credits: State expanding Medicaid: 138% to 400% FPL Minnesota: 200% to 400% FPL because the Basic Health Plan covers 138% to 200% State NOT expanding Medicaid: 100% to 400% FPL Cost-sharing reductions if < 250% FPL

AI/AN BENEFITS Enrolled members of federally recognized Tribes and ANCSA corporations qualify for specific plans: Zero cost-sharing plan variation < 300% FPL Limited cost-sharing plan variation > 300% FPL These plans provide AI/AN with access to essential health benefits. This includes mental health and substance use disorder services, including behavioral health treatment. No copays or deductibles for third-party provider care with a referral from IHS, Tribal, urban Indian health clinic, or contract health services (if required). Find out requirements as to when referral required.

10 ESSENTIAL HEALTH BENEFITS Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventative and wellness services and chronic disease management Pediatric services, including oral and vision care

INCREASED RESOURCES FOR INDIAN HEALTH AI/AN enrollment in Medicaid, CHIP, or Marketplace plans means increased revenue for IHS, Tribal, or urban Indian clinics. IHS, Tribal, or urban Indian health clinics will be able to bill insurance for health services provided. Reduced burden on contract health services frees up resources to serve more community members and increase services and programs. IHS, Tribal, urban Indian health clinics may become network providers in insurance networks. In Federally facilitated Marketplaces (FFM) states, issuers will have to offer contracts to IHS, Tribal, and urban Indian health clinics. ATR staff may be able to contact issuers and become network providers.

TRIBAL SPONSORSHIP Some Tribes are considering paying premiums for Marketplace health plans for: Some or all Tribal members. Some or all of the clinic user population. Enrolled members will be eligible for: Tax credits so monthly premium may be low. Zero or limited cost-sharing plan variations. Monthly enrollment periods. Tribal sponsorship will ensure increased revenue to the IHS or Tribal clinic.

PARTNERING WITH STAKEHOLDERS

SUSTAINABILITY DEFINED Sustainability is defined as the ability to be sustained, supported, upheld or confirmed. American Heritage Dictionary

PROGRAM SUSTAINABILITY Program sustainability requires leadership to address: Capacity building. Diversification of revenue sources. Collaborative strategies and partnerships. Community capacity building. Organizational capacity building. Program sustainability requires a program to be viable and well managed.

CAPACITY BUILDING Focused on program and organizational development Addresses Mission Strategy Infrastructure Capacity Leadership Capacity building is essential to program sustainability.

STRATEGIES FOR CAPACITY BUILDING Establish partnerships with community members and organizations: Community members and organizations Organizations at all levels community, State, Federal, nonprofit, for-profit, and foundations Engage in marketing and promotion: Market activities that promote your program or organization. Use all media.

FUNDRAISING AND RESOURCE DEVELOPMENT Principles of Fundraising Don t depend on government funding. Don t put all of your eggs in one basket diversify! Demonstrate community support. Focus on individuals. Seek out all sources. Highlight organizational outcomes and efficiency. Highlight organizational commitment to sustainability.

SUSTAINABILITY PLAN Sustainability Plan = How You Tell Your Story Elements: Identify and define the problem/challenge/issue. Determine the root cause of the problem. Describe what is needed. Develop a response to the need. Define the desired outcome. Develop a shared vision. Define support to achieve vision. Develop a case to support.

HOW GRANTEES HAVE USED FUNDING Honor Traditional Healers and healing ways by using them as recovery support service providers and in recovery support activities. Acknowledge the need to honor the impact of history and historical trauma, grief, and loss on the behavioral health of Tribal members and communities in general. Define what works, in cultural contexts, for themselves and for their communities in general. Reduce and remove the negative images of behavioral health challenges cast on individuals and communities. Raise awareness and promote hope for recovery of the individual while raising hope for the health of the community and the Nation. Respect, honor, and support the voices of lived experience (peers) as important tools for healing. Develop and implement evidence-informed and suggested practices and services that are culturally centered (e.g., recovery coaching). Create new partnerships with other health care providers to ensure total wellness for Tribal members, their families, and the Tribe as a whole.

OPPORTUNITIES FOR COLLABORATION AND PARTNERSHIPS POST GRANT Services to AI/AN communities are opportunities for collaboration and partnerships to sustain ATR-funded services post grant: Bureau of Indian Affairs/Department of the Interior IHS Department of Veterans Affairs Department of Justice Office for Victims of Crime and the Office of Juvenile Justice and Delinquency Tribal health programs, urban Indian health programs, and State and local service agencies and schools, including nonprofit and/or religious and traditional healing/ceremonial resources. It is vital to develop strong collaborative partnerships based on mutual understanding to ensure that the needs of individuals and communities are being met in cultural contexts.

LOW- TO NO-COST ACTIVITIES THAT ARE EASY TO SUSTAIN Activity Partners/Collaborators/ Opportunities Funding for Activity Aim/Goal of Activity Powwow/ Gatherings Tribal Nations (Intertribal), public health services, prevention, and screenings Vendors, the gate, competition fees (if appropriate) Community building, prevention, screening, early intervention, information sharing, honor elders, teach youth Talking Circles Tribal Nations, behavioral health service providers No cost in the context of the community/group rate in a service provider Community building, trauma healing, peer support for behavioral health challenges Use of Elders and Youth in Community Activities Tribal Nations, public health providers Transportation, lodging, food, if necessary (donation) Re-rooting in traditional ways, bringing youth together with Elders Sweat Lodge Tribal Nations, Veterans, Department of Corrections, behavioral health services No cost Trauma healing, peer support, healing for other behavioral health challenges, detoxification

GRANT RESOURCES U.S. Department of Health and Human Services, Access to HHS Grants by Indian Tribes, Tribal Organizations, Native and Other Entities: Eligibility, and Selected Grant Characteristics, March 2014.

Southcentral Foundation Nuka System of Care Southcentral Foundation Nuka System of Care Alaska Native People Shaping Health Care Access to Recovery Presenter: Judith Alger, Program Manager Copyright 2011 Southcentral Foundation. All Rights Reserved. NOTICE: Unless otherwise indicated, this work represents copyrighted material protected by United States and international law. This work may not be used, reproduced, downloaded, disseminated, published, transferred or transmitted, in whole or in part, in any form or by any means, electronic or mechanical, including photocopying, recording or information storage and retrieval, except with the express written permission of the publisher. This work may not be edited, altered, or otherwise modified, in whole or in part, except with the express written permission of the publisher.

Vision & Mission Vision A Native community that enjoys physical, mental, emotional and spiritual wellness Mission Working together with the Native community to achieve wellness through health and related services Copyright 2011 Southcentral Foundation. All Rights Reserved.

Core Concepts Core Concepts Work together in relationship to learn and grow. Encourage understanding. Listen with an open mind. Laugh and enjoy humor throughout the day. Notice the dignity and value of ourselves and others. Engage others with compassion. Share our stories and our hearts. Strive to honor and respect ourselves and others. Copyright 2011 Southcentral Foundation. All Rights Reserved.

Alaska Native Concepts of Wellness Tlingit Dancer, Yakutat, Alaska Serve Alaska Native and American Indian customer owners and their families. Culture is intimately connected to recovery. Integrating cultural and spiritual activities bridges gaps between Alaska Native concepts of wellness and Western-based behavioral health practices. Copyright 2011 Southcentral Foundation. All Rights Reserved.

Access to Recovery 3 Provides funding to experience unique and alternative recovery options different from the traditional clinical treatment model, such as cultural and faith-based services Helps customers build healthy relationships in the community based on their interests and choices to promote long-term recovery and lifelong wellness Copyright 2011 Southcentral Foundation. All Rights Reserved.

Expected Outcomes Customer owner choice (access); target goal to serve 7108 Meet GPRA follow-up requirement consistently at 80%. Provide long-term recovery support and options beyond ATR relationships built, skills learned engage primary care, emergency room, mental health, and traditional healing. Copyright 2011 Southcentral Foundation. All Rights Reserved.

Expected Outcomes (continued) Engage customers in a recovery-oriented system of care (ROSC), utilizing care coordinators to meet needs Teach customer owners and clinical providers about the value of recovery support services (RSS). Build a diverse network of community partnership agencies. Build an auditing team that will build relationships within the provider network, and train and monitor them while holding them accountable for fraud, waste, and abuse.

Accomplishments Customer owner choice served 5700; customer owners in ATR and beyond ATR said they do not want silos. They said where and when they want access for substance use support and mental health. As a result, we used the infrastructure of ATR as one springboard to redesign our system with a new service delivery integration model. (See the Sustainability slides.) We successfully built partnerships in the community in both clinical and recovery support areas and strengthened our connection to the VA and faith-based community. We have 13 clinical providers, 29 RSS, and 7 access centers. The SCF Fraud, Waste and Abuse Audit Team has built relationships with community partners. We taught them how to document and how to ensure compliance. If an audit had findings, partners corrected any issues immediately.

Accomplishments (continued) Maintained a GPRA Rate of 83% on average Continue to partner with agencies in the community for referral and coordinating care; work in relationship and non-compete. Ensure data is defined, collected, and measured/analyzed through a central data repository called SCF Data Mall. Introduced new terms and concepts to the community recovery support services, care coordination through recoveryoriented systems of care, customer owner concept taking down walls between mental health, substance use disorder treatment, primary care, and emergency room.

Lessons Learned We had to learn how to: Sell recovery support services to clinical providers and the court system, while allowing customer choice. Enroll providers in the community and trust them to comply with our grant requirement. Pay providers and set rates for vouchers in Alaska, which is very difficult among urban and rural locations. Train, enroll, and manage access centers and motivate them to collect GPRA data.

Lessons Learned (continued) Manage burn rate of vouchers. Sell integrating services in emergency room and primary care: Being involved with us would create more work for them, but in the long run our customer owners wellness would improve. Involved many conversations and moving staff around Selling the use of behavioral health services as part of overall health care Training and aligning language and terms we use/expectations Top executive buy-in and support

Sustainability What elements of ATR do you think are the most important to sustain? Focus on sustaining healthy relationships between customers and their community in support of customers long-term recovery and life-long wellness by ensuring same-day access and reducing discrimination (stigma) by providing services in primary care setting as well as traditional mental health and substance use disorder treatment programs. Reducing stigma (discrimination). Bring psychiatrists, psychiatric nurse practitioners, master s level clinicians, care coordinators, and administrative assistants to the primary care teams with the goal to serve customer owners where they are Keep them in primary care and serve them versus going into traditional substance use and mental health programs.

Sustainability (continued) What elements of ATR do you think are the most important to sustain? Providing care coordination to assist customers in their journey to wellness in all aspects that touch their lives Providing relationship-based learning circles to maximize the sense of community and caring: faith-based, educational, support, and clinical learning circles. Ensuring that crisis management and emergency services are available when they need it and then coordinating their care into our new redesign system. Expanding our medication-assisted treatment services to a population

PREVIOUS APPROACH We can t serve the population alone. It s all about RELATIONSHIPS.

Nuka System of Care Nuka System of Care System Integration To Achieve SCF s Vision Vision: A Native Community that enjoys physical, mental, emotional, and spiritual wellness. Community Partnerships Collaboration with API, ANMC, VA, etc.

Thank You! Qaĝaasakung Aleut Quyanaq Inupiaq Awa'ahdah Eyak Mahsi' Gwich in Athabascan Quyana Yup ik Igamsiqanaghhalek Siberian Yupik Way Dankoo Tsimshian Háw'aa Haida Gunalchéesh Tlingit Tsin'aen Ahtna Athabascan Quyanaa Alutiiq Chin an Dena ina Athabascan Copyright 2011 Southcentral Foundation. All Rights Reserved.

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CONCLUSION

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