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“Excellence in Rural Health Care”

Improve the quality & quantity of services provided to tribal members

Recognize Tribe’s right to determine priorities, redesign and create new programs to meet local needs

Formalize relations between the United States and Indian Tribes on government-to-government basis as provided for in the US Constitution

Promote greater social, economic, political, cultural stability and self-sufficiency among Indian tribes

Establish better fiscal accountability through expanded Tribal Governmental decision making authority

Institute administrative cost-efficiencies through reduced bureaucratic burdens and streamline decision-making authority

Change roles of the Federal Departments and agencies serving Indian Tribes by shifting their responsibilities from day-to-day management of Tribal affairs to that of Protectors and Advocate of Tribal interests

Federal Control Tribal Control

$$$

Advance Lump Sum Payments

Recurring Base Budgets

Flexibility

Ability to redesign programs

Ability to merge and assign program funds

Ability to adopt revised regulations

Changes Focus of Program Design/Delivery

Community-Driven

Needs-Driven

Priority-Driven

Changes at Tribal Level

Outcomes versus jobs

Long-term planning

Collaboration between tribal departments

Collaboration between tribe and other governmental entities

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Programs, Services, Functions and Activities;

Programs (high level), Activities (detailed level);

Describe all “contractible” operations of the IHS, both administrative and programmatic, at each organizational level;

Detailed information is needed on all PSFAs considered for assumption by the Tribe;

For new SG Tribes, it is advised that information be obtained on all PSFAs;

Research will allow the Tribe to make informed decisions about PSFAs to assume, conduct internal management planning, as well as to provide awareness of remaining responsibilities of the IHS.

PSFA Information Sources:o Agency Lead Negotiator (ALN);

o Office of Tribal Self-Governance;

o HQ, Area and Service Unit staff;

o Self-Governance Education/Communication;

o Other Self-Governance Tribes.

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Steps:o Request/Obtain financial and

PSFA information from the ALN, including all PSFA manuals applicable to your Tribe;

o Review in conjunction with the financial information provided;

o Request meetings with HQ, Area or SU staff as needed to answer questions and provide in-depth information about IHS operations;

o Utilize SG Tribal networks.

PSFA's

User population reports (by facility and Tribe)

IHS Budget & Tribal Share – Service Unit, Area and Headquarters

Facilities Account Budget & Administrative Costs, and Tribal Shares

Tribal Allocation (Methodology) of dollars under Funding Agreement, at each level

Evaluation of current level of services (type, quantity, quality)

Patient workload, by service

CHS workload, by Tribe

Budget and expenditure reports (Service Unit, Area)

Billing report, billed vs. collected

Contracts listing (including PRC contracts)

Operational Cash Flow showing where third party is budgeted

Third party revenue trends, sources, billed vs. collected

Organizational charts, staffing lists, position descriptions

Recommendations on how Tribe could improve or redesign delivery systems

Community and Tribal Leader direction – this should guide overall PSFA analysis and priority-setting. This will ensure that the resulting course of action will contain strategies to make health services more responsive to the articulated needs and desires of the Tribal community and its Leaders.

The methods of garnering community input should be relevant to the Tribe.

“The Congress hereby recognizes the obligation of the United States to respond to the strong expression of the Indian people for self-determination by assuring maximum Indian participation in the direction of educational as well as other Federal services to Indian communities as to render such services more responsive to the needs and desires of those communities.”

(25 U.S.C. § 450a(a))

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Management Meetings

o Tribal Management – ensure all departments understand the

potential impact on the tribe and their departments

o Tribal Council/Committees – ensure the governing body of the Tribe

understands the potential impact on the tribe and their constituents

o IHS Area Office and IHS Headquarters – Intent of Tribe

o Other Tribes served

o Service Unit or facility impacted

Employee Meetings

o Explain Self-Governance Overview & Authority

o Update on Intent to Compact

o Explain Plans for Future including services redesign, etc.

o Explain Employment Benefits and Options (IPA/MOA)

Printed Communications

o Tribal Letter of Intent to IHS

o Tribal Letter to other Tribes served

o Information Packets for Elected Officials (Tribal, Local, & State)

o Press Release(s)

o Webpage

o Information Handout (FAQ) for Employees

Oral Communications

o Tribal Communities

• Explanation of Self-Governance and its authorities

• Ascertain their desires and needs

o Other Tribes

• Meet with other Tribes for Resolutions and/or support and collaboration

Determining feasibility of assuming specific PSFAs, or portions thereof:

o Population to be served;

o Financial considerations;

o Opportunities and challenges;

o Internal management preparedness;

o Improvement of healthcare outcomes;

o “Phase-in” strategies.

Consideration of opportunities and challenges:

o Review and consider strategies to capitalize on opportunities that may be available to the Tribe to leverage its health care services, such as third party billing; partnerships with IHS and other organizations and providers; Inter-Tribal partnerships; Affordable Care Act opportunities; and innovative health care delivery system models.

o Identify barriers and challenges and develop strategies to address such barriers.

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Orderly transition to Tribal administration of health

care programs: o Identify management systems and infrastructure needed;

• Appropriations and budget;

• Tribal legal infrastructure;

• HR, Finance and other management systems;

• Health service delivery infrastructure;

o Identify transition strategies;

• Exp: Purchased and referred care; personnel, vendor contracts, etc.

o Identify health care program implementation strategies.

• Partnerships, health priorities, health service delivery models, facilities,

providers and staffing.

Governance/Organizational Structure

Health Department or System

Internal Management Support

o Finance

o Human Resources

o IT

o Procurement/Contracts

o Facilities

Governance and Decision-Making Structure

o Health Governance Models

o Organizational Structure

o Decision Making hierarchy

• Budget

• Programmatic design/partnerships

• Policy

Considerations

o Responsiveness to Community

o Flexibility

o Unique healthcare operations

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Extent of current Health programs operatedo Community based, outpatient, inpatient, etc.

Health Professional Leadership

o Medical Direction

o Health Administration

Health Systems of Support

o Accreditation

o Recruitment/retention

o Billing/collection

o Credentialing

o Quality Improvement/Compliance

Health Policy o What policies already exist, and what policies are needed

o Integration with existing Tribal systems/programs

Provider Network Development - PRC

Finance/Contractingo Budget/Appropriations process;

o Reallocation of budgets;

o Billing/collections;

o Expenditure authorities and approvals;

o Integration of Tribal policy;

• Preferences for hiring and contracting

• Competition

• Contract provisions

o Responsiveness/flexibility;

o Indirect Cost Pool Planning;

o Financial Reporting.

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Human Resourceso Transition of Federal staff

o Recruitment & retention of health professionals

o Policy changes/development

• 24 hour operations

• Management of health professionals

• Health Professional salary scale

• Continuing Education

• Licensure

• Etc.

o Organizational development

Use of Internal Teamso Organized by subject matter/expertise

• Planning

• Negotiation

• Implementation

Phase-in strategies: o Very useful for Tribes new to SG;

o “Roll over” Title I Contracts into FA and add Tribal Shares and related

PSFAs;

o Incrementally add ‘feasible’ PSFAs over time ;

o Allows infrastructure growth along side Tribal assumption of health

programs.

Office of Information Technology:o Frequent decisions by Tribes to assume portions of PSFAs, based upon

cost and Tribal IT system and infrastructure.

o For ease of decision making, IHS is preparing OIT “packages” of

related IT services.

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Purchased and Referred Care:o Example: Tribal share of PRC identified at less than $100k for user

population identified at 1,200 patients. One catastrophic PRC case could cause a cash flow crisis. Tribe elected not to assume PRC at that time.

o Example: Tribe elected to assume PRC without also assuming the associated Primary Care. Problems with continuity of care and cost control.

o Example: Tribe elects to shift traditionally-purchased services to direct services, rather than PRC, for cost savings and timely services.

Sanitation Facilities Construction:o Example: Tribe elects to remain with IHS SU due to its small size for

purposes of competing for SFC projects. Tribal members get served on a more frequent basis.

o Example: Tribe elects to compact SFC, but partners with Tribal communities, municipal and rural water systems to extend funding further and serve more Tribal members.

Primary Health Care:o Example: Tribe elects to join other Tribes in a consortium for

economies of scale.

o Example: Tribe elects to partner with other Tribes either granting a

resolution or obtaining a resolution for pooling resources and health

care administration.

o Example: In an area where a number of private facilities exist, Tribe

elects to change the mix of purchased vs. directly operated health

programs to extend services.

o Example: Tribe elects to purchase insurance for patients on the

Marketplace to provide a revenue source.

Variations in PSFA assumption and implementation can be as

varied and unique as the Tribes themselves.

“Excellence in Rural Health Care”