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FINAL REPORT
2013
American Indian Health Commission
for Washington State 8/1/2013
Healthy Communities: Maternal Infant Early Childhood Home Visiting
American Indian Health Commission for Washington State
Final Report – Tribal and Urban Indian MIECHV - P a g e 1
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American Indian Health Commission for Washington State
Final Report – Tribal and Urban Indian MIECHV - P a g e 2
The American Indian Health Commission (AIHC) for Washington
State is a Tribally-driven non-profit organization with a mission of
improving health outcomes for American Indians and Alaska Natives
(AI/AN) through a health policy focus at the Washington State level.
AIHC works on behalf of the 29 federally-recognized Indian Tribes and
two Urban Indian Health Organizations (UIHOs) in the state. The AI/AN
population continues to experience poor health outcomes and the highest
overall mortality rates than any other population in Washington. AIHC
serves as a forum where a collective Tribal government voice is shaped on
shared health disparity priorities and Tribes, and UIHOs then work
collaboratively with Washington State health leaders, the Governor’s
office and the legislature to address these priorities. The AIHCs policy-
work improves individual Indian access to state-funded health services,
enhances reimbursement mechanisms for Tribal health programs to deliver
their own culturally-appropriate care, and creates an avenue for Tribes and
UIHOs to receive timely and relevant information for planning purposes
on state health regulations, policies, funding opportunities, and health-
specific topics. By bringing state and Tribal partners together, specific
health disparity priorities can be addressed across multiple systems—
pooling resources and expertise for greater health outcomes.
Member Tribes
Chehalis
Colville
Cowlitz
Jamestown S’Klallam
Kalispel
Lower Elwha Klallam
Lummi
Makah
Muckleshoot
Nisqually
Nooksack
Puyallup
Quileute
Quinault
Samish
Sauk-Suiattle
Shoalwater Bay
Skokomish
Snoqualmie
Spokane
Squaxin Island
Stillaguamish
Suquamish
Swinomish
Tulalip
Upper Skagit
Member Organizations
Seattle Indian Health Board
NATIVE Project of Spokane
© 2013 American Indian Health Commission for Washington State
Preferred citation: American Indian Health Commission for Washington State. (2013). Healthy Communities: Maternal Infant Early
Childhood Home Visiting: Olympia, Wa. Prepared by Ward Olmstead, Jan
American Indian Health Commission for Washington State
Final Report – Tribal and Urban Indian MIECHV - P a g e 1
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American Indian Health Commission for Washington State
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TABLE OF CONTENTS Introduction .................................................................................................................................................................. 2
Home Visiting ........................................................................................................................................................... 4
Background ............................................................................................................................................................... 5
AI/AN Maternal Infant Health Disparities ............................................................................................................ 7
Funding .................................................................................................................................................................. 8
Home Visiting Services Account ............................................................................................................................ 9
American Indian Health Commission’s Home Visiting Project ............................................................................... 10
T-U MIECHV Strategic Direction ........................................................................................................................... 12
Other Relevant Work/Projects .................................................................................................................................... 14
Healthy Tribal and Urban Indian Communities Framework .............................................................................. 14
Maternal Infant Health (MIH)-Implementation of the MIH Strategic Plan ........................................................ 14
Women, Infants and Children (WIC)-Implementation of MIH Strategic Plan Recommendations ...................... 15
Pregnancy Risk Assessment Monitoring System (PRAMS)-Improve Response Rates, Quality and Use of Data
Specific to AI/AN Women in WA State; Putting Data Into Action ....................................................................... 15
Immunizations-Assess Potential Issues Regarding Healthcare Worker Vaccination Hesitancy and
Implementation of MIH Strategic Plan Recommendations .................................................................................. 15
Methodology for Gathering Information and Knowledge ......................................................................................... 16
Survey Questionnaire and Results ......................................................................................................................... 16
Roadmap Exercise Questions and Findings .......................................................................................................... 20
A Day of Learning about Home Visiting ............................................................................................................... 25
What We Learned from the One-ay Event ........................................................................................................... 26
What We Learned from Tribal MIECHV Grantees .............................................................................................. 27
Family Spirit and Other Models of Interest ........................................................................................................... 28
Family Spirit ........................................................................................................................................................ 28
Healthy Start Program ........................................................................................................................................ 28
Family Home Visiting Program with Aboriginal Families in South Australia .................................................... 28
Challenges and Lessons Learned ............................................................................................................................... 30
Findings and Key Considerations .............................................................................................................................. 31
Recommendations ....................................................................................................................................................... 33
Next Steps .................................................................................................................................................................... 33
References ................................................................................................................................................................... 34
American Indian Health Commission for Washington State
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HEALTHY COMMUNITIES: TRIBAL-URBAN INDIAN
MATERNAL INFANT EARLY CHILDHOOD
HOME VISITING
INTRODUCTION
The American Indian Health Commission of Washington State (AIHC) is working in partnership
with the Washington State Department of Early Learning (DEL) to identify Tribal and Urban
Indian program needs, and capacity for maternal infant early childhood home visiting
(MIECHV) and other critical early learning services to support the healthy development of
American Indian and Alaska Native (AI/AN) children and families in Washington State. This
project began in May of 2012.
Washington State leads the nation with the lowest Infant Mortality Rate (IMR). However this
achievement is not consistent for all populations of the state. AI/ANs account for about two
percent of the state population according to the 2010 census. Babies born to AI/AN mothers
experience an IMR over three times that of babies born to Asian mothers and twice as high as
White mothers. (Citation) Infant mortality is associated with poor maternal health, poor quality
of and access to medical care and preventive services, and low social economic. Healthy
Communities: Maternal Infant Health Strategic Plan. This maternal infant health (MIH)
disparity puts AI/AN mothers and babies at significantly higher risk than any other racial group
in the state.
No single intervention reduces all infant mortality. However, prenatal care, participation in the
Women, Infant Children (WIC) nutrition program, and receipt of high-risk neonatal care reduce
deaths. Other proven strategies included the use of infant car seats, smoking cessation
intervention, folic acid supplementation to prevent some types of birth defects, placing infants to
sleep on their backs, and efforts to reduce preterm births (Washington State Department of
Health. Health of Washington State Report – Infant Mortality. Olympia, WA: Washington State
Department of Health; 2013, p. 1).
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In September 2010, DEL completed the Washington Early Learning Plan.1 The plan included a
strategy to make evidence-based and promising pre-natal and child (birth to five) home visiting
(HV) services more accessible to at risk families. It emphasized the role of the AIHC and its
efforts to improve health status and address disparities through state-tribal collaboration,
particularly related to infants and pregnant women.
Earlier in January of 2010, the Washington State Department of Health (DOH) published the
results of a statewide Home Visiting Needs Assessment2 indicating higher health and social risks
factors exist among AI/AN pregnant women than any other racial group. Of the 29 federally
recognized sovereign American Indian Tribal governments and two Urban Indian Health
Organizations (UIHOs) in the state, eight offered evidence-based or other HV programs.
However, this information was provided by the HV programs and not necessarily by the Tribes
or UIHOs themselves.
This report is intended to serve as a tool for Tribes and UIHOs to raise awareness and
engagement in MIECHV program and system development. It will also serve as a means to
begin to understand the Tribal and Urban Indian program needs and capacity for
MIECHV, and other critical early learning services of Tribes and UIHOs.
1 Department of Early Learning. Washington Early Learning Plan, September 2010, www.del.wa.gov/plan.
2 Department of Health. Washington State Home visiting Needs Assessment Narrative, 2010, Revised, 2011.
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HOME VISITING
Home Visiting is a voluntary program that serves
pregnant women, expectant fathers, children birth to
Kindergarten, parents and caregivers; supported by
state and federal funds. HV programs are a proven way
to provide parents in need with effective tools to
positively impact their children’s well-being and ensure
a successful start. Benefits of HV programs include:
Improvements in maternal and prenatal health,
infant health, and child health and development.
Increased school readiness.
Reduction in the incidence of child maltreatment.
Improved parenting related to child development outcomes.
Improved socio-economic status.
Greater coordination of referrals to community resources and supports.
Reduced crime and domestic violence.
Home visiting programs have also demonstrated that they can have a host of interconnected
outcomes that address multiple risk factors and sources of family stress. (Washington Early
Learning Plan, 2010, p. 84)
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BACKGROUND
The AIHC’s public health work is focused on improving the health status of Indian people of
Washington State. The public health projects are interlinked by the overarching concept of
building and sustaining Healthy Tribal and Urban Indian Communities through interventions
that include policy, environment, system, and program changes. The AIHC uses facilitation
methods to ensure projects are Tribally-Urban Indian driven and applies values to ensure
outcomes are culturally appropriate and community specific (See diagram below).
The AIHC considers historical trauma and adverse childhood experiences significant factors in
addressing health disparities experienced by AI/ANs. Strategies to use the best data available are
sought for all projects through multiple sources. AIHC recognizes the importance of Tribal-State
Partnerships and the key public health relationships with the Washington State Departments of
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Health and Early Learning to achieve improved health status and to address existing health
disparities of AI/ANs in the state.
The AIHC public health work is also rooted in the foundational efforts reflected in, AIHC’s
Healthy Communities: A Tribal Maternal-Infant Health Strategic Plan, 2010. The MIH Plan
was inspired by a goal in the AIHC-DOH American Indian Health Care Delivery Plan for 2010-
2013. The specific goal is to improve health status by decreasing health disparities for AI/AN
pregnant women and infants with appropriate, multiple approaches as a shared goal with state
government. Although the plan focus is on needs of pregnant women and children, many of the
strategies include interventions that embrace fathers and
intergenerational family members.
The MIH work was initiated in 2008 by a workgroup,
jointly convened by AIHC and DOH, which focused on
identifying strategies to address the significant health
disparities for AI/AN pregnant women and babies. In
December 2010, the AIHC published Healthy
Communities: A Tribal Maternal-Infant Health Strategic
Plan, which provides data, goals and objectives, and
identifies MIH health disparities and recommendations to
address them through culturally appropriate strategies and
continued partnership with the state. Since the then, the
MIH workgroup has continued to serve as the advisory
group responsible for guiding the efforts to address the MIH
Strategic Plan Recommendations to improve MIH
outcomes. Through a recent priority setting process, the
AIHC determined MIH HV would be the top priority and
focus for 2013-14 MIH workgroup activities. The second
priority area is the promotion of breastfeeding policy. The
purpose of its HV focus is to align with the MIH goals and
objectives and to leverage efforts to further Tribal and Urban Indian HV capacity.
American Indian (AI) Causes of Infant Mortality in Washington State compared to the population as a whole
Sudden Infant Death Syndrome (SIDS)-rate is 3 times higher Birth Defects. Death rate is 30 % higher Injury. Death rate is 5 times higher Complications in Pregnancy and Delivery. Death rate is 50% greater Prematurity and Low Birth Weight mortality Death rate is 60% higher Infectious Disease. Death rate is 3 times higher (Influenza and pneumonia 7 times higher) Digestive System Problems. Death rate 3 times higher.
Unknown Causes. Death 4.5 times higher.
AIHC, Healthy Communities: A
Tribal Maternal-Infant Health
Strategic Plan, 2010
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AI/AN MATERNAL INFANT HEALTH DISPARITIES
AI/AN health disparities among infants and pregnant women are a serious problem in
Washington State. AI/AN families have been identified as having the highest risk of any of the
five racial groups. (Washington State Department of Health,
Home Visiting Needs Assessment, 2011. p. 81) As
referenced earlier, the March 2013 DOH Infant Mortality
Report reiterates the IMR disparities of babies born to
AI/AN mothers. It shows that AI/AN babies IMR has
increased since 1994, while all other racial and ethnic
groups in the state have either decreased or stayed the same.
There are multiple risk factors for infant mortality that tend
to cluster together. Further, infant mortality rates are higher
for those born to mothers who are low income, smoke, have
poor nutrition, and those that are younger than 20 or older
than 40. There is a high prevalence of these risk factors
among AI/AN women.
AI/AN pregnant women are more likely than women in any
other racial group to have late or no prenatal care, to smoke
or abuse drugs or alcohol, have a mental health diagnosis, or
have suffered abuse by a partner. (Washington State
Department of Health, 2011. p. 4) AI/ANs with Medicaid in
Washington State experience higher risk for mental health,
alcohol and or substance abuse, smoking, high preterm birth,
infant mortality and high and low birth weight babies.
(AIHC, 2010, p. 23-24)
The MIH Strategic Plan serves as the foundational plan in setting out the work of AIHC to
address maternal infant health issues. It clearly identified the high risk areas for AI/AN moms
and babies which result in poor pregnancy outcomes and strategies to address them.
American Indian with Medicaid
Top Six Risk Factors for
Pregnancy Outcome
Mental Health. Affects over 1/3 of
AI pregnant women. A risk factor
for low birth weight that affects
more AI pregnant women that any
other risk factor.
Alcohol and/or Substance Abuse
during pregnancy or 1 year
postpartum. AI births 3.3 times the
rate compared to all Medicaid
births.
Smoking-Nearly 28% of AI
pregnant women smoked during
their pregnancy, compared to 17%
of all pregnant women on Medicaid.
Threatened PreTerm Labor. The
rate for symptoms was 2 times
higher for AI births than for all births
on Medicaid.
History of Prior Low Birth Weight
Baby, Preterm Delivery, or Fetal
Death. 50% greater for AI than for
total Medicaid population.
Nutrition and Weight. About 25%
of AI births have this risk factor,
30% higher than all Medicaid.
Causes a higher risk for of
complications in childbirth from high
weight baby and for preterm.
AIHC, Healthy Communities: A
Maternal Infant Strategic Plan, 2010.
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HV is called out in four of the 14 identified plan
strategies as a best practice. It is also notable that as
AIHC has increased its knowledge around HV,
potential linkages have been identified in 11 of the 14
strategies areas of the AIHC MIH Strategic Plan. The
plan has served as a platform for Washington Tribes
and UIHOs to begin raising awareness and building
efforts and partnerships across the state addressing
AI/AN MIH health disparities.
FUNDING
Washington State Department of Early Learning receives federal funding through the Affordable
Care Act, administered by the U.S. Department of Health & Human Services (HHS). This
funding allows Washington to bring evidence-based HV services to high-risk communities. It
provides $1.5 billion over five years for state-based early childhood HV grants to serve families
in high-risk communities through the Health Resources and Services Administration’s (HRSA)
Maternal Infant Early Childhood Home Visiting (MIECHV) program.
Through 2015, Washington State expects to receive about $25 million from the MIECHV
program administered by HRSA. That is $1.8 million annually to:
Support direct home visitation services in local communities,
Develop systems to build quality implementation of evidence-based HV,
Integrate HV as a strategy in a comprehensive statewide system for early childhood
services, and
Collaborate with and partner across agencies and throughout communities.
There are also three Tribal/Urban HV research grants initiatives funded by the Administration of
Children and Families (ACF) MIECHV program. United Indians of All Tribes (UIAT), South
Puget Intertribal Planning Agency (SPIPA) and Port Gamble S’Klallam Tribe, referred to here
after as the Tribal MIECHV grantees, have received these grants and are at various stages of
implementation. See page 29 of this report for What We Learned from Tribal MIECHV Grantees.
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HOME VISITING SERVICES ACCOUNT
The Washington State HV Services Account (HVSA) was established by the legislature in 2010.
It is a public-private organization that leverages state dollars through private sector investment in
HV programs. HVSA helps fund and evaluate HV programs and leverages state dollars by
providing private dollars as a match. The account also helps build and maintain training, quality
improvement and evaluation infrastructure needed for effective statewide HV services. There is
commitment from the private sector, through Thrive by Five
(www.thrivebyfive.org),Washington to match what the state deposits in the HVSA. The 2013-14
biennial general fund allocation for HV is $1.87M, which is 9.5% of total funds in the HVSA.
American Indian Health Commission for Washington State
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AMERICAN INDIAN HEALTH COMMISSION’S HOME VISITING
PROJECT
Tribal-Urban Indian Maternal Infant Early Child
Home Visiting (T-U MIECHV) is a Tribally-
Urban Indian driven project to identify maternal
infant-child health needs and capacity in Tribal
and Urban Indian communities. Its purpose is to
support healthy development of AI/AN children
and families in Washington State. The AIHC
facilitated the project, in partnership with DEL, to
gather information concerning:
Status of HV services for mother and babies and promising practices,
Gaps and barriers to program participation and effective programs,
Culturally appropriate strategies, and recommendations for developing and/or
expanding quality or capacity of HV systems and local interventions, and
Development priorities, funding and leveraging opportunities.
The AIHC convened its first T-U MIECHV meeting on August 27, 2012, providing an overview
of the project and an opportunity for Tribes and UIHOs to network with other HV partners in the
state. Participants included Tribes, UIHOs, Tribal MIECHV grantees, State and Federal
partners, and private HV programs and advocates. At the following meeting in October, Tribal
and UIHO representatives requested a change in structure allowing them to meet monthly, in
additional to the larger group of partners coming together quarterly. This change supported
AIHCs commitment to a Tribally-Urban Indian driven framework, and resulted in the
establishment of two groups: 1) the T-U MIECHV Coalition and 2) T-U MIECHV Plus Partners.
The T-U MIECHV Coalition and the T-U MIECHV Plus Partners memberships and participation
have been open and fluid.
The T-U MIECHV Coalition purpose is to enhance or expand existing services, ensure models
are culturally appropriate, and identify potential HV funding opportunities. The focus for both
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the groups is to promote ongoing collaboration to build strong connections between Tribes and
UIHOs, statewide HV and early learning coalitions, service providers, and other state, federal,
private, and nonprofit partners to benefit AI/AN children and families in Washington State. The
membership is as follows:
AIHC Consultants
Jan Ward Olmstead, AIHC Public Health Consultant Coordinator, Home Visiting Lead
Marsha Crane, AIHC Clinical Consultant, MIH Lead
Maternal Infant Child Home Visiting Coalition Members
Alfreda Charlie, Tulalip Tribes
Beth Dodge, Chehalis Tribe
Bonnie Pimms, Yakama Tribe
Carmen Kalama, SPIPA
Caroline Sedano, Shoalwater Bay Tribe
Cherol Fryberg, Tulalip Tribes
Cheryl Sanders, Lummi Nation
Christina Hicks, Chehalis Tribe
Cynthia Gamble, Chehalis Tribe
Deanna Warren, Squaxin Island Tribe
Debbie Gardipee-Reyes, SPIPA
Debbie Kautz, Nisqually Tribe
Glenda Butler, Makah Tribe
Jeanne Dengate, Tulalip Tribes
Jhon J. Valencia, Chehalis Tribe
John McCoy, Washington State Legislature
Katie Hess, United Indians of All Tribes
Linda Charette, SPIPA
Leanna Ray-Colby, Lower Elwha Klallam
Lonnie Johns Brown, AIHC
Lorraine Van Brunt, Squaxin Island Tribe
Lynnette Jordan, United Indians of All Tribes
Jinny Marchand, Quinault Indian Nation
Marilyn Scott, AIHC and Upper Skagit Tribe
Mary Sanders, Chehalis Tribe
Misti Saenz-Garcia, Squaxin Island Tribe
Natosha Kautz, Nisqually Tribe
Pam James, SPIPA
Shannon Sullivan, Chehalis Tribe
Teresa Pope, Spokane NATIVE Project
Tina Fox, United Indians of All Tribes
Toni Lodge, Spokane NATIVE Project
Alan Harney, Tulalip Tribes
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Partners
Jen Estroff, Children’s Alliance
Jenni Olmstead, Washington State Department of Early Learning
Judy King, Washington State Department of Early Learning
Laura Wells, Fight Crime Invest in Kids
Lauren Platt, Nurse Family Partnership
Lauren Hipp, Thrive by Five Washington
Laurie Lippold, Partners for our Children
Laurie Wylie, HHS, Health and Resources Services Administration
Leslie Dozono, Children’s Alliance
Linda Clark, Parents as Teachers
Liv Woodstrom, Thrive by Five Washington
Lorrie Grevstad, HHS, Health and Resources Services Administration
Molly Boyajian, Thrive by Five Washington
Nancy Ashley, Parent Child Program
Quen Zorrah, Thrive by Five Washington
Riley Peters, Washington State Department of Heath
Shannon Blood, Washington State Department of Early Learning
The T-U MIECHV Coalition developed strategic direction (see below) and a project work plan
(see Appendix A) to guide the project, and provided input in developing key questions to better
understand the needs of Tribes and Urban Programs, and the capacity for HV and services for
mothers and babies.
T-U MIECHV STRATEGIC DIRECTION
VISION: All Native Children Live Happy, Healthy Lives for Generations to Come.
MISSION: Promote health and well-being of Native American families and children through
culturally appropriate home visitation services.
GUIDING PRINCIPLES: Demonstrate honor and respect of cultural differences and
commonalities.
GOALS (reflected in the work plan, see Appendix A):
1. Improve the health status of AI/AN pregnant women and infants with appropriate,
multiple approaches as a shared goal with state government.
2. Identify status of HV programs.
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3. Identify local intervention strategies and promising practices.
4. Identify gaps and barriers of program services and adaptations to current evidence-based
models.
5. Support culturally appropriate parent education and activities.
6. Support health prevention activities.
7. Collaborate, prioritize voice and act on Indian health issues.
8. Provide recommendations for developing and/or expanding quality or capacity of HV.
9. Identify development priorities, funding and leveraging opportunities.
10. Establish networking and collaboration opportunities to support HV efforts in
Tribal/Urban Indian communities.
11. Serve as a national model for state-tribal collaboration on Tribal/Urban MIECHV policy
and program development.
OBJECTIVES (Reflected in the work plan, see Appendix A):
1. Develop and implement work plan to achieve goals.
2. Convene monthly meetings for Tribes/Urban Indian organizations to identify HV status,
needs and strategies.
3. Convene quarterly meetings with Tribes, UIHOs and other partners (State, Federal,
private, and non-profit) to collaborate on HV needs of Tribal and Urban Indian
communities.
4. Collect and review data to identify gaps or barriers to HV services.
5. Serve as a clearinghouse for HV programs and Tribal, State and Federal partners through
meetings, webinars, and email.
6. Share resource and funding opportunities information with Tribes and UIHOs.
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OTHER RELEVANT WORK/PROJECTS WITH LINKAGES TO T-U
MIECHV
The AIHC is working on many public health projects that focus on improving the health of
AI/AN families, and has identified projects that potentially link to T-U MIECHV:
HEALTHY TRIBAL AND URBAN INDIAN COMMUNITIES FRAMEWORK
The framework focuses on a comprehensive prevention strategy integrating Native and
western knowledge to reduce risk factors for chronic disease among AI/ANs. This
integrated model utilizes a Policy, Environment, Systems (PES) change approach and
incorporates culturally appropriate strategies designed for Tribal and Urban Indian
Communities.
MATERNAL INFANT HEALTH (MIH) IMPLEMENTATION OF THE MIH STRATEGIC
PLAN
The plan to improve the health status for AI/AN pregnant women and infants with
appropriate, multiple approaches as a shared goal with state government, included four
outlined objectives. Three of the four objectives form the basis of the MIH Strategic
Plan:
1) Establish a Maternal-Infant Workgroup to research causes of poor health status
and birth outcomes among Indian women, and identify promising practice
models from Tribal and Urban Indian delivery of MIH services nationally and
in Washington State,
2) Identify specific barriers to Tribal/Urban Indian health program participation in
the DOH WIC Program and the Department of Social and Health Services
(DSHS) First Steps Services (maternity and infant support); develop and
implement strategies to improve AI/AN access to and Tribal Health programs'
ability to provide these services, and
3) Identify options and opportunities for Tribes and UIHOs to ensure access for
all AI/AN women to high quality obstetrical care, and develop methods to
successfully engage them in healthy lifestyles.
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WOMEN, INFANTS AND CHILDREN (WIC)-IMPLEMENTATION OF MIH STRATEGIC
PLAN RECOMMENDATIONS
The objective of the project is to identify culturally and tribally appropriate methods
for enhancing the use of WIC services and supports in Tribal communities, including
in the areas of food access, breastfeeding, health education, and information and
referral to other programs and services.
PREGNANCY RISK ASSESSMENT MONITORING SYSTEM (PRAMS)-IMPROVE
RESPONSE RATES, QUALITY AND USE OF DATA SPECIFIC TO AI/AN WOMEN IN WA
STATE; PUTTING DATA INTO ACTION
The PRAMS Flu project is a direct result of Tribal and Urban Indian concerns regarding
immunization issues that occurred during the H1N1 Flu pandemic, and MIH disparities,
both very clearly articulated during the AIHC Tribal Leaders Health Summit of 2010.
AI/ANs experienced more severe health outcomes from H1N1 Flu than the general
population (http://www.cdc.gov/h1n1flu/in_the_news/deaths_american_indians.htm), as
did pregnant women. Flu immunization rates for AI/AN pregnant women in Washington
were not then, and are still not, optimal. Improving immunization rates for pregnant
women will save lives, and fulfill a strategy for improving MIH health disparities that is
listed in the AIHC’s MIH Strategic Plan.
IMMUNIZATIONS-ASSESS POTENTIAL ISSUES REGARDING HEALTHCARE WORKER
VACCINATION HESITANCY AND IMPLEMENTATION OF MIH STRATEGIC PLAN
RECOMMENDATIONS
American Indians and Alaska Natives are impacted the most of any group by illnesses
that could have been prevented through proper immunizations
(http://www.cdc.gov/h1n1flu/in_the_news/deaths_american_indians.htm) which raised
the issue of Vaccine Hesitancy for Health Care Workers in Tribal settings. The AIHC
conducted an assessment, analysis, and recommendations regarding Tribal Health Care
Workers’ Knowledge, Attitudes and Practices regarding immunizations.
In addition, prior to the initiation of the AIHC/DEL T-U MIECHV project, the
University of Washington and DSHS convened the Tribes and Recognized American
Indian Organizations (RAIOs) for a Health Priorities Summit entitled “From
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Cradleboard to Career3”, focusing on MIH and early childhood development. The
issues identified in the summit related to HV concepts and/or maternal infant child
health from the perspective of Tribes and Urban Indian communities. Attendees
included Tribal council members, Tribal leaders, Tribal and UIHO employees, RAIOs,
Native Elders and Native community members and youth. Valuable information was
gleaned from this summit to support culturally relevant programs and practices to
establish an expanded network with Tribal and Urban Communities.
(http://uwashington.uberflip.com/i/106618/35)
The commission will continue to identify linkages to strengthen work across these projects, and
build and strengthen partnerships and leveraging opportunities to improving AI/AN maternal
infant child health status.
METHODOLOGY FOR GATHERING INFORMATION AND KNOWLEDGE
Several approaches were used to gather information, including administering a Survey Monkey
questionnaire, conducting regional forums/meetings and hosting a one day HV conference to
gather information and knowledge to support the project.
SURVEY QUESTIONNAIRE AND RESULTS
The AIHC administered a Survey Monkey questionnaire entitled, American Indian Health
Commission for Washington State HV Services for Mothers and Children, (attached as
Appendix B). The survey was initially conducted from March 12 to May 5, 2013; however, it
was extended through the end of May to achieve AIHC’s goal of reaching an 85% response rate.
The purpose of the questionnaire was to establish baseline information about services provided
to mothers and children directly from the Tribes and UIHOs. Questions were also asked about
the appropriate contact staff for HV services. The questionnaire was developed through
guidance from the T-U MIECHV coalition and in consultation with DEL staff. The AIHC lead
HV consultant served in designing the survey and analyzing the results for this report. The
survey had a 90% return rate; 28 of 31 Tribes and/or UIHOs responded; however, not all
questionnaires were completed nor all questions answered by every respondent.
3 UW, From Cradleboard to Career, 2012
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Question 1: 28 responses. It was an agreement to participate in the survey.
Question 2: 28 responses.
Question 3: 11 responses, reflected below.
Model Number
Early Head Start 3
Head Start/Promotional Maternal Health (NCAP) 1
Home visiting through family services is a social service model, accessing
through the state
1
Maternal Support Services 1
Nurse Family Partnership 1
Parents as Teachers with cultural enhances 1
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Parents as Teachers, Ages and Stages, Life Skills Progression 1
PCAP WIC 1
Positive Indian Parenting and Parents as Teachers Curricula 1
Question 4: 21 responses. Respondents could choose more than one answer. Additionally, other
comments indicated the following services: public health nurses, social services, head start, WIC,
Positive Indian Parenting.
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Question 5: 22 responses. Other comments included MIH programs and public health nurses,
MSS at clinic and prenatal Ed at Head Start.
Question 6: Are there other (non-Tribal/Urban Indian) community based organizations that
provide HV services to mothers and children in your community? If yes, provide Name and
model.
Model
First Steps
Mason County Health Department (not sure of services)
MSS at Olympia Hospital
Nurse Family Partnership through the Health Dept.
Nurse-Family Partnership and Early Head Start and many others in King County
Parents Place in Longview
Yakima Valley Farm Workers Clinic
Question 7: 24 responses. Who is the appropriate contact for HV services for mothers and
children? The responses provide AIHC with the appropriate contacts within the Tribes and
Urban Programs for HV Services.
Question 8: 20 responses. What funding is available to support the HV services for mothers and
families? Participants could choose more than one.
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What funding is available to support the home visiting services for mothers and families?
Answer Options Response
Percent Response Count
Federal funds 70.0% 14
State funds 30.0% 6
Tribal funds 40.0% 8
Other 35.0% 7
ROADMAP EXERCISE QUESTIONS AND FINDINGS
The AIHC used a Roadmap Exercise as a method to better understand needs and capacity of
Tribes and UIHOs for HV services. The four facilitated sessions were held at Spokane
NATIVE project, Tulalip Tribe, Yakima Tribe and Little Creek Casino during the One Day
Conference on HV.
Eight key questions were developed through the guidance of the T-U MIECHV Coalition and in
partnership with DEL.
“We have always celebrated, laughed, mourned &
healed together as a community for thousands of
years; we will always possess this genetic memory
of our healing process and practice it. This is why
funders need to consider culturally appropriate
Tribal and Urban Indian programs that have rapport
within the community that they serve. If that trust
and relationship is non-existent, then the healing
process is ineffective and never really begins.”
Dylan Dressler, MPA
Clinic Manager
NATIVE Health of Spokane
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Eight Questions and Salient Themes:
Question 1: What services do families need to ensure that all Native Children live happy,
healthy lives?
Hierarchy of need: Families must have basic needs met like housing, food, safety,
employment, and transportation.
Good nutrition—mind, body, spirit and heart.
Alcohol, commercial tobacco, and drug free environments.
Domestic violence prevention.
Safe environments: natural and personal understanding about relationships to all things.
Access to health care, immunization and medications.
Services to address: OB care, Teen Pregnancy, Pre-term generational CPS involvement.
Home visiting services need to be flexible in the way they are provided to allow them to
be conducted in a group or with extended family members and elders.
Services that meet the needs of families; from a Tribal/Urban Indian perspective.
Services: Preferred that they are “from our people for our people”.
Holistic, comprehensive, wrap-around services.
Culturally relevant services.
Healing, with the involvement of elders who have done their own healing, through
training and education to families and providers.
Elder protection and preservation.
Service providers from outside the Tribe/community need to understand the
Tribe's/communities’ history.
Consistent messaging—all service providers reinforcing the same message (e.g., smoking
cessation, promoting breastfeeding, etc.).
Empowerment, advocacy and opportunity.
Question 2: What Maternal-Infant-Child Services are available in your community; what
services do they provide?
Baby Face
Boys and Girls Club
Colleges-Olympic and Highline have programs
Early Head Start
Family Haven-teen moms and life and parenting classes
First Steps
First Steps/MSS/ICM
Home Visiting Programs
Mason County Early Learning Coalition (Tribes not very involved)
PHSKC-Muckleshoot
Planned Parenthood
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Port Gamble & Suquamish Tribes Early Health Start, Head Start, child care, birthing,
Nurse Family Partnership, WIC
Seattle-Teen Parent Housing
Seattle-YWCA, have 600+ case management.
South Puget Intertribal Planning Agency (SPIPA) using Parents As Teachers HV model
Spokane-DSHS-children and family services
Spokane-Sacred Heart Hospital-low income breast pump rental
Spokane-Sally’s-Emergency shelter
Tribal and Urban Indian Clinics
Tulalip-Little Red School House-early childhood prevention
United Way-Q’s outreach early
WIC
Yakama-Hospitals available for delivery, great OB care, neonatologists, and great
Pediatric services.
Yakima-MCH Moms’ group
Yakima-Children’s Village is an asset, but paperwork is a challenge.
Question 3: Do the Existing Services meet the needs of Native families? (Identify Gaps)
Lack of funding for HV and other services.
Lack of knowledge about HV availability of programs, benefits and funding.
Lack of access to independent culturally relevant HV programs.
Lack of holistic, comprehensive, wrap-around services.
Concern about high risk pregnancies with CPS involvement, no pre-natal care, substance
abuse involvement.
Lack of adequate behavioral health services.
Concern about high asthma diagnosis.
Services for families at risk of losing their children.
Question 4: Is culture important in an effective home visiting program, and if so, why?
Home Visiting is a relationship based work; cultural knowledge and understanding is
imperative to effective home visiting.
Culture gives Native people the knowledge of who they are, where they belong, and an
understanding of their shared beliefs and practices.
Culture gives a foundation for healthy growth, development, and self-identity for children
and families.
Cultural appropriate models, like Family Spirit, should be reviewed for their potential use
for Tribes and Urban Programs in Washington.
Parent Education Curriculum should be flexible for Tribal home visiting implementation.
Tribes should not be forced to use evidence-based curriculum that is not culturally
relevant or that they have to adapt to make it fit into native communities. This is no
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different than any other assimilation or acculturation effort. Native Tribes and
communities should have the opportunity to develop parenting education materials that
are culturally appropriate to their customs, practices and needs.
We have always celebrated, laughed, mourned and healed together as a community for
thousands of years; we will always possess this genetic memory of our healing process
and practice it. This is why funders need to consider culturally appropriate Tribal and
Urban Indian programs that have rapport within the community that they serve. If that
trust and relationship is non-existent, then the healing process is ineffective and never
really begins.
Question 5: What do you think the barriers are to families seeking services?
Not a priority—many families striving to meet basic needs.
Lack of understanding of the benefits and need for HV.
Lack of trust: history, experiences; referrals not from a trusted source or community
member.
Lack of culturally appropriate curriculum.
Non-native service providers.
Different worldviews/service providers lack of understanding Native culture; need a
cultural interpreter.
Fear of having people/strangers come into their home.
Eligibility issues can be a barrier. (Sometimes including different or conflicting
requirements for different services) can be a barrier even for eligible people.
Lack of transportation.
Lack of child care.
Safety of home visitor.
Time commitment: hours inconvenient.
Alcohol and drug addictions.
Mental health issues.
Domestic violence.
Fear of child welfare.
Homelessness and couch surfing.
Lack of phone service.
Legal issues.
Hopelessness: feeling inferior, low self-esteem.
Paperwork.
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Question 6: What do you think a home visitor needs to know to effectively work in your
community?
Maternal Infant HV with tribal people requires the integration of traditional cultural
generational wisdom to be shared from the elder generation with the young adult families
to keep the promising practice from the past to survive.
Understanding historical and intergenerational trauma.
Knowledge of culture and history of the Tribal or Indian Community.
Needs to know the community and the people.
Needs to be aware of seasonal livelihoods.
Needs to know the resources.
Needs to know the elders.
Needs to know appropriate cultural protocol for visiting, introductions, and decision
making.
Needs to have empathy, a sense of humor; and ability to build relationships.
Needs to be able to listen and not judge.
Needs to be aware of surroundings to ensure personal safety and aware of risky
behaviors.
Needs to be strong and self-aware.
Question 7: Who are the best messengers?
Trusted Tribal/community member: Grandmas, Moms, Aunties, Nurses.
Connections with nurses in the clinic/hospital.
Good reputation in the community.
Male role models.
Elders as resources.
Families who have been successful at overcoming adversities.
Question 8: What would help engage families in HV programs?
Identifying benefits of and need for HV programs.
Building trusting relationships requires consistency: punctual, respectful, positive, and
flexible.
Having trusted Tribal/community members.
Having an appropriate cultural program and making adaptations like having the visit
outside of the home, including extended family or holding group sessions.
Flexibility around hours.
Addressing the families’ needs.
Tangible resources: Incentives.
Food.
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Knowing someone else in the program.
Using social media.
A DAY OF LEARNING ABOUT HOME VISITING
The AIHC and T-U MIECHV convened
a one day conference as a Day of
Learning: How Home Visiting Builds
Resilient Children and Families (see
attached agenda, Appendix C). This
activity had not been envisioned at the
beginning of the project, but deemed
necessary to support identified needs by
the T-U MIECHV Coalition about
training, education and outreach as the
project developed. The event was co-sponsored by the DEL, DOH-Office of the Secretary,
DOH-WIC Nutrition Program, United Indians of All Tribes Foundation, and South Puget Inter
Tribal Planning Agency.
The agenda objectives were to:
Develop understanding of cultural resilience to historical and intergenerational
trauma with a focus on Tribal/Urban Indian maternal infant-child health.
Develop understanding of the Adverse Childhood Experiences (ACE) study and
efforts to address impacts of ACE through HV programs. (Citation)
Develop understanding of the landscape of HV system developments in Washington
State.
Identify Tribal and Urban Indian specific barriers, gaps, and needs to accessing
effective programs.
Sixty-one participants attended the one-day HV conference, exceeding the AIHC goal of 50
registering attendees. Participants included representatives from Tribes and UIHOs from clinics,
maternal infant health programs, HV program staff, MIECHV grantees, WIC staff, and early
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learning staff; as well as partners from state, federal, nonprofit, and evidence-based HV
programs.
WHAT WE LEARNED FROM THE ONE-DAY EVENT
There is a need for additional training regarding cultural resilience to historical and
intergenerational trauma and ACEs specifically designed for Tribes and UIHOs.
There is a need to continue to build infrastructure for Tribal and Urban Indian maternal
infant health and to find avenues to integrate or partner in providing services to the same
population/families with programs like WIC.
There is interest in learning more about cultural adaptations to evidence-based HV
models.
There is a need to continue to work with evidence-based programs to develop
curriculums more culturally relevant for Native families and to continue to work with
state programs that serve Washington Native populations to make sure the parenting
education honors traditional parenting practices and is relevant and useful for Native
families.
The Community Health Representative model known to be effective in Tribal and Urban
Indian communities and should be considered for maternal infant HV.
There is interest in exploring ways to bill for and sustain an ongoing program that can be
part of a medical home model for Tribal members.
“Maternal Infant home visiting with tribal
people requires the integration of traditional
cultural generational wisdom to be shared
from the elder generation with the young
adult families to keep the promising practice
from the past to survive.”
Marilyn Scott, AIHC Chairwoman
Vice Chair of Upper Skagit Tribe
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WHAT WE LEARNED FROM TRIBAL MIECHV GRANTEES
A significant barrier to HV is lack of knowledge
and awareness about HV programs. Additionally,
some associate HV with Child Protective Services
(CPS) and Indian Child Welfare (ICW). There
may also be unrealistic expectations of services
provided by home visitors.
Services for fathers, is an important part of
supporting moms and babies and strengthening
our families. This may include the necessity for specific components to assist men to
gain skills necessary to maintain healthy relationships.
Services to multigenerational units that share parenting responsibility for children and
grandchildren is a culturally relevant approach. The use of a “Circle of Aunties and
Grandmas” who can model and teach pregnant woman and young families, including
facilitating healthy relationship classes is relevant.
Evidence-based programs have some flexibility to make adaptations, but it takes effort to
develop understanding about cultural relevance and how adaptations can be made while
maintaining the fidelity of the program.
There are many bureaucratic barriers ranging from phone system issues to lack of
providers’ knowledge about services specifically for AI/ANs.
Eligibility requirements for services can be a barrier. Programs providing services to
AI/AN communities limit eligibility by many factors, including substance use (or lack
thereof), presence and age of children, place of residence, tribal enrollment status, age,
and income. Not only do eligibility requirements exclude people who don’t meet them,
but having to navigate them (sometimes including different or conflicting requirements
for different services) can be a barrier even for eligible people.
Racism and discrimination continue to challenge AI/AN people creating obstacles in
school environments, and by service providers and the general public.
Urban Indians may have distinct issues regarding access and transportation due to being
geographically scattered.
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There may be a need for Tribes and UIHOs who implement an HV program to upgrade
technology for data collection and data sharing purposes.
Staff turnover can be a challenge.
FAMILY SPIRIT AND OTHER MODELS OF INTEREST
The T/U MIECHV Coalition and the MIH Workgroup have expressed interest in exploring and
learning more about three HV models that have demonstrated their effectiveness in Tribal and
indigenous communities:
FAMILY SPIRIT
An evidence-based and culturally tailored HV intervention delivered by Native American
paraprofessionals as a core strategy to support young Native parents from pregnancy to three
years post-partum. The Family Spirit Program consists of 63 lessons to be taught from
pregnancy up to the child’s 3rd
birthday. It is an in-home parent training and support program
designed, implemented, and rigorously evaluated by the Johns Hopkins Center for American
Indian Health in partnership with the Navajo, White Mountain Apache, and San Carlos Apache
Tribes since 1995. http://www.jhsph.edu/research/centers-and-institutes/center-for-american-
indian-health/Research_and_Programs/Current%20Projects/Family_Services/Family_Spirit.html
HEALTHY START PROGRAM
Healthy Start Program (HSP) is designed to prevent child abuse and neglect and to promote child
health and development in newborns of families at risk for poor child outcomes. The program
operates statewide in Hawaii and has inspired national and international adaptations.
http://www.hawaiifamilysupportinstitute.org/prevention-programs/the-hawaii-healthy-start-
program/
FAMILY HOME VISITING PROGRAM WITH ABORIGINAL FAMILIES IN SOUTH AUSTRALIA
The South Australian Children, Youth and Women's Health Service has adopted and adapted a
model of Family HV from the USA, using professional nurse home visitors and Indigenous
Cultural Consultants (ICCs) in program delivery for Aboriginal clients in South Australia. The
purpose of HV is to provide children with the best possible start in life and to assist families in
providing the best support possible for their children. Home visits are provided by qualified child
health nurses supported by a multidisciplinary team of psychologists, social workers, Aboriginal
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health workers and family brokers.
http://www.indigenousjustice.gov.au/db/publications/290119.html
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CHALLENGES AND LESSONS LEARNED
There were several challenges and lesson learned through the course of this project:
1. There is a lack of knowledge about the benefits of HV in Tribal and Urban Indian
communities. The project plan initially focused on gathering information in through
regional forums that focused on the status of HV services for mother and babies; gaps
and barriers to program participation and effective programs; culturally appropriate
strategies and recommendations for developing and/or expanding quality or capacity of
HV systems and local interventions; and development priorities, funding and leveraging
opportunities. As the project evolved, it became clear that an outreach, education and
training component would be useful to clearly communicate the benefits of HV to engage
Tribes and Urban Programs in the project.
2. Lack of Funds for Tribal and Urban Indian HV programs. It is difficult to ask Tribes and
UIHOs to allow staff involvement in a project that doesn’t currently have funding
available.
3. Methodology for Information Gathering and Established Protocols.
As a result of the HV and other similar projects, the AIHC has identified the need to
establish standardized protocol for information gathering to include involvement of an
Institutional Review Board (IRB) as a policy. This will increase AIHC’s capacity for
future assessment work and increase the level of engagement and ability to collect more
detailed information.
4. No two Tribal communities are the same. It is important to note this when discussing
culturally appropriate program designs. The models need to be flexible to meet the needs
of the people in each unique community. Also, it is important to note that there are
differences between Tribal and Urban Indian communities. This was apparent in T-U
MIECHV coalition discussions and forum responses.
5. The AIHC and Thrive by Five engaged in initial discussions regarding engagement of
Tribes and UIHOs in Thrive by Five’s work with rural communities. They have also
begun discussing a readiness assessment that Thrive by Five is working on. AIHC is
interested in continuing that relationship to learn more about the assessment and whether
it could be adapted for AIHC’s use with Tribes and UIHOs.
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FINDINGS AND KEY CONSIDERATIONS
1. Engagement in intentional outreach and education with tribes and urban tribal
populations to further the HV strategy in communities with AI/AN families.
a) This report establishes a baseline about HV in Tribal and UIHOs. Additional detailed
assessment work should be conducted to find out more about services provided and
determine T-U MIECHV Readiness.
b) There is a need for increased outreach and education about the benefits of HV and
cultural appropriate models.
c) There is a need for more training to understand and address cultural resiliency to
historical and intergeneration trauma and Adverse Childhood Experiences to support
strengthening families and HV efforts.
2. Engagement in ongoing efforts to support building cultural relevance, appropriate
cultural practices in current home visiting programs.
a) Evidence-based models need to be flexible and adaptable to be effective in Tribal and
Urban Indian Communities. It is important to continue to work with evidence-based
HV models to learn more about how they are working with Tribes and Urban Indian
Communities across the nation to adapt their models to be more culturally aligned.
b) This should include outreach strategies, trust building work, program staffing
considerations, approaches, formal “cultural adaptations”, relevant materials, data
usage and feedback loops for Tribal and Urban Indian Communities.
3. Exploration of HV programs shown to be effective with Tribal and Urban Indian
families.
a) Home Visiting programs need to be cultural appropriate to be effective Tribal and
Urban Indian communities. The Family Spirit model and other promising models
used in Indigenous communities should be examined by the T-U MIECHV coalition
for potential effectiveness in T-U communities.
b) Effort should be made to seek and identify funding to pilot at least one promising
practice and one evidence-based model with cultural adaptations should be a next
step. Funding should be for a minimum of two years to determine an initial result.
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c) Considerations should be given to the development of selection criteria, timeline,
readiness, resources and funding needed to pilot a culturally appropriate model.
4. Identification of opportunities to further link and grow work across Tribal and State
driven initiatives.
a) The partnerships between the statewide HV and the T-U MIECHV Coalition and Plus
Partners have been crucial to stay informed and build important networks to support
HV development in Tribes and UIHOs.
b) There are significant linkages between the HV goals and objectives and the MIH
Strategic Plan that should be explored and leveraged. The support and partnership
between DEL and DOH is significant to AIHC’s level of success.
c) There is public health and behavioral health work underway that have potential
linkages to HV models or systems. It would be beneficial to explore the possibility of
sharing expertise or leveraging opportunities in program and/or system development.
At a minimum, establishing a connection between AIHC, UW and DSHS
“Cradleboard to Career” conveners to discuss possible benefits would be useful.
d) AIHC and Thrive by Five Washington have just begun to establish a partnership to
support Tribal and UIHOs’ HV readiness.
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RECOMMENDATIONS
1. Continue T-U MIECHV Coalition monthly meetings.
2. Continue T-U MIECHV Coalition and Plus Partners quarterly meetings.
3. Develop Outreach and Education tools about benefits of HV.
4. Provide training regarding Resiliency to Historical and Intergenerational Trauma.
5. Provide training regarding ACEs and strengthening families.
6. Collaborate AIHC with UW and DSHS “Cradleboard to Career” conveners to discuss
exploring possible sharing of expertise, or if there are leveraging opportunities in
program and/or system development.
7. Further develop partnership with Thrive by Five to develop Tribal and UIHOs Readiness
framework.
8. Develop and conduct a HV Services and Readiness Assessment Survey.
9. Develop Engagement plan to include regional presentations to Tribes and UIHOs
regarding HV.
10. Merge the efforts of T-U MIECHV Coalition and DEL with the MIH workgroup and
DOH to leverage resources and efforts.
11. Provide Webinars/Education on Tribal/Indigenous HV Models: Family Spirit and others
identified by AIHC’s T-U MIECHV coalition and/or the MIH Workgroup.
12. Support and provide technical assistance to pilot a promising practice HV model and
evidence-based model with cultural adaptations.
NEXT STEPS
1. Present Report and Findings to key DEL staff—September 9, 2013.
2. Present Report and Findings to the AIHC Delegates for comments and final
approval—September 13, 2013.
3. Present Report and Findings to the Director of DEL and key stakeholders—Oct 7,
2013.
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REFERENCES
American Indian Health Commission for Washington State. (2010). Healthy Communities: A
Tribal Maternal-Infant Health Strategic Plan, Port Angeles, WA. http://www.aihc-
wa.com/wp-content/uploads/2011/09/MIH-Plan-web-FINAL-030811-13.pdf. Access10-
4-13.
American Indian Health Commission for Washington State. (2013). Tribal Leaders Health 2012
Summit Report: Journey Forward into 2014: “Healthy Tribal Communities”.
South Puget Intertribal Planning Agency. (2011). Needs Assessment 2011, Part 1: Facts &
Figures, Part 2: Stakeholder Input, Healthy Families Partnership for a Healthy Future.
United Indians of All Tribes Foundation. (2012). Ina Maka Family Program Community Needs
Assessment 2012. http://www.unitedindians.org/documents/IMFPNAMay12.pdf. Accessed 10-
4-13.
Washington Tribes & Recognized American Indian Organizations (RAIOs) Health Priorities
Summit. (2012). Summary Report, Cradleboard to Career. Prepared by: Thomas, Lisa,
Ph.D. and Austin, Lisette, MA, et al. http://uwashington.uberflip.com/i/106618/35.
Accessed 10-4-13.
Washington State Department of Health. Health of Washington State Report – Infant Mortality.
Olympia, WA: Washington State Department of Health; 2013.
http://www.doh.wa.gov/Portals/1/Documents/5500/MCH-IM2013.pdf. Accessed 10-4-13.
Washington State Department of Early Learning. (2010). Washington Early Learning Plan,
http://www.del.wa.gov/publications/elac-qris/docs/ELP.pdf. Accessed: 10-4-13.
Washington State Department of Health. (2010). Washington State Home visiting Needs
Assessment Narrative.
Washington State Department of Health. Revised, 2011. Washington State Home Visiting Needs
Assessment Narrative. http://www.doh.wa.gov/Portals/1/Documents/Pubs/950-165-
FinalNarrative.pdf. Accessed 10-4-13.