Annual EMSC Grantee Meeting

Indian Health Services EMS Update

June 20 – 22, 2006

JIM FLAHERTY: Good morning. We have some extra handouts at the back half of this side of the room. We ran out of handouts, so we made some more. So, they’re on the back table -- the round table. So, if people in the back half of this side of the room want to get up and get the handouts. There are three of them; there’s one on the slide, there’s one that is a booklet -- a draft booklet, and there’s a one-page profile of the Indian Health Service.

So, Betty Hasting and I are going to split this talk. I am going to give the first half and talk to you about a profile of Indian Health Service and give you some background on the interagency agreement and some specific data on injury mortality on Alaskan native and American Indian children. And then, Betty is going to talk specifically about the objectives of the interagency agreement and her work plan. So, for those of you who aren’t familiar with the Indian Health Service, we are an agency of the Department of Health and Human Services.

Many people think that Indian Health Services is a part of the Bureau of Indian Affairs and it used to be, about 50 years ago, but since we’ve moved on to first, health, education and welfare and now, HHS. We are an agency of HHS just like HRSA is and the CDC and the NIH. And our director reports to the Secretary of Health and Human Services.

In terms of the organizational structures of the Indian Health Service, the one-page profile that I gave you, gives you a fair amount of detail. I’m going to give you some few items to think about. We have three levels of function and one is our headquarters level of function, which is largely political in terms of working with congressional offices for the appropriation of the Indian Health Service. And now, we have 12 area offices, which are not the same as the DHHS regional offices. Ours are geographic offices and I’ll show you a map, and they have to do with associations of tribes more than they do with HHS regions. And then, we have service units and the sum total of all the facilities that come under Indian Health Service and tribal programs are 48 hospitals and 585 clinics. And budgetary information and breakdown of patient visits and those kinds of details are on your one page.

Within the Indian Health Service, Dan mentioned that we have a new office and it’s called the Office of Emergency Services. And there are six people out of seven have taken positions in this office. We have a director; his name is Sid Caesar, because his nickname is Steve Caesar. His information for contact is on the back. I’m the EMS Medical Director and Betty is the EMS Coordinator there in yellow. The director and the three positions at the bottom are the -- and Betty holds the full-time and headquarter-based positions. This is exciting, because what in for the purposes of emergency services and particularly the medical emergency services, we have never had an office and never had a line item budget and operated through pathways of indirect funding and indirect management.

So, this is a new place for us to be and it’s an exciting one and we have within this office, both Emergency Preparedness and Emergency Management, Trauma Systems and EMS of course and Betty’s interagency. Her position as the coordinator of the interagency agreement is within this office.

I mentioned we have 12 areas and there’s the map, and you can see that each area has a name. The area where you see the words, Headquarters East in the eastern United States represents just to the office in Rockfield. The gray area, that’s the background there, are the states that have no reservations. So, all the colored areas are states that have reservations and there are 35 reservation states.

In terms of the interagency agreement, the interagency agreement with the Indian Health Service between HRSA and the Indian Health Service was started in 1999. It was started because of the vision of Dr. David Heppel in maternal child health bureau because he recognized that the EMSC Act of 1984 had special target populations and one of them was Alaska Natives, American-Indian children, their families and their communities and yet, there was no direct fund in eligibility to tribal governments. So, Dr. Heppel decided that an approach that we could take would be to develop an inter-agency agreement with the Indian Health Service and that’s what he did. And I think his vision has carried us to a point where through years of struggle we may actually be able to, now in our new office and with Betty’s position being in headquarters, really implement some of the resources of the EMSC program into all our tribal communities.

In thinking about the facility number that I gave you with the Indian health service there were about 50 hospitals and over 500 health clinics, you need to know the perspective that in that setting there are 80 tribal EMS programs and they are in 25 of the states, then they’re spread all over the country and so, twenty five of you EMSC coordinators are going to have reservations with Tribal EMS programs in your states and the other 25 of you aren’t.

So, the interagency agreement started in 1999 and it was service unit based in Navajo Area. I was a part time EMSC coordinator and since then, beginning in 2003 we moved the position to IHS headquarters and developed it as a full time position. And now in 2006 we have this new office in the division of clinical and preventive services that has other inter-agency agreements with other departments in the government to help support the function of emergency services. It’s important to know that other states, I shouldn’t say other states, some states here have done some great projects with tribal EMS programs, tribal governments particularly with regard to injury prevention and with regards to secondary education for tribal EMTs.

When I think of tribal EMS programs, I think of them as being equivalent to rural EMS programs and we participated and we, meaning the IHS and tribal EMS programs, in the writing of the rural and frontier EMS Agenda and so that’s the context in which I think of it and I also think of it in terms of our own health needs and health challenges. At this point, we’re going to look at a little brief video that will make you all happy that you have job security because as we know, a lot of what we do is work with injuries and Betty brought to us, anytime you can start the video on the next slide that will be great.

UNKNOWN SPEAKER: All right.

UNKNOWN SPEAKER: It worked earlier.

JIM FLAHERTY: I don’t know if any of you ever seen it, I haven’t seen it. Betty showed it to me and we decided to put in our presentation is a little levity about on what we do, this is from America’s Funniest Videos but if it’s not going to work we can go on.

UNKNOWN SPEAKER: All right.

JIM FLAHERTY: Okay, well. One of the challenges for the inter-agency agreement for the Indian Health Service has been to bring the resources of the EMSC program and the expertise out to these remote world areas; 80 tribal EMS programs, many more facilities with emergency departments and urgent care. And we actually tried to incorporate many of the goals and objectives of the five-year plan that were aimed at all children not just Alaska Native and American Indian children, which is the area that I work in.

But one of the things that you need to know about our target population -- my population that I work in is the target population of the EMSC languages, is that we actually have a very high injury mortality rate, as well as very high number of years of productive life lost and the next four slides we’re going to show you some of that injury data which is I think very disturbing. And there’s a doc here from Washington, Bryan Johnson who works in Harbor view who -- Bryan where are you? He has worked for years in injury prevention activities starting out his career at Crown Point in New Mexico. I think I pushed the wrong button. Thank you.

Some basic facts about the epidemic of injury in Indian country, injury takes the life of one Native American child or teenager everyday. When you consider that the overall population that served on reservation is about 1.8 million, that’s a significant number. And injury kills more Native American children than all causes combined and I’ll show you the pie chart to really drive that point home, and compared to the size of the problem that really receives not as much attention as it should. And there’s our age-related death rates from American Indian children for those years but we know them up to 2004 and the pie chart hasn’t changed. But you look at all the other causes and the infectious disease causes, as well as cancer and congenital hearth disease, and injuries are the leading cause of death and actually, within our population, injuries are the leading cause of death up to age 54.

Now, we know that’s not any different in the United States for all races for ages 1 to 44, but what is different is our rates of injury, they are much higher. In general, they are two to three times higher than the US all races rate. And there’s our mechanisms of death. And you can see that most of them are motor vehicle crashes and about 20 percent of those are alcohol related. And then, we have a high rate of intentional injuries as well.

But the public health impact is significant, we have the highest unintentional injury rates of any racial groups in the country and motor vehicles are the third leading cause of death versus eight in the United States. We have the high suicide rates in our young people and the second highest homicide rates. If you add all mechanisms of injury for unintentional injury and intentional injury together, they actually are the leading cause of death for native American people ages 1 to 44, above diabetes, heart disease and cancer. And for bi-mechanism of injury, the rates range from one and a half to eight times greater depending on the region and the cause and the age group. So, at this point, I would like to turn the podium over to Betty who’s going to specifically talk about the interagency agreement, objectives and work plan relative to the information that I’ve given you. Thank you.

BETTY HASTING: Good morning everybody. It’s good to see old friends and hopefully, makes some new friends before I leave; and this is an exciting time in the program that Dan is so generously funded to have at IHS. And the goals of the interagency agreement, I’ve learned over time, and can reframe now, are to facilitate the opportunities between tribes and state programs toward relationships because I’ve learned that absolutely nothing will happen without that relationship and it’s taken me two years to find the resources in the community to make the connections to get out and actually talk to people about doing some real work and know we will have the ability to follow up and follow through.

And the, another role of the inter-agency agreement is that I am a liaison to other federal organizations and activities for Indian Health Service. I fund an interagency agreement with Mountain Plains Health Consortium who has a pediatric trainer as an FTE and actually takes the equipment and goes out to the reservations to do the training because we found that that’s much more practical and much more affordable. And then, with the injury prevention activities, I’m funding the ride safe program for the next three years that NITSA Funding will end in FYO6, and also helping to get them, Protecting You, Protecting Me Program which is an agreement between mothers and (inaudible) and Indian Health Service to help get that up and running and started. And then, to strengthen the pediatric infrastructure at the National Native Organization went through their conference what they’re offer in terms of training but also their membership.

One of the objectives of my work plan was to bring together state, local, federal and tribal people to develop consensus recommendation guidelines for all of you, to guide you on how to work with the tribal programs in your states and I’m happy to tell you it’s in your chair, it’s rolled out it’s our first final draft and I believe a very historical document in a very historical event to have federal, state, tribal government, local government and local participants all come to consensus in a day in a half and with this document should like. I actually think the greatest benefit, was that none of us has any money to fight it over so we had to really come together and figure out how we can share resources, and I think I’m on to something with that. Bring no money you have no fighting. Let’s see what we here.

The brochure of essential information, which is on your desk and on your seat and if it’s not, we have extra copies in the back or there maybe some extras on the empty seats, addresses these six things. And this was laid out by the group and what we will do is develop a fancy culturally appropriate booklet, that will be available hopefully through the resource center and through Indian Health Service in my program. A cover letter will go out with it explaining what it is and what the goal is, which is to bring together state EMS for children, grantee managers with tribal EMS, program directors but there’s a way to do it that’s culturally appropriate and respectful of the government to government relationship and it’s based to these things.

Culture considerations you need to know when you go out to a reservation and want to work with tribes. It’s just not simply showing up and saying, “I’m here to help and I want to share my resources.” It’s much more involved than that. And we hope that we’ve spelled it out in these new guidelines merely signing be that it and then on how to proceed, a step by step of how to proceed and I’m available by request if you would like me to help facilitate in any part of that and there -- like Jim said, there will be 25 of you and I really want to thank Doreen Risley from Alaska, Claudia Hines from Minnesota, Zenith Ritchell and Diana Fendi who sat on the committee to help make this happen and brought great perspectives.

The how to for this looks like this: you the EMSC grantee will contact your NRC -- I wasn’t sure what to call Diana yet. I need to get with her -- the NRC coordinator, liaison, who will then contact me and say this grantee would like to do some things with this tribe in your state. There are 80 tribal EMS’s and so divide that amongst this 25 states. I will then send out letters to the tribal EMS program director, that program director supervisor and the stadium SC manager and then from there, hopefully, the ESMC grantee and the tribal EMS supervisor will make contact and I’d be happy to facilitate that part, and then let me know how it goes and we can take it from there and hope to follow up and develop relationships and opportunities for sharing resources. It’s really not that complicated. It was just figuring out what it needed to look like.

Another exciting development in the program is the IHS tribal EMS for children assessment. There had been previous assessments done, however, none of them captured anything about pediatric needs and these are -- and one I really think, Diana Fendi and Mike Ely, who sat with the panel of many other people. And I try very hard to be sure to include a community that we’re serving in everything that we do. And these are the areas of data that we’re going to collect, the equipment and just as you are all responding to the performance measures, we are too, in my program; to be able to provide that information to Dan Shuck.

So, these rural data points that we’re collecting and the really awesome thing is, I know I probably will get at least 99 percent participation because I’m offering a huge scholarship for the recipient that completes and gets it back to me within three weeks. A full scholarship to the National Native American EMS Association Conference which one will help build their membership, which is much needed. But also will help bring in greater tribal representation from all around the country versus the ones that are more local to Nevada, where their conference is held. So, I am very excited about that too.

So, the goals of the interagency agreement are to facilitate the collaboration between your program and the tribal EMS programs, to provide and share information, to take this booklet, that you have a draft copy of and turn it into -- how many of you are familiar with Rainbow Series Books in the programs? We would like to develop something comparable to your Rainbow Book Series with what we’re doing in IHS and with tribes and then to get the information back from the assessment, have it analyzed and be able to really concretely direct the program and the activities. And also hopefully create opportunities with the information for shared resources between you and them, and then, to utilize the performance measures.

What I believe it takes is vision; a common vision. Time, it can be frustrating, but it really, really does take some steps to make it (inaudible) to tribal communities. Persistence, don’t give up because it doesn’t go as planned and accordingly in the beginning. It takes resources. No matter how small, it still takes resources for opportunity. Respect for differences, that’s really important and relationships, because without them, it is really not going to happen. This is a challenge I leave you with, where and who the tribal EMS programs in your state? What are their needs and how can you start working with them? And that’s the challenge I leave you with today.

These are your contacts; they’re in your handout for resources. That’s me, open door, open-phone policy. Call me anytime I can be of help to you. And thank you for having me today and I thank Dan for his generous support of what I believe is a program that’s really getting ready to take off. So, any questions? I’m really sorry I didn’t see the video. It’s hysterical. Maybe next time. Thanks.