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National Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report & Appendices July 2009 Submitted to: Substance Abuse and Mental Health Services Administration Child, Adolescent and Family Branch 1 Choke Cherry Road, Room 6-1047 Rockville, MD 20857 Under Contract Number 280–05–0135 Submitted by: Walter R. McDonald & Associates, Inc. ICF Macro Study Team: Holly Echo-Hawk, M.S. Michelle DiMeo, M.A. Nancy Weller, B.A. Carolyn Lichtenstein, Ph.D. Katherine Lewis Brown, M.B.A. Elizabeth Oppenheim, J.D. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report & Appendices • Page i Table of Contents Introduction ................................................................................................................................. 1 Description of the Study ................................................................................................................. 2 Tribal Starting Place—The Cultural Framework ................................................................................ 3 Planning for Sustainability .............................................................................................................. 4 Political Entities and Sustainability ................................................................................................... 5 Developing Sustainable Services ..................................................................................................... 6 Strengthening Infrastructure ........................................................................................................... 8 Role of Data in Financial Sustainability ............................................................................................ 9 Assessing and Mobilizing Funding Sources .................................................................................... 10 Determining the Cost of Services .................................................................................................. 12 Medicaid as a Funding Source ..................................................................................................... 12 Developing and Sustaining Key State Partnerships .......................................................................... 14 Implications for Long-Term Financial Sustainability ........................................................................ 15 Recommendations for Financing and Sustainability in American Indian and Alaska Native System of Care Communities ....................................................................................................... 16 Planning for Sustainability ....................................................................................................... 16 Interacting With Political Entities Regarding Financing ............................................................... 16 Developing Sustainable Services .............................................................................................. 17 Strengthening Infrastructure .................................................................................................... 17 Using Data in Financial Sustainability Planning ........................................................................ 18 Assessing and Mobilizing Funding Sources ............................................................................... 19 Determining the Cost of Services ............................................................................................. 19 Determining the Feasibility of Medicaid as a Funding Source .................................................... 20 Developing and Sustaining Key State Partnerships .................................................................... 20 Appendices Appendix A. Understanding the Challenge: The Cultural Framework ...................................... A1 Appendix B. Purpose and Description of the Exploratory Description Study ............................... B1 Appendix C. Findings From Discussions With Project Directors, Fiscal Managers and Tribal Board or Council Representatives ...................................................................... C1 Appendix D. Findings From Interviews With State Representatives ........................................... D1 Appendix E. National Evaluation Sustainability Study Findings for Tribal System of Care Communities .................................................................................................... E1 Appendix F. Discussion Guides ............................................................................................. F1 Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report & Appendices • Page ii Index of Tables Table 1. American Indian and Alaska Native System of Care Grant Communities ........................... 2 Table B–1. American Indian and Alaska Native System of Care Grant Communities ......................... B2 Table E–1. General Strategies for Maintaining Tribal Communities’ Systems of Care ........................ E2 Table E–2. Financing Strategies for Maintaining Tribal Communities’ Systems of Care ...................... E3 Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 1 Introduction he Comprehensive Community Mental Health Services for Children and Their Families Program (also referred to as the Child Mental Health Initiative [CMHI]), funded by the Center for Mental Health Services (CMHS) at the Substance Abuse and Mental Health Services Administration (SAMHSA), was initiated in 1992 to provide grants to States, communities, territories, and American Indian and Alaska Native (AI/AN) communities to develop systems of care to serve children and adolescents with, or at risk for, emotional disorders and their families.1,2 A system of care promotes the full potential of all children and youth by addressing their physical, emotional, intellectual, cultural, and social needs.3 AI/AN communities entered the system of care movement in 1994 with the initial Federal grant award to the Restoration of K’e: The Navajo Nation Child Mental Health Project, located on the Navajo Reservation in New Mexico. The experiences of this initial Tribal venture into the world of national system of care reform helped to open the doors for the Tribal communities that followed. Fifteen Tribal communities were funded between 1994 and 2006 and they represent the broad diversity of Tribal people (see Table 1 for a list of the grant communities and their primary States of residence).4 Their cultures and languages are as diverse as their geographic locations, which include rural reservations, Urban Indian communities, and Alaska Native villages. Half of the Tribal system of care communities were previous recipients of a 3-year Circles of Care planning grant. The Circles of Care Initiative— 1 For the purpose of this report, the terms “American Indian/Alaska Native,” “Native American,” “Indian,” and “Tribal” are one and the same. 2 The 125 communities that have received, or were receiving at the time of the study, funding through CMHI represent all 50 States and two U.S. territories. 3 http://systemsofcare.samhsa.gov/, retrieved March 25, 2008. 4 CMHI grants were awarded to 13 Tribal sovereign nations and two Urban Indian organizations between 1994 and 2006. described by community representatives as invaluable—supports federally recognized Tribes, State-recognized Tribes, and Urban Indian communities with financial and technical assistance to plan a culturally respectful mental health system of care. The material presented in this report is supported by additional material included in the following report appendices: ■ Appendix A. Understanding the Challenge: The Cultural Framework ■ Appendix B. Purpose and Description of the Exploratory Description Study ■ Appendix C. Findings from Discussions with Project Directors, Fiscal Managers, and Tribal Board or Council Representatives ■ Appendix D. Findings from Interviews with State Representatives ■ Appendix E. National Evaluation Sustainability Study Findings for Tribal Communities In addition, the discussion guides used to gather the data summarized in this report can be found in Appendix F. T Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 2 Description of the Study The purpose of the exploratory study, conducted between July 2007 and January 2008, was to examine the unique financing opportunities and challenges of Tribal systems of care in relation to program sustainability. The overall goal of collecting the information from this exploration was to use study results to identify and improve financing and sustainability strategies specifically for Tribal communities. It is important to note that the findings of the study are based on a small number of participants (two or three staff from each of the 15 Tribal system of care communities) and the findings cannot be generalized to all Tribal communities. The National Evaluation Team facilitated telephone discussions and conducted site visits with Tribal system of care communities funded by CMHS between 1994 and 2006. Telephone discussions with the project director and fiscal manager of all 15 communities covered broad thematic areas that included perspectives on sustainability; the economic, social, and political environment; infrastructure; services; and funding. The discussions, conducted from July through October 2007, were unstructured, but were steered by a topical guide. In addition, site visits were conducted with five Tribal system of care communities between November 2007 and January 2008. On-site discussions were held with a project director, fiscal manager, Tribal Board or Council representative, and State representative. These discussions explored financing and sustainability successes and challenges in more depth than the telephone discussions. Discussions with State representatives Table 1. American Indian and Alaska Native System of Care Grant Communities System of Care Population of Focus State Funding Period Graduated Communities Restoration of K’e: The Navajo Nation Child Mental Health Project Navajo Nation New Mexico 1994–1999 Sacred Child Project North Dakota Tribes North Dakota 1997–2003 Kmihqitahasultipon (“We Remember”) Project Passamaquoddy Nation Maine 1997–2003 With Eagles’ Wings Project Northern Arapaho and Shoshone Tribes Wyoming 1998–2004 M’no Bmaadzid Endaad Program Sault Ste. Marie Tribe of Chippewa Indians and Bay Mills Tribe of Chippewa Indians Michigan 1998–2004 People Working Together Project Yup’ik Eskimo and Athabascan Indians Alaska 1999–2005 Nagi Kicopi–Calling the Spirit Back Project Oglala Sioux Tribe South Dakota 1999–2005 Ak-O-Nes Project Northern California Tribes California 2000–2006 Currently Funded Communities (at the time of the study) Choctaw Nation CARES Project Choctaw Nation Oklahoma 2002–2008 “Ch’eghutsen” A System of Care Alaska Native Communities Alaska 2002–2008 Urban Trails Project Urban Indian Community California 2003–2009 The Po’Ka Project (Blackfeet Children System of Care) Blackfeet Nation Montana 2005–2011 Tiwahe Wakan (Families as Sacred) Yankton Sioux Tribe South Dakota 2005–2011 Seven Generations System of Care Urban Indian Community California 2005–2011 Sewa Uusim Systems of Care Pascua Yaqui Tribe Arizona 2006–2012 Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 3 focused on State agency support for Tribal systems of care. A Native researcher conducted all discussions in a culturally competent manner; respect for AI/AN historical concerns about data gathering and data analysis guided the entire research process. The notes taken for all discussions were qualitatively analyzed by isolating emergent themes. Tribal Starting Place—The Cultural Framework The core values of a system of care specify that services should be child-centered, family-focused, community-based, and culturally competent—all values shared with many Tribal communities as part of their traditional values and beliefs. Most of the Tribal communities further capitalize on this alignment by translating the system of care terminology and approach into phrases and terms that are meaningful to their Tribal cultures. Tribal communities understand the relationship between a cultural foundation to services and improved outcomes for Tribal youth and families, and use the system of care framework to strengthen the development of healthy Tribal nations. The cultural importance of program sustainability cannot be ignored. Sustainability of community mental health programs is especially important within Tribal communities that lack financial resources. For example, one leader of a Tribal community-based substance abuse prevention and intervention program stated, We have a responsibility to our program recipients. They’ve had so many losses in their lives, and [if we] come in for a year or two or three and give them hope, only to have the program go away, we’ve just caused another loss and further hopelessness in their lives.5 5 Noe, T., Fleming, C., & Manson, S. (2004). Reducing substance abuse in American Indian and Alaska Native communities: The Healthy Nations Initiative. In Nebelkopf, E. Although the system of care principles and Tribal belief systems may be in alignment, Tribal systems of care continue to face serious challenges in developing and implementing financing strategies for sustainability. Financing any system of care is a strategic endeavor that involves determining what funds will be used, how they will be used, and how they will be managed.6 However, the financing of Tribal systems of care is particularly complicated. This is due to many reasons, including the lack of financial resources in remote Tribal communities, the impact of Tribal–State history on the willingness and ability to pursue financial partnerships, and the potential funding sources’ lack of knowledge about the advantages of working with Tribes. Adding to the complexity of the challenge is the meaning of federally recognized Tribes’ sovereign status as it relates to financing; the role of Tribal self determination; the history of confusing policies guiding support for Tribal services; the financial options of Tribes that are recognized by States, but lack Federal recognition; and the unique financial situation faced by Urban Indian communities. These challenges become barriers to reform when there is & Phillips, M., (Ed.), Healing and mental health for Native Americans. New York: Altamira Press. 6 Stroul, B. A. (2007). Issue brief 1: Effective strategies to finance a broad array of services and supports (RTC study 3: Financing structures and strategies to support effective systems of care, FMHI pub. #235-IB1). Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 4 a lack of cross-cultural and cross-system problem solving. Planning for Sustainability Findings Many of the Tribal system of care community representatives stressed that active and early planning for sustainability was critical. Community representatives discussed how planning for systemwide transformation built on a foundation of Tribal beliefs and Tribal ownership provided an opportunity to break away from a previous cycle of non-productive “planning” that had been reactionary and short-term in nature. Some community representatives felt that recognizing the impact of colonialism and historical trauma on the Tribal community’s efforts to plan was an essential first step in breaking non-productive cycles. One community representative argued that there was little value in building large-scale services with Federal funding if there was no effort to plan for long-term sustainability. Additionally, a few communities cautioned that fast program growth resulting from an infusion of Federal funds can diminish the quality of service provision if the service structure is not carefully planned; community representatives recommended expanding services carefully and only to the extent that supports are in place to ensure quality service provision. The Tribal system of care communities engaged in a number of approaches to planning, which usually began with their seeking input from the local community on needs and service priorities as part of their logic model development.7 Many Tribal community representatives discussed the value of gathering data about their community’s strengths and needs to help with program planning and to 7 A logic model is a process to articulate the theory of change underlying systems of care for children and families. It is a tool for describing theories and beliefs about how and why service systems are expected to produce particular results. increase their competitive edge with other funding opportunities. Some of the planning approaches used by the Tribal communities included ■ developing local definitions of health and wellness with the input of community members and Tribal elders; ■ having Tribal elders help design strategies to infuse Tribal values, practices, and cultural supports throughout their system of care; ■ analyzing all of the fund sources that affected the Tribal youth and families in their States of residence, and then determining which of the fund sources they currently accessed and which they needed to pursue; ■ determining the true cost of services using time and cost studies; ■ incorporating visits to the State Medicaid office to better understand the Medicaid provider and billing requirements; ■ using a backward mapping process to identify the community’s ultimate goal and detail the steps necessary to reach the goal without sacrificing cultural integrity; ■ developing ways to build evidence of effectiveness and a cost base for traditional practices; ■ developing methods to track the non-Federal matching fund requirement. Discussion The close alignment of system of care values and principles with many Tribal values and beliefs empowers a Tribal system of care to include the Tribal community in its planning efforts. System of care grant requirements such as providing culturally competent services that best meet the community to be served, creating ways to ensure family-driven and youth-guided care, consistently evaluating the factors related to child and family progress, and developing a social marketing plan that helps the community understand the meaning of a system of care are all opportunities for a more culturally and Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 5 linguistically appropriate and inclusive planning model. Authentic community involvement in all levels of planning not only gives family voice to the process, but can clarify community needs and wants, and helps to determine which elements of the system of care should be sustained after the Federal grant ends. The Tribal system of care communities stressed that adherence to the cultural strengths of Tribal values becomes the screen through which all services and fund-seeking decisions must pass. Within this framework, the written sustainability plan can clarify financing priorities, outline steps to be accomplished toward each financing priority area, list timelines for the completion of tasks, designate key leadership roles and responsibilities, and detail benchmarks to monitor progress toward long-term sustainability of the Tribal system of care. Political Entities and Sustainability Findings The willingness of those who hold the power and authority to make funding decisions has tremendous influence on the financial sustainability of the Tribal systems of care. The AI/AN systems of care described the ways in which their sustainability efforts were impacted by government agencies at the Federal, State, Tribal, and county levels. Each Tribal system of care community described making significant investments of time to increase the government funding sources’ knowledge about why system of care services are needed and why Tribal-driven services increase community access and produce better outcomes. This work included providing education about Tribal culture, Tribal needs, Tribal sovereignty, and the Tribal approach to child and family services. The Tribal systems of care became expert in ways to generate political and policy-level support for their systems of care through education and relationship building. Tribal–State relationships varied by State, often for historical reasons, and community representatives reported the value of developing partnerships with key State officials and administrators. Many community representatives participated in State and county planning meetings to make Tribal needs known, but pointed out that Tribal staff time was limited and travel to State or county planning meetings was time consuming. Tribal system of care communities also provided numerous examples of their efforts to monitor and influence State health planning initiatives, such as social marketing efforts to draw policy attention to Tribal family needs. A further complication is that several of the Tribal system of care service areas encompass multiple States, resulting in a multilayered process of developing relationships with State administrators and the need to understand multiple State child-serving initiatives. Many community representatives discussed the impact of Tribal politics on their sustainability planning efforts. Some communities reported that frequent elections of Tribal government officials were disruptive to sustainability planning; the Tribal election process can occur as frequently as every 2 years, and the system of care staff had to repeatedly provide orientation about the transformative meaning of “systems of care” to prospective, or newly elected, leadership. Community representatives also discussed the impact of turnover in key Tribal government positions that lead to a shift in priorities for the Tribe or Tribal organization. Community representatives emphasized that Tribal elections sometimes caused rules to change overnight. Discussion Support from those with power and influence over funding decisions is critical for the sustainability of any system of care, but the Tribal systems of care have the additional task of educating funding sources about their culture and approach to Tribal services. Tribal systems of care spend a significant Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 6 amount of time explaining what services and supports work for Tribal families, developing ways to document the benefits of their service array, and negotiating strategic alliances that support the sustainability of their systems of care. In order to sustain financially, the Tribal system of care communities must advance each of these areas. For example, although each Tribal community is aware of what mix of clinical and cultural supports works best for it, there remains a need to better articulate how the cultural supports may help advance the clinical interventions, or how clinical and/or medical interventions may help open the door for increased understanding of the stabilizing role of cultural supports. Also, Tribal academicians, researchers, and evaluators are interested in better describing the benefits of a Tribal service array, but many struggle with how to describe the intersection of the different world views represented by clinical and traditional services. And, while Tribal communities are experienced in developing tactical alliances, the ultimate accomplishment of turning allied support into actual contract dollars remains a challenge. Developing Sustainable Services Findings The Tribal system of care communities described their efforts to build an array of services that best responded to the behavioral health needs of their community. Their inherent knowledge of all things Tribal (social and cultural lifestyles, spiritual beliefs, values, communication styles, and resources) offered a cultural advantage in designing services to match the local need. In general, not only do the program names of many Tribal systems of care reflect the AI/AN value of honoring children and youth, but their arrays of services reflect that their culture is the foundation of their services. Some of the communities addressed an ongoing workforce shortage in Tribal behavioral health by investing in training and credentialing programs for staff to increase the quality of care and to provide career advancement steps for paraprofessional staff. In addition, several Tribal communities were successful in marketing their training program to the State, which resulted in modification of State provider standards to enable the certified, Tribal paraprofessionals to meet requirements for third-party reimbursement. These successful partnerships between the Tribal systems of care and State governments resulted in training and education programs that met State credentialing requirements as well as the cultural service needs of Tribal communities. Many Tribal systems of care encouraged partnership with the State from the beginning of the curriculum development to ensure that any obstacles to becoming a State licensed provider of behavioral health services were readily addressed and resolved. Community representatives described successful partnerships with Tribal community colleges and universities to develop and provide training. One community representative noted that while higher education strengths lie in providing an academic foundation to behavioral health knowledge, such a setting may not always be as successful for teaching the practical skills needed by staff to provide mental health services. Given the urgent situations of many Tribal youth, some communities felt that Tribal system of care staff needed on-the-ground clinical skills more than academic theory. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 7 The Tribal communities developed a range of approaches to address the role of culture as part of the assessment and treatment planning process, including ■ relying on local cultural advisors to guide the development of the services; ■ developing extensive cultural assessment protocols based on the local definition of wellness; ■ developing treatment goals to include both a clinical and cultural assessment; ■ setting the pace and location of the “treatment” according to local culture and individualized needs; ■ developing Tribal behavioral health training that benefited both the Tribal practitioner and non- Native clinical supervisor; ■ incorporating traditional practices into the “treatment” plan that were individualized according to particular Tribal beliefs and family requests. Many of the Tribal communities discussed their struggles with determining whether and how to seek financial support for traditional practices. Traditional practices can be defined in many different ways and are an important cultural link to the healing process. In general, the Tribal systems of care expressed concern that seeking financial support for traditional practices might result in requirements for adhering to licensing and accreditation standards. Tribal community representatives suggested various solutions, which included ■ developing a line item in their system of care budgets for broadly defined cultural supports, which might include traditional practices; ■ including references to traditional practices within their system of care coordinator certification process; ■ cross-walking the “treatment” goals of Tribal traditional practices with their clinical outcome counterparts. Whether a treatment approach was referred to as a traditional practice or not, many felt that promoting culturally competent service provision was just as important to the sustainability of their system of care as securing financial resources. In addition, several communities discussed the impact of the large infusion of Federal system of care grant dollars on their program design. Although the Federal support enabled the community to pay detailed attention to all elements of Tribal service provision, a few communities advised that too much program growth too quickly could diminish the quality of service provision. That is, the addition of staff without program underpinnings in place (e.g., a full orientation to the system of care framework, training on system of care service expectations, and an understanding of how the service array links to outcome measures) could mean that the newly hired staff were not able to work effectively as a team of system of care providers. Therefore, some community representatives recommended building slowly and expanding services only to the extent that quality service provision could be assured. Discussion Tribal systems of care are challenged by building services that can be sustained beyond the Federal grant. This requires that the system of care leadership maintain a balance between cultural and clinical knowledge, address workforce recruitment and training needs, provide effective supervision and oversight, and develop meaningful ways to measure outcomes related to the full range of their services. Training and education costs are critical for workforce readiness, and supervision supports could be an important element of workforce retention. Another program cost is Tribal administrative time, essential for building Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 8 relationships and educate funding sources on the value of Tribal-driven services. Strengthening Infrastructure Findings Each of the Tribal system of care communities was at a different point on the continuum of infrastructure development. Those that were part of a Tribal primary health care organization often had a reasonably strong infrastructure in place (e.g., computerized care management documentation, an information technology department for computer trouble shooting, a fully staffed finance and billing office). Tribal systems of care that were not attached to a health care system often had to build their organizational infrastructure from the ground up. This was complicated by their remote locations, which hindered their ability to recruit and hire staff to support their infrastructure development. The communities discussed how the lack of local and well organized culture-based services contributed to the disproportionate numbers of American Indians and Alaska Natives in juvenile justice, foster care, child welfare, and behavioral health systems. Most Tribal communities are rich in culture, but poor in financial resources. When funding for services is received in such high need communities, the immediate focus is on delivering services to the community. Strengthening the service system infrastructure often takes a back seat to mobilizing services to meet the community need. One community representative suggested that Tribal communities should take the time to build a solid administrative and financial infrastructure, one that is designed for growth. Another community representative reported that hiring or contracting with a public accountant to review the Tribal system of care’s accounting system, billing capacity, and fund oversight was an essential step in building such infrastructure. Community representatives discussed other aspects of their organizational infrastructure that affected their system of care, including the following: Internet. The remote locations of many of the Tribal systems of care have sporadic Internet connectivity. This was mentioned as affecting electronic billing capability and diminishing their ability to comply with State contract performance standards, such as those mandating a maximum time period between when the service was provided and when the data was input into State databases. One community that increased its use of electronic communication found that many members of its Tribal Council were unfamiliar with the technology, so that training had to be provided to improve the Council members’ comfort and skill with computer technology. Office space. Office space is extremely scarce for many Tribal communities, as is housing for newly recruited staff. Due to a lack of available office space, several communities reported having uncomfortable working conditions or offices scattered across several locations, creating a barrier in staff unity. To address the lack of space, some communities received office space from school districts to provide school-based services. Other communities built their own facilities. Building office facilities, which also served as community centers, was a large part of promoting program sustainability for these systems of care. Billing infrastructure. Tribal billing capacity is critical for many financial sustainability plans, but many finance staff in smaller Tribal organizations have a narrowly defined responsibility of meeting payroll and billing a grant funding source on a once-a-month basis. Thus, establishing a complex, third-party billing system can require a huge investment of resources. Technical assistance from State representatives was helpful for some to better understand their billing processes and reduce future billing errors. Others reported facing the challenges of insufficient financial software or keeping up with Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 9 necessary software upgrades to meet the changing requirements of payers. On the other hand, those that were part of a large Tribal health care organization reported being able to tap into existing billing infrastructures, making the transition to billing for mental health services less challenging. Staff transformation. Some community representatives discussed the challenge of transitioning Tribal direct service staff from a long history of working within a grant funding environment, with no uniform expectation for a specific number of direct service hours per week, to a billable service hour model. The billable hour model requires that each staff person work within specific weekly service expectations that include an established goal of a certain number of billable service hours. Transitioning staff into billable hour performance expectations was successful when the Tribal organizations turned the billable hour expectation into a visible team effort that emphasized increased service to the community. Discussion Many Tribal organizations have made important advances in strengthening their organizational infrastructure as part of sustainability planning. Consultation with financial oversight and grants management advisors has been helpful and has resulted in a list of action steps to achieve a stronger infrastructure. Many Tribal systems of care have gained much support and advice from peer-to-peer learning opportunities. Establishing relationships with State funding sources and State contracts offices has been useful in better understanding data requirements and billing processes. Tribal systems of care have gained additional insight by exploring a State or national accreditation process that provides a list of action steps to prepare for accreditation. Continuous awareness of integrating cultural norms into the infrastructure development is critical. Developing a process for continuous quality improvement (CQI) is another important step toward financial sustainability. Unless a CQI process is institutionalized within the Tribal organization—especially in communities where the need for services is great and the environment may frequently be crisis driven—it can be easy to lose sight of the sustainability plan. Institutionalizing a CQI process requires the formal allocation of responsibility for quality improvement to a person or team with the power and authority to transform and improve services and financing opportunities. It is helpful for this person or team to have experience in managing in a changing environment. Role of Data in Financial Sustainability Findings The Tribal system of care representatives discussed general concerns about data collection that reflected the historical mistrust held by many Tribes. Tribal hesitation about data collection, ownership, and analysis is based on the historical misuse and abuse of Tribal data by some non-Tribal researchers. However, many community representatives also recognized the importance of tracking service use information as part of financial reporting. The system of care funding legislation requires grant community participation in a national evaluation of system of care implementation; some Tribal communities have used this involvement as a springboard to further develop their own local evaluation efforts. Community representatives emphasized the importance of Tribal “ownership” of, and a voice in, the data collection and analysis processes to ensure a cultural interpretation of the data. Discussion participants also reported the need to improve Tribal data systems. Community representatives from one community stressed the usefulness of having information on the number of clients served, the number of services rendered to each client, the types of services rendered, and client characteristics. Another community representative stated that program evaluation cannot Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 10 occur without data and benchmarks. Tribal strategic planning and system of care coordination is hindered when basic service information is not available across the child-serving systems. Coordination between State reporting systems and Tribal databases was also reported as a challenge. One community discussed the double challenge of using an outdated data tracking system within the Tribal organization, but also having to enter data into a complex State database. Technical assistance from the State regarding the State databases proved helpful for one community, but another community discussed the need for increased Tribal advocacy and input into State decisions about technology upgrades and electronic reporting requirements. Tribal–State partnerships in improving data technology were often successful. A State discussant described efforts to help Tribal organizations in obtaining technology grants to upgrade computer equipment and to increase the Internet speed for remote Tribal locations, enabling reports and data for billing to be transmitted quickly. In this win–win situation, the State’s motivation was to facilitate Tribal access to Medicaid billing and data tracking, and the Tribal organization gained a multipurpose technology upgrade. While data collection was reported as being a time-consuming requirement for the Tribal system of care, it was also considered essential for justifying the need for staff positions, revamping program foci, securing additional funding sources, negotiating changes with the State for provider qualifications, focusing staff training on emerging community needs, and promoting social marketing endeavors. Discussion The system of care national evaluation process is challenging to some Tribal communities. However, the communities acknowledged advancements in the use of data for sustainability planning, program planning, and organizational change. The ability to have program managers and evaluators on staff who became trained and experienced with system and client outcome indicators, sustainability assessment measures, and other aspects of data use was recognized as valuable. Although Tribes and Tribal organizations hold a historical distrust of data requirements, the system of care evaluation effort provides an opportunity for Tribal communities to build knowledge and adapt the data requirements in ways that best support local needs. Tribal systems of care are at different places on the continuum of data use, but the ability to develop data-based arguments for funding of Tribal services is essential for long-term sustainability planning. Assessing and Mobilizing Funding Sources Findings Tribal community representatives expressed frustration with the scarcity of available funding sources for their communities. The shortage of funding for Tribal communities is partly due to regional economies, confusion about which government entity is responsible for Tribal services and omission of Tribal services from funding applications. One community representative mentioned the practice of some States and counties of including Tribal statistics in their overall statement of need in State and/or county grant applications, but to provide little funding to Tribal service providers. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 11 There is a substantial lack of available funding in rural and remote Tribal locations. One community reported it had three experienced grant writers on staff, but the community lacked any funding opportunities to pursue, especially those that would support the youth-guided and family-driven values of a system of care. In another instance, upon the Tribe’s receipt of the system of care grant funding, the county within which the Tribe resided stopped providing all previous funding to the Tribal community and would not re-establish the financial support once the CMHS grant funding ended, despite system of care staff efforts. Communities were also challenged in finding grants with sufficient indirect cost funding to support program administration needs. To further complicate fund-seeking efforts, some of the Tribal system of care communities encompass service areas that are part of more than one State. In these situations, multi-State political and economic environments affect the systems of care, requiring that Tribal communities become knowledgeable about multiple States’ children’s initiatives, Medicaid regulations, provider standards, and credentialing requirements. Matching Funds Requirement The Federal system of care funding requires that the grant community must make non-Federal contributions toward program costs. Meeting the Federal cost-sharing requirement (informally referred to as the match requirement) is consistently one of the greatest challenges for the Tribal systems of care. Although the requirement encourages local investment in the system of care by other child-serving systems, Tribal communities represent some of the most impoverished areas of the country. One community reported that there were not enough financial resources in the area to meet the match requirements. Another community addressed this issue by joining a coalition of Tribes to negotiate with the Federal Government to have the requirements waived for the poorest counties in the country. Communities stressed the importance of understanding what can and cannot be used toward the match requirement under the Federal cost-sharing guidelines. Although eligible Tribes and Tribal organizations receiving funds under the Self- Determination and Education Assistance Act are exempt from the restriction prohibiting the use of Federal funds as match, they must ensure that the funds received under this Act are not being used as Federal match by other components of the Tribal organization or Tribal government.8 Those community representatives who reported having the most success with meeting the match requirements had long-term relationships with State or county funding sources; the State or county cash grants were their match, or cost-sharing, dollars. Most communities reported meeting the cost-sharing requirements by assigning a cash value to in-kind contributions. However, searching for and documenting in-kind contributions was a labor-intensive process that pulled time away from direct services. Discussion The Tribal, State, and regional economic environments that surround the Tribal system of care have a direct impact on its ability to locate and access funding support. The fund-seeking challenge is greatly exacerbated because many of the Tribal systems of care are located in the most economically depressed regions in the country. The shortage of available funding sources makes it even more important for the Tribal system of care communities to avoid “chasing” dollars as they become available. Instead, time spent in developing a sound strategic plan and a logic model delineating the community’s theory of change would be well spent. 8 Tribes receiving funds under the Self-Determination and Education Assistance Act (PL 93-638, as amended) are exempt from the restriction that prohibits the use of those Federal funds as match as long as the funds are not being used as match for other funding sources. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 12 Analysis and identification of funding sources that meet the Tribal vision as well as the funding source vision is a business-smart, strategic process. This fund-seeking process should be focused by the community’s strategic plan for sustainability that includes a well-thought- out theory of how the local community will change from “service as usual” to a new framework of a Tribal system of care. Additional development of strong financial and contract reporting systems will not only help build well-organized and effective services, but will result in setting the stage for replication of best service and infrastructure practices. Determining the Cost of Services Findings A fundamental step in sustainability planning is to determine the true cost of service provision. One community’s representatives reported that they determined the actual cost of their services through the use of time and cost studies. Using a time study form, each administrative and direct service staff person tracked how he/she spent each work day over a specified period of time (e.g., 2 weeks). The time study approach categorizes typical activities and requires staff to record the amount of time spent in each type of activity. Using this foundation of information, the actual cost of various services (including time spent completing client paperwork, administrative costs, supervision costs, transportation, etc.) was calculated. With this information in hand, the Tribal system of care could then negotiate payment rates with funding sources. Discussion Tribal programs that develop a budget or negotiate a contract without a full determination of the actual cost of their service provision are fiscally vulnerable and always in a disadvantageous position during contract negotiations. Determining an accurate cost of services is especially critical for culture-based services because this type of service usually involves a longer process for cultural engagement and usually requires an expanded amount of time to render service. Time studies can help determine the length of time used for culture-engagement strategies, and the amount of time needed for each step of culture-based treatment. Tribal communities can then negotiate cost-based rates for the full range of Tribal services (e.g., clinical and cultural assessments, community health aide services, behavioral health care, case management), which is critical. States are interested in ways to reduce the high cost of some State services and increase their effectiveness. Negotiating with States for Tribal service contracts is more effective if Tribal organizations know the cost of their services and can demonstrate that their approach to service provision will not only be less costly to the State, but will likely result in better outcomes. Medicaid as a Funding Source Findings An essential part of many of the Tribal system of care sustainability plans included exploration of a partnership with Medicaid (the largest payer in the country for behavioral health services). The Medicaid structure, designed as a shared expense between the Federal and State governments for State plan-approved Medicaid services also includes a special provision for Tribal partnerships. This provision is related to the Federal share of the Medicaid service cost, which is referred to as the Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 13 Federal Medical Assistance Percentage (FMAP).9 Several community representatives reported that they spent significant amounts of time meeting with State officials to explain the potential benefits of Tribal–State partnerships and to negotiate access to reimbursement rates through this special provision in the Indian Health Care Improvement Act, through federally qualified health center rates, or through changes in provider standards that better support Tribal-driven services. The exploration of Medicaid access had many starting places, depending on the organizational structure and infrastructure capacity of the Tribal system of care. For example, Tribal communities that did not already have a national or State license or accreditation status as a behavioral health provider first pursued the steps to become licensed or accredited—a necessary step toward being able to bill Medicaid for eligible services. Most of these communities realized that in addition to further development of their behavioral health policies and procedures, they also needed to focus attention on developing their third-party billing capacity. Some communities became knowledgeable about Medicaid enrollment standards and explored ways to co-locate Medicaid enrollment staff in Tribal community locations. The potential relationship between traditional services and Medicaid reimbursement were addressed in a variety of ways. Traditional services could be classified as behavior management or rehabilitation services in some State Medicaid Plans 9 The FMAP rate is based on the State per capita income, thus varying from State to State; the State share of Medicaid service costs range from 50 percent to 85 percent. A Congressional provision of the Indian Health Care Improvement Act established a match rate of 100 percent Federal dollars and zero State dollars for Medicaid services offered through the Indian Health Service (IHS), Public Law 93-638 Tribes, or Public Law 93-638 Tribal organizations. In addition, the Tribal services must be provided through a tribally owned/leased and operated facility that is on the official IHS facility list. If all the requirements are met, this FMAP option can result in cost savings to States and is one of that recognized the value of selected traditional practices as part of the service array. One Tribal community employed a licensed counselor as a clinical staff supervisor who provided cultural services as part of the treatment plan. Some communities addressed the use of traditional approaches as part of treatment in their training and certification curriculum. Careful analysis of the State Medicaid reimbursement rates and behavioral health billing categories was important in Tribal community service planning, as was the financial calculation of the number of billable hours per week per staff person. Some Tribal communities conducted a crosswalk of the planned Tribal system of care’s services with Medicaid behavioral health billing categories to determine categorical alignment. Some Tribal communities worked closely with State Medicaid staff and other Medicaid providers to explore and submit State Plan Amendments to increase Tribal access to Medicaid services. If amendments were not possible, continued collaboration with the State Medicaid office sometimes led to regulatory changes (e.g., easing of duplicate paperwork) that facilitated a Tribal system of care’s involvement as Medicaid providers of services. Challenge areas included unsuccessful access to the State’s behavioral health managed care system and, hence, unsuccessful access to Medicaid. Some communities were not able to access Medicaid services because they did not have licensed staff or did not offer any billable services at their current stage of service development. Some communities were unaware that transportation is a service that may be eligible for Medicaid reimbursement. This is unfortunate because transportation is a significant cost in Tribal services due to limited community member vehicle ownership, the long geographic distances to reach services, and the lack of financial resources for fuel. the reasons that Tribal systems of care explore Medicaid as a resource for eligible services. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 14 Discussion The historical funding resources for Tribal behavioral health services, primarily Indian Health Service and Bureau of Indian Affairs, remain too meager to fully address the growing disparities and behavioral health needs of local Tribal communities. Tribal system of care communities recognize that they must search for additional financial support, and Medicaid is prominent in most of the Tribal sustainability plans. Key to pursuing Medicaid service coverage are several factors: the ability of the Tribal organization or Tribal government to develop a working relationship with State Medicaid officials; the design and efficacy of the Tribal service array; the ability to recruit (or develop) a licensed workforce; and the capacity of the Tribal infrastructure to effectively support a third-party billing mechanism. Developing and Sustaining Key State Partnerships Findings The majority of the community representatives spoke about the value of establishing a working relationship with a key State administrator that later became an important part of their sustainability efforts. The Tribal communities used a variety of approaches to build relationships with State administrators, but common to their approaches was conducting Tribal–State meetings to educate each other on mutual needs and priority areas and provide information about the connection between a cultural foundation to service and improved outcomes. One community’s strategy was to include representatives from the county on its Tribal advisory board to increase their exposure to Tribal needs. Some community representatives stressed the need to start relationship-building with the State as early as possible, as it could take years to get into the State system and, ultimately, into the State budget. Often, the State contact person became a “champion” for Tribal services—that is, someone who advocated within the State system for the value of Tribal services. The State contacts that were developed also provided insight into the inner workings of State system priorities and data systems, which proved invaluable to several Tribal systems of care. For example, some State contacts provided training on how to negotiate a maze of county program requirements and reporting forms. One State champion provided assistance in understanding how to reduce the error rate in Medicaid billing. Another was helpful in advocating for changes in minimum provider qualifications for case managers and care coordinators. The State champions were valued because they understood sovereignty rights, valued the Tribal expertise regarding providing services to Tribal communities, and understood how Tribal services could benefit the State. However, some community representatives observed that the development of positive relationships with representatives of their States’ agencies was challenged by State personnel lack of knowledge about Tribal sovereignty and historical trauma, lack of trust between the Tribe and the State, and staff turnover within partnering agencies and representatives. Discussion Developing working relationships with key State partners can be helpful for Tribal communities that are trying to expand their funding sources. Tribes and Tribal organizations that pay particular attention to Tribal members disproportionately using high-cost State services can then develop a data-driven argument for Tribal service contracts. That is, if the number of Tribal youth in high-cost State services (e.g., juvenile corrections, non-Native foster care, residential treatment) continues to be out of proportion to the percentage of Tribal youth in the overall State population, the Tribal organizations can build their argument that placement of Tribal youth in mainstream institutions is not only ineffective, but very costly to Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 15 the State. Relationship building with State partners, combined with demonstration of the effectiveness of Tribal services, can result in service contracts for Tribal systems of care. Implications for Long-Term Financial Sustainability Examination of the financial sustainability efforts of the 15 American Indian and Alaska Native (AI/AN) system of care communities has resulted in information that will be useful to Tribal service planners, Tribal finance administrators, and system of care funding sources. It is clear that Tribal sovereignty and Tribal political structures (including Urban Indian structures) have a significant impact on financing. Other factors impact sustainability. Historical trauma can affect the ability of the Tribal community to come together for productive sustainability planning, as well as impact how much Tribes want to develop a working relationship with the State or county. Tribal infrastructures (e.g., computer technology, finance and billing systems, and human resources) are critical to implementation of sustainability plans, but are under-developed in some Tribal communities. Determining the true cost of Tribal and culturally based services is challenging but possible. Matching fund requirements (non- Federal cost sharing) remain a significant challenge in Tribal system of care communities that have limited resources. Implications of the study’s findings for next steps include the need for finance-focused training and technical assistance, broader dissemination of best practices, and the importance of peer-to-peer learning opportunities on a range of topics such as accreditation, Tribal– State agreements, Medicaid negotiations, third-party billing systems, and other finance-related topics. The AI/AN system of care communities have made significant contributions to the field of cultural competence through their community-engagement strategies, cultural and clinical assessments, culturally based treatment plans, and culturally based services. This report summarizes the Tribal contributions to the field of sustaining systems of care through examples of Tribal infrastructure development, Tribal–fund source relationship building, and a range of approaches that lead to financing for culturally based services. Successful planning for long-term financial sustainability ■ is a strategic process that starts early; ■ is facilitated by proactive leadership; ■ builds on a strong and stable infrastructure; ■ ensures that the system of care theory of change is integrated into fund development plans; ■ builds collaborative relationships with national and local Tribal resources. The development of financial relationships that meet serious Tribal community needs can benefit from quality cross-cultural communication; respect for Tribal self-determination; understanding of mutual financial needs, opportunities, and restrictions; data-driven and anecdotal understanding of the urgency of Tribal community needs; and a commitment to decrease reliance on ineffective service systems that are not working for Tribal families. Following are recommendations for each of the financing and sustainability subject areas discussed in this report. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 16 Recommendations for Financing and Sustainability in American Indian and Alaska Native System of Care Communities Planning for Sustainability ■ Begin planning for long-term financial sustainability on the first day of the system of care grant (or even before actually receiving the grant), taking care to build planning on the foundation of local cultural strengths. ■ Create a sustainability planning team that includes key decision makers (e.g., Tribal elected officials or Tribal administrators who have the authority to make the needed changes, Tribal program planners, and Tribal finance staff). ■ Ensure active involvement of Tribal youth and family members at the planning table, and examine and resolve the cultural basis of any resistance to their active leadership. ■ Use the system of care grant requirements categories as a guide to developing a framework for Tribal planning efforts. ■ Review the Tribal Constitution, Tribal Codes, or the Tribal organizational mission statement for compatibility with key system of care principles; use the constitution, codes, or mission statement as the mechanisms through which the system of care transformation goals can be met. ■ Determine the readiness of the local Tribal offices and Tribal programs to understand and willingly adhere to system of care values and principles. If needed, develop a system of care orientation for Tribal members that explains a system of care in simple terms; use local cultural concepts as examples. ■ Work with Tribal leadership to examine Tribal financial capacities and resources for long-term sustainability strategies. ■ Determine ways to incorporate the system of care sustainability plan into the broader Tribal financial planning; if barriers exist, discuss with Tribal leadership ways to create a cohesive system of care team across Tribal programs, Tribal offices, and other Tribal resources. ■ Discuss how local Tribal values and beliefs fit with a logic model concept and/or contribute to the description of the Tribal theory of change. ■ Use a logic model-planning tool that best fits the Tribal community to combine all needs assessment and service design information into a sustainability plan; update the plan annually and make sure the plan is tied into the timeframe of the overall Tribal planning process. Interacting With Political Entities Regarding Financing ■ Determine who makes funding decisions within the Federal, State, Tribal, and county governments; determine how funding decisions are made within these entities. ■ Assign a point person, or join a Tribal coalition, to follow the development of State legislative health policy and/or State administration regulatory processes for proactive planning. ■ Stay alert to the annual or bi-annual Tribal, State, and county budget-building processes and make sure decision makers are aware of system of care operational and non-Federal match needs. ■ Build an educative relationship with Tribal elected officials, key State Legislators, and other local policymakers, taking care to stay in contact on a regular basis throughout the year and not just during a financial crisis. ■ Build alliances with Tribal elected officials, Tribal service administrators, and/or Tribal governing boards; negotiate inclusion of the Tribal system of care as a standing agenda item on the Tribal governing board agenda and Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 17 provide ongoing updates on the system of care transformation and child and family improvements. ■ Meet with candidates for Tribal elected offices and orient them to the system of care approach to services, the meaning of system of care transformation, and budget needs. ■ Develop a data-driven argument for the need for Tribal system of care funding, emphasizing human and financial cost-savings by redeploying funds from high-cost State services that tend to be less effective to lower-cost Tribal services that tend to be more effective. ■ Develop a cultural competence argument for Tribal services, linking culturally competent service provision with increased access to services and improved child and family service outcomes. ■ Develop a Tribal–State workgroup to examine the over-representation of Tribal people in child welfare, juvenile justice and education, and to propose solutions for the elimination of disparities. ■ Participate in Tribal, State, and county planning meetings and present Tribal behavioral health needs and cost-effective services that meet those needs; request statutory or fund-shifting changes to support the Tribal system of care. ■ Develop and/or participate in a Tribal–State Medicaid workgroup and develop working relationships with Tribal Medicaid liaisons. Developing Sustainable Services ■ Conduct a planning retreat or process to convene with key community stakeholders to determine a local definition of wellness and to describe how Tribal traditional culture and other cultural influences impact access, services provision, and service outcomes. ■ Design a cultural approach to services (individualized for each family) that includes strengths-based language; a cultural assessment component of the clinical assessment; treatment goal setting that includes attention to the role of culture in wellness; treatment benchmarks that include cultural strengths; and outcome measures that show how attention to culture can improve treatment outcomes. ■ Review traditional practices used in the community for healing and stabilization purposes and review the therapeutic aspects of traditional practices (e.g., some traditional practices may help resolve grief); cross-walk these therapeutic practices with State-approved behavioral health billing categories. ■ Meet with State representatives to discuss Tribal services and any changes that are needed in provider qualifications (e.g., expanding Targeted Case Management to include a provision for Tribal providers, modifying State educational requirements for becoming a licensed Tribal behavioral health provider). ■ Develop a staff-training curriculum based on local Tribal values and local Tribal service design to advance staff service skills and credentials; meet with the State credentialing board for licensed behavioral health providers to discuss the Tribal curriculum concept to ensure that the State licensing board will approve the Tribal curriculum. ■ Partner with Tribal colleges and the State credentialing program to implement a Tribal system of care training and education program. ■ Develop a training plan for program managers, clinical supervisors, and other program management staff to ensure their knowledge is current regarding managing change in complex environments, staff supervision, staff development, contract oversight, and financing strategies. Strengthening Infrastructure ■ Conduct a scan of infrastructure needs by reviewing the list of system of care grant requirements and any fundraising goals to determine if the Tribal program has appropriate • physical buildings and adequate service locations; • space for individual and family services that meet privacy requirements; Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 18 • group space for community activities; • office furnishings that reflect professionalism and offer family comfort; • clinical tools and equipment for service provision; • cultural tools and equipment for service provision; • adequate computer hardware for communication, reporting, and training; • functional computer software that meets day-to-day communication and reporting needs, including data tracking and accounting needs; • consistently available computer technology staff for trouble shooting and repair; • personnel policies and procedures, job descriptions, and salary scales; • policies and procedures for services, grants management, and fiscal controls; • billing manuals. ■ Consider hiring a Certified Public Accountant to review current financial systems and to make recommendations for improvement and further development. ■ Develop and implement infrastructure development plan that supports service growth and includes actions steps and timelines; ensure that it is framed within the broader context of a Tribal logic model or theory of change. ■ Assess the feasibility of becoming a State-licensed or nationally accredited organization by reviewing the accreditation options, examining the fit with the Tribal belief system, determining the overall benefits and drawbacks to licensing and/or accreditation, determining whether the cost of pursuing accreditation is feasible, and determining whether the Tribal system of care has administrative staff available to lead the accreditation team. ■ Upgrade billing and data reporting software after determining if the purchase of new software is cost effective when compared to the volume of Tribal data processing needs. ■ Implement third-party billing capacity, including the training and supervision needed to transition from grants management to a third-party billing system. ■ Overcome Tribal staff resistance to increased documentation requirements by using Tribal supervisors for professional modeling, oversight and helping Tribal staff understand the relationship between third-party billing, budget, and increased services for the community. ■ Conduct computer skill development training for Tribal Council or Tribal governing board members for increased communication and access to resources. ■ Conduct a site visit to another Tribal system of care that has successfully implemented a sustainability strategy, for a peer-to-peer learning opportunity. ■ Work with Tribal administrators to ensure that all internal systems (e.g., fiscal, technology, management, human resources, training) interlock, maintain close communication with each other, and share a common goal of advancing the Tribal system of care. Using Data in Financial Sustainability Planning ■ Discuss with Tribal leadership any concerns or questions about data use and clarify the Tribal stance on data collection, data analysis, and data ownership. ■ Provide orientation on Tribal system of care data use for Tribal elected officials, Tribal governing board members, and Tribal administrators; link data use examples to client progress, program planning, fund development, and contract negotiations; and emphasize ways that Tribal data use can support Tribal self-determination and data-driven decision making. ■ Discuss Tribal capacity for, and affiliated costs of, a sustained data collection and data analysis process and allocate resources for implementation. ■ Develop data-driven arguments to support inclusion of Tribal services in fund opportunity Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 19 language and regulatory changes to funding processes (e.g., ways to increase Tribal access to Medicaid reimbursement of services). ■ Determine the role of Tribal data in program evaluation, sustainability planning, and contract reporting. ■ Visit a Tribal system of care that has been successful in using data for a peer-to-peer learning opportunity. ■ Analyze aggregate data to demonstrate youth and family improvements and related human and financial savings. ■ Identify existing Tribal and non-Tribal data sources that may be useful for the sustainability planning process. ■ Advocate that State technology decisions related to data transmission requirements must be consistent with the technology capacities of Tribal communities. Assessing and Mobilizing Funding Sources ■ Conduct a financial environmental scan and list all funding sources in the State or region that support Tribal children and youth; determine which funding sources the Tribal system of care is not accessing, and list the reasons why the system of care has not been able to access these sources. ■ As part of building a case for funding, compare the percentage of the Tribal youth population in the State with the percentage of Tribal youth in State or county services (e.g., juvenile justice, child welfare, residential treatment). ■ Develop data-driven funding arguments by determining the monthly (or yearly) cost of State, county, and private institutional care and comparing these costs to the cost of Tribal services. ■ Imbed the Tribal system of care sustainability plan into all aspects of the Tribe or Tribal organization’s overall fund development and business operations. ■ Write a business plan for the system of care. ■ Follow the development of behavioral health policy in Indian Health Service (IHS) and the State legislature, or any State regulatory discussion of existing behavioral health policy; participate in State planning meetings as much as possible to track and influence evolving State initiatives and ensure that Tribal needs are included in legislative language. ■ Develop an accreditation team to assess the organization’s ability to complete required steps toward State behavior health licensure and/or national behavioral health accreditation. ■ Explore the financial feasibility of out-of-the-box financing ideas such as developing a business arm of the non-profit corporation. ■ Clarify what can and cannot be used as match under the Federal cost-sharing guidelines, with particular attention to understanding the exemption for eligible Tribes and Tribal organizations, which allows use of certain Federal funds as match. ■ Develop annual goals for in-kind contributions and local non-Federal cash contributions; monitor all match goals on a monthly or quarterly basis. ■ Create a list of potential in-kind contributions (e.g., space donations, pro bono consultation) and non-Federal cash resources (e.g., State grants, private foundation grants). ■ Develop processes to document in-kind contributions and the assignment of cash value to contributions. Determining the Cost of Services ■ Determine if the Tribe or Tribal organization is currently using, or has previously used, a cost study process; if necessary, seek advice from a cost-study-experienced Tribal organization or an Indian health planning board. ■ Determine a timeframe to implement a cost study. ■ Provide an orientation of cost study expectations for Tribal administration, governing board, and staff. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 20 ■ Determine the actual service and administrative costs of the full range of Tribal behavioral health and support services, including the costs for administrative and supervisory time, staff training, transportation, home visits, and traditional practices (i.e., conduct a cost study). ■ Ensure that cost formulas address the costs of delivering services in remote Tribal areas, including time spent in cultural translation of services; computer technology development and computer training (especially related to cultural application of service); rural Internet challenges; cultural-based telemedicine consultation; and off-site supervision due to the geographic range of Tribal service locations. Determining the Feasibility of Medicaid as a Funding Source ■ Work closely with the Tribal government or Tribal organization to determine the percentage of the local Tribal population that is eligible for and enrolled in Medicaid services. ■ Meet with Tribal administrators or the Tribal governing board to discuss any community perception that participation in the Medicaid program would result in loss of IHS benefits; consider a public community meeting to clarify any confusion. ■ Consider negotiating the co-location of State Medicaid enrollment staff at the Tribal location. ■ Review Tribal services, including traditional practices, for compatibility with Medicaid behavioral health billing categories. ■ Consider including access to Medicaid funding as part of the Tribal sustainability plan and outline the steps to becoming a State Medicaid provider. ■ Develop a close and ongoing working relationship with the State Medicaid office to increase Tribal access to information about Tribal enrollment strategies, provider standards, eligible services, and billing process. ■ Meet with State Medicaid and Tribal health representatives to determine if the 100% Federal Medical Assistance Percentage (FMAP) option is being fully utilized. ■ Meet with State Medicaid representatives to discuss the development of a Tribal services section in the State’s provider billing manual. ■ Join a coalition of Tribes in the State to explore a waiver to the State Medicaid Plan to support Tribal services and system of care partnerships. Developing and Sustaining Key State Partnerships ■ Invest in educating State officials and State funding source administrators about the Tribal system of care. ■ Recognize that there may be steep cultural learning curves for Tribal and State representatives about their respective service systems. ■ Develop relationships with Tribal champions within State government (e.g., non-Tribal State administrators who acknowledge the value of Tribal services) and provide them with information on how Tribal-operated services can result in positive service outcomes. ■ Ensure that the Tribal organization has the right person at the right table; for example, send a Tribal staff person with decision-making responsibility to a Tribal–State meeting if decision-making authority is needed. ■ Recognize the multiple influences on the development of positive Tribal–State relationships, including historical trauma and key staff turnover at the State and in the Tribe. ■ Recognize that both States and Tribes are concerned about the financial cost of ineffective services and the resulting human cost to both the Tribe and the State. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A1 APPENDIX A. Understanding the Challenge: The Cultural Framework Although the system of care principles and Tribal belief systems are very much aligned, Tribal systems of care continue to face unparalleled challenges in developing and implementing financing strategies for sustainability. This is due to many reasons, including the lack of knowledge by potential funding sources, such as States, of the advantages of working with Tribes, the impact of Tribal–State history on the willingness and ability to pursue financial partnerships, and the lack of financial resources in remote Tribal communities. Adding to the complexity of the challenge is ■ the history of confusing and contradictory Federal policies about support for Tribal services; ■ the meaning of sovereign status of federally recognized Tribes as it relates to financing; ■ the financial options of Tribes that are recognized by States but lack Federal recognition; ■ the role of Tribal self-determination and the financial implications of Tribal assumption of services that were previously provided by Federal agencies. All of these challenges are further deepened by a lack of cross-cultural and cross-system problem solving when partnership barriers arise. The result are complicated jurisdictional and policy conditions that exist between Tribes, Federal, and State governments with many implications for financial strategic planning. Negotiation for financial partnership must often start with the education of Federal, State, or private funding sources about the relationship between a cultural foundation to services and improved outcomes; the impact of Tribal sovereignty on financial partnerships; and the values and decision-making processes of Tribal governments, Urban Indian organizations, and Tribal nonprofit organizational structures. Mental health services for the American Indian and Alaska Native (AI/AN) population are widely documented as inadequate to provide for the needs of the people. There are a number of reasons for the shortage of services: the annual Federal budget for the Indian Health Service (IHS) is under-funded by an estimated 40–60 percent of the need for care; only 7 percent of the IHS budget is allocated for mental health services; a large percentage of AI/AN people live in remote rural areas where behavioral health services are not routinely available; and Medicaid and other third party payers often exclude Tribal providers from participation in mental health networks, do not purchase the types of services offered by Tribal health providers, or Tribal providers are unable to employ the types of clinical providers necessary to render billable services. These disparities combined with the economic conditions in Indian country result in a disproportionate representation of the AI/AN population in social service programs, juvenile and adult detention facilities, and treatment facilities for mental health and substance abuse problems. Thus, the impact on Federal- and State-funded programs is also disproportionate to the population. Statistics demonstrate that Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A2 mainstream efforts to address health, social and economic issues in Indian country are ineffective in addressing the root causes of these problems. State government programs, particularly in States with large Native American populations, are recognizing these costs and have become interested in partnering with Tribal organizations for community based service delivery. Tribal Entities in the United States American Indian and Alaska Native people have long demonstrated a high level of resilience and have retained, or re-established, the traditions and beliefs that serve as their cultural core. Hundreds of Tribes continue to thrive and remain culturally and politically unique in the United States. Each Tribal group is organized according to historical and cultural influences (e.g., Tribe, Band, Nation, Pueblo, Village, community, corporation). The Federal Government holds special trust obligations towards Tribal members to provide basic social, medical, and educational services. The statutes and treaties under which Tribal communities are organized have a direct influence on their financial sustainability options. Recognition Status More than 560 federally recognized Tribes exist in the United States. Federally recognized Tribes hold a government-to-government relationship with the Federal Government. Nearly one-half of the federally recognized Tribes are in Alaska. Tribes with Federal recognition status are legal sovereign nations. Federally recognized Tribes are rare and distinctive as they function as independent nations within the nation of the United States. Therefore, a unique legal and political relationship exists between the Federal Government and Indian Tribes. (Similarly, a special legal relationship exists between the Federal Government and Alaska Native Corporations.) This relationship is grounded in the U.S. Constitution, treaties, statutes, U.S. Supreme Court decisions, and Federal laws and regulations. The relationship between the Federal Government and Tribes is also grounded in political, legal, moral, and ethical principles. It is important to note that the relationship is not based upon race, but is a government-to-government relationship. The U.S. Department of Health and Human Services (DHHS) has a formal consultation policy with Tribes. Consultation with AI/AN Tribes must occur to the extent practicable and permitted by law before any action is taken that will significantly affect the Tribes. In short, any DHHS policy requires consultation with Tribes before action by the Federal Government is taken if the policy substantially and directly affects one or more AI/AN Tribes; the relationship between the Federal Government and Tribes; or the distribution of power and responsibilities between the Federal Government and Tribes. The legal and political power of sovereignty is deep. As sovereign nations, Tribal governments have the right to hold elections, determine their own citizenship, and consult directly with the Federal Government on policy, regulations, legislation, and funding. Tribal governments can also create and enforce laws to govern their Tribal members. Tribal laws can be stricter or more lenient than State laws, but they are not subservient to State law. State laws cannot be Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A3 applied to a Tribe if the laws interfere with the right of a Tribe to make its own laws protecting the health and welfare of its citizens, or if they would interfere with any Federal interest. Tribal district courts and supreme courts can be established to administer justice in criminal, civil, and juvenile matters. Tribal tax commissions, economic development corporations, environmental protection agencies, public works, and gaming commissions are other examples of entities that may be part of a Tribal government structure. In addition to the federally recognized Tribes, there are 245 Tribes whose lands and rights are recognized solely by the State. A State-recognized Tribe is an Indian Tribe that does not have a recognized relationship with the Federal Government through historic treaty, Congressional act, or administrative process, but is recognized as a Tribe by the government of the State in which members reside or are historically based. A lack of Federal recognition limits the capacity of State recognized Tribes to fully govern themselves, seek compensation for previous loss of land, or be eligible for certain Federal benefits and funds designated for federally recognized Tribes. Many State-recognized Tribes are seeking formal Federal recognition. Another important segment of the Tribal population is the Urban Indian community. ‘Urban Indians’ is a term used to describe American Indians and Alaska Natives, or descendents of American Indians and Alaska Natives, who have moved from their Tribes to cities or urban areas, either voluntarily or through forced Federal Government relocation programs.1 Poverty and lack of economic opportunities also contribute to the movement of Tribal people from reservations to cities or urban areas. More than 60 percent of all Tribal people in the United States now live in cities or urban areas and they remain part of the congressionally mandated trust responsibility. Regardless of Federal or State recognition, or Urban Indian status, each Tribal community reflects a distinct culture, belief system and, often, Native language. Despite these differences, common across all Tribal people is a deeply ingrained sense of respect and honor for their children (as illustrated by the names selected for their systems of care). Many Tribal systems of care program names reflect the Tribe’s special recognition of children and youth and the principal role that culture plays as the foundation of their services. American Indians and Alaska Natives live within the complex and overlapping worlds of Tribal, State, and Federal Governments—each of these entities has unique laws, manners of conducting business, and interpretation of sovereignty. The relationships between Tribes and the Federal Government, and Tribes and the State in which they are located, are constantly evolving. The role of Federal trust responsibility, sovereign Tribal governments, interpretation of Tribal and State laws, the Urban Indian relationship with urban and Tribal services, and the overall changing needs of Tribal communities add to this changing environment. All of these are key factors affecting the financial relationships and collaboration between Federal, State, County, 1 National Council of Urban Indian Health (2007). Fact Sheet. Retrieved January 2008 from http://www.ncuih.org/Fact%20Sheet.pdf Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A4 and other funding sources and Tribal communities. Impact of Federal Policies Federal Government policies related to Tribal affairs have fluctuated from open warfare to later attempts to assimilate Tribal people into mainstream society, from termination of Tribal rights to later restoration of Tribal rights, and from attempts to limit Tribal government to later compliance with Tribal government self-determination. These inconsistencies have created a legacy of policy confusion that continues to affect Tribal–Federal and Tribal– State relationships and financing strategies today. A strength of the Tribal financing picture is the Indian Self-Determination Act (Public Law 93- 638), which gives authority to Tribal governments to assume the budget and operations of programs and services that had been previously carried out by the Federal Government. This not only supports Tribal self-determination, but also reflects support for culturally competent practices and community ownership. The Indian Self-Determination Act provides the legal framework for federally recognized Tribes and Tribal organizations to assume the budget and operations of services previously provided by the Federal Bureau of Indian Affairs or the IHS. A Tribe or Tribal organization that enters into a 638 agreement with the Federal Government is referred to as a “Tribal 638 organization” in this report. Importance of Sustainability Shediac-Rizkallah and Bone suggest three reasons why program sustainability is important.2 First, if a program ends while there is still a need for services, rates of people with untreated needs may regress to pre-intervention levels. This is important when considering rural AI/AN communities, which likely have limited mental health agencies and may depend heavily on the contributions of each agency.3 Second, programs often incur significant start-up costs in human, technical, and monetary resources, only to have funds removed before a program has reached its fullest potential. This is especially relevant to Tribes that may have no health care infrastructure at program start-up resulting in a need to design an unfamiliar program, implement major computer technology upgrades, develop a third-party billing structure, or provide additional training for staff who are cultural experts but do not meet the higher education requirements established by State or national accreditation bodies. Third, program sustainability promotes community investment in future community programs and lack of sustainability may lead to community confusion toward future programs. Community support is essential to the existence and persistence of Tribal community mental health programs due to the collectivistic orientation of AI/AN communities. 2 Shediac-Rizkallah, M. C. & Bone, L. R. (1998). Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice, and policy. Health Education Research, 13, 87–108. 3 Jim, N. (2004). The morning God comes dancing: Culturally competent mental health and HIV services. In Nebelkopf, E. & Phillips, M., (Ed.), Healing and mental health for Native Americans. New York: Altamira Press. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A5 Interest in the topic of system of care sustainability has reached new peaks in the past few years. Several studies have been developed to examine aspects of system of care sustainability. In their work, The Sustainability of Systems of Care for Children’s Mental Health, Stroul and Manteuffel discuss the sustainability study undertaken by the National Evaluation Team.4 The development of the Web-based survey included an examination of the various definitions of sustainability. Emphasized was the acknowledgement that adopting the system of care approach for the long term requires a “sea change” in policy, clinical practice, and administration of children’s mental health systems and maintenance of all of these elements of systems of care in the face of budgetary challenges and changing political environments. The University of South Florida Research and Training Center, in partnership with the National Technical Assistance Center for Children’s Mental Health at Georgetown University, the Human Service Collaborative of Washington, DC, and Family Support Systems, Inc., of Arizona, initiated a study titled “Financing Strategies and Structures to Support Effective Systems of Care.” The goal of the study is to develop a better understanding of the critical financing structures and strategies that support systems of care. Seven critical financing strategies are being examined and a series of guides have been developed. None of these studies is focused specifically on AI/AN financing. Although the findings of these studies provide a framework of sustainability issues relevant to any system of care community, none of the studies address in detail the cultural, 4 Stroul, B.A., Manteuffel, B.A. (2007). The Sustainability of Systems of Care for Children’s Mental political, and economic issues that are specific to AI/AN communities and that have a direct impact on their long term sustainability. The cultural importance of program sustainability must not be ignored. Sustainability of community mental health programs within Tribal communities is especially important to empower and avoid re-victimization. Lucidly expressing this point, one leader of a Tribal community-based substance abuse prevention and intervention program stated, We have a responsibility to our program recipients. They’ve had so may losses in their lives, and [if we] come in for a year or two or three and give them hope, only to have the program go away, we’ve just caused another loss and further hopelessness in their lives.5 The 400 years of persecution, genocide, and forced assimilation experienced by Native Americans have led many to experience a perception of great loss leading to anxiety and depression or anger and avoidance.6 These psychological consequences have been termed “historical trauma.” It is hypothesized that program sustainability can function to combat such trauma by empowering Tribal communities to decrease reliance on outside support and Health: Lessons Learned. Journal of Behavioral Health Services & Research. 5 Noe, T., Fleming, C., & Manson, S. (2004). Reducing substance abuse in American Indian and Alaska Native communities: The Healthy Nations Initiative. In Nebelkopf, E. & Phillips, M., (Ed.), Healing and mental health for Native Americans. New York: Altamira Press. 6 Whitbeck, L. B., Adams, G. W., Hoyt, D. R., & Chen, X. (2004). Conceptualizing and measuring historical trauma among American Indian people. American Journal of Community Psychology, 33, 119–130. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A6 foster a sense of pride in being able to care for their own community. Factors Affecting Sustainability Program sustainability at every level can be impacted by the effectiveness of critical sustainability factors. Mancini and Marek have developed seven key elements critical for program sustainability: (1) competent leadership to develop a program’s vision and provide staff training; (2) effective collaboration with community members and key stakeholders; (3) understanding of community needs and resources; (4) program results demonstration; (5) strategic funding; (6) staff involvement and commitment to sustainability; and (7) program responsiveness to a community’s changing needs.7 While it is clear that many variables interact to affect sustainability, underlying each of these components is the need to understand the culture of a population served. For example, effective collaboration with Tribal community members will be facilitated through a program leader’s ability to integrate Tribal culture into the development of a program’s vision. Further, program response and results demonstrated within an AI/AN community hinges on a programs’ ability to provide culturally competent care.8 Finally, obtaining long-term financial support requires knowledge of the resources both within Tribal communities and outside of the Tribal community. Following are brief discussions of key sustainability factors known to affect program sustainability among Tribal programs. 7 Mancini, J. A., & Marek, L. I. (2004). Sustaining community based programs: Examination of relationships between sustainability factors and program results. Family Relations, 53, 339–347. 8 LaFromboise, T. (1988). American Indian mental health policy. American Psychologists, 43, 388–397. Economic and Political Environments In 2000, the AI/AN poverty rate was 26 percent, twice the national rate and greater than that of any other ethnic group.9 Socioeconomic conditions vary from Tribe-to-Tribe and in different regions of the country. Some Tribal system of care communities report unemployment rates as high as 80 percent in the local Tribal population. The Center for Disease Control also mentions geographic isolation, cultural barriers, and economic conditions as barriers that contribute to poorer health outcomes.10 Other studies have focused on Tribal income increases associated with the legalization and institution of casino gambling for the effects on aspects of American Indian well-being, including the effects on poverty levels, medical care, and risk-taking behavior, all of which are indirectly associated with health status.11 The political environment of Tribes and Tribal organizations is complicated; sovereign nation status, and the Alaska Native Claims Settlement Act (1971) which promised 44 million acres and $1 billion to Alaska Natives, are examples of the unique aspects of the AI/AN political environment. 9 Centers for Disease Control and Prevention. (2003).Surveillance for health behaviors of American Indians and Alaska Natives: Finding from the behavioral risk factor surveillance system, 1997-2000. Morbidity and Mortality Weekly Report. 52, 1. Retrieved January 20, 2008 from http://www.cdc.gov/mmwr/preview/ mmwrhtml/ss5207a1.htm 10 Rural Assistance Center (2008). Tribal health frequently asked questions. Retrieved January 5, 2008 from http://www.raconline.org/info_guides/tribal/ tribalhealthfaq.php 11 Taylor, J. B., Kalt, J. P. (2005). Cabazon, The Indian Gaming Regulatory Act, and the Socioeconomic Consequences of American Indian Governmental Gaming–A Ten-Year Review. American Indians on Reservations: A Databook of Socioeconomic Change between the 1990 and 2000 Censuses. Cambridge, MA: The Harvard Project on American Indian Economic Development. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A7 The Harvard Project on American Indian Economic Development, at Harvard University’s John F. Kennedy School of Government, aims to understand and foster the conditions under which sustained, self-determined social and economic development are achieved among American Indian nations. At the heart of the Harvard Project research program is the systematic, comparative study of social and economic development on American Indian reservations. Relevant for the Tribal system of care communities are their key research findings: ■ Sovereignty Matters. When Native nations make their own decisions about what development approaches to take, they consistently out-perform external decision makers—on matters as diverse as governmental form, natural resource management, economic development, health care, and social service provision. ■ Institutions Matter. For development to take hold, assertions of sovereignty must be backed by capable institutions of governance. Nations do this as they adopt stable decision rules, establish fair and independent mechanisms for dispute resolution, and separate politics from day-to-day business and program management. ■ Culture Matters. Successful economies stand on the shoulders of legitimate, culturally grounded institutions of self-government. Indigenous societies are diverse; each nation must equip itself with a governing structure, economic system, policies, and procedures that fit its own contemporary culture. ■ Leadership Matters. Nation building requires leaders who introduce new knowledge and experiences, challenge assumptions, and propose change. Such leaders, whether elected, community, or spiritual, convince people that things can be different and inspire them to take action. The Native Nations Institute is an outgrowth of the Harvard Project on American Indian Economic Development and serves as a self-determination, development, and self-governance resource to Indigenous nations. For more than 15 years, the Harvard Project and the Native Nations Institute researchers have worked systematically to understand the conditions under which sustained economic development can be successful on American Indian reservations in the United States and among First Nations in Canada. These findings indicate that, while a number of things contribute to initiating and sustaining reservation economic development, five are particularly important: ■ Practical Sovereignty (genuine decision-making power) Native nations that have been willing and able to assert self-governing power over their affairs and resources have significantly increased their chances of sustainable economic development. ■ Capable Governance (effective governing institutions and practices) Sovereignty is not enough to produce economic growth unless those rights and powers are exercised effectively; the chances of sustainable development rise as Native nations put in place effective, nonpoliticized, dispute-resolution mechanisms that can shut down opportunistic behavior by politicians, place buffers between day-to-day business management and political decisions or interference and build capable bureaucracies. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A8 ■ Cultural Match (fit between governing institutions and political culture) Effective Trial governing institutions require legitimacy with the people whose future is at state, rooted in the fit between the formal institutions of governance and the indigenous conceptions of how authority should be organized and exercised. ■ Strategic Orientation (decision making that takes strategic considerations into account) Successful Native nations tend to approach development not as a quick fix for poverty but as a means of building a society that works, considering long-term priorities and concerns as well as assets and opportunities, and bring strategic criteria to bear on development decisions. ■ Leadership (individuals and groups who recognize that fundamental change may be necessary, and who can envision a different future and persuade the community to join them) Successful Native nations have some group or set of individuals who recognize the need for fundamental change in a way things are done; they have a vision of a future of assertive, capable, effective self-determination and self-governance, and can bring the community along with them in building that future. In addition to these findings, gaining community consensus on the approach to Tribal system of care sustainability can be complicated. Tribal systems of care often operate within multiple governing structures that must work together in sustainability planning. The Tribal governing structure may have frequent elections of Tribal officials that result in leadership turnover and starts and stops in sustainability planning. All of the variables discussed, exacerbated by health disparities, affect the AI/AN sustainability planning process. Planning Planning and infrastructure development assistance has been available for years to some Tribal communities through the Federal Infrastructure Development for Children’s Mental Health Systems in AI/AN Communities Initiative, more commonly known as the Circle of Care Initiative. Available through a competitive application process, the Circle of Care Initiative supports AI/AN communities with funding and technical assistance to plan, design, and assess the feasibility of a culturally respectful mental health system of care. The Circle of Care Initiative provides 3-year grants to State and federally recognized Tribes, Urban Indian organizations, Tribal colleges and Tribal universities. Successful applicants gain community planning tools and resources to design a holistic, community-based system of care to support mental health and wellness for their children, youth and families. Nearly half of the Tribal system of care communities had previously received a Circle of Care planning grant that enabled them to conduct an in-depth analysis of the existing infrastructure of the local child-serving system to identify policy, service gaps and potential resources, and to facilitate culturally respectful strategic planning activities. Also important to the Circle of Care planning process is community-wide engagement, development of Tribal logic models, and development of a local evaluation process. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A9 Partnerships Tribal leader hesitancy to develop State or Federal partnerships is often based in historic distrust. Broken treaty agreements, conflicts over land or water rights, and the removal of Tribal children from their homes to be raised in non-Indian boarding schools or non-Indian foster care homes are just some of the reasons for Tribal partnership hesitancy. State motivation to pursue partnerships with Tribes and Tribal organizations has generally been reliant on the personal interest of a few State representatives. However, the system of care movement, combined with increased national interest in addressing racial health disparities and the lack of culturally competent services, has sparked more interest at the State level for Tribal-State partnerships. States are searching for methods that could more effectively address high cost institutional and residential treatment services that are utilized when behavioral health needs are not met in the community. Thus, some States are exploring ways to engage more Tribal organizations as partners in behavioral health services. Transformation of State organizational structures, with increased support for culturally competent practices and a re-examination of the use of evidence-based practices, are all opportunities to develop new partnerships with Tribes and Tribal organizations. Conversely, Tribal systems of care may be able to access previously untapped State revenue sources, and influence current and future State policy to better address Tribal needs. For example, Tribal–State partnerships can not only be beneficial to Tribal communities but can improve the health of State budgets as the high cost of institutionalized care is transferred to lower cost and more effective Tribal systems of care services. Jurisdictional confusion and misinformation about Tribal needs also complicate communication and partnership building. Some State administrators erroneously believe that Tribal needs are being met by the Indian Health Service (IHS), when only 55 percent of American Indians and Alaska Natives rely on the IHS or Tribal-operated clinics or hospitals for care. Further, the IHS budget meets less than 60 percent of the national Tribal needs, and less than 5 percent of the Tribal mental health needs.12 Tribal–State partnerships are also challenged by growing State requirements that tie evidence-based practices (EBPs) to State behavioral health contracts.13 Tribal systems of care are concerned that EBPs are not normed on Tribal populations and might not be easily transferable or appropriate for use with Tribal populations, yet growing numbers of State and Federal contracts require the use of EBPs. In addition, the cost of training for manualized EBPs is often too costly for many Tribal communities. However, growing interest in the fields of cultural adaptation of EBPs and support for practice-based evidence approaches (which include field-driven practices and traditional practices) has opened new opportunities for financing discussions between Tribes and States. 12 Gone, J. P. (2004). Mental Health Services for Native Americans in the 21st Century United States. Professional Psychology: Research and Practice, 35(1), 10–18. 13 For the purpose of this report, the term ‘evidence-based practices’ is used to define interventions and approaches shown to be effective through rigorous research. This term is synonymous with the term ‘evidence-based treatment.’ Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A10 Infrastructure Many Tribes have both a traditional Tribal leadership structure and a “business council” governing structure. The Tribal business council structure usually involves a formal election process. Each Tribe determines its frequency of Tribal elections (which can occur as often as every 2 years). Election of “business” council members is not a historic Native tradition; rather, the Federal Government mandated it. Tribal elections can result in the re-setting of Tribal priorities and funding strategies. Ensuring that Tribal council candidates and Tribal elected officials understand the framework and purpose of a system of care for children and families is critical because Tribal-elected officials are politically powerful and play a critical role in both short and long-term sustainability plans. The national field of behavioral health rests on a foundation of formal licenses, credentials, and program accreditation—all critical components of sustainability, especially if the sustainability plan includes third-party billing for behavioral health services. Another factor that can complicate sustainability plans is AI/AN preference in hiring practices. Part of Tribal self-determination policy, Tribes and Tribal organizations are legally sanctioned to have AI/AN preference in hiring practices through Tribal exemption to Title VII of the Civil Rights Act (1964). AI/AN preference in hiring is not only allowable, but often a policy and mission for Tribal organizations that support the Nation Building concept.14 AI/AN preference in hiring is an important part of Tribal self-determination, but may conflict with 14 Nation Building refers to the process of constructing or structuring a nation using the power of the State (in this case, the term “State” refers to the Tribe). contract requirements for licensed and credentialed staff. Staffing AI/AN mental health counselors are more likely to provide culturally competent services to Native children, youth and families because they share a cultural affinity. As such, hiring Native staff will promote sustainability by increasing staff integration and involvement in the program.15 However, AI/AN mental health community programs often have great difficulty finding credentialed service providers who are AI/AN. For example, the IHS behavioral health programs employ approximately two psychiatrists and four psychologists per 100,000 people for the 1.5 million Native people currently eligible for IHS funded services, in contrast to general U.S. availability of 14 psychiatrists and 28 psychologists per 100,000 people.16 Providing funding to support the higher education of Tribal community members is one strategy used to address this challenge. Promoting the accreditation of AI/AN mental health service providers allows a community to become self reliant in the provision of mental health care and is posited to promote the sustainability of mental health programs. In a study involving 401 American Indian youths and 188 American Indian providers, 15 Mancini, J. A., & Marek, L. I. (2004). Sustaining community based programs: Examination of relationships between sustainability factors and program results. Family Relations, 53, 339–347. 16 West, J., Kohout, J., Pion, G. M., Wicherski, M. M., Vandivort-Warren, R. E., Palmiter, M. L. , et al. (2000). Mental health practitioners and trainees. In R.W. Manderscheid & M.J. Henderson (EDs.), Mental health, United States, 2000. Rockville, MD: U.S. Department of Health and Human Services Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A11 researchers found that providers were more likely to correctly identify the problems of American Indian youth and offer them, or refer them for, services when the provider was knowledgeable about mental health problems and available resources in the community.17 These results suggest that to best assess the needs of American Indian youth, providers need to have both an understanding of the local culture and community resources, and a formal education in mental health service provision to provide the most culturally and clinically meaningful services. Effective treatment will in turn promote program sustainability. Primarily due to the shortage of Master’s- and Ph.D.-level Tribal behavioral health specialists, many Tribal systems of care hire non-Native professionals to serve in clinical supervisory or managerial positions. A frequent challenge to newly hired non-Native clinical supervisors is that they must recognize that the Tribal paraprofessionals hold the expert knowledge on Tribal community needs and cultural engagement strategies. Training in Tribal approaches and Tribal life ways can be a multiyear transition for the non-Native professional, however investment in training and supervision of non-Native staff is critical to prevent costly staff turnover. To address the immediacy of the mental health needs of the AI/AN population, many mental health programs have developed cultural competence training curriculums to teach non-Native providers about the culture of the AI/AN community in which they will be providing 17 Stiffman, A. R., Freedenthal, S., Dore, P., Ostmann, E., Osborne, V., & Silmere, H. (2006). The role of providers in mental health services offered to American-Indian Youth. Psychiatric Services, 57, 1185–1191. services.18 Direct service supervisors can also serve as important role models for day-to-day sustainability practices, such as generating staff enthusiasm about the value of Tribal data for program planning, and ways to increase billing accuracy. Financing Long-term financial sustainability requires funding. Generally, the economic status of Tribal communities results in meager financial resources to draw upon and significant competition for limited Tribal funds. Although system of care funding and technical assistance resources have provided training on new approaches to the fund-development process, some Tribal communities are able to seize these opportunities, while the ability of others to maximize such opportunities has been compromised. There are many reasons why some Tribal communities are challenged in developing their financing capacity, which often include a lack of a comprehensive strategic plan to address the behavioral health needs of children, youth and families and the lack of an administrative and billing infrastructure. It also requires a commitment from Tribal administrative staff to build relationships with funding sources in order to gain access to budgets or grant cycles. Even if a strategic plan, infrastructure, and consistent leadership is in place, the Tribal system of care can still be challenged by limited resources. Last, some Tribal organizations have difficulty in adopting a proactive approach 18 Nebelkopf, E., & King, J. (2004). A holistic system of care for Native Americans in the San Francisco Bay Area. In Nebelkopf, E. & Phillips, M., (Eds.), Healing and mental health for Native Americans. New York: Altamira Press. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A12 which some feel is the result of generations of Federal paternalism, while others point to historical trauma. American Indian/Alaska Native Medicaid Provisions Medicaid is the largest payer for mental health services in the country. Medicaid services are a shared expense between the Federal Government and State governments. The Federal Government pays a percentage of the total payments for services which varies based on each State’s per capita income. The Federal share, called the Federal Medical Assistance Percentage (FMAP) ranges between 50 percent and 85 percent of the total cost expended in the State. Important to AI/AN financing is a special Congressional provision, embedded in the Indian Health Care Improvement Act, which established a match rate of 100 percent Federal dollars and zero dollars from States for Medicaid services offered through IHS, 638 Tribes, or 638 Tribal organizations. The 100 percent match rate was enacted because Congress did not want to burden States with what had been a Federal responsibility – the health care of AI/AN people. In addition, the 100 percent FMAP rate is specifically tied to the location of where the services are provided; services must be provided through a tribally owned / leased and operated facility that must be on the official IHS facility list. Tribal 638 organizations (Tribe or Tribal organizations entering into a 638 agreement with the Federal Government) providing services at a location on the official IHS list are eligible to receive payments are the 100 percent FMAP rate, which means that 1. States do not have to pay a State match for services offered through these Tribal organizations because the Federal Government will pay for 100 percent of the service; 2. Tribal–State Medicaid partnerships can result in behavioral health services to Medicaid eligible and Medicaid enrolled Tribal people; 3. dollars that a State would normally pay as its part of the Medicaid matching fund could instead remain in the State general fund; 4. State general fund savings can be spent on other needs within the State instead of being spent for Medicaid match. This arrangement is a significant win-win opportunity for both States and Tribes where Tribal organizations provide increased health services to Tribal youth and families at little or no cost to the State. Many State decision makers are not aware of this partnership opportunity and may often be suspicious of what appears to be a too-good-to-be-true situation. There are significant barriers to enrollment of American Indians and Alaska Natives in Medicaid and SCHIP, which has led State and Tribal policy experts to believe that the population is significantly under enrolled in these programs.19 If the AI/AN community is not part of a Tribal 638 organization, a financially successful alternative might be acquiring Federally Qualified Health Center (FQHC) status, which also allows for higher reimbursement rates. 19 Langwell, K., Laschober, M., Melman, E. & Crelia, S. (2003). American Indian and Alaska Native Eligibility and Enrollment in Medicaid, SCHIP, and Medicare Individual Case Studies for Ten States. BearingPoint, Inc. and Westat, Inc. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A13 FQHCs (and Rural Health Clinics) must be paid on a cost basis under Federal law. States have flexibility in determining the scope of ambulatory services covered under the FQHC model, which may include a variety of behavioral health services that can support a system of care grantee. Match All system of care communities are required to make contributions, also referred to as cost sharing, toward the system of care costs as outlined in the Federal authorizing legislation for systems of care (Title V, Part E section 565(b)(2) of the Public Health Services Act). The match requirement requires that the applicant entity will provide, directly or through donations from public or private entities, non- Federal contributions according to the below formula: ■ For the first, second, and third fiscal years of the cooperative agreement (grant), the awardees must provide at least $1 for each $3 of Federal funds. ■ For the fourth fiscal year, the awardees must provide a least $1 for each $1 of Federal funds. ■ For the fifth and sixth fiscal years, the awardees must provide at least $2 for each $1 of Federal funds. The purpose of match is to encourage local investment in the system of care by other child-serving systems, and as evidence of the potential of the initiative to sustain itself beyond the 6- year award period. Matching resources may be cash or in-kind, including facilities, equipment or services, and must be derived from non- Federal sources (e.g., State or sub-State non- Federal revenues, foundation grants). Indian Tribes receiving funds under the Self- Determination and Education Assistance Act (PL 93-638, as amended) are exempt from the restriction of not using Federal sources as match. Although only in-kind donations and cash funds from non-Federal sources can be used as matching funds by non-Tribal system of care grantees, eligible Tribes and Tribal organizations may also use Federal funds as match under certain conditions.. Although Federal dollars are generally not permissible for use as “match” dollars, P.L. 638 enables Tribal organization to use Federal dollars assumed by Tribes through the 638 legislation as match dollars as long as the identified 638 dollars are not being used as Federal match by other components of the Tribal organization or Tribal government. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A14 Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix B • Page B1 APPENDIX B. Purpose and Description of the Exploratory Description Study Background and Purpose of Study The Comprehensive Community Mental Health Services for Children and Their Families Program (referred to as the Child Mental Health Initiative [CMHI]), funded by the Center for Mental Health Services (CMHS) at the Substance Abuse and Mental Health Services Administration (SAMHSA), was initiated in 1992. The program was created to provide grants to States, communities, territories, and American Indian and Alaska Native (AI/AN) Tribes to develop systems of care to serve children and adolescents with, or at risk for, emotional disorders and their families.20 A system of care is a coordinated network of community-based services and supports organized to meet the challenges of children and youth with serious mental health needs and their families. Families and youth work in partnership with public and private organizations to design mental health services and supports that are effective, that build on the strengths of individuals, and that address each person’s cultural and linguistic needs. A system of care helps children, youth and families function better at home, in school, in the community and throughout life. Systems of care is an approach to services that recognizes the importance of family, school and community, and seeks to promote the full potential of every child and 20 For the purpose of th
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Title | Exploratory description |
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Full text | National Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report & Appendices July 2009 Submitted to: Substance Abuse and Mental Health Services Administration Child, Adolescent and Family Branch 1 Choke Cherry Road, Room 6-1047 Rockville, MD 20857 Under Contract Number 280–05–0135 Submitted by: Walter R. McDonald & Associates, Inc. ICF Macro Study Team: Holly Echo-Hawk, M.S. Michelle DiMeo, M.A. Nancy Weller, B.A. Carolyn Lichtenstein, Ph.D. Katherine Lewis Brown, M.B.A. Elizabeth Oppenheim, J.D. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report & Appendices • Page i Table of Contents Introduction ................................................................................................................................. 1 Description of the Study ................................................................................................................. 2 Tribal Starting Place—The Cultural Framework ................................................................................ 3 Planning for Sustainability .............................................................................................................. 4 Political Entities and Sustainability ................................................................................................... 5 Developing Sustainable Services ..................................................................................................... 6 Strengthening Infrastructure ........................................................................................................... 8 Role of Data in Financial Sustainability ............................................................................................ 9 Assessing and Mobilizing Funding Sources .................................................................................... 10 Determining the Cost of Services .................................................................................................. 12 Medicaid as a Funding Source ..................................................................................................... 12 Developing and Sustaining Key State Partnerships .......................................................................... 14 Implications for Long-Term Financial Sustainability ........................................................................ 15 Recommendations for Financing and Sustainability in American Indian and Alaska Native System of Care Communities ....................................................................................................... 16 Planning for Sustainability ....................................................................................................... 16 Interacting With Political Entities Regarding Financing ............................................................... 16 Developing Sustainable Services .............................................................................................. 17 Strengthening Infrastructure .................................................................................................... 17 Using Data in Financial Sustainability Planning ........................................................................ 18 Assessing and Mobilizing Funding Sources ............................................................................... 19 Determining the Cost of Services ............................................................................................. 19 Determining the Feasibility of Medicaid as a Funding Source .................................................... 20 Developing and Sustaining Key State Partnerships .................................................................... 20 Appendices Appendix A. Understanding the Challenge: The Cultural Framework ...................................... A1 Appendix B. Purpose and Description of the Exploratory Description Study ............................... B1 Appendix C. Findings From Discussions With Project Directors, Fiscal Managers and Tribal Board or Council Representatives ...................................................................... C1 Appendix D. Findings From Interviews With State Representatives ........................................... D1 Appendix E. National Evaluation Sustainability Study Findings for Tribal System of Care Communities .................................................................................................... E1 Appendix F. Discussion Guides ............................................................................................. F1 Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report & Appendices • Page ii Index of Tables Table 1. American Indian and Alaska Native System of Care Grant Communities ........................... 2 Table B–1. American Indian and Alaska Native System of Care Grant Communities ......................... B2 Table E–1. General Strategies for Maintaining Tribal Communities’ Systems of Care ........................ E2 Table E–2. Financing Strategies for Maintaining Tribal Communities’ Systems of Care ...................... E3 Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 1 Introduction he Comprehensive Community Mental Health Services for Children and Their Families Program (also referred to as the Child Mental Health Initiative [CMHI]), funded by the Center for Mental Health Services (CMHS) at the Substance Abuse and Mental Health Services Administration (SAMHSA), was initiated in 1992 to provide grants to States, communities, territories, and American Indian and Alaska Native (AI/AN) communities to develop systems of care to serve children and adolescents with, or at risk for, emotional disorders and their families.1,2 A system of care promotes the full potential of all children and youth by addressing their physical, emotional, intellectual, cultural, and social needs.3 AI/AN communities entered the system of care movement in 1994 with the initial Federal grant award to the Restoration of K’e: The Navajo Nation Child Mental Health Project, located on the Navajo Reservation in New Mexico. The experiences of this initial Tribal venture into the world of national system of care reform helped to open the doors for the Tribal communities that followed. Fifteen Tribal communities were funded between 1994 and 2006 and they represent the broad diversity of Tribal people (see Table 1 for a list of the grant communities and their primary States of residence).4 Their cultures and languages are as diverse as their geographic locations, which include rural reservations, Urban Indian communities, and Alaska Native villages. Half of the Tribal system of care communities were previous recipients of a 3-year Circles of Care planning grant. The Circles of Care Initiative— 1 For the purpose of this report, the terms “American Indian/Alaska Native,” “Native American,” “Indian,” and “Tribal” are one and the same. 2 The 125 communities that have received, or were receiving at the time of the study, funding through CMHI represent all 50 States and two U.S. territories. 3 http://systemsofcare.samhsa.gov/, retrieved March 25, 2008. 4 CMHI grants were awarded to 13 Tribal sovereign nations and two Urban Indian organizations between 1994 and 2006. described by community representatives as invaluable—supports federally recognized Tribes, State-recognized Tribes, and Urban Indian communities with financial and technical assistance to plan a culturally respectful mental health system of care. The material presented in this report is supported by additional material included in the following report appendices: ■ Appendix A. Understanding the Challenge: The Cultural Framework ■ Appendix B. Purpose and Description of the Exploratory Description Study ■ Appendix C. Findings from Discussions with Project Directors, Fiscal Managers, and Tribal Board or Council Representatives ■ Appendix D. Findings from Interviews with State Representatives ■ Appendix E. National Evaluation Sustainability Study Findings for Tribal Communities In addition, the discussion guides used to gather the data summarized in this report can be found in Appendix F. T Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 2 Description of the Study The purpose of the exploratory study, conducted between July 2007 and January 2008, was to examine the unique financing opportunities and challenges of Tribal systems of care in relation to program sustainability. The overall goal of collecting the information from this exploration was to use study results to identify and improve financing and sustainability strategies specifically for Tribal communities. It is important to note that the findings of the study are based on a small number of participants (two or three staff from each of the 15 Tribal system of care communities) and the findings cannot be generalized to all Tribal communities. The National Evaluation Team facilitated telephone discussions and conducted site visits with Tribal system of care communities funded by CMHS between 1994 and 2006. Telephone discussions with the project director and fiscal manager of all 15 communities covered broad thematic areas that included perspectives on sustainability; the economic, social, and political environment; infrastructure; services; and funding. The discussions, conducted from July through October 2007, were unstructured, but were steered by a topical guide. In addition, site visits were conducted with five Tribal system of care communities between November 2007 and January 2008. On-site discussions were held with a project director, fiscal manager, Tribal Board or Council representative, and State representative. These discussions explored financing and sustainability successes and challenges in more depth than the telephone discussions. Discussions with State representatives Table 1. American Indian and Alaska Native System of Care Grant Communities System of Care Population of Focus State Funding Period Graduated Communities Restoration of K’e: The Navajo Nation Child Mental Health Project Navajo Nation New Mexico 1994–1999 Sacred Child Project North Dakota Tribes North Dakota 1997–2003 Kmihqitahasultipon (“We Remember”) Project Passamaquoddy Nation Maine 1997–2003 With Eagles’ Wings Project Northern Arapaho and Shoshone Tribes Wyoming 1998–2004 M’no Bmaadzid Endaad Program Sault Ste. Marie Tribe of Chippewa Indians and Bay Mills Tribe of Chippewa Indians Michigan 1998–2004 People Working Together Project Yup’ik Eskimo and Athabascan Indians Alaska 1999–2005 Nagi Kicopi–Calling the Spirit Back Project Oglala Sioux Tribe South Dakota 1999–2005 Ak-O-Nes Project Northern California Tribes California 2000–2006 Currently Funded Communities (at the time of the study) Choctaw Nation CARES Project Choctaw Nation Oklahoma 2002–2008 “Ch’eghutsen” A System of Care Alaska Native Communities Alaska 2002–2008 Urban Trails Project Urban Indian Community California 2003–2009 The Po’Ka Project (Blackfeet Children System of Care) Blackfeet Nation Montana 2005–2011 Tiwahe Wakan (Families as Sacred) Yankton Sioux Tribe South Dakota 2005–2011 Seven Generations System of Care Urban Indian Community California 2005–2011 Sewa Uusim Systems of Care Pascua Yaqui Tribe Arizona 2006–2012 Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 3 focused on State agency support for Tribal systems of care. A Native researcher conducted all discussions in a culturally competent manner; respect for AI/AN historical concerns about data gathering and data analysis guided the entire research process. The notes taken for all discussions were qualitatively analyzed by isolating emergent themes. Tribal Starting Place—The Cultural Framework The core values of a system of care specify that services should be child-centered, family-focused, community-based, and culturally competent—all values shared with many Tribal communities as part of their traditional values and beliefs. Most of the Tribal communities further capitalize on this alignment by translating the system of care terminology and approach into phrases and terms that are meaningful to their Tribal cultures. Tribal communities understand the relationship between a cultural foundation to services and improved outcomes for Tribal youth and families, and use the system of care framework to strengthen the development of healthy Tribal nations. The cultural importance of program sustainability cannot be ignored. Sustainability of community mental health programs is especially important within Tribal communities that lack financial resources. For example, one leader of a Tribal community-based substance abuse prevention and intervention program stated, We have a responsibility to our program recipients. They’ve had so many losses in their lives, and [if we] come in for a year or two or three and give them hope, only to have the program go away, we’ve just caused another loss and further hopelessness in their lives.5 5 Noe, T., Fleming, C., & Manson, S. (2004). Reducing substance abuse in American Indian and Alaska Native communities: The Healthy Nations Initiative. In Nebelkopf, E. Although the system of care principles and Tribal belief systems may be in alignment, Tribal systems of care continue to face serious challenges in developing and implementing financing strategies for sustainability. Financing any system of care is a strategic endeavor that involves determining what funds will be used, how they will be used, and how they will be managed.6 However, the financing of Tribal systems of care is particularly complicated. This is due to many reasons, including the lack of financial resources in remote Tribal communities, the impact of Tribal–State history on the willingness and ability to pursue financial partnerships, and the potential funding sources’ lack of knowledge about the advantages of working with Tribes. Adding to the complexity of the challenge is the meaning of federally recognized Tribes’ sovereign status as it relates to financing; the role of Tribal self determination; the history of confusing policies guiding support for Tribal services; the financial options of Tribes that are recognized by States, but lack Federal recognition; and the unique financial situation faced by Urban Indian communities. These challenges become barriers to reform when there is & Phillips, M., (Ed.), Healing and mental health for Native Americans. New York: Altamira Press. 6 Stroul, B. A. (2007). Issue brief 1: Effective strategies to finance a broad array of services and supports (RTC study 3: Financing structures and strategies to support effective systems of care, FMHI pub. #235-IB1). Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children’s Mental Health. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 4 a lack of cross-cultural and cross-system problem solving. Planning for Sustainability Findings Many of the Tribal system of care community representatives stressed that active and early planning for sustainability was critical. Community representatives discussed how planning for systemwide transformation built on a foundation of Tribal beliefs and Tribal ownership provided an opportunity to break away from a previous cycle of non-productive “planning” that had been reactionary and short-term in nature. Some community representatives felt that recognizing the impact of colonialism and historical trauma on the Tribal community’s efforts to plan was an essential first step in breaking non-productive cycles. One community representative argued that there was little value in building large-scale services with Federal funding if there was no effort to plan for long-term sustainability. Additionally, a few communities cautioned that fast program growth resulting from an infusion of Federal funds can diminish the quality of service provision if the service structure is not carefully planned; community representatives recommended expanding services carefully and only to the extent that supports are in place to ensure quality service provision. The Tribal system of care communities engaged in a number of approaches to planning, which usually began with their seeking input from the local community on needs and service priorities as part of their logic model development.7 Many Tribal community representatives discussed the value of gathering data about their community’s strengths and needs to help with program planning and to 7 A logic model is a process to articulate the theory of change underlying systems of care for children and families. It is a tool for describing theories and beliefs about how and why service systems are expected to produce particular results. increase their competitive edge with other funding opportunities. Some of the planning approaches used by the Tribal communities included ■ developing local definitions of health and wellness with the input of community members and Tribal elders; ■ having Tribal elders help design strategies to infuse Tribal values, practices, and cultural supports throughout their system of care; ■ analyzing all of the fund sources that affected the Tribal youth and families in their States of residence, and then determining which of the fund sources they currently accessed and which they needed to pursue; ■ determining the true cost of services using time and cost studies; ■ incorporating visits to the State Medicaid office to better understand the Medicaid provider and billing requirements; ■ using a backward mapping process to identify the community’s ultimate goal and detail the steps necessary to reach the goal without sacrificing cultural integrity; ■ developing ways to build evidence of effectiveness and a cost base for traditional practices; ■ developing methods to track the non-Federal matching fund requirement. Discussion The close alignment of system of care values and principles with many Tribal values and beliefs empowers a Tribal system of care to include the Tribal community in its planning efforts. System of care grant requirements such as providing culturally competent services that best meet the community to be served, creating ways to ensure family-driven and youth-guided care, consistently evaluating the factors related to child and family progress, and developing a social marketing plan that helps the community understand the meaning of a system of care are all opportunities for a more culturally and Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 5 linguistically appropriate and inclusive planning model. Authentic community involvement in all levels of planning not only gives family voice to the process, but can clarify community needs and wants, and helps to determine which elements of the system of care should be sustained after the Federal grant ends. The Tribal system of care communities stressed that adherence to the cultural strengths of Tribal values becomes the screen through which all services and fund-seeking decisions must pass. Within this framework, the written sustainability plan can clarify financing priorities, outline steps to be accomplished toward each financing priority area, list timelines for the completion of tasks, designate key leadership roles and responsibilities, and detail benchmarks to monitor progress toward long-term sustainability of the Tribal system of care. Political Entities and Sustainability Findings The willingness of those who hold the power and authority to make funding decisions has tremendous influence on the financial sustainability of the Tribal systems of care. The AI/AN systems of care described the ways in which their sustainability efforts were impacted by government agencies at the Federal, State, Tribal, and county levels. Each Tribal system of care community described making significant investments of time to increase the government funding sources’ knowledge about why system of care services are needed and why Tribal-driven services increase community access and produce better outcomes. This work included providing education about Tribal culture, Tribal needs, Tribal sovereignty, and the Tribal approach to child and family services. The Tribal systems of care became expert in ways to generate political and policy-level support for their systems of care through education and relationship building. Tribal–State relationships varied by State, often for historical reasons, and community representatives reported the value of developing partnerships with key State officials and administrators. Many community representatives participated in State and county planning meetings to make Tribal needs known, but pointed out that Tribal staff time was limited and travel to State or county planning meetings was time consuming. Tribal system of care communities also provided numerous examples of their efforts to monitor and influence State health planning initiatives, such as social marketing efforts to draw policy attention to Tribal family needs. A further complication is that several of the Tribal system of care service areas encompass multiple States, resulting in a multilayered process of developing relationships with State administrators and the need to understand multiple State child-serving initiatives. Many community representatives discussed the impact of Tribal politics on their sustainability planning efforts. Some communities reported that frequent elections of Tribal government officials were disruptive to sustainability planning; the Tribal election process can occur as frequently as every 2 years, and the system of care staff had to repeatedly provide orientation about the transformative meaning of “systems of care” to prospective, or newly elected, leadership. Community representatives also discussed the impact of turnover in key Tribal government positions that lead to a shift in priorities for the Tribe or Tribal organization. Community representatives emphasized that Tribal elections sometimes caused rules to change overnight. Discussion Support from those with power and influence over funding decisions is critical for the sustainability of any system of care, but the Tribal systems of care have the additional task of educating funding sources about their culture and approach to Tribal services. Tribal systems of care spend a significant Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 6 amount of time explaining what services and supports work for Tribal families, developing ways to document the benefits of their service array, and negotiating strategic alliances that support the sustainability of their systems of care. In order to sustain financially, the Tribal system of care communities must advance each of these areas. For example, although each Tribal community is aware of what mix of clinical and cultural supports works best for it, there remains a need to better articulate how the cultural supports may help advance the clinical interventions, or how clinical and/or medical interventions may help open the door for increased understanding of the stabilizing role of cultural supports. Also, Tribal academicians, researchers, and evaluators are interested in better describing the benefits of a Tribal service array, but many struggle with how to describe the intersection of the different world views represented by clinical and traditional services. And, while Tribal communities are experienced in developing tactical alliances, the ultimate accomplishment of turning allied support into actual contract dollars remains a challenge. Developing Sustainable Services Findings The Tribal system of care communities described their efforts to build an array of services that best responded to the behavioral health needs of their community. Their inherent knowledge of all things Tribal (social and cultural lifestyles, spiritual beliefs, values, communication styles, and resources) offered a cultural advantage in designing services to match the local need. In general, not only do the program names of many Tribal systems of care reflect the AI/AN value of honoring children and youth, but their arrays of services reflect that their culture is the foundation of their services. Some of the communities addressed an ongoing workforce shortage in Tribal behavioral health by investing in training and credentialing programs for staff to increase the quality of care and to provide career advancement steps for paraprofessional staff. In addition, several Tribal communities were successful in marketing their training program to the State, which resulted in modification of State provider standards to enable the certified, Tribal paraprofessionals to meet requirements for third-party reimbursement. These successful partnerships between the Tribal systems of care and State governments resulted in training and education programs that met State credentialing requirements as well as the cultural service needs of Tribal communities. Many Tribal systems of care encouraged partnership with the State from the beginning of the curriculum development to ensure that any obstacles to becoming a State licensed provider of behavioral health services were readily addressed and resolved. Community representatives described successful partnerships with Tribal community colleges and universities to develop and provide training. One community representative noted that while higher education strengths lie in providing an academic foundation to behavioral health knowledge, such a setting may not always be as successful for teaching the practical skills needed by staff to provide mental health services. Given the urgent situations of many Tribal youth, some communities felt that Tribal system of care staff needed on-the-ground clinical skills more than academic theory. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 7 The Tribal communities developed a range of approaches to address the role of culture as part of the assessment and treatment planning process, including ■ relying on local cultural advisors to guide the development of the services; ■ developing extensive cultural assessment protocols based on the local definition of wellness; ■ developing treatment goals to include both a clinical and cultural assessment; ■ setting the pace and location of the “treatment” according to local culture and individualized needs; ■ developing Tribal behavioral health training that benefited both the Tribal practitioner and non- Native clinical supervisor; ■ incorporating traditional practices into the “treatment” plan that were individualized according to particular Tribal beliefs and family requests. Many of the Tribal communities discussed their struggles with determining whether and how to seek financial support for traditional practices. Traditional practices can be defined in many different ways and are an important cultural link to the healing process. In general, the Tribal systems of care expressed concern that seeking financial support for traditional practices might result in requirements for adhering to licensing and accreditation standards. Tribal community representatives suggested various solutions, which included ■ developing a line item in their system of care budgets for broadly defined cultural supports, which might include traditional practices; ■ including references to traditional practices within their system of care coordinator certification process; ■ cross-walking the “treatment” goals of Tribal traditional practices with their clinical outcome counterparts. Whether a treatment approach was referred to as a traditional practice or not, many felt that promoting culturally competent service provision was just as important to the sustainability of their system of care as securing financial resources. In addition, several communities discussed the impact of the large infusion of Federal system of care grant dollars on their program design. Although the Federal support enabled the community to pay detailed attention to all elements of Tribal service provision, a few communities advised that too much program growth too quickly could diminish the quality of service provision. That is, the addition of staff without program underpinnings in place (e.g., a full orientation to the system of care framework, training on system of care service expectations, and an understanding of how the service array links to outcome measures) could mean that the newly hired staff were not able to work effectively as a team of system of care providers. Therefore, some community representatives recommended building slowly and expanding services only to the extent that quality service provision could be assured. Discussion Tribal systems of care are challenged by building services that can be sustained beyond the Federal grant. This requires that the system of care leadership maintain a balance between cultural and clinical knowledge, address workforce recruitment and training needs, provide effective supervision and oversight, and develop meaningful ways to measure outcomes related to the full range of their services. Training and education costs are critical for workforce readiness, and supervision supports could be an important element of workforce retention. Another program cost is Tribal administrative time, essential for building Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 8 relationships and educate funding sources on the value of Tribal-driven services. Strengthening Infrastructure Findings Each of the Tribal system of care communities was at a different point on the continuum of infrastructure development. Those that were part of a Tribal primary health care organization often had a reasonably strong infrastructure in place (e.g., computerized care management documentation, an information technology department for computer trouble shooting, a fully staffed finance and billing office). Tribal systems of care that were not attached to a health care system often had to build their organizational infrastructure from the ground up. This was complicated by their remote locations, which hindered their ability to recruit and hire staff to support their infrastructure development. The communities discussed how the lack of local and well organized culture-based services contributed to the disproportionate numbers of American Indians and Alaska Natives in juvenile justice, foster care, child welfare, and behavioral health systems. Most Tribal communities are rich in culture, but poor in financial resources. When funding for services is received in such high need communities, the immediate focus is on delivering services to the community. Strengthening the service system infrastructure often takes a back seat to mobilizing services to meet the community need. One community representative suggested that Tribal communities should take the time to build a solid administrative and financial infrastructure, one that is designed for growth. Another community representative reported that hiring or contracting with a public accountant to review the Tribal system of care’s accounting system, billing capacity, and fund oversight was an essential step in building such infrastructure. Community representatives discussed other aspects of their organizational infrastructure that affected their system of care, including the following: Internet. The remote locations of many of the Tribal systems of care have sporadic Internet connectivity. This was mentioned as affecting electronic billing capability and diminishing their ability to comply with State contract performance standards, such as those mandating a maximum time period between when the service was provided and when the data was input into State databases. One community that increased its use of electronic communication found that many members of its Tribal Council were unfamiliar with the technology, so that training had to be provided to improve the Council members’ comfort and skill with computer technology. Office space. Office space is extremely scarce for many Tribal communities, as is housing for newly recruited staff. Due to a lack of available office space, several communities reported having uncomfortable working conditions or offices scattered across several locations, creating a barrier in staff unity. To address the lack of space, some communities received office space from school districts to provide school-based services. Other communities built their own facilities. Building office facilities, which also served as community centers, was a large part of promoting program sustainability for these systems of care. Billing infrastructure. Tribal billing capacity is critical for many financial sustainability plans, but many finance staff in smaller Tribal organizations have a narrowly defined responsibility of meeting payroll and billing a grant funding source on a once-a-month basis. Thus, establishing a complex, third-party billing system can require a huge investment of resources. Technical assistance from State representatives was helpful for some to better understand their billing processes and reduce future billing errors. Others reported facing the challenges of insufficient financial software or keeping up with Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 9 necessary software upgrades to meet the changing requirements of payers. On the other hand, those that were part of a large Tribal health care organization reported being able to tap into existing billing infrastructures, making the transition to billing for mental health services less challenging. Staff transformation. Some community representatives discussed the challenge of transitioning Tribal direct service staff from a long history of working within a grant funding environment, with no uniform expectation for a specific number of direct service hours per week, to a billable service hour model. The billable hour model requires that each staff person work within specific weekly service expectations that include an established goal of a certain number of billable service hours. Transitioning staff into billable hour performance expectations was successful when the Tribal organizations turned the billable hour expectation into a visible team effort that emphasized increased service to the community. Discussion Many Tribal organizations have made important advances in strengthening their organizational infrastructure as part of sustainability planning. Consultation with financial oversight and grants management advisors has been helpful and has resulted in a list of action steps to achieve a stronger infrastructure. Many Tribal systems of care have gained much support and advice from peer-to-peer learning opportunities. Establishing relationships with State funding sources and State contracts offices has been useful in better understanding data requirements and billing processes. Tribal systems of care have gained additional insight by exploring a State or national accreditation process that provides a list of action steps to prepare for accreditation. Continuous awareness of integrating cultural norms into the infrastructure development is critical. Developing a process for continuous quality improvement (CQI) is another important step toward financial sustainability. Unless a CQI process is institutionalized within the Tribal organization—especially in communities where the need for services is great and the environment may frequently be crisis driven—it can be easy to lose sight of the sustainability plan. Institutionalizing a CQI process requires the formal allocation of responsibility for quality improvement to a person or team with the power and authority to transform and improve services and financing opportunities. It is helpful for this person or team to have experience in managing in a changing environment. Role of Data in Financial Sustainability Findings The Tribal system of care representatives discussed general concerns about data collection that reflected the historical mistrust held by many Tribes. Tribal hesitation about data collection, ownership, and analysis is based on the historical misuse and abuse of Tribal data by some non-Tribal researchers. However, many community representatives also recognized the importance of tracking service use information as part of financial reporting. The system of care funding legislation requires grant community participation in a national evaluation of system of care implementation; some Tribal communities have used this involvement as a springboard to further develop their own local evaluation efforts. Community representatives emphasized the importance of Tribal “ownership” of, and a voice in, the data collection and analysis processes to ensure a cultural interpretation of the data. Discussion participants also reported the need to improve Tribal data systems. Community representatives from one community stressed the usefulness of having information on the number of clients served, the number of services rendered to each client, the types of services rendered, and client characteristics. Another community representative stated that program evaluation cannot Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 10 occur without data and benchmarks. Tribal strategic planning and system of care coordination is hindered when basic service information is not available across the child-serving systems. Coordination between State reporting systems and Tribal databases was also reported as a challenge. One community discussed the double challenge of using an outdated data tracking system within the Tribal organization, but also having to enter data into a complex State database. Technical assistance from the State regarding the State databases proved helpful for one community, but another community discussed the need for increased Tribal advocacy and input into State decisions about technology upgrades and electronic reporting requirements. Tribal–State partnerships in improving data technology were often successful. A State discussant described efforts to help Tribal organizations in obtaining technology grants to upgrade computer equipment and to increase the Internet speed for remote Tribal locations, enabling reports and data for billing to be transmitted quickly. In this win–win situation, the State’s motivation was to facilitate Tribal access to Medicaid billing and data tracking, and the Tribal organization gained a multipurpose technology upgrade. While data collection was reported as being a time-consuming requirement for the Tribal system of care, it was also considered essential for justifying the need for staff positions, revamping program foci, securing additional funding sources, negotiating changes with the State for provider qualifications, focusing staff training on emerging community needs, and promoting social marketing endeavors. Discussion The system of care national evaluation process is challenging to some Tribal communities. However, the communities acknowledged advancements in the use of data for sustainability planning, program planning, and organizational change. The ability to have program managers and evaluators on staff who became trained and experienced with system and client outcome indicators, sustainability assessment measures, and other aspects of data use was recognized as valuable. Although Tribes and Tribal organizations hold a historical distrust of data requirements, the system of care evaluation effort provides an opportunity for Tribal communities to build knowledge and adapt the data requirements in ways that best support local needs. Tribal systems of care are at different places on the continuum of data use, but the ability to develop data-based arguments for funding of Tribal services is essential for long-term sustainability planning. Assessing and Mobilizing Funding Sources Findings Tribal community representatives expressed frustration with the scarcity of available funding sources for their communities. The shortage of funding for Tribal communities is partly due to regional economies, confusion about which government entity is responsible for Tribal services and omission of Tribal services from funding applications. One community representative mentioned the practice of some States and counties of including Tribal statistics in their overall statement of need in State and/or county grant applications, but to provide little funding to Tribal service providers. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 11 There is a substantial lack of available funding in rural and remote Tribal locations. One community reported it had three experienced grant writers on staff, but the community lacked any funding opportunities to pursue, especially those that would support the youth-guided and family-driven values of a system of care. In another instance, upon the Tribe’s receipt of the system of care grant funding, the county within which the Tribe resided stopped providing all previous funding to the Tribal community and would not re-establish the financial support once the CMHS grant funding ended, despite system of care staff efforts. Communities were also challenged in finding grants with sufficient indirect cost funding to support program administration needs. To further complicate fund-seeking efforts, some of the Tribal system of care communities encompass service areas that are part of more than one State. In these situations, multi-State political and economic environments affect the systems of care, requiring that Tribal communities become knowledgeable about multiple States’ children’s initiatives, Medicaid regulations, provider standards, and credentialing requirements. Matching Funds Requirement The Federal system of care funding requires that the grant community must make non-Federal contributions toward program costs. Meeting the Federal cost-sharing requirement (informally referred to as the match requirement) is consistently one of the greatest challenges for the Tribal systems of care. Although the requirement encourages local investment in the system of care by other child-serving systems, Tribal communities represent some of the most impoverished areas of the country. One community reported that there were not enough financial resources in the area to meet the match requirements. Another community addressed this issue by joining a coalition of Tribes to negotiate with the Federal Government to have the requirements waived for the poorest counties in the country. Communities stressed the importance of understanding what can and cannot be used toward the match requirement under the Federal cost-sharing guidelines. Although eligible Tribes and Tribal organizations receiving funds under the Self- Determination and Education Assistance Act are exempt from the restriction prohibiting the use of Federal funds as match, they must ensure that the funds received under this Act are not being used as Federal match by other components of the Tribal organization or Tribal government.8 Those community representatives who reported having the most success with meeting the match requirements had long-term relationships with State or county funding sources; the State or county cash grants were their match, or cost-sharing, dollars. Most communities reported meeting the cost-sharing requirements by assigning a cash value to in-kind contributions. However, searching for and documenting in-kind contributions was a labor-intensive process that pulled time away from direct services. Discussion The Tribal, State, and regional economic environments that surround the Tribal system of care have a direct impact on its ability to locate and access funding support. The fund-seeking challenge is greatly exacerbated because many of the Tribal systems of care are located in the most economically depressed regions in the country. The shortage of available funding sources makes it even more important for the Tribal system of care communities to avoid “chasing” dollars as they become available. Instead, time spent in developing a sound strategic plan and a logic model delineating the community’s theory of change would be well spent. 8 Tribes receiving funds under the Self-Determination and Education Assistance Act (PL 93-638, as amended) are exempt from the restriction that prohibits the use of those Federal funds as match as long as the funds are not being used as match for other funding sources. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 12 Analysis and identification of funding sources that meet the Tribal vision as well as the funding source vision is a business-smart, strategic process. This fund-seeking process should be focused by the community’s strategic plan for sustainability that includes a well-thought- out theory of how the local community will change from “service as usual” to a new framework of a Tribal system of care. Additional development of strong financial and contract reporting systems will not only help build well-organized and effective services, but will result in setting the stage for replication of best service and infrastructure practices. Determining the Cost of Services Findings A fundamental step in sustainability planning is to determine the true cost of service provision. One community’s representatives reported that they determined the actual cost of their services through the use of time and cost studies. Using a time study form, each administrative and direct service staff person tracked how he/she spent each work day over a specified period of time (e.g., 2 weeks). The time study approach categorizes typical activities and requires staff to record the amount of time spent in each type of activity. Using this foundation of information, the actual cost of various services (including time spent completing client paperwork, administrative costs, supervision costs, transportation, etc.) was calculated. With this information in hand, the Tribal system of care could then negotiate payment rates with funding sources. Discussion Tribal programs that develop a budget or negotiate a contract without a full determination of the actual cost of their service provision are fiscally vulnerable and always in a disadvantageous position during contract negotiations. Determining an accurate cost of services is especially critical for culture-based services because this type of service usually involves a longer process for cultural engagement and usually requires an expanded amount of time to render service. Time studies can help determine the length of time used for culture-engagement strategies, and the amount of time needed for each step of culture-based treatment. Tribal communities can then negotiate cost-based rates for the full range of Tribal services (e.g., clinical and cultural assessments, community health aide services, behavioral health care, case management), which is critical. States are interested in ways to reduce the high cost of some State services and increase their effectiveness. Negotiating with States for Tribal service contracts is more effective if Tribal organizations know the cost of their services and can demonstrate that their approach to service provision will not only be less costly to the State, but will likely result in better outcomes. Medicaid as a Funding Source Findings An essential part of many of the Tribal system of care sustainability plans included exploration of a partnership with Medicaid (the largest payer in the country for behavioral health services). The Medicaid structure, designed as a shared expense between the Federal and State governments for State plan-approved Medicaid services also includes a special provision for Tribal partnerships. This provision is related to the Federal share of the Medicaid service cost, which is referred to as the Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 13 Federal Medical Assistance Percentage (FMAP).9 Several community representatives reported that they spent significant amounts of time meeting with State officials to explain the potential benefits of Tribal–State partnerships and to negotiate access to reimbursement rates through this special provision in the Indian Health Care Improvement Act, through federally qualified health center rates, or through changes in provider standards that better support Tribal-driven services. The exploration of Medicaid access had many starting places, depending on the organizational structure and infrastructure capacity of the Tribal system of care. For example, Tribal communities that did not already have a national or State license or accreditation status as a behavioral health provider first pursued the steps to become licensed or accredited—a necessary step toward being able to bill Medicaid for eligible services. Most of these communities realized that in addition to further development of their behavioral health policies and procedures, they also needed to focus attention on developing their third-party billing capacity. Some communities became knowledgeable about Medicaid enrollment standards and explored ways to co-locate Medicaid enrollment staff in Tribal community locations. The potential relationship between traditional services and Medicaid reimbursement were addressed in a variety of ways. Traditional services could be classified as behavior management or rehabilitation services in some State Medicaid Plans 9 The FMAP rate is based on the State per capita income, thus varying from State to State; the State share of Medicaid service costs range from 50 percent to 85 percent. A Congressional provision of the Indian Health Care Improvement Act established a match rate of 100 percent Federal dollars and zero State dollars for Medicaid services offered through the Indian Health Service (IHS), Public Law 93-638 Tribes, or Public Law 93-638 Tribal organizations. In addition, the Tribal services must be provided through a tribally owned/leased and operated facility that is on the official IHS facility list. If all the requirements are met, this FMAP option can result in cost savings to States and is one of that recognized the value of selected traditional practices as part of the service array. One Tribal community employed a licensed counselor as a clinical staff supervisor who provided cultural services as part of the treatment plan. Some communities addressed the use of traditional approaches as part of treatment in their training and certification curriculum. Careful analysis of the State Medicaid reimbursement rates and behavioral health billing categories was important in Tribal community service planning, as was the financial calculation of the number of billable hours per week per staff person. Some Tribal communities conducted a crosswalk of the planned Tribal system of care’s services with Medicaid behavioral health billing categories to determine categorical alignment. Some Tribal communities worked closely with State Medicaid staff and other Medicaid providers to explore and submit State Plan Amendments to increase Tribal access to Medicaid services. If amendments were not possible, continued collaboration with the State Medicaid office sometimes led to regulatory changes (e.g., easing of duplicate paperwork) that facilitated a Tribal system of care’s involvement as Medicaid providers of services. Challenge areas included unsuccessful access to the State’s behavioral health managed care system and, hence, unsuccessful access to Medicaid. Some communities were not able to access Medicaid services because they did not have licensed staff or did not offer any billable services at their current stage of service development. Some communities were unaware that transportation is a service that may be eligible for Medicaid reimbursement. This is unfortunate because transportation is a significant cost in Tribal services due to limited community member vehicle ownership, the long geographic distances to reach services, and the lack of financial resources for fuel. the reasons that Tribal systems of care explore Medicaid as a resource for eligible services. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 14 Discussion The historical funding resources for Tribal behavioral health services, primarily Indian Health Service and Bureau of Indian Affairs, remain too meager to fully address the growing disparities and behavioral health needs of local Tribal communities. Tribal system of care communities recognize that they must search for additional financial support, and Medicaid is prominent in most of the Tribal sustainability plans. Key to pursuing Medicaid service coverage are several factors: the ability of the Tribal organization or Tribal government to develop a working relationship with State Medicaid officials; the design and efficacy of the Tribal service array; the ability to recruit (or develop) a licensed workforce; and the capacity of the Tribal infrastructure to effectively support a third-party billing mechanism. Developing and Sustaining Key State Partnerships Findings The majority of the community representatives spoke about the value of establishing a working relationship with a key State administrator that later became an important part of their sustainability efforts. The Tribal communities used a variety of approaches to build relationships with State administrators, but common to their approaches was conducting Tribal–State meetings to educate each other on mutual needs and priority areas and provide information about the connection between a cultural foundation to service and improved outcomes. One community’s strategy was to include representatives from the county on its Tribal advisory board to increase their exposure to Tribal needs. Some community representatives stressed the need to start relationship-building with the State as early as possible, as it could take years to get into the State system and, ultimately, into the State budget. Often, the State contact person became a “champion” for Tribal services—that is, someone who advocated within the State system for the value of Tribal services. The State contacts that were developed also provided insight into the inner workings of State system priorities and data systems, which proved invaluable to several Tribal systems of care. For example, some State contacts provided training on how to negotiate a maze of county program requirements and reporting forms. One State champion provided assistance in understanding how to reduce the error rate in Medicaid billing. Another was helpful in advocating for changes in minimum provider qualifications for case managers and care coordinators. The State champions were valued because they understood sovereignty rights, valued the Tribal expertise regarding providing services to Tribal communities, and understood how Tribal services could benefit the State. However, some community representatives observed that the development of positive relationships with representatives of their States’ agencies was challenged by State personnel lack of knowledge about Tribal sovereignty and historical trauma, lack of trust between the Tribe and the State, and staff turnover within partnering agencies and representatives. Discussion Developing working relationships with key State partners can be helpful for Tribal communities that are trying to expand their funding sources. Tribes and Tribal organizations that pay particular attention to Tribal members disproportionately using high-cost State services can then develop a data-driven argument for Tribal service contracts. That is, if the number of Tribal youth in high-cost State services (e.g., juvenile corrections, non-Native foster care, residential treatment) continues to be out of proportion to the percentage of Tribal youth in the overall State population, the Tribal organizations can build their argument that placement of Tribal youth in mainstream institutions is not only ineffective, but very costly to Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 15 the State. Relationship building with State partners, combined with demonstration of the effectiveness of Tribal services, can result in service contracts for Tribal systems of care. Implications for Long-Term Financial Sustainability Examination of the financial sustainability efforts of the 15 American Indian and Alaska Native (AI/AN) system of care communities has resulted in information that will be useful to Tribal service planners, Tribal finance administrators, and system of care funding sources. It is clear that Tribal sovereignty and Tribal political structures (including Urban Indian structures) have a significant impact on financing. Other factors impact sustainability. Historical trauma can affect the ability of the Tribal community to come together for productive sustainability planning, as well as impact how much Tribes want to develop a working relationship with the State or county. Tribal infrastructures (e.g., computer technology, finance and billing systems, and human resources) are critical to implementation of sustainability plans, but are under-developed in some Tribal communities. Determining the true cost of Tribal and culturally based services is challenging but possible. Matching fund requirements (non- Federal cost sharing) remain a significant challenge in Tribal system of care communities that have limited resources. Implications of the study’s findings for next steps include the need for finance-focused training and technical assistance, broader dissemination of best practices, and the importance of peer-to-peer learning opportunities on a range of topics such as accreditation, Tribal– State agreements, Medicaid negotiations, third-party billing systems, and other finance-related topics. The AI/AN system of care communities have made significant contributions to the field of cultural competence through their community-engagement strategies, cultural and clinical assessments, culturally based treatment plans, and culturally based services. This report summarizes the Tribal contributions to the field of sustaining systems of care through examples of Tribal infrastructure development, Tribal–fund source relationship building, and a range of approaches that lead to financing for culturally based services. Successful planning for long-term financial sustainability ■ is a strategic process that starts early; ■ is facilitated by proactive leadership; ■ builds on a strong and stable infrastructure; ■ ensures that the system of care theory of change is integrated into fund development plans; ■ builds collaborative relationships with national and local Tribal resources. The development of financial relationships that meet serious Tribal community needs can benefit from quality cross-cultural communication; respect for Tribal self-determination; understanding of mutual financial needs, opportunities, and restrictions; data-driven and anecdotal understanding of the urgency of Tribal community needs; and a commitment to decrease reliance on ineffective service systems that are not working for Tribal families. Following are recommendations for each of the financing and sustainability subject areas discussed in this report. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 16 Recommendations for Financing and Sustainability in American Indian and Alaska Native System of Care Communities Planning for Sustainability ■ Begin planning for long-term financial sustainability on the first day of the system of care grant (or even before actually receiving the grant), taking care to build planning on the foundation of local cultural strengths. ■ Create a sustainability planning team that includes key decision makers (e.g., Tribal elected officials or Tribal administrators who have the authority to make the needed changes, Tribal program planners, and Tribal finance staff). ■ Ensure active involvement of Tribal youth and family members at the planning table, and examine and resolve the cultural basis of any resistance to their active leadership. ■ Use the system of care grant requirements categories as a guide to developing a framework for Tribal planning efforts. ■ Review the Tribal Constitution, Tribal Codes, or the Tribal organizational mission statement for compatibility with key system of care principles; use the constitution, codes, or mission statement as the mechanisms through which the system of care transformation goals can be met. ■ Determine the readiness of the local Tribal offices and Tribal programs to understand and willingly adhere to system of care values and principles. If needed, develop a system of care orientation for Tribal members that explains a system of care in simple terms; use local cultural concepts as examples. ■ Work with Tribal leadership to examine Tribal financial capacities and resources for long-term sustainability strategies. ■ Determine ways to incorporate the system of care sustainability plan into the broader Tribal financial planning; if barriers exist, discuss with Tribal leadership ways to create a cohesive system of care team across Tribal programs, Tribal offices, and other Tribal resources. ■ Discuss how local Tribal values and beliefs fit with a logic model concept and/or contribute to the description of the Tribal theory of change. ■ Use a logic model-planning tool that best fits the Tribal community to combine all needs assessment and service design information into a sustainability plan; update the plan annually and make sure the plan is tied into the timeframe of the overall Tribal planning process. Interacting With Political Entities Regarding Financing ■ Determine who makes funding decisions within the Federal, State, Tribal, and county governments; determine how funding decisions are made within these entities. ■ Assign a point person, or join a Tribal coalition, to follow the development of State legislative health policy and/or State administration regulatory processes for proactive planning. ■ Stay alert to the annual or bi-annual Tribal, State, and county budget-building processes and make sure decision makers are aware of system of care operational and non-Federal match needs. ■ Build an educative relationship with Tribal elected officials, key State Legislators, and other local policymakers, taking care to stay in contact on a regular basis throughout the year and not just during a financial crisis. ■ Build alliances with Tribal elected officials, Tribal service administrators, and/or Tribal governing boards; negotiate inclusion of the Tribal system of care as a standing agenda item on the Tribal governing board agenda and Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 17 provide ongoing updates on the system of care transformation and child and family improvements. ■ Meet with candidates for Tribal elected offices and orient them to the system of care approach to services, the meaning of system of care transformation, and budget needs. ■ Develop a data-driven argument for the need for Tribal system of care funding, emphasizing human and financial cost-savings by redeploying funds from high-cost State services that tend to be less effective to lower-cost Tribal services that tend to be more effective. ■ Develop a cultural competence argument for Tribal services, linking culturally competent service provision with increased access to services and improved child and family service outcomes. ■ Develop a Tribal–State workgroup to examine the over-representation of Tribal people in child welfare, juvenile justice and education, and to propose solutions for the elimination of disparities. ■ Participate in Tribal, State, and county planning meetings and present Tribal behavioral health needs and cost-effective services that meet those needs; request statutory or fund-shifting changes to support the Tribal system of care. ■ Develop and/or participate in a Tribal–State Medicaid workgroup and develop working relationships with Tribal Medicaid liaisons. Developing Sustainable Services ■ Conduct a planning retreat or process to convene with key community stakeholders to determine a local definition of wellness and to describe how Tribal traditional culture and other cultural influences impact access, services provision, and service outcomes. ■ Design a cultural approach to services (individualized for each family) that includes strengths-based language; a cultural assessment component of the clinical assessment; treatment goal setting that includes attention to the role of culture in wellness; treatment benchmarks that include cultural strengths; and outcome measures that show how attention to culture can improve treatment outcomes. ■ Review traditional practices used in the community for healing and stabilization purposes and review the therapeutic aspects of traditional practices (e.g., some traditional practices may help resolve grief); cross-walk these therapeutic practices with State-approved behavioral health billing categories. ■ Meet with State representatives to discuss Tribal services and any changes that are needed in provider qualifications (e.g., expanding Targeted Case Management to include a provision for Tribal providers, modifying State educational requirements for becoming a licensed Tribal behavioral health provider). ■ Develop a staff-training curriculum based on local Tribal values and local Tribal service design to advance staff service skills and credentials; meet with the State credentialing board for licensed behavioral health providers to discuss the Tribal curriculum concept to ensure that the State licensing board will approve the Tribal curriculum. ■ Partner with Tribal colleges and the State credentialing program to implement a Tribal system of care training and education program. ■ Develop a training plan for program managers, clinical supervisors, and other program management staff to ensure their knowledge is current regarding managing change in complex environments, staff supervision, staff development, contract oversight, and financing strategies. Strengthening Infrastructure ■ Conduct a scan of infrastructure needs by reviewing the list of system of care grant requirements and any fundraising goals to determine if the Tribal program has appropriate • physical buildings and adequate service locations; • space for individual and family services that meet privacy requirements; Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 18 • group space for community activities; • office furnishings that reflect professionalism and offer family comfort; • clinical tools and equipment for service provision; • cultural tools and equipment for service provision; • adequate computer hardware for communication, reporting, and training; • functional computer software that meets day-to-day communication and reporting needs, including data tracking and accounting needs; • consistently available computer technology staff for trouble shooting and repair; • personnel policies and procedures, job descriptions, and salary scales; • policies and procedures for services, grants management, and fiscal controls; • billing manuals. ■ Consider hiring a Certified Public Accountant to review current financial systems and to make recommendations for improvement and further development. ■ Develop and implement infrastructure development plan that supports service growth and includes actions steps and timelines; ensure that it is framed within the broader context of a Tribal logic model or theory of change. ■ Assess the feasibility of becoming a State-licensed or nationally accredited organization by reviewing the accreditation options, examining the fit with the Tribal belief system, determining the overall benefits and drawbacks to licensing and/or accreditation, determining whether the cost of pursuing accreditation is feasible, and determining whether the Tribal system of care has administrative staff available to lead the accreditation team. ■ Upgrade billing and data reporting software after determining if the purchase of new software is cost effective when compared to the volume of Tribal data processing needs. ■ Implement third-party billing capacity, including the training and supervision needed to transition from grants management to a third-party billing system. ■ Overcome Tribal staff resistance to increased documentation requirements by using Tribal supervisors for professional modeling, oversight and helping Tribal staff understand the relationship between third-party billing, budget, and increased services for the community. ■ Conduct computer skill development training for Tribal Council or Tribal governing board members for increased communication and access to resources. ■ Conduct a site visit to another Tribal system of care that has successfully implemented a sustainability strategy, for a peer-to-peer learning opportunity. ■ Work with Tribal administrators to ensure that all internal systems (e.g., fiscal, technology, management, human resources, training) interlock, maintain close communication with each other, and share a common goal of advancing the Tribal system of care. Using Data in Financial Sustainability Planning ■ Discuss with Tribal leadership any concerns or questions about data use and clarify the Tribal stance on data collection, data analysis, and data ownership. ■ Provide orientation on Tribal system of care data use for Tribal elected officials, Tribal governing board members, and Tribal administrators; link data use examples to client progress, program planning, fund development, and contract negotiations; and emphasize ways that Tribal data use can support Tribal self-determination and data-driven decision making. ■ Discuss Tribal capacity for, and affiliated costs of, a sustained data collection and data analysis process and allocate resources for implementation. ■ Develop data-driven arguments to support inclusion of Tribal services in fund opportunity Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 19 language and regulatory changes to funding processes (e.g., ways to increase Tribal access to Medicaid reimbursement of services). ■ Determine the role of Tribal data in program evaluation, sustainability planning, and contract reporting. ■ Visit a Tribal system of care that has been successful in using data for a peer-to-peer learning opportunity. ■ Analyze aggregate data to demonstrate youth and family improvements and related human and financial savings. ■ Identify existing Tribal and non-Tribal data sources that may be useful for the sustainability planning process. ■ Advocate that State technology decisions related to data transmission requirements must be consistent with the technology capacities of Tribal communities. Assessing and Mobilizing Funding Sources ■ Conduct a financial environmental scan and list all funding sources in the State or region that support Tribal children and youth; determine which funding sources the Tribal system of care is not accessing, and list the reasons why the system of care has not been able to access these sources. ■ As part of building a case for funding, compare the percentage of the Tribal youth population in the State with the percentage of Tribal youth in State or county services (e.g., juvenile justice, child welfare, residential treatment). ■ Develop data-driven funding arguments by determining the monthly (or yearly) cost of State, county, and private institutional care and comparing these costs to the cost of Tribal services. ■ Imbed the Tribal system of care sustainability plan into all aspects of the Tribe or Tribal organization’s overall fund development and business operations. ■ Write a business plan for the system of care. ■ Follow the development of behavioral health policy in Indian Health Service (IHS) and the State legislature, or any State regulatory discussion of existing behavioral health policy; participate in State planning meetings as much as possible to track and influence evolving State initiatives and ensure that Tribal needs are included in legislative language. ■ Develop an accreditation team to assess the organization’s ability to complete required steps toward State behavior health licensure and/or national behavioral health accreditation. ■ Explore the financial feasibility of out-of-the-box financing ideas such as developing a business arm of the non-profit corporation. ■ Clarify what can and cannot be used as match under the Federal cost-sharing guidelines, with particular attention to understanding the exemption for eligible Tribes and Tribal organizations, which allows use of certain Federal funds as match. ■ Develop annual goals for in-kind contributions and local non-Federal cash contributions; monitor all match goals on a monthly or quarterly basis. ■ Create a list of potential in-kind contributions (e.g., space donations, pro bono consultation) and non-Federal cash resources (e.g., State grants, private foundation grants). ■ Develop processes to document in-kind contributions and the assignment of cash value to contributions. Determining the Cost of Services ■ Determine if the Tribe or Tribal organization is currently using, or has previously used, a cost study process; if necessary, seek advice from a cost-study-experienced Tribal organization or an Indian health planning board. ■ Determine a timeframe to implement a cost study. ■ Provide an orientation of cost study expectations for Tribal administration, governing board, and staff. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report • Page 20 ■ Determine the actual service and administrative costs of the full range of Tribal behavioral health and support services, including the costs for administrative and supervisory time, staff training, transportation, home visits, and traditional practices (i.e., conduct a cost study). ■ Ensure that cost formulas address the costs of delivering services in remote Tribal areas, including time spent in cultural translation of services; computer technology development and computer training (especially related to cultural application of service); rural Internet challenges; cultural-based telemedicine consultation; and off-site supervision due to the geographic range of Tribal service locations. Determining the Feasibility of Medicaid as a Funding Source ■ Work closely with the Tribal government or Tribal organization to determine the percentage of the local Tribal population that is eligible for and enrolled in Medicaid services. ■ Meet with Tribal administrators or the Tribal governing board to discuss any community perception that participation in the Medicaid program would result in loss of IHS benefits; consider a public community meeting to clarify any confusion. ■ Consider negotiating the co-location of State Medicaid enrollment staff at the Tribal location. ■ Review Tribal services, including traditional practices, for compatibility with Medicaid behavioral health billing categories. ■ Consider including access to Medicaid funding as part of the Tribal sustainability plan and outline the steps to becoming a State Medicaid provider. ■ Develop a close and ongoing working relationship with the State Medicaid office to increase Tribal access to information about Tribal enrollment strategies, provider standards, eligible services, and billing process. ■ Meet with State Medicaid and Tribal health representatives to determine if the 100% Federal Medical Assistance Percentage (FMAP) option is being fully utilized. ■ Meet with State Medicaid representatives to discuss the development of a Tribal services section in the State’s provider billing manual. ■ Join a coalition of Tribes in the State to explore a waiver to the State Medicaid Plan to support Tribal services and system of care partnerships. Developing and Sustaining Key State Partnerships ■ Invest in educating State officials and State funding source administrators about the Tribal system of care. ■ Recognize that there may be steep cultural learning curves for Tribal and State representatives about their respective service systems. ■ Develop relationships with Tribal champions within State government (e.g., non-Tribal State administrators who acknowledge the value of Tribal services) and provide them with information on how Tribal-operated services can result in positive service outcomes. ■ Ensure that the Tribal organization has the right person at the right table; for example, send a Tribal staff person with decision-making responsibility to a Tribal–State meeting if decision-making authority is needed. ■ Recognize the multiple influences on the development of positive Tribal–State relationships, including historical trauma and key staff turnover at the State and in the Tribe. ■ Recognize that both States and Tribes are concerned about the financial cost of ineffective services and the resulting human cost to both the Tribe and the State. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A1 APPENDIX A. Understanding the Challenge: The Cultural Framework Although the system of care principles and Tribal belief systems are very much aligned, Tribal systems of care continue to face unparalleled challenges in developing and implementing financing strategies for sustainability. This is due to many reasons, including the lack of knowledge by potential funding sources, such as States, of the advantages of working with Tribes, the impact of Tribal–State history on the willingness and ability to pursue financial partnerships, and the lack of financial resources in remote Tribal communities. Adding to the complexity of the challenge is ■ the history of confusing and contradictory Federal policies about support for Tribal services; ■ the meaning of sovereign status of federally recognized Tribes as it relates to financing; ■ the financial options of Tribes that are recognized by States but lack Federal recognition; ■ the role of Tribal self-determination and the financial implications of Tribal assumption of services that were previously provided by Federal agencies. All of these challenges are further deepened by a lack of cross-cultural and cross-system problem solving when partnership barriers arise. The result are complicated jurisdictional and policy conditions that exist between Tribes, Federal, and State governments with many implications for financial strategic planning. Negotiation for financial partnership must often start with the education of Federal, State, or private funding sources about the relationship between a cultural foundation to services and improved outcomes; the impact of Tribal sovereignty on financial partnerships; and the values and decision-making processes of Tribal governments, Urban Indian organizations, and Tribal nonprofit organizational structures. Mental health services for the American Indian and Alaska Native (AI/AN) population are widely documented as inadequate to provide for the needs of the people. There are a number of reasons for the shortage of services: the annual Federal budget for the Indian Health Service (IHS) is under-funded by an estimated 40–60 percent of the need for care; only 7 percent of the IHS budget is allocated for mental health services; a large percentage of AI/AN people live in remote rural areas where behavioral health services are not routinely available; and Medicaid and other third party payers often exclude Tribal providers from participation in mental health networks, do not purchase the types of services offered by Tribal health providers, or Tribal providers are unable to employ the types of clinical providers necessary to render billable services. These disparities combined with the economic conditions in Indian country result in a disproportionate representation of the AI/AN population in social service programs, juvenile and adult detention facilities, and treatment facilities for mental health and substance abuse problems. Thus, the impact on Federal- and State-funded programs is also disproportionate to the population. Statistics demonstrate that Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A2 mainstream efforts to address health, social and economic issues in Indian country are ineffective in addressing the root causes of these problems. State government programs, particularly in States with large Native American populations, are recognizing these costs and have become interested in partnering with Tribal organizations for community based service delivery. Tribal Entities in the United States American Indian and Alaska Native people have long demonstrated a high level of resilience and have retained, or re-established, the traditions and beliefs that serve as their cultural core. Hundreds of Tribes continue to thrive and remain culturally and politically unique in the United States. Each Tribal group is organized according to historical and cultural influences (e.g., Tribe, Band, Nation, Pueblo, Village, community, corporation). The Federal Government holds special trust obligations towards Tribal members to provide basic social, medical, and educational services. The statutes and treaties under which Tribal communities are organized have a direct influence on their financial sustainability options. Recognition Status More than 560 federally recognized Tribes exist in the United States. Federally recognized Tribes hold a government-to-government relationship with the Federal Government. Nearly one-half of the federally recognized Tribes are in Alaska. Tribes with Federal recognition status are legal sovereign nations. Federally recognized Tribes are rare and distinctive as they function as independent nations within the nation of the United States. Therefore, a unique legal and political relationship exists between the Federal Government and Indian Tribes. (Similarly, a special legal relationship exists between the Federal Government and Alaska Native Corporations.) This relationship is grounded in the U.S. Constitution, treaties, statutes, U.S. Supreme Court decisions, and Federal laws and regulations. The relationship between the Federal Government and Tribes is also grounded in political, legal, moral, and ethical principles. It is important to note that the relationship is not based upon race, but is a government-to-government relationship. The U.S. Department of Health and Human Services (DHHS) has a formal consultation policy with Tribes. Consultation with AI/AN Tribes must occur to the extent practicable and permitted by law before any action is taken that will significantly affect the Tribes. In short, any DHHS policy requires consultation with Tribes before action by the Federal Government is taken if the policy substantially and directly affects one or more AI/AN Tribes; the relationship between the Federal Government and Tribes; or the distribution of power and responsibilities between the Federal Government and Tribes. The legal and political power of sovereignty is deep. As sovereign nations, Tribal governments have the right to hold elections, determine their own citizenship, and consult directly with the Federal Government on policy, regulations, legislation, and funding. Tribal governments can also create and enforce laws to govern their Tribal members. Tribal laws can be stricter or more lenient than State laws, but they are not subservient to State law. State laws cannot be Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A3 applied to a Tribe if the laws interfere with the right of a Tribe to make its own laws protecting the health and welfare of its citizens, or if they would interfere with any Federal interest. Tribal district courts and supreme courts can be established to administer justice in criminal, civil, and juvenile matters. Tribal tax commissions, economic development corporations, environmental protection agencies, public works, and gaming commissions are other examples of entities that may be part of a Tribal government structure. In addition to the federally recognized Tribes, there are 245 Tribes whose lands and rights are recognized solely by the State. A State-recognized Tribe is an Indian Tribe that does not have a recognized relationship with the Federal Government through historic treaty, Congressional act, or administrative process, but is recognized as a Tribe by the government of the State in which members reside or are historically based. A lack of Federal recognition limits the capacity of State recognized Tribes to fully govern themselves, seek compensation for previous loss of land, or be eligible for certain Federal benefits and funds designated for federally recognized Tribes. Many State-recognized Tribes are seeking formal Federal recognition. Another important segment of the Tribal population is the Urban Indian community. ‘Urban Indians’ is a term used to describe American Indians and Alaska Natives, or descendents of American Indians and Alaska Natives, who have moved from their Tribes to cities or urban areas, either voluntarily or through forced Federal Government relocation programs.1 Poverty and lack of economic opportunities also contribute to the movement of Tribal people from reservations to cities or urban areas. More than 60 percent of all Tribal people in the United States now live in cities or urban areas and they remain part of the congressionally mandated trust responsibility. Regardless of Federal or State recognition, or Urban Indian status, each Tribal community reflects a distinct culture, belief system and, often, Native language. Despite these differences, common across all Tribal people is a deeply ingrained sense of respect and honor for their children (as illustrated by the names selected for their systems of care). Many Tribal systems of care program names reflect the Tribe’s special recognition of children and youth and the principal role that culture plays as the foundation of their services. American Indians and Alaska Natives live within the complex and overlapping worlds of Tribal, State, and Federal Governments—each of these entities has unique laws, manners of conducting business, and interpretation of sovereignty. The relationships between Tribes and the Federal Government, and Tribes and the State in which they are located, are constantly evolving. The role of Federal trust responsibility, sovereign Tribal governments, interpretation of Tribal and State laws, the Urban Indian relationship with urban and Tribal services, and the overall changing needs of Tribal communities add to this changing environment. All of these are key factors affecting the financial relationships and collaboration between Federal, State, County, 1 National Council of Urban Indian Health (2007). Fact Sheet. Retrieved January 2008 from http://www.ncuih.org/Fact%20Sheet.pdf Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A4 and other funding sources and Tribal communities. Impact of Federal Policies Federal Government policies related to Tribal affairs have fluctuated from open warfare to later attempts to assimilate Tribal people into mainstream society, from termination of Tribal rights to later restoration of Tribal rights, and from attempts to limit Tribal government to later compliance with Tribal government self-determination. These inconsistencies have created a legacy of policy confusion that continues to affect Tribal–Federal and Tribal– State relationships and financing strategies today. A strength of the Tribal financing picture is the Indian Self-Determination Act (Public Law 93- 638), which gives authority to Tribal governments to assume the budget and operations of programs and services that had been previously carried out by the Federal Government. This not only supports Tribal self-determination, but also reflects support for culturally competent practices and community ownership. The Indian Self-Determination Act provides the legal framework for federally recognized Tribes and Tribal organizations to assume the budget and operations of services previously provided by the Federal Bureau of Indian Affairs or the IHS. A Tribe or Tribal organization that enters into a 638 agreement with the Federal Government is referred to as a “Tribal 638 organization” in this report. Importance of Sustainability Shediac-Rizkallah and Bone suggest three reasons why program sustainability is important.2 First, if a program ends while there is still a need for services, rates of people with untreated needs may regress to pre-intervention levels. This is important when considering rural AI/AN communities, which likely have limited mental health agencies and may depend heavily on the contributions of each agency.3 Second, programs often incur significant start-up costs in human, technical, and monetary resources, only to have funds removed before a program has reached its fullest potential. This is especially relevant to Tribes that may have no health care infrastructure at program start-up resulting in a need to design an unfamiliar program, implement major computer technology upgrades, develop a third-party billing structure, or provide additional training for staff who are cultural experts but do not meet the higher education requirements established by State or national accreditation bodies. Third, program sustainability promotes community investment in future community programs and lack of sustainability may lead to community confusion toward future programs. Community support is essential to the existence and persistence of Tribal community mental health programs due to the collectivistic orientation of AI/AN communities. 2 Shediac-Rizkallah, M. C. & Bone, L. R. (1998). Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice, and policy. Health Education Research, 13, 87–108. 3 Jim, N. (2004). The morning God comes dancing: Culturally competent mental health and HIV services. In Nebelkopf, E. & Phillips, M., (Ed.), Healing and mental health for Native Americans. New York: Altamira Press. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A5 Interest in the topic of system of care sustainability has reached new peaks in the past few years. Several studies have been developed to examine aspects of system of care sustainability. In their work, The Sustainability of Systems of Care for Children’s Mental Health, Stroul and Manteuffel discuss the sustainability study undertaken by the National Evaluation Team.4 The development of the Web-based survey included an examination of the various definitions of sustainability. Emphasized was the acknowledgement that adopting the system of care approach for the long term requires a “sea change” in policy, clinical practice, and administration of children’s mental health systems and maintenance of all of these elements of systems of care in the face of budgetary challenges and changing political environments. The University of South Florida Research and Training Center, in partnership with the National Technical Assistance Center for Children’s Mental Health at Georgetown University, the Human Service Collaborative of Washington, DC, and Family Support Systems, Inc., of Arizona, initiated a study titled “Financing Strategies and Structures to Support Effective Systems of Care.” The goal of the study is to develop a better understanding of the critical financing structures and strategies that support systems of care. Seven critical financing strategies are being examined and a series of guides have been developed. None of these studies is focused specifically on AI/AN financing. Although the findings of these studies provide a framework of sustainability issues relevant to any system of care community, none of the studies address in detail the cultural, 4 Stroul, B.A., Manteuffel, B.A. (2007). The Sustainability of Systems of Care for Children’s Mental political, and economic issues that are specific to AI/AN communities and that have a direct impact on their long term sustainability. The cultural importance of program sustainability must not be ignored. Sustainability of community mental health programs within Tribal communities is especially important to empower and avoid re-victimization. Lucidly expressing this point, one leader of a Tribal community-based substance abuse prevention and intervention program stated, We have a responsibility to our program recipients. They’ve had so may losses in their lives, and [if we] come in for a year or two or three and give them hope, only to have the program go away, we’ve just caused another loss and further hopelessness in their lives.5 The 400 years of persecution, genocide, and forced assimilation experienced by Native Americans have led many to experience a perception of great loss leading to anxiety and depression or anger and avoidance.6 These psychological consequences have been termed “historical trauma.” It is hypothesized that program sustainability can function to combat such trauma by empowering Tribal communities to decrease reliance on outside support and Health: Lessons Learned. Journal of Behavioral Health Services & Research. 5 Noe, T., Fleming, C., & Manson, S. (2004). Reducing substance abuse in American Indian and Alaska Native communities: The Healthy Nations Initiative. In Nebelkopf, E. & Phillips, M., (Ed.), Healing and mental health for Native Americans. New York: Altamira Press. 6 Whitbeck, L. B., Adams, G. W., Hoyt, D. R., & Chen, X. (2004). Conceptualizing and measuring historical trauma among American Indian people. American Journal of Community Psychology, 33, 119–130. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A6 foster a sense of pride in being able to care for their own community. Factors Affecting Sustainability Program sustainability at every level can be impacted by the effectiveness of critical sustainability factors. Mancini and Marek have developed seven key elements critical for program sustainability: (1) competent leadership to develop a program’s vision and provide staff training; (2) effective collaboration with community members and key stakeholders; (3) understanding of community needs and resources; (4) program results demonstration; (5) strategic funding; (6) staff involvement and commitment to sustainability; and (7) program responsiveness to a community’s changing needs.7 While it is clear that many variables interact to affect sustainability, underlying each of these components is the need to understand the culture of a population served. For example, effective collaboration with Tribal community members will be facilitated through a program leader’s ability to integrate Tribal culture into the development of a program’s vision. Further, program response and results demonstrated within an AI/AN community hinges on a programs’ ability to provide culturally competent care.8 Finally, obtaining long-term financial support requires knowledge of the resources both within Tribal communities and outside of the Tribal community. Following are brief discussions of key sustainability factors known to affect program sustainability among Tribal programs. 7 Mancini, J. A., & Marek, L. I. (2004). Sustaining community based programs: Examination of relationships between sustainability factors and program results. Family Relations, 53, 339–347. 8 LaFromboise, T. (1988). American Indian mental health policy. American Psychologists, 43, 388–397. Economic and Political Environments In 2000, the AI/AN poverty rate was 26 percent, twice the national rate and greater than that of any other ethnic group.9 Socioeconomic conditions vary from Tribe-to-Tribe and in different regions of the country. Some Tribal system of care communities report unemployment rates as high as 80 percent in the local Tribal population. The Center for Disease Control also mentions geographic isolation, cultural barriers, and economic conditions as barriers that contribute to poorer health outcomes.10 Other studies have focused on Tribal income increases associated with the legalization and institution of casino gambling for the effects on aspects of American Indian well-being, including the effects on poverty levels, medical care, and risk-taking behavior, all of which are indirectly associated with health status.11 The political environment of Tribes and Tribal organizations is complicated; sovereign nation status, and the Alaska Native Claims Settlement Act (1971) which promised 44 million acres and $1 billion to Alaska Natives, are examples of the unique aspects of the AI/AN political environment. 9 Centers for Disease Control and Prevention. (2003).Surveillance for health behaviors of American Indians and Alaska Natives: Finding from the behavioral risk factor surveillance system, 1997-2000. Morbidity and Mortality Weekly Report. 52, 1. Retrieved January 20, 2008 from http://www.cdc.gov/mmwr/preview/ mmwrhtml/ss5207a1.htm 10 Rural Assistance Center (2008). Tribal health frequently asked questions. Retrieved January 5, 2008 from http://www.raconline.org/info_guides/tribal/ tribalhealthfaq.php 11 Taylor, J. B., Kalt, J. P. (2005). Cabazon, The Indian Gaming Regulatory Act, and the Socioeconomic Consequences of American Indian Governmental Gaming–A Ten-Year Review. American Indians on Reservations: A Databook of Socioeconomic Change between the 1990 and 2000 Censuses. Cambridge, MA: The Harvard Project on American Indian Economic Development. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A7 The Harvard Project on American Indian Economic Development, at Harvard University’s John F. Kennedy School of Government, aims to understand and foster the conditions under which sustained, self-determined social and economic development are achieved among American Indian nations. At the heart of the Harvard Project research program is the systematic, comparative study of social and economic development on American Indian reservations. Relevant for the Tribal system of care communities are their key research findings: ■ Sovereignty Matters. When Native nations make their own decisions about what development approaches to take, they consistently out-perform external decision makers—on matters as diverse as governmental form, natural resource management, economic development, health care, and social service provision. ■ Institutions Matter. For development to take hold, assertions of sovereignty must be backed by capable institutions of governance. Nations do this as they adopt stable decision rules, establish fair and independent mechanisms for dispute resolution, and separate politics from day-to-day business and program management. ■ Culture Matters. Successful economies stand on the shoulders of legitimate, culturally grounded institutions of self-government. Indigenous societies are diverse; each nation must equip itself with a governing structure, economic system, policies, and procedures that fit its own contemporary culture. ■ Leadership Matters. Nation building requires leaders who introduce new knowledge and experiences, challenge assumptions, and propose change. Such leaders, whether elected, community, or spiritual, convince people that things can be different and inspire them to take action. The Native Nations Institute is an outgrowth of the Harvard Project on American Indian Economic Development and serves as a self-determination, development, and self-governance resource to Indigenous nations. For more than 15 years, the Harvard Project and the Native Nations Institute researchers have worked systematically to understand the conditions under which sustained economic development can be successful on American Indian reservations in the United States and among First Nations in Canada. These findings indicate that, while a number of things contribute to initiating and sustaining reservation economic development, five are particularly important: ■ Practical Sovereignty (genuine decision-making power) Native nations that have been willing and able to assert self-governing power over their affairs and resources have significantly increased their chances of sustainable economic development. ■ Capable Governance (effective governing institutions and practices) Sovereignty is not enough to produce economic growth unless those rights and powers are exercised effectively; the chances of sustainable development rise as Native nations put in place effective, nonpoliticized, dispute-resolution mechanisms that can shut down opportunistic behavior by politicians, place buffers between day-to-day business management and political decisions or interference and build capable bureaucracies. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A8 ■ Cultural Match (fit between governing institutions and political culture) Effective Trial governing institutions require legitimacy with the people whose future is at state, rooted in the fit between the formal institutions of governance and the indigenous conceptions of how authority should be organized and exercised. ■ Strategic Orientation (decision making that takes strategic considerations into account) Successful Native nations tend to approach development not as a quick fix for poverty but as a means of building a society that works, considering long-term priorities and concerns as well as assets and opportunities, and bring strategic criteria to bear on development decisions. ■ Leadership (individuals and groups who recognize that fundamental change may be necessary, and who can envision a different future and persuade the community to join them) Successful Native nations have some group or set of individuals who recognize the need for fundamental change in a way things are done; they have a vision of a future of assertive, capable, effective self-determination and self-governance, and can bring the community along with them in building that future. In addition to these findings, gaining community consensus on the approach to Tribal system of care sustainability can be complicated. Tribal systems of care often operate within multiple governing structures that must work together in sustainability planning. The Tribal governing structure may have frequent elections of Tribal officials that result in leadership turnover and starts and stops in sustainability planning. All of the variables discussed, exacerbated by health disparities, affect the AI/AN sustainability planning process. Planning Planning and infrastructure development assistance has been available for years to some Tribal communities through the Federal Infrastructure Development for Children’s Mental Health Systems in AI/AN Communities Initiative, more commonly known as the Circle of Care Initiative. Available through a competitive application process, the Circle of Care Initiative supports AI/AN communities with funding and technical assistance to plan, design, and assess the feasibility of a culturally respectful mental health system of care. The Circle of Care Initiative provides 3-year grants to State and federally recognized Tribes, Urban Indian organizations, Tribal colleges and Tribal universities. Successful applicants gain community planning tools and resources to design a holistic, community-based system of care to support mental health and wellness for their children, youth and families. Nearly half of the Tribal system of care communities had previously received a Circle of Care planning grant that enabled them to conduct an in-depth analysis of the existing infrastructure of the local child-serving system to identify policy, service gaps and potential resources, and to facilitate culturally respectful strategic planning activities. Also important to the Circle of Care planning process is community-wide engagement, development of Tribal logic models, and development of a local evaluation process. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A9 Partnerships Tribal leader hesitancy to develop State or Federal partnerships is often based in historic distrust. Broken treaty agreements, conflicts over land or water rights, and the removal of Tribal children from their homes to be raised in non-Indian boarding schools or non-Indian foster care homes are just some of the reasons for Tribal partnership hesitancy. State motivation to pursue partnerships with Tribes and Tribal organizations has generally been reliant on the personal interest of a few State representatives. However, the system of care movement, combined with increased national interest in addressing racial health disparities and the lack of culturally competent services, has sparked more interest at the State level for Tribal-State partnerships. States are searching for methods that could more effectively address high cost institutional and residential treatment services that are utilized when behavioral health needs are not met in the community. Thus, some States are exploring ways to engage more Tribal organizations as partners in behavioral health services. Transformation of State organizational structures, with increased support for culturally competent practices and a re-examination of the use of evidence-based practices, are all opportunities to develop new partnerships with Tribes and Tribal organizations. Conversely, Tribal systems of care may be able to access previously untapped State revenue sources, and influence current and future State policy to better address Tribal needs. For example, Tribal–State partnerships can not only be beneficial to Tribal communities but can improve the health of State budgets as the high cost of institutionalized care is transferred to lower cost and more effective Tribal systems of care services. Jurisdictional confusion and misinformation about Tribal needs also complicate communication and partnership building. Some State administrators erroneously believe that Tribal needs are being met by the Indian Health Service (IHS), when only 55 percent of American Indians and Alaska Natives rely on the IHS or Tribal-operated clinics or hospitals for care. Further, the IHS budget meets less than 60 percent of the national Tribal needs, and less than 5 percent of the Tribal mental health needs.12 Tribal–State partnerships are also challenged by growing State requirements that tie evidence-based practices (EBPs) to State behavioral health contracts.13 Tribal systems of care are concerned that EBPs are not normed on Tribal populations and might not be easily transferable or appropriate for use with Tribal populations, yet growing numbers of State and Federal contracts require the use of EBPs. In addition, the cost of training for manualized EBPs is often too costly for many Tribal communities. However, growing interest in the fields of cultural adaptation of EBPs and support for practice-based evidence approaches (which include field-driven practices and traditional practices) has opened new opportunities for financing discussions between Tribes and States. 12 Gone, J. P. (2004). Mental Health Services for Native Americans in the 21st Century United States. Professional Psychology: Research and Practice, 35(1), 10–18. 13 For the purpose of this report, the term ‘evidence-based practices’ is used to define interventions and approaches shown to be effective through rigorous research. This term is synonymous with the term ‘evidence-based treatment.’ Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A10 Infrastructure Many Tribes have both a traditional Tribal leadership structure and a “business council” governing structure. The Tribal business council structure usually involves a formal election process. Each Tribe determines its frequency of Tribal elections (which can occur as often as every 2 years). Election of “business” council members is not a historic Native tradition; rather, the Federal Government mandated it. Tribal elections can result in the re-setting of Tribal priorities and funding strategies. Ensuring that Tribal council candidates and Tribal elected officials understand the framework and purpose of a system of care for children and families is critical because Tribal-elected officials are politically powerful and play a critical role in both short and long-term sustainability plans. The national field of behavioral health rests on a foundation of formal licenses, credentials, and program accreditation—all critical components of sustainability, especially if the sustainability plan includes third-party billing for behavioral health services. Another factor that can complicate sustainability plans is AI/AN preference in hiring practices. Part of Tribal self-determination policy, Tribes and Tribal organizations are legally sanctioned to have AI/AN preference in hiring practices through Tribal exemption to Title VII of the Civil Rights Act (1964). AI/AN preference in hiring is not only allowable, but often a policy and mission for Tribal organizations that support the Nation Building concept.14 AI/AN preference in hiring is an important part of Tribal self-determination, but may conflict with 14 Nation Building refers to the process of constructing or structuring a nation using the power of the State (in this case, the term “State” refers to the Tribe). contract requirements for licensed and credentialed staff. Staffing AI/AN mental health counselors are more likely to provide culturally competent services to Native children, youth and families because they share a cultural affinity. As such, hiring Native staff will promote sustainability by increasing staff integration and involvement in the program.15 However, AI/AN mental health community programs often have great difficulty finding credentialed service providers who are AI/AN. For example, the IHS behavioral health programs employ approximately two psychiatrists and four psychologists per 100,000 people for the 1.5 million Native people currently eligible for IHS funded services, in contrast to general U.S. availability of 14 psychiatrists and 28 psychologists per 100,000 people.16 Providing funding to support the higher education of Tribal community members is one strategy used to address this challenge. Promoting the accreditation of AI/AN mental health service providers allows a community to become self reliant in the provision of mental health care and is posited to promote the sustainability of mental health programs. In a study involving 401 American Indian youths and 188 American Indian providers, 15 Mancini, J. A., & Marek, L. I. (2004). Sustaining community based programs: Examination of relationships between sustainability factors and program results. Family Relations, 53, 339–347. 16 West, J., Kohout, J., Pion, G. M., Wicherski, M. M., Vandivort-Warren, R. E., Palmiter, M. L. , et al. (2000). Mental health practitioners and trainees. In R.W. Manderscheid & M.J. Henderson (EDs.), Mental health, United States, 2000. Rockville, MD: U.S. Department of Health and Human Services Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A11 researchers found that providers were more likely to correctly identify the problems of American Indian youth and offer them, or refer them for, services when the provider was knowledgeable about mental health problems and available resources in the community.17 These results suggest that to best assess the needs of American Indian youth, providers need to have both an understanding of the local culture and community resources, and a formal education in mental health service provision to provide the most culturally and clinically meaningful services. Effective treatment will in turn promote program sustainability. Primarily due to the shortage of Master’s- and Ph.D.-level Tribal behavioral health specialists, many Tribal systems of care hire non-Native professionals to serve in clinical supervisory or managerial positions. A frequent challenge to newly hired non-Native clinical supervisors is that they must recognize that the Tribal paraprofessionals hold the expert knowledge on Tribal community needs and cultural engagement strategies. Training in Tribal approaches and Tribal life ways can be a multiyear transition for the non-Native professional, however investment in training and supervision of non-Native staff is critical to prevent costly staff turnover. To address the immediacy of the mental health needs of the AI/AN population, many mental health programs have developed cultural competence training curriculums to teach non-Native providers about the culture of the AI/AN community in which they will be providing 17 Stiffman, A. R., Freedenthal, S., Dore, P., Ostmann, E., Osborne, V., & Silmere, H. (2006). The role of providers in mental health services offered to American-Indian Youth. Psychiatric Services, 57, 1185–1191. services.18 Direct service supervisors can also serve as important role models for day-to-day sustainability practices, such as generating staff enthusiasm about the value of Tribal data for program planning, and ways to increase billing accuracy. Financing Long-term financial sustainability requires funding. Generally, the economic status of Tribal communities results in meager financial resources to draw upon and significant competition for limited Tribal funds. Although system of care funding and technical assistance resources have provided training on new approaches to the fund-development process, some Tribal communities are able to seize these opportunities, while the ability of others to maximize such opportunities has been compromised. There are many reasons why some Tribal communities are challenged in developing their financing capacity, which often include a lack of a comprehensive strategic plan to address the behavioral health needs of children, youth and families and the lack of an administrative and billing infrastructure. It also requires a commitment from Tribal administrative staff to build relationships with funding sources in order to gain access to budgets or grant cycles. Even if a strategic plan, infrastructure, and consistent leadership is in place, the Tribal system of care can still be challenged by limited resources. Last, some Tribal organizations have difficulty in adopting a proactive approach 18 Nebelkopf, E., & King, J. (2004). A holistic system of care for Native Americans in the San Francisco Bay Area. In Nebelkopf, E. & Phillips, M., (Eds.), Healing and mental health for Native Americans. New York: Altamira Press. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A12 which some feel is the result of generations of Federal paternalism, while others point to historical trauma. American Indian/Alaska Native Medicaid Provisions Medicaid is the largest payer for mental health services in the country. Medicaid services are a shared expense between the Federal Government and State governments. The Federal Government pays a percentage of the total payments for services which varies based on each State’s per capita income. The Federal share, called the Federal Medical Assistance Percentage (FMAP) ranges between 50 percent and 85 percent of the total cost expended in the State. Important to AI/AN financing is a special Congressional provision, embedded in the Indian Health Care Improvement Act, which established a match rate of 100 percent Federal dollars and zero dollars from States for Medicaid services offered through IHS, 638 Tribes, or 638 Tribal organizations. The 100 percent match rate was enacted because Congress did not want to burden States with what had been a Federal responsibility – the health care of AI/AN people. In addition, the 100 percent FMAP rate is specifically tied to the location of where the services are provided; services must be provided through a tribally owned / leased and operated facility that must be on the official IHS facility list. Tribal 638 organizations (Tribe or Tribal organizations entering into a 638 agreement with the Federal Government) providing services at a location on the official IHS list are eligible to receive payments are the 100 percent FMAP rate, which means that 1. States do not have to pay a State match for services offered through these Tribal organizations because the Federal Government will pay for 100 percent of the service; 2. Tribal–State Medicaid partnerships can result in behavioral health services to Medicaid eligible and Medicaid enrolled Tribal people; 3. dollars that a State would normally pay as its part of the Medicaid matching fund could instead remain in the State general fund; 4. State general fund savings can be spent on other needs within the State instead of being spent for Medicaid match. This arrangement is a significant win-win opportunity for both States and Tribes where Tribal organizations provide increased health services to Tribal youth and families at little or no cost to the State. Many State decision makers are not aware of this partnership opportunity and may often be suspicious of what appears to be a too-good-to-be-true situation. There are significant barriers to enrollment of American Indians and Alaska Natives in Medicaid and SCHIP, which has led State and Tribal policy experts to believe that the population is significantly under enrolled in these programs.19 If the AI/AN community is not part of a Tribal 638 organization, a financially successful alternative might be acquiring Federally Qualified Health Center (FQHC) status, which also allows for higher reimbursement rates. 19 Langwell, K., Laschober, M., Melman, E. & Crelia, S. (2003). American Indian and Alaska Native Eligibility and Enrollment in Medicaid, SCHIP, and Medicare Individual Case Studies for Ten States. BearingPoint, Inc. and Westat, Inc. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A13 FQHCs (and Rural Health Clinics) must be paid on a cost basis under Federal law. States have flexibility in determining the scope of ambulatory services covered under the FQHC model, which may include a variety of behavioral health services that can support a system of care grantee. Match All system of care communities are required to make contributions, also referred to as cost sharing, toward the system of care costs as outlined in the Federal authorizing legislation for systems of care (Title V, Part E section 565(b)(2) of the Public Health Services Act). The match requirement requires that the applicant entity will provide, directly or through donations from public or private entities, non- Federal contributions according to the below formula: ■ For the first, second, and third fiscal years of the cooperative agreement (grant), the awardees must provide at least $1 for each $3 of Federal funds. ■ For the fourth fiscal year, the awardees must provide a least $1 for each $1 of Federal funds. ■ For the fifth and sixth fiscal years, the awardees must provide at least $2 for each $1 of Federal funds. The purpose of match is to encourage local investment in the system of care by other child-serving systems, and as evidence of the potential of the initiative to sustain itself beyond the 6- year award period. Matching resources may be cash or in-kind, including facilities, equipment or services, and must be derived from non- Federal sources (e.g., State or sub-State non- Federal revenues, foundation grants). Indian Tribes receiving funds under the Self- Determination and Education Assistance Act (PL 93-638, as amended) are exempt from the restriction of not using Federal sources as match. Although only in-kind donations and cash funds from non-Federal sources can be used as matching funds by non-Tribal system of care grantees, eligible Tribes and Tribal organizations may also use Federal funds as match under certain conditions.. Although Federal dollars are generally not permissible for use as “match” dollars, P.L. 638 enables Tribal organization to use Federal dollars assumed by Tribes through the 638 legislation as match dollars as long as the identified 638 dollars are not being used as Federal match by other components of the Tribal organization or Tribal government. Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix A • Page A14 Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities Summary Report Appendix B • Page B1 APPENDIX B. Purpose and Description of the Exploratory Description Study Background and Purpose of Study The Comprehensive Community Mental Health Services for Children and Their Families Program (referred to as the Child Mental Health Initiative [CMHI]), funded by the Center for Mental Health Services (CMHS) at the Substance Abuse and Mental Health Services Administration (SAMHSA), was initiated in 1992. The program was created to provide grants to States, communities, territories, and American Indian and Alaska Native (AI/AN) Tribes to develop systems of care to serve children and adolescents with, or at risk for, emotional disorders and their families.20 A system of care is a coordinated network of community-based services and supports organized to meet the challenges of children and youth with serious mental health needs and their families. Families and youth work in partnership with public and private organizations to design mental health services and supports that are effective, that build on the strengths of individuals, and that address each person’s cultural and linguistic needs. A system of care helps children, youth and families function better at home, in school, in the community and throughout life. Systems of care is an approach to services that recognizes the importance of family, school and community, and seeks to promote the full potential of every child and 20 For the purpose of th |
Date created | 2012-01-13 |
Date modified | 2012-01-13 |