How One Program Improves Access to Care for Tribal Communities

 

It became apparent to NurseWise, a 24-hour telephonic call center accredited by URAC, that the tribal nations they served were high utilizers of behavioral health crisis services. NurseWise is the contracted service provider for Cenpatico, a Regional Behavioral Health Authority (RBHA) in Southern Arizona.

Typical interactions with tribal members usually occurred at point of emergency and involved local providers of EMS, Indian Health Service emergency rooms, police and fire departments. As health outcome trends indicated, tribal community members were in serious trouble by the time a third party contacted the 24/7 crisis line.

In the early fall of 2011, NurseWise launched the Tribal Warm Line (TWL). The TWL is a technologically enhanced service delivery model for tribal members to connect telephonically with others who share the same culture and belief system. The TWL purpose is twofold: 1) Improve access to care for Native American communities and 2) Implement a service that will positively impact healthcare disparities and lower costs.

The network of tribally based telecommuter set-up is situated within reservation borders of Arizona tribes and employs tribal members who call upon their own cultural strengths to provide coaching, support and spirituality for their callers. Access to care for many rural tribal communities remains challenging due to lack of public transportation options, remote locations and centralized healthcare hubs. Disparities in healthcare, poverty and a reluctance to access established behavioral health programming contribute to poor healthcare outcomes.

The TWL is indicative of how telecommunication technology is on the burgeoning edge of bringing an underserved, often misunderstood group a resource that can be used to directly challenge geographic isolation, unrelenting poverty and lack of economic opportunity. Disparities in the overall health of American Indians indicates a need for substantive measures such as the TWL. For many tribal members, access to healthcare proves prohibitive due to vast areas with limited public transportation options, centralized healthcare facilities and widespread lack of resources. Telehealth technology has the potential to abate these challenges by offering a service that is immune to time, distance, scheduling conflicts and lack of human capital. Emerging technologies such as increased broadband access and dedicated funding from the FCC will change the landscape for telemedicine within the next five years across Indian Country.

 

A Conduit to Health: 4 Steps

The TWL program has limitless potential to proffer a conduit for tribes so that their inherent cultural strengths can be utilized to increase wellness. Each tribe possesses traditional cultural teachings and spirituality to buffer against the disparities they face. The TWL aspires to combine technology and indigenous knowledge to increase peoples’ access to support. An ancillary benefit will be acknowledgement of the value of this paradigm in promoting recovery.

While in the early stages of program implementation, the following insights have become clear. The importance of recognizing the cultural differences of the individual tribal communities is vital. The design of the TWL allows for each tribe to rely on their own tribal belief systems since tribes are diverse and one application would belie culturally supportive methods. Also, an understanding of their historical interaction with western culture provides a framework for approaching and interacting with individual tribes. When setting up the TWL the initial areas to be addressed were:

1. Engagement. Partnering with a local tribal agency, such as San Carlos Apache Wellness Center, provided access to local culture and added legitimacy to the implementation of the TWL.
    
2. Relevance. The TWL has to be presented to the governing body through the legislative process. Formal memorandums of understanding were required by some of the tribes. The tribal council needs to agree that the proposed program will be a benefit to their community, but more importantly that it will protect its constituents against an irrelevant venture that may lead to disappointment.
    
3. Legitimate Leadership. In tribal communities, leadership has a long and storied history. Indian leaders have to prove themselves to the people and the existing leadership through acts of self-sacrifice, selflessness and vision. The tribal member who is leading the line for their community needs to be viewed as legitimate, by their own definition. This is why one of the questions I asked during the interview process was, “How would your community view you?”
    
4. Community Awareness and Support. Foremost, the community must be well aware of the resource and its purpose. More important, the TWL has to integrate itself into the community in order to thrive. To plan for success we must attempt to adapt to their paradigm. A measurement of success will be whether tribal members call upon their own community members for help. We can no longer afford to offer distant call centers as the only option when the benefit is not reflected in improved access to care and the ultimate goal of improved overall health and wellness.

Native American communities can benefit from initiatives such as the TWL as it speaks to increased self-reliance. Tribes have long been marginalized, their belief systems maligned and their alienation a by-product of subscription to foreign ideology and outside influence. The TWL program provides a framework for tribal communities to overcome barriers and honor their traditions.

Emerging technology is the driving force for development and it has the potential to confront poverty in tribal communities. The key to the potential success of the TWL lies with the collective shared experience and paradigm that defines the strength of tribal communities. Separated by different languages, ecological surroundings and divided by their efforts to resist colonization, they share a commonality, a bond that ties them to their past.

Often, other mainstream cultures question their desire to hold onto their unique history and past experiences. However, it is this very act that protects them from greater harm and loss of cultural continuity. Augmenting indigenous knowledge with telehealth technology can pave the road to recovery and healing for native communities.

 

Janel Striped-Wolf, BS, is a program coordinator for the Tribal Warm Line program through which she endeavors to serve tribal communities in Southern Arizona. NurseWise/Nurse Response has launched an innovative program designed to honor traditions in combination with today’s technology. Contact: jwolf@centene.com