By Alan Sorense
How do you improve an accreditation evaluation that brought you 100 percent scores all the way around?
If you're the Rocky Boy's Tribal Health Board, you expand your programs, facilities and offerings you make even better what was perfect before.
And that's just what the Health Board and its entire medical and support staff are doing as a self-governance Tribe getting ready for a new accreditation cycle this summer.
Health Board oversees the operation of far-flung facilities, from its clinic to its chemical dependency center to its personal care attendant programs.
Prime movers at tribal health are Chief Executive Officer Ed Parisian, Director of Planning and Legislation Sybil Sangrey, and Health Board Chairman Alvin Windy Boy.
Parisian said he's seen a lot of changes in health delivery on Rocky Boy's Indian Reservation in his short tenure as CEO.
"We've come a long ways in the four years since I came here," Parisian said. "I'll have completed four years in June, since '96, and they'd been going for two years at that time."
Sangrey said that when Parisian took over, the administration and finances were stable, but that programmatic expansion and vision needed strong leadership. She credited Alvin Windy Boy with the vision of determining local health care needs and the strength needed to take on the full responsibility of providing health care for the Rocky's community.
Some administrative improvements were realized during Parisian's tenure. There is a need for more control of the contract services totaling about $3 million so far this a year. Most of that goes to Northern Montana Hospital in Havre, he said.
A total of about $6 million are carried over from previous years in several restricted reserves each year, Sangrey said. They include a building reserve, personnel benefits reserve, equipment replacement reserve, and medical costs reserve. These reserves are a result of conservative spending in the first two years of the compact and prudent investment of reserve and budget dollars over the years, she said.
"We're still only funded about 44 percent of what we should be," Parisian said. "Medicaid earmarks $3,400 per person nationally and the Tribe is only allowed $1,400 per person. You can see the huge disparity.
Parisian said tribal health could close the disparity in service it offers in comparison to other non-tribal facilities with the extra money. Still, what the Tribe offers is a lot more than Indian Health Service (IHS) offered before it pulled out.
"I'm really a strong supporter of self-governance," Parisian said. "We've doubled the budget, doubled the number of employees, doubled the quality of care."
Parisian said the changes were only possible because of strong support Tribal Health receives from its Board of Directors, its administrators, and the Chippewa Cree Business Committee (tribal council).
Sangrey has been with Chippewa Cree Health since it went self-governance and became independent of IHS. She's witnessed firsthand the changes over the last six year. She's been part of the changes that have taken place since Tribal Heath's first accreditation cycle.
"Since we started in '95, we used to have a dentist we shared with Fort Belknap," Sangrey said. "Now we have two full-time dentists and we're still shorthanded. We're backlogged, but I know everybody is, not just us."
The dental department, like many other at the clinic, is now addressing problems that IHS regulations disallowed. "They had speaking, eating problems that were not a priority with IHS," Sangrey said. "There were a lot of people with low self esteem."
Tribal members who never received dental corrections from crooked teeth to two rows of teeth are now being served. The tribe has contracted with two orthodontists from Great Falls to perform work on its clientele.
Some of the corrections must be done surgically and others through orthodontics. People can now get partials and dentures are available to diabetics, Sangrey said, "so they can eat."
Another improvement is the diabetes center the Tribal Health erected as the result of a 5-year granting program, a presidential initiative. Sangrey said the money was used to set up a modular unit for diabetes wellness center with a full-time physical therapist. Diabetic amputees and diabetics who suffer a variety of injuries benefit from therapy.
"We share a nutritionist with Northern Montana Hospital," Sangrey said. "They're difficult to get. We share number of things with Northern Montana Hospital."
Among those, she said, were: a contract podiatrist, Dr. Marino, who makes periodic visits to the tribal clinic; contract psychiatrist, Dr. Soofi and Dr. Sarasua, who visit from their home base in Florida.
Tribal Health even contracts with an acupuncturist who visits the reservation regularly. "We have such a pain management crisis here," Sangrey said, "that we try different methods with pain."
She said acupuncture aids in preventing patients from becoming hooked on pain medications. Medications remain among the most prominent medical treatments offered at the Tribal Health Clinic and among its most significant expenses.
"When we first took over, we had just one full-time pharmacist," Sangrey said. "Now we have three full-time pharmacists."
While the cost of medications is rising above many people's means in the United States, Tribal Health at Rocky Boy has significantly reduced its costs in that area.
"We are the first tribe in the nation to use Prime Vendor to purchase pharmaceuticals at cost," Sangrey said. "We get the minimal cost. It's all computerized, they hooked us up and we should be seeing a reduction in our pharmaceuticals."
Parisian explained that the pharmacy is equipped with bar coded prescriptions and medications that are constantly inventoried. Orders can be sent directly from the clinic's computers to the pharmacy supplier, the Veterans Administration. "We don't have to pay the middle man anymore," he said.
Sangrey said the recent outbreak of a deadly hepatitis strain in Great Falls has a direct impact on the Rocky Boy community.
"Most of the people who died had very strong ties with our people here," she said. "We've been notified that a $99,000 grant to help public health nursing to immunize has been awarded to us and Hill County."
Since October 1998, 10 of the 20 or so people infected with the Hepatitis B and C strain died. They were both men and women between the ages of 20 and 52. All were Native American and all were IV drug users people.
Sandra Friede, R.N. at Tribal Health, said that the tribe has the vaccine on hand that is specifically for Native Americans. Anyone wanting more information, she said, should call her or Janet Runnion, R.N. at Tribal Health, 395-4486, or Bonnie Blevins, R.N. at Hill County Health Department, 265-5481.
The clinic also offers all optometric services including eye exams, glasses and contact lenses. The clinic's full-time optometrist position is vacant at the moment. "We're interviewing and should be up and running with a full-time optometrist within a week or so," Sangrey said.
Tribal Health also addresses nutrition, exercise and other health issues through a variety of community outreach and clinic programs.
The increase in services has created a need for additional patient transportation. With an unemployment rate edging up between 70 and 85 percent, few people can afford transportation or fuel.
"More services means more rides, getting people to where they need to go," Sangrey said. "We've been doing that, but it's not enough."
Self-governance means tribal members have to take charge and take responsibility.
"When the Tribe first attained self-governance, it was considered a demonstration project," Sangrey said. Now Congress has made self-governance legislation permanent for all tribes that have chosen it.
"It provides for greater planning, more psychologically stable consensus," she said. "Congress can't come in and shut us down."
Because of its independent status, the Tribe has to work even harder to maintain, let alone expand on its assets from the government.
Right now, the Tribe is facing its 10-year reauthorization to which are attached the appropriations for the services Tribal Health provides. Sangrey said the Senate Select Committee on Indian Affairs will be holding its hearings in coming weeks. The Tribe is working with other tribes to maintain the special trust relation reservation tribes have with the federal government.
"We have a special relationship (with the federal government)," Sangrey said. "That's what makes us different from other minority groups."
Rocky Boy's troubles are doubled because of the Tribe's success with self-governance.
"This is such an issue with the federal government that we've taken much of the functions and funding from bureaucracies that had total control of local health care, because we've proven that we could do it ourselves, and they don't like that," Sangrey said.
Under self-governance, Tribal Health officials get their lump-sum funding directly from the federal government and decide for themselves where they should be spent. They no longer have to give up a large share of their funding to bureaucratic red tape.
"That's what the state governments have been trying to do all along," Sangrey said.
Windy Boy, chairman of the Tribal Health Board, is a hard man to track down. He serves American Indian health at several different levels and is frequently moving from one venue to another to protect and enhance Indian health rights.
Windy Boy left for Washington, D.C. this week in his capacity as chairman of the National Indian Diabetes Work Group. He also serves as vice chairman of the National Self-Governance Advisory Group, chairman of the Montana-Wyoming Indian Health Board, and with the World Health Organization.
Parisian said Tribal Health uses a government credit card for all its travel. The card carries GSA rates and is especially beneficial to Windy Boy. "The biggest advantage is you can change flights anytime without penalty," Parisian said. "Alvin's got to be able to come and go at a moment's notice."
Tim Rosette, environmental health division chief for the Tribe, said the Health Board invested $200,000 in expanding its clinic building.
"We were experiencing quite a flow of people and on occasions it was standing room only," Rosette said. "We added 1,000 square feet to the waiting room, including a private patient registration area, private dental waiting area, and a private pharmacy waiting area in all of that."
The clinic also got two new examination rooms through remodeling in the back, Rosette said. One of the exam rooms was made out as a procedures room, so some minor procedures could be performed at the clinic rather than sending the patients off to Havre or Great Falls.
Now Tribal Health is facing accreditation again with little hopes of doing better than before, despite its facelift. The first time around, the clinic received scores of 100 percent in its X-ray lab, chemical dependency center, and outpatient clinic.
But Sangrey is confident that the facility can live up to the 100 percent mark. Sangrey credits that confidence to the spirit of Peggy Nagel, a tribal leader who died of accidental carbon monoxide inhalation in Dec. 13, 1994 at the age of 42.
Nagel, who founded Stone Child (tribal) College 11 years earlier, had a hand in numerous projects on the reservation.
"This is really an exciting time," Sangrey said. "It took a while for us to recover the leadership of Peggy Nagel. She was the force of our community growth. We've all had to grow and find our way without her.
"She had very clear focus."