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Chapter 8 SEWS SERVICE WIT OF To I=I~ ATE SERVICE Since 195 5 ~ the U. S . Publ ic Health Service has fulf illed the co~it- ment of the federal government to assure comprehensive health services to Amer ican Indians and Alaskan natives. Over the last 28 years, the Indian Health Service has evolved a comprehensive caraunity-ba~ed health program offering an impressive array of primary care, enviroronental health, and public health services. Incited in the recipient com~uni~cy, each -service unit. tailors its progrue to the specif ic needs of the community, and increasingly the tribal organ- izations are playing a role in staffing and managing the health program. With over 85 separate se rvice units located in over half of the states, the Ind fan Health Service represents the largest and most consistently developed model of COPC in this country. The Indian Health Service has not been the subject of the intense evaluation efforts that characterize the history of many other federal health programs. Consequently the re is a very small body of published literature that describes either the operations, the costs, or the impact of this particular model of COPC. We Sells Service Unit. is located in southern Arizona and serves 8 community of 14,000 Papago Indians, many of whom live on or near a 2.8 million acre reservation. Although typical in general design, two features distinguish the Sells program from the other IES programs and make it a particularly interesting case study. First, Sells is closely allied to the Office of Research and Development of the Indian Bealth Service. mid program has been actively engaged in health services research and development, focus ing on the tools necessary to practice COPC. As a part of the research and development effort, Sells has been supported by ~ large scale populat ion-based health information system for more than 10 years. Sells emphasizes ca~unity-oriented primary care, increasing by over the past 12 years. There are several historical events that have provided the underpinnings for this ef fort. We Sells Service Unit. is *Rereader referred to as Sells. 137

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138 Papago tr ibal leaders participated in the OEO activities of the 1960s, which emphasized local initiative and local control . Me Papago Tr ibe en joyed strong leadership in the person of Thomas Segundo, who, as chairman of the Tribal Council in the 19 60s gave impetus to coordinating the health system within Sells. The emergence and implementation of the community health representative program {CHR} is largely attributed to his leadership. A tr ibal health board (the Executive Health Staf f ~ was created in 1972 by the Tr ibal Council and all health matters were dele- gated to this group. . . Sells and the Papago Tribe maintain a close and unique relation- ship with the Indian Health Services' Office of Research and Development FORD), which in based in Tucson. The ORD consists of health professionals, social scientists, statisticians and administrators who explore and develop new programs intended to improve the health of Native Americans. Sells often has served as the operational unit where these systems are first implemented and tested. m e Office of Research and Development used Sells for the devel- opment of a state-of-the-art Patient Care Information System (PCTS). In place since 1969, it has greatly increased the accessibility to the kind of data that are needed to practice ca~unity-oriented primary care. A more recent development at Sells, which has further potentiated its performance as a COPC practice, was the appointment of Felix ~ Burtado, M.D., as the service unit director. Dr. Burtado has 23 years experience with the Indian Health Service and has a very strong community orientation. Dr. Hurtado feels that although it is important to have a good hospital and a good outpatient department, the moat important element for an Indian Health Service Unit is to have a community orientation--to remember that it is the entire community that is to be served. Dr. Burtado's interest in community. health, combined with an imaginative use of the PCIS data base, has resulted in a number of examples of COPC at Sells. ME PRIMARY CARE PROGRAM Organization of the Proq~am Staff and Facilities As a component of the service unit, the Sells Indian Hospital is a 40-bed fully accredited general medical hospital that provides both in- patient and outpatient services for approximately 8, 000 Papago people

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139 who reside on the reservation. The hospital has a 4-bed obstetrical unit, 16-bed pediatric unit, and 20-bed general medicine unit. Cur- rently, the hospital does not accommodate surgery nor does it maintain equipment and staff for an intensive care unit. Patients needing surgery or specialty care are referred to one of the hospitals in Tucson or to the Phoenix Indian Medical Center. The Sells hospital census is highly variable, but averages about 60-70 percent of capacity. High-risk obstetrics are referred, but about 100 deliveries a year are done at the hospital. The general medicine unit usually has patients who are waiting to be placed in nursing homes. Mere is an emergency room at the Sells hospital that is available 24 hours a day. In addition to inpatient and outpatient medical ser- vices there in a pharmacy, a laboratory, radiology services, physical therapy, nutr ition and dietetics services, medical records, dental service., community health nursing, and social services. Under a contractual arrangement other hospitals, university centers, and health care providers in Tucson are engaged for additional diagnostic, therapeut ic, and Sung ical services when necessary. Emergency cases are referred to these facilities by ambulance or air evacuation. There is an active outpatient clinic in the hospital, which handles 33 ,000 to 3S,000 visits per year. There are two health centers; one at Santa Papa (about 40 miles west of Sells), and one at San Xavier on the southern edge of Tucson (60 miles from Sells). A mobile health unit in located in the small village of Pisinimo and operates only one day a week, serving the people living in the western districts of the reser- vation. The San Xavier clinic is on the southern edge of Tucson and sees residents both of Tucson and the reservation; many of the urban residents are Indians with other tribal affiliation, e.g., Navajo and Apache. The Santa Rosa Clinic is near the center of the reservation and almost all its patients are Papago. There is a staff of seven physicians for the Sells hospital and clinic complex. Two cam~unity health medics provide care at the Santa Rosa Clinic. San Xavier has two full-time physicians and two part-time phys ic fans ~ f ram the health services research staf f ~ plus f amily prac- tice residents and students from the University of Arizona. On its one~day-per-week schedule, the mobile health unit is staffed by a physician, a physician assistant, and a community health nurse. In addition to the services provided directly by the Indian Health Service, a wide array of services are available through tribal health programs supported by IBS contract funds. In the summer of 1983, the tribal health programs included a nutrition program, a disease con- trol program, psychological servicer, an alcoholism program, a program for the elderly, the community health representative program, ~ program for traffic and highway safety, and the Papago Children's Home. The tribal health programs and the hospital staff have also worked closely with the Headstart Program. The tribal programs have employed as many as loo people in this effort, although recent budgetary constraints have reduced the manpower of many of the programs.

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140 Medical Records Although a good computerized data system is available to support patient care, the hard copy of the medic-1 record is maintained. The records are filed by individual (rather than by family) and patients may have separate records at more than one facility. Linking the var ious records for any g iven patient is the PCIS Health Sun"..ary , which is available to the provider of service on each patient encounter. There is no routine mechanism for identifying the household or the family constellation in either the hard copy medical record or in the PCIS. There is no family problem list maintained nor does there seem to be any other socioeconomic information routinely recorded in the medical record. Data System Direct patient care and health program management are supported by the Patient Care Information System (PCIS). The early development of this system in the 1970s represented a pioneering effort in automated patient care systems. Developed through a cooperative effort between Sells and the IES Off ice of Research and Development, located in Tucson, the system was designed to integrate and display appropriate patient care data assimilated from different providers of care, often separated in time and space, and operating from various disciplinary bases. The developmental goal was to produce an organized patient-oriented data base containing relevant health care data, available to all providers of health service-. For each patient and facility or provider of service within Sells, the PCIS contains a summary of relevant health status and health care information linked to specific encounters and to the facility and providers of service. milt information provides the base from which summaries can be generated. PCIS enables: linkage of records between facilities and disciplinary groups health summaries available to providers during each patient visit multipurpose encounter forms that serve both as the progress note in the medical record and ss the input document for the data system numerous special reports to support program, quality assurance. and system management decisions. PCIS produces a health summary by which the practitioner, at each patient visit, is given a concise overview of a patient's relevant health care data . Me health summary egg regales data f rom the patients multiple encounters with different practitioners and facilities, and contains a variety of information including demographic data, measure- ments, problem lists, active medications, previous inpatient and out- patient encounters, immunizations, skin tests, and lab/X-ray results.

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141 The health scary contains data only on the ind ividual pat lent and prom vices no information on the family constellation, socioeconomic statue, or f Emily health problems. As an additional feature, the PCIS can can- pare these data to predetermined triter ia and suggest the need ~ in the form of ~pr~pts. on the health summary) for selected health care tasks as a function of the patient 'a past health history and pattern of care. With this set of capabilities, the health sublunary can provide the infor- m~tion support that ideally can turn a typical crisis oriented, chief complaint visit into a comprehensive health care encounter with a focus on prevention, early detection, and treatment of preexisting health problems. It takes approximately two weeks for the health summaries to be updated so that they can be used by the providers at the time of patient contact. Practitioners enter information into the system by writing their progress note on the PCIS encounter form that replaces the open-ended progress; note in the hard copy of the medical record. The data in the PCIS also can be displayed in a variety of ways and provided to both clinicians and managers in the form of batch reports or special requests. Ear example, the system can generate a listing of all individuals in the community who have been diagnosed as hyperten- si~re, along with a count or a detailed liming of all visits to one or more f acilitzes made by this group of patients during the previous calendar year. Or as an aid to follow-up, a listing could show all patients who have not seen a provider in the last six months, or whose med icat ion has run out . A small set of such Batch reports ~ are routinely provided to the administrative stat f of the service unit as well as to the tribal programs. Special reports can be requested with the approval of the service unit director, for further investigation of particular problems. Fran our discussions, it seems that Dr. Hurtado is the primary user of the PCIS beyond the routine use of the health Hungary as an aid to d irect pat lent care. Except for mention of some problems with the accuracy and currency of the data, most people interviewed at Sells found the PCIS to be useful in support of direct patient care. Dr. Hurtado noted that there is the standard problem with accuracy of information and the relative inf legibility of the system. The reports that are qanerated routinely, already programmed into the system, are very helpful, but if one were interested in splaying with the data, ~ manipulating the information, looking for information and searching for different ways of looking at the data, this system is less f legible. Requesting special reports often involves reprogramming that results in delays sometimes as log as two or three months. Relationships to Academic Programs Several member. of the Health Care Research Branch of the Off ice of Research and Development have faculty appointment. with the Department of Family and Community Medicine of the University of Arizona. Family practice residents rotate through the San Xavier Health Center and medi- cal and other health professional students participate in the research

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142 program on an intermittent basis. It is worth noting in thin context that Sells also maintains a very close relationship with the Office of Research and Development (ORD) which has an Indian Health Service-wide research and development responsibility. ORD is phys ically located in the same building as the San Xavier satellite health center. ORD has collaborated on a number of occasions with Sells in developing inno~ vative approaches to primary care as well as in some health services research activities. Organization of Financing Sells derives its operating revenues almost exclusively (97 per- cent) fram the Indian Health Service recurring budget with a small, but growing portion (3 percent} from Medicare and Medicaid reimbursements (Table 8.1) . me INS budget is organized into clinical services, pre- ventive health, and program management with clinical services by far being the largest s ingle category. TABLE 8.1 Total Revenues for Sells Service Unit of INS by Source and by Year 1983 1982 1981 TOTAL1 14, 929, 300 13, 189, 876 IS, 848, 700 ~ 1001 ~ ~ 1001 ~ (100. ~ Clinical Services2 10, 761, 600 9, 289, 576 10, 293, 200 (73~) (70~) (65%) Preventive 1, 464, 700 1, S42, 600 1, 948, 800 (10%) (128) (12%) Program Management3 2,102,000 2,210,700 3,471,700 (14~) (178) (22~) Medicare 148, 000 lS0, 000 INS, 000 (A ~ B) (1~) (1%) {18) Medicaid 3 S2, 0 00 --a Includes inpatient and outpatient services. 2Some clinical services dollars are also utilized for elements of the ORD national mission. 3Program management dollars support developmental and training activities related to the Ind fan Bealth Ser~rice-wide role of the Off ice of Research and Development.

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143 Over the past three years, clinical services that have averaged about 69 percent of total revenues include hospitals and clinics, dental services, mental health services, an alcoholism program, maintenance and repair, and contract health services--~ervices delivered to Papago Indians by providers outside THS (Table 8. 2) . In 1983, hospitals and clinics and contract health services accounted for almost 90 percent of the total clinical services, a drop from the previous two years. TABLE 8.2 IES/Sells Service Unit Revenues for Clinical Services Category and by Year . 1983 1982 1981 TOTAL REVENUE FOR 10,978,100 9,286,576 10,293,200 CLINICAL SE=ICES1 (1001 ) (1001 ) (100. ) Hospitals and Clinics2 7,107,500 6,094,S00 6,205,400 (661) (66~) (668) Dental 202, 000 160, 500 146, 800 (21) (2%) (11) Mental Health 226,000 187,000 185,000 (21) (2%) (21) Alcoholism 370, 000 187, 000 8, 600 (31) {2%) {*) Ma intenance and Repair 182, 600 77, 000 62, 000 (18) (11) Aft) Contract Health Service 2,457,000 2,499,576 3,682,100 {221) (271) (361) Reimbursement 433,000 86,000 3,300 (Medicare and (4~) (1%) (*) Medicaid) Includes inpatient and outpatient services. 2Some clinical services dollars are also utilized for elements of the Indians Health Service~wide mission of the Office of Research and development. Less than 0.1 percent.

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144 Preventive health, which represents about 10 percent of total reve- nues, includes sanitation, public health nursing, health education and the community health representative {Table 8.3~. The largest single component of this category, although decreasing rather sharply, has been the community health representative program averaging about 70 percent of preventive health revenues over the last three years. Not all of the IES recurring budget funds go to the service unit for direct service delivery. They are distributed among the service unit for actus1 provision of services, the several tribal health prom grams administered and implemented by tribal health workers, and non- IRS and nontr ibal providers in the form of contract health services. The largest single recipient of the funds is the service unit. In 1976, Public Law 94-437 authorized the Indian Health Service to collect and retain Medicare and Hedicaid dollars. These funds are designated to be used in attaining and maintaining JCAH accrediation. For Sells, reimbursement f row Medicare represents about 1 percent of total revenues. Until recently, the State of Ar izona has not had a Medicaid program that the IES Service Unit could bill. In the last year, however, with the implementation of Ar Ozone Health Care Cost Con- ta~nment system (ARCCCS)--the new Medicaid program in Arizona--Selle has been able to bill for services rendered to elig ible native Americans . in 1983, Sells received Sd33,000 from Medicare and Medicaid relmburse~ cents that represented about 4 percent of total revenues for that year. . - TABS: 8 . 3 IHS/Sells Service Unit Revenues for Preventive Bealth by Service Category and by Year 1983 1982 1981 TOTAL REVENUES FOR 1,464,tOO 1,S42, 600 1,948,800 PREVENTIVE HEALTE1 (100~) {100~} (100~) Sanitation 244,000 169,000 211,000 {171} (111) {11%) Public Health Nursing 296,700 262,400 249,900 (201) (17%) (138) Bealth Education 20,000 18,000 100 (1%) (1%) (*) Community Bealth 904,000 1,093,200 1,487,800 Representative Program (62~) {711) (76%) Include inpatient and outpatient services. Less than 0.1 percent.

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145 There is also the expectation, according to Charles Erickson, acting d irector of Tucson area, that Medicaid revenues will grow at a rapidly accelerating rate. The revenues obtained from third parties such as Medicare and Medicaid stay in the service unit and help its administrators defray some costs, which may, in turn, afford them a substantial amount of flexibility in directing the revenues to program emphasis areas and more COPC activities. The COMMUNITY Demography Sells defines its community as all of the people in the Papago tribe and it is responsible for assuring the health of the Papago people who live both on and off the reservation. The Papago reservation consists of four land areas; the largest covers an area of 2.8 million acres to the west of Tucson, sharing its southern boundary with Mexico. Three smaller land areas, disconnected from the main reservation, include the San Lucy reservation north and west of Sells, a small reservation near Florence, Ar izona, and the San Xavier reservation lying in the southern suburbs of Tucson. The service unit also assumes responsibility for the provision of services to the population of native Americans in the Tucson area, through the outpatient clinic located on the San Xavier reservation. The urban Indian population also may receive health services f rom the Traditional Indian Alliance, a health care program operating in Tucson and supported in part by funds f rom the Indian Health Service. According to the 1980 census, there were 8, 900 Papagos on the reservation, while the PCIS data base includes 14, O 50 Papago registrants fran all of southern Arizona. Based on previous trend data, approximately 70 percent of the 8,900 reservation residents will make contact with the health care system in the course of one year, while 95 percent will make contact over f ive years. Life on the Papago reservation today is a combination of traditional lifestyle with an ever increasing presence of modern influences. There are 20 major villages on the reservation with populations greeter than 100 people, although a larger number of small settlement'; exist. The ccxemunity of Sells is located near the geographic center of the reser- vation and is approximately 70 miles west of Tucson. It is the center of much of the reservation activities and is the largest village on the reservation with a population of about 2,400 people. In addition to the Papago population, there are a small namer of non-Indian employees of the Bureau of Indian Affairs, the public school system, and the Indian Health Service. The occupational prof ile of the Papagos is var led . Many Papagos raise cattle. There are family herds, district herds, and a tribal herd. They also engage in dry and irrigated farming. In addition, a number of Papago. work for the federal and tribal go~rerr~ment. Others work in Tucson and a some have been employed by several large copper mining coantes south of Tucson. The exact or even approximate figures of working and nonworking Papagos fluctuates and is difficult to estimate.

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146 The Papago community is highly organized and functions as a politi- cal entity. The Papago tribe is governed by a tribal council consisting of 22 Members. Bach of the eleven political districts elect two members to serve on the tribal council. It meets monthly and to conduct the government business of the Papago tribe. A tribal chairman, vice chairman, secretary, and a treasurer of the tribe are elected at large and serve four-year terms. In addition to the tribal council, each of the 11 districts has its own district council elected by the people. The district council po88eB8e8 a high degree of local rule and policy making. Most major decisions affecting the Papago tribe are discussed at tribe1 council, but then are referred back to the district councils for their consideration. Before any major decisions are made, local opinion is sought and carefully considered. Consensus in decision making is highly valued, an attitude that has strong implications for the community ' ~ involvement in identif ication of health needs and planning of health services. Community Involvement Community participation in the health program comes largely through the Execut ive Health Staf f, which cons ists of the heads of the var ious tribal health programs funded by the Indian Health Service. The Indian Bealth Service encouraged the development of this group as a way to institute broader organization and planning on the tribal side with regard to Indian Bealth Service-funded program. Frae the perspective of COPC, the Executive Health Stat f is a central feature of the comau- nity's participation. Created in 1972, this tribal group functions as both a tribal health board and an administrative entity. As a tribal health board, this group adviser Sells on tribal priorities, serves as an advocate for Indian health legislation, and represents the tribe at national Indian meetings on health issues. As an administrative group that manages an increasingly sophisti- cated program of tribal health departments, the Executive Health Staff is very influential in determining the health needs and health priori- ties of the Papago people. The interrelationship between Sells and the Executive Bealth Staf f of the Papago tr ibe is deeply woven and forms a major foundation for the health care system of the Papago people. The Executive Bealth Staff has until recently managed over 100 employees and field health workers and controls a sizeable budget, obtained fray IES under contract with the Indian Bealth Service. me Indian Bealth Service has a personnel policy that gives absolute preference to the hiring of Indian people for any position to which they are even minimally qualified. Although this policy has definite draw- backs for a health program that must continually strive for profeselona1 excellence, it does result in a very large proportion of the service unit staff being members of the community. In itself, this seems to have a tremendous ~co~un$ty participation. effect on the decisions and pert ormance of the service unit as a whole . In 1968, the IES funded the development of the C~un$ty Bealth Representative Program, a completely camunity based tr ibal health

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147 program designed to establish linkages between the health care system operated by the INS and the Papago people. Areas of activity include transportation of patients to the clinical facilities, cooperation in the implementation of special health programs, and coordination of health skills training. The program has continued since 1968 and has been funded by the Indian Health Service. Two studier of the tribal health programs recently have been pub- lished (Atencio, 1974 ; Bashur, 1979), and one notes that the number of both home health visits and health transports have increased dramati- cally over the 15 years of operation of the Community Health Represen- tative (C~) Program (Bashur, 1979) . It cites; an a ma jor achievement of the programs, the provision of the bulk of transportation to and f rom the hospital and clinics. This study notes that although special d far rhea and strep control pro jects are usually thought to be respon- sible for the reduction in diarrhea and rheumatic fearer, the increased access to the hospital prov ided by CHas probably was an important factor . COPC ACTIVITES AT SEI~I~S Inf ant Gastroenter itis The sooner and ear ly f all of each year had long been known to be a time of prevalent and very often severe diarrhea among the young chil- dren of the Papago community. Every clinician and outreach worker was well acquainted with the problem, and the hospital staf f of ten planned for the endemic peak with add itional personnel and supplies for the pediatric ward. In the endemic peak of 1971 July to December}, 94 percent of all infants in the community experienced one or more epi- sodes of clinically signif icant diarrhea, 29 percent had one or more episodes resulting in clinically documented dehydration, and 2 percent (a total of 8 infants) died from dehydration secondary to diarrhea {Nuts ing et al ., 1983} . Early in 1972, a program was - developed that involved a prospective r isk analysis to identify specif ic infants arc high risk deco gastroenter- i tis and a protocol format that allowed tr ibal outreach personnel to identify infants with clinically signif leant diarrhea, make a sophisti- cated assessment of the stage of severity, and either treat the child symptomatically or refer to a physician, as a function of the assessed stage of severity (Nutting et al., 1975a, 1978) . A risk model was developed for the program and was used to identify specif ic infants with an elevated rink for severe diarrhea. The model was based on a set of ten weighted risk factors, and each individual infant's risk level was determined by summing their total risk points. A simple educational task was developed for use by the tribal outreach workers. which instructed the parent or guardian in the serious nature of gastro- enteritis, the early treatment of diarrhea, and the recognition of and the appropriate response to dehydration. During the program operation, the educational task wan specifically targeted at those infants in the community identified at high risk.

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152 range. The service unit continues to monitor immunization rates, as well as known cases of diphtheria, tetanus, whooping cough, rubeola, rubella, mumps, and poliomyelitis. ANALYS IS OF SELI5 AS A C0~5UNI=~RI=TED PRIMLY == ORGANIZATION The Functions of COPC Defining and Characterizing the Community Sells characterizes the community largely through the use of the PCIS. Developed primarily to link health and health care cats among geographically different sources of care for the Papago people, the PCIS contains data on over 14,000 Papago Indians in southern Arizona who have received services over the past 15 yearn. Consequently, while being driven largely by patient contact, the data system has been in place long enough to include virtually all members of the community. Frequent contact by the large corps of outreach workers in the program maintains a reasonable level of accuracy of the demographic data on the individual members of the community. The use of a data base specific to the community from which information is regularly drawn to define and characterize relevant subsets of the community, places the Sells program at stage III of development for this function. Ident i fy ing Commun i ty Heal th Needs In general, Sells is at stage I I I for the identif ication of cononu- nity health need e. All f ive examples of CO PC activities involved health problems that were identif fed and characterized through the use of the PCIS data base. Although this data base is used to identify the severi~cy, extent, and correlates of a target health problem, the initial identif ication of the problem as a pr for ity is a more compl icated process. In many cases, problem identif ication at Sells is a long-term consensus building effort, involving the tribe and its various levels of decision making as well as the Indian Health Service. Thus, many examples would be inaccurately descr ibed as a stepwine process in which certain data were gathered, analyzed, and a program decided upon. Often a problem is suspected by the clinicians and or tribal groups, and an attempt is made to document evidence of the actual extent of it. During the site visit, it became apparent that several health problems that have been recently ~discovered. at Sells were not recently identified as problems so much as it was recently decided that they were problems that needed to be dealt with more effectively. Among the COPC activities described above, the newly expanded effort to deal with diabetes mellitus is an example of this consensus building process. The PCIS is an extensive and detailed population-based data system which, if fully used, would probably allow Sells to operate at stage IV

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153 for this function. However, the system does not appear to be fully exploited for this purpose, as there appears to be no regular reports of health status indicators that might be used to monitor the health community. However, var ious surveillance reports have been developed and used as early as the late 1960~. One recent var iation i. the two-part Health Status Report. Part I compares the previous with the current year and lists births and deaths; the ten leading communicable diseases; the three leading causes of injuries; various kinds of prenatal and post partum data, including the number of deliveries, miscarriages, and the number of postpartum revisits; and the ten major health problems and the number of patient contacts for each. Part II of the report contains a complete listing of all the health problems seen, giving the number of people and percent of the total having each health problem. These data were also compared with the same numbers for the previous f iscal year. However, these reports have not been available for several years. During a recent data conversion as part of an effort to standardize the data Sets of the various patient care data systems within the Indian Health Service, the Health Status Report had to be rewritten and it in currently in the backlog of programs waiting to be modified. Modifying The Health Care Program There is some variation in the level of development of the activi- ties of this function at Sells, although most tend to be at stages III and IV. m e exception is the effort to increase the immunization levels of inf ants in the community, which falls at stage I. While identif fed as a problem in the c~..unity, infant immunization became a dedicated effort with the Public Health Service initiative, which set standards for all THS service units. The efforts to address streptococcal pha ryng itis and the planned diabetes program are both tailored to the part icular characteristics of the Sells community, and employ a balance of primary care and community health strateg ies, which place. them at stage I II. The efforts to combat infant gas~croenteritis and to improve prenatal care are examples of stage IV development, since both syste- matically identified specific high risk individuals and designed the proved to target services on them, in thin case with active outreach efforts. In this function, Sells differs somewhat fran the other study sites in that most program modif ications are based largely on community health efforts. Many program modif ications appear to have less ef feet on the primary care program and often the major effect is the result of secon- dary changes in the workload, due to more aggressive outreach or case finding. Most program modif ications are substantially enhanced by the PCIS, which can evilly provide lists of individuals who are due for targeted health services and can monitor program implementation with measure. of process and outcome.

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154 Monitor ing the Impact of Program Modif ications In general, the Sells program operates an an advanced level of development in monitoring the impact of its COPC ef forts. For this function stage III is characterized by systematic efforts to monitor impact f ram a data base that is specif ic to the community. The of forts to monitor impact of the emphasis programs for both streptococcal pharyng itis and infant immunization utilized the PCIS to monitor both measures of process and outcane . In both cases, add itional data wan collected as a routine component of the program modif ication, which end iched the data available in the PCIS and gave a more sensit ive measure of total program impact. Stage TV differs fray III in the use of evaluation techniques that are specific to program objectives and account for differential impact among risk groups. Both the efforts to address infant gastroenteriti~ and to improve prenatal care identif fed specif ic high risk individuals and groups, and monitored the program impact on each. In both cases, accounting for differential impact among risk group- provided important information that would have been missed by an evaluation approach that treated all individuals in the target population of the community as of equal priority for the program services (Nutting et al., 1979, 1983) . In contrast to these ef forts, however, the planned ef fort to monitor the impact of the emphasis program for diabetes mellitus is based on anticipated increases in the number of patients presenting for and receiving services. This evaluation strategy is based on a denominator of patients rather than on the community, e.g., all individuals in the community with diabetes, and thus is at stage O. . Envi ronmental Inf luences Sells operates in an environment that is particularly fertile ground for the practice of co~nunity~oriented primary care, and as such, probably represents an ideal site to explore some of the internal limitations to community~oriented primary care. Many of the other case studies descr ibe environmental constraints, of ten related to the way that they are funded, which impede the full development of COPC. At Sells, the en~riror~ent is extremely conducive to COPC, and the impedi- meets to full realization of a COPC model may be related to either the inherent concept itself or to a lack of Cools and techniques required for the practice of con~unity~oriented primary care. Histor ical irar tables There are several historical factors that have had an obvious impact on the ability of the organization to practice con~unity~oriented pri- mary care. The service unit was or iginally set up to serve a def ined community with the full range of health services. From its inception, the program was joined in the effort by the Papago tribe, representing

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155 a single community, actively functioning as a social, cultural, and political entity. Although an obvious point, such a clear mission with an o rganizational and f inancial base of support is unusual in the Un i ted S tates . Another historical factor is the lack of major conflict between the Papago tr the and the federal government. In general, the relationship between the Papago tr ibe and the U. S. government has been relatively less hostile and resentful than with many other tribes. This does not mean that there are not sane differences in goals and strategies between the two parties, but at least there has been the opportunity for cooperation to develop. Organization of the Program Sells has a number of organizational character istics that are very supportive of con~unity~or tented pr imary care, and not usually available to other programs that aspire to practice COPC. me main feature of the organization lies in its mission to assure the provision of the f ull range of health services, including public health and community medic ine servicer . Because it is a single organization, and health care services are funded f ram a single budget category, there is nothing to inf luence the service unit to either favor or f ight hospital dominance, a problem that plagues many efforts to provide comnunity-based primary care. One of the most positive organizational feature at Sells is its Built in. community nursing program which, in most other communities, is conducted by an agency separate from the primary care practice. me outreach ef fort is considerably strengthened by the existence of the Community Health Representative (CER} and other tr ibally operated programs. These indigenous pare-professional health aides provide a vital service in translating health issues across cultures. A1 though it would be possible for the CHR program to function in a very limited way, such as merely delivering patients to the service unit without being integrated into a co~nunity~oriented care system, it appears that at Sells the CARS operate as functional members of informal community Stealth teams. Finally, of particular importance is the location of the Indian Health Service Office of Research and Development within the Tucson Program Area. Over the past ten years, efforts at the research center were directed toward the development of tools for COPC. Several impor- tant ca~unity~orien~ced pr Nary activities in the early 1910s were the direct result of cooperation between the emerging Executive Health Staff and several research physicians at the research center. This work was directed toward the development of reliable and economical methods for identifying specific individuals in the community at risk for particular health problems {Burkhalter and Nutting, 1981; Nutting et al., 1975b, 1983; Shore et al. , 1975) . Of these, the risk model to identify infants at risk to severe gastroenteriti. has been described above. Other work resulted in a method for examining the quality of care as received by the entire community, as opposed to the quality of

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156 care provided by the program to active users (Nutting et al., 1981, 1982; Shorr and Nutting, 197t). Although this is a subtle distinction, it nonetheless is one which lies at the heart of the CO PC concept. In another line of research, a method was developed by which auxiliary health workers could extend the problem solving process of clinical care into their community outreach ef forts, using protocols for the care of pr for ity health problems. Through this method, tr ibal health workers were able to directly participate in the process of care as an integral part of the primary care team, and their efforts resulted in measurable benef its in both the processes and outcasts of care for pr i- ority health problems of the community (Nutting et al., 1978, 1981) . Lastly, one of the d istinctive f eatures of Sells ' ef forts to practice co~unity~oriented primary care is the Patient Care Information System (PCIS ~ . Developed at the research center, this data system is population-based and provides information at a level of detail and integration that Simply is not available to most other primary care, service delivery organizations. While its potential is not fully exploited, it nonetheless supports a broad range of analyses that are fundamental elements of the practice of co~unity~oriented primary care. Organization of Financing The way that Sell. is funded in highly conducive to the practice of con~unity~oriented primary care. The service unit is not funded on a reimbursement basis, let alone a reimbursement-by-procedure basis. It in essentially a lump sum grant, but unlike the grants given to many other primary care efforts (such as Community Health Centers), it is a grant for the total range of services including public health and cononu- nity health services. Strictly speaking, the service unit is funded by the Indian Health Service out of an annual appropriation, but budgeting is done on an incremental basis. This makes it possible for the program to predict with a fair degree of accuracy it funding level for each sub- sequent year, and except for f iscal year 1981, the budget has increased each year. The way in which the service unit has been funded has made it possible to conduct long range planning, a luxury that many other primary care services do not enjoy. Also, the budget structure within the service unit is very flexible. There are only a few broad categor- ies of services, and these allow considerable latitude in the way that they can be applied. On the other hand, community health nursing is a separate line-item within the service unit budget, which nerves to pro- tect it fray being consumed by primary acute care services. In many other comprehensive health service delivery efforts, the community nurses and other outreach efforts are the first to be eliminated when budget rests Actions are encountered. At Sells the co~wnuni~cy health nursing budget had not suffered more than other programs in the recent budget reduction. There are also Awe categor ies within the service unit budget that are devoted to funding tr ibal health programs. Sells we. among the first of the OHS service units to permit the use of that budget category for supporting a wide range of tribal health programs. Current funding

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157 supports programs in alcoholism, aging, mental health, nutrition, and programs for disease control and the community health representatives. Although a budget that in generally stable in overall s ize, and which is internally f legible, may support COPC in a way that the f inancing of other practices does not, that very stability does not provide a great deal of incentive for major shifts or changes in programming. Like other large federal programs, the THS must also comply with a complex set of regulations and often administrative obstacles make planned program modif ications cliff icult. The Community The Sells program, like other Indian Health Service units, serves an actively functioning sac iocultural community. Clearly the tribe is well org anized and views the community in terms of its health needs in the context of larger goals of community development. The tr the has been active in health affairs and accepts full responsibility for its own health destiny. In all respects the involvement of the Papago com- munity represents the pinnacle of community involvement. The benef icial impact of the community involvement in promoting COPC cannot be of er emphas ized . SUMMARY The Sells program stands out among the study sites as operating in an envirorunent most conducive to COPC. It serves a community that in an intact and well functioning social, cultural, and political conenu- nity. It is well defined and is active in planning, operating, and evaluating its health care needs and programs. The financial base of the program is a recurring federal budget that provides funds for acti- vities well beyond those reserved for the provision of primary care services. Thus, the organization of financing not only permits, but encourages programs for community outreach and publ ic health activities. Within budget categories, the service unit has a great deal of flexibil- ity for m"-shalling funds to operate programs designed for the unique needs of the community. The stability of the recurring f inancial base permits long term planning and allows considerable continuity of the CO PC functions over tme. The organization of f inancing of the program has contributed to an organ ization of practitioners that also is conducive to the practice of CO9C. The multidisciplinary nature of the staff and the inclusion of nutr itionists, health educator., community health nurser, and a var iety of community outreach workers all contribute to the basic capability for COEC. Although there is rapid turnover of the physician staff, the practitioner staff overall is relatively stable. The Sells program provides examples of COK: activities that appear to be at a fairly high stage of development, as summarized in Table 8.4. One wonders, however, why such a supportive environment has not produced examples of COPC activities at the very highest levels possible. With

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1S8 its relatively few environmental constraints, further study of the Sells program might help to identify internal constraints to COPC, such as those due to the concepts itself, or those due to the lack of tools and techniques for CO PC which are feasible in the busy clinical setting. Since the Sells program operates in an environment conducive to the pr actice of COPC, it would be an ideal setting for studies that attempt to examine the marg inal costs and associated impacts of the COPC. TABLE 8.4 Cooper ison of the Level of Development of the Ma jor Functional Elements of COPC in the Sells Service Unit Identify Modify Def ine and Community the Monitor Character ize Health Health Impact of the Community Problems Program Modif ications STAGE O STAGE I STAGE I I DIABETES IMMUNIZE STAGE I II X GAS TRO DIABETES IMMUNIZE IMMUNIZE STREP STREP STREP DIABETES PRENATAL STAGE IV GAS TRO GAS TRO PRENATAL PRENATAL - GAS5~0 refers to the emphasi~s program to address infant gastroenteriti~. IMMUNIZE refers to the program to increase the rate of immunization in children. STREP refers to the program to combat streptococcal pharyngitis and its sequella, rheumatic fearer. DIABETES denotes the planned effort to address the problem of diabetes n~ellitus . PRENATAL refers to the effort to improve the care for high risk preg- nancies.

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159 INTERVI ENS Charles Erickson, Acting Director, Tucson Program Area Felix Hurtado, M.D. ~ Service Unit Director, Sells Service Unit Steven Permisan, H.D., Clinical Director, Sells Service Unit David Logan, M . D ., c 1 in ic fan Francisco Jose, Vice Chairman, Papago Tribe of Ar Ozone Rosemar ie Lopez, Tribal Council Fred Stevens, Tribal Council Cecil Williams, Sells Service Unit, Project Officer Pauline Sequiero, Social Services, Sells Service Unit Sister Solano Schmedler, Director of Medical Records, Sells Service Unit Geraldine Guyon, R.N., Director of Community Health Nursing, Sells Service Unit Elisa Hurtado, H.D., Office of the Director, Tucson Program Area

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160 REFERENCES . Atencio, To 1974. A Journey in Self Reliance: A Report on the Status of Papago Health Programs, Sells, Arizona. Bashur, Re 1979e Technology Serves the People: The Story of a Cooperative Telemedicine Project by NASA, the Indian Health Service, and the Papago People. Of f ice of Research and De ve lo~nent, Tucson, Ar i zone . Burkhalter, B.R. 1979. Investigations of Rapidly Changing Papago Tribal Health Programs. Sells, Arizona: Papago Tribe of Arizona. Burkhalter, B.R., and Nutting , P.A. 1981. The concept of risk in the evaluation and operation of maternal and child health programs. Paper presented at Third National Conference on Need Assessment in Health and Human Systems, Louisville, Kentucky, March, 1981. Indian Health Service (n.d. ~ The Indian Health Program of the U Public Health Service {DREW Publication No. (HSA) 78-10031, Washington D.C. Indian Health Service (n.d. ~ Selected Vital Statistics for Indian ..=alth Service Areas and Service Units, 1972 to 1977 (DREW Publication No. (HSA) 79-100 5), Wash ington, D.C. Indian Health Service. 1971. Indian Health Trends and Services (PubliC Health Service Publication No. 2092), Washington D.C. Lindor, Keith. 1983. Guidelines on Diabetes Mellitus. Sells, Ar Mona: The Sells Service Unit. Nutting, P.A., Barrick, J.E., and rogue, S.C. 1979. The Impact of a maternal and child health care program on the quality of prenatal care: An analysis by risk group. Journal of Community Health 4 :267-279. Nutting, P.A., Burkhalter, B.R., and Carney, J.P. 1983. The Development of Population-based Risk Models (Doe. No. R4A-0607), Off ice of Re search and Development, Tucson, Ar i zone .

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161 Nutting, P.A., Burkhalter' B.R., Dietrich, D., and Helnick, E. 1982. Relationship of size and payment mechanism to system performance in 11 medical care Systems. Medical Care 20:676-690. Nutting, P.A., Shorr, G.I., and Berg, L.E. 1975. Process and outcome measures of tribal health workers in direct patient care. In Advanced Med. ical Systems: Issues and Challenges, C . D. Flagle, ed . New York: Stratton Medical Book Corp. Nutting, P.A., Shorr, G.I., and Burkhalter, B.~. 1981. Assessing the performance of medical care systems: A method and its application. Medical Care 19:281-296. Nutting, P.A., Strotz, C.R., Shorr, G.I., and Berg, L.E. 1975. Reduction of gastroenteritis morbidity in high risk infants. PediatriCs 5 5: 3S4-3 S8. Nutting, P.A., Tirador, D.F., and Pambrun, A.M. 1978. An approach to utilizing health auxilliaries in direct patient care. Bulletin of the Pan American Health Organiztion 12:283. Papago Tribal Specif ic Health Plan, August 1, 1979, P. IlI-14. Re inhard, K.R. 1973. A Report on the Streptococcus Disease Surveillance Project, Office of Research and Development, Tucson, Arizona. Reinhard, X.R., and Greenwalt, N.I. 1974. Problem-specific time loss impact of disease in southwestern American Indian communities. Proceedings 102nd Annual Meeting, APHA. Reinhard, K.R., Greenwalt, N.I., and Roberson, M.K. 1976a. Disease experienced profiles in a southwestern American Indian population. Proceedings 104th Annual Meeting, APHA. Reinhard, K.R., Krauss, P.E., Sheffer, K.E., RDberson, M.K., and Greenwalt, N. I. 1976b. Diabetes-related disease in American Indian people indigenous to Sonoran Biome. Indian Health Service, ORD, Tucson, Arizona. Sells Service Unit, INS, Tuscan Program Area. 1983. Diabetes Mellitus Program Planning. Sells, Arizona: The Sell Service Unit. Shorr, G. I., and Nutting, P.A. 1977. A population-based assessment of the continuity of ambulatory care. Medical Care 15: 455-464 . Shorr, G.~., Sanders, J., and Nutting, P.A. 1975. Prediction of Abnormal Screening Blood Pressure in the Population of Risk to Hypertension (Doe. 3. 9.4), Office of Research and Development, Tucson, Arizona. Tatum, W. 1974. The Papago Ind fan Reservation and the Papago People . Sells, Arizona: The Papago Tribe of Arizona.

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