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OCR for page 137
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 co—antes 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
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.
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Burkhalter, B.R. 1979. Investigations of Rapidly Changing Papago
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Lindor, Keith. 1983. Guidelines on Diabetes Mellitus. Sells,
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Representative terms from entire chapter:
indian health
