By Michael B. Garrett, MS, CCM, CVE
Personal Reflections
November is National Native American Heritage Month, recognized by federal agencies and other organizations. Like most Americans, I have a blend of racial and ethnic heritages, including Native heritage. My mother's father, Walter Bowen, was an enrolled member of the Moses-Columbia band of the Confederated Tribes of the Colville Reservation, a federally recognized tribe located in northeastern Washington State. The reservation was established by Presidential Executive Order in 1872, and the size of the reservation was reduced over time through other orders and Congressional acts, making the best lands in the area available for settlement by European Americans.
The Colville tribes and the associated bands are considered to be a part of the interior Salish peoples. My grandfather's father died during the Spanish flu epidemic in 1917, leaving his Native mother, Eunice Gobar Bowen, to take care of four sons. As a Native woman at that time, she struggled with the necessary resources to manage and support a household with four sons. She ultimately decided that she could not take care of them, so they were sent to an Indian Boarding School. I understand she was heartbroken when she made that difficult decision. Although I have not been able to determine which school it was, I suspect it was Chemawa Indian School, located in Oregon, which is still in operation. At that school, like most Indian boarding schools in the early twentieth century, corporal punishment was frequent and harsh. He did not speak about that experience often, but you could tell that it was a cruel environment.
My grandfather only made it through grade school. His family encountered many of the same issues that other Native families face, including poverty, lack of education, higher unemployment, suppression of Native culture and language, and challenges with physical, behavioral, and oral health as well as social determinants of health. My grandfather joined the Navy in his teens and had four years of Naval adventures on the USS Arizona, including stops in Central America and Panama.
He returned to Spokane, Washington, after the Navy, where he met and married my grandmother, Margaret Migliuri Bowen (yes, I also have Italian heritage!). My grandmother was a housekeeper for a dorm on the Gonzaga University campus, and she was still cleaning dorms when I went to Gonzaga for my undergraduate degree! She also took care of the finances and bills in their household, even though she did not get her high school degree either. Yet, she was very proficient in math! Ultimately, my grandfather went to work for the Spokane County Road Department, where he worked for more than forty years. He was diligent in keeping in contact with his brothers, who had their own challenges.
I remember that he would take us to the fisheries to see how the fish aged from minnows to whole adult fish. I realize he was likely drawn to the fisheries since the Colville tribes relied on fishing as part of their historical subsistence living. My grandparents had three daughters, the oldest was my mother, Nancy Bowen Garrett. They bought a modest home near the Gonzaga campus in Spokane and had the first and last Dodge cars with push-button transmissions! My grandmother died first, and that is when we discovered my grandfather's limitations with reading and writing, likely due to the poor education he received at the Indian Boarding School. Family members helped him with his bills and any paperwork issues. Despite all of the challenges in his life, my grandfather lived to the age of 84. At his memorial service, his oldest grandson conducted a smudging ceremony. Smudging is a common Native cultural practice that eliminates negative spirits and invites positive spirits, leaving peace and harmony with the survivors. When he died, he had six grandchildren and six great-grandchildren as his descendants, although there are even more now.
Professional Reflections
Although I prefer the term Native, this community is frequently referred to as First Nation, First American, American Indian, and Alaska Native or AI/AN. The estimates are that in the U.S. there are an estimated 3.2 million people who identify as AI/AN alone, which translates to 1.3% of the U.S. population. Over 8.5 million people identify as AI/AN alone or in combination with one or more races. The estimates are that 87% of the AI/AN population live in urban areas while only 13% live on reservations or Tribal lands. The top ten states with the most significant percentage of AI/AN people are (in order of size) Alaska, New Mexico, Oklahoma, South Dakota, Montana, North Dakota, Arizona, Wyoming, Washington State, and Oregon. (OMH, n.d.)
AI/AN people have the lowest life expectancy at birth among all racial and ethnic groups in the U.S. This is a sobering reality. In 2021, the leading causes of death in non-Hispanic American Indians and Alaska Natives were COVID-19, heart disease, cancer, unintentional injuries, and chronic liver disease. (OMH, n.d.). There are many significant health challenges faced by Natives (Mangla & Agarwal, 2023), including:
- High infant mortality rates; about double non-Hispanic white (NHW)
- High rates of HIV infections; twice as high as NHW
- Native adults are almost three times more likely to have diabetes and 2.5 times more likely to die from the same than NHW adults
- Native adolescents are 30% more likely than NHW adolescents to be obese.
There are also significant behavioral health conditions (Mangla & Agarwal, 2023) as well, including:
- Higher rates of tobacco use
- Higher risks of experiencing trauma and development of post-traumatic stress disorder
- Higher rates of substance use disorders
- Higher suicide rate compared to every other racial and ethnic group in the U.S.
These statistics are staggering, especially when viewed within the context of multigenerational trauma due to historical systemic racism, colonization, genocide, and oppression of Native peoples. This presents significant challenges to the professional case manager and the entire healthcare team. A few strategies and tactics can be used to serve Native communities and individuals better.
Provider and Healer Preferences
Traditional healers are common in most Native tribes, although most health plans do not cover traditional healing services. Traditional medicine practitioners incorporate physical, spiritual, social, and environmental factors when working with a client. Native healing practices can include (Kessler, 2015):
- Use of herbal remedies to treat physical conditions
- Purifying rituals to cleanse the body in preparation for healing
- Shamanism focuses on the concept that spirits cause illness
A client may choose to receive services from traditional healers while also receiving services from Western medicine practitioners. The professional case manager needs to honor the client's preferences and choices regarding whether, when, and what kind of practitioner they seek for healthcare services. Despite what the professional case manager may value or believe, it is critical that the Native client's preferences and choices are honored.
If you discover that a client wants to be referred to a provider of similar racial or ethnic background, there are a couple of resources to access. The Association of American Indian Physicians (AAIP) mission is to pursue excellence in Native American healthcare by promoting education in the medical disciplines, honoring traditional healing practices, and restoring the balance of mind, body, and spirit. The National Alaska Native American Indian Nurses Association (NANAINA) is a committed group of persons from every corner of the country dedicated to the health and well-being of the American Indian and Alaska Native people. It is advisable to check with the client's health plan to see if the selected providers are considered in-network to optimize benefit plan coverage.
The Indian Health Service (IHS) is an agency within the U.S. Department of Health and Human Services and is responsible for providing federal health services to approximately 2.6 million AI/AN individuals in 37 states. The IHS has hospitals, health centers, dental clinics, and behavioral health facilities. Typically, to receive healthcare services from an HIS facility, the individual needs to be an enrolled member of a federally recognized tribe. So, the professional case manager needs to understand the enrollment status of the Native client before discussing IHS facilities as healthcare service options. (IHS, n.d.)
Culture, Language, and Communication
There are numerous Native tribes, cultures, and languages. Although there are some similarities, there are also differences. Professional case managers should not assume that their experience with one Native client can be applied to another Native client, especially if that client comes from a different tribe. The professional case manager needs to understand that there are many cultural systemic issues that impact a specific client (Lee, 2019), including but not limited to the client's racial and ethnic identity, tribal affiliation and involvement, definition of the family of origin, the role of family of choice, and view of respected tribal and spiritual leaders. The professional case manager may need to communicate with the client's identified tribal and/or spiritual leaders to better understand the client's beliefs, values, and practices and their identified community or tribe. For example, there may be practices to follow as the client initiates treatment or goes into surgery. There may also be certain practices for the client who is going through the death and dying process. The professional case manager should be aware of their own cultural biases while being willing to learn about and honor the cultural values, beliefs, and practices to the Native client.
There are verbal and non-verbal aspects of communicating. For verbal communication, the Native client may prefer to communicate in their Native language. If that is the case, the professional case manager should engage the services of a Certified Medical Interpreter to assist in communicating, and family members or friends should be used as interpreters. Health education materials should also be provided in the client's preferred language. There also should be attention to the readability of any written materials, for example, the reading level is set at an eighth-grade level. For clients with visual and/or hearing loss, the professional case manager needs to make accommodations to ensure the information is accessible.
For non-verbal communication, there are nuances that the professional case manager should be aware of. For some Native communities and individuals, there are some non-verbal aspects to be aware of (Stanford Medicine, n.d.), such as:
- Comfort with silence, since some Native clients might be comfortable with long periods of silence, so the professional case manager needs to learn to "sit with silence"
- Discomfort with direct eye contact, since some Native clients consider this to be disrespectful or impolite, while European Americans usually prefer direct eye contact
- Expression of emotion through facial or other gestures may be misinterpreted, so a Native client might smile or nod the head which the professional case manager might interpret as agreement or understanding but this might not be the case.
The professional case manager needs to be aware of both verbal and non-verbal communication styles and techniques with the Native client to ensure that messages are correctly relayed. Additionally, the professional case manager should confirm the client's understanding, so that the client verbalizes in their own words what they understand about their health (AHRQ, n.d.)
Assessments and Interventions
In light of the health challenges cited above, the professional case manager needs to be prepared to assess and address the full spectrum of health conditions. This will allow for the development of a comprehensive case management plan of care that addresses all health conditions while also prioritizing and sequencing the interventions based on the acuity of the conditions. In light of all of the challenges cited above, the professional case manager should incorporate key tools in their assessment process, including assessing:
- Literacy
- Health literacy
- Digital health literacy
- Health insurance literacy
- Behavioral Health
- Social determinants of health (SDOH)
Regardless of the presenting diagnosis and treatments, these domains need to be assessed in order to better serve all of the needs of the Native client. For example, the Native client might live in a rural area with limited broadband connectivity or may lack the latest technology devices, so the use of digital health apps would likely not be appropriate. If an SDOH need is identified, the professional case manager should ask if the Native client would like to explore social services from the tribe or access services from a community-based organization that is focused on meeting the needs of Native clients. Whenever the professional case manager does an assessment and a need is detected, that should be incorporated into the case management plan of care with identified interventions to address those needs.
Summary
Native peoples in this country have faced systemic racism in healthcare, education, and justice systems as well as in other arenas. Native peoples are also diverse in their cultures, languages, and beliefs. Professional case managers need to be aware of the obstacles facing Native peoples, including health disparities. Professional case managers also need to incorporate more inclusive ways to engage, communicate, interact, and work with Native peoples in order to improve the access to, experience of, and outcomes from healthcare services.
Bio: Michael Garrett possesses more than 30 years of progressively responsible experience in managed care, care/case management, utilization management and review, chronic condition management, health information technology, healthcare quality, and population health management services. He has served in operational management, business development, product development, and strategic planning roles. His experience includes developing and implementing new care delivery models, such as patient centered medical homes and accountable care organizations (ACOs). Michael has experience working in a range of benefit programs, including fully insured medical plans, self-funded health plans, workers compensation, Medicaid, government employee plans, and long term disability. He served as the leader in the successful development, implementation, and on-going maintenance of quality management programs for care management programs He has also worked with health plans and healthcare providers in evaluating, improving, and optimizing health information technology and healthcare quality programs. His commitment to the healthcare industry is demonstrated by leadership roles in key organizations, including serving as a member and chair on the Commission for Case Manager Certification, a committee member and chair of URACs clinical accreditation committee, and a member of the Case Management Society of America's Task Force for the Revision of the Standards of Practice for Case Management. He has served as an author, editor, and contributor on six case/care management books as well as the author of numerous journal articles in the field of care/case management. Michael's professional credentials include a Master of Science degree from the University of Idaho in clinical psychology and a Bachelor of Arts degree in psychology and religious studies from Gonzaga University. He is also a Certified Case Manager, Certified Vocational Evaluator, Nationally Certified Psychologist, and a Board Certified Patient Advocate.
The Case Management Society of America (CMSA™) has had diversity, equity, inclusion, and belonging (DEIB) and health equity incorporated into the Standards of Practice for Case Management for many years. In light of the increased emphasis on DEIB and health equity, CMSA leadership determined it was time to amplify this focus. Join us on 12/4/24 for a Free Webinar "Enhancing the Focus on DEIB and Health Equity in Case Management Practice Standards. Free for both members and non-members. Register at cmsa.org
References:
Native American Heritage Month; https://www.nativeamericanheritagemonth.gov/ Accessed 10/3/2024
Confederated Tribes of the Colville Reservation; https://www.colvilletribes.com/ Accessed 10/3/2024
Chemawa Indian School; https://chemawa.bie.edu/ Accessed 10/3/2024
Office of Minority Health (OMH), U.S. Department of Health and Human Services, American
Indian/Alaska Native Health; https://minorityhealth.hhs.gov/american-indianalaska-native-health Accessed 10/3/2024
Mangla A, Agarwal N. Clinical Practice Issues in American Indians and Alaska Natives. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
Kesler, D., et al. (2015) Assimilating Traditional Healing into Preventive Medicine Residency Curriculum; American Journal of Preventive Medicine, Volume 49, Issue 5, S263 - S269; November 2015.
Indian Health Service (IHS); https://www.ihs.gov/aboutihs/ Accessed 10/3/2024
Association of American Indian Physicians (AAIP); https://www.aaip.org/ Accessed 10/3/2024
National Alaska Native American Indian Nurses Association (NANAINA); https://nanaina.org/
Lee, C. (2019). Multicultural issues in counseling: New approaches to diversity, Fifth edition. American Counseling Association: Alexandria, VA; 2015.
The National Board of Certification for Medical Interpreters; https://www.certifiedmedicalinterpreters.org/ Accessed 10/3/2024
Stanford Medicine; Non-Verbal Communication; https://geriatrics.stanford.edu/culturemed/overview/assessment/non_verbal_communication.html Accessed 10/3/2024
Agency for Healthcare Research and Quality (AHRQ); The SHARE approach: Using teach-back technique: A reference guide for health care practitioners; https://www.ahrq.gov/health-literacy/professional-training/shared-decision/tool/resource-6.html#:~:text=With%20the%20teach%2Dback%20technique,to%20do%20to%20get%20better. Accessed 10/3/2024
Burnette CE, Clark CB, Rodning CB. "Living off the Land": How Subsistence Promotes Well-Being and Resilience among Indigenous Peoples of the Southeastern United States. Soc Serv Rev. 2018 Sep;92(3):369-400. doi: 10.1086/699287. PMID: 30853722; PMCID: PMC6407868. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6407868/#:~:text=Subsistence%20has%20been%20described%20as,(Kancewick%20and%20Smith%201990). Accessed 10/3/2024
Native American Smudging. https://www.powwows.com/native-american-smudging/ Accessed 10/3/2024