By Lailani Upham
HELENA — The State-Tribal Relations Committee took on several weighty issues at its two-day meeting at the Montana State Capitol last week. Topics were: Budget cuts in Indian Country, substance abuse, suicide prevention, missing persons and human trafficking, the state correctional system, improving Indian student achievement, and improving outcomes for tribal members on parole and probation.
Agenda items will be reported in a series in upcoming Char-Koosta News publications. The first series will center on a report from the Montana Department of Public Health and Human Services involving budget cuts, the Tribal Health Improvement Program, suicide prevention, and DPHHS Spring Tribal Tours.
Budget Cuts Impacting Indian Country
In November 2017, the legislative special session resulted in approximately $121 million in state general fund cuts to agencies across the state. While the budget cuts have impacted nearly every part of state government DPHHS has taken some of the deepest cuts. Its general fund line item was reduced by $49 million. Before the special session, DPHHS was already implementing cost constraints due to budget reductions enacted during the summer.
“This has been difficult for all involved, and I know Indian Country is feeling the impacts as well with Medicaid and office closures. There’s no question there are plenty of impacts across the state,” Sheila Hogan, DPHHS Director told the commission on Thursday, March 29.
Hogan said what she does know is the agency must continue to communicate and work together. “I have listened and worked with providers and the general public and held back reductions where it made the most sense based on comments we received,” Hogan said. “Last fall, we communicated information about the budget cuts to the Tribes during our agency Tribal Tour. We also further communicated to Tribes in December during a Tribal consultation in Helena. There’s been numerous public hearings regarding changes to Medicaid where folks have had a chance to provide public comment, and we have listened.”
Hogan said that funding reductions included the closure of 19 Offices of Public Assistance (OPA) across the state in January, but none were located on Indian reservations. She said some were in reservation border communities such as Cut Bank, Malta and Chinook. She added that computer labs were set up with partner organizations for people to access online applications, but she added it does not work for everyone.
As a result of the feedback received during the Tribal Tour last fall, the Department did adjust its workload and call structure to keep cases close to home in reservation counties. This means local OPA staff, with the exception of long-term care cases, are handling the eligibility and case management for those individuals residing in reservation counties. Long-term care cases continue to be handled in a centralized unit for the state. When clients call into the Public Assistance Helpline, their calls will be routed to the closest office, Hogan said.
Hogan said other impacts include provider rate cuts, changes to dental and vision coverage and the implementation of prior authorization for intensive substance abuse and mental health services.
Medicaid dental program eliminated high cost dental services and Vision Services have cut down vision exams and eye-glasses to once every two years.
Tribal Health Improvement Program (T-HIP)
The new Tribal Health Improvement Program (T-HIP) is a historic partnership between tribal, state, and federal agencies launched early last summer. T-HIP is designed for the governments to address factors that contribute to health disparities in the American Indian population eligible for Medicaid and residing on a reservation. “It is an innovative health promotion, disease prevention program and encompasses three service tiers,” Hogan said, adding that Tribes have full authority to decide if they wish to participate and to what degree (meaning level of Tier implementation).
“It provides a unique opportunity for Tribes to incorporate cultural practices into their respective prevention programs,” Hogan stated.
Tier-one focuses on high-risk, high cost members who are provided intensive care coordination to improve the health of members with chronic illness or are at risk of developing serious health conditions. The second tier addresses specific health focus areas that contribute to health disparities and will generally focus on improving the health of a population within a respective reservation.
Hogan said over the past six months, DPHHS hasmade considerable progress in beginning the implementation of T-HIP. Currently, there are four tribal nations — Fort Peck, Rocky Boys, Fort Belknap and CSKT — that have fully implemented Tier 1 services and discussions are ongoing with the Tribes as they consider the addition of Tier 2 services.
“We are excited about this new program and the long-term impact it will make on our collaborative effort to reduce health disparities among American Indians in Montana,” Hogan said.
Dphhs Fall Tribal Tour
Ongoing communication is important to creating a successful working relationship with tribes, said Hogan. A key part of this effort is the Department Tribal Tour that takes place in the spring and fall to meet with governing bodies of tribal governments. “These visits allow us an opportunity to be in the tribal chambers and hear directly from tribal leadership about topics most important to them. Our visits this last fall were critically important as we spent a great deal of time sharing, discussing and receiving important feedback about the state budget and the impact to tribal governments and their communities. While in these tribal communities, we also make visits to the CEO and their staff at each of the Indian Health Service Units.”
The spring tour will begin in May.
Montana Native Youth Suicide Reduction
Hogan updated the commission on Governor Steve Bullock’s announcement last May on a new partnership with the Montana Broadcaster’s Association to produce several TV and radio PSAs regarding suicide prevention. She said the PSAs have aired statewide with no cost to the state. The PSAs focused on youth, veteran, and high risk individuals and can be viewed from their website.
“Another PSA that has garnered a lot of attention is the video produced by the Arlee Warriors basketball team,” said Hogan. “It has over one million views.” She asked the commission if she could play the video and they agreed.
The room was silent for a few minutes after the viewing and Hogan thanked the commission for allowing time. “It’s a very powerful video and I’m just so proud of these youth for their efforts,” she said.
She talked about the Native Youth Suicide Reduction Advisory Council a group comprised of representatives from each Tribe and Urban Indian Health Center. She told the commission the Coalition built the Montana Native Youth Suicide Reduction Plan that was released by DPHHS in January 2017.
“This Coalition’s guidance has been key to the Department on how to make the most effective use of our limited funding. The Department fully implemented their recommendations in 2017 as outlined in the strategic plan, which included convening a Zero Suicide Academy in Helena in October of 2017,” Hogan said. Nearly 75 participants attended the Academy which included representatives from Tribes, Urbans, Indian Health Service and DPHHS and was the first time a governor attended and spoke to Academy participants.
Hogan said the Coalition met recently in early December 2017 to update the Strategic Plan for 2018 and develop recommendations to present to DPHHS on how best to utilize the $250,000 provided in House Bill 118. She added she was present to hear those recommendations and accepted the Advisory Council recommendations and is currently working on and implementing them.
The recommendations include:
• Establishing an Advisory Council to include a youth component. Invitation letters will be sent to tribal governments and Urban Indian Centers requesting nominations for four individuals to be on the Advisory Council - two adults and two youth. Once the nominations are received back, appointment letters from Hogan will be sent to the Advisory Council members.
• Provide direct funding to each Tribe and Urban Indian Center to continue Zero Suicide implementation within their health and behavioral health programs and to provide self-care practices training for their frontline health and behavioral health staff.
• Establish an electronic newsletter that shares information about tools, resources, or local stories about Zero Suicide implementation, conducting webinars and calls to keep the Coalition connected and provide updates, share ideas and conduct mini-trainings focusing on Zero Suicide along with developing a listserv of interested parties to share information.
Suicide Prevention Funding (HB 118)
“On Feb. 28, I was honored to participate in a press event in Columbus with Governor Bullock to announce part of the remaining $750,000 in suicide prevention funding. On this day, we announced $372,000 in grant awards,” Hogan said. The Columbus announcement was part of a grant award to Billings Clinic to implement a community-based suicide detection and prevention program in 11 eastern Montana Critical Access Hospital emergency departments. Other grant awards went to local county health departments, schools and other organizations all across Montana.
“Several additional schools will be implementing the PAX Good Behavior Game, including in the Missoula County Public Schools, schools in Billings, Wibaux, and Carbon County, Helena and Clancy,” said Hogan. These school districts join at least 18 others across the state that have already implemented PAX, including schools on the Flathead and Blackfeet Indian Reservations that have implemented the Indigenous version of PAX.
Hogan said the agency requires that applicants submit proposals based on evidence-based programs, and PAX is one of the programs that have shown to be effective.
PAX is known to provide trauma-informed care within the delivery of program. PAX mitigates the effects of trauma and childhood adversity, thereby minimizing the effects of a high Adverse Childhood Experience, or ACE, score. “I know within our agency, especially with Child and Family Services, we work with children with high ACE scores so I know how important that component is,” she said.
Hogan closed by reporting she will announce the rest of the grant awards in the near future.
Senate members of the State Tribal Relations Commission are: Jen Gross (D-Billings), Steve Hinebauch (R-Wibaux), Jason Small (R-Busby), and Frank Smith (D-Poplar). House members of the STRC are Alan Doane (Vice Chair, R-Bloomfield), James O’Hara (R-Fort Benton), Rae Peppers (D-Lame Deer), and Jonathan Windy Boy (Chair, D-Box Elder).