UIHP Operations Survey Results 2008

Welcome to The NCUIH Urban Indian Health Programs Survey 2008 page!

Please click on one of the items below


II. Results

a) Historical facts

b) Internal  Operations

c) Collaborations and Partnerships

d) Media and Communications

e) Current Funding Sources & Distribution

f)Federal Grants/Funding

f) Technical Assistance Needs on Grants Opportunities

h) e-Readiness

III. Methodology

IV. Data Limitations

V. Conclusions & Recommendations

I. Introduction

Little is known about the Urban Indian Population. Funds have never been enough to appropriately document the challenges and   circumstances that Urban Indian Health Programs have to face in a daily and yearly basis. Keeping the afore-mentioned in mind, NCUIH found it critical to get a better understanding of operational circumstances of the UIHPs as well as, the local environment they have evolved in. For such reason,  in  Spring 2008 the NCUIH team developed a UIHP Operations Survey designed to collect the information needed for NCUIH to both inform itself about how to improve technical assistance provided to UIHPs as well as to establish a more informed dialogue with the Federal Government on the design of governmental programs.  NCUIH believes it is necessary for government agencies to understand both of these aspects in order to work with UIHPs in a culturally sensitive and correct fashion.  Additionally, the collected information is expected to lay the ground work for a more comprehensive needs assessment. Thus, the survey was created also for the results to be used not only as the contextual background of the online Knowledge Resource Center but also as a preliminary data on the areas that our programs need assistance on to expand the scope and depth of their services to our community. 

II. Results

>A) Historical Facts

  • Average Years of Service :
    The average age as an Indian serving agency is 26.67 years with a wide range from 1 year to 39 years of existence. 

  • Origins & Formation:
    More than half of all UIHPs were organically grown from the need and interest by the local community. The rest of the UIHPs began because of legislation, some type of health crisis, or other reason such as family, general opportunities, or to create a better life.

  • Relocation:
    The top three reasons why community members settled in the city where the UIHP operates were:

  1.  for work,
  2.  it was their place of birth, or
  3.  they moved due to government relocation policies 
Main Event that Triggered UIHP Formation

B) Internal  Operations

  • Human Resources:

Approximately 40% of the UIHPs reporting have more than 51 full-time employees.

Number of Full-Time Employees

The lack of human resources emerged throughout the data as a major obstacle to operations and the top staff positions most needed to hire included doctor, nurse, case manager, and development officer. The most difficult positions to find candidates for were reported as doctor, nurse, financial staff, case managers and behavioral health staff. Further, staff training needs identified include (in order of significance) management skills, cultural competence, leadership, and communication flows.

  • Methods for Recruiting

UIHPs also reported on their methods for recruiting staff. The top three recruitment methods identified by the UIHPs were
1) Online
2) Local newspapers
3) Local Indian community.

  • Top five health disparities dealt with in internal operations (in order of significance):

1) Diabetes,
2) Heart Disease,
3) Cancer,
4) Behavioral Health, and

  • Operational Accreditation

Of the UIHPs reporting-57.2% had some form of accreditation;
of those, 25% were state or partial accreditation (i.e., accreditation for one type of service).
For UIHPs that were not accredited, nearly sixty percent (58.3%) reported it was too expensive.

  • Current Board of Directors Training:

UIHP Board of Directors are so critical for the direction and development of the organization. The UIHPs reported on current training that the Board of Directors received as follows:

-          40% of the UIHP Boards had training on the role of non-profits
-          20% had training on providing technical assistance
-          20% had training on decision making capabilities
-          25% had training on level of involvement
-          35% had training on fundraising and responsibility
-          55% had training on governance vs. management
-          35% had training on legal/ethical issues
-          30% had training on board self-evaluation
-          5% had training on how to build community ownership
-          25% had training on developing policy
-          15% had training on managing diversity and conflict
-          5% had training on spiritual leadership
-          5% had training on Indian traditions and customs
-          10% had training on strategic planning.

  • Desired Future BoD Training

The UIHPs also had the opportunity to present the top needs with regards to board training.

Top three needs were:
1) Fundraising and responsibility
2) Governance vs. Management  and
3) Level of Involvement

Although these were the top three, only 35% actually received training on fundraising and responsibility, 55% on governance vs. management, and 25% on level of involvement.

Bottom three desired Training topics:
1) Managing Diversity and Conflict/Spiritual Leadership (tied)
2) Legal/Ethical Issues, and
3) Indian Customs and Traditions/ Decision Making Capabilities/ Role of Non-profits (three-way tie). 

The entire list of board training needs reported is as follows:

-          65% of the UIHPs needed Board training on Fundraising and responsibility
-          41% on Governance vs. Management
-          35% of Level of involvement
-          29% on Building  Community Ownership
-          29% on Developing Policy
-          24% on Board self-evaluation
-          18% on Indian Customs and Traditions
-          18% on the Role of Non-profits
-          18% of Decision Making Capabilities
-          12% on Legal/Ethical Issues
-          6% on Spiritual Leadership
-          6% of Managing Diversity and Conflict

C) Collaborations & Partnerships

  • Activity in Mainstream Communities
    Nearly fifty percent of all UIHPs reporting indicated that the respective American Indian/Alaska Native Community is Active in the larger mainstream community.
Activity of AI_AN people in
  • State Government Partnerships

Of the UIHPs surveyed 95% reported some form of collaboration with the state government and 85.7% receive grants and/or contracts from a state agency.

  • Academic & Educational Partnerships

Of the UIHPs surveyed, 85.7% reported a relationship with a university on a variety of partnership activities:

-          68.4% of these UIHPs partner with University to offer apprenticeship positions
-          57.9% have research/evaluation projects
-          52.6% use Universities to recruit for positions
-          52.6% have projects to increase some type of health awareness
-          42.1% partner on community development work
-          36.8% partner on training efforts
-          15.8% use Universities to assist with providing clinical and support services

  • Urban-Tribal Partnerships

Eighty one percent (81%) of UIHPs reported relations with tribes and partner in a number of ways:

-          63.2% of these UIHPs partner with Tribe(s) on Medical Services
-          57.9% partner on Fundraising Activities
-          57.9% partner on Cultural Activities
-          57.9% partner on Advocacy efforts
-          15.8% partner on Awareness Activities
-          15.8% collaborate on programs or service access (i.e., referrals)
-          5.3% partner on Training

  •  Local Government/Counties

Of the UIHPs reporting, 47.6% receive a grant and/or contract from a County Agency. Most of these grants/contracts are in the area of:

-Health (90%)
-Education (20%)
-Emergency Services (20%)
-Specialty programs (30%; i.e., Behavioral Health and Title VII).

The Health contracts or grants were for Outpatient Services (33.3%), Outreach and Referral (33.3%), Promotion and Prevention (22.2%), HIV/AIDS (11.1%), Mental Health/Counseling (66.7%), Nutrition (11.1%), Substance Abuse (77.8%), and Traditional Medicine (11.1%). A number of UIHPs also had other types of county grants/contracts including immunization, healthy start, elderly, and child protection services.

Of the UIHPs reporting, 90.5% have a relationship with a local government and 47.4% reported having grants and/or contracts from local agencies. Again, most partnerships were in the area of
- Health (81%)
- Development (14.3%)
- Justice (38.1%)
- Social Services (61.9%)
- Administrative (19%)
- Various community projects (25%; i.e. Homelessness, Cultural, etc).

Of those UIHPs receiving local Health grants and contracts; they included Outpatient Services (16.7%), Referral and Outreach (16.7%), Promotion/Prevention (33.3%), Nutrition (50%), Lab (16.7%), Pharmacy (16.7%), Mental Health/Counseling (16.7%), Substance Abuse (16.7%), Tobacco (16.7%), Youth Health Programs (16.7%), and other programs such as Dental and Medical Supplies.

  • Partnerships with other Native Organizations

Every single UIHP surveyed (100%) had multiple Native organization partnerships, which further shows the collaboration between the UIHP and the surrounding community. These partnerships with non-Indian organizations include a number of activities:

-          95.2% have joint efforts
-          81% have information exchange
-          33.3% have sub-contracts
-          14.3% have pro-bono activities
-          28.6% have sub-grants

  • Partnerships with NON-Native Organizations

Ninety-five percent (95%) of UIHPs surveyed had multiple non-Indian organization partnerships. These partnerships with non-Indian organizations include the following:

-          90% have joint efforts
-          70% have information exchange
-          40% have sub-contracts
-          40% have pro-bono activities
-          25% have sub-grants

D) Media and Communications 

Although the majority of UIHPs work with media to increase awareness of their activities in the community (85.7%), it is limited. Of those UIHPs that work with media, 88.9% do so for special events only. Fortunately, in marketing for special events, UIHPs use diverse methods of communicating to the public and 88.9% work with both native and non-native media. Of those UIHPs using native media: 

-          72.2% use native newspapers for marketing
-          16.7% use native magazines
-          44.4% use native internet sites
-          27.8% use native television
-          55.6% use flyers and other social marketing strategies within native community
-          44.4% use native radio stations

  • Marketing & Awareness

UIHP marketing within the broad mainstream or non-native community includes the following:

-          94.4% use non-native newspaper
-          22.2% use non-native magazines
-          61.1% use non-native internet sites
-          72.2% use non-native television
-          66.7% use flyers and other social marketing strategies within the non-native community
-          50% use non-native radio stations

E) Current  Funding Sources and Distribution

On average, the UIHPs reporting rely on Indian Health Services (IHS) for half of their funding, however there is incredible variability (Mean= 50.59, St Dev=33.71). Other funding sources show as much variability with federal grants making up 14.50% (St Dev = 19.37), Medicaid 9.06% (St Dev=12.03), and 3rd Party billing 8.86% (St Dev=12.28). The wide variability means that some UIHPs have many sources of funding revenue and are more diversified while others have very few sources and rely more heavily on IHS.Overall, federal grants are the largest funding source for UIHPs, second to IHS. However, UIHPs only receive an average of 14.50% of their revenue from federal grants.

UIHP Funding Sources
  • Foundational Grants

Although foundation funding (grants and donations) is small for UIHPs, 38% of all UIHPs reporting received some foundation funding. Of those, 100% get local funding and 37.5% get national funding.  This begins to paint a picture of how the UIHPs fit into the overall community and most UIHPs have some level of partnership at local, state, and/or tribal levels.

  •  State Grants 

Most of these state grants/contracts received were in the area of Health (95%), however UIHPs also partnered on projects dealing with:

-          Justice (35%)
-          Community Development (10%)
-          Social Services (65%)
-           Administration (25%)

State grants or contracts in the area of health included:

-          Outpatient Services (41.2%)
-          Referral and Outreach (35.3%)
-           Cancer (23.5%)
-          Promotion/Prevention (29.4%)
-           HIV/AIDS (35.3%), Lab (11.8%)
-           Mental Health/Counseling (35.3%)
-           Nutrition (23.5%)
-           Pharmacy (5.9%)
-           Optical Services (5.9%)
-           Substance Abuse (47.1%)
-           Tobacco (23.5%)
-           Youth Health Programs (17.6%)
-          Elders Support (5.9%).

F) Federal Grants/ Funding

In aggregate, Federal Funding represents a significant portion of UIHPs overall budget (again, see variability restraints as discussed above).  NCUIH wanted to understand where federal funding was being obtained and identify ways to improve federal funding for UIHPs. 

The reporting UIHPs receive the following IHS grants:

-          76.2% reported receiving a grant for Behavioral Health Programs
-          4.8% for Chief Clinical Consultants
-          14.3% for Child Health/Pediatrics
-          4.8% for Clinical Information Resources
-          0% for Clinical Support Staff
-          0% for Consumer Health Information
-          33.3% for Dental
-          0% for Desert Visions Youth Wellness
-          85.7% for Diabetes
-          9.5% for Elder Programs
-          9.5% for Health Care Information
-          42.9% for HIV/AIDS Program
-          9.5% for Injury Prevention
-          0% for Kidney Disease Program
-          9.5% for Maternal Child Health
-          14.3% for Womens Health
-          4.8% for Medical Imaging
-          0% for National Marrow Donor Program
-          0% for National Pediatric Height and Weight Study
-          23.8% for Nursing
-          0% for Nutrition and Diabetic Training
-          4.8% for Optometry
-          9.5% for Pharmacy
-          4.8% for Pharmacy Issues
-          0% for Physician Assistant Position Report
-          0% for Research Program
-          33.3% for Other (immunizations, child/youth programs, health promotion/disease prevention)

  • Grants from DHHS Sub-Agencies OTHER than I.H.S.

The UIHPs reported receiving grants from the following federal divisions:

-          4.8% received grant funding from the Administration for Children and Families
-          9.5% from the Administration on Aging
-          0% from the Agency for Healthcare Research and Quality
-          0% from the Agency for Toxic Substances & Disease Registry
-          28.6% from the Centers for Disease Control & Prevention
-          9.5% from the Centers for Medicare & Medicaid Services
-          0% from the Food & Drug Administration
-          28.6% from Health Resources & Services Administration
-          4.8% from the National Institute of Health
-          33.3% from Substance Abuse & Mental Health Services Administration
-          4.8% from Federal Emergency Management Agency

  • Grants from Federal Departments

The UIHPs reported receiving grants from the following federal departments:

-          0% received grant funding from the US Department of Education
-          0% from the US Department of Justice
-          0% from the US Department of Defense
-          0% from the Bureau of Indian Affairs
-          5.9% from the US Department of the Interior)
-           23.5% from other federal departments (i.e., Department of Labor and Drug Administration).

G)Technical Assistance Needs on Grants Opportunities

  • Main obstacles identified for applying to Government Grants included:

1.       Lack of personnel to write grants
2.       Eligibility to apply
3.       Lack of personnel to implement the grant.

  • Major obstacles to implementing government programs once the grant was obtained.

1.       Too many tasks for too little money
2.       Lack of adequate grant funding
3.       Lack of personnel

  • Perceived  responsiveness and  cultural appropriateness of  federal agencies (other than I.H.S)

Of those UIHPs reporting, 40% deemed that SAMHSA was the most culturally appropriate agency and 46.2% deemed SAMHSA as the best prepared from a grants management perspective. HRSA and CDC tied as being the best at training (28.6%).

Further, UIHPs recommended a number of options for improving federal grant writing trainings including 1) Technical writing skills, 2) Improving information dissemination, 3) Improving the RFPs cultural tailoring, 4) Finding and using local data for the application, and 5) Better Guidance from the Project Officer. Nearly twenty percent (18.8%) of UIHPs reporting indicated that they did not know that federal grant writing trainings existed. Finally, UIHPs recommended the top initiatives they would like to see funded to include (in order of importance) 1) Dental, 2) Elder Care and Aging, and 3) Traditional Medicine.

H) e-Readiness

  • Indian Community Access to Internet/e-mail

According to UIHP respondents, Within their community, nearly sixty percent of American Indians have access to Internet and Email (59 and 57%, respectively).

  • Access  to Internet @ UIHP  & Staff

Approximately 95% of all staff has email access.

UIHPs use the following methods for Internal Operations:

-          41.88% using Email/PDF
-          2.64% Fax
-          11.50%Written
-          33.00% Face-to-face
-          2.67% intercom
-          2.86% memos
-          16.40% phone/cell

UIHPs use the following methods for External operations:

-          48.75% Email/PDF
-          6.07% Fax
-          25.31% Telephone/Cell
-          10.93% Written letters
-          14.47% face to face
-          .46% text

100% of UIHPs reporting has their own server, with a specific email for work used by staff, and most with an organizational website (94.1%). UIHP websites offer General UIHP Information (100%), Programmatic Information (100%), Contact Information (87.5%), News/Events (81.3%), Job Opportunities (31.3%), Community Resources (43.8%), Online Services (25%), Community Stats (25%), and Forums (12.5%).

III. Methodology

NCUIH team decided to structure the UIHP Survey following the analysis and recommendations stemming from both the NCUIHs Strategic Plan 2006-2011 and NCUIHs Business Plan 2007-2012.   In the first internal project meeting, it was decided that the Survey would tackle all of the main topics affecting all UIHPs in common.  These topics included: UIHP history, internal operations, collaborations and partnerships; media and communications; grants & funding; technical assistance; funding sources and distribution and e-Readiness (ability to use the Internet and electronic means to carry out operations), among others. The labor division among the team members was established in May 2008. During June and July the team worked on the structure of the Survey. By early august, the first draft had been created.

The first document was sent to Urban Indian health Specialist, and former executive director of the Indian Walk-In Center of Utah, Ms. Dena Ned, PhD Candidate. Using her previous experience dealing with UIHPs, Ms. Ned reviewed the Survey to ensure the questions were culturally appropriate. Ms. Ned edited the survey to clear up any confusion.  In September--following the revision,--the NCUIH team incorporated changes to the document and then sent the same to Jami Bartgis, PhD, who at the time collaborated with the Indian Health Care Resource Center in Tulsa, Oklahoma.   Dr. Bartgis completed the review in October, 2008, when she officially accepted the position of Director of Technical Assistance and Research at NCUIH. The Survey was also shared with the Evaluation Consultant, Roger Schimberg, for review and feedback. NCUIH members reconvened in mid October to finalize the Survey and have it ready to be sent to all of the UIH Programs.

NCUIH then sent the Survey to the Executive Directors of all of the 36 Programs electronically. The Survey contained a message explaining the goals, objectives and the rationale behind the project. The message presented precise instructions for the survey as a whole as well as for each one of the sections. Programs were offered a $500 stipend for completing the survey.The original deadline for the Survey Collection was November 25th; however, many programs werent able to complete it by the indicated date, thus the projects Director extended the deadline. All surveys were received by April, 2009.

Surveys were collected both electronically as well as via fax.   Received documents were turned into PDF files and stored in an electronic folder. By the same token, the NCUIH team created a Tracking device to keep count of the document received and stored.Approximately  60% of the programs (21 reporting) returned the survey, which improves the generalizability of the data aggregation and reporting on the current status of the UIHPs operations.

IV. Data Limitations

The primary limitation of the data is the small sample size. There were 21 reporting UIHPs, representing nearly 60% of the UIHPs. Given that there are so few UIHPs overall, this number is a very reasonable sample of the population. However, a sample of 21 is relatively small and any outlier can change the data significantly. The second limitation is that there is incredible variability throughout the data and is tied to the first limitation of small sample size. Variability means the range of differences between the UIHPs reporting. This is extremely important to take into account when considering the generalizability of the data. The overarching goal of this data reported in aggregate is to provide a snapshot of how many of the UIHPs are functioning. However, given the variability, the snapshot may not be representative of all programs. This was particularly evident in funding distribution. For example, some UIHPs have 100% IHS funding while other has less than 10%. Although this data describes an aggregated snapshot of the UIHPs, it is critical to remember that the aggregate is not representative of every UIHP as there is much diversity in the organizational structure and functioning.

V. Conclusions & Recommendations

This data suggests that UIHPs are an integral part of the broader community they serve and provide services to native people who reside in urban settings for reasons that may be outside of their control. The data highlights the many challenges UIHPs face in obtaining funding and implementing projects and suggests wide variability between programs in both needs and resources.  This preliminary survey provides basic information about the infrastructure and systems of Urban Indian Health Programs. However, much more information is needed to understand the complete state of Urban Indian Health. 

The last needs assessment on urban Indian Health was conducted in 1981. The methods of the 1981 needs assessment included examining assessments administered by UIHPs, academic literature reviews, collection of some archival data from 1970 US Census and IHS, and the interviewing of eight UIHPs.  The 1981 report primarily focused on access barriers, including economics, geography, advocacy, provider, discrimination, and cultural barriers in various segments of health care (i.e. medical, dental, emergency, mental health, etc.). An updated needs assessment should expand beyond the 1981 report by fully examining the system infrastructure and service capacity, major health disparities, demographics of urban Indian people and service availability, access, use, and outcomes.  In addition to a literature review and collecting archival and survey data for UIHP consumers, it will be critical to assess communities that do not have a UIHP, as well as, examining the various levels of the system (i.e. consumer, provider, agency,).

More fully examining the demographics of urban Indian people is critical in determining not only where services should be provided, but also what type. Demographic data should include, at a minimum, a correct count of urban Indians by city, employment, education, marital status, number of children, economic status (including housing), and health insurance status.  Examining demographic data is the first step to determining which communities need to be targeted for further assessment.  Additionally, archival data can provide a clearer picture of the state of health for Indian people. Archival data should include, in addition to the IHS and US Census, the county, state, and national data from health and social service agencies.

Service access was thoroughly examined in the 1981 report; however, service access, utilization, and availability should be more clearly delineated. These three concepts are imperative for helping identify the health status of American Indian people and are not interchangeable. For example, a patient may have a particular service available in their community, however they may not be able to access the service. Likewise, a patient may be able to access a service but may not utilize the service for a variety of reasons that include environmental barriers and cultural barriers.  Perhaps most importantly, the 1981 report had no focus on health outcomes for American Indian people. Available, accessible, and utilized health care is ineffectual if people do not receive positive outcomes.

Today, we must demand that the available health care people access and use is appropriate, needed, and results in improvements in health. Therefore, examining system infrastructure and service capacity, major health disparities, demographics of urban Indian people and service availability, access, use, and outcomes of health care is a necessity in determining the current state of health for urban Indian people. A comprehensive national needs assessment for Urban Indian Health is a critical next step.