THE INTEGRATION OF MEDICINE AND CULTURE
United Indian Health Services

Arcata, California
Primary Contact: Timothy Nicely, MD
Age: 52
Years in Practice: 24 years
Medical School: University of Southern California
Residency: Deaconess Hospital, Medical College of Wisconsin, Milwaukee, Wisconsin

The history of the United Indian Health Services, Inc. (UIHS) in inextricably intertwined with the history of the Indian tribes in far northern California. The history of UIHS officially begins in the late 1960s when development was initiated as a solution to the ongoing health crisis of California's Indian population. Government health assistance for the region's native people had been terminated in 1954, leaving the Indian people with inadequate health resources. Fortunately, the '60s and '70s welcomed a growing awareness of Indian issues and set the stage for UIHS and other related programs.

In 1972 UIHS built a clinic at the Trinidad Rancheria. The American Indian community actively supported the construction with donations, volunteer labor and fundraising efforts. As demand for programs and services increased UIHS outgrew its space and began planning for its current Health Village. Potawot is the Wiyot tribal name for the Mad River, which flows just to the north of the Potawot Health Village. Today, even as a large, thriving medical center, UIHS continues to achieve its goal of incorporating traditional values and customs into its daily activities. CEO Jerry Simone explains, "The American Indian structures indigenous to the area are the basis for the design of the clinic. By placing culture first, and then integrating the clinical requirements, the design makes an emotional connection between two worlds."

The Board of Directors of UIHS has forged a very clear mission statement: "UIHS commits itself to providing culturally sensitive, high quality and comprehensive health care services to the Indian Communities of Humboldt and Del Norte Counties."

The Indian tribes that founded UIHS have lived in Humboldt and Del Norte counties for hundreds of years. Abandoned by the state, they were left without health care for many years. First incorporated in 1970, UIHS is a tribally owned and governed Indian Health Care Service with a main facility-Potawot-and five sites in outlying areas. In its 35-year history, it has grown from a staff of less than a dozen people to a comprehensive health care of more than 180 employees. It is governed by a Board of Directors that includes Indian community representatives from five different regions and Tribal Government representatives from each of the primary tribes and rancherias.

Many of the values of the Native American culture are shared by the physicians and staff of UIHS. As Dr. Nicely explains, "Very early on the Indians welcomed us and took us in as part of the community, and part of their extended family." He personally felt privileged to be selected as the 2003 California Family Physician of the Year by the CAFP. He was chosen for "exhibiting the finest qualities of family physicians and for going above and beyond in service to patients, colleagues and community." After he received the award he was honored by the Indian tribes in a special ceremony. "As the cultural centerpiece for the local Indian people, Potawot is true to their traditions and values. The integration of American Indian culture into a modern health care facility is part of our promise to our clients."

UIHS serves American Indians in Humboldt and Del Norte counties, about 300 miles north of San Francisco. With a combined population of nearly 150,000, there are approximately 15-20,000 American Indians. Potawot Health Village is in the city of Arcata, with a population of around 16,000.

In 2001, UIHS dedicated Potawot Health Village — a dream many years in the making. Located on 40 acres, Potawot is more than a medical building; its design embodies its core values, including the restoration of the surrounding landscape, programs to integrate traditional knowledge into daily activities, and a consistent focus on enhancing strong American Indian culture.

The 20 acres adjacent to Potawot is a designated restoration area to enhance and protect the wetlands, uplands and meadows and to create space for wildlife habitat, cultural education, recreation, gathering, food production and meditation.

The entire range of patients, from newborn to elderly, seeks care through UIHS, although it is often the women who initiate visits. With the exception of the 20% who are non-Indian members of Indian households, all of the patients are American Indian. Most of the providers feel fortunate to work with "extended, intact families who support one another in many, many ways." It is typical for many generations of a family to visit at the same time.

One physician notes, "It is refreshing to be in a setting where patients are in control, rather than physicians. Patients don't show any special deference to us." Others note that it takes a long time for patients to trust health care providers because they have had poor treatment in the past from Anglo doctors. As the Chair of the UIHS Board of Directors describes the relationship from her perspective, "It usually takes new doctors a while to learn our ways, but when they do, they become part of our community and cry along with us when we lose someone."

Understanding the spiritual basis for change is also important to the Potawot Diabetes Prevention Program. To prevent and treat this disabling disease, "we rely on community members to be mentors and coaches to form a spiritual foundation for change," explains Dr. Raymer.

UIHS is a family medicine Indian Health program with four FTE physicians and four mid-level providers who work the equivalent of 7.5 full time clinical employees. In addition, there are specialists on contract for specialty clinics such as ophthalmology and optometry, rheumatology, and allergy.

Comprehensive outpatient services provided by this group include: medical, dental, nutrition, mental health and substance abuse, outreach, and diabetes case management. Mid-level providers are utilized primarily in the outpatient FP clinic setting. The FNP manages the practice's perinatal outreach program. RNs act as triage nurses and clinic nurse managers, while the PHN/RNs in the outreach and diabetes programs work as case managers.

The practice provides inpatient services 24/7 at the local hospitals in Arcata, Eureka and Crescent City, including both low- and high-risk obstetrics. At these hospitals physicians make rounds first thing in the morning, with clinic services generally four-and-a-half to five days per week.

Additional services provided in the office include:

• In-house lab and phlebotomy for labs sent to LabCorp
• Limited OB ultrasound at Smith River
• Flexible sigmoidoscopy
• Colposcopy, cryotherapy, LEEP
• Circumcision
• Vasectomy

The practice has considered providing stress EKG, but is unable to due to the lack of training and space. However, there is one physician who performs this procedure at the hospital in Crescent City. If a patient needs a service not provided by United Indian Health Services the office helps make appointments and utilizes a referral tracking system.

Compensation and Benefits

Physicians at UIHS can choose to become an employee of UIHS or join the Public Health Service. For physicians who are employees of UIHS, the beginning base salary is usually $95-100K. The Indian Health Service provides an annual bonus of $8-10,000. UIHS physicians in Del Norte County also receive a location differential of $10,000 annually. UIHS-employed physicians receive paid health insurance, life insurance, and holiday, jury duty and bereavement pay. They also receive supplemental disability insurance. UIHS contributes up to three percent of wages to a retirement account. Physicians also receive up to five days a year for continuing medical education and an annual allocation of $1,500. Physicians earn personal leave on a graduated scale, depending on length of employment, of between 16 days-per-year the fi rst year up to 26 days-a-year after five years.

Three of the eight physicians are Commissioned Corps Officers in the US Public Health Service. This option offers significant advantages for those doctors who intend to work in Indian Health as a long-term career. The annual salary and bonuses are generally better; vacation, health care, and CME benefits are approximately the same as UIHS employees. Retirement benefits are available for service of 20-30 years (basically the same package as military officers). UIHS is a loan repayment site for the Indian Health Service.

Hours/Practice Flexibility

While most of the UIHS physicians work full-time, several work part-time and others have non-clinical responsibilities. Full-time is considered four days a week. Several of the physicians spend one day a week at one of the outlying clinic sites. For Dr. Nicely, a typical week involves one day at the Weitchpec Clinic, one day a week doing administrative work, and the remaining 3 days at Potawot Clinic. He has call every fifth weekend. He also does hospital rounds most mornings. With his active involvement in the local community, the Indian community and the medical community, Dr. Nicely says "life is very full."

Employees

All UIHS employees are considered part of the team and receive similar benefits. All serve the same communities and provide a range of health care services. It is well-recognized that no one can function autonomously and expect to provide adequate care. Dr. Nicely adds, "In health care, it 'takes a village.'"

Balance

When asked about balance Dr. Nicely says that spending 60-70 hours a week in medicine "has not been a significant personal conflict because that is who I am — a physician." He admits to not being able to spend as much time with his family as he would like, "but the primary priority for my personal time is my family." As he describes, "When I get involved, I go for it, both personally and professionally." He founded a local chapter of Physicians for Social Responsibility and "finally learned that I couldn't sustain it all by myself."

Dr. Nicely and his wife are involved in an interfaith gospel choir, and when their children were young they were involved in the children's choir. "Doing things as a family was one way that I could stay connected with them and the community," says Dr. Nicely. Other UIHS physicians comment that working with UIHS allows them the time to develop other interests and to nurture precious family time. There is a predictability to the schedule which may not be enjoyed in other settings.

UIHS physicians are employed by the clinic's tribal owners, and some choose to become PHS Commissioned Corps officers. Important qualifications for employed physicians or prospective new partners include board-certified FP with OB skills, and an interest in serving the underserved. Additionally, the clinic has a preference for Native Americans, or those physicians with a strong interest in and curiosity about learning Native American culture and belief systems. Every physician who has ever been made partner is still with the clinic.

When determining the need for additional physicians or providers the clinic looks primarily at the volume of demand and expansion of services, i.e., addition of new clinic sites or hours. Currently, patients choose the physician they would like to see. According to Dr. Nicely the clinic has not yet "closed" any physician's practice to new patients; though this may soon become necessary. In order to promote and establish the relationship of a new physician in the practice with community physicians, the clinic sends letters of introduction and makes personal introductions.

The primary needs of the community are diabetes, hypertension, obstetrics, immunizations and dental care. These needs are determined via top 10 diagnoses and visit types, community surveys and chart audits. The clinic meets these needs in a number of ways, including diabetes and pre- and post-natal case management, patient education, community health representatives (outreach program), and collaboration with other agencies.

Dr. Nicely finds the community to be "wonderful and appreciative" and adds, "After many years of service and association, the Indian community has become my second extended family." The community at large is also a good fit for him. The progressive, small town of Arcata, as well as Humboldt State University adds significantly to the cultural options for recreation and entertainment.

Within the community UIHS is highly respected as an important health care program, even more so after the opening of the new Potawot Health Village. UIHS sees the Health Village as much more than a medical building. "It is as much an artistic expression of dreams for a healthy American Indian community as it is a way to provide modern health care to clients."

UIHS doctors are highly respected members of the local medical community. Practice-wide community involvement by UIHS includes:

• Dental screenings and community nutrition education in Headstart and schools
• Coordination with tribal agencies
• Active involvement on local hospital medical staffs (all of the doctors are highly respected and involved); in the local medical society, and with the local independent practice association.

Dr. Nicely cites his additional training and work in obstetrics as one of his most fulfilling accomplishments. He is also intensely involved in developing the Turtle Health Plan, an Indian-owned and operated Medi-Cal managed care plan. Based on a capitated plan in Washington State, the Turtle Health Plan covers 25,000 lives, and most of the specialists in the county are involved in the plan. Dr. Nicely will definitely stay involved in Turtle Health to make sure it is successful. For the future, Dr. Nicely would like to stay involved in (although not lead) the UIHS clinic redesign efforts that are currently underway. "I am still trying to learn that personal success as a leader means sharing and giving power away to others."

Immunization rates, diabetes parameters, and Government Performance and Results Act indicators are all important tools used by UIHS to measure outcomes. The results of these indicators are reported to Indian Health Service of California, the state Indian Health Program and JCAHO. Internally, they are used as part of the ongoing process of quality improvement. Patient satisfaction is also measured by the clinic in the form of time studies, overall patient satisfaction surveys and perinatal/prenatal care measures.

The latest clinical information is accessed primarily via the Internet. The clinic's library is another important source of information, and includes an online UpToDate subscription and Epocrates.

UIHS maintains a diabetes registry in conjunction with the IHS. At this time the clinic is not involved with any research protocols. According to Dr. Nicely it is rare to conduct research at UIHS, "primarily due to the fact that Indian people are very sensitive about being used as 'guinea pigs.'"

To ensure that patients receive excellent care from others to whom they are referred, recruitment of excellent physicians and FNPs/PAs is done very carefully, and ongoing peer review, case reviews and discussions occur regularly.

In addition, regular CME attendance by all providers is encouraged. A variety of CME opportunities are available both locally and nationally. There are weekly grand rounds at the hospital, IHS-sponsored programs throughout the country, and other CME conferences through the usual sources. Each physician chooses his/her program(s) each year based on personal needs, with an emphasis on programs that will enhance knowledge and skills useful to the practice at UIHS.

One method used to foster a team approach when treating/referring patients is the open discussion of patient care among members of the primary care team. This happens informally all the time, as well as in the context of roundtable case discussions. Additionally, consultants are chosen who have demonstrated willingness to communicate back with the primary care provider, and to involve the clinic in the ongoing management of the patient's care.

Relationships with Other Health Providers

Since UIHS is owned by Indian tribes there is a strong relationship between the Indian culture and the culture of American medicine. The physicians here understand that traditional medicines can be used to complement pharmaceuticals. They also understand that many of the tribal traditions such as basket weaving and sweat lodges are healing in themselves because they put the patient in harmony with nature. As Paula Allen, UIHS Traditional Resource Specialist, explains, "I was one of the lucky ones who learned our traditions from my mother and grandmother. We believe in the healing power of our culture, and I try to pass on our ways to my daughter and the kids at our camps."

One of the special integrative aspects of UIHS is its organic Community Food Garden, which is on one-and-a-half acres of Potawot Village. The adjoining herb garden provides the UIHS community with traditional native and European culinary and medicinal herbs. Twice a week there is a popular fresh food market outside the front doors of Potawot Health Clinic.

Hospital Relationships

The following hospitals are affiliated with UIHS:

• Mad River Community Hospital, Arcata — chosen for its proximity to the clinic and friendliness to Family Medicine
• St. Joseph's Hospital, Eureka — chosen for its heart program and the fact that many UIHS patients live in Eureka and are closer to St. Joe's
• Sutter Coast Hospital, Crescent City — chosen for UIHS patients living in Del Norte County

Dr. Nicely and his fellow staff have extensive involvement in the affiliated UIHS hospitals. Physicians hold active medical staff privileges at Mad River, with courtesy privileges at the others. All the doctors serve various functions on medical staff entities. Dr. Nelson is the current Chief of Staff at Mad River Community Hospital, while Dr. Nicely held the same title years ago. Additionally, UIHS admits its own patients to the hospital, and the physicians provide back-up coverage for admissions of unassigned patients. Back-up coverage of OB/GYN emergencies is provided by Dr. Nicely, who has C-section privileges.

Relationships with University/Other Educational Settings

UIHS has no formal affiliations with any university; however, it has provided teaching opportunities in the past for PA/FNP students at the UC Davis program. The program is in close proximity to Humboldt State University and College of the Redwoods. Both schools rotate students from their nursing programs through the clinic, and students from other disciplines participate regularly in the rich cultural, wetlands restoration, and community garden activities.

Relationships with Medical Students and Residents

Teaching is a daily part of UIHS' professional relationships with its PA/FNPs. In the past Dr. Nicely has worked with medical students in various capacities, depending on the level of the students' training and interests. Work with med students and residents happens rarely, however. He has an interest in combining third year residents with medical student precepting, in order to relieve some of the time burdens required for teaching.

UIHS is currently improving its decision-making process with the addition of new biotechnology equipment and services. Dr. Nicely explained that new services are usually approved if the service fits into UIHS' primary care mission, the program has a clinician with the required skills, and the new service is at least a "break-even" proposition financially.

The most recent addition was the purchase of an office ultrasound machine, and UIHS now offers limited OB ultrasound at the Smith River office. The machine was an obvious choice as the service is reimbursable and fits well into the clinic's delivery of prenatal services.

Patient Communication

UIHS has a website ("an ongoing work in progress"); however, it is not used often in the medical department. It is best utilized for contact information, and also features the clinic's Potawot Health Village project and the wetlands restoration/community garden project. Currently, UIHS does not use e-mail or messaging with patients, physicians, or health care providers. Dr. Nicely anticipates that with the coming of an electronic health record the clinic will make much greater use of these tools for communications with patients and colleagues.

Practice Management Technology

RPMS, practice management software provided by the Indian Health Service, and its Patient Care Component, have been used for several years. While not an EHR, it has provided a nice system of organizing problem lists and creating reports from its registries and aggregate patient data. The RPMS system is also used for scheduling and coding. Other software is used for billing. Each of the providers has a PC at his or her desk, as well as a PDA. Both are used primarily for information access (Epocrates, UpToDate) and communication via e-mail.

UIHS often receives IT additions as a result of various grants (IHS, Tides Foundation). At the moment, the biggest advancement is the addition of a combined Next Gen patient management and the electronic health record system, which is slated to go live in the next several months. An EHR will revolutionize how UIHS functions in its day-to-day patient care/clinic work, and will allow for better integration of the clinic's practice management, medical charting, and disease management functions.

To ensure convenience, comfort, and efficiency for patients UIHS periodically issues patient surveys to solicit feedback, both positive and negative. UIHS is currently undergoing a process of organizational redesign, focusing on exploring the core values of both the staff (including physicians) and the community.

Practice Management

The CFO and CEO are ultimately responsible for the financial health of the practice. In addition there is a department devoted to finance and billing. UIHS annually reviews the organization’s needs to determine the best way to cover those needs and services financially.

Financial Management

Financial management is handled by the CEO and finance staff with regular reports to the UIHS Board of Directors.

Other Practice Resources

Legal issues are handled by an attorney. UIHS uses an independent auditor and also undergoes periodic audits by IHS, the California Rural Indian Health Board and the state Indian Health Program. A human resources department deals with all employment issues.

Governance/Physician Leadership

Aside from the medical director (who is the designated leader for the overall program) and the associate medical director in the Smith River Clinic, physician leadership is delegated, somewhat informally, based on projects and tasks assigned. The medical director is actively involved in both departmental and organizational decision-making processes. He attends and reports to the monthly Board of Directors meeting.

Marketing

Strategic planning is done periodically. Marketing targets primarily American Indian people and their families; however, there is not a dedicated PR/Marketing program. Dr. Nicely does feel that there are aspects of the clinic that would lend themselves to this kind of an effort. One effective tool is The Acorn Basket, a periodic newsletter featuring health-related topics and services offered at UIHS.

Although UIHS is a unique program it must stay competitive with local primary care options, such as the other community health centers. One reason that the Potawot Health Village was built was so that UIHS could competein its local marketplace.

Coverage/Reimbursement

The percentage of the practice covered by various payers can be broken down as follows: Private health plans: 25%; Medicare: 30%; Medi-Cal or other state plan: 25%; and self pay/no insurance: 20%. All third-party insurance is fee-for-service. Self-pay is largely written off as uncompensated care, with the exception of a few services for which there is a co-pay (pharmacy, glasses, dental lab). Those who are un- or under-insured are encourage to apply for Medi-Cal or other third-party coverage. UIHS receives large annual subsidies from Indian Health Service.

UIHS belongs to a local IPA, which has been particularly helpful in getting local specialists on board with the aforementioned Turtle Health Plan, due to be operational very soon. The IPA does most of the direct contracting with private health plans and other contracts are negotiated by various individuals and departments. The fiscal/billing department oversees insurance contract management.

 

Primary Contact:	Tim Nicely, MD
	United Indian Health Services
	Arcata, California

Dr. Corinne Frugoni, United Indian Health Services, Arcata, California

Pat Girczyc, FNP, Outreach Coordinator, United Indian Health Service, Arcata, California

Dr. Terry Raymer, United Indian Health Services, Arcata, California

Dr. Kathleen Terra, United Indian Health Services, Arcata, California

Practice Staff:

• Paula Allen, Traditional Resource Specialist, United Indian Health Services, Arcata, California
• Susan Dahl, MHA, RHIA, California Rural Indian Health Board, Inc., Sacramento, California
• Susan Golledge, RN, Community Health Care Services Manager, United Indian Health Service, Arcata, California
• Sherri Provolt, Clinical Services Division Director, United Indian Health Services, Arcata, California
• Jerome J. Simon, Chief Executive Officer, United Indian Health Services, Arcata, California
• Kathy Stone, NP, Coordinator, Maternal and Child Health Programs, United Indian Health Services, Arcata, California

Others contacted for this profile:

• Amos Tripp, Legal Counsel, United Indian Health Service, Arcata, California
• Maria Tripp, Chairman, Board of Directors, United Indian Health Service, Arcata, California

Other Resources:

• www.uihs.org
• "A Place of Our Own"-brochure describing Potawot Health Village
• "Client Handbook: Respecting Health & Wellness, Harmony & Tradition"
• "Growing Healthy Communities," Ku' wah-dah-wilth Restoration Area Self-Guided Tour Booklet
• The Acorn Basket, newsletter of UIHS