maternal infant early childhood home visiting - aihc-wa · final report – tribal and ......

FINAL REPORT

2013

American Indian Health Commission

for Washington State 8/1/2013

Healthy Communities: Maternal Infant Early Childhood Home Visiting

American Indian Health Commission for Washington State

Final Report – Tribal and Urban Indian MIECHV - P a g e 1

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The American Indian Health Commission (AIHC) for Washington

State is a Tribally-driven non-profit organization with a mission of

improving health outcomes for American Indians and Alaska Natives

(AI/AN) through a health policy focus at the Washington State level.

AIHC works on behalf of the 29 federally-recognized Indian Tribes and

two Urban Indian Health Organizations (UIHOs) in the state. The AI/AN

population continues to experience poor health outcomes and the highest

overall mortality rates than any other population in Washington. AIHC

serves as a forum where a collective Tribal government voice is shaped on

shared health disparity priorities and Tribes, and UIHOs then work

collaboratively with Washington State health leaders, the Governor’s

office and the legislature to address these priorities. The AIHCs policy-

work improves individual Indian access to state-funded health services,

enhances reimbursement mechanisms for Tribal health programs to deliver

their own culturally-appropriate care, and creates an avenue for Tribes and

UIHOs to receive timely and relevant information for planning purposes

on state health regulations, policies, funding opportunities, and health-

specific topics. By bringing state and Tribal partners together, specific

health disparity priorities can be addressed across multiple systems—

pooling resources and expertise for greater health outcomes.

Member Tribes

Chehalis

Colville

Cowlitz

Jamestown S’Klallam

Kalispel

Lower Elwha Klallam

Lummi

Makah

Muckleshoot

Nisqually

Nooksack

Puyallup

Quileute

Quinault

Samish

Sauk-Suiattle

Shoalwater Bay

Skokomish

Snoqualmie

Spokane

Squaxin Island

Stillaguamish

Suquamish

Swinomish

Tulalip

Upper Skagit

Member Organizations

Seattle Indian Health Board

NATIVE Project of Spokane

© 2013 American Indian Health Commission for Washington State

Preferred citation: American Indian Health Commission for Washington State. (2013). Healthy Communities: Maternal Infant Early

Childhood Home Visiting: Olympia, Wa. Prepared by Ward Olmstead, Jan



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TABLE OF CONTENTS Introduction .................................................................................................................................................................. 2

Home Visiting ........................................................................................................................................................... 4

Background ............................................................................................................................................................... 5

AI/AN Maternal Infant Health Disparities ............................................................................................................ 7

Funding .................................................................................................................................................................. 8

Home Visiting Services Account ............................................................................................................................ 9

American Indian Health Commission’s Home Visiting Project ............................................................................... 10

T-U MIECHV Strategic Direction ........................................................................................................................... 12

Other Relevant Work/Projects .................................................................................................................................... 14

Healthy Tribal and Urban Indian Communities Framework .............................................................................. 14

Maternal Infant Health (MIH)-Implementation of the MIH Strategic Plan ........................................................ 14

Women, Infants and Children (WIC)-Implementation of MIH Strategic Plan Recommendations ...................... 15

Pregnancy Risk Assessment Monitoring System (PRAMS)-Improve Response Rates, Quality and Use of Data

Specific to AI/AN Women in WA State; Putting Data Into Action ....................................................................... 15

Immunizations-Assess Potential Issues Regarding Healthcare Worker Vaccination Hesitancy and

Implementation of MIH Strategic Plan Recommendations .................................................................................. 15

Methodology for Gathering Information and Knowledge ......................................................................................... 16

Survey Questionnaire and Results ......................................................................................................................... 16

Roadmap Exercise Questions and Findings .......................................................................................................... 20

A Day of Learning about Home Visiting ............................................................................................................... 25

What We Learned from the One-ay Event ........................................................................................................... 26

What We Learned from Tribal MIECHV Grantees .............................................................................................. 27

Family Spirit and Other Models of Interest ........................................................................................................... 28

Family Spirit ........................................................................................................................................................ 28

Healthy Start Program ........................................................................................................................................ 28

Family Home Visiting Program with Aboriginal Families in South Australia .................................................... 28

Challenges and Lessons Learned ............................................................................................................................... 30

Findings and Key Considerations .............................................................................................................................. 31

Recommendations ....................................................................................................................................................... 33

Next Steps .................................................................................................................................................................... 33

References ................................................................................................................................................................... 34



HEALTHY COMMUNITIES: TRIBAL-URBAN INDIAN

MATERNAL INFANT EARLY CHILDHOOD

HOME VISITING

INTRODUCTION

The American Indian Health Commission of Washington State (AIHC) is working in partnership

with the Washington State Department of Early Learning (DEL) to identify Tribal and Urban

Indian program needs, and capacity for maternal infant early childhood home visiting

(MIECHV) and other critical early learning services to support the healthy development of

American Indian and Alaska Native (AI/AN) children and families in Washington State. This

project began in May of 2012.

Washington State leads the nation with the lowest Infant Mortality Rate (IMR). However this

achievement is not consistent for all populations of the state. AI/ANs account for about two

percent of the state population according to the 2010 census. Babies born to AI/AN mothers

experience an IMR over three times that of babies born to Asian mothers and twice as high as

White mothers. (Citation) Infant mortality is associated with poor maternal health, poor quality

of and access to medical care and preventive services, and low social economic. Healthy

Communities: Maternal Infant Health Strategic Plan. This maternal infant health (MIH)

disparity puts AI/AN mothers and babies at significantly higher risk than any other racial group

in the state.

No single intervention reduces all infant mortality. However, prenatal care, participation in the

Women, Infant Children (WIC) nutrition program, and receipt of high-risk neonatal care reduce

deaths. Other proven strategies included the use of infant car seats, smoking cessation

intervention, folic acid supplementation to prevent some types of birth defects, placing infants to

sleep on their backs, and efforts to reduce preterm births (Washington State Department of

Health. Health of Washington State Report – Infant Mortality. Olympia, WA: Washington State

Department of Health; 2013, p. 1).



In September 2010, DEL completed the Washington Early Learning Plan.1 The plan included a

strategy to make evidence-based and promising pre-natal and child (birth to five) home visiting

(HV) services more accessible to at risk families. It emphasized the role of the AIHC and its

efforts to improve health status and address disparities through state-tribal collaboration,

particularly related to infants and pregnant women.

Earlier in January of 2010, the Washington State Department of Health (DOH) published the

results of a statewide Home Visiting Needs Assessment2 indicating higher health and social risks

factors exist among AI/AN pregnant women than any other racial group. Of the 29 federally

recognized sovereign American Indian Tribal governments and two Urban Indian Health

Organizations (UIHOs) in the state, eight offered evidence-based or other HV programs.

However, this information was provided by the HV programs and not necessarily by the Tribes

or UIHOs themselves.

This report is intended to serve as a tool for Tribes and UIHOs to raise awareness and

engagement in MIECHV program and system development. It will also serve as a means to

begin to understand the Tribal and Urban Indian program needs and capacity for

MIECHV, and other critical early learning services of Tribes and UIHOs.

1 Department of Early Learning. Washington Early Learning Plan, September 2010, www.del.wa.gov/plan.

2 Department of Health. Washington State Home visiting Needs Assessment Narrative, 2010, Revised, 2011.



HOME VISITING

Home Visiting is a voluntary program that serves

pregnant women, expectant fathers, children birth to

Kindergarten, parents and caregivers; supported by

state and federal funds. HV programs are a proven way

to provide parents in need with effective tools to

positively impact their children’s well-being and ensure

a successful start. Benefits of HV programs include:

Improvements in maternal and prenatal health,

infant health, and child health and development.

Increased school readiness.

Reduction in the incidence of child maltreatment.

Improved parenting related to child development outcomes.

Improved socio-economic status.

Greater coordination of referrals to community resources and supports.

Reduced crime and domestic violence.

Home visiting programs have also demonstrated that they can have a host of interconnected

outcomes that address multiple risk factors and sources of family stress. (Washington Early

Learning Plan, 2010, p. 84)



BACKGROUND

The AIHC’s public health work is focused on improving the health status of Indian people of

Washington State. The public health projects are interlinked by the overarching concept of

building and sustaining Healthy Tribal and Urban Indian Communities through interventions

that include policy, environment, system, and program changes. The AIHC uses facilitation

methods to ensure projects are Tribally-Urban Indian driven and applies values to ensure

outcomes are culturally appropriate and community specific (See diagram below).

The AIHC considers historical trauma and adverse childhood experiences significant factors in

addressing health disparities experienced by AI/ANs. Strategies to use the best data available are

sought for all projects through multiple sources. AIHC recognizes the importance of Tribal-State

Partnerships and the key public health relationships with the Washington State Departments of



Health and Early Learning to achieve improved health status and to address existing health

disparities of AI/ANs in the state.

The AIHC public health work is also rooted in the foundational efforts reflected in, AIHC’s

Healthy Communities: A Tribal Maternal-Infant Health Strategic Plan, 2010. The MIH Plan

was inspired by a goal in the AIHC-DOH American Indian Health Care Delivery Plan for 2010-

2013. The specific goal is to improve health status by decreasing health disparities for AI/AN

pregnant women and infants with appropriate, multiple approaches as a shared goal with state

government. Although the plan focus is on needs of pregnant women and children, many of the

strategies include interventions that embrace fathers and

intergenerational family members.

The MIH work was initiated in 2008 by a workgroup,

jointly convened by AIHC and DOH, which focused on

identifying strategies to address the significant health

disparities for AI/AN pregnant women and babies. In

December 2010, the AIHC published Healthy

Communities: A Tribal Maternal-Infant Health Strategic

Plan, which provides data, goals and objectives, and

identifies MIH health disparities and recommendations to

address them through culturally appropriate strategies and

continued partnership with the state. Since the then, the

MIH workgroup has continued to serve as the advisory

group responsible for guiding the efforts to address the MIH

Strategic Plan Recommendations to improve MIH

outcomes. Through a recent priority setting process, the

AIHC determined MIH HV would be the top priority and

focus for 2013-14 MIH workgroup activities. The second

priority area is the promotion of breastfeeding policy. The

purpose of its HV focus is to align with the MIH goals and

objectives and to leverage efforts to further Tribal and Urban Indian HV capacity.

American Indian (AI) Causes of Infant Mortality in Washington State compared to the population as a whole

Sudden Infant Death Syndrome (SIDS)-rate is 3 times higher Birth Defects. Death rate is 30 % higher Injury. Death rate is 5 times higher Complications in Pregnancy and Delivery. Death rate is 50% greater Prematurity and Low Birth Weight mortality Death rate is 60% higher Infectious Disease. Death rate is 3 times higher (Influenza and pneumonia 7 times higher) Digestive System Problems. Death rate 3 times higher.

Unknown Causes. Death 4.5 times higher.

AIHC, Healthy Communities: A

Tribal Maternal-Infant Health

Strategic Plan, 2010



AI/AN MATERNAL INFANT HEALTH DISPARITIES

AI/AN health disparities among infants and pregnant women are a serious problem in

Washington State. AI/AN families have been identified as having the highest risk of any of the

five racial groups. (Washington State Department of Health,

Home Visiting Needs Assessment, 2011. p. 81) As

referenced earlier, the March 2013 DOH Infant Mortality

Report reiterates the IMR disparities of babies born to

AI/AN mothers. It shows that AI/AN babies IMR has

increased since 1994, while all other racial and ethnic

groups in the state have either decreased or stayed the same.

There are multiple risk factors for infant mortality that tend

to cluster together. Further, infant mortality rates are higher

for those born to mothers who are low income, smoke, have

poor nutrition, and those that are younger than 20 or older

than 40. There is a high prevalence of these risk factors

among AI/AN women.

AI/AN pregnant women are more likely than women in any

other racial group to have late or no prenatal care, to smoke

or abuse drugs or alcohol, have a mental health diagnosis, or

have suffered abuse by a partner. (Washington State

Department of Health, 2011. p. 4) AI/ANs with Medicaid in

Washington State experience higher risk for mental health,

alcohol and or substance abuse, smoking, high preterm birth,

infant mortality and high and low birth weight babies.

(AIHC, 2010, p. 23-24)

The MIH Strategic Plan serves as the foundational plan in setting out the work of AIHC to

address maternal infant health issues. It clearly identified the high risk areas for AI/AN moms

and babies which result in poor pregnancy outcomes and strategies to address them.

American Indian with Medicaid

Top Six Risk Factors for

Pregnancy Outcome

Mental Health. Affects over 1/3 of

AI pregnant women. A risk factor

for low birth weight that affects

more AI pregnant women that any

other risk factor.

Alcohol and/or Substance Abuse

during pregnancy or 1 year

postpartum. AI births 3.3 times the

rate compared to all Medicaid

births.

Smoking-Nearly 28% of AI

pregnant women smoked during

their pregnancy, compared to 17%

of all pregnant women on Medicaid.

Threatened PreTerm Labor. The

rate for symptoms was 2 times

higher for AI births than for all births

on Medicaid.

History of Prior Low Birth Weight

Baby, Preterm Delivery, or Fetal

Death. 50% greater for AI than for

total Medicaid population.

Nutrition and Weight. About 25%

of AI births have this risk factor,

30% higher than all Medicaid.

Causes a higher risk for of

complications in childbirth from high

weight baby and for preterm.

AIHC, Healthy Communities: A

Maternal Infant Strategic Plan, 2010.



HV is called out in four of the 14 identified plan

strategies as a best practice. It is also notable that as

AIHC has increased its knowledge around HV,

potential linkages have been identified in 11 of the 14

strategies areas of the AIHC MIH Strategic Plan. The

plan has served as a platform for Washington Tribes

and UIHOs to begin raising awareness and building

efforts and partnerships across the state addressing

AI/AN MIH health disparities.

FUNDING

Washington State Department of Early Learning receives federal funding through the Affordable

Care Act, administered by the U.S. Department of Health & Human Services (HHS). This

funding allows Washington to bring evidence-based HV services to high-risk communities. It

provides $1.5 billion over five years for state-based early childhood HV grants to serve families

in high-risk communities through the Health Resources and Services Administration’s (HRSA)

Maternal Infant Early Childhood Home Visiting (MIECHV) program.

Through 2015, Washington State expects to receive about $25 million from the MIECHV

program administered by HRSA. That is $1.8 million annually to:

Support direct home visitation services in local communities,

Develop systems to build quality implementation of evidence-based HV,

Integrate HV as a strategy in a comprehensive statewide system for early childhood

services, and

Collaborate with and partner across agencies and throughout communities.

There are also three Tribal/Urban HV research grants initiatives funded by the Administration of

Children and Families (ACF) MIECHV program. United Indians of All Tribes (UIAT), South

Puget Intertribal Planning Agency (SPIPA) and Port Gamble S’Klallam Tribe, referred to here

after as the Tribal MIECHV grantees, have received these grants and are at various stages of

implementation. See page 29 of this report for What We Learned from Tribal MIECHV Grantees.



HOME VISITING SERVICES ACCOUNT

The Washington State HV Services Account (HVSA) was established by the legislature in 2010.

It is a public-private organization that leverages state dollars through private sector investment in

HV programs. HVSA helps fund and evaluate HV programs and leverages state dollars by

providing private dollars as a match. The account also helps build and maintain training, quality

improvement and evaluation infrastructure needed for effective statewide HV services. There is

commitment from the private sector, through Thrive by Five

(www.thrivebyfive.org),Washington to match what the state deposits in the HVSA. The 2013-14

biennial general fund allocation for HV is $1.87M, which is 9.5% of total funds in the HVSA.



AMERICAN INDIAN HEALTH COMMISSION’S HOME VISITING

PROJECT

Tribal-Urban Indian Maternal Infant Early Child

Home Visiting (T-U MIECHV) is a Tribally-

Urban Indian driven project to identify maternal

infant-child health needs and capacity in Tribal

and Urban Indian communities. Its purpose is to

support healthy development of AI/AN children

and families in Washington State. The AIHC

facilitated the project, in partnership with DEL, to

gather information concerning:

Status of HV services for mother and babies and promising practices,

Gaps and barriers to program participation and effective programs,

Culturally appropriate strategies, and recommendations for developing and/or

expanding quality or capacity of HV systems and local interventions, and

Development priorities, funding and leveraging opportunities.

The AIHC convened its first T-U MIECHV meeting on August 27, 2012, providing an overview

of the project and an opportunity for Tribes and UIHOs to network with other HV partners in the

state. Participants included Tribes, UIHOs, Tribal MIECHV grantees, State and Federal

partners, and private HV programs and advocates. At the following meeting in October, Tribal

and UIHO representatives requested a change in structure allowing them to meet monthly, in

additional to the larger group of partners coming together quarterly. This change supported

AIHCs commitment to a Tribally-Urban Indian driven framework, and resulted in the

establishment of two groups: 1) the T-U MIECHV Coalition and 2) T-U MIECHV Plus Partners.

The T-U MIECHV Coalition and the T-U MIECHV Plus Partners memberships and participation

have been open and fluid.

The T-U MIECHV Coalition purpose is to enhance or expand existing services, ensure models

are culturally appropriate, and identify potential HV funding opportunities. The focus for both



the groups is to promote ongoing collaboration to build strong connections between Tribes and

UIHOs, statewide HV and early learning coalitions, service providers, and other state, federal,

private, and nonprofit partners to benefit AI/AN children and families in Washington State. The

membership is as follows:

AIHC Consultants

Jan Ward Olmstead, AIHC Public Health Consultant Coordinator, Home Visiting Lead

Marsha Crane, AIHC Clinical Consultant, MIH Lead

Maternal Infant Child Home Visiting Coalition Members

Alfreda Charlie, Tulalip Tribes

Beth Dodge, Chehalis Tribe

Bonnie Pimms, Yakama Tribe

Carmen Kalama, SPIPA

Caroline Sedano, Shoalwater Bay Tribe

Cherol Fryberg, Tulalip Tribes

Cheryl Sanders, Lummi Nation

Christina Hicks, Chehalis Tribe

Cynthia Gamble, Chehalis Tribe

Deanna Warren, Squaxin Island Tribe

Debbie Gardipee-Reyes, SPIPA

Debbie Kautz, Nisqually Tribe

Glenda Butler, Makah Tribe

Jeanne Dengate, Tulalip Tribes

Jhon J. Valencia, Chehalis Tribe

John McCoy, Washington State Legislature

Katie Hess, United Indians of All Tribes

Linda Charette, SPIPA

Leanna Ray-Colby, Lower Elwha Klallam

Lonnie Johns Brown, AIHC

Lorraine Van Brunt, Squaxin Island Tribe

Lynnette Jordan, United Indians of All Tribes

Jinny Marchand, Quinault Indian Nation

Marilyn Scott, AIHC and Upper Skagit Tribe

Mary Sanders, Chehalis Tribe

Misti Saenz-Garcia, Squaxin Island Tribe

Natosha Kautz, Nisqually Tribe

Pam James, SPIPA

Shannon Sullivan, Chehalis Tribe

Teresa Pope, Spokane NATIVE Project

Tina Fox, United Indians of All Tribes

Toni Lodge, Spokane NATIVE Project

Alan Harney, Tulalip Tribes



Partners

Jen Estroff, Children’s Alliance

Jenni Olmstead, Washington State Department of Early Learning

Judy King, Washington State Department of Early Learning

Laura Wells, Fight Crime Invest in Kids

Lauren Platt, Nurse Family Partnership

Lauren Hipp, Thrive by Five Washington

Laurie Lippold, Partners for our Children

Laurie Wylie, HHS, Health and Resources Services Administration

Leslie Dozono, Children’s Alliance

Linda Clark, Parents as Teachers

Liv Woodstrom, Thrive by Five Washington

Lorrie Grevstad, HHS, Health and Resources Services Administration

Molly Boyajian, Thrive by Five Washington

Nancy Ashley, Parent Child Program

Quen Zorrah, Thrive by Five Washington

Riley Peters, Washington State Department of Heath

Shannon Blood, Washington State Department of Early Learning

The T-U MIECHV Coalition developed strategic direction (see below) and a project work plan

(see Appendix A) to guide the project, and provided input in developing key questions to better

understand the needs of Tribes and Urban Programs, and the capacity for HV and services for

mothers and babies.

T-U MIECHV STRATEGIC DIRECTION

VISION: All Native Children Live Happy, Healthy Lives for Generations to Come.

MISSION: Promote health and well-being of Native American families and children through

culturally appropriate home visitation services.

GUIDING PRINCIPLES: Demonstrate honor and respect of cultural differences and

commonalities.

GOALS (reflected in the work plan, see Appendix A):

1. Improve the health status of AI/AN pregnant women and infants with appropriate,

multiple approaches as a shared goal with state government.

2. Identify status of HV programs.



3. Identify local intervention strategies and promising practices.

4. Identify gaps and barriers of program services and adaptations to current evidence-based

models.

5. Support culturally appropriate parent education and activities.

6. Support health prevention activities.

7. Collaborate, prioritize voice and act on Indian health issues.

8. Provide recommendations for developing and/or expanding quality or capacity of HV.

9. Identify development priorities, funding and leveraging opportunities.

10. Establish networking and collaboration opportunities to support HV efforts in

Tribal/Urban Indian communities.

11. Serve as a national model for state-tribal collaboration on Tribal/Urban MIECHV policy

and program development.

OBJECTIVES (Reflected in the work plan, see Appendix A):

1. Develop and implement work plan to achieve goals.

2. Convene monthly meetings for Tribes/Urban Indian organizations to identify HV status,

needs and strategies.

3. Convene quarterly meetings with Tribes, UIHOs and other partners (State, Federal,

private, and non-profit) to collaborate on HV needs of Tribal and Urban Indian

communities.

4. Collect and review data to identify gaps or barriers to HV services.

5. Serve as a clearinghouse for HV programs and Tribal, State and Federal partners through

meetings, webinars, and email.

6. Share resource and funding opportunities information with Tribes and UIHOs.



OTHER RELEVANT WORK/PROJECTS WITH LINKAGES TO T-U

MIECHV

The AIHC is working on many public health projects that focus on improving the health of

AI/AN families, and has identified projects that potentially link to T-U MIECHV:

HEALTHY TRIBAL AND URBAN INDIAN COMMUNITIES FRAMEWORK

The framework focuses on a comprehensive prevention strategy integrating Native and

western knowledge to reduce risk factors for chronic disease among AI/ANs. This

integrated model utilizes a Policy, Environment, Systems (PES) change approach and

incorporates culturally appropriate strategies designed for Tribal and Urban Indian

Communities.

MATERNAL INFANT HEALTH (MIH) IMPLEMENTATION OF THE MIH STRATEGIC

PLAN

The plan to improve the health status for AI/AN pregnant women and infants with

appropriate, multiple approaches as a shared goal with state government, included four

outlined objectives. Three of the four objectives form the basis of the MIH Strategic

Plan:

1) Establish a Maternal-Infant Workgroup to research causes of poor health status

and birth outcomes among Indian women, and identify promising practice

models from Tribal and Urban Indian delivery of MIH services nationally and

in Washington State,

2) Identify specific barriers to Tribal/Urban Indian health program participation in

the DOH WIC Program and the Department of Social and Health Services

(DSHS) First Steps Services (maternity and infant support); develop and

implement strategies to improve AI/AN access to and Tribal Health programs'

ability to provide these services, and

3) Identify options and opportunities for Tribes and UIHOs to ensure access for

all AI/AN women to high quality obstetrical care, and develop methods to

successfully engage them in healthy lifestyles.



WOMEN, INFANTS AND CHILDREN (WIC)-IMPLEMENTATION OF MIH STRATEGIC

PLAN RECOMMENDATIONS

The objective of the project is to identify culturally and tribally appropriate methods

for enhancing the use of WIC services and supports in Tribal communities, including

in the areas of food access, breastfeeding, health education, and information and

referral to other programs and services.

PREGNANCY RISK ASSESSMENT MONITORING SYSTEM (PRAMS)-IMPROVE

RESPONSE RATES, QUALITY AND USE OF DATA SPECIFIC TO AI/AN WOMEN IN WA

STATE; PUTTING DATA INTO ACTION

The PRAMS Flu project is a direct result of Tribal and Urban Indian concerns regarding

immunization issues that occurred during the H1N1 Flu pandemic, and MIH disparities,

both very clearly articulated during the AIHC Tribal Leaders Health Summit of 2010.

AI/ANs experienced more severe health outcomes from H1N1 Flu than the general

population (http://www.cdc.gov/h1n1flu/in_the_news/deaths_american_indians.htm), as

did pregnant women. Flu immunization rates for AI/AN pregnant women in Washington

were not then, and are still not, optimal. Improving immunization rates for pregnant

women will save lives, and fulfill a strategy for improving MIH health disparities that is

listed in the AIHC’s MIH Strategic Plan.

IMMUNIZATIONS-ASSESS POTENTIAL ISSUES REGARDING HEALTHCARE WORKER

VACCINATION HESITANCY AND IMPLEMENTATION OF MIH STRATEGIC PLAN

RECOMMENDATIONS

American Indians and Alaska Natives are impacted the most of any group by illnesses

that could have been prevented through proper immunizations

(http://www.cdc.gov/h1n1flu/in_the_news/deaths_american_indians.htm) which raised

the issue of Vaccine Hesitancy for Health Care Workers in Tribal settings. The AIHC

conducted an assessment, analysis, and recommendations regarding Tribal Health Care

Workers’ Knowledge, Attitudes and Practices regarding immunizations.

In addition, prior to the initiation of the AIHC/DEL T-U MIECHV project, the

University of Washington and DSHS convened the Tribes and Recognized American

Indian Organizations (RAIOs) for a Health Priorities Summit entitled “From



Cradleboard to Career3”, focusing on MIH and early childhood development. The

issues identified in the summit related to HV concepts and/or maternal infant child

health from the perspective of Tribes and Urban Indian communities. Attendees

included Tribal council members, Tribal leaders, Tribal and UIHO employees, RAIOs,

Native Elders and Native community members and youth. Valuable information was

gleaned from this summit to support culturally relevant programs and practices to

establish an expanded network with Tribal and Urban Communities.

(http://uwashington.uberflip.com/i/106618/35)

The commission will continue to identify linkages to strengthen work across these projects, and

build and strengthen partnerships and leveraging opportunities to improving AI/AN maternal

infant child health status.

METHODOLOGY FOR GATHERING INFORMATION AND KNOWLEDGE

Several approaches were used to gather information, including administering a Survey Monkey

questionnaire, conducting regional forums/meetings and hosting a one day HV conference to

gather information and knowledge to support the project.

SURVEY QUESTIONNAIRE AND RESULTS

The AIHC administered a Survey Monkey questionnaire entitled, American Indian Health

Commission for Washington State HV Services for Mothers and Children, (attached as

Appendix B). The survey was initially conducted from March 12 to May 5, 2013; however, it

was extended through the end of May to achieve AIHC’s goal of reaching an 85% response rate.

The purpose of the questionnaire was to establish baseline information about services provided

to mothers and children directly from the Tribes and UIHOs. Questions were also asked about

the appropriate contact staff for HV services. The questionnaire was developed through

guidance from the T-U MIECHV coalition and in consultation with DEL staff. The AIHC lead

HV consultant served in designing the survey and analyzing the results for this report. The

survey had a 90% return rate; 28 of 31 Tribes and/or UIHOs responded; however, not all

questionnaires were completed nor all questions answered by every respondent.

3 UW, From Cradleboard to Career, 2012



Question 1: 28 responses. It was an agreement to participate in the survey.

Question 2: 28 responses.

Question 3: 11 responses, reflected below.

Model Number

Early Head Start 3

Head Start/Promotional Maternal Health (NCAP) 1

Home visiting through family services is a social service model, accessing

through the state

1

Maternal Support Services 1

Nurse Family Partnership 1

Parents as Teachers with cultural enhances 1



Parents as Teachers, Ages and Stages, Life Skills Progression 1

PCAP WIC 1

Positive Indian Parenting and Parents as Teachers Curricula 1

Question 4: 21 responses. Respondents could choose more than one answer. Additionally, other

comments indicated the following services: public health nurses, social services, head start, WIC,

Positive Indian Parenting.



Question 5: 22 responses. Other comments included MIH programs and public health nurses,

MSS at clinic and prenatal Ed at Head Start.

Question 6: Are there other (non-Tribal/Urban Indian) community based organizations that

provide HV services to mothers and children in your community? If yes, provide Name and

model.

Model

First Steps

Mason County Health Department (not sure of services)

MSS at Olympia Hospital

Nurse Family Partnership through the Health Dept.

Nurse-Family Partnership and Early Head Start and many others in King County

Parents Place in Longview

Yakima Valley Farm Workers Clinic

Question 7: 24 responses. Who is the appropriate contact for HV services for mothers and

children? The responses provide AIHC with the appropriate contacts within the Tribes and

Urban Programs for HV Services.

Question 8: 20 responses. What funding is available to support the HV services for mothers and

families? Participants could choose more than one.



What funding is available to support the home visiting services for mothers and families?

Answer Options Response

Percent Response Count

Federal funds 70.0% 14

State funds 30.0% 6

Tribal funds 40.0% 8

Other 35.0% 7

ROADMAP EXERCISE QUESTIONS AND FINDINGS

The AIHC used a Roadmap Exercise as a method to better understand needs and capacity of

Tribes and UIHOs for HV services. The four facilitated sessions were held at Spokane

NATIVE project, Tulalip Tribe, Yakima Tribe and Little Creek Casino during the One Day

Conference on HV.

Eight key questions were developed through the guidance of the T-U MIECHV Coalition and in

partnership with DEL.

“We have always celebrated, laughed, mourned &

healed together as a community for thousands of

years; we will always possess this genetic memory

of our healing process and practice it. This is why

funders need to consider culturally appropriate

Tribal and Urban Indian programs that have rapport

within the community that they serve. If that trust

and relationship is non-existent, then the healing

process is ineffective and never really begins.”

Dylan Dressler, MPA

Clinic Manager

NATIVE Health of Spokane



Eight Questions and Salient Themes:

Question 1: What services do families need to ensure that all Native Children live happy,

healthy lives?

Hierarchy of need: Families must have basic needs met like housing, food, safety,

employment, and transportation.

Good nutrition—mind, body, spirit and heart.

Alcohol, commercial tobacco, and drug free environments.

Domestic violence prevention.

Safe environments: natural and personal understanding about relationships to all things.

Access to health care, immunization and medications.

Services to address: OB care, Teen Pregnancy, Pre-term generational CPS involvement.

Home visiting services need to be flexible in the way they are provided to allow them to

be conducted in a group or with extended family members and elders.

Services that meet the needs of families; from a Tribal/Urban Indian perspective.

Services: Preferred that they are “from our people for our people”.

Holistic, comprehensive, wrap-around services.

Culturally relevant services.

Healing, with the involvement of elders who have done their own healing, through

training and education to families and providers.

Elder protection and preservation.

Service providers from outside the Tribe/community need to understand the

Tribe's/communities’ history.

Consistent messaging—all service providers reinforcing the same message (e.g., smoking

cessation, promoting breastfeeding, etc.).

Empowerment, advocacy and opportunity.

Question 2: What Maternal-Infant-Child Services are available in your community; what

services do they provide?

Baby Face

Boys and Girls Club

Colleges-Olympic and Highline have programs

Early Head Start

Family Haven-teen moms and life and parenting classes

First Steps

First Steps/MSS/ICM

Home Visiting Programs

Mason County Early Learning Coalition (Tribes not very involved)

PHSKC-Muckleshoot

Planned Parenthood



Port Gamble & Suquamish Tribes Early Health Start, Head Start, child care, birthing,

Nurse Family Partnership, WIC

Seattle-Teen Parent Housing

Seattle-YWCA, have 600+ case management.

South Puget Intertribal Planning Agency (SPIPA) using Parents As Teachers HV model

Spokane-DSHS-children and family services

Spokane-Sacred Heart Hospital-low income breast pump rental

Spokane-Sally’s-Emergency shelter

Tribal and Urban Indian Clinics

Tulalip-Little Red School House-early childhood prevention

United Way-Q’s outreach early

WIC

Yakama-Hospitals available for delivery, great OB care, neonatologists, and great

Pediatric services.

Yakima-MCH Moms’ group

Yakima-Children’s Village is an asset, but paperwork is a challenge.

Question 3: Do the Existing Services meet the needs of Native families? (Identify Gaps)

Lack of funding for HV and other services.

Lack of knowledge about HV availability of programs, benefits and funding.

Lack of access to independent culturally relevant HV programs.

Lack of holistic, comprehensive, wrap-around services.

Concern about high risk pregnancies with CPS involvement, no pre-natal care, substance

abuse involvement.

Lack of adequate behavioral health services.

Concern about high asthma diagnosis.

Services for families at risk of losing their children.

Question 4: Is culture important in an effective home visiting program, and if so, why?

Home Visiting is a relationship based work; cultural knowledge and understanding is

imperative to effective home visiting.

Culture gives Native people the knowledge of who they are, where they belong, and an

understanding of their shared beliefs and practices.

Culture gives a foundation for healthy growth, development, and self-identity for children

and families.

Cultural appropriate models, like Family Spirit, should be reviewed for their potential use

for Tribes and Urban Programs in Washington.

Parent Education Curriculum should be flexible for Tribal home visiting implementation.

Tribes should not be forced to use evidence-based curriculum that is not culturally

relevant or that they have to adapt to make it fit into native communities. This is no



different than any other assimilation or acculturation effort. Native Tribes and

communities should have the opportunity to develop parenting education materials that

are culturally appropriate to their customs, practices and needs.

We have always celebrated, laughed, mourned and healed together as a community for

thousands of years; we will always possess this genetic memory of our healing process

and practice it. This is why funders need to consider culturally appropriate Tribal and

Urban Indian programs that have rapport within the community that they serve. If that

trust and relationship is non-existent, then the healing process is ineffective and never

really begins.

Question 5: What do you think the barriers are to families seeking services?

Not a priority—many families striving to meet basic needs.

Lack of understanding of the benefits and need for HV.

Lack of trust: history, experiences; referrals not from a trusted source or community

member.

Lack of culturally appropriate curriculum.

Non-native service providers.

Different worldviews/service providers lack of understanding Native culture; need a

cultural interpreter.

Fear of having people/strangers come into their home.

Eligibility issues can be a barrier. (Sometimes including different or conflicting

requirements for different services) can be a barrier even for eligible people.

Lack of transportation.

Lack of child care.

Safety of home visitor.

Time commitment: hours inconvenient.

Alcohol and drug addictions.

Mental health issues.

Domestic violence.

Fear of child welfare.

Homelessness and couch surfing.

Lack of phone service.

Legal issues.

Hopelessness: feeling inferior, low self-esteem.

Paperwork.



Question 6: What do you think a home visitor needs to know to effectively work in your

community?

Maternal Infant HV with tribal people requires the integration of traditional cultural

generational wisdom to be shared from the elder generation with the young adult families

to keep the promising practice from the past to survive.

Understanding historical and intergenerational trauma.

Knowledge of culture and history of the Tribal or Indian Community.

Needs to know the community and the people.

Needs to be aware of seasonal livelihoods.

Needs to know the resources.

Needs to know the elders.

Needs to know appropriate cultural protocol for visiting, introductions, and decision

making.

Needs to have empathy, a sense of humor; and ability to build relationships.

Needs to be able to listen and not judge.

Needs to be aware of surroundings to ensure personal safety and aware of risky

behaviors.

Needs to be strong and self-aware.

Question 7: Who are the best messengers?

Trusted Tribal/community member: Grandmas, Moms, Aunties, Nurses.

Connections with nurses in the clinic/hospital.

Good reputation in the community.

Male role models.

Elders as resources.

Families who have been successful at overcoming adversities.

Question 8: What would help engage families in HV programs?

Identifying benefits of and need for HV programs.

Building trusting relationships requires consistency: punctual, respectful, positive, and

flexible.

Having trusted Tribal/community members.

Having an appropriate cultural program and making adaptations like having the visit

outside of the home, including extended family or holding group sessions.

Flexibility around hours.

Addressing the families’ needs.

Tangible resources: Incentives.

Food.



Knowing someone else in the program.

Using social media.

A DAY OF LEARNING ABOUT HOME VISITING

The AIHC and T-U MIECHV convened

a one day conference as a Day of

Learning: How Home Visiting Builds

Resilient Children and Families (see

attached agenda, Appendix C). This

activity had not been envisioned at the

beginning of the project, but deemed

necessary to support identified needs by

the T-U MIECHV Coalition about

training, education and outreach as the

project developed. The event was co-sponsored by the DEL, DOH-Office of the Secretary,

DOH-WIC Nutrition Program, United Indians of All Tribes Foundation, and South Puget Inter

Tribal Planning Agency.

The agenda objectives were to:

Develop understanding of cultural resilience to historical and intergenerational

trauma with a focus on Tribal/Urban Indian maternal infant-child health.

Develop understanding of the Adverse Childhood Experiences (ACE) study and

efforts to address impacts of ACE through HV programs. (Citation)

Develop understanding of the landscape of HV system developments in Washington

State.

Identify Tribal and Urban Indian specific barriers, gaps, and needs to accessing

effective programs.

Sixty-one participants attended the one-day HV conference, exceeding the AIHC goal of 50

registering attendees. Participants included representatives from Tribes and UIHOs from clinics,

maternal infant health programs, HV program staff, MIECHV grantees, WIC staff, and early



learning staff; as well as partners from state, federal, nonprofit, and evidence-based HV

programs.

WHAT WE LEARNED FROM THE ONE-DAY EVENT

There is a need for additional training regarding cultural resilience to historical and

intergenerational trauma and ACEs specifically designed for Tribes and UIHOs.

There is a need to continue to build infrastructure for Tribal and Urban Indian maternal

infant health and to find avenues to integrate or partner in providing services to the same

population/families with programs like WIC.

There is interest in learning more about cultural adaptations to evidence-based HV

models.

There is a need to continue to work with evidence-based programs to develop

curriculums more culturally relevant for Native families and to continue to work with

state programs that serve Washington Native populations to make sure the parenting

education honors traditional parenting practices and is relevant and useful for Native

families.

The Community Health Representative model known to be effective in Tribal and Urban

Indian communities and should be considered for maternal infant HV.

There is interest in exploring ways to bill for and sustain an ongoing program that can be

part of a medical home model for Tribal members.

“Maternal Infant home visiting with tribal

people requires the integration of traditional

cultural generational wisdom to be shared

from the elder generation with the young

adult families to keep the promising practice

from the past to survive.”

Marilyn Scott, AIHC Chairwoman

Vice Chair of Upper Skagit Tribe



WHAT WE LEARNED FROM TRIBAL MIECHV GRANTEES

A significant barrier to HV is lack of knowledge

and awareness about HV programs. Additionally,

some associate HV with Child Protective Services

(CPS) and Indian Child Welfare (ICW). There

may also be unrealistic expectations of services

provided by home visitors.

Services for fathers, is an important part of

supporting moms and babies and strengthening

our families. This may include the necessity for specific components to assist men to

gain skills necessary to maintain healthy relationships.

Services to multigenerational units that share parenting responsibility for children and

grandchildren is a culturally relevant approach. The use of a “Circle of Aunties and

Grandmas” who can model and teach pregnant woman and young families, including

facilitating healthy relationship classes is relevant.

Evidence-based programs have some flexibility to make adaptations, but it takes effort to

develop understanding about cultural relevance and how adaptations can be made while

maintaining the fidelity of the program.

There are many bureaucratic barriers ranging from phone system issues to lack of

providers’ knowledge about services specifically for AI/ANs.

Eligibility requirements for services can be a barrier. Programs providing services to

AI/AN communities limit eligibility by many factors, including substance use (or lack

thereof), presence and age of children, place of residence, tribal enrollment status, age,

and income. Not only do eligibility requirements exclude people who don’t meet them,

but having to navigate them (sometimes including different or conflicting requirements

for different services) can be a barrier even for eligible people.

Racism and discrimination continue to challenge AI/AN people creating obstacles in

school environments, and by service providers and the general public.

Urban Indians may have distinct issues regarding access and transportation due to being

geographically scattered.



There may be a need for Tribes and UIHOs who implement an HV program to upgrade

technology for data collection and data sharing purposes.

Staff turnover can be a challenge.

FAMILY SPIRIT AND OTHER MODELS OF INTEREST

The T/U MIECHV Coalition and the MIH Workgroup have expressed interest in exploring and

learning more about three HV models that have demonstrated their effectiveness in Tribal and

indigenous communities:

FAMILY SPIRIT

An evidence-based and culturally tailored HV intervention delivered by Native American

paraprofessionals as a core strategy to support young Native parents from pregnancy to three

years post-partum. The Family Spirit Program consists of 63 lessons to be taught from

pregnancy up to the child’s 3rd

birthday. It is an in-home parent training and support program

designed, implemented, and rigorously evaluated by the Johns Hopkins Center for American

Indian Health in partnership with the Navajo, White Mountain Apache, and San Carlos Apache

Tribes since 1995. http://www.jhsph.edu/research/centers-and-institutes/center-for-american-

indian-health/Research_and_Programs/Current%20Projects/Family_Services/Family_Spirit.html

HEALTHY START PROGRAM

Healthy Start Program (HSP) is designed to prevent child abuse and neglect and to promote child

health and development in newborns of families at risk for poor child outcomes. The program

operates statewide in Hawaii and has inspired national and international adaptations.

http://www.hawaiifamilysupportinstitute.org/prevention-programs/the-hawaii-healthy-start-

program/

FAMILY HOME VISITING PROGRAM WITH ABORIGINAL FAMILIES IN SOUTH AUSTRALIA

The South Australian Children, Youth and Women's Health Service has adopted and adapted a

model of Family HV from the USA, using professional nurse home visitors and Indigenous

Cultural Consultants (ICCs) in program delivery for Aboriginal clients in South Australia. The

purpose of HV is to provide children with the best possible start in life and to assist families in

providing the best support possible for their children. Home visits are provided by qualified child

health nurses supported by a multidisciplinary team of psychologists, social workers, Aboriginal



health workers and family brokers.

http://www.indigenousjustice.gov.au/db/publications/290119.html



CHALLENGES AND LESSONS LEARNED

There were several challenges and lesson learned through the course of this project:

1. There is a lack of knowledge about the benefits of HV in Tribal and Urban Indian

communities. The project plan initially focused on gathering information in through

regional forums that focused on the status of HV services for mother and babies; gaps

and barriers to program participation and effective programs; culturally appropriate

strategies and recommendations for developing and/or expanding quality or capacity of

HV systems and local interventions; and development priorities, funding and leveraging

opportunities. As the project evolved, it became clear that an outreach, education and

training component would be useful to clearly communicate the benefits of HV to engage

Tribes and Urban Programs in the project.

2. Lack of Funds for Tribal and Urban Indian HV programs. It is difficult to ask Tribes and

UIHOs to allow staff involvement in a project that doesn’t currently have funding

available.

3. Methodology for Information Gathering and Established Protocols.

As a result of the HV and other similar projects, the AIHC has identified the need to

establish standardized protocol for information gathering to include involvement of an

Institutional Review Board (IRB) as a policy. This will increase AIHC’s capacity for

future assessment work and increase the level of engagement and ability to collect more

detailed information.

4. No two Tribal communities are the same. It is important to note this when discussing

culturally appropriate program designs. The models need to be flexible to meet the needs

of the people in each unique community. Also, it is important to note that there are

differences between Tribal and Urban Indian communities. This was apparent in T-U

MIECHV coalition discussions and forum responses.

5. The AIHC and Thrive by Five engaged in initial discussions regarding engagement of

Tribes and UIHOs in Thrive by Five’s work with rural communities. They have also

begun discussing a readiness assessment that Thrive by Five is working on. AIHC is

interested in continuing that relationship to learn more about the assessment and whether

it could be adapted for AIHC’s use with Tribes and UIHOs.



FINDINGS AND KEY CONSIDERATIONS

1. Engagement in intentional outreach and education with tribes and urban tribal

populations to further the HV strategy in communities with AI/AN families.

a) This report establishes a baseline about HV in Tribal and UIHOs. Additional detailed

assessment work should be conducted to find out more about services provided and

determine T-U MIECHV Readiness.

b) There is a need for increased outreach and education about the benefits of HV and

cultural appropriate models.

c) There is a need for more training to understand and address cultural resiliency to

historical and intergeneration trauma and Adverse Childhood Experiences to support

strengthening families and HV efforts.

2. Engagement in ongoing efforts to support building cultural relevance, appropriate

cultural practices in current home visiting programs.

a) Evidence-based models need to be flexible and adaptable to be effective in Tribal and

Urban Indian Communities. It is important to continue to work with evidence-based

HV models to learn more about how they are working with Tribes and Urban Indian

Communities across the nation to adapt their models to be more culturally aligned.

b) This should include outreach strategies, trust building work, program staffing

considerations, approaches, formal “cultural adaptations”, relevant materials, data

usage and feedback loops for Tribal and Urban Indian Communities.

3. Exploration of HV programs shown to be effective with Tribal and Urban Indian

families.

a) Home Visiting programs need to be cultural appropriate to be effective Tribal and

Urban Indian communities. The Family Spirit model and other promising models

used in Indigenous communities should be examined by the T-U MIECHV coalition

for potential effectiveness in T-U communities.

b) Effort should be made to seek and identify funding to pilot at least one promising

practice and one evidence-based model with cultural adaptations should be a next

step. Funding should be for a minimum of two years to determine an initial result.



c) Considerations should be given to the development of selection criteria, timeline,

readiness, resources and funding needed to pilot a culturally appropriate model.

4. Identification of opportunities to further link and grow work across Tribal and State

driven initiatives.

a) The partnerships between the statewide HV and the T-U MIECHV Coalition and Plus

Partners have been crucial to stay informed and build important networks to support

HV development in Tribes and UIHOs.

b) There are significant linkages between the HV goals and objectives and the MIH

Strategic Plan that should be explored and leveraged. The support and partnership

between DEL and DOH is significant to AIHC’s level of success.

c) There is public health and behavioral health work underway that have potential

linkages to HV models or systems. It would be beneficial to explore the possibility of

sharing expertise or leveraging opportunities in program and/or system development.

At a minimum, establishing a connection between AIHC, UW and DSHS

“Cradleboard to Career” conveners to discuss possible benefits would be useful.

d) AIHC and Thrive by Five Washington have just begun to establish a partnership to

support Tribal and UIHOs’ HV readiness.



RECOMMENDATIONS

1. Continue T-U MIECHV Coalition monthly meetings.

2. Continue T-U MIECHV Coalition and Plus Partners quarterly meetings.

3. Develop Outreach and Education tools about benefits of HV.

4. Provide training regarding Resiliency to Historical and Intergenerational Trauma.

5. Provide training regarding ACEs and strengthening families.

6. Collaborate AIHC with UW and DSHS “Cradleboard to Career” conveners to discuss

exploring possible sharing of expertise, or if there are leveraging opportunities in

program and/or system development.

7. Further develop partnership with Thrive by Five to develop Tribal and UIHOs Readiness

framework.

8. Develop and conduct a HV Services and Readiness Assessment Survey.

9. Develop Engagement plan to include regional presentations to Tribes and UIHOs

regarding HV.

10. Merge the efforts of T-U MIECHV Coalition and DEL with the MIH workgroup and

DOH to leverage resources and efforts.

11. Provide Webinars/Education on Tribal/Indigenous HV Models: Family Spirit and others

identified by AIHC’s T-U MIECHV coalition and/or the MIH Workgroup.

12. Support and provide technical assistance to pilot a promising practice HV model and

evidence-based model with cultural adaptations.

NEXT STEPS

1. Present Report and Findings to key DEL staff—September 9, 2013.

2. Present Report and Findings to the AIHC Delegates for comments and final

approval—September 13, 2013.

3. Present Report and Findings to the Director of DEL and key stakeholders—Oct 7,

2013.



REFERENCES

American Indian Health Commission for Washington State. (2010). Healthy Communities: A

Tribal Maternal-Infant Health Strategic Plan, Port Angeles, WA. http://www.aihc-

wa.com/wp-content/uploads/2011/09/MIH-Plan-web-FINAL-030811-13.pdf. Access10-

4-13.

American Indian Health Commission for Washington State. (2013). Tribal Leaders Health 2012

Summit Report: Journey Forward into 2014: “Healthy Tribal Communities”.

South Puget Intertribal Planning Agency. (2011). Needs Assessment 2011, Part 1: Facts &

Figures, Part 2: Stakeholder Input, Healthy Families Partnership for a Healthy Future.

United Indians of All Tribes Foundation. (2012). Ina Maka Family Program Community Needs

Assessment 2012. http://www.unitedindians.org/documents/IMFPNAMay12.pdf. Accessed 10-

4-13.

Washington Tribes & Recognized American Indian Organizations (RAIOs) Health Priorities

Summit. (2012). Summary Report, Cradleboard to Career. Prepared by: Thomas, Lisa,

Ph.D. and Austin, Lisette, MA, et al. http://uwashington.uberflip.com/i/106618/35.

Accessed 10-4-13.

Washington State Department of Health. Health of Washington State Report – Infant Mortality.

Olympia, WA: Washington State Department of Health; 2013.

http://www.doh.wa.gov/Portals/1/Documents/5500/MCH-IM2013.pdf. Accessed 10-4-13.

Washington State Department of Early Learning. (2010). Washington Early Learning Plan,

http://www.del.wa.gov/publications/elac-qris/docs/ELP.pdf. Accessed: 10-4-13.

Washington State Department of Health. (2010). Washington State Home visiting Needs

Assessment Narrative.

Washington State Department of Health. Revised, 2011. Washington State Home Visiting Needs

Assessment Narrative. http://www.doh.wa.gov/Portals/1/Documents/Pubs/950-165-

FinalNarrative.pdf. Accessed 10-4-13.

http://www.aihc-wa.com/wp-content/uploads/2011/09/MIH-Plan-web-FINAL-030811-13.pdf

http://www.aihc-wa.com/wp-content/uploads/2011/09/MIH-Plan-web-FINAL-030811-13.pdf

http://www.unitedindians.org/documents/IMFPNAMay12.pdf

http://uwashington.uberflip.com/i/106618/35

http://www.doh.wa.gov/Portals/1/Documents/5500/MCH-IM2013.pdf

http://www.del.wa.gov/publications/elac-qris/docs/ELP.pdf

http://www.doh.wa.gov/Portals/1/Documents/Pubs/950-165-FinalNarrative.pdf

http://www.doh.wa.gov/Portals/1/Documents/Pubs/950-165-FinalNarrative.pdf