The chairman of the tribal council pointed to the rusting van and the community garden gone to seed. Outsiders often come here with good intentions, he observed, but when they leave, our Tribe is no better off. This encounter has framed all of Empire Health Foundation’s (EHF’s) subsequent work with Native American partners in profound ways.
We work for this health foundation in Eastern Washington, the goal of which is to make measurable improvements in our region’s health. Given the profound disparities in health outcomes between Native Americans and the general population, this has inevitably led us to focus on our local tribes, including Spokane, Colville, and Kalispel.
EHF has a decidedly quantitative evaluation culture, whether we are focused on adverse childhood experiences (ACEs), obesity in public schools, or the uninsured rate in our community. What is clear is that tribal partnerships cannot focus solely on numbers but must strive for good results within a context of mutual trust and action. After several missteps (“burn to learn”), we have found a successful strategy based on three basic tenets:
Build trust first.
Develop mutually beneficial outcome measures.
Always leave something behind.
Build Trust First
At our very first meeting with one group of tribal partners, we were asked what insurance products we were selling! From that inauspicious beginning, we have returned again and again to build a dialogue and relationship. One of the clear lessons learned is that there can be no firewall between their goals and ours, and we must actively resist the tendency toward an asymmetric funder–grantee relationship. Because of their openness and our benign persistence, we now are linked in increasingly deep ways: members of our leadership team serve on the boards of several tribal nonprofits, while representatives from all three local tribes serve on our foundation’s board. We were deeply gratified when EHF board member Tawhnee Colvin recently observed: “Our relationship with EHF and their staff has been very positive and rewarding. Face to face communication and open transparency has made our relationship successful. I appreciate that EHF has been very sensitive to the Spokane Tribe’s traditions and customs, and has been overwhelmingly resourceful and respectful to our aging community.”
Develop Mutually Beneficial Outcome Measures
One of our tribal initiatives is Health Coaching for Activation, which seeks to improve the health, wellness, independence, and quality of life for seniors living on the reservations. Tribal Health Coaches visit the elders’ homes, conduct assessments, set goals, and provide resources and connections within the community to address a variety of needs, primarily related to social determinants of health. Research has demonstrated a strong link between improvements in patient activation and improved health outcomes in measures related to emergency department (ED) visits, obesity, smoking, blood sugar levels, and more.
Hal Harvey wrote in the Chronicle of Philanthropy, “Reporting must benefit, in obvious ways, the grant maker, the grantee, or, ideally, both.” As we work with tribes, we look for outcome measures that balance the need for objective evaluation with the goals and constraints of our partners. The Patient Activation Measure (PAM) survey measures activation through a simple, ten-question instrument, which is administered every three months and is easily incorporated into regular home visits. For Tribal Health and Human Services (HHS), it provides regular feedback on the well-being of participants and the efficacy of Tribal HHS’s program in partnership with the foundation. For our foundation, it provides empirical data to evaluate the effectiveness of our grants and guide future funding decisions.
Always Leave Something Behind
Leaving something behind does not always mean a physical asset. Early in our work with one tribe, we met a young mother of four who was working as a driver taking seniors to and from the community center for meals and other activities. Two things quickly became evident: she had the trust and respect of the seniors, and she was bright and eager to build new skills. With the support of Tribal HHS leadership, we provided training that enabled her to become a certified nursing assistant. She now serves as the Lead Health Coach for her tribe, and the Health Coaching for Activation program has achieved our shared objective of a 20 percent improvement in activation while reducing hospital readmissions by 65 percent. Regardless of the future of this program, she has grown her qualifications, skills, and confidence in important ways.
Of course, no two tribes are alike, and what we are suggesting here is not offered as a one-size-fits-all formula. Yet, we think these principles can be powerful guides to building effective program partnerships with our country’s first communities. Our journey began as one to address health disparities but has blossomed into a rich tapestry of relationships with vastly greater potential for impact.
Related reading:
“Building New Partnerships For American Indian And Alaska Native Health,” by Aaron Wernham of the Montana Healthcare Foundation, GrantWatch section of Health Affairs Blog, August 9, 2016.
