Partnering for one public health
Utah, a land of diverse counties and tribes, says people must come first in data modernization
promising practices
- Implement communities of practice and touch-base meetings to help understand the different needs of local and tribal health departments, hospitals and clinics.
- When working with tribes, listen first. Be respectful of the tradition of who it is you’re trying to serve or help.
- Be strategic when working with different priorities from local health departments (e.g., consider the time on the state side to make requested enhancements to a system, but also the value the local health department gains from those changes.)
- Shift the mindset that local health departments and tribal agencies are simply partners who sometimes participate in discussions —they should assist the state with prioritization, tools and evaluation for shared data systems.
Collaborating between state and local levels
Nicole Yerkes, DMI Director at the Utah DHHS, says there are many different considerations when working with local health departments. “With our local health departments, we have rural counties, urban counties, frontier counties [less than six people per square mile], we have some of our jurisdictions that are a single county; we have some that are multi-county. They have varying funding capacities, varying staff capacities. So all of these things we needed to take into consideration working with our local health departments.”
Tribal partnerships
Utah is home to approximately 60,000 Native Americans, representing more than 50 tribal nations, with eight being federally recognized.
Utah DHHS works directly with tribes through its American Indian/Alaska Native Health and Family Service (IHFS) tribal liaison. Established in 2007, Utah was one of the first states to employ a dedicated liaison model for working with tribes. The IHFS develops strategies and policies to improve Indian Health in Utah. It also facilitates working relationships between Utah DHHS, tribal health programs, local health departments, other state agencies, and private provider sectors–cutting the bureaucracy for tribes. “This elevates tribes’ public health concerns and honors the government-to-government relationship between state and tribe,” says Jeremy Taylor, IHFS tribal liaison. During the COVID-19 pandemic, the state and tribes worked together to respond rapidly because “bridges were already built through the IHFS,” says Taylor.
In addition, Utah DHHS hosts the Utah Indian Health Advisory Board and a monthly touchpoint meeting with tribal public health staff. Yerkes also points out that tribes are sovereign nations and may work more closely with federal agencies in their area versus the state. However, she says it’s tribe-dependent—“[at the state level] there are some tribes we’ve had a consistent working relationship with and other tribes where we’re still building a relationship.”
Benge worked with tribes in a past position with the San Juan County health department and his current position in the TriCounty area (Daggett, Duchesne and Uintah counties). He says tribal connections are important, and, for a holistic view of the community, involve more than relying on the usual systems. Some counties might have a local tribal-owned and operated health center. In other cases, community members may go to an Indian Health Services (IHS) facility, which could be in different states—requiring coordination with neighboring states. “We have residents in the TriCounty area that, for them, it’s more convenient to go to a facility in Colorado or Wyoming for treatment or diagnosis and those systems are non-EpiTrax. And so that’s always a blind spot to us. We have to coordinate with those other state entities to better understand holistically what’s actually happening in our communities.”
Shawn Begay is the Public Health Director for the Utah Navajo Health System (UNHS), which is governed by the Navajo Nation Department of Health. Like Benge, Begay believes EpiTrax naturally creates a helpful working relationship with the state. The communicable disease data shared in EpiTrax has been “a gateway for education and sets the interview process so patients get better care,” says Begay. Through EpiTrax, Begay sees the cases for communicable diseases, such as sexually transmitted infections (STIs), tuberculosis (TB) or COVID-19, and can then assign the case to a UNHS nurse. Begay says “The nurse accepts the case, facilitates the investigation and educates the person in the community on how to get on a better track to health.”
Begay also participates in the Utah Indian Health Advisory Board, hosted by DHHS. It’s a forum for discussing changes to Medicare or other health laws and for discussing successes and challenges among tribes. In addition, Begay participates in a monthly touchpoint meeting for situational awareness of the infectious disease landscape in the state.
Begay says, “The state of Utah has been an excellent partner for education, grants, vaccines and personal protective equipment (PPE), among other things. So they’ve been listening to our needs, and have really looked out for any kind of federal dollars that would benefit our tribe or the tribes in Utah.”
For a local-tribe relationship, Benge says the TriCounty area is making an effort to work more directly with the local Uintah-Ouray tribe. Their Board of Health recently amended their bylaws to create a seat on the Board of Health for a tribal representative. An issue that may come up, says Benge, is that people may not feel empowered to speak for the entire tribe. “That’s really the issue that you face, making sure that you’re connecting with somebody that is empowered, or they feel like they can speak for the tribe or make a decision. And that’s where the real effort has to come in building personal relationships and being able to rely on each other.”
Benge continues, “When you talk about tribes and reservations, we’re really a shared community. We shop at the same stores; we go to the same gas stations; we go to the same schools. And that distinction of tribal or ‘I live on-reservation or off-reservation’ isn’t in the forefront of many people’s day-to-day lives.”
Begay says there’s truth in that statement, but also says the perspective can change when living on a reservation. “We shop at the same stores, we go to the same gas stations, that is true. We’re able to see people who we associate with every single day. And when COVID hit us, it really did do a number to us [the Navajo Nation]. And so people that we used to see at the gas station, at the schools, at the stores, we didn’t see around anymore, because a lot of them might have been sick from COVID, a lot of them might have perished from the disease.”
During the COVID-19 pandemic, Begay says talking to people about how to protect themselves, especially the elderly, created a challenging reservation-specific issue. It required communicating the dangers of COVID-19 from English into Navajo. “There are really no words in Navajo that describe COVID. You just talk about a deadly cough. And so that [communications] issue, more or less, was applicable to the people that we served in the tribe.”
He continues: “So I think the mindset is different off the reservation and those living on the reservation. It just depends on your perspective.”
Working with different perspectives
Local health departments are interacting with the state, tribes, hospitals, clinics and the public at large. “Each relationship is a little bit different, but we’re all the same in the sense that everybody wants healthy communities. So we all start with that same premise; we’re all working toward improving health. But there is a nuance, I think, with understanding each and everybody’s roles in how they relay,” says Benge.
Benge continues, “For example, when working with a tribe, the tribe really wants to protect the health of their communities and the health of the people that live and work in their area or on the reservation or off the reservation. But the tribe is free to work directly with the state, they’re free to work with IHS or the feds or they’re free to work with us. And at the end of the day, they’re going to work better with us if we build a solid relationship where they trust that what we are going to do is in the best interest of our community.”
One way that health departments can build relationships with tribes is to “be respectful of traditional practices,” says Begay. He advises listening first to understand what is important to tribes. “I think people have this understanding just to come in and do good. However, do they really take time to listen to the landscape of the people there? Or is it because Western medicine is the best, we have the answers? For some people, that could be the case, but for others, we’ve had ancestors who’ve lived here far beyond the settlers and some of them practice traditional ways of healing. First and foremost, be respectful of the tradition of who it is that you’re trying to serve or help.”
Yerkes says having a shared data modernization strategy with so many different partners and perspectives can be challenging, but “we’re really fortunate because we have a lot of people who are very excited about data modernization and want to be involved and see it succeed…it’s just been a matter of getting everyone to the table and deciding our strategy, our vision and what we’re going to prioritize…making sure that everyone’s voice is being heard.”
Technical priorities
On the technical side, a challenge can be working with different priorities. Rachelle Boulton, Health Informatics Program Manager, gives the example of a recent measles outbreak that was centralized in one local health jurisdiction. “There were some enhancements to EpiTrax that were totally doable and would help them to manage that outbreak. The challenge is nobody else needed that at the moment, right?”
She says her team tries to be strategic when responding to local health departments, such as adding enhancements that would be valuable to other situations in the future. A challenge is how much time and energy to devote to these kinds of changes: “We have to make the decision whether we pull people out of the work that they’re currently doing, delay timelines, those sorts of things to reprioritize and get those things done. We want to meet those needs though, because if we really focus on centralized systems, it does take some power and control away from some of the local groups.”
She adds: “And if we can’t immediately address their needs, it does dilute the value to them. It’s challenging and it’s difficult to find that right place and that right balance with addressing everybody’s needs, often we can’t address them all at the same time.”
One public health together
Yerkes says, “Data modernization in a public health sphere is unique because it’s people first … we’re utilizing these systems and data, but it’s for people.” She adds that collaboration is important. “It’s everyone working together to improve a system so that we all have better health outcomes and better access.”
Boulton agrees, and says the mindset around partnerships should change. “Rooted in some core principles, we are shifting from the state-centric mindset that local health departments and the tribes are secondary partners. They are public health along with the state health department. They’re not our customers. They’re not a partner who sometimes participates—we are all public health altogether. And so they really do need to be at that table. They need to be assisting us [the state] with prioritization, with defining features or tools, and evaluation.”
Going forward, Yerkes says funding and capacity have to be priorities. “And how can we leverage those that have more to lift up our smaller jurisdictions? We’re only going to be able to move forward with everyone being there.” Despite all the work at building partnerships, she recognizes there are areas where they need to know more about what’s happening. “If it’s a black void, then we can’t address it. We need to ensure that everyone has a seat at the table.”
key takeaways
- Each level of public health in Utah—state, local and tribal—brings unique perspectives, priorities and complexity to data sharing.
- EpiTrax, Utah’s disease surveillance system, has helped create a smooth relationship between the state and the 13 local health departments in Utah (representing 29 counties) and six tribal public health agencies that use it.
- Collaborative forums such as the Data Modernization Initiative (DMI) Council and the Utah Indian Health Advisory Board have helped the state listen to the needs of local and tribal health departments. The IHFS tribal liaison model also creates a direct link between the state and tribes.
- Critical partnerships at the local level are with local hospitals’ infection preventionists and clinicians—monthly touch-bases help streamline communications.
- Because of the complexity of where tribal members may get care, data from the usual surveillance systems can’t be relied on alone. To get a holistic view of all of Utah’s communities, Utah’s state, local and tribal health agencies continue to work on building relationships.
“Data modernization in a public health sphere is unique because it’s people first ... we’re utilizing these systems and data, but it’s for people...It’s everyone working together to improve a system so that we all have better health outcomes and better access.” - Nicole Yerkes
