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Integrated Care in Indigenous Populations

Posted By Melissa Lewis, Laurelle Myhra , Monday, September 12, 2016

Indigenous people of the United States and the world suffer from some of the worst health disparities. Disparities are linked to historical trauma, healthcare barriers, and epigenetic processes due to social, political, cultural and environmental violence. Indigenous health disparities are a result of historical oppression of these communities, as well as, the current inequities that exist in these settler-colonial states.


The systems of living that Indigenous people have continued to assert (e.g., Traditional ecological knowledge [TEK], Indigenous knowledge [IK], Indigenous economics, health knowledge, family and community systems) have been challenged or outright legally banned. These include the right to fish, hunt, forage, and use medicine, religious and cultural practices for health and well-being. In fact, until 1978, due to the American Indian Religious Freedom Act, many of these activities were illegal. Therefore, without the land, access to traditional food, and right to practice traditional cultural ways of being (including spiritual practices and medicine), health and wellbeing was compromised with increased incidences of cancer, heart disease, depression, and suicide. These diseases were uncommon before colonization and the subsequent disruption to Indigenous lifeways.

Indigenous communities continue to practice their traditions today, but with continued obstruction from state and federal government, as well as private citizens. For instance, treaty rights (which were granted by the United States government in exchange for land cessation-think of it as rent) allow fishing, hunting, foraging, and cultural/spiritual practices.


Despite this treaty obligation, Indigenous communities who practice these rights remain at risk for being (unlawfully) arrested, cited or jailed. Several northern Minnesota Ojibwe tribes- with leadership from Winona LaDuke, White Earth Ojibwe and executive director of Honor the Earth-are fighting for rights guaranteed by their 1855 Treaty to hunt, fish and gather, which are being threatened by the two major pipeline proposals, Sandpiper and Enbridge Energy’s Line 3 Replacement, which would impact wild rice waters and wildlife habitat and could adversely affect health for generations.


Further, the Dakota Access Pipeline has received approval by the United States Army Corps Engineers without the consultation of the original and current owners of the land, the Hunkpapa Lakota (and others) of the Standing Rock reservation, which, again, is a violation of treaty obligations. This pipeline threatens the health of the land and water-the very tools that these communities need to maintain their traditional ways of being. In other words, "If the land is sick, we are sick.”


While research with Native communities has historically been focused on problems, a shift has occurred and there is an increased amount of research on the resilience of Native people highlighting the importance of cultural practices for the health of Native people. For instance, Native people that identify strongly and positively with their identity and take part in traditional cultural activities are more likely to have improved academic performance, positive mental health for youth and adults, reduced substance use for and youth and adults, and improved physical health. Therefore, programs that facilitate cultural knowledge and pride may be able to redress the imbalance that so many Indigenous communities see by improving health and well-being outcomes.


In our own research we discovered that collaborative/integrated care appears to be an effective healthcare system for Native people. However, when Native culture was also integrated into care (see Figure 1 below), the positive effects appeared stronger. Integrated care at Native-serving sites resulted in a wide variety of health and well-being improvements including reduced depression, smoking, drinking, and criminal behavior; improved general health, employment status, and housing status; significant reduction in ED visits and hospitalizations; reduced turnover and increased employee satisfaction (see reference list).

Integrating behavioral healthcare into a medical setting resulted in discovering that Native-serving healthcare systems had a lack of mental health screening, lack of resources, and a high comorbidity of physical and behavioral health diagnoses. Healthcare systems integrated behavioral health care for a variety of reasons including:

1.      High comorbidity of behavioral and physical health symptoms

2.      Acculturation and general life stress related to a complex of physical and mental health problems are related to behavior-related mortality

3.      High disease burden (both behavioral and physical) that requires quality, collaborative care

4.      Patients with active mental health symptoms see medical provider but failed to be properly screened and treated

a.       Untreated behavioral health symptoms can be ‘caught’ at medical sites due to comorbid physical complaints, i.e., medical visits

b.      60% of presenting problems in IHS primary clinic are attributable to mental health problems

5.      More likely to seek mental health services from medical providers than behavioral health when compared to White population.

a.       96% feel comfortable talking to medical provider about their mental health

6.      High turnover rates of physicians at IHS so rapport can not be built.

7.      IC is validated by national health organizations for effective assessment and treatment of an array of health concerns.


While there were many positive outcomes, there were also a number of challenges to integrating care:

1.      Provider anxiety around asking personal questions

2.      Being able to address behavioral health symptoms in limited time frame

3.      Behavioral health providers concerned that physicians had the appropriate skills to address depression symptoms

4.      Adequate staff to support the follow-up appointments

5.      Time Management (Case managers spent a lot of time calling and scheduling appointments)

6.      Human resistance to change

7.      Departmental turf wars

8.      Reluctance of staff to take on additional work

9.      Staff turnover

10.  Lack of resources for providers

a.      Which is related to lower performance of clinical quality

11.  Lack of funding

a.      IHS receives only half of the funding needed to care for the patients it serves


A model program for integrative care in an Indigenous community is the Nuka System of Care at the Southcentral Foundation in Anchorage, Alaska. Dr. Myhra and Dr. Lewis had an opportunity in 2012 to present our results and tour this system, and we were blown away! As you enter the primary care building the first thing you see on the outside is a traditional medicine garden. As you walk in past the stunning Alaskan Native art and photos of customer-owners (not patients) the first service you see is traditional healing. With several specialties inside, this large primary care center operates as a one-stop shop. In Family Medicine, all care providers (physicians, nurses, behavioral health coordinators, administration) sit in an open-air, team setting, which facilitates communication. Large patient rooms allow many family members to attend. Health outcomes include (Gottlieb, 2007):

  • Evidenced-based generational change reducing family violence
  • 50% drop in Urgent Care and ER utilization
  • 53% drop in Hospital Admissions
  • 65% drop in specialist utilization
  • 20% drop in primary care utilization per patient
  • 75-90%ile on most HEDIS outcomes and quality
  • Childhood immunization rate of 93%
  • Diabetes with 50% of HbA1c below 7%
  • Employee Turnover rate less than 12% annualized
  • Customer overall satisfaction 91% 

This system of care provides a model for integrated care across the world and demonstrates that integration of behavioral health care into medicine should not be linear but be regional and community specific and address the culture and needs of the community.


Melissa Lewis, PhD, LMFT is an Assistant professor at the University of Missouri School of Medicine in the Department of Family & Community Medicine.

  Laurelle Myhra, PhD, LMFT is the Director of Health Services at Catholic Charities of St Paul and Minneapolis. Her clinical work and research has focused on families, resiliency, trauma, mental health, substance abuse and integrated care among American Indians. She received her doctorate in Family Social Science/Marriage and Family Therapy from the University of Minnesota.  


 Lewis, M. E., & Myhra, L. L. (Under review). Integrated Care with Indigenous Populations: Considering the Role of Healthcare Systems in Health Disparities. Part I. Under review at Families, Systems, & Health.

Lewis, M. E., & Myhra, L. L. (Under review). Integrated Care with Indigenous Populations: A Systematic Review of the Literature. Part II.

 Integrated Care in Indigenous Communities

 1.      Abbott, P. J. (2011). Screening American Indian/Alaska Natives for alcohol abuse and dependence in medical settings. Current Drug Abuse Reviews, 4(4), 210-214.

2.      Doorenbos, A. Z., Demiris, G., Towle, C., Kundu, A., Revels, L., Colven, R., . . . Buchwald, D. (2011). Developing the native people for cancer control telehealth network. Telemedicine and e-Health, 17(1), 30-34. doi:10.1089/tmj.2010.0101

3.      Gottlieb, K. (2007). The family wellness warriors initiative. Alaska Medicine, 49(2), 49-54.

4.      Madras, B. K., Compton, W. M., Avula, D., Stegbauer, T., Stein, J. B., & Clark, H. W. (2009). Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Dependence, 99(1-3), 280-295. doi:10.1016/j.drugalcdep.2008.08.003

5.      Parker, T., May, P. A., Maviglia, M. A., Petrakis, S., Sunde, S., & Gloyd, S. V. (1997). PRIME-MD: Its utility in detecting mental disorders in American Indians. International Journal of Psychiatry in Medicine, 27(2), 107-128. doi:10.2190/C6FD-7QWB-KNGR-M844

6.      Sequist, T. D., Cullen, T., Bernard, K., Shaykevich, S., Orav, E. J., & Ayanian, J. Z. (2011). Trends in quality of care and barriers to improvement in the Indian health service. Journal of General Internal Medicine, 26(5), 480-486. doi:10.1007/s11606-010-1594-4

Indigenous Resilience and Culture

1.      Whitbeck LB, Hoyt DR, Stubben JD, LaFromboise T. Traditional culture and academic success among American Indian children in the upper Midwest. Journal of American Indian Education. 2001;40(2):48-60.

2.      Petrasek MacDonald J, Ford JD, Ross NA, Cunsolo Willox A. A review of protective factors and causal mechanisms that enhance the mental health of indigenous circumpolar youth. Int J Circumpolar Health. 2013;72(1):1-18. doi: 10.3402/ijch.v72i0.21775.

3.      Garroutte EM, Goldberg J, Beals J, et al. Spirituality and attempted suicide among American Indians. Social Science and Medicine. 2003;56(7):1571-1579. doi: 10.1016/S0277-9536(02)00157-0.

4.      Yu M, Stiffman AR. Culture and environment as predictors of alcohol abuse/dependence symptoms in American Indian youths. Addict Behav. 2007;32(10):2253-2259. doi: 10.1016/j.addbeh.2007.01.008.

5.      Stone RAT, Whitbeck LB, Chen X, Johnson K, Olson DM. Traditional practices, traditional spirituality, and alcohol cessation among American Indians. J Stud Alcohol. 2006;67(2):236.

6.      Wilson K, Rosenberg MW. Exploring the determinants of health for First Nations peoples in Canada: Can existing frameworks accommodate traditional activities? Soc Sci Med. 2002;55(11):2017-2031. doi: 10.1016/S0277-9536(01)00342-2.


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