Advancing healthcare access in rural and tribal communities

Advancing healthcare access in rural and tribal communities

After a decade, the health coaching and medication management programs are transitioning from EHF to community-led programs.


For most of the past decade, Nora Flett, a Spokane Tribal member born and raised on the reservation in Wellpinit, has been working as a health coach to support elders in her community. As a trusted, familiar face, Flett has advocated for her community members and helped them face a wide range of health and quality of life challenges.


Flett’s status as a community member has been key to her ability to reach and work with her community. “I already had relationships with them, they knew who I was, so that made it a lot easier for me to do home visits,” Flett said. “Our elders do not just let anyone come up to their door and let anyone just come in.”


One of the first elders Flett worked with was able to manage her diabetes to the point where she no longer needed medicine. At the outset of the pandemic, Flett helped another tribal member get access to emergency dental care after a botched oral surgery --- advocating for needed care and following up to get him to the appointments he needed. When Flett learned one of her clients was heating her home with pinecones she started by helping the elderly woman access firewood. As she followed up and went through that elder’s financials, she found out the woman was paying too much in taxes. So, she helped her get her property taxes corrected, saving her $500 a month.


Since 2014, health coaches and medication management professionals like Flett have been addressing the needs of community members in Eastern Washington through the Health Coaching and Medication Care Coordination programs. Over the next year, EHF will be winding down these two long-standing programs. This transition will free up EHF staff to tackle new programs directed by our Equity Healing Framework.


Through this transition, we are committed to providing the resources and assistance our partners require to continue this work.


Partnering to improve healthcare access in underserved communities


Tribal nations and rural areas in Eastern Washington are among the region’s most underserved communities when it comes to healthcare access. That leads to worse health outcomes than our neighbors in Western Washington in key areas like diabetes, respiratory disease and cancer, according to Washington State University.


A decade ago, EHF endeavored to address these health access inequities through the rural health coaching program aimed at reaching elders and older adults in their homes and helping them stay there. We also ran a medication management program to address the challenges of polypharmacy for elderly community members. This work has been carried out with a variety of partners over the years including rural hospitals and nonprofits, social work students at Washington State University, and the Spokane Tribe, Kalispel Tribe and the Confederated Tribes of the Colville Reservation.


Anne Whigham has supported the rural health initiatives since their inception as a contractor for EHF. Whigham came to EHF with a wealth of knowledge and connections working on rural health issues and has helped mentor health coaches and craft the various iterations of the health coach and medication management programs.


Throughout the process, Whigham said one of the most valuable assets EHF brought to the work was a collaborative spirit and willingness to listen and be responsive to community partners. “EHF didn't go in and say, ‘here's a grant that we have, here's what we're going to do,’” Whigham said. Instead, EHF laid out some basic parameters for the grant, including the population that would be served and the patient activation score (a metric for a person’s ability to self-manage their care), and allowed its partner organizations to design programs that met the needs of their respective communities, Whigham said.


Partners shared Whigham’s sentiments on EHF being a good partner. “Empire Health as an organization — much more so than some of my other partners — is very supportive, very helpful and willing to listen to and make adjustments to programs to fit needs and identified gaps,” said Terry Titmus, the former director of Rural Resources Community Action in Colville, WA. “We've been very successful in identifying some pretty critical needs in our community that are unmet and developing programs to address those needs.”


Flett echoed Titmus. “We’ve learned over the years what works best with our community members and our elders,” Flett said. “It was fun to customize our health coaching program to fit our community, which Empire Health was amazing at letting us do,” she said. “EHF was totally fine with letting us figure out what is best for our elders.”


“Working with Native people is different than working with non-tribal people, but we have a little bit of both on the reservation,” Flett said. “That was another thing that was really amazing for Empire Health to say: ‘If you want to work with tribal and non-tribal people go ahead… do what works for your community.’”


Years of experimentation and growth have generated new ideas and led to unique approaches to rural health outreach. Some programs have fizzled out because they didn’t meet the needs of the community or were hampered by a lack of local resources like doctors or specialists. But other programs have grown to become their own initiatives that no longer need EHF’s support. Both the Spokane Tribe and Colville Confederated Tribes have transitioned their health coaching programs to the Community Health Representative model that’s supported by federal funding through the Bureau of Indian Affairs.


Partnerships with third party funders


EHF administered the rural health programs with the support of outside funding from Margaret A. Cargill Philanthropies (MACP). That funding, which focused on aging populations in rural communities, brought new opportunities to create and develop health infrastructure across Eastern Washington.


That partnership has continued to evolve and create new opportunities with MACP and other outside funders. One of the keys to that relationship has been transparency and a willingness to learn when programs weren’t working. Some of our early programs in partnership with MACP failed because we weren’t doing the type of deep listening embedded in the Equity Healing Framework. “EHF listened to the institutions: child and family services, behavioral health, law enforcement, the council,” said Dan Aune, EHF Senior Program Director. But that focus on institutions didn’t give us the full view of community needs. “You’ve got to go deep,” Aune said. “You have to start with the people who are going to access services.”


“It was a stark realization that moving forward anything that we do we’ve got to start with the very folks who are going to be most impacted,” said Aune.


Through the trust built with this partnership, EHF is continuing to partner to develop new ways of supporting community-led health initiatives. Under a current grant, EHF is working, with MACP’s support, to better understand community needs and build responses based on community feedback. This partnership uplifts opportunities in Eastern Washington by leveraging outside funding to support our partner organizations and communities. “These resources serve the communities that we really want to serve,” said Aune.


Creating sustainable programs


EHF is currently in a transition phase with our rural health programs. Through this transition we’re focused on building capacity for our partners to continue this important community health work with tribal nations and in rural communities.


This transition is guided by the principle of transforming barriers set out in EHF’s Equity Healing Framework. That means helping our partners figure out sustainable funding sources and program models moving forward, said Jeri Rathbun, EHF’s Program Officer.


“Our partners are telling us: ‘this is valuable and we want to continue this,’” Rathbun said. So, EHF is using our experience and existing relationships to help them understand what program options are available and the challenges and opportunities each of those different models and funding sources comes with.


“We're winding this program down, but we don't want to just totally let people go,” said Rathbun. “We want to be a good partner and help our partners stay whole.”


Titmus said that the relationship with EHF has helped Rural Resources create a plan for continuing these important programs after we step out of the role of funder. “[EHF] helps us do some of that strategic level work which is so important in these rural communities,” Titmus said. “That’s a void that Empire Health has filled.”


Flett said that the transition from an EHF-led program to the federal CHR program comes with challenges but that the lessons and connections from her work with EHF will continue to be valuable. “I’m going to bring the health coaching experience with me when I transition over to the CHR program,” Flett said.  “We've done it for years and years and have had such good results with it. We're definitely going to continue to provide it to our community.”