Emerging Evidence Case Study: Reimbursing Tribal Traditional Practices in Oregon

Background and Problem Scope

Case Study Written by Terry Cross MSW, LCSW, Ph.D., National Indian Child Welfare Association, John Spence, MSW, Ph.D., Northwest Indian Training Associates, and Caroline Cruz, BS, CPS, Confederated Tribes of Warm Springs

Tribal Communities in Oregon

Oregon is the original homeland of nine federally recognized tribes. The tribes represent diverse cultures and languages ranging from coastal tribes to plateau tribes. These tribes are sovereign nations having a government-to-government relationship with the United States, and with the State of Oregon. Together, the Oregon tribes represent a population of over 50,000 people. Oregon tribal members are citizens of their tribe, the State of Oregon, and since 1924, citizens of the United States (source)

History of Health Services for Members of Oregon Tribes

Until the 1970s and the passage of the Indian Self-Determination and Education Assistance Act of 1975 (Public Law 93-638) (Wilkinson, 2005) Oregon tribal members received few if any formal behavioral health services. Those who did received care from the federal government through Indian Health Service or through state agencies. Access was poor and what services were available were often not utilized because they did not fit the culture of the tribal population. In the '70s, tribes began to take over their own health care and social services via contracts based on several pieces of empowering legislation, including the Indian Health Care Improvement Act, the Indian Child Welfare Act, and the Indian Self-determination Act. In addition, American Indian self-help movements and Indian non-profits emerged whose approaches were built on culturally-based concepts and practices.

Oregon Commitment to Cultural Issues

As Oregon’s awareness of the need for cultural competence grew in the '80s and '90s, the state increasingly contracted with tribes and American Indian non-profits to provide behavioral health and child welfare services. In 1999, the Oregon legislature passed SB 555, which requires culturally-appropriate and gender-specific services to be provided through comprehensive community planning and implementation. The demand for culturally-appropriate systems of service delivery, in turn, led to policy changes at both the state and local levels.


 

Oregon state capitol

Emergence of State Policy Regarding Evidence-Based Practice

Just four years later, in 2003, the Oregon Legislature passed SB 267, an evidence-based programming requirement law. SB 267 applies to adult corrections, juvenile justice, child and youth services, as well as mental health and addiction services. Under SB 267, these state agencies were required to devote 75% of program funding to evidence-based programs by 2011.

Through the rigid funding requirements in SB 267, state agencies were mandated to rely increasingly on evidence-based programs. In some instances, tribal programs that had not been rigorously evaluated were threatened with being defunded, even if these programs have been traditionally provided, had known positive outcomes, or have been viewed by local communities as being beneficial. The implementation of SB 267 put state agencies in conflict with SB 555 described above, and with tribal governments, and tribal providers.

Tribal Reaction and Advocacy

SB 267 became a focus of Native American scholars, researchers, providers, and tribal leaders.

Native American providers and researchers expressed concern that the approach established by the state for defining and implementation of EBPs placed Native American programs at a disadvantage. 

The body of formal research related to practices delivered by Native American programs remains relatively small, and few researchers have focused on evaluating culturally-validated practices. In most cases, the type of research necessary to qualify as an EBP is neither feasible nor advisable in the tribal setting. Under SB 267 tribal providers felt pressured to replace practices that have strong cultural validation with practices from the state list that have no evidence of effectiveness for Native Americans.

Tribes feared that resisting the adoption of EBPs on the formal list in order to maintain culturally validated practices could result in loss of funding.

Representatives from all the nine tribes met several times during 2003-2005 and drafted a response to this mandate in a paper titled “Oregon Tribal Evidence based and Cultural Best Practices” (Spence and Cruz, 2005). 

In the words of Spence and Cruz (2005), the “Oregon Tribes should be allowed time to design research and evaluation tools relevant to their communities, and Native American researchers and evaluators should be consulted on culturally appropriate methods.”

At the Oregon Tribal Perspectives on Evidence Based Practices Summit in May 2007, Native American scholars voiced their objections to the state direction to impose a linear approach to funding requirements that are greatly at odds with the worldview held by most Native American people.  

Oregon Addictions and Mental Health Division Response

In 2007 the Oregon Addictions and Mental Health Division (AMH) responded to tribal advocacy by declaring that:

 “AMH does not believe that an evidence-based practice from the AMH list should be assumed to be better than a culturally validated practice unless the assumption is supported by scientific evidence.  Because scientific evidence for imposing practices on Native American providers is lacking, AMH concludes that we need a different framework for working with Native American stakeholders.  Native American stakeholders must take the primary role in defining what works for Native American clients.” (citation: Position paper on Native American Treatment Programs and Evidence-Based practices.

Tribal Evidence Framework

Representatives from all of the nine Oregon tribes met with tribal researchers several times over the next couple of years to develop a process that would culturally validate many time-honored practices that the tribes believe are effective in preventing or reducing many destructive behaviors.  A Tribal Best Practices (TBP) Review Panel was formed and a process for nominating TBP’s was established. A TBP Logic Model was developed (Cruz and Bigelow, 2007) as well as rationale for a systematic approach (Bigelow, 2010) 
 

Review Criteria

*Tribal Best Practice Principles of Native American Programming Checklist

Longevity in Tribal history

Elders have approved the project.

Transparency

Each person is accepted, nurtured and empowered.

Description on file

Program includes teaching of specific tribal worldview.

Standardization

Tribal language is integrated into programming whenever possible.

Cultural replication within Tribe or other Tribe

There is an emphasis on specific Tribal holistic approaches including community, family, relatives, and children.

Replication

Activities are multigenerational.

Meets Tribal principles

Family and Tribal histories are included and emphasized.

Research

Traditional teaching and leadership strategies are drawn from tribal practices.

Measurable outcomes

Native peoples, especially local Tribal members, are engaged in key in planning, leadership, and teaching roles.

Outcomes

Program addresses historical trauma.

Study Design

Tribal story telling is part of programming.

Random selection, Control group

Tribal sovereignty plays role in the program.

Adherence to key elements

Young people are given meaningful leadership roles.

Fidelity

Program addresses risk and protective factors.   

Accepted? Date of approval.

Programming includes Community-Based Participatory Research Approach (CBPR). List of community members involved with the review.

TBP Reviewed Programs

Since 2007 The TBP Review Panel has reviewed and adopted 23 TBPs using this framework. These TBPs include:

Adventure Based (2008)  
Baby Dolls Circle Time (2016)
Basketball Against Alcohol and Drugs (2011)
Canoe Journey/Family (2008)
Ceremonies and Rituals (2008)
Cradle Boards (2008)            
Culture Camp  (2008)
Domestic Violence (2012)
Family Unity (2008)
Horse Program  (2008)
Healthy Relationships Curriculum (2011)
Native American Community Mobilization (2011)
Native American Story Telling  (2012)  
Positive Indian Parenting (2012)
Pow Wow (2012)
Return to the Land (2016)
Round Dance (2012)
Story Telling (2011)
Sweat Lodge (2008)
Talking Circle  (2012)
Tribal Crafts (2008)
Tribal Family Activities (2008)
Tribal Youth Conference (2008)

State Legislation

Following several TBP Review Panel meetings, and with input from other Oregon tribal stakeholders, Caroline Cruz at Warm Springs and David Fullerton at Grand Ronde were able to have the language “include tribal best practices” added into HB 4165 ("Early Learning Council") that was passed in 2012.  Therefore, in addition to having TBP officially recognized and accepted as culturally validated practices by OHA/AMH, the TBP concept is now accepted into statutory authority under Oregon law. In 2011, HB 3110 ORS relating to substance abuse programs was revised to include Evidence-Based/Tribal-Based Programs. 

TBP is now accepted as a culturally-validated process.  This can be seen in the Oregon Health Authority/Addiction and Mental Health Department’s inclusion on their website of 20 Tribal Best Practices.

Tribal Best Practice is currently being updated and and can be accessed at the following website.

Last Updated: 06/22/2017