Flagstaff (AZ) Medical Center, part of Northern Arizona Healthcare System, created a program to accommodate the beliefs and practices of their Native American patients, which make up about 40% of the hospital’s patient population.

The health system serves the Navajo Nation, the largest Native American reservation in the United States. The reservation is roughly the size of the state of West Virginia, and includes the Hopi reservation within its boundaries. Both populations have very traditional Indian medicine beliefs, says Lisa Brugh, MS, BSN, RN, ACM, system director of case management for the two-hospital system.

The reservation has limited services and only one assisted living facility, which sometimes makes it challenging to create a workable discharge plan, she says.

“Because we have such a large population who identify as Native American and they have such different cultural beliefs, it’s really important for us to learn about their beliefs so we can take them into consideration when we create a treatment plan or a discharge plan. Our staff goes through extensive education on Native American beliefs and practices,” Brugh says.

The hospital has three full-time Navajo interpreters who cover the hospital seven days a week and contracts with an interpreter service for evening hours. The Navajo chaplain is available to provide assistance. There are 39 back-up interpreters who work in various departments of the hospital.

To make its Navajo patients feel comfortable, the hospital offers traditional foods such as Navajo tea and blue corn mush on request, and support for alternative healing traditions such as medicine men and herbal medicine.

Patients frequently ask for a medicine man or traditional medical practices, says Susan Wells, manager of patient services. To meet their requests, the hospital recently hired a traditional healer to coordinate the spiritual side with the physical side of treatment.

“We respect traditional medicine and our patients’ beliefs and try to accommodate them whenever possible. Our staff has been educated on the beliefs and practices of our Native American patients and tries to accommodate them,” says Gigi Sorenson, RN, MSN, director of telehealth and community connected care.

In their initial assessment of patients, care managers determine the patients’ language skills and bring in an interpreter if the patient or family members have trouble understanding what they are saying. The care managers spend a lot of time getting to know the patients and their families, and building trust, Brugh says.

When members of the care management team participated in a study to determine how well the patients understood their discharge instructions, they found that there was a disconnect between what the care managers were teaching and what the Native American patients were able to understand, says Tiffany Ferguson, LMSW, ACM, director of community care management.

“Participating in the study made us stop and look at the relationship between the patient and family and their own community, and the role we play,” Ferguson says. As a result, the case management team made changes in the discharge education, worked on building relationships with providers on the reservation, and improved transitions of care and relationships with the medical homes on the reservation.

At the time, all patients received a big packet of educational materials, prescriptions, and discharge instructions written in English when they were discharged. But the researchers found that many of the Native American patients didn’t open the packet when they got home, but took it to their primary care providers to open during follow-up visits.

“Many patients speak Navajo primarily and can’t read English or see the value in what we try to teach them, but they trust their medical homes and their primary care providers. We have cut back on the extensive education we provide and focus on their immediate needs while they are in the hospital. We then ensure that the discharge information and educational materials are given to the providers the patients trust in the medical homes on the reservation,” Ferguson says.

The care management team arranges for patients to fill their prescriptions before they leave the hospital and collaborates with the primary care providers on the reservation to make sure patients have follow-up visits shortly after discharge.

“We found it was very important to involve the primary care providers and case managers in the clinics in remote areas in the discharge planning process,” she says.

The hospital care managers work closely with their counterparts at the patient’s medical home to create a workable discharge plan, Ferguson says. “They help us with post-discharge options and assist us in getting follow-up appointments with the right people,” Ferguson says.

Diet is a problem, particularly for patients who live in remote areas and have limited access to fruits and vegetables.

The care management team at the hospital works with the Indian Health Service dietician to help patients adhere to their dietary restrictions. “They can go into the home, see what is in the cupboards, and educate the patients about healthful foods they can make with the ingredients they have on hand. This works better than if we dictate to them what they should eat,” Sorenson says.

It’s often difficult to line up post-acute services for patients who live in remote areas of the reservation, Brugh points out. For instance, setting up a patient with oxygen may require a two-hour trip to get to his or her home. (For details on the telehealth program for Native Americans, see related article in this issue.)

“It’s very challenging for durable medical equipment providers,” Brugh says. Some clinics in remote sites have wheelchairs and walkers that patients can use. If there is no other option, the hospital provides a walker.

Indian Health Service funding specifies that care be based on needs, Sorenson says. “The money goes only so far, and walkers are a low priority. Wheelchairs are another story because living conditions make it impossible for patients to use wheelchairs,” Sorenson says.

The hospital care management team and representatives from the healthcare providers who serve the residents of the Navajo reservation meet regularly to collaborate on ways to better serve the patients.

“The end goal is to partner with outlying hospitals and clinics so they provide care management on the reservation. Our care management team is collaborating with several reservation clinics as they work to meet the requirements for medical home designation,” Brugh says.