BH2I Initiative Sites

Choctaw Nation of Oklahoma (CNO) Exit Disclaimer: You Are Leaving www.ihs.gov 

Choctaw Nation of Oklahoma (CNO) is a non-reservation tribe that covers 10½ counties that are roughly the size of the state of Vermont. CNO runs its own health care systems that include a state-of-the-art hospital, a well-developed Behavioral Health system, a diabetic wellness center, two residential addiction treatment programs, nine satellite clinics, and various other services.

CNO is implementing their integrated care model across three locations: Durant, Talihina, and Idabel, Oklahoma. Each site has differing levels of engagement with very different facilities.

In Durant, the BH2I model is implemented in a beautiful and fairly new primary care center. In Talihina, the BH2I model is two places, the Emergency Department and the Women’s Center, which is unique to this cohort. The Idabel Clinic consults with the primary care providers at Idabel.

Address: PO Box 1210, Durant, Oklahoma 74702

Ho-Chunk Nation Behavioral Health Integrated Team Exit Disclaimer: You Are Leaving www.ihs.gov 

The Ho-Chunk Nation Health Department has a 16-county service area (15 in Wisconsin and 1 in Minnesota) and serves 5,400 tribal members, 4,280 of which live in 15 Wisconsin counties. The project serves Ho-Chunk Tribal members as well as other tribal members and tribal employees. Ho-Chunk Nation operates two ambulatory health clinics and four satellite health offices. Each clinic has behavioral health staff on site.

Ho-Chunk Nation implemented their integrated care model into two site locations: Ho-Chunk Health Center in Black River Falls, WI, and House of Wellness in Baraboo, WI. Both clinics are large, very nice medical facilities. Ho-Chunk is implementing a pharmacy-based integrated care model at both clinics. Advance Practice Pharmacists work together with their staff psychiatrist and co-manage patients, mostly at the House of Wellness.

The BH2I team is looking into extending the tele-psychiatric service from House of Wellness to Black River Falls to assist with warm handoffs. The program has also initiated Lunch & Learn training for the behavioral health and primary care providers. These in-house trainings have led to the primary care providers becoming more comfortable with managing mild to moderate mental illness and prescribing psychotropic medications

Address: W9814 Airport Road, Black River Falls, Wisconsin 54615

Indian Health Board of Minneapolis, Inc. Exit Disclaimer: You Are Leaving www.ihs.gov 

Indian Health Board of Minneapolis, Inc. (IHB) is a full service medical, dental and mental health community health center established in November 1971 to serve the urban American Indian population in the Phillips neighborhood of Minneapolis. Serving over 7,000 urban Indians, IHB is a diverse urban community with many tribes and nations represented among their medical, dental and counseling and support clients.

The main feature of the project is to integrate mental and behavioral health care into the medical clinic while also blending in culture. Through the use of brief therapeutic intervention, health coaching and education, and care coordination, they aim to empower individuals with the skills, knowledge, and resources to address their health and wellness needs. IHB uses psychology interns from their internal APA- accredited doctoral program as well as grant-funded social workers and psychiatric nurse practitioners.

A unique feature of the IHB BH2I program is the inclusion of a Health Educator to help with physical concerns and provide health coaching for the behavioral health staff. Cultural programming is being incorporated into the BH2I integrated care model through Indigenous Yoga for Youth, sweet grass and sage bundles for patients to take home, and drum group referrals from BH2I staff. The BH2I project staff members also develop culturally appropriate patient education handouts to promote the cultural programs.

Address: 1315 E. 24th Street, Minneapolis, Minnesota 55404

Indian Health Center of Santa Clara Valley Exit Disclaimer: You Are Leaving www.ihs.gov 

Indian Health Center of Santa Clara Valley (IHC) was established in 1977 as an Urban Indian Health community health center to provide services to relocated American Indians. In 1993, IHC received HRSA 330 Federally Qualified Health Center status. Approximately 180 tribal nations are represented in Santa Clara Valley with Apache, Cherokee, Navajo, and Sioux with the largest populations; Santa Clara Valley is the original homeland of the Muwekma, and Amah Mutsun Ohlone. Santa Clara Valley has approximately 1.9 Million residents, with 1 million residing in San Jose, CA: 54% Caucasian; 36.5% Asian; 26% Hispanic/Latino; 3% African American; 1.3% American Indian.

IHC serves the medical and wellness needs of American Indians/Alaska Natives and people from all walks of life, regardless of race, ethnicity, religion, gender, sexual orientation, or disability. The project has been implemented in two locations: Meridian Clinic (Main Clinic) and Silver Creek Clinic.

Address: 1333 Meridian Avenue, San Jose, California 95125

Kodiak Area Native Association (KANA) Exit Disclaimer: You Are Leaving www.ihs.gov 

KANA was founded in 1966 as a 501c3 nonprofit that provides Medical, Dental, Behavioral Health, and Community services throughout the Kodiak region. The Kodiak Island group lies 30 miles off Alaska’s southwest coast. The main population surrounds the City of Kodiak with six thriving rural communities located in Ouzinkie, Old Harbor, Larsen Bay, Akhiok, Port Lions, and Karluk that can be reached by small aircraft or boat.

Kodiak Area Native Association (KANA) is unique within the cohort because their Behavioral Health Consultants not only serve Kodiak's entire patient population, but also provide integrated care to six outlying villages through behavioral health aides. KANA’s main feature is embedded Behavioral Health Consultation in exam room medical appointments.

In addition, the KANA BH2I program has implemented BHCs in a Medicated-Assisted Treatment (MAT) clinic and released a video about integrated care in the KANA service area.

Address: 3449 Rezanof Drive East, Kodiak, Alaska 99615

Muscogee Creek Pathway Project Exit Disclaimer: You Are Leaving www.ihs.gov 

The Muscogee (Creek) Nation is a large, non-reservation, rural Tribe located in the Northeastern region of Oklahoma that spans 7,246 square miles. The geography is characterized by small towns and rural areas with a large urban area (Tulsa) located on the northern border. Substantial portions of the service area are functionally isolated, rural, impoverished, and under-served. Though some Native Americans live in reasonable proximity to affluent areas, they remain functionally isolated from mainstream society due to cultural, economic, social, and educational barriers.

The project is being implemented in two tribal clinics – Okmulgee and Koweta - and will eventually expand to other sites. Combined, the two clinics have 31,002 registered patients – 6,820 children and adolescents under age 19, and 24,182 AI adults. While all AI age groups receive project services, the Muscogee BH2I project primarily targets children and youth under age 19.

Address: 1401 Morris Drive, Okmulgee, OK 74447

Northern Cheyenne Sweet Medicine Network

The reservation spans 444,000 acres in southeastern Montana and includes five districts — Ashland, Birney, Busby, Muddy, and Lame Deer — where approximately 5,021 out of 11,266 tribal members reside. Nearly 100% of those living on the reservation are Northern Cheyenne. The most apparent challenge to reservation members is distance.

To address the issues that distances to the clinic create, the Northern Cheyenne BH2I project plans to purchase a mobile van/vehicle to facilitate delivery of Behavioral Health, Primary Care, and Maternal Health Outreach Services to outlying areas. In the future, a mobile van/vehicle can help facilitate additional Primary Care Services.

Address: 100 Eagle Street Drive, Lame Deer, Montana 59043

Red Lake Bemidji IHS Service Unit

The Red Lake Service Unit (RLSU) is a Federal/Direct Service program, which falls under the jurisdiction of the Bemidji Area Office of the Indian Health Service and is located within an isolated, hardship area. The RLSU serves a migratory, intertribal (predominantly Red Lake Nation) treatment population of approximately 8,671 registered patients. The community Treatment Population continues to suffer from well-documented effects of colonization, historical trauma, poverty, limited access to care, and intergenerational hardships; all of which continue to impact the community’s epidemiology. The recruitment and retention of qualified staff, Mental Health Professionals, is a tremendous challenge.

The RLSU BH2I project’s unique feature is a pharmacist-run model, has a strong registry using iCare, and have three wellness specialists. They are currently building group therapy programs that are 6-week series with a new group starting every 3 weeks covering common topics such as pain management, sleep hygiene, weight loss, smoking cessation, stress management, employer-employee wellness topics.

Address: 24760 Hospital Drive, Red Lake, Minnesota 56671

Rocky Boy Health Board (Chippewa Cree) Exit Disclaimer: You Are Leaving www.ihs.gov 

The Rocky Boy Reservation is home to two tribes: Chippewa and Cree, established in 1916, and is located in Box Elder, Montana on 124,000 acres, the smallest of the seven reservations established in Montana. It is the first tribe to enter into self-governance program and is the only compacted health in the region. A population of 6,860 enrolled members with 4,012 residing on the reservation.

The BH2I Project is located in the new Rocky Boy Health Center (RBHC) in Box Elder, and serves all residents of the Rocky Boy Reservation. Currently, patients are screened by a care manager before a primary care provider sees them and the behavioral health counselor conducts a brief intervention if the PHQ-9 screening warrants it.

Address: 96 Clinic Road, Box Elder, Montana 59521

South Dakota Urban Indian Health, Inc. Exit Disclaimer: You Are Leaving www.ihs.gov 

South Dakota Urban Indian Health (SDUIH) serves the Native Population in urban areas of South Dakota Pierre/Sioux Falls. SDUIH is one of 32 Urban Indian Health Programs in the nation authorized under Title V of the Indian Health Care Improvement Act. SDUIH program serves two urban Indian communities in South Dakota: Pierre (central) and Sioux Falls (southeastern), which are located 3 hours apart. These communities are located close to several reservations (Yankton, Flandreau Santee, Lower Brule, Crow Creek and Cheyenne River) in the state. Services, such as pharmacy, dental/eye and specialty care (i.e. podiatry, cardiology etc.) are coordinated between SDUIH and IHS/Tribal programs.

The primary population focus in this grant (BH2I) is to provide services to 2,500 federally recognized American Indian/Alaska Natives (AI/AN) both male and female age 5 years and older. That translates to approximately 300 individuals in Year 1, which is based on the program’s current “active” unduplicated patient data.

SDUIH’s two clinics (Sioux Falls and Pierre) are doing well with their integration grant efforts. These efforts include a strong cultural component. The Sioux Falls clinic moved into a new building and held an open house in July 2019. They have also been able to hire needed staff and include a Culture Keeper who leads a very robust cultural wellness program. The Pierre Clinic is working hard to increase the cultural wellness activities available to the Pierre community as it has been very successful in Sioux Falls.

Address: 1714 Abbey Rd., Pierre, South Dakota 57501

United American Indian Involvement, Inc. Exit Disclaimer: You Are Leaving www.ihs.gov 

United American Indian Involvement, Inc. (UAII) is a 501(c)(3) private nonprofit Urban Indian Health Organization (UIHO) that provides health and human services to eligible American Indian/Alaska Natives (AI/ANs) primarily residing within the County of Los Angeles. Approximately 165,000 AI/ANs are dispersed over the entire county. More than 125 different tribes are represented and more than 200 distinct tribal languages are spoken.

At present, the BH2I Project Coordinator is invited into exam rooms for warm handoffs and patients are referred for Behavioral Health Department appointments. In addition, the BH2I Project Coordinator is participating in medical clinic huddles, helping to identify patients that need screening or a brief intervention during the visit. Furthermore, the behavioral health staff are “on call” for crises or additional help to brief interventions during clinic hours.

To aid in screening, UAII is working on installing electronic kiosks. Ultimately, the kiosks will link with the RPMS and behavioral health databases and will utilize both PHQ-9 and CAGE screening tools. UAII has also implemented Tiger Connect with 50 subscriptions, which they learned about from Kodiak Area Native Association, to increase communication among primary care and behavioral health providers.

Address: 1125 W. 6th Street Suite 103, Los Angeles, California 90017

Yellowhawk Tribal Health Center Exit Disclaimer: You Are Leaving www.ihs.gov 

Yellowhawk Tribal Health Center is located on the Confederated Tribes of the Umatilla Indian Reservation (CTUIR) in rural Northeastern, Oregon. YTHC serves all eligible American Indian and Alaska Native people in the area. The CTUIR was established by the Treaty of 1855, comprises the Cayuse, Umatilla, and Walla Walla tribes, and currently has an enrollment of 2,965. YTHC provides comprehensive ambulatory healthcare to the approximately 3,000 AI/AN patients living in a two-county area.

The YTHC project is unique in that it is integrating substance use disorder with primary care. YHTC already has an existing behavioral health and primary care integration in place. The Certified Alcohol Drug Counselor (CADC) is located in the nursing station with access to the Talking Rooms. A patient must have one chronic medical condition plus SUD to qualify for the YTHC BH2I program as well as committing to substance use abstinence.

The YTHC SUD-model process:

1. Warm hand-off from primary care provider to CADC
2. CADC leads patient to Talking Room.
3. CADC conducts a 90-minute American Society of Addiction Medicine (ASAM) evaluation.

Address: 73265 Confederated Way, Pendleton, Oregon 97801