Integrated Care with Indigenous Populations: Considering the

Role of Health Care Systems in Health Disparities

Melissa E. Lewis, Laurelle L. Myhra

Journal of Health Care for the Poor and Underserved, Volume 29, Number
3, August 2018, pp. 1083-1107 (Article)

Published by Johns Hopkins University Press

DOI: https://doi.org/10.1353/hpu.2018.0081

For additional information about this article

https://muse.jhu.edu/article/701004

[ Access provided at 23 Aug 2020 03:17 GMT from Massey University Library ]
LITERATURE REVIEW

Integrated Care with Indigenous Populations:

Considering the Role of Health Care Systems in
Health Disparities
Melissa E. Lewis, PhD, LMFT
Laurelle L. Myhra, PhD, LMFT

Abstract: Introduction. There is increased evidence for the effectiveness of integrated

behavioral health care, however, it is unknown if integrated care is effective or culturally
appropriate for Indigenous populations—the population with the largest health disparities
in the nation. Methods. We conducted a literature review to analyze the state of Indigenous
health care focusing specifically on the appropriateness of integrated care in this population.
Results. Integrated care could improve access to comprehensive care, quality of care, and
may be a promising model to reduce health disparities for Indigenous people. Discussion.
Indigenous people experience significant barriers to effective health care services that
require strategic, systemic, and collaborative interventions to close these gaps. Integrated
care appears to be an appropriate solution but additional research is needed to determine
this. Further, any health intervention must be carried out in collaboration with tribal com-
munities and nations to ensure success.
Key words: Integrated care, primary care, systems of care, Native American, Indigenous,
American Indian, health disparities.

T here is a growing body of evidence regarding the effectiveness of integrated care,1,2

however, it is unclear how effective or culturally appropriate integrated care is for
racial and ethnic minority populations3—specifically, Indigenous populations.* Inte-
grated care is the coordination of health care through a holistic approach, and for the
purpose of this paper, the use of behavioral health interventions within medical care.4
Compared with all other racial/ethnic groups in the United States (U.S.), Indigenous

* We use the term Indigenous to refer to the Native people of North America (United States and Canada)
(otherwise known as First Nations, Native American, Alaskan Native and Native Hawaiian). We under-
stand the complexity and political implications for the use of labels and do not wish to perpetuate insen-
sitivity of many of these labels and recommend that local and regional terms be used when possible. In
addition, the word Indigenous will be capitalized to indicate that it is representing a population group.

MELISSA  E. LEWIS is affiliated with the Department of Family and Community Medicine at the
University of Missouri School of Medicine in Columbia, Missouri. LAURELLE L. MYHRA is the Director
of Behavioral Health, Native American Community Clinic, 1213 Franklin Ave, Minneapolis, MN 55404,
lmyhra@nacc-healthcare.org. Please address all correspondence to Melissa Lewis, PhD, LMFT, University
of Missouri, MA301 Medical Sciences Building DC032.00, Columbia, MO 65212; Fax: 218-726-7559;
E-mail: lewismeli@health.missouri.edu.

© Meharry Medical College Journal of Health Care for the Poor and Underserved 29 (2018): 1083–1107.
1084 Integrated care with indigenous populations

people suffer from the largest mental health, substance use, and physical health dis-
parities.5,6 The health care settings with the largest minority populations tend to be the
lowest-performing practices, clinics, and hospitals.7,8 Further, a review of health care
quality discovered that “significant disparities in the quality of health care for AIANs
(American Indian/Alaskan Natives) exist in all dimensions of quality (structure, pro-
cess, outcomes).”7,9[p. 6] Systems are not designed to reduce health disparities, and pay-
for-performance measures may even increase health disparities because it can lead to
cherry picking and widening of the resource gap.10
Therefore, we reviewed the state of the literature to determine the fit of integrated
care with Indigenous patients as part one of a two-part series. We first scanned the
health care environment with this population in mind and gathered the most up-to-date
information including physical and mental health statistics, representation in different
levels and systems of care, the effectiveness of health interventions and systems of care,
and, finally, the health needs of Indigenous population. With this information gathered,
we were able to provide recommendations for Indigenous-serving integrated care sites.
Next, however, we had to rate the current Indigenous-serving integrated care sites to
discover if they were meeting the needs of this population. This was accomplished in
another project11 (Author, 2017).

Methods
In this literature review, the authors sought to uncover whether integrated care is an
appropriate approach to health care for Indigenous populations. As well as literature
review methodology, this research was informed by critical theory12 and guided by
decolonizing principles and methodologies.13 Critical theory brings attention to the criti-
cal consciousness, or a critical understanding, of the power dynamics around privilege
and oppression, as well as providing recommendations to increase equity.12 Decolonizing
Indigenous principles extend critical theory to Indigenous communities by pointing to
the role of colonialism in assigning value to key Indigenous lifeways, beliefs, and theories.
Decolonizing, similar to acquiring a critical consciousness, first requires an evaluation
of how colonialism has erased, devalued, or usurped Indigeneity as its own and, second,
requires an application of methods to highlight Indigenous voices, beliefs, and needs.
Dr. Smith defines decolonizing research as “committed to producing research knowledge
that documents social injustice, that recovers subjugated knowledges, that helps create
spaces for the voices of the silenced to be expressed and ‘listened to,’ and that challenge
racism, colonialism and oppression . . . ”13[p. 198] In this paper, we aim to highlight the
inequity of health care in Indigenous communities and provide recommendations to
improve health equity by emphasizing the importance of community-led action.
A comprehensive literature search was conducted using three databases (i.e., Eric,
Medline, and PsycInfo) and a combination of key words (Native American, American
Indian, First Nations, Indigenous; integrated care, primary care, family medicine, behav-
ioral health, mental health) resulted in 2,889 hits. Articles were selected for inclusion
that provided pertinent information about the health care environment for Indig-
enous populations including health statistics, access to and representation in different
 Lewis and Myhra 1085

health care systems, and the gaps in health care services. Although we did not exclude
articles from outside of the U.S., we also did not use search terms that might increase
the likelihood of incorporating more international populations. Articles that were not
methodologically sound were excluded. Selected articles were further analyzed for
additional resources via citations. At the completion of the literature review, authors
critically analyzed and synthesized data systematically into themes.

Results
Racial and ethnic minorities experience physical and mental health inequities due to
historical, current, systemic, political and environmental barriers to health and well-
being.14 These barriers—often referred to as social determinants of health—encompass
factors within the social environment that influence an individual’s, family’s, and com-
munity’s subsequent trajectory. Commonly cited social determinants include socioeco-
nomic status, education, early childhood experiences, social exclusion, lack of social
support, exposure to stress, unemployment, substance use, food insecurity, and lack of
access to transportation that predict health outcomes such as susceptibility to increased
illness and disease and reduced lifespan.15 The barriers that lead to health disparities
are rooted in history and current perpetuation of racism and discrimination16,17 and
colonization.18,19 Many authors argue that in order to improve care and address health
disparities, a decolonizing process must occur.20–21
The first step in decolonization includes an increased awareness of disparities. This
section will highlight disparities that exist for Indigenous people within the medical
system including accessing care, receiving preventive care, and receiving intervention
services. Next, culturally safe and effective care will be covered including the role of bias
in health care, trust within the medical system, patient-provider relationship dynamics
for Indigenous people, and accessibility of culturally appropriate care.
Health care services. Indigenous health disparities. Indigenous people are more
than twice as likely as the general U.S. population to live in poverty (26% vs. 12%)22
and to be victims of violent crimes.23 Indigenous women in particular are 2.5 times
more likely to be raped or sexually assaulted than the general population of women
in the U.S.24 Indigenous children are six times more likely to experience many adverse
childhood experiences (≤4 ) than non-Indigenous children.25 Indigenous people are
three times less likely to have health insurance compared with other Americans, while
57% use Indian Health Service (IHS). However, the average amount spent for an IHS
enrollee per year is $1,900 compared with $5,200 for Veterans and $6,000 for Medicaid
recipients.26 Indigenous people have higher rates of mental health distress compared
with the American populations (1.5 x)27 with twice the rate of post-traumatic stress
disorder (PTSD) and alcohol dependence.28 Heart disease prevalence and premature
death is double that of non-Indigenous people, and rates are rising for Indigenous
people as they have flattened for the general population.29–31 Compared with the U.S.
as a whole, Indigenous people have a shorter life expectancy (six years shorter), higher
rates of infant mortality,32 and die from tuberculosis, diabetes, or unintentional injuries
at higher rates (6 x higher).6
1086 Integrated care with indigenous populations

Access to care. Access to care includes the availability, accessibility, accommodation,

affordability, and acceptability of care.33 Approximately 80% of Indigenous people desire
basic wellness care, but only 14% have seen a medical doctor in the previous year.34,35
While Indigenous people are more likely to have sought medical treatment due to a
medical need,36,37 they are less likely to have received preventive care or have a primary
care provider compared with other groups. Additionally, Indigenous people who live in
rural areas have little access to specialty care due to being underinsured, a lack of local
specialty providers, and transportation barriers.38 Furthermore, Indigenous adolescents
and adults have less access to mental health treatment than their non-Indigenous
counterparts.39,40 This is due, in part, to the fact that there are minimal mental health
and substance use services at clinics frequented by Indigenous people.41
Gaps in specialty and behavioral health care at IHS facilities result in delayed
diagnosis and treatment, leading to greater need for intensive and emergent services.6
Indigenous adults and adolescents experience hospitalization rates 2.5 times higher than
the general population and have 1.5 times more preventable hospitalizations.42,43 Shah
and colleagues43 concluded that primary care is not only difficult to access, but may
be ineffective for this population. Another driver to lack of access is lack of culturally
acceptable services.33 Incorporation of Indigenous health beliefs, and respect for them,
is starkly missing from the care Indigenous people receive. The combination of lack of
access to care and lack of fit of health care needs and services may be why Indigenous
people do not receive the same benefits of primary care as the general population.
Prevention services. Indigenous patients of all ages do not receive adequate health
prevention services.44,45 Indigenous children receive the lowest rates of well-child visits in
the country, at 63%, compared with non-Hispanic White children at 85%.46 Specifically,
less than 30% of Indigenous children receive a developmental check-up, only 10% ever
had vision checked, and 8% had their hearing screened.47 Further, the dental health
of Indigenous children is also significantly worse than that of non-Hispanic White
children.48 Only 40% of Indigenous children have a medical home, which is 27% lower
than their non-Indigenous counterparts.49 For this reason, mental health screenings,
which are typically conducted during preventive care visits, may not be obtained until
a mental health crisis and therefore are often conducted at an emergency department.50
Further, Indigenous children ages 2–17 receive significantly less advice about physical
activity compared with non-Hispanic White children,51 despite suffering from obesity
more than other racial/ethnic groups in the U.S.52
Indigenous adults experience health care disparities in preventive areas such as
prenatal care (two times more than non-Hispanic Whites) and colorectal cancer
screening.51 For Indigenous elders, only 56% of the population meet the standard for
mammograms, 37% for fecal occult blood testing, 33% for hearing, 50% for vision,
and 49% for influenza vaccination.53 However, when elderly Indigenous patients
have health insurance, they are more likely to complete prevention check-ups and
assessments.53
Treatment services. Major health inequities for Indigenous people include unmet
needs in the areas of medical, mental health, dental, vision, and hearing.36 In one study,
23% of Indigenous patients had hypertension but did not have the diagnosis in their
chart; this suggests that proper assessment of hypertension in Indigenous people is
 Lewis and Myhra 1087

not occurring, and as a result that treatment of Indigenous people for hypertension is
delayed or in some way prohibited.54 Additionally, Indigenous people experience some
of the worst cancer survival rates,55 mainly because they are less likely to receive 1)
optimal cancer care and 2) surgery.55,56 Further, Indigenous adults are less likely to be
prescribed psychiatric medications than non-Hispanic Whites,39 despite the staggering
mental health diagnoses and needs of this population.
Bias in health care services for Indigenous patients. The role of bias in health care.
Treatment differences among racial/ethnic groups are related to unconscious or implicit
bias. Non-Hispanic Whites are more likely to receive more services, more thorough
diagnostic work, and better treatment than racial and ethnic minorities, even when
controlling for socioeconomic factors.57,58 Microaggressions—subtle and sometime
unconscious racist remarks or behaviors— 59 are found to be correlated with history
of heart attack, worse depressive symptoms, and prior year hospitalization for diabetes
patients.60 Providers working with Indigenous patients also engage in unconscious bias,
microaggressions, and discriminatory practices.61 For instance, a study of implicit and
explicit bias towards Indigenous people in emergency room providers found that one
third of providers believed negative stereotypes about Indigenous people.62 This study
used pictures of local non-Hispanic White and Indigenous patients, as well as identi-
cal, written case vignettes (randomly assigned by race/ethnicity). Providers viewed
Indigenous children in these vignettes as significantly more challenging to work with
and their parents as less compliant to their treatment recommendation in comparison
with non-Hispanic White patients. Such practices produce negative patient experiences
including increased feelings of stigma and poor physician-patient relationships, as well
as reduced help-seeking behaviors and poor treatment adherence.5,63,64 Further, experi-
ences of bias for Indigenous patients are related to worse health outcomes.65
Trust in the medical system. Indigenous people may hesitate to enter the medical
system due to both historical and contemporary instances of discrimination and inef-
fective contemporary cross-cultural communication. Lack of trust may occur at the
individual level and the intergenerational family level. Trust is rated as the single most
important theme in the patient-provider relationship and at a clinic visit,55,66 making
this a major barrier to adequate care. In a review regarding pain, a theme emerged
that Indigenous patients felt their providers did not take into account their pain and,
therefore, did not believe their providers could effectively treat them.67 Similarly, provid-
ers believed that Indigenous patients were exaggerating their pain ratings. This study
suggests reasons that Indigenous patients may not trust their providers or health care
system in the present day: they sense and experience bias against themselves and their
relations within these institutions. Emerging research in minority populations has found
that physicians provide less care and prescribe less medication to minorities, from pain
medication68 to antiretroviral medicine.69 This inequitable treatment and care between
races and ethnicities demonstrates that discrimination occurs within the health care
system. The combination of worse health care treatment and negative experiences
that Indigenous patients have in health care settings may explain the reduced use of
preventive services and worse chronic disease management within IHS.45
Culturally appropriate treatment. Indigenous people are more likely than others
to view health through a holistic, biopsychosocial-spiritual lens, which is inherently
1088 Integrated care with indigenous populations

interconnected with family and community.70–72 These are some of the basic tenets of
Traditional Indian Medicine (TIM). Indigenous patients seek TIM for a variety of physi-
cal health conditions (e.g., arthritis, hypertension, type 2 diabetes), as well as mental
health concerns (e.g., trauma and pain).73–76 Traditional Indian medicine differs from
traditional Western medicine in that it not limited to guidance and treatment in the
domain of physical health but also in cultural and spiritual arenas and is grounded in
Indigenous knowledge, beliefs, practices, and ceremonies. Traditional Indian Medicine
also differs from Western medicine in that health is not conceptualized within an
individual framework, but rather depends on family, community, and larger ecological
systems.77 Therefore, assessment and treatment consider these larger systems.
In one study, TIM utilization was 70% in an urban primary care location,53 and it
appears to be a growing practice among Indigenous people.78 However, the increase
in TIM utilization does not mean Indigenous patients are using Western medicine
less frequently. Patients who use TIM also tend to use Western medicine for the same
ailment and they do not believe that the services are in conflict with one another.34,76,79
In one study, around 50% of patients accessed medical services, while 42% accessed
TIM, with a 16% overlap.80 The main barriers in accessing TIM include the cost of
services,76 the high rate of new and non-Indigenous providers in Indigenous-serving
facilities unfamiliar with TIM, and limited access to traditional healers due to historical
holdovers from policies prohibiting Indian religion until 1978.38
While many Indigenous people prefer to receive culturally tailored care, the health
care system and workforce are not prepared to provide these services. Jimenez and
colleagues pointed out that, “research indicates that Native patients embrace culturally
grounded health beliefs and values . . . that distinguish them from their health care
providers and sometimes result in medical miscommunication.”67[p. 7] This finding was
consistent with reports from a cohort of family medicine residents in urban Canada,
where 40% felt ill-prepared to work with Indigenous people.81 Providers and patients
are more likely to rate medical visits differently when patients identify less with White-
American culture. Patients who identify most closely with Indigenous culture are
significantly less satisfied with their provider.82 Therefore, cultural differences result
in worsened relationship between patient and provider.
Providers generally cannot define what TIM is and what its benefits and risks are,83
and thus are unable to determine which patients prefer TIM as part of their health
visit.84 Further, TIM is the least accepted of all complementary and alternative medi-
cine practices.85 Providers are more likely to accept TIM for the use of general health
and well-being, non-malignant illnesses, and palliative care, but not for malignancies
or other life-threatening conditions or in intensive care units.83 It is important to note
that training experience, not evidence of effectiveness of TIM, is related to likelihood
of referral for alternative medicine. Only 5% of medical doctors have received any
training on TIM.85
Physicians who had previous exposure to Indigenous issues, people, or communities
were more willing to work with this population and/or allow TIM in their practice.81
Specifically, they knew at least five patients who used TIM or were currently working at
an Indigenous-serving clinic.83 Providers changed their practice style to meet the needs
of their Indigenous patients by: 1) learning more about Indigenous people (including
 Lewis and Myhra 1089

their cultural ways of being), 2) increasing the value of the patient’s community in
their practice, and 3) incorporating Indigenous health beliefs into their practice (e.g.,
culture, community, and patient care cannot be separated).86 Providers learned culturally
appropriate interpersonal behaviors, which included talking less, becoming comfort-
able with silence, taking more time with their patients, and performing self-critique
of their inherent biases and beliefs.
Culturally safe care. Culturally safe care includes redressing behaviors that, “diminish,
demean, or disempower the cultural identity and well being of an individual.”87[p. 198]
Culturally safe care creates a minimum standard needed to prevent physical, emotional,
or moral injury to the patient.88 Rooted in critical race theory and founded in nursing
care in New Zealand in the 1980s around Maori health, the main attributes of this type
of care include addressing the effects of colonization in care, critical self-reflection and
awareness, and attention to respecting the rights and dignity of the patient.89 Cultural
safety is related to patient care and quality of care because they both aim to reduce
negative patient outcomes. Cultural safety also adds unique dimensions of care around
the moral safety of Indigenous patients and providers, redressing power inequities, and
reduces discrimination in care.90 Similar constructs include social justice beliefs, cultural
intelligence, cultural responsiveness, ethnocultural empathy, or cultural humility. It
differs from cultural competence in that it focuses on addressing power, self-reflection,
and humility instead of knowledge attainment.91
It is important that all patients feel culturally safe in the clinic or hospital. However,
about 44% of health professionals say that addressing culture is somewhat to extremely
stressful and cite several sources of this stress including the health care organization,
providers and staff, time constraints, and difficulty explaining cultural concepts.92
When providers do not attend to culture in their medical visits they risk increased
and unnecessary visits, stays, and readmissions,93–96 both increased and decreased use
of procedures for racial and ethnic minority patients,97–99 medical errors resulting in
negative clinical outcomes,100–104 longer stays at the hospital,105 and less adherence to
treatment plan.57,106 Providers who receive cultural training are more likely to increase
knowledge about the role of culture in health and health outcomes improve for racial
and ethnic minority patients.107
Fit of integrated care for Indigenous populations. Given that health and health
care system disparities persist for Indigenous people, it is critical to find models that
can effectively reduce these health inequities. It appears that integrated care—which
interweaves types of care with one another and with patient/caregiver feedback—may
be a good fit for this population for several reasons: 1) Integrated care models offer an
opportunity to address both behavioral and physical health needs simultaneously and
Indigenous populations suffer disproportionately from comorbid and multi-morbid
health conditions that requires sophisticated, coordinated care. 2) integrated care is
based in systems theory, which allows for the assessment and treatment of illness in
the biological, psychological, social, and spiritual domains.108 The social and ecological
domains of health and well-being are often ignored in traditional Western health care,
while this is not true of integrated care. 3) Besides addressing the biopsychosocial-
spiritual health of an individual, integrated care aims to provide equitable care in which
providers and patients work collaboratively.109,110 This approach allows for the beginning
1090 Integrated care with indigenous populations

stages of decolonization to occur by flattening the uneven hierarchy that Indigenous

people routinely experience, in health care systems and elsewhere. 4) The integrated
care model utilizes the strengths and collaborative skills of many health profession-
als and specialists, depending on the population. Given the importance of TIM and
culturally appropriate care for Indigenous patients, it is critical that these sources of
healing are integrated into their care.
Recommendations for integrated care with Indigenous patients and their fami-
lies. Central components of integrated care programs include 1) collaboration among
financial, administrative, and clinical worlds; 2) a shared theoretical foundation; 3)
integration of family and community into care; 4) patient-centered care; 5) effective
interprofessional collaboration; 6) flattening of the patient-provider hierarchy; and 7)
interprofessional training experiences.111–115 These seven key traits of integrated care
were selected based on foundational evidence from the integrated care literature.
In what follows we make seven recommendations based on the articles reviewed
above. Some recommendations are based on both practical needs of the Indigenous
patient population such as access to care or service delivery. Others emphasize the
need for culturally relevant and safe care free from bias and discrimination (see Box 1).
1. Financial and administrative considerations. Some of the most promising results
in integrated care in both general and Indigenous populations are in the reduction of
emergency room visits and associated cost offset through improved chronic health
management.116–118 Therefore, we note that creative funding and billing strategies, as well
as innovative service delivery, are necessary119 to meet the needs of Indigenous people who
have less access to health care services. This can be accomplished by providing incentives
to receive preventive services,120 use telehealth,121 train paraprofessionals,122 implement
home visits,123 and collaborate in order to leverage payers.
2. Shared theoretical foundation. It is important to supplement the foundational prin-
ciples of integrated care with regional and cultural Indigenous beliefs when considering
collaboration models. Specifically, integrated care specialists working with Indigenous
populations should add TIM and/or Indigenous belief systems to the biopsychosocial-
spiritual (BPSS) model. Indigenous knowledge encompasses the traditional belief
systems that Indigenous people hold in areas such as family dynamics, ecology, and
health.71 This information must be respectfully incorporated into a health clinic with
the permission and collaboration of the local community.
When providers from different disciplines who work on the same care team and use
a shared health view, such as the BPSS lens, they are more effective than teams who
do not use shared health theories and beliefs.124 For example, eliciting TIM beliefs and
needs at initial encounters can then be stored in the electronic medical record system
for all providers to access and make treatment recommendations based on the patient’s
health belief system.84 The chasm between medical and mental health worlds may be
split even larger when Indigenous viewpoints are added to the treatment team (e.g., the
difference between the medical model, the BPSS model, and Indigenous health beliefs).
3. Family and community. A review of integrated care interventions found that only
one out of 75 sampled articles used family therapy despite evidence of the effective-
ness of family therapy in primary care settings.125 This is problematic for Indigenous
patients for whom family is a significant source of strength. Notably, successful
 Lewis and Myhra 1091

Box 1.
RECOMMENDATIONS FOR INTEGRATING HEALTH
CARE SERVICES WITH INDIGENOUS PATIENT
POPULATIONS

Recommendation for
Integrated Care at
Key Integrated Indigenous-serving
Care Component sites Special Considerations

1. Financial and Build creative Build proposals for desired

administrative funding and billing programs to send to
considerations strategies, as well potential funders, including
as innovative foundations and tribes.
service delivery, to Build programs with billing
meet the needs of capacity that will help to
Indigenous people offset unbillable services.
who have less Leverage findings with payers.
access to health
care services.
2. Shared theoretical Add TIM and Techniques of cultural humility
foundation Indigenous beliefs must be taught first to allow
to the BPSS model space for new viewpoints.
at Indigenous- Indigenous knowledge and
serving clinics. Western scientific theories
must be equally used and
valued for true equity.
3. Family and Consider the family Implement larger exam rooms
community and community or family meeting spaces,
as a possible unit flexibility in utilization of
of care and plan conference space, engage all
accordingly. family members with special
acknowledgment of the elders.
Understand the complexities
of multigenerational family
systems. Community advisory
council.
(continued on p. 1092)

Indigenous-serving clinics have larger exam rooms to accommodate up to seven support

persons.126 In addition, community and tribal networks are important for Indigenous
people. Therefore, Indigenous patient navigators and interpreters are critical because
they can guide the integrated care team in privileging patients’ belief systems.127 Fur-
ther, a community advisory board that informs culturally specific care and policies is
an important consideration at Indigenous-serving clinics.61 Integrated care services that
1092 Integrated care with indigenous populations

Box 1. (continued)

4. Patient-centered Mandate orientations Utilize local, regional

care for all new hires knowledge. Best practices
in which history, based on patient-provider
culture, and collaboration. Patient
beliefs of regional oversight in development and
tribal people are implementation of training.
highlighted. Culturally appropriate
interpersonal skills, which
may include talking less,
becoming comfortable with
silence, taking more time
with patients, and perform
self-critique of inherent biases
and beliefs.
5. Interprofessionalism Create a strategic and More time/resources needed
collaborative plan to be put forth compared
to redress historical with other populations
and current to fill the gaps that exist.
inequities between Due to the larger gap in
Indigenous and hierarchy between patient-
non-Indigenous provider compared with
people in health other populations, trust
care delivery building strategies including
practices. consistency in providers,
all staff trainings, team
approach to care, and efforts
to personalize service are
needed.
6. Flattening the Health care providers Integrate Indigenous health
patient-provider should receive beliefs into training
hierarchy training and programs, providers should
supervision early engage in community
and consistently projects and activities to build
throughout their rapport with community
careers to ensure and gain more knowledge,
appropriate opportunities for patients
patient-provider to engage in training and
interactions. advisory capacity with
providers. Clinic policies
should require supervision,
community projects, and
continued learning in the area
of Indigenous health.
(continued on p. 1093)
 Lewis and Myhra 1093

Box 1. (continued)

7. Cross-training Create co-training Support pipeline programs;

opportunities engage skilled and culturally
with racially and knowledgeable providers
ethnically diverse and trainers in teaching
peers, as well as of teachers; and outreach
preceptors. to youth regarding health
care careers and offer
field experiences. Engage
community knowledge
holders into collaborative
training experiences.

serve Indigenous patients should always consider the family and community as a possible
unit of care and plan accordingly.
4. Patient-centered care. Patient-provider trust may be particularly critical when
working in an Indigenous-serving setting due to the historically negative relationship
between tribal and medical communities. This history, coupled with current mistreat-
ment has resulted in mistrust and reduced satisfaction with health care services.128 When
providers know about historical treaties and policies of the U.S., Indigenous culture
and values, and current societal and health inequities, they can address inherent and
unconscious biases they may hold. Therefore, it is critical that health care providers
learn more about Indigenous culture so that these work interactions can be positive, free
from discrimination, and eventually collaborative. This can be attended to by having
orientations for all new hires in which the history, culture, and beliefs of regional tribal
people are highlighted. Further, regular in-service presentations by tribal members will
continue education and growth of the collaborative team over time.
5. Interprofessionalism. In integrated health care systems, exposure to mental- and
physical- health care providers results in enhanced acculturation to the language and
treatment assumptions of the other profession.129 Increased communication between
providers leads to a cross-training effect where an exchange of skills and knowledge
between providers takes places.130 This results in a holistic assessment and treatment
of the illness/disease2 and increased patient agency, which is associated with adher-
ence to treatment plans.124 Further, medical professionals and patients both feel more
satisfaction when collaboration is high.
For Indigenous-serving integrated care sites, the culture of the tribal community
must be incorporated into the care system. Integrating Indigenous viewpoints requires
exposure to Indigenous patients and the community, strategic in-service trainings man-
aged by a competent and culturally knowledgeable administration, and shared core
competencies—both in integrated care and in Indigenous health beliefs.125,131 However,
historically, (just as Indigenous people have been given less respect and autonomy in
society) patients have been given less power in the exam room. Therefore, the harms
1094 Integrated care with indigenous populations

of oppressive hierarchies are far reaching requiring administration, providers, clinic staff,
and patients to create a strategic and collaborative plan to redress historical and current
inequities in health care delivery practices for Indigenous patients.
6. Flattening the patient-provider hierarchy. Redressing the hierarchical practices that
occur between provider and patient may be even more pronounced with Indigenous
patients.132,133 Americans are exposed to inaccurate and damaging images and historical
accounts of Indigenous people from very early ages resulting in conscious and uncon-
scious biases that carry harmful outcomes for Indigenous people.134 In the health care
setting, medical providers with limited exposure and understanding of Indigenous
people may pathologize and fail to adequately treat patients. In order to be ethically
responsible to Indigenous patients, health care providers should receive training and
supervision (didactic and experiential) early and consistently throughout their careers to
effectively work in integrated care sites that serve Indigenous patients.
7. Interdisciplinary training. Early cross-training experiences for medical and behav-
ioral health students and early professionals increase the likelihood of effective and
positive collaboration,125,135 which should include Indigenous collaborators. While there
are very few Indigenous medical providers,136 this number is rising due to an increase
in awareness of the inequities, funding for pipeline programs, and the presence of
professional groups like the American Association of Indian Physicians (AAIP) and
American Indian/Alaskan Native Society of Indian Psychologists (AIANSIP).137 There-
fore, consistent with previous recommendations, cross-training with Indigenous culture
keepers and healers should occur. In particular, Mehl-Madrona138 presents training
recommendations for health care professionals who plan to work within an Indigenous
health framework. Co-training opportunities with racially and ethnically diverse peers,
as well as preceptors, is critical in effective integrated care with Indigenous populations.
This first requires the support of pipeline and other programs that increase the opportu-
nity for Indigenous students to access and succeed in schooling and then work within the
health care field. This can be accomplished by 1) recruiting/retaining more Indigenous
medical students,137,139 2) adding Indigenous health content to medical school curricu-
lum140,141 and 3) hiring more Indigenous faculty to train all medical students.137,142 The
same recommendations can be applied to behavioral health students and providers.

Discussion
Systemic changes must occur to address Indigenous health disparities within primary
care. Our analysis suggests that Indigenous people experience disparities within health
care systems, which limits their potential for health and healing. Indigenous patients
experience barriers to accessing care, discrimination, and worse care (e.g., less preven-
tion and treatment services), and are less likely to receive culturally safe care and/or
care within their cultural belief system or from someone from a similar background.
While systems of care is only one factor that influences health outcomes, the disparities
that exist within this factor alone for Indigenous people is astounding and sounds an
alarm for all those working within the health care field.
Integrated care appears to be an exciting opportunity to reduce mental and physical
health disparities for Indigenous people, yet it must be carried out collaboratively and elicit
 Lewis and Myhra 1095

local knowledge. Our results are based on a review of available literature in the area of
integrated care coupled with a critical analysis of the literature. Our results require further
empirical validation. For that reason, we call on researchers and tribal members to work
in collaboration to examine the effectiveness of integrated care programs with Indigenous
patients using scientific inquiry and Indigenous knowledge, beliefs, and lifeways to reduce
the burden of mental health, substance use, and chronic illness in tribal communities.
Limitations. Although we did not rule out Indigenous populations from places other
than the United States in our search, we also did not use specific search terms that could
increase the amount of articles selected for such populations. Therefore, the majority of
our review covers the population on Indigenous communities in the United States only.
Many commonalities exist across Indigenous populations internationally; it should be
noted that the literature reviewed here might be generalizable to the North American
context more broadly. In addition, we anticipate that international literature (e.g., New
Zealand, Australia, Canada) on Indigenous health may focus more on addressing the
effects of colonization than what we reviewed here.13
Conclusion. Integrated health care systems are best suited to provide care to people
with complex health care needs and result in positive health outcomes by improving
access, quality, efficiency and effectiveness of service delivery.119,143 By this definition,
integrated health care should be effective in treating the comorbid conditions of
Indigenous patients—those patients most severely affected by health inequities in this
country. Our review highlighted the need for thorough assessment of health care system
practices and a need to engage community in the development and implementation
of health programs to eliminating health disparities within health care systems for
Indigenous communities. Improving the health care experience (e.g., access, preven-
tion and treatment services) should incorporate strategies that combine evidence-based
and promising practices and deepen community relationship by leveraging the wisdom
of elders and community members. This should be accomplished through changes
throughout the health care system from a more equitable recruitment plan of ethnic
and racial minorities into health care positions to more equitable health care resource
allocation at the federal level. Recommendations for implementation of integrated care
programs or models with Indigenous communities were presented as a preliminary
guide to clinicians and administrators making this transition.

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