Facilities Appropriation Advisory Board (FAAB) Establish ed as a standing committe e of Tribal and Indian Health Service (IHS) representa tives. Primary purpose is to make recommendations to the IHS Director on matters involving all Office of Environmental Health and Engineering (OEHE) programs.  

FAAB Activities The Indian Health Care Improvement Act, 25 U.S.C. § 1631(c), requires the IHS to: Re-established the FAAB to provide the IHS recommendations on policies, procedures and other OEHE programs pursuant to facilities appropriations. Every five years update the Health Care Facilities’ Needs Report to describe the national, comprehensive, ranked list of all facilities’ needs for AI/AN, including newly authorized healthcare facilities. 2016 Report showed a need of approximately $14.7 billion.

FAAB Accomplishments FAAB Letters: Distributed the Charter on May 22, 2015: IHS Circular No. 2015-04: Facilities Appropriation Advisory Board. Established a Facilities Needs Assessment Workgroup to assist updating reports. Completed and submitted 2016 Report to Congress in July 2016. Produced and updated an annual OEHE Appropriation Information Package. FAAB Letters: To national budget formulation group in support of increasing FY2017 Maintenance and Improvement (M&I) funding. To IHS Director endorsing Health Care Facilities Construction Priority System. To IHS Director recommending tribal leaders identify their health care facility’ needs. To IHS Acting Director recommending all federal and tribal sites to update the Facilities Engineering Deficiency System.

IHS Appropriation Services and Facilities The Services Appropriation has increased about 7% per year while the Facilities Appropriation has remained fairly flat.

IHS Services Appropriation Clinical Services Hospitals & Health Clinics Dental Services Mental Health Alcohol & Substance Abuse Preventive Health Public Health Nursing Health Education Community Health Representatives Immunization AK Other Services Urban Health Indian Health Professions Tribal Management Grants Direct Operations Self-Governance

IHS Facilities Appropriation Health Care Facilities Construction Maintenance and Improvement Equipment Sanitation Facilities Construction Facilities and Environmental Support Facilities Support Environmental Health Support Office of Environmental Health and Engineering Support Health Care Facilities Construction – Construction of new and replacement health care facilities. Small Ambulatory Program. Joint Venture Maintenance and Improvement – Routine Maintenance, Projects to resolve the backlog of Essential Maintenance, Alteration and Repair (BEMAR); Environmental Audits and Remediation; Demolition of Vacant, excess, or obsolete federally owned buildings Equipment – Replaces medical equipment; Project TransAm; Ambulances; Equipment funding for tribal constructed facilities using non-IHS funding Sanitation Facilities Construction – Projects for Water, Sewer, and Solid Waste needs for Existing Homes and Communities; New Homes Facilities Support – O&M of health care facilities and staff quarters (Real Property); Medical equipment technical support and repair; Construction management support; Construction management support; National maintenance management system for facilities and medical devices including traclign FDA alerts on medical equipment Environmental Health Support – Environmental health service/staff; Injury prevention service/staff; Sanitation Facilities Construction Staff Office of Environmental Health and Engineering Support – Staff at IHS Headquarters OEHE and in the two regional Engineering Services, for direct support/management of all the Facilities Appropriation activities.

Fifty-five percent of all IHS facilities are older than 30 years of age. The IHS hospitals, which now average 40 years of age, are almost four times older than U.S. hospitals in general (10.6 years of age). Source: Almanac of hospital financial & operating indicators: a comprehensive benchmark of the nation’s hospitals (2015 ed., pp. 176-179) Fort Yuma CA, 1936

The IHS facilities vary widely in age, capacity, design, and function The IHS facilities vary widely in age, capacity, design, and function. Some were constructed decades ago before the modern era of medical practice, standards, and codes. Some of the oldest facilities continue in use well past their expected useful life and many older facilities are overcrowded. By contrast, recent IHS facilities are designed for state-of-the art medical practice such as patient/family center models of care. Their internal configuration is updated, which improves productivity and patient flow.

IHS Completed Construction Projects Cheyenne River Health Center, Eagle Butte, SD Kayenta Health Center, Kayenta, AZ Norton Sound Regional Hospital, Nome, AK San Carlos Alternative Rural Health Care Center, San Carlos, AZ

Health Care Facilities Construction Health Care Facilities Construction Appropriations are the primary source for new or replacement healthcare facilities. The number, location, layout, design, capacity and other physical features of healthcare facilities are essential in eliminating health disparities, improving patient outcomes and increasing Access. The absence of an adequate facility frequently results in either treatment not being sought, sought later prompted by worsening symptoms and/or referral of patients to outside communities which significantly increases the cost of patient care and causes travel hardships for many patients and their families. At the current appropriations rate (~$110 million/year), a new facility in 2017 would not be replaced for 300 to 400 years. To replace IHS facilities every 60 years (twice a 30 year design life), would need appropriations of ~$500 million/annually. The IHS would need appropriations of ~$1 Billion/annually to reduce the need by 95% by 2040. IHS would need HCFC appropriations of ~$750 million/annually to match the U.S. expenditures in healthcare facility construction. Without a sufficient, consistent, and re-occurring appropriations the entire IHS system is unsustainable.

Construction Grandfathered list

2016 Facility Needs Assessment The table shows facility need in square feet and estimated cost by IHS Area in 2016. The data is based on IHS Health Facilities Data System existing program space, the Health System Planning recommended space, approved Planning Documents, and the Facilities Budget Estimating System. The Importance of the Facility Environment to Patient Outcomes The healthcare physical environment has long been recognized as having a substantial impact on patient care experiences and outcomes. There is overwhelming rigorous research, more than 600 credible studies, that link the physical environment of care to health outcomes. The impact of the healthcare facility physical environment on the occupants is significant.

Maintenance and Improvement Maintenance and improvement (M&I) funds are the primary source for maintenance, repair, and improvements for facilities which house IHS funded programs, whether provided directly or through P.L. 93-638 contracts/compacts. The FY-2017 and 18 Maintenance and Improvement (M&I) funding is $75.7 million which is a 2.9% increase from 2016. The M&I program funding is distributed through a formula allocation methodology Adequate funding is essential to ensure functional health care facilities that meet building/life safety codes, conform to laws and regulations and satisfy accreditation standards. From 2007 to 2015, M&I appropriations remained flat at about $53 million annually. Funding for facilities maintenance began to dip below sustainment levels in 2011 and by 2015 was only about 80% of the amount required to properly maintain the existing facilities.

Sanitation Facilities Construction Funds appropriated for water supply and waste disposal facilities are under the Sanitation Facilities Construction (SFC) line item. Projects are cooperatively developed and transferred to Tribes who assume responsibility for the operation of safe water, wastewater, and solid waste systems, and related support facilities. The sanitation project need is almost $3.4 billion, which includes 171,674 homes that are in need of some form of sanitation facility improvement.

The IHS continues to have several opportunities to provide critically needed new and renovated facilities including: The 2018 and 2019 Facilities Appropriation was 60% high than 2017 levels with a large increase in the M&I, SFC and HCFC funding; IHS has also received well over $120 million in Non-Expended Funds (NEF) facility projects in 2019; There will be a 2019 solicitation for applications for the $15 million for the Small Ambulatory Program (SAP); There will be a 2019 solicitation Joint Venture Construction Projects as well; and The 2019 facilities appropriation allowed IHS to partially fund all of the remaining projects on the 1992 grandfathered priority list.

Approved Joint Venture Projects 2016 – Yakutat Tlingit Tribe, Ysletta del Sur Pueblo, Ponca Tribe of Nebraska, White Earth Band of Chippewa Indians 2015 – Choctaw Nation, Cherokee Nation, Yukon Kusokwim Health Corp 2014 – Muskogee (Creek) Nation, Eastern Shoshone/Norther Arapahoe, Alaska Pribilof Island Association 2011 – Kenaitze Indian Tribe, Mississippi Band of Choctaw, Chickasaw Nation The IHS partners with Tribes or Tribal organizations (T/TO) in Joint Venture Construction Projects where a T/TO would acquire, construct, or renovate a health care facility and lease it to the IHS, at no cost, for a period of 20 years. Participants in this competitive program are selected from among eligible applicants who agree to provide an appropriate facility. The facility may be an inpatient or outpatient facility. The Tribe must use Tribal, private or other available (non-IHS) funds to design and construct the facility. In return the IHS will submit requests to Congress for the staff, operations, and maintenance funding of the facility per the Joint Venture Agreement.

Completed Joint Venture Projects Cherokee Nation - Vinita Cherokee Health Center, Vinita, OK Chickasaw Nation - Ardmore Indian Health Center, Ardmore, OK Chickasaw Nation - Tishomingo Indian Health Center, Tishomingo, OK Southcentral Foundation Valley Native Primary Care Center, Wasilla, AK Tanana Chiefs Conference, Fairbanks, AK

Small Ambulatory Grants Program The Indian Health Service (IHS) Small Ambulatory Program (SAP) is authorized by Section 306 of the Indian Health Care Improvement Act, Title III, Public Law (P.L.) 94-437. The SAP is available for American Indian and Alaska Native tribes or tribal organizations to competitively obtain funding for the construction, expansion, or modernization of tribally owned small ambulatory health care facilities. Applications are currently being accepted and are Due December 1, 2017. Make sure to review the eligibility criteria prior to submitting. Legislative Requirements: Funding can be provided only to eligible applicants who meet the program criteria and can demonstrate compliance with the following:  Funding, under this authority, may be provided Only to a Federally recognized Indian tribe or tribal organization, who Operates An Indian Health Care Facility Pursuant to a Health Care Services Contract entered into Under The Indian Self-Determination and Education Assistance Act, P.L. 93-638, when: o the facility is not owned or constructed by the IHS; or o the facility was not originally owned or constructed by the IHS and transferred to the tribe.  The ambulatory health care facility in the proposed project is located apart from a hospital, and is not contiguous or immediately adjacent to a hospital.  The proposed project has not received any funding already under Section 301 or Section 307 of P.L. 94-437.  Upon completion of the proposed project, the health care facility will: o have a total capacity appropriate for its projected service population; o serve no less than 500 eligible Indians annually; and o provide ambulatory care in a service area (specified in the services contract entered into under the P.L. 93-638) having not less than 2,000 eligible Indians. For the purposes of carrying out the SAP, the condition containing the phrase  Be competitively selected from applications submitted in accordance with published selection criteria.  Must be able to provide reasonable assurances, that upon completion of the proposed project, the applicant will: o have adequate financial support available for providing the services at the health care facility; o make the health care facility available to eligible Indians without regard to ability to pay or source of payment; and o provide services to non-eligible persons on a cost basis, in accordance with Federal Law, without diminishing the quality or quantity of services provided to eligible Indians.  A need exists for increased ambulatory health care services.  Currently, there is insufficient capacity to deliver needed services.

SAP – Completed Projects OK - Purcell Outpatient Clinic CA - Santa Ysabel Health Care Facility AK - YKHC Toksook Bay Regional Clinic PO – Makah Tribal Health Administration and Wellness Center CA - Mariposa Indian Health Clinic PO - Inchelium Health Care Facility – Colville Tribe CA - Campo Satellite Clinic –Southern Indian Health Council AK - Hooper Bay Sub-Regional Clinic - YKHC PO - Tribal Medical & Dental Clinic-The Klamath Tribes PH - Reno-Sparks Indian Colony Clinic AK - Kake Clinic Expansion – SEARCH Village Kake AK - Chenega Bay Health Clinic – Chugachmiut Village PH - Las Vegas Paiute Colony Health Care Facility AQ - Pueblo Jemez Health and Dental Clinic CA - Shingle Springs Rancheria Health Clinic OK - Stigler Clinic –Choctaw Nation of Oklahoma PO - Roger Saux Health Center – Quinault Indian Nation BI - Chippewa Cree Health Center – Rocky Boy Indian Reservation BE - Lac du Flambeau – Health Clinic replacement CA - Yreka Clinic – Karuk Tribe of California BE - Bad River Replacement Clinic PO - Cowlitz health Center – Cowlitz Tribe BE - Bois Forte Health Clinic of Minnesota Chippewa Tribe BE - Ho-Chunk Health Care Center PO - Cow Creek Satellite Clinic PO - Warm Springs Clinic Renovation PO - White Swan Health Clinic – Yakama Nation NS - Narragansett Indian Health Center PO - Siletz Clinic Expansion – Conf. Tribes of Siletz Indians SAP Awards have ranged from $190 K to $2 million and have included 17 replacement facilities, 7 additions, 4 new satellite facilities and one renovation. The last appropriated funds for the SAP Program were in FY 2008. Below is a list of the 29 Projects and facilities that IHS has provided funding through the Small Ambulatory Program:

Continuing work for the FAAB Updating and editing an Annual Appropriation Information Package Preparing for 2021 Facilities Assessment Report Updating and enhancing the OEHE FEDS database Review of SDS Guidance Update Comments Updating and converting the Health System Planning program Create New Web-Based Version Developed In-House Utilizing Existing IHS SQL Server Maintained and Upgraded In-House Accessible for Use by Everyone Uniformity of Procedures One Version – What’s on the Web. Next Meeting –August13 and 14, 2019: Seattle, WA