U.S.
Indian Health Service and CSHCN
Originally webcast May 22, 2002, 1:30 pm CST
Faye: Hello, everyone. This is Faye Manaster Eldar from the University of Illinois at Chicago, School of Public Health, Center for the Advancement of Distance Education. I’m the Family Coordinator for the Quality Community Managed Care Project, and I’m happy to be with you to bring you the last webcast in our series on Children with Special Healthcare Needs in Managed Care Organizations. Today’s webcast is on the United States Indian Health Service and Children with Special Healthcare Needs. Our speakers are Dr. Judith Thierry, who is the Maternal Child Health Coordinator for the Indian Health Service, and she’s a pediatrician with many years of experience. The other speaker is Patricia Thomas, who is a parent of two young adults with special healthcare needs, and she is the National Outreach Coordinator for Family Voices. We’re very pleased to have these two experts with us today. I’d like to start with Dr. Thierry. Could you please tell us a little bit about what is the Indian Health Service and some of its history and background.
Dr Thierry: Hello. It’s great to be here today. The Indian Health Service really begins with kind of a mini-Civics lesson. The Indian Health Service is under the Department of Health and Human Services, much like the FDA and the Center for Disease Control, and National Institute of Health. It’s one of those agencies. We are a direct-patient care agencies that services about 1.5 million American Indians and Alaska natives throughout the United States and Alaska. We’re divided up in regions, twelve regions particularly, and that then is developed over health centers and service units, and other small tribal programs and urban clinics as well to provide care. We are situated here in Rockville, Maryland, but all of the work for direct patient care is in the field in these different areas. The Indian Health Authorization and Improvement Act comes out of the Snyder Act, which was in 1921, and we are right now in a reauthorization phase. The initial act was in 1976, which established the Indian Health Service to provide services--direct services--to American Indians and Alaska natives.
Faye: And Dr. Thierry, what types of services does the Indian Health Service provide, first of all to all children, and secondly to children who have special healthcare needs?
Dr. Thierry: Well, we have primary care programs, which would be everything from entering the door and having an ear infection assessed to having a child with special needs and having their hearing assessed, or to acute care of any sort, well child care, immunizations. Many facilities have emergency rooms. If children need higher level of care we have referrals systems and transport mechanisms set up to take care of their needs. On site there are family practice doctors as well as pediatricians, people trained in the care of children and women, and people of all ages.
Faye: Okay so it could serve the entire family, not just children?
Dr. Thierry: Absolutely. And it does.
Faye: Okay. How many children with special healthcare needs are being served by the Indian Health Service and what types of special needs do they have?
Dr. Thierry: That’s a very good question, and I looked into that. We do not have any clear numbers. And as I was engaging with that we were looking at birth defects registries state by state. The states also have a lot of work to do in looking at this kind of registry process. From my personal experience, particularly as a pediatrician, we would tend to see more children with special healthcare needs. I would say that that population would range from anywhere from five to ten percent.
Faye: And
are there any particular special healthcare needs and concerns connected with
children who get their care at the Indian Health Service?
Dr. Thierry: I would say it runs the gamut of what you would see in private
practice. I did see children with Down Syndrome, children with anomalies, children
with learning problems, children with several types of medical problems such
as asthma, diabetes; adult on-set diabetes occurring in childhood. As I said,
learning issues, behavior issues, mental health needs that would probably sit
over on this children with special healthcare needs side also.
Faye: Well thank you for explaining that to us. Now I have some questions for our parent speaker, Trish Thomas. Trish could you please share with us a little bit about your family and your children with special healthcare needs and your family’s history of involvement with the Indian Health Service?
Trish: I would love to. I have two children, who are now young adults, who both have special healthcare needs. Originally my daughter was diagnosed as having cystic fibrosis, but as it turned out that wasn’t the case. She became very sensitive to various pollens in the air, so she has actually--when she was born--she had severe allergies and asthma and so she had to go through therapy for a couple of years before it became under control and the right types of medication were given. And then after my daughter I had a son who was born with a bi-lateral hearing loss. Which was--and he was identified when he was two and a half, and he also has allergies, which are on medications, and plants and trees and animals. And then when he was five years old he acquired an injury to his eye, which caused him to have a severe vision loss. And so they’ve received, since their birth, services through the Indian Health Service. Indian Health Service contracted for me to go outside and actually have the delivery in Albuquerque, which is one of the larger cities in the state. And then their primary care was taken care of. And we live on a reservation that’s approximately 57 miles away from our largest city, which is Albuquerque. And so they receive, and have received, their primary healthcare through the Indian Health Service unit that’s located out near my reservation.
Faye: Okay, now do your children have health insurance Trish?
Trish: Yes. Periodically throughout their lives we’ve always tried to have health insurance. And so we networked with the Indian Health Service, as well as our private health insurance, and at several points in time my son was on Medicaid. And so with the three agencies we networked together to obtain all the services that Travis needed. He has also had a metabolic disorder, so he had numerous specialists that weren’t on staff at the current IH Service unit. He received services from all those who are contract service or we went through networking with our insurance company and Medicaid to make sure that all his healthcare services were covered.
Faye: Well that sounds pretty complicated, but I know that you’re an expert at that. Now Dr. Thierry, what is the relationship between the Indian Health Service and other government agencies that are involved with healthcare for children with special healthcare needs such as Medicaid, the State Children’s Health Insurance Program, and the Title V Program for Children with Special Healthcare Needs?
Dr. Thierry: Well children who are eligible for Medicaid we do have a health benefits coordinator who will enroll children, and anybody who would be eligible. We certainly look to support families and what ever direct care we can provide within the Indian Health Service we do do that, which includes dental and optometry, behavioral health. audiology we do have come out also. So we’re a little bit more comprehensive, but nevertheless, as Trish was saying, we do have to send children to specialists for a variety of reasons. Then we either rely on Indian Health Service care dollars or Medicaid, or if they’re not eligible for Medicaid they may be eligible for S-CHIP or their own private insurance, or as you mentioned Title V. So it really varies depending on income and need. We do try, in our limited contract health dollars, to provide services using those monies as well. But sometimes those are limited to life threatening, and as you know with the children with special healthcare needs they’re not necessarily life threatening, but their ongoing maintenance, rehabilitation and evaluation things.
Faye: And are many of the children who receive services from the Indian Health Service also covered by health insurance?
Dr. Thierry: They can be. In the State of New Mexico we know that there’s many children who are not covered. And the Indian Health Service though is not an insurance program, as I said, provides direct primary care so that we are a healthcare system and we do work to try and get children covered with other third party means.
Faye: And if the children don’t have insurance do their families have to pay for the care at the Indian Health Service?
Dr. Thierry: No. That is all free.
Faye: Well that’s wonderful.
Dr. Thierry: Yes.
Faye: And what percent of the children that your agency serves live in rural areas versus urban areas?
Dr. Thierry: Well as Trish mentioned, people do live a distance from urban areas. They’re not only just rural but there’s quite a distance to travel to get to cities. With our populations right now we understand that probably 60 percent of our American Indians, Alaska natives are in urban areas and 40 percent live rural. That is in the population that we’re taking care of, and that’s a mixture of urban Indian data as well as Indian Health Service data, census data.
Trish: And I’d like to mention that some of those not only rural areas but they’re considered frontier areas across the country where some of the Indian Health Service units are located.
Dr. Thierry: Yes.
Faye: Could you explain a little bit more about that to us please ,Trish.
Trish: Well it has to do with the distance and population within areas. Rural areas are more, are slightly more populated than what they consider frontier areas. Frontier areas, their square mileage might have only one or two families. And so within that area, and I’m thinking of like of maybe Montana or North Dakota, you know, those states are considered frontier states, and we do have Indian populations and service units and clinics located in those areas. So it makes it a little bit harder regarding getting those families, if they need specialty services because the states themselves, because they are considered a frontier state, do not have a tendency to attract special needs pediatricians or any of the specialty services that some of the children with special healthcare needs require.
Faye: I see. Now let’s talk a little bit about the role of the Indian Health Service and providing support of services to families in frontier situations and other situations. Things like interpreters, transportation and family support. How does that work?
Trish: I’d like to do a comment to that because I think they do a really good job. Because what they do is they hire individuals from the communities, from the reservations or if there’s several reservations they have numerous--and I’ll speak to my service unit out here--they serve three tribes, the Navajo, the Acomas and Lagunas, as well as any other tribe who has married into one of those other tribes. And so they hire individuals from those communities, and so they have individuals who can speak the native language and if interpretation services are required they have someone within the service unit. And what we’ve done is really encourage the families to kind of have two interpreters, if in fact they are needed. A family interpreter--with the family interpreter then may not know the medical terminology, whereas the hired native person might have more understanding of the medical terminology and how that would be explained to families. So I think they do a fairly excellent job with language interpretations. They also do, I think, a really good job in looking at the materials to making sure that they are, what I would consider, culturally appropriate to the service unit area. And having--knowing the culture and traditions so that it’s specific to the area they’re serving. Because not all tribes have the same culture and traditions, and some of the graphics that are used need to be looked at because some of them are not used within certain tribes and they mean certain things, so they’re really aware of what those differences are, and they make sure that in their literature and pamphlets that they are, what I would consider, culturally appropriate.
Faye: Well these are things that we will be posting in the resource section of our web case, and also contact information for our speakers when people want more specific detailed information it will be there. And what about supports for transportation? Because I know in all rural communities this is a big issue for families with children with special healthcare needs.
Dr. Thierry: Let me make a few comments and then maybe Trish can talk about kind of personal issues with transportation as well. We have public health nurses, and also community health aides and community health representatives. So there’s a whole other team that can support the family, can go to the house. You know, say some assistive devices need to built, say a ramp or something, we can work with the tribe and our health care side in developing that and supporting the family, and you know, not only meeting their culturally appropriate needs but their specific healthcare supportive needs. And if they can’t get into the Clinic, you know, we can have people that can come out to the house. And sometimes, you know, loading a baby into a car seat and bringing everything in is harder, and we also like to see people in their home settings and do assessments there. And they really do appreciate that.
Faye: Oh, that’s wonderful.
Trish: And I think they work very closely with the early intervention program, and with, like Dr. Thierry mentioned, the community and the community health representatives program. And those programs they have also a maternal and child health worker, which works with young moms or families who have newborns that are born. They go to the house, make the visit, and they do that on a depending if the child is at risk, you know, the time spent varies from children who are, you know, have the transportation, and are born without being at risk. They kind of correlate that with the early intervention programs they have. And I’m speaking specifically to my service units. They also network with the Medicaid system there in getting them rides, you know, to their clinic. And in some reservation areas, particularly I’m speaking about my reservation, we do have a transit system where it’s set up where they have, you know, they can call in and if it’s specifically to be taken to appointments they can arrange that with them. And there is no cost, or very minimal cost, for those to go back and forth.
Dr. Thierry: Another thing about transportation that Trish brought up earlier too was the miles people have to travel, so we’re very sensitive to that when we schedule appointments, making sure it works as the time of day that they have transportation or that we need to set that up. Also, if you’re looking at Alaska, people sometimes there’s not the--you don’t have a car you have an airplane you have a scheduled flight that we have to take somewhere. So we’re talking very, very different logistics throughout Indian country.
Faye: And so the Indian Health Service connects with community agencies to arrange the flights?
Dr. Thierry: In the case of Alaska, yes that’s kind of a pre-arranged set up system.
Faye: And Trish, when your children were growing up did you consider the Indian Health Service to be their medical home?
Trish: Yes, I did. I think next to the military I think the Indian Health Service is, and has the potential to be, children with special healthcare needs’ in their service units’ medical home. And I was really lucky in having a pediatrician who stayed within the Indian Health Service for a very long time. And so I had a continuum of service. They were very knowledgeable of the overall services within the state. I think the only kind of problem that I was presented sometimes was transportation, because on and off sometimes I didn’t have a vehicle. But I had to get work done, but they worked with me in making sure that appointments to their specialists were kind of coordinated. And because my children received numerous specialists outside the Indian Health Service they really worked to coordinate the services. That wasn’t initially in probably the first five years of life, but learning the program because I think there tends to be a large turnover every two years of our doctors who come in. But like I said, I was very lucky in my children’s pediatricians because they stayed in for 10 12 years, and so there was a continuum of service and they really knew them. And even after they moved on we maintained that relationship with the new doc and they let me know that--they let me know where they moving, they let me know that we could call on them because--if--and that they were available to provide their new primary docs updates and information. Or if they didn’t understand about, like, whatever it had to do with their medical care, they were very willing and I think went above and beyond, you know, what other docs may not do, but to carry on a continuum and make sure that transition went very well, especially when they were very vulnerable at certain times in their lives. They really, you know, kept a tab on how they were doing, seeing how they--the services again were being correlated, and try to mentor them. Their new--when they knew they were leaving they kind of took the new docs who were coming in and assigned them to their--the their different--the cases to the new people who were coming on and mentored them. And I think that really made a difference. And I think because I had such a good relationship with them, and I worked very hard at maintaining that, that, you know, it just added to really what I would consider their medical home. The only part of the medical home that I think was, and I think was lacking, was the emergency medical care because the hospital is not open 24/7. And so it was correlating the emergency medical care services. Even though we did go to the Indian Health Service sometimes we were in Albuquerque, and almost every holiday my son- since he was five years old until he was probably 16 - ended up in an emergency room. And so learning that and dealing with that I learned how to work with all the insurance companies that we had throughout his life, and the Indian Health Service, make sure that the information, because he may have received emergency medical care in Albuquerque but to make sure that that information got back out to the Indian Healthcare Service regarding any new meds, any follow-ups we needed, and if it affected his special healthcare needs. That especially, I made, I wanted to make sure that the information flow was open and ongoing until he transitioned totally back into his services with the Indian Health Care Service people.
Faye: You know, Trish when you had to take Travis to the emergency room in town and your local hospital was closed, did you have to transport him yourself or use the paramedics, or how did you do that?
Trish: It depended. A couple of times we actually had to use, you know, ambulances services and call them because I didn’t have transportation at that point in time. And that was networked with paying for that service through our insurance and at point in time through Medicaid, then Health Service did not have to cover that at that point in time. On other occasions I had my own transportation so he was transported down. On other occasions when we ended up going to the Indian Health Service emergency room and his care was--his care--his emergency care required immediate intervention and specialty care that they could not provide there, he was then transported through their ambulance service into Albuquerque where he could be taken care of there. And they provided that transportation. But the majority of the time we were in the city, and so I was able to transport him to one of the bigger hospitals here where he got his specialty care and it depended on what his emergency care need was, which hospital I went to. If it had to do with, you know, his eye care I went to a particular hospital because that’s where he was taken care of before, they had his records there. And that was a little tricky because the ambulance service systems are told where to go. I had to kind of work with them also and build a relationship with the ambulance companies in the city so that they knew why I was wanting them to take him to a particular hospital when that may have not been what their protocol was. But we worked that out. So if it had to do with his eyes he went to a certain hospital. If it had to do with his metabolic disorder he went to another hospital. If it had to do with his orthopedic problems he was taken to a different hospital.
Faye: Wow, that must have been really, really difficult for you Trish.
Trish: Oh, it was in the beginning. But I think really building those relationships with all, that group really made a difference. And then they understood too it was having to get the information that they needed right then, and explaining that to them they were--they became, you know, very flexible. And in fact some of their policies changed and so they now ask the client, or the patient, if they have a preference and so that’s kind of how the system is set up currently.
Faye: I see. Now another question about the Indian Health Service, is there a relationship with any managed care organizations in the various states where you have service centers?
Dr. Thierry: Well, a relationship inside a managed care world, so to speak. The Indian Health Service does provide its own direct care. We will see all the patients who enter our doors for direct patient care. If we need to send them for contract or specialty care, much like ‘Trish was talking about, whether that’s emergency room or elected outpatient visits, we do that. There’s not any particular gate keeping that we have to go through unless they do have some other private insurance. So if a child’s part of a managed care organization through the parent’s health insurance, or through the managed Medicaid, which does exist in some states and particularly in New Mexico where we’re talking about here as an example. Then there are certain hospitals, like Trish was saying, that they can go to or not go to. If it’s an emergency room visit that’s pretty much, you know, they can just go where they need to go. But as far as admissions or specialty care there may be some management there.
Faye: Okay. So you work this out on an individual basis? Is that what you’re saying?
Dr. Thierry: Yes. That’s correct.
Faye: Okay now, Trish when--sounds like you have had many, many medical encounters and are really familiar with the system. While you were going through all of this when your children were growing up, was there a coordinator, a point person who assisted you in navigating the multiple systems?
Trish: Not originally. I think I was totally both their overall--their coordinator for sometime until they got a little older and then networking with all of their assigned care coordinators. And what I did was try to facilitate ongoing communications with, and in one point in time I think my son had 12, from the various agencies that he received services from, he had an early intervention, the Indian Health Service, the other three hospitals he was with, the specialty clinics he went to, and then he was on Title V services, so he had one there. So it was kind of trying to make sure that they all knew each other existed so that his services were coordinated in a manner so that they were not conflicting and that, you know, again looking at everything; transportation, time away from school, so I think I worked to facilitate that type of ongoing communication. Toward the end, as he got older, and we kind of learned, I mean, I helped them mentor into this coordination and as he didn’t require services then one of the nurses actually took on a lot of the care coordination. So it was just kind of mentoring at that, but that didn’t happen until he was pretty much set and everybody knowing what his--all of his healthcare needs were identified and knowing which ones he would need throughout the rest of his life and the ones that he no longer needed. As well as my daughter, she still maintains--she has severe allergies and asthma but she maintains that very well. And I now have a granddaughter who is following in the footsteps of her mother; she had almost exactly the same healthcare needs that her mother had when she was little. She’s now been identified as having recurrent otitis media and so they’re looking at, you know, coordinating some testing regarding her speech and early intervention and possibly looking at putting some tubes in her ears. My daughter is now learning, and I’m back in the system again, we’re working with my granddaughter and my daughter in getting services for my granddaughter.
Faye: Wow, so you can put to use everything that you have learned--
Trish: And it makes it--
Faye: --with your two children.
Trish: --makes it so much easier to know who the players are, and to really let them know how to--well my daughter - mentoring her into, you know, keeping--just knowing really who she needs to be speaking to and how that flows, regarding you know like some of the early intervention and how that works with, you know, her checkups and she has been identified already as being allergic to certain medications as well as certain food items. So it’s--it’s been a very, I think, rewarding and an ongoing learning experience working with all the healthcare systems plus the educational system, and providing the care that both my children needed and now my granddaughter.
Faye: Sounds like you’re an expert ,Trish. I’d like to discuss a little bit about how families of children with special healthcare needs are involved in the Indian Health Service, both at the program and/or the policy level.
Dr. Thierry: Well that’s a good question- I think it comes--sits very well with the 2010 objectives for the Medical Home and integration of the children with special needs into the community and to schools, and we can’t do that without families speaking and addressing that. And, you know, given everything that’s on their plate with just their own individual child or children that they’re taking care of, then to just go a level higher and interact and want to be developing policy. One of the committees and inter-agencies that I sit on is called the Federal Inter-agency Coordinating Council. It’s actually through the Department of Education. And it looks at children with special healthcare needs and their--not only their healthcare but their education needs, their after-school care needs, you name it. And we have parents on that large committee, as well as in the subgroups, which looks at integration of services and legislation. So really an upper level agency; we have family involvement, and also I would say on health boards back at the individual healthcare center and service units such as Trish’s, you know, we have parent involvement there. Many times parents work at the hospital so they, you know, have dual functions and can advocate on those levels also. So really from the service unit level right up through the agency we have participation by parents, and we look for that. One of the strengths of the Indian Healthcare System is the tribal consultation and involvement in all manner of the healthcare decision-making.
Faye: Well I’m very happy to hear that. Now Trish, could you please tell us a little bit about your role at Family Voices. First of all, what is Family Voices? And in your position there how you’re involved in working with families, and the Indian Health Service in particular.
‘Trish: I work for, again Family Voices, a national grassroots organization that speaks and educates on behalf of children with special healthcare needs. We work with policy makers at all levels; the local, state, regional and national level, the media and other family organization. The American Academy of Pediatrics, and other organizations that serve children with special healthcare needs, whether it be education or early intervention. And I work as the National Outreach Coordinator. And what I do is I network with--we have a network of individuals--members--who are mostly families of children with special healthcare needs across the country as well as other healthcare and interested professional partners, and I provide them ongoing information on issues that affect our children through a quarterly newsletter which is called Voices. We also are hooked up to various list servs, one being the Medical Home list-serv. Each region has a list serv, so that we get information out to our families so that we--I think we have a very extensive networking system, that we’re always looking for, to update and improve. I also provide and read a lot of materials to make sure that they are culturally competent and appropriate for the area that they’re going to. And I do that within Family Voices, as well as with our other core partners which is HRSA MCHB, AAP, Special Education, Early Intervention, various programs and we have--we also work with the National Center on Cultural Competency in providing information and training through the individuals that we work with, our core partners, throughout. I also have a pulse on our network with some information, try and keep again a pulse on what’s happening in the states regarding issues that are affecting our children as well as not only issues but good things that are happening; the partnerships that are being formed. And most recently I’ve been working with finding out how our states are connected to their American Academy of Pediatrics chapters. And making sure that our most vulnerable populations, which are the, you know, traditionally underserved and minority populations who receive the vast majority of services either through Medicaid, SCHIP, or other programs, really get the information so that they can make an informed decision on the services that their special needs child or children might need. Getting them to, again through our coordinator network such as Faye, yourself, in helping mentor families into how to become a good advocate and educator on what children with special healthcare needs. I also wear other hats with working to review various grants, review the Title V block grants for--the National Title V Block Grants, and work with AAP the American Academy of Pediatrics on their CATCH grants.
Faye: Well Trish, it sounds like you have really lots of resources, lots of knowledge and you’re highly involved. We will have a link to Family Voices in the resource section so people can get more information about this and certainly there’s a lot more out there that everyone needs to know about, including families whose children are getting care from Indian Health Service. Now as we’re closing the web cast I have some questions for each of you. First of all, what advice do you have for professionals who are serving children with special healthcare needs and their families in the Indian Health Service system? Dr.Thierry, could you go first, please?
Dr. Thierry: I would say to professionals know your community, get to know the public health nurses, the social workers, everybody in the--where you work at. Get to know how things are conducted, people’s expectations, and as they build their practice, really listen to the parents. The parents are expert about their kids; nobody’s going to care more or know more about their children and be able to tell you those little details about, you know, how they’re breathing or what they’re concerned about, or why they think they may have a learning problem, whatever the issue. So really, include the parents fully and completely in that care, and the history they provide is--is--is to be really cared for and looked at and stayed with, and, you know, parents will just walk out of the room feeling much more comfortable and a trust and rapport will build on that. And that’s really one of the essentials for quality healthcare.
Faye: I see, and what advice do you have families of children with special healthcare needs who are coming to the Indian Health Service?
Dr. Thierry: Persist. Keep asking questions. On the same side, develop the rapport and the trust, and if you don’t find that, persist. Ask to see another provider. I mean, people do have to do that in healthcare systems for various reasons, but you want to make sure that your questions and your needs and your child’s needs are getting heard and treated comprehensively. There is a huge support system there. We haven’t talked about Head Start or Women and Infant Child Nutrition, or the school systems, but this huge support services that are available and neither the parent nor the single provider can do that alone. So really building a team of care around each child, the medical home.
Faye: Well thank you. Now Trish, what are your recommendations, first of all, for professionals who are serving children with special healthcare needs in the Indian Health Service?
Trish: First off I would recommend that they really partner the families, just echoing Dr. Thierry, is that they really build a partnership with the family, but not only the family, the community. And kind of immerse themselves within the community so that they’re known within the community so that, that trust relationship can be built faster. And families become more comfortable with them. I would also say, that they need to be asking families information and letting them know that they’re only asking because they don’t know. Families repeatedly tell me that, you know, they’re waiting to be asked, and I would encourage them to learn about the cultural differences so that they don’t become barriers to accessing the services. A lot of times our healthcare providers come from the mainstream, and it’s often a cultural shock on both sides, for the families as well as the healthcare provider, because they’re not aware of what those cultural differences are. And if they immerse themselves within the community and really start building those partnerships that eases and almost always alleviates them not knowing what those cultural differences are that sometimes become barriers to accessing those services. And I think too--and I think most docs who come into it are committed. Like I said, I was very fortunate in having them come in and look at, you know, kind of staying longer into the service units that they come into so that a lot of the families build those trust relationship, but then are aware that, you know, they transition out quite frequently. But I think my biggest thing would be really to have them learn about the community and really partner with those families because they are the ones who kind of know the system already and what services are out there, and to really share information. Share new information that they receive so that, you know, families are aware of the changes within the Indian Health Service. And just to build a strong partnership.
Faye: And Trish, what recommendations do you have for families of children with special healthcare needs?
Trish: I would say, also, for the families to share the information that they know. And to be patient with, you know, the services or the individuals because a lot of times, again, you know, you’re serving a lot of individuals who come into the hospitals and clinics. And I think to be--become more actively involved by asking more questions, and again sometimes that is a cultural difference and to know that they really need to share that type of information with their docs regarding cultural events that are taking place so that if it’s in conflict, you know, they’re just not showing up for their appointments, but really having an ongoing dialogue with not only their primary care but their specialty care docs. And just becoming more informed, I think the more informed they are the better decisions they can make for their children. And sometimes that’s a little hard because of the information dissemination flow is sometimes a little slower in the rural communities than it is if you lived in a city. So I would really encourage them to become more knowledgeable informed of practices or information that’s out there that affects their children with special needs.
Faye: Well, I want to thank you both very much. You’re both very knowledgeable and have lots of experience and good information and advice for us. And you’re really knowledgeable about addressing the needs of children who have special healthcare needs within the Indian Health Service. Thanks again. Thank you for logging onto our final web cast production. We’re really interested in your comments and questions about the web cast, and we invite you to contact us. Our email address is cade@uic.edu. Our Internet address is uic.edu/sph/cade/kidsmco. Our telephone number is area code 312-996-2233. We’re located in Chicago, Illinois and we’re on Central Time. We hope that you’ve enjoyed this broadcast. This is the last broadcast in the series. We invite you to access our many archived web casts at your convenience. They’re available any time day or night. Thank you for joining us.