Highlighting Frontline Voices in Health

In this episode of the NCUIH Native Healthcast, we will highlight the voices of frontline healthcare workers who are employed by UIOs. This episode intends to create a space for UIO staff members to share their experiences related to implementing IPC practices, share policies which have proven successful in protecting patients and frontline staff, and share what challenges exist in providing high-quality health services in the unique setting which serves urban Indigenous communities. Indigenous Storytelling strategies will be used to convey experiences and takeaways within the conversation.

Transcript

Vickie Oldman: Welcome to the National Council of Urban Indian Health’s podcast on infection prevention and control education topics for our frontline warriors, our healthcare team members, serving American Indians and Urban Indian Health Organizations. My name is Vickie Oldman, your host for these broadcasts. I am Diné (Navajo) and a resident of New Mexico. I am an independent consultant and have been working with Native communities and nationally for over two decades. In these broadcasts, I will be interviewing leaders, advocates, and practitioners with a focus on infection prevention and control strategies in urban Indian healthcare settings. Thank you for joining us.

Welcome back. Good rising. Good afternoon, good evening, and good day. This is our third year, third episode of NCUIH’s Native Healthcast, using indigenous storytelling as a way to convey experiences and takeaways within our conversation. In this episode, we will highlight the voices of frontline healthcare workers who are employed by Urban Indian Organizations, UIOs.

We want to create a space for you, for UIO staff members to share their experiences relating how they are implementing infection prevention and control, IPC practices, as well as sharing policies which have proven successful in protecting patients and frontline staff and share what challenges exist in providing high-quality health services in the unique setting which serves urban Indigenous communities. Today, we literally have UIOs from the East Coast to the West Coast.

Our guests are from Boston and Los Angeles. So, from Boston we have a representative with an organization with the UIO called Native American Lifelines, and our guest from Native American Lifelines is Nicole Brewer Lowry, who is a Site Director of Native American Lifelines of Boston.

She is an enrolled member of the Lumbee Tribe in North Carolina. She enjoys being a relative, and what I mean by that, she's an auntie and she of course loves spending time with her family. She has various degrees in the field of biochemistry, biomedical science, health administration and has been a professor at various colleges, and during the pandemic actually was teaching science to seventh and eighth graders. Boy, she has patience, doesn't she? And she did that in her own tribal community, so we have Nicole with us. We're gonna bring her on in just a minute. We also have a team from Los Angeles that works with the United American Indian Involvement UIO, the team that is here with us is Jeff Rosenberg, who is the Chief Medical Officer. He's a board certified thoracic surgeon and has well over 25 years of experience in specializing in areas of adult cardiac minimal invasive in robotic surgery and other areas. He's worked in Nevada in California and his interest is focused on physician wellness. Along with Jeff, we also have Amanda Simon, who is the acting Director of Health services, and Amanda has been with UAII, the United American Indian Involvement, which stands for UAII, she's been with them for almost 20 years. She started there actually as a student volunteer and then became employed, worked with the youth programming and has received her bachelor's in English and biology as her minor. She currently is a candidate for the Master of Science in Healthcare Management. She's Díne from the Navajo Nation from the Todích'íí'nii Clan and also was born for the Choctaw Nation. We also have the other member of this team is Xochitl Quintero who is a public health nurse and completed her Master's in Nurse Science and has a concentration in community and population health.

I would love for you all to bring your voice into the space so the listeners can hear from you, if you don't mind adding additional color to your bio, something that's interesting, or anything that you want the listeners to know. And if you don't mind also sharing what's budding for you.

Budding for me is not fully bloomed, but you're excited. It's starting to form, so additional color to your bio and what is budding for you.

Amanda Simon: I'll go ahead and go first. So some things that I'm looking forward to, and it's gonna be budding, is I'm soon gonna have a kindergartener at home. My son is starting school next week and it’s gonna be an exciting transition for our whole family. So really looking forward to that for him and just for all of us. And just some additional things about myself. Big lover of cats. Love them, any cat fans out there? I'm right there with you.

Nichole Brewer Lowry: For me, I'm Nicole and something interesting that is added to my work today is that I became very sick in medical school and I spent two and a half years bedbound. And so I used the experience of being a patient as well as my background of going to medical school to help me teach my community here in Boston and in North Carolina on how to advocate for themselves in the healthcare community.

And what is budding here is that I've finally gotten some traction with the local healthcare facilities here in Boston. As many of you know, it's a, it's, I call it one of the healthcare meccas along with California. To actually start to see the Native American community that is here in Boston and actually engage with us and work with us for so long.

They've worked with native communities and other places, mostly out West, but have not engaged with the local natives. And so it's, it's really nice to see that they're starting to open up and learn about the cultures here and how they can actually be helpful in what we would call our home community.

Jeff Rosenburg: Good morning. My name is Jeff. Some other things about me are that I live near the ocean with my wife and my wife and I moved to Los Angeles about a year and a half ago. So, we're now near our two adult sons, which is very exciting. And we also acquired about a year and a half ago, a mini golden doodle. Very, very sweet dog. Brings a lot of joy into our lives, so we're enjoying that very much. Some experiences that I had recently was that we went to our youth program summer camp. We had 53 of our youth there, and that was uh, very much fun. We were there for about a week and got to experience with them and a lot of our other staff. So, it was very good team building experience also.

Budding for us at UAII in Los Angeles is that we're constructing nearly constructed a dental clinic and we hope to be opening services by early 2024.

And so we're very excited to be able to provide those services to our clients.

Xochitl Quintero: So this is Xochitl. One thing about me that's interesting is that I have a small bookstore that I run on the weekends here in the LA area. I run completely on donations. So I can offer free to low cost books to the community. So that's something I've been really excited about. Something that's budding for me would be that I'm just really excited to be here at UAII and to learn more about the community and the needs of the community at this time.

Vickie Oldman: Beautiful. Thank you all so much for being here and wanna extend thanks to you all in what you do for our communities and how you show up in these communities. As you all are aware, in these episodes, we really focus on IPC education topics, strategies for our frontline warriors and healthcare team member that work in the various UIOs across the country. So my first question, love for, for anyone to just jump in how do you all define or what does frontline worker mean to you?

Jeff Rosenburg: Well, to me, frontline worker means anyone who's really patient facing or works directly with any of our clients. We have a lot of other departments within our organization that aren't specifically healthcare-related, but so anyone who, who interacts directly with our clients, I would consider frontline.

Xochitl Quintero: I would definitely agree with that. And I would also say that, oftentimes as frontline workers we're the first point of contact for a patient in a given situation like if we think about Covid and know I was giving Covid vaccinations, some of the first Covid vaccinations for healthcare workers, and the relief and joy that I witnessed alongside these patients who are also healthcare providers themselves made me realize like, wow, I'm really here at the forefront of what's happening, and I feel you really walk alongside the patient in these situations as a frontline worker.

Vickie Oldman: Thank you. I, I love that you also pointed out like the first point of contact, 'cause it made me think about when I go to the UIO in my local area it's actually the first point a person is the security for me. Like when I'm pulling in the security guard and then when I go into the facility, there's another security person there asking, if I have these symptoms, making sure I have a mask, so they're the first people I see before I see the doctor, the

doctor's the last one I see. I've gone through a series of different people before I even actually see the physician. I think a lot of folks think it's the doctors and nurses and we forget about all the other players, the teammates that have contact with clients and community people. Based on that, we're lifting and highlighting frontline workers and getting perspective feedback from you all.

Curious about what your experience has been like in developing, and, adapting IPC policies and procedures in your facilities. What's that been like? What have you been adapting, what you've maybe even developing.

Amanda Simon: I think for us here at UAII some applications began really early. We had a pretty strong IPC policy in place, but, you know, when Covid came, there was just things that, couldn't always be 100% prepared for. But some adaptations we were able to do were we were able to initiate some phone triage. So, talking to patients over the phone prior to them coming in just to get a better picture of what their needs were.

We were able to implement some outdoor waiting areas for patients when they would come in. Just also having very well-ventilated open spaces for them when they're waiting. And then I, one also thing I think was just a part of that adaptation was just also understanding our community. I know some of, for myself, in some doctor offices I went to, they had policies where only one person could come to the office. But just for some people in our, in a community that wasn't always possible. They live in a multi-generational family, so if they're going somewhere, they have to bring grandma, they have to bring their little ones with them 'cause they can't leave 'em home alone. So just understanding that and making a safer space for them when they would come to the office.

Vickie Oldman: Oh, I love that. I love the fact that your facility is looking at the definition of family differently. It's not just that person but knowing that there's multiple generations living in the household, and they may need to bring members to support them and even maybe even help advocate.

I'm curious with the phone triage, video or phone may be much more convenient on families’ budgets and time. With some of those practices there have you all kept those particular practices in place for families?

Jeff Rosenburg: You know, the experience of COVID-19, I think is in a lot of ways accelerated, but also revolutionized how we provide healthcare. What you're touching on is the sort of the tele-visit. So, a lot of it was we were self-isolating. We had the stay-at-home orders for quite a while, so to be able to access healthcare or to limit person to person interaction, to, to cut down on the potential of transmissions that really advanced the tele-visit. There used to be a lot of laws for billing where tele-vist wasn’t, you couldn’t really bill for it or anything like that, but they put in temporary exemptions for billing for both, well, in our state-funded insurance, like for us it's called Medi-Cal, and then also for Medicare that they allowed that you could bill equally for a tele-visit as for an in-person visit and a lot of that has kept in place. Those laws have been kept in place.

I wanted to go back to one thing that Amanda said that I think is so key is that COVID-19 brought infection prevention or how diseases are transmitted to the forefront of the population. I don't think anybody ever really thought about that before. Nobody ever thought about the importance of staying home when you were sick. It was encouraged that you were a tough person, and you would go to work no matter what, but actually you're, potentially hurting others by not staying home when you're sick or the importance of just frequent hand washing or cleaning surfaces. The other aspect of what Amanda said, which I think is so interesting, is that when people go to healthcare, they give up control, when you access healthcare, you have to abide by the doctor's office or the hospital's rules you're vulnerable and you're maybe not at a hundred percent, so you also don't have all the same kind of defense mechanisms that you normally would have. And then there's a lot of fear as well. People didn't want to go to doctor's offices because they thought they would get sick there. And then on top of that, you couldn't have any support with you, no familiar support, no family member, nothing could be with you.

So that was really, really, I think, frightening and challenging for people when they accessed healthcare and may have actually inhibited people from accessing care when they needed it.

Nichole Brewer Lowry: Those are really great points. And those are some of the things that, we've also dealt with in Boston. And I will say we continue to do the phone triage and some emailing through secure portals. I have found kind of a hybrid response from the community. Some of the community members will call and say, "I got this call, but I wanna make sure it's someone from you and it's not a scammer."

So, there is still that heightened fear of people being scammed to receive their information. And then for telehealth, it's been a blessing, but I have gotten some pushback from some community members saying, oh, that's not the Native way, we get together. We are always in person we understand that, but we also have to keep everyone safe.

It has brought about some opportunities to allow people to actually access care that they normally wouldn't have access 'cause of timing and transportation hurdles. I think that just trying to listen to community members and meet them where they are at can be a challenge, especially when you're a small team. Butut we tend to see the, best reward when we do meet them where they're at and try to work with them to create a treatment plan or that that will work for their schedule and their needs.

Vickie Oldman: I love the fact that just bringing back what COVID-19 brought, more awareness and light on IPC and how to prevent infection from spreading. How do you all ensure that your staff continues to maintain proper hand hygiene and how are you encouraging that with your patients?

Nichole Brewer Lowry: I think constant reminders and also teaching the proper skills of hand washing and why it's important, and also with community members explaining, I get that you may not wanna listen to the local healthcare system, but we're asking you to consider taking these practices, and actually utilizing them and this is why and then, explaining it from more of a cultural aspect of like, you are not just protecting yourself, but you're protecting the elders that you may be around, or the young children or anyone who is at a higher risk.

And my staff picks on me because they say I should have never taken microbiology because I constantly will remind them of how you can pick up some of these bugs. They're like, “Sometimes I just don't wanna know Nicole.” But you know, that's to try to like, help them stay safe. And especially as we have elders coming to our office, I keep reminding our staff we have to continue those protocols because we are gonna be around people that are gonna be more vulnerable, and so we need to do our part too, to help protect our community.

Amanda Simon: I think going off of that also is one way that we encourage

continued practices with our patients is just also, besides education, just offering them the tools to do that. We currently have a team of community health workers that is able to provide face masks, PPE, cleaning products, hand sanitizers, that they provide free of charge and they actually deliver to families at their homes. They're able to take those items and use them along with the education they're already receiving as well.

Xochitl Quintero: And I also think along with that in my practice, I've noticed just leading by example, like letting the patient see you put that hand sanitizer on your hands when you come in the room or wash your hands when you come in the room. Just as part of like normalizing that practice. And it's something that is beneficial for all of us.

Vickie Oldman: I wanna just emphasize the normalizing the practice. I think that's important. Just almost like at home, right? Did everybody wash their hands before we eat? It's something that we do, comes a part of our habit. For both facilities what are some goals that you all are thinking about to improve and enhance IPC practices?

Nichole Brewer Lowry: I think for us, you know, keeping in mind that we're getting ready to enter into the fall season and it's flu season and so making sure people understand that some of the things that we did during the pandemic will also help us keep our community safe from the flu. And I think that people don't always really consider the flu as being serious. And, you know, my mother-in-law died from complications from the flu. These are things that we need to continue to encourage our community members to continue those practices because it can protect us from other diseases and hopefully, we don't have another pandemic, but that's always a possibility now, right, if we should experience another one, we hopefully we will have a better footing and foundation of going into that season. Like Amanda said, you know, encouraging if you still wanna use the masks, let's, let's continue to help supply those.

If you want the gloves, if you, need any of the hygiene products, you know, as your UIO's, please reach out to us and we can help continue to provide those. And like she said we, we will deliver because we wanna make sure that we're removing any hurdles from you, accessing the things that you think will keep you and your family safe.

Jeff Rosenburg: For the healthcare worker education and repetition and monitoring, is mostly what we do to ensure that we're using proper hand washing and infection prevention practices. We assign annual monitors, annual modules for proper technique for hand washing and so forth.

Constantly talk about cleaning your hands on the way into the room and cleaning your hands on the way out of the room. There are hand sanitizer dispensers, you know, everywhere. They're in our hallways and they're in every room as well. We have modules that are required on an annual basis for bloodborne infection transmission and practices to keep both the health worker patients safe from bloodborne diseases.

I know when I interact with patients, I narrate like what I'm doing and why I'm doing it in regards to, oh, I'm cleaning my hands on the way in, or cleaning on the way out. And then talk about how it's important for them, particularly if they're doing wound care changes or something like that, that they should be cleaning their hands before and after using gloves. The importance of those things.

We have a lot of community events where we have a lot of education for our community. And we have different booths for our different departments. And so we oftentimes have information or we interact with our clients in regards to infection prevention practices or the benefits of vaccination in preventing diseases.

And then we also have regular events for some of our other clients, particularly our elderly groups that meet regularly. And we have many of our departments come in and give talks on infection prevention or, current state of like flu or covid in the community.

Nichole Brewer Lowry: I was just gonna add to that. Yes, and when we are doing a booth and a powwow, we will take extra hand sanitizer and give it to other booths to make sure that as people are, going around the booth at the powwow, that they have the option to sanitize their hands.

And I also wanted to speak on the vaccine. I think that doing more education as to what the vaccine is there for, not that it's gonna cure, 'cause I think a lot of people had that understanding that, oh, if I have the vaccine, then I'm not gonna get X, Y, or Z. Rather the vaccine is more prevention and rather than a

cure. And so I think that having that education also has maybe helped some people make better decisions for their own help. But in some cases it's also been a challenge to get people to understand, in particular the covid vaccines versus flu vaccines or any vaccines that children may take in order to attend school.

Why does that vaccinate you differently than the others? And how is the trust of getting that vaccine been, not there compared to other vaccines? And I know that it's, it relates to, for some people, relates to the timing of the development of the vaccine. Pushing education has also been one of the things that has been helpful for our communities and needed.

Vickie Oldman: Absolutely. I really feel like the more education that UIOs provide to the patients, it helps. And when a nurse or a doctor came into the room and I didn't see them wash their hands, I would call it out gently. I'm like "Can you wash your hands before you touch my son?” I was an advocate, right? Advocating for my son, I understood the importance of hand washing and, it's accountability. I think the more that community people are aware and understand, it's just making each other accountable in a loving way, because we wanna all be healthy.

Given what Covid has done and where we're at, do you all feel that you're prepared for a future pandemic or any other infectious outbreaks?

Nichole Brewer Lowry: So in Boston and Baltimore we're both referral and outreach, so we don't have providers at our, our centers. And so, like you said, Vicki, it is important to me to teach our community members on how to advocate for themselves. And strengthening our partnership with the state of Massachusetts.

To be sure that they are listening to the Native community and the needs of the Native community. One of the challenges that they had during the pandemic was Native community members in both Baltimore and Boston were wanting the vaccine, but we didn't have anyone that was in our part of our team that could administer the vaccine. And so there was a delay going through all the red tape and hurdles of being a provider in those states and getting someone from the state to actually provide someone to administer the vaccines was a challenge. And community members became very frustrated it went back to see we're not, we're n

And that's how it came off, whether that's what the state intended or not. And so I think that, we've had some conversations now with the state to let them know these are the things that the community members felt during the Covid pandemic. And going forward, we wanna know that you guys are responding to us quicker and to our needs.

Through these conversations, we're still working through it and we're still working out plans. But I do hope that We will have a better outcome than we did before. Now my only fear is that we are small as a team and so, it can, be overwhelming if another pandemic hit us.

How do I make sure that, my team is also taken care of while also providing care for community members I do think would be a challenge. We are talking through those things on how do we balance both care and self-care. And so, the short answer is yes and no.

Jeff Rosenburg: I agree with the yes and no. I think the yes part is that different components of our community, meaning, for example, our local, our county, and then our state, and then also federal. And then also collaborating with other like, healthcare organizations. I mean, like with, in NCUIH and bringing us together.

It makes it easier. We're more used to collaborating and reaching out and not feeling like that we're on our own and that it's important to work together. For us, which has been really good, is that we had a lot of different grants from the county, the state and federal, to help us institute a community health worker program because it was so important to go out and have outreach in the community.

Most of that was around deploying personal protective equipment, educating about that, and then also encouraging educating about vaccine. There have been a lot of joint events mostly for our American Indian, Alaska Native clients, but it was open to all, community members where we would have on our site here, events on Saturdays or whatever that were geared mostly towards encouraging vaccination.

We would have our county Health department for would provide resources like administering and documenting that the vaccines had been distributed. Our workers would help also coordinate with our clients, signing them up and getting them there. And then also gave us an opportunity to have our other departments have booths and so forth that were available to provide knowledge about the services that we provide and also education or, giveaways to clients like some of, you know, hand sanitizer and things like that.

In that way I think that we're better prepared, but I think, God forbid, whatever the next pandemic is, and hopefully it won't be, I sort of like the last one we had was flu in 1918, so it was a hundred years ago. So hopefully we won't have any too soon. But they all carry their own fears and unknowingness about it and a discovery period of learning about, or what the, the infectious agent is, and then also being able to develop testing and, and vaccinations or therapeutics, and so at least our clients know what that process is like. So I think that, that's helpful. So, but you never know what the, what's coming from the unknown.

Vickie Oldman: Yeah. What I'm hearing loud and clear, from both UIOs is there's a challenge in coordinating with other agencies locally, the state, regionally, nationally, there are all these different players and most of our UIOs are small. Small budgets, small staff in terms of capacity and the service of who you all are reaching, the community is large. So the desire and the need to have more collaboration, which means more communication, which means more time to do that work. I always mess up that saying something about going slow to go fast. It would be ideal for the UIOs and locations to slow down. With the other agencies and really connect and think about how to do this intentionally.

So, I wanna talk a little bit about Indigeneity and our Indigenous practices in the work that you all are doing. I've learned that in recent conversation there's been this marriage between facilities providing traditional healing practices. So, I'm curious how can you apply modern infection and policies and practices to those traditional services?

Amanda Simon: Some of our traditional practices healing practices that we have here at UAII, such as talking circles and recently education on Indigenous foods and how that can enhance immunity and just offer better

overall wellbeing and health for individuals and families. We've made it available through Zoom as a way to help keep our families safe. Other things that we have done is our gatherings are outdoors now when we're outdoors, we, we still continue to offer our hand sanitizers. We continue to offer our masks. So that was just one way that we were able to adapt and practices that we still continue to offer.

Nichole Brewer Lowry: The challenge is winter season here for us in Boston, 'cause we can't do things outdoors and so moving things inside, but how do we stagger people to come to our events so that we don't have too many in one small space at one time. Or considering the space that we're in, is there an entrance and an exit so that people don't have to be side by side, so that if the event flows and you're decreasing the amount of contact.

Those are some of the things that, you know, we have to think through as we have some of our community events. And yes, like you said, Amanda, like nutrition, highlighting our traditional foods and, and how they are healing and how they're anti-inflammatory and can be protective has been a focus as well.

We deal with a lot of food insecurity and, and housing here due to like the cost of living in Boston. So how can we get people to be safe and okay and get their needs addressed, but also doing it in a traditional way so that they feel supported and welcomed and maybe Boston is home to so many different tribes due to like the students that we have coming to our great universities here, or you know, a lot of startups are here and, making sure that we are addressing the traditional needs of all those tribes sometimes can be a lot. We try to find ways that is common or encourage them to, to reach back out to their tribe and then how can we amend those practices to help them.

And then another thing that we have also encouraged is herbal bundles that are, can be used as smokeless bundles because, a lot of people live in apartments, they can't burn or if they're in a working environment but need the sage. So, encouraging, you know, using the sage between your hands or smelling the sage and putting it in certain places in your space without having to burn it, but still get the benefits.

That also has been helpful for even myself. I've had some lung damage, anytime anything is burning it irritates and I me and I start to cough so, learning

how to adapt some of those traditions, but still getting the effect and the relief from it I think is another thing that we've tried to encourage with our community here.

Jeff Rosenburg: Some of my observations have been in the medical clinic, most of the treatments that we deliver are Western and not so much traditional. What we do have is when we have events or whatever, we definitely have the traditional practices are present. We always begin events with an opening prayer.

We have a plate that's put aside for the creator. We have song and dance and drumming at our events. I would say that some traditional practices occur more. And it's not so much infection prevention, but they occur more in our, behavioral health areas. I think where we found that a lot of behavioral health disorders can come actually from having sort of a, not feeling either not recognizing or having at the forefront of your identity, your, Native roots that embracing the Native cultural practices actually help our clients feel more connected and in that way, through that connectivity, there's less depression or behavioral health disorders. We've tried to have sweat lodges and things like that so much. We definitely recognize them, and many of our substance abuse therapists and so forth advocate for it or connect people up with it. But we, we haven't been able to really find a location to have that ourselves. So, I think trying to have cultural practices at all of our events, I think is you know, much more welcoming for us.

Vickie Oldman: I love that how you all touched on the whole person in terms of the physical part of the person, the mental part of the person, the relational part of the person, the connection piece is really important for our Indigenous communities and members of those communities.

This last question is two-pronged. I wanted you all to talk a little bit about like what are some ongoing challenges, we're working on in terms of IPC and policy strategies.

What tends to continue to be a thorn in how you all want to overcome challenges?

But in terms of the success, I'd love for y'all to toot your horns a little bit and share with us what makes your UIO unique in the approach that you all have.

Some highlights in those areas, if you don't mind sharing.

Nichole Brewer Lowry: One of the things that the community members continue to tell me about that they appreciated was, care boxes that they received during the pandemic and how that was so helpful, included paper towels, gloves, hand sanitizers, and herbs. I think that was like one of the highlights for Native American Lifelines.

And the state of Massachusetts seems very small, but it can be a lot, to take on when you're driving and delivering these boxes to all these households and just kinda checking in from the outside of the door and making sure that everyone is safe. Our community is seeing that, we are pushing our local healthcare facilities and we're pushing the state to see us and respect us, and have the desire to work with our communities rather than being the afterthought. That's taken a lot of time, a lot of trust from both sides, finding allies within those organizations that can push when I'm not able to be at those meetings and those background conversations. I think that we are starting to see some traction here in Massachusetts as it particularly relates to the state of Massachusetts Department of Public Health actually viewing us as more of a partner rather than someone they can just call on for temporary needs. And having that partnership throughout the year. I think some of the challenges that we're gonna continue to see is that we're not gonna be able to address everything that our community needs. We just don't have the capacity to do that. And we can always strive to do our best and take the feedback.

I ask all the time from our community, what can we do better? What worked, what did you enjoy? What did you like, but what can we do better as well? And what may work in one season may not work in another. And so making sure that, as a team, we're willing to pivot and not be stuck into the things that we, that are easy sometimes for us to do as a team, but rather what the community needs. I expect that to always continue to be evolving and something that could be a challenge for us.

Amanda Simon: For us here at UAII kind of echoing what Nicole was saying is just our area. Living here in Los Angeles, the metropolitan area, it's such a huge expanse and for some of our clients and patients, who may live on one part of the city, being able to get them in regularly for clinical visits or just any other sort of encounters has proven difficult.

We have done our best and continue to work with our community health worker team to be able to fill that gap to be able to go out to the homes of our families as best they can. We are actually really happy to have Xochitl onboard as a public health nurse 'cause she'll also be now able to go out to her community for home visits for healthcare.

And so, I think that just continues to be a challenge. Another one is just the visibility of Natives in Los Angeles. I know recently there has been a push for more targeted public health campaigns, which is amazing. But I think as part of, us here at UAII is just continuing to just push for more of that, like, we don't want to see that fade off as the pandemic dwindles. We want to continue to see higher visibility of our community. One thing I would like to say that is just one of our successes here at UAII , is just, I think our vaccination campaign especially for our elder group, I believe recently looking at our numbers, we had about over 90% vaccinations for our elder patient population.

And I think that is just amazing. I think there's a big push to protect our elders and I think everyone within our community just really fills that need that they're the foundation of UAII, they're the foundation of our community. And if we wanna continue to grow and have our community grow, just always remembering that.

Jeff Rosenburg: Yes, I think a success for UAII in Los Angeles is that during the pandemic we, in our community clinic, which is a primary care clinic, we were always able to stay open for our clients. So, we were, had that resource available for our community and our clients. Many of our other departments went remote, but our community clinic was always here every day and in person providing services.

Vickie Oldman: Wonderful. I enjoyed hearing what you all are doing. Also learning about the challenges in the locations that you both are representing and what continues to be areas of improvement. Just letting our frontline workers, our practitioners importance of keeping to the basics and like continuing to educate yourself, continuing to keep each other accountable in these practices.

We're gonna bring on another guest and hear what NCUIH is doing, some highlights, and I'd love for you all to come back and share any final thoughts

in terms of maybe sharing resources that have been most helpful in your IPC work or also lessons that you've learned along the way that you wanna share with practitioners.

So, if you can sit with that, I'll have you come back and then we will wrap up. thank you so much. All right, listeners. So to give the NCUIH highlight, we have Dr. Kimberly Fowler. Kimberly has led the development of various projects focused on UIOs capacity building and sustainability to support operational and programmatic growth, as well as supporting research centered on the urban Indian health sector.

She has been with NCUIH since 2011 and comes with a doctor of philosophy. Dr. Fowler oversees NCUIH’s overall initiative. Welcome, Kimberly. I am so glad you're here. Bring your voice into this space.

Kimberly Fowler: Hello. Thank you. I'm, honored to be here, to be in this space with all of you all and also share. I think what's budding for me right now is, I have to actually a little bit piggyback off of what was said earlier about school and kids starting to date is the first day of school here. And so it has been really exciting. I have a daughter that is starting high school and so that has just been, I'll say a joy in getting ready for that, but also having a true learning experience about engaging with the new school system that she's going into. So that's been very interesting in our household.

And then as far as work at NCUIH I think we are just doing a lot of infrastructure work right now, and so there, there is a lot of great opportunities for us to improve a lot of our practices, especially with our staff. And that continues to grow. And so just finding opportunities to ensure that they have what they need and that they understand all of the different ways in which we move in this space that we're in. So that is all.

Vickie Oldman: I am excited that you're here given that this particular episode is really highlighting frontline workers, and I had asked our guests, to define and share with us what that means. I'm curious for you anyway, why is it important to support frontline healthcare workers?

Kimberly Fowler: Yes. It's really important because I do believe that they are the first line of identifying and treating community members. I believe it was

Xochitl that mentioned about them being present when you first walk through the door. And that is definitely true and it's important to even understand that their expertise is present in order to ensure that the spread of diseases within their facility, both for staff and for patients, is how they actually move within this infection prevention control space.

It's important to support them because they really wear, they are in a place where they can wear down easily, because they're involved on a daily basis, not only physically and serving the community and their patients but also mentally, because they're caring for others, they're putting others before them to ensure their safety, to ensure that they get what they need when they walk through the door.

So, we definitely want to support them and lift them up as well through all the work that they do.

Vickie Oldman: I love the fact you're noting reality and, being in the healthcare field is, it can be tiring, with, the roles that they play.

NCUIH has done such a fantastic job in providing various modalities and how they're supporting frontline healthcare workers through training, technical assistance through these telecast episodes. What do you feel in terms of where you're at now? What are new ideas or even strategies that you're thinking about that maybe are not completely thought out, but like, Hey, this might be an idea in how you all wanna continue to support UIOs and frontline healthcare workers through Project Firstline.

Kimberly Fowler: Yeah, that's a great question. I do think we are always trying to be innovative and creative. One thing we did learn during the pandemic is someone sitting and watching a, a webinar or a training for, you know, a couple of hours or hour of time, it does wear on you and you start to lose focus at times, especially when it's day in and day out.

And so we've been really brainstorming to come up with some other creative ways to share out information and materials. And I know one that's being planned is the use of PhotoVoice and what PhotoVoice is, it gives the opportunity for, I'll just say frontline workers since this is specific to them.

But it would give the opportunity for frontline workers to really take a second look at their environment, take pictures of that environment. Based on questions or prompts that we might give them so that they can share from their point of view, through their lens, quote unquote, of what they're seeing, what they're feeling even what their successes are through pictures so that they can share with other frontline staff, other Urban Indian Organizations about the work that they've been doing.

And in a way that hopefully resonates through the visual aspect versus hearing it through words. Of course, there would be some report or writeup with that photo voice activity that they would be doing, but it primarily would be seen through pictures and understanding even the day-to-day of what a frontline worker might encounter and how they help to assist their clients.

So that's exciting and it's coming up and that's just one way we're kind of thinking through how to really get people outside of the box of just something that's virtual, something that you're staring at a screen or something that you even have to read because pictures can take on various senses within you. Right? Not only are you seeing I guess you also are hearing, depending on if it's narrated for the report itself, but you're also stimulated in a way that a picture could actually invoke some type of emotion in you too as well. So I'm looking forward to that and I'm, I'm happy that our team is really trying to think through that and put that in place.

Vickie Oldman: How exciting. I can't wait for y'all to launch that. It made me curious too, like what would it look like or what would it take to even get pictures from patients from what they see and them submitting pictures, with a little voice memo. Using that to educate and train healthcare workers and frontline workers as well.

So that sounds like a really fun way to really do some learning and some stretching as well. In terms of NCUIH, you've all have been doing a lot what would you say are still some existing barriers in supporting the urban Indian population?

Kimberly Fowler: The question we just touched on is definitely one of them trying to be innovative for outreach and delivery of information. From our lens, in the work that NCUIH does, just ensuring that the needs of our UIOs

are heard and seen, even at the national level.

So, making sure that we as NCUIH are raising our voice about all of the great successes and work that they're doing, but also raising some of the gaps and needs. Because if legislature, congressional members the state doesn't understand or even comprehend that this community is present and also needs support, those funding sources then may not come their way.

So, I do think the funding is another aspect. Funding always comes out when you talk about barriers, but it's, true. If you don't have the funds to even buy what you need or provide what you need, then you're kind of in this stuck spot of course, finding other innovative ways to do that. I have to say our UIOs are very creative in stretching their dollars.

But it is also helpful if there's funding dedicated specifically to UIOs and to tribes in order to fulfill the trust and treaty obligations that are there as well. Another barrier could be something that was brought up earlier by Nicole, in which she was talking about providing traditional services and that because urban areas do, are represented by multiple tribes and citizens, I do think that that is sometimes somewhat difficult to meet everyone's needs and the traditions from which they would practice back home if they lived on the reservation.

I do believe that finding ways in which even for reimbursement of traditional services comes into play so that you can provide those services without any barriers. That may not necessarily always come in the way of funding it. It also may come in the way of having elders and other traditionalists present that can provide that service within the community.

So really trying to seek out an outreach in order to make sure that everyone gets their needs, but traditionally too, as well.

Vickie Oldman: There's always gonna be learnings and challenges and I know I get excited when I see and hear how they turn into successes, I'm curious in terms of everything that you all have been doing, and, it's been a couple years in terms of Project Firstline, what successes has NCUIH seen in how you all are supporting UIOs and frontline healthcare workers? Kimberly Fowler: I would say that for successes, one of the key areas that this work has really touched is the ability to work side by side with a UIO in assessing their own needs. So, I know that there may be committees or even internal subcommittees within a UIO that really try to brainstorm and ensure that the practices and policies that are in place and even the plan for how they're training their staff is in place is done.

But I do believe that this this project, one of its main successful outcomes have been the ability to work side by side with the UIO and sharing the knowledge that we have internally at NCUIH, but also from what we are learning from the Centers for Disease Control and Prevention to provide that directly to our UIOs. Working directly with their medical staff, working directly with providers themselves sharing that knowledge in a way that we can actually see the outcomes of a plan that's created, that they've been implement. And that's exciting 'cause it's great to be able to say we supported them to get to this point of having a plan. And then also as they uncover challenges along the way, we provide technical assistance and alternatives that can help them move beyond that challenge to ensure that something is implemented accurately.

It also has been very successful in some of the funding that we've been able to provide through this project. During the pandemic I think everyone was just like really trying to find opportunities to, how can I get PPE how can I purchase PPE? Where is that funding coming from to be able to do that?

Even though there might have been some supplies available, but when the pandemic happened, now everyone needs these supplies, even your community members, and you need to provide that to them. So, I do feel like the funding with NCUIH was able to sub-grant out was also helpful in ensuring that UIOs were able to continue the work that they were doing on the ground.

Whether it was through telehealth or whether it was in person, those funds went towards supporting infrastructure and those needs itself.

Another success from NCUIH is since some of the precautions happened, or restrictions I should say, were lifted, we were actually able to do onsite visits with two UIOs that had partnered with us through this infection prevention control project. And it was just a great opportunity to see onsite, in-person all

of the great work that had been done at those facilities.

We were very honored to be there, but also to help them in a, in real time assessment of their IPC program and plan. And I think that that really benefited them to get those recommendations and suggestions from NCUIH and how they could also improve areas at their own facility in a way that just talking on online or just through a chat wouldn't been able to really gather that information in person to see it and understand what was in practice.

So, we were really excited to be able to do that this year and hope to continue that for next year too, as well.

Vickie Oldman: Wow, wonderful. How exciting. What about next year? What are the plans for next year?

Kimberly Fowler: Yeah, we're, we're definitely going to continue all of the training and technical assistance that we've provided in the past. We really want to ensure that we're providing ways in which even providers can sustain their credentialing. So, we did a pilot this current year in which we were able to provide continuing education units through some of our trainees that were provided on IPC.

We want to continue that. It was definitely successful. We had people come back to us and just share that no other way would they have been able to meet the funds that are needed in order to even receive the CEUs. So, NCUIH providing that at no cost was really important to them and will help in their credentialing sustainability at the UIO.

That's one aspect. We definitely are looking forward to continuing and growing in the way in which it was interesting that earlier we talked about frontline staff, not only being providers. They could even be your front desk help and support that you have. So, I do think that ensuring your front desk staff also can receive that training too as well. So, we're trying to find different topics that would relate to them too, as well as part of our Communities of Learning series that we will also provide in the next upcoming year.

So, looking at ways to infuse cultural practices within that work. Looking at the Standard Precautions on messaging because some of that front deck stuff may be helping with creating flyers and posters but finding opportunities to

infuse cultural practices within that messaging too as well.

Vickie Oldman: Yeah. No, I love that because in offering training that way, it's also from cross-pollination and it's always good to have everyone know a little bit of something. You, we don't expect everyone to be like a, a nurse, right? But enough to know where to navigate and where to point to, and maybe even explain in different terms.

Thank you so much for giving us updates. I, I appreciate it. I know that folks that are listening are excited to hear what you all are thinking about and how you're implementing all these learnings. Any final thoughts, wisdom that you wanna share to UIOs?

Kimberly Fowler: I just wanna share that NCUIH will always be here to support our UIOs. We did just launch a three-year strategic plan with UIOs in mind, of course based on our mission. But we really are trying to aim to be a resource center for not only UIOs but also individuals within your communities to improve the health of American Indians, Alaska Natives, living in urban areas.

So, with that, we are going to continue working within our advocacy, our education, our technical assistance, even our leadership training. We work with our board of directors, or your board of directors, I should say in ensuring that they also have what they need. But I know that through the strategic plan it really will be able to ensure that NCUIH is taking into account all of the evolving needs as well as opportunities that we can put in place that we've heard over the last year.

And I know that this work on infection prevention and control through the Project Firstline was part of giving some of that input. And so it will definitely, you'll start to see it reverberate through all the work and that we do throughout the next year. So, we're definitely looking forward to continuing our work.

Vickie Oldman: Thank you so much. I wanna bring back our guests and have them also share any final words of wisdom, thoughts to other practitioners, frontline health workers, UIOs, whatever it is bubbling up for you right now. Please bring your voice in and share.

Nichole Brewer Lowry: I just wanted to say, we would like to give a public thank you to NCUIH because it was the efforts of NCUIH that helped us to get over some of the hurdles that we had during the pandemic at Native American Lifelines. And so, we appreciate your support and continuing to advocate for us as a UIO. I think for frontline workers, we get it. You are the face of the organizations and you're the ones who make the community feel loved and supported. So, just make sure that you continue to consider yourself as well and what your needs are. I know that during the pandemic, we only thought of first line workers initially as the nurses and the doctors, and not everyone like we were talking about earlier just know that you are seen and that you are supported. I also would like to just say that for providers that have not worked with Native community members, I just encourage you to just ask, your, patients, what are they comfortable with. It's not a session of them educating you, but ask the questions that you need to ask appropriately so that you can provide care.

And just remember that they are the leader of the care team. Because if you don't provide a treatment plan that works for them, it doesn't matter if they saw you in the clinic or not. And so, reminding yourself to put them the patient and their needs first, and, and asking the questions of, is this something that you're okay with, you're comfortable with?

Is it traditionally okay? Do you have access to this medication? And I think that a lot of people who don't know Indian Health Service or how things work, they don't always understand some of the timelines that we have to work with. Just prescribing a medication and thinking a patient can get it, that same day is not always possible. So always take into consideration and asking those questions of your patient.

Jeff Rosenburg: I also wanted to express gratitude to the other UIOs. Communicate with each other. We learn from each other, and we support each other. And that's always really valuable. And, NCUIH provides a way for us also to come together, be supported, to be able to even now, once again, be able to be in person and, to network with our, partners to be able to provide, grow and, learn how to provide services to our clients better. And also wanted to express gratitude to IHS and all the educational opportunities that they provide and how they are accessible and, and have a face and reach out to us and provide us resources to be able to come together, go to

conferences, continue to learn and encourage us to one of the aspects of the quest you're talking about, like for the accreditations for other organizations that would help us become more standardized and improve the services that we provide.

And then also gratitude for everyone in our organization who continues to fight for our communities and our clients every day. Their commitment, that's really why they're here. And they fight through all the challenges that we have, both internally and externally to always be present for our clients. So, I'm very grateful for that as well.

Amanda Simon: I just also want to express gratitude to NCUIH for offering this space just to share our stories. Similarly, gratitude to all of our staff who have been here working hard for the community. And also, just to thank you to our community for supporting us as we support them as well.

There's a reason why we're here. I think also just, our staff and our community are connected, so appreciate both of them.

Xochitl Quintero: I really like what was said earlier regarding taking into account what the patients want for their treatment and their care. I think that's super, super important when working with any patient because we need to tailor the care to what they want. And I also agree with the idea that the patients are the head of their healthcare team. So, I think that is also very important as we move forward dealing with different issues that come up with patients and respecting that maybe what they're looking to address may be different than what we think should be addressed first. But having that conversation and being able to keep in mind what the patient wants in the center.

Vickie Oldman: Thank you. Ahéhee'. I appreciate everyone sharing words of wisdom. I heard from each and every one of these individuals the expression of gratitude for all the support system and in ways that you're learning and the resources that you're getting. So gratitude for that.

I'm also hearing that your stories do matter and we do learn from stories. To share those stories, to listen to the patients to hear, to ask. Don't be afraid to ask them what they need in terms of their healthcare and to remember that you as frontline workers, that you are the face, you are seen, and you are

supported.

So, thank you so much. I hope you'll have a wonderful day and that you continue to do the little things that matter. So, until then, you'll hear from us later. Have a beautiful day.