Health Committee Meeting – 7/15/2019

Health Committee Meeting - 7/15/2019



if appreciate bringing us all together today tough let's do the best work we can keep our nation strong Lord we try to serve you the best we can and we know it's hard it's like it's over the nation's very hard to keep things straight but we all care about the nation or we wouldn't be here so help us in this thank you has everybody read the minutes anybody want to make a motion to approve them second all those in favor say aye okay reports as George are you here with this thing hi Carrie how are you today apologizing for not making another month sent me instead so greetings from Claremore as far as our staffing goes we're still down a general surgeon and one Midwife we do have one other nurse practitioner opening in our clinic that looks like we're gonna hire the locals that's been serving there so we really only have these two positions open our outpatient visits are up three and a 3.6 percent over the same time period last year and our revenues are up twenty four point seven percent over the same time period our er remodel we are really close we were really close to getting that open we're still hoping to get get it open before the end of the month constructions done there's just a few contracting contractor check out items that we have to get resolved before we take take possession of it our outpatient visits are up 3.6 percent dental visits are down seven point nine percent missions down a little bit twelve point three percent and our newborns are down five point six percent it looks like we're still gonna be reading reaching over three hundred deliveries for the year collections overall our main collections are at 2.2 million year today they're at twenty point eight million and our collections are up compared to our fiscal year 2018 for the same time period by four million PRC activities we funded three hundred seventy nine cases this month two hundred of which were Cherokee Nation citizens we have 479 denials we're at 68 deferred cases report does anyone have any questions yes sir buzzer yes I know what you've done it's been a long time sometimes okay well our our existing er space and we've still been using it will stay the same we were adding for exam rooms to the to the south of the ER where I don't know if you ever been to Claremore there's the South backdoor that a young emergency room there were some storage spaces back there so we added for exams am rooms like I told me what happened it how many four there are six in the hall the one in the across into all the three beds and we have the big the big room a house for bail and on the other side of that hallway we're adding a registration and waiting room area so when you come into the ER instead of having to go through the ER and into the main lobby right now we're gonna be registering those patients they're putting and getting them in the waiting room there so they can get in and screen much faster yeah I've used before any any of you are in the area come by because we'd love to show that fill that space off I'll make it a point to come by night thank you anyone else have any questions Gary can I ask a question how far out do you all schedule your patient appointments depends on the clinic as I mean as far as the adult medicine clinic usually we schedule them at least a month and I know our established care appointments are out a couple months surgery clinic are out four to six months audiology is out a couple of months so it really depends on on the clinic do you have any idea how far how far you schedule out on your dental appointments no I I don't right off the top of my head that we can look and get back with you on that I would just be curious to know that okay anybody else here was a great beat Orton tell Georgia low for us okay thank you very much thank you now Cherokee Nation Health Service dr. Steve Jones good afternoon dr. Jones thank you for having me so we'll talk a little bit about the report that is included in your packets I'm not gonna read it to you just to point out a few things that are usually questions so we can emphasize those and I think earlier today counselor Dobbins have pointed out our vacancy rate you can see on page three there the report 5.3 percent currently against the benchmark of 25% for IHS another benchmark is in the private sector for our region is around 12 to 14 percent so we're doing pretty good at retaining and filling our our vacancies the other one is the referral approval rate you'll see that we're 97.1% approved usually those ones that fall in that 2.9 percent there it's our two type of appeals process so currently for this this month that we're reporting nice and what 1 percent of the contract health referrals were approved last month you asked me a question counselor buzzard about if those reported visits included pharmacy and the only thing it does not include is dental because everything that's in Cerner does include if it creates a patient visits or a pin number it creates a number as a you know coming in for pharmacy coming in for for physical therapy anything like lab then that's gonna be counted in those numbers in a different electronic record time so ok that's why we record it separately on here trends you can see everything on if you look at the next last page you can see most things are either trending the same or up a little slight decrease it at Salina but everything else is trending up and services deliver the other question I was asked last week I want to clarify too is on J the new vs. refills on prescriptions we looked into that there's a been a workaround that they've been using to do medical or medication reconciliation which is causing the refills to be recorded as new prescriptions so there was a process that we've had to correct with our providers on how they're recording that to flip that around the other part of that number is the fact that we're fully staffed there at J so that has increased the number of prescriptions also some of those are in fact new prescriptions but there is a workaround you'll see that number of increase as we've educated people on how to do it correctly but it was creating a new new prescription when in fact they were just discontinuing the old one in refilling with a new one you should see it now this this is we had already talked about it when this one was because we're always on a recording but you should start to see those members change over time the other issue thing that I want to talk about is our joint venture building the outpatient clinic there in Tahlequah the reason it took a little while to get two responses back to you I usually get those back within 10 days but this time it took a little longer we were on a push to get beneficial occupancy before July 1st so it took a lot of our administrative folks and a lot of other folks outside of health to get that done and we did accomplish that and got beneficial occupancy as of the 18th or 19th of June so we hit it a little bit ahead of time which into meaning that we got some funding that we would not have been able to get have we not been able to achieve that so the next push is to get us there for September 30th now so so we get out of you know out of one situation into the next and we're working hard to do that it has enabled us to transition things moving a little so our staff is going through different types of exercises for a day if we call it a day in the life what it's going to look like when we get over into the new facility how patients will be routed how staff will route patients how we'll communicate with one another and we're going through those exercises now for the transition that's all I have to report questions yes doc dress I had someone in the in the business of the health field there had some questions we talked about a little bit and that's gonna ask you to please define what our elective procedure referrals elective procedure referrals okay I'll have to get you a list of those but anything that would be considered elective a knee replacement may be considered elective it may not depending on the situation I surgery could be considered elective depending on the on the medical necessity of it so there's different types and different layers to that it's not simple as this is an elective surgery this isn't so cosmetic surgery is an elective surgery there are different things that are that fall under different categories and different levels of those categories don't want to elective not at least I don't have a list per se but I'm sure we can come up with something that would would give you yeah some guidance but typically those are decided through our committee and that was one of exploration who determines what is elective well that they go through a a system of what is approved and what is not approved initially and I guess it'd be an algorithm and then those don't automatically fit into the approved status then they are reviewed to see if they should be approved or not at that point if it is chosen not to be approved and there's a fuel process that will go to a different different medical personnel that will look at that and see if they feel like it should be overturned or not now that's all in-house so I can ask you and the committee does have their own different medical doctors doctors and they'll decide one right whether it's black do it or not yeah I'd like to see it just a general list do you know what and maybe some scenarios of like you were talking to eyes this would not be elective so if a person is uninsured what is process for elective or not elective if they're uninsured because they're getting down to a question any patient our patients ask to take an insurance plan out that may have a cost for a procedure our patients ask to take any time that we have contract health and money's being spent the Cherokee Nation is the payer of last resort okay so if they are not covered by insurance are not covered by a third party payer we ask them to meet with one of our counselors and see if there's a way we can get them covered so that we can pay what's left it's not very so they're not under obligation to take any of those plans sometimes we can we can get a plan that is no cost to the patient sometimes it's like Medicaid sometimes just simply getting them signed up and then that saves us contract health dollars to be able to spend and down the road so anybody can understand that let me just ask you and let's say they couldn't find a plan and it there were some cost do we make them do that and not serve if it's a if it's a medical necessity no we always pick up the cost if we refer somebody out and it's medical necessity they're gonna pick up a better cost they it's no cost to the patient but in some cases patients have found that they could get gold medical insurance for less than $20 a month and that's used to do it you know we don't pay that medical necessity there could be a plan out there that could help them they're not necessarily gonna give the service with that maybe taking out one of these plans right and maybe the service is completely paid for under one of those plans so you know there's different different plans for different individuals and it's all very convoluted and I can't speak to the details of it but it's there's a mole in that marketplace there's a hundred plans you know if a person has Medicare Part A only because they cannot for a for Part B what is the process for them not having partly they only have a similar to what we just talked about yeah that would be something that I would have to check into and see the specific situation because everything is those you know those things are very there's a lot of regulations that go along with getting someone signed up on the different parts and that probably boils down to you know whatever you can or cannot afford bottom line is if it's a necessity it's gonna get taken care of right and also I've got to ask you where are we I'm still cleaning I mean today what we're we're I didn't check into it before I came in yeah I know that we've signed the contracts for the trailers to be put in place we came to a and now to spend on on what we thought was fair for leases for those trailers I know the taps have been done we've paid the city for those taps so I haven't been over there to check and see if they've delivered the trailers yet or not but that's the that's the step we're in right now we've met with the architects and we've gotten through the the redesign of the front of the building to allow elders and handicapped patients to be able to park I think we end up getting between 25 and 35 extra parking spots up on the sound of Alaska as the clinic that took some time to redesign that because of the civil engineering that's required to get rid of the water because we are landlocked and we don't want to put water on their neighbors so those things have been done now and we're at that point where the trailer should be delivered at that point we'll start certifying them to get ready to move the robot from the pharmacy into the trailer and make sure that we have everything secure and they get certified by the state once that happens then we can start the transition of moving you don't know but you foresee the trailers didn't set up and I'm not finger to that we've talked about those trailers and tasks for last couple months deeper you know you see that probably in a month some of that is out of our control but some that has been you know one thing was the flood setback setlist setting back some of the work that was need to be done because the same contractors that will be delivering those trailers and doing the dirt work there we're getting pulled away for other jobs so to my knowledge the last time that I met with with our folks they were in the process I know personally I signed off on the PIO for the trailers so I know that those checks are being cut or have been cut that was a couple of last two weeks ago so I know we're at that phase I just don't know delivery dates and and when the transition will start occurring you know again you know I told you also we were looking for a place to park our employees because once we start making this transition and we start staging the the demolition of the old part of the building part of the parking lot goes away and so we have to have a place to allow our patients to still mark but we're going to transition our employees and and transfer them back and forth from wherever we find and so far the closest place we've found is that that you know that is actually reasonable we had a couple other areas but they were mud and in winter time when it starts getting bad you know you're not going to want to have people parking their cars out in the mud yeah that's just growing pains I mean nobody likes to get hauled back and forward if it means getting that getting back together trying to come up with a vehicle that will transport them and having some type of schedule so if someone's kid gets sick at school they're able to get them back to their car to get them to their school I mean there's a lot of logistics to work out to keep everybody happy so look forward to next month madam chair I was gonna let you start the discussion whenever you're ready about the our dental meeting everything I think councillor Dobbins is going to discuss we can do that whenever I would council Dobbins would you like to discuss that at this time well I'm sure a lot of heard phone calls from constituents kind of frustrated with the dental appointment procedure keep in mind this is just for new patients now if you have constituents that are patients already they've been examined even they've had their treatment completed but placed on a six-month recall we may be one of maybe the only tribe in America that has a recall system but we're still kind of looking for I think the dental staff has done the best at this point to figure out a way to get new patients scheduled and right now there's just a window every day at 4:00 or 4:30 and we can only take X number of new patient exams every day and then at all our clinics our doctors at could be corrected but I think all our doctors do for new patient exams a day and and and that's all they can do we can't have our doctors just impatient exams all day they could but they have to do treatment and in anyway chairman Shah has asked me to look at other models that might be able we could use to improve our system of new patient scheduling but I think right now the dental staff they've tried different things and this seems to work the best although it may not be perfect but I will look into the other alternative our system I would like to add my thanks to dr. Jones for arranging that meeting account councillor Dobbins councillor crittenton and myself did attend and it was very informative I mean I to sit down and hear what the dental clinic is dealing with and the staff was very informative and hopefully you know we can come up maybe with some alternative suggestions or something and I really appreciate councillor Dobbins investigating that but again thank you for setting that up appreciate it yes councillor Crittenton to follow up and I'm a transition to the new building that's gonna help out a lot feeding and we I wasn't sold yet on the 4:30 call in it's the best thing simply because I get so many calls about it and I've been in on a few of those ups picture the season on our break we had three phones at one time you know trying to trying to get in but then once the transition takes place it'll be interesting to see just how much that helps you know with some more chairs so I'm not a fan of the 430 deal but I'm gonna give it a chance to get switched over to the big building and see how that goes well they're also gonna be expanding our dental services and still well we're going from a 12 to a 16 chair clinic so it increase in the number of chairs and number of providers they're also so we're trying to take the pressure off of the system but right now with that clinic being closed a limited amount of chair if we have a Hastings it's not a perfect system but it's it works right now and it's gotten our no-show rate way down so it doesn't do any good to schedule the patients if the patients don't show up then we have a provider that's doing sitting there with an empty slot so it's it's the best that we have right now no question on that like the new patients that's the 430 folks now like a teeth-cleaning that is that a walk-in not usually in some cases it can occur if if you're walk-in on a day whenever things are a little bit you know not as busy and if you're a patient that's looking to get into our system for a denture or for a partial because those patients will be ultimately referred out for that service if there's something we can do while they're there to get them through the system quicker then they will do that now it doesn't always happen but if the hygienist or dest has an opening because someone didn't show up others will walk in as that need they will they will put them in the chair and get it done but it doesn't always happen that way so they they would be a part of the Colleen to in so in most cases now meaning if for example it's a diabetic patient then we prioritize and get those people we have certain days where they'll do diabetic exams and we try to get those patients labeled and get them in as quickly as I can because we recognize that that's a that's a serious issue when they can't eat properly and they have diabetes so thank you speaker Berg yes and with the injection of the joint venture we've got a first drawdown I think those funds are used for operation and new hires and we're hiring and and some equipment yeah yeah so operational things but right now we're we're trying to utilize that money to get staphon and get them trained before we as we go through this transition of course so there's a lot of a lot of new people showing up and not a lot of space to put them in right now but we're trying to get people identified who we need up upfront for example you know as we get areas of that building turned over to us we've gotta go in and do a clean you know get it up to standards to be able to see patients because they turn it over to us with the construction cleaning which as if you've ever been involved with construction is not a detail cleaning so we have to identify those people we've been hiring those people and getting them trained so they can go into the facility and start the cleaning process and that's been going on for about a month thank you keep up the good work dr. John thank you how many questions dr. Jones where there's been a lot of discussion in this past week about raises and salaries are we competitive with the salaries that our health care professionals are currently being paid we're looking into that I will I've got several projects working 37 I think currently and one of them is a looking at compensation not only at our physicians that are nurses that different levels at all different levels of our health systems so but that's something we do jointly with HR and and as we move through this you know it can all be done at once you've got to do it a little at a time and we've got to see what the budget impact is and then present that budget to you guys to approve or disapprove so we're working through those things now we're looking at whether our compensation package is good or not we feel like right now with our vacancy rate the way it is it you know in some areas we need to work a little harder in some areas we're doing okay you know I hope you would know that I think council could be very supportive of ensuring that we you know retain the best qualified people in their positions I just want to make sure that we're you know we are comparable to what's being offered up in other places let's retain those if that's what it takes and I agree I agree totally with them I also agree on the back side of that there has to be some accountability there has to be some expectations on what we get for that a amount of money that we pay in other systems we're looking at how they model those things and and we'll be coming with some recommendations you know one thing I do want to share with Council is that one thing I admire so much about dr. Jones as he has held our employees to be accountable and I for one is very grateful on that it's it's resulted in some very needed changes and I person grateful and that you have done that a couple of questions do we utilize insulin pumps I can't answer that for sure I don't know if I can find out okay thank you and then over the weekend we had a CCL conference and I had a several at-large citizens with some questions and I want to thank dr. Montgomery and specific for being available to help me and assist me on some of these and I'm grateful for that uh I have a question that I got to thinking about do we have a forum or something when an at-large citizen needs to be referred is there a forum where they may be sign something to let them know they they will be responsible for any charges outside of our health system and they're being referred for medical for something that they've come to us as a beneficiary and they are being referred out great if it's something that my understanding of that is if we refer them out and Steve may be able to correct me if I'm wrong but if we referral mouth and we're gonna take care of that that responsibility I don't believe that is correct electives something selected it may not be if it's something that we're seeing them for and referring them for that service and my understanding is that we're being that we're paying for that but I can ask that for sure I'm mistaken yeah my suggestion is quite simple could we I don't know if we do have a form but a form to let that person that Cherokee citizen know that they will be responsible for those charges if they followed through with that referral I find that to be quite a common occurrence with our at-large citizens they don't seem to understand that they will be responsible for those charges and I think if you had them sign something and give them something that states they will be I think that could eliminate a lot of misconceptions so certainly we'll look at that and try to get that process fixed I think that would be very beneficial for everyone yes counselor okay another thing doctor has going to ask you about is – and it's a problem we talked about a few years back as the people that they're gonna get their bill paid but it's going to the credit companies they're they're really concerned about that did we ever devised a letter we talked about that Konica see here some sort of bladder that can ease these people's mind plus the creditors what's the discussions you've had about that cuz I get I get lots of calls I'm sure everybody's paid credit people are calling this collections well I I don't know if we have a letter yet I'll have to check on that and see if Steve can you speak to that how are we informing that like the patients themselves cuz can we can we do better on saying hey look now you're gonna get denied maybe but that we send it in again and then the creditor start coming can we can we inform the the patient later [Applause] I appreciate Kari he's he's really done a good job and yes I can't think of a situation that that he hadn't helped me with and madam chair gonna ask you a question here yeah I've got a we recognize lots of people here yeah I mean we recognize lots of people and I've got a couple rocky mister miss rocky Carroll good I made him at a gospel singing yeah just real fine people they're not they're not complainers they're not they're not gonna you know say anything out of line I talked to counsel Shambo about it but if I may can I have five minutes mr. Carroll has some concerns and just he's right here and I'd sure love it if he could maybe some suggestions to us this is not a point fingers that mr. Carey like I said he's helped me with it but rocky was visiting with me and I never got a counselor Shambo and he's got some pretty good points and it might help some of us just just a few minutes will that be okay counselor cringing me I suggest that you all need after this meeting I'd be happy to volunteer you know my office even but to discuss that and and see if we can get it in writing right mr. Carey would you mind to visit with this a little bit and you've got some it's on paper rocky yeah okay yeah and I can get it to the yeah we'll do it that way so don't run off with me right here thank you guys for coming thank you thank you and I want to say one thing about that sometimes it's educating the introverts milk because they have turnovers they have office manage that turnover and educating them on how to get the bill back to us to be paid the easy way is to turn it over to collections facility that we were furtively referring to they have a turnover and we found that before where they have a turnover and then they send that bill to collections instead of sending it back to us because I see the patient's name on it rather than Cherokee Nation as the payer so sometimes it's as simple as getting back with them and re-educating their office manager on how to correctly do the paperwork to get the bill paid so I have found that several times has happened councillor Mike Canadians sometimes I feel like you know some ball that drops Anwar and I don't know word maybe what's understand the patient's themselves keep telling this collection agency I don't know you that's a private and so the belly gets to a certain point pressure and so then they start calling either using names from your clinic and only they have six months later we're trying to figure out why wouldn't play and so I'm not sure process and sometimes it's it's the difference in inpatient and outpatient so if it's inpatient and it's in the area of Claremore operations then it has to go through them first before it we can touch well and if it's outpatient then we can almost automatically they were playing and I think the ball is dropped somewhere maybe on the other end I always wondered what was that but nobody continued but anyways I don't know if there's additional step could add to the process an additional piece of paperwork saying all this used to be graduated call this number I'll use his name he's not here to defending so call this number for help and assistance and paying them and pose they usually go about six months and these people are mad by the time they called me and we simply said no we did it because something right sometimes like it says as simple as the contractor the provider were contracting with if not doing the appropriate paperwork sent back for payment it's all outlined to them when they enter into a contract with us but sometimes I don't take the time to read that and they sign off on it and then they then we have to educate them after the fact so that happens a lot they assume that this the way that normal billing takes place by billing the patient would take care of it but that's not the case with us because we don't require our patients to pay for that look back and I see a couple guys I think you were here then also what you're telling me is Frick shouldn't there always be a rotating Compensation Committee judging as to what if we're keeping up with the Joneses well there is a place there is you know there's a thing called MGM a standards which are put out by the Medical Association I'm assuming I don't know who publishes that but it is the standards by which most entities use to look at their compensation in their region and so those things are done independently and objectively and then you have to take those and apply them to your system and see how they fit into your system I think initially I think initially there was an attempt to reinvent the wheel so we're looking at how how everyone else does it and trying to modify that into our system I just would say in the last three months I've had eight cases and they've been real good to work with me on some of them they were turned down the first time and he was on the paperwork and we went back and then make call and within two three days we had the problem service alt and the people I had the noses were happy and I just thought was a good job to make seem like y'all got on a real fast and I had a case of done document Imam and facial did a good job we had that one hard lady but it wasn't our fault thank you on the billing I think the big problem is it's the late sometimes all your bills come in within that two months later you seem to get that five hundred dollar bill for whatever reason they're three months later and that doesn't get addressed you know and for whatever reason it probably doesn't get turned in or or the people assume that the hot you know Hospital sent to us and I think that's the base reason why we get dinged are they people get dinged a lot is those three months late bills and they don't get sent to you guys that's that's been my take on it but what I was really want to tell you is I was at the Jay clinic it's been several months ago and I'm sorry I didn't bring it to your attention but and I think it was she was given a certificate I was coming out of the clinic and there was an elderly man coming up and the parking that that Jay clinic is horrible they have to walk so far the handicap parking is you know it's quite a ways away I don't know if there's anything can be done with that or move it to where they can come in closer to the back but he would walk about ten yards to stop ten yards and stop and I actually went out there and talked to him and asked him if he wanted me if he wanted me get him a wheelchair he said no it's good exercise so I kind of didn't like my truck and watched him for a little bit well a nurse came uh uh actually she's a baby she works that behavior Hill clerk came out and brought him a wheelchair and wheeled him in and he was very very appreciative that I think he's just a little too proud to ask for one yeah her name was Brenda Larson and she did went above and beyond to come out she said she noticed him having trouble and she went and got a wheelchair from her office and when you got him and I just thought that was pretty great make sure we acknowledge that hey any other questions dr. J dr. Jones thank you so much for coming today we she ate it please check your reports thank you I really appreciate how you answer our questions thank you okay next we have elder care tell Moffit night Pittman I believe Connie Davis is here as well good afternoon ladies we missed you last month sad to see you here today we apologize oh you can't help we have an you can talk going on and the only way from the council you did which I believe you have the report submitted for the month just a little bit of an update from that and we're up to 180 participants which is an all-time high for an elder care program and have a couple being enrolled this month well we were under construction when I first started the contract in March for administrative building these ladies and gentlemen have been working out of mobile home for ten years and literally had holes for the floor so they're very excited to be in the new facility and its operating very well sorry about that it's paid for as we understand yes completely paid for so we paid as we went the building itself came in around one hundred and twenty three dollars a square foot so we're real proud of that number we got it down that low the only thing that we have left I'm working with five star on the furnishings and we estimated around $25,000 for a new furnishing for eleven workspaces I pushed it up to 14 and I'm gonna have we're going to have to pay another $1,300 for an additional three workspaces so we did real well on the furnishings also worst where's this construction taking place by my ass it's on our side and eldercare it's right behind the the formal building when you have a design for that somewhere that we could see yes sir I can get that to you okay as soon as we get smart from genome is helping us with some art for the hallways and conference room we'll have an open house and have you guys go take a look at the new facility– I can email you the floor plan do that to Gail would you please show the other exciting news is when I served on the board in my other role we talked about expansion and the need to go to other zip codes that's how we serve people based on need and we're excited to be able to begin the process of expanding it to Muskogee next and we're hoping to maybe use some property at Three Rivers to build on the highway access is good and what allow us to get close to Sequoyah County and I don't have the specific zip codes because we haven't even started the application process but we are doing that we have to secure location and address and then we'll be working on feasibility and official and document submission hopefully within the year would it be within the 14 counties Muskogee yes yes okay but in the foot anybody have any questions they'd like to ask these ladies yes counselor Buzzard that was a question other than I asked about when this initially started we had looked at maybe doing six pace centers throughout the Cherokee Nation 14 county jurisdiction but now that you mention it Tony I'm gonna make sure some of our zip codes are gonna say north of Fort oil because it certainly needs something else no nursing home visit they certainly feel they're kind of like the everything California so make sure if you look at code north – it's like Rogers County maybe in the private area but via the next place where is this to strategically go and you just mentioned those names right now this sounds like the more populated areas don't forget though where's we do not have access to Hamlet's there's hospitals little things like that and we seem to get overlooked about everything like this Rogers can't even not playing anything with Rogers County that's pretty populated county so Adelbert county's not that popular we don't have an image service so don't want me to be taken consideration Thank You manager Chancellor Austin in response to the Rogers County North Rogers County there's a the northeast part of our dyskinetic water as it is 20 minutes to anybody there that is not as area with services Clem well branch does but there's a big area there without that's a it's kind of a big Brush this is the whole can endure yeah councillor Dobbins thank you madam chair how many constituents to say you serve I think about 46% we might gonna finally having total D service a 180 yes well there's 180 participants but 46% of those are native and 51% right now are non-native so but that fluctuates councilman's from it usually sits around around 50 50 50 on constituents and you have 68 boys yes sir and 70 percent are native and 30% are non-native can you kind of tell me what Cherokee elder care buddy we provide what kind of yes sir we we are a full-blown have a full-blown clinic if they need a specialty service we send that send them out for specialty we pay for ambulance we pay for inpatient we pay for their meds it's a program that has been within the federal registry for almost 30 years now there's 126 pay sites in the United States we were the first pay site to be sponsored by an Indian nation we still are the first one to be sponsored by an Indian nation we've been here almost 12 years log in here 12 years we will have our 11th anniversary in October or excuse me August and whatever their needs are we have occupational therapy and physical therapy on-site we have 18 of our participants in nursing homes that we provide for some of them are insisted living whatever their needs are we provide those needs we have an interdisciplinary team that looks into their needs and their services we provide DME hospital beds for homes if they need a hospital bed for rehab we are a full-blown service for our participants their homebound we have contracts with home health agencies Cherokee Nation home health and several others that we send aids into the home to help our participants yes sir that's a crittenton yes man we talked about this last month I just wanna make sure I got this in my old feeble brain here yes sir yeah like the building that's that's being constructed mm-hmm no that that's no Cherokee dollars no sir no none of those employees are paid by the nation no sir and so now when you say sponsor what do you mean every pay center usually has a sponsor especially a rule paste in the beginning as councilman Buzzard said there was a feasibility study and actually they wanted for pay sites within the 14 County area Cherokee Nation did sponsor the dollars to get started and to construct the first facility which we made monthly payments back to Cherokee Nation business to pay off that loan and Medicare and Medicaid we are subsidized by them yeah when you see that word elder and I see I see your vehicles out it's just a win for everybody yes sir but in my position you know some people think that you have to listen to me some people think you have to listen to the chief but in actuality it's not Cherokee Nation right it's a separate we are an agency of the Cherokee Nation within the executive branch of the Cherokee Nation we are an agency so we have contracts with risk management we pay for our insurance just like I think the housing authority does and those type things but we're an agency within the nation but we exist on federal dollars and the board is appointed by by the chief embedded by your counsel all right I think I got it now okay thank you I have a question you all are operating at a loss if I'm not mistaken of almost a half a million dollars this year who covers your loss we do you – yes ma'am okay and one other questions how many inquiries are there daily if you can give me an estimate of people wanting elder care services it has increased I some days it's two Sunday's is 20 it just depends on if somebody sees our van yeah you know they see our newsletter or those kind of things so it varies Speaker I'm you excuse me German varies daily but there absolutely is a need for you all to actually have be larger actually yes ma'am there is a mnemonic that's awesome councilman lay asked me last time about Tulsa County and I hope you've got the information that I gave to mr. Enlow to forward to you councilman like yeah I'm interested all right I know it to be their life Senior Services in Tulsa covers and it's a pace facility and and it's federally subsidized as we are and they would entertain native as well as non-native and I wanted you to understand that and also Broken Arrow their expanded to Broken Arrow also so we when you tell me you're saying to me and that's something that I think that you would continue the further out together yes sir well I want to make sure that you had the information thank you okay any other questions thank you all so much for being here today we appreciate it entertain a motion to adjourn

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