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BILLINGS, Montana (Billings Gazette) — It’s been ongoing for years now and discussed even longer, but now greater efforts are being made across Montana to bridge the gaps in Native American health care.

Since last year, Josiah Hugs has worked with Billings Clinic as a Native American liaison with its recently formed Diversity, Equity, Inclusion and Belonging (DEIB) department to increase and promote the education of and outreach to local Native communities.

DEIB refers to the belief that equal access to services and employment be given to all people regardless of their racial, sexual, gender, religious and socioeconomic backgrounds. Businesses and organizations have increasingly adopted this approach to meet the needs of groups and communities that have been underrepresented or under-served in the past.

Recognizing growing needs for local community inequities across patients, visitors and personnel, the hospital formed its DEIB department in 2020 to address them and created the liaison position in 2022 to have greater focus on the needs of local Native American communities.

“As we continued to grow and see needs, we had interest and really sort of intentionality as we think of our Native American community being such a large and important part of our communities,” said Billings Clinic DEIB director Sara Agostinelli.

Hugs applied for the new position shortly after it became available and would begin to make an immediate impact. A member of the Apsaalooke Nation, he was raised in the Arrow Creek District of the Crow Reservation in Pryor before moving to Billings to work as a resource coordinator for the Downtown Billings Alliance, an addiction counselor and then a suicide prevention coordinator at Billings Urban Indian Health and Wellness Center in Billings.

He said it was the cumulative experiences from this background that made him uniquely qualified to bridge the cultural gap.

“So, when I go into the ED (emergency department) and talk to their people and their biggest concern is the Native Americans coming in and off the street, I’m like ‘Oh yeah, I’ve worked with them for two years. I know exactly what you’re talking about,’ and am able to relate to them on that level. And then when there are other departments talking about burnout and compassion fatigue, I’m like ‘Yeah, I’ve been there (too),’” he said.

Hugs’s current work with the hospital isn’t meant to be a one-person job, though. Rather than act as a hospital chaplain or social worker for patients directly, his work mostly entails educating hospital staff on how to proceed with their usual functions in culturally informed ways. The goal is that every worker can provide the appropriate care as needed rather than only a few who are qualified.

Education has included meeting clinic staff and leadership and asking what they did or didn’t know about Montana reservations or historical homelands. Hugs would also consult with Native Americans already on staff to understand what they felt needs to be taught or communicated, like differences in family structures and cultural norms. He would then communicate the appropriate information to Billings Clinic’s entire staff over time through presentations, a series of training sessions, instructional videos and a weekly podcast.

Hugs said the goal ultimately is to create a safe and productive space for staff to express their questions and feelings about previous experiences with Native American patients and families.

“Hopefully, I can educate or speak to that experience of cultural or social norms that I adhere to and grew up being taught that are not adhered to here in Billings and, as I say, mainstream society,” he said.

Certain types of nonverbal communication, for example, can convey widely different messages depending on the norms one knows. Hugs said the most common topics he’s received from staff to date involves a lack of eye contact maintained with native patients. The reason, he explained, is because of the sign of respect it represents is the opposite to what most people might interpret.

“Back home, to stand in front of somebody and maintain eye contact is very confrontational, very forward and disrespectful. Where (here), to stand in front of someone, make contact and have a conversation is a norm,” he said.

Another significant change over the past year has come in the hospital’s spiritual care leading up to a patient’s death. In addition to bringing in families for a final prayer while they’re alive, Hugs advised that they stop saying the name of the dying patient during end-of-care treatment.

He explained that traditional belief is that death is the process of entering the spirit realm and that uttering their name brings them back to the physical world.

“So it’s very disrespectful to the family, to the individual, and it just sort of adds insult to injury,” he said.

Adding to the benefits for both patients and staff is the inclusion of regular smudging ceremonies in the hospital. With his background both in living on the Crow Reservation and working as a counselor, Hugs said the traditional burning of herbs like sage, tobacco, bitterroot and sweet grass can provide mental and spiritual relief to anyone suffering from stress.

“I had experienced that. So I thought, ‘What cultural piece could I bring that could help our employees with self-care and wellbeing to re-set their day?’” he said. “And then I was like, ‘Oh, smudging.’”

Policies allowing patients to smudge in their rooms have been in place at Billings Clinic since 2004, but further adjustments have allowed Hugs to hold regular smudging ceremonies in the hospital chapel to release any negative energy.

From stressed out staff to patients’ families waiting for discharge to end-of-life care or even visitors simply wanting to experience it, the ceremonies have been positively received throughout the clinic.

Hugs added that this approach has proven to be meaningful for patients and families who practice similar traditions while at the hospital.

“There’s been at least one instance where a patient was transitioning to hospice and it was an end-of-life type situation,” he said. “And we were able to provide that one little, cultural piece since they weren’t able to go home….coming to the chapel and being able to smudge and pray one last time.”

Hugs is currently one of the only fully staffed liaisons at a Montana hospital, but his hiring is far from the only DEIB action taken toward Native populations across the state.

In 2021, RiverStone Health hired a justice, equity, diversity and inclusion senior director and has since worked with Billings Clinic along with the Rocky Mountain Tribal Leaders Council and Montana State University Billings’ Native American Achievement Center on public presentations and conferences on Native American education.

Over the years, St. Vincent Healthcare, much like Billings Clinic, has also trained its caregivers on Native American family dynamics, spirituality towards the end of life and other traditions through ongoing education and, at one time, patient advocacy through their own cultural liaison for appropriate treatment.

In 2006, Benefis Health System in Great Falls opened its Papoose Rattler Memorial Native American Welcoming Center to support the traditions and culture of local Native American patients and families. The same year, an advisory committee on Native affairs with neighboring hospitals and tribes was formed before it grew into an advisory board in 2008.

To date, representatives from the Blackfeet, Chippewa Cree, Little Shell, Assiniboine and Sioux tribes along with representatives from Indian Health Services and Indian Family Health Clinic currently occupy the board which has become a model of sorts to replicate.

“It’s extremely unique,” Benefis Chief Nursing Officer Rayn Ginnaty said of the board. “We see a large number of Native Americans in our hospitals and we wanted to make sure that we were meeting those needs. But as we talk about this in different states and different settings, it’s something that we often receive immediate feedback on…so it is an extremely rare focus, I think, for many hospitals and health systems.”

Efforts throughout these hospitals to date have included updating their facilities to reflect native populations through local art, acknowledging the sacred grounds they’re located on, allowing patients and families to perform their own smudging ceremonies, educational presentations by guest speakers and observing Missing and Murdered Indigenous Persons Awareness Day May 5 and Native American Heritage month in November.

One shortcoming of these types of efforts in the past has been a dependence on grant funding through organizations like the Montana Healthcare Foundation and the Cigna Foundation.

Because of this historical lack of consistency, one of Hugs’ first questions he had for Billings Clinic before accepting the job was the assurance that this would not be the case.

“Is this in the budget? Is this perpetual? Is this part of the organization’s dream? Because that was one of my biggest concerns,” Hugs said. “If this is grant funded, I don’t want it. Because when the money goes away, the people go away, the cause goes away, and all that education and all that learning goes away.”

The work to address equity gaps has begun, but is far from over.

In Polson, Providence St. Joseph Medical Center made similar strides in creating a more mindful approach to treating local communities on the Flathead Reservation over the past year through a new cultural committee. These efforts have included similar measures to the other hospitals, but also included a greater commitment to addressing current inequities.

“Native Americans are our largest cultural patient population…and so we made that our primary focus from a DEIB standpoint,” Director of Nursing at Providence St. Joseph Erin Rumelhart said. “And then we went a little bit deeper as far as social determinants of health and inequities within the tribal population.”

She explained that St. Joseph and many of the other state hospitals have made strides with diversity and inclusion, but equity pertaining to Native American health care remains their biggest challenge. She pointed to recent medical studies identifying generational trauma, lower birthrates, and higher maternal mortality rates as health trends currently more common to Native populations than others.

“Why is that? What do we have within our structure that we’re not able to provide? Is there an access to care issue? Do they feel unsafe? Where does that opportunity lie to ensure that Native American women are not having more health concerns than Caucasian women? It is astounding to me that that’s still an issue,” Rumelhart said.

With regard to addressing these inequities, measures to expand health care to Native populations has included the development of Urban Wellness Center in 2018 as a regional office in Billings to expand health care by Indian Health Services. The same year, grant funding was awarded to St. Vincent Healthcare to work toward improving Native women and babies’ health outcomes through greater access to prenatal care, drug education and intervention when needed.

Ginnaty said that discussions with Benefis have progressed over the years into ongoing efforts to expand medical information and possibly implement certain hospital services into nearby tribal areas represented on their advisory board.

Along with increasing efforts to directly address inequities, the consensus among the hospitals remains that continuing education is essential to achieve this. Billings Clinic plans to educate future nursing resident students with the same Native American education staff have received and has also begun updating electronic medical records to recognize patients’ federally recognized tribes along with their tribal names and homelands.

Last fall, a newly created Native American liaison position was developed at the University of Montana’s Family Medicine Residency of Western Montana in Missoula both to train current staff on Montana’s Native populations and address a shortage of medical workers from Native American backgrounds.

Shortly after getting hired, Hugs was contacted to discuss what he has successfully implemented to date and how that could be applied to not just their own staff training, but to future recruitment of native communities for medical schools.

Agostinelli said, in addition to benefiting current staff going forward, this type of inclusive training and approach at the beginning of a medical professional’s career could leave a lasting impact on the work they go on to do.

“There’s so much research that talks about how doctors perform based on how they were taught,” she said. “And so, I think that’s not just Billings Clinic, but that’s changing the future of rural medicine.”

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