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Telephone Calls To Reduce 30-Day Readmissions For Older Adults With Heart Failure, Juanette G. Clark May 2015

Telephone Calls To Reduce 30-Day Readmissions For Older Adults With Heart Failure, Juanette G. Clark

Doctor of Nursing Practice Final Manuscripts

Abstract

Purpose: The purpose of this evidenced based practice project was to evaluate the effectiveness of discharge follow-up calls for heart failure (HF) patients recently discharged from a private hospital.

Background: HF is the number one discharge diagnosis among patients 65 years and older. It affects 5.8 million people in the United States. HF admissions total (1) million annually, however, 24% of these patients are readmitted within 30 days of discharge. Re-hospitalizations are associated with high mortality rates and expenditures approximated at $13,000 per patient contributing to the overall annual expenditure of $33.7 billion. In 2012, the Centers for Medicare …


Improving Dental Care To The Elderly In A Nursing Home, Cara M. Licavoli May 2015

Improving Dental Care To The Elderly In A Nursing Home, Cara M. Licavoli

Master's Projects and Capstones

The project is about the collaboration between Peninsula Health Care District (PHCD) and Apple Tree Dental (ATD) in a team approach to address the current issues of improving dental care of frail and elderly patients in nursing home facilities. The specific aim is to improve dental care of clients at the San Mateo County nursing home facility by 100% by May, 2015. The methods use in this project was the adaptation and implementation of existing dental/oral health assessment tools, that is nurse driven for patient assessment upon admission to the nursing facility. The process includes staff education regarding the adapted …


Fueling The Flame: Complementary And Alternative Methods To Prevent Burnout, Natalie Masco Dixon May 2015

Fueling The Flame: Complementary And Alternative Methods To Prevent Burnout, Natalie Masco Dixon

Nursing Faculty/Staff Publications

Do you feel tired, stressed or overwhelmed? Do you have little time to care for yourself or are looking for new ways to bring wellness to your life? Nurses must be healed in order to heal. Modalities often considered complementary or alternative may offer the rejuvenation in your health and wellness you have been looking for! This session introduces the audience to common causes of burnout and ways in which acute and critical care nurses can find balance in their own lives through self-care practices. Modalities to be examined and practiced include centering, mindfulness, acupressure and aromatherapy. Personal experiences with …


Perinatal Health Education Intervention For Adolescent And Young Adult Pregnant Homeless Women Living In Transitional Housing, And Best Practice Teaching Intervention Program For Staff Responsible For Care Of The Mother-Baby Dyad, Colleen Carrington May 2015

Perinatal Health Education Intervention For Adolescent And Young Adult Pregnant Homeless Women Living In Transitional Housing, And Best Practice Teaching Intervention Program For Staff Responsible For Care Of The Mother-Baby Dyad, Colleen Carrington

Seton Hall University DNP Final Projects

Purpose: A population at great risk is pregnant homeless adolescents and young adult women. Research shows that about 20% of homeless young women become pregnant (Bender, & Thompson, 2007). These pregnant young women are at an increased risk for low birth weight infants and a high infant mortality due to inadequate health care, poor dietary habits, and a knowledge deficit related to maintaining good health during pregnancy and to care of the infant and growing child. A transitional shelter may offer many psychosocial services to assist the women in becoming independent; however, a significant gap exists regarding the medical …


The Relationships Among Perceived Stress, Birth Satisfaction, And Breastfeeding Self-Efficacy In Early Postpartum Women, Katherine Hinic May 2015

The Relationships Among Perceived Stress, Birth Satisfaction, And Breastfeeding Self-Efficacy In Early Postpartum Women, Katherine Hinic

Seton Hall University Dissertations and Theses (ETDs)

This descriptive correlational study examined the relationships among perceived stress, birth satisfaction, and breastfeeding self-efficacy in women in the early postpartum period. The study, guided by self-efficacy and stress and coping theories, aimed to identify factors related to breastfeeding self-efficacy, an important psychological variable in sustained breastfeeding. The sample (N =107) was comprised of primarily well-educated, higher income, non-Hispanic White (69.8%) women recruited from a single New Jersey hospital in the first four days postpartum. The sample was comprised of nearly equal numbers of primiparous and multiparous women, all of whom expressed an intention to breastfeed, with an overall …


Health-Related Beliefs, Practices, And Experiences Of Migrant Dominicans In The Northeastern United States, Constance Sobon Sensor May 2015

Health-Related Beliefs, Practices, And Experiences Of Migrant Dominicans In The Northeastern United States, Constance Sobon Sensor

Seton Hall University Dissertations and Theses (ETDs)

Purpose: This study aimed to discover and describe migrant Dominican cultural beliefs and practices related to health, the ways that migrant Dominicans take care of their health in their new environment, and their experience with professional health care in the Northeastern United States.

Design: This descriptive qualitative study was guided by Leininger’s Theory of Culture Care Diversity and Universality and four-phase analysis method. The health-related beliefs, practices and experiences of a convenience sample of 15 self-identified adult Dominicans living in the United States for six months or more were explored in three focus groups, assisted by trained culturally appropriate interpreters. …


Lipoprotein-Associated Phospholipase A2 And The Young Adult, S. K. Reid May 2015

Lipoprotein-Associated Phospholipase A2 And The Young Adult, S. K. Reid

Graduate Research Projects

No abstract provided.


Factors Contributing To Registered Nurse Job Satisfaction In The Nursing Home, Michael Shipley May 2015

Factors Contributing To Registered Nurse Job Satisfaction In The Nursing Home, Michael Shipley

Seton Hall University Dissertations and Theses (ETDs)

Over the next several years the aging population will increase the number of patients suffering from chronic illness. A sicker aging population, coupled with changes in healthcare reimbursement will require nursing homes to admit sicker patients for shorter lengths of stays. To meet the needs of the increased number of chronic patients and those patients with higher acuities, nursing homes will require more skilled, registered nurses. Registered nurses (RNs) are the linchpin to providing high-quality care in the healthcare environment and especially in nursing homes.

Understanding the factors of RN job satisfaction in the nursing home is important in increasing …


Nurses' Self-Efficacy For Managing Elder Abuse, Alana Anderson May 2015

Nurses' Self-Efficacy For Managing Elder Abuse, Alana Anderson

Nursing Theses and Dissertations

Elder abuse is a serious issue that negatively affects physical and mental health in a significant portion of the older population. Abuse of older adults is not adequately detected or reported. Nurses have frequent contact with older victims of abuse, providing them the opportunity to play a significant role in detecting, reporting, and intervening in such cases. Nurses are reluctant to intervene due to lack of education on elder abuse and lack of self-efficacy in their ability to properly manage elder abuse. This quantitative, descriptive study was designed to determine whether educational content on elder abuse, perceived capability, and self-efficacy …


Family And Child Development Education For Harrisonburg Adolescents, Mollie M. Moran, Jennifer E. Corser, Julia M. Glauber May 2015

Family And Child Development Education For Harrisonburg Adolescents, Mollie M. Moran, Jennifer E. Corser, Julia M. Glauber

Senior Honors Projects, 2010-2019

The pregnancy rate among 15- to 17-year-old women in Harrisonburg is double Virginia's state rate (Townsend, 2008). While meeting administers and guidance counselors of Harrisonburg High School we learned that Harrisonburg High School views this issue as one that cannot be addressed by teaching abstinence in their public school. They have found that because of cultural beliefs, abstinence is not an effective tool for preventing teenage pregnancy. Instead, HHS teaches their students about safe sexual practices and how to have a healthy pregnancy in the event they were to become pregnant. The high school offers a class called “Child and …


Transitioning Teens With Diabetes To Adult Healthcare, Rebecca Ann Meyer May 2015

Transitioning Teens With Diabetes To Adult Healthcare, Rebecca Ann Meyer

Dissertations

Adolescents must enter adult health care services at age 18, yet most are not ready and have not mastered daily self management of their type 1 diabetes. The purpose of this study was to determine the feasibility of a transition planning intervention, focused on educating adolescent/parent dyads about diabetes self management in preparation for the transition from pediatric to adult health care, using a newly developed transition plan and framework. The setting was a diabetes endocrinology clinic where 95% of young type 1 diabetics in the metropolitan area are seen. The intervention included supporting the parent in the relinquishing of …


Using Technology To Improve Diabetes Self-Management Within A Federally Qualified Community Health Center, Lisa Diane Morgan May 2015

Using Technology To Improve Diabetes Self-Management Within A Federally Qualified Community Health Center, Lisa Diane Morgan

Doctoral Projects

The Patient Centered Medical Home (PCMH) concept places the patient and family at the center of healthcare. The patient becomes actively involved in their own care. One aspect of PCMH is managing care and increasing chronic disease self-management. Diabetes, a chronic disease, is a leading diagnosis among the patients served by the federally qualified community health center (FQCHC). The prevalence of diabetes in Mississippi in 2012 was 12.3%. The purpose of this DNP Capstone project was to implement a pilot study to increase diabetes self-management knowledge. The program utilized the current technology of text messaging to send biweekly supportive and …


Transitional Care Of Adult Patients With Diabetes Following Hospitalizations, Eric Tobin May 2015

Transitional Care Of Adult Patients With Diabetes Following Hospitalizations, Eric Tobin

Doctor of Nursing Practice Final Manuscripts

Purpose: The purpose of this evidence-based practice project was to incorporate a diabetes transitional care program using group visits to improve self-care management behaviors and glycemic control in diabetic patients at a southern California hospital.

Background: Diabetes is a challenging healthcare problem associated with significant mortality and morbidity issues. In 2012, 29.1 million people, or 9.3% of the U.S. population, were diagnosed with diabetes, and 28.9 million of those patients were 20 years of age and older. Today, diabetes is of epidemic proportion worldwide, and a projection of 5.4% of the adult population will have diabetes by 2025. The …


Using Education And A Prevention Protocol Tool To Decrease The Incidence Of Pressure Ulcers In A Nursing Home, Kristina L. Scalzitti May 2015

Using Education And A Prevention Protocol Tool To Decrease The Incidence Of Pressure Ulcers In A Nursing Home, Kristina L. Scalzitti

Evidence-Based Practice Project Reports

Over 1.3 million persons are residents in nursing homes (NHs); one in ten have pressure ulcers. The purpose of this evidence based practice project was to determine if implementation of a pressure ulcer prevention tool, along with staff education, decreases the incidence of pressure ulcers within the NH. Florence Nightingale’s Environmental Model and the Stetler Model were used to guide this project. The setting was a NH in northwest Indiana. Eleven nurses attended a 15 minute educational session on pressure ulcer prevention and implementation of the Pressure Ulcer Prevention Protocol Intervention (PUPPI) tool. PowerPoint slides were distributed and flyers about …


Illness Beliefs And Adherence Among Louisiana Adults With Type 2 Diabetes, Denise L. Stagg May 2015

Illness Beliefs And Adherence Among Louisiana Adults With Type 2 Diabetes, Denise L. Stagg

Nursing Theses and Dissertations

Type 2 diabetes mellitus (T2DM) is having an enormous impact on the health of the nation. New cases of diabetes are diagnosed yearly across all states. Currently, 9.3% of the population has diabetes (Centers for Disease Control and Prevention {CDC}, 2014). While the prevalence of this disease is nationwide, it is not evenly distributed. Louisiana currently has a rate of 11.5%, with some parishes having rates of 14.5% (CDC, 2014). This rate places increased demands on healthcare and financial systems in Louisiana. Cultural elements and population distribution may be parts of this phenomenon. While many studies explored new medications and …


Use Of Immunotherapy In The Treatment Of Peanut Allergies In The Pediatric Population, Bethany Rauscher May 2015

Use Of Immunotherapy In The Treatment Of Peanut Allergies In The Pediatric Population, Bethany Rauscher

Senior Honors Theses

Peanut allergies are a serious issue that must be monitored and treated effectively to avoid severe adverse effects and death. In the last decade, their incidence has increased significantly, due to indeterminate factors. Because people typically do not outgrow peanut allergies and the effects of exposure can be life-threatening, it is important that a cure or management method is developed and refined. Recent research regarding treatment for peanut allergies has focused on the use of immunotherapy, a process aimed at desensitizing children's immune systems so that they do not reject foods that contain peanuts. Some studies utilizing immunotherapy have provided …


The Contemporary Use Of Nurse Practitioners In U.S. Emergency Departments, Jeffrey L. Bevan May 2015

The Contemporary Use Of Nurse Practitioners In U.S. Emergency Departments, Jeffrey L. Bevan

Doctor of Nursing Practice Scholarly Projects

Problem: The increased demand for emergency care in the United States (U.S.) has been well-documented and there is growing utilization of nurse practitioners in U.S. emergency departments. However, little is known about the nurse practitioner (NP) role in the emergency department setting within the past five years.

Purpose: The purpose of this project was to describe the demographic characteristics of patients, patient conditions treated, diagnostic tests ordered, and procedures performed by nurse practitioners in a national sample of U.S. emergency departments.

Methodology: This secondary analysis used a non-experimental quantitative, descriptive exploratory design to review data from the National Hospital Ambulatory …


The Effects Of An Evidence-Based Food Allergy Management Plan To Keep Children With Food Allergies Safe At School, Scarlet R. Spain May 2015

The Effects Of An Evidence-Based Food Allergy Management Plan To Keep Children With Food Allergies Safe At School, Scarlet R. Spain

Evidence-Based Practice Project Reports

The prevalence of food allergies in children has increased 18% between 1997 and 2007 (CDC, 2013). Furthermore, 84% of food allergic children will experience a reaction at school (Powers, Bergren, & Finnegan, 2007). An exposure in a sensitive child may progress quickly into potentially life threatening symptoms and death if not treated. The purpose of this evidence based practice (EBP) project was to determine if implementation of a food allergy management policy in a school setting reduced overall incidence rates of food allergy reactions in school children and to examine compliance to policy guidelines. The project encompassed implementation of a …


Chhs May 2015 E-Newsletter,, Dr. John Bonaguro, Dean, Vashon S. Wells, Editor, Wku College Of Health & Human Services May 2015

Chhs May 2015 E-Newsletter,, Dr. John Bonaguro, Dean, Vashon S. Wells, Editor, Wku College Of Health & Human Services

College of Health & Human Services Publications

No abstract provided.


Support For Breastfeeding Mothers: Are You Violating The Law?, Phillip Atherton, Christine Buttrick May 2015

Support For Breastfeeding Mothers: Are You Violating The Law?, Phillip Atherton, Christine Buttrick

Nursing Student Publications

On March 23, 2010, President Obama signed the “Break Time for Nursing Mothers” law in the Patient Protection and Affordable Care Act that requires employers to provide an opportunity for nursing mothers to breastfeed while at work. The law necessitates employers give a “reasonable” amount of time and a private space that is not a bathroom for the first year of a new infant’s life. In order to help mothers have access to breastfeeding, awareness of this law must be expanded, and the implementation of lactation programs in every workplace must be enforced so that mothers can continue to breastfeed …


Caregiving Factors Affecting Breastfeeding Duration Within A Neonatal Intensive Care Unit., Sharon G. Casavant, Georgine Burke, Carrie-Ellen Briere, Jacqueline Mcgrath May 2015

Caregiving Factors Affecting Breastfeeding Duration Within A Neonatal Intensive Care Unit., Sharon G. Casavant, Georgine Burke, Carrie-Ellen Briere, Jacqueline Mcgrath

University Scholar Projects

Abstract

Background: Increasingly, evidence supports oral feeding of very-low-birth-weight (VLBW) preterm infants exclusively at breast or with breastmilk. Despite known breastmilk benefits, outcomes related to exclusive breastmilk provision are poor. Identifying factors that promote breastmilk provision is critical.

Purpose: Breastfeeding practices of mothers of VLBW infants admitted to neonatal intensive care unit (NICU) were explored to identify factors associated with mode of feeding at discharge.

Method:

This retrospective study replicates previous work. Subjects were VLBW preterm infants consecutively admitted during a 24-month period. Primary outcomes included receiving any breastmilk at discharge. Infant variables included gestational age (GA), post-menstrual age (PMA) …


Medical Crises In Older People: Cohort Study Of Older People Attending Acute Medical Units, Developmental Work And Randomised Controlled Trial Of A Specialist Geriatric Medical Intervention For High-Risk Older People; Cohort Study Of Older People With Mental Health Problems Admitted To Hospital, Developmental Work And Randomised Controlled Trial Of A Specialist Medical And Mental Health Unit For General Hospital Patients With Delirium And Dementia; And Cohort Study Of Residents Of Care Homes And Interview Study Of Health-Care Provision To Residents Of Care Homes, John Gladman, Rowan Harwood, Simon Conroy, Pip Logan, Rachel Elliot, Rob Jones, Sarah Lewis, Jane Dyas, Justine Schneider, Davina Porock, Kristian Pollock, Sarah Goldberg, Judi Edmans, Adam Gordon, Lucy Bradshaw, Matthew Franklin, Katherine Whittamore, Isabella Robbins, Aidan Dunphy, Karen Spencer, Janet Darby, Lukasz Tanajewski, Vladislav Berdunov, Georgios Gkountouras, Pippa Foster, Nadia Frowd May 2015

Medical Crises In Older People: Cohort Study Of Older People Attending Acute Medical Units, Developmental Work And Randomised Controlled Trial Of A Specialist Geriatric Medical Intervention For High-Risk Older People; Cohort Study Of Older People With Mental Health Problems Admitted To Hospital, Developmental Work And Randomised Controlled Trial Of A Specialist Medical And Mental Health Unit For General Hospital Patients With Delirium And Dementia; And Cohort Study Of Residents Of Care Homes And Interview Study Of Health-Care Provision To Residents Of Care Homes, John Gladman, Rowan Harwood, Simon Conroy, Pip Logan, Rachel Elliot, Rob Jones, Sarah Lewis, Jane Dyas, Justine Schneider, Davina Porock, Kristian Pollock, Sarah Goldberg, Judi Edmans, Adam Gordon, Lucy Bradshaw, Matthew Franklin, Katherine Whittamore, Isabella Robbins, Aidan Dunphy, Karen Spencer, Janet Darby, Lukasz Tanajewski, Vladislav Berdunov, Georgios Gkountouras, Pippa Foster, Nadia Frowd

Publications and Research

Background: This programme of research addressed shortcomings in the care of three groups of older patients: patients discharged from acute medical units (AMUs), patients with dementia and delirium admitted to general hospitals, and care home residents.

Methods: In the AMU workstream we undertook literature reviews, performed a cohort study of older people discharged from AMU (Acute Medical Unit Outcome Study; AMOS), developed an intervention (interface geriatricians) and evaluated the intervention in a randomised controlled trial (Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study; AMIGOS). In the second workstream we undertook a cohort study of older people with mental health problems …


Coping Mechanisms Of Children With Atopic Dermatitis, Whitney A. St. Mary May 2015

Coping Mechanisms Of Children With Atopic Dermatitis, Whitney A. St. Mary

Honors Theses

This was a qualitative study that explored the lived experience of parents who had children with atopic dermatitis, otherwise known as eczema. The study had seven volunteer participants and the objective of this study was to determine any coping mechanisms used to overcome the negative aspects of atopic dermatitis. Volunteers were obtained from the Oak Grove Family Clinic. Phone interviews were then conducted and the participants were asked a series of eight questions. After the interviews concluded the researcher then transcribed the interviews and determined common themes from parents’ responses. All of the parents discussed how using unscented lotion, preventing …


Acculturation Factors Associated With The Prevalence Of Obesity In Immigrant Children And Adolescents, Suzeline Desir May 2015

Acculturation Factors Associated With The Prevalence Of Obesity In Immigrant Children And Adolescents, Suzeline Desir

HIM 1990-2015

Childhood obesity (CO) is a significant public health issue in the United States, including the immigrant populations. Obese children and adolescents are at increased risk for multiple preventable comorbidities that affect their physical health and psychological well-being. The perception exists that the immigrant child population may possess protection against CO, but this group also experienced an increased prevalence of CO. Acculturation, or the adaptation to American culture and lifestyles, has been shown to be associated with the increased obesity rate among immigrant children and adolescents. Understanding the association between acculturation factors and CO is necessary to effectively combat obesity among …


Activity-Rest And Skin Temperature Circadian Rhythms And Sleep Patterns In Community-Dwelling Women, Kristina L. Leyden May 2015

Activity-Rest And Skin Temperature Circadian Rhythms And Sleep Patterns In Community-Dwelling Women, Kristina L. Leyden

Dissertations and Theses (Open Access)

Purpose: The purpose of the study was to explore activity-rest and temperature circadian rhythms and sleep patterns in ambulatory women of reproductive, perimenopausal, and postmenopausal stages. Study aims were to (1) correlate the patterns of activity-rest with skin temperature and determine (2) lead-lag relation between activity-rest and circadian temperature rhythm, (3) stability of activity-rest patterns during work and non-work days, (4) duration of actigraphy sampling sufficient to reliably capture activity-rest patterns, and (5) sleep parameters in participating women across reproductive stages.

Design: Analysis of extant data sets.

Sample and Setting: Seven community-dwelling women, 27-to-54-years old

Methods: Participants wore an actigraph …


The Impact Of Shift Work On Diabetes Self-Management Activities, Daniel Navarro May 2015

The Impact Of Shift Work On Diabetes Self-Management Activities, Daniel Navarro

UNLV Theses, Dissertations, Professional Papers, and Capstones

In the United States 26 million people are affected by diabetes, which can result in microvascular and macrovascular complications. As a consequence, once a person is diagnosed with diabetes, aggressive clinical management is imperative to minimize poor glycemic control’s devastating outcomes. However, for some patients reaching optimum blood glucose levels is challenging due to the complexity of diabetes’ care. In order for patients with diabetes to achieve good blood glucose control, they must engage in self-care activities that include routine blood glucose checks, dietary control, physical activity, and routine medical provider visits, simultaneously with their medication regimen. Diabetes associated self-care …


Commercial Sexual Exploitation: The Role Of The Advanced Practice Nurse In Screening Patient At-Risk, Sheri Rickman Patrick May 2015

Commercial Sexual Exploitation: The Role Of The Advanced Practice Nurse In Screening Patient At-Risk, Sheri Rickman Patrick

Doctoral Projects

Problem: Human trafficking or commercial sexual exploitation (CSE) is a global problem effecting every country including the United States. The impact of human trafficking while it is devastating to individuals, the impact goes well beyond individual victims and undermines the health, safety and security of all nations (U.S. Department of State Publication, 2007, p. 5).This research is an attempt to assess the knowledge of advance practice nurses or nurse practitioners (NP) in the subject of commercial sexual exploitation and their willingness to screen their patients who may be at-risk.

Methods: The design was web-based with advanced practice nurses who are …


The Correlation Between Maternal Diabetes And Birth Defects, Erin Stanton May 2015

The Correlation Between Maternal Diabetes And Birth Defects, Erin Stanton

Senior Honors Theses

Diabetes mellitus is one of the most common health problems in the United States, and it is shown to have negative outcomes in infants born to women who are diabetic. Although gestational diabetes mellitus is linked with a few birth defects, research has shown that women with pre-gestational diabetes mellitus have an increased risk of giving birth to infants with birth defects. Among all the defects studied, cardiac and neural tube defects occur most commonly. Appropriate measures should be taken to provide patient teaching, as well as appropriate and effective prenatal care, to women who are at the highest risk …


Efficacy Of Behavioral Interventions In African-Americans With Type Ii Diabetes: A Comparative Effectiveness Analysis, Tangela Nicole Hales May 2015

Efficacy Of Behavioral Interventions In African-Americans With Type Ii Diabetes: A Comparative Effectiveness Analysis, Tangela Nicole Hales

Dissertations

Context: The efficiency and effectiveness of the healthcare system are prime foci for nursing research.

Objective:The purpose of this study was to review and critically appraise the current state of the evidence in the treatment of African American adults with type II diabetes. To address this objective, a systematic review was undertaken that investigated the comparative effectiveness of behavioral interventions in improving glycemic control.

Methods: Robust methodological approaches to comparative effectiveness research (CER) serve to improve the transparency, consistency, and scientific rigor of the research. The methods for this systematic review of literature followed those recommended in the Agency …


The Voices Of The People: Lower Sioux Indian Community Members Speak Out On What They Need And Want In A Primary Health Care Clinic On The Reservation, Darin Michael Prescott May 2015

The Voices Of The People: Lower Sioux Indian Community Members Speak Out On What They Need And Want In A Primary Health Care Clinic On The Reservation, Darin Michael Prescott

UNLV Theses, Dissertations, Professional Papers, and Capstones

American Indian/Alaska Native (AI/AN) people who live on reservations or in urban areas typically receive their health care in clinics that are operated by their tribe or are affiliated with Indian Health Service (IHS), a federal agency that provides care to AI/AN people. The Lower Sioux Indian Community (LSIC) is a federally recognized tribe located in southwest Minnesota near Morton, MN. LSIC members currently receive health care from outside providers at various locations near the reservation. The outsourced services include primary care, emergency care, hospitalization, surgery, dentistry, and podiatry. Because the providers are independent groups and do not work for …