M21 · AI/AN · Tribal Health
American Indian / Alaska Native
Population view for IHS-eligible beneficiaries · 638 contracts · urban Indian programs · Medicare and tribal CHS coordination. Sourced from IHS RPMS, CMS attribution, and tribal EHRs.
VISN 22 + IHS Phoenix Area · May 2026
2,184 beneficiaries
across 14 partnered tribes and urban Indian health programs · IHS + Medicare + VA dual-eligible coordinated through CloudCare.
Active in CCM/APCM
418
19% enrollment
DM2 prevalence
28%
vs 13% US adult
CHS authorizations · 30d
142
routed via 638 contracts
Tribal entities 14
Prevalence
Care plan templates
CHS authorizations
Dual eligibility
Language & outreach
Filter · All partnered entities
Salt River Pima-Maricopa Indian Community
SRPMIC · 638 contract
412
94
CCM
128
DM2
31
CKD
IHS clinic
638 contract
Gila River Indian Community
GRIC · IHS direct
386
82
CCM
142
DM2
38
CKD
IHS clinic
Tohono O'odham Nation
TON · 638 contract
298
62
CCM
98
DM2
28
CKD
638 contract
IHS clinic
Navajo Nation · Western Agency
NN · IHS direct + Section 105(l)
284
58
CCM
72
DM2
22
CKD
IHS clinic
Fort McDowell Yavapai Nation
FMYN · 638 contract
142
28
CCM
42
DM2
11
CKD
638 contract
Native American Connections
Phoenix urban Indian
218
42
CCM
54
DM2
14
CKD
Urban Indian
Disease prevalence · AI/AN cohort vs US adult CDC + IHS surveillance · age-adjusted
View by tribe ↓
Diabetes mellitus type 2
E11 · panel adults ≥ 20
2.2×
Chronic kidney disease
N18 · all stages
1.3×
Hypertension
I10 · adult cohort
1.1×
Obesity (BMI ≥ 30)
all adults
1.1×
Substance use disorder
F10–F19 · 12-mo
1.6×
PTSD (lifetime)
F43.1
3.1×
Disparities driven by structural and historical factors. CloudCare prioritizes culturally-adapted care plans (right) and routes through tribal community health workers when available rather than default outreach.
Culturally-adapted outreach
Community Health Representative (CHR) routing
CGAE outreach prefers CHR over VIDA voice for tribal cohorts. CHR talks first; CloudCare routes via 638-contract integration to tribal CHR teams.
CHR-first
638 routing
Trauma-informed BH approach
PHQ-9 / GAD-7 paired with PCL-5 (PTSD checklist) at intake; psych consult routes to provider with IHS / tribal training when available.
PCL-5 default
Trauma-informed
Traditional healing acknowledgment
Care plans include space for traditional healing practices alongside conventional medicine. Configurable per tribal partner.
Configurator
CHS / PRC authorization workflow
Contract Health Services / Purchased Referred Care eligibility checked before referral; pre-auth bundled with referral packet.
CHS auto-check
Data sovereignty
Tribal data stays within partner-controlled boundary unless explicit data-sharing agreement signed by tribal IRB. CloudCare honors per-tribe data residency.
Per-tribe DSA
Tribal IRB
Language at home · 2,184 ben.
English (primary)
limited English: 184 (8.4%)
1,704
Diné bizaad (Navajo)
often paired with English
218
O'odham
Tohono O'odham · Akimel
142
Apache
San Carlos · Tonto
62
Yaqui · other
multiple
58
VIDA voice supports English for all cohorts. Diné bizaad voice models pilot active with NN; O'odham CHR-first routing.
Care plan templates · AI/AN-adapted
DM2 · IHS Diabetes Best Practice
Annual eye + foot + nephro per IHS DBP · CHS auth pre-bundled · CHW co-management slot.
2,184 ben eligible
CKD · IHS Kidney program
SGLT2i + ACEi protocol · neph consult via 638 contract · transplant referral path through Mayo AZ.
CKM track
BH · trauma-informed
PCL-5 baseline · psych consult preferring IHS-trained · traditional healing acknowledgment.
BH track
SUD · MAT pathway
Buprenorphine + counseling · CHR support · Wellbriety / Red Road resources optional.
14 active
Maternal health · perinatal
Doula coverage via tribal program · doula-friendly delivery facility · postpartum CHR follow-up.
28 active
Eligibility coordination · 2,184 ben.
IHS only
direct service
IHS
784
IHS + Medicare dual
primary payer rules apply
IHS
MED
982
IHS + VA
tribal veterans · MISSION Act
IHS
VA
312
IHS + Medicare + VA
triple eligible
IHS
MED
VA
88
CHS / PRC routing
contract health services pending
CHS
18
Dual + triple-eligibility rules auto-resolve in ORAK; CloudCare bills correct primary payer per service. 88 triple-eligible ben highest-revenue cohort.