What are examples of Tribal behavioral health and traditional healing programs?

The three programs featured in this brief illustrate a variety of Tribal behavioral health programs and explore a spectrum of partnerships between Tribal programs and Medicaid.¹ The Sacred Child Project of the Turtle Mountain Band of Chippewa Indians (in North Dakota) is a case management program primarily supported through Medicaid funding, an arrangement that came about through dedicated relationship-building. The Wahzhazhe Early Learning Academy of the Osage Nation (in Oklahoma) is an early childhood program primarily supported through Tribal funding but recently partnered with the Osage Nation Health System and Oklahoma Medicaid to sustainably fund a play therapy service. Healing Horse Ranch of the Mandan, Hidatsa, Arikara (MHA) Nation (in North Dakota) is an equine therapy program primarily funded through the Tribal council that is exploring additional funding sources, including Medicaid reimbursement.

The Sacred Child Project

Case management programs are designed to help people with complex physical or behavioral health needs access the supports they need to stay healthy. The Sacred Child Project is a case management program for teens who are members of the Turtle Mountain Band of Chippewa Indians, one of five federally recognized Tribal nations in North Dakota.

The Sacred Child Project has served youth for the last 25 years by providing ongoing support that involves families and broader networks. Currently, it is funded through a flat-fee Medicaid reimbursement.

Services and activities offered

The Sacred Child Project serves enrolled members or descendants of the Turtle Mountain Band of Chippewa Indians who are 14 to 18 years old, enrolled in Medicaid, and have a current DSM-5 mental disorder diagnosis. Its case management services include: a comprehensive needs assessment; an individualized plan of care that identifies health and well-being goals and how those goals can be met; the ability of youth to access medical, social, educational, and other services included in their plan of care; and monitoring and follow up. Many plans of care include spiritual and cultural elements. Youth who need the services often “feel like they have lost their identity or are displaced,” said Jan Birkland, project coordinator, and request services like sweat lodges or spirit naming ceremonies.

Many youth involved with the Sacred Child Project are referred by other systems in North Dakota including child welfare, juvenile justice, special education, substance use disorder treatment, and health care. Sacred Child Project’s case managers work intensively with the youth, their families, and across these systems — especially with schools — to understand challenges and work on solutions together. Using a strengths-based approach, which identifies areas where youth are succeeding and how those can be a foundation for greater success, is a first step to building strong relationships between the youth, their families and Sacred Child Project staff. Birkland emphasized the value of being consistent and staying in contact with youth and their families even during times when they may want to disengage.

Staffing and training

Initial funding and training for the Sacred Child Project, which was founded in 1998, were provided through a federal grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). Staff training was based on the Wraparound approach proven successful in Alaska. Learning from an existing program, especially one that worked with native youth, was valuable. During its early years, the Sacred Child Project focused on tracking data to demonstrate fidelity to program design and value. In addition to case management training, project staff are trained on documentation and claims submission to ensure the program is providing Medicaid-eligible services and is appropriately reimbursed.

Funding and sustainability

When the Sacred Child Project started, it was housed within the Indian child welfare division of the Turtle Mountain Band of Chippewa Indians. While the program and the agency served a similar population, the child welfare division was underfunded, and both entities struggled to meet the needs of their community. The project is now independent of the agency, creating a clearer separation and allowing the project to focus more on upstream prevention, serve families without child welfare involvement, reach more families overall, and access more sustainable, long-term funding.

The Sacred Child Project started working with Medicaid at the outset, attending meetings with the state, sharing data, and exploring reimbursement opportunities. Enrollment as a Medicaid provider requires upfront work and may have a high start-up cost including training staff on documentation and data submission practices and building data systems. The Sacred Child Project’s strong relationships with the state Medicaid agency allows staff to reach out to access technical assistance and get questions answered.

In 1999, North Dakota Medicaid submitted a State Plan Amendment that designated the Sacred Child Project as a targeted case management (TCM) program. TCM is a Medicaid state plan option designed for a specific population and requires: (1) assessment; (2) development (and revision) of a care plan; (3) referral and linkage to services; and (4) follow-up and monitoring. While North Dakota Medicaid has opted to require staff in other approved TCM programs to have a social work degree, staff at the Sacred Child Project do not have to meet this requirement due to its history of success, longstanding relationship and collaboration with Medicaid, and fidelity to the original program design.

Under Medicaid, the Sacred Child Project receives a flat fee tied to the amount of time it spends caring for the individuals it serves. This flat fee can pay for any services the program provides that support the goals in the individual’s defined care plan, including transportation, telephone consultations, and arranging referrals.

Wahzhazhe Early Learning Academy

The Whazhazhe Early Learning Academy (WELA) provides comprehensive early childhood services — including culturally-based services — to Osage Nation children from 6 weeks old to 12 years old. The Osage Nation, one of 39 federally recognized Tribal nations in Oklahoma, has compacted with the federal government to exercise Tribal sovereignty and therefore manages many of its own social service programs, including child welfare, childcare, and health care.²

Over the last five years, WELA has expanded its use of evidence-based child development curricula, introduced new services focused on children’s behavioral health, gained state licensure for all four of its sites, and earned national accreditation at one site through the National Association for the Education of Young Children. The program uses Teaching Strategies GOLD to assess learning and development, including skills related to social and behavioral health. Scores in self-help, relationship-building, problem-solving, and speech development skills have shown substantial improvements. While WELA is primarily funded by the Osage Nation, some services are covered through other funding streams, including Medicaid.

Services offered

The WELA operates four sites across the Osage Nation, primarily serving children from 6 weeks to 5 years old, but also school-aged children between 4 and 12. Services include childcare, education, health, social and emotional growth, and overall well-being. In late 2024, the WELA opened its newest site, which was custom-built to incorporate Osage culture through design — featuring traditional ribbon work, art by Osage artists, and use of the Osage language on signage and labels around the building.

The WELA uses a variety of curricula focused on trauma-informed care, social-emotional learning, self-regulation, and building positive relationships between children and teachers. The program also focuses on Osage culture and language development, and partners with the Osage Nation’s language department to teach both staff and children.

The WELA also provides physical and behavioral health services. Children are served nutritious meals, which often include food grown at the Osage Nation Harvest Land. The WELA works with a speech pathologist for speech and hearing screenings; conducts vision, height, and weight screenings; monitors immunizations; promotes good oral health; and works with the Osage Nation’s Women, Infants, and Children program to promote infant health, including breast- and bottle-feeding supports. The WELA holds an annual health fair that includes vision and hearing screenings and dental checkups.

The WELA employs teachers with bachelor’s degrees in education, and teaching assistants who have associate’s degrees in early childhood development. The WELA partners with a local educational and career training center to help staff earn degrees. This partnership helps grow staff and has helped the WELA meet state licensing and national accreditation standards. The WELA also offers up to six hours of education leave per week to support employees pursuing further education.

In early 2024, in collaboration with the Osage Nation Health System, the WELA hired a play therapist who works across all four sites. “When I became director, I met with center managers and listened to their concerns and ideas,” said Tara McKinney, who leads WELA. “I learned we did not have a curriculum or play therapist, and teachers were asking for trainings on behavior.” Based on this feedback, leadership identified appropriate curricula and hired an education coach to help train staff on it. The new play therapist also offers staff training on behavioral management.

Funding and sustainability

The Osage Nation is the primary funder of WELA. Parents and caregivers of the children enrolled in the program pay a small fee. The WELA is licensed by Oklahoma’s Department of Human Services and Osage Nation’s Child Care Department, which allows some families to access childcare subsidies. Osage Nation has run its own health system since 2015, which has allowed for greater flexibility in hiring and the ability to pursue additional revenue sources, including billing Medicaid. The WELA play therapist, for example, is able to bill Medicaid for services provided to Medicaid-eligible children, which helps ensure the service’s sustainability.

Healing Horse Ranch

Healing Horse Ranch, funded by the Tribal Council of the Mandan, Hidatsa, Arikara Nation (MHA Nation), provides equine therapy services. As one of five federally recognized Tribal nations in North Dakota, the MHA Nation has deep historical connections and cultural traditions connected to horses. Healing Horse Ranch builds on those traditions by supporting people of all ages with behavioral health needs, helping them form meaningful connections with horses through riding, caretaking, and other therapeutic activities.

Healing Horse Ranch has expanded its offerings over the years, starting with programming for any of the approximately 5,000 children who are members of the MHA Nation and growing to include therapeutic services for adults. The ranch is exploring new funding pathways, including Medicaid reimbursement, with staff meeting with other Tribe-affiliated equine therapy programs to learn about their funding models. The ranch also is building relationships with North Dakota Medicaid to review existing policy and identify opportunities for service reimbursement.

Services and activities offered

Most of the people in the equine therapy program are citizens of the MHA Nation, but the program is open to members of other Tribes. Children can come individually or as part of organizations like the Boys and Girls Club, 4H Clubs, and home-school groups. The program also serves people who are in inpatient behavioral health care.

Building a relationship with a horse over time — and gaining confidence in that connection — can help children struggling with personal identity and mental health by teaching consistency in language and expectations, and the responsibility of caring for another being. This relationship also can help people become more open to other forms of culturally connected therapy that may support their healing. For citizens of the MHA Nation and other Tribes with historical and cultural connections to horses, riding can also foster a sense of culture and community.

Upon entering the ranch, program participants take time to meet, spend time with, and care for the horses before they learn to ride. Horses are chosen for their temperament and ability to build relationships with other horses and people at the ranch.

Healing Horse Ranch also hosts riding competitions and rodeo activities such as cattle roping and barrel racing, which help build community and buy-in for the program. In recent years, the ranch built a heated indoor barn, which allows operation of the program during winter. Year-round operations help keep people engaged with therapy.

Staffing and training

Community members with ranching backgrounds staff Healing Horse Ranch, and individuals receiving services from the equine therapy program also can find work at the ranch, for example, to herd cattle needed for weekly cattle roping practice. Healing Horse Ranch trains its therapeutic practitioners through the Equine Studies program of MHA Nation’s Tribal college, which helps students attain certifications for a variety of equine-assisted therapy. The goal is to create a staffing pipeline grounded in the culture of the Mandan, Hidatsa, and Arikara people.

Funding and sustainability

Currently, Healing Horse Ranch is fully funded by the MHA Nation’s Tribal Council. Reliance on one funding source, however, always carries risk so the ranch is exploring additional opportunities, including Medicaid. Although the program has engaged with Medicaid staff — who have expressed general support for equine therapy services — North Dakota Medicaid currently does not reimburse for equine therapy. Medicaid coverage of equine therapy varies across the country. In some states, equine therapists must have specific licenses (such as in Colorado), and in others, services are targeted to specific populations or waiver programs (such as in Washington state’s Children’s Intensive In-Home Behavioral Support Waiver). Hiring licensed therapists with experience in equine therapy can be challenging in rural areas that have a limited behavioral health workforce.

Sharing the successes of equine therapy outside of Tribal communities can be challenging. There is not always widespread acceptance of culturally grounded approaches as effective ways to address behavioral health needs, despite strong evidence that cultural connection builds resiliency and well-being. To bridge this gap, staff at Healing Horse Ranch have met with other equine therapy programs, including Medicine Horse in Boulder County, Colo., to share lessons and best practices related to funding and communication. Exploring opportunities for Medicaid to broaden criteria of qualified staff and covered services — potentially through a waiver for Tribal communities — can help recognize the value of staff with cultural knowledge and of services that draw on culture, ultimately supporting improved behavioral health outcomes for Native American children and families.

1 The content of this brief was informed by interviews with Tara McKinney, Director, Wahzhazhe Early Learning Academy, Osage Nation, on September 3, 2025; James Baker, Senior Supervisor, Healing Horse Ranch, on October 21, 2025; and Jan Birkland, Project Coordinator, Sacred Child Project, on October 28, 2025.

2 Sovereign Tribal governments can compact with the federal government to run programs for their own members that were historically run by the federal government. Over half of Tribes in the U.S. have compacted with the federal government to manage part or all of their own health care systems, as opposed to continuing to have the federal Indian Health Service serve their communities.