Tribal Care Coordinator helps Native American community members access care

Vincent Jones had been working in behavioral health for two decades when he was offered the chance to help Native Americans get the care they need.

Jones, a member of the Tuscarora people, leaped at the opportunity.

"It’s a dream to be able to do this work," he said.

Jones is now the first tribal care coordinator for behavioral health at Sentara Health Plans. In his role, he serves Medicaid and Dual Eligible Special Needs Plan members.

Since he started in this new role in 2023, Jones has helped Native American health plan members throughout Virginia access providers and other services, such as community resources.

He focuses on behavioral health needs, which include mental health and substance use disorders.

“A lot of times, members don’t understand their health insurance,” Jones said. “I reach out to try to assess their needs and check if they’re connected to all the health services they need.”

As a Native American, Jones is better positioned to help this population, he said.

“It is important for the care coordinator to have indigenous heritage because Native Americans have experienced generational traumas that others may not be able to relate to,” said Jones.

“Having that understanding can help the coordinator be more effective.”

Jones at a community event.

Improving the health of a historically marginalized community

Mental health and substance use issues are particularly severe in Native American communities.

Native American suicide rates are higher than those of any other group in the country. Rates for substance use disorders are also disproportionately high.

Virginia has eleven state-recognized tribes, and members of other tribes also live in the state. In 2016, the U.S. Census Bureau estimated that more than more than 29,000 Virginians identify as Native American.

Sentara Health Plans created the tribal care coordinator role to meet behavioral health needs in this historically marginalized community, said Lavinia Smith, senior director for behavioral health.

“We wanted to make sure that our tribal members received specialized attention around substance use and suicidal ideation since this population has some of the highest substance use and suicide rates in the nation," said Smith.

The outreach and coordination by Jones has already produced significant results, according to Smith.

In 2024, Sentara Health Plans saw a roughly 30% decrease in substance use rates for those engaged in tribal care coordination. Sentara Health Plans saw a nearly 13% decrease in suicidal ideation for both adults and adolescents.

"Since we implemented this program, we’ve seen really great results,” Smith said.

Before joining Sentara Health Plans, Smith oversaw a similar tribal care coordination program for an insurer that operated in Arizona.

Smith, who also has Native American ancestry, had seen the need up close. While she was growing up, she would visit her grandmother on the Kaibab Indian Reservation in the northern part of Arizona.

"As a kid, I watched these individuals who didn’t know they were eligible for Medicaid and didn’t know where to go and get resources," she said.

Through the tribal care coordination program, Smith worked to help those individuals access care. After joining Sentara Health Plans, she learned about Virginia’s Native American population and recognized there was a similar need here.

“It’s our job to make sure our members get the services and support they need,” said Smith.

Jones at a community event with Smith (far right).

Making sure behavioral health resources ‘resonate’

Jones, who grew up in Portsmouth, Virginia, learned more about his own Native American heritage while living in Boston, where he was working in physical rehabilitation. A patient introduced him to members of the local Wampanoag tribe, who welcomed him and became like a “surrogate family” to him.

In his role at Sentara Health Plans, Jones connects members to Native American providers, if desired.

“Being able to connect members to Native American providers who understand their lived experiences and cultural background is crucial,” said Jones. “It’s not just about offering resources—it’s about making sure those resources resonate.”

To educate members about the benefits and services available to them, Jones calls them from his home in Franklin, Virginia, where he works remotely. He also visits powwows, clinics, and community events.

The response has been overwhelmingly positive, he said.

“They get very excited and say, ‘I didn’t know this existed,’” said Jones. “And then I explained to them that it’s a fairly new role. And they are very receptive.”