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Moving Forward with Reforming the Indian Health Service

by U.S. Medicine

February 9, 2013

By Yvette Roubideaux, MD, MPH, director, Indian Health Service

The IHS Mission, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social and spiritual health to the highest level.

Yvette Roubideaux, MD, MPH

The focus of the Indian Health Service (IHS) during the past few years has been to change and improve the organization so it can better meet its mission. IHS focuses on direct delivery of healthcare services for approximately 2 million American Indians and Alaska Natives in 35 states through a network of more than 600 hospitals, clinics and health stations managed by IHS, tribal or urban Indian health programs. The population that IHS serves suffers from significant health disparities, and IHS delivers care under very challenging circumstances in mostly rural areas and with limited resources. However, progress has been made in IHS reform efforts over the past few years.

One of the most remarkable signs of progress has been increases to the IHS budget to address the growing need for services. Since 2008, the IHS budget has increased by 29% overall, with targeted increases in priority areas. For example, funding for referrals to the private sector through the IHS Contract Health Services Program has increased by 46% and has resulted in some facilities being able to pay for care beyond emergent priorities. As a result, access to needed care is increasing, including services for preventive care, which will help reduce overall costs in the future. While there is still a significant demand for services, these funding increases have helped increase access to basic healthcare.

Our focus on changing and improving the IHS during the past few years is necessary to ensure that we meet the needs of our patients and use federal resources efficiently and effectively. Input gathered in 2009 revealed the need for improvements in how IHS conducts business operations and ensures the delivery of quality healthcare. IHS has used a framework of four agency priorities to guide our efforts to change and improve IHS. These priorities are used in everyday discussions of agency activities, serve as priority goals for the overall organizational performance metrics and are used as a framework to monitor and communicate progress and outcomes.

 Strengthening Partnership with Tribes

Our first agency priority is to renew and strengthen our partnership with tribes. This priority is founded on our belief that the only way to improve the health of our communities is to work in partnership with them. We have seen evidence throughout our system that we accomplish more when we work in partnership with the communities we serve.

President Obama issued a Memorandum on Tribal Consultation in 2009 that directed all federal agencies to develop plans to consult with tribes. IHS has had a tribal consultation policy since1997, and we are focusing on improvements to the IHS tribal consultation process based on tribal recommendations. These improvements include better communication about consultation activities, listening sessions in all 12 IHS areas each year, increased participation in tribal meetings, a new website with updates on consultation activities, participation in over 400 tribal delegation meetings and national Tribal Consultation Summits to provide a forum for Tribes to provide input.

For 2013 and beyond, we will continue to implement tribal recommendations to improve the consultation process. Tribal consultation is critical, because our efforts to deliver healthcare are much more likely to be effective with the input and partnership of the communities we serve.

Bringing Reform to IHS

Our second priority is to bring reform to IHS. This priority has two parts — the first part includes how the Affordable Care Act (ACA) will help us reform IHS. American Indians and Alaska Natives can benefit from the ACA in many ways, whether they have insurance now, want to purchase affordable insurance through the exchanges or choose to access the Indian Health System. The ACA also contains the permanent reauthorization of the Indian Health Care Improvement Act, which modernizes and updates IHS with new and expanded authorities for a variety of healthcare services.

The focus in 2013 will be on implementation of and ensuring access to the benefits in the ACA for both American Indian and Alaska Native individuals and the Indian health system. Efforts are focusing on preparing our health facilities to assist patients in understanding their health-coverage options, reassuring them that IHS will always be an option for them and improving our business practices around eligibility, enrollment and third-party collections. If more patients have health coverage and continue to use IHS facilities, more resources will be available to improve services for all patients.

 The second part of this priority is about bringing internal reform to IHS. We are focused on improving the way we do business and how we lead and manage our staff, based on input from staff and the Tribes we serve. Overall, we have implemented many improvements over the past few years, including setting a strong tone at the top for change, greater coordination and communication among leadership, implementation of more consistent business practices, improvements in budget and financial management and a stronger performance management process focused on agency priorities and measurable outcomes.

To improve how we lead and manage staff, IHS has implemented new supervisory training and reduced the average overall hiring time from 140 days to 81 days. We also are working on improvements to our compensation systems and strategies to improve recruitment and retention. These improvements are important because it has been historically difficult for IHS to recruit and retain healthcare providers, due to remote locations and noncompetitive salaries. Recommendations from the 2010 Senate Committee on Indian Affairs investigation of the IHS Aberdeen Area are helping us make improvements in business practices systemwide through area-management reviews. All of these improvements will help us more efficiently and effectively meet our mission and ensure responsible use of federal resources. In fiscal year 2013, we will continue progress on our reform activities.

Improving Quality and Access to Care

Our third priority is to improve the quality of and access to care. IHS is focusing on improvements in customer service through implementation of activities for our staff, such as customer service training, education, feedback and awards for notable achievements. IHS also continues its implementation and expansion of our Improving Patient Care (IPC) initiative to sites throughout the Indian health system. This patient-centered medical home initiative is designed to improve the coordination of care for patients through team-based improvement activities. IPC sites are providing better continuity of care through the establishment of care teams, empanelment of patients, improvements in care processes and continuous evaluation and measurement of changes and their associated outcomes.

A few other initiatives also are helping us improve the quality of care. The congressionally-mandated Special Diabetes Program for Indians (SDPI) continues its successful activities to prevent and treat the epidemic of diabetes in tribal communities through implementation of innovative and culturally appropriate services. The SDPI evaluation data have shown that, since 1998, the programs have dramatically increased access to diabetes treatment and prevention services.

We also are giving top priority to behavioral-health issues, through implementation of our recently-released National Behavioral Health Strategic Plan and National Suicide Prevention Plan. Our congressionally-funded IHS Methamphetamine and Suicide Prevention Initiative and Domestic Violence Prevention Initiative continue to provide evidence-based strategies for some of the most challenging issues in tribal communities. The IHS Healthy Weight for Life initiative unifies all our efforts to promote a healthy weight among American Indians and Alaska Natives. And we have joined the first lady’s “Let’s Move! in Indian Countryinitiative, which includes our IHS Baby-Friendly Hospital initiative that is working to promote breastfeeding to help reduce childhood obesity.IHS also is participating in the Department of Health and Human Services’ Million Hearts Campaign, with its goal of preventing a million heart attacks and strokes during the next five years. Our participation in the new HHS Partnership for Patients initiative will help reduce harm and improve patient safety in our hospitals through a focus on reducing hospital-acquired conditions and hospital readmissions. All of these efforts are contributing to improvements in the quality measures that IHS tracks over time. IHS will continue to make progress on these quality-of-care initiatives in FY 2013.

Transparent, Fair, Inclusive

Our fourth priority is to make all our work transparent, accountable, fair and inclusive. We have been working hard to improve transparency and communication about the work of the agency with the patients and tribes that we serve. We have enhanced our website to provide information on facility locations and tribal consultation activities, and have added an IHS director’s blog to provide important updates and information on agency activities. This priority also is about how we conduct business and make decisions that must benefit all of our patients, whether they are served by IHS, tribal or urban Indian health programs.

IHS has made progress on these priorities during the past few years, and we are beginning to hear from our patients and tribes that they are starting to notice improvements. While much remains to be done to improve IHS and the health status of American Indian and Alaska Native people, we are confident that 2013 will be a year of even more progress toward this goal.


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