Transforming Care in the Indian Health Service

by U.S. Medicine

January 25, 2012

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. Since its establishment over 50 years ago, the IHS has done much to improve the health status of American Indians and Alaska Natives; however, we realize there is still much to be done. Health disparities continue for the population we serve, and access to care is still a challenge. When  I assumed the role of director of the IHS over two years ago, I set four priorities to address these issues and to guide our efforts to change and reform the IHS. Over the past year, we have made some significant strides in accomplishing these goals as we work to improve the health of American Indian and Alaska Native people. We still have much to do, but progress is being made.

Yvette Roubideaux, MD, MPH, IHS Director

Our first priority is to renew and strengthen our partnership with tribes. I truly believe the only way we are going to improve the health of our communities is to work in partnership with them. We have done a lot to improve tribal consultation at the national level – I held Area listening sessions with all 12 IHS Areas  again this year, either in person or by phone or videoconference. I have held more than 300 tribal delegation meetings to date and regularly meet with tribal advisory groups and attend tribal meetings.

We have implemented several tribal recommendations to improve the consultation process, including holding our first Tribal Consultation Summit in July 2011, where tribes could learn about several current consultation activities in a “one-stop shop” event. We also have developed a new website to increase access to all letters from the IHS director to tribal leaders.

We have been consulting with tribes on many important issues in the past year. For every decision we make, we always consider their input.

Our second priority is to bring reform to IHS. This priority has two parts, the first of which included  passage of the health-reform law, the Affordable Care Act (ACA). We are grateful for passage of the ACA because it will make quality and affordable healthcare accessible to all Americans, including our first Americans. It is designed to increase access to health insurance, help create stability and security for those who have insurance and reduce healthcare costs.

The focus of this past year has been on access to health-insurance provisions in the Affordable Care Act. Discussions have begun on two measures to begin in 2014: implementation of the State Affordable Insurance Exchanges and the Medicaid expansion up to 133% of poverty level. This could result in more health-coverage options for our patients. We also are pleased that funding requirements for the exchanges included a requirement for states to develop a plan to consult with tribes.

The ACA also contains the permanent reauthorization of the Indian Health Care Improvement Act (IHCIA), which modernizes and updates the IHS with new and expanded authorities for a variety of healthcare services. We are consulting with tribes on an ongoing basis on the implementation of these new authorities.

To help with outreach and education concerning these important new laws, the IHS developed a table summarizing current progress on implementation of the reauthorization of the IHCIA and sent it to tribal leaders in July 2011. National and regional tribal organizations help us with outreach and education to tribal leaders and our patients. 

The second part of this priority involves bringing internal reform to the IHS. Clearly, tribes, staff and our patients want change. Tribal priorities for internal reform included more funding for IHS and improvements in the contract health services (CHS) program, which is how we pay for referrals to the private sector.   

We are pleased that the IHS received a budget increase for FY 2011 when most other agencies had cuts, indicating continued strong support of IHS by this administration and the Congress. This included an increase in CHS funding that, along with the large increase in CHS funding in FY2010, for the first time allowed sites to approve more CHS referrals beyond Priority 1. Also, catastrophichealth-emergency cases were funded until mid-September, not running out of funds as early as June, as has happened. These much-needed resources mean more patients are getting the care they need. 

Transforming Care in the Indian Health Service Cont.

We also are progressing on the top staff priorities for internal IHS reform: overall, staff-emphasized reforms to improve the way we do business and how we lead and manage our staff. To improve the way we do business, we have improved our overall financial management and are working to make our business practices more consistent and effective throughout the system. 

In addition, we are working on improvements in pay systems and strategies to improve recruitment and retention. For example, collaborative work by IHS and the Health Resource and Services Administration has resulted in 490 IHS, tribal and urban Indian health programs being approved for placement of National Health Service Corps healthcare providers. The number of placements increased to 221 providers in 2011, allowing the IHS loan repayment program to expand its awards to additional disciplines. 

To improve how we lead and manage staff, we are working on specific activities to streamline the hiring process to be more efficient and less time-consuming. As a result, the IHS has reduced its average overall hiring time from 140 days to 81 days. We are holding training sessions for our supervisors to improve our ability to lead and manage our work force. 

Our third priority is to improve the quality of and access to care. We started by identifying the importance of customer service – how we treat our patients and how we treat each other. We are now starting to see many activities to improve customer service throughout the Indian healthcare system. To encourage these efforts, I established a new Director’s Award for Customer Service, honoring 19 recipients from IHS and tribal programs in 2011.          

I am pleased to report a lot of improvements in the quality of and access to care in 2011. For the first time, we met all of our Government Performance and Results Act clinical measure goals for the fiscal year, demonstrating that, in spite of limited resources, if we have strong teamwork and focus we can improve care.

In 2011, the IHS became the first large federal system to achieve certification of its electronic health record (EHR), enabling our facilities to register to receive EHR incentive payments for meaningful use.

IHS also met the deadline to obligate 100 percent of its Recovery Act funding. This means many American Indian and Alaska Native people will be benefiting from new equipment, facility renovations, sanitation facility construction and information technology improvements.

Also in 2011, access to care was addressed through the congressionally-funded IHS Methamphetamine and Suicide Prevention (MSPI) Initiative. During this first year of the MSPI, intensive screening efforts resulted in 4,370 individuals being identified with a methamphetamine disorder and 1,240 people entering into a treatment program. In 2011, more than 4,000 people participated in suicide-prevention activities; 42,895 youth participated in prevention or intervention programs; and 647 people were trained in suicide-crisis response.  

In 2011, the IHS established its first-ever Sexual Assault Treatment Policy under the authority of the IHCIA and the Tribal Law and Order Act. The IHS Domestic Violence Prevention Initiative (DVPI) created 21 interdisciplinary Sexual Assault Response Teams in 2011. The DVPI served more than 2,100 victims of domestic violence and/or sexual assault in 2011, and more than 3,300 referrals were made for domestic-violence services, culturally-based services and clinical behavioral-health services.  Over 9,100 patients were screened for domestic violence, and nearly 9,500 community members were reached through community and educational events.   

Our fourth priority is to make all our work transparent, accountable, fair and inclusive. Since I began my tenure as the director of the IHS, I have worked hard to improve our transparency and communication about the work of the agency. This includes working with the media, sending more e-mail messages to staff, sending more information directly to tribal leaders and holding regular internal meetings.  We also have enhanced our website with the IHS Reform page, Director’s Corner and Director’s Blog, which contain important public updates and information about reform activities. The Director’s Blog, which is the first place we post important updates on our website, had more than 10,000 views in the last three months, indicating a high level of interest in our activities. 

While much remains to be done to improve the Indian Health Service and the health status of American Indian and Alaska Native people, 2011 has been a year of major progress toward this goal. I plan to continue our reform efforts and the challenging work of changing and improving the IHS during the next few years. While improving the IHS may be daunting, I believe we are in a unique time in history, with support from the president, administration and Congress for reform.  We must continue to take advantage of this opportunity to change and improve the IHS. 

Back to Outlook 2012

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