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In Focus: Promoting Quality Throughout Indian Country

By Vida Foubister

American Indians and Alaska Natives, the population served by the Indian Health Service, face many of the same disparities in care as do other racial and ethnic minorities in the United States. They also suffer from a disproportionate burden of chronic disease; among these the prevalence of diabetes has been well publicized.

As a result, diabetes prevention and management have been the focus of many improvement efforts and have benefited from grant funding, leading to the establishment of strong diabetes programs and departments throughout the system. But, when the Indian Health Service started work in 2006 on a new initiative to improve the treatment of other chronic diseases, there was a general recognition that the advances made in treating diabetes were, in the words of many, siloed.

"We've had a system-wide project to improve diabetes care for a long time, but a lot of the improvements in diabetes care didn't spill over to other conditions," says C. Ty Reidhead, M.D., national chief clinical consultant in internal medicine for the Indian Health Service. "When we started thinking about how to improve care [more broadly] within our system, we decided that, instead of working on a new condition or a series of conditions, we wanted to try to take it all on at one time. We recognized the only way to really improve care for chronic disease was to change the way we take care of patients."

Or, as its partner in this new improvement process, the Cambridge, Mass.–based Institute for Healthcare Improvement (IHI), describes it, the Indian Health Service's Chronic Care Initiative had "scope creep," says Cindy Hupke, R.N., B.S., M.B.A., an IHI director. "It rapidly evolved into a model that has more depth and breadth then when they started." The pilot that grew out of the Chronic Care Initiative, called the Innovations in Planned Care for the Indian Health System collaborative, has begun evaluating patients' experiences and the costs of the care, as well as measuring providers' ability to meet the standards of care for managing and preventing various chronic diseases.

Prioritizing Change to Maximize Limited Funds
An agency within the Department of Health and Human Services, the Indian Health Service is an integrated health system that serves 562 American Indian and Alaska Native tribes in 35 states. It provides medical services through federally run hospitals and health clinics, tribally operated facilities, and urban health centers.

Based on a comparison with a federal employee's health benefit package, the Indian Health Service's budget is estimated to be funded at 54 percent of the level of need, says Robert G. McSwain, its director. The agency's chronic underfunding has forced it to ensure that the "resources we do have, which are limited, are used as a catalyst" to help providers deliver care in different ways than they have in the past, he says. This includes having clinic and hospital staff learn how to work together in care teams and to make patients the focus of care.

McSwain's predecessor, Charles W. Grim, D.D.S., M.H.S.A., started down this path when he chose to reduce the director's priorities from up to a dozen initiatives to three: behavioral health, chronic care, and health promotion and disease prevention. The goal, which McSwain has continued to push in his year-long tenure, has been to integrate these three initiatives into a single effort across the Indian Health Service.

"We have been having discussions about the three initiatives and how they begin to work together," says McSwain. "Part of that, as one example, is ensuring there are mental health workers that are located physically in the primary care settings." Because many Indian Health Service facilities are located in rural areas, patients may travel long distances for their appointments. Research has shown that they are much more likely to follow through on a referral if they can meet with those providers at one site.

A representative cross section of sites was chosen to participate in the first phase of the Innovations in Planned Care collaborative. When it began in 2007, the pilot involved eight federally operated sites, five tribal facilities, and one urban program, which were selected from each of the 12 regions within the Indian Health Service. "The change package that has to be developed for all these organizations to benefit really has to be something that could be applied anywhere," explains Hupke.

The second phase of the pilot, which was launched this October, includes 40 sites across the Indian Health Service. Phase II will continue to measure providers' performance in three areas: prevention and management of chronic disease, patient experiences, and cost of care. But the measures will be refined to better reflect desired clinical outcomes and prioritized to ensure sites address the most important features of the model at the outset of the project. By the time the initiative is rolled out to the entire system—currently proposed for 2010—"we should have a change package that's much more polished and much more well tested," says Hupke.

Drawing on Clinical Data, a Systemwide Strength
Much of the pilot sites' efforts to improve care processes rely on data available in the Indian Health Service's information system, the Resource and Patient Management System (RPMS), which was developed internally in the 1970s. This system stores personal health information and epidemiological data for local populations, including clinical data on physical exam findings such as blood pressure measurements, laboratory and radiology results, medication prescriptions, and billing information. Since 2003, the Indian Health Service has been working to develop user-friendly interfaces that increase the ease of data analysis for performance measurement and quality improvement.

Currently, most health care facilities within the Indian Health Service maintain an RPMS database and, as of August 2008, 182 hospitals and clinics have implemented the Indian Health Service Electronic Health Record (EHR). Additional sites have adopted a Windows-based user interface that offers some improvements on the RPMS system, yet lacks all the features of a fully implemented EHR. iCare, which was first released in May 2007, functions as a population management software tool that has the ability to create multiple panels of patients with common characteristics—such as age, diagnosis, and community—and enables providers to personalize the way patient data are viewed.

"Prior to 2000, there wasn't a focus on quality measurement and quality reporting in the Indian Health Service," says Tom Sequist, M.D., an assistant professor of medicine and health care policy at Brigham and Women's Hospital and Harvard Medical School, who is working with the Indian Health Service to identify how best to use its information systems to improve care. "This really allows them to take a closer look, not just across the country but at individual clinic sites," and identify gaps in quality as well as high-performing disease management and treatment programs that other sites could learn from.

The Indian Health Service EHR and iCare have also helped the Indian Health Service meet new, federally mandated quality reporting requirements. Since 2002, the Government Performance and Results Act has required the Indian Health Service (and other federal agencies, including the Department of Veterans Affairs and the Department of Defense) to report 24 national-level performance measures to Congress and the Office of Management and Budget annually. This year, in response to a 2006 Presidential Executive Order, the Indian Health Service launched a health transparency Web site that includes facility-level data on seven clinical performance measures for diabetes, immunizations, pneumonia, asthma, and stroke (see Text Box). It plans to report on five additional measures in 2009.

Individual sites involved in the Innovations in Planned Care pilot, including one within the Cherokee Nation, have also chosen to display performance results at the team level within participating clinics. "It's really transparent," says Gloria A. Grim, M.D., medical director for the Cherokee Nation. "[Patients] can see how the physicians in that facility are doing and make sure they're receiving quality health care."

Working with the Community
Many of the pilot sites have found that their reach can be extended through partnerships with tribal programs. Within the Cherokee Nation, for example, the tribe's Healthy Nation program (also known as the Health Promotion/Disease Prevention Initiative) "serves as a link between the clinic and the community," says Julie Deerinwater, M.P.H., Healthy Nation primary prevention coordinator for the Cherokee Nation.

Community health representatives design interventions around risk factors for chronic diseases such as diabetes, obesity, and asthma and offer educational classes on topics ranging from healthy eating and cooking to smoking cessation. They have found that, as providers at the health clinics implement the Innovations in Planned Care pilot, their referrals have grown. Over the past year, for example, as one clinic raised its tobacco screening rate from 71 percent to 92 percent, the number of patients participating in the community's tobacco cessation classes increased.

The health care facilities also refer patients to other community programs, such as vocational rehabilitation or social services. "We try to look at the whole person and all of the things that contribute to their health status indirectly and try to find ways to meet those needs," says Grim.

Such linkages are perhaps easier to establish between tribally run health facilities and community leaders and services, and can spread a message to more people than providers are able to reach through individual patient visits. Cherokee Nation health facilities, for example, were able to drive a policy change that led to the removal of soda and candy machines from schools, broadening discussions about nutrition to all families in the area with school-age children. Though similar partnerships between federally operated facilities and tribal programs can require greater effort, they, too, can be successful.

Jana Towne, R.N., an assistant nurse executive at the Whiteriver Indian Hospital in Arizona, a federally operated facility, was able to increase the rate of colorectal cancer screening among the mostly White Mountain Apache patient population through a partnership with the tribe's community health representatives. She overcame the first obstacle to achieving this by presenting data to the health representatives showing that colorectal cancer was not "a white man's disease" and had in fact affected 10 members of the community, of whom half had died. After that, members of the care team began to accompany community health representatives on home visits, an effort that increased the colorectal cancer screening rate from 39 percent to 64 percent within the past year.

Harvesting Results After One Year

Based on the Wagner model of chronic care, the Innovations in Planned Care pilot formed care teams and divided patient care responsibilities in ways that best utilized each team member's strengths. They empanelled patients and reviewed charts prior to scheduled visits, and launched Plan-Do-Study-Act cycles to achieve improvements in the care provided.

"We made a lot of strides and we've been able to see that the changes we've made have resulted in improvement, but we've just scratched the surface," says Teresa L. Chaudoin, M.P.H., M.A., director of the Cherokee Nation's diabetes program. Further efforts, she says, should focus on: strengthening self-management support, establishing information systems that enable decision support at the point of care, and developing closer relationships between the clinics and the community health representatives, as well as between care teams and patient's families. "I know it's going to keep me busy until I retire," says Chaudoin.

Her enthusiasm for change has been echoed by many of those involved in the initial pilot. It has also been evidenced by the overwhelming interest in participation in the initiative. Nearly 300 Indian Health Service staff members attended the Institute for Healthcare Improvement's annual meeting in 2007. The Chronic Care Initiative developed a "Readiness Curriculum" to share information on the Wagner care model, as well as other quality improvement methodologies, through a monthly, Web-based call series.

"Our hope is that this becomes how we do business," says Towne of Whiteriver Hospital. "It's not Innovations in Planned Care, not a microsystem, but it's how Whiteriver operates and it's how we go about improving care."

Quality of Care Web Site
The Indian Health Service began reporting on seven clinical performance measures, as listed below, in 2008. It will add two immunization and three cardiovascular disease-related measures in 2009. This information is being reported at the facility level, and patients can compare the care at their clinic or hospital with others within their region, or with the performance of other facilities on a regional or national basis.

Diabetes: Hemoglobin A1c – Blood Sugar Control
Diabetes: LDL Cholesterol
Diabetes: Blood Pressure Control
Immunizations – Flu Shot
Pneumonia – Oxygen Assessment
Appropriate Medication for Asthma
Ischemic Stroke with Atrial Fibrillation – Anticoagulant Therapy

See the health transparency Web site for more details.

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