Performance Improvement 1995. Indian Health Service


MISSION: To provide a comprehensive health services delivery system for American Indians and Alaska Natives, allowing for maximum tribal involvement in developing and managing programs to meet their health needs.


IHS Evaluation Program The evaluation program of the Indian Health Service (IHS) serves the Agency's programmatic and policy objectives. These objectives, developed in consultation with tribal communities, were most recently articulated in a "vision statement" of the IHS Director in November 1994. The statement calls for the IHS to continue to be the best primary care rural health system in the world. This goal is predicated, in part, on additional program emphasis in areas in which demographic and disease indicators point to a strong need for service delivery: elderly care, child abuse, women's health care, and substance abuse. Substance abuse, for example, is considered to be one of the most pressing problems facing American Indians and Alaska Natives[1] because of its toll in morbidity, mortality, and social turmoil.

The IHS evaluation program provides valid and reliable information to help the Director promote this vision for the Agency, and the evaluation program is also expected to help guide its implementation. The program traditionally has addressed three general areas--service delivery, health status, and management. The areas are interrelated, especially as the IHS faces times of fiscal austerity. If the IHS is to improve service delivery and maintain quality care, it must increase efficiency, effectiveness, and accountability. Management practices are continually being reviewed to ensure that IHS programs operate efficiently to ensure quality patient care and preventive care--the cornerstones of the IHS.

The IHS conducts technical and policy reviews of proposed evaluations--much like other PHS evaluation programs--but the program also has several distinguishing features. The most noteworthy feature is the active participation of tribes in the development and execution of evaluation studies. American Indians are recognized as primary stakeholders whose needs and concerns must be addressed, especially if the IHS is to help tribes develop and provide health care to their communities. For example, the IHS sponsors roundtable discussions with tribal leaders and Indian health program officials to elicit advice and consultation about directions for evaluations and policies. This approach to evaluation--a responsiveness to stakeholders and an orientation toward a pluralism of cultural values--is referred to by professional evaluators as a "fourth-generation" evaluation. Earlier types of evaluations, which began after World War II, were more technical, descriptive, and marked by the judgments and values of the evaluator.

Another distinguishing feature is that most evaluations are performed by contracting firms owned and operated by American Indians. This policy is an outgrowth of regulations and guidelines intended to increase the participation of American Indians and tribes in program management and service delivery.


Summary of FY 1994 Evaluations The IHS completed nine evaluations in FY 1994, focusing on service delivery, health status, and management. These areas are pivotal to the Director's vision of ensuring the delivery of high-quality primary care. Three of these evaluations deserve special notice because they address areas that are slated for renewed programmatic emphasis in the coming years.

One evaluation assessed the availability, utilization, and quality of data sets describing the health status of women and children in the Navajo area. Maternal and child health (MCH) data sets play a vital role in monitoring the health status of American Indian populations, shaping programs and assessing their effectiveness. The first phase of the project sought, through interviews and site visits, to determine whether IHS service unit staff were able to fulfill existing data requirements use the data that were generated. The project found staff to be inundated with data requests that did not completely meet their needs for the care of patients and for the promotion of maternal and child health. The second phase examined the quality of a specific automated data set on childbirth outcomes by comparing it with original chart entries. The comparisons were favorable, thus reinforcing the quality of the automated data set. The findings and recommendations of the first phase of the report are leading to a better understanding of MCH data needs and to refinements in the types of MCH data required of service area staff, along with improved vehicles for obtaining them.

Another evaluation, highlighted in chapter II, analyzed the health status of American Indians in California. It documented the health status of, and access to health care services for, those in both federally recognized and non-federally recognized tribes. These and other comparisons showed that the overall health status of both groups was poorer than that of the California population as a whole. The findings underscore the significance of maintaining and expanding coverage to the entire American Indian population of California.

A third evaluation developed long-term health care projections for alcohol-related hospitalizations. The projections--which were based on a new method called "long-term projection methodology"--sought to determine the impact of changes in hospitalizations as a result of advances and innovations in treatment, tech-nology, and behavior. The technique forecast a 20 percent decline in alcohol-related hospitalizations. While these projections were encouraging, they were insufficient to meet Healthy People 2000 objectives. This finding is one of many that have led to a renewed IHS emphasis on prevention of substance abuse. This study will be used specifically to guide evaluations such as that planned on regional adolescent alcoholism treatment centers (described below under "New Directions for Evaluation") and will provide tribes with information relevant to alcoholism program planning, policy development, and program evaluation. For example, the study informs IHS providers that the only age-gender group showing increases in alcohol-related hospitalizations is American Indian women over the age of 45.


Evaluations in Progress The IHS currently is sponsoring 21 evaluations covering service delivery, management, and prevention. Two of these evaluations underscore the IHS commitment to the development of new programs to prevent child abuse and family violence. Violence and abuse are serious problems that erode the quality of family life and can result in death, serious injury, or long-term health and behavioral problems. Family violence and child abuse are difficult to study because of underreporting and shifting definitions of what is acceptable behavior. The diversity of cultures, languages, and customs of American Indian tribes also heightens the difficulty of determining the extent of these problems and evaluating what works to prevent them.

One report, which is expected to be completed in FY 1995, is an assessment of the extent of child abuse and neglect among American Indian tribes and the ways in which the IHS responds to these problems. The evaluation also develops a model program to combat child abuse and neglect. Preliminary results from survey data indicate about 34 percent of American Indian children are at risk of becoming victims, and substance abuse commonly plays a role. The intervention program under development is being modeled after a successful program developed in 1985 by the State of Hawaii. The program provides home visitor services to new mothers, ensures continuity of medical care for children, and links families with essential services.

The other evaluation report is a case study of family violence in four distinct American Indian communities. Researchers conducted more than 100 unstructured interviews at the four sites to probe the nature and extent of family violence, which was defined as spousal abuse, child abuse and neglect, child sexual abuse, or elder abuse. They found little consensus across the four study sites about which type of family violence represents the gravest problem. These and other study findings are being incorporated into a model to guide the development of prevention programs. Eventually, this model will be available for use by an individual, family, group, or tribe to develop programs to prevent or reduce family violence in American Indian communities.


New Directions for Evaluation The IHS foresees the need for evaluations in the following areas: mental health services for urban Indians, regional treatment centers (RTCs) for substance abuse disorders, and health services for elderly American Indians. Urban American Indians, who account for approximately 56 percent of the American Indian population according to the 1990 Census, have important mental health needs. The urban American Indian usually lives in poverty and has little or no support system, in contrast to the American Indian living on a reservation among others who live at the same economic level and rely on the security of extended family and housing assistance. Indians who come to the cities encounter a physical environment, social organization, interpersonal behavior, attitudes, values, and sometimes even language that are foreign to their experience. They may suffer from feelings of isolation, depression, desperation, and anxiety, and may have problems with self-esteem. The traditional support of the extended family may be totally lacking. In 1976, Congress passed the Indian Health Care Improvement Act (P.L. 94-437), which was landmark legislation for all Indian health concerns but particularly for urban populations. Title V of the legislation specifically authorized health outreach and referral and the delivery of services to American Indian people in urban areas. Before this, health care delivery was not permitted off the reservation. The urban health program was expanded in 1988 in the Indian Health Care Amendments (P.L. 100-713). These amendments clarified the types of primary care and outreach services that could be provided, paving the way for the provision of mental health services. Mental health services are considered ripe for evaluation because the IHS supports extensive services in some urban areas and few, if any, services in other urban areas. This disparity needs to be evaluated.

Nine RTCs offer residential substance abuse treatment to Indian youth, most of them aged 12 to 19, in recognition of the fact that young people are especially vulnerable to long-term patterns of alcohol and drug abuse. Although alcoholism is decreasing among older American Indians, it remains stable in adolescents. Alcohol abuse among American Indian youth usually begins during adolescence or earlier. The RTC programs were legislated into existence by Congress and are an important part of the continuum of care for American Indian youth. Programs that began in the late 1980s and were accredited by the Joint Commission on Accreditation of Health Care Organizations are now deemed ready for evaluation because they have been in operation for several years and they appear to play an important role in reducing substance abuse. Evaluations are needed to document the impact of these programs, including outcome measures; to determine the level of agreement between referring and discharge diagnoses of individuals admitted to RTCs; to examine the characteristics and histories of youth and staff at the RTCs; and to determine the impact these centers have had in the local areas. The results can be used to redefine the operation of existing RTCs and guide the design of future centers.

Longer life expectancy among American Indians is posing new challenges for IHS service delivery. Demographics showing that life expectancy has increased from 61 years in 1972-74 to 71.6 years in 1986-88 have led to the creation and expansion of special services geared to the elderly. Evaluation of health services for elderly persons who are ambulatory, homebound, or institutionalized is considered critical if the IHS is to effectively meet the needs of this growing population. Evaluations should address the increasing need for long-term care. The emerging nature of the problem gives the IHS an opportunity to define and develop the most appropriate services for American Indian elders before the need overwhelms American Indian communities and leaves many without services. Improving the quality of life for elderly American Indians is thought to be a critical need in the next few decades.

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