Performance Improvement 1996. Indian Health Service


MISSION: To provide a quality health services delivery system for American Indians and Alaska Natives with opportunity for maximum tribal involvement in developing and managing programs to meet health needs.

IHS Evaluation Program

The goal of IHS is to raise the health status of its principal beneficiary, American Indians and Alaska Natives to the highest level possible. The importance of evaluation in supporting this goal has increased significantly in recent years. The IHS evaluation process seeks to include American Indians and Alaska Natives as primary stakeholders in defining the purpose, design, and execution of evaluations. Stakeholders are the users of the end product of evaluations and typically are the population or groups most likely to be affected by evaluation findings. The principles of responsive evaluation practice have been adopted by IHS because they can best address these needs and concerns of American Indians and Alaska Natives.

The purpose of the Office of Planning, Evaluation, and Legislation (OPEL) is to advise the Director of IHS on policy formulation; conduct and manage program planning, operations research, program evaluation, health services research, legislative affairs, and programs statistics; develop the long- range program and financial plan for IHS in collaboration with appropriate agency staff; coordinate with HHS, Indian tribes, and organizations on matters that involve planning, evaluation, research, and legislation; and develop and implement long-range goals, objectives, and priorities for all activities related to resource requirements and allocation methodologies and models. OPEL serves as the principal advisory office to IHS on issues of national health policy. It also coordinates these four evaluation functions:

  • Health Program Evaluations--collect and analyze information useful for assisting IHS officials in determining the need for improving existing programs or creating new programs to address health needs.
  • Policy Analysis--conduct analyses when a change in the IHS health services delivery system must be considered, when issues emerge in an area where no policy currently exists, and when current policies are perceived as being inappropriate or ineffective.
  • Health Services Research--undertake analyses of the organization, financing, administration, effects, and other aspects of IHS health services.
  • Special Studies and Initiatives--conduct studies and prepare special reports required by Congress in response to pending legislation or policies, often using a roundtable whenever an issue or a health problem requires immediate action and it is unclear what type of action should be taken.

OPEL meets part of IHS evaluation needs with two types of short- term studies: policy or program assessments and evaluation studies. The policy study contributes to IHS decisionmaking about budget, legislation, and program modifications and includes background information to support IHS initiatives. Evaluation studies are carried out at the program level, or area offices, and focus on specific program needs.

Annually, OPEL identifies the high-priority health care and health management issues and concerns through the submission of headquarters and area office proposals for assessment or evaluation. IHS area and associate directors are asked to submit proposals for possible areas of evaluation study. These proposals are reviewed and rated by a panel of subject matter experts and evaluation experts. They are also reviewed by IHS staff for more specific concurrence with IHS strategic goals, objectives, and priority areas. The proposals are then prioritized and forwarded to the OPEL Associate Director for review and approval. The Director of IHS reviews the final proposals and decides the respective funding levels.

Summary of Fiscal 1995 IHS Evaluations

During fiscal 1995, OPEL completed four evaluation projects of several major Indian health topics.

"Case Study of Family Violence in Four Native American Communities: Final Report." Family violence on Indian reservations is devastating for individuals, families, and reservation communities. There are many families in American Indian communities who have experienced violent behaviors, who have coped with violent behaviors positively, or who wish to learn more about violent behaviors and their prevention. IHS sponsored this study to produce the information and data needed to guide program planning and development.

"Evaluation of Diabetes Services Provided by IHS Model Diabetes Program: Final Report." This evaluation of the IHS diabetes model projects used data from 634 patient medical records, four focus groups, and 20 informant interviews to describe these projects and examine their effect on two patient health outcomes--blood sugar control and hospitalizations. Two diabetes project sites (Winnebago, Nebraska, and Fort Totten, North Dakota) and one "usual care" site (Rosebud, South Dakota) were selected for the evaluation. Data from the 1993 Diabetes Program Audit were used to assess whether or not the findings from this evaluation of two diabetes projects could generally represent other diabetes team approaches in other IHS areas.

"Evaluation of IHS Midlevel Health Providers: Final Report." IHS must determine its needs for midlevel health providers (MLHPs), such as physician assistants, nurse practitioners, certified nurse midwives, and clinical nurse specialists through the year 2000 and address recruitment and retention of MLHPs. This study resulted in obtaining responses from 119 MLHPs and 14 primary care managers. The survey confirmed that MLHPs are making a major contribution to the IHS primary care program and are well utilized. However, IHS must begin immediately to address the shortfall of MLHPs that is projected to be approximately 51 percent over the next 6 years.

"Phase III Final Report: Child Abuse (CA) and Child Neglect (CN) in American Indian and Alaska Native Communities and the Role of the Indian Health Service." Indian child and adolescent abuse and neglect are issues of widespread concern; however, no reliable statistics exist on the prevalence of abuse or neglect. Recent data have indicated that more than 6,500 referrals for suspected child abuse and neglect were made to the Bureau of Indian Affairs (BIA), reflecting a minimum of 1 percent of Indian children in the BIA service area. This study provided comprehensive assessments of the effectiveness of IHS and tribal policies, procedures, and personnel in recognizing and treating CA/CN, and facilitated the design of an intervention program flexible enough to be used by American Indian and Alaska Native communities across the country.

IHS Evaluation in Progress

During fiscal 1995, IHS funded more than 10 studies, including health program evaluations, policy analysis projects, health services research, and special studies and initiatives. Examples of these projects follow.

"Analyzing the Underreporting of American Indian and Alaska Native Deceased Persons on State Death Certificates, 1986- 1988." The fiscal 1990 phase of the project funded the matching of the IHS patient registration records with State death certificate records. The records of American Indians and Alaska Natives matched with certificates from the National Death Index (NDI) for 1986, 1987, and/or 1988. The output was a computer tape and hard copy printout of probable and possible matched records. The results from the NDI match are used to develop estimates for each IHS area and each Reservation State on the number and proportion of deaths occurring each year that are misreported by race. These data will indicate which States have significant problems in underreporting American Indians and Alaska Natives on death certificates.

"A Mental Health Service Delivery Model for Urban Native Americans: An Evaluation of Utilization Rates and Mental Health Treatment Factors in an Urban Setting." This study will investigate utilization rates for mental health services over a 9-year period in an urban Indian population so that a profile of service use can be assessed over time. The approach will include the use of historical time analysis to examine the patterns of use over a set period within the context of events taking place during the those years and the effect on the population being served. The study will also examine the interaction of a service delivery model with traditional and western approaches within the same operational framework.

"Evaluation of the IHS Adolescent Regional Treatment Centers." This study evaluates the effectiveness of the regional treatment centers (RTCs) that provide alcoholism rehabilitation for American Indian and Alaska Native youth. The study will define the issues facing RTCs and help establish the parameters of what these programs have accomplished and plan to accomplish over the next 10 years. It will also provide guidance on how the success rate of RTCs can be improved.

"Evaluation of the IHS-Supported Substance Abuse Treatment Program for American Indian/Alaska Native Women." This study assesses the current IHS substance abuse and treatment program. It seeks to improve program effectiveness by monitoring behaviors that enhance risk, because research is virtually nonexistent on the scope of the problem of alcohol and other substance use among American Indian and Alaska Native women. The study will also evaluate the effectiveness of treatment.

New Directions for IHS Evaluation

IHS is responding to dramatic changes taking place inside and outside the government. The causes of the many changes include a decrease in the funding level of discretionary Federal programs, greater involvement of tribal governments in the Indian health care system, technological innovations, the changing patterns of disease to more chronic conditions, and the transfer of many Federal programs and resources to individual States.

These changes will affect the IHS evaluation strategy in the coming years. Nevertheless, IHS remains committed to comprehensive community-based, preventive, and culturally sensitive projects that empower tribes and communities to overcome health issues. The Director of IHS has placed increased emphasis on several initiatives to focus attention on specific health areas and to serve as a management tool to prioritize IHS' workload. These initiatives include emphasis on women's health, youth, traditional medicine, and elder care and on establishing working relationships with Federal and State government agencies. The initiatives will undoubtedly affect new directions for evaluation.

Research and evaluation proposals to be considered in upcoming years include the following topics: childhood obesity; elderly wellness; program review of training the practitioner in the assessment and treatment of adolescent sexual perpetrators; impact of the Alaska tribal health compact on programs and services in the Anchorage Service Unit; Pueblo of Zuni end-stage renal disease quality of life; and village-based women's preventive health services delivered by community health aides/practitioners.