Performance Improvement 1997. 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.

Evaluation Program

The goal of the Indian Health Service (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 the evaluation findings. The principles of responsive evaluation practice have been adopted by the 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 the IHS on policy formulation; to conduct and manage program planning, operations research, program evaluation, health services researches, legislative affairs, and program statistics; to develop the long-range program and financial plan for the IHS in collaboration with appropriate agency staff; to coordinate with HHS, Indian Tribes, and organizations on matters that involve planning, evaluation, research and legislation; and to 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 the IHS on issues of national health policy and 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 service delivery system must be considered, when issues emerge in an area where no policy currently exists, or when current policies are perceived as inappropriate or ineffective.
  • Health Services Research--Undertake analyses of the organization, financing, administration, effects, and other aspects of the IHS.
  • 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 the IHS evaluation needs with two major types of short-term studies: policy or program assessments and evaluation study. The policy study contributes to IHS decision making 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 submit proposals for possible areas of evaluation study. These proposals are reviewed and rated by a panel of subject-matter experts and evaluation experts and also reviewed by IHS staff for more specific concurrence with IHS strategic goals, objectives, and priority areas. The proposals are then ranked by priority and forwarded to the OPEL Associate Director for review and approval. The Director of the IHS reviews the final proposals and decides the respective funding levels.

Summary of Fiscal Year 1996 Evaluations

During FY 1996, OPEL completed three evaluation projects of several major Indian health topics.

Methodology for Adjusting IHS Mortality Data for Inconsistent Classification of Race-Ethnicity of American Indian and Alaska Natives Between State Death Certificates and IHS Patient Registration Records

The study findings indicate a large variation in the number of deaths reported from 1986 to 1988 across IHS area offices and extensive variation in the number of deaths reported in the matched IHS-National Death Index data across States of occurrence. There is also a great variation in the percentage of consistently reported American Indian and Alaska Native race identification on State death records and IHS patient registration records by State of a resident. Recommendations include replicating the study using data on deaths occurring since 1988, using the adjustment factors developed in the study, and working with States to decrease inconsistent race reporting.

Evaluation of the Indian Health Service (IHS) Adolescent Regional Treatment Centers

The principal conclusion based on this study's findings is that regional treatment centers have developed effective adolescent alcohol and substance abuse programs. The continuity of care and aftercare, however, is the biggest problem. The regional treatment centers need additional mental health staff resources, client charting improvements, and innovative ways to increase family involvement. Recommendations include improving the continuum of care to adolescent substance abusers, self-evaluation, and regional treatment center effectiveness and efficiency.

Evaluating the Effectiveness of Alcohol and Substance Abuse Services for Native American and Alaska Native Women: Phase II Final Report

This evaluation provides both qualitative and quantitative information about a group of women that has been traditionally underrepresented in research. The life conditions of women about whom information was gathered are extreme, and for many women, adverse or abusive childhood experiences and conditions have carried through to adulthood. The vast majority of women were exposed to various types of abuses--such as physical, sexual, and emotional abuse--from childhood to adulthood. Women entered treatment through a variety of ways. Those who were mandated tended to enter treatment as an alternative to incarceration. Women hear about the availability of services through the court system, word-of-mouth, or through a community or an American Indian and Alaska Native social service agency. Women in the focus groups tended to select their current alcohol and other drug treatment program over alternatives because of its focus on American Indian and Alaska Native tradition and culture. The women and staff also espoused the benefits of the family-like environment that the treatment centers promoted. The availability of women-centered, family-focused approaches to alcohol and other drug treatment is severely limited in the United States. Several barriers to services for potential participants exist. The leading obstacle for parenting women is the lack of child care for their children while in treatment. It was strongly emphasized that a woman's recovery was dependent on three key factors: herself, her social networks, and her community. One of the strongest impressions that has been derived from this evaluation is that the women who have participated in alcohol and other drug treatment programs are, overall, a cadre of strong women.

Evaluations in Progress

During FY 1996, the IHS funded more than ten projects, including health program evaluations, policy analysis projects, health services research, and special studies and initiatives. Examples of evaluations in progress follow.

Elderly Wellness

This study will focus on collecting data to determine if the provision of health care and health promotion services specially designed for the elderly will increase their use of these services and ultimately improve their health status. Comprehensive care remains an unmet need for the elderly. Recent reviews show that less than 50 percent of the elderly population residing in the Fort Peck Service Unit (Billings, Montana, area office) has had a health care visit of any kind in the last two fiscal years.

Prior Trauma Care of Intoxicated Patients as a Predictor of Subsequently Fatal Injury

In FY 1996, the IHS funded the first part of this study to begin the preliminary data collection, crude data reporting, and initial death certificate-hospital record linkage. The purpose of this study is to identify intervention opportunities associated with nonfatal, alcohol-related injuries reported in IHS emergency departments and clinics that could, over time, decrease alcohol-related injury death in the Billings, Montana, Service Units. This study will provide baseline data for postintervention comparisons by expanding the existing data base about alcohol-related injuries and death. The study will identify different intervention and prevention strategies directed at decreasing alcohol-related injuries and deaths in the Billings, Montana, Service Units. Injury-control efforts will include a new policy regarding referrals by emergency room treatment staff to alcohol treatment staff. Prevention of alcohol-related injuries and deaths will also include activities focused on informing youth about the relationship between alcohol consumption and high-risk behavior.

Resource Requirements Methodology Update

In the early 1970's, the IHS formulated the Resource Requirements Methodology (RRM) as a management tool to provide a comprehensive, systematic, and uniform process for estimating the level of resource requirements necessary to provide adequate health care to IHS customers and to assist in the allocation of unearmarked resources. To reaffirm the purpose of the RRM, a study was conducted in 1995 to determine the validity and accuracy of the present methodology for use in today's health care environment. Preliminary findings support the need to update the current methodology to meet the future program demands of the IHS. The update of the RRM will include a complete revision and documentation of the RRM and will consist of the following phases: (1) Update Staffing Criteria and Modules, (2) Formulate Needs Assessment Cost Model, and (3) Needs Assessment Model Training.

Development of a Health Services Research Agenda for American Indian and Alaska Native Populations

The IHS and the Agency for Health Care Policy and Research cosponsored a health services research conference as a first step in a long-term agenda-setting process to identify the most important health services research issues facing American Indian and Alaska Native communities and their health care systems over the next 5 to 10 years. The health services research agenda is intended to promote collaboration among American Indian or Alaska Native organizations, tribal and urban health systems, medical communities, foundations, and government agencies to increase communications and produce research information on health program services for the American Indian or Alaska Native patient. The health services research agenda is also intended to provide a forum for discussing health care reform changes that are creating new directions in the Indian health care system.

Evaluation of Indian Health Service-Supported Substance Abuse Treatment Program for American Indian/Alaska Native Women

This evaluation consists of Phases III and IV of a multiphase effort by the IHS to improve the health of American Indian and Alaska Native women who abuse alcohol or other substances. Phase I of this effort focused on designing the study, and Phase II collected descriptive data on the women who use IHS-supported substance abuse treatment centers. The primary objectives of this project are to assess and measure the treatment outcomes achieved by the women receiving treatment in the IHS-sponsored projects, to attempt to relate treatment outcomes to treatment services provided, and to describe the organization and provision of substance abuse treatment and aftercare services available for adult American Indian and Alaska Native women, identifying common strengths, problems, and recommendations for improvement.

New Directions for Evaluation

The IHS is responding to dramatic changes taking place inside and outside the Government. The causes of the many changes include a decrease in 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, the IHS remains committed to comprehensively community-based, preventive, and culturally sensitive projects that empower tribes and communities to overcome health issues. The Director of the IHS has increased emphasis on several initiatives to focus attention on specific health areas and to serve as a management tool to prioritize the IHS's workload. These initiatives focus on women's health, youth, traditional medicine, elder care, and establishment of working relationships with Federal and State governmental agencies. The initiatives will undoubtedly affect new directions for evaluation.

Research and evaluation proposals to be considered in upcoming years include the following topics: evaluation of the effects of medical nutrition therapy on patient outcomes among Native Americans with newly diagnosed type II diabetes mellitus, evaluation of the elders clinic at the Zuni (New Mexico) Ramah Service Unit, evaluation of the impact of the Northern Cheyenne End-Stage Renal Disease Prevention Project, and evaluation of IHS aftercare services provided by IHS's regional treatment centers.