Performance Improvement 1998. Indian Health Service


MISSION: The mission of the Indian Health Service, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social, and spiritual health to the highest level.

Evaluation Program

The goal of the Indian Health Service (IHS) is to assure that comprehensive, culturally acceptable, personal and public health services are available and accessible to American Indian and Alaska Native people. The importance of evaluation in supporting this goal has increased significantly in recent years and includes American Indians and Alaska Natives as the primary stakeholders in defining the purpose, design, and execution of evaluations. The stakeholders use the end product of the evaluations, and are typically the population or groups most likely to be affected by the evaluation findings. The IHS has formally adopted the principles of a responsive evaluation practice to address the needs and concerns of American Indians and Alaska Natives.

The evaluation program of the IHS is managed by the Office of Public Health, Staff Office of Planning, Evaluation, and Research (OPH-SOPER), which provides national leadership and consultation for IHS and Area Offices on strategic and tactical planning, program evaluation and assessment, public health and medical services, research agendas, and special public health initiatives for the Agency. The OPH-SOPER serves as the principal advisory office on issues of national health policy and coordinates the following 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 delivery of 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.

The evaluation needs of the IHS service components are coordinated by OPH-SOPER using two major types of short-term studies: policy assessments and program evaluation studies. The IHS policy assessments contribute to decisionmaking about budget, legislation, and program modifications and include background information to support the Agency's initiatives. Evaluation studies are focused at the program level, or Area Offices, and focus on specific program needs.

Each year OPH-SOPER selects high-priority health care and management studies for funding through the submission of proposals to headquarters and Area Offices. These proposals are reviewed and rated by a panel of subject-matter experts, evaluation experts, and IHS staff for concurrence with IHS strategic goals, objectives, and priority areas. The proposals are then prioritized and forwarded to the IHS Director, who reviews the projects that are recommended for funding and determines the respective funding levels.

Summary of Fiscal Year 1997 Evaluations

During FY 1997, IHS completed two major evaluation projects.

The Evaluation of the Impact of the Alaska Tribal Health Compact on Programs and Services in the Anchorage Service Unit, Alaska Area (6407) project is the first research to systematically evaluate the perceptions of a wide range of beneficiaries, officials, and employees of the IHS and the tribal system regarding the Alaska Tribal Health Compact, Title III Self-Governance Demonstration Project. There are almost 200 federally recognized tribes in a single Areawide Compact, organized via 13 separate consigners, each of which has its own Annual Funding Agreement. Seven of these consigners are in the Anchorage Service Unit, which is one of nine Service Units in the Alaska Area. The evaluation concludes that more village representatives have seen either no change or have seen a negative change in in-village services than those who have seen a positive change. The perceptions of the officials and employees of the Alaska Native Medical Center and the Alaska Area Native Health Service have revealed problems in staff morale and shifts in workload resulting from Compact consigners transferring patients to the Alaska Native Medical Center who were previously treated outside the Anchorage Service Unit. These changes are considered as having a negative impact on the Anchorage Service Unit. The "microcosmic" view from the Ahtna Region indicates that there is a distinct difference in the perception of those who are participating in the Compact and those who are not. The analysis of the village respondent data, comparing the information that came from the Title III villages with the information from the Title I villages, further solidified the conclusion that individuals in villages that are not served by a Compact consigner hold a consistently more negative view than those who live in villages that are served by a Compact consigner.

The Prior Trauma Care of Intoxicated Patients as a Predictor of Subsequently Fatal Injury (6451) study was undertaken to identify intervention opportunities that are the result of nonfatal, alcohol-related injury contacts in emergency departments and clinics that could, over time, decrease alcohol-related injury deaths in the IHS area in Billings, Montana. The concept was to determine the frequency of injury treatment recidivism, both alcohol- and non-alcohol related, and further to determine if patterns can be established to suggest that injury death is predictable based on those previous nonfatal contacts. The findings indicate a high degree of recidivism and a strong correlation between nonfatal incidents and eventual injury death. This study further reveals that there is a high prevalence of alcohol in nonfatal injury-related incidents among this cohort. There appears to be a strong relationship between repeated episodes of nonfatal injury with alcohol as a contributing factor and subsequently fatal events among this cohort. These nonfatal episodes should serve as warning signals and opportunities for alcohol intervention strategies to take place.

Evaluations in Progress

The IHS currently has several major evaluations under way in the following general areas: the IHS Resource Requirement Methodology (RRM), aftercare services provided by IHS regional treatment centers, and effectiveness of alcohol and substance abuse services for American Indian and Alaska Native women. The IHS also has a number of smaller evaluations in progress at several area offices.

The Elderly Wellness (6452) study focuses on collecting data to determine if providing 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 that 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.

The Cross Sectional Evaluation of the Prevalence of Childhood Obesity Among American Indians in the Aberdeen Area (6859) studies the trend in the prevalence of diabetes among American Indians in the Aberdeen, South Dakota area over a 10-year period. Findings suggest that not only are diabetes prevalence rates increasing, but the gap is widening between Aberdeen, South Dakota area rates and national IHS rates. This study will establish baseline rates of childhood obesity and will facilitate early intervention efforts among 100 schools attended by Indian children. Obesity is the most important risk factor for diabetes in American Indian communities. The study results will be used by service unit directors and their staff (diabetes coordinators, public health nurses, and nutritionists) to assess their progress toward the Healthy People 2000 objectives and the Aberdeen Area Clinical Objectives to determine childhood obesity prevalence and plan primary prevention programs.

The Evaluating the Effects of Medical Nutrition Therapy on Patient Outcomes Among Native Americans with Newly Diagnosed Type II Diabetes Mellitus (6746) study will evaluate the effectiveness of medical nutrition therapy (MNT) on clinical/behavioral outcomes of American Indians/Alaska Natives with newly diagnosed Type II diabetes. The evaluation will include the creation of a uniform methodology for collecting nutrition-oriented outcome data that is consistent among participating tribes, IHS service units, and urban programs. The outcome data will be analyzed to determine differences in the type and amount of MNT provided with regard to patient outcomes. They will also be linked with current clinical data from the IHS Diabetes Program that identifies continuous quality and performance improvement and measures. The analysis will also describe individual cases in which MNT has contributed to improved patients perceived quality of life.

The purpose of the Evaluation of IHS Capacity for Epidemiologic Surveillance (6745) is to determine the epidemiologic surveillance capacity of the Indian/Tribal/Urban (I/T/U) health system and to make recommendations for improving the capacity to meet the needs of the IHS and its stakeholders. The IHS health care environment is undergoing unprecedented change; reorganizing, consolidating, and downsizing are part of the overall restructuring of services to its customers. Limited resources will be available to conduct epidemiologic surveillance, and the I/T/U health system will become more reliant on local capacity. The evaluation will be designed to collect data from a representative sample of IHS direct service providers, P.L. 93-638 contracts, self-governance compacts, and urban programs to determine the availability of epidemiological useful data and the capacity to perform disease surveillance and epidemiologic analyses of data at the local level.

The objective of the Evaluation of the Effectiveness of the Indian Health Service Alcohol and Substance Abuse Treatment Programs, Phase I (6744) is to evaluate the effectiveness of aftercare and continuing care services provided to youth and adult patients who have received treatment for alcohol and substance abuse at a primary treatment facility, a regional treatment center, or other IHS-funded program. The study will examine the availability, accessibility, acceptability, and cost of community-based followup services, as well as the potential for coordinating and integrating these services with the other aspects of alcohol and substance abuse treatment, such as detoxification, residential treatment, and halfway houses. The purpose of Phase I is to develop a methodology to assess the effectiveness of the IHS-sponsored aftercare/continuing care program to meet the needs of tribal and urban programs. Phase II will include a national assessment to measure the outcomes of aftercare and continuing care services attained by patients/clients of alcohol/substance abuse treatment programs in a representative sample of Indian communities that have IHS-sponsored alcohol and substance abuse programs. The study will include recommendations and an implementation plan to improve aftercare/continuing care services in Indian communities.

In the early 1970s, 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 1995 study determined the validity and accuracy of the present methodology for use in today's health care environment. The study findings support the need to update the current methodology to meet the future program demands of the IHS. The Resource Requirement Methodology Update (6450) 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.

The Evaluation of Indian Health Service-Supported Alcohol and Substance Abuse Treatment Program for American Indian/Alaska Native Women (6201) is part of a four-phase evaluation of alcohol and substance abuse services for adult American Indian and Alaska Native women in alcohol and other drug treatment centers that are funded by the IHS. Phases I and II of this study were completed; a report was prepared in December 1995. The primary objectives of this project are to assess and measure the treatment services provided; to describe the organization and provision of substance abuse treatment and aftercare services available for adult American Indian and Alaska Native women; and to identify common strengths, problems, and recommendations for improvement. Phase I of this effort focused on designing the study, and Phase II collected descriptive data on the women who use IHS-sponsored substance abuse treatment centers. Phase III will be a prospective client outcomes study, and Phase IV will consist of an evaluation of the efficacy of IHS-funded treatment centers.

Development of a Health Services Research Agenda for American Indian and Alaska Native Populations (6153). The IHS and the Agency for Health Care Policy and Research co-sponsored 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 between American Indians and 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 American Indian and Alaska Native patients. 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.

Malignant neoplasm survival rates for well-defined American Indian populations are scarce. Although a national cancer surveillance system is in place, information relevant to Native Americans in the Northern Plains is not available. The Evaluation of Available Cancer Surveillance Systems for Montana Native Americans and Correlates of Decreased Cancer Survival Among Native Americans in Montana (5944) will examine the utility of the IHS Resource and Patient Management System and the Montana Central Tumor Registry as a cancer surveillance system for the Native Americans in Montana. The results of this evaluation may determine the current level of cancer detection and treatment for Montana Native Americans compared to non-Native Americans in the same region. The development of health promotion and disease prevention activities requires an efficient surveillance system and knowledge of the current deficiencies and strengths of the current system. A better understanding of the sites of late stage cancer at diagnosis will help providers direct education and early detection efforts to Montana Native Americans.

The Study of the Interaction of Persons Treated for Alcoholism with the Health Care Delivery System (6742) will evaluate the results of alcohol treatment for American Indians who abuse alcohol, focusing on the overall health care delivery system. The evaluation design and methodology will be developed and applied to the population served by the Crow Agency Service Unit. Data retrieval, audit instruments, and analytical strategies will be piloted for two years.