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Tribal Self-Governance Health Care and Social Services Delivery Effectiveness Evaluation Feasibility Study: Draft Work Plan

Publication Date
Oct 27, 2002

Submitted to:

Andrew Rock, Task Order Manager
Office of Planning and Evaluation
Department of Health and Human Services
200 Independence Ave., SW, Suite 447-D
Washington, DC  20201

Delivery Order 27
Under Contract No. HHS-100-97-0017

Submitted by:
Westat
1650 Research Blvd.
Rockville, MD  20850

"

I. Overview and Objectives

The Tribal Self-Governance Evaluation Feasibility Study, being conducted by Westat, Project HOPE Center for Health Affairs, and Kauffman and Associates, Inc., will provide the Office of the Assistant Secretary for Planning and Evaluation (OASPE) with in-depth background information and detailed review of issues and data systems for that may affect the extent to which a rigorous and defensible evaluation of Tribal Self-Governance of Indian Health Service and other non-IHS programs can be conducted. While a number of assessments of Tribal Self-Governance programs have been conducted, these have been primarily qualitative in nature. OASPE is interested in determining the feasibility of conducting an evaluation that examines both processes associated with effective Self-Governance programs and impacts of Tribal Self-Governance on outcomes, including: services, costs, resources, access to care, quality, financial performance, customer satisfaction, and program stability.

This Revised Draft Work Plan for the project includes augmentations and modifications to the Task Descriptions, a revised schedule, and a discussion of outstanding issues and processes that will be put in place to manage the task activities. Changes to the Work Plan described in the original Technical Proposal reflect agreements reached during negotiations prior to award of the project, advice and guidance obtained during the Initial Project Meeting (held on September 30, 2002), and additional discussions with the government during the first five weeks of the project. We anticipate that additional revisions to the Work Plan will be made following the first Technical Work Group (TWG) Meeting which is scheduled for early February, 2003.

II. Revised Work Plan

Task 1. Project Initiation and Ongoing Communications

1.1 Initial Project Meeting

The initial project meeting was held on September 30, 2002. The Meeting Agenda and Meeting Summary is included, for reference, in Appendix A of this Work Plan.

1.2 Establish Technical Work Group

The criteria developed for the composition of the TWG, during the initial project meeting, included:

4-5 Tribal leaders;

4-5 Tribal program staff experts with hands-on experience including an emphasis on financial management personnel (e.g., CPA experience;

1 data expert (subsequently amended); and

1 researcher (subsequently amended).

It was also agreed that efforts will be made to choose TWG members who represent large tribes, small tribes, and Tribal associations; also that the Tribal program staff selected should include those with experience with Head Start and TANF programs, as well as health programs. In addition, the composition of the TWG will reflect geographic diversity. A process will be initiated to contact knowledgeable individuals from Tribal organizations and the federal government to solicit names of potential TWG candidates.

A preliminary list of potential TWG members was prepared and submitted to the TOM, during the week of December 12, 2002(1). After discussion of this preliminary list, and additional recommendations from OASPE, a final list of potential candidates will be prepared and submitted to the TOM for approval. Because it may be difficult to obtain agreement to participate from all of the people identified, at least two potential candidates will be provided for each category of expertise. The TOM will be asked to indicate which of these two candidates should be approached first about participation; if that candidate cannot participate then the alternate candidate will be asked to participate.

The recruitment process for the TWG will include: 1) a packet of materials describing the study and the role of the TWG, with a letter from OASPE inviting the individual to serve on the TWG (to be sent by FedEx); 2) one of the Co-Principal Investigators will contact the individual by telephone, within 2 days after the packet is sent, to discuss the project, answer any questions, and obtain their agreement to participate; and 3) a formal agreement to participate, specifying the details of participation, the TWG member's role, and the honorarium to be paid, will be sent to each TWG member.

The original schedule for the first meeting of the TWG would have required it to be held two weeks before Christmas (Week 12 of the project). It was agreed during the initial project meeting that this timing was not optimal, and a decision was made to re-schedule this first TWG meeting (to the first week in February).

A Draft Agenda for the First TWG Meeting was distributed for review prior to the initial project meeting. Discussion of the draft agenda produced agreement on three changes.

During the initial 'Introductions/Welcome' session, ground rules for participation of non-TWG members in the discussion would be established;

At the close of the 'Project Overview' session, each TWG member would be asked to provide their individual definitions of 'Self-Governance' and to identify key issues for Self-Governance that they think are most important;

A "brainstorming" session would be held at the end of the first day to identify priority topics for the breakout groups on the second day.

The Revised Agenda for the First TWG Meeting, incorporating these changes, is presented in Appendix B to this report.

1.3 Ongoing Communications

Communications between the government TOM, the project staff, and interested individuals and groups representing AI/AN interests are of critical importance for this project. Preliminary suggestions for ongoing communications discussed at the initial project meeting included:

· A monthly conference call with the TOM to discuss progress and outstanding issues;

· Preparing a summary of the monthly conference call, documenting issues and progress, that would be sent to the TOM for approval and then sent to each TWG member and any other interested individuals;

· Disseminating final versions of all reports, once approved by the TOM, to each TWG member and other interested individuals;

· Contacting AI/AN organizations (e.g., National Council of American Indians; National Indian Health Board, Indian Health Service) and requesting that they post information about the study, including contact information for the Co-Principal Investigators and the OASPE TOM;

· If invited, the Co-Principal Investigators will also agree to do a presentation on the goals and methodology of the study at national conferences of AI/AN organizations.

The discussion of the project communications strategy at the initial project meeting also suggested that the DHHS website established for the project continue to broadcast what is happening with the project. It was also suggested that a link be established from the IHS website to the project website. The project team and government staff on this initial conference call agreed to have a monthly conference call and minutes will be distributed to participants and posted on the website. Communications with Tribal leaders about the project will begin with dissemination of a one-page project description and a letter inviting comments and questions, with a contact list and the DHHS website address. (A draft of the project description and letter are presented in Appendix C.) A complete Communications Strategy Report will be prepared and submitted to the TOM by Week 6 of the project.

Task 2. Work Plan and Preliminary Information Gathering

2.1 Work Plan

The Revised Work Plan will be submitted to the TOM during the week of October 28, 2002.

2.2 Report on History and Development of Tribal Self-Governance

A report on the legislative and programmatic history and current status of Tribal Self-Governance is being prepared during the initial six weeks of the project. This report will provide background for the study and ensure that the project team, TWG, and other key stakeholders have a solid understanding of the legal basis for Tribal Self-Governance, regulations that guide Self-Governance, and the current status of Self-Governance with respect to number of Tribes with Self-Governance contracts/compacts, number of people receiving services under those contracts/compacts, and the range of programs that are operated by Tribes under contracts/compacts.

Frank Ryan, J.D., project consultant, is taking the lead role in preparing the report on legislative and programmatic history of Self-Governance, working with Project HOPE. Mr. Ryan has extensive knowledge of this area and is supplementing this prior experience by conducting an exhaustive LEXIS-NEXIS search and review of laws and case reports relevant to Tribal Self-Governance. In addition, he is contacting federal government officials and staff, Tribal leaders, and Tribal organizations that have been involved in Tribal Self-Governance issues to obtain current and historical background and input for the report. The Report on Legislative and Programmatic History and Development of Tribal Self-Governance will be submitted to the TOM in Week 6 of the project.

The report will be revised with DHHS input and possibly further revised based on TWG advice.

2.3 Review and Synthesis of Literature/Research on Experience of Tribal Self Governance of Health and Social Programs

The existing literature and research on the effectiveness and experiences of Tribal Self-Governance of health and social programs is limited and primarily qualitative in nature. A comprehensive search of the literature is being conducted, including search of electronic databases, AI/AN organization websites, and federal websites. A bibliography will be prepared and reviewed with the TOM and with the Technical Working Group at the first meeting to identify any additional citations and individuals that may be working on current research or who may have conducted unpublished studies that should be included in the review. These additional citations will be obtained and identified researchers will be contacted by telephone to discuss their current research and obtain copies of any unpublished or preliminary reports that they have completed.
 

The preliminary outline of the Review and Synthesis includes:

· Introduction and Objectives;

· Background on Tribal Self-Governance Programs;

· Issues for Tribal Self-Governance;

- Transition to Self-Governance;

- Management;

- Financing;

Measures of Effectiveness;

Review of Evidence on Self-Governance of Health Programs;

Review of Evidence on Self-Governance of Social and Other Programs;

Research Limitations and 'Gaps';

Discussion/Conclusions.

The Review and Synthesis of the Literature/Research on Experience of Tribal Self Governance of Health and Social Programs will be completed and submitted to the TOM by Week 8 of the project.

1.4 Prepare Tribal/Reservation Matrix

A matrix will be prepared, showing for each Tribe, the 12 DHHS-identified health, social, and other programs and whether those programs are Tribally-managed under a contract or compact or are direct services. In addition, to the extent possible, federal funds received by Tribally-managed programs or that are available for direct services will be documented. Other information on each Tribe will also be provided in the matrix, including total number of Tribal members and Tribal members residing on or near the Reservation. DHHS program staff who can provide information and data for the development of this matrix have been identified by the TOM. These individuals will be contacted to discuss the project and to request data to complete the matrix. Additional data on Tribal population and residence on/near the reservation may be obtained from the Bureau of Indian Affairs.

The matrix will provide background data for the project and for identification and selection of the six study sites that will be examined in the site visit/case study component of the project. It will be submitted to the TOM in Week 8 of the project.

Task 3. First Meeting of the Technical Work Group

The First Meeting of the TWG, to be scheduled during the week of February, 2003, will be a three day meeting held in Washington, D.C. The Washington, DC location will permit interested OASPE and other federal agency staff and additional Westat and Project HOPE staff to attend without incurring travel costs. The TWG meeting will be held either at OASPE, if feasible, or at a large conference room at Westat or at Project HOPE. Light refreshments and lunch will be available to participants.

3.1 Prepare Agenda and Arrange Meeting

The initial TWG meeting will be held for 2 full day and 1 half day sessions, with sessions focusing on key topic areas for the feasibility study. A Preliminary Agenda, incorporating suggestions from participants in the initial project meeting, is presented in Appendix B to this report.

Arrangements for the First TWG Meeting will begin as soon as the TWG composition is finalized, with identification of dates that would be feasible for all participants. Once the date is finalized, a letter or email will be sent to all TWG members to confirm their attendance on that date and to provide information on making hotel and travel arrangements. Approximately 10 days before the meeting, a packet of information will be sent to each TWG (and to the TOM and project staff) containing the following:

· Final Agenda;

· Location of the TWG Meeting;

· Local travel directions;

· Project Description;

· Revised Work Plan;

· Draft Report on Legislative and Programmatic History and Draft Report on Literature Review/Synthesis;

· Memorandum on Site Selection Issues;

· Memorandum on Small Group Discussions Issues and Potential Topic Areas;

· Memorandum on Ongoing Communications Strategies;

· Contact List: TOM, Westat Team Key Staff, and all TWG Members.

All materials to be sent to the TWG will be sent in draft form to the TOM for review and approval prior to being sent to the TWG members.

3.2 Convene First Meeting

Jo Ann Kauffman, Co-Principal Investigator, will serve as moderator for the meeting and will facilitate the discussions for each topic area. Staff from Kauffman and Associates, Inc., and from Project HOPE will take detailed notes throughout the meeting to ensure that all discussions and guidance are documented. Following the meeting, a summary of the First TWG Meeting will be prepared and submitted to the TOM for review and approval. Once it is finalized and approved, this Summary will be disseminated to the TWG members and to other attendees at the meeting.

Task 4. Planning for Implementation of Tribal Site Visits and Small Group Sessions

3.1 Report on AI/AN Population and Socio-Economic Characteristics

As background for selecting the six specific sites for study, a report will be prepared documenting the geographic distribution of the AI/AN population, urban/rural and reservation/non-reservation distribution, economic characteristics, health status, and other measures of social well-being. Much of the data that will be presented in this report are accessible and held in-house by Project HOPE, or are available in summary form in federal government publications. The Bureau of Indian Affairs data provides information on Tribal enrollment and number of enrolled members residing on/near specific Reservations. BIA also publishes data on average income and unemployment rates for each Tribe. (Note: Because BIA's website has been closed, due to legal issues, it may be necessary to obtain these data through BIA contacts.) Census 2000 data are available on total AI/AN population, by State and by urban/rural residence. Census data include income, household composition, residence, education, and a limited number of measures of disability. (Note: Census data do not identify enrolled members of federally recognized Tribes, but do include information on the Tribe that the respondent self-reports.) Indian Health Service publishes reports on mortality, morbidity, and other health indicators, by IHS Area, as well as data on service use. (Note: Tribes that contract/compact health services may not report service use and, thus, these data may not be available.) IHS also has data on funding of health services for Indian Tribes and Alaska Natives, for both direct service and contracting/compacting Tribes. For purposes of this proposal, we assume that the TOM will request IHS data on funding levels by Tribe. The Report will be completed in draft form by Week 14 of the contract and submitted to the TOM.

3.2 Identify Tribal Site Selection Criteria and Characteristics of Small Discussion Groups

Tribal Site Selection Criteria. Six sites will be selected for study that are representative of:

· IHS Self-Governance compacting Tribes;

· IHS Self-Determination contracting Tribes;

· Tribes that operate non-IHS programs under contracts or grants;

· Tribes that do not operate either IHS or non-IHS programs under contracts or grants.

Additional criteria that will be taken into consideration for selection of contracting/compacting sites include:

· Tribes that have operated health systems under contracts/compacts since the beginning of the IHS Self-Governance program;

· Tribes that have managed their health programs for a sufficient time that they are not in early start-up and that are not undergoing a major change or transition;

· Tribes that contract/contract to manage all health services and not just one or two specialized programs (e.g., substance abuse treatment programs);

· Contracting/compacting Tribes with adequate fiscal, management, and program policies in place; and

· Tribes that have operated three or more of the 12 target non-IHS programs for at least a year, under contract or grant.

Criteria for Tribes that do not contract or compact include:

· Tribes that have had direct IHS provision of health services for at least 5 years;

· Tribes that are not pursuing or anticipating pursuing transition to contracting/compacting for at least 2 years;

· Tribes that are not currently operating under a grant or contract any of the non-IHS target programs.

In addition, for both types of Tribes, Tribal population should be of sufficient size to permit valid and significant analyses and reporting. In all cases, viable sites should also have expressed a clear willingness and interest in being included, if selected, in both the feasibility study and in a potential subsequent evaluation phase.

Possible additional criteria that may be considered in identifying potential sites include:

· Geographic representativeness, relative to the distribution of federally recognized Tribes and AI/AN population residing on Reservations;

· Socio-economic characteristics, including income, percent of households below the federal poverty level, unemployment, and education levels;

· Characteristics of Tribal-State government-to-government relationships;

· Characteristics of State Medicaid and SCHIP program eligibility and benefits; and

· IHS per capita funding levels for Tribal health.
 

The TWG may also suggest other selection criteria and these will be incorporated into the selection process to the extent feasible.

Once the criteria are finalized, the Tribal matrix and other background information will be used to identify all Tribes that match the study requirements. This list of potential sites will then be reviewed with the TOM and a 'priority' list of 15 sites will be identified for further investigation. The project team will then prepare a packet of information that will be sent to the Tribal President/Chairman of each potential site. The packet will include a description of the project, a letter explaining that their Tribe is being considered for participation in the study, what participation in the study involves, and a 'checklist' of information that is required to further explore the Tribe's qualifications for participation in the study. Within a few days after the packet has been sent, one of the Co-Principal Investigators will contact the Tribal President/Chairman to discuss their interest in participation and to obtain additional information about their organizations, programs, and capabilities. This information will be summarized and added to the data on each of the 15 Tribes that are on the 'short list.'

Full information and interest in participation will be summarized for each Tribe and discussed with the TOM, and with the TWG at the second meeting, after which a final list of six 'priority' sites and an alternate for each site will be developed. Each 'priority' site will then be contacted, told that they have been selected for the study, and asked to provide a letter of commitment to participate in the study. If, for any reason, a 'priority' site declines to participate at that point, then the process will be re-initiated with the alternate site chosen.

It is sometimes difficult to reach the Tribal Chairman/President and, even after reaching him/her, it may also be difficult to obtain a commitment to participate in a federal study. We have found, on previous studies, that a personal contact from someone that the Tribal leader trusts and is familiar with can facilitate this process. Thus, we will draw on our TWG members, IHS staff, and our project consultants--Frank Ryan and Pam Iron-- to assist with this task, if necessary. In addition, Jo Ann Kauffman has many years of experience working with a number of Tribal leaders and members and will be a valuable resource for making contact and persuading individual Tribes to respond to our inquiries and commit to participation in the study.

The Small Group Discussions will bring together experienced managers and experts in self-governance program management to further discuss specific technical and management issues that are relevant to the Tribal Self-Governance Demonstration and Evaluation.

Each Discussion Group will include people who are financial managers/MIS directors, legal/regulatory experts, and program administrators. The anticipated size of each group is 10-12 participants, with no more than three to four from each area of expertise. (Tribal leaders also will be extended an open invitation to participate in the Discussion Groups.) This mix will provide broad and integrated discussion of the challenges and successful approaches to developing, implementing, and successfully managing Tribally-operated programs.

Each Discussion Group will consider and discuss, from individual participants' perspectives, the following set of key topic areas:

· For Tribes that are embarking on Self-Governance programs, what are the key issues that need to be addressed to ensure smooth transition and management?

- Health programs;

- Other HHS programs.

· What are the pitfalls? What experiences have participants had that illustrate potential problems that should or could be addressed in planning for a new program?

· What are the 'keys for success' in transition and management of new programs?

Prior to the first set of Discussion Groups, the project team will prepare a Discussion Guide that includes these topic areas and also prompts the participants on a number of management and operational issues that are expected to be relevant for the discussion.

We anticipate working with the National Council of American Indians (NCAI) to obtain their agreement for the project to advertise and conduct the first three discussion groups at the NCAI's January meeting in Washington D.C. Similarly, our current plan is to contact and work with the IHS to conduct the second round of three discussion groups at the Self-Governance conference that will be held in April 2003. These conferences and meetings bring together large numbers of Tribal leaders, Tribal health directors, and other Tribal program managers who can be recruited to participate in the small group discussions. Once we have obtained agreement from the organization that is sponsoring the conference/meeting, we will begin the recruitment process to ensure that we have sufficient numbers and the appropriate mix of participants for each of the Discussion Groups. We will request that the conference sponsor include announcements about the purpose and timing of the Discussion Groups and information for interested people to contact us and sign up to participate. In addition, we will send arrange for announcements of the Discussion Groups to be posted on conference website and also on websites of other organizations that represent or are used by financial managers, legal/regulatory staff, and program managers. Since a $50 honorarium will be offered to participants, this information will also be publicized. We will accept applications to participate from up to four people per category (e.g., financial, MIS, program managers) for each session in order to ensure an appropriate mix of participants.
 

3.3 Expert Consultations

Consultations with federal and State officials and with representatives of national AI/AN organizations will be conducted to obtain additional information on a range of issues relevant to the feasibility of conducting a demonstration/evaluation of Tribal Self-Governance. The issues discussed may include topics such as:

· Internal and external barriers to Self-Governance;

· Impact of expanded Self-Governance programs on States and on State-Tribal government-to-government relationships;

· Technical assistance and management support necessary to transition to Self-Governance;

· Strategies for development of management experience and systems needed for successful Self-Governance programs;

· Examples of successes in Self-Governance and the factors that contribute to success;

· Examples of problems that have arisen with Self-Governance and factors that have contributed to these problems;

· Additional published and unpublished studies and data compilations that might be useful for assessing feasibility;

· Recommendations for data systems and data strategies for ensuring good information capabilities for Self-Governance.

The selection of State and federal officials to be interviewed for this task will be a joint decision of the project team and OASPE, with input from the TWG. While the specific individuals to be interviewed will be determined through this joint process, we anticipate that it is likely that categories of federal and State officials to be interviewed would include representatives from:

· Indian Health Service, in Rockville and at IHS Area Offices;

· Administration for Children and Families;

· Administration for Native Americans;

· SAMHSA;

· Bureau of Indian Affairs;

· Centers for Medicare & Medicaid Services, in Baltimore and Native American Contacts in Regional Offices;

· State Departments of Health, Social Services, Human Services, and Tribal Relations.

In addition to these government interviews, we will also interview representatives from national AI/AN organizations such as the National Indian Health Board, the National Congress of American Indians, and leaders of appropriate sub-groups within these organizations. Selected interviews will also be conducted with knowledgeable individuals who have had 'hands on' responsibilities for implementing and managing both health services and other social programs under contracts/compacts or grants.

Informal interview guides for the expert consultations will be developed and reviewed with the TOM, prior to beginning the interviews.

3.4 Feasibility Study Topics

Developing the feasibility study topics for this project requires, first, developing the specific objectives and research questions, including outcomes and measures of effectiveness, which would be addressed in an evaluation. A preliminary set of objectives of conducting an evaluation of processes, effectiveness, and impacts of Tribal contracting and compacting for management of health services or other non-IHS programs include:

· To determine the effectiveness of Tribal management of health services and other programs;

· To identify factors and processes which are associated with successful management of programs and services by Tribes;

· To determine what support and assistance to Tribes is important to increase success in Self-Governance of programs;

· To identify differences among Tribes which are associated with greater or lesser success in Tribal Self-Governance;

· To identify differences among Tribes which are associated with interest/willingness in Self-Governance.

Outcomes and measures of effectiveness that might be investigated in an evaluation include:

· Quantitative estimates of the extent to which Self-Governance leads to outcomes relative to outcomes of IHS direct-managed health services or other federal/state provision of services. These outcomes include:

· Efficient financial management, including maintaining or improving services provided per capita, provider-population ratios, obtaining increased revenues from non-IHS sources (e.g., Medicare, Medicaid, private insurance, grants for special programs), bringing 'contract services' in-house or negotiating better financial arrangements with contract providers;

· Access to and use of health services, including improved timeliness of access to health services, management of health care for people with chronic conditions, outreach and education programs;

· Quality of health care system, including maintenance of JCAHO-accreditation and meeting requirements for other certification bodies, board-certification of system physicians, stability of physician and other provider employees;

· Health outcomes, including morbidity and age-adjusted mortality rates, management of progression of disease in people with chronic conditions (e.g., diabetes), childhood immunization rates, reduction in health disparities relative to U.S. all races rates;

· Qualitative and quantitative analyses to determine the quantifiable factors that contribute to effective Tribal Self-Governance of programs (e.g., financial resources, geography, education, number of years experience in operating Tribal health systems and other programs);

· Qualitative analyses to assess the management structure, management processes, and other factors that differentiate successful from less successful Tribally-managed programs;

· Quantitative and qualitative analyses to identify the factors that influence some Tribal governments to take over management of programs and other Tribal governments to reject Self-Governance.

The feasibility of conducting an evaluation of the processes, effectiveness, and impacts of Tribal contracting and compacting to manage Tribal health systems and other non-IHS programs would be dependent on:

· Cooperation of the Tribes;

· Cooperation of the Indian Health Service and other relevant federal agencies;

· Availability, comparability, and completeness of data for measuring financial performance, accessibility of services, use of services, and health outcomes;

· Availability of data to categorize Tribally-managed and non-Tribally managed health systems and other programs to establish valid comparisons, controlling for differences in socio-economic, educational, government-to-government relationships, and geography.

The feasibility study will, therefore, focus on:

· Discussions with Tribal leaders to gain 'buy-in' and agreements to participate in the study;

· Discussions with the Indian Health Service and with other federal and state agencies to obtain agreement to provide information and data, and to designate a 'coordination' liaison with authority to facilitate data provision and other assistance to the evaluation;

· Comprehensive review of availability, comparability, and completeness of data collected and maintained by IHS, contracting, and compacting Tribes (e.g., administrative data, financial data, and patient data). (Note: The IHS Resource and Patient Management System (RPMS) would provide much of the patient-level data, but not all Tribes that manage health systems submit data to the RPMS). It will also be necessary to review and assess data for other federal/state programs and Tribal data on these programs to determine whether they are sufficient to permit their use in an evaluation.

4.5 Data Requirements Identification

For the site visit component of the project, under this subtask, we will develop a detailed site visit protocol to collect information and data that are critical to assessing the feasibility of conducting a Tribal Self-Governance Evaluation. This protocol will include:

· Specification of the data-dependent feasibility study issues and subtopics for examination during site visits.

· Identification of key individuals and operational departments that will be interviewed and reviewed during the site visits;

· A matrix of interviewees/operational departments to be reviewed, by the feasibility study topics that will be examined with each;

· Detailed Interview and Department Review Guides that specify the questions that will be asked and the operational reviews that will be conducted.

The project team has prepared a detailed list of research questions and associated data requirements to address each of these questions (see Table 1). The evaluation would assess performance of Tribally-managed health systems (and possibly other programs) relative to the performance of IHS direct service facilities. It will be necessary, as a first step, to work with the Indian Health Service to determine the availability of data within IHS - by Service Unit - to address each of the research questions in Table 1. Once we determine the specific data elements, at the specific unit of analysis, that can be obtained from IHS, we then will develop a detailed Data Requirements and MIS Review Protocol that will be used by the site visit team visiting each of the selected sites.

Table 1

AVAILABILITY OF SERVICES/ACCESS TO CARE



Key Questions


Data Requirements
   
What services are available 'in house'?
 

Have the quantity and type of 'in-house' services increased/decreased over the past three years?

 

What is the ratio of primary care physician-to patient users? Dentist-to-patient users?

At the Service Unit level, most recent year and previous two years:

§ number of FTE physicians, by primary care and type of specialty

§ number of FTE primary care dentists and specialist dentists

§ number of FTE NP, RN, and PA staff

§ number of FTE dental hygienists

§ number other FTE clinical staff, by type

§ availability of full pharmacy services

§ number of patients provided services in SU, by age and gender

What services are referred out to Contract Health Services?
 

Have the quantity and type of Contact Health Services used changed over the past three years?

 

What criteria are used to determine whether a patient is referred for Contract Health Services paid by the Service Unit?

 

Is there 'rationing' of Contract Health Services? All year? At some point in the fiscal year?


 
§ number and type of Contract Health Services provided and paid, by quarter of the fiscal year

§ number and type of Contract Health Services denied for payment, by patient insurance coverage and by quarter of the fiscal year

§ Contract Health Services policies and procedures

What is the waiting time for a routine appointment? With a Service Unit primary care physician? With a Service Unit Dentist? § Percent of patients who are 'walk in'

§ Days between making and having appointment with PCP

§ Days between making and having appointment with dentist




 

Table 1 continued

QUALITY OF CARE: PROCESS



Key Questions


Data Requirements
   


What proportion of Service Units are JCAHO-accredited or have other accreditation?
 

What proportion of physicians are board-eligible or board-certified?




 

What proportion of nursing and ancillary personnel are licensed and meet federal/state continuing education requirements?

All Service Units, separately by direct service, contracted, compacted:

§ Percent JCAHO-accredited or other accreditation (specified)

 

§ Percent primary care physicians board-eligible/certified

§ Percent specialist physicians board-eligible/certified

§ Percent specialist physicians board-eligible/certified

 

§ Percent nursing personnel licensed and meeting CE requirements

§ Percent ancillary personnel licensed/certified

What is the annual 'turnover rate' for physicians, dentists, nurses, and ancillary personnel? § Percent of physicians, dentists, nurses, and ancillary personnel leaving employment at the SU each year


Does the Service Unit have a Quality Assurance/Review Committee? What are its functions/ How often does it meet?
For each Service unit:

§ QA/QR Committee policies and procedures

§ QA/QR Committee Meeting Minutes



What proportion of patients receive routine preventive services? Has the proportion increased/decreased over the past 3 years?
For each Service Unit, past year and preceding 2 years

§ Percent children under age 5 immunized

§ percent aged 50+ receiving influenza immunizations

§ Percent of women over 18 with annual Pap smears

§ Percent pregnant women obtaining prenatal care in first trimester

§ Percent of adults screened for diabetes

What proportion of people with diabetes receive screening for diabetic complications? Has the proportion increased/decreased over three years? For each Service Unit, for all patients with diabetes, three years:

§ Percent seeing physician at least once in 3 months

§ Percent receiving HbA1c testing once in 3 months

§ Percent receiving dilated eye exam annually

§ Percent receiving annual dental examinations




 

Table 1 continued

QUALITY OF CARE: HEALTH OUTCOMES



Key Questions


Data Requirements
   


What is the breast cancer 5-year survival rate?
 

What is the cervical cancer 5-year survival rate?

 

What percent of births are low-weight or premature?

 

What percent of births are high-weight?

For each Service Unit:

§ Percent diagnosed with breast cancer surviving 5 years

 

§ Percent diagnosed with cervical cancer surviving 5 years

 

§ Percent of births that are low-weight or premature

 

§ Percent of births that are high-weight

What is the proportion of deaths attributable to diabetes  

What proportion of people with diabetes are diagnosed with diabetic retinopathy?

 

What is the proportion of people with diabetes who have extremities amputated?

§ Percent of deaths attributable to diabetes
 

§ Percent of people with diabetes who have diabetic retinopathy




 

§ Percent of people with diabetes who have had amputation




 

Table 1 continued

QUALITY OF CARE: PATIENT SATISFACTION



Key Questions


Data Requirements
   
What proportion of the population eligible for services uses the SU annually? § Number of eligible people within each SU market area

§ Number of eligible people with at least two visits to a PCP

Does the Service Unit or Tribal Health Department conduct periodic surveys of patients' experiences and satisfaction? § 'Yes' or 'No' by individual SU
How do SU users rate access to care, their providers, Contract Health Services, and other dimensions of care?
 

What proportion of the eligible population goes outside for services?

 

What are the reasons for using non-HIS or non-Tribal health providers?

 

How do patients who obtain care outside rate their care?

Remaining questions would require a survey of users/non-users




 

Table 1 continued

FINANCIAL PERFORMANCE



Key Questions


Data Requirements
   
What proportion of users has public or private insurance? At the Service Unit level, last year and two preceding years:

§ Percent with Medicare

§ Percent with Medicaid

§ Percent with SCHIP

§ Percent with Private Health Insurance

How many total units of service are provided, by type of service? § Number of hospital admissions

§ Number of hospital days

§ Number of primary care visits

§ Number of specialist physician visits

§ Number of dental visits

§ Number of prescriptions filled

§ Number of Contract Health services, by type of service

What proportion of potential third-party revenues is billed and collected? § Number of patients with third-party insurance, by type

§ Total billing, by type of insurance

§ Total receipts, by type of insurance

Is the Service Unit operating at 'break even' or with a 'surplus' § Total revenues from HIS, by category (services, facilities, diabetes, administrative, other (?))

§ Total third-party revenues, separately for Medicare, Medicaid, SCHIP/Private insurance

§ Total revenues from other sources (e.g., grants)

What is average coast per unit of service? Average cost per capita? § Total expenses (labor, rent, operating expenses, supplies, depreciation, etc), by department (outpatient, inpatient, dental, nutrition, etc.)

§ Total Contract Health expenses, by provider type

§ Balance Sheet/Statement of Financial Position (assets, by category; liabilities, by category)

§ Fee schedule/charges, by type of services

What are average out-of-pocket costs for patients? § Total charges to patients for in-house services

§ Total patient liability of Contract Health Services not paid by health facility

A similar process will be used to develop the evaluation research topics that are not dependent on existing data - that is, the research questions will be specified and the data requirements will be discussed. These data requirements will, for the most part, be qualitative in nature (e.g., key informant interviews) or will require primary data collection. These specifications will then provide the foundation for identifying key informants to be interviewed during the site visits and for development of the Site Visit Interview Guide.

A preliminary list of categories of individuals and operational departments that will be visited at each site includes:

· Tribal leaders;

· Tribal health directors;

· Health facility Service Unit Directors;

· Non-IHS program managers;

· Information Systems/Data Reporting Department staff;

· Medical Directors/QA program staff;

· Caseworkers and other staff of non-IHS programs;

· Financial/accounting Department managers and staff;

· IHS Area Office staff;

· State program staff (for some non-IHS program sites).

Depending on the specific non-IHS programs that are Tribally-operated, other individuals may also be interviewed (e.g., county caseworkers that may coordinate with caseworkers from Tribally-managed TANF programs).

Task 5. Second Meeting of the Technical Work Group

The second meeting of the TWG will be held around Week 20 of the project, to obtain input from the TWG on selecting the specific sites that will be studied and to provide input on the plan for small group discussions and expert consultations. A packet of information on each of these issues will be sent to the TWG members 10 days prior to the scheduled meeting. This packet will include:

· Information and data on all Tribes that have been identified as meeting the requirements for participation in the feasibility study, including results of initial contacts with key personnel at each Tribe and an indication of their potential interest in participation;

· The Draft Site Visit Protocol, Interview Guides, and Site Visit Plan;

· Draft Small Group Discussion Plan, including identified locations for conducting small group discussions, and topics to be explored through the discussions;

· Draft list of individuals with whom expert consultations will be conducted and the Draft Interview Guide for these consultations.

The Second Meeting of the TWG will be conducted through a telephone conference call, for budgetary and travel burden reasons. We anticipate that it will be scheduled for approximately four hours, with a 20 minute break mid-meeting. A detailed summary of the Second TWG Meeting will be prepared and submitted to the TOM for review and approval. It will then be disseminated to the TWG members and other attendees.

Task 6. Arrange and Conduct Site Visits, Small Group Sessions, and Expert Consultations

After the Second Meeting of the TWG, revisions will be made to the work plans for the site visits, small group discussions, and expert consultations. Once these revisions have been approved by the TOM, we will initiate these activities.

6.1 Selection of Sites

Based on input from the TOM and the TWG, additional discussions will be held with key individuals at each of the 'priority' sites that have been identified to obtain additional information on their suitability for inclusion in the study. Results of these discussions will be summarized in a written memorandum to the TOM that will include an assessment of the positive and problematic issues that may be associated with each Tribes' selection as a study site. The TOM will then make the final decision on the six specific sites that will be included in the feasibility study.

6.2 Negotiate Study Procedures with Study Sites

Once the study sites are selected, we will provide each Tribe with the specific details of the site visit protocol and discuss with each the approach that will be most effective and ensure that each of the study topics will be appropriately addressed during the site visit. We will also request that each study site identify an individual who will act as liaison for the site visit team to facilitate information gathering and access to key individuals and to operational department managers and staff.

6.3 Conduct Site Visits and Small Group Discussions

By Week 24 of the project, a schedule for the six site visits will be developed and the site visits will be initiated. Each site visit will be carefully structured to address all of the issues identified in the Site Visit Protocol and to collect information from all of the categories of individuals and operational departments that are essential to develop a complete profile of the Tribe's operations, capabilities, and resources to participate in a Self-Governance Evaluation. Each site visit will be conducted for three days, with a team of two project staff participating.

After the site visit is completed, it is very likely that some follow-up telephone interviews and data requests will also be necessary. These will be completed, to the extent possible, within two weeks of the site visit. Once all of the site visit findings and follow-up information is obtained, site visit staff will prepare summaries (with relevant attachments of materials) of each interview conducted. These detailed summaries will then be used to prepare a Case Study Report on each site that addresses each feasibility study topic and highlights the relevance of the findings for the feasibility of including that site in the Self-Governance Evaluation. The Draft Case Study Report will be provided to the Tribe for review prior to it being submitted to the TOM, if this is the preferred process selected by the TOM and the Tribes.

Assuming that it is determined that a Tribe is a feasible candidate for inclusion in the Self-Governance Evaluation, and with TOM approval, the site visit team will then conduct follow-up activities with Tribal leaders and Tribal program directors to obtain letters of agreement to participate in the Self-Governance Evaluation. To the extent possible, letters of support and agreement to participate will also be sought from IHS Area Offices, relevant State and local governments, and other organizations whose cooperation and assistance will be important to the success of the Tribal Self-Governance Evaluation.

6.4 Conduct Expert Consultations

In-person and/or telephone discussions with each of the individuals identified to be interviewed for this task will be scheduled during Weeks 20-26 of the project. A one-page summary of key points from each of these interviews will be prepared and submitted to the TOM, one week after each interview is completed.

Task 7. Conduct Analyses and Prepare Draft Reports

Once the site visits, small group discussions, and expert consultations are completed, the information and documentation collected will be analyzed and reports will be prepared on the findings.

7.1 Assess Tribal Data Availability, Completeness, and Comparability

A cross-cutting report on data issues for the Tribal Self-Governance Evaluation will be prepared, based on findings from the activities conducted and review of data collected and available from relevant federal and state agencies. Data availability, completeness, and comparability will be examined for both IHS and non-IHS programs that may be included in the Self-Governance Evaluation. The report on data issues will present findings on:

· Availability and completeness of Tribal data for each program area;

· Comparability of Tribal data with data available from IHS and non-IHS program offices;

· Potential problem areas for design and conduct of the evaluation;

· Suggested strategies that could be used to overcome problems and to permit a rigorous and quantitative evaluation.

This report will be prepared within four weeks of the completion of all site visits, small group discussions, and expert consultations.

7.2 Draft Feasibility Report

The Draft Feasibility Study will provide a synthesis and assessment of the feasibility of a rigorous quantitative and qualitative evaluation of Tribal Self-Governance, based on the findings of the site visits, small group discussions, expert consultations, and other activities of this project. There will be three major components of this report:

· The feasibility of conducting an evaluation of Tribal Self-Governance will be described, with appropriate documentation of the information obtained that supports/refutes feasibility;

· The extent to which there would be limitations to the evaluation, given the findings of the feasibility study, and potential strategies that might be used to address these limitations;

· Recommendations for pre-evaluation study steps that should be undertaken to ensure that the Self-Governance Evaluation can be conducted and will produce rigorous and defensible analytic results.

The Draft Feasibility Study will be prepared within four weeks of the completion of all site visits, small group discussions, and expert consultations. It will be sent to the TOM and concurrently to members of the TWG.

Task 8. Third Meeting of the Technical Work Group

The third and final meeting of the Technical Work Group will be held once the Data Assessment Report and the Draft Feasibility Report are completed. The procedures for arranging and conducting the meeting will be consistent with the approach described in Task 3. At least 10 days prior to the meeting, the Draft Data Assessment Report and the Draft Feasibility Report will be sent to each TWG member, along with the meeting agenda. Given the large amount of detailed information that will be reviewed in this TWG meeting, we have assumed that it will be a two-day meeting and that it will be held in the Washington, DC area to permit attendance of interested OASPE and other federal staff.

After the meeting, a summary of the Third TWG Meeting will be prepared and sent to the TOM for review and approval. It will then be sent to all TWG members and to other attendees.

Task 9. Complete Final Reports

9.1 Final Report and Briefing on Study Findings

The Final Report on the Feasibility Study will be prepared, after the Third TWG and additional discussions and consultations with the TOM. A preliminary outline of the Final Report includes:

· Overview and Objectives of the Feasibility Study;

· Description of IHS and Non-IHS Programs of Interest;

· Evaluation Objectives, Research Questions, and Outcome Measures;

· Feasibility Study Issues and Methodologies;

· Findings: Site Visits;

· Findings: Small Group Discussions;

· Findings: Expert Consultations;

· Feasibility of Self-Governance Evaluation of IHS Programs;

· Feasibility of Self-Governance Evaluation of Non-IHS Programs;

· Potential Limitations of the Evaluation;

· Recommendations for Strategies to Address Limitations in Designing and Conducting the Evaluation ;

· Potential Usefulness of Evaluation Findings for Expansion of Tribal Self-Governance.

A Draft Outline of the Final Report will be submitted to the TOM in Week 36 of the project, for review and approval. The Draft Final Report will be completed and submitted to the TOM, for review and comments and for dissemination to selected audiences, in Week 42 of the project. After comments are received from the TOM, the Final Report will be prepared, incorporating requested revisions, and submitted to the TOM in Week 52.

A formal briefing on the design, conduct, and findings of the Feasibility Study will be conducted by the project Co-Principal Investigators during the final month of the project, as requested and arranged by the TOM. Briefing materials and the briefing presentation will be prepared and submitted to the TOM, for review and comment, one week prior to the scheduled briefing. A briefing for the Technical Work Group and other audiences may also be conducted, if requested by the TOM, either in Washington, DC or by telephone or videoconference.

Task 10. Monthly Progress Reports and Reports on Topics of Special Interest

10.1 Monthly Progress Report

Each month of the project, Westat will prepare and send to the TOM a progress report, detailing accomplishments of the preceding month, planned activities for the following month, problems encountered and resolutions, and ongoing consultations and communications activities. This report will also include a monthly project financial analysis.

In addition to the Monthly Progress Reports, there be monthly scheduled teleconference calls involving the project team and the TOM to discuss and address issues that arise, scheduling of activities, and other project matters. A brief summary of each of these teleconference calls and decisions made will be prepared and sent to the TOM and all project team members. We also anticipate that there will be frequent informal telephone and email contact between the Co-Principal Investigators and the TOM on a range of issues that arise throughout the project.

10.2 Final Progress Report

In the last week of the project, a Final Summary Progress Report will be prepared and submitted to the TOM. This Final Summary Progress Report will succinctly review all activities conducted during the project, problems encountered and resolutions, schedule changes, products delivered, and briefly summarize the key findings from the study.

10.3 Reports on Topics of Special Interest

During the course of the project, issues may arise that were not anticipated at the initiation of this study and that are identified as important additional topics for review and examination. Up to two special technical or topic reports may be requested by the TOM. These special reports will be on limited issues and are expected to be completed and submitted in draft form to the TOM within 6 weeks of initiation.

III. Revised Project Schedule

The project schedule in the original Scope of Work for the project has been revised, based on discussion and clarifications during the initial project meeting. The revised project schedule is shown below.

Changes in the original schedule are indicated in italics. Reasons for these changes include:

· The List of Potential TWG Members originally was scheduled to be submitted in Week 4 of the project. It will be submitted the week of November 11, 2002 to permit the project team to obtain input on candidates during the November 8th meeting in San Diego;

· The Draft Agenda for the first TWG meeting (originally scheduled for Week 8) was discussed and revised to be included in the project Work Plan, submitted the week of October 27th;

· The First TWG Meeting (Task 3) was originally scheduled in Week 12 - one week before Christmas. To avoid holiday conflicts, it was decided at the initial project meeting that it would be held the week of December 2nd. The associated Meeting Summary will then be submitted three weeks following the meeting;

· The report on Characteristics of Small Groups (Task 4), scheduled in Week 15, was accelerated and included in the Work Plan submitted the week of October 27th because of the need to begin working with NCAI to arrange to hold these Discussion Groups at the January conference;

· The Data Requirements Identification and the Feasibility Study Topics (Task 4), scheduled in Weeks 18 and 16, were accelerated and will be delivered during the week of November 25th. This timing will permit these documents to be made available for discussion during the First TWG Meeting.

Other deliverables are scheduled to be completed in accordance with the original schedule in the project contract.

Revised Project Schedule

Task 1: Initial Project Meeting… ………………..Held September 30, 2002

Summary of Initial Project Meeting Submitted October 6, 2002

List of Potential TWG Members Week of November 11, 2002

Draft Communications Strategy Week of October 28, 2002

Task 2: Work Plan Week of October 28, 2002

Report on Legislative History……………. Week of October 28, 2002 (2)

Report on Literature Review Week of November 11, 2002

Tribal Matrix Week of November 11, 2002

Task 3: Draft Agenda for First TWG Week of October 28, 2002

First TWG Meeting Week of December 2, 2002

First TWG Meeting Summary Week of December 23, 2002

Task 4: Report on AI/AN Data Week of December 23, 2002

Site Selection Criteria Week of December 30, 2002

Characteristics of Small Groups Submitted Week of Oct. 27,2002

Expert Consultation Plan Week of December 30, 2002

Data Requirements Identification Week of November 25, 2002

Feasibility Study Topics Week of November 25, 2002

Preliminary Site Selection Week of January 20, 2003

Task 5: Agenda for Second TWG Week of January 20, 2003

Second TWG Meeting Week of February 3, 2003

Summary of Second TWG Meeting Week of February 24, 2003

Task 6: Final Site Selection Recommendation Week of February 10, 2003

Conduct Small Group Discussions January-April, 2003

Conduct Site Visits March-April, 2003

Conduct Expert Consultation Interviews February-March, 2003

Task 7: Report on Tribal Data Review May 2003

Draft Feasibility Report May 2003

Task 8: Agenda for Third TWG Meeting Week of April 21, 2003

Third TWG Meeting Week of May 12, 2003

Summary of Third TWG Meeting Week of June 2, 2003

Task 9: Draft Final Report Week of July 7, 2003

Final Report Week of September 8, 2003

Reports on Special Topics To Be Determined

Task 10:Monthly Progress Reports Monthly

Final Progress Report Week of September 8, 2003

Appendix A

Initial Teleconference Meeting

Monday, September 30, 2002, 1:00 p.m. ET

Agenda

Introductions

Overview of Project Background/Objectives - Andy Rock, ASPE Project Officer

Review of Project Schedule

Criteria for Choosing 10 Technical Working Group Members

Agenda for First TWG Meeting

Contacts within DHHS for Collecting Data to Develop the Tribal Matrix

Priority Topics for 6 Discussion Groups

Potential Conferences for Convening Discussion Groups

Communications Strategy

Other Issues

Participants:

HHS: Andy Rock, Tom Hertz, Peggy Halpern, Hunter McKay, Eric Broderick

IHS.: Sharon Hoppman

Project HOPE/South Dakota: Kathy Langwell, Valerie Meiners, Tom Dunn

Project HOPE/Maryland: Janet Sutton, Jeff Stensland

Iron & Associates: Pam Iron

IMT Inc.: Frank Ryan

Westat: Sherm Edwards, Cindy Helba, Brian Colhoff
 

Overview:

This teleconference was scheduled as the initial meeting of the Tribal Self-Governance Evaluation Feasibility Study group. Issues to be discussed at the meeting included review of the project schedule, criteria for selecting the Technical Working Group members and agenda for the first TWG meeting, DHHS contacts for obtaining data for development of the Tribal Matrix; topics for the Small Group Discussions, and the Communication Strategy for the project.

Participants on the conference call each introduced themselves. Andy Rock, the ASPE Project Officer, then gave a brief summary of the background and objectives of the project.
 

Project Schedule:

Two project schedule issues were raised and discussed:

1. The time frame between selection of Tribes to receive site visits and completion of the site visits is only eight weeks. This is likely to be an underestimate of the time required to negotiate agreements to participate, arrange the agenda for each site visit, and conduct the site visits to six Tribes. If possible, selection of Tribes to receive site visits should be resolved by Week 18 which give the project team an additional month for gaining agreements to participate, organizing, and conducting the visits. The Project Officers agreed that it was a tight schedule and that an earlier decision would be made, if possible.

2. The First Meeting of the Technical Working Group is scheduled for Week 12 of the project, which is the week before Christmas. After discussion, a decision was made to move this TWG Meeting to the week of December 2, 2002.

Criteria for Selection of Technical Working Group Members:

The group discussed what criteria would be used to choose the 10 technical Working Group members. After much discussion, it was decided that the group would consist of:

· 4-5 Tribal leaders;

· 4-5 Tribal program staff experts with hands-on experience including an emphasis on financial management personnel (e.g., CPA experience);

· 1 data expert;and

· 1 researcher.

It was also agreed that efforts will be made to choose TWG members who represent large tribes, small tribes, Tribal associations, and that the Tribal program staff selected should include those with experience with Head Start and TANF programs, as well as health programs. A process will be initiated to contact knowledgeable individuals from Tribal organizations and the federal government to solicit names of potential TWG candidates. Once these discussions are completed, a list of 10 candidates and 10 alternates will be prepared and submitted to the Government Task Order Managers for discussion and final selections.

Draft Agenda for the First TWG Meeting:

A Draft Agenda for the First TWG Meeting was distributed for review prior to the conference call. Discussion of the draft agenda produced agreement on three changes.

1. During the initial 'Introductions/Welcome' session, ground rules for participation of non-TWG members in the discussion would be established.

2. At the close of the 'Project Overview' session, each TWG member would be asked to provide their individual definitions of 'Self-Governance' and to identify key issues for Self-Governance that they think are most important.

3. A "brainstorming" session would be held at the end of the first day to identify priority topics for the breakout groups on the second day.
 

Contacts within DHHS for Collecting Data to Develop Tribal Matrix:

The project team will develop a Tribal Matrix, by Week 8, that presents for each Tribe the programs (e.g., health, TANF, Head Start) that they are currently managing under contracts or compacts. Data for this Matrix will necessarily be obtained through DHHS offices responsible for these programs. The Government Project Officers indicated that they would follow-up and identify the appropriate government contacts that can provide this information. One possibility raised was the Technical Assistance providers for these programs. There are currently 34 Tribal TANF programs and over 100 Tribally managed Head Start programs.

Priority Topics for 6 Small Group Discussions and Potential Sites:

It was decided during project negotiations that six Small Group Discussions would be held at two major conferences held by national AI/AN organizations or at federal workshops or meetings that bring together Tribal members. Some possibilities include the National Conference of American Indians conferences in either January or June 2003 or the Budget Consultation meetings in May 2003. Another possibility is a regional meeting or conference that would draw large numbers of Tribal members and program staff.

Discussion of specific priority topics for the Small Group Discussions was postponed until the next conference call on October 7 at 1 p.m. ET. Prior to that meeting, a list of possible topics will be circulated for review.
 

Communication Strategy:

The discussion of the project communications strategy included a suggestion that the DHHS website established for the project continue to broadcast what is happening with the project. It was also suggested that a link be established from the IHS. website to the project website. The main website might be interactive with the audience so that people could provide comments or post questions. The project team and government staff on this initial conference call agreed to have a monthly conference call and minutes will be distributed to participants and posted on the website. Communications with Tribal leaders about the project will begin with dissemination of a one-page project description and a letter inviting comments and questions, with a contact list and the DHHS website address. A complete Communications Strategy Report will be prepared and submitted to the TOM by Week 6 of the project.

Report on Legislative History and Self-Governance Experience:

Frank Ryan is preparing the 'Report on Legislative History of Tribal Self-Governance', for submission to the TOM in Week 6. Frank pointed out the multi-faceted nature of Self-Governance and the fact that the history of Self-Governance went as far back as 1938. He asked how far back the group felt he should go with the history. Andy suggested that the history be inclusive enough to be interesting to readers with little background in this area, but brief. Frank briefly explained the many different levels of Tribal Self-Governance and how those levels have developed and evolved over time.
 

Next Steps:

· The Government TOM will identify appropriate contacts within DHHS from whom data from the Tribal Matrix may be obtained;

· Kathy will prepare a draft "Dear Tribal Leader" letter and a one-page project description and forward it to the TOM for review;

· Jo Ann and Kathy will develop a list of possible topics for Small Group Discussions and forward it to project participants for discussion at the next conference call, scheduled for Monday, October 7th, at 1 p.m. ET;

· The project team will begin the process of identifying potential candidates for the TWG.

Appendix B

Preliminary Agenda for First Technical Working Group Meeting

For Discussion

The initial TWG meeting will be held for 1 full day and 1 half day sessions, with the second half day sessions focusing on key topic areas for the feasibility study. A Preliminary Agenda is:

Day One

9:00 a.m.- 4:30 p.m.

Introductions, Project Objectives, and 'Groundrules' (TOM);

Overview of Project and Role of the TWG ;

Discussion: What is 'Self-Governance?' What are important issues to consider for 'Self-Governance?'

Outline of the Report on Legislative and Programmatic History;

- Discussion/Input from TWG;

Outline of Literature Review/Synthesis on Self-Governance;

- Discussion/Input from TWG;

Feasibility Issues for Study: Overview and Discussion;

- Transition/Management Issues;

- Data Requirements/Information Systems Capabilities;

- Financing Issues;

- Measures of Performance/Effectiveness;

Site Selection: Overview and Discussion;

Small Group Discussions: Overview, Topic Areas, and Discussion;

Ongoing Communications;

Discussion: What are the most important issues for consideration and in-depth discussion in Break Out Sessions?
 

Day Two

9:00 a.m. - 12Noon

Breakout Groups (Members of the TWG will be able to choose two Breakout Groups to attend)

- Transition/Management Issues;

- Data Requirements/Information Systems Capabilities;

- Financing Issues;

- Measures of Performance/Effectiveness.

Appendix C

Sponsor: DHHS Project Officers:

OASPE/DHHS Andrew Rock

(address) 202-260-0398

Tom Hertz

202-690-7779

Start Date: September 2002 End Date: September 2003

Project Director: Co-Principal Investigators:

W. Sherman Edwards Kathryn Langwell

Westat Project HOPE Center for Health Affairs

1650 Research Boulevard Telephone: 605-584-2414

Rockville, MD 20850 Email: klangwell@projecthope.org

Telephone: 301-294-3993

Email: EDWARDS1@Westat.com Jo Ann Kauffman

Project Consultants: Kauffman and Associates, Inc.

Pamela Iron Telephone: 509-747-4994

Frank Ryan Email: joann@kauffmaninc.com

The Office of the Assistant Secretary for Planning and Evaluation, DHHS, has funded this one-year project to assemble background information and to assess the availability of data and the feasibility of conducting a rigorous and defensible evaluation of the effectiveness and impacts of Tribal Self-Governance of health and other social service programs. The primary tasks that will be conducted by Westat and its subcontractors, Project HOPE and Kauffman and Associates, Inc., include:

· Compilation and synthesis of background information and existing research on the legislative history, experience, and effectiveness of Tribal Self-Governance, including identification of gaps in the research and limitations of previous studies;

· Identification of a set of Tribes that meet specific criteria, including experience with Tribal Self-Governance, management and data capabilities sufficient to permit evaluation of Tribally-managed programs, and interest in/willingness to participate in an evaluation.

· Assessment of data availability, completeness, and comparability for Tribally-managed programs, relative to data that are available from federal and State agencies that provide services to Tribes;

· Consultation and ongoing communication with Tribal leaders and Tribal organizations in designing, conducting, and reviewing findings of the feasibility study.

A Technical Working Group, consisting of Tribal leaders, directors of Tribally-managed programs, representatives of Tribal organizations, and knowledgeable researchers and data experts will advise the project on key issues and review interim and final project findings.
 

NOTE: THIS LETTER WOULD BE MOST EFFECTIVE IF IT WAS ON DHHS LETTERHEAD AND SIGNED BY AN HHS OFFICIAL, BUT IT COULD ALSO COME FROM WESTAT


 

Dear Tribal Leader:

The Office of the Assistant Secretary for Planning and Evaluation (OASPE), U.S. Department of Health and Human Services (DHHS), has been given responsibility for identifying and assessing the feasibility and effectiveness of Tribal Self-Governance of several DHHS health and social service programs and services that are currently directly provided to Tribes. As one component of that responsibility, OASPE has identified 10 DHHS programs, in addition to health services, that could be transferred to Tribes for management.

However, there is currently a lack of good information and research on the most effective processes for transferring management responsibility to Tribes and on the outcomes associated with Tribally-managed programs relative to direct service programs. Evaluation of these issues would provide information that could be used to develop systems that would assist Tribes to take over management of additional DHHS programs.

A one-year study to assess the feasibility of conducting an evaluation of Tribal Self-Governance processes and outcomes has been funded by OASPE that will lay the groundwork for designing the evaluation and identifying Tribes that may be interested in and have the data capabilities for participating in the evaluation. The project study team - Westat, Project HOPE, and Kauffman and Associates, Inc. and project consultants Pam Iron and Frank Ryan - will be conducting background data collection and site visits over the next 12 months for this study. A description of the project is attached to this letter.

Your advice and input to this project is encouraged. Telephone and email contact information for the OASPE Project Officers and the project team are included in the attachment, if you would like additional information or have suggestions or information you would like to provide. Results of the study will be sent to you next summer, with an overview of the next stages of this effort.

Sincerely,


 

Notes

1.This date is a change from the Statement of Work; it will allow the project team to obtain input on candidates during a November 8 meeting in San Diego.

2.This deliverable will be sent the week of 11/4/02.

Populations
American Indian & Alaska Native People (AI-AN)
Location- & Geography-Based Data
Tribal Communities