Transforming & Modernizing the American Indian & Alaska Native Healthcare System Nationally, State, and Locall

1. Transforming & Modernizing the American Indian & Alaska Native Healthcare System Nationally, State, and Locally 2008 Self-Governance Conference Sandra Haldane, BSN, RN, MS

2. Prevalence of Diagnosed Diabetes AI/ANs compared to U.S. population 1980- 2004 Source: IHS Program Statistics and National Diabetes Surveillance System. Age-adjusted to the 2000 US standard population with the exception of 1981–1993 data for AIAN, which was age-adjusted to the 1980 US standard population.

3. Age Adjusted Heart Disease Mortality Rates by Population, 1986-1997 Rate per 100,000 Division of Program Statistics, Indian Health Service Trends in Indian Health Series

4. EFFICIENCY International Comparison of Spending on Health, 1980–2004 Average spending on healthper capita ($US PPP) Data: OECD Health Data 2005 and 2006. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 58

5. EFFICIENCY International Comparison of Spending on Health, 1980–2004 Average spending on healthper capita ($US PPP) Data: OECD Health Data 2005 and 2006. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 58

6. Mortality Amenable to Health Care Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care Deaths per 100,000 population* International variation, 1998 * Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease. See Technical Appendix for list of conditions considered amenable to health care in the analysis. Data: International estimates—World Health Organization, WHO mortality database (Nolte and McKee 2003); State estimates—K. Hempstead, Rutgers University using Nolte and McKee methodology. Schoen C, Davis K, How SKH, Schoenbaum SC. US health system performance: A national scorecard. Health Aff. 2006;25(6):w457-w475.

7. Optimism Pockets of Excellence & Islands of Innovation “The Energy of Few” The Champions

8. Hope Reliably high quality care Every patient, every time, everywhere Leadership Ideas+ Improvement Tools “The Energy of Many”

9. Hope for a Healthcare System “The care I need and want, when I need and want it!”

10. IHS Diabetes Care & Outcomes Audit Mean A1C, 1996-2007 A1C, % year Source: IHS National Diabetes Program Statistics 1996-2007 *p<0.0001 comparing mean A1C levels in FY96 and FY07

11. Age-specific ESRD-DM incidence trends among Native Americans with diabetes 65+ 45-64 20-44

12. Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Productive Interactionsthrough effective asset based partnering over time Informed, Empowered Patient and Family PatientDriven Coordinated Prepared, Proactive Practice Team Timely and Efficient Evidence-based and Safe Improved achievement of patient and community goals

13. Innovating and Planning Care • Everybody who is part of the relationship with patients or process • Includes people who are not typical partners • Relationships within the Team are essential. • Care must be planned and patients should be prepared

14. Synergy“the phenomenon in which two or more discrete influences or agents acting together create an effect greater than that predicted by knowing only the separate effects of the individual agents” IHS Mission... to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. IHIStrategies Motivate: Build will and optimism for change Innovate: invent new solutions, create new healthcare models with far superior value CCI IPC/IHS Get Results: partnerships that can leverage results for thousands; learn from and assist leaders to get results. Raise Joy in Work Support community and individual wellness and strength

15. Chronic Care Collaborative-Innovations in Planned Care (CCI/IPC) Pilot Sites The eight federal pilot sites: • Wind River Service Unit • Sells Service Unit • Whiteriver Service Unit • Rapid City Service Unit • Gallup Indian Medical Center • Albuquerque Service Unit • Warm Springs Service Unit • Chinle Comprehensive Health Care Center The five Tribal sites: • Indian Health Council, Inc. • Cherokee Nation Health Services • The Choctaw Health Center • Eastern Aleutian Tribe  • Forest County Potawatomi Health & Wellness Center The Urban program: • The Gerald L. Ignace Indian Health Center 

16. “Some is not a number, and soon is not a time…” - Donald Berwick, IHI’s President and CEO

17. IPC Measures (Fall 2007)

18. Intake Screening Bundle

19. Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do

20. Colorectal Cancer Screening

21. Tobacco Assessment

22. Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that A P will result in improvement? S D D S P Act Plan A A Study Do P S D A P S D Testing Changes Changes That Result in Improvement in Practice DATA and Learning Implementation of adapted guideline(Large cost of failure) Wide-scale tests of adaptations Adaptation and follow-up Tests Very small scale test (Small Cost of failure)

23. Average visit cycle timePatient experience

24. Where are we? $

25. $ $ $ $ $ Southcentral Foundation

26. Emergency Room/Urgent Care Visits

27. Parallel Work Flow Redesign $ $ $ Southcentral Foundation

28. P A D S IHS CCI/IPC Pilot Collaborative We are here… Where does it go from here? Harvest Virtual LS 3 LS 1 Site visit Virtual LS 4 LS 5

29. Building a System in Which: Care is Safe, Effective, Patient-Centered, Timely, Efficient, Equitable Quality Improvement • Patient Satisfaction • Health Outcomes • Workforce Satisfaction • GPRA Quality Assurance • Accreditation • Credentialing • Facilities Process Improvement • HR • Contracting • Business Office

30. Strategy for Spread Second Round of Full Scale For sites not ready the first time around Full Scale National collaborative for 200+ sites supported by regional infrastructure Capacity Building Training of Improvement Support Teams (6 – 12) to support improvement in the field IPC II Addition of 26 new sites to the IPC: Includes readiness stage, sequencing and staging changes Readiness Curriculum Training remaining sites (200+) on models, project management and leadership for improvement Five Million Lives Campaign IPC I Intensive work with initial 14 pilot teams Mar 07 Fall 07 Apr 08 Oct 08 2010 2011

31. Chronic Care Initiative-Innovations in Planned Care • Through the Director’s Health Initiatives, the Indian Health System will improve in outcomes and processes. • The creativity, resiliency, and resources of our local communities are essential and will become an integral part of the healthcare system.