Health Care Systems for American Indians/Alaska Natives in the United States <br />Rochelle Lacapa, MPH<br />Johns Hopkins...
Presentation Overview<br />History- Federal Trust Agreement<br />Historical Context of American Indian/Alaska Native Healt...
Our History<br />3<br />
Social Influences: Wars, Conquest, Health and Governance <br />1779: First U.S. Congress established Indian Health office ...
Basis for Federal Health Benefits to American Indians<br />Treaties exchanged indigenous lands for federal trust responsib...
Our Present<br />
The Indian Health Services (IHS)<br />MISSION: …to raise the physical and mental, social and spiritual health of American ...
The Indian Health Care System<br />Indian Health Service (IHS) Direct Health Care Services<br />12 Area Offices<br />163 T...
IHS Service Population and Annual Patient Services<br />IHS Service Population<br />565 federally recognized tribes in the...
IHS User Population by Area (2005)<br />10<br />Alaska<br />128,095<br />TOTAL IHS USER POPULATION<br />FOR 2005:  1,438,1...
IHS Appropriations and Third Party Collections<br />Appropriations<br />FY 2010: IHS Federal Budget Appropriation $4.05 bi...
2010 IHS Funding Distribution<br />
IHS Per Capita Health Care Expenditures and Human Resources<br />Per Capita Personal Health Care Expenditures<br />IHS Ser...
Indian Health Service Population<br />14<br />1.4m<br />AI/ANs<br />Unserved<br />1.8m<br />AI/ANs<br />Served<br />3.3m A...
 71% high school graduates (80% U.S.) & 12% college graduates (24% U.S.)
 26% of AI/ANs fall below poverty standard
 Unemployment is 3.0 times the US rate</li></li></ul><li>Top 10 Mortality Disparities Among American Indians and Alaska Na...
Health Disparities Cont.<br />Leading Causes of Death<br />Heart Disease<br />Malignant Neoplasm<br />Unintentional Injuri...
Changes in Morbidity and Mortality Over the PastThree Decades<br />Shift from Infectious to Chronic Illness<br />Diabetes<...
1956 IHS Hospital  in Shiprock, New Mexico<br />Inadequate space for all sick children so dresser drawers were utilized as...
Changes in Mortality Among American Indians and Alaska Natives<br />Top 10 Diseases Over Two Time Periods<br />Rates are p...
Emerging Health Issues and Potential Impacts on Service Delivery<br />Obesity<br />Suicide<br />HIV/Sexually Transmitted I...
Emerging Health Issue: Obesity<br />Historically, obesity was not a concern among Native Americans.<br />21<br />
Emerging Health Issue: Suicide<br />22<br />THE WHOLE BEING<br />Inter-active circles represent a metaphor for the thought...
Suicide Rates by Ethnicity and Age<br />
Emerging Health Issue: HIV/Sexually TransmittedInfections<br />Number of HIV & AIDS Diagnoses Among AI/AN, 1993-2001<br />
HIV/Sexually Transmitted Infections Cont.<br />Rates<br />Through 2008, approximately 3500 cases of HIV/AIDS with a rate o...
Challenges In Service Delivery<br />Diversity Among Tribes and Cultural Appropriateness<br />Continuity of Care <br />Acce...
Diversity and Cultural Appropriateness<br />Diverse Tribes, Cultures, Languages, Lifestyles, and Locations<br />
Continuity of Care<br />IHS facilities experience high turn-over rates in medical staff<br />Slow shift towards a primary ...
Access to Care<br />Vast geography to cover<br />Travel time and expense may be too large for patients to receive care<br ...
Funding for Prevention Programming<br />Appropriations focus primarily on direct care<br />No distinct line-item for preve...
Collaborations to Meet Health Care Needs:The Johns Hopkins Center For American Indian Health (CAIH)<br />MISSION<br />To w...
CAIH Role in the Health System<br />Formal Memorandum of Understanding (1991)<br />Assist to fill prevention gaps<br />Con...
CAIH Milestones in American Indian Health<br />33<br />
CAIH Milestones Cont.<br />Prevention of Infant Deaths from Diarrhea: Introduction of Oral Rehydration Therapy (ORT) among...
Keys to High Quality Health Care for American Indians and Alaska Natives<br />Culturally appropriate health care delivery<...
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Health Care Systems for American Indians

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  • Important Dates:Indian Health Office in Department of War- Indian health/infections seen as a threat to the future of an expanding nation.1934 American Indians granted citizenship1987 IHS moved to the Department of Health and Human Services
  • Snyder Act- authorized funds “for the relief of distress and conservation of health…[and] for the employment of…physicians..for Indian tribes throughout the United State.” (1921)Transfer Act (1955)placed Indian health programs in the Public Health System. (1955)Indian Sanitation Facilities Act- give the SFC (abbreviation?) program authority for providing essential water supply, sewage, and solid waste disposal facilities for American Indian and Alaska Native homes and communities.
  • Indian Health Services provides a comprehensive health service delivery system for approximately 1.8 million of the 3.3 million American Indian and Alaska natives
  • This slide provides a geographic distribution of the IHS service locations in 2005.
  • Expenditures in the general U.S are 2.5 times greater and the IHS appropriationsThis could contribute to the gap in health disparities
  • The American Indian and Alaska Native people have long experienced lower health status when compared with other Americans.  Lower life expectancy and the disproportionate disease burden exist perhaps because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences.  These are broad quality of life issues rooted in economic adversity and poor social conditions. Diseases of the heart, malignant neoplasm, unintentional injuries, diabetes mellitus, and cerebrovascular disease are the five leading causes of American Indian and Alaska Native deaths (2004-2006). American Indians and Alaska Natives born today have a life expectancy that is 5.2 years less than the U.S. all races population (72.6 years to 77.8 years, respectively; 2003-2005 rates American Indians and Alaska Natives die at higher rates than other Americans from tuberculosis (500% higher), alcoholism (514% higher), diabetes (177% higher), unintentional injuries (140% higher), homicide (92% higher) and suicide (82% higher). (Rates adjusted for misreporting of Indian race on state death certificates; 2004-2006 rates.) Given the higher health status enjoyed by most Americans, the lingering health disparities of American Indians and Alaska Natives are troubling.  In trying to account for the disparities, health care experts, policymakers, and Tribal Leaders are looking at many factors that impact upon the health of Indian people, including the adequacy of funding for the Indian health care delivery system.
  • The American Indian and Alaska Native people have long experienced lower health status when compared with other Americans.  Lower life expectancy and the disproportionate disease burden exist perhaps because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences.  These are broad quality of life issues rooted in economic adversity and poor social conditions. Given the higher health status enjoyed by most Americans, the lingering health disparities of American Indians and Alaska Natives are troubling.  In trying to account for the disparities, health care experts, policymakers, and Tribal Leaders are looking at many factors that impact upon the health of Indian people, including the adequacy of funding for the Indian health care delivery system.
  • Mention that disease burden shifting to chronic disease which require long-term care—large shift on needed health care resources
  • Native Americans have a very holistic approach to life and approach mental health in the same way.Can be in contradiction with Western medicine, which tends to compartmentalize the parts of a person in order to provide treatment.Within the IHS system, there is a shortage of mental health professionals to address the increasing needs in tribal communities.
  • American Indians and Alaska Natives (AI/AN) are ranked third in the nation in rate of new infections (incidence) of human immunodeficiency virus (HIV) compared with all other races and ethnicities. Health disparities and disproportionate co-risk factors (including sexually transmitted infections, substance use, and stigma) among AI/ANs contribute both directly and indirectly to the risk of HIV transmission. HIV/AIDS is communicable, affects a younger population, and has no cure or vaccine.
  • There are 565 tribes in the U.S. with their own distinct language, cultural and traditions. This can make it difficult to develop a universal method or approach for health care delivery.Tribal communities are also geographically diverse ranging from urban to rural and frontier or very isolated.
  • Health Care Systems for American Indians

    1. 1. Health Care Systems for American Indians/Alaska Natives in the United States <br />Rochelle Lacapa, MPH<br />Johns Hopkins Center for American Indian Health<br />
    2. 2. Presentation Overview<br />History- Federal Trust Agreement<br />Historical Context of American Indian/Alaska Native Health Disparities<br />The Indian Health Care System<br />Health Disparities of American Indians and Alaska Natives<br />Emerging Health Issues<br />Challenges in Service Delivery<br />Partnerships to Improve Service Delivery- Johns Hopkins Center for American Indian Health<br />
    3. 3. Our History<br />3<br />
    4. 4. Social Influences: Wars, Conquest, Health and Governance <br />1779: First U.S. Congress established Indian Health office in Dept. of War <br />1890: Indian Wars – 471 treaties signed through 1890<br />1849: Indian Health Office Moved to Department of Interior<br />1890: End of Indian Wars<br />World War I <br />1928: Meriam Report <br />1934: American Indians Granted Citizenship<br />WW II - 1940’s<br />1945-46: Nuremberg Trials<br />1955: Transfer Act<br />1987: IHS is a DHHS Agency<br />
    5. 5. Basis for Federal Health Benefits to American Indians<br />Treaties exchanged indigenous lands for federal trust responsibilities and benefits.<br />Snyder Act (P.L. 67-85): first legislation authorizing funds to manage health issues<br />Transfer Act (1955): Shifted the IHS from the War Department to the Department of Health and Human Services<br />Indian Sanitation Facilities Act (P.L. 86-121): provided water, sewage and solid waste services.<br />Indian Self-Determination and Education Assistance Act (P.L. 93-638, as amended): Allows tribes to administer health services provides tribes (1975)<br />Indian Health Care Improvement Act (P.L. 94-437): Expands of the self-determination act and includes planning and management of health services (1976) (2008)<br />
    6. 6. Our Present<br />
    7. 7. The Indian Health Services (IHS)<br />MISSION: …to raise the physical and mental, social and spiritual health of American Indians and Alaska Natives to the highest possible level.<br />GOAL: …to assure that comprehensive, culturally personal and public health services are available and accessible to American Indian and Alaska Native people.<br />Dr. Yvette Roubideaux, Director<br />
    8. 8. The Indian Health Care System<br />Indian Health Service (IHS) Direct Health Care Services<br />12 Area Offices<br />163 Tribally Managed Service Units<br />Service Units Represent: 33 hospitals, 53 health centers, 38 health stations<br />Tribally Managed Health Care Services<br />78 Self-Determination Contracts<br />232 Self-Governance Compacts<br />Contracts and Compacts Represent: 15 hospitals, 221 health centers, 97 health stations, 176 Alaska village clinics<br />Urban Indian Health Care Services and Resource Centers<br />34 Urban Programs<br />600,000 American Indians/Alaska Natives served by urban programs<br />
    9. 9. IHS Service Population and Annual Patient Services<br />IHS Service Population<br />565 federally recognized tribes in the United States- mostly in the Western United States<br /> 2 million American Indian and Alaska Natives residing on or near reservations<br />Annual Patient Services<br />Inpatient Admission: 50,349<br />Outpatient Visits: 11,778,527<br />Dental Services: 3,568,201<br />
    10. 10. IHS User Population by Area (2005)<br />10<br />Alaska<br />128,095<br />TOTAL IHS USER POPULATION<br />FOR 2005: 1,438,196<br />Portland<br />99,139<br />Billings<br />70,473<br />Bemidji<br />96,222<br />Aberdeen<br />118,114<br />Phoenix<br />147,299<br />IHS Headquarters<br />Rockville, MD<br />California<br />73,648<br />Navajo<br />238,515<br />Oklahoma<br />306,727<br />Albuquerque<br />86,674<br />Tucson<br />24,412<br />Nashville<br />48,878<br />
    11. 11. IHS Appropriations and Third Party Collections<br />Appropriations<br />FY 2010: IHS Federal Budget Appropriation $4.05 billion<br />FY 2009: IHS Federal Budget Appropriation $3.58 billion<br />Third-Party Collection (Private Insurance)<br />FY 2010 $702 million<br />FY 2011 (estimated) $829 million<br />
    12. 12. 2010 IHS Funding Distribution<br />
    13. 13. IHS Per Capita Health Care Expenditures and Human Resources<br />Per Capita Personal Health Care Expenditures<br />IHS Service Population: $2,741<br />Total U.S. Population: $6,909<br />Human Resources<br />Total IHS Employees: 16,159<br />70% are American Indian/ Alaska Native<br />900 Physicians<br />2,700 Nurses<br />35 Physician Assistants/Nurse Practitioners<br />300 Dentists<br />650 Pharmacists<br />605 Engineers/Sanitarians<br />
    14. 14. Indian Health Service Population<br />14<br />1.4m<br />AI/ANs<br />Unserved<br />1.8m<br />AI/ANs<br />Served<br />3.3m AI/ANs<br />IHS Service Population Growth<br /><ul><li>Population growth rate of 1.6% per year
    15. 15. 71% high school graduates (80% U.S.) & 12% college graduates (24% U.S.)
    16. 16. 26% of AI/ANs fall below poverty standard
    17. 17. Unemployment is 3.0 times the US rate</li></li></ul><li>Top 10 Mortality Disparities Among American Indians and Alaska Natives<br />IHS Service Area2004-2006 and U.S. All Races 2005(Age-adjusted mortality rates per 100,000 population)<br />
    18. 18. Health Disparities Cont.<br />Leading Causes of Death<br />Heart Disease<br />Malignant Neoplasm<br />Unintentional Injuries<br />Mortality Rates Relative to the General U.S. Population<br />Tuberculosis (500% higher)<br />Alcoholism (514% higher)<br />Diabetes (177% higher)<br />Average Life Expectancy: 72.6 years (5.2 years less than the average)<br />Confounding Factors: <br />Inadequate education<br />High poverty<br />Discrimination in health care delivery<br />Cultural differences<br />Inadequacy of funding for health care systems<br />
    19. 19. Changes in Morbidity and Mortality Over the PastThree Decades<br />Shift from Infectious to Chronic Illness<br />Diabetes<br />Liver Disease<br />Cancers<br />Mental Health and Behavioral Health Disorders<br />Emerging Health Issues<br />Obesity<br />Suicide<br />HIV and STIs<br />
    20. 20. 1956 IHS Hospital in Shiprock, New Mexico<br />Inadequate space for all sick children so dresser drawers were utilized as beds.<br />18<br />
    21. 21. Changes in Mortality Among American Indians and Alaska Natives<br />Top 10 Diseases Over Two Time Periods<br />Rates are per 100,000<br />
    22. 22. Emerging Health Issues and Potential Impacts on Service Delivery<br />Obesity<br />Suicide<br />HIV/Sexually Transmitted Infections<br />
    23. 23. Emerging Health Issue: Obesity<br />Historically, obesity was not a concern among Native Americans.<br />21<br />
    24. 24. Emerging Health Issue: Suicide<br />22<br />THE WHOLE BEING<br />Inter-active circles represent a metaphor for the thought-life process<br />
    25. 25. Suicide Rates by Ethnicity and Age<br />
    26. 26. Emerging Health Issue: HIV/Sexually TransmittedInfections<br />Number of HIV & AIDS Diagnoses Among AI/AN, 1993-2001<br />
    27. 27. HIV/Sexually Transmitted Infections Cont.<br />Rates<br />Through 2008, approximately 3500 cases of HIV/AIDS with a rate of 12.8 per 100,000<br />HIV screening rates have more than tripled<br />Incidence rate is 14.7 per 100,0009<br />Risk Factors<br />Disproportionate rates of STI<br />Second highest rates of gonorrhea, Chlamydia and syphilis combined in the nation<br />Alcohol and Substance Abuse<br />Depression<br />Domestic Violence<br />Low Socioeconomic Status<br />Young Population (relative to other groups)<br />Social and Cultural Norms<br />Implications for Health Care Delivery<br />Short timeline from diagnosis to death- emphasis on early diagnosis, treatment and surveillance<br />AI/AN half as likely to use contraceptives as non-Native peers- emphasis on “safe sex” practices<br />
    28. 28. Challenges In Service Delivery<br />Diversity Among Tribes and Cultural Appropriateness<br />Continuity of Care <br />Access to Care<br />Funding for Prevention Programming<br />
    29. 29. Diversity and Cultural Appropriateness<br />Diverse Tribes, Cultures, Languages, Lifestyles, and Locations<br />
    30. 30. Continuity of Care<br />IHS facilities experience high turn-over rates in medical staff<br />Slow shift towards a primary care physician model<br />Relationship building is essential to promote medical compliance<br />Physician/patient interaction time limits this<br />
    31. 31. Access to Care<br />Vast geography to cover<br />Travel time and expense may be too large for patients to receive care<br />Shortage of specialized services providers<br />Mental Health Professionals<br />Surgeons<br />
    32. 32. Funding for Prevention Programming<br />Appropriations focus primarily on direct care<br />No distinct line-item for prevention<br />Prevention efforts can take a long period of time until results are seen<br />
    33. 33. Collaborations to Meet Health Care Needs:The Johns Hopkins Center For American Indian Health (CAIH)<br />MISSION<br />To work in partnership with the American Indian and Alaska Native communities to raise health status, self-sufficiency and health leadership to the highest possible level.<br />VISION<br />To support American Indian and Alaska Native communities in achieving:<br />1. optimum physical, mental and social well-being,<br />2. autonomy over community-based research and health services, and<br />3. worldwide leadership to overcome health inequalities.<br />VALUES<br />A commitment to integrity, professional excellence, compassion, and mutual respect for individuals, cultures and nations.<br />
    34. 34. CAIH Role in the Health System<br />Formal Memorandum of Understanding (1991)<br />Assist to fill prevention gaps<br />Conduct research to provide information on health disparities<br />Address emerging health issues<br />Help fill the training gap for American Indian health professionals<br />Operates 7 field sites in <br />
    35. 35. CAIH Milestones in American Indian Health<br />33<br />
    36. 36. CAIH Milestones Cont.<br />Prevention of Infant Deaths from Diarrhea: Introduction of Oral Rehydration Therapy (ORT) among White Mountain Apache and Navajo<br />Eradication of Hib Disease and Bacterial Meningitis: Clinical trial proving efficacy of vaccine to eliminate HaemophilusInfluenzae type b (Hib)<br />Wiping Out Pneumococcal Disease: A large-scale vaccine trial marking the advent of efficacious vaccine to prevent pneumonia, meningitis and middle ear infections. <br />Promoting Youth Development: Native Vision promotes healthy lifestyles, fitness, education, leadership and community service<br />Family Spirit- Child Care Education and Outreach for Teen Parents: Home-based outreach program for vulnerable families to promote a lifetime of health.<br />Training American Indian Health Professionals and Scholars: Graduate training for American Indian/Alaska Native health professionals at Johns Hopkins.<br />Stopping Youth Suicide: Utilizing a para-professional model to screen and refer suicidal youth for crisis care and the development of and innovative community-based intervention<br />Preventing RSV Disease: Clinical trial to show the effectiveness of an antibody to reduce RSV hospitalizations among Navajo and Apache babies.<br />34<br />
    37. 37. Keys to High Quality Health Care for American Indians and Alaska Natives<br />Culturally appropriate health care delivery<br />Partnerships and Collaborations with services providers and tribes<br />Inclusion of American Indian and Alaska Native tribes in the development and implementation of services<br />Utilization of diverse resources to fund prevention efforts<br />Continued development of indigenous health care professionals<br />
    38. 38. Our Future<br />36<br />
    39. 39. Acknowledgements<br />The Johns Hopkins Center for American Indian Health<br />Dr. Phil Smith, Native American Research Centers for Health<br />The Indian Health Services<br />The Centers for Disease Control<br />
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