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  • As I mentioned before, in order to effectively combat chronic conditions, we must address a host of factors. This requires active partnerships with tribal, federal, state, and private organizations. This is why the IHS has established many partnerships with private and public entities, including the ones you see here.
    One important collaboration I would like to highlight is the IHS/Veterans Health Administration partnership, which has resulted in several initiatives of value to Indian veterans. One outcome of this partnership has been the IHS/VHA website collaboration. This website contains important information specifically for Indian veterans, including key points of contact for IHS/VHA services, updated information on various programs that are offered, and answers to questions frequently asked by Indian veterans.
    Other examples of IHS/VHA partnership initiatives include areas such as patient safety, health information technology, diabetes prevention, and behavioral health. There is also an important program called “Seamless Transition” that is currently underway to address issues for all veterans, including Indian veterans, who are returning from recent and current conflicts abroad.
    Another important collaboration I would like to mention is a recent signing of an MOU between the IHS and the Mayo Clinic. The purpose of this MOU is to establish a formal collaborative relationship in support of efforts to reduce health burdens in American Indian and Alaska Native communities.
  • The underlying principle of prevention in the IHS is that the best health promotion programs are those that are developed in consultation with our key stakeholders, the American Indian and Alaska Native people. We know that listening to those of you who are most effected by the outcomes helps us to best target the specific needs of each community.
    And we know that building on the existing strengths and assets of Indian people, families, and communities ensures the most effective use of resources and yields the best possible results, whether we are dealing with ongoing chronic conditions or emerging infectious diseases.
  • The underlying principle of prevention in the IHS is that the best health promotion programs are those that are developed in consultation with our key stakeholders, the American Indian and Alaska Native people. We know that listening to those of you who are most effected by the outcomes helps us to best target the specific needs of each community.
    And we know that building on the existing strengths and assets of Indian people, families, and communities ensures the most effective use of resources and yields the best possible results, whether we are dealing with ongoing chronic conditions or emerging infectious diseases.
  • AFHCAN technology is now deployde throughout the state of Alaska, and has been embraced by the US Coast Guard for not only their bases in Alaska but also their remote LORAN stations and all their ships that sail in Alaska waters. For example, An AFHCAN system was on the US Coast Guard cutter Alex Hailey when it was involved in the rescue of the crew of the Selendang Ayu as it broke in half off the coast of Alaska.
    NOTES:
    Photos of the ship wreck Selendang Ayu on Unalaska Island near Dutch Harbor, Alaska
    Photos of the ship wreck Selendang Ayu on Unalaska Island near Dutch Harbor, Alaska. (Dec 11 2004 - Jan 8, 2005). A stranded Malaysian cargo ship that lost power on December 8, 2004, still sits in shallow water in the Alaska Maritime National Wildlife Refuge. The vessel has been there since it lost power and broke in half on its way to China from Tacoma, Washington with a cargo of 60,000 tons of soybeans.
    Picture of a Coast Guard Jayhawk helicopter 6020 from Air Station Kodiak hovering over the cutter Alex Haley to transfer crewmen from the Selendang Ayu to the cutter Wednesday afternoon. AFHCAN telehealth carts were available for use on the Alex Hailey during this crisis, in 30 foot seas.
    Note: The Jayhawk 6020 crashed later Wednesday evening while hoisting the final eight crewmen from the Selendang Ayu.
  • The Chronic Care Model is the framework that guides the delivery of care for chronic conditions.
    Diabetes work over the past 20 years
    We have learned from experience in our own Division of Diabetes Treatment and Prevention that there are better ways to provide care to people with chronic conditions. This has been depicted graphically with the use of the Chronic Care Model developed by Dr. Wagner with the MacColl Institute for Healthcare Innovation.
    If we want to obtain improved outcomes in the care of patients with chronic conditions, then we must facilitate productive interactions between informed, active patients and a prepared, proactive practice. In order to create both of these, we need to facilitate improvements in the Health Care System through improvementes in Self-Management Support, Delivery System Design, Clinical Information Systems, and Decision Support.
  • Here are the outcomes of the cases seen by the audiologist.
    In 27% of the cases, the patient did not need to be seen by a specialist (which they were scheduled to visit). This opened up appointments for other needy patients – essentially a double advantage (travel savings for the removed patient, earlier appointment for the next patient).
    Many of the patients received immediate attention, and 23% were referred directly to ANMC for further testing or care without waiting to be seen in specialty clinic. For many, the audiologist determined that consultation with the otolaryngologist was not necessary. For example, a patient needing adjustment of a hearing aid. Some were truly wasted encounters, but this determination was made before the patient was made to travel and use an appointment slot with the ENT physician.
    This data speaks to the tremendous unmet need for specialty care in this population of patients. Overall, this project resulted in faster access for patients, earlier identification of problems and effective triage for our specialists.
  • Power Point

    1. 1. “The Future is Here – A Regional Health Information Technology Summit” Friday, June 15th 10:30 am – 11:55 am Regional Indian Health Service Projects and Programs Christopher Lamer, PharmD, BCPS, CDE on behalf of Mark Carroll, MD IHS Telehealth Program Director
    2. 2. Indian Health Service Mission, Goal, and Foundation • The Mission, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social and spiritual health to the highest level. • The Goal is to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to all American Indian and Alaska Native people. • The Foundation is to uphold the Federal Government’s obligation to promote healthy American Indian and Alaska Native people, communities and cultures, and to honor and protect the inherent sovereign rights of Tribes.
    3. 3. IHS Overview • Provides a comprehensive health service delivery system for approximately 1.9 million of 3.3 million American Indians and Alaska Natives. • Serves members of 561 federally recognized Tribes in 35 states. • FY 2007 appropriation is approximately $3.2 billion. • Indian Health Service total staff consists of about 15,850 employees, which includes approximately 2,600 nurses, 930 physicians, 390 engineers, 500 pharmacists, 300 dentists, and 170 sanitarians
    4. 4. Partnership with Tribal Governments • The Indian Self-Determination Act of 1975 includes an opportunity for Tribes to assume the responsibility of providing health care for their members, without lessening any Federal treaty obligation. • Tribes now administer health care contracts and compacts with the IHS valued at over $1.5 billion. This represents approximately 54% of the IHS budget authority appropriation.
    5. 5. 163 Service Units in 12 Areas Located in 35 States
    6. 6. Indian Health Care Systems Source: IHS Regional Differences, 2000-2001 Hospitals Health Centers Alaska Village Clinics Health Stations IHS 33 54 N/A 38 Tribal 15 229 162 116 The IHS also supports 34 Urban Clinics across the nation.
    7. 7. Rural Primary Care System – with some Urban Locations                                                                                                                                                                           Hospital Ambulatory Center 60% of IHS hospitals and ambulatory centers are in remote areas
    8. 8. IHS Hospital System • JCAHO/CMS Accredited • Size varies: – 156 Beds - 6 Beds • 59,000 Admissions per year (2006) • 9,797,000 Outpatient visits per year (2006)
    9. 9. Community Oriented Programs • Community oriented primary care • Public health emphasis • Traveling services in remote villages • Community health representatives • Village health aids • Community & school health education Traveling dental team visits remote villages in Alaska
    10. 10. 80.4 76.3 66.0 64.1 59.6 57.1 45.7 39.7 38.7 16.8 0 20 40 60 80 100 Tuberculosis Cervical Cancer Infant Deaths Maternal Deaths Accidental Homicide Alcohol-Related Cerebrovascular Pneumonia & Influenza Suicide Percent Decrease in Mortality Rates (Adjusted for misreporting of AI/AN race on State death certificates.) CY 2000-2002 Mortality Rates for Indian People Have Declined Since 1973
    11. 11. U.S. Ratio: AI/AN All Races AI/AN Rate Rate to U.S. 2001- 2003 2002 All Races ALL CAUSES 1042.2 845.3 1.2 Tuberculosis 1.8 0.3 6.0 Alcoholism 43.6 6.7 6.5 Diabetes 75.2 25.4 3.0 Motor vehicle crashes 51.1 15.7 3.3 Unintentional Injuries 93.8 36.9 2.5 Homicide 12.7 6.1 2.1 Suicide 17.1 10.9 1.6 Cervical cancer 4.4 2.6 1.7 Infant deaths 1/ 9.8 7.0 1.4 Cerebrovascular diseases 54.7 56.2 1.0 1/ Infant deaths per 1,000 live births NOTE: American Indian and Alaska Native (AI/AN) rates were adjusted to compensate for misreporting of AI/AN race on state death certificates. AI/AN rates are based on 2000 census with bridged-race categories developed by the Census Bureau and the National Center for Health Statistics. Jan. 2007 Mortality Rate Disparity Continues American Indians and Alaska Natives in the IHS Service Area 2001-2003 (Age-adjusted mortality rates per 100,000 population)
    12. 12. Prevalence of Diagnosed Diabetes: AI/ANs Compared to U.S. Pop Source: IHS Program Statistics and National Diabetes Surveillance System. 0 5 10 15 20 1980198219841986198819901992199419961998200020022004 Year Percent AIAN US
    13. 13. Per Capita Expenditures Trend: IHS Compared to US Average $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 $4,500 $5,000 $5,500 $6,000 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 IHS Per Capita Expenditure US Per Capita Expenditure *for personal health care services
    14. 14. Summary of the IHS • The IHS is diverse and rich with experiences • Mostly rural health care services provided • Many disparities exist - staffing and age of the facilities • High incidence and prevalence of chronic disease • Low per capita funding Health Care Needs Health Care Funding
    15. 15. Telehealth as a Business Tool • To improve service delivery in the face of: – Increasing service population/need – Disparities in: • Mortality data • Funding • Staffing • Facilities http://www.ihs.gov/CIO/InfoTech_index.asp
    16. 16. ‘Service to the Point of Need’ • For patients, families, and health care teams – Enhancing access • To care • To health data – Improving value • For communities • For health system – Assuring quality • By decreasing variations • Through ‘right time’ health information
    17. 17. Key Questions • What are the opportunities for shared/collaborative service delivery? – To help improve ROI • What is the opportunity specific to chronic care? – To improve access to care, system efficiencies, and quality of service delivery
    18. 18. IHS Telehealth Program: Leveraging Investments Integrated HIT System –RPMS-EHR –Vista Imaging –iCARE Partnerships –Joslin Diabetes Center Outreach Technology –AFHCAN
    19. 19. Resource Patient Management System (RPMS):Resource Patient Management System (RPMS): ---- A.K.A. ---- Really Powerful at Measuring Stuff Integrated HIT System – IHS Health Information Solution since 1984 – Comprised of over 60 component applications – Foundation for the IHS EHR
    20. 20. PCC Patient Database Case Management Data EntryReferred Care Diabetes Management Elder Care Patient Registration Laboratory Emergency Room Public Health Nursing Pharmacy Appointment System Occupational Med CHR Radiology Immunizations Women’s Health Dental Behavioral Health Clinical Data Integration
    21. 21. IHS EHR • Graphical User Interface to RPMS – User-friendly access to RPMS database for clinicians/other staff – ‘Componentized’ architecture • to allow incorporation of functionality developed within IHS or another agency/organization
    22. 22. IHS VistA Imaging Project • Implementation of VA’s multimedia program as multimedia software component of the IHS EHR, for: – Scanned documents – Non-DICOM images – DICOM images
    23. 23. iCARE • Integrated Case Management Application – GUI application – 1st release May, 2007 • Able to: – Create and manage patient lists or panels – Share created lists or panels – Display outcome performance measures for any panel – “Auto-tag” records for pts with specific diagnoses – Customize layouts – Flag abnormal events/results for users
    24. 24. iCARE • Perspectives for: – An individual patient – A clinician’s patients – A population of patients – A community of patients
    25. 25. ` Cover Sheet Flags Re- mind- ers Pt. GPRA stats Face Sheet Health Summary Well- Ness Summary Labs Meds Radi- ology Problem List
    26. 26. IHS Joslin Vision Network • Retinal screening for patients with diabetes • 57 sites nationally in 15 states • Single reading center at Phoenix Indian Medical Center • Over 21,000 interpretations completed to date
    27. 27. • Phoenix, AZ • Sells, AZ • Tuba City, AZ • Parker, AZ • Hopi, AZ • San Carlos, AZ • Salt River, AZ • Peach Springs, AZ • Ft Belknap, MT • Crow Agency, MT • Pine Ridge, SD • Rosebud, SD • McLaughlin, SD • Shiprock, NM • Santa Fe, NM • Albuquerque, NM • Mescalero, NM • Crown Point, NM • Fairbanks, AK • Cass Lake, MN • Livingston, TX • Clinton, OK • Wewoka, OK • Lawton, OK • Eufaula, OK • Okmulgee, OK • Oklahoma City, OK • Pawnee, OK • Ft. Yuma, OK • Winnebago, NE • Lawrence, KS • Warm Springs, OR • Nespelem, WA • Yakama, WA • Wellpinit, WA • Tacoma, WA • Fort Hall, ID • Lapwai, ID • Plummer, ID • Rock Hill, SC • Elko, NV • Reno Sparks, NV • Schurz, NV • Washoe, NV • McDermitt, NV • Fallon, NV • Ft. Defiance, AZ • Tucson, AZ – Pascua Yaqui Tribe – San Xavier • Tahlequah, OK • Jicarilla, NM • Kayenta, AZ • Inscription House, AZ • Montezuma Creek, UT • Blanding, UT • Monument Valley, UT • Navajo Mountain, AZ Diabetic Retinopathy IHS/JVN Teleophthalmology Program
    28. 28. “Mobile Joslin Vision Network” • Proof-of-concept to the Artic Circle
    29. 29. IHS-AFHCAN Collaboration • National Telehealth Infrastructure in Indian Health – Offer a secure enterprise solution for store-and- forward telemedicine across Indian health
    30. 30. Multi-Modality “Store&Forward” T-Health
    31. 31. AFHCAN Telehealth • 8 years operational history • R&D Telehealth System • 10,000 cases / year • Manufacturing of Medical Devices • Whole Product Solution • Installed Customer base includes: – 248 sites, 44 organizations • 37 Tribal organizations • US Army sites (6) • US Air Force bases (3) • State of Alaska Public Health Nursing (26) • US Coast Guard clinics (5) • US Coast Guard cutters and ice breakers (6) Design  Installation  Training  Support  Marketing
    32. 32. Product Evaluation
    33. 33. Integrated Systems of Care • Focus on standards and information systems integration – AFHCAN to be integrated with - • The IHS Electronic Health Record • And VistA Imaging
    34. 34. New Service Models Possible For: • Radiology • Retinopathy screening • Mental health • Dermatology • ENT • Cardiology • Pharmacy • AIDS-HIV care • Neurology • Nutrition/Dietetics
    35. 35. Emerging Capability • “High Tech” – Broad application • Tele-pharmacy – Focused application • Electronic ICU • “Robotic surgery” – Training • “Low Tech” – Broad application • Home telehealth • Medical nutrition Rx – Focused application • Pediatric specialists
    36. 36. ENT Tele-Consultation Center • Specialists at Alaska Native Medical Center – Statewide experience via the AFHCAN network • Extended in 2006 to patients at the Yakima Indian Health facility in eastern Washington • Further extension in 2007 to other Indian health facilities outside Alaska – “Expert triage” model
    37. 37. Tele-Pharmacy • Aberdeen Area – Pilot project began last summer – Supporting the Pine Ridge Service unit and surrounding clinics • Based on work done at ANMC and outside Indian health
    38. 38. Access to “Best Practices” Specialists • National Jewish Medical Center – Leader in Asthma Care • University of California, San Francisco – Consultation for patients with HIV/AIDS
    39. 39. Tele-Behavioral Health • Behavioral health service is an ideal target for telehealth – Growing experience already within Indian health – Service delivery models ready to go • Other ‘real-time’ telehealth is maturing – Cardiology, Rheumatology, Nutrition services – Reimbursement models improving
    40. 40. Chronic Care Initiative PURPOSE: • Re-engineer clinical programs to more effectively manage chronic disease • Link community-based primary prevention with patient centered secondary prevention • Create a healthcare system that is proactive, supportive, and evidence-based • Promote interactive relationship between informed, motivated patients and prepared/proactive health care teams
    41. 41. Adapted from Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4. Self- Management Support Delivery System Design Clinical Information Systems Decision Support Community: Resources and Policies Health System: Health Care Organization The Care Model
    42. 42. The Care Model Self- Management Support Delivery System Design Clinical Information Systems Decision Support Community: Resources and Policies Health System: Health Care Organization Patient Driven Coordinated Timely/Efficient Evidenced/Safe PRODUCTIVE
    43. 43. The Care Model Self- Management Support Delivery System Design Clinical Information Systems Decision Support Community: Resources and Policies Health System: Health Care Organization Patient Driven Coordinated Timely/Efficient Evidenced/Safe PRODUCTIVE 1. Develop a multidisciplinary team that optimizes the role of each member in clinic & community 2. Optimize the Care Team: each member performs at the highest level of their licensure. 3. Focus on access, efficiencies and flow 4. Provide clinical case management services for complex patients 5. Give care that patients understand and that fits with cultural background 6. Think about alternative approaches to traditional 1:1 face to face care: telehealth, group visits, etc. 7. Integrate traditional medicine
    44. 44. Self- Management Support Delivery System Design Clinical Information Systems Decision Support Community: Resources and Policies Health System: Health Care Organization The Care Model Informed, Activated Patient & Family Prepared, Proactive Practice Team Patient Driven Coordinated Timely/Efficient Evidenced/Safe PRODUCTIVE
    45. 45. The Care Model Self- Management Support Delivery System Design Clinical Information Systems Decision Support Community: Resources and Policies Health System: Health Care Organization Informed, Activated Patient & Family Prepared, Proactive Practice Team Patient Driven Coordinated Timely/Efficient Evidenced/Safe PRODUCTIVE IMPROVED ACHIEVEMENTS
    46. 46. Home Telehealth/Remote Monitoring • Improving literature and experience – Chumbler et al, 2005: 455 VA patients • 50% reduction in hospitalization • 11% reduction in ED visits • Improved health-related quality of life – Noel et al, 2004: 104 elderly “high use” VA pts • Decreased hospital bed days, ED visits • Decreased Hgb A1C • Improved cognitive scores • Decreased resource needs, increased treatment compliance
    47. 47. VA Home Telehealth • 25,000 patients currently enrolled across the VA health system • For a range of services: – Mental health – Heart Failure, HTN – Diabetes care – Other chronic conditions
    48. 48. Home Telehealth in IHS • Continues Development – Pros • Improves patient access to care • Improves chronic care • Extends health care team more efficiently • Decreases inappropriate hospital utilization • Promotes guideline-driven care – Cons • Reimbursement policy only beginning to take shape
    49. 49. HEART Health Enhancement for American Indians & Alaska Natives Through Residential Telemedicine ‘Success with Failure’ Home Telehealth for Heart Failure
    50. 50. Note: Cost/Hospitalization from Dasta (2005) AHA 6th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease & Stroke POTENTIAL SAVINGS
    51. 51. Economics of Home Telehealth • Annualized cost per patient ~ $2,500 – Includes cost of equipment and shared staff (new) to oversee day-to-day program • Annualized savings per patient ~$30,000 – Assumes prevention of roughly 1.5 hospitalizations per year for patients with heart failure as primary diagnosis
    52. 52. Home T-Health Reimbursement • System savings don’t equal individual facility budget savings – Savings to 3rd party insurers vs. individual facility CHS budget • Reimbursement policy in home telehealth is still evolving • And some incentives are “malaligned” – E.g. Decreased hospitalizations are not advantageous to some referral facility operating budgets
    53. 53. Telehealth Reimbursement • Medicare reimburses for real-time telehealth • A growing # of Medicaid programs also reimburse for real-time thealth services • More Medicaid programs reimburse for some store-and-forward telehealth services – E.g. AZ Medicaid is especially proactive
    54. 54. T-Health Business Models • Lapsed salaries – Use T-health for unfilled vacancies • Reimbursement – Relies on 3rd party payer policy and rates • Cost Avoidance – Eg.For contract health budgets • Agreements/contracts – Shared costs among facilities/communities for specialist FTEs/services
    55. 55. Note: Percentages may not add to 100% due to multiple outcomes per case. About 73% of the patients seen needed something done (meds, surgery, ongoing monitoring) and 27% needed to be screened out. Alaska ENT Outcomes (n=897)
    56. 56. Next Steps • Regional telehealth service “menus” • Continued modeling, with business planning • Important opportunities for emerging tools to complement/shape new service delivery models – Chronic Care
    57. 57. Collaborations are Key • Within Indian health – Southwest Telehealth Consortium – Alaska Federal Health Care Access Network (AFHCAN) – Inter-Area “corporate” projects • With other federal agencies – Veterans Health Administration • With universities, states, and other organizations
    58. 58. Thank You

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