Regional Indian Health Service Projects and Programs

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Regional Indian Health Service Projects and
Programs

• Christopher Lamer, PharmD, BCPS, CDE
• on behalf of Mark Carroll, MD
• IHS Telehealth Program Director

The Future is Here A Regional Health
Information Technology Summit Friday, June 15th
1030 am 1155 am
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Indian Health ServiceMission, 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
  Governments obligation to promote healthy
  American Indian and Alaska Native people,
  communities and cultures, and to honor and
  protect the inherent sovereign rights of Tribes.

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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

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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.

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163 Service Units in 12 Areas Located in 35
States
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Indian Health Care Systems
The IHS also supports 34 Urban Clinics across the
nation.
Source IHS Regional Differences, 2000-2001
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Rural Primary Care System with some Urban
Locations
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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)

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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
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Mortality Rates for Indian People Have Declined
Since 1973
CY 2000-2002
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Mortality Rate Disparity Continues American
Indians and Alaska Natives in the IHS Service
Area 2001-2003(Age-adjusted mortality rates per
100,000 population)
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
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Prevalence of Diagnosed DiabetesAI/ANs Compared
to U.S. Pop
Source IHS Program Statistics and National
Diabetes Surveillance System.
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Per Capita Expenditures TrendIHS Compared to
US Average
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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
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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
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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

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Key Questions

• What are the opportunities for shared/collaborativ
  e 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

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IHS Telehealth ProgramLeveraging Investments

• Outreach Technology
• AFHCAN

• Integrated HIT System
• RPMS-EHR
• Vista Imaging
• iCARE

• Partnerships
• Joslin Diabetes Center

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Integrated HIT System
Resource Patient Management System (RPMS)

• IHS Health Information Solution since 1984
• Comprised of over 60 component applications
• Foundation for the IHS EHR

---- A.K.A. ---- Really Powerful at Measuring
Stuff
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Clinical Data Integration
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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

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IHS VistA Imaging Project

• Implementation of VAs multimedia program as
  multimedia software component of the IHS EHR,
  for
• Scanned documents
• Non-DICOM images
• DICOM images

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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

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iCARE

• Perspectives for
• An individual patient
• A clinicians patients
• A population of patients
• A community of patients

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Flags
Radi- ology
Problem List
Cover Sheet
Pt. GPRA stats
Health Summary
Labs
Meds
Re- mind- ers
Face Sheet
Well- Ness Summary
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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

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Diabetic Retinopathy IHS/JVN Teleophthalmology
Program

• 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

• 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

• 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

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Mobile Joslin Vision Network

• Proof-of-concept to the Artic Circle

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IHS-AFHCAN Collaboration

• National Telehealth Infrastructure in Indian
  Health
• Offer a secure enterprise solution for
  store-and-forward telemedicine across Indian
  health

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Multi-Modality StoreForward T-Health
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AFHCAN Telehealth

• 8 years operational history
• RD 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
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Product Evaluation
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Integrated Systems of Care

• Focus on standards and information systems
  integration
• AFHCAN to be integrated with -
• The IHS Electronic Health Record
• And VistA Imaging

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New Service Models Possible For

• Radiology
• Retinopathy screening
• Mental health
• Dermatology
• ENT

• Cardiology
• Pharmacy
• AIDS-HIV care
• Neurology
• Nutrition/Dietetics

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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

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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

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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

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Access to Best Practices Specialists

• National Jewish Medical Center
• Leader in Asthma Care
• University of California, San Francisco
• Consultation for patients with HIV/AIDS

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(No Transcript)
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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

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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

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The Care Model
Adapted from Wagner EH. Chronic disease
management What will it take to improve care for
chronic illness? Effective Clinical Practice.
199812-4.
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The Care Model
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The Care Model

• Develop a multidisciplinary team that optimizes
  the role of each member in clinic community
• Optimize the Care Team each member performs at
  the highest level of their licensure.
• Focus on access, efficiencies and flow
• Provide clinical case management services for
  complex patients
• Give care that patients understand and that fits
  with cultural background
• Think about alternative approaches to traditional
  11 face to face care telehealth, group visits,
  etc.
• Integrate traditional medicine

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The Care Model
Informed, Activated Patient Family
Prepared, Proactive Practice Team
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The Care Model
Informed, Activated Patient Family
Prepared, Proactive Practice Team
IMPROVED ACHIEVEMENTS
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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

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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

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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

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Home Telehealth for Heart Failure
HEART Health Enhancement for American Indians
Alaska Natives Through Residential
Telemedicine Success with Failure
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POTENTIAL SAVINGS
Note Cost/Hospitalization from Dasta (2005) AHA
6th Scientific Forum on Quality of Care and
Outcomes Research in Cardiovascular Disease
Stroke
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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

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Home T-Health Reimbursement

• System savings dont 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

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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

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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

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Alaska ENT Outcomes (n897)
About 73 of the patients seen needed something
done (meds, surgery, ongoing monitoring) and 27
needed to be screened out.
Note Percentages may not add to 100 due to
multiple outcomes per case.
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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

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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

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Thank You