Neurological Care within the Indian Health Service.

American Indians and Alaska Natives (AI/AN) are the Indigenous peoples of the United States. According to the U.S. Census Bureau, approximately 9.7 million people self-identified as AI/AN (alone or in combination with other races), representing 2.9% of the total U.S. population. These people represent diverse groups of discrete Tribes, each with their language, culture, and geographic home. As part of the conquest and settlement of North America, some Indigenous peoples signed treaties with the U.S. government, surrendering their lands in return for various government commitments, including health care. The Indian Health Service (IHS) was born out of these agreements. The IHS is an agency in the U.S. Department of Health and Human Services under the U.S. Public Health Service. The IHS provides a comprehensive health service delivery system for approximately 2.7 million AI/AN who belong to 574 federally recognized Tribes/nations in 37 states. The aim of this paper is to make recommendations regarding the initiation of sustainable neurology care in marginalized or underserved populations by reviewing 40 years of neurology care provision within the IHS. We will discuss (1) the IHS, (2) neurological care provided within the IHS, including midlevel provider extension of neurology care and traditional medical care, and (3) select neurological diagnoses within AI/AN populations. Marginalized populations, including those in the United States that are rural, remote, or low socioeconomic status, lack access to specialty neurology care. This includes many AI/AN. The IHS has developed novel solutions to promote specialty care, including neurology. Notably, initial IHS investments in full-time neurology providers have led to more robust neurology care, often receiving attention from university programs. This suggests that an initial investment in stable on-site full-time neurology services provides a path to potential sustainable care for marginalized populations.

Tribal Perspectives on Patient Navigation for Rural Native Veterans Using Veteran Health Administration Services.

American Indian and Alaska Native (Native) Veterans enrolled in the U.S. Department of Veterans Affairs (VA) benefits program are far less likely to access health care compared to other racial/ethnic groups, in part driven by challenges posed by often distant, complex, and culturally unresponsive health care that does not easily interface with the Indian Health Service (IHS) and local Tribal Health Care. To address this disparity, in 2020 the Veteran's Health Administration's (VHA) Office of Rural Health (ORH) initiated the development of a patient navigation program designed specifically for rural Native Veterans. There are no navigation programs for rural Native Veterans to guide development of such a program. Hence, the project team sought perspectives from rural Native Veterans, their families, and community advocates, (n = 34), via video and phone interviews about the role and functions of a Veteran patient navigator and personal characteristics best be suited for such a position. Participants believed a navigator program would be useful in assisting rural Native Veterans to access VHA care. They emphasized the importance of empathy, support, knowledge of local culture, and of Veteran experience within tribal communities, adeptness with VHA systems, and personnel consistency. These insights are critical to create a program capable of increasing rural Native Veteran access to VHA services.

Infusing geriatrics in Indian Health Service general primary care clinics: Extending VA workforce development training.

As federal partners, the Veterans Health Administration (VA) and the Indian Health Service (IHS) agreed to share resources, such as education. The VA Geriatric Scholars Program, a workforce development program, provides one of its training programs on team-based primary care of elders to clinicians working in IHS and Tribal Health Programs. The practical impact of that training is described. A mixed methods approach was applied to the course's evaluation survey at five clinics in the Northwestern Plains, Southwest, Pacific Coast, and Alaska. Quantitative approaches assessed participants' self-reported intention to improve recognition and assessment of common geriatric syndromes. A qualitative approach applied to open-ended text responses revealed intensions to improve team-based care. Among the 51 respondents in our sample, we found significant improvements in self-reported ability to recognize previously unfamiliar potential risks to elders' health and safety, t(49) = 8.0233, p < .001, as well as increased comfort with conducting geriatric assessments and increased confidence in interprofessional team-based communication. Improvements to team-based care included enhanced clinical skills, organizational factors and the need to train additional employees. This evaluation demonstrates the value of sharing resources among federal partners and its value for participants in IHS and Tribal Health Programs.

The Indian Health Service and American Indian/Alaska Native Health Outcomes.

The Indian Health Service (IHS) has made huge strides in narrowing health disparities between American Indian and Alaska Native (AI/AN) populations and other racial and ethnic groups. Yet, health disparities experienced by AI/AN people persist, with deep historical roots combined with present-day challenges. Here we review the history of the IHS from colonization to the present-day system, highlight persistent disparities in AI/AN health and health care, and discuss six key present-day challenges: inadequate funding, limited human resources, challenges associated with transitioning services from federal to Tribal control through contracting and compacting, evolving federal and state programs, the need for culturally sensitive services, and the promise and challenges of health technology.

Health-Related Behavioral Risk Factors and Obesity Among American Indians and Alaska Natives of the United States: Assessing Variations by Indian Health Service Region.

INTRODUCTION: Health-related behavioral risk factors and obesity are linked to high risk for multiple chronic diseases. We examined the prevalence of these risk factors among American Indians and Alaska Natives (AI/ANs) compared with that of non-Hispanic Whites and across Indian Health Service (IHS) regions. METHODS: We used 2017 Behavioral Risk Factor Surveillance System data from participants in 50 states and the District of Columbia to assess 4 behavioral risk factors (current cigarette smoking, heavy drinking, binge drinking, and physical inactivity) and obesity. We analyzed disparities in these risk factors between AI/AN and non-Hispanic White participants, nationwide and by IHS region, by conducting log-linear regression analyses while controlling for potential confounders. RESULTS: Nationwide, crude prevalence of current smoking, physical inactivity, and obesity were significantly higher among AI/AN than non-Hispanic White participants. After adjustment for sociodemographic characteristics, AI/AN participants were 11% more likely to report current smoking (P < .05) and 23% more likely to report obesity (P < .001) than non-Hispanic White participants. These patterns persisted in most IHS regions with some exceptions. In the Southwest region, AI/AN participants were 39% less likely to report current smoking than non-Hispanic White participants (P < .001). In the Pacific Coast region, compared with non-Hispanic White participants, AI/AN participants were 54% less likely to report heavy drinking (P < .01) but 34% more likely to report physical inactivity (P < .05). Across IHS regions, AI/AN participants residing in Alaska and the Northern Plains regions had the highest prevalence of current smoking and binge drinking, and those in the Southwest and Pacific Coast regions had the lowest prevalence of current smoking. AI/AN participants in the Southwest region had the lowest prevalence of physical inactivity, and those in the Southern Plains region had the highest prevalence of obesity. CONCLUSIONS: The findings of this study support the importance of public health efforts to address and improve behavioral risk factors related to chronic disease in AI/AN people, both nationwide and among IHS regions, through culturally appropriate interventions.

The costs of treating all-cause dementia among American Indians and Alaska native adults who access services through the Indian Health Service and Tribal health programs.

INTRODUCTION: Little is known about treatment costs for American Indian and Alaska Native (AI/AN) adults with dementia who access services through the Indian Health Service (IHS) and Tribal health programs. METHODS: We analyzed fiscal year 2013 IHS/Tribal treatment costs for AI/ANs aged 65+ years with dementia and a matched sample without dementia (n = 1842) to report actual and adjusted total treatment costs and costs by service type. Adjusted costs were estimated using multivariable regressions. RESULTS: Mean total treatment cost for adults with dementia were $13,027, $5400 higher than for adults without dementia ($7627). The difference in adjusted total treatment costs was $2943 (95% confidence interval [CI]: $1505, $4381), the majority of which was due to the difference in hospital inpatient costs ($2902; 95% CI: $1512, $4293). DISCUSSION: Knowing treatment costs for AI/ANs with dementia can guide enhancements to policies and services for treating dementia and effectively using health resources.

COVID-19 Pandemic and Indigenous Representation in Public Health Data.

Public Health 3.0 calls for the inclusion of new partners and novel data to bring systemic change to the US public health landscape. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has illuminated significant data gaps influenced by ongoing colonial legacies of racism and erasure. American Indian and Alaska Native (AI/AN) populations and communities have been disproportionately affected by incomplete public health data and by the COVID-19 pandemic itself. Our findings indicate that only 26 US states were able to calculate COVID-19‒related death rates for AI/AN populations. Given that 37 states have Indian Health Service locations, we argue that public health researchers and practitioners should have a far larger data set of aggregated public health information on AI/AN populations. Despite enormous obstacles, local Tribal facilities have created effective community responses to COVID-19 testing, tracking, and vaccine administration. Their knowledge can lead the way to a healthier nation. Federal and state governments and health agencies must learn to responsibly support Tribal efforts, collect data from AI/AN persons in partnership with Indian Health Service and Tribal governments, and communicate effectively with Tribal authorities to ensure Indigenous data sovereignty. (Am J Public Health. 2021;111(S3): S208-S214. https://doi.org/10.2105/AJPH.2021.306415).

High-Risk Outreach for COVID-19 Mortality Reduction in an Indigenous Community.

Indigenous populations have been disproportionally affected by COVID-19, particularly those in rural and remote locations. Their unique environments and risk factors demand an equally unique public health response. Our rural Native American community experienced one of the highest prevalence outbreaks in the world, and we developed an aggressive management strategy that appears to have had a considerable effect on mortality reduction. The results have implications far beyond pandemic response, and have reframed how our community addresses several complicated health challenges. (Am J Public Health. 2021;111(11):1939-1941. https://doi.org/10.2105/AJPH.2021.306472).

Disparities in Care Experienced by American Indian and Alaska Native Medicare Beneficiaries.

BACKGROUND: Little is known about the health care experiences of American Indians and Alaska Natives (AIANs) due to limited data. OBJECTIVE: The objective of this study was to investigate the health care experiences of AIAN Medicare beneficiaries relative to non-Hispanic Whites using national survey data pooled over 5 years. SUBJECTS: A total of 1,193,248 beneficiaries who responded to the nationally representative 2012-2016 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. METHODS: Linear regression models predicted CAHPS measures from race and ethnicity. Scores on the CAHPS measures were linearly transformed to a 0-100 range and case-mix adjusted. Three AIAN groups were compared with non-Hispanic Whites: single-race AIANs (n=2491; 0.4% of the total sample), multiple-race AIANs (n=15,502; 1.3%), and Hispanic AIANs (n=2264; 0.2%). RESULTS: Among AIAN groups, single-race AIANs were most likely to live in rural areas and areas served by the Indian Health Service; Hispanic AIANs were most likely to be Spanish-language-preferring (P's<0.05). Compared with non-Hispanic Whites, single-race AIANs reported worse experiences with getting needed care (adjusted disparity of -5 points; a "large" difference), getting care quickly (-4 points; a "medium" difference), doctor communication (-2 points; a "small" difference), care coordination (-2 points), and customer service (-7 points; P<0.001 for all comparisons). Disparities were similar for Hispanic AIANs but more limited for multiple-race AIANs. CONCLUSIONS: Quality improvement efforts are needed to reduce disparities faced by older AIANs. These findings may assist in developing targeted efforts to address cultural, communication, and health system factors presumed to underlie disparities in health care access and customer service.

How Hands-On Pain Skills Intensive Trainings Complement ECHO Pain and Opioid Management Programs: A Program Evaluation with the Indian Health Service.

OBJECTIVE: To evaluate the impact of Pain Skills Intensive trainings (PSIs) as a complement to the Indian Health Service (IHS) and the Chronic Pain and Opioid Management TeleECHO Program (ECHO Pain) collaboration. DESIGN: On-site PSIs conducted over two to three days were added to complement ECHO Pain at various IHS areas to enhance pain skills proficiency among primary care teams and to expand the reach of ECHO collaboration to ECHO nonparticipants. SETTING: This evaluation focuses on two PSI trainings offered to IHS clinicians in Albuquerque, New Mexico, and Spokane, Washington, in 2017. METHODS: The mixed-methods design comprises CME surveys and focus groups at the end of training and 12 to 18 months later. Quality of training and perceived competence were evaluated. RESULTS: Thirty-eight participants attended the two PSI workshops. All provided CME survey results, and 28 consented to use of their postsession focus group results. Nine clinicians participated in the virtual follow-up focus groups. IHS clinicians rated the PSIs highly, noting their hands-on and interdisciplinary nature. They reported above-average confidence in their skills. Follow-up focus groups indicated they were pursuing expanded options for their patients, consulting other clinicians, serving as pain consultants to their peers, and changing prescribing practices clinic-wide. However, rurality significantly limits access to ancillary and complementary services for many. Clinicians reported the need for additional training in integrating behavioral health into their practice. CONCLUSIONS: Hands-on pain skills and information on medication-assisted treatment (MAT) are critical to the successful treatment of chronic pain and opioid use disorder. The PSIs provide clinicians with critical competencies in assessment and screening, pain management, and communication skills, complementing required IHS training and telementoring from ECHO Pain.

The Indian Health Service Primary Care-Based Teleophthalmology Program for Diabetic Eye Disease Surveillance and Management.

Background: Historically, fewer than half of American Indians and Alaska Natives (AI/AN) with diabetes received the annual diabetic retinopathy (DR) examination that is considered the minimum standard of care; this rate is similar to that of the general United States (U.S.) population with diabetes. Solution: The Indian Health Service-Joslin Vision Network (IHS-JVN) Teleophthalmology Program in 2000 to increase compliance with DR standards of care among AI/AN through validated, primary care-based telemedicine. The IHS-JVN provides remote diagnosis of DR severity, with a report including management recommendations that is returned to the patient's primary care provider. The program conforms with the American Telemedicine Association (ATA) Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. Outcomes: The IHS-JVN has been expanding incrementally since the first patients were recruited in 2000; this expansion coincides with large improvements in the annual DR examination rates reported as part of local, regional, and national regulatory compliance under the Government Performance and Results Act (GPRA). Currently, with 99 clinical implementations in 23 states, IHS-JVN is the largest primary care-based ATA validation category three telemedicine program in the U.S. Summary: This article describes the program's workflow, imaging and reading technologies, diagnostic protocols, reports to providers, training, quality assurance processes, and geographical distribution. In addition to its clinical use, the program has been utilized in research on utilization of diabetic eye care, cost-effectiveness, technology development, and DR epidemiology of the AI/AN population. Potential next steps for this program are discussed.

Hepatitis C drug prescriptions and Medicaid policies--four states, Indian health care system, USA 2018.

Medicaid, the state-level public insurance in the United States, has widely differing criteria treatment for hepatitis C virus (HCV) such as stage of liver fibrosis, documented sobriety, and specialist consultation. In a rural health network, facilities located in two less restrictive states prescribed HCV drugs at a significantly higher rate than two more restrictive states (rate ratio 4.7, CI 2.6-8.5). Prescription rates per population were highly associated with HCV treatment policies.

Unintentional injury deaths among American Indian residents of the Fort Apache Indian Reservation, 2006-2012.

This study aims to describe the epidemiology of unintentional injury deaths among American Indian residents of the Fort Apache Indian Reservation between 2006 and 2012. Unintentional injury death data were obtained from the Arizona Department of Health Services and death rates were calculated per 100 000 people per year and age adjusted using data obtained from Indian Health Service and the age distribution of the 2010 US Census. Rate ratios were calculated using the comparison data obtained through CDC's Web-based Injury Statistics Query and Reporting System. The overall unintentional injury mortality rate among American Indians residing on the Fort Apache Indian Reservation between 2006 and 2012 was 107.0 per 100 000. When stratified by age, White Mountain Apache Tribe (WMAT) mortality rates for all unintentional injuries exceed the US all races rate except for ages 10-14 for which there were no deaths due to unintentional injury during this period. The leading causes of unintentional injury deaths were MVCs and poisonings. Unintentional injuries are a significant public health problem in the American Indian and Alaska Native communities. Tribal-specific analyses are critical to inform targeted prevention and priority setting.

Outcomes and Lessons Learned from the Tribal Veterans Representative Program: A Model for System Engagement.

American Indian and Alaska Native Veterans are more rural than Veterans of any other race or ethnicity and face significant barriers to accessing care. Since 2001, the Tribal Veterans Representative (TVR) Program, a partnership between the U.S. Department of Veterans Affairs (VA) and tribal nations, has trained liaisons from tribal communities to facilitate access to VA benefits and services. We delineate the TVR program model alongside supporting data. We reviewed TVR training materials and program evaluations to identify components of the program essential for increasing access to VA services and benefits. We then report a quantitative assessment of benefits attained in one tribal community. The TVR model is characterized by the exchange of two sets of knowledge and resources-'institutional' and 'community'-during a co-sponsored educational program aiming to train community liaisons about the institution. The institution leads the program's content; the community's traditions inform its process. Following the program, liaisons use support networks comprising trainers, trainees and local organizations to teach other community members to access health care and benefits. In the evaluation community, one liaison has facilitated access for hundreds of Veterans, with financial compensation exceeding $400,000 annually. The TVR program has begun to demonstrate its utility for other rural populations, though further formal evaluation is recommended. Compared with similar models to increase rural populations' access to health care and benefits, the long-term support networks from the TVR model may be most useful when the institution must build trust and engage with the target population.

Building a Tribal-Academic Partnership to Address PTSD, Substance Misuse, and HIV Among American Indian Women.

OBJECTIVES: To describe our partnership and research infrastructure development strategies and discuss steps in developing a culturally grounded framework to obtain data and identify a trauma-informed evidence-based intervention. METHOD: We present funding strategies that develop and maintain the partnership and tools that guided research development. We share how a community research committee was formed and the steps taken to clarify the health concern and develop a culturally tailored framework. We present results from our needs/assets assessment that led to the selection of a trauma-informed intervention. Finally, we describe the agreements and protocols developed. RESULTS: We produced a strong sustainable research team that brought program and research funding to the community. We created a framework and matrix of program objectives grounded in community knowledge. We produced preliminary data and research and publication guidelines that have facilitated program and research funding to address community-driven concerns. CONCLUSIONS: This study highlights the importance of bidirectional collaboration with American Indian communities, as well as the time and funding needed to maintain these relationships. A long-term approach is necessary to build a sustainable research infrastructure. Developing effective and efficient ways to build culturally based community research portfolios provides a critical step toward improving individual and community health outcomes.

Population Health for CKD and Diabetes: Lessons From the Indian Health Service.

Despite extensive clinical guidelines, innovative efforts to improve care, and well-funded efforts to raise awareness, limited progress has been made in reducing the burden of kidney disease in the United States, and the prevalence continues to increase worldwide. The Indian Health Service and the Centers for Disease Control and Prevention recently reported a 54% decrease in the incidence of kidney failure among American Indian and Alaska Native people with diabetes. This decrease in end-stage renal disease incidence was associated with a population health approach to diabetes care based in the community and the primary clinical setting. The effort focused on integrating better care for kidney disease within the context of routine diabetes care. Although the American Indian population and the Indian Health Service may be unfamiliar to many clinicians and health system administrators, the demonstration that simple evidence-based interventions implemented in a comprehensive and consistent way can reduce the burden of end-stage renal disease suggests that population-based approaches to chronic disease offer significant potential benefits. Large pragmatic trials may offer the best way to rigorously test this hypothesis.

Improving cancer care for American Indians with cervical cancer in the Indian Health Service (IHS) system - Navigation may not be enough.

OBJECTIVES: Patient navigation programs have been shown to positively impact cancer outcomes for minority populations. Little is known regarding the effects of these programs on American Indian (AI) populations. The purpose of this study is to characterize the impact of a patient navigation program on AI cervical cancer patients at a tertiary care center. METHODS: A retrospective review of all AI cervical cancer patients receiving navigation services and a cohort of AI patients treated prior to navigation services was performed. Additional comparisons were made between those with and without Indian Health Service (IHS) funding. Summary statistics were used to describe demographic, clinical characteristics, treatment, and survivorship across groups. RESULTS: Of 55 patients identified, 34 received navigation and 21 did not. In navigated patients, median age was 46years (27-80years) compared with 42years (17-68years) in pre-navigation patients (p=0.53). There was no difference between stage at diagnosis (p=0.73). No difference was noted in treatment received between groups (p=0.48). Distance traveled for treatment between groups did not differ (p=0.46). Median time to initiation of treatment was not different between groups, 30.5days vs. 27.5days (p=0.18). Among patients with IHS funding, navigation services did not alter time to initiation of treatment (p=0.57), and there was no difference in completion of prescribed therapy between groups (92% navigated vs 100% pre-navigation). CONCLUSIONS: Navigation services for AI cervical cancer patients did not alter initiation or completion of treatment. Navigation programs may provide less tangible benefits to AI cervical cancer patients and further study is warranted.

Trends in Pelvic Inflammatory Disease Among American Indian and Alaska Native Women, Indian Health Service, 2001-2015.

OBJECTIVES: To describe trends in rates of pelvic inflammatory disease (PID) encounters among American Indian/Alaska Native (AI/AN) women aged 15 to 44 years in the United States receiving care within the Indian Health Service (IHS). METHODS: We analyzed IHS discharge data sets for PID encounters during 2001 to 2015 with International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes. We calculated rates of PID encounters per 100 000 women overall and stratified by age group, region, and health care setting. We used regression to identify trends in the total, annual, and average annual percent changes in the rate of PID encounters. RESULTS: There were 44 042 PID encounters during 2001 to 2015 (rate = 825 per 100 000). The highest rates were among women aged 20 to 24 years (1104) and from the Alaska region (1556). Rates significantly decreased overall (2001: 1084; 2015: 512; P < .001) and within all age groups and health care settings. There was variability in Alaska, with large increases during 2001 to 2010 followed by large decreases during 2010 to 2015. CONCLUSIONS: We observed decreasing trends in PID encounters among AI/AN women aged 15 to 44 years during 2001 to 2015, with the exception of increases in the Alaska region.