An American Indian community implements the chronic care model: evolution and lessons learned.

The chronic care model (CCM) has been initiated most frequently in clinical settings with outreach to the community to obtain involvement and guidance. Implementation of the CCM by communities that reach out to clinicians and develop linkages and coordination to improve care for community members with chronic conditions is less frequently observed. This commentary describes the implementation of the CCM by the Eastern Shoshone Tribe of the Wind River Indian Reservation. The design emphasized community-based leadership, with the Tribe having the primary role in developing and implementing culturally tailored community self-management supports, improving linkages with Indian Health Service (IHS) clinicians and cultural knowledge of providers, and developing a coalition of organizations with additional resources to create a more comprehensive system of diabetes care for Tribal members with diabetes. Results indicate that community-initiated implementation of the CCM can be an effective strategy for creating a comprehensive community-clinical system of care for community members with diabetes. Overall, by the fourth implementation year, approximately 25% of Tribal members with diabetes had participated in the program and 28% of people on the Diabetes Registry had HbA1c levels above 9.0 compared to 32% before the Wind River ARDD program. The success of the Wind River program suggests that community-driven approaches are a valuable strategy in our nation's efforts to eliminate health disparities and ensure equal and fair access to quality health care for all citizens.

Cross-site evaluation of the Alliance to Reduce Disparities in Diabetes: clinical and patient-reported outcomes.

Alliance programs implemented multilevel, multicomponent programs inspired by the chronic care model and aimed at reducing health and health care disparities for program participants. A unique characteristic of the Alliance programs is that they did not use a fixed implementation strategy common to programs using the chronic care model but instead focused on strategies that met local community needs. Using data provided by the five programs involved in the Alliance, this evaluation shows that of the 1,827 participants for which baseline and follow-up data were available, the program participants experienced significant decreases in hemoglobin A1c and blood pressure compared with a comparison group. A significant time by study group interaction was observed for hemoglobin A1c as well. Over time, more program participants met quality indicators for hemoglobin A1c and blood pressure. Those participants who attended self-management classes and experienced more resources and support for self-management attained more benefit. In addition, program participants experienced more diabetes competence, increased quality of life, and improvements in diabetes self-care behaviors. The cost-effectiveness of programs ranged from $23,161 to $61,011 per quality-adjusted life year. In sum, the Alliance programs reduced disparities and health care disparities for program participants.

Breast and cervical cancer screening patterns among American Indian women at IHS clinics in Montana and Wyoming.

OBJECTIVES: We investigated factors associated with primary and secondary breast and cervical cancer screening among American Indian (AI) women receiving care from the Indian Health Service (IHS) in Montana and Wyoming. METHODS: Rates of primary screening (i.e., screening without evidence of a prior abnormal) and secondary screening during a three-year period (2004-2006) were determined in an age- and clinic-stratified random sample of 1,094 women at six IHS units through medical record review. RESULTS: Three-year mammography prevalence rates among AI women aged ≥45 years were 37.7% (95% confidence interval [CI] 34.1, 41.3) for primary and 58.7% (95% CI 43.9, 73.5) for secondary screening. Among women aged ≥18 years, three-year Pap test prevalence rates were 37.8% (95% CI 34.9, 40.6) for primary and 53.2% (95% CI 46.0, 60.4) for secondary screening. Primary mammography screening was positively associated with number of visits and receiving care at an IHS hospital (both p<0.001). Primary Pap test screening was inversely associated with age and positively associated with the number of patient visits (both p<0.001). Secondary mammography screening was inversely associated with driving distance to an IHS facility (p=0.035). CONCLUSION: Our results are consistent with other surveys among AI women, which report that Healthy People 2010 goals for breast (90%) and cervical (70%) cancer screening have not been met. Improvements in breast and cervical cancer screening among AI women attending IHS facilities are needed.

Financing American Indian health care: impacts and options for improving access and quality.

(1) Indian Health Service (HIS) per patient funding is less than half of national per capita health spending, and declined further between 2003 and 2006. (2) Under-funding of the IHS system has led to explicit rationing of services to American Indian and Alaska Native patients, with many specialized services provided only for "life or limb threatening" conditions. (3) IHS patients report experiencing access barriers and rate the quality of care process substantially lower than do Medicaid beneficiaries, but most indicate they prefer to use IHS for their health care. (4) Options to increase the funding for American Indian and Alaska Native health care exist, but would impose higher costs on federal and state budgets and are unlikely to be feasible in the current economic environment. However, IHS might be able to make certain organizational changes that would increase efficiency and its ability to extend existing funding to cover more services.

Strategies for Medicare health plans serving racial and ethnic minorities.

The Medicare Managed Care (MMC) Consumer Assessment of Health Plans Study (CAHPS) survey offers an opportunity to examine differences in health plan experiences and patterns of use of services of racial and ethnic minority beneficiaries enrolled in health plans. Analysis of the survey data and review of prior literature indicate significant health disparities and different patterns of health care use by racial and ethnic minorities. Improved measurement of health plan performance in serving minority enrollees, and development of performance improvement strategies, could have the potential to reduce the observed health disparities.

Assessing Medicare Health Plan Performance in Serving Beneficiary Subpopulations.

In this analysis, the authors examined differences in managed care health plan performance ratings between selected subgroups of the Medicare population who may have exceptional health care needs (EHCNs) or may require special plan efforts to facilitate effective service use compared with the residual enrolled population. Findings indicated that disabled enrollees have lower plan ratings across all dimensions of performance than do other enrollees. Aged enrollees in self-reported fair/poor health and those with limited independence have lower ratings for most dimensions of performance. Finally, although Hispanic persons and persons other than white were more satisfied with their health plans, overall, they had lower ratings for dimensions of the process of care and access to services.

Medicare Managed Care CAHPS®: A Tool for Performance Improvement.

The Medicare+Choice (M+C) program, created by the 1997 Balanced Budget Act (BBA), expands Medicare's health insurance options to include a wider range of health plan options. In this article, we describe the Consumer Assessment of Health Plans Study (CAHPS®) survey and its use with beneficiaries receiving care through Medicare managed care (MMC) plans. We also discuss the implications of these efforts for future quality improvement efforts.

Building healthy tribal nations in Montana and Wyoming through collaborative research and development.

We describe a collaborative approach to reducing health disparities affecting Montana and Wyoming tribal nations while promoting health-protective practices and interventions among these populations. Under the auspices of the Montana-Wyoming Tribal Leaders Council, a consortium has undertaken activities to (1) establish the research infrastructure necessary for conducting ongoing health disparities research, (2) develop a target research agenda that addresses tribally identified priority health issues and tests the feasibility of interventions, (3) develop increased research skills and cultural competency through mentoring activities, and (4) develop effective collaborative relationships. All research projects are user-defined and -authorized, and participation is voluntary.