Indian Health Service (IHS) Director's Corner Blog updates on important issues affecting the Indian Health Service.en-usSustaining Quality Health Care Delivery at Indian Health Service, January 19, 2017 ]]>It’s been quite a year at the Indian Health Service. During my tenure leading here, I met with patients and tribal and community leaders to hear ideas on how the patient experience could be improved, specifically how the agency could work with tribes to raise the quality of care and expand access to services.  In these conversations, I was also reminded of the long-standing systemic problems that often made it difficult for IHS to provide its patients with the best care possible.

Some of these challenges include a rapidly growing service population, medical inflation, aging infrastructure, difficulties attracting and retaining staff in rural areas, and the impact of behavioral health issues affecting the population. For example, limited capital investment means IHS faces a significant backlog in health care facilities maintenance and construction – over $14 billion -- and so the age of our facilities continues to increase. IHS hospitals are now almost four times older than U.S. hospitals.

Aging facilities translate into lower productivity as the space is not designed for current needs which makes it more difficult to attract staff. Ultimately, this affects the quality of care and the patient experience.

I knew confronting these challenges would require a sustained investment of resources and funding over time, something the agency could not change wholly on its own. But when I took the helm early last year, I also knew that with some creative thinking and determination, there was much IHS could do to address these problems and forge a new way of doing business.

Throughout 2016, IHS was proactive and relentless in its confrontation of the severe operational, budgetary, and staffing challenges we faced.

With the support across the U.S. Department of Health and Human Services, including the Executive Council on Quality Health Care, IHS executed a bottom to top review, working with top managers, clinicians, and program experts who took a fresh look at long-standing obstacles to jumpstart a multitude of initiatives to improve the quality of care delivered to patients and enact sustainable reforms. 

As we learned lessons in one area, we shared it across our facilities on how we could improve our operations to better serve our patients. And we are already making strides to strengthen IHS’ quality of care delivery and instill a culture of quality care, leadership and accountability across the agency. Collaboration through the Executive Council also led to the development of the 2016-17 Quality Framework [PDF - 147 KB] that IHS will use to establish and implement a sustained, effective quality program.

New partnerships with the Centers for Medicare & Medicaid Services and the Joint Commission – an independent organization that accredits and certifies nearly 21,000 health care organizations and programs – were also established to support best health care practices and other operational improvements for IHS hospitals. This means our IHS teams, who are making a medical decision for a patient, can ask for daily advice from CMS partners, an outside organization like the Joint Commission, or use telemedicine to get a second opinion from another doctor. This is part of ongoing work to prevent quality issues in hospitals before they affect patients.

Reducing staffing shortages is also linked to improving quality of care for patients, and we continue to pursue a mix of short- and long-term solutions to build the IHS workforce. Over 160 U.S. Public Health Service Commission Corps officers were deployed in 2016 to IHS facilities most in demand of staff to meet immediate workforce needs. To promote sustainable workforce development, IHS expanded the number of its facilities eligible to participate with the National Health Service Corps, a program that provides student loan assistance in exchange for working in areas with staffing shortages.

IHS also refocused its scholarship and loan repayment program on the most-needed disciplines in Indian health programs such as physicians, nurses, pharmacists, and behavioral health providers among others to provide patients with more service options.

Improving the patient experience also means making it easier for patients to access specialty services perhaps not readily available in their neighborhood clinic. This spring, IHS will begin implementing telemedicine services to more than 100,000 patients in the Great Plains Area service units in North Dakota, South Dakota, and Nebraska. Patients will be able to visit a nearby facility and using technology, they can have one-on-one time with a health care provider without traveling long distances to see the physician in person.

As my time leading the agency comes to a close, I look ahead knowing that IHS is better positioned to provide its patients with quality care and possesses the momentum to keep improving and moving forward. There is still a lot of work to be done; however, if there is anything I learned throughout my time, it is that it is only through sustained effort over time working side-by-side with our tribal partners and with Congress that we will be able to achieve real and sustainable change to transform health care for the American Indians and Alaska Natives across the country.

Ms. Smith, a member of the Cherokee Nation, leads IHS, a nationwide health care delivery program responsible for providing preventive, curative and community health care to approximately 2.2 million American Indians and Alaska Natives.

IHS and VA Renew, Expand Partnership, January 19, 2017 ]]>I am pleased to share with you two new developments regarding IHS’ ongoing collaboration with the Veterans Affairs (VA). This partnership aims to provide eligible American Indian and Alaska Native veterans with access to care closer to their homes; promote cultural competence and quality health care; and focus on increasing care coordination, collaboration, and resource-sharing between the agencies.

In 2010, the IHS and the VA signed a Memorandum of Understanding with the goal of improving the health status of American Indian and Alaska Native veterans. In 2012, this was augmented with a reimbursement agreement allowing the VA to financially compensate IHS for direct health care provided to American Indian and Alaska Native veterans that are eligible for and enrolled in the VA's health care system.

Last week, I signed an amendment with the VA to extend the period of a national reimbursement agreement [PDF] for direct health care services through June 30, 2019. Extending the reimbursement agreement has been a major priority for tribes and the IHS this past year. Between 2012 and 2015, the VA reimbursed over $16.1 million for direct care services provided by the IHS and tribal health programs covering 5,000 eligible Veterans. I encourage you to read more about the results of this partnership in the IHS-VA MOU Annual Report that is available on the VA website at: Exit Disclaimer: You Are Leaving [PDF].

I am also excited to announce a new Interagency Agreement with the VA authorizing the IHS to use the VA’s Consolidated Mail Outpatient Pharmacy (CMOP) [PDF]. This program benefits veterans and non-veterans alike.

The VA CMOP is a sophisticated mail order pharmacy program which uses 7 highly automated facilities to efficiently and safely deliver filled prescriptions directly to patient homes across the U.S. The IHS began using the CMOP on a trial basis in 2010. Since then, approximately 60 IHS pharmacies have filled more than 2 million prescriptions, increasing access to care, decreasing wait times and improving the patient experience.

Under the newly signed agreement, eligibility for accessing the CMOP will be expanded to tribes and tribal organizations with Indian Self-Determination and Education Assistance Act agreements. This is an exciting development, and the IHS is assisting tribes as they work to meet technical requirements and implement the program.

The collaboration between the IHS and the VA is a great example of how the IHS is innovating and maximizing resources to meet needs and overcome challenges, and I want to thank the VA for their continuing support.

Ms. Smith, a member of the Cherokee Nation, leads IHS, a nationwide health care delivery program responsible for providing preventive, curative and community health care to approximately 2.2 million American Indians and Alaska Natives.

Improving Tribal Solid Waste Program Capacity and Closing Solid Waste Open Dumps, January 17, 2017 ]]>The Indian Health Service and the U.S. Environmental Protection Agency (EPA) are committed to reducing the number of solid waste open dump sites because they threaten the health and safety of residents of Indian and Alaska Native lands. We are working together with tribal leaders to strengthen tribal government capacity to implement effective solid waste management programs and reduce solid waste open dumps throughout Indian country. 

A new January 2017 Memorandum of Understanding (MOU) [PDF - 937 KB] establishes the role of each agency in this effort. The IHS has committed to improve the accuracy and completeness of data characterizing open dumps impacting tribal communities, and the EPA has committed to complete regular assessments, evaluations and reporting on tribal solid waste programs, including their effectiveness in reducing open dumping activities. IHS will utilize the improved open dumps data and EPA tribal solid waste program assessments to develop, prioritize and fund projects to close the open dumps. 

Also included in the MOU is a joint commitment by IHS and EPA to develop and deliver training and technical assistance to improve the effectiveness of tribal solid waste management programs.  This work is already underway through a 2016 interagency funding agreement [PDF - 1.79 MB] between EPA and IHS to support a multi-year training effort to help tribes develop and implement effective solid waste enforcement codes and ordinances that are appropriate for their communities.

I would like to extend my gratitude to the tribal, IHS, EPA and State of Alaska staff of the interagency waste work group that assessed current open dump data and developed the actions included in the MOU. Read more about the IHS commitment to environmental health in Indian country on our IHS Office of Environmental Health and Engineering page.

Ms. Smith, a member of the Cherokee Nation, leads IHS, a nationwide health care delivery program responsible for providing preventive, curative and community health care to approximately 2.2 million American Indians and Alaska Natives.

IHS Celebrates World AIDS Day, December 9, 2016 ]]>On the first day of December, and along with the rest of the world, the Indian Health Service (IHS) commemorated World AIDS Day Exit Disclaimer: You Are Leaving The IHS is committed to working in partnership with tribes to deliver high quality health care to the people we serve and we are strongly devoted to our HIV/AIDS program.

IHS, along with our tribal and urban partners, has long valued the strength of our communities and we have been working to prevent HIV infection and to treat AIDS since the earliest days of the epidemic. For the most part, IHS clinics have only a handful of current HIV patients, or none at all. However, two large programs in the Southwest treat upwards of 200 HIV patients each. Each have populations that can be hard to reach due to geography and lack of phones.

But through locally managed, comprehensive programs run by the most devoted care providers in the country, recognized protocols are being followed and culturally relevant services are offered to our Native clients. My sincere gratitude goes out to the tireless front-line health professionals in our IHS clinics - working sometimes seven days a week - to diagnose and compassionately treat the hundreds of Native people living with HIV.

Employees from several HHS agencies at the 5600 Fishers Lane building celebrated World AIDS Day with a program titled, Leadership, Commitment, Impact, through Collaboration.
Employees from several HHS agencies at the 5600 Fishers Lane building celebrated World AIDS Day with a program titled, "Leadership, Commitment, Impact, through Collaboration."

I want to point out that much of the success we see in our HIV treatment programs is owed to our Community Health Technicians. Health reps are community members trained in HIV who speak the local language, and will travel to homes or shelters of HIV patients who are deemed at high risk for non-adherence due to their recent HIV diagnosis, behavioral health issues, denial, lack of understanding, being overburdened by new medicines, and many other factors.

Statistics show that early screening has made a difference. HIV screening - as per national recommendations - is now a core measure of quality of care. This year IHS tied the screening of 13-64 year olds for HIV to a core GPRA measure - as was suggested by the Centers for Disease Control and Prevention- and we expect this move to help prioritize screening in all of our IHS clinics.

I want to bring your attention to a relatively new development in the prevention of HIV. Pre-Exposure prophylaxis, or PrEP, is a way for people who don't have HIV, but who are at very high risk of getting it, to prevent HIV infection by taking a pill every day. In October IHS sent out PrEP Guidelines to our Area chief clinical directors in order to expand access to PrEP. These guidelines are now posted to our IHS website.

Finally, we turn to what the future holds and therefore, we have initiated the "Indian Country Emergent HIV Strategies Collaborative." The aim of the Collaborative is to improve, promote, and facilitate adoption of emergent HIV strategies for prevention, screening, management and treatment in Indian Country, and specifically targets clinicians.

IHS and American Indian/Alaska Native communities acknowledge the complex problems of HIV, and we at IHS continue to look for opportunities to work with and learn from our HHS sister agencies, and to see what more we can do and how we can share our knowledge and experience. We are learning best practices from the field and from people on the ground. We are embracing new frameworks for treatment and learning networks. IHS is continuing to work to ensure HIV/AIDS care is delivered consistently across all facilities in the Indian health system while working to infuse quality into everything we do.

As IHS Acting Chief Medical Officer, RADM Linde, M.D., provides medical advice and guidance to the Office of the Director and staff on American Indian and Alaska Native health care policies and issues. She serves as the primary liaison and advocate for IHS field clinical programs and community-based health professionals.

American College of Emergency Physicians Shares Emergency Room Expertise with IHS Staff, December 8, 2016 ]]>The American College of Emergency Physicians (ACEP) and Indian Health Services’ Work Session was held at the IHS Omaha-Winnebago Hospital in Winnebago, Nebraska on November 17, 2016, the day before our first snowfall in Nebraska. The meeting was attended onsite in person by over 30 IHS and AB Staffing physicians, nursing, quality and leaders from IHS facilities throughout the nation. Several sites called into the session individually and with colleagues from conference rooms. Overall this initiation of the collaboration between IHS and ACEP was well attended.

This work session allowed top-level physicians and emergency medical professionals the ability to share knowledge, training regarding emergency care.
This work session allowed top-level physicians and emergency medical professionals the ability to share knowledge, training regarding emergency care.

The agenda included opening remarks from Mr. Gary Wabaunsee, CEO Omaha Winnebago Hospital, Ms. Mary L. Smith IHS Principal Deputy Director, Dr. Lee Lawrence, Great Plains Area CMO and Dr. Vindell Washington, HHS National Coordinator for Health IT. Dr. Jay Kaplan provided a dynamic engaging presentation about leadership, responsibility and workflow in the emergency room. Dr. Robert Galli talked about the importance and capacity for emergency telemedicine. Dr. Thomas Wyatt a Native physician and past president from the ACEP Minnesota Chapter shared his experiences working in rural hospitals for IHS and other facilities. Dr. Wyatt offered support for the Comprehensive Advanced Life Support (CALS) as an appropriate training program for emergency medical education for rural and remote locations. Dr. Wyatt encouraged cultural training for providers and briefly reviewed EMTALA regulations. Finally, Dr. Vindell Washington offered a wrap up and next steps session to close the work session. The whole day stirred a lively discussion about key IHS Emergency Department and provider issues.

Participants from the American College of Emergency Physicians and Indian Health Service at the work session held on November 17, 2016 at the Omaha-Winnebago Hospital in Winnebago, Nebraska.
Participants from the American College of Emergency Physicians and Indian Health Service at the work session held on November 17, 2016 at the Omaha-Winnebago Hospital in Winnebago, Nebraska.

ACEP advocates for physicians, patients and the public for the highest quality emergency care. The ACEP and IHS collaborative work session brings together top physicians and emergency medical professionals to share telehealth information, training resources and emergency care knowledge. The goal of this innovative work will be to improve the quality of care and management of patient care in the 26 emergency departments at IHS operated facilities throughout Indian health communities in the nation which further advances the IHS mission to raise the health status of American Indian and Alaska Native people. Additionally, this collaboration will allow sharing of best practices, models of care and policies throughout the Indian healthcare system for stronger partnerships with Tribes, local communities and broader health care systems.

The Great Plains Area Office would like to express our appreciation for the ACEP contributors, the Office of the National Coordinator for Health IT and everyone who was able to attend the work session.

Dr. Lee Lawrence is the Chief Medical Officer for the Great Plains Area. He serves as the lead regional expert on IHS medical and public health services, providing technical leadership and guidance to facility CMO’s and clinical staff in the region.

Portland Area Mobilizes to Prevent Seasonal Influenza, November 23, 2016 ]]>Thanksgiving is almost upon us. As we prepare to gather together with family and friends, let us be mindful that one guest is not invited--influenza! Influenza has been shown to have a greater impact on American Indians and Alaska Natives and people with chronic medical conditions. The Portland Area IHS and Tribal clinics have been hard at work this year in vaccinating our communities against the flu. One strategy that we focused on last year was to vaccinate as early as possible. Because flu vaccine supplies are sometimes delayed by production or distribution factors outside of our control, we needed to add to this strategy. This year, clinics are focusing on not only vaccinating as early as possible, they are taking it to the streets by vaccinating in multiple sites outside of the clinic's four walls. Here are some examples of the great efforts our clinical sites are undertaking here in the Pacific Northwest:

  • Yakama Service Unit: The clinic has scheduled weekly flu-shot clinics every afternoon. In addition, they have added one late evening clinic each week. On Thursday mornings, during Administrative Time when the clinic is closed, they are holding "drive-through flu shot clinics" where folks can get their flu shots without even getting out of their car. Flu vaccinations were also given during the Tribal Head Start screening clinic, which had about 50 children.
  • Western Oregon Service Unit (Chemawa): Clinic staff have given about 500 flu shots so far to community members. Among Health Care Providers, 99 percent have received a flu shot this year, according to the new mandatory policy for annual flu vaccinations of Health Care Providers. Angela Zimmerman, Public Health Nurse, is gearing up to vaccinate all 400+ students at the nearby Chemawa Boarding School before they travel home for the Thanksgiving break.
  • Colville Service Unit: The Colville Service Unit has been doing drive-through flu clinics for many years. The first one for this year was held at the main clinic location (Nespelem) on September 21 in which about 100 flu shots were given. A week later, they held another drive-through flu clinic at a smaller satellite clinic in Omak. This was the first time they had done this at Omak and they reported a good turn-out. Both clinics have a policy to vaccinate at all visits and anecdotally they report about 80 percent of those offered accepted the flu vaccine this year. According to Immunization coordinator Sadie Cano, over 90 percent of employees have been vaccinated for flu so far this year.
  • Wellpinit Service Unit: The first ever drive-through flu clinic was held this week reaching 24 patients. CDR Elizabeth Sachse, Public Health Nurse, reports that many of the people she usually sees at home or in elder programs have already gotten their flu shots and observed that the clinic nurses seem to be more active in giving flu shots in clinic because many of the folks she has seen have already gotten their flu shots.
  • Warm Springs Service Unit: Activities at the Warm Springs Health and Wellness Center have focused on making flu shots available at every visit throughout the clinic, including medical clinics, pharmacy and Community Health. In addition, flu shots have been offered at multiple locations and venues outside of clinic. These include many high traffic areas such as the Post Office, Administration Center, Community Center and Family Resource Center. They have also worked to coordinate with many tribal programs such as Corrections, Human Resources, Assisted Living and Children's Group Home. In each location, flu shots are provided for both clients and tribal staff. Nearly all Warm Springs Health and Wellness Center employees have received their flu shots this year!
  • Fort Hall Service Unit: The Ft. Hall Service Unit worked with Shoshone-Bannock Tribal Health Partners again this year to hold two successful drive-through flu clinics. Last year they gave 38 flu shots in just one hour, this year they gave 50! A second drive-through clinic was smaller (just 23 patients) but the Ft. Hall staff was dedicated, working outside in near freezing temperatures. Dr. Bernadette Corum, Acting Clinical Director, reports they have been increasing their use of media and advertising with messages in the clinic, Facebook and tribal newspaper. So far it has paid off with over 1,000 adults and 99 percent of employees vaccinated against influenza this year.
Drive-through flu clinic at the Ft. Hall Service Unit
Drive-through flu clinic at the Ft. Hall Service Unit

Tribal clinics in the area are also joining in the effort. One clinic reports starting to give flu shots earlier this year than before while another reports that they have vaccinated over 400 people so far. They held a flu clinic at the Elder's Center over lunch two different days and even brought their Clinical Director, Dr. Allison Spencer, to discuss the differences between regular adult and high dose flu vaccines. As a result of these activities, 55 elders were vaccinated. Two of our Tribal clinics have also adopted mandatory employee flu shot policies to help protect staff and patients from influenza.

Across the Pacific Northwest, clinical providers employ a number of "best practices" to get people vaccinated. These include:

  • Using Electronic Health Record reminders to help remind staff of who needs a flu shot.
  • Checking for and offering a flu shot at every clinic visit, including eye clinic, dental clinic and the pharmacy refill window.
  • Providing flu shots at out-of-clinic venues: elder meetings, day care and Head Start facilities, and drive-through flu clinics like the one pictured below at Ft. Hall Service Unit.
  • Making flu shots available at special walk-in flu clinics staffed by nurses.
  • Adopting extended-hour clinics on weekends and evenings specifically for providing flu shots.
  • Utilizing pharmacists who are authorized in most states to provide a variety of immunizations, including flu shots.
  • Providing community outreach through radio, newspaper and social media outlets to educate the community about the importance of getting a flu shot each year.

The Portland Area Office is extremely proud of the efforts being made by everyone across our three states. We believe that these efforts are important to prevent influenza morbidity and mortality among the patients that we serve. Learn more about influenza vaccination, prevention and disease surveillance.

CAPT Thomas Weiser, MD, MPH is the Medical Epidemiologist for the IHS Portland Area Office and is assigned to the NW Tribal Epidemiology Center at the Northwest Portland Area Indian Health Board.

Dr. Chris Percy: National Leader in Health Promotion Programs, November 22, 2016 ]]>Dr. Chris Percy is a valued family medicine doctor and a leader in health promotion not only in the Indian Health Service but throughout Indian Country. Dr. Percy is Bi'ké Ts'in Diné (Wooden Shoe or Dutch people), born for the Irish people. He and his wife, Carol, grew up in Wisconsin. They have been a part of the Navajo family for more than 30 years, residing near and working with the Shiprock Service Unit of the Navajo Area IHS in northern New Mexico. His two sons, Matt and Sam, got their start in Shiprock and are now doctors themselves.

Many Diné (Navajo) families know Dr. Percy as a Family Medicine doctor at the Northern Navajo Medical Center where he has provided care for multiple generations - sometimes delivering babies while also taking care of their great-grandparents. He has been welcomed into many families and appreciates all the things his patients have taught him over the years. He enjoys working together with a caring team of doctors, nurses and other health professionals at Northern Navajo Medical Center. He also serves as the Director of the Division of Community Health in the Shiprock Service Unit and is the Director of the Shiprock Health Promotion Program.

Dr. Chris Percy (second from right) and his wife Carol (second from left) take time to take a photo with Northern Navajo Nation Fair parade attendees.
Dr. Chris Percy (second from right) and his wife Carol (second from left) take time to take a photo with Northern Navajo Nation Fair parade attendees.

Dr. Percy is a local and national leader in health promotion and wellness activities- working with people and communities to stay healthy and prevent illness. He is a role model in carrying out the mission of the Shiprock Health Promotion Program, which is Working Together to Build and Strengthen Healthy Families and Communities.

Traditional Navajo philosophy defines a healthy family or community as balanced with appropriate attention being given to stages of life and issues represented by the four directions -east, south, west and north. The Navajo Health Promotion Program is based on this positive model of wellness and partners with a variety of innovative programs.

Dr. Percy commented that to make a difference in prevention, it takes a whole group of partners working together. This is very evident in the Shiprock region where it is common to see people of all ages learning about their language and culture at a Restoring and Celebrating Family Wellness event, or thousands of people walking and running together at Just Move It events in every chapter, young people seeing a counselor or provider at a school-based clinic, a family making healthy food choices, or elders connecting to the next generation with storytelling.

Dr. Percy's energy and commitment was recognized in 2003 by the Director of IHS when he was asked to convene a group to strengthen prevention efforts for the entire IHS, including federal, Tribal and Urban health programs. He worked closely with Tribal leaders throughout the U.S. to bring about results such as sharing best and promising prevention practices, the growth of the national "Just Move It" physical activity promotion campaign, the establishment of a Healthy Native Communities Fellowship, and sharing community wisdom through a series of regional Community Wellness Champion Forums.

Through the efforts and leadership of Dr. Percy and partners in Shiprock, the programs Dr. Percy started have grown successfully. Each of the 12 IHS Areas now has a Health Promotion Coordinator. The Just Move It campaign reaches more than 350 Native communities across the U.S. and Canada. More than 300 Healthy Native Communities Fellows work together for wellness in their communities from Alaska to Maine. Hundreds of Native Digital Storytellers create and share authentic stories about wellness and hundreds more program partners have joined regional Native Wellness Networks in Alaska, California and New Mexico. These efforts are sustained across the country through tribal and community partners and the non-profit Healthy Native Communities Partnership.

Dr. Percy, a much beloved family medicine doctor at the Northern Navajo Medical Center, was the Grand Marshal for the 105th Northern Navajo Nation Fair parade. Shown here with his wife, son and grandchildren.
Dr. Percy, a much beloved family medicine doctor at the Northern Navajo Medical Center, was the Grand Marshal for the 105th Northern Navajo Nation Fair parade. Shown here with his wife, son and grandchildren.

Bringing together community members, local, State, Federal, Tribal agencies, private sector partners and traditional healers to implement the national IHS Health Promotion program is only the latest step in Dr. Percy's career-long commitment to social justice through empowerment for underserved populations. Whether it has been working with the Miskito Indian people of Nicaragua as a University of Wisconsin undergraduate, the local Health Boards of Boston's Neighborhood Health Centers while at Harvard Medical School, the Navajo people, or tribal members from Alaska to Maine, his path shows a focus on partnerships for wellness by building on local strengths to meet local needs.

Recently, this year's 105th Northern Navajo Nation Fair in Shiprock celebrated the foundation of wellness in traditional teachings and blessings. Chris and his wife, Carol Percy, were honored to be recognized as the Grand Marshals of the parade. Hundreds of spectators, including many of Dr. Percy's patients and wellness champions, cheered them on the parade route.

Dr. Percy is a graduate of Harvard Medical School, in Boston, Massachusetts. He completed his undergraduate degree at the University of Wisconsin in Madison. He did his residency at the University of Washington in Seattle, Washington. In addition, he has received numerous awards, including the American Medical Association's Dr. Nathan Davis Award for Outstanding Member of the Federal Executive Branch in Career Public Service and the National Indian Health Board National Impact Award.

CAPT Brian Johnson is the Acting Area Director for the Navajo Area Indian Health Service and serves as Director of the Office of Environmental Health and Engineering, IHS Navajo Area.

Public and Environmental Health Improves with the First Vacuum Sewer System on the Navajo Nation, November 16, 2016 ]]>Every autumn, farmers in Shiprock, New Mexico harvest, steam and dry their Indian corn to make traditional nas chizhi stew, a delicious and popular soup made with dried corn and meat, usually mutton or lamb. Fertile soils and irrigation canals make the town’s Mesa Farm area great for farming but problematic for on-site wastewater disposal. Over 300 homes in the area use septic tanks with drain fields to dispose of wastewater on-site. Irrigation raises the water table, preventing many drain fields from emptying properly. Instead, wastewater accumulates and then surfaces in yards or homes, causing serious environmental health concerns.

Mrs. Marilynn Johnson-King and 82 other families in the Mesa Farm area of Shiprock, New Mexico are grateful for the new vacuum sewer system that was completed in 2015, the first of its kind on the Navajo Nation. She lives in the same area where her grandparents lived and farmed for many years. Prior to the vacuum sewer system, the families in the area had water back-ups in the septic tanks. She commented that they couldn’t wash or use the washer because of the water and raw sewage was coming out of the homes and pooling.

Mrs. Marilynn Johnson-King and her neighbors in the Mesa Farm area near Shiprock, NM are thankful for the sewer system installed by the IHS Division of Sanitation Facilities Construction program.
Mrs. Marilynn Johnson-King and her neighbors in the Mesa Farm area near Shiprock, NM are thankful for the sewer system installed by the IHS Division of Sanitation Facilities Construction program.

Now, with the vacuum sewer system her family is able to do a lot of things that they didn’t do before and they don’t have to worry about getting sick. Mrs. King-Johnson says that her neighbors also like the idea of being connected to a sewer system because it feels healthier and it feels cleaner.

The project began in 2004 when Shiprock’s community leadership requested that the Indian Health Service Sanitation Facilities Construction program plan a community sewer system to eliminate the use of drain fields in the Mesa Farm area. The goal of the IHS Division of Sanitation Facilities Construction program is to improve the health of Native American people by improving access to sanitation facilities like water and wastewater infrastructure.

Initially, the IHS project team began planning a gravity sewer system. However, several obstacles were encountered in the rocky terrain of the Mesa Farm area. Flat topography required sewer depths exceeding 20 feet in some areas. Narrow roads and existing utilities like high voltage power lines and aging asbestos cement water lines provided little space for excavating the proposed deep trenches. The water table was near the surface in some places and the soil was unstable for trenches. The construction costs for a gravity sewer were too expensive.

The vacuum sewer system allows proper drainage and lowers environmental health concerns.
The vacuum sewer system allows proper drainage and lowers environmental health concerns.

Other types of sewer systems were investigated and the vacuum sewer system was determined to be more cost effective than a gravity sewer system. Vacuum sewer systems assist wastewater movement with the use of vacuum pumps and air valves. A vacuum sewer system usually allows for more line placement options, shallower trenches and easier field alignment changes. The capital costs for the vacuum sewer system can be significantly lower in areas where high groundwater, unstable soils, congested utilities, flat or difficult terrain, right-of-way restrictions or other challenges exist. Operations and maintenance costs may be higher for vacuum sewer systems unless one vacuum station can replace several proposed gravity lift stations. A vacuum sewer system may be the most economically feasible solution when site constraints make gravity sewer prohibitively expensive.

Other partners assisted in making the project a reality. The design of the vacuum sewer system was finalized in August 2013 and the Navajo Engineering and Construction Authority Exit Disclaimer: You Are Leaving, a tribal enterprise and contractor for the project, began construction that same month. The $2.8 million dollar project was completed in August 2015. The Navajo Tribal Utility Authority operates and maintains the system. The project successfully eliminated 83 septic tank and drain field systems in the Mesa Farm area. Several hundred homes in the Mesa Farm area are waiting for subsequent phases of the sewer project. This successful project will serve as a case study for other communities on the Navajo Nation seeking to extend community sewer services into areas where gravity sewer systems may not be feasible.

Although the families have to pay a small fee for the vacuum sewer services, Mrs. King-Johnson stated that the benefits far outweigh what one would have to pay for it and just having that peace of mind that one knows that you are safe and you are healthy. It also assures the community of Mesa Farm that there will be less disease due to water-borne illnesses in this rural Southwestern region, thanks to the Indian Health Service.

Colin Daly, P.E., Field Engineer, Office of Environmental Health and Engineering, Shiprock Service Unit, Navajo Area Indian Health Service.

IHS Offers Quality Continuing Dental Education, November 14, 2016 ]]>Dentists, dental hygienists and many dental assistants are required to complete a certain number of hours each year to maintain licensure by their state dental board. These educational courses are offered throughout the U.S., often at a substantial price. For dental staff in IHS and Tribal programs, attending outside courses involves not only the costs of the course but also travel expenses and, more importantly, time away from patients to meet these requirements. The Indian Health Service Division of Oral Health offers a Continuing Dental Education (CDE) program that allows dental staff to meet state licensure and certification requirements, often times without ever leaving their home dental program.

The art and science of dentistry is continuously evolving with the emergence of new technology and new approaches at addressing oral diseases. New and improved health care equipment combined with innovations in treatment and clinical procedures mean that Indian health dental professionals need to remain on top of such new developments. The IHS CDE program offers many opportunities for dental staff to be on the cutting edge of technology and advances in clinical interventions and offers the unique opportunity for IHS and tribal dental staff to receive culturally competent continuing education at the same time.

 Continuing Dental Education courses benefit IHS dentists, dental hygienists and dental assistants.
Continuing Dental Education courses benefit IHS dentists, dental hygienists and dental assistants.

In 2017, the IHS CDE program will consist of over 100 individual courses varying in length from one hour to one week, and an additional 50-75 courses are being planned for the year. While some courses are geared towards clinical dentistry, this year’s offerings include a strong emphasis on building public health leadership within the IHS by offering 15 courses for IHS dental leaders and those aspiring to be leaders in the future. A dentist who recently took the Area Dental Officer Concepts course remarked that as a result of his experiences, the course allowed him to foster working relationships with Area and National IHS leadership and provided him with an array of program resources to broaden his institutional knowledge base.

In recent years, the IHS has placed a renewed emphasis on utilizing expanded function dental assistants to provide clinical services. In 2016, the IHS certified more than 70 dental assistants to provide these clinical services, all who must go through intense training through a week-long course followed by additional work in their home clinic.  One expanded function dental assistant and dental assistant supervisor at the San Carlos Apache Healthcare Corporation located in Arizona benefited tremendously from the expanded function CDE offered. A dental assistant supervisor there, stated that the IHS CDE Program has had a phenomenal impact on her program. The courses that were made available to the dental assistants definitely helped them in increasing patient care, as far as their ability to place restorations or fillings. The courses also helped to build their confidence and enabled them to take pride in their work and services provided in the dental program.

The impact of this IHS CDE program extends to all dental staff in IHS and Tribal programs across the country. Dr. Joe Salamon, the Chief Dentist at the Seneca Nation of Indians in New York, noted that the CDE program strengthened his clinical competency and provided communication, collaboration and comradery with fellow early career IHS dentists along with more seasoned practitioners they serve with.  Similarly, Juanita Simpson, a dental hygienist at the Warm Springs Service Unit in Oregon, remarked that as an experienced IHS dental hygienist, she has learned ways to address the challenges of the many disparities that they treat on a daily basis such as access to care, treatment, prevention, grant writing, goal setting, accountability and last but not least networking. Furthermore, the dentists have increased access to quality care by attending IHS Challenges and utilizing dental assistants who because of IHS CDE can do restorations and assist with dentures.

Perhaps Dr. Todd Smith, the IHS National Periodontal Consultant who is based at the Phoenix Indian Medical Center in Arizona, summed it up best when he said that the one reason many serve a career with the IHS is the dedicated professionals he has met over the years at IHS sponsored face to face meetings and courses where friends are made, comradery established and best practices for patient care are shared. These CDE courses are critical as they fill a knowledge void regarding culturally sensitive, effective public health practices that can be implemented in our service areas.

IHS is committed to providing a high quality continuing dental education program that provides culturally competent education on the latest technological and clinical approaches to preventing and intervening in oral diseases. Learn more about the programs that are offered and upcoming deadlines. 

CAPT Timothy Ricks, DMD, MPH, is the deputy director in the IHS Division of Oral Health and the IHS Continuing Dental Education Coordinator.

Indian Health Service launches telehealth program to expand health care access for native veterans, November 10, 2016 ]]>The Indian Health Service has launched an exciting new program using telehealth to improve the health status of American Indian and Alaska Native veterans. The partnership will allow eligible veterans at IHS facilities to be seen and treated by physicians at VA medical centers through the use of technology such as videoconferencing, transmission of still images, electronic health records and remote monitoring of vital signs.

By working together to advance telehealth services, we can increase access to care for our native veterans. The IHS and the VA both face challenges in providing care in rural areas, including access to transportation. This program will allow patients to receive specialized care nearer to home instead of travelling long distances to see a specialist. By expanding access to specialty care, we are improving the quality of health care our patients receive.

IHS Western Oregon Service Unit Director of Nursing Michelle Livingston, R.N., demonstrates the new telehealth system at the Chemawa Health Center in Salem, Ore. Livingston, a veteran, has worked with the Department of Veterans Affairs to develop protocols and implement the new telehealth service.
IHS Western Oregon Service Unit Director of Nursing Michelle Livingston, R.N., demonstrates the new telehealth system at the Chemawa Health Center in Salem, Ore. Livingston, a veteran, has worked with the Department of Veterans Affairs to develop protocols and implement the new telehealth service.

The first IHS facility participating in the new program is the Chemawa Health Center in Salem, Oregon. This is a comprehensive family health care facility serving American Indians and Alaska Natives from more than 100 tribes.

Individuals eligible for care from both IHS and the VA will receive specialized behavioral health care from VA providers in the IHS facility through telehealth. Collaboration between the IHS care team and VA specialists will strengthen the patient-centered care provided to veterans as they move forward. There are approximately 300 American Indian and Alaska Native veteran patients in the Chemawa Health Center service area. The new system is operational and we are getting the word out to native veterans in the area.

Telehealth services use electronic communications to facilitate the provision of health care, with clinical appointments provided remotely, as well as some nonclinical services such as provider training. In some cases, specialty care furnished through telehealth is supplemented by a nurse or assistant who is co-located in the room with the patient. Telehealth delivery is provided in a private office and the connection is encrypted to protect patient privacy. IHS has found that telehealth can be one of the best ways to get health care services where they are needed most.

IHS has a long history of using telehealth to meet the needs of patients:

  • The IHS TeleBehavioral Health Center of Excellence was established in 2009 to provide behavioral health services for patients across the Indian health system. The Center works to provide, promote and support the delivery of high quality, culturally competent telebehavioral health services to American Indians and Alaska Natives. Read more:
  • The IHS Teleophthalmology Program was established in 2001 to screen IHS patients across the country for diabetic retinopathy, the leading cause of blindness in patients with diabetes. Read more:

The new initiative builds on an existing IHS-VA partnership of coordination, collaboration, and resource-sharing between VA and IHS. Other examples of the partnership include the use of the VA’s Consolidated Mail Outpatient Pharmacy to increase efficiency and reduce cost for prescriptions, and reimbursement for services provided to eligible American Indian and Alaska Native Veterans.

Dean M. Seyler, a member of the Confederated Tribes of Warm Springs Reservation of Oregon, joined IHS in 1995. The Portland Area IHS serves more than 100,000 American Indians/Alaska Natives, primarily members of the 43 federally recognized Tribes in Oregon, Washington, and Idaho.