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Addressing Critical Concerns of Healthcare Systems Serving American Indians/Alaska Natives

Disease Management & Prevention


Christine G. Williams, M.Ed., Director, Office of Health Care Information, Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services, Rockville, MD.

Timothy D. Noe, M.Div., Deputy Director, Healthy Nations National Program Office, Department of Psychiatry, University of Colorado Health Sciences Center, Denver, CO.

Simone Carter, R.N., Coordinator, Houlton Band of Maliseet Indians Diabetes Program, Houlton Band of Maliseet Indians Health Department, Houlton, ME.

Putting Prevention into Practice

A number of Federal prevention initiatives are currently under way:

  • Healthy People 2010 presents national health objectives in 10 areas.
  • AHRQ has convened the U.S. Preventive Services Task Force to develop the Guide to Clinical Preventive Services. An expert panel met in 1984 and 1998 to develop/update recommendations for preventive services in clinical settings.
  • The Centers for Disease Control and Prevention has convened the Task Force on Community Preventive Services to develop the Guide to Community Preventive Services, with population-based interventions geared to State and local communities.
  • AHRQ has also developed the Putting Prevention into Practice (PPIP) program, with strategies to implement the recommendations of the U.S. Preventive Services Task Force. Its goals are to increase appropriate use of clinical preventive services and to help providers, patients, and health systems track preventive care. Resources and tools are available for both providers and for patients (with the understanding that empowering patients is an important piece of effective prevention). The program partners with other entities to "get the word out"; partnerships for American Indians/Alaska Natives (AI/AN) outreach include the National Indian Council on Aging, Indian Health Service (IHS, particularly area offices and service unit directors), tribal health directors, and urban health directors.

Resource materials connected with the Guide to Clinical Preventive Services and the Guide to Community Preventive Services will be published chapter by chapter, because the entire updates are not expected to be completed before 2002.

Healthy Nations Initiative

The Healthy Nations Initiative is a national program sponsored by The Robert Wood Johnson Foundation (RWJF) to prevent and reduce substance abuse among AI/AN. Begun in 1993, the initiative has provided a total of $13.5 million in 6-year grants to 14 grantees, including both tribes/reservations and urban Indian programs/community entities.

All grantee sites have developed or facilitated communities' development of four program areas:

  • A public awareness campaign.
  • Multifaceted communitywide prevention efforts.
  • Early identification and treatment.
  • Accessible options for aftercare.

How these are implemented is left to the grantee sites. Timothy Noe stressed that neither RWJF or the initiative's national office could be prescriptive, as the grantees understand what works in their communities far better than outside entities.

An analysis of the initiative is currently under way. Mr. Noe asserted that it appears the initiative has been very successful in increasing interest in dealing with substance abuse, changing health behaviors, and getting more tribal members involved. Flexibility in use of funds appears to have had a direct impact on the initiative's success.

Successful strategies developed by the grantees include:

  • Increasing community capacity and ownership through such strategies as:
    • Creating self-sustaining nonprofit coalitions.
    • Convening volunteer advisory boards and action teams to develop and implement projects.
    • Training village-based counselors who then develop community teams and projects.
    • Distributing mini-grants to community groups to develop projects.
  • Use of cultural knowledge, values and practices, both indigenous and mainstream. Mr. Noe commented that the Initiative has become an impetus for traditional cultural renewal in many of these communities.
  • Knowledge dissemination and accessing resources through biannual grantee meetings, a website/discussion forum, and sharing of information technology.

Successful activities include mentoring, recreation activities promoting healthy lifestyles, translating national initiatives into local programming, and technology (especially in urban areas).

Strategies for sustaining projects include:

  • Integration into existing departments and infrastructure.
  • Community groups taking ownership.
  • Securing grants and contracts.
  • Wholesale adoption.
  • Tribal/organizational collaboration with the community.
  • Endowments.

Houlton Band of Maliseet Indians Diabetes Program

The Houlton Band of Maliseet Indians Diabetes Program has developed innovative disease management strategies to meet the challenges of tracking and improving care when multiple providers share care for tribal members with diabetes. The Health Department is a contract facility in rural Maine, offering direct services on a part-time basis with a physician available 16 hours per week. Tribal members obtain care from various physicians in the community.

Simone Carter developed business cards that people with diabetes could carry in their wallets, to help them better understand their own health status and care. Know Your Numbers cards allow people to compare their lab test values with target values. Ms. Carter has provided one-on-one education as to why these lab tests are important and suggested presenting these cards during doctor visits.

The Tribal Health Department participates in an IHS pilot project called Diabetes Care Partnerships. Ms. Carter completed the following process as part of that project:

She developed an inventory of diabetes services offered by the Tribal Health Department. These services include:

  • Diabetes education/nutrition counseling.
  • Blood glucose monitoring supplies.
  • Social service/behavioral health counseling.
  • An exercise program.
  • Vouchers for dental care.
  • Immunizations.
  • Foot care.
  • Community health representatives.

She formalized systems for managing and measuring data. These include:

  • Developing a diabetes registry.
  • Determining the methods for data collection and maintenance.
  • Creating and implementing information releases.
  • Determining how best to share data with providers.

The next step was to enlist community support. The partnership project gained visibility by networking with local healthcare organizations and hospital discharge planners.

To introduce the partnership idea to physicians, the Health Department held a dinner in which physicians received continuing medical education credits for listening to the latest research on standards of care and quality benchmarks for diabetes. The dinner was covered by the local news media.

To establish partnership agreements, a list of providers was prioritized according to number of patients with diabetes served and a past relationship with the Health Department. In approaching a physician, Ms. Carter emphasized how partnering would decrease the practice's workload. If the physician agreed to partner, a key contact person was established (usually a nurse).

Once a partnership agreement was established, Ms. Carter made quarterly visits to the practice. The contact person pulled the charts in advance; Ms. Carter reviewed the charts and updated the Diabetes Care Flow Sheet she created reflecting IHS standards of care. She shared the results of this review with the contact person.

The Diabetes Partnerships have shown success in improving communication, coordinating care in a more comprehensive way, and improving the quality and quantity of patient data. Since the partnerships began in May 1999, diabetes-related preventive care has resulted in the following:

  • Blood glucose and hemoglobin A1C levels have decreased.
  • Education on diet, exercise, and diabetes management have increased.
  • Immunizations have increased.
  • Foot, eye, and dental exams have increased.
  • The number of lab tests ordered has increased.

Ms. Carter noted that other health facilities could implement such methods. She asserted that the key is assigning responsibility to one person for case management and ensuring that information is kept up to date.


Acton K. A critical issue: blood sugar control. Albuquerque (NM): National Indian Council on Aging; 1999.

Adelman AM, Harris RI. Improving performance in a primary care office. Diabetes 1998 Oct;16(4):1-9.

AHRQ research on diabetes care. Rockville (MD): Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; 2000 Feb. AHRQ Pub. No.00-P020.

Put Prevention Into Practice: availability of materials. Rockville (MD): Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; 2000 Jan. AHRQ Pub. No.00-P029.

Put Prevention Into Practice: overview. Rockville (MD): Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; 2000 Feb. AHRQ Pub. No.00-P028.

The U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; 2000 Apr. AHRQ Pub. No.00-P046.

About the Healthy Nations Initiative. Denver (CO): Healthy Nations Initiative, University of Colorado Health Sciences Center; 1996.

Healthy Nations Initiative grantee list. Denver (CO): Healthy Nations Initiative, University of Colorado Health Sciences Center; 1996.

Information about host community organizations: Minneapolis American Indian Center, Northwest New Mexico Fighting Back, Inc., Eastern Band of Cherokee Indians of North Carolina, Confederated Tribes of the Warm Springs Reservation of Oregon, White Mountain Apache Tribe Fort Apache Indian Reservation, Seattle Indian Health Board, United Indian Health Services, Inc., Norton Sound Health Corporation, Confederated Tribes of the Colville Reservation, Circle of Strength, Confederated Salish and Kootenai of the Flathead Reservation, Cheyenne River Sioux Tribe of the Cheyenne River Reservation, Cherokee Nation of Oklahoma, Central Council of Tlingit and Haida Indian Tribes of Alaska. Denver (CO): Healthy Nations Initiative, University of Colorado Health Sciences Center; 1996.

Heath SW. Disease management guidelines: promoting quality care and cost effective prescribing behaviors. The IHS Prim Care Provider 1998 Jul;23(7):85-7.

Zoorob RJ, Hagen MD. Guidelines of the care of Diabetic nephropathy, retinopathy, and foot disease. Am Fam Phys 1997 Nov 15;56(8).

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