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Director's Initiatives Chronic Disease Management

Director’s Chronic Care Initiative


Chronic conditions such as diabetes, cardiovascular disease, asthma, renal disease, depression, and cancer have become increasingly prevalent in American Indian and Alaska Native communities and are placing growing demands on health care systems. Given the limited available resources, there is an urgent need for a strategic plan to address the treatment and prevention of chronic conditions in the Indian Health Service (IHS) health care system.


The goal of this initiative is to develop a process for the IHS to effectively and efficiently address chronic conditions. A strategic plan will be developed using a model for chronic illness care created from the experience of the IHS Division of Diabetes Treatment and Prevention, the Chronic Care Model, the WHO Innovative Care for Chronic Conditions Framework, and the Institute of Healthcare Improvement. These models and experience suggest that our approach to chronic conditions can be improved by creating a health care system that is practical, supportive, population-based, and evidence-based. The system should promote an interactive relationship between informed, motivated patients and a health care team that is prepared and proactive. The Chronic Care Model has been successfully applied to a variety of chronic illnesses, health care settings, and target populations.

To accomplish this goal, the agency will focus on these strategic areas:

  • Create a positive policy environment by establishing funding sources, a project management team, and a multi-disciplinary team from within and outside of IHS to develop expertise in specific areas of chronic disease prevention and care.
  • Create an executive committee and designate an executive leader responsible for moving the process forward.
  • Create multi-disciplinary workgroups to focus on aspects of implementing this chronic disease initiative such as communication, information technology, measurement, training, and pilot programs.
  • Describe current activities and enhance future activities around chronic illness care using the six elements from the Chronic Care Model. These elements are:
    • The community
    • The health system
    • Self-management support
    • Delivery system design
    • Decision support
    • Clinical information systems
  • Leverage resources and raise awareness about chronic conditions by establishing community partnerships and working with advocacy groups, non-profit organizations, and other federal agencies.
  • Focus on patient and family by developing and testing culturally appropriate and known effective education materials for people at risk of chronic conditions and those with existing chronic conditions.
  • Conduct continuous evaluation by tracking and reporting agreed upon measures.

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This file last modified: Tuesday July 22, 2008  9:43 AM