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
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
The health system
Delivery system design
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.