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A Beacon in the Labyrinth of the Indian Health Service

Sofer, Dalia

AJN The American Journal of Nursing: April 2017 - Volume 117 - Issue 4 - p 14
doi: 10.1097/01.NAJ.0000515215.07839.39
In the News

The success of a diabetes program offers hope.

Dalia Sofer

Amid a seemingly unrelenting stream of discouraging news about the Indian Health Service (IHS), an innovative, team-based diabetes treatment and prevention program has succeeded in reducing by more than half the incidence of diabetes-related kidney failure among Native Americans.

Native Americans are twice as likely as whites to have diabetes, and in about two out of three Native Americans with kidney failure, diabetes is the cause, according to the Centers for Disease Control and Prevention (CDC). However, between 1996 and 2013, kidney failure from diabetes dropped by 54% among Native Americans as a result of the Special Diabetes Program for Indians (SDPI), which provided funding for telemedicine consults and other types of community outreach.

The achievement is a bright spot in otherwise bleak federal assessments of the IHS in recent years. The agency was created in 1955 to provide health care to Native Americans (American Indians and Alaska Natives), and today operates a network of 45 hospitals and 617 health centers and clinics that employ 15,369 people (including 2,648 nurses) and serve 2.2 million members of 567 federally recognized tribes.

But difficulties have dogged the agency. A congressional investigation in 2010 of IHS services in four states—South Dakota, North Dakota, Nebraska, and Iowa—found that mismanagement, lack of employee accountability, financial mishandling, and insufficient oversight had negatively affected the quality of health care provided to 18 Indian tribes. In 2014, the IHS hospital in Winnebago, Nebraska, lost its Medicare and Medicaid certification following multiple reports of patient safety violations, according to a report in Modern Healthcare, which also noted close calls in 2016 for South Dakota's IHS Pine Ridge and Rosebud hospitals, and the forced closure of the ED at the IHS's Sioux San Hospital owing to substandard conditions. And, as recently as January, the Government Accountability Office echoed some of Congress's 2010 findings, citing “a lack of agency-wide performance standards and significant leadership turnover.”

Underlying these performance problems are budgetary ones. In fiscal year 2016, the IHS's budget was $4.8 billion, resulting in spending of about $3,700 per year per patient—far below the per capita U.S. health spending of about $9,500 per year. This disparity translates into lesser care for Native Americans, about 13% of whom are in “fair or poor health,” with the leading causes of death being heart disease, cancer, and accidents, according to the CDC.

Amid these challenges, the diabetes program—established by Congress through the Balanced Budget Act of 1997—has managed to achieve remarkable success. Under the program, IHS facilities and other Indian health centers are eligible to receive $150 million per year for diabetes treatment and prevention services.

The Public Health Nursing Department at the Zuni Comprehensive Community Health Center in New Mexico is one participant in the program. Gayle Romancito, RN, a renal case manager there, told AJN that use of telemedicine has been key to the SDPI's success at her center because it allows patients to continue consultations with Dr. Andrew Narva, a nephrologist who served the community for nearly 25 years before leaving in 2009. Another critical component has been community outreach. “There is a lot of fear around chronic kidney disease, and part of my job is to dispel these fears,” said Romancito. She explained that to make sure patients show up to their appointments, they are contacted multiple times, and transportation is arranged when necessary. “I don't want to call myself a nag,” she laughed, “but outreach and persistence are what helped.”—Dalia Sofer

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