**ISSUE UPDATE for FY 2005**

**VHA and IHS Support for American Indian / Alaska Native Veterans**

**ISSUE**

Over the last two years, Indian Health Service (IHS) and Veterans Health
Administration (VHA) have implemented a memorandum of understanding
(MOU) to promote greater cooperation and sharing between the two health
services to enhance the health of American Indian and Alaska Native
veterans. This brief summarizes the progress made under the MOU to date
and highlights a few of the more than 150 activities and programs
undertaken in FY2005.

**BACKGROUND**

American Indians and Alaska Natives (AI/AN) have a distinguished history
of exemplary military service to the United States. They have served in
high numbers and were often assigned to forward combat areas. As a
result, they have a wide range of combat related health care needs.
AI/AN veterans may be eligible for health care from VHA or from IHS or
both. Despite this dual eligibility, Indian veterans report the highest
rate of unmet health care needs among veterans and exhibit high rates of
disease risk factors.

**PROGRAM SUMMARY**

The MOU between the Departments of Health and Human Services and
Veterans Affairs, specifies five objectives to enhance the health of
AI/AN veterans; (1) improving communication, (2) encouraging partnership
and sharing, (3) expanding access to health services for Indian
veterans, (4) ensuring organizational support, and (5) improving health
promotion and disease prevention services.

**[National Activities]{.underline}**

The Office of the Deputy Under Secretary for Health for Health Policy
Coordination (DUSH / HPC), 10H, is the principal office responsible for
coordinating implementation of the MOU within VHA. The office works with
the leadership and staff of VHA and IHS to identify priority actions and
ensure they are carried out. The office fosters progress on national
initiatives and supports local implementation activities through the
annual VHA strategic planning process and quarterly VISN monitoring
system.

*Communication*: The Headquarters Advisory group meets monthly, the
Steering Committee meets three times each year and the Area and Network
Directors have twice been convened to discuss priorities and coordinate
activities. A FAQ sheet about the collaborations has been developed, an
annual report was produced in August 2004, and an implementation guide
highlighting best practices was completed in January 2005. A website is
under development. VHA has initiated connections to tribal and national
AI/AN organizations such as the National Indian Health Board and
National American Indian Veterans, Inc. Briefings and presentations
about the partnerships have been made at more than a dozen events around
the country.

*Sharing and Collaboration*: VHA Employee Education Service (EES) and
the Nashville Area of IHS signed an operational agreement in April 2005
to implement a sharing demonstration of VHA educational resources with
IHS and tribes in the region. A password protected website has been
established to provide IHS staff with electronic educational materials
and to provide and track continuing education credits. Twenty programs
were made available to IHS staff in 2005.

VHA and IHS have a long partnership of sharing in software development,
and new activities are underway to enhance this partnership. The VHA/IHS
Information Technology Collaboration has developed a five-point work
plan and has established a shared website to facilitate joint project
management. An Interconnection Security Agreement that paves the way for
direct network-to-network electronic communication has been signed. A
project agreement for IHS use of VISTA imaging has been drafted and is
under review. IHS and VHA staff are regularly attending the planning,
development and training meetings of the other agency.

*Expanding Access*: Access is focused at the local level. However, the
national telehealth collaboration supports the use of telehealth to
provide remote access to health services for AI/AN veterans. In April
2005, eighteen IHS staff attended the annual VHA telehealth coordination
meeting for the first time. During the meeting, VHA agreed that IHS and
tribal representatives will join each VHA VISN-level telehealth
coordination workgroup and two test sites for joint network development
were identified; the Billings Area IHS and the Utah telehealth network
(which includes tribes.)

*Organizational Support*: VHA has developed an implementation guide that
shares best practices with the field. Both VHA and IHS require progress
reports from the field on collaboration and the expansion of services to
AI/AN veterans. VHA sharing is an element of the IHS Area Directors
performance contract with the Director of IHS. Starting in 2005, VHA
requires that each facility provide access to American Indian spiritual
practices equivalent to that provided for other religious affiliations.
EES is developing a national Tribal Veteran Representative training
curriculum.

*Health Promotion / Disease Prevention*: IHS / VHA workgroups in
Diabetes Prevention and Behavioral Health were established. On the
recommendation of the Diabetes Prevention workgroup, three diabetes
prevention partnerships were funded in Albuquerque, Los Angeles and San
Diego. The programs incorporate primary prevention measures, including
diet modification and physical activity, into activities targeted to
AI/AN veterans.

The Behavioral Health workgroup developed a framework for AI/AN
communities to assist the 3,668 returning Operations Iraqi Freedom and
Enduring Freedom (OIF/OEF) AI/AN service members and veterans
reintegrate with their families and communities and readjust to civilian
life. The objective is to promote a community health model that gives
tools to Tribal communities and families to help returning veterans
address emerging adjustment reactions, traumatic stress, and Post
Traumatic Stress Disorder (PTSD), emphasizing recovery as the goal.
Outreach and informational materials have been developed and, to date,
have been shared directly with four Tribes for local customization and
adaptation. The program also includes education for local VHA, IHS and
Tribal clinical staff on special health care concerns that arise
following combat exposure; and training for VHA staff on cultural and
spiritual needs of AI/AN veteran patients.

Three projects have been funded to pilot-test evidence-based mental
health treatment resource kits for use with veteran and AI/AN veteran
populations.

**[IHS Area and VHA Network Activities]{.underline}** (Examples,
**Attachment 1**)

*Communication*: In FY2005, VISNs reported more than 120 contacts with
IHS, Tribal leaders or AI/AN veteran groups. Nearly two-thirds of these
discussions occurred directly with Tribes.

*Sharing and Collaboration*: The Networks reported more than 25
agreements to promote sharing and collaboration in FY2005. Projects
included the sharing of space, information technology expertise,
educational programming, joint purchasing, and contracting for
laboratory or diagnostic services.

*Access*: By the end of FY2005, VISNs reported more than 20 programs
that expand access to services for AI/AN veterans. For example, Network
19 reported nearly 300 telepsychiatry patient contacts, 84 veteran
participants in traditional ceremonies or native healer consults, and
the completion of a residential substance abuse treatment program by 10
patients. Other programs around the country include a dedicated AI
coordinator to assist with nursing home placements, Tribal/reservation
based CBOCs, telehealth home health care, telecardiology services,
emergency room care agreements and reservation based housing for
homeless AI/AN veterans. Network 18 reported an overall 17% increase in
the number of AI/AN patients served in FY2005.

*Organizational Support*: At the local level, organizational support
frequently manifests as VHA sponsored health fairs, pow wow or homeless
stand downs for AI/AN veterans, often held on or near a reservation.
VISNs reported holding or participating in more than 70 such events in
FY2005.

*Health Promotion / Disease Prevention*: Three Networks reported
prevention oriented programs: OIF/OEF readjustment outreach in VISN 18
and 20 and health promotion programs in VISN 18 and 22.

**[Two Year Review]{.underline}**

The Steering Committee (SC) met in April 2005 to review progress under
the MOU, hear from veterans and Tribal leaders, and determine if changes
were needed to the agreement. The SC recommended that the MOU and the
programs under it continue unchanged. However, the SC expects to see a
greater emphasis on communication, outreach and the sharing of program
and benefit information with veterans and Tribes including information
on housing programs and support for homeless AI/AN veterans. In
addition, the leadership of each organization has been asked to develop
a joint policy for the coordination of health care for dual use
veterans. Finally, the development of a new home health care
demonstration for long term care elderly patients is expected.

**ATTACHMENT 1**

Examples of IHS / VHA Sharing and Collaboration Activities

FY2005

+-------------------------+-------------------+------------------------+
| **PROGRAM EXAMPLES**    | **LOCATION**      | **COMMENT**            |
+-------------------------+-------------------+------------------------+
| ***Access***            |                   |                        |
+-------------------------+-------------------+------------------------+
| 1.  Telecardiology      | SC, IHS at        | 12 clients served to   |
|     Services            | Rockhill          | date                   |
+-------------------------+-------------------+------------------------+
| 2.  Patient diet        | NM, IHS Gallup    | IHS provided           |
|     counseling          |                   | counseling for VA      |
+-------------------------+-------------------+------------------------+
| 3.  Home based care     | AZ, LA            | Telehealth enabled     |
+-------------------------+-------------------+------------------------+
| 4.  Tribal staffed CBOC | OK, Choctaw       | 1000 vets; save 130    |
|                         | Nation            | mile drive             |
+-------------------------+-------------------+------------------------+
| 5.  ER diagnostic /     | OK, Choctaw       | Saves 2 hour emergency |
|     treatment           | Nation            | trip                   |
+-------------------------+-------------------+------------------------+
| 6.  Health fair prevent | LA, Jena Band     | Enrolled vets w/       |
|     screen              | Choctaw           | presumptive Dx         |
+-------------------------+-------------------+------------------------+
| 7.  Mental Health       | AZ, reservation   | 2 group; 63 indiv      |
|     Therapy             | based             | consults Q2            |
+-------------------------+-------------------+------------------------+
| 8.  Telepsychiatry      | WY                | @ 100 patient          |
|                         |                   | contacts, Q2           |
+-------------------------+-------------------+------------------------+
| 9.  Residential SA      | UT                | Eight patients         |
|     treatment           |                   | completed              |
+-------------------------+-------------------+------------------------+
| 10. Co-management       | > SD/ND; Pine     | IHS staff can view VA  |
|     w/CPRS              | > Ridge, Ft.      | records for all shared |
|                         | > Yates, Eagle    | patients               |
|                         | > Butte           |                        |
+-------------------------+-------------------+------------------------+
| 11. Homeless Housing    | > SD, Pine Ridge  | Building dedicated Nov |
|                         |                   | 2005                   |
+-------------------------+-------------------+------------------------+
| 12. Vet Centers         | > AZ, SD, OK, AK  | > Hopi, Navajo, Pine   |
|                         |                   | > Ridge, Rosebud,      |
|                         |                   | > Tahlequah, AK Native |
|                         |                   | > Villages             |
+-------------------------+-------------------+------------------------+
| 13. Shared FTE veteran  | > NC, Cherokee    | 108 clients served     |
|     coord.              | > Hospital        | FY2005                 |
+-------------------------+-------------------+------------------------+
|                         |                   |                        |
+-------------------------+-------------------+------------------------+
| ***Sharing &            |                   |                        |
| Collaboration***        |                   |                        |
+-------------------------+-------------------+------------------------+
| 1.  Radiology and       | KS, Haskell       | 100-200 reads / month  |
|     Pathology           | Nation            |                        |
+-------------------------+-------------------+------------------------+
| 2.  Space Lease         | WI, Ho-Chunk      | 5,661 sq ft space      |
|                         | Nation            | leased                 |
+-------------------------+-------------------+------------------------+
| 3.  Tribal College      | OK, Cherokee      | Training for student   |
|     affiliation         | Nation            | RN, opt, rad           |
+-------------------------+-------------------+------------------------+
| 4.  Laboratory contract | TX                | \$3,361 revenue        |
|                         |                   | generated Q2           |
+-------------------------+-------------------+------------------------+
| 5.  PTSD education      | AK                | Prepare IHS for        |
|     training            |                   | OIF/OEF vets           |
+-------------------------+-------------------+------------------------+
|                         |                   |                        |
+-------------------------+-------------------+------------------------+
| ***Organizational       |                   |                        |
| Support***              |                   |                        |
+-------------------------+-------------------+------------------------+
| 1.  Veteran Tours of    | NC, Cherokee      | Tours introduce AI     |
|     VAMC                | Hospital          | vets to VA             |
+-------------------------+-------------------+------------------------+
| 2.  Credentialing       | NC, Cherokee      | Smooth referral,       |
|     Tribal staff        | Hospital          | access CPRS            |
+-------------------------+-------------------+------------------------+
| 3.  Share patient edu   | VISN 12, Bemidji  |                        |
|     material            | IHS               |                        |
+-------------------------+-------------------+------------------------+
| 4.  Tribal veteran rep  | VISN 23, 19, 18,  |                        |
|     training            | 12                |                        |
+-------------------------+-------------------+------------------------+
| 5.  Weekly talking      | AZ                | PTSD patients enrolled |
|     circle              |                   |                        |
+-------------------------+-------------------+------------------------+
| 6.  Full Time AI        | AZ                | Assist nursing home    |
|     Coordinator         |                   | placement              |
+-------------------------+-------------------+------------------------+
|                         |                   |                        |
+-------------------------+-------------------+------------------------+