Name of Area: \_*[Albuquerque]{.underline}*
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Introduction:**

The Albuquerque Area is in the process of developing a Strategic Plan
that will integrate the Directors three initiatives 1) Behavioral Health
2) Health Promotion/Disease Prevention (HPDP) and 3) the Management of
Chronic Disease with input from our tribal communities. Although much
work has already been done, through surveys and forums conducted via
Behavioral Health and the HPDP Programs, several other projects
developed by the Area Diabetes Programs and coordinated for Chronic
Disease Management have also been initiated and serve as examples of
activities for the integration of all 3 initiatives.

In addition to our focus on integrating the 3 initiatives, the
Albuquerque Area has approached planning activities for FY 2006 by
focusing on community needs identified by our Area tribes and developing
programs to address changes due to the State of New Mexico's Behavioral
Health Redesign as our immediate priorities.

What follows is a description of the planning and implementation
activities that have already occurred, as well as our ideas for
completing the integration of all 3 initiatives into a Strategic Plan
during the 2007 fiscal year.

**BEHAVIORAL HEALTH:**

In 2005 the State of New Mexico implemented a complete redesign of their
Behavioral Health System (BH). All State Agencies that had previously
provided any type of BH funding were asked to contribute their dollars
into a single fund that would be managed by the "State Entity". Value
Options was selected as the contractor (State Entity) that would manage
all behavioral health program funds, including Medicaid, Medicare and
3^rd^ party reimbursements for Behavioral Health Program services.

Organizationally, the State was divided into Six geographic Region's,
with Native American Communities comprising the entire State of New
Mexico and receiving the designation as Region Six. Each Region is
represented by a "Local Collaborative" (LC). The purpose of the LC is to
serve as the voice of the community in the process of identifying
existing services and more importantly identifying the unmet Behavioral
Health needs in each community.

The Region Six Local Collaborative Council (RSLCC), initially chaired by
the Area IHS, was formed with approval from the All Indian Pueblo
Council, a governmental body consisting of the Governor's from each of
the 19 Pueblo Tribes, the Mescalero Apache Tribe, the Jicarilla Apache
Nation and the To'Hajiillee Navajo community to coordinate the
development of a Native American Local Collaborative. The RSLCC was
formally recognized on May 2, 2006.

The RSLCC is organized geographically around the 7 Service Units in the
Albuquerque Area and also has an identified Urban group. The tribes
comprising each Service Unit have been collectively designated as a
Service Area and each of these 8 Service Areas is represented by tribal
members and IHS staff that function as a Community Advisory Board (CAB).
The CABs serve as the voice of the tribal communities and Service Areas
they represent, send members to all RSLCC, State and other related
organizational meetings, and assist in getting information to their
tribal leaders and community members, as well as assist in the various
data gathering activities required by the State Behavioral Health
Planning Council.

As the foundation for the Local Collaborative has been developed and the
Community Advisory Boards are becoming more active in voicing the needs
of their communities, the tribes are beginning to assume most of the
responsibilities that were initially provided by the IHS. Although the
IHS continues to work closely with the Management Council in
coordinating the most activities, the of primary focus at this time is
in obtaining involvement from Service Unit staff and community members
in the formation of the Community Advisory Boards.

**TRAININGS:**

The following trainings have been provided to IHS sand Tribal staff in
an effort to enhance service delivery in each community. Training topics
were identified by asking community providers to complete a training
survey designed to identify the top ten training priorities. Once these
topics were identified a training schedule was developed for the FY.
What follows is a listing of the trainings provided:

-   8 Communities received Suicide Awareness Presentations, with an
    average of 25 participants attending each presentation.

-   2 Applied Suicide Intervention Skills Training's were conducted with
    25 participants attending each training.

-   A 2 day training on Methamphetamine addiction and Treatment
    Alternatives was provided with 35 providers participating.

-   A two day workshop on "Mood Disorders" was provided with 35
    participants attending. Attendees learned to recognize the basic
    symptoms of clients experiencing a wide range of affective
    disorders, as well as effective treatment approaches.

-   Two 2 day trainings on Motivational Interviewing were conducted with
    Behavioral Health, Substance Abuse, CHR's and HPDP Coordinators
    attending.

-   A 2 day training in the Community Reinforcement Approach to
    treatment was conducted with 40 participants attending.

-   A 2 day training on Clinical Supervision, with a one day Train the
    Trainers component was conducted with 30 participants attending.

**DATA COLLECTION:**

As a means of obtaining information on the existing Behavioral Health
Services in each community, the communities view and utilization of
these services and information on service gaps, and unmet needs in each
community the RSLCC conducted a survey of community providers and
service programs, plus a survey of community members who use these
available services. One hundred eighty nine surveys were completed. The
RSLCC also administered a survey during Indian Day at the State Fair,
obtaining an additional 73 completed survey's.

Additional data collection activities involved conducting a BH needs
assessment, a BH Resource Inventory and 9 Focus Group Forums that were
conducted in 9 tribal communities and were designed to obtain health
need information from active clients.

The survey data and Resource Inventory information is in the process of
being analyzed and will be used to identify available resources,
identify services gaps and used to strategically plan methods of
addressing the identified service gaps.

The Focus Group data was used to develop the top 5 priority Behavioral
Health service needs and further narrowed to the top 2 priorities that
were submitted to State Legislators for consideration of funding
appropriations for 2007. The top two priorities identified were:

1)  The maintenance of existing services or services that would
    otherwise not be

> able to continue and are a priority for a specific Local Collaborative
> Area.

2)  Service development for populations with specific needs such as
    DD/MI,

> persons who are homeless and mentally ill and /or substance abuse
> addicted, persons with co-occurring disorders, especially substance
> abuse and mental illness, youth with behavioral health needs who are
> transitioning to adulthood, seniors, etc...

Although only two specific meetings or forums have been held to address
the three initiatives (1 for BH Directors, 1 for HPDP Coordinators), we
believe we have the data and necessary input from each of our
communities to begin working toward integrating BH, HPDP and CDM
activities as we develop our Area Plan.

**BEHAVIORAL HEALTH FORUM**

As a result of the forum on August 11, 2006 the participants identified
best practices of how to integrate behavioral health with the other two
Director's Initiatives (chronic disease and health promotion/disease
prevention) and these best practice(s) are:

a\) Integrate behavioral health activities with the other 2 Director's
initiatives into a local strategic health plan for the Area.

b\) Participate in the development of a joint IHS/Tribal plan to include
promising practices into the local Tribal Health Plans in the Area.

c\) Coordinate Tribal program services with activities conducted by the
IHS, the University of New Mexico, Value Options, State Agencies and the
Region Six Local Collaborative Council (RSLCC) to address issues related
to: certification/licensure, youth residential treatment, Telemedicine,
and teaming with local medical providers on chronic care issues.

d\) Invite HPDP staff and primary care providers to the next
Inter-tribal Director's meeting to assess the activities currently in
place, to improve service coordination, to identify service gaps, and to
conduct strategic planning on filling the identified service gaps.

The behavioral health/chronic disease/health promotion/disease
prevention best practices that came out of this forum were shared with
or is planned to be shared with the following other Areas, Tribal
programs, or I/T/U programs.

a\) RSLCC

b\) Community Advisory Boards (CABs)

c\) Service Units

d\) Tribal Programs.

e\) IHS and Tribal Diabetes Programs

As a result of this forum, some of the outcomes were:

-   A decision by the Tribal Program Directors to participate in the
    development of a joint Area/Tribal plan to integrate promising
    practices into the local tribal health plan in the Area.

-   A plan/list of activities to integrate behavioral health with the
    other two Director's Initiatives into a local strategic health plan.
    These activities are:

> 1\) Participation in the local Community Advisory Board Meetings that
> serve to meet the goals and objectives of the Region Six Local
> Collaborative.
>
> 2\) Explore the Integrated Model of Service Delivery developed by Kurt
> Strossel.
>
> This Model requires the Primary Care Provider and a BH staff person to
> work together in addressing a clients overall health starting from the
> first point of contact.
>
> 3\) Continue and expand the utilization of the SIBRT Model currently
> used in three Service Units. The Model process begins with a nurse
> administering a substance abuse screening instrument to all patients
> presenting for medical care on any given day. If the patients score
> falls within a defined range then the Primary Care Provider who will
> see the client is briefed by the nurse and the Provider adds substance
> abuse issues to the list of health issues that are discussed with the
> patient. If the patient is agreeable then an immediate referral is
> made to a counselor, who comes to the exam room and takes the patient
> into an office for further discussion and /or intervention.

4)  As the RSLC, the Tribal CABs, the IHS Behavioral Health, and the
    HPDP

> Programs move forward in developing a comprehensive system of health
> care the integration and focus on the Director's Initiatives will
> become more apparent. Individual Tribal Health Plans will also be
> developed to further activities to meet these Initiatives.

5)  Behavioral Health staff currently screen clients presenting for
    services from a

> medical provider in order to pick up on any life style related issues
> or behaviors that may be contributing to the persons overall health.

**HEALTH PROMOTION DISEASE PREVENTION (HPDP)**

-   The Community Survey: I.H.S. Health Promotion and Disease Prevention
    (HPDP) What's Happening In Your Community Related To Wellness and
    Health? was developed by the Preventive Health Council (PHC) based
    on similar surveys and adapted to our population.

-   Different versions of the survey were pilot tested in three
    different communities on Oct 27, Oct 28, 2005 and Jan 11, 2006.
    Survey was finalized in Jan 2006 and approval was sought through the
    I.H.S. IRB in Feb 2006. Exempt Approval from the IRB was granted in
    March 2006.

-   During March 2006 surveys were mailed out to 27 Diabetes
    Coordinators, delivered to tribes on site visits and events, emailed
    and faxed to tribal members and programs seeking their assistance on
    returning the surveys before the deadline of May 26, 2006.

-   A total of 156 HPDP surveys were received back from 18 tribal
    communities.

-   The surveys are in the process of being entered into MS ACCESS data
    base for analysis and expect to have data summarized by Sep 30,
    2006.

-   HPDP is supporting the efforts of Santa Clara's tribal community
    assessment and serving as a working group member.

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-   While awaiting the results from the HPDP surveys a review of tribal
    needs data from eight sources[^1] were used as a guide to direct the
    HPDP program that yielded the following health needs and priorities
    in order of frequency:

1.  Chronic disease

2.  Substance abuse, suicide including youth suicide, homicide,
    accidents and injuries, and intimate partner violence.

3.  Infectious disease, mental health, and dental issues.

4.  Immunizations

5.  Pneumonia, influenza, respiratory diseases, elder health and
    long-term care, access to services, capacity development, and
    promotion of physical activity and health.

6.  Teen pregnancy, infant mortality, prenatal care, disaster
    preparedness, veteran\'s care, children and youth, the need for
    data, multigenerational trauma, high school dropout rates,
    responsible sexual behavior, and environmental quality needs.

**CHRONIC DISEASE MANAGEMENT**

[Renal Case Management Program**:**]{.underline} A multi-disciplinary
approach to care, which attempts to integrate culture and native
language in the process of caring for individuals with advancing kidney
disease, dialysis and/or needing kidney transplant by developing a plan
and evaluating services to patients with renal disease. This
intervention centers on a Renal Case Manager in the community to provide
pre-renal education about dialysis option early to allow patients to
make informed decision about dialysis treatment and their options for
intervention. This approach also attempts to include the diabetic
patient and family to formulate a unique support system, in which to
plant the seed for prevention measures.

Zuni Service Unit -- Renal Case Management program sponsored thru the
Public Health Nursing (PHN) program in collaboration with Dr. Narva. The
PHN provides follow up assessment/maintenance care via home visits with
patient and family (in coordination with Renal Clinic care). **ACL,
AIHC, and Santa Fe Service Unit** -- A Nurse from the Diabetes Area
Program is working to establish and replicate the Zuni project at these
three sites. At present, this Nurse is available at ACL, AIHC, and SFSU
Renal Clinics and works closely with Dr. Narva and the PHNs to
coordinate this service between the clinic and the home. Attempts to
implement this service at other facilities are difficult due to staffing
shortages.

[Kidney Early Evaluation Program (KEEP)]{.underline}

KEEP is a free kidney health community-screening program designed to
raise awareness about kidney disease among high risk individuals and
provide free testing and educational information, so that kidney disease
and its complications can be prevented or delayed.

Target Audience: KEEP focuses on high-risk individuals---those with
known diabetes or hypertension or who have first degree relatives with
hypertension, diabetes or chronic kidney problems.

Albuquerque Area Diabetes Grant Special Diabetes Programs for Indians
(SDPI) - Diabetes Grant Programs:

*[Non-Competitive]{.underline} Grant funding:* 34 diabetes grant
programs located within the Albuquerque Area (New Mexico, Texas and
Colorado). 27 Tribal Diabetes Grants; 2 Urban; 4 IHS Service Units; and
1 Area Data. 80% are focusing on Diabetes prevention activities.

Competitive Grants in 2004 -- 6 applications awarded within the
Albuquerque Area and will be funded to 2008 to address diabetes
prevention or cardiovascular disease: San Felipe Consortium (includes
Cochiti and Santa Ana); Zuni; Ramah-Navajo School Board; Albuquerque
Service Unit Consortium (includes First Nations and Santa Ana Pueblo);
Santo Domingo and Taos-Picuris Service Unit.

Example of Area Diabetes Program projects that include some chronic
disease initiatives:

1.  Kidney Early Evaluation Program (KEEP): Organized community-based
    health screening to assess for health risk associated with
    hypertension and kidney disease.

2.  Renal Case Management Program: A multi-disciplinary approach to
    care, which attempts to integrate culture and native language in the
    process of caring for individuals with kidney disease, on dialysis
    (End Stage Renal Disease) and/or needing kidney transplant by
    developing a plan and evaluating services to patients with renal
    disease.

3.  Just Move It: A national campaign to promote physical activity for
    American Indians and Alaska Natives. SDPI programs have incorporated
    this activity in their work plans.

4.  Lower Extremity Amputation Prevention (LEAP) Program/Initiative: A
    coordinated effort initially started with the New Mexico Department
    of Health and the Albuquerque Area Diabetes Program to reduce the
    rate of amputations due to diabetes in Native American communities.

5.  Diabetes Prevention Program (DPP): Train diabetes grant programs in
    use of the "Lifestyle Balance" curriculum, an evidence-based
    curriculum using a case management approach in preventive education.

Albuquerque Area Diabetes Data Projects:

6.  Area-wide Documentation and Coding Project: Project to improve
    overall area diabetes data, and addresses possible discrepancies in
    documentation, billing and coding at service units.

7.  Web Based Data Projects: Collaborative effort with the Indian Health
    Performance Evaluation System (IHPES) to develop a web-based tool to
    track community primary prevention activities on cardiovascular
    (CVD) or diabetes; and, the New Mexico Tribal diabetes prevalence
    data web site per Indian Health Service User Population in the Alb.
    Area.

8.  The Yearly Diabetes Care and Outcomes Audit: Clinical programs
    complete the annual Diabetes audit (23) including 2 Urban Programs.
    Provides data on the quality of patient care provided.

9.  Data collection and management workshops: Trainings have been held
    to assist programs with use of the RPMS, Diabetes Management System
    (DMS), and Epi Info. Technical assistance is provided throughout the
    year.

The Area is currently involved in 3 patient management projects with the
UNM, CDC and the State of New Mexico:

1.  [The ECHO Project,]{.underline} is a joint effort designed to assist
    in providing standardized medical management/treatment for patients
    infected with Hepatitis C. While a primary care provider and a nurse
    serve as the core management team, a mental health professional must
    screen the patient for a history of depression, anxiety, and
    suicidal ideation. HPDP staff are involved in the provision of
    patient education. Teams for the care, screening and management of
    each identified patient will be developed and assigned. HIV/AIDS and
    substance abusing patients are at high risk for the development of
    this disease and will be monitored and referred by IHS and tribal
    Behavioral Health Program staff.

2.  [Envision New Mexico]{.underline}, which is funded by UNM Dept of
    Pediatrics and the

> State Medicaid Bureau. It is a part of the National Initiative to
> Improve Child Healthcare Quality, a spin off of IHI. They are
> implementing a statewide QI project implementing Scott Gee's (Kaiser
> Northern California) training model around childhood overweight
> screening, prevention, and management. The training model is well
> designed for implementation in rural western states. It
>
> focuses on clinic wide change around measuring and recording BMI %,
> getting key messages out to parents/children (screen time, activity,
> sweetened drinks, 5 a day)and following the '98 Dietz, Whitaker paper
> outlining the guidelines for management of childhood obesity. It also
> includes several hours of Motivational Interviewing training to help
> improve the effectiveness of those interactions and to increase the
> likelihood that the patients will decide to try to effect behavioral
> change. This approach is consistent with the patient centered chronic
> care model and with HPDP objectives.
>
> The Santa Fe and Taos Service units were two of the sites where this
> project was implemented. The project is ongoing at these sites. Chart
> reviews to assess changes in provider behavior (is BMI % measured and
> documented? Messages given? Readiness to change assessed? Plan
> negotiated?) will be conducted in Sept '06.

3.  [Telemedicine]{.underline} is another project and service modality
    through which the Albuquerque Area is utilizing to integrate the
    Directors 3 Initiative. We have recently established a collaborative
    Agreement with the University of New Mexico and the State Department
    of Health for the provision of direct Child Psychiatry services, as
    well as patient medication management, patient consultations and
    training that will serve all Service Units and Tribal facilities
    that have the necessary Tele-video equipment.

> The Area has entered into a Tele-Medicine Consortium with the Tucson,
> Phoenix, and Navajo Area's to coordinate Tele-health services. Through
> this consortium we have conducted activities in cardiology,
> psychiatry, distance learning, dermatology, child abuse, and
> radiology.

**BEHAVIORAL HEALTH/HPDP INTEGRATION**

As a result of the collaboration efforts, outcome/s was/were:

*As a result of collaboration efforts between interagency programs we
found a way to better communicate and seek new ways to partner our
efforts for better services to our tribal communities.*

The HPDP/BH programs collaborated on two training efforts addressing
Alcohol prevention: 1) ***Protecting You Protecting Me*** and 2)
***Youth In Action***.

The Albuquerque Area Indian Health Service Health Promotion and Disease
Prevention and Behavioral Health Program collaborated with the New
Mexico and National Mothers Against Drunk Driving (MADD) to teach
children how to protect themselves and make informed decisions about
alcohol use in the Albuquerque Area. ***Protecting You Protecting Me***
***- PYPM*** is an evidenced-based alcohol use prevention curriculum for
grades 1-5. The program is a nation wide effort to equip young children
with the skills necessary to make healthy decisions to keep themselves
safe.

The Albuquerque Area Indian Health Service Behavioral Health and Health
Promotion and Disease Prevention Program collaborated with the New
Mexico and National Mothers Against Drunk Driving (MADD) to address the
prevention of underage alcohol use in Native Communities in the
Albuquerque Area. ***Youth In Action - YIA*** is a MADD program designed
to reduce underage drinking by targeting social and retail availability
of alcohol for youth under the age of 21. The program promotes
partnerships with community change agents and aims to change the
perceptions of underage drinking of individuals in the community. (See
curriculum and evaluation summary Appendix \# 7.)

> [Accomplishments/Results:]{.underline}

-   Attended ***Protecting You Protecting Me*** - ***PYPM***
    facilitators training in San Diego, CA and assisted with the
    coordination of the training for all HPDP coordinators and community
    programs.

-   Planning meetings with New Mexico MADD and I.H.S. began in February
    2006 and continued until training implementation in June 2006. The
    trainings and the partnership efforts were a huge success from all
    involved.

    -   Coordinated in partnership with I.H.S. Behavioral Health and New
        Mexico MADD the ***Protecting You Protecting Me - PYPM***
        two-day training (June 7-8, 2006) at the Nativo Lodge in
        Albuquerque, NM. The training was presented to 19 participants
        that included classroom teachers, DWI coordinators, RN's,
        Counselors, Prevention Specialist and Coordinators, and
        Community Outreach Workers. Positive feedback was received about
        the ***PYPM*** training.

    -   Information on the training was distributed area wide and at the
        tribal level.

    -   Flyers were distributed via email and fax to tribal behavioral
        health programs, diabetes educators, social services, youth
        programs, education departments, tribal law enforcement, BIA and
        Charter schools, prevention programs, CHR programs, and
        community wellness programs in the 27 tribal communities.

    -   Coordinated in partnership with I.H.S. Behavioral Health and New
        Mexico MADD the ***Youth In Action*** - ***YIA*** training (June
        8, 2006) at the Nativo Lodge in Albuquerque, NM. The one-day
        training was presented to 17 participants that included youth
        and adult community members.

    -   Youth from two Pueblo communities expressed an interest in
        ***Youth In Action*** and made connections to work with MADD in
        their respective communities. MADD was invited to present at an
        upcoming conference sponsored by the youth themselves and hope
        to launch some MADD supported projects related to underage
        drinking.

**FUTURE PLANNING EFFORTS AND ACTIVITIES**

While our focus has been on establishing a new system of care and
developing partnerships between the IHS, the Area Tribes, and various
other private and State organizations we expect the focus on the
Director's Initiatives to become a major part of our Area Strategic
Health Plan as we move forward.

The Behavioral Health, Health Promotion Disease Prevention, and Chronic
Disease Programs met in Washington DC during May 23-25 to discuss
collaboration efforts. The HPDP team gave suggestions on what is needed
and what we can offer. For details see minutes from "052506 - Integrate
3 int.doc" dated 8/7/2006.

The Albuquerque Area Behavior Health and Health Promotion Disease
Prevention programs met to discuss previous efforts and data collection
to collaborate efforts.

As a result of our meetings we discovered that we have collected
feedback in different forms and venues from our tribal communities
through the BH needs assessment, Resource Inventory, and 9 focus Group
Forums plus the HPDP survey on What's Happening In Your Community
Related To Wellness and Health?

Through these efforts our data will guide our efforts to identify best
practices of how to integrate behavioral health and HPDP services with
the other Director's Initiative (chronic disease management).

[^1]: SOURCES: The New Mexico Department of Health, the Colorado
    Department of Health, tribal priority papers, the New Mexico
    Strategic Plan, Healthy People 2010, GPRA measures, the Director\'s
    Initiatives, and a needs assessment from Zia Pueblo.