**Recommendations and Actions**

IHS / VHA Steering Committee

April 2005

**Two Year Review**

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. 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 MOU 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. (A
brief summary of progress to date under each objective is included in
Appendix I.)

The SC recommended that the MOU and the programs under it continue
unchanged. However, the SC suggests placing 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 both organizations has been asked to develop a joint
policy for the coordination of health care for dual use veterans.
Finally, a focus on collaboration in long term care services has been
encouraged. The specific recommendations and proposed actions are
outlined below.

**Recommendations**

### Recommendation 1. Increase the number of American Indians and Alaska Natives (AI/AN) in the VA workforce. Encourage the recruitment of AI/AN into VA jobs through the sharing of best practices between Veterans Integrated Service Networks (VISNs) and from IHS. This information should be incorporated into the VHA Workforce Succession Strategic Planning guide for FY2007-2011. {#recommendation-1.-increase-the-number-of-american-indians-and-alaska-natives-aian-in-the-va-workforce.-encourage-the-recruitment-of-aian-into-va-jobs-through-the-sharing-of-best-practices-between-veterans-integrated-service-networks-visns-and-from-ihs.-this-information-should-be-incorporated-into-the-vha-workforce-succession-strategic-planning-guide-for-fy2007-2011. .unnumbered}

> **Actions:**

-   Identify promising practices from IHS and share with the VA National
    Workforce Planning and Analysis Team (VA NWPAT). Assigned:
    Headquarters Advisory Group (HQAG) / 10H.

-   Identify promising practices submitted by VISNs in the 2006-2010
    workforce succession plans and include these in the FY2007-2011
    succession plan at VA. Assigned: VA NWPAT

-   With assistance from IHS, work with VA Office of Diversity
    Management and Equal Employment Opportunity and VHA Health Care
    Staff Development and Retention Office to fully implement Executive
    Order 13270. Specifically, an academic affiliation should be
    established with all of the Tribal Colleges and Universities and
    VISNs should be encouraged to develop outreach and mentoring
    programs for secondary school students, where possible. Assigned: VA
    Office of Academic Affiliations / IHS Office of Public Health
    Support (OPHS).

### Recommendation 2. Improve the coordination of patient care between IHS and VHA. Facilitate referrals between IHS and VHA and ensure that dual eligible AI/AN veterans have coordinated access to appropriate services from both agencies. Develop a joint policy statement from the Director, IHS, and the Under Secretary for Health, VA, that; {#recommendation-2.-improve-the-coordination-of-patient-care-between-ihs-and-vha.-facilitate-referrals-between-ihs-and-vha-and-ensure-that-dual-eligible-aian-veterans-have-coordinated-access-to-appropriate-services-from-both-agencies.-develop-a-joint-policy-statement-from-the-director-ihs-and-the-under-secretary-for-health-va-that .unnumbered}

-   describes and clarifies the existing policy of each agency for dual
    eligible patients; and

-   develops new policy clarifying when and how standard referral
    agreements should be used and how resulting reimbursement issues
    should be addressed.

> **Actions:**

-   Establish a senior level joint task group to draft the new policy.
    Assigned: HQAG to establish task group and manage process.

### Recommendation 3. Improve communication and outreach to AI/AN veterans. To improve direct communications with veterans living on reservations, VHA should direct VISN and facilities to hold town hall forums, veteran round table discussions, dialogues at health fairs or other forums on reservations at least annually. Traveling to a reservation to hear the concerns of American Indian veterans is a sign of respect for their service to the nation and it is particularly important that elder veterans be accorded such courtesies.  {#recommendation-3.-improve-communication-and-outreach-to-aian-veterans.-to-improve-direct-communications-with-veterans-living-on-reservations-vha-should-direct-visn-and-facilities-to-hold-town-hall-forums-veteran-round-table-discussions-dialogues-at-health-fairs-or-other-forums-on-reservations-at-least-annually.-traveling-to-a-reservation-to-hear-the-concerns-of-american-indian-veterans-is-a-sign-of-respect-for-their-service-to-the-nation-and-it-is-particularly-important-that-elder-veterans-be-accorded-such-courtesies. .unnumbered}

### Actions:  {#actions .unnumbered}

-   Update the VHA/IHS Collaboration and Sharing guide for the 2008
    strategic planning cycle. VHA facilities would be required to
    include AI/AN veteran town hall meetings and travel to reservations
    in their outreach and communication efforts. Assigned: 10H

-   HQAG will expand their efforts to meet with Tribal representatives
    and national Native American organizations to discuss the MOU and
    the work of the agencies. HQAG will continue to pursue opportunities
    throughout the year to make presentations about the collaboration at
    forums and meetings that have AI/AN individuals and organizations as
    a primary audience. Assigned: HQAG.

### Recommendation 4. Provide a mechanism for better Interagency collaboration and local communication by identifying a VHA/ IHS liaison in each IHS Area Office and VISN Office. This individual will serve as the point of contact for veteran issues and collaborative activities.  {#recommendation-4.-provide-a-mechanism-for-better-interagency-collaboration-and-local-communication-by-identifying-a-vha-ihs-liaison-in-each-ihs-area-office-and-visn-office.-this-individual-will-serve-as-the-point-of-contact-for-veteran-issues-and-collaborative-activities. .unnumbered}

### Actions: {#actions-1 .unnumbered}

### This requirement is included in the instructions from the Under Secretary for Health (USH) accompanying the release of the IHS collaboration and sharing guide. Assigned: Office of Under Secretary for Health (OUSH). 

-   IHS will establish this requirement for their Area offices.
    Assigned: Office of the Director (OD).

### Recommendation 5. AI/AN veterans have difficulty with access to disability compensation and benefits. The USH should ask that the Veterans Benefits Administration (VBA) establish a working group to focus on making benefits information accessible to AI/AN veterans and their families and to improve outreach to this population.  {#recommendation-5.-aian-veterans-have-difficulty-with-access-to-disability-compensation-and-benefits.-the-ush-should-ask-that-the-veterans-benefits-administration-vba-establish-a-working-group-to-focus-on-making-benefits-information-accessible-to-aian-veterans-and-their-families-and-to-improve-outreach-to-this-population. .unnumbered}

### Actions: {#actions-2 .unnumbered}

-   Develop an issue brief that describes the concerns raised by AI/AN
    veterans. Assigned: 10H

-   Provide the issue brief to VBA and offer to discuss it with the
    Under Secretary for Benefits Assigned: OUSH or 10H.

### Recommendation 6. Better data are needed on AI/AN veterans and dual users of VHA and IHS. The USH, VA, and the Director, IHS, should direct data resources to be developed that identify AI/AN veteran patterns of utilization in both VHA and IHS and track the quality of care and health outcomes for AI/AN veterans.  {#recommendation-6.-better-data-are-needed-on-aian-veterans-and-dual-users-of-vha-and-ihs.-the-ush-va-and-the-director-ihs-should-direct-data-resources-to-be-developed-that-identify-aian-veteran-patterns-of-utilization-in-both-vha-and-ihs-and-track-the-quality-of-care-and-health-outcomes-for-aian-veterans. .unnumbered}

> **Actions:**

-   Develop both a short term and long term plan to accomplish this
    goal. The short term plan is likely to involve establishing a data
    use sharing agreement between IHS and VHA for quality improvement
    purposes that will allow the organizations to duplicate the
    methodology developed under a research protocol to match patients
    shared between IHS and VHA. The long term plan should address the
    current inaccuracies in the data capture systems of both
    organizations. At this time, VHA does not accurately assign
    race/ethnicity in the Veterans Integrated System and Technology
    Architecture and IHS does not accurately assign veteran status in
    the Computerized Patient Record System . Assigned: HQAG, the Office
    of Resource Access and Partnerships, IHS, and the Chief Business
    Officer, VHA.

### Recommendation 7. Amend the IHS/VA Steering Committee Charge to include the following statement: Promote activities and programs that improve the welfare and quality of life for the American Indian and Alaska Native veteran population, including efforts to improve their access to and use of long term care services, homeless programs, home loan programs and other benefits and services that impact the health and well being of this population. (Appendix II.) {#recommendation-7.-amend-the-ihsva-steering-committee-charge-to-include-the-following-statement-promote-activities-and-programs-that-improve-the-welfare-and-quality-of-life-for-the-american-indian-and-alaska-native-veteran-population-including-efforts-to-improve-their-access-to-and-use-of-long-term-care-services-homeless-programs-home-loan-programs-and-other-benefits-and-services-that-impact-the-health-and-well-being-of-this-population.-appendix-ii. .unnumbered}

-   See the attached committee charge, addendum and current membership
    list for approval by the USH, VA, and Director, IHS.

**APPENDIX I: IHS / VHA COLLABORATION PROGRESS SUMMARY**

The MOU 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 and regional progress are summarized.

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

The Office of the Deputy Under Secretary for Health for Health Policy
Coordination (DUSH / HPC), VHA, and the Chief Medical Officer at IHS are
the principal offices responsible for coordinating implementation of the
MOU at VHA and IHS. The offices work with the leadership and staff of VA
and IHS to identify priority actions and ensure they are carried out.
The offices foster progress on national initiatives and support the
development of sharing plans and implementation activities at the local
level through annual planning processes and performance monitoring
systems.

*Communication*: The Headquarters Advisory Group (HQAG) 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 Frequently Asked Questions 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 IHS Nashville Area Office signed an operational agreement in April
2005 to enable the sharing of VHA educational resources with the
Nashville Area staff and Tribes in the region.

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 developed and presented to VA for clearance. 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, 18 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 and describes the successful
implementation of the MOU at the local level. Both VHA and IHS require
progress reports from the field on collaboration and the provision of
services to AI/AN veterans. VHA sharing is an element of the IHS Area
Director's performance contracts 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 Service
Representative training curriculum and has convened a workgroup to
develop a cultural competency curriculum for VHA. The workgroup includes
staff from both VA and IHS.

*Health Promotion / Disease Prevention*: IHS / VHA workgroups in
Diabetes Prevention and Behavioral Health were established. The Diabetes
Prevention workgroup was funded to support diabetes prevention
partnerships at four to six sites around the country. VHA facility
proposals will incorporate primary prevention measures, including diet
modification and physical activity, into programs targeted to AI/AN
veterans to be conducted in partnership with IHS, Tribal or Urban Indian
Health programs.

The Behavioral Health workgroup developed a framework for AI/AN
communities to assist 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 work with Tribes to develop and promote a community
health model that gives tools to Tribal communities and families to help
returning veterans. If successful, they will have the knowledge and
ability to intervene early with veterans and be able to 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 are being shared with
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.

The DUSH/HPC is soliciting joint proposals from VHA/Vet Center and AI/AN
health providers to adapt and 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}**

*Communication*: In the first quarter of FY2005, VISNs reported more
than 50 contacts with IHS, Tribal leaders or AI/AN veteran groups; just
over half of these contacts occurred directly with Tribes.

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

*Access*: In the first quarter of FY2005, VISNs reported 15 existing
programs that expand access to services for AI/AN veterans. For example,
Network 19 reported providing 91 telepsychiatry patient contacts, 25
native healer consults, and the completion of a residential substance
abuse treatment program by three patients during this quarter. Twelve
additional programs are anticipated to be established across the country
by mid- FY2006.

*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 28 such events.

*Health Promotion / Disease Prevention*: Five Networks reported eight
specific programs to meet the health and prevention needs of AI/AN
veterans (two ongoing, six anticipated). However, only one is a
prevention oriented program: OIF/OEF readjustment outreach in VISN 20.

**APPENDIX II**

![](media/image1.png){width="6.572916666666667in"
height="8.466666666666667in"}

**IHS / VA Steering Committee Charge -- Addendum**

-   Promote activities and programs that improve the welfare and quality
    of life for the American Indian and Alaska Native veteran
    population, including efforts to improve their access to and use of
    long term care services, homeless programs, home loan programs and
    other benefits and services that impact the health and well being of
    this population.

Addendum approved:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Jonathan B. Perlin, MD, PhD, MHSA, FACP RADM Charles W. Grim, DDS, MHSA

Under Secretary for Health Director

Veterans Health Administration Indian Health Service

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date

IHS / VA Steering Committee

Membership -- June 2005

**[Department of Veterans Affairs]{.underline}**

Frances M. Murphy, MD, MPH -- Co-Chair

Deputy Under Secretary for Health for Health Policy Coordination

Robert Petzel, MD

Network Director, VISN 23

Alfonso R. Batres, PhD, MSSW

Chief Officer, Readjustment Counseling Service

Lucretia McClenney

Acting Director, Center for Minority Veterans

James Floyd

Director, Salt Lake City VAMC

Linda Pyne

Veterans Benefit Administration -- Outreach Analyst

**[Indian Health Service]{.underline}**

RADM Craig Vanderwagen, MD -- Co-Chair

Acting Chief Medical Officer

Jim Toya

Director, Albuquerque Area

Bruce Finke, MD

Consultant, National Elder Care Initiative

Elmer Brewster

Director, Division of Business Office Enhancement

Office of Resource Access & Partnership

Tammie Cannady

Northern Area Deputy Administrator, Choctaw Nation

XXXXXXX

(tribal leader)