**Open Door Forum on Director's Three Health Initiatives**

**Moderator: Doug Peter**

**October 24, 2006**

**1:00 pm CT**

Coordinator: All sites please stand by and today's conference is about
to begin. Hello welcome to today\'s open door forum on health
initiatives. At this time all participants are in a listen only mode.
After the presentation we will have a question and answer session. To
ask a question please press star one.

You will be prompted to record your first and last name for the Q&A
portion. With the request of the company this call is being recorded.
And now I will turn the meeting over to your host, Dr. Charles Grim, IHS
Director. Sir you may begin.

(Charles Grim): Thank you and I want to welcome everyone to today's
call. We've decided to hold several open door forum conference calls to
keep you updated on things that are occurring around the three health
initiatives and also to get feedback from you and try and answer any
questions.

The agenda will start out with me making some comments and then we are
going to have three presentations by different staff about the health
initiatives and then after that we will open it up to Q&A. We are going
to try to hold our presentations to about fifteen minute updates so that
we will have plenty of time for Q&As at the end.

This first will focus on the three initiatives in general: Behavioral
Health, Health Promotion/Disease Prevention and Chronic Disease
Management. The agency launched these three initiatives officially back
in July of 2005 to coincide with the 50th Anniversary celebration of the
Indian Health Service.

Since that time we've made a lot of progress on the three health
initiatives. In fact, we had started some of them prior to that official
launching, but we launched them as official initiatives of the agency at
that time.

I want to first thank everyone in all of our hospitals and clinics
whether Tribal, Federal, or urban for the work that you've done to try
to promote these initiatives.

I want to thank the people here in Headquarters and in the field that
are the leads on all of these initiatives too. These issues have
resonated greatly with Tribal leadership around the country as I have
been at meetings or as I have visited different Tribal reservations and
villages around the country.

I have had Tribal leader after Tribal leader tell me that they are glad
that we're focusing on these three areas. They see them as three of the
most important health issues in Indian country today. So, we have
received a lot of positive feedback from Tribal leadership.

I think probably most of you know the reason that we chose these three
initiatives is that we looked at the epidemiology of the diseases that
our populations was starting to face.

The types of diseases and chronic conditions are related a lot to
lifestyle issues such as obesity, physical inactivity, poor diet,
substance abuse, and of course injuries.

And, so we took a look at those health issues and how we could manage
the most critical issues and focused on these three initiatives. Before
we launched them officially we put them through a fair amount of
vetting, not only in Tribal arenas, but also within the agency as well.

I want to talk to you just really briefly about the goals of the
initiatives and then I am going to turn it back over to Dr. Doug Peter
our Chief Medical Officer (CMO). He'll be introducing our speakers and
they will give you an update on each of the three initiatives.

The goal of the Health Promotion Disease Prevention Initiative is to
create a healthier American Indian and Alaska Native communities.

We are trying to do that by helping to develop, coordinate, implement
and disseminate effective health promotion and chronic disease
prevention programs through a collaborative effort with key stake
holders And trying to build upon individual, family, and community
strengths and assets.

For many Indian communities, there has been a lack of understanding on
the role of behavioral health in health promotion and disease
prevention. So when we talked about behavior health being an initiative,
we weren't talking about only the traditional role of behavioral health.

We still are very much focused on substance abuse, trauma, and the years
of intergenerational issues on forced cultural change, poverty and lack
of economic opportunity and some of the rural isolation factors that
continue to make things difficult for us to improve health.

But, we're also talking about the fact that there are many chronic
health conditions that are linked to life-long behavioral health
patterns and therefore can be prevented by a change in lifestyle.

And, so our Behavioral Health Initiative not only focuses on the
historical and well known issues around alcohol, substance abuse, mental
health, and social services issues, but also around behavioral health
and lifestyle issues in some of the key chronic diseases today.

I think most people that work in our system or are familiar with any of
our health statistics, realize that diabetes, cardiovascular disease,
asthma, renal disease, depression, arthritis, dementia, and cancer have
become increasingly prevalent in our communities and are placing growing
demands on our health care system.

The goal of the Chronic Disease Initiative is to develop a process for
the Indian Health Service to effectively and efficiently address chronic
conditions.

I am very excited about getting this initiative implemented this year.
It was essentially a year in the making as we had an interdisciplinary
workgroup take a look at various models that were out there.

We looked at what we've learned from the way we provide diabetes care in
the agency, and we're certainly well renowned with the way we deal with
our diabetic patients. So, we took what we learned from diabetes care
along with some of the research and models in chronic diseases.

I am also excited that we're partnering with a group called the
Institute for Healthcare Improvement as well as the Agency for
Healthcare Research and Quality on this initiative. We have many key
partners that you will hear more about when Dr. Reidhead speaks about
this initiative.

> I think one of the goals we have for these open door forums is that we
> want to talk with you about how we are trying to tie all three of the
> initiatives together.

They started out as separate and distinct initiatives with distinct
leaders and champions and now we're trying to better bring together the
activities because they really do need to be coordinated for them to be
most effective.

I am anxious to have our three presenters share with you all of the
accomplishments we've made around these initiatives. In the time they
have, they will only be focusing on some of the highlights and about how
we are integrating them into our programs and polices.

But, I am anxious for you all to hear what's been going on a more global
basis. So, I will just close my comments and again thank all of you for
what you are doing out there in Indian country. Dr. Peter, I'll turn the
program back over to you to continue.

(Douglas Peter): Thank you Dr. Grim and welcome everyone to today\'s
forum. I'll be introducing the three speakers, but before I do that I
want to make sure everyone knows that the PowerPoint slides are on the
website at [www.ihs.gov](http://www.ihs.gov/) at the Director's Health
Initiatives webpage.

After you reach the IHS website, you go to Nationwide Programs and
Initiatives and then you click on that and there's the Directors
Initiatives. You will find the open door forum site and at the bottom of
the page and the three PowerPoint presentations that you can click on
and follow along with the speakers. So hopefully you have already
located that website and the presentations.

We will proceed to hear about each of the initiatives, one by one
starting with Gary Quinn who is here at Headquarters and he is going to
speak for about 12 to 15 minutes on the Behavioral Health Initiative.
So, Mr. Quinn the time is all yours. Thank you.

(Gary Quinn): Thank you Dr. Peter. My name is Gary Quinn and I am a
member of the Tohono O'odham Nation in Arizona. My current position here
at Headquarters is a public health advisor in the Division of Behavioral
Health. I will talk about some of the activities that have been going on
with the integration of behavioral health.

In Fiscal Year 2006, we advised \$5000 to each of the 12 Areas and the
purpose of this money was to hold a forum in which integration
activities unique to that Area would be identified.

In addition, each Area was required to identify action steps toward this
sort of integration that they intended to build into their local Tribal
strategic health care plans. And this element was important because that
would link to one of the performance objectives for the director and
that objective was, "emphasizing faith and community based solutions."
And, as a result we were able to have six Areas host a Forum and
complete a Forum report on time.

They reported their results on time in support of that performance
objective and the Areas were Alaska, Albuquerque, California, Nashville,
Phoenix, Portland and Tucson. Tucson Area sent a completed template in
but unfortunately it didn't make the cutoff time for submission. But the
Tucson Area did send in a template with their results and it will be
posted to the website soon.

And, I wanted to just mention in general that the leadership and support
of the Directors Initiatives by the Behavioral Health branch chiefs from
each of these forums was what made this effort work and their efforts
were the real work. I had the pleasure to put together their results,
but they\'re the ones who did the work on the front lines.

And, I wanted to just acknowledge that from Alaska it was (Scott Prinz.)
From Albuquerque it was (Tony Danielson), from California (Dr. David
Springer), from Nashville (Dr. Palmeda Taylor), from Phoenix (Linda
Westover), from Portland (Dr. Connie Hunt and Dr. Donnie Lee), and from
Tucson (Dr. Pat Nye).

I think even more importantly a special thanks to Ms. Gayle Riddles who
is the Headquarters performance officer. I had a meeting with her and my
boss, Jim Stone, prior to sending a template out to the Areas and she
was very helpful to identify how we could best capture some objectives
from these forums.

And the results were captured from a Forum template we disseminated to
each of the Areas and they responded back with those 7 completed
templates. So, I wanted to make note and emphasize the hard work was
done by these branch chiefs.

Next, I want to talk a little about the forum template from those Areas.
I wanted to cite one example from each of them just so you get a feel of
the different activities going on out in Indian country. And you will
notice that they all took a different approach to how they wanted to
integrate behavioral health.

For example, in Alaska, they hosted a think tank forum that generated
interest throughout the Alaska Area. And they had over 70 Tribal health
leaders and direct service providers attend this forum.

What they accomplished is identifying the benefits of integration and
they identified the barriers to integration as well. But they also had a
list of community priorities that they wanted to focus on. Now there are
other details to this and you can find them on the Directors Initiatives
website. At this site, you will find complete results of these forums.

Next is Albuquerque Area. What they are doing is the development of a
joint Indian Health Service and Tribal plan to include promising
practices into local Tribal health plans in their Area with a focus on
behavioral health.

The California Area presented the Director's Three Initiatives to the
Tribal advisory committee and they also presented an update on their
disease case management project and the relationship to the chronic
disease model as well as behavioral health. The California Area also
obtained feedback from Tribal leaders on how they best wanted to
integrate the initiatives into their health plans.

The Nashville Area is seeking to improve patient care and increase the
national Area behavioral health screening rate. And they are going to
document this in RPMS for data analysis purposes.

The Phoenix Area is focused on improving and collaborating for a more
user friendly version of accessing the IHS Tribal urban sites via the
RPMS data collection system because what this forum discovered is that
there are some common barriers and they feel that addressing this
element is a priority for their integration effort. Phoenix Area has a
focus on having a strong data set.

The Portland Area is working on the integration of a new depression
screening standard from the IHS standard of care for patients with Type
II diabetes using the September 2006 version. And they are going to
integrate that into clinical and community practice for people with
diabetes at the Warm Springs site.

Finally, Tucson Area Behavioral Health Program is working with the local
Tribal behavioral health program to design and paint culturally relevant
murals on the walls of the waiting areas as a way of enhancing the
behavioral health counseling office.

Now as I mentioned, these are just a few examples from these Areas. The
complete results of the forums are at the Director's website under the
"What's New" section of six promising practices. And I would encourage
you to check them out and you can find the complete details.

Next, I want to talk a little bit about the Director's Initiative
website and a "What's New" section for behavioral health, chronic
disease, and health promotion and disease prevention. And we encourage
you to check it periodically because we post new events that are coming
up whether it is a conference or trainings or identified results as I
mentioned in the six promising practices. It is a good resource for you
to find what's new within the integration of the Director's Initiatives.

I want to talk a little bit about Headquarters integration efforts
because I think we are in agreement that integration has to occur at the
Headquarters level and it certainly has to occur at the Area level and
certainly the service unit level and I would say at the Tribal and urban
level. So, there are many levels of integration that would have to take
place to make this a complete wrap around service and so that's why I
wanted to take just a few moments to talk about what's happening at
Headquarters because there is integration happening there as well.

But, I want to give this disclaimer because there are many headquarters
examples and I only have 15 minutes so I only chose three examples. So,
I apologize to my colleagues that if I don't mention your integration
efforts, it's not because your integration effort is not important, but
I am limited by time and therefore only have time for three examples.

Now that I have announced my disclaimer, I will go ahead with the first
example. The first one centers on alcohol screening and brief
intervention (ASBI). And, ASBI is an effort to link behavioral health to
shock trauma victims and this effort is headed up by Dr. David Boyd of
the IHS Headquarters Emergency Services.

Dr. Boyd is working with us in the Division of Behavioral Health and
linkage is he says, "trauma is the fourth most common cause of death in
the United States and it's related to injuries which are the most common
cause of death for American Indians and Alaska Natives less than 45
years of age. In fact, alcohol intoxication has been shown repeatedly to
be associated with at least half of this mortality.

As we all know, among the American Indian and Alaska Native population,
trauma mortality and alcohol-related trauma rates are 2 to 6 times
higher than the wider community.

So, what this means is that there's room for us to decrease that sort of
disparity and we can do that by providing alcohol screening and brief
counseling intervention or ASBI during the acute EB or inpatient care
for alcohol-related trauma.

And, so Dr. Boyd's overall goal is to integrate alcohol screening and
brief intervention at the shock trauma and emergency care facilities
located at Indian Health Service Units, Tribal facilities, and Contract
Health Services shock trauma centers because research shows that there
is efficacy of screening at this golden moment of awareness. So, that is
one example that we at Headquarters are working on at the national
level.

The second example is focused on nutrition. Jean Charles-Azure is the
National nutrition consultant with the Division of Clinical and
Community Services. Ms. Charles-Azure has come to the Division of
Behavioral Health because she wanted to enhance her nutrition tool kits.
She has two nutrition tool kits that she is working on: "Healthy Eating"
and "Healthy Beverage" kits.

What she sought was input about behavioral health and how to make her
tool kits more effective. There were many points that were discussed,
but one in particular was she included a brief one page description of
the stages of change as a background for the community to understand a
little bit about the process of change as it relates to effectively
using these tool kits.

The one page description was not meant to make the users of the tool
kits behavioral health clinicians, but was intended to provide a
background of what the stages of change and linkage to effecting healthy
eating and improve consumption of healthy beverages.

The third example occurred this past year at the 2006 Indian Health
Service and Substance Abuse and Mental Health Services Administration
(SAMHSA) National Behavioral Health Conference. And, in that example the
project officer, Frank Canizales, with assistance from a community work
group, determined that one conference tract that was missing was a link
to chronic disease. So, they decided to design and include a medical
track. They invited two medical staff people - Carolyn Aoyama who is
from our Headquarters Office of Clinical and Preventive Services,
Division of Nursing Services and Dr. Jim Berner from the Alaska Native
Medical Center as committee members.

They provided technical assistance in shaping a medical track and for
the first time, the 2006 Behavioral Health Conference contained a
medical track. They also offered CME's for the participants.

Finally, I guess what's left is covering what is happening in FY07 for
Behavioral Health and you might kind of predict it, we're going to send
\$5,000 to each Area to further activities they identified in their
Forums this past year.

We want to also increase the communication between the 12 Behavioral
Health branch chiefs and we are currently doing that. We have monthly
teleconference calls with the branch chiefs. We are, with their
assistance, revising the IHS national chapters of mental health and
social services and alcohol and substance abuse.

And, we also want to increase the dissemination of promising practice
examples among the IHS Areas. And, how we are going to do that is we
want to post them at the IHS website as a resource.

We also want to identify funding and other resources from Federal
agencies that support integration efforts and so with that, one of our
objectives is we will encourage and support each of the behavioral
health branch chiefs to draft a specific behavioral health integration
activity in preparation of us locating additional funding. And, we are
also encouraging them to design this around a program evaluation
element.

And, when I say program evaluation it makes me think of math and the
type of reaction people have to this word is typically, "Wow, I am not
good at math." The same reaction comes with program evaluation for many
of us.

I think or I know that program evaluation is the direction we want to go
and we want to support and encourage behavioral branch chiefs on this
element. We also want our activities to have that sort of component to
evaluate what it is that we are doing well and to have more than just a
personal opinion that drives whether or not something is working well.

And finally, we want to increase data collection. We are going to do
that by demonstrating the effectiveness of the integration of these
three activities from the individual projects that the branch chiefs
will draft and design. Our HQ role is to support that effort and to
locate funding to make those projects happen.

And, so I have no other things to report other than the activities
already mentioned for FY06 and the upcoming activities in FY07 are
listed at t the Director's website. If you go there and look at the six
promising practices, you will have a list of our FY07 activities in the
complete form as well as FY06 activities that were completed.

And, of course if you have any questions, I look forward to any that you
post to me. My contact information is listed on my PowerPoint
presentation and I am in the IHS directory. Thank you.

(Douglas Peter): Thank you Mr. Quinn. Let me turn the time over now to
Dr. Reidhead who is joining us from Whiteriver Service Unit in the
Phoenix Area. So, Dr. Ty Reidhead is going to introduce himself and talk
about the Chronic Disease Initiative.

(Ty Reidhead): Yes sir. This is Ty Reidhead. I recently worked with the
tribes of North Dakota. Thank you Dr. Peter. I have been stationed in
Whiteriver for the last nine years. I am the chief clinical consultant
in internal medicine. I have also been asked to take the clinical lead
for the Chronic Disease Initiative. I have to say upfront and apologize
if you hear me taking deep breaths. I have an acute respiratory illness,
so I hope you can put up with that.

I am also recognizing that not everybody has the slides. So, I will try
to talk without using the slides, but also give those who do have the
slides a notice that I am going to another slide so you can following
along if you want to.

So, I am going to go to the second slide and talk just briefly about the
history of the Chronic Disease Initiative. Dr. Grim mentioned that and
recognized the fact that we have an excellent track record of innovation
in addressing the epidemic of diabetes over the last 20 years and
realize that in addition we have new epidemiologic challenges that are
facing the Indian Health Service in these other chronic illnesses.

And, in order to address those, Dr. Kelly Acton and Dr. Nat Cobb brought
together a group of national leaders in the care of chronic conditions
to try to create a plan to address the improvement of these other
chronic conditions.

I am going to the next slide and it depicts how I think, and we all
felt, that the current health system takes care of chronic conditions
right now. We've developed into the system that we currently have from
acute condition care of the past.

Things like pneumonia have ended up with a provider in the middle.
Really it is a provider centric type model of care with the patient not
being in the center and having them interact with the system mostly
through the provider. There are exceptions, but in general the providers
are in the middle of that care.

And we recognize that this may not be optimal, but now if you look at
the next slide I am going to give credit to Dr. Don Berwick with
Institute for Healthcare Improvement for saying this, but I am sure
other people have said it and know it. And that's just that every system
is perfectly designed to get the results that it gets. So, if we're
expecting improvements in chronic care with our current system, then we
may not be approaching it in the best fashion.

The next slide just depicts what the Chronic Care Model is. Basically
Dr. Wagner with the MacColl Institute for Health Care Innovations came
up with this model. The Chronic Care Model creates a map for us to
achieve improved care and outcomes in chronic disease. We must have a
prepared, proactive practice that interacts with an informed, activated
patient and has productive interactions when those two come together.

Now, it's easy to say, but in order to get prepared proactive practices
and informed patients you really have to approach the whole system and
the community. The patient only lives maybe less than 1% of their life
in the health care setting.

We tend to forget that, but in order to make improvements we really can
look at self management support, delivery system design, clinical
information systems, and decision support. While this is the picture for
our health care system that we would like to have, but it's a little bit
harder to get that thing on the ground and put it into practice.

I am going to go to the next slide and just reflect for a minute on
quality improvement efforts that have occurred in the Indian Heath Care
system. The improvements that have happened in the Indian Health system
are important and significant.

There are some improvements that we have seen across multiple illnesses
and those have largely occurred through clinical information systems and
some decision support, for example tools that we have such as RPMS. The
automatic calculation of glomerular filtration rate that we have in
RPMS, and the use of registries, help with multiple chronic illnesses
and are not necessarily disease specific.

Health management improvements and delivery system design improvements
have really occurred with disease specific problems. And, lastly with
this quality improvement effort we don't do a very good job of sharing
successes and failures.

We may realize an important improvement here in Whiteriver, but the
facility next door at San Carlos may never hear about the improvements
that we've made and even sometimes more importantly, they definitely
wouldn't hear about one of our failures, which are just as important as
our successes.

So, I will go to the next slide and it's just asking the question how we
get from our acute care system to the Chronic Care Model that we would
like to get to.

> In the next slide, it basically just explains the difference between
> Chronic Care Model and we are going to achieve improvements. The
> Chronic Care Model is a model for change. The mechanisms for change
> are what we're going to talk about as a collaborative and the
> Institute for Healthcare Improvement partnership.

The collaborative is basically a pilot test of a few facilities working
together closely to try to create improvements or changes that so that
we can prove that these changes are improvements. And, then spread those
improvements throughout the Indian Heath Care system.

I'll get back to that in a minute and we will go to the next slide which
is the Institute for Healthcare Improvement. The Institute for
Healthcare Improvement is a non-profit organization and international
leader of creating change and improvement in health care. They have a
commitment in improving outcomes for underserved and vulnerable
populations and they really are the world's expert. We think that they
can help us develop innovations and facilitate broad scale adoption of
sound changes that will improve the heath care for the patients and the
population that we serve. Their website is on that slide if you
downloaded the presentation, at [www.ihi.org](http://www.ihi.org/) and
there are lots of improvement stories and resources on that site.

> The next component of the Initiative is that integration of the three
> health initiatives will be key. It also has to be feasible within the
> existing funding structure because there is not a lot of money out
> there. And, finally, we will try to activate leadership through the
> Indian Health System to support the redesign of the Chronic Illness
> Care through the Chronic Care Model.
>
> The next slide is a reiteration of some of the jargon that I a using
> when I talk about the Chronic Disease Initiative. The initiative is
> the program that will strive to improve the care for chronic
> conditions in the Indian Health System using organized improvement
> processes.
>
> The Chronic Disease Collaborative is the process that will introduce
> IHS to the improvement processes and facilitate the work of the
> Initiative through a pilot site project. The Chronic Care Model is jus
> the framework that can guide the delivery of care for chronic
> conditions.

The next slide depicts the engine of how we will make changes and assure
that those changes are improvements, not just changes. This is model for
improvement, and I would guess that the majority of people on the call
are familiar with this model as the PDSA process. To use this, we have
to first decide what we are trying to accomplish with a change. Second,
we have to decide how we will know if the change is an improvement. And,
then third, what changes can we make that will result in improvements.
IHI is trying to help us bring an organized improvement process to our
efforts for the Chronic Disease Initiative.

The next slide describes the Chronic Disease Initiative and the aim of
the initiative. I am just going to read what we have here. The aim of
the Chronic Disease Initiative is to improve the health status of those
affected by chronic disease and reduce the prevalence and impact of
those diseases by adapting and implementing the Chronic Care Model..

You can already see that there is some integration with the health
promotion and disease prevention initiative because we are talking about
reducing even the prevalence of some of those illnesses.

> The focus will be placed on developing care processes that apply
> across multiple chronic conditions instead of care based only on
> managing individual diseases. And, that separates the Chronic Disease
> Initiative from some of the individual programs that we have such as
> the diabetes program now. Another important part of the aim is that
> the lessons learned will be packaged so that they can be spread easily
> to the rest of the Indian Health System.
>
> Other components of the aim of the initiative are described by the
> guidance. In the Initiative, we will support other innovative efforts
> that already exist outside or throughout the Indian Health System
> instead of creating beginning from scratch.
>
> Another way to look at this is that we will try to adapt what we
> already do for chronic illness care, into some of the innovation that
> will take place. As such, we hope to make the most efficient use of
> our resources. When we try to make improvements in the Indian Health
> System or a least the parts that I am very familiar with, we do really
> well at planning and doing, but don't really get around to studying
> and acting on those results very often. We also tend to not be formal
> in asking ourselves those first three questions before beginning. I
> want to clarify a bit what I mean when I note that we don't study
> because we all know that we have some excellent tools for studying our
> changes. We have tools such as the Clinical Report System (CRS) and
> the diabetes audit to help us study. The problem is we usually end up
> studying on a longer scale so we plan and we do and then we study at
> the end of the year or maybe after three months. Then we try to act
> and start over again. But, the rapid cycle improvement and studying we
> don't really get to see. So, we just see the outcomes of our
> improvements at the end of the year when we get the data back from CRS
> or the diabetes audit.

The next slide is really just a larger picture of what I am talking
about. The ultimate goal is to get answers to those three questions in
any change. In order to get to those answers, we want to try it on a
small scale and then we want to study and get the results to see if that
was really an improvement or whether it was just a change that didn't
really help anything. And, then we can learn from those results, and if
it's good enough, then we try on a little wider scale. We try to spread
it a little bit and then we test again and we go through the cycle. And
if you can do that in a rapid succession at local facilities, hopefully
when you try to change something you can do so and know it is an
improvement. This way you won't be wasting time on implementing things
that we don't yet know or haven't proven to be a success.

The next slide is basically just where we are as far as the
Collaborative. What we are calling it is a Planned Care Innovation
Community. We are going to have up to 12 pilot sites that will work in
the fashions that we have talked about.

Improve, implement and we say implement the Chronic Care Model, but in
actuality the pilots are going to be testing changes to make sure that
their improvements work within the Care Model. Once we prove that their
improvements are successful, then we will try to spread them.

Right now we have five Federal sites and one Tribal site and those sites
are Albuquerque, Chinle, Gallup Indian Medical Center, Sells Service
Unit, Warm Springs, and Mississippi Choctaw Band of Indians that are
participating and then we are going to select up to six more
tribal/urban facilities to help us in the initial pilot site phase.

So, once we get though the pilot site phase, we'll have a pretty good
slice of the Indian Health Care System. Having tested these innovations
so that when we go to spread them throughout the Indian Health System it
should be easier to demonstrate their effectiveness.

We've got a great team of people who have been selected to help us with
the Chronic Disease Initiative and we look forward to hopefully some
good successes. I am sure I have gone close to my time so I will turn it
back over to Dr. Peter. Thank you.

(Douglas Peter): Thank you Dr. Reidhead. I hope that you are going to be
able to stay and take some questions in case there are questions in 15
more minutes.

(Ty Reidhead): Absolutely.

(Douglas Peter): Great. Thanks. I think most of those who have called in
a very familiar with the model for change in (PDCA) or (PDSA) in this
instance and there may be questions or comments on the initiative for
you. But, thanks again. Let me turn the time over to Ms. Alberta Becenti
in IHS Headquarters.

She's responsible for the Health Promotion Disease Prevention Initiative
nationally and in Indian country. So, Ms. Becenti, thank you.

(Alberta Becenti): Thank you Dr. Peter. I am a member of the Navajo
Tribe from New Mexico and my title is Health Promotion Disease
Prevention Coordinator. I have several slides, please advance to the
second slide.

Our overall goal is to create healthier American Indian and Alaska
Native communities by building on individual, family, and community
assets and strengths. We really want to know what is working out there.
There are some new strategies that may be working for some tribes that
we may not be aware of, so we really want to go identify strategies that
are working..

Moving on to the second slide. In order to address the many disparities
that were mentioned earlier, we must focus on proven public health
strategies to prevent disease and promote health at both the clinical
and community levels.

Our overall goal is to implement best and promising practices which will
lead to a reduction in disease burden as well as reducing health care
costs. Community capacity is necessary for the development,
implementation, and maintenance of effective community based health
promotion and disease prevention programs and efforts. As well as
building on the infrastructure to support preventive behaviors.

Moving on to the next slide. Some of the strategies that are being used
are establishing the HP/DP Policy Advisory Committee to provide
oversight and policy guidance to the agency.

We have representation from tribal leaders from across the country with
representation from the National Congress of American Indians, the
National Indian Health Board, National Council of Urban Indian Health,
Tribal Self Governance Committee, Direct Service Tribes, and a
representative from the Centers for Disease Control and Prevention (CDC)
and the National Institutes of Health as well.

The committee wanted to focus on four major doable areas which are
educational policies, partnerships, community assessment, and marketing.
I will go ahead and go through each one of them.

The reason why we wanted to focus on educational polices is that we
wanted to focus on population based interventions to reach a maximum
number of people and we thought the best way to do this was to go
promote school policies that are supportive of healthier behaviors such
as increasing physical activity and providing more nutritious meals at
the schools.

And at the national level it was great timing because the Women, Infant
and Children (WIC) Reauthorization Act was signed and the WIC
Reauthorization Act actually is to extend the ability to provide
nutritious meals and snacks to children in school and then advance
summer school nutrition programs.

And as part of this effort, the Area Coordinators who came on board were
charged to identify and assess how many schools have actually are in
compliance with the new WIC Authorization Act which is how many school
policies were in place that are supportive of healthier behaviors. If
they are not in compliance, how can we help?

They are actually out there looking at those policies to see how many we
can provide technical assistance to. And then we're also compiling all
the existing polices that were already developed and adopted across
Indian country and we put that on a CD and so those are for IHS-wide
dissemination. We do disseminate those at the national meetings and then
they'll go down to the local and regional Areas as well.

And the other ideas that emerged to support this educational policy is
the tribal leaders are interested in initiating a dialogue with the
National Governors Association just to put it on their radar screen that
we are working toward similar efforts and how they can support IHS and
tribes and urban Indians and adopt this policy.

And then of course the second part is the partnerships where we do have
many partners out there from academia and other Federal partners as
well. We want to include our focused areas for strategies to our
partners and we wanted to look at other partners who want to increase
physical activity, encourage healthier eating behaviors, and address
underage drinking, and increased community capacity. So, those are our
focus areas. We also want to provide, community assessment tools.

We wanted to make it more accessible for tribal members and urban
programs to access these tools. We want to create a large template at a
website so folks can be able to access it and customize the tools to
their needs.

The last area is marketing. We wanted to do a better job at marketing
what the HP/DP initiative is about. So, right now we're focusing on
developing brochures and we want to go develop a very catchy slogan that
people can go identify with. So, those are the four strategies for our
Policy Advisory Committee.

And the next slide. The Prevention Taskforce includes program
representation from all across the disciplines.

In May 2006 when the Prevention Task Force met, we were fortunate enough
to meet with the three initiatives working group to discuss ideas and
ways that we can integrate the other two initiatives into our Prevention
Task Force Strategic Plan. Our plan does reflect the integration of both
the Chronic Care Model and the Behavior Health and it also is reflective
of the newly revised IHS Strategic Plan as well.

In our draft comprehensive strategic plan, the main focus is developing
a structural focus for prevention, expand and maintain community
capacity, develop an operational plan and support model, and to expand
coalitions and partners to create incentives and accountability, and to
expand wellness policies to support healthier behaviors.

Our future plan for the Prevention Taskforce is to be reestablished as
the National Health Promotion Disease Prevention Council and be
recognized by a charter. So that charter is currently in the draft form.

Next slide. I mentioned that we were talking about some of the
strategies to build community capacity. One thing that I wanted to talk
about is the Healthy Native Community Fellowship.

Through the Community Healthy Native Fellowship, we identify folks out
there who want to participate in this four-week program that are broken
down to four one week programs four times a year.

The idea behind the Healthy Native Community Fellowship is to help the
community realize their vision of health and wellness and then to create
effective plans and coalitions to help improve community health,
mobilize the community for positive change, and then to energize and
develop their leadership skills.

Next slide. The Healthy Native Community Fellowship is actually based on
an learning model in which insight skills and new knowledge are shared
and applied in real life situations. So far we have 81 fellows from
across the country who have graduated from the Fellowship in 2005 and
2006.

This year in fiscal year 2007, 15 more teams were selected for the
Healthy Native Community Fellowship. Next slide. Just to give you an
idea of where the fellows are from you'll notice that there's a slide
that has a white star and then a dark star. The red star which is the
darker one actually reflects the 2005 Healthy Native Community Fellows
and the white star represents the 2006 Fellows. This is just to give you
an idea of where the fellows are from as you'll notice we have a lot of
participants from the southwest and Alaska and Northern areas.

> Next slide. The other strategy is to implement community champions'
> forums. That is a forum to identify tribal "doers" and the champions
> who are out there who are making a difference in their community. The
> idea is for them to go come together and share success stories and to
> be able to network and to recognize these local champions who are the
> doers and the change agents in the community.

So far, Community Champion Forums have been held in 11 of the 12 IHS
Areas and the effort is ongoing and in some Areas HP/DP coordinators
decided to do regional community champions to keep this effort going.

The other strategy is to expand the "Just Move It Campaign", the goal is
to get one million American Indians and Alaska Natives moving.

> The third strategy is to increase our partnerships. We established a
> partnership with Mothers Against Drunk Driving (MADD) to address
> underage drinking and drunk driving.

Next slide. Some of the youth projects that we've been working on is to
get youth involved in positive activities. Through the Regional Youth
Summit we were able to get the youth engaged in addressing these issues.

Who are the youth that are invited to this summit? They are young people
who are already involved in making positive differences in their
communities. So we recognize them and they come together and utilize
strategies and share ideas of how they'll be able to take these ideas
back to their community. The first Youth Summits was held in Albuquerque
and we had over 500 youth in 2005; and in 2006 the Youth Summit in
Eugene, Oregon had 250 youth and adults attend. And we hope to keep this
going again this year in 2007. And some other youth projects are the
Youth in Actions, in collaboration with Mothers Against Drunk Driving.
We want to revise and modify the Youth in Action programs for culturally
appropriateness for American Indian Alaska Native communities.

So we're in the talking stages regarding this project. Okay, next slide.
The other strategy is the competitive grants. We received Congressional
funds in 2005 to support health promotion and disease prevention
programs. The competitive grants focus on behavioral risk factors that
contribute to obesity, cancer, cardiovascular disease, and substance use
among youth.

In fiscal year 2005, 20 competitive grants awards were given out and the
amount was \$64,500 and that grant cycle was for one year.

In fiscal year 2006, we awarded 13 competitive grants by reducing the
number of grants and increasing the funds to \$100,000 per year for
three years. On the next slide you'll notice the 2005 grantees - this is
just a picture for people who are visual.

Next slide. In 2006, these are our new grantees that were awarded just
this year. So their award will be from 2006 through 2009; all this
information is located at our website.

Next slide. On the website clearinghouse, we have all the best and
promising practices. And we have all grant announcements that are
available out there. Those are put at the website and then we have other
resources such as training.

Our future plan is to develop community assessment tools and to make
them available for our community members that include step by step
instructions on how to do a community assessment.

So folks can go to the website and access that information and also
develop a health profile by age and look at the existing published
health indicators that are currently available. At some point we also
want to look at community report cards as well.

Next slide. We conduct process, impact, and outcome evaluations that are
aligned with GPRA and the Healthy People 2010 objectives through annual
health promotion disease prevention reports.

We also look at process, impact, and outcomes. We look at trend reports,
RPMS, GPRA, and community health assessment and behavioral risk surveys
and the director's health promotion disease prevention bench marks.

These are integrated into the prevention task force strategic plan. Next
slide. If you'd like more information you can go visit us at the
website. That's all I have. Thank you.

(Douglas Peter): Thank you Alberta. I want to thank again Gary Quinn and
Dr. Reidhead for presenting this material on the three initiatives and
also Dr. Grim who had to exit the call today but is interested in the
questions and as was stated by the operator, this conversation is being
transcribed and will be available on the Director's Initiatives website.

I will turn it back over to the operator to talk to the callers and she
will announce how you can participate in the Q&A portion of this forum.
Operator?

Coordinator: Thank you. If you would like to ask a question at this time
simply press star one on your phone. You will be prompted to record your
first and a last name for the Q&A session. Once again that's star one if
you have a question and star two to cancel. One moment please. Thank you
and our first question is from Liz Hunt.

(Liz Hunt): Hi. I'm from the Indian Health Center in (Tennessee).
Actually the question I had I found the answer on the slides so my
question was answered. Thank you very much.

Coordinator: Thank you. And our next question is from Deborah
Yellowhorse.

(Deborah Yellowhorse): Are there any plans to develop uniformity in
integrating spiritual practices and counseling specifically including
sweat lodges, sweat lodge ceremonies and a development of position
descriptions for hiring traditional medicine people?

This kind of national support can reduce the risk of red tape in
implementing culturally relevant services. This is my question and
comment.

(Douglas Peter): Okay, thank you. We'll ask Mr. Quinn to start and if
others have comments, they can join in. Gary.

(Gary Quinn): To answer your question that is a part of what we see as
an effective approach to enhancing Behavioral Health and we are
recognize that element is important and so do our Tribal communities.
They see how it fits with this type of integration. So it sounds like
you have some ideas of how you want to do that.

I'll encourage you to work within your Area and your behavioral health
branch chief to discuss how that can be added in your Area. Thanks for
asking that question.

(Deborah Yellowhorse): Thank you.

Coordinator: Thank you. And the next question is from Carol Dahozy.

(Carol Dahozy): Okay. I just have a simple question for Dr. Reidhead.
Can you give us an example of what one of the pilot projects is looking
at and just kind of give a little brief overview of what one of the
pilot projects is about?

(Ty Reidhead): Okay I can take care of that. We are still really in the
planning stages of what we're going to ask the pilot sites to do. Each
of the pilot sites when they were selected, gave us their infrastructure
and their experience with making improvements within their facilities as
well as their use of clinical information systems. So we will begin work
with the pilot sites in January or February to really get started in
earnest.

We're going to ask them to address care practices at their facilities
that are going to be able to go across diseases. Now, you know, you ask
what that is and I know it's a little bit difficult.

But it's not necessarily disease specific but we're going to ask them to
use the chronic care model to figure how to make the patients will be at
the center of the care team or actually the center of the care instead
of the provider.

And we're going to ask them to develop care teams in order to deliver
that care. All of this hasn't really been worked out and in January
we're going to get an expert panel together to try to brain storm some
of the actual changes that we're going to ask the pilot sites to test.

And also the pilot sight themselves are going to have their own ideas on
how to deliver that type of care to their individual patients at their
facilities. So the bottom line is we don't have all the answers figured
out yet but we hope that some experts are going to be able to give us
some other ideas on how go about this process.

And the pilot sites will be able to have their own input and hopefully
in February. It's going to be a learning process as we go and we're
going to test as we go and make sure that it's what we're asking them to
do is improvement. So I'm sorry to be so vague but I think we'll have to
see how it goes as we get going.

(Carol Dahozy): Thank you. I know that we're just waiting to see what
the model is going to look like and how public health nurses are going
to be involved and I know they're going to play a big role in this.

(Ty Reidhead): I very much agree with you. That's one of the main points
of the client care model in this initiative is that right now the
providers tend to be in the middle of the care team and we sometimes
ignore -- I don't know if necessarily ignore but we don't fully include,
to the best capacity, team members such as public health nurses and
community health representatives just an example of a couple. Hopefully
including them more in what we're doing in improving communications
throughout the local care system and can reap the benefits that we
aren't seeing right now. Definitely improving communications with public
health nurses is one key component of what we need to try to improve on.

(Carol Dahozy): Okay, thank you.

(Ty Reidhead): Thank you.

Coordinator: Thank you. Our next question is from (Michelle Dewey).

(Michelle Dewey): Hi. I'm calling from Nevada and I am the Partnership
Coordinator for the National Cancer Institutes Cancer Information
Service. A lot of what I do working with the tribes here in Nevada is
providing them with the "cancer 101" program as well as any prevention
programs that they might have in terms of risk prevention, screening, et
cetera, et cetera.

I also provide technical assistance and a lot of what I've heard today
in this open door forum and I think it's a wonderful idea. So kudos for
the forum and especially during the second presentation was the increase
in implementation and communication and really getting people to adapt
these programs especially, you know, adaptation gets kind of threatening
especially in terms of fit and fidelity. Ask Michelle Dewey what she
said.

And two resources that I really have found helpful and that you may be
familiar with but they are cancer related but could be used, you know,
across the board in chronic disease is the cancer control program as
well as a program training put on through the National Cancer Institute
called "Using What Works" which helps these people too.

And getting these grant monies, you know, to really use evidence based
programs or at least evidence informed programs in there grant
applications. My question long story short is: are there any other
resources that you are aware of where or is there is a site the acts as
a repository or will that eventually act as a repository for these pilot
programs that you are doing so that others can learn from them and
communication will be increased?

(Douglas Peter): Let me ask Ty if you have any comments. I know you know
about the IHI sites and could you comment on that for us.

(Ty Reidhead): Yes, I'll give it a shot. I'm not familiar with the two
projects that you're talking about and referencing - I'll have to check
on those.

(Michelle Dewey): And I would be happy to share.

(Ty Reidhead): That'd be great. And as far as a repository for resources
so that we can share better, right now the IHI has their own website and
extranet where people who are participating in other collaboratives
outside the health service can share some of those resources. People can
also get to those resources just on the website. All you have to do is
just share your log in information and it's a free registration. Now in
the future that's hopefully one of the things that we're going to get
out of these pilot site collaboratives. We need to have a site where we
can put information in one place and have it assessable to everybody
within the Indian health system including tribal sites and urban sites
and that site has not been developed yet.

So that's definitely a goal, unfortunately I don't have a website or any
other such thing to say, where you should go right now but hopefully
within the next year or so that will become available.

(Michelle Dewey): Well I do agree with their focus on any chronic
disease or risky behaviors, they could definitely look on the cancer
control website just to get some ideas of how to adapt a program
properly especially when you're looking at planning and that type thing.

(Douglas Peter): Ms. Becenti, would you like to comment as well?

(Alberta Becenti): Hi, this is regarding the prevention initiative. Our
future plan with the competitive grants awards is we want to actually
add this information to the website for all the competitive grant
recipients and to put all the information on the website so we can also
learn from each other as well. And part of that plan, we really want to
thoroughly evaluate it and it may not be actually be chronic disease but
actually behavioral risk factors that contribute to chronic diseases.

(Douglas Peter): Thanks Alberta. Operator.

(Alberta Becenti): Thank you.

Coordinator: Thank you. And our next question is from (Margaret
Alspaugh).

(Margaret Alspaugh): Yes, I'm the Medical Director at Greenville
Rancheria. I was interested in the granting. There have been rumors that
grant awards may be based on different outcomes in the future. How are
these grants awarded and could someone give us an idea?

(Douglas Peter): I'll have Alberta comment on the Health Promotion grant
awards.

(Alberta Becenti): The grantees for the competitive grants for health
promotion/disease prevention were focused on areas related to obesity,
cardiovascular disease, cancer, and substance abuse among youth. Each of
the competitive grant awards were based on established criteria. In the
grant announcement we did encourage people to visit the evidence based
practices that were available at the websites and we encouraged them to
be able to apply or adapt some of those interventions to the community.
We were looking at risk factors that contribute to those diseases that I
had mentioned.

(Douglas Peter): Did that answer your question caller?

(Margaret Alspaugh): Yes, I guess so.

(Douglas Peter): Do you have a follow up?

(Margaret Alspaugh): For example, on diabetes grants in general you
haven't really spoken about that but we use GPRA for that, you know, for
our (clients). Is there any feeling that among the group that the
different indicators in the future will be used for partial awarding. I
mean in some aspects awarding grants for diabetes for example. Just as
an example.

(Douglas Peter): At the present time we do not intend to award diabetes,
noncompetitive grants other than the way we are doing presently. And
that is to award certain amounts and the Areas decide the amounts for
each of the individual awardees.

As far as the competitive grants, they've been awarded for the Diabetes
Prevention Program (DPP) and the cardiovascular risk reduction efforts.
And I don't see any change in that award process in the near future.
Those awardees have a five year life cycle and we're only in year two I
believe. So I guess the answer to your question is we don't intend to
base competitive or noncompetitive awards on different results.
Operator.

Coordinator: Thank you. Our next question is from Constance James.

(Constance James): Hi, I think this question is for Dr. Reidhead. I'm a
bit concerned about certainly the cost related to the participating in
the Institute for Healthcare Improvement collaborative but perhaps I
just don't understand.

Are you saying then that these chronic disease management collaboratives
and pilot sites are the sights that participate with these (super)
health care improvements? And if that's so, how are we affording it
within the Indian Health Service?

(Ty Reidhead): So first of all we have a team from the Institute for
Healthcare Improvement that is helping us design the intervention and
the changes that we're going to begin with. If you're familiar with the
primary care collaboratives that have taken place in the past, they
basically approach these collaboratives from a disease specific
background.

The Indian Health Service has a history of doing that in one sense
especially since we've made some improvements on a system wide basis of
diabetes care and in some respect we end up with health system that
facilitates diabetes care, but this has not been in an organized
collaborative process.

So we wanted to try to approach it with multiple chronic illnesses. Now
we basically have a team of four or five people from the Institute for
Healthcare Improvement that are helping us with that and we're working
on a partnership agreement with the IHI to help us with that effort. At
a local level, the pilot sites are getting just a very small amount of
money to help them with travel to a few trainings and small meetings as
well as being able to make sure they have access to WebEx technology so
that we can have virtual meetings with the pilot sites that are
participating.

And that small amount of money really doesn't pay for much of a position
or anything else but it hopefully will help them to learn how to make
changes within their own system that they're providing care right now.
So I don't know if I answered your question or if you want to ask again
to help make it clearer.

(Constance James): I know that there are several Indian Health System
facilities who have participated in a collaborative not through the
Indian Health Service but have approached IHI individually in a
collaborative and depending on how many you want to participate, there
is an average cost about \$30,000 per collaborative.

So if we could somehow use the technology and as you say spread the
technology, is this some sort of collaborative purchase that we could
buy in?

(Ty Reidhead): Right, right. Well the pilot sites are not being asked to
pay for anything with the Institute for Healthcare Improvement to
participate that's more of a collective agreement that we're
negotiating.

(Constance James): You\'re negotiating nationally?

(Ty Reidhead): Nationally correct.

(Constance James): Okay. Thank you.

Coordinator: Thank you. Our next question is from (Manuel Rodriquez).

(Manuel Rodriquez): Hi, yes my name is Manuel Rodriquez. I think maybe a
previous caller had already somewhat touched on the question I had but
is relevant to the chronic disease initiative where it says that the
focus will be placed on developing care practices that apply across
multiple chronic diseases instead of care based on managing individual
diseases.

I was just wondering how that was going to effect the existing programs
that are concentrating on diabetes -- diabetes wellness grants?

(Ty Reidhead): I hope that they will just integrate the systems that are
already in place.

(Manuel Rodriquez): Yes.

(Ty Reidhead): Utilize the diabetes case managers in the way that
they've been used in the past but I don't know how that's going to
effect them as far as maybe asking them to branch out a little bit and
we need to talk about it.

When somebody goes and sees a diabetes case manger they hopefully
receive care for their other illnesses including hypertension,
hyperlipidemia, those sorts of issues. So I hope that we'll just
integrate what's already in place. I don't think it's going to affect
them in any other way.

(Manuel Rodriquez): Okay so it will probably improve the care then which
is part of the yang.

(Ty Reidhead): Exactly.

(Manuel Rodriquez): Okay thank you.

(Ty Reidhead): Thank you.

Coordinator: Thank you. And at this time I show no questions.

(Douglas Peter): We'll wait a minute or two and see if any other
questions pop up. I do want to remind everybody the PowerPoint slides
are on the website. I also want to mention that we have individuals here
in Headquarters in the broadcast booth from every program. We have them
from experts in elder care, medicine, and experts in injury prevention.

We have guests that are here from the CDC with us as well today. So if
you have questions for the CDC or other questions you might have in the
areas I mentioned, we'd be happy to field those questions as well.

Coordinator: Thank you and we have a question from Shirley Nelson.

(Shirley Nelson): Hello this is Shirley Nelson. I'm the Health Promotion
Coordinator for the Fort Defiance Hospital. The question was more
related to the previous discussion about moving towards community
capacity and working with communities to work on health promotion,
chronic diseases and behavioral health services.

I'm just wondering if there's going to be a change in the way the job
descriptions are made for people doing this kind of work because what we
see notice is people with clinical focus doing community work and if job
descriptions are going to be changed in the future for that and also
will we see more resources and staffing for these types of jobs in the
future?

(Douglas Peter): I think you know as far as job descriptions it's up to
every site I believe and every community to determine what types of
experts they need to hire to perform the type of work that they feel
must be performed.

In some cases the dietitians are the most appropriate, in some cases a
nutritionist may be. RNs are appropriate for some circumstances and
CHR's for others. I don't know that we're going to standardize the job
descriptions for particular functions I/T/U wide.

I think it's really better if the Areas and the I/T/U sites look at that
issue themselves and identify the types of experts they need. If you
have a specific follow up Shirley, I wish that you could send that to
Alberta Becenti here at Headquarters because if you have a specific
issue related to job descriptions for HP/DP, address it to her and send
a copy to me if you would.

Coordinator: Thank you. And there are no questions at this time sir.

(Douglas Peter): Let me ask Nancy Bill to describe briefly our injury
prevention program and in the context of that work with ASBI which you
heard about under behavioral health work and health promotion and I
thank her for her brief presentation in the next minute or two.

(Nancy Bill): Okay thank you Dr. Peter. This is Nancy Bill with the
Injury Prevention Program. I just want to make a comment about
integration and Injury Prevention. I'll just make a few comments about
the alcohol screening and brief intervention. I just wanted to say that
I was working and giving some feedback to Dr. Boyd on the instrument
that he uses on the ASBI.

And as far as Health Promotion, I have been working closely with Alberta
Becenti on several initiatives especially the one with the MADD and
under age drinking initiative. But I have a question actually for
everyone. All the three presenters mentioned integration is one of the
areas that has a real impact on health care and years of potential life
lost and health cost.

I'd like to ask each of the presenters to give at least some feedback on
how they see injury prevention can be integrated into each of the
initiatives. Because on each presentation, I was trying to hear how it's
integrated on the field level to Area to Headquarters. I just wanted to
hear your comments on that.

(Douglas Peter): Let me start with Alberta Becenti and injury prevention
and the obvious connection to injury prevention and health promotion. I
know there are activities going on in all locations regarding not only
seat belts but infant seat use and other areas you may have.

(Alberta Becenti): Okay. The health promotion/disease prevention
initiative has integrated all the various disciplines into the
Prevention Task Force. And one of the areas was to go look at primary
seat belts laws and how a multidisciplinary team can support this
effort.

And as far as the other collaborations, at the prevention task force
meetings we wanted to really collaborate and work with the injury
prevention folks. We had talked about the Area behavioral health
meetings and creating a team of behavioral health, injury prevention ,
and health promotion and to go out and meet with the tribes and come up
with some ideas. We have sought Tribal input and urban input on how they
can integrate some of the three initiatives into their plans.

And then at the Area and community levels, there is collaboration that
is going on with the injury prevention folks as far as supporting them
in efforts like seat belts and maybe hospital or community based seat
belt clinics and car seat clinics and things like that.

Other areas of collaboration include community capacity training to
provide the knowledge and skills for communities to be involved and to
address their own issues. So those are some of the points that we've
been working with injury prevention.

(Douglas Peter): Mr. Quinn talked about ASBI briefly and I don't know if
he has any other comments on ASBI but in the moment of truth in any
emergency room that program is one that prevents and saves lives. So
Gary, do you have any comments?

(Gary Quinn): Thank you sir. Ms. Bill, as you know, I talked briefly
about ASBI and it's a very important effort led by Dr. Boyd. We're just
in the beginning stages of identifying what it is that we can do but one
of the things that we are exploring is identifying how the Areas will be
interested in furthering this type of intervention in trauma centers and
how to coordinate behavioral health services to the recipients of the
screening when they are brought in for treatment at our primary care
centers.

So, I had mentioned one of the objectives for FY 2007, is for the
Headquarters Division of Behavioral Health to support and encourage the
12 Area branch chiefs to promote their specific plans to integrate
behavioral health with some other initiative element within their Area.
So perhaps one of the 12 Areas might want to take that on as integration
or suggest a potential policy within their respective Area to address
integration with Injury Prevention and Behavioral Health. When this
occurs, we can follow the model and approach that has been successful
and has been demonstrated by my colleagues here - Dr. Reidhead and Ms.
Becenti.

There have been a few Areas identified and these particular sites are
interested in further integration for a particular idea and we will
support them testing to see if it's effective. They will also work out
the bugs and then disseminate the results to the other Areas to
encourage them to do similar efforts as well. So that is a beginning
point that we are looking at with the ASBI.

(Douglas Peter): Several ASBI pilot sights have already been selected in
Indian country in various locations. I don't see how they can function
without outreach and so the integration there is crucial.

Additionally the surveillance forms that (H&E) has traditionally kept
track of, that whole system needs improving. So as we go forward the
goal would be to improve things across the board in Indian country
together across these initiatives. Operator we have time for one more
call and then our 90 minutes will be up. See if there's one extra call
out there.

Coordinator: Thank you. And once again that's star one if you have any
questions. And you will need to record your first and last name. One
moment please. And once again it's star one if you have a question or
comment. Thank you. We do have a question from (Carol Dahozy).

(Carol Dahozy): Hi this is just an FYI but the Alaska Native Medical
Center is sponsoring evidence based practice nurse internship programs
and one of our programs at the Hopi Health Care Center did submit a
proposal to institute the ASBI screening tool and they were selected for
this internship program so we're really excited to see what the outcome
is and what they'll be able to do with that but that's just another bit
of information on what some of the programs are doing.

(Douglas Peter): Thank you Carol. I think some of the other sites at
PIMC, Gallup Indian Medical Center, Tahlequah Hospital and the Alaska
Native Medical Center and I don't recall the others are working on
implementing ASBI and if Dr. Boyd is on the call, he might chime in here
but he's not. There are several pilot sites and we'll get that
information out there. Thanks for that information Carol. Operator,
another question perhaps?

Coordinator: Sir and I show no questions at this time.

(Douglas Peter): I think we will wrap up. I want to thank all the 90
plus sites or so that called in today. This is the first effort of its
kind that we're aware of in the Indian Health Service.

Hopefully our Tribal participants are open to what some Federal sites
found to be a productive forum. We anticipate doing this quarterly so
we're looking at January 24 or 25 for the next forum. We'll announced
that date in the next couple of weeks And the emphasis of the call will
be to hear from individual Areas such as the Tucson Area for example and
a couple other Areas that we'll ask for sharing of what they are doing
with regards to the three initiatives. How they approach it is up to
those individual Areas and they may have tribal sites or urban sites or
federal sites present. We'll coordinate all that between now and
January.

> Let me see if there are last comments from any of the folks here on
> the panel. Again I want to thank Mr. Quinn, Ms. Becenti, and Dr.
> Reidhead and all of you out there who participated in this forum. Have
> a good afternoon and we'll talk to you next time.

Coordinator: And thank you for joining this conference and have a great
day.

END