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####### 

####### Indian Health Service

FY 2005 Performance Plan

FY 2004 Revised Final Performance Plan

and FY 2003 Performance Report

*January 26, 2004*

This seventh Congressional Justification Submission of the *Indian
Health Service Fiscal Year (FY) 2005Performance Plan, FY 2004-Revised
Final Performance Plan, and FY* *2003 Performance Report* reflects the
commitment and determination of the Indian Health Service (IHS) to make
a positive difference in the health status of American Indians and
Alaska Natives.

This document is provided in accordance with the Government Performance
and Results Act (GPRA) of 1993. The principles and values underlying
this Act have been part of the IHS culture for some time. The IHS and
its stakeholders have always considered the GPRA and its requirements as
a natural extension of the public health model the Agency has used
effectively for almost a half century to make significant improvements
in the health status of Indian people.

The FY 2005 Performance Plan portion of this document also defines the
Agency\'s concerted effort in response to the President\'s Management
Agenda, the One Department initiative of the Secretary of Health and
Human Services (HHS), and the *Healthy People 2010* goals of achieving
equivalent and improved health status for all Americans over the next
decade. The long-term projected outcome of the FY 2005 Performance Plan
has been enhanced this year to incorporate revisions to the IHS
Strategic Plan and the new HHS Strategic Plan. For example, a roadmap
table shows individual GPRA annual performance measures linked to
specific long-term health outcome goals developed for the IHS Strategic
Plan.

Achieving both the short- and long-term health goals in the face of
increasing health status disparities experienced by American Indian and
Alaska Native people represents a formidable challenge for the IHS,
particularly for the local IHS, Tribal, and Urban Indian health
programs. To meet this challenge, the FY 2005 Performance Plan is
designed to use available resources effectively, and balance the
investment in treatment and prevention priorities with the development
of a critical infrastructure along with the capacity to evaluate program
effectiveness.

As the FY 2004 Revised Final Performance Plan and the FY 2003
Performance Report portions of the document show, the Indian health
system is up to the challenge of improving health services and programs
as well as meeting the emerging health needs of an aging population.
Furthermore, we are pilot testing promising new technologies through
collaborative efforts with other HHS partners. Indeed, achieving the
elimination of health disparities between the general and the American
Indian and Alaska Native populations will require the best efforts of
One Department. We continue to be optimistic that the future holds forth
better health care services, programs, and outcomes that will result in
the improved health status of American Indian and Alaska Native people.

Charles W. Grim, D.D.S., M.H.S.A.

Assistant Surgeon General

Interim Director

# Executive Summary {#executive-summary .unnumbered}

MISSION:

*The mission of the Indian Health Service, in partnership with American
Indian and Alaska Native people, is to raise their physical, mental,
social, and spiritual health to the highest level.*

GOAL:

*To assure that comprehensive, culturally acceptable personal and public
health services are available and accessible to American Indian and
Alaska Native people.*

FOUNDATION:

*To uphold the Federal Government's obligation to promote healthy
American Indian and Alaska Native people, communities, and cultures and
to honor and protect the inherent sovereign rights of Tribes.*

The Indian Health Service (IHS) is the Operating Division (OPDIV) within
the Department of Health and Human Services (HHS) that carries out the
federal government's trust responsibility to provide health care
services to eligible American Indian and Alaska Native (AI/AN) people.
IHS provides these health services through a network of 594 healthcare
facilities, including 49 hospitals, 231 ambulatory clinics, 309 health
stations, 15 school-based clinics, and numerous Alaskan village clinics.
These facilities provide direct health care services to over 1.6 million
AI/AN people. Many of these people live in isolated areas where there is
no access to health care services other than those offered by IHS or
tribally operated programs. Until the mid 1990s, IHS operated most of
these facilities and programs as federal programs. Currently, over 50%
of the Indian health system is operated directly by tribal governments
through contracts or compacts. In addition to these tribally operated
programs, IHS contracts with 34 urban Indian organizations to provide
services to eligible AI/AN people who reside in large metropolitan
areas.

Since 1955, IHS has demonstrated the ability to utilize limited
resources to improve the health status of the AI/AN people by focusing
on preventive and primary care services. The development and
implementation of a community-based, public health system has lead to
significant improvements in the health status of AI/AN people. Examples
can be seen in the dramatic decreases in mortality rates for certain
health problems between 1972-74 and 1997-99:

-   Maternal mortality reduced 79% (31.6 to 6.7 per 100,000);

-   Tuberculosis mortality reduced 86% (10.7 to 1.5 per 100,000);

-   Gastrointestinal disease mortality reduced 72% (6.7 to 1.9 per
    100,000);

-   Infant mortality reduced 65% (25.0 to 8.8 per 1,000 live births);
    and

-   Unintentional injuries mortality reduced 54% (206.7 to 95.1 per
    100,000).

    These changes are even more significant when one considers that IHS
    achieved these improved outcomes despite the following:

-   IHS receives lower per capita funding than the average Medicaid
    patient;

-   IHS has higher costs for health care due to increased disease burden
    and lack of access;

-   Provider recruitment and retention problems limit the availability
    of providers (e.g., half the physicians and nurses per capita as the
    general population);

-   Facilities are lacking or inadequate in numerous locations (i.e.,
    the average age of IHS facilities is 32 years in comparison to 9
    years for the private sector); and

-   High unemployment, poverty, lack of education, substandard housing,
    and other social determinants of health lead to poor health status

Our current FY 05 performance plan includes 39 performance measures,
including outcome measures, output measures, and efficiency measures.
Within this document, the initial FY 2005 and revised final FY 2004
Performance Plans have merged with the FY 2003 Performance Report
consistent with the required format developed with the Department of
Health and Human Services. In 2005, there are 39 GPRA indicators; we
have eliminated two indicators and changed an additional three
indicators from the FY 04 plan. These changes were made in conjunction
with clinicians and tribal input that was obtained over the course of
the last 12 months. In FY 2003, the IHS GPRA plan included 41 measures.
In 2003, 30 target measures were met; eight targets were not met, and
three are not currently reported. In FY 04, 2 measures have been
modified to achieve an increased number of outcome measures.
Modification of FY 03 measures to include outcomes will enable us to
assess the impact of improved clinical quality on outcome. Changed
measures include or will include obesity, fetal alcohol prevention,
cardiovascular disease prevention, domestic violence prevention, and
pregnant HIV transmission prevention. IHS is also pegging performance
targets to HP 2010 goals, as well as HEDIS goals. Additionally,
performance goals continue to be integrated into the PART reviews, as
well as the IHS Strategic Plan.

Performance successes included our ability to continue to meet our
diabetic indicators, despite an increasing diabetic population
throughout Indian country. In addition, IHS continues to display
improvement in immunization rates and injury prevention initiatives.
Ongoing challenges to improving clinical quality continue to confront
our Agency, as we face an increasing population, as well as
significantly increasing disease burdens. Ongoing health disparities
exist throughout the majority of AI/AN communities, and will require
additional comprehensive, community-oriented interventions for
significant impact.

While the IHS public health model has been effective in eliminating
certain infectious diseases, improving maternal and child health, and
increasing access to clean water and sanitation, the problems facing
AI/AN people and communities today are very different from those that
existed historically. The health problems in AI/AN communities today
mirror the health problems confronting U.S. All Races. These problems
include obesity, substance abuse, and lack of exercise, tobacco
dependence, and violence. The impact of these conditions in AI/AN
populations is reflected in increased disease burden and decreased life
expectancy. These often lead to the development of chronic diseases that
require costly long-term treatment such as cardiovascular disease,
diabetes (including kidney disease, dialysis, and blindness), liver
disease, cancer, and injuries.

In addition, the recent fully analyzed and racially adjusted mortality
data (FY 1999) available from the National Center for Health Statistics
documents an overall 4.5% increase in death rate for AI/AN people from
698.4 per 100,000 population for the period 1994 to 1996 to 730.1 per
100,000 population for the period 1997 to 1999. See Table 1 on page 7
for disease specific information.

Community based, public health oriented program provided a cost
effective positive impact on health status when health problems were
more clearly linked to disease processes prevalent many years ago.
However, this model has yet to be adapted to the more recent behavioral
and lifestyle issues that face IHS today. Implementing appropriate
prevention and patient education programs while continuing to provide
high quality medical services to AI/AN communities will require
additional resources that are not currently available to IHS.

The current plan presents a strategic set of performance indicators
intended to approach the growing health disparities between the American
Indian and Alaska Native population and the rest of the US population
(see chart below). However, achieving these performance targets will be
insufficient in reversing the worsening health status of American Indian
and Alaska Native people. Health disparities between American Indian and
Alaska Native's and the US population in general are unlikely to improve
unless additional resources become available to target these ongoing
disparities.

[IHS GPRA Contact:]{.underline}

Theresa Cullen, MD, MS

Planning and Evaluation

Office of Program Support/Office of Public Health

Phone: (301) 443-1549

Fax: (301) 443-0114

Table 1: Mortality Rate Disparities Continue Among AI/AN and All Races\
in the IHS Service Area

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# TABLE OF CONTENTS {#table-of-contents .Style-Heading-1Section-Title-+-Centered-Left:--0\"-First-line:--0\" .unnumbered}

[Executive Summary iii](#executive-summary)

[1.0 PERFORMANCE plan and Report 1-1](#performance-plan-and-report)

[1.1 Treatment Performance Measures
1-5](#treatment-performance-measures)

[1.1.1 Diabetes Group 1-5](#diabetes-group)

[1.1.2 Oral Health Group 1-5](#oral-health-group)

[1.2 Prevention Performance Measures
1-6](#prevention-performance-measures)

[1.2.1 Developmental Prevention Group
1-6](#developmental-prevention-group)

[1.3 Consultation, Partnerships, Core Functions, and Advocacy
Performance Measures
1-6](#consultation-partnerships-core-functions-and-advocacy-performance-measures)

[1.4 Information Technology Development and GPRA
1-6](#information-technology-development-and-gpra)

[1.5 Key External Factors Influencing Success
1-7](#key-external-factors-influencing-success)

[1.5.1 The Role of Poverty 1-7](#the-role-of-poverty)

[1.5.2 A Lack of Cost-Effective Interventions for Chronic Diseases
1-7](#a-lack-of-cost-effective-interventions-for-chronic-diseases)

[1.5.3 Third Party Collections 1-7](#third-party-collections)

[1.5.4 Recruitment and Retention of Health Care Providers
1-7](#recruitment-and-retention-of-health-care-providers)

[1.6 Budget and Program Aggregation
1-10](#budget-and-program-aggregation)

[Performance Analysis 1-16](#performance-analysis)

[Treatment and Prevention Categories
1-16](#treatment-and-prevention-categories)

[1.6.1 Program Description and Context
1-16](#program-description-and-context)

[1.6.2 Treatment Aggregation 1-16](#treatment-aggregation)

[1.6.3 Prevention Aggregation 1-17](#prevention-aggregation)

[1.6.4 Treatment Indicators 1-18](#treatment-indicators)

[Performance Budget Integration 1-29](#performance-budget-integration)

[1.6.4.1 Diabetes Group: 1-29](#diabetes-group-1)

[1.6.4.1 Cancer Screening Group: 1-38](#cancer-screening-group)

[1.6.4.2 Substance Abuse Treatment Group:
1-40](#substance-abuse-treatment-group)

[1.6.4.3 Oral Health Group: 1-42](#oral-health-group-1)

[1.6.4.4 Family Violence, Abuse, or Neglect Indicator:
1-47](#family-violence-abuse-or-neglect-indicator)

[1.6.4.5 Information Technology Development Group:
1-48](#information-technology-development-group)

[1.6.4.6 Quality of Care Indicator Group:
1-51](#quality-of-care-indicator-group)

[1.6.5 Prevention Indicators 1-54](#prevention-indicators)

[Performance Budget Integration 1-60](#performance-budget-integration-1)

[1.6.5.1 Public Health Nursing Indicator:
1-60](#public-health-nursing-indicator)

[1.6.5.1 Immunization Group: 1-62](#immunization-group)

[1.6.5.2 Injury Prevention Group: 1-66](#injury-prevention-group-1)

[1.6.5.3 Suicide Prevention Indicator:
1-68](#suicide-prevention-indicator-1)

[1.6.5.4 Developmental Prevention and Treatment Group:
1-69](#developmental-prevention-and-treatment-group)

[1.6.5.5 HIV/AIDS Indicator: 1-72](#hivaids-indicator)

[1.6.5.6 Environmental Surveillance Indicator:
1-74](#environmental-surveillance-indicator-1)

[1.7 Capital Programming/Infrastructure Category
1-75](#capital-programminginfrastructure-category)

[1.7.1 Program Description and Context
1-75](#program-description-and-context-1)

[1.7.2 Capital Programming /Infrastructure: Performance Indicators
1-75](#capital-programming-infrastructure-performance-indicators)

[1.7.3 Capital Programming/Infrastructure Indicators
1-76](#capital-programminginfrastructure-indicators)

[1.7.3.1 Capital Programming /Infrastructure Group:
1-78](#capital-programming-infrastructure-group)

[1.8 Partnerships, Consultation, Core Functions, and Advocacy Category
1-82](#partnerships-consultation-core-functions-and-advocacy-category)

[1.8.1 Program Description and Context
1-82](#program-description-and-context-2)

[1.8.2 Performance Indicators 1-82](#performance-indicators)

[1.8.3 Partnerships, Consultation, Core Functions, and Advocacy
Indicators
1-83](#partnerships-consultation-core-functions-and-advocacy-indicators)

[Performance Budget Integration 1-86](#performance-budget-integration-2)

[1.8.3.1 Consultation Improvement Indicator:
1-86](#consultation-improvement-indicator)

[1.8.3.2 Administrative Efficiency, Effectiveness, and Accountability
Group:
1-87](#administrative-efficiency-effectiveness-and-accountability-group)

[1.8.3.3 Managing Human Capital Indicator:
1-92](#managing-human-capital-indicator)

[2.0 APPENDIX 1: Linkage to HHS and Agency Strategic PlanS
2-1](#appendix-1-linkage-to-hhs-and-agency-strategic-plans)

[3.0 Appendix 2: CHANGES anD Improvements
3-1](#appendix-2-changes-and-improvements)

[3.1 FY 2005 Performance Plan 3-1](#fy-2005-performance-plan)

[3.2 Revisions to FY 2004 Performance Plan
3-1](#revisions-to-fy-2004-performance-plan)

[4.0 APPENDIX 3: PARTNERSHIPS AND COORDINATION
4-1](#appendix-3-partnerships-and-coordination)

[4.1 Program Coordination By Partners Within DHHS
4-1](#program-coordination-by-partners-within-dhhs)

[Food and Drug Administration 4-3](#food-and-drug-administration)

[Centers for Medicare and Medicaid Services
4-3](#centers-for-medicare-and-medicaid-services)

[Health Resources and Services Administration
4-4](#health-resources-and-services-administration)

[National Institutes of Health 4-4](#national-institutes-of-health)

[HHS Office of Women\'s Health 4-4](#hhs-office-of-womens-health)

[Substance Abuse and Mental Health Services Administration
4-5](#substance-abuse-and-mental-health-services-administration)

[4.2 Collaboration With Other Federal Agencies
4-5](#collaboration-with-other-federal-agencies)

[Department of Interior/Bureau of Indian Affairs
4-5](#department-of-interiorbureau-of-indian-affairs)

[Department of Justice 4-5](#department-of-justice)

[Department of Veterans Affairs 4-5](#department-of-veterans-affairs)

[4.3 Injury Prevention 4-5](#injury-prevention)

[5.0 Appendix 4: Data Verification and Validation
5-1](#appendix-4-data-verification-and-validation)

[5.1 Data Sources to Describe the American Indian and Alaska Native
Population
5-1](#data-sources-to-describe-the-american-indian-and-alaska-native-population)

[5.2 IHS Automated Data Systems 5-2](#ihs-automated-data-systems)

[5.3 IHS Diabetes Care and Outcomes Audit
5-3](#ihs-diabetes-care-and-outcomes-audit)

[6.0 Appendix 5: Performance Measurement Linkages
6-1](#appendix-5-performance-measurement-linkages)

[6.1 Performance Measurement Linkages with Budget
6-1](#performance-measurement-linkages-with-budget)

[6.2 Cost Accounting 6-1](#cost-accounting)

[6.3 Human Resources 6-2](#human-resources)

[6.4 Capital Planning 6-3](#capital-planning)

[6.5 Program Evaluation 6-3](#program-evaluation)

[6.6 Summary of Select Evaluations Activities
6-4](#summary-of-select-evaluations-activities)

[6.7 New Directions for Evaluation 6-5](#new-directions-for-evaluation)

[7.0 APPENDIX 6: SUMMARY FULL COST OF PERFORMANCE PROGRAM AREAS
7-5](#appendix-6-summary-full-cost-of-performance-program-areas)

[7.1 Performance Program Summary Table
7-5](#performance-program-summary-table)

#  {#section-1 .unnumbered}

#  {#section-2 .unnumbered}

# PERFORMANCE plan and Report 

A.  INTRODUCTION

    MISSION:

*The mission of the Indian Health Service, in partnership with American
Indian and Alaska Native people, is to raise their physical, mental,
social, and spiritual health to the highest level.*

GOAL:

*To assure that comprehensive, culturally acceptable personal and public
health services are available and accessible to American Indian and
Alaska Native people.*

FOUNDATION:

To uphold the Federal Government's obligation to promote healthy
American Indian and Alaska Native people, communities, and cultures and
to honor and protect the inherent sovereign rights of Tribes.

The Indian Health Service (IHS) is the Operating Division (OPDIV) within
the Department of Health and Human Services (HHS) that carries out the
federal government's trust responsibility to provide health care
services to eligible American Indian and Alaska Native people. IHS
provides these health services through a network of 594 healthcare
facilities, including 49 hospitals, 219 ambulatory clinics, 309 health
stations, 15 school-based clinics and numerous Alaskan village clinics.
These facilities provide direct health care services to over 1.4 million
American Indian and Alaska Native people; many of these people live in
isolated areas where there is no access to health services other than
those offered by IHS or tribally operated programs. Until the mid 1990s,
IHS operated most of these facilities and programs as federal programs.
However, IHS has long advocated for and supported the federal policy of
Indian self-determination. Because of this commitment, currently over
50% of the Indian health system is operated directly by tribal
governments. In addition to these tribally operated programs, IHS has
contracts with 34 urban Indian organizations to provide services to
eligible Indian people who reside in large metropolitan areas.

This performance plan outlines the incremental steps necessary to
achieve our Strategic Goals and our Mission. The Strategic Goals provide
the framework for key long-term outcome goals that are reflected through
the performance indicators in this plan. The performance indicators in
turn address the most significant health problems facing the American
Indian and Alaska Native population as identified by representatives of
the local I/T/U programs as well as management areas of the President\'s
Management Agenda.

**Strategic Goal 1 is to Build Healthy Communities.** Health care is
significantly determined at the community level; lifestyles established
at that level profoundly influence health. The application of
collaborative public health models remains critical to the development
of healthy communities. These public health models can help empower
communities to identify their own health problems as well as actively
involve them in developing the solutions.

**Strategic Goal 2 is to Achieve Parity in Access by 2010.** Achieving
parity in access to essential health care services is essential. This
requires a focused advocacy effort coordinated across an expanded Indian
health network. It also requires improving efficiencies, increasing
collections, and tapping alternative revenue streams across I/T/Us. It
requires appropriate organizational capacity and expertise within the
Indian Health System.

**Strategic Goal 3 is to Provide Compassionate, Quality Health Care.**
Improving the quality, safety, effectiveness, and acceptability of
comprehensive, culturally appropriate health care for American Indian
and Alaska Natives remains a management priority. An adequate
information technology infrastructure helps ensure access to safe,
evidence-based standards of care as well as health information to
providers and consumers.

**Strategic Goal 4 is to Embrace Innovation.** The IHS can only achieve
the previous three goals by embracing innovation. The IHS must develop a
more a proactive and entrepreneurial corporate culture, and expand
partnerships and coalitions to expand the Indian health network. This
requires the IHS to improve its coordination and communications capacity
and support the development of new structures, which can assist the
Indian health network advocacy efforts in multiple dimensions.

**Table 2: Program Performance Report Summary Table**

+----+----------+-------+--------+--------+--------+--------+--------+
| FY | Measures | Effic | O      | Output | R      | R      | Unre   |
|    | in Plan  | iency | utcome | Me     | esults | esults | ported |
|    | by       |       |        | asures | Re     | Met    |        |
|    | Budget   |       | Me     |        | ported |        |        |
|    | Category |       | asures |        |        | Comp   |        |
|    |          |       |        |        |        | letely |        |
+----+----------+-------+--------+--------+--------+--------+--------+
| 19 | Tre      |       |        |        | 17     | 12     |        |
| 99 | atment - |       |        |        |        |        |        |
|    | 17       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Prev     |       |        |        | 3      | 1      |        |
|    | ention - |       |        |        |        |        |        |
|    | 3        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Capital  |       |        |        | 3      | 2      |        |
|    | Prog     |       |        |        |        |        |        |
|    | ramming/ |       |        |        |        |        |        |
|    | Infrast  |       |        |        |        |        |        |
|    | ructure- |       |        |        |        |        |        |
|    | 3        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Consu    |       |        |        | 4      | 3      |        |
|    | ltation, |       |        |        |        |        |        |
|    | Partn    |       |        |        |        |        |        |
|    | erships, |       |        |        |        |        |        |
|    | Core     |       |        |        |        |        |        |
|    | Fu       |       |        |        |        |        |        |
|    | nctions, |       |        |        |        |        |        |
|    | Ad       |       |        |        |        |        |        |
|    | vocacy - |       |        |        |        |        |        |
|    | 4        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Total -  | 2     | 9      | 16     | 27     | 18     | 0      |
|    | 27       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
| 20 | Tre      |       |        |        | 18     | 13     |        |
| 00 | atment - |       |        |        |        |        |        |
|    | 18       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Prev     |       |        |        | 8      | 5      |        |
|    | ention - |       |        |        |        |        |        |
|    | 8        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Capital  |       |        |        | 3      | 2      |        |
|    | Prog     |       |        |        |        |        |        |
|    | ramming/ |       |        |        |        |        |        |
|    | Infrastr |       |        |        |        |        |        |
|    | ucture - |       |        |        |        |        |        |
|    | 3        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Consu    |       |        |        | 5      | 4      |        |
|    | ltation, |       |        |        |        |        |        |
|    | Partn    |       |        |        |        |        |        |
|    | erships, |       |        |        |        |        |        |
|    | Core     |       |        |        |        |        |        |
|    | Fu       |       |        |        |        |        |        |
|    | nctions, |       |        |        |        |        |        |
|    | Ad       |       |        |        |        |        |        |
|    | vocacy - |       |        |        |        |        |        |
|    | 5        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Total -  | 3     | 12     | 19     | 34     | 24     |        |
|    | 34       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
| 20 | Tre      |       |        |        | 19     | 13     |        |
| 01 | atment - |       |        |        |        |        |        |
|    | 19       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Prev     |       |        |        | 10     | 6      | 1      |
|    | ention - |       |        |        |        |        |        |
|    | 11       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Capital  |       |        |        | 3      | 2      |        |
|    | Prog     |       |        |        |        |        |        |
|    | ramming/ |       |        |        |        |        |        |
|    | Infrastr |       |        |        |        |        |        |
|    | ucture - |       |        |        |        |        |        |
|    | 3        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Consu    |       |        |        | 5      | 4      |        |
|    | ltation, |       |        |        |        |        |        |
|    | Partn    |       |        |        |        |        |        |
|    | erships, |       |        |        |        |        |        |
|    | Core     |       |        |        |        |        |        |
|    | Fu       |       |        |        |        |        |        |
|    | nctions, |       |        |        |        |        |        |
|    | Ad       |       |        |        |        |        |        |
|    | vocacy - |       |        |        |        |        |        |
|    | 5        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Total -  | 3     | 13     | 22     | 37     | 25     | 1      |
|    | 38       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
| 20 | Tre      |       |        |        | 21     | 18     | 0      |
| 02 | atment - |       |        |        |        |        |        |
|    | 21       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Prev     |       |        |        | 11     | 9      | 1      |
|    | ention - |       |        |        |        |        |        |
|    | 12       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Capital  |       |        |        | 2      | 2      | 0      |
|    | Prog     |       |        |        |        |        |        |
|    | ramming/ |       |        |        |        |        |        |
|    | Infrastr |       |        |        |        |        |        |
|    | ucture - |       |        |        |        |        |        |
|    | 2        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Consu    |       |        |        | 4      | 2      | 1      |
|    | ltation, |       |        |        |        |        |        |
|    | Partn    |       |        |        |        |        |        |
|    | erships, |       |        |        |        |        |        |
|    | Core     |       |        |        |        |        |        |
|    | Fu       |       |        |        |        |        |        |
|    | nctions, |       |        |        |        |        |        |
|    | Ad       |       |        |        |        |        |        |
|    | vocacy - |       |        |        |        |        |        |
|    | 5        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Total -  | 3     | 15     | 22     | 38     | 31     | 2      |
|    | 40       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
| 20 | Tre      |       |        |        | 20     | 15     | 1      |
| 03 | atment - |       |        |        |        |        |        |
|    | 21       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Prev     |       |        |        | 11     | 10     | 1      |
|    | ention - |       |        |        |        |        |        |
|    | 12       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Capital  |       |        |        | 2      | 2      | 0      |
|    | Prog     |       |        |        |        |        |        |
|    | ramming/ |       |        |        |        |        |        |
|    | Infrastr |       |        |        |        |        |        |
|    | ucture - |       |        |        |        |        |        |
|    | 2        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Consu    |       |        |        | 5      | 4      | 1      |
|    | ltation, |       |        |        |        |        |        |
|    | Partn    |       |        |        |        |        |        |
|    | erships, |       |        |        |        |        |        |
|    | Core     |       |        |        |        |        |        |
|    | Fu       |       |        |        |        |        |        |
|    | nctions, |       |        |        |        |        |        |
|    | Ad       |       |        |        |        |        |        |
|    | vocacy - |       |        |        |        |        |        |
|    | 6        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Total -  | 3     | 17     | 21     | 38     | 30     | 3      |
|    | 41       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
| 20 | T        |       |        |        |        |        |        |
| 04 | reatment |       |        |        |        |        |        |
|    | -- 21    |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Prev     |       |        |        |        |        |        |
|    | ention - |       |        |        |        |        |        |
|    | 12       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Capital  |       |        |        |        |        |        |
|    | Prog     |       |        |        |        |        |        |
|    | ramming/ |       |        |        |        |        |        |
|    | Infrastr |       |        |        |        |        |        |
|    | ucture - |       |        |        |        |        |        |
|    | 2        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Consu    |       |        |        |        |        |        |
|    | ltation, |       |        |        |        |        |        |
|    | Partn    |       |        |        |        |        |        |
|    | erships, |       |        |        |        |        |        |
|    | Core     |       |        |        |        |        |        |
|    | Fu       |       |        |        |        |        |        |
|    | nctions, |       |        |        |        |        |        |
|    | Ad       |       |        |        |        |        |        |
|    | vocacy - |       |        |        |        |        |        |
|    | 4        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Total -  | 3     | 18     | 20     |        |        |        |
|    | 39       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
| 20 | T        |       |        |        |        |        |        |
| 05 | reatment |       |        |        |        |        |        |
|    | -- 21    |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Prev     |       |        |        |        |        |        |
|    | ention - |       |        |        |        |        |        |
|    | 12       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Capital  |       |        |        |        |        |        |
|    | Prog     |       |        |        |        |        |        |
|    | ramming/ |       |        |        |        |        |        |
|    | Infrastr |       |        |        |        |        |        |
|    | ucture - |       |        |        |        |        |        |
|    | 2        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Consu    |       |        |        |        |        |        |
|    | ltation, |       |        |        |        |        |        |
|    | Partn    |       |        |        |        |        |        |
|    | erships, |       |        |        |        |        |        |
|    | Core     |       |        |        |        |        |        |
|    | Fu       |       |        |        |        |        |        |
|    | nctions, |       |        |        |        |        |        |
|    | Ad       |       |        |        |        |        |        |
|    | vocacy - |       |        |        |        |        |        |
|    | 4        |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+
|    | Total -  | 4     | 21     | 15     |        |        |        |
|    | 39       |       |        |        |        |        |        |
+----+----------+-------+--------+--------+--------+--------+--------+

The FY 2003 performance report highlights several noteworthy
accomplishments as well as conveys the challenges and difficulties faced
by the I/T/U programs in achieving these measures. A few are presented
here as representative of the overall report.

## Treatment Performance Measures

### Diabetes Group

IHS has been cited as a model of community involvement and program
effectiveness for the use of the IHS *Diabetes Care and Outcome Audit*
to measure diabetes care in American Indian and Alaska Native
communities. The Diabetes Care Audit assesses diabetes care and
education for approximately 85,000 IHS diabetes patients. These measures
reflect the National Council on Quality Assurance/American Diabetes
Association proposal for national performance benchmarks for diabetes
care.

IHS chose seven (including dental) of these audit measures as GPRA
performance goals for 2005. Trends from the 2003 audit data indicate a
continued improvement in these indicators. The IHS National Diabetes
Program attributes these clinical improvements to the extensive
commitment that IHS and local communities have made to improve diabetes
control. The IHS National Diabetes Program is encouraging programs to
use the new diabetes funding to continue to enhance their clinical care
programs as well as their prevention projects. In addition, in FY 2003,
our data source switched from the diabetic audit to GPRA+ data, which is
obtained from the local RPMS databases. Our diabetic audit data mirrors
our GPRA+ data, even though there may be occasional absolute
differences.

### Oral Health Group

Dental indicators provide a measure of three aspects of the dental
program that collectively have the potential to affect oral health
outcomes. Access to dental care is strongly associated with oral health.
Periodic examinations allow for the detection and treatment of dental
disease. Addressing overall access to dental care remains the dental
programs greatest challenge. It is worth noting that the national
average for access to dental has stood at just over 60% for several
years. Access remains a continued priority for the IHS.

The benefits of water fluoridation and dental sealants in reducing the
prevalence and severity of tooth decay are well supported in the
scientific literature and access to dental services has been associated
with better oral health status. In 2003, the IHS surpassed its
performance targets for maintaining access to dental care and applying
dental sealants but came up slightly short of reaching its target for
expanding coverage of water fluoridation. As a result, the Office of
Environmental Health and the Headquarters Division of Oral Health are
implementing a new centralized effort to promote fluoridation in Indian
communities.

## Prevention Performance Measures

### Developmental Prevention Group

Cardiovascular disease, obesity and tobacco are GPRA indicators that are
dependent upon pilot projects with tribes and outside organizations to
address these prevention issues. All targets were achieved in 2003. For
FY 2004 and beyond, the indicators addressing prevention of
cardiovascular diseases, obesity and tobacco use have evolved into
global IHS-wide efforts. Effective programs that address these problems
are critical to effective prevention and improved health status in
American Indian and Alaska Native communities.

## Consultation, Partnerships, Core Functions, and Advocacy Performance Measures

For FY 2003, accomplishments included meeting four of these five
indicators; data for one indicator is still pending.. These all
represent critical internal management functions that significantly
contribute to our Mission.

## Information Technology Development and GPRA

The IHS health information system provides user-friendly tools to
facilitate tracking and improving direct patient care at the local
sites; they also facilitate health data aggregation that is transparent
to the end user. Reporting on GPRA indicators is dependent upon this
reliable health information system. This system, RPMS (Resource Patient
Management System), supports and facilitates the integration of
clinical, administrative, and financial data at more than 80% of Indian
healthcare facilities. The Patient Care Component of the RPMS is an
automated system for the collection, storage, and output of data
gathered at the point of patient contact in the outpatient, inpatient,
and field visit settings. The National Patient Information Resource
System (NPIRS) database includes data from both facilities using RPMS as
well as those using other Health Information systems.

Indian Health Service has developed and deployed a software application
(GPRA+ Clinical Performance Indicator System) designed to extract GPRA
clinical indicator information from the RPMS system. This application
facilitates local, as well as regional, compilation of clinical GPRA
indicator results. The application allows a provider to track its' own
performance based upon the GPRA clinical indicators (similar to the use
of HEDIS by individual providers) based upon site-specific times. GPRA+
also allows us to report on active clinical users, as opposed to all
facility users. These results are used to report the FY 03 data.

IHS obtained data for most clinical indicators using electronic queries
on current FY 2003 local health information databases. Automating
extraction of data in this way allows IHS to add new performance
measures in the most cost-effective way, without imposing additional
data collection burdens on health care staff. A data warehouse is being
developed to ensure accurate user population information as well as
clinical data.

## Key External Factors Influencing Success

### The Role of Poverty

Socioeconomic determinants of health for both acute and chronic
conditions are documented worldwide. In fact, many of the racial and
ethnic disparities in health status disappear when analyses control for
education and socioeconomic status. While increasing access to
comprehensive health services over time will reduce both mortality and
morbidity to some degree in American Indian and Alaska Native
communities, health services alone are not likely to eliminate the huge
health disparity gap that now exists, unless the other complex factors
contributing to poverty are addressed. Poor health status should be
viewed as both a cause and an effect of poverty.

### A Lack of Cost-Effective Interventions for Chronic Diseases 

Prevention, diagnosis and treatment of diseases such as obesity,
alcoholism, diabetes, and cancer are extremely costly. The IHS is funded
at approximately \$1400 per person per year with Medicare/Medicaid;
private insurance collections and out of pocket expenditures adding an
estimated \$500-700 more. Thus, health care for American Indian and
Alaska Native people is funded at approximately \$2000 per person
annually compared to almost \$4500 for the U.S.general population. In
communities where the diabetes prevalence is approaching 40-50 percent,
the entire available per capita funding is used to treat acute medical
problems, leaving no resources for other critical health prevention and
disease management.

### Third Party Collections

The IHS is committed to the identification of available alternate
resources and full optimization of third party collections for delivery
of health care services. IHS has significantly increased its third party
collections, because of higher negotiated Medicare and Medicaid rates,
new authority to bill under CHIP and more efficient business management
practices involving patient eligibility determination, documentation of
services and processing of claims. These increases have been critical to
the I/T/Us ability to meet increasingly demanding accreditation and
quality standards and maintain access to services in the face of growing
health demands driven by population growth and increasing health
disparities. Third-party collections contribute to many performance
measures and are considered in a general way in setting performance
targets.

### Recruitment and Retention of Health Care Providers

Vacancy rates for some health care providers are at the highest level in
IHS history and relate directly to difficulties in recruitment and
retention of these providers. External factors include the growing debt
levels for health professionals leaving school, and relative shortages
of certain health professionals. Internal factors include isolation,
lack of amenities in many reservation settings, limited spousal
employment opportunities, as well as limited access to consultants and
diminished professional support from IHS Headquarters. Collectively
these trends and associated reductions in career development and
training opportunities have resulted in ongoing issues with recruitment
and retention.

B. Discussion and Performance analysis

**Program Description and Context:**

Table 3 outlines the relationship between the IHS Strategic Plan's four
broad Strategic Goals, their supporting long-term outcome goals, and the
FY 2005 performance indicators. Annual performance indicators contribute
to the realization of the long-term outcome goals that serve as the
progress measures for the IHS Strategic Goals.

Table 3:\
Roadmap of Relationship of IHS Strategic Goals, Long Term Outcome
Goals,\
and Annual Performance Indicators

+---------------+-----------------+----------------------+-----------+
| IHS Strategic | Long Term       | Annual Performance   | Budget    |
| Goals         | Outcome Goals   | Indicators           | Category  |
+===============+=================+======================+===========+
| GOAL 1: BUILD | By 2010 we will | -   Indicator 1:Poor | Treatment |
| HEALTHY       | decrease years  |     blood Sugar      |           |
| COMMUNITIES   | of productive   |     Control          |           |
|               | life lost       |                      |           |
|               | (YPLL) by 20%   | -   Indicator 2:     |           |
|               | over the 2002   |     Good Diabetic    |           |
|               | level.          |     Blood Sugar      |           |
|               |                 |     Control          |           |
|               |                 |                      |           |
|               |                 | -   Indicator 3:     |           |
|               |                 |     Diabetic Blood   |           |
|               |                 |     Pressure Control |           |
|               |                 |                      |           |
|               |                 | -   Indicator 4:     |           |
|               |                 |     Diabetic Lipid   |           |
|               |                 |     Screening        |           |
|               |                 |                      |           |
|               |                 | -   Indicator 5:     |           |
|               |                 |     Diabetic Kidney  |           |
|               |                 |     Disease          |           |
|               |                 |     Screening        |           |
|               |                 |                      |           |
|               |                 | -   Indicator 7: Pap |           |
|               |                 |     Screening        |           |
|               |                 |                      |           |
|               |                 | -   Indicator 8:     |           |
|               |                 |     Mammography      |           |
|               |                 |     Screening        |           |
|               |                 |                      |           |
|               |                 | -   Indicator 15:    |           |
|               |                 |     Domestic         |           |
|               |                 |     Violence         |           |
+---------------+-----------------+----------------------+-----------+
|               |                 | -   Indicator 22:    | P         |
|               |                 |     Public Health    | revention |
|               |                 |     Nursing visits   |           |
|               |                 |                      |           |
|               |                 | -   Indicator 23:    |           |
|               |                 |     Children's       |           |
|               |                 |     Immunizations    |           |
|               |                 |                      |           |
|               |                 | -   Indicator 24:    |           |
|               |                 |     Adult Influenza  |           |
|               |                 |     Immunizations    |           |
|               |                 |                      |           |
|               |                 | -   Indicator 25:    |           |
|               |                 |     Adult            |           |
|               |                 |     Pneumococcal     |           |
|               |                 |     Immunizations    |           |
|               |                 |                      |           |
|               |                 | -   Indicator 26:    |           |
|               |                 |     Injury           |           |
|               |                 |     Prevention       |           |
|               |                 |     Projects         |           |
|               |                 |                      |           |
|               |                 | -   Indicator 27:    |           |
|               |                 |     Reduce           |           |
|               |                 |     Unintentional    |           |
|               |                 |     Injury Mortality |           |
|               |                 |     Rates            |           |
|               |                 |                      |           |
|               |                 | -   Indicator 28:    |           |
|               |                 |     Suicide          |           |
|               |                 |     Surveillance     |           |
|               |                 |     System           |           |
|               |                 |                      |           |
|               |                 | -   Indicator 29:    |           |
|               |                 |     Screen patients  |           |
|               |                 |     for lipids       |           |
|               |                 |                      |           |
|               |                 | -   Indicator 31:    |           |
|               |                 |     Screen patients  |           |
|               |                 |     for tobacco use  |           |
+---------------+-----------------+----------------------+-----------+
|               | By 2010 we will | -   Indicator 30:    | P         |
|               | decrease        |     Screen patients  | revention |
|               | obesity rates   |     for obesity      |           |
|               | for children by |                      |           |
|               | 10% over the    |                      |           |
|               | 2002 rate.      |                      |           |
+---------------+-----------------+----------------------+-----------+
|               |                 | Other Annual         | Treatment |
|               |                 | Milestones for       |           |
|               |                 | Strategic Goal 1:    |           |
|               |                 |                      |           |
|               |                 | -   Indicator 9:     |           |
|               |                 |     Youth Regional   |           |
|               |                 |     Treatment        |           |
|               |                 |     Centers          |           |
|               |                 |                      |           |
|               |                 | -   Indicator 10:    |           |
|               |                 |     Screen Potential |           |
|               |                 |     Mothers for      |           |
|               |                 |     Substance Abuse  |           |
|               |                 |                      |           |
|               |                 | -   Indicator 11:    |           |
|               |                 |     Water            |           |
|               |                 |     Fluoridation     |           |
+---------------+-----------------+----------------------+-----------+
|               |                 | -   Indicator 34:    | P         |
|               |                 |     Environmental    | revention |
|               |                 |     Health           |           |
|               |                 |     Surveillance     |           |
|               |                 |     Systems          |           |
+---------------+-----------------+----------------------+-----------+
|               |                 | -   Indicator 39:    | Cons      |
|               |                 |     Assess Public    | ultation, |
|               |                 |     Health           | Part      |
|               |                 |     Infrastructure   | nerships, |
|               |                 |                      | Core      |
|               |                 |                      | F         |
|               |                 |                      | unctions, |
|               |                 |                      | and       |
|               |                 |                      | Advocacy  |
+---------------+-----------------+----------------------+-----------+
| GOAL 2:       | By 2010 we will | -   Indicator 13:    | Treatment |
| ACHIEVE       | assure 70% of   |     Dental Sealants  |           |
| PARITY IN     | AI/AN children  |                      |           |
| ACCESS BY     | receive dental  |                      |           |
| 2010          | sealants.       |                      |           |
+---------------+-----------------+----------------------+-----------+
|               | By 2010 we will | -   Indicator 23:    | P         |
|               | increase        |     Childhood        | revention |
|               | childhood       |     Immunizations    |           |
|               | immunization    |                      |           |
|               | rates to 95%.   |                      |           |
+---------------+-----------------+----------------------+-----------+
|               | By 2010 we will | -   Indicator 2:     | Treatment |
|               | assure that 40% |     Diabetic Blood   |           |
|               | of AI/AN        |     Sugar Control    |           |
|               | diabetics       |                      |           |
|               | achieve         |                      |           |
|               | \"ideal\" blood |                      |           |
|               | sugar control.  |                      |           |
+---------------+-----------------+----------------------+-----------+
|               | By 2010 we will | -   Indicator 35:    | Capital   |
|               | assure that 94% |     Sanitation       | Pro       |
|               | of AI/AN homes  |     Facilities       | gramming/ |
|               | have safe and   |                      | Infra     |
|               | adequate        |                      | structure |
|               | sanitation      |                      |           |
|               | facilities.     |                      |           |
+---------------+-----------------+----------------------+-----------+
|               |                 | Other Annual         | Treatment |
|               |                 | Milestones for       |           |
|               |                 | Strategic Goal 2:    |           |
|               |                 |                      |           |
|               |                 | -   Indicator 12:    |           |
|               |                 |     Access to Dental |           |
|               |                 |     Services         |           |
|               |                 |                      |           |
|               |                 | -   Indicator 14:    |           |
|               |                 |     Diabetic Access  |           |
|               |                 |     to Dental        |           |
|               |                 |     Services         |           |
+---------------+-----------------+----------------------+-----------+
|               |                 | -   Indicator 22:    | P         |
|               |                 |     Public Health    | revention |
|               |                 |     Nursing Services |           |
+---------------+-----------------+----------------------+-----------+
|               |                 | -   Indicator 36:    | Capital   |
|               |                 |     Construction of  | Pro       |
|               |                 |     Health Care      | gramming/ |
|               |                 |     Facilities       | Infra     |
|               |                 |                      | structure |
+---------------+-----------------+----------------------+-----------+
|               |                 | -   Indicator 38:    | Cons      |
|               |                 |     CHS Rate         | ultation, |
|               |                 |     Agreements       | Part      |
|               |                 |                      | nerships, |
|               |                 | -   Indicator 42:    | Core      |
|               |                 |     Placement of     | F         |
|               |                 |     Healthcare       | unctions, |
|               |                 |     Scholarship      | and       |
|               |                 |     Recipients       | Advocacy  |
+---------------+-----------------+----------------------+-----------+
| GOAL 3:       | By 2010 we will | -   Indicator 19:    | Treatment |
| PROVIDE       | assure that at  |     Accreditation of |           |
| C             | least 90% of    |     Facilities       |           |
| OMPASSIONATE, | the AI/AN       |                      |           |
| QUALITY       | consumers       | -   Indicator 21:    |           |
| HEALTH CARE   | receiving       |     Consumer         |           |
|               | health care in  |     Satisfaction     |           |
|               | IHS facilities  |                      |           |
|               | perceive it to  |                      |           |
|               | be good, very   |                      |           |
|               | good, or        |                      |           |
|               | excellent while |                      |           |
|               | maintaining     |                      |           |
|               | 100%            |                      |           |
|               | accreditation.  |                      |           |
+---------------+-----------------+----------------------+-----------+
|               |                 | Other Annual         | Treatment |
|               |                 | Milestones for       |           |
|               |                 | Strategic Goal 3:    |           |
|               |                 |                      |           |
|               |                 | -   Indicator 6:     |           |
|               |                 |     Diabetic         |           |
|               |                 |     Retinopathy      |           |
|               |                 |     Screening        |           |
|               |                 |                      |           |
|               |                 | -   Indicator 16:    |           |
|               |                 |     Local Data       |           |
|               |                 |     Quality          |           |
|               |                 |                      |           |
|               |                 | -   Indicator 17:    |           |
|               |                 |     Expand Use of    |           |
|               |                 |     Behavioral       |           |
|               |                 |     Health Data      |           |
|               |                 |     System           |           |
|               |                 |                      |           |
|               |                 | -   Indicator 18:    |           |
|               |                 |     Urban Common     |           |
|               |                 |     Data Set         |           |
|               |                 |                      |           |
|               |                 | -   Indicator 20:    |           |
|               |                 |     Implement        |           |
|               |                 |     Medication Error |           |
|               |                 |     Reporting System |           |
+---------------+-----------------+----------------------+-----------+
|               |                 | -   Indicator 33:    | P         |
|               |                 |     HIV/AIDS         | revention |
|               |                 |     Prevention       |           |
|               |                 |     Education at     |           |
|               |                 |     Prenatal         |           |
|               |                 |     Evaluations      |           |
+---------------+-----------------+----------------------+-----------+
| GOAL 4:       | By 2010, the    | -   Indicator 37:    | Cons      |
| EMBRACE       | work of the     |     Satisfaction     | ultation, |
| INNOVATION    | Indian health   |     with             | Part      |
|               | network will    |     Consultation     | nerships, |
|               | result in the   |     Policy           | Core      |
|               | per capita      |                      | F         |
|               | funding         |                      | unctions, |
|               | available for   |                      | and       |
|               | health care for |                      | Advocacy  |
|               | AI/AN people to |                      |           |
|               | be comparable   |                      |           |
|               | to the US All   |                      |           |
|               | Races level.    |                      |           |
+---------------+-----------------+----------------------+-----------+

*NOTE: Indicators 9, 33, 36, 42, and 45 have been discontinued for FY
2005.*

## Budget and Program Aggregation

Table 3 above relates our performance measures to our budget. We have
selected four functional areas for the aggregation of the 24 budget
categories identified in the IHS Detail of Changes Table: 1) Treatment,
2) Prevention, 3) Capital Programming/Infrastructure, and 4)
Consultation, Partnerships, Core Functions, and Advocacy.

Most chronic diseases such as diabetes, obesity, injuries, and family
violence require multidisciplinary interventions to be successful. In
such cases, there may be several providers, as well as health programs
and funding categories, simultaneously addressing these health problems.
Moreover, tribal programs, which now manage over 50% of the total IHS
budget, have the legal flexibility to reprogram funding categories to
meet their identified health priorities and likewise use an accounting
system tailored to their needs and preferences. As a result, with the
exception of the facilities construction category, tribes tend to use
resources based on individual tribal priorities; consequently, the link
between named categories in the IHS budget and how the funds actually
are used in tribal programs may not be highly correlated.

For IHS managed programs, aggregation of budget categories that splits
out activities and funding sources and facilitates a valid cost
accounting link to health outcomes cannot be provided at this time.
Despite these limitations, specific calculations for the four functional
budget areas are included within this plan.

The estimate for treatment costs have been calculated based upon known
health care costs in published medical literature, clinical user
population, and level of need funded. If no external cost data is
available, costs are calculated based upon percentage of provider time
as a part of Medicare reimbursement rates. Specific line item budgets
determine costs for indicators that have line item budgets. (e.g.
dental, public health nursing)

The estimate for prevention costs have been calculated based upon known
health care costs in published medical literature, clinical user
population, and level of need funded as well. Once again, specific line
item budgets determine costs for indicators that have line item budgets
(e.g. dental, public health nursing). Many of the prevention indicators
are tracking indicators; for these, we have included costs of tracking,
and NOT the cost of the interventions.

The estimate for capital programming and infrastructure include the
costs of building new facilities, as well as new and improved sanitation
costs. However, these estimates do not include the costs of supporting
and updating old facilities, equipment, and environmental costs.

The estimate for consultation, partnerships, core functions, and
advocacy includes the cost of supporting these programs (as the measures
are output measures), and not the cost of providing these services. The
actual costs for most of these services (e.g. Contract Health Costs;
Scholarships) are embedded in the other three budget categories.

Current FY 05 performance indicator budget aggregation accounts for
approximately two billion of the budget submission. However, many of our
projected indicator costs do not include the actual cost of services.
For instance, our Contract Health Service indicator cost is based upon
the cost of assessing the current number of contracts; it does not
include the basis for these costs---which is the CHS line item budget
within the treatment budget. The CHS budget amount accounts for 16% of
the treatment budget category. If IHS included the costs of providing
the service in each of our projected performance evaluation costs, as
well as the cost of the evaluation, budget performance linkages would
exist for approximately 2.6 billion of our proposed budget.

IHS is working towards a set of sentinel indicators that will reflect
the majority of our budget. For instance, cardiovascular disease (CVD)
is the number one cause of AI/ AN death. At the current time, due to
data system and clinical constraints, IHS has only one performance
indicator that addresses only one aspect of CVD treatment and
prevention. Development of additional data systems, as well as outcome
monitoring, should enable us to develop a more comprehensive CVD
indicator---and allow us to monitor appropriate and effective
utilization of additional treatment and prevention dollars.

Table 4 below shows the relationship between the funding categories in
IHS Detail of Changes Table and the appendix of the "Budget of the
United States" and our GPRA aggregation.

Table 4:\
Budget Category Aggregation

+---+---+--------------+---+---+----------------+---+---+------------------------+
| [ |   |              |   | [ |                |   | [ |                        |
| I |   |              |   | A |                |   | G |                        |
| N |   |              |   | P |                |   | P |                        |
| D |   |              |   | P |                |   | R |                        |
| I |   |              |   | E |                |   | A |                        |
| A |   |              |   | N |                |   | A |                        |
| N |   |              |   | D |                |   | G |                        |
| H |   |              |   | I |                |   | G |                        |
| E |   |              |   | X |                |   | R |                        |
| A |   |              |   | ] |                |   | E |                        |
| L |   |              |   | { |                |   | G |                        |
| T |   |              |   | . |                |   | A |                        |
| H |   |              |   | u |                |   | T |                        |
| S |   |              |   | n |                |   | I |                        |
| E |   |              |   | d |                |   | O |                        |
| R |   |              |   | e |                |   | N |                        |
| V |   |              |   | r |                |   | ] |                        |
| I |   |              |   | l |                |   | { |                        |
| C |   |              |   | i |                |   | . |                        |
| E |   |              |   | n |                |   | u |                        |
| ] |   |              |   | e |                |   | n |                        |
| { |   |              |   | } |                |   | d |                        |
| . |   |              |   | \ |                |   | e |                        |
| u |   |              |   | B |                |   | r |                        |
| n |   |              |   | u |                |   | l |                        |
| d |   |              |   | d |                |   | i |                        |
| e |   |              |   | g |                |   | n |                        |
| r |   |              |   | e |                |   | e |                        |
| l |   |              |   | t |                |   | } |                        |
| i |   |              |   | o |                |   | \ |                        |
| n |   |              |   | f |                |   | i |                        |
| e |   |              |   | t |                |   | t |                        |
| } |   |              |   | h |                |   | e |                        |
| \ |   |              |   | e |                |   | m |                        |
| D |   |              |   | U |                |   | s |                        |
| e |   |              |   | n |                |   | f |                        |
| t |   |              |   | i |                |   | r |                        |
| a |   |              |   | t |                |   | o |                        |
| i |   |              |   | e |                |   | m |                        |
| l |   |              |   | d |                |   | l |                        |
| o |   |              |   | S |                |   | e |                        |
| f |   |              |   | t |                |   | f |                        |
| C |   |              |   | a |                |   | t |                        |
| h |   |              |   | t |                |   | c |                        |
| a |   |              |   | e |                |   | o |                        |
| n |   |              |   | s |                |   | l |                        |
| g |   |              |   |   |                |   | u |                        |
| e |   |              |   | i |                |   | m |                        |
| T |   |              |   | t |                |   | n |                        |
| a |   |              |   | e |                |   |   |                        |
| b |   |              |   | m |                |   |   |                        |
| l |   |              |   | s |                |   |   |                        |
| e |   |              |   | f |                |   |   |                        |
|   |   |              |   | r |                |   |   |                        |
|   |   |              |   | o |                |   |   |                        |
|   |   |              |   | m |                |   |   |                        |
|   |   |              |   | l |                |   |   |                        |
|   |   |              |   | e |                |   |   |                        |
|   |   |              |   | f |                |   |   |                        |
|   |   |              |   | t |                |   |   |                        |
|   |   |              |   | c |                |   |   |                        |
|   |   |              |   | o |                |   |   |                        |
|   |   |              |   | l |                |   |   |                        |
|   |   |              |   | u |                |   |   |                        |
|   |   |              |   | m |                |   |   |                        |
|   |   |              |   | n |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| [ |   |              |   | [ |                |   |   |                        |
| S |   |              |   | S |                |   |   |                        |
| E |   |              |   | E |                |   |   |                        |
| R |   |              |   | R |                |   |   |                        |
| V |   |              |   | V |                |   |   |                        |
| I |   |              |   | I |                |   |   |                        |
| C |   |              |   | C |                |   |   |                        |
| E |   |              |   | E |                |   |   |                        |
| S |   |              |   | S |                |   |   |                        |
| : |   |              |   | : |                |   |   |                        |
| ] |   |              |   | ] |                |   |   |                        |
| { |   |              |   | { |                |   |   |                        |
| . |   |              |   | . |                |   |   |                        |
| u |   |              |   | u |                |   |   |                        |
| n |   |              |   | n |                |   |   |                        |
| d |   |              |   | d |                |   |   |                        |
| e |   |              |   | e |                |   |   |                        |
| r |   |              |   | r |                |   |   |                        |
| l |   |              |   | l |                |   |   |                        |
| i |   |              |   | i |                |   |   |                        |
| n |   |              |   | n |                |   |   |                        |
| e |   |              |   | e |                |   |   |                        |
| } |   |              |   | } |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | H |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | p |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | & |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | C |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 2 | D |              |   |   |                |   | 1 | Treatment              |
|   | e |              |   |   |                |   | \ | (1,2                   |
|   | n |              |   |   |                |   | . | ,3,4,5,10,11,12,14,15) |
|   | t |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | v |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 3 | M |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 4 | A |              |   |   |                |   | 2 | Prevention             |
|   | l |              |   |   |                |   | \ | (6,7,8,9,19b)\*        |
|   | c |              |   |   |                |   | . |                        |
|   | o |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | & |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | b |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | A |              |   |   |                |   |   |                        |
|   | b |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 5 | C |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | v |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
|   | T |              |   | 1 | Clinical       |   | 3 | Capital Programming/\  |
|   | o |              |   |   | Services (1-5) |   | \ | Infrastructure         |
|   | t |              |   |   |                |   | . | (16-20)\*\*            |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | , |              |   |   |                |   |   |                        |
|   | C |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | v |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 6 | P |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | b |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | N |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | g |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 7 | H |              |   |   |                |   | 4 | Partnerships,          |
|   | e |              |   |   |                |   | \ | Consultation,\         |
|   | a |              |   |   |                |   | . | Core Functions, and    |
|   | l |              |   |   |                |   |   | Advocacy               |
|   | t |              |   |   |                |   |   | (13,19a-c)\*\*\*       |
|   | h |              |   |   |                |   |   |                        |
|   | E |              |   |   |                |   |   |                        |
|   | d |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 8 | C |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | m |              |   |   |                |   |   |                        |
|   | m |              |   |   |                |   |   |                        |
|   | . |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | R |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | p |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 9 | I |              |   |   |                |   |   |                        |
|   | m |              |   |   |                |   |   |                        |
|   | m |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | z |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | A |              |   |   |                |   |   |                        |
|   | K |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
|   | T |              |   | 2 | Preventive     |   |   | \*The Prevention       |
|   | o |              |   |   | Health (6-9)   |   |   | category includes 35%  |
|   | t |              |   |   |                |   |   | of Environmental       |
|   | a |              |   |   |                |   |   | Health Support (19b)   |
|   | l |              |   |   |                |   |   | activities.            |
|   | , |              |   |   |                |   |   |                        |
|   | P |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | v |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | U |              |   | 3 | Urban Health   |   |   |                        |
| 0 | r |              |   |   | (10)           |   |   |                        |
|   | b |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | I |              |   | 4 | Indian Health  |   |   | \*\*The Capital        |
| 1 | n |              |   |   | Professions    |   |   | Prog                   |
|   | d |              |   |   | (11)           |   |   | ramming/Infrastructure |
|   | i |              |   |   |                |   |   | category includes 80%  |
|   | a |              |   |   |                |   |   | of Facilities Support  |
|   | n |              |   |   |                |   |   | (19a), 60% of          |
|   | H |              |   |   |                |   |   | Environmental Health   |
|   | e |              |   |   |                |   |   | Support (19b), and 20% |
|   | a |              |   |   |                |   |   | of OEHE Support (19c)  |
|   | l |              |   |   |                |   |   | activities.            |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | P |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | f |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | T |              |   | 5 | Tribal         |   |   |                        |
| 2 | r |              |   |   | Management     |   |   |                        |
|   | i |              |   |   | (12)           |   |   |                        |
|   | b |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | M |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | g |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | m |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | D |              |   | 6 | Direct         |   |   |                        |
| 3 | i |              |   |   | Operations     |   |   |                        |
|   | r |              |   |   | (13)           |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | O |              |   |   |                |   |   |                        |
|   | p |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | S |              |   | 7 | Self           |   |   | \*\*\*The              |
| 4 | e |              |   |   | Governance     |   |   | Partnerships,          |
|   | l |              |   |   | (14)           |   |   | Consultation, Core     |
|   | f |              |   |   |                |   |   | Functions, and         |
|   | G |              |   |   |                |   |   | Advocacy category      |
|   | o |              |   |   |                |   |   | includes 20% of        |
|   | v |              |   |   |                |   |   | Facilities Support     |
|   | e |              |   |   |                |   |   | (19a), 5% of           |
|   | r |              |   |   |                |   |   | Environmental Health   |
|   | n |              |   |   |                |   |   | Support (19b), and 80% |
|   | a |              |   |   |                |   |   | of OEHE Support (19c)  |
|   | n |              |   |   |                |   |   | activities.            |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | C |              |   | 8 | Contract       |   |   |                        |
| 5 | o |              |   |   | Support Costs  |   |   |                        |
|   | n |              |   |   | (15)           |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | p |              |   |   |                |   |   |                        |
|   | p |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | C |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
|   | T |              |   |   | Total,         |   |   |                        |
|   | o |              |   |   | Services       |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | , |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | v |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| [ |   |              |   | [ |                |   |   |                        |
| F |   |              |   | F |                |   |   |                        |
| A |   |              |   | A |                |   |   |                        |
| C |   |              |   | C |                |   |   |                        |
| I |   |              |   | I |                |   |   |                        |
| L |   |              |   | L |                |   |   |                        |
| I |   |              |   | I |                |   |   |                        |
| T |   |              |   | T |                |   |   |                        |
| I |   |              |   | I |                |   |   |                        |
| E |   |              |   | E |                |   |   |                        |
| S |   |              |   | S |                |   |   |                        |
| : |   |              |   | : |                |   |   |                        |
| ] |   |              |   | ] |                |   |   |                        |
| { |   |              |   | { |                |   |   |                        |
| . |   |              |   | . |                |   |   |                        |
| u |   |              |   | u |                |   |   |                        |
| n |   |              |   | n |                |   |   |                        |
| d |   |              |   | d |                |   |   |                        |
| e |   |              |   | e |                |   |   |                        |
| r |   |              |   | r |                |   |   |                        |
| l |   |              |   | l |                |   |   |                        |
| i |   |              |   | i |                |   |   |                        |
| n |   |              |   | n |                |   |   |                        |
| e |   |              |   | e |                |   |   |                        |
| } |   |              |   | } |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Maint. &     |   | 9 | Maint. &       |   |   |                        |
| 6 |   | Improvement  |   |   | Improvement    |   |   |                        |
|   |   |              |   |   | (16)           |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Sanit.       |   |   |                |   |   |                        |
| 7 |   | Facil.       |   |   |                |   |   |                        |
|   |   | Constr.      |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Hlth Care    |   | 1 | Hlth Care      |   |   |                        |
| 8 |   | Facs.        |   | 0 | Facs. Constr.  |   |   |                        |
|   |   | Constr.      |   |   | (17-18)        |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Facility &   |   | 1 | Facil. &       |   |   |                        |
| 9 |   | Envir. Hlth  |   | 1 | Envir. Hlth    |   |   |                        |
|   |   | Support      |   |   | Sup (19a-c)    |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Facility     |   |   |                |   |   |                        |
| 9 |   | Support      |   |   |                |   |   |                        |
| a |   |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Env. Health  |   |   |                |   |   |                        |
| 9 |   | Support      |   |   |                |   |   |                        |
| b |   |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | OEHE Support |   |   |                |   |   |                        |
| 9 |   |              |   |   |                |   |   |                        |
| c |   |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 2 |   | Equipment    |   | 1 | Equipment (20) |   |   |                        |
| 0 |   |              |   | 2 |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
|   |   |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
|   |   | Total,       |   |   | Total,         |   |   |                        |
|   |   | Facilities   |   |   | Facilities     |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| \ |   |              |   | \ |                |   | \ |                        |
| ( |   |              |   | ( |                |   | ( |                        |
| 2 |   |              |   | 1 |                |   | 4 |                        |
| 0 |   |              |   | 2 |                |   | \ |                        |
| \ |   |              |   | \ |                |   | ) |                        |
| ) |   |              |   | ) |                |   | T |                        |
| T |   |              |   | T |                |   | o |                        |
| o |   |              |   | o |                |   | t |                        |
| t |   |              |   | t |                |   | a |                        |
| a |   |              |   | a |                |   | l |                        |
| l |   |              |   | l |                |   | , |                        |
| , |   |              |   | , |                |   | I |                        |
| I |   |              |   | I |                |   | H |                        |
| H |   |              |   | H |                |   | S |                        |
| S |   |              |   | S |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+

Budget Category Aggregation

Table 5: Crosswalk to FY 2005 Budget Request

  ----------------------------------------------------------------------------------------
                       Category/Sub-sub activity                         FY 2005 Request
  -------------------- ------------------------------------------------- -----------------
                       TREATMENT                                         

  1                    Hospitals & Health Clinics                        \$1,228,096,000

  2                    Dental Services \*                                109,013,000

  3                    Mental Health                                     55,780,000

  4                    Alcohol and Substance Abuse                       143,571,000

  5                    Contract Health Services                          495,203,000

  10                   Urban Health                                      32,371,000

  11                   Indian Health Professions                         35,472,000

  12                   Tribal Management                                 2,406,000

  14                   Self-Governance                                   10,308,000

  15                   Contract Support Costs                            271,734,000

                       M/M and PI Collections (85%)                      477,462,000

                       Diabetes                                          150,000,000

                       Total                                             \$3,011,416,000

                                                                         

                       PREVENTION                                        

  6                    Public Health Nursing \*                          \$ 45,091,000

  7                    Health Education                                  12,371,000

  8                    Community Health Representatives                  53,022,000

  9                    Immunization AK                                   1,623,000

  19b                  Environmental Health Support (35%)                20,306,000

                       Total                                             \$132,413,000

                                                                         

                       CAPITAL PROGRAMMING/INFRASTRUCTURE                

  16                   Maintenance & Improvement                         \$ 47,331,000

  17                   Sanitation Facilities                             114,382,000

  18                   Health Care Facilities Construction               70,947,000

  19a                  Facilities Support (80%)                          59,578,000

  19b                  Environmental Health Support (60%)                34,811,000

  19c                  OEHE Support (20%)                                2,349,000

  20                   Equipment                                         16,294,000

                       M/M and PI Collections (15%)                      84,258,000

                       Quarters                                          5,900,000

                       Total                                             \$435,850,000

                                                                         

                       PARTNERSHIPS, CONSULTATION, CORE FUNCTIONS, AND   
                       ADVOCACY                                          

  13                   Direct Operations                                 \$ 58,205,000

  19a                  Facilities Support (20%)                          14,894,000

  19b                  Environmental Health Support (5%)                 2,901,000

  19c                  OEHE Support (80%)                                9,396,000

                       Total                                             \$85,396,000

  \* The Dental and                                                      
  Public Health                                                          
  Nursing performance                                                    
  measures are                                                           
  evaluated in a                                                         
  disaggregated way                                                      
  from the Treatment                                                     
  and Prevention                                                         
  categories in an                                                       
  effort to explore a                                                    
  closer                                                                 
  budget/performance                                                     
  linkage for these                                                      
  programs.                                                              
  ----------------------------------------------------------------------------------------

## Performance Analysis {#performance-analysis .unnumbered}

## Treatment and Prevention Categories {#treatment-and-prevention-categories .unnumbered}

### Program Description and Context

Treatment and Prevention indicators are combined in this section. These
indicators are based on specific selection criteria that include but are
not limited to the following:

-   critical health problems to our population;

-   identified priority areas in terms of addressing health problems;

-   existence of passive data sources;

-   no rewards exist for under reporting of conditions; and

-   evidenced-based and supportive of recognized standards of care.

For many indicators, a measurable change in the ultimate outcome is
unlikely to be seen in the one-year time span of the performance plan.
Indeed, the one-year target indicators may not be related to funding
levels in a simple linear relationship within that one-year period.

The data that support the treatment and prevention indicators comes
primarily from the IHS automated information system (Resource and
Patient Management System). A discussion of data validation processes
relative to this system is on Appendix 1 of page 4-1.

Ultimately, our performance in treatment and prevention activities will
determine our level of success in improving the health of the American
Indian and Alaska Native population. However, the proposed IHS funding
for FY 2005 does not allow for target level increases over FY 2004 for
many of these indicators. Our commitment to continue to meet these
targets, given the population growth of over 1.7% annually and the
rising cost of providing services, is challenging.

### Treatment Aggregation

**Hospitals and Clinics** - supports inpatient and ambulatory care and
support services such as nursing, pharmacy, laboratory, nutrition,
medical records, etc (see page IHS-29 in FY 2004 budget document).

**Dental Services** - supports the provision of dental care through
clinic based treatment and prevention services and community oral health
promotion and disease prevention activities including water fluoridation
and dental sealants (see page IHS-37 in FY 2005 budget document).

**Mental Health** - supports community oriented clinical and preventive
mental health and social services programs (see page IHS-41 in FY 2005
budget document).

**Alcohol and Substance Abuse** - supports the efforts of tribes in the
provision of holistic alcoholism and other drug dependency treatment,
rehabilitation, and preventive services for individuals and families
(see page IHS-49 in FY 2005 budget document).

**Urban Indian Health** - supports contracts and grants to 34 urban
health programs funded under Title V of the Indian Health Care
Improvement Act (see page IHS-93 in FY 2005 budget document).

**Indian Health Professions** - supports self-determination and access
to health care through efforts to enable American Indian and Alaska
Native to enter health professions, and effective recruitment of health
staff by providing scholarships, loan repayment, temporary employment,
and health professions recruitment (see page IHS-99 in FY 2005 budget
document).

**Self-Governance** - supports the Office of Tribal Self-Governance and
Self-Governance Planning and Negotiating grants. (see page IHS-113 in FY
2005 budget document).

**Contract Support** - provides administrative costs for tribal managed
programs in addition to what would have been provided under the direct
provision of the program as authorized under Section 106(a) (2) of P.L.
93-638, the Indian Self-Determination Act, as amended (see page IHS-121
in FY 2005 budget document).

### Prevention Aggregation

Public Health Nursing - supports the community-based Public Health
Nursing program that provides treatment, counseling, health education,
and referral activities carried out in such setting as homes, schools,
jails, bars, and community centers in conjunction with a diversity of
other health care providers (see page IHS-75 in FY 2005 budget
document).

Health Education - supports activities directed towards promoting
healthy lifestyles, community capacity building, and the appropriate use
of health services through public health education targeted at school
health, employee health promotion, community health, and patient
education (see page IHS-79 in FY 2005 budget document).

Community Health Representative - supports the tribally administered
program of training American Indian and Alaska Native community members
in basic disease control and prevention. These activities include
serving as outreach workers with the knowledge and cultural sensitivity
to effect change in community acceptance and utilization of health care
resources and use community-based networks to enhance health
promotion/disease prevention (see page IHS-83 in FY 2005 budget
document).

Alaska Immunization Program - supports the Alaska immunizations program
to address hepatitis and haemophilous influenza through collaboration
with the CDC (see page IHS-87 in FY 2005 budget document).

Environmental Health Support - supports the IHS injury prevention
program that coordinates and provides grants for primary preventive
community-based collaborative programs using defined problem
identification and evaluation methods (see page IHF-37 in FY 2005 budget
document).

### Treatment Indicators

Table 6: Treatment Indicators Performance Summary

+--------------------+-------------------+-------------+-------------+
| Performance        | FY Targets        | Actual      | Reference   |
| Indicator          |                   | Performance |             |
+====================+===================+=============+=============+
| Diabetes Group     |                   |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | FY 05: assess     | FY 05:      | P: p. 3-11  |
| 1:]{.underline}    | proportion of     |             |             |
| Assure that the    | patients with     | FY 04:      | B: p.       |
| proportion of      | poor diagnosed    |             | IHS-29      |
| patients with      | control           | FY 03: 2/04 |             |
| diagnosed diabetes |                   |             | p.  IHS-127 |
| that have poor     | FY 04: establish  | FY 02:      |             |
| glycemic control   | the baseline of   | database    | 3           |
| (outcome)does not  | patients with     | maintained  |             |
| increase           | diagnosed         |             | HP 2010     |
|                    | diabetes that     | FY 01:      |             |
| Aggregated         | have poor         | database    | \*          |
| Indicator 1-5      | glycemic control. | maintained  | indicates   |
|                    |                   |             | revised FY  |
| full cost ( in     | Prevalence of     | FY 00:      | 2004        |
| millions)          | Diabetes          | database    | measure.    |
|                    |                   | maintained  | See summary |
| FY 05: 820.8       | FY 04: maintain   |             | of Changes  |
|                    | database          | FY 99:      | Table 10 on |
| FY 04: 817.5       |                   | baseline    | page 5-1    |
|                    | FY 03: maintain   | established |             |
| FY 03: 814.2       | database          |             |             |
|                    |                   |             |             |
|                    | FY 02: maintain   |             |             |
|                    | database          |             |             |
|                    |                   |             |             |
|                    | FY 01: maintain   |             |             |
|                    | database          |             |             |
|                    |                   |             |             |
|                    | FY 00: maintain   |             |             |
|                    | database          |             |             |
|                    |                   |             |             |
|                    | FY 99: establish  |             |             |
|                    | baseline          |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | [Ideal Glycemic   | FY 05:      | P: p. 3-12  |
| 2:]{.underline}    | Con               |             |             |
| Address the        | trol]{.underline} | FY 04:      | B: p.       |
| proportion of      |                   |             | IHS-29      |
| patients with      | FY 05: maintain   | FY 03:      |             |
| diagnosed diabetes | at FY 04 level    | 28\*\*\*    | p\. IHS-127 |
| that have          |                   |             |             |
| demonstrated       | FY 04: +1% over   | FY 02:      | 3, 5        |
| improved glycemic  | FY 03 level\*     | 30          |             |
| control.           |                   | %/25%\*\*\* | HP 2010     |
| \[outcome\]        | FY 03: maintain   |             |             |
|                    | at FY 02 level    | FY 01: 29%  | \*          |
| Full cost (        |                   | \*\*        | indicates   |
| included in cost   | FY 02: improve    |             | revised FY  |
| of indicator 1-5)  | from FY 01        | FY 00: 26%  | 2004        |
|                    |                   |             | measure.    |
|                    | 1FY 01: improved  | FY 99: 24%  | See Summary |
|                    | from FY 00        |             | of Changes  |
|                    |                   | FY 98: 22%  | Table 10 on |
|                    | FY 00: improved   |             | page 5-1.   |
|                    | from FY 99        | FY 97: 25%  |             |
|                    |                   |             | \*\*        |
|                    | FY 99: 25%        | FY 99: 35%  | revised     |
|                    |                   |             | 8/03        |
|                    | **[Good           | FY 98: 35%  |             |
|                    | Glyc              |             | \*\*\*      |
|                    | emic]{.underline} | FY 97: 25%  | GPRA+ data  |
|                    | Control**         |             |             |
|                    |                   |             |             |
|                    | FY 99: 38%        |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | [Ideal            | FY 05:      | P: p. 3-13  |
| 3:]{.underline}    | Hypertension      |             |             |
| Address the        | Con               | FY 04:      | B: p.       |
| proportion of      | trol]{.underline} |             | IHS-29      |
| patients with      |                   | FY 03: 37%  |             |
| diagnosed diabetes | FY 05: maintain   | \*\*\*      | p\. IHS-127 |
| that have achieved | at FY 04 level    |             |             |
| blood pressure.    |                   | FY 02:      | 3, 5        |
| \[outcome\]        | FY 04: +1% over   | 34/7%\*\*   |             |
|                    | FY 03 level\*     | /36%\*\*    | HP 2010     |
| See \# 1 for full  |                   |             |             |
| cost               | FY 03: maintain   | FY 01:      | \*          |
|                    | at FY 02 level    | 36%\*\*     | indicates   |
|                    |                   |             | revised FY  |
|                    | FY 02: maintain   | FY 00: 35%  | 2004        |
|                    | at FY 01 level\*  |             | measure.    |
|                    |                   | FY 99: 36%  | See Summary |
|                    | FY 01: improve    |             | of Changes  |
|                    | from FY 00        | FY 98: 38%  | Table 10 on |
|                    |                   |             | page 5-1.   |
|                    | FY 00: improve    | FY 97: 27%  |             |
|                    | from FY 99        |             | \*\*\*      |
|                    |                   |             | GPRA+ data  |
|                    | FY 99: 41%        |             |             |
|                    |                   |             | \*\*revised |
|                    |                   |             | 1/04        |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | [LDL              | FY 05:      | P: p. 3-14  |
| 4:]{.underline}    | Cholest           |             |             |
| Address the        | erol]{.underline} | FY 04:      | B: p.       |
| proportion of      |                   |             | IHS-29      |
| patients with      | FY 05: maintain   | FY 03:      |             |
| diagnosed diabetes | at FY 04 level    | 48%\*\*\*   | p\. IHS-127 |
| assessed for       |                   |             |             |
| dyslipidemia.      | FY 04: +1% over   | FY 02: 64%/ | 3, 5        |
| \[outcome\]        | FY 03 level\*     | 44%\*\*\*   |             |
|                    |                   |             | \*\*\*      |
| See \# 1 for full  | FY 03: maintain   | FY 01: 60%  | GPRA+ data  |
| cost               | at FY 02 level    |             |             |
|                    |                   | FY 00: 54%  | HP 2010     |
|                    | FY 02: improve    |             |             |
|                    | from FY 01        | FY 99: 46%  | \*          |
|                    |                   |             | indicates   |
|                    | FY 01: improve    | FY 98: 29%  | revised FY  |
|                    | from FY 00        |             | 2004        |
|                    |                   | FY 99: 72%  | measure.    |
|                    | FY 00: improve    |             | See Summary |
|                    | from FY 99        | FY 98: 79%  | of Changes  |
|                    |                   |             | Table 10 on |
|                    | FY 99: 32%        | FY 97: 83%  | page 5-1.   |
|                    |                   |             |             |
|                    | [Total            |             |             |
|                    | Cholest           |             |             |
|                    | erol]{.underline} |             |             |
|                    |                   |             |             |
|                    | FY 99: 82%        |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | FY 05: maintain   | FY 05:      | P: p. 3-15  |
| 5:]{.underline}    | at FY 04 level    |             |             |
| Address the        |                   | FY 04:      | B: p.       |
| proportion of      | FY 04: +1% over   |             | IHS-29      |
| patients with      | FY 03 level\*     | FY 03:      |             |
| diagnosed diabetes |                   | 36%\*\*\*   | p\. IHS-127 |
| assessed for       | FY 03: maintain   |             |             |
| nephropathy.       | at FY 02 level    | FY 02:      | 3, 5        |
| \[outcome\]        |                   | 56          |             |
|                    | FY 02: improve    | %/35%\*\*\* | \*\*\*GPRA+ |
| See \# 1 for full  | from FY 01        |             | data        |
| cost               |                   | FY 01: 54%  |             |
|                    | FY 01: improve    |             | HP 2010     |
|                    | from FY 00        | FY 00: 41%  |             |
|                    |                   |             | \*          |
|                    | FY 00: improve    | FY 99: 36%  | indicates   |
|                    | from FY 99        |             | revised FY  |
|                    |                   | FY 98: 33%  | 2004        |
|                    | FY 99: 36%        |             | measure.    |
|                    |                   | FY 97: 36%  | See Summary |
|                    |                   |             | of Changes  |
|                    |                   |             | Table 10 on |
|                    |                   |             | page 5-1.   |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | FY 05: maintain   | FY 05:      | P: p. 3-16  |
| 6:]{.underline}    | at 04 level       |             |             |
| Address the        |                   | FY 04:      | B: p.       |
| proportion of      | FY 04: +3% over   |             | IHS-29      |
| patients with      | FY 03 level       | FY 03:      |             |
| diagnosed diabetes |                   | 58%\*\*\*   | p\. IHS-127 |
| who receive an     | FY 03: +3% over   |             |             |
| annual diabetic    | FY 02 level       | FY 02:      | 3, 5        |
| retinal            |                   | 55%\*\*\*   |             |
| examination at     | FY 02: no         |             | \*\*\*GPRA+ |
| designated sites.  | indicator         |             | data        |
| \[outcome\]        |                   |             |             |
|                    |                   |             | HP 2010     |
| full cost          |                   |             |             |
|                    |                   |             |             |
| FY 05: 1.8 M       |                   |             |             |
|                    |                   |             |             |
| FY 04: 1.7 M       |                   |             |             |
|                    |                   |             |             |
| FY 03: 1.6 M       |                   |             |             |
+--------------------+-------------------+-------------+-------------+
| Cancer Screening   |                   |             |             |
| Group              |                   |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | [Pap              | FY 05:      | P: p. 3-18  |
| 7:]{.underline}    | Scree             |             |             |
| Address the        | ning]{.underline} | FY 04:      | B: p.       |
| proportion of      |                   |             | IHS-29      |
| eligible women     | FY 05: maintain   | FY 03:      |             |
| patients who have  | FY 04 level       | 61%\*\*\*   | 3, 5        |
| had a Pap screen   |                   |             |             |
| within the         | FY 04: maintain   | FY 02:      | \*\*\*GPRA+ |
| previous three     | FY 03 level       | 43.2% w/in  | data        |
| years. \[outcome\] |                   | 3 years     |             |
|                    | FY 03: maintain   | (+1.3% over | HP 2010     |
| full cost for \# 7 | FY 02 level       | FY          |             |
| &8                 |                   | 2001        |             |
|                    | FY 02: +2% over   | )/62%\*\*\* |             |
| FY 05: 12.5 M      | FY 01 level       |             |             |
|                    |                   | FY 01: 21%  |             |
| FY 04: 12.1 M      | FY 01: +3% over   | w/in 1 year |             |
|                    | FY 00 level       | , 42% w/in  |             |
| FY 03: 11.6 M      |                   | 3 years     |             |
|                    | FY 00: +3% over   |             |             |
|                    | FY 99 level[\     | FY 00: 12%  |             |
|                    | ]{.underline}     | w/in 1      |             |
|                    |                   | year, 18%   |             |
|                    | FY 99: no         | w/in 3      |             |
|                    | indicator         | years       |             |
|                    |                   |             |             |
|                    | [Cervical         | FY 99:      |             |
|                    | Ca                | baseline    |             |
|                    | ncer]{.underline} | not         |             |
|                    |                   | adequate    |             |
|                    | FY 99: determine  |             |             |
|                    | incidence of      | FY 99: 8-10 |             |
|                    | cervical cancer   | per 100,000 |             |
|                    |                   | based on    |             |
|                    |                   | 40% of      |             |
|                    |                   | AI/AN       |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | FY 05: maintain   | F.Y 05:     | P: p. 3-19  |
| 8:]{.underline}    | the FY 04 level   |             |             |
| Address the        |                   | FY 04:      | B: p.       |
| proportion of      | FY 04: maintain   |             | IHS-29      |
| eligible women     | FY 03 level       | FY 03:      |             |
| patients who have  |                   | 41%\*\*\*   | 3, 5        |
| had mammography    | FY 03: maintain   |             |             |
| screening within   | FY 02 level       | FY 02:      | \*\*\*GPRA+ |
| the last 2 years.  |                   | 24.7% w/in  | data        |
| \[outcome\]        | FY 02: +2% over   | 2 years     |             |
|                    | FY 01 level       | (+3.7% over | HP 2010     |
| See \# 7           |                   | FY          |             |
|                    | FY 01: +2% over   | 2002        |             |
|                    | FY 00 level       | )/42%\*\*\* |             |
|                    |                   |             |             |
|                    | FY 00: +3% over   | FY 01: 21%  |             |
|                    | FY 99 baseline    | w/in 2      |             |
|                    |                   | years       |             |
|                    | FY 99: establish  |             |             |
|                    | baseline          | FY 00: 15%  |             |
|                    |                   | w/in 2      |             |
|                    |                   | years       |             |
|                    |                   |             |             |
|                    |                   | FY 99:      |             |
|                    |                   | baseline    |             |
|                    |                   | not         |             |
|                    |                   | adequate    |             |
+--------------------+-------------------+-------------+-------------+
| [Alcohol and       |                   |             |             |
| Substance          |                   |             |             |
| Abuse]{.underline} |                   |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | [RTC              | FY 05:      | P: p. 3-23  |
| 9]{.underline}:    | Accreditat        |             |             |
| Assure quality and | ion:]{.underline} | FY 04:      | B: p.       |
| effectiveness of   |                   |             | IHS-49      |
| Youth Regional     | FY 05: ensure     | FY 03: +4%  |             |
| Treatment Centers. | 100%              | over FY 02  | 1, 3, 5     |
| ( outcome)         | accreditation     | for         |             |
|                    |                   | modifiable  |             |
| full cost          | [RTC Assessment   | criteria    |             |
|                    | Crit              |             |             |
| FY 05: 19.5 M      | eria]{.underline} | FY 02:      |             |
|                    |                   | baseline    |             |
| FY 04: 19.0 M      | FY 04: +2% over   | established |             |
|                    | FY 03 for 4       |             |             |
| FY 03: 18.9 M      | criterion         | FY 03: no   |             |
|                    |                   | indicator   |             |
|                    | FY 03: +5% over   |             |             |
|                    | FY 02 for 4       | FY 02: no   |             |
|                    | criterion         | indicator   |             |
|                    |                   |             |             |
|                    | FY 02: establish  | FY 01: 60%  |             |
|                    | RTC baseline for  |             |             |
|                    | 4 criterion       | FY 00: 48%  |             |
|                    |                   | % -12 mos   |             |
|                    | [Follow-up        | (+17%)      |             |
|                    | R                 |             |             |
|                    | ates]{.underline} | FY 99:      |             |
|                    |                   | 40.9%       |             |
|                    | FY 04: no         |             |             |
|                    | indicator         | FY 03: no   |             |
|                    |                   | indicator   |             |
|                    | FY 03: no         |             |             |
|                    | indicator         | FY 02: no   |             |
|                    |                   | indicator   |             |
|                    | FY 02: no         |             |             |
|                    | indicator         | FY 01: no   |             |
|                    |                   | reliable    |             |
|                    | FY 01: FY 00      | data source |             |
|                    | level or higher   |             |             |
|                    |                   | FY 00: no   |             |
|                    | FY 00: 45% (+10%  | reliable    |             |
|                    | over FY 99 for 3  | data source |             |
|                    | follow-ups by 12  |             |             |
|                    | months post       |             |             |
|                    | discharge)        |             |             |
|                    |                   |             |             |
|                    | FY 99: establish  |             |             |
|                    | baseline          |             |             |
|                    |                   |             |             |
|                    | [Abstin           |             |             |
|                    | ence]{.underline} |             |             |
|                    |                   |             |             |
|                    | FY 04: no         |             |             |
|                    | indicator         |             |             |
|                    |                   |             |             |
|                    | FY 03: no         |             |             |
|                    | indicator         |             |             |
|                    |                   |             |             |
|                    | FY 02: no         |             |             |
|                    | indictor          |             |             |
|                    |                   |             |             |
|                    | FY 01: +5% over   |             |             |
|                    | FY 00             |             |             |
|                    |                   |             |             |
|                    | FY 00: no         |             |             |
|                    | indicator         |             |             |
+--------------------+-------------------+-------------+-------------+
| Indicator 10:      | [Provide Alcohol  | FY 05:      | P: p. 3-24  |
| Address alcohol    | Scree             |             |             |
| use in female      | ning]{.underline} | FY 04:      | B: p.       |
| patients of        |                   |             | IHS-29      |
| childbearing age.  | FY 05: increase   | FY 03: 95%  |             |
| \[outcome\]        | screening over    |             | 1, 3, 5     |
|                    |                   | FY 02:      |             |
| full cost          | FY 04: During FY  | 90.5%       | HP 2010     |
|                    | 2004, establish   | (increase   |             |
| FY 05: 1.6 M       | the screening     | of 5.5%     |             |
|                    | rate for alcohol  | over FY 01) |             |
| FY 04: 1.6 M       | use in women of   |             |             |
|                    | childbearing age. | FY 01: 85%  |             |
| FY 03: 1.6 M       |                   | (decrease   |             |
|                    | [Implement        | of 2.6%)    |             |
|                    | Screening         |             |             |
|                    | Prot              | FY 00:      |             |
|                    | ocol]{.underline} | 87.6%       |             |
|                    |                   | (+9.2% over |             |
|                    | FY 04: No         | FY 99)      |             |
|                    | indicator         |             |             |
|                    |                   | FY 99:      |             |
|                    | FY 03: Maintain   | 78.4%       |             |
|                    | FY 02 level       |             |             |
|                    |                   |             |             |
|                    | FY 02: + 2% over  |             |             |
|                    | FY 01             |             |             |
|                    |                   |             |             |
|                    | FY 01: + 10% over |             |             |
|                    | FY 00             |             |             |
|                    |                   |             |             |
|                    | FY 00: +5% over   |             |             |
|                    | FY 99             |             |             |
|                    |                   |             |             |
|                    | FY 99: establish  |             |             |
|                    | baseline          |             |             |
+--------------------+-------------------+-------------+-------------+
| Oral Health Group  |                   |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | FY 05: 0.5% over  | FY 05:      | P: p. 3-26  |
| 11]{.underline}:   | FY 04 pop.        |             |             |
| Address access to  | receiving flour.  | FY 04:      | B: p.       |
| optimally          | water             |             | IHS-37      |
| fluoridated water  |                   | FY 03:      |             |
| for the AI/AN      | FY 04: 1% over FY | +0.37%      | 3           |
| population.        | 03 for pop.       |             |             |
| \[outcome\]        | receiving fluor.  | FY 02: +1%  | HP 2010     |
|                    | water             | for pop     |             |
| full cost (        |                   |             |             |
| indicator 11-14)   | FY 03: 1% over FY | FY 01: 28%  |             |
|                    | 02 for pop.       | over FY 00  |             |
| FY 05: 92.7 M      | receiving fluor.  | for demo    |             |
|                    | water             | Areas       |             |
| FY 04: 90.9 M      |                   |             |             |
|                    | FY 02: 5% over FY | Same % FY   |             |
| FY 03: 89.4 M      | 01 for AI/AN pop. | 00 for      |             |
|                    | receiving fluor.  | other Areas |             |
|                    | water             |             |             |
|                    |                   | FY 00: 18   |             |
|                    | FY 01: 10% over   | systems in  |             |
|                    | FY 00 for demo    | compliance  |             |
|                    | Areas\            | (38%        |             |
|                    | 5% over FY 00 for | increase)   |             |
|                    | other Areas       |             |             |
|                    |                   | FY 99: 13   |             |
|                    | FY 00: 15% over   | systems in  |             |
|                    | FY 99 for demo    | compliance  |             |
|                    | Areas             | for demo    |             |
|                    |                   | Areas or 2% |             |
|                    | FY 99: no         |             |             |
|                    | indicator         |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | FY 05: maintain   | FY 05:      | P: p. 3-28  |
| 12:]{.underline}   | at FY 04 level    |             |             |
| Address the        |                   | FY 04:      | B: p.       |
| proportion         | FY 04: maintain   |             | IHS-37      |
| patients who       | at FY 03 level    | FY 03:      |             |
| obtain access to   |                   | 28.1% (     | 3, 5        |
| dental services.   | FY 03: maintain   | increase)   |             |
| \[outcome\]        | at FY 02 level    |             | HP 2010     |
|                    |                   | FY 02:      |             |
| full cost (see \#  | FY 02: 1% over FY | 27.35% (+1% |             |
| 11)                | 01                | over FY 01) |             |
|                    |                   |             |             |
| EFFICIENCY MEASURE | FY 01: 27%        | FY 01:      |             |
|                    |                   | 26.3%       |             |
|                    | FY 00: 23%        |             |             |
|                    |                   | FY 00:      |             |
|                    | FY 99: 21%        | 25.1%       |             |
|                    |                   |             |             |
|                    |                   | FY 99:      |             |
|                    |                   | 25.1%       |             |
|                    |                   |             |             |
|                    |                   | FY 98:      |             |
|                    |                   | 24.5%       |             |
|                    |                   |             |             |
|                    |                   | FY 97: 22%  |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | [Total Sealants   | FY 05:      | P: p. 3-30  |
| 13:]{.underline}   | Pl                |             |             |
| Address the number | aced]{.underline} | FY 04:      | B: p.       |
| of sealants placed |                   |             | IHS-37      |
| per year in AI/AN  | FY 05: at F.Y 04  | FY 03:      |             |
| children.          | levels            | 243,499     | 3, 5        |
| \[outcome\]        |                   |             |             |
|                    | FY 04: at FY 03   | FY 02:      | HP 2010     |
| full cost (see \#  | level             | 227,945     |             |
| 11)                |                   | (+7.2% over |             |
|                    | FY 03: at FY 02   | FY 01)      |             |
|                    | level             |             |             |
|                    |                   | FY 01:      |             |
|                    | FY 02: +2.5% over | 212,617     |             |
|                    | FY 01 total       |             |             |
|                    | sealants placed   |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | FY 05: maintain   | FY 05:      | P: p. 3-31  |
| 14:]{.underline}   | at FY 04 level    |             |             |
| Address the        |                   | FY 04:      | B: p.       |
| proportion of      | FY 04: 1%         |             | IHS-37      |
| patients diagnosed | increase over FY  | FY 03:      |             |
| with diabetes who  | 03                | 36%\*\*\*   | 3, 5        |
| obtain access to   |                   |             |             |
| dental services.   | FY 03: 2%         | FY 02:      | \*\*\*GPRA+ |
|                    | increase over FY  | 36%\*\*\*   | data        |
| \[outcome\]        | 02                |             |             |
|                    |                   | FY 01: 32%  | HP 2010     |
| full cost (see     | FY 02: 2%         |             |             |
| #11)               | increase over FY  | FY 00: no   |             |
|                    | 01                | indicator   |             |
|                    |                   |             |             |
|                    | FY 01: no         | FY 99: no   |             |
|                    | indicator         | indicator   |             |
|                    |                   |             |             |
|                    | FY 00: no         |             |             |
|                    | indicator         |             |             |
|                    |                   |             |             |
|                    | FY 99: no         |             |             |
|                    | indicator         |             |             |
+--------------------+-------------------+-------------+-------------+
| Family Abuse,      |                   |             |             |
| Violence, and      |                   |             |             |
| Neglect Indicator  |                   |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | [Scree            | FY 05:      | > P: p.     |
| 15:]{.underline}   | ning]{.underline} |             | > 3-32      |
| Address the        |                   | FY 04:      | >           |
| proportion of      | FY 05: maintain   |             | > B: p.     |
| women who are      | FY 04 level       | FY 03: no   | > IHS-41    |
| screened for       |                   | indicator   | >           |
| domestic violence  | FY 04:at least    |             | > p\.       |
| at health care     | 15% screened      | FY 02: no   | > IHS-29    |
| facilities.        |                   | indicator   |             |
| \[outcome\]        | FY 03: no         |             | 1, 3        |
|                    | indicator         | FY 03: 60%  |             |
| full cost          |                   |             | HP 2010     |
|                    | FY 02: no         | FY 02: 70%  |             |
| FY 05: 1.9 M       | indicator         |             |             |
|                    |                   | FY 01: no   |             |
| FY 04: 1.8 M       | FY 01: no         | indicator   |             |
|                    | indicator         |             |             |
| FY 03: 1.4 M       |                   | FY 00: 54%  |             |
|                    | FY 00: no         | (baseline)  |             |
|                    | indicator         |             |             |
|                    |                   | FY 04:      |             |
|                    | FY 99: no         |             |             |
|                    | indicator         | FY 03: 84%  |             |
|                    |                   |             |             |
|                    | [Staff            | FY 02: 85%  |             |
|                    | Trai              |             |             |
|                    | ning]{.underline} | FY 01: 82%  |             |
|                    |                   |             |             |
|                    | FY 04: no         | FY 00: 72%  |             |
|                    | indicator         |             |             |
|                    |                   | FY 99: 64%  |             |
|                    | FY 03: 60%        |             |             |
|                    |                   | FY 04:      |             |
|                    | FY 02: 56%        |             |             |
|                    |                   | FY 03:      |             |
|                    | FY 01: no         | standard    |             |
|                    | indicator         | data code   |             |
|                    |                   | established |             |
|                    | FY 00: no         |             |             |
|                    | indicator         | FY 02: no   |             |
|                    |                   | indicator   |             |
|                    | FY 99: no         |             |             |
|                    | indicator         |             |             |
|                    |                   |             |             |
|                    | [Policies and     |             |             |
|                    | Proced            |             |             |
|                    | ures]{.underline} |             |             |
|                    |                   |             |             |
|                    | FY 04: no         |             |             |
|                    | indicator         |             |             |
|                    |                   |             |             |
|                    | FY 03: 85%        |             |             |
|                    |                   |             |             |
|                    | FY 02: 82%        |             |             |
|                    |                   |             |             |
|                    | FY 01: 80%        |             |             |
|                    |                   |             |             |
|                    | FY 00: 70%        |             |             |
|                    |                   |             |             |
|                    | FY 99: 60%        |             |             |
|                    |                   |             |             |
|                    | [Data             |             |             |
|                    | Code]{.underline} |             |             |
|                    |                   |             |             |
|                    | FY 04: codes      |             |             |
|                    | implement in RPMS |             |             |
|                    |                   |             |             |
|                    | FY 03: develop    |             |             |
|                    | standard data     |             |             |
|                    | code              |             |             |
|                    |                   |             |             |
|                    | FY 02: no         |             |             |
|                    | indicator         |             |             |
|                    |                   |             |             |
|                    | FY 01: no         |             |             |
|                    | indicator         |             |             |
|                    |                   |             |             |
|                    | FY 00: no         |             |             |
|                    | indicator         |             |             |
|                    |                   |             |             |
|                    | FY 99: no         |             |             |
|                    | indicator         |             |             |
+--------------------+-------------------+-------------+-------------+

+--------------------+-------------------+-------------+-------------+
| Performance        | FY Targets        | Actual      | Reference   |
| Indicator          |                   | Performance |             |
+====================+===================+=============+=============+
| Information        |                   |             |             |
| Technology         |                   |             |             |
| Development Group  |                   |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | FY 05: add 2 new  | FY 05:      | > P: p.     |
| 16:]{.underline}   | measures of       |             | > 3-34      |
| Expand the         | automated data    | FY 04:      | >           |
| automated          | quality           |             | > B: p.     |
| extraction of GPRA | assessment        | FY 03:      | > IHS-63    |
| clinical           |                   | complete    |             |
| performance        | FY 04: a.         | baseline of | 3, 5        |
| measures and       | Implement quality | initial     |             |
| improve data       | training in all   | measures;   |            |
| quality.           | Areas             | new         |             |
|                    |                   | measures    |             |
| full cost (        | > b\. +2 new      | automated;  |             |
| measures 16-18)    | > measures to     | automated   |             |
|                    | > automated data  | mapping     |             |
| FY 05: 8.2 M       | > quality         | tools       |             |
|                    | > assessment      | distributed |             |
| FY 04: 6.7 M       | > "package"       | to all      |             |
|                    |                   | I/T/U sites |             |
| FY 03: 6.5 M       | FY 03: a.         |             |             |
|                    | complete baseline | FY 02: 5    |             |
|                    | of initial        | sites       |             |
|                    | measures          | assessed    |             |
|                    |                   | for         |             |
|                    | b\. automate new  | performance |             |
|                    | measures          | measures    |             |
|                    |                   |             |             |
|                    | c\. distribute    | FY 01: 5    |             |
|                    | automated mapping | sites for   |             |
|                    | tools to all      | testing 5   |             |
|                    | I/T/Us            | performance |             |
|                    |                   | measures    |             |
|                    | FY 02: assess 5   | established |             |
|                    | sites for 5       |             |             |
|                    | performance       |             |             |
|                    | measures          |             |             |
|                    |                   |             |             |
|                    | FY 01: setup 5    |             |             |
|                    | sites for testing |             |             |
|                    | 5 performance     |             |             |
|                    | measures          |             |             |
|                    |                   |             |             |
|                    | FY 00: no         |             |             |
|                    | indicator         |             |             |
|                    |                   |             |             |
|                    | FY 99: no         |             |             |
|                    | indicator         |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | [Expand MH/SS     | FY 05:      | P: p. 3-36  |
| 17:]{.underline}   | Use]{.underline}  |             |             |
| Expand the         |                   | FY 04:      | B: p.       |
| Behavioral Health  | FY 05: increase   |             | IHS-41      |
| Data System by     | by 5%             | FY 03: 3%   |             |
| assuring an        |                   | increase    | p\. IHS-49  |
| additional 5% of   | FY 04: +5% use    |             |             |
| the programs will  | over FY 03        | FY 02: 5%   | 3, 5        |
| report minimum     |                   | increase    |             |
| agreed-to          | FY 03: +3% use    |             |            |
| behavioral         | over FY 02        | FY 01:      |             |
| health-related     |                   | +12.1%      |             |
| data into the      | FY 02: +5% use    | increase    |             |
| national data      | over FY 01        |             |             |
| warehouse.         |                   | FY 00:      |             |
|                    | FY 01: +10% use   | +24.7%      |             |
| full cost ( see \# | over FY 00        | increase    |             |
| 16)                |                   |             |             |
|                    | FY 00: +10% use   | FY 99: 51%  |             |
|                    | over FY 99        | reported    |             |
|                    |                   |             |             |
|                    | FY 99: 50%        | FY 98:      |             |
|                    | reported          | 40-45%      |             |
|                    |                   | baseline    |             |
|                    | [Submit Minimum   | est.        |             |
|                    | Data              |             |             |
|                    | Set]{.underline}  | FY 03: 50%  |             |
|                    |                   |             |             |
|                    | FY 04: 55% submit | FY 02: no   |             |
|                    | minimum data      | accepted    |             |
|                    |                   | data set    |             |
|                    | FY 03: 50% submit |             |             |
|                    | minimum data      |             |             |
|                    |                   |             |             |
|                    | FY 02: no         |             |             |
|                    | indicator         |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | [I/T/U IT         | FY 05:      | P: p. 3-37  |
| 18:]{.underline}   | Enhance           |             |             |
| Expand Urban       | ment]{.underline} | FY 04:      | B: p.       |
| Indian Health      |                   |             | IHS-63      |
| Program capacity   | FY 04: no         | FY 04:      |             |
| for securing       | indicator\*       |             | 3, 5        |
| mutually           |                   | FY 03: 5    |             |
| compatible         | FY 03: no         | sites added |            |
| automated          | indicator         |             |             |
| information system |                   | FY 02: 2    | \*          |
| that captures      | [Urban IT         | sites added | indicates   |
| health status, and | Enhance           |             | revised FY  |
| patient care data  | ment]{.underline} | FY 01: 32%  | 2004        |
| for the Indian     |                   | (11 of 34)  | measure.    |
| health system.     | FY 05: implement  | urban       | See Summary |
|                    | C&G language      | programs    | of Changes  |
| full cost ( see#   |                   |             | Table 10 on |
| 16)                | FY 04: develop    | FY 00:      | page 5-1.   |
|                    | language\*        | tested in   |             |
|                    |                   | several     |             |
|                    | FY 03: +2 sites   | sites       |             |
|                    | over FY 02 level  |             |             |
|                    |                   | FY 99:      |             |
|                    | FY 02: +2 sites   | a           |             |
|                    | over FY 01 level  | ccomplished |             |
|                    |                   | 8/99        |             |
|                    | FY 01:            |             |             |
|                    | implemented in    |             |             |
|                    | 30% of urban      |             |             |
|                    | programs          |             |             |
|                    |                   |             |             |
|                    | FY 00: test in at |             |             |
|                    | least one site    |             |             |
|                    |                   |             |             |
|                    | FY 99: develop    |             |             |
|                    | specs and plan    |             |             |
+--------------------+-------------------+-------------+-------------+
| Quality of Care    |                   |             |             |
| Group              |                   |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | FY 05: 100%       | FY 05:      | P: p. 3-38  |
| 19:]{.underline}   |                   |             |             |
| Maintain 100%      | FY 04: 100%       | FY 04:      | B: p.       |
| accreditation of   |                   |             | IHS-29      |
| all IHS hospitals  | FY 03: 100%       | FY 03: 100% |             |
| and outpatient     |                   |             | p\. IHF-9   |
| clinics.           | FY 02: 100%       | FY 02: 100% |             |
|                    |                   |             | 3, 5        |
| \% of full cost    | FY 01: 100%       | FY 01: 100% |             |
|                    |                   |             |             |
| FY 05: 16%         | FY 00: 100%       | FY 00: 100% |             |
|                    |                   |             |             |
| FY 04: 16%         | FY 99: 100%       | FY 99: 100% |             |
|                    |                   |             |             |
| FY 03: 15%         |                   | FY 98: 100% |             |
|                    |                   | (baseline)  |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | FY 05: all direct | FY 04:      | P: p. 3-38  |
| 20:]{.underline}   | care facilities   |             |             |
| Address medication | shall be using    | FY 03:      | B: p.       |
| errors by          | the NCCMERP       | baseline    | IHS-29      |
| developing a       | nationally        | assessed    |             |
| reporting system   | recognized        | and pilot   | 3,          |
| to reduce          | medication error  | sites       |             |
| medication error.  | definition, and   | e           |             |
| \[outcome\]        | shall have a      | stablished; |             |
|                    | non-punitive      |             |             |
| full cost          | m                 | FY 02: 3    |             |
|                    | ulti-disciplinary | elements    |             |
| FY 05: 6.0 M       | medication error  | assessed    |             |
|                    | reporting system  |             |             |
| FY 04: 3.0 M       | in place.         |             |             |
|                    |                   |             |             |
| FY 03: 0.3 M       | FY 04: establish  |             |             |
|                    | baseline data for |             |             |
|                    | medication error  |             |             |
|                    | reporting for all |             |             |
|                    | IHS Areas         |             |             |
|                    |                   |             |             |
|                    | > b\. pilot test  |             |             |
|                    | > standardized    |             |             |
|                    | > medication      |             |             |
|                    | > error reporting |             |             |
|                    | > system in two   |             |             |
|                    | > additional      |             |             |
|                    | > areas           |             |             |
|                    |                   |             |             |
|                    | FY 03: assess     |             |             |
|                    | baseline and      |             |             |
|                    | establish pilot   |             |             |
|                    | sites             |             |             |
|                    |                   |             |             |
|                    | FY 02: assess     |             |             |
|                    | current systems   |             |             |
|                    | for 3 elements    |             |             |
+--------------------+-------------------+-------------+-------------+
| [Indicator         | FY 05: improve by | FY 05:      | P: p. 3-39  |
| 21:]{.underline}   | 1% over FY 04     |             |             |
| Assess consumer    |                   | FY 04:      | B: p.       |
| satisfaction with  | FY 04: improve 3% |             | IHS-29      |
| the acceptability  | over FY 03        | FY 03:      |             |
| and accessibility  |                   | baseline    | 3           |
| of health care     | FY 03: establish  | established |             |
|                    | baseline          |             | 5           |
| full cost          |                   | FY 02: OMB  |             |
|                    | FY 02: secure OMB | clearance   |             |
| FY 05: 0.2 M       | clearance         | secured     |             |
|                    |                   |             |             |
| FY 04: 0.2 M       | FY 01: secure OMB | FY 01:      |             |
|                    | clearance         | waiting     |             |
| FY 03: 0.2 M       |                   | final OMB   |             |
|                    | FY 00: Federal    | approval    |             |
|                    | clearance and     |             |             |
|                    | establish         | FY 00:      |             |
|                    | baseline          | submitted   |             |
|                    |                   | but         |             |
|                    | FY 99: develop    | clearance   |             |
|                    | instrument and    | not         |             |
|                    | protocol          | completed   |             |
|                    |                   |             |             |
|                    |                   | FY 99:      |             |
|                    |                   | instrument  |             |
|                    |                   | and         |             |
|                    |                   | protocol    |             |
|                    |                   | complete    |             |
+--------------------+-------------------+-------------+-------------+
| Total Treatment    | FY 05:            |             | P: page \#  |
| Funding:           | \$3,011,416,000\* |             | in perform. |
|                    |                   |             | plan        |
|                    | FY 04:            |             |             |
|                    | \$2,964,983,000\* |             | B: page \#  |
|                    |                   |             | in budget   |
|                    | FY 03:            |             | justif.     |
|                    | \$2,907,957,000   |             |             |
|                    |                   |             |             |
|                    | FY 02:            |             |             |
|                    | \$2,746,954,000   |             |             |
|                    |                   |             |             |
|                    | FY 01:            |             |             |
|                    | \$2,117,008,000   |             |             |
|                    |                   |             |             |
|                    | FY 00:            |             |             |
|                    | \$1,931,326,000   |             |             |
|                    |                   |             |             |
|                    | FY 99:            |             |             |
|                    | \$1,811,951,000   |             |             |
|                    |                   |             |             |
|                    | FY 98:            |             |             |
|                    | \$1,711,018,000   |             |             |
|                    |                   |             |             |
|                    | \*includes 85% of |             |             |
|                    | M/M and PI        |             |             |
|                    | collections and   |             |             |
|                    | Diabetes          |             |             |
+--------------------+-------------------+-------------+-------------+

#### Performance Budget Integration {#performance-budget-integration .unnumbered}

These 21 indicators account for approximately 59% of this budget
category. Additional indicators within the Partnerships/ Consultation
budget category account for approximately 17% more of the performance
budget (contract health services; scholarships). If the costs of these
services (not solely the oversight of these programs) were included in
this category, these performance indicators would reflect 69% of the
proposed treatment budget for FY 05.

#### 1.6.4.1 Diabetes Group: {#diabetes-group-1 .unnumbered}

The following six indicators address the ongoing monitoring and
treatment of diabetes in the American Indian and Alaska Native
population. Diabetes continues to be a growing problem in American
Indian and Alaska Native communities with rates increasing rapidly in
the majority of IHS Areas. The age at diagnosis is occurring younger,
with no signs of decline in any IHS Area. The treatment indicators (1-6)
were selected because of their proven benefits in reducing the morbidity
and mortality associated with diabetes. We have changed indicator 1 to
focus on improving diabetic control; we will continue to collect
prevalence data, and report the diabetic indicators within the context
of this information.

While two-thirds of the *Special Diabetes Program for Indians* (SDPI)
grantees are focusing significant efforts on primary prevention of type
2 diabetes, one third are focusing resources on secondary and tertiary
prevention geared at reducing diabetes complications. The IHS National
Diabetes Program has developed an infrastructure and methodology to
track both clinical treatment and prevention efforts carried on by the
SDPI grantees. The grantees are evaluated on clinical care through the
Annual IHS Diabetes Care and Outcomes Audit. We expect performance to
remain unchanged in grant programs focused on primary prevention. This
is because their target audience is those *at risk for diabetes* and not
patients who already have the disease. We hope to see improvement in the
GPRA indicators at sites that are focused on improving clinical care,
and will report data on this group separately in FY 05.

The IHS Diabetes Program conducts a yearly medical record review (either
electronically or by manual chart audit) of a random sample of over
19,000 medical records in I/T/U facilities in order to assess compliance
with the IHS Standards of Care for Diabetes. This record review uses a
strict protocol to assure statistical integrity and comparability of
both process and outcome measures over time. In addition, GPRA+, our
RPMS GPRA extraction software, enables us to track these trends at local
facilities running RPMS. GPRA+ data has been used for the GPRA report
for FY 2003. . Trends over time for I/T/U facilities, service units,
Areas, and IHS-wide( using both diabetic audit data and GPRA+ data) are
also constructed for indicators 1-6.

Performance targets for the FY 2005 indicators 1-6 are set at a
maintenance level over the FY 2004 level due to projected increase in
the diabetic population, as well as known costs and budget projections.

[**Indicator 1**:]{.underline} During FY 2005, assure that the
proportion of patients with diagnosed diabetes that have poor glycemic
control does not increase over FY 2004 level.

During FY 2004, establish the baseline of patients with diagnosed
diabetes that have poor glycemic control.

![](media/image4.wmf)

\*Age-adjusted based on the 2000 U.S.population.

*Source: FY 01 IHS APC file. Excludes data from 39 service units (7% of
the IHS user population).*

Area age-specific diabetes prevalence rates have been prepared for the
American Indian and Alaska Native population based on patients diagnosed
with, treated for diabetes, and having at least one outpatient visit
during FY 2002. This information is the contextual basis for our series
of diabetic indicators.

[Rationale:]{.underline} This indicator is directed at reducing diabetic
complications through improved blood sugar control by decreasing the
percentage of patients with poor glycemic control

**[Approach:]{.underline}** Glycemic control is measured with a test
called the Hemoglobin A1C (HgbA1c) that measures the average blood sugar
over the last 1-2 months. The IHS Diabetes Care and Outcomes Audit
divides these control levels into "Ideal" ; "Good" ; "Fair" ; "Poor";
and "Very Poor" based on national diabetes care standards.

**[Data Source:]{.underline}** Diabetes registries, yearly IHS Diabetes
Care and Outcomes Audit. Achievement of this indicator will be
determined by calculating the mean HgbA1c of the entire diabetic
population for a given audit year as well as dividing these data into
the categories of \"ideal\", \"good,\" \"fair,\" \"poor,\" and \"very
poor.\"

Those sites that have chosen to focus on the problem by applying the
best practices associated with glycemic control will be assessed as a
defined group using the *IHS Diabetes Care and Outcomes Audit.* In FY
2004, the mean HgA1c of this group and categories of glycemic control
will be reported as a baseline and compared with the performance of the
I/T/U system as a whole. Then, in subsequent years, the performance of
this group will be followed and compared to the larger group, with
results for both being reported in the GPRA reports. Further analysis of
their specific activities related to glycemic control may provide
guidance and answers to other sites hoping to address this problem in
the future.

**[Program Performance:]{.underline} IHS met this indicator in 2002.
2003 data is still pending.** This indicator was to monitor the
prevalence of diabetes. Current FY 2003 data is being evaluated. Results
are expected to be reported in February 2004, though preliminary
analysis indicates that there is a continued epidemic of diabetes in
American Indian/ Alaska Native communities.

Indicator 2: During FY 2005, maintain the proportion of patients with
diagnosed diabetes that have demonstrated improved glycemic control
(defined as ideal control) at the FY 2004 level.

![](media/image5.wmf){width="3.15625in" height="1.9270833333333333in"}

[Rationale:]{.underline} This indicator is directed at reducing diabetic
complications through improved blood sugar control.

**[Approach:]{.underline}** Glycemic control is measured with a test
called the Hemoglobin A1C (HgbA1c) that measures the average blood sugar
over the last 1-2 months. The IHS Diabetes Care and Outcomes Audit
divides these control levels into "Ideal" (\<7%); "Good" (7.0-7.9%);
"Fair" (8.0-9.5%); "Poor" (9.5-11.9%); and "Very Poor" (\>12%) based on
national diabetes care standards. The current guidelines recommend the
use of HgbA1c cutoffs that determine control at the \"Ideal\" level.

**[Data Source:]{.underline}** Diabetes registries, yearly IHS Diabetes
Care and Outcomes Audit, GPRA+ data from local RPMS.

Those sites that have chosen to focus on the problem by applying the
best practices associated with glycemic control will be assessed as a
defined group using the *IHS Diabetes Care and Outcomes Audit.* Starting
in FY 2004, the mean HgA1c of this group and categories of glycemic
control will be reported as a baseline and compared with the performance
of the I/T/U system as a whole.

**[Program Performance:]{.underline} IHS met this indicator in FY 2002
and 2003.** The FY 2003 Indicator was to maintain the proportion of
I/T/U clients with diagnosed diabetes who have improved their glycemic
control (defined by ideal control) at the FY 2002 level. Our current
rates of measuring HgA1c values far surpass the Healthy People 2010
target. Our baseline of ideal control, established in FY 98, was 22%,
with increases as noted above, even though the definition of ideal
control has become stricter. GPRA+ data, used to report clinical
indicators starting in FY 2003, mirrors the trends previously
established in the diabetic audit. The difference in absolute
percentages is due to the use of the diabetic audit versus a solely
electronic audit for GPRA+ data.

**[Indicator 3:]{.underline}** During FY 2005, maintain the proportion
of patients with diagnosed diabetes who have achieved blood pressure
control at the 2004 level.

![](media/image7.wmf){width="3.15625in" height="1.9270833333333333in"}

Purple - Diabetic Audit Data Source

Red - GPRA+ Data Source

Gold - IHS 2010 Goal

**[Rationale:]{.underline}** This indicator is directed at reducing
complications of diabetes. Large clinical studies have demonstrated that
blood pressure control significantly reduces the incidence of
complications related to diabetes, most notably heart disease, strokes
and kidney disease.

[**Approach**:]{.underline} National standards recommend that the ideal
goal of diabetic blood pressure control should be 130/80. For the GPRA
process, the "ideal" control is defined as 130/80, though this will
change as clinical care guidelines are modified.

[**Data Source**:]{.underline} Diabetes registries and yearly IHS
Diabetes Care and Outcome Audits, GPRA+ data from local RPMS. This
indicator is determined by calculating the proportion of clients with
diabetes who have "ideal" blood pressure control (defined as systolic
BP\<130 and diastolic BP\<80) and the proportion who fall into the
"controlled" category (defined as systolic BP\<140 and diastolic BP\<90)
in the current audit year. The current year mean systolic and diastolic
blood pressures of the "ideal" category are compared to that of the
previous year to determine if improvements were maintained for this
fiscal year.

**[Program Performance:]{.underline}** **IHS did not met this indicator
in FY 2002; IHS did met this indicator in FY 2003.** The FY 2003
indicator was to maintain the proportion of I/T/U clients with diagnosed
diabetes who have achieved blood pressure control at the FY 2002 level.

In FY 2002, 34.7% of clients falling into the "ideal BP control"
category based on the diabetic audit; in FY 2003, 37% of patients were
in control using GPRA+ electronic data. This improvement, which mirrors
the diabetic audit data from a trend perspective, occurred in spite of
the fact that we "tightened" our definition of "ideal control" (lowering
the acceptable diastolic BP from 85mm Hg to 80 mm Hg) in response to new
National Guidelines on Blood Pressure Control in people with diabetes.

**[Indicator 4:]{.underline}** During FY 2005, maintain the proportion
of patients with diagnosed diabetes assessed for dyslipidemia (LDL
cholesterol) at the FY 04 levels.

![](media/image8.wmf){width="3.15625in" height="1.9270833333333333in"}

Purple - Diabetic Audit Data Source

Red - GPRA+ Data Source

Gold - IHS 2010 Goal

**[Rationale:]{.underline}** This indicator is directed at reducing
diabetic complications from heart disease through lowering of serum LDL
cholesterol.

**[Approach:]{.underline}** This indicator will measure screening of LDL
in diabetic patients. The diabetes grant programs choosing to focus on
cardiovascular risk reduction, of which treatment of dyslipidemia is a
large, will be tracked separately to see if their overall performance is
better than the group as a whole. Trends over time for I/T/U facilities,
service units, Areas and IHS-wide are constructed for selected
indicators.

[**Data Source**:]{.underline} Diabetes registries, yearly IHS Diabetes
Care and Outcomes Audit; GPRA+ data. Achievement of this indicator is
determined by calculating the proportion of patients with diabetes who
have had LDL cholesterol performed in the past year. The current year's
data is compared to that of the previous year to determine if
improvements were maintained for this fiscal year.

[Program Performance:]{.underline} IHS met this indicator in both FY
2002 and FY 2003. The FY 2003 Indicator was to maintain the proportion
of I/T/U clients with diagnosed diabetes assessed for LDL cholesterol at
the FY 2002 level. The proportion of I/T/U clients diagnosed with
diabetes assessed for LDL cholesterol increased from 46% for FY 1999 to
64% in FY 2003. GPRA+ data showed an increase from 44% to 48%, mirroring
the trend from the diabetes audit data. This improvement in performance
is due to better awareness in both providers and patients through the
National Cholesterol Education Program efforts and increased I/T/U
provider awareness of the growing problem of heart disease in AI/AN
through Diabetes Program (and others) efforts to publicize results of
the Strong Heart Study showing that the rate of heart disease in AI/AN
is increasing.

**[Indicator 5:]{.underline}** During FY 2005, maintain the proportion
of patients with diagnosed diabetes assessed for nephropathy at the FY
2003 level.

![](media/image9.wmf){width="3.15625in" height="1.9270833333333333in"}

Purple - Diabetic Audit Data Source

Red - GPRA+ Data Source

Gold -- IHS 2010 Goal

**[Rationale:]{.underline}** This indicator is directed at reducing
diabetic complications. End stage renal disease (ESRD), or diabetic
kidney disease, is a significant and growing problem in Indian
communities. The assessment of proteinuria not only indicates who is at
risk for ESRD, but is an independent predictor of cardiovascular risk,
which is the number one killer of American Indian and Alaska Native
adults.

**[Approach:]{.underline}** The benefits of aggressive interventions to
lower blood pressure in diabetics relative to kidney health have been
well described in the literature and numerous practice guidelines and
standards exist. The use of appropriated diabetes funding enhancements
will improve the performance of this indicator with grants /cooperative
agreements for special activities aimed at targeted diabetes-related
treatment and prevention areas.

A special sub-report of the IHS Diabetes Care and Outcomes Audit, called
the Kidney Health Profile, generated annually, assesses screening and
treatment for kidney health in a community. Each year's reported rate
will be used to provide trend analysis.

**[Data Source:]{.underline}** Diabetes registries, yearly IHS Diabetes
Care and Outcomes Audit, and GPRA+ data from local RPMS systems.

Achievement of this indicator is determined by calculating the
proportion of patients with diabetes and a normal proteinuria screen who
have had a test for microalbuminuria performed in the past year. The
present year's data is compared to that of the previous year to
determine if the level of assessments were maintained.

**[Program Performance:]{.underline} IHS met this indicator in both FY
2002 and FY 2003.** The FY 2003 Indicator was to maintain the proportion
of I/T/U clients with diagnosed diabetes assessed for nephropathy at the
FY 2002 level and was met. Screening for microalbuminuria to assess
early diabetic nephropathy increased from 33% in 1998 to 56% in FY 2002
using the diabetic audit, and from 35-38% (from 2002 to 2003), using
GPRA+ reports on local RPMS data.

**Indicator 6:** During FY 2005, maintain the proportion of patients
with diabetes who receive an annual diabetic retinal examination at
designated sites at the FY 2004 rate.

![](media/image10.wmf){width="3.5569444444444445in"
height="1.9013888888888888in"}

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
the level of vision loss from diabetic retinopathy in the American
Indian and Alaska Native population. According to the Early Treatment of
Diabetic Retinopathy Study (ETDRS) timely laser, treatment of diabetic
retinopathy nearly eliminates severe vision loss due to diabetes. It is
estimated that the benefits of treatment include a net savings of almost
\$500,000,000 and almost 100,000 person years of sight across the USA.

**[Approach:]{.underline}** Early detection and timely treatment is
necessary to minimize or prevent vision loss due to diabetic
retinopathy. The Indian Health Service began tracking the rate of annual
eye exams many years ago, documenting the perennial rate of annual
diabetic eye exams/retinal screenings consistently at between and
53-56%. An improved strategy will be implemented in three phases. The
first phase involves facilities that have telemedicine projects in place
designed to screen diabetics for diabetic retinopathy. Those facilities
participating in phase one are: Phoenix Indian Medical Center, Pine
Ridge Hospital, Tuba City Medical Center, Fairbanks Health Center, Sells
Hospital and Carl Albert Indian Health Facility

**[Data Source]{.underline}:** The calculation of annual dilated retinal
exams on diabetics is obtained from GPRA+ run on local RPMS databases.

**[Program Performance]{.underline}**: **IHS met this indicator for FY
2003.** The FY 2003 indicator was to increase the proportion of patients
with diagnosed diabetes who receive an annual diabetic retinal
examination at designated sites by 3%. Many barriers that exist within
the IHS system prevent significant improvement in the diabetic eye
screening rates. The implementation of diabetic retinopathy screening
programs utilizing telemedicine may be one method to decrease some of
these barriers. With the renewal of funding for the Special Diabetes
Program for Indians (SDPI), it is expected that more sites will
implement solutions such as this in an effort to reach the IHS 2010 goal
of 70%.

#### Cancer Screening Group:

These two indicators are directed at increasing the coverage of women
receiving screening for breast and cervical cancer.

**Indicator 7:** During FY 2005, maintain the proportion of eligible
women who have had a Pap screen within the previous three years at the
FY 2004 levels.

![](media/image11.wmf){width="3.4479166666666665in" height="2.09375in"}

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
the mortality and morbidity of cervical cancer, which occurs at higher
rates among American Indian and Alaska Native women than in the general
U. S. population. The long-range goal is to reduce both cervical cancer
incidence and death rates to achieve parity with the U.S. all-races rate
by 2010.

[**Approach**:]{.underline} The IHS Office of Public Health is
responsible for overall coordination of efforts to achieve these
indicators.

[**Data Source**:]{.underline} The total number of women age18 through
64 who have had at least one Papanicolaou screening test performed
(cervical cytology or Pap smear) in the previous three years will be
determined from IHS Laboratory reports and PCC electronic patient
records. The baseline for this measure as reported in FY 2000
performance report is 18%.

**[Program Performance:]{.underline}** **IHS did not meet this indicator
for FY 2003** The FY 2003 indicator was to maintain the proportion of
women 18 and older that had a Pap in 2003 at the FY 2002 level.

The IHS performance for 2003 was determined from electronic medical
record queries using GPRA+ at the local sites. Even though we were
unable to show an increase over FY 2002, we were able to show a
significant increase using local data derived from the local health
information system. IHS believes that our current screening rate of 61%
is a major achievement in our cancer prevention strategy. During FY
2003, funding remained stable for Pap screening and cancer prevention in
general. IHS did not increase overall expenditures for women's health,
and CDC did not fund any additional Tribal screening projects. Problems
with recruitment and retention of providers continue to exist.

IHS plans to renew our focus on cancer screening. This will include
providing feedback to providers on their individual and local facility
pap screening rates.

Indicator 8: During FY 2005, maintain the proportion of eligible women
who have had mammography screening at the FY 2004 rate.

![](media/image12.wmf){width="3.25in" height="1.9479166666666667in"}

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
the mortality and morbidity of breast cancer among American Indian and
Alaska Native women.

**[Approach:]{.underline}** Mammography screening is provided to
American Indian and Alaska Native women directly by IHS facilities, by
mobile mammography units supported either by CDC funds, or through
contract health arrangements with private radiology groups. The IHS
Office of Public Health performs the overall coordination of this
effort. Linkages with CDC and State screening programs are critical to
success. CDC has funded the National Indian Women's Health Support
Center to provide technical assistance to Tribal mammography programs.

**[Data Source:]{.underline}** IHS electronic medical records are the
principal data source. The numerator is the total number of women age 50
through 64 who have had at least one mammogram performed in the previous
two years. We have increased the lower age limit from 40 to 52, because
considerable controversy remains about the efficacy of mammography for
women under 50. We set an upper age limit of 64 to have rates that are
comparable with CDC reporting, and because women over 65 are Medicare
eligible and therefore more likely to have mammograms performed by
outside facilities that do not report to IHS.

**[Program Performance:]{.underline}** **IHS did not meet this indicator
for FY 2003.** This indicator committed to maintaining the proportion of
American Indian and Alaska Native women who received clinically
indicated screening mammography in the previous 2 years.

In FY 2003, 41%of American Indian and Alaska Native women had a
mammogram during the previous 2 years. The graph illustrates the
increase in overall screening rates when data is derived from local
health information systems using GPRA+. This increase in screening
reflects better data collection and capture of mammography at the local
level.

IHS plans to increase mammography rates by providing electronic
reminders as well as feedback to individual providers.

#### Substance Abuse Treatment Group:

These two indicators address substance abuse treatment. The first
targets improved residential treatment of adolescents with
alcohol/substance abuse problems. The second addresses prevention of
fetal alcohol syndrome.

**Indicator 9: During FY 2005, the Youth Regional Treatment Centers that
have been in operation for 18 months or more will achieve 100 %
accreditation through either CARF, or a comparable accreditation
process.**

**[Rationale:]{.underline}** This indicator is intended to evaluate
youth regional treatment centers, and ensure that these programs are
appropriately managed. Successful completion of residential treatment
can help reduce drug and alcohol use relapse in youths.

**[Approach:]{.underline}** Accreditation by JCAHO, CARF, or comparable
state accrediting bodies ensures that the Youth Regional Treatment
Centers met acceptable standards of treatment care. This indicator has
changed to focus on accreditation, as the components of the previous
indicator are met and surpassed with accredited facilities.

**[Data Source:]{.underline}** Data for this indicator are collected
from the YRTCs. The Division of Behavioral Health, Office of Public
Health will be responsible for coordinating data collection from the
Regional Treatment Centers.

**[Program Performance:]{.underline}** **In 2003, IHS met the intent of
this indicator.** The FY 2003 performance measure was to improve
baseline YRTC data for the following measures by 5%

-   Percent of youths who successfully completed alcohol/substance abuse
    treatment at IHS funded YRTCs. (Stable at 63% from 62.6%)

```{=html}
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-   Percent of youth (that completed treatment) who developed an
    aftercare plan with their appropriate aftercare agency (99.6% from
    99.0%)

-   Percent of youth who have this after care plan communicated to the
    responsible follow-up agency; documentation of this communication
    must be in the youth YRTC record (99.5% from 89.5%)

-   Percent of YRTC programs that have a family week opportunity for
    youth that participate in the YRTCs (100% from 100%)

All YRTC's have reported data on these measures. Completion of
treatment, established aftercare, and an established family week are
known factors in predicting success. Improvement in after care
communication, as well as youth with aftercare plans, and family week
opportunities are essential to improving outcomes. IHS believes that we
met the spirit of this measure, as we say marked improvement in the
communication of after care plans. However, we were unable to increase
the percentage of youth who have completed treatment, as this is
multifactorial.We will continue to track this indicator in FY 2004,
prior to the change to accreditation in FY 2005.

Indicator 10: During FY 2005, increase the screening rate for alcohol
use in women of childbearing age over the FY 04 rate.

During FY 2004, establish the screening rate for alcohol use in women of
childbearing age.

![](media/image13.wmf){width="3.34375in" height="1.9479166666666667in"}

**[Rationale:]{.underline}** The purpose of this indicator is a
reduction in the incidence of Fetal Alcohol Syndrome (FAS). Surveillance
conducted at two IHS Areas indicated FAS rates greatly exceed general
population rates. Thus, the purpose of this indicator is to assure that
providers consistently screen and make appropriate referrals for women
at risk. Indian Health Service had implemented screening and case
management protocols at the majority of our facilities by 2002.

**[Approach:]{.underline}** The Division of Behavioral Health works with
facilities to educate establish and increase the rates of screening for
alcohol use in this age cohort. In addition, RPMS Health Summary ensures
that there is an automatic health care reminder for alcohol screening.
This reminder is visible to the end health care provider at the time of
the provider visit.

**[Data Source:]{.underline}** RPMS data extraction

**[Program Performance:]{.underline}** **IHS met this indicator.** The
FY 2003 indicator committed to maintaining the proportion of I/T/U
prenatal clinics utilizing a recognized screening and case management
protocol(s) for pregnant substance abusing women at the FY 2002 level
For FY 2002, 209 out of 231 clinics had implemented such protocols for a
rate of 90.5%. In FY 2003, 95% of clinics met this indicator.IHS is
changing this indicator in FY 2004 to reflect the desire to move towards
an outcome indicator.

#### Oral Health Group:

Oral conditions of American Indian and Alaska Native participants are
far worse than the U.S. general population. These poor oral conditions
profoundly influence their quality of life, including their ability to
attend school, work, and sleep, eat, and socialize.

The 1999/2000 IHS Oral Health Survey of American Indian and Alaska
Native dental patients underscored the significant disparities in oral
health that continue to exist between native and non-native Americans.
Key findings concerning the Native American population examined include:

-   Native American patients experience roughly three times the amount
    of tooth decay and periodontal disease as compared to the general
    U.S. population;

-   Very young Native Americans experience tooth decay at rates
    significantly greater than general U.S. population children;

-   The use of tobacco is strongly associated with both oral cancer and
    periodontal disease. The prevalence of tobacco use starts at about
    13 years of age among Native Americans and steadily increases with
    age; and

-   Most Native American adults and elders have lost teeth because of
    dental disease or oral trauma.

Indicator 11: During FY 2005, increase the proportion of American Indian
and Alaska Native population receiving optimally fluoridated water by
0.5 % over FY 2004 levels for all IHS Areas.

**[Rationale]{.underline}:** Fluoridation is one of the most cost
effective public health measures for reducing the prevalence of dental
decay in all age groups. However, despite the known benefits of
fluoridation, the number of fluoridated water systems in Indian country
has declined by 68% during the 1990's because of more rigorous
monitoring standards developed by the Center for Disease Control. The FY
2005 fluoridation objective is formulated as a 0.5 % increase in the
number of individuals having access to fluoridated water. The tribal
utilities yet to be fluoridated are the relatively small ones. The
average number of individuals served by tribal utilities that remain
unfluoridated is approximately 300. A proposed 0.5 % increase at first
glance might appear quite modest. However, it will take the fluoridation
of approximately 25 individual utilities to achieve this goal. This
reasonable objective postulates a smaller increase in fluoridation
coverage than previous objectives for recent years. This is in
recognition of a number of factors:

-   The successes documented at our pilot sites in previous years have
    proven to be less exportable than originally envisioned.

-   Remaining utilities yet to be fluoridated are relatively small.
    Efforts similar to those made in recent years will yield diminishing
    returns in the future, as in general it takes a similar level of
    effort and resources to start up fluoridation at an individual
    utility regardless of size or number of individuals served.

-   Significant positive outcomes from reorganizing and centralizing
    fluoridation coordination are not expected until FY 2005.

-   Relying upon Area Offices to provide fluoridation data has
    introduced variability into our annual assessments. A primary thrust
    of national efforts during both FY 2003 and FY 2005 will be to
    establish a consistent national database with which to monitor
    future efforts toward fluoridation.

**[Approach]{.underline}:** The IHS Dental Program, Office of
Environmental Health and Engineering Branch, and the Centers for Disease
Control and Prevention's Division of Oral Health entered into an
interagency agreement in FY 2000 to support a demonstration fluoridation
project in the Albuquerque and Phoenix Areas.

This indicator expanded to address all IHS Areas in FY 2001, because of
earmarked recurring funding of \$500,000 in FY 2001 to support water
fluoridation IHS-wide. Each Area will submit an annual plan of action
and an annual report of activities and outcomes. Because of the very
limited success Area dental programs have had with respect to
fluoridation in recent years, Headquarters Office of Environmental
Health and Engineering and Headquarters Division of Oral Health are
initiating a new effort to promote fluoridation.

**[Date Sources:]{.underline}** (1) Water Fluoridation Reporting System
(WFRS) and database maintained by CDC. The FY 2002 level will provide
the comparison or baseline for assessing the annual gain. (2) Reports
from IHS Area fluoridation coordinators and Area Dental Officers.
Individual Area reports continue to be solicited for two reasons: (1)
WFRS lacks the detail and the personal observations that can be provided
by field personnel; and (2) few tribal utilities have chosen to use
WFRS.

**[Program Performance:]{.underline}** **IHS did not meet this
indicator.** The FY 2003 indicator committed to a 1%increase in the
number of American Indian and Alaska Native people benefiting from
fluoridated drinking water. However, an increase of 0.37% was achieved
and documented. .

Individual reports from IHS Areas other than the two demonstration sites
make it clear that significant progress has been made in most Areas with
respect to water fluoridation, but the final objective of all the
efforts, successful fluoridation, has not yet occurred. As noted above,
the Headquarters Office of Environmental Health and Engineering and
Headquarters Division of Oral Health are initiating a new centralized
effort to promote fluoridation across the IHS.

Indicator 12: During FY 2005, maintain the proportion of patients who
obtain access to dental services at the FY 2004 level.

During FY 2004, maintain the proportion of patients who obtain access to
dental access at the FY 2003 level.

![](media/image14.wmf){width="3.8125in" height="2.28125in"}

**[Rationale:]{.underline}** This indicator is directed at improving the
oral health status of the American Indian and Alaska Native population.
There has been almost a 10% reduction in the percent of the American
Indian and Alaska Native population annually receiving dental services
in recent years. The proposed FY 2005 indicator supports the capacity to
maintain dental access at 100% of the FY 2004 level.

**[Approach:]{.underline}** Access to dental services in FY 2005 will be
maintained at 100% of the FY 2004 level through a combination of
strategies that include:

-   Increasing the I/T/U dental workforce.

-   Increasing retention and productivity of dental providers.

-   Updating and simplify the automated dental record keeping system.

-   Expanding essential dental specialty services through contracts with
    the private sector.

-   Targeting specific populations.

The vacancy rate for dental providers, which has fluctuated slightly
between approximately 18% and 22%, is a key determinant in limiting
access to care. The current vacancy rate of approximately 20% has
remained relatively stable over the last few years despite increased
emphasis upon recruiting. This suggests that additional efforts toward
retention of dental providers will be necessary to ensure stabilizing
this indicator.

**[Data Source:]{.underline}** IHS Dental Data System component of the
RPMS; GPRA+ data from local RPMS.

[**Program Performance**:]{.underline} **IHS met this indicator.** The
FY 2003 indicator committed to maintaining the proportion of the
American Indian and Alaska Native population having access to dental
care compared to FY 2002. 28.1% of the user population received dental
care in FY 2003 compared to 27.35% receiving care in FY 2002. GPRA+ data
is also stable at 25% for FY 2002 and FY 2003.

Indicator 13: During FY 2005, maintain the number of dental sealants
placed per year in American Indian and Alaska Native patients at the FY
2004 level.

![](media/image15.wmf){width="3.21875in" height="2.0416666666666665in"}

**[Rationale:]{.underline}** Dental sealants, a recognized standard in
preventive dental care, are an effective measure for reducing dental
decay rates and can be effectively applied by dental auxiliaries at
relatively low cost. Because surveys of American Indian and Alaska
Native children have consistently identified them as having
significantly higher decay rates than the general U.S. population,
sealants are essential to reduce both the ravages and costs of treating
dental decay.

The intent of this indicator is to reduce dental decay by increasing
both the number of patients with dental sealants (the prevalence of
sealants in the population) and the number of sealants per patient (the
intensity of coverage per individual

**[Approach:]{.underline}** Local dental clinics are responsible for
implementing/maintaining effective and efficient sealant programs that
are either school-based or school-linked and targeted for children ages
6-14 years (to coincide with the eruption of first and second permanent
molar teeth). In order to maintain the number of sealants placed on the
posterior teeth of Indian patients in FY 2005, an innovative approach
will be required. One option involves the use of contract 4-handed
dental sealant teams hired from the private sector. Dental Community
Health Aides may be trained to assist dental hygienists and dental
assistants in placing sealants. Additional portable equipment to be used
in the schools is an efficient way to make use of lack of clinic space
and going to where the children are -- the schools.

**[Data Source:]{.underline}** IHS Dental Data System component of the
RPMS. This revision of data collection is expected to result in
significantly larger data sets and data that are more reliable. In
contrast to the previous measure, these data will provide an estimate of
both prevalence of sealants and intensity of care, by providing an
estimate of the number of sealants placed per patient.

**[Program Performance:]{.underline}** **IHS met this indicator.** In FY
2002, 227,945 sealants were placed in the IHS dental program. In FY
2003, 243,499 sealants were placed in patients of all ages. This
represents an increase over sealants placed in FY 2002.

Indicator 14: During FY 2005, maintain the proportion of patients
diagnosed with diabetes who obtain access to dental services at the FY
2004 level.

![](media/image16.wmf){width="3.4479166666666665in"
height="2.0416666666666665in"}

**[Rationale:]{.underline}** The purpose of this indicator is to improve
both oral health status and diabetic control for American Indian and
Alaska Native diabetics. Restoring access to both primary and secondary
treatment and preventive services for diabetics can lessen periodontal
disease progression and the subsequent effects on diabetes and overall
health. Improving access and thus increasing utilization of dental
services can also result in less costly care, improved health status,
and quality of life.

**[Approach]{.underline}:** Individual I/T/U hospitals and clinics
provide access to care for diabetic patients in a wide variety of ways.
At a minimum, a yearly examination provides an educational opportunity
to enlighten the diabetic patient on their oral health status and proper
home care to reduce periodontal disease and its effect on diabetic
control. Those programs with additional time and resources can provide
anything from extraction of teeth that are severely involved with
periodontal disease to comprehensive periodontal therapy and dentures.
The proposed FY 2005 IHS budget will support the capacity to maintain
access at the FY 2003 level in the face of population growth and rising
costs of treatment.

**[Data Source:]{.underline}** Diabetes registries, yearly *IHS Diabetes
Care and Outcomes Audit*.

**[Program Performance:]{.underline}** **IHS did not meet this indicator
in FY 2003. IHS did meet this indicator in FY 2002.** This indicator was
to increase access to dental services at 2% over FY 2002 level. Ongoing
shortages of dental professionals make this aggressive target difficult
to reach. Our ability to maintain services is remarkable, given the
increasing diabetic population that needs to access limited services.

#### Family Violence, Abuse, or Neglect Indicator:

Indicator 15: During FY 2005 the IHS will ensure that 15% of women
between the ages of 15 and 40 are screened for domestic violence.

![](media/image17.wmf){width="3.0305555555555554in"
height="1.9395833333333334in"}![](media/image18.wmf){width="2.8201388888888888in"
height="1.9513888888888888in"}

**[Rationale:]{.underline}** This indicator is designed to help
ascertain, evaluate and reduce the prevalence of family violence, abuse
and neglect in American Indian and Alaska Native communities. Rates of
intimate partner violence are double for American Indian and Alaska
Native people compared to whites, and 1½ times greater than U.S. all
races. (MMWR)

**[Approach:]{.underline}** IHS has developed training materials that
are specific for American Indian and Alaska Native communities. IHS has
entered into a collaborative agreement with the Family Violence
Prevention Fund as well as ACF, DHHS. This agreement facilitated the
development of our teaching materials as well as the implementation and
evaluation of a multifaceted systems approach to screening at clinical
facilities throughout American Indian and Alaska Native communities.

[**Data Source:**]{.underline} RPMS data will be used to obtain and
aggregate domestic violence screening rates.

**[Program Performance]{.underline}**: **IHS did not meet this
indicator.** The FY 2003 indicator was to assure that at least 85% of
I/T/U medical facilities who provide direct clinical care have written
policies and procedures for routinely identifying, treating, and/or
referring victims of domestic violence, abuse or neglect as well as
child abuse/neglect and elder abuse/neglect.

In addition, 60% of sites needed to provide staff training to their
direct clinical staff on these policies. The aggregate rate for policies
and procedures for FY 2003 was 84%. 60% of sites provided training in
these policies and procedures. A code for screening for domestic
violence was developed and integrated into our health information
system; this will facilitate our ability to report on the screening for
domestic violence in high-risk female populations starting in FY 2004.
IN FY 2004, this indicator changes to an outcome indicator.

#### Information Technology Development Group:

The following three indicators address the development of improved
automated data capabilities that support clinical care and performance
measurement.

Indicator 16: During FY 2005, implement a national program to improve
the quality, accuracy and timeliness of Resource Patient Management
System (RPMS) Patient Care Component (PCC) clinical data to support the
Agency's GPRA clinical measures by expanding the current automated data
quality assessment "package" to include two new additional clinical
measures.

**[Rationale:]{.underline}** This indicator is part of an on-going
effort to improve the overall accuracy, completeness and timeliness of
clinical data from the Agency's primary clinical data repository -
Resource Patient Management System (RPMS) Patient Care Component (PCC)
used for GPRA clinical measures. The goal of this indicator is to
improve the overall quality of clinical data including completeness,
timeliness, accuracy and movement of data to the national programs for
future national electronic GPRA reporting.

**[Approach:]{.underline}** The I/T/Us are responsible for managing
local RPMS clinical applications including data quality. The agency will
provide an expanded data quality application that will allow individual
sites to assess electronically collected clinical data received at the
national program level with patient "medical records" maintained at the
local health facility.

**[Data Source:]{.underline}** Local programs export RPMS clinical data
to the national programs.

**[Program Performance:]{.underline}** **IHS met this indicator.** For
FY 2003 this indicator committed to:

-   Automate new performance measures

-   Complete baseline for any performance measures where electronic data
    collection was implemented during this FY;

-   Distribute automated mapping tools for LOINC to all I/T/U's

This serves as part of a long-term effort to expand the IHS capacity to
derive GPRA performance data directly from clinical automated
information systems, including the Resource and Patient Management
System (RPMS). This allows IHS to add new performance measures in the
most cost-effective way and efficient way. The majority of the GPRA
clinical indicators are reported in FY 03 using GPRA+ data. Finally, a
LOINC software patch was distributed to all I/T/U sites that were
interested in deploying this enhancement.

Indicator 17: During FY 2005, improve the Behavioral Health (BH) Data
System by assuring at least an additional 5% of the I/T/U programs will
report minimum agreed-to behavioral health-related data to the national
data warehouse.

![](media/image19.wmf){width="3.4375in" height="2.1458333333333335in"}

**[Rationale:]{.underline}** The purpose of this indicator is to collect
data in order to track and evaluate improvements in the behavioral
health status of American Indian and Alaska Native people. Better BH
data collection and analysis will improve planning, implementation and
evaluation of mental health, alcohol and substance abuse, and social
services efforts across I/T/U programs.

**[Approach:]{.underline}** Improving behavioral health outcomes relies
on two important activities: data collection as close to point of care
as possible, and data reporting in a standardized way that can be
understood across the Indian health system. Standardized data reporting
can be achieved by providing a usable, provider-driven and provider
friendly computerized application to I/T/U sites.

A key activity that began in FY 2002 was the design and implementation
of an integrated Behavioral Health system. The behavioral health Interim
Solution, deployed during FY 2003, helped address the need for
incremental improvements in existing RPMS systems, as well as
facilitated a standardized suicide data collection system within the
RPMS package.

The IHS Indian Health Performance Evaluation System (IHPES) has also
developed a national Mental Health SAS database.

**[Data Source:]{.underline}** RPMS, the Mental Health Database, and
appropriate surveys.

[**Program Performance**:]{.underline} **IHS met this indicator.** The
FY 2003 performance measure was to increase the percent of I/T/Us that
have implemented the use of the Mental Health/Social Services (MH/SS)
data reporting system by 3% over the FY 2001 level. In FY 2003, an
additional 25 sites began to collect and share data.

The FY 2003 totals for this indicator were taken directly from the
national data center. "Actual" data was exported and received from all
included I/T/U programs by the national data center. This comparative
data was based upon data sent to the national database since 1990.

Indicator 18: During FY 05, IHS will have in place contract and grant
requirements for all urban Indian programs to provide a specified data
set in a standard format.

FY 2004 indicator: During FY 04, IHS will develop a specific minimum
data set as well as appropriate language for the urban C&G.

**[Rationale: ]{.underline}** The urban health programs are currently
capturing data for the Urban Indian Health Program Common Reporting
Requirement (UCRR). However, a minimum data set needs to be developed to
address additional urban data needs, including GPRA reporting.

**[Approach:  ]{.underline}**The urban program will facilitate a data
workgroup to develop this minimum data set. This group will develop this
minimum data set by during FY 04. Mandatory reporting on this data set
will be included as part of the C&G language starting in FY 05.

**[Data Source:]{.underline}** Review of Urban Program Contracts and
Grants language

[Program Performance:]{.underline} IHS met this indicator for FY 2003.
The FY 2003 performance measure was to increase by 5% (+2 sites over FY
02 level), the proportion of Urban Indian health care programs that have
implemented mutually compatible automated information systems that
capture health status and patient care data over the FY 2002 level. The
intent of the measure is to 1) build Urban Indian Health Program (UIHP)
information technology and data collection infrastructure capacity, 2)
create a system which allows standardized data collection, data
reporting and data sharing, 3) provide centralized technical support to
UIHPs and to share programmatic knowledge among UIHPs, and 4) create a
resource for developing advocacy data.

IHS met this indicator with the installation of the IHS Resource and
Patient Management System (RPMS) at five new sites. The new sites,
located within the state of Montana, Billings Area Office, are Billings,
Butte, Great Falls, Helena and Missoula.

The measure was surpassed through the collective efforts of the Urban
Indian Health Program (UIHP) contractors and grantees, the Urban Indian
Health Program Branch office and the Indian Health Performance
Evaluation System (IHPES) staff in developing the urban Indian health
care data mart within the IHS data warehouse and with the establishment
of an UIHP data workgroup that has begun to develop the minimum data set
needed to address additional urban data needs.

Adequate health status and health services data are essential for the
effective planning and management of any health care delivery system.
Urban data must eventually reach parity with that collected by tribal
and IHS facilities to allow for a more accurate portrayal of the needs
and services available to American Indians and Alaska Natives (AI/AN)
residing in urban areas, the existing disparities in health status that
afflict them, and supporting local health program needs as well as
provide data for the larger IHS requirements, including GPRA. The UIHPs
advocate for the considerable health care need of the AI/AN people
residing in urban areas and to meet the Healthy People 2010 goal of
achieving equivalent and improved health status for all Americans.

#### Quality of Care Indicator Group:

The following indicators address the quality of health care provided in
IHS settings from both the perspective of accreditation, medication
errors, and consumer satisfaction.

Indicator 19: During FY 2005, maintain 100% accreditation of all IHS
hospitals and outpatient clinics.

**[Rationale:]{.underline}** The accreditation of IHS hospitals and
clinics represents the most objective and respected measure of health
care quality. In addition, accreditation is essential for maximizing
third-party collections, and contributes both directly and indirectly to
many other indicators presented in this plan.

**[Approach:]{.underline}** The local I/T/U multidisciplinary team
approach to accreditation and ongoing quality management has been the
mainstay of success in this important activity. Additional support and
guidance from Areas and Headquarters staff will continue to support this
indicator. This is one of the most demanding indicators to meet, given
the growing clinical quality of care assessments that are required as
well as issues related to health facilities maintenance, improvement,
and renovation that are critical to accreditation. The accrediting body
used for hospitals and some ambulatory health centers is the Joint
Commission on the Accreditation of Health Care Organizations (JCAHO).
However, there was an increase in the ambulatory health centers that
obtained accreditation from the American Association of Ambulatory
Health Centers (AAAHC).

**[Data Source:]{.underline}** IHS compiled a database generated from
accreditation reports submitted by IHS Area Quality Assurance
coordinators.

**[Program Performance:]{.underline}** **IHS met this indicator in FY
2003.** The FY 2003 committed to maintaining 100% accreditation of all
IHS hospitals and outpatient clinics and was achieved. During FY 2003,
fifteen IHS hospitals were evaluated by JCAHO and all fifteen maintained
full accreditation. In addition, 13 ambulatory health centers
participated in accreditation visits from JCAHO and AAAHC and all were
accredited.

Indicator 20: During FY 2005, **all direct care facilities shall be
using the NCCMERP nationally recognized medication error definition, and
shall have a non-punitive multi-disciplinary medication error reporting
system in place.**

**[Rationale:]{.underline}** The intent of this indicator is to improve
patient safety by reducing medication errors. The current system in
place does not require national reporting. Many sites still have
punitive systems in place that discourage reporting of medication
errors. By developing a national anonymous reporting system, IHS will be
able to determine a more accurate medication error rate and identify
frequent problems throughout our health care system.

**[Approach:]{.underline}** The IHS examines the many different
medication error reporting processes and training used throughout the
I/T/U, as well as other health networks. IHS works with Areas to
establish baseline data for medication error reporting.

**[Data Source:]{.underline}** In FY 2005, baseline medication error
reporting data is obtained from sites using in place local systems
including reports to Risk Management Officers and data entered into the
Resource and Patient Management System (RPMS).

**[Program Performance:]{.underline}** **IHS met this indicator.**
Number range CHAPTERThe FY 2003 performance indicator was that the IHS
would assess the current processes in place in I/T/Us that affect
medication error reporting, and:

a.  establish pilot sites

b.  assess baseline at the initial sites

The two sections of the indicator related to Medication Error Reporting
were met. Med Marx, the web based medication error reporting system, was
pilot tested for one year at all of IHS and most tribal sites in the
Phoenix and Albuquerque areas. Results of the pilot test were favorable
and other areas were encouraged to adopt Med Marx or another
standardized medication error reporting system. To date, 55 facilities
in the Alaska, Aberdeen, Bemidji, Oklahoma, and Phoenix areas are using
Memorex.

The second part of the Medication Error Reporting indicator related to
assessing baseline data for reported errors. The Phoenix area was the
pilot and established an area-wide baseline both prior to and after
implementation of the Med Marx reporting system. In September 2003, Med
Marx rolled out a Multi-Facility Module that will allow for tracking and
trending of medication errors at the regional and national level. IHS
has purchased this module and expects to have out first national data
available in the second quarter of FY 2004

Indicator 21: By the end of FY 2005, maintain consumer satisfaction
rates at the FY 2004 level.

**[Rationale:]{.underline}** The intent of this indicator is to maintain
consumer satisfaction. Assessing consumer satisfaction is fundamental to
health care quality, and is one of the Institute of Medicines
cornerstones of health care quality. Improved consumer satisfaction is
also associated with higher consumer compliance levels with provider
health recommendations, which can result in improved health outcomes.

**[Approach:]{.underline}** In FY 1999, the IHS developed a
comprehensive culturally sensitive consumer satisfaction survey
instrument that was based on a tested and validated instrument from the
private sector. Clearance was obtained in late FY 2002, and baseline
data was obtained during FY 02. Additional assessments have been
undertaken in FY 2003, with a follow-up survey to determine improvement
scheduled to be completed in FY 2004.

The responsible parties for implementation are the local service sites
with assistance from the IHS Area office staff. The local staff is part
of the local quality assurance program and the aggregate staff will be
part of the IHS epidemiology centers/program.

**[Data Source:]{.underline}** IHS Consumer Satisfaction Survey

[**Program Performance**:]{.underline} **IHS met this indicator.** The
FY 2003 indicator committed to establishing a baseline for consumer
satisfaction using the OMB approved instrument. instrument, which was
obtained in late FY 02. Use of the survey instrument began in late FY
2002, and a baseline was established by the end of FY 2003.

### Prevention Indicators

Table 7: Prevention Indicators Performance Summary

+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | Performance         |   |   | FY Targets        |   | Actual          |   | Re      |
|   | Indicator           |   |   |                   |   |                 |   | ference |
|   |                     |   |   |                   |   | Performance     |   |         |
+===+=====================+===+===+===================+===+=================+===+=========+
|   | Public Health       |   |   |                   |   |                 |   |         |
|   | Nursing Indicator   |   |   |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | [Indicator          |   |   | [Total            |   | FY 05:          |   | P: p.   |
|   | 22:]{.underline}    |   |   | Vi                |   |                 |   | 3-46    |
|   | Address the number  |   |   | sits]{.underline} |   | FY 04:          |   |         |
|   | of public health    |   |   |                   |   |                 |   | B: p.   |
|   | nursing services    |   |   | FY 05: maintain   |   | FY 03:359,089   |   | IHS-75  |
|   | (primary and        |   |   | FY 04 levels      |   | \*\*\*          |   |         |
|   | secondary treatment |   |   |                   |   |                 |   | 1, 3, 5 |
|   | and preventive      |   |   | FY 04: maintain   |   | FY 02:          |   |         |
|   | services) provided  |   |   | FY 03 level       |   | 400,34          |   | \*\*    |
|   | by public health    |   |   |                   |   | 7/343,844\*\*\* |   | \*GPRA+ |
|   | nursing             |   |   | FY 03: maintain   |   |                 |   | data    |
|   |                     |   |   | FY 02 level       |   | FY 01: 383,436  |   |         |
|   | EFFICIENCY MEASURE  |   |   |                   |   | (+3.1%)         |   |         |
|   |                     |   |   | FY 02: +2% over   |   |                 |   |         |
|   | full cost           |   |   | FY 01             |   | FY 00: 371,548  |   |         |
|   |                     |   |   |                   |   | (9.5 % over     |   |         |
|   | FY 05: 46.5 M       |   |   | FY 01: +3% over   |   | FY97)           |   |         |
|   |                     |   |   | FY 00             |   |                 |   |         |
|   | FY 04: 43.1 M       |   |   |                   |   | FY 99: 336,134  |   |         |
|   |                     |   |   | FY 00: 7% over 97 |   |                 |   |         |
|   | FY 03: 39.6 M       |   |   | or 363,033        |   | FY 97: 339,283  |   |         |
|   |                     |   |   |                   |   | baseline        |   |         |
|   |                     |   |   | FY 99: no         |   |                 |   |         |
|   |                     |   |   | indicator         |   | FY 05: no       |   |         |
|   |                     |   |   |                   |   | indicator       |   |         |
|   |                     |   |   | [Home             |   |                 |   |         |
|   |                     |   |   | Vi                |   | FY 04:          |   |         |
|   |                     |   |   | sits]{.underline} |   |                 |   |         |
|   |                     |   |   |                   |   | FY 03:          |   |         |
|   |                     |   |   | FY 05: no         |   | 160,650\*\*\*   |   |         |
|   |                     |   |   | indicator         |   |                 |   |         |
|   |                     |   |   |                   |   | FY 02:          |   |         |
|   |                     |   |   | FY 04: maintain   |   | 151,3           |   |         |
|   |                     |   |   | FY 03 level       |   | 70/156263\*\*\* |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 03: +2% over   |   | FY 01: 153,852  |   |         |
|   |                     |   |   | FY 02             |   | (+20%)          |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 02: +2% over   |   | FY 00: 127,873  |   |         |
|   |                     |   |   | FY 01             |   | (7% over 97)    |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 01: +3% over   |   | FY 99: 111,836  |   |         |
|   |                     |   |   | FY 00             |   |                 |   |         |
|   |                     |   |   |                   |   | FY 97: 119,482  |   |         |
|   |                     |   |   | FY 00: 7% over 97 |   | baseline        |   |         |
|   |                     |   |   | or 127,846        |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 99: no         |   |                 |   |         |
|   |                     |   |   | indicator         |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | Immunization Group  |   |   |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | [Indicator          |   |   | FY 05: maintain   |   | FY 05:          |   | P: p.   |
|   | 23:]{.underline}    |   |   | FY 04 level       |   |                 |   | 3-47    |
|   | Address rates for   |   |   |                   |   | FY 04:          |   |         |
|   | recommended         |   |   | FY 04: +2% over   |   |                 |   | B: p.   |
|   | immunizations for   |   |   | FY 03             |   | FY 03: 80%      |   | IHS-29  |
|   | AI/AN children      |   |   |                   |   |                 |   |         |
|   | patients 19-35      |   |   | FY 03: at FY 02   |   | FY 02: 80%      |   | p\.     |
|   | months. \[outcome\] |   |   | level             |   |                 |   | IHS-75  |
|   |                     |   |   |                   |   | FY 01: 83% 12   |   |         |
|   | full cost ( \#      |   |   | FY 02: +1% over   |   | of 12 Areas     |   | p\.     |
|   | 23-25 )             |   |   | FY 01 level       |   | (-3%)           |   | IHS-83  |
|   |                     |   |   |                   |   |                 |   |         |
|   | FY 05: 8.6 M        |   |   | FY 01: +1% over   |   | FY 00: 86% 12   |   | p\.     |
|   |                     |   |   | FY 00 level       |   | of 12 Areas     |   | IHS-87  |
|   | FY 04: 7.9 M        |   |   |                   |   | (-3%)           |   |         |
|   |                     |   |   | FY 00: +2% over   |   |                 |   | 1, 3    |
|   | FY 03: 7.0 M        |   |   | FY 99 level       |   | FY 99: 89% 12   |   |         |
|   |                     |   |   |                   |   | of 12 Areas     |   | HP 2010 |
|   |                     |   |   | FY 99: 91%        |   |                 |   |         |
|   |                     |   |   |                   |   | > 87% 11 of 12  |   |         |
|   |                     |   |   |                   |   | > Areas         |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   |                   |   | FY 98: 88%      |   |         |
|   |                     |   |   |                   |   | (baseline 11 of |   |         |
|   |                     |   |   |                   |   | 12 Areas)       |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   |                   |   | \* previously   |   |         |
|   |                     |   |   |                   |   | reported at 78% |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | [Indicator          |   |   | [Influ            |   | FY 05:          |   | P: p.   |
|   | 24:]{.underline}    |   |   | enza]{.underline} |   |                 |   | 3-48    |
|   | Address influenza   |   |   |                   |   | FY 04:          |   |         |
|   | vaccination rates   |   |   | FY 05: at FY 04   |   |                 |   | B: p.   |
|   | among               |   |   | levels            |   | FY 03: 51%      |   | IHS-29  |
|   | no                  |   |   |                   |   | \*\*\*          |   |         |
|   | n-institutionalized |   |   | FY 04: at FY 03   |   |                 |   | p\.     |
|   | adult patients aged |   |   | level             |   | FY 02:          |   | IHS-75  |
|   | 65 years and older. |   |   |                   |   | 31%/51%\*\*\*   |   |         |
|   | \[outcome\]         |   |   | FY 03: at FY 02   |   |                 |   | p\.     |
|   |                     |   |   | level             |   | FY 01: 34.8%    |   | IHS-83  |
|   | full cost ( see \#  |   |   |                   |   |                 |   |         |
|   | 23)                 |   |   | FY 02: +1% over   |   | FY 00: 30.7%    |   | 1, 3, 5 |
|   |                     |   |   | FY 01 level       |   |                 |   |         |
|   |                     |   |   |                   |   | FY 03: moved to |   | HP 2010 |
|   |                     |   |   | FY 01: +1% over   |   | \# 25 below     |   |         |
|   |                     |   |   | FY 00 level       |   |                 |   | \*\*    |
|   |                     |   |   |                   |   | FY 02: no       |   | \*GPRA+ |
|   |                     |   |   | FY 00: 65%        |   | indicator       |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 99: no         |   | FY 01: data not |   |         |
|   |                     |   |   | indicator         |   | available       |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | [Pneumoco         |   | FY 00: data     |   |         |
|   |                     |   |   | ccal]{.underline} |   | source          |   |         |
|   |                     |   |   |                   |   | inadequate      |   |         |
|   |                     |   |   | FY 04:            |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 03: moved to   |   |                 |   |         |
|   |                     |   |   | \# 25 below       |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 02: no         |   |                 |   |         |
|   |                     |   |   | indicator         |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 01: secure     |   |                 |   |         |
|   |                     |   |   | electronic        |   |                 |   |         |
|   |                     |   |   | baseline          |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 00: 65%        |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 99: no         |   |                 |   |         |
|   |                     |   |   | indicator         |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | [Indicator          |   |   | FY 05: maintain   |   | FY 05:          |   | P: p.   |
|   | 25:]{.underline}    |   |   | at FY 04 levels   |   |                 |   | 3-49    |
|   | Address             |   |   |                   |   | FY 04:          |   |         |
|   | pneumococcal        |   |   | FY 04: at FY 03   |   |                 |   | B: p.   |
|   | vaccination rates   |   |   | level             |   | FY 03:          |   | IHS-29  |
|   | among               |   |   |                   |   | 65%\*\*\*       |   |         |
|   | no                  |   |   | FY 03: at FY 02   |   |                 |   | p\.     |
|   | n-institutionalized |   |   | level             |   | FY 02: 17%/     |   | IHS-75  |
|   | adult patients age  |   |   |                   |   | 64%\*\*\*       |   |         |
|   | 65 years and older  |   |   | FY 02: no         |   |                 |   | p\.     |
|   |                     |   |   | indicator         |   | FY 01: 11.2%    |   | IHS-83  |
|   | \[outcome\]         |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 01: secure     |   | FY 00: data     |   | 1, 3, 5 |
|   | full cost ( see \#  |   |   | electronic        |   | source          |   |         |
|   | 25)                 |   |   | baseline          |   | inadequate      |   | HP 2010 |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 00: 65%        |   |                 |   | \*\*    |
|   |                     |   |   |                   |   |                 |   | \*GPRA+ |
|   |                     |   |   | FY 99: no         |   |                 |   |         |
|   |                     |   |   | indicator         |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | ######## Inju       |   |   |                   |   |                 |   |         |
|   | ry Prevention Group |   |   |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
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|   |                     | t |   |                   |   |                 |   |         |
|   |                     | l |   |                   |   |                 |   |         |
|   |                     | e |   |                   |   |                 |   |         |
|   |                     | a |   |                   |   |                 |   |         |
|   |                     | s |   |                   |   |                 |   |         |
|   |                     | t |   |                   |   |                 |   |         |
|   |                     | 2 |   |                   |   |                 |   |         |
|   |                     | 5 |   |                   |   |                 |   |         |
|   |                     | s |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | t |   |                   |   |                 |   |         |
|   |                     | e |   |                   |   |                 |   |         |
|   |                     | s |   |                   |   |                 |   |         |
|   |                     | \ |   |                   |   |                 |   |         |
|   |                     | * |   |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     | F |   |                   |   |                 |   |         |
|   |                     | Y |   |                   |   |                 |   |         |
|   |                     | 0 |   |                   |   |                 |   |         |
|   |                     | 1 |   |                   |   |                 |   |         |
|   |                     | : |   |                   |   |                 |   |         |
|   |                     | n |   |                   |   |                 |   |         |
|   |                     | o |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | n |   |                   |   |                 |   |         |
|   |                     | d |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | c |   |                   |   |                 |   |         |
|   |                     | a |   |                   |   |                 |   |         |
|   |                     | t |   |                   |   |                 |   |         |
|   |                     | o |   |                   |   |                 |   |         |
|   |                     | r |   |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     | F |   |                   |   |                 |   |         |
|   |                     | Y |   |                   |   |                 |   |         |
|   |                     | 0 |   |                   |   |                 |   |         |
|   |                     | 0 |   |                   |   |                 |   |         |
|   |                     | : |   |                   |   |                 |   |         |
|   |                     | n |   |                   |   |                 |   |         |
|   |                     | o |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | n |   |                   |   |                 |   |         |
|   |                     | d |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | c |   |                   |   |                 |   |         |
|   |                     | a |   |                   |   |                 |   |         |
|   |                     | t |   |                   |   |                 |   |         |
|   |                     | o |   |                   |   |                 |   |         |
|   |                     | r |   |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
| [ |                     | [ |   |                   | F |                 | P |         |
| I |                     | D |   |                   | Y |                 | : |         |
| n |                     | e |   |                   | 0 |                 | p |         |
| d |                     | a |   |                   | 5 |                 | . |         |
| i |                     | t |   |                   | : |                 | 3 |         |
| c |                     | h |   |                   |   |                 | - |         |
| a |                     | s |   |                   | F |                 | 5 |         |
| t |                     | ] |   |                   | Y |                 | 0 |         |
| o |                     | { |   |                   | 0 |                 |   |         |
| r |                     | . |   |                   | 4 |                 | B |         |
| 2 |                     | u |   |                   | : |                 | : |         |
| 7 |                     | n |   |                   |   |                 | p |         |
| : |                     | d |   |                   | F |                 | . |         |
| ] |                     | e |   |                   | Y |                 | I |         |
| { |                     | r |   |                   | 0 |                 | H |         |
| . |                     | l |   |                   | 3 |                 | F |         |
| u |                     | i |   |                   | : |                 | - |         |
| n |                     | n |   |                   | A |                 | 3 |         |
| d |                     | e |   |                   | v |                 | 7 |         |
| e |                     | } |   |                   | a |                 |   |         |
| r |                     |   |   |                   | i |                 | 1 |         |
| l |                     | F |   |                   | l |                 | , |         |
| i |                     | Y |   |                   | a |                 | 5 |         |
| n |                     | 0 |   |                   | b |                 |   |         |
| e |                     | 5 |   |                   | l |                 | H |         |
| } |                     | : |   |                   | e |                 | P |         |
| A |                     | m |   |                   | D |                 | 2 |         |
| d |                     | a |   |                   | e |                 | 0 |         |
| d |                     | i |   |                   | c |                 | 1 |         |
| r |                     | n |   |                   | e |                 | 0 |         |
| e |                     | t |   |                   | m |                 |   |         |
| s |                     | a |   |                   | b |                 |   |         |
| s |                     | i |   |                   | e |                 |   |         |
| t |                     | n |   |                   | r |                 |   |         |
| h |                     | o |   |                   | 2 |                 |   |         |
| e |                     | r |   |                   | 0 |                 |   |         |
| n |                     | r |   |                   | 0 |                 |   |         |
| u |                     | e |   |                   | 6 |                 |   |         |
| m |                     | d |   |                   |   |                 |   |         |
| b |                     | u |   |                   | F |                 |   |         |
| e |                     | c |   |                   | Y |                 |   |         |
| r |                     | e |   |                   | 0 |                 |   |         |
| o |                     | F |   |                   | 2 |                 |   |         |
| f |                     | Y |   |                   | : |                 |   |         |
| u |                     | 0 |   |                   | A |                 |   |         |
| n |                     | 4 |   |                   | v |                 |   |         |
| i |                     |   |   |                   | a |                 |   |         |
| n |                     | F |   |                   | i |                 |   |         |
| t |                     | Y |   |                   | l |                 |   |         |
| e |                     | 0 |   |                   | a |                 |   |         |
| n |                     | 4 |   |                   | b |                 |   |         |
| t |                     | : |   |                   | l |                 |   |         |
| i |                     | m |   |                   | e |                 |   |         |
| o |                     | a |   |                   | D |                 |   |         |
| n |                     | i |   |                   | e |                 |   |         |
| a |                     | n |   |                   | c |                 |   |         |
| l |                     | t |   |                   | e |                 |   |         |
| i |                     | a |   |                   | m |                 |   |         |
| n |                     | i |   |                   | b |                 |   |         |
| j |                     | n |   |                   | e |                 |   |         |
| u |                     | o |   |                   | r |                 |   |         |
| r |                     | r |   |                   | 2 |                 |   |         |
| i |                     | r |   |                   | 0 |                 |   |         |
| e |                     | e |   |                   | 0 |                 |   |         |
| s |                     | d |   |                   | 5 |                 |   |         |
| f |                     | u |   |                   |   |                 |   |         |
| o |                     | c |   |                   | F |                 |   |         |
| r |                     | e |   |                   | Y |                 |   |         |
| A |                     | F |   |                   | 0 |                 |   |         |
| I |                     | Y |   |                   | 1 |                 |   |         |
| / |                     | 0 |   |                   | : |                 |   |         |
| A |                     | 3 |   |                   | A |                 |   |         |
| N |                     |   |   |                   | v |                 |   |         |
| p |                     | F |   |                   | a |                 |   |         |
| e |                     | Y |   |                   | i |                 |   |         |
| o |                     | 0 |   |                   | l |                 |   |         |
| p |                     | 3 |   |                   | a |                 |   |         |
| l |                     | : |   |                   | b |                 |   |         |
| e |                     | m |   |                   | l |                 |   |         |
| . |                     | a |   |                   | e |                 |   |         |
| \ |                     | i |   |                   | F |                 |   |         |
| [ |                     | n |   |                   | e |                 |   |         |
| o |                     | t |   |                   | b |                 |   |         |
| u |                     | a |   |                   | r |                 |   |         |
| t |                     | i |   |                   | u |                 |   |         |
| c |                     | n |   |                   | a |                 |   |         |
| o |                     | o |   |                   | r |                 |   |         |
| m |                     | r |   |                   | y |                 |   |         |
| e |                     | r |   |                   | 2 |                 |   |         |
| \ |                     | e |   |                   | 0 |                 |   |         |
| ] |                     | d |   |                   | 0 |                 |   |         |
|   |                     | u |   |                   | 4 |                 |   |         |
| f |                     | c |   |                   |   |                 |   |         |
| u |                     | e |   |                   | F |                 |   |         |
| l |                     | F |   |                   | Y |                 |   |         |
| l |                     | Y |   |                   | 0 |                 |   |         |
| c |                     | 0 |   |                   | 0 |                 |   |         |
| o |                     | 2 |   |                   | : |                 |   |         |
| s |                     | r |   |                   | A |                 |   |         |
| t |                     | a |   |                   | v |                 |   |         |
| ( |                     | t |   |                   | a |                 |   |         |
| s |                     | e |   |                   | i |                 |   |         |
| e |                     |   |   |                   | l |                 |   |         |
| e |                     | F |   |                   | a |                 |   |         |
| \ |                     | Y |   |                   | b |                 |   |         |
| # |                     | 0 |   |                   | l |                 |   |         |
| 2 |                     | 2 |   |                   | e |                 |   |         |
| 6 |                     | : |   |                   | F |                 |   |         |
| ) |                     | a |   |                   | e |                 |   |         |
|   |                     | t |   |                   | b |                 |   |         |
|   |                     | F |   |                   | r |                 |   |         |
|   |                     | Y |   |                   | u |                 |   |         |
|   |                     | 0 |   |                   | a |                 |   |         |
|   |                     | 1 |   |                   | r |                 |   |         |
|   |                     | r |   |                   | y |                 |   |         |
|   |                     | a |   |                   | 2 |                 |   |         |
|   |                     | t |   |                   | 0 |                 |   |         |
|   |                     | e |   |                   | 0 |                 |   |         |
|   |                     | , |   |                   | 4 |                 |   |         |
|   |                     | o |   |                   |   |                 |   |         |
|   |                     | r |   |                   | F |                 |   |         |
|   |                     | l |   |                   | Y |                 |   |         |
|   |                     | e |   |                   | 9 |                 |   |         |
|   |                     | s |   |                   | 9 |                 |   |         |
|   |                     | s |   |                   | : |                 |   |         |
|   |                     |   |   |                   | 9 |                 |   |         |
|   |                     | F |   |                   | 5 |                 |   |         |
|   |                     | Y |   |                   | . |                 |   |         |
|   |                     | 0 |   |                   | 5 |                 |   |         |
|   |                     | 1 |   |                   | / |                 |   |         |
|   |                     | : |   |                   | 1 |                 |   |         |
|   |                     | n |   |                   | 0 |                 |   |         |
|   |                     | o |   |                   | 0 |                 |   |         |
|   |                     | i |   |                   | , |                 |   |         |
|   |                     | n |   |                   | 0 |                 |   |         |
|   |                     | d |   |                   | 0 |                 |   |         |
|   |                     | i |   |                   | 0 |                 |   |         |
|   |                     | c |   |                   |   |                 |   |         |
|   |                     | a |   |                   | F |                 |   |         |
|   |                     | t |   |                   | Y |                 |   |         |
|   |                     | o |   |                   | 9 |                 |   |         |
|   |                     | r |   |                   | 6 |                 |   |         |
|   |                     |   |   |                   | - |                 |   |         |
|   |                     | F |   |                   | 9 |                 |   |         |
|   |                     | Y |   |                   | 8 |                 |   |         |
|   |                     | 0 |   |                   | : |                 |   |         |
|   |                     | 0 |   |                   | 9 |                 |   |         |
|   |                     | : |   |                   | 4 |                 |   |         |
|   |                     | n |   |                   | . |                 |   |         |
|   |                     | o |   |                   | 7 |                 |   |         |
|   |                     | i |   |                   | / |                 |   |         |
|   |                     | n |   |                   | 1 |                 |   |         |
|   |                     | d |   |                   | 0 |                 |   |         |
|   |                     | i |   |                   | 0 |                 |   |         |
|   |                     | c |   |                   | , |                 |   |         |
|   |                     | a |   |                   | 0 |                 |   |         |
|   |                     | t |   |                   | 0 |                 |   |         |
|   |                     | o |   |                   | 0 |                 |   |         |
|   |                     | r |   |                   | d |                 |   |         |
|   |                     |   |   |                   | e |                 |   |         |
|   |                     | F |   |                   | a |                 |   |         |
|   |                     | Y |   |                   | t |                 |   |         |
|   |                     | 9 |   |                   | h |                 |   |         |
|   |                     | 9 |   |                   | s |                 |   |         |
|   |                     | : |   |                   |   |                 |   |         |
|   |                     | 9 |   |                   | F |                 |   |         |
|   |                     | 3 |   |                   | Y |                 |   |         |
|   |                     | / |   |                   | 9 |                 |   |         |
|   |                     | 1 |   |                   | 4 |                 |   |         |
|   |                     | 0 |   |                   | - |                 |   |         |
|   |                     | 0 |   |                   | 9 |                 |   |         |
|   |                     | , |   |                   | 6 |                 |   |         |
|   |                     | 0 |   |                   | : |                 |   |         |
|   |                     | 0 |   |                   | 9 |                 |   |         |
|   |                     | 0 |   |                   | 2 |                 |   |         |
|   |                     | ( |   |                   | . |                 |   |         |
|   |                     | I |   |                   | 6 |                 |   |         |
|   |                     | C |   |                   | / |                 |   |         |
|   |                     | D |   |                   | 1 |                 |   |         |
|   |                     | - |   |                   | 0 |                 |   |         |
|   |                     | 9 |   |                   | 0 |                 |   |         |
|   |                     | ) |   |                   | , |                 |   |         |
|   |                     | \ |   |                   | 0 |                 |   |         |
|   |                     | 9 |   |                   | 0 |                 |   |         |
|   |                     | 5 |   |                   | 0 |                 |   |         |
|   |                     | . |   |                   | d |                 |   |         |
|   |                     | 8 |   |                   | e |                 |   |         |
|   |                     | 4 |   |                   | a |                 |   |         |
|   |                     | / |   |                   | t |                 |   |         |
|   |                     | 1 |   |                   | h |                 |   |         |
|   |                     | 0 |   |                   | s |                 |   |         |
|   |                     | 0 |   |                   |   |                 |   |         |
|   |                     | , |   |                   | F |                 |   |         |
|   |                     | 0 |   |                   | Y |                 |   |         |
|   |                     | 0 |   |                   | 9 |                 |   |         |
|   |                     | 0 |   |                   | 2 |                 |   |         |
|   |                     | ( |   |                   | - |                 |   |         |
|   |                     | I |   |                   | 9 |                 |   |         |
|   |                     | C |   |                   | 4 |                 |   |         |
|   |                     | D |   |                   | : |                 |   |         |
|   |                     | - |   |                   | 9 |                 |   |         |
|   |                     | 1 |   |                   | 5 |                 |   |         |
|   |                     | 0 |   |                   | . |                 |   |         |
|   |                     | ) |   |                   | 0 |                 |   |         |
|   |                     |   |   |                   | / |                 |   |         |
|   |                     | [ |   |                   | 1 |                 |   |         |
|   |                     | H |   |                   | 0 |                 |   |         |
|   |                     | o |   |                   | 0 |                 |   |         |
|   |                     | s |   |                   | , |                 |   |         |
|   |                     | p |   |                   | 0 |                 |   |         |
|   |                     | i |   |                   | 0 |                 |   |         |
|   |                     | t |   |                   | 0 |                 |   |         |
|   |                     | a |   |                   | d |                 |   |         |
|   |                     | l |   |                   | e |                 |   |         |
|   |                     | i |   |                   | a |                 |   |         |
|   |                     | z |   |                   | t |                 |   |         |
|   |                     | a |   |                   | h |                 |   |         |
|   |                     | t |   |                   | s |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | o |   |                   | F |                 |   |         |
|   |                     | n |   |                   | Y |                 |   |         |
|   |                     | s |   |                   | 0 |                 |   |         |
|   |                     | ] |   |                   | 1 |                 |   |         |
|   |                     | { |   |                   | : |                 |   |         |
|   |                     | . |   |                   | d |                 |   |         |
|   |                     | u |   |                   | a |                 |   |         |
|   |                     | n |   |                   | t |                 |   |         |
|   |                     | d |   |                   | a |                 |   |         |
|   |                     | e |   |                   | n |                 |   |         |
|   |                     | r |   |                   | o |                 |   |         |
|   |                     | l |   |                   | t |                 |   |         |
|   |                     | i |   |                   | a |                 |   |         |
|   |                     | n |   |                   | v |                 |   |         |
|   |                     | e |   |                   | a |                 |   |         |
|   |                     | } |   |                   | i |                 |   |         |
|   |                     |   |   |                   | l |                 |   |         |
|   |                     | F |   |                   | a |                 |   |         |
|   |                     | Y |   |                   | b |                 |   |         |
|   |                     | 0 |   |                   | l |                 |   |         |
|   |                     | 1 |   |                   | e |                 |   |         |
|   |                     | : |   |                   |   |                 |   |         |
|   |                     | 7 |   |                   | F |                 |   |         |
|   |                     | 0 |   |                   | Y |                 |   |         |
|   |                     | p |   |                   | 0 |                 |   |         |
|   |                     | e |   |                   | 0 |                 |   |         |
|   |                     | r |   |                   | : |                 |   |         |
|   |                     | 1 |   |                   | d |                 |   |         |
|   |                     | 0 |   |                   | a |                 |   |         |
|   |                     | , |   |                   | t |                 |   |         |
|   |                     | 0 |   |                   | a |                 |   |         |
|   |                     | 0 |   |                   | n |                 |   |         |
|   |                     | 0 |   |                   | o |                 |   |         |
|   |                     |   |   |                   | t |                 |   |         |
|   |                     | F |   |                   | a |                 |   |         |
|   |                     | Y |   |                   | v |                 |   |         |
|   |                     | 0 |   |                   | a |                 |   |         |
|   |                     | 0 |   |                   | i |                 |   |         |
|   |                     | : |   |                   | l |                 |   |         |
|   |                     | 7 |   |                   | a |                 |   |         |
|   |                     | 1 |   |                   | b |                 |   |         |
|   |                     | . |   |                   | l |                 |   |         |
|   |                     | 5 |   |                   | e |                 |   |         |
|   |                     | p |   |                   |   |                 |   |         |
|   |                     | e |   |                   | F |                 |   |         |
|   |                     | r |   |                   | Y |                 |   |         |
|   |                     | 1 |   |                   | 9 |                 |   |         |
|   |                     | 0 |   |                   | 8 |                 |   |         |
|   |                     | , |   |                   | : |                 |   |         |
|   |                     | 0 |   |                   | 7 |                 |   |         |
|   |                     | 0 |   |                   | 2 |                 |   |         |
|   |                     | 0 |   |                   | . |                 |   |         |
|   |                     |   |   |                   | 5 |                 |   |         |
|   |                     |   |   |                   | / |                 |   |         |
|   |                     |   |   |                   | 1 |                 |   |         |
|   |                     |   |   |                   | 0 |                 |   |         |
|   |                     |   |   |                   | , |                 |   |         |
|   |                     |   |   |                   | 0 |                 |   |         |
|   |                     |   |   |                   | 0 |                 |   |         |
|   |                     |   |   |                   | 0 |                 |   |         |
|   |                     |   |   |                   | h |                 |   |         |
|   |                     |   |   |                   | o |                 |   |         |
|   |                     |   |   |                   | s |                 |   |         |
|   |                     |   |   |                   | p |                 |   |         |
|   |                     |   |   |                   | . |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   |                   | F |                 |   |         |
|   |                     |   |   |                   | Y |                 |   |         |
|   |                     |   |   |                   | 9 |                 |   |         |
|   |                     |   |   |                   | 6 |                 |   |         |
|   |                     |   |   |                   | : |                 |   |         |
|   |                     |   |   |                   | 7 |                 |   |         |
|   |                     |   |   |                   | 4 |                 |   |         |
|   |                     |   |   |                   | . |                 |   |         |
|   |                     |   |   |                   | 7 |                 |   |         |
|   |                     |   |   |                   | / |                 |   |         |
|   |                     |   |   |                   | 1 |                 |   |         |
|   |                     |   |   |                   | 0 |                 |   |         |
|   |                     |   |   |                   | , |                 |   |         |
|   |                     |   |   |                   | 0 |                 |   |         |
|   |                     |   |   |                   | 0 |                 |   |         |
|   |                     |   |   |                   | 0 |                 |   |         |
|   |                     |   |   |                   | h |                 |   |         |
|   |                     |   |   |                   | o |                 |   |         |
|   |                     |   |   |                   | s |                 |   |         |
|   |                     |   |   |                   | p |                 |   |         |
|   |                     |   |   |                   | . |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
| # |                     |   |   |                   |   |                 |   |         |
| # |                     |   |   |                   |   |                 |   |         |
| # |                     |   |   |                   |   |                 |   |         |
| # |                     |   |   |                   |   |                 |   |         |
| # |                     |   |   |                   |   |                 |   |         |
| # |                     |   |   |                   |   |                 |   |         |
| # |                     |   |   |                   |   |                 |   |         |
| # |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
| S |                     |   |   |                   |   |                 |   |         |
| u |                     |   |   |                   |   |                 |   |         |
| i |                     |   |   |                   |   |                 |   |         |
| c |                     |   |   |                   |   |                 |   |         |
| i |                     |   |   |                   |   |                 |   |         |
| d |                     |   |   |                   |   |                 |   |         |
| e |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
| P |                     |   |   |                   |   |                 |   |         |
| r |                     |   |   |                   |   |                 |   |         |
| e |                     |   |   |                   |   |                 |   |         |
| v |                     |   |   |                   |   |                 |   |         |
| e |                     |   |   |                   |   |                 |   |         |
| n |                     |   |   |                   |   |                 |   |         |
| t |                     |   |   |                   |   |                 |   |         |
| i |                     |   |   |                   |   |                 |   |         |
| o |                     |   |   |                   |   |                 |   |         |
| n |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
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| n |                     |   |   |                   |   |                 |   |         |
| d |                     |   |   |                   |   |                 |   |         |
| i |                     |   |   |                   |   |                 |   |         |
| c |                     |   |   |                   |   |                 |   |         |
| a |                     |   |   |                   |   |                 |   |         |
| t |                     |   |   |                   |   |                 |   |         |
| o |                     |   |   |                   |   |                 |   |         |
| r |                     |   |   |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
| [ |                     | F |   |                   | F |                 | P |         |
| I |                     | Y |   |                   | Y |                 | : |         |
| n |                     | 0 |   |                   | 0 |                 | p |         |
| d |                     | 5 |   |                   | 5 |                 | . |         |
| i |                     | : |   |                   | : |                 | 3 |         |
| c |                     | e |   |                   |   |                 | - |         |
| a |                     | s |   |                   | F |                 | 5 |         |
| t |                     | t |   |                   | Y |                 | 2 |         |
| o |                     | a |   |                   | 0 |                 |   |         |
| r |                     | b |   |                   | 4 |                 | B |         |
| 2 |                     | l |   |                   | : |                 | : |         |
| 8 |                     | i |   |                   |   |                 | p |         |
| ] |                     | s |   |                   | F |                 | . |         |
| { |                     | h |   |                   | Y |                 | I |         |
| . |                     | b |   |                   | 0 |                 | H |         |
| u |                     | a |   |                   | 3 |                 | S |         |
| n |                     | s |   |                   | : |                 | - |         |
| d |                     | e |   |                   | i |                 | 4 |         |
| e |                     | l |   |                   | n |                 | 1 |         |
| r |                     | i |   |                   | c |                 |   |         |
| l |                     | n |   |                   | r |                 | P |         |
| i |                     | e |   |                   | e |                 | . |         |
| n |                     | d |   |                   | a |                 | I |         |
| e |                     | a |   |                   | s |                 | H |         |
| } |                     | t |   |                   | e |                 | S |         |
| : |                     | a |   |                   | d |                 | - |         |
|   |                     |   |   |                   | b |                 | 4 |         |
| S |                     | F |   |                   | y |                 | 9 |         |
| u |                     | Y |   |                   | 3 |                 |   |         |
| p |                     | 0 |   |                   | 0 |                 | 3 |         |
| p |                     | 4 |   |                   | % |                 | , |         |
| o |                     | : |   |                   |   |                 | 5 |         |
| r |                     | i |   |                   | F |                 |   |         |
| t |                     | m |   |                   | Y |                 | H |         |
| s |                     | p |   |                   | 0 |                 | P |         |
| u |                     | l |   |                   | 2 |                 | 2 |         |
| i |                     | e |   |                   | : |                 | 0 |         |
| c |                     | m |   |                   | 2 |                 | 1 |         |
| i |                     | e |   |                   | 2 |                 | 0 |         |
| d |                     | n |   |                   | % |                 |   |         |
| e |                     | t |   |                   | o |                 |   |         |
| p |                     | n |   |                   | f |                 |   |         |
| r |                     | a |   |                   | I |                 |   |         |
| e |                     | t |   |                   | / |                 |   |         |
| v |                     | i |   |                   | T |                 |   |         |
| e |                     | o |   |                   | / |                 |   |         |
| n |                     | n |   |                   | U |                 |   |         |
| t |                     | a |   |                   | s |                 |   |         |
| i |                     | l |   |                   | i |                 |   |         |
| o |                     | r |   |                   | m |                 |   |         |
| n |                     | e |   |                   | p |                 |   |         |
| p |                     | p |   |                   | l |                 |   |         |
| r |                     | o |   |                   | e |                 |   |         |
| o |                     | r |   |                   | m |                 |   |         |
| g |                     | t |   |                   | . |                 |   |         |
| r |                     | i |   |                   | ( |                 |   |         |
| a |                     | n |   |                   | + |                 |   |         |
| m |                     | g |   |                   | 1 |                 |   |         |
| s |                     | p |   |                   | 0 |                 |   |         |
| . |                     | l |   |                   | % |                 |   |         |
|   |                     | a |   |                   | o |                 |   |         |
| f |                     | n |   |                   | v |                 |   |         |
| u |                     |   |   |                   | e |                 |   |         |
| l |                     | F |   |                   | r |                 |   |         |
| l |                     | Y |   |                   | F |                 |   |         |
| c |                     | 0 |   |                   | Y |                 |   |         |
| o |                     | 3 |   |                   | 0 |                 |   |         |
| s |                     | : |   |                   | 1 |                 |   |         |
| t |                     |   |   |                   | ) |                 |   |         |
|   |                     | + |   |                   |   |                 |   |         |
| F |                     | 5 |   |                   | F |                 |   |         |
| Y |                     | % |   |                   | Y |                 |   |         |
| 0 |                     | o |   |                   | 0 |                 |   |         |
| 5 |                     | v |   |                   | 1 |                 |   |         |
| : |                     | e |   |                   | : |                 |   |         |
| 2 |                     | r |   |                   | 1 |                 |   |         |
| 8 |                     | F |   |                   | 2 |                 |   |         |
| . |                     | Y |   |                   | % |                 |   |         |
| 0 |                     | 0 |   |                   | o |                 |   |         |
| M |                     | 2 |   |                   | f |                 |   |         |
|   |                     | l |   |                   | I |                 |   |         |
| F |                     | e |   |                   | / |                 |   |         |
| Y |                     | v |   |                   | T |                 |   |         |
| 0 |                     | e |   |                   | / |                 |   |         |
| 4 |                     | l |   |                   | U |                 |   |         |
| : |                     |   |   |                   | s |                 |   |         |
| 2 |                     | F |   |                   | i |                 |   |         |
| 6 |                     | Y |   |                   | m |                 |   |         |
| . |                     | 0 |   |                   | p |                 |   |         |
| 0 |                     | 2 |   |                   | l |                 |   |         |
| M |                     | : |   |                   | e |                 |   |         |
|   |                     |   |   |                   | m |                 |   |         |
| F |                     | + |   |                   | . |                 |   |         |
| Y |                     | 1 |   |                   |   |                 |   |         |
| 0 |                     | 0 |   |                   | F |                 |   |         |
| 3 |                     | % |   |                   | Y |                 |   |         |
| : |                     | o |   |                   | 0 |                 |   |         |
| 2 |                     | v |   |                   | 0 |                 |   |         |
| 4 |                     | e |   |                   | : |                 |   |         |
| . |                     | r |   |                   |   |                 |   |         |
| 0 |                     | F |   |                   | F |                 |   |         |
| M |                     | Y |   |                   | Y |                 |   |         |
|   |                     | 0 |   |                   | 9 |                 |   |         |
|   |                     | 1 |   |                   | 9 |                 |   |         |
|   |                     | l |   |                   | : |                 |   |         |
|   |                     | e |   |                   |   |                 |   |         |
|   |                     | v |   |                   | F |                 |   |         |
|   |                     | e |   |                   | Y |                 |   |         |
|   |                     | l |   |                   | 9 |                 |   |         |
|   |                     |   |   |                   | 8 |                 |   |         |
|   |                     | F |   |                   | : |                 |   |         |
|   |                     | Y |   |                   | e |                 |   |         |
|   |                     | 0 |   |                   | s |                 |   |         |
|   |                     | 1 |   |                   | t |                 |   |         |
|   |                     | : |   |                   | i |                 |   |         |
|   |                     | 5 |   |                   | m |                 |   |         |
|   |                     | 0 |   |                   | a |                 |   |         |
|   |                     | % |   |                   | t |                 |   |         |
|   |                     | o |   |                   | e |                 |   |         |
|   |                     | f |   |                   | d |                 |   |         |
|   |                     | I |   |                   | 2 |                 |   |         |
|   |                     | / |   |                   | 5 |                 |   |         |
|   |                     | T |   |                   | % |                 |   |         |
|   |                     | / |   |                   |   |                 |   |         |
|   |                     | U |   |                   |   |                 |   |         |
|   |                     | s |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | m |   |                   |   |                 |   |         |
|   |                     | p |   |                   |   |                 |   |         |
|   |                     | l |   |                   |   |                 |   |         |
|   |                     | e |   |                   |   |                 |   |         |
|   |                     | m |   |                   |   |                 |   |         |
|   |                     | . |   |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     | F |   |                   |   |                 |   |         |
|   |                     | Y |   |                   |   |                 |   |         |
|   |                     | 0 |   |                   |   |                 |   |         |
|   |                     | 0 |   |                   |   |                 |   |         |
|   |                     | : |   |                   |   |                 |   |         |
|   |                     | n |   |                   |   |                 |   |         |
|   |                     | o |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | n |   |                   |   |                 |   |         |
|   |                     | d |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | c |   |                   |   |                 |   |         |
|   |                     | a |   |                   |   |                 |   |         |
|   |                     | t |   |                   |   |                 |   |         |
|   |                     | o |   |                   |   |                 |   |         |
|   |                     | r |   |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     | F |   |                   |   |                 |   |         |
|   |                     | Y |   |                   |   |                 |   |         |
|   |                     | 9 |   |                   |   |                 |   |         |
|   |                     | 9 |   |                   |   |                 |   |         |
|   |                     | : |   |                   |   |                 |   |         |
|   |                     | n |   |                   |   |                 |   |         |
|   |                     | o |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | n |   |                   |   |                 |   |         |
|   |                     | d |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | c |   |                   |   |                 |   |         |
|   |                     | a |   |                   |   |                 |   |         |
|   |                     | t |   |                   |   |                 |   |         |
|   |                     | o |   |                   |   |                 |   |         |
|   |                     | r |   |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | ########            |   |   |                   |   |                 |   |         |
|   | Developmental Preve |   |   |                   |   |                 |   |         |
|   | ntion and Treatment |   |   |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | **[Indicator        |   |   | FY 05: baseline   |   | FY 05:          |   | P: p.   |
|   | 29:]{.underline}**  |   |   | number of         |   |                 |   | 3-53    |
|   | Support clinical    |   |   | eligible patients |   | FY 04:          |   |         |
|   | and community-based |   |   | screened for      |   |                 |   | B: p.   |
|   | cardiovascular      |   |   | lipids            |   | FY 03: 4 sites  |   | IHS-79  |
|   | disease prevention  |   |   |                   |   | implementing    |   |         |
|   | initiatives.        |   |   | FY 04: Evaluation |   |                 |   | p\.     |
|   |                     |   |   | implemented and 1 |   | Intervention    |   | IHS-29  |
|   | \[outcome\]         |   |   | site added        |   | plans           |   |         |
|   |                     |   |   |                   |   |                 |   | 1, 3    |
|   | full cost ( #29-30) |   |   | FY 03: Evaluation |   | FY 02: 3 sites  |   |         |
|   |                     |   |   | implemented and 1 |   | implemented     |   | HP 2010 |
|   | FY 05: 12.5 M       |   |   | site added        |   | intervention    |   |         |
|   |                     |   |   |                   |   | plans           |   |         |
|   | FY 04:2.7 M         |   |   | FY 02: 3 sites    |   |                 |   |         |
|   |                     |   |   | implementing      |   | FY 01: 3 sites  |   |         |
|   | FY03:1.5 M          |   |   | interventions     |   | with            |   |         |
|   |                     |   |   |                   |   | intervention    |   |         |
|   |                     |   |   | FY 01: 3 sites    |   | plans           |   |         |
|   |                     |   |   | with intervention |   |                 |   |         |
|   |                     |   |   | plans             |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 00: no         |   |                 |   |         |
|   |                     |   |   | indicator         |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   |   | FY 99: no         |   |                 |   |         |
|   |                     |   |   | indicator         |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | [Indicator          |   | [ |                   |   | FY 05:          |   | P: p.   |
|   | 30]{.underline}:    |   | B |                   |   |                 |   | 3-54    |
|   | Support clinical    |   | M |                   |   | FY 04:          |   |         |
|   | and community-based |   | I |                   |   |                 |   | B: p.   |
|   | obesity prevention  |   | m |                   |   | FY 03: 3        |   | IHS-29  |
|   | initiatives.        |   | e |                   |   | element obesity |   |         |
|   | \[outcome\]         |   | a |                   |   | prevention      |   | 1, 3    |
|   |                     |   | s |                   |   | /treatment plan |   |         |
|   | full cost ( see \#  |   | u |                   |   | implemented     |   | \*      |
|   | 29)                 |   | r |                   |   |                 |   | in      |
|   |                     |   | e |                   |   | FY 02: 3        |   | dicates |
|   |                     |   | d |                   |   | element obesity |   | revised |
|   |                     |   | ] |                   |   | prevent/        |   | FY 2004 |
|   |                     |   | { |                   |   | treatment plan  |   | m       |
|   |                     |   | . |                   |   | developed       |   | easure. |
|   |                     |   | u |                   |   |                 |   | See     |
|   |                     |   | n |                   |   | FY 01:          |   | Summary |
|   |                     |   | d |                   |   | implementation  |   | of      |
|   |                     |   | e |                   |   | and monitoring  |   | Changes |
|   |                     |   | r |                   |   | commenced at    |   | Table   |
|   |                     |   | l |                   |   | sites           |   | HP      |
|   |                     |   | i |                   |   |                 |   | 201010  |
|   |                     |   | n |                   |   | FY 00: pilot    |   | on page |
|   |                     |   | e |                   |   | sites           |   | 5-1     |
|   |                     |   | } |                   |   | established     |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   | FY 99: approach |   |         |
|   |                     |   | Y |                   |   | and baseline    |   |         |
|   |                     |   | 0 |                   |   | accomplished    |   |         |
|   |                     |   | 5 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | % |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | f |                   |   |                 |   |         |
|   |                     |   | p |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | w |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | h |                   |   |                 |   |         |
|   |                     |   | B |                   |   |                 |   |         |
|   |                     |   | M |                   |   |                 |   |         |
|   |                     |   | I |                   |   |                 |   |         |
|   |                     |   | m |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
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|   |                     |   | r |                   |   |                 |   |         |
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|   |                     |   | d |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | 4 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
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|   |                     |   | B |                   |   |                 |   |         |
|   |                     |   | M |                   |   |                 |   |         |
|   |                     |   | I |                   |   |                 |   |         |
|   |                     |   | m |                   |   |                 |   |         |
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|   |                     |   | d |                   |   |                 |   |         |
|   |                     |   | \ |                   |   |                 |   |         |
|   |                     |   | * |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
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|   |                     |   | D |                   |   |                 |   |         |
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|   |                     |   | Y |                   |   |                 |   |         |
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|   |                     |   | h |                   |   |                 |   |         |
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|   |                     |   | b |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | l |                   |   |                 |   |         |
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+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
| [ |                     |   | [ |                   |   | Y 05:           |   | P: p.   |
| I |                     |   | D |                   |   |                 |   | 3-55    |
| n |                     |   | e |                   |   | FY 04:          |   |         |
| d |                     |   | t |                   |   |                 |   | B: p.   |
| i |                     |   | e |                   |   | FY 03: 5 year   |   | IHS-29  |
| c |                     |   | r |                   |   | tobacco control |   |         |
| a |                     |   | m |                   |   | plan for IHS    |   | 1, 3    |
| t |                     |   | i |                   |   | developed       |   |         |
| o |                     |   | n |                   |   |                 |   | \*      |
| r |                     |   | e |                   |   | FY 02: commence |   | in      |
| 3 |                     |   | S |                   |   | all prescribed  |   | dicates |
| 1 |                     |   | c |                   |   | control         |   | revised |
| : |                     |   | r |                   |   | activities in 5 |   | FY 2004 |
| ] |                     |   | e |                   |   | sites           |   | m       |
| { |                     |   | e |                   |   |                 |   | easure. |
| . |                     |   | n |                   |   | FY 01: 7        |   | See     |
| u |                     |   | i |                   |   | tobacco control |   | Summary |
| n |                     |   | n |                   |   | centers         |   | of      |
| d |                     |   | g |                   |   | established     |   | Changes |
| e |                     |   | R |                   |   |                 |   | Table 0 |
| r |                     |   | a |                   |   | FY 00: baseline |   | on page |
| l |                     |   | t |                   |   | rates           |   | 5-1     |
| i |                     |   | e |                   |   | established     |   |         |
| n |                     |   | s |                   |   |                 |   | HP 2010 |
| e |                     |   | ] |                   |   |                 |   |         |
| } |                     |   | { |                   |   |                 |   |         |
| S |                     |   | . |                   |   |                 |   |         |
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|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | f |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | I |                   |   |                 |   |         |
|   |                     |   | H |                   |   |                 |   |         |
|   |                     |   | S |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | 2 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | m |                   |   |                 |   |         |
|   |                     |   | m |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | l |                   |   |                 |   |         |
|   |                     |   | l |                   |   |                 |   |         |
|   |                     |   | p |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | b |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | d |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | l |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | v |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | 5 |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | 1 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | b |                   |   |                 |   |         |
|   |                     |   | l |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | h |                   |   |                 |   |         |
|   |                     |   | 5 |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | b |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | l |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | b |                   |   |                 |   |         |
|   |                     |   | l |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | h |                   |   |                 |   |         |
|   |                     |   | b |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | l |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | f |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | b |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | u |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | g |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 9 |                   |   |                 |   |         |
|   |                     |   | 9 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | d |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | ####                |   |   |                   |   |                 |   |         |
|   | #### HIV/AIDS Group |   |   |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
| [ |                     | F |   |                   | F |                 | P |         |
| I |                     | Y |   |                   | Y |                 | : |         |
| n |                     | 0 |   |                   | 0 |                 | p |         |
| d |                     | 5 |   |                   | 5 |                 | . |         |
| i |                     | ; |   |                   | : |                 | 3 |         |
| c |                     | b |   |                   |   |                 | - |         |
| a |                     | a |   |                   | F |                 | 5 |         |
| t |                     | s |   |                   | Y |                 | 6 |         |
| o |                     | e |   |                   | 0 |                 |   |         |
| r |                     | l |   |                   | 4 |                 | B |         |
| 3 |                     | i |   |                   | : |                 | : |         |
| 2 |                     | n |   |                   | n |                 | p |         |
| : |                     | e |   |                   | o |                 | . |         |
| ] |                     | s |   |                   | i |                 | I |         |
| { |                     | c |   |                   | n |                 | H |         |
| . |                     | r |   |                   | d |                 | S |         |
| u |                     | e |   |                   | i |                 | - |         |
| n |                     | e |   |                   | c |                 | 2 |         |
| d |                     | n |   |                   | a |                 | 9 |         |
| e |                     | i |   |                   | t |                 |   |         |
| r |                     | n |   |                   | o |                 | p |         |
| l |                     | g |   |                   | r |                 | \ |         |
| i |                     | o |   |                   |   |                 | . |         |
| n |                     | f |   |                   | F |                 | I |         |
| e |                     | p |   |                   | Y |                 | H |         |
| } |                     | r |   |                   | 0 |                 | S |         |
| \ |                     | e |   |                   | 3 |                 | - |         |
| R |                     | g |   |                   | : |                 | 5 |         |
| e |                     | n |   |                   | n |                 | 9 |         |
| d |                     | a |   |                   | o |                 |   |         |
| u |                     | n |   |                   | i |                 | H |         |
| c |                     | t |   |                   | n |                 | P |         |
| e |                     | w |   |                   | d |                 | 2 |         |
| t |                     | o |   |                   | i |                 | 0 |         |
| h |                     | m |   |                   | c |                 | 1 |         |
| e |                     | e |   |                   | a |                 | 0 |         |
| i |                     | n |   |                   | t |                 |   |         |
| n |                     | f |   |                   | o |                 |   |         |
| c |                     | o |   |                   | r |                 |   |         |
| i |                     | r |   |                   |   |                 |   |         |
| d |                     | H |   |                   | F |                 |   |         |
| e |                     | I |   |                   | Y |                 |   |         |
| n |                     | V |   |                   | 0 |                 |   |         |
| t |                     |   |   |                   | 2 |                 |   |         |
| o |                     | F |   |                   | : |                 |   |         |
| f |                     | Y |   |                   | 3 |                 |   |         |
| H |                     | 0 |   |                   | a |                 |   |         |
| I |                     | 4 |   |                   | r |                 |   |         |
| V |                     | : |   |                   | e |                 |   |         |
| i |                     | n |   |                   | a |                 |   |         |
| n |                     | o |   |                   | s |                 |   |         |
| A |                     | i |   |                   | a |                 |   |         |
| I |                     | n |   |                   | s |                 |   |         |
| / |                     | d |   |                   | s |                 |   |         |
| A |                     | i |   |                   | e |                 |   |         |
| N |                     | c |   |                   | s |                 |   |         |
| c |                     | a |   |                   | s |                 |   |         |
| o |                     | t |   |                   | e |                 |   |         |
| m |                     | o |   |                   | d |                 |   |         |
| m |                     | r |   |                   |   |                 |   |         |
| u |                     |   |   |                   | F |                 |   |         |
| n |                     | F |   |                   | Y |                 |   |         |
| i |                     | Y |   |                   | 0 |                 |   |         |
| t |                     | 0 |   |                   | 1 |                 |   |         |
| i |                     | 3 |   |                   | : |                 |   |         |
| e |                     | : |   |                   | A |                 |   |         |
| s |                     | n |   |                   | r |                 |   |         |
|   |                     | o |   |                   | e |                 |   |         |
| f |                     | i |   |                   | a |                 |   |         |
| u |                     | n |   |                   | b |                 |   |         |
| l |                     | d |   |                   | a |                 |   |         |
| l |                     | i |   |                   | s |                 |   |         |
| c |                     | c |   |                   | e |                 |   |         |
| o |                     | a |   |                   | l |                 |   |         |
| s |                     | t |   |                   | i |                 |   |         |
| t |                     | o |   |                   | n |                 |   |         |
| ( |                     | r |   |                   | e |                 |   |         |
| # |                     |   |   |                   | p |                 |   |         |
| 3 |                     | F |   |                   | a |                 |   |         |
| 2 |                     | Y |   |                   | r |                 |   |         |
| - |                     | 0 |   |                   | t |                 |   |         |
| 3 |                     | 2 |   |                   | i |                 |   |         |
| 3 |                     | : |   |                   | a |                 |   |         |
| ) |                     | 3 |   |                   | l |                 |   |         |
|   |                     | A |   |                   | l |                 |   |         |
| F |                     | r |   |                   | y |                 |   |         |
| Y |                     | e |   |                   | e |                 |   |         |
| 0 |                     | a |   |                   | s |                 |   |         |
| 5 |                     | s |   |                   | t |                 |   |         |
| : |                     | a |   |                   | a |                 |   |         |
| 3 |                     | s |   |                   | b |                 |   |         |
| . |                     | s |   |                   | l |                 |   |         |
| 6 |                     | e |   |                   | i |                 |   |         |
| M |                     | s |   |                   | s |                 |   |         |
|   |                     | s |   |                   | h |                 |   |         |
| F |                     | e |   |                   | e |                 |   |         |
| Y |                     | d |   |                   | d |                 |   |         |
| 0 |                     |   |   |                   |   |                 |   |         |
| 4 |                     | F |   |                   | F |                 |   |         |
| : |                     | Y |   |                   | Y |                 |   |         |
| 3 |                     | 0 |   |                   | 0 |                 |   |         |
| . |                     | 1 |   |                   | 0 |                 |   |         |
| 0 |                     | : |   |                   | : |                 |   |         |
| M |                     | o |   |                   | p |                 |   |         |
|   |                     | n |   |                   | a |                 |   |         |
| F |                     | e |   |                   | r |                 |   |         |
| Y |                     | A |   |                   | t |                 |   |         |
| 0 |                     | r |   |                   | i |                 |   |         |
| 3 |                     | e |   |                   | a |                 |   |         |
| : |                     | a |   |                   | l |                 |   |         |
| 3 |                     | a |   |                   | l |                 |   |         |
| . |                     | s |   |                   | y |                 |   |         |
| 0 |                     | s |   |                   | e |                 |   |         |
| M |                     | e |   |                   | s |                 |   |         |
|   |                     | s |   |                   | t |                 |   |         |
|   |                     | s |   |                   | a |                 |   |         |
|   |                     | e |   |                   | b |                 |   |         |
|   |                     | d |   |                   | l |                 |   |         |
|   |                     |   |   |                   | i |                 |   |         |
|   |                     | F |   |                   | s |                 |   |         |
|   |                     | Y |   |                   | h |                 |   |         |
|   |                     | 0 |   |                   | e |                 |   |         |
|   |                     | 0 |   |                   | d |                 |   |         |
|   |                     | : |   |                   |   |                 |   |         |
|   |                     | e |   |                   |   |                 |   |         |
|   |                     | s |   |                   |   |                 |   |         |
|   |                     | t |   |                   |   |                 |   |         |
|   |                     | a |   |                   |   |                 |   |         |
|   |                     | b |   |                   |   |                 |   |         |
|   |                     | l |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | s |   |                   |   |                 |   |         |
|   |                     | h |   |                   |   |                 |   |         |
|   |                     | b |   |                   |   |                 |   |         |
|   |                     | a |   |                   |   |                 |   |         |
|   |                     | s |   |                   |   |                 |   |         |
|   |                     | e |   |                   |   |                 |   |         |
|   |                     | l |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | n |   |                   |   |                 |   |         |
|   |                     | e |   |                   |   |                 |   |         |
|   |                     | r |   |                   |   |                 |   |         |
|   |                     | a |   |                   |   |                 |   |         |
|   |                     | t |   |                   |   |                 |   |         |
|   |                     | e |   |                   |   |                 |   |         |
|   |                     | s |   |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     | F |   |                   |   |                 |   |         |
|   |                     | Y |   |                   |   |                 |   |         |
|   |                     | 9 |   |                   |   |                 |   |         |
|   |                     | 9 |   |                   |   |                 |   |         |
|   |                     | : |   |                   |   |                 |   |         |
|   |                     | n |   |                   |   |                 |   |         |
|   |                     | o |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | n |   |                   |   |                 |   |         |
|   |                     | d |   |                   |   |                 |   |         |
|   |                     | i |   |                   |   |                 |   |         |
|   |                     | c |   |                   |   |                 |   |         |
|   |                     | a |   |                   |   |                 |   |         |
|   |                     | t |   |                   |   |                 |   |         |
|   |                     | o |   |                   |   |                 |   |         |
|   |                     | r |   |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | [Indicator          |   | F |                   |   | FY 04:          |   | P: p.   |
|   | 33:]{.underline}    |   | Y |                   |   |                 |   | 3-56    |
|   | Maintain the        |   | 0 |                   |   | FY 03: .1 %     |   |         |
|   | percentage of       |   | 5 |                   |   | over baseline   |   | B: p.   |
|   | high-risk sexually  |   | : |                   |   |                 |   | IHS-29  |
|   | active persons who  |   | n |                   |   | FY 02: baseline |   |         |
|   | know their HIV      |   | o |                   |   | in 3 areas      |   | p\.     |
|   | status and have     |   | i |                   |   |                 |   | IHS-59  |
|   | received risk       |   | n |                   |   | FY 01: baseline |   |         |
|   | reduction           |   | d |                   |   | for limited     |   | 1,HP    |
|   | counseling. \[      |   | i |                   |   | sites           |   | 2010 3  |
|   | outcome\]           |   | c |                   |   |                 |   |         |
|   |                     |   | a |                   |   | FY 00: no       |   |         |
|   | full cost ( see \#  |   | t |                   |   | baseline        |   |         |
|   | 32)                 |   | o |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | 4 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
|   |                     |   | + |                   |   |                 |   |         |
|   |                     |   | 1 |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | S |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | 3 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
|   |                     |   | + |                   |   |                 |   |         |
|   |                     |   | 5 |                   |   |                 |   |         |
|   |                     |   | % |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | v |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | 2 |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | 2 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | u |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | b |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | l |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | 3 |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | w |                   |   |                 |   |         |
|   |                     |   | A |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | 1 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
|   |                     |   | E |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | b |                   |   |                 |   |         |
|   |                     |   | l |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | h |                   |   |                 |   |         |
|   |                     |   | b |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | s |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   | l |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | e |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | 0 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | d |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
|   |                     |   |   |                   |   |                 |   |         |
|   |                     |   | F |                   |   |                 |   |         |
|   |                     |   | Y |                   |   |                 |   |         |
|   |                     |   | 9 |                   |   |                 |   |         |
|   |                     |   | 9 |                   |   |                 |   |         |
|   |                     |   | : |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | n |                   |   |                 |   |         |
|   |                     |   | d |                   |   |                 |   |         |
|   |                     |   | i |                   |   |                 |   |         |
|   |                     |   | c |                   |   |                 |   |         |
|   |                     |   | a |                   |   |                 |   |         |
|   |                     |   | t |                   |   |                 |   |         |
|   |                     |   | o |                   |   |                 |   |         |
|   |                     |   | r |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
|   | #######             |   |   |                   |   |                 |   |         |
|   | # Environmental Sur |   |   |                   |   |                 |   |         |
|   | veillance Indicator |   |   |                   |   |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
| I |                     | F |   |                   | F |                 | P |         |
| n |                     | Y |   |                   | Y |                 | : |         |
| d |                     | 0 |   |                   | 0 |                 | p |         |
| i |                     | 5 |   |                   | 4 |                 | . |         |
| c |                     | : |   |                   | : |                 | 3 |         |
| a |                     | + |   |                   |   |                 | - |         |
| t |                     | 1 |   |                   | F |                 | 5 |         |
| o |                     | 5 |   |                   | Y |                 | 7 |         |
| r |                     | % |   |                   | 0 |                 |   |         |
| 3 |                     | o |   |                   | 3 |                 | B |         |
| 4 |                     | v |   |                   | : |                 | : |         |
| : |                     | e |   |                   | + |                 | p |         |
| I |                     | r |   |                   | 1 |                 | . |         |
| m |                     | F |   |                   | 6 |                 | I |         |
| p |                     | Y |   |                   | % |                 | H |         |
| l |                     | 0 |   |                   | o |                 | F |         |
| e |                     | 4 |   |                   | v |                 | - |         |
| m |                     | l |   |                   | e |                 | 3 |         |
| e |                     | e |   |                   | r |                 | 7 |         |
| n |                     | v |   |                   | F |                 |   |         |
| t |                     | e |   |                   | Y |                 | 3 |         |
| a |                     | l |   |                   | 0 |                 | , |         |
| u |                     |   |   |                   | 2 |                 | 4 |         |
| t |                     | F |   |                   | l |                 |   |         |
| o |                     | Y |   |                   | e |                 |   |         |
| m |                     | 0 |   |                   | v |                 |   |         |
| a |                     | 4 |   |                   | e |                 |   |         |
| t |                     | : |   |                   | l |                 |   |         |
| e |                     | + |   |                   | ( |                 |   |         |
| d |                     | 1 |   |                   | f |                 |   |         |
| w |                     | 5 |   |                   | r |                 |   |         |
| e |                     | % |   |                   | o |                 |   |         |
| b |                     | o |   |                   | m |                 |   |         |
| - |                     | v |   |                   | 1 |                 |   |         |
| b |                     | e |   |                   | 9 |                 |   |         |
| a |                     | r |   |                   | t |                 |   |         |
| s |                     | F |   |                   | o |                 |   |         |
| e |                     | Y |   |                   | 2 |                 |   |         |
| d |                     | 0 |   |                   | 2 |                 |   |         |
| e |                     | 3 |   |                   | s |                 |   |         |
| n |                     | l |   |                   | i |                 |   |         |
| v |                     | e |   |                   | t |                 |   |         |
| i |                     | v |   |                   | e |                 |   |         |
| r |                     | e |   |                   | s |                 |   |         |
| o |                     | l |   |                   | ) |                 |   |         |
| n |                     |   |   |                   |   |                 |   |         |
| m |                     | F |   |                   | F |                 |   |         |
| e |                     | Y |   |                   | Y |                 |   |         |
| n |                     | 0 |   |                   | 0 |                 |   |         |
| t |                     | 3 |   |                   | 2 |                 |   |         |
| a |                     | : |   |                   | : |                 |   |         |
| l |                     | + |   |                   | i |                 |   |         |
| h |                     | 1 |   |                   | m |                 |   |         |
| e |                     | 5 |   |                   | p |                 |   |         |
| a |                     | % |   |                   | l |                 |   |         |
| l |                     | o |   |                   | e |                 |   |         |
| t |                     | v |   |                   | m |                 |   |         |
| h |                     | e |   |                   | e |                 |   |         |
| s |                     | r |   |                   | n |                 |   |         |
| u |                     | F |   |                   | t |                 |   |         |
| r |                     | Y |   |                   | e |                 |   |         |
| v |                     | 0 |   |                   | d |                 |   |         |
| e |                     | 2 |   |                   | i |                 |   |         |
| i |                     | l |   |                   | n |                 |   |         |
| l |                     | e |   |                   | 1 |                 |   |         |
| l |                     | v |   |                   | 9 |                 |   |         |
| a |                     | e |   |                   | m |                 |   |         |
| n |                     | l |   |                   | o |                 |   |         |
| c |                     |   |   |                   | r |                 |   |         |
| e |                     | F |   |                   | e |                 |   |         |
| d |                     | Y |   |                   | s |                 |   |         |
| a |                     | 0 |   |                   | i |                 |   |         |
| t |                     | 2 |   |                   | t |                 |   |         |
| a |                     | : |   |                   | e |                 |   |         |
| c |                     | i |   |                   | s |                 |   |         |
| o |                     | m |   |                   |   |                 |   |         |
| l |                     | p |   |                   | F |                 |   |         |
| l |                     | l |   |                   | Y |                 |   |         |
| e |                     | e |   |                   | 0 |                 |   |         |
| c |                     | m |   |                   | 1 |                 |   |         |
| t |                     | e |   |                   | : |                 |   |         |
| i |                     | n |   |                   | a |                 |   |         |
| o |                     | t |   |                   | u |                 |   |         |
| n |                     | i |   |                   | t |                 |   |         |
| s |                     | n |   |                   | o |                 |   |         |
| y |                     | a |   |                   | m |                 |   |         |
| s |                     | t |   |                   | a |                 |   |         |
| t |                     | l |   |                   | t |                 |   |         |
| e |                     | e |   |                   | e |                 |   |         |
| m |                     | a |   |                   | d |                 |   |         |
| i |                     | s |   |                   | s |                 |   |         |
| n |                     | t |   |                   | y |                 |   |         |
| t |                     | 1 |   |                   | s |                 |   |         |
| r |                     | 0 |   |                   | t |                 |   |         |
| i |                     | s |   |                   | e |                 |   |         |
| b |                     | i |   |                   | m |                 |   |         |
| a |                     | t |   |                   | d |                 |   |         |
| l |                     | e |   |                   | i |                 |   |         |
| s |                     | s |   |                   | s |                 |   |         |
| y |                     |   |   |                   | t |                 |   |         |
| s |                     | F |   |                   | r |                 |   |         |
| t |                     | Y |   |                   | i |                 |   |         |
| e |                     | 0 |   |                   | b |                 |   |         |
| m |                     | 1 |   |                   | u |                 |   |         |
| s |                     | : |   |                   | t |                 |   |         |
| . |                     | 1 |   |                   | e |                 |   |         |
|   |                     | 5 |   |                   | d |                 |   |         |
| f |                     | % |   |                   | t |                 |   |         |
| u |                     | o |   |                   | o |                 |   |         |
| l |                     | f |   |                   | a |                 |   |         |
| l |                     | c |   |                   | l |                 |   |         |
| c |                     | o |   |                   | l |                 |   |         |
| o |                     | m |   |                   | I |                 |   |         |
| s |                     | m |   |                   | H |                 |   |         |
| t |                     | u |   |                   | S |                 |   |         |
|   |                     | n |   |                   | f |                 |   |         |
| F |                     | i |   |                   | i |                 |   |         |
| Y |                     | t |   |                   | e |                 |   |         |
| 0 |                     | i |   |                   | l |                 |   |         |
| 5 |                     | e |   |                   | d |                 |   |         |
| : |                     | s |   |                   | s |                 |   |         |
| 0 |                     | a |   |                   | i |                 |   |         |
| . |                     | s |   |                   | t |                 |   |         |
| 3 |                     | s |   |                   | e |                 |   |         |
| M |                     | e |   |                   | s |                 |   |         |
|   |                     | s |   |                   |   |                 |   |         |
| F |                     | s |   |                   | F |                 |   |         |
| Y |                     | e |   |                   | Y |                 |   |         |
| 0 |                     | d |   |                   | 0 |                 |   |         |
| 4 |                     |   |   |                   | 0 |                 |   |         |
| : |                     | F |   |                   | : |                 |   |         |
| 0 |                     | Y |   |                   | p |                 |   |         |
| . |                     | 0 |   |                   | r |                 |   |         |
| 2 |                     | 0 |   |                   | o |                 |   |         |
| M |                     | : |   |                   | t |                 |   |         |
|   |                     | d |   |                   | o |                 |   |         |
| F |                     | e |   |                   | c |                 |   |         |
| Y |                     | v |   |                   | o |                 |   |         |
| 0 |                     | e |   |                   | l |                 |   |         |
| 3 |                     | l |   |                   | a |                 |   |         |
| : |                     | o |   |                   | n |                 |   |         |
| 0 |                     | p |   |                   | d |                 |   |         |
| . |                     | s |   |                   | p |                 |   |         |
| 2 |                     | u |   |                   | l |                 |   |         |
| M |                     | r |   |                   | a |                 |   |         |
|   |                     | v |   |                   | n |                 |   |         |
|   |                     | e |   |                   | p |                 |   |         |
|   |                     | i |   |                   | a |                 |   |         |
|   |                     | l |   |                   | r |                 |   |         |
|   |                     | l |   |                   | t |                 |   |         |
|   |                     | a |   |                   | i |                 |   |         |
|   |                     | n |   |                   | a |                 |   |         |
|   |                     | c |   |                   | l |                 |   |         |
|   |                     | e |   |                   | l |                 |   |         |
|   |                     | p |   |                   | y |                 |   |         |
|   |                     | r |   |                   | c |                 |   |         |
|   |                     | o |   |                   | o |                 |   |         |
|   |                     | t |   |                   | m |                 |   |         |
|   |                     | o |   |                   | p |                 |   |         |
|   |                     | c |   |                   | l |                 |   |         |
|   |                     | o |   |                   | e |                 |   |         |
|   |                     | l |   |                   | t |                 |   |         |
|   |                     | a |   |                   | e |                 |   |         |
|   |                     | n |   |                   | d |                 |   |         |
|   |                     | d |   |                   |   |                 |   |         |
|   |                     | p |   |                   | F |                 |   |         |
|   |                     | l |   |                   | Y |                 |   |         |
|   |                     | a |   |                   | 9 |                 |   |         |
|   |                     | n |   |                   | 9 |                 |   |         |
|   |                     |   |   |                   | : |                 |   |         |
|   |                     | F |   |                   | n |                 |   |         |
|   |                     | Y |   |                   | o |                 |   |         |
|   |                     | 9 |   |                   | s |                 |   |         |
|   |                     | 9 |   |                   | u |                 |   |         |
|   |                     | : |   |                   | r |                 |   |         |
|   |                     | n |   |                   | v |                 |   |         |
|   |                     | o |   |                   | e |                 |   |         |
|   |                     | i |   |                   | i |                 |   |         |
|   |                     | n |   |                   | l |                 |   |         |
|   |                     | d |   |                   | l |                 |   |         |
|   |                     | i |   |                   | a |                 |   |         |
|   |                     | c |   |                   | n |                 |   |         |
|   |                     | a |   |                   | c |                 |   |         |
|   |                     | t |   |                   | e |                 |   |         |
|   |                     | o |   |                   | s |                 |   |         |
|   |                     | r |   |                   | y |                 |   |         |
|   |                     |   |   |                   | s |                 |   |         |
|   |                     |   |   |                   | t |                 |   |         |
|   |                     |   |   |                   | e |                 |   |         |
|   |                     |   |   |                   | m |                 |   |         |
|   |                     |   |   |                   | s |                 |   |         |
|   |                     |   |   |                   | i |                 |   |         |
|   |                     |   |   |                   | n |                 |   |         |
|   |                     |   |   |                   | p |                 |   |         |
|   |                     |   |   |                   | l |                 |   |         |
|   |                     |   |   |                   | a |                 |   |         |
|   |                     |   |   |                   | c |                 |   |         |
|   |                     |   |   |                   | e |                 |   |         |
+---+---------------------+---+---+-------------------+---+-----------------+---+---------+
| T |                     | F |   |                   |   |                 | > |         |
| o |                     | Y |   |                   |   |                 |   |         |
| t |                     | 0 |   |                   |   |                 | P |         |
| a |                     | 5 |   |                   |   |                 | : |         |
| l |                     | : |   |                   |   |                 | > |         |
| P |                     | \ |   |                   |   |                 |   |         |
| r |                     | $ |   |                   |   |                 | p |         |
| e |                     | 1 |   |                   |   |                 | a |         |
| v |                     | 3 |   |                   |   |                 | g |         |
| e |                     | 2 |   |                   |   |                 | e |         |
| n |                     | , |   |                   |   |                 | > |         |
| t |                     | 4 |   |                   |   |                 |   |         |
| i |                     | 1 |   |                   |   |                 | \ |         |
| o |                     | 3 |   |                   |   |                 | # |         |
| n |                     | , |   |                   |   |                 | > |         |
| F |                     | 0 |   |                   |   |                 |   |         |
| u |                     | 0 |   |                   |   |                 | i |         |
| n |                     | 0 |   |                   |   |                 | n |         |
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| i |                     | F |   |                   |   |                 |   |         |
| n |                     | Y |   |                   |   |                 | p |         |
| g |                     | 0 |   |                   |   |                 | e |         |
| : |                     | 4 |   |                   |   |                 | r |         |
|   |                     | : |   |                   |   |                 | f |         |
|   |                     | \ |   |                   |   |                 | o |         |
|   |                     | $ |   |                   |   |                 | r |         |
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|   |                     | 2 |   |                   |   |                 | . |         |
|   |                     | 8 |   |                   |   |                 | > |         |
|   |                     | , |   |                   |   |                 |   |         |
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|   |                     | 8 |   |                   |   |                 | l |         |
|   |                     | 3 |   |                   |   |                 | a |         |
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|   |                     |   |   |                   |   |                 | B |         |
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|   |                     | $ |   |                   |   |                 | e |         |
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|   |                     | 2 |   |                   |   |                 |   |         |
|   |                     | 5 |   |                   |   |                 | \ |         |
|   |                     | , |   |                   |   |                 | # |         |
|   |                     | 3 |   |                   |   |                 | > |         |
|   |                     | 8 |   |                   |   |                 |   |         |
|   |                     | 7 |   |                   |   |                 | i |         |
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|   |                     | 0 |   |                   |   |                 | > |         |
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|   |                     | 0 |   |                   |   |                 | b |         |
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|   |                     | F |   |                   |   |                 | d |         |
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|   |                     | 0 |   |                   |   |                 | e |         |
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|   |                     | $ |   |                   |   |                 | j |         |
|   |                     | 1 |   |                   |   |                 | u |         |
|   |                     | 1 |   |                   |   |                 | s |         |
|   |                     | 8 |   |                   |   |                 | t |         |
|   |                     | , |   |                   |   |                 | i |         |
|   |                     | 2 |   |                   |   |                 | f |         |
|   |                     | 2 |   |                   |   |                 | . |         |
|   |                     | 4 |   |                   |   |                 |   |         |
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|   |                     | F |   |                   |   |                 |   |         |
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|   |                     | 0 |   |                   |   |                 |   |         |
|   |                     | 1 |   |                   |   |                 |   |         |
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|   |                     | \ |   |                   |   |                 |   |         |
|   |                     | $ |   |                   |   |                 |   |         |
|   |                     | 1 |   |                   |   |                 |   |         |
|   |                     | 1 |   |                   |   |                 |   |         |
|   |                     | 3 |   |                   |   |                 |   |         |
|   |                     | , |   |                   |   |                 |   |         |
|   |                     | 5 |   |                   |   |                 |   |         |
|   |                     | 5 |   |                   |   |                 |   |         |
|   |                     | 8 |   |                   |   |                 |   |         |
|   |                     | , |   |                   |   |                 |   |         |
|   |                     | 0 |   |                   |   |                 |   |         |
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|   |                     | 1 |   |                   |   |                 |   |         |
|   |                     | 0 |   |                   |   |                 |   |         |
|   |                     | 9 |   |                   |   |                 |   |         |
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+---+---------------------+---+---+-------------------+---+-----------------+---+---------+

####  Performance Budget Integration {#performance-budget-integration-1 .unnumbered}

These 13 indicators account for approximately 74 % of this budget
category. This includes 33% for public health nursing (inclusion of
their line item budget), as well as an estimated 30 % for unintentional
injury prevention. Unintentional injuries are an ongoing cause of
decreased life expectancy in AI/AN populations. Resources are spent on
health education, community health representatives and environmental
support to address this issue.

#### 1.6.5.1 Public Health Nursing Indicator: {#public-health-nursing-indicator .unnumbered}

> [Indicator 22:]{.underline} During FY 2005, maintain the total number
> of public health nursing services (primary and secondary treatment and
> preventive services) provided to neonates, infants, and elders in all
> setting at the FY 2004 workload levels.

![](media/image20.wmf){width="3.4590277777777776in"
height="1.93125in"}![](media/image21.wmf){width="3.5208333333333335in"
height="1.9222222222222223in"}

**[Rationale:]{.underline}** The purpose of this indicator is to improve
the health status of American Indian and Alaska Native people through
maintaining access to services associated with improved health outcomes.
Many of the successes in Indian health such as a decrease in infant
mortality, high immunization rates, and increased prenatal care are
attributed to the efforts of public health nursing.

Public Health Nursing is a unique service because individual and group
health promotion and disease prevention activities are provided in the
home and in the community setting. Public Health Nursing Programs are a
crucial link between health care services and the community. Public
Health Nursing Programs strive to improve the quality of care provided
to the community. .The unique quality of Public Health Nursing (PHN)
service is that care can be provided in any setting where the patient is
accessible. This is especially effective for high-risk patients and
families. Therefore, public health nursing workload, especially
community based visits, is used as measure of program effectiveness and
an overall indicator of health status of the community.

**[Approach:]{.underline}** The population base for public health
nursing services is the IHS user population residing within the official
boundaries of the Area. However, in some service units, the user
population is greater than the reported census population. In these
cases, the Indian user population is used as an estimate of the service
population to reflect PHN service to both stable communities and
transient populations.

**[Data Sources:]{.underline}** IHS PCC, GPRA+ , and written reports
submitted by Tribes using non-RPMS systems.

**[Program Performance:]{.underline} The IHS met this indicator in FY
2003.** The FY 2003 performance indicator committed to maintaining the
total number of Public Health Nurse visits to the American Indian and
Alaska Native population at the 2002 level, and increasing the number of
home visits by 2%. The FY 2003 Public Health Nurse report reflects that
359,089 visits compared to 343,844 visits in FY 2002 total Public Health
Nurse visits were provided and 3% more home visits (compared to in FY
2002- ) were provided over FY 2002 data. The combination of
community-based and home-based primary, secondary, and tertiary
prevention efforts and improved documentation practices by I/T/U PHN
Programs may reflect in the increase of visits overall, but also with
the increase in home visits.

#### Immunization Group:

The following three indicators support immunization coverage in children
and adults at high risk for preventable diseases and represent perhaps
the most efficacious \"impact\" interventions known to public health.

Indicator 23: During FY 2005, maintain baseline rates for recommended
immunizations for American Indian and Alaska Native children 19-35
months compared to FY 04.

![](media/image22.wmf)

**[Rationale:]{.underline}** The National Immunization Survey, which is
used to estimate immunization coverage for each state and for the U.S.,
collects information on children 19 - 35 months. In addition, the
Healthy People 2010 goal is 90% coverage with routine immunizations for
children 19 - 35 months. IHS will establish baseline data on children
19 - 35 months in FY 04. We will continue to assess our performance
using the 19 - 35 month indicator rather than the 3 - 27 month
indicator.

**[Approach:]{.underline}** The purpose of this indicator is to increase
age appropriate immunization coverage for American Indian and Alaska
Native children. Immunizations are one of the most cost-effective public
health measures available for improving health outcomes in children and
are a recognized standard of care and a standard of public health.

**[Data Source:]{.underline}** Quarterly immunization reports are based
on IHS patient care records and public health nursing records of
children who receive immunizations at an IHS facility. IHS will be
primarily responsible for completing the reports. Comparison data for
the 19 -- 35 month rate are available from the National Immunization
Survey reported by CDC.

Program Performance: IHS MET this indicator. The FY 2003 performance
indicator \# 23 was to reduce the incidence of preventable disease by
maintaining the FY 2002 proportion of AI/AN children who have completed
all recommended immunizations for ages 3-27 months (as recommended by
Advisory Committee on Immunization Practices) during FY 2003.

Data is collected on a quarterly basis. Because the same child may be
eligible for immunization in each quarter as they move through the age
cohort, the totals for the year do not represent individual children. We
can, however, determine the number of vaccination opportunities in FY
2003, and the number of vaccination opportunities that were realized.
"Immunization opportunities" are defined as the number of times in FY
2003 that children were eligible to receive a vaccine. "Realized
immunization opportunities," means the child received the required
vaccination.

The percent of immunization opportunities for children 3 -- 27 months
that were realized in FY 2002 was 80%. The FY 2003 goal was to maintain
80%. Based on quarterly reports from all 12 IHS areas from July 1^st^,
2002 -- June 30^th^, 2003, there were 113,962 immunization opportunities
for AI/AN children 3 -- 27 months. Of those, 90,890 or 80% were
realized; the FY 2003 performance measure of 80% was achieved

Challenges in meeting the FY 2003 performance indicator include:

-   Vaccine Shortages - Throughout FY 2001 and 2002 there were extensive
    shortages for 6 of the routinely recommended childhood vaccinations,
    including DTaP, some hepatitis B/Hib combination vaccines, and
    MMR.[^1] Shortages led to the suspension of routinely recommended
    doses in some states (such as the 4^th^ DTaP), so that many children
    were not up-to-date with their vaccines. While the shortages were
    resolved in FY 2003, there may have been delays in catching children
    up that would have affected vaccine coverage levels for FY 2003.

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-   Vacancies in positions essential for the delivery, tracking and
    reporting of immunizations (i.e. public health nurses, medical
    records staff)

-   IHS Immunization software package is not fully utilized at many
    local facilities

-   An increasingly complex immunization schedule as new vaccines are
    added

-   Incomplete tracking due to the multiple sources of health care (many
    non-IHS)

Steps taken to address challenges:

-   IHS is working with CDC and state immunization programs to
    prioritize limited vaccine supply to ensure the highest risk and
    most vulnerable children receive priority

-   Data quality initiatives are on-going and will likely result in
    lower immunization coverage levels initially. Improved data,
    however, will also allow IHS to identify low-performing areas to
    target for intervention.

-   IHS is addressing agency-wide recruitment and retention problems

-   A contract is in place to update the RPMS Immunization software
    package and to provide training in its use to facilitate its
    implementation in all clinics

-   IHS is currently involved in a pilot data exchange project with
    three state immunization registries that should result in improved
    tracking.

**[Indicator 24]{.underline}:** In FY 2005, maintain the FY 2004 rate
for influenza vaccination levels among non-institutionalized adult
patients age 65 years and older.

![](media/image23.wmf){width="3.4479166666666665in"
height="2.0416666666666665in"}

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
morbidity and mortality due to influenza among adults. Improving
immunization coverage rates for influenza among adults will reduce the
incidence of this disease.

[**Approach**:]{.underline} IHS clinics are encouraged to provide
influenza vaccine to adults 65 years of age during clinic visits and
during mass immunization clinics. Educating patients is a part of the
strategy to ensure influenza vaccine is provided. The proposed FY 2005
IHS budget will support the capacity for sites to continue existing
strategies and maintain current immunization coverage levels in the face
of population growth.

**[Data Source:]{.underline}** RPMS data system; GPRA+ Influenza
vaccination rates are based on having received vaccination within the
prior 12 months.

**[Program Performance:]{.underline}** **IHS met this indicator.** This
indicator was to maintain the percentage of adults 65 years old and
older that receive influenza vaccine at the FY 2002 level.

The percent of adults 65 years and older that received influenza vaccine
in FY 2003 was 51%, which was equal to the same percentage in FY 2002
using GPRA+ data.

IHS continues to addressing this issue by changing the data system to
ensure that historical data is available, and working with CDC to ensure
equitable distribution of influenza vaccine. In addition, there is a
continued emphasis on electronic healthcare reminders as well as
individual electronic provider feedback.

Indicator 25: In FY 2003, maintain the FY 20042 rate for pneumococcal
vaccination levels among non-institutionalized adult patients age 65
years and older.

![](media/image24.wmf){width="3.4479166666666665in"
height="2.0416666666666665in"}

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
morbidity and mortality due to pneumococcal disease among adults.
Improving immunization coverage rates for pneumococcal disease among
adults will reduce the incidence of these diseases.

**[Approach:]{.underline}** IHS clinics are encouraged to provide
pneumococcal vaccine to adults 65 years of age during clinic visits. The
proposed FY 2005 IHS budget will support the capacity for sites to
continue existing strategies and maintain current immunization coverage
levels in the face of population growth.

**[Data Source:]{.underline}** RPMS data system and GPRA+. Pneumococcal
vaccination rates are based on clinically appropriate patients having
ever received the pneumococcal vaccine.

**[Program Performance:]{.underline}** **IHS met this indicator.** IHS
developed an approach to obtain the needed data for this indicator and
in FY 2003; we were able to show an increase of almost 2% in this
vaccination. IHS achieved this increase in this immunization rate by
focusing on improving Pneumococcal immunization rates at the local
facilities. IHS continues to focus on improved pneumococcal vaccine
rates through increasing electronic healthcare reminders to providers.

#### Injury Prevention Group:

The following two indicators address the process and outcome of
comprehensive community-based injury prevention efforts across I/T/U
settings.

[Indicator 26]{.underline}: During FY 2005, develop a web-based data
collection system to report injury prevention projects.

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
injury rates in the American Indian and Alaska Native communities
through the implementation of proven injury intervention strategies
across I/T/U settings. This indicator builds on the work conducted by
the IHS Injury Prevention Program and documents initiatives and
strategies initiated through the Injury Prevention Program 5-year Plan.

Proven injury prevention interventions are projects that address a
specific identified injury problem; employ a multiple-strategy approach;
are based on a proven effective, evaluated injury prevention strategy;
or are epidemiologically identified from local data and designed on a
proven prevention approach. Examples of projects include Sleep Safe
Project sites, national IHS Part II Injury Infrastructure Grants, and
Injury Prevention Specialist Fellowship.

**[Approach:]{.underline}** Since the mid-1980\'s IHS has developed the
capacity of IHS staff and tribes to epidemiologically assess the injury
hazards and risk factors in communities and develop intervention
strategies. Injury intervention projects are underway through I/T/U
settings to reduce the burden of injury experienced. This measure will
report on the community specific initiatives underway throughout IHS.

**[Data Sources:]{.underline}** Data to report on this indicator is
compiled and reported by Area Injury Prevention Specialists.

**[Program Performance:]{.underline}** **IHS met this indicator.** The
FY 2003 indicator committed to implementing at least 36 community
prevention projects. This objective was met in FY 2003.

Indicator 27: During FY 2005, reduce deaths caused by unintentional
injuries to no higher than the FY 2004 level.

**[Rationale:]{.underline}** Injuries are a leading cause of
hospitalization for American Indian and Alaska Native people. Annually,
forty six percent (46%) of the Years of Potential Life Lost (YPLL) for
American Indian and Alaska Native people are the result of injuries.
Furthermore, injuries are the number one cause of mortality for American
Indian and Alaska Native people for ages 1-44 years and third for
overall death rates. The single largest expenditure of contract medical
care funds is for the treatment of injuries. The systematic
implementation of prevention strategies through partnerships with tribes
and outside agencies has demonstrated significant improvements in injury
rates across American Indian and Alaska Native.

**[Approach:]{.underline}** The IHS has assigned an Injury Prevention
Program Manager, who coordinates activities and resources with specially
trained Injury Prevention Specialists at the Area, District, Service
Unit and tribal levels. IHS maintains a broad base Injury Prevention
program that includes a \$1.475 million Infrastructure Grant Program, an
internationally recognized training program, community-based
epidemiologic assessment, and partnerships with other agencies to fund
and implement proven intervention projects in communities.

**[Data Source:]{.underline}** In its original form in the FY 1999
performance plan, this indicator targeted injury mortality as the
performance measure. However, efforts to apply this approach in FY 2000
and FY 2001 revealed that the hospitalization data do not accurately
reflect the number of unintentional injury cases that are hospitalized
in IHS or tribal hospitals. Coding omissions have resulted in injury
codes frequently not being noted. For FY 2002, the IHS will again depend
on adjusted death rates generated from the official injury mortality
data from the NCHS.

**[Program Performance:]{.underline} No data is currently available to
report on this indicator. IHS expects that we will be able to report on
this indicator by 2005.**

The FY 1999 indicator committed to reduce deaths by unintentional
injuries for American Indian and Alaska Native people to no more than 93
per 100,000 people. The Healthy People 2010 target is 17.5
deaths/100,000 population. IHS has determined that the indicator was met
for 1999. The 1999 unintentional injury rate of 93/100,000 indicator was
established using the International Classification of Disease, 9^th^
edition (ICD-9). The IHS reported rate of 95.5/100,000 used the newer
ICD-10 classification system.

The two versions of the classification system are not directly
comparable. In the September 21, 2001 edition of \"National Vital
Statistic\" (Deaths: Final Data for 1999), the National Center for
Health Statistics published comparability ratios to adjust and compare
ICD-9 and ICD-10 data.

When the performance target of 93/100,000 is adjusted for ICD-10, using
the adjustment ration of 1.0305 for unintentional injuries, the rate is
95.84/100,000. The rate IHS reported was 95.5/100,000, based on ICD-10.

#### Suicide Prevention Indicator:

Indicator 28: During FY 2005, establish baseline data on suicide from
the new suicide reporting system.

In FY 2004, implement the national suicide reporting system

**[Rationale:]{.underline}** This indicator is part of an expanding
systematic effort at reducing the prevalence of suicide in the American
Indian and Alaska Native population. The suicide death rate for the
American Indian and Alaska Native population has actually increased in
the 1990s and is currently 72% greater than the national average.
However, IHS has known that our data is incomplete, as many attempted
suicides and completed suicides are not currently recorded in our data
system. The Division of Behavioral Health, along with the Information
Technology Support Center, has developed a comprehensive suicide data
reporting system.

**[Approach:]{.underline}** Programs are responsible for implementing a
national suicide reporting system. A suicide surveillance system is
being encouraged for use at clinical facilities to assure that routine
suicide screenings and case management are nationally consistent, but
also tailored to the needs and resources of each site. This suicide
surveillance instrument is integrated into the interim behavioral health
software application

**[Data Source:]{.underline}** Local programs send reports to the
national ITSC with identified data sources linked with RPMS as
appropriate. Aggregated data is used to assess current rates. Effective
deployment of the new interim behavioral health application ensures that
the national suicide reporting system is being utilized.

**[Program Performance:]{.underline}** **IHS met this indicator.** The
2003 indicator committed to reducing suicide rates by assuring that by
the end of FY 2003, there would be at least a 5 % increase in the number
of I/T/U programs that have implemented a suicide surveillance system to
monitor the incidence and prevalence rates of suicidal acts (attempts,
and completions). This surveillance system is coupled with assuring that
those at risk receive appropriate services, and that appropriate
population-based prevention interventions are implemented. At the
current time, 60 I/T/U programs are reporting suicide data, including
attempts and completions. This represents an increase of over 35% over
the number of programs reporting in FY 02. In 2004, this indicator
changes to focus on the implementation of the new Behavioral Health
package that includes a suicide reporting form.

#### Developmental Prevention and Treatment Group:

The following three indicators represent efforts to identify and
disseminate the finding and learning from research and demonstration
projects addressing significant chronic diseases afflicting American
Indian and Alaska Native people. These measures target the development
and implementation of effective prevention and treatment programs to
address cardiovascular disease, diabetes and tobacco use.

**Indicator 29: During FY 2005, establish the number of adult patients
that receive appropriate screening for blood lipids.**

**[Rationale:]{.underline}** Cardiovascular disease represents the
single largest cause of death for American Indian and Alaska Native
people above the age of 45.

**[Approach:]{.underline}** This indicator focuses on evaluating
screening and prevention for CV disease in adult patients.

**[Data Source:]{.underline}** RPMS, GPRA+

**[Program Performance:]{.underline}** **IHS met this indicator.**
During FY 2003, the three Tribal programs:

-   continued to implement their Community Action Plan;

-   did actual tracking of the Cardiovascular Disease Clinical
    Indicators selected by the three Tribes (lipids, cholesterol, body
    mass index, tobacco cessation rates, and exercise education) through
    GPRA+ software designed especially to track CVD; and

-   assessed their communities through evaluating community knowledge,
    behaviors, and risks of CVD.

In addition, another site initiated a culturally sensitive
community-directed pilot cardiovascular disease prevention program.

Activities for FY 2005 include the establishment of a baseline of the
number of adult patients that received appropriate screening for blood
lipids. This data will be evaluated by using the RPMS GPRA+ software
application.

Indicator 30: During FY 2005, each area will increase the number of
patients for whom BMI data can be measured by 5% percent.

In 2004, establish baseline rates for BMI on children and adults.

**[Rationale:]{.underline}** This indicator is part of a comprehensive
long-term effort to identify effective interventions to prevent and
reduce obesity in American Indian and Alaska Native people. IHS must
blaze a new trail into unknown territory in order to address the
escalating obesity and diabetes rates. In FY 2004 and 2005, IHS is
committed to establishing the obesity rates for the communities that we
serve. This will enable IHS to track the impact of interventions that
have been developed by the Obesity Control Projects.

**Approach**: The approach to this revised indicator for FY 2004 and
2005 includes developing an increased data capacity for BMI data
evaluation.

**[Data Source:]{.underline}** IHS RPMS system, IHS/ITCA national
pediatric height weight survey; GPRA+ data from local facilities

**[Program Performance:]{.underline}** **IHS met this indicator.** This
FY 2003 indicator committed to implementing a 3-element obesity
prevention and treatment plan throughout IHS. IHS implemented this
three-element plan in conjunction with tribes and local facilities.

> Indicator 31: During 2005, rates of screening for tobacco use will be
> maintained at FY 04 rates.
>
> During FY 2004, IHS will establish rates of screening for tobacco use.

**[Rationale:]{.underline}** The use of tobacco represents the second
largest cause of preventable deaths for American Indian and Alaska
Native people. Smoking rates in many American Indian and Alaska Native
communities are almost twice the national average. The Indian Health
Service has not yet addressed the tobacco problem with a specific action
plan or budget request. Because tobacco has a unique status among many
American Indian and Alaska Native tribes as a sacred plant, any plan for
control activities must have significant input from American Indian and
Alaska Native community leaders.

Screening for tobacco use is essential to identifying patients at risk
for complications of tobacco abuse. IHS plans on tracking these rates of
screening, as well as rates of intervention for those patients are at
risk for complications from tobacco abuse.

**[Approach:]{.underline}** The changed 2004 indicator calls for the IHS
to establish rates of screening for tobacco use. In FY 2005, IHS will
maintain these screening rates. During FY 2003, recommendations made by
the tobacco workgroup were presented to IHS senior leadership and to the
National Indian leadership organizations.

**[Data Source:]{.underline}** IHS Program records; GPRA+ data from
local facilities

[Program Performance:]{.underline} IHS met this indicator. The FY 2003
indicator committed to developing a 5-year tobacco control plan. The IHS
strategy for tobacco control involves two distinct approaches: 1)
clinical cessation; and 2) community-based prevention programs. A
workgroup of staff from IHS HQ, Areas, and clinics was formed to address
clinical cessation issues. This workgroup has developed a framework for
clinic-based tobacco cessation efforts that will guide IHS and Tribal
health programs as they build capacity for tobacco control. Plans were
also developed to monitor clinical data on tobacco education and use
through the GPRA+ software. In a separate process, the seven CDC-funded
Tribal Tobacco Control Centers met with IHS to provide input on the
community-based component of our tobacco control and prevention effort.
The resulting Plan will be used by the Centers to guide their activities
in youth tobacco prevention, and will be disseminated to other AI/AN
communities and health programs. These organizations are currently in
their second year of a five-year funding project from the Office on
Smoking and Health, Centers for Disease Control. Their purpose is to
build capacity and infrastructure at the tribal level for tobacco
control and prevention. Thus far, the assistance provided to tribes
includes: training and technical assistance, partnership building,
education/awareness, and policy development.

#### HIV/AIDS Indicator:

The following indicator addresses implementation of risk reduction
counseling for high-risk sexually active individuals with the long-term
goal of reducing the spread of HIV infection in the American Indian and
Alaska Native population.

Indicator 32: No FY 2003 or FY 2004 indicator

Indicator 32: FY 05: Establish the baseline for number of pregnant women
screened for HIV in pregnancy.

[Rationale:]{.underline} The purpose of this indicator is to reduce the
spread of HIV infection in American Indian and Alaska Native
communities. Identification of HIV in pregnancy can result in decreased
transmission of HIV.

[Approach:]{.underline} A baseline of HIV screening in pregnancy will be
established in FY 05. RPMS will be used for documentation of screening
and/ or patient education

[Data Source]{.underline}: RPMS database

[Program Performance:]{.underline} New indicator in FY 05

Indicator 33: FY 05 -- No Indicator

During FY 2004, Determine the percentage of high-risk sexually active
persons who have been tested for HIV at an additional 10 sites.

**[Rationale]{.underline}:** The purpose of this indicator is to reduce
the spread of HIV infection in American Indian and Alaska Native
communities. The Indian Health Service is working to increase
availability and access to voluntary and confidential HIV diagnostic
testing by constituents who do not know their HIV status, link them to
care and prevention services, and assist them in adhering to treatment
regimens and in sustaining risk reduction behavior. The FY 2002
indicator was designed to obtain baseline measures in at least 3 areas.
The FY 2005 indicator is designed to measure the expansion of obtaining
HIV testing data in high-risk sexually active patients in additional
sites throughout IHS.

**[Approach:]{.underline}** A baseline was established in FY 2002. In FY
2004, RPMS will once again be queried for documentation of completed HIV
testing for this defined high-risk population.

**[Data Source:]{.underline}** RPMS database and chart reviews

**[Program Performance:]{.underline}** **IHS did not meet this
indicator.** The FY 2003 performance indicator was committed to
increasing the percentage of high-risk sexually active persons (defined
as people who have a positive test for gonorrhea, Chlamydia and/or
syphilis) who have been screened for HIV by 5%. .

IHS was able to increase screening rates for HIV in high risk patients
by approximately 1%, but was unable to reach the goal of a 5% increase.
This inability to increase screening rates reflects a myriad number of
reasons, including patient refusal as well as concerns about
confidentiality and anonymity. IHS is working with tribes and
communities on education and anonymity issues.

#### Environmental Surveillance Indicator:

*[Environmental Surveillance Indicator:]{.underline}*

> [Indicator 34:]{.underline} During FY 2005, the IHS will increase the
> number of active tribal user accounts for the automated Web-based
> environmental health reporting system by 15% over the FY 2004 level
> for American Indian and Alaska Native tribes not currently receiving
> direct environmental health services.

[Rationale:]{.underline} This indicator is directed at reducing
environmental threats to health by collecting community information for
decision-making. Community environmental health status has traditionally
been determined by completing environmental health surveys of individual
facilities listed on the Facility Data System (FDS) inventory. Current
changes in data collection methodology and technological advances will
support more consistent assessment of community environmental health
services by building a more comprehensive dataset to analyze and use to
determine direction. Ultimately this change will support setting
specific targets for reducing environmental threats across I/T/U
settings. In order to collect a more complete set of data it is
necessary to have the participation of American Indian and Alaska Native
tribes to add to the data and verify the accuracy of FDS elements that
are not part of the Indian Health Service.

**[Approach:]{.underline}** The Environmental Health Services program
utilizes the Web-based Environmental Health Reporting System (WebEHRS)
in conjunction with Tribal partners to collect community and facility
information to be used for ongoing surveillance. At the regional level,
this project is coordinated with the IHS Area Environmental Health
Officers in partnership with the tribes and local IHS Environmental
Health Services programs.

[Data Source:]{.underline} Data is gathered using the current Web-based
Environmental Health Reporting System (WebEHRS) developed in FY 2000 and
implemented in IHS in FY 2001.

[Program Performance:]{.underline} IHS MET THIS INDICATOR. The FY 2003
indicator committed to achieve a 15% increase in active tribal user
accounts receiving direct environmental health services to the WebEHRS.
3 additional sites began using WebEHRS by the end of the reporting
period, for an increase of 15%.

The Division of Environmental Health developed and implemented WebEHRS,
[webehrs.hqe.ihs.gov](http://www.webehrs.hqe.ihs.gov/), a web-based
bottom up driven environmental health data and field support system. The
data fields consist of environmental health related facilities and
services found in American Indian and Alaskan Native communities.
WebEHRS database is maintained on an IHS HQ-based server. The data and
associated files are aggregated and available for analysis and reporting
by users on successively higher levels.

## Capital Programming/Infrastructure Category 

*Performance Budget Integration*

These 2 indicators account for approximately 43% of this budget
category. Ongoing maintenance, repairs and equipment are not covered
with a performance indicator at this time.

### Program Description and Context

Capital Programming/Infrastructure indicators represent the physical
infrastructure that contributes to a healthy environment by assuring
safe water and sewage facilities, medical facilities where health
services can be adequately provided, and the ability to maintain the
medical facilities that are critical to our mission.

**Sanitation Facilities Construction** -- supports the construction of
water, sewage, and solid waste systems (see page IHF-13 in FY 2005
budget document).

**Health Care Facilities Construction** -- supports the construction of
new or replacement health care facilities (see page IHF-19 in FY 2005
budget document).

**Maintenance and Improvement** -- supports ongoing health care facility
maintenance, alteration, and repair (see page IHF-9 in FY 2005 budget
document).

### Capital Programming /Infrastructure: Performance Indicators

These indicators are selected and based on the following criteria:

-   supports components of the Indian Health Facilities Appropriation
    and funding priorities of I/T/Us identified in the budget
    formulation process;

-   supports existing data systems that record the need for physical
    infrastructure or improvements to the existing infrastructure;

-   follows the formula-based prioritization of each project\'s relative
    need; and

-   has demonstrable link to improved access to health services or
    healthier living environments.

Data is recorded at the local level where projects are conceptualized
based on strict protocols and formulas. These data are compiled at the
Area and Headquarters level and reviewed for accuracy and then compared
against similar projects. The validation and verification of this
information is essential to the facilities program; it is used to
distribute resources as well as measure performance. The link between
funding levels and our ability to accomplish these indicators is
relatively direct and supported by well-quantified and validated
planning formulas.

These indicators support many of the Departmental and IHS areas of focus
by providing a foundation where health services are effectively
delivered and objectives reached. Without a healthy living environment,
access to safe medical facilities, and proper maintenance, most of the
objectives could not be met.

### Capital Programming/Infrastructure Indicators

Table 8: Capital Programming/Infrastructure Performance Summary

+---------------------+-----------------+------------------+----------+
| Performance         | FY Targets      | Actual\          | R        |
| Indicator           |                 | Performance      | eference |
+=====================+=================+==================+==========+
| Capital             |                 |                  |          |
| Program             |                 |                  |          |
| ming/Infrastructure |                 |                  |          |
| Group               |                 |                  |          |
+---------------------+-----------------+------------------+----------+
| [Indicator          | **FY 05:**      | FY 05:           | P: p.    |
| 35:]{.underline}    | 22,000 homes    |                  | 3-61     |
| Provide sanitation  |                 | FY 04:           |          |
| facilities to new   | **FY 04:** 20,  |                  | B: p.    |
| or like-new homes   | 000 homes       | FY 03: 22,750    | IHF-13   |
| and existing Indian |                 | homes            |          |
| homes. \[outcome\]  | FY 03: 15,255   |                  | 3        |
|                     | homes           | FY 02: 3,342     |          |
| EFFICIENCY MEASURE  |                 | New/L.           | HP 2010  |
|                     | FY 02: 2,528    |                  |          |
| full cost           | New/L. New      | [17,             |          |
|                     |                 | 883]{.underline} |          |
| FY 05: 123.3 M      | [12,7           | Existing         |          |
|                     | 27]{.underline} |                  |          |
| FY 04: 120.9 M      | Existing        | Total: 21,225    |          |
|                     |                 |                  |          |
| FY 03: 98.6 M       | Total 15,255    | FY 01: 3,551     |          |
|                     |                 | New/L. New       |          |
|                     | FY 01: 3,800    |                  |          |
|                     | New/L. New      | [14,             |          |
|                     |                 | 451]{.underline} |          |
|                     | [10,9           | Existing         |          |
|                     | 30]{.underline} |                  |          |
|                     | Existing        | Total 18,002     |          |
|                     |                 |                  |          |
|                     | Total 14,730    | FY 00: 3,886     |          |
|                     |                 | New/L. New       |          |
|                     | FY 00: 3,740    |                  |          |
|                     | New/L. New      | [14,             |          |
|                     |                 | 490]{.underline} |          |
|                     | [11,0           | Existing         |          |
|                     | 35]{.underline} |                  |          |
|                     | Existing        | Total 18,376     |          |
|                     |                 |                  |          |
|                     | Total 14,775    | FY 99: 3,557     |          |
|                     |                 | New/L. New       |          |
|                     | FY 99: 5,900    |                  |          |
|                     | New/L. New      | [13,             |          |
|                     |                 | 014]{.underline} |          |
|                     | [9,3            | Existing         |          |
|                     | 30]{.underline} |                  |          |
|                     | Existing        | Total 16,571     |          |
|                     |                 |                  |          |
|                     | Total 15,230    |                  |          |
+---------------------+-----------------+------------------+----------+
| [Indicator          | FY 05: complete | FY 05:           | P: p.    |
| 36:]{.underline}    | scheduled phase |                  | 3-62     |
| Improve access to   | of construction | FY 04:           |          |
| health care by      | of appropriated |                  | B: p.    |
| construction of the | facilities      | FY 03: phases    | IHF-19   |
| approved new health |                 | for 12 of 12     |          |
| care facilities.    | FY 04: complete | projects         | 3        |
|                     | scheduled phase | completed on     |          |
| \[outcome\]         | of construction | schedule         |          |
|                     | of appropriated |                  |          |
| full cost           | facilities      | FY 02: phases    |          |
|                     |                 | for 10 of 10     |          |
| FY 05: 76.3 M       | FY 03: complete | projects         |          |
|                     | scheduled phase | completed on     |          |
| FY 04: 74.0 M       | of construction | scheduled , plus |          |
|                     | of appropriated | phases for 2     |          |
| FY 03: 86.3 M       | facilities      | projects not     |          |
|                     |                 | completed the    |          |
|                     | FY 02: complete | previous year    |          |
|                     | scheduled phase | were completed   |          |
|                     | of construction |                  |          |
|                     | of appropriated | FY 01: Phases    |          |
|                     | facilities      | for 5 of 7       |          |
|                     |                 | projects         |          |
|                     | FY 01: complete | completed on     |          |
|                     | scheduled phase | schedule, plus   |          |
|                     | of construction | phase for one    |          |
|                     | of appropriated | project not      |          |
|                     | facilities      | completed the    |          |
|                     |                 | previous year    |          |
|                     | FY 00: complete | was completed.   |          |
|                     | scheduled phase |                  |          |
|                     | of construction | FY 00: phases    |          |
|                     | of appropriated | for 5 of 6       |          |
|                     | facilities      | projects         |          |
|                     |                 | completed on     |          |
|                     | FY 99: complete | schedule         |          |
|                     | scheduled phase |                  |          |
|                     | of construction | FY 99: phases    |          |
|                     | of appropriated | for ad projects  |          |
|                     | facilities      | completed on     |          |
|                     |                 | schedule         |          |
+---------------------+-----------------+------------------+----------+
| Total Capital       | FY 05:          |                  | P: page  |
| Programming/        | \$              |                  | \# in    |
| Infrastructure      | 435,850,000\*\* |                  | perform. |
| Funding:            |                 |                  | plan     |
|                     | FY 04:          |                  |          |
|                     | \$              |                  | B: page  |
|                     | 431,293,000\*\* |                  | \# in    |
|                     |                 |                  | budget   |
|                     | FY 03:          |                  | justif.  |
|                     | \$411,630,000   |                  |          |
|                     |                 |                  |          |
|                     | FY 02:          |                  |          |
|                     | \$357,034,000   |                  |          |
|                     |                 |                  |          |
|                     | FY 01:          |                  |          |
|                     | \$322,377,000   |                  |          |
|                     |                 |                  |          |
|                     | FY 00:          |                  |          |
|                     | \$277,303,000   |                  |          |
|                     |                 |                  |          |
|                     | FY 99:          |                  |          |
|                     | \$255,953,000   |                  |          |
|                     |                 |                  |          |
|                     | FY 98:          |                  |          |
|                     | \$221,009,000   |                  |          |
|                     |                 |                  |          |
|                     | \*\* includes   |                  |          |
|                     | 15% of M/M and  |                  |          |
|                     | PI Collections  |                  |          |
|                     | and Quarters    |                  |          |
|                     | Collections     |                  |          |
+---------------------+-----------------+------------------+----------+

####  Capital Programming /Infrastructure Group:

> Indicator 35: During FY 2005, provide sanitation facilities projects
> to 22,000 Indian homes with water, sewage disposal, and/or solid waste
> facilities.
>
> ![](media/image25.wmf){width="5.302083333333333in"
> height="2.4270833333333335in"}

[Rationale:]{.underline} This indicator directly supports improved
environmental health for American Indian and Alaska Native people. The
IHS Sanitation Facilities Construction Program has carried out those
authorities since 1960 using funds appropriated for Sanitation
Facilities Construction and contributed funds from Tribes and other
Federal agencies to provide potable water and waste disposal facilities
for American Indian and Alaska Native people. This work is recognized as
a significant factor contributing to a reduction in the rates for infant
mortality, gastroenteritis morbidity, and other environmentally related
diseases by as much as 80 percent since 1973. American Indian and Alaska
Native homes are still seven times more likely to be without clean water
than homes in the broader U.S. with most of these homes located in
geographically isolated areas.

**[Approach:]{.underline}** This program regularly updates the needs for
sanitation facilities based on the Indian Health Care Improvement
Amendments (Title II, Section 302(g) 1 and 2 of P.L. 100-713). Based on
the end-of-year FY 2002 estimates, the cost of technically and
economically feasible projects to correct these needs for existing homes
was \$900 million out of a total need of \$1.578 billion. It is
considered feasible to provide sanitation facilities for between 95 and
98 percent of all existing Indian homes.

**[Data Source:]{.underline}** The SFC Sanitation Deficiency System
(SDS), and Project Data System

**[Program Performance:]{.underline}** **IHS met this indicator.** The
FY 2003 performance measure to provide sanitation facilities to 15,255
homes by the end of FY 2003.was met. moreover, exceeded. IHS provided
this service to 22,750 homes during FY 2003. This measure indicates the
number of homes served with water, sewer and solid waste facilities.
This significant increase in existing homes was the result of funding
more projects to upgrade existing community sanitation facilities
infrastructure. IHS has received between \$30 million to \$44 million
annually from outside contributors since FY 1996. IHS will continue to
work cooperatively with tribes to attract funds from outside IHS to
construct needed sanitation facilities.

1.7.3.3 Indicator 36: During FY 2005, increase the modern health care
delivery system to improve access and efficiency of health care by
assuring the timely phasing of construction of the following health care
facilities:

> a\. Red Mesa, AZ -- complete construction of a new health center,
> including supporting staff quarters.
>
> b\. Sisseton, SD -- complete construction of a replacement health
> center, including supporting staff quarters.
>
> c\. Zuni, NM -- complete design and construction of staff quarters
> project.
>
> d\. Wagner, SD -- design-build staff quarters project.

[Rationale]{.underline}: This indicator supports the replacement of
health care facilities to increase access to medical services supported
by the IHS. These medical services are comparable to medical services
available to the general population (appointments to see primary care
physicians, nurses, dentists, etc.). Efficient space for health care
delivery allows for more appointments, and for patients to see more
health care providers in one trip. Although accessible is synonymous in
this usage with obtainable health care services, the IHS can demonstrate
that workloads have increased or services that are more comprehensive
are provided in new facilities.

Modern facilities help recruit and retain health care providers, which,
in turn, can result in improved access and continuity of health care.
Once a replacement facility has been completed and fully staffed, the
IHS has experienced an average increase in patient visits of
approximately 60% over the old facility. Where private sector housing is
not available for the increased staffing levels, additional staff
quarters are needed for non-local staff in support of the identified IHS
health care facilities.

[Approach]{.underline}: The IHS developed the Health Facilities
Construction Priority System (HFCPS) methodology in response to
Congressional directive to identify planning, design, construction, and
renovation needs for the 10 top-priority inpatient care facilities and
the 10 top-priority outpatient care facilities and to submit those needs
through the President to the Congress. Under the three-phase HFCPS
process, the IHS Headquarters solicits proposals for facility
construction from the IHS Area Offices and ranks them according to their
relative need for construction. Responding to Congressional language
accompanying the FY 2000 appropriations, the IHS, in consultation with
the tribes, currently is reviewing the HFCPS for possible revision to
reflect a methodology that will reflect appropriate factors in
determining the relative need for all IHS health care facilities
construction.

Current factors used to determine relative need are workload, existing
facility age, isolation (availability of alternatives sources of care),
and existing space data. The IHS uses the current HFCPS methodology to
review proposals and determine which will be considered during a more
intensive Phase II review. The IHS examines these Phase II proposals in
detail and applies the methodology to determine the proposals that will
be considered during Phase III. During Phase III, applicable IHS Area
Offices prepare a Program Justification Document (PJD) for review by IHS
Headquarters. If the PJD justifies construction, it is approved and the
project is placed on the appropriate priority list below those already
on the list.

The IHS has developed the Quarters Construction Priority System (QCPS)
to identify staff quarters projects to support existing health care
facilities. (Note staff quarters associated with replacement health care
facilities is part of those projects and are not processed under the
QCPS.) Like the HFCPS, quarters projects are processed through three
phases and new staff quarters projects are added to the Quarters
Priority List as Program Justification Documents for Staff Quarters
(PJDQ) are approved.

Proposed projects that have been approved and placed on the respective
priority lists remain on the lists until they have been fully funded by
Congressional appropriations or other funding mechanism. After projects
are placed on the Priority Lists, IHS updates its five-year planned
construction budget. That budget is updated yearly and is used as the
basis for funding requests.

[Data Source]{.underline}: The HFCPS and QCPS generate projects that are
reflected in a five-year funding plan in the Health Care Facilities
Planned Construction Budget. The IHS Inpatient, Outpatient and Quarters
Priority Lists are used to show the needed construction priorities.

[Program Performance:]{.underline} IHS met this indicator. The FY 2003
indicator was accomplished with the timely phased construction of the
following health care facilities as outlined below and will lead to
enhance access to care for the American Indian and Alaska Native
population.

[Ft. Defiance, AZ]{.underline}: For the replacement, hospital that was
completed in June 2002, and opened for service on August 1, 2002, the
replacement and additional staff quarter's portion of the project
proceeded on schedule under a design-build contract, with 46 units being
completed and turned-over for use. This portion of the project continues
with a scheduled 3^rd^ quarter FY 2004 completion.

[Winnebago, NE]{.underline}: Construction continued for the replacement
hospital, with a 2^nd^ quarter FY 2004 completion scheduled for this
portion of the project. The modification of the Drug Dependency Unit is
scheduled for 1^st^ quarter FY 2005 completion, which will complete this
project.

[Pinon, AZ]{.underline}: Construction continued for the new health
center and staff quarters project, with a scheduled 3^rd^ quarter FY
2005 project completion.

[Red Mesa, AZ]{.underline}: Funding to date is being used for the first
phase of construction. Using funding appropriated in FY 2004 and that
being requested in FY 2005, the project could be scheduled for 2^nd^
quarter FY 2006 completion.

[Pawnee, OK]{.underline}: Construction by the Pawnee Tribe, under a
Public Law (P.L.) 93-638 Subpart J contract is scheduled for 2ne
quarters FY 2004 completion.

[St. Paul, AK]{.underline}: Project is proceeding and is scheduled for
4^th^ quarter FY 2006 completion.

[Metlakatla, AK]{.underline}: Project is proceeding and is scheduled for
4^th^ quarter FY 2005 completion.

[Sisseton, SD]{.underline}: Project is proceeding. The Tribe will
develop the site for the IHS under a P.L. 93-638 Subpart J construction
contract. Using funding appropriated in FY 2004 and that being requested
in FY 2005, the project could be scheduled for 3rd quarter FY 2006
completion.

[Clinton, OK]{.underline}: Funding for project design was provided in FY
2004. Using funding anticipated in FY 2006, the project could be
scheduled for 1^st^ quarter FY 2008 completion.

[Bethel, AK]{.underline}: Funding provided in FY 2004 will be used to
complete this project, which is being provided by the Yukon-Kuskokwin
Health Corporation through a design-build contract under an agreement
with the IHS. The project is scheduled for a 2^nd^ quarter FY 2005
completion.

[Small Ambulatory Program]{.underline}: For the FY 2001 Small Ambulatory
Program (SAP), tribes have received awards for nine projects, and two
projects have been completed. For the FY 2002 SAP, tribes have received
awards for eight projects. For the FY 2003 SAP, awards are anticipated
for four projects, two in the 1^st^ quarter and two in the 2^nd^ quarter
of FY 2004. Uncompleted projects are either in design or under
construction by the tribes.

[Dental Facilities Program]{.underline}: Two additional projects are
being processed for design and construction under this program. As
additional funding is appropriated, additional dental units are provided
by the IHS.

## Partnerships, Consultation, Core Functions, and Advocacy Category

### Program Description and Context

The Partnerships, Consultation, Core Functions, and Advocacy aggregation
encompasses the IHS administrative and management functions,
relationships with stakeholders and consumers, and strategies for
collaboration in pursuit of the IHS mission. Data for these indicators
come from recognized sources including budget reports and audits, a HHS
survey, and a survey of the universe of stakeholders using recognized
social survey methods. The two components of this aggregation are:

-   **Direct Operations** - supports management and administrative
    functions for Area and Headquarters staff including policy
    development, budget formulation, health program support, and
    accountability requirements (see page IHS-107 in FY 2005 budget
    document).

-   **Facilities and Environmental Health Support** - provides
    administrative and management support for the construction,
    maintenance, and operation of health care facilities, staff housing,
    and sanitation facilities (see page IHF-29 in FY 2005 budget
    document).

### Performance Indicators

The choice of indicators for this aggregation category is based on the
following criteria:

-   Supports and encourages tribal sovereignty, the government to
    government relationship between tribes and the Federal government,
    and tribal self-determination;

-   supports and encourages collaboration with stakeholders, agencies,
    and organizations directed toward improving the health of American
    Indian and Alaska Native people; and

-   supports and encourages sound management practices.

Achieving these performance indicators, as well as the overall
coordination of the GPRA and other Federal accountability requirements,
represent a significant challenge for the IHS and its reduced management
and public health infrastructure. The reorganization of Headquarters and
many Area offices has resulted in flatter organizational structures,
less specialization in function, and greater use of self-directed teams
in order to increase efficiency. However, it has become increasingly
clear that, coupled with improved data management capacity, there are
two functions that must be supported to assure overall program success
and these are:

-   Assuring that continued and expanded opportunities for tribal
    consultation and participation in IHS endeavors is supported;

-   Assuring effective recruitment of needed health disciplines is
    achieved and that orientation, training, and support are available
    to enhance the retention these staff. The scholarship program is one
    effective tool available for ongoing recruitment and retention.

### Partnerships, Consultation, Core Functions, and Advocacy Indicators

Table 9: Consultation, Partnerships, Core Functions, and Advocacy
Indicators Performance Summary

+-----------------------+-------------------+---------------+----------+
| Performance Indicator | FY Targets        | Actual        | > R      |
|                       |                   |               | eference |
|                       |                   | Performance   |          |
+=======================+===================+===============+==========+
| Consultation          |                   |               |          |
| Improvement Indicator |                   |               |          |
+-----------------------+-------------------+---------------+----------+
| [Indicator            | FY 05: meet or    | F.Y 05:       | P: p.    |
| 37:]{.underline}      | exceed FY 04      |               | 3-69     |
| Improve the level of  |                   | Y 04:         |          |
| satisfaction with the | FY 04: 3%         |               | B: p.    |
| processes for         | increase over FY  | FY 03:        | IHS-107  |
| consultation and      | 03                | baseline rate |          |
| participation         |                   | established   | 3        |
| provided by the IHS,  | FY 03: establish  |               |          |
| as measured by a      | baseline          | FY 02:secured | \*       |
| survey of I/T/Us.     | satisfaction      | clearance; no | i        |
|                       | rate\*            | baseline      | ndicates |
| full cost             |                   |               | lack of  |
|                       | FY 02: secure OMB | FY 01: policy | ad       |
| FY 05: 0.1 M          | clearance for     | implemented   | justment |
|                       | instrument and    | and           | in not   |
| FY 04: 0.1 M          | baseline          | instrument    | meeting  |
|                       |                   | submitted     | FY 02    |
| FY 03: 0.1 M          | FY 01: implement  |               | measure. |
|                       | policy and submit | FY 00:        | See      |
|                       | instrument        | revised       | Summary  |
|                       |                   | policy        | of       |
|                       | FY 00: revise     | proposed and  | Changes  |
|                       | policy and        | instrument    | Table 10 |
|                       | instrument        | developed     | on page  |
|                       |                   |               | 5-1      |
|                       | FY 99: establish  | FY 99: policy |          |
|                       | policy and        | established   |          |
|                       | collect baseline  | but baseline  |          |
|                       |                   | delayed       |          |
+-----------------------+-------------------+---------------+----------+
| Administrative        |                   |               |          |
| Efficiency,           |                   |               |          |
| Effectiveness, and    |                   |               |          |
| Accountability Group  |                   |               |          |
+-----------------------+-------------------+---------------+----------+
| [Indicator            | F.Y 05: TBD       | FY 05:        | P: p.    |
| 38:]{.underline}      |                   |               | 3-70     |
| Improve the level of  | FY 04: +1% over   | FY 04:        |          |
| Contract Health       | FY 03             |               | B: p.    |
| Service (CHS)         |                   | FY 03:        | IHS-55   |
| procurement of        | FY 03: +1% over   | Available     |          |
| inpatient and         | FY 02             | Sept 2004     | 3, 8     |
| outpatient hospital   |                   |               |          |
| services for          | FY 02: 88%        | FY 02: 89%    |         |
| routinely used        |                   |               |          |
| providers under       | FY 01: 79%        | FY 01: 80%    |          |
| contracts or rate     |                   |               |          |
| quote agreements at   | FY 00: no         | FY 00: no     |          |
| the IHS-wide          | indicador         | indicator     |          |
| reporting level.      |                   |               |          |
|                       | FY 99: no         | FY 99: 86%    |          |
| full cost             | indicador         |               |          |
|                       |                   | FY 97: 74%    |          |
| FY 05: 3.7 M          |                   |               |          |
|                       |                   |               |          |
| FY 04: 3.3 M          |                   |               |          |
|                       |                   |               |          |
| FY 03: 3.0 M          |                   |               |          |
+-----------------------+-------------------+---------------+----------+
| [Indicator            | FY 05: assess pub | FY 05:        | P: p.    |
| 39:]{.underline}      | health            |               | 3-71     |
| Assure appropriate    | infrastructure in | FY 04:        |          |
| administrative and    | additional 3 area |               | B: p.    |
| public health         | offices           | FY 03: PH     | IHS-107  |
| infrastructure is in  |                   | i             |          |
| place in response to  | FY 04: assess     | nfrastructure | 2        |
| agency reorganization | pub. health       | assessed for  |          |
| and accountability    | infrastructure in | HQ and 3      | 3        |
| requirements.         | one additional    | areas ( not 6 |          |
|                       | Area Offices\*    | areas)        |         |
| full cost             |                   |               |          |
|                       | FY 03: assess     | FY 02: no     | \*       |
| FY 05: 0.1 M          | pub. health       | indicator     | i        |
|                       | infrastructure    |               | ndicates |
| FY 04: 0.1 M          | for HQ and 6      | FY 01: no     | revised  |
|                       | Areas             | indicator     | FY 2004  |
| FY 03: 0.1 M          |                   |               | measure. |
|                       | FY 02: no         | FY 00: 1,569  | See      |
|                       | indicador         | FTE           | Summary  |
|                       |                   |               | of       |
|                       | FY 01: no         | FY 99: -22%   | Changes  |
|                       | indicator         | (1,619 FTE)   | Table 10 |
|                       |                   |               | on page  |
|                       | FY 00: 1876 FTE   | FY 97: 2085   | 5-1      |
|                       | or less           | FTE baseline  |          |
|                       |                   |               |          |
|                       | FY 99: at least   |               |          |
|                       | 10% under FY 97   |               |          |
|                       | level or 1876 FTE |               |          |
+-----------------------+-------------------+---------------+----------+
| [Indicator            | F.Y 05: no        | FY 05: no     | P: p.    |
| 40:]{.underline}      | indicator         | indicator     | 3-72     |
| **Increase the        |                   |               |          |
| proportion of I/T/Us  | FY 04: no         | FY 04: no     | B: p.    |
| who have implemented  | indicator\*       | indicator     | IHS-107  |
| Hospital and Clinic   |                   |               |          |
| Compliance Plans to   | FY 03: improve    | FY 03: 100%   | 3        |
| assure that claims**  | 10% over FY 02    | compliance    |          |
| meet the rules,       | baseline          |               |         |
| regulations, and      |                   | FY 02: no     |          |
| medical necessity     | FY 02: no         | indicator     | \*       |
| guidance for Medicare | indicator         |               | i        |
| and Medicaid payment. |                   | FY 01: no     | ndicates |
|                       | FY 01: no         | indicator     | revised  |
| full cost             | indicator         |               | FY 2004  |
|                       |                   |               | measure. |
| FY 03: 0.4 M          |                   |               | See      |
|                       |                   |               | Summary  |
|                       |                   |               | of       |
|                       |                   |               | Changes  |
|                       |                   |               | Table 10 |
|                       |                   |               | on page  |
|                       |                   |               | 5-1      |
+-----------------------+-------------------+---------------+----------+
| [Indicator            | Technical         | FY 05 :       | P: p.    |
| 41:]{.underline}      | Assistance        |               | 3-73     |
| Support Tribal        |                   | FY 04:        |          |
| Self-Determination    | FY 05: No         |               | B: p.    |
| through technical     | indicator         | FY 03: 100%   | IHS-121  |
| assistance            |                   | of new tribes |          |
|                       | FY 04: No         |               | > 3      |
| full cost             | indicator\*       | FY 02: tribal | >        |
|                       |                   | approval      | >       |
| FY 05: 1.0 M          | FY 03: 100% of    |               |          |
|                       | new tribes        | FY 01:        | \*       |
| FY 04: 1.0 M          |                   | protocol      | i        |
|                       | FY 02: tribal     | developed     | ndicates |
| FY 03: 1.0 M          | approval of       |               | revised  |
|                       | protocol          | FY 04:\       | FY 2004  |
|                       |                   | FY 03: 10/03  | measure. |
|                       | FY 01: develop    |               | See      |
|                       | protocol          | FY 02: tribal | Summary  |
|                       |                   | acceptance    | of       |
|                       | Contract Support  |               | Changes  |
|                       | Cost Review       | FY 01:        | Table 10 |
|                       |                   | protocol      | on page  |
|                       | FY 05: No         | developed     | 5-1      |
|                       | indicator         |               |          |
|                       |                   |               |          |
|                       | FY 04: No         |               |          |
|                       | indicator\*       |               |          |
|                       |                   |               |          |
|                       | FY 03: 100% use   |               |          |
|                       | of protocol for   |               |          |
|                       | new tribes        |               |          |
|                       |                   |               |          |
|                       | FY 02: secure     |               |          |
|                       | tribal acceptance |               |          |
|                       |                   |               |          |
|                       | FY 01: develop    |               |          |
|                       | protocol          |               |          |
|                       |                   |               |          |
|                       | FY 00: no         |               |          |
|                       | indicator         |               |          |
|                       |                   |               |          |
|                       | FY 99: no         |               |          |
|                       | indicator         |               |          |
+-----------------------+-------------------+---------------+----------+
| Quality of Work Life  |                   |               |          |
| and Staff Retention   |                   |               |          |
| Group                 |                   |               |          |
+-----------------------+-------------------+---------------+----------+
| [Indicator            | [Placement        | FY 05         | P: p.    |
| 42:]{.underline}      | Scholarship       |               | 3-75     |
|                       | Recipi            | FY 04:        |          |
| Assess scholarship    | ents]{.underline} |               | B: p.    |
| program for placement |                   | FY 03: nurse  | IHS-29   |
| and efficiency        | FY 05: improve    | retention     |          |
|                       | placement rate by | assessed and  | 3        |
| EFFICIENCY MEASURE.   | 2%                | plan          |          |
|                       |                   | developed     | 8        |
| full cost             | FY 04: Secure     |               |          |
|                       | baseline rate for | FY 02: no     |         |
| FY 05: 0.7 M          | placement of      | indicator     |          |
|                       | scholarship       |               | \*       |
| FY 04: 0.7 M          | recipients\*      | FY 01: no     | i        |
|                       |                   | indicator     | ndicates |
| FY 03: 1.0 M          | [Nurse            |               | revised  |
|                       | Reten             |               | FY 2004  |
|                       | tion]{.underline} |               | measure. |
|                       |                   |               | See      |
|                       | FY 03: identify   |               | Summary  |
|                       | nurse retention   |               | of       |
|                       | problems and      |               | Changes  |
|                       | develop plan      |               | Table 10 |
|                       |                   |               | on page  |
|                       | FY 02: no         |               | 5-1      |
|                       | indicator         |               |          |
|                       |                   |               |          |
|                       | FY 01: no         |               |          |
|                       | indicator         |               |          |
+-----------------------+-------------------+---------------+----------+
| Total Consultation,   | FY 05:            |               | > P:     |
| Partnerships, Core    | \$85,396,000      |               | > page   |
| Functions, and        |                   |               | > \# in  |
| Advocacy Funding:     | FY 04:            |               | >        |
|                       | \$82,923,000      |               | perform. |
|                       |                   |               | > plan   |
|                       | FY 03:            |               | >        |
|                       | \$89,907,000      |               | > B:     |
|                       |                   |               | > page   |
|                       | FY 02:            |               | > \# in  |
|                       | \$89,282,000      |               | > budget |
|                       |                   |               | >        |
|                       | FY 01:            |               | justify. |
|                       | \$75,823,000      |               |          |
|                       |                   |               |          |
|                       | FY 00:            |               |          |
|                       | \$72,884,000      |               |          |
|                       |                   |               |          |
|                       | FY 99:            |               |          |
|                       | \$69,729,000      |               |          |
|                       |                   |               |          |
|                       | FY 98:            |               |          |
|                       | \$67,038,000      |               |          |
+-----------------------+-------------------+---------------+----------+

####  Performance Budget Integration {#performance-budget-integration-2 .unnumbered}

These five indicators account for approximately 4% of this budget
category. All of these measures are output measures at the current time;
the cost of these measures is based upon the fiscal requirements to
monitor these outcomes, not the cost of the intervention itself.

#### Consultation Improvement Indicator:

> Indicator 37: During FY 2005, the IHS will maintain stakeholder
> satisfaction with the agency's consultation process at the FY 2004
> level

[Rationale]{.underline}: The purpose of this indicator is to improve the
consultation process with IHS stakeholders. Given the number and
diversity of I/T/Us, formal policies are essential to assure broad
input, a rational and equitable approach to making timely decisions, and
the highest possible buy-in across I/T/Us. Equally important is securing
the data to assess how well the processes are actually working, and then
improving them. Finally, the IHS encourages opportunities for local
I/T/Us to evaluate the agency's progress in enhancing the consultation
process and supporting recommended changes.

[Approach:]{.underline} A partnership is essential to ensure that
resources are effectively and efficiently utilized to maximize the
positive impact health programs have on the target I/T/U populations.
Partnerships already exist with such tribal entities as the National
Indian Health Board (NIHB), the Tribal Self-Governance Advisory
Committee (TSGAC) and the National Congress of American Indians (NCAI).
A survey was developed to collect baseline data and identify the
weaknesses in the implementation of the consultation policy by the
headquarters and area offices. The information collected by the survey
instrument will be used by management and staff to establish baseline
data, identify consultative strengths and weaknesses, design
improvements, and provide feedback to local IHS, Tribal and Urban health
officials, health boards, and community members regarding stakeholder
satisfaction with the Agency's tribal consultation process.

[Data Source:]{.underline} Consultation and Participation Policy Survey.

[Type of Indicator:]{.underline} Process and Balance Scorecard: internal
perspective

[Linkages:]{.underline} This indicator supports the DHHS Strategic Plan,
Objective 6: Increase customer satisfaction, Objective 10, Maximize
collaboration with HHS stakeholders. It also underpins the IHS'
commitment supporting the Self-Determination process and AI/AN community
empowerment.

[Program Performance:]{.underline} IHS met this indicator in FY 03. In
FY 03, IHS conducted a nation-wide survey to establish baseline data to
assess the level of satisfaction ITUs have with IHS\'s consultation
process. The survey instrument was mailed to representatives of 584
federally recognized tribes, 39 urban programs and 13 tribal health
boards. Survey responses were received and are being analyzed by the
Agency.

#### Administrative Efficiency, Effectiveness, and Accountability Group:

This group of indicators addresses the improvement of administrative
functions that support the improvement of health care efficiency and
effectiveness, as well as improved agency accountability.

Indicator 38: During the FY 2005 reporting period, the IHS will have
improved the level of Contract Health Services (CHS) procurement of
inpatient and outpatient hospital services for routinely used providers
to at least 1% over the FY 2004 level of the total dollars paid to
contract providers or rate quote agreements at the IHS-wide reporting
level.

**[Rationale:]{.underline}** The CHS regulations require the use of
medical priorities to assure that persons with the most urgent need
receive services and that alternate resources pay prior to IHS expending
funds. We are seeking to ensure that contracts or rate quote agreements
are in place that provides reduced rates to IHS and its patients with
routinely used hospitals. It should be noted that IHS might never be
able to reach 100 percent because the majority of our facilities are in
rural settings. Many times, there is only one hospital in the vicinity
and they are unwilling to offer discounted rates to the IHS. The 90%
level of procuring inpatient and outpatient facility services to
routinely used providers of the total dollars paid to contract providers
will be maintained in future years.

**[Approach:]{.underline}** IHS is primarily interested in obtaining
contracts or rate quote agreements with frequently used providers. As
providers determine that agreements are feasible with the IHS, the
percentage of facilities on contract should increase.

 Frequently used hospitals are defined as those facilities to which IHS
paid more than \$50,000 for inpatient services per year and/or more than
\$10,000 in outpatient services per year. Not all hospitals meet both
criteria, and inpatient and outpatient service contracts and rate quotes
will be tracked separately.

**[Data Source:]{.underline}** The IHS contracts with Blue Cross and
Blue Shield of New Mexico for Fiscal Intermediary (FI) services. The FI
collects the claims data and maintains the IHS/CHS database. The IHS
will use FY 1999 claims paid data as the baseline because data for this
year are 99 percent complete. The IHS is the payer of last resort, which
means any alternate resource available to the patient must be billed
first. It typically takes 2 years for claims data to become complete for
a fiscal year. As the FY data becomes complete, the percent of providers
under contract within the thresholds stated above will be updated in the
GPRA Performance Report annually. Listed below are some of the
assumptions made in analyzing the data:

1.  All inpatient and outpatient claims for hospital services, processed
    by the FI for the reporting year, defined as the Purchase Order
    Fiscal Year (POFY), are eligible.

2.  Providers are considered under contract if there is a number in the
    contract field and an effective date for appropriate reporting year.
    This includes regular contracts and Rate Quotes.

3.  Payments were defined as contract or open market at a claim level.
    If any charge on a claim was paid at a contract rate, the claim is
    considered a contract payment. If all charges on a claim were paid
    at open market (i.e., paid at billed charges), the claim is
    considered open market.

4.  The provider number used to determine the total paid for the POFY is
    defined as the provider's base EIN. This is a 9-digit provider
    EIN/TIN, and includes all suffixes assigned to that EIN.

5.  Under IHS regulations, certain catastrophic cases are eligible for
    Catastrophic Health Emergency Fund (CHEF). These cases often involve
    emergencies or the need for specialized providers, which may be out
    of the area. The area may have little control over which providers
    these patients see. The CHEF threshold is \$21,700 for an episode of
    care for FY 2002. To target inpatient claims that could be CHEF
    eligible, data was run excluding any inpatient claim where IHS paid
    \$21,700 or more.

6.  Outpatient providers were included if they were paid \$10,000 or
    more under contract and/or open market. Inpatient providers were
    included if they were paid \$50,000 or more under contract and/or
    open market.

The percent of dollars paid under contract is calculated as follows:

$$\frac{\text{IHS payments  to contract providers}}{\text{Total  IHS paid dollars to providers meeting thresholds}}$$

[Program Performance:]{.underline} This data will be available in
September 2004. Purchase Order Fiscal Year 2002 claims data is used in
the calculation and is only 89% complete as of December 2002. Typically,
it takes 2 years for claims data to complete processing through the
Fiscal Intermediary (FI). It is estimated that FY 2002 data will become
complete by September 30, 2003. The CHS indicator for FY 2002 was
targeted at 88% of frequently used providers will have medical contracts
in place. This indicator was fully met.

Indicator 39: By the end of FY 2005, the IHS will have completed a
systematic assessment of the public health infrastructure for
Headquarters in an additional three Area Offices.

**[Rationale:]{.underline}** The purpose of this indicator is to assure
that a systematic and rational process is utilized to assess public
health performance. This new indicator commits IHS to evaluate our
current delivery of essential public health and related administrative
services to American Indian and Alaska Native populations.

IHS believes that it is prudent to assess systematically the delivery of
public health services to its client population using established
assessment tools. This approach can provide a rational basis for public
health planning, including workforce and organizational changes in the
IHS.

**[Approach]{.underline}**: IHS will use instruments developed by CDC\'s
National Public Health Performance Standards Program (NPHPSP), based
on the nationally recognized "Ten Essential Services of Public Health"
The NPHPSP has tested and validated the assessment process with state
and local public health programs; this tool is now considered by many to
be the best available approach to benchmarking public health programs.

**[Data Source:]{.underline}** The data for determining this indicator
will be derived from the adapted survey instruments that assess public
health and administrative infrastructure at IHS Headquarters and Area
Offices (including Tribal Epidemiology Centers). The indicator will be
considered accomplished if IHS Headquarters and all 12 Area Offices are
formally assessed, using the adapted protocol and instruments, by the
end of FY 2005.

[**Program Performance**:]{.underline} **IHS did not meet this indicator
in FY 2003.** IHS was unable to assess infrastructure at six sites; only
four sites have been completed. This indicator changes in FY 04 to
reflect our current performance. Our performance reflects lack of
national resources to conduct this work at the current time.

> **Indicator 40: No indicator for FY 04 or FY 05.**

Indicator 40: By the end of FY 2003, the IHS will increase by 10% over
the FY 2002 level the proportion of IHS facilities that have implemented
Hospital and Clinic Compliance Plans to assure that claims meet the
rules, regulations, and medical necessity guidance for Medicare and
Medicaid payment.

**[Rationale:]{.underline}** By law, IHS has been given the authority to
bill and collect reimbursement from the Medicare and Medicaid (M&M)
programs, per Title XXVIII and XIX of the Social Security Act. In order
to receive payments for services rendered, bills must be submitted to
M&M fiscal intermediaries. All bills must be supported by medical record
provider documentation, as well as medical necessity; they must be
accurately coded in order to comply with the rules and regulations of
the M&M programs. Hospital and Clinic Compliance Plans set up policy and
procedures that help insure that claims that are generated by our
facilities meet these guidelines for payment purposes. These policies
and procedures work to prevent fraud, waste and abuse so prevalent in
the health care industry.

**[Approach]{.underline}**: A survey will be provided to Areas asking
how many of their facilities have compliance plans adopted by their
respective Governing Boards and which facilities have draft plans. In
addition, Areas and Service Unit hospital and clinics will be required
to submit copies of audits and corrective actions plans for further HQs
analysis. Key criteria include status of plan development and
implementation and analysis of any external third party audits on
compliance with the rules and regulations of Medicare and Medicaid for
reimbursement.

**[Data Source:]{.underline}** The data source will be a survey provided
by HQs to the SUs through the Area Office. This information will be
tabulated by HQs and shared with Areas/SUs through its management
control tracking system.

**[Program Performance:]{.underline} IHS met this indicator.** IHS was
able to achieve 100% compliance with implemented Hospital and Clinical
Compliance Plans in 2003. Due to this, this indicator will be
discontinued after FY 2003.

> **Indicator 41: FY 05- No Indicator**
>
> **FY 04- No Indicator**

**[Rationale:]{.underline}** Funding appropriated for contract support
costs has grown to approximately \$270 million over the last five years.
The Congress and the Office of Management and Budget have requested that
the Indian Health Service review. the soundness of allocation policies
concerning contract support costs and to take steps to assure that
contract support costs provided to tribes are reasonable and do not
duplicate other funding provided to tribes by the IHS under
self-determination agreements. Technical assistance provided to tribes,
and the review of Contract Support Cost requests that are consistent
with the IHS contract Support Cost Policy and the Indian
Self-Determination Act.

[Approach:]{.underline} By the end of first quarter of FY 2003, the IHS
had met with tribal representatives complete the development of review
standards and obtain acceptance by the Director, IHS. These standards
are now utilized in the review of contract support cost requests from
contracting and compacting tribes. Verification is documented in the
Annual Funding Agreements that are approved and signed by tribes and the
IHS. In FY 2005, the IHS will provide technical assistance to each tribe
submitting proposals or letters of intent based on identified areas of
need and with specific technical assistance in the area of calculating
contract support costs.

[Data Source:]{.underline} CSC Requests and Signed Annual Funding
Agreements.

**[Program Performance:]{.underline} IHS met this indicator.** The FY
2003 performance indicator committed to support the efficient, effective
and equitable transfer of management of health programs to tribes
submitting proposals or letters of intent to contract or compact IHS
programs under the Indian Self-Determination Act by 100% use of tribes
using the new protocol, and 100% of tribes receiving technical
assistance. Since this is a federal mandate, we are electing to drop
this indicator for the future.

#### Managing Human Capital Indicator:

This indicator addresses improving the recruitment and retention of
health care providers at local I/T/Us through the efficient use of the
IHS Scholarship Program.

**[Indicator 42:]{.underline} During FY 2005, the IHS will increase its
efficiency in placing Health Profession Scholarship recipients in Indian
health settings within 90 days of graduation by 2% over the established
FY 2004 baseline.**

[Indicator 42:]{.underline} By the end of FY 2004, IHS will establish a
baseline for the proportion of Health Professions Scholarship recipients
that are placed in I/T/U programs within 90 days of graduation from
their health/allied health discipline program.

[Rationale:]{.underline} The purpose of this indicator is to increase
the efficiency in placing Health Profession Scholarship recipients in
Indian health settings and ultimately increase access to critical health
services for AI/AN people. It has replaced the previous indicator that
addressed the attrition of nurses because it represents a valid
efficiency measure and addresses a specific IHS budget line item.

The Indian Health Care Improvement Act (IHCIA), P.L. 94-437, as amended,
authorizes IHS to conduct three interrelated scholarship programs to
train the health professional personnel necessary to staff IHS, tribal,
and urban health programs serving American Indians and Alaska Natives.
During the 2002/2003 academic year, 376 students were funded for the
various health/allied health professions through section 104. Of that
number, 128 will graduate in 2003, with 27 students (Medicine, Clinical
Psychology, etc.) being placed in a deferment status while they complete
an internship, residency, or other advanced clinical training that is
required for the practice of their health profession.

[Approach:]{.underline} The IHS will utilize Area Office staff, IHS
Headquarters health professionals, IHS website, mailings to tribes and
urban facilities for announcement of students who will be completing
their degree programs. Specific activities will include:

> a\. Identify a staff person at each Area Office to assume the
> responsibility of an IHS Area Scholarship Coordinator.
>
> b\. Provide IHS, Tribal, and urban recruiter's information on students
> who are graduating from their degree programs for recruitment
> purposes.
>
> c\. Maintain a comprehensive database to track students during their
> award year in order to provide information on students by date of
> graduation and health/allied health professions.

[Data Source:]{.underline} During FY 2003, the IHS Scholarship program
implemented a new data system to monitor the status of scholarship
recipients and their placement in I/T/U settings. For FY 2004 a baseline
rate for placing these recipients will be established and the system
will be used to monitor progress in improving the efficiency in placing
them in succeeding years.

**Program Performance: The IHS MET this indicator.** The FY 2003
indicator was evaluating nurse recruitment issues. The purpose of this
indicator was to reduce nursing vacancy and attrition rates at the local
I/T/U clinical setting and ultimately improve the quality of care. The
current number of nurse positions in I/T/U programs is approximately
4000. The average vacancy rate for nurses during FY 2003 was 11%, though
some areas have an 18% rate. The attrition rate improved by 3% with the
implementation of Title 38 special pay authority. It is estimated that
the recruitment, relocation, orientation, education, and training cost
of hiring a new registered nurse is \$40,000. A nation-wide nursing
shortage continues to exist, especially in the nurse specialty
categories of ICU, ER, OR, OB, and Certified Registered Nurse
Anesthetists (the CRNA vacancy rate is approximately 33%). The current
nursing shortage makes it even more imperative that we retain the nurses
we currently employ, providing a potential for significant cost savings
and improved quality of nursing and overall health care.

# APPENDIX 1: Linkage to HHS and Agency Strategic PlanS

The IHS FY 2005 GPRA Performance Plan is a supportive and interdependent
extension of the HHS Strategic Plan and the new IHS Strategic Plan. In
Table 3 on page 2-1 of this plan, we have shown the relationship between
the four broad Strategic Goals of the IHS Strategic Plan and the FY 2005
performance indicators. Every indicator selected for our performance
plan directly or indirectly supports Objective 3.6 *Increase access to
health services for American Indians and Alaska Natives* and Objective
3.4 *Eliminate racial and ethnic health disparities.* In addition, many
IHS indicators address other components of the HHS plan and include:

> 1\. Cardiovascular Disease Prevention Indicator 30 and Obesity
> Prevention Indicator 31 directly support HHS Objective 1.1 *Reduce
> behavioral and other factors that contribute to the development of
> chronic diseases.*
>
> 2\. HIV Indicator 34 directly supports HHS Objective 1.2 *Reduce the
> incidence of sexually transmitted diseases and unintended
> pregnancies.*
>
> 3\. Immunization Indicators 23 and 24 directly support HHS Objective
> 1.3 *Increase immunization rates among adults and children*.
>
> 4\. Substance Abuse Indicators 10 and 11 directly support HHS
> Objective 1.4 *Reduce substance abuse.*
>
> 5\. Tobacco Indicator 32 directly supports HHS Objective 1.5 *Reduce
> tobacco use, especially among youth.*
>
> 6\. Injury Prevention Indicators 27 and 28 and Domestic Violence
> Indicator 16 directly support HHS Objective 1.6 *Reduce the incidence
> and consequences of injuries and violence.*
>
> 7\. Public Health Infrastructure Indicator 41directly supports HHS
> Objective 2.1 *Build the capacity of the health care system to respond
> to public health threats in a more timely and effective manner,
> especially Bioterrorism threats*
>
> 8\. Medication Error Indicator 21 directly supports HHS Objective 5.1
> *Reduce medication errors.*
>
> 9\. Accreditation Indicator 20 directly supports HHS Objective 5.4
> *Improve consumer and patient protections.*
>
> 10\. IT Development Indicators 17 and 18 directly support HHS
> Objective 5.5 *Accelerate the development and use of an electronic
> health information infrastructure.*
>
> 11\. Staff Retention Indicator 46 directly supports HHS Objective 8.2
> *Improve the strategic management of human capital.*
>
> 12\. Contract Health Care Indicator 40 directly supports HHS Objective
> 8.3 *Enhance the efficiency and effectiveness of competitive sourcing*
>
> 13*.* IT Development Indicators 17 and 18 directly support HHS
> Objective 8.6 *Enhance the use of electronic commerce in service
> delivery and record keeping.*

In a similar vein, there is considerable consistency of focus between
the new IHS Strategic Plan and the current version of the HHS Strategic
Plan. While this is not surprising relative to health care specific
areas that could fill pages, we would offer the following associations
between objectives from **HHS Goal 8 *Achieving Excellence in Management
Practices*** and selected Action Performance Goals from the IHS
Strategic Plan:

**HHS Objective 8.2 Improve the Management of Human Capital**

-   Increase the percentage of IHS Area and Headquarters staff meeting
    recommended training and experience standards for their respective
    positions.

-   Increase the number of people completing Executive Leadership
    Development Program training annually.

-   Increase the relative annual amount of training provided to I/T/U
    staff by non-IHS resources.

-   Increase the number of I/T/U staff funded through IHS completing
    long-term training annually.

-   Increase the number of partnerships with universities or other
    organizations to help train Indian people.

HHS Objective 8.3 Enhance the Efficiency and Effectiveness of
Competitive Sourcing

-   Increase the number and scope of negotiated contracts with health
    care providers.

**HHS Objective 8.4 Improve Financial Management**

-   Increase the percentage of I/T/U sites with a comprehensive IT
    system that allows for aggregation and export (sharing) of clinical,
    financial and administrative data.

-   Increase the percentage of I/T/U sites developing managerial cost
    accounting capacity.

-   Increase the percentage of I/T/U sites developing business plans
    with identified service/product lines.

**HHS Objective 8.5 Enhance the use of Electronic Commerce in Service
Delivery and Record Keeping**

-   Increase the percentage of I/T/U sites with a comprehensive IT
    system that allows for aggregation and export (sharing) of clinical,
    financial and administrative data.

-   Increase the percentage of I/T/U site able to extract clinical data
    on lifestyle components (tobacco use, alcohol us, seat belts use,
    etc).

**HHS Objective 8.6 Achieve Integration of Budget and Financial
Performance Information**

-   Increase the percentage of I/T/U sites with a comprehensive IT
    system that allows for aggregation and export (sharing) of clinical,
    financial and administrative data.

# Appendix 2: CHANGES anD Improvements

## FY 2005 Performance Plan

The FY 2005 Performance Plan represents our ongoing effort to link
annual performance indicators to the long-term health outcome goals from
the recently revised IHS Strategic Plan. This plan and it performance
targets are based on updates in baseline data and other data related
issues, the ability to address key external factors influencing success,
the level of attainment of related FY 2003 performance indicators, and
the most current proposed funding level.

In FY 05, the IHS has decreased the number of performance indicators
from FY 03 by two, and has increased the number of efficiency measures
by one. In addition, IHS has increased the number of outcome measures by
three. Over 60% of our performance measures in FY 05 are either
efficiency and/ or outcome measures.

## Revisions to FY 2004 Performance Plan

The iterative process of developing the FY 1999-FY 2003 performance
plans and drafting the FY 2005 performance report continues to be a
significant learning process for the IHS. It requires the auditing of
many different data sets to assess current access to health services and
baseline rates of various conditions. This iterative process continues
to point to needed changes in the performance evaluation process. The
table that follows summarizes the significant changes in content or
magnitude to FY 2004 indicators originally submitted with the FY 2004
budget.

Table 10: Summary of Changes to the FY 2004 IHS Performance Indicators

+----------------------+---------------------+-------------------------+
| Original FY 2004     | Revised FY 2004     | Rationale for Change    |
| Indicator            | Indicator           |                         |
+======================+=====================+=========================+
| Indicator 1:         | Indicator 1:        | This indicator will     |
| Maintain information | Address the         | allow us to add an      |
| on the prevalence of | proportion of       | additional outcome      |
| diabetes             | patients with       | measure- the percentage |
|                      | diagnosed diabetes  | of diabetic patients    |
|                      | that have poor      | who are in poor         |
|                      | glycemic control    | control. We will still  |
|                      |                     | report on the diabetic  |
|                      |                     | prevalence data; this   |
|                      |                     | data will serve as the  |
|                      |                     | background for          |
|                      |                     | indicators 1-6.         |
+----------------------+---------------------+-------------------------+
| Indicator 2: During  | Indicator 2: During | The diabetic population |
| FY 2004, increase    | FY 2004, increase   | continues to increase   |
| the proportion of    | the proportion of   | .The goal for ideal     |
| I/T/U clients with   | I/T/U clients with  | glycemic control has    |
| diagnosed diabetes   | diagnosed diabetes  | become more difficult   |
| that have            | that have           | to achieve as national  |
| demonstrated         | demonstrated        | standards continue to   |
| improved glycemic    | improved glycemic   | be tightened. IHS       |
| control by 2% over   | control by 1% over  | recognizes increasing   |
| FY 2003.             | FY 2003.            | difficulty in           |
|                      |                     | continuing to meet      |
|                      |                     | these goals.            |
+----------------------+---------------------+-------------------------+
| **[Indicator         | **[Indicator        | The diabetic population |
| 3:]{.underline}**    | 3:]{.underline}**   | continues to increase.  |
| During FY 2004,      | During FY 2004,     | The goal for ideal      |
| increase the         | increase the        | diabetic blood pressure |
| proportion of I/T/U  | proportion of I/T/U | control has become more |
| clients with         | clients with        | difficult to achieve as |
| diagnosed diabetes   | diagnosed diabetes  | national standards      |
| who have achieved    | who have achieved   | continue to be          |
| blood pressure       | blood pressure      | tightened. IHS          |
| control by 2% over   | control by 1% over  | recognizes increasing   |
| the FY 2003 level.   | the FY 2003 level.  | difficulty in           |
|                      |                     | continuing to meet      |
|                      |                     | these goals.            |
+----------------------+---------------------+-------------------------+
| **[Indicator         | **[Indicator        | The diabetic population |
| 4:]{.underline}**    | 4:]{.underline}**   | continues to increase.  |
| During FY 2004,      | During FY 2004,     | This increase affects   |
| increase the         | increase the        | our ability to improve  |
| proportion of I/T/U  | proportion of I/T/U | by 2%.                  |
| clients with         | clients with        |                         |
| diagnosed diabetes   | diagnosed diabetes  |                         |
| assessed for         | assessed for        |                         |
| dyslipidemia (i. e.  | dyslipidemia (i.e., |                         |
| LDL cholesterol) by  | LDL cholesterol) by |                         |
| 2% over the FY 2003  | 1% over the FY 2003 |                         |
| level.               | level.              |                         |
+----------------------+---------------------+-------------------------+
| **[Indicator         | **[Indicator        | The diabetic population |
| 5:]{.underline}**    | 5:]{.underline}**   | continues to increase.  |
| During FY 2004,      | During FY 2004,     | This increase affects   |
| increase the         | increase the        | our ability to improve  |
| proportion of I/T/U  | proportion of I/T/U | by 2 %.                 |
| clients with         | clients with        |                         |
| diagnosed diabetes   | diagnosed diabetes  |                         |
| assessed for         | assessed for        |                         |
| nephropathy by 2%    | nephropathy by 1%   |                         |
| over the FY 2003     | over the FY 2003    |                         |
| level.               | level.              |                         |
+----------------------+---------------------+-------------------------+
| [Indicator           | [Indicator          | The recent urban PART   |
| 18:]{.underline} No  | 18:]{.underline}    | review resulted in a    |
| FY 2004 indicator    | During FY 2004, IHS | renewed focus on Urban  |
|                      | will develop a      | program IT development. |
|                      | specific minimum    |                         |
|                      | data set as well as |                         |
|                      | appropriate         |                         |
|                      | language for the    |                         |
|                      | urban C&G           |                         |
+----------------------+---------------------+-------------------------+
| Indicator 28: During | Indicator 28:       | Indian Health Service   |
| FY 2004, increase by | During FY 2004,     | developed and deployed  |
| 3% over the FY 2002  | implement national  | the new Behavioral      |
| level, the           | reporting plan to   | Health System           |
| proportion of I/T/Us | support national    | throughout the I/T/U    |
| that have            | performance         | communities. Because of |
| implemented          | management of AI/AN | this new software       |
| systematic suicide   | suicide.            | application, that       |
| evaluation and       |                     | includes a robust       |
| referral systems     |                     | suicide reporting form; |
| that include:        |                     | IHS has modified this   |
|                      |                     | indicator to reflect    |
| a\. Monitoring the   |                     | our new comprehensive   |
| incidence and        |                     | ability to facilitate   |
| prevalence rates of  |                     | suicide national        |
| suicidal acts        |                     | reporting.              |
| (attempts and        |                     |                         |
| completions);        |                     |                         |
|                      |                     |                         |
| b\. assuring         |                     |                         |
| appropriate          |                     |                         |
| population-based     |                     |                         |
| prevention and       |                     |                         |
| interventions are    |                     |                         |
| available and        |                     |                         |
| services are made    |                     |                         |
| accessible to        |                     |                         |
| individuals          |                     |                         |
| identified at risk;  |                     |                         |
|                      |                     |                         |
| c\. establishing     |                     |                         |
| baseline rates for   |                     |                         |
| adolescent suicide   |                     |                         |
| (12-19 year olds).   |                     |                         |
+----------------------+---------------------+-------------------------+
| [Indicator           | [Indicator          | IHS is streamlining all |
| 30:]{.underline}     | 30:]{.underline} In | indicators to have only |
| During FY 2004,      | 2004, establish     | one part. This          |
| continue the         | baseline omission   | indicator is part B of  |
| incremental          | rates for BMI on    | the former FY 04        |
| implementation of    | children and        | indicator. We expect to |
| all components of    | adults.             | continue to meet part A |
| the Indian Health    |                     | and part C of this      |
| Service Obesity      |                     | indicator as part of    |
| Prevention and       |                     | our commitment to       |
| Control Plan that    |                     | developing effective    |
| was developed in FY  |                     | ways to combat obesity. |
| 2001. This includes  |                     |                         |
| IHS Area or regional |                     |                         |
| planning meetings;   |                     |                         |
| staff development    |                     |                         |
| and IT development   |                     |                         |
| to monitor American  |                     |                         |
| Indian and Alaska    |                     |                         |
| Native BMI (height   |                     |                         |
| weight data); an     |                     |                         |
| infrastructure to    |                     |                         |
| collect, interpret,  |                     |                         |
| and diffuse the      |                     |                         |
| approaches from      |                     |                         |
| obesity related      |                     |                         |
| demonstration        |                     |                         |
| projects and studies |                     |                         |
| to IHS Areas and     |                     |                         |
| I/T/Us.              |                     |                         |
|                      |                     |                         |
| a\. Each IHS Area is |                     |                         |
| responsible for      |                     |                         |
| implementation for   |                     |                         |
| an Area wide, long   |                     |                         |
| range, comprehensive |                     |                         |
| Obesity Prevention   |                     |                         |
| and Control Plan     |                     |                         |
|                      |                     |                         |
| b\. Each Area will   |                     |                         |
| decrease height and  |                     |                         |
| weight measurement   |                     |                         |
| omission rates and   |                     |                         |
| will report BMIs on  |                     |                         |
| children and adults. |                     |                         |
|                      |                     |                         |
| c\. Area Offices to  |                     |                         |
| host National and    |                     |                         |
| Area training(s)     |                     |                         |
| among I/T/U          |                     |                         |
| stakeholders that    |                     |                         |
| emphasize Area wide  |                     |                         |
| Obesity Prevention   |                     |                         |
| and Control Plan.    |                     |                         |
+----------------------+---------------------+-------------------------+
| [Indicator           | [Indicator          | Tobacco control         |
| 31:]{.underline} By  | 31:]{.underline} By | requires establishing   |
| the end of 2004, the | the end of 2004,    | appropriate rates of    |
| IHS and its          | the IHS and its     | tobacco use. This       |
| stakeholders will    | stakeholders will   | activity is the         |
| have implemented the | have established    | foundation for the      |
| identified           | rates of screening  | proposed tobacco        |
| activities as        | for tobacco use.    | control plan.           |
| specified by the     |                     |                         |
| five-year plan for   |                     |                         |
| tobacco control in   |                     |                         |
| American Indian and  |                     |                         |
| Alaska Native        |                     |                         |
| communities.         |                     |                         |
+----------------------+---------------------+-------------------------+
| Indicator 37: During | Indicator 37:       | Note, the FY 2004       |
| [FY                  | During [FY          | measure is not being    |
| 2003]{.underline},   | 2003]{.underline},  | change but we are       |
| the IHS will improve | the IHS will secure | reporting that the IHS  |
| the stakeholder      | a baseline rating   | missed revising the FY  |
| satisfaction with    | of stakeholder      | 03 target in last       |
| the agency\'s        | satisfaction with   | year's CJ submission in |
| consultation process | the agency\'s       | the face of not         |
| by 5% over the FY    | consultation        | securing the baseline   |
| 2002 level.          | process.            | as set in our FY 02     |
|                      |                     | target. By missing that |
|                      |                     | target, as we clearly   |
|                      |                     | reported last year, it  |
|                      |                     | was not appropriate to  |
|                      |                     | secure both a baseline  |
|                      |                     | and an improved score   |
|                      |                     | in the same year. Thus, |
|                      |                     | the target for FY 03    |
|                      |                     | was intended to be      |
|                      |                     | changed to securing the |
|                      |                     | baseline score. The FY  |
|                      |                     | 04 target remains       |
|                      |                     | unchanged and focused   |
|                      |                     | on documenting a        |
|                      |                     | measured improvement.   |
+----------------------+---------------------+-------------------------+
| Indicator 39: By the | Indicator 39: By    | IHS has changed this    |
| end of FY 2004, the  | the end of FY 2004, | indicator, as IHS was   |
| IHS will have        | the IHS will have   | unable to meet the      |
| completed a          | completed the       | indicator in FY 03 due  |
| systematic           | systematic          | to lack of resources to |
| assessment of the    | assessment of the   | complete his            |
| public health        | public health       | evaluation. Due to      |
| infrastructure for   | infrastructure for  | this, IHS has modified  |
| Headquarters in      | one additional Area | this indicator in FY 04 |
| three additional     | Office.             | to reflect FY 03        |
| Area Offices.        |                     | results                 |
+----------------------+---------------------+-------------------------+
| [Indicator           | [No FY 2004         | IHS has previously met  |
| 40:]{.underline} By  | Ind                 | this indicator. In      |
| the end of FY 2004,  | icator]{.underline} | response to guidance to |
| the IHS will         |                     | increased efficiency    |
| increase by 10% over |                     | and outcome measures,   |
| the FY 2003 level    |                     | and decrease process    |
| the proportion of    |                     | measures, IHS elected   |
| IHS facilities that  |                     | to drop this measure.   |
| have implemented     |                     |                         |
| Hospital and Clinic  |                     |                         |
| Compliance Plans to  |                     |                         |
| assure that claims   |                     |                         |
| meet the rules,      |                     |                         |
| regulations, and     |                     |                         |
| medical necessity    |                     |                         |
| guidance for         |                     |                         |
| Medicare and         |                     |                         |
| Medicaid payment.    |                     |                         |
+----------------------+---------------------+-------------------------+
| Indicator 41: During | [No FY 2004         | IHS has consistently    |
| FY 2005, the IHS     | Ind                 | met this indicator, and |
| will support the     | icator]{.underline} | must meet this due to   |
| efficient, effective |                     | Congressional mandates. |
| and equitable        |                     | Due to this, IHS will   |
| transfer of          |                     | drop this indicator in  |
| management of health |                     | FY 2004.                |
| programs to tribes   |                     |                         |
| who submit proposals |                     |                         |
| or letters of intent |                     |                         |
| to contract or       |                     |                         |
| compact IHS programs |                     |                         |
| under the Indian     |                     |                         |
| Self-Determination   |                     |                         |
| Act. IHS will do     |                     |                         |
| this by providing    |                     |                         |
| technical assistance |                     |                         |
| to each tribe        |                     |                         |
| submitting proposals |                     |                         |
| or letters of intent |                     |                         |
| based on identified  |                     |                         |
| areas of need and    |                     |                         |
| with specific        |                     |                         |
| technical assistance |                     |                         |
| in the area of       |                     |                         |
| calculating contract |                     |                         |
| support costs.       |                     |                         |
+----------------------+---------------------+-------------------------+
| [Indicator           | [Indicator          | This indicator has been |
| 42:]{.underline}     | 46:]{.underline}    | selected to replace the |
| During FY 2004, the  | During FY 2004,     | nursing attrition       |
| IHS will             | secure baseline     | indicator because it    |
| systematically work  | rates for the       | more directly under the |
| to improve nurse     | placement of Health | control of the IHS,     |
| attrition rates by:  | Professions         | directly linked to and  |
|                      | Scholarship         | IHS funding category,   |
| a\. Implementing the | recipients in I/T/U | and less influenced by  |
| National Council of  | setting within 90   | external market trends. |
| Nurses Recruitment   | days of graduation. |                         |
| and Retention Plan   |                     |                         |
| in all IHS Areas and |                     |                         |
| Headquarters.        |                     |                         |
|                      |                     |                         |
| b\. Assessing Area   |                     |                         |
| vacancy and          |                     |                         |
| attrition rates,     |                     |                         |
| on-line exit         |                     |                         |
| interviews, and job  |                     |                         |
| satisfaction surveys |                     |                         |
| to include salary    |                     |                         |
| and benefits         |                     |                         |
| analysis to identify |                     |                         |
| those locations      |                     |                         |
| where nursing        |                     |                         |
| vacancy and          |                     |                         |
| attrition rates are  |                     |                         |
| most problematic.    |                     |                         |
+----------------------+---------------------+-------------------------+

# APPENDIX 3: PARTNERSHIPS AND COORDINATION

The magnitude of American Indian and Alaska Native health disparities
and the resource demands require the IHS to identify and collaborate
with secondary available outside organizations that have the capacity,
capability, and interest to assist in addressing these diverse health
problems. Our resolve to develop this crosscutting network is evident by
the number and diversity of collaborative activities that are currently
in place and described in this section.

The IHS has continued to develop and expand its crosscutting
collaborations and partnership with other agencies and organizations to
achieve common goals and objectives addressing health disparities of
American Indians and Alaska Natives.

## Program Coordination By Partners Within DHHS

**[Administration for Children and Families/Head Start
Bureau]{.underline}**

-   training and technical assistance to 177 Head Start grantees,
    including a full-time health and safety specialist position and a
    computerized data system for the IHS Head Start program.

-   monitor and develop programs to address the 0-5 age group of
    American Indian and Alaska Native in prevention. This is an
    intervention program to address rising trends in obesity in this age
    group.

-   co-sponsor pilot projects to improve the health care response to
    domestic violence. (Indicator 16)

**[Agency for Healthcare Research and Quality]{.underline}**

-   supporting work to strengthen health services research; increasing
    opportunities for the Native American population into research;
    development of an Indian Primary Care Based Research Network;
    involvement of American Indian and Alaska Native in the Medical
    Expenditures Planning Survey; incorporation of IHS data into the
    Healthcare Utilization Project and strengthening the research
    infrastructure of American Indian and Alaska Native organizations.

-   support evaluation of medication errors in the Indian health system
    (Indicator 21)

-   IHS-AHRQ Electronic Health Record Evaluation

**[Centers for Disease Control and Prevention Umbrella
Agreement]{.underline}**

Annually develop a collaborative umbrella work plan that includes
specific agreements with the following CDC entities:

-   [CDC/Agency for Toxic Substances and Disease Registry Tribal
    Liaison]{.underline}: strengthen inter-government response to tribal
    public health needs

-   [Epidemiology/Preventive Medicine Training:]{.underline} hosts CDC
    Epidemic Intelligence Service (EIS) Officers for their two-year
    field epidemiology training experience and Preventive Medicine
    Residents (PMRs) for a one-year field training.

-   [CDC/National Center for Chronic Disease Prevention and Health
    Promotion-Chronic Disease Annual Work plan:]{.underline}
    intra-agency agreement/work plan was developed in 1990:

    -   Division of Cancer Prevention and Control (DCPC):

        -   provide technical assistance/guidance for capacity building
            with state health departments, IHS tribes and tribal
            organizations.

        -   provides funds for colposcopy training and other IHS cancer
            control activities.

        -   direct technical assistance and consultation to tribes and
            tribal organizations through the National Breast and
            Cervical Cancer Early Detection Program (Indicator 7-8)

    -   Health Promotion Activities for Older Adults: technical
        assistance in the design, implementation and analysis of surveys
        for health promotion activities for older adults.

    -   Behavioral Surveillance Branch (BSB): uses the CDC Behavioral
        Risk Factor Surveillance Survey (BRFSS).

    -   Cardiovascular Health: technical assistance in the design,
        implementation, and evaluation of cardiovascular risk factor
        prevention and intervention programs. (Indicator 30)

    -   Division of Oral Health: develop, implement and promote water
        fluoridation in American Indian and Alaska Native communities
        for dental disease prevention. (Indicator 12)

    -   Division of Diabetes Translation (DDT): providing technical
        consultation and assistance on public health surveillance of
        diabetes to define the burden of diabetes and diabetes-related
        complications among the Native population. (Indicators 1-6)

    -   Gallup National Diabetes Prevention Center: provide national
        leadership to plan, develop, implement and evaluate the National
        Diabetes Prevention Center. (Indicators 1-6).

> o Office on Smoking and Health (OSH): develop, establish, and maintain
> a community-based program for the prevention and control of tobacco
> use, and related health problems among American Indian and Alaska
> Native populations. (Indicator 32)

-   Division of Reproductive Health (DRH): address reproductive-related
    health problems in American Indian and Alaska Native, including
    Sudden Infant Death Syndrome, and to assist tribes in community
    health surveys.

```{=html}
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```
-   [National Center for HIV, STD and TB Prevention
    (NCHSTP)]{.underline}

> o Division of Sexually Transmitted Disease Prevention: planning,
> development and implementation of sexually transmitted disease control
> programs between American Indian and Alaska Native.
>
> o Division of HIV/AIDS Prevention:

-   assist in the coordination of national surveillance, prevention, and
    control activities for HIV/AIDS and related opportunistic
    infections, STDs, and hepatitis B and C among American Indian and
    Alaska Native people. (Indicator 33)

-   provide HIV prevention program activities for the implementation and
    evaluation of HIV prevention education for American Indian and
    Alaska Native children and youth in schools on reservations, rural
    areas, and urban metropolitan areas. (Indicator 33)

```{=html}
<!-- -->
```
-   [National Center for Infectious Diseases (NCID)]{.underline}

    -   Division of Viral and Rickettsial Diseases, Hepatitis Branch:
        epidemiologist to assist in the planning development, and
        implementation of hepatitis prevention and control programs
        between American Indian and Alaska Natives.

    -   Special Pathogens Branch: assist in the planning, development
        and implementation of Hantavirus prevention and control programs
        between American Indian and Alaska Natives.

-   [National Center for Injury Prevention and Control
    (NCIPC):]{.underline} reduce unintentional and intentional injuries
    between American Indian and Alaska Natives. The CDC has assisted IHS
    with pilot injury surveillance projects (Indicators 27-28 )

-   [National Immunization Program (NIP)]{.underline}:
    Vaccine-Preventable Disease Control - assists in the planning,
    development and implementation of vaccine-preventable disease
    control programs among American Indian and Alaska Natives.
    (Indicators 24-26)

### [Food and Drug Administration]{.underline} {#food-and-drug-administration .unnumbered}

-   reduce patient and occupational exposures; to promote principles of
    radiation protection, and to allow the FDA to monitor radiation
    protection for conformance with existing agency and Federal
    policies.

-   support in the evaluation and use of medical radiologic equipment.

### [Centers for Medicare and Medicaid Services]{.underline}  {#centers-for-medicare-and-medicaid-services .unnumbered}

The collaboration with the Centers for Medicare and Medicaid Services
(CMS) covers an array of issues that critically impact operational
issues related to the Indian health care system and the provision of
services by the IHS to its stakeholders.

-   The IHS and CMS Joint Indian Health Steering Committee includes:

    -   Legislation Subcommittee: work on legislative issues, e.g.,
        reauthorization of the Indian Health Care Improvement Act, using
        Medicare rates for CHS payments

    -   Operations Subcommittee: work on program policy and operation
        issues such as reimbursement policies, outreach and education,
        and data sharing and other policy guidance.

    -   Cost Reports Subcommittee: addresses short and long-range plans
        for development of hospital cost reports.

    -   the National Medical Education program (NMEP) Task Force, which
        ensures that beneficiaries receive accurate, reliable
        information about their benefits, rights and health plan
        options; have the ability to access information needed to make
        informed choices.

-   Home Health Care workgroup to develop draft regulations to implement
    the Prospective Payment System.

-   HHS Value-Based Purchasing Work Group that is part of the Quality
    Interagency Coordination Council. They have pursued the national
    goal to reduce the number of medical errors in health care
    environments and to build a safer health system nationally.

-   Input into the Prospective Payment System Minimum Data Sets that
    include current cost reports.

-   New Medicare and Medicaid reimbursement rates for the IHS and
    IHS-funded tribal facilities.

-   guidance and proposed regulations exempting American Indian and
    Alaska Native from any cost sharing provisions under CHIP for
    eligible children.

-   Medicare enrollment data to provide more accurate information for
    assessing outreach to Medicare beneficiaries that are American
    Indian and Alaska Native to establish an accurate database for IHS.

### [Health Resources and Services Administration]{.underline} {#health-resources-and-services-administration .unnumbered}

-   support for the PHS Primary Care Policy Fellowship program

-   provide HIV/AIDS education and training to health care providers
    that provide health care services to American Indian and Alaska
    Native people (Indicator 33)

-   share software enabling IHS to receive occupational health,
    environmental assessment and health information management support
    services

### [National Institutes of Health]{.underline} {#national-institutes-of-health .unnumbered}

-   collaborating academic research institutions, Indian tribes or
    Indian community based organizations.

-   development of treatment regimens for individuals with diabetes who
    also suffer from periodontal disease. (Indicator 15)

-   conduct clinical research studies primarily in the areas of diabetes
    and digestive diseases

### [HHS Office of Women\'s Health]{.underline} {#hhs-office-of-womens-health .unnumbered}

-   conducting 11 surveys through Indian country to identify women\'s
    health issues

### [Substance Abuse and Mental Health Services Administration]{.underline} {#substance-abuse-and-mental-health-services-administration .unnumbered}

-   support several Native American collaborations addressing mental
    health and the \"Indian Self Determination: Summit on Tribal
    Strategies to Reduce Alcohol, Substance Abuse and Violence.\"

## Collaboration With Other Federal Agencies

### [Department of Interior/Bureau of Indian Affairs]{.underline}  {#department-of-interiorbureau-of-indian-affairs .unnumbered}

-   support several Native American collaborations addressing mental
    health, domestic violence abuse and neglect (Indicator 16)

-   provide technical assistance and training for background checks of
    employees of tribal health programs.

-   support of the IHS/BIA Annual Youth Conference reaching junior high
    and high school and college teens

### [Department of Justice]{.underline} {#department-of-justice .unnumbered}

-   support coordinated activities in mental health and community safety
    for American Indian and Alaska Native children, youth, and families.

-   co-sponsor the \"Indian Self Determination: Summit on Tribal
    Strategies to Reduce alcohol, Substance Abuse and Violence.\"

### [Department of Veterans Affairs]{.underline} {#department-of-veterans-affairs .unnumbered}

-   collaborating with the VA on targeted data systems and credentialing

-   develop an agreement targeting education and outreach of veteran
    beneficiaries who are underutilizing their benefits and services.

-   develop care agreements and pharmaceutical supply agreements

-   participates in the VA Pharmaceutical Prime Vendor Program

## Injury Prevention

[National Center for Injury Prevention and Control of the
CDC]{.underline}. Present briefings on injury issues to staff from the
Senate Select Subcommittee on Indian Affairs.

# Appendix 4: Data Verification and Validation 

> **[Data Validation]{.underline}** is the process for ensuring that
> data collected matches the intended area of performance.
>
> **[Data Verification]{.underline}** is the assessment of data
> completeness, accuracy, consistency and timeliness and related quality
> control practices.

The verification of clinically based performance indicators is supported
by the IHS automated data system (RPMS), and/or the IHS Diabetes Care
and Outcomes Audit.

For the Capital Programming/Infrastructure Indicators 34-36, the data
are recorded at the local level where projects are conceptualized based
on strict protocols and formulas. These data are compiled at the Area
and Headquarters level and reviewed for accuracy and then compared
against similar projects.

For indicators that survey our consumers (indicators 21 and 37), the
required Paperwork Reduction Act clearance process effectively addresses
both validation and verification process as required in submitting the
instrument and collection protocol.

The remaining indicators in this plan are process measures for which
verification is less formalized. They are based on the integrity of IHS
reporting structures as well as our health information system --RPMS.

## Data Sources to Describe the American Indian and Alaska Native Population

The IHS utilizes outside (non-IHS) and IHS data sources to manage its
diverse programs and assess Indian health status. The two principal
outside data sources are the Bureau of the Census and the Centers for
Disease Control and Prevention, in particular, the National Center for
Health Statistics (NCHS). The Census Bureau is the source of Indian
population counts and social and economic data. However, reliable Indian
census data at the county level are only available from the Decennial
Census, once every 10 years. The IHS prepares American Indian and Alaska
Native population estimates for years between the Censuses.

The NCHS provides IHS with natality and mortality files that contain all
births and deaths for USA residents, including those identified as
American Indian or Alaska Native*.* The NCHS obtains birth and death
records from the State departments of health, based on information
reported on official State birth and death certificates. The IHS
receives these records with essentially the same basic demographic
information as the records maintained by NCHS, but with names,
addresses, and record identification numbers deleted as required by the
Privacy Act. The NCHS does perform numerous edit checks and imputes
values for non-responses. The IHS assigns IHS organizational (Area and
service unit) identifiers to the birth and death records in setting up
its Indian database. The IHS computer routines for accomplishing this
have been thoroughly verified, and the results are continuously
monitored. The IHS utilizes factors based on a National Death Index
study to adjust Indian mortality rates for race miscoding. Because of
significant time lags in obtaining mortality and natality data, IHS has
chosen not to use mortality data for annual performance plan indicators
except in special circumstances. The IHS will continue to use mortality
data for tracking long-term trends in Indian health status and to make
comparisons with other population groups.

## IHS Automated Data Systems

The IHS has its own clinical information systems to collect data on the
services provided by IHS and tribal direct and contract programs. The
software used by IHS facilities and most tribal facilities is the
Resource and Patient Management System (RPMS). It is estimated that the
national RPMS data set accounts for approximately 90 percent of the IHS
user-population and clinical visits.

The local RPMS system supports a robust clinical and administrative data
set. The PCC component (patient care component) of RPMS facilitates the
collection, aggregation, display, and utilization of patient specific
information. The PCC component includes many different software
applications that are pertinent to the electronic retrieval of GPRA
data, including lab, patient education, purpose of visit, and referral
information.

IHS applies a series of edits at the facility and central database
levels to detect and correct invalid data. At the central database
level, additional edit checks are applied to ensure that the validity of
data sorts. Reports are also assessed for linearity (is the data
consistent month to month) and completeness (how it compares to last
year) prior to sending data for review and approval. Other data quality
issues that cannot be detected by computer are identified through the
monitoring for reasonableness that is performed in the field, and by
Area and Headquarters health program staff.

Each facility that utilizes PCC has a facility-level database that
contains the detailed PCC data collected at that site. A subset of the
detailed PCC data (to meet the routine information needs of IHS
Headquarters) is transmitted to the IHS central database. The PCC data
are the source of most of IHS' GPRA measures; these measures reflect
prevention activities and morbidity and do not have the time lags
described previously for mortality data. .

The IHS has developed and deployed a clinical software application,
GPRA+. This software monitors the IHS GPRA clinical indicators at a
local level, and ensures standard data queries (through specified data
logic and data fields) at individual sites. This software facilitates
ongoing local feedback on GPRA indicators based upon site-specified
times, locations, and providers. This application enables sites to track
performance in a timelier manner, and implement appropriate responses to
their results.

Defining current user population is also critical to our data systems.
New user population data reflects a process of eliminating duplicate
patients. In addition, IHS has established a 'clinical user population',
similar to the VHA definition. This 'clinical user population' is based
on the traditional user population definition; however, in addition,
patients are included in this population if they have had two or more
visits to a set of pre-defined clinics within the last 3 years. By using
this specific population, we are able to evaluate clinical care for
AI/AN patients who are receiving some degree of ongoing care from our
system.

IHS also supports an ongoing data quality integration project. This
ensures that national clinical indicators, regardless of etiology, are
developed in a similar manner, rely on specific data sets, and have
well-defined data extract routines. The development of these processes
supports our ongoing clinical quality improvement initiative.

Our information technology path is designed to increase quality data, as
well as improve health care outcomes. Ensuring quality data for GPRA and
performance indicators remains a major focus of our information
technology development path, as does developing point of care order and
data entry through a graphical user interface.

In the course of preparing this 2003 report, IHS identified issues that
will be addressed in 2004 in order to further improve the quality of
data for clinical indicators. Some of the actions that are planned
include the following:

-   Provide training for Area GPRA coordinators after the release of the
    next version of GPRA+ software. This training provides information
    and instructions about the software and will provide a forum to
    share best practices that have been identified during the analysis
    of the 2003 performance. In addition, coordinators discuss effective
    ways of using GPRA results to work with individual facilities.

-   Provide local health program training within each Area to identify
    quality of care issues, barriers to access, and system problems that
    have a negative impact on performance. The training addresses issues
    that may cause under-reporting of results, such as backlogs in data
    entry, lack of procedures to enter lab results, or inadequate
    collection of patient information about prior history, especially
    immunizations. Coding issues may also result in underreporting of
    care and will be addressed. See GPRA checklist on page 27.

-   Encourage those tribal facilities not running RPMS to either begin
    to use it or to develop or purchase software that is compatible with
    GPRA+. Require urban contractors to do the same.

## IHS Diabetes Care and Outcomes Audit 

A final important data set that underpins the diabetes treatment
indicators 1-6 is the [IHS Diabetes Care and Outcomes
Audit]{.underline}. Since 1986 a yearly medical record review to assess
diabetes care has been conducted in more than 75% of the IHS and tribal
facilities, representing care to nearly 70,000 American Indian and
Alaska Native people with diabetes. The medical staffs at participating
facilities are encouraged to maintain active diabetes registries using
uniform definitions. Each registry is maintained in the IHS medical
record system and includes information about individuals with diagnosed
diabetes who have been seen at least once in the past three years. Each
year a systematic random sample is drawn from each facility\'s registry,
using a sample size sufficient to provide estimates of
[+]{.underline}10% of the true rates of adherence for that facility with
a confidence of \>90%.

The medical record review measures selected clinical interventions,
performance measures, and intermediate outcomes using the uniform set of
definitions. The Area diabetes consultants conduct chart reviews and
other professional staff trained by them in accordance with written
instructions and definitions provided by the IHS Diabetes Program. The
abstracted data are entered into a microcomputer-based epidemiologic
software program. Summary reports are printed for immediate use by
facility staff in their quality improvement and program planning
activities. Regional and national rates are constructed for each item of
the medical record review after data are aggregated from all
participating sites.

During the period 1995-1999, approximately 150 sites submitted data to
be compiled for the IHS total. Indian health facilities and tribally
contracted facilities that do not provide direct patient services did
not participate in the audit. Participation from each of the 12 IHS
administrative regions varied by year and by federal or tribal
management. All regions were represented in each year and approximately
2/3 of all the facilities contributed data in a given year. Tests of
trend over the 3- year period were performed by the Mantel-Hanzel test
except as noted in the text.

Our diabetic indicators are reported using diabetic audit data for FY
2002. However, due to the delay in obtaining this data, and the
successful development and deployment of our GPRA+ software, GPRA+ data
was used for the FY 2003 report. We anticipate that future data will be
reported using GPRA+, as well as continuing to track the results of the
manual diabetic audit. Our hope is the eventual synthesis of these two
data sources into one report.

# Appendix 5: Performance Measurement Linkages 

## Performance Measurement Linkages with Budget

For the first time, the 05 budget includes budgetary links to
performance by positing costs for achieving specific indicator goals.
These projections must be cautiously evaluated. IHS is unable to
evaluate costs for many of our performance measures. The vast majority
of our clinical measures rely on interdisciplinary approaches to the
delivery of care. Consequently, we are unable to designate specific
costs for each separate activity at the current time. The budget
category narrative includes an overview into the development of the
budget costs assigned to that category. We anticipate incremental
improvement in this evaluation over the next few years. **Our GPRA
indicators are representative of our programs, but not a comprehensive
reflection of our program portfolio.**

Our agency health care funding is annually prioritized to the acute and
chronic problems of greatest need and concern to our consumers. Health
outcomes (i.e., mortality and morbidity) are well articulated annually
in our publication *Trends in Indian Health* with 2-3 year old data. Our
indicator set reflects these current and chronic problems.

Similarly, while performance targets for indicators addressing
facilities construction are linked to funding levels in a linear way,
this is often not the case for indicators addressing health care
services when viewed through a one-year timeframe. In some cases,
investments in the supportive infrastructure are the highest priority
for long-term effectiveness but will do nothing in the short-run to
increase access to services.

In addition, the American Indian and Alaska Native population increases
over 1.7 percent annually. Thus, service capacity must be increased over
1.7 percent just to remain at the same level of coverage each year for
the indicators that set a target for the percent of the population
covered. Many health care related indicators have minimal target level
increases or commit to the same level as FY 2004 due to this. Achieving
these levels of care, however, are unlikely to reverse the downward
trend in health status of the American Indian and Alaska Native
population.

## Cost Accounting

In 2002, we prepared Medicare cost reports for all inpatient facilities,
both direct federal and tribal. There were 47 facility reports and 12
home office reports (10 are offices, Headquarters, and Alaska Native
Tribal Health Consortium) for 50 separate reports. It is anticipated
that we will continue to prepare a report for each inpatient facility
each year/ The cost reports determine our billing rates (both inpatient
and outpatient) for other Medicare and Medicaid with the exception of
Medicare inpatient, which is paid via DRG.

## Human Resources

The IHS is committed to human resource development (HRD) and work life
improvements as an essential component of performance planning and
performance management. Historically, we have invested in long- and
short-term training for all staff to assure capable public health
leaders, healthcare providers and administrative support. The current
IHS Strategic Plan includes Objective 2.3 *Expand and Maintain
Organizational Capacity and Experti*se that is support by a series of
strategies and the following Action Performance Goals:

> 1\. Increase the percentage of IHS Area and Headquarters staff meeting
> recommended training and experience standards for their respective
> positions.
>
> 2\. Increase the number of people completing Executive Leadership
> Development Program training annually.
>
> 3\. Increase the relative annual amount of training provided to I/T/U
> staff by non-IHS resources.
>
> 4\. Increase the number of I/T/U staff funded through IHS completing
> long-term training annually.
>
> 5\. Increase the number of partnerships with universities or other
> organizations to help train Indian people.

The requested FY 2005 IHS budget includes a renewed commitment to find
cost-effective approaches to better meet HRD\--including clinical,
public health, management, information technology, and general
organizational effectiveness training\-- and work life needs. Through
our human capital projects we are addressing succession planning;
competency and development needs of direct health-care providers;
developmental needs of managers, supervisors and leaders;
state-of-the-art workplace practices such as flexible working hours and
workplace; and communication of organizational and professional
information to support performance. The IHS\' approach to CCA
implementation will follow the example of the Department in delegating
responsibility and authority to the Area Directors for Area IT capital
planning and investment control.

HHS information technology will be managed on an enterprise basis with a
common infrastructure, rather than by many separate agencies. One of the
efforts underway is a unified financial management system. Specifically,
HHS will have one financial management system for the Centers for
Medicare and Medicaid Systems and the Medicare contractors called
HIGLAS, and another management system for the rest of the department.
The purpose of this endeavor is to achieve greater economies of scale,
eliminate duplication, and provide better service delivery. The unified
financial management system will reduce costs, mitigate security risks
and provide timely and accurate information for management purposes.
With the unified system, IHS and the rest of the department will have
uniform business rules, data standards and accounting policies and
procedures and a more efficient implementation as administrative support
functions are incorporated.

## Capital Planning

The maintenance deficiencies for health care facilities are captured and
presented to Congress in the Backlog of Essential Maintenance,
Alteration, and Repair for IHS and participating tribal facilities.
Sanitation Facilities Construction needs are identified and reported to
Congress through the Sanitation Deficiency System. Capital asset
planning for health care facilities construction is done in accordance
with the IHS Health Care Facilities Priority System Methodology and
submitted to OMB through Circular A-11, Preparation of Budget Estimates,
and Section III for reporting capital assets. These activities are
represented in this performance plan by the three Capital
Programming/Infrastructure Indicators in section 3.2.3.

## Program Evaluation

IHS recognizes the growing importance of evaluation in supporting the
IHS Mission, Goal and GPRA performance planning. The IHS evaluation
process seeks to include American Indians and Alaska Natives as primary
stakeholders in defining the purpose, design, and execution of
evaluations. The IHS has worked with it stakeholders in identifying and
implementing principles of responsive evaluation practice and setting
evaluation priorities.

The purposes of IHS evaluation efforts are:

-   to advise the Director of the IHS on policy formulation; to conduct
    and manage program planning, operations research, program
    evaluation, health services researches, legislative affairs, and
    program statistics;

-   to develop the long-range program and financial plan for the IHS in
    collaboration with appropriate agency staff;

-   to coordinate with HHS, Indian Tribes, and organizations on matters
    that involve planning, evaluation, research and legislation; and

-   to develop and implement long-range goals, objectives, and
    priorities for all activities related to resource planning and
    allocation methodologies and models.

The Office of Public Health (OPH) serves as the principal advisory
office to the IHS on issues of national health policy and coordinates
these four evaluation functions:

-   *Health Program Evaluations*\--Collect and analyze information
    useful for assisting IHS officials in determining the need for
    improving existing programs or creating new programs to address
    health needs;

-   *Policy Analysis*\--Conduct analyses when a change in the IHS health
    service delivery system must be considered, when issues emerge in an
    area where no policy currently exists, or when current policies are
    perceived as inappropriate or ineffective;

-   *Health Services Research*\--Undertake analyses of the organization,
    financing, administration, effects, and other aspects of the IHS;
    and

-   *Special Studies and Activities*\--Conduct studies and prepare
    special reports required by Congress in response to pending
    legislation or policies, often using a roundtable whenever an issue
    or a health problem requires immediate action and it is unclear what
    type of action should be taken.

The OPH meets part of the IHS evaluation needs with two major types of
short-term studies: policy or program assessments and evaluation study.
The policy study contributes to IHS decision-making about budget,
legislation, and program modifications and includes background
information to support IHS projects. Evaluation studies are carried out
at the program level, or area offices, and focus on specific program
goals.

## Summary of Select Evaluations Activities

Several evaluation projects funded in FY 04 have significant direct
and/or indirect implications for IHS performance planning and are thus
summarized below:

***An Evaluation of Influenza and Pneumoccocal Vaccination coverage in
Adults***

This project is designed to help the IHS to evaluate the accuracy of the
NIPIRS data and to quantify the degree, if any, of under-estimation of
influenza and Pneumoccocal vaccination coverage levels for each IHS
Area. Once this is determined, the IHS and Area offices will be able to
adjust the NPIRS-based rates and provide a more accurate measure of
influenza and pneumoccocal coverage. This in turn will allow IHS to
better identify possible barriers to immunization with influenza and
pneumoccocal and develop strategies to improve coverage.

***The Effects of Fluoridation on the Prevalence of Oral Disease in
American Indian Youngsters***

This project focuses on health program evaluation and health services
research. It proposes an epidemiologic evaluation of the efficacy of
water fluoridation in Indian Country. This evaluation will help identify
the impact of water fluoridation on oral health.

***Domestic Violence Pilot Project Evaluation***

This project will strengthen the Indian, Tribal and Urban (I/T/U)
facility responses to domestic violence through a "Health program
Evaluation". Recently funded IHS-ACF domestic violence pilot projects
will be evaluated for efficacy. These results will be shared with other
health care facilities throughout Indian country.

***Cost Effectiveness of a Rural IHS Tele-medicine Consultation
Services***

Since 1999, an Indian Health Service Hospital, located in remote, South
Dakota, has been using a clinical tele-medicine program to deliver a
wide range of clinical specialist's consultation and disease management
services. Before 1999, these services required traditional face-to-face
encounters between the patient and the specialist. This work-time; a
high-risk of failed follow-through by the patient, weather delays a
restricted range of services that fit Contract Health Services priority
one definitions; and off-site care delivery which precluded revenue
generation by the Service Unit. This study will evaluate the economic
impact of this method of care delivery.

***Suicide Data Collection and Surveillance For Prevention Program***

The purpose of this project is to reduce the high rate of suicide
completions and attempts among youth and young adults on an American
Indian Reservation by increasing the tribe's efforts to collect
meaningful surveillance data to support the development of a
comprehensive, evidence based on prevention program.

## New Directions for Evaluation

The IHS is responding to dramatic changes taking place inside and
outside the Government including greater involvement of tribal
governments in the Indian health care system, technological innovations,
the changing patterns of disease to more chronic conditions, and the
transfer of many Federal programs and resources to individual States.
IHS remains committed to comprehensively community-based, preventive,
and culturally sensitive projects that empower tribes and communities to
overcome health issues. In addition, IHS continues to embrace GPRA as a
cornerstone of our ongoing commitment to clinical quality improvement.

# APPENDIX 6: SUMMARY FULL COST OF PERFORMANCE PROGRAM AREAS

## Performance Program Summary Table

Estimated Full Cost by Program

(\$ in Millions)

  ---------------------------- --------------- -------------- -------------
  Performance Program Area     FY 2003         FY 2004        FY 2005

  Treatment                    \$2,934.8       \$3,012.5      \$3,133.9

  Prevention                   \$133.7         \$139.6        \$145.9

  Capital                      \$439.0         \$452.3        \$469.3
  Programming/Infrastructure                                  

  Partnerships, Consultation,  \$3.0           \$2.8          \$2.9
  Core Functions, and Advocacy                                

  Total Full Cost of           \$3,510.5       \$3,607.2      \$3,752.0
  Performance Program Areas \*                                
  ---------------------------- --------------- -------------- -------------

  -------------------------- --------------- -------------- -------------
  IHS Total Program Level    \$3,510.5       \$3,607.2      \$3,752.0
  \*\*                                                      

  -------------------------- --------------- -------------- -------------

\* Equals the sum of the full cost of each performance program area in
Attachment 3

\*\* Equals the total program level included in the tables for
Attachment 1.

TREATMENT\*

+---------------------------+--------------+-------------+------------+
| Request, Full Costs &     | FY 2003      | FY 2004     | FY 2005    |
| Annual Measures           |              |             |            |
|                           |              |             |            |
| (\$ in millions)          |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Budget Request (Program | \$2,882.4    | \$2,962.7   | \$3,082.6  |
| Level)**                  |              |             |            |
|                           | \$2,934.8    | \$3,012.5   | \$3,133.9  |
| **Estimated Full Cost**   |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 1**               | \$814.2      | \$817.5     | \$820.8    |
|                           |              |             |            |
| Incorporates measures:    |              |             |            |
|                           |              |             |            |
| 1-5                       |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 2**               | \$1.6        | \$1.7       | \$1.8      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 6                         |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 3**               | \$11.6       | \$12.1      | \$12.5     |
|                           |              |             |            |
| Incorporates measures:    |              |             |            |
|                           |              |             |            |
| 7-8                       |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 4**               | \$18.9       | \$19.0      | \$19.5     |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 9                         |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 5**               | Pending      | \$1.6       | \$1.6      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 10                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 6**               | \$89.4       | \$90.9      | \$92.7     |
|                           |              |             |            |
| Incorporates measures:    |              |             |            |
|                           |              |             |            |
| 11-14                     |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 7**               | \$1.4        | \$1.8       | \$1.9      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 15                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 8**               | \$6.5        | \$6.7       | \$8.2      |
|                           |              |             |            |
| Incorporates measures:    |              |             |            |
|                           |              |             |            |
| 16-18                     |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 9**               | \$471.5      | \$477.5     | \$477.5    |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 19                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 10**              | \$0.3        | \$3.0       | \$6.0      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 20                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 11**              | \$0.2        | \$0.2       | \$.2       |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 21                        |              |             |            |
+---------------------------+--------------+-------------+------------+

\* The distribution of full costs to performance measures may not equal
the full cost of the performance program area.

**PREVENTION**\*

+---------------------------+--------------+-------------+------------+
| Request, Full Costs &     | FY 2003      | FY 2004     | FY 2005    |
| Annual Measures           |              |             |            |
|                           |              |             |            |
| (\$ in millions)          |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Budget Request (Program | \$121.7      | \$128.1     | \$134.3    |
| Level)**                  |              |             |            |
|                           | \$133.7      | \$139.6     | \$145.9    |
| **Estimated Full Cost**   |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 1**               | \$39.6       | \$43.1      | \$46.5     |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 22                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 2**               | \$7.0        | \$7.9       | \$8.6      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 23-25                     |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 3**               | \$37.8       | \$38.6      | \$40.5     |
|                           |              |             |            |
| Incorporates measures:    |              |             |            |
|                           |              |             |            |
| 26-27                     |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 4**               | \$24.0       | \$26.0      | \$28.0     |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 28                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 5**               | \$1.5        | \$2.7       | \$12.5     |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 29-30                     |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 6**               | \$.5         | \$1.5       | \$5.0      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 31                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 7**               | \$3.0        | \$3.0       | \$3.6      |
|                           |              |             |            |
| Incorporates measures:    |              |             |            |
|                           |              |             |            |
| 32-33                     |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 8**               | \$0.2        | \$0.2       | \$0.2      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 34                        |              |             |            |
+---------------------------+--------------+-------------+------------+

\* The distribution of full costs to performance measures may not equal
the full cost of the performance program area.

CAPITAL PROGRAMMING/INFRASTRUCTURE\*

+---------------------------+--------------+-------------+------------+
| Request, Full Costs &     | FY 2003      | FY 2004     | FY 2005    |
| Annual Measures           |              |             |            |
|                           |              |             |            |
| (\$ in millions)          |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Budget Request (Program | \$418.7      | \$431.2     | \$447.0    |
| Level)**                  |              |             |            |
|                           | \$439.0      | \$452.3     | \$469.3    |
| **Estimated Full Cost**   |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 1**               | \$98.6       | \$120.9     | \$123.3    |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 35                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 2**               | \$86.3       | \$74.0      | \$76.3     |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 36                        |              |             |            |
+---------------------------+--------------+-------------+------------+

\* The distribution of full costs to performance measures may not equal
the full cost of the performance program area.

**PARTNERSHIPS, CONSULTATION, CORE FUNCTIONS, AND ADVOCACY**\*

+---------------------------+--------------+-------------+------------+
| Request, Full Costs &     | FY 2003      | FY 2004     | FY 2005    |
| Annual Measures           |              |             |            |
|                           |              |             |            |
| (\$ in millions)          |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Budget Request (Program | \$0          | \$0         | \$0        |
| Level)**                  |              |             |            |
|                           | \$3.0        | \$2.8       | \$2.9      |
| **Estimated Full Cost**   |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 1**               | \$0.1        | \$0.1       | \$0.1      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 37                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 2**               | \$3.0        | \$3.3       | \$3.7      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 38                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 3**               | \$0.1        | \$0.1       | \$0.1      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 39                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 4**               | \$0.4        | N/A         | N/A        |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 40                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 5**               | \$1.0        | \$1.0       | \$1.0      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 41                        |              |             |            |
+---------------------------+--------------+-------------+------------+
| **Group 6**               | \$1.0        | \$0.7       | \$0.7      |
|                           |              |             |            |
| Incorporates measure:     |              |             |            |
|                           |              |             |            |
| 42                        |              |             |            |
+---------------------------+--------------+-------------+------------+

\* The distribution of full costs to performance measures may not equal
the full cost of the performance program area.

#  {#section-3 .unnumbered}

[^1]: Pneumococcal conjugate (PCV) and Varicella (VZV) vaccines were
    also in short supply, but are not included in the vaccine coverage
    calculations and therefore do not affect vaccination coverage
    levels.