USET Impact Week 2017/W… · •Impact 7 tentative offers now ... -ernance Alaska Albuquerque Bemidji Billi.ngs California Great Plains Na.>lni lle Navajo Oklahoma City Phoeniii:

USET Impact WeekPresenter: Martha Ketcher, Nashville Area Director, IHS

February 8, 2017

Hiring Freeze

• Hiring Freeze• 1/22/17 Confirmed Offer• 2/22/17 EOD

• Request for Exemption – Guidance from Agency Head• Provide info on positions that should be exempt 600 series including ancillary

positions as HR

• Impact 7 tentative offers now on hold, 2 ok – 63

• January 31 letter from the Senate Democratic members of the SenateCommittee on Indian Affairs to Pres. Trump regarding the hiring freeze.The Senators request Pres. Trump exempt IHS from the hiring freeze.

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Realignment

• Follow Up from the USET Annual Meeting in Cherokee NC

• Questions/Responses

• EOC

Financial Transparency

• Averted a shutdown with the first CR CR #1 - December 9, 2016

• CR #1 percentage is 19.18% with a reduction of 0.496%

• CR #2 percentage is 38.35% with reduction of .1901%

• April 28

• Up to 57.43%

• Tribal Payments are complete

Highlights - 2017

Assessing Care & Improving Quality• Opioid Crisis

• Pamunkey

• Urban Tech Assist

• Onondaga

• Accreditation – Unity and Mashpee

How we Deliver• QPP/MACRA

• Clinical Leadership and Accountability– CMO

• Telehealth

• Strengthening Management

• Lockport Lease & service

Staffing

• CMO – Dr. Toedt assisting HQ , Dr. Finke OPH (A) Director

• Management Analyst

• Urban Tech Assist

• ALN/OTA Dir (A)

• Physicians @ 75% (Micmac Physician hired)

Accomplishments

• 2016 Annual Report

• Awards Ceremony

• NABO finished year with collection of over 1.2 million which was a 53% increase from FY2015 collections

• FY 2019 Budget Formulation

• HR: 22 positions in the game, appx. 10 EOD’s now through February

• PMAPs

• Ensured that all RPMS applications patches have been released and installed throughout the Nashville Area so that all RPMS facilities have the latest software available.

Quality and Access2016

• Assisted with IHS-CMS Systems Improvement Agreement GPA

• Restored Emergency Department operations, providing over 4,053 visits between July and October.

• Ensured continuity of operations for health care services in theNashville Area

• Reduced the federal Clinical Director vacancy rate in the Nashville Area from 100% to 25%

Quality and Access2016

• 24 of 24 GPRA at Federal sites, 17 of 24 for all reporting sites

• 18 Nashville Area sites using RPMS upgraded to 2014 certified EHR

• Fully transitioned to ICD-10

• Capacity building – EHR, PCMH

• Peer chart reviews

• Improving the patient experience

• Improving access to care

• Capacity-building - EHR

Quality and Access 16/17

• FY 2016: 681 Tele-Behavioral Health Encounters• Catawba (506)• Micmac (95)• American Indian Community House (80)

• FY 2016: 94 telemedicine visits at Cherokee Indian Hospital

• Growing infrastructure

• Tele dermatology contract

• Tele psychiatry expansion

Ensuring Patient Safety2016/2017

• Provider training on pain management and opioid prescribing

• Review of state prescription database monitoring reports

• Weekly check-in call with federal Clinical Directors

• Clinical Director orientation

• Clinical decision support

Thank You

Questions ?

14

The FY 2019 Tribal Budget Formulation Team includes Nashville Area IHS, USET, and healthleaders from Nashville Area Tribes and Urban Programs. Tribal representatives arenominated by the USET Health Committee. Team Kickoff meeting was held on October 13, 2016; with additional meeting dates: Oct 20, Nov 3, 7, 17; and December 1, 8.

This year ’s team recently concluded the FY 2019 Tribal Budget Formulation process, andincluded the following representatives:

• Mark Skinner, Lindsay King, Catherine Willis – IHS• Dee Sabattus, Hilary Andrews - USET• Kerry Hawk Lessard - Native American Lifelines - Urban Programs• Edie Jackson – Poarch Band of Creek Indians - Title V• Theresa Cochran – Aroostook Band of Micmac Indians - DST• Myra Sylestine- Alabama Coushatta Tribe of Texas - Title I

Process

TOP 8 BUDGET INCREASES

1. Alcohol/Substance Abuse (A/SA) +$246.4 M

2. Mental Health +$201.6 M

3. Purchased/Referred Care (PRC) +$179.2 M

4. Hospitals & Clinics +$156.8 M

5. Dental Health +$112.0 M

6. Maintenance and Improvement +$112.0 M

7. Health Care Facility Construction +$67.2 M

8. Indian Health Professions +$67.2 M

Budget Proposals

The Nashville Area offers the following budget recommendations for FY 2019:

• Fund the Indian Health Service at $6.896 billion, +33% over the FY 2016 enacted budget levels, a recommended increase of $1.586 billion.

• At +33% fully fund Current Services and Binding Obligations at an estimated $444 million• Federal & Tribal Pay Costs $12.8 million• Medical & Non-Medical Inflation $23.6 million• Population Growth $33.5 million• Staffing for New Facilities $75.0 million• Health Care Facilities Construction $100.0 million

Budget Proposals cont.

At +33%, fund Program Expansion beyond Current Services and BindingObligations at $571.5 million for the following Clinical Services programs:

• Alcohol/Substance Abuse $246.4 million

• Mental Health $201.6 million

• Purchased and Referred Care $179.2 million

• Hospitals & Clinics $156.8 million

• Dental Health $112.0 million

• Maintenance and Improvement $112.0 million

• Health Care Facilities Construction $67.2 million

• Indian Health Professions $67.2 million

Hot Issues

• Increase incidence of domestic violence

• Substance Abuse Rehabilitation and Aftercare

• Increases in Pharmaceutical Costs

• Maintenance & Improvement Funding Needed

FY 2019National Tribal Budget Formulation Meeting

Washington DC, February 16-17, 2017

NAS Team representatives: Dee Sabattus, Kerry Hawk Lessard

Technical Support: Edie Jackson

Nashville Area

CMO Update

CAPT MICHAEL TOEDT, MD, FAAFP

USET IMPACT MEETING

FEBRUARY 8, 2017

Quality and Access

2016

Assisted with IHS-CMS Systems Improvement

Agreement GPA

Restored Emergency Department operations, providing

over 4,053 visits between July and October.

Ensured continuity of operations for health care

services in the Nashville Area

Reduced the federal Clinical Director vacancy rate

in the Nashville Area from 100% to 25%

Quality and Access

2016

24 of 24 GPRA at Federal sites, 17 of 24 for

all reporting sites

18 Nashville Area sites using RPMS

upgraded to 2014 certified EHR

Fully transitioned to ICD-10

Capacity building – EHR, PCMH

Quality and Access

2016/2017

Peer chart reviews

Improving the patient experience

Improving access to care

Capacity-building - EHR

Telehealth

2016/2017 FY 2016: 681 Tele-Behavioral Health Encounters

Catawba (506)

Micmac (95)

American Indian Community House (80)

FY 2016: 94 telemedicine visits at Cherokee Indian

Hospital

Growing infrastructure

Tele dermatology contract

Tele psychiatry expansion

Ensuring Patient Safety

2016/2017

Provider training on pain management and opioid

prescribing.

Review of state prescription database monitoring

reports

Weekly check-in call with federal Clinical Directors

Clinical Director orientation

Clinical decision support

Meet & Maintain

Accreditation

2016/2017

Mock Surveys

Medical Staff Bylaws

Credentialing and Privileging

Policies and Procedures

SecurityHIPAA Security Rule

(45 C.F.R 164.302- 318)

Risk Analysis Requirement

Risk Analysis

• First step in complying with the standards contained in the HIPAASecurity Rule

• Security Rule is not “intended to be a one-size-fits-all blueprint forcompliance with the risk analysis requirement”

• Organization should determine the most appropriate way to achievecompliance

• Only federal agencies are ‘REQUIRED to follow guidelines’ set by theNational Institute of Standards and Technology (NIST) – non-federalorganizations may find the guidelines vaulable

Risk Analysis (Continued)

• All e-PHI created, maintained, transmitted by an organization is subject to the security rule

• Security Rule requires entities to evaluate risks and vulnerabilities andto implement reasonable and appropriate security measures toprotect that data.

• Security rule “DOES NOT PRESCRIBE A SPECIFIC RISK ANALYSISMETHODOLOGY….” but establishes several objectives that anymethodology must achieve

Risk Analysis (Continued)

• Elements of a Risk Analysis• Scope of the Analysis

• Data Collection

• Identify and document potential threats and vulnerabilities

• Assess current security measures

• Likelihood of threat occurrence

• Potential impact of each threat

• Level of Risk

• Finalize document

Cybersecurity Threats - 2017

• Hackers will become even more innovative

• Ransomware will become more widespread – Washington DC policesecurity camera system was infected with Ransomware prior to the2016 inauguration.

• Expect the return of self-propagating worms such as Nimda (Adminbackwards), Code Red etc. The recent attack on the San FranciscoMunicipal Transport Authority – 2000 systems were locked withransomware.

Cybersecurity Threats – 2017

• IoT – Internet of Things attacks will spread from home networkeddevices (security cameras, refrigerators, etc.) to attacks on powergrids and manufacturing companies

• Internal Threats – use of social media, email can easily bypass themost effective firewalls, URL filters, anti-virus software.

• TDOS – Telephony Denial of Service Attack – external attack on VoiceOver Internet Protocol (VOIP) system that eventually culminates inbreaking into the network

Telehealth

• Nashville is still working with the University of Miami on theTeledermatology Program.

• If you are considering working with a telehealth provider, pleaseensure their equipment is compatible with any teleconferencingequipment you intend to use.

Telehealth / Telemedicine Overview

CAPT Michael Toedt, MD, FAAFP

USET Impact Meeting

February 8, 2017

Agenda

• Provide Background of Telehealth and Telemedicine

• Identify what Telehealth Services are currently available

• Provide information about TeleBehavioral Health Center of Excellence

• Discuss future Telehealth programs

• Questions

Background

• Telemedicine / Telehealth Definition

• Telehealth Services currently available within Indian HealthService (IHS)1. TeleBehavioral Health Center of Excellence

2. Teleophthalmology

3. Teleradiology

4. Pediatric Emergency Department (ED) Telehealth Service (Albuquerque Area)

5. Medical ED Telehealth Service (Billings Area)

6. Teledermatology (Nashville Area expanding to Albuquerque Area)

7. Telewoundcare (Oklahoma Area)

8. Telenutrition (Phoenix Area)

Benefits

• Benefits

– Improved access

The right care, at the right place, and at the right time

– Cost efficiencies and improved clinical value (quality/cost)

– Improved quality of care and clinical outcomes

– For patients:

Reduced travel times

Increased access to primary and specialty care

Improved patient satisfaction

1. http://www.americantelemed.org/about-telemedicine/what-is-telemedicine#.Vv0_7U2FOpo2. http://annals.org/article.aspx?articleid=2434625

TeleBehavioral Health Center of Excellence (TBHCE)

Dr. Chris Fore (Director of TBHCE)

• Provides ongoing outpatient psychiatry and counseling services• Occurs in real time• 2015 Highlights

– 5,685 patient visits– 3,047 hours of service

• Resource Information

– TeleBehavioral Health Center of Excellence Toolkit

– TeleBehavioral Health Implementation Checklist from the TBHCE

– Website: https://www.ihs.gov/telebehavioral/index.cfm/telehealth/

TeleBehavioral Health Center of Excellence FY 2015 Clinical Hours

900

800

700

600

500

400

300

200

100

0

Q1 Q2 Q3 Q4

Total Hours

Child

Adult

Addiction

Psychology

TeleBehavioral Health Center of Excellence Total Clinical Hours

1000

500

0

1500

3500

3000

2500

2000

FY13 FY14 FY15

Hours

TeleBehavioral Health Sites

IHS-Joslin Vision Network Teleophthalmology Program

Dr. Mark Horton (Director IHS-JVN Program)

• Provides remote diagnosis and management of diabetic retinopathy

• Preventing Diabetes-Related Blindness in American Indians and Alaska Natives

• Store and forward, not real time

• 2015 Highlights

– IHS JVN Eye exams = 19,184

• Resource Information

– https://www.ihs.gov/teleophthalmology/

JVN Physical Components

Retinal CamerasDiagnostic Display

(National Reading Center)

Diabetic Retinopathy SurveillanceIHS-JVN Teleophthalmology Program

96 Fixed/Hybrid sites + 13 Portable Sites in 25 States

Clinical OutcomeIHS DR Exam Rate pre/post JVN Ramp-up

Future State: Possibilities

• Additional Telehealth Services:

– Behavioral Health

– Cardiology

– Maternal/Child Health

– Nephrology

– Pain Management

– Pediatric Behavioral Health

– Rheumatology

– Wound Care

– ENT

Questions to Group

• How can we work together to use telemedicine optimally to support quality health care in your community?

• How can telemedicine services best be used to expand and improve services for your community? In what types of careinteractions are you in favor of expanded telemedicine?

• What telemedicine services are being considered and how will they impact current services?

• What will be the impact of telemedicine services on current hired staff at IHS facilities and jobs for local communitymembers?

• How can current telemedicine services be improved?

Behavioral Health ProgramUpdate

Palmeda D. Taylor, PhD

USET Meeting

February 8, 2017

Presentation Goal

• To apprise the audience of the BH Program’s recent accomplishments/ongoing efforts relative to:• Professional staff training

• Telebehavioral health services

• Opioid crisis response support

“The 2017 Suicide & Depression Meeting”

Meeting-Site, Dates, and Sponsor

• Site:• The Nashville Area Office

• Dates:• November 14-16, 2016

• Sponsor:• BH Program, OPH, Nashville Area Office

Target Audience/Participants

• Nashville Area behavioral health professionals, MSPI project staff, andinterested parties

• Participants• 9 Area Tribes

• 2 Area Service Units

• USET and BIA staff

Conference Objectives

• To increase the competence of participants in recognizing andresponding to individuals who are suicidal or at risk for suicide

• Through the provision of evidence-based strategies and research-informed models of care

• To give meeting attendees a chance to share with each other about their suicide prevention efforts at the community-level

Conference Format

• Lecture, Role-Play, Large Group Discussion, and Focus Groups

Conference Agenda

• Topics covered:

• Suicide Assessment and Prevention

• Treatment Planning

• Building Resilience

• Documentation of Risk

• Safety Planning and Counseling on Access to Lethal Means

Conference Presenters

• David A. Jobes, PhD, ABPP, Professor of Psychology and Associate Director of Clinical Training, The Catholic University of America

• Shawn C. Shea, MD, Director, Training Institute for Suicide Assessment and Clinical Interviewing

• Adam Graham, MS, LPC-MHSP, Program Manager of Emergency Psychiatric Diversion Services, Mental Health Cooperative, Nashville, TN

• All leading authorities in the field of suicidology

Conference Outcome

• Sample Participant Comments:• “Your efforts in this fight for prevention and treatment are remarkable.

The conference was very good. Thank you to all involved.”

• “Thank you to my bosses for allowing me to attend. I am grateful and I know the information learned will help some of our clients at Behavioral Health.

• “We were delighted to be a part of this very informative and useful training.”

Conference Outcome

• Sample Participant Comments:• “Information gained will assist in more accurate assessment in detecting

suicidal thoughts in individuals.

• “The interviewing strategies were excellent. The safety plan was wonderful. Each of these will need to be tailored; but they are excellent tools.”

• Overall Conference Rating• Very Good to Excellent

Future Conference(s)

• To provide front-line clinicians ample opportunity for experiential learning, in order to help further hone their suicide assessment, treatment and prevention skills

Telebehavioral Health Services

Status Update

• The NAO provided telebehavioral health services to two Areaprograms (one SU and one urban site), in 2016• Through MSPI-awarded funds

• Resulting in 586 encounters compared to 351 encounters last fiscal year

Status Update

• Services provided included medication management (by apsychiatrist) and telecounseling (by one LCSW and one psychologist)

• Services were provided by the Albuquerque Area’s Telebehavioral Health Center of Excellence

Status Update

• Patients’ top three primary diagnoses @ the SU were: PTSD, generalized anxiety disorder, and major depressive disorder

• Patients’ top three primary diagnoses @ the urban site were: PTSD, major depressive disorder and schizophrenia

• Patients’ response to the telehealth services provided continue to behighly requested and favorable

Opioid Crisis Response Support

Reflecting on a Crisis

“Many tribal nations are facing extreme impacts of drug abuse on their citizens, maternal and family health, and the safety of their communities.”

“Among AI/ANs the opioid epidemic has been destructive.”

“The Mashpee Wampanoag Tribe declared a state of emergency inresponse to the rise in opioid drug abuse in July 2016.”

--National Congress of American Indian

Policy Research Center (2016)

BH Program Support to theMashpee Wampanoag Tribe

• Drafted a job description for a Substance Abuse Clinical Case ManagerSpecialist

• Hold membership on the Tribe’s Opioid Crisis Response TeamCommittee

• Will provide training to the community in QPR and Mental HealthFirst Aid

• Will provide ongoing supervision to SU BH clinicians, as needed andrequested

Questions?

Contact Information:

Palmeda D. Taylor, PhD

Behavioral Health Consultant

Nashville Area Indian Health Service

615-467-1534