We recognize that the best outcomes are achieved by working directly with communities and helping communities to develop their own unique approaches and capabilities. Sundance Research Institute assists communities through organizing and providing trainings of community members and staff of community programs to improve technical skills in research design, survey design and data collection methods, confidentiality and HIPAA requirements, grant-writing and grants management skills, cultural sensitivity/awareness skills, human resources management skills, and business management processes and operations skills. We also support communities to identify priority health and well-being issues through jointly conducted assessments of needs, resources and opportunities, community strengths and weaknesses, and community priorities. These collaborative activities are conducted with support from Federal, State, and private foundation grant-makers. Our current projects include small program evaluations that provide information and data to assist communities and Tribes to monitor and improve the services they offer to residents, trainings and workshops on specific issues that help develop skills of program staff members, and large multi-year interventional and evaluation efforts.

Sundance Research Institute staff members have experience in many substantive areas and have worked previously for Federal government agencies, universities, major research, survey, and statistical organizations, health systems, and health associations. This diverse prior experience allows us to reach out to other organizations and experts to meet specific needs for expertise beyond the internal capabilities of our organization.

Featured Current Project: Honoring Your Heart on the Wind River Indian Reservation

Honoring Your Heart on the Wind River Reservation is a coordinated clinical-community health education program aimed at increasing cardiovascular health knowledge and reduce cardiovascular disease risk factors among members of the Eastern Shoshone Tribe on the Wind River Indian Reservation. The two-part program consists of Honoring the Gift of Heart Health classes and the Group Lifestyle Balance Program, the latter of which focuses on physical activity and healthy diet. The program aims to produce measurable improvement in clinical measures (e.g., reduction in blood pressure levels, cholesterol, triglyceride levels, weight), as well as improve participant knowledge about cardiovascular disease and increase participants’ confidence in their ability to self-manage their heart health.

Honoring Your Heart is funded by a two-year $436,852 grant from the AstraZeneca HealthCare Foundation’s Connections for Cardiovascular HealthSM program. The program awards Foundation grants of $150,000 and more annually to U.S.-based, nonprofit 501(c)(3) organizations or similar nonprofit organizations working to improve cardiovascular health in their communities.


Monitoring Services For Tribal Injury Prevention Cooperative Agreements

Sundance Research Institute, under subcontract to Econometrica, Inc., is assisting the Indian Health Service (IHS) to monitor and provide technical assistance for 33 Tribal Injury Prevention Cooperative Agreement Program (TIPCAP) grantees in 8 IHS areas.

TIPCAP provides funds to American Indian and Alaska Native Tribal organizations to develop their infrastructure and capacity in injury prevention. Econometrica is providing oversight and technical assistance to the 33 TIPCAP grantees in support of IHS’s priority of increasing accountability. Specifically, Sundance Research Institute staff members are performing the following tasks:

  • Conduct semiannual conference calls with each TIPCAP grantee. The calls include an assessment of each grantee’s progress toward written objectives and requirements, an account of barriers and challenges, identification of each grantee’s needs, and technical assistance. In addition, calls sometimes involve a discussion of program updates, methods to improve grantee performance generally, and general technical guidance.
  • Conduct ongoing training in community-based injury prevention. Sundance Research Institute is developing worksheets to document each assigned grantee’s injury prevention goals, progress toward those goals, and parties responsible for tasks; annually reviewing and updating the TIPCAP Handbook; and responding to technical assistance requests, as needed.
  • Plan and participate in the Annual TIPCAP Workshop. The workshop includes effective strategies in injury prevention, strategies in capacity building and sustainability, resource development, skill-building exercises, and networking.
  • Sundance Research Institute is providing ongoing training and technical assistance, identifying grantees that are experiencing challenges and developing corrective action steps, and compiling an annual profile of each grantee.
  • Conduct site visits. Sundance Research Institute is visiting assigned TIPCAP grantees once per year. The purpose of the site visits is to assist grantees in accomplishing program goals.

This project is awarded for a five-year period to provide services on an ongoing basis to the 33 Tribal Injury Prevention grantees.

Indian Health Service Hospital Inpatient Safety Technical Assistance

IHS is responsible for designing and leading a patient safety initiative focusing on 12 areas of focus: (1) adverse drug events; (2) catheter associated urinary tract infections; (3) central line associated blood stream infections; (4) injuries from falls and immobility; (5) obstetrical adverse events; (6) pressure ulcers; (7) surgical site infections; (8) venous thromboembolism; (9) ventilator associated pneumonia; (10) readmissions to hospitals within 30 days of discharge; (11) patient and family engagement; and (12) leadership engagement. IHS has implemented the IHS Hospital Quality Consortium to provide organizational structure for the Partnership for Patients initiative and develop and share quality improvement strategies. The IHS Hospital Consortium is comprised of 28 IHS hospitals in eight States.

The purpose of this project is to provide support and technical assistance to the 28 IHS hospitals participating in the Partnership for Patients initiative in several areas. These include: assessing current data capabilities for establishing a baseline for the 12 focus area measures and reporting on changes in these measures over time; providing assistance to improve data capabilities in targeted areas to ensure accurate and comparable measure reporting across all 28 hospitals; and developing, facilitating, and providing training and learning sessions for the hospitals that will assist them to design and implement quality improvement initiatives to achieve positive improvements in the key quality measures and increases in patient, family, and leadership engagement over time.

Sundance Research Institute, under a subcontract from Econometrica, Inc., is providing technical assistance and training on patient safety measures, reporting, and quality improvement strategies through hospital-specific assessments, site visits, and training events that are targeted to the individual hospital’s identified needs and improvement goals and through learning sessions and trainings that are provided through webinars, meetings, and other learning collaborative events.

Consumer Assessment of Health Providers and Systems Surveys and Analysis with Tribes

The CAHPS survey was developed by the Agency for Healthcare Research and Quality (AHRQ) as a standardized method for assessing patient experiences and rating of health care providers and health care systems. There are several versions of CAHPS surveys, including clinicians/medical groups, hospitals, dialysis centers, home health care, and others. CAHPS survey results offer a number of advantages to users:

  • The CAHPS survey is in the public domain and may be used by anyone.
  • Users can augment the core CAHPS survey questions with additional questions covering topics of specific interest and importance to individual users.
  • The core CAHPS survey questions are standardized and can be compared to survey results from other health care providers and systems that are available on the CAHPS Benchmarking Database.
  • The CAHPS survey is used by the Centers for Medicare & Medicaid Services to assess patient experiences with Medicare Advantage plans and with Medicare fee-for-service providers.
  • The National Quality Forum has endorsed the use of the Clinician-Groups CAHPS survey for assessing patient experiences.

An IHS/Tribal version of CAHPS has been developed by Sundance Research Institute, with input from Tribal Health Directors and Indian Health Service representatives, and implemented at several Indian Health Service ambulatory facilities for performance monitoring and identifying opportunities for quality improvement.

  • At two IHS facilities, the American Indian (AI) CAHPS was conducted before and two years after these facilities began participating in the IHS Improving Patient Care (IPC) initiative. At both facilities, statistically significant improvement in patient ratings of their experience with IHS were documented two years after IPC began.
  • The CAHPS survey has also been used by one IHS facility to identify opportunities for quality improvement. Regression analysis methods were used to identify the specific dimensions of the care process that had significant association with the Overall Rating of IHS by patients. Quality improvement initiatives were then developed to target one of the significant factors, resulting in significant improvement in patients’ ratings of IHS.

Sundance Research Institute currently has a contract with the Great Plains Tribal Chairmen’s Health Board to conduct and analyze the CAHPS survey with three Tribes and IHS facilities in South Dakota.

Good Health and Wellness in Indian Country: Technical Assistance and Evaluation Services to Support the Montana-Wyoming Tribal Leaders Council

The Montana-Wyoming Tribal Leaders Council (TLC) serves 11 Tribes residing on eight Reservations in Montana and Wyoming. In 2014, TLC was awarded a five-year grant by the Centers for Disease Control and Prevention (CDC) to assist and provide support to Tribes in the Billings Indian Health Service Area with developing and implementing programs that assist Tribal members to prevent and manage chronic diseases, including diabetes, heart disease, and obesity. The purpose of this project is to provide technical assistance, training, and support to Tribes in the Billings Area (MT and WY) that will provide them with an understanding and the tools to implement a comprehensive program that builds a coordinated system of care and provides resources to individuals for prevention and management of chronic disease among Tribal members. The conceptual framework for the project approach combines the Tribal Participatory Research Approach and the Chronic Care Model to reduce chronic disease and complications of chronic disease among American Indians in the Billings Area.

TLC activities include grant management; establishing an Area-wide Coalition to guide the project; providing training to all Tribes in the area on self-management for chronic disease, coalition building, and other skills; recruiting and providing technical assistance to five Tribes to implement a chronic disease prevention and management strategy; development and implementation of a communications plan and strategy; and collaboration with the evaluator and CDC to meet all evaluation and data reporting requirements. Two Tribes have volunteered to implement the program during the first year of the project and all of the Tribes served by TLC have indicated interest in serving on the Billings Area Coalition, sending staff to participate in the training workshops, and potentially serving as project sites in the third through fifth years of the program.

Sundance Research Institute, under subcontract to TLC, will assist with training activities, develop administrative data collection protocols, and design and conduct annual and final evaluations of the program. Evaluation activities will have several components: (1) local evaluation, focused on the effectiveness of TLC’s training and technical assistance, participating Tribes’ processes and outcomes, reach of the program, and impacts on Tribal members who enroll; (2) data collection and reporting required for CDC outcome performance measures and monitoring; and (3) collaboration with the CDC national evaluation to collect and report additional data as needed.

Centers for Medicare & Medicaid Services Health Insurance Exchange Navigator Services in Support of the Great Plains Tribal Chairmen’s Health Board

Great Plains Tribal Chairmen’s Health Board (GPTCHB) was awarded Health Insurance Marketplace Navigator Program cooperative agreements in 2013 and 2014 to serve the American Indian population in South Dakota and North Dakota. Under the Affordable Care Act, a number of special provisions affecting American Indians were implemented, including a waiver of the ACA mandate for coverage and open enrollment throughout the year. American Indians have access to primary health services through the Indian Health Service, but are less likely to have comprehensive health insurance to cover specialist and hospital care than are other racial/ethnic groups in the U.S. The goals of the current and new GPTCHB Navigator Program include: Goal 1: Increase awareness of the ACA opportunity to obtain health insurance and benefits of insurance coverage among AIs residing in SD and ND; and Goal 2: Provide enrollment assistance at convenient locations throughout the two-State region through certified employed and volunteer Navigators. Volunteer Navigators are recruited from Tribal and urban Indian health centers, Healthy Start programs, and Indian Health Service facilities.

GPTCHB has subcontracted with Sundance Research Institute to provide technical assistance for data collection, database management, and reporting on a weekly, monthly, quarterly, and annual basis on the Navigator activities and completed enrollments. In addition, Sundance Research Institute staff members have completed training and are certified as Navigators, which permits us to support GPTCHB enrollment events, as needed.

Diabetes Disparities on the Wind River Indian Reservation

The purpose of this five-year project, funded by the Merck Foundation, was to create and support a comprehensive community-health system partnership to improve outcomes for American Indian people with diabetes and to reduce the substantial health disparities experienced by American Indians. The age-adjusted prevalence of diabetes among American Indians and Alaska Natives served by the Indian Health Service is substantially higher than for other racial/ethnic groups in the U.S., at 16.1 percent of the adult population. Although there has been considerable attention to development of strategies and interventions to reduce diabetes risk factors in this population, there has been limited research on the effectiveness of these interventions. This project included design and implementation of an interventional program conducted by participating Tribes, in partnership with Indian Health Service clinicians, to improve diabetes management and outcomes for Tribal members with diagnosed diabetes or pre-diabetes. The interventions included development of culturally-tailored diabetes self-management education (DSME) programs; training of Tribal staff to deliver the DSME, followed by 16 weeks of additional physical activity based on the Lifestyle Balance program; and creation of a community-clinical partnership to increase cultural competency and effective patient-provider communication, referrals to the Tribal program, and sharing of data and resources to support people with diabetes. Evaluation of the impact of the initial four years of the program indicate that DSME provided by lay health educators, combined with increased communication and support from Indian Health Service physicians, resulted in statistically significant increases in confidence in ability to manage diabetes, positive changes in self-reported eating patterns and physical activity levels, and improvements in perceptions of the support from the diabetes care team. Clinical outcomes were assessed using pre-post intervention clinical data for 103 program participants who had provided HIPAA authorization for release of these data. Findings indicate that that HbA1c levels declined for 46 percent, with a decrease in average HbA1c of 1.12 points. Participants with initial HbA1c levels above 12.0 achieved an average reduction of 3.0 points.

A COMPREHENSIVE STRATEGY FOR PREVENTION AND MANAGEMENT OF DIABETES FOR AMERICAN INDIANS Guide for Replication of the Wind River Reservation Alliance for Reducing Diabetes Disparities Project merck-Guide-for-Replication Final Draft 8-4-14.docx

Honoring your Health: A Diabetes Self-Management Education Curriculum Instructor Manual DSMECurriculumInstructorManual.doc

Consultation Services to Assist the Aberdeen Area Office of the Indian Health Service to Develop a Strategic Plan, 2012–2017

Sundance Research Institute, in partnership with Econometrica, Inc., developed a Strategic Plan for the Aberdeen Area Indian Health Service (AAIHS) for the years 2012–2017. Strategic planning for the Indian Health Service is particularly complex due to:

  • The number of organizations and entities that comprise the complete Indian health care system—IHS Service Units, Tribal health programs, Urban Indian Health Programs (UIHPs)—each of which may have unique priorities, goals, and objectives determined by its local stakeholders and circumstances.
  • The importance of developing the Plan in partnership with Tribes to ensure that the priorities and issues of Tribal leaders and Tribal members are reflected and addressed in the Plan.
  • The need to ensure that the AAIHS Strategic Plan is coordinated and consistent with the goals and objectives of the national IHS Strategic Plan and with the U.S. Department of Health and Human Services (DHHS) Strategic Plan.
  • Limitations and uncertainties about the funding levels that will be available to AAIHS over the years 2012–2017 that would support initiatives to implement Strategic Plan goals and objectives.
  • Anticipated significant changes in the national health care system that will affect AAIHS, stakeholders, Tribal members, and all components of the local health care system, through expanded insurance coverage, increased revenue opportunities, changing reimbursement levels, expanded use of health information technologies, and a wide range of regulatory changes and reporting requirements.

The key activities conducted during this one-year project included:

  • Conduct Internal Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) Environmental Scan: The internal I/T/U environmental scan documented current resources, types and quantities of services provided, characteristics of patients, performance measures and monitoring, existing initiatives (e.g., Improving Patient Care activities, electronic health records (EHRs), and other health information technology plans), identified needs for improvement, and challenges faced by the I/T/U system. The internal environmental scan was conducted through interviews with managers and key staff of the I/T/U system; focus groups with I/T/U patients; interviews with Contract Health Service providers; interviews with other individuals who coordinate and partner with AAIHS; and review of program statistics, internal documents, and other materials that provide insight into the strengths, weaknesses, and issues that guided development of the Strategic Plan.
  • Conduct External Environmental Scan: The external environmental scan documented the health care system within which AAIHS and the I/T/U system operates, including:
    • Documentation of available non-I/T/U health resources that provide services to American Indian/Alaska Native (AI/AN) people in the four-State AAIHS region.
    • Key informant interviews with a small number of managers of non-I/T/U health facilities to obtain information and perceptions of their role and contribution to Indian health.
    • Documentation of Medicaid/SCHIP programs in each AAIHS State and any special AI/AN health-related programs and initiatives in each State.
    • Review the Indian-specific provisions in the Affordable Care Act and identify those that will require AAIHS and the I/T/U system to make changes and/or present opportunities or threats.
    • Review provisions of the Indian Health Care Improvement Act and identify specific issues that may affect AAIHS and the I/T/U system.
    • Review U.S. DHHS Strategic Plans and national IHS Strategic Plans.
  • Prepare Environmental Scan Report: The Internal and External Environmental Scan Report summarized and documented strengths, weaknesses, opportunities, and threats that provided background for AAIHS, the Great Plains Tribal Chairmen’s Health Board (GPTCHB), and other stakeholders to assist them in identifying priorities and specific objectives that might be necessary and feasible. In addition, the Environmental Scan identified potential new partnerships and resources that can be useful in advancing and achieving elements of the Strategic Plan.
  • Gather Partner and Stakeholder Input: AAIHS partners with the Tribes it serves to establish priorities, address issues, and resolve problems that occur within the IHS system. AAIHS Area Office division leaders, individual Service Units, Tribally-operated health programs, and UIHPs are also stakeholders in the I/T/U system and collaborate and coordinate with the Area Office to ensure that services are available, accessible, of high quality, and are user friendly. Other possible stakeholders include Contract Health Service providers, State and local public health agencies, State Medicaid/SCHIP programs, and other non-governmental health-related organizations and programs that provide services and resources to AI/AN people in the Aberdeen Area. Input from all partners and stakeholders is an essential and critical component of the strategic planning process and was gathered throughout the project through multiple approaches, including:
    • Involvement of GPTCHB in all stages of the Work Plan and strategic planning process, through a joint process with AAIHS.
    • Meetings and key informant interviews with Area Office division managers and other key staff.
    • Design and analysis of a survey of stakeholders to identify issues they would like to have addressed in the Strategic Plan and their suggestions and recommendations.
    • Meetings with Aberdeen Area health care facility leadership to identify issues of concern, priorities in their individual strategic plans, and recommendations for integrating facility strategic goals and objectives into the Aberdeen Area Strategic Plan.
    • A broad process of sharing interim information and draft deliverables with all stakeholders identified by AAIHS.
  • Identify Priorities and Goals: Priorities and goals for the two Strategic Plans—Aberdeen Area Office Strategic Plan and Aberdeen Area Strategic Plan—were identified through an iterative process with AAIHS leadership, GPTCHB, Area Office division managers, and other stakeholders. Based on meetings and discussions with AAIHS and GPTCHB, the Environmental Scan findings, the Stakeholder Survey analyses and results, and input and feedback from stakeholders, the Econometrica/Sundance Research Institute team developed a preliminary outline of Mission and Values, Strategic Priorities, and Measurable Goals. This preliminary outline was circulated to AAIHS, GPTCHB, and appropriate stakeholders identified by AAIHS and GPTCHB, and a second draft of the Mission and Values, Strategic Priorities, and Measurable Goals was prepared and again disseminated to AAIHS, GPTCHB, and other stakeholders. Feedback and input on this second draft was then used to prepare the final version of these dimensions of the strategic planning process.
  • Identify Feasible Objectives Under Each Priority/Goal: Once a consensus was reached on Strategic Priorities, a similar process was used to obtain consensus on specific objectives under each Priority. These specific objectives are sub-priorities within the Strategic Priority—i.e., if Prevention is a Strategic Priority, there are many prevention targets that might be considered, such as preventing infant mortality, preventing cervical cancer, or preventing long-term consequences of tobacco use. Each preliminary specific objective identified was broadly assessed for feasibility and other considerations and ranked in terms of potential resources required and other factors that might affect feasibility.

Culture, Traditions, and Consumer Engagement With the Wind River Indian Reservation Health Care System

This project, funded by The Robert Wood Johnson Foundation, was a partnership among Sundance Research Institute, the Wind River Indian Reservation Indian Health Service, and the Eastern Shoshone and Northern Arapaho Tribal Health Departments. The objective of the project was to engage and activate the community and individual Tribal members to participate in and guide changes to IHS and support individual consumers to become active and involved participants in their health care and processes through use of technology, social media, and a Patient Navigator. Involvement of cultural and traditional leaders in collaborating with the IHS and Tribal health systems was a unique aspect of this project. This project focused both on community engagement and individual consumer engagement in the health care system and included implementation and evaluation components. Engagement of American Indian consumers in their health care system and health processes offers a unique opportunity to develop a model of consumer engagement for Indian County that integrates cultural and traditional values of the community into the health system and encourages more effective use of available health resources to improve processes of care and outcomes.
The specific objectives of this project were:

  • Engage the Wind River community actively in the assessment and guidance of quality improvement initiatives.
  • Involve traditional healers and Tribal elders to develop culturally-appropriate supports and linkages to support consumer engagement and activation.
  • Use social media processes to engage the community and individual consumers in managing their health and health care.
  • Establish a patient navigator program to assist consumers.
  • Evaluate the program and its impacts and lessons learned and disseminate findings to other Tribes, IHS programs, and the research community.

The major outcome anticipated was an increase in community and individual consumer engagement with IHS and Tribal Health systems that results in positive improvement in health care access, quality, and patient satisfaction. Tribal Work Groups were actively engaged in identifying key factors for quality improvement that would increase access and patient satisfaction. Indian Health Service and Tribal Health directors worked closely with the working groups to identify priorities and feasible Quality Improvement strategies that were subsequently implemented. Findings can be generalized to IHS facilities throughout Indian Country, as well as to Tribally-run health systems. Institutionalizing community and individual consumer engagement processes will support sustainability, providing consumers with experience in active involvement to improve services and processes of care.

Eastern Shoshone Tribe IHS MSPI Suicide Prevention Demonstration Program

The purpose of the Eastern Shoshone Suicide Prevention Demonstration Program was to develop and implement a comprehensive and sustainable program to reduce suicide attempts and the number of completed suicides in Eastern Shoshone communities.

The approach was developed to address identified needs and had four primary goals:

  • Increase community awareness, support, and coordination for suicide prevention.
  • Strengthen community-based capacity and resources for providing screening, early identification, referral, and follow-up of at-risk adults and youth and support for their families.
  • Develop and implement a community-based “crisis response” program to assist families, friends, peers, and the community when a suicide occurs.
  • Contribute to knowledge base of effective strategies for suicide prevention in American Indian communities through participating in local and national evaluations, building capacity for local data collection and evaluation, and dissemination of findings.

Sundance Research Institute assisted the Eastern Shoshone Tribal Health Department as the evaluator of the demonstration program. Internal evaluation and monitoring of the Eastern Shoshone Suicide Prevention Project were conducted and reported annually.

The three primary components of this internal evaluation and monitoring were the following:

  • Monitoring the implementation/operations of the program, problems encountered, resolutions of problems, and lessons learned.
  • Assessment of the effectiveness of the training components of the project in terms of increased knowledge of participants and perceptions of training program participants of effectiveness and usefulness of the training components.
  • Establishing baseline measures for requirements of the Government Performance and Results Act and annually updating these data.
    Annual reports on the progress and implementation issues and “lessons learned” were prepared and provided to the Tribe to assist in program monitoring and reporting.

Evaluation of the Wind River Indian Reservation Infant Mortality Prevention Program

This five-year project was conducted by the Northern Arapaho Tribe, under a grant from the Centers for Disease Control and Prevention (CDC). Sundance Research Institute provided technical assistance, training, data management, and evaluation services in support of the project.
Infant mortality rates on the Wind River Indian Reservation are nearly three times the national IM rates. Interventions were designed and implemented to:

  • Increase community awareness of the importance of early and adequate prenatal and well-baby care.
  • Outreach and support to pregnant women to increase early prenatal care.
  • Well-baby workshops.
  • Culturally-appropriate parenting classes.
  • Peer support group Talking Circles for young mothers and young fathers.
  • Education about healthy pregnancies and reproductive health and planning for high school students.
  • Providing support and assistance to families who are facing homelessness and other challenges that contribute to child neglect and maltreatment.

Sundance Research Institute assisted the Northern Arapaho Tribe to meet CDC administrative and data reporting requirements, designed and provided training to Tribal staff on data collection requirements and protocols, and conducted annual evaluations of progress, processes, and outcomes of the interventions.

CAHPS III: Improving Performance of the Indian Health Care System Using CAHPS as a Measurement Tool

As a subcontractor to Yale University, Sundance Research Institute used a modified CAHPS survey approach to identify opportunities for IHS quality improvement. The purpose of this project was to demonstrate the potential usefulness of a modified CAHPS survey approach to identify opportunities for IHS quality improvement (QI). Two Indian Health Service Units, working collaboratively with their respective Tribal Health Departments and Sundance Research Institute, developed a modified CAHPS survey instrument that retained the core CAHPS measures and added questions reflecting the unique characteristics of IHS services. Both Service Units were also participating in the IPC II initiative; one Service Unit designed a targeted QI initiative based on the CAHPS survey results, and the other Service Unit served as a control site for the project. The baseline American Indian CAHPS survey was administered in mid-2010 to 400 IHS patients at each site, and the results were used by the joint IHS-Tribal Working Group at the intervention site to identify areas for improvement and significant factors associated with overall rating of IHS services. This information was used to develop specific QI initiatives focused on customer service that were implemented in 2011. Sundance Research Institute provided support and assistance to the design of the QI initiatives and monitored ongoing implementation and related activities through site visits and key informant interviews. A follow-up American Indian CAHPS survey was conducted in spring 2012 to assess the impact of the targeted QI initiative on patient ratings of Service Unit performance in the targeted dimensions of service and on overall patient satisfaction. Survey results indicated a statistically significant increase in patient ratings of IHS staff courtesy and helpfulness and in overall rating of IHS services.

Navajo Nation Medicaid Agency Study

This study, conducted under a subcontract to Econometrica, Inc., examined the feasibility and potential cost implications of the Navajo Nation operating its own independent Medicaid agency. The Navajo Nation has a population of nearly 300,000 and a land base of more than 26,649 square miles within the States of Arizona, New Mexico, and Utah. Under the Indian Health Care Improvement Act provisions of the Affordable Care Act, the Department of Health and Human Services was mandated to conduct a study of the feasibility of a Navajo Medicaid Agency to serve all American Indians and Alaska Natives living within the boundaries of the Navajo Nation and to submit a Report to Congress on the findings of the study. The project team was responsible for meeting with the Navajo Nation Tribal leadership and the Navajo Nation Department of Health to discuss the project and secure demographic data, as well as with the States of Arizona, New Mexico, and Utah to obtain data on the eligibility requirements, covered services, number of American Indians enrolled in Medicaid who reside within the boundaries of the Navajo Reservation, per capita Medicaid costs for American Indians enrolled in Medicaid, and sites of care for services provided to AI enrolled in Medicaid in each State. The statutory requirements for providing Medicaid coverage for all Medicaid applicants or recipients within the Reservation boundaries were identified and alternative options for addressing the issue of multiple-State benefit packages were explored. Our work under this contract included developing an estimation methodology that was used for projecting enrollment, service utilization by site, administrative costs, and claims costs that would be associated with the Navajo Nation Medicaid Agency; calculating a Federal Medical Assistance Percentage (FMAP) for the Navajo Medicaid Agency; and analyzing the potential impact of the Navajo Medicaid Agency on enrollment levels, Medicaid costs, and FMAPs for the three affected States. The project team then worked closely with the Centers for Medicare & Medicaid Services (CMS) to prepare the Report to Congress on the Feasibility of a Navajo Medicaid Agency, which CMS finalized and submitted to Congress on June 14, 2014.

Indian Health Service Tribal Epidemiology Centers Assessment

The first Tribal Epidemiology Center (TEC) was established in 1997, with other TECs established over the following decade to provide regional capacity throughout all of Indian Country. As the program is now fully established, the Indian Health Service was interested in assessing the performance and limitations of the TECs, relative to the IHS Division of Epidemiology and Disease Prevention (DEDP) and individual TEC goals and objectives; identifying the needs of the TECS that would assist them to strengthen their performance; and developing recommendations for the future development of the TECs.

Sundance Research Institute, in partnership with Econometrica, Inc., developed an approach to the assessment of the IHS Tribal Epidemiology Centers that had three major components:

  • Development of a historical and current profile of each TEC. Because the 12 TECs have original start-up dates that range from 1997 to 2008, some are “mature” and others are in early development stages with less history and evolution. The profiles provided a description of each TEC and permitted it to be compared with TECs of the same stage of development. Individual TEC profiles were constructed to describe the history and development of each TEC. In addition, a summary report was prepared that permitted a comparison across the TECS that will document evolution over time in organizational characteristics and development to determine the extent to which TECs of the same cohort are developing similarly or differently and whether there are patterns of development that emerge from this examination.
  • Assessment of TEC success in achieving IHS DEDP requirements as stated in the Cooperative Agreement Funding Announcement and assessment of TEC success in achieving specific goals and objectives in each TEC’s submitted Work Plan.

An Assessment Tool was developed with three components:

  • An initial general section that focuses on IHS requirements of TECs, based on the most recent funding announcement under which the TEC is operating.
  • A TEC-specific section that focuses on the specific Work Plan goals and objectives of each TEC.
  • A section on challenges, limitations, and recommendations for future development and changes in the TEC program.
  • Assessment of the progress and status of each TEC in developing as a public health entity was conducted, using the Local Public Health System Performance Assessment Instrument developed by the National Public Health Performance Standards Program (NPHPSP). The NPHPSP is a collaborative program of CDC, American Public Health Association, Association of State and Territorial Health Officials, National Association of County and City Health Officials, National Association of Local Boards of Health, National Network of Public Health Institutes, and the Public Health Foundation. The Assessment Tool is based on the 10 Essential Public Health Services.

This approach to the Assessment of the TECs was designed to provide a comprehensive and detailed understanding of the current accomplishments and successes of the Tribal Epidemiology Center Program and of the individual TECs. In addition, the approach offered the opportunity to identify limitations and challenges faced by the TECs in meeting the goals and objectives of the TEC Program and potential changes and directions that would strengthen the program as it moves forward.

Evaluation of Culturally-Tailored Mental Health and Substance Abuse Services

This two-year project was conducted for With Eagles Wings, a non-profit mental health and substance abuse organization, under a State of Wyoming/Substance Abuse and Mental Health Services Administration grant.

Evaluation of the program included assessing the organizational and operational processes, number and growth in services provided, administration and analysis of a survey of client experiences and satisfaction with services, development and conduct of a survey to assess community members’ needs for services, and an assessment of sustainability of the program and recommendations for operational and other changes that would strengthen financial sustainability.