1. GPRA Update CAPT S. Miles Rudd, MD Chief Medical Officer Portland Area October 24, 2013

2. GPRA GPRA- Government Performance and Results Act GPRA= Good Patient Care Who would not want their healthcare system to meet standards for diabetes care? Give them all the recommended vaccines? Provide dental care? Screen for common diseases?

3. GY 2013 Final There were 22 clinical indicators for GY 2013 Nine indicators were to establish baseline data. IHS National (IHS/Tribal) Met or exceeded all 22 indicators

4. IHS National GPRA 2013 Results

5. GY 2013 Final There were 22 clinical indicators for GY 2013 Nine indicators were to establish baseline data. IHS National (IHS/Tribal) Met or exceeded all 22 indicators Portland Area (IHS/Tribal) Met or exceeded 15 of 22 indicators

6. Portland Area - GPRA 2013 Results

7. GY 2013 Final There were 22 clinical indicators for GY 2013 Nine indicators were to establish baseline data. IHS National (IHS/Tribal) Met or exceeded all 22 indicators Portland Area (IHS/Tribal) Met or exceeded 15 of 22 indicators Portland Area (IHS Only) Met or exceeded 21 of 22 indicators Wellpinit and Western Oregon met all indicators 2 nd year in a row!

8. Portland Area- IHS GPRA 2013 Results

9. Moving the Bar GPRA Best Practices Diabetes Indicators (National Targets) Western Oregon Good Glycemic Control (HbA1c < 8%)- 67.2% (Baseline) Nephropathy Assessment- 90.1% (64.2%) Retinopathy Screening- 70.9% (56.8%) Warm Springs Blood Pressure Control (<140/90)-75.2% (Baseline) LDL Assessment- 87.3% (68%)

10. Moving the Bar GPRA Best Practices Dental Indicators (National Targets) Warm Springs Dental: General Access- 41% (26.9%) Sealants- 31.4% (Baseline) Topical Fluoride- 52.1% (Baseline) Best Practices: School based clinics at the elementary, middle and high school IPC Team works with Well Child Clinic, monitoring the schedule to see what children are due and coordinating with medical clinic to send (if possible warm hand off) of parent/child to dental Did Spring Break and Summer Kid’s day – 2 days devoted to kid exams/fluoride/sealants and well-advertised Exams done during Sports Physical days and also Head Start / ECE round ups Walk-in hours every day for dental care Dental exams at Correction Facility and High Lookee Lodge (ALF) to identify needs and arrange treatment plans Dental was partnering with medical and DM department for DM patients to get worked in for exams when they presented for medical care.

11. Moving the Bar GPRA Best Practices Immunization Indicators (National Targets) Warm Springs Influenza vaccine(≥ 65 years old)-79.4% (62.3%) Best Practices: Pharmacy based adult immunization clinic Coordinating with Community Health Nurses to track down elders and high risk patients needing influenza Community based clinics by CHN department Clinical Reminder dialogues “Friendly Competition” publishing weekly data on number of flu shot given and by whom – recognition for “sharp shooters”

12. Moving the Bar GPRA Best Practices Immunization Indicators (National Targets) Western Oregon Influenza vaccine(≥ 65 years old)-79.4% (62.3%) Pneumococcal vaccine (≥ 65 years old)-97% (84.7%) Childhood Immunizations- 91.7% (Baseline) 4 DTaP (Diphtheria, Tetanus, acellular Pertussis) 3 Polio 1 MMR (Measles, Mumps, Rubella) 3 or 4 HiB (Haemophilus influenza type B) 3 Hepatitis B 1 Varicella (Chickenpox) 4 Pnemococcal

13. Moving the Bar GPRA Best Practices Cancer Screening Indicators (National Targets) Colville Pap Smears- 81.8% (Baseline) Best Practice- Nurse champion in clinic that looks for every opportunity to connect with patients in need of pap smears. Western Oregon Colorectal Cancer Screening- 61.4% (Baseline) Colonoscopy, FIT, FOBT

14. Moving the Bar GPRA Best Practices Cancer Screening Indicators (National Targets) Wellpinit Mammograms- 58.9% (49.7%) Best Practices USE OF WOMEN’S HEALTH PACKAGE Managed by RN Historical mammograms entered by Medical Records I-CARE USED TO IDENTIFY WOMEN NEEDING MAMMOGRAMS Managed by RN of Nurse-Provider team Reports run quarterly by RN of Provider team to identify and contact women needing mammograms. MA schedules those without transportation for coach and then those requesting to be on the coach.

15. Moving the Bar GPRA Best Practices Best Practices TRIBAL HEALTH EDUCATOR Connects women needing screening to available resources. Manages the Susan G. Komen Grant – arranges and pays for the coach, provides transportation support (gas cards, etc) for women with transportation barriers, pays for screening of direct care patients and those without insurance. Manages the Breast and Cervical/Colon Cancer grant through Regional Health Department – a great resource for direct care patient without insurance. Coordinates the Pink Shawl Pow Wow, other community education events. Provides articles for tribal paper. Providing leadership of the breastfeeding/lactation support grant, further educating women in the community about breast health, including importance of screening.

16. Moving the Bar GPRA Best Practices Best Practices PINK SHAWL POW WOW A celebration of survivors and supporters of women affected by breast cancer in the community. Held annually in October (Breast Cancer Awareness Month). Pink Shawls are given to survivors and event has become a large community awareness event making it “OK” to talk about breast cancer and spread word about importance of screening. Pow Wow has grown to encompass other cancer survivors as well due to its success MAMMOGRAM PARTIES Started with a family of related women who all went together to get mammograms in honor of their mother who died from breast cancer. Event was spread word or mouth and spurred others to do the same.

17. Moving the Bar GPRA Best Practices Best Practices EMPLOYMENT OF WOMEN’S HEALTH PRACTITIONER Women are used to coming in yearly for pap/annual exam and expect Mammogram as part of that service. Community events have raised awareness to where women ask for their mammogram referral instead of health care providers asking them. USE OF MAMMOGRAM VAN SERVICE – 4 TIMES PER YEAR Cost of transportation to Imaging Center is a barrier to many women Mobile Coach comes 4 times per year, women with transportation issues given priority – can see about 24 per coach trip Clinic pays for gas for coach, Susan G. Komen Grant pays for the reading fee (by Inland Imaging) and the mammogram fee (by Sacred Heart Medical Center).

18. Moving the Bar GPRA Best Practices Prevention Indicators (National Targets) Fort Hall Alcohol Screening (FAS Prevention)- 77% (61.7%) Domestic Violence/Intimate Partner Violence- 72.9% (58.3%) Best Practice- Assign screening responsibility to nursing staff to perform with every patient visit.

19. Moving the Bar GPRA Best Practices Prevention Indicators (National Target) Warm Springs Prenatal HIV Screening- 94.4% (82.3%) Best Practice- 1 st prenatal standing orders for labs – order entry grouped so nurse just orders 1 st PN labs. Nursing / CHN enter labs and get at Positive pregnancy test if possible. Entering historical data in for those women transferring care to the clinic.

20. Moving the Bar GPRA Best Practices Prevention Indicators (National Target) Warm Springs Breastfeeding- 66.7% (Baseline) Best Practice- MCH nurse visits mom’s in hospital and assists with lactation counseling MCH nurse does home visits in first few days home to assist with successful breastfeeding and providing support Providers and clinic staff encourage breastfeeding during prenatal care. WIC counselors promote breastfeeding throughout antenatal visits and post- partum visits as well. MCH provides breast pumps (electric) at no charge for working moms Our clinic policies for staff promote breast feeding by providing time/space for pumping or feeding (Many staff are patients and community members as well).

21. Moving the Bar GPRA Best Practices Prevention Indicators (National Targets) Fort Hall Alcohol Screening (FAS Prevention)- 77% (61.7%) Domestic Violence/Intimate Partner Violence- 72.9% (58.3%) Best Practice- Assign screening responsibility to nursing staff to perform with every patient visit.

22. Moving the Bar GPRA Best Practices Prevention Indicators (National Targets) Wellpinit Childhood Weight Control- 13.6 % (< 24%) Best Practice- We have a very active tribal health educator who promotes health eating and physical activity in the community. Health educator has worked with the local store/trading post to incorporate more healthy choices in child visible areas of the store. Until just recently we had a tribal fitness coordinator who spent time with kids at HeadStart, Grade school We also have had meetings of our HeadStart Health Advisory Board where we’ve discussed ways to integrate physical activity into the routine of the child's day there. Head Start physicals (the 3-4 yo well child visit) particularly tries to target this issue.

23. Moving the Bar GPRA Best Practices Best Practice- We promote “Well Child Clinic” in our clinic practice where part of the focus is dedicated to discussing the child's ht/wt growth curve, concepts such as “screen time”, and healthy eating/snacking. Children above the growth curve are referred for education of parent with Health Educator The WIC program addresses trends towards obesity as well just failure to thrive. Our clinic strongly and vocally supports breastfeeding (shown to potentially decrease childhood and adult obesity) and all our nurses recently received training to act as lactation consultants. Our clinic has established an area for women to nurse, and public announces our support of breastfeeding as a healthy start in life. (We received a WA State DOH grant for lactation support this past year so have been able to provide training for our staff, educational materials, support supplies for women who breastfeed. etc.)

24. Moving the Bar GPRA Best Practices Prevention Indicators (National Targets) Western Oregon Tobacco Cessation Counseling- 64.4% (Baseline) Depression Screening- 78.9% (58.6%) Yakama Domestic Violence/Intimate Partner Violence- 72.9% (58.3%) Comprehensive Cardiovascular Disease Assessment- 60.9% (32.3%) Blood Pressure Assessment (Two in past 2 years) LDL Assessment (In past 1 year) Ht and Wt assessment for Body Mass Index (BMI) (In past 5 years) Lifestyle counseling (In past 1 year)

25. IHS National 2014 GPRA Goals

26. 2014 GPRA- Indicator Changes Pap Smear Previous- Women ages 25-64 with a Pap smear in the past 4 years. New Women ages 25-64 with a Pap smear in past 3 years OR Women ages 30-64 with a Pap smear and an HPV DNA in the past 5 years. Diabetic Nephropathy Assessment Dipstick for protein will no longer count Pneumovax Previous- Patients 65+ who have had a Pneumovax ever. New- Patients 65+ who had had a Pneumovax after the age of 65 or within the past 5 years.

27. Million Hearts ™ Campaign National initiative co-sponsored by CDC and CMS. IHS is one of 13 public and 30 private-sector supporters Goal: Prevent 1 million heart attacks and strokes by 2017. Optimizing care Asprin for people at high risk Blood pressure control (<140/90) Cholesterol management Smoking cessation

28. Million Hearts ™ Campaign It Doesn’t Take Much to Have a BIG Impact Small Reductions in Systolic BP Can Save Many Lives

29. Million Hearts ™ GPRA Indicator Controlling High Blood Pressure Numerator- Patients with a BP < 140/90 Denominator- User population patients ages 18-85 diagnosed with hypertension and no documented history of End-Stage Renal Disease or current pregnancy US National Baseline= 46% MH Target= 65%