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Statement by
Randy Grinnell, MPH
Deputy Director
Indian Health Services

Veterans Collaborations with Indian Health Service: Improving Access to Care for Natives American Veterans by Maximizing the se of Federal Funds and Services 

Committee on Appropriations
United States Senate

Tuesday August 30, 2011

Mr. Chairman and Members of the Committee:

Good morning. I am Randy Grinnell, the Deputy Director of the Indian Health Service (IHS). I am pleased to have the opportunity to testify on the Indian Health Service - Veterans Affairs (VA) collaboration.

The Indian Health Service plays a unique role in the Department of Health and Human Services (HHS) because it is a health care system that was established to meet the federal trust responsibility to provide health care to American Indians and Alaska Natives (AI/ANs). The mission of the IHS is to raise the physical, mental, social, and spiritual health of AI/ANs to the highest level. The IHS provides comprehensive health service delivery to approximately 1.9 million AI/ANs through hospitals, health centers, and clinics located in 35 States, often representing the only source of health care for many AI/AN individuals, especially for those who live in the most remote and poverty-stricken areas of the United States. The purchase of health care from private providers through the Contract Health Services (CHS) program is also an integral component of the health system for services unavailable in IHS and Tribal facilities or, in some cases, in lieu of IHS or Tribal health care programs. IHS accomplishes a wide array of clinical, preventive and public health objectives within a single system for AI/ANs.

American Indian/Alaska Native Veterans Dual Use of IHS and Veterans Health Administration

In 2006, a joint Veterans Health Administration (VHA) - IHS study was initiated to review dual use of the two systems by AI/AN veterans. The findings of this study indicate that AI/AN veterans using the VHA are demographically similar to other VHA users with similar medical conditions, such as Post Traumatic Stress Disorder (PTSD), hypertension, and diabetes. The review found that dual-users are more likely to receive primary care from IHS, and general medical diagnostic services and mental health care from the VHA. They are likely to be receiving complex care from both VHA and IHS.

Many AI/AN veterans are eligible for healthcare services from both IHS and VHA. IHS has an estimated 45,000 Indian beneficiaries registered as veterans in the agency’s patient registration system. Some AI/AN veterans who live in urban locations do not have geographic access to care in IHS facilities on or near reservations and must use the local systems of care or Urban Indian Health Programs (UIHP) where they are available. In some of these locations the UIHPs provide limited direct care and assist these patients in accessing VHA and other services in the local area. AI/AN veterans residing on reservations in some cases are not easily able to access VHA health facilities and services.

IHS recognizes that the complexity of IHS-CHS program and VHA eligibility requirements can make it difficult for AI/AN veterans to access care. IHS pays for the care referred outside of IHS for AI/ANs including veterans if all the CHS program rules and regulations are met. For the AI/AN veteran, the VHA is an alternate resource along with Medicare, Medicaid and private insurance in accordance with the CHS regulations.

HHS/Indian Health Service – VA/Veterans Health Administration Memoranda of Understanding

A Memorandum of Understanding (MOU) between the HHS/IHS and the Department of Veterans Affairs /Veterans Health Administration was signed in 2003 to encourage cooperation and resource sharing between the two Departments. The 2003 MOU outlined joint goals and objectives for ongoing collaboration between VA and HHS to be implemented primarily by IHS and VHA. The MOU advanced our common goal of delivering quality health care services to and improving the health of the 383,000 veterans who identified as AI/ANs within the VHA system, a portion of which are served by IHS. The HHS/IHS and the VA entered into this MOU to further their respective missions, to serve AI/AN veterans who comprise a segment of the larger beneficiary population for which they are individually responsible.

Tribes stressed the need to improve collaboration and coordination of services for veterans eligible for both the VA and IHS services. The IHS Director met with VA Secretary Shinseki in May 2010, and they agreed to update the 2003 VA-IHS MOU to improve collaboration and coordination of services for AI/AN veterans. The updated MOU was signed in October 2010 and a consultation on implementation of the MOU was initiated with Tribes in November, 2010. Tribal leaders identified priorities for implementation and the VA and IHS are working on improvements to better coordinate care, services and benefits, state level agreements, implementation of new technologies, payment and reimbursement, health information technology, training and cultural competency. IHS Area Directors are already working locally in some areas with the VHA and Tribes to make improvements specific to the unique needs of veterans in the IHS Area and local levels.

The MOU identifies 5 mutual goals to (1) improve beneficiary access to healthcare and services; (2) improve communication among the VA, American Indian/Alaska Native veterans and Tribal governments with IHS assistance; (3) encourage partnerships and sharing agreements among VHA, IHS, and Tribal governments in support of American Indian/Alaska Native veterans; (4) ensure the availability of appropriate support for programs serving American Indian/Alaska Native veterans; and (5) improve access to health promotion and disease prevention services for American Indian/Alaska Native veterans.

Indian Health Service – Veterans Health Administration Collaborations

The principal focus of the interagency communication and cooperation is to provide optimal health care for the AI/AN veterans who rely on the IHS and/or VHA for their medical needs. Together, we strive to achieve multiple goals outlined by the MOU by developing projects that, for example, improve access to VHA services by allowing VHA staff to utilize Indian health facilities for providing health care to AI/AN veterans while the joint working relationship expands opportunities for professional development of clinical skills by IHS providers. IHS' experience with the use of traditional healing in its system became a model for the VHA when it began incorporating traditional approaches to healing for AI/AN veterans.

Area Director Meetings with Veteren’s Integrated Service Network

Other collaborations that meet the goals of the MOU range from expansion of access to VHA home based primary care for AI/AN veterans through the collaboration with IHS and Tribal health facilities to the improvement of interagency partnership on health information and the use of tele-health modalities. The home-based primary care program expansion will increase availability of services for AI/AN veterans with complex chronic disease and disability through 13 collaborative projects located in states including New York, North Carolina, Oklahoma, Oregon, New Mexico, California, Mississippi, and Minnesota and two locations in South Dakota (Rosebud and Pine Ridge). In 2010, this collaboration resulted in a five-fold (11 to 55 veterans) increase in the number of AI/AN veterans served by Home-Based Primary Care. In Arizona, the IHS and the VHA are working together to increase mental health services by locating VHA social workers in IHS health facilities on the Navajo and Hopi reservations.

Sharing Facilities

The Wagner IHS facility recently opened a a VA Community Based Outpatient Clinic (CBOC) . IHS has an audiology booth in the facility and the VA has an audiologist they can send to the facility to see both VA and service unit patients. Both agencies are also sharing lab services, the service unit provides onsite lower level lab services to the VA while the VA provides some higher level lab services at an alternate location. The service unit is developing the capacity to provide radiology services to the CBOC. The service unit also provides onsite dietary services to the CBOC patients.

The Navajo Area IHS (NAIHS) is currently working on an approval for the Prescott VA providers to be allowed space in an IHS facility to increase access to VA services for Veterans on the Navajo Nation. The NAIHS already has an agreement with Prescott VA that allows office space for a PTSD Counselor in an IHS facility to provide counseling and increase access to services. The NAIHS is also working with Veteran’s Integrated Service Network (VISN) 18 to develop an IHS/VA Task Force to address specific issues to these organizations.


In Montana, the Billings Area IHS and the VHA Montana Healthcare System (VHAMHCS) have ongoing collaborative efforts such as tele-psychiatry established at each service unit to facilitate VHA mental health services for AI/AN veterans. Because of the geographic remoteness and difficulty in accessingtransportation to a VHA facility, this service greatly benefits the AI/AN veterans. The Billings Area IHS and VHAMHCS have formalized a PTSD protocol that is utilized by the service units and Fort Harrison. Among the protocol elements,the VHA has created a position designated as a Tribal Outreach Worker (TOW) who works on-site to actively seek and educate veterans who may benefit from the services provided through tele-psychiatry clinics. Each service unit has a designated VHA liaison to help the AI/AN veterans needing medical services as well as working with the TOW and local Tribal Veteran Representative (TVR). As the primary IHS contact, they can provide information, assistance, and guidance on VHA services and health benefits to AI/AN veterans. To distinguish the different roles and responsibilities, the TVRs function as an arm of the VA program with the IHS providing and coordinating the medical care for the AI/AN veteran. These collaborative efforts are reviewed on an on-going basis in efforts to address patient-related issues, improve services, outreach, and rural initiatives, and to assist AI/AN veterans to utilize both the IHS and VHA systems.

Outreach (TVRs)

VA’s development and use of the Tribal Veterans Representative (TVR) program has been and is critical to addressing issues related to communicating about and reducing

barriers to VHA services and to the IHS-CHS program for AI/AN veterans through coordinated training on benefits and eligibility issues for each of the two programs.

Health Information Technology

The IHS and VHA have a long history of working jointly on health information technology (HIT) that dates back to the early 1980s. The Resource and Patient Management System (RPMS) is the IHS’ comprehensive health information system that is derived from and evolved alongside the VHA’s acclaimed VistA system. IHS/Tribal/UIHP (I/T/U) facilities use many components of VistA along with IHS-developed components that address the population and public health mission of IHS.

The model for the RPMS Electronic Health Record (EHR) is the Computerized Patient Record System (CPRS), the EHR component of VistA. Since its release in 2005, the RPMS EHR has been deployed to over 300 I/T/U health care facilities nationwide. IHS continues to leverage VHA healthcare software development by adapting it for our use where possible.

VistA Imaging

Another important example of IT sharing between VHA and IHS is VistA Imaging (VI), the VHA’s Food and Drug Administration (FDA)-certified system for capture, storage and viewing of diagnostic images and scanned documents. Vista Imaging provides the multimedia component of both agencies’ EHR systems, and has now been deployed to more than 90 I/T/U facilities across the country. This deployment would not have been possible without Interagency Agreements that have allowed VHA staff and contractors to provide implementation support and Help Desk services to our facilities. The VHA’s VistA Imaging program is critical to IHS.

Bar Code Medication Administration

Like VistA Imaging, the VHA Bar Code Medication Administration (BCMA) system is an integral component of modern hospital practice. BCMA ensures that the right patients are receiving the right doses of the right medications in the inpatient setting. The IHS, in cooperation with the VHA Bar Code Resource Office, is just beginning a joint effort to deploy BCMA in IHS and interested Tribal hospitals. This effort will be modeled after the successful VistA Imaging collaboration previously described.

Meaningful Use

The Meaningful Use initiative authorized by the HITECH Act of 2009 has given the IHS an opportunity to materially assist the VHA with an important effort. In April 2011, the IHS became the first Government agency to have its health information system certified according to the requirements for Meaningful Use. The VHA is seeking to certify the VistA system in 2012, and has reached out to IHS staff for consultation on how we addressed the various certification criteria. Our staff is more than willing to do so, as IHS has greatly benefited from so many VHA innovations in health information technology for more than two decades.

Alaska Area IHS – VHA HIT Collaborations

The Alaska Area IHS has partnered with the VHA since 1995 via the Alaska Federal Health Care Partnership (AFHCP) which includes IHS/Tribal, VHA, Army, Air Force and Coast Guard partners. The AFHCP office’s primary responsibility is to coordinate initiatives between the partners that result in increased quality and access to federal beneficiaries, or an overall cost savings to the federal government. Current initiatives in the Alaska Area include: joint training offerings, a neurosurgery contract services agreement, a perinatology contract services agreement, tele-radiology, sleep studies, home tele-health monitoring, partner staffing needs assessment, emergency planning and preparedness, and tele-behavioral health.

Past projects of AFHCP include the Alaska Federal Health Care Access Network (AFHCAN) which deployed network capability (backbone) along with hundreds of telemedicine equipment carts, the Teleradiology Project, deploying digital imaging radiology services to 51 federal, and tribally managed IHS-funded facilities, video teleconferencing equipment to promote administrative and clinical consults, as well as an IT Partnership bridge (“Raven Bridge), allowing federal and Tribal partners to connect to each other.

The AFHCP frequently shares workload data during its investigations of possible joint services analyses; a recent example is a study for joint-agency tele-dermatology and tele-rheumatology contracts. One of the AFHCP committees is the Partnership Telehealth & Technology Committee (PT&T) which brings together information technology staff to discuss partner organization needs, identify potential telehealth and technology applications to meet those needs, and find avenues for shared technology resources. PT&T members and their clinical champions will monitor patient results and gather feedback on the use of new technologies to improve clinical outcomes and access to care.

Consolidated Mail Outpatient Pharmacy

The Consolidated Mail Outpatient Pharmacy (CMOP) is a VHA program that consolidates and automates the mailing of prescriptions and refills to veterans across the country, relieving workload from pharmacy staff at VHA facilities. The VHA has permitted IHS to use the CMOP facility at Leavenworth, Kansas to provide prescription mail-out services for IHS beneficiaries. The pilot has been going on for more than a year, right here in Rapid City. Over 21,000 prescriptions have been processed through the IHS CMOP to date, allowing 2 full time pharmacists to move from the pharmacy into the clinic where they can provide direct patient care services, (i.e., anti-coagulant clinic) and improve access to care. The program has improved patient safety by reducing medication errors, and has improved both patient and staff satisfaction. IHS use of the CMOP facilities will centralize routine prescription filling and increase pharmacy collections, and will greatly reduce travel time for patients. In addition, it will enable pharmacy staff to focus on patient counseling, adverse drug event prevention, and primary care.

Future Opportunities of Partnership

Local IHS – VHA efforts to improve access and develop formal partnerships have increased since 2003. IHS will continue joint efforts on issues related to access to health care for AI/AN veterans. We are committed to working on these issues, within the Indian Health system, as well as with the Department of Veterans Affairs and the Veterans Health Administration. American Indian and Alaska Native communitieshave always honored their veterans and we are committed to improving the health services they utilize and the quality of their lives.

Mr. Chairman, this concludes my testimony. I appreciate the opportunity to appear before you to discuss the collaboration between the Department of Health and Human Services through the Indian Health Service and the Department of Veterans Affairs through the Veterans Health Administration. I will be happy to answer any questions that you may have. Thank you.

Last revised: June 18, 2013