Wednesday, May 17, 2006
Mr. Chairman and Members of the Committees:
Good morning, I am Dr. Charles Grim, Director of the Indian Health Service (IHS). I am accompanied by Dr. Jon Perez, National Behavioral Health Consultant. Today I am pleased to have this opportunity to testify on behalf of Secretary Leavitt on suicide prevention programs in Indian Country.
The IHS has the responsibility for the delivery of health services to an estimated 1.9 million Federally recognized American Indians and Alaska Natives through a system of IHS, Tribal, and urban (I/T/U) operated facilities and programs based on treaties, judicial decisions, and statutes. The mission of the agency is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level, in partnership with the population we serve. The agency goal is to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to the service population. Our foundation is 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.
Two major pieces of legislation are at the core of the Federal government's responsibility for meeting the health needs of American Indians/Alaska Natives: The Snyder Act of 1921, P.L.67 85, and the Indian Health Care Improvement Act (IHCIA), P.L.94 437, as amended. The Snyder Act authorized regular appropriations for "the relief of distress and conservation of health" of American Indians/Alaska Natives. The IHCIA was enacted "to implement the Federal responsibility for the care and education of the Indian people by improving the services and facilities of Federal Indian health programs and encouraging maximum participation of Indians in such programs." Like the Snyder Act, the IHCIA provided the authority for the provision of programs, services and activities to address the health needs of American Indians and Alaska Natives. The IHCIA also included authorities for the recruitment and retention of health professionals serving Indian communities, health services for people and the construction, replacement, and repair of health care facilities.
Secretary Leavitt has also been proactive in raising the awareness of Tribal issues within the Department by contributing to our capacity to speak with one voice, as One Department, on behalf of the Tribes, and through the process of Tribal consultation. As such, he recognizes the authority provided in the Native American Programs Act of 1974, and utilizes the Intradepartmental Council for Native American Affairs to address cross cutting issues and seek opportunities for collaboration and coordination among HHS programs serving Native Americans.
We are here today to discuss suicide prevention programs and their application in Indian Country.
External demands upon individuals, families, and communities are many and powerful. Long histories of subjugation and continued resulting challenges of maintaining cultures, managing poor economies, and subsisting with lack of opportunities mean most of these demands are negative and destructive. The most common IHS mental health program model provides acute crisis oriented outpatient services. Inpatient services are purchased from non IHS hospitals or provided by State or County mental hospitals. Triaged care is the rule, not the exception, in virtually all of our behavioral health programs. The Indian Health Service is requesting a total of $62 million for mental health in FY 2007, an increase of 5% percent over FY 2006.
Addressing Suicide Among American Indians
This is particularly true in Indian Country. To address it appropriately requires public health and community interventions as much as direct, clinical ones. In late September of 2003, I announced the IHS National Suicide Prevention Initiative, designed to directly support I/T/U's in three major areas associated with suicide in our communities:
Since then, substantial progress has been made in developing plans and delivering programs, but it is still only the beginning of a long term, concerted and coordinated effort among Federal, Tribal, State, and local community agencies to address the crisis. The initiative addresses all eleven goals of the Department of Health and Human Services (HHS) National Strategy for Suicide Prevention (NSSP), which represents the combined work of advocates, clinicians, researchers and survivors around the nation. It lays out a framework for action to prevent suicide and guides development of an array of services and programs that must be developed. It is designed to be a catalyst for social change with the power to transform attitudes, policies, and services. The NSSP Goals and Objectives for Action was published by the U.S. Department of Health and Human Services in May of 2001, with leadership from the Surgeon General.
It also extends and enhances work between Tribal communities, local, State, and Federal agencies, and now even includes the greater Tribal and Indigenous populations of North America through our ongoing partnerships with Health Canada, First Nations, and Inuit.
Let me briefly summarize some of the efforts we have undertaken in each of the three major initiative areas:
As over sixty percent of the IHS mental health budget goes directly to Tribal programs, it is clear that Tribes, are primarily providing services to their communities. IHS now seeks to support those direct services with programs and program collaborations to bring resources and methodologies to the communities themselves. The IHS National Suicide Prevention Committee was impaneled in February, 2004, to help guide the overall IHS/Tribal effort. Composed of primarily Tribal behavioral health professionals from across the country, it serves not only to assist in providing direction for efforts, but also crisis services, training, and community mobilization tools for communities in need. It also serves to provide representative membership in some of the specific programs that have been developed. In September 2005, the Suicide Prevention Committee created the Indian Health Service Suicide Prevention Work Plan to reduce the impact of suicide and suicide related behaviors utilizing a comprehensive, culturally sensitive and linguistically appropriate community based approach.
IHS Headquarters is currently working with IHS Areas, Tribal communities, and States to:
IHS is collaborating with the National Institute of Mental Health, Health Canada, and the Canadian Institute for Health Research, on a multiyear effort to better understand suicide in Indian Country, and to develop evidence based interventions for prevention. While we have increasingly more accurate prevalence data, as in the IHS RPMS reporting system, and SAMHSA's National Survey on Drug Use and Health (NSDUH), and Drug and Alcohol Services Information System (DASIS), substantive programmatic and evaluative research is still very limited. Additionally, what research is available suggests suicide in our communities differs in substantial ways from other populations.
After three years of international planning and collaboration, the Indigenous Suicide Prevention Research and Programs in Canada and the U.S. Conference was held in Albuquerque, NM, February 7 9, 2006. It was the first time a conference was held to specifically address the research needs among First Nations, Inuit and American Indians and Alaska Natives regarding suicide and suicide prevention. The IHS collaborated with the National Institute of Mental Health (NIMH) and Health Canada to facilitate this international conference with representatives from the National Congress of American Indians (NCAI), the Assembly of First Nations (AFN), the Inuit Tapariit Kanatami (ITK), U.S. Territories, Indigenous researchers, clinicians, program personnel, wisdom keepers, and community members. Over 200 international participants met to share current programs and methodologies and develop a concrete research agenda and specific programs for Indigenous populations.
These research agendas, clinical programs, and community mobilization efforts are all driven and evaluated using data. IHS has spent $4,000,000 over the last four years on system wide improvements to its Behavioral Health Management Information System (BH MIS), including a comprehensive upgrade of its patient information and documentation systems, as well as programs and personnel to support clinics and Tribes using them. In fiscal year '05, the most recent upgrade to the Resource and Patient Management System (RPMS) behavioral health patient care system and the completely digital Suicide Reporting Form were deployed as an integrated part of the Behavioral Health Management Information System (BH MIS) Resource and Patient Management System (RPMS) Package. Now patients can be screened for potential suicide risk, suicide clustering can be discerned quickly in communities and Areas, and clinicians have comprehensive treatment planning and documentation tools to support their clinical interventions and create more effective programs. The system is now deployed and in operation in over 250 clinical sites across the country.
For the first time, far more accurate data are being gathered and shared from individual clinicians to communities, and with national policy makers and programs. The data on prevalence in this testimony, for example, came directly from the information gathered via the IHS Behavioral Health Management Information System (BH MIS). No longer are we estimating or extrapolating, because we now have representative information for the country and communities affected.
Future activities involve continued upgrading of the Behavioral Health Management Information System (BH MIS). The new Electronic Health Record will, for the first time, fully integrate behavioral health and medical patient documentation in a single electronic chart. Telehealth technology is also being developed using the Behavioral Health Management Information System (BH MIS) to provide direct clinical services, as well as sharing patient care documents and electronic charts across wide geographic areas in realtime. This will be primarily to support distant psychiatric services to remote communities where such services are not available now. Aberdeen, Alaska, Albuquerque, and Phoenix areas are already using these technologies as a cost effective method to delivering high quality, specialized psychiatric services over vast, remote areas.
Finally, the IHS has established a National Suicide Prevention Network, composed of at least one person from each IHS Area. During 2005, the NSPN project provided suicide prevention skills training to approximately 20 NSPN team members and 370 community members, who were mostly youth (ages 15 21), in Albuquerque, NM, Billings, MT, Ft. Yates, ND, and Red Lake, MN. In 2006, IHS allocated $300,000 to carry the NSPN project forward. The NSPN project is providing (1) suicide prevention services/trainings to a minimum of 7 communities in crisis or in need of suicide prevention services; (2) at least one Area wide suicide prevention training for each of the 4 IHS Areas with the highest rates of suicide (Aberdeen, Alaska, Bemidji, and Tucson Areas); and (3) one or more suicide prevention trainings for NSPN team members to continue to build capacity. Some of the communities that are receiving assistance to date include:
1. Red Lake Tribe
So, taken all together, where are we?
I think we are still engaged in a battle for hope. For those young people who see only poverty, social and physical isolation, lack of opportunity, or familial dissolution, hope can be lost and self destructive behavior becomes a natural consequence. The initiative and programs I have described are some methods and means to restore that hope and engage youth and their communities to sustain and nurture it. These efforts are not sufficient, in and of themselves, to significantly change many peoples' living conditions. However, if we can act together, among agencies, branches of government, Tribes, States, and communities, I believe that the tide can be turned and hope restored to these young people who have lost hope. To that end, I commit to work with you and anyone else in and out of government to bring services and resources to that effort.
Mr. Chairman, this concludes my statement. Thank you for this opportunity to discuss suicide prevention programs in Indian country. I will be happy to answer any questions that you may have.
Last Revised: May 18, 2006