Institute for Healthcare Improvement: Chronic Care Initiative

About the Chronic Care Initiative

Chronic conditions such as diabetes, cardiovascular disease, asthma, renal disease, depression, and cancer have become increasingly prevalent in American Indian and Alaska Native communities and are placing growing demands on health care systems. Given the limited available resources, there is an urgent need for a strategic plan to address the treatment and prevention of chronic conditions in the Indian Health Service (IHS) health care system.

To address the health challenges and disparities facing Indian people today, the IHS Director launched three health initiatives to address the health and wellness of Indian people: Health Promotion/Disease Prevention, Management of Chronic Disease, and Behavioral Health. These initiatives are linked together and have the potential to achieve positive improvements in the health of Indian people. The Institute for Healthcare Improvement (IHI) and the Indian Health Service launched a partnership in 2006 to support the planning and implementation of the Chronic Care Initiative, which is the Director’s signature Management of Chronic Disease initiative.

The aim of the Chronic Care Initiative (CCI) is to implement strategies within the Indian Health System (federal, tribal, and urban health organizations) that support community and individual wellness and strength. To achieve this aim a project called Innovations in Planned Care (IPC) for the Indian Health System was designed and started in 2007. By adapting an extended version of the Chronic Care Model, the IPC aims to improve the health status of patients and populations by reducing the prevalence and impact of multiple conditions (instead of care based on managing individual conditions). These improvements will be developed, tested, and packaged in such a manner that they can be spread throughout the Indian Health System.

Aims of the Initiative

The aim of Innovations in Planned Care (IPC) for the Indian Health System, the learning and innovation arm of the Chronic Care Initiative, is to improve health and promote wellness for American Indians and Alaska Natives across all ages. The redesigned system of care will be grounded in the values and culture of the community served. It will focus on strengthening the positive relationships between the health care system and care team and the community, family, and individual. The adapted Care Model serves as a framework to guide the creation of an efficient and accessible system of care that provides safe, timely, effective, equitable, and patient-centered care.

Participating organizations will show improvement in preventive care, management of chronic conditions and experience of care, while maintaining financial viability, within an 18-month period. These improvements will be spread across the Indian Health System in an ongoing journey of transformation.

Learn more about the current IPC work in the Overview section.

For More Information

Please address inquiries about the Chronic Care Initiative to Candace Jones, Program Officer, Indian Health Service, at candace.jones@ihs.gov, or to Lindsay Hunt, Project Manager, Institute for Healthcare Improvement, at lhunt@ihi.org.

Related Information and Resources:

Visit the Chronic Care Initiative website.

Read the Improvement Story on Innovations in Planned Care at a Cherokee Nation Clinic.

Read the April 2009 article in the IHS Primary Care Provider monthly publication that describes the Chronic Care Initiative accomplishments thus far.

Read about Quality Improvement in the Indian Health Service in the November 2008 issue of the Commonwealth Fund's Quality Matters.

Learn more about the Chronic Care Model and changes to improve Chronic Conditions in the Topics section of IHI's website.