Innovations in Planned Care at a Cherokee Nation Clinic

The Cherokee Nation AMO Salina Health Center
Tahlequah, Oklahoma, USA


The Cherokee Nation AMO Salina Health Center, located in rural northeastern Oklahoma, has been a participant since January 2007 in Innovations in Planned Care (IPC), a Learning and Innovation Community sponsored by IHI and the Indian Health Service (IHS) Chronic Care Initiative. The purpose of the initiative is to transform the current Indian Health System to a patient-centered system with planned care for all patients, in order to reduce the prevalence and improve the management of chronic conditions.


AMO Salina Health Center:

Brett Gray, MD, Medical Director, AMO Salina Health Center, Care Team Physician
Rae Ann Meisenheimer, RN, Care Manager/Diabetes Coordinator, Care Team
Shannon Backwater, LPN, Care Team
Kimberley Bobb, Medical Assistant, Care Team
Heather Zimmerman, ARNP, Project Leader on-site (January 2007 – July 2008)
Charles Smith, MPA, Senior Clinic Administrator, AMO Salina Health Center, Improvement Team Member


Cherokee Nation Administration:
Gloria Grim, MD, Medical Director, Cherokee Nation, Executive Leader for Improvement Team
Teresa Chaudoin, MPH, MA, Director, Cherokee Nation Diabetes Program, Improvement Team Sponsor
Rhonda Stanley, BSN, Cherokee Nation Nursing Adviser, Improvement Team Member



The Salina Health Center provides care to 8,000 patients and had 5.4 primary care providers at the start of the IPC. We began with Dr. Gray’s Care Team and set out to achieve the following: “We will transform our health care system into one in which health care teams partner with patients and families to meet their health care needs and goals. We are committed to providing care that is appropriate, safe, and evidence-based, in a timely, cost-efficient, collaborative manner. Our goal is to improve the health and reduce the burden of chronic disease on Cherokee citizens, families, and communities.”


Specific aims and goals include:

  • 80 percent of patients will be screened for breast, cervical, and colorectal cancer according to evidence-based guidelines
  • 90 percent of patients will meet six evidence-based intake screening components
  • 100 percent of patients will be screened in the past 12 months for depression
  • 70 percent of diabetes patients will meet six evidence-based components of diabetes comprehensive care
  • 70 percent of patients 20 years and older will have controlled blood pressure
  • Decrease average office visit cycle time to no more than 90 minutes



  • Cancer Screening: Percent of patients seen in the clinic within the last 12 months who have been screened within the appropriate timeframe for ALL of the following types of cancer that are applicable to them as individuals (based on their age, gender, and past medical history):  Breast, cervical, and colorectal cancer
  • Intake Screening Measure: Percent of patients seen in the clinic in the last 12 months who have been screened within the past year for ALL of the following six screening components that are applicable to them as individuals (based on their age and gender): Alcohol misuse, depression, domestic/ intimate partner violence, tobacco use or exposure, body mass index (BMI), and blood pressure
  • Depression Screening Measure: Percent of patients >18 years old seen in the clinic in the last 12 months with Depression Screening (this measure is a component of the intake screening measure)
  • Diabetes Comprehensive Measure: Percent of patients with diabetes seen twice in the clinic in the last 12 months who have received ALL of the following six annual components:  Documented A1c, blood pressure (BP), LDL, nephropathy assessment, retinal screen, and foot exam
  • Blood Pressure in Control Measure: Percent of patients >20 years old seen in the clinic in the last 12 months with BP in control (patients without a diagnosis of diabetes or ischemic heart disease (IHD) with BP<140/90, and patients age 20+ with diabetes or IHD with BP<130/80)
  • Average Office Visit Cycle Time: Total minutes divided by the number of visits sampled, with time measured from patient check-in until patient leaves the clinic (i.e., time from patient “toes-in” to “toes-out”) 
We tracked additional measures, including Nutrition Education for At-Risk Population: Exercise Education for At-Risk Population: Total Cost of Outside Services: Percent of Patients with Self-Management Goal Set: Patient Confidence: Patient Recommending Health Facility: Continuity of Care: and Third Next Available Appointment.


The theoretical framework for this innovation work is an adapted version of the Chronic Care Model, with a focus on the essential relationship between the patient and the care team. Changes at Salina have concentrated on improving the delivery of care system to foster the development of the patient/care team relationship and have resulted in measurable clinical improvements.

Key changes include:
  • Forming a Care Team consisting of a physician, RN care manager, LPN, and .25 FTE medical assistant
  • Formally empanelling patients with the primary care provider of their choice for continuity of care
  • Defining Care Team roles to move work away from the physician and to ensure that all team members work at the top of their licensure
  • Pre-visit planning for all scheduled appointments
  • Printing a computer-generated “reminders” list before each patient visit to identify any care measures that are due
  • Routine use of standing orders and nursing visits for follow-up appointments, to move work away from the physician
  • Max-packing”: Updating as many preventive and routine care measures as possible for patients at each appointment
  • Facility redesign to support planned care: Small nursing stations and halls were remodeled to create a single larger area for Care Team “pods” to facilitate communication between Care Team members and other Care Teams
  • Mapping processes to eliminate unnecessary steps and reduce patient visit cycle time










Summary of Results / Lessons Learned / Next Steps
The literature tells us that if evidence-based processes are followed, improved patient outcomes will follow, including control of diabetes and hypertension, and lower incidence of chronic disease and late stage cancer diagnoses. Through the persistent use of reliability science and a well-functioning care team, we were able to improve the reliability of key prevention and disease management processes by at least 8 percent (blood pressure in control) to as high as 15 percent (diabetes comprehensive care). In addition, average office visit cycle time was reduced by 49 percent.  

Lessons Learned:
  • We found that having the support of the senior executive leadership in Cherokee Nation Health Services was essential to conducting this work.
  • We learned that “planned care for all” is more effective than “disease-silo” care. Cherokee Nation adopted a systems approach to diabetes care in 2002, which included many of the concepts in the IPC change package, such as patient and population management by RN diabetes care managers; evidence-based guidelines; planned visits; care by a multidisciplinary team; diabetes self-management support and education; use of registries for population management; and data-driven improvement. One of the most surprising results from participating in IPC is that since implementing “planned care for all” clinic-wide at Salina, in addition to improving care processes across multiple conditions, we have surpassed the significant improvements we had already achieved in diabetes care and intermediate outcomes with the Diabetes Program alone!  
  • We learned that it was difficult to make changes to improve processes with only Dr. Gray’s Care Team and patient panel involved, so in September 2007 we added “spread” goals to Salina Clinic’s FY 2008 Balanced Scorecard. Those goals included:
    • Empanelment of all primary care patients by November 1, 2007
    • Formation of Care Teams for all primary care providers
    • 45-minute weekly spread team meetings for all Care Teams, and clinical and administrative department heads
    • Monthly all-employee staff meeting (was previously an annual meeting)
    • Training for all staff in the Model for Improvement
    • Training for all nursing staff in “iCare,” a newly-developed Indian Health Service data retrieval software package useful in pre-visit planning and patient panel management
  • We have learned that adoption of the Care Team concept and optimization of roles has had the most impact on moving work away from the provider, improving screening measures, and reducing cycle time.
Next Steps:
  • Continue spread of the “planned care for all” model to the other eight Cherokee Nation clinics.
  • Tackle the access issue: Salina Clinic now has 4 primary care providers, down from 5.4 at the start of IPC, and we strongly suspect that our demand is much greater than our supply at Salina, as well as at all Cherokee Nation facilities. This is the next huge issue that we need to address. 

Contact Information

Teresa Chaudoin, MPH, MA
Cherokee Nation Diabetes Program 

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