The Indian Health Service is offering this grant to improve behavioral health outcomes through Public Health Nursing case management.

First Phase: Assessment – Complete a generic community assessment (most PHN programs have this readily available as a part of their annual program plans). Include, if available, pertinent data from local community assessments and behavioral health statistical data in the assessment; include the local behavioral health staff as subject matter experts and any data available. In addition, obtain input from key stake-holders such as community members, Tribal leaders, healthcare administration and community health groups to determine the health care priorities. Obtain approval for the establishment of the PHN case management program from the healthcare administration, governing boards and medical executive committees as needed.

Second Phase: Planning – Based on the community assessment, the high risk behavioral health population is identified and the planning of the case management project begins. Develop case management services addressing the behavioral health priority health issues identified from the community assessment. Collaborate with the local behavioral health programs on planning in this phase. Plan specific guidelines for the case management services of the high risk group of patients such as admission criteria, caseload size, policies and procedures, and an evaluation plan to include data tracking for outcomes generated. Identify if there is a best practice case management model available to replicate to target the identified high risk behavioral health population (such as the Pine Ridge PHN Case Management community suicide prevention program or the Resources to Enhance All Caregiver’s Health, REACH, into Indian Country). Obtain additional staff training needed for the community based nurse case management model such as evidence based practices, motivational interviewing, nurse competencies and any other training that would be applicable to the behavioral health issues identified. Identify or develop patient education materials and community education materials for the program. Develop plans for project sustainability.

Third Phase: Implementation – The case management program includes admission criteria of the high risk behavioral health population, caseload size, and appropriate health care standards. Establish patient caseload. Monitor progress and make adjustments as needed. Track patient data outcomes. Continue to plan ongoing sustainability of the program after the award period ends.

Fourth Phase: Patient Satisfaction – In order to evaluate program services; initiate a patient satisfaction program, such as one that provides patients with an opportunity to provide feedback on their experiences to assess the satisfaction of the services. Analyze findings so a concentrated effort is made to relate the customer satisfaction results to internal process metrics, and examine trends over time in order to take action on a timely basis. Evaluate and revise the case management program if needed, review policies and procedures, education materials and staff competencies semi-annually. To the extent permitted by law, report back to key stake-holders progress of the project, especially to inform clients about changes brought about as a direct result of listening to their needs. Each site will share program material with IHS Headquarters PHN program. This information will be shared IHS-wide for replication of the project across IHS with credit given to the organization that developed the material. Poster presentation or oral presentation will be given at the national meetings and/or webinars.