Diabetes Education Approaches for American IndianAlaska Native Populations

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Diabetes Education Approaches for American
Indian/Alaska NativePopulations
Nathan Peterson, MPH Utah Diabetes Prevention
Control Program www.health.utah.gov/diabetes
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Quiz Time

• 1) How many American Indians Alaska Natives
  (AI/AN) are in the U.S. (2007)?
• 2) Number of Federally-recognized AI/AN Tribes?
• 3) Percent of AI/AN adults who have diagnosed
  diabetes?
• 4) Percent of AI/AN with diabetes who have type 2
  diabetes?
• 5) Average annual medical care cost for a person
  with diabetes?

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Quiz Time

• 3.3 million
• 561
• 16.3
• 95
• 13,243 (compared to 2,560 for a person without
  diabetes)
• Source http//www.ihs.gov/MedicalPrograms/Diabete
  s/FactSheets/fs_index.asp

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Utah Tribal Facts

• Salt Lake County has the largest number of AI/AN
  at 9,000 (largest urban area in Utah)
• San Juan County has the second largest number of
  AI/AN at 8,000 (4 Corners Area)
• Utahs AI/AN population is very young, with
  almost half 45 years or younger
• Utahs AI/AN children have the highest rate of
  poverty compared to Utah overall

Approximately 33,000 American Indians live in
Utah, representing at least 35 tribes.
Source Utah Bureau of Indian Affairs, 2006
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Utahs Five Federally Recognized Tribes

• Goshute
• Navajo
• Shoshone
• Paiute
• Ute

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Utahs Seven Tribal Governments

• Confederated Tribes of the Goshute Reservation
  410
• Navajo Nation 8,100
• Northwestern Band of Shoshone 460
• Paiute Indian Tribe of Utah 840
• Skull Valley Goshute Indians 125
• Ute Tribe 3,100
• Ute Mountain Ute (White Mesa Ute) 380

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Utah Tribal Facts

• I/T/U organization in Utah
• One IHS program Ute Tribe
• Six Tribal programs Goshute, Skull Valley,
  Shoshone, Paiute, Navajo, Ute Mountain Ute
• One Urban program Indian Walk-In Center

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Why the Utah DPCP Collaborates with Tribes
Age-Adjusted Percentage of Utahns with Diabetes
by Race/Ethnicity, 2001
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Why the Utah DPCP Collaborates with Tribes

• At the 2006 DDT Conference in Denver, it was
  recommended that DPCPs initiate or improve
  collaboration with AI/AN tribal organizations
• Due to that call, we decided to improve our
  tribal partnerships and activities

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Systems Change Approach

• Implement comprehensive and basic diabetes
  education programs in AI/AN communities and
  tribal lands
• Many tribal organizations lack funding and
  especially resources
• State Diabetes Programs may be in a position to
  provide some resources for implementing new
  programs or improving current ones

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Systems Change Approach

• Components of a diabetes self-management
  education (DSME) program can include the
  following, among other methods
• Population needs assessment
• Patient/program forms
• Curriculum
• Patient education plan
• Patient-defined goals and outcomes
• Follow up plan
• Continuous quality improvement plan

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Ideas for Innovation

• How can a State Diabetes Program support AI/AN
  diabetes education programs with innovative ideas
  and approaches?
• Develop forms/policies in electronic format that
  conform with the National Standards for DSME
• Provide a written curriculum with learning
  objectives covering the ADA content areas
• Coordinate a needs assessment-driven training for
  healthcare staff

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Ideas for Innovation

• Provide a patient registry to manage data and for
  quality improvement purposes
• Offer data analysis from your best available data
  person
• Establish agreements/contracts to identify a
  formal partnership and to facilitate data
  collection and evaluation, for basic or formal
  programs

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Ideas for Innovation

• Develop relationships with each tribe by making
• in-person visits
• Offer or coordinate as many free resources as
  possible
• Implement elements of the Chronic Care Model for
  improving the measurement and performance of
  diabetes care

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Ideas for Innovation

• Even if tribes do not have resources for formal
  education programs (National Standards for DSME),
  they may still benefit from developing basic
  programs
• Basic programs can still lead to improved patient
  outcomes by creating a structured program that
  addresses aspects of diabetes care with a focus
  on quality improvement

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Chronic Care Model Application

• The HRSA Health Disparities Collaboratives
  program uses the structure of the Chronic Care
  Model. This model identifies 6 major categories
  that must be addressed to achieve change
• Health care organization
• Community resources and policies
• Self-management support
• Decision support
• Delivery system design
• Clinical information systems

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Chronic Care Model Application
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Chronic Care Model Application

• The Chronic Care Model (CCM) identifies the
  essential elements of a health care system that
  encourages high-quality chronic disease care
• Evidence-based change concepts under each
  element, in combination, foster productive
  interactions between informed patients and
  prepared providers
• In theory, the result is better health outcomes
  and a better diabetes education program
• Lets apply it to our DSME concept

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Chronic Care Model Application

• Health Care Organization (1)
• Administrative support for the DSME program
• Organizational structure leading to the diabetes
  education program
• Mission statement
• DSME Program goals

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Chronic Care Model Application

• Community Resources and Policies (2)
• Link with community programs and resources
• Partnerships formed with community organizations
  to support interventions that fill gaps in needed
  services (i.e., smoking cessation for persons
  with diabetes)
• Materials and resources to provide ongoing
  diabetes self-management support
• Advocate for policies to improve patient care

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Chronic Care Model Application

• Self-Management Support (3)
• To help patients acquire skills and confidence to
  self-manage their diabetes
• DSME is at the heart of this CCM component
• Strategies to strengthen SMS include
• Assessment
• Goal setting
• Action planning
• Problem solving
• Follow up
• Fill in the blank for other ideas _______

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Chronic Care Model Application

• Decision Support (4)
• Assure that providers have access to
  evidence-based guidelines
• National DSME Standards case management
  interventions
• Integrating specialist expertise and primary care
• Using proven provider education methods
  (trainings and continuing diabetes education
  opportunities)
• Sharing information with patients to encourage
  their participation

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Chronic Care Model Application

• Delivery System Design (5)
• Defines the care team (RN, RD, LPN, MA, etc.) and
  each members role
• Where is the diabetes education being provided
  clinic, wellness program, pharmacy, at home, by
  phone, etc.
• Is the program delivered in a culturally
  appropriate manner (staff, materials, office
  setting)
• How often is education provided at scheduled
  clinic appointments, clinic Diabetes Day, once
  a year, etc.

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Chronic Care Model Application

• Clinical Information Systems (6)
• System change approach
• Organizes patient and population data to
  facilitate efficient and effective care
• Allows for the sharing of information to reduce
  errors and unnecessary procedures
• Identify patients in need of diabetes services
  and treatments
• Generate diabetes program performance reports
• In Utah, we use CDEMS, DQCMS and Excel

Information on CCM drawn from www.healthdisparitie
s.net and AADE in Practice Fall 2007/Winter 2008
editions.
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DSMEData Analysis
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DSMEData Analysis
A1C Level
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DSMEData Analysis
A1C Level
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DSMEData Analysis
A1C Level
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AI/AN Projects in Utah

• Case management initiative with the urban program
  addressing the ABCs of diabetes care program
  integration project
• Improving DSME programs with each tribal
  organization
• Certifying at the State level, where feasible
• Contracts in place with three tribes to address
  health disparities

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AI/AN Projects in Utah

• Monthly continuing education program called the
  Diabetes Telehealth Program (http//health.utah.go
  v/diabetes/telehealth/telehealth.htm)
• Providing and installing free patient registries
  as a quality improvement strategy
• Providing healthcare resources such as journals
  for providers, cultural-specific materials,
  donated meters
• Trainings for Native American clinic support staff

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AI/AN Projects in Utah

• Formal data analysis agreement with the IHS
  program
• Hypertension control initiative with the IHS
  program program integration project between
  Heart Disease Diabetes Programs
• Language-specific resource.

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Navajo Language Resource

• In April 2008, we partnered with a Navajo tribal
  member in Shiprock, NM to develop a basic
  diabetes education manual in Navajo
• Audio version is planned to address literacy
  challenges and needs
• Will soon be available at (http//health.utah.gov/
  diabetes/resourcesmain/multicultmanuals.htm)

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Contact Information

• Utah Department of Health
• Diabetes Prevention Control Program
• www.health.utah.gov/diabetes
• Nathan Peterson, MPH
• nathanpeterson_at_utah.gov
• [phone]