Lake county tribal health consortium- sdpi grant application - the lake county tribal health consortium, INC. (LCTHC) is the only IHS clinic in rural, poor, remote lake county, california

Based on patient data, LCTHC estimates local AI/an diabetes prevalence at 8.8%. AI/an are at higher risk of diabetes and experience more rapid and intense disease progress and severity than the general population. Local AI/an also have high rates of CO-morbidities e.g., obesity and tobacco use. About 40% of LCTHC's AI/an patients and 93% of its AI/an diabetics are overweight or obese. Patient recruitment/retention is the key local challenge to preventing and managing diabetes. Barriers to recruitment/retention include covid-related disruption of in-person services and patients' lives; lost program and patient momentum; staff recruitment/retention; lack of transportation and internet access; lack of access to healthy foods and cooking classes; and local AI/an perceptions that diabetes is both shameful and inevitable. However, local AI/an also recognize the negative impact of diabetes on their community and prioritize preventing/delaying onset among younger generations. LCTHC is a highly experienced provider of diabetes-related education and wellness support. IT has offered diabetes screening, education, and services to the AI/an community since 1998. LCTHC's diabetes prevention and self-management program is accredited through the ADA. Current services include diabetes self-management education workshops, the CDC-recognized diabetes prevention program, 1:1 nutrition education from registered dietitians, "together we can" (TWC) a home-based lifestyle education and psycho-social program for native youth; and the KWA XHO community garden (the garden), established in 2000 to provide garden skills, education on healthy foods and cooking, and food distribution. The hinth'el wellness council (formed in 2014) and the youth wellness group conduct needs assessments, reach out to peers to engage them in diabetes-related activities, and meet monthly with LCTHC staff to provide community input to sustain and improve AI/an participation in diabetes-related programs. Our overarching goal is to reduce the progress and severity of diabetes among the AI/an community, including delaying or preventing onset. The chosen best practice is diabetes related education: 4-5 six-week self-management workshops/year, rotated among the 6 rancherias and offered live online. Participants are referred to the garden, bingocize, walk with ease, walk to wellness, 1:1 follow-up with a registered dietitian, and other services as needed. The optional activities are: (1) the garden, offering gardening skills and supplies, healthy food, exercise, cooking demonstrations, and food distributions: (2) increased community leadership from HWC and youth wellness; (3) the CDC-recognized diabetes prevention program, "learning to live in balance," focusing on weight loss and exercise for higher-risk patients; (4) the 18-month TWC for youth aged 10-18; and (5) chronic care management to encourage all patients to meet their standards of care each year (eye/foot/dental exams, flu shots, and 1:1 medical nutrition therapy consultation with a registered dietitian). The project plans to serve 1,000 people and benefit many more as participants share their new skills, healthy foods, wellness choices, and progress with family and friends.