Cooperative Agreement H1D1IHS1195

FY2023 SPECIAL DIABETES PROGRAM FOR INDIANS - MACT HEALTH BOARD, INC. IS COMMITTED TO PREVENTING DIABETES AND IMPROVING THE HEALTH STATUS OF AMERICAN INDIANS/ALASKAN NATIVES (AI/AN) WITH DIABETES TO THE HIGHEST LEVEL THROUGH PROVISION OF PUBLIC HEALTH, PRIMARY AND PREVENTATIVE SERVICES. CURRENTLY, APPROXIMATELY 7.2% OF OUR NATIVE AMERICAN CLINIC POPULATION HAVE DIABETES AND 45% OF OUR HONORED ELDERS HAVE DIABETES. OUR CLINIC POPULATION HAS A PREDIABETES PREVALENCE RATE OF 4.4 PERCENT. SDPI PLAYS A VITAL ROLE IN IMPROVING CARE OF OUR POPULATION THROUGH INCREASED PROVIDER AND PATIENT AWARENESS AND EDUCATION AND IN THE TRACKING OF OUR DIABETIC AI/AN PATIENTS TO ENSURE THAT WE HAVE ACCURATE DATA FOR TRACKING PURPOSES. MACT HEALTH BOARD'S PROGRAM HAS 5 MEDICAL CLINICS, 5 DENTAL CLINICS, 5 BEHAVIOR HEALTH LOCATIONS, 1 OPTOMETRY CLINIC, 1 WOMEN'S HEALTH AND 1 PHARMACY. INTEGRAL SERVICES INCLUDE DIABETIC-FOCUSED VISITS, MEDICAL LAB WORK INCLUDING DIABETIC SCREENING FOR AT-RISK PATIENTS, IMMUNIZATIONS, DIABETES EDUCATION, RETINAL EYE, DENTAL, AND FOOT EXAMS, AND DISTRIBUTION OF DIABETIC SUPPLIES. WE HAVE A MULTI-DISCIPLINARY TEAM, WITH THE MEDICAL DIRECTOR AND DIABETIC COORDINATOR TO OVERSEE THE PROGRAM AND ENSURE WE CONTINUE TO STRIVE TOWARD THE STANDARDS OF CARE SET FORTH BY INDIAN HEALTH SERVICES. WE WILL HOST TWO WELLNESS FAIRS FOR THE NORTHERN AND SOUTHERN COMMUNITIES DURING THE WEEKEND TO INCREASE PARTICIPANT TURNOUT. MEDICAL PROVIDERS, DIABETIC COORDINATOR, OPTOMETRY STAFF, DENTAL STAFF, DIABETIC COORDINATOR, CHIROPRACTIC AND BEHAVIORAL HEALTH SPECIALISTS WILL ATTEND TO BRING A CENTRALIZED FOCUSED TO OUR AI/AN PATIENTS. THE GOAL IS TO ENCOURAGE COMPLETION OF THE STANDARDS OF CARE REQUIREMENTS, PROMOTE FAMILY/FRIENDS INVOLVEMENT AND ACTIVELY EDUCATE ALL ATTENDEES ON THE IMPORTANCE OF CONSISTENT DIABETES CARE MANAGEMENT, WHILE INCORPORATING CULTURAL INFLUENCES. DIABETES EDUCATION IS OFFERED AT ALL 4 CLINICAL SITES WITH DIABETIC COORDINATOR. THE GOAL IS TO REACH AND EDUCATE OUR PATIENTS ABOUT DIABETES, PREDIABETES, AND GESTATIONAL DIABETES. MEETINGS GUIDE PATIENTS TO BE PROACTIVE IN DEVELOPING SELF-MANAGEMENT SKILLS AND TO UNDERSTAND WHAT COMPRISES HEALTHY LIFESTYLE AND DIABETES CARE. COLLABORATION WITH NATIVE AMERICAN SERVICES ENSURES THAT NEWLY DIAGNOSED AI/AN PATIENTS ARE GUIDED THROUGH STANDARDS OF CARE TO MOVE TOWARD A PREVENTATIVE HEALTH CARE MODEL. MACT HEALTH BOARD ALSO OFFERS DIABETIC SHOES TO PARTICIPANTS WHO HAVE MET THEIR STANDARDS OF CARE, AS WELL AS A MEMBERSHIP TO A LOCAL GYM, AS LONG AS THEY COMMIT TO UTILIZING AT LEAST TWICE A WEEK. WE HAVE EXPANDED THE GYM PROGRAM TO INCLUDE PREDIABETICS WHO SEEK PRIMARY CARE SERVICES AT MACT WHO HAVE COMPLETED THEIR A1C AND CHOLESTEROL SCREENINGS YEARLY. WE HAVE STARTED A CONTINUOUS GLUCOSE MONITORING (CGM) PROGRAM FOR PATIENTS WITH HGA1C GREATER THAN OR EQUAL TO 8.4 AND/OR LONG-TERM USE OF INSULIN WITH ASSOCIATED CO-MORBIDITY. WE WILL TRACK HGA1C TRENDS WITHIN OUR I2I POPULATION MANAGEMENT SYSTEM. DIABETIC COORDINATOR WILL LEAD PILOT PROGRAM TO KEEP PATIENTS ON CGM UP TO DATE WITH CARE PLAN. WHEN COMPARING THE PERCENTAGES OF PATIENTS WHO HAVE HAD THEIR ANNUAL INFLUENZA IMMUNIZATION, THERE WAS A NOTABLE DROP FROM FY2021 AT 59% TO 37% IN FY2022. THIS SIGNIFICANT DROP SHOWS WE ARE BELOW THE AVERAGE AREA PERCENTAGE IN FY2021 AT 44% AND BELOW THE IHS PERCENTAGE AT 51%. FOR THIS REASON, WE DECIDED OUR REQUIRED KEY MEASURE WILL BE TO INCREASE INFLUENZA IMMUNIZATIONS IN FY2023. OTHER BEST PRACTICES INCLUDE FOOT EXAMS, RETINAL EYE EXAMS AND TUBERCULOSIS SCREENING.