Masu diabetes program implementation - initial patient identification, screening, education and the establishmentof a patient diabetic registry - the mid-atlantic service unit (masu) began providing…

Masu diabetes program implementation - initial patient identification, screening, education and the establishmentof a patient diabetic registry - the mid-atlantic service unit (masu) began providing purchased/referred care (PRC) services for 7 newly federally recognized virginia tribes in march of 2020. An extensive needs study supported the expansion to direct care services. As a result, two clinics are under construction. Because of the prevalence of diabetes in the native american and alaska native communities, mid-atlantic tribal health center, (mathc) will have a wing dedicated to diabetic health that includes training and office space, kitchen, exam and treatment room. Masu is committed establishing a strong health care system for the mid-atlantic tribes with a focused approach on addressing diabetes recognition, treatment, care and management. Additionally, masu has invested in the accessibility of care services within the tribal communities themselves. Four modular health stations will be located in the more remote tribal areas and will house community health representatives (chrs). The chrs serve an integral role as community health educators, among others. As masu is a new service unit, this initial grant year will prove foundational in the establishment of our robust diabetes services. Masu will identify and educate our native american population using the significant sdpi library of existing culturally-adapted nutrition, physical activity and overall diabetes education materials. Additionally, masu will deploy a tobacco use screening tool as standard practice at each patient encounter. Masu will use these screening results to identify patients, provide tobacco cessation interventions and support them in those efforts; and, report on required key measures with the goal of increasing the number and/or percent of individuals who achieve or show improvement in this measure. These activities will be conducted by medical, dental, behavioral health, patient registration personnel and chrs year one, this grant will focus on identification and population management/screening. Tribal user populations have grown beyond those identified at the time of federal recognition. Through many planned events, masu will identify and register tribal members. Masu will identify the patients with diabetes or target population and establish a patient diabetic registry for the service unit. Masu will employ a building block approach to implement a comprehensive diabetes management program over the scope of four years. Year one: population management/screening/education; year two: education/panel management; year three: integrating case management into best practices; and finally, in year four, diabetes self-management and personal responsibility; year five: program sustainability.