Special diabetes program for indians - northern valley indian health, INC. (nvih) serves a five county area in northern california

We currently provide primary diabetes care at our medical clinics located in willows, woodland, and chico. Community needs assessments done on an ongoing basis have consistently shown that diabetes and its related health complications are a primary concern in the native american communities we serve. Sdpi funding has enabled the nvih diabetes program to address the special needs of our communities and implement action plans that lessen diabetes burden. For 2023 we have chosen to implement the eye exam best practice due to poor completion rates of this standard of care (SOC) item over several years. Data from the annual IHS diabetes care and outcomes audit (DM audit) showed a persistent decline in retinopathy screening rates from 2018 to 2021. We were able to substantially improve eye exam rates in audit year 2022 after implementing a new in-clinic teleophthalmology program and making improvements in our outside referral and tracking process to improve retinal screening by an eye care specialist for those with known eye complications. We made organization wide improvements to ensure eye exams are scheduled, completed, reports are retrieved from the eye care provider, and the data is captured for reporting purposes. We would like to continue this positive momentum and work to improve eye exam rates further. In addition to implementing our chosen best practice we will continue to provide a variety of clinical and community based diabetes and diabetes prevention services. Our certified diabetes care and education specialists (cdcess), who have key roles in the nvih diabetes program, will continue to provide diabetes self-management education and support, case management services, and act as primary provider extenders to ensure SOC items are completed, and high quality culturally appropriate diabetes care is delivered. We also strongly support comm unity advocacy and utilize a clinic-community partnership to plan activities and events. Community based activities and events promote healthy eating, physical activity, and wellness behaviors. In conclusion, the overall mission of the nvih diabetes program is to use sdpi funding to improve the health and wellness of native americans living with diabetes.