Addressing dementia in cherokee nation - dementia is significantly under-recognized and under-diagnosed in indian country

Cherokee Nation received a $200,000 Cooperative Agreement under the Indian Health Service (IHS) Health Management Development Program (CFDA 93.228) effective September 1, 2025, through August 31, 2028. The award supports the development of comprehensive dementia care services at Cherokee Nation Health Services, the largest tribally operated healthcare system, by funding two dedicated clinical support positions: a Patient Navigator and a Nurse Case Manager. These positions will join existing teams within the health system to address the significant under-recognition and under-diagnosis of dementia in Indian Country by providing specialized support to patients living with dementia and their caregivers.

The funded initiative implements a multidisciplinary approach encompassing awareness and recognition of dementia warning signs, timely and accurate diagnosis, multidisciplinary assessment, clinical management and referral services, and dedicated caregiver support. By establishing these support services, the program aims to improve patient and caregiver satisfaction while expanding existing clinical services to deliver integrated care for this underserved population. Success will be evaluated through multiple performance metrics aligned with the broader goal of enhancing health management capacity within the tribal health system to better serve Cherokee Nation citizens across its 14-county reservation in northeastern Oklahoma.

Cherokee nation health services is able to provide clinical services to patients living with dementia, however, there are not any existing support services dedicated to helping these patients and their caregivers navigate the required care that is associated with this diagnosis. Our health system needs support staff to fill this role, as IT is a critical element of reaching desired health care outcomes. The overall project objective is to expand upon existing services to develop a comprehensive approach to care and services for patients living with dementia and their caregivers. Specific elements of this approach include: • awareness and recognition • timely and accurate diagnosis • multidisciplinary assessment • management and referral • caregiver support if successful, the program's efforts will result in patients and caregivers being satisfied with the support that they have received while navigating dementia diagnosis and treatment. Additionally, another goal of this project will be to increase awareness and recognition of the warning signs for dementia and alzheimer's disease. The success of the program will be evaluated based on numerous factors. Cherokee nation health services is the largest tribally operated health care system. If awarded, grant funds will be utilized to hire a new patient navigator as well as a nurse case manager dedicated to serving patients with dementia and their caregivers. The new patient navigator will be joining the patient experience team - a group of employees that are dedicated to improving patient satisfaction within our health system and increasing access to health care for cherokee citizens living outside of the reservation. The new nurse case manager will be joining the specialty nurse coordination team within cherokee nation health services. This team is dedicated to serving patients within the clinical care setting.