Albuquerque Area Model
Diabetes Program
Albuquerque Service Unit Model Diabetes Program
Zuni Community Health Model
Zuni Service Unit Model Diabetes Program
Albuquerque
Service Unit Model Diabetes Program
Albuquerque, New Mexcio
Norma Cruz, R D, Coordinator
PHS Indian Hospital
801 Vassar Drive, N E
Albuquerque, New Mexico 87106
Phone: (505) 256-4017
FAX: (505) 256-7697
E-mail: Norma.Cruz@ihs.gov
Program Description
The Albuquerque Service Unit (A S U) Diabetes Program began
in 1979 to provide services at seven clinic sites. Services
include clinical care and community interventions. The multidisciplinary
staff, with 68 years of cumulative diabetes experience, includes
four certified diabetes educators, two part-time physicians
and support staff. Current registry shows approximtely 1,800
patients with diabetes.
Diabetes Clinics
- Clinical services at seven New Mexico sites provide comprehensive
care to people with diabetes
- Services include diabetes treatment and prevention of
kidney disease, eye disease, heart disease, stroke, amputations
and cancer. Prenatal care and diabetes prevention services
are also provided
- Diabetes and nutrition education and foot care are provided
at all clinics
- Diabetes Management Guidelines and IHS standards of care
are used to guide testing and therapy. A yearly chart audit
is conducted and goals & program changes are based on
the results
- Awarded the American Diabetes Association Provider Recognition
Certificate in December, 1999.
Community Services
- The A S U Diabetes Program partners
with communities, including tribal grant programs, to develop
health interventions. This includes consultations, technical
assistance and direct education services such as health
fairs, cooking classes and support groups
- Monthly training for tribal diabetes grant staff is provided
based on the training needs of A S U tribes but is open
to all tribes.
- Quarterly meetings for tribal diabetes staff are coordinated
throught the program
Resource and Products
- Educational materials, curriculum and programs are developed
and tested by the program staff. These have included:
- Living Well with Diabetes-- a 6-week class to help people
learn the skills needed to live well with diabetes. This
program provides practical information in diabetes and how
to care for it.
- Newly Diagnosed Program--a comprehensive education curriculum
for all newly diagnosed D M patients
- Trimdown--a 6-week class designed to help people lose
weight by changing eating and exercise habits. This program
can help people to control diabetes, high blood pressure
and high cholesterol.
- Wellpower--a quarterly newsletter on diabetes and general
health for A S U Diabetes Program patients
- Development of numerous education materials, some have
been adapted for widespread use in I H S.
Education
- Individual diabetes self-management sessions and medical
nutrition therapy by certified diabetes educators are available
at all sites
- group education is also provided in a variety of clinic
and community settings.
- The A S U Diabetes Program provides education for medical
staff, C H R s, tribal health staff, nurses, medical residents,
University of New Mexico students, and other health care
providers. This is done through formal training sessions,
mentoring and preceptorships. Training is provided at A
S U, the I H S Albuquerque Area and at other sites nationally.
Unique Contributions
- First program in I H S awarded American Diabetes Association
Diabetes Education Recognition-able to share lessons learned,
resources and curriculums developed Also awarded American
Diabetes Association Provider Recognition Certificate that
acknowledges program provides high standard of diabetes
care and treatment.
- Leadership and participation in national and regional
groups developing policy, programs and materials. Recent
examples include Albuquerque Area I H S disease guidelines,
I H S Diabetes Education Curriculum, I H S Diabetes Education
Standards, and I H S automated diabetes audit, American
Association of Diabetes Educators and I H S Speciality Practice
Group.
Zuni
Community Health Model
Zuni, New Mexico
Lydia Simplicio, Health Promotion Specialist
Pueblo of Zuni
P.O. Box 308
Zuni, New Mexico 87327
Phone: (505) 782-2665
FAX: (505) 782-4388
Program Description
The Zuni Wellness Center (Z W C) has earned national and
international recognition as a community-based program promoting
wellness and health among the native people of Zuni
In 1999, Z W C programs were featured in the I H S Primary
Care Provider, the Native American Turning Point Project Newsletter
and the Bristol-Myers Squibb Foundation Report entitled Extending
and Enhancing Human Life. Again, the Zuni Wellness Center
has earned the reputation for quality advances in fitness
and health promotion.
The concepts of the Wellness Center are practical and easily
replicable in other Native American communities. The Z W C
staff are consultants for local and other tribal organizations.
It is the hope of the Wellness Center staff that more individuals
at risk for diabetes are able to participate in exercise and
health promotion activities.
Community empowerment is necessary for the successful creation
of a wellness campaign. Listed below are 1999 attendance figures
for all fitness classes and health promotion events.
1999 |
Aerobic Classes |
Circuit Trng & Weight Room Attendance |
Cardio Training & Cardio Room Attendance |
Diabetes Clinic Contacts |
Attendance for Individuals w/Diabetes |
Southwest Forest Firefighters |
Driving under the Influence |
Jan |
210 |
176 |
145 |
36 |
87 |
71 |
14 |
Feb |
256 |
178 |
155 |
51 |
104 |
52 |
18 |
Mar |
291 |
203 |
167 |
52 |
111 |
133 |
10 |
April |
303 |
176 |
269 |
49 |
109 |
138 |
10 |
May |
295 |
188 |
216 |
23 |
111 |
165 |
12 |
June |
242 |
135 |
151 |
35 |
117 |
218 |
8 |
July |
275 |
179 |
227 |
31 |
109 |
112 |
7 |
Aug |
274 |
204 |
193 |
34 |
115 |
149 |
7 |
Sept |
230 |
192 |
153 |
27 |
95 |
134 |
13 |
Oct |
242 |
205 |
82 |
19 |
95 |
85 |
4 |
Nov |
233 |
184 |
122 |
16 |
94 |
63 |
5 |
Dec |
266 |
170 |
129 |
36 |
96 |
0 |
0 |
Zuni Fitness Series |
Healthy Lifestyles Youth Conference |
Youth Aerobic Exhibition |
Holiday Eating Learning Program |
Strong in Body and Spirit Curriculum Participants |
Driving Under the Influence |
1338 |
188 |
67 |
176 |
432 |
108 |
Zuni Service Unit Model Diabetes Program
Zuni, New Mexico
Scott Doughty, M D, Coordinator
P H S Indian Hospital
P O Box 467
Zuni, New Mexico 87327
Phone (505) 782-4431
Fax: (505) 782-5723
Scott.Doughty@ihs.gov
Program Description
Hospital-based program involved in clinical, research, and
community activities.
Data/Epidemiology
- Approximately 1,400 people with diabetes in a service
population of 9,781
- 25% of those ages 29 and older have diabetes
- 50% of those ages 49 and older have diabetes
- Active registries for diabetics, gestational diabetics,
impaired glucose tolerance and "lost to follow-up"
patients. Amputation registry is being developed
Clinical Accomplishments
- Weekly multi-disciplinary diabetes clinic, guided by
I H S Standards of Care for Diabetes and Staged Diabetes
Management
- On-site nutrition and diabetes education by appointment
- Incidence of lower extremity amputation markedly reduced
(to 0%!) since podiatry clinic began 12/98.
Research
- Proposed "Health Foods First" project being
formulated. Drug use evaluations (metformin/troglitazone)
with immediate feedback to healthcare providers at Zuni-Ramah
Service Unit
- Numerous abstracts, research and review articles published
in Diabetes Care, I H S Provider, Journal of Family Practice,
and others.
- Presentations at regional and national conferences
Community
- Active member of the local diabetes partnership effort
to promote prevention through education and active participation
in lifestyle modification.
- Other partners include representatives from:
Tribal Council |
Zuni Wellness Center |
W I C |
Zuni Healthy Lifestyles |
Zuni Senior Center |
Zuni Headstart |
Zuni Teen Health Center |
Zuni Health Board |
Diabetes Prevention Program |
Zuni PHS Pharmacy and Physical Therapy departments |
|
|
- Most succesful and established (17 years) pr0ogram is
the Zuni Fitness Series.
Education
- On-going patient/family education in clinic and office
appointments
- Staff education for nurses, physicians, and physician
assistants
- Community education through local radio and newspaper
events
recently produced diabetes education video
- Health fairs & school class sessions
- Zuni Fitness Series and Zuni Wellness Center events
- Meet with D W I offenders monthly to educate about diabetes/alcohol
dangers
- Plan to incorporate student researchers in program activities
through a National Diabetes Prevention Center effort with
Dine College
Resource Development
- Assisted Zuni Wellness Center in developing materials
for replicating community wellness programs which have succeeded
in Zuni
- Working with other diabetes care providers in Albuquerque
Area to develop treatment guidelines for diabetes, hypertension,
and dyslipidemia
- Involvement with National Diabetes Prevention Center development.
Challenges
- Recognizing the proven benefit of case management for
improving glycemic control, the Public Health Nursing department
is assisting P H N staff members to become Certified Diabetes
Educators. This effort should improve our local outreach
to meet the needs of individuals having difficulty attaining
the recommended level of glycemic control or meeting standards
of care
Unique Contributions
- Establishment of protocols for microalbuminuria screening
- Comprehensive multidisciplinary weekly diabetes clinic
with all physicians and physician assistants participating.
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PROGRAM DIRECTORY |
Division of Diabetes
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