Nashville Area Model Diabetes Programs

Houlton Band of Maliseet Indians Diabetes Program
Mississippi Band of Choctaw Indians Model Diabetes Program
Passamaquoddy/Pleasant Point Model Diabetes Program
Passamaquoddy Indian Township Model Diabetes Program
Penobscot Nation Health Department

Houlton Band of Maliseet Indians Diabetes Program
Houlton, Maine

Simone Carter, R N, Coordinator
Health Department
Rural Route 3, Box 460
Houlton, Maine 04730-9514
Phone: (207) 532-2240
FAX: (207) 532-2402
E-mail: scarter@nshbmi.nashville.ihs.gov

Data/Epidemiology

• User population--360
• Diabetic Registry--18
• Diabetes prevalence--5%

Program Accomplishments

• Direct diabetes care with a medical provider twice a week
• Full time nutritional services
• Diabetes education; individual and group; once a year, 4 two-hour classes, 15 attendees
• Monitoring supplies;glucometers and test strips for all diabetics
• Exercise facility, rent space in Houlton; gymnasium/community center open in February
• Cooking classes; twice a month for one hour
• Water aerobics; contract pay attendance 6 weeks
• Home visits--client advocate services
• Complete foot exams
• Purchase supportive foot wear yearly for clients who comply with standards of care
• Standing orders for standard labs and immunizations
• Monthly support group activities, which include screenings, a meal, education, exercise and recreational activities
• Diabetes case management for contract health service and on-site clinic patients.

Resource Development

• 2" x 3½" business card with the standards of care. People with diabetes use as reminders and documentation of needed services at physician appointments
• Trifold card patients can use to list medications, record lab values and pertinent medical information. Also contains target lab values.

Unique Contribution

• Developed a handbook entitled "Building Diabetes Care Partnerships between Tribes and Contract Health Service Providers." Presented the handbook and our case management project at the Diabetes in American Indian Communities Conference in Albuquerque, New Mexico in October 1999.
  
  
  

Mississippi Band of Choctaw Indians Model Diabetes Program
Choctaw, Mississippi

Lynda Johnson, Coordinator
Choctaw Health Center
210 Hospital Circle
Choctaw, M S 39350
Phone: (601) 656-2211
FAX: (601) 656-5091
E-mail: lyndagjohnson@hotmail.com

Program Description

Choctaw Health Center Model Diabetes Program (M D P) is located in the Nashville Area. It is a tribal program providing services to the community, inpatient and ambulatory settings. The diabetes registry is on computer and is updated on a monthly basis

Data/Epidemiology

• Service population is 8,300
• Current registry includes 1,233 people with diabetes

Clinical Accomplishment

• Computerized diabetes registry
• Physical plant that is conducive to learning
• On-site monthly diabetic retinopathy screening clinic held with a contract optometrist
• Ophthalmology follow-up is provided when eye problems are identified
• Eyeglasses are provided to people with diabetes when needed
• Twice monthly podiatry clinic with a contract podiatrist
• Provision of orthotic and/or extra-depth shoes to people with foot deformities, amputations, etc.
• The 1996 IHS diabetes chart audit indicated dental compliance in the Nashville Area at 25%. By working with, our dental staff we developed a referral procedure from the diabetes department. The 1998 dental compliance on the I H S Diabetes audit was 55%, a 20% improvement.
• Adaptation of staged diabetes management guidelines
• Two diabetes nurse educators are certified diabetes educators (C D E)
• Obesity and prevalence study is ongoing in all of our tribal schools
• Presentations are given at local, regional and national conferences regarding diabetes among the Mississippi Band of Choctaw Indians.

Community Involvement

• Participates in yearly nutrition health fair where over 2,400 tribal school students and adults participate. Health fairs offer education & screening for diabetes and diabetes prevention; safety in home, school, bicycle, etcetera; obesity, weights, heights, basal metabolic index and vision screening; and blood sugar, cholesterol and hematocrits screening.
• With tribal council support, walking trails are available to people in several outlying communities
• Educational programs relating to diabetes prevention and management is available to all tribal members, departments, agencies and club meeting, etcetera on request.
• For the past three years, our M D P sponsors a 2-mile walk/run for diabetes awareness. Each year the number of participants increases. This year over two hundred and twenty competed
• Educational presentations have been given to our law enforcement branch, mental health/behavioral health department, dental staff, governing board, and M S Vocational School
• Rehab Annual Convention
• Our model diabetes program has a contractual agreement and serves as a preceptor for the East Central Community R N nursing program.

Resource Development, products and challenges

• Participation in pilot testing for IHS pamphlets
• Participation in a focus group sponsored by the American Diabetes Association to improve their diabetes educational material
• Glucose monitors, test strips, and lancets are provided at no cost to patients
• Provision of walking shoes (styles have been approved by the diabetes nurses, M D, podiatrist) at no cost when the patient meets the minimal standards of diabetes care
• Some of the governing board members participated recently in our program as "newly diagnosed diabetic". This activity was scheduled for an afternoon.
• The diabetes nurse coordinator meets with the hospital governing board at least once a year to update them on our M D P.
• Demonstration kitchen located in diabetes department used for cooking and food preparation presentations.

Presentations

• Governing Board
• M S State Vocational Rehab.
• Mental Health/Behavioral Health
• I H S governing board

Passamaquoddy/Pleasant Point Model Diabetes Program
Perry, Maine

Carol Francis, RN, Coordinator
Health and Social Service Dept.
P. O. Box 351
Perry, Maine 04467
Phone: (207) 853-0644
FAX: (207) 853-2347

Program Description

• The Model Program first began providing services to the community in 1978. In 1980, a new structure was built and continues to house the present facility.
• Medical services provided by 2 physicians, 2 family nurse practitioners, 2 R N's, registered dietitian and certified nursing assistant
• Diabetes team that meets twice monthly
• Mental health program
• Eye clinic twice monthly
• Podiatrist twice monthly
• Chiropractic services weekly
• On-site pharmacy
• Dental clinic 3 times per week and dental assistant
• W I C program
• Breast and cervical cancer screening program
• Spiritual healer

Data/Epidemiology

• Diabetes Program General Registry through I H S R P M S system
• Annual Indian Health Diabetes Program chart audit
• Quarterly diabetes chart audits & reports to I H S
• Quarterly diabetes grant program reports to U S E T.
  

Clinical Accomplishments

• Bi-monthly diabetes team meetings with chart reviews
• Maine Intertribal diabetes program meets twice annually
• Prenatal screenings on site
• Gestational diabetes screenings on site
• On-site fructosamine testing
• Affiliation with Sunrise County Home Health Agency for home visits
• Community-wide diabetes screening
• Diabetes flow sheet used in all diabetes charts
• Provision of home blood sugar monitoring equipment and supplies to people with diabetes
• IHS Standards of Care followed in clinic
  

Community

• Community wellness and fitness center
• Youth recreation center
• Weekly diabetes support group
• Walking program

Education

• " Totally Awesome" Comprehensive health curriculum at Beatrice Rafferty school includes diabetes education component
• " Down East Healthy Tomorrows" smoking cessation program
• Fresh Start and the NoTT program for smokeless tobacco
• Domestic violence response program
• Down East telemedicine network

Unique Contribution

• Well established in-house referral system
• Annual Diabetes Walk (14th Annual in 1999). This event is used to screen for diabetes in the community
• Yearly participation from the Diabetes Team in the ADA Tour de Cure. This annual bike event in Bar Harbor raises money for diabetes research
• Moosehorn Fun Ride/Walk (2nd Annual in 1999). The focus is to promote awareness of diabetes, to encourage physical activity and to visit the Moosehorn National Wildlife Refuge in Baring, Maine.
  
  
  

Passamaquoddy Indian Township Model Diabetes Program
Princeton, Maine

Alan Majka, Coordinator
Passamaquoddy Indian Township Health Center
P.O. Box 97
Princeton, Maine 04668
Phone:(207) 796-2322
FAX:(207) 796-2422
E-mail: amajka@nspit.nashville.ihs.gov

Program Description

Established in 1985 as one of four sites in the Maine Intertribal Diabetes Prevention and Care Program.Program emphasis and diabetes team membership has varied since inception.

Data/Epidemiology

• Diabetes prevalence in user population has increased from 4.9% in 1985 to 7.5% in 1999. The largest increases are in those over 40 years of age with approximately half of diagnoses in those over age fifty: AGE: ALL 20+ 30+ 40+ 50+ 60+
• F Y 85 Population 587 299 163 102 51 28
• F Y 85 #D M 29 28 27 24 12 8
• F Y 85 %D M 4.9 9.4 16.6 23.5 23.5 28.6
• F Y 99 Population 839 441 316 170 101 53
• F Y 99 #D M 63 60 59 57 49 26
• F Y 99 %D M 7.5 13.6 18.6 32.0 48.5 49.4

Clinical Accomplishments

• Early in project entire community screened for diabetes and diabetes risk factors through events, home visits and school
• On-site care provided by interdisciplinary team that includes a physician, nurse, pharmacist, dietitian, dentist, community health representatives, mental health professionals, and contract podiatrist
• Referrals to ophthalmologists and other specialists
• Provision of blood sugar meters, supplies, medications, dentures, shoes, and books and other educational materials

Community Activities

• Early in the program, fully equipped fitness center established where group and individual exercise programs were made available for community members of all ages and abilities
• Community members trained and certified as fitness specialists
• Health fairs, group walks and diabetes dinners to promote prevention and improved self care
• Development of an elderly meals program menu and education program.

Education Programs

• Host for national diabetes conference in Bar Harbor in 1986
• Presentations at I H S sponsored training in other service areas
• Development of culturally specific self-care assessment and education program
• Regular support group and self-care classes

Resource and Product Development

• Development of culturally specific diabetes and nutrition education materials.

Challenges

• High staff turnover and recruitment difficulties

Penobscot Nation Health Department Model Diabetes Program
Old Town, Maine

Madeleine Martin, Coordinator
Penobscot Nation Health Department
23 Wabanaki Way
Indian Island, Maine 04468
Phone: (207) 817-7426
FAX: (207) 827-5022
mmartin@pnhd.nashville.ihs.gov

Program Description

• Clinic with diabetes team (M D, 2 family nurse practitioners, registered dietitian, registered nurse, registered dental hygienist, C H R)
• Diabetes registry and tracking system for diabetes care
• Fitness center in community staffed by fitness specialist
• Prevention activities for children (for example, Walking Club; cooking demonstrations at Girl's group and Youth group).
  

Data Epidemiology

• Manual registry and tickler file until we have access to computer \
• Computerized registry
• Computerized diabetes program
• Annual heights and weights of schoolchildren, age 4-14
• Plan to integrate diabetes care and data into new computerized medical records system.
  

Clinical accomplishments

• Diabetes team (physician, nurse practitioner, nurse, dietitian, dental hygienist, C H R)
• Monthly meetings of diabetes team
• Diabetes program policies and procedures
• Screening for diabetes in adults and prenatal screening for gestational diabetes
• Chart audits; audit criteria; program planning
• Diabetes flow sheet developed
• Foot exam at most visits
• Provision of blood sugar monitors and strips
• Health maintenance guidelines (eye exams, P A P tests, immunizations, labs).

Community

• Diabetes prevention fitness activities: Running Camp; Fitness Adventure Camp; Ski Club
  Walking club for 4-10 year olds
• Fitness center for diabetes control and diabetes prevention (both aerobics and strength training).
  

Education

• Diabetes Support Group
• Cooking demonstrations
• Food Sampling
• Smoking cessation
• Individual supermarket tours
• Development of Comprehensive School Health Education curriculum, with diabetes education included.
  

Unique Contribution

• How-to booklet written in collaboration with C D C on establishing effective community fitness programs.

Challenges

• Local staff turnover