Portland Area Model Diabetes Programs

Warm Springs Diabetes Program
Portland Area Diabetes Program

Warm Springs Diabetes Program
Warm Springs, Oregon

Jennie Smith, Coordinator
Warm Springs Health & Wellness Center
P. O. Box 1209
Warm Springs, Oregon 97761
Phone: (541) 553-2478
FAX: (541) 553-2457
E-mail: Jennie.Smith@ihs.gov

Program Description

A comprehensive diabetes education program focused on positive lifestyle changes, tailored to the individual and an amputation prevention program. Staff includes coordinator, family nurse practitioner, two nurse educators and a medical clerk.

Data/Epidemiology

• Active Registry-332 clients
• Active Service Population-6354
• Diabetes prevalence-5.2%
  

Research/Publications/Presentations

• Poster presentation at the 3rd International Conference on Diabetes & Indigenous People
• Diabetes Data Analysis Project Pilot site (I H S National Diabetes Program & National Indian Council on Aging (N I C O A)
• Mortality causes in diabetes patients at Warm Springs-study by Program Staff
  in development: Obesity as a risk factor in type 2 diabetes development in the Warm Springs population, with Northwest Portland Area Indian Health Board (N P A I H B).
  

Registries

• Diabetes, gestational diabetes, elevated blood glucose, impaired glucose tolerance and diabetes complications
• Metabolic Syndrome
• High Risk Foot
• Diabetes Management System
  (R P M S-based).
  

Prevention Programs

• Primary nutrition education services; weekly healthy cooking classes; floor and water aerobic classes; and 'at-risk' clients are placed in 'Watch' category for annual reminders for testing
• Primary Prevention Program (being developed)
• Secondary education and nutrition services; available clinics: foot, optometry, audiology, and dental; A/C ratio and hemoglobin A1C screenings; bi-monthly diabetes support group breakfasts; an extensive group fitness program; offer glucometer to all patients with diabetes
• Tertiary podiatry and renal clinics, and monthly dialysis support groups
• Multidisciplinary diabetes team sets service unit policy regarding diabetes care
• Annual I H S Diabetes Audit
• Quarterly case management on active clients to monitor Standard of Care
• In-services on Standards of Care, medications, treatment, and other issues related to diabetes, held on a monthly basis
• Utilize Staged Diabetes Management as resource in the treatment of clients with diabetes.
  

Community Programs

• Bi-monthly community 'screenings' (at 9 sites)
• Annual 4-H camp education days, and annual 'Heart Smart' dinner
• Health Fairs, including a month long "November Fitness Challenge"
• Monthly education/awareness session at Senior Center luncheon
• Education days at local High School and Alternative Education school
  
  

Education Programs

• Training site for other Portland Area Indian health programs
• Implemented "Strong in Body and Spirit" community-based diabetes education curriculum
• Staff participation in Continuing Education programs and training to advance knowledge
• Provide support for paraprofessionals (for example, C H R's) to attend diabetes-related training
• Offer individual, family, and group classes in clinic, home, or community setting.
  
  

Resource & Product Development

• Site specific nursing orientation manual
• Client education handout "What is a carbohydrate?"
• Numerous recipe handouts
• Case management form
• Printed diabetes P C C forms
• Screening Information Card
• Walking Program booklet
• Diabetes Program services brochure
• Reminder' form (mailed to patient when care is due)
• Serve as education materials warehouse for the Portland Area.
  
  

Challenges

• Due to limited budget, we are not able to fully staff this program, attend some advanced training, or purchase some needed equipment.
  

Unique Contribution

• Conduct a diabetes awareness program that is broadcast on a local radio station (program is re-broadcast throughout the year)

Recipient of the I HS Director's Award for distinguished service.

Portland Area Diabetes Program
Portland, Oregon

Donnie Lee, Coordinator
Portland Area I H S
1220 S W Third Avenue
Portland, O R 97204-2892
Phone: (503)326-2017
FAX: (503) 326-7280
E-mail: Donnie.Lee@ihs.gov

Program Description (Established 1995)

Established in 1985 with a regional emphasis. Initial programming activities with 14 Portland Area Service Units. Program goals were to establish working diabetes registries, evaluate approaches to diabetes care and education and to provide technical assistance related to diabetes care and outcomes within the Portland Area.

Data/Epidemiology

• Portland Area Diabetes Program has helped over 14 I H S clinic and Tribal programs to establish active diabetes registries. Assistance was given in creating R P M S databases, clinician cross-reference and chart review for diagnosis accuracy
• Publication in Diabetes Care (2) & I H S Provider (1) on Portland Area diabetes prevalence.

Clinical

• Established consensus with Portland Area Clinical Directors on standards for diabetes care and education. Standards served as basis for diabetes audit
• Assistance to all participating in Annual Diabetes Care and Outcomes Audit with annual diabetes audit reports generated.
• Assistance to I H S National Diabetes Program in programming EpiInfo Diabetes Audit software package and analysis for all I/T/U's participating in audit.

Primary Prevention

• Assistance with over 14 health fairs within Portland Area
• Development of community-based walking and nutrition programs within tribal communities in partnerships with Northwest Indian College.

Secondary/Tertiary Prevention

• Work with Northwest Washington Service Unit to establish screening protocols
• Provision of foot screening tools and provider education to clinics (14+)--monofilaments, foot care equipment, training programs, education materials.
• Provision of special shoes and inserts for people at risk for amputations (special emphasis funds)
• Provision of home blood sugar monitoring equipment and supplies
• Assistance with speciality provider contracts and training (podiatry, retinal screening)
• Area-wide funds to help support pharmaceutical costs.
• Adult Nurse Practitioner/C D E and M D services to local tribal clinic.

Unique Contribution

• Adapted A D A screening tool for use in tribal communities
• Assisted Model Diabetes Program and I H S S U in establishing Staged Diabetes Management Protocols
• Assistance in developing protocols for diabetes and microalbuminuria screening
• Development of booklet series, poster series, nutrition and fitness education training programs used throughout the Indian health network

Education

• Publications (4) in Diabetes Care, The Diabetes Educator and Nurse Practitioner Forum on diabetes education within American Indian/Alaska Native communities.
• Teleconference series with American Diabetes Association and State Diabetes Control Programs (neuropathy, diabetes and pregnancy, nutrition, retinopathy, nephropathy, medications)
• Annual C E U program for I/T/U diabetes coordinators
• Leadership in development and field testing of 16+ diabetes education materials
• Multiple C H R training programs
• Partnership with Northwest Indian College and U S D A Commodity Food Program in developing nutrition training program for communities
• Support of community walking programs throughout Portland Area
• Support of diabetes camps/Pow-Wows for tribal communities.

Challenges

• Personnel changes in 1999.