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.
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PROGRAM DIRECTORY |
Division of Diabetes
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