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
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PROGRAM DIRECTORY |
Division of Diabetes
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Aberdeen Area
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Alaska Area
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Albuquerque Area
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Bemidji Area
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Billings Area
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California Area
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Nashville Area
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Navajo Area
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Oklahoma Area
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Phoenix Area
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Portland Area
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Tucson Area
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