Indian Health Service Online Submission, Consultation, and Reporting (OSCAR) System for Evidence Based and Promising Practices, Local Efforts, Policies and Resources. (logo: A Circle of Healthy Initiatives for American Indians and Alaska Natives)

Indian Health Care Resource Center Diabetes Management and CVD Risk Reduction

Program Type: Local Effort - Programs and/or activities that have not been evaluated but are identified by local programs as producing positive results.

Description:
Diabetes-Cardiovascular Disease Risk Reduction Grant Program Using the Census 2000 Indian population (AI/AN primary race) of 29,316 for Tulsa County, IHCRC estimates that approximately 10% of this population has diabetes or about 3,000 American Indians. IHCRC serves a population base of over 86,000 American Indians (persons identifying as one or more races) who live in the five-county Tulsa MSA (2000 Census). IHCRC has analyzed its active Indian patient clinic population and found that 1169 (20%) of IHCRC patients age 19 and over are severely overweight, and 1944 (33%) are obese. Approximately 10% of overweight or obese adults also have diabetes diagnoses. Our 2007 diabetes chart audit indicated 625 active diabetic patients, compared to the first chart audit in 1998, which showed only 148 diabetic patients. The increasing number of diabetic patients indicates a rapidly growing chronic disease threat.

Our DM-CVD grant utilizes a case management approach, employing a counselor (LPC) as the case manager. The team also includes a dietitian and data coordinator. The concept of employing a counselor as a case manager occurred after the first nurse case manager resigned. We brainstormed to determine what our patients have in common, why they were not progressing, and what they really needed. We felt that a commonality among the patients was depression and family issues. These things prevented the patients from making their diabetes care a priority. At that point, we decided to hire a counselor as the case manager, in an effort to address these underlying issues.

Patients see the counselor/case manager and the dietitian for monthly appointments. Many patients have started to open up about their lives, and to be more honest about their lifestyle habits. This type of progress is difficult to monitor, as the lifestyle changes are coming slowly. We do feel strongly that over the course of time, the counselor as a case manager will be very beneficial to our patients in helping them get their lives in order, and slowly but surely make their diabetes care a priority.

Age Group(s):
Adults

Site Type(s):
Clinic/Health Center, Hospital

Health Indicator(s):
Diabetes , Cardiovascular Disease

Service Area:
Oklahoma

Keyword(s):

URL: www.ihcrc.org

Name: Nancy O’Banion
Site or Location Name: Indian Health Care Resource Center of Tulsa
Address:
550 S. Peoria
Tulsa, OK 74120
Email: nobanion@ihcrc.org
Phone: 918-382-1220