Dementia Models of Care Grantees

Absentee Shawnee Tribal Health System Exit Disclaimer: You Are Leaving www.ihs.gov  (Oklahoma City Area) launched a three-year initiative to create a dementia care model that blended traditional healing with evidence-based practices. This included:

• Preparing more than 400 health professionals
• Expanding dementia screening and services
• Strengthening team-based care and caregiver support
• Developing a shareable model for other tribal health systems

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Central Oklahoma American Indian Health Council, Inc. Exit Disclaimer: You Are Leaving www.ihs.gov  (Oklahoma City Area) developed a culturally sensitive dementia care program to deliver earlier diagnoses and stronger caregiver support. This included:

• Using new screening tools and assessments
• Developing person-centered care plans
• Enhancing community partnerships
• Improving care coordination across services

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Cherokee Nation Health Services Exit Disclaimer: You Are Leaving www.ihs.gov  (Oklahoma City Area) expanded dementia care with a comprehensive support model to help patients and families navigate care. This includes:

• Raising awareness and improving early diagnosis
• Implementing coordinated management and support
• Hiring a patient navigator and nurse case manager
• Strengthening caregiver support, access to services, and community knowledge

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Chickahominy Indian Tribe Exit Disclaimer: You Are Leaving www.ihs.gov  (Nashville Area) strengthened dementia care through its Weaving Pathways of Care initiative to enhance quality of life and build a sustainable support system. This included:

• Hiring a brain health navigator to guide families and provide education
• Tracking care through a new case management system
• Building key partnerships with health and community organizations
• Expanding screenings and caregiver support

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The Confederated Tribes of Grand Ronde Community of Oregon Exit Disclaimer: You Are Leaving www.ihs.gov  (Portland Area) expanded their Dementia Education and Care Program to improve awareness, early detection, coordinated care, and caregiver support. This included:

• Offering wellness education for mid-life adults and home-based screenings
• Training caregivers with culturally responsive resources
• Developing culturally tailored care plans
• Launching a Caregiver Champion mentorship network

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Denver Indian Health and Family Services Exit Disclaimer: You Are Leaving www.ihs.gov  (Albuquerque Area) expanded its dementia program to improve early detection, caregiver support, and culturally grounded services. This included:

• Expanding screenings for adults 50 and older
• Providing advanced dementia care training for staff
• Coordinating assessments, medication management, and behavioral health support
• Strengthening caregiver resources and case management

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The Fallon Paiute-Shoshone Tribe Exit Disclaimer: You Are Leaving www.ihs.gov  (Phoenix Area) strengthened its dementia care model through a community-led steering committee, with a focus on better outcomes and fewer emergency care needs. This included:

• Assessing dementia rates and identifying service gaps
• Expanding screenings and coordinated care planning
• Supporting caregivers through home safety evaluations and related resources
• Using electronic health records to guide care

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First Nations Community Health Source Exit Disclaimer: You Are Leaving www.ihs.gov  (Albuquerque Area) improved care by launching dementia screenings, educational workshops, and assessments led by community health workers. This included:

• Making referrals for early intervention and support
• Offering traditional wellness activities for brain health
• Addressing social needs like housing, transportation, and nutrition
• Tracking and evaluating program effectiveness

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Norton Sound Health Corporation Exit Disclaimer: You Are Leaving www.ihs.gov  (Alaska Area) expanded dementia services by closing gaps in early recognition, care coordination, and in-home support. This included:

• Standardizing screenings in clinics and hospitals
• Providing culturally appropriate education
• Developing caregiver-informed care plans and case management
• Hiring a referral coordinator to link families with resources and partners

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Seattle Indian Health Board Exit Disclaimer: You Are Leaving www.ihs.gov  (Portland Area) created a dementia care initiative that blends Indigenous knowledge with clinical best practices to improve awareness, diagnosis, care coordination, and caregiver support. This included:

• Offering culturally relevant care coordination, including traditional medicine
• Expanding screenings and assessments
• Developing caregiver support programs tailored to urban communities
• Sharing best practices and tracking outcomes

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Indian Health Board of Minneapolis, Inc. Exit Disclaimer: You Are Leaving www.ihs.gov  (Bemidji Area) provided holistic care and expanded community education on dementia while integrating traditional practices into urban Indian medical care models. This included:

• Increasing access to earlier dementia diagnosis
• Focusing on physical, emotional, and spiritual support
• Improving the interdisciplinary assessment and care planning process
• Supporting care plans that reflect cultural values and beliefs for caregivers and people with dementia

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Indian Health Council, Inc. Exit Disclaimer: You Are Leaving www.ihs.gov  (California Area) enhanced care coordination and increased community outreach efforts for the consortium of nine tribes served by the clinic. This includes:

• Integrated care model expansion
• Increasing community outreach and education through the Cognitive Health and Wellness Program
• Developing culturally sensitive care plans tailored to individuals
• Providing caregiver resources and support groups

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Nez Perce Tribal Health Authority Exit Disclaimer: You Are Leaving www.ihs.gov  (Portland Area) advanced culturally relevant dementia care by building stronger support systems for both patients and caregivers served by its Nimiipuu Health primary care clinic. This included:

• Enhancing culturally appropriate care practices
• Strengthening caregiver support networks
• Developing educational materials with traditional knowledge
• Training providers in culturally sensitive care

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The Northern Valley Indian Health, Inc. Exit Disclaimer: You Are Leaving www.ihs.gov  (California Area) Community Health and Outreach program strengthened support networks and clinical services for dementia patients. This included:

• Enhancing care coordination within the community
• Improving care coordination between providers and community services
• Training staff on dementia care best practices
• Expanding access to diagnostic services for early detection

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Santo Domingo Pueblo Exit Disclaimer: You Are Leaving www.ihs.gov  (Albuquerque Area) improved dementia care through community-led initiatives that bridged gaps in cognitive care and services. This included:

• Creating educational programs for early detection and treatment
• Integrating traditional practices and knowledge into dementia care programs
• Training community members to provide in-home dementia care and support
• Providing comprehensive caregiver support

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Tuba City Regional Healthcare Corporation Exit Disclaimer: You Are Leaving www.ihs.gov  (Phoenix Area) expanded its comprehensive care program for dementia patients and their caregivers to help improve access to specialized services, housed in their Neurology department. This included:

• Building community-clinical linkages
• Focusing on access to specialized dementia services in rural areas
• Increasing caregiver support services, including respite care
• Implementing community outreach to raise dementia awareness

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Absentee Shawnee Tribal Health System Exit Disclaimer: You Are Leaving www.ihs.gov  (Oklahoma City Area) improved its patient-focused dementia care for rural, non-reservation American Indian communities. This included:

• Creating culturally tailored treatment
• Expanding dementia care services
• Reducing symptoms for tribal elders
• Improving caregiver well-being
• Lowering health care costs

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Cherokee Nation Health Services Exit Disclaimer: You Are Leaving www.ihs.gov  (Oklahoma City Area) used grant funds to hire a patient services advocate. This advocate improved overall dementia care by:

• Giving dedicated support to patients and caregivers.
• Coordinating outreach efforts.
• Raising awareness and promoting early diagnosis.
• Providing educational resources.
• Building community partnerships to help those affected by dementia.

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The Cheyenne and Arapaho Tribes Exit Disclaimer: You Are Leaving www.ihs.gov  (Oklahoma City Area) started a new program to improve dementia support for tribal members. This program offered:

• Assessments
• Support for caregivers
• Training for the Healthy Aging Team
• Opportunities to gather data on cognitive problems

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The Confederated Tribes of Grand Ronde Community of Oregon Exit Disclaimer: You Are Leaving www.ihs.gov  (Portland Area) started a comprehensive, culturally tailored dementia program to meet the increasing needs of its community. This program focused on:

• Early detection.
• Supporting caregivers.
• Promoting holistic wellness.

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The Fallon Paiute-Shoshone Tribe Exit Disclaimer: You Are Leaving www.ihs.gov  (Phoenix Area), guided by a Dementia Care Steering Committee with members from various tribal health organizations, promoted public education and creating caregiver support groups. The Tribe hired a dementia care specialist to:

• Assess how common dementia is in the tribe's service area.
• Identify gaps in care.
• Introduce a culturally relevant, community-based approach.

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The Kenaitze Indian Tribe Exit Disclaimer: You Are Leaving www.ihs.gov  (Alaska Area) introduced a comprehensive dementia care program for tribal elders. The program included:

• Care from various providers.
• Careful supervision.
• A commitment to sharing insights.

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Norton Sound Health Center Exit Disclaimer: You Are Leaving www.ihs.gov  (Alaska Area) hired staff to coordinate patient assessments, referrals, and various team efforts. The center focused on:

• Collaborating with regional tribal and community services.
• Sharing best practices with IHS programs through the Alaska Native Tribal Health Consortium.
• Exploring funding options, including a pilot program for respite care.

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Seattle Indian Health Board Exit Disclaimer: You Are Leaving www.ihs.gov  (Portland Area) focused on improving culturally relevant, comprehensive dementia care for American Indian and Alaska Native people in Seattle/King County. The program concentrated on:

• Traditional Indian medicine.
• Knowledge-sharing among urban Indian groups.
• Support for urban Native elders, caregivers, and health care providers.

Indian Health Board of Minneapolis, Inc. Exit Disclaimer: You Are Leaving www.ihs.gov  (Bemidji Area) addressed dementia in the community by:

• Creating a culturally appropriate way to diagnose dementia
• Hiring a program manager and a community elder
• Working with community health workers to raise awareness about dementia

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Indian Health Council, Inc. Exit Disclaimer: You Are Leaving www.ihs.gov  (California Area) took a multi-level approach to help people with dementia and their caregivers. It focused on early detection of dementia. It also used a case management system to:

• Deliver patient-centered care.
• Monitor progress.
• Support caregivers.
• Provide timely access to specialized services.

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Nez Perce Tribal Health Authority Exit Disclaimer: You Are Leaving www.ihs.gov  (Portland Area), through Nimiipuu Health, made major efforts to address dementia within the community by:

• Educating tribal programs and clinical teams on how to recognize the signs of dementia.
• Supporting elders and caregivers affected by dementia.

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Northern Valley Indian Health, Inc. Exit Disclaimer: You Are Leaving www.ihs.gov  (California Area) increased its support for those affected by dementia by:

• Hiring a program coordinator to oversee its Stronger Together Dementia Awareness Program.
• Creating an early detection tool.
• Developing individualized health plans to empower people living with dementia and their caregivers.

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