The Mid-Atlantic Service Unit (MASU) began providing Purchased/Referred Care (PRC) services for 7 newly federally
recognized Virginia Tribes in March of 2020. An extensive needs study supported the expansion to direct care
services. As a result, two clinics are under construction. Because of the prevalence of diabetes in the Native
American and Alaska Native communities, Mid-Atlantic Tribal Health Center, (MATHC) will have a wing dedicated to
diabetic health that includes training and office space, kitchen, exam and treatment room. MASU is committed
establishing a strong health care system for the Mid-Atlantic Tribes with a focused approach on addressing
Diabetes recognition, treatment, care and management. Additionally, MASU has invested in the accessibility of
care services within the tribal communities themselves. Four modular health stations will be located in the more
remote tribal areas and will house Community Health Representatives (CHRs). The CHRs serve an integral role as
community health educators, among others.
As MASU is a new service unit, this initial grant year will prove foundational in the establishment of our robust
diabetes services. MASU will identify and educate our Native American population using the significant SDPI
library of existing culturally-adapted nutrition, physical activity and overall diabetes education materials.
Additionally, MASU will deploy a tobacco use screening tool as standard practice at each patient encounter. MASU
will use these screening results to identify patients, provide tobacco cessation interventions and support them
in those efforts; and, report on required key measures with the goal of increasing the number and/or percent of
individuals who achieve or show improvement in this measure. These activities will be conducted by medical,
dental, behavioral health, patient registration personnel and CHRs
Year one, this grant will focus on identification and population management/screening. Tribal user populations
have grown beyond those identified at the time of federal recognition. Through many planned events, MASU will
identify and register tribal members. MASU will identify the patients with diabetes or target population and
establish a Patient Diabetic Registry for the Service Unit.
MASU will employ a building block approach to implement a comprehensive diabetes management program over the
scope of four years. Year One: Population Management/Screening/Education; Year Two: Education/Panel Management;
Year Three: Integrating Case Management into Best Practices; and finally, in Year Four, Diabetes Self-Management
and Personal Responsibility; Year Five: Program Sustainability.