Friday, April 11, 2025
4/11/2025
IHCRC Diabetes Prevention and Management Program - For 24 years, Indian Health Care Resource Center of Tulsa (IHCRC) has been the primary source of diabetes treatment and prevention for the American Indian community in Tulsa and the surrounding area. Today, the diabetes program serves more than 1,200 individuals a year. In addition to Medical Nutrition Therapy (MNT), IHCRC offers a wide range of other diabetes treatment and prevention services including Diabetes Self-Management Education and Support (DSMES), cooking classes, exercise and fitness, diabetes case management, and youth and family nutrition classes. IHCRC primarily serves American Indian individuals and families living in the Tulsa MSA. The Tulsa MSA comprises seven counties: Creek, Okmulgee, Osage, Pawnee, Rogers, Tulsa and Wagoner. During fiscal year 2021, 72% of the 10,208 individuals served by IHCRC were Cherokee or Muscogee (Creek). 112 tribes were represented in total. Approximately, 17% of individuals lived in rural communities with the largest majority living in the city of Tulsa and its adjacent communities. IHCRC's SDPI program is an integrated part of IHCRC's services. Located in the same facility as all other services, the Diabetes Team is in daily contact with the medical providers. Diabetes Team visits are documented in the clinic's EHR. Referrals for dental, optometry, and behavioral health services can be made on-site as needed or prescribed by standard of care. The IHCRC SDPI Team has been receiving approximately 100 additional referrals per year. A review of the 2021 and 2022 audits along with current chart reviews revealed that currently 19% of diabetes patients (209 of 1080 patients) have an A1c ≥ 9. The National GPRA goal is 15.6%. These 209 individuals represent the target population. 68% of those individuals (143 of 209) have also been diagnosed as obese. Fifty-three percent (112) are female and 47% are male. Seventy-three individuals (35%) are ages 60 and up; 30% (60 individuals) are ages 50 to 59; 44% (92 individuals) are ages 30 to 49; and four are ages 20 to 29. The majority have also been diagnosed with hypertension. IHCRC's diabetes team has chosen glycemic control as its best practice for this grant cycle. The percentage of patients with an A1c ≥ 9 continue to increase each year. The project objective is to increase by 15 (7%) the number of individuals in the Target Group (209 individuals with A1c ≥ 9 in 2022) whose A1c drops below 8 during the first project year. IHCRC will advertise for a fourth dietitian upon receipt of the award. The fourth dietitian will allow IHCRC’s diabetes team to see individuals with A1c ≥ 9 every six weeks. The Project Coordinator and the Medical Director will meet with IHCRC physicians to share the best practice goal and to review the list of patients in the target population. Physicians will be asked to make referrals and to ensure that labs are being addressed according to best practices. Patients will receive labs, medications, and testing supplies or CGM for patients in the target population. GCMs have proven to be effective in helping individuals reduce their A1c. The team will also assist Medicaid and Medicare patients in reaching the requirements for the CGM (regular blood glucose testing, etc). The IHCRC diabetes team will assist with glucose monitoring, diabetes self-management education and support (DSMES) and medical nutrition therapy (MNT) to the target population. Patients will learn the relationship between their blood glucose and their food and activity choices resulting in improved glycemic control. The goal of education is to increase the patient competencies for nutrition, physical activity, medication compliance, monitoring blood sugar, problem solving, reducing risks, and healthy coping. These are the AADE7 Self-Care Behaviors that are essential for successful diabetes management.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).