Native American Rehabilitation Association of the Northwest Special Diabetes Program for Indians (SDPI) - The Native American Rehabilitation Association of the Northwest (NARA NW) is an Urban Indian Organization and Federally Qualified Health Center (FQHC) working with the mission ‘to provide education, physical and mental health services, and substance abuse treatment to American Indian and Alaska Natives (AI/AN) and other vulnerable populations’. NARA is a unique agency in terms of honoring the cultural heritage and world view of Native Americans and delivering services with clinical practices that are culturally sensitive to the needs of AI/AN clients. No one is turned away from services due to an inability to pay for their care. Through the Special Diabetes Program for Indians (SDPI), NARA NW seeks to address the most prominent diabetes related health issues in our community which include cardiovascular disease, hypertension, obesity hyperlipidemia, depression, peripheral neuropathy, poor dentition, retinopathy and chronic kidney disease. Of the 3,315 active AI/AN patients served by the NARA primary health care clinics, 525 patients or 15.8% have a diagnosis of diabetes. This is above the prevalence for the National AI/AN population of 14.5% (CDC, 2014). When placed within the context of the diabetes prevalence for the general population in the State of Oregon of 9.4%, the prevalence of 15.8% among the NARA AI/AN population is alarming (Oregon Health Authority, 2015). With a 24-year history of SDPI funding, NARA NW has established a multi-disciplinary Diabetes Treatment & Prevention Team that is well-known in the Portland Urban Indian community. Over the last two decades this program has provided culturally relevant innovative services and activities. These include comprehensive “one-stop shop” Saturday Diabetes Clinics, Diabetes Self-Management Education and Diabetes Prevention groups, cooking classes and walking programs. Furthermore, intensive clinical case management services are offered to support all AI/AN people living with diabetes to address social determinants of health, to improve quality of life and to help prevent complications of diabetes. The proposed project is designed to address diabetes related community needs and reduce access barriers to diabetes screening, prevention, and treatment for low income American Indian and Alaska Natives living in the metropolitan area of Portland, Oregon. A special focus of the project will be to improve blood pressure control in patients with diabetes and hypertension. Blood pressure control reduces the risk of heart attack and stroke, diabetes complications and chronic kidney disease. Other ongoing practices include screening all medical patients aged 10 and older for diabetes, offering group health education for people living with diabetes and prediabetes, special Saturday Diabetes Clinics, as well as nutrition and physical activity counseling with a Registered Dietitian. The staff resources supported by the requested funding include a Family Nurse Practitioner at .10 FTE, Program Director at .10 FTE, Program Manager at .15 FTE, Program Coordinator at 1.0 FTE, Registered Dietitian at .9 FTE, Diabetes Data Manager at .25 FTE and a Nurse Case Manager at .10 FTE. The Diabetes Team is an integral part of the NARA primary care clinics and works closely with the medical provider teams to provide quality clinical care, health education and intensive case management for patients living with and/or at risk for diabetes.