Special Diabetes Program for Indians Diabetes Prevention and Treatment Project - Bakersfield American Indian Health Project (BAIHP) is a 501(c)3 non-profit organization and is governed by a diverse Board of Directors that represent the community and different tribes. BAIHP’s mission is, “To serve the American Indian and Alaska Native people residing in Bakersfield, Arvin, Lamont and Oildale by providing services that contribute to the health and vitality of the community in a respectful manner with high regard for cultural values, Tribal affiliation, spiritual and personal values of individuals." While the vision is, “BAIHP envisions a vibrant, healthful life for future generations of American Indians & Alaska Natives in Kern County by delivering sustainable, culturally integrated services, and fostering continuous community connection and whole wellness." Originally established in 1997, BAIHP is an urban Indian health program funded by the Indian Health Service as an outreach and referral center. It is the only Indian health care facility in Kern County. BAIHP provides medical case management, public health nursing services, mental health counseling, substance abuse counseling, transportation assistance, and referrals and payment assistance for medical, dental, and vision care needs. Services are available at no cost for all AIAN regardless of tribal affiliation, whom are living in Kern County (individuals must show evidence of eligibility). BAIHP serves a client population representative of over 220 tribes across the nation, whom currently reside in Kern County. Home to over 905,801 residents, Kern is the eleventh most populous county in California, which is larger than the states of South Dakota, North Dakota, Alaska, Vermont, and Wyoming. In 2018, Kern County’s AIAN population was estimated as 2.6%2 or 23,550. The City of Bakersfield, Kern County’s largest urban area, spans over 151 square miles, with a population density of approximately 2,516 inhabitants per square mile. There is one federally recognized tribe in the county: the Tejon tribe. However, the area has a rich history of early Native American settlement and cultural history. The AIAN population within Bakersfield and suburban areas suffer from many unmet health needs. Residents in these areas struggle with significantly poorer water quality, a lack of health and wellness resources, and poor air quality that increases the incidence of chronic health issues. According to the 2017 California Health Interview Survey, 18% of the AIAN population in Kern County suffers from diabetes, 18% have heart disease, 21.5% high blood pressure, 33.2% obesity, and 11% have reported suicidal ideations. BAIHP has established an integrated care model starting with our clients having access to a Family Nurse Practitioner, Registered Dietitian, Massage Therapist, and a collaborated integrated care wellness program. BAIHP offers Diabetes case management, nutrition classes & education, and mental health services. This year, our outreach strategy has improved and expanded its small group activities. The wellness program started off with 6 unique users to a current count of 31. Diabetes education is supported with a healthy eating program and partners with our Registered Dietitian who has 43 unique users, 24 of which have participated in the wellness program. Having a significantly improved outreach approach, our program will address the 3 above listed items through promotion and awareness of the importance of the examinations during these group settings along with incentivising them to lower their BMI. Using an integrated healthcare approach, our Massage Therapist can assist with education about the importance of foot exams and refer to the FNP for further collaboration, and our FNP refers clients as needed for Behavioral Health related services. BAIHP will use funding from the SDPI grant to continue its ongoing commitment to the community in providing Diabetes-related Education and services to 60 people which makes up approximately 20% of our client population