Shining Mountain Health and Wellness Program - The Shining Mountain Health and Wellness Program provides services to our Tribal community for Diabetes Prevention, Diabetes Treatment and Healthy Lifestyle Promotion. We meet these needs through individual appointments, home visits, group classes, participation in special events such as Health Fairs, Walks and Fitness Events. We reach out to all ages in the life span from early childhood to Elders. Our diabetes program worked to impact A1C, Foot Exams, Nutrition education, and Self-Management education. We also offer diabetes education and diet/nutrition instruction to adults and youth through For our program recipients with uncontrolled DM or of those with A1C’s out of target range, we work with clinic staff to contact patients to keep regular clinic appointments, lab assessments and medication compliance. To address Foot Exams, the program continues to contact patients who are due for these and schedule appointment; we coordinate with clinic staff who refer patients to a podiatrist. We also encourage and initiate scheduling of our clients for Dilated Eye Exams and Dental Exams, which are both available at our clinic. Program staff will educate patients regarding lifestyle intervention to decrease blood pressure, A1C and other diabetes risk factors. We will also consult with our Public Health Nurses, who conduct much of the immunization for hard-to-reach patients. We will address the need to increase foot exams with our clinic staff and provided an in-service on foot exams and proper documentation. We hope as a team to continue to develop more effective system-wide interventions to address these issues. We attempt follow-up with individuals through communication and care coordination for patients with diabetes, pre-diabetes, or those at high-risk of the disease. We receive referrals from providers, conduct patient health assessments, offer diabetes self-management education, individualized fitness assessments and resources to fitness centers, nutrition lifestyle treatment, goal setting, care coordination, and patient follow-up. We offer home visits, particularly to elders or those who are homebound, and make many phone and mail contacts to keep communication. The program continues to publish bimonthly newsletters that are sent to enrollees of the program. With relationships we develop with patients, who lack the skills, motivation, or knowledge of navigating the system. We also refer to other providers as needed, including public health nursing, community health representatives, and mental/behavioral health. Our program educates about the importance of all health exams and helps to set patients up for tests and screenings, diabetes check-ups, foot, dental and optometry visits. Many patients utilize our program as a resource for information, assistance, and support for health lifestyle changes. We always welcome family involvement and family visits to increase support and extend our educational efforts.
