Prairie Island Indian Community Special Diabetes Program - In our targeted approach to diabetes care, our primary focus is on the most high-risk patients, identified by having an A1c level of eight or higher. Our data reveals that there are currently 22 patients falling into this category. To address their specific needs, we are implementing a patient-centered care program that leverages the expertise of the consulting Registered Dietician (RD), PIHC providers, fitness trainers, and on-staff nutritionist. Since this is a new program, we will develop a patient registry to accurately monitor and track the progress of these high-risk patients. Our commitment is to streamline their healthcare experience by organizing appointments and treatments within the clinic. The proposed process entails a sequential meeting with the healthcare provider, followed by consultation with the RD, and culminating in a session with the fitness trainers. This "one-stop appointment" approach ensures that patients receive comprehensive education in a single visit. These high-risk patients will engage closely with our on-staff nutritionist, providing education on low-carbohydrate recipes and adopting healthy cooking and lifestyle changes. Additionally, participants in this program will collaborate with fitness trainers to establish a tailored walking program and other personalized fitness routines. The objective is to increase physical activity levels, contributing to the overall goal of decreasing A1c levels. To monitor progress and maintain ongoing support, all staff members will stay updated with quarterly measures of A1c levels, glucose levels, and weights. This tracking will be facilitated by the implementation of PIHC's new Electronic Health Record (EHR) system. Through this comprehensive and personalized approach, we aim to provide effective care for our high-risk patients and systematically track their journey toward improved health outcomes.
