Riverside-San Bernardino County Indian Health, Inc. (RSBCIHI) is applying for the SDPI Community Directed Grant after successfully participating since its inception in 2000(Grant number H1D1IHS0212-18-01). RSBCIHI is a non-profit tribally controlled and managed health care organization, established to meet the medical and health needs of American Indians/Alaska Natives living on or near nine (9) reservations in rural, medically underserved areas of Southern California (www.rsbcihi.org). We have seven health clinics and one outreach site across a 400 mile radius in Riverside and San Bernardino Counties. According to 2022 Government Performance and Review Act (GPRA) data, our user population is 16,482. There are 1233 active AI/AN patients with a diagnosis of diabetes for a prevalence rate of 7.5%. The diabetes registry tracks 1035 active AI/AN users as of September 2022.
There will be no delay in implementing the grant as the current Diabetes Program is fully functioning with highly qualified staff, adequate facilities, laboratory requirements, equipment and educational materials. RSBCIHI also has data expertise with both the NextGen system, Population Health Software and a mechanism for feedback from the community through a Diabetes Workgroup that meets quarterly.
The RSBCIHI required Best Practice will focus on Glycemic Control with the Target Group being Diabetics from 18+ in with an A1c>8. The proposed project will include robust clinical interventions that combine community outreach with a patient centered care engagement that includes all members of the interdisciplinary health care team. The adoption of the Patient Centered Medical Home (PCMH) model by the organization facilitated the changes that allows for the introduction of the Glycemic Control Project. These changes include the integration of diabetes team to work in the clinical setting, with offices onsite, placing our staff member in direct contact with other members of the health care delivery team. The purpose of the Glycemic Control Best Practice will be to decrease complications in diabetics that have ravaged the Native American Community.
Activities that will support the Glycemic Control Best Practice include population management tools such as NextGen PopHealth (population management), NextGen Care Outcomes program that allow timely follow up, Provider and Health Care Team education and engagement, Pharmacy Medical Management, Self Management Education and patient engagement, and specialty care through Tele-Endrocrinology.
The amount requested is $1,075,100.00 which will be used to implement the required Best Practice, but also the objectives of educating the community about diabetes and prevention of diabetes. These activities will include youth and adult prevention programs, community outreach and telemedicine. The RSBCIHI Diabetes Program has extensive experience implementing diabetes and community activities and besides the Community Directed Grant has also been a Healthy Heart Grant beneficiary. Combined these two grants have served over 1,000 Diabetics and planned or participated in close to 300 Community events and multiple Educational Classes during the grant periods.