Indian Health Board of Minneapolis Memory Care and Wellness Program - Indian Health Board of Minneapolis (IHB) is an Urban Indian Organization that receives funding from IHS under Title 5 of the Indian Health Care Improvement Act. Our mission is to provide high quality healthcare services for American Indians in the Urban Minneapolis/St. Paul area and to promote health education and wellness. Our clinic was established in 1971 and provides full service primary medical, dental, behavioral health, and recovery services to the urban American Indian population in the Phillips neighborhood of Minneapolis. IHB was a recipient of the previous round of IHS funding to address dementia in tribal and urban Indian communities (2022-2024). During the initial round of funding to address dementia in tribal and urban Indian communities, the objectives of the project where based on the five drivers of 1) increased awareness and recognitive of dementia, 2) accurate and timely diagnosis, 3) interdisciplinary assessment to identify need for services and appropriate care plans for individuals with dementia and their caregivers, 4) comprehensive, person-centered management and referrals to meet needs, and 5) caregiver support. During the initial funding period we were able to accomplish significant community education and outreach about dementia awareness, to connect and collaborate with organizations and researchers focused on dementia in Native communities, to build cultural programming with our Elder in residence and Indigenous Services department, and to focus on caregiver support through class programming, coaching, and the development of enrichment focused memory kits for individuals with dementia and caregivers. The current proposal focuses on continuing the programming we have established so far while outlining how we will expand to meet our goals and objectives further across all drivers. Through our work in the first funding period, we discovered that to expand our project and more fully meet objectives across all drivers that we need to increase staffing in the clinic to focus on increasing cognitive screening for higher risk patients, to provide enhanced care coordination to patients who need it, to organize the interdisciplinary team assessment and care planning process, and to provide caregiver coaching. We also recognized the opportunity to expand the work of our community health worker to include conducting brief screenings at our elder-focused classes and groups, as well as conducting home visits for higher needs patients with dementia. Our proposed objectives are informed by evidence-based programs, practice guidelines, and the clinical expertise within our organization. Our expected outcomes include an increased number of cognitive screenings in both the clinic and community setting which will increase further evaluation as appropriate and improve access to earlier diagnosis of dementia and connection to support earlier in the disease process. We anticipate improvements in quality of health and general wellbeing in patients who receive interdisciplinary assessment and care planning and similar positive impacts on the health of caregivers who participate in our caregiver support programming.
