DIHFS Healthy Aging - We, Denver Indian Health and Family Services, Inc., are an Urban Indian Organization and Urban Indian Health Program that provides culturally appropriate care for American Indian and Alaskan Native (AI/AN) adults, children, and families in the Denver metropolitan area. We are the only Urban Indian Health Program in Colorado. Our organization was founded in 1978 as the result of a needs assessment conducted by the Denver Native Americans United that called for the co-location of medical services for the Indian community at one site; the provision of health education in addition to primary services; and the delivery of services in a manner that was comfortable to Indian patients. The Denver area has one of the largest urban Indian populations in the country.1 We provide ambulatory clinical services directly, offering a variety of care including primary care, dental care, behavioral health, health and wellness programs such as diabetes prevention and management, as well as an on-site pharmacy and gym. We also help our clients enroll in health insurance and connect with community partners and resources. Our service area consists of seven contiguous counties and comprises approximately 629 square miles. Ninety-two percent (92 %) of our patients are AI/AN individuals. We are the only primary care clinic that provides culturally competent, comprehensive health care and prevention services specifically for AI/AN families and individuals in the area. In March of 2024, we earned Accreditation Association for Ambulatory Health Care (AAAHC) certification. Our vision is a thriving Denver AI/AN community where elders living with dementia and their caregivers receive compassionate, culturally grounded care that honors traditions, promotes dignity, and supports overall well-being. We aim to enhance the delivery of culturally responsive dementia care and support services to AI/AN individuals and their caregivers in the Denver metropolitan area, improving health outcomes and quality of life. To achieve this, we propose implementing targeted strategies and activities across all five care drivers. Our dementia program takes a comprehensive, culturally responsive approach to awareness, detection, and care coordination. Outreach will include elders’ luncheons, community events, social media, newsletters, and integration with our trusted diabetes program to share dementia education, early signs, prevention strategies, and caregiver resources. We will expand cognitive screening using the MoCA tool for patients aged 50+, regardless of insurance status, and train staff through the GeriScholars Program and TRIAD framework. Primary care, pharmacy, and behavioral health staff will collaborate to assess cognitive health, manage medications, address mood disorders, and deliver personalized assessments. We will provide medication management tools like blister packs and CGMs, create a dementia registry to support RN-led case management, and conduct home visits to evaluate safety and provide real-time support. 1 American Indian and Alaska Native Population Percentage by City — Quick Facts.” IndexMundi, accessed 28 July 2025, https://www.indexmundi.com/facts/united-states/quick-facts/cities/rank/american-indian-and-alaskan-native-population-percentage
