Enhancing Sustainable Models of Care - The Absentee Shawnee Tribal Health System (ASTHS) proposes to develop, implement, and disseminate a replicable, culturally-adapted dementia care model that aligns with IHS priorities to improve care, services, and outcomes for American Indian and Alaska Native (AIAN) people living with dementia, their caregivers, and communities across Oklahoma's five-county Shawnee Service Unit serving 69,707 AIAN residents. This three-year initiative addresses critical gaps in dementia care within a population experiencing poverty rates of 19.8% compared to 13.4% for non-Native Oklahomans (Morris, 2024), where the AIAN population aged 65+ is experiencing unprecedented growth. Building upon ASTHS's existing infrastructure that currently addresses three of the five primary drivers of comprehensive dementia care—accurate and timely diagnosis through Mini-Cog screening protocols, interdisciplinary assessment via established care teams, and management and referral through coordinated care pathways—this project will expand to encompass all five drivers while integrating evidence-based approaches from the CMS GUIDE Model and CDC Healthy Brain Initiative. The project directly addresses IHS program priorities by: (1) expanding local capacity through training 400+ clinical and community health professionals in culturally relevant dementia care; (2) strengthening existing care approaches through integration of traditional Shawnee healing practices with evidence-based protocols; (3) creating new service opportunities through mobile outreach clinics, community-based screening events, and partnerships with neighboring tribal sovereign nations and national dementia organizations; and (4) establishing robust evaluation frameworks to document and disseminate this emerging tribal health practice model. Key activities include standardized dementia screening for patients aged 50+, interdisciplinary care teams with dedicated Dementia Care Specialists, culturally-adapted caregiver training programs, automated referral systems, and community-clinical linkages with elder services programs. Expected outcomes include 25% increase in early-stage dementia diagnoses, 25% improvement in caregiver burden scores, 40% faster time-to-diagnosis, and enhanced quality of life for patients and caregivers. The project will directly serve 8,000+ individuals with dementia and their families. This rigorously evaluated model will be documented and disseminated as an emerging practice for tribal health systems nationwide, with comprehensive sustainability planning including reimbursement strategies ensuring continuation beyond the grant period. The requested $200,000 per all three years will position ASTHS as a regional leader in tribally led dementia care innovation, directly contributing to IHS's mission and to national dialogue on culturally anchored health systems transformation.
