The Urban Indian Center of Salt Lake (UICSL) proposes to use an "Accountable Health Communities Model" (AHC Model) to lower risk behavior in AI/ANs for Type 2 Diabetes and heart disease and stroke who reside in the Salt Lake Valley and along the Wasatch Front. We believe it ‘takes a village’ that relies on the social-ecological model (individual, family & community-systems efforts) to effectively address chronic disease prevention. The AHC Model uses an evidence-based case management and community health worker (CHW) approach to intervene at the individual and family level. The AHC Model will also be used to engage our organizational network into participating in a statewide Obesity Prevention Coalition whose mission is to create community-systems change and policies to improve healthy eating, increase physical activity, and increase breastfeeding/lactation supportive environments. The premise of the AHC Model is that social service needs (i.e., food insecurity, housing & employment insecurity, transportation issues, social isolation) must be concurrently addressed alongside reducing chronic disease risk behaviors. Failure to do so results in high risk individuals neglecting their preventive behaviors due to attention needed for more important and pressing problems. In our AHC Model, we triage high risk AI/AN clients into our program who have been seen at one of the numerous area integrated health clinics (addressing behavioral, oral health, & primary care). High risk clients include those with prediabetes and/or hypertension and/or high cholesterol. Once clients are referred and engaged into our program, our case manager assesses and helps address their immediate unmet social service needs. Participants with prediabetes are referred to our UICSL Native sensitive Diabetes Prevention Program (DPP), or other DPPs in our area. Participants with prediabetes, or hypertension and/or high cholesterol are encouraged to wor
k with our indigenous community health workers (CHW). Our CHWs provide an array of culturally sensitive support services including: healthy eating and physical activity education, oral hygiene literacy, blood glucose and/or blood pressure monitoring skills, and motivational interviewing supporting improvements in self-management skills. At the community-systems and policy level, UICSL will use the evidence-based Community Coalition Action Theory as a practical framework for coalition development, assessing coalition membership policy priorities, policy development, implementation, and enforcement. Through synergy created by multiple organizations involved, this Coalition will create policies to prevent obesity. Our evaluation effort involves process, formative and outcome evaluation strategies. The process evaluation provides frequency counts and percentages of project activities and characteristics about our clientele. Formative evaluation will include 2 annual nominal group processes (focus groups) (for project staff & participants) to provide feedback for program refinement. Our outcome evaluation includes pre, mid-point, and post assessments of: 1) clinical measures (i.e., BMI; A1C Levels; BP; LDL/VLDL/ HDL Cholesterol Levels, and triglycerides); 2) Oral Health Measures (i.e., DMFT {decayed, missing, filled teeth}; CPI (Community Periodontal Index-a measure of periodontal disease); 3) educational knowledge/literacy (healthy eating/24 hour food recall {a measure of recent eating habits}; health literacy survey on blood pressure and cholesterol; physical activity/recall; oral hygiene behaviors/recall); 4) "Measuring Support I Receive"(a measure of social support assessing types of social support including-emotionally sustaining, instrumental, informational, & support of others); and 5) Participants' progress made on goals and measurable objectives stated within their electronic wiki, and 4 quadrants (Health Behaviors; Mental Health; Socia
l Service Needs; Connection to Family/Community) of Medicine Wheel
