Denver Indian Health and Family Services GHWIC Project - Our organization, Denver Indian Health and Family Services (DIHFS), is an Urban Indian Organization (UIO) that provides culturally appropriate care for American Indian and Alaskan Native (AI/AN) adults, children, and families in the Denver metropolitan area. The problem we plan to address is lack of cultural strategies and activities aimed to prevent, manage, and control chronic diseases among AI/AN individuals and families in the Denver metro area. The Denver metro area includes Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, and Weld Counties. We are applying for Component 1 (C1) funds to continue existing systems and establish new ones that are consistent with the strategies and activities in the NOFO and will allow us to achieve the outcomes in the NOFO. All existing and new systems are or will be a part of our organization’s Health and Wellness program. As part of our existing systems, providers play a crucial role in the detection, management, and prevention of diabetes, particularly through glucose testing and referring patients to our existing prediabetes prevention and type 2 diabetes management programs. Our existing programs include wellness visits for diabetes self-management education and support (DSME) and our Spirit Within Project and Warrior Program. The Spirit Within Project includes family-centered cultural workshops that focus on traditional and contemporary physical activity, nutrition, and indigenous coping skills; and shared medical appointments (SMAs) for DSME. The Warrior Program supports patients with their weight management goals by monitoring labs and providing one-on-one monthly visits with our registered dietitian and healthy lifestyle coach. With GHWIC funds, we are proposing to continue those existing services and provide wellness visits for hypertension management, SMAs for hypertension management, and mini health fairs to connect community members to our services, programs, and other resources. Using the logic model of the Component 1 program description, the outcomes we expect to achieve or make progress on by the end of the 5-year period of performance include increased cultural connectedness among community members; increased referrals for community members to clinical, social, and community service providers and programs who completed a visit; increased participation in prevention, management, and control programs, including self-management and self-monitoring, for commercial tobacco use, diabetes (including prediabetes), high blood pressure, obesity (physical activity and nutrition), and oral health; increased participation in traditional and contemporary wellness activities that prevent commercial tobacco use, diabetes (including prediabetes), high blood pressure, obesity, and oral diseases; increased use of multidisciplinary care teams that provide patient care using evidence-based practices and guidelines to prevent and manage chronic diseases and risk factors; and increased use of services for patients from multidisciplinary care teams.