Ponca Tribe of Nebraska's Healthy Tribes Program - The Ponca Tribe of Nebraska Ponca Health Service (PHS) will implement and manage a Healthy Tribes Program in conjunction with various PHS and Tribal Affairs departments utilizing a multi-disciplinary healthcare approach at 5 unique Ponca Tribe of Nebraska Health communities. Goal one: Build and grow a sense of community for AI/AN participant that reside within the Ponca Tribe Service Delivery Area (SDA) and/or who are actively involved in programs within the Ponca Tribe of Nebraska (PTN). This will include community events and activities focused on tradition and a healthy lifestyle. Our 2025 goals include to double physical activity activities offered compared to 2024, and also expand our number of participants by 50% from 2024. Goal two: To positively impact health outcomes in participants served by Ponca Health Services and Ponca Tribe of Nebraska. Provide diabetes self-management education and support (DSMES) to participants by Diabetes Education Team (DMT). Our 2025 goals include 100% increase in individual or group DSMES performed compared to 2024. Goal Three: Chronic disease state management with a multidisciplinary with improved outcomes in A1c (2025 Audit goal of 60% of patients with A1c <8%), tobacco cessation (100% of patients identified as commercial tobacco users be offered counseling or tobacco cessation services along with 50% improvement of successful quit rates at 6 months) and blood pressure (2025 Audit goal of 60% of patients with mean BP <130/<80 mmHg). Methods: Ponca Tribe of Nebraska (PTN) diabetes education team (DMT) will provide outreach and support community events for the cities of Omaha, Lincoln, Norfolk, Sioux City, and Niobrara, serving participants that reside within the SDA and/or who are actively involved in programs within the PTN. The PTN DMT will document each participant encounter, including number of participants attending community and cultural events, health literacy and educational encounters, HCP visits and pertinent clinical outcomes, including A1c and tobacco cessation counseling/quit rates. Key outcomes envisioned include high community and cultural event participation, sustained engagement in community events, healthcare provider follow-up for participants (including A1c labs, blood pressure, utilization of nutrition, education, materials or classes as appropriate), and increased tobacco cessation counseling/quit rates.
