Alliance to Reduce Disparities in Diabetes

Wind River Team at the Second World Congress on Integrated Care

Implementation of a Tribal Participatory Chronic Care Model (TP-CCM): Integrating Primary and Community-Based Care to Coordinate Diabetes Management on Wind River Indian Reservation, Wyoming USA

Second World Congress on Integrated Care
November 23-26, 2014
Sydney, Australia

Kathryn Langwell, Catherine Keene, Kelley Le Beaux, Linda Chioma Ogu & Matthew Zullo

Background: Age-adjusted diabetes prevalence is 15.9 percent among American Indian and Alaska Native adultsserved by the U.S. Indian Health Service, the highest among all U.S. racial and ethnic groups. NorthernPlains tribal communities also experienced the highest age-adjusted death rate attributable to diabetesacross all Indian Health Service regions, exceeding the national rate for American Indians and AlaskaNatives by almost 50 percent. While there has been considerable development of strategies to reducediabetes risk factors in the American Indian and Alaska Native population, additional evidence of theireffectiveness when directed by tribal communities is warranted.

Theory and Methods: The proposed Tribal Participatory Chronic Care Model (TP-CCM) is an approach integratingfundamental aspects of Tribally-Directed Participatory Research and the Chronic Care Model. Tribalmembers inform adaptations to the community, health system, self-management support, deliverysystem design, decision support and clinical information systems components of the traditional ChronicCare Model to foster productive interaction between tribal entities and a public healthcare system. TheWind River Alliance to Reduce Diabetes Disparities program integrated various patient-level, providerleveland system-level interventions using the TP-CCM and targeted barriers to diabetes managementon Wind River Indian Reservation.

Results: The TP-CCM improved dietary behavior, clinical endpoints and self-management support at thepatient-level; cultural competency and health care delivery at the provider-level; and collaboration,referral processes and clinical information sharing between tribal government and federal governmenthealth systems.

Conclusions: The Wind River Alliance to Reduce Diabetes Disparities program provides encouraging preliminaryevidence that the TP-CCM can serve as a structured community-clinical approach to support tribalcommunities with high chronic disease prevalence.