Wind River Reservation
American Indian and Alaska Native communities face distinct challenges in preventing and treating leading causes of mortality when compared with other racial groups. Records from the Indian Health Service's (IHS) annual survey indicate that 16.1 percent of adults treated by the agency had type 2 diabetes, a higher prevalence than found in any other race in comparable studies.1 Disparities also extend to adolescent populations; in the last 2 decades diabetes diagnosis rates among American Indian and Alaska Native adolescents, who are already nine times as likely to have diabetes as non-Hispanic Whites of the same age, increased 110 percent.2
Those disparities become particularly sharp for American Indian and Alaska Native communities living in the Northern Plains region, where diabetes is a leading cause of mortality. The adjusted death rate from diabetes among American Indians in this area is over five times that of the U.S. population, and is over 50 percent higher than the diabetes death rate of all American Indians/Alaska Natives served by the IHS.3 Diabetes is the fourth leading cause of death among American Indians residing on reservations in Montana and Wyoming, accounting for 6.3 percent of all deaths.4 Reducing leading causes of mortality for this population means that providers must ensure patients' equal access to care while respecting the cultural communities in which those patients live.
About Wind River Reservation/Eastern Shoshone Tribal Health
The Wind River Reservation is located in the heart of the Northern Plains in southwestern Wyoming, and currently serves as the home of the Eastern Shoshone and Northern Arapaho tribes. Roughly 12,500 residents live on the reservation, approximately 12 percent of whom of have diabetes and 71 percent of whom are clinically obese.5 In 2009, the Eastern Shoshone Tribal Health Department, in partnership with the Northern Arapaho Tribe, IHS, and Sundance Research Institute, was awarded a 5-year grant to create a community-clinical partnership on the reservation to address barriers to diabetes management and prevention, and create a comprehensive system of care to provide education and support services to assist tribal members with or at-risk of diabetes to manage their condition and improve outcomes.
Awarded to five sites through the Merck Foundation's Alliance for Reducing Diabetes Disparities (ARDD), the 5-year grant emphasized development of a comprehensive approach to impact diabetes outcomes by focusing on the individual patient, clinicians, and the community-clinical system of care. The grant offered care delivery staff on the reservation an opportunity to gain valuable insight through the development and testing of various models to promote improved diabetes outcomes that would possibly be replicable by many other American Indian tribes struggling to meet the needs of their tribal members with diabetes.
Overview of Activities
Wind River's diabetes management program responds to specialized needs unique to tribal patient populations. The purpose of the Wind River project was to create and support a comprehensive community health system partnership to improve outcomes for American Indians with diabetes and to reduce the substantial health disparities experienced by American Indians. Although there are many organizations and resources available to support and assist tribal members with diabetes on the reservation, lack of communication and coordination among these organizations is often a barrier to patient awareness and access to these services and resources.
First, the Wind River ARDD project team identified each organization on the reservation that had a common interest in prevention and management of diabetes, and recruited each organization to participate in a coalition for sharing resources and information and developing a more seamless system of care for tribal members with diabetes. The Wind River Reservation Coalition for Diabetes Management and Prevention included tribal health and other tribal organizations, the Wind River Indian Health Service, Fremont County Public Health Department, the University of Wyoming's Cent$ible Nutrition Program, Sundance Research Institute, and the State of Wyoming Department of Health's Diabetes Prevention Program. This coalition held focus groups with reservation residents to better understand perceived barriers and disparities in diabetes care and contribute to the planning of the program.
With input from these focus groups, the Coalition developed a structured disease management program based on the Chronic Care Model, and implemented it throughout all official and unofficial channels in which Tribal members with or at risk of diabetes received any sort of health care. The program design emphasized community-based leadership, with a primary role for the tribes in developing and implementing culturally tailored community self-management support systems, improving linkages with IHS clinicians, and developing a coalition of organizations with additional resources to create a more comprehensive system of diabetes care for tribal members with the disease. On an individual level, the type of program intervention depended on whether the person showed signs of pre-diabetes or was already diagnosed with diabetes. For people who were at risk, the Coalition implemented a tailored exercise and nutrition program to help individuals make balanced lifestyle changes to prevent onset of the disease; for those already diagnosed, a diabetes self-management education program developed by tribal staff delivered culturally tailored lessons that addressed the barriers identified in earlier focus groups.
By the end of the 5-year grant period, providers and tribal participants made significant and sustainable strides in coordination, communication, and resource-sharing among tribal and non-tribal organizations serving reservation residents with diabetes and individual disease self-management skills.
More than 25 percent of tribal members with diabetes participated in the program and, as a whole, saw notably improved clinical outcomes. Participants documented improvements in eating and exercise habits attributable to the tailored exercise and nutrition program, and also in clinical measures such as blood pressure, body weight, and blood glucose levels.6 In addition, 47 percent of program participants exhibited a decrease in their HbA1c levels, a common measure of a person's blood sugar, where a lower number represents improved diabetes management, with an average decrease of 1.12 points. Those with HbA1c levels above 12.0 achieved even stronger results, with average decreases of 3.0 points.7
Wind River also made substantial progress toward creating a permanent diabetes care system with clinician buy-in based on collaboration, coordination, and communication between tribal programs and IHS clinical services that would continue after any grants expired. Local clinicians and health support staff folded process improvements into standard operating procedures at each diabetes care location and in treatment processes with each affected family on the reservation. After the initial grant expired in 2014, however, the program's successes attracted a 2-year grant from the AstraZeneca Foundation meant to design similar programming for up to 350 reservation residents with or at-risk for cardiovascular disease, in addition to the original population with diabetes.8 The coalition expects to receive initial results from this second grant period in late 2015.
Alignment to the National Quality Strategy (NQS):
These efforts promote:
- Effective communication and coordination of care.
- The most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
- Working with communities to promote wide use of best practices to enable healthy living.
For more information about the program, contact Catherine Keene, the Executive Director of Health Programs for the Eastern Shoshone Tribe, at email@example.com.
1 Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. Retrieved from http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf.
2 Indian Health Service. Diabetes in American Indians and Alaska Natives: Facts At-a-Glance, 2012. U.S. Department of Health and Human Services, Indian Health Service, 2012. Retrieved from http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Resources/FactSheets/2012/Fact_sheet_AIAN_508c.pdf.
3 U.S. Department of Health and Human Services, Indian Health Service. Regional Differences in Indian Health, 2000–2001. Rockville, MD, 2003. Retrieved from http://diabetesnpo.im.wustl.edu/programs/documents/MT-WYreport.pdf.
4 Eastern Shoshone Tribal Health Department & Sundance Research Institute. (2014, June). A comprehensive strategy for prevention and management of diabetes for American Indians: Guide for replication of the Wind River Reservation Alliance for Reducing Diabetes Disparities project, 2014.
5 U.S. Department of the Interior, Bureau of Indian Affairs. (n.d.). Indian Affairs: Wind River Agency. Retrieved from http://www.bia.gov/WhoWeAre/RegionalOffices/RockyMountain/WeAre/WindRiver/.
6 Keene, C. (2014, November 6). Battling Diabetes on Reservations: A Two-Part Look at Coalitions and Culture. Retrieved from http://indiancountrytodaymedianetwork.com/2014/11/06/battling-diabetes-reservations-two-part-look-coalitions-and-culture-157707.
7 Eastern Shoshone Tribal Health Department & Sundance Research Institute. (2014, June). A comprehensive strategy for prevention and management of diabetes for American Indians: Guide for replication of the Wind River Reservation Alliance for Reducing Diabetes Disparities project, 2014.
8 Eastern Shoshone Tribal Health Department & Sundance Research Institute. (2014, June). A comprehensive strategy for prevention and management of diabetes for American Indians: Guide for replication of the Wind River Reservation Alliance for Reducing Diabetes Disparities project, 2014.