Chapa-De Indian Health Program, INC. Auburn, Grass Valley, & Woodland, California

1. Program statistics • Chapa de Indian Health Program, Inc. Chapa-De Indian Health Program, INC. Auburn, Grass Valley, & Woodland, California Diabetes Program Manager: Jamie Sweet, MSN, RN Contact: (530) 889-3765 jsweet@chapa-de.org

2. Chapa-De’s Community 321 Tribes served 61% Native Americans 49% Non-Native Americans Predominantly: California tribes, Cherokee Nation, Choctaw Nation, Creek Nation, Covelo, Citizen Potawatomi Nation, Karuk Tribe, Washoe Tribe, Navajo & Ogalala Sioux

3. Chapa-De Mission: “To empower and enhance the spirit of the American Indian People. We pledge to accomplish this by providing quality healthcare, encouraging diverse cultural awareness, recognizing traditional holistic healing, promoting self-esteem and demonstrating excellence in leadership. Thus, we are committed to preserving the heritage of our elders and children, by inviting all people to walk in unity to maintain well-being as we meet our ever changing needs.”

4. Ashley Pechin, Data CoordinatorBonnie Bates, MFT, TherapistDarla Clark, MPH, Chief Operations Officer Jamie Sweet, MSN, RN, Diabetes Program Manager Karen Panek, MDKathy Wright, RN, PHN, Director Of NursingMary Heinz, MBA, EHR Clinical CoordinatorPatty Creekbaum, Medical Administrative Coordinator This is our Diabetes Team: (But there are so many others who make our program happen-everyday) We meet monthly for 2 hours and call special meetings when we have specific projects.

5. Target Population: Registry Data • Diabetes Total: 856 • Active Registrants: 296 • RMPS Registry is used to send a monthly DM newsletter. Examples: Foot Care, Vision Month, Women’s Health months. • RPMS Registry data is used for outreach to our dental clinic • We plan to add iCare to manage panels of DM’s assigned to PCP’s for case management. • Pre-diabetes Total: 402 • 338 pre-diabetics were seen within the past 2 years. • The 338 will be reviewed for DPP eligibility & recall. • RPMS assisted us in creating criteria: DX, PCP & Location to narrow down our first DPP group for recall. • The RPMS Pre-diabetes Registry will be utilized to manage mailing and contact with all Pre-diabetics. • Then, we will use iCare to manage our DPP cohorts. • We will use Excel for our Coordinating Center data.

6. Community Assessment: Listening to our communities Methods: Participation in local Pow Wows and cultural events in the community Meetings with the Tribal Council: Auburn Video Interviews with clients. Patient satisfaction surveys: 83% Liked patient hand-outs/education 93% wanted reminders of upcoming appointments Requests for complimentary medicine Favorable attitudes on use of Electronic Health Record (prior to implementation) Feedback indicated a need for staff education on customer service Customer preference for health care teams (panels) Actions/ how information was used: Customer Service training was provided for staff Client comments were shared at all-staff meetings Complimentary Medicine services were added Clinic adopted a “panel” approach to customer care Health Board provides oversight of clinical activities/services Tribal involvement/meetings enhances membership on advisory committees (Health Board) and communicates needs of individual tribes.

7. Diabetes Audit Results/Actions: Our Diabetes program is under construction. But we are re-building: 2010 Audit Results: 90% Screening for depression 80% Diabetes Education 69% Dental exam Fresh Ideas: We send out monthly newsletters highlighting the DM Standards of care to all DM registrants. The newsletter also has a calendar of local events that features cultural activities, physical activity opportunities in the area & events like Farmer’s markets. Each month we have a foyer display on standards of diabetes care, Healthy Recipes, Foot Care, Eye care & Women’s Health We’re planting a 3 Sister’s garden: Corn, beans & Squash at our Auburn clinic site. We want to enhance oral traditions through the use of Digital Storytelling to teach future generations. We want to develop new methods for outreach: SOCIAL MEDIA Currently working on the P/P for Facebook

8. Program Highlights (bragging rights, cont.) • We’re growing our DPP Program We’ve developed job descriptions for a Data Coordinator, Lifestyle Coach and Registered Dietician. We’re met with local leaders to discuss the DPP Program We’ve conducted site visits with established DPP Programs: Sonoma County Indian Health Project, INC., United Indian Health Services & The Indian Health Center of Santa Clara valley We’ve secured an awesome location for our program! We’ve begun working on walking maps, purchased pedometers and supplies for our classes! We’re in the process of reviewing IGT, IFG diagnoses for pre-diabetes registries. We’ve attended the Auburn Maidu school family night and the Maidu Museum screening for DPP participants and sharing information about our program.