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Service Delivery Innovation Profile

Comprehensive, Culturally Sensitive Care and Self-Management Support Improves Health-Related Behaviors, Clinical Outcomes, and Emotional Health in Native Americans with Diabetes


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Snapshot

Summary

The Full Circle Diabetes program provides comprehensive care and self-management support for Native Americans who have diabetes in and around Minneapolis-St. Paul, MN. The program builds on the traditional Native American circle of life (a symbol of infinity, unity and wholeness)1 by offering a holistic and culturally appropriate assessment of the needs of the body, spirit, mind, and emotion. To that end, the program includes community involvement in leadership and programming, regular assessment and monitoring of diabetes patients by a multidisciplinary team, ongoing diabetes education classes, regular opportunities for healthy eating and physical activity, and a peer support group designed to help participants maintain a healthy lifestyle. The program has attracted widespread participation and enhanced the ability of Native Americans with diabetes to manage their condition, leading to better health-related behaviors, clinical outcomes, and emotional health.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of key metrics related to knowledge and confidence in self-management skills, health-related habits, clinical outcomes (including blood glucose, blood pressure, cholesterol, and triglyceride levels), and emotional health. The data cover the period between 2004 and 2007, with most results coming from a survey of 249 participants conducted at intake and a followup survey completed by a subset of these individuals at the end of the grant period.
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Developing Organizations

Minneapolis American Indian Center; Native American Community Clinic
Minneapolis, MNend do

Use By Other Organizations

Leaders of an organization serving the Somali population in Minneapolis are contemplating whether to adapt the Full Circle model to the local culture.

Date First Implemented

2004
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Patient Population

Race and Ethnicity > American indian or alaska nativeend pp

Problem Addressed

Native Americans have higher rates of diabetes than many other ethnic groups. Although high-quality medical care and support in adhering to healthy lifestyles (e.g., appropriate diet, regular physical activity) can prevent diabetes-related complications, many Native Americans experience significant barriers to accessing such care and self-management support. As a result, they suffer more complications and experience lower quality of life and shorter longevity.
  • More likely to have diabetes: American Indian and Alaskan Native adults face a greater risk of diabetes than do members of other ethnic groups. For example, they are 2.5 times more likely than whites to suffer from the disease. Native Americans also tend to develop diabetes at a younger age. In fact, the number of Native American youth diagnosed with diabetes increased by 68 percent between 1994 and 2004.2
  • Many barriers to accessing quality care and self-management support: Virtually all Native Americans with the disease suffer from type 2 diabetes,2 which can be effectively managed through high quality medical care and support in adhering to healthy lifestyles, including proper diet, regular physical activity, and management of stress. However, Native Americans face many barriers to accessing such care and support. For example, in both rural areas and inner cities, poverty and the lack of available transportation, health insurance, and education make it difficult to access care and develop and maintain healthy habits. Cultural differences in approaches to health and health care can further complicate this already difficult situation.
  • Leading to complications and death: The combination of neglected health care, poor health habits, and early onset of diabetes means that many Native Americans have undiagnosed or poorly controlled diabetes for a long period of time. Consequently, they face increased risk of amputations, kidney failure, and even death. For example, compared with the average individual, American Indians face a 3.5 times greater risk of kidney disease and lower limb amputations due to diabetes.2

What They Did

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Description of the Innovative Activity

The Full Circle Diabetes program provides comprehensive care and self-management support for Native Americans who have diabetes in and around Minneapolis-St. Paul, MN. The program builds on the traditional Native American circle of life by offering a holistic and culturally appropriate assessment of the needs of the body, spirit, mind, and emotion. To that end, the program includes community involvement in leadership and programming, regular assessment and monitoring of diabetes patients by a multidisciplinary team, ongoing diabetes education classes, regular opportunities for healthy eating and physical activity, and a peer support group designed to help participants maintain a healthy lifestyle. Details on these key elements appear below:
  • Shared leadership gleaned from Native American custom: In Native American tradition, elders carry the wisdom and help guide the actions of a community. As initially designed and implemented, the Full Circle Diabetes program used a Diabetes Community Council to provide this wisdom and guidance, thus promoting cultural competency and sensitivity to those it serves. Council members came from a variety of tribes and professional backgrounds, with most having diabetes and thus having experienced firsthand the many barriers to accessing effective care and self-management support. The council not only played an integral role during the initial stages of program development (see the Planning and Development Process section for more details), but members also played an ongoing role in community events, sharing of stories during traditional talking circles, and teaching classes (see bullets below for more details on these activities). Unlike all other program activities described below, the council did not continue once initial grant funding ran out (although it has been replaced by an advisory body, as discussed in the Adoption Considerations section).
  • Regular visits to culturally competent, multidisciplinary facility and team: Patients in the program come to the Native American Community Clinic at least once every 3 month to visit a multidisciplinary patient care team, with more frequent visits if a change in treatment plan is required. The clinic is located in the heart of Phillips, the center of Native American life in the Twin Cities. The clinic's physical plant reflects the culture of the patients it serves, with Native American artwork on the walls and flute music playing in the waiting room. These features serve to make patients feel comfortable and confident that they will receive culturally competent care. During each visit, patients spend 30 minutes with at least two members of the team. Having key providers at the same site allows patients to take care of all aspects of their diabetes at the same time. This approach helps to solve problems quickly and remove barriers to ongoing management of the disease. Key roles of each team member appear below:
    • Primary care provider: The primary care provider monitors laboratory values and the patient's treatment plan. All providers have worked in the community for many years and understand the cultural needs of the community. Every 3 months, these providers test patients’ hemoglobin A1c, blood pressure, cholesterol, and triglyceride levels.
    • Diabetes educator: Patients see the diabetes educator at most visits to ensure they understand instructions and have a chance to ask questions about self-care.
    • Dietitian: Patients who have questions about diet and nutrition, and those having difficulty preparing and procuring healthy meals, may see the dietitian for advice and guidance.
    • Case manager: Although all providers work together to address barriers to accessing care and self-management support, the case manager (a nurse who is also Native American) meets with all patients to set up appointments, and follows up with them to ensure they do not run into barriers in accessing care and support. The case manager also meets with each primary care provider once a month to go over case plans and review patient charts.
    • Counselor: Many patients have relatives or loved ones who have died or become disabled as a result of diabetes. Hence, being diagnosed and treated for the disease often provokes stages of grief and loss. Every 3 months, patients take a short questionnaire (the Patient Health Questionnaire or PHQ-9) designed to detect depression or other mental health issues. If the questionnaire or other discussions reveal a possible emotional issue or other upheaval, patients see the onsite counselor immediately. The counselor may also follow up with a phone call after the visit to see how the patient is feeling.
    • Social worker: Because unemployment and housing insecurity make it difficult to follow recommended treatment and keep diabetes under control, patients facing job security and/or housing-related issues can see the team social worker for connections to job placement, retraining, and/or housing services.
    • Referrals to traditional healers as needed: Although the program does not have a traditional healer on staff, clinicians can refer patients to one. By bringing up and validating the role of such healers, primary care providers often get patients to discuss their use of traditional Native American medicine more openly.
  • Diabetes classes: In addition to providing one-on-one educational sessions with team members, the program offers a variety of educational opportunities to participants and the community at large.
    • Basic education: Once a week, patients and their family members can participate in free classes known as Diabetes Basics, with healthy snacks served during each session. The dietitian, diabetes educator, diabetes case manager, and health educator take turns teaching patients, family members, and friends. Typical topics include an overview of diabetes, a review of how stress affects the disease, and discussion of the role of exercise in preventing and managing diabetes. The same topics rotate every 5 weeks, although attendees can come at any time and do not have to attend classes in order. As an incentive to complete the entire course, anyone attending all five classes receives a $20 grocery store coupon.
    • Living in Balance: Adapted from Stanford’s Chronic Disease Self-Management program to reflect the culture of Native American patients, Living in Balance classes help participants set goals and develop skills to better manage diabetes. Held over the dinner hour, these free classes include a healthy meal catered by a local Native American restaurant. Participants receive bus tokens to get to the class and a $20 gift card upon completion of the program. Graduates with strong communication skills who have their diabetes under control can qualify to teach the program to others. These peer educators (many of whom are members of the Diabetes Community Council) receive $30 for each class they teach.
  • Regular opportunities to engage in healthy behaviors: The program provides regular opportunities for participants to learn about and practice healthy behaviors, including eating an appropriate diet and engaging in physical activity.
    • Monthly breakfasts: Once a month, the program organizes free community breakfasts at the Minneapolis American Indian Center for patients and family members, along with their neighbors and friends. The breakfast opens with a traditional Native American blessing, after which participants enjoy a healthy meal planned by the program’s dietician and catered by a local Native American restaurant. Organizers bring in speakers on different topics connected to diabetes prevention and/or treatment (e.g., exercise, stress management). Typically approximately 70 people attend these monthly events.
    • Multiple opportunities for exercise: Participants can choose from a variety of opportunities to participate in low-cost or free exercise programs. The Minneapolis American Indian Center offers some classes, and patients can also take advantage of free memberships at the Running Wolf Gym (owned by the Native American Community Clinic) or discounted memberships at the local YWCA. In addition, the program offers a walking group that uses an indoor basketball court in winter. Piped-in music and onsite blood pressure and blood sugar testing add to the appeal.
  • Peer support through "talking circles": Following Native American tradition, talking circles provide a support network in which community members share stories and support each other in their journeys to better health. During the grant period, these sessions, which were free and open to the public, were held monthly in a conference room at the Minneapolis American Indian Center. The sessions, which were led by elders from the community, opened with a traditional blessing, included a meal, and covered health topics from the mind/body/spirit perspective. A program counselor attended and when appropriate provided referrals or resources to attendees.

Context of the Innovation

In 2003, four clinicians founded the Native American Community Clinic in Minneapolis, with the goal of creating a place where Native Americans feel at home in the health care system. As a Federally Qualified Health Center, the clinic serves all people regardless of background, handling more than 13,000 visits each year. Native Americans from at least 5 or 6 tribes and 70 different reservations comprise 85 percent of the patient population. An estimated 44,000 Native Americans reside in Minneapolis, more than one-third of whom live below the poverty level.4 The clinic provides medical, dental, counseling, and community health services; staff includes a dietitian, diabetes case manager, patient advocate, health educator, and prenatal case manager. The clinic also offers health classes, health fairs, and exercise classes through the Running Wolf Fitness Center. Founded in 1975, the Minneapolis American Indian Center provides educational and social services to Native Americans in the area.

The impetus for the program came from conversations with the community during the planning phase for the clinic. During these discussions, diabetes care and prevention emerged as a major concern. As a result, the concept and funding for the Full Circle Diabetes Program became fully integrated into the clinic’s initial design and structure.

Did It Work?

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Results

The program has attracted widespread participation and enhanced the ability of Native Americans with diabetes to manage their condition, leading to better health-related behaviors, improved clinical outcomes, and better emotional health.
  • Widespread participation in educational activities: An analysis of the first 3 years of program operation (from 2004 to 2007) found that nearly every enrolled individual participated in at least one activity or service during this time. Two-thirds participated in 2 or more activities, including a third who came to more than 20 different events. The monthly breakfasts and nutritional counseling proved most popular, but other program components also drew many participants.3 Many program activities attracted friends and family members of enrollees, along with residents from the general community.
  • Increased knowledge and confidence related to managing diabetes: Two-thirds of participants reported that program activities helped them manage their diabetes more effectively. A separate analysis found that those who participated in the program significantly improved their knowledge of how to manage diabetes (as compared with a similar group of individuals who did not participate).1 Respondents expressed high levels of confidence in their ability to make changes in their health habits (8.6 on a 10-point scale), suggesting a high degree of self-efficacy.3
  • Improved health-related behaviors: Pre- and post-implementation surveys show that participation increased the likelihood of an individual testing his or her blood sugar on a daily basis. Although the surveys showed no change in the percentage of participants exercising on a regular basis, the frequency and duration of such exercise did increase. Nearly all those surveyed after taking the Living in Balance course reported making changes in one or more areas as a result of the class, such as better coping with a health condition, engaging in more physical activity, communicating more with their providers, and/or creating or improving an eating plan. Almost 80 percent reported making changes in how they take their medication.3
  • Better clinical outcomes: Nearly 60 percent of those tested at followup either reduced previously elevated hemoglobin A1c levels or maintained healthy levels; more than half did the same with respect to blood pressure. More than three-fourths of participants improved or maintained cholesterol levels, and a significant number improved triglyceride levels.3
  • Better emotional health: Those completing the followup survey reported a significant decline in the number of days they felt sad or depressed. More than 9 in 10 reported sharing what they had learned with family and friends, indicating active social contact and community participation that can ease stress and improve emotional outlook.3

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of key metrics related to knowledge and confidence in self-management skills, health-related habits, clinical outcomes (including blood glucose, blood pressure, cholesterol, and triglyceride levels), and emotional health. The data cover the period between 2004 and 2007, with most results coming from a survey of 249 participants conducted at intake and a followup survey completed by a subset of these individuals at the end of the grant period.

How They Did It

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Planning and Development Process

Key steps included the following:

  • Identifying community needs through talking circles: To elicit community feedback and involvement, program developers worked with the Golden Eagles program of the Minneapolis American Indian Center to set up talking circles. Following Native American tradition, these sessions were attended by elders and others concerned about the community. The sessions identified diabetes care and prevention as pressing concerns, particularly with respect to barriers to care and opportunities for healthy living. For example, participants stressed how harsh Minneapolis winters make regular outdoor exercise difficult and noted that many indoor options have fees that limit participation among low-income residents.
  • Recruiting council members: Program organizers used existing formal and informal ties within the Native American community to recruit members of the Diabetes Community Council, including e-mail lists, word-of-mouth, and contacting housing complexes, the Indian center, and other Indian agencies. Recruited members included artists, county employees, and a traditional healer who played a leadership role in making sure the program adhered to and respected Indian traditions.
  • Monthly council meetings: The council met on a monthly basis for 6 months to share stories about barriers to diabetes self-management and coping strategies. Members also developed a mission statement and logo for the program, and produced a video of the stories that was shared with the local community and other Native American groups.
  • Incorporating circle-of-life theme: In Native American tradition, the circle of life recognizes the interdependency of all life and people in a community. Developers of the Full Circle Diabetes program decided to incorporate this theme into the program. To that end, the Diabetes Community Council identified four recurrent themes (body, spirit, mind, and emotion) during its meetings that served as the key focal points for the program.
  • Pilot testing and official program launch: To test the concept, the council created and tested a pilot version of the program with 50 participants. Learning from the pilot informed the official launch in July 2004.
  • Securing grant funding: Working with a staff member at the Minneapolis Indian Center, program developers applied for and received 3 years of funding from the Robert Wood Johnson Foundation (RWJF) for a program at the Native American community clinic to address barriers to effective self-management of diabetes.

Resources Used and Skills Needed

  • Staffing: Program staff include a diabetes educator, a psychologist, two family counselors, an executive director (a pediatrician), two family practice doctors, two half-time nurse practitioners, a full-time nurse case manager, a data entry person, and a part-time dietitian.
  • Costs: Program costs totaled $370,000 for the first 3 years, which covered salaries for the dietitian and health educator and the costs of the education and exercise programs (e.g., meals and snacks, gift cards).
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Funding Sources

Robert Wood Johnson Foundation
As noted, RWJF provided $370,000 in funding for the first 3 years of the program. Since that grant ended, funding has come from a variety of other sources too numerous to mention. Other funds come from reimbursement by insurance companies and fees paid by uninsured patients (who pay on a sliding scale based on their income) for services provided by clinicians.end fs

Tools and Other Resources

Developed with support from RWJF, the 66-page Full Circle Diabetes Program Resource Toolkit, 2006, describes the program and lessons learned. A digital copy can be obtained by contacting the program developer.

Adoption Considerations

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Getting Started with This Innovation

  • Let community help develop program: To ensure that the Native American community felt invested and involved, program founders actively encouraged input into the development of the Full Circle Diabetes program. The Diabetes Community Council served as a primary vehicle for providing such input. In addition to providing insights into culture and the challenges of living with diabetes, council members also contributed innovative ideas for outreach and suggested program elements that providers had not previously considered.
  • Use storytelling to involve and engage community: One of the first jobs for council members was to share their individual stories of living with diabetes. This process helped program developers identify barriers and potential solutions. It also encouraged council members to take a more active role in their own health.
  • Acknowledge and respect commitment of council members: Council members should be made to feel respected, appreciated, and valued. For example, developers of the Full Circle program allowed potential members to attend a meeting as a visitor before committing to joining the council. Program staff also offered council members a $20 stipend per meeting. Although some turned it down and others opted for a grocery store gift card instead, the offer served as a way to honor their commitment and recognize the value of their time.
  • Budget staff time to coordinate council activities: Build coordination of council activities into a staff member’s job description to ensure that information gets transferred between the council and staff and to make sure meetings occur in an orderly fashion.
  • Assemble staff that knows community: Connections to the community help ensure that the program reflects the needs of the patients and help spread the word about program offerings. As noted, the majority of Full Circle program staff are Native American, while program developers either come from the local community or have worked in it for many years. As noted, the Diabetes Community Council also consisted of community members living with diabetes.
  • Create convenient office that reflects culture of clientele: As noted, the clinic is located in the heart of Native American life in the area, and the physical plant reflects the culture of the patients it serves.

Sustaining This Innovation

  • Explain program and benefits to patients: Once patients realize the connection between program elements and its mission (to prevent or treat diabetes), they become more engaged, comfortable, and satisfied, and more willing to spread the word to others about the program.
  • Write minigrants for specific program elements: Once funding ended for the whole Full Circle program, staff started looking to secure funds for individual components. For example, pharmaceutical foundations provided funding for the community breakfasts. Having a grant writer on staff helps the program take advantage of available resources.
  • Plan for long term: The Diabetes Community Council has now evolved into the Community Health Council, which is beginning to address needs beyond diabetes management. Both staff and the council are currently looking to develop nutrition, exercise, and educational programs focused on preventing diabetes in the community.
  • Add partners to respond to evolving needs: The program has expanded over time in response to community needs; it now includes 17 partners that work interdependently. For example, in response to a need for dental care among program participants and the wider community, the Native American Community Clinic added dental services in 2010 through a partnership with the University of Minnesota. To encourage referrals and make patients feel comfortable, the dental office is located next to the clinic and offers services on a sliding scale.

Use By Other Organizations

Leaders of an organization serving the Somali population in Minneapolis are contemplating whether to adapt the Full Circle model to the local culture.

More Information

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Contact the Innovator

Connie Norman
Community Health Educator
The Native American Community Clinic
1213 East Franklin Avenue
Minneapolis, MN 55404
(612) 462-1706

Innovator Disclosures

Ms. Norman has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Castro S, O'Toole M, Brownson C, et al. A diabetes self-management program designed for urban American Indians,” Prev Chronic Dis. 2009;6(4):A131. [PubMed]

Footnotes

1 Castro S, O'Toole M, Brownson C, et al. A diabetes self-management program designed for urban American Indians,” Prev Chronic Dis. 2009;6(4):A131. [PubMed]
2 Indian Health Service, Diabetes in American Indians and Alaska Natives: Facts At-a-Glance. Available at: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Resources/FactSheets/2012
/Fact_sheet_AIAN_508c.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
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3 Schauden L, Chase R. Full Circle Diabetes Program: Results of a project of the Minneapolis American Indian Center's Ginew/Golden Eagle program in collaboration with the Native American Community Clinic. Wilder Research, February 2007.
4 U.S. Census 2000. Available at: http://factfinder2.census.gov.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: August 03, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 17, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.