1. Healthy Heart Project 2011 Review of Services Presented to the Taos-Picuris Health Board September 2011 Review of program services Taos-Picuris Service Unit *The clinical measures listed on these documents were used by the programs over the past 10 years and were current at their time of use. However, these example documents are not intended to serve as current clinical guidelines. Programs using these documents will need to ensure the clinical measures are current for their intended use.

2. TPSU Healthy Heart Project Group Classes Community Action Individualized Care The Gift of Heart Health Balancing your Life with Diabetes Women’s Group Cooking Group Diabetes Forum Mentoring opportunities Senior Center Educational Series Case Management Certified Diabetes Educator Care Incentive Program with fitness assessments/personal trainers.

3. TPSU Healthy Heart Project Medications Exercise Diet The goal is to improve the overall wellness of those enrolled & the Taos Pueblo Community through:

4. Why TPSU Case Management Patient Provider

5. TPSU Case Management TrainersCase Management DietitianEducation Self-CareNutrition ExerciseMedication Self-care, Nutrition, Exercise and Medication are the components to improve control of most disease processes. Case Managers help enrolled members navigate challenges to make better choices, improving outcomes

6. TPSU Case Management Process Referral Baseline medical exam Enrollment documents per Grant Case Management Case Managers help individuals identify goals After 2 Case Management visits, incentives begin. Goals Case managers assist enrolled members to develop new goals, improve health literacy or understanding. Help members make better health choices thus improving wellness of the community.

7. TPSU Healthy Heart Project Readiness Access Success Current reports show that this project has met over 65% of its reporting goals since 2006. This is well above some programs that report in the 16-20% response categories. Why is this important?

8. Special Diabetes Project for Indians (SDPI Grant) Communication Community ProgramsIndian Health Service Clinic Incentive Program Requirements MembershipMonitoring Grant Funded Program Requirements Reporting Record Keeping

9. SDPI Grant Participation TPSU Project updates the National Program using web-based data programs It is required for the Grant Grant funds are additional funds to serve the community. Promote wellness, delay onset of complications. Improve Cardiovascular Health

10. Diabetes Audit Results January – June 2011 Compared with Last Year & Area Various indicators are used by Indian Health Service to evaluate the Diabetes specific care. 239 Diabetics on Registry The Following will be shared today: Blood sugar control Blood pressure control Cholesterol management Continuity of services: dental/eye/nutrition Age Duration of Diabetes

11. Diabetes Audit with Comparison Healthy Heart Project Data for TSPU (n=100) Blood Sugar ControlWeight Management

12. Diabetes Audit with Comparison Healthy Heart Project Data for TPSU Blood Pressure ManagementCholesterol Management

13. Healthy Heart Report Data The total number of complete baseline records = 100 (between 2006 – 2009) Total number of retained members = 74 @ end of 2009 data collection Total number of retained members at year 3 of program = 38 Baseline A1C @ goal = 24% Annual data A1C @ goal = 27% Baseline Average Waist circumference = 48 inches Annual Average Waist circumference = 42 inches (corrected) Baseline Average weight = 200 lbs Annual Average Weight = 197 lbs

14. Readiness for Exercise Change A Rapid Assessment of Physical Activity (RAPA) was performed for all new entry patients, baseline were collected on 86 participants prior to 2009. At annual assessment, if participants wanted to complete the RAPA survey, they were encouraged to do so – 47 did.

15. TPSU Healthy Heart Project The Project Staff will be focusing to compare these Diabetes Registry findings against next years’ comparison data on those enrolled in the program. The hope is to improve the outcomes, improve access to prevention activities and improve overall wellness of the community. Questions?