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

Background: Age-adjusted diabetes prevalence is 15.9 percent among American Indian and Alaska Native adults served by the U.S. Indian Health Service, the highest among all U.S. racial and ethnic groups. From years 2000-2009,Northern Plains tribal communities also experienced the highest age-adjusted diabetes death rate across all Indian Health Service regions, exceeding the national rate for American Indians and Alaska Natives by almost 50 percent. While there has been considerable development of strategies to reduce diabetes risk factors in the American Indian and Alaska Native population, additional evidence is warranted of their effectiveness when directed by the tribal communities themselves. Theory and methods: The proposed Tribal Participatory Chronic Care Model (TP-CCM) is an approach integrating fundamental aspects of Tribally-Directed Participatory Research and the Chronic Care Model. Tribal members inform adaptations to the community, health system, selfmanagement support, delivery system design, decision support and clinical information systems components of the traditional Chronic Care Model to foster productive interaction between tribal entities and a public health care system. The Wind River Alliance to Reduce Diabetes Disparities program integrated various patient-level, provider-level and system-level interventions using the TP-CCM and targeted barriers to diabetes management on Wind River Indian Reservation. Results: The TP-CCM improved dietary behavior, clinical endpoints and self-management support at the patient-level; cultural competency and health care delivery at the provider-level; and collaboration, referral processes and shared clinical information between tribal government and federal government health systems. Conclusions: The Wind River Alliance to Reduce Diabetes Disparities program provides encouraging preliminary evidence that the TP-CCM can serve as a structured community-clinical approach to support tribal communities with high chronic disease prevalence.