**Chronic Conditions in the Indian Health Service:**

**The Potential Utility of the World Health Organization's *Innovative
Care for Chronic Conditions* Framework and the**

***Chronic Care Model***

**Report prepared by**

**Susan S. Gilliland, PhD, Contract Epidemiologist,**

**and the IHS Division of Diabetes Treatment and Prevention (DDTP)**

***Executive Summary***

-   ***Preventing and managing chronic conditions effectively and
    efficiently will require an evolution of the traditional health care
    model used by the Indian Health Service.***

While great successes have been made in medicine and technology that
allow people to live longer, new public health issues have emerged --
chronic conditions. The appearance of chronic conditions is placing new
and additional demands on health care systems. While many chronic
conditions are preventable, most current health care systems have been
built on responding to acute health care issues and are not structured
to address the needs of patients with long-term chronic conditions nor
prevent these conditions. Preventing and managing chronic conditions
requires an evolution of the model for health care that can address
prevention and long term care of chronic conditions effectively. This
process will require involvement of policy makers, health care
organizations, communities and patients.

-   ***The Innovative Care for Chronic Conditions Framework (ICCC)
    developed by the World Health Organization (WHO) offers an approach
    to address chronic conditions in the Indian Health Service health
    care system.***

The Indian Health Service (IHS) system evolved around providing services
to people with acute needs. Today chronic conditions, such as diabetes,
cardiovascular disease, and asthma, have emerged as increasing prevalent
chronic conditions and have placed new long-term demands on the IHS
health care system. The MacColl Institute for Healthcare Innovation
developed a framework, called the Chronic Care Model, to provide a
structure for organizing health care for chronic conditions. (ref Wagner
EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading
chronic disease management programs: Are they consistent with the
literature? Managed Care Quarterly, 1999. 7 (3):56-66.)

The World Health Organization's (WHO) non-communicable Diseases and
Mental Health cluster expanded the Chronic Care Model to include a
broader policy environment that includes patients and their families as
well as health care organizations and communities to assist countries in
reorganizing their health care systems and provide more effective and
efficient prevention and management of emerging chronic conditions. This
framework may be applicable to the IHS.

-   ***To implement the important elements of these models will require
    the IHS, tribes, and urban organizations to secure new resources and
    partners as traditional patient care needs will remain and likely
    grow in magnitude.***

New resources will be needed to address the broader scope of the ICCC
model. A coherent plan using the ICCC framework and the CC Model could
be the first step in developing a funding request. New and strengthened
partnerships with federal, state and local governments and tribes and
community groups will be needed to improve care for chronic conditions.

-   ***The experience of the IHS Division of Diabetes Treatment and
    Prevention (DDTP) provides examples of how an IHS program is
    addressing a chronic condition by strengthening traditional health
    care to include prevention and long-term care approaches while
    broadening partnerships and resources.***

The DDTP is illustrative of the ICCC framework and the Chronic Care
Model. The DDTP provides examples of partnerships, informing policy
makers, creating new funding sources, developing practical mechanisms to
involve communities to build community capacity, providing evidence for
the effectiveness of clinical approaches, and evaluating programs to
improve the health care system and chronic care outcomes.

-   ***The purpose of this report is to use diabetes as a specific
    example of a chronic condition and identify the lessons learned from
    the IHS Division of Diabetes Treatment and Prevention***
    ***experience in context to the ICCC framework and the Chronic Care
    Model and to make recommendations regarding the utility of the
    frameworks for improving care and prevention of other chronic
    conditions IHS-wide.***

> Section 1 provides a brief summary of the World Health Organization's
> (WHO) Innovative Care for Chronic Conditions (ICCC) framework and the
> MacColl Institute for Healthcare Innovation's Chronic Care Model.
> Section 2 addresses how the elements of the frameworks have been
> utilized by the DDTP and partners to create innovations in diabetes
> care. Section 3 provides a starting point for committee members to
> generate a shared understanding of what others are doing in relation
> to chronic conditions; identify the IHS performance objectives that
> may be addressed by applying an integrated approach to chronic
> conditions; assess the desire/willingness to work within an integrated
> approach to chronic conditions; define an integrated approach to
> chronic conditions and determine the expected outcomes that could be
> achieved; identify potential benefits and challenges of working
> together in an integrated approach to chronic conditions through the
> discussion of common issues; identify potential solutions to these
> challenges and the requirements necessary to implement the solutions
> and to identify concrete "next steps" for implementation of an
> approach to chronic conditions. Ideas for consideration on potential
> approaches to chronic conditions in the IHS agency are provided.

***Section One***

***Summary of the Chronic Care Model***

-   ***The elements of good chronic illness care require productive
    clinical interactions between informed patients and prepared &
    proactive practice teams***

![](media/image1.pct)

**The Development of the Chronic Care Model**\
The MacColl Institute for Healthcare Innovation of Group Health
Cooperative developed the Chronic Care Model drawing on [available
literature](http://www.improvingchroniccare.org/resources/bibliography/citations.html)
about promising strategies for chronic illness management. The model was
further refined during a nine-month planning project supported by The
Robert Wood Johnson Foundation. After revision from a large panel of
national experts, the model was subsequently used to collect and analyze
data from innovative programs recommended by experts. RWJF then funded
the MacColl Institute to test the model nationally across varied health
care settings: the national program being called "Improving Chronic
Illness Care" (ICIC).

The Chronic Care Model (CCM) provides an organizational approach for
caring for people with chronic disease in a primary care setting. The
CCM advocates that improvements in approaches to chronic conditions can
be accomplished by creating a health care system that is practical,
supportive, population- and evidence-based and promotes an interactive
relationship between patients who are informed and motivated and a
health care team that is prepared and proactive.

The Chronic Care Model identifies the six essential elements of a health
care system that encourage high-quality chronic disease care. These
elements are

-   [the
    community](http://www.improvingchroniccare.org/change/model/community-test.htm),

-   [the health
    system](http://www.improvingchroniccare.org/change/model/healthsystem-test.htm),

-   [self-management
    support](http://www.improvingchroniccare.org/change/model/smsupport-test.htm),

-   [delivery system
    design](http://www.improvingchroniccare.org/change/model/deliv_design-test.htm),

-   [decision
    support](http://www.improvingchroniccare.org/change/model/dec_support-test.htm),
    and

-   [clinical information
    systems](http://www.improvingchroniccare.org/change/model/community-test.htm).

The six essential elements of health care systems that encourage
high-quality chronic illness care are listed below with specific
examples for each:

+----------+----------+------------+----------+----------+----------+
| ***Commu | *        | ***Self-   | ***      | ***      | ***      |
| nity-*** | **Health | management | Delivery | Decision | Clinical |
|          | Care     | Support*** | System-  | Su       | Inf      |
| ***r     | Organ    |            | cu       | pport*** | ormation |
| esources | ization- |            | lturally |          | System - |
| &        | patient  |            | co       |          | Care     |
| pol      | safety,  |            | mpetent, |          | Coordin  |
| icies*** | care     |            | case     |          | ation*** |
|          | coordin  |            | manag    |          |          |
|          | ation*** |            | ement*** |          |          |
+----------+----------+------------+----------+----------+----------+
| E        | Chronic  | Providers  | Team     | Evidence | Registry |
| ffective | c        | emphasize  | roles    | based    | with     |
| programs | ondition | patient\'s | defined  | gu       | cl       |
| id       | goals    | active     | & tasks  | idelines | inically |
| entified | are      | role to    | d        | set into | useful & |
| &        | me       | manage     | elegated | clinical | timely   |
| patients | asurable | illness    |          | practice | inf      |
| par      | part of  |            |          |          | ormation |
| ticipate | annual   |            |          |          |          |
|          | plan     |            |          |          |          |
+----------+----------+------------+----------+----------+----------+
| C        | Benefits | St         | Planned  | Sp       | Care     |
| ommunity | that     | andardized | visits   | ecialist | r        |
| part     | health   | patient    | used to  | e        | eminders |
| nerships | plans    | as         | provide  | xpertise | &        |
| develop  | provide  | sessments: | care     | is       | feedback |
| eviden   | designed | self-      |          | in       | for      |
| ce-based | to       | management |          | tegrated | p        |
| programs | promote  | skills,    |          | into     | roviders |
| &        | good     | c          |          | primary  | &        |
| policies | chronic  | onfidence, |          | care     | patients |
| that     | illness  | supports,  |          |          | built    |
| support  | care     | & barriers |          |          | into     |
| chronic  |          |            |          |          | inf      |
| care     |          |            |          |          | ormation |
|          |          |            |          |          | system   |
+----------+----------+------------+----------+----------+----------+
| Health   | Provider | Effective  | Co       | Provider | Relevant |
| plans    | in       | behavior   | ntinuity | e        | patient  |
| co       | centives | change     | assured  | ducation | s        |
| ordinate | designed | include    | by       | mo       | ubgroups |
| chronic  | to       | int        | primary  | dalities | id       |
| illness  | improve  | erventions | care     | used     | entified |
| gui      | chronic  | & ongoing  | team     | proven   | for      |
| delines, | illness  | support    |          | to       | p        |
| measures | care     | with       |          | change   | roactive |
| &        |          | peers/     |          | practice | care     |
| r        |          | pro        |          | behavior |          |
| esources |          | fessionals |          |          |          |
| th       |          |            |          |          |          |
| roughout |          |            |          |          |          |
| c        |          |            |          |          |          |
| ommunity |          |            |          |          |          |
+----------+----------+------------+----------+----------+----------+
|          | E        | Col        | Regular  | Patients | In       |
|          | ffective | laborative | f        | informed | dividual |
|          | st       | planning & | ollow-up | of care  | patient  |
|          | rategies | problem    | ensured. | gu       | care     |
|          | used to  | solving    |          | idelines | planning |
|          | achieve  | assured by |          |          | aided by |
|          | compr    | care team  |          |          | inf      |
|          | ehensive |            |          |          | ormation |
|          | system   |            |          |          | system   |
|          | change   |            |          |          |          |
+----------+----------+------------+----------+----------+----------+
|          | Leaders  |            |          |          |          |
|          | support  |            |          |          |          |
|          | imp      |            |          |          |          |
|          | rovement |            |          |          |          |
|          | in       |            |          |          |          |
|          | chronic  |            |          |          |          |
|          | c        |            |          |          |          |
|          | ondition |            |          |          |          |
|          | care     |            |          |          |          |
+----------+----------+------------+----------+----------+----------+

Evidence-based change concepts under each element, in combination,
foster productive interactions between informed patients who take an
active part in their care and providers with resources and expertise.
The model has been applied to a variety of chronic illnesses, health
care settings and target populations. The bottom line is healthier
patients, more satisfied providers, and cost savings. The Chronic Care
Model, when implemented through multifaceted interventions, can improve
process and outcome measures for diabetes. Using the Chronic Care Model
has been shown to reduce short-term costs through reduced hospital
admissions, emergency department visits and physician consultations in
people with diabetes. Other studies have shown that improved glycemic
control through implementing elements of the model is associated with
short-term reductions in hospital stay and reduced hospital and
outpatient use compared with usual care.

**World Health Organization's *Innovative Care for Chronic Conditions*
Framework**

***Summary of the ICCC Framework***

-   The ICCC framework advocates that better health outcomes for chronic
    conditions occur when efforts occur at the 3 levels of care

  -----------------------------------------------------------------------
  Macro level- policy

  Meso level- health care organization & community

  Micro level- patient interaction
  -----------------------------------------------------------------------

-   ***The ICCC identifies the triad at the center of the framework as a
    partnership of patients and families, health care teams, and
    community supporters. This triad functions optimally when each
    member is informed, motivated, and prepared to manage their health,
    and communicates and collaborates with the other members of the
    triad.***

-   ***The inner triad is supported by a broader group consisting of the
    community, the health care organization and the policy
    environment.***

+----------------------------+-----------------------------------------+
| **World Health             |                                         |
| Organization Innovative    |                                         |
| Care for Chronic           |                                         |
| Conditions Framework**     |                                         |
+----------------------------+-----------------------------------------+
| **Six Guiding Principles** | **Eight Essential Elements**            |
+----------------------------+-----------------------------------------+
| -   Evidence-based         | -   Support a paradigm shift            |
|     decision making        |                                         |
|                            | -   Manage the political environment    |
| -   Population focus (vs.  |                                         |
|     individual)            | -   Build integrated health care        |
|                            |                                         |
| -   Prevention focus       | -   Align sectoral policies for health  |
|                            |                                         |
| -   Quality focus          | -   Use health care personnel more      |
|                            |     effectively                         |
| -   Integration            |                                         |
|                            | -   Center care on patient and family   |
| -                          |                                         |
|   Flexibility/adaptability | -   Support patients in their           |
|                            |     communities                         |
|                            |                                         |
|                            | -   Emphasize prevention                |
+----------------------------+-----------------------------------------+

***Section Two***

The DDTP Program has actually been implementing many of the elements of
the ICCC framework and the Chronic Care Model for years, but the Special
Diabetes Program for Indians (SDPI) funding has helped expand the number
of programs that have been able to implement and expand this type of
quality diabetes care. Thus DDTP provides an illustration of the
potential use of these elements for prevention and treatment of other
chronic conditions in the IHS context. (Do we need to use I/T/U language
in this document?KA)

**Macro Level - Positive Policy Environment**

***Diabetes is an important public health issue and is receiving
attention at the national, state and local levels through scientific
research, advocacy groups and the media. This has created a positive
policy environment to reduce the burden of diabetes among AI/AN
communities***.

-   

**Strengthen partnerships**

The DDTP has established new partnerships with tribes, tribal leaders,
Indian organizations, community groups, schools, other federal agencies
and non-profit organizations to leverage resources and combine diabetes
expertise to improve diabetes care and treatment.

**Integrate policies**

The mission of the DDTP is to develop, document, and sustain public
health efforts to prevent and control diabetes in AI/AN peoples. This
mission, and the policies that support this mission, are consistent with
DHHS and IHS policy. The DDTP develops policies on diabetes treatment
and prevention consistent with those of other division and programs
within IHS, as well as with those of other agencies to the extent that
they apply to this special population.

**Promote consistent financing**

The IHS Diabetes Program has traditionally been funded to address
diabetes treatment. Funding for primary or secondary prevention efforts
has been minimal. Through Congressional legislation the DDTP now
receives earmarked funding for the Special Diabetes Programs for Indians
(SDPI) grants program to conduct community-directed diabetes prevention
(including primary prevention) and treatment efforts.

**Support legislative frameworks**

The SDPI is a result of national legislative action to help reduce the
burden of diabetes among AI/AN communities. In addition, Public Law
93-638, the Indian Self-Determination and Education Assistance Act of
1975, Titles I and III, has made it possible for Tribes to take specific
program shares (dollars) under Title I, Annual Funding Agreement, or to
become totally self-governing under Title III,
Compacting/Self-Governance. This has allowed Tribes to become active
diabetes partners. Adaptations to the SDPI program have been made to
accommodate the self-governance tribes' funding agreements. Tribes were
also named as eligible entities for SDPI grant funding in the
legislation.

**Provide leadership and advocacy**

The DDTP provides diabetes expertise, leadership, education, advocacy,
and resources that enable tribal leaders, tribal health workers, health
care organizations, communities and patients to advocate for and achieve
better diabetes outcomes. The DDTP provides research forums, continuing
education materials and activities, publications, and a network of
online resources. Regional and local diabetes expertise is provided
through Area Diabetes Consultants (ADCs) and an extensive network
amongst SDPI grantees and Indian health programs. DDTP also participates
in interagency efforts, like the Diabetes Interagency Coordinating
Committee (DMICC), the National Diabetes Education Program (NDEP), the
Diabetes Education in Tribal Schools project (DETS), and with advocacy
groups like the American Diabetes Association (ADA).

**Develop and allocate human resources**

The DDTP supports continuing education, training and technical
assistance for health professionals and health care workers. The SDPI
grant program encourages personnel development at all levels and
provides resources for critical diabetes team members.

**Meso Level -- Health Care Organization**

-   ***The DDTP is taking positive steps to improve the environment of
    the health care organizations.***

**Promote continuity and coordination**

The DDTP is working with Indian health care organizations to ensure that
patients with diabetes receive the best diabetes care possible. Model
Diabetes Programs (MDP) have developed and tested many of the elements
of diabetes care that are considered fundamental to diabetes care today.
(diabetes teams, registries, flow sheets, education materials, audit,
clinics, standards of diabetes care,). The DDTP created the Diabetes
Best Practice approaches to care and prevention which provide
evidence-based guidelines for clinical and community-based activities.
Many IHS health care programs have partnered with the tribes who have
Special Diabetes Programs for Indians (SDPI) grants to develop and test
approaches to community-directed diabetes efforts at all levels of
prevention.

**Encourage quality care through leadership and incentives**

The DDTP has developed the IHS Standards of Care for Diabetes to help
provide consistent, quality care to AI/AN patients with diabetes. DDTP
has also developed the IHS Diabetes Care and Outcomes Audit to track how
programs are performing in relation to themselves year to year (trends),
compared to other programs within their region, and compared to the
national IHS aggregate as a whole. These aggregate measures are trended
over time to provide the IHS with a "report card" for the quality of
diabetes care being delivered in Indian health care facilities. The DDTP
has developed and offers an integrated diabetes education recognition
program and is available to all interested diabetes programs to improve
care for diabetes.

**Organize and equip health teams**

The DDTP supports the development of diabetes teams in our health care
facilities that have the necessary supplies,essential medications,
laboratory testing for assessment of diabetes control and complications,
team expertise for basic clinical exams and multidisciplinary diabetes
team staffing to provide good diabetes care. The DDTP has developed the
Standards of Care for Diabetes, and the Integrated Diabetes Education
Recognition Program to help provide consistent, quality care to patients
with diabetes. Through the SDPI many programs have been able to purchase
new and essential diabetes medications.

**Support self-management and prevention**

Diabetes self- management education is a key element of diabetes
prevention and treatment. The DDTP has written a best practice approach
on self-management to help patients and their families follow medical
protocols to reduce the risk of complications and potential disability
associated with diabetes. The DDTP has developed and offers an
integrated diabetes education recognition program (IDERP) which is
available to all interested diabetes programs to improve care for
diabetes. This program provides sites with the opportunity to bill for
their diabetes education activities. DDTP serves as the deeming entity
for certifying recognition for this program.

**Use Information systems**

The DDTP conducts annual Indian Health Diabetes Care and Outcomes Audit
chart reviews to help programs improve important clinical diabetes
outcome measures and used for evaluation of diabetes activities. DDTP
has been actively involved in the Data Warehouse Project, as well as
supporting the Diabetes Management System within RPMS, GPRA+, the
electronic health record (EHR) and an electronic version of the Diabetes
Care and Outcomes Audit.

**Meso Level - Community**

**Raise awareness and reduce stigma**

Diabetes is a diagnosis associated with stigma in many AI/AN
communities. Through efforts such as the SDPI grant programs, regional
meetings, and the Tribal Leaders Diabetes Committee, individual
communities conducting appropriate diabetes education, awareness
activities and outreach are increasing the awareness of diabetes and
reducing the stigma. Traditional healing methods and approaches such as
talking circles and story-telling have been used in some SDPI programs
to promote living healthy/well with diabetes.

**Encourage better outcomes through leadership and support**

The DDTP works with the Tribal Leaders Diabetes Committee, Indian Health
Boards and the SDPI grant programs to advocate for better health care
for diabetes and support community members who are living with diabetes.
Examples include more tribal worksite wellness policies encouraging
physical activity during the work day, more school food service policies
such as healthy food choices in vending machines and cafeteria services,
and more tribal input into diabetes programs since the advent of SDPI.
Community physical fitness and nutrition services have increased.

**Mobilize and coordinate resources**

The SDPI grant programs provide resources to enhance what communities
can do and work for coordination by developing partnerships. The DDTP
also developed a community advocacy Best Practice to mobilize AI/AN
communities on diabetes efforts, resulting in more community volunteers
in some settings. Community diabetes need assessments that can be used
to discover unmet community needs and determine priorities for local
programs have increased under SDPI.

**Provide complementary services**

The SDPI allows tribes and grantees to complement the local health care
organization which provides a more comprehensive public health model of
care.

**Micro Level -- Patient and Family**

The DDTP Best Practice Approaches to diabetes care and prevention focus
on the patient and family. DDTP develops culturally appropriate
education materials that are specifically written for the patient and
their family. The DDTP encourages health care organizations to form
diabetes teams that are patient oriented. The DDTP IDERP program and the
diabetes self-management education program focus on helping the person
with diabetes and his/her family learn to live with and manage diabetes
within the context of the individual's goals and constraints.

***Section Three***

***This section offers ideas for consideration that are based on the
ICCC framework, the Chronic Care Model and the experience of the DDTP
and provides a starting point for committee members to:***

-   ***generate a shared understanding of what others are doing in
    relation to chronic conditions. For example,***

    -   what is already in place to address other chronic conditions?

    -   what data needs exist, where are the gaps?

> In addition to diabetes, the following are likely some of the chronic
> conditions of concern to the IHS. **Arthritis** (data sources?)
> **Chronic respiratory diseases** (good data source from the CA Health
> Interview Study -- shows that AI have the highest rates of asthma in
> CA; COPD -- data sources?), **depression/substance abuse/mental health
> issues** (data sources?), **CVD** (Dr. Galloway IHS data, Strong Heart
> Study data), **HIV** (data sources?), **Renal disease** (Andy Narva
> IHS data), **disabled** --result of trauma, ESRD, amputations, other
> (IHS data)

-   ***identify IHS performance objectives that may be addressed by
    applying an integrated approach to chronic conditions. For example,
    adoption of a chronic condition framework may address the following
    priorities:***

> ***1) Prevention -- the chronic condition framework is designed to
> help build infrastructure and capacity to implement effective primary,
> secondary and tertiary prevention activities***
>
> ***2) Quality Health Care-- the chronic condition framework encourages
> the use of clinical registries and patient care reminder systems to
> assist health care providers to make safer and more informed diagnoses
> and decisions***
>
> ***3) Decreasing Disparities-- the chronic condition framework
> supports the use of strategies and tools to improve quality care of
> patients, including a case management approach to care and up-to-date
> medical prevention and treatment***
>
> ***4) Partnerships -- the chronic condition framework is based on
> enhancing existing and developing new partnerships between
> communities, health care organization and patients and their families
> as a way to promote better outcomes***

-   ***assess the desire/willingness to work within an integrated
    approach to chronic conditions***

-   ***define an integrated approach to chronic conditions and determine
    the expected outcomes that could be achieved***

-   ***identify potential benefits and challenges of working together in
    an integrated approach to chronic conditions through the discussion
    of common issues***

-   ***identify potential solutions to these challenges and the
    requirements necessary to implement the solutions***

-   ***identify concrete "next steps" for implementation of an approach
    to chronic conditions***

The following are initial ideas for thought. (This section needs to be
completed by the chronic condition committee).

**Macro level -- Positive Policy Environment**

-   Establish national chronic care committee including: MDs,
    subspecialists, Pharm Ds, RNs, RDs, CDEs (educators), behavior
    specialists, prevention specialists, OT, PT, community leaders and
    patients with chronic conditions and chronic care experts to create
    policies and provide expertise and leadership to develop, implement
    and evaluate community-directed chronic condition care and
    prevention interventions

-   Need for chronic control office (designated team of health
    professionals) to take the lead to work with IHS leadership to
    generate data to make the case to Congress that it is important to
    get funding and implement policy and environmental changes for
    prevention and treatment of chronic conditions

-   Consider the DDTP model? i.e. Establish a chronic condition office
    to communicate with "area chronic condition consultants" and a field
    network about best practice approaches to prevention and treatment
    of chronic conditions

-   Establish local clinical practice recommendations and guidelines as
    policy -- the CCM provides a process to establish guidelines: 1)
    establish a guideline development team 2) generate list of current
    published guidelines through literature review, review articles,
    etc 3) establish appropriate guidelines for IHS system 4) educate
    providers about current guidelines 5) develop policies for
    implementation -- standing orders, reminder systems, etc 6)
    establish system to monitor implementation and compliance 7)
    establish timeline and protocol to revisit and update guidelines as
    needed

-   CCM offers specific ideas on how to facilitate the interaction
    between health care providers and patients and their families and to
    promote appropriate chronic condition care among health care
    organizations (see CCM table in section one).

-   Grant process (similar to Special Diabetes Programs for Indians) may
    be a good way to involve the Tribes, communities, health care
    centers, urban centers 1) to establish new and strengthen existing
    partnerships 2) to leverage resources and combine expertise to
    implement chronic condition program(s)

-   Establish programs for related groups of chronic conditions (?) (eg
    many chronic conditions share the same risk factors) through
    legislative process

-   Consider creating a model ICCC project of sentinel sites to figure
    out how to implement a chronic condition program clinically and how
    to mobilize communities

-   Provide training/technical assistance of chronic conditions at the
    local, area-wide and national levels to improve the health of AI/AN
    communities

-   Support efforts to implement evidence based clinical practice
    guidelines

-   Promote public health activities with a focus on nutrition, obesity
    prevention and prevention programs

-   Establish best practice models for chronic conditions

-   Consider directing public health efforts at specific regional needs
    to prevent chronic conditions

-   Conduct public health program evaluation to determine if process and
    chronic condition program(s) are working and include estimated costs

**Meso level -- Health Care Organization**

-   Establish evidence based standards of care for treatment and
    prevention of chronic conditions to provide consistency in medical
    care

-   Coordinate with and partner with federal, state, community and
    tribes to target modifiable risk factors to support prevention of
    chronic conditions including shared risk factors of obesity,
    physical inactivity, calorie-dense foods, unhealthy diets.

-   Surveillance of chronic conditions to facilitate monitoring and
    evaluation of program activities

-   Facilitate and expand data collection -- generate quality data
    including cost on an ongoing basis

-   Establish systems to track and facilitate preventative practices

-   Establish prospective chronic condition registries (IGT/IFG,
    obesity)

-   Need program to fund and evaluate new innovative diabetes (chronic
    care) models.

-   Work to decrease barriers to chronic care management.

-   Conduct public health program evaluation to determine if process is
    working

**Meso level - Community**

-   Increase awareness of chronic conditions and preventive behavior
    among those at high-risk through chronic condition campaigns.
    Increasing awareness can help to stimulate dialogue and reduce
    stigma

-   Establish tribal leaders chronic condition committees to encourage
    new leaders in community and include their ideas and concerns

-   Partner with advocacy groups such as the ADA, AHA, ACS, Arthritis
    foundation etc to make education materials available, provide
    community education programs, etc

-   Partner with community to increase public education to prevent
    chronic conditions

**Micro level -- Patient and Family**

-   Develop "quality" culturally appropriate diabetes education
    materials and programs that involve registered dietitians,
    registered nurses and certified diabetic educators, etc that are
    written at the patient level of understanding

-   Health care providers trained to be sensitive to patient concerns
    and needs and respectful of all members of the community

-   Involve patients and their families in program design, development,
    implementation and evaluation process