Family Focus Helps Pharmacist Improve Diabetes Care for Native Americans
When Cherith Smith started work about a decade ago as a pharmacist at the Missoula Urban Indian Health Center in Montana, she saw a common thread of hopelessness in people with diabetes who visited the center.
Young people saw no point in trying to manage their diabetes because the outcome was always the same.
"They would say, 'I'm going to have an amputation, and I'm going to die. . . . It's not something that we can do anything about,'" Smith recalled.
She said such perceptions are exacerbated by limited experience with and access to preventive care services along with a historical perception among Native Americans that medical help is available only in dire circumstances.
Diabetes affects about 16% of American Indians and Alaska Natives, as compared with 8% of whites, according to the Centers for Disease Control and Prevention (CDC).
The Missoula Urban Indian Health Center, which offers education, care coordination, and patient-navigator services to members of more than 30 tribes in the region, participates in a federally supported diabetes program for Native Americans.
But Smith, an enrolled member of the Rosebud Sioux and Piegan Blackfoot tribes, said the center's initial approach to diabetes education didn't align with the traditions or social needs of the local community.
"The way that system was set up was to basically put that burden on the individual that has the chronic disease—all the doctor's visits, the education, the self-management," Smith explained. "And when they go home, they go home to families who have much higher needs in the basic things of survival. Housing, food—there's all kinds of other issues that they're facing."
Also lacking in the program, she said, was recognition of the importance of a patient's extended family and the community in individual healthcare decisions.
To address these problems, Smith said, the center changed its program to address social and mental health issues and showed the household how to support family members with diabetes through exercise, diet changes, and even help with foot inspections.
"We also add in the historical context—recognizing and acknowledging where the families have come from and where they are now"—and promoting the resilience of Native Americans and ways to empower community members, Smith said.
And the revised program also stresses that diabetes is neither inevitable nor a death sentence.
"We emphasized, with the individual who had diabetes, that it was important for them to understand that diabetes was preventable, and diabetes progression could be slowed or stopped," she said.
Smith said the more holistic approach includes diabetes screening for family members and support for those who are found to have prediabetes or diabetes.
Overall, she said, the program is improving outcomes among the population served by the center.
A recent CDC report found that a community health approach can result in improved diabetes outcomes—specifically, a reduced rate of kidney failure—in Native American and Alaska Native communities.
According to CDC, an Indian Health Service (IHS) initiative consisting of team-based, population-level services for patients with diabetes boosted the use of medications that protect the kidneys and yielded improvements in the areas of hypertension and blood glucose control. CDC tied the initiative to a 54% drop in the rate of kidney failure among Native Americans with diabetes during the period 1996–2013.
At a January 11 media briefing, Ann Bullock, director of the IHS division of diabetes treatment and prevention, praised the educational programs offered through Urban Indian Health Program (UIHP) facilities and other tribal partners. She also acknowledged the difficulties faced by Native Americans with diabetes.
"Our patients made remarkable efforts overcoming huge obstacles and barriers of care to get in for their appointments, to exercise, eat healthfully, as their budgets will allow, to take their medications as prescribed," Bullock said.
To bolster its population health efforts, IHS in 2008 launched the Improving Patient Care (IPC) initiative, which promotes a patient-centered medical home model of care and in 2015 included 78 federal, 69 tribal, and 25 UIHP programs.
According to IHS, immediate diabetes-related benefits from IPC implementation included a 44% increase in neuropathy screenings at an Illinois IHS hospital and a 46% increase in retinopathy screenings at a New Mexico facility.
Mark Feltner, deputy director of pharmacy services and outpatient pharmacy chief at 45-bed Whiteriver Indian Hospital in Arizona, said the IPC initiative supports pharmacists' role on ambulatory care teams.
"They're right there, working and making medication recommendations," Feltner said.
At Whiteriver, Native Americans who have diabetes can receive care at a pharmacist-managed chronic disease clinic. Initially the clinic operated 3 days per week, but last year a Monday–Friday schedule was implemented in order to improve access to primary care services.
"With that clinic, we have 3 pharmacists that rotate through," he said. "They have their own set of patients that they're following in conjunction with the other providers," he said. The pharmacists work under collaborative practice agreements approved by the hospital's pharmacy and clinical directors.
During the 2015 fiscal year, Whiteriver's clinical pharmacists logged about 935 primary care encounters, said Elizabeth Helm, director of pharmacy services for the hospital.
"The pharmacists have their hands in everything," she said. "A lot is expected of us."
Whiteriver's hospital is located on the Fort Apache Indian Reservation and serves a community of about 17,000 Native Americans.
According to the Government Accountability Office, IHS operates 26 hospitals, 56 health centers, and 32 health stations in 33 states, offering services to about 2.2 million American Indians and Alaska Natives—descendants of 567 federally recognized tribes.
IHS also funds 33 urban Indian health centers, which operate as independent, nonprofit entities in 19 states.
Smith, of the Missoula Urban Indian Health Center, said there's a need for pharmacists and other healthcare providers to understand, when they work with Native American patients, some of the barriers to care that they face and to foster a trusting, culturally sensitive relationship with these patients.
"One of the important things to understand, is that when we deal with American Indian–Alaska Native population, is there are so many different, distinct tribes out there. And that means different cultures, different languages, different ways of doing things," Smith said.
Smith said she mentors pharmacy students at the center, which also serves as a community health rotation site for University of Montana family medicine residents.
"It's about helping people to see the Indian population through a different lens and really building relationships," Smith said.
And she noted that many healthcare professionals aren't aware that much of the Native American population in the United States has moved away from isolated reservations and tribal areas and into more diverse urban areas.
Funding, she said, has not kept up with the need for healthcare in this urban population, she said.
"We have over 4,000 people who are eligible for our services, but we are only able to . . . see maybe 400 or so. So a lot of times, we're turning people away," she said.
[This news story appears in the March 1, 2017, issue of AJHP.]