Squaxin Island Tribe's Diabetes Intervention Program

By Cindy Beck, Diabetes Program Coordinator, Squaxin Island Tribe in collaboration with the NWRPCA Workforce Development Team

Nestled between the vibrant city of Olympia, WA, and the serene surroundings of Shelton, WA, lies the heart of the Squaxin Island Tribe's community which stands as a beacon of tradition, resilience, and healthcare innovation.
 
The Squaxin Island Tribal health facility, a community cornerstone, operates under a dual designation an Indian Health Service (IHS) tribal health facility and a federally qualified health care center. Its doors are primarily open to tribal members, their descendants, and their families, providing a broad spectrum of care that transcends mere medical treatment to encompass a holistic approach to wellness. This commitment to health and well-being extends not only to the tribe's members, regardless of their marital status or background, but also to a significant portion of its workforce. Reflecting the challenges healthcare providers face everywhere, the facility recently found itself at a crossroads. Last summer, due to overwhelming demand that tested the bounds of capacity, the difficult decision was made to halt enrollment for employees who were not already part of the program and did not possess a tribal affiliation. In this context, the Squaxin Island Tribe's healthcare facility emerges not just as a provider of medical services but as a vital organ of the community, adapting to its internal needs and the pressures of an ever-evolving healthcare landscape.

The Health Service Clinic offers a comprehensive range of medical, dental, and behavioral health care services. A significant focus within this spectrum is the clinic's innovative diabetes program, spearheaded by Cindy Beck, a naturopathic physician specializing in diabetes care. Beck's approach is holistic and preventive; she emphasizes therapeutic lifestyle interventions, including nutritional assessment and counseling. Her expertise is not limited to diabetes; she also adeptly manages adjunctive care for various chronic diseases and conditions related to weight, eating disorders, digestive issues, and specialized dietary needs.
 
Diabetes poses a significant challenge within the Squaxin tribe, impacting not only the adult population but younger members as well. In an innovative effort to engage families more effectively in health management, the clinic has employed creative strategies. A particularly compelling case involved a family grappling with diabetes. They encouraged the fourth sister to visit the clinic by initiating a friendly competition among siblings. They utilized continuous glucose monitoring systems to track their glucose levels over time, fostering a sense of communal engagement in health monitoring and education. This unique approach educated them on the importance of regular health checks. It motivated the initially reluctant sister to overcome her hesitations and seek treatment, demonstrating the power of a supportive family environment in managing health challenges.
The clinic integrates various technologies, such as Professional Continuous Glucose, monitoring to further enhance patient care. These initiatives encourage individual responsibility toward health and foster communal support for adopting healthier lifestyle choices.
 
Enhancing food quality while minimizing the presence of unhealthy options in communities is a complex endeavor, largely due to long-established cultural and taste preferences. This issue is accentuated when addressing the needs of individuals with specific health conditions, such as Type 1 diabetes, against a backdrop of diverse heritages. For example, consider a person with Latin American and Mexican parentage for whom staples like black beans and rice are fundamental. This situation necessitates innovative educational methods, such as teaching carbohydrate counting in a culturally sensitive manner and emphasizing the importance of insulin management during larger evening meals typical of certain work schedules.
 
Cindy's advocacy for moderation and informed food choices in managing diabetes represents a beacon of practical advice in this context. This strategy is replicated in the elders' kitchen, where fry bread is cut into quarters and served with stew or gravy during lunch to reduce portion sizes without eliminating traditional dishes. Furthermore, Beck's emphasis on timing meals correctly, advocating for heavier meals earlier in the day, and opting for lighter dinners showcases a holistic approach to dietary adjustments. Proposals aimed at encouraging healthier eating habits—such as bringing homemade meals to work—are certainly steps in the right direction but face the challenge of changing deeply ingrained behaviors. Through patient-centered care and motivational interviewing, healthcare providers like Beck adapt interventions to individual lifestyles and cultural nuances, underscoring the possibility of improving diet and health outcomes without dismissing cultural dietary preferences.
 
Beyond individual dietary habits, significant barriers to accessing healthy food stem from transportation and financial limitations, particularly affecting those in unstable employment, the elderly, and young families. Despite recognizing the benefits of nutritious eating, a pervasive reluctance to choose healthier alternatives to convenient, processed foods remains a strong societal force.
 
The local clinic is taking proactive steps to combat diabetes by directly engaging patients and offering clinic visits at no additional cost to Native American patients through grant funding. These visits involve screenings for pre-diabetes and consultations with healthcare providers. The clinic's approach emphasizes flexibility, including phone consultations, to ensure patient-friendly care. Despite some patients' initial reluctance to seek health services, the clinic's commitment to adapting to diverse cultural and personal needs is evident. For instance, the clinic's informal yet impactful approach to addressing a patient's frustrations over specialist wait times highlights its dedication to responsive and adaptive patient care. This nuanced approach sets the clinic apart from traditional healthcare settings, showcasing its commitment to providing effective, personalized care.
 
This initiative encounters resistance from some patients reluctant to utilize the available health services, underscoring the intricate nexus of cultural, socioeconomic, and personal elements affecting healthcare access and utilization. The staff's willingness to adjust and take on different roles, including phone consultations, epitomizes a versatile and patient-friendly environment. One noteworthy aspect is how the clinic deals with a patient experiencing liver failure who regularly shares his disappointments over the prolonged wait to see a specialist. This scenario showcases a distinct, more informal yet profoundly impactful approach to healthcare, further exemplifying the clinic's commitment to responsive and adaptive patient care.
 
At this tribal clinic, building strong personal connections and trust with patients while handling clinical responsibilities efficiently is the main focus. Staff members are deeply involved in community health education, conducting A1C screenings and delivering direct patient education at community events like health fairs and tribal council elections. They skillfully integrate patient information into the Resource and Patient Management System (RPMS) and ensure necessary follow-ups for those needing additional care.
 
Despite operating on a flexible schedule to accommodate both appointments and walk-ins, the clinic faces challenges with funding constraints. These limitations affect their ability to provide incentives for health visits or to reward the achievement of specific health goals. The clinic has organized a designated service to address transportation issues for patients needing to attend health appointments. This initiative ensures that if a patient requires a ride, there is someone available to transport them to their appointment.
 
Additionally, once a week, a bus service is available in the community that takes people to local grocery stores. Operating between 9:00 AM and 5:00 PM, this service facilitates access to healthier food options by allowing people to shop for groceries and transport them back to their homes.
 
To further support patient education and health management, the clinic distributes informational resources, including a document entitled 42 Factors That Affect Blood Glucose. This document is intended to enhance patient understanding of how many factors influence health, some they can control, and some they cannot.  These resources bolster the clinic's limited ability to offer extensive support services.
 
Adapting to modern needs, the clinic has embraced telemedicine, offering remote consultations to ensure accessibility for all, particularly those unable to travel. This organized, patient-centric approach highlights the clinic's dedication to improving health outcomes and disease management.
 
The recent appointment of a public health nurse to lead outreach and education has enabled Beck, a dedicated staff member, to shift her focus toward clinical tasks while actively promoting physical wellness. Certified by the National Strength and Conditioning Association and an experienced Pilates instructor, Beck directs tailored exercise classes for the elderly. She also collaborates with a yoga instructor for after-work sessions, contributing to the clinic's inclusive strategy to enhance physical well-being across all age groups. This collaboration extends to organizing native games for youth sports, in line with the spirit of the Olympics, and providing health and fitness guidance for the Squaxin tribe's canoe journey preparations. Engaging in regular physical activity is particularly beneficial for young diabetics, helping them improve insulin sensitivity and effectively control blood sugar levels.
 
Further demonstrating her commitment to preventative care, Beck has expressed interest in launching a pre-diabetes program targeted at teenagers. This initiative, aimed at instilling lifelong healthy habits, encapsulates the broader objective of leveraging local infrastructure—such as the community center—to support health education without the need for additional investment.
 
There is a strong intention to establish a diabetes support group led by behavioral health professionals who can relate to the challenges of the disease to create a sense of emotional connection for patients. Beck has considered the practicalities of arranging support groups and envisions engaging volunteers to facilitate support groups for individuals struggling with diabetes management. Eager to lead these support groups, Beck illustrates her commitment to this important cause. However, the community's policy prioritizes work-life balance by restricting overtime, demonstrating a dedication to the well-being of its members, which limits her ability to work after hours.
 
This multifaceted strategy reveals a deep understanding of the challenges at play, suggesting that overcoming obstacles to health and wellness necessitates a blend of modern medical practices with profound respect for cultural and individual perspectives. In doing so, the community illuminates a path forward where health and heritage coalesce, striving for a future where access to care and healthy living are readily within reach for all its members.
 

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