Diabetes-related kidney failure has declined dramatically among Native Americans—54% between 1996 and 2013— largely thanks to team- and population-based approaches begun by the IHS in the mid-1980s.
In addition to lowering the prevalence of kidney failure, those approaches led to other improvements:
- Use of medicines to protect kidneys increased from 42% to 74% in 5 years
- Average blood pressure in people with hypertension is well controlled (133/76 mm Hg in 2015)
- Blood sugar control improved by 10% between 1996 and 2014
- Kidney testing in adults aged ≥ 65 years increased > 10% compared with the Medicare diabetes population
The CDC and IHS advise team-based care should include patient education; community outreach; care coordination; tracking of health outcomes; and access to health care providers, nutritionists, diabetes educators, pharmacists, community health workers, and behavioral health clinicians. For instance, care managers use clinical data to identify people who need to be linked to health care and call patients if they miss appointments. The care model also includes integrating kidney disease prevention and education into routine diabetes care.