Scaling community-clinic coordination and outreach: Chronic disease prevention in Navajo Nation

As in many places around the world, poverty and disease go hand-in-hand in Navajo Nation. The chronic disease burden is disproportionally shouldered by the poor—many of whom are unable to access the healthcare system available through Indian Health Services (IHS). The COPE project, a formal collaboration between Navajo Nation Community Health Representative Outreach Program (CHR), IHS, and Brigham and Women's Hospital (Boston, MA) aims to strengthen the Navajo Nation Community Health Representative (CHR) Program through training, enhanced community-clinic coordination, and a culturally-relevant health promotion curriculum. CHRs, in turn, deliver intensive home-based outreach to promote healthy behavior changes among individuals with uncontrolled chronic health problems, such as diabetes and obesity. The COPE project has already seen improvements in both clinical outcomes of enrolled patients and also coordination between the community and clinic levels of care. Starting in 2012, the COPE project began to scale from its initial pilot phase in two service units of Navajo Nation (Gallup and Shiprock) to two additional service units. At the invitation of Navajo Nation, COPE will continue this phased scale-up to the entire Navajo Nation by 2015. COPE will share lessons learned during this phased implementation of scale-up, including: collaborating with tribal and federal health care teams, overcoming structural challenges in new service units, increasing local training and supervisory capacity, creating culturally-appropriate adaptations of health education materials and trainings, standardizing education and training for CHRs, generating ongoing program evaluation and quality improvement, and ensuring the long-term sustainability of these programs to prevent chronic disease.