Tulalip Diabetes Care and Prevention Program: An award-Winning clinical program grounded in food, nature, prayer, community, and wellness

By Indian Country Echo; photos by Micheal Rios and Kalvin Valdillez, Tulalip News 

In 2016, the Tulalip Diabetes Care and Prevention Program was awarded the Indian Health Service Portland Area Director’s Award for Excellence. Since then, the program has seen remarkable successes in treating patients and bringing the community together. In late March 2020, we had the pleasure of speaking with Veronica “Roni” Leahy- Diabetes Program Manager for Tulalip to learn more about their secrets to success. 

Roni, who is a member of the Chiricahua Apache Tribe in New Mexico has worked in healthcare since the 1980s, explained to us that it was her father, who inspired her to work for tribal people. Since beginning at Tulalip, Roni has humbly viewed her role as someone who helps create spaces where community members can connect and feel that they are listened to and cared for by staff. She also sees it as her role to create a culture of care that is responsive to patients’ needs.

When Roni started in her position 12 years ago, the diabetes program was much smaller, consisting of only three full-time staff members. Shortly after, the Clinic’s leadership made sweeping changes that helped the program grow. Their first effort was to actively seek out and hire a dedicated Registered Nurse and Certified Diabetes Educator. Then, leadership put Tulalip’s Clinical pharmacists at the center of diabetes medication management by designating them as case managers. Additionally, through the diabetes team’s urging, the program and tribe began covering the costs for needed supplies and services for patients with diabetes, including medications, eye-exams, orthotics, physical therapy, chiropractic care, alternative medicine, dental care, and lab work not covered by insurance. Finally, the program began to expand outside of the clinic walls. With Special Diabetes Program for Indians (SDPI) funding, they created a wellness garden and trail and began to offer classes on herbal medicines, gardening, cooking, nutrition education, and wellness. Community members and their families began socializing, learning from one another and staff, and growing their toolbox of skills to take care of their health and the health of their loved ones.

Roni was delighted to see that when staff and community members interacted during diabetes program events real relationships and trust began to form. Roni believes that these relationships, as well as the program’s focus on engaging the whole community, have helped the program succeed. 

Today, the Tulalip Diabetes Care and Prevention Program meets and, at times, exceeds the SDPI and IHS standards of care. It offers community member’s 1-on-1 support from diabetes case managers and the support of a coordinated care team of providers including – pharmacists, primary care doctors and advanced registered nurse practitioners, herbalist, acupuncturists, nurse educators, behavioral health specialists, optometrists, and podiatrists. It even has an Elder Advocate- a tribal member who is respected and valued as a spiritual person, who does home and hospital visits, oversees all program activities, and imbues program events with daily prayer and spiritual wellness.  This person is Dale Jones, and he often will be heard saying “Every good thing starts with prayer and ends with prayer.” 

The program has seen remarkable success – a majority of patients with diabetes have an A1C of less than 8.0 as well as blood pressure readings of <140/<90, and almost all patients have received diabetes education. Roni credits the program’s successes to the vision of a committee of dedicated community elders who provide guidance. Through incorporating the wisdom of elders, staff work to implement consistent programming and regularly scheduled events, offer activities tailored for different age groups, and include as many community members as possible in growing the program. Finally, elders have encouraged Roni to develop a virtual walking journey that community members will take to the intended landing site of this year’s Canoe Journey. After receiving permission to make the journey to Snuneymuxw in British Columbia from the Snuneymuxw Chief and Council- Tulalip community members will join each other in counting their steps to “walk” the 340 miles. 

Given the Tulalip Diabetes Care and Prevention Program’s commitment to building a culture of wellness, it is clear that their efforts will continue to take the Tulalip people far- one step at a time.  

To Learn More about the Tulalip Diabetes Program please contact Veronica “Roni” Leahy at 360-716-5642 or at vleahy@tulaliptribes-nsn.gov