Addressing Critical Concerns of Healthcare Systems Serving American Indians/Alaska Natives

Long-term Care

Presenters: David Baldridge (Cherokee), Executive Director, National Indian Council on Aging, Albuquerque, NM. Regis Pecos, Ph.D. Candidate (Cochiti Pueblo), Executive Director, New Mexico Office of Indian Affairs, Santa Fe, NM. Margaret Dosedo (Pueblo of Zuni), Director, Elderly Services, Pueblo of Zuni Senior Citizens Center, Zuni, NM.

Scope of AI/AN Elder Needs

There are estimated to be more than 236,000 American Indians/Alaska Natives (AI/AN) elders. Only one-half live on reservation. Almost 27 percent of those ages 65 to 74, one-third of those over age 75, live below the Federal poverty level (FPL), and almost 60 percent live below 200 percent FPL.

In 1995, approximately 157,000 Indians were eligible but not enrolled in Medicaid. Only 65 percent of Indian elders who qualify for Medicaid receive it. Benefits counseling is not often available, and most elders are not conversant on basic benefits. The National Indian Council on Aging is working in partnership with the Health Care Financing Administration (which oversees Medicare and Medicaid) and other Federal agencies on education/outreach initiatives to establish alternative communication strategies, develop presentation materials, train educators at pilot sites, and eventually establish a national program.

Because only about one-quarter of elders are high school graduates, education and outreach efforts need to take their communication preferences into account and should include:

• Simple words.
• Culturally appropriate education methods and content.
• Educators whom people know and trust.
• Elders who serve as role models.
• High visibility.

Very few long-term care services exist among tribes. Approximately 90 percent of this care is provided by family members. Only 12 nursing facilities are operated by tribes. IHS facilities do not provide long-term care services.

David Baldridge reported that Indian values will affect the design and implementation of any kind of long-term care services. These values include:

• Recognition of the elders' importance in community life, particularly as role models and cultural guardians.
• Strong family support for home care.
• Importance of the caregiver role.
• Community commitment to elder care.
• Holistic understanding of health to include physical, mental, and social well-being.

New Mexico's Programs for AI/AN Elders

Services for Indian elders are a high priority for the State of New Mexico. Twenty-one senior programs receive a total of approximately $1.5 million annually from the State. There are also two Indian Area Agencies on Aging (AAAs).

The State's Office of Indian Affairs handles long-term care as one of many issues in its role as liaison between the State and 22 federally recognized tribes. It was established by Executive Order. AI/AN capacities within each State agency were also mandated by this order. Regis Pecos noted that the State found it necessary to institutionalize this "forced relationship" in order to make it permanent.

Mr. Pecos agreed with the assertion that Indian values affect how long-term care is implemented. He commented that the interventions tied to Federal dollars are often based on what works in urban areas, but these may not work on rural areas or reservations. For example, a Meals on Wheels program implemented in a pueblo did not work because it displaced the means by which community members cared for elders.

In successful programs, local leaders are involved in designing and developing how services are delivered. The New Mexico Indian Health Advisory Council was established so tribal leaders could convene periodically to work on health-related issues. This year, the council developed policy recommendations on long-term care. First, three goals and objectives were established:

• Goal 1: Develop services that keep elders at home by providing services in the home or community that support family and other caregivers.

  Objective 1: Develop a process that involves Title VI programs, working with community representatives and other tribal service providers to develop a variety of services that offer options to the elders and their families.

• Goal 2: Work with the IHS to make long-term care services a priority and implement long-term care programs within their healthcare structure.

  Objective 2: Develop a comprehensive policy to guide a coordinated approach in the use of existing resources on the delivery of services.

• Goal 3: Increase options and access to Medicare and Medicaid long-term care services and reimbursement.

  Objective 3: Develop a comprehensive policy to guide a coordinated approach in the use of existing resources in the delivery of services.

Pueblo of Zuni Senior Citizens Center

The Pueblo of Zuni Senior Citizens Center (in Zuni, New Mexico) started 20 years ago with a dilapidated building, few clients, limited staff, and almost no funding. Today the Center is in a $1.5 million building and has developed piece by piece with the goal of providing all-inclusive care.

Services offered include:

• TANF (Temporary Assistance to Needy Families) beneficiaries are employed in providing non-medical care, both within homes and at the center.
• The adult day care program is the largest in New Mexico for Indians, caring for 20 elders and holding a waiting list. The center is in the final stages of having its facility certified so it can collect third-party reimbursement. It also offers a congregate meals program on site.

Margaret Dosedo described her strategies for developing the center:

• Persistence in finding funds from State, tribal, Federal, and private sources, for example, a $50,000 1999 SHARE grant allowed an expansion of the home care staff. Working with State legislators has resulted in "bricks and mortar" money.
• Risk-taking, such as accruing and not spending fiscal year dollars.
• Understanding tribal entities and the unique issues to be addressed, such as sovereignty, use of funds, and getting approval by tribal leadership for actions.
• Commitment, as Ms. Dosedo noted that she often uses her own time and resources to get things done.

Ms. Dosedo's recommendations for tribes seeking to develop comprehensive elder centers include:

• It's OK to start small and build.
• Understand grantsmanship, partnering, and budgets.
• Find a successful program and follow its "map."
• Identify mentors/consultants to guide you in the process.
• Work with others involved in serving elders. For example, Ms. Dosedo convened service providers including the local Indian Area Agency on Aging, doctors, nurses, and others to determine how to best use available resources. This led to the development of a transportation agreement among providers.
• It isn't easy, but it's doable.

References

Home and community-based long-term care in American Indian and Alaska Native communities. Washington (DC): Administration on Aging, U.S. Department of Human Services; 1996 Dec.

Baldridge D. Caring for our elders. Albuquerque (NM): The Albuquerque Tribune 2000.

John R, Baldridge D. The NICOA report: health and long-term care for Indian elders. Washington (DC): National Indian Policy Center; 1996.

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