Home Care Assistance Programs in Indian Country: What Could it Look Like in Your Community?

1. Home Care Assistance Programs in Indian Country: What Could it Look Like in Your Community? Laurai Atcitty, Inter Tribal Council of Arizona, Inc., Area Agency on Aging, Region 8 Jackie Edwards, Inter Tribal Council of Arizona, Inc., Area Agency on Aging, Region 8 Mary Weston, Gila River Indian Community Crystal Nish-Wright, Gila River Indian Community

2. Care Needs in Indian Country: What Do We Know? • According to the American Society on Aging: • 26% of American Indian/Alaska Natives (AI/AN) and 31% of Native Hawaiians (NH) live in poverty, while only 11% of non-Hispanic whites live in poverty • Access to care is limited due to a number of factors such as fear of discrimination, historic mistrust of government and research agencies, and physical proximity of services • Compared to the general population, American Indian/Alaska Native/and Native Hawaiians are: • 368% more likely to be diagnosed with Chronic Liver Disease and Cirrhosis • 177% more likely to have a diagnosis of diabetes mellitus • 138% more likely to experience unintentional injuries

3. Long Term Care Facilities for Native Elders According to the Department of Health and Human Services, and Centers for Medicare and Medicaid Services: • Most Elders prefer to stay in their homes and “age in place” • Many Native elders do not seek long term services and supports until later stages in their disease due to: • Lack of cultural competency in facilities • Geographic isolation • Lack of access to healthcare and insurance This creates a validated need to support Home and Community-Based Services in your community!

4. The Basics of Home and Community Based Services: • Home and Community Based Services: Due to injury and illness in advancing years, the need is increased to require assistance with both Activities of Daily Living (ADLs), and Instrumental Activities of Daily Living (IADLs) • Examples of Home and Community Based Services: home health care, durable medical equipment, case management, health promotion programs, caregiver program, home care assistance, congregate and home delivered meal service, to name a few. Wide range!

5. Activities of Daily Living • Activities of Daily Living (ADLs) Necessary for basic functioning. These include: • Eating (meal prep, diets, feeding, monitoring) • Personal hygiene (oral, hair, nail & foot, baths) • Toileting (transfer, pans, catheter, incontinence) • Infection Control (hand washing, cleaning methods) • Dressing and Undressing • Skin care and sores prevention • Ambulation

6. Instrumental Activities of Daily Living • Instrumental Activities of Daily Living (IADLs) Not necessary for basic functioning, but they help an individual live as independently as possible. These include: • Cleaning and home maintenance • Money Management • Socialization/Companionship • Shopping • Using the telephone • Medication Management

7. Home Care Assistance • Examples of three levels of Home Care Assistance: • Level 1: basic housekeeping, i.e., cooking, shopping, light and heavy chores, laundry, etc. (IADLs) • Level 2: Some personal care, i.e., assistance with bathing, dressing, grooming, walking, etc. and housekeeping (some ADLs, mostly IADLs) • Level 3: Limited housekeeping and extensive personal care, i.e., bathing and/or showering, grooming, lifting, transferring, and toileting (mostly ADLs, some IADLs)

8. Non-Paid Family Caregiver • Family Caregiver definition per the Older Americans’ Act: • adult family member, or other individualwho is an informal provider of in-home and community care to an older individual or to an individual with Alzheimer’s disease or a related disorder with neurological and organic brain dysfunction • Family Caregiver Support Program: Provides a range of supports that assist non-paid family caregivers to assist loved ones in order for them to remain independent in their homes for as long as possible. Services provided: • Information and assistance; counselor or support groups; caregiver training and respite; and supplemental services

9. Caregiver Training • Training to assist caregivers in performing caregiving activities • 1 to 1, classroom training, conferences • Evidence-based programs • Community Health Professionals (CHRs, CHNs, Social Services, Legal Services, School Counselors, Diabetes Educators) • Universities & Cooperative Extension Programs • Home Health Care & Hospice

10. Caregiver Training Topics • Health, nutrition, personal care, medication management, money management, use of assistive technology • Home Safety • Alzheimer’s Disease & Dementia • End of Life Issues • Stress Management, Problem Solving • Family Care Planning • Caregiver library with DVDs, books, tapes, etc. • Webinars

11. Caregiver Respite • Caregivers to receive services from a Direct Care Worker to provide care on a temporary, basis so the primary caregiver gets a break • Senior Center • Adult Day Care

12. Case Management • A collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services necessary to meet an elder’s health and human service needs

13. Non-medical case management Non-medical case management: encompasses an array of services, from personal care to home-delivered meals and respite for the caregiver. • Examples: • Non-medical home and community-based services (NMHCBS) provided through Area Agencies on Aging in collaboration with the Arizona Department of Economic Security-Department of Aging and Adult Services (DES-DAAS) and Tribal Senior Service Divisions • HCBS provided through the Arizona Long Term Care System (ALTCS) for ALTCS-eligible individuals

14. Title VI Assessments: Used to Drive Program Direction • Title VI assessment required every three years, which assists with: • Title VI Grant application and other grant applications • Community’s goals for contracts • Senior Center community program and staff planning • Education and outreach • Educating Tribal Council on community needs • Flexibility to utilize funding to fit your community’s needs • Opportunity to create policy for your community

15. Who Completes the Assessment? • Tribal staff who work with the elder and family • Care plan to be established with elder and family, if necessary

16. Eligibility for Home Care Assistance (Title VI Requirements) Suggested documentation template to use to determine eligibility (located in Title VI Manual)

17. Eligibility for Home Care Assistance (Title III Requirements) Respite services Personal care, Housekeeping/ Homemaker Requirements

18. Assessment of Daily Living Activities: Part of the Short Form Intake Document (SFID) Activities of Daily Living criteria Instrumental Activities of Daily Living criteria

19. Service Plan Example: Salt River Pima Maricopa Indian Community, Senior Services Department (AZ) First page: discuss schedule and determination of level for client

20. Home Care Assistance Plan Second page: Begin service plan assessment

21. Home Care Assistance Plan page 2 Covers ADL and IADL needs such as toileting, etc.

22. Home Care Assistance Plan page 3 Can also cover essentials to help keep a senior comfortable, such as positioning and basic skin care

23. Home Care Assistance Plan page 4 Household assistance

24. Home Care Assistance Plan page 5 IADLs such as bathroom and laundry, and assistance with medications

25. Home Care Assistance Plan page 6 Other IADLs, including companionship and organizing

26. Home Care Assistance Plan page 7 Tailor your service plan to meet the needs of your community

27. Title III Assessments • It is a tool used to measure program eligibility • It justifies the need for services in your community, going beyond just Home Delivered Meals, etc. • To collect enough information to assist seniors in all aspects of their lives • It is a grant requirement for Title III funding • It is part of case management, and serves as the foundation for additional services for elders, caregivers and adults with disabilities • Can be used in conjunction with Title VI services

28. Staffing Needs • Follow all State and Federal requirements when hiring Home Care Assistance Staff: • Tribal Background checks • References • Current First Aid/CPR/AED • Direct Care Worker (DCW) certification • Good physical and emotional health (many aspects of this work may test one’s physical and emotional abilities) Create a waitlist to track the community’s needs, justify support for the service, and additional funding.

29. Sources • Braun, K.L. and LaCounte, C. (2015, February 20). The Historic and Ongoing Issue of Health Disparities Among Native Elders. Retrieved from http://www.asaging.org/blog/historic-and-ongoing-issue-health-disparities-among-native-elders. • Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2015, March 16). LTSS Research: Nursing Home Facility Inventory, Nursing Homes in Indian Country. https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-Technical-Assistance-Center/Documents/revised-CMS-OY1-NHF-Inventory-Report-Final.pdf. • Division of Aging and Adult Services Policy – Chapter 3000. (2013, October 30). SFID Service Matrix DES AZ DAAS. http://itcaonline.com/wp-content/uploads/2015/06/Service-Matrix-DES-AZ-DAAS.pdf. • Moulton, P., et al. (2005, October). Prevalence of Chronic Disease Among American Indian and Alaska Native Elders. Retrieved from http://www.asaging.org/blog/historic-and-ongoing-issue-health-disparities-among-native-elders.

30. Contact Information • Laurai Atcitty Director Inter Tribal Council of Arizona, Inc. Area Agency on Aging, Region 8 Phone: 602-258-4825 Email: Laurai.Atcitty@itcaonline.com • Jackie Edwards Family Caregiver Support Program Coordinator Inter Tribal Council of Arizona, Inc. Area Agency on Aging, Region 8 Phone: 602-258-4825 Email: Jackie.Edwards@itcaonline.com

31. Elderly Services Program Mary Weston, Elderly Services Program Coordinator Crystal Nish-Wright, Homemaker Services Program Coordinator (520) 562-5232

32. Homemaker ServicesProgram

33. Services Key Points Funding Challenges Eligibility Partnerships Process Marketing

34. Homemaker Services Program provides . . . Non-medical, custodial care for eligible adults who live alone and have medical or physical conditions that restrict them from performing daily household chores. Assistance with: Cooking Cleaning Washing Dishes Laundry Social Interaction

35. Funding • Funded by the Bureau of Indian Affairs (BIA) through Tribal Social Services - limited to only paying for salaries of Homemakers • Background checks required - state and Tribal • Tribal funding used to pay for background checks, training, supplies, and incentives

36. GRIC Community Member/Member of a Federally recognized tribe Community Eligibility Have medical conditions and restrictions that prevent them from doing daily household chores Income must not exceed the Federal Poverty Income (200%) Must be medically denied by Arizona Long Term Care System (ALTCS) Must Live Alone: Eligible adult must not have any family available or resources to assist within the applicant’s home

37. Process Home Assessment • Elderly Liaisons • Elderly Coordinators • Case Managers • APS • Public Health Nursing • Approval/Denial • Homemaker/Client Orientation • Sign Agreement • Financially Ineligible • Application • ALTCS Application • Determine Financial Eligibility • Release of Authorization Forms Referral Decision

38. Challenges • Funding limited to salaries only • Hiring • Clean Background Checks • Non-relatives working for clients • Turn over rate of Homemaker Providers • Transportation • Supplies

39. Partnerships • Adult Protective Services • Gila River Caring House Skilled Nursing Facility • Gila River Healthcare Corporation • Gila River Dialysis Center • Public Health Nursing

40. Marketing • Brochure, Gila River Newspaper • Internet, Public Service Announcements • Tribal Website, Gila River Broadcasting Corp. • Community Events, Conferences, Elder Meetings • Flyer distribution to homebound elders • HDMs (Home Delivered Meals), Elderly Housing Complexes • Outreach Presentations

41. Contact Information • Mary WestonElderly Services Program Coordinator Gila River Indian Community Phone: (520) 562-5232 Email: Mary.Weston@gric.nsn.us • Crystal Nish-WrightHomemaker Services Program CoordinatorGila River Indian CommunityPhone: (520) 562-5232 Email: Crystal.Nish-Wright@gric.nsn.us