Long Term Care Needs of Alaska Native Elders “Elders need to be near the river where they were raised.” —Rose Jerue, 1989 August 2005 Long Term Care Needs of Alaska Native Elders Prepared by: Kay Branch Alaska Native Tribal Health Consortium Division of Community Health Services 4000 Ambassador Drive Anchorage, Alaska 99508 Funded by: US Department of Health and Human Services, Indian Health Service Research and Evaluation Grant With support from the National Resource Center for American Indian, Alaska Native and Native Hawaiian Elders August 2005 Contact: [email protected] (907) 729-4498 Table of Contents Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Chapter 1 1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.2 Alaska Native Elder Health Advisory Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.3 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.4 Population Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.5 IHS and Long Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.6 University of Alaska Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.7 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Chapter 2 2.1 The LTC Service Delivery System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2.2 Services Available in Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.3 Funding for Long Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 2.4 Service Availability By Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 2.4.1 Barrow Service Area – Arctic Slope Native Association . . . . . . . . . . . . . . . . . . . . . . . . . . 19 2.4.2 Kotzebue Service Area – Maniilaq Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 2.4.3 Norton Sound Service Area – Norton Sound Health Corporation . . . . . . . . . . . . . . . . . 21 2.4.4 Yukon-Kuskokwim Delta Service Area – Yukon-Kuskokwim Health Corporation . . . . . 22 2.4.5 Bristol Bay Service Area – Bristol Bay Area Health Corporation . . . . . . . . . . . . . . . . . . . 22 2.4.6 Mt. Edgecumbe and Annette Island Service Areas – SouthEast Alaska Regional Health Consortium (SEARHC), Metlakatla Indian Community, Hoonah Indian Association, Yakutat Tlingit Tribe, Ketchikan Indian Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2.4.7 Interior Service Area – Tanana Chiefs Conference (TCC), Council of Athabascan Tribal Governments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 2.5 Anchorage Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 2.5.1 Municipality of Anchorage – Southcentral Foundation (SCF), Native Village of Eklutna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 2.5.2 Anchorage Service Unit – Matanuska-Susitna Valley – Southcentral Foundation, Knik Tribe and Chickaloon Native Village . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Rural Anchorage Service Unit 2.5.3 Aleutian/Pribilof Islands Association & Eastern Aleutian Tribes, Inc. . . . . . . . . . . . . . . . 26 2.5.4 Kodiak Area Native Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2.5.5 Kenai Peninsula – Chugachmiut, Kenaitze Indian Tribe, Ninilchik Traditional Council, Seldovia Village Tribe, Native Village of Tyonek . . . . . . . . . . . . . . . . . . . . . 27 2.5.6 Valdez-Cordova-Glennallen – Chugachmiut, Copper River Native Association, Mt. Sanford Tribal Consortium, Native Village of Eyak, Valdez Native Tribe . . . . . 28 Chapter 3 3.1 Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3.2 Cancer and Alaska Native Elders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 3.3 Diabetes and Alaska Native Elders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 3.4 Pharmaceuticals and Alaska Native Elders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 3.5 Trauma and Alaska Native Elders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.5.1 Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.5.2 Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 3.5.3 Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Chapter 4 4.1 Statewide Alaska Native Elder Service Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4.2 Nursing Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4.3 Other Medicaid Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 4.4 Assisted Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 4.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Chapter 5 5.1 Facility and Service Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 5.2 Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 5.2.1 Tanana Chiefs Conference, Home Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 5.2.2 Yukon-Kuskokwim Health Corporation, Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 5.3 Other Services on the LTC Continuum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 5.3.1 Southcentral Foundation Elder Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 5.3.2 Bristol Bay Area Health Corporation, Helping Hands Program . . . . . . . . . . . . . . . . . . . . 55 5.3.3 Marrulut Eniit Assisted Living (MEAL), Dillingham . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 5.3.4 Norton Sound Health Corporation, Quyanna Care Center . . . . . . . . . . . . . . . . . . . . . . . 57 5.4 Lower 48 Service Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5.4.1 IHS Elder Care Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5.4.2 Zuni Elders Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5.4.3 Southern Ute Geriatric Assessment Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 5.5 Federal Models of Long Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 5.5.1 Program for All-Inclusive Care for the Elderly(PACE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 5.5.2 Green House . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 5.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Chapter 6 6.1 Determining Need for LTC Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 6.2 Estimates of Functional Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 6.3 Need for Nursing Home Beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 6.4 Regional Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 6.4.1 Barrow Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 6.4.2 Kotzebue Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 6.4.3 Norton Sound Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 6.4.4 Yukon-Kuskokwim Delta Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 6.4.5 Bristol Bay Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 6.4.6 Mt. Edgecumbe & Annette Island Service Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 6.4.7 Interior Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 6.4.8A Anchorage Service Area – Municipality of Anchorage . . . . . . . . . . . . . . . . . . . . . . . . . . 73 6.4.8B Anchorage Service Area – Matanuska-Susitna Borough . . . . . . . . . . . . . . . . . . . . . . . . 74 6.4.9 Rural Anchorage Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 6.4.9A Aleutians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 6.4.9B Kodiak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 6.4.9C Kenai Peninsula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 6.4.9D Valdez-Cordova . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Chapter 7 7.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 7.2 Themes From ANEHAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 7.3 Continuum of Long Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 7.3.1 Home Care/Personal Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 7.3.2 Assisted Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 7.3.3 Supportive Housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 7.3.4 Nursing Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 7.3.5 Other Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 7.4 Considerations in Developing LTC Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 7.4.1 Cultural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 7.4.2 Regulatory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 7.4.3 Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 7.4.4 Organizational Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 7.4.5 Workforce Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 7.5 Conclusion – Creating Good Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Chapter 8 8. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 8.1 Priority Health Needs Identified by Alaska Native Elders . . . . . . . . . . . . . . . . . . . . . . . . . 93 8.2 Statewide Service and Facility Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 8.3 Long Term Care Needs by Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 8.3.1 Barrow Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 8.3.2 Kotzebue Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 8.3.3 Norton Sound Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 8.3.4 Yukon-Kuskokwim Delta Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 8.3.5 Bristol Bay Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 8.3.6 Mt. Edgecumbe and Annette Island Service Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 8.3.7 Interior Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 8.4 Anchorage Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 8.4.1 Municipality of Anchorage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 8.4.2 Matanuska-Susitna Borough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Rural Anchorage Service Unit 8.4.3 Aleutians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 8.4.4 Kodiak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 8.4.5 Kenai Peninsula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 8.4.6 Valdez-Cordova-Glennallen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 8.5 Continued Research and Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Appendix A – Alaska Native Elder Health Advisory Committee . . . . . . . . . . . . . . . . . . . . . 109 Appendix B – PCC Comprehensive Elder Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 IHS Preventive Care Guidelines for the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Comprehensive Geriatric Assessment in Indian Country . . . . . . . . . . . . . . . . . . . . . 115 Appendix C – List of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Appendix D – List of Tables and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Long Term Care Needs of Alaska Native Elders 1 Long Term Care Needs of Alaska Native Elders Executive Summary “Elders need to be near the river where they were raised.” — Rose Jerue, 1989 These and similar words from countless Alaska Native elders and their families guide the work to establish long term care services within the Alaska Tribal Health System (ATHS). Like elders anywhere, Alaska Native elders say they would prefer to be in their own home throughout their lives. In the past elders did stay at home with their families. But in these changing times, that is not always possible and more elders are finding themselves in nursing and assisted living homes in urban areas, far from the river where they were raised. The Project The Alaska Native Tribal Health Consortium (ANTHC) received funding from the Indian Health Service to assess the health status and long term care needs of Alaska’s Native eld- ers. This project approaches the needs from a systems and service delivery perspective. The objectives are to determine what services are needed, what services are currently available and where, and how the system can develop services for elders that are culturally appropriate and close to home. Quantitative data were gathered from the U.S. Census, Alaska Department of Labor, IHS reports and RPMS data, Medicaid utilization data, the Alaska Trauma Registry, Adult Protective Services and State Troopers, ANTHC Diabetes Program, the Office of Alaska Native Health Research, and ANMC Social Work Department. Qualitative data was collected from elders during regional meetings, telephone interviews with service providers, and the author’s twelve years of experience working with elder care service development in rural Alaska. Long term care is the provision of services, including health care, personal care, social servic- es and economic assistance, delivered over a sustained period of time in a variety of settings, ranging from a person’s own home to institutional settings, to ensure quality of life and max- imum independence. Most long term care is still provided by families. Medicaid is the pri- Alaska Native Tribal Health Consortiumhh 2 Long Term Care Needs of Alaska Native Elders mary funding source for paid long term care services, through both nursing homes or home and community based waivers. The type of long term care services available to Alaska Native elders differs significantly depending on where they live, and on the capacity of local health and social service providers. This report includes a description of long term care serv- ices, estimates of current and future numbers of elders needing services, and recommenda- tions for service development in each region of the state. The ANTHC Board of Directors formed the Alaska Native Elder Health Advisory Committee (ANEHAC) to guide this project and assist with other efforts to provide services to elders. The project includes a partnership with the National Resource Center for American Indian, Alaska Native and Native Hawaiian Elders at the University of Alaska Anchorage. Alaska Native Elders According to the most recent estimates by the Alaska Department of Labor, there are 7,135 Alaska Native people over 65, and 8,040 between the ages of 55 and 64. The most rapid increase is seen in the number of elders between 70 and 74, followed by those 85 and older. Health status of Alaska Native people has improved due to increased availability of medical care and improved treatment of infectious diseases and acute illnesses, which lead to longer life expectancies. There is now a higher prevalence of chronic illnesses such as cancer and heart and lung diseases. These illnesses can lead to a higher incidence of functional disability, and a corresponding need for long term care. The average number of Alaska Native nursing home residents each year is approximately 280. An additional 327 elders and 240 adults with physical disabilities receive long term care services in another setting, either their home or an assisted living home. A total of 635 Alaska Native people received personal care services in 2003. Model Programs Rural Alaska presents some particular challenges in delivering services that may be typically available to seniors in more urban areas of the state. However, there are some excellent long term care services provided in rural areas. The personal care programs operated by the Yukon-Kuskokwim Health Corporation and Tanana Chiefs Conference provide services that allow many elders to remain at home, as well as offer employment to local residents. Marrulut Eniit assisted living in Dillingham and Quyanna Care nursing home in Nome are two examples of facility-based care that incorporate the cultural needs of the residents. Although there are ongoing funding, staffing and regulatory challenges for these programs, they are good models for replication. Alaska Native Tribal Health Consortium Long Term Care Needs of Alaska Native Elders 3 Key Considerations for Planning Long Term Care Services Cultural—programs and services need to be based on local culture and tradition. Regulatory—program regulations should be flexible enough to meet the needs of a culturally diverse population. Funding—investigate all sources of funding: Medicaid, grants and tribal contributions. Organizational capacity—develop expertise in operation and funding. Workforce Development—the availability of a well trained, competent and caring workforce is crucial to the development and success of long term care services. Priority Health Needs Identified by Alaska Native Elders Personal care services: PCA services are most important because they are community based and allow elders to remain in their own homes. Comprehensive care and tracking of chronic illnesses: Comprehensive elder health care based on prevention and maintenance of chronic conditions over time. Medication issues: Regular review and monitoring of medications for elders. Elder abuse: Greater understanding of the nature and extent of elder abuse. Housing: Need for housing that supports people as they age, through modifications of pri- vate homes and the development of culturally relevant facility based care. Alzheimer’s Disease and Related Disorders: Understanding the extent of Alzheimer’s Disease and other dementias in the Alaska Native population, and information about treatment and family caregiving challenges. Unintentional injuries: Further investigation into the causes and prevention of falls. Telemedicine: Expansion of telemedicine to include aspects of home health. Elder and youth activities: Sharing traditions and participating in intergenerational activities to support youth and community. Palliative care: Appropriate care in all communities so elders can return when approaching death. Traditional healing: Ensure the integration of traditional healing methods in long term care services. Urban/rural differences: Understand why elders are moving to town and the implications this relocation has on service availability in urban and rural areas. Recommendations: Statewide Service and Facility Needs 1. Work to expand and improve personal care and other home and community-based services statewide. Personal care services are in jeopardy in our tribal communities. The removal of state grants and lack of adequate Medicaid reimbursement; the lack of funding for people not eligible for Medicaid; and inadequate wages for assistants leading to high turnover and shortage of providers in many communities, all contribute to the unavailability of personal care services in many areas of the state. Alaska Native Tribal Health Consortiumhh 4 Long Term Care Needs of Alaska Native Elders • Commitment from the tribal leadership to developing and enhancing personal care and other home and community-based services would fulfill the desire of Alaska Native elders to remain at home. 2. Develop an ongoing position within the tribal health system for elder care planning. The work of this study provides a baseline of services available and health needs for Alaska Native Elders and offers directions for future planning. This is only the beginning. Ongoing planning and technical assistance is needed for the ATHS to fully address the long term care needs of Alaska Native elders. • An elder care position within ANTHC to provide technical assistance and the maintenance of an elder care website, would ensure the continued development of programs that serve Alaska Native elders, and would assist tribal health organizations in achieving their goals for elder care. 3. Initiate geriatric assessments and preventive programs for elders. Tools for both health assessment and prevention guidelines are available, and models of elder clinics in the Zuni and Ute IHS service areas can be reviewed for replication or modification. • Adoption of the Comprehensive Elder Exam tool and Preventive Care Guidelines would enhance health care delivery to Alaska Native Elders and improve data collection on elder health status. 4. Plan for facility-based care thoughtfully and cautiously. Although elders would prefer to stay in their homes, sometimes this is not possible and their care needs exceed what their family and other supports can provide and they require nursing or assisted living care. Whether to build a regional nursing home, local assisted living home or some other type of supportive housing requires ample discussion and planning. • Participate in thoughtful planning for housing and facility-based care. Include both health services and housing agencies in discussions. Recommendations: Long Term Care Needs by Region The recommendations for each region focus primarily on the development or expansion of home and community based services, since elders would prefer to remain in their own homes. Home and community based services are also the most cost effective and will pro- vide employment opportunities to local residents. Long range planning should include the impact of the rising numbers of elders in the region, which will correspond to an increase in those needing services. A continued monitoring of population growth and the functional and long term care needs of elders at the regional level, through comprehensive elder assess- ments, will be needed to ensure the accuracy of the future planning for services and facility- based care. The most critical regional needs are: Alaska Native Tribal Health Consortium