Working with Tribal Communities: Title III and Title VI Coordination · 2020. 6. 7. · those...
Transcript of Working with Tribal Communities: Title III and Title VI Coordination · 2020. 6. 7. · those...
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Working with Tribal Communities:Title III and Title VI Coordination
Shelly Zylstra
August 2017
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Overview
• What the Law Says
• A History Lesson
• Just the Facts
• OR AAA Best Practices
• Successful Models
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It’s the Law…• Sec 306(a)(11)(B) – Each Area Agency Plan shall provide
information concerning services to older Indians andassure the Area Agency will coordinate services with those provided under Title VI
• Sec 307(a)(21)(A) – The State Plan shall assure that the State Agency will coordinate programs under Title III with programs under Title VI
• This is over and above the targeting requirements in section 306; not just one of the targeted races
• How do we know if you are successful?
– Service Outcomes (% served)
– The Moccasin Telegraph
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But It’s Tough… And worth it!
• Is it safe?
• Sovereignty
• Eligibility
• Understanding
• Indian Time
• No Extra Funds
• Misunderstandings
• Culturally appropriate?
• Provides expanded program services to meet the needs of Tribal Elders
• Improves quality of life for Tribal Elders
• Increases your knowledge about Title VI
• Reduces unnecessary duplication of services
• Develops partnerships to address unmet needs
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Oregon Statistics• About 1.8% of
Oregon’s older adults (60+) are Native Elders
• 2014 state data indicate that Native Elders served are:– Congregate—1.4%
– Home-delivered—1.1%
– All “registered” clients—1.2%
• 646 total—2005;
564 total—2014
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Socio-demographic Status: Indian Elders(Social Security.gov, 2012; ASA, 2/20/2015))
• 22% of AI/AN live on reservations
• Target Populations for OAA
Low income
Ethnic minority
Frail; Poor Health
Rural; Isolated
ADRD
Characteristic AI/ANAll Races
Population
Home Ownership 48% 64%
Living <100% Poverty 20.1% 11.8%
Life Expectancy (born today)
73 78
Fair or Poor Health 46% 34%
Disability 23.8% 15.3%
Median Income $7,996 $13,189
Grandparents Raising Grandkids
4.26% 1%
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Health Status: Indian Elders(IHS, 2015)
• Although medical care is a treaty right like education, food, and religious practice, the funding for the Indian Health Service sits on the discretionary side of the budget
Cause of Death AI/ANAll Races
PopulationRatio
Heart 182.4 192.1 0.9
Cancer 170.8 176.4 1.0
Injury 94.5 39.2 2.4
Diabetes 61.0 22.0 2.8
Liver Disease 43.1 9.2 4.7
Flu/Pneumonia 24.1 17.8 1.4
Youth Suicide 22.5 15.8 1.4
Life expectancy is low 70’s in Region X; 68 years in South Dakota
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Not News! Started with Columbus!
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History Lesson
• “Columbian Exchange”• 1778—Cont. Congress
– All lands west of Appalachians were NA
• 1830– Indian Removal Act– All NA must move west of
Mississippi
• 1880—First Boarding School
• Dawes (1887) and Curtis (1898) Acts– Assimilation through land
allotment; took back OK
• 1924—Indians became citizens– Move about freely
– All get vote in 1965
• 1934—Reorganization Act – Restored gov’t; culture;
religion
• 1952—Relocation Act
• 1953—Termination Act; – All Federal programs
cancelled and not fully reinstated until 1975
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For An Oregon Perspective
• http://www.opb.org/artsandlife/series/brokentreaties/
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Boarding Schools
• Compulsory education for tribal children began in 1880-1883
• Highest enrollment in the 1970s; ICWA in 1978 first gave parent the right to say no…
• Children sent to distant schools at age 5 and returned at age 18
• No language or culture• Abuse• Effectively eliminated the
traditional ways that appropriate behavior was passed down
This is not ancient history. The elders we serve today attended similar schools.
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Some Definitions• Coordination – open
discussion, active listening, sharing data and information
• Collaboration –Memorandum of Understanding; having a voice in how/when/ where services are provided; joint funding commitment
• Cooperation – implement the coordinated service project; provide follow-up; agree on continuation plan
• Partnership – A written agreement entered into by two or more persons in which each agrees to furnish something
• Relationship – What works in Indian Country.
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Reviewing Area Plans
• Took time to review all of them
• Some very good, thoughtful, complete
• Some very light in substance
• A few had some misunderstandings..
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Think about These…
• Native American/ American Indian targeting is not just another minority
• If the largest minority population in your County is American Indian you need to have a plan to serve them, even if there are no reservations present
• Petitioning a tribal casino for funds is not tribal outreach
• Asking a tribe for money to provide meals for tribal members is contrary to the targeting language in the OAA; targeting means focusing the money you have on a specific population
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Apparent Misunderstandings
• Tribes define their own age of elderhood, not all at 55+; they are funded on elders who are 60+
• Annual contacts do not a good marriage make…
• Tribes have many services for their elders, however they are generally underfunded and not available regularly– Priority One for IHS
• The average Title VI Part A in Oregon is around $114,000 to provide I&A, Transportation, Nutrition and administer the program
• Title VI Programs are not able to limit their programs to enrolled members
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Thoughtful, Innovative, Effective
• AAAs with no reservations focused on agencies which served tribal people for outreach
– NAYA, NARA, Portland Area Indian Health Board
– FQHCs
– Veterans Programs
• Linguistics is more than language!
– Being mindful of communication styles and the importance of face-to-face, ONGOING meetings
• Care Coordination staff
– We know that works!
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Thoughtful, Innovative, Effective
• Multi-disciplinary teams
• Elderabuse agreements and team efforts
• Resource Guides with tribal resources with input from tribal resource experts
• Tribal-specific dementia training
• “Cross AAA” coordination on behalf of individuals needing services
• Identification of tribal strengths and working with them
• Collaboration on events with tribal communities
• Outreach to Leadership
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Thoughtful, Innovative, Effective
• Using proven, Tribal-specific models
– Wisdom Warriors
– IHS partnerships
– Native Caring Conference
• Including representation on Advisory Councils
• Recognizing that state boundaries sometimes prevent “outlying” tribal members from their own tribal services
• Attending Native events– First Salmon ceremonies
– Namings, Funerals, Elders Dinners
– Canoe Journey
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Suggestions for Success
• You NEED to get to know the staff PERSONALLY—as with any part of the network, it will work better if folks have a personal understanding of the hopes and dreams of the program, not just the statistics
• Stop by to visit. Go to lunch. Ask about simple things which might help
– Hand-me-down kitchen equipment
– Ride to a meeting
– Proofread a grant
– Coordinate cooks training with a provider
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Suggestions for Success
• If you don’t get a response, try another avenue. If the second avenue didn’t work, go face to face.
– Keep in mind the cultural barriers caused by generational trauma
– Keep in mind the barriers which may exist due to “rural and isolated”
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Suggestions for Success
• Do not assume that if it works at one tribe, it will work at another– If you know one tribe,
you know one tribe
– Common threads include healthy skepticism due to false or unfulfilled promises and an enormous respect for Elders
• The Only Important Stuff is what is happening this minute. Do not be offended if another event preempts a meeting.– Understand that a death
in the community will usually cancel EVERYTHING so the bereaved family is supported
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Suggestions for Success
• There is nothing ruder than interrupting. Pauses in conversation are for thinking, not filling.
• Humor is important. Laugh together.
• Food is important. Don’t have a meeting without it.
– You will likely have to bring from home or pay privately
• If you don’t know, ask. Study US Indian History, local tribal cultural traditions, work to understand Indian Health Service and how it is operated in the local tribal communities.
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Suggestions for Success• In 2016, CMS changed the rules
about 100% FMAP for tribal services
• Expanded to include “other than doctor” services– Transportation (NEMT)
– LTSS
• In lean times, states can used these resources and tribes may need someone to interpret for them and help them walk through the process
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Tribal Outreach
• In 1990 our AAA decided to develop an outreach programs for tribes.
• “Circuit Rides” to all six reservations – Eats lunch– Visits– Helps and shares
information
• Funded with Administrative Claiming and Title IIIB, D, and E
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Purpose of Tribal Outreach
• Share ideas between tribes
• Collect information for planning purposes
• Talk about services available and helped elders sign up
• Give feedback to non-Indian contractors that serve elders
• Develop and share evidence-based programs
• Communicate information about clinic programs, school and preschool programs, and elders programs that need support in order to make connections in town
• Monthly TVI Training
• Establish relationships with local communities
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Results of Tribal Outreach
• Relationships with local tribal communities
– Travel together
– Attend cultural and business events together
– Billing agreements for Medicaid Services
– Collaboration on grants• Mutual Letters of Support
• Incorporation of efforts
• Thousands of Dollars of tribal-specific grants, – Chronic Disease Self
Management
– Elder Abuse prevention
– Nursing Home diversion
– Oral Health
• Thousands of Indian Elders served successfully
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A Menu of Possibilities
• Medicaid Providers• Benefits Counselors• Elder’s Dinners• Caregiver Recognition• Caregiver Training• Kinship Care Conferences• Diabetes Education• Title VI Director Training• Adult Foster Home
business plan• Planning and service
development
• Assistance with Medicare and Medicaid Access
• Medication Management Training
• Foot Care• Alzheimer’s Grant• Homecare Agency
development• Transportation Services• Home Care Worker
Recruitment• Health Care Career Path
mentoring• Elder Abuse Councils
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Oregon Tribal Needs?
• Caregiver Services—help to figure out how to set up a program
• Training about Medicare/Medicaid
• Access to Waiver Services for Elders
• Assistance to contract for Medicaid reimbursement for services
• Your ideas????
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Contracting
• Meet face to face ALWAYS
• Don’t try without having a champion on the reservation
• Review your process for barriers– Educational requirements
• Remain Flexible and Realistic
• May need to assist with process and review the final product with them.
• Remember that tribal programs serve a “higher power” because they are sovereign nations– It is likely their requirements
for other contracts are much more stringent than the ones you want to impose
– Don’t make them jump through your hoops when the ones they have already jumped through are tougher
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When Times are Tough…
• And they are….
• Think about 100% FMAP and what that could mean to your state budget
• Multicultural focus can tremendously strengthen your grantsmanship
• Bring new programs to your area and support existing staff
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For more information or to discuss:Shelly Zylstra Aging Services Program Specialist U.S. Dept of Health and Human Services U.S. Administration for Community Living - Region X 701 Fifth Ave, M/S RX -33 Suite 1600 Seattle, Wa 98104 [email protected] (206) 615-2299 (Office) (206) 615-2305 (FAX)