A study funded by AOA examined issues affecting access to home- and community-based long-term-care services among AI/ANS. Study results indicated that home healthcare was one of the most frequently needed services among AI/ANS. Further, 88% of the services sometimes, rarely, or never met the need, and 36% of services were rarely to never available (Jervis, Jackson & Manson, 2002). Only twelve tribally operated nursing homes exist in the U.S., and these rely predominantly on funding from Medicaid and tribal subsidies. Many tribes would like to have nursing homes but are blocked by state certificate-of-need requirements, Medicaid licensing requirements, and lack of commercial financing. The lack of alternate medical resources, whether private insurance or public programs, may limit for AI/ANS access to specialty medical care and long-term care not included as part of IHS benefits. This situation makes older AI/ANS particularly likely to experience disruption in continuity of care. Tribes have started to express a growing interest in providing options for home -- and community-based long-term care to keep ciders in their homes as long is possible. Some important services funded through Title 6 of the Older Americans Act include congregate and home-delivered meals, information and referral, home assistance services, and the relatively new Family Caregiver Support program (Goins & Spencer, 2005).

2.

The goals and objective of the change effort

There are three main goals for this policy initiative as follows:

1. The main goal is to increase accessibility for individuals who will need these services. This will help reduce institutionalization of this group and enable them to remain in their own home.

2. Create an environment where individuals who receive services will have their rights protected and not have services denied unjustifiably.

3. Quality of these services should be maintained or increased when possible.

In support of the three overarching goals above stated, the policy initiative will also be guided by the following objectives:

1. Educate the "community" to increase participation in this program. Most eligible people don't even know that programs like these exist.

2. Work with area hospitals to ensure that individuals being discharged are recommended for waiver services which will enable them to return to their own homes or communities.

3. State of Alaska will ensure that enhance services are available to qualified individuals in the most effective manner.

4. Ensure that the state has an efficient system for those who don't qualify can appeal their cases.

5. Address the shortage of staff at the state level to ensure that people needing HCBWS are located and assessed quickly.

3.

Overall policy strategy.

The unique political relationship between the federal government and AI/AN tribes adds another layer that must be considered in determining how to best serve this population (Goins & Spencer, 2005). Therefore, the overall policy strategy that will be used to achieve the above-stated goals and objectives are as follows:

1. Since there could be a waiting period for recipients to get screened for HCBWS, early application should be encouraged.

2. Grants should be readily available as a stopgap measure for those on the waiting lists.

3. As noted above, Alaskan communities are far and wide. Agencies located in remote areas should also meet the same certification requirements as those in big cities. With no one to take care of their elderly parents, the cost to society in hospital care begins to strain the system.

Therefore, one viable approach will be to have HCBWS services in place to help reduce costs in the long run as described further below.

4.

Alternative proposals for the change effort, and the criteria used to select an alternative.

Usually there will be many criteria to follow when selecting a proposal. This will depend greatly on the "complexity" of the proposal. In the case of the HCBWS proposal, I will use the value-based criteria. This is an important criteria according the class text, "they provide a normative basis for comparing options," in this case the options will be the fairness of leaving the elderly and disabled to be institutionalized or having them back in their homes where they may be more comfortable in among their neighbors while cost of care is reduced at the same time. Therefore, the policy issue addressed in this project concerns the role of home and community-based waiver services (HCBWS) and the role played by in-home support services in the lives of frail elderly individuals in Alaska.

Formulation

1.

Rationale for the proposal. Identify additional data to be compiled to back up proposal.

At present, a broad array of evidence-based practices exist to care for the elderly in their communities,...

For example, according to Padgett (1999), "Our recognition and understanding of health and mental health problems of older Indians have been slow to mature in spite of evidence of extensive need. Programs to identify and intervene among the elderly in the general population have been found to be effective. Yet, few of these have found their way to Indian and Native communities" (p. 140).
2.

The arena for policy change.

The proposed budget for the home and community-based waiver services (HCBWS) program will consist of funding requests that will sustain the program over the next two years. We have included the salary request for various staff members who will be involved with the program in the final narrative provide the explanation for the total cost of the program. The initiative would use the state's fiscal year July 1 through June 30 as its budget year. Some funding will come from the federal government because this program is a partnership between the state and federal government.

This program will be seeking funding based on what it would take to administer education provide in-home support; providing training to direct caregivers intercessors who will qualify consumers of this program over the year. It is anticipated that 1000 applicants will enroll in the first year with roughly 10% not deemed qualified to enroll for the program. It is anticipated that of the qualified enrollees 5% might not make it through the year because of the severely of their illness. The narrative for funding and expenses is located at the end of this budget report.

3.

An analysis of political feasibility of the policy/program including your approach to garnering support from decision-makers (both for and against) who will be involved in the change effort.

With the current healthcare environment undergoing fast changes in policies and laws by the state and federal governments, it is very easy for HCBWS and in-home supports issues for the elderly to fall by the wayside. Successful advocacy on this will require taking this issue to the legislature and insisting that legislative power and political clout to determine which strategies will work most. Some of the strategies will include initiating policy proposals, identifying and understanding the relevant legislative committee chairpersons, as well as developing a comprehensive understanding of these committees and also how to communicate and negotiate with them. Stakeholders will work to develop solutions by providing information and tools to ensure that elderly individuals who need HCBWS as are not overlooked.

4.

An analysis of economic feasibility, including the projected costs and the availability of current and future funding.

The director of HCBWS ensures that the program is established and remains successful. The director is the head of SDS and is in charge of all seniors and disabilities services and reports directly to the commission of the HHS who reports to the governor. The director can also answer to the legislature, works with all other community-based organizations.

Program managers will ensure that the programs are implemented according to state regulations and standards. They will ensure individualized program success through education, adult protection, quality assurance, etc. The program also ensures that assessments are carried out on applicants to determine their eligibility for the program. Administrative assistants and office assistants will ensure that all office supplies, travel request, administrative support are maintained. The total cost to implement my proposal in 2011 is projected to be $6,910,000 and for 2012, the figure will be $9,025,000.

Implementation

1.

A projection of the effectiveness of the policy.

It is anticipated that by 2012 the program would have been well-known in the community hence the increase.

2.

A discussion of interactions among policies/programs or possible unintended outcomes.

There are some potential cross-cultural constraints to the delivery of the healthcare services envisioned in this policy initiative that may adversely affect the effectiveness of the program. Such cross-cultural differences are well documented in other settings, but even here, there remains a paucity of timely and relevant research concerning the needs of frail elderly AI/ANS today. In this regard, Goins and Spencer emphasize that, "The professional move toward acknowledging and effectively addressing the role of culture in provision of appropriate care or services is referred to as cultural sensitivity or cultural competence. Challenges associated with measuring and assessing cultural competence have been well documented. Still, the role of culture in the public health of AI/ANS necessitates an effort to better understand the effect of cultural differences on service provision"…