Community-Based Waiver Services Program in Alaska

Home and Community-Based Waiver Services Program in Alaska

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According to Goins and Spencer (2005), the provision of services to specific populations, particularly those groups who face barriers to equity in healthcare, has always been an important focus of public health. The public health perspective outlines a societal approach to protecting and promoting health, which emphasizes prevention, macro-level interventions, and the reshaping of public policy. A primary difference between public health and the more biomedical model is that the government often subsidizes care providers in public health, with a focus on preventing, rather than curing, disease (Goins & Spencer, 2005).

Older American Indians and Alaska Natives (AI/ANS) life expectancy has increased dramatically since the early 1970s. This increase, from 63.5 years in 1972 to 73.2 years in 1994, is largely attributed to the efforts of the Indian Health Service (IHS) to eliminate infectious disease and meet the acute-care needs of AI/ANS (Goins & Spencer, 2005). Despite these improvements, much remains to be done to bring the healthcare standards of these peoples up to the national standard. In this regard, Padgett (1999) emphasizes that, “Problems with health and mental health that face older American Indians and Alaska Natives are widespread and likely to intensify if current trends continue. Several publications have detailed their excess morbidity and mortality and in comparison with whites and other ethnic minorities” (p. 139).

The IHS reports that The Alaska Area Indian Health Service (IHS) works in conjunction with Alaska Native Tribes and Tribal Organizations (T/TO) to provide comprehensive health services to 139,107 Alaska Natives (Eskimos, Aleuts, and Indians). Approximately 99% of the Alaska Area budget is managed by T/TOs pursuant to the Indian Self-Determination and Education Assistance Act, P.L. 93-638, as amended. The Alaska Area negotiates and administers 14 Title I contracts and one Title V compact with 25 separate tribal funding agreements. The latter has resulted in the Alaska Tribal Health Compact, which sets forth terms and conditions for tribal management of a comprehensive system of health care that covers all 228 federally recognized tribes in Alaska.

IHS-funded, tribally-managed hospitals are located in Anchorage, Barrow, Bethel, Dillingham, Kotzebue, Nome and Sitka. There are 37 tribal health centers, 166 tribal community health aide clinics and five residential substance abuse treatment centers. The Alaska Native Medical Center in Anchorage is the state-wide referral center and gatekeeper for specialty care. Other health promotion/disease prevention programs that are state-wide in scope are operated by the Alaska Native Tribal Health Consortium (ANTHC), which is managed by representatives of all Alaska tribes.

There are 37 residual positions in the Alaska Area IHS, which perform inherently federal functions that cannot be contracted to T/TOs. The Alaska Area supports USPHS Commissioned Corps officers and civil service employees to T/TOs to aide them in the provision of health services. Additionally, to address the critical shortage of medical providers in remote facilities, the Alaska Area IHS awards federal personal services contracts for itinerant and emergency providers to work in tribal facilities. During FY 2010, providers hired through Area Office PSCs numbered 44 dentists, 27 physicians, 3 nurses, 20 pharmacists, 3 optometrists and 4 nurse practitioners. Other federal agencies such as the Arctic Investigations Laboratory of the Centers for Disease Control (CDC), work closely with the Alaska Area IHS and the tribes to improve the health status of Alaska Natives. The Indian Health Service still holds title to six tribally operated hospitals and three tribally operated health centers in Alaska, and is responsible for their maintenance (Alaska Area Indian Health Service, 2011).

Although the life expectancy of AI/ANS has improved, it is still below the national average. Certain demographic characteristics make older AI/ANS particularly vulnerable to experiencing health disparities, compared to the general population. Poverty and low educational levels are common among AI/ANS; 27% of AI/ANS ages 65 to 74 live below the poverty level, compared to 10% of the general population and 8% of Caucasians, and one-third of AI/AN elders age 75 years or older live in poverty, compared to 17% for the general population and 15% for Caucasians. Some 8.9% of AI/ANS have a bachelor’s degree or higher, compared to 20.3% of the general population and 21.5% of Caucasians. Taken together, poverty and low educational levels are strongly associated with poor health and an increased likelihood of chronic and disabling conditions (Goins & Spencer, 2005).

As they have for other ethnic groups, the most notable population health problems experienced by AI/ANS have shifted from infectious diseases to chronic diseases. Two of the most prevalent chronic diseases among older adults in this group are diabetes and arthritis. AI/AN elders experience some of the highest rates of diabetes in the world. In general, diabetes is four to eight times more common among AI/ANS than among the overall U.S. population. The prevalence of arthritis is also greater among AI/ANS than among non-AI/ANS, a difference most likely genetic in origin. Furthermore, the age of disease onset may be earlier. For example, half of one reservation population with rheumatoid arthritis was diagnosed with the disease before age 35, much earlier than is commonly found among non-AI/ANS. Mounting evidence suggests that such chronic and disabling diseases among AI/ANS are increasing and represent substantial healthcare costs (Goins & Spencer, 2005).

One of the strongest determinants of use of long-term care, either institutionalized or non-institutionalized, is health and functional status. Estimates suggest that AI/AN elders experience some of the highest physical disability rates of any U.S. ethnic group. While African-Americans are more likely than Caucasians to experience the disadvantages of shorter life and longer periods of health impairment, for AI/ANS, the levels of impairment and length of inactive life are the highest among all ethnic groups, with approximately 50% to 60% of the later years spent with disabilities (Goins & Spencer, 2005). Thus it is not surprising that long-term-care provision is especially important in Indian Country, because of the socioeconomic disadvantages to which AI/ANS are subject and the growing rates of chronic disease and physical disability that they experience, as described above. While one of the core functions of public health is to ensure that all populations have access to appropriate care, a number of issues present particular problems in delivery of services-especially provision of long-term care. Distinctive factors related to culture, AI/ANS political status, and related implications for health policy appear to compound the problems of low socioeconomic status and poor health for AI/ANS (Goins & Spencer, 2005).

Federally recognized tribes have a unique political status that has influenced provision of public health services that is based on the sovereignty of federally recognized tribal governments, the treaty-making process under which the U.S. assumed certain responsibilities to tribal governments, and the resulting federal-Indian relationship. A breakdown of the native peoples of Alaska is provided in Table __ below.


Breakdown of Native Peoples of Alaska

Native People



More than half of all Alaska Natives are Eskimo. The two main Eskimo groups, Inupiat and Yupik, differ in their language and geography. The former live in the north and northwest parts of Alaska and speak Inupiaq; the latter live in southwest

Alaska and speak Yupik. Few Eskimos can still speak their traditional Inupiaq or Yupik language as well as English. Along the northern coast of Alaska, Eskimos are hunters of the bowhead and beluga whales, walrus and seal. In northwest Alaska, Eskimos live along the rivers that flow into the area of Kotzebue Sound. Here, they rely less on sea mammals and more upon land animals and river fishing. Most southern Eskimos live along the rivers flowing into the Bering Sea and along the Bering Sea Coast from Norton Sound to the Bristol Bay region.


Most Aleuts originally lived in coastal villages from Kodiak to the farthest Aleutian Island of Attu. They spoke three distinct dialects, which were remotely related to the Eskimo language. When the Russians came to the Aleutian Islands in the 1740s, Aleuts inhabited almost every island in the chain. Now, only a few islands have permanent Aleut villages. Severe and unpredictable weather conditions in the Aleutian Islands make transportation both expensive and time-consuming. The region is dependent on the fishing industry, which is variable from year to year.

Interior Indians

The Athabascans inhabit a large area of Central and Southcentral Alaska. They may have been the first wave of Natives to cross the land bridge over 15,000 years ago. Although their language is distinct, they may be linguistically related to the Navajo and Apaches of the Southwest U.S. There are eight Athabascan groups in Alaska. Characteristics of all eight groups include similar language, customs and beliefs.

Source: Indian Health Service Alaska Area Services (2011)

The Indian Health Service is a federal agency in the U.S. Department of Health and Human Services that provides free healthcare to tribally enrolled AI/ANS, more than 1.6 million individuals, principally through the operation of sixty-one health centers and thirty-six hospitals (Goins & Spencer, 2005). It should be noted, though, that the provision of these healthcare services is constrained by the vast geographic distances that are involved in Alaska. The majority of communities in Alaska are separated by vast distances and the distance from many communities to the nearest medical facility is equivalent to the distance from New York to Chicago (Indian Health Service Alaska Area Services, 2011).

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).


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.


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.


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.



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, but there remains a lack of application of these practices to the population of interest to this study. 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).


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.


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.


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.



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.


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” (2005, p. 32).


The steps which would be necessary to get the policy ratified or program adopted.

Because there are local, state and federal agencies involved in the administration of healthcare services to the targeted population, the steps that will be needed to secure the approval of the policy and its adoption statewide will involve several points of contact. At present, federally recognized tribes, including those set forth in Table 1 above, are free to elect to receive their healthcare through the IHS or to receive funds from IHS to operate their own healthcare delivery through a contracting-compacting system. If a tribe chooses to manage its own healthcare delivery system, the tribe can contract with the IHS to take over the management of specific programs, and, after a few years with a good record, the tribe is eligible for a compact. A compact is more like a treaty or block grant than a contract and provides the tribe much more management authority and flexibility to move funds between programs and to develop new programs (Goins & Spencer, 2005).

Currently, though, the IHS nor individual tribes provide the full range of medical specialty care within their clinics and hospitals, so the tribes contract with the private sector for some services. The Indian Health Care Improvement Act (P.L. 94-437) provided that the IHS could be reimbursed through the Medicare and Medicaid programs for care rendered to the AI/ANS who are eligible for services; however, enrollment of AI/ANS in Medicare and Medicaid has been relatively low compared to that of other ethnic groups. The IHS is not specifically authorized in legislation to provide comprehensive long-term-care services, and funds have never been appropriated to the IHS for long-term care. For this, AI/AN elders most often rely on services funded by the tribe, services funded by Medicaid, and services funded by the Administration on Aging (AOA), or they go without (Goins & Spencer, 2005).


Translate the policy objectives into specific tasks and activities.

The specific tasks and activities that will be used to achieve the above-stated project goals are set forth in Table __ below.


Specific Tasks and Activities to Achieve Project Goals


Associated Tasks/Activities

Educating the “community” will increase participation in this program. Most people do not even know that programs like these exist.

1. Deploy a series of television and radio public service messages concerning the availability of program services and who is eligible.

2. Direct mail notices of available services to remote geographic regions.

3. Launch Web page concerning program information.

4. Develop network of point of contacts for remote geographic regions to ensure complete coverage of educational messages.

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.

1. Print material (fliers, brochures, handouts) will be provided to area hospitals concerning the availability of waiver services and eligibility requirements.

2. Periodic follow-up contacts will be made to determine status and progress of referrals.

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

Establish liaison with State of Alaska point of contact for this purpose.

Ensure that the state has an efficient system for those who do not qualify can appeal their cases.

1. Review existing protocols to identify constraints to administration and equitable provision of services.

2. Identify opportunities for improvement.

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

1. Recruit qualified staff members for these positions.

2. Determine the feasibility of using volunteers for these positions in the alternative.


Provide a complete implementation and evaluation plan utilizing all of the above concepts.

The program envisioned herein will be implemented and evaluated as set forth in Table __ below.


Implementation and Evaluation Plan of Three Main Goals




Increase accessibility for individuals who need these services to help reduce institutionalization and enable them to remain in their own home.

1. Establish benchmarks concerning current service usage rates for targeted population.

2. Periodically (every 3 months or as needed) evaluate percentage of eligible clients who receive care compared to benchmarks to identify trends, problem areas, and opportunities for improvement.

3. Make those regions with lowest access rates a priority until the situation improves.

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

1. Provide ombudsman services to eligible candidates for services.

2. Track and trend denials of service to identify specific cause of denial to determine if revisions to educational materials concerning eligibility for services are required.

Maintenance and increase of the quality of these services.

1. Apply traditional quality improvement methods to the program through the use of quantifiable metrics.

2. Monitor effectiveness of program over time to identify problem areas and opportunities for improvement.


Alaska Area Indian Health Service. (2011). Indian Health Service. Retrieved from http://www.

Goins, R.T. & Spencer, S.M. (2005). Public health issues among older American Indians and Alaska natives. Generations, 29(2), 30-33.

Indian Health Service Alaska area services. (2011). Indian Health Service. Retrieved from

Jervis, L.L., Jackson, Y. & Manson, S.M. (2002). Need for, availability of, and barriers to the provision of long-term care for older American Indians. Journal of Cross-Cultural

Gerontology, 17, 295-311.

Padgett, D.K. (1999). Handbook on ethnicity, aging and mental health. Westport, CT:

Greenwood Press.

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