LTSS Program Examples

Point of Contact

Sharon Hilton
Director
Cherokee Elder Care Program
918-456-5051

The Cherokee Elder Care Program, which began in 2008, is a Program of All-inclusive Care for the Elderly (PACE), meaning it follows a program model in which a diverse team of health providers deliver different health and every day living services to those who need care.

The Cherokee Elder Care Program uses a team effort to increase the availability and quality of services, deliver prompt care, and enhance the lives of the elderly by helping them stay in their homes as long as possible.

The program is:

• One of only 15 rural PACE sites in the nation
• One of the first PACE programs to serve rural communities
• The first PACE program in Oklahoma
• The first PACE program sponsored by an American Indian or Alaska Native tribe or tribal organization

The program is led by a primary care physician and includes different professional and paraprofessional staff members with certain skill areas to assess needs, develop care plans, and deliver services. It serves about 83 elders in need of care each month.

Services Provided

Services provided under Cherokee Elder Care include:

• Home health aides who provide some medical services in the home
• Hospice care
• Meals and nutritional counseling
• Medical prescriptions
• Personal care assistance, such as help bathing or getting dressed
• Physical therapy
• Primary care
• Respite support
• Some transportation services
• Speech and occupational therapy

The program also helps clients navigate some processes that can be difficult by offering:

• Case management
• Help completing the Medicaid application

The State of Oklahoma does eligibility assessments to determine which services a potential client is eligible for.

Eligibility

The Cherokee Nation Elder Care Program is a long-term care option for anyone who is:

• Able to safely live in a home within the program’s service area
• Age 55 or older
• Certified by a nurse from the Department of Health and Human Services as needing a nursing home level of care

Those who enroll in the program are required to use it as their primary medical provider. Program participants do not need to be members of the Cherokee Nation or Native American.

Funding

Medicare and Medicaid reimburse the program for services provided to elders who are eligible for both types of coverage. People who are eligible for Medicare, but not Medicaid, make monthly payments to the program.

To be covered by Medicaid, a PACE program must be included in the state’s Medicaid plan as an available care option. Once this option is available, the state can contract with a PACE provider. The Cherokee Nation worked with the State of Oklahoma to be listed as an option in the state Medicaid plan. This allowed the program to contract with the Oklahoma Department of Health and Human Services.

Point of Contact
Casi Foster
Director
Cherokee Nation Home Health Services, Inc.
918-453-5554

Cherokee Nation Home Health Services, Inc., (CNHHS) is a tribally incorporated, nonprofit home health care agency that is Medicare and Medicaid certified to provide state-licensed home health care services.

The program started in 1996 when the State of Oklahoma contracted with CNHHS to provide services under two state Medicaid programs:

• The Home- and Community-Based Services 1915(c) Advantage Care waiver plan, which is funded by Medicaid and covers services like personal care, home chores, case management, and skilled nursing care for Medicaid-eligible people
• The Oklahoma State Personal Care Program, which is funded by Medicaid and covers services like personal care and home chores for Medicaid-eligible people

These programs allow CNHHS to offer many services directly.

Services Provided

Services provided directly by the program staff include:

• Home health aides who assist with daily activities
• Home-based hospice care (only available through the Advantage Care waiver)
• Personal care, such as help bathing or getting dressed
• Respite support
• Skilled nursing care
• Therapies
• Transportation

CNHHS also provides the following services that help patients navigate difficult processes:

• Assessments to figure out which services a client needs and is eligible for, with the first assessment done by a state nurse
• Case management
• Help completing the Medicaid application

Other services covered by the Medicaid programs, but not offered directly by CNHHS, are contracted out to other providers. These services include:

• Home modification
• Medical equipment supplies

CNHHS serves an average of 400 Medicaid beneficiaries monthly. Through Advantage Care and Personal Care, it serves 290 and 110 people, respectively.

Eligibility

To receive services through CNHHS, both state Medicaid programs require that a person:

• Be a Medicaid beneficiary
• Live within the service area, which includes 16 ZIP codes in and around Cherokee County in Oklahoma
• Meet the Oklahoma Department of Human Services Medicaid guidelines

Participation is not limited to Cherokee tribal members or Native Americans. About 70% of the people who receive services through both programs are Cherokee citizens.

Advantage Care Waiver

To qualify for the Advantage Care waiver, a person must:

• Be age 55 or older
• Be certified as needing a nursing home level of care, but also be able to stay at home safely when services are not being performed
• Meet certain medical and income requirements

Personal Care Program

To qualify for the Personal Care Program, a person must:

• Be age 55 or older
• Earn an income that is below a certain amount
• Meet certain medical requirements
• Need assistance with daily living activities

Funding

Most of the program’s funding comes from Medicare (Part A) and Medicaid, but there are other payers as well.

Funding Sources by Percentage

*When clients pay out-of-pocket, rates are slightly lower than they would be for Medicaid.

Point of Contact
David Larson
Director
dlarson@oneidanation.org
920-869-4820

In 1994, Oneida Nation signed a contract with the State of Wisconsin that gives the tribe better access to state and Medicaid home- and community-based services (HCBS).

Wisconsin’s Community Option Program

Through Wisconsin’s Community Option Program (COP), Oneida Nation is treated as a county so it can provide home- and community-based LTSS to eligible American Indians and Alaska Natives living within its jurisdiction. To ensure this arrangement would work, the tribe first did a feasibility study to determine how many clients it might serve and see if the program would be sustainable.

Oneida Nation is currently the only tribal community with a COP contract through the State of Wisconsin.

Oneida’s COP-Waiver Program

Oneida Nation serves people who are eligible for care under the Medicaid home- and community-based 1915(c) waiver. Oneida’s COP-waiver (COP-W) mainly covers frail elders and persons with disabilities. The COP-W Program is housed under Oneida Nation’s Comprehensive Health Division.

The Oneida COP-W, which is separate from other tribal run elderly programs, serves between 20 and 24 people each month.

Funding

Prior to 2007 – Oneida Nation’s COP-W was partly funded by the state (42%), with the majority of support coming from federal Medicaid funds (58%).

Since 2007 – Oneida Nation successfully petitioned to have waiver services included under its contract with IHS. This means that all costs now go to the federal government, rather than being shared by the federal government and the state. Oneida Nation is currently the only tribe to have this included in its contract with IHS.

This change also affected Oneida Nation’s arrangement with the state. Before this, the state limited the number of people the tribe could serve under the COP-W. Since the funding responsibility shifted away from the state, this enrollment cap has been removed.

Services Provided

Through the COP-W Program, Oneida Nation directly provides the following services:

• Job coaching for the developmentally disabled
• Physical therapy
• Respite care
• Skilled nursing care (up to once a week)
• Traditional healing (when possible)

To help patients navigate processes that are often difficult, the Oneida COP-W Program also offers:

• Case management
• Help completing the Medicaid application
• Help determining which services a patient is eligible for

The program contracts out some services to other providers. These services include:

• Medical equipment
• Personal care services, such as help bathing or getting dressed
• Skilled nursing care for people who need it more than once a week
• Speech and occupational therapy
• Transportation

Currently, Oneida Nation Reservation is the COP-W service area. The tribe is working with the Wisconsin Medicaid office in an effort to expand its service delivery to all of Brown and Allegheny Counties. This would allow the program to serve many tribal members who live nearby, but off of the reservation.

Watch a short video on Oneida Nation’s collaboration with the State of Wisconsin.

Oneida Nation’s Story

David Larson shared the following story of how Oneida Nation worked with the State of Wisconsin to become the administrator of the COP-W:

We have worked very hard for many years to establish a good working relationship with our state, and that relationship helped us greatly in these negotiations. It took over a year of talking to state health department staff and educating them about the financial benefits of a new arrangement before they agreed to let us administer the waiver.

First, we grabbed their attention. We showed them some rough calculations of how much money the state could save by allowing Oneida to administer the waiver (and take advantage of 100% FMAP for services provided in tribal facilities). The number was a big one, so they wanted to know more.

We had done careful calculations to determine these numbers. As we educated them about the reimbursement process through FMAP and they began to understand it more fully, we supplied more and more detailed numbers so they could understand our projections. They began to see the financial advantages, and to understand how it could be a win-win situation for both the state and our tribe.

We worked together for a very long time. We formed a joint committee that met for over a year. A subcommittee did most of the work, and it met once a month in person and had phone conferences every few weeks. But, at the end of this long process, Wisconsin agreed to have Oneida Nation administer the waiver services for our tribal members.

Points of Contact
Karen Leekity
Title VI Director
kleeki@ashiwi.org
505-782-5541

Theresa Bowannie
Home Health Care Services Director
zhhczinc@hotmail.com
505-782-5544

Pueblo of Zuni has a wide network of long-term services and supports that are focused on elders. These programs work together to provide comprehensive care to elders within the community. The main programs in this network are listed in the following sections.

The Zuni Adult Day Center

The Adult Day Center offers respite care and activities for tribal members with dementia. Volunteers began the program in 1998 and ran it out of a room in the senior center. The program had its own facility built in 2006. The Adult Day Center receives financial support from the Title VI Nutrition for the Elderly Program, the Title V Older Worker Program, and the State of New Mexico.

Zuni Home Health Services

Zuni Home Health Services provides skilled nursing care, which includes services such as injections and wound care. The program also offers home health aide services, which assist those who need care with daily activities. Zuni Home Health Services is a federally qualified health center and receives Medicaid and Medicare reimbursement.

The Zuni Senior Center

The senior center provides many services to the elderly, including:

• Companionship
• Disease prevention and health promotion activities
• Education
• Home-delivered meals
• Household chores
• Nutrition
• Recreational and social activities
• Transportation

The Zuni Senior Center also administers six programs:

1. State Title VI Program
2. Title V Older Worker Program
3. Title VI Nutrition for the Elderly
4. Zuni Foster Grandparent Volunteer Program
5. Zuni Senior Companion Volunteer Program
6. Community Services Block Grant

The IHS Hospital’s Elder Care Program

This program assesses and manages the needs of elders. The Elder Care Program collaborates with Zuni Home Health Services, the Zuni Senior Center, public health nurses, and other community groups.

The Elderly Services Coordinating Committee

The Committee is responsible for coordinating the programs listed on this page, as well as other services. Originally known as the Elder Task Force, it was formed to find and address gaps in services for elders. In 2009, because its services had increased, the Pueblo of Zuni changed the group into a committee that meets quarterly.

Watch a short video about the development of the Pueblo of Zuni’s LTSS programs and how those programs have benefited the community.

Point of Contact
Jennifer Stevens Manager
White Earth Band of the Ojibwe LTCC
jens@whiteearth.com
918-456-5051

The White Earth Band of the Ojibwe (White Earth) manages a division of its tribal health service called Long Term Care Consultation (LTCC). The White Earth LTCC was formed in 2005 when White Earth began contracting with the state of Minnesota to provide case management and eligibility assessments for home- and community-based long-term services and supports. The program serves about 300 clients each month.

The White Earth LTCC administers several waivers, meaning that several different programs may be available, depending on a person’s medical and social needs, income, and level of care needed. Programs include:

• Community Alternative Care
• Community Alternative Care (hospital-level care for anyone)
• Community Alternatives for Disabled Individuals
• Community Programs
• Elderly (65 and older)
• Traumatic Brain Injury
• Tribal Health Services

The White Earth LTCC is currently adding a waiver for individuals who are developmentally delayed, meaning a program for people meeting those requirements will be available soon. Tribal members who are not approved for these waivers rely on tribal funds to obtain limited services.

Services Provided

To help patients navigate difficult processes, the program offers:

• Case management
• Help applying for Medicaid
• Help determining which services a patient is eligible for

Depending on which program or programs a person is eligible for, services can include:

• A home health aide to provide personal care services, such as help bathing or getting dressed
• A life-line service
• A personal care attendant
• Advocacy
• Caregiver support
• Home modifications
• Home-delivered meals
• Homemaking
• Medical equipment
• Referrals to community programs and services
• Respite services
• Skilled nursing care visits
• Transportation

Services offered by the White Earth LTCC are available to non-Native beneficiaries but limited to people who live on the White Earth Reservation.

Funding

Much of the program’s funding comes from Medicaid, and several other funding sources, including the Veterans Administration (VA), provide the rest.

Funding Sources by Percentage

The program is working on a contract with a managed care organization (MCO) that would allow the White Earth LTCC to provide case management for people who are signed up under the MCO. This would give clients of the MCO who live on the White Earth Reservation the option of having a tribal provider.

All content on this page was originally posted on the CMS.gov website here.