native elder caregiver curriculum necc: 3.2 health care system caring for our elders: health care...

NATIVE ELDERCAREGIVER CURRICULUMNECC: 3.2HEALTH CARE SYSTEM

Caring for Our Elders: Health Care System: Accessing Resources for Native Elders 3.2

Caring for Our Elders: Health Care System: Accessing Resources for Native Elders 3.2

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Health Care System: Overview

Caring for Our Elders: 3.2 Health Care System: Accessing Resources for Native Elders

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“System” can be very confusing

Elders & Families have many questions about access Who to go to? Where to go? How to pay?



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Excuse me…Could you tell me how to access the health care system????

By Understanding a Piece at a Time…


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I.H.S. (Indian Health Service) Medical, public health nursing, dental care, pharmacy services

Hospital & Clinic access No nursing homes No defined system of long-term

care

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Health Care System: OverviewI.H.S. (Indian Health Service) Available services vary depending on: Federal Budget Alternative servicesContract care partnersService Area

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Tribal CHR Program (Community Health Representatives) “Vital Link” between health care

system & community’s access to services

Services vary by Tribe: determined by Tribal leadership

Some CHR programs are very dedicated to eldercare services



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Tribal CHR Program

Need to know each Tribe’s priorities for the CHR program in their community

Potential for CHR programs to improve health care access is an untapped resource !!Would be logical for CHRs to lead HCBS



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Other Tribal Health-Related Programs Access for all tribal members

Services vary Tribe to Tribe Administered by Tribe directly Variety of services dependent on

available funding sources

Health System Overview


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Contract Health Services Mechanism to

purchase health-care services

Services that cannot be provided by I.H.S. or Tribal facilities

Health System Overview


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Contract Health Services Person must be referred by I.H.S. Eligibility is generally restricted to:

those living on or near their home reservations

students/dependents away at school Because of limitations on funding

Priorities given to “life-threatening” & “urgent” needs



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Diabetes Programs IHS Special Diabetes Program for Indians (SDPI)Administered by I.H.S. or Tribal Health Programs

Programs designed to be specific to local Tribal needs



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Diabetes Programs I.H.S. I.H.S. Department of Diabetes Treatment & PreventionClinical guidelines & public health approaches

Research & training & technical support

Develop educational materials



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MEDICARE & MEDICAID* *with appreciation to the following resources:1)Baldridge, Benson, Carlson & Redford:

2004 “Tribal Guide for Elder Care: A Primer on Long-Term Care Services & Financing for Indian Elders”

2)“Building Partnerships: CMS, States, Tribes & Aberdeen Area I.H.S.” 2009 CMS Medicare & Medicaid Training, Sioux Falls, SD June, 2009

3) Wallace, S.P., Satter, D.E., Zubiate, A. 2003 “Medicaid Home Care and Tribal Health Services”: A tool kit for developing new programs.

MEDICARE as Health Insurance


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A few slides about “Medicare”…

Health Care System: Medicare


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Medicare: FEDERAL program People 65 years and older People who are disabled Based on a work history of the

individual (or the individual’s spouse) that entitles them to Social Security benefits



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Medicare: Special “eligibility” If not 65 years old yet & need services?

For knowing about special eligibility, it is best to visit with: Contract Health (CHS) Contract Health Services at IHS

IHS works with insurance eligibility and reimbursement issues full-time!

Easy to visit with CHS in own community



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Medicare PART A Covers: Hospitals for in-patient care

Including I.H.S. hospitals Skilled Nursing homes Home Health Care Hospice Care Blood transfusions



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Medicare PART B Covers: Outpatient medical/surgical services

Medical supplies Diagnostic tests Outpatient therapies



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Medicare PART B Covers: (cont’d)

Hospital and clinics (including I.H.S.) for health care services from: Doctors, nurse-midwives, clinical

social workers, clinical psychologists, registered dieticians, physical therapists & occupational therapists



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Medicare PART B Services (cont’d)

Part B can also cover: Outpatient Mental Health Some Preventive Services Other medical services



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Medicare PART C A form of “managed care”

insurance plan Not really applicable to Tribal communities



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Medicare PART D Prescription Drug

Coverage Available to all people with

Medicare eligibility IHS is approved as a

prescription drug providerElders can get their medications from IHS



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Medicare Regulations for Home Health:

Must require “skilled” care in the home professional nurse, therapist skills, etc.

Must be “homebound”, but can go to:religious servicesan adult day care programclinic or hospital



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Medicare for Home Health Will NOT be provided permanently Will NOT cover Personal care services

Unless part of the “skilled care” package for a limited period of time only

May cover medical supplies & equipment Will cover Hospice Care under Part A



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Medicare: Federal program Standardized services are available across the nation according to national eligibility regulations

Medicaid: A Federal-State program But is State administered Eligibility is determined by states Services are determined by states

Health Care System: Medicaid


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Medicaid: STATE-ADMINISTERED program…

SO, Services & eligibility vary

from State to State

“could you say that again?”



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Medicare & Medicaid are both government funded health-related programs

Medicare is FEDERAL Program Same services across

the nation in every state



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Medicaid is STATE –ADMINISTERED Program… so, Services vary from “state to state”

Eligibility is determined “state to state”

“thanks for the clarification!”



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Medicaid Usually is the “Payer of last resort”

But in Indian Country, I.H.S. is usually the “payer of last resort”

IHS will pay for services after all other insurance options have been utilized for health care payment Including CMS* payment

*Center for Medicare & Medicaid Services



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Medicaid: Eligibility for ELDERLY Based on financial need

Not based on work-history Elders 65 years of age & older Elders who are disabled Elders on Social Security Income (SSI)

automatically are eligible for Medicaid



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Medicaid Eligibility for Elders (continued): Elder must have extremely

low amount of assetsVaries from state to stateDon’t have to count the

elder’s home, car, clothing, household goods, burial plot



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Medicaid Pays for nursing home care

The elder’s resources have to be extremely limited they can keep their home, car, belongings



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Medicaid… (continued) Can ask the “estate” for some “pay-

back” after a person passes away…

BUT Medicaid will NOT take Tribal land or

income from Tribal land or items with spiritual or cultural significance to the Indian community



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Medicaid… (continued) Home Health Care Options under

Medicaid Will pay for “personal care” if elder is eligible

Bathing, dressing, cooking, cleaning Different from Medicare… more “non-medical”

type of services in the home Each State has its own mechanism for Personal Care Services through Medicaid Some states are very generous with elder benefits

for Home & Community-Based Services (HCBS)

Health Care System: Can feel confusing!


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Health Care System


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Challenge is to learn to navigate all of these agencies and services !

It can be done… Work with the “people”

who are in the system… A “system” is only as good

as its people! Essential to Build partnerships!

Can Find the Way to Resources!


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Know the PEOPLE For every program, find the

“key person” to “unlock the network resources” !

Use the RESOURCES MANY AVAILABLE! Websites, literature, Toll free phone numbers,

etc.

Understanding a Piece at a Time


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QUICK REVIEW ! MedicareA “standard” federal

programPart A: Hospital insurancePart B: Medical insurancePart C: Medicare Advantage Part D: Prescription Drugs



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QUICK REVIEW ! MedicaidFederal-State Health Care Program, but…Services & eligibility determined “state by state”Need to find out what is available for elderly in EACH state

Health Care System


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Resource people can be the “guides through the maze”: Contract Health Services staff at IHS

Extremely knowledgeable of CMS funding resources, eligibility requirements, deductibles, monthly premiums, etc.

County Social Service Programs Particularly well-informed about

Medicaid funding & eligibility



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“Thanks very much…”


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native elder caregiver curriculum necc: 3.2 health care system caring for our elders: health care...

Documents

health system overview

health care access

healthcare services

native elders

dental care

public health nursing

indian health service

confusing elders families