American Indian and Alaska Native Long Term Services - Kauffman ...

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American Indian and Alaska Native Long Term Services - Kauffman ...

PROGRAM


Table of Contents

Planning Committee List................................................................................................................................................ 2

Detailed Agenda ................................................................................................................................................................ 3

Workshop Descriptions .............................................................................................................................................. 12

Track 1: Home- and Community-Based Care Services (HCBS).................................................................................... 12

Track 2: Facility-Based Services............................................................................................................................................. 14

Track 3: Hospice/Palliative Care ........................................................................................................................................... 14

Track 4: Care Transitions ......................................................................................................................................................... 15

Presenter Biographies ................................................................................................................................................. 16

Online Evaluation .......................................................................................................................................................... 23

Curtis Denver Hotel Map ............................................................................................................................................ 24


Planning Committee List

The Centers for Medicare & Medicaid Services (CMS) wishes to thank the following individuals for their time and

efforts in ensuring the success of this year’s Long Term Services and Supports Conference:

Randella Bluehouse, National Indian Council on Aging

Kay Branch, Alaska Native Tribal Health Consortium

Connie Bremner, Blackfeet Eagle Shield

Karen Cook, Chicakasaw Nation

Kathy Correa, Laguna

Joan Dominick Johnson, Blue Spruce Health Systems Consulting

Bruce Finke, Indian Health Service

Margaret Garcia, Pueblo of Jemez

Meg Graves, Administration on Aging

John Johns, Centers for Medicare & Medicaid Services

Cynthia LaCounte, Administration on Aging

Karen Leekity, Pueblo of Zuni

Kitty Marx, Centers for Medicare & Medicaid Services

Ann Miller, University of North Dakota National Resource Center

Judy Parker, Chicakasaw Nation

Babbie Peterson, Karuk Tribe

Nancy Quest, Department of Veterans Affairs

Rick Richards, Cherokee PACE

Cindy Smith, Centers for Medicare & Medicaid Services

Frances Stout, Tohono O’odham

Oneida Winship, Choctaw Nation

Anita Yuskauskas, Centers for Medicare & Medicaid Services

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Detailed Agenda

Tuesday, March 20, 2012

4:00 p.m. – 7:00 p.m. Preconference Registration and Information

Desk

Flower Foyer

7:00 p.m. – 7:30 p.m. Moderator Orientation Jax

Wednesday, March 21, 2012

7:00 a.m. – 5:15 p.m. Registration and Information Desk Marco Polo Ballroom Foyer

8:30 a.m. – 10:15 a.m. Plenary Session Marco Polo Ballroom

10:15 a.m. – 10:30 a.m. Break

Opening Prayer

Drum

Posting of Colors

Day 1 Welcome Remarks

o (video), Director, Office of Public

Engagement, Centers for Medicare and Medicaid

Services (CMS)

Kathy Greenlee (video), Assistant Secretary for

Aging, Administration on Aging (AoA)

Yvette Roubideaux, MD, MPH (video),

Director, Indian Health Service (IHS)

Home- and Community-Based Services:

Panel Discussion

Facilitator: Cynthia LaCounte, AoA

Panelists: Karen Leekity, Zuni Pubelo; and

Joyce Johnson, Oneida Nation

10:30 a.m. – 11:30 a.m. Workshops

10:30 a.m. – 11:30 a.m. Track 1: HCBS and Track 3:

Hospice/Palliative Care

The Cherokee Project

Penny James and Laura Slagle, Charles George

VA Medical Center (CGVAMC), and Kimberly

Morris, Community Living Center

Hopscotch

3


Wednesday, March 21, 2012 - Continued

10:30 a.m. – 11:30 a.m. Track 1: HCBS

Home- and Community-Based Services:

Just the Facts!

Shelly Zylstra, Northwest Regional Council

10:30 a.m. – 11:30 a.m. Track 2: Facility-Based Services

Denali Center of Fairbanks, AK

Jordan Lewis, Alaska Native Elder Care

10:30 a.m. – 11:30 a.m. Track 3: Hospice/Palliative Care

’Hoot oo ’ M d c l C nt (Fo t Defiance)

Palliative Care Program

Lucinda Martin, Fort Defiance

10:30 a.m. – 11:30 a.m. Track 4: Care Transitions

Medicare Quality Improvement Organization

(QIO) Care Transitions Activity: The Good News

So Far

Kimberly Irby, Colorado Foundation for Medical

Care

Red Rover

Duck, Duck Goose

Red Light

Jax

11:30 a.m. – 1:00 p.m. Lunch (On Own)

1:00 p.m. – 2:00 p.m. Plenary Session Marco Polo Ballroom

2:00 p.m. – 2:15 p.m. Break

2:15 p.m. – 3:15 p.m. Workshops

Long Term Services and Supports: CMS

Emerging Trends

Barbara Edwards, CMS

2:15 p.m. – 3:15 p.m. Track 1: HCBS

Aligning Tribal Home and Community Support

Programs

Jane Smith and Dave Larson, Oneida Tribe of

Indians

Hopscotch

4


Wednesday, March 21, 2012 - Continued

2:15 p.m. – 3:15 p.m. Track 1: HCBS

ohono O’odh m – Working to Build a Home

and Community Support Program

Frances Stout and Betty Arond, Tohono

O’odham Nation

2:15 p.m. – 3:15 p.m. Track 1: HCBS

Zuni Elder Day Health Program

Karen Leekity and Erika Lewis, Zuni Pueblo

2:15 p.m. – 3:15 p.m. Track 2: Facility-Based Services

Denali Center of Fairbanks, AK

(Repeat Session)

Jordan Lewis, Alaska Native Elder Care

2:15 p.m. – 3:15 p.m. Track 3: Hospice/Palliative Care

EOL Care at 4 Sites

Dave Baldridge, International Association for

Indigenous Aging

2:15 p.m. – 3:15 p.m. Track 4: Care Transitions

Integrated Medicaid Models for Long Term

Services and Supports

Anita Yuskauskas, Cindy Smith, and Christa

Speicher, CMS

Marco Polo Ballroom

Red Rover

Duck, Duck Goose

Red Light

Jax

3:15 p.m. – 3:30 p.m. Break

3:30 p.m. – 4:30 p.m. Track 1: HCBS and Track 3:

Hospice/Palliative Care

Home-Based Primary Care at the G.V. (Sonny)

Montgomery VA Medical Center – Serving

American Indian and Alaska Native Veterans

Donna Alford and Dwan Siggers Wolfe, G.V.

(Sonny) Montgomery VA Medical Center

Hopscotch

5


Wednesday, March 21, 2012 - Continued

3:30 p.m. – 4:30 p.m. Track 1: HCBS

Zuni Elder Day Health Program

(Repeat Session)

Karen Leekity and Erika Lewis, Zuni Pueblo

3:30 p.m. – 4:30 p.m. Track 2: Facility-Based Services

Adult Family Homes

Shelly Zylstra, Northwest Regional Council

3:30 p.m. – 4:30 p.m. Track 3: Hospice/Palliative Care

’Hoot oo ’ M d c l C nt (Fo t D f nc )

Palliative Care Program (Repeat Session)

Lucinda Martin, Fort Defiance

3:30 p.m. – 4:30 p.m. Track 4: Care Transitions

Medicare Quality Improvement Organization

(QIO) Care Transitions Activity: The Good News

So Far (Repeat Session)

Kimberly Irby, Colorado Foundation for Medical

Care

Red Rover

Duck, Duck Goose

Red Light

Jax

4:30 p.m. – 4:45 p.m. Break

4:45 p.m. – 5:15 p.m. Plenary Session Marco Polo Ballroom

End-of-Day Gathering

Review and Sharing

Adjourn for the Day

6


Thursday, March 22, 2012

7:30 a.m. – 5:00 p.m. Registration and Information Desk Marco Polo Ballroom Foyer

8:30 a.m. – 9:45 a.m. Plenary Session Marco Polo Ballroom

9:45 a.m. – 10:00 a.m. Break

Day 2 Welcome Remarks

Protecting the Vulnerable: National Indigenous

Elder Justice Initiative

Jacqueline Gray, Director, National Indigenous

Elder Justice Initiative (NIEJI), Center for Rural

Health, University of North Dakota School of

Medicine

10:00 a.m. – 11:00 a.m. Workshops

10:00 a.m. – 11:00 a.m. Track 1: HCBS

Alaska Native Elder Care

Jordan Lewis, Alaska Native Elder Care

10:00 a.m. – 11:00 a.m. Track 1: HCBS

Developing and Offering a Chronic Disease Self-

Management Program

Diana Abeyta, New Mexico Department of

Health, Shelly Zylstra, Northwest Regional

Council, Archie Mariano, Area Agency on Aging,

Region 8, and Percy Devine, AoA

10:00 a.m. – 11:00 a.m. Track 2: Facility-Based Services

Integrating Facility-Based Residents

Jane Smith and Dave Larson, Oneida Tribe of

Indians

10:00 a.m. – 11:00 a.m. Track 3: Hospice/Palliative Care

Cherokee Nation Home Health Services

Rick Richards, Cherokee Nation Home Health,

Outreach, Hospice of the Cherokee

Hopscotch

Red Rover

Duck, Duck Goose

Red Light

7


Thursday, March 22, 2012 - Continued

10:00 a.m. – 11:00 a.m. Track 4: Care Transitions

Home Visits for Vulnerable Elders

Akwesasne Health Center (St. Regis Mohawk)

Theresa Gardner, St. Regis Mohawk

Jax

11:00 a.m. – 12:30 p.m. Lunch (On Own)

12:30 p.m. – 1:30 p.m. Plenary Session Marco Polo Ballroom

1:30 p.m. – 1:45 p.m. Break

Innovative and Best Long Term Care Practices

Through Self-Governance Authority Panel

Discussion

Facilitator: Benjamin Smith, IHS

Panelists: Dave Larson and Jane Smith,

Oneida Nation, Cyndi Nation, Tanana Chiefs,

Theresa Gardner, St. Regis Mohawk, and

Elizabeth Lee, Yukon-Kuskokwim Health

Corporation

1:45 p.m. – 2:45 p.m. Workshops

1:45 p.m. – 2:45 p.m. Track 1: HCBS

Pawnee Elders Outreach Program

Interdisciplinary Team Visits in the Home

Steven Sanders, IHS

1:45 p.m. – 2:45 p.m. Track 1: HCBS

Money Follows the Person, Meaningful Use, and

Other CMS Initiatives: Benefits for Indian

Country

Anita Yuskauskas, Cindy Smith, and Alice

Hogan, CMS

Marco Polo Ballroom

Hopscotch

8


Thursday, March 22, 2012 - Continued

1:45 p.m. – 2:45 p.m. Track 1: HCBS

Developing and Offering a Chronic Disease Self-

Management Program (Repeat Session)

Diana Abeyta, New Mexico Department of

Health, Shelly Zylstra, Northwest Regional

Council, and Archie Mariano, Area Agency on

Aging, Region 8, and Percy Devine, AoA

1:45 p.m. – 2:45 p.m. Track 2: Facility-Based Services

Integrating Facility-Based Residents

(Repeat Session)

Jane Smith and Dave Larson, Oneida Tribe of

Indians

1:45 p.m. – 2:45 p.m. Track 3: Hospice/Palliative Care

ohono O’odh m u ing Care Authority, Desert

Pathways Program

Dorothy Low, Frances Stout, and Charlene

Conde, Tohono O’odham Nursing Care Authority

1:45 p.m. – 2:45 p.m. Track 4: Care Transitions

Home Visits for Vulnerable Elders Akwesasne

Health Center (St. Regis Mohawk) (Repeat

Session)

Theresa Gardner, St. Regis Mohawk

Red Rover

Duck, Duck Goose

Red Light

Jax

2:45 p.m. – 3:00 p.m. Break

3:00 p.m. – 4:00 p.m. Workshops

3:00 p.m. – 4:00 p.m. Track 1: HCBS

Cherokee PACE Program

Sharon Washington-Hilton and Jennifer Leep,

Cherokee Nation

Hopscotch

9


Thursday, March 22, 2012 - Continued

3:00 p.m. – 4:00 p.m. Track 1: HCBS

Navigating Long Term Services and Supports –

Single-Entry Points, No Wrong Door

Amanda Lofgren, State of Alaska, Health and

Social Services

3:00 p.m. – 4:00 p.m. Track 2: Facility-Based Services

Adult Family Homes (Repeat Session)

Shelly Zylstra, Northwest Regional Council

3:00 p.m. – 4:00 p.m. Track 3: Hospice/Palliative Care

EOL Care at 4 Sites (Repeat Session)

Dave Baldridge, International Association for

Indigenous Aging

3:00 p.m. – 4:00 p.m. Track 4: Care Transitions

Integrated Medicaid Models for Long Term

Services and Supports (Repeat Session)

Anita Yuskauskas, Cindy Smith, and Christa

Speicher, CMS

Red Rover

Duck, Duck Goose

Red Light

Jax

4:00 p.m. – 4:15 p.m. Break

4:15 p.m. – 5:00 p.m. Plenary Session Marco Polo Ballroom

End-of-Day Gathering

Review and Sharing

Adjourn for the Day

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Friday, March 23, 2012

7:30 a.m. – 12:30 p.m. Registration and Information Desk Marco Polo Ballroom Foyer

8:30 a.m. – 10:45 a.m. Plenary Session Marco Polo Ballroom

10:45 a.m. – 11:00 a.m. Break

Day 3 Welcome Remarks

Learning from Each Other: Tribal

Kay Branch, Alaska Native Tribal Health

Consortium, and Rick Richards, Cherokee Nation

Home Health Services

Learning from Each Other: Federal

CMS, IHS, and AoA representatives

Preparing for Action

Bruce Finke, IHS

11:00 a.m. – 12:30 p.m. Plenary Session Marco Polo Ballroom

Weaving the Pieces Together

Rick Richards, Cherokee Nation Home Health

Services

Closing Remarks

Closing Prayer

Drum

Retiring of Colors

Adjourn

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Workshop Descriptions

Track 1: Home- and Community-Based Care Services (HCBS)

The Cherokee Project

The collaboration between the CGVAMC HBPC program, Cherokee Indian Hospital Authority (CIHA), and the

Eastern Band of Cherokee Tribe, known as The Cherokee Project.

Home and Community-Based Services: Just the Facts!

Understanding how HCBS waivers work to provide care in an elder’s own home is a great way to serve the elders

in your community. Knowing how to help elders qualify for the program is an important role for tribal social

workers and Title VI directors.

Tribes can provide the service to the elders by establishing their own home care agency or by working with a local

agency with training and employment programs. In addition, many states have add-on services that tribes can

provide using their existing staff.

Aligning Tribal Home and Community Support Programs

How to better align tribal home and community support programs to measurably improve health and social

services for elders, the disabled, and others in nonfacility settings, leveraging revenue streams and program staff

for sustainable service delivery.

Tohono O’odham – Working to Build a Home and Community Support Program

The Tohono O’odham Elder Care Consortium, a network of care and service providers, has been thoughtfully

constructed over the last 7 years. Consideration of the needs of the tribal elders has remained the central focus

throughout the formation and growth of the consortium. The goal for this presentation will be to share how we

have gotten to where we are as a working coalition with shared vision and shared goals to improve the quality of

life for the elders and for the Tohono O’odham Tribe as a whole. We are currently implementing the second of what

is intended to be three HRSA grants, and we will describe what each grant has enabled us to accomplish and how

we intend to maintain the drive and passion necessary throughout this critical phase and into the future.

Zuni Elder Day Health Program

The presentation will cover getting an adult daycare program started in a Native American community. The first

part will cover the startup of a program, and the second part will cover the services that are provided to frail elders

who need one-to-one care in an adult day need care setting. The program’s primary clientele are those elders

afflicted with dementia and Alzheimer’s disease.

Home-Based Primary Care at the G.V. (Sonny) Montgomery VA Medical Center – Serving American Indian

and Alaska Native Veterans

Home-Based Primary Care (HBPC) at the G.V. (Sonny) Montgomery VA Medical Center has a Native American

outreach program that provides care to rural veterans with the Mississippi Band of Choctaw Indians. Our

interdisciplinary team approach also provides support and assistance to rural caregivers of veterans. Our

population ranges in age from 24 to 97, with diabetes being the most common diagnosis. HBPC provides care for

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ural veterans using the Starburst Model, which brings HBPC nurse practitioners (NP) and an interdisciplinary

team into the community setting where each patient lives. NPs in the home setting provide direct patient care,

which includes assessment, monitoring, and education regarding prevention, health and home safety, prevention of

falls, immunizations, caregiver support, and caregiver education.

Alaska Native Elder Care

This presentation will summarize the findings of two regional elder needs assessments conducted in two rural

regions of Alaska and what is being done to maintain elders at home.

Developing and Offering a Chronic Disease Self-Management Program

Participants will learn about evidence-based disease prevention programs; understand the value of evidencebased

disease prevention programs such as the chronic disease self-management program; and learn how to

develop and offer the program and the experience one or two tribes.

Pawnee Elders Outreach Program Interdisciplinary Team Visits in the Home

The elders outreach program is a new program that is just starting in the service unit. It grew out of the desire of

the executive leadership team to offer a patient-centered geriatric program that would offer patients a team

approach to their health care. Candidates for the program are part of the empanelled patients of a particular

improving patient care team, and as a part of the holistic approach to their health care, different members of the

clinic’s health care team are involved in the visit, depending on the patient’s needs.

Money Follows the Person, Meaningful Use, and Other CMS Initiatives: Benefits for Indian Country

This session will address the potential benefits from recent CMS grant programs and initiatives. Specifically, the

presentation will focus on the Money Follows the Person (MFP) grant program that assists people with living in the

community and receiving necessary long term services. The MFP program will offer expanded resources for

development in Indian Country. Additionally, the use of health information technology (HIT) will be presented

along with what it means for beneficiaries, providers, and states as well as the opportunities it presents to better

integrate the exchange of information across primary and long term services and supports. Other grant programs

related to home- and community-based services will also be discussed.

Cherokee PACE Program

Overall view of Programs of All-Inclusive Care for the Elderly (PACE) and its impact on participant and community

resources.

Navigating Long Term Services and Supports – Single-Entry Points, No Wrong Door (SEPs/NWD)

Participants will learn about Aging and Disability Resource Centers (ADRCs) and the valuable role they play in

helping individuals assess their long term services and supports (LTSS) needs, develop a service plan, and activate

that service plan. Participants will learn the functions of an ADRC and the experience that tribal organizations have

had in developing SEPs/NWDs.

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Track 2: Facility-Based Services

Denali Center of Fairbanks, AK

Presentation on the culturally appropriate services provided to residents; discussion of importance of cultural

competence in long term care services.

Adult Family Homes

Long term services and supports don’t have to take place in the elder’s home. Adult care homes are small family

homes where nursing home care can be provided in a congregate setting. These smaller facilities require much less

capital expense, accommodate 6 to 12 people (number of residents varies from state to state), and are a

remarkably good match for Indian Country. Come and see how your tribe can provide eldercare on a small scale in

multiple locations.

Integrating Facility-Based Services

Presentation of key design elements and operational changes to support improved health care outcomes and

choice. Demonstration of how facility-based residents (elders) can remain integrated rather than isolated from the

Native community through joint programming. Demonstration of cost savings of joint programming and

operations and enhanced funding – Federal Medical Assistance Program (FMAP).

Track 3: Hospice/Palliative Care

Tse’Hootsooi’ Medical Center (Fort Defiance) Palliative Care Program

This presentation will highlight “a working continuum of care model that addresses the needs of the Dine’ Elders

and those at End of Life.” This will include staffing required to accomplish program goals. In summer 2005, the

Defiance Indian Hospital on the Navajo Nation in Fort Defiance, Arizona, admitted its first patient. The Fort

Defiance Home-Based Care (HBC) program grew out of the need to provide postacute hospital care, subacute and

chronic care of certain high-risk outpatients, and hospice and palliative care in the home. There are no formal

home care or hospice programs near Fort Defiance. Prior to the start of the program, patients requiring these

services were either kept in the hospital for long periods or were transferred far from home, or they simply did not

receive these necessary services.

The program is patterned on the Medicare Hospice Benefit interdisciplinary team approach, with some features of

the Medicare PACE. The program integrated the Navajo Traditional Values and Belief (for cultural sensitivity) to

establish an advance directive for our Dine’ patient “as how I want to be cared for at the end of life.” The numbers

of established advance directives and durable medical power of attorney are reported monthly for hospital

performance improvement and quality assurance.

End of Life (EOL) Care at 4 Sites

Our project team examined EOL programs serving American Indians and Alaska Natives (AI/AN) in four diverse

settings. By eliminating preconceptions about the populations served, simplifying interactions with patients and

their families, and emphasizing empathy, each of these programs has achieved extraordinary results far superior to

national averages.

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Cherokee Nation Home Health Services

Hospice focuses on caring, not curing. In most cases, care is provided in the patient’s home but may also be

provided in freestanding hospice centers, hospitals, nursing homes, and other long term care facilities. The

presentation will focus on how hospice of the Cherokee provides end-of-life health care in the home environment

while providing insight into the daily clinical and administrative operations of a Medicare-certified hospice.

Tohono O’odham Desert Pathways Program

We believe it is important to provide our fellow community members the background and how-to information so

they can potentially replicate the Desert Pathways Program. This presentation will share the background and

development of the program, barriers encountered, lessons learned, and replication approaches for other tribes.

Track 4: Care Transitions

Program Medicare Quality Improvement Organization (QIO) Care Transitions Activity: The Good News So

Far

Description of the 10th SOW QIO program related to care transitions; discussion of community-based efforts

ongoing nationally; discussion of how local organizations can get involved to form communities, conduct root

cause analysis, select and implement interventions, and measure results.

Integrated Medicaid Models for Long Term Services and Supports

This session will address LTSS that enable individuals to live in their own homes and communities. These services

include personal care, transportation, nutrition, and chore services as well as social and medical model elder day

services. The presentation covers the history of community-based LTSS and current models of services and

supports, including fee-for-service Medicaid waivers, managed care services, and integrated programs, such as

PACE, special needs plans, dual-eligible initiatives, and MFP. Presentations in this track will share what is working

in AI/AN communities.

Home Visits for Vulnerable Elders

Our home care program in Akwesasne has been very successful because we are able to meet the needs of our

patients through a strong sense of community and a commitment to our patients. Tribal council is very supportive

of this program and recognize this as a dire need in our community. Our medical providers look to us to assist

patients who require a higher level of medical care than can be provided through our medical clinic.

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Presenter Biographies

Diana Abeyta currently serves as the Tribal and Northern Liaison for the New Mexico Department of Health

(NMDOH) Office of Community Health Workers. She has been with the Department of Health, Public Health

Division for 4 years serving in this capacity. Ms. Abeyta’s role involves outreach, support, and training of

community health representatives throughout Indian Country. She is a lead trainer in “Chronic Disease Self-

Management,” a Stanford University-developed curriculum, as well as a lead trainer in “Honoring the Gift of Heart

Health,” an Indian Health Service (IHS)-developed curriculum. Prior to taking on the role of liaison, Ms. Abeyta

managed and monitored contracts for county and tribal health councils, and through a NMDOH contract, she

facilitated community health trainings. She has a background in academics, fundraising, conflict resolution, and

health and wellness, and she holds a bachelor of science degree in biology.

Donna Alford, MSN, APRN-BC, ANP/GNP/PNP, has 30 years of nursing experience, with half of these in the role of

nurse practitioner. She is currently working in the role of a nurse practitioner in the G.V. (Sonny) Montgomery

VAMC in Jackson, Mississippi, as a home-based primary care (HBPC) provider with the care of Native American

veterans. Her previous work experience includes nurse practitioner in the urgent care setting at Jackson VAMC.

She has worked with the Mississippi Band of Choctaw Indians for over 10 years in both the emergency and

community-based settings. Ms. Alford is currently completing requirements for a doctor of nursing practice.

Betty Arond, MSN, has worked in health care since 1985. After graduating with an associate degree in nursing, she

worked as an intensive care RN for 12 years and then obtained her BSN while working in ICU/CCU. In 1996 Ms.

Arond obtained her master’s degree in language, reading, and culture from the University of Arizona, with her

thesis in culturally aware nursing care in a multicultural environment. Since 1996 Ms. Arond has worked in

hospital management as a logistics and throughput director. In this role, she provided rural health care support

and development, while obtaining a Six Sigma Green belt from G.E. Healthcare. Ms. Arond completed her MSN in

2011 and is now a PhD student at the University of Arizona, College of Nursing, with her body of research in

systems and rural and at-risk populations. Ms. Arond began working with the Tohono O’odham Nation’s Elder Care

Consortium in fall 2011. She has lived and worked in Tucson, Arizona, since 1980.

Dave Baldridge, Executive Director of the International Association for Indigenous Aging (IAIA), served as

executive director of the National Indian Council on Aging (NICOA) from 1991-2003. Under his leadership, NICOA

became the nation's foremost nonprofit advocate for older Indians and Alaska Natives. The organization tripled in

size while significantly influencing legislation and Federal policies affecting AI/AN elders. Mr. Baldridge has been

actively involved in public policy and research efforts on Federal, state, and local levels. His publications on a wide

variety of Indian aging issues have been widely distributed and cited.

Kay Branch is employed as the Elder/Rural Health Program Coordinator at the Alaska Native Tribal Health

Consortium, focusing on the health status and long term care needs of Alaska Native elders. She has over 15 years

of experience working with Alaska Native elders, including Older Americans Act programs, personal care services,

assisted living, and workforce development issues. Under agreement with IHS, Ms. Branch provides technical

assistance in long term care service development to IHS elder care grantees. She received a bachelor’s degree in

anthropology from the University of Alaska Anchorage and a master’s degree in applied anthropology from the

University of South Florida, with a focus in gerontology, specifically related to AI/AN elders.

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Charlene Conde, CNA, is a member of the Tohono O’odham Nation and a fluent O’odham speaker. Her insights into

traditional O’odham culture, and the ability to have O’odham conversation with the elders make her a valuable

asset to the program.

Percy Devine III serves as Bi-Regional Administrator of the AoA in Region VI and Region VIII (Dallas and Denver

regional offices) with responsibility for representing the Assistant Secretary for Aging and advocating for seniors

in the regions, and for maintaining stewardship of the aging services program in Arkansas, Louisiana, Oklahoma,

New Mexico, and Texas of Region VI and Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming of

Region VIII.

Barbara Coulter Edwards, Director of the Disabled and Elderly Health Programs Group in the Center for Medicaid

and CHIP Services at CMS, has considerable experience in public and private sector health care financing. She is a

nationally recognized expert in Medicaid policy, including managed care, cost containment, long term care, and

state and Federal health care reform. She was a principal with Health Management Associates, Inc. for 4 years,

focusing on Medicaid, national health reform, and service delivery for persons with chronic and disabling

conditions. She also spent 6 months as the interim director of the National Association of State Medicaid Directors

and served 8 years as the Ohio State Medicaid director. As Ohio’s Medicaid director, she led significant program

reforms, including implementation of Ohio’s comprehensive strategy to promote access to home- and communitybased

long term services and supports, development of a preferred drug list for outpatient prescription drugs,

expansion of managed care to serve Medicaid consumers, and implementation of Ohio’s State Children’s Health

Insurance Program. Ms. Edwards presents frequently on Medicaid trends and state health policy challenges.

Dr. Bruce Finke is a family physician and geriatrician. Since 1998 he has provided support to tribal, IHS, and

urban programs in the development of improved clinical and preventive care for the elderly and in the

development of long term services and supports. As a physician at the IHS Hospital in the Pueblo of Zuni from 1991

to 2003, he worked in an interdisciplinary team setting to develop comprehensive geriatric assessment and fall

prevention programs and collaborated closely with tribal programs in the development of services in the

community, including a tribal palliative care program. He now works with the Tribes of the Nashville Area and

nationally in the development of health care services for elders and Long Term Services and Supports, and he is on

part-time detail to the Center for Medicare and Medicaid Innovation.

Theresa Gardner, NP, has been a family nurse practitioner for 23 years. She operated a home visit program out of

the Akwesasne Health Center for 20 years and then transferred to the Outreach department.

Jacqueline Gray is an assistant professor at the Center for Rural Health at the University of North Dakota (UND)

School of Medicine and Health Sciences. Ms. Gray is director of the National Indigenous Elder Justice Initiative

(NIEJI) and works with several projects, including the Idea Network for Biomedical Research Excellence (INBRE),

the Northern Plains Native American Research Center for Health (NARCH) Mood Disorder Assessment Validation

Study with Northern Plains Indians, the VISN23 Rural Veterans Resource Program, Cankdeska Cikana Community

College Community Education, Research and Tribal Empowerment (CREATE) Project with INBRE, the Death

Investigator Training Grant, National Resource Center on Native American Aging (NRCNAA) and the UND American

Indian Health Research Conference. Ms. Gray also directs the Native Research Health Team and mentors over 20

Native students on research in Indian Country.

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Meg Graves has been at the U.S. AoA in the Office of American Indian, Alaska Native, and Native Hawaiian

Programs since 1989. She has been very involved in the Native American Caregivers Support Program and other

activities related to long term care for much of her time at AoA. Prior to employment at AoA, she was at the Walter

Reed Army Medical Center for 7 years, working directly with patients and their families on dialysis and those

persons awaiting and receiving kidney transplants. She has a bachelor’s degree in psychology and a master’s

degree in social work.

Alice Hogan is a health insurance specialist with the CMS Community Systems Transformation Division. She

currently works as a project officer on several initiatives, including Money Follows the Person, Real Choice Systems

Change, MDS 3.0 Section Q, and the Balancing Incentive Program. She graduated from the University of Hawaii with

a bachelor’s degree in business administration, and she earned her MBA from the University of Phoenix. She is also

a certified Project Management Professional. She has worked in government and nonprofit human services for

over 10 years, with a focus on community-based long term services and supports for older adults and people with

disabilities. Prior to joining CMS, Ms. Hogan was the project director for the State of Georgia’s Money Follows the

Person program and the director of HCBS Waiver Services.

Kimberly Irby, MPH, is program manager for Care Transitions activities for Colorado Foundation for Medical Care

(CFMC), the Medicare Quality Improvement Organization (QIO) for Colorado. She currently serves as the program

manager of analytics for the Integrating Care for Populations and Communities National Coordinating Center (ICPC

NCC), supporting QIOs across the country as they identify local target communities and work to implement

improvement plans that coordinate hospital and community-based systems of care. While at CFMC, Ms. Irby has

managed a variety of CMS-funded projects. Ms. Irby has more than 6 years of experience in health care quality

improvement, public health program initiatives, and project management. She has a master of public health degree

in epidemiology from The George Washington University. Ms. Irby recently completed the Harvard Kennedy School

of Executive Education course “Leadership, Organizing, and Action: Leading Change,” designed to teach leaders of

civic associations, community groups, and social movements how to organize communities that can mobilize

power to make change.

Penny James, MSW, LCSW, LCAS, graduated from University of North Carolina-Chapel Hill with an MSW in 2002.

Ms. James has extensive work experience in the mental health field, serving adults in western North Carolina for

more than 20 years. She joined the Charles George VA Medical Center HBPC program in 2009 as the HBPC program

coordinator to serve veterans in western NC.

John Johns joined CMS in October 2009 and works with the Tribal Affairs Group (TAG). The TAG serves as the

point of contact for the agency and AI/AN communities, including tribal leaders, health providers, beneficiaries and

other Federal agencies in regards to AI/AN health issues and CMS programs. Prior to joining CMS, Mr. Johns was a

Federal regulations and policy analyst for the National Indian Health Board (NIHB). Mr. Johns received a juris

doctor degree from the University of North Dakota School of Law. While attending law school, John twice served as

a legal intern for the U.S. Senate Committee on Indian Affairs on the staff of Senator Byron L. Dorgan of North

Dakota.

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Joyce A. Johnson has been the Elder Abuse Prevention Coordinator for the Oneida Tribe's Elder Services

Department since March 2004. Ms. Johnson also supervises the Elder Services In-Home Service staff. She earned

her bachelor's degree in social work from the University of Wisconsin Green Bay in September 2002 and is a

Certified Social Worker for the State of Wisconsin. Prior to Ms. Johnson’s employment by the Oneida Tribe, she was

an abstinence educator in the Oneida Tribal Turtle School, Green Bay, and Keshena. Ms. Johnson’s experience

reaches from working with youth and teaching healthy relationship skills to educating elders and community

members about elder abuse. She oversees the in-home services staff who provide services to assist the elders to

remain independent as long as possible.

Cynthia LaCounte (Turtle Mountain Chippewa) has been with the U. S. AoA since January 2012 as the director of

the Office for American Indian, Alaska Native, and Native Hawaiian Programs. She began her work with tribal

elders in 1976 as an Area Agency on Aging director for the Montana tribes, and she has an extensive history with

aging issues. Prior to working for AoA, she was the project manager for the Title VI Training and Technical

Assistance Project through Kauffman and Associates, Inc. Cynthia also served as the chairwoman for the Trenton

Indian Service Area, and she has been a national advocate for tribal elders throughout her career.

David Larson holds a master’s degree and is a licensed nursing home administrator. He has over 30 years of

management experience, more than 18 of those in health care. He has held administrative positions in hospital,

medical center, and skilled nursing facilities. He has been employed by the Oneida Comprehensive Health Division

for 17 years and is currently the Ancillary Services director, supervising the highest volume pharmacy in the State

of Wisconsin and managing the Oneida Home and Community-Based Waiver Program. He also is a member of the

Oneida Nation team that works directly with the State of Wisconsin Department of Health Services on issues

related to long term care redesign and implications for Native peoples and providers.

Elizabeth Lee is Director of Home Care Services for the Yukon-Kuskokwim Health Corporation in Bethel, Alaska.

She administers personal care and waiver services in 48 remote Alaska Native villages and is closely involved in

the development of the region’s first nursing home. Ms. Lee is Yupik Eskimo, received a bachelor of science in

biology and holds a variety of public management and leadership certifications.

Karen Leekity, Zuni Elderly Services Director, currently oversees all the elderly services programs in Pueblo of

Zuni, New Mexico. Ms. Leekity attended University of New Mexico where she acquired degree in business

administration in 2000. She has been with the Zuni Elder Programs for 22 years and served in various capacities

since 1990, becoming elderly services director in 2002. Ms. Leekity initiated the Zuni Adult Day Care program in

1998, and the facility was licensed by the State of New Mexico in 2005.

Jennifer Leep, Community Education Liaison for Cherokee Elder Care, has a bachelor of science in health care

administration. Jennifer has worked with Cherokee Elder Care since March of 2010 after completing her college

internship with the program.

Erika Lewis, Zuni Adult Day Care Coordinator, was born and raised in Zuni, New Mexico. She graduated from Zuni

High School in 1994, attended the University of New Mexico, and received a certificate after taking the New Mexico

State exam for nursing assistants in 1994. Ms. Lewis has worked with the Zuni Adult Day Care from 2006 to the

present, working with and coordinating a program for dementia and Alzheimer’s disease-afflicted elders.

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Dr. Jordan Lewis is the owner of Alaska Native Elder Care, where he facilitates individual and community

assessments, sustaining elders in their homes and communities and ensuring elders can live with dignity,

surrounded by family and friends. Dr. Lewis received his doctoral degree in cross-cultural community psychology

from the University of Alaska Fairbanks (UAF), where he did his research with Alaska Native elders in Bristol Bay

(SW), Alaska, to establish an Alaska Native model of successful aging. His research interests include rural

community health, Indigenous gerontology, and tribal long term care services. In June 2012 he will be starting an

NIMH-funded postdoc training program at the University of Washington School of Medicine focused on geriatric

mental health and behavioral health sciences.

Amanda Lofgren works for the State of Alaska, Department of Health and Social Services, Division of Senior and

Disabilities Services as the rural long term care coordinator, providing technical assistance and support to rural

providers and communities regarding home- and community-based services. Amanda will complete her master of

gerontology degree this summer, and she lives in Anchorage with her husband and son.

Dorothy Low, RN, ANP-C, is manager of the Desert Pathways program. Originally from Michigan, she has worked

on the Tohono O’odham Nation for 14 years in a variety of medical roles. She has been part of the hospice and

palliative care program development for the past 5 years.

Archie Mariano (Navajo Nation) is the caregiver support program specialist with the Inter Tribal Council of

Arizona, Inc., (ITCA) Area Agency on Aging, Region 8. He oversees the development and implementation of the

National Family Caregiver Support Program funded by the Older American Act. He represents ITCA as a member

with the DES Governor’s Advisory Council on Aging and Arizona Caregiver Coalition. He coordinates the annual

Tribal Family Caregiver and the Arizona Indian Council on Aging Conferences. He presents at local, state, and

national conferences, and he is a certified Master Trainer for the C.D.S.M.P. and for the Powerful Tools for

Caregivers programs. Mr. Mariano holds a bachelor of arts degree in communication from the University of New

Mexico, and he has experience in program administration, program development, and studied health education at

the graduate level.

Lucinda Martin has been employed with IHS for 40 years, more than 22 of them with Fort Defiance Indian

Hospital (FDIH). She transferred to FDIH in 1980 from Albuquerque IHS, Crownpoint, Gallup, and Phoenix BIA

Area Office. She has worked as a medical social worker, therapist, supervisor, consultant, liaison, and

administrator. Her concentration while in the master’s program was in case work, group work in hospital and

clinical settings, administration, program management, community organization, and state contract program

evaluation at the tribal, state and Federal levels. She served for 15 years as the NAO-IHS Project Officer for the PL-

638 Navajo Children Special Advocacy Project for children in need of a mental health treatment program.

Kimberly Morris, MD, CMD, has been chief of Geriatrics and Extended Care at the Charles George VA Medical

Center (CGVAMC) since November 2008. She also serves as medical director of the Community Living Center (CLC).

Ms. Morris was the recipient of the 2011 VA-IHS Collaborative Grant to work with the Eastern Band of Cherokee

Indians (EBCI) in helping to improve hospice and palliative care, education, and resources.

20


Cyndi Nation, BSW, is Koyukukon-Athabascan from Rampart, Alaska. She is currently the director of Community

Health Outreach Programs for the Tanana Chiefs Conference (TCC). She brings 20 years of experience as a direct

provider of human services in cross-cultural settings; 20 years of experience in program administration and staff

supervision; and 15 years of experience in grants writing and administration. She has a proven record of

accomplishments in program development and delivery in rural interior Alaska. She travels extensively to TCC

region villages, visiting each village at least once a year, and has developed relationships in each community. She

enjoys her travels and meeting people, which keeps her grounded. She has three daughters and eight

grandchildren who she loves to spend time with. She desires that services be provided to where “our” people live

and to empower them to seek out the services they need.

Rick Richards is the CEO of Cherokee Nation Home Health Services and the program director of Cherokee Elder

Care PACE . Mr. Richards has served as the CEO for Cherokee Nation Home Health Services for more than 16 years.

During that time, the agency has grown from just over 2 dozen staff members serving an average of 60 clients daily

to an agency with over 250 staff members serving about 700 clients each day. When Mr. Richards assumed duties

at Cherokee Nation Home Health Services, the agency was offering Medicare home health services only. Today,

Cherokee Nation Home Health Services provides services through Cherokee Nation Home Health Outreach, a

department that provides services under the Medicaid Waiver Program as well as Hospice of the Cherokee, a

department providing end-of-life services to eligible clients. Mr. Richards is a member of the Cherokee Elder Care

PACE development team for Cherokee Nation and oversees the daily operations of Cherokee Elder Care. Cherokee

Elder Care is currently the only PACE program in Oklahoma and the only PACE center sponsored and operated by a

Native American tribe.

Steven Sanders, DO, is the clinical director of the Pawnee Service Unit and has been an employee of IHS for 26

years. Dr. Sanders is a board-certified family practice physician. Dr. Sanders has served on a wide range of service

unit and area committees.

Dwan Siggers Wolfe, PhD, APRN-BC, FNP, has 20 years of experience as a nursing leader and is currently working

in the role of a nurse practitioner (NP) in the G.V. (Sonny) Montgomery VAMC in Jackson, Mississippi. She works as

a HBPC provider with the care of Native American veterans. She has 13 years of previous NP experience in primary

care in internal medicine, family medicine, and women’s health. She served as the Women Veterans Health

Program manager, a liaison between women veterans and needed services at the Jackson VA. Ms. Wolfe earned a

doctor of philosophy in preventive medicine from the University of Mississippi Medical Center.

Laura Slagle, RN, has more than 15 years of experience in home health and hospice as a field nurse in western

North Carolina, including the Cherokee Reservation. During the past 3 years Ms. Slagle has worked at the Charles

George VAMC in the satellite HBPC program in Franklin, NC, which also serves veterans in western NC, including

the Cherokee Reservation.

Cindy Smith has worked for CMS since 1998, first as a managed care specialist in Medicaid, and more recently as

the Native American contact in Medicaid for six states, including Montana, Wyoming, North Dakota, South Dakota,

Utah, and Colorado. Prior to CMS, she worked for the Kansas State Medicaid Agency, EDS, and she was a coronary

care nurse for many years.

21


Benjamin Smith is the deputy director for IHS Office of Tribal Self-Governance. He oversees all aspects of the

administration of the Tribal Self-Governance Program authorized by Title V of the Indian Self-Determination and

Education Assistance Act, including providing information, technical assistance, and policy coordination in support

of IHS Tribal Self-Governance activities. Mr. Smith holds a master of arts degree in international peace and conflict

resolution from the American University and a bachelor of arts degree from Brigham Young University. He also

holds postgraduate certificates in senior executive leadership and business from Georgetown University and a

graduate certificate in epidemiology and biostatistics from the Johns Hopkins Bloomberg School of Public Health.

He has extensive international development fieldwork experience in Western Africa and Europe. In 2003, the

American University conferred Mr. Smith a Lou Torres Fellow to promote AI/AN involvement in international

affairs. At the same time, he assisted in building, promoting, and honoring self-sustaining AI/AN communities

through education and leadership as an American Indian Graduate Fellow.

Jane Smith, BA, RN, NHA, has over 30 years of experience in education, critical care, mental health care, and long

term care as a nurse manager, director of nursing, and nursing home administrator. She has been employed by the

Oneida Comprehensive Health Division for 12 years and currently serves as the administrator of Anna John

Nursing Home. She served as the Oneida Nation representative to Wisconsin Council on Long Term Care Reform

2006-2007. Since 2009 she has been the Oneida Nation’s team leader for interface with the State of Wisconsin

Department of Health Services on issues related to long term care redesign and implications for Native people and

providers. She is an enrolled member of the Bay Mills Indian Community of Michigan.

Christa Speicher – Biography not available.

Frances Stout, retired RN, BA, and a member of the Tohono O’odham Nation, is chairperson of the Tohono

O’odham Nursing Care Authority, the governing board of the nation’s skilled nursing facility and Desert Pathways

program.

Sharon Washington-Hilton, Center Manager for Cherokee Elder Care PACE, has a BBA in management of

information systems. Ms. Hilton has worked within Cherokee Nation’s business entities since 2003 in many roles to

include communication/staff development trainer and manager, and she completed the first Cherokee Nation

leadership training program. In October 2007 she was one of the original four employees hired to start Oklahoma’s

first Programs of All-inclusive Care for the Elderly as the compliance officer.

Anita Yuskauskas is currently the technical director for quality in Medicaid Home- and Community-Based

Services with CMS and a liaison with tribes regarding HCBS issues. She was previously an analyst at CMS involved

with the HCBS self-direction and tribal issues. Preceding her Federal tenure, Dr. Yuskauskas served as a division

chief in Hawaii's Department of Health, overseeing the developmental disabilities, Hansen’s Disease, and brain

injury programs. She also served as chief policy analyst for the Center for Outcome Analysis in Rosemont,

Pennsylvania. Dr. Yuskauskas received her Ph.D. in rehabilitation from Syracuse University. She conducted

numerous program evaluation and research projects specializing in organizational change, and she taught

undergraduate and graduate courses in human services and special education. Dr. Yuskauskas previously

volunteered her time as an advisor for Speaking for Ourselves, a statewide self-advocacy organization in

Pennsylvania, and she is a trained mediator.

22


Shelly Zylstra is the planning director at the Northwest Regional Council, the Area Agency on Aging for four

counties in Northwest Washington State. She has worked with the tribal communities in her area for 20 years and

enjoys and learns from them daily. She has extensive background in community-based long term care and is willing

to work with tribal communities who need some coaching.

Online Evaluation

Please visit http://www.kauffmaninc.com/ltss/evaluation and complete an online conference evaluation. Upon

completion of the online evaluation, you will be provided a downloadable Certificate of Participation.

23


Curtis Denver Hotel Map

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