Needs Vs. Utilization

Existing research indicates high levels of need for health care services for American Indian elderly, and relatively low levels of service utilization for those services which may be available (John, 1999).

Availability

Transportation, meals programs, Public Health Nurses, and Community Health Representatives (health paraprofessionals) are the most consistently used services. Some American Indian elders use non-IHS services such as the VA or private health care providers (Medicare HMO’s), and thus would not show in utilization data. To help serve the urban Indian population there is a small number of urban Indian health programs which comprise only 1.2% of the IHS annual budget.

Long-Term Care. The Indian Health Service does not have a program for the provision of long-term care (LTC) services for the growing numbers of elders. A large focus group of American Indian Elders (IHS Annual Research Conference, Albuquerque, NM, 2001) indicated that elders considered Long- Term Care and Diabetes their #1 and #2 priorities. Most long-term care services are given by extended family, clan, and fictive kin. There are few LTC resources in Indian Country, , although some tribes have established social models of Adult Day Care. Since IHS does not include LTC services, tribes are responsible for providing any LTC that exists. There are only 12 tribally run Nursing Homes, and elderly American Indian have to be placed sometimes several hundred miles away from family, ancestral lands, and other Indians. Isolation and functional decline have been shown to result from this kind of placement. (Hennessey &John, 1996) Lack of LTC services is of major concern to elders in Indian Country and to their caregivers. Caregiver studies indicate that LTC services would be utilized if available (John, Henessey, Roy, & Salvini, 1996).

Although most care is still given by extended family members, lack of development on Indian lands has led to permanent migration of young and middle-aged American Indian to urban areas, thereby reducing the availability of caregivers in rural and reservation areas. It has been suggested that poverty is a major determinant of extended family households due to cultural norms and the sharing and reciprocity of scarce resources (Manson& Callaway, 1990b). However, today’s Indian families are subject to the same stresses for economic survival as other ethnic groups.

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Accessibility

A major barrier to service provision for many elders living on or near reservations is the long distance to clinics and hospitals, many times coupled with lack of transportation. Lack of ability to communicate in English with providers and staff of health care agencies who speak only English also reduce the accessibility. Bruce Finke, MD, (IHS Elder Care Initiative) points out that IHS data indicate increased use of services as a percentage of population, but decreased hospital use when compared to all races (based on discharge days), and increased length-of-stay. This is believed to reflect scarcity of subacute care services and resources in the IHS service areas.

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Acceptability

Potential barriers in acceptability of services include culturally incongruent treatment regimens; cultural differences in concepts of modesty and propriety; lack of respect; long clinic waits; and, staff turnover. Many American Indian elders will not apply for Medicaid benefits for which they are eligible as a matter of pride because it is perceived as a hand-out from the government, or because it is believed that medical care was assured by treaty, or because the system is too complicated. A “fatalistic attitude” (whatever comes, the people will survive) toward health also sometimes makes care seem less acceptable.