This presentation outlines the current state of Alzheimer’s and dementia in the United States. Presented by Jeff D. Williamson, MD, MHS, and Mark Espeland, Ph.D. who outline what causes Alzheimer’s and current prevention tactics. This presentation also discusses current public health measures that focus on risk factors of Alzheimer’s and dementia. The presentation also discusses …
This provider guide provides guidance for primary care providers and highlights how to promote brain health to patients. The provider guide is intended to support healthcare providers and administrators to inform and guide their conversations with American Indian and Alaska Native patients about the connections between brain health, including risk factors, protective health behaviors, and …
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The probability of Tribal participation is greater when one can show Tribal gatekeepers that they have taken the time to learn the value of culture, tradition, and humility. Tribal values emphasize family/clan/group/Tribe, not the self or individual as in Western society. When working with Tribal entities it is important to represent the greater good of the group. Questions are best framed in a manner that conveys awareness that our individual and group behaviors can help and/or hurt current efforts to solve community problems.
Encouraging Trust Among Tribal People
Engaging Tribal Leadership
Hosting an Event
Recognize that time may not have the same meaning for tribal members. Meetings may not start on time or end on time. There is more value in the process than the structure of the meeting. Build in “conversation time” prior to and after the meeting, to allow time to address issues and build connections.
Respect is by far the most important aspect of successful collaboration with the Native American community. It is crucial to be aware of the great status that a chief or chairman of the tribe has. Remember that Native American women, people, and Tribes are the experts on their own lives. Walk into meetings with sincere attitudes and the goal “to listen, understand, and learn to help.”
Develop and cultivate contacts with the local tribal community programs, Indian Health Center, social services, and Elder services programs. You may need to submit a written request about your project to the tribal secretary, and ask to be put on the tribal council agenda. The elected tribal leaders may not be your first contact with the tribe. Reach out to the Elders or other traditional leaders in the community. Maintain a practice of patience for tribal procedures. Many tribal communities practice proper introductions for each tribal member present. Take the time to sit and talk with the members of the tribe. Build long-term relationships, before you discuss business. When presenting, make the tribal Elders the center of your presentation, but be brief. Solicit support, input and guidance.
Remember that the Indigenous community is the expert and their support and guidance in creating long-lasting relationships will be an important factor in your ability to serve tribal communities.
What if I Am Not Native?
Learn as much as you can about the local tribe(s), especially their history and relationship with federal and state programs. Take the time to learn about key tribal organizations. Express commitment to being part of the community. Attend community functions (e.g., pow wows, cultural gatherings, health fairs).
Engagement Strategies
Respect the Tradition of Oral History and Personal Interaction
Recognize Historical Trauma
Understand how Native Values Conflict with Current Policies/Practices
Partner with Tribes and Agencies
Culturally Responsive Communities, Tribes, and Native Organizations increase Cross-Cultural Understanding through the following Actions
For more information, visit the Tribal STAR website.
When interviewed, Native American elderly persons typically do not report experiencing abuse or neglect when asked directly. However, when using the alternative terms “disrespect” or “bothered” many elderly persons discussed incidents that included abusive acts.
It is important to be aware of language, cultural sensitivities and aspects of practice that differ from other ethnicities while working with Native American elderly. It is also important to consider the role of the community and family in Native culture. As an example, Native American elderly feel it is their role to take care of the entire family. Some people may perceive this as a form of exploitation. It is important to consider the elderly person’s willingness, and desire to provide or take care of their family, how this reflects their cultural traditions, and the contributions from other family members to the well-being of the entire family to ensure the Elder’s generosity is not being exploited.
The following are examples of interview questions you may use to assess an elderly person’s risk of neglect or physical abuse. When interviewing Native elderly, make sure to allow them time to tell their story. This method is often more effective than direct questions.
Recruiting Native elderly, who are fluent in the Indigenous language to serve as translators can be effective when interviewing Native elderly.
Background Information
Housing Questions
Caregiver
General Finance Questions
Suspect Related Questions
Case Specific Questions
Neglect
Physical Abuse
Highest priority is to ensure the safety of the elderly person while respecting their autonomy.
Example: Elderly Health & Safety Screen
Statement 1
This primary care office would like to ask you some questions we ask all of our patients 60 years of age or older.
Statement 2
Many people are hurt by or have problems with their family members, loved ones, friends, or neighbors. Others may feel pressured by strangers or other care providers.
Statement 3
You do not need to complete this screen to see your doctor today, but your doctor is interested in your safety and may want to talk about any concerns you may have. This safety screen is private and will not shared with anyone without your agreement.
Statement 4
If you have answered yes to any of these questions or if you are feeling at all under pressure, we would like to have a representative from (designated local Victims Services agency) call you.
Roles and Responsibilities
As sovereign nations, tribes are the direct recipients of federal funding from the United States Department of Housing and Urban Development (HUD). Each tribe chooses a Tribally Designated Housing Entity (TDHE), to administer its housing programs with these federal dollars. The TDHE may be a department within the tribe, a tribal housing authority with a separate board of commissioners, or a nonprofit organization. The entity designated by the tribe to receive HUD funds must comply with the rules and requirements of the federal program.
The tribal housing authority representative is designated as the main contact for all tribal housing authority services. As a member of the Elder protection team (EPT), this representative’s roles include, but are not limited to:
The Native American Housing Assistance and Self Determination Act of 1996 (NAHASDA) PL104-330 became a law on January 3, 1996, and is the governing statute of the Office of Native American Programs (ONAP). The goal is to provide federal assistance for Native American tribes in a manner that recognizes the right of tribal self-governance.
Regulations for NAHASDA, which are negotiated with tribes after each reauthorization of the statue, can be found in the Code of Federal Regulations at 24 CFR Part 1000. HUD’s Office of Public and Indian Housing issues notices to articulate regulations in more detail. Notices are reviewed and approved by HUD’s Office of General Counsel. HUD’s ONAP issues program guidance, which are less formal interpretations of a regulation and are not vetted by the Office of General Counsel.
HUD Assisted Housing Program
HUD develops income limits based on Median Family Income estimates and Fair Market Rent area definitions. These income limits determine eligibility for assisted housing programs including:
Tribal HUD Training
HUD’s office of Native American Programs sponsors several tuition free trainings and workshops for Tribal leaders, Tribal housing staff, board members, housing professionals, and community and nonprofit partners.
Some examples of trainings include:
Available Programs
The ONAP administers the following six programs available to American Indian/Alaska Native/Native Hawaiian (AI/AN/NH):
National Tribal Housing Directory
For more information, contact your area ONAP office in:
Various professional disciplines are represented on the Tribal Elder Protection Team (EPT), one of which is law enforcement. This page defines the roles and responsibilities of a law enforcement officer EPT member. This representative is designated as the main contact for law enforcement services. You may want to recruit this representative from your local tribal law enforcement agency or choose a Bureau of Indian Affairs (BIA) agent or a federal or state official. Recruit officers who have a vested interest in Elder case investigations. The law enforcement officer roles include but are not limited to:
Abuse may make it harder for an older person to stand up for his/her rights. It is often more difficult for people to disclose abuse by relatives and friends than abuse by strangers. People who have been victims of Elder abuse, neglect, and exploitation may be unwilling to report the abuse or have the abusers prosecuted. The victims may:
These issues must be taken into account when responding to reports of Elder abuse. It is important to be mindful that cultural factors may affect perceptions of Elder abuse and approaches to problem solving among people from culturally and linguistically diverse communities.
All federally recognized Indian tribes that do not reside in states governed by Public Law 280 [67 Stat. 588 (1953)] are required to maintain a three-pronged (executive, legislative, and judicial) democratic government. This includes a law enforcement agency as part of its judicial arm. Indian reservations located in states governed by Public Law 280 are usually policed by local city or county law enforcement agencies and are required to have a democratic government in place. The type of crime often determines who has criminal jurisdiction. Most tribal police departments have jurisdiction only over misdemeanors and ordinances found in the tribal code. Felonies fall under the jurisdiction of either the BIA Law Enforcement Services or the Federal Bureau of Investigation (FBI).
| Offender | Victim | Jurisdiction |
|---|---|---|
| Indian | Indian | Federal jurisdiction for felonies listed in Major Crimes Act 18 U.S.C. 1153; Tribal jurisdiction for misdemeanors; no jurisdiction for felonies not in 1153. |
| Indian | Non-Indian | Federal jurisdiction for felonies listed in 1153; felonies and misdemeanors not listed in 1153 (including assimilative crimes) unless the tribe has already punished the defendant; Tribal jurisdiction for misdemeanors. |
| Non-Indian | Indian | Federal jurisdiction for felonies and misdemeanors, including assimilative crimes. |
| Non-Indian | Non-Indian | State jurisdiction applies for both felonies and misdemeanors. |
| Indian | Victimless Crime | Tribal jurisdiction applies in most cases; Federal jurisdiction applies in some cases. |
| Non-Indian | Victimless Crime | State jurisdiction applies in most cases; Federal jurisdiction applies in some cases. |
Tribal codes authorize law enforcement to perform certain duties within the boundaries of the reservation. These duties include responding to calls for service, enforcing tribal laws and ordinances, and maintaining order on the reservation. Power is vested in law enforcement by the members of the tribal community. When tribal members observe officers acting in a positive, unbiased manner, the officers earn the trust and confidence of the community. When this is accomplished, they become more respected and accepted by the majority of the tribal members.
Most descriptions of law enforcement in Indian Country indicate a rural working environment with rural-style policing. Many tribal communities operate with no more than three officers and as few as one officer on duty at any given time. Tribal communities have a government-to-government relationship with the U.S. They have significantly more scope for policy-making than individual U.S. cities or states. Tribal nations adopt constitutions, write civil and criminal laws to regulate conduct within their territorial boundaries, and enforce these laws with their own judicial systems.
Departments in Indian Country face these challenges with a limited resource base. Existing data suggest that tribes have between 55% and 75% of the resource base that is available to non-Native communities. This disparity may stem from the unique culture, geography, and economics on Native American reservations, such as: limited administrative and technological resources available to tribal police departments, inadequate coordination between tribal and federal agencies, and management problems common to tribal and BIA police departments. These disparities create a crisis in reservation policing.
The experience and research on community policing is congruent with the findings on effective governing institutions in Indian Country. Community policing provides a framework that tribes can use to design and implement new Native approaches to policing. These approaches help align police priorities and values with those of the community, improve the quality of policing in Indian Country, and strengthen the tribe as a whole.
Operation Golden Shield
Operation Golden Shield is a voluntary program. It has successfully provided protection and prevention of Elder abuse and neglect through the Anadarko Agency. Officers make random, friendly visits to vulnerable adults in response to the growing concerns of Elder abuse and neglect. Initially, 27 vulnerable Elders received a friendly visit from officers. In order to accomplish this task, each officer made three to four Elder visits per shift. If Elder abuse was suspected, the officer reported back to the BIA Law Enforcement Agency office and then enlist Tribal Social Services for assessment.
Interviewing Victims: Special Concerns When Interviewing Older Victims
Content for this document was contributed by Royleen Ross, PhD, and Iva Grey Wolf, PhD.
As a member of the Elder Protection Team (EPT), this representative is designated as the main contact for any medical referral. This representative may be a physician, a licensed nurse, an emergency medical technician, or any other medical service staff member. This team member acknowledges this responsibility to be available to assist the elderly patient or will arrange for an alternate EPT attendee when they are unavailable. The Medical Service Representative roles include, but are not limited to:
Implement a Safety Screening
Elderly safety screening procedures are implemented in various medical office settings. Each office may have their own set of procedures and practices for conducting an elderly safety screening. While there is no “right” way to implement the screening, an annual safety screening should be conducted. Before your medical office implements a screening protocol, make sure to call your local Area Agency on Aging, Adult Protective Services office, or a Title VI program to ensure you have the appropriate contact information if you need to refer a patient. Implement the following during a safely screening:
If your patient may be cognitively impaired or have dementia, you will need to consider your responsibilities under state or tribal laws to report Elder abuse to Adult Protective Services or appropriate victim’s services agency in your tribal community. This may also require staff assistance for the completion of the screening form, rather than a caregiver or family member.
Elder Abuse Screening Instruments
Workers need to be aware of warning signs that Elder abuse may be occurring, and learn to identify signs of abuse. Screening instruments do not confirm Elder abuse. They are tools to assist the worker in determining the need for more assessments or if a referral to Adult Protective Services or appropriate Victim’s Services agency in your tribal community may be required. A few examples of Elder abuse screening instruments include:
Reporting Allegations of Abuse
Reporting Parties:
Physicians, psychologists, members of the clergy and attorneys are not required to report such information communicated by a person if the communication falls under client privilege (Consult your state and tribal government, as each have their own laws on mandated reporter requirements).
Required Information:
Reports of abuse must include the following information, if known:
Mandatory reporting statutes grant immunity to the professional who reports their suspicions in good faith, and the reporter often remains anonymous. Make sure to not label the reporting process as an investigation but as an attempt to gather information to determine what services might benefit the Elder.
Please contact your local attorney to determine the laws and rules applicable to your medical practice.
Various professional disciplines are represented on the Elder Protection Team (EPT), one of which is the Adult Protection Services (APS) team member. Every state has an APS Department, but not all tribal communities have suspected reports of Elder abuse are reported, while other tribes may rely on an Elderly Protection Program to conduct investigations. Finally, some tribes may not have a designated office to report suspected cases of Elder abuse. Reports then fall to the tribal law enforcement department.
Adult Protective Services Definition
Adult Protective Services is “a social services program provided by state and local government nationwide serving older persons and adults with disabilities who are in need of assistance due to abuse, neglect, self-neglect and/or exploitation.”
The Tribal Adult Protective Service Representative Role
Eligibility for Adult Protective Services in Indian Country
An individual must meet the basic requirements:
Age for consideration may vary from tribe-to-tribe, but usually persons aged 55 years or older are considered elderly in some tribes.
Services
Services are provided for vulnerable adults and elderly persons when they are:
Cooperation with Court Systems
Adult protective services provide cooperation with relevant court systems to make interventions and coordinate services to the elderly person including but not limited to any of the following:
National Adult Protective Service Association (NAPSA): Guiding Principles and Practice Guidelines:
The APS Representative should also follow the APS Guiding Principles and the NAPSA Practice Guidelines when developing a plan of action to address the identified needs and risks of the adult. The APS program is guided by Practice Guidelines that emphasize the need to:
APS Report Documentation Procedures
APS programs have a systematic method of documenting the entire case process. When completing case documentation, the APS worker:
APS Guiding Principles:
As a member of the Elder Protection Team (EPT), this representative is designated as the main contact for any social service need. There may be one or more depending upon the services available. This team member is available to assist the elderly person, or will arrange for an alternate when they are unavailable. The Social Worker’s roles include, but is not limited to:
Information to Collect in a Comprehensive Assessment:
Social Workers should ask the client about their typical day-to-day activities, in a natural way, to pick-up cues about how the Elder is being treated by family members, friends, or other caregivers.
Client Information:
Functioning:
Legal:
Factors such as confusion around finances, social isolation, cognitive impairment, and a recent loss of a loved one can increase an Elder’s risk of abuse. In addition to these characteristics, social workers should collect the following information:
In relation to advanced directives, determine if the client made any decisions regarding medical intervention, where they want to pass in peace (at home, hospice, hospital), and who is designated to carry out the Elder’s wishes.
Physical Environment:
Social workers can learn a lot about the Elder and their abilities from how the living spaces are arranged. A decrease in mobility can lead to an increased risk of Elder abuse and neglect. In the assessment you are looking for potential risks for falls (e.g., a loose floor rug). The physical location of the client within the home may also indicate risk for abuse, neglect, or self-neglect.
Physical Health:
The assessment of issues related to physical and psychological health is important because of the interconnection between health and other aspects of well-being. The Elder’s answers to these questions can alert the social worker to possible abuse, neglect, or self-neglect. The following are a few examples of topics that Social Workers would cover as part of a physical health assessment. The list is not exhaustive.
Psychological Health:
The National Center on Elder Abuse (NCEA) reports that Elders living with dementia are at a greater risk for abuse than those without. A 2010 study found that 47% of participants with dementia were abused by their caregivers. Social workers should assess the caregiver’s mental and emotional status as well as the availability of support.
Examples of information typically collected include:
Social Supports:
Inadequate social support and social isolation are risk factors for abuse, neglect, and exploitation. It is important to get a good sense of who is in the Elder’s social network. The social worker should ask about:
To make sure an Elder Protection Team (EPT) is managed appropriately, and to increase accountability of team members, it is recommended to designate an EPT Coordinator or Director. This individual may have dual roles on the EPT as the coordinator, and as a representative for a tribal agency (e.g. Title VI Director). This team member has an important role on the EPT. They will facilitate a group of professional community members in the unification of collaborative efforts to assist Elders who may be experiencing Elder abuse, neglect, and exploitation. Some tribes may choose to have a coordinator and a director to share the responsibilities and work load. For many Tribal EPTs, the director of an Elderly Services Program will serve as the EPT Coordinator. Each EPT is as different as the tribal communities in which they serve. A EPT Coordinator is primarily responsible for administrative tasks, which may include:
The Tribal EPT Coordinator’s Role
Some tribal communities are able to hire a full-time EPT Coordinator as they may have funding to sustain this position, where other tribal communities many not have funds available. In these cases, this would require a highly motivated individual who would volunteer their time to this position.
Additional considerations during implementation.
Code(s) must include policies and procedures that clearly identify authorized key agencies in each phase, stages in reporting and investigations, timelines, and penalties. Protocol should include:
The final draft should be presented to your tribal council or governing body for approval. If the code is not approved, the working group should decide what needs to be changed in the document based upon the concerns or suggested changes identified by the council or governing body. A revised draft can then be resubmitted for review from the tribal council or governing body for approval. Endorsement by an Elder group can help in advocating for the adoption of the code.
From the working group, select a task group to draft your Elder abuse and protection code including tribal values and areas of concern from collected data.
Identifying tribal values held by the community members will guide all who use the code such as; tribal leaders, tribal members, service providers, police, and the court. When Elder abuse codes are being established always involve tribal Elders.
Gathering information about Elder abuse to ensure understanding on the areas of concern in your community.
The working group is tasked with gathering community information to identify the areas of concern to be addressed, including “who, what, where, when and how”. Always involve both male and female tribal Elders when establishing the working group. The working group may choose to assign its members specific responsibilities such as; facilitator, organizer, cultural interpreters (Elders), and task groups. Additional working group members should include:
The process of obtaining support of tribal government may vary from tribe-to-tribe. Gaining approval for the development of an Elder abuse code may range from an endorsement by the tribal leader to the passage of a resolution by the tribal council.
Elder Protection Teams (EPTs) generally appear to have similar challenges that prevent the best outcomes for Elders and the EPT. Service agencies struggle to provide help to clients in the face of dwindling funding and resources, and staff members may feel that utilizing the EPT creates an additional burden. Some barriers to service that EPTs face include:
You will need to develop a sustainability plan.
Program considerations include:
You will need to learn about the state and Tribal laws in your area.
If the tribe does not have codes established by the tribe, you will need to facilitate the development of a tribal Elder protection code.
Develop organizational rules for the Elder Protection Team (EPT):
Identify the tribal community’s concerns for the elderly through a Community Needs Assessment. A Community Needs Assessment should include:
Complete a Statement of Needs summary report, this document should present all of the findings from the Community Needs Assessment. This document should include a proposed response to any Elder abuse problems and clarify the areas of need to help address Elder abuse, neglect, and exploitation. The Statement of Needs Report is required for any grant proposal. Additional documents include:
Things to consider when building your team:
To build a solid foundation for your tribal Elder Protection Team (EPT), the EPT Coordinator will want to know what Elder service agencies are available in the tribal community. The creation of a tribal EPT will allow agencies to share the burden of investigating and efficiently responding to cases of Elder abuse in a timely manner. Team members can support each other’s roles, which decreases additional trauma to the Elder and allows them to continue as a valued and respected member of the tribal community. Elders benefit from EPTs by:
Elder protection programs vary across Indian Country in terms of:
One of the most successful models for addressing Elder abuse in Indian Country is utilized by the Confederated Tribes of Warm Springs (CTWS) in Oregon. The CTWS-MDT representatives have served their tribal community since 1999 through a multidisciplinary team approach. This MDT provides assistance to their clients when coordinating with social service programs, health systems, and legal proceedings. The CTWS-MDT coordinates documentation, and evidence gathering efforts for legal procedures (civil and criminal cases), and assists in community crime prevention efforts.
The CTWS-MDT members include representatives from: The Senior Wellness Center, Tribal Police, Tribal Prosecutor’s Office, BIA/Tribal Social Services, Tribal Housing Authority, Indian Health Service (IHS), Community Health Representatives (CHR), Victims of Crimes Office, Assisted Living, and the Oregon Adult Protective Services.