American Indian Elderly and Long-Term Care : Interorganizational Barriers to the Use of Oregon\u27s Home and Community-Based Medicaid Waiver

Developing culturally supportive long-term care services for Native American elderly has gained increasing attention on the federal level. On the state level, Oregon\u27s Senior and Disabled Services Division (SDSD) possesses a federal Medicaid waiver that allows for the development of home and community-based long-term care services. While this waiver is culturally neutral, its value is that it would allow tribal governments within Oregon to develop their own culturally supportive home- and community-based services, yet none have done so. The purpose of this study was to determine why senior service agencies of tribal governments within Oregon have not participated in the state\u27s home- and community-based Medicaid waiver to be able to offer culturally supportive alternatives to nursing home placement for elderly American Indians. The proposition is that interorganizational barriers discourage the tribal agencies from participating in the state\u27s waiver program. This research used a multiple case study to identify and explain the barriers to interorganizational relations between SDSD and senior service agencies of two tribal governments within Oregon that obstruct the use of Oregon\u27s home and community-based Medicaid waiver. Data collection techniques included: (a) in-depth interviews using open-ended questions; (b) direct observation; (c) document review; and (d) field notes. At the organizational level, in one case information and coordination were sufficient to override other identified barriers to facilitate an informal interorganizational relationship. In the other case, lack of information and lack of coordination were detrimental to the development of an interorganizational relationship. At the governmental level, interorganizational theory was insufficient explaining the barriers between the state and tribal governments. However, the broad picture that developed from the use of the interorganizational framework is that, in general, the state treats tribal governments as if they were organizations rather than heterogeneous governments. Policy recommendations at the organizational level support the gathering of information and coordination of activities as the focus of organizational energy in developing interorganizational relationships. At the governmental level, recommendations support the interactions between the state and tribal governments at the government-to-government level