CMS-10651 CMS Tribal LTSS Program Survey

CMS Tribal LTSS Program Survey
Please take a few minutes to complete the survey below. The purpose of this survey is to obtain
information to help the Centers for Medicare and Medicaid (CMS) develop of a list of tribally operated
long-term services and supports (LTSS) programs across Indian Country. Tribes and tribal organizations
may provide these services directly, or through a contract or agreement with an outside organization.
LTSS are a set of health care, personal care, and social services delivered over an extended period to
help persons who are unable to independently perform activities of daily living, such as getting in and
out of bed, dressing, bathing, eating, and using the bathroom. LTSS may be provided in community and
institutional settings or in a person’s own home.
Your response is voluntary. The information from this survey will be shared online on the CMS’ LTSS
Technical Assistance Center webpage. Thank you for your time.
The following questions are about types of LTSS that your tribe/tribal program offers or coordinates.
1. Does your tribe/tribal program have a senior center?
 Yes
 No
2. Does your tribe/tribal program provide independent senior housing?
 Yes
 No
(Independent senior housing: Homes or apartments reserved specifically for older adults or people
with disabilities who do not need assistance with activities of daily living.)
3. Does your tribe/tribal program have an assisted living facility?
 Yes
 No
(Assisted living facilities: Facilities of any size—including adult foster homes, group homes, or
congregate housing—that provide housing and personal care services, such as meals, housekeeping,
transportation, and assistance with activities of daily living, as needed, to persons who can still live
independently in their homes.)
4. Does your tribe/tribal program have an adult day care program?
 Yes
 No
(Adult day care programs: Non-residential facilities that support the daily living and social needs of
elderly or chronically ill adults or people with disabilities.)
5. Does your tribe/tribal program have a nursing home?
 Yes
 No
(Nursing home: An institution that provides residential accommodations and regular, skilled nursing
care to older and/or chronically ill adults or people with disabilities who are Medicaid recipients.)

ID No: CMS-10651 | PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-New (Expires: TBD). The time
required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

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The following questions are about the types of medical care services and programs your
tribe/program provides.
6. Does your tribe/tribal program provide physical therapy services?
 Yes
 No
7. Does your tribe/tribal program provide case management services?
 Yes
 No
(Case management: Includes the coordination of mental and physical care services for patients by
assigning a health professional to ensure that a patient or client obtains the full range of required
services.)
8. Does your tribe/tribal program have a PACE program?
 Yes
 No
(Program of All-Inclusive Care for the Elderly (PACE): A Medicare and Medicaid program that
provides comprehensive and coordinated medical and social services to frail individuals, 55 years of
age and older.)
9. Does your tribe/tribal program provide wellness and disease management education?
 Yes
 No
(Wellness and disease management: Provides health and disease prevention information to older
adults and people with disabilities.)
10. Does your tribe/tribal program provide palliative care or hospice services?
 Yes
 No
(Palliative care: Symptom-focused care for people with life-limiting illnesses that focuses on quality
of life.)
In-Home Care and Home Assistance
11. Does your tribe/tribal program have a home-delivered meal program?
 Yes
 No
(Home-delivered meal program: Often called meals-on-wheels; a program that delivers food to older
adults who are unable to leave their homes to come to a congregate meal.)
12. Does your tribe/tribal program provide home maintenance and repair services?
 Yes
 No
(Home maintenance and repair services: Include basic household upkeep and repairs for individuals
who are unable to independently care for their homes.)
ID No: CMS-10651 | PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-New (Expires: TBD). The
time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

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13. Does your tribe/tribal program provide home modification services?
 Yes
 No
(Home modification services: Services that provide assistance with home alterations (such as building
wheelchair ramps, widening doorways, installing lifts and handrails, etc.) that enable older adults or people
with disabilities to live independently in their homes.)
14. Does your tribe/tribal program provide homemaker and chore services?
 Yes
 No
(Homemaker and chore services: Include assistance with basic, household chores for older adults or people
with disabilities.)
15. Does your tribe/tribal program provide durable medical equipment or supplies?
 Yes
 No
(Durable medical equipment: Reusable equipment, including walkers, wheel chairs, and hospital beds,
prescribed or ordered by a doctor for use in the home. Supplies: necessary items to assist people with their
health and personal care such as incontinence supplies, nutrition supplements, wipes, lotions, etc.)
16. Does your tribe/tribal program have one or more Medicare-certified home health agency(ies)?
 Yes
 No
(Medicare-certified home health agencies observe Medicare laws and regulations to provide in- home
services, such as skilled nursing care, physical therapy, occupational therapy, speech therapy, or pharmacy
services for reimbursement through Medicare.)
Personal Care
17. Does your tribe/tribal program provide personal care services? (If you answer no, please skip to Question 19.)
 Yes
 No
(Personal care services: Include assistance for older adults or people with disabilities that need help with
activities of daily living.)
18. Do personal care providers in your tribe/tribal program receive Medicaid or state funding to provide services?
 Yes
 No

ID No: CMS-10651 | PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-New (Expires: TBD). The time required to complete
this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Caregiver Support
19. Does your tribe/tribal program have caregiver support groups?
 Yes
 No
(Caregiver support groups: Support groups that allow caregivers to meet in a supportive atmosphere to
express their feelings and share coping skills, knowledge, and resources.)
20. Does your tribe/tribal program provide respite services for caregivers?
 Yes
 No
(Respite services: Services that provide caregivers with temporary relief from the responsibilities of
caregiving. Skilled or semi-skilled workers take over caregiver responsibilities for a brief period of time and
care can be provided either at home or in another location.)
Functional Services
21. Does your tribe/tribal program provide transportation services?
 Yes
 No
22. Does your tribe/tribal program provide financial planning services?
 Yes
 No
23. Does your tribe/tribal program provide nutrition services, such as nutrition education or counseling?
 Yes
 No
24. Does your tribe/tribal program provide language translation services for older adults or people with disabilities
who speak their Native language?
 Yes
 No

Partnerships/Funding

25. Does your tribe/tribal program partner with any of the following entities in order to provide or improve its
LTSS program(s)? (Select all that apply.)
a. Other tribes
b. Indian Health Service
c. Urban Indian health programs
d. Private company/provider
e. County
f. State
g. VA
h. Other (Please describe): _________________________________________
i.
Unsure/Do not know
ID No: CMS-10651 | PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-New (Expires: TBD). The
time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

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26. Does your tribe/tribal program support its LTSS program(s) with funding from any of the following sources?
(Select all that apply.)
a. Tribal support
b. Indian Health Service (IHS)
c. Medicaid
d. Medicare
e. County support
f. State (non-Medicaid) support
g. VA
h. Other federal (non-Medicaid and non-IHS) support
i. Other (Please describe): _________________________________________
j. Unsure/Do not know

Tribal Contact Information
Tribe Name:
__________________________________________________________________________________
Tribe/tribal program name:

Tribe/tribal program contact name:

Contact title:

__________________________________________________________________________________
Contact phone number:

Contact email address:

Contact title:

__________________________________________________________________________________
Current tribal leader:

Tribal leader phone number:

Tribal leader fax number:

__________________________________________________________________________________
Tribal Leader email address:
__________________________________________________________________________________

ID No: CMS-10651 | PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-New (Expires: TBD). The
time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

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