Tribal Community Health Provider and Community Health Aide Program Projects CRIHB/NPAIHB Quarterly Board Meeting July 17, 2019 Christina Peters, TCHPP Director Sue Steward, CHAPP Director Introduce ourselves

Goals for Today Provide a brief history of CHAP in Alaska Discuss the Draft Interim Policy, CHAP TAG and the President’s proposed budget Review CHAP and CHR programs, how they complement each other Inform about the Portland Area CHAP Board Advisory Workgroup Familiarize about the Dental Health Aide Therapist (DHA/T); Behavioral Health Aide Practitioner BHA/P; and Community Health Aide Practitioner CHA/P Conclude with Why CHAP Matters!

Northwest Portland Area Indian Health Board What is CHAP? The Community Health Aide Program (CHAP) is a multidisciplinary system of mid-level behavioral, community, and dental health professionals working alongside licensed providers to offer patients increased access to quality care in tribal communities. Community Health Aide/Practitioners are primary care, mid level providers who provide full spectrum, wrap around care for oral, behavioral and medical health in the clinic or in the home. This can include patient history, vitals, diagnostics, assessments, dispensing of medications and follow up care. CHAP is a unique community-based outreach program, staffed by a cadre of well-trained, medically-guided, tribal and Native community people, who provide a variety of health services within American Indian and Alaska Native communities. CHAPs are capable of providing preventive, promotional and rehabilitation care to these communities. Northwest Portland Area Indian Health Board

What is CHAP? Inception Providers Remote Alaska access by air or water IHS physician visits Traditional healers Physician extenders CHA/P, BHA/P and DHAT TB epidemic High rate of infant mortality High rate of unintentional injury Typically Tribal or Village Member Often Generational Role model for the village Understands and may also speak the language Understands and participates in ceremonies Is familiar with and open to Tribal based or best practices understanding that evidence based is not always preferred IHS describes the Community Health Aide Program as a multidisciplinary system of mid level behavioral, community, and dental health professionals working alongside licensed providers to offer patients increased access to quality care in rural Alaska areas. The program was developed to create local providers who could act as physician extenders to combat the TB epidemic, high infant mortality and high rate of unintentional injuries that was occurring in remote Alaskan communities. CHA/P’s are typically generational, meaning that their mother’s, uncle’s, grandmother’s, grandfather’s, sister’s and so on have been or still are CHA/P’s. Many CHA’s chose to go back to training to become DHAT’s and BHA/P’s when those options became available. All CHAP providers are role models for their communities demonstrating healthy living, good oral health, healthy relationships, and investment in their communities.

National Policy on CHAP (May 2019) As a result of Tribal Consultation in 2016, where Tribes overwhelmingly supported CHAP expansion outside of Alaska, IHS began putting in motion the necessary step to implement CHAP. The Indian Health Service, as a result of the 2016 consultation formed the CHAP Tribal Advisory Workgroup (TAG) IHS Circular 18-01 The CHAP TAG in partnership with IHS released a draft interim National Policy on CHAP for Tribal Consultation This policy development included Tribal and IHS representation The CHAP TAG does not support eliminating or defunding the CHR program Northwest Portland Area Indian Health Board

National Policy on CHAP The Purpose of this Interim National Policy on CHAP To permit those Areas, that do have Resources and Infrastructures to Implement CHAP, to move forward with CHAP expansion at their own expense This Policy does not require Tribes or Areas to implement CHAP or hire CHAP providers This policy does not affect CHR program or its funding Congress has not yet provided funding for this policy implementation There has been NO consultation on the elimination of the CHR program which is separate from the current tribal consultation on CHAP policy. The comment period was extended to July 8, 2019. Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board CHR and CHAP Legislative Authority- CHAP is authorized under 25 USC § 1616 a-d while the CHR Program is authorized under IHCIA PL. 100-713. Funding Sources- The Alaska CHAP is funded through the hospital and health clinics (H&HC) line item in the IHS budget and CHRs are funded through a specific CHR line item. Scopes of Work- While the “community health” portion of the names are similar, the scope of work for a Community Health Aide and Community Health Representative are vastly different. CHAs are mid-level primary medical providers who can provide basic medical attention and can connect a patient to clinical care. CHRs provide health promotion, prevention, and outreach to community members. Northwest Portland Area Indian Health Board

Complementary Programs CHR CHRs fill critically important roles to the health of their communities Longstanding presence in some communities Trained from the community May include indigenous knowledge informed systems of care Experience navigating patients to care and services in that specific community Deep understanding of culture, community, and existing health care infrastructure CHAP Broad scope of practice, provides routine, preventative, and emergent care Respects the knowledge and resources in the tribal community and grows providers from that source. Trains AI/AN community members who speak the native languages and provide culturally appropriate care Breaks down barriers to care and barriers to training; Training minimizes time away from communities and families. Brings care to communities; Fosters a team approach to delivering health care services. Not an exhaustive list of CHR or CHAP characteristics Northwest Portland Area Indian Health Board

Complementary Programs CHR is a great place to recruit for CHAP providers Thriving CHR program supports the entire health delivery system CHR and CHAP providers work together with the rest of the medical/dental team to improve the health of the community Northwest Portland Area Indian Health Board

President’s FY 2020 proposed budget (March 2019) The President’s FY 2020 proposed budget includes a cut of $39 million from the CHR program and at the same time creates a new $20 million line item for CHAP nationalization. The Administration has indicated their intent to transition CHRs into the CHAP Congress has not yet funded this proposal Tribes oppose CHAP expansion at the expense of reducing or eliminating the CHR Program Tribes would like to preserve and strengthen the CHR program For those Tribes that CHOOSE to implement a transition from CHR to CHAP, then resources and technical assistance must be provided by IHS To date, there has been no tribal consultation on elimination of the CHR program. Any substantial changes to the CHR program should, at a minimum, come only after a rigorous consultation process between the federal government and Tribes. Northwest Portland Area Indian Health Board

CHAP Board Advisory Workgroup Andrew Shogren, Chair – Suquamish Libby Cope, Co-Chair - Makah Kay Culbertson, Secretary - Cowlitz CHAP Board Advisory established 7/18/18 36 member workgroup Meets monthly via zoom and in person at QBMs Priorities IHS Interim Policy for CHAP; Portland Area CHAP Certification Board (PACCB); PACCB Membership Recommendations; Portland Area Standards and Procedures for DHAT, BHA/P and CHA/P; and Dental Health Academic Review Committee (DHARC), Behavioral Health Academic Review Committee (BHARC) and Community Health Academic Review Committee (CHARC)

Northwest Portland Area Indian Health Board Progress toward PACCB This pillar diagram represents where the CHAP Board Advisory Workgroup and NPAIHB is in the process of standing up the Portland Area CHAP Certification Board. We are in a holding pattern as we await the approved IHS CHAP Interim Policy. We have a draft resolution to stand up our certification board which we will provide to the policy committee at the first QBM following the approved policy. We have a white paper with recommendations prepared to provide to NPAIHB for PACCB membership. We will prepare a resolution for membership once we have NPAIHB agreement and provide that to the Area Director for consideration. At the first PACCB we will elect officers and approve PACCB Standards & Procedures, which were amended from the Alaska CHAP Standards and Procedures Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board DHAT Education DHAT Curriculum Year 1: basic health sciences, basic dental concepts, professional role development, introduction to clinic, patient and facilities management. Year 2: clinical year, expansion of concepts learned in first year, extractions, community project, village dental rotations. 10/9/2019 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board DHAT Scope of Practice Primary DHA (CDHC) Oral Health Educators Expanded Function DHA Restorations, cleanings, temporary fillings DHA Hygienist Local anesthesia DHA Therapist (DHAT) Prevention, operative, urgent 10/9/2019 Northwest Portland Area Indian Health Board

BHA Education & Training BHA-I Screening Initial intake process Case management Community education, prevention, early intervention BHA-II Substance abuse assessment and treatment BHA-III Rehabilitative services for clients with co-occurring disorders Quality assurance case reviews BHP Team leadership Mentor/support BHA-I, II, and III BHAs are hired by a Tribe or Tribal Health Organization before they are qualified to be enrolled in an education program. There are four levels of BHA certification (BHA-I, BHA-II, BHA-III, and BH Practitioner) The scope of practice 1) varies by level and 2) build upon each other. Alaska has developed a BHA education program that culminates in an AAS degree after 2 years of education and certification as a BHA II. This is the program that we plan to replicate for our NW tribes. Once a BHA has completed their preceptorship they can take a handful of additional classes to earn their BSW. BHAs provide services across the continuum from prevention, early intervention, intervention, and post-vention.

Behavioral Health Aides / Practitioners Village-based counselors to provide culturally-informed, community-based, clinical services Provide behavioral health prevention, intervention, aftercare, and postvention Training and practicum requirements On-the-job training Four levels of certification BHAs are educated to provide Alcohol, drug & tobacco abuse Grief, depression & suicide counseling. BHA positions in Alaska are growing with 52 last year at this time and 65 BHA/Ps as of June 2019. BHAP – 2 WA Tribes students have been accepted into the ANTHC/Ilisagvik BHA 2 year Education program, one from Swinomish and one from Lower Elwha S’Klallam and they start their on-line education August 19th following a 2 day orientation with iPad assignment in Anchorage on August 6 & 7. Both BHA students have Field Supervisor/Instructors provided by their Tribes who will attend orientation with their students. These BHAs are paid by their Tribe, provided paid time in their week to attend their on-line education and are able to provide care as they learn in their clinics and communities. Both students are recipients of Amerigroup Scholarships that pay their course fees (Ilisagvik waived tuition) and their travel for 3 intensive learnings in Anchorage for year 1 and year 2, culminating in their AS BHA degree. NPAIHB/Yellowhawk HOWTO grant awarded from OHA and OHSU for a virtual BHA education and training program for OR Tribes. This 3 year grant includes partnerships with NWIC for curricula and degree granting, NNACoE for student identification and mentoring, Yellowhawk will provide input and the space for the required 3 intensives each year for each class, Ilisagvik and ANTHC will provide consultation and technical support to the project for a successful launch. The BHA Advisory Workgroup is working on tribal based practices to include in the NW Tribes curricula and eBHAM for regional differences, Tribal based practices policy for clinic use in the NW Tribes and affiliated THOs, BHARC membership recommendations to the CHAP Board Advisory Workgroup, Student Selection Criteria and development of a Council of Elders to mentor and support our efforts and particularly our BHA Students. This dynamic workgroup is led by Marilyn Scott, Cheryl Rasar and Charlene Abrahamson. 10/9/2019 Northwest Portland Area Indian Health Board

CHA Education & Training Hired, usually by village council Pre-session: Intro to CHAM/CHA role/ETT or EMT Session I: 4 weeks 60 hours in village clinic Session II: 4 weeks 200 hours in village clinic Session III: 3 weeks 200 hours in village clinic Session IV: 4 weeks 200 hours in village clinic Session IV Blended: 18 weeks (16 weeks in village via Distance Learning Network, 2 weeks at Training Center )200 hours in village clinic, Blended Session I/II in progress Preceptorship: 1 week-skills & patient encounters; exam CHA trainee to CHP takes 3 to 4 years to complete. The wage scale varies greatly in Alaska, but a trainee is hired in around $14.00 to $16.00 per hour. According to Alaska Department of Labor, they can be considered exempt employees if a Tribe so chooses. Tribes vary greatly in how they compensate for increased levels of education and skill as well, but one idea to consider is a career ladder with increased wages based on certification at the next level. A new CHP might start at $28.00 per hour or a salary of $58,250.00. Alaska Certification Board reports that there are currently 104 vacant CHA/P positions out of 615 available. There are 456 practicing CHA/Ps in Alaska as of June 2019. 10/9/2019 Northwest Portland Area Indian Health Board

Community Health Aides and Community Health Practitioners Alaska Education Includes CHA/Ps Local people Initially described as “the eyes, ears and hands of the physician” 300,000 encounters per year Includes emergency, acute, chronic, and preventive health components Does not include differential diagnosis but does provide an assessment Under medical supervision of a licensed physician CPR / AED Emergency Trauma Technician or Emergency Medical Technician Certification Remote clinics operate as 24 hour access to emergency care The CHA/P is the local health care provider who provides emergency care, acute care, chronic care and preventative medicine.

Northwest Portland Area Indian Health Board Home grown, culturally knowledgeable and respected providers Competency based, skilled providers who increase access to care Extend the reach of services into hard to access areas Creates wrap around care and referral services for Tribes Increases the number of AI/AN providers Creates a career path for AI/AN providers Why CHAP Matters Proven history of safe, quality care in Alaska for over 50 years Uniquely developed for Alaskans by Alaskan and the same is true for Lower 48 Tribes Tribes can tailor their programs to their needs Decreases travel for routine or non emergency care Increases AI/AN local workforce 10/9/2019 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Questions? Three Pillars and a Glacier. 10/9/2019 Northwest Portland Area Indian Health Board