1. Behavioral Health Aides: A Grassroots Approach to Rural Behavioral Healthcare
Presented By: Xiomara Owens, MS

2. Objectives Describe key elements of BHA program Context
Certification program
Describe BHA scope of work
Across the continuum of care
Identify factors related to program implementation and sustainability

3. Overview Context History & current events Stakeholders and partners
AK Health Aides Programs
Certification Board
Standards & Procedures
Behavioral Health in Alaska
BHA scope of practice
BHA billing & reimbursement
BHA Training & Resources
Behavioral Health Aide Manual
Context
-Symposium priority areas (involuntary commitment, access to services, and recruitment/retention of qualified BH staff)
-Alaska
History & Current events
Partners
Certification program
BHAM

4. Program Context: Geography, Culture, State

5. Population Demographics
Alaska’s area: 570,641 miles2
Total Alaska population: 737, 354
Alaska Native/American Indian population: 143,367
Median age: 26.8 years
Diverse Alaska Native cultural groups
11 distinct cultures
11 different languages, 22 different dialects
Alaska is the least densely populated state
Alaska Department of Labor (2014)
Alaska's total estimated population (N=737,354).
143,367 Alaska Native/American Indian people lived in Alaska (19.4%)
The estimated median age for the Alaska Native population was 26.8 years, compared with 34.3 years for all races.
More than one third (38.7%) of the estimated Alaska Native/American Indian population was under the age of twenty. Less than a tenth (6.9%) of the Alaska Native/American Indian population was aged 65 years or older.
Vary by region
Most regions have AK Native populations less than 8,000 (as low as 1,635)
Three regions with populations between 16,000 and 23,000
Largest population in Anchorage/Mat-Su (48,732)

6. Alaskan Context Geography Weather Seasons Culture Natural resources
Hrs. of daylight
Culture
Natural resources
Subsistence
Community
Beautiful
Extreme weather
Subsistence living
Remote/rural
Limited access to resources (including healthcare)
In state travel (connecting between communities

7. Alaska’s Tribal Health System
To meet the healthcare needs of our state, we have a system of care that divides the state into regions
Generally speaking, each region has tribes and tribal councils who oversee and inform their regional Tribal Health Organization
All Health Aides are employed by their regional Tribal Health Organization

8. A Statewide System Village-based Sub-regional Regional Statewide
Contract health
Village-based services
Small village clinics, Community Health Aides, Behavioral Health Aides, Dental Health Aides, home health/ personal care attendants
Subregional services
Mid-level practitioner serving several villages
Regional services
Referral hospital or physician health center
Statewide services
Alaska Native Medical Center
Contract health services
External or private sector referrals

9. Alaska Native Health Care Referral Patterns

10. Partners and Partnership
Indian Health Services
Alaska Native Tribal Health Consortium
Community Health Aide Program
Dental Health Aide Program
Behavioral Health Department
Community Health Aide Certification Board (CHAPCB)

11. Partners and Partnership
Tribal Health Organizations
Tribal Behavioral Health Directors
State of Alaska, Dept. of Behavioral Health
Alaska Behavioral Health Association
Local, regional, and statewide providers
Training partners

12. Key Contextual Factors
Alaska is REALLY big (and extreme)
Alaska is like a village
Tribal Sovereignty and the Tribal Health System
Coordinated access to higher levels of care
Cultural identities and practices
$$$
Funding, cost of living, travel, billing/revenue
Autonomy and Partnership

13. Who are YOU serving? Demographics Cultural identity & practices
Where are they located?
Rural, remote, urban
Issues related to access?
Including stigma and/or familiarity with MI/SA
Are you investing in prevention and early intervention?
Clients and workforce

14. Who are YOUR partners?
Similarities and differences between communities, regions, organizations?
Where is the common ground?
What systems need to be in place/ coordinated?
Levels of care and provider types
Billing systems and sources of revenue
What is your vision for integrating BHAs?
In your healthcare system? Communities?
Who needs to have a seat at the table?
Current partners and opportunities for new

15. Program History: Healthcare Close to HOme

16. CHAP History
1950s Chemotherapy Aides (Volunteers) Direct Observed Therapy for TB patients
1960s Formal Training/Federal Funding 1968
1976 Indian Health Care Improvement Act (IHCIA) (PL )
1992 IHCIA amended to add § 119 that provided for the Alaska Community Health Aide Program under authority of the 25 U.S.C. § 13 and required a Certification Board (PL )
WALTER: A key time event in the evolution of the Community Health Aide Program, I would say, was the February 1964 meeting of the area service unit directors in Anchorage. That is, those individuals, in this case, physicians, that would be responsible for the various service units in Alaska having a -- you had a meeting in Anchorage.
The thrust of this meeting was how to get the community involved. And I actually have the letter that was sent out by the area director, Dr. Holeman Warrick, to those of us who participated to talk about getting more community involvement.
The idea of training local people came up at the meeting, and it was a very animated discussion.
A number of the Public Health nurses who had carried this burden as itinerants, going to the villages, instructing people in midwifery and -- and giving immunizations and all the other things they did, always came back with a list of medical problems and would sit down with us physicians and try to resolve them. These problems that they had encountered in the villages.
Pilot programs from
Congress did then approve and budget, in 1968, funds to support 185 health aide positions in 157 villages. That being the official beginning of the funded Community Health Aide Program.
As a little sidelight, these folks were called -- were referred to as medical aides, usually, but because of all this emphasis on community was sort of the buzz word at the time, that's switched over.
And also, it took -- in retrospect, that took a little of the sting out of the -- out of the threat to the -- the medical hierarchy, probably. And because they were “health” rather than “medical” was less of a hot button.

17. Health Aide History
Alaska Area Director appoints a CHAP Certification Board (CHAPCB)
2002 Standards amended to address Dental Health Aides and Therapists (DHA/T)
2005 First DHA/Ts Certified
2008 Standards amended to address Behavioral Health Aides and Practitioners (BHA/P)
2009 First BHA/Ps Certified
1998 Alaska Area Director appoints a CHAP Certification Board (CHAPCB)
Majority of tribal representatives.
CHAPCB Standards and Procedures adopted
CHA/Ps formally certified
2002 Standards amended to address Dental Health Aides and Therapists (DHA/T)
2005 First DHA/Ts Certified
2008 Standards amended to address Behavioral Health Aides and Practitioners (BHA/P)
2009 First BHA/Ps Certified

18. Certification Board Members
Training Center Regions (4)
CHA Training Centers (1)
CHAP Directors’ Association (1)
CHA Association (1)
Medical Director (1)
Federal [Alaska Area Native Health Service] (1)
State of Alaska (1)
Dental Health (1)
Behavioral Health (1)
www. akchap.org
Standards & Procedures
Summary of Certification requirements
Application Forms

19. Standards and Procedures
Certification requirements
Program oversight
Supervision requirements
Scope of practice
Competencies (Knowledge & Skills Checklist)
Training & related curriculum
Practicum
Continuing education
Approved training sponsors
Side note about
Medicaid billing being tied to Standards and Procedures (CHAPCB as certifying entity)
SPA being informed by the CHAPCB Standards and Procedures

20. CHAPCB Program Operations
Ongoing review of applications & granting certification
Maintain database and applicant files
Facilitate 3 Board meetings per year
Travel and support for Board Members
Billing, budget projection & reconciliation
Correspondence, newsletter & website
Additional Board meetings may be held as needed
Certification period is 2 years. Fee is $500 for any action on application in that time period.

21. Individuals who are certified as a BHA/P…
Why Certification?
Completed Board-specified training and work requirements
Have knowledge and skills specific to their scope of practice
Stay updated on best practices (Continuing Education)
Quality services
Standards of care
Recognized provider type
Shows a person has mastered knowledge and skills for providing certain services
Implies that services are provided ethically and according to the healthcare standards of care.
Recognizes BHAs as an important provider for substance use and mental health services

22. How will YOUR BHAs get certified?
Why certification?
What is it? Why is it important? What does it represent?
Structure for certification
Interdisciplinary Certification Board
Committed, detail oriented, collaborative, informed
Board staff
Staff at organization
Commitment to model, supervision, integration of BHAs into service model

23. How will YOUR BHAs get certified?
Standards and Procedures
Establish requirements to meet and maintain a standard
Designed to honor context and culture
Scope of work
Consider and/or align with other systems
Other providers’ scope of practice
Local and regional resources
Standards: integrates value of culture, community, clinical; training, practicum, work experience hours, and continuing education)

24. Behavioral Health: BHA Scope of Practice

25. Behavioral Health in Alaska
Adverse Childhood Events
Historical trauma
Unintentional injury
Suicide
Substance abuse
Binge drinking
Alcohol abuse mortality
Domestic violence

26. Alaska’s BHA/Ps

27. Standards and Procedures: Behavioral Health Aide Program
Employed by tribe or tribal organization
Administrative oversight (Licensed)
Clinical supervision (Licensed or unlicensed)
Four levels of certification
BHA-I, BHA-II, BHA-III, BHP

28. Standards and Procedures: Behavioral Health Aide Program
Scope of practice
Culturally-informed, community-based, clinical services
Behavioral health prevention, intervention, aftercare, and postvention
Certification requirements
Training
Practicum
# of work hours
40 CEUs every 2 years

29. BHA Scope of Practice BHA-I BHA-III BHP BHA-II Screening
Initial intake process
Case management
Community education, prevention, early intervention
BHA-II
Substance abuse assessment & treatment
BHA-III
Rehabilitative services Quality assurance case reviews
BHP
Team leadership
Mentor/support BHA-I, II, and III
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
Provide services across the continuum from prevention, early intervention, intervention, and post-vention
Per the Certification Standards and Procedures, these are the services BHAs are trained to provide
Variation in regional needs, access, and capacity of BH services may influence the actual services provided (e.g., if they have substance abuse counselors, BHAs may focus more on prevention-based activities)

30. Aligning systems CHAPCB / State of Alaska
Clinical Associate
Behavioral health screening/ client status review
Short-term crisis stabilization
Case management
Peer support services
Screening and brief intervention
In the SoA system, BHAs fall under the category of Clinical Associate
Clinical Associates have less than a master’s degree and based on their competencies, are able to provide the services listed here
These services are billable under Medicaid

31. Aligning systems CHAPCB / State of Alaska
Clinical Associate (continued)
Comprehensive community support services (adults)
Individual & Group
Therapeutic behavioral health services (children)
Family (with & without patient)
Can be primarily with BHA
Can complement clinician’s clinical work
Often focuses on skills-development and maintenance (e.g., coping strategies, safety planning and use)

32. Aligning systems CHAPCB / State of Alaska
Substance Abuse Counselor
Assessments
Treatment
Can be primarily with BHA
Can complement clinician’s clinical work
Often focuses on skills-development and maintenance (e.g., coping strategies, safety planning and use)

33. Who do BHAs Serve? Families Elders Individuals Youth
The Blues & the News
National Geographic
Alaska Native Tribal Health Consortium
Individual (grief and loss, case management, substance abuse assessment and treatment, skills building)
Elder (case management, welfare checks, community luncheons, appointments, housing or other resource applications, psychoeducation)
Youth (IEP meetings, skill development, anti-bullying activities, youth groups, presentations, culture camps)
Family (case management, resource identification and coordination, referrals, ICWA, WIC assistance, disability and Medicaid applications)
Elders
Families
Individuals
Youth

34. BHAs Serve Their Communities
Alaska Dispatch News
fenton.com
Alaska Dispatch News
Meetings (building community partnerships, meeting coordination and logistics, facilitation, identify elders and presenters)
Activities (drum making, berry picking, walks/runs, health fair, craft events, exercise groups, family fun nights)
Psychoeducation (information about different topics, how they effect health and well-being, reviving traditional knowledge and practices to address modern-day issues)

35. Domestic Violence: Prevention & Intervention
KYUK.org
ANTHC
Domestic violence prevention and intervention (healthy relationships and healthy communication presentations, resource development and identification, community campaigns)

36. Substance Abuse: Prevention and Intervention
Tobacco Free Alaska
Indian Health Services
Indian Health Services
Substance abuse prevention and treatment (presentations, groups, sober activities, welfare checks, case management)
Tobacco cessation (psychoeducation, referrals, counseling)

37. Suicide, Grief, and Loss: Prevention, Intervention, Postvention
KTVA.com
Suicide prevention and intervention (crisis stabilization, case management, on-call)
Grief and loss (crisis response, community support, support groups)

38. Defining Your BHA Scope
What is your vision for the BHA program?
In your healthcare system? Communities?
Prevalence of behavioral health problems
Current providers and scope
Within behavioral health
Interdisciplinary team
Clear distinction between certification levels
Scope of practice
Competencies

39. Behavioral Health Aide: Training towards certification

40. ----------------------------
BHA Training
THO Employment
Supervised by Master’s level clinician
Work experience hours
Training curriculum
100 hour Practicum
Competency evaluation
Employee development plans
Related to scope of work
Specific to cert. level
Specific courses and curriculum (CHAPCB)
Curriculum builds upon itself
Two pathways to certification
Non-academic (Specialized)
Academic (Alternative)
Must be CHAPCB approved

41. BHA Training: Two Pathways
Specialized
Alternative
Based on CHAPCB curriculum
Blended delivery
Online LMS
Distance and OJT
In-person
Intensives
Annual BHA Forum
Industry certificate/ degree
Not be specific to CHAPCB curriculum
Add’l courses required to meet cert. requirements
Pipeline to career

42. BHA-I Courses General Orientation (28)
Orientation to Village-based BH Services (8)
Ethics & Consent (6)
Confidentiality & Privacy (6)
Intro to Behavioral Health (24)
Intro to Counseling (12)
Intro to Documentation (12)
Survey of Community Resources & Case Mngmt (8)
Working with Diverse Populations (12)
Intro to Group Counseling (8)
Crisis Intervention (16)
HIV/AIDS & Blood-Borne Pathogens (8)
Community Approach to Promoting BH (8)
Family Systems I (16)
Recovery, Health, Wellness, & Balance (8)

43. BHA-II Courses Psycho-physiology & Behavioral Health (16)
Intro to Co-Occurring Disorders (8)
Tobacco Dependency Treatment (8)
DSM Practice Application (12)
Advance Interviewing Skills (16)
ASAM Practice Application (12)
Case Studies & Clinical Case Management (8)
Traditional Health Based Practices (8)
Intermediate Therapeutic Groups Counseling (16)
Applied Crisis Management (8)
Community Development Approach to Prevention (12)
Family Systems II (16)

44. BHA-III Courses Treatment of Co-Occurring Disorders (12)
Advanced Behavioral Health Clinical Care (40)
Documentation & Quality Assurance (16)
Intro to Case Management Supervision (16)
Applied Case Studies in Alaska Native Culture Based Issues (8)
Behavioral Health Clinical Team Building (12)
Intro to Supervision (8)

45. BHP Courses Issues In Village-Based BH Care (40)
Special Issues in BH Services (16)
Competencies for Village-Based Supervision (16)
Principals & Practice of Clinical Supervision (40)

46. BHA Training: Resources
CHAP and DHAT training programs
Existing training partners
In-house
Online Learning Management System
Local substance abuse counselor training program
University certificate and degree programs
Developing model of training delivery
Blended delivery
Maximize distance-delivery
Course blocks
Find a partner who honors/prioritizes YOUR curriculum

47. BHA Training: Current Events
Training includes:
Course work
Practical application
Integrating current events into training
OJT with supervision
Evaluation of competencies
Training should:
Be thoughtful
Prepare skilled providers
Offer career opportunities
AAS Degree Program at Iļisaġvik College
Meets BHA-I and BHA-II cert. reqs
Certificate (yr. 1), AAS (yr. 2)
Registered Apprenticeship (RA)
Model for workforce training and development
Recognized nationally, earn and learn, wage increases
Billing/revenue
BHA State Plan Amendment
Certified BHAs as a billable provider
Encounter rate for specific services
Reduced documentation requirements
Side note about SPA being informed by the CHAPCB Standards and Procedures

48. Behavioral Health Aide Manual eBHAM
Professional Orientation
Clinical Skills for Client Care
Client Care Chapters
Overlapping BH Concerns
Introduction
The BHAM was created exclusively for the BHA program. Due to our funding source, this first edition of the BHAM has an emphasis on working with children and adolescents, though the majority of its contents can be used to support clients of any age.
The BHAM is grounded in Alaska Native ways of knowing and recommends culturally and clinically appropriate services based on best practices adapted specifically for Alaska. It is intended to compliment BHA training and often defers to Organization’s unique Policies and Procedures and/or clinical supervisors for guidance. It is not intended to be a general medical reference or self-teaching tool. It is a practice manual that is intended to reinforce BHA training and guide them to practice within their scope of training and certification.
Based on the recommendations of the Statewide committee, the BHAM includes 5 primary section:

49. BHA Knowledge & Skills (Competencies)
Working with Others
Screening and Assessment
Planning Services
Providing Services
Linking to Community Resources
Community Education and Advocacy
Cultural Competency and Individualizing Care
Documenting
Professional and Ethical Practice
Professional Development

50. How Will You Train YOUR BHAs?
Standards and Procedures
What is their scope of practice?
Knowledge, skills, abilities (competencies)
BHAs
BHA supervisors
Process for evaluation
Curriculum and training tied to competencies
Teamwork: BHAs, Supervisors, Instructors

51. How Will You Design Your Model of Training?
In-house & Partners
Staff & Community expertise
Instructional designers
Distance & In-Person
Synchronous & Asynchronous
Competencies and evaluation
OJT and Supervision
Industry certificate & career opportunities

52. Key Factors to Grow a BHA Program
Partnerships and resources
Certification Board
Training
Consistency / fidelity
Integration
Into BH system
Included in tx plan
Train other providers how to work with BHAs
Sustainability
Billing systems and revenue potential

53. web: anthc.org/behavioral-health-aide-program/
Quyana!
ANTHC:
CHAPCB:
BHA program
web: anthc.org/behavioral-health-aide-program/