Alaska Tribal Health Systems

"Serving rural Alaskan Natives through an integrated system of community practitioners and telemedicine."

By Tom Rowley

Providing quality health care to the people of rural Alaska is no small challenge. Vast distances, rugged terrain, severe weather and the lack of transportation options make it exceedingly difficult. The problems require solutions every bit as big and unique as the state itself. Indeed, they require multiple solutions involving multiple providers working together and evolving over time.

A very brief summary of that might look something like this.

Alaska has 229 federally recognized tribes and some 130,000 Alaska natives. About 85,000 of those people live in rural Alaska—many in communities of only a few hundred souls reachable only by boat, plane, snow machine, or dogsled. From 1970 on, Alaska Natives have increasingly taken over from the Federal government the responsibility for managing their own health care system. To do that the various tribes negotiated and signed an agreement known as the Alaska Tribal Health Compact with each other and the Indian Health Service. Through the compact, the Alaska Tribal Health System--a group of 39 tribal health organizations linked by an agreement on common goals and objectives—operates a half-billion- dollar-a-year health care sector, employs more than 6,000 people and runs the largest telemedicine system in the world. Included in the system are the Alaska Native Medical Center (a statewide referral and tertiary facility in Anchorage), six regional hospitals; and clinics in some 200 rural communities across the state.

As mentioned, the solutions are as big and unique as the state itself.

Big and unique, however, are not enough. Integration is key. Because health problems are multi-dimensional, so must the solutions be. And in rural Alaska they are. Consider, for example, the integration of Community Health Aides/ Practitioners and telemedicine.

Community Health Aides

Developed in the late 1960s, the Community Health Aide/Practitioner Program puts health providers on the ground in the remote rural villages of Alaska. Those health providers come from those very same villages, ensuring cultural sensitivity in the provision of care. Today the program, which is authorized and funded by Congress, has some 600 Community Health Aides/Practitioners (CHA/Ps) providing primary care in more than 170 rural Alaskan villages and acting as the first link in the Alaska Tribal Health System.

The program, unique in the world, works like this.

Aides are selected to serve by the people of their communities. Each CHA then goes through four training sessions lasting three to four weeks each at one of four regional training centers around the state. In between sessions, the CHA work in their home clinics, learning on the job, honing their skills and completing a required practicum. CHA are qualified to practice under standing orders of doctors hundreds of miles away, and become Community Health Practitioners after being certified by a statewide certification board.

According to Paul Sherry, CEO of the Alaska Native Tribal Health Consortium, which supports the CHA/P program and other aspects of the Tribal Health System, the areas served by CHA/Ps have the highest barriers to health care access in the United States.

“In these communities, the CHA/Ps do it all. They provide emergency and routine medical care. They arrange for referrals to the regional hospitals or to Anchorage, and they support medical and dental professionals who come in to the villages to provide additional services.”

In somewhat larger communities, those with 1,000 people or more, physician assistants and nurse practitioners are providing service. And many of them, says Sherry, are former CHA/Ps who have gone on for additional training.

In addition to primary care CHA/Ps, the consortium is working to get other types of small-community practitioners deployed:

• Behavioral Health Aides. In 2003, the consortium received $5 million from Congress to launch the Behavioral Health Aide Program and begin providing mental health care and substance abuse counseling in the villages. With that funding, the consortium worked with 13 regional health organizations to create and train 50 new positions.
• Home Health Providers. With an increasing elderly population, few long-term care options and the rising costs of the options that are available, home health is rapidly becoming a necessity. Consequently, the consortium is working to also include home health providers to complement the CHA program.
• Dental Health Aides. As in many rural areas, dental care is particularly lacking in rural Alaska. Creating trained Dental Health Aides with skill levels ranging from education and preventive services all the way up to oral exams, restorations and extractions would go a long way toward helping meet the needs. The consortium, however, is running into resistance by the American Dental Association, despite the fact that Dental Health Aides are authorized under the Indian Health Care Improvement Act. According to Sherry, ADA is expressing concern about “second-class dental treatment for Natives.” Those concerns, he says, are not proven. Worse still, he adds, the dental needs in Alaska are great and are not being met. According to the ANTHC website, Alaska Natives suffer rates of dental caries 2.5 times the national rate; and one-third of rural Alaska school children miss school because of dental pain.

The Navajo Foster Grandparents Program, run by the Navajo Area Agency on Aging office within the Navajo Division of Health, is one of only four such programs within the state of Arizona, but with a volunteer rate that is three to four times higher than the other Arizona projects. It falls under the Senior Corp program of Corporation for National Service, a federally funded national program with 30,000 volunteers throughout the U.S. Participants work 20 hours a week and are paid $2.65 an hour. The program initially began in the mid-1960s and the Navajo Nation joined in 1971.

"The Navajo Nation Foster Grandparents Program is a model program in Indian country," said Lenny Teh, an official with the Save the Children Foundation. Carole Mandino, who has spent 20 years working with senior volunteers throughout northern Arizona, believes the high volunteer rate in the Navajo Nation is because the Navajo signed on when the national project was in its infancy.

"It is [now] entrenched in Navajo culture," said Mandino, senior program coordinator for Northern Arizona University's Gerontology Institute. "There have been so many generations of volunteers on Navajo, that it has become part of the culture," she said, adding that the Navajo have great respect for their elders. "They have better relationships with children, than off-reservation people. They are the knowledge of the people and are an untapped resource."

There's an estimated 20,000 tribal members age 60 years on up across the reservation. Elders said they enjoy volunteering because it makes them feel good.