Updated Summary

Addendum to the ethnomedical curriculum on Health and Health Care of Alaska Native Older Adults

Author: P. Kay Branch, M.A.

The federal government has a special trust responsibility to individuals of American Indian/Alaska Native (AI/AN) descent, based on a long history of treaties, court decisions, federal law and policies. As part of that trust responsibility, Congress provides health care services for AI/ANs through a regulatory framework developed in the Indian Health Service. AI/AN tribes prepaid for this health care by relinquishing their land to the U.S government and early settlers.

Two important laws passed in the 1970s continue in effect today, the Indian Health Care Improvement Act and the Indian Self-Determination and Education Assistance Act (PL 93-638), which states “… it is the policy of this nation, in fulfillment of its special responsibilities and legal obligations to the American Indian people, to meet the national goal of providing the highest possible health status to Indians and provide existing Indian health services with all resources necessary to effect that policy” (ISDEA Act, 25 USC 450). PL 93-638 has given tribes in Alaska the ability to operate and run programs formerly carried out by the Bureau of Indian Affairs and the Indian Health Service. Tribal contractors and compactors have a strong commitment to excellence in service, challenged by adequacy of funding provided by Congress.

For a complete history of public health policy for this population, please see Promises to Keep, edited by Mim Dixon and Yvette Roubideaux (2001).

In the context of understanding Alaska Native health and health care in addition to some of the devastating infectious diseases and historical trauma, it is also important to have knowledge of how federal medical care has been provided to Alaska Native people since the 1950s and how it is evolving today. Anyone interested in a comprehensive history of health care in Alaska should review Dr. Robert Fortuine’s Chills and Fever: Health and Disease in the Early History of Alaska (1989). The current overview will chronicle the important events in the creation of what is now an exceptional model for providing health care in the most remote areas of the U.S.

Timeline

1835 – 1840

Small pox epidemic

1900

Measles and influenza epidemics

1930s

Tuberculosis epidemic, first time Alaska Native people were relocated from villages for treatment

1950s

Sanitation and Chemotherapy Aides began as volunteers in villages

1953

The Indian Health Service (IHS) opened the Alaska Native hospital in Anchorage

1955 – 1980s

Indian Health Service operated six hospitals and a statewide community health program

1965

Formal training began for village volunteers now known as Community Health Aides

1969

Community Health Aide training manual created; training centers established. Creation of the Alaska Native Health Board to offer advisory Native perspective at the
policy and planning level

1975

Passage of the Indian Self-Determination and Education Assistance Act (P.L. 638), which led to the transfer of Native health programs from federal to Native ownership.
Under this authority, Alaska tribes and tribal organizations have assumed
responsibility for most IHS programs.

1976

Passage of the Indian Health Care Improvement Act

1980s

First Community Health Aide Manual (CHAM) published with a Village Drug Reference

1998

Alaska Native Tribal Health Consortium formed and assumed responsibility for the operations of the majority of the Indian Health Service’s Alaska Area office programs.

2013 – Current Status

Most of the funding for IHS services in Alaska (99%) now goes to tribal non-profit health organizations around the state. The Alaska Tribal Health Compact is the self-governance agreement with the IHS. The tribal health organizations negotiate annually as a group with the IHS for the following year’s funding. This group of tribal health providers makes up the Alaska Tribal Health System (ATHS).

The Alaska Tribal Health System is a multi-level system of birth-to-death care. Comprised of a Tribal network of over 160 village clinics, 36 health centers, seven hospital facilities, and two nursing homes, the ATHS is divided into eight major geographic regions covering a land mass approximately one-fifth that of the 48 contiguous U.S. The user population consists of approximately 140,000 Alaska Native people, 70% of whom are dispersed among more than 200 rural remote villages with no connecting road or rail system. The other 30% reside in more urbanized areas, primarily the Anchorage vicinity. At the village level, trained Community Health Aides/Practitioners (CHA/P) provide routine primary care and 24-hour emergency care to village members under the supervision of staff physicians located at regional hospitals. Regional staff physicians assigned responsibility for specific villages conduct periodic field clinics.

Primary and secondary services are provided in the six regional hospitals in Barrow, Kotzebue, Nome, Bethel, Dillingham and Sitka. Varying in size from 14 beds to 50 beds, these hospitals are operated by their own regional tribal health organization with a local Board of Directors. All have an emergency medical department, family medicine, pediatrics, obstetrics, pharmacy, physical therapy, dental and vision care.
Tertiary and Specialty Medical Services are provided statewide through the Alaska Native Medical Center (ANMC) in Anchorage. ANMC is jointly managed by the Alaska Native Tribal Health Consortium (ANTHC) and Southcentral Foundation (SCF), a Native primary care entity serving the Anchorage area Alaska Native population. ANMC services are provided within a 150-bed acute tertiary specialty referral hospital. For specialty services within and beyond the Anchorage service area, ANMC collaborates with Tribal partners that independently operate the six rural hospitals and 178 village clinics to provide care through on-site field clinics, consultation and referral planning, and joint patient management via telemedicine technology. Specialty services include medicine (cardiology, internal medicine, oncology, neurology, dermatology, gastroenterology and pediatrics); surgery (general surgery, orthopedics, otolaryngology, ophthalmology, and urology); adult and pediatric intensive care; and high-risk obstetrics and perinatology.

In addition to co-management of the hospital, ANTHC provides an array of statewide services formerly provided by the Indian Health Service. The ANTHC Board of Directors is composed of regionally-elected or Tribally-appointed Alaska Native representatives from 15 Tribal organizations. ANTHC provides statewide community health services primarily through two major divisions: the Division of Environmental Health and Engineering (DEHE) and the Division of Community Health Services (DCHS).

DEHE provides planning, design, construction and operations support of public health infrastructure in Alaska Native communities across the state. DEHE has overseen the construction of village clinics in more than 150 villages, and works to ensure safe drinking water and sanitation facilities throughout rural Alaska. DCHS works to elevate the health status of Alaska Native communities while monitoring and improving Alaska Native health through research, training health providers, and providing education for disease prevention. DCHS staff study trends and develop solutions for priority health problems and work with many tribal health organizations and communities to improve the health of Alaska Native families. ANTHC also develops and presents training to village-based community health aide programs including medical, dental, and behavioral health aides.

Community Health Aide Program

The Community Health Aide Program is unique to Alaska. It is a distinctive health care delivery system developed to serve a population that is dispersed over a large geographical area with limited transportation options. The program trains local people to provide a specified level of health care to residents of her/his community. There are over 600 Community Health Aides/Practitioners (CHA/P) providing health care in Alaska. The primary care model is used and includes emergency, acute, chronic and preventive health components. Health aides manage a full range of health care issues across the life span, function under the medical supervision of a licensed physician, and are first responders in local emergency situations. Health aides participate in an extensive four-level training program within the Alaska Tribal Health System and operate within the scope of a federally approved Alaska Community Health Aide/Practitioner Manual (CHAM). Health aides and training centers are certified under the federally authorized Community Health Aide Program Certification Board.

The CHAM provides patient care protocols for CHA/P daily practice; it provides consistent treatment guidelines and is intended to reflect best practices adapted to the level of training, remote locations and resource allocations of the CHA/P in villages throughout Alaska. The CHAM includes a section on assessing an elder, including conditions more common in this population. A specific Elder Care module is provided in the CHA/P level four training session. Some of the specific tools available in the CHAM are a fall risk assessment, a home safety survey and an assessment of activities of daily living.

Community Health Aides are the lifeline to health care throughout the Alaska Tribal Health System and one reason for the improved health status and increased life expectancy of Alaska Native people. CHA/Ps are the main source of full-time healthcare in many villages, with mid-level practitioners, physician assistants and nurse practitioners located in some larger sub-regional villages. The Community Health Aide Program is the model standard for two additional programs added in recent years: the ATHS Dental Health Aide Therapist (DHA) and Behavioral Health Aide (BHA) programs.

Telemedicine

Increasingly telemedicine is playing a larger role in the provision of health care in rural Alaska. There are telemedicine carts and capabilities in nearly all regional village clinics that are being utilized in a variety of ways. AFHCAN, a program of the Alaska Native Tribal Health Consortium, designed and developed an innovative store-and-forward telehealth software solution to meet the health care needs of rural Alaska. AFHCAN has evolved into an FDA listed medical device manufacturer that provides an array of telehealth services that empower organizations to improve health care delivery worldwide. The combination of the store-and-forward system, used for services such as primary care, surgery, dermatology, neurology, and otolaryngology; coupled with highly-successful clinical program development has made AFHCAN a leading authority in the telehealth world. In working with multiple independent health care organizations for nearly a decade, AFHCAN has developed an evolving line of supported telehealth services. AFHCAN staff collaborate with individuals and organizations to establish successful telehealth programs intended to fit within existing clinical workflows. More recently, programs have expanded to conduct real-time video consultations and examinations for Cardiology, Oncology, Pediatric Endocrinology, Speech Language Pathology and other specialty services. These telemedicine services have saved millions of dollars in travel costs and have provided quality care closer to home for patients.

Additional Resources

Alaska Community Health Aide Program:
http://www.akchap.org/html/home-page.html

AFHCAN Telehealth:
http://afhcan.org/

Alaska Native Tribal Health Consortium
http://www.anthctoday.org/

ANTHC Elder Care
http://anthctoday.org/community/eldercare.html