Executive Summary
Background and Introduction to CHAP
National CHAP Planning
Dental Health Aid Therapy (DHAT)
SPTHB CHAP Planning and Assessment
SPTHB CHAP TAP Community Survey Results
SPTHB CHAP TAP
Tribal Leadership and Healthcare Provider Survey Results
Successful Implementation 31-33
Aknowledgements, Conclusion and References
The Community Health Aide Program (CHAP), rooted in the principles of community engagement and cultural sensitivity, is successful in indigenous communities. Originating in Alaska, CHAP has evolved into a model that respects Native American populations’ unique needs and traditions, fostering a whole-person approach to healthcare and considering the importance of social, ecological, and indigenous determinants of health. The CHAP model emphasizes community involvement in healthcare delivery. Local community members are trained as health aides, enabling them to provide basic healthcare services, health education, and preventive care within their communities and empowering them to actively contribute to the health and well-being of their community. The CHAP brings healthcare services directly to Native American communities, reducing barriers to access and promoting early intervention. This grassroots, community-engaged approach ensures culturally relevant and readily available healthcare services, including closing the time gap between on-site and follow-up provider visits.
The CHAP model is adaptable to the diverse needs of different Native American communities within the broad disciplines of primary, dental, and behavioral healthcare. As evident in Alaska, health aides receive education in a range of healthcare services, including emergent care, maternal and child health, behavioral health, dental, and chronic disease management. This versatility allows them to address a wide array of health concerns within the community. Further, CHAP encourages collaboration between health aides and existing healthcare systems. By fostering partnerships with local clinics, hospitals, and Tribal health organizations, the program ensures an integration of services, maximizing the impact on community health outcomes. The staple of the CHAP model includes the efficient use of existing resources within Native American communities. By identifying and leveraging local assets, including community spaces and traditional healers, CHAP creates a sustainable and cost-effective healthcare solution that aligns with and supports Tribal values.
While an educational program has not been established in the Oklahoma
City Area (OCA), established programs from Alaska and the Portland Area Tribes developed for their communities provide a trusted resource guide for development that supports quality and comprehensive education for health aides that align with national standards.
The OCA is home to diverse Native American communities, each with distinct healthcare challenges. Recognizing the need for a tailored and communitydriven approach, this report provides resources and support for planning and implementing CHAP, an evidence-based model that has successfully addressed similar healthcare gaps. CHAP represents a sustainable, cost-effective, and culturally responsive strategic approach to addressing healthcare disparities among Native American communities. By empowering local communities to take charge of their health, CHAP can significantly improve health outcomes, promote cultural continuity, and build stronger, healthier Tribal communities. The CHAP creates both education and employment opportunities within communities, contributing to local economic development and it enhances the overall social fabric. Through collaborative efforts, the implementation of CHAP can serve as a model for Tribal self-determination, fostering healthier and even more resilient Tribal nations in the OCA.
The OCA Indian Health Service (IHS) serves the states of Oklahoma, Kansas, a portion of Texas, and Richardson County, Nebraska. Forty-three federally recognized tribes are represented within the states of Kansas (4), Oklahoma (38), and Texas (1).1 In FY 2023, the OCA user population was 420,385, the largest user population in IHS.1 The OCA is the lowestfunded IHS area per capita. The IHS, Tribal, and Urban Indian (I/T/U) health systems within the area manage nine hospitals, 64 health centers (which includes five health clinics in urban locations) and one regional youth alcohol and substance abuse treatment center.1 The large number of Tribal healthcare facilities and programs is a strong reflection of the partnership and cooperation within the OCA to fulfill our community’s existing healthcare needs.1
The Southern Plains Tribal Health Board (SPTHB) is recognized by the Internal Revenue Service as a 501(c)(3) non-profit organization and is regarded as a tribally designated organization. The SPTHB is a Native American representative body, is centrally located in Oklahoma City, Oklahoma, and was established in 1972 to provide a united voice for the 43 federally recognized Tribes located in the OCA. The SPTHB became a federally funded Tribal Epidemiology Center in 2004, creating the Oklahoma Area Tribal Epidemiology Center (OKTEC).
The OKTEC has been offering epidemiology and statistical services to area Tribes, Tribal organizations, and urban Indian organizations (TTU) continuously since its inception. The governing body of the SPTHB includes representation from each of the 12 IHS Service Units within the OCA (KS, OK, and TX). Each person on the 12-member board is nominated by a local Tribe or consortium of Tribes from each area to represent them. Non-voting board membership also includes urban Indian organizations and OCA IHS. The SPTHB has a well-established, successful history of grant, project, and outreach management.
Furthermore, the SPTHB has established and continues to maintain a network of partnerships composed of individuals and organizations at local, county, state, and national levels. These collaborations span the multiple sectors necessary to influence change in various health areas, including assistance with assessment, improvement planning, and evaluation. The SPTHB is committed to providing TTUs with education/training, technical assistance (TA), and resources to support success. The SPTHB provides public health leadership, surveillance, epidemiology, public health program design, implementation and evaluation, and technical support to address a wide range of public health issues.
Originating in the 1960s in Alaska, CHAP was created to address emergent health concerns across the state such as tuberculosis, high infant mortality, and high rates of injury.
Since the program received formal recognition and federal funding in 1968, CHAP has evolved into a tribally led multidisciplinary health provider education and certification system enhancing Alaska’s healthcare delivery system by increasing the number of available healthcare providers to increase access to primary, dental, and behavioral healthcare to rural Native American communities,2 which has resulted in improved health status across Alaska.3
This success is attributed to the strong collaboration between Tribal health organizations, and state and federal governments. In 2010, based on CHAP’s success at addressing health disparities and social determinants of health in Alaska, Congress included language in the Indian Health Care Improvement Act (IHCIA) to make the program available to Tribes outside of Alaska. Tribal leaders began advocating for CHAP in 2015; subsequently, this action initiated program expansion to the lower 48 states starting in 2018.
The Alaska CHAP consists of roughly 550 Community Health Aides/Practition-
ers (CHA/Ps) in more than 170 rural villages. These CHA/Ps are often the only medical providers in smaller rural Alaskan communities. They receive their education and training at certified CHAP training centers in Alaska and they operate within the guidelines of the Community Health Aide/Practitioner Manual (CHAM) that outlines the assessments of treatments and protocols.4 The CHA/ Ps have an established referral relationship with Advanced Practice Providers (APPs), physicians, and the Alaska Medical Center. Established CHAP physicians will visit the rural communities they oversee whenever possible in collaboration with the local CHA/Ps who are in the communities full time. Therefore, CHA/ Ps can treat certain conditions under standing orders from a referral physician and/or after consultation with an assigned provider.2
Additionally, CHAP includes dental health aides. In Alaska, primary dental health aides provide patient education and preventative services such as fluoride and oral hygiene education. They can also be trained to be a dental assistant, take radiographs, provide cleanings, complete atraumatic restorative treatment, and place sealants. Expanded function dental health aides can be educated to either place restorations or provide cleanings. Dental Health Aide Hygienists must hold a state license as a registered dental hygienist. Dental Health Aide Therapists/Practitioners (DHAT/DHATPs) receive three academic years of education through the Ilisaġvik College/ANTHC Alaska Dental Therapy Educational Program or another Commission on Dental Accreditation (CODA) accredited program. DHATs can provide diagnosis and treatment planning, cleanings, sealants, fillings, and extractions. The goal of the dental health aide therapist practitioner (DHATP) certification is to recognize DHATs who have proven over time that they are reliably providing competent care for their patients. The result is a change in the supervision requirements to allow them to practice more efficiently while putting other safety mechanisms in place to ensure these providers continue to deliver high-quality dental healthcare to Alaska residents accessing dental care through Tribal health organizations. All dental health aides earn certification from the Alaska Community Health Aide Program Certification Board.5
DHAT/DHATPs are the providers with the largest scope of practice in oral health under the CHAP umbrella. They operate under the supervision of a licensed dentist to provide restorative and preventative oral care, and they can perform uncomplicated extractions when necessary.6 The first DHAT in the United States began practicing in 2004 after completing training in New Zealand.7 Since then, the literature has well established that DHATs have contributed to improved oral
health outcomes in the communities in which they work. Notably, in these communities, fewer dental extractions are necessary, and the community receives more preventative oral care.8
The most recent discipline of CHAP includes the Behavioral Health Aides/Practitioners (BHA/Ps) who serve their communities in various roles such as health educator, case manager, counselor, and advocate. This facet of CHAP creates avenues of care for those who struggle with behavioral health conditions, such as anxiety, depression, grief, or addiction, but who might not feel safe asking for traditional help due to the risk of stigma, societal judgment, or personal shame. Because these BHA/Ps are community members, they have the unique ability to understand the cultural and historical contexts of their communities, which hopefully reduces the stigma a patient might feel when seeking help.9 BHA/Ps are educated in traditional and spiritual healing and they can provide holistic care for their communities.9
The Tribal Community Health Provider Project (TCHPP) in Portland, Oregon, oversees the Dental Health Aide Program (DHAP), the Behavioral Health Aide Program (BHAP), and the CHAP Program. The TCHPP partners with Portland Area Tribes to increase access to high-quality, culturally responsive medical, behavioral, and oral healthcare through training and employing CHA/Ps, BHA/ Ps, and DHA/Ts. Tribal leadership and Tribal health organizations in the Portland Area saw the need for health aides to address chronic health provider turnover and shortages, address important social determinants of health, increase access to primary care, and create professional wage jobs for their Tribal citizens in their health programs. Tribes in the northwest have been building CHAP infrastructure, including education programs, since 2015.
The CHAP model is grounded in its ability to facilitate access to competencybased, skilled professionals who provide routine primary, behavioral, and dental care for Tribal members in rural communities or other areas that do not have access to full-time physicians, dentists, or other behavioral health professionals. Not only is CHAP helpful for improving the quality of life for Native American communities but it also creates wrap-around care. Meaning that everyone can receive comprehensive care from providers that have strong relationships with the larger health systems nearby, so the referral processes are streamlined and efficient.
CHAP’s core, and what makes it successful, is that it was developed by Tribes
for Tribes, and it allows for the development of local Tribal members to train to become certified within the CHAP in their own communities. Through national expansion, there is an opportunity for homegrown and culturally responsive providers to serve their communities’ diverse and unique needs, which translates lived experiences and community connections to improved health and well-being.
One of the important facets of CHAP that sets it apart from other programs is its sustainability and its commitment to Tribal sovereignty. The ability to invest in local community members means Tribes can support and guide providers to address specific community needs. In turn, this increases Native American providers and local workforce while protecting the Tribes’ rights as individual sovereign nations.
The Portland Area has been instrumental in expanding CHAP nationally. As of 2023, there are 25 CHAP providers in the Portland Area, 20 that completed another level of their training at the end of 2023, and four students on track to complete their training by the end of 2025. The Portland Area has three CHAP education programs. One Dental Health Aide Therapy Education Program and two Behavioral Health Aide Education Programs. The Community Health Aide Education Program accepted its first cohort in the fall of 2023 in collaboration with four Tribal health organizations. By the end of 2026, it is expected that the CHAP in the Portland Area will be over 100 providers strong.
Congress authorized IHS in 2010 to nationalize CHAP to advance the achievement of the health status objectives in the Indian Health Care Improvement Act (IHCIA).
After national advocacy by Tribal leaders, in 2016, IHS consulted with Tribes and Tribal organizations about expanding the CHAP nationally that led to the development of a CHAP Tribal Advisory Group (CHAP TAG). This group brings together Tribal leadership and experts on CHAP to advise the IHS on expanding the CHAP in the lower 48 states and to advance the program in Alaska.
The focus of the CHAP TAG has been on implementing a policy, formatted as a chapter of the Indian Health Manual and published as circular 20-06 to establish a National Advisory Committee and support Area Certification Board development and operation.1, 10 Alaska and the Portland Area operate federal authorized certification boards. The Billings Area CHAP Certification Board is in development and expected to launch in 2024.1, 10
The CHAP TAG advocates for a Tribal–Federal partnership and a CHAP that is tribally regulated and tribally designed.11 The IHS Circular No. 20-06 provides Title I Contracting Tribes and Title V Compacting Tribes located outside of Alaska the ability to include CHAP in their ISDEAA agreements.11 The circular provides policy specifically to implement the CHAP for Tribes and Tribal organizations in the contiguous 48 states consistent with the structure of the Alaska CHAP without affecting the Alaska CHAP or its funding. Further, the circular requires health aides to be certified by either an Area Certification Board (ACB) or the Alaska Community Health Aide Program Certification Board.11
Due to the stagnancy of the national CHAP rollout, IHS Director Roselyn Tso has directed her team at IHS to develop a new approach to CHAP that is clear and proactive and respects Tribal sovereignty while meeting the federal obligations. This includes a rewrite of the current CHAP policy (IHS Circular 20-06) that will better reflect the unique Tribal nature of CHAP while establishing the necessary federal infrastructure, including consultation responsibilities related to Programs, Services, Functions, and Activities (PSFAs) or inherent federal functions.
The new policy will also ensure institutional CHAP knowledge from the Tribal communities most experienced with CHAP is integrated into implementation.
The IHS seeks to find the right balance between providing clear and meaningful guidance that supports the development of necessary CHAP infrastructure while respecting the leadership, expertise, and sovereignty of the Tribes. At the time of this publication, the policy is being revised.
A provision of the IHCIA (P.L. 111-148), inserted just before the bill passed, presents a barrier for CHAP’s full expansion. In a section governing IHS’s expansion of CHAP, Congress included language limiting Tribal use of dental therapy (also referenced as DHAT, DHA/T under CHAP).
This law is a significant burden for Tribes such that a Tribe is prohibited from hiring a dental therapist under CHAP unless state law authorizes dental therapists to practice within that state.
The exact legal text of IHCIA with this limitation is found in Section 25 U.S.C. § 1616l (d), and reads:
“(d) Nationalization of program
(1) In general, except as provided in paragraph (2), the Secretary, acting through the Service, may establish a national Community Health Aide Program in accordance with the program under this section, as the Secretary determines to be appropriate.
2) Requirement; exclusion Subject to paragraphs (3) and (4), in establishing a national program under paragraph (1), the Secretary(A) shall not reduce the amounts provided for the Community Health Aide Program described in subsections (a) and (b); and (B) shall exclude dental health aide therapist services from services covered under the program.
(3) Election of Indian tribe or tribal organization (A) In general Subparagraph (B) of paragraph (2) shall not apply in the case of an election made by an Indian tribe or tribal organization located in a State (other than Alaska) in which the use of dental health aide therapist services or mid-level dental health provider services is authorized under State law to supply such services in accordance with State law. (B) Action by Secretary on an election by an Indian tribe or tribal organization under subparagraph (A), the Secretary, acting through the Service, shall facilitate implementation of the services elected.”
In July 2021, the SPTHB Board of Directors passed Resolution 2021-002 that expresses support for dental therapy as a solution to Indian Country’s oral health challenges.
This resolution catalyzed the creation of resources to support dental therapy advocacy in Oklahoma. In 2022, through funding the National Indian Health Board’s Tribal Oral Health Initiative provided, the SPTHB published the toolkit titled, Expanding the Oral Health Workforce: A Dental Therapy Toolkit for Oklahoma. Along with a myriad of resources and data included, this toolkit provides results from a consumer-based survey SPTHB administered to understand better the concerns, challenges, and potential solutions to increased access to oral healthcare in Oklahoma.
The responses from 201 participants pointed to three major concerns: oral health services to rural populations, lack of covered benefits for oral health services, and decreasing oral healthcare-related emergency room/urgent care visits.12 Additionally, 96% of respondents believe dental therapy is a practical solution for Oklahoma, 92% would encourage Tribal or organizational leadership to support dental therapy as one solution to improve access to oral healthcare in their communities, and 82% believe their community members would be willing to receive treatment from a dental therapist.12
In October 2023, the SPTHB co-chaired the inaugural in-person American Dental Therapy Association’s Annual Conference held in Oklahoma City. This conference brought together Tribes, dentists, dental hygienists, and others from all over the nation to discuss the benefits and possibilities of dental therapists in communities. Representatives from Oklahoma Tribes participated in state-wide discussions alongside elected officials to learn more about how dental therapy could be integrated into Tribal clinics to improve access to dental care.
The National Indian Health Board created a Dental Therapy Start-Up Guide for Tribal Leadership and other resources to support their efforts in state advocacy efforts as part of their Oral Health Initiative.13 The National Partnership for Dental Therapy (NPDT) is another hub for resources and tools to assist Tribes, Tribal organizations, and other advocates that want dental therapists in their state. Co-chairs of the NPDT include the National Indian Health Board, Community Catalyst, American Dental Therapy Association, and the National Coalition of Dentists for Health Equity.14
Starting in 2021, with the $5 million appropriated for CHAP expansion, the IHS established two CHAP granting frameworks: Tribal Assessment and Planning (TAP), and Tribal Planning and Implementation (TPI). In 2021, the SPTHB was awarded the CHAP TAP grant along with two Tribal Nations in the OCA. The CHAP TAP purpose is to help Tribes/ Tribal organizations (T/TO) assess the feasibility of implementing CHAP into their existing Tribal health system through the two-year funding period. The program is designed to support the regional flexibility required for T/TO to design a program unique to the needs of their individual communities across the country through identifying feasibility factors. The CHAP TAP grant goal is carried out through the following objectives.
whether the Tribe/Tribal organization can integrate CHAP into the Tribal health system including the healthcare workforce.
systematic barriers that prohibit the complete integration of CHAP that exist within the healthcare system related to clinical infrastructure, workforce, certification of providers, training of providers, and the inclusion of culture in the services provided by a CHAP provider.
partners across the Tribe/Tribal organization geographic region to address the systematic barriers that may include reimbursement, training, education, clinical infrastructure, implementation cost, and system integration.
The crux of the SPTHB CHAP TAP program was to evaluate and establish internal infrastructure, assess need area-wide, establish a learning collaborative, engage and support Tribes that are interested in implementing CHAP, and identify and engage key stakeholders.
The SPTHB CHAP team developed three surveys:
The surveys were developed in collaboration with the OK Area CHAP Learning Collaborative. The surveys were developed based on the community readiness assessment model that incorporated key elements of the CHAP TAP grant such as:
1. clinical infrastructure
2. workforce training
3. cultural inclusion
4. implementation
5. cost
The SPTHB CHAP team dedicated most of its time and resources to achieve an appropriate sample of community survey responses and began efforts to engage with Tribal healthcare providers and health directors. Thus, a complete sample of provider and leadership were not obtained.
Community readiness is a measurement used to determine a community’s likelihood to take action on a certain issue and/or embrace a new intervention. Readiness is described by nine levels and increases as the levels increase.
No awareness of the issue: The community or leaders do not generally recognize the issue as a problem.
Denial/resistance to the issue: At least some community members recognize that it is a concern, but there is little recognition that it might be occurring locally.
Vague awareness of the issue: Most feel that there is a local concern, but there is no immediate motivation to do anything about it.
Preplanning of the intervention: There is clear recognition that something must be done, and there may even be a group addressing it. However, efforts are not focused or detailed.
Preparation of the intervention: Active leaders begin planning in earnest. The community offers modest support of their efforts
Initiation of the intervention: Enough information is available to justify efforts. Activities are underway.
Stabilization of the intervention: Activities are supported by administrators or community decision-makers. Staff are trained and experienced.
Confirmation/expansion of the intervention: Efforts are in place. Community members feel comfortable using services, and they support expansions. Local data are regularly obtained.
High level of community ownership of the intervention: Detailed and sophisticated knowledge exists about prevalence, causes, and consequences. Effective evaluation guides new directions. The model is applied to other issues.
Once community readiness is gauged on a certain topic, program developers can begin to plan the intervention effort at the community’s readiness level. Then, the goal is to move the community through the levels, one at a time, to achieve successful program implementation to address the needs of the specific issue at hand.15
For CHAP, the community readiness score provides insight into the community’s willingness to embrace the program and measure its understanding of various aspects of program implementation. Per the CHAP Community Survey Responses, the community has a vague awareness (Level 3) of the clinical, workforce, and training infrastructure that affect CHAP implementation. Additionally, the community is at Level 5 in terms of the cultural inclusion necessary for CHAP implementation.
The purpose of the CHAP community survey was to identify knowledge, attitudes, and beliefs about integrating CHAP into Tribal health systems in the OCA. The CHAP survey for Native American community members was administered using the geo-cluster approach, or geographic and demographic segmentation. Populations were targeted based on several variables, including cultural preferences, rurality, race, state, and where they receive their healthcare services. This allowed for a more comprehensive profile of our audience. The survey was distributed among Kansas, Oklahoma, and Texas Native American communities during private and public community events the SPTHB CHAP team had been invited to attend, such as health fairs, health conferences, outreach events, wellness walks, and training summits.
The survey was also distributed in common gathering areas within the community, such as health programs, clinics, senior centers, cultural centers, and cultural events. Community members completed the mobile, self-administered questionnaire using personal cell phone devices as well as company-owned tablets made available to those who did not have the ability to access the online survey via link or QR code. The SPTHB CHAP opted to incentivize the survey in hopes of encouraging community members to participate, complete, and share information on how to access the survey within their communities to improve sample quantity and quality target respondents.
The key areas of CHAP that were assessed were clinical infrastructure, workforce infrastructure, certification of providers, training of providers, and cultural inclusion. This survey was reviewed and determined to be exempt from a full review by the OCA IHS Institutional Review Board (IRB).
The results include responses from community members, healthcare providers, and Tribal leadership.
1
The ages of the participants ranged from 19-65+ years old.
Seventy-two (25%) participants were in the 35-44 age range, 58 (19%) in the 25-34 age range, 50 (17%) in 45-54 age range, 50 (17%) in the 65+ age range, 43 (14%) in the 55-64 age range, and 27 (9%) in the 19-24 age range (Figure 2).
A total of 295 community members completed the survey, and 87% (257/295) identified as Native American. The other 13% (38/295) identified as a non-native employee of a Tribe, a non-native family member, native Hawaiian/white, and/or a member of a nongovernmental organization (NGO) serving Tribal nations.
A total of 236 (79%) of the participants who completed the survey identified as female, 61 (20%) as male, and 3 (1%) as nonbinary/two-spirit/third gender.
Figure 2
Most community members pay for healthcare with IHS coverage (38%) or private insurance (33%).
Others pay for healthcare with Medicare/Medicaid (15%) coverage, a combination of private insurance and cash (8%), cash only (3%), and other methods not specified (3%) as displayed in Figure 3.
3
To better understand access to healthcare, community members were asked if there was a time when they needed healthcare, such as primary care or dentistry, and were unable to get it; 33% said yes, and 67% said no.
Reasons for being unable to access healthcare included long wait times, costs, lack of transportation to get to the doctor, being unable to find a doctor or set up an appointment, unavailability of culturally trained healthcare providers, fear, embarrassment, or stigma (Figure 4).
‣ When asked why it had been more than a year since participants had an annual checkup, reasons included being unable to take off work, costs, only going to a doctor if sick, and fear of doctors.
‣ Many community members surveyed indicated they have a dental provider (74%), and primary care provider (82%), and only 38% indicated having a behavioral healthcare provider.
‣ Many community members indicated that they use an IHS clinic (59%) when sick, followed by urgent care (20%) or other sources (11%). Other sources included a primary care provider or clinic as well as Tribal clinics.
‣ When asked about community members’ general knowledge of their physical, mental, and dental health needs, 75% indicated basic knowledge, 13% indicated no knowledge, 9% indicated intermediate knowledge, and 3% indicated expert knowledge.
‣ Community members were asked if, in the last year, there was a time when they needed to see someone to talk about problems such as stress, anxiety, or emotions but could not; 36% said yes, and 64% said no (Figure 5).
Reasons for being unable to talk to someone included lack of transportation to get to a counselor, not knowing how to find a doctor or set up an appointment, long wait times for appointments, no culturally trained counselor available, fear, embarrassment or stigma, cost, and other (Table 1).
‣ When asked if community members would be willing to be trained as health aides, 159 (54%) said yes, and 42 (14%) said no. When probed on why not, participants wrote responses related to older age and being retired, currently working a full-time job, working as a nurse or as another type of healthcare professional already, being too busy or not having enough time to be trained, living with health problems preventing them from being trained, being a student in school, and/or not being interested.
‣ When asked if community members would be interested in a career as a health aide, 138 (41%) said yes, 77 (26%) said no, and 78 (27%) were uncertain. When probed on why not, participants wrote responses similar to those about being trained as health aides (Figure 6).
Figure 6: Willingness to have a career as a Community Health Aide
Figure 6: Willingness to be trained as a Community Health Aide
Community members seemed very willing (displayed as a range of involvement from 0-100%) to engage in CHAP in various capacities, including supporting community efforts; participating in developing, improving, or implementing efforts; and playing a key role as a leader or driving force (Table 2).
‣ When asked if community members are in support of their Tribe investing in training and developing more healthcare providers from the community, 97% said yes. Generally, community members would support expanding efforts in their community to increase access to healthcare providers through a CHAP that provides education, training, and economic opportunities.
‣ When asked about concerns related to lack of access to culturally responsive healthcare providers for members of the community, 55% said it was somewhat of a concern, 35% said it was a big concern, and 10% said it was not a concern.
‣ Further, 99% of participants believe that cultural knowledge is important in healthcare delivery to Native Americans, and 98% believe it is beneficial to provide cultural training to healthcare providers.
‣ Cultural awareness and credibility in the community may help shape changes in health behavior. Participants were asked about interest in cultural health practices to be implemented in their community, and Figure 7 shows their responses.
Figure 7: Which of the following cultural practices would you be interested in having implemented in your community? (Select all that apply)
‣ When asked how important traditional healing practices are to their community, 48% said very important, 46% said somewhat important, and 6% said not important (Figure 8).
‣ When asked if they would support their Tribe expanding traditional healing practices in the community, 97% said yes, and 3% said no.
When asked if community members and leadership would support use of available resources to increase access to healthcare providers through CHAP, 95% of respondents said yes. When asked if community members and leadership would be willing to allocate additional resources to help fund CHAP’s implementation efforts, the majority (88%) said yes (Table 3.).
When conducting interviews (in person or via Zoom) with Tribal leadership (health directors and those serving in senior roles) related to CHAP, themes that were found include needs for CHAP success, barriers to implementing CHAP, and benefits and opportunities.
To ensure CHAP success, Tribal leadership communicated a need for more information related to CHAP that can be shared with the community, other Tribal leadership, partners, facilities, and providers to educate patients on the benefits of CHAP. Specific types of information include training curriculum and credentials for CHAP providers, evidence of CHAP success in other communities, and how CHAP complements current services provided and would not result in competition for funding of current programs.
Barriers to implementing CHAP from Tribal leadership’s perspectives include ongoing and current staff shortages, concerns about long-term funding and sustainability, and building trust in new programs and people, especially given the low community awareness of CHAP.
Benefits and opportunities of CHAP from Tribal leadership’s perspectives include partnerships with local high schools and colleges for recruitment of CHAP providers, utilizing CHAP to expand home healthcare, especially for elders, and the enthusiasm that a CHAP provider would foster in patients to see the same healthcare provider more consistently. Further, CHAP could provide more education and employment opportunities for community members, especially among rural clinics.
The overall readiness score for implementing the CHAP among Tribal leadership is Level 4, preplanning.
Existing Community Efforts
(5) Preparation
Community Knowledge of the Efforts (4) Preplanning
Leadership (5) Preparation
Community Climate (4) Preplanning
Community Knowledge About the Issue (3) Vague Awareness
Resources Related to the Issue (5) Preparation
OVERALL READINESS SCORE (4) Preplanning
Table 5
READINESS SCORES—All Responses (7)
The provider readiness score concerning clinical infrastructure for CHAP was 29%, with the stage of readiness being no awareness (1). When providers were asked about the most important needs/barriers to healthcare access in the community, transportation and provider shortages were the greatest need reported.
The provider readiness score for workforce infrastructure for CHAP was 52%, with the stage of readiness being denial/resistance (2). With severe underfunding for the CHAP, providers were asked what suggestions they had for building
and sustaining the program. Responses included more exposure, volunteering a set number of hours each month, Centers for Disease Control and Prevention (CDC) and National Indian Health Board (NIHB) funding, utilizing Tribal resources, and searching for other outside sources of funding.
When providers were asked what problems they had identified with planning and implementing CHAP, responses included a need for more information on the program, providers not seeing any problems that need to be addressed with the program, political views that clash with those of the program, a misunderstanding of the program, financial barriers, staff shortages, volunteer shortages, resistance of Tribal governments being willing to change, and unwillingness to start a new program at supervisory and administrative levels.
When providers were asked what resources were available, staffing, facility space or meeting sites, training, financial support, and technological resources were reported.
When providers were asked whether they were willing to investigate the possibility of becoming a CHAP supervisor and working with health aides, 64% responded yes and 36% said no.
The merits of CHAP are evident through the success of the Alaska CHAP, proving the value of CHAP services to Native American communities. The Oklahoma City Area Tribal grantees have conducted assessments to determine knowledge, attitudes, and beliefs relating to CHAP integration into their Tribal health systems. Through the CHAP Tribal assessment and planning phase, it has been determined that funding for CHAP implementation and ongoing support is the major barrier to CHAP implementation, including widespread education and general awareness of the program. As it currently stands, Tribes will receive no annual appropriation, and no additional Tribal shares are available. The CHAP providers outside of Alaska will have to operate strictly on third-party revenue or other revenue sources. While this is substantive and essential for sustainability, funding through Tribal shares allows for the incorporation of cultural traditions and Indigenous ways of healing not yet recognized by third-party reimbursement. Additionally, there is currently no funding dedicated to supporting CHAP that includes education and regulatory infrastructure necessary to support CHAP providers. Outside of Alaska, to ensure success and sustainability for CHAP, education programs need to be funded adequately as part of
638 programs. Without strong, dedicated financial support from Congress for CHAP’s administrative and educational functions, the program will struggle with growth, maintenance, and expansion. The Alaska CHAP provides evidence that it works as an expansion to providing and accessing healthcare services in Indian Country, just as Self-Governance has been proven to work for healthcare under the Indian Self-Determination and Education Assistance Act (ISDEAA).
In the contiguous 48 states, CHAP expansion should be funded as a Program, Service, Function, and Activity (PSFA) as a 638 program under the ISDEAA. As an IHS PSFA, CHAP should be funded as a Tribal share so that funds are available for distribution to every Tribe in the country, with the option to leave their share with IHS or take it under the authority of Title 1 or Title V of ISDEAA, a proven vehicle for funding successful Tribal healthcare through contracting or compacting with IHS. Additionally, funding should be provided for associated contract support costs to fully support the breadth and intention of CHAP. Further, funding should continue to be made available for CHAP planning and implementation efforts.1
The OCA Tribal representatives on the National Tribal Budget Formulation Workgroup for the IHS FY 2026 budget recommend that grant distribution continue to aid Tribes exploring the development of CHAP outside Alaska and grant funding should be increased commensurate to needs.1 At the same time, IHS should request from Congress a permanent recurring annual base for the CHAP.1 These recurring funds should be distributed throughout IHS areas so the appropriate infrastructure can be established at national and area levels. Areas will be able to utilize this funding to create ACBs customized to their unique needs.1
From SPTHB’s community survey, when asked if community members utilize certain resources to obtain Tribal health information, responses were wide-ranging, from websites and IHS clinics to other Tribal members (Table 6). A widespread awareness campaign should be initiated to provide information about CHAP. During SPTHB’s outreach through CHAP TAP activities, many had heard of CHAP but were unaware of the details, progress, outcomes, and implications. Broad engagement with Tribes to share information about CHAP has been discussed during CHAP TAG meetings as a priority.
Tribal consultation for the OCA should be conducted to further identify area priorities and needs and how best the OCA can continue to support national and area infrastructure development. The SPTHB intends to continue to leverage the OCA CHAP Learning Collaborative and other platforms to facilitate opportunities to provide subject-matter experts to share information and engage in implementation activities surrounding CHAP.
The SPTHB CHAP staff, Tribal partners, and other key stakeholders are committed to the success of CHAP as an action of Tribal sovereignty and Tribal selfdetermination as a means toward achieving health equity. The SPTHB has been honored to facilitate and support CHAP planning for the OCA Tribes for the last three years and, with Tribal input and direction, have established collaborative platforms and engaged multiple stakeholders to begin organizing the pieces of CHAP that make for the development of a successful program.
A convenience sampling strategy was utilized for this survey. The goal of this survey was to hear from Native American community members in Kansas, Oklahoma, and Texas. The survey was distributed at private and public community events. Because of this nonprobability sampling strategy, the results of the survey may not be generalizable to other populations.
The lack of general awareness of CHAP during SPTHB’s outreach could be viewed as a limitation. While there was information available about CHAP prior to survey administration (brief oral presentation, flyer, etc.), without foundational knowledge of CHAP, the respondents could have misinterpreted questions on the survey that were specifically related to CHAP or health aides.
Conducting community surveys requires resources in terms of time, money, and personnel. The funding amount, limited staff, geographical scope, and abbreviated grant timeline (30 months) reduced the size of the sample, the geographical reach, and the methods of data collection. These limitations resulted in resource allocation toward the community survey administration that prompted a smaller sample size of provider and Tribal leadership responses.
The Southern Plains Tribal Health Board would like to acknowledge the following authors and contributors that supported the development of this report. Many thanks to our tribal partners and community members for your time, expertise and sharing your experiences, we greatly appreciate it.
Authors
Julie Seward (Cherokee), RDH, MEd
CHAP Program Manager
Southern Plains Tribal Health Board
Amanda J. Llaneza, MPH
Epidemiologist
Southern Plains Tribal Health Board
Taylor Middendorf, MPH, CPH
Health Promotion Sciences Student
University of Oklahoma College of Public Heath
Contributors
Christina Friedt Peters, M.J.
Tribal Community Health Provider Project Director
Northwest Portland Area Indian Health Board
Kimberlee Burgess (Otoe Missouria), RN, BSN
CHAP Program Coordinator
Southern Plains Tribal Health Board
Kynsington Cochran (Kiowa)
CHAP Public Health Specialist
Southern Plains Tribal Health Board
Leader, LLC
CHAP Consultants for the Wichita and Affiliated Tribes
Katie Ferguson (Cherokee)
Special Projects Officer-CHAP
Cherokee Nation
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2. Health Aides of Alaska. Community Health Aide Program (CHAP). https://akchap.org/community-health-aide/about/.
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