Community Health Aide Program

Refer to: OCPS

1. PURPOSE. To implement, outline, and define a National Community Health Aide Program (CHAP) policy for the contiguous 48 states. The policy encompasses community-based provider selection, culturally tailored care and curriculum, and competency-based education. The policy is also inclusive of health aides as part of a team of healthcare providers focused on providing effective, efficient, and patient- centered care, consistent with the structure of the Alaska CHAP.
2. SCOPE. This policy implements the statutory requirements of the Indian Health Care Improvement Act (IHCIA) that apply to CHAPs operated by the Indian Health Service (IHS) and Indian Self-Determination and Education Assistance Act (ISDEAA) contractors outside of Alaska. It is not applicable to the Alaska CHAP. In this policy, CHAP refers to the CHAPs operated by the IHS or ISDEAA contractors in the contiguous 48 states. This policy is not applicable to Urban Indian Organizations (UIOs) because UIOs are not authorized by law to implement CHAPs.

   BACKGROUND. The CHAP was established under the Snyder Act and the IHCIA to address significant unmet needs during an epidemic in Alaska. Over the years, it expanded to systematically train community health aides and practitioners, and maintain a system of certifying community health aides that have completed training and are competent to provide health care, health promotion and disease prevention services in rural Alaska. In 1992, Congress made CHAP a permanent program in Alaska and in 2010, it expressly permitted the IHS to develop a national CHAP to promote the achievement of the health status objectives in the IHCIA. These objectives are broad in scope and address virtually every aspect of health care, including access, delivery, and health status. Specialized training in medical, dental and behavioral health care and certification furthers those objectives by creating opportunities for health aides to focus their training and practice on particular health issues and delivery strategies. In 2016, the IHS consulted with Tribes and Tribal Organizations on expanding the CHAP nationally and in 2018, formed the CHAP Tribal Advisory Group (CHAP TAG) to make recommendations to IHS on expanding the National CHAP outside the State of Alaska.

3. AUTHORITIES.
   1. Snyder Act, 25 U.S.C. § 13
   2. Transfer Act, 42 U.S.C. § 2001
   3. Indian Health Care Improvement Act, 25 U.S.C. § 16161(d)
   4. Indian Self Determination and Education Assistance Act, 25 U.S.C. §§ 5301 et seq.
   5. Indian Health Service Tribal Consultation Policy, Circular No 2006-01
   6. U.S. Department of Health and Human Services Tribal Consultation Policy
4. POLICY. It is the policy of the IHS that:
   1. Tribes and Tribal Organizations outside of Alaska may carry out a CHAP, including those that include dental health aide therapists (DHAT), by amending their ISDEAA agreements.
   2. All CHAP providers certified by the Alaska Community Health Aide Program Certification Board (Alaska CHAPCB), who wish to provide services in a CHAP outside Alaska must submit a copy of their certification to the receiving CHAP Area Certification Board (ACB) for review and approval prior to being certified in that Area. Any CHAP provider certified by an ACB outside of the Area where he or she will provide services must submit a copy of their certification to the receiving ACB for review and approval prior to being certified in that Area.
   3. Only community health aides, behavioral health aides, and dental health aides, including DHATs actively certified by either an ACB in the contiguous 48 states or the Alaska CHAPCB, can provide services in a CHAP authorized by 25 U.S.C. § 16161. If Tribes or Tribal Organizations outside Alaska include a CHAP as a program, service, function, or activity (PSFA) in their ISDEAA contract or compact, the community health aides, behavioral health aides, and dental health aides, including dental health aide therapists (DHATs) and any other CHAP providers authorized by IHS providing services as part of the CHAP must be certified by either the Alaska CHAPCB or one of the ACBs authorized under this policy.
   4. Nothing in this policy shall restrict the ability of the Service, an Indian Tribe, or a Tribal Organization to participate in any program or to provide any service authorized by any other federal law.
   5. To date, Congress has not appropriated specific funding for the expansion of the CHAP. At the time of the effective date of this policy, the IHS Director has not determined how much, if any, of IHS’ lump-sum appropriation will be used to carry out the CHAP in the contiguous 48 states. Tribes and Tribal Organizations may propose to redesign or re-budget a PSFA in their ISDEAA agreement subject to any other applicable requirements to include this program.
   6. DHATs also must meet the federal training requirements for certification. However, DHATs shall only practice in states that authorize the use of DHAT services. This requirement applies to Tribes and Tribal Organizations seeking to include a CHAP as a PSFA in an ISDEAA contract or compact.
   7. Community Health Aides (CHAs) will be authorized to provide services in IHS-operated health programs once CHAs series and classification of position descriptions are created and approved by the Office of Personnel Management (OPM). This requirement does not apply to ISDEAA contractors.
   8. The IHS will not fill any federal vacancy for a licensed dentist with a DHAT. ISDEAA contractors are not subject to this restriction.
   9. Behavioral Health Aides (BHAs) may be utilized in IHS-operated health care programs using existing OPM-approved description for mental health specialists (OPM Series 0181 Psychology Technician and/or GS 0186 Social Service Aid) or other approved positions that may be established.
   10. Expansion of CHAP will comply with the IHCIA and not reduce funding amounts of the Alaska CHAP.
   11. The National Certification Board (NCB) is a federal board, and its membership may include Tribal and Federal representatives.
   12. No representative of either the NCB or ACB may represent the interest of a professional association on the respective certification board.
   13. The ACBs are federal boards and their membership may include at least one Federal representative appointed by the respective IHS Area Director.
   14. In the absence of an ACB, an IHS Area Director, in accordance with applicable tribal consultation policies, will consult with Area Tribes and Tribal Organizations before entering into a relationship with another IHS Area that has an ACB or with the Alaska CHAPCB for the purposes of certifying its CHAP providers. IHS Area Directors will make the final decision after consultation regarding entering such relationships.
   15. While ACBs are federal boards and comprise the NCB, an IHS Area Director may partner with Tribes or Tribal Organizations to carry out the support for the operation and maintenance of the ACB.
   16. NCB and ACB records shall be maintained in accordance federal records management requirements.
5. DEFINITIONS. This section provides background on the terms used in this policy. This section does not provide policy direction and should be used as a reference point for language in the policy.
   1. Academic Review Committees (ARC). Specialized body of practitioners, representing the behavioral, primary, oral health, and other relevant fields, that reports and makes recommendations to ACB regarding the training standards for all CHAP provider types.
   2. Area. Refers to one of the 12 IHS service Areas: Alaska, Albuquerque, Bemidji, Billings, California, Great Plains, Nashville, Navajo, Oklahoma City, Phoenix, Portland, and Tucson.
   3. Certification Boards. All providers who wish to provide services under the CHAP must be certified by one of the following boards:
      1. CHAP National Certification Board (NCB). The NCB is a federal board chaired by the IHS Chief Medical Officer (CMO) or his or her delegate and may be comprised of Federal and Tribal representatives from each ACB. Functions of the NCB and board composition are addressed in the Standards and Procedures.
      2. CHAP Area Certification Boards (ACBs). The ACBs are federal certification boards located in the contiguous 48 states and may be comprised of Federal and Tribal representatives. Their membership must include at least one federal representative appointed by the respective IHS Area Director. The ACB establishes board composition in its standards and develops the procedures of each respective board to certify individuals as their respective provider types.
   4. Community Health Aide Program (CHAP). The program certifies and provides education and training of Tribal community health providers who work as part of a team with other health professionals to provide health care, health promotion, and disease prevention services. CHAP currently includes three provider types listed below:
      1. Behavioral Health Aide. Refers to a behavioral health aide I, II, III, and practitioner, except when a level is specified. The specific roles and responsibilities of each level will be defined in the National CHAP Standards and Procedures and other applicable ACB requirements.
      2. Community Health Aide. Refers to community health aide I, II, III, IV, and practitioner, except when a level is specified. The specific roles and responsibilities of each level will be specified in the National CHAP Standards and Procedures and other applicable ACB requirements.
      3. Dental Health Aide. Refers to a primary dental health aide level I-II, expanded function dental health aide level I-II, dental health aide hygienist, and DHAT, except when the level is specified. The specific roles and responsibilities will be specified in National CHAP Standards and Procedures and other applicable ACB requirements.
   5. Standards and Procedures.
      1. National CHAP Standards and Procedures. Adopted in part from the Alaska CHAPCB Standards and Procedures to outline the minimum program standards for all CHAP provider types operating outside of Alaska. The National CHAP Standards and Procedures include, but are not limited to, the minimum training, training equivalency, supervision, and scope of practice requirements.
      2. Area Standards and Procedures. At a minimum, the Area Standards and Procedures must include the National CHAP Standards and Procedures and may have additional supplemental requirements above and beyond the national standards that are specific to the cultural considerations of the region, community specific needs, as well as the health care delivery system.
6. RESPONSIBILITIES.
   1. IHS CMO. Chairs the NCB. Consults with the CHAP Tribal Advisory Group to request initial membership for the NCB. Accepts nominations of Tribal representatives to serve on the NCB. Appoints members of the NCB. Ensures that NCB members shall not represent the interest of any professional association and will be comprised of representatives from across IHS Areas. The IHS CMO will make a good faith effort to ensure that the membership of the Board reflects the diversity of the geographic areas served and includes Tribal practitioners and Tribal administrators with relevant expertise.
   2. OCPS Director. The Director of the Office of Clinical and Preventive Services updates the National CHAP Standards and Procedures at the direction of the IHS CMO. Tracks national certification data. Serves as the Executive Secretary of the NCB. Ensures that the Divisions under the purview of OCPS provide appropriate subject matter expertise on the NCB.
   3. IHS Area Directors. Consults with Area Tribes to appoint members of the ACB and makes recommendations for appointments to the NCB. Provides ACB members with direction to establish board composition in its charters and to develop the procedures of each respective board. Certifies CHAP providers based on recommendations from ACBs. Approves and signs individual certification documents for CHAP providers. Appoints a federal representative to serve on the ACB.
   4. Area Director Designee. Appointed by an IHS Area Director. Provides recommendations regarding the operation of the ACB to the IHS Area Director based on discussions of the ACB on individuals who have met the CHAP training standards and should be certified to practice.
   5. NCB. Establishes National CHAP Standards and Procedures and approves the CHAP minimum training standards for all CHAP provider types outside of Alaska, for ACBs to utilize to ensure consistency across IHS Areas.
      1. Specifies baseline requirements and scope of practice for all CHAP provider types, including community health aides and practitioners, dental health aides (including primary dental health aides, expanded functions dental health aides, dental health aide hygienists, and DHATs), and behavioral health aides and practitioners.
      2. Conducts review of CHAP operations every three years to ensure consistency across all IHS Areas.
      3. Convenes ACBs at a minimum of every three years to review National CHAP Standards and Procedures.
      4. Determines what will constitute equivalent training of providers as authorized in the IHCIA.
      5. Maintains annual records of ACB actions regarding certification of CHAP providers. The IHS will maintain a database and make it accessible to tribal contractors and compactors to encourage them to extend reciprocity in appropriate circumstances.
   6. Area and/or Regional Certification Boards (ACBs).
      1. Maintains records of certifications of individuals certified by the Alaska CHAPCB or other ACB who work in the Area or Areas under the jurisdiction of the local ACB, and maintain a record of all CHAP providers certified, denied, recertified, revoked, and approved after appeal who work in the Area or Areas under the jurisdiction of the local ACB.
      2. Creates procedures that detail terms, chairmanship, quorum, meetings, duties, and transition functions.
      3. Ensures National CHAP Standards and Procedures established by the NCB, as well as any additional requirements set forth by the ACB for its applicable provider type(s), are met before certifying individuals for all CHAP provider types identified in 6D.
      4. Certifies CHAP providers. Certification is approved and executed when an IHS Area Director or their federal designee signs an individual's certification document. Once signed, a copy of the certification is sent to the NCB.
      5. Adopts Area-specific curriculum, consistent with the National CHAP Standards and Procedures established by the NCB, as needed, to ensure Area-specific needs are met.
      6. Ensures the National CHAP Standards and Procedures and the respective Area curriculum are culturally tailored and accessible to Area Tribal members.
      7. Ensures the portability of health aide certification across Areas.
      8. Reviews and approves the Area Standards and Procedures curriculum for each CHAP provider type on at least a three-year recurring cycle.
      9. ACB members shall not undertake activities or positions that promote the objective or agenda of a private organization, state, local, or Tribal government while serving in their ACB duties.
   7. Academic Review Committees (ARC).
      1. Conducts an independent review of the curriculum to ensure its alignment with the current health needs of American Indians and Alaska Natives.
      2. Develops recommendations to the NCB through the ACB on curriculum.
      3. Members of the ARC shall not undertake activities or positions that promote the objective or agenda of a private organization, state, local, or Tribal government while acting in their ARC duties.
7. SUPERSEDURE. None.
8. EFFECTIVE DATE. This circular becomes effective on the date of signature.
/Michael D. Weahkee/
RADM Michael D. Weahkee, MBA, MHSA
Assistant Surgeon General, U.S. Public Health Service
Director, Indian Health Service