This report is based on record-level data extracted from records written by village CHA/Ps. These records were coded at the regional health centre and submitted electronically into the Indian Health Services’ National Patient Information Reporting System (IHS NPIRS) (17). Data were made available by request from the Office of Information Technology at IHS NPIRS and included only patient care given by a CHA/P in a village clinic.

This project was a program evaluation, not research, as determined by the Alaska Area Institutional Review Board. Permissions to utilize data for this evaluation were obtained from the Association of Alaska Community Health Aide Program Directors, Association of Tribal Health Directors and individual Tribal Health Directors from each participating organization.

Patient visit data, without individual identifiers, were examined from 11 of the 27 (40.7%) Tribal Health Organizations employing CHA/Ps between October 1, 2004 and September 30, 2006. While only 40.7% of Tribal Health Organizations are included in this analysis, these organizations comprise 92% of the CHA/P work force and serve 90% of all patients served by village Community Health Aides and Practitioners in Alaska (18,19).

For a patient encounter to be included in this review, care must have been provided directly by a CHA/P and the record must have the date of visit, age, sex, and a diagnosis or procedure code (International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The first diagnosis for a visit fitting inclusion criteria was used for this analysis. ICD-9-CM codes were grouped into categories consistent with CHAM assessments by the author and the list is available on request. SAS Statistical Software, 9.1 (SAS Institute, Inc., Cary, NC) was used to summarize CHA/P diagnoses by region, age group, sex, clinical diagnosis, and treatments provided.

In order to evaluate emergency care, all diagnostic codes listed in an NPIRS encounter were reviewed for inclusion as potential emergencies or urgencies. These were categorized into larger groups for analysis. (A list of ICD-9-CM codes included with grouping is available in Appendix 1.) A diagnosis that was an emergency or urgency will appear both in the major categories of diagnoses and in the urgency/emergency category as seen in Tables IV and Table V.

A total of 272,242 CHA/P visits from 150 villages were recorded in IHS NPIRS between October 1, 2004 and September 30, 2006. Of these encounters, 197,190 (72.4%) had at least 1 recorded clinical diagnosis (Table I). While the focus of this report is on clinical practice, 75,052 (28%) of the 272,242 CHA/P records examined did not contain a recorded diagnosis. Most (>98%) of these visits without a diagnostic code were for pharmacy activities, including medication refills and delivering medications. In addition, of the 197,190 encounters with diagnoses, 11,832 were recorded as a diagnosis of “medication refill” (ICD-9 CM code V68.1). Together this means 86,884 (32%) of total workload was for medication and/or pharmacy related activities. Other nonclinical reasons for visits to the clinics included 7,040 (4%) for administrative tasks (ICD-9 CM codes V68.0, 68.2) and 2,326 (1%) for laboratory tests without a specific diagnosis.

The 10 most common tests or procedures accounted for 98% of all procedures performed by CHA/Ps and were in rank order: oxygen saturation testing, antibiotic injections, immunizations other than influenza, phlebotomy, injury care, nebulizer therapy, other injections, respiratory testing (including peak expiratory flows), culture collection, and influenza immunizations. Injury care includes wound irrigation, packing, skin closure and splinting injured limbs.

Community Health Aides and Community Health Practitioners are the frontline healthcare providers in remote Alaskan communities. Although the CHA/P program has formally existed since 1968, this report is the first state-wide assessment of CHA/Ps’ practice. CHA/Ps see a broad scope of health care problems on a regular basis, as documented above. Their care of patients is directed by their training, reference manual, and system procedures within an integrated referral system that includes physicians, regional hospitals, and a tertiary hospital. They are an important first point of contact for health care in the Alaska Tribal Health System.

The Community Health Aide Program's origin was to provide chronic tuberculosis medication to patients living in remote villages. During the 40 years of existence, the scope of care has expanded, but CHA/Ps continue to help with patient's chronic medication needs. The Community Health Aide/Practitioner Manual has specific sections that address follow-up of chronic problems, including evaluating patient health status, providing patient education and assisting with medication refills. From this study, we found nearly one-third of CHA/P practice involves assisting patients with their medications, including helping them obtain refills for management of chronic health problems. This is an important finding and has implications on work load and training. However, it is unclear from the methods we used if these visits were only for facilitating medication refills or if they also included an evaluation of the patient's status. Since these data were collected, some regional pharmacies have begun sending medication refills directly to patients via the US Postal Service. It remains to be seen how this will affect Community Health Aide workload.

Community Health Aides and Community Health Practitioners may be compared to Community Health Workers in the USA and elsewhere in the world. Within the literature we reviewed, we found a wide variety of definitions and duties for Community Health Workers. CHWs in countries such as Peru, Pakistan, and Iran provide direct patient care as do Alaska CHA/Ps (22–26). In the US in 2005, there were an estimated 121,000 Community Health Workers. They play an important role in patient education, advocacy and linking patients to medical providers (27–29). They have been employed to improve outcomes in diabetes, cancer screening, prenatal care, and childhood immunizations through counselling, linguistic and cultural translation, and by arranging transportation for patients and families (27,29,30). Brownstein describes Community Health Workers as “uniquely qualified to be connectors to the community because they generally live in the communities where they work and understand the social context of patients’ lives” (29). CHAPs are similar to Community Health Workers in that they typically live in the communities they serve; many work in the same village where they were raised from childhood. CHA/Ps, however, differ substantially from US Community Health Workers in that they provide direct patient care for acute illness, chronic diseases, preventive services, mental health and medical emergencies.

Approximately 56% of CHA/P workload state-wide is entered into the Indian Health Service's Resource and Patient Management System (RPMS), an electronic health record, and exported to NPIRS (31). No provision was made to identify individuals who have repeat visits during the study period. The effects of multiple encounters by individuals may influence the rank and order of reported diagnosis. This might have increased the apparent number of visits for problems requiring follow-up. In addition, because we limited our review to the first diagnosis listed in NPIRS (except for emergency diagnoses), we have no certainty that we captured the most important diagnosis, or indeed, adequately described the full complexity of care provided by CHA/Ps. For example, a child who was seen primarily for otitis media and who also received preventive services such as well-child care or immunizations would register as only an otitis media visit. A more complete assessment of CHA/P practice could be obtained by using “any listed” diagnosis from the NPIRS data. The findings from this review should not be used to infer prevalence or incidence of specific diseases or conditions in the served population.

Uta Lehmann and David Sanders state “CHW programmes are not cheap or easy, but remain a good investment, since the alternative, in reality, is no care at all for the poor living in geographically peripheral areas”. They add, “We need to learn from examples of large-scale successful programmes in this regard, particularly providing longitudinal evidence of what works and what does not work” (32). Recently, Balcazar and others have advocated for integrating Community Health Workers into the full range of health care delivery (33). We believe that the longevity of the Community Health Aide Program and the wide range of their scope of practice points to the program as an example of how CHWs can be successfully integrated into a health care delivery system.

Further study of Alaska's Community Health Aide program should include qualitative research on how well-prepared students are for their clinical practice, what the most effective methods of instruction have been for preparing CHA/Ps, and the benefits and changes to practice and healthcare that have come with increased use of telemedicine. In addition, a systematic evaluation of patient health outcomes is warranted.

Since the inception of the CHA/P program, numerous health status indicators have dramatically improved among the Alaska Native population, including lower infant mortality, longer life expectancy, and dramatically lower rates of tuberculosis (34,35). While the CHA/P program cannot take full credit for these improvements, we believe that easy access to the health care system provided by village-based CHA/Ps has contributed substantially to these health gains. Prior to having local health care provided by CHA/Ps, village residents received only episodic care by itinerant providers, needed to travel to receive care, or did without trained medical care entirely. The expanded role of the Community Health Worker as demonstrated by Alaska's Community Health Aides and Community Health Practitioners can serve as a model for adaptation in other communities with challenging health care access both in the USA and elsewhere.