As the behavioral health workforce shortage continues and states have launched the national 988 Suicide and Crisis Lifeline, state leaders are looking for new mechanisms to meet the increased demand for behavioral health services. Workforce pipeline challenges, such as the time and resources required to obtain university degrees and licensure status, complicate states’ efforts to address their immediate workforce shortage. These efforts are further complicated in rural and frontier settings by a lack of population density and the need for regionally specific cultural competence. To address behavioral health needs in rural and frontier areas, Alaska has developed a training program to support a non-licensed provider type, Behavioral Health Aides.

Alaska’s Approach

The Behavioral Health Aide (BHA) program promotes behavioral health and wellness in Alaska Native individuals, families and communities through culturally relevant training and education. Key components of the program include:

• Standard practitioner qualifications: BHAs live in the communities where they work. Individuals are often identified by community members or members of the village council to serve in the BHA role, based on their innate qualities and relationship to the community.
• Because BHAs are community members who understand — and often share — the cultural and historical context of their clients, they connect with community members and reduce the stigma that many people associate with seeking help.
• Technical assistance: The Alaska Native Tribal Health Consortium (ANTHC) BHA Program offers technical assistance to regional tribal health partners who operate Behavioral Health Aide programs in primary care settings and other community-based services.
• Training for certification: The ANTHC BHA Training Center designs, develops, and delivers training that is required for BHAs to complete prior to certification. These courses are designed to align with the BHA scope of work and competencies specific to their level of certification, while also giving consideration for the rural, remote, and cultural contexts that BHAs work in.

Qualifications for Behavioral Health Aide Certification

A Behavioral Health Aide (BHA) is a job class and certification type within the Alaska Tribal Health System (ATHS). There are currently four levels of BHA certification that are differentiated by their requirements for work experience, specialized training, and scopes of practice, with the Behavioral Health Practitioner being credentialed to supervise the other three certification levels. To provide services as a BHA, individuals must be:

• Employed by the Indian Health Service (IHS), a tribe, or a Tribal Health Organization
• Supervised by a master’s level or above clinician
• Provide behavioral health services to clients or community members

Payment

IHS provides approximately $4.6 million for the statewide Behavioral Health Aide Program annually. Those funds are distributed through ANTHC to regional tribal health organizations to support BHA positions and their supervisors. The ANTHC BHA Program receives nearly $1 million to support statewide efforts through the provision of technical assistance and certification planning, supporting the Behavioral Health Academic Review Committee, and designing and developing BHA trainings and resources. Additionally, Alaska received approval from the Centers for Medicare and Medicaid Services (CMS) for a state plan amendment that allows Medicaid reimbursement for services provided by certified BHAs as health professionals in an integrated care model.

What Does This Mean for Other States Who Are Engaged with IHS?

IHS is expanding the Community Health Aide Program through assessment, planning, and implementation grants. As a part of that work, a Tribal Advisory Group meets on an ad hoc basis to provide subject matter expertise, program information, innovative solutions, and advice to the IHS to establish a National Community Health Aide Program. States engaged with IHS who are seeking to implement a program like the Behavioral Health Aide Program may find resources and information through the Tribal Advisory Group.

Next Steps

As states are thinking about how to enhance crisis services, particularly in rural and frontier areas, the workforce providing these services will be a critical component. States seeking an expansion of their non-licensed workforce may consider the state-supported training and credentialing options like those of Alaska’s BHA Program. Robust training curricula, clear roles for credentialed individuals within existing service models, and direct pathways from training to job placements can create a workforce pipeline that may be more nimble and responsive to the needs of communities, especially those in rural and frontier areas.

Acknowledgements

The authors would like to thank Drs. Xiomara Owens and Cody Chipp with the Alaska Native Tribal Health Consortium for their contributions to this publication. This work was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials (NOSLO) cooperative agreement totaling $836,859.00. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.