Evaluation of the Tribal HPOG ProgramPractice BriefOPRE 2011-48 December 2011An Introduction to the Tribal Health ProfessionOpportunity Grants (HPOG) and EvaluationMichael Meit, MA, MPH, Jessica Bushar, MPH, Heather Langerman, BS, Hilary Scherer, BA, Carol Hafford, Ph.D., Alana Knudson, Ph.D.,Aleena Hernandez, MPH, Evangeline Dotomain, MBA, Paul Allis, M.Ed.This practice brief is the first in a series of practice briefs being developed by the Tribal HPOG evaluation team, comprised of NORC at the Universityof Chicago, Red Star Innovations, and the National Indian Health Board. The briefs will be used to disseminate important lessons learned and findingsfrom the Evaluation of the Tribal Health Profession Opportunity Grants (HPOG) program , which is being funded by the Office of Planning, Researchand Evaluation within the Administration for Children and Families. The Tribal HPOG program is funded by the Affordable Care Act (ACA) to support32 demonstration projects, including 5 Tribal Organizations and Colleges, to train Temporary Assistance for Needy Families (TANF) recipients andother low-income individuals as health care professionals. The purpose of this first practice brief is to: (1) describe the unique aspects of the TribalHPOG grantee organizations and the target populations they serve; (2) introduce the program frameworks of the Tribal HPOG grantees; and (3)provide an overview of the Federally-sponsored evaluation of the Tribal HPOG grantees.Increasing the number of well-trained health professionals working in underservedareas is a critical issue that has gained momentum as a result of the Affordable CareAct (ACA). The Health Resources and Services Administration’s Bureau of HealthProfessions estimates a nationwide shortage of almost 100,000 physicians, asmany as 1 million nurses and 250,000 public health professionals by 2020.1 Thishealth workforce shortage can be attributed to a range of factors including stateand local budget cuts, increased demand as the population grows older, and changinghealth care work conditions and expectations, among others. Additionally, the ACAgoal to increase access to health insurance coverage is expected to cause a furthersurge in demand, necessitating an increased health workforce to meet this need.2In response to the critical need to expand the health workforce to meet the growingdemand for health care, the ACA, signed into law by President Obama in March 2010,provides funding to develop and sustain a health workforce that meets highstandards for education, certification and professional development. To this end,the Health Professions Opportunity Grants (HPOG) program, funded by the ACA andadministered by the Administration for Children and Families (ACF) Office of FamilyAssistance, has funded 32 five-year demonstration projects to design andimplement innovative health workforce development training programs that targetTemporary Assistance for Needy Families (TANF) recipients and other low-incomeindividuals. As stipulated by the grant, the projects: (1) are required to partner withstate TANF offices, local and state workforce investment boards, and stateapprenticeship agencies; (2) can use grant funding to provide supportive services toparticipants; and (3) should result in an employer- or industry-recognized certificateor degree.Tribal HPOG Grantees Blackfeet Community College Location: Browning, MT (Glacier County)ff Project: Issksiniip Project: Meeting the HolisticHealth and Education Needs of the Niitsitapiff Cankdeska Cikana Community College Location: Fort Totten, ND (Benson County)ff Project: Next Steps: An Empowerment Modelfor Native People Entering the HealthProfessionsff College of Menominee Nation Location: Keshena, WI (Menominee County)ff Project: College of Menominee’s CNA to RNCareer Ladder Programff Cook Inlet Tribal Council, Inc. Location: Anchorage, AK (Anchorage County)ff Project: Cook Inlet Tribal Council HealthProfessions Opportunity Programff Turtle Mountain Community College Location: Belcourt, ND (Rolette County)ff Project: Project CHOICE: Choosing Health Opportunities for Indian Career Enhancementff

An Introduction to the Tribal Health Profession Opportunity Grants (HPOG) and EvaluationFive of the 32 demonstration projects were awarded to TribalOrganizations and Tribal Colleges. The five Tribal HPOG granteesare: (1) Blackfeet Community College (Browning, MT), (2) CankdeskaCikana Community College (Fort Totten, ND), (3) College ofMenominee Nation (Keshena, WI), (4) Cook Inlet Tribal Council, Inc.(Anchorage, AK), and (5) Turtle Mountain Community College(Belcourt, ND). Tribal grantees will integrate health professionstraining programs with culturally-informed models of learning andpractice to nurture and educate TANF recipients and other lowincome individuals into health professions. Tribal grantees willintegrate health professions training programs with culturallyinformed models of learning and practice, such as the FamilyEducation Model (described below), to nurture and educate TANFrecipients and other low-income individuals into health professions.Tribal HPOG Grantee Organizations andCommunitiesFour of the five Tribal HPOG grantee organizations are TribalCommunity Colleges. A number of tribes have exercised self-determination by establishing fully accredited Tribal Colleges toaddress the educational needs of their members. The TriballyControlled Community College Assistance Act of 1978 defines aTribal college as “ an institution of higher education which isformally controlled, or has been formally sanctioned, or chartered,by the governing body of an Indian tribe or tribes.”. By thisdefinition, Tribal colleges are essentially extensions of the Tribe andare held to the same responsibility to protect their members. Thefifth Tribal HPOG grantee organization is Cook Inlet Tribal Council, aTribal human and social services organization governed by Tribalappointees that provides education, workforce development, andemployment services for Native people in the Anchorage area. TribalColleges and human services organizations rely on Native Americanheritage, culture, knowledge and values to guide their work andprogramming.The five Tribal HPOG grantees are recruiting prospective studentswho reside on or near Tribal reservations. The communities servedby the Tribal HPOG grantees are briefly described below. rimarily serves individuals on the Blackfeet reservation located on ancestral lands in northwestern ruralPMontana. our nations comprise the Blackfoot Confederacy, otherwise known as the “Niitsitapi”. These include theFNorthern Piegan, the Kainai Nation, the Siksika Nation and the Southern Piegan. I nitial program training will be offered to individuals located on or near three reservations - Spirit Lake SiouxReservation (primarily served by CCCC), Standing Rock Sioux Reservation, and Three Affiliated Tribes of FortBerthold Reservation. The program will also provide training to Tribal students located in and around Bismarck. he Standing Rock Sioux and Spirit Lake Sioux people are members of the Dakota and Lakota nations. EachTSioux division has unique cultural and linguistic distinctions. The Mandan, Hidatsa and Arikara Nations areknown as the three Affiliated Tribes of Fort Berthold Reservation. Primarily serves individuals located on and around the Menominee reservation which is located close to bothof the college campuses in Keshena and Green Bay, Wisconsin. CMN also serves students representing 22tribal nations, as well as non-tribal students. he Menominee Nation is comprised of five clans, the Bear, Eagle, Wolf, Moose, and Crane, and is indigenous toTthe area surrounding the mouth of the Menominee River, less than 60 miles from the current MenomineeReservation.Turtle MountainCommunity College(TMCC) Serves the Turtle Mountain Band of Chippewa. The Tribe once stretched across Minnesota, North Dakota andinto Canada, but is now located in Belcourt, North Dakota. he Turtle Mountain Band of Chippewa view people as their most important asset and aim to achieve selfTsufficiency, financial independence and healthy lifestyles through knowledge and education of their people.Cook Inlet TribalCouncil, Inc. (CITC) Provides services to American Indians and Alaska Natives located in the municipality of Anchorage andthroughout the Cook Inlet Region. he native population in Anchorage is not reservation-based but comprised of people from rural native villagesTand regions across Alaska that have migrated to the Anchorage metropolitan area.Blackfeet CommunityCollege (BCC)Cankdeska CikanaCommunity College(CCCC)College of MenomineeNation (CMN)Community Context and the Health Workforce in TribalCommunitiesOverall, American Indians and Alaska Natives (AI/AN) experience alower health status as compared to other Americans and lifeexpectancy for American Indians and Alaska Natives is lower thanfor the rest of the U.S. population (AI/AN adjusted life expectancy is72.6 years of age and the average U.S. life expectancy is 77.8 yearsof age; 2003-2005 rates).3 Furthermore, in the Indian HealthService’s (IHS) designated Aberdeen Areai, served by both TMCCand CCCC, the adjusted life expectancy rate is consistently one ofthe lowest among other IHS designated areas (66.8 years of age;1991-2001 rate).4 Diabetes, cardiovascular disease, cancer,2 Evaluation of the Tribal HPOG Program December 2011tuberculosis and mental health concerns are among the leadinghealth conditions impacting the health of AI/AN people.5 Accordingto the IHS National Patient Information Reporting System (NPIRS),the age-adjusted prevalence of diabetes for AI/ANs is 16.1%, twicethe prevalence of diabetes among non-Hispanic whites.6 Elder care– noted as a pressing issue by three of the five Tribal HPOGgrantees– is also a major health concern for many tribalcommunities.Contributing to the poor health outcomes described above, accessto health care is especially problematic in AI/AN communities.Nearly half of low-income AI/ANs are uninsured, and although IHSprovides care for approximately 1.5 million AI/ANs, IHS services areOPRE 2011-48

An Introduction to the Tribal Health Profession Opportunity Grants (HPOG) and Evaluationestimated to reach only half of uninsured AI/ANs.7 The significanthealth disparities and limited health care access faced by Tribalpopulations further highlight the need for a competent and culturallyappropriate health workforce in these communities.Conceptual Framework for Tribal HPOG ProgramsIn general, the communities served by the Tribal HPOG grantees havelimited regional job markets; however, the demand for healthprofessionals is high. Health care providers are among the mostprominent employers in Tribal communities on and off reservations.On reservations, employers often include Tribal health departmentsand clinics and IHS units, hospitals and clinics. Off reservation,employers include nearby hospitals, clinics, private health careproviders, and long term care organizations. Tribal employers oftenpromote self-determination through AI/AN hiring preferences andprioritize employing a culturally competent workforce.While the demand for health professionals is high, the vacancy andturnover rates for these positions are also high which can furtherlimit access to health care for tribal populations. In general, healthcare providers tend to come from off reservation and researchdemonstrates that there may be an especially high turnover rate fornon-Native health professionals working on reservations.8 Three ofthe five counties/municipalities where grantee institutions arelocated (Glacier County, Rolette County and Benson County) aredesignated in full as a Health Professional Shortage Area (HPSA)and areas within the remaining county and municipality (MenomineeCounty and municipality of Anchorage County) are also designatedas HPSAs.ii Many of these health positions require industryrecognized certificates and training and low educational attainmentlimits available career opportunities for Tribal members.The Tribal HPOG programs are designed to benefit underservedmembers of Tribal communities who are eligible for or receive TANFor have incomes that fall below the federal poverty level. Given thehigh rates of unemployment — across the areas served by the TribalHPOG grantees unemployment rates as high as 68.5%9 have beenreported — the HPOG program is an important catalyst for Tribalworkforce development and has the potential to develop a culturallycompetent workforce, ultimately improving Tribal self-sufficiencywhile improving access to needed services for Tribal people.Overview of Tribal HPOG ProgramsIn this section we provide an overview of the Tribal HPOG programs,with an emphasis on the unique approaches grantees plan to take tobest support their community members in successfully completing ahealth professions degree or certificate. Several of the keycomponents of the conceptual framework guiding the Tribal HPOGprograms are described below to highlight the initial approachesutilized by the Tribal HPOG grantees in developing and implementingtheir programs.InfrastructureStrategic PartnershipsThe Tribal grantees are required to partner with key agencies –Tribaland state TANF offices, Tribal, local and state workforce investmentboards, and state apprenticeship agencies – to facilitate acoordinated approach to workforce development and highereducation.iiiIn addition to the required partnerships, all of the grantees havedeveloped additional partnerships to encourage community andregional collaboration and increase awareness about the TribalHPOG program. Several grantees have partnered with local socialservice agencies and one stop centers (career centers that pairemployment counselors with job seekers to explore interests,abilities, career choices and training opportunities); four havepartnered with academic institutions and/or vocational technicaltraining centers; and three have partnered with employers – Tribalhealth departments, hospitals, etc. – in their communities. Partnerswill provide supportive services, employment assistance and/ortraining. Because of the interdependent nature of many Tribalcommunities, collaborative partnerships and strong relationshipsare important for successful implementation of each program; thesepartnerships, whether newly developed or strengthened, will play animportant role in helping participants achieve successful outcomes.Tribal HPOG ProgramsTraining and Educational ProgramsThe Tribal HPOG programs are intended to incorporate a careerpathway approach – a series of connected educational trainingprograms, often coupled with support services, which enableindividuals to advance in a chosen occupational field. In the case ofTribal community colleges, this approach may include facilitatingstudent transfer to a four-year institution. HPOG grantee programsaim to train and prepare participants for careers in a wide variety ofhealth fields. Nursing is a key focus of the Tribal HPOG programs; allgrantees plan to provide one or more degrees and/or certificates innursing. As part of its program, CMN will establish a CertifiedNursing Assistant (CNA) program that will create a pipeline intotheir pre-existing Licensed Practical Nurse (LPN) and RegisteredNurse (RN) programs. CCCC will also develop a career ladderprogram in nursing that offers training necessary to receive CNA,LPN and RN certification. CITC will enroll students in the CNA, LPNand RN programs offered by the Alaska Institute for Technology(prerequisite classes for LPN training will be offered through theUniversity of Alaska, Anchorage). BCC will offer students theopportunity to enroll in CNA and LPN training, and TMCC studentscan enroll in Licensed Vocational Nursing (LVN) training.Tribal grantees will also focus their efforts on additional careerpathways by providing training in fields including: allied health (e.g.,Quality Service Provider, Emergency Medical Technician); nutritionThe Indian Health Service is comprised of twelve regional administrative units called Area Offices. Health Professional Shortage Areas (HPSAs) are designated by HRSA and have shortages of primary medical care, dental or mental health providers and may be based on geographiclocation (a county or service area), a demographic group (low income population) or institutional (comprehensive health center, federally qualified health center or other public facility).OPRE 2011-48Evaluation of the Tribal HPOG Program December 2011 3

An Introduction to the Tribal Health Profession Opportunity Grants (HPOG) and EvaluationTribal HPOG Grantee Partnerships Blackfeet Community Collegeff Blackfeet Manpower Program; Glacier County Office ofPublic Assistance; Blackfeet Care Center; Blackfeet EarlyChildhood Center; Blackfeet Community Hospital;Blackfeet Tribal Health Department; University of Montana;Montana State University; Salish Kootenai College;Flathead Valley Community College Cankdeska Cikana Community College North Dakota Department of Commerce; North DakotaDepartment of Labor; North Dakota TANF Office; Universityof North Dakota Recruitment and Retention of AmericanIndians into Nursing (RAIN) Program; Lake Region StateCollegeff College of Menominee Nation Bay Area Workforce Development; Fox Valley WorkforceDevelopment; Keshena Community Resource Center; NorthCentral Technical College; Department of Transit Services;Kaplan; Clinical partners including local clinics, hospitalsand nursing homesff Cook Inlet Tribal Council, Inc. University of Alaska, Anchorage; Alaska Institute ofTechnology; Southcentral Area Health Education Center;Alaska Workforce Investment Board; Alaska’s PeopleCareer Center; local one-stop job centersff Turtle Mountain Community College North Dakota Department of Commerce; North DakotaDepartment of Human Services; North Dakota Job Service;Heart of America Medical Center; Presentation MedicalCenter; Indian Health Service-Quentin N.BurdickComprehensive Health Care Facility; St.Andrews HealthCenter; Northland Community Health Centerff(e.g., Registered Dietician); pharmacy (e.g., Pharmacy Technician);and clinical laboratory sciences (e.g., Medical Lab Technician). Forstudents who are interested in health careers not offered by theTribal HPOG grantee programs, some grantees have developedpartnerships with other academic institutions to facilitate studenttransfers. For example, as part of its grant, TMCC plans to develop a“gateway program” focused on basic skills preparation and coreclasses that will prepare students for transfer to health occupationsprograms at state colleges and universities.All of the Tribal HPOG grantee programs include academic orvocational instruction as their foundation; training curricula willfocus on developing students’ competencies in their selected courseof study. Tribal grantees will deliver curricula to meet accreditationor industry requirements, and where appropriate, integrate culturalconcepts and/or use culturally appropriate instructional methods.CMN is currently developing their own CNA curricula guided bystudent achievement benchmarks conceived by project staff. Thecurricula will be reviewed by the State of Wisconsin and then theCMN curricula committee. Similarly, as part of their HPOG grant,CCCC worked with the TrainND Northeast program at the LakeRegion State College to inform the standardization andenhancement of the Qualified Service Provider curriculum in NorthDakota.4 Evaluation of the Tribal HPOG Program December 2011Student and Family Engagement and Supportive ServicesEngaging students and families in the Tribal HPOG programs beginswith student recruitment. An important focus of Tribal HPOGgrantee recruitment efforts is collaboration with communitypartners. Grantees plan to work with partner service providers suchas Tribal TANF offices, one stop career centers and regionalworkforce development agencies to advertise the HPOG program toprospective