Q&A: Sandra Heffern on Community Based Health

In 2017, the CDC reported that community level health care was key to improving health outcomes saying, “[it] promotes healthy living, helps prevent chronic diseases and brings the greatest health benefits to the greatest number of people in need.” 

Alaska uses a hub-and-spoke model of healthcare at the community level to overcome geographical and demographic diversity. We spoke with Sandra Heffern, Consultant, Alaska Health Reform, about the importance of community health in Alaska, some of the obstacles the model faces, and its future as a viable model. 


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Channon Pedersen: I did a little experiment the other day. I went to Google Maps and tried to get directions from Sitka to Juneau. It returned ‘no routes are available between these destinations.’ Of course, you can get between these two cities, it just means that there’s no way to get there by walking, driving, or public transportation. But it does demonstrate a key issue that Alaska struggles with perhaps more than any other state and that’s it’s geographic diversity. Knowing how difficult it can be to physically get places in Alaska, how important is it to have a community-based health system? 

Sandra Heffern: Oh, it’s crucial. The two communities that you identify, Sitka and Juneau, are both in Southeast Alaska. Southeast Alaska is very different than South Central, which is very different than the interior, which is very different than the northern part of the state. When we’ve looked at healthcare and Alaska, we’ve really tried to look at it from a regional perspective, you know, because the needs are different, the populations are different, the needs of the communities are different, the infrastructure is different. The complexity is compounded by the fact that the total population of Alaska is only 735,000-ish people. It’s like you’ve got this pie and then each region is a much smaller piece of the pie. It just is very difficult to try to have a regional or community-based model with smaller and smaller communities. 

Channon: So then what would a community-based model look like in Alaska? 

Sandra: Well, I still think that you have to look at it from a regional perspective. And I think that if you look at the tribal health system, when you get outside of the rail belt, or the road system. The tribal health system really does have a community based model of healthcare delivery. I’ll take Bethel as an example. Bethel is a hub community in the Yukon Kuskokwim region, that serves like 25,000, people that are living in many different villages. The smaller villages may have a community health aide, or a community behavioral health aide, or even a dental aide but in order to get some of the more complex services, they would travel into Bethel. 

Channon: It seems like cost would be an obvious barrier to this model. If you have somebody in a remote community that has to have cancer treatments? How do you handle that and how do you overcome them? 

Sandra: That’s going to depend on the individual circumstances. If it’s somebody that would need to be treated in Anchorage for a period of time they would live in Anchorage because it would definitely be cost prohibitive to travel back and forth between Bethel and Anchorage. It used to be that if you had a cancer diagnosis, you went outside, you went to Seattle. We didn’t have those types of treatment options, even in Anchorage. We have spent probably the last 50 years, growing our healthcare system. 

Channon: Picking cancer is probably not the best because people often have to move to a city temporarily to receive cancer treatments, no matter where they are. They could be in Washington and still have to go to Seattle. 

Sandra: Yeah. I think I think another example would be something like cardiology. We have cardiologists in the state. We don’t have tons of cardiologists, but we have cardiologists. They may not have an office in another location outside of Anchorage, but they travel to some of the different health communities. And then telehealth really ramped up [during the pandemic] so how much of that is going to continue? I think that that’s probably a $64,000 question throughout the country. How much of healthcare is going to continue being provided through telehealth mechanisms? That would be a crystal ball that I would love to have clear vision on, because I don’t think we know. I don’t think anybody really knows. 

Channon: What do you think is possible with telehealth? There are certain things that are not possible: you can’t vaccinate through a phone line. What other things could you do? 

Sandra: Behavioral health has been a has been a huge piece. I think that’s one thing [that’s] not as hands on. I mean, literally, touching a person. But I think that the expansion of behavioral health [is something that the] Tribal Health System is really looking at and they have increased their behavioral health services through telehealth mechanisms. So I think that’s one place we’re going to see it. I think that, from that perspective, telehealth will continue and will be more of a viable option for folks. Although I did read something just this morning that talked about only 61% of households in Alaska [having] access to adequate broadband so that would be one of those barriers that we would need to overcome in Alaska. 

Channon: It’s interesting you should mention that because I spoke with Jerry Jenkins at the Alaska Behavioral Health Association and he mentioned telehealth being a huge benefit, but that it couldn’t necessarily be internet based. It had to also be a landline. That’s a disadvantage if a doctor needs to physically see something. 

Sandra: I think it’s important to make that person-to-person connection, you know? It’s better than nothing, but it’s not as good as what we’re doing right now. 

Channon: I wrote a story on [health care] in Arizona. They did a study about community health-based services, specifically geared towards improving birthweight outcomes and prebirths. It was a significant enough improvement that it was measurable. 

Sandra: Yes. I think that part of what we have to do is, in order for us to really change our healthcare system, and look at a community-based health model, we really need to know how much we’re spending. Not just from Medicaid, not just from state employees, but from all sources. And we don’t have that information. That information’s out there but we don’t have it in a collective place for us to really do that analysis. Do we have a lot of low value care? Do we have utilization patterns that we could influence? What are those cost drivers? We can always say that it’s because of our geography or our low population, that’s easy. Those are the easy answers to why our health care is so expensive, but until we’re able to really collect that information, and do the analysis of it, I just think that we’re really kind of spinning in the wind. 

Channon: That’s a really good point.

Sandra: And I think that there are solutions that are out there, but I’m trying to get the will. Whether it’s the politicians, or the administration, or providers. Getting that political will to make change. Because it’s a business. It’s like we’re spending an enormous amount of money on health care throughout the country, not just in Alaska, and you want to mess with somebody’s business model. That’s a hard sell. 

This Q&A has been edited for length and clarity.