COMMUNITY HEALTH REPRESENTATIVES (CHR)

+--------------+-------------+-------------+-------------+-------------+
|              | 2002        | 2003        | 2004        | Increase    |
|              |             |             |             |             |
|              | Actual      | President's | Estimate    | or Decrease |
|              |             |             |             |             |
|              |             | Budget      |             |             |
+--------------+-------------+-------------+-------------+-------------+
| BA           | \           | \           | \           | +\$859,000  |
|              | $49,789,000 | $50,774,000 | $51,633,000 |             |
+--------------+-------------+-------------+-------------+-------------+
| FTE          | 3           | 3           | 3           | 0           |
+--------------+-------------+-------------+-------------+-------------+
|              |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| Number of    | 1,749       | 1,749       | 1,644       | -105        |
| CHRs         |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+
| \# of        | 2,200,000   | 2,200,000   | 2,200,000   | 0           |
| Tribally     |             |             |             |             |
| Operated     |             |             |             |             |
| Svcs         |             |             |             |             |
| Provided     |             |             |             |             |
+--------------+-------------+-------------+-------------+-------------+

**[PURPOSE AND METHOD OF OPERATION]{.underline}**

The Indian Health Service (IHS) Community Health Representatives (CHR)
provides a wide-ranging array of services in their individual
communities. Because needs vary tremendously among the tribes, no single
job description can account for the multiplicity of duties and
responsibilities that these important paraprofessionals provide.

The 284 Community Health Representative programs are tribally
administered, contracted or compacted health care outreach programs.
Trained in the basic skills of health care provision, disease control
and prevention, CHRs as community members can successfully create change
in community acceptance and utilization of Western health care resources
while respecting and attempting to incorporate traditional practices.
The Indian Health Service works with tribes and provides leadership and
guidance to the CHR Program.

CHRs are health educators, providing workshops and classes on a variety
of topics to an assortment of audiences. They are also health promoters
who develop and implement programs in areas such as safety, exercise and
fitness, nutrition or drug alternatives for youth. They are advocates,
both for individual patients and for tribal concerns in a variety of
settings in American Indian and Alaska Native, and non-Indian community;
and they provide direct patient care in specialized areas for which they
are trained.

CHRs provide services such as screening and identification of health
problems; education and outreach; monitoring patient status; planning,
development and implementation of projects in areas listed below:

-   Diabetes

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-   Cardiovascular disease

-   Cancer

-   FAS/FAE

-   Vision needs

-   Nutrition and obesity

-   Safety awareness and injury prevention

-   Maternal and child health, elder care, alcohol and drug abuse
    prevention and referral.

The CHR is literally a "jack of all trades.\" CHRs provide prenatal
education in the home of a mother-to-be who is afraid to visit the
clinic. They monitor vital signs and provide water to emergency workers
fighting fires. A CHR provides regular home visits and a listening ear
to elders, ensures medications are taken properly and assesses the home
environment for adequate care and risks such as loose carpet or frayed
electrical cords.

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**CHRs prove themselves over and over as indispensable assets to
American Indian and Alaska Native communities**. Whether they are:

-   Translating;

-   Taking blood pressures and sugar readings at weekly screenings in
    the community center;

-   Helping in the school setting;

-   Organizing and conducting exercise programs;

-   Speaking to the benefits of enrollment in Medicare/Medicaid;

-   Providing medical assistance on an elder group's field trip;

-   Delivering medications to homebound patients;

-   Transporting someone without the resources or ability to get to
    medical care;

-   Planning and coordinating community Health Fairs;

-   Arranging medical appointments and coordinating lodging for patients
    who cannot for themselves,

CHRs maintain a patient caseload for which they provide innumerable
services to American Indian and Alaska Native individuals ranging in age
from the newest baby to the oldest elder.

The CHR program plays an important role in the successful implementation
of IHS/Tribal health promotion and disease prevention initiatives and
efforts to improve access to and utilization of medical services. The
CHRs serve indigenous people and are well positioned within their
communities to provide the needed educational and related services that
can result in healthier lifestyles and earlier treatment and lower
morbidity among their people. The CHRs are effective outreach health
care providers and have established an efficient network system through
which health promotion and disease prevention activities and access to
services are being delivered to the American Indian and Alaska Native
people.

Many of the health problems American Indian and Alaska Native people
encounter are preventable. Most relate to lifestyle, improper or lack of
education and information, poor environmental health, and even lack of
proper health screening. The CHR is in a unique position to attempt to
make a positive impact on many of these maladies.

**[ACCOMPLISHMENTS]{.underline}**

-   Working to more closely collaborate with other health care
    initiatives, CHR Programs have implemented a variety of programs
    aimed at youth and children in areas of risk education, injury
    prevention and safety awareness.

-   A demonstration project is beginning to show positive outcomes via
    CHR efforts to more assertively identify and enroll eligible tribal
    members in Medicare and Medicaid, thereby expanding the resources
    available to pay for health care costs for American Indian and
    Alaska Native people and more importantly, filling in gaps or lack
    of health care services to individuals who need it most.

#### **PERFORMANCE MEASURES** 

The Community Health Representatives budget contributes to the
accomplishment of the following FY 2004 performance measures:

[Indicator 2]{.underline}: During FY 2004, increase the proportion of
I/T/U clients with diagnosed diabetes that have demonstrated improved
glycemic control by 2% over the FY 2003 level.

[Indicator 3]{.underline}: During FY 2004, increase the proportion of
I/T/U clients with diagnosed diabetes who have achieved blood pressure
control standards by 2% over the FY 2003 level.

[Indicator 24]{.underline}: During FY 2004:

a\. increase the rates for all recommended immunizations for AI/AN
children ages 3‑27 months by 2% over the FY 2003 rates

b\. establish baseline rates for recommended immunizations for AI/AN
children 19‑35 months.

[Indicator 25]{.underline}: In FY 2004, maintain the FY 2003 rate for
influenza vaccination levels among non-institutionalized adults age 55
years and older.

[Indicator 26]{.underline}: In FY 2004, maintain the FY 2003 rate for
pneumococcal vaccination levels among non-institutionalized adults age
65 years and older.

Following are the funding levels for the last 5 fiscal years:

+--------------------+--------------------------------+---------------+
| # Year             | **[Funding]{.underline}**      | **[FTE]{      |
|                    |                                | .underline}** |
+--------------------+--------------------------------+---------------+
| 1999               | \$45,960,000                   | 5             |
+--------------------+--------------------------------+---------------+
| 2000               | \$46,380,000                   | 0             |
+--------------------+--------------------------------+---------------+
| 2001               | \$48,061,000                   | 0             |
+--------------------+--------------------------------+---------------+
| 2002               | \$49,789,000                   | 0             |
+--------------------+--------------------------------+---------------+
| 2003               | \$50,774,000                   | 3             |
+--------------------+--------------------------------+---------------+

**[RATIONALE FOR BUDGET REQUEST]{.underline}**

[TOTAL REQUEST]{.underline} \-- The request of \$51,633,000 and 3 FTEs
is an increase of \$859,000 over the FY 2003 President's Budget request
of \$50,774,000 and 3 FTEs. The increase includes the following:

# Pay Cost Increase: +\$777,000

The request of \$777,000 will fund tribal pay costs which will assist
the IHS in maintaining access to services for the IHS patient
population. Provision of these funds is necessary to maintain the
current I/T/U health system which works to eliminate disparities in
health status between the American Indian and Alaska Native population
and the rest of the U.S.

#### Phasing-In of Staff for New Facilities: +\$82,000 

The request of \$82,000 provides for the phasing-in of staff and related
costs for new facilities allowing IHS to expand services in areas where
existing capacity is most overextended. The staffing of new facilities
also contributes to the recruitment and retention of dental staff and
promotes self-determination activities. The following table displays the
requested increase.

  ---------------------------------- --------------- ---------- ------------
  **Facility:**                      **Dollars**     **FTE**    **Tribal**

  Winnebago, NE Hospital             \$82,000        0          3
  ---------------------------------- --------------- ---------- ------------