Department of Health and Human Services 
OFFICE OF 
   
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
ACCE  SS TO MENTAL HEALTH  
 
S I H
ERVICES AT  NDIAN  EALTH 
 
SERVIC  E AND TRIBAL FACILITIES 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
September 2011 
OEI-09-08-00580   
   
 E X E C U T I V E   S U M M A R Y  
OBJECTIVE
 
To determine the extent to which American Indians and Alaska Natives 
(AI/AN) have access to mental health services at Indian Health Service 
(IHS) and tribal facilities. 
BACKGROUND 
A member of Congress expressed concern about AI/ANs access to 
mental health services and requested that the Office of Inspector 
General conduct this evaluation.  According to a Government 
Accountability Office report, the demand for mental health services 
outstrips capacity at some IHS and tribal facilities. 
AI/ANs experience a disproportionately higher rate of mental and 
behavioral health challenges compared to other populations in the 
United States.  AI/ANs rank first among ethnic groups as likely to 
suffer mental health disorders such as anxiety and depression that can 
lead to suicide.  They rank second to white non-Hispanics in suicides.  
The suicide rate among AI/ANs age 13 to 20 is 2.3 times the national 
average.  Additionally, AI/AN communities experience high rates of 
suicide risk factors, such as low household income and high 
unemployment.   
IHS and the tribes provide mental health services, including inpatient 
and outpatient care and residential substance abuse treatment.  Mental 
health services include, but are not limited to, all psychiatric services, 
behavioral health services, substance abuse treatment, and traditional 
healing practices.  These services are performed by licensed and 
unlicensed health care providers and are generally delivered in 
hospitals, health centers, urban Indian programs, and health stations. 
Our findings are based primarily on a survey of IHS and tribal facilities 
that provided health care services from January 2008 to June 2009.  
The survey response rate was 82 percent (630 of 772 facilities).  We also 
conducted onsite interviews at a sample of 98 facilities and at all IHS 
Area Offices.   
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E X E C U T I V E   S U M M A R Y  
FINDINGS 
Eighty-two percent of IHS and tribal facilities reported that they 
provide some type of mental health service; however, the range of 
available services is limited at some facilities.  Of the 630 IHS and 
tribal facilities that responded to our survey, 514 reported that they 
provided some level or type of mental health service.  The 116 facilities 
that do not provide mental health services refer clients to other 
providers either in the non-AI/AN community or on the reservation.  
Thirty-nine percent of the facilities reported that they provide crisis 
intervention 24 hours a day.   
Staffing issues and shortages of highly skilled providers limit 
AI/ANs access to mental health services at IHS and tribal facilities.  
Although 82 percent of the surveyed facilities reported that they provide 
mental health services, a variety of staffing issues affect access to 
services.  Facilities that do not provide mental health services reported 
that staff shortages are part of the reason.  Shortages of psychiatrists 
and other licensed providers at IHS and tribal facilities limit access to 
mental health services.  Some facilities reported that social workers, 
counselors, and nurses provided pharmacotherapy (medication 
management) services to meet AI/ANs needs.  To help address 
shortages of licensed providers, 17 percent of IHS and tribal facilities 
(87 of 514) use telemedicine for mental health services.  
Physical, personal/social, and economic challenges may affect 
access to mental health services at IHS and tribal facilities.  
Approximately half of facilities (274 of 514) reported that physical 
barriers, such as travel conditions, affect clients access to services.  
Approximately one-third of facilities (175 of 514) reported that personal 
and social barriers, such as the lack of child care, affect clients access to 
services.  Nearly one-third of facilities (147 of 514) reported that 
economic issues, such as difficulty paying copayments, affect access to 
services.   
RECOMMENDATIONS 
The high rates of suicide, substance abuse, depression, 
unemployment, and poverty in AI/AN communities contribute to the 
need for access to mental health services.  Although 82 percent of IHS 
and tribal facilities reported that they provide mental health services, 
access to some services is limited by shortages of highly skilled 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT INDIAN HEALTH SERVICE AND TRIBAL FACILITIES  ii   
   
E X E C U T I V E   S U M M A R Y  
providers and by other staffing issues.  In addition, the majority of 
AI/ANs attempting to obtain these services live in rural areas and 
face physical, personal/social, and economic barriers that limit access.  
When we conducted this study, IHS could not provide a complete and 
accurate list of all IHS and tribal health care facilities.  Therefore, we 
have no assurance that we have a database that represents all such 
facilities. 
To address these issues, we recommend that IHS:  
Provide guidance and technical assistance to help tribes explore 
potential partnerships with non-AI/AN providers of community mental and 
behavioral health services. 
Continue to expand its telemedicine capabilities and provide guidance 
and technical assistance to tribal health care providers to expand and 
implement telemedicine. 
Develop a plan to create a single database of all IHS and tribal health care 
facilities. 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
IHS concurred with all of our recommendations.  We did not make 
any changes in the report based on IHSs comments.  For the full text 
of those comments, see Appendix G. 
 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT INDIAN HEALTH SERVICE AND TRIBAL FACILITIES  iii   
 T A B L E   O F   C O N T E N T S  
EX ECUT I VE  SUM M ARY  .....................................i 
 
 
I NT RO DU CT I O N  ............................................ 1 
 
 
F I NDI NG S  .................................................  10 
Eighty-two percent of IHS and tribal facilities reported that  
they provide some type of mental health service; however,  
the range of available services is limited at some facilities ......  10 
Staffing issues and shortages of highly skilled providers  
limit AI/ANs access to mental health services at IHS and  
tribal facilities .........................................  15 
Physical, personal/social, and economic challenges  
may affect access to mental health services at IHS and  
tribal facilities .........................................  18 
 
 
RECO M M END AT I O N S  .....................................  21 
  Agency Comments and Office of Inspector General Response ....  23 
 
 
APP EN DI X ES  .............................................  24 
  A:  Health Disparities ...................................  24 
  B:  Glossary of Terms ....................................  25 
  C:  Response Rates ......................................  28 
  D:  Population Served and Screened by Type of Facility ........  30 
  E:  Crisis Intervention Services ............................  31 
  F:  Mental Health Care Staff Onsite at Facilities .............  32 
  F:  Agency Comments ...................................  33 
 
 
ACKNO WL E DG M E N T S ..................................... 36   
       
I N TI NR OT DR UO CD TU I CO TN I  O N  
OBJECTIVE 
To determine the extent to which American Indians and Alaska Natives 
(AI/AN) have access to mental health services at Indian Health Service 
(IHS) and tribal facilities. 
BACKGROUND 
A member of Congress expressed concern about AI/ANs access to 
mental health services and requested that the Office of Inspector 
General (OIG) conduct this evaluation.  According to a Government 
Accountability Office (GAO) report, the demand for mental health 
services outstrips capacity at some IHS and tribal facilities.1   
AI/ANs experience a disproportionately higher rate of mental and 
behavioral health challenges compared to other populations in the 
United States.  AI/ANs rank first among ethnic groups as likely to 
experience mental health disorders such as anxiety and depression    
that can lead to suicide.2  They rank second to white non-Hispanics in 
suicides.  See Table A in Appendix A for further information on health 
disparities.   
In comparison to other populations, AI/AN youth have more serious 
problems with mental health disorders related to suicide, such as 
anxiety, substance abuse, and depression.3  The suicide rate among 
AI/ANs age 13 to 20 is 2.3 times the national average.  Suicide is the 
second leading cause of death and accounts for 19 percent of all deaths 
among AI/AN youth.   
Additionally, AI/AN communities experience high rates of suicide risk 
factors, such as low household income and high unemployment.4  The 
 
1 GAO, Indian Health Service:  Health Care Services Are Not Always Available to Native 
Americans, GAO-05-789, August 2005. 
2 L.M. Olson and S. Wahab, American Indians and suicide:  A neglected area of 
research.  Trauma, Violence, and Abuse, 2006, 7(1), 19-33. 
3 Suicide Prevention Resource Center, Suicide Among American Indians/Alaska Natives, 
April 5, 2007.  Accessed at http://www.sprc.org/library/ai.an.facts.pdf on April 19, 2010. 
4 Peggy Halpern, Office of the Assistant Secretary for Planning and Evaluation, 
U.S. Department of Health & Human Services, An American Indian/Alaska Native Suicide 
Prevention Hotline:  Literature and Discussion with Experts, November 2009.  Accessed at 
http://aspe.hhs.gov/hsp/09/AIAN-SuicidePreventionHotline/index.shtml#risk on March 29, 
2011. 
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I N T R O D U C T I O N  
income of one in every four AI/ANs falls below the Federal poverty level, 
a rate approximately twice that of the total population.5  In the first half 
of 2009, the AI/AN unemployment rate was 13.6 percent.  
The Federal Government first authorized appropriations for AI/AN 
health care in 1921 under the Snyder Act, which provided for relief of 
distress and conservation of health.6  The Indian Health Care 
Improvement Act (IHCIA) was enacted in 1976 to improve the services 
and facilities of Federal AI/AN health care programs.7  The IHCIA 
expired in 2000, but Congress continued to appropriate funds annually 
for AI/AN health care.  In 2010, the President signed the Patient 
Protection and Affordable Care Act of 2010 (ACA),8 which reauthorized 
appropriations for the IHCIA and stated that it is the policy of this 
Nation, in fulfillment of its special trust responsibilities and legal 
obligations to Indiansto ensure the highest possible health status for 
Indians and urban Indians and to provide all resources necessary to 
effect that policy....9   
IHS-Funded Health Services 
IHS is an agency in the Department of Health and Human Services 
(HHS) responsible for providing Federal health services to AI/ANs.  
Headquartered in Rockville, Maryland, IHS operates from 12 Area 
Offices across the country; these offices oversee the delivery of health 
services and provide administrative and technical support.  IHSs 
mission is to raise AI/ANs physical, mental, social, and spiritual health 
to the highest level.10  Members of the 564 federally recognized tribes 
are eligible for IHS health care.  In partnership with the tribes, IHS 
 
5 U.S. Census, Population Profile of the United States:  Dynamic Version, Part V: 
Household Economics, Poverty in 2005.  Accessed at 
http://www.census.gov/population/www/pop-profile/files/dynamic/poverty.pdf on 
June 23, 2011.  
6 Snyder Act, 1921, P.L. 67-85  13, 42 Stat. 208, 25 U.S.C.  13.   
7 IHCIA, P.L. 94-437, 25 U.S.C. 1602. 
8 ACA, P.L. 111-148. 
9 ACA, Title X Part III  10221, S. 1790 Title I  103. 
10 IHS, Indian Health Service Fact Sheets:  Indian Health Service.  Accessed at 
http://www.ihs.gov/PublicInfo/PublicAffairs/Welcome_Info/ThisFacts.asp on  
February 15, 2009. 
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I N T R O D U C T I O N  
provides services to 1.9 million11 of the approximately 4.3 million 
AI/ANs living in the United States.12   
Indian Self-Determination and Education Assistance Act.  In accordance 
with the Indian Self-Determination and Education Assistance Act 
(ISDEAA) (1975), as amended, there are three options for IHS-funded 
health care services.13   
1.  Tribes, independently or through tribal organizations or tribal 
consortiums, may choose to have IHS continue to provide health 
services directly to their members.   
2.  Through Title I, tribes can receive a share of money that IHS 
would have used to administer and operate health services.  
Under this option, commonly known as 638 contracting, tribes 
negotiate with IHS for funds to provide health services directly 
to their members, and IHS retains a measure of oversight and 
supervision. 
3.  Under Title V, self-governance compacts allow tribes to receive 
their share of money from IHS to provide direct health services 
and to assume greater control over the administrative functions 
that support the delivery of the services and tailor services to 
the needs of their communities.14  Self-governance compacts 
offer tribes a greater degree of autonomy than does 
638 contracting.   
Direct Care Services.  AI/ANs receive direct care services from  
IHS-operated or tribally operated facilities, generally hospitals, health 
centers, or health stations that provide direct health care services.  In 
some situations, IHS and tribal programs share a building or hospital in 
which they operate their respective programs.  Tribes, tribal 
consortiums, and IHS also may enter into cooperative arrangements 
with independent providers for specific services to be performed at their 
 
11 The remainder of AI/ANs may receive health care through other sources such as 
employer-provided health benefits, veterans health services, or Medicare and Medicaid. 
12 U.S. Census Bureau, We the People:  American Indian and Alaska Natives in the 
United States, February 2006.  Accessed at 
http://www.census.gov/population/www/socdemo/race/censr-28.pdf  on May 9, 2011. 
13 ISDEAA, 1975, P.L. 93-638, as amended. 
14 IHS, IHS Fact Sheets:  Tribal Self-Governance, January 2009.  Accessed at 
http://info.ihs.gov/TrblSlfDtrm.asp on January 14, 2009.  
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I N T R O D U C T I O N  
facilities.  These may include dialysis and dialysis services, mobile 
diagnostic services, and psychiatric services. 
IHS and tribal facilities may also bill Medicare and Medicaid for 
services provided to eligible AI/ANs.15  For AI/AN Medicaid beneficiaries 
receiving services from IHS or tribal facilities, the Centers for Medicare 
& Medicaid Services (CMS) reimburses State Medicaid programs at 
100 percent of the Federal medical assistance percentage.  AI/ANs 
receiving services under Medicare at non-IHS or nontribal facilities are 
responsible for appropriate copayments and deductibles. 
Contract Health Services Program.  When an IHS or tribal facility cannot 
provide the required services, IHS and tribes rely on the Contract 
Health Services (CHS) program, which contracts with private providers 
such as hospitals and physicians to deliver services.  The CHS program 
is the payer of last resort and often defers or denies lower priority 
services. 16  According to IHS, the CHS program can typically fund only 
the highest priority, or Level I, health services.  The highest of the four 
priority levels, Level I servicesEmergent/Acutely Urgent Care 
Servicesare necessary to prevent immediate death or serious 
impairment, and include emergency psychiatric care.17  Services to 
address non-life-threatening mental and behavioral health issues are 
not considered to be Level I.   
IHS mental health care programs.  IHS and the tribes provide mental 
health services, including inpatient and outpatient care and 
residential substance abuse treatment.  IHSs 2010 budget 
appropriation for mental health and alcohol and substance abuse 
services was 9 percent of its total clinical services budget 
($267 million of $2.95 billion).18  IHS apportions approximately 
 
15 IHCIA, P.L. 94-437,  401 and 402. 
16 42 CFR  136.61.  AI/ANs receiving services through CHS programs or Medicaid may 
not be charged copayments.   
17 IHS, Contract Health Services, RequirementsPriorities of Care.  Accessed at 
http://www.ihs.gov/NonMedicalPrograms/chs/index.cfm?module=chs_requirements_prioritie
s_of_care on April 8, 2010. 
18 The fiscal year 2010 appropriation for mental health care ($267 million) is the sum of 
two line items in the IHS budget for clinical services:  mental health ($73 million), and 
alcohol and substance abuse ($194 million).  Accessed at 
http://www.ihs.gov/NonMedicalPrograms/BudgetFormulation/documents/IHS%20FY%2020
11%20Congressional%20Justification.pdf on May 10, 2010.   
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I  N T R O D U C T I O N  
 
50 percent of the $267 million for mental and behavioral health 
services directly through the tribes, via 638 contracting and  
self-governance compacts.19   
Mental Health Care  
Mental health services.  For the purposes of this report, the term mental 
health services includes, but is not limited to, all psychiatric services, 
behavioral health services, substance abuse treatment, and traditional 
healing practices.20   
Psychiatric and behavioral health services use a variety of techniques to 
improve individuals functioning.  Psychiatric services include, but are 
not limited to, psychotherapy and pharmacotherapy (i.e., medication 
management).  Behavioral health services and substance abuse 
treatment include techniques to improve individuals physical, mental, 
social, and spiritual well-being.21  These services often include 
health-promotion counseling, 12-step addiction recovery programs, 
behavioral modification, and therapeutic drug treatment. 
In addition, IHS and tribes provide traditional healing practices 
relevant to a communitys unique culture, using a holistic approach to 
physical, spiritual, and mental health.  In the AI/AN community, such 
treatments can include talking circles and sweat lodges.22   
Some providers perform mental health services via telemedicine, 
sometimes called telepsychiatry.  Telemedicine is the use of medical 
information exchanged from one site to another via electronic 
communications, such as video conferencing.  See Glossary of Terms in 
Appendix B for more information. 
Mental health services providers.  A range of providers, with varying 
scopes of practice, perform mental health services.  However, such 
services are generally performed by licensed health care providers,  
 
19 Bryan Wooden, Deputy Director of IHSs Division of Behavioral Health.  Interviewed 
on November 19, 2008.    
20 For additional definitions of selected terms and concepts in this report, see the 
Glossary of Terms in Appendix B. 
21 IHS, Behavioral Health Home Page.  Accessed at 
http://www.ihs.gov/MedicalPrograms/Behavioral/ on February 15, 2010. 
22 A talking circle is a traditional method of conducting a discussion in a respectful, 
egalitarian manner.  A sweat lodge is a structure heated by a central fire or steam from 
water poured on hot stones and is used for ritual or therapeutic sweating. 
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I N T R O D U C T I O N  
 
including psychiatrists, clinical psychologists, clinical social workers, 
and marriage and family counselors.  Licensure requirements vary by 
State.  Primary care providers, such as physicians and nurse 
practitioners, also perform some mental health services, (e.g., 
pharmacotherapy and emergency care). 
Not all States require that other providerssuch as aides, addiction 
counselors, mental health counselors, and peer counselorsbe 
licensed.  Regulations for counselor certification vary from State to 
State,23 as do the training requirements for aides.  
The IHS Community Health Aide Program includes certification 
requirements for Behavioral Health Aides (BHA), who provide some 
mental health services, such as case management and community 
outreach.24  BHAs commonly provide mental health services in 
remote areas, such as Alaskan villages.25   
Related Reports 
In 2005, GAO visited 13 IHS facilities to determine the extent to 
which AI/ANs had access to health care.26  GAO found that most 
facilities offered primary care and dental and vision services, but that 
access was not always assured because of waiting times and lack of 
transportation.  GAO also found that in some cases, gaps in specialty 
and behavioral health care resulted in diagnosis or treatment delays 
that made patients conditions worse and created a need for more 
intensive treatment. 
In 2009, OIG examined the extent to which IHS and tribes paid for CHS 
hospital claims above the required Medicare rate from January to 
March 2008.  The study found that IHS and tribes paid above the 
Medicare rate for 22 percent of hospital claims, resulting in $1 million 
 
23 American Counseling Association, Licensure and Certification.  Accessed at 
http://www.counseling.org/Counselors/LicensureAndCert.aspx on March 29, 2011. 
24 The Community Health Aide Program was established pursuant to IHCIA, 
P.L. 94-437,  119, 25 U.S.C.  1616l. 
25 IHCIA, P.L. 94-437,  121, 25 U.S.C.  1616l. 
26 GAO, Indian Health Service:  Health Care Services Are Not Always Available to 
Native Americans, GAO-05-789, August 2005. 
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I N T R O D U C T I O N  
in overpayments.  If payments for nonhospital claims were capped at 
the Medicare rate, IHS could have saved as much as $13 million.27 
In 2010, Senator Byron Dorgan, Chairman of the Senate Committee on 
Indian Affairs, released a report citing problems with credentialing and 
licensing of providers, accountability of controlled substances, and 
management of CHS program funds, among other issues, in the region 
covered by the IHS Area Office in Aberdeen, South Dakota.28  
Companion Report 
This report is one of two on AI/ANs access to health care.  The 
companion report is Access to Kidney Dialysis Services at Indian Health 
Service and Tribal Facilities  (OEI-09-08-00581). 
METHODOLOGY   
Scope 
This evaluation determines the extent to which AI/ANs had access to 
mental health services at IHS and tribal facilities between 
January 2008 and November 2009.  We conducted this evaluation 
concurrently with our evaluation of AI/ANs access to kidney dialysis 
services.   
We did not review the quality and medical necessity of mental health 
services or review whether IHS paid appropriately for the services in 
accordance with Federal laws and regulations. 
 
27 OIG, IHS Contract Health Services Program:  Overpayments and Potential Savings, 
OEI-05-08-00410, September 2009. 
28 U.S. Senate Committee on Indian Affairs, In Critical Condition:  The Urgent Need to 
Reform the Indian Health Services Aberdeen Area, December 28, 2010. 
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I N T R O D U C T I O N  
Survey and Fieldwork  
Stage 1:  Survey of IHS and tribal facilities.  To identify all IHS and 
tribal health facilities, we took the following steps:   
  To create one master list of IHS and tribal facilities, we 
combined the multiple lists that IHS provided to us, removing 
all duplicates.   
  Because the list was missing information (e.g., names of 
current representatives of the facilities), we conducted 
research online and used an HHS employee directory to 
confirm information about facilities and their representatives.  
We also confirmed this information with IHS and tribal staff.  
  We then attempted to contact each facilitys representative to 
confirm the name and type of facility and confirm whether it 
was IHS operated or tribally operated. 
We identified 777 IHS and tribal facilities that were providing health 
care services from June 2009 to November 2009.29  For the purpose of 
this report, we excluded five facilities that provided only dialysis 
services.  Therefore, this report is based on 772 IHS and tribal 
facilities.    
We sent one survey per facility to the contact person we had 
identified.  Some contacts were responsible for multiple facilities.  We 
asked them to complete one survey for each facility so that we could 
attribute each response to the appropriate facility.  We made a 
minimum of three attempts by email and/or telephone to ensure that 
all contact people submitted their surveys.  We received completed 
surveys from 630 of the 772 facilities, for a response rate of 
82 percent.  See Tables C-1 and C-2 in Appendix C for details 
regarding responses.  
Stage 2:  Fieldwork at 98 IHS and tribal facilities.  We visited 98 IHS and 
tribal facilities in 51 AI/AN communities and reservations.  These 
facilities offered a range of health services, including inpatient and 
outpatient services and primary and specialty care.  We also visited 
11 of 12 IHS Area Offices in person and interviewed IHS officials at 
 
29 We sent surveys to all IHS and tribal facilities beginning in June 2009 and continued 
to receive responses for 6 months, until November 2009. 
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I N T R O D U C T I O N  
the remaining Area Office by telephone.  We used standardized 
interview guides and interviewed 436 IHS and tribal administrators, 
providers, and clients.  
Analysis 
We based our findings on the synthesis of survey data, interviews, and 
observational fieldwork.  The data we collected during the onsite work 
supplemented the survey data.  Using SAS software, we analyzed the 
data collected through our survey and fieldwork.   
Limitations 
The findings in this report are not projected to all IHS and tribal 
facilities but are limited to the 630 survey respondents.  We 
conducted the interviews concurrently with our evaluation of AI/ANs 
access to dialysis services.  Therefore, not all of the 436 interviews 
specifically addressed access to mental health services. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors 
General on Integrity and Efficiency. 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  9 
   
   F  I N D I N G S      
Of the 630 IHS and tribal facilities that 
Eighty-two percent of IHS and tribal facilities 
responded to our survey, 514 reported 
reported that they provide some type of 
that they provide some level or type of 
mental health service; however, the range of 
mental health service.  Most of the  
available services is limited at some facilities 
514 facilities provide psychotherapy and 
various support groups.  The most 
commonly provided services include individual child and adult 
psychotherapy, family and couples support groups, and addiction 
treatment and support programs.  The type and level of services 
provided are generally determined by the type of facility and the 
qualifications of the staff.  These facilities reported screening 
approximately 536,000 clients for mental and/or behavioral health 
problems during the 18 months beginning January 1, 2008.  See Table 1 
for more information on the types of services and referrals provided by 
facilities. 
 
Table 1:  Services and Referrals at IHS and Tribal Facilities 
Percentage  Facilities That Do Not Provide  
of Facilities  the Service 
  Type of Service  That Provide  (n=116) 
 the Service  Percentage That  Percentage That Do  
(n=514)   Provide Referrals  Not Provide Referrals 
Psychotherapy (all)  81%  51%  49% 
   Individual  adult  81%  44%  56% 
   Individual  child  81%  52%  48% 
   Group  adult  44%  28%  72% 
   Group  child  35%  28%  72% 
Support groups (all)  80%  84%  16% 
   Family and couples  71%  24%  76% 
   Addiction and 12-step programs  51%  36%  64% 
   Family violence  24%  8%  92% 
   Victim of childhood sexual abuse  20%  7%  93% 
   Suicide  19%  10%  90% 
   Child of an alcoholic  18%  13%  87% 
   Family and friends of an alcoholic  18%  9%  91% 
   Parent of an alcoholic  16%  8%  92% 
   Parent of chemically dependent child  16%  11%  89% 
   Child of chemically dependent parent  16%  8%  92% 
   Chronically mentally ill  15%  8%  92% 
Pharmacotherapy  46%  8%  92% 
Traditional healing  33%  1%  99% 
Hypnotherapy  4%  <1%  >99% 
Electroconvulsive therapy  1%  2%  98% 
     Any Service  100%  88%  12% 
  Source: OIG analysis of survey data, 2010. 
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F I N D I N G S  
Of the 116 facilities that do not provide mental health services,  
88 percent (102 of 116) reported that they refer clients to other 
providers.  Generally, the facilities that do not provide mental health 
services refer clients to local support groups and individual 
psychotherapy, depending on the type of services the client may need.  
Because these facilities do not provide mental health services, the staff 
may have limited knowledge of where to refer clients for certain types 
and levels of services.  
The range of mental health services varies by the type of facility  
Most facilities reported that they provide mental health services, but 
the availability of some services is limited at certain types of facilities.  
Although all types of facilities reported providing some type of 
psychotherapy service or support group, hospitals and health centers 
were more likely to provide pharmacotherapy.  Less than half of alcohol 
and substance abuse treatment and behavioral health facilities and only 
22 percent of Alaska village clinics (25 of 112) reported that they 
provide pharmacotherapy.  Traditional healing is provided most 
frequently in urban and school health centers (63 percent).  See Table 2 
for more information on the range of mental health services at IHS and 
tribal facilities.  See Appendix D for more information on the 
community population served and number of clients screened by these 
facilities.  
Table 2:  Range of Mental Health Services at IHS and Tribal Facilities  
  Total Facilities  Percentage of Facilities That Offer the Service 
That Report 
Providing Mental  Psycho-  Support  Pharmaco-  Traditional  Hypno-  Electro- 
Type of Facility  Health Services  therapy*   Groups*  therapy  Healing  therapy  convulsive 
(n=514)  Therapy 
Health center  192  93%  91%  60%  25%  5%  1% 
Alaska village clinic  112  86%  72%  22%  30%  4%  4% 
Alcohol and substance 
55  75%  82%  36%  48%  2%  -- 
abuse treatment center  
Hospital  35  100%  91%  77%  34%  3%  -- 
Health station  32  81%  81%  53%  16%  19%  -- 
Behavioral health 
31  87%  74%  45%  32%  --  -- 
facility 
Urban health center  28  79%  82%  50%  63%  --  -- 
School health center  20  95%  70%  5%  63%  --  -- 
Remote health location  7  86%  86%  --  50%  --  -- 
Other residential  2  50%  50%  50%  --  --  -- 
* At least one type of psychotherapy service or support group is offered at the facility. 
Source:  OIG analysis of survey data, 2010. 
 
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F I N D I N G S  
Thirty-nine percent of IHS and tribal facilities that provide mental health 
services reported that they provide crisis intervention services 24 hours per 
day, 7 days per week 
Thirty-nine percent of facilities that provide mental health services  
(199 of 514) reported that they provide crisis intervention services  
24 hours a day.  Crisis intervention is emergency psychological care 
provided by trained counselors in a variety of settings that enables an 
individual to return to normal levels of functioning.  Only 26 percent 
of facilities providing 24-hour crisis intervention services (52 of 199) 
reported that mental health care staff are onsite the minimum 
number of hours necessary to provide 24-hour care (i.e., 168 total 
hours per week).  The remaining facilities that provide 24-hour crisis 
intervention services (147 of 199) use on-call staff to respond to 
after-hours crises.  In general, because of the limited number of 
mental health staff, most crisis intervention services are provided 
through primary care and emergency room providers. 
Fifty-one percent of facilities (262 of 514) reported that they provide 
crisis intervention services fewer than 24 hours a day.  Ten percent of 
facilities (53 of 514) do not provide any crisis intervention services.  
See Table 3 for more information on crisis intervention services at 
IHS and tribal facilities.  
 
Table 3:  Crisis Intervention Services at IHS and Tribal Facilities  
Percentage  Number of 
Scope of Intervention Services Provided at Facilities 
of Facilities  Facilities 
Provide crisis intervention services 24 hours per day, 7 days per week  39%  199 
   Staff are onsite a minimum 168 hours per week   10%  52 
   Staff are onsite fewer than 168 hours per week  29%  147 
Provide crisis intervention services fewer than 24 hours per day,  
51%  262 
7 days per week 
Provide no crisis intervention services  10%  53 
     Total respondent facilities that provide mental health services  100%  514 
Source:  OIG analysis of survey data, 2010. 
 
Lack of licensed providers limits referrals to psychiatric facilities  
In many instances of acute psychiatric crises, clients may have to be 
treated by health care providers in an acute-care hospital or by licensed 
providers who can admit the client to an inpatient psychiatric facility.  
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  12 
   
       
F I N D I N G S  
The 52 facilities that have mental health care staff onsite to provide  
24-hour crisis intervention services are likely staffed with social 
workers and counselors who cannot admit patients to an inpatient 
psychiatric facility.  The lack of staff and clinical training in these 
facilities limits the mental health services that can be provided during 
psychiatric emergencies and after-hours crises.  See Table E in 
Appendix E for more information on the staffing levels at IHS and tribal 
facilities that provide onsite 24-hour crisis intervention services.   
The director of a youth residential facility that provides onsite 24-hour 
crisis intervention services reported:  
If we had adequate resources we could provide a better 
quality of care for mental health and family mental health 
needs of our patients.  The majority of our patients come 
with PTSD [Post-Traumatic Stress Disorder] and chemical 
dependencies.  Our 24-hour monitoring staff falls far short of 
being able to engage therapeutically due to the lack of skills 
and training.  We can only afford to hire non-skilled 
individuals.  
IHS and tribal facilities provide limited inpatient psychiatric care   
Approximately 81 percent of facilities that provide mental health 
services (416 of 514) provide only outpatient mental health services.  
Approximately 15 percent provide both inpatient and outpatient mental 
health services, and 4 percent provide only inpatient mental health 
services.  The types of facilities providing inpatient mental health 
services include, but are not limited to, substance abuse and behavioral 
health residential treatment facilities.  
IHS and tribes operate 43 inpatient medical hospitals, 4 of which 
provide short-term inpatient psychiatric care.  The four hospitals that 
provide such care do so under special circumstances.  Two of the four 
hospitals are in remote areas of Alaska.  One has four psychiatric 
observation beds in a locked ward, supervised by a psychiatric nurse.  
The other provides inpatient crisis intervention.  Both hospitals refer 
their patients to the States only psychiatric hospital, which is in 
Anchorage and is accessible from their communities only by air.    
IHS operates one inpatient psychiatric hospital, an adolescent 
treatment facility that admits patients ages 13 to 17.  The hospital has 
capacity for 20 patients; however, at the time of our visit, it could 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  13 
   
       
F I N D I N G S  
accommodate no more than 12 patients because it was not fully 
staffed.30   
Most AI/ANs who need inpatient psychiatric care must use non-IHS/ 
nontribal facilities.  Almost all IHS operated and tribally operated 
hospitals (39 of 43) can medically stabilize clients in psychiatric crisis, 
but most do not admit clients for psychiatric care.  Once clients are 
stabilized, these hospitals will generally refer them to non-IHS/ 
nontribal psychiatric facilities.   
Although inpatient psychiatric care may be provided at public and 
private general medical hospitals and public and private psychiatric 
hospitals, finding available inpatient psychiatric care for clients is 
challenging.  At 29 facilities that we visited, 40 providers (including 
20 physicians) who are on the front lines of psychiatric emergencies 
reported that it is often difficult to find inpatient psychiatric care for 
their clients.  Non-IHS/nontribal psychiatric beds are scarce in rural 
areas.  For example, Montana, North Dakota, South Dakota, and 
Wyoming have a total of only eight psychiatric hospitals.  IHS and tribal 
facilities assist clients in finding inpatient psychiatric care, but provider 
interviews indicate that their staff cannot meet the demand for care.  
Frequently, non-IHS/nontribal psychiatric hospitals are full and cannot 
admit clients in a timely fashion.  Furthermore, psychiatric care 
provided at non-IHS/nontribal facilities may not be culturally sensitive. 
Additionally, States reimbursement policies may affect AI/AN Medicaid 
beneficiaries access to inpatient psychiatric services.  During our visits 
to two AI/AN inpatient youth residential treatment facilities, staff 
reported that they were unable to bill for out-of-State patients referred 
to their facilities because the patients State of residence did not enroll 
out-of-State providers.  CMS reimburses State Medicaid programs for 
the full cost of inpatient services provided to Medicaid-eligible AI/ANs 
at IHS and tribal facilities, regardless of their State of residence or the 
location of the facility.  However, some States do not recognize  
out-of-State providers and will not pay for out-of-State services except 
for emergency care. 
 
30 IHCIA, P.L. 94-437,  708, 25 U.S.C.  1665g authorizes the Secretary of HHS, acting 
through IHS, to construct at least one youth regional treatment center for addiction and 
behavioral health services in each region covered by an IHS Area Office.  
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  14 
   
       
F I N D I N G S  
Staffing issues and shortages of  Although 82 percent of the surveyed 
facilities reported that they provide 
highly skilled providers limit AI/ANs 
mental health services, the type of care 
access to mental health services at 
and services are limited by an inadequate 
IHS and tribal facilities 
number of skilled professional staff.   
IHS and tribal facilities that provide mental health services reported 
that a variety of staffing issues affect access to services 
Forty-seven percent of IHS and tribal facilities that provide mental 
health services (243 of 514) have licensed medical providers  
(i.e., physicians, midlevel practitioners, and/or nurses) onsite.  These 
providers render medical assistance and treatment to clients in crisis, 
including medically stabilizing patients, locating an appropriate 
psychiatric hospital, and arranging for clients to be admitted and 
transported to the hospitals.   
Thirty-nine percent of the facilities (200 of 514) reported that access to 
services was affected by a variety of staffing issues.  During interviews, 
providers explained that the lack of resources (e.g., financial, staff, and 
infrastructure) affected their ability to hire contractors, establish 
outreach programs, and provide adequate staff support.  Survey 
responses indicated that access was limited by the number of 
appointments they could schedule with available staff and the number 
of hours the facility could remain open.  See Table 4 for barriers related 
to staffing difficulties that limit AI/ANs access to mental health 
services.   
 
Table 4:  Barriers That Limit Access to Mental Health  
               Services at IHS and Tribal Facilities  
Percentage of  Number of 
Type of Barrier to Care  All Facilities   Facilities  
  (n=514) 
Facilitys lack of resources  37%  192 
Appointment availability  34%  173 
Limited facility hours  25%  131 
Source: OIG analysis of survey data, 2010. 
 
Staff shortages prevent some IHS and tribal facilities from providing mental 
health services.  Fifty-six of the 116 facilities that provide no mental 
health services reported that staff shortages and geographical 
remoteness prevent them from providing the services.  These facilities 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  15 
   
       
F I N D I N G S  
reported that they cannot retain and recruit mental health care 
providers.  Half of these facilities (29 of 56) are clinics in Alaska that 
serve communities of fewer than 500 residents.  Typically, facilities that 
do not provide mental health services (54 of 116) refer clients to 
facilities that do, including other IHS or tribal facilities and/or private 
facilities.   
Shortages of psychiatrists at IHS and tribal facilities limit access to 
mental health services 
The shortage of full-time psychiatrists is a problem in most IHS and 
tribal facilities.  Seven percent of IHS and tribal facilities that provide 
mental health care (36 of 514) employ full-time psychiatrists.  Although  
32 percent of the facilities (162 of 514) reported that they employ 
psychiatrists, at half of such facilities (87 of 162), psychiatrists work 
8 or fewer hours per week.  In contrast, psychologists, licensed social 
workers, and counselors are onsite at 437 of the facilities, and their 
average hours per facility are approximately 4 times those of 
psychiatrists.  See Table F in Appendix F for information on the median 
hours per week for mental health care staff by provider type.  
Thirty-one percent of IHS and tribal facilities that do not employ  
full-time psychiatrists (146 of 478) are in designated health professional 
shortage areas (HPSA).  HPSAs are designated by the Health Resources 
and Services Administration (HRSA) as having shortages of health 
providers in primary care, dental health, and mental health.  HRSA has 
designated 208 AI/AN communities as having the highest possible 
degree of shortages of mental heath care providers. 31    
Unlicensed providers provide pharmacotherapy to meet access needs  
Facilities often do not have appropriately licensed staff available to 
provide pharmacotherapy.  Pharmacotherapy is the treatment of 
disease, especially mental disorders, with drugs.32  Treatment can 
include dispensing drugs and monitoring clients; however, only licensed 
providers can prescribe the drugs used in pharmacotherapy.  Forty-six 
 
31 The Public Health Service Act  332 (amended by P.L. 101-597) requires HRSA to 
designate HPSAs.  The aforementioned 208 AI/AN communities have unusually high needs 
for mental health services.  HRSA, Shortage Designation:  HPSAs, MUAs [medically 
underserved areas] & MUPs [medically underserved populations].  Accessed at 
http://bhpr.hrsa.gov/shortage/index.htm on January 29, 2010.   
32 MedlinePlus, Pharmacotherapy, Medical Dictionary.  Accessed at 
http://www.merriam-webster.com/medlineplus/pharmacotherapy on February 14, 2010. 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  16 
   
       
F I N D I N G S  
percent of facilities that provide mental health care (236 of 514) provide 
this treatment.  Of the facilities that provide pharmacotherapy, 38 of 
236 reported that social workers, counselors, and nurses provided some 
type of pharmacotherapy service, which may have included drug-related 
treatment other than prescribing medication.  In addition, in  
8 States that do not license psychologists to prescribe medicine,  
13 facilities reported that psychologists perform pharmacotherapy.33   
During our visits to five facilities in remote areas, respondents reported 
that they employ no providers who are licensed to prescribe medication 
that may be an essential part of crisis intervention treatment.  The 
facilities reported that licensed providers who are not onsite write the 
initial prescriptions for clients.  Unlicensed providers who are onsite 
then dispense the medication and monitor the clients.  Providers 
reported that there are no alternatives in the community for clients who 
require medication.  One hospital reported that clients wait 7 weeks to 
get an appointment with a psychiatrist for a prescription and treatment. 
To help address shortages of licensed providers, 17 percent of IHS and 
tribal facilities use telemedicine for mental health treatment 
Given staff shortages, telemedicine can be a practical and 
cost-effective way to expand health services to offsite locations.  The 
IHCIA authorizes the Secretary of HHS to expend funds for the 
development and expansion of telehealth and telemedicine programs, 
where appropriate.  In addition, Medicare34 and some Medicaid State 
programs and third-party payers pay for certain telemedicine 
services.   
Although telemedicine is being used in IHS and tribal facilities in fields 
such as cardiology, nutrition counseling, and eye care, only 17 percent of 
facilities (87 of 514) reported that they use it for mental health services.  
More than half of the facilities that provide telemedicine (52 of 87) are 
in remote areas of Alaska.  Seventy-five percent of these facilities (65 of 
the 87) provide pharmacotherapy via telemedicine. 
Providers reported that pharmacotherapy is one of the services most in 
demand for telemedicine and one of the services best suited for it.  We 
 
33 This figure does not include Louisiana or New Mexico.  At the time of this evaluation, 
Louisiana and New Mexico were the only States that licensed clinical psychologists to 
prescribe medication. 
34 42 CFR  410.78. 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  17 
   
       
F I N D I N G S  
visited 11 facilities that currently use telemedicine.  Providers at these 
facilities said they hoped to expand their existing telemedicine services, 
and providers at other facilities expressed interest in using telemedicine 
in the future.  However, some facilities may encounter challenges with 
telemedicine.  At one facility, providers reported that older clients are 
uncomfortable with telemedicine, especially for mental health services.  
Therefore, the facility does not provide psychiatric consultations or 
pharmacotherapy via telemedicine.   
 
Approximately 69 percent of the 
Physical, personal/social, and 
facilities that provide mental health 
economic challenges may affect 
services (353 of 514) reported that 
access to mental health services at  AI/ANs face physical, personal/social, 
IHS and tribal facilities   or economic barriers in obtaining 
mental health services at IHS and 
tribal facilities.  See Table 5 for the individual barriers related to 
access to mental health services.   
 
Table 5:  IHS and Tribal Facilities That Reported That  
               Their Clients Experience Barriers to Mental  
               Health Services  
Number of 
Percentage of 
Type of Barrier to Care  Facilities 
All Facilities 
(n=514) 
Physical barriers     
   Transportation  53%  274 
   Weather  37%  191 
   Distance  36%  187 
   Poor roads  19%  98 
Personal and social barriers     
   Lack of child care  34%  175 
   Work schedule  31%  159 
   Personal schedule  30%  154 
Economic barriers     
   Financial  28%  147 
   Copayments  11%  61 
Source: OIG analysis of survey data, 2010. 
 
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F I N D I N G S  
Approximately half of facilities reported that physical barriers affect 
clients access to services 
Approximately 53 percent (274 of 514) of facilities reported that 
transportation was a barrier to accessing services.  More than  
one-third of the facilities reported that physical barriers, such as poor 
roads, distance, or weather, prevented clients living on rural 
reservations from obtaining mental health services.  During 
interviews, providers and clients related concerns about dangerous 
travel through remote areas to access facilities.  Twenty facilities 
reported that their clients may use alternative means of 
transportationincluding snowmobile, dogsled, tractor, horse, or 
boatto get to facilities. 
Approximately one-third of facilities reported that personal and social 
issues affect clients access to services 
Approximately 30 percent of facilities reported that work and personal 
schedules affected clients access to mental health services.  Survey 
responses from 34 percent of the facilities that provide mental health 
services indicate that their clients have limited access to these services 
because of lack of child care.   
During onsite visits, providers and clients in 24 communities related 
other personal and social barriers that affect access.  According to 
respondents, domestic violence and sexual abuse, addiction to drugs 
and alcohol, and the personal stigma associated with seeking help for 
mental illness limited clients ability and willingness to obtain mental 
health services.  Clients in small communities were particularly 
concerned about confidentiality, fearing that their mental health 
treatment would become common knowledge.   
Nearly one-third of facilities reported that economic issues affect 
clients access to services 
Twenty-eight percent of IHS and tribal facilities reported that their 
clients financial situations may limit their access to mental health 
services.  For example, 11 percent of the facilities reported that 
copayments may present a barrier to care when the AI/AN clients are 
referred to non-IHS/nontribal facilities.35  The financial condition of 
clients also was mentioned in interviews with clients and staff.  In 
 
35 SSA  1916(j).  AI/ANs referred to facilities under CHS are not charged copayments. 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  19 
   
       
F I N D I N G S  
many instances, economic issues combine with personal and social 
factors to affect access to services.  In rural areas, clients may not 
have enough money for transportation or other personal costs 
associated with trying to obtain services.  For example, in several of 
our interviews, clients and providers cited clients inability to pay for 
child care and the cost associated with clients taking leave from their 
jobs as socioeconomic problems that serve as barriers to services. 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  20 
   
       
 R E C O M M E N D A T I O N S  
 
The high rates of suicide, substance abuse, depression, unemployment, 
and poverty in AI/AN communities contribute to the need for access to 
mental health services.  Although 82 percent of IHS and tribal facilities 
reported that they provide mental health treatment, access to some 
services is limited by staffing issues and shortages of highly skilled 
providers.  In addition, the majority of AI/ANs attempting to obtain 
these services live in rural areas and face physical, personal/social, and 
economic barriers that limit access to services.   
When we conducted this study, IHS could not provide a complete and 
accurate list of all IHS and tribal health care facilities.  Although IHS 
attempts to collect information annually about IHS-funded health 
services, tribal facilities funded under Title I and Title V of the ISDEAA 
are not required to report specific information about their facilities.  
Therefore, IHS was unable to provide a complete, accurate list of all IHS 
and tribal health care facilities and contact individuals for them. 
To address these issues, we recommend that IHS:  
Provide guidance and technical assistance to help tribes explore 
potential partnerships with non-AI/AN providers of community mental and 
behavioral health services 
To improve access to and coordination of community mental health 
services for AI/ANs, IHS should develop written guidance that 
addresses service gaps and lack of coordination among States, IHS and 
tribal facilities, and non-AI/AN providers.  The written guidance should 
include a strategy to improve relationships with non-AI/AN community 
providers and access for and treatment of AI/ANs in underserved tribal 
communities.  This may enable IHS and tribal providers to expand 
coverage for critical mental health services.   
IHS should provide technical assistance to tribes and non-AI/AN 
providers serving AI/ANs regarding the Federal reimbursement policy 
for eligible AI/ANs under the IHCIA.  Lastly, given that the needs of 
AI/ANs vary significantly among tribes and locations, IHS should assist 
tribes in collaborating with States and non-AI/AN providers to address 
the challenges of obtaining culturally sensitive services. 
 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  21 
   
       
R E C O M M E N D A T I O N S  
Continue to expand its telemedicine capabilities and provide guidance 
and technical assistance to tribal health care providers to expand and 
implement telemedicine 
Seventeen percent of IHS and tribal facilities use telemedicine to help 
address staff shortages and expand access to professional health 
services.  IHS should continue to address technical barriers to support 
and encourage use of telemedicine at IHS and tribal facilities.  In 
addition, IHS should develop written guidance to work with and educate 
IHS and tribal providers, States, and non-AI/AN providers regarding 
telemedicine services.  IHS should continue to provide technical 
assistance, if needed, to tribes that use telemedicine to ensure that they 
have the capability to bill Medicare, Medicaid, and third-party payers 
for appropriate telemedicine services.  By being able to charge third-
party payers, the facilities can increase their revenue to support facility-
specific telemedicine services.   
Develop a plan to create a single database of all IHS and tribal health care 
facilities 
Our attempts to compile a comprehensive list of all IHS and tribal 
health care facilities were limited because there is no single database
either in IHS or among tribes and tribal organizationsof all IHS and 
tribal health care facilities, with the facilities addresses and the names 
of contact people.  Although tribes are not required under 
638 contracting or self-governance compacting to report information 
about their facilities to IHS, a single database that identified all health 
care facilities and the services they offer would help the tribes and IHS 
to expand services under the reauthorized IHCIA.  IHS should develop a 
plan to work with tribes, States, and Federal agencies to create a 
national database of AI/AN health care facilities, and it should include 
all such facilities, regardless of funding sources.  Such a database would 
assist the Secretary in meeting the Administrations mandate to 
formulate a comprehensive approach to Indian health care reform and 
provide planning information relative to the distribution of health 
services for AI/ANs throughout the country.  
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  22 
   
       
 
R E C O M M E N D A T I O N S  
 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
IHS concurred with all three of our recommendations.  In response to 
our first recommendationthat IHS provide guidance and technical 
assistance to help tribes explore potential partnerships with non-AI/AN 
providers of community mental and behavioral health servicesIHS 
stated that it will collaborate with the Substance Abuse and Mental 
Health Services Administration (SAMHSA) to develop written guidance 
that addresses service gaps and lack of coordination among States, IHS, 
tribal facilities, and non-AI/AN providers.  IHS also stated that it will 
provide technical assistance to tribes regarding Federal reimbursement 
policies for eligible AI/ANs and that it will assist tribes in collaborating 
with SAMHSA, States, and non-AI/AN providers to address the 
challenges of obtaining culturally sensitive services for AI/AN patients. 
In response to our second recommendationthat IHS continue to 
expand its telemedicine capabilities and provide guidance and technical 
assistance to tribal health care providers to expand and implement 
telemedicineIHS stated that it will continue to expand 
implementation of telemedicine for behavioral health services, educate 
IHS and tribal providers regarding the use and effectiveness of 
telemedicine for behavioral health services, and address potential 
technical barriers to the use of telemedicine for behavioral health 
services at IHS and tribal facilities.  IHS stated that it will also provide 
technical assistance to tribes that use telemedicine for behavioral health 
services to increase their ability to bill third-party payers for those 
services. 
In response to our third recommendationthat IHS develop a plan to 
create a single database of all IHS and tribal health care facilitiesIHS 
stated that it will work with tribes, States, and Federal agencies to 
create a database of AI/AN health care facilities to include physical 
locations, contact information, and available services. 
We did not make any changes in the report based on IHSs comments.  
For the full text of IHSs comments, see Appendix G. 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  23 
   
       
 A P P E N D I X ~ A  
 
Health Disparities  
Table A:  Prevalence of Health Conditions and Mortality Rates by Race and Ethnicity 
Asian  
   AmAerliacsakna  INndatiaivne/     Non-HisWphainteic,    Hispanic  Non-HisBplaanckic,    andIs Plaancdifeicr   or More RaTcweos   
Health Condition *   Prevalence of Health Condition 
 
Two or more chronic conditions  18%  10%  6%  11%  5%  9% 
Diabetes  12%  5%  6%  8%  5%  3% 
Frequently anxious or depressed  23%  16%  13%  14%  8%  21% 
  Obesity  39%  28%  31%  38%  12%  20% 
Cause of Death **  Mortality Rate Per 100,000 
Heart disease  141.8  210.7  157.3  271.3  113.3  --- 
Cancer  123.2  187.0  122.8  222.7  110.5  --- 
Diabetes  41.5  21.5  33.6  46.9  16.6  --- 
Chronic liver disease  22.6  8.7  13.9  7.7  3.6  --- 
Unintentional injuries  54.7  41.0  31.3  38.7  17.9  --- 
Motor vehicle accidents  24.8  15.5  14.7  14.5  7.6  --- 
Suicide  11.7  12.9  5.6  5.2  5.2  --- 
*Source:  A Profile of American Indians and Alaska Natives and Their Health Coverage, September 2009, Figure 4:  Prevalence of Health Conditions by Race/Ethnicity,  
2004-2007. 36 Based on a percentage of the defined population.   
**Source:  A Profile of American Indians and Alaska Natives and Their Health Coverage, September 2009, Figure 6:  Mortality Rate by Race/Ethnicity, 2005.37  Based on 
age-adjusted death rates per 100,000 population. 
 
36 Cara James, Karyn Schwartz, and Julia Berndt, Race, Ethnicity & Health Care Issue Brief:  A Profile of American Indians and Alaska 
Natives and Their Health Coverage, September 2009.  Accessed at http://www.kff.org/minorityhealth/upload/7977.pdf on February 12, 2010.  
37 Ibid. 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES            24 
   
       
A P AP EP NP DE INXD~ I BX  ~ B  
Glossary of Terms 
 
Clinic.  A facility, physically separated from a hospital or health center, 
in which primary care physician services are available on a regularly 
scheduled basis but for less than 40 hours a week for outpatient care.  
Clinics are similar to health stations.38 
Clinical Social Worker.  A health professional trained in client-centered 
advocacy who assists clients with information, referral, and direct help in 
dealing with local, State, or Federal government agencies.39 
Crisis Intervention.  A brief therapeutic approach that is ameliorative 
rather than curative of acute psychiatric emergencies.40 
Electroconvulsive Therapy.  A procedure in which electric currents are 
passed through the brain, deliberately triggering a brief seizure.  
Electroconvulsive therapy seems to cause changes in brain chemistry that 
can immediately reverse symptoms of certain mental illnesses.41 
Health Center.  A facility, physically separated from a hospital, with a full 
range of ambulatory services, including physician, nursing, pharmacy, 
laboratory, and x-ray services.  Services are available at least 40 hours 
per week for ambulatory care.42 
Health Station.  See Clinic,  above. 
Hypnotherapy.  The use of exercises that bring about deep relaxation and 
an altered state of consciousness.  Persons in a deeply focused state can 
affect their own psychological responses.43 
Marriage and Family Therapist.  A person who evaluates and helps resolve 
problems in the context of a marriage or family.  Such a therapist 
typically has a masters or doctoral degree. 44  
 
38 Definition accessed at http://www.anthc.org/ref/hs/codebook/asufac.cfm on  
March 30, 2011. 
39 Definition accessed at http://www.mentalhealthchannel.net/csw.shtml on June 13, 2010.   
40 Definition accessed at http://psycnet.apa.org on February 14, 2010. 
41 Definition accessed at http://www.mayoclinic.com/health/electroconvulsive-
therapy/MY00129 on January 4, 2010. 
42 Definition accessed at http://www.anthc.org/ref/hs/codebook/asufac.cfm on  
March 30, 2011. 
43 Definition accessed at http://www.umm.edu/altmed/articles/hypnotherapy-000353.htm on 
January 4, 2010. 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  25 
   
       
A P P E N D I X ~ B  
Mental Health Counselor.  A broad term for a person who provides 
counseling.  Most such individuals have at least a masters degree in 
social work or a related field, have several years of supervised work 
experience, and are licensed or certified.  A mental health counselor may 
also be called a licensed professional counselor, licensed mental health 
counselor, or professional counselor.45 
Midlevel Practitioner.  A nurse midwife, nurse practitioner, or physician 
assistant, licensed by the State in which the individual practices.46 
Pharmacotherapy.  The treatment of disease, and especially mental 
disorder, with drugs.47 
Post-Traumatic Stress Disorder (PTSD).  A disorder in which a person 
experienced, witnessed, or was confronted with an event or events that 
involved actual or threatened death or serious injury, or a threat to the 
physical integrity of self or others and in which a persons response 
involved intense fear, helplessness, or horror.48 
Psychiatric Crisis.  A psychological or social condition characterized by 
unusual instability caused by excessive stress and either endangering or 
felt to endanger the continuity of an individual or group.49 
Psychiatric Hospital.  An institution that:50  
  is engaged primarily in providing, by or under the supervision of a 
Doctor of Medicine or Osteopathy, psychiatric services for the 
diagnosis and treatment of mentally ill persons; 
 
44 Definition accessed at 
http://therapists.psychologytoday.com/rms/content/therapy_professionals.html  
on March 30, 2011. 
45 Ibid. 
46 Centers for Medicare & Medicaid Services (CMS), Medicare State Operations Manual 
Provider Certification.  Accessed at http://www.cms.gov/transmittals/Downloads/R32SOM.pdf 
on April 8, 2010. 
47 Definition accessed at http://www.merriam-ebster.com/medlineplus/pharmacotherapy 
on March 29, 2011. 
48 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders 
DSM-IV-TR, 2000. 
49 Definition accessed at http://www.merriam-webster.com/medlineplus/crisis  
on March 29, 2011. 
50 CMS, Psychiatric Hospitals.  Definition accessed at 
http://www.cms.hhs.gov/CertificationandComplianc/14_PsychHospitals.asp on  
February 14, 2010. 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  26 
   
       
A P P E N D I X ~ B  
  satisfies the requirements of sections 1861(e)(3) through (e)(9) of the 
Social Security Act (general hospital requirements); 
  maintains clinical and other records on all patients as the Secretary 
finds necessary to determine the degree and intensity of the 
treatment provided to individuals entitled to hospital insurance 
benefits under Part A; and 
  meets such staffing requirements as the Secretary finds necessary 
for the institution to carry out an active program of treatment for 
individuals receiving services in the institution. 
Psychologist (Clinical Psychologist).  A specialist in one or more branches 
of psychology, especially a practitioner of clinical psychology, counseling, 
or guidance.  Psychology is a doctoral-level profession.51 
School Health Center.  A health center that is based at a school site and 
serves primarily students. 
Telemedicine.  The use of medical information that is exchanged from one 
site to another via electronic communications to improve clients health. 
Closely associated with telemedicine is the term telehealth, which often 
encompasses a broader definition of remote health care that does not 
always involve clinical services.  Videoconferencing; transmission of still 
images; e-health, including patient portals; remote monitoring of vital 
signs; continuing medical education; and nursing call centers are all 
considered part of telemedicine and telehealth.  Telemedicine is not a 
separate medical specialty.52 
 
 
51 Definition accessed at http://www.merriam-webster.com/medlineplus/psychologist  
on March 29, 2011. 
52 Definition accessed at http://www.americantelemed.org/i4a/pages/index.cfm?pageid=3333 
on February 4, 2010. 
  OEI-09-08-00580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  27 
   
 A P P E N D I X ~ C  
Response Rates 
 
Table C-1:  Fieldwork and Survey Response Rate by IHS and Tribal Facility Type   
  SURVEYS 
Total 
Facilities 
Total in Population  Nonrespondents  Respondents 
Visited  Response 
Type of Facility 
 Rate 
Total   Tribal  IHS  Total   Tribal  IHS  Total   Tribal  IHS 
Alaska village clinic  3  94%  160  160  0  10  10  0  150  150  0 
Alcohol and substance abuse treatment  
18  66%  99  93  6  34  34  0  65  59  6 
center 
   Residential  13  78%  50  44  6  11  11  0  39  33  6 
   Nonresidential   5  53%  49  49  0  23  23  0  26  26  0 
Behavioral health facility  10  79%  42  41  1  9  9  0  33  32  1 
   Residential  1  100%  7  7  0  0  0  0  7  7  0 
   Nonresidential   9  71%  35  34  1  10  9  1  25  25  0 
Health center  36  84%  274  220  54  44  40  4  230  180  50 
Health station  2  65%  68  56  12  24  24  0  44  32  12 
Hospital  23  93%  44  14  30  3  2  1  41  12  29 
   Medical   22  88%  43  14  29  5  4  1  38  10  28 
   Psychiatric  1  100%  1  0  1  0  0  0  1  0  1 
Other residential  0  100%  5  5  0  0  0  0  5  5  0 
Remote health locations  0  85%  13  13  0  2  2  0  11  11  0 
School health center  0  79%  28  5  23  6  3  3  22  2  20 
Urban health center  0  82%  34  34  0  6  6  0  28  28  0 
Wellness/fitness center  0  20%  5  5  0  4  4  0  1  1  0 
     Total  98  82%  772  646  126  142  134  8  630  512  118 
Source:  Office of Inspector General (OIG) analysis of survey data, 2010. 
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  A P P E N D I X ~ C  
 
 
 
Table C-2:  Fieldwork and Survey Response Rate by IHS Service Area   
  VISITS  SURVEYS 
Total in Population  Nonrespondents  Respondents 
Response  
IHS Service Area  Total Facilities  
Rate 
Total   Tribal  IHS  Total   Tribal  IHS  Total   Tribal  IHS 
Aberdeen, SD  13  51%  45  28  17  21  20  1  24  8  16 
Alaska  19  92%  252  252  0  19  19  0  233  233  0 
Albuquerque, NM  6  83%  24  10  14  4  3  1  20  7  13 
Bemidji, MN  12  67%  86  81  5  27  27  0  59  54  5 
Billings, MT  7  95%  22  11  11  1  0  1  21  11  10 
California  10  93%  71  71  0  4  4  0  67  67  0 
Nashville, TN*  4  67%  35  33  2  11  11  0  24  22  2 
Navajo  3  83%  42  4  38  6  2  4  36  2  34 
Oklahoma  8  78%  63  51  12  14  14  0  49  37  12 
Phoenix, AZ  13  71%  68  51  17  20  19  1  48  32  16 
Portland, OR  7  76%  55  49  6  13  13  0  42  36  6 
Tucson, AZ  8  73%  9  5  4  2  2  0  7  3  4 
     Total  110  82%  772  646  126  142  134  8  630  512  118 
Source:  OIG analysis of survey data, 2010.    
*Interviewed Area Office by phone.   
             
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 A P P E N D I X ~ D  
Population Served and Screened by Type of Facility  
 
Table D:  Community Population Served and Number of Clients  
                Screened for Mental Health Services by Type of Facility 
Total Facilities That  Approximate Number 
Mean Community 
Report Providing  of Clients Screened for 
Type of Facility  Population Served 
Mental Health  Mental Health 
by the Facility* 
Services  Services* 
Health center  192  27,000  238,000 
Alaska village clinic  112  300  6,000 
Alcohol and substance 
55  60,000  37,000 
abuse treatment center 
   Residential  36  87,000  7,000 
   Nonresidential  19  54,000  30,000 
Hospital  35  32,000  183,000 
Health station  32  5,000  10,000 
Behavioral health facility  31  38,000  28,000 
   Residential  7  44,000  2,000 
   Nonresidential  24  36,000  26,000 
Urban health center  28  51,000  34,000 
School health center  20  600  1,000 
Remote health location  7  3,000  <1,000 
Other residential  2  6,000  <1,000 
     Total  514  22,000  536,000 
*Based on facility-reported information on the population of the community served by the facility.  Number of clients 
screened is from approximately January 2008 to November 2009. 
Source:  Office of Inspector General analysis of survey data, 2010. 
 
 
 
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 A P P E N D I X ~ E  
 
Crisis Intervention Services 
 
Table E:  Staffing Levels at IHS and Tribal Facilities That Provide 24-hour Crisis Intervention Services With Onsite Mental Health 
               Care Staff 
    By Provider Type and Total Median Hours 
   
   
    Social Worker, 
  Any Medical  Counselor, Aide,  Any Mental Health 
  Psychiatrist  Psychologist 
  Provider  and/or   Care Staff 
 
  Traditional Healer 
 
Total Facilities That  
  Provide 24-Hour  
  Onsite Crisis    Median  Median  Median  Median  Median 
Facilities*  Facilities*  Facilities*  Facilities* 
Type of Facility  Intervention Services    Facilities*  Hours**  Hours**  Hours**  Hours**  Hours** 
Alcohol and substance abuse treatment center  12  6  16  9  76  6  40  12  200  12  235 
Behavioral health facility  8  7  39  8  78  3  20  7  248  8  321 
Health center  16  13  8  16  204  9  16  16  120  16  341 
Hospital  14  13  40  13  114  12  40  14  165  14  305 
Urban health center  2  1  32  2  84  1  32  2  291  2  387 
    Total   52  40  32  48  84  31  32  51  200  52  321 
     Percentage of All Facilities That Reported  
10%  8%  ---  9%  ---  6%  ---  10%  ---  10%  --- 
     Providing Mental Health Services (n=514) 
*Facilities are counted once if they have at least one or more of each provider type.  
**Median hours include all hours for each provider type per facility type.  Facilities may employ more than one of each provider type. 
Source:  Office of Inspector General analysis of survey data, 2010. 
 
 
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 A P P E N D I X ~ F  
Mental Health Care Staff Onsite at Facilities 
 
Table F:  Median Hours Per Week for Mental Health Care Staff    
               by Provider Type    
Percentage of 
 
Type of Provider  Facilities*  Median Hours Per Week** 
(n=514)   
Mental health care providers  85%  40   
   Psychologist  29%  34   
   Social worker  35%  40   
   Counselor/therapist  69%  40   
   Mental health care aide  13%  22   
   Peer counselor  7%  38   
Physician  41%  25   
   Psychiatrist  32%  8   
   All other physicians  20%  40   
Midlevel practitioners  21%  40   
   Physician assistant  9%  32   
   Psychiatric nurse practitioner  4%  40   
   Nurse practitioner  15%  40   
Traditional providers  12%  16   
   Medicine man/woman  2%  4   
   Spiritual advisor  5%  25   
   Traditional healer  10%  8   
Registered nurse  10%  40   
Other  4%  39   
 
    Any level provider  100%  66 
 
*Facilities are counted once if they have at least one or more of each provider type.  
**Median hours include all hours for each provider type per facility type.  Facilities may employ more than one of each   
provider type. 
Source:  Office of Inspector General analysis of survey data, 2010.   
 
 
 
 
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 A P P E N D I X ~ G  
Agency Comments 
 
 
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A P P E N D I X ~ G  
 
 
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  A  P  PEN  D  x  G 
Page 3 - Inspector General 
The IHS will continue to expand implementation of tele-behavioral health services, educate IRS 
and Tribal providers regarding the use and effectiveness oftele-behavioral health services, and 
address potential technical barriers to such utilization at IRS and Tribal facilities. The IHS will 
also provide technical assistancet6 Tribes that use tele-behavioral health services to increase 
their ability to bill third party payers for those services. 
3.  Develop a plan to create a single database of aU ms and Tribal health care facilities. 
The IRS concurs with this recommendation. The Agency will develop a plan to create a single 
database that identifies all IRS and Tribal health care facilities to better assist Tribes and IRS in 
identifying and expanding services. The illS will work with Tribes, States, and Federal agencies 
to create the single database ofAIlAN health care facilities to include physical locations, contact 
information, and available services. 
Thank you for providing illS the opportunity to comment on the orG's draft report.  The illS is 
committed to improving our health delivery system and increasing access to those requiring our 
services.  We will continue to work in partnership with our Tribal health system to assist them in 
their ongoing efforts. 
Yvette Roubideaux, M.D., M.P.H. 
OEI090800580  ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES  35   
       
 A C K N O W L E D G M E N T S  
This report was prepared under the direction of Timothy S. Brady, 
Regional Inspector General for Evaluation and Inspections in the  
San Francisco regional office, and Michael Henry, Deputy Regional 
Inspector General.   
Steven Zerebecki served as the team leader for this study.  Other 
principal Office of Evaluation and Inspections staff from the  
San Francisco regional office who contributed to the report include:   
Loul Alvarez, Veronica Gonzalez, Camille Harper, Cynthia Lemesh, 
Christina Lester, Linda Min, China Tantameng, and Marcia Wong.  
Central office staff who contributed include Ruth Davis, Melinda Golub, 
Amitava Jay Mazumdar, and Talisha Searcy.  
 
OEI-09-08-00580    ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES                                             36 
   
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of Department of Health and Human Services (HHS) 
programs, as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.