Department  of  Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
REVITALIZING  THE  COMMUNllY  HEALTH 
REPRESENTATIVE  PROGRAM 
APRIL  1993  OFFICE OF INSPE~OR  GENERAL 
The  mission  of the  Office of Inspector  General  (OIG),  as mandated  by Public  Law 95-452, as 
amended,  is to protect  the  integrity  of the  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 three  OIG  operating  components:  the  Office of Audit  Services,  the 
Office of Investigations,  and the  Office of Evaluation  and Inspections.  The  OIG  also informs 
the  Secretary  of HHS  of program  and management  problems  and recommends  courses  to 
correct  them. 
OFFICE OF AUDIT  SERVICES 
The  OIGS  Office of Audit  Services  (OAS)  provides  all 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  in order  to reduce  waste,  abuse,  and 
mismanagement  and to promote  economy  and efficiency throughout  the  Department. 
OFFICE OF INVESTIGATIONS 
The  OIGS  Office of Investigations  (01)  conducts  criminal,  civil, and administrative 
investigations  of allegations  of wrongdoing  in HHS  programs  or to HHS  beneficiaries  and of 
unjust  enrichment  by providers.  The  investigative  efforts  of 01  lead to criminal  convictions, 
administrative  sanctions,  or civil money  penalties.  The  01  also oversees  State  Medicaid  fraud 
control  units which investigate  and prosecute  fraud  and patient  abuse  in the  Medicaid  program. 
OFFICE OF EVALUATION  AND  INSPECIIONS 
The  OIGS  Office of Evaluation  and Inspections  (OEI)  conducts  short-term  management  and 
program  evaluations  (called  inspections)  that  focus on issues of concern  to the  Department, 
the  Congress,  and the  public.  The  findings  and recommendations  contained  in these  inspection 
reports  generate  rapid,  accurate,  and up-to-date  information  on the  efficiency, vulnerability, 
and effectiveness  of departmental  programs. 
This report  was prepared  under  the direction  of William Moran,  the  Regional  Inspector 
General  for the  Office  of Evaluation  and Inspections,  and Natalie  Coen,  Deputy  Regional 
Inspector  General,  Office of Evaluation  and Inspections,  Region  V.  Participating  in this prject 
were  the  following  people: 
Region  V  Headquarters 
Barbara  Butz, Team  Leader  Alan  Levine 
Jennifer  Antico,  Lead  Analyst 
Jean  Dufresne 
Jo Lynn Antonik  Department  of  Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
REVITALIZING  THE  COMMUNITY  HEALTH 
REPRESENTATIVE  PROGRAM 
APRIL  1993  OEI-O5-91-O1O7O  EXECUTIVE  SUMMARY 
PURPOSE 
This  report  describes  factors  which make  Community  Health  Representative  (CHR) 
programs  effective.  The  Public  Health  Service  (PHS)  could  use these  factors  to 
revitalize  the  program. 
BACKGROUND 
The  CHR  program  is based  on the  concept  that  indigenous  community  members, 
trained  in the  basic  skills of health  care  provision,  disease  control,  and  prevention,  can 
successfully  effect  change  in community  acceptance  and  utilization  of health  care 
resources.  The  CHR  program  is governed  by the  Indian  Health  Care  Improvement 
Act  of 1988.  In Fiscal  Year  (FY)  1992, the  Indian  Health  Service  (IHS),  within  PHS, 
spent  $39 million  for  1,544 CHRS in 260 programs.  The  program  is funded  through 
contracts,  grants,  or cooperative  agreements  based  on the  Indian  Self-Determination 
and  Education  Assistant  Act  (P.L.  93-638), hereafter  referred  to as 638. 
In  1983, Congress  mandated  that  IHS  establish  guidelines,  goals,  and  clear  evaluation 
standards  for the  CHR  program.  The  IHS  produced  guidelines  and  goals  for the 
program  which  are  written  in Chapter  16 of the  Indian  Health  Manual.  They  also 
developed  two management  tools:  the  Scope  of Work  (SOW),  for planning  purposes, 
and  the  CHR  Information  System  II (CHRIS  II), for reporting. 
Although  Chapter  16 states  that  tribal  CHR  programs  will be  evaluated  on a triennial 
basis,  IHS  has neither  developed  evaluation  criteria  nor  conducted  a national 
evaluation  of the  program. 
SCOPE  AND  METHODOLOGY 
This  report  should  be  read  along  with  our  companion  report  entitled  Management 
Issues  in the  CHR  Program.  In that  report,  we recommended  that  PHS,  and  tribes, 
thoroughly  re-examine  the  CHR  program  and  decide  whether  to retain  it in its current 
form,  revise  it to become  a transport  program,  or abolish  it.  Should  they  retain  the 
program,  we recommended  that  they  develop  a national  strategy  to revitalize  it. 
This  report  presents  information  which  could  be useful  to PHS  in developing  a 
revitalization  strategy.  It describes  what  403 respondents  - from  the  national,  area, 
and  local  levels  - said were  the  most  important  factors  that  make  individual  CHR 
programs  effective,  and  why they  make  programs  effective.  It also  describes  how the 
factors  can be  used  to judge  the  effectiveness  of a CHR  program. 
i  FINDINGS 
According  to respondents,  four  factors  make  CHR  programs  effective. 
Factor 1: Agreement  on the Role of the CHR 
Area  and  local  respondents  ranked  this factor  number  one.  Their  view is that  the  role 
of the  CHRS  at a program  must  be well defined  and  understood  by everyone  involved 
before  any of the  other  factors  can have  any impact  on the  effectiveness  of the 
program. 
Factor 2: Integration into the Health  Care @stem 
A majority  of the  CHRS ranked  this as the  factor  with  the  greatest  influence  on the 
effectiveness  of their  program.  Other  respondents  all spoke  of the  need  for CHRS to 
work  closely with  health  care  professionals,  especially  if they  provide  medical  care  to 
patients.  They  also said that  this is important  in the  CHRS role  as link to the 
community. 
Factor 3: lh3aI  Suppo~  and Direction 
Respondents  say that  a lack  of tribal  support  and  direction  may cause  a CHR  program 
to deteriorate.  It may also lower  the  morale  of the  CHRS. 
Factor 4: IHS Supp~  and Direction 
Respondents  believe  IHS  support  has less impact  on the  effectiveness  of CHR 
programs  than  other  factors.  However,  they  also say that  IHS support  is needed  to 
make  programs  strong. 
CONCLUSION 
When  we applied  these  factors  at  two CHR  programs,  using a case  study  approach, 
we found  that  they were  useful  in judging  the  effectiveness  of the  programs.  If PHS 
decides  to revitalize  the  CHR  program,  we encourage  them  to consider  these  factors 
in developing  a multi-faced  national  strategy  for doing  so. 
COMMENTS 
The  Assistant  Secretary  for Planning  and  Evaluation  (ASPE)  and  PHS  commented  on 
the  report.  The  ASPE  agreed  that  more  attention  should  be  paid  to the  CHR 
program.  The  PHS  described  steps  that  IHS has initiated  to revitalize  the  CHR 
program,  noting  that  their  revitalization  strategy  will take  into  account  the  factors 
described  in this report.  The  full text  of the  comments  is in Appendix  B. 
ii  TABLE  OF  CONTENTS 
PAGE 
EXECUTIVE  SUMMARY 
INTRODUCTION .  . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1 
FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5 
Factor  l:  Agreement  on the  Role  ofthe  CHR  . . . . . . . . . . . . . . . . . . . . . . . . . . ..6 
Factor  2: Integration  inthe  FIealth  Care  System  . . . . . . . . . . . . . . . . . . . . . . . . ...9 
Factor  3: Tribal  Support  and  Direction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...11 
Factor  4: IHSSupport  and  Direction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...14 
CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...17 
APPENDICES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
A  Endnotes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l 
B:  Agency  Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-l  INTRODUCTION

PURPOSE 
We  conducted  this study to identi~  and  assess factors  which  make  Community  Health 
Representative  (CHR)  programs  effective.  The  Public  Health  Service  (PHS)  could  use 
these  factors  to revitalize  the  program. 
BACKGROUND 
Pkogram Hktoy 
In  1968, under  the  1921 Snyder  Act  (25 U.S.C.  13), Congress  established  the  CHR 
program  within  the  Indian  Health  Service  (IHS)  in PHS.  The  program  was intended  to 
provide  outreach  health  care  services  for American  Indian  and  Alaska  Native  tribal 
governments  and  organizations.  It is based  on the  concept  that  indigenous  community 
members,  trained  in the  basic  skills of health  care  provision,  disease  control,  and 
prevention,  can  successfully  effect  change  in community  acceptance  and  utilization  of 
health  care  resources.  A CHR  is a tribal  or Native  community-based,  well-trained, 
medically-guided,  health  care  provider,  who may include  traditional  Native  concepts  in 
his/her  work.1 
The  program  is currently  governed  by the  Indian  Health  Care  Improvement  Act 
Amendments  of 1988.  In Fiscal  Year  (FY)  1992, IHS spent  $39 million  for  1,544 CHRS 
in 260 programs  throughout  the  continental  United  States  and  Alaska.  Currently,  IHS 
spends  about  $1 million  of this amount  on training  for CHRS, including  funding  a 
national  training  officer  and  a number  of training  facilities. 
The  CHR  program  is funded  through  contracts,  grants  or cooperative  agreement 
arrangements  with  Native  or tribal  governments  and  organizations  based  on the  Indian 
Self-Determination  and  Education  Assistance  Act  (P.L.  93-638),  hereafter  referred  to as 
638.  The  IHS  is increasingly  using 638 contracts  as a mechanism  to provide  health 
services  to  Indian  people.  Under  them,  tribes  are  delegated  responsibility  for 
administering  programs,  and  have  great  latitude  in designing  and  operating  them.  The 
IHS  sets basic  parameters  and  guidelines,  and  is responsible  for management  and 
oversight  of the  national  CHR  program;  however  in terms  of the  day-to-day  operation  of 
individual  programs,  IHS  assumes  more  of a consultation  and  technical  assistance  role. 
The  program  grew quickly  from  1968 to  1980.  At that  time,  however,  Congress  grew 
concerned  that  the  budget  for the  program  could  not be  adequately  justified.  Program 
activities  had  not  been  clearly  documented  and  monitored  by IHS,  and  programs  varied 
widely across  tribes.  Congress  grew concerned  about  a lack  of program  goals  and 
objectives  and  an adequate  reporting  system,  and  reports  that  the  CHR  program  was 
little  more  than  a jobs or employment  program  for reservations.  In FY  1981 and  1982, 
Congress  began  to reduce  the  number  of CHR  positions,  and  in FY  1983 the  program 
1
 came  close  to being  eliminated.  Although  the  program  ultimately  survived,  Congress  cut 
513 slots from  a peak  of 2,293.  This  decline  continued  until  FY  1990, when  Congress 
slowly began  to increase  slots to the  1,544 of today. 
lYogram Administration 
In  1983, Congress  mandated  that  IHS  establish  guidelines,  goals,  and  clear  evaluation 
standards  for the  CHR  program.  In response,  IHS  established  the  position  of a national 
CHR  program  director  and  developed  program  goals,  objectives  and  guidelines  which  are 
written  in Chapter  16 of the  Indian  Health  Manual. 
Individual  CHR  contracts  are  administered  by the  12 IHS  area  offices.  The  national 
CHR  program  director,  in the  Office  of Health  Programs  under  the  Special  Initiatives 
Branch,  has  no direct  line  authority  over  these  area  offices  or staff.  In more  of a 
consultation  or technical  assistance  role,  that  office  develops  and  implements 
management  standards  and  tools,  plans  training,  and  conducts  program  reviews. 
In each  area  office,  a CHR  coordinator  is the  primary  contact  with the  national  program 
director  and  the  one  area  staff person  with direct  responsibility  for CHR  programs. 
Project  officers  also have  certain  program  and  fiscal responsibilities  in connection  with 
monitoring  contracts,  including  CHR  contracts,  and  facilitating  the  interaction  between 
tribal  CHR  programs  and  the  service  unit  or area  health  care  programs.  Most  CHR 
coordinators  and  project  officers juggle  CHR  duties  with other  responsibilities. 
The  IHS  uses  two important  management  tools  in the  CHR  program.  The  Scope  of 
Work  (SOW)  is a form  tribes  may use  to plan  their  CHR  programs.  The  CHR 
Information  System  II, or CHRIS  II, is a reporting  system  based  on the  SOW.  Although 
not  required  to use  either  the  SOW  and  CHRIS  II, at present  most  of the  tribes  are 
doing  so. 
Chapter  16 states,  Tribal  programs  will be  evaluated  on a triennial  basis,  through  the  use 
of a nationally  developed  instrument,  with  tribal  consultation  and  concurrence.2  To 
date,  however,  IHS  has neither  developed  evaluation  criteria  or tools  nor  conducted  a 
national  evaluation  of the  program. 
SCOPE  AND  METHODOLOGY 
The  intent  of this study was to identify  and  assess factors  that  make  CHR  programs 
effective.  This  report  describes  those  factors.  A  companion  report  entitled 
Management  Issues  in the  CHR  Program  (OEI-O5-91-O1O71) describes  certain 
management  issues  that  arose  in the  course  of the  study. 
As background  for the  study, we conducted  a review  of literature:  legislation  and 
regulations  on the  CHR  program,  the  Indian  Self Determination  Act,  and  the  Indian 
Health  Care  Improvement  Act;  Chapter  16 of the  IHS manual;  annual  reports,  CHRIS  II 
reports  and  other  documents  related  to the  CHR  program;  and  reports  on Indian  health. 
2
 We  also spoke  with persons  in the  Office  of Management  and  Budget,  and  the  Office  of 
the  Assistant  Secretary  for Planning  and  Evaluation  in the  Department  of Health  and 
Human  Services. 
Data  collection  took  place  in three  phases.  As this chart  shows, we contacted  over  400 
respondents  for the  study. 
Piziicl  
Phase  1  Phase  2  Phase  3  Total 
National  6  23  29 
Area  22  30  10  62 
16  58 25  99 
E  .:  :: :  : 
Phase  One:  In November  and  December  1991, we visited  2 of the  12 IHS  area  offices 
and  5 CHR  programs,  chosen  in collaboration  with IHS Area  coordinators  to represent  a 
variety  of types  of programs.  We  talked  with over  75 respondents:  people  involved  in 
creating  the  program;  IHS  staff in area  offices;  and  people  in CHR  programs  and  service 
units.  We  also held  focus  groups  with  area  CHR  coordinators  and  CHRS  and  talked  to 
the  national  training  officer  and  persons  from  the  National  Association  of CHRS.  We 
asked  them  What  makes  a CHR  program  strong  (effective)?  They  identified  four 
broad  factors  that  make  programs  effective.  In Phases  Two  and  Three  of the  study, we 
set out  to learn  more  about  the  factors  and  assess their  usefulness  in judging  program 
effectiveness  in a real life situation. 
Phase  Two:  In February,  March,  and  April  1992, we contacted  an additional  272 
respondents  to learn  their  perceptions  about  the  factors:  how important  are  they,  and 
why?; if a factor  is not  present  in a CHR  program,  is the  program  weakened?;  and,  what 
can  IHS  do to strengthen  or promote  these  factors? 
	 At  the  national  level, we talked  to Congressional  staff,  people  in the  Office  of the 
Assistant  Secretary  for Health  in PHS,  and  IHS Headquarters  staff. 
.	 At  the  area  level, we chose  five IHS area  offices  (Oklahoma  City, Oklahoma; 
Aberdeen,  South  Dakota;  Window  Rock,  Arizona,  Navajo  Nation;  Portland, 
Oregon;  and  Nashville,  Tennessee)  which  are  diverse  in terms  of geography, 
program  sizes and  types,  and  together  represent  half  of the  1,544 CHRS 
nationwide.  We  talked  to area  directors,  CHR  coordinators,  and  other  health  care 
professionals  in these  offices. 
3
   For  respondents  at the  local,  or program,  level, we chose  three  CHR  programs  in 
each  of these  five areas  (15 total).  They  were  programs  that  had  more  than  two 
CHRS, represented  a geographic  and  programmatic  mix, and  agreed  to participate 
in the  study.  We  spoke  by telephone  with the  tribal  health  directors,  CHR 
supervisors,  service  unit  directors,  and  health  care  professionals  at  these  programs. 
We  also contacted  161 CHRS.  One  of the  15 tribal  officials we contacted 
responded  to our  inquiries. 
  We visited  a third  IHS  area  office  and  three  other  CHR  programs  in connection 
with a review  conducted  by the  national  CHR  program  director.  We  also  talked 
to tribal  health  directors  at a conference. 
Phase  Ihree:  In April  1992, using a case  study approach,  we visited  two CHR  programs 
in two IHS  areas,  to apply  these  factors  in a real life situation.  We  chose  the  programs 
in collaboration  with the  national  program  director,  the  CHR  coordinator  in each  area, 
and  the  tribes  themselves.  Each  program  had  10 CHRS, most  of them  working  as 
generalists  although  some  positions  were  dedicated  to clerical  or data  entry  work.  The 
sites were  rural.  Both  had  IHS semice  units.  We contacted  55 respondents  in this phase. 
This  study was conducted  in accordance  with  the  Interim  Standards  for Inspections  issued 
by the  Presidents  Council  on Integrity  and  Efficiency. 
4  FINDINGS

INTRODUCTION 
In our  report  entitled  Management  Issues in the  CHR  Program,  we recommended  that 
PHS,  and  tribes,  undertake  a thorough  re-examination  of the  CHR  program  and  decide 
whether  to retain  the  program  in its current  form,  revise  it to become  a transport 
program,  or abolish  it.  Should  they  opt  to retain  the  program,  we recommended  that 
they develop  a strategy  to revitalize  it. 
This  report  describes  what  the  403 respondents  in this study - from  the  national,  area, 
and  local  levels  - said were  the  four  most  important  factors  that  make  individual  CHR 
programs  effective.  Should  PHS  decide  to revitalize  the  CHR  program,  these  four 
factors  should  be  considered  in the  development  of a strategy  to do so. 
The  factors  are: 
.-
Factorsthat Influencethe Effectiveness 
of CHR Programs 
Factor  1  Agreement  on the  role  of the  CHR

Factor  2  Integration  into  the  health  care  system

Factor  3  Triial  support  and  direction

Factor  4  IHS  support  and  direction

L 
We  describe  why respondents  think  the  factors  make  programs  effective,  and  what 
specific  building  blocks,  or elements,  comprise  each  one.  We  also  explain  how  the 
factors  and  elements  can be  used  to judge  the  effectiveness  of a CHR  program.  We 
discuss each  factor  in the  following format,  and  then  present  our  conclusions. 
Importance  of the  Factor	 Why respondents  think  the  factor  makes  CHR  programs 
strong,  and  what  impact  its presence  or absence  has  on a 
programs  effectiveness. 
Elements  for the  Facto~  What  respondents  said  comprises  the  factor. 
Case  Study  Analysis:	 How we applied  the  factor  and  its elements  in two CHR 
programs,  and  what  we learned  about  the  programs  using 
them. 
5
 FACIOR  1:  AGREEMENT  ON THE  ROLE  OF THE  CHR 
Importance  of Factor 
Local  and area respondents think that there must be agreement on the role of the CHR at a 
program  before any of the other facton  can z%zpactthe program 
In terms  of its influence  on the  effectiveness  of CHR  programs,  local  and  area 
respondents  ranked  Agreement  on the  Role  of the  CHR  number  one  in importance 
among  the  four  factors.  Their  view is that  the  role  of the  CHRS  at a program  must  be 
well defined  and  understood  by everyone  involved  before  any of the  other  factors  can 
have  any impact  on the  effectiveness  of the  program.  They  say that  if tribal  officials, 
health  directors,  medical  staff and  CHRS do not  have  consensus  about  the  CHR  role, 
services  will become  fragmented  and  chaotic.  Also,  CHRS would  operate  on an ad  hoc 
basis with  each  going their  own way, like, as one  respondent  described,  a covey of 
quails. 
The  CHRS  ranked  this factor  third  in importance.  Numerous  CHRS  commented  on the 
need  for more  focused  direction  and supervision;  some  complained  that  they  had  too 
many  bosses. 
The  IHS  headquarters  respondents  believe  that  once  there  is consensus  on the  role, 
programs  will have  greater  stability  if the  community,  health  care  staff,  and  tribal  officials 
have  the  same  expectations  for the  program.  They  were  particularly  concerned  about 
how a lack  of agreement  affects  CHR  morale.  They  are  troubled  that  CHRS are 
perceived  as the  answer  to everyones  problems.  They  said that  CHRS  are  often  pulled 
in different  directions  between  what  they think  they should  do and  tribal  members  who 
might  ask them  to do inappropriate  things:  non-health-related  things  not  in the  SOW 
such as delivering  groceries  or commodities,  chopping  wood, janitorial  services  or 
transporting  people  to non-health-related  functions. 
Elements 
Respondents  suggested  the  following  elements  to identify  whether  there  is agreement  on 
the  role  of the  CHR  at a given program. 
A.  Are  there  written  goals,  objectives,  policies,  procedures,  job  descriptions,  a tribal 
health  plan,  and  a written  transportation  policy?  Have  they been  implemented? 
B.  Do  tribal  leaders,  community  members,  health  program  administrators  and  CHRS 
understand  the  CHR  role?  Do  they  all have  the  same  understanding  of the  role? 
c. 
What  kinds  of requests  for service  do CHRS get  from  the  community  and  medical 
staff?  Are  the  requests  within  the  range  of semices  agreed  on for  CHRS? 
6  D.	 Are  CHRIS  II and  SOW  reports  available?  Do  they  show that  CHRS  are 
providing  intended  sexvices? 
E.	 Do  CHRS work  closely with the  tribes  health  care  system?  Is there:  continuity  of 
care,  coordinated  effort,  good  communication,  and  teamwork? 
F.	 Are  there  many  consumer  complaints?  Are  consumers  satisfied  with the  CHR 
program? 
Case  Study  Analysis 
The elements  told us that there k agreement on the role of the CHR b  the two case study 
programs.  Z7ieyako  toki us that this agreed-upon role k to provide  transpatatkm  % 
elements  were easy to apply, but obsema~onwas @  to accurately assessing the programs. 
A.	 With  the  notable  exception  of a tribal  health  plan,  we had  little  difficulty  obtaining 
written  policies,  procedures,  goals,  objectives  and  reports  at  either  site.  Both  sites 
were  rich in such documentation.  However,  we found  that  simply reviewing  these 
documents  was inadequate;  only observation  enabled  us to learn  what  was really 
happening  in these  programs. 
The  CHR  position  descriptions  we found  at both  programs  provide  one  example 
of how written  documents  can be  misleading.  They  were  very broad  and  included 
services  such  as referral/liaison,  direct  health  services,  health  education,  and 
counseling.  Transportation  was included,  but  not  emphasized.  Yet  in both 
programs,  we observed  that  CHRS were  heavily  involved  in transportation. 
Observation  thus  gave  us a very different  - a more  real - picture  of what  CHRS 
were  actually  doing,  as opposed  to what  the  position  descriptions  said  they were 
doing. 
Both  programs  had  some  kind  of transportation  policy that  set  limitations  on CHR 
transportation  sexvices.  However,  we could  not  tell how strictly  the  policies  were 
enforced. 
At  one  site, the  most  revealing  written  documents  were  the  monthly  and  quarterly 
reports  produced  by the  program  manager  summarizing  CHR  activities  for  the 
time  period.  Transportation  activities  clearly  dominate.  The  reports  also 
mentioned  other  activities  such  as delivering  medication  and  commodities,  and 
assisting  families  at funerals. 
B.	 At both  sites we talked  to people  about  their  view of the  CHR  role.  Most  of 
them  talked  about  transportation  semices.  Tribal  officials,  medical  staff, 
community  members,  and  the  CHRS were  very supportive  of this function.  Only a 
few people  brought  up  the  notion  of CHRS doing  other  types  of activities,  like 
home  care  and  personal  care  semices.  At one  sfie we  talked  to a tribal  official 
who  stressed  the  importance  of transportation,  but  seemed  open  to an expanded 
7
 role  for CHRS  and  was interested  in hearing  about  what  other  tribes  do with their 
CHR  programs. 
c. 
Community  members,  medical  staff, and  tribal  officials  request  services  from  the 
CHRS  at these  programs.  The  CHR  supemisor  schedules  requests  that  are  made 
in advance,  but  CHRS  also spend  time  responding  to immediate  needs.  At both 
sites,  the  primary  requests  were  for transportation  and  delivery  services.  We 
learned  about  requests  for service  by observing  CHRS in their  daily activities,  and 
by reviewing  some  of their  daily activity  logs. 
D.  Both  programs  use the  SOW  and  CHRIS  II, and  they  provided  us with their  latest 
reports.  We  compared  the  CHRIS  II reports  to the  SOW  to see  if CHRS were 
carrying  out  planned  activities.  We  generally  found  the  two documents  to be 
comparable.  However,  at one  program,  we were  troubled  that  the  reports  did not 
reflect  our  own observation  of the  services  being  provided.  The  SOW  and  CHRIS 
II showed  transport  services  to be  15 percent  and  22 percent  of total  CHR  time 
respectively.  Yet  our  impression  was that  transport  is the  primary  if not  the  only 
activity  of the  CHRS in those  programs.  This  example  accentuates  the  point  that 
written  documents  and  reports  should  not  be  relied  on exclusively  to gauge 
program  performance. 
E.  We were  able  to assess  the  degree  of interaction  between  the  CHR  program  and 
the  other  health  programs  through  interviews  with CHRS  and  health  care  staff. 
We  asked  about  the  relationship  between  the  programs.  At both  sites 
respondents  told  us that  the  primary  purpose  for interaction  was for CHRS  to 
provide  transportation.  We  discuss this further  in the  next  section:  Integration 
with  the  Health  Care  System. 
F.  The  element  that  we found  most  difficult  to apply  was consumer  satisfaction.  As 
people  who  spent  only a few days with each  program,  we found  it difficult  to learn 
key community  perspectives  about  the  CHR  program  in any depth.  A few times 
we heard  complaints  or hints  of dissatisfaction.  Generally,  though,  community 
members  expressed  satisfaction  with programs  and  were  grateful  for  the  services 
they  have  received  from  CHRS. 
In summary,  these  elements  told  us that  there  is strong  agreement  on the  role  of the 
CHR  in both  programs.  That  agreed-upon  role  is primarily  one  of transporting  patients 
to and  from  medical  appointments,  and  delivering  medications. 
We were  able  to apply  all of the  elements  related  to agreement  on the  role  of the  CHR, 
although  some  were  easier  to apply  than  others.  Furthermore,  we found  that  some 
elements  could  be  misleading,  and  that  obsemation  is key to getting  a full and  accurate 
picture  of a program.  For  example,  CHRIS  II reports  and  CHR  position  descriptions 
portrayed  CHRS as involved  in a wide variety  of activities,  yet we observed  that  these 
programs  were  concentrated  on providing  transportation.  We learned  also  that  the 
8  absence  of documents  (like  a tribal  health  plan)  can  tell us about  program  priorities, 
interests,  and  goals  - or the  lack  thereof. 
FACIOR  2:  INTEGRATION  INTO  THE  HEALTH  CARE  SYSTEM 
Importance  of Factor 
A  majority of the CHfi  ranked Intqyation  into the Health  Care @stem  as the factor  w~h 
the greatest influence on the effectiiwmxs of their program 
Fifty-eight  percent  of the  CHRS ranked  Integration  the  number  one  factor  that 
influences  CHR  program  effectiveness.  In addition,  71 percent  of the  area  and  local 
respondents  believe  that  a CHR  program  will be weakened  greatly if integration  does 
not  occur. 
Respondents  from  the  local,  area,  and  national  levels  all spoke  of the  need  for  CHRS to 
work  closely with health  care  professionals,  especially  if CHRS provide  medical  care  to 
patients.  They  also said  this is important  in the  CHRS role  as the  link to the 
community. 
A CHR  program  that  lacks integration  with the  rest  of the  health  care  system  could  be 
affected  in a variety  of ways.  Some  respondents  said that  duplication  and  gaps  in 
services  would  occur,  and  that  health  care  professionals  might  lose  their  link to the 
community.  Other  respondents  were  concerned  that  without  interaction  with  a health 
care  professional,  a CHR  might  make  a mistake  or provide  misinformation  in the  course 
of providing  health  semices.  Still others  voiced  that  CHRS might  provide  semices  that 
are  not  even  related  to health,  such as janitorial  or clerical. 
Elements 
Respondents  suggested  the  following  types  of elements  to identi&  whether  a CHR 
program  is integrated  with the  tribes  health  care  system. 
A.	 Are  there  referrals  between  CHR  programs  and  other  health  care  programs? 
What  are  the  types  of referrals?  What  semices  are  provided  as a result  of 
referrals? 
B.  Do  health  care  professionals  know,  respect,  and  support  CHR  programs? 
c.  Do  CHRS participate  in meetings  and  committees  with  health  care  professionals? 
D.	 Are  CHR  activities  closely related  to defined  community  health  needs?  Is there  a 
tribal  health  plan? 
E.  Is CHR  training  planned/coordinated  with training  of health  care  professionals? 
9
 F.  Do  CHRS document  their  services  for patients  in patient  medical  records?3 
G.  Does  the  CHR  position  description  speci~  interaction  with health  care 
professionals? 
H.  Does  the  CHR  manager/supervisor  have  a health  care  background? 
I.  Is integration  specified  in the  tribes  contract  with IHS? 
Case  Study Analysis 
l%e elementi for Intqration were easy to apply. l%ey provided  vay  strong evidknce that 
neither program  k well iktqyated  with other health care programs, and that CH&  are not 
ikvolved  in providing  health care semces. 
A.  We  asked  about  the  referral  system  at both  sites.  At one  site,  referrals  were 
numerous  and  most  were  for transportation.  Referrals  in the  other  program  could 
not  be  tracked,  both  in terms  of the  number  of referrals  or the  kind  of service 
provided  as a result  of referrals. 
We  also looked  at reports  for evidence  of referrals.  At one  program  we found  the 
reports  unreliable.  For  example  in 1991, the  CHRIS  II report  counts  857 
referrals,  but  the  tribes  annual  report  claims  a total  of 151. 
B.  Discussions  with health  care  professionals  revealed  that  they  saw the  CHRS solely 
as transporters.  At one  site the  CHR  program  is co-located  with another  health 
program  and  supemised  by the  same  person.  There  did appear  to be  some 
interaction  and  referral  between  the  two programs,  but  it was ad hoc  and 
primarily  for transportation  services.  At the  same  time,  a conflict  between  the 
CHR  program  manager  and  another  department  head  stood  in the  way of those 
two programs  working  together. 
At the  other  site,  although  the  CHRS transport  many  diabetic  patients  to and  from 
the  clinic, the  diabetes  counselor  did not  know that  CHRS had  any knowledge  or 
training  about  diabetes,  including  nutrition  and  foot  checks.  If the  CHRS have  any 
valuable  information  about  patients  and  their  home  life, we saw nothing  to 
indicate  that  it is being  utilized  by health  care  professionals. 
c.  The  CHRS  at both  programs  we visited  did not  meet  at all with other  health  care 
professionals.  We  did hear  that  one  of the  CHR  supewisors  is invited  to health 
promotion/disease  prevention  committee  meetings  but  does  not  attend. 
D.  We  looked  for  a tribal  health  plan  to  determine  whether  CHRS  are  included  in 
tribal  plans  to  provide  health-related  sewices  (as  opposed  to  strictly  transport). 
We  found  no  such  plan,  nor  in  either  setting  did we see  a any other  plan 
specifically  tying CHR  activities  in to defined  community  health  needs. 
10  E.  Training  of CHRs  was not  coordinated  with health  care  professionals.  The  day we 
visited  one  site, many  of the  service  unit  health  care  professionals  were  attending 
an  all-day  seminar  at the  sexvice unit.  The  CHRS were  not  invited,  nor,  we 
learned,  was it conceivable  to the  health  care  professionals  that  CHRS would  ever 
be invited  to such  training. 
F.  None  of the  other  elements  suggested  by respondents  was present  at these  two 
programs.  CHR  activities  were  not  documented  in patient  medical  records,  we 
saw no instances  where  CHR  position  descriptions  specified  integration, 
managers/supervisors  did not  appear  to have  health  care  backgrounds,  and 
integration  was not  specified  in IHS  contracts  for these  CHR  programs. 
Together  these  elements  provided  strong  evidence  that  these  CHR  programs  were  not 
well integrated  with  other  health  programs,  particularly  with  those  at the  service  unit. 
Health  care  professionals  and  CHR  program  administrators  saw integration  solely in 
terms  of referrals  to CHRS for transportation  services  or delivering  medications. 
We  found  the  elements  on health  professionals  opinions  about  the  CHR  program  (B) 
and  referrals  (A)  particularly  useful  for assessing  this factor.  However,  in terms  of 
referrals,  we agreed  with respondents  who said that  we should  go beyond  simply counting 
the  number  of referrals  between  departments  to get an  accurate  picture  of the  extent  or 
quality  of integration.  It is also important  to know what  types  of referrals  are  being 
made,  and  the  outcome.  For  example,  if referrals  are  solely for transportation,  that  tells 
us that  CHRS may not  be working  to provide  health  care  semices  alongside  health  care 
professionals. 
FACTOR  3: TRIBAL  SUPPORT  AND  DIRECIION 
Importance  of Factor 
Reqxxaden~  say that a lack of trrbalsupport and direction jeopardhx  the flectivenew  of a 
CHR program  and lowets  CHR morale. 
Respondents  at IHS  headquarters  ranked  Tribal  Support  and  Direction  as the  number 
one  influence  on program  effectiveness.  They  think  that  tribal  officials  and  community 
members  should  understand  and  support  the  role  of the  CHR. 
The  CHRS  ranked  tribal  support  and  direction  second  in importance.  They  had  strong 
opinions  about  some  of the  elements  for this factor.  For  example,  seventy-eight  percent 
feel  that  CHR  employment  decisions  and  CHR  daily activities  should  not  be  influenced 
by tribal  politics. 
The  view of local  and  area  respondents  was that  the  CHR  program  would  deteriorate 
without  support  from  the  tribe.  Like  CHRS, these  respondents  were  concerned  that 
CHR  prog~ams  are  vulnerable  to becoming  political  Footballs.  They  said  that  tribal 
leadership  can  change  frequently,  often  impacting  hiring  and  firing decisions  with  each 
11  new  administration.  Also, they  noted  that  both  pressure  on CHRS by tribal  officials  to 
respond  to inappropriate  requests,  and  community  complaints,  may serve  to lower  CHR 
morale. 
Elements 
Respondents  suggested  the  following  types  of elements  to identify  the  degree  of tribal 
support  and  direction  in a CHR  program. 
A.  Does  the  program  have  strong  management  and  supervision? 
B.	 Is the  CHR  program  insulated  from  tribal  politics?  Does  the  tribe  support  the 
program  by providing:  resolutions  or letters  of support,  CHR  access  to tribal 
leadership,  and/or  a formal  system  for resolving  co-mplaints from  the  community? 
c.	 What  is the  level  of satisfaction  with  the  program  on the  part  of tribal  officials, 
community  members,  and  CHRS themselves? 
D.	 Do  tribes  make  adequate  equipment  and  materials  available  to the  CHR  program 
(e.g. office  space/supplies,  adequate  travel  reimbursement,  training,  and  salaries)? 
E.	 Does  the  tribe  see  the  CHR  program  as part  of the  health  care  system?  In an 
organizational  chart,  where  is the  CHR  program  located  in relation  to other 
health  care  programs?  Is there  a tribal  health  plan? 
Study Analysis 
We found  tribal  support  to be  the  most  difficult  factor  to assess.  Some  elements  include 
sensitive  or hard-to-obtain  information. 
A.	 To  assess  management  and  supemision,  we asked  to see  managerial  tools  such  as 
activity  logs, reports,  and  schedules.  Next, we talked  to the  CHR  supervisors 
about  their  day-to-day  operations  and  how the  CHRS are  monitored.  We  found 
that  both  programs  had  management  systems  in place  and  were  reasonably  well 
organized  and  supervised. 
In relation  to strong  management,  respondents  also noted  the  importance  of 
having  a strong  CHR  supemisor,  who could  compensate  for a lack  of involvement 
or support  by the  tribe.  Based  on our  obsemations,  we agree  that  this position 
could  play an important  role  in focusing  and  improving  these  two programs.  The 
supervisors  at both  appeared  to have  little  health  care  background  or training  in 
managing  a health  care  program.  We believe  that  this may partially  explain  why 
the  programs  have  not  established  a role  in the  health  care  system  beyond 
transportation. 
12
 B.  One  of the  more  difficult  elements  for us to assess was the  impact  of tribal  politics 
on these  CHR  programs.  We  found  that  the  only way to learn  about  the  political 
environment  was from  people  in the  program  and  the  community.  Therefore, 
much  of our  evidence  about  tribal  politics  is anecdotal. 
For  example,  a manager  at one  program  complained  that  the  tribal  chief  or the 
tribal  health  administrator  could  call at the drop  of a hat for a CHR  to pick 
someone  up.  Also,  one  tribal  official  told  us that  there  were  sometimes 
complaints  that  CHRS serve  mainly  their  own relatives.  However,  we could  not 
verifj  these  stories.  As another  illustration  of how tribal  politics  can  affect  a 
program,  at  one  site hiring  decisions  about  CHRS are  made  by the  tribal  council 
rather  than  the  program  manager,  who can  only suggest possible  candidates. 
We  found  no official  recognition  from  the  tribe  in either  program  in the  form  of 
resolutions  or letters  of support,  commendations,  certificates  or honors  for  the 
CHRS.  While  the  IHS  area  office  provides  some  of these  things,  we found  no 
evidence  that  the  tribes  do. 
co 
As we have  mentioned  under  Factor  1, it was difficult  to gauge  community  opinion 
about  the  CHR  program.  When  asked  about  the  program,  tribal  officials  and 
community  members  spoke  quite  favorably;  they believe  that  the  services  provided 
by the  CHRS  are  very important.  Our  conclusion,  however,  is that  their  support  is 
very much  based  on the  programs  status  quo,  i.e. transportation.  Beyond  verbally 
supporting  the  programs,  these  tribes  appeared  to be  minimally  involved  with 
them.  In fact we were  struck  by the  lack  of knowledge,  beyond  transportation, 
about  the  program  on the  part  of most  tribal  officials we talked  to. 
On  the  surface,  CHRS appeared  to be  satisfied  with their  programs  and 
leadership,  though  it is difficult  for us to say after  only a few days.  At  one  site, a 
few CHRS spoke  of some  dissatisfaction  with tribal  administration. 
D.  Respondents,  particularly  CHRS, suggested  we look  at the  types  of resources  that 
tribes  provide  for  the  CHR  program  to gauge  the  level  of tribal  support.  In terms 
of transportation,  one  program  provides  cars for their  CHRS,  and  at the  other  site, 
CHRS use  their  personal  vehicles.  At these  two sites  (as well as the  eight  others 
we visited  for this study),  CHRS  complained  about  the  low level  of reimbursement 
for travel,  and  low salaries.  At one  program,  CHRS said  they  had  not  received 
any pay increases  in the  past  10 years,  while they watched  staff in other  tribal 
health  programs  receive  various  raises  and  bonuses. 
E.  As for Factors  1 and  2, respondents  suggested  we look  for  evidence  that  health  is 
a priority  for  the  tribe  (i.e. studies,  health  plans,  needs  assessments,  etc.)  as an 
element  of tribal  support  and  direction.  As stated  earlier,  these  two programs 
lacked  this element.  The  fact  that  this element  appears  for Factors  1, 2, and  3 
points  both  to its importance  and  to the  interrelatedness  of the  factors  and 
elements. 
13  Based  on these  elements,  our  conclusion  is that  there  is tribal  support  for  these  two 
programs,  but  that  it is based  on their  being  transportation  programs.  Beyond  supporting 
a transportation  role  for their  CHRS, the  tribes  showed  little  interest  or active 
involvement  in the  programs.  There  were  no written  documents  voicing  support,  no 
health  plans,  and  little  discernible  interest  in expanding  the  CHR  role  to encompass 
health  care  services. 
We had  some  difficulty  assessing  this factor.  Although  we heard  that  tribes  supported 
the  CHR  programs,  we found  no written  forms  of support  or evidence  of it, including 
evidence  that  health  is even  a priority  for these  tribes.  Also, while  CHRS  as a group 
seemed  satisfied,  some  of them  individually  expressed  concerns  about  political  influence 
on their  program. 
We  did not  have  enough  time  to delve  sufficiently  into  this conflicting  information. 
Furthermore,  lacking  a historical  perspective,  it was difficult  for us to gauge  what  impact 
tribal  politics  might  have  on these  programs.  We believe  that  someone  in closer  contact 
with a tribe,  such as the  area  CHR  coordinator,  might  find it easier  to apply  these 
particular  elements. 
FA~OR  4: IHS  SUPPORT  AND  DIRECTION 
Importance  of Factor 
Reqxmden&  believe  that while IHS supprt  has less impact  on the effectiveness of CHR 
programs than other factors,  it k important  to make programs strong. 
The  CHRS  ranked  this element  third  in importance  of the  four  factors.  Area  and  local 
respondents  ranked  it fourth.  Even  so, they still believe  that  IHS  can  strengthen 
programs.  For  example,  one  said that,  without  IHS support,  a CHR  program  would be 
a rudderless  ship  . . . (CHRS)  might  be busy, but  they wont be effective. 
Elements 
Respondents  identified  the  following  elements  as ways to gauge  IHS support  and 
direction  for  a CHR  program, 
A.  Is there  a positive  relationship  between  IHS and  the  tribe?  Is IHS  responsive  to 
requests?  Is there  on-going  communication  between  the  CHR  program  and  IHS 
area  and  local  staff? 
B.  Does  the  IHS  area  office have  a full-time  CHR  coordinator,  with an 
appropriate  background  and  support? 
co 
Does  IHS  provide  adequate  funding,  equipment,  materials,  and  training  to the 
program? 
14  D.  Does  IHS  provide  technical  assistance  to tribes  on how to  use  the  various 
management  tools  - especially  the  SOW  and  CHRIS  II? 
E.  Is the  IHS  service  unit  at the  program  providing  regular  and  useful  technical 
assistance,  management,  and  professional  assistance? 
F.  Does  IHS  monitor  and  review  the  program,  i.e. conduct  audits,  evaluations,  and 
site visits? 
Case Study Analysis 
The  elements  told  us that  IHS provides  administrative  and  financial  support  for these 
CHR  programs  but  does  not  actively  promote  or encourage  tribes  to involve  their  CHRS 
in the  health  care  system beyond  a transport  role. 
A.  To  learn  about  the  relationship  between  IHS and  the  two tribes,  we talked  to both 
tribal  and  IHS  staff.  At  one  program,  the  IHS area  office  clearly  had  a close 
relationship  with the  CHR  program.  Staff  there  were  verbally  supportive  of the 
program  and  felt  it was one  of the  best  in the  area.  This  area  office  has  provided 
significant  extra  funding  for this program,  including  funds  for  cash bonuses  for  the 
CHRS.  The  CHR  coordinator  makes  periodic  visits and  makes  training  available 
to the  program. 
The  relationship  was more  difficult  to assess  at the  other  site.  The  IHS  project 
officer  and  sewice  unit  director  told  us that  they work very  closely with  the  tribe. 
However,  the  CHR  coordinator  was new and  not  yet familiar  with  the  program. 
We  got a different  perception  about  the  degree  of IHS support  from  some  people 
at the  tribal  level. 
B.  One  of the  CHR  coordinators  is full-time,  the  other  has multiple  responsibilities  in 
addition  to the  CHR  program.  This  is common  in the  CHR  program  as a whole; 
only 2 of the  12 area  CHR  coordinators  are  full-time. 
c. 
Funding  and  resources  appear  to be  adequate  for the  programs  we visited. 
However,  we frequently  heard  complaints  from  CHRS about  low salaries.  (Even 
though  salaries  are  set by the  tribes,  many  people  seem  to expect  IHS  to be 
responsible  for salary  increases.)  People  also talked  of a need  for better  travel 
reimbursement  or more  government  cars. 
In terms  of training,  IHS  provides  the  basic  training  course  to all CHRS but 
availability  of other  training  varies  from  program  to program.  At  one  program, 
IHS  rather  than  the  tribe  makes  training  available;  CHRS  are  encouraged  to 
attend  training  and  other  regional  conferences.  At the  other  site, we saw that 
until  recently,  CHRS had  not  received  any training  from  IHS, nationally  or at  the 
service  unit  level. 
15  D.  The  area  CHR  coordinators  do provide  technical  assistance  to tribes  on how to fill 
out  the  SOW  and  the  CHRIS  II reports,  and  stress  the  importance  of reporting 
CHR  activities.  However  we do not  know  how much  they  focus  on their  use as 
management  tools.  For  example,  while  the  CHR  coordinator  for one  program 
expressed  concern  about  the  incongruence  of transportation  services  listed  on the 
SOW  and  CHRIS  II reports,  the  thought  was more  that  the  SOW  needed  to be 
updated  to match  the  latest  CHRIS  II report  rather  than  reorienting  CHR 
activities  to conform  to the  SOW. 
We  did not  get  the  impression  that  programs  use the  SOW  and  CHRIS  II for 
management  purposes.  Rather,  administrators  largely  viewed  CHRIS  II reports  as 
necessary  ways to get funding  for their  programs.  The  supervisor  at  one  program 
said  she planned  to use  the  SOW  and  CHRIS  II for management  purposes, 
however  this program,  like the  other,  still remained  focused  primarily  on 
transportation. 
E.  We  saw little  effort  on the  part  of IHS service  unit  staff  to offer  these  programs 
the  guidance  needed  to change  or expand  them  into  health  service  areas  beyond 
than  transportation.  To  the  contrary,  service  unit  medical  staff  relied  on CHRS 
for transportation.  In addition,  neither  service  unit  provided  any training  to the 
CHRS. 
F.  The  two CHR  coordinators  monitor  their  programs  primarily  by phone,  with 
occasional  site visits.  The  project  officers  also monitor  the  programs  in terms  of 
contractual  issues  and  problems.  However,  IHS  staff did not  appear  to formally 
audit  or evaluate  these  programs  on a regular  basis.  We  did not  hear  of any fiscal 
review  of these  programs  by the  program  officers.  And  we learned  that  required 
audits  cover  a tribes  entire  contract  rather  than  one  program  alone. 
At  one  program,  we learned  that,  a few years  ago, an internal  control  review  by 
the  area  office  had  recommended  that  a formal  link be  established  between  the 
CHR  and  public  health  nursing  programs.  However  the  recommendation  was 
never  acted  upon,  and  was eventually  quietly  dropped. 
Although  we found  that  we could  apply  these  elements  in a program,  in our view their 
usefulness  is somewhat  limited.  We found  that  they  can be  present  in a program,  yet  not 
have  a significant  impact  on making  the  program  effective  in meeting  health  care  needs. 
For  example,  neither  the  nature  of the  relationship  between  the  tribe  and  the  CHR 
coordinator,  nor  whether  the  coordinator  was full- or part-time,  seemed  to  affect  the 
outcome  of the  programs;  they  both  remained  heavily focused  on transportation. 
The  more  important  issue seems  to be  the  focus of support  that  IHS gives these 
programs.  That  is, we noticed  that  IHS  emphasis  seems  to be  on administrative  issues 
(like  reporting  and  budget),  and  perpetuates  the  status  quo  of transport  rather  than  help 
the  programs  expand  beyond  it. 
16  For  this reason,  we suggest  that  another  element  be  added  for this factor: 
G.  IHS  area  and  service  unit  staff actively  encourage  and  assist tribes  to incorporate 
in their  CHR  programs:  (1) agreement  on the  role  of the  CHR,  (2) integration 
into  the  health  care  system,  and  (3) strong  tribal  support  and  direction. 
CONCLUSION 
As an increasing  number  of tribes  take  over  their  own health  care  programs  under  P.L. 
638, it is critical  that  IHS  develop  management  and  evaluation  tools  to ensure 
accountability  in these  programs.  In this report  we have  presented  an example  of how 
IHS  could  develop  such tools.  We found  these  factors  and  elements  useful  for assessing 
two CHR  programs.  However  we recognize  that  IHS might  develop  others  as well, and 
we encourage  them  to develop  their  own system  to monitor  and  measure  the  CHR 
program. 
This  study  shows that  these  factors  and  elements  are  indeed  useful  as a basis  for gauging 
CHR  program  effectiveness.  They  are,  in effect,  common  denominators  for all 260 CHR 
programs.  If used  flexibly and with  common  sense,  they will demonstrate  many  things 
about  how, and  how well, a program  is functioning.  We  think  they  are  particularly  valid 
because  they  came  from  a wide variety  of people  who know  about,  and  are  involved  in, 
the  CHR  program. 
We  learned  a number  of valuable  lessons  about  the  factors  and  elements: 
The  factors  and  elements  are  interrelated.  Respondents  named  some  elements  in 
connection  with more  than  one  factor.  For  example,  they  named  the existence  of a 
tribal  health  care  plan  as an element  for Factors  1, 2, and  3.  They  named  consumer 
support/satisfaction  for Factors  1 and  2.  Or, sometimes  one  of the  factors  is also  an 
element  for  another  factor.  For  example,  do CHRS work  closely with the  tribes  health 
care  system, which  is Factor  2 (Integration),  is one  of the  elements  for Factor  1 
(Agreement  on the  Role).  Thus  one  element  may shed  light on a number  of factors. 
Also, no. single factor  or element  can  tell the  whole  story of how a program  functions. 
The  elements  must  be  applied  flexiily.  Elements  should  not  be viewed  rigidly or used  in 
a cookbook  manner.  Depending  on the  program,  some  elements  may be more  useful 
than  others  and  some  may not  make  sense  at all.  Interpreting  information  must  also be 
done  flexibly.  For  example,  the  fact  that  a tribe  uses  a variety  of management  tools  does 
not  necessarily  mean,  in and  of itself,  that  the  program  is well managed.  Or,  the  fact  that 
a CHR  coordinator  is part-time  does  not  necessarily  mean  that  a program  gets  less 
support  from  IHS  than  from  a full-time  coordinator. 
Obsemation  is a critical  part  of applying  the  elements.  We found  that  observation 
helped  us to identi~  issues that  we could  not  find directly  when  looking  for  the  elements. 
For  example,  one  of the  most  substantial  conclusions  we made  about  these  two programs 
was that  they  are  primarily  transportation  programs.  Yet  none  of the  elements  specifically  focuses  on the  issue  of transportation.  We  only learned  that  these  were 
transportation  programs  through  observing,  spending  time  with  CHRS,  and  holding 
numerous  conversations  with people  at both  the  local  and  area  levels. 
COMMENTS 
The  Assistant  Secretary  for  Planning  and  Evaluation  (ASPE)  and  PHS  commented  on 
the  report.  The  full  text  of their  comments  is in Appendix  B. 
The  ASPE  agreed  with us that  that  more  attention  should  be  paid  to the  CHR  program 
and  that  our  report  provides  IHS with an approach  to move  in this direction. 
The  PHS  concurred  with the  findings  and  recommendation  in our  companion  report 
entitled  Management  Issues  in the  Community  Health  Representative  Program.  They 
described  steps  that  IHS has  initiated  to revitalize  the  program  and  noted  that  their 
revitalization  strategy  will take  into  account  the  factors  described  in this report. 
We  thank  ASPE  and  PHS  for  their  comments. 
18
 APPENDIX 
A 
ENDNOTES 
1. Indian  Health  Manual,  3-16.2B 
2. Indian  Health  Manual,  3-16.13C 
3.
This is a potentially  controversial  issue.  Some  respondents  expressed  concern  about  CHR 
access  to medical  records  and  patient  confidentiality.  One  suggested  allowing  limited  access. 
A -1  APPENDIX  B 
AGENCY  COMMENTS 
B-1  C*F-
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:.  *  DEPARTMENT  OF HEALTH  & HUMAN  SERVICES  l%bliiHeamM1 
: 
3
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Memorandum 
Date 
From  Acting  Assistant  Secretary  fo~  Health 
Office  of  Inspector  General  (OIG)  Draft  Reports  Management 
Subject	
Issues  in  the  Community  Health  Representative  (CHR)  Programf 
and  Revitalizing  the  CHR Program 
To 
Acting  inspector  General,  OS 
Attached  are  the  Public  Health  service  comments onzthe subject 
draft  reports.  We  concur with the xecommendationto  thoroughly 
re-examine the CHR program and determine its future direction. 
The  lndian  Health  Service  has  begun  activities  to  revitalize 
the  program.  The  attached  comments  ciiscuss  the  actions  planned 
or  taken  to  develop  a  national  strate~  to  revitalize  the  CHR 
program. 
UkL-# 
A@+
Audrey F  Manley,  M.D., M.P.H. 
Attachment

 
.0 
B-2  , 
, 
. 
General Comments 
The OIG reports on the Community Health Representative  (CHR) 
program provide valuable information.  They highlight problems 
that the Indian Health Se-ice  (IHS) is aware of and is working 
actively to re801ve.  The reports also supported PHS efforts to 
implement long-range initiatives in collaboration with the IHS 
Headquarters East  and  the  Tucson-based  Office of Health 
Programs Research and Development. 
The IHS, in order to determine if Area Office CHR programs are 
meeting  the intent of Congress and program objectives, will 
utilize an evaluation methodology developed by the Oklahoma 
City Area Office.  The Oklahoma Area Offices CHR annual 
program assessment  is  comprised  of a standardized table of 
scores that are derived from a comparison of the scope of work 
and data in the CHR Information System II (CHRIS II) records. 
Using  methodology, the Oklahoma Area Office has performed 
this 
annual evaluations to compare the progress of individual CHR 
programs  between Fiscal  Yea=s  (FY)  1990  and  1991.  Because  of 
the  satisfactory  results  obtained  in  the  Oklahoma  Area  Office, 
a  version  of  this  management  tool  will  be  tistr~uted  to  the 
other  Area  Offices. 
In  acidition,  lIIS  is  cieveloping  outcome  and  quality  oriented 
evaluati0n8  for the C!HRprogram.  The evaluations  be based 
will 
on Healthy People 2000objectives, the pati~t  Care  component 
of the Resource and patient Management System, and data 
contained in CHRIS II. 
OIG Recommendation 
The PHS, together with Tribes, should thoroughly re-examine the 
CHR program to determine its future direction.  If a consensus 
is reached to revise the program, PHS should develop  the 
appropriate  legislative proposals to do so.  If it remains as a 
PHS
broad-based  health care program,  should develop a 
multifaceted  national strategy to revitalize the m  program. 
PHS
Comments 
We concur and  actions to revitalize the program. 
will  initiate 
IHS has be- activities in this regard.  The Area Office CHR 
Coordinators met with IHS Headquarters staff the week  of 
October  26,  1992,  and  drafted  an  action  plan  to revitalize the 
B-3  4  .  . 
. 
. 
2 
CHR program.  This draft action plan was presented to  the  Board 
of Directors  of  the  National  Association  Of  ~.  The  purposes 
of this presentation were to (1) brief Board mtiers  on-the 
goals and objectives of the draft action plan, and (2) seek 
Board member comments on, criticisms of, and suggested 
improvements to the draft action plan. 
The IHs  FY  1993 activities to revitalize the CHR program will 
culminate in a national IHS/~  Tribal p~ership  Conference 
which is tentatively scheduled for late September 1993.  It is 
expected that this conference will be attended by IHS 
executives and managers, tribal leade~s, ~,  -d. consumers. 
At this conference, IHS intends to summarize the findings and 
recommendations contained in the OIG reports.  Position papers 
on the national goal and objectives of tie ~  program and 
role of the CHRW will be presented also. 
In developing a national strategy for revitalizing the CHR 
program,  IHS will carefully consider the factors, identified in 
the OIG reports, that influence the effectiveness of CHR 
programs.  IHS acknowledges that: 
o  The role of the CHR must be well-defti~  and understood 
by tribal governments, community members, and the IHS 
health care team. 
0  A community-based health care outreach program should 
work closely with the health care professionals serving 
the respective communities.  Therefore, CHRS must be 
integrated into the health care system. 
0  The CHR program is a community-based, ~ibally-operated 
program that can only be effective with full tribal 
support and direction. 
o  IHS  support and direction is important to  make a  strong 
CHR program. 
The  national  strategy  will  address  the  factors  mentioned above. 
B-4  44+,?  $*-r$   O, 1
:*.   DEPARTMENT OFHEAL~  & HUMAN  SERVICES  ofTlcoofthosea@=Y 
s
8%,> 
Wuhhgtlmm,.  2020 
DECIW2 
TO:	 Bryan  B.  Mitchell 
Principal  Deputy Inspector General 
FROM :	 Assistant Secretary for 
Planning and Evaluation 
SUBJECT  :  OIG Draft Reports:  Management Issues in the Community 
Health Representative Program, OEI-OS-01071 and 
Revitalizing the Community Health Representative

Program, OEI-O5-91-O1O7O

The  draft  reports  on the IHS Communitv Health Representa
 tive
Program present compelling evidence that more at;e~tion should

be p~i~ LU dhis program.  Your findings are dramat$c and-the 
proposed  elements of  a revitalization  strategy psovide a 
thoughtful  framework for further action.  The  indication 
clearest 
that the program could be strengthened  is  the  finding that the 
majority  of local respondents are not familiar with its goals and 
objectives.  Your examination of the SOW ud  CnlS  II reports 
calls  into  question  the usefulness  of these instruments as 
managementtools.  In addition, the lack of  of CHRS 
htegration 
into Native American primary care systems is particularly 
problematic.  This report provides  IIIS  with  m  approach  to  begin 
exaxnination  of  the  program. 
We  have  the  following  specific  comments. 
o	 The  reports  document  that  transpofiation  is  an  tiportant 
component  of  CHR  responsibilities.  The%e  exist  large, 
unexplained  discrepancies,  however,  between  diffezent 
sources  of  information  on  the  proportion  of  the  c~s  time 
which  is devoted to transportation  services.  It is not 
clear that revision of the progrm  to beco~  pr~ily  a 
transport program is actually a reason~le  option to be 
considered  by IHS,  based  on  these preltinaq  findings. 
o

Tribal support and direction  is listed as one of the four

key factors influencing CHR program effectiveness.  However,

as noted on page 4 of the  Management Issues report,

only one of 15  surveyed  tribal  members responded to IHS 
inquiries.  This  report  would  be  stren@ened  by an 
increased  effort  to  include  tribal input as an integral 
component of your  evaluative  process. 
e:  .  ,s.  P-.-l 
J  /  ),- &  u-1  ----
---.-+ 
B-5  - 1-- -;:! =02:;4:: 
-- *t-*%m*a 8*  * 
.  . 
   
 
I 
Page  2  - Bryan  B.  titchell 
o 
It would be helpful to clarify how information was gathered 
from the 403 respondents.  When you  tallcai  to  respondents, 
was a questiomaire  used,  oz  we=e  these  fsee  flowing 
conversations?  Was a standard  set  of  questions  used  to 
base the contacts? 
o  How were the four factors that most influence the 
effectiveness of CHR programs developed?  Were respondents

presented with a list of factors cxeated by your staff?

Were they elicited through focus groups?  llanyperspectives

were represented in the comments:  a statisticalbreakdown
of the commentary would clarify the agreement on various 
elements and assertions. 
o  The organization of the papers is somewhat confusing.  It is 
not clear which report should be read first, and the reader

often finds it necessary to consult one document in order to

fuily understand same ef the points made h  the @hero  It

might be preferable to consolidate the reports into a single

document, with the methods, findings and recommendations 
clearly organized. 
o  Your  case  studies  indicate  that  the information  presented  in 
written  documents was sometimes contradicted by yOUX 
observations.  Did  you  ask  any  of  the  respondents  to  address 
the  apparent  discrepancy  between  the written materials and 
your obsemations  on elements A and D  of Factor 1? 
o	 References to the presence or absence of tribal health plans 
in the Revitalizing report are confusing and should be 
clarified.  The discussion of Factor 2, Element D, on page

10 states that as mentioned under Factor 1, Element A, we

found no plan.  The referenced section on Factor 1,

Element A does not mention this finding, however, and even

states on page 7 that Both sites were rich in documenta

tion.
 In the summary section following the individual 
discussions of the elements, at the bottom of page 8, there 
is also an indirect reference to the absence of documents 
(like a tribal health plan). 
/ 
B-6