OIG SITE VISITS TO 

INDIAN HEALTH SERVICE HOSPITALS 

IN THE BILLINGS, MONTANA AREA 

August 2015 
OEI-09-13-00280 
The following site visit summaries include our observations of Blackfeet 
Community Hospital and Crow-Northern Cheyenne Hospital, both located in 
the Indian Health Services (IHS) Billings Area, which covers the States of  
Montana and Wyoming.  We visited these hospitals in June 2014.  During the 
site visits, we interviewed hospital officials and representatives from tribes 
served by these hospitals.  We also observed key hospital departments and 
reviewed hospital documentation.  Our observations highlight the challenges 
faced by these hospitals and the strategies that the hospitals use to provide 
services to their patients.  These site visits expand on prior OIG work that has 
examined longstanding challenges that IHS and tribal facilities face and that 
affect IHS beneficiaries access to care.  
In partnership with tribes, IHS provides health services for more than 
2 million American Indians and Alaska Natives living in the United States.  
IHS directly operates 28 acute-care hospitals in 8 States and provides 
preventive health and primary care services at other health care facilities.  
Together, these facilities serve members of the 566 federally recognized 
tribes.  
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SITE VISIT:  BLACKFEET COMMUNITY HOSPITAL 
Blackfeet Indian Reservation 
Overview  Services (Fiscal Year 2014)  
Location   Emergency Services  
Browning, Montana  Services available 24 hours a day, 
7 days a week 
Size 
28-bed hospital  Surgery Services  
Staffing  (Fiscal Year 2014)   Diagnostic Services 
About 250 clinical and nonclinical staff 
Pharmacy Services  
positions   
o 	  12 physicians  Hospital-Based Outpatient Services 
o   4 nurse practitioners  o 	  Family practice  
6 vacant physician positions   o 	  Childrens health  
o 	  Womens health 
Average Daily Census  
o 	  Dental 
1112 patients, lower during summer months   
o 	  Physical therapy  
IHS Funding (Fiscal Year 2014)    o 	  Specialty services  
o 	  Direct clinical services = $10.8 million  o 	  Mental and behavioral health  
o 	  Purchased/Referred Care = $ 8.0 million  
OIG Site Visit  June 1112, 2014 
OIG staff visited the Blackfeet Community Hospital to gather information for the case study.   
During the onsite visit, we: 
o	  observed key hospital departments (e.g., outpatient clinics, inpatient ward, emergency 
department); 
o	  collected and reviewed hospital documentation (e.g., policies, contracts, agreements) and 
patient records; 
o	  interviewed hospital officials; and 
o	  interviewed representatives from  Blackfeet tribal health programs. 
 
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.  
 
 
Site Visits to IHS Hospitals in the Billings, Montana Area, OEI-09-13-00280     Page 2 
   
OBSERVATIONS 
Unless otherwise indicated, we based our observations on our review of hospital documentation and a  
sample of patient medical records, and on interviews with hospital officials and representatives of Blackfeet  
tribal health programs.  
At the time of our site visit in June 2014, Blackfeet Community Hospital faced 
staffing challenges in providing services 
Blackfeet Community Hospital (BCH) faced staffing challenges associated with its hiring 
process, its remote location, and reductions in its funding.  BCHs permanent staff members are 
Federal employees; therefore, the hospital uses the Federal hiring process to fill its permanent 
positions.  BCHs officials stated that they experienced delays using this process, which made it 
more challenging to bring new staff to the hospital; delays can cause BCH to lose candidates to 
other facilities before it is able to offer them a position.   At the time of our visit, BCH had 
vacancies for providers and ancillary staff in a number of departments.   Officials also found it 
difficult to hire providers willing to settle long-term in BCHs remote location.  Providers who 
came to the hospital often  left to take positions at other facilities.  Furthermore, in the 18 months 
prior to our visit, BCH lost an audiologist, surgeon, and pediatric physician because of  
reductions in the Federal funding that the hospital received. 
BCHs staffing challenges led to longer waits and difficulty in managing patient care.  BCHs 
officials reported that on occasion, BCH shifted staff from outpatient clinics and the inpatient  
ward to ensure adequate staffing in the emergency room.  This redistribution led to longer waits 
for patients in outpatient clinics. In addition, according to tribal representatives, staffing 
challenges made it difficult for patients to receive consistent care for chronic conditions from  
providers who were familiar with their medical histories.   
BCH used various strategies that partially addressed these staffing challenges  
To address its staffing challenges, BCH contracted with individual providers to supplement 
services provided directly by hospital staff. At the time of our visit, BCH used temporary 
contracts to fill a number of positions throughout the hospital, such as an emergency room  
physician, nurse anesthetist, surgery department health technician, and family practice physician.  
These temporary contracts typically lasted a year.   
BCH used Purchased/Referred Care (PRC) funds when patients required services that were not 
available directly from hospital staff; however, those funds were limited.  All IHS hospitals can 
use PRC funds to pay for services for eligible tribal members1 that are not available from the 
 
                                                            
1 42  CFR  136.23(a).  
Site Visits to IHS Hospitals in the Billings, Montana Area, OEI-09-13-00280     Page 3 
   
OBSERVATIONS 
Unless otherwise indicated, we based our observations on our review of hospital documentation and a  
sample of patient medical records, and on interviews with hospital officials and representatives of Blackfeet  
tribal health programs.  
hospitals providers. To be eligible for PRC-funded services, members of federally recognized 
tribes must live on their tribes reservation or within a designated service area.  At the time of 
our visit, BCH maintained PRC-funded contracts to provide neurology, nephrology, optometry, 
urology, oral surgery, and cardiology services to its patients.  BCH typically offered these 
services onsite about 1 to 3 days a month. BCH also referred its patients to non-IHS providers 
and paid for these services using PRC funds. However, in accordance with IHS policy, BCH 
prioritizes which services it will cover using these funds because PRC funds are limited.2  As a 
result, BCHs officials reported that it could not pay for services needed by some patients with 
pressing but non-life-threatening needs.  Furthermore, BCH could not use PRC funds to pay for 
services when patients, because of their tribal membership or area of residence, were not eligible 
to receive these services.   
Using PRC funds may not be a cost effective way to provide services to patients.  One hospital 
official reported that it can be more expensive to pay for services using PRC funds than to hire 
someone to provide the service directly.   
Despite efforts to address continuity of care, BCH faced challenges arranging for 
post-discharge services for patients 
At the time of our visit, BCH used a discharge planning process to assess and plan for patients 
continuing care needs after discharge from the hospital.3  BCHs officials reported that, as part of 
this process, the hospitals admission nurse assessed patients and referred them for discharge 
planning services.  If not referred by the admission nurse, patients could still request discharge 
planning services. The hospitals discharge planner and social worker conducted discharge 
planning evaluations to help assess patients continuing care needs.  BCH created and used a 
discharge planning evaluation form  to collect patient information such as the patients medical 
coverage, home environment (e.g., patient lives alone, patient lives at home with family support), 
and recent hospitalizations.  BCHs officials reported that they were continuing to revise and 
develop the hospitals discharge planning policies and procedures. 
 
                                                            
2 IHSs standardized medical priority levels are as follows:   IEmergent  or Acutely Urgent Care Services,  
IIPreventive Care Services, IIIPrimary and Secondary Care Services, IVChronic Tertiary Care Services, and  
VExcluded Services.  Accessed at 
http://www.ihs.gov/chs/index.cfm?module=chs_requirements_priorities_of_care on May 5,  2015.  
3 Medicares hospital Conditions  of Participation  require that hospitals have in effect a discharge planning process 
that applies to  all patients.  42 CFR  482.43.  
Site Visits to IHS Hospitals in the Billings, Montana Area, OEI-09-13-00280    Page 4 
   
OBSERVATIONS 
Unless otherwise indicated, we based our observations on our review of hospital documentation and a  
sample of patient medical records, and on interviews with hospital officials and representatives of Blackfeet  
tribal health programs.  
Our review of 40 patient discharge summaries indicated that BCH made plans to address 
patients continuing care needs by providing instructions, counseling, or transfers to other   
facilities. We found that all summaries except one documented discharge instructions provided 
to patients and/or their family members or discussions between BCH staff and patients regarding 
counseling services and/or arrangements for transfer to another hospital or facility.4  The 
discharge summaries generally addressed at least one of the following:  patients followup 
outpatient appointments, medication orders, or self-care at home. 
BCH faced challenges arranging for aftercare services because the facilities that provided these 
services were often full, did not provide the level of care needed by discharged patients, or were 
far away. Although BCH had relationships with other facilities that provided long-term-care 
services and rehabilitation servicessuch as skilled nursing facilities, home health agencies and 
hospice agenciesit was a challenge for BCH staff to arrange for their patients to receive care 
from these facilities.  For example, BCHs officials reported that skilled nursing facilities did not 
always have space available for its patients.  It was also difficult for BCH to arrange for 
comprehensive long-term-care services because IHS did not directly provide these services to 
beneficiaries living in Montana or elsewhere.  Although the Blackfeet Tribe operates one 
long-term-care facility, that facility does not provide the level of skilled nursing care that some  
patients require.  Finally, the communitys remote location also created challenges in arranging 
aftercare services. Even when private providers and other non-IHS providers made 
long-term-care services available to BCH patients, it has not always been feasible for patients to 
access these services because of the distance that they and their families would need to travel for 
them to receive care.  Of the three main hospitals to which BCH referred patients, two were over 
100 miles away from the town in which BCH is located.   
                                                            
4 The one discharge summary without this information was for a patient who left the hospital against medical advice.  
Site Visits to IHS Hospitals in the Billings, Montana Area, OEI-09-13-00280    Page 5 
   
SITE VISIT:  CROW-NORTHERN CHEYENNE HOSPITAL 
Crow Reservation 
Overview  Services (Fiscal Year 2014)  
Location   Critical Access Hospitals are limited in size   
Crow Agency, Montana  (no more than 25 beds) and typically are  
located in rural areas. These hospitals must 
Size 
offer emergency services 24 hours a day,  
24-bed Critical Access Hospital  
7 days a week and maintain average inpatient 
stays of no more than 4 days (96 hours). 
Staffing  
About 200 clinical and nonclinical staff   Emergency Services  
Average Daily Census   Limited Surgery Services  
12 patients 
Pharmacy Services 
Emergency Department Visits  
Hospital-Based Outpatient Services 
3,383 patients from JanuaryMarch 2014  
o	   Family practice  
IHS Funding (Fiscal Year 2014)    o	   Childrens health  
o	   Direct clinical services = $14.3 million  o	   Womens health 
o   Purchased/Referred Care = $ 8.5 million   o	   Dental 
     o	   Mental and behavioral health 
 
 
OIG Site Visit  June 1112, 2014 
Methodology  
OIG staff visited the Crow-Northern Cheyenne Hospital to gather information for this 
case study. During the onsite visit, we: 
o	  observed key hospital departments (e.g., outpatient clinics, inpatient ward, 
emergency department); 
o	  collected and reviewed hospital documentation (e.g., policies, contracts, 
agreements) and patient records;  
o	  interviewed hospital officials; 
o	  interviewed representatives of the Crow Tribal Health Department; and  
o	  interviewed representatives of the Northern Cheyenne Tribe.  
 
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.
  
 
Site Visits to IHS Hospitals in the Billings, Montana Area, OEI-09-13-00280    Page 6 
   
OBSERVATIONS 
Unless otherwise indicated, we based our observations on our review of hospital documentation and a 
sample of patient medical records, and on interviews with hospital officials and representatives of the 
Crow and Northern Cheyenne tribes.  
In response to staffing and service limitations, Crow-Northern Cheyenne Hospital 
used temporary contracts and Purchased/Referred Care funding to provide 
services to its patients 
Prior to our visit, Crow-Northern Cheyenne Hospital (CNCH) eliminated a number of services 
that previously were available at the hospital.  As part of OIGs national study examining IHS 
hospitals, we learned that CNCH no longer offered pediatric inpatient care and a variety of 
specialty services.  The hospital offered limited prenatal services, but no longer scheduled 
deliveries or provided prenatal care after 30 weeks gestation.  
In response to staffing shortfalls and funding uncertainty, CNCH used short-term contracts to 
provide services in its emergency department.  CNCH experienced staffing shortfalls in the 
emergency department because, according to hospital officials, it had difficulty recruiting 
physicians. As a result, CNCH used short-term  contracts to staff its emergency department.  
CNCH also faced uncertainty about its funding, which increased the hospitals dependence on 
short-term contracting.  CNCHs officials reported that the hospital was unable to make 
long-term plans in fiscal year 2013 because IHS was operating without an approved budget.  In 
some cases, CNCH extended short-term contracts to staff the emergency department for 1 and 
2 months at a time.  
CNCH used Purchased/Referred Care (PRC) funds on a limited basis to pay for patient services 
that were not available from IHS providers.  All IHS hospitals can use PRC funds to pay for 
services for eligible tribal members that are not available from the hospitals providers.1 To be 
eligible for PRC-funded services, members of federally recognized tribes must live on their 
tribes reservation or within a designated service area.2 In accordance with IHS policy, CNCH 
prioritized which services it covered using these funds because PRC funds were limited.3 CNCH 
cannot use PRC funds to pay for services when patients, because of their tribal membership or 
area of residence, are not eligible to receive these services.  At the time of our visit, CNCHs 
officials reported that the hospital used PRC funds primarily for emergency situations.  CNCH 
also used PRC funds to pay for other services under limited conditions.  For example, although 
CNCH typically denied PRC payments for screening exams, hospital officials reported that 
                                                            
1 42  CFR  136.23(a). 
 
2 Ibid. 
 
3 IHSs standardized medical priority levels are as follows:   IEmergent  or Acutely Urgent Care Services, 
 
IIPreventive Care Services, IIIPrimary and Secondary Care Services, IVChronic Tertiary Care Services, and 
 
VExcluded Services.  Accessed at 

http://www.ihs.gov/chs/index.cfm?module=chs_requirements_priorities_of_care on May 5,  2015.  

Site Visits to IHS Hospitals in the Billings, Montana Area, OEI-09-13-00280    Page 7 
   
OBSERVATIONS 
Unless otherwise indicated, we based our observations on our review of hospital documentation and a 
sample of patient medical records, and on interviews with hospital officials and representatives of the 
Crow and Northern Cheyenne tribes.  
CNCH would cover a screening exam if it was needed by a high-risk patient.  
CNCH used patient transfers and agreements with other facilities to link patients 
to the services they needed    
CNCH transferred patients to other facilities when they needed a higher level of care than was 
available at CNCH. As a Critical Access Hospital, CNCH focuses on common conditions, short 
hospital stays, and outpatient services.  In the 30 days prior to our site visit, CNCH made  
77 patient transfers to other facilities. Of these 77 transfers, we randomly selected 10 and 
reviewed the associated patient records.  CNCH transferred these patients because it did not have 
the services or equipment available to fully treat their medical needs.  The hospital transferred 
one pediatric patient because it no longer provided any pediatric inpatient services.  Other 
patients transferred by CNCH needed a range of services, from optometry services to dialysis 
and intensive care treatment.  CNCH also transferred patients who needed imaging services, such 
as ultrasounds and CT scans. 
At the time of our visit, CNCH maintained agreements with four other hospitals to supplement 
the services it provided to patients.  CNCH maintained transfer agreements with two acute-care 
hospitals within about 60 miles of its facility.  These agreements established the procedures by 
which CNCH transferred patients who required the skills, resources, and physical facilities of the 
receiving hospitals.  CNCH also maintained a transfer agreement with a university hospital two 
States away that could provide intensive burn, trauma, and surgical treatment for those CNCH 
patients who needed it. Finally, CNCH maintained an agreement with one acute-care hospital 
that provided pediatric specialty care to CNCH patients by using telemedicine services.  
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