Department  of  Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
MANAGEMENT  ISSUES  IN THE 

COMMUNITY  HEALTH  REPRESENTATIVE 

PROGRAM 
 OFFICE  OF INSPECTOR  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 
assessmentsof 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 
 EXECUTIVE  SUMMARY 
PURPOSE 
This report  describes management issues in the Community  Health  Representative 
(CHR)  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  the 
Public Health  Service (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. 
We contacted 403 people involved with  the program  at the national,  area, and local 
levels to obtain  information  about factors which make CHR  programs strong.  See our 
report  entitled  Revitalizing  the CHR  Program  (OEI-0501070).  During  the course of 
obtaining  that information,  we discovered selected management issues that are 
described in this report. 
SCOPE AND  METHODOLOGY 
Our  intent  in this study was to identify  factors that make CHR  programs strong, 
factors which  IHS  and tribes could use to manage and evaluate the program.  During 
the course of the study, certain management  issues arose that we believe are 
important;  this report  describes those issues. 
Our  companion  report  entitled  Revitalizing  the CHR  Program  (OEI-05-91-01070) 
describes the factors that the 403 respondents for this study said make individual  CHR 
i  programs effective, and why they make programs effective.  It  also describes how the 
factors might  be used to judge the effectiveness of a CHR  program. 
FINDINGS 
MOST  RESPONDENTS  ARE  NOT  F~ILJXR  WllX  THE  GOAL  AND 
ORIEC7lVl.3  OF  THE  CHR  PROGRAM. 
Except for  area CHR  coordinators,  respondents who knew the CHR  program  were 
not familiar  with  its national  goal or objectives. 
THERE  IS  WZDESPREAD  DISAGREEMENTABOUT  7HE  APPROPRhiljE  ROLE 
FOR  CHRs. 
Although  respondents agree that CHRs should be a part  of the health  care system, 
there are widely varying opinions  about how this integration  should occur. 
Respondents say that if there is not consensus on a role for  CHRs, the program  will 
be less effective. 
TRAN-SPORT  IS A  MYJOR  UNRESOLmD  ISSUE  IN  THE  CHR  PROGRAM. 
Compared  to other  services CHRs  could provide, transpqrt  is a disproportionately 
large CHR  activity.  Respondents disagree on whether  CHRs should be transporting 
clients.  Many  see it as a needed service as well  as what tribes want CHRs to do. 
THE  SOWAND  CHHS  II  HAYE  LIMITED  USEFULNESS. 
We question the usefulness of the SOW as a planning  tool,  and the CHRIS  II  as both 
a management  tool  and reporting  system.  Analysis of CHRIS  II  data raises questions 
about its accuracy and reliability.  Respondents also voiced mixed opinions  on the 
usefulness of the SOW and CHRIS  II. 
REEOMMENDATIONS 
THE  PHS,  TOGElXER  WITH  TRIBES,  SHOULD  RE-EX4MINE  lXE  CHR 
PROGRAM  TO DETERMINE  ITS  FUTURE  DIRECTION. 
The PHS, and tribes, should consider the following  options in determining  the future 
direction  of the CHR  program:  retain  it in its current  form,  revise it to become a 
transportation  program,  or abolish it if it is no longer needed. 
II;  A  CONSENSUS  IS REACHED  TO REVISE  OR ABOLISH  THE  PROGM,  PHS 
SHOULD  DEVELOP  XUE  APPROPRIATE  LEGISLATM?  PROPOSALS  TO DO  SO. 
11  IF  ITREUAINS  AS A  BROAD-BASED  HEALTH  CARE  PROGRAM,  PHS  SHOULD 
DEWLOPA  MULTT-FACETED  NAZ!ONA  STRATEGY  TO REWlXLJZE  THE 
CHR  PROGRAM 
This strategy should include:  (1) a clarification  of the national  goal and objectives, (2) 
a revised national  policy on transport,  (3) development  of performance  indicators,  (4) 
improvement  of the SOW and CHRIS  II,  (5) development  of technical  assistance and 
training  plans, and (6) periodic  program  evaluation. 
COMMENTS 
The Assistant Secretary for  Planning and Evaluation  and PHS commented  on the 
report.  Both  concurred with  the findings and recommendation,  and PHS described 
steps that IHS  has initiated  to revitalize  the CHR  program.  We made some editorial 
changes in the report  based on technical comments from  ASPE.  The full  text of the 
comments is in Appendix  D. 
... 
111  TABLEOFCONTENTS 

PAGE 
EXECUTIVESUMMARY 

INTRODUmON  ................................................. 
 1 
FINDINGS  ...................................................... 
 5 
Goal amd Objectives  ............................................... 
 5 
Role  of CHRs  .................................................... 
 5 
Transport  ........................................................ 
 6 
Management  Tools  ................................................. 
 9 
RECOMMENDATIONS  ........................................... 
 13 
Re-examine  CHR  Program  .......................................... 
 13 
To Revise or Abolish  Program, Develop  Legislative Proposals ................  13 

To Retain  Program, Develop  Strategy to Revitalize  ........................  13 

APPENDICES..  ................................................... 

A:ChrisIIReport  ...............................................  A-l 

B: Scope of Work  Form  ...........................................  B-l 

C:Endnotes  ....................................................  C-l 

D: Agency Comments  ............................................  D-l 
 INTRODUCTION 
PURPOSE 
We conducted this study to identify  factors which make Community  Health 
Representative  (CHR)  programs strong, factors which could be used in the future  to 
plan, monitor,  and evaluate these programs.  This report  describes management  issues 
that arose in the course of the study. 
BACKGROUND 
Program  Hirtory 
In  1968, under the 1921 Snyder Act  (25 U.S.C. 13), Congress established the CHR 
program  within  IHS.  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. 
The program  is currently  governed by the Indian  Health  Care Improvement  Act 
Amendments  of 1988.  In Fiscal Year  (FY)  1992, the Indian  Health  Service (IHS),  within 
the Public Health  Service (PHS), 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 
1  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 
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. 
Program  Admihirtration 
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.  To 
date, however, IHS  has neither  developed national  evaluation  criteria  or tools, nor 
conducted a national  evaluation  of the program. 
SCOPE AND  METHODOLOGY 
Our intent  in this study was to identify  factors that make CHR  programs strong, factors 
that IHS  - and tribes - could use in the future  as a basis to manage and evaluate the 
program.  During  the course of the study, certain management issues arose that we 
believe are important.  This report  describes these issues. Our companion  report  entitled 
Revitalizing  the CHR  Program  (OEI-05-91-01070)  describes the factors that 
respondents said make CHR  programs strong. 
2 
 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. 
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 (HHS). 
Data  collection  took  place in three phases. As this chart shows, we contacted over 400 
respondents for  the study. 
Respondents  1 Phase 1  Phase 2  Phase 3  Total 
National  16  23  29 
II
Area  22  I 30  I  10  I 62  II 
Local  II16  I 58  I 25  I 99  II 
CHRs  ]  32  161  20  213 
Total1  76  272  55  403 
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 respondents, What makes a CHR  program  strong (effective)?  We found 
that their  responses could be grouped into  four  broad categories, or: 
Factors that  Influence  the Effectiveness 
of CHR  Programs 
Factor  1  Agreement  on the role of the CHR 

Factor  2  Integration  into  the health care system 

I/
Factor 3  Trib-d  support  and direction 

Factor 4  MS  support  and direction 

3 
 Phase Two:  In February,  March,  and April  1992, we contacted an additional  272 
respondents to learn their  perceptions  about these four  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 
l 	
Assistant Secretary for Health  in the Public Health  Service, and IHS  Headquarters 
staff. 
At  the area level, we chose five IHS  area offices (Oklahoma  City, Oklahoma; 
l 	
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. 
For respondents at the local, or program,  level, we chose three CHR  programs in 
l 	
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 
0 	
with  a review conducted by the national  CHR  program  director.  We also talked 
to tribal  health  directors at a conference. 
Phase Three:  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.  We contacted 55 respondents in this phase. 
This study was conducted in accordance with  the hterim  Standards  for  Inspections  issued 
by the Presidents Council  on Integrity  and Efficiency. 
4 
 FINDINGS 
MOST  RESPONDFHIS  ARE  NOT  FAMILIAR  WITH  THE  GOAL  AND 
OBJECiTIVES  OF THE  CJ3.RPROGRAM. 
In  1983, IHS  developed a goal, objectives and guidelines for the CHR  program  which are 
written  in Chapter  16 of the Indian  Health  Manual.3 
cHRProgramGoal 
/I 
The CHR Program was implemented  to improve the health knowledge, attitudes  and practices of 
Indian  people  by promoting,  supportin&  and asskxiug the IHS  in  deIivering~ a total  health  care 
program.  The efforts of CHR program staff have produced an American Indian  and Al&a  Native 
health  service delivey  system, which provides for follow-up  and continued  contact with the health 
care delivery system at the community  level, thereby meeting the most basic needs of the American 
Indian  and Alaska Native population- 
The  goal of the CHR Program is to addresshcaIth care needs through the provfsiofi of community-
oriented  primary  care services, including  traditional  Native concepts in multiple~settings,  utilizing 
community-based, well-trained,  medically-guided  hcaIt.h care worker!& 
The  14 program  objectives are mainly  a listing of possible services such as home health 
care, transport,  language interpreter  and health education.  Other  objectives include 
activities such as development  of an annual program  plan, assurance of the availability  of 
appropriate  IHS  medical guidance to the CHR  program,  and compliance with  the CHR 
data collection  plan. 
Two-thirds  of the local respondents in our study, and 40 percent of those from  IHS  area 
offices, said they are not familiar  with  the goal and objectives of the CHR  program.  This 
includes 2 of the 5 area directors, 9 of the 11 tribal  health directors, 4 of the 8 service 
unit  directors,  and 8 of the 12 public  health  nurses.  In contrast, area CHR  coordinators 
not only,know  the goal and objectives but emphasize that they help direct  and assist 
CHR  programs:  Chapter  16 has been very handy.  It is a guidepost or a guideline 
overall, something for us to work  with. 
THERE  IS WIDESPREAD  DISAGREEMENT  ABOUT  THE  APPROPRIATE  ROLE 
FOR  CHRs. 
In reviewing  contracts, observing CHR  programs, and talking  to respondents, we found 
that there are many different,  and sometimes conflicting,  opinions  about what CHRs 
should do.  We found  that a CHR  can be an animal  control  officer,  dental  assistant, 
janitor,  billing  clerk, data entry clerk, or appointment  clerk in a clinic.  Some people said 
that tribal  officials  want CHRs  primarily  to transport  or do domestic work:  cutting 
5 
 wood, making  meals, or taking  out garbage.  At  one program,  we both  observed and 
were told  that medical  staff sometimes expect CHRs to act as go-fers. 
Respondents  say that  CHRs  should  play  a role  in their  tribes  health  care system, but  there  iv 
no  clear  or con&tent  view of that  role. 
We asked national,  area, and local respondents to explain how they define  an effective 
program.  Whether  they mentioned  CHRs providing  outreach and advocacy, accessto 
care, or delivering  health  services, respondents clearly believe that a CHR  program 
should be part  of the tribes health  care system.  However,  few offered  specifics about 
exactly what  activities CHRs should undertake.  Comments were vague and varied: 
CHRs  should be health  care workers,  they should work  closely with  a health  care 
professional  (especially public  health nurses), or, a team approach is important. 
The CHR  responses to questions reveal that they feel strongly that the program  must be 
linked  with  the health  care system.  However,  they also disagree on the specifics of how 
this should occur.  For example, almost 60 percent ranked working  as a team with 
medical  staff  as the most important  factor  to make a CHR  program  strong.  A strong 
majority  think  that there should .be referrals between CHRs and medical  staff (88 
percent),  CHRs  should be included  in meetings with  medical staff (65 percent),  and 
medical  staff should regard CHRs  as competent  (87 percent).  Yet,  CHRs  disagree on 
whether  they should be the eyes and ears of the community  or assistants to health  care 
professionals, and on whether  they should work  closely with  or independently  from  health 
care professionals. 
Respondents  say that  if people  do not  agree on the role,  CHRs  may  be less flective. 
According  to respondents, confusion or disagreement about what  CHRs  are supposed to 
be doing can limit  their  effectiveness.  Some said that CHRs, often perceived as the 
answer to everyones problems,  are pulled  in different  directions  and asked to do 
inappropriate  things until  they burn out.  Others said that CHRs  can become unfocused 
and confused about what they should do, which can lower morale.  The  CHR  services 
may become fragmented  and chaotic, lacking cohesiveness or continuity  with  other health 
care services.  Finally,  some people said specifically that without  a clearly defined  role for 
CHRs,  a program  could become focused solely on transport. 
TRANSPORT  IS A MAJOR  UNRESOLVED  ISSUEi IN  THE  CHR  PROGRAM. 
We did not set out in this study to specifically  address the issue of transport  as a CHR 
role.  However  we quickly  found  that the subject arose repeatedly  as we talked  to 
respondents and visited programs. 
Historically,  transport  has been a major  activity for  CHRs, and transport,  including  the 
delivery of medications,  remains an allowable  CHR  service today.  Chapter  16 sets forth 
certain boundaries  governing it.  Transport  shall be within  the local community  to/from 
an IHS  or tribal  hospital  or clinic for  routine,  non-emergency problems,  to a patient 
6  without  other means of transportation,  when necessary.4 Transport  includes waiting 
for  a patient...to  finish  treatment.  Chapter  16 also states that programs must have a 
tribally  developed transportation  policy, although  there is no further  explanation  of 
exactly what this means. 
Dansport  is a disproportionately  large  CHR  activity. 
An  analysis of the FY  1991 CHRIS  II  report  (see Appendix  A)  reveals that  as a 
proportion  of their  total  time  (service hours plus travel hours), CHRs  recorded almost a 
quarter  of their  time  in transport/deliver.  As the chart below  shows, this is more than 
twice the proportion  of time  recorded for  each of the four  next highest services. 
CHRs,erKmllc+lmorenmeul 
t  transport(dehver  than on top 4 other senkes 
24  22.7 
!a 
20 
18 
16 
14 
12 
10 
8 
6 
4 
At  8 of the 10 programs we visited, we observed that transport  was a major,  if not the 
primary,  CHR  activity.  When we asked people - CHRs, their  supervisors, and many 
others - to describe what CHRs  did, they talked  about transport.  The transport  they 
described included  delivering  medications  and commodities,  and taking  patients to clinics, 
dialysis facilities,  hospitals far away for  delivery of babies, or funerals. 
Even at a program  where there is a written  transportation  policy, it didnt  appear to be 
enforced, since most of the CHRs were heavily involved in transport.  At  another 
program,  where  transport  is clearly discouraged as a CHR  activity, the CHRs  said that 
they still feel pressured on occasion to provide  it. 
Opinions  of the CHRs  at these programs about transport  differed.  Some seemed 
satisfied with  a transport  role.  Others feel torn because we arent  sure whether  or not 
we should be transporting  people.  Still  others seemed ambivalent,  recognizing a need 
for  transport  but wanting  to do more.  Some mentioned  that because they were so 
involved in transporting,  they could not use many of the skills they learned in training  -
which they regretted. 
7  Analysis of the CHRIS  II  reports  at one of the case study sites showed 70 percent of 
CHR  time  as transport;  other  reports  and CHR  logs confirmed  this.  (In  fact, the logs 
themselves are called transportation  verification  forms.)  At  the other  case study site, 
CHR  logs showed that in 9 workdays, 2 CHRs transported  almost 40 people  and 
delivered  medications  to 26; the only other  activity noted in the logs was 5 home visits. 
Also, the CHR  supervisors narrative  report  to the tribe  talked  only of transport. 
Respondents  disagree  on  whether  transport  ir a desirable  or legitimate  CHR  activity.  Many 
believe that  it should  be better  dejined  or limited 
These quotes from  respondents illustrate  the range of opinions  about transport  in the 
CHR  program: 
Transportation  is a basic need and CHRs should be providing  it. 

Transport  is an important  service, but it is inappropriate  for  CHRs  to be doing 

this. 

If  CHRs  are viewed as transporters,  they are less effective and less involved in 

other  activities.  Transport  is not an optimal  use of their  skills and services. 

Access to health  care is essential, but it should be provided  by IHS.  It  is 

inefficient  for  CHRs to spend a great deal of their  time  driving  people  around. 

The CHRs we surveyed seem to view transport  as an integral  duty.  They made specific 
comments to us about the need for more government  cars, higher mileage 
reimbursement,  and money for  auto insurance, comments which in and of themselves 
would  seem to indicate  that transport  is a significant  activity for them.  Yet  they also 
seem to want limits;  three-quarters  strongly favor a tribal,  written,  transportation  policy 
that clearly describes what kind  of transportation  CHRs  are and are not allowed  to 
provide. 
Respondents other  than CHRs  said that problems  can arise if the role of transport  in a 
program  is not clearly defined,  or limited.  This comment  sums up what  can happen: 
People have expectations for  a ride from  CHRs, so CHRs  comply and therefore 
activities in other  areas are diminished  and everybody is confused about the goals of the 
program. 
There  are many  reasons  why  transport  is a major  CHR  activity. 
The main  reason that transport  may be the primary  activity at many CHR  programs is 
because this is what tribes expect and want CHRs to do.  During  a focus group, we asked 
respondents what they thought  tribes wanted CHRs  to do.  The first  answer was 
transport.  Elsewhere we heard: Tribal  people dont  know the role of the CHR.  They 
think  of it as transport.  Some CHRs  told  us that if they refuse to transport  people, 
there may be complaints  to tribal  officials,  placing them in an awkward  position  since 
they depend on those officials  for  their jobs. 
8  There  are several other reasons, which we both heard about and saw for  ourselves, why 
transport  may still be a major  CHR  activity: 
At  many reservations that cover huge areas or are remote  from  health  care 
l 	
facilities,  the need for transport  is great. 
Many  families  no longer accept responsibility  for taking  relatives to the doctor  as 
l 	
they did in the past. 
On some reservations, there is an increased need for  transport  to dialysis facilities, 
l 	
which  are often  hours away. 
Health  professionals sometimes take advantage of CHRs  as go-fers to bring 
0 	
patients to clinic or deliver medications. 
Tribes  have not sought or used other resources (contract  health  care, for example) 
0 	
to provide  transportation. 
THE  SOW AND  CHRIS  II  HAVE  LIMITED  USE-. 
In recent years, IHS  has developed two important  management  tools for  the CHR 
program.  The SOW is a document  tribes can use to plan their  CHR  programs.  The 
CHRIS  II  is a reporting  system based on the SOW.  Although  many tribes are apparently 
now submitting  the SOW and CHRIS  II,  they are not required  to use them; they may 
submit narrative  reports instead. 
The SOW provides a framework  for tribes to plan their  CHR  programs.  Appendix  B 
contains a copy of the SOW form.  It  is comprised of a combination  of service categories 
(e.g. health  education, case management)  and health areas (e.g. diabetes, cancer), which 
together  provide  a matrix  of 240 different  categories into which projected  CHR  activities 
can be placed. 
The CHRs  report  their  activities in CHRIS  II  using the SOW matrix  of health  areas and 
services, as well  as client age and gender, time  spent on each service, place of service, 
and number  of clients served per service.  They report  activities for  1 week (consecutive 
days) each month. 
According  to the IHS  1990 annual report  on the CHR  program,  CHRIS  II  is currently 
providing  valuable data to (1) assist tribal  programs and area offices evaluate CHR 
performance  and (2) provide  the national  CHR  program  office the pertinent  data to 
prepare  reports  to Congress and others, as well  as to justify  the annual budget 
appropriation.j 
The most important  concept behind  CHRIS  II  is that the activities reported  for  a CHR 
program,  and the amount  of time  spent in them, should generally match those projected 
in the SOW. 
9  As  nunagement  took,  the SOW  and  CHRIS  II  appear  to have minimal  bnpact  on  how 
tribes run  their  CHR  programs. 
For  a number  of years, the national  program  director  and area CHR  coordinators  have 
encouraged tribes to use the SOW and CHRIS  II  to manage their  CHR  programs, and a 
national  Mangement  Applications  Guide is now being developed to move tribes in this 
direction.  Tribal  CHR  program  managers should be comparing  CHRIS  II  reports with 
the SOW and redirecting  CHR  activities when necessary to make sure that  CHRs  are 
doing what the tribe  projected.  However,  these respondents say that many tribes are not 
yet using the SOW and CHRIS  II  in this way. 
A copy of two CHRIS  II  summary reports for  1991 is in Appendix  A.  After  analyzing 
these reports, we also believe that tribes are not using the SOW and CHRIS  II  to 
manage programs.  Furthermore,  we think  the data also show that tribes are not 
directing  their  CHRs to provide  health care services directed  at specific health  problems. 
For example: 
In  1991,-CHRs  recorded almost 40 percent of their  service time  in training  and a 
0 	
variety  of administrative  services, and 17 percent in trans/del.  They recorded 
only 43 percent in specific health care services (e.g. case management,  health 
education,  and monitoring)  to consumers. 
Also  in  1991, CHRs  recorded over half of their  service hours in the health  areas 
0 	
of not applicable,  other  general medical,  and unknown.  Also, the percent of 
service time  recorded in not applicable  rose from  12 percent in  1990 to 31 
percent in  1991. 
Overall,  CHRs  recorded only  10 percent of their  senice  hours. combined,  in the 
l 
health  areas of substance abuse, diabetes, and cancer.  Respondents commonly 
told  us these were the most serious health problems in their  communities,  and 
they are well  documented  in the literature  as significant  Indian  health  problems. 
We are also concerned that, as management  tools, the SOW and CHRIS  II  are too 
heavily focused on activities.  They do not reflect  the quality,  effectiveness, and impact  of 
CHR  services. 
Anarysis  of  CHRIS  II  data  also raises questions  related  to accuracy  and  reliability. 
The development  of the SOW and CHRIS  II  has been a process of continuous  attempts 
at improvement  by IHS.  The forms have been refined  and simplified  over time,  and 
training  on their  use has been conducted for  many program  directors, supervisors and 
CHRs.  However,  IHS  is aware that problems  remain.  In the year-end FY  1990 report 
on the CHR  program,  IHS  recommended  that  training  of CHRs  on using CHRIS  II  be 
improved,  and the language for  the other  general medical  and not applicable 
categories be refined  to reduce the amount  of time  reported  in them and to increase 
10 
 reporting  in other, more specific, areas.  In addition,  IHS will  spend over $135,000 this 
fiscal year on quality  control  for  national  CHRIS  II  data. 
The two summary reports in Appendix  A contain breakdowns  of service time, number 
served, and number  of activities by health  area and service.  Some of the numbers, in 
particular,  raise questions about the accuracy and reliability  of the data. 
The number  of persons served in 1991 was 4,258,66X 
0 
The  CHRs  spent 17 percent of their  service time  on the service trans/del 
0 	
(transporting  people  and delivering  medications). 
The CHRs  spent over half  (56 percent)  of their  service time  in the non-specific 
l 	
health  areas other  general medical,  not applicable,  and unknown. 
The CHRs  spent 33 percent of their  service time  on administrative  services 
0 	
(admin  rep/ret,  pt clerical, meetings, other  admin). 
First, the data do not give us an.unduplicated  count of how many people the CHR 
program  served in  1991. The 4.2 million  figure  is not only inaccurate but misleading;  it is 
clearly not an unduplicated  count, since the entire American  Indian/Alaska  Native 
population  in the United  States is only 1.5 million.  Furthermore,  IHS  uses this figure  to 
calculate the average cost per person served, by dividing  the amount  funded for the 
program  by the total  number  served.  This means that this cost figure  is also misleading 
because it counts a person more than once. 
Next, the proportion  of time  reported  for  trans/del, at 17 percent, strikes us as low, 
since transport  appears to be such a major  CHR  activity.  Or, is the definition  of the 
category in CHRIS  II  inaccurate in terms of the kinds of transportation  that CHRs 
actually provide? 
Next we ask whether  the large proportion  of service time  reported  in non-specific  health 
areas, particularly  not-applicable  at 31 percent, accurately depicts what  CHRs  are 
doing.  Are  the other, specific, categories, such as case management  and monitoring,  not 
meaningful  in terms of what CHRs  actually do, and if so, why are they there?  Or is it 
that CHRs  are not filling  out their  reports  accurately because the categories are 
confusing or unclear, or because the reporting  process is too complicated? 
As for  the data reported  in the services categories, our first  observation is that many of 
the categories are not services but activities - for example, training,  record-keeping  and 
reporting,  and meetings.  This gives a misleading picture,  then, of the time  CHRs spend 
providing  services to consumers.  Secondly, the large amount  of time  reported  in these 
categories raises the same questions about accuracy that we explained relative  to the 
health  areas. 
11 
 Finally,  we are curious about the relatively  large proportion  of time  devoted to 
reports/recordkeeping  - at 12 percent, the second highest, after  transport/deliver.  We 
wonder  whether  this could be an unintended  result of how the CHRIS  II  reporting 
system works;  that is, CHRs  could be reporting  the time  they spend filling  out CHRIS  II 
reports, which is time  they do not spend during the other  3 weeks of the month.  If so, 
this figure  is also an unreliable  reflection  of how CHRs  are spending their  time. 
MANY  AREA  AND  LOCAL  RESPONDENTS  ARE  SOMEWHAT  FAMILIAR  WITH 
THE  SOW AND  CHRIS  II.  OPINION  IS MIXED  ON THEIR  USEFULNESS. 
Two-thirds  of the area and local respondents are familiar  to some extent with  the SOW 
or CHRIS  II.  People generally see the SOW as useful for  providing  guidelines or 
direction  for  CHR  programs.  However,  they have some criticisms of CHRIS  II:  (1) 
reports  are far too detailed  and burdensome to complete;  (2) the data in CHRIS  II  are 
misleading, inaccurate  or inflated;  (3) CHRIS  II  provides only a general or partially 
accurate picture  of what CHRs  are doing; and, most of all, (4) CHRIS  II  does not reflect 
the quality,  effectiveness, or outcome  of services. 
Some people  commented  also that both  the SOW and CHRIS  II  are only as good as the 
people filling  them out, or that they will  only really be effective if tribes actively use 
them to manage their  CHR  programs. 
Area  CHR  coordinators,  who work  most closely with  tribes, find  both  tools useful but 
also identify  problems.  They appreciate  the SOW as a tool for  defining  clear and specific 
expectations for  CHR  programs but see a number  of problems:  some programs refuse to 
use the SOW, people who fill  it out do not understand it; some programs have projected 
such small percentages over so many categories that it is impossible  for them to really 
be workable;  and CHRs feel that the SOW has been imposed on them without  their 
input  and therefore  does not really define what they are doing.  One person said also 
that it is very important  to give clear instructions  on the SOW to tribes, and good 
examples to follow. 
As for  CHRIS  II,  area CHR  coordinators  see it as a necessary accountability  mechanism 
but also have concerns: it does not tell  the story since it contains data for  only  1 week 
per month;  there is no mechanism to ensure that the forms are filled  out accurately; and, 
many tribal  people  do not value the information,  so do not use it to manage their 
programs. 
12 
 RECOMMENDATIONS 
When discussing what makes CHR  programs strong, many respondents for this study also 
raised deeper questions about the purpose and the management  of the program.  Their 
comments, combined  with  our own observations at 10 programs, revealed some 
fundamental  problems  at the heart of this program  - a poor  understanding  of goals and 
objectives, confusion and disagreement about the appropriate  role of CHRs, especially 
transport,  and questions about the usefulness of certain management  tools.  Unless PHS 
takes steps to address these concerns, we would  have difficulty  supporting  the 
continuation  of the CHR  program  in its current  form. 
THE  PHS, TOGETHER  WITH  TRIBES,  SHOULD  THOROUGHLY  RE-EXAMINE 
THE  CHR  PROGRAM  TO  DETERMINE  ITS FUTURE  DIRECTION. 
Such an examination  should take into  account legislative intent,  health  care needs, and 
current  program  practices and results.  It should consider the following  options: 
Retain  the program  as a broad-based health care program,  if they conclude that 
l 	
this is the greatest need; 
revise the program  to become primarily  a transport  program,  if they conclude that 
0 	
transport  is the greatest need; 
abolish the orogram,  if they conclude that it is no longer needed to meet Indian 
0 	
health  care needs. 
IF  A  CONSENSUS  IS REACHED  TO  REVISE  OR ABOLISH  THE  PROGRAM,  PHS 
SHOULD  DEVELOP  THE  APPROPRIATE  LEGISLATIVE  PROPOSALS  TO  DO 
so. 
IF  IT  REMAINS  AS A BROAD-BASED  HEALTH  CARE  PROGRAM,  PHS 
SHOULD  DEVELOP  A MULTI-FACETED  NATIONAL  STRATEGY  TO 
REVITALIZE  THE  CHR  PROGRAM. 
If  PHS, together  with  tribes, decides that the CHR  program  should continue,  and should 
provide  a wide variety  of health  care services, PHS should develop a broad  national 
strategy to address the problems  described in this report.  The following  elements should 
be included  in such a strategy. 
ClarjtL  the national  goal  and  objectives  of the  CHR  program 
The CHR  program  should be sharply focused and strategically geared to results.  A 
clearly defined  framework,  including  goals and objectives, is needed for PHS and tribes 
to effectively  focus resources and management  efforts on the program.  We suggest that 
PHS and tribes develop a consensus on the goal and objectives of the CHR  program. 
13  They should consider: how CHR  programs can be linked  to other  Indian  health care 
programs; what  are and are not appropriate  CHR  activities; whether  the program  should 
focus as a priority  on specific health  care problems  or populations;  and what outcomes or 
measures of effectiveness should be established. 
Then PHS should publish the goal and objectives in Chapter  16 and disseminate them 
widely  to tribes.  The goal and objectives should serve as a basis for  providing  technical 
assistance and developing  and refining  management tools for the program. 
If  transport  remains  an  allowable  CHR  activity,  develop  a clear  national  policy  which 
govenls  it. 
As described in this report,  most respondents for this study have only a general notion  of 
what the CHR  program  should be and what are appropriate  CHR  activities.  Nationally, 
transport  appears to be a major  CHR  role.  We question whether  PHS should be 
funding  a program  which is heavily transport,  whether  it is appropriate  for  CHRs to be 
providing  transport,  and whether  over $1 million  annually should be spent on training 
CHRs who are mainly  transporters.  Furthermore,  given morbidity  and mortality  statistics 
on Indian  health, it seems clear that much more than transport  is needed. 
At  the same time, we recognize that transport  may be a legitimate  need for  some tribes, 
and that PHS and tribes may therefore  decide that, to some degree, transport  should be 
an allowable  CHR  activity.  In this case, we recommend  that the role of transport  in the 
CHR  program  be carefully  and clearly defined, and that a national  policy be developed 
in accordance with  it;  the policy should then be issued by the Director  of IHS. 
We also suggest that PHS and tribes explore other sources of funding  for transportation, 
including  contract health  care, Medicaid,  or others, so that CHRs  can devote their  time 
to activities more directly  related  to health  care. 
Develop  performance  indicators 
The Chief  Financial  Officers  Act  requires the development  of performance  indicators, 
and in response, IHS  is now developing performance  indicators for  some programs.  In 
addition,  as part  of the reauthorization  of the Indian  Health  Care Improvement  Act, 
Congress recently established voluntary  targets for decreasing death and disease rates for 
Native Americans,  in light  of concerns for  increased accountability  and effectiveness in 
Indian  health  care programs.  We recommend  that performance  indicators  be developed 
for  the CHR  program  which are consistent with  a revised program  goal, and that the 
indicators  be published  in Chapter  16. 
Improve  the SOW  and  CHRIS  II. 
Issues of accountability  and oversight relative  to IHS  programs are particularly  timely  as 
the regulations  for  P.L. 93-638 are being finalized  and the relationship  of the Federal 
Government  and tribes is being re-examined  in this light.  The Inspector  General  has 
14  gone on record in support  of the inclusion  of data collection  requirements  in these 
regulations. 
We have described a number  of shortcomings causing us to question the usefulness of 
the SOW and CHRIS  II  as management  tools for  this program.  We recommend  that 
they be improved:  based on a revised program  goal, simplified,  made to capture what 
CHRs  actually  do, and include  measures of effectiveness besides strictly  number  of 
activities - beginning with  an unduplicated  count of people served.  This is especially 
important  because we understand that IHS  may replicate  CHRIS  II,  or a similar 
reporting  system, in other  programs.  If  so, every effort  should be made to develop as 
accurate and useful a reporting  system as possible. 
In order to assure effective oversight and technical assistance for  this program, we also 
believe that tribes should be required  to submit the SOW and CHRIS  II  reports.  These 
are still  optional,  and some tribes continue  to submit narratives instead. 
Develop  technical  assirtance  and  training  plans. 
Under  P.L. 93-638, the role of IHS  is shifting  away from  direct  service provider  towards 
consultation  and technical  assistance to tribes.  It  is becoming increasingly important  for 
IHS  to work  cooperatively  with  tribes to share knowledge  and expertise so that they can 
run their  638 programs effectively.  We recommend  the development  of a more strategic 
plan for  providing  technical  assistance and training  for  the CHR  program,  based on a 
more  clearly defined  goal and objectives.  In terms of training,  specifically, we believe 
that training  should be closely related  to what CHRs  are actually doing, and that it 
should be focused most heavily on CHRs whose primary  role is providing  health care 
services of some sort rather  than transport. 
Develop  an  evaluation  tool  and  conduct  periodic  evaluations. 
As noted in the Background,  IHS  has not yet developed the evaluation  criteria  for  this 
program  mandated by Congress in  1983.  The national  CHR  program  has never been 
evaluated, nor are formal  evaluations conducted of individual  programs.  We recommend 
that such evaluation  criteria  and tools be developed and applied  in periodic  evaluations 
of both  the national  program  and individual  programs. 
We suggest that PHS use the information  in our report  entitled  Revitalizing  the CHR 
Program   in connection with  this recommendation.  It describes a number  of factors 
which respondents said should be present in strong CHR  programs.  Together,  we 
believe these factors provide  a solid framework  for developing  a strategy to plan, 
manage, and evaluate CHR  programs. 
15 
 COMMENTS 
The Assistant Secretary for  Planning and Evaluation  (ASPE)  and PHS commented  on 
the report.  The full  text of their  comments is in Appendix  D. 
The ASPE  agreed with  us that more attention  should be paid to the CHR  program  and 
believes that our report  provides IHS with  an approach to re-examine it.  Based on 
technical comments they made on the text, we made some editorial  changes in the 
report. 
The PHS concurred with  our findings and recommendation  to revitalize  the program  and 
described steps that IHS  has initiated  to address the problems  described in the report. 
In addition  to developing  an action plan, they noted that the IHS  strategy to revitalize 
the program  will  take into  account the factors described in our companion  report 
Revitalizing  the Community  Health  Representative  Program,  factors found  to influence 
the effectiveness of CHR  programs. 
We thank  ASPE  and PHS for their  comments. 
16 
 APPENDIX  A 
CHR REPORT  NO.  1 

TfME  SPENT,  NUMBER SERVED, NwBER  of  ACTIVITIES  by  HEALTN AREA 

ALL AREAS 
257  Progrva  codes 
AREAS:  ALL 
For  the  52  mkr  of  the  fiscal  yew  ending  9/91 
Made  JAN 011, 1992) 
MEALTN AREA  SERVICE  HOURS  TRAVEL HCURS  111)(8ER SERVED  NUUBER OF ACTIV 
. . . . . . . . . . . . . ..-..........-............-...-................................................ 
TOTAL  l,B37,C90  100%  401,921  100%  1,258,665  100%  1,9s7,37c  100% 
1 DIABETES  l&B,927  B%  ss,59B  14%  3n,704  px  237,616  12X 
2 CANCER  16,595  1%  6,367  2%  26,124  1%  i9,ait  ix 
3  NYPERTENSIW  61,290  3%  20,579  5%  259,16B  6%  134,293  n; 
4 AIDS  6,648  0%  1,136  ox  CO,866  1%  CTJ2  OX 
5 CQWIlrIUBLE  DIS  26,813  1%  aa3  2%  143,551  3%  77,208  LX 
6  SUBSTANCE ABUSE  21,690  1%  5,121  1%  51,lOB  1%  24,636  1% 
7 -1lY  INJ  CTRL  11,312  1%  3,94n  1%  67,132  2x  15,35L  1% 
B PRWlIQ(,  PREVEN  136,312  n  27,108  n  654,665  15%  lCQ,S70  7X 
91  OTNEB ELI  NED  323.m  tax  9a,96a  tsx  886,116  21X  Cl6,3L8  21% 
92  DENTAL  39,705  2x  ii.as3  3x  166,022  4x  u,a94  2% 
93  GERWTOLOCI CAL  127.197  =  39,534  10%  341,550  B%  lPl,cM  10X 
94  NCN  130,919  7x  3aJa9  la%  399,876  9X  207,712  11% 
%  MENTAL  18,670  1%  c,ass  1x  38,263  1x  26,060  1% 
%  ENVlROWENlAL  61,7J5  3%  lS.271  LX  343,469  a%  CL.767  2% 
NOT APPLICABLE  s72,ou  31%  CS,O%  11%  290,19a  7%  2822,256  1LX 
126,656  n,  19,117  5x  170,535  4%  &,a30  LX 
CHR REFORT NO.  2 

TIME  SPENT,  WLWBERSERVED, NWBER of  AClIVlT~ES  by  SERVICE 

SERVlCE  SERVICE  HCURS  TRAVEL MJRS  WER  SERVTD  MMBER  OF ACTIV 
. . . ..-...--..........-.--..--...-...........................--.....--.-.-..--............... 
TOTAL  1,837,cpo  loox  C01.921  100%  4,2s8,665  100%  1,937,37b  1QOX 
1 HEALTN ED  101,162  6%  12,351  3%  563,asL  13%  134,197  7X 
2 USE  Fly0  80,293  4X  13,286  3x  LR,CCI  11x  120,237  6% 
3wt- 116,478  6%  ia,sot  5X  367,986  9x  214,051  11% 
4 WfTOB  135,961  7x  a,892  12%  376,247  9x  291,691  1sx 
f  EMERGENCYCARE  20,089  1%  3.w  1x  20,072  ox  11,658  1% 
6  NW-EMRGENCY  CARE  126,242  n  25,a  . 6%  389,123  9x  220.432  11% 
7 -I  SERVICE  29,a'zp  2x  4,095  1%  16.m  1x  29.77a  2% 
8  MANS/DEL  315,950  1n  193,060  68x  616,578  14x  c11,96O  21% 
9  INTERPRET  17,562  1%  1,677  ox  99,101  2x  za,iki  ix 
10 ENVIROWNT  51,3ia  3%  It,31  3x  323,211  ax  31,425  2% 
11 AD(IIN  REP/REC  225,290  12%  a,952  2%  12c,cO9  3x  131,127  n; 
12  PT.  CLERICAL  126,nL  rX  3,aik  ix  32l,t40  B%  8&,592  LX 
13 MEETINGS  84,284  5%  1c.m  4%  lW,mB  5x  35,985  2x 
16  TRAINING  117,7&s  6X  13,212  3X  19,313  0%  25,797  1% 
1s  OTMER ADMIN  168,552  9X  11,614  3X - 110,1cs  3x  63,963  LX 
16 OTNER SERVICES  115,125  6%  16.255  6%  200,2Sl  sx  8r;,oa6  LX 
UNKNaW  4,786  ox  1.616  OX  7,920  QX  5,251  0% 
A -1  APPENDIX  B 

INDIAN  HEALTH  SERVICE 

CHR  PROGRAM 

SCOPE  OF WORK  MATRIX 

HEALTH  A  R  E- .A- 
FY: 
TRIBE: 

CHR FUNDS: 

coNTRAcr~ 

-DATE: 

PROG.CODE:,,- -

L HEALTH  EDUCATION 

zcAsE

fCMEMANAGEMEM 

4wIbimmmrAm 

IEh4EBGmCARE 

L PATImT  CARE 

1.-Mvlm 

8.TBANBmRTPATlmr 

9.lNmBmrrrlmAmLATu 

1o.mliPATImwBBavxcB3 

11.ENvIB0NMBmALsEBvxcEs 

l2.ADMlNAKANAGEMENT 

13.OBTAIN TBAlNING 
TOTAL 
B-l  APPENDIX  C 

ENDNOTES 
1.  Indian  Health  Manual,  3-I6.28 
2.  Indian  Health  Manual,  3-16.13C 
3.  Indian  Health  Manual,  3-16.5A 
4.  Indian  Health  Manual,  3-16.583 
5.  Indian  Health  Manual,  3-16.9D4f 
6. Indian  Health  Service, Community  Health  Representative  Program;  Annual  Report for  F&al 
Year  1990, p.  1. 
C-l  APPENDIX  D 

AGENCY  COMlMENTS 
D-l  DEPARTMENTOFHEALTH&HUMANSERVICE!3 
FublicHeelthselvia3 
Memorandum 
M/if?
.  2419x1 
Date 
Acting  Assistant  Secretary  for  Health 
From 
Office  of  Inspector  General  (OX)  Draft  Reports  "Management
Subject 
Issues  in  the  Community  Health  Representative  (CHR)  Program,"
and  "Revitalizing  the  CHR Program" 
To 
Acting  Inspector  General,  OS 
Attached  are  the  Public  Health  Service  comments  on  the  subject
draft  reports.  We concur  with  the  recommendation  ko  thoroughly
re-examine  the  CHR program  and  determine  its  future  direction. 
The  Indian  Health  Service  has  begun  activities  to  revitalize 
the  program.  The  attached  comments  discuss  the  actions  planned
or  taken  to  develop  a  national  strategy  to  revitalize  the  CHR 
program. 
G&J-@+
Audrey  F  Manley,  M.D.,  M.P.H. 
Attachment 
D-2  PUBLIC  HEALTH SERVICE  IPHS)  COMMENTSON THR OFFICE 
OF  INSPECTOR GENERAL fOIG)  DRiW!CREPORTS "MANAGEMENTISSUES  IN 
THE  COMMUNITY HEALTH REPRESENTATIVE PROGRAM." OEI-05-91-01071, 
AND  "REVITALIZING  THE COMMUNITYHEALTH REPRESENTATIVE 
PROGRAM." OEI-05-91-01070 
General  Comments 

The  OIG  reports  on  the  Community  Health  Representative  (CHR) 

program  provide  valuable  information.  They  highlight  problems

that  the  Indian  Health  Service  (IHS)  is  aware  of  and  is  working

actively  to  resolve.  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  Office's  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  this  methodology,  the  Oklahoma  Area  Office  has  performed
annual  evaluations  to  compare  the  progress  of  individual  CHR 
programs  between  Fiscal  Years  (FY)  1990  and  1991.  Because  of 
the  satisfactory  results  obtained  in  the  Oklahoma  Area  Office, 
a  version  of  this  management  tool  will  be  distributed  to  the 
other  Area  Offices. 
In  addition,  IHS  is  developing  outcome  and  quality-oriented

evaluations  for  the  CHR program.  The  evaluations  will  be  based 

on  '*Healthy  People  2000"  objectives,  the  patient  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 

broad-based  health  care  program,  PHS should  develop  a 

multifaceted  national  strategy  to  revitalize  the  CHR program. 

PHS Comments 

We concur  and  will  initiate  actions  to  revitalize  the  program.

IHS  has  begun  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 

D-3 
 2 

CHR program.  This  &aft  action  plan  was  presented  to  the  Board 

of  Directors  of  the  National  Association  of  CERs.  The  purposes

of  this  presentation  were  to  (1)  brief  Board  members  on  the 

goals  and  objectives  of  the  &aft  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/CHR  Tribal  Partnership  Conference 

which  is  tentatively  scheduled  for  late  September  1993.  It  is

expected  that  this  conference  will  be  attended  by  IHS 

executives  and  managers,  tribal  leaders,  CHRs,  and.consumers. 

At  this  conference,  IHS  intends  to  summarrize  the  findings  and 

recommendations  contained  in  the  OIG  reports.  Position  papers 

on  the  "national  goal  and  objectives  of  the  CHR program"  and 

"role  of  the  CHR"  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: 

The  role  of  the  CHR must  be  well-defined  and  understood 
0 	
by  tribal  governments,  community  members,  and  the  IHS 
health  care  team. 
A  community-based  health  care  outreach  program  should 
0 	
work  closely  with  the  health  care  professionals  serving
the  respective  communities.  Therefore,  CHF& must  be 
integrated  into  the  health  care  system. 
The  CHP program  is  a  community-based,  tribally-operated 
0 	
program  that  can  only  be  effective  with  full  tribal 
support  and  direction. 
IHS  support  and  direction  is  important  to  make  a  strong
0 	
CHR program. 
The  national  strategy  will  address  the  factors  mentioned  above. 
D-4 
 DEPARTMENT  OF HEALTH  & HUMAN  SERVICES  cmkmofttmsoc7amv 
wshhgtm.  DC  2020 
OEC lm2 
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-05-01071  and 
"Revitalizing  the  Community  Health  Representative
Program,"  OEI-05-91-01070 
The  &aft  reports  on  the  IHS  Community  Health  Representative 
Program  present  compelling  evidence  that  more  attention  should 
be  ljtiiii  Lu  &is  program.  Your  findings  are  aramatic  and-the 
proposed  elements  of  a  revitalization  strategy  provide  a 
thoughtful  framework  for  further  action.  The  clearest  indication 
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  SOWand  CHRIS  II  reports
calls  into  question  the  usefulness  of  these  instruments  as 
management  tools.  In  addition,  the  lack  of  integration  of  CHRs 
into  Native  American  primary  care  systems  is  particularly 
problematic.  This  report  provides  IHS  with  an  approach  to  begin
examination  of  the  program. 
We have  the  following  specific  comments. 
0 	 The  reports  document  that  transportation  is  an  important 
component  of  CHR responsibilities.  There  exist  large,
unexplained  discrepancies,  however,  between  different 
sources  of  information  on  the  proportion  of  the  CHR's  time 
which  is  devoted  to  transportation  services.  It  is  not 
clear  that  revision  of  the  program  to  become  primarily  a 
transport  program  is  actually  a  reasonable  option  to  be 
considered  by  IHS,  based  on  these  preliminary  findings. 
0 	 "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  strengthened  by  an 
increased  effort  to  include  tribal  input  as  an  integral 
component  of  your  evaluative  process.  Page  2  - Bryan  B.  Mitchell 
0 	 It  would  be  helpful  to  clarify  how  information  was  gathered
from  the  403  respondents.  When you  "talked  to'  respondents, 
was  a  questionnaire  used,  or  were  these  free  flowing 
conversations7  Was  a  standard  set  of  questions  used  to 
base  the  contacts? 
0 	 How were  the  four  factors  that  most  influence  the 
effectiveness  of  CHR programs  developed?  Were respondents
presented  with  a  list  of  factors  created  by  your  staff? 
Were  they  elicited  through  focus  groups?  Many  perspectives 
were  represented  in  the  comments:  a  statistical  breakdown 
of  the  commentary  would  clarify  the  agreement  on  various 
elements  and  assertions. 
0 	 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 
fully  understsd  soze  of  the  points  made  in.the  other.  It 
might  be  preferable  to  consolidate  the  reports  into  a  single
document,  with  the  methods,  findings  and  recommendations 
clearly  organized. 
0 	 Your  case  studies  indicate  that  the  information  presented  in 
written  documents  was  sometimes  contradicted  by  your
observations.  Did  you  ask  any  of  the  respondents  to  address 
the  apparent  discrepancy  between  the  written  materials  and 
your  observations  on  elements  A  and  D  of  Factor  13 
0 	 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)." 
D-6