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 Service’s (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 

Location 

Browning, Montana 

Size 

28-bed hospital 

Staffing (Fiscal Year 2014) 

About 250 clinical and nonclinical staff 

positions 

o	 12 physicians 

o 4 nurse practitioners 

6 vacant physician positions 

Average Daily Census 

11–12 patients, lower during summer months 

IHS Funding (Fiscal Year 2014) 

o	 Direct clinical services = $10.8 million 

o	 Purchased/Referred Care = $ 8.0 million 

Services (Fiscal Year 2014) 

Emergency Services 

Services available 24 hours a day, 

7 days a week 

Surgery Services 

Diagnostic Services 

Pharmacy Services 

Hospital-Based Outpatient Services 

o	 Family practice 

o	 Children’s health 

o	 Women’s health 

o	 Dental 

o	 Physical therapy 

o	 Specialty services 

o	 Mental and behavioral health 

OIG Site Visit – June 11–12, 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. 

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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. BCH’s permanent staff members are 

Federal employees; therefore, the hospital uses the Federal hiring process to fill its permanent 

positions. BCH’s 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 BCH’s 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. 

BCH’s staffing challenges led to longer waits and difficulty in managing patient care. BCH’s 

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). 
 

                                                            

 

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 tribe’s 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, BCH’s 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

 BCH’s officials reported that, as part of 

this process, the hospital’s 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 hospital’s 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 patient’s medical 

coverage, home environment (e.g., patient lives alone, patient lives at home with family support), 

and recent hospitalizations. BCH’s officials reported that they were continuing to revise and 

develop the hospital’s discharge planning policies and procedures. 

2 IHS’s standardized medical priority levels are as follows: I—Emergent or Acutely Urgent Care Services, 

II—Preventive Care Services, III—Primary and Secondary Care Services, IV—Chronic Tertiary Care Services, and 

V—Excluded Services. Accessed at 

http://www.ihs.gov/chs/index.cfm?module=chs_requirements_priorities_of_care on May 5, 2015. 3 Medicare’s hospital Conditions of Participation require that hospitals have in effect a discharge planning process 

that applies to all patients. 42 CFR § 482.43. 

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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 services—such as skilled nursing facilities, home health agencies and 

hospice agencies—it was a challenge for BCH staff to arrange for their patients to receive care 

from these facilities. For example, BCH’s 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 community’s 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. 
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SITE VISIT: CROW-NORTHERN CHEYENNE HOSPITAL 

Crow Reservation 

Overview 

Location 

Crow Agency, Montana 

Size 

24-bed Critical Access Hospital 

Staffing 

About 200 clinical and nonclinical staff 

Average Daily Census 

1–2 patients 

Emergency Department Visits 

3,383 patients from January–March 2014 

IHS Funding (Fiscal Year 2014) 

o	 Direct clinical services = $14.3 million 

o Purchased/Referred Care = $ 8.5 million 

 

Services (Fiscal Year 2014) 

Critical Access Hospitals are limited in size 

(no more than 25 beds) and typically are 

located in rural areas. These hospitals must 

offer emergency services 24 hours a day, 

7 days a week and maintain average inpatient 

stays of no more than 4 days (96 hours). 

Emergency Services 

Limited Surgery Services 

Pharmacy Services 

Hospital-Based Outpatient Services 

o	 Family practice 

o	 Children’s health 

o	 Women’s health 

o	 Dental 

o	 Mental and behavioral health 

OIG Site Visit – June 11–12, 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.
 
                                                            

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 OIG’s 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 hospital’s dependence on 

short-term contracting. CNCH’s 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 

tribe’s 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, CNCH’s 

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 IHS’s standardized medical priority levels are as follows: I—Emergent or Acutely Urgent Care Services, 

II—Preventive Care Services, III—Primary and Secondary Care Services, IV—Chronic Tertiary Care Services, and
 

V—Excluded Services. Accessed at 

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

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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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