Department of Health and Human Services 

OFFICE OF

INSPECTOR GENERAL

 

 

ACCESS TO MENTAL HEALTH 

SERVICES AT INDIAN HEALTH 

SERVICE AND TRIBAL FACILITIES 

 

Daniel R. Levinson 

Inspector General 

September 2011 

OEI-09-08-00580 
 

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 EXECUTIVE SUMMARY

OBJECTIVE

To determine the extent to which American Indians and Alaska Natives 

(AI/AN) have access to mental health services at Indian Health Service 

(IHS) and tribal facilities.

BACKGROUND

A member of Congress expressed concern about AI/ANs’ access to 

mental health services and requested that the Office of Inspector 

General conduct this evaluation. According to a Government 

Accountability Office report, the demand for mental health services 

outstrips capacity at some IHS and tribal facilities.

AI/ANs experience a disproportionately higher rate of mental and 

behavioral health challenges compared to other populations in the 

United States. AI/ANs rank first among ethnic groups as likely to 

suffer mental health disorders such as anxiety and depression that can 

lead to suicide. They rank second to white non-Hispanics in suicides. 

The suicide rate among AI/ANs age 13 to 20 is 2.3 times the national 

average. Additionally, AI/AN communities experience high rates of 

suicide risk factors, such as low household income and high 

unemployment. 

IHS and the tribes provide mental health services, including inpatient 

and outpatient care and residential substance abuse treatment. Mental 

health services include, but are not limited to, all psychiatric services, 

behavioral health services, substance abuse treatment, and traditional 

healing practices. These services are performed by licensed and 

unlicensed health care providers and are generally delivered in 

hospitals, health centers, urban Indian programs, and health stations. 

Our findings are based primarily on a survey of IHS and tribal facilities

that provided health care services from January 2008 to June 2009. 

The survey response rate was 82 percent (630 of 772 facilities). We also 

conducted onsite interviews at a sample of 98 facilities and at all IHS 

Area Offices. 
 

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EXECUTIVE SUMMARY

FINDINGS

Eighty-two percent of IHS and tribal facilities reported that they 

provide some type of mental health service; however, the range of 

available services is limited at some facilities. Of the 630 IHS and 

tribal facilities that responded to our survey, 514 reported that they 

provided some level or type of mental health service. The 116 facilities 

that do not provide mental health services refer clients to other 

providers either in the non-AI/AN community or on the reservation. 

Thirty-nine percent of the facilities reported that they provide crisis 

intervention 24 hours a day. 

Staffing issues and shortages of highly skilled providers limit 

AI/ANs’ access to mental health services at IHS and tribal facilities. 

Although 82 percent of the surveyed facilities reported that they provide 

mental health services, a variety of staffing issues affect access to 

services. Facilities that do not provide mental health services reported 

that staff shortages are part of the reason. Shortages of psychiatrists 

and other licensed providers at IHS and tribal facilities limit access to 

mental health services. Some facilities reported that social workers, 

counselors, and nurses provided pharmacotherapy (medication 

management) services to meet AI/ANs’ needs. To help address 

shortages of licensed providers, 17 percent of IHS and tribal facilities 

(87 of 514) use telemedicine for mental health services. 

Physical, personal/social, and economic challenges may affect

access to mental health services at IHS and tribal facilities. 

Approximately half of facilities (274 of 514) reported that physical 

barriers, such as travel conditions, affect clients’ access to services. 

Approximately one-third of facilities (175 of 514) reported that personal 

and social barriers, such as the lack of child care, affect clients’ access to 

services. Nearly one-third of facilities (147 of 514) reported that 

economic issues, such as difficulty paying copayments, affect access to 

services. 

RECOMMENDATIONS

The high rates of suicide, substance abuse, depression, 

unemployment, and poverty in AI/AN communities contribute to the 

need for access to mental health services. Although 82 percent of IHS 

and tribal facilities reported that they provide mental health services, 

access to some services is limited by shortages of highly skilled 
 

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EXECUTIVE SUMMARY

providers and by other staffing issues. In addition, the majority of 

AI/ANs attempting to obtain these services live in rural areas and 

face physical, personal/social, and economic barriers that limit access. 

When we conducted this study, IHS could not provide a complete and 

accurate list of all IHS and tribal health care facilities. Therefore, we 

have no assurance that we have a database that represents all such

facilities.

To address these issues, we recommend that IHS: 

Provide guidance and technical assistance to help tribes explore 

potential partnerships with non-AI/AN providers of community mental and 

behavioral health services. 

Continue to expand its telemedicine capabilities and provide guidance 

and technical assistance to tribal health care providers to expand and 

implement telemedicine. 

Develop a plan to create a single database of all IHS and tribal health care 

facilities.

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

IHS concurred with all of our recommendations. We did not make 

any changes in the report based on IHS’s comments. For the full text 

of those comments, see Appendix G.
 TABLE OF CONTENTS

EXECUTIVE SUMMARY ................................ ..... i

INTRODUCTION ............................................ 1 

FINDINGS ................................................. 10

Eighty-two percent of IHS and tribal facilities reported that 

they provide some type of mental health service; however, 

the range of available services is limited at some facilities ...... 10

Staffing issues and shortages of highly skilled providers 

limit AI/ANs’ access to mental health services at IHS and 

tribal facilities ......................................... 15

Physical, personal/social, and economic challenges 

may affect access to mental health services at IHS and 

tribal facilities ......................................... 18

RECOMMENDATIONS ..................................... 21

Agency Comments and Office of Inspector General Response.... 23

APPENDIXES ............................................. 24

A: Health Disparities ................................... 24

B: Glossary of Terms.................................... 25

C: Response Rates...................................... 28

D: Population Served and Screened by Type of Facility ........ 30

E: Crisis Intervention Services............................ 31

F: Mental Health Care Staff Onsite at Facilities ............. 32

F: Agency Comments ................................... 33

ACKNOWLEDGMENTS ..................................... 36
 

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INTRODUCTION

OBJECTIVE

To determine the extent to which American Indians and Alaska Natives 

(AI/AN) have access to mental health services at Indian Health Service 

(IHS) and tribal facilities.

BACKGROUND

A member of Congress expressed concern about AI/ANs’ access to 

mental health services and requested that the Office of Inspector 

General (OIG) conduct this evaluation. According to a Government 

Accountability Office (GAO) report, the demand for mental health 

services outstrips capacity at some IHS and tribal facilities.1 

AI/ANs experience a disproportionately higher rate of mental and 

behavioral health challenges compared to other populations in the 

United States. AI/ANs rank first among ethnic groups as likely to 

experience mental health disorders such as anxiety and depression 

that can lead to suicide.2 They rank second to white non-Hispanics in 

suicides. See Table A in Appendix A for further information on health 

disparities. 

In comparison to other populations, AI/AN youth have more serious 

problems with mental health disorders related to suicide, such as 

anxiety, substance abuse, and depression.3 The suicide rate among 

AI/ANs age 13 to 20 is 2.3 times the national average. Suicide is the 

second leading cause of death and accounts for 19 percent of all deaths 

among AI/AN youth. 

Additionally, AI/AN communities experience high rates of suicide risk 

factors, such as low household income and high unemployment.4 The 

1 GAO, Indian Health Service: Health Care Services Are Not Always Available to Native 

Americans, GAO-05-789, August 2005.

2 L.M. Olson and S. Wahab, “American Indians and suicide: A neglected area of 

research.” Trauma, Violence, and Abuse, 2006, 7(1), 19-33.

3 Suicide Prevention Resource Center, Suicide Among American Indians/Alaska Natives, 

April 5, 2007. Accessed at http://www.sprc.org/library/ai.an.facts.pdf on April 19, 2010.

4 Peggy Halpern, Office of the Assistant Secretary for Planning and Evaluation, 

U.S. Department of Health & Human Services, An American Indian/Alaska Native Suicide 

Prevention Hotline: Literature and Discussion with Experts, November 2009. Accessed at 

http://aspe.hhs.gov/hsp/09/AIAN-SuicidePreventionHotline/index.shtml#risk on March 29, 

2011.

 INTRODUCTION
 

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INTRODUCTION

income of one in every four AI/ANs falls below the Federal poverty level,

a rate approximately twice that of the total population.5

The Federal Government first authorized appropriations for AI/AN

health care in 1921 under the Snyder Act, which provided for “relief of 

distress and conservation of health.”

In the first half 

of 2009, the AI/AN unemployment rate was 13.6 percent. 

6 The Indian Health Care 

Improvement Act (IHCIA) was enacted in 1976 to improve the services 

and facilities of Federal AI/AN health care programs.7 The IHCIA 

expired in 2000, but Congress continued to appropriate funds annually 

for AI/AN health care. In 2010, the President signed the Patient 

Protection and Affordable Care Act of 2010 (ACA),8 which reauthorized 

appropriations for the IHCIA and stated “that it is the policy of this 

Nation, in fulfillment of its special trust responsibilities and legal

obligations to Indians—to ensure the highest possible health status for 

Indians and urban Indians and to provide all resources necessary to 

effect that policy....”9

IHS-Funded Health Services

 

IHS is an agency in the Department of Health and Human Services 

(HHS) responsible for providing Federal health services to AI/ANs. 

Headquartered in Rockville, Maryland, IHS operates from 12 Area 

Offices across the country; these offices oversee the delivery of health 

services and provide administrative and technical support. IHS’s 

mission is to raise AI/ANs’ “physical, mental, social, and spiritual health 

to the highest level.”10 Members of the 564 federally recognized tribes 

are eligible for IHS health care. In partnership with the tribes, IHS 

5 U.S. Census, Population Profile of the United States: Dynamic Version, Part V: 

Household Economics, Poverty in 2005. Accessed at

http://www.census.gov/population/www/pop-profile/files/dynamic/poverty.pdf on

June 23, 2011. 

6 Snyder Act, 1921, P.L. 67-85 § 13, 42 Stat. 208, 25 U.S.C. § 13. 

7 IHCIA, P.L. 94-437, 25 U.S.C. 1602.

8 ACA, P.L. 111-148.

9 ACA, Title X Part III § 10221, S. 1790 Title I § 103.

10 IHS, Indian Health Service Fact Sheets: Indian Health Service. Accessed at 

http://www.ihs.gov/PublicInfo/PublicAffairs/Welcome_Info/ThisFacts.asp on 

February 15, 2009.
 

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INTRODUCTION

provides services to 1.9 million11 of the approximately 4.3 million 

AI/ANs living in the United States.12 

Indian Self-Determination and Education Assistance Act. In accordance 

with the Indian Self-Determination and Education Assistance Act 

(ISDEAA) (1975), as amended, there are three options for IHS-funded 

health care services.13

1. Tribes, independently or through tribal organizations or tribal 

consortiums, may choose to have IHS continue to provide health 

services directly to their members. 

 

2. Through Title I, tribes can receive a share of money that IHS 

would have used to administer and operate health services. 

Under this option, commonly known as “638 contracting,” tribes 

negotiate with IHS for funds to provide health services directly 

to their members, and IHS retains a measure of oversight and 

supervision.

3. Under Title V, self-governance compacts allow tribes to receive 

their share of money from IHS to provide direct health services 

and to assume greater control over the administrative functions 

that support the delivery of the services and tailor services to 

the needs of their communities.14 Self-governance compacts 

offer tribes a greater degree of autonomy than does 

638 contracting. 

Direct Care Services

11 The remainder of AI/ANs may receive health care through other sources such as 

employer-provided health benefits, veterans’ health services, or Medicare and Medicaid.

. AI/ANs receive direct care services from 

IHS-operated or tribally operated facilities, generally hospitals, health 

centers, or health stations that provide direct health care services. In 

some situations, IHS and tribal programs share a building or hospital in 

which they operate their respective programs. Tribes, tribal 

consortiums, and IHS also may enter into cooperative arrangements 

with independent providers for specific services to be performed at their 

12 U.S. Census Bureau, We the People: American Indian and Alaska Natives in the 

United States, February 2006. Accessed at 

http://www.census.gov/population/www/socdemo/race/censr-28.pdf on May 9, 2011.

13 ISDEAA, 1975, P.L. 93-638, as amended.

14 IHS, IHS Fact Sheets: Tribal Self-Governance, January 2009. Accessed at 

http://info.ihs.gov/TrblSlfDtrm.asp on January 14, 2009. 
 

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INTRODUCTION

facilities. These may include dialysis and dialysis services, mobile 

diagnostic services, and psychiatric services. 

IHS and tribal facilities may also bill Medicare and Medicaid for 

services provided to eligible AI/ANs.15 For AI/AN Medicaid beneficiaries 

receiving services from IHS or tribal facilities, the Centers for Medicare 

& Medicaid Services (CMS) reimburses State Medicaid programs at 

100 percent of the Federal medical assistance percentage. AI/ANs 

receiving services under Medicare at non-IHS or nontribal facilities are 

responsible for appropriate copayments and deductibles.

Contract Health Services Program. When an IHS or tribal facility cannot 

provide the required services, IHS and tribes rely on the Contract 

Health Services (CHS) program, which contracts with private providers 

such as hospitals and physicians to deliver services. The CHS program 

is the payer of last resort and often defers or denies lower priority 

services. 16 According to IHS, the CHS program can typically fund only 

the highest priority, or Level I, health services. The highest of the four 

priority levels, Level I services—“Emergent/Acutely Urgent Care 

Services”—are “necessary to prevent immediate death or serious 

impairment,” and include emergency psychiatric care.17 Services to 

address non-life-threatening mental and behavioral health issues are 

not considered to be Level I. 

IHS mental health care programs. IHS and the tribes provide mental 

health services, including inpatient and outpatient care and 

residential substance abuse treatment. IHS’s 2010 budget 

appropriation for mental health and alcohol and substance abuse 

services was 9 percent of its total clinical services budget 

($267 million of $2.95 billion).18

15 IHCIA, P.L. 94-437, §§ 401 and 402.

 IHS apportions approximately 

16 42 CFR § 136.61. AI/ANs receiving services through CHS programs or Medicaid may 

not be charged copayments. 17 IHS, Contract Health Services, Requirements—Priorities of Care. Accessed at 

http://www.ihs.gov/NonMedicalPrograms/chs/index.cfm?module=chs_requirements_prioritie

s_of_care on April 8, 2010.

18 The fiscal year 2010 appropriation for mental health care ($267 million) is the sum of 

two line items in the IHS budget for clinical services: mental health ($73 million), and 

alcohol and substance abuse ($194 million). Accessed at 

http://www.ihs.gov/NonMedicalPrograms/BudgetFormulation/documents/IHS%20FY%2020

11%20Congressional%20Justification.pdf on May 10, 2010. 
 

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INTRODUCTION

50 percent of the $267 million for mental and behavioral health 

services directly through the tribes, via 638 contracting and 

self-governance compacts.

19 

Mental Health Care 

Mental health services. For the purposes of this report, the term “mental 

health services” includes, but is not limited to, all psychiatric services, 

behavioral health services, substance abuse treatment, and traditional 

healing practices.20

Psychiatric and behavioral health services use a variety of techniques to 

improve individuals’ functioning. Psychiatric services include, but are 

not limited to, psychotherapy and pharmacotherapy (i.e., medication 

management). Behavioral health services and substance abuse 

treatment include techniques to improve individuals’ physical, mental, 

social, and spiritual well-being.

 

21

In addition, IHS and tribes provide traditional healing practices 

relevant to a community’s unique culture, using a holistic approach to 

physical, spiritual, and mental health. In the AI/AN community, such 

treatments can include talking circles and sweat lodges.

 These services often include 

health-promotion counseling, 12-step addiction recovery programs, 

behavioral modification, and therapeutic drug treatment.

22

Some providers perform mental health services via telemedicine, 

sometimes called “telepsychiatry.” Telemedicine is the use of medical 

information exchanged from one site to another via electronic 

communications, such as video conferencing. See Glossary of Terms in 

Appendix B for more information.

 

Mental health services providers. A range of providers, with varying 

scopes of practice, perform mental health services. However, such 

services are generally performed by licensed health care providers, 

19 Bryan Wooden, Deputy Director of IHS’s Division of Behavioral Health. Interviewed 

on November 19, 2008. 

20 For additional definitions of selected terms and concepts in this report, see the 

Glossary of Terms in Appendix B.

21 IHS, Behavioral Health Home Page. Accessed at 

http://www.ihs.gov/MedicalPrograms/Behavioral/ on February 15, 2010.

22 A talking circle is a traditional method of conducting a discussion in a respectful, 

egalitarian manner. A sweat lodge is a structure heated by a central fire or steam from 

water poured on hot stones and is used for ritual or therapeutic sweating.
 

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including psychiatrists, clinical psychologists, clinical social workers, 

and marriage and family counselors. Licensure requirements vary by 

State. Primary care providers, such as physicians and nurse 

practitioners, also perform some mental health services, (e.g., 

pharmacotherapy and emergency care).

Not all States require that other providers—such as aides, addiction

counselors, mental health counselors, and peer counselors—be 

licensed. Regulations for counselor certification vary from State to 

State,23

The IHS Community Health Aide Program includes certification 

requirements for Behavioral Health Aides (BHA), who provide some 

mental health services, such as case management and community 

outreach.

as do the training requirements for aides. 

24 BHAs commonly provide mental health services in 

remote areas, such as Alaskan villages.25

Related Reports

 

In 2005, GAO visited 13 IHS facilities to determine the extent to 

which AI/ANs had access to health care.26

In 2009, OIG examined the extent to which IHS and tribes paid for CHS 

hospital claims above the required Medicare rate from January to 

March 2008. The study found that IHS and tribes paid above the 

Medicare rate for 22 percent of hospital claims, resulting in $1 million 

 GAO found that most 

facilities offered primary care and dental and vision services, but that 

access was not always assured because of waiting times and lack of 

transportation. GAO also found that in some cases, gaps in specialty 

and behavioral health care resulted in diagnosis or treatment delays 

that made patients’ conditions worse and created a need for more 

intensive treatment.

23 American Counseling Association, Licensure and Certification. Accessed at 

http://www.counseling.org/Counselors/LicensureAndCert.aspx on March 29, 2011.

24 The Community Health Aide Program was established pursuant to IHCIA,

P.L. 94-437, § 119, 25 U.S.C. § 1616l.

25 IHCIA, P.L. 94-437, § 121, 25 U.S.C. § 1616l.

26 GAO, Indian Health Service: Health Care Services Are Not Always Available to 

Native Americans, GAO-05-789, August 2005.

INTRODUCTION
 

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INTRODUCTION

in overpayments. If payments for nonhospital claims were capped at 

the Medicare rate, IHS could have saved as much as $13 million.27

In 2010, Senator Byron Dorgan, Chairman of the Senate Committee on 

Indian Affairs, released a report citing problems with credentialing and 

licensing of providers, accountability of controlled substances, and 

management of CHS program funds, among other issues, in the region 

covered by the IHS Area Office in Aberdeen, South Dakota.28

Companion Report

 

This report is one of two on AI/ANs’ access to health care. The 

companion report is Access to Kidney Dialysis Services at Indian Health 

Service and Tribal Facilities (OEI-09-08-00581).

METHODOLOGY 

Scope

This evaluation determines the extent to which AI/ANs had access to 

mental health services at IHS and tribal facilities between 

January 2008 and November 2009. We conducted this evaluation 

concurrently with our evaluation of AI/ANs’ access to kidney dialysis 

services. 

We did not review the quality and medical necessity of mental health 

services or review whether IHS paid appropriately for the services in 

accordance with Federal laws and regulations.

27 OIG, IHS Contract Health Services Program: Overpayments and Potential Savings,

OEI-05-08-00410, September 2009.

28 U.S. Senate Committee on Indian Affairs, In Critical Condition: The Urgent Need to 

Reform the Indian Health Service’s Aberdeen Area, December 28, 2010.
 

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INTRODUCTION

Survey and Fieldwork 

Stage 1: Survey of IHS and tribal facilities. To identify all IHS and 

tribal health facilities, we took the following steps: 

• To create one master list of IHS and tribal facilities, we

combined the multiple lists that IHS provided to us, removing 

all duplicates. 

• Because the list was missing information (e.g., names of

current representatives of the facilities), we conducted 

research online and used an HHS employee directory to 

confirm information about facilities and their representatives. 

We also confirmed this information with IHS and tribal staff. 

• We then attempted to contact each facility’s representative to 

confirm the name and type of facility and confirm whether it 

was IHS operated or tribally operated.

We identified 777 IHS and tribal facilities that were providing health 

care services from June 2009 to November 2009.29 For the purpose of 

this report, we excluded five facilities that provided only dialysis 

services. Therefore, this report is based on 772 IHS and tribal

facilities. 

We sent one survey per facility to the contact person we had 

identified. Some contacts were responsible for multiple facilities. We 

asked them to complete one survey for each facility so that we could 

attribute each response to the appropriate facility. We made a 

minimum of three attempts by email and/or telephone to ensure that 

all contact people submitted their surveys. We received completed 

surveys from 630 of the 772 facilities, for a response rate of 

82 percent. See Tables C-1 and C-2 in Appendix C for details 

regarding responses. 

Stage 2: Fieldwork at 98 IHS and tribal facilities. We visited 98 IHS and 

tribal facilities in 51 AI/AN communities and reservations. These

facilities offered a range of health services, including inpatient and 

outpatient services and primary and specialty care. We also visited 

11 of 12 IHS Area Offices in person and interviewed IHS officials at 

29 We sent surveys to all IHS and tribal facilities beginning in June 2009 and continued 

to receive responses for 6 months, until November 2009.
 

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INTRODUCTION

the remaining Area Office by telephone. We used standardized 

interview guides and interviewed 436 IHS and tribal administrators, 

providers, and clients. 

Analysis

We based our findings on the synthesis of survey data, interviews, and 

observational fieldwork. The data we collected during the onsite work 

supplemented the survey data. Using SAS software, we analyzed the 

data collected through our survey and fieldwork. 

Limitations

The findings in this report are not projected to all IHS and tribal 

facilities but are limited to the 630 survey respondents. We 

conducted the interviews concurrently with our evaluation of AI/ANs’

access to dialysis services. Therefore, not all of the 436 interviews 

specifically addressed access to mental health services.

Standards

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors 

General on Integrity and Efficiency.
 

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 FINDINGS

Eighty-two percent of IHS and tribal facilities 

reported that they provide some type of 

mental health service; however, the range of 

available services is limited at some facilities

Of the 630 IHS and tribal facilities that 

responded to our survey, 514 reported 

that they provide some level or type of

mental health service. Most of the 

514 facilities provide psychotherapy and 

various support groups. The most 

commonly provided services include individual child and adult 

psychotherapy, family and couples support groups, and addiction 

treatment and support programs. The type and level of services 

provided are generally determined by the type of facility and the 

qualifications of the staff. These facilities reported screening

approximately 536,000 clients for mental and/or behavioral health 

problems during the 18 months beginning January 1, 2008. See Table 1 

for more information on the types of services and referrals provided by 

facilities.

Table 1: Services and Referrals at IHS and Tribal Facilities

 Type of Service

Percentage

of Facilities 

That Provide

the Service

(n=514) 

Facilities That Do Not Provide 

the Service

(n=116)

Percentage That 

Provide Referrals

Percentage That Do 

Not Provide Referrals

Psychotherapy (all) 81% 51% 49%

 Individual – adult 81% 44% 56%

 Individual – child 81% 52% 48%

 Group – adult 44% 28% 72%

 Group – child 35% 28% 72%

Support groups (all) 80% 84% 16%

 Family and couples 71% 24% 76%

 Addiction and 12-step programs 51% 36% 64%

 Family violence 24% 8% 92%

 Victim of childhood sexual abuse 20% 7% 93%

 Suicide 19% 10% 90%

 Child of an alcoholic 18% 13% 87%

 Family and friends of an alcoholic 18% 9% 91%

 Parent of an alcoholic 16% 8% 92%

 Parent of chemically dependent child 16% 11% 89%

 Child of chemically dependent parent 16% 8% 92%

 Chronically mentally ill 15% 8% 92%

Pharmacotherapy 46% 8% 92%

Traditional healing 33% 1% 99%

Hypnotherapy 4% <1% >99%

Electroconvulsive therapy 1% 2% 98%

 Any Service 100% 88% 12%

 Source: OIG analysis of survey data, 2010.
 

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FIND INGS

Of the 116 facilities that do not provide mental health services, 

88 percent (102 of 116) reported that they refer clients to other 

providers. Generally, the facilities that do not provide mental health 

services refer clients to local support groups and individual 

psychotherapy, depending on the type of services the client may need. 

Because these facilities do not provide mental health services, the staff 

may have limited knowledge of where to refer clients for certain types 

and levels of services. 

The range of mental health services varies by the type of facility 

Most facilities reported that they provide mental health services, but 

the availability of some services is limited at certain types of facilities. 

Although all types of facilities reported providing some type of 

psychotherapy service or support group, hospitals and health centers 

were more likely to provide pharmacotherapy. Less than half of alcohol 

and substance abuse treatment and behavioral health facilities and only 

22 percent of Alaska village clinics (25 of 112) reported that they

provide pharmacotherapy. Traditional healing is provided most 

frequently in urban and school health centers (63 percent). See Table 2 

for more information on the range of mental health services at IHS and 

tribal facilities. See Appendix D for more information on the 

community population served and number of clients screened by these 

facilities. 

Table 2: Range of Mental Health Services at IHS and Tribal Facilities 

Total Facilities 

That Report 

Providing Mental 

Health Services

(n=514)

Percentage of Facilities That Offer the Service

Type of Facility Psychotherapy* 

Support 

Groups*

PharmacotherapyTraditional

Healing

Hypnotherapy

Electroconvulsive 

Therapy

Health center 192 93% 91% 60% 25% 5% 1%

Alaska village clinic 112 86% 72% 22% 30% 4% 4%

Alcohol and substance 

abuse treatment center 55 75% 82% 36% 48% 2% --

Hospital 35 100% 91% 77% 34% 3% --

Health station 32 81% 81% 53% 16% 19% --

Behavioral health 

facility 31 87% 74% 45% 32% -- --

Urban health center 28 79% 82% 50% 63% -- --

School health center 20 95% 70% 5% 63% -- --

Remote health location 7 86% 86% -- 50% -- --

Other residential 2 50% 50% 50% -- -- --

* At least one type of psychotherapy service or support group is offered at the facility.

Source: OIG analysis of survey data, 2010.
 

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FINDINGS

Thirty-nine percent of IHS and tribal facilities that provide mental health 

services reported that they provide crisis intervention services 24 hours per 

day, 7 days per week

Thirty-nine percent of facilities that provide mental health services 

(199 of 514) reported that they provide crisis intervention services 

24 hours a day. Crisis intervention is emergency psychological care

provided by trained counselors in a variety of settings that enables an 

individual to return to normal levels of functioning. Only 26 percent 

of facilities providing 24-hour crisis intervention services (52 of 199) 

reported that mental health care staff are onsite the minimum

number of hours necessary to provide 24-hour care (i.e., 168 total 

hours per week). The remaining facilities that provide 24-hour crisis 

intervention services (147 of 199) use on-call staff to respond to 

after-hours crises. In general, because of the limited number of 

mental health staff, most crisis intervention services are provided 

through primary care and emergency room providers.

Fifty-one percent of facilities (262 of 514) reported that they provide 

crisis intervention services fewer than 24 hours a day. Ten percent of 

facilities (53 of 514) do not provide any crisis intervention services. 

See Table 3 for more information on crisis intervention services at 

IHS and tribal facilities. 

Table 3: Crisis Intervention Services at IHS and Tribal Facilities 

Scope of Intervention Services Provided at Facilities Percentage

of Facilities

Number of 

Facilities

Provide crisis intervention services 24 hours per day, 7 days per week 39% 199

 Staff are onsite a minimum 168 hours per week 10% 52

 Staff are onsite fewer than 168 hours per week 29% 147

Provide crisis intervention services fewer than 24 hours per day, 

7 days per week 51% 262

Provide no crisis intervention services 10% 53

 Total respondent facilities that provide mental health services 100% 514

Source: OIG analysis of survey data, 2010.

Lack of licensed providers limits referrals to psychiatric facilities 

In many instances of acute psychiatric crises, clients may have to be 

treated by health care providers in an acute-care hospital or by licensed 

providers who can admit the client to an inpatient psychiatric facility. 
 

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FINDINGS

The 52 facilities that have mental health care staff onsite to provide 

24-hour crisis intervention services are likely staffed with social 

workers and counselors who cannot admit patients to an inpatient 

psychiatric facility. The lack of staff and clinical training in these 

facilities limits the mental health services that can be provided during 

psychiatric emergencies and after-hours crises. See Table E in 

Appendix E for more information on the staffing levels at IHS and tribal 

facilities that provide onsite 24-hour crisis intervention services. 

The director of a youth residential facility that provides onsite 24-hour 

crisis intervention services reported: 

If we had adequate resources we could provide a better 

quality of care for mental health and family mental health 

needs of our patients. The majority of our patients come 

with PTSD [Post-Traumatic Stress Disorder] and chemical 

dependencies. Our 24-hour monitoring staff falls far short of 

being able to engage therapeutically due to the lack of skills

and training. We can only afford to hire non-skilled 

individuals. 

IHS and tribal facilities provide limited inpatient psychiatric care 

Approximately 81 percent of facilities that provide mental health 

services (416 of 514) provide only outpatient mental health services. 

Approximately 15 percent provide both inpatient and outpatient mental 

health services, and 4 percent provide only inpatient mental health 

services. The types of facilities providing inpatient mental health 

services include, but are not limited to, substance abuse and behavioral 

health residential treatment facilities. 

IHS and tribes operate 43 inpatient medical hospitals, 4 of which 

provide short-term inpatient psychiatric care. The four hospitals that 

provide such care do so under special circumstances. Two of the four 

hospitals are in remote areas of Alaska. One has four psychiatric 

observation beds in a locked ward, supervised by a psychiatric nurse. 

The other provides inpatient crisis intervention. Both hospitals refer 

their patients to the State’s only psychiatric hospital, which is in 

Anchorage and is accessible from their communities only by air. 

IHS operates one inpatient psychiatric hospital, an adolescent 

treatment facility that admits patients ages 13 to 17. The hospital has 

capacity for 20 patients; however, at the time of our visit, it could 
 

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FINDINGS

accommodate no more than 12 patients because it was not fully 

staffed.30 

Most AI/ANs who need inpatient psychiatric care must use non-IHS/

nontribal facilities

Although inpatient psychiatric care may be provided at public and 

private general medical hospitals and public and private psychiatric 

hospitals, finding available inpatient psychiatric care for clients is 

challenging. At 29 facilities that we visited, 40 providers (including 

20 physicians) who are on the front lines of psychiatric emergencies 

reported that it is often difficult to find inpatient psychiatric care for 

their clients. Non-IHS/nontribal psychiatric beds are scarce in rural 

areas. For example, Montana, North Dakota, South Dakota, and 

Wyoming have a total of only eight psychiatric hospitals. IHS and tribal 

facilities assist clients in finding inpatient psychiatric care, but provider 

interviews indicate that their staff cannot meet the demand for care. 

Frequently, non-IHS/nontribal psychiatric hospitals are full and cannot 

admit clients in a timely fashion. Furthermore, psychiatric care 

provided at non-IHS/nontribal facilities may not be culturally sensitive.

. Almost all IHS operated and tribally operated 

hospitals (39 of 43) can medically stabilize clients in psychiatric crisis, 

but most do not admit clients for psychiatric care. Once clients are 

stabilized, these hospitals will generally refer them to non-IHS/ 

nontribal psychiatric facilities. 

Additionally, States’ reimbursement policies may affect AI/AN Medicaid 

beneficiaries’ access to inpatient psychiatric services. During our visits 

to two AI/AN inpatient youth residential treatment facilities, staff 

reported that they were unable to bill for out-of-State patients referred 

to their facilities because the patients’ State of residence did not enroll 

out-of-State providers. CMS reimburses State Medicaid programs for 

the full cost of inpatient services provided to Medicaid-eligible AI/ANs 

at IHS and tribal facilities, regardless of their State of residence or the 

location of the facility. However, some States do not recognize 

out-of-State providers and will not pay for out-of-State services except 

for emergency care.

30 IHCIA, P.L. 94-437, § 708, 25 U.S.C. § 1665g authorizes the Secretary of HHS, acting 

through IHS, to construct at least one youth regional treatment center for addiction and 

behavioral health services in each region covered by an IHS Area Office. 
 

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FINDINGS

Staffing issues and shortages of

highly skilled providers limit AI/ANs’

access to mental health services at 

IHS and tribal facilities

Although 82 percent of the surveyed 

facilities reported that they provide 

mental health services, the type of care

and services are limited by an inadequate 

number of skilled professional staff. 

IHS and tribal facilities that provide mental health services reported 

that a variety of staffing issues affect access to services

Forty-seven percent of IHS and tribal facilities that provide mental 

health services (243 of 514) have licensed medical providers 

(i.e., physicians, midlevel practitioners, and/or nurses) onsite. These 

providers render medical assistance and treatment to clients in crisis, 

including medically stabilizing patients, locating an appropriate 

psychiatric hospital, and arranging for clients to be admitted and 

transported to the hospitals. 

Thirty-nine percent of the facilities (200 of 514) reported that access to 

services was affected by a variety of staffing issues. During interviews, 

providers explained that the lack of resources (e.g., financial, staff, and 

infrastructure) affected their ability to hire contractors, establish 

outreach programs, and provide adequate staff support. Survey 

responses indicated that access was limited by the number of 

appointments they could schedule with available staff and the number 

of hours the facility could remain open. See Table 4 for barriers related 

to staffing difficulties that limit AI/ANs’ access to mental health 

services. 

Table 4: Barriers That Limit Access to Mental Health 

 Services at IHS and Tribal Facilities 

Type of Barrier to Care

Percentage of 

All Facilities 

Number of 

Facilities 

(n=514)

Facility’s lack of resources 37% 192

Appointment availability 34% 173

Limited facility hours 25% 131

Source: OIG analysis of survey data, 2010.

Staff shortages prevent some IHS and tribal facilities from providing mental 

health services. Fifty-six of the 116 facilities that provide no mental 

health services reported that staff shortages and geographical

remoteness prevent them from providing the services. These facilities 
 

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FINDINGS

reported that they cannot retain and recruit mental health care 

providers. Half of these facilities (29 of 56) are clinics in Alaska that 

serve communities of fewer than 500 residents. Typically, facilities that 

do not provide mental health services (54 of 116) refer clients to 

facilities that do, including other IHS or tribal facilities and/or private 

facilities. 

Shortages of psychiatrists at IHS and tribal facilities limit access to 

mental health services

The shortage of full-time psychiatrists is a problem in most IHS and 

tribal facilities. Seven percent of IHS and tribal facilities that provide 

mental health care (36 of 514) employ full-time psychiatrists. Although 

32 percent of the facilities (162 of 514) reported that they employ 

psychiatrists, at half of such facilities (87 of 162), psychiatrists work 

8 or fewer hours per week. In contrast, psychologists, licensed social 

workers, and counselors are onsite at 437 of the facilities, and their 

average hours per facility are approximately 4 times those of 

psychiatrists. See Table F in Appendix F for information on the median 

hours per week for mental health care staff by provider type. 

Thirty-one percent of IHS and tribal facilities that do not employ 

full-time psychiatrists (146 of 478) are in designated health professional 

shortage areas (HPSA). HPSAs are designated by the Health Resources 

and Services Administration (HRSA) as having shortages of health 

providers in primary care, dental health, and mental health. HRSA has

designated 208 AI/AN communities as having the highest possible 

degree of shortages of mental heath care providers. 31 

Unlicensed providers provide pharmacotherapy to meet access needs

Facilities often do not have appropriately licensed staff available to 

provide pharmacotherapy. Pharmacotherapy is the treatment of 

disease, especially mental disorders, with drugs.32 Treatment can 

include dispensing drugs and monitoring clients; however, only licensed 

providers can prescribe the drugs used in pharmacotherapy. Forty-six 

31 The Public Health Service Act § 332 (amended by P.L. 101-597) requires HRSA to 

designate HPSAs. The aforementioned 208 AI/AN communities have unusually high needs 

for mental health services. HRSA, Shortage Designation: HPSAs, MUAs [medically 

underserved areas] & MUPs [medically underserved populations]. Accessed at 

http://bhpr.hrsa.gov/shortage/index.htm on January 29, 2010. 

32 MedlinePlus, “Pharmacotherapy,” Medical Dictionary. Accessed at 

http://www.merriam-webster.com/medlineplus/pharmacotherapy on February 14, 2010.
 

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FINDINGS

percent of facilities that provide mental health care (236 of 514) provide 

this treatment. Of the facilities that provide pharmacotherapy, 38 of 

236 reported that social workers, counselors, and nurses provided some 

type of pharmacotherapy service, which may have included drug-related 

treatment other than prescribing medication. In addition, in 

8 States that do not license psychologists to prescribe medicine, 

13 facilities reported that psychologists perform pharmacotherapy.33

During our visits to five facilities in remote areas, respondents reported 

that they employ no providers who are licensed to prescribe medication 

that may be an essential part of crisis intervention treatment. The 

facilities reported that licensed providers who are not onsite write the 

initial prescriptions for clients. Unlicensed providers who are onsite 

then dispense the medication and monitor the clients. Providers 

reported that there are no alternatives in the community for clients who 

require medication. One hospital reported that clients wait 7 weeks to 

get an appointment with a psychiatrist for a prescription and treatment. 

 

To help address shortages of licensed providers, 17 percent of IHS and 

tribal facilities use telemedicine for mental health treatment

Given staff shortages, telemedicine can be a practical and 

cost-effective way to expand health services to offsite locations. The 

IHCIA authorizes the Secretary of HHS to expend funds for the 

development and expansion of telehealth and telemedicine programs, 

where appropriate. In addition, Medicare34

Although telemedicine is being used in IHS and tribal facilities in fields 

such as cardiology, nutrition counseling, and eye care, only 17 percent of 

facilities (87 of 514) reported that they use it for mental health services. 

More than half of the facilities that provide telemedicine (52 of 87) are 

in remote areas of Alaska. Seventy-five percent of these facilities (65 of 

the 87) provide pharmacotherapy via telemedicine.

and some Medicaid State 

programs and third-party payers pay for certain telemedicine 

services. 

Providers reported that pharmacotherapy is one of the services most in 

demand for telemedicine and one of the services best suited for it. We 

33 This figure does not include Louisiana or New Mexico. At the time of this evaluation, 

Louisiana and New Mexico were the only States that licensed clinical psychologists to 

prescribe medication.

34 42 CFR § 410.78.
 

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FINDINGS

visited 11 facilities that currently use telemedicine. Providers at these 

facilities said they hoped to expand their existing telemedicine services, 

and providers at other facilities expressed interest in using telemedicine 

in the future. However, some facilities may encounter challenges with 

telemedicine. At one facility, providers reported that older clients are 

uncomfortable with telemedicine, especially for mental health services. 

Therefore, the facility does not provide psychiatric consultations or 

pharmacotherapy via telemedicine. 

 

Physical, personal/social, and 

economic challenges may affect 

access to mental health services at 

IHS and tribal facilities 

Approximately 69 percent of the 

facilities that provide mental health 

services (353 of 514) reported that 

AI/ANs face physical, personal/social, 

or economic barriers in obtaining

mental health services at IHS and 

tribal facilities. See Table 5 for the individual barriers related to 

access to mental health services. 

Table 5: IHS and Tribal Facilities That Reported That

 Their Clients Experience Barriers to Mental 

 Health Services 

Type of Barrier to Care Percentage of 

All Facilities

Number of 

Facilities

(n=514)

Physical barriers

 Transportation 53% 274

 Weather 37% 191

 Distance 36% 187

 Poor roads 19% 98

Personal and social barriers

 Lack of child care 34% 175

 Work schedule 31% 159

 Personal schedule 30% 154

Economic barriers

 Financial 28% 147

 Copayments 11% 61

Source: OIG analysis of survey data, 2010.
 

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FINDINGS

Approximately half of facilities reported that physical barriers affect 

clients’ access to services

Approximately 53 percent (274 of 514) of facilities reported that 

transportation was a barrier to accessing services. More than 

one-third of the facilities reported that physical barriers, such as poor 

roads, distance, or weather, prevented clients living on rural 

reservations from obtaining mental health services. During 

interviews, providers and clients related concerns about dangerous 

travel through remote areas to access facilities. Twenty facilities 

reported that their clients may use alternative means of 

transportation—including snowmobile, dogsled, tractor, horse, or 

boat—to get to facilities. 

Approximately one-third of facilities reported that personal and social 

issues affect clients’ access to services

Approximately 30 percent of facilities reported that work and personal 

schedules affected clients’ access to mental health services. Survey 

responses from 34 percent of the facilities that provide mental health 

services indicate that their clients have limited access to these services 

because of lack of child care. 

During onsite visits, providers and clients in 24 communities related 

other personal and social barriers that affect access. According to 

respondents, domestic violence and sexual abuse, addiction to drugs 

and alcohol, and the personal stigma associated with seeking help for 

mental illness limited clients’ ability and willingness to obtain mental 

health services. Clients in small communities were particularly 

concerned about confidentiality, fearing that their mental health 

treatment would become common knowledge. 

Nearly one-third of facilities reported that economic issues affect 

clients’ access to services

Twenty-eight percent of IHS and tribal facilities reported that their 

clients’ financial situations may limit their access to mental health 

services. For example, 11 percent of the facilities reported that 

copayments may present a barrier to care when the AI/AN clients are 

referred to non-IHS/nontribal facilities.35 The financial condition of 

clients also was mentioned in interviews with clients and staff. In 

35 SSA § 1916(j). AI/ANs referred to facilities under CHS are not charged copayments.
 

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FINDINGS

many instances, economic issues combine with personal and social

factors to affect access to services. In rural areas, clients may not 

have enough money for transportation or other personal costs 

associated with trying to obtain services. For example, in several of 

our interviews, clients and providers cited clients’ inability to pay for 

child care and the cost associated with clients’ taking leave from their 

jobs as socioeconomic problems that serve as barriers to services. 
 

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 RECOMMENDATIONS

 

The high rates of suicide, substance abuse, depression, unemployment, 

and poverty in AI/AN communities contribute to the need for access to 

mental health services. Although 82 percent of IHS and tribal facilities 

reported that they provide mental health treatment, access to some 

services is limited by staffing issues and shortages of highly skilled 

providers. In addition, the majority of AI/ANs attempting to obtain 

these services live in rural areas and face physical, personal/social, and 

economic barriers that limit access to services. 

When we conducted this study, IHS could not provide a complete and 

accurate list of all IHS and tribal health care facilities. Although IHS 

attempts to collect information annually about IHS-funded health 

services, tribal facilities funded under Title I and Title V of the ISDEAA 

are not required to report specific information about their facilities. 

Therefore, IHS was unable to provide a complete, accurate list of all IHS 

and tribal health care facilities and contact individuals for them.

To address these issues, we recommend that IHS: 

Provide guidance and technical assistance to help tribes explore 

potential partnerships with non-AI/AN providers of community mental and 

behavioral health services

To improve access to and coordination of community mental health 

services for AI/ANs, IHS should develop written guidance that 

addresses service gaps and lack of coordination among States, IHS and 

tribal facilities, and non-AI/AN providers. The written guidance should 

include a strategy to improve relationships with non-AI/AN community 

providers and access for and treatment of AI/ANs in underserved tribal 

communities. This may enable IHS and tribal providers to expand 

coverage for critical mental health services. 

IHS should provide technical assistance to tribes and non-AI/AN 

providers serving AI/ANs regarding the Federal reimbursement policy 

for eligible AI/ANs under the IHCIA. Lastly, given that the needs of 

AI/ANs vary significantly among tribes and locations, IHS should assist 

tribes in collaborating with States and non-AI/AN providers to address 

the challenges of obtaining culturally sensitive services.
 

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RECOMMENDATIONS

Continue to expand its telemedicine capabilities and provide guidance 

and technical assistance to tribal health care providers to expand and 

implement telemedicine

Seventeen percent of IHS and tribal facilities use telemedicine to help 

address staff shortages and expand access to professional health 

services. IHS should continue to address technical barriers to support 

and encourage use of telemedicine at IHS and tribal facilities. In 

addition, IHS should develop written guidance to work with and educate 

IHS and tribal providers, States, and non-AI/AN providers regarding 

telemedicine services. IHS should continue to provide technical 

assistance, if needed, to tribes that use telemedicine to ensure that they 

have the capability to bill Medicare, Medicaid, and third-party payers 

for appropriate telemedicine services. By being able to charge thirdparty payers, the facilities can increase their revenue to support facilityspecific telemedicine services. 

Develop a plan to create a single database of all IHS and tribal health care 

facilities

Our attempts to compile a comprehensive list of all IHS and tribal 

health care facilities were limited because there is no single database—

either in IHS or among tribes and tribal organizations—of all IHS and 

tribal health care facilities, with the facilities’ addresses and the names 

of contact people. Although tribes are not required under 

638 contracting or self-governance compacting to report information 

about their facilities to IHS, a single database that identified all health 

care facilities and the services they offer would help the tribes and IHS 

to expand services under the reauthorized IHCIA. IHS should develop a 

plan to work with tribes, States, and Federal agencies to create a 

national database of AI/AN health care facilities, and it should include 

all such facilities, regardless of funding sources. Such a database would 

assist the Secretary in meeting the Administration’s mandate to 

“formulate a comprehensive approach to Indian health care reform” and 

provide planning information relative to the distribution of health 

services for AI/ANs throughout the country. 
 

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AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

IHS concurred with all three of our recommendations. In response to 

our first recommendation—that IHS provide guidance and technical 

assistance to help tribes explore potential partnerships with non-AI/AN 

providers of community mental and behavioral health services—IHS 

stated that it will collaborate with the Substance Abuse and Mental 

Health Services Administration (SAMHSA) to develop written guidance 

that addresses service gaps and lack of coordination among States, IHS, 

tribal facilities, and non-AI/AN providers. IHS also stated that it will 

provide technical assistance to tribes regarding Federal reimbursement 

policies for eligible AI/ANs and that it will assist tribes in collaborating 

with SAMHSA, States, and non-AI/AN providers to address the 

challenges of obtaining culturally sensitive services for AI/AN patients.

In response to our second recommendation—that IHS continue to 

expand its telemedicine capabilities and provide guidance and technical 

assistance to tribal health care providers to expand and implement 

telemedicine—IHS stated that it will continue to expand 

implementation of telemedicine for behavioral health services, educate 

IHS and tribal providers regarding the use and effectiveness of 

telemedicine for behavioral health services, and address potential 

technical barriers to the use of telemedicine for behavioral health 

services at IHS and tribal facilities. IHS stated that it will also provide 

technical assistance to tribes that use telemedicine for behavioral health 

services to increase their ability to bill third-party payers for those 

services.

In response to our third recommendation—that IHS develop a plan to 

create a single database of all IHS and tribal health care facilities—IHS 

stated that it will work with tribes, States, and Federal agencies to 

create a database of AI/AN health care facilities to include physical 

locations, contact information, and available services.

We did not make any changes in the report based on IHS’s comments. 

For the full text of IHS’s comments, see Appendix G.

RECOMMENDATIONS
 

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 APPENDIX~A

Health Disparities 

Table A: Prevalence of Health Conditions and Mortality Rates by Race and Ethnicity

 American Indian/ 

Alaska Native

White, 

Non-Hispanic Hispanic Black, Non-Hispanic

Asian 

and Pacific 

Islander

Two 

or More Races

Health Condition * 

Two or more chronic conditions

Prevalence of Health Condition

18% 10% 6% 11% 5% 9%

Diabetes 12% 5% 6% 8% 5% 3%

Frequently anxious or depressed 23% 16% 13% 14% 8% 21%

 Obesity 39% 28% 31% 38% 12% 20%

Cause of Death ** Mortality Rate Per 100,000

Heart disease 141.8 210.7 157.3 271.3 113.3 ---

Cancer 123.2 187.0 122.8 222.7 110.5 ---

Diabetes 41.5 21.5 33.6 46.9 16.6 ---

Chronic liver disease 22.6 8.7 13.9 7.7 3.6 ---

Unintentional injuries 54.7 41.0 31.3 38.7 17.9 ---

Motor vehicle accidents 24.8 15.5 14.7 14.5 7.6 ---

Suicide 11.7 12.9 5.6 5.2 5.2 ---

*Source: A Profile of American Indians and Alaska Natives and Their Health Coverage, September 2009, Figure 4: Prevalence of Health Conditions by Race/Ethnicity, 

2004-2007. 36 Based on a percentage of the defined population. 

**Source: A Profile of American Indians and Alaska Natives and Their Health Coverage, September 2009, Figure 6: Mortality Rate by Race/Ethnicity, 2005.37 Based on 

age-adjusted death rates per 100,000 population.

36 Cara James, Karyn Schwartz, and Julia Berndt, Race, Ethnicity & Health Care Issue Brief: A Profile of American Indians and Alaska 

Natives and Their Health Coverage, September 2009. Accessed at http://www.kff.org/minorityhealth/upload/7977.pdf on February 12, 2010. 

37 Ibid.
 

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APPENDIX~B

 

 APPENDIX~B

Glossary of Terms

Clinic. A facility, physically separated from a hospital or health center, 

in which primary care physician services are available on a regularly 

scheduled basis but for less than 40 hours a week for outpatient care. 

Clinics are similar to health stations.38

Clinical Social Worker. A health professional trained in client-centered 

advocacy who assists clients with information, referral, and direct help in 

dealing with local, State, or Federal government agencies.39

Crisis Intervention. A brief therapeutic approach that is ameliorative 

rather than curative of acute psychiatric emergencies.40

Electroconvulsive Therapy. A procedure in which electric currents are 

passed through the brain, deliberately triggering a brief seizure. 

Electroconvulsive therapy seems to cause changes in brain chemistry that 

can immediately reverse symptoms of certain mental illnesses.41

Health Center. A facility, physically separated from a hospital, with a full 

range of ambulatory services, including physician, nursing, pharmacy, 

laboratory, and x-ray services. Services are available at least 40 hours 

per week for ambulatory care.42

Health Station. See “Clinic,” above. 

Hypnotherapy. The use of exercises that bring about deep relaxation and 

an altered state of consciousness. Persons in a deeply focused state can 

affect their own psychological responses.43

Marriage and Family Therapist. A person who evaluates and helps resolve 

problems in the context of a marriage or family. Such a therapist 

typically has a master’s or doctoral degree. 44

38 Definition accessed at http://www.anthc.org/ref/hs/codebook/asufac.cfm on 

March 30, 2011.

39 Definition accessed at http://www.mentalhealthchannel.net/csw.shtml on June 13, 2010. 

40 Definition accessed at http://psycnet.apa.org on February 14, 2010.

41 Definition accessed at http://www.mayoclinic.com/health/electroconvulsivetherapy/MY00129 on January 4, 2010. 

42 Definition accessed at http://www.anthc.org/ref/hs/codebook/asufac.cfm on 

March 30, 2011.

43 Definition accessed at http://www.umm.edu/altmed/articles/hypnotherapy-000353.htm on 

January 4, 2010.
 

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APPENDIX~B

Mental Health Counselor. A broad term for a person who provides 

counseling. Most such individuals have at least a master’s degree in 

social work or a related field, have several years of supervised work 

experience, and are licensed or certified. A mental health counselor may 

also be called a licensed professional counselor, licensed mental health 

counselor, or professional counselor.45

Midlevel Practitioner. A nurse midwife, nurse practitioner, or physician 

assistant, licensed by the State in which the individual practices.46

Pharmacotherapy. The treatment of disease, and especially mental 

disorder, with drugs.47

Post-Traumatic Stress Disorder (PTSD). A disorder in which a person 

“experienced, witnessed, or was confronted with an event or events that 

involved actual or threatened death or serious injury, or a threat to the 

physical integrity of self or others” and in which a person’s response 

involved intense fear, helplessness, or horror.”48

Psychiatric Crisis. A psychological or social condition characterized by 

unusual instability caused by excessive stress and either endangering or 

felt to endanger the continuity of an individual or group.49

Psychiatric Hospital. An institution that:50

• is engaged primarily in providing, by or under the supervision of a 

Doctor of Medicine or Osteopathy, psychiatric services for the 

diagnosis and treatment of mentally ill persons;

 

44 Definition accessed at 

http://therapists.psychologytoday.com/rms/content/therapy_professionals.html 

on March 30, 2011.

45 Ibid.

46 Centers for Medicare & Medicaid Services (CMS), Medicare State Operations Manual 

Provider Certification. Accessed at http://www.cms.gov/transmittals/Downloads/R32SOM.pdf 

on April 8, 2010.

47 Definition accessed at http://www.merriam-ebster.com/medlineplus/pharmacotherapy

on March 29, 2011.

48 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders 

DSM-IV-TR, 2000.

49 Definition accessed at http://www.merriam-webster.com/medlineplus/crisis 

on March 29, 2011.

50 CMS, Psychiatric Hospitals. Definition accessed at 

http://www.cms.hhs.gov/CertificationandComplianc/14_PsychHospitals.asp on 

February 14, 2010.
 

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APPENDIX~B

• satisfies the requirements of sections 1861(e)(3) through (e)(9) of the 

Social Security Act (general hospital requirements);

• maintains clinical and other records on all patients as the Secretary 

finds necessary to determine the degree and intensity of the 

treatment provided to individuals entitled to hospital insurance 

benefits under Part A; and

• meets such staffing requirements as the Secretary finds necessary 

for the institution to carry out an active program of treatment for 

individuals receiving services in the institution. 

Psychologist (Clinical Psychologist). A specialist in one or more branches 

of psychology, especially a practitioner of clinical psychology, counseling, 

or guidance. Psychology is a doctoral-level profession.51

School Health Center. A health center that is based at a school site and

serves primarily students.

Telemedicine. The use of medical information that is exchanged from one 

site to another via electronic communications to improve clients’ health. 

Closely associated with telemedicine is the term “telehealth,” which often 

encompasses a broader definition of remote health care that does not 

always involve clinical services. Videoconferencing; transmission of still 

images; e-health, including patient portals; remote monitoring of vital 

signs; continuing medical education; and nursing call centers are all 

considered part of telemedicine and telehealth. Telemedicine is not a 

separate medical specialty.52

51 Definition accessed at http://www.merriam-webster.com/medlineplus/psychologist 

on March 29, 2011.

52 Definition accessed at http://www.americantelemed.org/i4a/pages/index.cfm?pageid=3333

on February 4, 2010.
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 APPENDIX~C

Response Rates

Table C-1: Fieldwork and Survey Response Rate by IHS and Tribal Facility Type 

Total 

Facilities 

Visited

SURVEYS

Type of Facility Response

Rate

Total in Population Nonrespondents Respondents

Total Tribal IHS Total Tribal IHS Total Tribal IHS

Alaska village clinic 3 94% 160 160 0 10 10 0 150 150 0 

Alcohol and substance abuse treatment 

center 18 66% 99 93 6 34 34 0 65 59 6 

 Residential 13 78% 50 44 6 11 11 0 39 33 6 

 Nonresidential 5 53% 49 49 0 23 23 0 26 26 0 

Behavioral health facility 10 79% 42 41 1 9 9 0 33 32 1 

 Residential 1 100% 7 7 0 0 0 0 7 7 0 

 Nonresidential 9 71% 35 34 1 10 9 1 25 25 0 

Health center 36 84% 274 220 54 44 40 4 230 180 50

Health station 2 65% 68 56 12 24 24 0 44 32 12

Hospital 23 93% 44 14 30 3 2 1 41 12 29

 Medical 22 88% 43 14 29 5 4 1 38 10 28

 Psychiatric 1 100% 1 0 1 0 0 0 1 0 1 

Other residential 0 100% 5 5 0 0 0 0 5 5 0 

Remote health locations 0 85% 13 13 0 2 2 0 11 11 0 

School health center 0 79% 28 5 23 6 3 3 22 2 20

Urban health center 0 82% 34 34 0 6 6 0 28 28 0 

Wellness/fitness center 0 20% 5 5 0 4 4 0 1 1 0 

 Total 98 82% 772 646 126 142 134 8 630 512 118

Source: Office of Inspector General (OIG) analysis of survey data, 2010.
 

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APPENDIX~C

Table C-2: Fieldwork and Survey Response Rate by IHS Service Area 

VISITS SURVEYS

IHS Service Area Total Facilities Response 

Rate

Total in Population Nonrespondents Respondents

Total Tribal IHS Total Tribal IHS Total Tribal IHS

Aberdeen, SD 13 51% 45 28 17 21 20 1 24 8 16

Alaska 19 92% 252 252 0 19 19 0 233 233 0 

Albuquerque, NM 6 83% 24 10 14 4 3 1 20 7 13

Bemidji, MN 12 67% 86 81 5 27 27 0 59 54 5 

Billings, MT 7 95% 22 11 11 1 0 1 21 11 10

California 10 93% 71 71 0 4 4 0 67 67 0 

Nashville, TN* 4 67% 35 33 2 11 11 0 24 22 2 

Navajo 3 83% 42 4 38 6 2 4 36 2 34

Oklahoma 8 78% 63 51 12 14 14 0 49 37 12

Phoenix, AZ 13 71% 68 51 17 20 19 1 48 32 16

Portland, OR 7 76% 55 49 6 13 13 0 42 36 6 

Tucson, AZ 8 73% 9 5 4 2 2 0 7 3 4 

 Total 110 82% 772 646 126 142 134 8 630 512 118

Source: OIG analysis of survey data, 2010. 

*Interviewed Area Office by phone. 

 
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 APPENDIX~D

Population Served and Screened by Type of Facility 

Table D: Community Population Served and Number of Clients 

 Screened for Mental Health Services by Type of Facility

Type of Facility

Total Facilities That 

Report Providing 

Mental Health 

Services

Mean Community 

Population Served 

by the Facility* 

Approximate Number 

of Clients Screened for

Mental Health 

Services*

Health center 192 27,000 238,000

Alaska village clinic 112 300 6,000

Alcohol and substance 

abuse treatment center 55 60,000 37,000

 Residential 36 87,000 7,000

 Nonresidential 19 54,000 30,000

Hospital 35 32,000 183,000

Health station 32 5,000 10,000

Behavioral health facility 31 38,000 28,000

 Residential 7 44,000 2,000

 Nonresidential 24 36,000 26,000

Urban health center 28 51,000 34,000

School health center 20 600 1,000

Remote health location 7 3,000 <1,000

Other residential 2 6,000 <1,000

 Total 514 22,000 536,000

*Based on facility-reported information on the population of the community served by the facility. Number of clients 

screened is from approximately January 2008 to November 2009.

Source: Office of Inspector General analysis of survey data, 2010.
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 APPENDIX~E

Crisis Intervention Services

Table E: Staffing Levels at IHS and Tribal Facilities That Provide 24-hour Crisis Intervention Services With Onsite Mental Health

 Care Staff

Type of Facility

Total Facilities That 

Provide 24-Hour 

Onsite Crisis 

Intervention Services 

By Provider Type and Total Median Hours

Psychiatrist Any Medical 

Provider Psychologist

Social Worker, 

Counselor, Aide, 

and/or 

Traditional Healer

Any Mental Health 

Care Staff

Facilities*

Median 

Hours** Facilities* Median Hours** Facilities* Median Hours** Facilities* Median Hours** Facilities* Median Hours**

Alcohol and substance abuse treatment center 12 6 16 9 76 6 40 12 200 12 235

Behavioral health facility 8 7 39 8 78 3 20 7 248 8 321

Health center 16 13 8 16 204 9 16 16 120 16 341

Hospital 14 13 40 13 114 12 40 14 165 14 305

Urban health center 2 1 32 2 84 1 32 2 291 2 387

 Total 52 40 32 48 84 31 32 51 200 52 321

 Percentage of All Facilities That Reported 

 Providing Mental Health Services (n=514) 10% 8% --- 9% --- 6% --- 10% --- 10% ---

*Facilities are counted once if they have at least one or more of each provider type. 

**Median hours include all hours for each provider type per facility type. Facilities may employ more than one of each provider type.

Source: Office of Inspector General analysis of survey data, 2010.
 

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 APPENDIX~F

Mental Health Care Staff Onsite at Facilities

Table F: Median Hours Per Week for Mental Health Care Staff 

 by Provider Type 

Type of Provider

Percentage of 

Facilities*

(n=514)

Median Hours Per Week**

Mental health care providers 85% 40

 Psychologist 29% 34

 Social worker 35% 40

 Counselor/therapist 69% 40

 Mental health care aide 13% 22

 Peer counselor 7% 38

Physician 41% 25

 Psychiatrist 32% 8 

 All other physicians 20% 40

Midlevel practitioners 21% 40

 Physician assistant 9% 32

 Psychiatric nurse practitioner 4% 40

 Nurse practitioner 15% 40

Traditional providers 12% 16

 Medicine man/woman 2% 4 

 Spiritual advisor 5% 25

 Traditional healer 10% 8 

Registered nurse 10% 40

Other 4% 39

 Any level provider 100% 66

*Facilities are counted once if they have at least one or more of each provider type. 

**Median hours include all hours for each provider type per facility type. Facilities may employ more than one of each 

provider type.

Source: Office of Inspector General analysis of survey data, 2010.
 

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 APPENDIX~G

Agency Comments
 

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APPENDIX~G
A P PEN D x G 

Page 3 - Inspector General 

The IHS will continue to expand implementation of tele-behavioral health services, educate IRS 

and Tribal providers regarding the use and effectiveness oftele-behavioral health services, and 

address potential technical barriers to such utilization at IRS and Tribal facilities. The IHS will 

also provide technical assistancet6 Tribes that use tele-behavioral health services to increase 

their ability to bill third party payers for those services. 

3. Develop a plan to create a single database of aU ms and Tribal health care facilities. 

The IRS concurs with this recommendation. The Agency will develop a plan to create a single 

database that identifies all IRS and Tribal health care facilities to better assist Tribes and IRS in 

identifying and expanding services. The illS will work with Tribes, States, and Federal agencies 

to create the single database ofAIlAN health care facilities to include physical locations, contact 

information, and available services. 

Thank you for providing illS the opportunity to comment on the orG's draft report. The illS is 

committed to improving our health delivery system and increasing access to those requiring our 

services. We will continue to work in partnership with our Tribal health system to assist them in 

their ongoing efforts. 

Yvette Roubideaux, M.D., M.P.H. 

OEI·09·08·00580 ACCESS TO MENTAL HEALTH SERVICES AT IHS AND TRIBAL FACILITIES 35 
 

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 ACKNOWLEDGMENTS

This report was prepared under the direction of Timothy S. Brady, 

Regional Inspector General for Evaluation and Inspections in the 

San Francisco regional office, and Michael Henry, Deputy Regional 

Inspector General. 

Steven Zerebecki served as the team leader for this study. Other 

principal Office of Evaluation and Inspections staff from the 

San Francisco regional office who contributed to the report include: 

Loul Alvarez, Veronica Gonzalez, Camille Harper, Cynthia Lemesh, 

Christina Lester, Linda Min, China Tantameng, and Marcia Wong. 

Central office staff who contributed include Ruth Davis, Melinda Golub, 

Amitava “Jay” Mazumdar, and Talisha Searcy. 
Office of Inspector General http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of Department of Health and Human Services (HHS) 

programs, as well as the health and welfare of beneficiaries served by those programs. This 

statutory mission is carried out through a nationwide network of audits, investigations, and 

inspections conducted by the following operating components:

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS.

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties.

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.