Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

MANAGEMENT ISSUES IN THE 

COMMUNITY HEALTH REPRESENTATIVE 

PROGRAM 
OFFICE OF INSPECTOR GENERAL 

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

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

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

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

inspections conducted by three OIG operating components: the Office of Audit Services, the 

Office of Investigations, and the Office of Evaluation and Inspections. The OIG also informs 

the Secretary of HHS of program and management problems and recommends courses to 

correct them. 

OFFICE OF AUDIT SERVICES 

The OIG’s Office of Audit Services (OAS) provides all auditing services for HHS, either by 

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

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

carrying out their respective responsibilities and are intended to provide independent 

assessmentsof HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the Department. 

OFFICE OF INVESTIGATIONS 

The OIG’s Office of Investigations (01) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 

unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions, 

administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 

control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AND INSPECI’IONS 

The OIG’s Office of Evaluation and Inspections (OEI) conducts short-term management and 

program evaluations (called inspections) that focus on issues of concern to the Department, 

the Congress, and the public. The findings and recommendations contained in these inspection 

reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, 

and effectiveness of departmental programs. 

This report was prepared under the direction of William Moran, the Regional Inspector 

General for the Office of Evaluation and Inspections, and Natalie Coen, Deputy Regional 

Inspector General, Office of Evaluation and Inspections, Region V. Participating in this prject 

were the following people: 

Region V Headquarters 

Barbara Butz, Team Leader Alan Levine 

Jennifer Antico, Lead Analyst 

Jean Dufresne 

Jo Lynn Antonik 
EXECUTIVE SUMMARY 

PURPOSE 

This report describes management issues in the Community Health Representative 

(CHR) program. 

BACKGROUND 

The CHR program is based on the concept that indigenous community members, 

trained in the basic skills of health care provision, disease control, and prevention, can 

successfully effect change in community acceptance and utilization of health care 

resources. The CHR program is governed by the Indian Health Care Improvement 

Act of 1988. In Fiscal Year (FY) 1992, the Indian Health Service (IHS), within the 

Public Health Service (PHS), spent $39 million for 1,544 CHRs in 260 programs. The 

program is funded through contracts, grants, or cooperative agreements based on the 

Indian Self-Determination and Education Assistant Act (P.L. 93-638), hereafter 

referred to as 638. 

In 1983, Congress mandated that IHS establish guidelines, goals, and clear evaluation 

standards for the CHR program. The IHS produced guidelines and goals for the 

program which are written in Chapter 16 of the Indian Health Manual. They also 

developed two management tools: the Scope of Work (SOW), for planning purposes, 

and the CHR Information System II (CHRIS II), for reporting. 

Although Chapter 16 states that tribal CHR programs will be evaluated on a triennial 

basis, IHS has neither developed evaluation criteria nor conducted a national 

evaluation of the program. 

We contacted 403 people involved with the program at the national, area, and local 

levels to obtain information about factors which make CHR programs strong. See our 

report entitled “Revitalizing the CHR Program” (OEI-0501070). During the course of 

obtaining that information, we discovered selected management issues that are 

described in this report. 

SCOPE AND METHODOLOGY 

Our intent in this study was to identify factors that make CHR programs strong, 

factors which IHS and tribes could use to manage and evaluate the program. During 

the course of the study, certain management issues arose that we believe are 

important; this report describes those issues. 

Our companion report entitled “Revitalizing the CHR Program” (OEI-05-91-01070) 

describes the factors that the 403 respondents for this study said make individual CHR 

i 
programs effective, and why they make programs effective. It also describes how the 

factors might be used to judge the effectiveness of a CHR program. 

FINDINGS 

MOST RESPONDENTS ARE NOT F~ILJXR WllX THE GOAL AND 

ORIEC7lVl.3 OF THE CHR PROGRAM. 

Except for area CHR coordinators, respondents who knew the CHR program were 

not familiar with its national goal or objectives. 

THERE IS WZDESPREAD DISAGREEMENTABOUT 7HE APPROPRhiljE ROLE 

FOR CHRs. 

Although respondents agree that CHRs should be a part of the health care system, 

there are widely varying opinions about how this integration should occur. 

Respondents say that if there is not consensus on a role for CHRs, the program will 

be less effective. 

TRAN-SPORT IS A MYJOR UNRESOLmD ISSUE IN THE CHR PROGRAM. 

Compared to other services CHRs could provide, transpqrt is a disproportionately 

large CHR activity. Respondents disagree on whether CHRs should be transporting 

clients. Many see it as a needed service as well as what tribes want CHRs to do. 

THE SOWAND CHHS II HAYE LIMITED USEFULNESS. 

We question the usefulness of the SOW as a planning tool, and the CHRIS II as both 

a management tool and reporting system. Analysis of CHRIS II data raises questions 

about its accuracy and reliability. Respondents also voiced mixed opinions on the 

usefulness of the SOW and CHRIS II. 

REEOMMENDATIONS 

THE PHS, TOGElXER WITH TRIBES, SHOULD RE-EX4MINE lXE CHR 

PROGRAM TO DETERMINE ITS FUTURE DIRECTION. 

The PHS, and tribes, should consider the following options in determining the future 

direction of the CHR program: retain it in its current form, revise it to become a 

transportation program, or abolish it if it is no longer needed. 

II; A CONSENSUS IS REACHED TO REVISE OR ABOLISH THE PROGM, PHS 

SHOULD DEVELOP XUE APPROPRIATE LEGISLATM? PROPOSALS TO DO SO. 

11 
IF ITREUAINS AS A BROAD-BASED HEALTH CARE PROGRAM, PHS SHOULD 

DEWLOPA MULTT-FACETED NAZ!ONA STRATEGY TO REWlXLJZE THE 

CHR PROGRAM 

This strategy should include: (1) a clarification of the national goal and objectives, (2) 

a revised national policy on transport, (3) development of performance indicators, (4) 

improvement of the SOW and CHRIS II, (5) development of technical assistance and 

training plans, and (6) periodic program evaluation. 

COMMENTS 

The Assistant Secretary for Planning and Evaluation and PHS commented on the 

report. Both concurred with the findings and recommendation, and PHS described 

steps that IHS has initiated to revitalize the CHR program. We made some editorial 

changes in the report based on technical comments from ASPE. The full text of the 

comments is in Appendix D. 

... 111 
TABLEOFCONTENTS 

EXECUTIVESUMMARY 

INTRODUmON ................................................. 

FINDINGS ...................................................... 

Goal amd Objectives ............................................... 

Role of CHRs .................................................... 

Transport ........................................................ 

Management Tools ................................................. 

RECOMMENDATIONS’ ........................................... 

Re-examine CHR Program .......................................... 

PAGE 

1 

5 

5 

5 

6 

9 

13 

13 

To Revise or Abolish Program, Develop Legislative Proposals ................ 13 

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

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

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

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

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

D: Agency Comments ............................................ D-l 
INTRODUCTION 

PURPOSE 

We conducted this study to identify factors which make Community Health 

Representative (CHR) programs strong, factors which could be used in the future to 

plan, monitor, and evaluate these programs. This report describes management issues 

that arose in the course of the study. 

BACKGROUND 

Program Hirtory 

In 1968, under the 1921 Snyder Act (25 U.S.C. 13), Congress established the CHR 

program within IHS. The program was intended to provide outreach health care services 

for American Indian and Alaska Native tribal governments and organizations. It is based 

on the concept that indigenous community members, trained in the basic skills of health 

care provision, disease control, and prevention, can successfully effect change in 

community acceptance and utilization of health care resources. A CHR is “a tribal or 

Native community-based, well-trained, medically-guided, health care provider, who may 

include traditional Native concepts in his/her work.“’ 

The program is currently governed by the Indian Health Care Improvement Act 

Amendments of 1988. In Fiscal Year (FY) 1992, the Indian Health Service (IHS), within 

the Public Health Service (PHS), spent $39 million for 1,544 CHRs in 260 programs 

throughout the continental United States and Alaska. Currently, IHS spends about $1 

million of this amount on training for CHRs, including funding a national training officer 

and a number of training facilities. 

The CHR program is funded through contracts, grants or cooperative agreement 

arrangements with Native or tribal governments and organizations based on the Indian 

Self-Determination and Education Assistance Act (P.L. 93-638), hereafter referred to as 

638. The IHS is increasingly using 638 contracts as a mechanism to provide health 

services to Indian people. Under them, tribes are delegated responsibility for 

administering programs, and have great latitude in designing and operating them. The 

IHS sets basic parameters and guidelines, and is responsible for management and 

oversight of the national CHR program; however in terms of the day-to-day operation of 

individual programs, IHS assumes more of a consultation and technical assistance role. 

The program grew quickly from 1968 to 1980. At that time, however, Congress grew 

concerned that the budget for the program could not be adequately justified. Program 

activities had not been clearly documented and monitored by IHS, and programs varied 

widely across tribes. Congress grew concerned about a lack of program goals and 

objectives and an adequate reporting system, and reports that the CHR program was 

1 
little more than a “jobs” or employment program for reservations. In FY 1981 and 1982, 

Congress began to reduce the number of CHR positions, and in FY 1983 the program 

came close to being eliminated. Although the program ultimately survived, Congress cut 

513 slots from a peak of 2,293. This decline continued until FY 1990, when Congress 

slowly began to increase slots to the 1,544 of today. 

Program Admihirtration 

In 1983, Congress mandated that IHS establish guidelines, goals, and clear evaluation 

standards for the CHR program. In response, IHS established the position of a national 

CHR program director and developed program goals, objectives and guidelines which are 

written in Chapter 16 of the Indian Health Manual. 

Individual CHR contracts are administered by the 12 IHS area offices. The national 

CHR program director, in the Office of Health Programs under the Special Initiatives 

Branch, has no direct line authority over these area offices or staff. In more of a 

consultation or technical assistance role, that office develops and implements 

management standards and tools, plans training, and conducts program reviews. 

In each area office, a CHR coordinator is the primary contact with the national program 

director and the one area staff person with direct responsibility for CHR programs. 

Project officers also have certain program and fiscal responsibilities in connection with 

monitoring contracts, including CHR contracts, and facilitating the interaction between 

tribal CHR programs and the service unit or area health care programs. Most CHR 

coordinators and project officers juggle CHR duties with other responsibilities. 

The IHS uses two important management tools in the CHR program. The Scope of 

Work (SOW) is a form tribes may use to plan their CHR programs. The CHR 

Information System II, or CHRIS II, is a reporting system based on the SOW. Although 

not required to use either the SOW and CHRIS II, at present most of the tribes are 

doing so. 

Chapter 16 states, “Tribal programs will be evaluated on a triennial basis, through the use 

of a nationally developed instrument, with tribal consultation and concurrence.“’ To 

date, however, IHS has neither developed national evaluation criteria or tools, nor 

conducted a national evaluation of the program. 

SCOPE AND METHODOLOGY 

Our intent in this study was to identify factors that make CHR programs strong, factors 

that IHS - and tribes - could use in the future as a basis to manage and evaluate the 

program. During the course of the study, certain management issues arose that we 

believe are important. This report describes these issues. Our companion report entitled 

“Revitalizing the CHR Program” (OEI-05-91-01070) describes the factors that 

respondents said make CHR programs strong. 

2 
As background for the study, we conducted a review of literature: legislation and 

regulations on the CHR program, the Indian Self Determination Act, and the Indian 

Health Care Improvement Act; Chapter 16 of the IHS manual; annual reports, CHRIS II 

reports and other documents related to the CHR program; and reports on Indian health. 

We also spoke with persons in the Office of Management and Budget, and the Office of 

the Assistant Secretary for Planning and Evaluation in the Department of Health and 

Human Services (HHS). 

Data collection took place in three phases. As this chart shows, we contacted over 400 

respondents for the study. 

Respondents 1 Phase 1 Phase 2 Phase 3 Total 

National 16 23 29 

Area II22 I 30 I 10 I 62 II 

Local II16 I 58 I 25 I 99 II 

CHRs ] 32 161 20 213 

Total1 76 272 55 403 

Phase One: In November and December 1991, we visited 2 of the 12 IHS area offices 

and 5 CHR programs, chosen in collaboration with IHS area coordinators to represent a 

variety of types of programs. We talked with over 75 respondents: people involved in 

creating the program; IHS staff in area offices; and people in CHR programs and service 

units. We also held focus groups with area CHR coordinators and CHRs and talked to 

the national training officer and persons from the National Association of CHRs. 

We asked respondents, “What makes a CHR program strong (effective)?” We found 

that their responses could be grouped into four broad categories, or: 

Factors that Influence the Effectiveness 

of CHR Programs 

Factor 1 Agreement on the role of the CHR 

Factor 2 Integration into the health care system 

I/Factor 3 Trib-d support and direction 

Factor 4 MS support and direction 

3 
Phase Two: In February, March, and April 1992, we contacted an additional 272 

respondents to learn their perceptions about these four factors: how important are they, 

and why?; if a factor is not present in a CHR program, is the program weakened?; and, 

what can IHS do to strengthen or promote these factors? 

l At the national level, we talked to Congressional staff, people in the Office of the 

Assistant Secretary for Health in the Public Health Service, and IHS Headquarters 

staff. 

l At the area level, we chose five IHS area offices (Oklahoma City, Oklahoma; 

Aberdeen, South Dakota; Window Rock, Arizona, Navajo Nation; Portland, 

Oregon; and Nashville, Tennessee) which are diverse in terms of geography, 

program sizes and types, and together represent half of the 1,544 CHRs 

nationwide. We talked to area directors, CHR coordinators, and other health care 

professionals in these offices. 

l For respondents at the local, or program, level, we chose three CHR programs in 

each of these five areas (15 total). They were programs that had more than two 

CHRs, represented a geographic and programmatic mix, and agreed to participate 

in the study. We spoke by telephone with the tribal health directors, CHR 

supervisors, service unit directors, and health care professionals at these programs. 

We also contacted 161 CHRs. One of the 15 tribal officials we contacted 

responded to our inquiries. 

0 We visited a third IHS area office and three other CHR programs in connection 

with a review conducted by the national CHR program director. We also talked 

to tribal health directors at a conference. 

Phase Three: In April 1992, using a case study approach, we visited two CHR programs 

in two IHS areas, to apply these factors in a “real life” situation. We chose the programs 

in collaboration with the national program director, the CHR coordinator in each area, 

and the tribes themselves. We contacted 55 respondents in this phase. 

This study was conducted in accordance with the hterim Standards for Inspections issued 

by the President’s Council on Integrity and Efficiency. 

4 
FINDINGS 

MOST RESPONDFH’IS ARE NOT FAMILIAR WITH THE GOAL AND 

OBJECiTIVES OF THE CJ3.RPROGRAM. 

In 1983, IHS developed a goal, objectives and guidelines for the CHR program which are 

written in Chapter 16 of the Indian Health Manual.3 

cHRProgramGoal 

“The CHR Program was implemented to improve the health knowledge, attitudes and practices of 

Indian people by promoting, supportin& and asskxiug the IHS in deIivering~ a total health care 

program. The efforts of CHR program staff have produced an American Indian and Al&a Native 

health service delivey system, which provides for follow-up and continued contact with the health 

care delivery system at the community level, thereby meeting the most basic needs of the American 

Indian and Alaska Native population-’ 

The goal of the CHR Program is to addresshcaIth care needs through the provfsiofi of communityoriented primary care services, including traditional Native concepts in multiple~settings, utilizing 

community-based, well-trained, medically-guided hcaIt.h care worker!&’ 

The 14 program objectives are mainly a listing of possible services such as home health 

care, transport, language interpreter and health education. Other objectives include 

activities such as development of an annual program plan, assurance of the availability of 

appropriate IHS medical guidance to the CHR program, and compliance with the CHR 

data collection plan. 

Two-thirds of the local respondents in our study, and 40 percent of those from IHS area 

offices, said they are not familiar with the goal and objectives of the CHR program. This 

includes 2 of the 5 area directors, 9 of the 11 tribal health directors, 4 of the 8 service 

unit directors, and 8 of the 12 public health nurses. In contrast, area CHR coordinators 

not only,know the goal and objectives but emphasize that they help direct and assist 

CHR programs: “Chapter 16 has been very handy. It is a guidepost or a guideline 

overall, something for us to work with.” 

THERE IS WIDESPREAD DISAGREEMENT ABOUT THE APPROPRIATE ROLE 

FOR CHRs. 

In reviewing contracts, observing CHR programs, and talking to respondents, we found 

that there are many different, and sometimes conflicting, opinions about what CHRs 

should do. We found that a CHR can be an animal control officer, dental assistant, 

janitor, billing clerk, data entry clerk, or appointment clerk in a clinic. Some people said 

that tribal officials want CHRs primarily to transport or do “domestic” work: cutting 

5 

/I 
wood, making meals, or taking out garbage. At one program, we both observed and 

were told that medical staff sometimes expect CHRs to act as “go-fers.” 

Respondents say that CHRs should play a role in their tribe’s health care system, but there iv 

no clear or con&tent view of that role. 

We asked national, area, and local respondents to explain how they define an “effective” 

program. Whether they mentioned CHRs providing outreach and advocacy, accessto 

care, or delivering health services, respondents clearly believe that a CHR program 

should be part of the tribe’s health care system. However, few offered specifics about 

exactly what activities CHRs should undertake. Comments were vague and varied: 

CHRs should be “health care workers,” they should work closely with a health care 

professional (especially public health nurses), or, a “team approach” is important. 

The CHR responses to questions reveal that they feel strongly that the program must be 

linked with the health care system. However, they also disagree on the specifics of how 

this should occur. For example, almost 60 percent ranked “working as a team with 

medical staff‘ as the most important factor to make a CHR program strong. A strong 

majority think that there should .be referrals between CHRs and medical staff (88 

percent), CHRs should be included in meetings with medical staff (65 percent), and 

medical staff should regard CHRs as competent (87 percent). Yet, CHRs disagree on 

whether they should be “the eyes and ears of the community” or assistants to health care 

professionals, and on whether they should work closely with or independently from health 

care professionals. 

Respondents say that if people do not agree on the role, CHRs may be less flective. 

According to respondents, confusion or disagreement about what CHRs are supposed to 

be doing can limit their effectiveness. Some said that CHRs, often “perceived as the 

answer to everyone’s problems,” are pulled in different directions and asked to do 

inappropriate things until they “burn out.” Others said that CHRs can become unfocused 

and confused about what they should do, which can lower morale. The CHR services 

may become fragmented and chaotic, lacking cohesiveness or continuity with other health 

care services. Finally, some people said specifically that without a clearly defined role for 

CHRs, a program could become focused solely on transport. 

TRANSPORT IS A MAJOR UNRESOLVED ISSUEi IN THE CHR PROGRAM. 

We did not set out in this study to specifically address the issue of transport as a CHR 

role. However we quickly found that the subject arose repeatedly as we talked to 

respondents and visited programs. 

Historically, transport has been a major activity for CHRs, and transport, including the 

delivery of medications, remains an allowable CHR service today. Chapter 16 sets forth 

certain boundaries governing it. Transport shall be “within the local community to/from 

an IHS or tribal hospital or clinic for routine, non-emergency problems, to a patient 

6 
without other means of transportation, when necessary.“4 Transport “includes waiting 

for a patient...to finish treatment.“’ Chapter 16 also states that programs must have a 

tribally developed transportation policy, although there is no further explanation of 

exactly what this means. 

Dansport is a disproportionately large CHR activity. 

An analysis of the FY 1991 CHRIS II report (see Appendix A) reveals that as a 

proportion of their total time (service hours plus travel hours), CHRs recorded almost a 

quarter of their time in “transport/deliver.” As the chart below shows, this is more than 

twice the proportion of time recorded for each of the four next highest services. 

CHRs,erK¶mllc+lmorenmeul t transport(dehver than on top 4 other senkes 

24 22.7 

!a 

20 

18 

16 

14 

12 

10 

8 

6 

4 

At 8 of the 10 programs we visited, we observed that transport was a major, if not the 

primary, CHR activity. When we asked people - CHRs, their supervisors, and many 

others - to describe what CHRs did, they talked about transport. The transport they 

described included delivering medications and commodities, and taking patients to clinics, 

dialysis facilities, hospitals far away for delivery of babies, or funerals. 

Even at a program where there is a written transportation policy, it didn’t appear to be 

enforced, since most of the CHRs were heavily involved in transport. At another 

program, where transport is clearly discouraged as a CHR activity, the CHRs said that 

they still feel pressured on occasion to provide it. 

Opinions of the CHRs at these programs about transport differed. Some seemed 

satisfied with a transport role. Others “feel torn because we aren’t sure whether or not 

we should be transporting people.” Still others seemed ambivalent, recognizing a need 

for transport but wanting to do more. Some mentioned that because they were so 

involved in transporting, they could not use many of the skills they learned in training -

which they regretted. 

7 
Analysis of the CHRIS II reports at one of the case study sites showed 70 percent of 

CHR time as transport; other reports and CHR logs confirmed this. (In fact, the logs 

themselves are called “transportation verification forms.“) At the other case study site, 

CHR logs showed that in 9 workdays, 2 CHRs transported almost 40 people and 

delivered medications to 26; the only other activity noted in the logs was 5 home visits. 

Also, the CHR supervisor’s narrative report to the tribe talked only of transport. 

Respondents disagree on whether transport ir a desirable or legitimate CHR activity. Many 

believe that it should be better dejined or limited 

These quotes from respondents illustrate the range of opinions about transport in the 

CHR program: 

“Transportation is a basic need and CHRs should be providing it.” 

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

this.” 

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

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

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

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

The CHRs we surveyed seem to view transport as an integral duty. They made specific 

comments to us about the need for more government cars, higher mileage 

reimbursement, and money for auto insurance, comments which in and of themselves 

would seem to indicate that transport is a significant activity for them. Yet they also 

seem to want limits; three-quarters strongly favor a tribal, written, transportation policy 

that “clearly describes what kind of transportation CHRs are and are not allowed to 

provide.” 

Respondents other than CHRs said that problems can arise if the role of transport in a 

program is not clearly defined, or limited. This comment sums up what can happen: 

“People have expectations for a ride from CHRs, so CHRs comply and therefore 

activities in other areas are diminished and everybody is confused about the goals of the 

program.” 

There are many reasons why transport is a major CHR activity. 

The main reason that transport may be the primary activity at many CHR programs is 

because this is what tribes expect and want CHRs to do. During a focus group, we asked 

respondents what they thought tribes wanted CHRs to do. The first answer was 

“transport.“ Elsewhere we heard: “Tribal people don’t know the role of the CHR. They 

think of it as transport.” Some CHRs told us that if they refuse to transport people, 

there may be complaints to tribal officials, placing them in an awkward position since 

they depend on those officials for their jobs. 

8 
There are several other reasons, which we both heard about and saw for ourselves, why 

transport may still be a major CHR activity: 

l At many reservations that cover huge areas or are remote from health care 

facilities, the need for transport is great. 

l Many families no longer accept responsibility for taking relatives to the doctor as 

they did in the past. 

l On some reservations, there is an increased need for transport to dialysis facilities, 

which are often hours away. 

0 Health professionals sometimes take advantage of CHRs as “go-fers” to bring 

patients to clinic or deliver medications. 

0 Tribes have not sought or used other resources (contract health care, for example) 

to provide transportation. 

THE SOW AND CHRIS II HAVE LIMITED USE-. 

In recent years, IHS has developed two important management tools for the CHR 

program. The SOW is a document tribes can use to plan their CHR programs. The 

CHRIS II is a reporting system based on the SOW. Although many tribes are apparently 

now submitting the SOW and CHRIS II, they are not required to use them; they may 

submit narrative reports instead. 

The SOW provides a framework for tribes to plan their CHR programs. Appendix B 

contains a copy of the SOW form. It is comprised of a combination of service categories 

(e.g. health education, case management) and health areas (e.g. diabetes, cancer), which 

together provide a matrix of 240 different categories into which projected CHR activities 

can be placed. 

The CHRs report their activities in CHRIS II using the SOW matrix of health areas and 

services, as well as client age and gender, time spent on each service, place of service, 

and number of clients served per service. They report activities for 1 week (consecutive 

days) each month. 

According to the IHS 1990 annual report on the CHR program, “CHRIS II is currently 

providing valuable data to (1) assist tribal programs and area offices evaluate CHR 

performance and (2) provide the national CHR program office the pertinent data to 

prepare reports to Congress and others, as well as to justify the annual budget 

appropriation.“‘j 

The most important concept behind CHRIS II is that the activities reported for a CHR 

program, and the amount of time spent in them, should generally match those projected 

in the SOW. 

9 
As nunagement took, the SOW and CHRIS II appear to have minimal bnpact on how 

tribes run their CHR programs. 

For a number of years, the national program director and area CHR coordinators have 

encouraged tribes to use the SOW and CHRIS II to manage their CHR programs, and a 

national Mangement Applications Guide is now being developed to move tribes in this 

direction. Tribal CHR program managers should be comparing CHRIS II reports with 

the SOW and redirecting CHR activities when necessary to make sure that CHRs are 

doing what the tribe projected. However, these respondents say that many tribes are not 

yet using the SOW and CHRIS II in this way. 

A copy of two CHRIS II summary reports for 1991 is in Appendix A. After analyzing 

these reports, we also believe that tribes are not using the SOW and CHRIS II to 

manage programs. Furthermore, we think the data also show that tribes are not 

directing their CHRs to provide health care services directed at specific health problems. 

For example: 

0 In 1991,-CHRs recorded almost 40 percent of their service time in training and a 

variety of administrative services, and 17 percent in “trans/del.” They recorded 

only 43 percent in specific health care services (e.g. case management, health 

education, and monitoring) to consumers. 

0 Also in 1991, CHRs recorded over half of their service hours in the health areas 

of “not applicable, ” “other general medical,” and “unknown.” Also, the percent of 

service time recorded in “not applicable” rose from 12 percent in 1990 to 31 

percent in 1991. 

Overall, CHRs recorded only 10 percent of their senice hours. combined, in the 

health areas of substance abuse, diabetes, and cancer. Respondents commonly 

told us these were the most serious health problems in their communities, and 

they are well documented in the literature as significant Indian health problems. 

We are also concerned that, as management tools, the SOW and CHRIS II are too 

heavily focused on activities. They do not reflect the quality, effectiveness, and impact of 

CHR services. 

Anarysis of CHRIS II data also raises questions related to accuracy and reliability. 

The development of the SOW and CHRIS II has been a process of continuous attempts 

at improvement by IHS. The forms have been refined and simplified over time, and 

training on their use has been conducted for many program directors, supervisors and 

CHRs. However, IHS is aware that problems remain. In the year-end FY 1990 report 

on the CHR program, IHS recommended that training of CHRs on using CHRIS II be 

improved, and the language for the “other general medical” and “not applicable” 

categories be refined to reduce the amount of time reported in them and to increase 

10 

l 
reporting in other, more specific, areas. In addition, IHS will spend over $135,000 this 

fiscal year on quality control for national CHRIS II data. 

The two summary reports in Appendix A contain breakdowns of service time, number 

served, and number of activities by health area and service. Some of the numbers, in 

particular, raise questions about the accuracy and reliability of the data. 

0 The number of persons served in 1991 was 4,258,66X 

0 The CHRs spent 17 percent of their service time on the service “trans/del” 

(transporting people and delivering medications). 

l The CHRs spent over half (56 percent) of their service time in the non-specific 

health areas “other general medical,” “not applicable,” and “unknown.” 

0 The CHRs spent 33 percent of their service time on administrative services 

(“admin rep/ret,” “pt clerical,” “meetings,” “other admin”). 

First, the data do not give us an.unduplicated count of how many people the CHR 

program served in 1991. The 4.2 million figure is not only inaccurate but misleading; it is 

clearly not an unduplicated count, since the entire American Indian/Alaska Native 

population in the United States is only 1.5 million. Furthermore, IHS uses this figure to 

calculate the average cost per person served, by dividing the amount funded for the 

program by the total number served. This means that this cost figure is also misleading 

because it counts a “person” more than once. 

Next, the proportion of time reported for “trans/del,” at 17 percent, strikes us as low, 

since transport appears to be such a major CHR activity. Or, is the definition of the 

category in CHRIS II inaccurate in terms of the kinds of transportation that CHRs 

actually provide? 

Next we ask whether the large proportion of service time reported in non-specific health 

areas, particularly “not-applicable” at 31 percent, accurately depicts what CHRs are 

doing. Are the other, specific, categories, such as case management and monitoring, not 

meaningful in terms of what CHRs actually do, and if so, why are they there? Or is it 

that CHRs are not filling out their reports accurately because the categories are 

confusing or unclear, or because the reporting process is too complicated? 

As for the data reported in the services categories, our first observation is that many of 

the categories are not services but activities - for example, training, record-keeping and 

reporting, and meetings. This gives a misleading picture, then, of the time CHRs spend 

providing services to consumers. Secondly, the large amount of time reported in these 

categories raises the same questions about accuracy that we explained relative to the 

health areas. 

11 
Finally, we are curious about the relatively large proportion of time devoted to 

reports/recordkeeping - at 12 percent, the second highest, after transport/deliver. We 

wonder whether this could be an unintended result of how the CHRIS II reporting 

system works; that is, CHRs could be reporting the time they spend filling out CHRIS II 

reports, which is time they do not spend during the other 3 weeks of the month. If so, 

this figure is also an unreliable reflection of how CHRs are spending their time. 

MANY AREA AND LOCAL RESPONDENTS ARE SOMEWHAT FAMILIAR WITH 

THE SOW AND CHRIS II. OPINION IS MIXED ON THEIR USEFULNESS. 

Two-thirds of the area and local respondents are familiar to some extent with the SOW 

or CHRIS II. People generally see the SOW as useful for providing guidelines or 

direction for CHR programs. However, they have some criticisms of CHRIS II: (1) 

reports are far too detailed and burdensome to complete; (2) the data in CHRIS II are 

misleading, inaccurate or inflated; (3) CHRIS II provides only a general or partially 

accurate picture of what CHRs are doing; and, most of all, (4) CHRIS II does not reflect 

the quality, effectiveness, or outcome of services. 

Some people commented also that both the SOW and CHRIS II are “only as good as the 

people filling them out,” or that they will only really be effective if tribes actively use 

them to manage their CHR programs. 

Area CHR coordinators, who work most closely with tribes, find both tools useful but 

also identify problems. They appreciate the SOW as a tool for defining clear and specific 

expectations for CHR programs but see a number of problems: some programs refuse to 

use the SOW, people who fill it out do not understand it; some programs have projected 

such small percentages over so many categories that “it is impossible for them to really 

be workable;” and CHRs feel that the SOW has been imposed on them without their 

input and therefore does not really define what they are doing. One person said also 

that it is very important to give clear instructions on the SOW to tribes, and good 

examples to follow. 

As for CHRIS II, area CHR coordinators see it as a necessary accountability mechanism 

but also have concerns: it “does not tell the story” since it contains data for only 1 week 

per month; there is no mechanism to ensure that the forms are filled out accurately; and, 

many tribal people do not value the information, so do not use it to manage their 

programs. 

12 
RECOMMENDATIONS 

When discussing what makes CHR programs strong, many respondents for this study also 

raised deeper questions about the purpose and the management of the program. Their 

comments, combined with our own observations at 10 programs, revealed some 

fundamental problems at the heart of this program - a poor understanding of goals and 

objectives, confusion and disagreement about the appropriate role of CHRs, especially 

transport, and questions about the usefulness of certain management tools. Unless PHS 

takes steps to address these concerns, we would have difficulty supporting the 

continuation of the CHR program in its current form. 

THE PHS, TOGETHER WITH TRIBES, SHOULD THOROUGHLY RE-EXAMINE 

THE CHR PROGRAM TO DETERMINE ITS FUTURE DIRECTION. 

Such an examination should take into account legislative intent, health care needs, and 

current program practices and results. It should consider the following options: 

l Retain the program as a broad-based health care program, if they conclude that 

this is the greatest need; 

0 revise the program to become primarily a transport program, if they conclude that 

transport is the greatest need; 

0 abolish the orogram, if they conclude that it is no longer needed to meet Indian 

health care needs. 

IF A CONSENSUS IS REACHED TO REVISE OR ABOLISH THE PROGRAM, PHS 

SHOULD DEVELOP THE APPROPRIATE LEGISLATIVE PROPOSALS TO DO 

so. 

IF IT REMAINS AS A BROAD-BASED HEALTH CARE PROGRAM, PHS 

SHOULD DEVELOP A MULTI-FACETED NATIONAL STRATEGY TO 

REVITALIZE THE CHR PROGRAM. 

If PHS, together with tribes, decides that the CHR program should continue, and should 

provide a wide variety of health care services, PHS should develop a broad national 

strategy to address the problems described in this report. The following elements should 

be included in such a strategy. 

ClarjtL the national goal and objectives of the CHR program 

The CHR program should be sharply focused and strategically geared to results. A 

clearly defined framework, including goals and objectives, is needed for PHS and tribes 

to effectively focus resources and management efforts on the program. We suggest that 

PHS and tribes develop a consensus on the goal and objectives of the CHR program. 

13 
They should consider: how CHR programs can be linked to other Indian health care 

programs; what are and are not appropriate CHR activities; whether the program should 

focus as a priority on specific health care problems or populations; and what outcomes or 

measures of effectiveness should be established. 

Then PHS should publish the goal and objectives in Chapter 16 and disseminate them 

widely to tribes. The goal and objectives should serve as a basis for providing technical 

assistance and developing and refining management tools for the program. 

If transport remains an allowable CHR activity, develop a clear national policy which 

govenls it. 

As described in this report, most respondents for this study have only a general notion of 

what the CHR program should be and what are appropriate CHR activities. Nationally, 

transport appears to be a major CHR role. We question whether PHS should be 

funding a program which is heavily transport, whether it is appropriate for CHRs to be 

providing transport, and whether over $1 million annually should be spent on training 

CHRs who are mainly transporters. Furthermore, given morbidity and mortality statistics 

on Indian health, it seems clear that much more than transport is needed. 

At the same time, we recognize that transport may be a legitimate need for some tribes, 

and that PHS and tribes may therefore decide that, to some degree, transport should be 

an allowable CHR activity. In this case, we recommend that the role of transport in the 

CHR program be carefully and clearly defined, and that a national policy be developed 

in accordance with it; the policy should then be issued by the Director of IHS. 

We also suggest that PHS and tribes explore other sources of funding for transportation, 

including contract health care, Medicaid, or others, so that CHRs can devote their time 

to activities more directly related to health care. 

Develop performance indicators 

The Chief Financial Officers Act requires the development of performance indicators, 

and in response, IHS is now developing performance indicators for some programs. In 

addition, as part of the reauthorization of the Indian Health Care Improvement Act, 

Congress recently established voluntary targets for decreasing death and disease rates for 

Native Americans, in light of concerns for increased accountability and effectiveness in 

Indian health care programs. We recommend that performance indicators be developed 

for the CHR program which are consistent with a revised program goal, and that the 

indicators be published in Chapter 16. 

Improve the SOW and CHRIS II. 

Issues of accountability and oversight relative to IHS programs are particularly timely as 

the regulations for P.L. 93-638 are being finalized and the relationship of the Federal 

Government and tribes is being re-examined in this light. The Inspector General has 

14 
gone on record in support of the inclusion of data collection requirements in these 

regulations. 

We have described a number of shortcomings causing us to question the usefulness of 

the SOW and CHRIS II as management tools for this program. We recommend that 

they be improved: based on a revised program goal, simplified, made to capture what 

CHRs actually do, and include measures of effectiveness besides strictly number of 

activities - beginning with an unduplicated count of people served. This is especially 

important because we understand that IHS may replicate CHRIS II, or a similar 

reporting system, in other programs. If so, every effort should be made to develop as 

accurate and useful a reporting system as possible. 

In order to assure effective oversight and technical assistance for this program, we also 

believe that tribes should be required to submit the SOW and CHRIS II reports. These 

are still optional, and some tribes continue to submit narratives instead. 

Develop technical assirtance and training plans. 

Under P.L. 93-638, the role of IHS is shifting away from direct service provider towards 

consultation and technical assistance to tribes. It is becoming increasingly important for 

IHS to work cooperatively with tribes to share knowledge and expertise so that they can 

run their 638 programs effectively. We recommend the development of a more strategic 

plan for providing technical assistance and training for the CHR program, based on a 

more clearly defined goal and objectives. In terms of training, specifically, we believe 

that training should be closely related to what CHRs are actually doing, and that it 

should be focused most heavily on CHRs whose primary role is providing health care 

services of some sort rather than transport. 

Develop an evaluation tool and conduct periodic evaluations. 

As noted in the Background, IHS has not yet developed the evaluation criteria for this 

program mandated by Congress in 1983. The national CHR program has never been 

evaluated, nor are formal evaluations conducted of individual programs. We recommend 

that such evaluation criteria and tools be developed and applied in periodic evaluations 

of both the national program and individual programs. 

We suggest that PHS use the information in our report entitled “Revitalizing the CHR 

Program ” in connection with this recommendation. It describes a number of factors 

which respondents said should be present in strong CHR programs. Together, we 

believe these factors provide a solid framework for developing a strategy to plan, 

manage, and evaluate CHR programs. 

15 
COMMENTS 

The Assistant Secretary for Planning and Evaluation (ASPE) and PHS commented on 

the report. The full text of their comments is in Appendix D. 

The ASPE agreed with us that more attention should be paid to the CHR program and 

believes that our report provides IHS with an approach to re-examine it. Based on 

technical comments they made on the text, we made some editorial changes in the 

report. 

The PHS concurred with our findings and recommendation to revitalize the program and 

described steps that IHS has initiated to address the problems described in the report. 

In addition to developing an action plan, they noted that the IHS strategy to revitalize 

the program will take into account the factors described in our companion report 

“Revitalizing the Community Health Representative Program,” factors found to influence 

the effectiveness of CHR programs. 

We thank ASPE and PHS for their comments. 

16 
1 

2 

3 

4 

5 

6 

7 

APPENDIX A 

CHR REPORT NO. 1 

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

ALL AREAS 

257 Progrva codes 

AREAS: ALL 

For the 52 mkr of the fiscal yew ending 9/91 

Made JAN 011, 1992) 

MEALTN AREA SERVICE HOURS TRAVEL HCURS 111)(8ER SERVED NUUBER OF ACTIV 

. . . . . . . . . . . . . ..-..........-............-...-................................................ 

TOTAL l,B37,C90 100% 401,921 100% 1,258,665 100% 1,9s7,37c 100% 

DIABETES l&B,927 B% ss,59B 14% 3n,704 px 237,616 12X 

CANCER 16,595 1% 6,367 2% 26,124 1% i9,ait ix 

NYPERTENSIW 61,290 3% 20,579 5% 259,16B 6% 134,293 n; 

AIDS 6,648 0% 1,136 ox CO,866 1% C‘TJ2 OX 

CQWIlrIUBLE DIS 26,813 1% aa3 2% 143,551 3% 77,208 LX 

SUBSTANCE ABUSE 21,690 1% 5,121 1% 51,lOB 1% 24,636 1% 

-1lY INJ CTRL 11,312 1% 3,94n 1% 67,132 2x 15,35L 1% 

B PRWlIQ(, PREVEN 136,312 n 27,108 n 654,665 15% lCQ,S70 7X 

91 OTNEB ELI NED 323.m tax 9a,96a tsx 886,116 21X Cl6,3L8 21% 

92 DENTAL 39,705 2x ii.as3 3x 166,022 4x u,a94 2% 

93 GERWTOLOCI CAL 127.197 = 39,534 10% 341,550 B% lPl,cM 10X 

94 NCN 130,919 7x 3aJa9 la% ‘399,876 9X 207,712 11% 

% MENTAL 18,670 1% c,ass 1x 38,263 1x 26,060 1% 

% ENVlROWENlAL 61,7J5 3% lS.271 LX 343,469 a% CL.767 2% 

NOT APPLICABLE s72,ou 31% CS,O% 11% 290,19a 7% 2822,256 1LX 

126,656 n, 19,117 5x 170,535 4% &,a30 LX 

CHR REFORT NO. 2 

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

SERVlCE SERVICE HCURS TRAVEL MJRS WER SERVTD MMBER OF ACTIV 

. . . ..-...--..........-.--..--...-...........................--.....--.-.-..--............... 

TOTAL 1,837,cpo loox C01.921 100% 4,2s8,665 100% 1,937,37b 1QOX 

1 HEALTN ED 101,162 6% 12,351 3% 563,asL 13% 134,197 7X 

2 USE Fly0 80,293 4X 13,286 3x LR,CCI 11x 120,237 6% 

3wt- 116,478 6% ia,sot 5X 367,986 9x 214,051 11% 

4 WfTOB 135,961 7x a,892 12% 376,247 9x 291,691 1sx 

f EMERGENCYCARE 20,089 1% 3.w 1x 20,072 ox 11,658 1% 

6 NW-EMRGENCY CARE 126,242 n 25,a . 6% 389,123 9x 220.432 11% 

7 -I SERVICE 29,a'zp 2x 4,095 1% 16.m 1x 29.77a 2% 

8 MANS/DEL 315,950 1n 193,060 68x 616,578 14x c11,96O 21% 

9 INTERPRET 17,562 1% 1,677 ox 99,101 2x za,iki ix 

10 ENVIROWNT 51,3ia 3% It,31 3x 323,211 ax 31,425 2% 

11 AD(IIN REP/REC 225,290 12% a,952 2% 12c,cO9 3x 131,127 n; 

12 PT. CLERICAL 126,nL rX 3,aik ix 32l,t40 B% 8&,592 LX 

13 MEETINGS 84,284 5% 1c.m 4% lW,mB 5x 35,985 2x 

16 TRAINING 117,7&s 6X 13,212 3X 19,313 0% 25,797 1% 

1s OTMER ADMIN 168,552 9X 11,614 3X - 110,1cs 3x 63,963 LX 

16 OTNER SERVICES 115,125 6% 16.255 6% 200,2Sl sx 8r;,oa6 LX 

UNKNaW 4,786 ox 1.616 OX 7,920 QX 5,251 0% 

A -1 
A 

APPENDIX B 

INDIAN HEALTH SERVICE 

CHR PROGRAM 

SCOPE OF WORK MATRIX 

HEALTH A R E- .-

FY: 

TRIBE: 

CHR FUNDS: 

coNTRAcr~ 

-DATE: 

PROG.CODE:,,- -

L HEALTH EDUCATION 

zcAsEfCMEMANAGEMEM 

4wIbimmmrAm 

IEh4EBGmCARE 

L PATImT CARE 

1.-Mvlm 

8.TBANBmRTPATlmr 

9.lNmBmrrrlmAmLATu 

1o.mliPATImwBBavxcB3 

11.ENvIB0NMBmALsEBvxcEs 

l2.ADMlNAKANAGEMENT 

13.OBTAIN TBAlNING 

TOTAL 

B-l 
APPENDIX C 

ENDNOTES 

1. Indian Health Manual, 3-I6.28 

2. Indian Health Manual, 3-16.13C 

3. Indian Health Manual, 3-16.5A 

4. Indian Health Manual, 3-16.583 

5. Indian Health Manual, 3-16.9D4f 

6. Indian Health Service, Community Health Representative Program; Annual Report for F&al 

Year 1990, p. 1. 

C-l 
APPENDIX D 

AGENCY COMlMENTS 

D-l 
DEPARTMENTOFHEALTH&HUMANSERVICE!3 FublicHeelthselvia3 

Date 

From 

Subject 

To 

Memorandum . M/if?2419x1 

Acting Assistant Secretary for Health 

Office of Inspector General (OX) Draft Reports "Management Issues in the Community Health Representative (CHR) Program," and "Revitalizing the CHR Program" 

Acting Inspector General, OS 

Attached are the Public Health Service comments on the subject draft reports. We concur with the recommendation ko thoroughly re-examine the CHR program and determine its future direction. 

The Indian 

the program. 

or taken to 

program. 

Attachment 

Health Service has begun activities to revitalize 

The attached comments discuss the actions planned develop a national strategy to revitalize the CHR 

G&J-@+

Audrey F Manley, M.D., M.P.H. 

D-2 
PUBLIC HEALTH SERVICE IPHS) COMMENTSON THR OFFICE 

OF INSPECTOR GENERAL fOIG) DRiW!CREPORTS "MANAGEMENTISSUES IN 

THE COMMUNITY HEALTH REPRESENTATIVE PROGRAM." OEI-05-91-01071, 

AND "REVITALIZING THE COMMUNITYHEALTH REPRESENTATIVE 

PROGRAM." OEI-05-91-01070 

General Comments 

The OIG reports on the Community Health Representative (CHR) 

program provide valuable information. They highlight problems that the Indian Health Service (IHS) is aware of and is working actively to resolve. The reports also supported PHS efforts to 

implement long-range initiatives in collaboration with the IHS 

Headquarters East and the Tucson-based Office of Health 

Programs Research and Development. 

The IHS, in order to determine if Area Office CHR programs are 

meeting the intent of Congress and program objectives, will 

utilize an evaluation methodology developed by the Oklahoma 

City Area Office. The Oklahoma Area Office's CHR annual 

program assessment is comprised of a standardized table of 

scores that are derived from a comparison of the scope of work 

and data in the CHR Information System II (CHRIS II) records. 

Using this methodology, the Oklahoma Area Office has performed annual evaluations to compare the progress of individual CHR 

programs between Fiscal Years (FY) 1990 and 1991. Because of 

the satisfactory results obtained in the Oklahoma Area Office, 

a version of this management tool will be distributed to the 

other Area Offices. 

In addition, IHS is developing outcome and quality-oriented evaluations for the CHR program. The evaluations will be based 

on '*Healthy People 2000" objectives, the patient care component of the Resource and Patient Management System, and data 

contained in CHRIS II. 

OIG Recommendation 

The PHS, together with Tribes, should thoroughly re-examine the 

CHR program to determine its future direction. If a consensus 

is reached to revise the program, PHS should develop the 

appropriate legislative proposals to do so. If it remains as a 

broad-based health care program, PHS should develop a 

multifaceted national strategy to revitalize the CHR program. 

PHS Comments 

We concur and will initiate actions to revitalize the program. IHS has begun activities in this regard. The Area Office CHR 

Coordinators met with IHS Headquarters staff the week of 

October 26, 1992, and drafted an action plan to revitalize the 

D-3 
2 

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

of Directors of the National Association of CERs. The purposes of this presentation were to (1) brief Board members on the 

goals and objectives of the &aft action plan, and (2) seek 

Board member comments on, criticisms of, and suggested improvements to the draft action plan. 

The IHS' FY 1993 activities to revitalize the CHR program will 

culminate in a national IHS/CHR Tribal Partnership Conference 

which is tentatively scheduled for late September 1993. It is expected that this conference will be attended by IHS 

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

At this conference, IHS intends to summarrize the findings and 

recommendations contained in the OIG reports. Position papers 

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

"role of the CHR" will be presented also. 

In developing a national strategy for revitalizing the CHR 

program, IHS will carefully consider the factors, identified in 

the OIG reports, that influence the effectiveness of CHR 

programs. IHS acknowledges that: 

0 The role of the CHR must be well-defined and understood 

by tribal governments, community members, and the IHS 

health care team. 

0 A community-based health care outreach program should 

work closely with the health care professionals serving the respective communities. Therefore, CHF& must be 

integrated into the health care system. 

0 The CHP program is a community-based, tribally-operated 

program that can only be effective with full tribal 

support and direction. 

0 IHS support and direction is important to make a strong CHR program. 

The national strategy will address the factors mentioned above. 

D-4 
DEPARTMENT OF HEALTH & HUMAN SERVICES cmkmofttmsoc7amv 

wshhgtm. DC 2020 

OEC lm2 

TO: Bryan B. Mitchell 

Principal Deputy Inspector General 

FROM: Assistant Secretary for 

Planning and Evaluation 

SUBJECT: OIG Draft Reports: Management Issues in the Community Health Representative Program," OEI-05-01071 and 

"Revitalizing the Community Health Representative Program," OEI-05-91-01070 

The &aft reports on the IHS Community Health Representative 

Program present compelling evidence that more attention should 

be ljtiiii Lu &is program. Your findings are aramatic and-the 

proposed elements of a revitalization strategy provide a 

thoughtful framework for further action. The clearest indication 

that the program could be strengthened is the finding that the 

majority of local respondents are not familiar with its goals and 

objectives. Your examination of the SOWand CHRIS II reports calls into question the usefulness of these instruments as 

management tools. In addition, the lack of integration of CHRs 

into Native American primary care systems is particularly 

problematic. This report provides IHS with an approach to begin examination of the program. 

We have the following specific comments. 

0 The reports document that transportation is an important 

component of CHR responsibilities. There exist large, unexplained discrepancies, however, between different 

sources of information on the proportion of the CHR's time 

which is devoted to transportation services. It is not 

clear that revision of the program to become primarily a 

transport program is actually a reasonable option to be 

considered by IHS, based on these preliminary findings. 

0 "Tribal support and direction" is listed as one of the four 

key factors influencing CHR program effectiveness. However, 

as noted on page 4 of the "Management Issues" report, only one of 15 surveyed tribal members responded to IHS 

inquiries. This report would be strengthened by an 

increased effort to include tribal input as an integral 

component of your evaluative process. 
Page 2 - Bryan B. Mitchell 

0 It would be helpful to clarify how information was gathered from the 403 respondents. When you "talked to' respondents, 

was a questionnaire used, or were these free flowing 

conversations7 Was a standard set of questions used to 

base the contacts? 

0 How were the four factors that most influence the 

effectiveness of CHR programs developed? Were respondents presented with a list of factors created by your staff? 

Were they elicited through focus groups? Many perspectives 

were represented in the comments: a statistical breakdown 

of the commentary would clarify the agreement on various 

elements and assertions. 

0 The organization of the papers is somewhat confusing. It is 

not clear which report should be read first, and the reader 

often finds it necessary to consult one document in order to 

fully understsd soze of the points made in.the other. It 

might be preferable to consolidate the reports into a single document, with the methods, findings and recommendations 

clearly organized. 

0 Your case studies indicate that the information presented in 

written documents was sometimes contradicted by your observations. Did you ask any of the respondents to address 

the apparent discrepancy between the written materials and 

your observations on elements A and D of Factor 13 

0 References to the presence or absence of tribal health plans in the "Revitalizing" report are confusing and should be 

clarified. The discussion of Factor 2, Element D, on page 

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

found no plan.' The referenced section on Factor 1, 

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

states on page 7 that "Both sites were rich in documentation." In the summary section following the individual 

discussions of the elements, at the bottom of page 8, there 

is also an indirect reference to "the absence of documents 

(like a tribal health plan)." 

D-6