Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

REVITALIZING THE COMMUNllY HEALTH 

REPRESENTATIVE PROGRAM 

APRIL 1993 
OFFICE OF INSPE~OR GENERAL 

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

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

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

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

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

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

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

correct them. 

OFFICE OF AUDIT SERVICES 

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

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

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

carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the Department. 

OFFICE OF INVESTIGATIONS 

The OIGS Office of Investigations (01) conducts criminal, civil, and administrative 

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

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

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

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

OFFICE OF EVALUATION AND INSPECI’IONS 

The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 

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

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

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

and effectiveness of departmental programs. 

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

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

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

were the following people: 

Region V Headquarters 

Barbara Butz, Team Leader Alan Levine 

Jennifer Antico, Lead Analyst 

Jean Dufresne 

Jo Lynn Antonik 
Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

REVITALIZING THE COMMUNITY HEALTH 

REPRESENTATIVE PROGRAM 

APRIL 1993 OEI-O5-91-O1O7O 
EXECUTIVE SUMMARY 

PURPOSE 

This report describes factors which make Community Health Representative (CHR) 

programs effective. The Public Health Service (PHS) could use these factors to 

revitalize the 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 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. 

SCOPE AND METHODOLOGY 

This report should be read along with our companion report entitled “Management 

Issues in the CHR Program.” In that report, we recommended that PHS, and tribes, 

thoroughly re-examine the CHR program and decide whether to retain it in its current 

form, revise it to become a transport program, or abolish it. Should they retain the 

program, we recommended that they develop a national strategy to revitalize it. 

This report presents information which could be useful to PHS in developing a 

revitalization strategy. It describes what 403 respondents - from the national, area, 

and local levels - said were the most important factors that make individual CHR 

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

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

i 
FINDINGS 

According to respondents, four factors make CHR programs effective. 

Factor 1: Agreement on the Role of the CHR 

Area and local respondents ranked this factor number one. Their view is that the role 

of the CHRS at a program must be well defined and understood by everyone involved 

before any of the other factors can have any impact on the effectiveness of the 

program. 

Factor 2: Integration into the Health Care @stem 

A majority of the CHRS ranked this as the factor with the greatest influence on the 

effectiveness of their program. Other respondents all spoke of the need for CHRS to 

work closely with health care professionals, especially if they provide medical care to 

patients. They also said that this is important in the CHRS’ role as link to the 

community. 

Factor 3: lh3aI Suppo~ and Direction 

Respondents say that a lack of tribal support and direction may cause a CHR program 

to deteriorate. It may also lower the morale of the CHRS. 

Factor 4: IHS Supp~ and Direction 

Respondents believe IHS support has less impact on the effectiveness of CHR 

programs than other factors. However, they also say that IHS support is needed to 

make programs strong. 

CONCLUSION 

When we applied these factors at 

we found that they were useful in 

two CHR programs, using a case study approach, 

judging the effectiveness of the programs. If PHS 

decides to revitalize the CHR program, we encourage them to consider these factors 

in developing a multi-faced national strategy for doing so. 

COMMENTS 

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

the report. The ASPE agreed that more attention should be paid to the CHR 

program. The PHS described steps that IHS has initiated to revitalize the CHR 

program, noting that their revitalization strategy will take into account the factors 

described in this report. The full text of the comments is in Appendix B. 

ii 
TABLE OF CONTENTS 

PAGE 

EXECUTIVE SUMMARY 

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

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5 

Factor l: Agreement on the Role ofthe CHR . . . . . . . . . . . . . . . . . . . . . . . . . . ..6 

Factor 2: Integration inthe FIealth Care System . . . . . . . . . . . . . . . . . . . . . . . . ...9 

Factor 3: Tribal Support and Direction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...11 

Factor 4: IHSSupport and Direction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...14 

CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...17 

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

A Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l 

B: Agency Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-l 
INTRODUCTION


PURPOSE 

We conducted this study to identi~ and assess factors which make Community Health 

Representative (CHR) programs effective. The Public Health Service (PHS) could use 

these factors to revitalize the program. 

BACKGROUND 

Pkogram Hktoy 

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

program within the Indian Health Service (IHS) in PHS. 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.”1 

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

Amendments of 1988. In Fiscal Year (FY) 1992, IHS 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 

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 

1

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. 

lYogram Administration 

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.”2 To 

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

national evaluation of the program. 

SCOPE AND METHODOLOGY 

The intent of this study was to identify and assess factors that make CHR programs 

effective. This report describes those factors. A companion report entitled 

“Management Issues in the CHR Program” (OEI-O5-91-O1O71) describes certain 

management issues that arose in the course of the study. 

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. 

2

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. 

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

respondents for the study. 

Piziicl ‘ Phase 1 Phase 2 Phase 3 Total 

National 6 23 29 

Area 22 30 10 62 

16 58 25 99 

E .: :: : : 

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 them “What makes a CHR program strong (effective)?” They identified four 

broad factors that make programs effective. In Phases Two and Three of the study, we 

set out to learn more about the factors and assess their usefulness in judging program 

effectiveness in a “real life” situation. 

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

respondents to learn their perceptions about the factors: how important are they, and 

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

can IHS do to strengthen or promote these factors? 

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

Assistant Secretary for Health in PHS, and IHS Headquarters staff. 

.	 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. 

3

� 

� 

Phase 

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. 

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. 

I’hree: 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. Each program had 10 CHRS, most of them working as 

generalists although some positions were dedicated to clerical or data entry work. The 

sites were rural. Both had IHS semice units. We contacted 55 respondents in this 

This study was conducted in accordance with the Interim Standards for Inspections 

by the President’s Council on Integrity and Efficiency. 

phase. 

issued 

4 
FINDINGS


INTRODUCTION 

In our report entitled “Management Issues in the CHR Program,” we recommended that 

PHS, and tribes, undertake a thorough re-examination of the CHR program and decide 

whether to retain the program in its current form, revise it to become a transport 

program, or abolish it. Should they opt to retain the program, we recommended that 

they develop a strategy to revitalize it. 

This report describes what the 403 respondents in this study - from the national, area, 

and local levels - said were the four most important factors that make individual CHR 

programs effective. Should PHS decide to revitalize the CHR program, these four 

factors should be considered in the development of a strategy to do so. 

The factors are: 

.-

Factorsthat Influencethe Effectiveness 

of CHR Programs 

Factor 1 Agreement on the role of the CHR


Factor 2 Integration into the health care system


Factor 3 Triial support and direction


Factor 4 IHS support and direction


L 

We describe why respondents think the factors make programs effective, and what 

specific building blocks, or “elements,” comprise each one. We also explain how the 

factors and elements can be used to judge the effectiveness of a CHR program. We 

discuss each factor in the following format, and then present our conclusions. 

Importance of the Factor	 Why respondents think the factor makes CHR programs 

strong, and what impact its presence or absence has on a 

program’s effectiveness. 

Elements for the Facto~ What respondents said comprises the factor. 

Case Study Analysis:	 How we applied the factor and its elements in two CHR 

programs, and what we learned about the programs using 

them. 

5

FACI’OR 1: AGREEMENT ON THE ROLE OF THE CHR 

Importance of Factor 

Local and area respondents think that there must be agreement on the role of the CHR at a 

program before any of the other facton can z%zpactthe program 

In terms of its influence on the effectiveness of CHR programs, local and area 

respondents ranked “Agreement on the Role of the CHR” number one in importance 

among the four factors. Their view is that the role of the CHRS at a program must be 

well defined and understood by everyone involved before any of the other factors can 

have any impact on the effectiveness of the program. They say that if tribal officials, 

health directors, medical staff and CHRS do not have consensus about the CHR role, 

services will become “fragmented and chaotic.” Also, CHRS would operate on an ad hoc 

basis with each going their own way, like, as one respondent described, “a covey of 

quails.” 

The CHRS ranked this factor third in importance. Numerous CHRS commented on the 

need for more focused direction ‘and supervision; some complained that they had “too 

many bosses.” 

The IHS headquarters respondents believe that once there is consensus on the role, 

programs will have greater stability if the community, health care staff, and tribal officials 

have the same expectations for the program. They were particularly concerned about 

how a lack of agreement affects CHR morale. They are troubled that CHRS are 

“perceived as the answer to everyone’s problems.” They said that CHRS are often pulled 

in different directions between what they think they should do and tribal members who 

might ask them to do inappropriate things: non-health-related things not in the SOW 

such as delivering groceries or commodities, chopping wood, janitorial services or 

transporting people to non-health-related functions. 

Elements 

Respondents suggested the following elements to identify whether there is agreement on 

the role of the CHR at a given program. 

A. Are there written goals, objectives, policies, procedures, job descriptions, a tribal 

health plan, and a written transportation policy? Have they been implemented? 

B. Do tribal leaders, community members, health program administrators and CHRS 

understand the CHR role? Do they all have the same understanding of the role? 

c. What kinds of requests for service do CHRS get from the community and medical 

staff? Are the requests within the range of semices agreed on for CHRS? 

6 
D.	 Are CHRIS II and SOW reports available? Do they show that CHRS are 

providing intended sexvices? 

E.	 Do CHRS work closely with the tribe’s health care system? Is there: continuity of 

care, coordinated effort, good communication, and teamwork? 

F.	 Are there many consumer complaints? Are consumers satisfied with the CHR 

program? 

Case Study Analysis 

The elements told us that there k agreement on the role of the CHR b the two case study 

programs. Z7ieyako toki us that this agreed-upon role k to provide transpatatkm % 

elements were easy to apply, but obsema~”onwas @ to accurately assessing the programs. 

A.	 With the notable exception of a tribal health plan, we had little difficulty obtaining 

written policies, procedures, goals, objectives and reports at either site. Both sites 

were rich in such documentation. However, we found that simply reviewing these 

documents was inadequate; only observation enabled us to learn what was really 

happening in these programs. 

The CHR position descriptions we found at both programs provide one example 

of how written documents can be misleading. They were very broad and included 

services such as referral/liaison, direct health services, health education, and 

counseling. Transportation was included, but not emphasized. Yet in both 

programs, we observed that CHRS were heavily involved in transportation. 

Observation thus gave us a very different - a more “real” - picture of what CHRS 

were actually doing, as opposed to what the position descriptions said they were 

doing. 

Both programs had some kind of transportation policy that set limitations on CHR 

transportation sexvices. However, we could not tell how strictly the policies were 

enforced. 

At one site, the most revealing written documents were the monthly and quarterly 

reports produced by the program manager summarizing CHR activities for the 

time period. Transportation activities clearly dominate. The reports also 

mentioned other activities such as delivering medication and commodities, and 

assisting families at funerals. 

B.	 At both sites we talked to people about their view of the CHR role. Most of 

them talked about transportation semices. Tribal officials, medical staff, 

community members, and the CHRS were very supportive of this function. Only a 

few people brought up the notion of CHRS doing other types of activities, like 

home care and personal care semices. At one sfie we talked to a tribal official 

who stressed the importance of transportation, but seemed open to an expanded 

7

role for CHRS and was interested in hearing about what other tribes do with their 

CHR programs. 

c. Community members, medical staff, and tribal officials request services from the 

CHRS at these programs. The CHR supemisor schedules requests that are made 

in advance, but CHRS also spend time responding to immediate needs. At both 

sites, the primary requests were for transportation and delivery services. We 

learned about requests for service by observing CHRS in their daily activities, and 

by reviewing some of their daily activity logs. 

D. Both programs use the SOW and CHRIS II, and they provided us with their latest 

reports. We compared the CHRIS II reports to the SOW to see if CHRS were 

carrying out planned activities. We generally found the two documents to be 

comparable. However, at one program, we were troubled that the reports did not 

reflect our own observation of the services being provided. The SOW and CHRIS 

II showed transport services to be 15 percent and 22 percent of total CHR time 

respectively. Yet our impression was that transport is the primary if not the only 

activity of the CHRS in those programs. This example accentuates the point that 

written documents and reports should not be relied on exclusively to gauge 

program performance. 

E. We were able to assess the degree of interaction between the CHR program and 

the other health programs through interviews with CHRS and health care staff. 

We asked about the relationship between the programs. At both sites 

respondents told us that the primary purpose for interaction was for CHRS to 

provide transportation. We discuss this further in the next section: “Integration 

with the Health Care System.” 

F. The element that we found most difficult to apply was “consumer satisfaction.” As 

people who spent only a few days with each program, we found it difficult to learn 

key community perspectives about the CHR program in any depth. A few times 

we heard complaints or hints of dissatisfaction. Generally, though, community 

members expressed satisfaction with programs and were grateful for the services 

they have received from CHRS. 

In summary, these elements told us that there is strong agreement on the role of the 

CHR in both programs. That agreed-upon role is primarily one of transporting patients 

to and from medical appointments, and delivering medications. 

We were able to apply all of the elements related to agreement on the role of the CHR, 

although some were easier to apply than others. Furthermore, we found that some 

elements could be misleading, and that obsemation is key to getting a full and accurate 

picture of a program. For example, CHRIS II reports and CHR position descriptions 

portrayed CHRS as involved in a wide variety of activities, yet we observed that these 

programs were concentrated on providing transportation. We learned also that the 

8 
absence of documents (like a tribal health plan) can tell us about program priorities, 

interests, and goals - or the lack thereof. 

FACI’OR 2: INTEGRATION INTO THE HEALTH CARE SYSTEM 

Importance of Factor 

A majority of the CHfi ranked Intqyation into the Health Care @stem as the factor w“~h 

the greatest influence on the effectiiwmxs of their program 

Fifty-eight percent of the CHRS ranked “Integration” the number one factor that 

influences CHR program effectiveness. In addition, 71 percent of the area and local 

respondents believe that a CHR program will be weakened “greatly” if integration does 

not occur. 

Respondents from the local, area, and national levels all spoke of the need for CHRS to 

work closely with health care professionals, especially if CHRS provide medical care to 

patients. They also said this is important in the CHRS’ role as the “link” to the 

community. 

A CHR program that lacks integration with the rest of the health care system could be 

affected in a variety of ways. Some respondents said that duplication and gaps in 

services would occur, and that health care professionals might lose their link to the 

community. Other respondents were concerned that without interaction with a health 

care professional, a CHR might make a mistake or provide misinformation in the course 

of providing health semices. Still others voiced that CHRS might provide semices that 

are not even related to health, such as janitorial or clerical. 

Elements 

Respondents suggested the following types of elements to identi& whether a CHR 

program is integrated with the tribe’s health care system. 

A.	 Are there referrals between CHR programs and other health care programs? 

What are the types of referrals? What semices are provided as a result of 

referrals? 

B. Do health care professionals know, respect, and support CHR programs? 

c. Do CHRS participate in meetings and committees with health care professionals? 

D.	 Are CHR activities closely related to defined community health needs? Is there a 

tribal health plan? 

E. Is CHR training planned/coordinated with training of health care professionals? 

9

F. Do CHRS document their services for patients in patient medical records?3 

G. Does the CHR position description speci~ interaction with health care 

professionals? 

H. Does the CHR manager/supervisor have a health care background? 

I. Is integration specified in the tribe’s contract with IHS? 

Case Study Analysis 

l%e elementi for “Intqration” were easy to apply. l%ey provided vay strong evidknce that 

neither program k well iktqyated with other health care programs, and that CH& are not 

ikvolved in providing health care sem”ces. 

A. 

B. 

c. 

D. 

We asked about the referral system at both sites. At one site, referrals were 

numerous and most were for transportation. Referrals in the other program could 

not be tracked, both in terms of the number of referrals or the kind of service 

provided as a result of referrals. 

We also looked at reports for evidence of referrals. At one program we found the 

reports unreliable. For example in 1991, the CHRIS II report counts 857 

referrals, but the tribe’s annual report claims a total of 151. 

Discussions with health care professionals revealed that they saw the CHRS solely 

as transporters. At one site the CHR program is co-located with another health 

program and supemised by the same person. There did appear to be some 

interaction and referral between the two programs, but it was ad hoc and 

primarily for transportation services. At the same time, a conflict between the 

CHR program manager and another department head stood in the way of those 

two programs working together. 

At the other site, although the CHRS transport many diabetic patients to and from 

the clinic, the diabetes counselor did not know that CHRS had any knowledge or 

training about diabetes, including nutrition and foot checks. If the CHRS have any 

valuable information about patients and their home life, we saw nothing to 

indicate that it is being utilized by health care professionals. 

The CHRS at both programs we visited did not meet at all with other health care 

professionals. We did hear that one of the CHR supewisors is invited to health 

promotion/disease prevention committee meetings but does not attend. 

We looked for a tribal health plan to determine whether CHRS are included in 

tribal plans to provide health-related sewices (as opposed to strictly transport). 

We found no such plan, nor in either setting did we see a any other plan 

specifically tying CHR activities in to defined community health needs. 

10 
E. Training of CHRs was not coordinated with health care professionals. The day we 

visited one site, many of the service unit health care professionals were attending 

an all-day seminar at the sexvice unit. The CHRS were not invited, nor, we 

learned, was it conceivable to the health care professionals that CHRS would ever 

be invited to such training. 

F. None of the other elements suggested by respondents was present at these two 

programs. CHR activities were not documented in patient medical records, we 

saw no instances where CHR position descriptions specified integration, 

managers/supervisors did not appear to have health care backgrounds, and 

integration was not specified in IHS contracts for these CHR programs. 

Together these elements provided strong evidence that these CHR programs were not 

well integrated with other health programs, particularly with those at the service unit. 

Health care professionals and CHR program administrators saw “integration” solely in 

terms of referrals to CHRS for transportation services or delivering medications. 

We found the elements on health professionals’ opinions about the CHR program (B) 

and referrals (A) particularly useful for assessing this factor. However, in terms of 

referrals, we agreed with respondents who said that we should go beyond simply counting 

the number of referrals between departments to get an accurate picture of the extent or 

quality of integration. It is also important to know what types of referrals are being 

made, and the outcome. For example, if referrals are solely for transportation, that tells 

us that CHRS may not be working to provide health care semices alongside health care 

professionals. 

FACTOR 3: TRIBAL SUPPORT AND DIRECI’ION 

Importance of Factor 

Reqxxaden~ say that a lack of trr”balsupport and direction jeopardhx the flectivenew of a 

CHR program and lowets CHR morale. 

Respondents at IHS headquarters ranked “Tribal Support and Direction” as the number 

one influence on program effectiveness. They think that tribal officials and community 

members should understand and support the role of the CHR. 

The CHRS ranked tribal support and direction second in importance. They had strong 

opinions about some of the elements for this factor. For example, seventy-eight percent 

feel that CHR employment decisions and CHR daily activities should not be influenced 

by tribal politics. 

The view of local and area respondents was that the CHR program would deteriorate 

without support from the tribe. Like CHRS, these respondents were concerned that 

CHR prog~ams are vulnerable to 

leadership can change frequently, 

becoming “political Footballs.” They said that tribal 

often impacting hiring and firing decisions with each 

11 
new administration. Also, they noted that both pressure on CHRS by tribal officials to 

respond to inappropriate requests, and community complaints, may serve to lower CHR 

morale. 

Elements 

Respondents suggested the following types of elements to identify the degree of tribal 

support and direction in a CHR program. 

A. Does the program have strong management and supervision? 

B.	 Is the CHR program insulated from tribal politics? Does the tribe support the 

program by providing: resolutions or letters of support, CHR access to tribal 

leadership, and/or a formal system for resolving co-mplaints from the community? 

c.	 What is the level of satisfaction with the program on the part of tribal officials, 

community members, and CHRS themselves? 

D.	 Do tribes make adequate equipment and materials available to the CHR program 

(e.g. office space/supplies, adequate travel reimbursement, training, and salaries)? 

E.	 Does the tribe see the CHR program as part of the health care system? In an 

organizational chart, where is the CHR program located in relation to other 

health care programs? Is there a tribal health plan? 

Study Analysis 

We found tribal support to be the most difficult factor to assess. Some elements include 

sensitive or hard-to-obtain information. 

A.	 To assess management and supemision, we asked to see managerial tools such as 

activity logs, reports, and schedules. Next, we talked to the CHR supervisors 

about their day-to-day operations and how the CHRS are monitored. We found 

that both programs had management systems in place and were reasonably well 

organized and supervised. 

In relation to strong management, respondents also noted the importance of 

having a strong CHR supemisor, who could compensate for a lack of involvement 

or support by the tribe. Based on our obsemations, we agree that this position 

could play an important role in focusing and improving these two programs. The 

supervisors at both appeared to have little health care background or training in 

managing a health care program. We believe that this may partially explain why 

the programs have not established a role in the health care system beyond 

transportation. 

12

B. One of the more difficult elements for us to assess was the impact of tribal politics 

on these CHR programs. We found that the only way to learn about the political 

environment was from people in the program and the community. Therefore, 

much of our evidence about tribal politics is anecdotal. 

For example, a manager at one program complained that the tribal chief or the 

tribal health administrator could call at “the drop of a hat” for a CHR to pick 

someone up. Also, one tribal official told us that there were sometimes 

complaints that CHRS serve mainly their own relatives. However, we could not 

verifj these stories. As another illustration of how tribal politics can affect a 

program, at one site hiring decisions about CHRS are made by the tribal council 

rather than the program manager, who can only “suggest” possible candidates. 

We found no official recognition from the tribe in either program in the form of 

resolutions or letters of support, commendations, certificates or honors for the 

CHRS. While the IHS area office provides some of these things, we found no 

evidence that the tribes do. 

co As we have mentioned under Factor 1, it was difficult to gauge community opinion 

about the CHR program. When asked about the program, tribal officials and 

community members spoke quite favorably; they believe that the services provided 

by the CHRS are very important. Our conclusion, however, is that their support is 

very much based on the programs’ status quo, i.e. transportation. Beyond verbally 

supporting the programs, these tribes appeared to be minimally involved with 

them. In fact we were struck by the lack of knowledge, beyond transportation, 

about the program on the part of most tribal officials we talked to. 

On the surface, CHRS appeared to be satisfied with their programs and 

leadership, though it is difficult for us to say after only a few days. At one site, a 

few CHRS spoke of some dissatisfaction with tribal administration. 

D. Respondents, particularly CHRS, suggested we look at the types of resources that 

tribes provide for the CHR program to gauge the level of tribal support. In terms 

of transportation, one program provides cars for their CHRS, and at the other site, 

CHRS use their personal vehicles. At these two sites (as well as the eight others 

we visited for this study), CHRS complained about the low level of reimbursement 

for travel, and low salaries. At one program, CHRS said they had not received 

any pay increases in the past 10 years, while they watched staff in other tribal 

health programs receive various raises and bonuses. 

E. As for Factors 1 and 2, respondents suggested we look for evidence that health is 

a priority for the tribe (i.e. studies, health plans, needs assessments, etc.) as an 

element of tribal support and direction. As stated earlier, these two programs 

lacked this element. The fact that this element appears for Factors 1, 2, and 3 

points both to its importance and to the interrelatedness of the factors and 

elements. 

13 
Based on these elements, our conclusion is that there is tribal support for these two 

programs, but that it is based on their being transportation programs. Beyond supporting 

a transportation role for their CHRS, the tribes showed little interest or active 

involvement in the programs. There were no written documents voicing support, no 

health plans, and little discernible interest in expanding the CHR role to encompass 

health care services. 

We had some difficulty assessing this factor. Although we heard that tribes supported 

the CHR programs, we found no written forms of support or evidence of it, including 

evidence that health is even a priority for these tribes. Also, while CHRS as a group 

seemed satisfied, some of them individually expressed concerns about political influence 

on their program. 

We did not have enough time to delve sufficiently into this conflicting information. 

Furthermore, lacking a historical perspective, it was difficult for us to gauge what impact 

tribal politics might have on these programs. We believe that someone in closer contact 

with a tribe, such as the area CHR coordinator, might find it easier to apply these 

particular elements. 

FA~OR 4: IHS SUPPORT AND DIRECTION 

Importance of Factor 

Reqxmden& believe that while IHS supprt has less impact on the effectiveness of CHR 

programs than other factors, it k important to make programs strong. 

The CHRS ranked this element third in importance of the four factors. Area and local 

respondents ranked it fourth. Even so, they still believe that IHS can strengthen 

programs. For example, one said that, without IHS support, a CHR program “would be 

a rudderless ship . . . (CHRS) might be busy, but they won’t be effective.” 

Elements 

Respondents identified the following elements as ways to gauge IHS support and 

direction for a CHR program, 

A. Is there a positive relationship between IHS and the tribe? Is IHS responsive to 

requests? Is there on-going communication between the CHR program and IHS 

area and local staff? 

B. Does the IHS area office have a full-time CHR coordinator, with an 

appropriate background and support? 

co Does IHS provide adequate funding, equipment, materials, and training to the 

program? 

14 
D. Does IHS provide technical assistance to tribes on how to use the various 

management tools - especially the SOW and CHRIS II? 

E. Is the IHS service unit at the program providing regular and useful technical 

assistance, management, and professional assistance? 

F. Does IHS monitor and review the program, i.e. conduct audits, evaluations, and 

site visits? 

Case Study Analysis 

The elements told us that IHS provides administrative and financial support for these 

CHR programs but does not actively promote or encourage tribes to involve their CHRS 

in the health care system beyond a transport role. 

A. To learn about the relationship between IHS and the two tribes, we talked to both 

tribal and IHS staff. At one program, the IHS area office clearly had a close 

relationship with the CHR program. Staff there were verbally supportive of the 

program and felt it was one of the best in the area. This area office has provided 

significant extra funding for this program, including funds for cash bonuses for the 

CHRS. The CHR coordinator makes periodic visits and makes training available 

to the program. 

The relationship was more difficult to assess at the other site. The IHS project 

officer and sewice unit director told us that they work very closely with the tribe. 

However, the CHR coordinator was new and not yet familiar with the program. 

We got a different perception about the degree of IHS support from some people 

at the tribal level. 

B. One of the CHR coordinators is full-time, the other has multiple responsibilities in 

addition to the CHR program. This is common in the CHR program as a whole; 

only 2 of the 12 area CHR coordinators are full-time. 

c. Funding and resources appear to be adequate for the programs we visited. 

However, we frequently heard complaints from CHRS about low salaries. (Even 

though salaries are set by the tribes, many people seem to expect IHS to be 

responsible for salary increases.) People also talked of a need for better travel 

reimbursement or more government cars. 

In terms of training, IHS provides the basic training course to all CHRS but 

availability of other training varies from program to program. At one program, 

IHS rather than the tribe makes training available; CHRS are encouraged to 

attend training and other regional conferences. At the other site, we saw that 

until recently, CHRS had not received any training from IHS, nationally or at the 

service unit level. 

15 
D. The area CHR coordinators do provide technical assistance to tribes on how to fill 

out the SOW and the CHRIS II reports, and stress the importance of reporting 

CHR activities. However we do not know how much they focus on their use as 

management tools. For example, while the CHR coordinator for one program 

expressed concern about the incongruence of 

SOW and CHRIS II reports, the thought was 

updated to match the latest CHRIS II report 

activities to conform to the SOW. 

We did not get the impression that programs 

transportation services listed on the 

more that the SOW needed to be 

rather than reorienting CHR 

use the SOW and CHRIS II for 

management purposes. Rather, administrators largely viewed CHRIS II reports as 

necessary ways to get funding for their programs. The supervisor at one program 

said she planned to use the SOW and CHRIS II for management purposes, 

however this program, like the other, still remained focused primarily on 

transportation. 

E. We saw little effort on the part of IHS service unit staff to offer these programs 

the guidance needed to change or expand them into health service areas beyond 

than transportation. To the contrary, service unit medical staff relied on CHRS 

for transportation. In addition, neither service unit provided any training to the 

CHRS. 

F. The two CHR coordinators monitor their programs primarily by phone, with 

occasional site visits. The project officers also monitor the programs in terms of 

contractual issues and problems. However, IHS staff did not appear to formally 

audit or evaluate these programs on a regular basis. We did not hear of any fiscal 

review of these programs by the program officers. And we learned that required 

audits cover a tribe’s entire contract rather than one program alone. 

At one program, we learned that, a few years ago, an internal control review by 

the area office had recommended that a formal link be established between the 

CHR and public health nursing programs. However the recommendation was 

never acted upon, and was eventually quietly dropped. 

Although we found that we could apply these elements in a program, in our view their 

usefulness is somewhat limited. We found that they can be present in a program, yet not 

have a significant impact on making the program effective in meeting health care needs. 

For example, neither the nature of the relationship between the tribe and the CHR 

coordinator, nor whether the coordinator was full- or part-time, seemed to affect the 

outcome of the programs; they both remained heavily focused on transportation. 

The more important issue seems to be the focus of support that IHS gives these 

programs. That is, we noticed that IHS emphasis seems to be on administrative issues 

(like reporting and budget), and perpetuates the status quo of transport rather than help 

the programs expand beyond it. 

16 
For this reason, we suggest that another element be added for this factor: 

G. IHS area and service unit staff actively encourage and assist tribes to incorporate 

in their CHR programs: (1) agreement on the role of the CHR, (2) integration 

into the health care system, and (3) strong tribal support and direction. 

CONCLUSION 

As an increasing number of tribes take over their own health care programs under P.L. 

638, it is critical that IHS develop management and evaluation tools to ensure 

accountability in these programs. In this report we have presented an example of how 

IHS could develop such tools. We found these factors and elements useful for assessing 

two CHR programs. However we recognize that IHS might develop others as well, and 

we encourage them to develop their own system to monitor and measure the CHR 

program. 

This study shows that these factors and elements are indeed useful as a basis for gauging 

CHR program effectiveness. They are, in effect, common denominators for all 260 CHR 

programs. If used flexibly and with common sense, they will demonstrate many things 

about how, and how well, a program is functioning. We think they are particularly valid 

because they came from a wide variety of people who know about, and are involved in, 

the CHR program. 

We learned a number of valuable lessons about the factors and elements: 

The factors and elements are interrelated. Respondents named some elements in 

connection with more than one factor. For example, they named “the existence of a 

tribal health care plan” as an element for Factors 1, 2, and 3. They named “consumer 

support/satisfaction” for Factors 1 and 2. Or, sometimes one of the factors is also an 

element for another factor. For example, “do CHRS work closely with the tribe’s health 

care system,” which is Factor 2 (Integration), is one of the elements for Factor 1 

(Agreement on the Role). Thus one element may shed light on a number of factors. 

Also, no. single factor or element can tell the whole story of how a program functions. 

The elements must be applied flexiily. Elements should not be viewed rigidly or used in 

a “cookbook” manner. Depending on the program, some elements may be more useful 

than others and some may not make sense at all. Interpreting information must also be 

done flexibly. For example, the fact that a tribe uses a variety of management tools does 

not necessarily mean, in and of itself, that the program is well managed. Or, the fact that 

a CHR coordinator is “part-time” does not necessarily mean that a program gets less 

support from IHS than from a full-time coordinator. 

Obsemation is a critical part of applying the elements. We found that observation 

helped us to identi~ issues that we could not find directly when looking for the elements. 

For example, one of the most substantial conclusions we made about these two programs 

was that they are primarily transportation programs. Yet none of the elements 
specifically focuses on the issue of transportation. We only learned that these were 

transportation programs through observing, spending time with CHRS, and holding 

numerous conversations with people at both the local and area levels. 

COMMENTS 

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

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

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

and that our report provides IHS with an approach to move in this direction. 

The PHS concurred with the findings and recommendation in our companion report 

entitled “Management Issues in the Community Health Representative Program.” They 

described steps that IHS has initiated to revitalize the program and noted that their 

revitalization strategy will take into account the factors described in this report. 

We thank ASPE and PHS for their comments. 

18

APPENDIX A 

ENDNOTES 

1. Indian Health Manual, 3-16.2B 

2. Indian Health Manual, 3-16.13C 

3.This is a potentially controversial issue. Some respondents expressed concern about CHR 

access to medical records and patient confidentiality. One suggested allowing limited access. 

A -1 
APPENDIX B 

AGENCY COMMENTS 

B-1 
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: DEPARTMENT OF HEALTH & HUMAN SERVICES l%bliiHeam’1

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Memorandum 

Date 

From Acting Assistant Secretary fo~ Health 

Subject	 Office of Inspector General (OIG) Draft Reports “Management 

Issues in the Community Health Representative (CHR) Programf” 

and “Revitalizing the CHR Program’” 

To 

Acting inspector General, OS 

Attached are the Public Health service comments onzthe subject 

draft reports. We concur with the xecommendationto thoroughly 

re-examine the CHR program and determine its future direction. 

The lndian Health Service has begun activities to revitalize 

the program. The attached comments ciiscuss the actions planned 

or taken to develop a national strate~ to revitalize the CHR 

program. 

UkL-# A@’+­

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

Attachment


— 

.0 

B-2 
, ,’ . 

General Comments 

The OIG reports on the Community Health Representative (CHR ) 

program provide valuable information. They highlight problems 

that the Indian Health Se-ice (IHS) is aware of and is working 

actively to re801ve. 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 Yea=s (FY) 1990 and 1991. Because of 

the satisfactory results obtained in the Oklahoma Area Office, 

a version of this management tool will be tistr~uted to the 

other Area Offices. 

In acidition, lIIS is cieveloping outcome and quality oriented 

evaluati0n8 for the C!HRprogram. The evaluations will be based 

on “Healthy People 2000””objectives, the pati~t 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, PHSshould develop a 

multifaceted national strategy to revitalize the m program. 

PHSComments 

We concur and will initiate actions to revitalize the program. 

IHS has be- activities in this regard. The Area Office CHR 

Coordinators met with IHS Headquarters staff 

October 26, 1992, and drafted an action plan 

the week of 

to revitalize the 

B-3 
4 . 

. . . 

CHR program. This draft action plan was presented 

of Directors of the National Association Of ~. 

2 

to the Board 

The purposes 

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

goals and objectives of the draft 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/~ Tribal p~ership Conference 

which is tentatively scheduled for late September 1993. It is 

expected that this conference will be attended by IHS 

executives and managers, tribal leade~s, ~, -d. consumers. 

At this conference, IHS intends to summarize the findings and 

recommendations contained in the OIG reports. Position papers 

on the ‘national goal and objectives of tie ~ program” and 

‘role of the CHRW 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: 

o 

0 

0 

The role of the CHR must be well-defti~ and understood 

by tribal governments, community members, and the IHS 

health care team. 

A community-based health care outreach program should 

work closely with the health care professionals serving 

the respective communities. Therefore, CHRS must be 

integrated into the health care system. 

The CHR program is a community-based, ~ibally-operated 

program that can only be effective with full tribal 

support and direction. 

o IHS support and direction is important 

CHR program. 

The national strategy will address the factors 

to make a strong 

mentioned above. 

B-4 
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:. DEPARTMENT OF HEAL~ & HUMAN SERVICES ofTlcoofthosea@=Y 4$1 s

8“%,> Wuhhgtlm, m. 2020’ 

DECIW2 

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-OS-01071 and 

“Revitalizing the Community Health Representative


Program,” OEI-O5-91-O1O7O


The draft reports on the IHS Communitv Health Representative ———
 Program present compelling evidence that more at;e~tion should


be p~i~ LU dhis program. Your findings are dramat$c and-the 

proposed elements of a revitalization strategy psovide 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 SOW ud CnlS II reports 

calls into question the usefulness of these instruments as 

management tools. In addition, the lack of htegration of CHRS 

into Native American primary care systems is particularly 

problematic. This report provides IIIS with m approach to begin 

exaxnination of the program. 

We have the following specific comments. 

o	 The reports document that transpofiation is an tiportant 

component of CHR responsibilities. The%e exist large, 

unexplained discrepancies, however, between diffezent 

sources of information on the proportion of the c~’s time 

which is devoted to transportation services. It is not 

clear that revision of the progrm to beco~ pr~ily a 

transport program is actually a reason~le option to be 

considered by IHS, based on these preltinaq findings. 

o
 “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 stren@ened by an 

increased effort to include tribal input as an integral 

component of your evaluative process. 

e: . ,s. P-.-l J “/ ),- & u-” “1

. - + 

B-5 - 1-- -;:!*t-*%m*a =02:;4:”: 
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Page 2 - Bryan B. titchell 

o It would be helpful to clarify how information was gathered 

from the 403 respondents. When you “tallcai to” respondents, 

was a questiomaire used, oz we=e these fsee flowing 

conversations? Was a standard set of questions used to 

base the contacts? 

o How were the four factors that most influence the 

effectiveness of CHR programs developed? Were respondents


presented with a list of factors cxeated by your staff?


Were they elicited through focus groups? llanyperspectives


were represented in the comments: a statistical breakdown

of the commentary would clarify the agreement on various 

elements and assertions. 

o 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


fuily understand same ef the points made h the @hero It


might be preferable to consolidate the reports into a single


document, with the methods, findings and recommendations 

clearly organized. 

o Your case studies indicate that the information presented in 

written documents was sometimes contradicted by yOUX 

observations. Did you ask any of the respondents to address 

the apparent discrepancy between the written materials and 

your obsemations on elements A and D of Factor 1? 

o	 References to the presence or absence of tribal health plans 

in the “Revitalizing” report are confusing and should be 

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


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


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


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


states on page 7 that “Both sites were rich in documenta­


tion.”
 In the summary section following the individual 

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

is also an indirect reference to “the absence of documents 

(like a tribal health plan).“ 

/ 

B-6