Chapter 16 - Community Health Representatives Program

Title	Section
Introduction	3-16.1
Purpose	3-16.1A
Policy	3-16.1B
History	3-16.3C
Definitions	3-16.2
Community Health Representative Program	3-16.2A
Community Health Representative	3-16.2B
Community	3-16.2C
Health Care	3-16.2D
Health Promotion	3-16.2E
Disease Prevention	3-16.2F
Appropriate Use of CHR Funds	3-16.3
Inappropriate Use of CHR Funds	3-16.4
Goals and Objectives	3-16.5
Program Goals	3-16.5A
Program Objectives	3-16.5B
Organization and Staff Responsibilities	3-16.6
Headquarters	3-16.6A
Area Offices	3-16.6B
Service Units	3-16.6C
Indian and Alaska Native Contractors	3-16.6D
Scope of Work (SOW)	3-16.7
CHR Program Scope of Work Matrix	3-16.7A
Workload Percentages	3-16.7B
All CHR Services Shall be Community-Based	3-16.7C
Transportation	3-16.7D
Preparation of the Contract Scope of Work	3-16.7E
Reporting Requirements	3-16.8
CHR Standards of Practice	3-16.9
Philosophy	3-16.9A
Purpose of Standards	3-16.9B
Description of Standards	3-16.9C
Standards and Practice	3-16.9D
Core Standards	3-16.9D1
Core Service Standards	3-16.9D2
Core Certification	3-16.9D3
Standards of Practice	3-16.9D4
Health Education	3-16.9D4a
Case Find/Screen	3-16.9D4b
Case Management/Coordinate	3-16.9D4c
Monitor Patient	3-16.9D4d
Provide Emergency Care	3-16.9D4e
Provide Non-Emergency Care	3-16.9D4f
Homemaker Services	3-16.9D4g
Transport	3-16.9D4h
Delivery	3-16.9D4i
Interpret/Translate	3-16.9D4j
Environmental Health	3-16.9D4k
Training	3-16.10
Basic Training	3-16.10A
Specialty Training	3-16.10B
Advanced Training	3-16.10C
Refresher CHR Course	3-16.10D
Responsibilities	3-16.10E
National Director IHS/CHR Program	3-16.10E1
Training Committee	3-16.10E2
National CHR Training Officer	3-16.10E3
Area CHR Coordinators	3-16.10E4
Curriculum Review Committee	3-16.10E5
Contractors/Grantees	3-16.10E6
Quality Assurance (QA)	3-16.11
Close Supervision	3-16.12
Evaluation	3-16.13
Retrocession/Assumption/Reassumption	3-16.14
Community Health Representatives Information System (CHRIS)	3-16.15
Community Health representatives Memoranda and Advisories	3-16.16

Exhibit	Description
Exhibit I	The IHS Response to the National CHR Task Force
Exhibit II	Sample CHR Scope of Work Matrix
Exhibit III	CHRIS II - Report of CHR Activities Form
Exhibit IV	CHR Program Standards Specification Involvement

3-16.1  INTRODUCTION

The Community Health Representatives (CHR) Program is an Indian Health Service (IHS) funded, tribally contracted/granted and directed program of well-trained, community-based, health care providers, who provide health promotion and disease prevention services in their communities.

1. PURPOSE

   This chapter establishes and defines program goals and objectives for the CHR Program of the IHS, as well as the organizational structure and performance standards of the IHS/CHR program personnel.  It sets forth the procedures and guidelines for the CHR Program regarding acceptable parameters of activities allowable for performance with program funds in terms of Health Care Areas, Functions, and Settings.

2. POLICY

   The CHR Program activities shall be managed and carried out only by American Indian and Alaska Native governments through legal (contract/grant/Cooperative Agreement (CA)) arrangements with the IHS.

   The CHR Program endeavors to provide quality outreach health care services, and health promotion/disease prevention services to American Indians and Alaska Natives within their communities through the use of well-trained CHRs, as mandated by the Indian Health Care Improvement Act Amendment Public Law (P.L.) 100-713, dated November 23, 1988.

   The IHS recognizes that the CHR Program has made basic and important contributions to Indian health in its efforts to provide paraprofessional community-oriented primary health care services, and that the CHR Program should maintain its unique capabilities to provide medically-guided primary health care services in the areas of need where no other program or resource is available, and declares that the Program will not be used to supplement IHS staffing.

3. HISTORY

   The CHR Program was established by the Congress in 1968 in response to the expressed needs of American Indian and Alaska Native governments, organizations, and the IHS, for a health care program which would provide an outreach component to meet specific tribal health care needs.  It was based on the concept that community members, trained in the basic skills of health care provision, disease control and prevention, would be able to achieve the most success in effecting change in community acceptance and utilization of limited health care resources.  However, lack of specific legislative, regulatory and policy guidelines at inception and the rapid growth of the program in its first decade, led to a wide variation in the scope and development status of individual CHR Programs.  The result was a need to define and/or redefine many of the program's goals, guidelines, policies, and resource allocation criteria.

   Although the CHR Program has received continued congressional support since 1981, in fiscal year (FY) 1983, the House Appropriations report stated that:
   
   The program has come into question again because IHS has not fulfilled its management responsibility by establishing guidelines and goals, and setting up evaluation standards for those projects that would ensure these goals are being met.

   ...Under no conditions should IHS merely allocate the total recommended funding to existing projects until the guidelines have been established and project eligibility determined.  Clear evaluation standards should also be included, and provision for a regular evaluation standard established."

   In granting continuing appropriations for the program, Congress has demanded that IHS establish guidelines and goals, as well as clear evaluation standards and also the provision for regular evaluation standards.

   In response to this congressional mandate the Director, IHS, appointed a task force of representatives from national Indian organizations and the IHS.  The task force made a number of recommendations which the IHS subsequently adopted, including a proposed definition of the scope of work and criteria to be considered in developing a resource allocation and evaluation methodology reporting system.  (See Exhibit I for recommendations.)

4. PREAMBLE

   The CHR Program is an IHS funded, tribally contracted/granted and directed program of well-trained, community-based, health care providers, who provide health promotion and disease prevention services in their communities.  The CHR Program activities shall be managed and carried out only by American Indian and Alaska Native governments and tribal organizations through legal (contract/grant/Cooperative Agreement (CA)) arrangements with the IHS.

5. MISSION STATEMENT

   To provide quality outreach health care services and health promotion/disease prevention services to American Indians and Alaska Natives within their communities through the use of well-trained CHRs as mandated by Section 107 of P.L. 100-713, dated November 23, 1988.

3-16.2  DEFINITIONS

1. Community Health Representatives Program - is a unique community-based outreach program, staffed by a cadre of well-trained, medically-guided, tribal and Native community people, who provide a variety of health services within American Indian and Alaska Native communities.
2. Community Health Representative - is a tribal or Native community-based, well-trained, medically-guided, health care provider, who may include traditional Native concepts in his/her work and is funded with IHS-CHR appropriations.
3. Community - is a tribally defined CHR service delivery area.
4. Health Care - is the provision of services that helps individuals achieve an optimal state of well-being, in any setting or stage in the human life cycle.  Provision of health services include:
   1. Health Education/Counseling
   2. Monitor Client/Community
   3. Case Management/Coordination
   4. Emergency Care
   5. Health Promotion
   6. Disease Prevention
   7. Transportation/Delivery
   8. Translation/Interpretation
5. Health Promotion - is the provision of information and/or education to individuals, families, and communities that encourage family unity, community commitment, and traditional spirituality, that make positive contributions to their health status, such as:
   1. Cessation of Tobacco Smoking
   2. Reduction in the Misuse of Alcohol and Drugs
   3. Improvement in Nutrition
   4. Improvement in Physical Fitness
   5. Family Planning
   6. Control of Stress
   7. Pregnancy and Infant Care (including prevention of Fetal Alcohol Syndrome)
6. Disease Prevention - to teach or promote methods and/or measures that have been proven effective in avoiding illness and/or lessening its effects, such as:
   1. Immunizations
   2. Control of High Blood Pressure
   3. Control of Sexually Transmittable Disease
   4. Prevention and Control of Diabetes
   5. Control of Toxic Agents
   6. Occupational Safety and Health
   7. Accident Prevention
   8. Fluoridation of Water
   9. Control of Infectious Agents

3-16.3  APPROPRIATE USE OF CHR FUNDS

The CHR funds shall be used to provide for personnel costs directly associated with the CHR Program.  Those costs include educational materials, health screening instruments (i.e., blood pressure cuffs, glucometers, etc. ), which are within established cost principles and allows the CHR to provide an outreach service to the community.

3-16.4  INAPPROPRIATE USE OF CHR FUNDS

The CHR funds shall not be used to provide patient medical care items, patient equipment, (including purchase of vehicles), patient medications, or other supplies for the patient.  The CHR funds shall not be used to supplement or duplicate other health services or functions traditionally provided by IHS.

3-16.5  GOALS AND OBJECTIVES

1. Program Goal

   The CHR Program was implemented to improve the health knowledge, attitudes and practices of Indian people by promoting, supporting, and assisting the IHS in delivering a total health care program.  The efforts of CHR program staff have produced an American Indian and Alaska Native health service delivery 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 address health care needs through the provision of community-oriented primary care services, including traditional Native concepts in multiple settings, utilizing community-based, well-trained, medically-guided health care workers.

2. Program Objectives
   1. To provide curative, preventive, and rehabilitative services in those areas of health care in which services would not otherwise be available to the American Indian and Alaska Native people.
   2. To provide home health care services.
   3. To provide transportation within the local community to/from an IHS or tribal hospital or clinic for routine, non-emergency problems, to a patient without other means of transportation, when necessary.
   4. To act as a liaison/advocate for the communities served by Federal, State, and local agencies.  The liaison/advocate motivates and assists the agencies by clarifying the role of Native traditions, value systems, and cultural beliefs, to meet the health care needs of the communities, thereby reducing the potential for conflict and misunderstanding regarding the health conditions of American Indian and Alaska native people.
   5. To interpret languages, if necessary, when the community-based language and the language used by other health care providers differ.
   6. To facilitate communications between community members and health care providers, thereby enhancing accessibility and acceptability of health care facilities.  The CHRs assist IHS and non-IHS health agencies to design and/or redesign services to ensure greater responsiveness to the needs of American and Alaska Native communities.
   7. To provide and retain community-based health care providers to meet reservation and community health care needs as part of their community's health care system and to ensure that program training and performance meet established national standards, as specified in the Indian Health Manual, Indian Self-Determination Memorandum (ISDM), 81-4, and Section 107 of P.L. 100-713, dated November 23, 1988.
   8. To develop annual program plans which address specific community health care needs.
   9. To assess community health care resources, both IHS and non-IHS, and to facilitate appropriate utilization of those resources.
   10. To ensure availability of appropriate IHS medical guidance to CHR Programs.
   11. To ensure compliance with the requirements of a CHR data collection plan.
   12. To provide and/or assist in demonstrations, conduct training sessions and community meetings in the areas of safety, nutrition/dietetics, environmental health, and in other areas of health concerns.
   13. To provide health care education and facilitate understanding by using the Native language when appropriate, thereby fostering greater cross-cultural understanding.
   14. To provide extensive health promotion/disease prevention information and instruction in self-help services that address chronic health problems.

3-16.6  ORGANIZATION AND STAFF RESPONSIBILITIES

1. Headquarters

   The IHS Headquarters CHR Program Office has been established to:  (1) Provide overall management, coordination, and support for all CHR activities agency-wide; (2) ensure delivery of high quality services by facilitating programs of research and development; (3) develop necessary policies, standards, and procedures to ensure effective implementation of CHR program management systems, in areas such as performance standards, resource allocation, contracting guidelines, reporting and training requirements, quality assurance, tribal and public relations, communications, budget formulation, program monitoring and evaluation; and (4) ensure tribal and contractor participation where appropriate and feasible.

   The IHS Headquarters CHR Program Office is staffed by a CHR Program Director, Program Analyst and a Secretary.  The Director has the following responsibilities:

   1. Plans, conducts, and evaluates the Program by providing policy guidance, coordination, and technical assistance.  Supports the IHS and Indian tribes with all aspects of the development and implementation of the CHR Program.
   2. Manages the Headquarters CHR Program Office in the administration and coordination of all CHR Program activities, provides policy guidance and technical assistance in the design and implementation of CHR Programs to IHS Area Offices.
   3. Ensures that all program planning services are consistent with the appropriate provisions and concepts of the Indian Self-Determination and Education Assistance Act (P.L. 93-6381, and the appropriate minimum standards of the IHS.
   4. Serves as the primary consultant to the Associate Director, Office of Health Programs, on CHR matters and as such develops and administers CHR program services on a national basis.
   5. Plans and implements the CHR Program and (within budgetary constraints) makes decisions based on appropriate consultations on the continuation/expansion of CHR programs throughout the IHS, including a major responsibility for the development and operation of a resource allocation system.
   6. Consults and conducts meetings with IHS Area Office personnel, Department of Health and Human Services (DHHS) officials, tribal government representatives, national Indian organizations, State health officials, other Federal agencies and other experts in the field, to gain acceptance of new methods, work procedures, organizational relationships, policies, etc., related to the CHR Program, and to identify emerging problems and their operable solutions with an impetus for implementing improvement.
   7. Contingent upon available resources, coordinates appropriate research and development activities for the implementation and/or revision of systems for management, operations, and quality assurance of the CHR Program; and provides program monitoring, review and evaluation to identify Area Office management action for research and development activities.
   8. Institutes development and implementation of appropriate information systems to support evaluation, monitoring, research and development, and program management.
   9. Analyzes major policy, program, and procedural issues including acceptable scope of services, quality and effectiveness criteria, resource allocation, communications, information system, and training requirements.
   10. Monitors resources to ensure that Appropriate and Inappropriate use of CHR funding practices are implemented as follows:
       1. Appropriate - CHR funds shall be used to provide for personnel costs directly associated with the CHR Program, educational materials, health screening instruments (i.e., blood pressure cuffs, glucometers, etc.), which are within established cost principles and will allow a CHR to provide an outreach service to the community.
       2. Inappropriate - CHR funds shall not be used to provide patient medical care items, patient equipment, (including purchase of vehicles) patient medications, or other supplies for the patient.  The CHR funds shall not be used to supplement or duplicate other health services or functions traditionally provided by IHS.
   11. Manages the development and implementation of management mechanism/policies/programs to promote and ensure appropriate quality assurance, training, and resource allocation.
   12. Develops and implements a system of review and evaluation to maintain continuous monitoring of program progress and resource utilization.  Such ongoing review and evaluation ensures that efficient and high quality professional services are delivered.
   13. Prepares regular and special reports for such matters as budget justification and congressional testimony.
   14. Keeps the Associate Director, Office of Health Programs and other appropriate IHS staff apprised of new or pending legislation, policy changes or other management actions which impact the CHR program.
2. Area Offices

   The responsibility for administration of the CHR Program at the Area Office level is vested with the IHS Area Director, who will discharge this responsibility with the assistance of his/her staff.

   The Area CHR Coordinator

   1. Ensures that each CHR Program's Scope of Work is in compliance with the guidelines established by IHS Headquarters.  (In accordance with the current rules and procedures of IHS, proposals submitted under P.L. 93-638 contracting regulations, which include a CHR component, will be reviewed by the CHR Coordinator.)
   2. Provides technical assistance to tribes in the development of proposals and provides periodic site visits to review program progress.
   3. Provides recommendations to the Area Director regarding methods of allocating and/or reallocating resources to accommodate further budget increases or decreases.
   4. Develops recommendations regarding the CHR Program for the Area Contracting Officer.
   5. Serve as the advisor to Area and service unit program managers regarding the CHR program.
   6. Serves as the Project Officer on CHR contracts.
   7. Is responsible for submitting CHR program data as required.
   8. Develops Area CHR Training Budget proposals in coordination with American Indian and Alaska Native contractors.  Training should be reflective and consistent with the services to be provided and as identified in the CHR contracts' Scope of Work (SOW).
3. Service Unit or IHS Area

   Each service unit should designate a Project Officer Representative to serve as the service unit liaison official with the tribal governments/contractors.

   1. Serves a Liaison official, on behalf of the service unit or Area Director, to the Tribal CHR Program Office and the Area CHR Coordinator;
   2. facilitates coordination and effective interaction between tribal CHR Programs and the service unit or Area health care program; and
   3. monitors the contractual requirements in the CHR SOW against the work performed and advises the Area CHR Coordinator of any apparent deviations.
4. American Indian and Alaska Native Contractors

   In line with the policy and procedural instructions (contracting regulations) issued by Headquarters and the Area Office, the responsibility for administration of the CHR Program at the "service provider" level is vested with the local American Indian and Alaska Native government, which will discharge this responsibility according to their organizational policies and procedures, and in accordance with specific contract requirements.

3-16.7  SCOPE OF WORK

The SOW is a mutually agreed upon document that specifies the responsibilities of a tribal entity to the government for a specified amount of funds.

1. The CHR Program SOW Matrix shall be used to indicate Workload objectives (percentages) of the contractor, and shall include the number of full-time/part-time CHRs by job title and IHS/CHR dollar amounts.
2. Workload percentages shall be negotiated by each tribal contractor and shall indicate total program workload.
3. All CHR services shall be community-based.
4. If transportation is to be provided, it shall be within the local community to/from an IHS or tribal hospital or clinic for routine, non-emergency problems, to a patient without other means of transportation when necessary.  A tribally developed transportation policy shall be in place.
5. Preparation of the Contract SOW.  The major purpose of the “CHR Program SOW Matrix” is to provide a local CHR Program with the framework for defining and monitoring its activities.  The SOW is defined in terms of 16 service categories and when the 16 services are further categorized according to the 14 health areas, a matrix of 240 different services/areas is formed, into which an activity may be categorized.  (For the purpose of SOW determination, the activity settings are excluded.)

   From the full list of service/area categories, underscore those that will be done by the CHR Program during the year.  Health areas 9 through 90 are currently unassigned.  These codes may be added and defined as the Community Health Representatives Information System (CHRIS) reporting changes are indicated.

   For a copy of the:

   CHR PROGRAM
   SCOPE OF WORK MATRIX

   Please contact your Area Directives, Delegations, and Control Officer for a copy of the CHR Program Scope of Work Matrix.

3-16.8  REPORTING REQUIREMENTS

The following items, which are included in the IHS Core Data Set Requirements (CDSR), shall be reported on a quarterly basis, by collecting a sample of one IHS nationally designated week (7 consecutive days) from each month:

1. Provider Number
2. Program Number
3. Date: Month, Day, and Year
4. Service Codes
5. Health Area
6. Setting
7. Client's Age
8. Client's Sex
9. Number of Clients Served per Individual Service
10. Referrals:  To and From the Health Worker
11. Minutes used:  Each Unit of Service and Travel Time

3-16.9  CHR STANDARDS OF PRACTICE

1. Philosophy - P.L. 100-713 establishes the CHR Program as a component of health care services of American Indian people.  It is an IHS funded, tribally contracted/granted and directed program of well-trained, community-based, health care providers, designed to integrate the unique helping of tribal life with the practices of health promotion and disease prevention.
2. Purpose of Standards - To provide a set of minimum uniform practices for the operation of the CHR Program. which are to be considered for adoption by each tribe, as applicable in their scope of work.
3. Description of Standards - A statement of the level of health services possible in the CHR Program SOW, to provide common guidance to aid individuals, families, and communities, in achieving an optimal state of well being, in any setting or stage in the human life cycle, by providing a common practice base, which serves as minimum guidance for the provision of health services, as part of a health team.
4. Standards and Practice - The following standards and practice shall serve as the minimum applicable to a tribe's SOW.  Additional standards and practice may be developed and approved by the tribal governing body serving the community, in accordance with accepted health practices.
   1. Core Standards At initial employment, each CHR will be provided an orientation which shall include:
      1. A copy of the CHR Program Standards.
      2. Orientation to the Tribal Program:
         1. Office/tribal organization policies and procedures;
         2. Contract SOW relative to the person's job;
         3. Introduction to health staff and how they interact/work together;
         4. CHRIS II reporting and forms; and
         5. Radio/communication skills for local/community needs, i.e., "CB" radio.
   2. Core Service Standards Within 6 months to a year of employment, each CHR shall at a minimum, receive training and skill certification in the following:
      1. Knowledge Base:
         1. Basic anatomy/physiology;
         2. Normal medical values, i.e., 98.6, the normal temperature reading etc.;
         3. Basic medical terminology;
         4. Basic nutritional and dietary needs;
         5. Disease etiology;
         6. Community organization and resource; and
         7. The norms, i.e., knows and respects tribal beliefs and customs.
      2. Range of Skills:
         1. First Aid/CPR;
         2. Vital signs/equipment use;
         3. Assessment/referral skills;
         4. Report verbally and written (Subjective/Objective) Assessment Plan);
         5. Communication/translate/interpret/persuasion/motivation;
         6. Investment skills;
         7. Teamwork; and
         8. Advocacy.
   3. Core Certification.  Certification, at a minimum, shall apply to the following standards of practice. Additional certification may be required for some standards of practice.
      1. Basic CHR Training;
      2. Advanced Training;
      3. Continuing Education Units;
      4. Optional credentialing/certification, i.e., college certification/degrees and other credentialing;
      5. Driver’s License;
      6. Defensive Driving Certificate; and
      7. Liability Insurance.
   4. Standards of Practice
      1. Health Education practice is designed to provide individuals, families and communities with the appropriate information to practice a healthy lifestyle.  Each CHR will be trained and tested for adequate knowledge in the health area to be practiced.
         1. Knowledge Base:
            1. Community Resources
            2. Health Care Resources
            3. Community Disease Profiles
            4. Cultural Norms
            5. Behavioral Modification Techniques
            6. Political Climate/Structure
            7. Program/Community/Contract Priorities
            8. Health Promotion/Disease Prevention
            9. Group Dynamics
            10. Disease Etiology
         2. Range of Skills:
            1. Communication ability to:
               • explain a specific health problem
               • explain the practice of prevention
               • relate the dangers of uncontrolled health problems
               • relate how to live with specific health problems
               • relate the self-management of health problems
            2. Organize, coordinate, conduct, plan, and evaluate presentations
            3. Public Speaking
            4. Apply behavior modification techniques
            5. Diplomacy
            6. Research
            7. Audio-visual equipment operation
            8. Group management
            9. Motivation
            10. Illustrative talent
      2. Case Find/Screen is carrying out efforts for the early detection of patients with diseases or conditions requiring medical attention (e.g., hypertension, TB, pregnancy, etc. 1.  This may be done by investigation in the community or with screening tests.  It may involve one individual or many.
         1. Knowledge Base:
            1. Screening Equipment
            2. Demographics/Community
         2. Range of Skills:
            1. Specific Screening Equipment Use
      3. Case Management/Coordinate is developing a patient care plan in conjunction with a community health nurse or physician, deciding upon the various responsibilities for the people involved in the patient's care.  Serve as a patient advocate by arranging appointments, filing complaints, helping the patient obtain services and coordinates with various service providers to ensure continuity of care.  Case management conferences and discharge planning are also included.
         1. Knowledge Base:
            1. Local Health Care System/Resources
            2. Medical Terminology
            3. Relationships of the Local Health Care
            4. Advanced Health Care Concepts
         2. Range of Skills
            1. Assessment of Patient, Family, and Environment
            2. Logical Decision Making Ability
      4. Monitor Patient is making periodic personal contact with a patient with a known health problem or is high risk for illness or disablement, by telephone or at home, to see if he/she is feeling well, has enough food and/or medicine, has unmet home health care needs, has adequate heating, etc., with immediate action taken to provide care for patient needs detected through monitoring.
         1. Knowledge Base:
            1. Specific Screening Equipment
            2. Specific Medical Terminology
            3. Specific Medical Treatment
            4. Individual Patient Care/Treatment Items
            5. Counseling Techniques
            6. Specific Disease Profile
            7. Standing Orders/Protocol
         2. Range of Skills
            1. Counseling Skills
            2. Assessment
            3. Referral/Followup
            4. Equipment Operation and Maintenance
            5. Triage Techniques
      5. Provide Emergency Patient Care is giving care to a sick or injured person while arranging or waiting for transportation to a hospital or clinic, contracting an ambulance or hospital driver, transporting a seriously ill patient to medical care or performing crisis intervention with an emotionally upset or suicide patient.
         1. Knowledge Base:
            1. Community Emergency Care System
            2. Panic Medical Values i.e., heart attack, shock, etc.
            3. Disaster Plan
         2. Range of Skills:
            1. First Responder
            2. Triage
            3. Crowd Control/Communication
      6. Provide Non-Emergency Care is the taking of vital signs or providing other clinical services, such as foot care, to persons with a diagnosed illness.  Also included, are services such as:  counseling for social, emotional, mental or other related problems.  When appropriate, provides for traditional tribal services for the sick, and other services requiring individual assessment, therapeutic and/or follow-up.  Home health care and maintenance of patient equipment such as:  crutches, wheelchairs, eyeglasses and hearing aids are included.  The services in this category are provided to patients with diagnosed illnesses.
         1. Knowledge Base:
            1. Specific Medical Treatment
            2. Individual Patient Care/Treatment Items
            3. Counseling Techniques
            4. Specific Disease Profile
            5. Standing Orders/Protocols
         2. Range of Skills:
            1. Basic Counseling Skills
            2. Assessment
            3. Referral/Followup
            4. Equipment Operation and Maintenance
            5. Triage Techniques
      7. Homemaker Services is assisting the disabled, homebound, or bedridden with household chores, preparing food and feeding incapacitated patients, or assisting with personal care such as bathing or hair washing.
         1. Knowledge Base:
            1. Specific Nutritional needs
            2. Hygiene
            3. Home Safety
            4. Responsible Friend/Family Members
         2. Range of Skills:
            1. Home Visit Techniques:
               • Patient handling techniques
               • Personal care/hygiene
            2. Homemaker Services
      8. Transport is the transportation of a patient, without other means of transport, to/from an IHS or tribal hospital/clinic when necessary for routine, non-emergency problems, which includes waiting for a patient, such as a dental patient, to finish treatment.
         1. Knowledge Base:
            1. State Traffic Laws
            2. Vehicle Maintenance/Safety
            3. Road System
         2. Range of Skills:
            1. Driving
            2. Work Scheduling
            3. Patient Transfer Techniques
            4. Minor Vehicle Repair i.e., tire changing, etc..
            5. Communication/Radio
         3. Communication:
            1. Driver’s License Defensive
            2. Driving/Traffic Safety
            3. Vehicle Insurance as Required
      9. Delivery includes delivering items such as medications, supplies and equipment, to the patient's home.
         1. Knowledge Base:
            1. Vehicle maintenance/Safety
            2. Road System
            3. Lab Specimen/Massage/Supplies/Medication and/or Equipment Care and Handling Requirements
            4. State Traffic Laws
         2. Range of Skills:
            1. Driving
            2. Work Scheduling
            3. Minor Vehicle Repair
            4. Communication/Radio
            5. Demonstrate Use of Equipment/Supplies Delivered
         3. Communication:
            1. Driver’s License
            2. Defensive Driving/Traffic Safety
            3. Vehicle Insurance as Required
      10. Interpret/Translate is the taking of a statement from one language and expressing the meaning, either orally or in writing, in another language, so as to enable people who do not speak the same language to communicate with one another.
          1. Knowledge Base:
             1. Basic Pharmacology.
             2. Illness/Wellness/Death Concepts of the Local Culture(s).
             3. Cultural Norms/Practices.
          2. Range of Skills:
             1. Language of the Local Culture(s)
             2. Fluency of Language
             3. Translation (English to language of the local culture and vice versa)
             4. Illustrative Talents
             5. Understand Health Record Information
      11. Environmental Health is inspecting the community's environment in one or more of the following:  water/waste-water management; vector control; air quality; solid waste; and, food handling.
          1. Knowledge Base:
             1. Ability to recognize, evaluate and promote the control of biological, chemical, and physical factors, which have an adverse effect on the health of the population.
             2. Injury Control
             3. Building Inspection
             4. Community Disaster Plan
             5. Food Quality
             6. Communicable Disease
             7. Community Clean-up
             8. Rabies Control
             9. Applicable Rules/Regulations
          2. Range of Skills:
             1. Initiative
             2. Pest Control
             3. Acceptable Methods of Testing/Treatment
             4. Record Keeping
             5. Referral
             6. Environmental Health Service Surveys:
                • Food
                • Water
                • Solid Waste
                • Injury Control
          3. Communication:
             1. Local Medical/Environmental Credentialing as Required

3-16.10  TRAINING

The training component of the CHR Program is to provide an environment that will promote the individual CHR's educational growth and proficiency in providing health care, health promotion, and disease prevention services.  The components of training are as follows:

1. Basic Training - To provide the nationally accredited health training to all IHS-CHR funded employees after their completion of the probationary period and designated prerequisites.
   1. Each employee, occupying a position supported by IHS-CHR finds, is required to successfully complete the CHR Basic Training Course within 1 year of employment.
   2. Each CHR will be given the opportunity to take a challenge test in place of the CHR Basic Training.
2. Specialty Training - To provide current information to increase proficiency in health care, health promotion and disease prevention services through special accredited courses.
3. Advanced Training - To provide academic and practical experience that may lead toward an Associate 01 Arts degree, licensure and certification, through colleges, universities and vocational technical schools.
4. “Refresher” CHR Course - The “refresher” CHR Course is required to be taken by CHRs between 36 and 48 months after completing the Basic CHR Training Course.
5. Responsibilities
   1. Director National IHS/CHR Program Office

      To be responsible for the overall management of the CHR Program, Office of Health Programs.

   2. Training Committee

      Develop national policies related to the training and development of CHRs.

      Develop national educational training standards.

      Coordinate training/educational activities with other disciplines associated with the CHR programs.

      Periodically assess, update, and evaluate training needs.

   3. National CHR Training Officer

      Manage and promote the national and regional training and educational activities of the CHR Program.

   4. Area CHR Coordinators

      Assess, update, and evaluate the training needs of CHRs in their respective areas and provide this information for use in policy formulation.

      Implement policies and procedures pertaining to CHR training.

      Ensure that each CHR receives and satisfactorily completes the 3-week Basic CHR Training Course.

      Coordinate training and educational activities with other disciplines associated with the Area CHR Program(s).

      Conduct and/or coordinate training for CHRs.

   5. Curriculum Review Committee

      Utilize subject matter experts as required for review and analysis of CHR curricula.

   6. Contractors/Grantees

      Ensure that CHRs are provided training commensurate with their duties under the awarded instrument.

3-16.11  QUALITY ASSURANCE (QA)

A tribally developed Quality Assurance Program will:

1. Care Evaluation:
   1. Structure
   2. Process
   3. Outcome Criteria
2. Internal Monitoring
3. Corrective Action Plan and Implementation

3-16.12  CLOSE SUPERVISION

Close supervision of CHRs is the responsibility of the tribal supervisor.  It includes:

1. Job Descriptions:
   1. Qualifications
   2. Services Performed
   3. Professional Supervision
   4. Reporting Requirements
   5. Performance Standards/Evaluation
   6. Continuing Education Requirements
2. Assurance that direct community health care, in accordance with the standards of care and protocol, is taking place.
3. Assurance that an annual evaluation is documented.
4. Assurance that each CHR is familiar with all tribal policies and procedures related to the CHR Program.
5. Assurance that each CHR is provided with regular in-service training.
6. Assurance that each CHR is familiar with the Contract/Grant/Cooperative Agreement SOW.

3-16.13  EVALUATION

Tribal programs will be evaluated on a triennial basis, through the use of a nationally developed instrument, with tribal consultation and concurrence.

3-16.14  RETROCESSION/ASSUMPTION/REASSUMPTION

The retrocession, assumption or reassumption of P.L. 93-638 CHR.  Program shall follow the procedures outlined in the Indian Self-Determination Act and its amendments (P.L. 93-638 and P.L. 100-472).

When a CHR Program is retroceded/assumed, or reassumed, the Area Director or his designee shall put into effect a contract/grant/cooperative agreement with another eligible Indian organization to continue the program.

3-16.15  COMMUNITY HEALTH REPRESENTATIVES INFORMATION SYSTEM (CHRIS)

The CHRIS, a provider-oriented information system, was approved by the Office of Management and Budget through February 1992.

The CHRIS is included in the DHHS, Public Health Service (PHS), IHS, Core Data Set Requirements, which are included in the final regulations implementing the 1988 amendments (P.L. 100-472) to P.L. 93-638.

3-16.16  COMMUNITY HEALTH REPRESENTATIVES MEMORANDA (CHRM) AND COMMUNITY HEALTH REPRESENTATIVES ADVISORY (CHRA)

Purpose The purpose of the CHRA is to establish and communicate guidelines, procedures, policies, standards and other developments affecting IHS operations.

The purpose of the CHRA is to alert the reader in capsulized format, that a particular issue has been addressed, and to highlight the consideration given the issue.  The Advisory provides a means of sharing such information with IHS staff, tribal CHR Program Managers and other interested parties.

Preparation

Prepare a CHRM or CHRA in the format shown in the attached examples.

Prepare the appropriate transmittal letters in the format shown in the attached examples.

Signature

CHRMs are prepared for the signature of the Director, IHS.  CHRAs are prepared for the signature of the Director, CHR Program.  Transmittal letters are signed by the Director, CHR Program.

Number of Copies

1. Make 50 copies of the signed CHRM or CRRA.
2. Make 50 copies of the signed transmittal letter.

Distribution (in the order shown)

1. Distribute 1 copy of the CHRM or CRRA to IRS Contracting staff (see attached distribution list).
2. Distribute 1 copy of the CHRM or CHRA to each IHS Headquarters CHR Program staff member.
3. Distribute 1 copy of the CHRM or CHRA, with appropriate transmittal letter, to IHS Executive Staff and other IHS Headquarters staff.  (See attached distribution list).
4. Distribute 1 copy of the CHRM or CHRA, with appropriate transmittal letter, by telecommunications, to each Area Program Director (insert the date and indicate that it was signed).
5. Mail 1 copy of the CHRM or CHRA, with appropriate transmittal letter to:
   1. Area Office Directors
   2. Area Office Coordinators
6. Place the original document of the CHRM or CHRA and the transmittal letter, in the appropriate CHR file.

IHS/CHR PROGRAM DOCUMENT DISTRIBUTION ACTIONS /____/ CHRM_____
/____/ CHRA_____

TO:    ALL AREA OFFICE DIRECTORS
    

THROUGH:  ALL AREA OFFICE CHR COORDINATORS

ACTIONS:

1. Reproduce copies you receive by WANG and distribute within 10 days to:  (refer to CHRM Distribution List)
   1. Tribal Affairs Directors (List F)
   2. Contracting Officers (List G)
   3. Tribal CHR Program Managers (List H)
   4. IHS/CHR Project Officers (List I)
   5. Service Unit Directors (List J)
2. The CHR Program Coordinator should discuss the content of these documents with the tribal CHR Program Managers and IHS staff to stimulate understanding.
3. Complete items A. - F. for each CHR Program and return this page, by WANG to the IHS Headquarters CHR Program Office within 20 days:
   1. Name of Area_____________________________________________
   2. Date document received by WANG in Area_______________________
   3. Date copies distributed________________________________________
   4. How copies distributed________________________________________
   5. To whom copies distributed_____________________________________
   6. Date(s) discussed document(s) with tribal/IHS leaders:__________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________
      ___________________________________________________________

Experiences, suggestions, comments, or questions should be directed to the CHR Program Office Staff at Headquarters (Room 6A-54) at FTS 443-2500.

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INDIAN HEALTH SERVICE
COMMUNITY HEALTH REPRESENTATIVE PROGRAM
CHRM/CHRA FOLLOWUP FORM

IHS/CHR PROGRAM DOCUMENT DISTRIBUTION ACTIONS:  \CHRM_______
\CHRA_______

Date Sent:_______
Date Follow-up:  (20 days from date)________

CHRM DISTRIBUTION LIST