Part 3, Chapter 16: Manual Exhibit I

Thank you for the Commnity Health Representative (CHR) Program recommendations submitted as part of the National CHR Task Force Report.  In the June memorandum approving the Task Force recommendations, I indicated that a more detailed response would be forthcoming.  Such detailed responses and comments to each Task Force recommendation are contained in the attached document.

Again, I would like to extend my appreciation to the CHR Task Force members and the CHR's involved in the development of these CHR Program recommendations.

1. Future Direction of the CHR Program
   1. That the Community Health Representatives (CHR) program be continued.  In FY 1983 the Congress provided $25 million in the IHS/CHR budget category and $4 million to be used for Emergency Medical Services (formerly budgeted under the CHR program).

      Response:  The IHS recognizes the important and essential health care services provided by CHRs, and will continue to support the goals and objectives of the CHR program and is committed to strengthening the program throughout the IHS.

   2. That the CHR program retain its unique qualities of providing services in areas of need where no other program or resource is available, and that the program not be used to supplement IHS staffing.

      Response:  Concur, this recommendation will continue as a National Program policy.

   3. That the IHS, cognizant of organizational constraints, utilize the perspective of tribal people to enhance program growth and development.

      Response:  The IHS has taken action to establish and organizational structure for a centralized CHR office.  One of the functions within this structure is the specific responsibility to assure public information and tribal involvement in program operations and policy issues.

   4. That a national mandatory reporting system be instituted, which will reflect credit for all services provided by CHRs, i.e., work performance as a dental assistant or as a sanitarian.

      Response:  Concur with this recommendation; the IHS plans to take action to establish a mandatory reporting system.

   5. That the Task Force work in developing a CHR policy manual be continued, with Area/Program and tribal contractor participation.  This manual should define policy and procedures at the Service Unit and Area/Program level.

      Response:  Concur with this recommendation; approval has been given to continue the development of the CHR Policy Manual begun by the National Task Force.  The responsibility for carrying out this recommendation will be part of the functions of the newly established IHS Headquarters CHR office.

   6. That funds should be identified and committed at the National level for the effective Directorship of the CHR program which will provide for:
      1. An IHS Headquarters Program Director position of equal status to other Headquarters Program Director positions.
      2. A National training initiative that provides for Area-based training activities.
      3. A National mandatory reporting activity.

      Further, such funds should evolve from the current "set aside" for administration of this program in an amount no to exceed $400,000.  Once the budget has been determined for FY 1983 this CHR administrative budget breakdown should be distributed to CHR contractors.

      Response:  Concur with this recommendation.  I have appointed Ms. Tonya Parker to serve a s the Acting Director until a position and office can be established.

2. Recommendation Regarding Methods for Meeting CHR Training Needs

   It is recommended:

   1. That hospital corpsmen training be investigated (regarding the Great Lakes area) and that Headquarters follow-up on whether the training arrangement, previously proposed, is currently available so that CHR contractors can take advantage of the training course.

      Response:  The option of an interagency agreement, between the PHS and the Department of the Navy, to provide training for certain CHRs was discussed with the IHS approximately 2 to 3 years ago.  Such an arrangement generated interest and IHS initially explored its feasibility.  However, at the time that the overall structure, appropriate scope and future direction of the CHR Program began to receive considerable attention and study, further exploration was discontinued.

      In conjunction with the national CHR Task Force, the IHS has recently completed a program assessment in preparation for the development of revised CHR program guidelines and requirements.  Such training standards and requirements will need to be consistent with the revised CHR program scope and medical efficiency criteria that will be contained in these guidelines.  As this process progresses, IHS will consider all training possibilities that would best meet the CHR training requirements.  This would be the most appropriate time to consider and further develop the necessary interagency agreement.

   2. That strong emphasis on training for CHR staff be continued as part of the total CHR program.  This training should respond to the training needs identified at the local level and should also be identified in the CHR annual contract proposals with the "dollarized" plan, that related to the capabilities necessary to carry out the scope of work.  Training requirements and funds should then be negotiated into the contracts.  The National CHR training initiative should assist areas in meeting those needs.  Training should be recognized as an integral part of the program and certification/college credits should be given by the agency/institution providing the training.

      Response:  Within the National CHR Headquarters management structure, a CHR training component will be developed and implemented.  This component will address:  the development of options for assessing and meeting training needs and requirements; and, the development of training programs.  The factors mentioned will be considered as this activity progresses.

   3. That every effort should be made by IHS to secure training funds from sources other than the CHR budget, both within and outside of the IHS.

      Response:  Concur.

   4. That a study, with recommendations, be conducted, of past and currently available CHR training activities, to determine their adequacy in meeting training needs.

      Response:  Concur with this recommendation.  This would be a responsibility of the Director of the National CHR Program Office.

   5. That training and certification be carried out in accordance with recognized standards of health care.

      Response:  Concurrence with this recommendation.

3. Development of Recommendation for Methods of Allocating and/or Reallocating Resources to Accommodate Future Budget Increases or Decreases

   It is recommended:

   1. That the Community Health Representative Program cannot endure further budgetary cutbacks.

      Response:  I concur that further budget reductions for the Community Health Representatives Program will further erode the already limited services available in the community.

   2. That resource allocation should avoid competition as this serves to fragment the Indian communities.

      Response:  The act of allocation of resources involves a series of decisions as to the best use of the resources.  I am not sure how one can avoid some degree of competition.  Where all other factors are equal, I concur.

   3. That IHS should discontinue tapping CHR funding before allocation to American Indian and Alaska Native organizations, with the exception of those funds identified in recommendation No. (6) under Future Direction of the CHR Program.

      Response:  I am not aware that CHR funds have been tapped prior to allocation.  In periods of extreme budget constraints, IHS must utilize all resources in ways that provide the best balance to the overall program.

   4. That the IHS develop a methodology for the allocation of community health program resources that will utilize three program modules:  1) scope; 2) effectiveness; 3) needs.  This methodology should be developed with the active participation of an advisory group consisting of Indian and Alaska Native Community Health leaders.

      Program scope criteria should be consistent with those health care delivery settings, functions, and areas which have been delineated for the CHR program by this Task Force.

      Program effectiveness criteria should include factors which measure medical efficacy and cost effectiveness.

      Program needs criteria should be derived from an array of Resource requirement Methodology modules which represent community health care needs which are fulfilled by CHR program resources.

      The development of this methodology should be done in a manner consistent with the staff paper entitled "Consideration Regarding Future Allocation of CHR Resources", included in the National CHR Task Force Report.

      Furthermore, this methodology should be developed in FY 1983.

      Response:  We are already pursuing this recommendation in that three projects have been developed which follow the guidance of recommendation #4.  Implementation of all three projects began in FY 1983.

   5. Recognizing the evaluation of the CHR program from a community outreach liaison health care program to one that particularly provides direct health care services; it is recommended further:  That the CHR line item within the IHS budget be shifted from the IHS budget "Preventive Health" category to the "Clinical Services" category, and that the CHR budget line item status be maintained.

      Response:  The most appropriate category for the CHR program may very well be the clinical services budget category.  Upon further investigation, if this seems to be the most appropriate action, the IHS will carry out this recommendation.

4. Development of Recommendation for Data Collection for CHR Program Review and Congressional Request and Inquiries

   The CHR program has been criticized as not being accountable and not complying with reporting requirements.  The CHR Task Force has addressed these issues and recommends that further efforts be made to improve the reporting system to bring about program accountability.

   It is recommended:

   1. That there be a uniform mandatory reporting system for all programs, and that a clause in each contract be included, mandating it use.  That the data collection system be designed in such a way that information stored and used will be reflective of program accountability.

      It is further recommended that a group consisting of (1) Tom Bonifield, (2) Tonya Parker (3) Ada White, President of the National CHR Association, and (4) a tribal representative be convened by January 15, 1983 to develop and/or adapt a data system, that will provide information for the justification and allocation of CHR program resources at the national level.  The system should receive appropriate review and comment by CHRs before implementation.

      Response:  The CHR reporting system, in effect 1974 through 1981, provided an array of useful information.  However, because of certain problems such as:  (1) error rate; (2) slow turnaround; (3) lack of training for users; (4) need for revisions as the CHR program grew and expanded, the system's use began to decrease and the criticism of its usefulness increased.  When budget cuts began the system was discontinued because if lack of use and the above mentioned reasons.

      After a review of position papers written which contained recommendations regarding the system, it seems that the most cost effective and beneficial means of meeting program needs is to:

      1. Conduct a thorough review of the previous system which has already begun;
      2. revision be made to meet today's data needs at the tribal, Area/Program and Headquarters levels;
      3. reinstate a system to incorporate any redesign, reprogramming or revisions thought necessary;
      4. form a workgroup, including individuals named in the NCHRTF recommendations, to track the establishment of a resisted data system.
   2. It is recommended that the IHS/CHR Manual contain specific reporting requirements.

      Response:  Based on the revised reporting system, the IHS/CHR Manual will contain specific reporting requirements.

   3. It is recommended that CHR reporting requirements must be specified in each contract and that the contractors be held in compliance with these requirements.

      Response:  Concur.

   4. It is recommended that the National CHR Coordinator or Director at IHS Headquarters be assigned the responsibilities for data collection.

      Response:  Concur.  Proposed functional statements have been developed regarding the responsibilities of a CHR Program Director.  Included in those responsibilities is data collection.

   5. It is recommended that data collection from other program activities which has already been collected by IHS, be used by inference, when appropriate, to credit the CHRs.
   6. The accountability of the CHR Program has been limited, due to a lack of and the use of a nation-wide reporting system.  An adequate reporting system for all CHR programs is crucial because of the great variance among CHR programs.  As an absolute minimum, the reporting system should produce accumulative data on each CHR activity by specific health care delivery, function and area.  This method will produce the accountability of the CHR program and still retain the program's flexibility at the tribal level.  Hard statistical data of this nature has never been utilized in justification of the program.
   7. It is recommended that the IHS explore analyzing statistics in terms of declines in mortality and morbidity, that have occurred since the CHR programs began, particularly tuberculosis and infant mortality.
   8. It is recommended that the data collected by IHS be distributed back to the Tribes for their use and that IHS be responsible for providing meaningful interpretation of this data.

      Responses:  (5. - 8.)  Concur with recommendations 5-8, and will request that in the development of the redesign of the reporting system, these recommendations be considered.

5. Recommendations Added at the Final CHR Task Force Meeting in Phoenix, Arizona The National CHR Task Force Recommend:
   1. That no more than 15% of CHR program resources be expended for administrative costs, both direct and indirect.  Funding of direct administrative costs should have priority over indirect costs.  Allowable administrative costs in excess of 15% should be secured from funding sources other than CHR program resources.

      Response:  This recommendation reflects the current IHS policy regarding CHR program administrative costs.

   2. Than an evaluation of the CHR program should be conducted in a manner that allows for measurement of its medical efficacy and cost effectiveness on a health care delivery function and area specific basis.

      Response:  Approval has been given to three projects which together make up the evaluation component which does allow for the measurement of CHR program medical efficacy and cost effectiveness.  The IHS initiated all three of these projects by June 1983.

   3. That the FY 1983 CHR contract and grant scopes of work be developed consistent with the health care delivery functions, areas, and settings, as defined in the first report of the Assessment of Indian and Alaska Native CHR Program Resource Distribution.  All CHR program contract and grant scope of work, which will be monitored to assure compliance as recommended.

      Response:  The final report of the Assessment of Indian and Alaska Native CHR Program Resource Distribution has been complete.  This report includes contract audit of all 218 CHR program contract and grants scope of work, which will be monitored to assure compliance as recommended.

   4. That the second phase of the IHS/CHR program assessment project, as described in the project summary dated April 25, 1982, be conducted as soon as possible.  The second phase of the project will include a review of all 234 CHR program contracts with, the primary objective of determining the health care delivery functions and the areas to which they relate.  It is expected that the base information gained through this phase of the assessment will be valuable in the future management and direction of the CHR program.

      Response:  The second phase of the project, including a review of 218 CHR program contracts, has been completed.  This information will be utilized to proceed with the development of a revised CHR program contract and grants scopes of work.