Chapter 19 - Urban Indian Health Program
Part 3 - Professional Services
- Purpose. The purpose of this chapter is to establish policy, procedures and responsibilities for the Urban Indian Health Program in the Indian Health Service (IHS). Under the authority of the Snyder Act of November 2, 1921 (25 United States Code 13), the IHS is authorized to enter into contracts and grants with nonprofit urban Indian organizations.
The purpose of these formal agreements is to assist such organizations in the establishment and administration of urban Indian health programs and related activities as authorized by Title V, "Health Services for Urban Indians," of the Indian Health Care Improvement Act (IHCIA) (9/30/76), Public Law (P.L.) 94-437, as amended.
- Background. The advocacy of urban Indian community leaders in the 1960s recognized the growing unmet health needs of Indian people residing in urban areas. It was through their efforts that Indian organizations were formed. During that period these Indian organizations provided community health services and developed community volunteer-run clinics operating on limited budgets.
In 1972, under the authority of the Synder Act, Congress appropriated funds for pilot urban Indian health programs in Minneapolis, Seattle, and San Francisco. These programs documented cultural barriers, economic barriers, and lack of access to health care for urban Indians. This information was utilized in the passage of Title V, "Health Services for Urban Indians," of the Indian Health Care Improvement Act (9/30/76), Public Law (P.L.) 94-437.
This law is considered the landmark legislation to improve the health and well-being of all American Indian and Alaska Natives (AI/AN), including those who live in urban areas.
Title V of the Act, "Health Services for Urban Indians," specifically authorized health outreach and referral and the delivery of health services to AI/AN people who have migrated to urban settings. Amendments to Title V have strengthened these programs to expand direct medical services, alcohol services, mental health services, AIDS services, and health promotion and disease prevention services.
- Policy. It is the policy of the IHS to: (1) ensure that within available resources, a comprehensive program of health services or access to health services is developed for each urban Indian community; (2) support community programs to prevent alcoholism and substance abuse; (3) ensure that eligible patients or clients, regardless of age or sex, have access to and are provided high quality health care services; and (4) evaluate and monitor program performance of IHS-supported urban Indian health programs.
- Goals. The goals are to assist in elevating the health status of urban AI/ANs to the highest possible level; assist urban AI/AN organizations to establish and improve health services designed to meet the needs of the urban AI/AN community; and to assess unmet needs of AI/ANs who reside in urban centers.
- Objectives. The objectives are:
- To provide assistance to IHS staff for IHS-supported urban Indian health programs in the development of a comprehensive, culturally sensitive, health services delivery program based upon unmet needs of the urban Indian population.
- To provide guidance for a comprehensive, accessible network of local community resources for the delivery of ambulatory health care services. Such a network shall be provided through direct or subcontracted services, or through formal and informal agreements.
- To provide direct health care services for AI/ANs to include primary care, behavioral health, community health, health promotion and prevention programs, and other programs that target unmet needs.
- Definition of Urban Center
Urban center means any community which has a sufficient Indian population with unmet health needs to warrant assistance under Title V, Indian Health Care Improvement Act, as determined by the IHS.
- Definition of Urban Indian Organization
Urban Indian organization means a nonprofit corporate body situated in an urban center governed by a board of directors of whom at least 51 percent are AI/ANs, for the purpose of establishing and administering an urban Indian health program and related activities as described in Title V of the Indian Health Care Improvement Act.
- Eligibility for Grants and Contracts
To be eligible for a grant or a contract, an urban Indian health program (UIHP) must be a nonprofit corporate body situated in an urban center and governed by a board of directors.
- Provision of Services
The IHS will enter into grants and contracts with urban Indian organizations for the provision of health care and referral services to AI/ANs who reside in the urban area. The scopes of work in the contracts and grants agreement shall be based on the unmet needs of the urban AI/AN community to be served.
- Determination of Eligibility for Services
Determination of eligibility for services must be in accordance with P.L. 94-437. Specifically, any AI/AN who resides in an urban center, and who meets one or more of the following criteria is eligible for services:
- Is a member of a tribe, band, or other organized group of AI/ANs, or is descendent in the first or second degree of any such member. This includes membership in tribes, bands, or groups terminated since 1940, as well as those recognized now, or in the future, by the State in which they reside. The individual does not have to live on or near a reservation.
- Is an Eskimo or Aleut or other Alaska Native.
- Is considered by the Secretary of the Interior to be an AI/AN for any purpose.
- Is determined to be AI/AN under any regulations promulgated by the Secretary of Health and Human Services (P.L. 94-437, Section 4, DEFINITIONS).
- Headquarters
- The Director, IHS, Associate Director, Office of Health Programs (OHP) is responsible for the overall implementation and monitoring of all the legislative and regulatory requirements and IHS policies of IHS funded urban Indian health programs.
- Urban Indian Health Programs Branch
The Urban Indian Health Programs Branch (UIHPB) is responsible for carrying out the provisions of Title V and for providing central oversight of the programs and services authorized under Title V.
The Chief, UIHPB, on behalf of the Associate Director, OHP, is responsible for the following:
- Developing and implementing guidelines, standards, policies and procedures, resource allocation methodology, and training for the implementation of Title V.
- Coordinating, reviewing and monitoring urban Indian health programs for compliance with standards.
- Providing technical assistance and support to IHS Area, urban Indian health programs and other Federal, State, local and urban Indian organizations.
- Coordinating reports and responses to inquiries related to the urban Indian health programs, to the IHS Director, Public Health Service (PHS), Department of Health and Human Services (HHS), the Congress, and the President, tribal/urban organizations, and other interested organizations and individuals.
- Ensuring compliance with the FMFIA by establishing and implementing a management control system in the IHS UIHP in accordance with the Indian Health Manual Part 5, Chapter 16.
- Grants Management Officer. Responsibilities of the Headquarter's Grants Management Officer (in coordination with authorized program officials) shall be in accordance with the PHS Grants Administration Manual and Title V, Section 503.(a), "Contracts and Grants for the Provision of Health Care and Referral Services," and shall include but not be limited to the following:
- Ensures an objective review process for grant applications and grant awards.
- Interprets and implements grants management policies and procedures.
- Ensures the effective use of funding and that grants are awarded in a timely manner. Reviews financial status reports and progress reports.
- Ensures that all PHS Grants Administration Manual requirements are carried out and all legislative and regulatory requirements are met.
- Provides business management consultation and technical assistance to grantees.
- Evaluates prior approvals, equipment requests, and requests for grant modifications.
- Area Offices
The IHS Area offices shall have administration, management, evaluation, contract/grant monitoring, and funding responsibilities. The IHS Area offices will provide urban Indian health programs the support and assistance required to fulfill the contract requirements in accordance with Title V of the IHCIA.
- Area Director. Responsibilities of the Area Director include but are not limited to the following:
- Providing technical assistance and program support to ensure that a comprehensive urban Indian health program is developed for each urban AI/AN community within available resources.
- Ensuring the implementation of national policies and procedures for administering, managing, monitoring and evaluating the urban Indian health programs at the Area level, in consultation with the UIHPB.
- Ensuring that contract or grants are awarded and monitored in accordance with established regulatory guidelines and policies.
- Assigning and supporting the Area Urban Indian Health Programs coordinator and project officer.
- Area Program Coordinator. Responsibilities of the Area Urban Indian Health Program Coordinator include but are not limited to the following:
- Serves as the primary liaison between the IHS Area office and Headquarters on urban AI/AN health affairs.
- Ensures coordination of administrative, management, evaluation, and analysis activities within the IHS Area and service unit of IHS funded urban Indian health programs.
- Management Control System - ensures coordination of the corrective action plan (CAP) process in the Area office, which includes:
- Identifying any urban Indian health program weaknesses and assisting in developing CAPs within a reasonable, specified timeframe.
- Ensuring that CAPs are completed and forwarded along with a status report to the Chief, UIHPB, at IHS Headquarters East.
- Coordinates the technical assistance and training to meet the needs of the Urban Indian Health Programs.
- Ensures the coordination of urban Indian health programs with interested Federal and non-Federal agencies and institutions.
- Coordinates the development, implementation, revision, and integration of Area activities for the improvement of urban Indian health programs.
- Ensures that the urban Indian health programs are evaluated in the manner described in this chapter, Section 3F, "Program Evaluation and Review."
- Provides consultation on Urban Indian Health Program services to Area Directors, Area staff, and other outside agencies.
- Ensures that the institutional file for each urban Indian health program is current and updated as changes occur.
- Area Contract/Grants Project Officer. The responsibilities of the Area contract/grants project officer shall be in accordance with Title V, Section 503. (a), "Contracts and Grants for the Provision of Health Care and Referral Services," and shall include but not be limited to the following:
- Reviews and understands the general and specific terms and conditions of the contract or grant and Title V of the IHCIA.
- Participates in the writing and implementation of CAPs.
- Advises and reports to the contract/grants officer on the progress of the work.
- Makes site visits as necessary to review contractor/grantee performance and to provide technical assistance.
- Assists the contractor/grantee in the resolution of problems encountered in the performance of the contract or grant.
- Receives requests from and initiates training and technical assistance to urban Indian health programs.
- Monitors program performance and recommends changes when required.
- Reviews and recommends for approval all invoices for payment under the contract, progress reports, modification requests, subcontracts, or property acquisitions requests.
- Participates in the annual Urban Indian Health Programs evaluations.
- Area Contracting Officer. Responsibilities of the Area contracting officer shall be in accordance with Title V, Section 503.(a), P.L. 94-437 "Contracts and Grants for the Provision of Health Care and Referral Services," and shall include but not be limited to the following:
- Ensures all legislative and regulatory requirements are included in contracts and are monitored in accordance with the contract requirements and Title V, Section 503.(a).
- Negotiates and administers all Urban Indian Health Program contracts.
- Ensures physical property (equipment, facility, and etc.) is accounted for.
- Ensures all contract requirements are completed upon completion of contract.
- Responds to other agencies concerns on contract activities.
- Makes the final decisions regarding the Urban Indian Health Program's contracting responsibilities.
- Approves CAPS in accordance with contracting and Title V regulations.
- Ensures implementation and monitoring of the HHS/PHS/IHS Justification for Other than Full and Open Competition.
- Area Director. Responsibilities of the Area Director include but are not limited to the following:
- Service Units
Service Unit Director. The service unit director's responsibilities are to provide technical assistance and program support, and to advise the Area Director and the Chief, UIHPB, IHS Headquarters, on the needs of urban AI/ANs within the service unit's jurisdiction.
Ensures that a comprehensive health program is developed for each urban AI/AN community and integrated into the healthcare delivery system within the service unit's jurisdiction.
- Urban Indian Health Program
The responsibilities of the contractor/grantee funded to provide health care services and referral services include but are not limited to the following:
- Ensure that health care services are of the highest quality consistent with recognized health care standards and provided with respect for the rights and dignity of the client.
- Ensure planning, monitoring, evaluation, and operation of urban Indian health programs and the development and implementation of policies and procedures governing the delivery of health care.
- Ensure that all services are developed in response to the unmet needs of the local urban Indian community.
- Ensure that all services are appropriately documented and reported in compliance with contract/grant requirements and certifying agencies.
- Ensure that program activities are appropriately modified as a result of evaluation assessments and the certifying agency's requirements.
- Ensure that program services are developed and provided in conformity with minimum national or applicable State and local standards, whichever is the most thorough and comprehensive to ensure the quality and effectiveness of operations and services.
3-19.3 ADMINISTRATION/MANAGEMENT
- Purpose. The purpose of this section is to provide guidelines for the development and implementation of the IHS urban Indian health programs.
- Goals. The goals are to establish minimum requirements for the management of urban Indian health programs that include the following:
- Ensuring that quality health services are provided to clients of IHS funded urban Indian health programs.
- Ensuring that the legislative requirements of P.L. 94-437, as amended, are implemented in accordance with the law.
- Objectives
The major objective of this section is to provide criteria for development of quality health services and outreach and referral programs responsive to the needs of urban AI/AN communities. This section identifies structural issues that must be met for the successful development and maintenance of the program.
Adherence to standards in the IHS Urban Program Review Manual is required. Local programs may establish additional criteria as policy and procedure manuals are completed for their program components.
- Management Aspects
The IHS funded Urban Indian Health Programs shall be managed in accordance with the criteria outlined in the IHS Urban Program Review Manual for each of the following areas:
- Governance
- Administration
- Financial Management
- Facilities, Environment, and Safety
- Medical Program Management
- Dental Program Management
- Outreach/Community Services
- Transportation
- Allied Health Services
- Quality Assurance
- Medical Records
- Patients Rights and Responsibilities
- Contract Services
- Substance Abuse Services
- Scope of Services
- Within the mission and goals to elevate the health status of AI/ANs to the highest level possible, the following health services may be provided by an urban Indian health program. The services can be delivered directly by a subcontract or through a referral process. The specific scope of work will depend on the negotiated contract or grant.
Primary Health Services
- Family Planning
- Prenatal Care/Obstetrician/Gynecologist
- Well Child Care
- Adolescent Care
- Well Adult Care
- Dental Diagnostic, Treatment, and Preventive Services
- Periodic Screening (Child/Adult)
- Acute Episode Medical Care
- Management of Chronic Medical Problems
Support Services
- Laboratory (Basic Diagnostic)
- Diagnostic X-ray
- Pharmacy
- Medical Specialty Consultation
- Aftercare
Substance Abuse Services
- Prevention
- Treatment
- Rehabilitation
- Education
Allied Health Services
- Mental Health
- Social Services
- Health Education
- Nutrition Assessment & Education
- Transportation
- Home Health Services
- Community Health Services (Outreach/Referral)
- Substance Abuse Counseling
- Optometry
- Podiatry
- Community Health Nursing
- Traditional healing
- For each of the services provided there must be written protocols for delivery.
- For each of the services provided there must be a quality assurance program to ensure health services are being provided in accordance with the IHS Urban Program Review Manual.
- Within the mission and goals to elevate the health status of AI/ANs to the highest level possible, the following health services may be provided by an urban Indian health program. The services can be delivered directly by a subcontract or through a referral process. The specific scope of work will depend on the negotiated contract or grant.
- Program Evaluation and Review
- On-site Evaluations. The IHS must conduct annual on-site evaluations of urban health programs using the IHS Urban Program Review Manual criteria, the Urban Indian Health Programs Common Reporting Requirements annual reports, and IHS Categorical Program Standards.
- Verification of Current Accreditation. The IHS will annually verify the current accreditation by the Joint Commission of Accreditation of Health Care Organizations, Health Care Finance Administration, or other recognized accrediting body, to satisfy compliance with the IHS Urban Program Review Manual criteria, for applicable services.
- Noncompliance or Unsatisfactory Performance.
Based on paragraphs 1 and 2 above, if the urban Indian health program does not meet contract/grant performance standards, the IHS will take immediate corrective action. The action must meet the requirements set forth in Title V of the Indian Health Care Improvement Act, Sec. 505, "Evaluations and Renewals."
If the items of noncompliance or unsatisfactory performance cannot be resolved, the contract or grant awarded the urban program will not be renewed. The contract or grant can then be made available to another urban Indian organization in that same urban center to provide the Urban Indian Health Program services.
- IHS Urban Program Review Manual Criteria Not Required. It's possible that all sections of the program evaluation criteria may not be needed. If there are no major changes in the contractor's scope of work or in the policies and procedures, some sections may be identified as not applicable.
The project officer can make a professional judgment that a comprehensive review using the IHS Urban Program Review Manual criteria was not required. The project officer's decision must be documented as part of the annual review program requirements.
- Resource Allocation
Resources appropriated by the Congress for urban AI/AN health programs shall be distributed to urban AI/AN Title V contractors/programs, based on a resource allocation methodology. The methodology must be developed in consultation with the urban AI/AN health programs.
- Urban Health Services Contracts/Grants Requirements
- Contract Requirements
- Purpose. The purpose of the contract is to provide high quality health care and referral services consistent with the recognized health care standards and with respect for the rights and dignity of the urban AI/ANs residing in urban centers.
- Criteria. The following are the contract criteria:
- Estimate the population of urban AI/ANs residing in the urban center.
- Estimate the current health status of AI/ANs in the urban center.
- Estimate the current health care needs of urban AI/ANs in the urban center.
- Identify all public and private health service resources in the urban center that are or may be available to urban AI/ANs.
- Determine the use of public and private health services resources by the urban AI/ANs in the urban center.
- Assist the local health care services organization in providing high quality services to urban AI/ANs.
- Assist in becoming familiar with and using the local health services resources.
- Provide basic health education, including health promotion and disease prevention education, to urban AI/ANs.
- Establish and implement training programs to accomplish the referral and educational tasks of:
- Assisting local health services resources in providing services to urban AI/ANs.
- Assisting urban AI/ANs in becoming familiar with and using the local health services resources.
- Providing basic health education, including health promotion and disease prevention education, to urban AI/ANs.
- Identify gaps between unmet health needs of urban AI/ANs and the resources available to meet those needs.
- Make recommendations to the IHS and Federal, State, local, and other resource agencies on methods of improving health service programs to meet the needs of urban AI/ANs.
- Where necessary, provide or enter into contracts for the provision of health care services for urban AI/ANs.
- Needs Assessment Contracts
- Purpose. The purpose of the contracts is to conduct activities to assist the IHS in assessing the health status and health care needs of AI/ANs in urban centers not served under an IHS contract and determining whether the IHS should contract with the organization for urban AI/AN health services within available funds.
- Requirements. Any assessment contract will require the urban AI/AN organization to:
- Document the health care status and unmet health care needs of urban AI/ANs in the urban center.
- Determine the size of the AI/AN population in the urban center.
- Determine accessibility to and use of other health care services by AI/ANs in the urban center.
- Determine the extent, if any, to which potential urban AI/AN health service contract requirements would duplicate any existing private or public health services projects.
- Determine the extent of existing or likely future participation in urban AI/AN health services required activities by appropriate health and health-related Federal, State, local, and other agencies.
- Complete performance of the contract within one calendar year.
- Contract Renewal. Contracts for the determination of unmet health care needs are not renewable.
- Grants Program.
- Purpose. The purpose of the grants program is to provide health-related substance abuse services in accordance with Title V of the IHCIA:
- Prevention of alcohol and substance abuse
- Treatment of alcohol and substance abuse
- Alcohol and substance abuse rehabilitation
- School or community based alcohol and substance abuse education
- Criteria. The following are the grants program criteria:
- Estimate the size of the urban AI/AN population, defined as number of project users and service area population.
- Estimate accessibility to and utilization of other health resources available to the population. Utilization is defined as the number of AI/ANs served by all substance abuse programs in the service area of the AI/AN population.
- Estimate duplication of existing IHS or other Federal substance abuse grants or contracts. Duplication is defined as providing the same service to the same clients.
- Determine the capabilities of the organization to adequately perform the grant program activities. Adequate performance of the grant activities is determined by the relative performance score on the administrative, financial, governance, and substance abuse portions of the IHS Urban Program Review Manual criteria.
- Establish satisfactory performance standards for the organization in meeting the goals set forth in the grant. Satisfactory performance in meeting the goals is determined by the relative performance toward meeting the grant objectives.
- Establish the identification of need for services. Identification is defined as those factors established by local, State, and national health agencies as drug/alcohol related mortality rates for the service area AI/AN population.
- Purpose. The purpose of the grants program is to provide health-related substance abuse services in accordance with Title V of the IHCIA:
- Contract Requirements
- TECHNICAL ASSISTANCE
All questions regarding interpretation, implementation, or technical assistance incidental to this issuance should be addressed to IHS Headquarters, Attention: Chief, Urban Indian Health Program Branch, Indian Health Service, Parklawn Building, Room 5A-41, 5600 Fishers Lane, Rockville, Maryland 20857, (301) 443-4680.
For grants and contracts questions (administrative and programmatic) the urban health program should contact the assigned Area project officer, or write directly to the Area contracting officer.
- ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) PROGRAM
- Scope of Work. The contractor shall provide the following services for the AIDS Education and Prevention Activities:
- Provide AIDS education workshops to the AI/AN community.
- Provide AIDS education and counseling to AI/AN clients potentially practicing high risk behavior for AIDS.
- Develop formal referral agreements with other AIDS community resources.
- Provide general public education on AIDS through the dissemination of information in newsletters, brochures, and other informative materials.
- Provide Human Immune Deficiency Virus (HIV) testing, pre-test and post-test counseling to AI/ANs requesting HIV testing.
- Conduct in-service AIDS training for staff members.
- Reporting Requirements.
- Quarterly Report. The contractor shall provide two copies of a quarterly report listing actual activities compared to scope of work activities as detailed in Section 3-19.9A, Reports. The quarterly report must be submitted to the IHS Area project officer within 10 days following the end of each quarter. The Area project officer will send a copy to the Area contract/grants officer, and to the Chief, Urban Indian Health Programs, IHS Headquarters East, Rockville, Maryland.
- IHS URBAN AIDS ACTIVITY REPORT. The contractor shall provide a report that will include the following information, titled: IHS URBAN AIDS ACTIVITY REPORT FOR FISCAL YEAR ____:
- Background
- Goals and Objectives
- Description of how AIDS funding was spent and on what activities.
- Summary
- Final Report. Two copies of the final report will be submitted to the IHS project officer. The project officer will then send a copy to the Area contracting officer and the Chief, Urban Indian Health Programs, IHS Headquarters East, Rockville, Maryland.
- Scope of Work. The contractor shall provide the following services for the AIDS Education and Prevention Activities:
- HEALTH PROMOTION AND DISEASE PREVENTION PROGRAM. The purpose of the grants is to facilitate access to or to provide health promotion and disease prevention services.
- IMMUNIZATION SERVICES PROGRAM
- Purpose. To facilitate access to or to provide immunizations against vaccine-preventable diseases to urban AI/ANs without charge.
- Grant Criteria.
- Estimate size of the urban AI/AN population.
- Estimate immunization levels of the urban AI/AN population, particularly infants, children, and the elderly.
- Establish use of alternative low or no-cost immunization resources.
- Establish capability of the urban AI/AN organization to carry out the immunization services.
- MENTAL HEALTH SERVICES PROGRAM
- Purpose. To prepare assessments of the mental health needs of the urban AI/AN community. Assess the mental health services and other related resources available to the urban AI/AN community, and the barriers to obtaining the services and resources required. This assessment shall also estimate the unmet needs of those services and resources.
- Outreach, Educational, and Referral Services. Provide outreach, educational, and referral services in relation to:
- Availability of direct mental health services.
- Education of urban AI/ANs about mental health issues and services.
- Coordination with existing mental health providers.
- Outpatient Mental Health Services. To provide outpatient mental health services to urban AI/ANs, which may include the following:
- Identification and assessment of illness:
- Therapeutic treatments
- Case management
- Support groups
- Family treatment
- Other treatment
- Development of innovative mental health service delivery models that incorporate Indian cultural support systems and resources.
- Identification and assessment of illness:
3-19.5 REPORTS. All urban AI/AN health programs funded under the Indian Health Care Improvement Act, Title V, must submit the following reports to the project officer:
- Semi-annual Urban Indian Health Programs Common Reporting Requirements report. The Urban Indian Health Programs Common Reporting Requirements must be submitted semi-annually.
- Quarterly Report
- Detailed information on activities conducted by the urban AI/AN program pursuant to the contract or grant.
- Detailed accounting of the amount of contract funds, and the purpose for which they were spent.
- Identification of gaps between unmet health needs of urban AI/ANs and the resources available to meet those needs.
- Estimation of the current health status of Indians residing in urban centers.
- Recommendations to the IHS and other Federal, State, and local resource agencies on methods of improving health service programs to meet the needs of urban AI/ANs.
- Quarterly Progress Report. The urban AI/AN programs funded under Section 511, Title V, of the Indian Health Care Improvement Act must submit a quarterly program progress report detailing activities conducted toward meeting project goals and objectives.
The IHS is authorized to allow an independent annual financial audit conducted by a certified public accountant as a cost under any contract/grant funded under Section 503, Title V, of the Indian Health Care Improvement Act.
