Chapter 16 - Community Health Representative Program

3-16.1 INTRODUCTION

1. Purpose . This chapter establishes goals, objectives, responsibilities, and requirements for the Indian Health Service (IHS) Community Health Representative (CHR) Program with recommendations for Tribal and Urban Indian communities. Tribes and Tribal Organizations predominantly carry out the CHR Program activities through contracts and compacts with IHS under the Indian Self-Determination and Education Assistance Act (ISDEAA), 25 U.S.C. § 5301 et seq.
2. Background . The CHR Program was established by Congress in 1968 in response to the expressed needs of American Indian and Alaska Native (AI/AN) governments, organizations, and the IHS for a health care program that would provide a community outreach component to meet specific Tribal health care needs. Community Health Representatives are frontline public health workers who provide outreach, education, patient-centered care, informal counseling, social support, and advocacy services.
3. Authorities .
   1. Indian Health Care Improvement Act, 25 U.S.C. § 1601 et seq., including 25 U.S.C. § 1616 – “Community Health Representative Program”
   2. Snyder Act, 25 USC § 13
   3. Transfer Act, 42 USC § 2001
4. Goals . The goals of the IHS CHR Program are to:
   1. Improve health and human service care management for patients and communities;
   2. Improve the prevention and management of health conditions; and
   3. Monitor program processes and outcomes at the CHR, patient, community, and health and social system levels.
5. Policy . The IHS will ensure that this policy applies to all IHS CHR Programs in all stages of planning, implementation, and assessment of CHR services and activities and, as appropriate, to all Tribal CHR Programs while respecting AI/AN communities’ inherent cultural strengths and unique challenges.

3-16.2 ORGANIZATION AND STAFF RESPONSIBILITIES

1. Director, Indian Health Service . The Director of IHS is responsible for supporting and promoting a comprehensive CHR Program as defined by this chapter.
2. Chief Medical Officer . The IHS Chief Medical Officer (CMO) is administratively responsible for the issuance of this policy.
3. Director, Office of Clinical and Preventive Services . The Director of the Office of Clinical and Preventive Services is responsible for developing and facilitating IHS-wide CHR policies, standards, initiatives, and procedures.
4. National Community Health Representative Consultant . The National CHR Consultant serves as the coordinator, consultant, and advisor for all matters relating to the provision of CHR Programs and services throughout the IHS.
5. Area Director . The Area Director is responsible for:
   1. Ensuring that administrative support and necessary resources are available at the IHS CHR Programs in their respective Areas in order to implement this policy; and
   2. Ensuring that this policy is fully implemented.
6. Area Chief Medical Officer . The CMO is responsible for:
   1. Monitoring the IHS Area facilities; and
   2. Ensuring compliance with this policy.
7. Area Community Health Representative Consultant . The Area CHR Consultant serves as the Area-level coordinator, consultant, and advisor to the National CHR Consultant, Area Director, Area program staff, and health care facility staff on all matters relating to the provision of CHR services. The Area CHR Consultant also responds to Urban Indian health programs as needed.
8. Facility Chief Executive Officer . The Facility Chief Executive Officer (CEO) is responsible for ensuring that:
   1. The CHR Supervisor develops the facility’s CHR policy;
   2. The policy is fully implemented and reviewed in accordance with Area Governing Board procedures; and
   3. The CHR Supervisor is informed about all policy changes that affect or concern the CHR Program.
9. Program Supervisor . Serves as the coordinator, consultant, and advisor to the Area CHR Consultant, facility CEO, and facility staff on all matters relating to the provision of CHR services. The Program Supervisor is responsible for ensuring that:
   1. Direct community health care is provided within the parameters of the CHR Scope of Work (SOW) and in accordance with the CHR Standards of Practice (SOP);
   2. All program reviews, assessments, and annual reporting are documented as a part of the yearly evaluation process;
   3. Each CHR is familiar with all policies and procedures related to the CHR Program;
   4. Each CHR and supervisor completes the required online CHR training;
   5. Each CHR is provided with regular in-service training;
   6. Each CHR is provided the opportunity to receive the required continuing education;
   7. Each CHR maintains a record of continuing education; and
   8. Each CHR is familiar with the CHR Program SOW.
10. Indian Self-Determination and Education and Assistance Act . The Indian Self-Determination Education and Assistance Act (ISDEAA) (Code Pub. L., 93-638, 25 USC §§ 5301 et seq.) , also known as Public Law 93-638, authorizes Indian Tribes and Tribal Organizations to contract for the administration and operation of certain Federal programs that provide services to Indian Tribes and their members. Under the ISDEAA, Tribes and Tribal Organizations have the option to either (1) administer programs and services the IHS would otherwise provide under Title I of the ISDEAA (referred to as Title I Self-Determination Contracting) or (2) assume greater control over health care programs and services that the IHS would otherwise provide under Title V of the ISDEAA (referred to as Title V Tribal Self-Governance Compacting). These options are not exclusive; Tribes may choose to combine them based on their individual needs and circumstances. Tribes and Tribal Organizations that have assumed programs, functions, services, and activities may request consultation services from the IHS.

3-16.3 PROGRAM REQUIREMENTS

The IHS CHR Programs will operate according to an SOW, including a CHR SOP, Health Information Management (HIM) procedures, training, and knowledge-based requirements established under 25 U.S.C. § 1616.

1. Scope of Work . Serves as a mutually agreed-upon document for IHS-directed CHR Programs and tribally contracted programs based on the IHS CHR SOP, the National CHR Strategic Plan, and the community's health priority areas. The SOWs will vary based on the capacity and needs of the community approved by the Tribal government.
2. Standards of Practice . The SOP is an all-inclusive list of the CHR occupation's roles and competencies, and it serves as the minimum applicable to a CHR Program's SOW. Additional roles and scope may be developed and approved by the Tribal governing body serving the community. These SOPs align with the national Community Health Worker Core Roles & Competencies and the US Department of Labor Standard Occupational Classification (21-094).

   The CHR performs the roles in the SOP, including the following:

   1. Serve as a Cultural Liaison among individuals, communities, and health and social service systems;
   2. Provide culturally appropriate health education and information;
   3. Participate in care and resource coordination, case management, and system navigation;
   4. Provide coaching and social support;
   5. Advocate for and strengthen the capacity of individuals, families, and communities;
   6. Provide direct service;
   7. Implement individual and community assessments;
   8. Conduct outreach; and
   9. Participate in evaluation and quality improvement projects.
3. Health Information Management .
   1. Documentation . The CHR will document all patient and health encounters using the Resource and Patient Management System (RPMS), Electronic Health Record, or equivalent documentation system.
   2. Resource and Patient Management System, Community Health Representative, Patient Care Component Records . The CHR will follow, at a minimum, documentation standards set forth by their institution, organizational standards, and billing resources.
   3. Confidentiality . The patient record is confidential and will only be accessed by the CHR providers for official medical, quality, and operational use. The information must be handled in accordance with all applicable Federal privacy laws, including the Privacy Act of 1974, as amended, and the Health Insurance Portability and Accountability Act of 1996, as amended, and will follow the requirements outlined in IHM 3-3, "Health Information Management."
   4. File Management . The CHR staff will maintain all patient records and administrative files in accordance with the IHS file management guidelines. (See IHM 5-15, "Records Management Program.")
4. Training . The training component ensures proficiency in CHR SOP and relevant services, skills, and knowledge base.
   1. Community Health Representative Training . Provides nationally accredited CHR training on the IHS CHR SOP to all IHS CHR-funded employees. Each employee occupying a position supported by IHS CHR funds must complete the CHR Training E-learning course within ninety (90) days of hire. The IHS CHR employee receives a certificate upon completion.
   2. Specialty Community Health Representative Training . Provides current information to increase proficiency in specialty areas relevant to the CHR SOP. The IHS CHR employee receives a certificate upon completion.
   3. Advanced Community Health Representative Training . Provides training on advanced CHR roles related to the IHS CHR SOP. The IHS CHR employee receives a certificate upon completion.
   4. Continuing Education . After completing the CHR training, CHRs will complete at least 20 hours of online or in-person continuing education every two years.
5. Knowledge Base . The knowledge base informs CHR Programs on topic areas to meet the needs of CHRs in all settings. Areas may include but are not limited to, social determinants of health, basic medical terminology, anatomy and physiology, standard disease process screenings, public health principles, health promotion, disease prevention, environmental health, and knowledge of local, state, and Federal health and social service systems.

3-16.4 PROGRAM ASSESSMENT

Pursuant to 25 U.S.C. § 1616, the IHS maintains responsibility for reviewing and evaluating the work of community health representatives. The IHS CHR Programs will use program reviews and annual reports to determine the accessibility and quality of its health services. The IHS also uses program assessments to gauge and evaluate the manner and extent to which Federal programs achieve intended objectives. The IHS uses this information to make management decisions, which are also recommended for Tribal and Urban program adoption.

1. Program Reviews . Reviews conducted pursuant to this policy apply to the IHS direct service programs and are recommended applications for Tribal and Urban Indian health programs conducted by the Area CHR Consultant as requested. The program review process will:
   1. Determine the effectiveness of the CHR Program as evidenced by the RPMS CHR Patient Care Component Reporting, where applicable.
   2. Assess the attainment of CHR Program priorities, goals, and objectives incorporated from the National CHR Strategic Plan.
   3. Assess program administration, policies, procedures, and/or problem areas, including program support issues such as staffing, equipment, supplies, training, etc.
2. Annual Report . The year-end Annual Report will include the following:
   1. Indicators for reach and impact to include:
      1. Total number of CHRs;
      2. Total number of unduplicated patients;
      3. Total number of patient encounters;
      4. Total number of patient encounters for chronic disease services;
      5. Total number of patient encounters by health category;
      6. Total number of patient encounters by service provided;
      7. Total number of referrals made to CHRs and type of referral;
      8. Total number of referrals made by CHRs and type of referral; and
      9. Total number of CHRs completing continuing education.
   2. The National CHR Strategic Plan identifies priority areas to be addressed and monitored. The IHS CHR Programs will choose a minimum of one objective and strategy per priority area to report on annually using progress indicators. The report will include the following:
      1. A narrative summary of the approach used to address the priority, goal, and objective; and
      2. A description of the measure to mitigate the issue or problem.