COMMUNITY HEALTH REPRESENTATIVE (CHR)
DO YOU KNOW WHEN THE FIRST GROUP OF CHR’s WERE TRAINED?
The CHR programs were first initiated in 1968. CHR’s are American Indians and Alaska Natives who are specially trained to provide health care, health promotion, and disease prevention services to the communities where they live. Working along with the health care team, they provide a valuable service to their community members.
(Excerpts from 1974, A Study of Indian Health Service and Indian Tribal Involvement in Health; Department of Health, Education and Welfare)
The Community Health Representative (CHR) Program evolved to become the largest program originally contracted to the tribes, not only in dollars and number of people involved, but also in the number of tribes holding contracts. The first CHR activity was designed to contain the spread of tuberculosis throughout several American Indian communities. CHR contracts were held by 256 tribes who employed over 1,200 CHR's and CHA's. In terms of accomplishments, the program was most successful. The IHS described it as the tribes' own program and distributed a variety of literature and public statements praising its accomplishments. Many tribes, on the other hand, rarely praised their own CHR program, and pointed out how their program differed from all other CHR programs. Opponents usually discussed its failures, its lack of direction, purpose, established goals and objectives. Although the CHR program is supposed to be under tribal administration, conflicting roles were played by IHS and the tribes as to the direction and control to the CHR's activities. Similar situations may exist at varying intensities in different tribes.
The concept of utilizing a community member as health paraprofessionals has been practiced for a number of decades world wide. These community members are regarded as extenders of health services and as agents for community change. These community health workers are members of the communities where they work, frequently are selected by the communities, answer to the communities for their activities, and have shorter training than professionals. The CHR's work directly with physicians and nurses.
THE ROLE OF CHR
The CHR program, initiated by IHS in 1968, is a unique concept for providing health care, health promotion and disease prevention service. CHR's are American Indians and Alaska Natives specially trained through IHS, but employed and supervised by their tribes and communities. They are paraprofessionals healthcare providers who are completely familiar with the dialects and the unique cultural and social aspects of their people's lives.
It is generally accepted that the CHR program began in 1968, but the CHR program was not a creation of the Indian Health Service. The Office of Economic Opportunity (OEO) initially funded the Community Health Aide Program in 1967. In 1969, IHS requested funds to train 250 Community Health Aides in Alaska. By 1972, the last OEO-CHR program was transferred to IHS, which increased its support and training of CHRs to 1,003 in FY'74. IHS has held that the CHR program was created to meet four needs:
- The need for greater involvement of American Indians/Alaskan Indians in their own health programs, and greater participation by Native Americans in the identification and solving of their problems.
- The need for greater understanding between the Indian people and the Indian Health Services staff.
- The need to improve cross-cultural communication between the Indian community and the providers of heath service.
- The need to increased basic health care and instruction in Indian homes and communities.
The CHR program was not initiated by the tribes, but rather was assumed by IHS to be useful in providing the tribes an opportunity to become involved in health by paying staff to perform an outreach, community organization function. The CHR program was a result of Native American Tribes identifying the need for such a program. Lobbying for it, and acquiring funding.
"Neighborhood workers", whatever their title (CHRs. etc.), were, in traditional OEO style, afforded too little training and almost none in substantive areas. Had the program remained in OEO, the question of function of CHRs might never have arisen and they might have continued to play a useful but ephemeral "helping" role. What was different in this case was that federal responsibility for the program passed from OEO to IHS; from the Community Action Program to the tribes themselves; and it was transferred at time when IHS was seeking a mechanism for Native Americans to achieve self-determination in health.
Typical of the services that CHRs are contracted to perform are:
- Explain health programs, policies, and procedures to the community members.
- Maintain continuous contact with their supervisor and MD, keep them informed of the overall impact and effectiveness of health programs, and attend staff meetings.
- Relate the expressed health needs of the community and programs in the delivery of health service to the service unit director.
- Help educate people concerning the health hazards of alcoholism, cigarette smoking, improper eating habits, poor hygiene, and organize health education programs.
- Conduct courses in safety in the home, use of machinery, automotive vehicles, drug storage, etc.
- Instruct the community in proper sanitation and maintenance of the community buildings and grounds.
- Organize communities and arrange for physicians and nurses to conduct immunization and well-baby clinics.
- Make home visits and refer people needing care to appropriate health resources.
- Offer needed transportation for people to clinics and hospitals (if your agency has such a policy).
- Arrange for the police to transport accident or emergency patients.
- Enter diagnostic patient specific data into the official patient medical record through the use of CHR component of the RPMS (Resource and Patient Management System).
The job related task of the CHR have changed somewhat throughout the years, but the original intent of IHS was that the CHR become a community health promoter/educator, a health advocate, and a health paraprofessional who would regularly visit the homes of clients and conduct health assessments and provide transportation, when needed.
Initially the CHR's may have been without direction from the Tribes or IHS. The typical IHS attitude towards CHRs was "hands off", since it considered the CHR program to be a tribal program that did not fall with in IHS jurisdiction. Therefore, without concrete direction from IHS or Tribes, CHRs struggled initially with their role among their people.
Today, the history of the CHR is well documented and an integral part of the health delivery system of most tribes, nations, and villages. The CHR is seen as an agent of the people, helping their clients tend to their health needs.
Transportation has always been a chronic problem on any reservation or tribal area. From its inception, the CHR program has provided much needed transportation for its clients to and from the clinic.
But the CHR role encompasses more than transportation. A CHR can be a role model for other members of the tribe to emulate. They are health educators, providing workshops and classes on a variety of topics to all of their constituents; youth, families, and elders. CHRs are health promoters, developing programs like walking, elderly nutrition, safety, and drug alternative programs for youth. The CHR is a community health advocate to the Tribal Council, the local Indian Health Board, and the Area Service Unit Director.
Today, the CHR program has grown to over 1,400 CHRs representing over 250 tribes in the 12 service areas. Many areas have their own CHR association, designed to meet and share ideas. The National Association of Community Health Representatives (NACHR) has a representative from each area to recommend national policies and share program ideas. The NACHR holds an education conference every three years, providing CHRs with an opportunity to come together and learn about new programs and ideas that will help them do a better job of providing health care services.
Public Las 93-638, the Indian Self-Determination and Education Assistance Act of 1975, Titles I and III. Have made it possible for Tribes to take specific program shares (dollars) under Title I, Annual Funding Agreement, or to become totally self-governing under Title III, Compacting/Self-Governance. CHR programs that still fall under IHS are supervised and controlled in some degree by Indian Health Service. IHS provides for the basic training of those CHR's and provides for documentation support and training. CRIHB member programs all have taken their share of CHR training dollars, therefore these programs are responsible to pay for CHR Basic and Refresher Course Training. CRIHB does provide supplemental training to CHR staff at quarterly/ Partnership and Planning training and the yearly Maternal & Child Health Conference . In addition, CRIHB staff will come present at CRIHB member programs on a number of health related topics.
Tribes that have opted for contracted share (Title I AFA) for their CHR program have more control over the amount of actual dollars spent on community health activities and the specific roles and job descriptions of the CHR's.
Every CHR must attend and successfully complete the Basic Training Course. The three-week course is designed to provide the CHR's with the education tools necessary to competently accomplish their jobs. The three-week course is designed to "introduce" the students to a broad base of health-related topics. The focus of the course is on public health, health promotion, disease processes and prevention, family health, and individual health. As with all basic health courses, there is a great deal of information on the human body and how it functions. This information is vital if the CHR is to learn how to adequately assess the needs of their individual clients. The Refresher course training is recommended every two to three years. IHS is not currently sponsoring any CHR training. Programs that are sponsored by IHS, will be provided the money to educate their CHR's. CRIHB member programs have the CHR money in their budgets to provide their own training. CRIHB does offer quarterly Partnership and Planning training and on-site training on numerous health related topics to further educate the CHR's.
Because of the variety of health-related tasks a CHR does, it is necessary that CHR's maintain a high level of proficiency and knowledge on the health subjects that apply to their tribal needs and specific job function.
Diabetes mellitus is a significant health problem in most tribes. CHR's need to know all they can about DM. In some tribes, a CHR may be designated as a DM specialist. This would require additional training in addition to the Basic and refresher courses. Whatever the tribal needs and the educational background of the CHR, CHR's will expand their knowledge base as they attend health related conferences and workshops. The medical team at each site may also provide on-site training to their CHR's.
CRIHB does not offer CHR Basic or Refresher course training. Contacting the CHR Representative from Indian Health Services or visiting the IHS Website to learn of upcoming training is the best way to find dates and locations. The Indian Health Services utilizes the Mountain Plains Health Consortium to provide these trainings.
CHR Basic begins with 1 week self-study prior to attending a 2-week live workshop covering a variety of topics including but not limited to: Anatomy and Physiology, Public Health, Cancer, Hypertension and heart disease, diabetes, dental issues, environmental health issues, Fetal Alcohol Syndrome, Addiction and drug abuse, child/elder abuse and domestic violence, Suicide awareness, Patient assessment and vital signs, wound care and dressing changes, infection control and PCC training as well as communication techniques.
CHR Refresher training provides an opportunity for seasoned CHRs and CHR Supervisors to update their skills, knowledge, and capacity to obtain further information on program administration and resources for health promotion/disease prevention.
CHR First Responder training teaches Recognition of emergencies, Delivery of life/limb saving treatment, Recognition and provision of supportive care for a variety of medical/traumatic situations. Nationally certified curriculum utilized.
Cathy Stueckemann, JD, MPA
Public Health Advisor/National Director
Community Health Representative Program
Indian Health Service Headquarters
801 Thompson Avenue, Room 326
Rockville, Maryland 20852
The Need for CHR's
Health care for the Native American and Alaskan native population has been far from adequate. Their health status in general lags some fifteen to twenty years behind that of the general population.
Federal health-care programs serving 1 million Native Americans living on reservations are made available through the Indian Health Service. It is the only federal entity that provides direct health services to Native Americans. The Indian Health Service operates hospitals and health centers throughout the nation; most are in Alaska and the western United States where the majority of Native Americans live.
Native Americans experience a number of major health problems. The leading cause of death on many Native Americans reservations is accidents. This is partially the result of the extensive distances over which many must travel. Many miles separate towns and villages on the reservations and connecting roads are often dangerous.
Accidents are also related to the problem of alcohol consumption. Alcohol-related deaths are five times that of the general population. Alcohol is a means of escape from unemployment, poverty, and frustration. Excessive drinking also leads to malnutrition, infection, mental health problems, and cirrhosis of the liver. Numerous programs at the community level have been established in an attempt to help reduce this heavy alcohol consumption.
Native Americans tend to have the various health problems associated with poverty-respiratory illnesses, dental concerns, lack of health education, and malnutrition. Tuberculosis, although a major problem in the past, is not so threatening to the health of Native Americans today. In 1955 there were fifty-eight deaths per 100,000 population from tuberculosis. At the end of the 1970's that statistic had been reduced to 6.1 per 100,000 population. However, tuberculosis among Native Americans is on the rise, and is again becoming a major health problem.
Adequate maternal and child health-care services for Native Americans have not been available traditionally. Statistics indicate that the birthrate among Native Americans is greater than the national rate. Infant mortality is still higher than that the National average. However, it should be noted that there has been an improvement in this morality rate in the past decade. Increased efforts at providing maternal and child health-care services in the home and in the community have contributed to this reduction. Programs designed to improve water supply, sewage disposal, and other related environmental factors have also contributed directly to improvement of child health although the problem continues to exist.
Infant diarrhea is a major problem on many reservations. This is often due to the fact that the water supplies are not always sanitary. Many Native Americans must obtain their water from some distance because they do not have indoor plumbing in their homes, and the purity of this imported water often is unacceptable.
Otitis media, an inflammation of the middle ear, is another major health problem among Native Americans. In comparison, otitis media is not even considered to be a minor program for the general American population. Seventy-five percent of the cases among Native Americans occur in preschool-aged children. This condition is a specific concern because it may result in permanent hearing impairment. Without proper screening for hearing deficiencies and with little knowledge of the problem, many Native Americans develop serious and permanent loss of hearing. Therefore, training in the proper hearing care is a priority for Native Americans.
Mental health problems are also much greater among Native Americans than the nation average. Although hospital days in mental health facilities have increased in recent years, this is not an indication of increased incidence of mental illness. Rather, it probably signifies the fact that Native Americans are less resistant to seeking help for mental disorders today than was the case in the past. The most common mental health disorders are alcoholism, drug abuse, schizophrenia, neurosis personality disorders, and organic brain syndrome. Homicide and suicide occur with alarming frequency on many reservations. Suicide is a special problem among teenagers. Conflicting values, expectations, and changing cultural patterns produce stress that results in a variety of maladaptive behavioral patterns.
As mentioned earlier, the Indian Health Service provides the only available health service for many Native Americans. The difficulty in providing health care to many clients, however, is compounded by the distance that separates homes from medical facilities. It is not unusual to find people living fifty to one hundred miles or more from the nearest health clinic. A physician or a nurse may visit many communities, isolated by miles from a clinic or a hospital. Such visits occur sporadically, resulting in a critical problem if medical help is needed in an emergency.
There have been some efforts made to improve the health status of Native Americans. In 1976, the federal government passed the Indian Health Care Improvement Act. The purpose of this legislation was to authorize funds for the improvement of the health status of Native Americans. As a result, health services on the reservations have expanded, safe drinking water and sanitary disposal facilities have been constructed, and the number of Native Americans trained to serve as health providers has increased, but the future health status of Native Americans is dependent upon even more measures.
Such programs as Title I (funding shares) and Title III (self-governance) may have a significant impact on the quality and availability of health care for Native Americans.
Many of the health problems facing Native Americans and Alaska Natives are preventable. They relate to lifestyle, lack of proper education, poor environmental health, or lack of proper health screening. The Community Health Representative can make a dramatic impact on all of these maladies.
Benefits of Community Health Representatives
The CHR (Community Health Representative) plays an important essential role in Prevention. CHR's goals are to prevent diseases, promote well being, empower community residents, act as a liason between health care providers and patient, and help gain access to services within the community. Research has shown that CHR's can reduce the cost of health care in several ways. Emergency room visits, hospital visits, the length of time in a hospital, and the number of complications are all decreased with the use of CHR's. Patients often wait to seen by a provider until it is an emergency, due to fear, lack of health knowledge or not knowing the choices that are available to them.
The CHR can provide an array of services as effectively as higher-paid health care professionals. These local, indigenous workers are aware of community needs and Culture. They have direct access to the patient population and are usually more accepted than the local health care providers are. CHR's can help establish and foster relationships between health care providers and patients, thus improving patient compliance. The time-intensive home and community based services that CHR's provide could not be replicated by degreed professionals, both because of their higher wage levels and the shortage of degreed health professionals actually living in underserved rural communities. The CHR is able to provide an array of health services.
Some examples of health services provided by the CHR include, diabetes education, childhood asthma, cancer, hypertension, childhood immunizations, community and domestic violence, smoking cessation and prevention, mental health issues, AIDS and HIV, nutrition, sudden infant death syndrome, lead poisoning, substance abuse, early childhood education, nutrition, and a host of other health related topics. CHR's are instrumental in community activities and empowering community members to become active in community events. CHR jobs provide career ladders for higher education and income opportunities.
CHR's help to strengthen families which can lead to reduction in child abuse. Visits from CHR's reduces isolation, violence and high-risk behavior. The CHR program is well known for its accomplishments and is being replicated outside the Native American population. Now there are Community Health Workers serving the Mexican American's and other high-risk populations throughout the world.
Public Health Nurse
“Public Health is the Science and Art of (1) preventing disease, (2) prolonging life, and (3) promoting health and efficiency through organized community effort for: the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of the social machinery to insure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize their birthright of health and longevity…”
CRIHB’S PHN is available for technical assistance to Indian Health Programs throughout California. The position is responsible for planning, providing leadership and evaluating public health nursing and community health representative programs for CRIHB Tribal health programs on behalf of this department. This position is also responsible for undertaking and completion of special projects and working on specific disease and illness related prevention projects such as HIV/AIDS and Injury Prevention. The PHN can assist with the following:
1. Responsible for planning, directing and evaluating a public nursing program. Services include but are not limited to: technical assistance and training for effective community based nursing, obtaining and providing educational materials for use in teaching, community health representative services and other health related activities.
2. Responsible for planning, directing and evaluating a community health representative program. Services include but not limited to planning both training and conferencing for the CRIHB program’s Community Health Representatives. Training may take place on site or at a collective gathering. Currently there is a Wellness Forum that takes place once a year that covers numerous health related topics.
3. Assists community members and health field personnel to assess, plan for, and provide needed health and related services.
4. Participates in programs to safeguard health of children, including child health conferences, school health, group instruction for parents, and immunization programs. Plan and coordinate yearly Maternal and Child Health Conference.
5. Facilitate office functions associated with the implementation and continuation of program sites and/or subcontracts.
6. Advises and assists Nursing personnel on nursing education matters as related to staff development, student nursing programs and training sponsored by Tribes or other agencies.
7. Assist nursing personnel in Policy and Procedure, and quality assurance program development.
8. Assist the FCHS Department Director in meeting the goals and objectives of the FCHS Department.
9. Manage special projects of the Family & Community Health Services Department as assigned.
10. Act as liaison/assistant with the Social Wellness Specialist in developing and conducting wellness related activities such as the Gathering of Native Americans (GONA).
11. Work with Federal Health and Human Services Agency on efforts to assist with enrollment of Medi-Cal eligible Families in the Health Families insurance program.
12. Other duties as assigned.
Please contact Barbara Hart at (916) 929-9761or