Community Health Representative (“CHR”) Program

Mission Statement
The CHR program office provides management to improve and maintain the delivery systems for general health care, gerontological health care, maternal and child health, and environmental health. The CHR program office coordinates with health resource agencies to assure the provision of necessary health care services to Pueblo members.


The CHR Program enhances and promotes health services as an identified by the Pueblo de San Ildefonso Department of Health and Human Services, with support of the Indian Health Service’s goal by providing quality outreach health care services and health promotion/disease prevention services to our Native People within our community. Our major goal is to be an advocate for our Native people.


“This program is funded by the US Department of Health and Human Services, Indian Health Service who is gratefully recognized.”


Vision Statement
To provide quality outreach health care services and health promotion/disease prevention services to Pueblo de San Ildefonso Community Members through well trained CHRs.



Health Education: Planning, preparing and/or providing education on health and wellness.


Case Management: We offer direct client care by monitoring their health needs. This includes assisting with completions of applications; home health services; coordinating needed services such as physical therapy, rehabilitative services, or other medical services.


Patient Care: Home visits to ensure the quality of care within the home; hospital and office visits; assist with medication refills and deliveries.


Monitor Client/Community – Monitoring Patients includes making periodic personal contact with a patient with a known health problem or is high risk for illness or disability, by telephone, telehealth option, 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.


Patient Transportation:

  • The CHR transportation service drives clients to Indian Health Services hospitals and clinics, as well as other health facilities, when necessary and only when no other means of transportation is available.
  • The CHR staff that is providing the transportation service may acts as an advocate for the client between doctors, nurses and other types of resource agencies.
  • The CHR staff that is providing the transportation service, transports prescribed equipment and medications by picking up orders/prescriptions and delivering to clients and any other reasonable requests approved by the HHS Director.
  • Patient transportation is Monday-Thursday with ride requests made three days in advance.


Referrals: Assist clients with referrals to/from other DHHS and/or medical programs, Public Health Nursing, Substance Use/Misuse, Mental Health, Environmental Services or other health care facilities.


Eligibility Requirements
Any American Indian and Alaska Native (AI/AN) registered within a federally recognized tribe, living within the Pueblo de San Ildefonso Pueblo. Request for transports are for those without any means of transportation within their household. We request at least a three-day advance notice for transportation to a health care facility. When you receive your appointment, it’s best to call us so we can schedule as early as possible. We do not transport those who are intoxicated or under the influence of a controlled substance for the safety of all involved.



Discarding Medications – Because of the concern of misuse of prescription medications, the CHRs will properly discard of your medications for you. Please contact the CHR program and we can pick them up from your residence.


Health Education/Counseling – Providing individuals, families and communities with the appropriate information to practice a healthy lifestyle. Sponsors health fairs during community events with discussions about Sexually Transmitted Infections (STI/STD’s), nutrition, exercise, family planning, substance use/misuse, diabetes prevention, and blood pressure checks.


Case Management/Coordinate – 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. We follow up with patients after hospital discharge by providing medical equipment, medications, and wound care, as needed.


Screenings – Carrying out efforts for the early detection of patients with diseases or conditions requiring medical attention (e.g., hypertension, cardiovascular disease, diabetes, TB, COVID-19 or other respiratory illnesses, pregnancy, etc.)


Non-Emergency Care – 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 facilitating the connection to 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.


Environmental Health – Evaluating the community’s environment in one or more of the following: water/waste-water management; vector control (including rabies, insects, and other natural transmission of disease pathogens); air quality disease risk reduction; solid waste disease prevention; and, food handling.


Our Partners