REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) ALBANY REGIONAL MEDICAL PROGRAM RM 00004 7/70.1 Albany Medical College of Union June 1970 University Review Committee 47 New Scotland Avenue Albany, New York 12208 Program Coordinator: Frank M. Woolsey, Jr., M. D. Requested Program Period lst Year 2nd Year 3rd Year TOTAL Direct Costs $61,700 $61,730 -0Q- $123,430 Indirect Costs 17,831 18,243 .-0- 36,074 TOTAL $79,531 $79 ,973 ~O- $159,504 HISTORY: The Albany Regional Medical Program received a planning award in June 1966, and its first operational award in April 1967. The current annual level of support is $1,534,208 total costs: $993,951 for core and $540,257 for eight projects. See History Supplement at the end of this Summary Sheet. After two years operating experience, a renewal request for the entire program (at that time, Projects #1, 2, 4, 5, 6, 7, 12, 13, and Core) was reviewed by May 1969 Council. The reviewers were concerned about the progress of the Region: it appeared not to have developed much beyond the initial continuing education efforts with concentration of activity at the Albany Medical Center; the Coordinator and the Department of Post-graduate Education seemed to dominate the planning, review and implementation process: and the Region lacked plans for phasing out support of present activities. A subsequent site visit in May, 1969, conveyed the reviewers' misgivings to the Region. Recommendations of the August 1969 Council on the renewal package and one supplemental operational project were designed to communicate the reviewers' concerns to the Region and provide time for program realignmert: e.g.,curtailed one year support was recommended for some projects about which there were concerns, but five years’ full funding was recommended for the supplemental operational project for a community leadership ALBANY : -2- RM 00004 7/70.1 Regional Medical Program ‘program. The Council felt that any future application for funds must indicate that the ARMP has come to grips with its problems. Subsequently, March 1970 Council recommended that Project #17, Comprehensive Community Stroke Program, be returned for further planning and revision. It was noted, however, that the stroke program proposal represented a welcome break from the Albany-based continuing education pattern which had been established. PRESENT APPLICATION: This application contains a proposal for renewal support for Project #7 - Community Hospital Coronary Care Training and Demonstration Program, which was initiated in April 1967. The project is presented in two parts, #7A and #7B, which are discussed separately below. The application also includes a reavest for supplemental funding of a new activity: Project #18 - Albany Regional Library Service Project, Improvement of Library Services and Resources in Community Hospitals. . Direct costs only are noted in the project descriptions below. Project #s 7A (R) and 7B (R) - Community Hospital Coronary Care Training and Demonstration Programs. August 1969 Council and the site visitors noted that the original intent of these two satellite centers to provide CCU training for nurses from nearby hospitals had been somewhat altered in practice, and the project appeared to be concentrating on training their own personnel. Consequently, only one year's additional funding was recommended with any future support dependent on the number of trainees from other area hospitals. The funding history of these two activities is as follows: 4/1/62-6/30/68 7/1/68-9/30/69 1.0/1/69-9/30/70 Project #7A $27,705 $23,435 $17,940 Project #78 27,705 24,485 18,990 Project #7A (R) ~ Community Hospital Coronary Care Training and Requested Demonstration Program, Berkshire Medical First Year Center, Pittsfield, Massachusetts. This is a $17,940 request for continued partial support to professional personnel in proportion to their involvement in the educational component of coronary care activities at the Berkshire Medical Center. Karly in Albany's history, as it became clear that the primary coronary care training program at the Albany Medical Center (Project #6) could not meet the staffing needs of all hospitals in the Region, a decision was made to establish secondary centers on a subrepional ALBANY -3- RM 00004 7/70.1 Regional Medical Program basis. The function of these facilities would be to share with the primary center the responsibility of training health personnel in intensive coronary care, to serve as a subregional demonstration unit and to relate in appropriate fashion with the Albany Medical Center on one hand and the smaller community hospitals on the other. It was in this atmosphere that the Berkshire Medical Center developed a subregional coronary care program early in 1968. In order to effectively implement the program, it was decided that a minimum of three physicians contribute at least ten percent of their time to training, educational, and consultative activities. Similarly, three nurses were to devote one third of their efforts to these activities. The services of one half-time secretary were also deemed necessary. To date, 82 nurses have been trained at the Center, 73 from the Center itself, 8 from other community hospitals, and one from an extended care facility. Of these nurses, 33 received training in the three 25-hour courses conducted during 1969, and five were from outside Berkshire Medical Center. Future plans include involving more nurses from smaller hospitals,(at the time this application was prepared, eight nurses from other hospitals were enrolled for the next scheduled course) arranging a number of advance seminars at the Albany Medical Center, adding the ROCOM Multimedia Instructional System to the existing coronary care program, and cooperating with the Tri-State Regional Medical Program in several joint ventures. These latter include a proposed Fellowship in Cardiology at the Berkshire Center and a system of telephonic ECG monitoring between the Center and a hospital and several institutions. Second Year: $17,940 Third Year: None Project #7B (R) - Community Hospital Coronary Care Training and Requested Demonstration Program, Vassar Brothers First Year Hospital, Poughkeepsie, New York. This $18,990 request is nearly identical to that made for Project #7A above, the single difference being that there are only two nursing positions in this proposal. The Vassar Brothers Hospital was another of the sites selected to be one of the secondary, subregional coronary care centers described above. Approximately 90 nurses have participated in the program so far, and again, the vast majority were on staff at Vassar Brothers Hospital. ALBANY ~4- RM 00004 7/70.1 Regional Medical Program (In 1968, six from other hospitals in the Poughkeepsie area partici-— pated.) Of these 90 nurses, 19 received training during 1969, and the application states that although an effort was made to involve partici~ pants from other area hospitals, no candidates were made available. In the future, courses will be extended to other ancillary personnel such as LPN's, efforts will be made to encourage more participation -by smaller coummunity hospitals, and along these lines, it has been suggested that the ROCOM system be used in these smaller hospitals. There will also be a series of advance seminars at the Albany Medical Center for nurses chosen for their leadership potential at both the educational and service level. Second Year: $18,990 Third Year: None Project #18 - Albany Regional Library Service Project ~ Improvement Requested of Library Services and Resources in Community First Year Hospitals. Partly as a result of repeated requests $24,770 by hospital administrators for assistance in training library personnel and partly due to the findings of a somewhat limited survey of library facilities and personnel, ARMP has concluded that there is an urgent need for improvement in these areas. To meet this need, the Region has developed a program that is to be implemented in two phases. The first phase will concentrate on training existing community hospital personnel in the basic essentials of medical librarianship, and it is for this phase that support is being requested in the present applica- tion. The second phase, which is to be initiated two years after the start of Phase I, will attempt to establish a cooperative medical library network within the Region for exchange of materials and reference service and to provide a professional librarian to coordinate and supervise the library network in the Region. During Phase 1, hospital administrators and executive committees of medical staffs will be informed of the nature of the project and will be given the opportunity of sending one individual to the nearest training center. They will be encouraged to seek candidates with bachelor degrees to fill vacancies that occur in hospital libraries. The hospital administrator sending a candidate into the program will also be encouraged to declare his institution's willingness to purchase a minimum core collection of library materials and provide a budget to insure its upkeep and servicing. The Phase I proposal is for two training centers to be established within the geographical bounds of the Albany region, Ellis Hospital located at ALBANY . -5- RM 00004 7/70.1 Regional Medical Progtam Schenectady, New York and Will Rogers Memorial Hospital, Saranac Lake, New York. Each training course will be given over a period of 40 hours. It .may be given in a one-week program or it may take place over a longer time interval depending on circumstances. There will be between four and six students in each course. As for evaluation, trainees will be examined before and after the course to determine the amount of knowledge acquired and again six months later to measure the degree of retention. The hospitals that have had personnel trained through this project will be surveyed by the project coordinator to determine the type of book and journal collections and to evaluate the amount and quality of services rendered to the staffs of these hospitals. Finally, and in anticipa- tion of Phase II, all community hospital libraries, regardless of whether they have sent people through the program, will be requested to maintain certain minimal statistics including the number of books and journals in the library, the number and types of items circulated in six months and one year, the number of reference questions received and interlibrary loans made in the same time period. This data collec- tion would begin with the start of Phase I. ARMP is aware of a number of other similar efforts in varying stages of development within the Region. These include New York State Inter- library Loans (NYSILL), Capital District Library Council, State University of New York Biomedical Network, New York and New Jersey Regional Medical Library, and several others. The Region states that the present proposal does not duplicate any of these other programs. More detailed information on Phase II will be submitted at a later date, but at present, it can be said that it intends to make available virtually all learning modalities: books, journals, tapes, films, records, etc. Services that are to be provided include reference, interlibrary loans, bibliographic and technical assistance, and rapid communications. Second Year: $24,800 Third Year: None ALBANY - . -6- RM 00004 7/70.1 Regional Medical Program HISTORY SUPPLEMENT . Current Year's Support or InitLation PROJECT # Project Title Status (DCO) Date _ 1 Two-Way Radio Communication System $143,975 4-1-67 2 Community Information Coordinator Now included 4-1-67 in Core 3 Communication and Information Disapproved Activities 4 Postgraduate Instruction Development Panel $80,745 4-1-67 5 Community Hospital Learning Centers $111,082 . 4-1-67 6 Albany Medical Center Coronary Care Training and Demonstration Programs $71,746 4-1-67 7 Community Hospital Coronary Care $36,930 4-1-67 Training and Demonstration Program 8 Regional Rehabilitation Team Disapproved 9 Training Program for Physical Therapy Aides Not Funded by Region 10 Expansion of Albany County Tumor Registry Not Funded by Region 1] Development of Computer Utilization Disapproved 12 Intensive Cardiac Care Unit - Herkimer $7,207 4-1-67 13 Schenectady Cancer Coordinator $5,000 1-1-68 14 Core $712 ,094* *Lt should be noted that the core budget included $60,020 in personnel costs for partial support of the planning and development stage of the Albany North End Community Health Center. The Health Center project is OCHP - approved but not funded. As soon as OCHP money is available, RMP support will end. ALBANY -7- Regional Medical Program 15 Establishment of Regional Cancer — Program 16 Development of Community Leadership Program 17 Comprehensive Community Stroke Program RM 00004 7/70.1 Disapproved $9,030 10-1-69 Returned for revision GRB-5/19/70 SUMMARY OF REVIEW AND CONCEITISTON OF JUNE 1970 REVIEN COMATICMGE ALBANY REGIONAL MEDICAL PROGRAM RM 00004 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee recalled its lengthy discussions of a year ago which were occasioned by the Albany Regional Medical Program's continued concentration of efforts in continuing education through the Albany Medical Center. It was noted that the Community Hospital Coronary Care Training and Demonstration Program, which is presented as Project #s 7A(R) and 7B(R) in the present application, represented an effort toward regionalization of RMP activities, and approval of renewal support was uc-omnended on those grounds. The Albany Regional Library Service Project f which supplemental funding is being requested, was not considered % enough developed to warrant approval at this time; the Committee ¢. > asted revision. Project #s 7A(R) and 7B(R) - Community Hospital Coronary Care Training and Demonstration Programs. Critique: These two satellite coronary care training programs in - community hospitals, Project 7A (Pittsfield, Massachusetts) and Project’ 7B (Poughkeepsie, New York), were discussed together because of their marked similarities. It was noted that there appears to be some increase of trainees from the area surrounding the Berkshire Medical Center (although still rather minimal) since Committee reviewed this project a year ago, but very little involvement of those hospitals in the Poughkeepsie area (but with expectations for future involvement expressed in the application). This prompted a discussion as to whether such a slight increase in the number of trainees from other hospitals was sufficient justification for further funding of the two projects. It was pointed out that one of the primary problems of the Albany RMP has been its abysmal lack of involvement outside of the city of Aibany itself and that these projects represent definite regionalization efforts; that these activities evidence an interest in the hea’th care world (albeit education); that efforts are being made to redu the apparent resistance on the part of other hospitals in the area to 1: to each of these two community centers for training of their personu: and that these programs are working to break down the seeming interprofe . ional animosity toward — this outward expansion. Many Committee members felt the modest amount of money requested for these two projects might get the Region over the hump. It was also noted that the costs of the programs will be absorbed at the local level at the end of two additional years of support. Recommendation: In light of the above arguments, the Committee recomended Approval I in the time and amount requested, with the two following stipulations: ALBANY kegional Medical Program -L~ RUL VUUUH Ff Ud 1. that a mechanism be developed to provide encouragement for the involvement of personnel of community hospitals in the two training centers, and 2. thatthe Region clearly specify that the training program will be continued beyond the project period without additional support from RMP. DIRECT COSTS ONLY: Project # Ist Year Qnd Year 3rd Year 7A(R) $17,940 $17,940 0 7B(R) 18,990 18,990 0 There were two dissenting votes. Project #18 - Albany Regional Library Service Project - Improvement of Library Services and Resources in Community Hospitals. Critique: The Committee was hampered in its evaluation of this project by the lack of basic information as to the number of courses planned and any supporting data documenting the availability of students. It was noted that there appeared to be little transition from data gleaned through a survey of library needs and the proposed solutions to problems which are contained in this project proposal. Specifically, although trained personnel does not surface from the survey as a primary need, the approach is to train personnel as a first step. There was also concern about the relationship between the budget and the Phase I proposal. Almost half of the request is for a project coordinator at the Albany Medical College while the training is to be carried out at the Ellis and Will Rogers Hospitals. A National Library of Medicine technical review indicated concern'as to the apparent over-emphasis which the project places on training without the important aspects of consultation and assistance to the librarians trained which might be necessary to make the system work. The NIM reviewer also noted that the application appears to propose the beginnings of training projects in the absence of any plan for the long~range measurement of library and information needs within the Region. Since one of the project coordinator's primary activities would be the planning of future projects, the reviewers believed that perhaps the main function that would be served by the project would be the development of a greatly expanded request for library activities in the Albany Region. In short, although the Region has collected data relative to the hospital library situation, it was felt that the resulting project is not adequately developed to warrant funding at this time. It was suggested that the project be returned for revision, pointing out the deficiencies mentioned above, and advising that the Region develop either a request for planning for library activities or a request for training personne’. If the revision is to be a training request, the proposal, in addition t: .pelling out the curriculum, should clearly define on a realistic base, t+ -imber of potential trainees and the number of times the courses \ be presented, Recommendation: Non-Approval Ii ~ Return for Revision wich advice. ALBANY Regional Medical Program ~3- RM 00004 7/70.1 Conclusions: Ql Year 02 Year 03 Year Project #7A(R) $17,940 $17,940 0 Project #7B(R) 18,990 18,990 0 Project #18 Non-Approval II - Return for Revision TOTAL | $36,930 $36,930 0 DRMP/GRB 7/10/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) ARIZONA REGIONAL MEDICAL PROGRAM | RMOOO5S 7/70.1 University of Arizona College of Medicine June 1970 Tucson, Arizona 85721 Review Committee Program Coordinator: Dermont W. Melick, M.D. Requested Program Period lst Year 2nd Year 3rd Year Total Direct Costs $151,395 $146,053 $150,628 $448, 076 Indirect Costs 33,189 34,786 36, 560 104,535 TOTAL $184, 584 $180,839 $187,188 $552,611 HISTORY: Support for initial planning in this Region was authorized for two years and three months (April 1, 1967 - June 30, 1969), $119,045 the first year, $409,108 the second year and $138,095 the third period of three months. During the second year, an application for earmarked funds for a Chronic Pulmonary Disease Program was disapproved by Council (November 1968) with advice to revise and resubmit. Due to delays in the review and funding of the Region's operational program, the planning period was extended by nine months, April 1 - December 31, 1969 (two separate extensions) with additional funds totaling $500,028. In May 1969, Council considered the initial operational application. As recommended, a site visit was made that same month to study the Region's operational capability. The application requested support for renewal of core staff activities and six projects. Two of the projects were in the medical library field, one for continuing education of nurses, one for recruitment and utilization of social service manpower, one cardiopul- monary resuscitation training and one revision of the previously submitted chronic pulmonary disease program, The site visit team was greatly concerned about the dominating needs of RMP in Phoenix and peripheral areas, and the contrast in the Region's plans to concentrate its head- quarters near the Medical School in Tucson. It was also believed that the evaluation capability of the Region should be strengthened by acquiring the services of a specialist. Impressions with staff leadership were favorable, The team believed that there was adequate evidence that the Region was ready to assume operational status. Although some major problems had hindered development of the Region's program, the visitors were convinced that further planning would not have increased the capacity to implement an operational program, ARIZONA Regional Medical -2- RMO0055 7/70.1 Program As recommended by Council during the August 1969 meeting, $795,406 (d.c.o.) was awarded for support of the operational program. This action excluded the cardiopulmonary resuscitation training project which was deferred pending further study and policy decision, The Council recorded its interest in observing this Region's progress in dealing with the problems of delivery of health care to the people of this state, particularly the widely dispersed rural population of American Indians, Mexican-Americans, and migrant workers, and others not being served. During the August 1969 meeting, Council also considered the Region's first supplemental operational application for support of three continuing education projects: Education In Coronary Care; Community Education for Nurses; and Long-Term Education for Nurses. Council recommended disapproval with advice to resubmit. Reasons for this action included: 1) absence of coordination between the three projects; 2) lack of medical school involvement; 3) inadequate physician partici« pation; and 4) weakness in objectives, curricula, and evaluation, With regard to the long term education project, the reviewers also believed there might be some overlap with the regular Master's Program in Medical Surgical Nursing offered in Tucson. Following the evolvement of a policy by Council during the December a 1969 meeting, the Region appropriately revised the "Cardiopulmonary LEA Resuscitation Training" project, including strengthening the evaluation aera component. Although approved, funding status has not been determined. Council also considered a new supplemental request for support of a "Nutrition Care Program for Heart, Cancer, Stroke, Diabetes and Related Diseases" project. Recommendation: Return for revision (with the suggestions of the Review Committee). PRESENT APPLICATION: In light of the August 1969 disapproval of three Continuing Education Training projects, and Council's suggestions, the Region redeveloped a program for coronary care training which will ultimately involve five projects, Two of these are submitted for funding consideration. The remaining three, still in development to be submitted later, deal with 1) outreach continuing education for nurses and physicians; 2) public information and education; and 3) continued education for nursing personnel in the Tucson area. The Region believes that the projects now meet all the suggestions by the Council and will provide basically needed education and consultation services, First Year Project #11 - Continuing Education Program for Nurses $76,583 Submitted by St. Joseph's Hospital, this is a project to be centered in the Phoenix metropolitan area. In planning the program, the ARIZONA Regional Medical ~3- RM00055 7/70.1 Program applicant was assisted by an Advisory Committee, membership which included representatives of appropriate agencies including the Region and the University of Arizona College of Medicine. The project proposes a series of courses for Arizona registered nurses. Training involves four levels of instruction; basic, advanced, refresher, and leadership. The four courses, ranging from three days to four weeks, will entail 11 sessions (23 weeks) for 420 enrollees. For purposes of sharing coronary care facilities for instruction and clinical experience, four other Phoenix hospitals will participate. Cooperating hospitals are: St. Joseph's Hospital and Medical Center, John C. Lincoln Hospital, Southside Hospital, Baptist Hospital and St. Luke's Hospital. In conjunction with the companion project #12, eight seminars are to be conducted in different localities. Jointly, the projects will also provide consultation to Arizona Hospitals. A Liaison and Coordinating Committee for the overall Coronary Care Program in Arizona is to provide guidance in scheduling and evaluation. A project Advisory Committee will also be utilized in the evaluation process as well as the professional assistance of the University Department of Systems Engineering, a subcontract arrangement. Approximately 50% of the budget is for personnel, three full-time positions (Nurse Director, R.N. Instructor and Secretary) and ten part- time (Project Director, Medical Director, M.D. Instructor, lecturers, four hospital nurse preceptors, Leadership Instructor and Physical Therapist). Support is also requested for an electronics engineer, equipment, supplies, travel, subcontracted evaluation-service, publications and per diem stipends for course enrollees. Second Year: $77,405 Third Year: $79,988 Project #12 - Coronary Care Training Program of Arizona, Post-graduate Courses and Seminars for Physicians, First Year Hospital Administrative Personnel and Trustees, $74,812 Submitted by the Department of Cardiology, College of Medicine, University of Arizona, this is a companion to project #11, "Continuing Education Program for Nurses." This is a three-year proposal to provide three annual five-day courses for physicians from hospitals where nurses have attended or are scheduled to attend recognized training programs. Alternating between Tucson and Phoenix, the training will be conducted in the coronary care units of five participating hospitals: Veterans Administration, Tucson; University of Arizona Medical Center, Tucson; St. Joseph's, Phoenix; St. Luke's, Phoenix; and Tucson Medical Center. It is anticipated that 108 physicians will be trained during the three-year project period. Courses will be conducted simultaneously with the "basic" nurse course offered by companion project #11. | ARIZONA Regional Medical -4- RM00055 7/70.1 Program Ao, SH In addition, eight annual one-day seminars will be conducted in eight localities and consultation services will be offered. Coordination with other projects of the "Coronary Care Training Program of Arizona", is to be accomplished through a Liaison and Coordinating Committee. This Committee and the Regional Core Staff, assisted by The Arizona Department of Systems Engineering, will be responsible for assessing program effectiveness. Approximately 40% of the budget is for personnel, 2 full-time positions (secretary and assistant to the project director) and four part-time positions (the project director, two physician instructors, and a practicing cardiologist instructor). Support is requested in all budget categories; the most significant amounts are for special consultant services to hospitals, three consultants for each of the eight seminars, evaluation subcontract and travel. Second Year: $68,648 Third Year: $70,640 ARIZONA Regional Medical -5- RMO00055 7/70.1 @ Program ist Year Planning Award 4/1/67 - 3/31/68 (February 1967 Council) REVIEW AND FUNDING HISTORY 2nd Year Planning Award 4/1/68 - 3/31/69 02 Supplement _ 1/1/69 - 3/31/69 (May 1968 Council) $119,045 346,125 62,983 Chronic Pulmonary Disease Program - Application for "Earmarked Funds" (May 1968 Council) (Site Visit August 1968) (November 1968 Council) 03 Year Planning Award 4/1/69 - 6/30/69 03 Year Extended with Funds 4/1/69 - 9/30/69 03 Year Extended with Funds 4/1/69 - 12/31/69 INITIAL OPERATIONAL APPLICATION (May 1969 Council) (Site Visit May 1969) (August 1969 Council) Deferred Disapproval with Advice to Resubmit 138,015 255,303 361,933 Funde? = Approved Future, Level Onis (1/1/70 - 12/31/73) 01 Year 02 Year 03 Year HOO - Core Staff Activities $503, 300 $503, 300 0 # 1 - Checklist - 20th Century Books (Approval in Principle) 0 0 0 # 2 - Medical Library Network 35,211 35,211 35,211 # 3 = Chronic Pulmonary Disease 150,000 112,000 120,000 # 4 = Continuing Education in Nursing Care of Patients 56,895 74,307 84,118 # 5 ~ Recruitment and Cont. Ed. Social Service 50, 000 50, 000 0 *i# 6 ~ CPR (revised March 1970) Approved - not funded as of 4/9/70 $795,406 $774,818 $239,329 FIRST OPERATIONAL SUPPLEMENT APPLICATION (August 1969 Council) # 7 + Continuing Education, Coronary Care Disapproval with # 8 ~ Continuing Education Pragram for Nurses Disapproval with # 9 - Long-Term Continuing Ed. for Nurses Disapproval with advice to resubmit advice to resubmit advice to resubmit ARIZONA Regional Medical -6- RMO0055 7/70.1 Program SECOND OPERATIONAL SUPPLEMENT APPLICATIONAL (March 1970 Council) #10 - Nutritional Care Program Disapproval with advice to resubmit *xAugust 1969 Council - Deferred for further study December 1969 - Adopted CPR policy March 24, 1969 Region submitted a revision in keeping with policy 5/5/70 A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE ARIZONA REGIONAL MEDICAL PROGRAM RM 00055>».7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Review Committee concluded that this application for $448,076 (d.c.o.) for three years should be funded in the re- duced amount of $426,326 with conditions and an expression of concerns as indicated below under specific projects. It was noted that this application is the outcome of the disapproval of three continuing education training projects reviewed in August 1969 and Council's suggestions. The Region is redeveloping a program for coronary care training which will involve five projects, two of which are in this application. The remaining three are still in the development stage and will be submitted later: Reasons for disapproval of the previous proj- ects were taken into account in the preparation of this application. Interlocking relationships between the two projects is noted as well as cooperative arrangements in the Tucson and Phoenix areas. Funding will allow the ARMP to begin a regionalized coronary care program. Project #11 - Coronary Care Training Program of Arizona, Continuing Education for Nurses Critique: The Committee noted the favorable review comments prepared by the Continuing Education and Training Branch staff. However, the Committee believed the project leadership may not be as strong as is implied in the application. Also, there was concern that the curriculum is too didactic and should be more clinically oriented. Committee questioned why "training in nursing administration" is a prerequisite for the associate project director position. It was also believed that send- ing hospitals should share half the costs for stipends. Recommendation: Approval I with the condition that only half the costs of stipends be supported with RMP funds, the remainder being the responsibility of the participating hospitals. It is also recommended that the ARMP be informed and requested to respond about the concerns, as well as the question about the administrative requirement for the associate project director. Project #12 - Coronary Care Training Program of Arizona, Post-graduate Courses and Seminars for Physicians, Hospital Administrative Personnel and Trustees & Trustees Arizona ~-2- Critique: Committee concurs with the review comments by the Continuing Education and Training Panel. In general, the plan seems.well designed and the need is adequately founded. The operational objectives are clear, but the goals relative to change of behavior are not and are less measurable. In terms of time frame, staffing and utilization of resources, the project is feasible. The foci of the evaluation are upon the acquisition of knowledge and the degree to which the project will stimulate the development of additional care facilities. There should be a greater focus on the outcome of training as it will effect patient care. Of major concern is the method of selecting physicians for train- ing. It is hoped that physicians accepted for the course would come from hospitals with specialized facilities and equipment, and that they would be utilized with greater precision after training. Recommendation: Approval I in the amount requested. It is also recom- mended that the ARMP be informed of the concern about the selection of physicians. gh SUMMARY OF RECOMMENDATIONS Direct Costs Projects 01 02 03 ' Total #11 Cont'g $ 69,333 $ 70,155 $ 72,738 $212,226 Ed. for Nurses #12 Post-grad. 74,812 68,648 70,640 214,100 Courses & Sem. for Phys. Hosp. Adm. Personnel TOTAL $144,145 $138,803 $143,378 $426,326 DRMP 7/2/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) ARKANSAS REGIONAL MEDICAL PROGRAM RM 00052 7/70.1 University of Arkansas Medical Center June 1970 Review Committee 500 University Tower Building 12th at University Little Rock, Arkansas 72204 PROGRAM COORDINATOR: Charles W. Silverblatt, M. D. Requested Program Pertod lst Year 2nd Year 3rd Year Total Direct Costs $88,149 $82,769 $83,896 $254,814 Indirect Costs 13,771 14,459 15,905 44,135 TOTALS $101,920 $97,228 $99,801 $298,949 HISTORY: Arkansas received its first planning grant ($341,846 d.c.o.) on April 1, 1967 and its second, for the same amount, on April 1, 1968. A site visit was conducted in September, 1968 to examine the Region's readiness for operational status. The site team had some reservations about the lack of a continuing education component on the core staff and the rather weak financial condition of the medical school, but on the whole, they were impressed with the community involvement, the active participation of the Regional Advisory Group, and the directions planned by the director and core staff. Following Council approval in November 1968, an 01 operational award ($687,506 d.c.o.) was issued on February 2, 1969, including support for core and ten projects. A second site visit was made in July 1969 for the twofold purpose of reviewing Arkansas's progress in developing its program and evaluating ten supplemental project proposals. The site team concluded that considerable progress had been made since the earlier visit, especially when consideration was given to the limited resources the Region had to work with. The only area of concern was the Regional Advisory Group's project rather than planning orientation. On February 1, 1970, the Region was awarded an 02 continuation award of $801,306 ($687,506 commitment plus $113,800 carryover) supporting core and 13 projects. See the History Supplement following this summary sheet for a listing of projects. ARKANSAS REGIONAL MEDICAL PROGRAM -2- RM 00052 7/70.1 As a result of the recent release to RMPS of funds that had been placed in administrative reserve by the Bureau of the Budget, negotiations are now under way to fund five of the Region's back- log of approved-unfunded projects in the amount of approximately $200,000. Also of note is the appointment in January 1970 of Charles W. Silverblatt, M.D., as Program Coordinator. Dr. Silverblatt succeeds Dr. Roger Bost. PRESENT APPLICATION: This application requests supplemental support for one new project, #35 - Continuing Education for Dieticians and Health Facility Food Service Supervisors in Arkansas. Direct costs only are noted below. Project #35 - Continuing Education for Dieticians and Health Requested Facility Food Service Supervisors in Arkansas. First Year The goals of this proposal are to improve the skills of the $88,149 personnel (dieticians, dietary consultants, and food service supervisors) in charge of nutritional services in hospitals, nursing homes, and related facilities and to encourage pre- sently inactive dietetic personnel to return to work. Of the 331 hospitals and nursing homes in Arkansas, only 71 have any supervision of food service by qualified dieticians (of which there are 59 working full and part-time). Because of the lack of qualified dieticians, greater responsibility for dietary services has fallen to the food service supervisors and to relatively wmtrained persons acting in this capacity. A survey of the 331 institutions showed that the ARMP could expect 520 participants per year at dietetic courses. There are 32 inactive dieticians in the State, 18 of whom indicated through a survey their interest in returning to active employment if training opportunities and jobs were available. Since the types of training will differ with the sophistication of the audience, several presentations are planned. These programs and public forums will be held in four different areas of the State as follows: 1. Seminars for dieticians and food service supervisors of two and one-half days length in Little Rock, Fayetteville, Jonesboro, and Arkadelphia are expected to accomodate 400 participants. 2. from the Medical School and ity Hospital a curriculum was in October 1968 with seven minority students, ruited from service staff at the Medical Cent . course in classroom and laboratory instruction, six o: these stucents were placed in the tact Palo Alto Neighborhood job ining. At the end of ular employees at the on-the-job training. Medical School and Health Center for this period all of facilities in which ic Director of the University Hospital and : F staff seminar groups to sspital in solving minority group eLiy Relations Department was formed sersons in hospital jobs; During the summer of Associate Dean stimutl: consider the role of © obLems, As a result to: Ll) recruit and CALIFORNIA Medical Education -8- RM 00019 7/70.1 and Research Foundation 2) develop training programs for minority persons in the Medical School and the University Hospital; 3) promote harmonious intergroup relationships within the hospital staff. By April 1969, the Intergraded Assistants Program described in this application was develoved as a result of suggestions requested from the various departments. It is not directed exclusively at disadvantaged or minority groups, although the program will provide unique opportunities for them. The program does envisage the creation of new careers in the allied health field and the provision of training programs designed to facilitate upward mobility into these careers. Phase 2? will concentrate on the training of health technology assistants. A high school education or its equivalent will be required for the approximate 40 persons to be trained. Two hundred interested recruits out of a possible 240 minority group employees of the Medical Center have expressed interest in participating in the program. One hundred and forty of these have an educational attainment of tenth grade or below and are appropriate for Phase 1 education. Thirty of the others are now holding semi-skilled jobs are interested and appear to be candidates for training in Phase 2. The initial eight weeks of training will be spent in laboratory instruction at the hospital. Instruction will be by means of lecture and reading assignments in several standard textbooks. Tutorial-type sessions with individual students or pairs will be arranged. Various experiments with discussion and interpretation of material, as well as individualized instruction is planned so the trainees can prepare for their specific assignment when they move to on-the-job training. Trainees can participate in parts of Phase 1 while enrolled in Phase 2. When students complete Laboratory instruction they will be assigned to various appropriate specific locations in the Medical Center for four months of on-the-job training. They will work under the direction of medical and health professionals and skilled technicians, who will instruct in a one-to~one manner for improvement of specific skills and techniques. Following training students will be assigned as follows: radiologic technologist, radiology nurse, X-ray service technician, inhalation therapist and technician, etc. During this portion of training these students will act as aides or assistants to the professional/ technical personnel. Students will be paid by the project during the two-month training period a rate of $400 per month. A further alternative for trainees is the opportunity to participate in an occupational training program in health sciences at DeAnza and Foothill Colleges in technical specialties. The Phase 3 portion of the application deals with the training and placement of Physicians Assistants. This involves 20 months of intensive training. Candidates will be trained largely by physicians to be a highly competent extension of the physician's technical arm in certain designated areas of CALIFORNIA Medical Educatian -9- RM 00019 7/70.1L and Research Founestl: cd by physicians. Classes will consist the Committee on Admissions and three faculty physicians, a physicians i antatives of the allied health ‘osentative of the consumers of health services. of Phase 2 and recommended by supervisors ved will be a high school diploma or its activilies now usuea of twelve students Graduations. This Assistant instructo specialties and a r Trainees will be or other persons. Requi Z equivalent, laboratory or hospital experience of at least two years, and equivalent traising to that in Phase @, tcovily on the Scholastic Aptitude Test iievement Test of the College Entrance satisfactory character references and ryiew aud personal evaluation by the Committee Candidates must score and Level 1 in the t Examination. He mu successfully pass | i of Admission and Graduation. Students will receive a stipend of $400 ses is the need for continuous by instructors as well as the al service, personnel department and other per month. Common to ail thy counseling. This will he hospitals department of appropriate sources, ‘ae parts consisting of one medical theory with emphasis stract. This will be followed practice through assignment Center. The final segment will consist of a residency «of : in a specialized area, working under the supervision ol! a phys in a hospital situation, doctor's office, private clinic, « rcaency room, A detailed outline of the curriculum is a; dezree of standardization will occur the projeet authors feel that it is approach in order to adapt the of the program on the basis of The curriculium will year of instruction upon the practical rather by s months spenk in arp to various locations in eventually, but ab the pres: essential to wwainteain «4 educational and practice experience. At this time physicians assiataats are not licensed in California For them to be employed as assistants 1 likely that Legislation to permit ; will be passed in the California and it is mot legally utilization of physicians assembly within the nex: first class from this The program will be evalie Ly) an inerease in 2) opening of new For training and i ook of all phases wiil aaLlth~related occupations. Evaluation on @ continuous basis in order that cC be designed and implemented « to the number and background of trainees cf siacemeut, and their acceptance in new positions nevessary alterations bien s auieckiy. Evalu recruited, the CALIFORNIA Medical Education ~10- and Research Foundation after graduation. Other evaluation measures will involve student progress (in all phases), job performance, continual feedback and > a final summary of evaluative analysis. Program direction and coordination will be the responsibility of the program director to be assisted in various administrative functions by the Minority Relations Department. Evaluation will be directed by Robert Heath, Ph.D. Associate. All instructors responsible for Phase 1, 2, & 3 have been identified. A number of methods for public and professional information will include a lecture circuit for physicians in CRMP Area III to reach physicians via county medical society meetings, specialty group meetings, etc. Second Year: $231,940 Third Year: $239,039 RM 00019 7/70.1 CALIFORNIA Medical Education ell- RM 00019 = 7/70.1 and Research Foundation 02 Operational Budget Period Support (14 month period) Core* CMERF $ 54,931 Regional Office 373,635 Area I 634,640 (Includes $6,500 0281) oe 244,854 T1I 354,244 Iv 802,288 v 646,993 VI 198 , 664 VII 224,649 VIII 225,104 (Includes $10,000 0282) Project #35 (Area IX) 185,464 TOTAL $3,945,466 Area I # 1 ~ Coronary Care Training - Area I 312,792* #15 - A Regional Cancer Program 330, 6 10*** #18 + Training of Physicians in Intensive Care for Small Hospitals (Pilot Program ~ Pacific Medical Center) 11, 000** #20 - Hypertension - Area I - Northwest Calif. 362 ,070* #25 - A Proposal for Rehabilitation and Continuity of Care Services 187 , O6 Lew #26 - Intensive Training Course in Cardiopulmonary Resuscitation for Emergency Rescue Personnel 10, 6342% 427 = University Medical Center - Rural Community Hospital Demonstration Cooperative Program in Primary Physician Training & Continuing Education 92,98 Lexx #55 - Solano Supplement to Program for Rehabilita- tion & Continuity of Care Services Approved 3/70 - Unfunded Area II # 2 - Roseville Pilot Program 92, 145% Area IV # 4 - A Training Program for Physicians in Coronary Care Cedars-Sinai Medical Center (UCLA) 236,192* #7R = RMP Medical TV Netweork ~ A Center for the Continuing Education of Health Care Profes-~ sionals Using Television and other Audio- visual Materials 392, 000%* #24 - San Fernando Valley and Pacoima Health Planning Project 160, 890* #58 - Training Program in Coronary Care Approved 3/70 - Unfunded Area V #11 + Program for Training Physicians and Nurses in Coronary Care Techniques 483,281* #23 ~ Chronic Respiratory Disease 113, 913%** Area VIII #21 ~ Pediatric Pulmonary (U.C. - Irvine) 206, 520* #28 - A Comprehensive Stroke Program 370 , 802% . (Transfer of $29,259 from indirect pending) #54 - Rapid Hospitalization for Acute Myocardtal Infarction Approved Area 1X #6 - Watts-Willowbrook Post-Graduate Education * commitment for one no future commitmen tek TOTAL future year ke commitment for two future years 498 314% $7,806,671 pDRMP/GRB/5/14/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) CALIFORNIA MEDICAL EDUCATION AND RM 00019 7/70.2 RESEARCH FOUNDATION June 1970 Review Committee 693 Sutter Street San Francisco, California 94102 PROGRAM COORDINATOR: Mr. Paul D. Ward Requested Program Period lst Year 2nd Year 3rd Year Total Direct Costs $77,307 $77,248 $81,393 $235,948 Indirect Costs 1,467 1,542 1,571 4,580 TOTAL $78,744 $78,790 $82,964 $240,528 HISTORY: This proposal was reviewed by February 1970 Review Committee and March 1970 Council and deferred for additional information concerning its relation to CHAIRS, a project in Los Angeles County approved by the Council, but subsequently funded by the National Center for Research and Development. Notes concerning an expert review of the two projects are attached. Project #56 - Community Resources and Information Services Ist Year (CRIS) - Area VIII. This project proposes to $77,307 create an organization which will make available, through one telephone call, knowledge of all the community services available to the caller in Orange County. It will establish a non-profit Community Referral and Information Center to be professionally staffed and managed to assure continuing and improving service to all the people. The Community Referral and Information Service (CRIS) will identify resources for total patient care in the broadest sense to meet the physical, social and emotional problems of the patient and his family. Its services will be available to all members, professional and lay, of the community. This program is similar to one which was reviewed by a site visit team in July 1969, (CHAIRS Project #30) and subsequently received approval and recommendation for funding by both the Review Committee and the National Advisory Council. Such a service of information and referral will contribute to regionalization by (1) identifying needs and opportunities for their solution; (2) coord- ination of the RMP with other activities in the Region; and (3) providing the Region with a continuously updated inventory of existing resources and capabilities. This project will provide a coordinating body for the numerous community service organizations and services providers. There are large gaps in services and under-utilization of many of the existing ones, and there . Bk ee ee TN Thies nentanrt will nrnvide information CALIFORNIA Medical Education = 2= RM 00019 7/70.2 and Research Foundation . and referral services to make known all available community resources in Orange County and coordinate with a network of referral programs in Los Angeles County. The service will be available on a 24-hour day, J-day week basis. It is hoped that the program will act as a catalyst to existing agencies in the action required to fill in identified gaps. Periodically, a directory will be published to guide the delivery of health, education, welfare, vocational and recreational services in Orange County. The program emerged from planning of an ad hoc committee, which includes representatives of the Regional Medical Programs, Area VIII, the University of California at Irvine, Orange County Health Department, the Medical Association, Chapters of the National Foundation, Tuberculosis Association, Heart Association, Cancer Society, the Medical Center, Mental Health Association, private industry and others. In May 1969, an ad hoc committee on incorporation was elected and a charter of incorporation was drawn up. Articles of Incorporation and approved Bylaws were formally adopted September 16, 1969 and are included in the application. The Community Referral and Information Service will operate under a Board of Directors. A technical advisory committee, made up of representatives of various professional disciplines will advise the i CRIS board and the executive director on programs and policies. An executive director will be hired by the Board of Directors. Funding through the Orange County United Way will be requested as well as other funding sources explored. Evaluation measures will be readily available from the beginning of the program and will be reflected in an increase in the number of referrals and the increase in the willingness of local agencies to assume financial support. The statistical reporting system presently in use at the Los Angeles Welfare Information Service will be utilized in the early part of the program. This is a tabulation of the media for the initial inquiry, its source, types of problems, kind of service provided, the community in which the person with the problem resides and the referral agency. The records per se of CRIS will be another form of evaluation of the project as well as a follow-up of calls. As volume increases, evaluation of a random sample of calls planned and controlled for accuracy will be utilized by the usual and accepted statistical techniques. 2nd Year: $77,248 3rd Year: $81,393 ® CALIFORNIA Medical Education -~3~ RM 00019 7/70.2 and Research Foundation Review Committee, February 1970: CRITIQUE: The Committee found the project to be well planned for an obvious need, and noted that the project will become self- supporting in three years. The question was raised as to the degree to which the source of the information can answer questions, and does the process in fact bypass the physicians? This in turn raised the question of the legality of such bypassing. It was also noted that California has the highest number of malpractice suits in the Nation. The similarity of this project to one previously reviewed from this Region (CHAIRS - Project #39) was recalled and it was noted that the National Center for Health Services Research and Development has funded this project for a five-year period in the total amount of approximately $700,000. This program is based in Area V (USC). In view of the decision to fund this program by the Sanazaro group, the Committee agreed that perhaps a deferment of the decision to approve would be in order until we are able to evaluate the success of the @ CHAIRS program. RECOMMENDATION: Deferral for further information subject to expert and indepth review in relation to the CHAIRS project in order to ascertain if it is (1) worthwhile; and (2) justified for funding under RMP. National Advisery Council, March 1970: Council reviewed additional information from CRMP, but requested infor- mation from an expert in the field of information and referral services on the comparison of CHAIRS and CRIS. Action was deferred pending this information. @ DRMP /GRB June 4, 1970 Date: Reply to Alin of: Subject: To: | DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION June 4, 1970 Telephone Conversation with Miss Eileen Lester, Comprehensive Health Services, Concerning Her Review of the CRIS Propos@l. #56 from Area VIII, California RMP Lf t For the Record Miss Lester was the project officer from one of the initial informa- tion and referral services (in Rhode Island) and has provided consultation to the majority of 15 programs funded under a Community Health Service contracts since then. She had reviewed both the CHAIRS project in Los Angeles County and the CRIS proposal in Orange County. I called her to request specific information about the , questions raised by Committee and Council regarding relationships, similarities and differences between the two activities. Following are her telephonic comparison of these two projects, her comments about strengths and weaknesses of the CRIS proposal and information about experience with other information and referral services: (1) The basis objective of both CHAIRS and CRIS is the same: to establish a Central Information and Referral Service. (2) The methodologies employed are different: the CHAIRS project is concerned with the application of computer technology to the process of referral and will utilize a well-established Information and Referral Service. The CRIS proposal wotld employ standard accepted and proven techniques in developing a new service. (3) Each project is unique in its own way. CHAIRS is a research and development activity which is experimenting with computer technology. The CRIS project is a seed activity for an essential component of a comprehensive health program in one of the fastest growing counties in the United States. The County has, and will continue to have limited resources which must be utilized to fullest effectiveness. The County Health Department has a very competent health officer who is unusually cooperative toward the medical school and the Regional Medical Program. Project planning has resulted in commitment from an array of community agencies, including industry. The number and variety of agencies involved at the planning stage is unique in Miss Lester's experience. « : (4) The fact that CHAIRS is located in Los Angeles County and CRIS in contiguous Orange County is an advantage since the CRIS 4 For the Record Page 2 personnel will have the benefit of consultation from CHAIRS, and will be able to utilize basic information on Los Angeles County facilities which serve Orange County residents and information on any Orange County facilities that Los Angeles residents may use. Miss Lester indicated that a provision of the listing alone will save six months time for CRIS and will enable them to pursue new agency information. Even more important, she said, was that the Los Angeles program has evaluated the agency information, a process which usually takes about two years to complete. (5) Miss Lester did not see any advantage in withholding a start on CRIS until the CHAIRS project is completed because CHAIRS is a three-year research and development activity in computer technology which may or may not be applicable for Orange County with only a 1.4 million population. (6) The strength of the CRIS proposal, Miss Lester feels is the creation of a basic service under Regional Medical Program auspices which can assure the provision of professional and medical talents. The newness of the University Medical Center and the known commitment of community agencies augur well for its future. (7) The major weakness of CRIS, she felt, was in the staffing proposed. She felt that more time of the project director should be devoted to building firm working relationships with the community agencies and medical profession. She felt also that the second position should be filled by someone with experience. in community organization rather than in case work. The emphasis of staff should be on developing the service; the cooperating agencies should provide any individual case work. (8) Miss Lester says that no other source of funds are available for developing central information and referral services. Experience with 15 contract projects has been that ali have been maintained through community resources after three years of initial support. United Community Funds have been the principal source for maintenance, and the Funds will not support the initiation of a service until it has been tested and proved effective; furthermore, the initial expenses in developing and evaluating referral information are barriers. (9) Miss Lester indicated she would be glad to provide consultation to CRIS. ’ Ld Hel 1 ae / Sarak SJ. Silsbee » Acting Chicf Grants Review Branch (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE CALIFORNIA REGIONAL MEDICAL PROGRAM RM 00019 7/70.1 & .2 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The California "package" presented at this review cycle consisted of two new operational projects and a revision of one (#41) previously submitted but returned with suggestions for specific revisions (7/70.1) plus another proposal (#56) which was reviewed by February 1970 Review Committee and March 1970 Council and deferred for additional information concerning its relation to another similar program in Los Angeles County, approved by Council, but subsequently funded by the National Center for Research and Development, (7/70.2). The combined direct cost budgets request $613,200. Project #41 - Area I ~- Patient Monitoring Critique: The Review Committee noted the technical concerns raised by the Ad Hoc Cardiovascular Study Panel, particularly the support of a 20-60 bed arrythmia detection system before documenting such a system in a one or two bed "live" system. The reviewers believed the objectives of the project to be clearly stated, although their attainment within the time proposed was thought to be problematical. The failure of the region to submit hard data to support their conviction that arrhythmia detection unit is feasible, valid and reliable detracted from a strong case for the application. The personnel budget seemed reasonable. The question was raised about the unusually high indirect costs for the Lockheed Corporation, as well’as the 15% profit. The application was unclear as to whether funds are being requested for equipment already installed in Mt. Zion Hospital. The Committee believed that evaluation plan based upon clinical experience at Mt. Zion would not necessarily be an appropriate analysis for small hospitals. There were no comparison groups included in the proposed analysis and the reviewers felt the extrapolation of experience at Mt. Zion for application to small hospitals would require peer review. The application was believed to be unapprovable on technical grounds since the state of the art (24 hour on-line monitoring) to date has not proven feasible and is still in the research and development stage. \ AES ‘appears to be overly ambitious. California RMP ~2- RM 00019 7/70.1 & .2 ’ Recommendation: Non-approval II ~ Revision to be referred to a panel of experts for technical review. Project #60 - Medical Information Services - Area VI Critique: The Review Committee recalled that a request for this project was submitted with the first operational proposal from this region, and its subsequent disapproval. The area has persisted in its desire to strengthen its medical information resources by bringing information directly to individual practitioners in the four-county Area VI, based at Loma Linda. The reviewers noted its obvious importance to the Area and the © excellent cooperative efforts of the Area VI office and committees to link all the major medical libraries with each other and with hospitals throughout the region. It will afford the Loma Linda facility with easy access to the larger library at UCLA. The representative of the National Library of Medicine, who also served as a consultant for this project, was present at the Review Committee meeting and was able to clarify this project's relationship to other similar programs in this Area. He did not feel that a reduction in funds would damage the project. Recommendation: Approval I ~ In a reduced amount. O01 Year: $30,000 02 Year: $40,000 03 Year: $40,000 Project #61 ~ Intergraded Assistants Program ~— Area III The reviewers concurred with the comments of the Continuing Education and Training Panel that proposed training course The curriculum content was thought to be unfeasible in that it includes too much for the length of training proposed. They cited page 232, item I, "Techniques of centrifugation including the use of refrigerated ultracentrifuge", as an apparent inconsistency with nationally established one year post high school programs for Certified Laboratory Assistants. Also, there is no Critique: - indication from radiologists or the State Medical Society that they endorse this program or would employ this level of trainee. It was a point of question as to whether trainees could be employed outside of Stanford, in view of the rigid California licensing laws for laboratory personnel. | , The request for such training was believed to be relatively expensive—- approximately $8,200 per full-time student. The proposal will probably add some personnel to the manpower pool at Stanford, but its overall contribution to patient care in the region was questioned. California RMP . -3- RM 00019 7/70.1 & .2 Phase III of the program was difficult to assess in view of the unaccept- ability of the Phase II portion above. The reviewers felt that the curriculum emphasizes the laboratory too much and not enough on general internal medicine. Also;the responsibilities of the physicians assistants are not spelled out. The relationships to existing health personnel are not stated. The applicant makes no reference to other similar programs under development in the country. Generally, this project was believed to be very poorly thought out. The training aspects are quite unclear, the licensure problem is not dealt with, and it would appear that the region has not investigated existing programs (such as Duke University) for preparation of this program. Recommendation: Non-Approval I Project #56 - Community Resources and Information Services (CRIS) ~ Area VIII Critique: The Review Committee acknowledged the review of this project by a staff member of Comprehensive Health Services, who has provided consultation to a majority of fifteen existing programs throughout the U.S., funded under Community Health Service contracts. “One of the original concerns of the Review Committee was the relationship of this project to one previously reviewed and funded by the NCRD (CHAIRS). The basic objective of both projects is the same: to establish a Central Information and Referral Service. The methodologies are different. The CHAIRS project is concerned with the application of computer , technology to the process of referral, whereas the CRIS proposal wili employ standard accepted and proven techniques in developing a new service. CHAIRS is a research and development activity, and the CRIS project is a seed activity for an essential component of a comprehensive health program in one of the fastest growing counties in the U.S. The county has, and will continue to have, limited resources which must be utilized to fullest effectiveness. The number and variety of agencies involved in the planning for this program is not only commendable but unique. The proximity of the two programs in continguous areas was believed to be a benefit which will enable personnel to utilize mutually beneficial basic information. It was noted that the provision of the listing alone will save six months time for CRIS, and will enable project staff to pursue new agency information. More important, the Los Angeles program has evaluated the information, a process which usually takes about two years to complete. The strength of the CRIS proposal is its creation under RMP auspices, which assures the provision of professional and medical talent. The known commitment of community agencies and the university medical center augur well for its future. California RMP ~4Ge- RM 00019 7/70.1 & .2 The major weakness of CRIS was believed to be the proposed staffing. The suggestion was made that more time of the project director should be devoted to building firm working relationships with the community agencies and be filled by than in case service; the Such central of funds for projects has medical profession. The second position should probably someone with experience in community organization rather work. The emphasis of staff should be on developing the cooperating agencies should provide individual case work. information and referral services have no other source their development. Experience with the fifteen contract been that all have been maintained through community resources after three years of initial support. The principal source for maintenance is from United Community funds, which will only give support after the service has been tested and proved effective. There was consensus on the basis of such a technical review, that this project fills a real need for an area with no existing hub for such services, and where all social services are fragmented an unorganized. The project has good self-supporting potential after three years and will obviously close existing gaps in improvement of health care.. Recommendation: Approval I Project # 4l 60 61 56 TOTAL 01 Year: $77,307 02 Year: $77,248 03 Year: $81,393 SUMMARY OF RECOMMENDATIONS Ol Year 02 Year - 03 Year ~0- -0- ~O- $30,000 $40 ,000 $40,000 ~0- -0- -0- $77,307 $77,248 $81,393 $107,307 $117,248 — $121, 393 Dr. Gerald Besson and Dr. Mitchell Spellman were not present during the diliberation of this region. RMPS/GRB 7/16/70 @ REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) CENTRAL NEW YORK REGIONAL RM 00050 7/70.1 MEDICAL PROGRAM June 1970 Review Committee State University of New York 750 East Adams Street Syracuse, New York 13210 Program Coordinator: Richard H. Lyons, M.D. Requested: Program Period lst Year 2nd Year 3rd Year Total Direct Costs: $48,649 $60,643 $64 ,658 $173,950 Indirect Costs: $15,328 $16,860 $18,546 $ 50,734 TOTAL $63,977 $77,503 $83,204 $224,684 Background: The Central New York Regional Medical Program consists of fifteen counties in Central New York State and two counties in Northern Pennsylvania. The Regional Advisory Group is fairly repre~ sentative of the medical needs and interests of the Region. It has been recently reorganized;16 new members, largely consumers, have been added to give each county representation. It is assisted by four standing committees in heart disease, cancer, stroke and continuing education, formed from RAG members and experts from the Region in these four areas. Altogether, the RAG has eight committees to deal with problems such as health manpower, hospital needs and community health education. The Central New York Regional Medical Program began its planning in January 1967, with a grant of $289,522. The operational phase of the program began in July 1968, with four projects. Since that time eight additional projects have been approved, five of which have been funded. The Region was awarded $1,069,762 (d.c.o.) for a 15-month period of which $462,500 (d.c.o.) is for core activities. The Region's funded projects are: DIRECT COSTS PROJECT 15 MONTHS #1 - Continuing Education in Nursing (02 Year) $201,800 #2 ~ Mobile Stroke Rehabilitation Service (02. Year) 183,092 #3 - Oneida County Tumor Conference (02 Year) 7,118 #4 - Family Practice Program at St. Joseph's Hospital 43,827 (02 Year) #5 - Nursing CCU Training Program (02 Year) 18,348 #8 - Sigmoidoscopy Demonstration Training Program 41,205 (O01 Year) Central New York RMP ~2- RM 00050 7/70.1 #9 - Medical Briefs by Telephone, Sayre, Pennsylvania 21,223 #11 - Regional Learning Resources Center for Nursing 90,649 Continuing Education (01 Year) #14 - Continuing Medical Education in Rural Pennsylvania and New York (no additional funds) Those approved projects which have not yet been funded are: #6 ~ Home Dialysis Training Unfunded #10 - Community Hospital Equipment Request Unfunded #12 - Prevention of and Effective Recovery from Cardiovascular Illnesses Through Knowledgeable Nursing Intervention Unfunded A site visit was made to this Region in January 1969. The reviewers recommended that the University Medical Center (U.M.C.) give priority to the recruitment of physicians for core staff (there are none other than the coordinator). The U.M.C. stated that until vacant departmental head positions are filled it will be difficult to interest physicians in faculty appointments. Once the vacant departmental head positions at the Center are filled, top priority will be given to filling the Regional Medical Program positions. The CNYRMP has organized a liaison faculty of board certified surgeons or internists who work in their local areas to coordinate Regional Medical Program activities with community needs. Some of these liaison personnel have been successful in serving as local regional stimulators for development of training and continuing education programs. Mainly through the efforts of an active Nurse Coordinator on the core staff, nurses throughout the Region have been involved in a number of continuing education projects for nurses. Present Application This supplemental grant application is requesting $173,950 (d.c.o.) for three years support of Project #15 - Medical Library and Information Service. Requested Project #15 - Medical Library and Information Service First Year This project sponsored by the Upstate $48 ,649 Medical Center Library proposes to establish an adequate inter- library loan system and to provide the Region's librarians and other persons responsible for library services the training and consultation they need. Omitting the Upstate Medical Center Library, there are only 8 full-time pro- fessional librarians employed by hospitals in the region. Four of these librarians are employed by hospitals within the city of Syracuse. Training programs are needed at a non-professional level for personnel presently employed in hospital libraries. The New York Academy of Medicine Library serves as the Regional Medical Library for New York and Northern New Jersey. It serves in a "backstopping" _ capacity only and has imposed limitations on the interlibrary loan TG service. These restrictions virtually exclude all libraries in the Central Central New York RMP -3- RM 00050 7/70.1 New York Regional Medical Program from access to the Academy Library except by referral. The Upstate Medical Center Library has been asked to serve as a referral library fer this region. The Upstate Medical Center Library proposes to meet the Region's need for library service by: (1) encouraging and assisting in the development and improvement of local library facilities; (2) providing training programs for health personnel on the effective use of medical library and information systems; (3) supplementing local library resources by providing an efficient interlibrary loan service; (4) providing literature searches and reference service to health professionals in the area; (5) providing a current awareness service to keep members of the health profession informed about new developments in their field; and, (6) providing reference service for all forms of information needed to support continuing education programs including audiovisual teaching aids. To carry out the proposed activities the applicant has requested support of a Project Director (10%), two Medical Librarians (100%) and a clerical position (100%). For evaluation the program proposes to maintain statistical records on the use of each service, utilize the reports of the consultant librarian and do a mail survey with those persons who have used the services offered. As potential-future support the applicant identifies the health pro- fessionals (practitioners), the hospitals, and other health agencies (voluntary, county, medical societies, etc.). Second Year: $60,643 Third Year: $64,658 DRMP 4/30/70 A Privileged Communication | SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE: CENTRAL NEW YORK REGIONAL MEDICAL PROGRAM RM 00050 7/70.1 , FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: Committee concluded that this application which requests $173,950 (d.c.o.) for a three-year program period be approved with con- ditions at a reduced level of $143,000 for three years support.of Project #15 - Medical Library and Information Service. Project #15 ~ Medical Library and Information Service Critique: Committee concurrs with the comments of, the reviewers from the National Library of Medicine that this is a well thought out project which attempts through a series of interrelated activities to improve the informational services available to health workers in the Central New York Region. The project as developed would appear to cover, in a balanced - way, most of the needs of a region for information services Committee believes that this project has been developed as a result of increased demands being placed on the SUNY-Upstate library due to RMP activities out in the field pointing. out to health professionals the li- brary resources available to them. Committee believes the goals and objec~-° tives of the program are commendable and that the applicant is capable of carrying it out. However, there is in the application a certain lack of specificity relative to how they are going to implement their goals, For example, under goal 3, out of five suggested implementation steps the words ‘will explore the possibility" are used in three and "it is anticipated" is ‘used in one, Committee is also unsure of Mrs. Suzanne Murray's status in this program and would like clarification on whether she will be utilized and paid as a full-time staff member of this project, or will she remain on salary as a core staff member. Committee believes the requested budget is to high, particularly the office furniture and travel categories and recommends a,reduction in the budget. Recommendation: Approval I - at a reduced level with the following condi- - tions: (a) That the Region render clarification on how the stated goals are to be implemented; (b) clarification on how the services of Mrs, Suzanne Murray are to be supported. First Year Second Year Third Year $40,000 $50,000 $53,000 CENTRAL NEW YORK RMP a Da RM 00050 7/70.1 COMMETTEE FUNDING RECOMMENDATIONS (D.C.0.) Project Year Requested ‘ Recommended #15 01 $48 , 649 $40,000 02 ‘ 60,643 50,000 03 | 64,658 | 53,000 Total $173,000. $143,000 RMPS/GRB/7/8/70 a REGIONAL MEDICAL PROGRAM SERVICES SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) Colorado-Wyoming Regional Medical Program RM 00040 7/70.1 University of Colorado Medical Center June 1970 Review Committee 4200 East Ninth Avenue Denver, Colorado 80220 PROGRAM COORDINATOR: Paul R. Hildebrand, M. D. Requested Ist Year 2nd Year 3rd Year Total Direct Costs $108,177 $123,024 $132,297 $363,498 Indirect Costs 18,185 22,399 24,231 64,815 TOTAL $126,362 $145,423 $156,528 $428,313 HISTORY: This Region's planning grant period was for two years, January 1, 1967 - December 31, 1968. A total of $361,984 was awarded during the first year and $366,723 during the second year. Also, during the second year of planning an earmarked project in pediatric pulmonary disease was approved for three years and funded at $49,615 the first year (six months). Following a September 1968 site visit and at the end of the second year of planning, the Region's initial operational application was approved for three years January 1, 1969 - December 31, 1971. The first year operation award was $1,003,902 (total cost), for the support of core staff ($481,976 d.c.), six new projects ($308,997 d.c.), and the second year of the pediatric pulmonary disease project ($58,080 d.c.). In February 1969, Council approved two of four projects submitted in a supplemental application which resulted in an award of $142,922 (total cost). Five new projects were considered during the August 1969 and December 1969 Review Cycles. All were approved, at the combined level of $117,505 (d.c.). A supplement application consisting of two projects was reviewed during the March 1970 Review Cycle resulting in the approval of one project and non-approval of the other. In December 1969, Staff reviewed the Region's 02 year Continuation Application which requested $1,229,192 (d.c.) for support of Core and ten on-going operational projects. It was Staff's observation that most of the projects were moving along very much as anticipated. However, three projects, #3 ~ Multi-Media Education, #4 -_Home Dialysis Training System and #13 - Pediatric Pulmonary Center, were cited as 3 Colorado/Wyoming RMP -2- RM 00040 7/70.1 exceptions. These projects shared the same basic weaknesses; they did not relate to the original objectives, they were vague, their evaluation design and techniques were poor, and they failed to coordinate with, and relate to, other projects. As a result of the review, the Region was awarded its 02 year committed level of $1,108,113 (d.c.), and was requested to submit revised budgets. In addition, it was also requested to submit revised progress reports on the three projects which received critical reviews, and new proposals for use of unexpended funds. In May 1970 Staff reviewed the revised progress reports, revised budgets, and new proposals for use of unexpended funds which were cvequested from the Region as a part of the action taken on the Continuation Application reviewed by Staff in December 1969. Staff found the revised progress reports on projects #3 - Multi- Media Education, #4 - Home Dialysis Training and #13 - Pediatric Pulmonary Center, to a large degree failed to relate to the specific questions posed to the Region in the advice letter. Many questions were not spoken to, while others were answered in the same vague generalizations which characterized the original progress reports. In many instances the educational programs being conducted appeared to be wustructured and absent of good educational design. It was noted evaluation is obviously lacking and apparently no assistance in this area is being provided by Core Staff or other qualified personnel. « . Staff found the revised budgets for use of 02 year committed support to be appropriate with exception of two projects. Project #13 - Pediatric Pulmonary Center, requested additional support for the 02 year which staff felt was not justified by the poor progress report. Project #15 ~ Pediatric Oncology Center requested support of Fellows previously denied by Committee. Of the 15 proposals submitted for use of $98,776 01 year unexpended funds, ten representing $73,217 were recommended for approval. See the attached chart for funding status resulting from the revised project budgets and the request for balances. A List of unfunded projects is attached, also. As a result of the recent release of funds by the Bureau of the Budget, a special supplement is pending which would increase the level of funding for Projects #14, 15, 18 and 19 by $100,000. PRESENT APPLICATION: This application consists of one project, #13 (R) - Diagnosis and Treatment of Pediatric Pulmonary Problems, which is requesting renewed support for three years. It was originally an earmarked project funded as a part of Core at $43,879 (d. c.),for the period July 1, 1968 - December 31, 1968. Included in the award was a commitment of support of two additional years. As a result of the Region going operational on Colorado/Wyoming RMP -3- RM 00040 7/70.1 January 1, 1969, the project was withdrawn from Core, given autonomy as Project #13 and was awarded $58,080 (d.c.) for the 01 operational year, January 1, 1969 - December 31, 1969. During the latter part of 1969 the Region submitted its non- competing continuation application for Core and eight operational projects, of which Project #13 was one. Staff review of this particular project was quite negative. They found the progress reports to be very sketchy and difficult to relate to the original objectives which were: to conduct 10 specific postgraduate work- shops throughout the Region, conduct speaking engagements and brief demonstrations, develop teaching aids for ensuing programs and make administrative arrangements for future workshops. The applicant's use of broad general terms, such as visits, meetings and trips to describe activities of the program over the past year, provided little insight into actual accomplishments. It was noted evaluation is neither process or product oriented. As a result of the staff review, the Region was requested to submit within 120 days, a revised progress report answering specific questions related to staffs' observations. The Region has responded with a revised progress report, included in this application, which Staff has identified as more of the same ambiguities, failing to answer specific questions conveyed to the Region in the advice letter. Staff has subsequently recommended to the Director RMPS, that this project be allowed new funds in the amount requested, $75,956, for the period January 1, 1970 - January 31, 1970, but that the request for use of $13,256 of the previous years unexpended funds for this project be denied. It is requested that the Staff of the Continuing Education and Training Branch, Division of Regional Medical Program Services, visit the Region as soon as possible to observe the project first-hand and offer what appears to be badly needed assistance. Project #13 R - Diagnosis and Treatment of Pediatric Pulmonary Requested Problems. The basic goals of this project are First Year to place in various areas of the Region, Fellows trained in $108,177 pediatric chest disease and to further the training of existing practitioners, nurses and public health nurses in the diagnosis and treatment of these conditions. These goals are to be approached, basically, by the following mechanisms: 1) A Fellow- ship Program whereby two Fellows wili be accepted each year for a program emphasizing pulmonary disease training and not research; 2 and 3) Visiting Consultation - Teaching Clinics for Physicians: Visiting Consultation - Teaching Clinicis for Hospital Nurses and Technicians: These two types of clinics, which ordinarily occur at the same time, will be conducted in 14 communities of 5 different states; 4) Visiting Consultation Clinics for Public Health Nurses and Visiting Nurses: These nurses will have the opportunity for any needed instruction in any specific procedures or treatments needed by the home patient and will receive any assistance she wishes or Colorado/Wyoming RMP -4- RM 00040 7/70.1 needs in evaluating the extent to which the patients are following physician's instructions and maintaining environmental control; 5) Short-Term Postgraduate Programs: There will be conducted as both a follow-up to and as a stimulant to participation in locally- conducted visiting clinics. Several postgraduate programs will be offered each year in cooperation with other RMP sponsored courses in Adult Pulmonary Disease and in. cardiovascular/cardiopulmonary disease; 6) University Preceptorship: will be offered to at least one interested community practitioner who would come to the medical center and work and study in Pediatric Intensive Care Ward. Depending upon the physician's particular needs, a formal ‘course of instruction and experience would be developed. No educational design or detailed curriculum is provided for the individual programs. The general course material which is outlined is essentially the same for all programs. It will differ only in that it will be presented in greater or lesser depth and breadth depending on previous levels of training. A progress report for the period July 1968 ~ January 15, 1970 is presented. Second Year: $123,024 Third Year: $132,297 Colorado/Wyoming RMP -5- STATUS OF PROJECTS NOT FUNDED Project Number Approved and Title Project Period #11-- Facilitation of Learning #12 - Continuing Education #16 #17 #19 #20 Workshops Comprehensive Cardiac Care 2 A Training Program for 2 the Development of Ultrasonic Techniques in Community Hospitals Chronic Disease Evaluation 3 and Management of Patient Care Daily Update of Laboratory Reports RM 00040 7/70.1 Status Not Approved for Funding Not Approved for Funding Approved but Unfunded Approved but Unfunded Approved but Unfunded Not approved for Funding ain tN AA COLORADO/WYOMING REGIONAL MEDICAL PROGRAM 5-GO3-RM-000 32-02 Revised Project Budgets&Request for Balances Requested Requested O1 Project Title 02 Year Committed Staff Yr.Unexpended Staff Total Total Staff and Number Funds Recommendation __Funds Recommendation Request Recommendat: - CORE $516,050 $516,050 A. Organization of Health Data $1,000 $1,000 B Provision of Heaith Programs 645 Non~App. C. Production of Slide & Voice Tapes 1,147 Non-App.- D. Electrocardiograph Data Phone 1,700 1,700 E. Preceptee Training 2,500 2,500 F Loan & Medical Teaching Aids 4,735 Non-App. G. Regional ECG 1,360 1,360 TOTAL CORE $516,050 $516,050 $13,087 $6 ,560 $529,137 $522,610 ~ CANCER REGISTRY 50, 340 50,340 -0- -0- 50, 340 50, 340 , = MULTI-MEDIA EDUCATION 26,739 26,739 16 ,000 8,000 42,739 34,739 ~ HOME DIALYSIS TRAINING 31,284 31,284 8,435 8,435(2) 39,719 39,719 5 - RESPIRATORY CARE 95,604 95,604 17,641 17,641 113,245 113,245 "> RADIATION THERAPY TRAINING 58,279 58,279 -0- -0- 58,279 58,279 | — SMOKING AND HEALTH 22,739 22,739 2,555 2,555 25,294 25,294 | — CONTINULNG EDUCATION FOR NURSES 70,912 70,912 -0- -0- 70,912 70,912 ‘Q- CONTINUING EDUCATION STAFF 90,687 90,687 21,786 Non-App. 112,473 90,687 3~ PEDIATRIC PULMONARY CENTER 75,956 75956 13,256 Non-App. 89,212 75,956 ‘4 - STATISTICAL DIAGNOSIS AND PROGNOSIS 13,317 13,317 9 , 364 Non~App. 22,681 13,317 '5—- PEDIATRIC ONCOLOGY CENTER 20,974 14,3751) 30,326 30 , 326 51,300 44,701 i8~ PATIENTS WITH ADVANCED CANCER 10,000 10,000 -0- -0O- 10,000 10 ,000 TOTAL $1,082,881 $1,076,282 $132,450 $73,517 $1,215,331 $1,149,799 $1,082,881 PLUS $98,776 Actual EQUALS $1,181,657 Committed Ol year unexpended Total level available Funds Available for for request Request (1) As recommended by Committee — No support for Fellows. (2) Restricted pending Staff visit. A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 ADVISORY COUNCIL COLORADO/WYOMING REGIONAL MEDICAL PROGRAM RM 00040 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee decided that this application should not be approved, although it recognized that the one project for which funding was requested was ongoing and represented the development of a valid regional referral resource. Project #13R ~- Diagnosis and Treatment _of Pediatric Pulmonary Problems. ‘Critique: Since consideration of this application occurred early in its meeting, the Committee flagged two areas of interrelated concern which prevailed throughout the Committee meeting; support of clinical training for fellows. and support for regional referral centers. Committee noted the progress of this project which had been funded from earmarked funds in 1968; the activities to date have stimulated referral of patients and physician consultations regarding management of the patients. These were considered valuable outcomes; although the Committee recognized that these accomplishments might not be an appropriate outcome of DRMP funding. Funding for fellowship training (whether it is advanced medical residency training was not clear) was requested, and the Committee felt this was a valuable addition to Regional resources even though it may not be an appropriate use of RMP funds. The Committee noted that the incidence of pulmonary disease in pediatric ‘patients is high. The reviewers observed, however, thut RMP qualities of the activity - continuing education for all referring physicians and allied health personnel, development of peripheral centers, etc. - were inadequately described both in the report of progress to date and in the project plans. The activity, in fact, seems unrelated to other RMP efforts in continuing education for hospital personnel. The RMP core staff in continuing education apparently is not involved. The project's inclusion in.a Regional Medical Program seems incidental. he Committee was concerned about the separateness of this activity within RMP and felt it should be integrated with other RMP efforts. g *COLORADO/WYOMING RMP” ~2- RM 00040 7/70.1 @ Recommendation: Non-Approval II ~ Return for revision with clarifica- tion of the following: 1. The relationship of this,project to Project 10 - Continuing Education Staff and Project’ #6.- Respiratory Care. 2. How will the project continue after the grant period and what other sources of support have been explored? Particularly, have the sources of support for Fellows been investigated? If-so, what are they? 3. Details of proposed educational activities. 4. What is the academic level of the Fellows being trained? Are they residents? 5. Is income being generated and if so, is it being applied against the grant? _DRMP/GRB 7/15/70 REGIGQNAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) Florida Regional Medical Program RM 00024 7/70.1 | Davis Boulevard, Suite 309 June 1970 Review Committee Tampa, Florida 33606 Program Coordinator: Granville W. Larimore, M.D. Requested Ist Year 2nd Year 3rd Year TOTAL Direct Costs $144,690 $95,588 $98,288 $338,566 Indirect Costs To Be Negotiated TOTAL $144,690 $95,588 $98,288 $338,566 Background: The Region received its first planning funds on November 1, 1967 after submitting three applications (an original and two revisions). Almost at the same time the Region received its planning continuation award, which included an earmarked hypertension study, it submitted its operational application and four supplemental planning applications. In February 1969, Council approved operational status for the Region and nine operational projects and three of the planning supplements. The level of support for core, $682,000, now includes funds for the coordinator's office in Tampa and for subregional programs in North, South and Mid-Florida. The current level of funding for core and nine projects is $1,471,000 . The Florida RMP is presently organized into three areas for ease of program management and administration. Coordinating the activities of the three area offices is a state office based in Tampa. The state office provides statistical, grants development and management, and public relations services for the Region. The three area offices have been staffed to varying degrees, the North Area office being the most active in stimulating projects. The applicant agency is the Florida Regional Medical Program, Inc., which is a nonprofit corporation established by eleven organizations with representatives from the University of Florida College of Medicine, University of Miami School of Medicine, University of South Florida, Florida Heart Association, Florida Florida Hospital Association, Florida Cancer Society, Florida Board of Regents, University of Miami Board of Trustees, Florida Board of Health, the Florida Medical Association and the general public. The 31 member Regional Advisory Group makes the final determinations on projects, but the FRMP, Inc., maintains a large degree of administrative control, as well as elects the members of the Regional Advisory Group. The Region has also established some Task Forces in categorical and functional areas. Florida Regional Medical Program -2- RM 00024 7/70.1 A program site visit was held in January 1970. The site team which visited the Reyion reported on a number of problems seriously hampering the RMP's operation. These problems related to the Regional Advisory Group--the need for a more representative, including minority group membership, the need for effective working committees and the need to wrest control of the program from the applicant agency; the seccesionist moves on the part of the North Florida Area and the program imbalance among three FRMP areas. The February Review Committee and March Council heard and approved the site visitors' recommendations relating to these problems. Specifically, they urged that secessionist moves be discouraged and that Florida remain a singlé Region. To this end, national reviewers were advised to give priority to programs in Southern and Central Florida to help redress the imbalance among the three areas. The reviewers also indicated that representation on the RAG should be broadened and that the actions of the applicant organization be monitored to insure that the legal authorities and responsi~ bilities of the RAG not be abrogated by FRMP, Inc. Finally, the development and review of projects, which have suffered a high disapproval rate during the past year, should be improved by strengthening core staff at the assistant level, the Task Forces and the RAG. As a result of the site visit, the Region has begun to resolve some of their problems. The Regional Advisory Group has added three new members, bringing the total minority representation to three and is taking a more active stand in its relations with the FRMP, Inc. The RMP is reorganizing its subregional offices so that instead of three area offices and various sub-area offices, responsible to the area offices, there will be nine district and three medical school offices, all directly responsible to the Coordinator. Each of these offices will be staffed by a physician who the Region feels should have as one of their main responsibilities that of liaison between FRMP and the medical society. Present Application: Requested Project #36 - A Hospital-Based Program for Cardiopulmonary Resusci- First Year tation in the State of Florida. The Florida Heart $144 ,690 Association will sponsor this proposal to establish a continuous training program in cardiopulmonary resuscitation in Florida. A program to accomplish this general aim has been developed with the following specific objectives: 1) train and retrain key physicians and registered nurses who will assume responsibility for training other hospital personnel in CPR; 2) encourage and assist hospitals in establishing emergency resuscitation measures; 3) establish uniform standards of training for hospital personnel according to the recom- mendations of the National Research Council; 4) provide training for future instructors in CPR at the community hospital and through a decentralized delivery system. The American Heart Association eurriculm and standards will be followed throughout the project. Of the 197 hospitals in the state, the proposers estimate that 127 would need teaching programs. The remaining 70 including large institutions, such as mental hospitals, would be spotchecked. A See Florida Regional Medical Program -3- RM 00024 7/70.1 survey of hospital facilities will be carried out in order to tailor the CPR program to the, individual hospital. The state would be divided into four geographical areas for ease of management. Each area will be staffed ty a full-time CPR Coordinator, who will conduct or assist in CPR training at the hospital level. Each faculty coordinator will receive four weeks of training at either the University of Florida or the University of Miami. The other training personnel mentioned in the proposal are CPR faculty and instructors, but the relationship among the three and the specific training responsibilities for each are not well defined in the proposal. The training design is marked by a similar lack of clear definition. CPR faculty will train instructors who will devise schedules for and offer training to physicians, nurses and other allied health personnel at institutions in their respective areas. Class size is limited to 15 people, but the project does not specify how many courses will be held during the three-year project period. The number of classes conducted, students trained and student proficiency in an AHA examination will be studied. When there appears to be no activity following initial CPR training (a measure of the percentage of persons trained compared to the total number to be trained), another effort will be made with a different person designated as the responsible authority in the same hospital. Ultimately, the proposers expect that more than 75% of the eligible personnel at each hospital will have been trained. "Random visitations" of courses by senior faculty personnel as the courses are being given will be another subjective measurement of success. Forms have been developed for personnel to record results of each CPR episode in the hospitals. The Florida Heart Association has been conducting a CPR pilot study since September 1969. This pilot study has shown that "it is necessary to have all equipment transported to the training site rather than relying upon availability of specialized apparatus at the location." Accordingly a standard panel truck is being requested for each of the area coordinators to haul the training aids from hospital to hospital. The amount of $11,630 in equipment for each area includes $3,000 for the van and $8,630 in teaching equipment and material. Additional funds for two teaching trainers at $10,000 each and for closed circuit TV at $3,500 round out the remainder of the $58,390 total equipment item in the budget. $54,000 in personnel is also requested for the state coordinator, three area coordinators and a secretary. The coordinators are expected to have a bachelor's degree in health education or health related fields. A cadre of physicians and nurses available as consultants are listed with the proposals. Second Year: $95,588 Third Year: $98,288 GRB-5/12/70 A PRIVILEGED GOUMMUNLUATLON FLORIDA RMP 00024 7/70.1 T/7TO.4 _ STAFF OBSERVATIONS History of Review Actions of Operational Projects (Direct Costs) 02 Award N #1 - Community Multitest Health Screening Center $179,150 N #2 - CCU for North Florida 24,727 N #3 - Regional Computerized EKG Processing Center 114,566 N #4 - Cardiovascular Laboratory Training Program Disapproved N #5 - Postgraduate Intensive Inservice Education for Physicians 67,148 N #6 - Continuing Medical Education via Open Circuit TV Deferred N #7 - Training of Pulmonary Function - Inhalation Therapy Technicians Withdrawn N #8 - Computerization of CCU's 39,706 N #9 - Diabetes Proposal Disapproved F #10 - Cardiovascular Screening Program in Four Rural Counties 95,631 F #11 - Stroke Survey and Rehabilitation Returned for Revision F #12 - Computerized EKG Screening Program 35,400 S #13 - Stroke Professional Education Program Deferred S #14 - Pediatric Pulmonary Disease Center Deferred S #15 - Supervision of Paramedical Personnel via Telemetry 37,443 S #16 - Coronary Care Nurse Training Program 112,917 S #17 - Consulting Conferences in Clinical Cardiovascular Disease Returned for Revision N #18 - A Computer Program for Blood Banking Disapproved F #19 - Smoking and Health Returned for Revision F #20 ~ Florida Cancer Control Program Disapproved S #21 - South Florida Regional Cancer Program : _ Returned for Revision N #22 - Pediatric Continuing Education Approved but Unfunded N #23 - Continuing Education - the Community Hospital Level Returned for Revision N #24 - Demonstration Project in Patient Care - ; Continuing Medical Education (Pensacola) Returned for Revision N #25 - Regional Streptococcal Disease Laboratory Disapproved M #26 - Cardiovascular Laboratory - Mid-Florida Area Disapproved N #27 - Cardiovascular Laboratory - North Florida Area Disapproved F #28 - Smoking and Health Approved but not Funded F #29 - Pediatric Pulmonary Care Unit Returned for Revision STAFF OBSERVATIONS -2- M #30 - Program for Prevention and Rehabilitation of Cerebrovascular Disease N #31 - South East Regional Self-Learning Program for Skeletal Pathology F #32 - Demonstration - Cardiovascular ~ Screening Program F #33 - A Regional Program for the Diagnosis and Treatment of Cancer in Children S #34 - A Rehabilitation Program for South Florida M #35 - A Demonstration of Health Guides for a Model Neighborhood Area Project Sub Total Hypertension Earmark TOTAL 1 Sw ew FLORIDA RMP Returned for Revision Disapproved Returned for Approved but Returned for Approved but Revision Unfunded 1 Revision Unfunded L $706, 688 82,280 $788 ,968 Funding Under Negotiation from the $5 million earmarked funds. - denotes application submitted by North Florida area organization/institution is uw iW " Mid " South " Statewide n ‘ " oO " ur Ww i "W " 1 " \ L A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE FLORIDA REGIONAL MEDICAL PROGRAM RM 00024 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: Review Committee recommended returning for revision this one~- ‘project application which requested $338,566 for a three-year program period to support A Hospital-Based Program for Cardiopulmonary Resuscitation in the State of Florida. The reviewers recalled from the site visit in January the need for statewide, in addition to southern and mid-Florida-based, projects to redress the imbalance among the three Areas. Although this project would serve all hospitals in Florida, re- viewers felt that the details were-not delineated well enough to warrant . approval in its present form. Committee also wondered about the need for this project in light of the health needs of the Region. Project. #36 - A Hospital-Based Program for Cardiopulmonary Resuscitation ~ in the State of Florida Critique: The reviewers recognized that this project has local support and would use the American Heart Association Course for. cardio- pulmonary resuscitation. However, only one and a half pages of narrative explain what will be done, how and by whom. No results of the pilot pro- gram conducted by the Heart Association are given. The Continuing Edu- cation and Training Branch believed the project was unclear about the use of consultants and the evaluation of the teaching capability of the indi-- vidual to be trained in the course (Evaluation of proficiency consists solely of a test given on the completion of the one day of training.) The names of those people listed as associate investigators are highly qualified, but the reviewers were not sure just how involved they would be. Committee thought this project could create an effective learning experi- ence if it attacked this as a problem in training teachers, but reviewers doubted that this could be. accomplished in the one-day training period described. The Committee also doubted that any other organization would want to assume the funding of the project when RMP support is. terminated. If revised, the project should give more information on the pilot study, the coordination of personnel, how consultants will be used, teaching methods, how trainees are selected and follow-up. Committee also recom mended the project should be phased into development. Recommendation: Return for revision. pRMP 7/2/70 GEORGIA Regional Medical Program -2- RM 00046 7/70.1 Attached is a summary of the operational projects currently being supported by GRMP and status of unfunded projects. . PRESENT APPLICATION Two (#31 & #32) of the three new projects that make up this’ applicatién- propose to assist in the establishment of area facilities concept which is | recognized, as high priority, in the accompanying Task Force Reports. i Through the area facility concept, GRMP has sought to identify the strongest hospitals in each geographical area of the State and has assisted them in providing improved services in the general areas of: continuing education of all health professionals, improved diagnostic services, development of case funding and development of case finding risk factor screening community program. The remaining project #33, was also developed in accordance with Task Force recommendations as cited in the accompanying Task Force Reports. Requested Project #31 - Development of Cardiovascular Area Facilities. The First Year goal of this project is to develop comprehensive $179,496 service components, consisting of prevention, diagnosis, treatment and rehabilitation on cardiovascular diseases in large hospitals designated as Area Cardiovascular Facilities. Six unidentified facilities will be designated the first year with a total of 15 to 20 in the project period. The specific objectives are: 1) to develop a mechanism for the selection and development of "facilities" based on a priority system, 2) provide for expansion of services in facili- ties which lead to comprehensive programs, 3) provide flexibility in the development of new services so that facilities may meet the most pressing needs of the area. The first step in implementing the program will be to survey all hospitals of 200 beds or more to identi- fy all existing services. From this tabulation the Task Force will establish priorities, and hospitals high on the priority scale will be notified of elegibility to submit requests for designation as area facilities and for GRMP support for development or expansion of services. In order to receive support, area facilities will submit detailed short and long range plans and make recommendations for funding. All facilities will be available to all patients regardless of their ability to pay. Other programs, cited by the applicant as "relating directly" to this project, include: the training programs in coronary care, the study of the feas*bility of linking small hospitals to larger hospitals for patient monitoring and consultation and the proposed demonstration in rehabilitation of cardiovascular patients. However, it is not specified how the programs will relate. In addition no mention is made of this project's relationship to project #8 - Improvement and Coordination of Facilities for Cardiovascular Diagnostic Services. The overall assessment of the project will be based on a determination of the statewide increase in services for cardiovascular patients and availability of these services to those who need them. In addition, assessment procedures are provided for each of the objectives. The first year budget request, which is based on the development of six area facilities, is reduced in proportion to the 20% time delay antici- pated in recruiting and implementing the project. 2 Second Year: $240,372 Third Year: $257,974 GEORGIA Regional Medical Program ~3- RM 00046 7/70.1 © ‘ Requested Project #32 - The Development of Stroke Area Facilities, This First Year project is designed to compliment an existing activity, $189,576 "A Comprehensive Statewide Stroke Progrdm'' by implementing area stroke facilities in various geographic areas of the state. The specific objectives are: 1) to stimulate the development of six comprehensive area stroke facilities until services are available in all parts of the state; 2) to allow flexibility in development so each facility can build its own resources at the time and date feasible for its service area; and 3) to provide assistance to the area facilities such as training programs for personnel, resource materials for health education, and consultative services. The first step will be to establish priorities for implementation of the primary area facilities. Primary consideration will be given to implementing area stroke programs in those facilities which already have personnel and resources to pro~ vide some services. The second level of priorities will be given to those facilities which may not have a range of services already available, but which serve an area notably lacking in stroke services. Each facility which meets priorities will develop a written plan based on its own resources, its estimate of community needs and what could be accom-~ plished with help from GRMP. The Task Forces of GRMP have estab- lished seven service area components which should be developed in each area facility and these components will be considered in establishing priorities for implementation. Participating agencies in the planning and implementation of the area facilities will include the Georgia Heart Association, the Georgia Division of Vocation Rehabilitation and GRMP. Training programs for area facility staffs are being developed by GRMP, in cooperation with both schools of medicine, Georgia and Emory, and the State Department of Health. Evaluation procedures will be focused on determining the degree to which all residents have access to comprehensive stroke services. The first year budget request, which is based on the development of six area facilities, is reduced in proportion to the 20% time delay anticipated in recruiting and implementing the project. Second Year: $254,232 Third Year: $273,220 Requested Project #33 - A Short-Term Preceptor Training Program to Introduce First Year Medical Students to Medical Practice in Rural Georgia. $7,800 This project was prompted by the disparity of distribution of physici- -ans between urban and rural areas. It is designed to provide medical students of the Medical College of Georgia and Emory Universities, an opportunity to participate firsthand in the challenges and opportunities provided by medical practice in some of the smaller communities of Georgia. Its major purpose is to cause a greater number of young physicians to practice medicine in Georgia'a non-metropolitan areas. Lesser objectives include: identifying some indicators of medical student interest in rural general practice, and to provide a learning experience for both preceptor and student. The program will not provide students with academic credits toward graduation. Initially it will consist of a group of ten students and will extend for six weeks. The selected students’ time will be spent with the preceptor observing and assisting in his practice. They will participate in office visits, home visits, and hospital and clinical rounds, plus - : a0 1 Pkt nen nae Ga mhinh tha nhveician GEORGIA Regional Medical Program -4- RM 00046 7/70.1 is engaged. An opportunity will also be given the student to participate in the community civic and family life. The Georgia Academy of General Practice-has taken an active interest in the program and some of its members have volunteered to serve as preceptors. The Rural Health Committee of the Medical Association of Georgia will make the final selection of all preceptors. Students will be selected by the medical schools. Criteria have been established for the selection of both preceptors and students. Evaluation will have two basic purposes: 1) to determine the degtee of effectiveness of the project in meeting its objectives, and 2) to attempt to identify some characteristics in medical students which would indicate potential interest in family medicine. Several other GRMP projects will be utilized to continue the education of the physician and student during the preceptorship; the Visiting Consultant Program, the Interlibrary Copying Service, the Communications Network and the Area Facilities for Continuing Education. Second Year: $11,400 Third Year: $15,000 -~5- GEORGIA Regional Medical Program RM 00046 7/70.1 Summary of Operational projects currently being supported by GRMP Approved Project Funded 2nd Year Project Title and Number Period (Direct Cost) 7/1/69-8/31/70 #1 - Short-Term Traineeships for Physicians 3 Years $ 106,985 #2 - Post-Residency Training Pediatric Cardi- 1 Year 10,350 ology and Hypertension Renal Disease #3 - Visiting Consultants to Community Hospitals 3 Years 24,500 #4 - Interlibrary Copying Service 3 Years 23,333 #5 - Columbus Medical Center ~- Emory University 3 Years 42,843 Teaching Affiliation #6 - Communications Network for the Region 3 Years 355,882 #8 - Improvement and Coordination of Facilities- 3 Years 93 ,333 Cardiovascular Diagnostic Services #10 - Cardiopulmonary Resuscitation 3 Years 113,658 #11 - Coronary Care Feasibility Study 2 Years 34,194 #13 - Statewide Cancer 3 Years 401,276 #14 - Pediatric Pulmonary 3 Years 170,810 #15 - Training Medical Specialist Assistants 3 Years 68,485 #17 - Communcations and Information 3 Years 22,998 #18 - Core 3 Years 761,321 #19 - Development of Area Program 3 Years 88,241 #20 ~ Development of an Area Facility for Funded lst Year Continuing Education 3 Years 7/1/69-8/31/70 95,900 #21 - Coronary Care Training 3 Years 53,692 #22 - Short-term Training in Cardiovascular 3 Years 26,116 Physiology and Medical Surgical Nursing #23 - Renal Failure Training and Demonstration 3 Years 37,819 #24 - Teaching, Training & Demonstration in 3 Years 43,776 Hypertension and Nephrology #28 - Comprehensive Statewide Stroke 3 Years 3,700 #29 - Education and Service in Chronic 2 Years 11,000 Pulmonary Diseases TOTAL $2,623,512 GEORGIA Regional Medical Program Status of Unfunded Projects #9 - Renal Dialysis and Transplant Program #12 - Stroke Instruction Clinic #18S-Core Staff Supplement #25 Development of Health Careers Council #26 - Refresher Courses for Inactive RNs #27 - Community High Blood Pressure Program for Atlanta #30 1 Planning for Area Cancer Facility in Augusta ¢ RM 00046 =7/70.1 ‘ Disapproved | Disapproved Approved but Unfunded Disapproved Disapproved Approved but Unfunded Approved but Unfunded DRMP/GRB 5/25/70 os ; \ @BUMMARY OF REVIEW AND CONCLUS ION OF JUNE 1970 REVIEW COMMITTEE GEORGIA REGIONAL MEDICAL PROGRAM RM 00046 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: In reviewing this application requesting funding for the , development of cardiovascular area and stroke facilities and for medical student preceptorships in rural Georgia, the Committee expressed some degree of frustration in their lack of up-to-date understanding of the ongoing Georgia RMP. The proposals appeared to some members as a unique approach to subregionalization planning, but the Committee was unclear about how these efforts related to the local advisory group and present operational and core activities. The Committee approved the application with specific conditions, at a greatly reduced budget and for two years only; one project was disapproved. The request. was for $376,872 the first year and for $1,429,070. for three years; the Committee recommended $100,000 for each of two years. Project #31 .- Development of. Cardiovascular Area Facilities. “Critique: Committee recognized that the activities of this project, which are described in very general terms, are basically planning in nature and questioned why such a program was not considered a part of the core activities; some observed-it has the characteristics of a supplement. to core. It was questioned how the budget which appears unrealistic was derived, and on what basis the large request for personnel’could be justi- fied. It was noted the comprehensive services to be provided are not defined and it is unclear as to whether this can be interpreted as services to both in and out-patients. It is not explained how this project relates to ongoing projects #8 - Improvement and Coordination of Facilities-Cardio- vascular Diagnostic Services and #19 = Development of Area. Program. Plans for phasing out. are described which indicate dependence on the establishment of "some type of pre-payment mechanism", however, no documentation was pre- sented to support how realistic this will be, and no mention is made of what - will happen: to the planning staff when’ the project terminates. Committee agreed with the Ad Hoc Cardiovascular Panel comment that the evaluation plan is restricted to measuring increases in services available and utilized, and that no assessment of effect on morbidity and mortality is planned. Further the reliability of need assessment procedures and ‘subsequent measurement of success is not adequately described. In view of the concerns expressed, the large scope of the project and the large budget, the Committee reasoned that a logical approach would be to initiate the project on a pilot base in one or two areas. Upon evidence that the program is successful in these areas, expansion into other areas would be appropriate. GEORGIA Regional Medical Program -2- RM 00046 7/70.1 Recommendation: Approval I - at $100,000 for each of 2 years for Projects #31 and 32. Because of the similarities of the programs the recommendation for this project is combine with recommendation for Project #32 - Development of Stroke Area Facilities. Project #32 - Development of Streke Area Facilities. Gritique: Committee observed this project, although related to stroke, has the same basic design as Project #31 - Development of Cardiovascular Area Facilities and that many of the observations made of that project can equally apply to this one, As with Project #31, Committee believed this project should be initiated as a pilot project in one or two areas and expanded to other areas as success allows. Recommendation: Approval I - at $100,000 for each of two years for Projects #31 and 32. Because of the similarities of the programs the recommendation for this project is combine with the recommendation for Project #31 - Development of Cardiovascular Area Facilities. Project #33.- Short Term Preceptor Training Program to Introduce Medical Students to Medical Practice in Rural Georgia. Critique: Committee and the Continuing Education Panel were in general : agreement regarding this project. It was noted the educational og ‘needs are identified only in the sense of common agreement about lack of rural practitioners. There is no evidence presented that there is a pool of interested students. No reference is made to experiences in states where rural preceptorships is a part of medical school curriculums. ‘It’ was observed the evaluation is not realistic in that there is no test for‘validity of the data, which can only be provided by time, i.e., do the students, enter rural practice? Committee did not agree with Panel's belief that this project did not represent continuing education and that the appropriateness of this type of activity is questionable under the present guidelines. It was concluded however, that this type of program should be supported either by the medical society or as an elective of the medical schools. curriculum. t Recommendation: Non~Approval I - No RMPS Funds Recommended. GEORGIA Regional Medical Program -3- RM 00046 7/70.1 SUMMARY OF RECOMMENDATION Recommenda ~ Project Title and # tion 01 02 03 - Total #31-Development of Approval~Ly Cardiovascular along with “\™- Area Facilities Project #32 for 2 years - $100,000 $100,000 ~O-~ $200,000 #32-Development of Approval I Stroke Area along with Facilities , Project #31 for 2 years #33-A Short Term Pre- . Non-Approval I -0- -0- -0- -0- ceptor Training No RMPS Support Program to Intro- Recommended duce Medical Stu- dents to Medical Practice in Rural Georgia TOTAL APPLICATION . Approval with $100,000 $100,000 -0- $200,000 conditions . DRMP/GRB ~ 7/15/70 a e REGICYAL MEDICAL PROGRAMS SERVICE SUMMARY OF A SUPPLEMENTAL OPERATIONAL GRANT APPLICATION (A Privileged Communication) GREATER DELAWARE VALLEY REGIONAL MEDICAL PROGRAM RM 00026 7/70.1 Wynnewood House - June 1970 Review Committee 300 East Lancaster Avenue Wynnewood, Pennsylvania 19096 Program Coordinator: George R. Clammer, M.D. Requested lst Yr. 2nd Yr. 3rd Yr. TOTAL Direct Costs $67,395 None None $67,395 Indirect Costs None None -None None TOTAL $67,395 -- “+ $67,395 History: In April 1967,this Region received its first planning grant of $1,531,494 and its first operational award in April 1969, following a site visit in October 1968. The operational award of $2,862,484 included “support for Core staff and support for initiating five operational projects, dditional projects were approved in a subsequent review cycle. In March 1970, Staff reviewed the Region's second-year operational continuation application (4/1/70-3/31/71). The continuation of the operational projects evoked little concern and, in general, were approved at the committed level. However, etaff had serious concerns about the basic organization (as described in the application) and the functions and activities of the large Core staff - in the Executive Director's office and in the five medical schools. The Core budget was approved at its committed level of $1,628,336 rather than the requested $1,795,240, with a $383,777 restriction of funds imposed ($340,000 of which is in the personnel category and $43,777 of which is in the subcontracts category). Further, it-was decided that a program site visit should be made , to the Region to explore the interrelationships of the Core staff with the projects, as well as the degree of coordination among the various staffs of the Core components, The personnel restriction may be lifted following the program site visit, while the subcontract restriction was imposed pending further clarification. The Region is in its second operational year (4/1/70-3/31/71) at a total cost of $2,443,486 (d.c.) - $2,126,099 basic and $317,387 carryover funds. (Please see History Supplement for a breakout of this total.) Present Application: This application requests one-ycar support to provide equipment only for coronary care units in seven selected hospitals, Direct costs only are shown in the project description, © GREATER DELAWARE VALLEY RMP ~2~ _ RM 00026, 7/70.1 Requested ; First Year Project #19 ~ Coronary Care Equipment for Hospitals $67,395 in Northeastern Pennsylvania. This proposal requests support solely for the ~parchase of coronary care equipment for seven selected community ee hospitals in Northeastern Pennsylvania. The Region states that by providing coronary care equipment to these sclected satellite hospitals, they will provide the nurses (who have ‘received, or will receive, special CCU training) with the tools to effectively apply the training at their home-base hospitals. The following criteria were the basis for the selection of these hospitals: , 1) The hospitals indicated an interest in developing or expanding their coronary care facilities. 2) The hospitals indicated a commitment to securing skilled nursing staff, as well as a commitment to the concept of regionalization for this purpose, as shown by their participation (or intention to participate) in the nurses’ training program, 3) The hospitals have the potential capability for providing services which are presently lacking or inadequate in the area, \ 4) The hospitals would be unable to develop their potential capabilities without additional support. The following hospitals were selected: Bloomsburg Hospital, Bloomsburg, Pa. This hospital has 138 beds and serves a population of approximately 70,000 within a fifty-mile radius. There were 85 admissions for acute myocardial infarction in 1968 end 33 died. Two nurses have had special training in coronary care, in training programs sponsored by GDVRMP, It is planned to provide training for four additional nurses within the next year. Plans have been made and are being implemented for. the construction of a new ‘five-bed CCU, Gnaden Huetten Memorial Hospital, Lehighton, Pa. In this 130-bed hospital, 92 beds are devoted to acute care. The hospital serves a population of approximately 60,000 within a 24-mile radius. Five nurses are trained in coronary care and five will be available for training within the next year. Plans are currently being implemented to build a six-bed CCU. This hospital is also interested in developing a training program for nurses who will work in small hospitals (100 beds or less). GREATER DELAWARE VALLEY RMP - 3+ ; RM 00026 7/70.1 Palmerton Hospital, Palmerton, Pa. This is a 65-bed hospital, serving a population of 30,000 to 40,000 within a 20 to 25-mile radius. In 1968, 94 patients were admitted for acute myocardial infarction; nineteen died during hospitalization. Two nurses are currently receiving training in coronary care and five will be available within the next year, The hospital currently has a two-bed CCU and plans are in effect to construct a new building which will have a total of four coronary beds. St. Joseph's Hospital, Carbondale, Pa, This hospital has 105 beds and serves a population of about 50,000. In 1968, 85 patients were admitted for acute myocardial infarction and 21 died in the hospital. Four nurses have had special coronary care training and five additional nurses plan to take the training within the next year. A new combined intensive care unit~coronary care unit will be constructed. Tyler Memorial Hospital, Tunkhennock, Pa. This hospital has 62 beds and serves a population of 17,000 within a 15-mile radius. Twenty-six patients were admitted in 1968 with a primary diagnosis of myocardial infarction. -Ten of these patients died, Eleven of the patients were admitted with a secondary diagnosis of myocardial infarction; eight of these patients died. (However, not’ all of these deaths were attributed to acute myocardial infarction.) Two nurses have had special training in coronary care and three additional nurses will be available for training within the year. The hospital currently has a four-bed combination intensive care unit-coronary care unit. Wayne County Memorial Hospital hax 79 beds and serves a population of 30,000 within a 20-mile radius. Forty-eight patients were admitted in 1968 for acute myocardial infarction, of which 14 died. Twenty-five nurses have had special training in coronary care and an additional five nurses will be available for training within the next year. This hospital has a new four-bed combination intensive care-coronary care unit, but only one bed is equipped for monitoring. Mid-Valley Hospital, Peckville, Pa. This hospital has 65 beds and serves: 60,000 people in a 15-mile radius. In 1968, fifty-eight patients were admitted with a diagnosis of myocardial infarction; eleven of these patients died. None of the nurses have had special coronary care training. However, six will be available far training within the next year. Patients with acute myocardial infarction are cared for in the general hospital, The hospital has resuscitation equipment in the operating and emergency rooms, but no special monitoring equipment is available. Plans are in effect to construct a new wing, consisting of a two-bed coronary care unit adjacent to a four~bed intensive care unit. © GREATER DELAVARE VALLEY RMP LISTING OF CURRENT STATUS OF CORK & OPERATIONAL PROJECTS JN GDVRMP ~4- HISTORY, SUPPLEMENT RM 00026 7/70.1 A - FUNDED PROJECTS Six Cooperating Philadelphia Nospitals Project Amount Supported Number Title Through 3/31/71 Basic Carryover 00 Core : 1) Executive Director $ 828,266 -- 2) Hahnemann 153,814 ae 3) Jefferson 142,332 -~ 4) Philadelphia Osteopathic 106,860 “ 5) University of Penna, 164, 363 -- 6) Temple 113,297 ~~ 7) Woman's Medical 119,404 ~~ | TOTAL (CORE) $1,628, 336 1 Coronary Care Training ~ : Wilkes-Barre General Hospital 73,947 17,391 \ 2 Coronary Care Training ~ Reading Hospital 60,840 20 , 964 3 General Intensive Care Courses - Allentown Hospital 94,278 -- 4 Philadelphia Regional Chronic Pediatric Pulmonary Disease Program 144,344 98,103 5 Retraining Program for Women Physicians ~ Woman's Collepe of Penna. 75,884 ~~ 6 Coronary Care Training Units ~ Wilmington Medical Center - 72,600 8 Centers for Respiratory Care ~ Hahnemann, Allentown, Wilkes-Barre “- 71,179 10 School of Radiotherapeutic Technology at ~- 37,150 re . . t . . : GREATER DELAWARE VALLEY RMP -~ 5 - ; RM 00026 7/70.1 HISTORY SUPPLEMENT (Continued) | Project Amount Supported Number Title / Through 3/31/71 Basic Carryover 13 Renal Disease Patient Support Program 48,470 -- (Note: This project was recommended for approval for three years during the March 1970 review cycle. The Division is currently in the process of awarding $48,470 for the first year.) TOTALS $2,126,099 $317,387 GRAND TOTAL (BASIC & CARRYOVER) $2,443,486 (D.C.0.) DMD AADLE (A Privileged Communication) "SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE © GREATER DELAWARE VALLEY REGIONAL MEDICAL PROGRAM RM 00026 7/70.1 Pie te FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee recommended that this supplemental operational application (7/70.1) which requested $67,395 d.c.o. for a one- year program period, not be approved - no RMPS funding recommended. Staff reported on its review of the Region's second-year operational continuation application during March 1970. The continuation of the | operational projects evoked little concern and, in general, the projects were approved at the committed level. However, Staff had serious concerns about the basic organization ‘as described in the application) and the functions and activities of the large Core staffs in the Executive Director's office and in the five medical schools. a In June, 1970, a program site visit was made by the Acting Director, RMPS, and other key Staff members to the Region to explore the interrelationships of the Core staffs with the projects, as well as the degree of coordination among the various staffs of the Core components. Project #19 - Coronary Care Equipment for Hospitals in Northeastern Penn. Critique: The Committee expressed ambivalence regarding this project. On the one hand, it was agreed that the small amount of funds requested for each of the seven hospitals may have the effect of assisting these small hospitals in establishing coronary care units. On the other hand, the reviewers believed that the modest amount requested (solely for equipment) would ultimately result in a fee-generating service. Therefore, the hospitals should use local funds to provide the equipment, It was questioned whether donors in the local communities had been solicited to supply the equipment. The reviewers commented that the awarding of funds for this type of activity, in this area, would establish a precedent for a national program. The reviewers agreed with the Cardiovascular Technical Panel that the proposal is unapprovable on technical grounds, Recommendation: Nonapproval - no RMPS funding recommended. 7/1/70 , REGIONAL MEDICAL PROGRAM SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) Hawaii Regional Medical Program RM 00001 7/70.1 Harkness Pavilion June 1970 Review Committee 1301 Punchbowl Street Honolulu, Hawaii 96813 PROGRAM COORDINATOR: Masato Hasegawa, M.D. Requested Program Period lst Year 2nd Year 3rd Year Total Direct Costs $202,743 $99,168 $108,252 $410,163 Indirect Costs -0- -0- -0- -0- TOTAL $202,743 $99,168 $108,252 $410,163 Note: Attached to this summary is a Review and Funding History, henceforth referred to as: R & F.H. HISTORY: The Hawaii Regional Medical Program received its initial plan- ing award for $90,005 in July 1966 and its continuation planning © award of $90,005 for 02 year in July 1967. In November 1967 the Region received a supplemental planning award, raising the total award for 02 year to $148,764. Dr. Masato Hasegawa replaced Dean Windsor Cutting as Program Coordinator in April 1968. An operational grant was awarded in September 1968 to provide continued support for the central staff, pending a site visit and Committee and Council review of the operational projects proposed. A site visit was conducted on September 16-17, 1968. The site visit team found Hawaii to be a viable Region and recommended its operational application be approved. . The November 1968 Council approved funding for nine operational projects, three of which were one-year projects. The proposed operational activ- ities centered around the development of strengthened continuing educa- tion for physicians, nurses and allied health personnel within the Region. In February 1969, Council approved the Regions first supplemental appli- cation at a level of $30,000 to develop a plan for extending activities -2- Hawaii RMP RM 00001 7/70.1 — to the Trust Territory before initiating activities in these widespread islands of the Pacific. In making this award, Council sharply reduced the $100,000 requested because of their concern that the Region might “spread inself too thin" and not concentrate its efforts sufficiently on building a Regional Medical Program in Hawaii. fe i In August 1969, the Division of Regional Medical Programs staff negotiated the 02 year operational continuation application with the Hawaii RMP. The Region was awarded $824,686 d.c.ocf which $336,101 was designated for core, and the other for support of eight projects and the Pacific Basin planning award. (Refer to R & FH) Around October 1969, the grantee agency was changed from the Universtiy of Hawaii to the Research Corporation of the University of Hawaii. Be The Region submitted to the December 1969 Council its second operational supplemental application requesting support for a core supplement and five projects(#12-#16). Council Approved funding the core supplement and pro- ject #13-Rehabilitation in Castastrophic Diseases-Guam and Trust Territory at a first year level of $93,768 (d.c.o.) It also approved "project #12 Treatment of Cardiac Arrest in Saipan" with no additional funds. Action on the other projects was withheld pending a site visit. (Refer to R & FH) A site visit to the Hawaii RMP was conducted on January 26-27,1970 as requested by the December Council. Council asked that the site visitors _— look at the projects in the December Application for which no action was taken and at the total program development of the RMP. The site visitors were impressed with the progress made by the Region in the past twelve months, Regionalization has moved forward at a reasonable rate and the present core staff is competent. However the site visitors recognized the need for a full-time professional person with experience in the developement and implementation of continuing education activities on cere staff. It, was also apparent to the site visitors that Dr. Hasegawa needed an associate director to help him administrate the day-to-day operations. This would allow Dr. Hasagawa to be free to spend more time in developing the philos- ophy and direction of the program. The visitors also believed that it was appropriate for the Region to begin operational activities in the Trust Ter- ritory (Micronesia), American Samoa and Guam. The March 1970 Council reviewed the Region's third operational supplemental application which requested support for projects #17-#20. Council approved three of the projects at a first year level of $165,200 (d.c.o.) and: dis- approved one. (Refer to R & FH) PRESENT APPLICATION: This is a supplemental operational application ~ requesting a funding level of $410,163 for support of two projects. The projects are a cervical cancer program and a program for training of health aids in the Trust Territory. De Project #21- Cervical Cancer Program for the Trust Territory First year The December 1969 Council disapproved this project $67,490 (a (Resubmittal) Hawaii RMP ~3- RM 00091 7/70.1 and recommended that it be returned for revision. They recommended that the revision include greater consideration of the ethnic problems, the methods of collecting smears, quality control in laboratory work and training of those who are to procure the smears. During the January 1970 site visit to the Fegion it became apparent to the visitors that the Hawaii RMP and people of Micronisia regarded this activity as a highly important means of gaining vis- ibility and entry into the health care system of Micronesia. The proposal involves the development of a . cytological screening program for cervical cancer among women who are over 25 years of age and who reside in Palau and Truk districts of the Trust Territory in the Pacific Islands. An estimated 10,000 women will be examined during a three-year period; it is anticipated that thirty women will have invasive lesions requiring ‘treatment in Hawaii and about 100 will have preinvasive lesions and can be treated in the hospitals. During the first year of the project, two laboratory technicians will be given six months training in eytotechnology at Hawaii: funds for train- ing will be provided through the Comprehensive Health Planning Agency. At the same time two clerk/stenographers will be trained on site by a con- sulting registrar; and all medical personnel including all medical officers, health aides and nurses will be providel in-service training in the procure ment of smears by consulting gynecologists. The cytotechnicians will read all slides to identify those with abnormal cells and send those with an abnormal reading to the pathologist located in Honolulu for confirmation and final classification. In addition, as a check in accuracy of cytology screening the cytotechnicians will send an equal number of "normal" slides as a control group for the pathologist to read. The consultant pathologist in Hawaii who reads all suspected slides will also assist in organizing the laboratory in the Palau and Truk district hospitals for cytological services and conduct periodic followups on the efficiency of the screening system. The participation of the Honolulu pathologist will be terminated after a certified pathologist is hired by the Trust Territory for a new hospital in Truk. Once: cancer has been detectéd and verified by laboratory studies, the patient will be referred to one of the six district hospitals in the Trust Territory. Patients who require medical procedures which can not be handled in the district hospitals are referred either to Guam or to Hawaii. For educational activities it is anticipated that advice and assistance from organizations such as the American Cancer Society (Guam Branch) will be solicited, For evaluation monthly reports will be made by clerk/stenographers on the number of slides obtained for cytology from each district. The volume will be matched with the census of the female pop- ulation to which the project is applicable. Once. the Regional Medical Program support has ended the program will be supported by the health ser- vices program of the Trust Territory. ‘Funds requested are primarily for per- sonnel, consultants travel, equipment, and alteration for the first year. Second Year: $54,054 Third Year: $60,304 Hawaii RMP -4- RM 00001 7/70.1 s Project #22 - Training of Health Aides in the Trust Territory First Year This support is for a pilot health aide train- $135,253 ing program in the Yap district of the Trust Territory. It pro- : vides a model upon which to build a territory-wide standardized heaith aide training program. The health aide, as defined in this application, is a member of a community who provides preventive, curative, rehabilata- ‘tive and referral health care for other members of that community. The applicant states that health care services are inadequate for half of 95,000 Micronesians who live on 100 islands cver an expanse of three million square miles of ocean in the Trust Territory of the Pacific Islands. In May 1969; coordinated efforts of the Regional Medical Pro- gram of Hawaii, Trust Territory Department of Health Services and the | International Health Program of the University of Hawaii School of Public Health, led to the formation of a team to study the feasibility of a coordinated and standardized health aide training program for Micronesia. This proposal is an outgrowth of the study instituted by this group. The proposed plan is to hire a director and eight Micronesian health workers who will be trained as health aide teachers. Three of the Micronesian teachers will be selected from the Yap district and one from each of the remaining five districts: Palau, Marianas, Truk, Ponape, Marshalls. By selecting a Micronesian health worker from each of the. districts, it will be possible to coordinate all health aide training activities in the Trust Territory from the inception of the program. Each teacher could begin planning for a health training program under the director of this project in his or her own district. The director of the project and the Micronésian health workers will initially spend five months at the University of Hawaii to develop teaching methods in the delivery of practical health care services in Ificronesia. The Yap district was selected by the district directors of health services and the Trust Territory Health Planning Council as the site for a pilot project in health aide training. In this pilot program 22 existing andfour new projected health aides will receive training and retraining. The objectives of this proposal are to accomplish the following activities: (1) Train Micronesian health workers to become health aide teachers for their own people; (2) Provide frequent retraining sessions for the existing health aides; (3) Offer health career and basic health information to high gthool seniors as part of their academic school work; (4) Train a selected number of high school graduates for health aide work; (5) Con- tinually evaluate and adapt the health aide training program in the pilot project to meet the stated goal of a standardized and coordinated health aide system for the entire Trust Territory of the Pacific Islands. An evaluation to determine success in accomplishing the above objectives has been built into the project. The majority of funds requested for this proposal are under the item of personnel, equipment and travel. Second Year: $45,114 Third Year: $47,948 Hawaii RMP Ist Yeay Planning Award 2nd_ Year. Planning Award Initial Operational Appli (Site 1} September 16-17, REVIEW AND FUNDING HISTORY * 7/1/66-6/30/67 7/1/67-6/30/68 9/1/68-8/31./69 ton Award - Visited on Amended Initial]. Operational. 1968) 9/1./68-8/31/69 Application Award ~ (February 14, 1969) Projects Approved Project Period #1--Core-Amended 3 years #2-Training in 3 years Rehabilitation #3-Health Personnel 3 years Training in Oncology Techniques- Renened to- Honolulu Howe Care Training Prograin Renaned to~ Home Care Training Progyan RM OOCOL Direct C Indirect TOTAL Amount o Direct C Indirect TOVAL Less Unobligated Balance Amount o Direct C Indirect TOTAL Amount o Direct C Indirect TOTAL 7/70.1 ost $ 90,005 Cost __ 18,001 $1.08 ,006 £ Award $108,006 ost $148,764 Cost. _ 40,007 $194,771 f Award ost Cost f£ Avard ost Cost Amount of Award Funded (deo) (01) $362, 872 - (03) 40,348 - 7 (01) 9,937 - $ 72,474 $122,297 $334,123 $369, 52). $369 ,521 $837,903 35,398 $873, 301 $873, 301. Hawaii RMP -6- Projects Approved Project Period #4-Continuing Education J year for Nurses in Patient Settings . #5-Continuing Education none Program in Pathology #6-Hawaii Tumor Registry none Expansion Program #7-Cardiopulmonary 3 years Resusictation Training #!8-Coronary Care 3 years Training Project (Queens Medical Center) #9-Coronary Care Unit 1 year (Hilo Hospital) #10-Coronary Care Unit 1 year ‘(Wilcox Memorial Hospital) #11-Regional Pediatric 3 years Pulmonary Program First Operational Supplement Application-- (January 1969 Review Comuitice, Februory 1969 Council). 5/1/69-8/31/69 Pacific Basin 02 Year Operational 10/1/69-9/30/70 Continunrtion Application Camporne ._ (Octcber 8, 1909) Projects #1-Core #2-Iyaining in Rehabilitation in Catastrophic Diseases #3-Home Care Training Program =e RM 00001 4/70... Funded (dco) (01) $ 29,467.- 7 mo (01) Oe (01) -0-— (01) 48,720 - 7 mo (01.) 52,966 - 7 mo (01) 38,042 ~ 7 mo (01) 44,649 - 7 mo (01) 210,852 - 7 mo $30 ,000 Direct Cost $824 ,686 Indirect Cost Oe TOTAL $824,686 Funded (dco) (02) $336,101 (02) 73,791. (02) 18,667 Hawaii RMP Projects #4-Continuing Education ol Nurses in Patient Settings #7-Cariopulmonary Resuscitation Training #8-Coronary Care Training (Queens Medical Center) #9-Coronary Care Training (Hilo Hospital) #10-Corcenary Care Training (Wilcox Memorial Hosipital) #1l-Regional Pediatric Pulmonary Program Pacific Basin Second Operational Supplement Application--(November 1969 -7- kM OOOO] 7/70.) Funded (dco) (02) $ 20,500 - 5 mo (02) 70,049 (02) 120,302 (02) 9,550 - 5 mo (02) 44,649 - 5 mo (02) 114,596 (02) 17,082 Review Committee--December 1969 Council) Projects #1S-Core, Expansion of Central Staff #12-Program for Treatment of Cardiac Arrest (Saipan) #13-Rehabilitation in Catastrophic Diseases (Guam and Trust Territory) #14-Cervical Cancer Program for trust Territory #15-Regional Cooperative Chemotherapy Program #16-Hawaii Tumor Registry Approved by Council Funded (dco) but Award is Pending (O01 yr.$87, 387) Approved with no funds Approved by Council but award is Pending (Ol yr-$6,381) NON-APPROVAL revision is required Approved by Council but award is pending (OL yr-$110,000) NON-APPROVAL revision required Hawaii RMP ~8- RM 00001 7/70.1 ' Third Operational Supplement Funded (dco) Application--(Febriary 1970 Review Committee--March 1970 Council) Projects #1 7-Hawaii Mass Screening Approved by Council. of Children for Heart but award is pending Disease (01 yr-$60,000) #18-Anti-Smoking Education Approved by Council Project for Hawaii but award is pending (O1 yr-$25, 200) #19-Continuing Health NON~APPROVAL, revision Education Council of required Hawaii #20-Constant Care unit Approved by Council Guam Memorial Hospital but award pending (01 yr-$80,000) Fourth Operational Supplement Application--(July 1970 Review Cycle) Now in Review Process Projects #21-Cervical Cancer Program For the Trust Territory #22-Training of Health Aides in the Trust Territory HAWALT REGIONAL MEDICAL PROGRAM BUDGET REQUEST FOR JULY REVIEW CYCLE Alteration & 6 : Total Project Yr. Personnel Consultant Equipment Supplies Travel Renovation Other Direct Cost _ 1 - Cervical Ol $24,623 $6 ,000 $7,205 $4,500 $19,200 $4,962 $1,000 $67,490 Cancer 02 25,854 4,500 ~ 4,500 18,200 - 1,000 54,054 03 29,814 4,000 2,990 4,500 18,000 _ 1,000 60,304 SUB-TOTAL 80,291 14,500 10,195 13,500 55.400 4,962 3,000 181,848 2 - Health Aid 01 25,441 8,840 48,218 9,400 40,904 - 2,450 135,253 Training 02 24,982 5,480 - 2,400 10,252 - 2,000 45,114 03 26, 335 5,480 = _ 2,300 11,553. 7 2,280 47,948 SUB-TOTAL 76,758 19,800 48,218 14,100 62,709 - 6,730 228,315 TOTAL O1 50,064 14,840 55,423 13,900 60,104 4,962 3,456 202,743 02 50,836 9,980 - 6,900 28,452 - 3,000 99,168 05 56,149 9,480 2,990 6 , 800 29,993 - 3,280 108,252 157,049 34,300 58,413 27,600 118,109 4,962 9,730 410 ,163 DRMP/GRB 5/21/70 A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE HAWAII REGIONAL MEDICAL PROGRAM RM 00001 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee approved this application which requests $410,163 (d.c.o.) for a three-year program period at the requested level to support Project #21 - Cervical Cancer Program for the Trust Territory (01 - $67,490; 02 - $54,054; 03 - $60,304) and Project #22 - Training of Health Aides in the Trust Territory (01 - $135,253; 02 - $45,114; 03 - $47,948). Background: The December 1969 Council disapproved Project #21 (then Pro~ ject #14) and recommended that it be returned for revision. They recommended that the revision include greater considera- tion of the ethnic problems, the methods of collecting smears, quality control in laboratory work, and training of those who are to procure the smears. During the January 1970 site visit to the Region, it became apparent to the visitors that the Hawaii Regional Medical Program and people of Micronesia regarded this activity as a highly important means of gaining visibility and entry into the health care system of Micronesia. Project #21 ~ Cervical Cancer Program for the Trust Territory. Critique: The Committee believes that the revised application has been considerably improved and recognizes that this project is important to the Hawaii Regional Medical Program because it serves as a means for gaining visibility and entry into the health care system of that area. In this revised application the Region has taken the expansive area and ethnic problems into consideration and will implement the program in phases. Included in the project is a training program for medical officers, health aides, and nurses who will be taught to obtain smears. Teaching will be accomplished by a consulting gynocologist who will go to MacDonald Memorial Hospital in Koror, Polau District, Trust Territory. The Laboratory technicians will receive six months training in cytotechnology at Pathology Associates, Medical Laboratories, Honolulu, Hawaii. The clerk-stenographers will be trained by a consulting registrar. All medical personnel will be given orientation in cancer of the cervix and the purpose of the project. There will be a consultant pathologist in Hawaii who will read all suspected slides. He will assist in organizing the laboratory in the Polau and Truk District Hospitals for cytological services and conduct periodic follow-ups on the efficiency of the screening system. For quality control the cytotechnician will send a "normal" slide with each slide identified with abnormal cells to the consulting pathologist. HAWAIL Regional Medical Program ~2- RM 00001 Committee sees this project's primary purpose as involvement and educational exposure for physicians in Micronesia. Recommendation: Approval I ae ist Year 2nd Year 3rd Year $67,490 $54,054 $60,304 Project #22 - Training for Health Aides in the Trust Territory. Critique: The Committee recognizes the magnitude of the geographic problems which are present in this area in which 95,000 Micronesians live on 100 islands over an expanse of 3,000,000 square miles of ocean in the Trust Territory of the Pacific Islands. It also recognizes the present limitations in medical manpower and the basic need of utilizing health aides which really function as physicians assistants in order to meet the health needs. Committee believes that this project must have a qualified director who is compe- tent in training and supervision if it is to succeed. This project is requesting $40,904 for travel and per diem of instructors and trainees who must travel to and from Honolulu, Hawaii and the Micronesian islands. Committee expressed extreme interest in this program and suggested that its development be closely observed. Recommendation: Approval I with the condition that a project director who is competent in training and supervision is employed. ist Year 2nd Year - 3rd_Year $135,253 $45,114 $47,948 REVIEW COMMITTEE FUNDING RECOMMENDATIONS Project # Year Requested Recommended 21 : 01 $67,490 $67,490 . 02 54,054 54,054 03 60,304 60,304 SUB TOTAL se $181,848 $181,848 22 OL $135,253 $135,253 , 02 45,114 45,114 03 47,948 47,948 SUB TOTAL $228,315 $228,315 TOTAL $410,163 $410,163 DRMP /GRB 7/10/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL GRANT APPLICATION (A Privileged Communication) ILLINOIS REGIONAL MEDICAL PROGRAM, INC. RM 00061 7/70.1 Suite 939 June 1970 Review Committee 122 South Michigan Avenue Chicago, Illinois Executive Director: Morton C. Creditor, M.D. (Half-time - April 1, 1970 through June 30, 1970; full-time ~ effective July 1, 1970) Requested lst Yr. 2nd Yr. 3rd Yr. TOTAL Direct Costs $323,493 $452,833 $518,821 $1,295,147 Indirect Costs 53,539 77,682 88,978 220,199 TOTAL $377,032* $530,515 $607,799 $1,515 ,346% *The applicant states that funds available locally for support are anticipated and pledged ($76,000 for the first year; $25,000 for the second and third year) by various official and voluntary agencies. When received, these funds would be credited to the grant. History: The Illinois Regional Medical Program was awarded its first planning grant during July 1967. Support was continued for the second year of planning @/68 - 6/69). Included in the second-year award (as a part of Core funds) was $193,690 in earmarked funds, to support a hypertension screening program at Presbyterian-St. Luke's Hospital. The target group of this program was the low-income population jn a mile-square area adjacent to the hospital. The second-year award was supplemented three times. One supplement provided support (again as a part of Core) for an educational resource study at the University of Illinois. The objective of this program is to serve as a central assembly of specialized personnel and materials upon which various IRMP groups could call for expertise in education, communication media and evaluation methods. To provide time for Council to consider both the IRMP renewal application for Core support, as well as the Region's initial operational application, funding was extended for a four-month period--from 7/69 to 10/69. A preoperational site visit was conducted in June 1969. The August Council recommended renewal of the planning and Core support, with the exception of any new positions requested. In addition, the August 1969 Council recommended that the Region become operational, with approval of seven of the eight projects submitted. Illinois Regional Medical Program -2- RM 00061 7/70.1 Due to fiscal limitations, only the Core portion ($750,151 d.c.) was funded in November 1969. Effective 2/1/70, the approved operational projects were funded. A total of $1,585,643 has been provided for the first operational yeare;..(See History Supplement for details) In March 1970 the Council considered an application which contained four new supplemental operational proposals (see History Supplement - Projects #9, #10, #11, and #12). The entire application was deferred for a June 2-3, 1970 site visit. A preliminary site visit report will be available during the June/July review meetings. Ef fective July 1, 1969, the name of the applicant organization was changed from the "University of Chicago College of Medicine" to the "Illinois Regional Medical Program, Inc." On April 1, 1970, Dr. Creditor replaced Dr. Wright Adams (retired) as Program Executive Director of the Illinois Regional Medical Program. Present Application: This supplemental application contains one new proposal which requests support to initiate a Unified Health Informati Referral and Counseling Service. Direct costs only are shown in the project description. Project #13 - Unified Health Information, Referral and Requested ; Counseling Service - Welfare Council of First Year Metropolitan Chicago. This project proposes to establish $323,493 a service which will guide persons with health needs to the appropriate health resources in the most efficient manner; and will identify the unmet needs and deficiencies in the community's health resources in order to stimulate improved programs and provide data for planning and research. The service will be available to the general public, to physicians and health care personnel, to social welfare agencies serving individuals with health problems, providing them with a resource of up-to-date and complete information on the availability of health services. The service will be operated initially on an eight-hour basis, and as the operation expands, will provide twelve-hour service. If warranted by demand, twenty-four-hour service will be provided. The spécific objectives of this proposal are: 1) to establish a referral inventory of health services; 2) to link all health referral services into one system that would be coordinated with the provision of direct health care; 3) to systematize referral procedures for the purpose of training staff and improving referral techniques; and’ 4) to explore the use of the data, derived from the information and referral operation, for improving the delivery of health services and providing information for planning and evaluation studies. Illinois Regional Medical Program ~3- RM 00061 7/70.1 The project is divided into four phases. The first phase is devoted to planning the program and gathering background information and would take place within the first year of the project. There are three major work components of Phase I which provide the basis for staff organization and the division of responsibilities: 1) Establishment of the Health Resource Inventory. This includes classification of health services, compilation of health resource data; investigation of technological application to store and retrieve information; and provision of information for the improve~ ment and planning of community health programs. 2) Coordination with Health Agencies. This entails working out cooperative relationships with the providers of health care - neighborhood centers and related agencies - in order to gain accurate information about their services and to gain their help in developing the referral service; also, to insure that the referral operation succeeds in helping the individual obtain the needed health services. 3) Codification of the referral process. This work component involves development of typology inquiries; recommendations for record-keeping and followup procedures; development of supervisory and training procedures for the referral staff; providing information and making referrals after the system becomes operational; and providing follow- up on referrals made and participation in the evaluation process. The second phase of the project implements the mechanics and procedures of the referral operation. The third phase is focused on a trial run of the referral system, assessing how well it works and where corrections should be fed back into the design of the system. During this phase the referral system becomes fully operational with a publicity program to inform the public of the service. Phase four deals with recommendations for future operation and development of the information and referral service. Three types of analyses would be employed to evaluate this project: 1) empirical evidence of the work elements identified in the project have been completed; 2) qualitative analyses of professional and technical work; and three quantitative analyses of service, for example, volume and type of inquiries, and percentage of successful referrals. The major portion of the total first year budget ($323,493) is in the personnel category. This accounts for $193,648 of the total budget. Second Year: $452,833 Third Year: $518,821 ILLINOIS REGIONAL MEDICAL PROGRAM RM 00061 7/70, 1 HISTORY SUPPLEMENT LISTING OF APPROVED AND DISAPPROVED PROPOSALS “IITHIN THE ILLINOIS RMP A - APPROVED PROPOSALS PROJECT TITLE AMOUNT SUPPORTED (D.C,) NUMBER THROUGH 1/31/71 GO Core $ 680,597 Hypertension Study ~ St. Luke's Hospital 145,600 Education Support Resource Study 174,500 CORE TOTAL $1,000,697 1 : Organization of a Coordinated Home Health Services :. Project in North Cook County 35,525 2 - Multiphasic Screening in Chicago Area Industrial ..Plants to Detect Coronary-Prone Persons and Individuals with Subclinical Heart Disease 199,826 4 ' Regional Coordinated Cancer Program 108 , 950 : 3 Radiation Therapy Treatment Planning Center 24,300 6 Macon County Stroke Coordination Program 33,790 7 Comprehensive Stroke Rehabilitation Program 111,225 8 Comparative Endoscopic Study and Training Program -in the Early Diagnosis of Gastric Cancer 71,330 TOTAL $1,585,643 B - PROPOSAL DISAPPROVED 3 Establish Remote Automatic Monitoring of Patient Physiologic Data C - PROPOSALS DEFERRED TO INCLUDE A SITE VISIT (June 2-3, 1970) 9 Community/University Heart and Stroke Program 10 A Program for Continuing Education in Nephrology 11 Chicago Regional Transplantation Program 12 A Pilot Program for a Regional Cancer Educational Program - DRMP et te @ A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE ILLINOIS REGIONAL MEDICAL PROGRAM RM 00061 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Review Committee recommended that this supplemental operational application - 7/70.1 (containing one project for which $1,295,147 d.c.o. is requested for a three-year program period) be funded for two years instead of the three years requested, in the reduced amount of $543,000 (d.c.o.) (with conditions as listed below), rather than the $776,326 (d.c.o.) requested for these two years. This proposal was one of the subjects of the June 2-3, 1970 site visit. The site visit team recommended approval in reduced amounts for three years contingent upon clarification of a number of issues (listed below). Project #13 - Unified Health Information, Referral and Counseling Service~ Welfare Council of Metropolitan Chicago. site visit team. Committee agreed with the site visitors that this is probably a worthwhile project and believed that it is needed in a Region which contains a complex Metropolitan Area. Committee recommended approval for two years (instead of the three years recommended by the site visitors) and shared many of the same concerns expressed by the site visitors. Committee agreed that these. concerns needed clarification or justification before any funds are awarded. These were: @ Critique: The Review Committee heard a report from the Chairman of the 1) The involvement of the Comprehensive Health Planning Agency in the planning of this proposal; 2) That the applicant be required to submit a more detailed budget justification with special emphasis on justification for personnel and consultants; 3) That the applicant agency be required to document its financial involvement in the project; 4) That plans for support for future years (after termination of RMPS support) be made more specific; 5) That both the amounts required under the subcontract category and the request for equipment during the first year be more fully explained; © ILLINOIS Regional Medical Program -2- RM 00061 6) That the applicant work with the Community Health Agency Information and Referral Service (CHAIRS) currently being funded in conjunction with the California RMP; and finally 7) That a technical site visit be made at the end of the first year. Recommendation: Approval for two years in a reduced amount subject to the contingents outlined above. Direct Costs Only: lst Year 2nd Year $226,000 $317,000 SUMMARY OF RECOMMENDATION Project Number Title Ist_year 2nd Year 3rd Year @ 13 Unified Health Informa- $226 ,000 $317,000 None tion, Referral and Counseling Service Year TOTAL DIRECT COSTS 01) $226,000 02) 317,000 03) None TOTALS $543,000 DRMP /GRB , 7/6/70 REGIONAL MEDICAL PROGRAMS SERVICE DIVISION OF REGIONAL MEDICAL PROGRAMS SUMMARY OF AN OPERATIONAL GRANT APPLICATION (A Privileged Communication) ILLINOIS REGIONAL MEDICAL PROGRAM INC. RM 00061 7/70.2 (formerly 3/70.1) Suite 939 February 1970 Review Committee 122 South Michigan Avenue March 1970 Council Chicago, Illinois June 1970 Review Committee Executive Director: Morton C. Creditor, M.D. (half-time, April 1, 1970 ‘through June 30, 1970. Full time, effective July 1, 1970. Requested lst Yr. 2nd Yr. 3rd Yr. 4th Yr. 5th Yr. TOTAL Direct Costs $1,290,991 1,012,211 1,053,860 604,800 604,800 4,566,662 Indirect Costs 214,937 229,549 241,769 122,766 122,766 931,787 TOTALS $1,505,928 1,241,760 1,295,629 727,566 727,566 5,498,449 History: The Illinois Regional Medical Program has been developing and operating under planning funds since July 1, 1967. (First year: July 1, 1967-June 30, 1968.) Support was continued for the second year (7/1/68-6/30/69), including $193,690 ear- marked funds for a hypertension screening program at Presbyterian- St. Luke's Hospital. The second year award was supplemented three times. Supplement I - supported a systematic study of continuing education programs within the Region - University of Illinois. Supplement 2 - supported additional staff positions, to develop liaison with the five medical schools and the School of Osteopathy; supported development of sub- regional planning; and supported ten subcontract planning studies. Supplement 3 - supported an educational support resource at the University of Illinois, to serve as a central assembly of specialized personnel and materials upon which various IRMP groups could call for expertise in education, communications media, and evaluation. To provide time for Council to consider both the IRMP core support renewal application, as well as the Region’s initial operational application, funding was extended for a four-month ILLINOIS Regional Medical Program -2- period (7/1/69-10/31/69), at the Region's current level of support. A preoperational site visit was conducted on June 24-25,1969. . In line with the recommendations of the site visit team, the August .1969 Council recommended renewal of the planning and core support, with the. exception of new positions requested. In addition, Council recommended that the Region become operational, with some modifications of seven of the eight projects submitted (see last page for History Supplement) . Due to fiscal limitations, only the core portion, and necessary continuation portions of the grant, have been awarded. $750,151 (D.C.) was awarded the Region for planning and core support for the period 11/1/69-10/31/70. The award also provided: (1) Continuation funds for the Hypertension Project - $145,600 (2) Carryover authorization for a Valley Project Feasibility Study - $71,400 . (3) Continued support for the Educational Support Resource Study at the University of Illinois - $174,500 The total award for the third year was $1,141,651 (p.Cc.). Therefore, the Region is currently in its third planning year pending receipt of operational project funds to initiate these programs. Effective July 1, 1969, the applicant organization was changed from the “University of Chicago College of Medicine" to the present "not-for-profit" organization, the "Tllinois Regional Medical Program, Inc." The Illinois Regional Medical Program's Regional Advisory Group is made up of 29 individuals. Twenty-one members are medical doctors, most of whom are from the Greater Chicago Area. Six task forces, as well as eight committees, have been formed within IRMP. , Present Application: This application requests support for four new operational projects. One project is in the field of heart-stroke; two are related to kidney disease; and one is in the field of cancer. Direct costs only are set forth in the project description. ILLINOIS Regional Medical Program -3- RM: 00061 7/70.2 Requested First Year Project #9 - Community/University Heart and $695,149 Stroke Program. The Chicago Medical School proposes < five-year project to initiate a community-university heart and stroke program. The complicated, innovative application is presented in three parts: (1) Central Administration (2) Stroke Care Project (3) Coronary Care Project It is proposed to establish a multidisciplinary program involving several departments within the medical school and its main teaching hospitals on one side; and, on the other side, several community hospitals and other health agencies within the western area of Cook County and neighboring Dupage County. The overall objective is to make the resources of the Medical School available to the community and its hospitals, through a cooperative program in the areas of heart and stroke prevention, treatment, and rehabilitation; and to "feed back" an analysis of the data so obtained to the Medical School so that the gap between medical excellence (and capability) and the community may be closed. This is to be accomplished through three subobjectives: (1) To develop and support centers for diagnosis, treatment and teaching in community hospitals - to be interlinked with other centers and a coordinating center in a Medical School. (2) To train medical and paramedical personnel primarily for the participating community hospitals. (3) To develop a registry program for data acquisition and analysis which permits an evaluation of the program; and which, in the long-range future, may be added to other information in order to improve and/or develop methods of evaluation of courses and treatment. Stroke Project. On page 308 of the application, a tracing of a typical stroke patient through a typical participating hospital is outlined. Paramount to the success of the program will be a hospital coordinator who will work ILLINOIS Regional Medical Program -4- RM 00061 7/70.2 Requested First Year with the admitting physician in the referral of his patient through both an intramural as well as a traveling, extramural stroke project team. In order to develop the necessary stroke teams, training will be provided for medical personnel - non-specialized physicians ~ as well as for eighteen classifications of paramedical personnel (listed on page 309 of the application). The training and continuing education will take place in programs already established such as the Mt. Sinai Hospital Medical Center's stroke demonstration "acute" and “non-acute" care units;Schwab Rehabilitation Hospital; and Fox River Extended Care Facility. Continuing education through refresher courses and in-training programs will be conducted at participating hospital bases such as Christ Community Hospital and Gottlieb Memorial Hospital. In addition, home care services will be offered to selected stroke patients "who are not sick enough to be in a hospital, but not well enough to enroll as outpatients". This service will be an extension of the already established home care service of the Mt. Sinai Hospital Medical Center. A multidisciplinary pilot screening clinic is proposed for the Martin Luther King Jr. Neighborhood Health Center. Essentially, the screening performed will be for hypertension and diabetes. A stroke registry is proposed. Coronary Care. A detailed outline of the coronary care portion of the proposal begins on page 335 of the application. Part I outlines core services to peripheral units such as EKG interpretation by telephone, heart sounding interpretation by telephone, treatment consultation, continuing education, training, rotation of nursing and medical staff py exchange method, electronic engineering consultation, evaluation and analysis of data and quality control unit audit team. Part II describes the core unit physical facilities (Mt. Sinai Hospital) which are to be utilized in this portion of the proposal. Each of the participating hospitals plans to appoint a committee, selected by its own medical staff and administrators, to ILLINOIS Regional Medical Program -5- RM 00061 7/70.2 coordinate project activities within its own institution. Also, it is the appointed member of that committee who will act as his institution's liaison coordinator between the institution and the Chicago Medical School. Second Year: $572,990 Third Year: $614,800 Fourth Year: $604,800 Fifth Year: $604,800 In summary, the applicant states that the intramural- extramural project to initiate a community/university cooperative heart and stroke program provides for regional cooperative arrangements; the interchange of personnel; maximum utilization of existing facilities; community- wide benefits; services to persons now less adequately served than others; continuing education of personnel; innovative provisions for rehabilitation and health care. Critique: February 1970 Review Committee. Project #9 - Community/University Heart and Stroke Program. Critique: The Committee expressed ambivalence regarding this project. While it was agreed that the two-fold program in the areas of heart and stroke prevention and/or treatment (with féed-back of the analysis of data obtained to the medical school) appeared to be a worthwhile endeavor for this large, complex Region, the proposal was presented in an ambig- vous form. The justification for combining two separate programs under one common administration (which is based on lowering costs) needs further explanation. It was noted that the sole preventive stroke aspect would be conducted in the Martin Luther King Jr. Neighborhood Center in Chicago, yet the proposal showed no endorsement from the Center. In fact, there was no evidence presented to show that the institution had been involved in the planning of the program. While admitting that some of the activities proposed were new and innovative, the Committee agreed with the conclusion of the Ad Hoc Cardio- vascular Study Panel that the proposal left many questions unanswered. Therefore, the Committee recommended that an expert site visit team review the proposal and explore the following points: 1) Five years of support was requested. This period of time was considered excessive. 2) A breakdown of the budget request into various segments should be obtained which would show a more clearly defined, ILLINOIS Regional Medical Program -6- RM 00061 7/70.2 identifiable pattern of the different phases and participation by the various community health centers and hospitals. 3) There should be further justification of the involvement of neighborhood health centers in the planning of the program and of the planned use of the lower socioeconomic group for paramedical training in these centers. 4) The possibility of terminating the coronary care training portion of the program at the end of two years. 5) If this program is funded, some concrete methods of evaluation should be established to ensure a complete review of the program at the end of two years. Recommendation: Deferral, including a site visit. Project #10 - A Program for Continuing Education $162,257 in Nephrology. Northwestern University proposes a three-year project to establish a continuing education program in nephrology. The projected program is a cooperative effort to establish nephrology units in Chicago and three other areas of the State - Springfield (Downstate), Peoria (Western), and Evanston (Northern). Initially, facilities and personnel of eight major hospitals within these areas (subregions) will serve as training centers for the program. These are: Northwestern University Medical School, Passevant, Wesley, V.A. Research, Childrens', Evanston Memorial (Springfield), and St. Francis Hospital of Peoria. An advisory group composed primarily of nephrologists from the cooperating hospitals has been established. Over the years as new nephrology units are established, they will be incorporated into the program. Through its present faculty and facilities, Northwestern University is in a position to offer valuable support and guidance to the program. Nine major objectives are set forth; seven are concerned with the provision of training for physicians, to improve the quantity and quality of care offered to the patient with kidney disease. ILLINOIS Regional Medical Program -7- RM 00061 7/70.2 ras - Requested First Year Funds are requested to support 50% of the time of a project director at Northwestern who will have the responsibility for the overall coordination of the program. In addition, 12.5% to 50% time is requested for four project coordinators and two subregional coordinators, each of whom will work in one of the hospitals which has major training capabilities. It will be the responsibility of the coordinator to direct the program at his institution as well as at affiliated units throughout his Region. The Advisory Committee will select prospective trainees and (with the help of the individual trainee) determine the most effective training program. Time limitations on practicing physicians have been considered. Therefore, a comprehensive training program is proposed for two-week segments until completion of time equal to an ideal three- month to six-month period. Specific training will be offered in the following methods and techniques: 1) renal biopsy; 2) assessment of renal function; 3) drugs; 4) hemo- Gialysis. Training for nurses and technicians would be offered for at least a three-week period. Initially, the program is organized to train 16 physicians each year - for a six-week period, divided into two-week segments. Also, over a period of a year, a total of 34 nurses and 34 technicians will be enrolled in three-week training courses. It is intendéd that the academic, basic, and specialized instruction be given at the university- affiliated institutions, while dialysis training and other practical procedures would be taught at all of the participating institutions. It is envisioned that this continuing education program will also relate to the Chicago transplantation program (Project #11) described below. Second Year: $181,948 Third Year: $191,883 Critique: February 1970 Review Committee. Project #10 - A Program for Continuing Education in Nephrology. Critique: Committee agreed that this activity is in keeping with the Region's plans for continuing education. The objectives outlined in a complex program were considered to be clear, well-defined, and attainable, The Committee noted that the Continuing Education and Training Panel believed that this project was feasible under specific mi A bed naman Af tha Danalle ranrarne and helieved that ILLINOIS Regional Medical Program -8- KEL UuUEL Fy ree a site visit should be made, with special attention given to clarifying issues raised by each review group, specifically: 1) What plans have been formulated for continued support after RMP funds are terminated? 2) Is additional information necessary with reference to the nursing education component of the project? 3) The major emphasis appeared to be on the dialysis procedure. Would it not be more prudent to expand the project to include other disciplines? 4) Also, would it not be more feasible (even though it would require a change in methodology) to expand the program to insure a more comprehensive approach to the care of the renal patient? oo 5) A clarifying statement was needed showing exactly how the University was to be involved in the project. 6) A clarification of the proposers' actual meaning of the terms "nurse, technician and physician trainee" would be helpful. Recommendation: Deferral, including a site visit. Project #11 - Chicago Regional Transplantation $384,430 Program. This three-year proposal was developed by the Chicago Medical School, the University of Chicago, the University of Illinois and Northwestern University Medical School. The proposed program (for leukocyte typing, organ procurement, and organ distribution) would provide a substructure for organ transplantation in the Chicago Regional Area. Renal and heart trans- plantations are currently being performed at eight medical centers in Chicago. It will serve as a rallying point for both interinstitutional and intra- institutional cooperation: in a number of important basic science areas contributing to the success of organ transplantation. The procurement of cadaver organs, plus their preservation and distribution, will constitute one important aspect of the program. Organs will be salvaged at various medical centers in Chicago and later in southern Wisconsin. (The Wisconsin RMP has had under review, since May, 1969, a similar proposal which has not yet been acted upon and is awaiting Council policy clarification.) Special preservation equipment will facilitate storage of the organs long enough to select an appropriate patient in need of the organ. Kidneys will be the principal organs transplanted but hearts, livers, and lungs will also be made available. ILLINOIS Regional Medical Program ~~ RM 00061 7/70.2 The selection of the appropriate recipient for any organ will be determined by a list of criteria to be established. High on the list of criteria for determining the appropriate recipient will be the results of leukocyte typing of both the donor and the potential recipient. All prospective recipients are to be studied by one of four standardized leukocyte typing laboratories. Education of the entire medical community regarding trans- plantation is expected to lead to more judicious patient care, including referral to the transplantation centers, when this is indicated. Second Year: $244, 984 Third Year: $247,177 Critique: February 1970 Review Committee Project #11 - Chicago Regional Transplantation Program. Critique: The Committee agreed that this project described a very complex program. Also, the objectives of the proposal are worthwhile, attainable, and reflect a keen awareness of the problems and complexities involved in tissue typing. An inherent weakness in the project was the lack of reference to possible plans for exportation of kidneys to other areas of the U.S. It was concluded that, if exportation was not planned, the requested budget could and should be substantially reduced. Further, the Committee was concerned with the inadequacies of this proposal as noted by the Kidney Disease Control Program in its review of the project. These are: 1) A failure to document the real need for this service. 2) A lack of planning to widen the recipient pool, and, if this is done, whether it will be accomplished through home or center dialysis. 3) The necessity for additional typing centers when there are already two excellent typing laboratories operating in the Region. 4) Failure to describe specific organ preservation tech- niques. 5) Failure to document the techniques of interinstitutional sharing of organs to be used for transplantation. 6) Method of description of program evaluation was weak. 7) The large amount requested for initial costs, in terms of personnel and equipment, needs much greater justi- fication. 8) In line with item #7, the entire budget was considered extremely excessive for this type of activity, in this particular geographic area, and should be fully described and ILLINOIS Regional Medical Program -10- RM 00061 7/70.2 9) Further assurance is needed that the activity would be carried on after Federal support is withdrawn. 10) Rather than merely relying on assurance of cooperation from the deans of medical schools, evidence should be presented which will prove that cooperation among the actual personnel involved in the transplantation effort will really occur. In addition, the Committee was interested in learning about detailed plans for the continuing education facet of the transplantation program. After a considerable amount of discussion and due to lack of a clearly defined DRMP policy on projects of this type, the Committee recommended that this project be site visited. Recommendation: Deferral pending a site visit. Project #12 - A Pilot Program for a Regional ~ $49,155 Cancer Education Program. This proposal was initiated by the Cancer Committee of the Illinois Regional Medical Program, developed with the North Suburban Association for Health Resources, and will be administered by the Evanston Hospital Association. The pilot program will be established at the Evanston Hospital. The proposed activity will involve fourteen member hospitals of the North Suburban Association for Health Resources (all located in North Suburban Cook County), plus two participating institutions which are located in the Downtown Area of Chicago. Support is requested, for one year, for a pilot study to demonstrate the feasibility of a cancer education program within the Region. In addition, support is requested for three months (of a second year) so that an evaluation may be performed. The main thrust of the proposal is cancer education for physicians, to be implemented by the establishment of a central cancer registry. The registry would accept and record information on cancer patients from the sixteen participating hospitals. AR secretary in charge of medical records in each hospital (working with the pathologist), would obtain pertinent information on cancer patients daily; record it on a basic information sheet; (suggested form: american College of Surgeons Cancer Reporting Sheet); and forward the forms to the office of the director of the program. In addition to ILLINOiS Regional Medical Program -1l- RM 00061 7/70.2 auditing the reports to insure their accuracy and completion, the director's office will provide for the transfer of the reported information to punch cards. The education program in the individual institutions would be based largely on the printout data which would flow back to the subregions, to the hospitals (and the professional staff of the hospitals), on a periodic basis. For the purposes of the program, each hospital would establish itself as part of a subregional group of hospitals. These subregional groups would consist of three to fifteen hospitals - all in a relatively small geographic area. A liaison fellow would be assigned to each subregion. He would serve as cancer advisor (on request), to individual hospitals, and also arrange annual or semiannual cancer programs for hospital staff. He would also provide information to the Cancer Committee of the Illinois Regional Medical Program on the quality of cancer care in his area. Anticipated benefits for participating hospitals are: (1) To educate professional staff regarding the desirability of a cancer education program. (2) To upgrade the cancer education program in hospitals which have not previously had a cancer registry. (3) To develop common standards for cancer programs in the various hospitals. Second Year: $12,289 (3 months) Critique: February 1970 Review Committee Project #12 - A Pilot Program for a Regional Cancer Educational Program. Critique: The Committee was impressed with the outreach of this pilot project which would eventually involve sixteen participating hospitals (all types, including hospitals in ghetto and underprivileged areas) with a total bed capacity in excess of 4,300. Approximately 4,000 new cancer patients are seen each year in these hospitals. The proposed cancer education program would be available to some 1,450 members of the pro- fessional staffs in the cluster of hospitals involved. The Committee noted that this project was engendered by the Cancer Committee of the Illinois Regional Medical Program and, if the results were successful, could easily serve as a prototype for other similar pvroarams throuchout the Reaqion. LLLINOIS Regional Medical Program -12- RM 00061 7/70.2 It was further noted that this plan included a format modification of a successful program developed by the Intermountain Regional Medical Program. The success of the Intermountain program is attributed to the fact that the education program is centered around information largely supplied by the participating hospitals. The Review Committee believed that this was a well-conceived program under capable direction. Recommendation: Approval in time and amount requested. Jirect Cost only: lst Yr. 2nd Yr. (3 months) $49,155 $12,289 verall Recommendation: February 1970 Review Committee. teneral: The Review Committee recommended that this Supplemental Opera- tional Application 3/70.1 - containing four individual projects and requesting $4,566,662 (D.C.0.) for a five-year program period - be sartially funded at $61,444 (D.C.0) to support Project #12 in the time and amount requested (15 months). Committee believed that action on Projects #9, #10, and #11 should be deferred pending a site visit. The be last site visit to the Region was conducted on June 24-25, 1969. a darch 1970 Council Action: Jeferral including a site visit and with the suggestions of the Review *ommittee. Note: The Council agreed generally with the Review Committee soncerning project 12 but recalled the difficulties in inter-institutional sooperation within the Region. They recommended that the entire application xe included in the site visit. 3ite visit - June 2-3, 1970. A report will be available for the June 1970 Review Committee. © ILLINOIS Regional Medical Program -13- RM 00061 7/70.2 HISTORY SUPPLEMENT LISTING OF APPROVED AND DISAPPROVED PROJECTS WITHIN THE ILLINOIS RMP (The approved projects are not funded due to fiscal limitations.) A - Approved Projects Project Amount Recommended Number Title First Year #1 Organization of a Coordinated Home Health Services Project in North Cook county § 35,525 #2 Multiphasic Screening in Chicago Area Industrial Plants to Detect Coronary- Prone Persons and Individuals with Subclinical Heart Disease 199,826 #4 Regional Coordinated Cancer Program 104,950 © #5 Radiation Therapy Treatment Planning Center 24,300 #6 Macon County Stroke Coordination Program 33,790 #7 Comprehensive Stroke Rehabilitation Program 141,255 #8 Comparative Endoscopic Study and Training Program in the Early Diagnosis of Gastric Cancer 71,460 TOTAL AMOUNT - APPROVED BUT $611,106 UNFUNDED PROJECTS B - Project Disapproved #3 Establish Remote Automatic Monitoring of Patient Physiologic Data © DRMP 6/1/70 A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE ILLINOIS KEGIONAL MEDICAL PROGRAM RM 00061 7/70.2 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Review Committee recommended that this Supplemental Operational Application ~ 7/70.2 - containing four individual projects and requesting $4,566,662 (d.c.o.) for a five-year program period - be partially supported for a three-year period, in a reduced amount of $1,047,532 (d.c.o.). This amount will support Project #10 in time and amount requested; Project #11 in the time requested but in a reduced amount; and will support Project #12 in the time and amount requested. Committee believed that action on Project #9 should be "non-approval - revision required." . All four individual projects were reviewed during the February/March, 1970 review cycle. At that time Committee recommended approval in time and amount requested for Project #12. Deferral to include a site visit was recommended on Projects #9, #10, and #11. The March 1970 Council recommended that Project #12 be included: for review as a part of the site visit. The site visit was conducted on Jue 2-3, 1970. The Chairman of the team presented the findings to the Review Committee. Project #9 - Community/University Heart and Stroke Program. Critique: The Reviewers, in agreement with the site visit team, con- sidered this to be an enormously pretentious proposal. While it appeared to be a comprehensive program including many cooperating agencies and facilities and involving the community, it was difficult to differentiate between the three activities proposed ~ coronary care, stroke, and screening. While recognizing the possible benefits and economies of sharing personnel, the Reviewers felt that the current central administrative setup was too complex to function effectively and that this program might better be presented as two separate proposals. During the February/March review cycle, an important concern of the Reviewers was the lack of involvement on the part of the Martin Luther King, Jr. Neighborhood Center in the planning of this proposal (where the sole preventive stroke aspect was to be conducted.) The site visit team members shared this concern. ! j ILLINOIS Regional Medical Program -2- RM 00061 Members of the Review Committee also agreed with the site visitors in regard to the diagnostic screening aspect of this proposal. If prevention and detection are basic objectives, it was believed that a larger screening component would be necessary to insure the success of the program. The Committee believed that the only salvageable aspect of the proposal might be the coronary care training aspect. However, due to the complex budget which was presented, it was impossible to separate this activity. In fact, the entire budget request was con- sidered ill-defined and unidentifiable. Also, the evaluation component (especially for the stroke portion) had not been clearly outlined. In recommending “non-approval - revision required," Committee con- curred with the site visit team in suggesting that the applicant separate the interwoven parts of the program (with a realistic budget for each division) before resubmitting the proposal for consideration. Recommendation: Non-approval - revision required. Project #10 - A Program for Continuing Education in Nephrology. Critique: Committee heard the report of the site visit team Chairman regarding this proposal. During the interim between the February/March review cycle and the June 2-3, 1970 site visit, the applicant had prepared a written statement in response to issues raised by the review group. The Committee, as well as the site visitors, was satisfied that the statement spoke to the issues. It was noted there are nine major objectives and two minor objectives which are to provide contir.uing education in nephrology for physicians, nurses, and other allied health personnel. Substantiation of a need for this type of education was well-documented and appeared to be relevant. Although the objectives for the physicians were strong, the educational objectives for nurses and technicians appeared to be generalities and would, therefore, be hard to evaluate. The proposal will complement regionalization. Its activities are not limited to dialysis. In recommending approval in time and amount requested, the Committee felt that the Region should be advised of the Reviewers’ concern regarding a lack of involvement of field nurses in both the planning and the continuing education program proposed. Also, it was noted that $3,500 is requested during the first and second year, and $4,000 during the third year, for staff and trainee travel. , ILLINOIS Regional Medical Program ~3- RM 00061 Recommendation: Approval in time and amount requested. Direct Costs Only: ist Year 2nd Year 3rd Year $162,257 $181,948 $191,883 Project #11 - Chicago Regional Transplantation Program. Critique: Committee noted that during the February/March 1970 review cycle, a series of ten important concerns regarding the inadequacies of this program had been expressed. The program was originally reviewed by the Kidney Disease Control Program. The original purpose of the proposed program was to provide Chicago and the Southern Wisconsin Area with a cooperative plan for organ procurement and preservation; and, in addition, to establish a comprehensive leukocyte typing and organ distribution operation. During the time this program has been in the review process, a compre- hensive renal program was in the process of being funded through the Wisconsin Regional Medical Program. The Committee was advised by the site visit team Chairman that the present Chicago program is currently in operation and the awarding of funds would serve to enhance and expand the current program. Four medical schools have operated through eight medical centers in the Chicago area in carrying out a limited transplantation program. The primary purpose of the requested RMP funds is to expand this program, due to an increasing demand and the development of more sophisticated technology. However, the Committee believed that because this is an on-going program most of the equipment neéded should already. be available and therefore should not be supported out of RMPS funds. The Committee agreed with the site visitors that the approval of this request would serve to cement cooperative relationships among the Chicago hospitals. It was further agreed that this project would complement Project #10 - A Program for Continuing Education in Nephrology - which was recommended for approval by both the site visitors and the Committee. In recommending approval for the three years requested (in an amount not to exceed $150,000 for each of the three years), the Committee further recommended the following conditions of approval: 1) That the funds be utilized for personnel rather than tissue-~ typing equipment; 2) That the program be expanded to serve multiregional and interregional typing programs; 3) That the budget be reduced from $384,430, $244,984, and $247,177 - for the first, second, and third year respectively - to $150,000 for each of the three years. ILLINOIS Regional Medical Program ~4- RM 00061 The Committee further urged that the Advisory Council establish a policy as it relates to RMPS involvement in nephrology and transplanta- tion programs. Recommendation: Approval with conditions noted above. Direct Costs Only: lst Year 2nd Year 3rd Year . $150,000 $150,000 $150,000 Project #12 - A Pilot Program for a Regional Cancer Education Program. Critique: The February/March 1970 Review Committee believed this to be a well-conceived program under capable direction and recommended that the proposal be approved in time and amount requested. However, March Council recommended that a site visit be made to review other proposals in this application and suggested that the team review this program during the visit. The Chairman of the site visit team gave a reinforcing report to the . -Review Committee's original recommendation. He reported that the inter- hospital relationships (Council's primary concern) seemed to be assured through the auspices of the North Suburban Association for Health Resources, a voluntary association of individuals and institutions which serves as an IRMP subregional resource. He further reported that the project proposes to demonstrate, on a piiot basis, the feasibility of a regional cancer education program for the State of Illinois. The self-audit type education program is to center around information largely supplied by the participating institutions. In recommending approval, Committee believed that this program, if successful, could lead to the development of similar programs throughout the Region. In line with the site visitors' recommendation, the Review Committee recommended this as a well-conceived project under capable direction and deserving of RMP support. Recommendation: Approval in time and amount requested. Direct Costs Only: lst Year 2nd Year (3 months) $49,155 $12,289 Doctors Alexander Schmidt and George Miller were not present during the deliberation of this application. ILLINOIS Regional Medical Program -5- RM 00061 Project Number #9 #10 #11 #12 Year 01) 02) 03) SUMMARY OF RECOMMENDATIONS Title ' Ist Year 2nd Year 3rd Year Community /University Non-approval - revision required Heart and Stroke Program A Program for Continuing $162,257 $181,948 Education in Nephrology . Chicago Regional Trans- $150,000 $150,000 plantation Program A Pilot Program for a § 49,155 $ 12,289 Regional Cancer Education Program $191,883 $150,000 None TOTALS $361,412 $344,237 DIRECT COSTS ONLY $361,412 344,237 341,883 TOTAL $1,047,532 DRMP /GRB 7/6/70 $341,883 ‘ . DRAFT A PRIVILEGED COMMUNICATION © RM 00061 SITE VISIT REPORT ILLINOIS REGIONAL MEDICAL PROGRAM June 2-3, 1970 SITE VISITORS John B. Johnson, M.D. (Chairman) Chief, Cardiovascular Research Laboratory Freedmen's Hospital Washington, D.C. William Drake, M.D. Neurologist San Rafael, California Frederic Westervelt, M.D. Professor of Internal Medicine _ The University of Virginia Medical School Charlottesville, Virginia STAFF, REGIONAL MEDICAL PROGRAMS SURVICE Mr. Charles Heaney, Grants Review Branch Mr. Joseph T. Jewell, Grants Review Branch Mr. Dale Robertson, Programs Assistance Branch ILLINOTS REGIONAL MEDICAL PROGRAM STAFF Morton Creditor, M.D., Executive Director Mr. Bryan Lovelace, Jr., Assistant Executive Director Patricia R. Brown, R.N., Ph.D., Assistant Director, Allied Health * Mr. James Wagner, Subregional Consultant Miss Lois Binkley, Planning Associate Mrs. Marilyn Leyland, Public Information Assistant Mrs. Una Creditor, Grants Manager Mr. Joseph Gallagher, Business Administrator Mr. Harry Auerbach, Assistant Director of Research Sheldon Waldstein, M.D., Executive Director, North Suburban Association for Health Resources (IRMP Subregional Coordinator) Mr. L. R. Brosi, Executive Director, Springfield-Central Illinois Health Care Planning Council (IRMP Subregional Coordinator) - MEDICAL SCHOOL COORDINATORS The University of Chicago - Ann Lawrence, M.D., Assistant Professor, Department of Medicine Chicago Medical School - Martin Bruetman, M.D., Director, Neurology. e@ Training Program *Dual listing - ILLINOIS RMP Site Visit -2- RM 00061 © MEDICAL SCHOOL COORDINATORS (Continued) University of Illinois - Nat E. Smith, M. D., Associate Dean, College of Medicine Northwestern University -*Jacob Suker, M.D., Assistant Dean, Postgraduate Education Chicago College of Osteopathic Medicine - Paul Vandervort, D.O. BOARD OF DIRECTORS’ William J. Grove, M.D. (Chairman) Dean, University of Illinois College of Medicine Mr. William J. Silverman (Vice-Chairman) Director, Michael Reese Hospital and Medical Center REGIONAL ADVISORY GROUP Oglesby Paul, M.D., (Chairman, RAG Executive Committee), Head, Department of Medicine, Passavant Memorial Hospital *Caesar Portes, M.D., Past President, Illinois State Medical Society TASK FORCES © Demography and Economics -*john C. Troxel, M.D., Vice-President, “Medical ° Director, Blue Cross-Blue Shield Manpower - Randolph Tucker, M.D.,; Presbyterian-St. Luke's Hospital ' Continuing Education - N. Kenneth Furlong, M.D., Medical Director, Methodist Hospital Education - Mr. Don C. Frey, Executive Director, Health Careers Council of Illinois , Research - Mr. Louis deBoer, Executive Director, Chicago Heart Association Evaluation - *Cecelia Fennessy, R.N., Assistant Professor, University of Illinois School of Nursing COMMITTEES Heart - Dexter Nelson, M.D., Illinois Heart Association Cancer -kEdward F. Scanlon, M.D., Evanston Hospital *Caesar Portes, M.D., Past President, Illinois State Medical Society © *Dual listing ILLINOIS RMP Site Visit -3- RM 00061 ©} COMMITTEES (Continued) Subcommittee on Radiation Therapy Frank R. Hendrickson, M.D., Director, Radiation Therapy Department, Presbyterian-St. Luke's Hospital James J. Nickson, M.D., Radiation Therapy Department, Michael Reese Hospital ; Nursing - *Cecelia Fennessy, R.N., Assistant Professor, University of Illinois School of Nursing OTHER PARTICIPANTS Albert W. Snoke, M.D. (and Pauline Snoke, M.D.) - Coordinator of Health Services, State of Illinois Mr. James Phillips, Executive Director, Comprehensive Health Planning Inc., Metropolitan Chicago Mr, Paul Callagher Mr. David M. Kinzer, Executive Director, Illinois Hospital Association J. Ernest Breed, M.D., President, Illinois State Medical Society Mr. Hiram Sibley, Executive Director, Hospital Planning Council for Metropolitan Chicago W. Randolph Tucker, M.D., Acting Executive Director, Illinois Health Education Commission Vernon Forney, D.D.S., Public Health Service Regional Office, Chicago, Ill. CONTRACTEES *Mark Lepper, M.D., Presbyterian-St. Luke's Hospital (Hypertension Study) Edsel K. Hudson, M.D., University of Illinois (Valley Project) George E. Miller, M.D., University of Illinois (Educational Resource Study) *Mr. James W. Wagner, "Mid-South Health Planning Organization" PROPOSAL #9 - COMMUNITY/UNIVERSITY HEART AND STROKE PROGRAM Leroy Levitt, M.D., Dean, The Chicago Medical School *Martin Bruetman, M.D., Chicago Medical School *Mr. Louis deBoer, Executive Director, Chicago Heart Association Marshall Falk, M.D., Medical Director, Fox River Rehabilitation Center Edward E. Cordon, M.D., Director of Physical Medicine, Fox River Rehabilitation Center Mrs. Mary Ellen Lavery, R.N., Director, Dept. of Nursing, Fox River Rehabilitation Center ‘ Israel Light, Ed.D., Dean, School of Related Health Sciences, The Chicago Medical School Kermit T. Mehlinger, M.D., Acting Project Director, Martin Luther King, Jr. Neighborhood Health Center OS Donald Pochyly, M.D., Assoc., Training Section, Center for Study of Medical Education, University of Illinois Medical Center Maurice A. Schwarts, M.D., Walther Memorial Hospital *Dpual Listing ILLINOIS RMP Site Visit ~4 - RM 00061 © PROPOSAL #9 - COMMUNITY/UNIVERSITY HEART AND STROKE PROGRAM (Continued) ‘Reverend William F. Siemers, Administrator, Christ Community Hospital Earl N. Silber, M.D., Cottlieb Memorial Hospital Sheldon Slodki, M.D., Asst. Coordinator for IRMP, Chicago Medical School PROPOSAL #10 - A PROCRAM FOR CONTINUING EDUCATION IN NEPHROLOGY Frank A. Carone, M.D., Northwestern University Nate Levin, M.D., Northwestern University Dr. Meyers, St. Frances Hospital, Peoria, Illinois Dr. Morris, Memorial Hospital, Springfield, Illinois Hazel Kellams, R.N., Springfield, Illinois Mrs. Annie Pope, M.S.W., Veterans Research Hospital *Dr. J. Suker, IRMP Coordinator PROPOSAL #11 - CHICAGO REGIONAL TRANSPLANTATION PROGRAM R. Peterson, M.D., The University of Chicago Dr. Frank P. Stuart, Assistant Professor, Dept. Surgery, Billings Hospital Dr. Warwick Coppleson, Assistant Professor, Department Surgery, Wyler Children's Hospital Dr. Olga Jonasson, Assistant Prof. Surgery, Illinois Research Hospital ‘Dr. Edward Lichter, Prof. Preventive Medicine, Illinois Research Hospital © Dr. John Bergan, Assoc. Prof. Surgery and Director of Organ Transplantation Registry, American College of Surgeons, Northwestern School of Medicine Robert €. Muercke, M.D., F.A.C.P., Director, West Side Dialysis Center and Director of Medical Education PROPOSAL #12 - A PILOT PROGRAM FOR A REGIONAL CANCER EDUCATIONAL PROGRAM *E. F. Scanlon, M.D., Evanston Hospital *Sheldon Waldstein, M.D., Executive Director, North Suburban Association for Health Resources PROPOSAL #13 - WELFARE COUNCIL HEALTH INFORMATION AND REFERRAL PROJECT Mr. John Ballard, Welfare Council of Metropolitan Chicago Albert Miller, M.D.,(Chairman of Steering Committee)--Michael Reese Hospital and Medical Center *J. C. Troxel, M.D., Vice President-Medical Director, Blue Cross-Blue Shield *Mark Lepper, M.D., Executive Vice President for Professional and Medical Affairs, Presbyterian-St. Luke's Hospital Mr. Tom Baab, Executive Vice President, American Cancer Society, Illinois Division, Inc. Mr. Robert Adams and Miss Gloria Duday, Welfare Council of Metropolitan Chicago © *Dual listing ILLINOIS RMP Site Visit -5 = RM 00061 @ vue on Illinois RMP. The boundaries of the Region, as in many other large Regions, are not well-défined. In its initial planning grant application, the Region was defined as encompassing the State. As other RMPs have evolved, the Bi-State RMP (based in St. Louis) has claimed the southern half of Illinois as being a part of that Region. Likewise to the west, Moline, Rock Island, and other communities of that area are considered a part of, and relate to, Davenport, Iowa, for medical care. The population of Illinois is approximately eleven million. Of this total, seven million persons reside in the Metropolitan Chicago Area. It was pointed out to the site visitors that this total (seven million) is almost equal to the entire population of the country west of the Mississippi © River to the California border. Five medical schools and a school of osteopathic medicine are located in Chicago. The Region contains 70 schools of nursing, 50 schools of medical technology, -and 59 x-ray technology facilities. There are 333 hospitals,with a total of 108,062 beds. Most of the hospitals are non-Federal. There are approximately fourteen thousand medical doctors and approximately 365 osteopathic physicians within the Illinois Region. Purposes of the Site Visit. The site visit was to serve multiple purposes. Primarily, it was to review four individual project requests which were considered during the February/March 1970 review cycle - the Council recommended deferral to include a site visit. The team was also asked to review a new proposal - To Establish’a unified © Health Information and Counseling Service - which will be reviewed during the June/July 1970 review cycle. ILLINOIS RMP Site Visit - 6 - RM 00061 Secondly, the team was interested in the Region's concept of the role of the Core staff (Dr. Creditor assumed the position of full-time Executive Director on the day before the site visit, June 1, 1970). They wished to explore the present interrelationships of the Core staff with the current operational projects as well as the degree of coordination of the Core staff with the medical schools, The team was interested in hearing a report on four rather large contracts which are currently being funded through the Illinois Regional Medical Program. Finally, the team's mission was to appraise the Region's total program. This included progress the Region has made in developing its Regional plan since the site visit during June 1969. The team was especially interested in progress which had been accomplished with regard to eight program recommendations made by the June 1969 site visitors. These recommendations were: 1) that the Regional Advisory Group, boards, task forces, and committees contain more representatives of minority groups and the lay consumers of service; 2) that there be a broader distribution of allied health and health manpower involvement in addition to the present nursing profession; 3) that there be a more realistic relationship established between the Board of Trustees (Directors) and the Regional Advisory Group, pertaining to the review of applications; 4) that concrete efforts be effected to solve the Upstate versus Downstate cast of the Region; ILLINOIS RMP Site Visit -7- RM 00061 5) that a more organized, realistic approach be obtained to the collection and collation of data; 6) that the aims and objectives of contractual arrangements be continually reviewed in relationship to their history, ready availability of any particular information sought, and the real, proposed effect on the future of the Region's program; 7) that a plan be developed and a policy established and agreed upon between agencies and institutions to provide for an auditable accounting procedure for any fees or funds earned in, or as a result of, any project-supported activity; and 8) that a primary order of business be the appointment and establishment of a Regionwide representative stroke committee. In his opening presentation, Dr. Creditor expressed his somewhat awkward position of having to greet a site visit team on his first day as full-time Coordinator of IRMP. -He then stated some of his concerns about the existing program and some elements of his strategy to improve it. Dr. Creditor agreed with the criticism of the previous site visitors that IRMP was heavily provider-oriented and that this was reflected in the ~physician-dominated Regional Advisory Group. He explained that the bylaws of the RAG were recently amended to enlarge the membership from 30 to 40, and that the new members were to represent other health professions as well as consumers, Another of Dr. Creditor's concerns was the apparent lack of understanding of RMP's basic interest on the part of participants in the program. He believed that health interests viewed RMP as just another source of federal monies. He also believed that this is in part illustrated by the series of unrelated projects which make up IRMP's operational activity. ILLINOIS RMP Site Visit -8- RM 00061 In developing new dimensions for IRMP, Dr. Creditor's first priority will be the "reenunciation of subregionalization." He envisions first building upon, and then adding to, the three existing subregions - the North Shore area, the Mid-South section of Chicago, and the Springfield area (encompassing the central and southern parts of the State). In this effort, he also sees the possibility of working more closely with CHP, Mental Health, and other agencies whose functioning depends to a large extent on the delineation of specific areas. The new coordinator's second priority follows naturally from the first, and that is to encourage the six medical schools to choose the geographic areas for which they want the primary responsibility, and to set new directions for these subregions. Dr. Creditor is well aware of the problems to be faced in this endeavor within the Greater Chicago area itself, since it is here that five of the schools are located. As for the a of the State, he is hopeful that the newly established Southern Illinois University Medical School (in Carbondale) will contribute to IRMP's outreach into the rural areas of the State, In terms of overall medical school participation, Dr. Creditor is thinking in terms of someone at the associate dean level in each school to be responsible for IRMP activities. Dr. Creditor again emphasized the need to work with CHP and the difficulty this agency was having in taking root in most areas of the State. He attributed this to the "A" agency being based in the State Department of Health with nothing to which to relate. One result is that there is presently only one funded "B" agency in the State (in Chicago). ILLINOIS RMP Site Visit -9- | RM 00061 There appears to be sufficient RMP-CHP cross-participation. For example, Dr. Creditor is a member of the advisory councils for both the "A" and "B" agencies, and Dr. Francis Weber, the "A" Agency Director, is a member of the IRMP Board of Directors, More specifically, Dr. Creditor believes it is essential for IRMP to work with the "B" Agency in Chicago, because, as it stands now, the provider-oriented RMP has no visible relevance to the needs of the community. To use his words, IRMP needs to "develop legitimacy within its community." He believes that joint efforts with the consumer-oriented CHP group will provide that legitimacy. In referring to the Core staff, Dr. Creditor pointed to a number of unbudgeted positions which he would fill with representatives of other professions - allied health, computer, and systems analysis were three specific areas he mentioned. He also expressed the desire to cultivate Core-type resources outside of the IRMP organization, similar to the Educational Support Resource developed by Dr. Ceorge Miller (a contractual arrangement with the University of Illinois). Following Dr. Creditor's opening statements, each member of the Core staff gave a brief account of his responsibilities and current activities. Mr. Bryan Lovelace, Assistant Executive Director, described his duties as a staff representative on three IRMP task forces and his present efforts to stimulate interest in health occupations in the junior colleges. New to IRMP, Patricia Brown, R.N., Ph.D., Assistant Director for Allied Health, also has staff duties on several committees and task forces and is an active member of a Statewide nursing committee. ILLINOIS RMP Site Visit - 10 - RM 00061 Mrs. Marilyn Leyland, Public Information Assistant, outlined the beginning of a more aggressive public relations program which includes a new quarterly to be distributed throughout the State. Mr. Joseph Gallagher, Business Administrator, is involved in the local _ review of applications to see that they conform to national guidelines tru AWNO: Soom Foo fF 41 8 er Opes ‘eS 1 San & and policy statements, Bop 7 Fae Frew Row Be wy Mr. James Wagner, Subregional Consultant and first black member of the Core staff, is President of the Mid-South Health Planning Organization, a voluntary organization partially funded by an IRMP contract. Its purpose is to bring together the providers and consumers of health care in the Mid-South area of Chicago in order to determine community needs and how to meet them. Miss Lois Binkley, Planning Associate, told of her continuing efforts to gather information on the number and types of health providers, to aid her in pursuing her primary interest - developing training programs for health occupations. Mr. L. Brosi, IRMP Subregional Coordinator and Executive Director of the Springfield-Central Illinois Health Care Planning Council, pledged his continued support as a planning resource for the central areas of the State. He also mentioned that since his office and the office of the Director of the CHP Agency are located in the same building, there is an opportunity for a close working relationship between that agency and IRMP. The third Subregional Coordinator, Dr. Sheldon Waldstein, is also the Executive Director of the North Suburban Association for Health Resources, a group partly supported by IRMP. It provides an outreach to the northern area of the State and provides IRMP with much valuable planning material. ILLINOIS RMP Site Visit - ll - RM 00061 The Medical School Coordinators were next to address the site visit team. Dr. Ann Lawrence of the University of Chicago, described her early attempts to communicate the RMP message to the clinical staff and to develop working relationships with the community hospitals. The initial enthusiasm was ‘somewhat dampened when a cytology training program was turned down, but it is being engendered again through a new emphasis on community medicine and the great strides made by the Mid-South Health Planning Organization in making the faculty aware of (and interested in) the health problems of the community. Dr. Martin Breutman of the Chicago Medical School, viewed his role as a buffer between IRMP, the community, and the faculty. He stated that CMS has always worked with and for the community in one way or another. For example, he cited the fact that a large number of CMS graduates have remained in Illinois. In speaking of the health problems of the underprivileged, Dr. Breutman referred to the work being done in the black and Puerto Rican communities by the Martin Luther King Health Center, which is staffed by CMS students and faculty. Dr. Nat Smith of the University of Illinois College of Medicine, spoke of the close communication between the Medical School Coordinators. They meet weekly and sometimes biweekly to exchange information on the activities at their respective institutions. He believes that these gatherings serve as a valuable self-education tool for the coordinators. With reference to the University, Dr. Smith mentioned the commitment to double the Medical School enrollment within the next ten years. He also described the Committee on Continuing Education which relied on Dr. Ceorge Miller's work, and the Valley project which is aimed at extending the University into the community, ILLINOIS RMP Site Visit -12- . RM 00061 Dr. Jacob Suker of Northwestern University Medical School, spoke of a bi- phasic approach to subregionalization - by first developing programs in specific specialty areas, and then applying these programs through the community hospitals. Dr. Paul Vandervort of the Chicago College of Osteopathic Medicine, mentioned the free flow of information between the coordinators and how this helped in overcoming the M.D.-D.0. barriers. He went on to mention his institution's concern with continuing education, allied health tradining, and reaching out into the community via the establishment of storefront clinics. Following the coordinators, brief statements were made by members of the IRMP Board of Directors, Regional Advisory Group, Task Forces, and Special Committees, Speaking for the Roard of Directors were its Chairman, Dr. William Grove, Dean of the University of Illinois College of Medicine, and its Vice-Chairman, Mr. William Silverman, Director of the Michael Reese Hospital and Medical Center. Both men commented on the action taken by the Board in response to the recommendations of the last site visitors, First, Board representa- ‘tion has been broadened to include other health professions, nursing, pharmacy, dentistry, and hospital administration. Second, the functional responsibilities of the Board and the Regional Advisory Group have been more clearly defined. The Board is now charged with the overall administrative and policy-making responsibilities of the program, while the RAG will concern itself with program development and the review process. ¢ Soury oe Rat Fe Keane The Chairman of the Regional Advisory Group, Dr. Oglesby Paul, also Gow CAD Red AM se, TiS & Wg we eo bY RS ed DY DL aT OMe Se addressed himself to the matters of expanding the RAG membership to ILLINOIS RMP Site Visit - 13 - RM 00061 include allied health professions and consumers and to the new role of the RAG, In addition to increasing the membership from thirty to forty, other interests are now represented although some difficulty was encountered in bringing about the involvement of active consumer participants. Concerning the RAG's expanded role, Dr. Paul stated that the group now considers projects that have been turned down by the various regional review committees, This, he says, allows the RAG to become aware of the ideas flowing into IRMP and to pursue those which it believes to be important to the program. ‘Task Force I - Demography and Economics. Dr. John Troxel expressed the concern © of this group over the consumer's lack of knowledge of available health services throughout the State. ° Accordingly, health resource data is being collected (County by County) with the intention of making this information available to the public, He also stated the importance of working with other data~gathering agencies such as CHP and the State Department of Health. Task Force II - Manpower. Dr. Randolph Tucker spoke of the activities of the State-supported Health Education Commission of which he is a member, This body reviews all manpower activities in the State and contributes funds to those it believes to be particularly meritorious, It is now in the process of studying the needs for various types of health manpower and establishing a central manpower data bank. Task Force IIT - Continuing Education. Dr. Kenneth Furlong reported on the activities of this group, which reviews the continuing education components of all: proposals submitted to IRMP. He is working with Dr. Ceorge Miller to facilitate the advancement of continuing education activities in the State. The task force is also workine toward unoradina tha lihrary and tatavutetan racanrane charad hu ILLINOIS RMP Site Visit - 14 - | RM 00061 the medical schools and the outlying hospitals. Task Force IV - Education. Mr. Donald Frey described this group's activities in encouraging proposals dealing with regionalizing education, upgrading the quality of care, and collecting information useful in manpower planning. Task Force V_- Research. Mr. Louis deBoer, the newly-appointed Chairman, reported that this group has had the basic responsibility for reviewing the research components of proposals. Dr. Creditor pointed out the inactivity of this task force and questioned the need for its existence. Task Force VI - Evaluation. Miss Cecelia Fennessy, R.N., told the site visit team that this group has not met during the past year due to the lack of project activity. She also pointed out that this group did not become involved in the evaluation aspects of proposals because they generally have their own built-in evaluative mechanisms. Heart Committee. Dr. Dexter Nelson reported on this committee's work in setting priorities for coronary care in the Region. It conducts special studies on resources available and makes decisions as to what is needed. Cancer Committee. Dr. Edward Scanlon commented that the regional priorities for dealing with the problems of cancer are: 1) education of professionals; 2?) detection: and 3) treatment. During a luncheon meeting, the site visit team was addressed by representa- tives from various State and voluntary organizations. The first to speak was Dr. Albert Snoke, Governor Oglesby's Coordinator for Health Services. Dr. Snoke declared that the Governor placed a high priority on health and health planning. In line with this, Dr. Snoke felt ILLINOIS RMP Site Visit - 15 - RM 00061 it was imperative that RMP and CHP work together, recognizing that at the present time, CHP is playing a somewhat minor role in the State. As for RMP itself, he is dissatisfied with the categorical limitations and the control of the program hy the medical school deans. He concluded by saying that power politics should be kept out of health planning, that manpower activities must be coordinated, and that there is a necessity for working together in times of funding shortages. Dr. Snoke was followed by Mr. James Phillips, Executive Director of Comprehensive Health Planning, Inc. - Metropolitan Chicago, who held the opposing view that both RMP and CHP are inextricably involved in politics and that this constitutes the major reason why CHP has failed to take a firm hold in the State, The next to speak was Mr. David Kinzer, Executive Director of the Illinois Hospital Association. The IHA represents three hundred hospitals, and, according to Mr. Kinzer, the primary concern has been the lack of coordination among approximately forty planning bodies in the Region. He sees RMP, with its emphasis on cooperative arrangements, as a tool to remedy this situation. Dr. Randolph Tucker, Acting Executive Director of the Illinois Health Education Commission, made his second appearance before the site visit team, to talk about the other major activity of the Commission, in addition to manpower as mentioned earlier. This group has at its disposal $14,000,000 for grants to medical schools, to increase their enrollment. At this time there is a commitment to double enrollment by 1980. ILLINOIS RMP Site Visit - 16 - | RM 00061 Ceneral Observations. The site visitors were favorably impressed by Dr. Creditor's insight regarding the problems of both the organization and the Region which it is intended to serve. The preliminary plans and priorities he has developed to cope with this situation give evidence of a strong fundamental grasp of the RMP concept. As for the recommendations of the last site visitors, all but one have been satisfactorily implemented - the exception being the establishment of a regional stroke committee. Dr. Creditor assured the team that a stroke committee was being developed and that he would do all he could to expedite its establishment. There were several criticisms, foremost of which was that IRMP has been, and still is, a Chicago program with little or no contact with the rural areas of the State. Changing this pattern, however, seems to be Dr. Creditor's first priority. Also noted was an inherent over- organization in the IRMP which was reflected in some of the projects. Another shortcoming was the apparent overdependence on data collection. Although gathering information is critical to planning, the site visitors believed that the various task forces and committees should also spend time talking with people in the communities which are being surveyed. This would serve the twofold purpose of giving RMP visibility and, at the same time, serve as a peat of the validity of the data - that is, do the needs deduced from the data coincide with the needs as expressed by consumers? Contracts. The site visit team was asked to review the progress of four contracts undertaken by IRMP: 1) Control of Hypertension in Selected Illinois Communities: Urban, Suburban, Rural - Dr. Mark Lepper, Presbyterian- St. Luke's Hospital. ILLINOIS RMP Site Visit -~ l7 - RM 00061 Contracts (Continued). 2) The Valley Project - Dr. Edsel Hudson, University of Illinois. 3) Educational. Support Resource - Dr. George Miller, University of Illinois. | 4) Mid-South Health Planning Organization ~ Mr. James Wagner. By and large, the site visitors were well satisfied with the progress of these activities, especially with the Valley and Mid-South Projects because of their direct outreach into the more needy segments of the community. Dr. Miller's Educational Resource Project has been mentioned several times in this report in relation to both the IRMP program and projects. The site visit team was genuinely impressed with the many facets of this most valuable activity. There were some concerns over the Hypertension Study - concerns over elements of the research methodology, provisions for followup and treatment, and the need to relate it to stroke planning. It was pointed out, however, that this was an earmarked project, rather hurriedly developed, and that, in general, stroke was one of the Region's weak areas, Projects. #9 - Community/University Heart and Stroke Program, Although impressed by the substantial efforts of many people that went into the planning of this proposal, the site visit team had sufficient concerns to preclude its approval. While recognizing the possible benefits and economies of sharing personnel, the reviewers felt that the current central administrative setup was too complex to ‘function effectively and that this program might better be presented as two separate proposals. ILLINOIS RMP Site Visit - 18 - RM 00061 © The team also felt that some consideration should be given to involving areas outside of Chicago, at least in the training aspects. The people who need help the most are often those in the remote communities, and there can be no regional program without provision for these smaller areas. The reviewers were also dissatisfied with the diagnostic screening aspect of the proposal. If prevention and detection are objectives, then reason would dictate a larger screening component. Yet the only screening proposed would take place at the Martin Luther King Health Center, and even this has been inadequately planned. - Finally, the evaluation component (especially for the stroke program) has not been clearly defined. Recommendation: Nonapproval - revision required. © Project #10 - A Program for Continuing Education in Nephrology. ‘ The reviewers were well satisfied with the statement prepared by the project proposers in response to the issues raised by the March 1970 Review Committee. with regard to funding for future years, the applicants alluded to State and Federal interests in renal disease as well as some private sources (Kidney Foundation and Illinois Heart Association), and tuition. Plans were also mentio:ied to develop an educational program aimed at producing a "renal health nurse" who will be trained in aspects of both prevention and treatment of renal disease, In speaking of the criticism that the program seemed heavily oriented to the dialysis procedure, the applicants pointed out that this was a comprehensive training and continuing education approach and did not restrict © itself to dialysis. ILLINOIS RMP Site Visit - 19 - | RM 00061 Although not feasible on a Statewide basis, the proposers felt that it would be reasonable and entirely within the scope of the project, to set up a model comprehensive care program in one area, preferably Springfield, since a specialized unit with full-time personnel and good facilities is presently in operation there. With respect to the role of the University - in addition to its duties as fiscal agent, it will contribute in terms of faculty, standard facilities, and special facilities such as electron microscopy, tissue culture, a renal biopsy library, fluorescence microscopy, specialized microbiologic techniques, and others. As for the definitions asked for (nurse, technician, and physician trainee), none of these categories would include individuals engaged in a formal training program. "Nurse" refers to a nurse at any level who is given specialized instructions in the field of renal disease. "Technician" refers to an individual trained in the laboratory aspects of renal care. "Physician trainee" refers to a physician who has completed the internship and residency training that he intends to have. He would be engaged in the clinical or laboratory practice of medicine before entering the program, The site visit team posed a question of its own as to whether or not there should be a direct linkage with Project #11, a Renal Transplantation Program. It was decided that such a relationship would develop of necessity as shared interests and experiences brought the two groups together, and that it would not be imperative to impose such a condition at this time. Recommendation: Approval in time and amount requested. lst Yr. Ind Yr. 3rd Yr. $162,257 $181,948 $191,883 ILLINOIS RMP Site Visit — - 20 - RM 00061 Project #11 - Chicago Regional Transplantation Program. The site visit team viewed this proposal favorably both in terms of its growing role in the treatment of renal disease and regional implications, but felt that the price tag was much too high, especially since this project is already ongoing. For the past several years, four medical schools have operated through eight medical centers in Chicago in carrying on a limited transplantation program. RMP funds are being sought to expand this program due to increasing demand and more sophisticated technology. The team believed that the prime factor in the high cost of the project was the procurement of good kidneys. Currently it is costing roughly $8,000 per kidney although other experience indicates that the same job can be done for one-quarter of that amount. The reviewers felt that the ‘very strict scientific standards of acceptability are resulting in the loss of many usable kidneys and hence the enormous cost per kidney. It was believed that a natural rapport would evolve between Project #10 (above) and this project, due to the interrelationships of the purposes and.objectives. In recommending approval for the three years requested (in an amount not to exceed $150,000 for each of the three years), the site visitors recommended the following conditions of approval: 1) that the funds be utilized for personnel rather than tissue-typing equipment; 2) that the program be expanded to serve multiregional and interregional typing programs; and 3) that the budget be reduced from $384,430, $244,984, and $247,177 - for the first, second, and third year respectively - to $150,000 for each of the three years. Recommendation: Approval for three years, at a reduced amount. lst Year 2nd Year 3rd Year $150,000 $150,000 | $150,000 ILLINOIS RMP Site Visit - 21 - RM 00061 Project #12 - A Pilot Program for a Regional Cancer Educational Program. This project had been approved by the February 1970 Review Committee, but the March Council requested that the site visitors include it in looking over the entire Illinois package. The interhospital relationships (Council's primary concern), seem to be assured through the activities of the North Suburban Association for Health Resources, a voluntary association of individuals and institutions which serves as an IRMP subregional resource. The project proposes to demonstrate, on a pilot basis, the feasibility of a regional cancer education program for the State of Illinois. This self-audit type education program will center around information largely supplied by the participating institutions. It appears reasonable to assume that this program, if successful, could lead to the development of similar programs throughout the State. The site visitors agreed with the Committee that this is a well-conceived project, under capable direction, and is deserving of RMP support. Recommendation: Approval for time and amount requested. lst Year Second Year (3 months) $49,155 $12,289 Project #13 - Unified Health Information, Referral, and Counseling Service - Welfare Council of Metropolitan Chicago. The reviewers were enthusiastic about this project and felt that it was very much needed. They observed with satisfaction that the program paid attention to both regional and subregional considerations. The initial parts of the program appeared very complex, and the team felt that some phasing-in time would be needed while the project gained momentum. The proposers contended that they could, with the people they had on board, Leet fat - ILLINOIS RMP Site Visit - 22 - RM 00061 The team also perceived a need for a clearer justification of the personnel budget. Several questions were raised regarding the rather expensive provision for consultants and the roles to be played by such people as a. social psychologist, a medical sociologist, and a consulting physician. Another concern was support for future years. Although other similar projects had fared rather successfully in this regard, the team felt that there should be a financial feasibility study, preferably by the end of the second year. In this connection, the reviewers felt that the Welfare Council should show some evidence of its own involvement in terms of ‘financial support. The team felt that the funding level for this project should not exceed $1,000,000 (total costs) for the three years - about a thirty percent reduction each year. Recommendation: Approval in reduced amounts for three years, contingent upon clarification of the following issues: detailed budget ; personnel justification; Welfare Council financial involvement and contribution; support for future years; subcontract activities; and hardware. lst Year 2nd Year 3rd Year (Direct Costs) $226,000 $317,000 $363,000 ILLINOIS RMP SITE VISIT ~ 23 - RM 00061 © SUMMARY OF SITE VISITORS' RECOMMENDATIONS ON OPERATIONAL PROPOSALS DEFERRED FOR SITE VISIT BY MARCH 1970 COUNCIL PROJECT NUMBER TITLE RECOMMENDATION lst Yr. 2nd Yr. 3rd Yr. (Direct Costs) 9 Community/University Heart and Nonapproval ---- Revision Stroke Program Required 10 A Program for Continuing Education in Nephrology $167,257 $181,948 $191,883 11 Chicago Regional Transplantation Program $150,000 $150,000 $150,000 12 . A Pilot Program for a Regional Cancer Educational Program $49,155 $12,289 APPLICATION SUBMITTED FOR JUNE/JULY REVIEW CYCLE PROJECT . NUMBER TITLE RECOMMENDAT ION ist Yr. 2nd Yr. 3rd Yr. (Direct Costs) 13 Unified Health Information, Referral, and Counseling Service - Welfare Council of Metropolitan Chicago $226,000 $317,000 $363,000 iii ILLINOIS RMP SITE VISIT G - 24 - RM 00061 SUMMARY OF FUNDS REQUESTED BY APPLICANT AND FUNDS RECOMMENDED BY SITE VISIT TEAM PROJECT AMOUNTS REQUESTED AMOUNTS RECOMMENDED NUMBER TITLE (DIRECT COSTS) (DIRECT COSTS) [Ist Yr. 9nd Yr. 3rd Yr.] Ist Yr. Ind Yr. 3rd Yr. 10 - Continuing Education ot . in Nephrology $162,257 181,948 191,883 162,257 181,948 191,883 il 12 13 TOTAL #10 - 3 Yr. request = $536,088 Chicago Regional Transplantation Program TOTAL #11 - 3 Yr. request = $876,591 384,430 244,984 247,177 A Pilot Program for © Regional Cancer Educational Program 49,155 12,289 TOTAL #12 - 1% Yr. request = $61,444 Unified Health Information, Referral, and Counseling Service TOTAL #13 - 3 Yr. request = 323,493 452,833 518,821 $1,295,147 TOTAL #10 - Recommended for 3 Yrs. = $536,088 150,000 150,000 150,000 TOTAL #11 - Recommended for 3 Yrs. = $450,000 49,155 12,289 TOTAL #12 - Recommended for 1% Yrs. = $61,444 226,000 317,000 363,000 TOTAL #13 - Recommended for 3 Yrs. = $906,000 $587,412 661,237 704,883 (TOTALS RECOMMENDED) 6/22/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) INDIANA REGIONAL MEDICAL PROGRAM Indiana University School of RM 0043 7/70.1 Medicine June 1970 Review Committee 1300 West Michigan Street Indianapolis, Indiana 46202 PROGRAM COORDINATOR: Robert B. Stonehill, M.D. Requested Program Period lst Year 2nd Year 3rd Year _ Total Direct Costs $82,534 $65,587 $69 ,953 $218,074 Indirect Costs 17,969 19,400 20,952 58,321 Total $100,503 $84,987 $90,905 $276,395 History: The Region received its first planning grant ($295,500 d.c.o.) on January 1, 1967 and an 02 planning award($491,479 d.c.v.) on January 1, 1968. In September 1968, a site visit was made in order to determine IRMP readiness for operational status. The visitors commented on the Regions strong leadership, community involvement, and good working relationship with the University, and therefore, strongly recommended approval of Indiana's operational application. The November 1968 Council agreed and an operational award ($1,363,571 d.c.o.) was made on January 1, 1969 including support for core, two operational pro- jects and two feasibility studies. An amended 02 continuation award ($1,513,690 d.c.o.) was issued for the period beginning January 1, 1970. This award included support for core and ten projects. A listing of current projects status follows the description of the present application. Present Application: This is a request for three year support of two new operational projects. Indiana RMP -2- RM 00043 7/70.1 Project #19 - Delivery of Genetic Counseling to the Indiana Region Requested * The major goal of this project is the development First Year of an efficient computerized system for the recognition of genetic $28,910 disease by pedigree linkage. A secondary objective is the provision of initial instruction and remedial education in medical genetics to physicians on a state-wide basis by lectures and through the use of video tape on the Indiana Higher Education Telecommunications System (IHETS). At the Indiana University School of Medicine, genetic counseling is currently being done by the Department of Medical Genetics which grew out a training program initiated in 1961. During the past nine years. 3,000: families have been seen in the Medical and Dental Genetics clinics and data have been obtained on 150,000 individuals in these families. All family data are punched on IBM cards for easy retrieval, sorting and analysis. Available equipment includes an IBM 7040 computer PDP-8 Analog to Digital converter. Calcomp XY plotter, disc storage unit, and ancil*ary keypunch and sorting equipment. In the belief that it has established a sound organizational framework _ for genetic counseling, the Region is proposing several activities to be included in this project. a The first is a Genetic Counseling Clinic which will meet weekly. Once a family is referred by a private physician, a ward physician in one of the local teaching hospitals or a private or government agency of some.type, it is the responsibility of the genetics fieldworker to make contact with the family, obtain a pedigree, and make an appoint- ment’.for the patient and relevant family members to be seen at the clinic. Graduate students will play an active part in obtaining pedi- gree information and performing appropriate diagnostic tests. This expanded clinic is based on an estimated 2,000 visits this year as compared to only 60, five years ago and 1,011 last year. A second activity will be the carrying out of population studies in two main areas, empirical risk data, and pedigree linkage. The former concerns the actual routine collection of data. Following completion of the diagnostic evaluation, the information obtained by the field- worker and from the laboratory tests js fed into the computer. The ultimate goal is to permit a rapid, accurate, and continual updating of the accumulated experience of the counseling center with respect to each type of problem. The other type of population study, pedigree linkage, is designed so that new patients with specific genetic diseases may be linked geneologically by computer techniques to other families with identical d#seases in a master file. The third component of the proposal is the addition and expansion of certain screening and diagnostic proceedures. These center around cytogenetics and biochemical studies. The present cytogenetics labor- tory provides routire karyotyping, autoradiography and meiotic studies, and various cytochemical studies of metabolic defects in tissue cul- ture, but the number of tests that can be performed is limited because of Indiana RMP ~3- PM 00043 7/70.1 insufficient lab space. It is anticipated that both lab space and personnel will have to double in order to meet the rising demand for services. As for the biochemical studies, there is a proposed addition of an amino acid laboratory, an enzyme laboratory and an electro micro-~ scopy laboratory, plus the expanding of the existing geneotyping, immunology, and lipid chemistry laboratories. There is also a research aspect in the proposed project. The sponsors contend that the new medical genetics counseling center would provide opportunities for research into areas such as twin studies, centromere napping cytoplasmic inheritance, chromosome breakage syndromes, and polymorphic markergenes. Since one of the projects major goals is the production of a computer program, the evaluation seems straightforward, i.e., the existence of a working computer program accompanied by a verbal narrative concerning the types of operations and the information they contain. The program can also be evaluated by counting (a) the number of searches made and (b) the number of successful pedigree linkages. Second Year: $31,467 Third Year: $34,414 Requested First Year Project #20 - Training Programs for Respiratory Care $53,624 Technicians This request proposes a respiratory care training program for selected "technicians" from nine institutions in the state of Indiana, this number to be increased as the program develops. The training consists of both theoretical and practical teaching for varying periods of time (1 or 2 months) depending on the student's level of competence. At the completion of the course, these "tech- nicians" are to return to their hospitals to resume their duties and to cooperate in the expansion of the local teaching and patient care activities. They would assist physicians in the care of patients with acute or chronic respiratory disorders, assuming, within the limits of their capabilities, more primary responsibility for such care. They would participate in setting up and/or expanding the operation of the local facilities, and in training other local paramedical personnel in order to augment such staff in the existing or proposed specialized facilities. The benefits of this program should be marked by a decrease in morbidity and mortality for patients with respiratory disorders, the return of a significant number of these patients to productive life, and a reduction in hospitalization costs (individual, state, federal) through optimal in-patient and out-patient care and the prevention of complications. Candidates will be selected by the physicians heading the program at each of the participating institutions. Those selected must be a paramedical employee at his institution and must have some expertise in Indiana RMP ~4~ RM 00043 7/70.1 one or more of the three areas of respiratory service: pulmonary function laboratory, rehabilitation, or intensive care. On the basis of their experience prior to entering the program and the competence gained during it, the trainees are expected to perform routine pulmonary function, to have practical experience in handling of respiratory emer- gencies, to understand the principles of mechanical therapy as applied to chest patients, and to be familiar with the equipment routinely used in the care of patients with respiratory disorders. Evaluation will consist of written tests before and after the course plus appraisal of on-the-job performance by the immediate supervisor and the program directors. Second Year: $34,120 Third Year: $35,539 Indiana RMP -5- { RM 00043 7/70.1 ONGOING OPERATIONAL PROJECTS (Direct Cost Only) Project # Current Budget Carryover Date and Title Including Carryover Included Initiated Core $460 ,967 $13,556 #2 - Multiphasic Screening ~- Flanner House 265,000 40,000 1/1/69 #3 - Regional Stroke Program 281,241 -0- 1/1/69 #4 - Network of Cor- onary Care Units 157,250 25,000 1/1/69 #5 - Health Manpower Recuitment 25,000 25,000 1/1/70 #6 - Education and Practice of Prospective Medicine 20,734 16,225 1/1/70 #9 - Community Health Centers ~ Metro- politan Health Council 169,550 19,550 1/1/69 #11 - System of Continuing Nurse Education 51,450 20,450 1/1/70 #13 - Educational Program for CCU Nurses 40,428 40,428 1/1/70 #14 - Medical Library Extension Service 26,197 26,197 1/1/70 #16 - Detection and Management of Chronic Pulmonary Disease 15,873 15,873 1/1/70 TOTAL $1,513,690 $242,279 Indiana RMP -6- RM 00043 7/70.1 APPROVED — UNFUNDED PROJECTS Project #15 - Fetal Cardiovascular Monitoring for Optimal Patient Care © 12/69 $35,264 #18 - Cooperative Arrangements for Community Coronary Care Program - Northwest Indiana 3/70 $41,966 5 STAFF OBSERVATIONS Re 06043 7/70.1 ®@ Project #19 | At its December 1969, meeting, the National Advisory Council, after reviewing special information obtained by the staff at. the request of the August Council, disapproved a project that would establish a medical genetics clinic. As a matter off policy, the Council stated. that, ". . . this project proposes the demonstration of technique which has not yet been developed to the extent that it is of primary importance in patient care and one which is not sufficiently relevant to the problems of the categorical diseases. In recognition of the continuing basic research and clinical investigation of this technique, the Council has agreed to reconsider, two years from now, its applicability to direct patient care! 5/22/70 A PRIVILEGED COMMUNICATION SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE INDIANA REGIONAL MEDICAL PROGRAM RM-90043 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL Project #19 - Delivery of Genetic Counceling to the Indiana Region Critique: This proposal was not considered by ‘the Committee due to a decision of the December 1969 National Advisory Council to withhold funding of such projects for two years pending the findings of fucther basic research and clinical investigation into the appli- cability of genetic counseling to direct patient care. Recommendation: Non-approval I - no RMP funds recommended. Project #20 - Training Programs for Respiratory Care Technicians Critique: The Review Committee was generally dissatisfied with this proposal, The reviewers felt that the project was poorly described; the curriculum was not clearly defined nor was much attene tion given to follow-up and evaluation of performance, There were also some concerns over who would be giving the instruction and what would be the exact duties of the graduates upon returning to their institutions. Question was also raised as to the appropriateness of leaving the deter-~- mination of educational qualifications up to the various institutions. his concerned the reviewers since the project intends to combine theor tical concepts with direct patient care. Throughout its deliberations, the Committee was concerned over the increasing number of categories in the allied health field and the possible effect of further fractionalizing health care delivery. As for this particular proposal, the reviewers wondered why there had been no mention made of any relationship with established inhalation therapy programs and what indeed were the need for separating seemingly like functions. Along these lines, it was suggested that contact be made with the newly formed Committee on Emerging Professions of the American Medical Association, The Committee thought that this proposal might be resubmitted as a pilot. project to determine the need for such a training program and if so, to develop an appropriate protocol and curriculum, Recommendation: Non-approval IL.+-return for revision INDIANA RMP 60043 7/70.1 SUMMARY OF FUNDING RECOMMENDATIONS Project 01-Year 02-Year 03-Year Total (#19-Requested) ($28,910) ($31,467) ($34,414) ($94,791) #19-Recommended -O- -O= -Q- -0- ” (#20-Requested ( 53,624) ( 34,120) ( 35,539) (123, 283) #20~-Recommended -0- — -O- -0- Qe (Total Requested) ($82,534) ($65,587) ($69,953) ($218 ,074) Total Recommended -0- «Qa ~~ ~-0- RMPS/GRB/7/6/70 (A Privileged Communication) REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION INTERMOUNTAIN REGIONAL RM 00015 7/70.1 MEDICAL PROGRAM June 1970 University of Utah Review Committee University and 2nd South Streets Salt Lake City, Utah 84112 Program Coordinator: C. Hilmon Castle, M.D. Requested Program Period lst Year 2nd Year 3rd Year Total Direct Costs $72,267 $70,426 $74,533 $217,226 Indirect Costs 17,884 19,672 21,640 59,196 TOTAL $90,151 $90,098 $96,173 $276,422 History: The Region initiated its third operational year with an amended award, effective April 1, 1969, in the direct cost amount of $2,407,622. Of the $2,407,622 direct cost level, $2,142,788 was financed with new funds and $264,834 by funds unexpended from prior grant periods. A site visit team evaluated a request for renewal of seven ongoing operational projects and one revised renal disease project on October 28, 29 and 30, with a resultant recommendation of approval for three additional years in the direct cost amount of $2,064,229 for the program's fifth year of operations. In addition, the team recommended funding of the renal disease program in the amount of $94,685. These recommendations were endorsed and concurred in by the Review Committee and the National Advisory Council. This project is awaiting funding from FY 1970. The Region was advised on January 15, 1970, of an impending grant to be awarded for the continuation of the components covered by the renewal application and the one project supplement (approved as referred to above) in the amount of $1,781,097. Council committed support for the balance of the ongoing program's fourth year is $348,641, which brings the Region's funding level to the direct cost amount of $2,129,738. This amount will support seventeen ongoing projects, two of which the Region is terminating March 31, 1970. The proposal for a Multiphasic Screening Program, Project #26, in the 314(e) approved Neighborhood Health Center in Salt Lake City was the subject of a site visit on March 25, 1970 and was presented to Council immediately thereafter. It was approved in a revised form which was prepared in line with the critique of the Review Committee and the site visitors. This project is earmarked for funds from FY 1971. INTERMOUNTAIN RMP ~2~ PROJECT j-Training Feedback Seminars 2-Network for Continuing Education 3-Communications & Information Exchange 4-CPR Training 5-CCU Training - M.D.s 6-Training for R.N.s 7-Clinical Cardiology Training 8-Community Cardiovascular 10-Computer-Based Monitoring System 11-Cancer Training 13-Stroke & Related 14-Respiratory Therapy Program 16-Endocrine Metabolic Laboratory 17-CCU - Small Hospitals 18-Model Stroke Care & Rehabilitation 19-Core Adminis. Planning & Eval. 20-Radiological Capability 21-Myocardial Infarction Data Systems 22-Renal Disease 23-Biomedical Information 24-Hypertension 25-Renal Disease 26—Multiphasic Screening Project #27 - Head, Neck and Oral Cancer Detection Training. This project builds on a feasibility study made RM 00015 7/70.1 STATUS Now merged with Core Renewal - 12/69.1 Now merged with Core Region terminating 3/31/70 Renewal - 12/69.1 Wt if tt w TF t! fF wt tf u Funded until 3/31/70 tw ca] uw tr tt 3/31/71 Region terminating 3/31/70 Funded until 3/31/71 Renewal - 12/69.1 Approved (May Council) as yet unfunded Approved (Feb. Council) funded from carryover for one year only (3/31/70) 2/69.2 - revised project newly submitted as #25 12/69.2 “pet 2/69.1 - returned for revision Pe 2/69.1 - returned for revision Coes Approved (Dec. Council) ewaiting award Approved (March Council) as yet unfunded ist Year $72,267 in April 1968 in Carbon County, Utah, in a community of 16,200 people. With cooperation from the State and local medical and dental associations, the Utah Division of the American Cancer Society, community leaders, hospital officials, church organizations and the Utah State Division of Health, a head, neck and oral cancer detection program was undertaken in the City of Price. Five of the community's seven physicians and three of its four dentists participated for two days and helped examine 1,400 people at a public clinic in the College of Eastern Utah. Procedures consisted of visual examinations of the skin of the head and neck, palpation of cervical lymph nodes and thyroid, intraoral examination and palpation, intrapharyngeal examination and indirect laryngoscopy if the patient complained of hoarseness. Of the 1,400 screened persons, 354 exhibited lesions suspicious enough to warrant further investigation through Pap smear and/or biopsies. INTERMOUNTAIN RMP -3- RM 00015 7/70.1 The present proposa. is designed for training in early detection and will reach 75% of the Region's physicians and dentists. Over a three-year period 36 programs (one each month) will be held in 36 individual communities in six states. These will consist of a teaching session in signs, symptoms and techniques of diagnosis, followed by a clinic at which approximately 500 people will be screened. This will provide a supervised, practical experience where the physicians and dentists can apply what they have learned. Support is requested for a maximum of 36 months. The teaching team is available and a curriculum has been established. Within six weeks of approval the first program can be held. Arrangements have already been made for pathological interpretations of the histological and cytological specimens. The project provides for professional training, public education and establishment of community cooperation. It will utilize the resources of the Cancer Teaching Projects, the IRMP Tumor Registry and of Core Administra- tion's Health Care Data Bank for followup and evaluation. The expertise of the Core staff's Communications and Information Service will be utilized in community relations, preparation of publications and news releases. This will be the first time IRMP's cancer activities will be extended to the area of early detection, as well as fostering a cooperative venture between medicine and dentistry. A two-hour intensive refresher course will first be presented to the local physicians and dentists on the differential diagnosis and treatment of head, neck and oral cancers. This will be in the form of two 16 mm. color movies and supplemented by visiting consultants' lectures using 35 mm. color slides. Diagnostic procedures will be illustrated. The following day a screening clinic will be held and these are designed to evaluate 500 persons. This will require eight examination booths, four staffed with IRMP physicians, dentists or consultants, and four staffed by local physicians and dentist on a rotating basis. As far as possible all Pap smears and biopsies will be performed during the clinic. An IBM key punch card, designed as a combination registration and patient information card will provide for efficient data handling. Informative evaluation will be conducted during the entire term of the project in an attempt to make the clinical learning experiences most meaningful to the practitioners as well as acceptable to the patients and communities. Increased diagnostic attention to oral, head and neck lesions will be assessed by the use of Core Administration's Health Information Data Bank. 2nd Year: $70,426 3rd Year: $74,533 Grp 5/14/70 SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE INTERMOUNTAIN REGIONAL MEDICAL PROGRAM RM 00015 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee recommended that this single component application which requests $217,226 for a three~year program period be returned for revision. Project #27 - Head, Neck and Oral Cancer Detection Training Critique: It was recognized by the reviewers that the application has many good aspects, the leading one being the involvement of dentists, which is not a simple affair, Also, the Region has an ongoing cancer registry, and the "cooperative venture" between medicine and den~- tistry was considered unique and undoubtedly based on sound relationships. There were, however, a number of reservations about the project. First of all, it seems doubtful that local practitioners would be able to fol- low through on the results of the feasibility study. An outstanding dis- advantage of a floating clinic is the improbability of follow-up. The Region apparently did not give sufficient thought to evaluation measures, which would result from the essential follow-up. The teaching team is available, but the Region fails to include documenta- tion for its organization. There were no curriculum vitae included, no indication of the leadership or qualifications of team members. The project planners have not spelled out the relationship of this project to the ongoing cancer registry. There does not appear to be a centralized biopsy review, and no apparent relationship to the broader aspects of cancer screening. There was another more philosophical concern which was related to what appears to be a somewhat fragmented diagnosis,i.e., what about the sub-specialties such as thyroid tumors that will be uncovered? The reviewers agreed that failure to name a qualified head and neck surgeon or to identify faculty who made the judgment necessary for proposing such training, the project lacks many of the elements necessary for its success, Recommendation: Non-Approval II - return for revision to include the the following: (1) Statement of project's relation- ship to the broader cancer screening program; (2)statement of anticipated follow-up procedures; and (3) indication of the leadership and qualifica- tions of the teaching team. RMPS/GRB/7/7/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION © (A Privileged Communication) KANSAS REGIONAL MEDICAL PROGRAM RM 00002 7/70.1 3909 Eaton June 1970 Review Committee Kansas City, Kansas 66103 PROGRAM COORDINATOR: Robert W. Brown, M.D. Requested lst Year 2nd Year 3rd Year 4th Year TOTAL Direct Costs $111,959. $123,680 $133,230 $142,881 $511,750 Indirect Costs 29,258 34,376 37,454 40,804 141,892 TOTAL $141,217 $158,056 $170,684 . $183,685 $653, 642 Background: Planning in this Region began almost four years ago in July 1966. The £irst operational grant was awarded one year later. The Region was awarded $2,536,975 for a 14-month period, of which $1,307,406 is for core. A new Coordinator, Dr. Robert Brown, was appointed in February 1969. The last site visit to this Region was held in January 1969. The organization of the Region stresses subregionalization. Twenty-one Local Actioa Groups, whose membership overlaps with Comprehensive Health Planning i Agencies, veview proposals before they reach the Research, Planning and Development Committee, Scientific Advisory Subcommittee and Regional Advisory Group. The Kansas RMP core staff structure also provides for four subregional coordinators, who work with both the planning and operational activities and as executive secretaries to the Local Advisory Groups. Subregional offices in Wichita, Great Bend, Topeka and Colby are presently staffed. Many of the proposals the Kansas RMP has submitted have dealt with training nurses and allied health personnel, as does the one in the present application. Previous reviewers have noted this emphasis and recommended that the Region develop a better mechanism for defining priorities and developing a coordinated approach to training these groups, as well as physicians. sent Application: Requested Project #39 - A Demonstration Project to Improve Community Chronic First Year Illness Care. The Committees on Public Health and $111,959 aa snemaatbearnaranenteimeenasnim Medical Service of the Shawnee County Medical Society - after reviewing data on medical care in adult care facilities - concluded that neither now nor in the forseeable future will it be possible for local physicians to provide all the medical care the aged chronically ill population requires, and they requested that Topeka-Shawnee County Health Department devise a plan for public health care nurses to assume a portion of the medical load. ‘There are 21 licensed proprietary homes and a 55-bed public-supported infirmary in the county. The Topeka~Shawnee County Health Department, in conjunction with the Shawnee County Medical Society, have developed a four-year demonstration project to: 1) establish within the Topeka~Shawnee County Heaith KANSAS REGIONAL MEDICAL PROGRAM -2- . RM 00002 7/70.1 Department a special, multi-discipline chronic disease team and to 2) develop a nurse-clinician. ‘ The Comprehensive Health Team will consist of a nurse coordinator, physical therapist, occupational therapist, dietician, social worker and two registered nurses. These individuals will be recruited, selected and directed by the Health Department Director. The team's function will be to assess patients in selected nursing homes, to be followed by assessment conferences in which personnel of the home participate; and evolve a total treatment plan and determine the need for basic instruction and continuing consultation to carry out that plan. The program will emphasize supplementing, reordering and improving patient care, not displacing the current efforts of physicians or the adult care facility staff. In later phases of the program, the team will concentrate on specific training program development, utilizing such existing community resources as the area vocational school, hospitals, physicians, Washburn University, and an anticipated model long term facility. A nurse with a bachelors degree and some experience in teaching and supervision, who will eventually assume responsibility for organizing, supervising and referring the "practicum" for other nurses, and a recently graduated nurse, who will handle patient care in local nursing homes, will be trained as nurse clinicians. A curriculum will be developed to prepare the nurses to provide psychological, education and medical services to the patients. During the second, third and fourth years of the project, the proposers hope to offer the course two or three times a year depending on its final form and direction, for a total of 28 to 35 nurses. Certain members of the Health Department staff and the Coordinator of the comprehensive care team will provide leadership and direction for the initial training course. A panel of nurses representing several related nursing specialties will serve as a consulting committee to review and advise on the nursing components of the program. The panel chairman of this group will serve on the Advisory Committee of the project, along with the clinical director of the mental health corporation, two physicians, three laymen, a hospital or nursing home administrator, and a welfare department representative. The proposers have planned for several forms of evaluation, such as studying patient records, observing nurse clinician performance, inter- viewing patients and analyzing statistical records. The first year budget consists principally of personnel ($75,563), but also includes funds for consultants ($20,000), equipment ($4,946), supplies ($1,300), travel ($7,200 and other ($2,950). If the program serves the community as expected, adequate local funding through some consideration of fees, contributions and support from public and private agencies appears reasonable by the end of the project period. Second Year: $123,680 Third Year: $133,230 Fourth Year: $142,881 5/11/70 ——e © STAFF OBSERVATIONS. KANSAS REGIONAL MEDICAL PROGRAM RM 00002 7/70.1 Summary of Review Actions A Privileged Communication @ #20 Therapists 8x STATUS AND PROJECT on CURRENT support! #1 - Educational Programs (Great Bend) renewal $303,655 #2 +- Reactivating Nurses (Great Bend) Terminated #30 - Circuit Course for Active Nurses 29,968 #4 - Cardiovascular Nurse Training 180,918 #5 - Cancer Detection | Terminated #6 - Physical and Occupational Workshops Terminated #7 - Cardiovascular Work Evaluation Terminated #8 - Continuing Education for Cardiac Care 82,162 #9 - Metropolitan Kansas City Nurse Retraining 85,365 @ Program . #10 - Health Data Bank 34,495 #11 - Self-Instructional Centers 17,050 #2 - Training Program for Cancer of Gastro- Withdrawn intestional Tract #13 - Project Stroke Deferred #14 - Perceptual Motor Dysfunction Assessment and Terminated Treatment #15 - Physical Therapy Workshop Terminated #16 - Therapeutic Nutrition Terminated #17 - Cancer Chemotherapy Seminar Terminated #18 - Core 1,307,406 #19 - Hypertension Screening Program (earmark) Phased out by the Region - Continuing Education Program for Occupational Comp leted KANSAS RMP STAFF OBSERVATIONS #21 #22 #23 #24 #25 #26 #27 #28 #29 #30 #31 #32 #33 #34 #35 #36 #37 #38 Ne ' Cerebrovascular and Neurological Nurse Training Biomedical Library Information Center Kansas Medical Library System Food Service Personnel Using the Dietary Consultant Approach Coordinated System for the Continuing Education of Medical and Paramedical Personnel Cancer Care Continuing Education Program Proposal for a Renal Dialysis Organ Transplant Program Seminar on Basic Medical Librarianship Kansas City Council on Health Careers Manpower Recruitment Program Mobile Workshop for Medical Technologists Subregional Office in Topeka (Core) Institute for Dieticians Nursing in Long Term Illness Proposal for a Basic Continuing Education Program in Community Health Nursing Basic Educational Program for Medical Record Clerks in Hospitals in Kansas Short Course in Instrumentation for Medical Technologists Care of Patients with Fluid Electrolyte and Renal Problems Basic Educational Program for Medical Record Clerks Employed in Hospitals in the State of Kansas TOTAL all amounts are for 14 month period funding under negotiation from the $5 million earmarked funds RM 00002 7/70.1 58,059 Combined with #23 222,094 3,175 58,779 12,630 Disapproved 6,050 Approved but Unfunded Returned for Revision 59,609 18 , 264 Disapproved Returned for Revision Returned for Revision Returned for Revision 57,296 Approved but Unfunded? $2,536,975 4/27/70 A Privileged Communication SUMMARY OF REVIEW AND CONCLUSIONS OF JUNE 1970 REVIEW COMMITTEE KANSAS REGIONAL MEDIGAL PROGRAM RM 00002 7/70. FOR CCNSIDERATION BY JULY:1970 ADVISORY COUNCIL General: Review Committee recommended return for revision of this one~ project application which requested $653,642 for a four-year program period to support A Demonstration Project to Improve Community Chronic Illness Care. While the reviewers believed that the venture into a new type of profession - the nurse clinician ~ is a laudable one, they found certain weaknesses in the project design which make it unapprovable in its present form. Project #29 ~ A Demonstration Project to Improve Community Chronic Iliness Care 7 Critique: . The Continuing Education and Training Panel described this ™ proposal as "primarily a service-centered project. with a continuing education component." They were critical of the lack of information about the educational design, including curriculum and rein- forcement of learning, the evaluation, staffing and budget. While Com- mittee thought that this project had shown evidence of area interest and documented the need, they essentially agreed with the Panel. The Commit- tee also stated that the proposal had not planned for the patients after discharge from the service and had no visible tie to the University of Kansas School of Nursing. Some concern was expressed about how patients would be fed into the system. Recommendation: In returning this project for revision, it should be stressed to the proposers to: (1) strengthen the evaluation (2) plan for patients after discharge from the service, and (3) show ties to the University of Kansas School of Nursing. DRMP 7/1/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) LOUISTANA RM 00033 7/70.1 Regional Medical Program June 1970 Review Committee 2714 Canal Street New Orleans, Louisiana 70112 PROGRAM COORDINATOR: Joseph A. Sabatier, Jr., M. D. Requested ist Year 2nd Year 3rd Year Total Direct Costs $519,992 $288,964 $288 , 886 $1,097,842 Indirect Costs 27,666 29,050 30,501 87,217 TOTAL $547,658 $318,014 $319 , 387 $1,185,059 HISTORY: The initial planning grant was awarded, after being returned for revision, in January 1967. The second year's award was made in March 1968. ‘The Region submitted its first operational applica- tion in August 1968, but the Review Committee and Council did not believe the materials reflected readiness for an operational program. @ Council recommended that the application, which included a project for Delineation of Medical Service Regions in Louisiana and a Health Careers Recruitment Program, be approved as planning activities. Core funds were also approved as requested to strengthen the central staff. The Region's second operational submission was approved by the August 1969 Council and includes funds for the following projects: #1 - A Training Program for Tumor Registry Secretaries $116,956 #2 - Proposal for Teaching Conferences for Diabetic 25,000 Patients #3 - Proposal to Establish an Office of Research and 106,954 Development in Educational Renewal (ORDER) #4 - Audiovisual Lecture Demonstrations in Radiology 24,791 and Radiologic Techniques : $273,701 Project #5 - Development of a Regional Medical Center Coronary Care Training Unit, a two-year $535,747 request for equipment was withdrawn by the Region after the November 1969 Review Committee meeting. @ LOUISIANA +2- RM 00033 7/70.1 Regional Medical Program The amount of $327,303 for core and $72,883 for the planning studies bring the Region's total funding level to $673,887 (d.c.o.). The Loulsiana Regional Medical Program has conceived its roie as a catalyst in effecting peripheral involvement and cooperative arrangements. A formal review process has been organized with staff assistance, Ad Hoc categorical review, and Regional Advisory Group evaluation and approval as the key elements. Planning committees have been developed in Heart Disease, Cancer, Stroke, Health Manpower and Continuing Education, Epidemiology and Statistics, Public Relations and Information, and Subregional Relations and Project Consultation. There are 17 persons on the core staff, including 14 professionals. Part-time advisors from Louisiana State University and Tulane University furnish liaison with their respective institutions. Planning studies the staff are currently working on include: 1) operations research in preparation for the establishment of a statewide cancer registry; 2) reduction of health care costs through voluntary cooperation among medical laboratories; and 3) consultation assessment of the administration and software activities of the statewide closed circuit medical TV network. Since the last site visit in June 1969, the Region has made several. organizational changes. The grantee institution has been changed from ~ the Louisiana State Department of Hospitals to the Louisiana Regional Medical Program, Inc., a non-profit corporation. The Regional Advisory Group has also been reorganized to give more representation to allied health and mireority groups. PRESENT APPLICATION: The Louisiana Regional Medical Program has included a short introduction to the application, which summarizes the projects and also describes four projects which were rejected by the Regional Advisory Group. At the end of each project, fairly extensive comments of the Ad Hoc Review Committees which reviewed the projects are given. Project #8 - Cardiopulmonary Resuscitation Program. The goal Requested of this project is to increase the number of First Year trained personnel in CPR techniques in order to significantly $172,755 reduce the mortality from cardiopulmonary failure in Louisiana. The Louisiana Heart Association as the sponsoring organization seeks funds to determine the extent of CPR training and the current LOULSIANA -3- RM 00033 7/70.1 Regional Medical Program : level of competence of individuals involved in CPR programs in the state and then to establish a statewide program to train and re-train at periodic intervals such groups as practicing and resident physicians, registered nurses, licensed practical nurses, dentists, safety and law enforcement personnel, firemen, general hospital personnel and families of cardiac patients. To accomplish these objectives, a full-time employee of the Louisiana Heart Association, preferably a physician, will be appointed as director for the program to 1) organize the training programs, 2) coordinate the faculty and instructors, 3) maintain and distribute supplies and equipment, 4) assist with establishing record keeping procedures and collection of data, 5) provide liaison with hospitals and other related groups, and 6) coordinate and assist in the overall evaluation. He will be assisted by physicians who will serve as senior faculty members. Their responsibilities will include the regular organization of CPR training programs in an area, consulting with hospitals, planning and implementing CPR procedures and evaluating program instructors. The state will be divided into four districts with a full~time district director to implement and coordinate the local programs. This indivi- dual would be paid $12,000 per year and required to have knowledge of and training in community organization and some knowledge of cardio- pulmonary resuscitation. Adequate secretarial help will be provided at the central office and district office level to maintain records and dispense material and equipment. The Heart Association will also make available time, equip- ment and "all of its organizational knowledge." Prior to initiation of the training programs, the director will attempt to determine the present extent of CPR training in Louisiana. To accomplish this, physicians, nurses, dentists, and hospital ambulance drivers will be given a written quiz and a practical evaluation of performance of CPR procedures. On the basis of experience with con- ducting CPR programs since 1960, the Heart Association estimates that 200 instructors will be needed in a minimum of eight hours of instruc- tion per year to train and re-train the necessary personnel. Re-training sessions will be held every six months. Evaluation will consist of an assessment of how many people were trained and what are the results of thetraining. The number of new CPR programs established within hospitals and the mortality figures following CPR attempts will also be appraised. : LOUISIANA . -4- RM 00033 7/70.1 Regional Medical Program The bulk of the request is for personnel. The Heart Association will assume responsibility for insuring that hospitals have enough trained individuals after RMP support has been terminated. Second Year: $152,875 Third Year: $158,912 Project #9 - Metropolitan New Orleans Organ Bank. The proposal Requested States that at the present time, there is no First Year coordinated, organized, centrally directed effort to promote $128,025 the development of an organ bank for the methodical procurement, preservation and supply of vital organs for purposes of renal transplantation in New Orleans. In New Orleans there are 41 dialysis facilities in six separate hospitals. These facilities can maintain approximately 123 patients. No facilities exist out- side New Orleans at present. Thus, the proposers feel that a feasibility study is indicated to: 1) facilitate maximum utilization of cadaver organs on a local basis, 2) determine practical guidelines for kidney preservation, 3) reach more definite answers regarding the efficiency of tissue typing in cadaver organ transplantation, 4) identify methods and resources for generation of continuing financial support, demonstrate need for additional banks, iB et 6) determine appropriate location of additional banks, 7) determine feasibility of storing organs other than kidneys, 8) utilize relationships which accrue the widest and optimal application of transplantation capabilities to patient benefit, and 9) determine useful sources of organ supply. Tae central headquarters of the organ bank will be located in Charity Hospital of New Orleans, where there will be a telephone manned on a 24-hour basis to enable physicians in any participating hospitals let the bank know when a donor becomes available. Bank physicians, LOUIS LANA -5- RM 00033 7/70.1 Kegional Medical Program assigned on a rotational basis, will arrange for perfusion and necessary transportation of the kidneys. The director of each transplantation program, the tissue typing technician on call, the physician responsible for procurement of organs, the perfusion technician on call and the director of the tissue typing laboratory will be provided with a two-way radio transmitter to keep them in touch with central headquarters. From computer comparison of blood type data on file, the appropriate recipient will be selected and the perfusing organ will be delivered to the recipient's hospital and transplanted. The organ bank will be directed by a Council which will develop priorities, aims and community support and advise proper approaches to obtain continued funding. The Council will be broadly representa- tive of the organizations and institutions involved in organ transplantation. Assisting the Council will be a Subcommittee for Delivery of Services which will be responsibile for the actual mechanics of obtaining organs, selecting the appropriate recipient and providing it to that individual. It will be composed of two representatives of each institution performing kideny transplantation. Data analysis and evaluation will be the on-going function of this committee. The first year request consists mainly of personnel, equipment and services. Second Year: $79,692 Third Year: $81,792 Project #10 - A Pilot Project for the Establishment of a Method Requested of Evaluating the Health Care Delivery Patterns First Year of Medically Indigent Persons with Heart Disease, $49,797 Stroke, Cancer and Related Diseases. Because those who need health services the most often are unable to pay for them, the Region believes that steps must be taken to identify and evaluate health care patterns, analyze suitable alternative systems of health care delivery, and plan to implement programs designed to meet health needs of the medically indigent. To this end, the Louisiana Capital Area Health Planning Council, a 314 b agency, will initiate a pilot study to determine health care pattern characteristics of low income residents in Baton Rouge, Hammond and New Roads. The project director will be supervised by the Executive Director of the CHP b agency. LOUISIANA -6- RM 00033 7/70.1 Regional Medical Program a The specific objectives include the following: 1) investigate efficient and reliable methods of securing data on medically indigent in the three areas 2) develop a prototype of reaearch methodology usable by similar area councils, 3) develop a uniform system of mapping flow of indigent patients, 4) analyze ecological factors which influence the pattern of health care, 5) determine the need for special planning to meet signi- ficant incidences of particular diseases, ard 6) determine the adequacy of the existing system of health care of the indigent. As the particular methods and techniques "have not yet been completely specified," a large part of the project will be to work out feasible’ methods. Essentially, however, the survey will attempt to 1) identify the type/number of medically indigent in the area by a formula method; 2) detect unmet health needs by examining hospital records for unpaid; high level bills, determining the extent of indigent patients treated by private practitioners and contracting schools, welfare departments and public health nurses; 3) collect data on payments made to practitioners, hospitals and clinics, and 4) compare family incomes with treated or untreated conditions. Interviewers will be hired from students at Louisiana State University and Southern University. The students will interview houseliold membéts in one poverty and one lower middle class neighborhoods to obtain information on economic characteristics of the household, hospitalization experience and on doctors' and dentists' visits. The proposer hdépes to form an Ad Hoc Committee on Compréhensive Health Services for low income citizens which might help evolve a plan for a comprehensive health service delivery system for low income citizens living in urban target areas. Such a system would include out-patient services in a neighborhood health center, multiphasic screening services and use of low income citizens in sub-professional positions: LOUISIANA . ~7~ RM 00033 7/70.1 Regional Medical Program The proposers believe that these objectives can be achieved within one year. Second Year: None Project #11 ~- Lymphomatous Tumors in Louisiana. Because Requested Hodgkin's Disease carries good prognosis First Year when diagnosed and treated early, especially in young adults, $56,621 newly occuring cases within Louisiana need to be reported to appropriate medical resources so that the patient may be effectively treated; clues to etiologic events may be studied and differences between mortality in the South versus the East may be studied. Within three years, the proposers on the staff of the Tulane University School of Public Health and Tropical Medicine hope to attain the following: 1) Establish a statewide surveillance system for identi- fication and histologic classification of all newly- diagnosed cases of Hodgkin's Disease occuring within a two-year period. 2) Through LRMP coordinate the availability of the State's medical facilities to assure the latest diagnostic evaluation, treatment, patient care, extended survival and, perhaps, cure for each case. 3) To interview each new occurrence to determine possible etiologic events, especially those identified as occuring around puberty and which may be amenable to preventable measures. 4) Determine the incidence of Hodgkin's Disease in New Orleans from 1951-1960 by a survey of existing records. 5) Measure the survival status of cases ascertained through retrospective incidence study. Personnel costs will comprise the main charge to this project, as funds are requested to support part of the project director's salary and a full-time nurse, research assistant, secretary and clerk- typist. Second Year: $46,994 Third Year: $48,182 LOUISIANA -8- RM 00033 7/70.1 Regional Medical Program Project #12 - Intensive Coronary Care Through the Use of. Requested Telemetry of Electrocardiograms. Since First Year ‘the usual smaller hospital has no full-time house staff $105,536 and since such hospitals have not been able to maintain a specially trained nurse Or technician on a reasonably permanent basis in a coronary care unit, the Sara Mayo Hospital of New Orleans proposes 4 study of the use of telemetry of electrocardiograms from an intensive coronary unit in the hospital to any of a panel of cardiologists located elsewhere in overcoming those difficulties. The unit would include the usual devices for electronic monitoring of patients, including a multitrace oscilloscope at the central nurses desk but with the addition of telephone transmission equipment to transmit EKG's to the cardiologists' own remote read-out equipment. When the attending nurse notes a suspicious rhythm on the scope, she would relay the signal to the cardiologist, who would give back diagnostic informa~ tion for treating any dangerous arrhythmia detected. An additional method of transmission, using an FM radio paging service which could broadcast the QRS translated into a "beep" would allow the cardiologist to use a portable radio receiver rather than the bulkier read-out equipment. The project will focus on coronary care treatment in the early detection and treatment stages. While the coronary care unit has four beds, several private rooms, the surgical recovery room and obstetrics unit would be connected as well to the central moni- toring station and the treatment compared to that of the central unit. In addition, this proposal will include telemetry trans mission of EKG's from St. Tammany Parish Hospital in Covington, Louisiana to the panel of cardiologists. Evaluation will consist of a comparison of the mortality rate in the hospital with a goal of 17%, and an assessment of the success of telemetry as a substitute for having an experienced electrocardiographer in the unit at all times. The funds requested are entirely for equipment. The hospital states it is completing a new building, it serves a low income segment of the New Orleans population, it has no endowment and thus does not have the funds to purchase the bulk of the equipment required for the monitoring, telephone and radio transmission. Second Year: None LOUISIANA -9- RM 00033 7/70.1 Regional Medical Program Project #13 - A Proposal to Establish a Continuing Education Requested Program for the Physicians of the Lincoln First Year General Hospital, Ruston, Louisiana. The $7,258 physicians of Ruston, Louisiana are currently developing a plan to supply health care services to the medically indigent, which comprise one-third of the parish population. Operation of the plan is expected to begin in September 1970, with a continuing education program antedating the overall plan by one year. Because they believe a continuing medical education program is a necessary component of the overall plan for delivery of health services, the proposers seek to develop a structured program to upgrade skills in their respective specialties. Physicians from Lincoln General will spend two weeks in appro- priate specialty departments at Baylor College of Medicine in Houston following individually designed programs in their specialty. Programs have been arranged for pediatrics (endocrine and cardiac), pathology (surgical and cytological), surgery (vascular cardiology and cardiac pacemakers), and pediatric neurology. Additionally, individualized physician programs will be arranged for other departments during the first twelve months. The second year, faculty from Baylor Medical College will spend time at Ruston as consultants and observers of health problems in a rural area remote from a medical center. The proposal states that Baylor College of Medicine is the natural referral source for difficult cases for physicians in the area. Results of increased training will be applied to other programs in which the physicians participate, such as those sponsored by the parish health department, Family Planning, Inc., Department of Public Welfare, Ruston Area Mental Health Clinic, etc., as a spin-off effect is generated. Sophisticated evaluation of behavioral changes will not be attempted but documentary records will be kept and an overall evaluation attempted. Funds are requested in the first year for travel and in the second year for travel and consultation fees. Second Year: $9,403 Third Year: None DRMP /GRB 5/21/70 A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE LOUISIANA REGIONAL MEDICAL PROGRAM RM 00033 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Louisiana RMP submitted a supplemental application for six projects requesting $1,185,059 for a three-year program period, The Committee concluded that the application be supported as follows: $147,532 the first year to support Projects #9 and 10, and $77,242 the second and $79,342 the third year to support Project #9. Projects #11 and 13 were approved without funds; Projects #8 and 12 were returned for revision. The reviewers noted that the projects in this application did not appear to have kept pace with the Region's stated priority of improved medical care for the disadvantaged within the context of cooperative arrangements between indfviduals and organizations concerned with health care delivery. Of the six projects in the application, only two dealt directly and one tangentially with this priority. Committee was pleased with the project summary and internal review sys~ tem the Region has developed. The Ad Hoc Committee Reports were partic~ ularly helpful to the reviewers. , Project #8 - Cardiopulmonary Resuscitation Critique: The Committee did not approve this project because of the num- ber of unanswered questions that arose. For instance, they were unable.to ascertain how many people would be trained or the train- ing time involved. Also, the application did not give much information about previous experience with this activity in the state. Certain budget items, ‘such as personnel, instructional materials and the $11,000 for telephone, were not adequately justified. Recommendation: Non-Approval II (revision required). Project #9 - Metrepolitan Organ Bank Critique: The Committee recommended approval of this project. The budget is well justified. An evaluation procedure is planned which would document the number of kidneys received and used, and study the function of grafts and the relationship of biologic compatability to Louisiana RMP -2- RM 00033 7/70.1 function. A broadly representative council would have as one of its. functions the responsibility for’ finding other means of support after RMP funds are no longer available. Although physician education was not a part of the project, some reviewers thought this type of project would lead into an educational process. The Committee agreed that the two-way radio network, the truck and the Belzer perfusion equipment were unnecessary, especially since most of the procedures will be done in New Orleans in the beginning. Recommendation: Approval I with reduction in the budget as outlined above. —_ 91 92 ——_—93 $97,735 $77,242 $79 , 342 Project #10 ~ A Pilot Project for the Establishment of a Method of Evalu- ating the Health Care Delivery Patterns of Medically Indi- gent Persons with Heart Disease, Stroke, Cancer and Related Diseases Critique: The Continuing Education and Training. Branch staff found that the need for the study based on the assumption that adequate data in existing health care delivery patterns of. the target population must be compiled before a comprehensive health service delivery system can be designed is valid and well substantiated. The time frame and staffing appeared reasonable, and good use of regional resources has been planned. The extensive evaluation plans seem adequate. » The Committee agreed with these statements. Some reviewers expressed the wish to have had some information on the pilot study in Eden Park and some documentation of cooperative arrangements. Concern was expressed as to whether the patients and local physicians would be amenable to the collection of data on unpaid bills. Recommendation: Approval in the amount and for the time requested. 01 - $49,797 Project #11 - Lymphomatous Tumors in Louisiana Critique: This project directed at a comparatively rare disease seems feasible and would be productive. It is, however, primarily of a research nature and centered in a medical school. While Committee believes it is within RMP's purview, they were not persuaded that it is within the Region's stated objective of increasing health care for the disadvantaged. The project could have considerable educational value if tied in to a radiological program. Louisiana RMP -~3- RM 00033 7/70.1 Recommendation: Approval II - (No additional funds recommended). Project #12 - Intensive Coronary Care Through the Use of Telemetry of Electrocardiograms Critique: This project raised several questions: t (1) Why is an elaborately equipped coronary care unit needed to test the transmission of electrocardiograms? (2) Will physicians actually be able to detect heart rhythms on the page beeper device? , (3) If the personnel in the unit are sufficiently intelligent and skilled to carry out the treatment-.indicated by the ECG information obtained, shouldn't they also be capable of assimilating the knowledge required to identify ECG abnormalities? In addition, the Ad Hoc Cardiovascular Study Panel stated that (1) moni- toring by a remote cardiologist would not achieve the objective of re- ducing mortality in the absence of on-the-scene skilled medical or para- medical personnel; (2) documentation of specific personnel resources is lacking; (3) the budget is unreasonable, especially in the equipment category; and (4) evaluation is inadequately planned. The Committee felt the project was an interesting effort’ of a community: hospital to get at the problem of transmitting and reading ECG's. How- ever, the questions that the project raised and the Panel comments make it unapprovable in its present form. If the Region should revise the project, the reviewers advise that the proposers place particular impor- tance on the capability of the individuals at the hospital end of the transmission, , Recommendation: Non-Approval II (revision required). (One vote opposed to recommendation) Project #13 - A Proposal to Establish a Continuing Education Program for the Physicians of the Lincoln General Hospital, Ruston, Louisiana , Critique: The reviewers had difficulty resolving their differences of opinion into a recommendation on this project. On the one hand, the Committee saw the value of such an educational program espe- cially in the context of a larger comprehensive health care plan: for the community. The Continuing Education and Training Panel believed that the proposed exchange experience for medical specialists in rural areas would be innovative and that the time frame and budget are reasonable. On the other hand, the proposal was unspecific about areas of instruction and method of evaluation. The proposers had also neglected to include a copy of the parish's Comprehensive Health Care Program, which includes Louisiana RMP -~4- RM 00033 7/70.1 eare for the disadvantaged. Committee realized that this project is under capable direction and has confidence that it would probably accomplish its aims. They recommend, however, that the project directors utilize the resources of the LRMP 's Office of Research and Development in Educational Renewal (ORDER). Recommendation: Approval II - (No additional funds recommended) ~ with the following conditions: (1) Baylor College of Medicine provide a description of the courses; (2) The project directors submit a description of the parishwide plan for comprehensive health care; and (3) The project directors discuss and develop withthe Office of Research and Development in Educational Renewal a better method of evaluation. Conclusion: A total of $304,116 for three years was recommended for Projects #9 and 10. Ol 02 03 Project #8 - Cardiopulmonary Resuscitation Program Returned for Revision Project #9 ~ Metro. N.O. $97,735 $77,242 $79 ,342 Organ Bank - : Project #10 - Study of Health _ 49,797 -0- -0- ‘Care Delivery Patterns of Medically Indigent Project #11 - Lymphomatous Tumors Approval Without Funds in Louisiana Project #12 - Telemetry of , Returned for Revision ECG's Project #13 - A Continuing Approval Without Funds Education Program for Physicians of Ruston, La. TOTAL $147,532 $77,242 $79,342 DRMP 7/9/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF A SUPPLEMENTAL OPERATIONAL GRANT APPLICATION (A Privileged Communication) MARYLAND REGIONAL MEDICAL PROGRAM RM 00044 7/70.1 550 North Broadway June 1970 Review Committee Baltimore, Maryland 21205 PROGRAM COORDINATOR: William J. Peeples, M. D. Requested lst Year 2nd Year 3rd Year Total Direct Costs $172,045 $173,076 $129,059 $474 ,180 Indirect Costs 32,058 35,190 23,243 90,491 TOTAL $204,103 $208, 266 $152,302 $564,671 HISTORY: The Maryland Regional Medical Program began its planning during January 1967. Following a site visit in December 1968, and a meeting of a special Reference Committee of Council, an award of $1,932,893 (d.c.o.) was made (effective March 1, 1969) to the Region to support Core activities ($724,360) and operational projects ($1,208,533) - (d.c.o.) for the first year. In February 1970, staff reviewed and was disappointed with the Region's progress as outlined in the 02 year application. There appeared to be only minimal coordination between the various institutional units and Core Staff, and even less coordination between Core staff and the individual projects. Although the second-year approval application was in the amount of $2,120,538 (d.c.o.) (see History Supplement for breakout of this total), they further recommended that a site visit be conducted to “explore the interrelationships of the Core staff with projects as well as the degree of coordination among the various Core components, i.e., Core units." Also, March 1970 Council recommended that a November 1969 supple- mental operational application be deferred for a site visit. The reviewers shared Staff's concern about the size of the Core staff supported in the Maryland Region and the obvious lack of intramural~ extramural contribution by this cadre of experts to the regionalization process as it was reflected in the supplemental operational application. The site visit was conducted on May 11 and 12, 1970. The report of the site visitors will be available to the reviewers during the June/ July 1970 review cycle. MARYLAND - -2- RM 00044 7/70.1 Regional Medical Program PRESENT APPLICATION: This application requests three-year support # for two projects in the field of cancer and ene: project in continuing education for dentists. Direct costs only are ‘noted in the following project descriptions. Project #28 - Regional Oncology Affiliation. Johns Hopkins Requested ma University, Baltimore, Maryland. This proposal First Year is ‘based on a RMP-supported feasibility study initiated at the $116,151 Easton Memorial Hospital in Easton, Maryland, and the Church Home..and Hospital in Baltimore. It is for the establishment ofan affiliation between the Johns Hopkins Oncology Center and other hospitals and an increasing number of community ‘phyZicians in order to provide comprehensive care to patients with, cancer and to provide a continuing education program for physicians. The applicant states that 1700 cancer cases are ‘regdstered each year at Johns Hopkins and Baltimore City Hospital sdlone. “This. project proposes to provide multidisciplinary care of patients ‘by providing: 1) 24-hour telephone consultation to physicians sso. that patients’ problems and clinical questions can be handled -promptly as they arise; 2) rapid access to comprehensive evaluation of ambulatory patients by a specific panel of consultants; and 3) by providing prompt admission for patients requiring major diagnostic and ttreatment procedures. ‘The rmajor emphasis of the educational activities will be directed ‘toward clinical application and the immediate improvement in ,patient care and. will be accomplished through the provision of -community hospital conferences, seminars, and an annual two-to-~ ithree day course in oncology. A detailed automated record system ‘wiki, be used to support all phases of the program. Approximately °$93,3000 6f the first year total request of $116,151 is for . personnel. SSecond Year: $122,426 Third Year: $129,059 Project #29 - A Cancer Detection Program in Children. The $ 48,895 oon primary objective of this proposal is the early detection and diagnosis of malignancies in children during the first five years of life. The project proposes to train and utilize non-physician personnel .to conduct the screening program. Overall program supervision MARYLAND -3- RM 00044 7/70.1 Regional Medical Program will be the responsibility of a special advisory committee com- posed of members from the Department of Pediatrics and the Baltimore City Department of Health. This committee will meet periodically to review progress and make general policy decisions. Initially, the screening procedures and techniques will be developed in the Comprehensive Health Care Clinic in the Depart- ment of Pediatrics at the Johns Hopkins Hospital, and it is expected that approximately 25,000 children from East Baltimore will be registered in the clinic by July 1970. The program will later be expanded to include Well Baby Clinics throughout Baltimore. Some of the screening techniques to be employed are: 1) funduscopy; 2) abdominal examination for the detection of visceral enlargement relating to Wilms' tumor, neuroblastoma and some of the lymphomas; 3) physical examination; and 4) urinary examination. Second Year: $50,650 Project #30 - Continuing Education Program — University of Requested Maryland School of Dentistry. The University First Year of Maryland School of Dentistry requests $6,999 for one-year $6,999 interim funds to help support the school's continuing educa- tion program in its present form while they develop a new and expanded continuing education program within the School of Dentistry. The new program will be expanded from 26 continuing education courses to 31 courses and will cover most disciplines of dentistry. This proposal gives no indication of how this program will be developed. Plans are being developed for submission of a request for a project grant to support the expanded program. MARYLAND REGIONAL MEDICAL PROGRAM le RM 00044 7/70.1 HISTORY SUPPLEMENT LISTING OF CURRENT STATUS OF CORE & OPERATIONAL PROJECTS IN MARYLAND RMP A - FUNDED PROJECTS Project Amount Supported (D.C.} Number Title Through 2/28/71 Basic Carryover 00 Core Central Unit . $207,504 -- Johns Hopkins University 98,271 -- University of Maryland 123,751 -- State Health Dept. 34,011 -- Epidemiology & Statistical Unit 239,092 -- Clinical Cancer Program and Registry Feasibility Study (Peninsula General) 3,220 -- Continuing Education Feasibility Study (York Hospital) 17,946 -- a Cancer Feasibility Study (Easton ue Hospital & Johns Hopkins) 4,728 7,272 CORE TOTAL $728,523 $7,272 1 Continuing Educational Program for Peninsula General Hospital 17,550 -- 2 | Development and Evaluation of a Comprehensive Technical Screening Program for School-age Children of Low-income Families - University of Maryland 76,816 300 Early Detection of Cardiac and Malignant Disease in Pre-school Children - Mercy Hospital 24,173 4 A Program for Mass Detection of Heart Disease in School Children - Baltimore City Hospital 22,543 6 Early Detection of Heart Disease in the Newborn - Johns Hopkins 20,000 7 Coronary Care Programs A) Univ. of Maryland 79,700 B) Baltimore City Hospital 21,846 MARYLAND REGIONAL MEDICAL PROGRAM ~5- RM 00044 7/70.1 HISTORY SUPPLEMENT (Continued) Project Amount Supported (D.C.) Number Title Through 2/28/71 Basic Carryover 8 Closed Chest Cardiopulmonary Resuscitation - Maryland Heart Association 38,000 -- 9 A) Acute Stroke Unit - Hopkins 103,638 oo B) Chronic Stroke Unit - Baltimore City 121,031 58,790 Hospital 10 Acute, Intermediate and Long-term Stroke Care - York Hospital 145,596 “- 11 A) Proposal on Stroke - University of Maryland 138,819 -- B) Proposal on Stroke - Nursing Education - Univ. of Maryland 42,555 -- C) Proposal on Stroke - Rehab. Nursing - Montebello Hospital 61,714 -- 12 Proposed Coordinated Discharge Planning Program for Wicomico & Somerset Counties - Wicomico County Health Department 15,083 -- 13 Regional Medical Program for Outpatient Strokes - Deer's Head Hosp. - Salisbury -- 18,594 14 Demonstration and Training Program in Rehabilitation of Stroke Patients - Sinai Hospital 163,653 -- 16 An Ambulatory Program for Comprehensive Pulmonary Services - Maryland General Hosp. 90,000 -- 19 A) Tissue Typing - Baltimore City - Johns Hopkins -- 78,977 B) Tissue Typing - Univ. of Maryland 21,642 24,023 (Note: The Division is currently in the process of awarding an additional $20,358 for the first year of this project.) TOTALS $1,932,882 $187,656 GRAND TOTAL - BASIC AND CARRYOVER $2,120,538 DRMP 5/8/70 & ¥ - 4 La] -A Privileged Communication "SUMMARY OF REVIEW AND CONCLUSION OF ‘JUNE 1970 REVIEW COMMITTEE MARYLAND REGIONAL MEDICAL PROGRAM RM 00044 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL * General: The Review Committee recommended that this Supplemental Opera- tional Application (containing three individual projects and requesting $474,180 d.c.o. for a three-year program period) not be approved. Committee believed that action on Project #28 should be "non-approval ~ -revision required," and that action on Projects #29 and #30 should be "non-approval - no RMPS funding recommended." During the February/March 1970 review cycle, Committee and Council deferred action on this application containing three individual projects (see RM 00044 7/70.2) and recommended a site visit not only to study the projects but to review program development in Maryland since it received “operational funds. The Chairman of the site visit team reported to the Committee the team's findings, which indicated the team's strong feeling ‘that the "core" component needs a great deal of strengthening. For exam- ple, the rapid turnover of staff and especially coordinators in the . Maryland RMP was of major concern. Since January 1967, when the Region received its first planning award, there has been a total of four coordin- ators (two of these being the same individual) directing the program. The team learned that the present coordinator planned to resign effective June 30, 1970. Coupled with the concerns regarding core staff in the central unit, the “site visit chairman related the outcome of the team's mission to explore the intramural-extramural contribution made to the Region by the rather large cadres of experts supported, in whole or in part, out of RMP funds in the two medical schools and state health department. He went on to report that the team believed that to strengthen the core should ultimately lead to strengthening the Region. Therefore, the visitors recommended that the possibility that additional sums be made available to the new ~ coordinator, administratively, to strengthen the planning, direction and -- professional aspects of his immediate office be considered, It was estimated that perhaps an additional $150,000 would be required: in order to develop an effectively staffed central unit in addition to the realign~ ment of certain positions in the institutional cores. If the recommendations are approved, the central core staff budget would be increased to approximately $450,000 exclusive of approximately $240,000 which is allocated to the epidemiology and statistical center of Johns Hopkins. #} \ . Maryland RMP -2- RM 00044 7/70.1 Project #28 - Regional Oncology Affiliation Critique: The Committee was advised that this was a proposal stemming out of a feasibility study which developed an oncology affili- ation with the Easton Hospital on the Eastern Shore of Maryland, an institution affiliated with Johns Hopkins. The primary objective is to extend the affiliation to include other small hospitals as a means of “upgrading the knowledge of local practitioners. The Chairman of the site visit team reported that the site visitors viewed this as a highly service- oriented program, seeking funds for a program which should already be an ongoing part of the Johns Hopkins program. The visitors could see little structure to the educational aspects of the program. Some plans were set forth for periodic rounds, annual seminars and for having physicians visit Johns Hopkins Hospital. A tumor registry was proposed without adequate investigation of the role of the tumor registries throughout the country. No determination has been made of how the professional fees collected would ‘relate to this’ project. The Review Committee was in agree~_ ; ment with the site visitors in believing this to be an ‘almost: ‘purely service= oriented program; that it served no demonstration purposes; did not serve as a pilot project; or. have significant educational value. . The Review Committee adopted the recommendation of the site visit team that ‘this proposal not be approved ~ revision required. They felt that / any revision should be recast to show the strengthening of the affilia- tion and educational aspects of the program. In addition, any revision should contain concrete commitments that cooperating hospitals are actu- , ally willing to develop affiliations; and the budget should be more real- istically planned to defray the cost involved in the educational and . demonstrational aspects of the program, rather than in the service aspects of the program. _ Recommendation: Non-Approval Il (revision required). . Project #29 - A Cancer Detection Program in Children Critique: Again, the Chairman of the site visit team reported findings of the team about this project, the primary objective of which is. the early detection and diagnosis of malignancies during the first five years ‘of life. The proposal would establish a training program for physicians’ assistants to detect solid tumors by ‘abdominal palpatation and viewing of the reflex “of the retina in extraocular movements. Certain lab tests would also “be incorporated. Members of the Review Committee were concerned, as were the site visitors, with reference to: (1) the depth of the physician assistants’ ability to evaluate incidence; (2) the ability to maintain interest on the part of examiners who do such routine work; (3) why this service was not incorporated as a part of a general screening program; pO ‘ e Maryland RMP ~3- RM 00044 7/70.1 and (4) lack of concern as to. what would be done for the follow-up of detected cases, While the site visitors recommended that the proposal not be approved and that revision would be required, the Review Committee recommended non- approval with no RMP funding recommended. It was the opinion of Committee that the proposed activity be incorporated into one or several of the ongoing detection programs which are currently funded in the Region. Recommendation: Non-Approval I (no RMP funding recommended). -/Project #30 - Continuing Education Program, University of Maryland School of Dentistry Critique: The chairman of the site visit team reported to the. Committee that the proposers of this activity did not appear at the time of the site visit. The Review Committee noted that the application was in the form of a letter rather than in conventional form, and had insuf- ficient information upon which to make any judgment. . Recommendation: Non-Approval I (no RMP funds recommended). SUMMARY OF RECOMMENDATIONS Project Number '. Title ist Year 2nd Year 3rd Year #28 Regional Oncology Affiliation Non-Approval II (revision required) #29 A Cancer Detection Program Non-Approval I (no RMP funds recom- in Children mended) #30 Continuing Education Program, Non-Approval I (no RMP funds recom— University of Maryland School . mended) of Dentistry DRMP/GRB 7/13/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) MARYLAND REGIONAL MEDICAL PROGRAM RM 00044 7/70.2 550 North Broadway February 1970 Review Committee Baltimore, Maryland 21205 March 1970 Council June 1970 Review Committee PROGRAM COORDINATOR: William S. Peeples, M.D. Requested; lst Year 2nd Year 3rd_Year TOTAL Direct Costs: $317,430 $154,651 $173,165 $645 ,246 Indirect Costs: 24,237 25,325 26,447 76,099 TOTAL $341,667 $179,976 $199,612 $721,255 History; The Maryland Regional Medical Program began its planning in January 1967. Following a site visit and a keference Comnittee of Council, an award of $1,932,883 (d.c.o.) was made effective March 1, 1969 for the Region to support core activities ($724,360 d.c.o.) and operational projects ($1,208,533 d.c.o.). The activities supported during this first operational year in- clude the following. Direct costs only are noted. PROJECTS CORE $724,360 #1] = Continuing Educational Program for Peninsula General Hospital 17,550 #2 - Development and Evaluation of a Comprehensive Technical Screening Program for School-age Children of Low-income Families 83,000 #3 + Early Detection of Cardiac and Malignant Disease in Pre-school Children 28,173 4 - A Program for Mass Detection of Heart Disease in School Children , 24,448 #6 - Early Detection of Heart Disease in the Newborn 20,115 #7 - Coronary Care Program ~ Maryland University 78,000 Coronary Care Program - Baltimore City Hospitals 24,362 #8 = Closed Chest Cardiopulmonary Resuscitation 38,240 #9 ~- Acute Stroke Unit 113,210 Cnronic Stroke Unit 110,438 ~2- RM 00044 . 7/70.2 Requested First Year MARYLAND Regional Medical Program Projects (continued) #10 + Acute Intermediate and Long Term Stroke Care 146,412 #11 - Proposal on Stroke - University of Maryland 138,819 Proposal on Stroke ~ Rehabilitation Nursing 45,252 Proposal on Stroke - Nursing Education Program 32,995 #12 - Proposed Coordinated Discharge Planiing Program for Wicomico and Somerset Counties 16,579 #13 - Regional Medical Program for Outpatient Strokes 39,509 #14 - Demonstration and Training Program in the Rehabilitation of Stroke Patients 161,421 #16 - An Ambulatory Program for Comprehensive Pulmonary Services 90,000 TOTAL $1,932,883 Approved but unfunded projects include Project #19 and Project #22 which are to establish tissue typing laboratories. These projects will be combined to reflect a combined Tissue Typing Service, listed as Project #19. Requested First Year Project #25 - Comprehensive Stroke Program ~- Prince George's General Hospital. This proposal is for $209 704 the establishment of a "Stroke Center" at Prince George's General Hospital. It will include the development of a cardio- vascular unit which will incorporate the latest technology for diagnosis and treatment, including rehabilitation and home care. The six-bed unit is to be set up and equipped with electronic monitoring equipment. One of the immediate objectives is to evaluate the effectiveness of this equipment. In addition, a fourteen-bed rehabilitation unit will be located within a 100- bed extended care facility to serve when needed. A record system will be set up for purposes of follow-up and evaluation of the proposed program. The ultimate objectives are: 1) integration of the continying education of physicians and the specialized training of allied health personnel with a combination of evalua- tion activities to find the best methods of achieving the desired results and of demonstrating the most effective patient care; 2) reduction in costs of illnesses in which care is traditionally fragmented; and 3) preservation and restoration of the family. The educational facets of the proposal include: 1) training of personnel who are to be manning the stroke center; 2) dissemina- tion of information or methods of patient care to practicing physicians and paramedical personnel; 3) family education con- cerning care and rehabilitation of the patient; and 4) public education with regard to cardiovascular disease. Post-hospital care will be made available to patients by Prince George's County Health Department, which has submitted for this review, Project #26 - Stroke Rehabilitation Program in the Home and in the Prince George's County Health Department Rehabilitation Clinic. > \ - 3- MARYLAND Regional Medical Program RM 00044 7/70.2 Requested First Year The Stroke Committee will attempt to evaluate whether care ina stroke unit measurably affects the total recovery of the patient, reduces mortality or shortens the length of hospital stay. Data available through PAS will also be utilized and evaluated, as will the treatment patterns provided each stroke patient. The applicant does not specify how the program will be supported after the third year. Second Year: $56,911 Third Year: $71,390 Project #26 = Stroke Rehabilitation Program in the $62,751 Home and in the Prince George's County Health Department Rehabilitation Clinic. The main objective of this proposal is to provide a comprehensive regimen of post-hospital care for approximately 150 cerebrovascular patients of Prince George's County. This will be accom- plished by: 1) setting up a coordinated comprehensive home care program using physician consultants, public health nurses, physical therapists, social workers and homemakers, 2) providing rehabilitation services at the Health Department Rehabilitation Services Clinic. Intermediate objectives include: developing a coordinated program with Prince George's General Hospital to insure adequate liaison prior to discharge for cerebro- vascular patients treated there, stressing the restorative aspects of cerebrovascular disease with emphasis on family's responsibility to the patient and the need for continuity of care at the family and professional level, and informing the medical profession of the Health Department's role in follow-up care of the stroke patient in a home care program of rehabilitation. The Health Department will accept any patient referred to it by the private physician or the hospital if the potential for rehabil- jtation exists. Payments for home care services will be on a sliding scale basis, with no charge for indigent patients. No information is provided as to how income from the project will be used. A definitive evaluation of the stroke patient's progress will be made and recorded to provide statistical documentation of the effectiveness of early referral, treatment, and coordinated home care. Second Year: $53,265 Third Year: $55,800 Project #27 = Management of Intestinal Stomas. The $44,975 ultimate objective of this proposal is to improve the management of ileostomy and colostomy patients during preeperative, immediate posteperative, and during V0) ba nA dantmante Thie will he accomplished bv: 1) The ~ & «- ! MARYLAND Regional Medical Programs RM 00044 7/70.2 Requested First Year establishment of Ostomy Clinics throughout the Maryland region which will provide inpatient consultations by a medical team, including physicians, enterostomal therapists, and social workers. The team will respond to consultation requests and will observe differences, and compare results of approaches and choice of appliances. This aspect of the program will initially involve 3 or 4 hospitals in Baltimore and several outside the citv; 2) Professional and public education programs consisting of lectures and seminars held at neighboring hospitals for physicians, nurses and allied health personnel, and at Ostomy Clubs and other lav groups; 3) Training physicians, nurses and psychologists in the management of ileostomy and colostomy patients.; 4) Estahlishing sources of aid for the patient by means of regional Ostomy Clinics, Ostomy Clubs, and a system for consultations with community physicians and hospitals throughout the region; and 5) Evaluating the nature and extent of problems facing the ileostomy and colostomy patient from the point of view of epidemiology, psychologic adjustment, interpersonal relation- ships, physiologic response, postoperative recovery and appliance difficulties. The program will investigate the many problems facing the ileostomy/colostomy patient and will attempt to devise a means of evaluating the comparative benefits of consultations by the medical teams, enterostominal therapists and fellow ostomates. Second Year: $44,475 Third Year: $45,975 Review Committee Critique - February 25-25, 1970 GENERAL: The Committee recommended that this supplemental operational application for a three-year program period be partially funded at $135,425 (DCO) to support Project #27 in the time and amount requested; also, that action on Projects #25 and #26 be deferred pending a site visit. The last site visit to the Region was conducted on December 11-12, 1968, The Review Committee was concerned over the size of the Core Staff supported in the Maryland Region and with the obvious lack of intramural-extramural contribution by this cadre of experts to the preparation of the supplemental operational application. - 5 - MARYLAND Regional Medical Program RM 00044 7/70.2 Council - March 1970: The Council concurred with Review Committee's recommendation with the exception of Project #27. and asked that it be deferred also for a site visit. The Council asked that the site visitors further assess the merit of this project (#27) without the film component. They question the value of teaching films for these patients or for physicians and allied health personne! who work with them, principally tecause of the great variation in the physical and emotional characteristics of the individual patients and the great variety of surgical procedures resulting in the stoma. Site Visit: A site visit was made to this region on May 21-22, 1970, and a report will be available to the Review Committee. (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE MARYLAND REGIONAL MEDICAL PROGRAM RM 00044 7/70.2 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL Ceneral: The Review Committee recommended that this supplemental operational application, containing three individual projects and requesting $645,246 d.c.o., for a three-year program period, be partially funded at $385,425 - to support Project #25 in the time and for a lesser amount than requested (Project #26 is merged with Project #75) and to fund Project #27 in the time and amount requested. During the February/March 1970 review cycle, this entire application ‘then containing four individual projects) was reviewed with the following recommendations: Project #24 - Position of Director of Continuing Medical Education - Anne Arundel General Hospital - Nonapproval; return for revision. Project #25 - Comprehensive Stroke Program - Prince George's General Hospital - Deferral to include a site visit. Project #26 - Stroke Rehabilitation Program in the Home and in the Prince George's County Health Department Rehabilitation Clinic ~ Deferral to include a site visit. Project #27 - Management of Intestinal Stomas - Approval in time and amount requested by Committee - deferral to include a site visit by Council. The site visit was conducted on May 11-12, 1970. The Chairman of the team presented the findings to the Committee. Project #25 - Comprehensive Stroke Program - Prince George's General Hospital. and . Project #26 - Stroke Rehabilitation Program in the Home and in the Prince Ceorge's County Health Department Rehabilitation Clinic, Critique: The Chairman of the site visit team advised the Committee that because of the complementary purposes of these two proposals (plus the actual physical locations of the applicant agencies), the site visitors considered them as a single proposal. It was noted that the applications had been in the process of development for over two years. The overriding concern of the visitors was that the applicants had been given erroneous information and were not really aware of the general types of programs which Regional Medical Programs Service supports. According to the site visitors, this was a sincere and dedicated group of people who were deeply concerned that stroke patients in their area were not receiving adequate care, These proposals envision a complete stroke service, MARYLAND Regional Medical Program -2- RM 00044 7/70.2 the acute phase being handled in the general hospital while followup- rehabilitation service is to be handled in the County Health Department. Approximately 25 stroke cases are now handled annually. The applicants estimate that this total may be increased to 100 stroke cases per year, if these requests are approved and funded. The major weakness of the proposal was the lack of planning for the educational phase of the proposal. The Review Committee agreed with the site visitors that there was a need to fund this activity to some extent, This would serve two purposes. It would emphasize the momentum that has been gained as it pertains to regionaliza- tion and would avoid prejudicing this large group of people against any future RMP activities. Further, the Committee believed that this group was obviously not in a position to utilize all of the facilities that they requested and that some future planning activity (along with some demonstration activities) Were in order. It was believed that the emphasis at this time, should be on developing more adequate educational techniques and emphasizing the physical therapy care of the patient beyond the acute stroke phase, and its relationship to home care and home-care planning. In recommending approval, the Review Committee, in line with the recommenda- tions of the site visitors, believed that funding of this project should be mainly for personnel who could initiate the home-care phases, and for such additional professional time as may be necessary for more adequate planning of the educational phase. The Review Committee concurred with the specific direct cost funding recommendations of the site visit team which were: Prince George's County Health Department Personnel Full-time physical therapist . § 9,189 Full-time occupational therapist 9,189 Half-time secretary 2,700 4,800 Full-time homemaker ; TOTAL - PERSONNEL $25,878 Supplies 1,400 Consultant Services 500 Other (Mileage) 1,400 TOTAL - HEALTH DEPARTMENT $29,178 Prince Ceorge's General Hospital Personnel 10% time - Project Director 5,200 15% time - Physiatrist : 5,200 Full-time Rehabilitation nurse 10,400 TOTAL - HOSPITAL $20,800 FIRST YEAR TOTAL FOR COMBINED PROJECTS ~ $49,978 MARYLAND Regional Medical Program -3- RM 00044 7/70.2 Again, Committee followed the recommendation of the site visit team that support for the second and third years be increased to provide additional funds for personnel, if justified by the progress made during the first year. Recommendation: Approval for a three-year period in amounts as listed above. Direct Costs Only: ist Year nd Year 3rd Year $50,000 $100 ,G00 $100,000 Project #27 ~ Management of Intestinal Stomas. Critique: During the February/March 1970 review cycle, the Committee recommended approval of this project in time and amount requested, while the Council recommended deferral for review by members of the site visit team. Council's primary concern was the value of providing teaching filme for etoma patients or for physicians and allied health personnel who work with them, principally because of the great variation in the physical and emotional characteristics of the individual patients and the great variety of surgical procedures resulting in the stoma. The site visit team Chairman advised the Committee that the team's miseion was believed to be fact finding rather than review of the concepts of thia proposal. Questions were raised with reference to producing films, phasing out the project, and the establishment of a registry. The site visitors were advised that: 1) The registry has been deleted. 2) Phasing out ie entirely conceivable, with the cost of this service to be included as a legitimate hospital cost, Clirics of thie type are a recognized part of hospital services. Funds requested in this proposal would be in reference to the educational agpects but this could be done incidental to the training of additional technicians and, therefore, the project would be self-supporting after the withdrawal of RMP funds. 3) The project proposers made a strong case for the support of filme which they felt would be the heart of the program. While the applicant agreed that some material is presently available from medical supply houses and device manufacturers, the films ete. were considered biased toward the preduct of the individual concern. Plans in this proposal include development of suitable films for showing to patients, both pre- operatively and postoperatively. They also plan films which would be instructional for physicians. The Chairman emphasized the applicant's statement that the films were not te be used out of context. Rather the films are to be used to refresh and reinforce the instructions provided in person by the physician, therapist, and technician, The Review Committee was further advised that an additional film is planned, aimed at teaching physicians some of the principles required of them in dealing with patients. Again, this is thought to be less technical and simply reinforcing to physicians of their role in the prepa-~ ration of patients and in the support of patients following such procedures. MARYLAND Regional Medical Program -4- RM 00044 7/70.2 Committee noted the low costs of the films when compared to the usual costs of production. In recommending approval, the Committee concurred with the site visit team that this is a legitimate request which should be supported in the time and amount requested. Recommendation: Approval in the time and amount requested. ‘Direct Costs Only: lst Year 2nd Year 3rd Year $44,975 $44,475 $45,975 SUMMARY OF RECOMMENDATIONS ‘ Project Number Title lst Year Ind Year 3rd Year 95-26 Comprehensive Stroke Program ~ $50,000 $100,000 $100,000 Prince George's General Hospital and County Health Department 27 Management of Intestinal Stomas 44,975 44,475 45,975 TOTALS - $94,975 $144,475 $145,975 Year Total Direct Costs 01) $ 94,975 02) 144,475 03) 145 975 $385,425 DRMP/GRB 7/13/70 © SITE VISIT REPORT 4 A PRIVILEGED COMMUNICATION RM 00044 MARYLAND REGIONAL MEDICAL PROGRAM May 11-12, 1970 LIST OF PERSONS ATTENDING THE TWO-DAY MEETING , BY MAJOR AFFILIATION SITE VISITORS Philip T. White, M.D. (Chairman), Member of RMPS Review Committee Professor and Chairman, Department of Neurology Marquette University School of Medicine ‘Milwaukee, Wisconsin J. Gordon Barrow, M.D. Program Director, Georgia Regional Medical Program Medical Association of Georgia 938 Peachtree Street Atlanta, Ceorgia William A. DeMaria, M.D. Assistant Dean, Continuing Medical Education Duke University School of Medicine Durham, North Carolina STAFF , REGIONAL MEDICAL PROGRAMS SERVICE Mr. Robert Jones, Acting Chief, Programs Assistance Branch Mr. Joseph Jewell, Public Health Advisor, Grants Review Branch Mrs. Lorraine Kyttle, Staff Assistant, Grants Review Branch MARYLAND REGIONAL MEDICAL PROGRAM CORE STAFFS A. Central Unit William Peeples, M.D., Coordinator Mr. Richard Metzinger, Business Manager Louis Heliman, Sc.D., Associate Coordinator for Evaluation Mr. Vern McMurrin B. Johns Hopkins Administrative Unit Edward Stafford, M.D., Associate Coordinator J.D. Allred, Ph.D., Associate Coordinator for Medical Education (Audiovisual) B.E. Strem, Ph.D., Assistant Coordinator for Continuing Education C. University of Maryland Administrative Unit Morton I. Rapoport, M.D., Associate Coordinator Mr. Richard Peters, Assistant Coordinator for Administration William Spicer, M.D. *Robert Evans, M.D. *Dual listing MARYLAND RMP Site Visit -~ 2 - MARYLAND REGIONAL MEDICAL PROGRAM CORE STAFFS (Continued) D. Maryland State Department of Health Administrative Unit Perry Stearns, M.D., Associate Coordinator *Edward Davens, M.D. E, Epidemiology and Statistical Unit Abraham Lilienfeld, M.D., Director : Maureen Henderson, M.D., Associate Director REGIONAL ADVISORY GROUP © Mr. M. Shakman Katz, Chairman Alexander Dowling, M.D., Member Edith Schoenrich, M.D., Member COMMITTEES IN MARYLAND REGIONAL MEDICAL PROGRAM A. Administrative John Moxley 3rd, M.D. - Dean, University of Maryland David Rogers, M.D. - Dean, Johns Hopkins University B. Continuing Education *Robert Evans, M.D., Chairman C. Heart Disease Leonard Scherlis, M.D., Chairman, University of Maryland Catherine Neill, M.D. Jerry Salan, M.D. Raymond Hepner, M.D. D. Cancer Morris Wisenberg, M.D. E. Renal Edward Hinman, M.D. F. Stroke A. Earl Walker, M.D., Chairman G. Pulmonary *Edward Davens, M.D. *Dual listing RM 00044 MARYLAND RMP Site Visit -3- RM 00044 OPERATIONAL PROJECTS (Ongoing) Erland Nelson, M.D., Stroke Project Director, University of Maryland Mrs. Ann Harvey, R.N., Stroke Project, University of Maryland Thomas Price, M.D., Stroke Project, University of Maryland John Gessner, M.D., Stroke Project Director, Montebello State Hospital OPERATIONAL PROPOSALS (Deferred pending site visit) A. #25 and #26 - Comprehensive Stroke Program ~ Prince George's County , General Hospital and Health Department Ruth Jacoby, M.D. Benjamin Strickland, M.D. Doctors Steinman and Stazio Messrs. Parker, Robards and Penn Mrs. Devlin, R.P.T. B. #27 - Management of Intestinal Stomas Marvin Shuster, M.D. Mrs. Charlotte Blackman, Enterostomal Therapist NEW SUPPLEMENTAL OPERATIONAL PROPOSALS (To be considered during June/July 1970 review cycle) © A, #28 - Regional Oncology Affiliation Raymond Lenhard Jr., M.D. B. #29 - Cancer Detection Program in Children William Zinkham, M.D. MARYLAND RMP Site Visit ~G- RM 00044 Purposes of the Site Visit. “This site visit served a dual purpose. Staff, during its February 9, 1970 review of the non- competing continuation application (Type Vv), made the following recommendation to the Deputy Director: "-- that a program site visit be scheduled in early June 1970, with a member of Committee, of Council, and of RMPS Staff, to explore the interrelationships of the Core staffs with projects, as well as the degree of coordination among the various Core components ---,'"' This recommendation and the other recommendations made during the review, were accepted by the Deputy Director on February 20, 1970. During the February/March 1970 review of a supplemental operational application which requested support for four new operational proposals, the reviewers expressed concern over the size of the Core staffs supported in the Maryland Region and the obvious lack of intramural-extramural contribution by this cadre of experts to the preparation of all the supplemental operational applications submitted by this Region to date. The March 1970 Council recommended that a site visit be conducted on the four proposals (three of which were deferred pending the visit, while the remaining proposal was recommended for "nonapproval - revision required"). In addition, the site visit would provide opportunity for both Staff and a Committee member to seek information relative to the viability of the Region. The last site visit (preoperational) to the Region was conducted during December 1968. Background of Maryland RMP. The Maryland Regional Medical Program encompasses the State of Maryland (with the exception of Montgomery County, which is one of the large counties adjacent to the District of Columbia), and includes York County, Pennsylvania. Approximately three and one-half million people live within the Region's 9,874 square miles. 73% of the population is considered urban and 83% Caucasian. The Region contains two large medical schools ~- Johns Hopkins University School of Medicine (enroliment 350) and the University of Maryland School of Medicine (enrollment 367). There are 13 schools of nursing, two of which are university based. As of 1965, there was a total of 86 hospitals with 33,366 beds - 18,796 of which are nonfederal, long-term. Also, during 1965 there were 5,450 medical doctors, 2,946 of whom were in private practice. The Region has 20 osteopathic physicians. One of the overriding concerns of Staff and the review groups has been the rapid turnover of coordinators within the Region. During January 1967 the Region received its first planning award - Coordinator, William J. Peeples ,M.D. During March 1967, Thomas Turner, M.D. was appointed as Program Coordinator. During January 1968, William S. Spicer, M.D. was appointed as Acting Coordinator of Maryland RMP. Following this, during November 1969, William J. Peeples, M.D. was again appointed as Coordinator. MARYLAND RMP Site Visit -5- RM 00044 position was soon to become vacant again. This was privately confirmed by the present coordinator to two of the professional site visitors. Then too, the deans of the medical schools alluded to an imminent change in program directorship. @:: the time of the site visit it was alleged that the coordinator's Regional Advisory Group and Committees. The Maryland Regional Advisory Group is composed of 27 members (18 M.D.s) and, of this total, only two members are considered to be from outside the Metropolitan Baltimore area. Two members of the group are black. The chairman is Mr. M. Shakman Katz. The Region may be considered a bit unusual in that this group meets ten times per year instead of quarterly. In spite of the frequent meetings, it was reported to the site visitors that an average of 17 members present is normal for each meeting. The chairman also advised the team that, in general, the Regional Advisory Group reviewed only those applications which were positive from other review committees within the Region. There are plans to expand the membership of the RAG - from the present 27 members to 33 voting members. When this new organization is effected, one-third of the membership shall be terminated each year. Membership to the RAG may be nominated by the RAG or the coordinator, subject to approval by the Administrative Committee. Administrative Committee. This committee is composed of the following ex officio members: Deans of the two medical schools; Commissioner of Health; Dean, Johns Hopkins School of Hygiene; Coordinator of RMP; and Chairman of the RAG (without vote). The functions of the committee are to: 1) appoint the coordinator; 2) make final decisions on all administrative matters; 3) appoint members of RAG; and 4) establish policy for administrative operation. Other Committees. The Region has seven Categorical Committees: Heart, Stroke, Cancer, Epidemiology and Statistics, Continuing Education, Kidney, and Pulmonary. Site Visit Team Findings. The site visit team requested that the agenda begin with discussions of the committee structure, administrative channels, the review process, and a program overview by the Central core, the institutional Associate Coordinators and the committee chairmen. Dr. Peeples opened the meeting with a presentation of the committee structure and its relationship to the central staff. MARYLAND RMP Site Visit -6- RM 00044 It was the consensus of the site visitors that the Regional Medical Program in Maryland had evolved and grown largely through the strengths that pre- existed in the two medical schools. Even though the arrangement accounted for a several-horned structure including the central Core, the two medical schools, an Epidemiology and Statistics Unit and the State Health Department Unit, the real strengths still lie in the two medical schools. This was emphasized by the role of the Administrative Committee (whose membership included the two deans), the Categorical Committee (the membership of which was. | largely composed of the two medical school faculties), the emphasis on con- tinuing education (which was really a prolongation of a preexisting relation- ship between Dr. Evans, Chairman, Continuing Education Committee, and the University of Maryland), and the relatively passive role of the Regional Advisory Group (which tends to accept the decisions. and the judgments of the Administrative Committee and the Categorical Committees.) It immediately became apparent that there are too few full-time people on the central Core staff and that they have found it difficult to guide or counteract the strengths of the schools. It was the feeling of the site visitors that a definite effort should be made to strengthen the central Core, not in an attempt to subjugate the schools per se or to destroy their roles in the creation of more programs, but to help give the schools directions which may be something other than the traditional ones the schools usually take. Some recognition of this apparent ly existed on the part of the Region. Mr, Katz, the Chairman of the Regional Advisory Group, expressed a recognition of the fact that this group needed to be enlarged to give additional repre- sentation to non-Baltimore-oriented members and to minority groups. He further recognized that the programs and projects of the Region to date had largely grown through preexisting interests and activities in the medical school, and had taken steps to appoint a hopefully active committee on planning and to establish a system of priorities. Further, each of the categorical committees had recognized the need for additional planning and were creating subcommittees. It was somewhat distressing to note that there was apparently no recognition of the need for the various subcommittees of the categorical committees to relate in some way to the Planning and Priority Committee of the Regional Advisory Group. The team also recognized that the associate coordinators at Hopkins and University of Maryland (whose time or effort and corresponding RMP salary is listed in the budget as 50% and 85% respectively) have a tendency to identify with the medical schools with whom they have an academic affiliation, rather than with the Regional Medical Program office. In view of this the site visitors would recommend, in addition to strengthening the staffing of the central Core, that the medical school associate coordinators have full-time appointments as Regional Medical Program employees. This recommendation is viewed as a necessary administrative adjustment so that the institutional core staffs would clearly relate to a central core Regional Medical Program associ- ate coordinator. Emphasis should be made here that minority groups do not seem to be represented, not only on the Regional Advisory Group, but within the administrative central structure of the Regional Medical Program. MARYLAND RMP Site Visit -T- RM 00044 There was also concern expressed about the avenues that had been established for the various associate coordinators, and assistant coordinators meeting from time to time to discuss mutual regional problems and concerns. Formal commmications have been established but there was some confusion as to how frequently these meetings are held. Dr. Hellman, Associate Coordinator for Evaluation-Central Staff, discussed some of the efforts he was making as a representative of Core staff to encourage community participation and regionalization. He discussed the efforts that were being made to hold seminars in reference to home care programs. He pointed out that he had jaunted through the Region at least once during his employment with RMP. He apparently had visited somewhere around 30-plus out of a possible 40-plus hospitals (with 100 beds or over) that exist in the State. It was not quite certain whom he had contacted or what had been accomplished by these meetings. He was making a sincere effort to acquaint them with the Regional Medical Program and its role. He was more than willing to agree that his efforts had been somewhat limited and. that probably more concerted effort was needed along these lines. At this point it was discussed by the site visitors whether or not there might be a need for some type of subregionalization, the appointment of area coordinators, or some other mechanism which would help develop closer relationships with communities, physicians, the public, and hospitals rather than just itinerant travelling. Questions were asked as to what relationships had been established with other health agencies. Little was offered except that not too close a relationship with Comprehensive Health Planning existed except possibly in reference to data collection. Apparently community health planners are cognizant of Dr. Lilienfeld and Dr. Henderson's expertise along these lines and are perfectly willing to cooperate in this regard. The visitors were advised that the development of interlocking efforts with CHP were difficult to establish because of the relatively weak CHP structure in this region. Dr. Stearns presented the viewpoint of the State Health Department as a part-time coordinator assigned to that department. (The budget for the upcoming year requests a 100% State Health Department Coordinator.) He emphasized that the State Health Department's concerns had been in reference to the involvement of small hospitals in the development of preventive programs. Dr. Hellman's efforts in this area apparently were reinforcing to Dr. Stearns' role because other priorities had been placed on Dr. Stearns' time by the Health Department. Dr. Stearns commented that he had acted as "yeferee" early in the course of the development of this program, injecting himself between the two medical schools but that this seemed to be abating as time passed. He seemed to indicate that there was now a greater atmosphere of cooperation and acceptance between the two schools. Dr. Stafford represented the viewpoints of the associate coordinator for Johns Hopkins University. He reaffirmed that there were discourses occurring between the two medical schools and their respective associate coordinators. His comments were reinforced by those of Dr. Strem, (Assistant Coordinator for Continuing Education), a full-time employee of Regional Medical Programs assigned to Johns Hopkins. Dr. Strem emphasized the activities that were MARYLAND RMP Site Visit -8- RM 00044 ongoing on the part of Hopkins to create an atmosphere of learning and education at community hospitals and their complete agreement to cooperate with the development of directors of continuing education in an atmosphere which would enhance education. Dr. Strem has been active in establishing seminars to teach how to teach, ~ in establishment of guidelines for educators; in the establishment of guidelines for library resources; in helping local hospital libraries to assess their resources and services. Further reinforcement was added by Dr. Allred, (Assistant Coordinator (50%), Hopkins, an expert in the field of audiovisual assistance, who emphasized that they were holding continuing workshops on the utilization of audiovisual materials and of their instructional technology. The visitors were impressed with this man's sincerity and his efforts to reach out into many areas of the Region, lending his expertise freely and openly. Dr. Allred commented that he was working with Dr. Neill in developing self- instructional materials in conjunction with Project #6 on the Mass Detection of Heart Disease in the Newborn. He, too, is working closely with local libraries to help them develop their resources and teaching aids. The University of Maryland Unit was represented by Dr. Rapoport, Associate Coordinator, reaffirming that affiliations do exist, particularly in the €ield of continuing education. Dr. Spicer, former RMP coordinator and recently appointed Associate Dean for Health Care Programs, University of Maryland, emphasized the commitment that was made by the University of Maryland to ¢ccvelop a truly reasonable health care system incorporating outreaching into the community both from a standpoint of health care and educational systems, and that he envisioned the Regional Medical Programs as having a significant role to play in this regard. As a part of this, plans were envisioned whereby medical students could actually obtain part of their training and teaching at the community hospitals. Hopefully, this might add ramifications for the future. Dr. Spicer reaffirmed that in essence they were trying to develop a more appropriate system for the delivery of care and education, utilizing communities and community hospitals and practitioners, and that there was no primary concern whether the relationships were with Johns Hopkins University or the University of Maryland. Dr. Robert Evans, (Chairman, Continuing Education Committee), outlined the experiences at York, Pennsylvania Hospital and indicated he was convinced that community education programs were of value as measured by changes in the medical structure in York, as measured by there being more doctors who were better educated and who were more active. It was his feeling that health care had been improved thereby. He further felt that this could serve as a model for regionalization throughout Maryland. Dr. Evans then continued as a representative of the Region's Committee on Continuing Education. He affirmed that their view on continuing education was closely :related to an emphasis on peer review, medical audits, self-review and thereby the identification of needs for further education and training. MARYLAND KMP-Site Visit -9- RM 00044 A report was made by the Epidemiology and Statistics Committee. It should be recognized that Dr. Lilienfeld and Dr. Henderson are an integral part of the Epidemiology and Statistics Center at Johns Hopkins. - The Committee therefore functions by advising itself. They have also recognized that they now must begin functioning in the evaluation of the region's projects. Currently, they review each of the projects submitted in reference to methodology, budget, etc. In addition, they will, in the very near future at least, begin functioning by structuring evaluation procedures which are to be built into each project. They indicated that they will now write out a detailed method of evaluation for the consideration of each project director. However, both physicians expressed the concern that there is still a lack of certain data in the Region which, if available, would help them create realistic evaluation procedures. Dr. Lilienfeld indicated that they were now on the verge of being able to demonstrate some of the characteristics of the Region based on the data that they were accumulating from hospitals, nursing homes, outpatient facilities and that the obtaining of the data would assist them to establish a baseline of regional characteristics and a further base for the establishment of evalu- ation procedures. Dr. Lilienfeld stated that they recognize the need to re- evaluate periodically to identify changes in disease, interpersonal relation- ships, care availability, etc. They hoped that this would eventually lead to their being able to identify that the Regional Medical Programs had had an impact on this Region. The Epidemiology and Statistical Unit has encountered certain delays in the development of their program due to the shortage of qualified people. A point was made here that funding uncertainties of the Regional Medical Program appeared to have hurt their recruiting efforts. The team was somewhat concerned as to the amount of monetary support required for this sort of activity. ($239,000 direct costs are budgeted for this activity in the current year.) It was clearly recognized, however, that there were sources of expertise here which did not exist in may areas of the country. Further, these individuals were capable of training others to really accumulate and collate very reliable data. It was agreed that these people are on the verge of making some significant statements with reference to incidence of prevalence of disease, health care patterns, etc. Further, it should also be viewed that this is probably not just purely local data but some of the infor- mation gathered would be pertinent to many Regions throughout the country. The team believed that this is more than just a simple data collecting center. They recognize the need for studying relationships between hospitals, physicians, individuals, medical students and all persons involved in the delivery of health care. Dr. Earl Walker reported as Chairman of the Stroke Committee. He gave a progress report on the various stroke projects that were ongoing. He related that the Deer's Head project for outpatient rehabilitation was under way and had picked up in activity since the end of the year. The program at the Johns Hopkins Hospital and the Baltimore City Hospital had not been initiated because of difficulties in the recruitment of appropriate personnel as well as remodeling of areas. The Peninsula General Hospital program was not completely staffed and had been recommended for continuation without additional funds. The MARYLAND RMP Site Visit _ -10- RM 00044 program at the Sinai Hospital was well under way with a number of patients having been reviewed, treated and incorporated into fairly active teaching programs. The program at York Hospital was well under way with 323 patients having been monitored and 232 of these fitting into the stroke category. Some early data from this study suggested that there was a higher than expected re- lationship between the stroke patient and cardiac conditions,namely arrhythmias. Dr. Walker then spoke of the program at the University of Maryland indicating that a fairly active outpatient program had been initiated but that the in- patient program was still awaiting the completion of purchase of equipment and renovations. The related program at Montebello State Hospital was active, both in the care of patients and in the sphere of training of nurse students in rehabilitation techniques. They have also begun to recognize the need for admitting relatively acute but fairly stable strokes to the rehabilitation ¥ program early. | Mrs. Anne Harvey, R.N., related the progress that has been made in holding nurse workshops. The site visitors were concerned after this review because while some of these projects were showing reasonably satisfactory progress, there seemed to be little concern on the part of the committee for developing interrelationships between these various programs as, for example, in the exchange of personnel or the training of personnel groups which might be applicable to one of the other programs. The Heart Program Committee activities were presented by Dr. Leonard Scherlis. The site visitors felt a similar concern that while a number of fairly worth- while projects were ongoing, there again appeared to be little interplay we! between them. Dr. Hepner reported on the progress of the phonocardioscan programs. It was recognized by him that this was only a minor part of the program and that screening programs of this sort should in reality tend to the uncovering of a multitude of diseases rather than just simply an emphasis on phonocardio scanning. He did indicate that about 3,000 children had been scanned so far with more disease being found than they had anticipated. The site visitors were advised that the Heart Disease in the Newborn Project which is apparently not entirely operational appears to be moving along reasonably satisfactorily. Dr. Scherlis reported on the progress that had been made in the cardiopulmonary resuscitation program. He reemphasized his concerns as to the absence of a suitable vehicle for transporting the educational apparatus from site to site. Staff had recommended that no funds be spent for either rental or purchase of a car. He asked that this be given serious reconsideration. Some of the site visitors felt that there might be some merit in his request for such a vehicle. The site visitors would not feel averse to approving purchase or rental of a vehicle if no additional funds are needed beyond those which are already budgeted. Dr. Scherlis then reported on the progress of the coronary care unit programs. This appears to be a rather traditional educational program for nurses and physicians that did not significantly differ from a number of programs in a number of other Regions. MAKYLANU nme Site visit ~1L- net YUU The next report was by Dr. Wisenberg in reference to the activities of the Cancer Committee. They apparently have identified four areas of concern which: 1) related to the establishment of a registry; 2) to the creation of a network of clinics with appropriate affiliations with medical centers; 3) development of a regional blood bank system; and 4) the establishment of a community uterine cancer control program. It was noted that this latter program was probably going to be picked up by the State Board of Health. He indicated that the Cancer Committee had been the last to submit projects but that some were now being submitted and considered. Pulmonary disease activities were elaborated by Dr. Davens. He felt that the. committe had been active in identifying the scope of the problem and the utter lack of facilities to deal with it within the Region. He indicated that this was a disease category of increasing proportions, currently accounting for the fourth greatest number of deaths in the State of Maryland. The committee's goals had been identified as: 1) creating adequate ambulatory care facilities; and 2) developing adequate prevention programs. Dr. Davens further reported that it was the feeling of the committee that Dr. Spicer's project, Ambulatory Progran. for Comprehensive Pulmonary Services, was progressing properly and was beginning to demonstrate the need for more attention to chronic pulmonary diseases. Dr. Davens further commented on the educational programs that were being carried out in the public school system. He felt that these were beginning to bear fruit in the sense that the youngsters were becoming more concerned about the incidence of smoking. They, hopefully, were also going to become more community-conscious and be more demanding of their elders in the development of anti-pollution programs. Dr. Hinman reviewed the activities of the Renal Committee. He indicated that the major efforts to this point had been directed toward identifying the needs for a more active transplant program, for the development of more adequate home dialysis facilities, and for establishing a program for detection and prevention of the disease in its reversible state. He indicated that no projects were ongoing at the present time but that a major grant request was in preparation, related to the training of personnel and the development of more adequate dialysis resources. Dr. Hinman made a point of stating that he felt this committee had been instrumental in engendering cooperation between the institutions. Dean Rogers and Dean Moxley reassured the site visitors that there was a good deal of desire on the part of each of them to regionalize the schools and their activities, and they viewed the Regional Medical Programs as being a significant instrument which could foster this. They assured the team that there was a good working relationship between the two schools; that mistakes had been made in the past and that they hoped to correct these so that pro- grams will not be duplicated but can interdigitate in a more meaningful fashion. They make a sincere effort to function well as part of the Administrative Committee. The Deans believe the Administrative Committee to be a decision~- making body which helped to resolve conflicts and make certain administrative MARYLAND RMP Site Visit -12- " RM 00044 decisions but which really did not bear on the policies, programs or projects of the Regional Medical. Program. They, for example, do have an instrumental voice in the creation of search committees for new coordinators, and, apparently, they have recognized the need for the creation of such a search committee at this time - anticipating a new coordinator in July 1970. Dr. Moxley made an interesting comment that upon his arrival in Maryland he did not view Regional Medical Programs with any great degree of enthusiasm but that since being in this area, he had recognized the role such programs | could play and how this could really strengthen and complement medical school programs. They did emphasize, however, that as far as they were concerned, ' Regional Medical Programs was not a medical school program per se but a parallel program of equal strength and one with which they could work without conflict. Since this Regional Medical Program was originally funded in January 1967 there has been a fairly rapid turnover of coordinators and central Core staff. Information developed during this visit suggests there will be further turnover not only of the coordinator but of some of the central staff and assistant coordinators as well. The turnover may not be entirely without benefit. Some egregious planning and fragmented operations of the past might be forestalled through personal consultation between the Acting Director of RMPS and the new administration of this region. The site visitors would recommend that concerted efforts be made to strengthen the central Core of this program and that the new Coordinator have the opportu- nity to discuss with the Acting Director, RMPS, the possibility that additional sums could be made available to hin, administratively, to strengthen the planning, direction and professional services aspects of his immediate office. {it is estimated that perhaps an.additional $150,000 would be required in order to develop an effectively staffed central unit in addition to the realignment of certain positions in the institutional cores and the rebudgeting of approxi- mately $40,000 from the institutional cores(where it ig currently budgeted) to the central Core (for vacant positions). These recommendations, the visitors calculate, would resuit in a central Core staff budget of approximately $450,000 (exclusive of the Epidemiology and Statistical Unit.}, Although the. "Core" seems to be supported by a rather sizeable budget, a fair proportion of it is dedicated to the Epidemiology and Statistical Center ($239,092 direct costs) for the support of approximately 30 positions almost all of which are full-time people who are presently on board. Site Visit Team's Review of Proposals Reviewed During February/March 1970 Review Cycle. Project #24 - Position of Director of Continuing Medical Education ~ Anne Arundel General Hospital. This proposal was reviewed and recommended for nonapproval - return for revision. It was not considered during this site visit. Projects #25 and #26 - #25 - Comprehensive Stroke Program, Prince Ceorge's General Hospital; #26 - Stroke Rehabilitation Program in the Home and in the Prince Ceorge's County Health Department Rehabilitation Clinic. These two proposals were recommended for deferral MARYLAND RMP Site Visit ~ 13 - RM 00044 to include a site visit. Because of their complementary purpose (plus the actual physical locations of the applicant agencies), the site visitors considered them as a single proposal. Quite a delegation from both the Prince Ceorge's County Hospital and the Health Department met with the site visitors. The general characteristics of the Region suggest that this is a principal hospital for Prince Ceorge's County. According to the applicant, somewhere between 75%-80% of the County physicians are affiliated with this hospital. The hospital has a full-time house staff, incorporating ten surgical residents, six medical residents, four OBCYN residents, three orthopedic residents, and fourteen interns. Some of these are assigned to the neurosurgical service from time to time. Only one of this staff is not a foreign graduate. The administration of the hospital seemed capable. There is an apparent recognition on the administration's part of a need to upgrade the institutions. They apparently had been misdirected in their request for equipment, thinking that direct support for equipment was available from RMP. It was obvious after talking to the delegation that this was a sincere and dedicated group of people who were deeply concerned that stroke patients in their area were not receiving adequate care. They had envisioned this project as one which would help demonstrate to the physicians of that area what could be done for stroke patients, given adequate facilities and adequate knowledge. They had even gone ahead on their own to start some initiation of the project. They had sent a nurse to Dr. Rusk for special rehabilitation training. Also, they had sent an x-ray technician to a hospital in the District of Columbia for training in appropriate x-ray techniques. The visitors were advised that the hospital has already purchased $150,000 worth of special equipment. In addition, they have hired a full-time physiatrist and apparently made some physical changes in the hospital so as to give him suitable space. An extended-care facility is, or will soon be, open and will have space dedicated to stroke patients. (An explanation is in order, and that is that these applicants had not been given adequate guidance or instructions as to the preparation of a project request and were not aware of the general types of programs which Regional Medical Programs Service supports. The team interjected at this point that this simply reaffirms the strong feeling that the "Core" in the Maryland Regional Medical Program needs a great deal of strengthening. This type of project should not have been presented to site visitors in its present form.) Dr. Eenjamin Strickland and Mrs. Devlin, R.P.T., represented the County Health Department's program in home care. They viewed this as 4 continuation of the acute stroke program and, in reality, would like to look upon the two projects as one. Mrs. Devlin and Dr. Steinman had already developed communication channels and were holding planning conferences so that strokes dismissed from the Prince Ceorge's Hospital MARYLAND RMP Site Visit - 14 - RM 00044 were assured of ongoing care. Mrs. Devlin estimated that in the last year approximately 25 such strokes had been referred to the Health Department, and they were anticipating that additional referrals would be made. They would like to plan on handling approximately 100 referrals per year. In discussing the educational aspects of the program, it became apparent that the proposers had not really given thought as to concrete methods to be used in education. They had felt that simply having a demonstration project would acquaint the physicians and nurses and technicians in the hospitals with the value of such methods. They had a vague concept that monthly meetings would be held and seminars presented. No actually well- constructed program had evolved, however, in reference to physicians, nurses, or allied health people. Nevertheless, the proposers did recognize this as their responsibility and indicated their willingness to develop a more formal and well-constructed stroke teaching program in conjunction with this project. The site visitors were impressed with the sincerity of this group. They were also impressed by the fact that these people had been working on this project for well over two years and,as a result of being misinformed, had gone through a number of revisions and were on the verge of becoming somewhat discouraged. The administrative personnel of the hospital made a sincere plea to give them some directions and, hopefully, some funds to get this project at least partially started. In the discussions that followed in reference to their request for equipment, it was apparent that they had misunderstood what kind of funding was available through RMP. When some clarification of this was forthcoming, they indicated that they might well be able fo find the funds elsewhere for the purchase of at least high-priority equipment items necessary to this project. In reviewing this project after the meeting, the site visitors were impressed with the need for funding this to some extent, to emphasize the regionalization, and to avoid prejudicing this particular group of people against any future RMP activities. The site visitors felt that this group was obviously not in a position to utilize all of the facilities that they requested and that some further planning activity, along with some demonstration activities, were in order, It was believed that the emphasis, therefore, at this time should be on developing more adequate educational techniques and emphasizing the physical therapy care of the patient beyond the acute stroke phase, and its relationship to home care and home care planning. Therefore, the team's recommendations are that funding of this project should be mainly for personnel which could initiate the home care phases, and such additional professional time as might be necessary for more adequately planning the educational phases. Along with this, the team - 15 - RM 00044 eo" RMP Site Visit uld be necessary for certain supplies, consultants, believed that support wo and travel. Therefore, the recommended first-year budget would be at the level of $50,000. In arriving at this total, the team recommended the following specific line items: Prince Ceorge's County Health Department Personnel ‘ Full-time Physical Therapist - $ 9,189 , Full-time Occupational Therapist - 9,189 . Half-time Secretary - 2,700 Full-time Homemaker - 4,800 TOTAL - PERSONNEL $25 ,878 $25,878 Supplies 1,400 1,400 Consultant Services 500 500 Other (Mileage) 1,400 1,400 TOTAL - HEALTH DEPARTMENT $29,178 Prince George's General Hospital Personnel 10% Time - Project Director ~ § 5,200 15% Time - Physiatrist - 5,200 ' Byll-time Rehabilitation Nurse < 10,400 ; TOTAL - HOSPITAL $20,800 $20,800 —_——— © FIRST-YEAR TOTAL FOR COMBINED PROJECTS . $49,978 The site visit team also recommended that support be given for the second and third years, with additional funds for personnel, as justified by the progress made during the first year. This should be no more than twice the amount authorized for the first year. Project #27 - Management of Intestinal Stomas. Although the February 1970 Review Committee recommended approval of this project in time and amount requested, the March 1970 Council recommended deferral for review by members of the site visit team. Members of Council asked that the site visitors further assess the merit of this project without the film component.. They questioned the value of teaching films for stoma patients or for physicians and allied health personnel who work with them, principally because of the great variation in the physical and emotional characteristics of the individual patients and the great variety of surgical procedures resulting in the stoma. A brief review was held as to the nature of the project in general. was not gone into in depth inasmuch as the Review Committee and Council had both approved the general concept, and the only questions raised were in reference to producing films, phasing out the project and establishing a registry. In reverse order, it should be commented that establishment of a registry has been deleted. This MARYLAND RMP Site Visit - 16 - RM 00044 The team was assured that phasing out is entirely conceivable and that the costs for this program can be considered a legitimate hospital cost. Apparently, clinics of this sort are a recognized part of hospital services, and technicians of this sort are legitimate employees of such clinics. The initial cost would be in reference to the educational aspects but this could be done incidental to the training of such additional technicians and, therefore, the project would be self-supporting after the withdrawal of RMP funds. The project directors felt that films were at the heart of their program. They have planned on developing films which would be suitable for showing to patients, both preoperatively and postoperatively. They were also planning films that would be instructional to physicians in the area, It should be emphasized that the films ate not to be used out of context and will only be used to refresh and reinforce the instructions provided in person by the therapist and technician. The'films will be used to illustrate rather general principles, to provide psychological and moral support to, the patient, and to reinforce the specific training provided by the technician and therapist. These will be produced in the form of film strips which could be shown through: portable, automatic projectors. (The projectors were demonstrated.) Dr. Allred, Associate Coordinator of RMP (Audiovisual), is intimately involved in this project. He and his staff will provide the expertise for the development of the appropriate script, pictorial material, and ae assembling of the film strip. He estimates that the total cost for a wey master and two or three copies would be somewhere around $80.00. ae Additional film is planned, aimed at teaching physicians some of the principles required of them in their dealing with patients, Again, this is thought to be less technical and simply reinforcing to physicians of their role in the preparation of patients and in the support of patients following such procedures. Again, Dr. Allred and his staff will be instrumental in the production of these films. His estimate is that about a half-hour film can be produced for around $900-$1200.. He indicated that this was at some variance with the usual commercial cost of $1,000 per minute but that their expertise and facilities permitted this lower cost. The site visitors were not totally aware of the availability of such films through other sources. They were advised that at the moment some material is available from medical supply houses and device manufacturers but that this is somewhat biased toward the product of that individual concern. The team was not aware as to whether or not other Regions are developing similar material. The site visit team recommended this project as a legitimate request and recommended that it be supported in the time and amount requested. MARYLAND RMP Site Visit ~1l7- RM 00044 Site Visit Team's Review of Proposals Submitted for June /July_1970 Review Cycle. Project #28 - Regional Oncology Affiliation. Dr. Lenhard, Johns Hopkins ‘ tiversity, presented the proposal to the site visitors. Apparently, this proposal stemmed out of a feasibility study, funded out of Core, in which they have developed an affiliation with the Easton Hospital, on the Eastern Shore of Maryland. Ostensibly, this was a program aimed at developing affiliations with small hospitals which hoped that this would upgrade the knowledge of the local practitioners. There was, apparently, to be feedback to these practitioners upon referral of patients. There . was to be heavy emphasis on the establishment of a registry which would give them an avenue for feeding back information to the practitioners. They hoped to develop practitioners who would have expertise enough to- recognize cases which should be referred to the Johns Hopkins Oncology . Program. Further elaboration of the program suggested that this was a highly service-oriented project, seeking funds for programs which the site visitors felt should be an ongoing part of Johns Hopkins programs at the present time. It was difficult to see any structure to the educational aspects of the program other than that there would be a close relationship to certain individual physicians and, thereby, assimilation of knowledge on their part. Some plans were made for periodic rounds, annual seminars, and for having physicians visit Johns Hopkins Hospital. A tumor registry was proposed although it seemed that perhaps investigation © of the role of tumor registries throughout the country had not been reviewed by this proposer. In fact, a tumor registry has apparently already been developed in conjunction with the feasibility study. It was difficult for the team to understand the justification for the salary support that was being requested. Also, it appeared that there might be some confusion as to how the collection of professional fees would relate to this project. The site visitors believed this to be an almost purely service-oriented program; that it served no demonstration purposes; did not serve as a pilot project; or have significant educational values. The one salvaging aspect might be that this program may have real significant regional- ization impact. : The recommendation of the site visitors was that this project should be returned for revision. In making this recommendation, the visitors believed that any revision should show the strengthening of the affiliation and educational aspects of the project. It would be helpful 4f£ some commitment could be obtained, to show that cooperating hospitals were committed to the development of some kind of affiliation;and the budget should be more realistically planned to defray the costs involved in the educational and demonstrational aspects of the program, rather than the service aspects of the program. MARYLAND RMP Site Visit | - 18 - RM 00044 Project #29 - A Cancer Detection Program in Children. This is a proposal to establish physician assistants trained in the techniques for detecting solid tumors by abdominal palpation and viewing of the reflex of the retina in extraocular movements. It would also incorporate certain urine tests and blood tests for the detection of abnormal metabolic products which might relate to the presence of neoplasms. It was proposed that three physician assistants be trained in these techniques, to serve in well-baby clinics. It was anticipated that they would have to examine somewhere around 10,000 youngsters per year, per examiner, in order to be sure that they were detecting significant numbers of neoplasms. , There appeared to be two aims to the project: 1) to determine the incidence — of carcinoma of this type in youngsters; and 2) to demonstrate the value of physician assistants as screening aids. The site visitors expressed concern with reference to: 1) the assistants’ ability to really evaluate incidence; 2) the ability to maintain interest on the part of examiners who do such routine work; 3) separation of pieces into parts rather than incorporating this as a part of a general screening program; 4) the lack of concern as to what would be done for followup of detected cases; 5) the amount budgeted for Dr. Kyser's salary. The site visitors believed that, while cancer detection is undoubtedly admirable, this project should be returned for revision with reference as to whether or not it could be incorporated in a larger, more comprehensive screening program. ; : Project #30 - Continuing Education Program - University of Maryland School of Dentistry. This proposal was not reviewed during the site visit. MARYLAND RMP Site Visit - 19 - RM 00044 Qo OF SITE VISITORS! RECOMMENDATIONS ON CORE & OPERATIONAL PROPOSALS Project Number Title Recommendation 00 Core Strengthen Central Core by: 1) Administratively adding $150,000 (new funds). ‘ 2) Rebudgeting approximately $40,000 from institutional ’ cores to the Central Core. 3) Transferring the present part- time Medical School Associate Coordinators to the Maryland RMP Central Core Staff as full-time employees (with salary corresponding to the increased time or effort.) ist Yr. 2nd Yr. 3rd Yr. 25. Comprehensive Stroke Program, $50,000 $100,000 $100,000 Prince George's General Hospital (Direct Costs) and #26 Stroke Rehabilitation Program in the Home and in the Prince George's County Health Department Rehabilitation Clinic (Because of the complementary purpose, plus the actual physical locations of the applicant agencies, the site visit team considered them as 4 single proposal.) TOTAL FOR THREE YEARS FOR #25 AND #26 ~ $250,000 27 Management _of Intestinal Stomas lst Yr. 2nd Yr. 3rd Yr. $44,975 $44,475 $45,975 (Direct Costs) TOTAL FOR THREE YEARS FOR #27 - $135,425 28 Regional Oncology Affiliation Return for Revision 29 A Cancer Detection Program in Children Return for Revision MARYLAND RMP Site Visit - 20 - RM 00044 SUMMARY OF FUNDS REQUESTED BY APPLICANT & FUNDS RECOMMENDED BY SITE VISIT TEAM Project Number Title Amounts Requested Amounts Recommended (Direct Costs) (Direct Costs) “Ist Yr. 2nd Yr. 3rd Yr. {jist Yr. nd Yr. 3rd Yr. 25 Comprehensive ; Stroke Program $209, 704 56,911 71,390 } TOTAL FOR 3 YEARS - $338,005 | 26 Stroke Rehabil- $62,751 53,265 55,800: , {tation Program, Prince George's Health Dept. TOTAL FOR 3 YEARS - $171,816 TOTALS OF PROJECTS #25 & +26 $272,455 $110,176 $127,190 $50,000 $100,000 $100,000 TOTAL FOR 3 YEARS - $509,821 (Requested) 27 Management of , Intestinal Stomas $44,975 44,475 45,975 $44,975 44,475 45,975 TOTALS ; $94,975 $144,475 $145,975 6/16/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) MEMPHIS REGLONAL MEDICAL PROGRAM RM 00051 7/70.1 62 South Dunlap June 1970 Review Committee Memphis, Tennessee 38103 Program Coordinator: James W, Culbertson, M.D. Requested Program Pertod lst Year 2nd Year 3rd Year TOTAL Direct Costs $360,683 $255,150 $278,358 $894,191 Indirect Costs 39,368 42,598 46,098 128 ,064 TOTAL $400,051 3297 , 748 $324,456 $1,022,255 Note: Project #27 has requested five years support: 4th year $234,255: Sth year $254,816; a total five~year support for the application of: $1,383,262 (d.c.o.). A Review and Funding History is attached to the back of this summary; henceforth referred to as (R & F.H.). History: The grantee institution for the Region is the University of Tennessee. The Mid-South Medical Center Council (MMCC) for Comprehensive Health Planning servés as the RMP Regional Advisory Group. The original planning grant period for this Region was approved for two years and three months, April 1, 1967 - June 30, 1969, The first-year award was for $136,056 (d.c.o.). A total of $294,737 (d.c.o.) was made available during the second year, An award of $118,043 (d.c.o.) was made for the third-year planning period of three months, In order to merge planning activities with the operational grant, the third-year planning grant period was extended three months, July 1 - September 30, 1969, and a supplemental $89,022 (d.c.o.) was provided, making a total of $207,065 (d,c.o.) available for the third-year (eix months) of planning. During its second year of planning, the Region implemented a three-year operational program with an award of $592,063 (d.c.o.) for the support of ten projects for the first year, July 1, 1968 ~ June 30, 1969. In November 1968, Council considered the Region's first supplemental operational appli- cation which contained three proposals in the areas of medical technology training, provision of diagnostic facilities and multiphasic screening. The total application was disapproved with advice that it be revised and resub- mitted, The application did not clearly relate to the developing regional MEMPHIS RMP -2- RM 00051 7/70.1 strategy. In February 1969, Council considered a second operational supplement which contained three new projects in the areas of coronary care training, education in medical technology, and medical laboratory service, The coronary care training program was approved and funded at $54,380 (d.c.o.) for the first-year, The remaining two projects were deferred for an April 1969 site visit and in May, Council recommended dis- approval of the medical technology project with advice that it be revised and resubmitted, since the proposal had failed to establish its importance in meeting regional.needs. The laboratory service project was disapproved and not considered appropriate for RMP support. Support for the coronary care training program and for the second year of operation for the ten projects funded ‘under the initial operational grant was provided through an award of $679,046 (d.c.o.) for the period of July 1, 1969 - August 31, 1970. However, use of funds for the peripheral vascular disease project and the Obion County General Hospital project was either partially or totally restrictdd pending the submission of additional imformation, It appeared that the vascular disease project, which had been approved for planning activities only, had actually become operational, The Obion Hospital project, which was funded to increase hospital capability for the categorical diseases, had made no progress and future plans were unclear. The financial restriction on the Obion Hospital project is still in effect. In May 1969, Council considered a third operational supplemental application which requested renewed and expanded support of core staff and eight new projects, two of which were multiphasic screening proposals. The remaining concerned cardiovascular clinics, renal failure training center, care of high risk infants, nuclear medicine technician training, bidod banking, and survetllance of hospital acquired infections, The application was site visited in July 1969, and considered again by the Council in August. Core staff support, the two multiphasic programs and the cardiovascular clinic program were recommended for funding. The hospital acquired infection proe- gram was approved, but without funds. The renal failure training and the nuclear medicine training projects were disapproved and considered inappro- priate for RMP support. The high risk infant and the blood banking projects were disapproved with advice that they be revised and resubmitted. The site visit team helped clarify the Region's sgate of program development. At that time, the overall goals and objectives were not clearly delineated. An attempt was being made, however, to create or even recreate an environ- ment wherein programs could be mounted, priorities assessed, and goals and objectives at least visualized if not established, Planning activities were not impressive up to that time, For example, there had been no formal recommendation for regionalization of the areas outside Shelby County area, here was a lack of involvement of many rural areas, There was evidence, however, that involvement of rural areas was slowly being inereased. Further, the team noted complications arising from the RMP and MMCC relation- ship. It was recommended that the RMP give top priority to overcoming the resultant problems, Also, it was believed that the RAG might function more effectively if it contained a larger representation from outside Shelby County. MEMPHIS RMP -3- RM 00051 7/70.1 In December 1969, Council reviewed the Regions Fourth Supplemental Operational Application which requested support for Projects #25 - Demonstration Program in Health Care, and #26 = Biomedical Information Network, Council approved with conditions the Home Health Care project and disapproved the Biomedical Information Network project. (Refer to R& FH.) The total amount recom- mended, but unfunded at this time, for the total application was $1,211,405. Two of the Region's approved but unfunded projects #17- Demonstration Program in Preventive Service, and #18-Mobile Multiphasic Health Screening, are to be partially funded in FY 1970 from the recently released $5 million of the $20 million carried forward from FY 1969. Also, currently under administrative consideration is the Region's request to use $155,172 of the $227,000 01 year unexpended funds to: help support projects #17, ($29,470) and #18, ($52,633); initiate three approved but unfunded projects, #19 « Cardiovascular Clinics, ($25,752), #24 - Surveiliance System ~- Hospital Acquired Infections, ($5,092) and #25 - Demonstration Program in Health Care, ($10,493); and to purchase: cinematic photograph equipment and additional office furniture and equipment for the core ataff facilities, ($31,732). Present Application: The supplemental grant application is requesting $1,022,255 (d.c.o.) for three-years support of two projects, Both projects in this application are resubmittals, project #4 - Peripheral Vascular Clinic, and project #23 - Regional Blook Bank and Trans- fusion Program, The Peripheral Vasculaz oroject was granted by Council in May 1968, a planning award for developmental activities and regional plan- ning. After one year of operation, staff reviewed the continuation applica- tion of this project and found that the project has assumed operational gtatus for which approval had not been granted, A restriction was imposed on 50% of the approved amount pending receipt of additional information regarding this proposal, After quite an extensive amount of negotiation with the region and a special action by Council in December 1969, the region was given approval to utilize their remaining funds to phase out their planning grant and recommended that they submit a revised proposal for full operational project support. The Region wag advised that the new proposal should not only clearly describe those activities which are considered as provision of patient services and those which are considered as training and educational components, but that a detailed budget justification be presented accordingly. The Bldod Banking and Transfusion Program was reviewed by Council in August 1969, and disapproved. Council believed that the relationship of this proposal with existing biéod banks, hospital, or medical care programs needed strength- ening and that the project needed to be coordinated with the local Memphis Blood Club, The financiai arrangements, especially those related to income to be derived from gale of blood derivatives needed classification. Council also believed that the proposed program needed more involvement of physicians and technologist in the Region, Further, the proposal raised major implica- tions of 4 unified transfusion service for all hospitals within the Tennessee Medical Center Complex. Project #27 - Peripheral Vascular Clinic The Region states that Requested during the planning and developmental stage, the First Year $47,761 MEMPHIS RMP ~4- RM 00051 7/70.1 first six months were devoted towards procurement of clinic space equip- ment and personnel, The sécond six months were devoted to developing a facility and to test various orgahizational concepts, function, methods of patient care delivery, improve efficiency and evaluate the feasibility of later self-support or community financing. This program proposes to implement the following Activities: A. Education ; (1) Public Education ~ Develop and disttibute pamphlets through- out the community which déscribes the warning Signals of vascular disease, the cause and possible complications, utilize the public infermation medias to urge medical and para-medical personnel to help disseminate knowlédge to patients’ friends and families. (2) Physician Education - By developing and distributing a Univer- sity Clinic brochure describing the facilities and services available at the clinic, by the staff of the university clinic preparing and presenting a lecture series on vascular disease, and through consultative services by the University Vascular Clinic Staff: to private practitioners. B. Increasing Quality and Quantity of the Skilled Professional and Paramedical Personnel in the Region ‘ (1) Nursing - Establishing nursing in service training programs for RNs and LPNs in hospitals and having seminars for public health nurges and Visiting Nurses Association Staff, by the University Vascular Clinic giving a nursing education workshop for nurses in the region who will staff regional clinics, (2) Paramedical Personnel - The vascular clinic staff will partic- ipate in the University School of Physical Therapy, delivering that portion of the instruction which applies to peripheral vascular disease. They will also sponsor an educational activity for paramedical personnel employed by the Division of Vocational Rehabilitation, C. Improving Patient Care (1) University Vascular Clinic - The organization function, and staffing of this clinic has proceeded feom the basic concept that total service should be provided in one centralized area. This involves physicians’ services for diagnosis and treat- ment, nursing care, adequate social and economic ddta, on-the- spot consultation with the vocational rehabilitation counsélor, a physiotherapist to advise both physicians and patients, and complete diagnostic instrumentation. Referrals will be received by letter or phone from physicians or any appropriate social agencies (DVR, VNA, etc.). Referral to the clinic will receive a clinical evaluation by one or more members of the staff. There will be available at the clinic out-patient angiography which will allow a more definitive immediate diagnosis and a complete workup, All patients will be scheduled for a fallow-up evaluation either post-treatment or after being returned to the Ma referring physician for management. MEMPHIS RMP -5e RM 00051 7/70.1 (2) Regionai Clinics - Regional Clinics will be instituted in the Memphis Region to expand the aducational and service function of this program. Physicians from Tennessee and one from Mississippi, have indicated interest in putting up a regional clinic, The interested physicians will be invited to Memphis to observe the functions of the clinic and have a planning session to determine their needs and the facilities available in their area. The physicians will | then select personnel from their area to attend the Univer~ sity Vascular Clinic weekly for four weeks for on-the-job training, This should include the secretary, the nurse, and the x-ray technician, At the conclusion of the training period the University Peripheral Vascular Clinic Staff woudd make a site visit to assist in setting up the regional clinic. The regional clinics would then begin operation with one or two members of the University Peripheral Vascular Clinic attending for three or four months and then they will function as an automomous unit. The basic concept is that the more routine cases would be handled locally and only the most difficult casee would be referred to the University Peripheral Vascular Clinic for consultation. D., Vascular Registry (1) A peripheral vascular disease registry will be established utilizing a keysort system with information stored on punch cards, Present Clinic population will be incorporated into the registry first and new patients will be added as they come to the clinic. Later as regional clinics become estab- lished patients who attend these clinics will be added to the master registry. The information to be stored on the cards will be obtained from the clinic charts and supplemented by patient interviews whenever necessary. E, Clinical Research (1) A close observation will be maintained for clinical research of those patients with Ilecfemoral Thrombophlebitis and Saphenous Vein Allografts. For evaluation of the program an annual statistical report of clinic activ- jties in the area of patient care will be compiled and reviewed. In addition, a questionnaire will be prepared and mailed to referring physicians request- ing his opinion of clinic activities. A subjective evaluation of educational activities in the clinics and community will be directed to those people who have been in contact with the clinic. The major portion of funds requested are under the category of personnel. The applicant states that the procurement of a vascular fellow is vital to the basic function of this clinic-education, The initial six-month scholor- ship stipend is for a potentiai candidate already contacted and interested in the position, After this, the region anticipates that fellows will be appointed by the University for, one year. Second Year: $57,056 Third Year: $62,991 MEMPHIS RMP -6- RM 09051 7/70.1 Project #28 - Regional Blaod Banking and Transfusion Program, Requested Submitted by the Baptist Memorial Hospital and the First. Year College of Medicine, University of Tennessee, this proposal presents $312,922 a plan to provide for the Region teaching and consultative services which are not now available. It is proposed that the local blood bank- ing center become an extension of existing facilities at the Baptist Memorial Hosptial and be housed away from the Baptist Hospital. The objectives of this project are: 1) to provide means of rapidly indenti- fying blood bank problems and determining if the problem can be cared for at the local facility, or hospital, or temporarily referred to the main center; 2) make available for patients blood and its components to improve patient care and educate those in the Region on the use of specific components; 3) make available facilities for Regional courses and workshops for continuing education in blood bank immunology; 4) make available facili- tiea for advanced training of technologist in all phases of blood banking; 5) make available facilities for training of medical and technical directors of blood bank facilities; 6) maintain an inventory of rare donors and rare blood; 7) stay abreast of the developments in this field to implement worth- while advancements for educational and improved patient care; 8) through a fellowship program, evaluate proposals which are in clinical investigative phases; and 9) maintain facilities for thorough investigations of problems in blood banking, including the recipient who has frequent transfusion reactions, The proposal is especially arranged so that its implementation would not pre-empt any of the blood supplying facilities and transfusion services of the Region. Rather, it is geared to strengthen these through a major year- round educational program. The Memphis blood bank directors support the program so long as it does not interfere with their routine service func-~ tions ag presently instituted, Thus, it does not appear possible to establish at present "a unified transfusion service for all hospitals with- in the Tennessee Medical Center Complex." The blood bank directors of Memphis and Jackson, Tennessee, have pledged support for the program as presented and will serve on the advisor committee, The Region believes this could be a nucleus for a future community blood bank operating as an entity outside of any single hospital. The service part of the proposed plan would entail only what established organizations cannot supply. Included would be rare donor biood from the frozen blood section and components for the treatment of hemorrhagic diseases, such as platelet concentrate, and cryoprecipitates and fresh frozen plasma, It will also include the availability of a “hot line" for insti- tutions in outlying areas. This would be utilized in case of any problems, such ag a cross-match problem, the situation can be considered immediately over this "hot line", A tissua typing service will be offered to outlying institutions, especially as the renal dialysis programs expand to include both center dialysis to home dialysis. The program's main activity will be in disseminating information on modern biood transfusion practices, As such, a major educational program for the region would be established emphasizing workshops, lectures, visits, and MEMPHIS RMP «= BM 00051 7/70.1 consultations, From these approaches the Region envisions greater interest in improving blood transfusion facilities and modernizing medical practice. Of the first years budget: 22% ig requested for personnel - 2 full time Instructors, 5 full-time technicians/technologists, 2 full-time clerk- typists, and 2 full-time custodial employees; 32.6% is for supplies; 20.3% for equipment; 23% for renovation; and 2% for travel and other items. Second Year: $198,094 Third Year: $215,367 Fourth Year: $234,225 Fifth Year: $254,816 ~Be ‘> RM 00051 7/70.1 MEMPHIS RMP REVIEW AND FUNDING HISTORY. - “Ist Year Plaming Award 4/1/67-3/31/68 $173,119 (February 1967 Council) . 2nd Year Planning Award 4'/1/68-3/31/69 - ~ 183,443 3rd Year Planning Award 4/1/69-9/30/69 . 249 ,490 INITIAL OPERATIONAL APPLICATION COMPONENTS | | , (Site visited June 1968) _ May 1968 Council) , . Approved Projects ; . Project “Period Funded (d.c.o.) #1 - Stroke Center in the Memphis Region “ 3 years (01)$ 86,606 (02) 148,522 #2 - Regional Laboratory for Gastrointesti- " nal Mucosal Suction Biopsy 3 years (01) 18,000 (02) 23,325 #3 - Prevention and Improved Treatment of Skin Cancer 3 years (01) 29,590 . ; (02) 34,998 #4 - Peripheral Vascular Disease 3 years (01) 20,000 (02) 23.936 #5 - Coronary Care Training Unit 3 years (01) 130,000 (02) 106,268 #6 - Emphysema and Cor Pulmonale ' 3 years (01) 59,928 (02) 69,144 #7 - Streptococcal Disease Center 3 years (01) 103,252 . (02) 101,310 #8 - Electrocardiographic Diagnostic Center 3 years (O01) 108,687 (02) 70,499 #9 - Obion County General Hospital Project 3 years (01) 21,000 (02) 23,322 1/ #10 -Combined Attack on Certain Forms of Heart Disease, Cancer and Stroke 3 years (01) 20,000 , (02) 23,332 aa 7 _. V (Total ‘restrictions on use of funds) FIRST OPERATIONAL SUPPLEMENTAL APPLICATION (November 1968 Council) ' Approved Project Period Funded #11 - Regional Medical Technology School Disapproved with Advice & to Revise and Resubmit gas Disapproved with Advice #12 - Radiological Diagnostic Equipment to Revise and Resubmit at Crittenden Hospital] #13 - Demonstration Program in Preventive . Disapproved with Advice One Bn awed ann nenel Danesh. te MEMPHIS RMP ~Ge RM 00051 7/70.1 © «000 SUPPLEMENTAL OPERATIONAL APPLICATION COMPONENTS Funded rao onroved F114, (February 1969 Council approved #14, and #15 and #16 were deferred for an April 1969 site vistt. Final action taken by May 1969 Council) #14 - A Proposal for a Cardiovascular Inten- sive Care Unit #15 - Education in Medical Technology #16 - Improved Quality Control and Service &f Medical Laboratories 3 years (01) $54,380 Disapproved with Advice to Revise and Resubmit THIRD SUPPLEMENTAL OPERATIONAL APPLICATION COMPONENTS x aOnebabAROTR “(May 1669 Gouncil deferred total application for July 1969 site visit. Final action taken by August 1969 Council) # O » Gore Staff #17 © Proposal for a Demonstration Program in Preventive Services for Heart Disease, Cancer, Stroke and Related Diseases #18 - Mobile Multiphasic Heéith Screening Unit in Northeast Mississippi #19 - Expansion of Cardiovascular Clinics in Northern Mississippi #20 - Development of a Chronic Renal Failure Training Center @21 - Care of High Risk Infants #22 - Improved Patient Care - Regional Nuclear Medicine Center #23 = Regional Blood Banking and Transfusion Peogram #24 - Feasibility Study - Establishment.éfia Central Regional Surveillance System for Control of Hospital Acquired Infections FOURTH SUPPLEMENTAL OPERATIONAL APPLICATION COMPGNENTS (December 1969 Council) Projects #25 » Demonstration Program in Health Care #26 - Biomedical Information Network Disapproved Approved Project Period Funded 2 years (01) $504,000 3 years (01) 240 ,000(new) 29 ,470(carry- éver) 3 years (01). 260 ,000(new) 52,633 (€arry- ae over) 3 years (91) 25,752(carry- over) Disapproved Disapproved with Advice to Revise and Resubmit Disapproved Disapproved with Advice to Revise and Resubmit 2 years (01) 5,095 (carry- over) 3 years (01) $20,600 10,493 (carry- over) Disapproved with advice to revise and resubmit RMPS/GRB/6/3/70 (A Privileged Commmication) SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTER MEMPHIS REGIONAL MEDICAL PROGRAM RM 00051 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee concluded that this application which requested $894,191 (d.c.o.) for three years support for two proposals sheuld not be approved. Both project proposals represented resubmissions, although of a different nature. Project #27, for a Peripheral Vascular Clinic has evolved into an ongoing operational activity during the ‘° first two years and funds were being requested to extend the program for over a three-year period, Project #38 for a Regional Blood Banking and Transfusion Program was a revised proposal and has never been initiated. Project #27 - Peripheral Vascular Clinic for operational funds; it was not approved as an operational project, but fuids were awarded for further planning. During review of a continuation application, staff noted that the activity had advanced beyond planning to operational status. Special action by Council clarified the region's authority for the ongoing clinic deveiopment.and permitted time for the Region to submit an application for continued support of the clinic. The Committee had real concerns about this activity, not for its inherent value but for its appropriateness as an RMP funded project. A referral service is being developed, and clinical fellow training is being supported. Two community clinics are being envisioned for small peripheral commmities, but the Committee questioned their essential value. The referral center in Memphis doubtless serves a function ~ a registry and research activities are also features planned. Professional education through referral of patients is valuable. The Committec did not question the value of the referral center, but it did question the validity of RMP's supporting it. The regionalization aspects - public, physician and allied health education, and the peripheral clinics are not well developed features of this project. The Committee concluded that this activity should be net approved for RMP funding. This recommendation does not reflect on the essential value of the referral center activity. Furthermore, the Committee recognized that the region may need to phase out this in an orderly manner and thetr recommendation does not preclude this. mendation: Non-Approval I, No RMPS funding recommended. Memphis Regional Medical Program ~2- RM 00051 7/70.1 Project #28 ~ Regional Blood Banking and Transfusion Program ‘Critique: The Committee recognized that this proposal was an adapt- ation of one which had been previously returned for revisicn. The previous review had raised questions concerning the relationship of the activity with existing blood bank, hospital and medical care programs, as well as to the Memphis Blood Banking Club. Financial arrangements needed clarification. The involvement of physicians, technologists as well as the unification of transfusion services for all hospitals within the Tennessee Medical Center Complex were also points of concern. The Committee was concerned that this revised proposal did not indicate clarification of the important relationships which the previous review requested. Regionalization is proposed, but it involves only one hospital in the Memphis Medical Center’ Complex and peripheral hospitals. In fact, it was noted that cooperative arrangements with other hospitals in Memphis were not feasible at this time. The Committee felt that this type of cooperative arrangement ~ outside of Memphis, but without other major Memphis hospital components ~ would jeopardize and hinder needed regionalization in this important area. Other aspects noted in review were the absence of objectives for the technologists' training, the lack of justification for the equipment and the question of fellowship training. Recommendation: Non-Approval I, No RMPS funding recommended REVIEW COMMITTEE FUNDING RECOMMENDATIONS Project Recommended # Year Requested 01 Year 02 Year 03 Year Total 27 OL $47,761 02 57,056 -0- ~O- ~-Q- -~O- 03 62,991 SUB TOTAL $167,808 28 OL $312,922 02 198 ,094 03 215,367 ~O- -0- -0- -O- 04 234,225 | 05 254,816 SUB TOTAL $1,215,424 TOTAL $1,383,232 -0~ -0- -0~ -0- RMPS 7/15/76 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) METROPOLITAN WASHINGTON D.C. RM 00031 7/70.1 Regional Medical Program June 1970 Review Committee 2007 Eye Street, N.W. Washington, D. C. 20006 PROGRAM COORDINATOR: Arthur M. Wentz, M.D. Requested: lst Year 2nd Year 3rd Year TOTAL Direct Costs $114,731 $106,515 $113,495 $334,741 Indirect Costs 40,148 43,134 46,098 129,380 TOTAL $154,879 $149,649 $159,593 $464,121 History: The Region's first year of planning was a 14-month period, 1/1/67- 2/28/68, and was supported at $188,000. Following a site visit in February 1968 the Region was awarded $241,642 for planning and $350,506 for support of three operational projects, both for the period 3/1/68-2/28/69. During the 02 year of operational status, 3/1/69-2/28/70, the Region was awarded $1,400,416, of this, $554,908 supported Core and $845,508 supported nine operational projects. As a result of the February 1969 Review of the Region's continuation application, it was awarded $980,514 for the 03 operational year 3/1/70-2/28/713; Core is supported at $554,034 and twelve @ vie: at $426,480. During the first two years of operational status the Region has submitted approximately 35 projects for DRMP review. The Region currently has four approved but unfunded projects. The projects currently being supported are outlined on an attachment to this summary, as are those projects which for one reason or another have not been funded. In its review of the continuation application for the third operational year, RMP staff noted that some progress had been made in core staff planning and coordination, that the RAG has been reorgariized with broader representation and that a Priority Committee of the RAG composed of representatives from the categorical review committee was actively engaged in overall priority determinations. Furthermore, this Region has actively sought involvement of the suburban Virginia and Maryland communities. However, involvement of the community representative of the City of Washington was not apparent; in fact, involvement of Blacks and consumer groups generally is minimal, particularly at the decision-making level. Furthermore, there seemed to be a dearth of core staff time and interest committed to cooperative planning for better health care of the inner-city residents. The Region has been asked to respond to these concerns of staff before July 1, 1970. Present Application Requested Project #36 - Diabetes and Obesity Evaluation and Prevention Program. First Year The long-range goal is the establishment of methodology $71,754 and standards for the early identification of those children likely to develop diabetes mellitus with its attending degenerative compli-~ cations and the institution of prophylactic measures to prevent further METROPOLITAN WASHINGTON D.C. -2- RM 00031 7/70.1 Regional Medical Program progression of the disease complex. The process for achieving this is based on the hypothesis, suggested by preliminary results of prior testing, that adult symptomatic diabetes is preceded by asymptomatic biochemical abnormalities in childhood which can be detected and identified; and that children of diabetic parents, siblings of diabetic children, and obese children and their siblings represent a predisposed group. A Pediatric Regional Community Diabetes Evaluation and Prevention Center established at Georgetown University Medical Center is proposed to provide a service for early diabetes detection in the pediatric age group and hopefully, for prevention. The Center would encourage referral from private practitioners, health departments and school agencies, of children in the predisposed group. Secondary screening centers will be established in five collaborating hospitals: Arlington Community, Fairfax, Children's, Providence, and the Hospital for Sick Children. Blood samples of children examined at the secondary centers will be referred to the primary center. Although it is estimated 50-100 siblings of diabetic children will be examined, no estimate is made for the number of children of diabetic parents, or obese children and their siblings, to be screened. Other goals are to: establish comprehensive diagnostic guidelines for the recognition of the prediabetic stage in the pediatric age group, and to establish monthly conferences and progress reviews as a form of continuing education in the private physicians and other interested groups. Evaluation as outlined is limited to blood testing procedures and analyses. The personnel budget request is based on experience gained during the past two years of preliminary research conducted on obese children and siblings of diabetic children, which was supported by a grant from the National Institute of Arthritis and Metabolic Diseases. The applicant states the proposed application of this experience cannot be continued without financial support. The budget request for personnel is $50,854. The major item in the equipment category is Gamma Counting Equipment, $12,000. Second Year: $61,397 Third Year: $64,067 Requested Project #37 - Early Detection of Chronic Obstructive Pulmonary First Year Disease (COPD). This project, presented by the $42,977 Pulmonary Division of the Howard University College of Medicine and Freedmen's Hospital, is directed at improving the effectiveness of unaffiliated practicing physicians in detecting and treating Chronic Obstructive Pulmonary Disease. A short course in the clinical, pathophysiologic and therapeutic features of COPD will be taught to 60 physicians and their assistants over a three-year period through lectures, demonstrations and the inquiry method. Four courses presented each year will accommodate five physicians and their office assistants. The curriculum is designed to be presented in two sessions for a total of six hours instruction. Attending METROPOLITAN WASHINGTON D.C. -3- RM 00031 7/70.1 e Regional Medical Program physicians and assistants, where appropriate, will be offered additional courses in pulmonary diseases at, and supported by Howard University. Upon completion of the course each partici- pating physician will be provided with a "relatively inexpensive" ($225) vitalor, and respiratory history forms, so that he may undertake private office screening of all patients over the age of 40 and all patients with histories or physical findings suggestive of COPD. Patients presenting positive findings will be directed to the function laboratory at Freedmen's Hospital for more detailed study. Initially ten patients weekly will be fully tested. This will be raised to 15-20 by the end of the first year. Those confirmed to have COPD will de referred back to the private physician for treat~ ment and follow-up. Although the applicant states the project will compliment the Georgetown University Adult Breathing Improvement Course and the Inhalation Therapy School at Washington Hospital Center, already approved by the Metro-Washington RAG, no specific plans for coordination are included. No specifics are provided as to how the Breathing Equipment Loan Service will serve as an assisting agency. A general plan for evaluation is presented. eo Year: $45,118 Third Year: $49,428 METROPOLITAN WASHINGION U,.L,. meh mb. vuvyv a. Pbewen Regional Medical Program Summary of projects currently being supported by Metro. D.C. RMP Project Title and Number Approved Project Funded 3rd Year - ° Period (direct costs) 3/1/70-2/28/71 #1 - Freedmen's Hospital Stroke Station 3 Years $ 16,100 #2 ~- Cardiovascular Disease Follow-up 3 Years : 97,812 and Surveillance - Georgetown #3 - Training for Cardiovascular Technicians 3 Years 19,600 Funded 2nd Year (direct costs) 3/1/70-2/28/71 Core 3 Years 554,034 #5 - Audiovisual Library of Ovarian Neoplasms 3 Years 2,500 for Continuing Education #10 - Comprehensive Care of Patients with 3 Years 7,500 Pulmonary Disease - Georgetown #12 - Mobile Coronary Care Unit 2 Years 50,000 #19 - Metropolitan Washington Regional 3 Years — 40,000 . Cancer Registry #20 - Metro Washington Peripheral Vascular 3 Years 50,000 Facility Funded lst Year (direct costs) 3/1/70-2/28/71 #23 - School of Inhalation Therapy 3 Years 12,600 #26 - Comprehensive Community Hospital 3 Years 49 438 Stroke Program ~ Arlington #28 - Coronary Care Nurse Training - 3 Years 14,790 Freedmen's School of Nursing #29 - Mass Screening, Treating and 1 Year 16,206 Eradicating Asymptomatic Bacteriuria TOTAL $980,514 Home Development ‘ METROPOLITAN WASHINGTON D.C. -5- RM 00031 7/70.1 © Regional Medical Program status of Projects not funded Project Title and Number Status #4 - Home Telecasts of Medical-Surgical Conferences Disapproved #6 ~- Comprehensive Hospital and Home Care of Stroke Patients Disapproved #7 - Puerperal Hemiplegia Disapproved #8 - Model Stroke for Metro. D.C. Disapproved #9 = Coronary Artery Disease: The Role of Exercise Disapproved in_its Management #11 - Mobile Coronary Care Unit for Metro. D.C, Disapproved #13 = Mobile Coronary Care Unit - Georgetown University Disapproved #16 ~ Paramedical Retraining by Video Tapes Approved (No funds recommended) #17 - Health Careers Council Approved (No funds recommended) H18 - Application of Technological Advances to Disapproved Education in Cancer #21 - Applying Community Health Research Findings in the Region Disapproved #22 ~ Pediatric Community Kidney Disease Prevention Center Approved (No funds recommended) #24 - Attempt to Improve Care and Patient Cooperation Returned for in Hypertension Revision #25 - Cancer Radiotherapy Unit - Education Consultation Service Approved but Unfundec #27 - Continuing Education and Social Services for Pediatric Oncology Disapproved #28 ~ Coronary Care Training - Freedmen's Approved but Unfundec #30 - Community Renal Diagnosis Service Using Immunoflourescence Disapproved #31 - Hemodialysis Training Program Approved but Unfundec #34 - Film on "Care of the Colostomy Patient'' for Patient Instruction Deferred for Additional Informatic #35 - National Medical Association Foundation Nursing Approved but Unfundec DRMP/GRB 5/27/70 rd SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE METROPOLITAN WASHINGTON D.C. REGIONAL MEDICAL PROGRAM RM 00031 7/70.1 . FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee approved this application with specific conditions; one project was not approved and one was approved at a reduced level. Committee's pbservations on these projects closely paralleled those of the outside reviewers. © Project #36 - Diabetes and Obesity Evaluation and Prevention Program. Critique: This project which was considered to be an applied research : project of activities previously supported by NIH was received unenthusiastically by Committee which cited numerous program concerns and . unc larified points in the narrative. It was questioned whether the hypothesis on which the program is based is sound enough for translation into: an action program and if so, whether it could be effectively evaluated. It. was noted the total number of children to be examined is not specified | © and it is unclear as ‘to what happens to the obese children in terms of specific corrective measures and follow-up. Also measures to be used in nonobese children who show prediabetic. changes are not described. The program is not structured for the low income group which need a screening and referral service. The letters of endorsement are non-committal and some Committee members were not assured of the cooperation of the private sector upon whom referral and follow-up would depend. The same members also doubted the walue of. the educational component which is designed to raise the index-of-suspicion of physicians, arguing practitioners are aware of the problem and it is questionable how many will make use of the facility. In relation to the budget it was noted no mention is made of the division of responsibility and duties. of personhel. In the absence of the number of children to be studied, it is. impossible to estimate the cost per child examined. Since there was no information given to estimate the number of tests the Gamma Counting equipment could do, the reviewers were not convinced ‘of the need for the equipment. The role of the M.D.-trainee is not clear - ‘is he a post resident or will he be in residency training. Although the project will probably generate income from charges for services, no. “information is provided on this aspect. Also no plan is presented to phase _ out RMP support. ‘Committee noted and concurred with the Continuing Education and Training “Branch comments that; specific information is lacking for the program of » continuing education for professionals, as well asfor the children and families; no information is provided to evaluate feasibility, no mention ois made of existing resources and the budget reflects the lack of staff for ‘the eontinuing education component. “Baeammendation: Non-Approval I - No DEMP Funding Recommended. ¥TROPOLITAN WASHINGTON DC. -2~ RM 00031 7/70.1 BRegional Medical Program Foject #37.- Early Detection of Chronic Obstructive Pulmonary Disease. pitique: Committee and the Ad Hoc Cardiovascular Panel were in basic agreement regarding this project. Both noted there is un- jestioned need to improve the effectiveness of the unaffiliated practicing tysician in the detection and treatment of chronic obstructive pulmonary psease. It was also recognized that this project is designed to improve ervices to the serious needs of ghetto patients. ; would seem, however, that the staff might train more physicians per bar and could provide some follow-up in the offices of physicians as - peded. It is not clear how baseline data will be obtained for later yaluation of success and although clinical research is suggested as a Pans of evaluation, no plans are included. The need for evaluation of ysicians' response and benefits to the community are recognized but me forms are extensive and vague, and the procedures need clarification. he six-hour course is not spelled out, making it impossible to evaluate hme educational design. The request to purchase Vitalors to be given to Bysicians as an incentive to participate was considered inappropriate in mat it would set a precedent that would initiate a flood of similar bquests. Some doubt was expressed that a full-time laboratory technician bd a full-time equipment maintenance specialist is justified, particularly mee latter, since Vitalors are subject to little breakdown. Plans for asing out RMP support is not in evidence. . bcommendation: Approval I - at the reduced level of 01 - $38,477, 02 - $40,618, 03 - $44,928 with the following conditions: 1) No support for Vitalors 2) Justification of maintenance technicians 3) Clarification of evaluation techniques PMMARY OF RECOMMENDATIONS Fo ject Title and # Recommendation OL 02 03 Total MS6 - Diabetes and Obesity Non-Approval I -0- -0- -0- -0- Evaluation and Pre- ; i vention Program - Early Detection of Approval I at | $38,477 $40,618 $44,928 $124,023 ciate ae crises wtettaigt eatin ema tae Chronic Obstructive reduced level Pulmonary Disease with conditions / Total Application Approval with $38,477 $40,618 $44,928 $124,023 \ Specific Condi- i tions ry. John Johnson was not present during the deliberation of this application DRMP/GRB 7/14/70 REGIONAL MEDICAL PROGRAMS SERVICE CUMMARY OF A SUPPLEMENTAL OPERATIONAL GRANT APPLICATTON (A Privileged Communication) MICHIGAN REGIONAL MEDICAL PROGRAM RM 00053 7/70.1 Suite 200 June 1970 Review Committee 1111 Michigan Avenue East Lansing, Michigan Program Coordinator: Albert E. Heustis, M.D. Requested lst Yr. 2nd Yr. 3rd Yr. TOTAL Direct Costs $ 897,822 $ 812,104 § 806,156 $2,516,082 {indirect Costs 134,053 192,340 204 ,492 530,885 TOTALS $1,031,875 $1,094 ,444 $1,010,648 $3,046,967 History: The Michigan Association for Regional Medical Programs was awarded its initial planning grant of $1,040,639 during June of 1967, The grant supported a central planning staff and separate subsidiary planning groups, These were: 1) Michigan State Department of Public Health (continued support for this agency not requested after the first year). 2) Michigan State University Medical School. 3) Wayne State University Medical School. 4) University of Michigan Medical School. A consolidated planning operational application was submitted near the end of the first planning year. Following a preoperational site visit during june 1968, the Region became operational as of July 1, 1968. In addition to Core, ten operational projects were supported, at $773,567. The budget period was changed from July 1 to September 1, 1969, at the end of the first year. The second operational year (14 months ~ 7/1/69 to 8/31/70) is funded at a total of $2,304,595 (d.c.) - $1,945,901 basic and $358,694 carryover funds. This amount supports the Core central planning and administrative staff, plus subsidiary Core components in the three medical schools. In addition, nineteen operational projects are, or will be, supported during this year (see History Supplement for details). Historically, the reviewers have noted the obviously excellent local, technical and RAG reviews that projects receive in this Region. In fact, since the Region became operational (July 1968) only one of a total of twenty-six projects has been recommended for nonapproval, and this action was based on DRMP policy involving the type of training activity proposed. Direct costs only are noted in the following project descriptions. MICHIGAN Regional Medical Program - 2 - RM 00053 7/70.1 Requested First Year Present Application: This application requests support for one renewal and two new three- year operational projects. -Project #16 (R) - Surveillance of Electronic Equipment $45,701 in Special Care Units - Wayne State University - Detroit, Michigan. This is a one-year renewal request to support a project previously approved by Council for one year in the amount of $49,135. While the total program request shown is $86,381, the Region anticipates $40,680 in grant-related income which will be credited to the project, Thus, the Region requests $45,701 RMP funds for the - twelve-month period. The specific objectives were: 1) to assess the practices with respect to electronic equipment in coronary and intensive care units and emergency rooms in Metropolitan Detroit hospitals; 2) to determine the degree to which use of such equipment fulfills the desired medical objectives; 3) to determine the potential hazards in the use of such equipment; 4) to determine the need and frequency of monitoring of such equipment; 5) to provide pertinent safety data about specific equipment to personnel in units surveyed 5 and 6) to determine if incompatibilities in equipment represent a significant safety hazard. By the end of the first year of operation 25 hospitals will have been ne initially surveyed, and numerous equipment discrepancies have been wt identified within each hospital. Some of the problems found were: 1) defibrillator cutput not meeting specifications; 2?) defibrillator carts were not reasonably ready for use; 3) equipment's internal components were not meeting reasonable standards; 4) pacemakers were not receiving adequate care; and 5) poor design by manufacturer, Because of the seriousness of the malfunctions associated with the electronic equipment, new objectives have been developed to broaden the scope of the new project. The new objectives are: 1) to establish a plan to continue the present project as an ongoing program without the financial support of RMP; 2) to continue and expand the scope of the present project; and 3) to inform the hospitals and medical community on the hazards involved in the misuse of electronic equipment. : The renewal request includes two electronic technicians to be employed to better facilitate continued evaluation of the hospital's electronic equipment. It is anticipated that with this additional help they will be able to screen 60 new hospitals (urban and rural). The Region states that the response to this offer of service has been much higher than anticipated, Also, the team plans to revisit 75% of the hospitals that were visited during the first year. Electronic equipment in operating and emergency rooms, special care and cardiac care units will be included in the expanded investigation. Inspection standards and frequencies will MICHIGAN Regional Medical Program ~ 3 - RM 00053 7/70.1 Requested First Year be established for equipment common toe most CCU and emergency rooms, Consultation will be provided to hospitals purchasing new equipment, building or remodeling special care units. As a means of informing the medical community on the hazards surrounding faulty electronic equipment, it is planned to: 1) conduct a three-day seminar for physicians; 2) publish four articles for inclusion in both regional and national health journals; and 3) produce a fifteen-minute color film. The publicity and distribution of the film will be made through the facilities of the Michigan Heart Association which will also provide assistance in the development of the three-day seminar for physicians. Two hospitals, Providence and Sinai, have already offered to cosponsor the seminar and will provide free facilities and staff support. long-range plans include the development of a course on the safe and effective use of medical and electronic equipment which will be included in the medical or osteopathic school curriculum, In- house educational programs to be presented to community hospitals will also be considered, These programs will acquaint the hospital staffs with the correct techniques of keeping and using safe medical electronic equipment. Several agencies will be approached in an effort to obtain sponsorship to guarantee continuity of support after termination of RMP funding. Project #27 - Demonstration of a Comprehensive Health Care $505,269 Program for the Urban Poor. Wayne County General Hospital requests $505,269 through the Michigan RMP, for the first year of a three-year program to initiate a demonstration program of comprehensive health care for the urban poor. This is a revised application. The original project was reviewed by the August 1969 Advisory Council, and approval of planning funds in an amount not to exceed $40,000 for each of two years, was recommended, The Council believed the project should be recast with specific, clear objectives and methods of procedure; and should include information pertaining to the following points: , 1) Concrete diagnostic, treatment and followup procedures should be set forth and documented; 2) Current demographic information as it relates to the target group; 3) An outline showing a more sophisticated screening program; 4) A realistic, cooperative, data-gathering program; 5) A clearly written commitment from relating ‘agencies; 6) A concrete commitment from Wayne County regarding support after termination of RMP funds; 7) A method of handling fees generated through project activities; 8) A complete, clear training program for "aides" and statements on the intended use of personnel after the training period; and 9) A clear statement of the value of this activity over the existing programs for the target population. RM 00053 7/70.1 £ 1 MICHIGAN Regional Medical Program - Requested First Year The revised proposal is for the development of a comprehensive health care clinic (including detection, diagnosis, treatment and followup procedures) with the outpatient department of Wayne County General Hospital. The major impact will be directed to the care of the medically indigent population in Wayne County. The project is designed to compare two systems of health care, both to operate concurrently in the outpatient department during the three-year project period, The first system refers to the episodic care system (processing of patients in the same manner used for years, except that every alternate patient will be referred to the second system). The second system is aimed at establishing a comprehensive care system involving an automated, computerized, multiphasic screening program and followup procedures, The project plans to utilize, as much as possible, nonprofessional personnel who will be expected to obtain employment in the operation of the Comprehensive Health Care Clinic after completion of their training. Currently there are 43 separate clinics operating in the outpatient department of Wayne County General Hospital. The outpatient visits have increased from 10,000 visits in 1950 to about 76,000 visits in 1969. The applicant describes three poverty-type target areas to ‘be served by this project: 1) City of Inkster - located a block from the hospital - has a population of 37,000, of which 42.3% are nonwhite; 2) Ecorse - PMs located a few miles from the. hospital - has a population of 17,238; a (the community's nonwhite population is estimated at 33.3% (99% black); and 3) Romulus Township (located a few miles from the hospital) has a population of 17,000, of which 16% are nonwhite. It is planned to process four groups of patients through the Comprehensive Care Clinic. The four groups are: 1) every alternate new indigent patient admitted to the clinic (sixty-five are expected weekly) ; 2) every alternate clinic patient who has not had a comprehensive health evaluation for over a year (two hundred and fifty expected weekly); 3) apparently "healthy" individuals referred from Wayne County OEO, Senior Citizen's and other similar community groups (one hundred and fifty expected weekly); and 4) every alternate patient admitted to the hospital who is not acutely ill. Screening tests, examinations and procedures will consist of: anthropometry; a twelve-lead electrocardiogram; chest x-ray; mammography; pelvic examination (including a pap smear); oral and dental inspection; visual acuity and tonometry; photographs of full and side face; spirometry; audiometry; blood and urine specimens. The Region states that during the local review of this proposal, the MICHIGAN Regional Medical Program ~ 5 - RM 00053 7/70.1 Requested First Year reviewers believed that all of the points raised by the RMPS reviewers had been satisfactorily covered in this proposal with the exception of the commitment of Wayne County to carry on the activity after termination of RMPS funds. The major portion of the requested budget is in the categories of personnel ($173,094), equipment ($163,175), alterations and renovations ($91,000) and "other." "Other" includes rental cost for a computer ($60,000). Second Year: $454,574 Third Year: $477,459 Project #28 - Proposal for the Southeastern Michigan Regional $346,852 Cancer Program. Wayne State University requests $346,852 through the Michigan Regional Medical Program for the first year of a three-year proposal which is to improve the care of cancer patients in a tri-county area, by providing a clearly identified and publicized network of cancer consultants in nursing, medicine and social service. This is the Region's first cancer project. The project proposes to establish cancer consultants throughout the tri-county area (Wayne, Oakland, and Macomb Counties) to increase the availability of expertise in cancer management to practicing physicians. A Central Teaching Group of Cancer Experts from Wayne State University will serve as faculty for training the cancer consultants and for developing "guidelines for management of patients with malignant disease." The cancer consultants will be identified and reappointed by the Project Director annually and will have the responsibility of: 1) implementing a monthly tumor board in their hospitals; 2) implementing and attending clinical teaching conferences in their own hospitals; 3) attending the monthly conferences of the Central Teaching Group; and 4) providing consultation (on a fee-for-service basis) to physicians and furnish information on current management and evaluation standards and therapy recommendations. An area-wide cooperative program among radiation therapists will be developed to provide needed services and to improve the scope and quality of the therapy offered. All pathologists in the tri-county area will be given an opportunity to become active participants in pathology slide seminars to be held at two hospitals (St. John and Wayne State). A two-week cancer educational program will be provided (maximum of two per year) which will enable key nursing personnel throughout the tri-county area to gain the necessary knowledge and skills to effectively provide cancer nursing care and to teach other nursing personnel. The establishment of hospital nursing units primarily devoted to the care of cancer patients requiring aggressive nursing care, will be encouraged. MICHIGAN Regional Medical Program -6- RM 00053 7/70.1 Each tri-county area hospital will be encouraged to work toward the establishment of a mandatory Papanicolaou cervical smear requirement for women admitted to the hospitals. The project proposes to demonstrate the feasibility of cooperative utilization of social workers in hospitals with less than 250 beds. A referral center telephone service will be made available to answer | such questions as where to go for financial assistance in purchasing costly drugs or where to obtain a bed for home care. , Diagnostic/therapeutic baselines (to be used as aids) for selected malignant diseases will be developed and will be disseminated to practicing physicians in the tri-county area. The Project Director will have overall responsibility for evaluating ongoing and terminal program accomplishments. Terminal evaluation of the extent to which program activities have improved patient care will consist of physician evaluators who will review all available records, x-rays, and tissue slides of two patient samples selected so as to permit generalizations. A systematic quantitative and qualitative analysis of all preceding project evaluation data will also be included in the terminal evaluation. $219,422 of the total request of $346,852, for the first year, is for personnel. $74,770 of the request includes stipends for the cancer consultant, mass program mailings to area physicians, Advisory Council luncheon conference costs and maintenance of off-campus office. Second Year: $357,530 Third Year: $328,697 MICHIGAN REGIONAL MEDICAL PROGRAM - 7s RM 00053 7/70.1 HISTORY SUPPLEMENT LISTING OF CURRENT STATUS OF CORE & OPERATIONAL PROJECTS IN MARMP A - FUNDED PROJECTS s PROJECT TITLE AMOUNT SUPPORTED NUMBER THROUGH 8/31/70 . BASIC CARRYOVER i* Central Planning & Administrative Staff (Rast Lansing & Subregions) $253,080 $22,000 3 Coordinated Data Collection and Analysis: Planning for Automation of Multiple Screening, MDPH 286 ,487 -- 4 Heart Association, Model CCU 103,590 50,250 5% MSU, Planning Office 228 ,568 -- 6 MSU, Hypertension Clinic 52,534 -- 7* U. of Mich., Administrative Secretariat 70.444 -- 8 Postgraduate Nursing Educ. - U. of Michigan 96,315 -- 9 U. of Mich. - Drug Information and Therapy Analysis 78,783 21,200 11 U., of Mich, - Medical Care Evaluation 100,292 22,288 12 School of Dentistry Program - U. of Mich. 31,636 -- 13 Survey of Physicians’ Attitudes - U. of Mich. -- 57,521 14* Wayne State Univ. - Planning Office 139,879 4,290 15 Zieger-Botsford Hospitals - Survey and Continuing Physician Education 64,840 10,100 16 Wayne State Univ. - Surveillance of Electronic Equipment in Special Care Units 13,211 39,855 21 Michigan Heart Association - Public Information Project -- 65,038 22 Development of a Cardiovascular Center, -- 34 ,440 Mercy Hospital, Benton Harbor *Core Planning MICHIGAN REGIONAL MEDICAL PROGRAM - 8 - RM 00053 7/70.1 A - FUNDED PROJECTS (Continued) PROJECT TITLE AMOUNT SUPPORTED NUMBER THROUGH 8/31/70 BASIC CARRYOVER 230 Demonstration of Comprehensive Health Care for -the Urban Poor - Wayne County General Hospital oo $ 31,712 25 Innovative Approach to a Continuing Medical Education System Based on Existing Satellite Hospital Concept 40,512 -- SUBTOTAL $1,560,171 $358,694 B- APPROVED - UNFUNDED PROJECTS $ 385,730 7- (Note: DRMP is in the process of awarding $385,730 - annual base - to partially fund the following approved, unfunded projects) 17 Stroke Base Center - Wayne State 18 Development of a Comprehensive Attack on the Problems of Stroke - Wayne State 19 Stroke Demonstration Unit at Detroit Osteopathic Hospital 20 Central Michigan Comprehensive Stroke Project 26 An Experimental Continuing Education Program for Small Inner-city Hospitals TOTALS $1,945,901 $358,694 C - DISAPPROVED PROJECT PROJECT TITLE NUMBER 24 Nuclear Medicine Technician Training - Hackley Hospital D - DISCONTINUED PROJECTS | 2 Michigan Department of Public Health - Planning 10 Nonprofessional Staff Utilization - Wayne State University DRMP 4/30/70 A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE MICHIGAN REGIONAL MEDICAL PROGRAM RM 00053 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee recommended that this supplemental operational application which requests $2,516,082 (d.c.o.) for a three- year program period by partially funded at $1,483,003 (d.c.o.) to support Project #16 for one year (renewal) and Project #27 in the time and amount -yequested (three years). Committee further recommended "non-approval - revision required"- for Project #28 for the reasons as set forth below. Once again as in past reviews, the Committee commented on the excellent local review of individual project proposals which are submitted from this Region. Project #16R - Surveillance of Electronic Equipment in Special Care Units - ‘ Wayne State University Critique: Members of the Committee were very pleased with the progress made thus far in this project. The Review Committee concurred with the Ad Hoc Cardiovascular Study Panel that the need for this type of service has certainly been demonstrated by the results obtained; that the objectives are clear and well defined; that the procedures utilized are apparently adequate; and the budget is modest. According to the appli- cant, a plan has been devised to continue and develop the present project as an on-going program without financial support from RMP after this year. ' Tt was noted that the project is beginning to acquire national recognition. The reviewers agreed with the study panel's unanimous recommendation that the project is technically sound, capably directed and recommends that it be continued in time and for the amount requested. : Recommendation: Approval‘in time and for the amount requested. Direct Costs Only: _ist Year _ _2nd Year _ 3rd_Year $45,701 Not requested Not requested Project #27 - Demonstration of A Comprehensive Health Care Program for Critique: This is a revision of an application which was originally reviewed during the April-May 1969 Review Cycle, in which this proposal was one of four proposals to be included in a technical site visit. Following a July 15, 1969, site visit, the August 1969 Council. Michigan RMP ~2- RM 00053 -7/70.1 recommended $40,000 for each of two years to continue planning of the proposal. In addition, nine specific points were raised which Council believed needed clarification. The reviewers believed this proposal satisfactorily relates to all issues raised, with the exception of the current demographic information on the target population and a commitment from Wayne County regarding support after termination of RMP funds. Members of Committee believed that more detailed demographic information would have been helpful in the review. Also, they realized that it is politically unrealistic to expect the present Board of Supervisors to commit funds three years hence, although the Board's interest in the services to be provided were noted. During the review, the Committee raised some questions and issues which they believed the Region should try to resolve. These were: (1) It was difficult to determine from the written application to what extent the people that are affected by the proposal were actually involved in the planning of the program; (2) The obligation to RMP to purchase, install and maintain costly and fixed equipment; and (3) Evaluation procedures were considered inadequate, although a cost- effectiveness factor may be determined at the end of three years. - It was noted that the Michigan School of Public Heaith plans to make use of the data obtained. In recommending approval, the Review Committee recommends that a condition of approval be that the applicant seek more participation from the target population: and suggested that this be accomplished through the establishment of a subcommittee on Health Care of the Poor. It was further recommended that the subcommittee be well represented by consumers of health services from the target. groups. (An Ad Hoc Committee member, a Program Coordinator, abstained in the vote on this proposal. He commented that he failed to understand how this project can be called comprehensive care rather than multiphasic screening since the patients in the study will receive treatment from the same sys~- tem as the control patients will. He further suggested that the follow- up period is insufficient for study and voiced his concern of the lack of community input into the project.) Recommendation: Approval ‘in time and amount requested subject to the condition . outlined above. Direct Costs Only: ist Year 2nd Year 3rd_ Year _ $505,269 / $454,574 $477,459 ‘i Michigan RMP ' -3- RM 00053 7/70.1 Project #28 - Proposal for the Southeastern Michigan Regional Cancer Program oa ara: Critique: This is the Region's first cancer proposal and is to improve the care of cancer patients in a tri~-county area by providing a clearly identified and publicized network of cancer consultants in nursing, medicine and social service. A survey indicated that the level ‘of practice regarding cancer management is outmoded by about ten years. Members of the Review Committee believed that the concept of training cancer consultants is naive (if a physician is an oncologist, he is a cancer consultant). It was difficult for the reviewers to understand why he should be paid. a per diem to do what he should or probably would do anyway. Additionally, it was believed the requirement that all hos- pital admissions have "pap" smears appeared to be an expensive duplica- tion. A question was also raised regarding the value of establishing cancer guidelines for this small geographic area. There was concern about the experience the proposed project director has had as an educator. In recommending non~-approval, the reviewers believed that the proposal should be recast to include much more planning of the educational aspects as well as concrete phase out plans, with a greatly reduced budget. Phasing of the program was also suggested. It was suggested that the Region utilize medical education evaluation consultation at Wayne State University and that the RMPS Continuing Education and Training Branch staff provide assistance in this effort. Récommendation: Non~approval II - revision required. SUMMARY OF RECOMMENDATIONS Project Number Title lst Year 2nd Year 3rd Year #16R Surveillance of Electronic $45,701 Not requested Not requested . Equipment in Special, Care , Units . #27 Demonstration of a Compre- 505,269 $454,574 $477,459 hensive Health Care Program for the Urban Poor #28 Proposal for the Southeastern Non~approval II - revision required Michigan Regional Cancer Program _ TOTAL Oo = $550,970 $454,574 $477,459 Michigan RMP Year 01 02 03 TOTAL ~4- $ 550,970 454,574 477,459 $1,483,003 RM 00053 7/70.1 DRMP/GRB 7/13/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) MISSISSIPPI REGIONAL MEDICAL PROGRAM RM00057 7/70.1 2500 North State Street June 1970 Jackson, Mississippi 39216 Review Committee Program Coordinator: Guy D. Campbell, M.D. Requested Program Period lst Year 2nd Year 3rd Year Total Direct Costs $520,713 $401,609 $420,679 $1,343,001 Indirect Costs 194,962 160,472 169 ,082 524,516 TOTAL $715,675 $562,081 $589,761 $1,867,517 HISTORY: This Region received a two-year planning grant beginning Julyl, 1967; $322,845 the first year and $505,932 the second. The first year award was supplemented in April 1968 by $131,361 to begin an earmarked two-year Comprehensive Stroke and Detection Center (Project #1). The second year planning award included $122,610 for the second year continuation of Project #1. A Supplement of $142,675 (earmarked) was awarded the second year for a Training Program in Diagnosis and Treatment of Chronic Pulmonary Disease (Project #2). Following the review of the initial operational application by the Review Committee in April, a site visit was made the following month to assess the Region's ability to assume operational status. The shocking lack of resources contrasted with the tremendous medical care needs impressed the site team. The shortage of health education resources outside of the University Medical Center is a serious problem which cannot be solved overnight and will influence the degree of quality medical care possible in this Region for years to come. But the site visitors were impressed with the commitment of the staff, participating organizations, and RAG in the Regional Medical Program. The site visitors felt that Mississippi had to have operational funds in order to begin this important task of effecting the facility of care. The May 1969 Council approved operational status. The first operational award included Core and nine projects. One other CPR training project was approved, but funding was deferred until Council policy was clarified. During the December 1969 meeting, Council reviewed and approved a supplemental renewal application of Project #1 for three years and three months. Subsequent to this action, the third period of the current award was extended from July 1, 1969 - March 31, 1970 (9 months) to July 1, 1969 - MISSISSIPPI Regional Medical -2- RMO00057 7/70.1 Program June 30, 1970 (12 months) to be sustained by anticipated unexpended current funds. Future support for three years is subject to fiscal restraints in FY 1971. For ease of reconciliation, please refer to the attached "Review and Funding History." PRESENT APPLICATION: This is a supplemental application for support of two new projects and one renewal, each for three years. They will be based at the University Medical Center, but are action-oriented at the peripheral community level. Requested Project #2R - Training Program in Diagnosis and Treatment First Year of Chronic Pulmonary Disease $323,730 This is a request for renewal of a two-year program which began as a feasibility project during the second planning year. The Council, during its review of the initial application in May 1968 believed that the proposal was well presented and in a Region needing better medical care. There was some question as to tenure of commitments and justi- fied level of support. Deferral for a site visit was recommended. The site visitors, September 1968, observed that the Region's capability was not then adequate enough to undertake all aspects of the proposed program. The visitors were also concerned about the weakness in the evaluation process, particularly the absence of baseline data, against which progress could be measured. During the November 1968 meeting, Council recommended approval for two years ina reduced amount of approximately half that requested. Following a favorable report of a site visit in May, 1969, Council recommended approval for continuation of the project in the second period, including $72,000 for needed remodeling of facilities. A continuation application for the third period of the current grant (July 1 - December 31, 1970 - 6 months), is expected in the near future. The level of support requested for three additional years' renewal beginning January 1, 1971, is considerably less than the amount requested for the same period of time in the original five year proposal. Current education and training programs include: 1) long and short term training activities for physicians, nurses and allied health personnel; 2) mobile demonstration seminars for outlying hospitals; 3) cooperative programs for pulmonary therapy aides; and 4) implementation of a formal four-month training program for pulmonary therapy aides. Other activities include: 1) demonstration of improved health care of children and adults with pulmonary disorders, particularly home care programs; 2) development of reproducible bacteriological surveillance techniques for therapy equipment; and 3) development of screening procedures for early detection of chronic airway obstruction. MISSISSIPPI Regional Medical -3- RMO0057 7/70.1 Program As reflected in the increased budget, five new programs are planned. In the development and demonstration of improved health care to patients with chronic pulmonary diseases, a special pediatric cliric will be conducted once each month. This is in addition to the current cystic fibrosis clinic which meets two half days per month. This clinic and laboratory will also be part o7 the facilities used for the project's continued education and training activities, Bacteriological studies will be undertaken to evaluate different practices for cleaning inhalation therapy equipment. An internship program (6 to 12 months) including evening seminars will be offered to graduates of approved schools of inhalation therapy.. The efficacy of the ambulatory home program is to be evaluated, By use of a mobile unit van, included in the equipment budget, demonstration seminars to peripheral hospitals are to be offered each week, an anticipated annual increase from 150 to 500 participants. Second Year $210,006 Third Year $219,179 Requested Oo First Year Project #13 - Emergency Nursing in Critical Illness $35,420 The purpose of this project is to upgrade the quality of nursing the critically ill, emergency and day-to-day care. In tune with this objective, a five-day course will be offered to 60 nurses annually. The budget indicates that twelve courses will be held each year, approximately five trainees per session. Mindful of the need for additional training of nurses in small hospitals, the courses will initially be limited to nurses who have close contact with extreme emergency and critically ill patients. Enrollees will be required to return annually for a one-day conference for updated information and to review individual problems. Program assessment includes pre and post-testing, on-the-job logs by trainees, on-the-job observation by a project facility member and evaluation of trainees by their hospital administration. Second Year $36,946 Third Year $39,455 Requested First Year Project #14 - Comprehensive Renal Training Program $161,563 This is a recast of Project #12, same title, which was funded in a greatly reduced amount for a one~year trial period for further planning and development of the program, This action by Council, May 1969, followed a site visit that same month. The site visitors recognized the need for the activity. However, it was believed that the proposal was overly ambitious and lacked sufficient planning. MISSISSIPPI Regional Medical -4- . RM00057 7/70,1. Program a The purpose of this project is to reduce the gap between knowledge | and its application. Utilizing present facilities, training programs will be offered to physicians, nurses, technicians, dietitians, social workers, and administrators, Present facilities include the Artificial Kidney Unit, the Renal Laboratory and the Home Dialysis Training Center. Other project aspects include testing screening procedures, teletype tie-in with a kidney donor data program, tissue typing training and statewide telephone consultation for physicians. Approximately 70% of the budget is for personnel. Support is requested in most other budget categories, most significant amounts of which are for equipment and travel, Second Year $154, 657 Third Year $162,045 . r ? MISSISSIPPI Regional Medical 5 RM00057. —-7/70.1 Program REVIEW AND FUNDING HISTORY Ist Year Planning Award 7/1/67 - 6/30/68 $322,845 February 1967 Council (return for revision) March 1967 Site Visit May 1967 Council Project #1 (feasibility study - earmarked funds) Stroke Detection and Treatment 4/1/68 - 3/31/70 (01-3 mos.) $131,361 Approved Future Level - Direct Costs 02 03 (9 mos.) $80,293 $61,927 2nd Year Pianning Award 7/1/68 - 6/30/69 $505, 932 (includes $122,610 for Project #1 - 02-12 mos.) September 1968 Site Visit Project #2 (feasibility study - earmarked funds) Training Chronic Pulmonary Disease - 1/1/69 - 12/31/70 (01-6 mos.) $142,675 Approved Future Level - Direct Costs 02 03 (6 mos.) $167,467 $89 ,000 Initial Operational Application Projects 7/1/69 - 6/30/72 May 1969 Site Visit May 1969 Council August 1969 Council MISSISSIPPI Regional Medical -6- RMO0057 7/70.1 Program : Direct Costs Funded Commitments 01 02 03 00 Core Staff $306,879 $329,678 $353,488 *#1 Stroke Detection and Treatment (9 mos.) 62,619 ) 0 #2 Training Chronic Pulmonary “Disease 200, 292 (6 mos) 89,000 0 #3 Post Graduate Institute in Medical Sciences 38,509 47,187 45,396 #4 Recruitment of Health Manpower 70,000 0 0 #5 Cardiovascular Clinics | 29,018 29,968 30,966 #6 System of Coronary Units 164,586 79,489 81,409 #7 Lowndes General Hospital Disapproved - No RMP Funds to be Used #8 CPR Training (9 mos.) 38,988 46,247 0 #9 Central Tumor Register Disapproved - No RMP Funds to be Used #10 Radiation Therapy 204,861 78,629 76,898 #11 Regional Neurology Clinics 67,494 66, 186 68,909 #12 Renal Disease Training 46,321 0 0 Totals $1,229,567 $766,384 $657,066 * Staff action on 2nd year continuation application. First Supplemental Operational Application December 1969 Council #IR Stroke Care Demonstration and Teaching 4/1/70 - 6/30/73 (3 years - 3 months). Subsequent to Council approval, the current 02 period was extended from July 1 - March 31, 1969 to July 1, 1969 - June 30, 1970 with no additional funds (to be sustained with current unexpended funds). Approved Future Level- Direct Costs 01 02 03 $119,803 $131,094 $141, 623 DRMP oy 6/3/70 8 aL _*. A Privileged Communication SUMMARY OF REVIEW AND CONCLUSIONS OF JUNE 1970 REVIEW COMMITTEE MESSTSSIPPT REGIONAL MEDICAL PROGRAM RM 00057 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Review Committee recommended that this Supplemental Opera- tional Application requesting $1,343,001 (d.c.o.) for three years, be partially supported at $378,821 (d.c.o.); $213,420 the first year, $125,946 the second and $39,455 the third. Throughout the review of this application, the Committee was mindful of the dearth of medical care in Mississippi and the lack of adequate medi- cal facilities and manpower. Although the recent second year continuation application indicated the Region has made some progress in tackling its problems the staff reported, the Committee expressed concern that the MRMP does not seem to be addressing "real world" priorities and the cate- gorical emphasis may have attributed to this problem. It was believed that there is great need for RMPS staff assistance in helping the Region study its representation on the RAG so that basic health needs of the people are considered in setting priorities. Project #2R - Training Program in Diagnosis and Treatment of Chronic Pulmonary Disease Critique: The Committee reviewed the history of this two-year project for which renewed support ($752,915 d.c.o.) is requested for three years. Previous site visit and Council actions outlined in the history summary were noted. It was believed that though needs are well documented, evaluation procedures are limited and reported accomplishments are meager. While the bacteriological surveillance of aspects would prob- ably go well, there is some question about the capability of carrying out meaningful education. The shortage of physician and allied health resour- ces in Mississippi is well known. MRMP programs are moving in categorical areas and perhaps the immediate needs are for more comprehensive activities. The question arose as to whether pulmonary training is a major unmet health need in Mississippi. Regardless of the project's priority status in the MRMP, the Committee felt that not enough documentation was pre- sented to justify approval of the amount nor the period of time requested. Recommendation: Approval at the current annual level ($178,000) for 18 months. The Region should be given assistance by the Continuing Education Branch staff of RMPS to assure that the next continu- - ation application includes progress defined in specific terms. Mississippi RMP -2- RM 00057 7/70.1 Project #13 - Emergency Nursing in Critical Illness Critique: The Committee agreed with the comments provided by the Continu- ing Education and Training Panel. The design in general is well written and developed and the direction is a helpful one for this Region. However, there is no indication of preassessment of learner's knowledge (especially in physiology and chemistry) necessary to compre- hend the course coatent. There is some quéstion of the appropriateness of course content for rural nurses. There is not enough indication of nursing participation in the development of the program, of nurse teach- ing in the course, or of the nature of follow-up support. Objectives are stated well in program terms, but learner behavior reference is not. There is a need for more evidence of interest in utilizing co-trainees' new skills from hospitals and their medical staffs. Evaluation, for which there is probably too little staff time allocated, is all in terms of learner's knowledge and attitudes rather than in behavior. A more mean- ingful evaluation might be in terms of the impact of training on patient care. The budget may be too modest for staff time for the secretary and nurse coordinator. There are no specifics presented about phasing out or continuing the activity beyond cessation of the grant. Although answers to questions and concerns are desired, the project was considered worthy of support. Recommendation: Approval I in the amount requested. It is also recom- : mended that the MRMP be informed about the reviewers' concerns and questions. Specific suggestions: (1) nursing faculty be utilized in teaching nursing content; (2) curriculum vitae for nursing personnel be provided to RMPS;(3) assurance of adequate staff time to carry out secretarial work, circuit riding and evaluation; and (4) docu- mentation of commitment of sending hospital's administration and medical staff to utilize training of students on their return to work. Project #14 - Comprehensive Renal Training Program Critique: The Review Committee noted that this project grew out of experience with Project #12, same title, which was funded in a greatly reduced amount ($46,321 d.c.o.) for one year for further plan- ning and development. Review comments indicating that the program was feasible under certain conditions by the Continuing Education and Training Panel were considered. Conditions included concerns that the physician courses are too minimal, the nurse course 201 seemed impossible for the time allotted, and the tissue typing course should be eliminated. The Panel believed that the curriculum should be better defined to indicate where all the different categories of personnel will fit in. Other concerns included equipment budget justification; specific information needed about the number and location of satellite dialysis programs; need for better description of TERT RRP Mississippi RMP -3- RM 00057 7/70.1 the trailer dialysis unit, and other types of dialysis facilities; clari- fication of fellowship program (e.g., is this for board certification) ; patient selection criteria needs should be better identified (e.g., will patients over 65, for whom medicare will reimburse, be selected over younger patients who cannot pay). This proposal stimulated a great deal of discussion in terms of (1) tech- nical soundness and feasibility of the application; (2) the priority of - renal disease programs’ in MRMP; and (3) RMPS' role and limitations in this area. The Committee had the benefit of comments from one of its members with expertise in nephrology and knowledge about the status of renal disease management in Mississippi. He stated that Mississippi seems to have most of the five basics needed for an end stage kidney program: (1) a dialysis center; (2) multiple satellite dialysis units; (3) tissue typing; (4) or- gan retrieval and (5) transplant facilities. He also believed the proj- ect director to be capable of conducting a successful program. It was noted that the trailer dialysis unit is a new innovative aspect that may prove to be very worthwhile in Mississippi. Some believed that RMP funds for renal disease should be limited to training, which is the purpose of this proposal. The question then arose that unless more dialysis facilities are needed and established, why train additional personnel? This question was not satisfactorily resolved. | Others believed RMP funds should not be used for programs in end stage kidney disease, that there are other greater needs for available dollars. The Committee, however, recognized that RMPS had to become involved in renal diseases but on a carefully considered basis. They request Council to spell out a clear policy for RMP funding to guide them. The high cost of the proposed program for 240 patients was considered in relation to other unmet health needs of more people, and the Committee felt that a RAG more representative of all the people in Mississippi might come up with a different order of priorities. Two motions for recommendations were defeated by a narrow margin. They were: (1) Approval I with conditions cited by the Continuing Education Panel and (2) Non-Approval I. Recommendation: Non-Approval II Revision Required. This action is not to be construed as encoufagement to submit a revision. It is strongly recommended that RMPS staff assistance be provided, parti- cularly regarding the relation of this activity to other health needs. RM 00057 7/70.1 Mississippi RMP -~4- SUMMARY OF RECOMMENDATIONS DIRECT COSTS O01 02 03 Total #2R Chr. Pul. Disease $178,000 $ 89,000 $ -0- $267 ,000 #13 Emerg. Nursing Critically I11 35,420 36,946 39,455 111,821 #14 Compr. Renal Trg. -0- -0- -0- -0- TOTAL $213,420 $125,946 $ 39,455 $378,821 DRMP 7/8/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privilezed Communication) MISSOURI REGIONAL MEDICAL PROGRAM RM 00009 7/70.1 Lewis Hall June 1970 Review Committee 406 Turner Avenue Columbia, Missouri 65201 PROGRAM COORDINATOR: Arthur E. Rikli, M.D., M.P.H. Requested lst Year 2nd Year 3rd Year Total Direct Costs $343,253 $223,540 $161,938 $728,731 Indirect Costs 105,856 81,075 61,554 248,485 TOTAL $449,109 $304,615 $223,492 $977,216 BACKGROUND: The Missouri Regional Medical Program is beginning its fifth year of planning and its fourth year of operations. The level of funding which the Region has requested for the year beginning July 1, 1970, is approximately $3.8 million (d.c.o.) of which $.74 million is carryover of unexpended funds from the 1969-1970 year. The $3.8 million includes $2.7 million for projects and $1.1 million for core (these amounts are currently under negotiation with staff). A complete list of Missouri's projects are included in an attached staff observation. The Region has no approved but unfunded projects. The Missouri Regional Medical Program has as its applicant organi-: zation, the University of Missouri, located in Columbia. Dr. Arthur Rikli, who had served as Director of Operations since early 1968, was appointed Coordinator in October 1968. The core staff, which has 27 positions, includes the Office of the Coordinator, the Office for Operations, which administers the projects, and the Office of Planning, which includes health care studies and six subregional offices. The 12-member Advisory Council, composed of practicing physicians, hospital administrators, a lawyer, state legislators, a sociologist and businessman, approves the applications and assists in determining program priorities. An eight-member Project Review Committee, chaired by the Dean of the School of Medicine at the University of Missouri, a Central Liaison Committee representative of 23 organizations and three area liaison committees assist the Advisory Council in its review function. The area liaison committees representing the Greater Kansas City, the Southeast Missouri, and the Southwest Missouri areas also serve to answer boundary or jurisdictional questions of project proposals. Although the majority of the Missouri RMP's earlier MISSOURI REGIONAL MEDICAL PROGRAM -2- RM 00009 7/70.1 projects are based at the University Medical Center, the Region's more recent submissions have been based in areas peripheral to the Medical Center - Kansas City, Sikeston and: Joplin. The Missouri RMP had been encouraged by DRMP in 1966 to develop an operational program and it. became one of the first Regions to become operational. It developed a program emphasizing a computer and bioengineering approach to improving the delivery of health care. However, in the meantime, changes in the federal health effort and RMP's role in that effort in the last three years and the lack of demonstrable success of these activities seemed to dictate a change in emphasis. A major program site visit was held in October 1969; the site visitors also believed that these pro- jects had not lived up to their expectations and noted growing enthusiasm among various Missouri RMP groups for subregional pro- grams. They recommended that the computer - bioengineering projects at the University be phased out by June 1971 and that the Region emphasize community-based activities. Review Committee and Council abreed to the need for the change, and made their recommendations for the Region's future funding levels accordingly. The Region's funding picture in direct costs for 1969-70 may be presented as follows: Computer and Bioengineering Activities. $2.0 million Subregional Projects -6 million Core 1.1 million . $3.7 million Carryover Funds 1.1 million $4.8 million Council's recommendation for 1970-71 was: For phase out of Computer and Bioengineering Activities $1.0 million Subregional Projects #25, 26, 27, 29, 33 and 46 .96 million Core 1,1 million $3.06 million Council also suggested the Region use $ .94 million up to approximately $940,000 in carryover funds for additional subregional activities $4.0 million MISSOURI REGIONAL MEDICAL PROGRAM ~3- RM 00009 7/70.1 Inherent in. the phase-out of the computer and bioengineering activities, for which support was not recommended beyond June 30, 1971, was an expansion of subregional activities. In the grant year beginning in July 1971 and 1972, Council recommended that approximately $2.2 million and $1.8 million, respectively, in new funding be available for the approved core, new supplemental and continuation projects. Council stated that these recommended levels in no way represented ceilings and that the Region could compete for additional funding with subsequent applications. Other recommendations which national reviewers made include: 1) expand the membership of the Regional Advisory Council to include a more representative group, analagous to the composition of the Liaison Committee: 2) differentiate more clearly between the pro- gram of the medical school and the program of the Missouri RMP; 3) concentrate more efforts in the Kansas City urban poverty area and delegate more responsibility to the new medical school in Kansas City for RMP activities there. Correspondingly, the core office should also make greater attempts to involve local people in communities outside Columbia in decisions affecting them; and 4) take cognizance of continuing education efforts throughout the Region rather than concentrating on improving the program of the medical school. Project #60 ~ Cameron Health Care System Project. This Requested proposal is geared toward improving both the First Year quality and quantity of health services in an established $108,335 medical service area. The Cameron Community Hospital ia a 58-bed facility located in the center of a four-county service area in the Northwest Corner of Missouri. The disappearance of M. D. physicians from rural areas has left Cameron with a staff composed entirely of osteopathic physicians. The proposers believe that the rural and attendant professional isolation has contributed to the loss of physicians from the area and hope to reverse this trend by instituting a better health care system with the following sub- systems: 1) Continuing Education of Physicians and Allied Health Personnel involves sending two physicians for a one-month course; sending five registered nurses to UMMC for training in intensive coronary care; subscribing to weekly videotape lecture series of wet clinics with faculty from both medical schools; obtaining special training for the home health agency discharge nurse at the UMMC: and sending four nurses to the UMMC for training in rehabilitation techniques. 2) Intensive Coronary Care Unit. The hospital would need RMP funds for training physicians and nurses, as the hospital would supply all the necessary monitoring MISSOURI REGIONAL MEDICAL-PROGRAM -4- RM 00009 7/70.1° equipment and a crash cart. Eventually the hospital will Build an addition to house an enlarged rehabilitation unit and an enlarged physical therapy unit and will increase the two-bed unit to four beds. The hospital will also add a third telephonic ECG link-up with cardiologists in Kansas City. 3) An Ambulance Service is needed because the advent of Wage and Hour Law is precipitating funeral directors' phase-out of such service. As the hospital is purchasing the two ambulances, RMP support is needed to supply an ECG and heart-lung resuscitation equipment and supplies. Nine atteadants will be sent to UMMC for 60 hours of training. When not devoted to ambulance’ service, the attendants will be used elsewhere in the hospital. 4) Rehabilitation Services would be made possible by hiring a physical therapist and training four rehabilitation nurses who would in turn train aides assigned to the unit. Because dental care is an important part of this service, RMP funds are requested to purchase dental equipment for the unit. 5) Home Health Agency Services would be provided by a nurse who would receive training at the UMMC and then function as a discharge nurse in the hospital. A Project Coordinating Committee composed of three lay board members and three professional staff members will determine policy for the project director. Each subsystem will have a staff member as chair-~ man. Each of the subsystems will be evaluated both objectively, by test scores, cost comparison, mortality figures, etc., and subjectively by physicians, nurses, administrators and the community. The bulk of the three-year $198,744 request is for personnel ($152,375). Second Year: $54,967 Third Year: $35,442 Project #61 — Branson Intensive Care and Rehabilitation Project. Requested This proposal would create within the Skaggs First Year Community Hospital in Branson, Missouri, a comprehensive - $135,188 intensive care unit and a rehabilitation unit. The hospital has 59 beds and is located in the Southwest corner of Missouri, 40 miles from any other hospital. The project would "provide a model for demonstrating effectiveness of regionalization in establishing new services in a small community hospital." Space will be remodeled to house the four-bed intensive care and the rehabilitation wits. Physicians and nurses would receive training in cardiovascular care techniques and in physical wedicine in the Springfield Cardiovascular Education and Evaluation Project (Project #22). A physical therapist and a part-time MISSOURI REGIONAL MEDICAL PROGRAM -5- RM 00009 7/70.1 occupational therapist would be hired. Continuing education would be conducted in regular seminar sessions and through the use of the ROCOM Program (a multimedia instructional system produced by John Sutherland). The staff of the Springfield project and the University of Missouri Medical Center will be available for consultation on establishing the program and for evaluation. While $23,084 is requested for the first year for equipment and $10.000 for alterations and renovations, funds are primarily budgeted for personnel and their training ($91,424). The third year's budget is for evaluation efforts. Second Year: $57,620 Third Year: $9,000 Project #62 - Drug Information Central. The UMMC Department of Requested Community Health and Medical Practice will First Year sponsor this proposal to develop a centralized comprehensive $99,730 drug information service that would be available to all health professionals throughout the Region. This system will serve to rapidly furnish drug information on request, supplement continuing education programs, save time for health professionals, and provide composite information on drug interaction and incom- patibilities. Operating in conjunction with the Computer FACT (Fast Access to Current Text) Bank, various types of drug information would be accessible by telephone or mail inquiry, as well as by personal visit. Additional access would be possible through the existing four-station Telex network (Springfield, Kansas City, Kirksville, Sikeston). It would make, available information of practical importance in the managment of patients, information not currently available in any single book, set of journals or review articles, and information being continually updated and expanded at a rapid rate. During the first six months of operation, D.1.C. Terminals will be established in six community hospitals. In the second year they will be placed in at least twelve more hospitals and probably in several group practices, clinics, and physicians's offices. During the third year, it is expected additional hospitals, clinics, etc., will request terminals and be prepared to cover their entire cost and that institutions and physicians in neighboring regions will arrange for D.1I.C. Terminals via negotiations with the Missouri RMP. MISSOURI REGIONAL MEDICAL “PROGRAM -6- . RM 00009 7/70.1 Together with computer-developed records, evaluation will be based on a questionnaire circulated at six-month intervals aimed at determining the number of inquiries received, the number answered and ehe mean time required, and the number of repeat inquiries from other sources in the same category. As for continuation of the Drug Information Central beyond the period of RMP involvement, the Region reports some promising preliminary talks with FDA, NIMH, and several other interested organizations. It also hoped that local institutions and individ- vali physicians would lend financial support in order to continue to enjoy the benefits of the system. Second Year: $110,953 Third Year: $117,496 DRMP /GRB 5/25/70 MISSOURI REGIONAL MEDICAL PROGRAM BM 00009 7/7071 — A Privileged Communication STAFF OBSERVATIONS Summary of Review Actions OT STATUS AND PROJECT CURRENT SUPPORT #1 - Smithville Community Health Service Program Terminated #2 - Communications Research Unit (04) $25 ,349 #4 - Multiphasic Testing (now in Project #49) (04) (67,673) #5 - Mass Screening Radiology (now in Project #49) (04) (37,693) #6 - Automated Patient History (mow in Project #49) (04) (72,880) #7 - Data Evaluation and Computer Simulation (now in (94,538) Project #49) (04) #8 - Computer Fact Bank (now in Project #49) (04) (107 , 348) #12 - Operations Research and Systems Design (now in (32,839) Project #49) (04) #13 - Populations Study Group Survey (04) 20,585 #14 - Automated Hospital Patient Survey (04) 36,955 #16 - Program Evaluation Center Terminated #17 - Bioengineering (now in Project #49) (04) (52,883) #18 and #30 ~ Core 1,100,000 #19 - Automated EKG (now in Project #49) (04) (223,257) #22 - Comprehensive CV Care Units, Springfield Terminated #23 - Manual of Services Terminated #25 - Stroke Intensive Care Unit (03) 150,662 #26 - Training Unit for the Intensive Care of the 155,735 Cardiac Patient (03) #27 - Programmed Comprehensive cardiovascular Care (03) 123,417 #28 - Tumor Registry Terminated #29 - Northeast Missouri Cooperative Stroke Pilot 67,314 . Project (03) MISSOURI RMP STAFF OBSERVATIONS #32 #33 #34 #35 #36 #37 #38 #39 #40 #41 #42 #43 #44 #45 #46 #47 #49 #50 #51 #52 #53 RM 00009 Effectiveness of the Detail Man Approach Continuing Education for the’ Health Professions (02) Community Services for Heart Disease, Cancer and Stroke , Education of Greene County Residents About Heart Attacks Missouri Cervical Cytology Project (02) Southeast Missouri Radioisotope Program (02) Homemaker Home-Health Aide Project (02) Phonocardioscan Project (02) | ICU and Pulmonary Function Laboratory, Sikeston Stroke Prevention and Rehabilitation Program, Joplin . Early Detection of Cervical Cancer Early Diagnosis and Treatment of Children with Diabetes Mellitus (02) Cardiac Care and Risk Evaluation Lebanon Model Project Hi-Blood (02) Core~Continuing Education Advanced Technology Project Stroke Prevention and Rehabilitation, Joplin (01) . Intensive Care Unit and Pulmonary Function Laboratory, Sikeston (01) Health Careers Program (Ol) | Early Detection of Cervical Cancer 7/70-1 Terminated 228,098 Terminated Disapproved 71,725 77,462 108,198 34,055 Returned for Revision Returned for Revision Disapproved 61,831 Returned for Revision Returned for Revision 129 ,985 Returned for Revision 917,111 91,819 95,983 62,240 Disapproved © MISSOURI RMP STAFF OBSERVATIONS - 3- RM 00009 7/70.1 #54 - On-Line Diagnostic and Reporting System - Disapproved #55 - Cancer Management and Education 112,973 Optimization (01) #56 - Supportive Communication for Satellite Units Disapproved #57 - Automated Patient History Acquisition Returned for Revision #58 - Cardiovascular Education and Evaluation, Springfield (01) 127,503 #59 - Regional Blood Inventory System Disapproved Total $3,800,000 1/ 1/ Award includes $3,074,230 new funds and $725,770 in carryover. GRB/6/19/70 ‘ A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION ON: JUNE 1970 REVIEW COMMITTEE MISSOURI REGIONAL MEDICAL PROGRAM RM 00009 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Missouri RMP submitted a supplemental application for three projects requesting $1,185,059 for a three-year program period. The Committee concluded that the application be supported as follows: $33,243 the first year, $36,984 the second year, and $39,165 the third year to support Project #62, Drug Information Central. Projects #60 and #61 were disapproved. The Committee was reminded that previous reviewers have encouraged the Region to submit community~based activities and deemphasize University- based projects in computer and bioengineering areas. While the Region has followed this advice in the present application (two projects are based ir hospitals in small communities and one at the University of Missour’ © partment of Community Health and Medical Practice), the re- viewers 2 generally disappointed with the projects. The projects. in Bransoti - .. Cameron appeared to be gapfilling measures for the hospitals where If) support was being substituted for what the community should be supporting. Specific criticisms concerning each project follow. Project #60 - Cameron Health Care System Project Critigue: This request is a potpourri of individual projects within one directed at improving care within a 58~bed hospital in the northwest corner cf Missouri. Because the hospital is served entirely by osteopathic physicians, who have not related well to the medical doctors in the area, an additional aim is the improvement of cooperation between these two groups. In reviewing the educational portion of the project, the Continuing Education and Training Panel concluded that the objectives were not stated in measurable terms and no mention was made of resources for educational methods. No provision is made for staff time or funds and no description of methods is given for evaluation. For these reasons and because the project would buy services with RMP funds which the Committee felt the community should be supporting, dis- approval was recommended. Missouri RMP ~ 2 - RM 00009 7/70.1 Project #61 - Branson Intensive Care and Rehabilitation Project Critique: This project also serves’ a small community in rural Missouri, - but reviewers thought it was representative of the ambitions of a single institution, rather than a truly regional cooperative effort. The Continuing Education and Training Panel believed that the need for a four-bed unit based on 90 patients a year was overstated. Some descrip- tion of in-hospital days, nature of diagnosis, ages of patients and use by ambulatory patients would have been useful in substantiating the. need for more beds. The Panel also felt evaluation could be improved: while the project would measure effectiveness in terms of morbidity, reviewers believed improvement in the functional capacity of patients should also be measured. A more adequate description was needed of how all health professionals, particularly nurses and allied health persomel, would be involved in further planning and operation of the project. In light of these technical criticisms and the lack of conviction that this project would truly further regionalization efforts, the Committee recommended disapproval. Project #62 - Drug Information Central Critique: The Committee was satisfied that the project would serve a need for physicians by providing adequate updated drug infor- mation from reliable sources. While the reviewers thought that the dial access system for drug information might be a useful tool in providing the information, the amount of funds requested seemed high. Furthermore, the hospital pharmacists do not seem to be an integral part of the system and the Committee felt that their involvement was essential. Accordingly, approval was recommended at one-third of the requested amount with the condition that the format be revised to involve existing hospital phar- Ihacy Manpower. , a Approval I at the following level with the condition that the format be revised to include existing hospital phar- Imacy manpower. O1 02 03 "$33,243 : $3 6 ; 98 4 ~~ "339,165 Conclusion: A total of $109,392 was recommended for Project #62. Doctor William Mayer was not present. during the deliberation of this application. , ‘ Missouri RMP: Project #60 - Cameron Health Care System Project Project #61 - Branson Intensive Care and Rehabilitation Project Project #62 - Drug Information Central TOTAL w ~ ; RM 00009 7/70.1 ol 02 03 Non-approval I - no RMP funds recommended Non-approval I - no RMP funds recommended $33,243 $36,984 $39,165 $33,243 $36,984 $39,555 DRMP 7/10/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) MISSOURI REGIONAL MEDICAL PROGRAM RM 00009 7/70.2 Lewis Hall June 1970 Review Committee 406 Turner Avenue Columbia, Missouri 65201 PROGRAM COORDINATOR: Arthur E. Rikli, M.D., M.P.H. Requested: Ist Year 2nd Year 3rd Year 4th Year Sth Year TOTAL Direct Costs $109,596 $179,345 $234,260 $485,531 $526,187 $1,534,919 Indirect Costs 34,860 55,183 75,133 151,849 167,034 484 ,059 TOTAL $144,456 $234,528 $309,393 $637,380 $693,221 $2,018,978 HISTORY: A general history for the Missouri RMP may be found in the summary (RM 00009 7/70.1). The project in the application (RM 00009 7/70.2), entitled Continuing Education - Coordination Project, was originally submitted on May 1, 1969. The original application requestea $1,384,647 for five years, most of which was in personnel, The proposal was divided into three parts: 1) the core cooperative activity, 2) the teacher-consultant activity, and 3) the local educational coordinator. A history of the reviewof this project is outlined in a Staff Observation. PRESENT APPLICATION Requested Project #63 - Continuing Education - Coordination Project. The First Year primary goal of this project is "the improvement of $109,596 patient care through the development of a meaningful system of con- tinuing education that is built into the day-to-day, week-to-week practice of health professionals of the Missouri Region." This propo- sal would develop the framework and linkage mechanisms of a meaningful continuing education system which would provide the bridge between the agencies and institutions in Missouri concerned with continuing education. Its objectives and methodology would serve to help under- stand: 1) the current efforts to avoid overlap and duplication; 2) the degree of effort the organizations are willing to exert in the future; 3) the degree to which these same organizations will use this project to enhance their own activities, as well as support others' activities; 4) the needs of individual professionalsand of each health profession and the means to communicate these to the system; and 5) a method whereby hospitals can receive assistance in developing programs for staff based in patient care needs. These understandings of the current system and the subsequent develop- ment of a more meaningful system will result from the following three related activities: MISSOURI Regional Medical Program -2- RM 00009 7/70.2 I. A Continuing Education Cooperative Activity proposes the establishment of an inventory of continuing education activities in the six subregions of Missouri. An outgrowth of this activity would be a clearing-house function to make available information on continuing education programs to all health professionals of the Region. An Advisory Committee whose miembers will be drawn from the producers ‘and consumers of continuing education activities in Missouri will review the inventory and appraisal data and recommend educational programs which should be initiated. Staffing for this part will consist of two half-time co- directors (salaries paid by the University of Missouri) and a secretary. Il. The Teacher-Consultant Activity is a cadre of various health professionals who will establish linkages with the various health professionals of the Region and between the health professionals and the Advisory Committee on Continuing Education. They will also serve as liaison with the organi- zations and institutions on the Advisory Committee and provide advice to those hospitals, clinics and organizations who wish to initiate and develop continuing education activities. Through these linkages the needs of the indivi- dual members of given health professions at specific locations will be coordinated. The proposers envision several full-time physicians, educa- tionalists, nurses, allied health professionals and secretarial personnel in this component. III. The Local Educational Coordinator Activity would place a physician-coordinator in each of five subregions to assist health care institutions and health professions in the institutions to develop and initiate a program of continuing education. The sixth subregion will be served by the central office. A coordinator will be placed in one of the subregions the first year with additional ones to be added to the other subregions during the subsequent years. All components will have available to them the facilities of the Medical Center and University and the benefit of contacts the non-campus staff of the University has made. Hopefully, other participating agencies will volunteer additional resources. The control of the project is shared with the Missouri RMP, the Advisory Committee on Continuing Education and the Dean of the School of Medicine. MISSOURL Regional Medical Program -3- RM 00009 7/70.2 Evaluation efforts will consider documentation of the time involvement of individual professionals, anecdotal reports of project personnel, surveys, information transfer and effect on patient care. The five-year $1,534,919 request consists primarily of personnel costs ($1,282,438). Second Year: $179,345 Third Year: $234,260 Fourth Year: $485,531 Fifth Year: $526,187 DRMP/GRB/5/19/70 A PRIVILEGED COMMUNICATION Missouri RMP 00009 7/70.2 STAFF OBSERVATIONS The following is a summary of the past review actions and comments of the Continuing Education - Coordination Project. July 30-31, 1969 Review Committee Core - Continuing Education Critique: The Review Committee and Continuing Education and Training Panel both agreed that this core activity speaks well to coordination of continuing education activities but beyond the philosophical tenets, the proposal gives little indication of the activities which are going to take place. Personnel costs, which constitute the largest budget item, are not justified by job descriptions or functions. Other than one general paragraph thereis little or no indication of the relation of this project to existing projects in continuing education, particularly Project #33, Continuing Education for the Health Professions. No evidence exists, in the form of letters, surveys or otherwise to indicate that the practicing physician, community hospitals or voluntary health agencies have been involved in planning this project, or would support or utilize its services. In view of the vagueness and the unanswered questions, the Review Committee defers a recommendation until after the site visit findings are available. Recommendation: To include the application with the material to be reviewed by the site visit team and defer a recom- mendation until the November 1969 Committee meeting when the site visit report is available. August 26-27, 1969 - Council recommended: Deferral for further consideration during the upcoming site visit. Site Visitors Comments, October 7-10, 1969. Core Continuing Education Spokesmen: Dr. William Mayer, Mr. Gail Bank, Mr. John Mowrer, Mr. Carl Marienfield, Dr. Vernon Wilson Dr. William Mayer was able to briefly describe his proposal, and the visitors discussed the proposal at greater length with Dr. Vernon Wilson, Mr. Carl Marienfield, and the proposed project staff. Unfortunately, Dr. Mayer was not present during the 'feedback session" on the final day of the site visit to hear the site visitors' perceptions and recommendations. STAFF OBSERVATIONS -2- This is an extensive three-level operation designed to bring about coordination of continuing education activities within the region. The first level of activity, and the first priority, is the estab- lishment of a state-wide advisory council to involve institutions and agencies concerned with continuing education. This framework would provide a headquarters for the University of Missouri Medical i Center continuing education programs. The second level of activity is the provision of teacher-consultant : teams to identify the personal-professional needs of individual pro- fessionals and professional groups. The manner in which these teams would accomplish this objective was not clearly defined. The third level of activity is the local education coordinator who serves as "extension agent’ in the communities. Considerable difference | of opinion was noted among the Missouri RMP, the Extension Division, the Medical Center representatives, and Dr. Vernon Wilson as to what the role and qualifications of this key person would be. There was considerable difference of opinion among the groups concerned as to whether this individual should be a physician or should be more of a 5 sociologist or educator, whether he should live in the local community 5 or be there on a part-time basis, whether he should work as a DME in : a local hospital or be based in other community resources. Impressions: The visitors, like the Continuing Education Panel, had major reservations about this proposal. It seemed, primarily, to be organiza- tionally oriented to furthering the continuing education effort of the University of Missouri Medical Center. There appeared to be no clear mechanism for feeding the educational benefits of RMP activities into this RMP "Core" proposal. The proposal tended to be isolated from the other activities of the Missouri RMP, rather than central to and ina position to coordinate these activities as a "Core" effort should. The team had the highestregard for the leadership of Dr. Mayer, but was much less certain about the capabilities of the project staff on whom success of the project depended. In view of the differences of opinion among the people concerned about the qualifications for the staff, the lack of philosophical agreement, the vagueness about the methods of identifying educational needs, the lack of systematic evaluation, and in view of the isolation of this project from the very activities which it should ‘be coordinating, the site visit team recommended that the proposal be returned for revision. The site visitors noted that this recommendation coincided with the unanimous opinion of the Continuing Education Panel. IORI OR SE ES ERD ORLD SL EEA a at November 5-6, 1969 Review Committee Project #47 - Core - Continuing Education. Critique: The site visitors were directed by the August 1969 Council to review this project during the October site visit. The — STAFF OBSERVATIONS -3- site visitors found that although this continuing education activity would be funded as a part of the Missouri RMP core, it appeared organizationally oriented to furthering the continuing education effort of the University of Missouri Medical Center. Interviews with several other project directors indicated that the proposal seemed to be iso- lated from other Missouri RMP activities and that a mechanism for feed- ing the educational benefits from community-based activities into the central core resource was lacking. These findings confirmed the under- standing the Continuing Education and Training Panel had about the project. Although the Dean of the Medical School was able to respond only briefly to the site visitors about this proposal, the visitors did hear from thoseconcerned with the direct operations of the core component. The visitors were unable to obtain samples of kinds of data which would be used to identify educational needs. There were varying opinions among the Missouri RMP, the Extension Division of the University, the Medical Center representatives and the Vice President for Academic Affairs, Dr. Vernon Wilson, as to whether the extension agent described in the third level of activity should be a physician, a sociologist or an educator; whether he should live in the local community or commute; whether he should be a DME in a local hospital or be based in other community resources. The major criticism of this proposal, however, was that its focus is on the development of an organization rather than on the improvement of patient care. The site visitors recommended that the Region revise the proposal and develop a vigorous continuing education program as part of RMP and directed to RMP needs. The Review Committee, however, believed that such a continuing educa- tion resource was needed in the Missouri RMP program and should be en- couraged, despite the substantial university influence. The site visitors' recommendation was modifigd to approval with no RMP funds to be included in the award for this component (the Region may rebudget its previously awarded funds) and with significant feedback to the Region detailing the site visitors’ concerns. The reviewers hoped that the Region would consider these concerns when requesting funds for this activity again. Recommendation: Approval, no new RMP funds recommended. “December 16-17, 1969 - Council recommended: Nonapproval with revision required. DRMP /GRB-5/19/70 | : . A Privileged Communication SUMMARY. OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE MISSOURI REGIONAL MEDICAL PROGRAM RM 00009 7/70.2 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL Project #63 - Continuing Education - Coordination Project Critique: Committee reviewed the background of this project which had . been reviewed by Committee, deferred for a site visit and returned for revision by Council. Previous criticisms related to the following points: (1) the focus was on development of an organization ‘rather than on the improvement of patient care; (2) reviewers, including site visitors, were unable to determine what kinds of data would be used to identify educational needs; (3) there were varying opinions among university, RMP and project representatives about the role of the exten- sion agent; (4). a mechanism for feeding the educational benefits from other _ Missouri RMP activities, especially community-based ones, into the continuing education core seemed lacking and (5) there was a lack of Systematic evaluation. Conmittee reviewed the revised proposal in light of these criticisms and were not satisfied that the previous deficiencies had been corrected. The project does not speak, except in passing, to the linkages which need to be built between the education function and other agencies, schools of allied health, and RMP projects which have already successful education activities. Evaluation efforts still seem vague and a more detailed method of identifying needs than appeared in the original application is “missing. Reviewers were not satisfied that the elaborate three-step organ- ization, unchanged since the original application, would improve continu~ ing education efforts in the Missouri RMP. i While the reviewers were impressed with the quality of leadership the Dean of the Medical School, as co-director, would bring to the project, they were uncertain that he would be able to devote enough of his time to the project to assure the quality of direction requisite for a project of this magnitude. There was agreement that the Missouri RMP needs to identify educational needs and coordinate their continuing education pro- grams, but it was pointed out that this type of activity is ordinarily .a function of core and performed at much less expense to the Region than an average cost of $400,000 per year. While some reviewers believed that - the project should be approved (at a much lower level) in order to permit the Region to initiate the clearinghouse and catalyst function, the majority were of the opinion that the project did not merit any support and should be disapproved. a Missouri RMP -2- RM 00009 7/70.2 Recommendation: Non-Approval I (no RMP funding recommended). There was one dissenting vote. / Note: The comments requested from an outside reviewer were not received until after the Review Committee meeting. His review essentially corraborated that of Committee. He, too, believed that the application had not responded to the criticisms of the site visitors, Committee and Council, and that the implicit principles upon which the proposal was based were educationally unacceptable. : While he could find some value in the local Educational Coordinator function, he too believed that the overall project should be disapproved. % RMPS/GRB 7/14/70 @ REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) MOUNTAIN STATES REGIONAL MEDICAL PROGRAM RM 00032 7/70.1 Western Interstate Commission June 1970 Review Committee for Higher Education University East Campus, 30th Street Boulder, Colorado 80302 PROGRAM COORDINATOR: Kevin P. Bunnell, Ed. D. Requested Program Period ist Year 2nd Year 3rd Year Total Direct Costs $184 ,976 $191,117 $197,804 $573,897 Indirect Costs 21,950% 27, 268* 28,348* 77,566* TOTALS $206 ,926 $218,385 $226,152 $651,463 HISTORY: The initial planning grant for this Region became effective in November 1966 and provided for the organization and staffing of the core program, a four~state study of resources necessary for an operational program, and the establishment of four state offices, the Regional Director's Office in Boise, and the Coordinator's Office in Boulder. The operational phase began in March 1968, and the current annual level of support is $1,541,557, which supports Core Administration, four State Offices, the Regional Director's Office and the Program Coordinator's (Executive Director) Office at the WICHE Headquarters, and seven on-going operational projects, as follows: PROJECT # TITLE FUNDING LEVEL (d.c.o.) 1 Core Administration $943,587 2 Coronary Care Training - Missoula 134,349 3 Diagnostic, Treatment, and Educational Program for Cancer 207,172 5 Continuing Education - Mont ana 104,956 * Does not include Idaho Heart Association Indirect Costs. MOUNTAIN STATES REGIONAL MEDICAL PROGRAM ~2- RM 00032 7/70.1 6 Tumor Registry , $134,472 7 Continuing Education - Nevada 78,243 8 Inhalation Therapy 79,659 “9 Intensive Cardiac Care ~- . Nevada 62,195 10 Consulting Team - Continuing Fducation ~ Rural Nevada 40,000 i Continuing Education - Idaho 38,196 TOTAL $1,822,829 PRESENT APPLICATION: This application requests funding for two projects to extend on-going successful activities into new geographic areas. Project #12 - CUU -ICU Training in Southwest Idaho. This Requested a program jis designed to provide nurse and First Year physician training for acute coronary and general intensive $107 ,469 care in Southwest Idaho and Eastern Oregon. This is a rela-~ tively dense population area of the Mountain States Region. The. program represents the combined efforts of three communities (Boise, Caldwell and Nampa), the Idaho Heart Association and the WICHE RMP. The program is patterned along similar lines of the Intensive Coronary Care Training Program in Missoula, Montana which serves communities of Montana, Northern Idaho and Wyoming. This was the-basis of the original operational grant to the Mountain States RMP. It has demonstrated the feasibility of a regional approach to training personnel to staff coronary care facilities in-small hospitals, and has trained 107 physicians and 148 nurses since May 1968, This proposal is also in line with the plan to develop subregional centers of continuing education through cooperative efforts of local health professionals, facilities and colleges. A nucleus of this plan is already present in seven locations in Idaho under the MS/RMP program. The training center for which support is requested is comprised of four core hospitals which have agreed to provide classroom space MOUNTAIN STATES REGIONAL MEDICAL PROGRAM -3- RM 00032 7/70.1 and clinical facilities. All four hospitals have established coronary care facilities and have experience in coronary care inservice training. They are: St. Alphonsus and St. Lukes Hospitals, Boise, Mercy Hospital, Nampa and Carwell Memorial Hospital in Carwell. Contributions by the four core hospitals and the Idaho Heart Association to conduct the initial courses for nurses have totaled $12,972; clerical assistance, office space and teaching time by nursing preceptors and physicians was donated. The staff of any hospital in the Region and eastern Oregon is eligible to participate in this training program providing certain conditions are met. They must provide usable space and a workable plan for installing an intensive care facility that is well integrated with other hospital services. They must agree to use the standardized data collection methods provided by the program and make these data available for study. A specific registered nurse to work with the RMP consultants must be designated, and cooperating hospitals must participate in the postgraduate training activities of the program. Approximately 96 to 100 nurses can be trained in the first year; priority will be given to nurses from Southwest Idaho and Eastern Oregon, who will be working in a CCU general intensive care unit or a combined unit. Initially, courses will be limited to 24 trainees.- Physicians have requested training programs designed especially for the small town practitioner. Three-day symposia for up to 24 physicians will be conducted three times a year with faculty of physicians and nurses staffing the training center, a physiologist, pathologist and a consultant cardiologist. One two-day session will be held each year offering information beyond the basic coronary care that physicians need to keep up to date. The WICHE organization will enter into an agreement of affiliation with the Idaho Heart Association, which will serve as the coordinating and fiscal agent for the project. The Executive Director of the Idaho Heart Association will serve as Project Director, without salary. The physician faculty will be employed part-time. The basic course curriculum will be evaluated in terms of the course objectives. The individual trainee entering and completing the MOUNTAIN STATES REGIONAL MEDICAL PROGRAM ~-4- RM 00032 7/70.1 course will evaluate her own progress through these objectives. After the.-student has returned to her/his own clinical environment and has-had opportunity to implement training, further evaluation of the, basic curri culum can be made through feedback. A physician and nurse consultant from other coronary care training programs will be invited to assist with an objective evaluation, i.e., Missoula, Montana, and Seattle, Washington. The general level of coronary care will be assessed through changes in mortality rates utilizing data collected throughout the four states. Several indices will reflect the degree of interest and cooperation in of applications become availabl talents, skills employers and a Second Year: $ the Regional Medical Community, such as the number . for training, number of facilities that have e to patients, evidence of sharing educational and tools, and opinion data from participants, ssociated staff. , 105,894 Third Year: $110,377 Project #13 - A Program for Continuing Nursing Education -~ — Requested Wyoming. This is a supplemental proposal for First Year continuing educ ‘third phase of continuing educ region. It wil for tmursing per ation of the Mountain States RMP, and is a $77,507 a course of action to develop a cooperative ation program for nursing for the four-state 1 provide a program of continuing education sonnel in Wyoming in cooperation with similar programs in Idaho, Montana and Nevada. The program wil 1: 1) develop a sustaining "system" of continuing education; 2) develop a sound educational approach which involves the-learners an ‘gramming; 3) tr 4) develop part and 5) develop anticipation th a necessary pre The. School of N d provides continuity and coordination in pro- ain key people in the process of adult education; of the program at ''the home base of the learner"; a continuing education program for nurses in at continuing education requirements may become requisite for annual licensure. ursing in the College of Health Sciences at the University of Wyoming will provide the administrative focus for the. project, an Education and C nursing teacher when the projec d will work closely with the Division of Adult ommunity Services. A Project Coordinator, one and an administrative secretary will be employed t is funded. Six months later a second nursing MOUNTAIN STATES REGIONAL MEDICAL PROGRAM -5- RM 00032 7/70.1 teacher and a clerk-typist will be added. The project staff will be an integral part of the University of Wyoming School of Nursing. The Region has developed a plan which will divide Wyoming into four zones. These are based upon geographic factors and representative of established patterns of relationships and cooperation between health facilities. The educational activities will involve workshops, clinical con- ferences, and consultative services. The project is ready to become operational immediately upon approval and funding. A feasibility study was initiated during the planning phase which organized four study groups of nursing personnel throughout the State to study the continuing education data from survey questionnaires. As an outcome, a statewide Continuing Education Advisory Committee for Nursing was appointed to serve for the duration of the project and will continue in a permanent capacity to the University of Wyoming School of Nursing. A Task Force selected from this Advisory Committee has been responsible for the development of this applica- tion. An independent study laboratory grant application has been approved under another program’ but not yet funded for the University of Wyoming School of Nursing. All of the seven community colleges in Wyoming support the project and offer full cooperation, making available faculty, and audiovisual materials and physical facilities. Other agencies such as the Nurses Association, the Wyoming League for Nursing, the Wyoming Heart Association, etc., have also documented their cooperation and commitment. The evaluation of the project will determine the effectiveness and efficiency of curriculum content, instruction and planned educational experiences and will involve mechanisms such as: descriptive progress, reports, questionnaires and conferences with participants in health care facility administrators. Reports will be prepared semi-annually, including appropriate project and curriculum changes. Second Year: $85,223 Third Year: 87,427 DRMP /GRB 5/22/70 A Privilegea Communication | \ SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE MOUNTAIN STATES REGIONAL MEDICAL PROGRAM (WICHE) RM 00032 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The committee approved the present application requesting $184,976 for two new operational projects to extend ongoing activities into ‘new geographical areas. Project #12 - CCU-ICU Training in Southwest Idaho Critique: The reviewers endorsed the findings and recommendation of the Ad Hoc Cardiovascular, Study Panel which found its objectives clear and obtainable within the proposed time limit, The reviewers believed that it would be helpful if "student objectives" for educational training program could be included. The procedures are adequately described and the approach is realistic and workable, The project should enhance inter and jntra-community cooperation, knowledge and respect. The Committee noted that provision is made for consultation with outside sources, The budget requested was believed to be reasonable, but it. was unclear as to whether $100 tuition fee is realistic. Other areas are: charging between $300 and $350 for a 7-week program, Although details about the mechanism for evaluation are not included in the’ application, evaluation seems to have been considered in all areas pertaining to the impact of the program upon the individual nurses and physicians, as well as the impact upon the community and region. Other resources of support are being utilized from a prior pilot project and the local Heart Association. Tuition fees are also expected to assist in defraying costs. . Phasing out would seem to evolve naturally but the reviewers raised the question of cost-sharing. The project overall shows excellent coordination within the region, is techni- cally sound and capably directed. Recommendation: Approval I Nama on aa EO First Year Second Year, Third Year $107,469 $105,894 $110,377 MOUNTAIN STATES RMP (WLUHE ) “Ln BL YUU Fev nk \ 1 Project #13 - A Program for Continuing Nursing Education - Wyoming Critique: There was consensus that this program is well organized and comprehensively planned, It is obviously supported by all professionals in the area which speaks highly of the involvement of the three baccalaureate schools of nursing, as well as the seven community colleges that have been involved. The program will emphasize "training the trainer" and using the "home base" of the learner as the teaching laboratory. The educational activities are déscribed but the behavioral objectives, content and length of courses will apparently be developed after the personnel are hired. : The reviewers noted that the application shows a weakness in that with all of the coordinated planning and preparation for this program, they have not spelled-out in any detail the curriculum that is proposed, For instance, will there be clinical experience to enrich the training? This is not to imply that there is doubt that the trainers will be well prepared but the Review Committee felt it would be advisable to have the region submit more details about the planned curriculum for staff review. The Review Committee noted that the university has agreed to assimilate this project, subject to the availability of funds and other resources at the end of the third year. Recommendation: Approval I - Conditional upon submission of curricula as they are developed for review by Continuing Education Branch. First Year 7 Second Year. "Third Year $77 ,507 $85,223 $87,427 SUMMARY OF RECOMMENDATIONS Project 01-Year 02-Year 63-Year TOTAL #12 $107,469 $105,894 $110,377 $323,740 #13 $ 77,507 = $ 85,223 0 $ 87,427 $250,157 Total $184,976 $191,117 -$197 ,804 $573,897 RMPS/GRB/7/13/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) NEW MEXICO Regional Medical Program RM 00034 7/70.1 The University of New Mexico ‘June 1970 Review Albuquerque, New Mexico 87106 Committee Program Coordinator: Reginald H, Fitz Requested Program Period: ist Year 2nd Year 3rd Year Total Direct Costs $180,895 $174,324 $112,834 $468 ,053 Indirect Costs 38,614 42,630 26,633 107 ,877 TOTAL $219,509 $216,954 $139,467 $575,930 HISTORY: The initial planning grant in the amount of $449,736 was awarded for the period of October 1, 1966 to November 30, 1967. Seven- month planning funds in the amount of $108,048 were made for the second- year planning continuation (December 1,1967 to June 30, 1968). This phasing was due to the Region*s submission of its first operational request, which was disapproved by the National Advisory Council in May 1967. The application comprised of 7 projects was revised and resubmitted for consideration by the May 1968 Council with a resultant affirmative action. The Region's first operational award in the direct cost amount of $965,305 was made, effective July 1, 1968, to support seven operational projects, Core staff, and one project (#8) from earmarked funds, and for the last two months of the grant year, (from anticipated unexpended funds) implemented a Cardiopulmonary Laboratory in Santa Fe (#10). Another supplement requested funds for Project #11, to establish a model rural clinic. ‘This project was later funded by NCHSR&D-by contract. A project to screen New Mexico School Children for Heart Sounds and Murmure (#12) was reviewed at the February/March cycle, The reviewers were in agreement that the proposal was a significant one for the region, but identified several areas in need of clarification and re-structuring, The recommendation was unanimous for a return for revision and resubmission, This will probably be forthcoming for the next cycle. NEW MEXICO Regional Medical Program -2- RM 00034 7/70.1 Continuing support for the second operational year was made in the direct cost amount of $1,252,911 for a 14-month period, The Region is presently funded at an annual level of $1,053,768. PRESENT APPLICATION: This is a three-part application requesting funds to support three new programs. One of these (Projecti#14) was presented to the staff in March as a request for rebudgeting of funds to support a pilot phase of a monitoting program for decentralized coronary care units, Because the proposal involved many technical and clinical com- plexities, and indeed presented a new dimension to the New México Program, it was the consensus of the staff that approval of any rebudgeting to imple- ment this pilot study before submission to the Review Committee and Council, was inappropriate, The other two operational projects making up this three-part supplement are (#13) Leukemia-~Lymphoma Program and (#15) Streptococcal Throat Culture Proe gram, These programs represent new operational efforts. Project #13 + Leukemia-Lymphoma Program, This proposal will initiate First Year a Leukemia-Lymphoma Center which will be organized to Requested provide.education, drugs and consultation to the referring physician $73,275 for patients with hemotologic malignancies, The project will be located at the Bernalillo Medical Center, a fully accredited general hospital and one of two major teaching hospitals of the University of New Mexico School of Medicine, A $6 million addition now under construction will be completed in 1970 to provide expanded laboratory and radiology facilities, a new emergency suite, new out-patient facilities consisting of 102 rooms, a new operating room suite and intensive cage facilities. This hospital also contracts with the USPHS for care of Indian patients from the Navajo, Apache and Pueblo Reservations, The majority of patients come fzom the more than 300,000 residents of the county. The Project Director is already identified. In collaboration with a health educator, who will probably need to be bi-lingual, he will develop an educational program to communicate to thephysicians throughout the State the availability of such collaborative care and investigation of patients with leukemia or lymphoma. This program will be designed for medical students, house staff and physicians, An in-patient therapy unit, including a patient isolation system will be established, in collaboration with the departments of Pathology, Radiology, Pediatrics, Microbiology, Epidemiology and Community Medicine, and the services of the Infectious Disease Laboratory and Blood Bank. Clinical records on all patients with leukemia and lymphoma will be main- tained for follow-up and epidemiologic studies in collaboration with the existing NM/RMP Tumor Registry. The M.D, Anderson Hospital and Tumor Institute in Houston and the South- west Cancer Chemotherapy Study Group will participate through other sources of funds to develop immunotherapeutic approaches to acute leukemia, first in animals and later in humans, in collaboration with the Immunology Program. NEW MEXICO Regional Medical Program <3- BM 00034 7/70.1 A full-time technician, a nurse social worker secretary, a full-time health educator will be required and a Co-Director will be employed at 15% of the time, Second Year: $67,355 First Year Project #14 = Monitoring of Decentralized Coronary Care Unit, The Requested proposal here is similar to a project underway in the Oklahoma RMP $85,520 since May 1969, It will build on experience of the Coronary Care Nursing Training project of the NM/RMP and will initiate pilot pro- jects involving satellite hospitals in Grants, Gallup, Espanola and Albuqgerque. The program will initiate training for physicians and nurses for monitoring and supervising personnel in the central monitoring unit. The training for nursing personnel at the remote unit will include training in cardic- pulmonary resuscitation, intravenous medication (where applicable), pro- cedurea for defibrillation, clinical recognition of emergencies, etc, The course, approximately 40 hours, will include onethe-job training in the central monitoring unit as well as the remote unit, These activities have already begun at the Osteopathic Hospital in Albuquerque, in anticipation of being tied into the Bernalillo Medical Center, Albuquerque, in the near future, The training of physicians in the remote units will conform to the outline of the course designed to acquaint physicians with che management of patients with acute myocardial infarction, particularly in the areas of prophylaxis and treatment of cardiac arrythmias. Although written documentation is not a part of this application the Espanola Hospital has indicated its willingness to participate. The -patient will be monitored on a continuous basis at 4 @entral tionitoring unit (CMU) in his geographical area by means of an electrocardiogram(ECG; to be transmitted by direct telephone wire from the remote station. A para}lel line will provide voice communication without dialing. The ECG monitoring will be done by skilled personnel at the CMU. Nursing personnel at the remote station will be trained in procedures to be applied when emergencies arise, The CMU and its remote station will function as an integrated coronary care unit. Training programs and operational procedures for physicians and nurses will be developed. Short courees for physicians and nurses have been designed to fill the immediate need for specialized personnel needed to staff newly formed units. The electrocardiographic signal of the patient is amplified at his bedside, and is transmitted over the telephone line as a frequency modulated signal. At the é@mtra} unit the signal is deemodulated, the electrocardiogram recovered, NEW MEXICO Regional Medical Program -he RM 00034 7/70.1 Voice contact can be established at anytime, including alarm situations, without interruping ECG transmission, Two telephone lines will be pro- vided by the telephone company on a monthly lease basis. One line will be conditioned for two-way voice communication; the other will be specially conditioned for uninterrupted transmission of the ECG signal. Whenever possible existing monitoring equipment will be used at both the CMU and remote station. This equipment, pius any new monitoring equip- ment, will be tied into the ECG transmission system by engineering personnel, These field engineers will also be responsible for maintenance and install special circuitry for monitoring purposes. It is anticipated that the physician and nurse at the remote station must help plan for the use of their units as they become functional, They will assist in preparing the initial training programs and other programs for the remote station and for CMU personnel. Each of the CMUs,in collaboration with remote unite, will form a Coronary Care Unit Committee (CCU) to formulate policies and recommend procedures. for operation of both units, The CCU Committee will be responsible for establishing refresher and continuing eduction programs for both physicians and nurses in its area. Second Year: $77,069 Third Year: $81,069 Project #15 - Streptococcal Throat Culture Program, This program, First Yr > developed in collaboration with the New Mexico Heart Requests. °. Association, and the New Mexico Public Health Laboratory, will $22,100 establish a statewide facility for jdentification of group A atrep- tococei on culture, It will address the problem of extremely high incidence of acute rheumatic fever and rheumatic heart disease in the . state, The program is designed to persuade physicians to seek identifi- cation of infections with subsequent appropriate treatment, 48 well as educate the lay public to seek medical aid for possible streptococcal illnesses, The University of New Mexico School of Medicine will participate through the Chairman of the Rheumatic Fever Committee of the Heart Association @r. Mortimer), who is also Chairman of the Department of Pediatrics of the New Mexico School of Medicine. The project will be limited the first year to the northern half of New Mexico, comprising a population of approximately 600,000. The second year the program will be extended to the remainder of the state, The physicians in the area to be served will be supplied with swabs, requisitions and mail-in envelopes. A daily pickup will be established at a Post Office box in Albuquerque and pamphlets will be processed by the State Public Health Laboratory. Positive results will be telephoned to the attending physician by laboratory personnel, Positive results will be reported to the Public Health facility in each community a8 well, All results, positive and negative, will be returned to attending physicians NEW MEXICO Regional Medical Programs ~5e RM 00034 7/70.1 by mail. The program will run seven daye a week by training part-time help, such as a university studenwjto staff the laboratory on weekends. With the 600,000 population to be served the first year, it is estimated that 40,000 cultures will be processed yearly, with a 25% yield gyoup A streptococci, The second year should produce 70,000 cultures. The sheep bidod agar plate-bacitracin disc technique will be used at an average cost of 50 cents per culture. Direct evaluation will not be possible without extensive preliminary study to determine exact rates of rheumatic fever within the state, It is not believed necessary to do such a study since other communities have already documented the effectiveness of such programs. Second Year: $29,900 Third Year: $31,765 NEW MEXICO RMP -6- RM 00034 7/70.1 OPERATIONAL STATUS - Based on a 14-month Award (D.C.) PROJECT NUMBER, TITLE : FUNDED (02) 1 Model Coronary Care Unit Training $§ 170,379* 2 Training Course in CCU Nursing 65, 305* 3 Training in Laboratory Sciences in Allied Health Professions 98,569 4 Stroke Program 178 ,877 5 Emergency Health Services 59,517 6 Circuit-Riding Continuing Education Courses 58,351 7 Eealth Information and Communication 38,662 8 Pediatric Pulmonary Center (Lovelace) (Earmarked Funds) 95,745 9 Core Support 467,958 10 Cardiopulmonary Evaluation Laboratory - St. Vincent's Hospital 21,048* 1i Rural-Urban Linkage for Improved Funded by Health Services NCH SR&D TOTAL $1,252,911 kIncludes a portion of unexpended balances of $104,791, direct costs. prMp/ 9/28/70 NEW MEXICO RMP : RM 00034 7/70.1 STAFF OBSERVATIONS Staff was concerned that the initial project proposal did not include certain relevant information, Staff requested additional information, some of which has been forthcoming. 1. 2. 5. 6. The curricule which we requested for physician and nurse train- ing have been received andéve helpful. The "letters of support" from the participating institutions have been received. However, they do not all indicate a firm intention of the institution to participate in the project, or even a good understanding of what the project is about. The addendum information makes reference to "initial pilot pro- jects" involving satellite hospitals. It should be pointed out that the Division has not granted approval for the establish- ment of such pilot projects; we are awaiting the action of Council on the value of this monitoring approach before considering the approval of such pilot activity. The addendum does not refer in depth to the experience with a similar kind of monitoring project in the Oklahoma Regional Medical Program, One anecdote is cited: The drop in the mortality rate from 31% to 6% in a small “remote” hospital following the beginning of monitoring, This 6% figure is sure prising, considering the fact that the mortality rate in most sophisticated coronary care units is considerably higher, It is still not clear what the Heart Association will contribute to this project. Lastly, although the Region was requested to do so, the addendum contained no description of how the monitoring might work in an actual clinical situation -- how cardiograms would be screened at the central monitoring unit (will nurses sit watching the screen?), how a nurse will be able to pick up a telephone handset to receive instructions while at the same time resuscitating a patient, etc. It is still hard for staff to visualize how this monitoring would work in a typical alarm.situation, _ riannton A Privileged Communication ' SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVEIW COMMITTEE NEW MEXICO REGIONAL MEDICAL PROGRAM FM 00034 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: This three-project application requesting $180,895 in supplemental funds received a recommendation of approval, with certain contin- gencies, in the amount of $92,100. In the case of #13, the project will need to be revised, including a new budget, Project #14 was presented to staff in March 1970 as a request for rebudgeting of funds to initiate a pilot phase of a monitoring program for decentralized coronary care units. Because the proposal involved many technical and clinical complexities, and indeed presented a new dimension to the NM/RMP, it was the consensus of staff that approval of any rebudgeting to implement this program before submission to the Review Committee and Council, was inappropriate. Project #13 - Leukemia-Lymphoma Program Critique: The reviewers found the project to be timely, well-planned, and it will obviously serve a great need. It will also be a valuable ‘research activity. However, there is no indication that it is tied into a larger program dealing with all aspects of cancer, or indeed that the Region has planned for the broader implications of a comprehensive cancer program. This is by and large a fragmented approach and the Region may be ignoring the overall necessity for planning a regionalized cancer program, The failure to identify therapeutic backup is another deficiency in the application, as well as a clear justification for the amount to be budgeted for drugs, return visits to laboratories, etc, This was questioned as to whether this is legitimate or permissible. . There is no evidence that this project is tied in with a clinical cancer activity, which one would surmise is ongoing in some area of the Medical School. There is no radiotherapist or radiologist listed. The Region is requesting in-patient as well as out-patient support largely to be able to follow the M. D. Anderson.technique of sterile isolation. Since there is doubt in the profession that this approach will be financially feasible, it would appear that this is not the area in which to experiment, or indeed, the point from which to start a cancer program. The necessity for a full-time health educator was not clear from the applica- tion. The project generally needs clarification of its place in a more broadly-based regional cancer program and further documentation as to its a relationship to other clinical cancer activities. Recommendation: Non-Approval IL - the revision should reflect: (1) this project's relationship to an overall regional cancer pro- pram; (2) statement of the proposed therapeutic and clinical backup;and (3) wi tamt Lt an btanm nF wane nn al hudaat NEW MEXICO RMP ~2- RM 00034 7/70.1 Project #14 - Monitoring of Decentralized Coronary Care Units Critique: The reviewers believed that the evaluation of this project must be judged on the basis of the experience gained in a similar project in the Oklahoma RMP. (The reviewer for this project was also the reviewer for the Oklahoma one.) os_. There was agreement that the budget includes equipment items which are probably unnecessary initially. The reduction in the number of central monitoring units and remote stations to two areas until the demonstration proves to be feasible would be a more practical approach. . There was no reference to other training programs which could possibly afford experience ~ that would be ra to this program. . The reviewers recognized that this is a high risk population, with lots of retirees with a complicating factor of high altitudes, The approach is reasonable in that it joins such facilities in the state along regional lines, : Recommendation: Approvel I - at $70,000 the first year, with the provision that; (1) An evaluation of the Oklahoma project be made both at the source and one of the remote stations; (2) the first year's activities should be limited to no more than two satellite installations with a com- mensurate reduction in the budget to reflect a request for no more than $5,000 for equipment. The second and third year's budgets are to be limited to $70,000 direct costs each year. Project #15 - Streptococcal Throat Culture Program Critique: There were a number of deficiencies noted, While operational procedures are adequately described, the technical procedures are not, Personnel described appear inadequate for operation on a seven-day week basis, and it would seem that an additional half-time technician would be necessary, as well as clerical assistance to maintain records and notify physicians. Good records will be necessary to provide evaluation of this program, While the difficulty in estimating the actual effect of reducing rheumatic fever is recognized, methodology for evaluation js not included, There is no evidence of follow-up of the cultures or indication of what will happen to these. The technical procedures are not adequately described, nor are the limitations of the techniques, It is assumed this method will improve the effectiveness of detection of streptococcal pharyngitis and thereby reduce the incidence and recurrence of rheumatic fever. Although two mechnisms are mentioned by which objectives may be obtained (physician education and parent and patient education), these are not adequately described. The need to expand the educational and information phases must be strengthened considerably. The reviewers also directed their attention to the relationship of this project to the State Department of Health and to the Indian Health Service, NEW MEXICO RMP ~3- : RM 00034 7/70.1 The region dees net report the means of contact with the Iadians and Spanish-American populations... It would appear that at least a Spanish speaking nurse would be required to elicit the kind of information that will be needed, The budget seems reasonable, but an additicnal $6,000 - $7,000 should be _ considered for additional staff unless cooperating agencies provide the staff suggested. It would seem that the support of the New Mexico State Health Department is essential and available, Recommendation: Approval I ~ with two contingencies: (1) The Region should identify the relationship of this project to the Indian Health Service and the State Department of Health; (2) provide a statement of the means of communication with Indians and with the Spanish-American population; and (3) clarify how the region plans to provide the treatment necessary for follow-up of positive cases in the population who live in remote areas, SUMMARY OF RECOMMENDATIONS Project Ol-Year , O2-¥ear O3-Year #13 - Leukemia«Lymphoma . Non-Approval II «' revision #14 ~ Monitoring of CCUs $70,000 $70,060 $70,000 ‘#15 - Streptococcal Throat ; Culture 22,100 29,900 31,765 __ TOTAL $92,100 $99,900 $101,765 eae > RMPS/GRB/7/8/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF A SUPPLEMENTAL OPERATIONAL GRANT APPLICATION (A Privileged Communication) NEW YORK METROPOLITAN REGIONAL MEDICAL PROGRAM RM 00058 7/70.1 Associated Medical School of Greater New York June 1970 Review Committee 2 East 103rd Street New York, New York 10029 PROGRAM COORDINATOR: I. Jay Brightman, M. D. Requested Program Period lst Year 2nd Year 3rd Year Total Direct Costs $1,524,229 $1,494,983 $1,528,195 $4,547,407 Indirect Costs 425,782 499,925 520,041 1,445,748 TOTAL $1,950,011 $1,994,908 $2,048,236 $5,993,155 NOTE: A Review and Funding History (R&FH) indicating Council action for this Region is attached. HISTORY: The National Advisory Council for Regional Medical Programs approved in February 1967 the initial planning application submitted by the Associated Medical Schools of Greater New York. Included in this grant award was a total of $123,660 for a cancer study by the Memorial Hospital for Cancer. In June 1968, the Region was awarded a non-competing continuation grant application at a level of $1,041,617 ($783,716 of new funds - $257,901 of carryover funds). Included in this award as $79,660 of unexpended funds for a seven-month extension of the Memorial Hospital Study. In addition, the Region was awarded from earmarked funds $206,870 Pediatric Pulmonary Disease Project at Babies Hospital and $88,399 for a Mobile Coronary Care Unif at St. Vincent's Hospital, a total award of $295,269. In November 1968, the Region was awarded a supplemental planning grant application of $76,100 for the Memorial Hospital Feasibility Study. In March 1969, Dr. Jay Brightman became the Region's Program Coordinator. In late August 1969, the Region submitted a continuation application requesting support for the Pulmonary Disease Program. This application modified the program by including two supplementary parts, one from Albert Einstein Hospital and one from St. Vincent's Hospital. The application was approved at the committed level for 02 year of $201,660 NEW YORK RMP -2- RM 00058 7/70.1 with the recommendation that the broader approach be utilized for greater coordination among the three institutions. In July 1969, the Council approved the Region's initial operational grant application. Although approved for operational status, support of the Region was continued by a planning grant award. This was due to the uncertainty of the level of the Fiscal Year 1970 appro- priation for Regional Medical Program grants (ref. to R&FH). Council received in August 1969 the Region's grant application requesting support for eight operational projects and renewal of’ Core. Council approved operational status for the Region as recommended by the July 1969 site visit team and the RMP Review Committee and the initial operational award was made in February 1970. The Operational Award of $1,864,141 (d.c.o.) consisted of $1,245,658 for Core and $618,483 for support of five projects. The amount for Core included $44,194 earmarked funds for planning with the New York Health and Hospital Corporation, and $141,010 for Project #7 - A Study of Facilities and Services for Respiratory Diseases and Disorders (ref. to R&FH). Council eviewed this Region's first operational supplemental application in December 1969; it approved three of the projects at a level of $325,746 (d.c.o.) and disapproved one project (ref. to R&FH). : The March 1970 Council reviewed the Region's second supplemental operational application which included two projects. They were projects #14 - RMP Coronary Care Training Center at New York Hospital and #15 - Pilot Neonatal Special Care Center at New York University College of Medicine. Council disapproved both projects and requested their revision. , PRESENT APPLICATION: This supplemental operational grant application is requesting $5,993,155 (d.c.o.) for three years' support of threeprojects, a Renal Disease Program, a Stroke Program and An Interlibrary Loan Training and Consultation Service Program. Project #16 - A Regional Program for Kidney Disease for Requested Brooklyn and Staten Island. This is the First Year third end-stage Renal disease project submitted by the New $1,033,411 York Metropolitan Regional Medical Programs. The first, submitted by the Mt. Sinai School of Mediciane and its affiliated Elmhurst Hospital of Queens, was disapproved NEW YORK RMP -3- RM 00058 7/70.1 by Council primarily because there appeared to be no overall Regional plan for Renal diseases. The second, sponsored by the New York Hospital in conjunction with the St. Luke's Hospital and the Brooklyn-Cumberland Medical Hospital, was approved by the Council after a site visit. Council approved a first year level of $181,300 for training and planning aspects. These projects are all considered by the Region to be components of a total master plan in Renal diseases that the Region expects to have completed within the next few months. This project is submitted by the Downstate Medical Center, Brooklyn, New York and is a collaborative effort by seven hospitals in Brooklyn and Staten Island coordinated by a Council made up of the Directors of Nephrology from each hospital. This Council will formulate policy and continually evaluate on-going programs of Renal care at the seven institutions. All of the unit directors hold faculty appoint- ments in the Department of Medicine of Downstate Medical Center. The seven participating institutions are: 1) Downstate Medical Center; 2) Brookdale Hospital; 3) Coney Island Hospital; 4) Jewish Hospital of Brooklyn; 5) Prospect Heights Division of Long Island College Hospital; 6) Maimonides Medical Center; and 7) Staten Island Hospital. This program proposes to institute the following activities: 1. Establish a central "routing office” that can locate available beds in the participating institutions for patients needing maintenance hemodialysis. 2. Increase homedialysis facilities for selected patients who appear socially and emotionally suited for this type of care: (a) as a permanent treatment modality or (b) while awaiting a suitable cadaveric donor. 3. Establish new collaborative relationships through the mechanism of the Project Council. 4. New transplant facilities will be developed at Downstate (four beds) for selected patients, properly worked-up on an out-patient basis, which includes tissue typing. All data will be recorded on standardized flow sheets developed by the transplantation registry. Additional transplant units will be developed in participating institutions. 5.. Teaching and training activities will be integral components of each of the seven programs. Extension of the services of special care units will be provided by arrangements between NEW YORK RMP -h- RM 00058 -7/70.1 the collaborating units and voluntary hospitals. A special com- munity education program will be devised to increase lay aware- ness of the signs of kidney disease and the need to encourage organ donations. Each institution will stress its special training skill as follows: A. Brookdale Hospital Center - A two-hour per week lecture series of approximately 20 weeks duration will be given twice yearly for community physicians. The lectures will include basic materials as well as practical aspects in the diagnosis and treat- ment of Renal disease. There will also be workshops which will offer first hand practical experience in peritoneal and hemo- dialysis. A participating physician may spend a half-day per week for 20 weeks in the institutional dialysis unit or he may elect an intensive period of daily sessions for two weeks. B. Coney Island Hospital ~ The Coney Island Hospital currently provides an extensive continuing education course in internal medicine for community physicians. It is anticipated that the number and depth of lectures and discussions dealing with Renal disease will be increased with participation of the Coney Island Hospital in the Regional Transplantation Program. The Coney Island Hospital Speakers Bureau has provided lectures on various aspécts of ‘medical problems to interested community groups. This program would be continued and the Renal aspects broadened both as an educational service and also as a means of informing the community concerning the necessity for, and activities of, the dialysis and transplantation facilities. There will also be instituted at this hospital a training program for nurses and technicians which will take place under the supervision of the chief dialysis nurse and the director of the Dialysis Unit. , C. The Jewish Hospital of Brooklyn ~ This hospital will offer education in the area of Renal diseases to the lay community by having teams of nurses and physicians speak before groups such as the P.T.A. and religious groups. They will also maintain contact with community physicians by attending meetings and speaking at the meetings of the county medical society and various smaller community hospitals and health clinics. D. Maimonides Hospital - This hospital will establish a staff and facility for the post-graduate education of visiting staff and interested physicians. E. Prospect Heights Hospital - This hospital will establish a comprehensive program for the education of community physicians in screening, recognition, diagnosis and treatment of kidney disease. A ws NEW YORK RMP -5- RM 00058 7/70.1 The program will consist of at least two hours weekly of lectures and four hours of practical workshops for a period of 20 weeks. The course will be given twice yearly with identical syllabus, once at the Long Island College Hospital and once at the Brookdale Medical Center. F. Staten Island Hospital - This institution will develop an education program for medical, allied health personnel, patients and families in home dialysis. The target population of this program will be all patients residing within this sub-region, all community physicians, and allied health personnel, and lay public. The Project Director will coordinate and make regular reports on the technical progress of the program including the participating institutions. The evaluation indices for the total program will include: how many additional patients are served; the improvement in: quality of care and quantity of survival; the number of classified personnel that are trained; and the extent to which these personrel have benefited from the training. The Region has submitted a separate budget itemizing funds needed for planning and training purposes if the National Advisory Council still considers this the highest priority for RMP support. The total requested by the combined institutions for the first year of support for planning and training purposes is $590,530. Of this total, $484,318 is for personnel and $106,212 is for equipment, supplies, etc. Second Year: $985,302 Third Year: $1,092,014 Project #17 - Harlem Region Stroke Program. This project Requested proposes to provide case finding, diagnosis First Year and therapy services to control pre-stroke conditions and $401,860 to provide adequate therapy to minimize disability from stroke. Submitted by the Columbia University College of Physicians and Surgeons and the Harlem Hospital Department of Medicine, the project will be a cooperative activity involving Harlem Hospital, Sydenham Hospital, Knickerbocker Hospital, Italian Hospital, the Upper Manhattan Medical Group, the Manhattan Central Medical Society, the Visiting Nurse Services of New York, the New York Health Department and its Central Harlem District Health Office, and other community and professional organizations. NEW YORK RMP b= - RM 00058 7/70.1. The target population ia the Harlem Community which has a total population of approximately 450,000 persons of whom more than 150,000 are classified as medically indigent. Cerebrovascular disease is a major disabling disorder in the Harlem community. The incidence of hypertension and related pre-stroke condition and the resulting cerebrovascular accidents in the socially deprived black population of communities such as Harlem is significantly higher than that in other segments of the pepu~ plation of the country. For example, at the Harlem Hospital 19.2% of cerebrovascular accidents are in patients under age 50, contrasted with a national figure of 4Z. This project would initiate the following activities: 1) Establish a stroke program at Harlem Hospital under a project director and a full-time senior neurologist, who will supervise daily operations and coordinate contributions of the many participating hospital departments (medicine, neurology, rehabilitation, medicine, surgery, neuro-surgery , social services, radiology, home care, health education, and ambulatory care services), as well as other agencies and other institutions participating in the program through cooperative arrangments. The director will be responsible to the stroke advisory committee consisting of the directors of the participating departments, plus designates from other hospitals and agencies. 2) Expand the screening capacity of the out-patient clinics of Harlem Hospital to improve detection of stroke and pre-stroke conditions; a special hypertension unit will be established within the medical out-patient clinic to screen, evaluate, and treat hypertension and related illness predisposing to stroke. 3) Establish a three to four bed stroke intensive care unit and a comprehensive stroke treatment and follow-up clinic. Both will be operated by a full-time neurologist under the direction of a project director. 4) Establish a training program for 20 community health workers in the technical aspects of stroke and pre~stroke symptomatology, screening and detection. 5) Establishment of a systematic case-finding network to reach the undetected stroke and pre-stroke cases in the Harlem region, with particular emphasize on hypertension. Case finding NEW YORK RMP ~7- RM 00058 7/70.1 will be carried out by the Community Health Workers through an expanded recruitment and deployment prozram in conjunction with several community organizations actively supporting the project; also in close collaboration with the Departments of Social Service and Ambulatory Services, the Central Harlem Health District of New York City Department of Health, and with community agencies. 6) Expand the training program for community paraprofessionals in health care and education related to stroke and focus upon further career developments for these workers. 7) Participate in a training program for registered nurses and para~nursing personnel in intensive care for stroke and related cerebrovascular diseases through linkage with an intensive care training program to be operated by the Schools of Nursing of Columbia University and Harlem Hospital. A delineation of the epidemiogical pattern of stroke in the Harlem area based on an evaluation of data gathered will be completed. Factors that will be considered in the evaluation of this program will include: additional patients served, quality of survival, morbidity rate, mortality rate, institutional agency involvement, quality of care, geographic assessibility, system of medical care delivery, training of skilled personnel, decreased costs, manpower training, and compare with similar programs elsewhere. The Region has requested $1,173,035 for three years support of this program. Through other sources of revenue, the program will contribute $997,260 to the support of this program. The major portion of funds requested from Regional Medical Programs will be utilized for personnel and equipment. Second Year: $421,175 Third Year: $350,000 Project #18 - A Project to Improve Interlibrary Loan Services Requested and to Provide a Training and Consultation First Year Service for Medical Librarians. This project $88,958 proposes to improve interlibrary loan services and to provide training and consultation service for medical librarians. Through the interlibrary loan system, an additional 15 of the larger hospitals will be encouraged to join the present 29 members of the interlibrary loan and delivery service of the Medical Library Center of the New York Academy of Medicine. 8 . + ~NEW YORK RMP : -8- RM 00058 7/70.1 To make it possible for additional hospitals to join, the center will reduce its annual membership fee of $2,000 to $500 for the first year, $1,000 the second, and $1,500 the third year. . In addition, it will add to its periodical holdings, 100 of the most -commonly used medical and other health-related journals to be made available to all members by loan or free photocopy along with the other journal holdings that the center makes available. Members are also entitled to borrow from one another. In all cases the. material borrowed will be delivered directly by truck. In addition to the Medical Library Center aspect of this program, the small libraries of the four Northern counties of this Region, will have access to expanded facilities of the Westchester Academy of Medicine Library. Hospital libraries in Staten Island, Brooklyn, — and parts of Queens will continue to be served by the Downstate Library on the basis of its resource grant from the National Library of Medicine; however, as NLM grant funds run out, the situation would be subject to review. Also as part of this proposal, both the Downstate Library and the Westchester Library will be linked by computer to the Medical Literature Data Bank of the New York Academy of Medicine to expedite their interlibrary loan activities. To run the training and consultation services, a central office will be established and a full-time trained librarian will carry out the following activities: 1. Serving any of the Region's hospital library needs. 2. Advise hospital administrators of standards of libraries and on. library personnel requirements. 3. Set up training courses for librarians. 4. Conduct or arrange seminars and workshops. 5. Provide consultation to the Region's librarians on extension cataloging, acquisition, circulation, interlibrary loan and other library systems. 6. Help coordinate the Region's libraries, sharing of acquistion, and responsibilities. 7. Visit hospital libraries periodically to see how security procedures are being implemented and to give encouragement to the librarians. NEW YORK RMP ~9- RM 00058 7/70.1 8. Evaluate the program of training and consultation. The hospital libraries with less than adequate facilities will be encouraged to enhance their holdings and their services at least to meet the everyday need of health professionals using them. Beyond that point, they will be served by interlibrary loan arrangements according to their needs. Collaborative arrangements exist with the Downstate Medical Center Library, Medical Center Library of New York and the Regional Medical Library. Discussions have already taken place with the administrative _ officials and the librarian of the Westchester Academy of Medicine Library who are anxious to enhance their own library activity and are waiting to serve the four-county region. A four-county committee for continuing education is presently spelling out the needs. there. In phasing out the interlibrary loan system at the end of the three year period of support, it is anticipated that the new participating members of the Medical Library Center will be able to assume full costs. Cost of rental. of computer systems would be assumed by the Downstate and Westchester Libraries. Phasing out of the training and consultation service will be done by the Region's permanent library community which is in great need of trained personnel absorbing the project personnel. The majority of funds requested in this proposal from RMP are in the category of personnel. The income acquired from graduated fees of new members of the Medical Library Center will make available a maximum revenue of $45,000. Whatever revenue is acquired from this source will be deducted from the total requested from RMPS. Second Year: $88,506 Third Year: $86,181 NEW YORK RMP ~10- RM 00058 7/70.1 REVIEW AND FUNDING HISTORY lst Year Planning Award 6/1/67 - 5/31/68 Amount of Award $967,010 (d.c.o.) ($98,785 of this award went to Memorial Hospital Project for Cancer and Allied Diseases) 2nd Year Planning Award 6/1/68 - 5/31/69 Amount of Award $1,041,617 (d.c.o.) Initial Supplemental Planning Award 6/1/68 - 5/31/69 Amount of Award $295,269 (d.c.o.) (Earmarked Funds Awarded) For Support of Pediatric Pulmonary Disease Center Mobile Coronary Care Unit Funded (d.c.o.) $206,870 Funded (d.c.o.) $ 88,399 Second Supplemental Planning Award 1/1/69 - 5/31/69 Amount of Award $76,000 (d.c.o.) (August Council) (Continuation Award for the Memorial Hospital Feasibility Study) Third Supplemental Planning Award 6/1/68 ~ 9/30/69 Amount of Award $275,889 (Provided Indirect Cost for Institutions Affiliated with the RMP) Third Year Planning Grant Award 10/1/69 - 9/30/70 Amount of Award $1,480,136 (d.c.o.) Includes Support of: Core $1,104,648 #1R-Mobile CCU (St. Vincent's Hospital) 62,262 #6 ~Regional Cancer Program (Memorial Hospital) 155,760 ae #2 -Pediatric Pulmonary Program (Babies Hospital) 157 ,466 Pe 1. Initial Operational Grant Award 2/1/70 - 1/31/71 Ol year - $1,864,141 (d.c.o.) - Commitment 02 year - $1,864,141 03 year ~ 1,606,574 Includes Support of: Core (Ineludes $44,194 for N.Y. $1,245,658 (d.c.o.) Health and Hospital Corporation, and $141,010 for project #7 - A Study of Facilities and Services for Respiratory Diseases and Disorders.) #1R - Mobile CCU (St. Vincent's Hospital) $ 62,262 (d.c.o.) #2 - Pediatric Pulmonary (Babies Hospital) 157,466 (d.c.o.) #5 - Hemipl. Patient Care (Grasslands Hospital) 25,997 #6 ~- Regional Cancer Program (Memorial Hospital) 179,333 #9 - Education Program for Allied Health (Burke 193,425 Rehabilitation Center) First Supplemental Operational Application December 1969 Council (The December 1969 Council deferred action on projects #10 and #13, They were site visited in February 1970 and March Council took action on both projects.) #10 - Feasibility Exploration and Demonstration Non-Approval II, Project in the Development of the Home as a revision required Health Care Facility (req. 01 year - $667,764 d.c.o.) NEW YORK RMP -ll- RM 00058 7/70.1 #11 - Continuing Education of the Community Approval I ~ pending funding Physician - St. Luke's Hospital (req. 01 year ~ $73,810 d.c.o.) #12 - Continuing Medical Education and Patient Referral Approval I - pending funding for Community Physicians (Brooklyn-Cumberland Medical Center, Brooklyn, New York) (req. 01 year - $70,636 d.c.o.) #13 - Training Physicians and Allied Health Personnel in Approval I - Pending funding Management of Chronic Renal Disease (req. O1 year - $181,300 d.c.o.) Second Supplemental Operational Application March 1970 Council #14 - RMP Coronary Care Training Center at New York Non~approval II, revision Hospital (Cornell University Medical College requested (req. O1 year $105,520 d.c.o.) #15 - Pilot Neonatal Special Care Center at New York Non-approval II, revision University College of Medicine - Bellevue requested Hospital (req. 01 year $479,037 d.c.o.) DRMP / GRE 5/26/70 (A Privileged Commmication) ' SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE NEW YORK METROPOLITAN REGIONAL MEDICAL PROGRAM RM 000658*..7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General:. The Committee recommended the following action on this application which requests a total of $4,547,407 (d.c.o.) for three years support. Committee took no action on Project #17 - Harlem Region Stroke Program and recommended a technical site visit to determine local participa- . tion in this program and negotiate an appropriate budget; disapproved Project #16 - A Regional Program for Kidney Diseases for Brooklyn and Staten Island, and disapproved Project #18 - A Project to Improve Interlibrary Loan Services and to Provide a Training and Consultation Service for Medical ' Project #16 - A Regional Program for Kidney Disease for Brooklyn and Staten Island. Critique: This is the third kidney disease project submitted by this region; the first was Project #8 ~ Treatment of Chronic Failure, County of Queens Mount Sinai School of Medicine, which requested three years support at a level of $2,310,615, and was disapproved by the August 1969 Council; and the second was Project #13 - Regional Program for Training of Physicians and Other Allied Health Disease Patients which requested $1,048,061, for three years support and the December 1969 Council approved, the training portion of the project at a funding level of $543,900 for three years support. The total funds requested for support of these three Renal Disease projects amounts to $6,469,403. Committee expressed concerns on the enormous amount of funds which can be easily spent in funding kidney disease programs and believes Council should take a close look on how and up to what level RMP dollars can appropriately be spent for Renal Disease. Reviewers questioned whether RMP should become involved in supporting the care of renal disease patients. Committee expressed concern over the Region's lack of coordination in planning and developing these three renal disease proposals. There is no ‘indication in any of these projects how they fit into a Regional plan for kidney disease. There appears to be a duplica- tion between projects rather than a coordinated effort to assure that variable component services are implemented and coordinated on a Regional basis, such as: a Regional Renal Disease Center for patients who cannot have transplanta-- tion or be maintained by a home dialysis program; a Regional Home Dialysis Program; a Regional Tissue Typing Center; a Regional Organ Procurement Center; a Regional plan for dialysis facilities as needed; and an early detection program. Recommendation: Non-Approval II - revision required. Jt is suggested that the Region not resubmit a revised project until they have developed a Regional plan for kidney disease and they havea clearly defined a - a NEW YORK METROLPOITAN -2- RM 00058 7/70.1 Regional Medical Program , ‘policy from the RMP Advisory Council regarding areas of support available from RMP for kidney disease activities. Project #17 - Harlem Region Stroke Program. Critique: Committee believes this project is well planned and should improve the quality and quantity of health care for stroke patients in the Harlem Community. This program will serve the total Harlem Community which includes residents in the Model Cities area. Committee believes, however that the proposal does not properly explain the involvement of community organiza- tions such as the Manhatten Medical Society in the planning and operational phase of this program. The involvement of Allied Health Professions was also questioned. Concern was also expressed about the salary structure presented in the proposed budget, which seems excessive. Recommendation: No Action Taken. Committee recommended a site visit to interpret community involvement and to negotiate an appropriate budget. Further, the Committee recommended that the site visit team be authorized to act in its. behalf in making a final recommendation on this project. Project #18 - A Project to Improve Interlibrary Loan Services and to Provide a Training and Consultation Service for Medical Librarians. Critique: Committee believed this proposal to be vague and nonspecific; and almost impossible of analysis in terms of activities to be under~ taken. The application does not adequately explain-the relationship between this Regional proposal and the Regional Medical Library or the current New York State Interlibrary Loan System. Committee believes this Region should seek assistance from the National Library of Medicine for development of an interlibrary program that would maximize the utilization of existing resources within the Region. Any plan which is developed should certainly take into | account the following points: a) the role of the proposed subregional units; b) the proper role for the Medical Library Center of New York; c) the defini- tion of the relationship of such a proposal to the current Regional Medical Library, the New York Academy of Medicine, and the Medical Library Center of New York; d) the necessity and desirability of computer terminals for mono- graphic materials which take such a small percentage of the interlibrary loan needs; e) the need or advisability of subscribing to 100 journals at the Center, when these materials are widely available within the Region; f£) more detail concerning the role of the Central Consultation Service and its relationship .with ongoing consultation and education activities within the Region; g) pro- posed cost effectiveness of truck service compared with other means of delivering information; and h) improved plans for continuation under other support of all proposed activities. Recommendation: Non~Approval I - No DRMP funding recommended. DRMP /GRB 7/10/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) NEW YORK METROPOLITAN REGIONAL MEDICAL PROGRAM RM 00058 7/70.2 Associated Medical Schools June 1970 Review Committee of Greater New York 2 East 103rd Street New York, New York 10029 PROGRAM COORDINATOR: I. Jay Brightman, M. D. Requested Ist Year 2nd Year 3rd Year Total Direct Costs $74,615 $73,790 $77,670 $226,075 Indirect Costs 22,935 24,475 26,015 73,425 TOTALS: $97,550 $98,265 $103,685 $299,500 HISTORY: Please refer to the NYMRMP application number RM 00058 7/70.1. BACKGROUND: This project was reviewed by Council in December 1969 under the title Project #14 - Regional Medical Program Coronary Care Training Center at New York Hospital - Cornell University Medical College. Although recognizing that the project was technically sound and capably directed, Council recommended that it be returned for revision. It was suggested that nurse instructors be involved more in the didactic phase of the training; that the Region develop an overall plan for phasing out grant support; and that the Region explore the possibility of the hospitals referring trainees to assume some of the costs, particularly the trainee stipends. The Heart Disease and Stroke Control Program has supported a coronary care training program at New York Hospital - Cornell Medical Center for about three years as part of a special study. This contract will terminate in July 1970. The NYMRMP is anxious to preserve and utilize "the experienced personnel from this project for the development of a Regional Training Center in Coronary Care. In order to meet this need, Dr. I. Jay Brightman, Coordinator, NYMRMP has requested that the revised project be considered with urgency. PRESENT APPLICATION: This application is requesting $299,500 for three years’ support of a coronary care training project for nurses. It is a resubmittal of Project #14, which has been revised and the amount requested reduced from $317,941 (d.c.o.) to $226,075 (d.c.o.). NEW YORK METROPOLITAN RMP ~2- RM 00058 7/70.2 aa Project # 19 - New York Hospital, Cornell Medical Center Requested Program for Continuing Education, for Nurses. First Year Recently published statistics indicate that in 1966 there - $74,615 were an estimated 205,000 persons having acute episodes of coronary heart disease and 31,000 deaths from myocardial in- farction in the Metropolitan New York area. The Region states that 5,000 to 7,500 deaths could be prevented in the Metropolitan New York area each year if effective coronary care facilities were available in most of the hospitals in this area. The Region projects a need of 2,428 CCU/ICU monitored beds and approximately 2,400 trained nurses to staff them. In view of the present turnover figures the Region expects it would have to train 1,000 nurses per year, of which approximately 370-400 nurses would remain active on CCU staff. In 1968 questionnaires were sent to 150 of the estimated 181 community hospitals in this Region; sixty-one replies were received. Twenty-nine of these community hospitals indicated a definite interest and proposed sending at least 156 nurses to a coronary care unit training course during the following year. The Region has developed a master plan to develop five to ten Cardiovascular Training Centers in the region to upgrade the preparation of the graduate nurse practitioner within the area of cardiovascular disease nursing so that adequate numbers of prepared nurses will be available to function effectively in Intensive Care Units and other related service areas. The Regional plan also includes the establishment of a Regional Council of Training Program Directors from the proposed participating regional centers for CCU training. This Council, under the auspices of the NYMRMP and the Heart Associations of this Region would be charged with the establishment of uniform standards for training, evaluation and supervision of these regional training programs. This approach will give the region a system of control over the quality and quantity of CCU Training Programs in the Region. This project proposes to develop at the New York Hospital - Cornell Medical Center the first primary center for Coronary Care Training of nurses within the NYMRMP master plan. It will serve as a model ~- for the development of other high quality nurses coronary care training programs throughout the Region. The training center will provide an intensive thorough four-week long course in coronary nursing care four times each year for at least three consecutive years (1970-1972). Registered nurses with leadership positions (supervisors, nursing instructors, head nurses and assistant head NEW YORK METROPOLITAN RMP -3- RM 00058 7/70.2 nurses) from hospitals in the nine-county metropolitan New York area will be accepted as trainees in the Coronary Care Training Course. Criteria for the selection of trainees into the program will emphasize nursing instructor trainees from basic education programs and in-service educator trainees from hospital settings. The primary purpose of the training center will be to train the nurses well enough that they will be able to set up and administer programs for CCU staff nurse training in their sponsoring hospitals. This could be an in-service continuing education activity in a hospital or a coronary unit training course in a nursing school basic education program. It is expected that this center will train 120 nurses on an annual basis. Both physicians and nurses will actively participate in teaching, planning, implementing, and evaluation of the educational activities. The nurses and physicians will work together to identify components in the training program which serve to enhance the development of knowledge and attitudes required by the nurse to accept and assume a changing role in relation to the physicians and other members of the health team. It is believed that this interaction will be crucial to the delivery of health care services for patients with problems other than coronary heart disease. In addition to the instructors which will be assigned to the course, faculty members of the School of Nursing, Medical College, and staff of the Center will serve to advise and/or participate in the program. The facilities of the Cornell University - New York Hospital School of Nursing will be available to conduct this course. These facilities include classrooms, laboratory and the Coronary Care Unit of the Medical Center. A newsletter will be developed and distributed to former trainees, hospitals and schools to promote continuing follow-up of current advances in the field of cardiovascular disease. The applicant estimates the cost per trainee will run in excess of $1,000 and that the trainee or her sponsoring institution could not assume this cost. The program plans to charge no tuition or fees during the first two or three years. Trainees who have to occupy temporary quarters will be provided with a daily per diem of $16 or $80 per week. Transportation costs will be assumed by the sponsoring hospital. It is anticipated by the Region that 70% of the students will be able to commute on a daily basis. The per diem rates stipulated above are within RMP policy limitations but the individual must travel a minimum of fifty miles round trip in order to be eligible. NEW YORK METROPOLITAN RMP he RM 00058 7/70.2 For evaluation students will be given a pre-test and final evaluation. Questionnaires will be sent to students and their. nursing directors © six months after completion of the course. Site visits will be utilized to determine not only how effective the students function in their own hospital but also to identify the difficulties they have encountered since their return. In addition the associate nurse and physician directors of the training course will review and evaluate existing training programs in the community hospitals that send personnel to the Regional Center. Efforts will be made to standardize the curriculum of the in-service coronary care training programs in community hospitals after the preceptors who will administer them have been trained. The Region plans to continue this program once RMP funding is terminated by implementing a tuition payment plan. The major portion of funds requested are for support of personnel and the payment of stipends for trainees. Second Year: $73,790 Third Year: $77,670 DRMP /GRB 5/22/70 (A Privileged Communication) 1 { i SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE NEW YORK METROPOLITAN REGIONAL MEDICAL PROGRAM RM 00058 7/70.2 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: This application requests a total of $226,075 for three-years support of Project #19 ~ New York Hospital Cornell Medical Center Program for Continuing Education of Nurses. Committee approved partial funding of this application at a level of $115,125 (D.C.0.) for two-years support. : Background: This project was reviewed by Council in December 1969 under the title Project #14 - Regional Medical Program Coronary Care Training Center at New York Hospital - Cornell University Medical College, Although recognizing that the project was technically sound and capably directed, Council recommended that it be returned for revision, It was suggested that nurse instructors be involved more in the didactic phase of the training; that the Region develop an overall plan for phasing out grant support; and that the Region explore the possibility of the hospitals referring trainees to assume some of the costs, particularly the trainee stipends, The Heart Disease and Stroke Control Program has supported a coronary care training program at New York Hospital - Cornell Medical Center for about three years as part of a special study. This contract terminates ‘in July 1970. The NYMRMP would like to preserve and utilize the experienced personnel from this project for the development of a Regional Training Center in Coronary Care. In order to meet this need, Dr. I. Jay Brightman, Coordinator, NYMRMP has requested that the revised project be considered with urgency. Project #19 - N.Y. Hospital Cornell Medical Center Program for Continuing Education of Nurses Critique: The Committee believes that for the most part, the Region has Satistactorily answered the questions posed by the December 1969 Council and that this project will produce much needed adtlitional trainees. The Committee however, still believes that there should be more involvement of nurses and nursing schools in the implementation of this program and that the program should give a guarantee that other sources of support will be available at the conclusion of two years when RMP support terminates, Com- mittee also feels that participating hospitals should contribute to the cost of training their own personnel by assuming the costs for stipends, In view of past support by the USPHS and Councils previous concern for phas- ing out the grant support Committee believed that two years support by the DRMP should give the Region sufficient time to develop an established. pro- gram which can be locally supported. A. f = from the DRMP, prior to release of funds for the first year's support; NEW YORK METROPOLITAN RMP -2- RM 00058 7/70.2 The Committee concurred with the Ad Hoc Cardiovascular Panel's favorable review and recognized the project as technically sound and capably directed, Recommendation: Approval I - at a reduced level with the following con- tingencies: (a) That nursing school participation can be clearly identified; (b) that the Region can give assurance of continuing support from other sources for the program at the end of two-years support (c) that the participating hospitals assume the costs for stipends of per- sonnel they refer for ‘training, The amount requested for stipends ($33,280) has been deducted from the requested level. First Year _ Second Year Third Year $57,975 , $57,150 $ -0- REVIEW COMMITTEE FUNDING RECOMMENDATION (D.C.0.) a Project Year Requested Recommended #19 Ol $74,615 $57,975 02 . 73,790 ~ 57,150 03 77,670 -0- TOTAL $226,075 $115,125. -RMPS/GRB/7/8/70 + DRAFT SITE VISIT REPORT NEW YORK METROPOLITAN REGIONAL MEDICAL PROGRAM RM 00058 JULY 21, 1970 Site Visitors Dr. John D. Thompson Professor of Health and Associate Dean for Planning Yale University School of Medicine New Haven, Connecticut Jessie B. Barber, Jr., M.D. Consultant, RMPS Professor of Neurosurgery Howard University School of Medicine Washington, D.C. Division Regional Medical Programs Service Mr. Cleveland R. Chambliss Office of Organizational Liaison Mr. Bob Morales Public Health Advisor Grants Review Branch Regional Advisory Group Members John L.S. Holloman, Jr., M.D. RAG and TCP - Stroke Member Regional Medical Programs Service Core Staff I. Jay Brightman, M.D. Director New York Metropolitan Regional Medical Program Jessie Aronson, M.D. Deputy Director Mrs. Margaret Barnett Program Representative Mrs. Fredrica Brooks Assistant Director for Administration and Communications NEW YORK METROPOLITAN “2- Regional Medical Program Project Representatives Ralph W. Rechter, M.D. Project Co-Director Charles A. Ragan, M.D. Project Co-Director George I. Lythcott, M.D. Columbia University and Harlem Hospital Bernard Challenor, M.D. Columbia University and Harlem Hospital Miss Barbara Bengan Columbia University and Harlem Hospital Others Mr. Preston Lewis Model Cities Mr. George Goodman, Director liarlem Neighborhoods Association Mr. Leo Rolle, Executive Director United Block Association Mr. George Lotham Executive Secretary United Block Association RM 00058 NEW YORK METROPOLITAN ~3- RM 00058 Regional Medical Program Background: In June 1970 the Review Committee reviewed an operational supplement application from the New York Metropolitan Regional Medical Program which included Project #17 - Harlem Region Stroke Program. Committee took no action on this project and-recom- mended a site visit to interpret community involvement and to negotiate an appropriate budget. Further, the Committee recommended that the site visit team be authorized to act in its behalf in making a final recom- mendation on this project. Concerns: The questions raised for consideration by the site visitors were the following: (1) What is the involvement of profes- sional and community organizations such as the Manhatten Medical Society, Block Association, and private practitioners in the planning and implementation phase of this program; (2) What is the involvement of allied health personnel in the planning and implementation of this pro- gram; (3) How will speech therapy and other rehabilitation services be provided by this program; and (4) Is the salary structure in the proposed budget appropriate? Project #17 - Harlem Region Stroke Program Dr. I. Jay Brightman initiated the meeting by commenting on the Region's enthusiasm and interest in this project. He mentioned that Dr. George I. Lytheott, M.D., the NYM/RMP representative at Columbia University, has been quite involved with community activities in the Harlem area, including this Stroke Program. the site visit team recognized the limited involvement of both profes- sional and community organizations in the planning phase of this program. The team, however, identified from the testimony of able representatives at the meeting, that there will be much more involvement of all community organizations in the implementation phase of this program. Dr. Charles A. Ragan, Project Co-Director, explained that the participating hospitals (Sydenham, Knickerbocker Hospital, Italian Hospital) have only limited services for the stroke patient in their facilities. Although a firm commitment cannot be given unless this project is funded, the Harlem Hospital has made a verbal agreement with these facilities to accept referrals of stroke patients, both indigent and non-indigent, to this program. Dr. Ragan explained that these hospitals were not too involved in the planning phase because there have been no previous successes and some insensitivity to needs of the community in previous program develop- ment attempts. Each of the hospitals will have a representative on the Advisory Committee of the program. The Region agreed with the site team's concerns that the Manhatten Medical Society should be more involved with this program. They indicated that ‘they are working toward gaining the Society's increased participation NEW YORK METROPOLITAN =~ ~h- RM 00058 Regional Medical Program and involvement with the program. Many of the Society's members are indirectly involved by participating in total hospital planning although not particularly with this program. Of a seven member Executive Committee of the Society, five are on the Department of Medicine Staff at Harlem Hospital. A representative of the society will be on the program's advisory committee. oo The Rehabilitation Department of the Harlem Hospital will provide complete rehabilitation services (including speech therapy) to patients entering in the program. Input into this program by allied health personnel has come primarily from staff of the Rehabilitation Department at Harlem Hospital. These personnel have been primarily involved with the development of the curriculum for training the community health workers identified in the proposal and will participate as instructors. They will also be involved in the treatment of patients, the evaluation of the program, and will be represented on the Advisory Committee. A strong facet of this project which was of interest to the site visitors -was the Block Association, a community organization in the Harlem area which will participate in this program. This organization remains active in the Harlem Community by helping to locate health services needed by the population in their area. They have much interest in health prevention programs and have had experience working with the lead poisoning and tuberculosis programs. The Block Association believes they can take an active role in the detection, education and follow-up phase of this stroke program. The representative from the Harlem Neighborhood Association expressed his organizations interest and willingness to cooperate with the program. The Harlem-East Harlem Model Cities representative indicated that his program supports the Harlem Regional Stroke Program which will serve the Model Neighborhood Area that includes more than 100,000 residents of Central Harlem. The Urban League has been invited to participate in the program and continued efforts will be made to gain their involvement The site visit team believes that it was able to convey to these community organizations the message that the RMP encourages them to become involved in planning and implementation of health programs in their community. All four of these community groups will have representatives on the Advisory Committee. The site visitors believe that the salary and equipment proposed in the project's budget is realistic and may possibly need to be supplemented through local resources. The applicant in addition to the $997,260 outlined in the application as its contribution to the support of this project, will be contributing an additional $50,000 to $100,000 in personnel and equipment, such as speech therapist, EEG, Echo Testing Equipment, blood gas determination equipment, etc. . The project representatives indicated that the evaluation of this program will be strengthened by the availability of retrospective data on hypertension NEW YORK METROPOLITAN | -5- RM 00058 Pegional Medical Program of residents from the Harlem community which will be available from. a community study and a hospital chart study at Lincoln Hospital that has been in operation for two years. The site visitors believed that the evaluation proposed by this project is adequate. The project representatives believe that it may be possible for the city government to absorb this program if it proves to be successful at the end of three years' support by RMP. They indicated that history has shown that successful programs have been absorbed by the city and cited a mental health program as an example. Conclusions: The site team believes that the concerns of the Review Committee have been more than adequately answered by the project representatives present at the site visit. It is clear that there is professional, community and allied health involvement and that the budget is realistic. In addition, the proposal has other positive aspects such as the close cooperation of the Department of Medicine, the proposed involvement of other poorly staffed and equipped hospitals in the Harlem Region, the availability of existing community organizations for case finding and follow-up and the obvious interest of well-qualified profes- sionals in the region. The site team is impressed over the preventive aspects of ths proposal as well as the proposed diagnosis and treatment activities. It could be a welcome contribution toward solving the problem of CVA particularly in this stroke-prone population. In addition, the site team recognizes the high professional caliber of project staff and the support it is receiving from community organizations such as the Model Cities Program, Harlem Neighborhood Association, and the United iiock Association. Recommendation: Site visit team recommends that this project be supported for three years at the requested level of funding. SUMMARY OF RECOMMENDED FUNDING IN DIRECT COSTS Project Year Requested Recommended #17 - Harlem 01 $401 , 860 $401,860 Region Stroke 02 421,175 421,175 Program 03 350 ,000 350,000 TOTAL $1,173,035 $1,173,035 DRMP /GRB 7/27/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) NORTH CAROLINA REGIONAL MEDICAL PROGRAM RM 00006 7/70.1 4019 North-Roxboro Road June 1970 Durham, North Carolina 27706 Review Committee Program Coordinator: F.M. Simmons Patterson, M.D. Requested Ist Year 2nd Year 3rd Year TOTAL Direct Costs $213,813 $197,153 $177,340 $588 , 306 Indirect Costs 37,428 52,913 56,711 147,052 TOTAL $251,241 $250,066 $234,051 $735,358 HISTORY: The planning grant period was for two years, July, 1966-June 30, 1968. During the first year $438,851 was awarded and $773,674 the second. In November 1967, a site visit was made to appraise the Region's capability for operational status. Initial operational support was being sought for core staff and nine projects. The visitors recognized a lack of an overall state plan for Regional development. Program development, however, was in the early stages and corrective resources were available. The site visitors were highly impressed with the Region's Research and Evaluation Division's continued parti- cipation and input into the programs. As recommended by Council in February 1969, the Region became operational with an initial award in the amount of $1,485,341 for the support of core staff and eleven projects. In May 1968, Council approved four of five component projects in the first supplemental application. Disapproved, the project for coronary care training for physicians and nurses was returned for revision. In November 1968, Council approved the second supplemental application for the support of two more projects, one being a revision of the coronary care training proposal. In February 1969, Council approved a third supplemental application consisting of one new project and a request for additional funds for another. In May 1969, Council approved four of five components in the fourth supplemental application. The disapproved project, Physicians Assistant Training Program, was returned for revision. It was revised and submitted with four new projects in the fifth supplemental application; all were approved by Council in August 1969. In December 1969, Council approved the sixth supplemental applica- tion consisting of two new projects. Council believed that one of the projects, Medical Student Operation of Edgemont Clinic (#24), could be supported through the core staff budget without additional grant support. In March 1970, Council recommended approval of the first renewal application consisting of two projects. In May 1969, DRMP staff reviewed the non-competing second year operational continuation grant application consisting of core staff and 14 projects. The individual project progress reports were in very general terms and failed to clearly specify progress in terms of stated objectives. There was also a scarcity of information about projected accomplishments in the. following year. The core staff report, however, indicated that much more had been achieved than was reflected in the individual reports. Based on information in the NORTH CAROLINA Regional Medical Program -2- RM 00006 7/70.1 in the core staff report, it was believed that there was substantial evidience of significant regionalization progress. Approval was recommended resulting in an award in the amount o (d.c.o.) including £ 3 3 Pub funds in Core. FASE V7EV A summary of the "Review and Funding History" is attached for reconciliation ease. PRESENT APPLICATION: Support is requested for two projects; one is a renewal. Requested Project #3R - Diabetic Consultation and Education Services. This First Year project was initially funded for two years and four $89,908 months, March 1, 1968-June 30, 1970, $132,081 (d.c.o.) the first period (16 months) and $79,442 the second period (12 months). The principal aim of the project was to bring advances in diabetes management to physicians, nurses and patients and their families in local communities. This was to be accomplished through seminars and other educational programs. As a pilot program, these services were to be delivered statewide by three teams. Goals included the expansion of consultation and teaching clinics in two hospitals, assistance in organizing a state association for the control of diabetes, and testing data collection techniques. | During the twenty-four months of operation, four major activities have evolved. One hundred and one (101) professional education programs, 20 for physicians and 81 for paramedical personnel, were conducted in 28 oats different counties reaching a total audience of 3,166. Consultation by . staff physicians and nurses was offered in conjunction with the continuing education program. In addition to direct patient teaching, the Diabetes Teaching Nurses were active in screening programs, inservice training for nursing personnel, public education, arranging for diabetic children to attend a special summer camp and organizing local diabetes societies. Numerous publications, i.e., references for physicians and nurses, patient guides, news bulletins and professional papers, were published and widely distributed. A major accomplishment was the formation of the North Caro- lina Diabetes Association, now an affiliate of the national parent organization. Present evaluation methods include program interest surveys, testing prior to programs, data collection, periodic reporting of activities and program response. Renewal support is requested for an additional three years to develop a broad lay and professional educational program to be continued by the North Carolina Diabetes Association after cessation of Federal support. Plans include: 1) continued educational activities for physicians, nurses and allied health personnel, and patients and their families; 2) multidisciplinary workshops; 3) expanding consultation service to include a dial access system, a new project being proposed to NCRMP; 4) use of available educational material, as well as the development and testing of new publications and 5) establishment of a central office. NORTH CAROLINA Regional Medical Program ~3- RM 00006 7/70.1 Plans also call for the provision of an organizational framework compatible with the North Carolina Diabetes Association's goals and functions. This will facilitate their eventual takeover. Evaluation will also provide for measuring changes in behavior as a result of inservice education programs. Approximately 90% of the budget is for personnel including $41,936 for contracting for the services of eight Diabetes Teaching Nurses; four are new positions. The applicant expects that support for four of these positions will be assumed locally after the first year and four by the North Carolina Diabetes Association in the third year. Second Year: $62,550 Third Year: $42,306 Requested Project #26 - Emphysema and Lung Disease Program. The overall goal of First Yea this project is to achieve a position in which every $123,905 citizen of North Carolina can obtain, within 50 miles of their homes, the most up-to-date diagnostic and treatment services for pulmonary disorders. Short term objectives during the first year: 1) develop- ment of a regional Pulmonary Training Center at Duke University Medical Center at Durham; 2) improvement of diagnostic and treatment capabilities of four hospitals located in the communities of Shelby, Wilson, Greenville and Winston-Salem and 3) implementation of a formal communication link-up between participating institutions to provide for consultation, improved referral resources for private practicing physicians and increased public awareness of respiratory disorders and the services necessary for their control. Through planning the project, working relationships have already begun between the project director, assistant directors and the representatives of hospitals (including the V.A. Hospitals), medical schools and State Sanitariums. Two State Sanitariums located in Asheville and McCain already have the capability and will serve as referral centers for the western and southeastern parts of the state. During the first year, the training center will train 36 persons (12 physicians 1-4 weeks, 12 nurses 2-6 weeks and 12 pulmonary laboratory technicians 8 weeks). Initial enrollment will be limited to personnel from participating hospitals and the length of the course will vary pending on the individual expertise of those to be trained. The Project Director, Assistant Directors and the Training Director assisted by other program participants, including NCRMP core staff, will periodically assess the program. Evaluation will include appraisal of productivity and capability of community care facilities, patient work- loads, physician and health care personnel involvement including those in training and/or in need of it, and annotational data. NORTH CAROLINA Regional Medical Program °° 4-3 -RM- 00006 I7470.1 Near the end of. the first year, an internal evaluation will be undertaken. If the program is progressing as planned, two new; training centers will be established during the second year, one in Winston-Salem and one in Greenville. If not, approximately $35,000 will be rebudgeted to establish or improve care centers in one hospital in each of the five communities of Wilmington, Raleigh, Rocky Mount, Fayetteville and Charlotte. Support requested is the sum of six sub-project budgets. A. composite of the budgets is attached. McCain Sanitarium is cooperating as a referral center, but is not requesting grant support. NORTH CAROLINA Regional Medical Program lst Year Planning Award (June 1966 Council) 01 Supplement (Site visited November 1966) (November 1966 Council) 2nd Year Planning Award 02 Supplement INITIAL OPERATIONAL APPLICATION COMPONENTS (Site visited November 1967) (February 1968 Council) #0 #1 #2 #3 #4 #5 #6 #7 #8 Core Planning and Staff - Education and Research in Community Medical Care-~ University of North Carolina Coronary Care Training And Development - Duke University* Diabetic Consultation and Education - Duke University* Development of Central Cancer Registry ~- Univer-~ sity of North Carolina Medical Library Extension Service-Duke University Cancer Information Service Duké University Continuing Education in Internal Medicine - Uni- veristy of North Carolina Continuing Education in Dentistry - University of North Carolina RM 00006 7/70.1 REVIEW AND FUNDING HISTORY 7/1/66-6/30/67 $287,266 1/1/67-6/30/67 148,585 7/1/67-6/30/68 600,944 9/1/67-6/30/68 172,730 Approved Approved Project Period Funded (d.c.o) Future Level 3 yrs (01)$530,991 (03)$589, 130 (02) 586,629 3 yrs-4 mos. (01) 209,200 (03) 240,993 (02) 201,119 3 yrs-4 mos. (01) 65,823 ye 84,067 (02) RYE Af SUG 2 yrs-4 mos. (01) 132,081 (03) -0O- (02) Nebmpeleniemeel PIBGES 3 yrs-4 mos. (01) 66,615 (03) 125,510 (02) 111,188 2 yrs-4 mos. (01) 25,839 (03) -0- (02) 23,763 2 yrs-4 mos. (O01) 41,716 (03) -O0- (02) 31,014 3 yrs-4 mos. (01) 24,428 (03) 23,834 (02) 21,253 3 yrs-4 mos. (01) 67,500 (03) 66,719 (02) 61,041 ’ NORTH CAROLINA Regional Medical Program.:.- ~6=.2 9!) (s. ). +4 RM? 00006 ET#IO.1 - Approved : Approved f vues = Project Bente funded {dsco) Future Leve #9. >, Continuing Education for. c¢ 3: yrs-4. mos. (01)$;275838:: * (03)9 28,381 Physical Therapists - (02) 25,543.;; Rep University of North. Carolina ae #10- Coronary Care Units in 3 yrs-4 mos. (01): 99,989. (03):.37,042 Small Hospitals (State (02) 33,338 of Franklin) - Bowman me re Gray* #11- Mobile Cardiac Intensive 1 yr-3 mos. oo F.COL)Y 18 485 200% (03) "" -0- Care - Haywood County (02) er ec st Hospital* a COMPONENTS OF FIRST SUPPLEMENTAL OPERATIONAL APPLICATION . (May 1968 Council) #12- Regional Coronary Care Unit Disapproved with “advice to Revise and Resubmit for Physician and Nurse Education - Bowman Gray rs Ct we oe #13- Cardiopulmonary Resuscita- 3 yrs-1 mo. (01), 60, 861 a -.. (03) 70,056 |. tion - Duke University and (02) 63,152 re Be North Carolina Heart Assoc. #14- Heart Consultation and 3 yrs-l a (01) 9,595. (03) 8,720 Education - Bowman Gray (02) 7,848.5) Go cie #15- A Community Stroke Program 3.yrs-l,mo. °.;.,(01). 152,375. .. (03) 258,740 Bowman Gray, : ~ #02). 172,930 7 #16- A Community Program -for the 3 yrs-1 mo; (01), 38,865. . -(03) 31,206 Early Detection and Manage- -. (02) 28,085 .., ment of Hypertension - University of North Carolina* COMPONENTS OF SECOND SUPPLEMENTAL APPLICATION : (November 1968 Council) #12- Regional Coronary Care Unit 1 year - (01) 90,000: L/ | (02)(03) -0- for Physician and Nurse ree oo , Education - Bowman Gray #17- Regional Center for Gesta- 3 years (01): 29,000 - » (02) 29,000 tional Throphoblastic . o rs* (03) 29,000 | Neoplasms - Duke University Lo ag NORTH CAROLINA Regional Medical Program -7- RM 00006 7/70.1 COMPONENTS OF THIRD SUPPLE- MENTAL APPLICATION x »! (February 1969 Council) Approved Approved Project Period Funded (d.c.o.) Future Level #2 - Supplement to Coronary 3 years £021) 23,584 (02)$ 23,584 Care Training and (03) 23,584 Development #18- Tumor Tissue Registry - 3 years (01) 6,916 (02) 6,916 Moses H. Cone Hospital, (03) 6,916 Greensboro , COMPONENTS OF FOURTH SUPPLE- MENTAL APPLICATION (May 1969 Council) #19- Physician's Assistant Disapproved with advice to Revise and Resubmit Training Program _ #20~ Mammography Technologists 1 year © (01) 9,867 1/ (02)(03) -0- Regional Training Program #21- Innovations in Clinic 3 years (01) 14,500 (02) 14,500 : Nursing: Patients, Person- . (03) 14,500 © nel and Practices #22- Coordinated Oncology Chemo- 3 years (01) 78,000 (02) 78,000 therapy Program (03) 78,000 #23- Pilot Study: Heart-Sounds 3 years (01) 48,000 (02) 48,000 Screening of School Children (03) 48,000 COMPONENTS OF FIFTH SUPPLE- Recommended MENTAL APPLICATION —— lst Year Funding Future Level (August 1969 Council) ; (d.c.o.) #19- (Revised) Physician's 3 years (01)$183,321 (025$169, 662 Assistant Training Program (03) 114,220 COMPONENTS OF SIXTH SUPPLE- MENTAL APPLICATION (December 1969 Council) #24- Medical Student Operation 3 years (01) -0- (02)(03) -0- of Edgemont Clinic #25- Problem-Focused, Group- —3:-:-years (01) 43,443 (02) 44,374 Oriented and Community- (03) 45,309 Based Continuing Education NORTH CAROLINA Regional Medical Program COMPONENTS OF FIRST RENEWAL APPLICATION (March 1970 Council) #5R- Medical Library Extension #6R- Cancer Information Service COMPONENTS OF SEVENTH SUPPLE- MENTAL APPLICATION (July 1970 Council) #3R- Diabetic Consultation and Educational Services #26- Emphysema and Lung Disease Program * (Earmarked) Approved.. Project Period RM 00006 7/70.1 Recommended 2 years 1 year 1/ Funded from 01 unexpended balance 2/ Funded $12,000 from 01 unexpended funds lst Year Funding Future Level (d.c.o.) (01) 23,763 (02) 23,763 (03) -0- (01) 31,050 (02)(03) -0- DRMP/GRB/5/11/70 -9- NORTH CAROLINA REGIONAL MEDICAL PROGRAM PROJECT #26 ~ EMPHYSEMA AND LUNG DISEASE PROGRAM BUDGET COMPOSITE CONSULTANT ALTER, & PERSONNEL _SERVICES EQUIPMENT SUPPLIES TRAVEL RENOV, OTHER TOTAL FIRST YEAR Cleveland $ 14,500 -0- $ 6,235 -0- $ 200 -0- -0- $20,935 Memorial Hospital, Shelby Wilson -0- -0- 2,900 -0- 200 $8,000 -0- 11,100 Memorial Hospital, Wilson Western. NC 2,500 -0- 3,600 -0- 200 -0- -0- 6,300 Sanitarium, Asheville McCain -0- -0- -0- -0- -0- -0- -0- -0- Sanitarium, McCain Duke, Univ., 33,665 $1,200 10,520 $ 900 1,000 -0- -0- 47,285 Durham Pitt Mem. 17,000 -0- 3,085 -0- 200 -0- -0- 20,285 Hospital, Greenville N.C. Baptist 11,600 -0- 5,000 -0- 200 1,200 -0- 18,000 Hospital, Winston-Salem TOTAL $ 79,265 $1,200 $31,340 $ 900 $2,000 $9,200 -O- $123,905 SECOND YEAR Shelby $ 11,500 S$ -0- $2,500 $ ~0- $ 200 $ -0- -O- $ 14,200 Wilson -0- -0- 2,500 -0- 200 -0- -0- 200 Asheville 2,500 -O0- -0- -0- 200 -0- -0- 2,700 MeCain -0- -0- -0- -0- -0- -0- -0- -0- Durham 47,031 ~0- -0- 2,000 2,000 -0- -0- 51,031 Greenville 29,000 -0- -0- 500 200 -0- -0- 29,700 Winston-Salem 32,386 -Q- 3,186 1,000 200 -0- -0- 36,772 TOTAL $122,417 -0- $5,686 $3,500 $3,000 -0- -O- $134,603 THIRD YEAR Shelby $ 8,500 $ -0- $ -0- $ -0- $ 200 $ -0- $ -0- $ 8,700 Wilson ~O- -0- -0- -0- 200 -0- -0- 200 Asheville -0- -0- -0- -0- 200 -0- -0- 200 McCain -0- -0- -O- -0- -0- ~O- -0- -0- Durham 51,734 -0- -0- 2,000 2,000 -0- -0- 55,734 Greenville 29,000 -0- -0- 500 200 -0- -0- 29,700 Winston-Salem 34,330 -0- -0- 470 200 -0- -0- 35,000 Other -0~ -0- -0- -0- -0- -O0- 5,500 5,500 Communities TOTAL $123,564 -0- -0- $2,970 $3,000 $ -O- $5,500 $135,034 TOTAL ALL $325,246 $1,200 $37,026 $7,370 $8,000 $9,200 $5,500 $393,542 YEARS $n A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE NORTH. CAROLINA REGIONAL MEDICAL PROGRAM ~ RM 00006 7/70.1 , FOR CONSIDERATION BY JULY, 1970 ADVISORY COUNCIL General: The Review Committee recommended that this supplemental opera- tional application for $588,306 (d.c.o.) for three years be partially funded in the amount of $194,764 (01 - $89,908, 02 - $62,550 and 03 - $42,306). Project #3R - Diabetic Consultation and Education Services Critique: The Committee noted that this is a request for renewed support for three years of a project initially funded for two years and four months. The Committee agreed with review comments prepared by the Continuing Education and Training Branch staff. The development of this project and the evaluation summary are well described, including information reviewers need and appreciate. Planning methods of procedures appear sound and capably directed. Published papers coming from the back- ground study are noted. Progress, projected activities, and planned take- over by the North Carolina Diabetes Association are encouraging. Based on the statements of rationale for renewal of the project, the objectives for the coming three years, plans for implementation and eval- uation, it would seem that the requested expenditure would be a well placed investment for RMPS. - Recommendation: Approval I in the amount requested with a commendation for Dr. Luther J. Kelley for his continued contribution as director at no charge to the project. Project #26 - Emphysema and Lung Disease Program Critique: The Committee concurs with the comments and recommendations. of the Ad Hoc Cardiovascular Panel. Need, objectives and proce- dures are clear. However, there is some question about the justification for equipment budgeted for six hospitals. There is also some question as to the ability of physicians in the satellite hospitals to operate effec- tive respiratory care units. The project may be feasible with conditions, that (1) budget be reduced, particularly equipment; (2) assurances of the availability of personnel; and (3) need for more information about proposed training. The Committee North Carolina ~2-— believed that this proposal could best be evaluated by a site visit. Recommendation: Deferral for a site visit and return to Committee. SUMMARY OF RECOMMENDATIONS (Direct Costs) Project 01 #3R Diabetic $ 89,908 Consultation & Educ. Services #26 Emphysema -0- & Lung * $ 89,908 *(Deferred for site visit) 02 03 Total $ 62,550 $ 42,306 $194,764 -0- -0- ~0- $ 62,550 $ 42,306 "$194,764 pRMP 7/2/70 DIVISION OF REGIONAL MEDICAL PROGRAMS SUMMARY OF AN OPERATIONAL GRANT APPLICATION © (A Privileged Communication) NORTH DAKOTA REGIONAL MEDICAL PROGRAM RM 00060 7/70.1 University of North Dakota June 1970 Review Committee 1600 University Avenue Grand Forks, North Dakota 58201 Program Coordinator: Theodore H. Harwood, M.D. Requested Program Period Ist Year 2nd Year 3rd Year Total Direct Costs: $191,305 $194,902 $201,257 $587,464 Indirect Costs: -0- -0- -O- -0- TOTAL $191,305 §194 ,902 $201,257 $587,464 History: The North Dakota Regional Medical Program is administered by the North Dakota Medical Research Foundation and covers the state of North Dakota which encompasses approximately 71,000 square miles containing a population of 650,000. A planning grant was awarded for a two-year period, July 1, 1967 - June 30, 1969. The first year award was in the amount of $188,010 and the second year award was $192,960, decreased by an unexpended balance of $113,193 from the first year, resulting in a total award of $79,767. — Staff assistance visits to the Region were conducted in November and December 1968. A site visit was made on June 12-13, 1969 to review the North Dakota RMP's initial Operational Application. In order to provide continuity to the program, an extension of four months to the planning grant with additional funds in the amount of $31,984, based on the Region's annual level of support, was made on July 1, 1969. Although the North Dakota RMP initial application was recommended for approval by the Council in August 1969, due to the restriction in funds, an operational award for the Core component only was made, effective January 1, 1970, in the amount of $255,942, An amendment to the operational award was made January 23, 1970 in the direct cost amount of $314,816 to authorize the region to implement its four operational projects as follows: NORTH DAKOTA Regional Medical Program ~2- RM 00060 7/70.1 OPERATIONAL STATUS - (DCO) PROJECT NUMBER TITLE FUNDING LEVEL Core $255,942 1 Dial Access 6,745 2 Training Nurses in Rehabilitation Techniques 30,489 3 Program for Caring for Patients with Electrolite Imbalance 9,583 4 Coronary Care 12,057 TOTAL $314,816 Present Application: The region has submitted five new operational projects, and they appear in the order of priority assigned by the Regional Advisory Group. All programs are oriented to the continuing education for physicians, nurses and allied health personnel. Requested — Proj. #5-Diabetes and Nutrition-This project resulted from a request First Ye from the North Dakota Dietetic Association to the North $33,507): Dakota RMP, to sponsor 4 one-day seminar on diabetes and atherosclerosis in November 1968. As a result, the region set about organizing a program whose objective was to study and develop educational methods to improve the care of patients with diabetes, and of others requiring expert direction in therapeutic dietetics. Advice was sought from Dr. Donnell Etzwiler, Director of the Diabetes Detection and Education Center, Minneapolis, and Dr. Edgar Haunz of Grand Forks Clinic, an officer of the American Diabetes Association. Co-sponsoring the symposium were the North Dakota RMP, the North Dakota State Nurses Association, and the University of North Dakota Medical School. Initially, a team consisting of a physician, two nurses and a dietician from each local area will attend a week-long intensive training program at the Diabetes Detection and Education Center in Minneapolis. Later this group will develop local teams, plan and develop informational meetings and disseminate information for pro- fessionals and patients. The North Dakota RMP will assist in the development of training programs for local personnel by two-day sessions covering the subject matter and by means of team teaching techniques. The region will supervise the local programs to enable the local team to conduct classes on a regular schedule. North Dakota RMP staff will provide much of the material for the programs. NORTH DAKOTA Regional Medical Program -3- RM 00060 = 7/70.1 Requested First Year A minimum of four seminars will be conducted the first year to develop four teaching teams, and four in each succeeding year until a network is established. The North Dakota RMP staff will cooperate with the State School of Science at Wahpeton to present a series of programs through- out the state on diabetes and nutrition. Eleven one-day sessions are planned for the first year to be held in key locations throughout the state, and at the North Dakota State University at Fargo. In an effort to encourage and support the Division of Continuing Education at the University of North Dakota in the establishment of courses in nutrition for food service personnel, seminars will be conducted for food service personnel of various institutions. These will be sponsored by the Division of Continuing Education and the Department of Home Economics at the University of North Dakota at Grand Forks, in cooperation with the State Department of Health, the North Dakota Hospital and Nursing Home Association and the North Dakota Dietetic Association. Faculty of the Department of Home Economics will conduct the classes on the campus of the University of North Dakota. Educational needs of patients with diabetes on Indian reservations in North Dakota will also receive attention. The USPHS Hospital on the Turtle Mountain Indian Reservation at Belcourt requested assistance of a nutritionist from the North Dakota RMP in teaching classes for patients with diabetes. Initially, Indian women now working as home health aides will’ be given training in dietary care for the diabetic patient, and this service will later be expanded to other reservations. The North Dakota RMP hopes to utilize the Human Nutrition Labora- tory at the University of North Dakota, slated for completion in late 1970. This is reported to be the only facility of this kind in the nation. Methodology for evaluation consists of complete records of all seminars and training sessions, curriculum contents of training sessions for the teaching teams, national consultants, evaluation by staff of the North Dakota RMP, interviews, etc. Second Year: $31,250 Third Year: $28,950 Project #6 - Stroke Nursing Care. This program will be based at $28,751 the Neuropsychiatric Institute at St. Luke's Hospitals, Fargo, North Dakota. It will be headed by a nurse to coordinate and administer the program in continuing medical education for nurses in the care of acute stroke patients and other diseases of the central nervous system. NORTH DAKOTA Regional Medical Program -4- RM 00060 7/70.1 . First Year.= Nurses from hospitals and other institutions in North Dakota as well as adjacent parts of South Dakota, Minnesota and Montana will be offered the’ opportunity to participate. The training program will be an intensive five-day plan, primarily of the acute stroke patient, but will include other hospitalized patients. A maximum of three courses will be offered each month with two to four nurses participating. A two-day workshop will be held semi-annually for nurses who have participated in the training to learn additional techniques and/or a refresher course. Instructional techniques will be varied and include lectures, discussion groups, the use of appropriate audio- visual materials, and clinical practice. Major emphasis will be directed toward the demonstration of new techniques, participation by the trainees in the actual care of patients, together with the proper use of treatment facilities. The course content will consist of classroom teaching and supervised clinical training. It will utilize the expertise of the staff of the Psychiatric Institute at St. Luke's Hospitals, whose staff has the competency to carry out all phases of the program. Dr. Lee Christoferson, who is also the Chairman of the Regional Advisory Group, will coordinate the contributions of the various members of the professional staff, assisted by Dr. Robert Ivers, Medical Director. Evelyn Elhard, R.N., will be the full-time program Director, assisted by Sister Carol Newburger, Director of Nursing Education, North Dakota RMP. Miss Elhard has been a full- time member of the North Dakota RMP Core staff since March l, 1970. She will be detached from the Core Staff and reassigned as Program Director for this project. During the five-day intensive training course for nurses, an evaluation of the daily course program will be made by staff members and by partici- pating nurses on special forms. Approximately two months following each two-month training course, appropriate evaluation measures will be followed up by staff of North Dakota RMP and the trainees. The Director of Nursing Education of the Core staff will visit periodically each institution which has participated in this program to discuss with the group the effect of this training on the total spectrum of care provided in that institution. The Stroke Committee of the North Dakota RMP will review and evaluate the curriculum, methodology and techniques of the training course on a continuing basis, and make recommendations for changes that might prove beneficial. Appended to the application are letters of interest and support from adjacent Regional Medical Programs. These include the Mountain States RMP (Montana), Northlands, Nebraska-South Dakota (both states). Second Year: $29,292 Third Year: $30,422 NORTH DAKOTA Regional Medical Program -5- RM 00060 7/70.1 © Requested : First Year Project #7 - Respiratory Care Center. This project will be based at $ 68,392 Deaconess Hospital, Grand Forks, North Dakota, and will provide special training for professionals and nonprofessionals in North Dakota in the use of special equipment and therapy for patients with chronic and obstructive lung diseases. The program will emphasize ambulatory care of patients and is designed to meet the critical needs for improved patient care of pulmonary diseases. This porject will serve a population base of a large rural area of North Dakota and Minnesota where there are many small communities with very small hospitals or nursing home facilities available for basic hospital and nursing home care. Twenty-two hospitals in the area already cooperate with Deaconess for in-service training of personnel, and there are fourteen nursing homes in this immediate area. During the past two years 4 Community Health Planning Committee has developed in Grand Forks and has made progress toward maximizing the facilities for personnel now available. This committee is made up of community representatives, plus individuals from the eight different health care organizations including hospitals, the University Medical School, the Rehabilitation Center, the Mental Health Center and the nursing homes, all of which have entered into a comprehensive health planning program study to develop the best possible program for the area. The Community Health Planning Committee retained the firm of Herman Smith Associates, Hospital Consultants, and measurable progress is already noted. This committee is working toward the development of a coordinated body to assist in improved communications and decision making between the two hospitals, the Grand Forks Clinic and other physicians, the University Medical School and related services, as well as the Mental Health Center and the nursing homes. The education and training of health care personnel is viewed as the primary function of the Respiratory Care Center which will be established through this program, Courses in didacticand practical instruction of inhalation therapy will be offered, and attention will be given to the development of programs for inhalation therapy assistants. This will in time provide the means for establishing an accredited school for inhala- tion therapy technicians at the Respiratory Care Center. Center personnel will provide advice and assistance to other institutions wishing to establish their own programs. Other medical and scientific personnel in the area will be encouraged to participate in the education program. Another primary function of the Respiratory Care Center will provide a definitive diagnosis of the type of disease present, the degree of its severity and the likely prognosis in each case. A full NORTH DAKOTA Regional Medical Program -6- - RM 00060 7/70.1 - First Year assessment of the patient's status will be presented to the referring physician. Also included is a patient education program designed to inform and educate the patient in the nature of his lung disease, its cause, what it means to him for the future, etc. The patient's status will be supervised on a continuing basis fcellowing his initial evaluation at the Care Center. This will involve a communications system utilizing several levels of health personnel, e.g., a Program Coordinator at the Care Center, the patient's family physician, a home visiting service, etc. Return visits to the Care Center at regular intervals for complete re- evaluation and necessary modification of the patient's therapeutic program will be encouraged. The Center will provide in-hospital care as well as ambulatory. The basic purpose, however, will be to provide services which will lessen the need for hospital admissions, insofar as possible, by preventive care at the Center and in the home. Nursing personnel of the county and city nursing units will be involved in the training sessions in order to participate actively in the patient education program and in the visits to those who are homebound. The proposed center will have the following staff initially: a Medical Director, Dr. Harold W. Evans (part-time), a Program Director, Inhalation Therapist of Deaconess Hospital, fulltime, an Associate Director, Dr. T. A. Gallantly (part-time) ,a Patient Service Coordinator and a secretary-typist to be selected. RMP support is requested for the organization and initial operation of the Respiratory Care Center only for those persons who will have administrative and teaching responsibility, and for a limited amount of additional equipment. The Deaconess Hospital expects to continue this program as a hospital service to the community following the expiration of any grant received. Second Year: $69,559 Third Year: $72,634 Project #8 - Physician Education .Program. This program was developed $42,530 under the auspices of the Education Committee which functions as a coordinating agency for the State Medical Association, other state associations and agencies related to health care, and the educational institutions of the state. It was concluded as a result of the response to a questionnaire submitted to practicing physicians in general practice or partial specialty, that there exists in North Dakota a real desire for an interchange of information with other physicians, particularly with specialists. It was also evident that there is available a large number of well-trained individuals in specialty practice throughout the state, who are willing and able to participate in such a program. ORTH DAKOTA Regional Medical Program -7- RM 00060 7/70.1 ospital administrators also indicated that their facilities were available for teaching programs when developed. It is proposed to develop a cadre of North Dakota specialists who are willing to become members of a visiting physician team to conduct educational conferences in interest of improving patient care. The ND/RMP will initially provide the staffing and direction for this program, with the understanding that the Department of Community Medicine at U.N.D. will add to their faculty a Director for Continuing Education. As soon as practical he will take over full responsibility for the development and further operation of the program. Methodology will vary, but initially, it will take the form of informal discussion with groups or among individuals, as may be mutually satis- factory. The conference trips will be rotated among participating visiting physicians, but a specific specialist may be requested. Students at the School of Medicine may be invited to accompany the visiting physician as a part of their training and orientation. The third component of this program is designed to increase library services for the health professions, It will expand the resources at the Chester Fritz Library at the U.N.D. A medical librarian will be added and a system will be initiated for physicians who are unable o come to the campus to request materials. As new systems for the etrieval of library information are developed, they will be added. Second Year: $45,571 Third Year: $49,074 Requested First Year Project #9 - Cancer Registry. This program was developed under the $18,126 auspices of the Cancer Committee of the ND/RMP, and will build on the experience of an existing registry at the Quain and Ramstead Clinic at Bismarck, North Dakota. The initial work began in April 1969 as a pilot study under the direction of Conrad Dietz, Director of Computer Services at the U.N.D., and a part-time staff member of the ND/RMP. DRMPS consultation has also been provided by the Operations Research and Systems Branch. The Cancer Committee recommended that Dr. Pablo Ramos of the Quain and Ramstead Clinic be sent to the computerized Tumor Registry Workshop in Salt Lake City on May 28-29, 1969. Subsequently, data from the registry at Bismarck was transferred to the U.N.D. Computer Center, a system of report forms was developed to provide specific data for physicians, hospitals, and others, and other activities preparatory to centralizing the registry were accomplished. The computer function, which will now become statewide, will assume some of the reporting functions of the local registries, which exist in all the larger hospitals and some of the smaller ones. The local registries will now need to keep only one file of each cancer patient. Z & NORTH DAKOTA Regional Medical Program -8- RM 00060 7/70. This project requests support for a Registry secretary for the regional registry, and a series of workshops of one and one-half days duration for registry secretaries throughout the region. The regional secretary will attend a four-week training workshop at the San Francisco Medical Center, and will later be designated as the instructor for the ND/RMP workshops. Evaluation for this project will be the joint responsibility of the regional staff and the U.N.D. Computer Center. Second Year: $19,230 Third Year: $20,177 4/28/70 NORTH DAKOTA RM 00060 7/70.1 STAFF OBSERVALION eeueneenres Project #9 » Cancer Registry This project has not included in its design the means for extending its services to the three Indian Hospitals in the region. In RNPs staff discussions with staff of the Bureau of Indian Health, the Bureau indie cated willingness to participate, and expressed an interest in knowing what Regional Medical Programs have funded ongoing Cancer Registrics. This information has been furnished by RMPS for dietribution to INS Hospitals, as well as offers of technical and other assistance. 6/4/70 A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE NORTH DAKOTA REGIONAL MEDICAL PROGRAM RM 00060 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: In reviewing the Region's first operational supplement composed of five projects requesting $191,305, the Review Committee noted - that the order in which therprojects appear indicates the order of priority _assigned by the RAG. The Committee also noted that the region continues its efforts in continuing education of physicians, nurses and allied health personnel, Two projects received a recommendation of approval with additional funds in the amount of $51,632. Three projects received the recommendation that they be returned for revision to incorporate certain conditions, Project #7 was negatively received and no funds recommended. Project #5 - Diabetes and Nutrition Critique: The consensus was that the project has demonstrated the feasibility ‘of an approach to the nutritional management of persons with dia- betes and other chronic diseases, It has been carefully planned and the demand seems to have been well established. The method of procedure would seem to be adequate for this region and speaks well of the harmonious relation- ship with the North Dakota Dietetic Association. The funding requested is very modest, and it is expected that the effort will go a long way to encourage continuing and closer relationships with the Division of Continuing Education at the University of North Dakota as well as assistance in the establishment of. the new Human Nutrition Laboratory. ‘Recommendation: Approval I - additional funds recommended, Ol-Year 02-Year 03-Year $33 ,506 $31,250 $28,950 r & maroc LEN Critique: This application was believed to be poorly designed. It is lacking in a statement about criteria for selection of learners whether RNs or LPNs, There is no plan for assessing neurologic function during or after coma, nor any indication that a plan for care is being developed. The competency of the nurse faculty is limited to intensive care unit practice and by minimal educational practice for this assignment (including the classroom instruction and more importantly the circuit riding). The impressions gleaned from the physicians who will participate in the proe gram appear to be largely general and without documentation. Neither is there an expression of interest or need by nurses, The project on the whole BUWAR LER APE RIN he ~ =e eS eee seems to be teacher oriented with broadly stated objectives which are felt to be quite immeasurable, unclear, and impossible for achievement. The proposal to put on 36 one-week courses per year with weeks "in between" for circuit riding indicates that the project directors have no idea of what is involved in supportive circuit riding, or in activities related to course conduct, Although there are several schools of nursing (hospital diploma and college based) in the region, there is no mention of their involvement. Their faculties might be very good local reinforcement, and should be invited to participate. The proposed evaluation was thought to be generally meaningless in its approach. This is unfortunate in that this kind of project lends itself very well to an adequate evaluation design, This aspect will need strengthening. The budget seems unrealistic and no mention is made of plans for phasing out. The reviewers noted that the need for the project is obviously urgent, but in its present form, it contains so many flaws that it is unacceptable without some serious restructuring. Recommendation: Non-Approval II - return for revision required which should reflect the following conditions: (1) Delineation of the curriculum; (2) Transmission to the region of the comments of the Continuing Education Panel; (3) Statement of the relationship of this project to Project’ #2 ~- Training Nurses in Rehabilitation Techniques--are they mutually. supportive? Project #7 - Respiratory Care Center Critique: The reviewers found the method proposed for organizing an educa- : tional program such as this to be unclear and somewhat short shrift. The functions of some of the project staff, such as the Patient Service Coordinator, are not given. The statement of need is based upon impressionistic data, with no firm beginning point. The objectives are not well defined and although related to patient care, are not measurable in the form in which they appear. The application does not indicate how the improved care of patients will be ascertained except that patients will be treated in the center. The project appears feasible and could probably be carried out, but more imformation is essential for an adequate appraisal. There is no descrip- tion of the medical school or other educational personnel as project resources. It is assumed that the project personnel possess all the expertise required for this undertaking The concept of evaluation is also traditional, It does not provide for a measurement of learning, or measurement of change in respiratory function as a result of treatment in the unit, .There is no plan to assess the dissemination of the technique to physicians, or to other institutions, as ‘ NORTH DAKOTA RMP 3 RM 00060 7/70.1 a result’ of the establishment of this center. The project would probably benefit greatly from the services cf an evaluation consultant, In the opinion of the reviewers some addition to the budget will be necessary in order to carry out an adequate evaluation. The salaries of the physicians ‘om.the project staff appear high when compared to urban standards; those of the nurse and secretary, however, seem lower than metropolitan areas, Another question was raised concerning how the two jndividuals, each devoting one-third of his time to the project would otherwise occupy their time, The activities described in the project would not appear to require two individuals with this percentage of effort. The project overall was felt to be flimsy with no certainty of attaining the aims it sets forth. It is also deficient in its regionalization aspects. In such a low density population, the reviewers thought it might be more useful to send its trainees to other regions (Northlands), with perhaps additional refzesher training. Recommendation: Non-Approval I - no DRMP funds Project #8 - A Comprehensive Physician Education Program Critigue: The reviewers felt that the educational plan was vague and did not appear to have made use of the experience of other programs, such as the Kansas Circuit Tour Program, in developing the format and design of the program. There seemed to be more concern with the form of the applica- tion than with its substance. The faculty is probably competent for the roles they will be given, but it was questioned whether the desire to partici- pate, and the possession of a specialty certificate, qualifies a teacher. The need for the project seems to be based on the interest of the physicians, but fails to emphasize the categorical goals of RMP. The physicians were contacted by means of a questionnaire with 41 responding. The total number sent out is unknown, Most of the ojectives, although questioned for clarity and their inability to measure impact, were felt to,be operational rather than behavioral in their end results. The approach is reasonable, but somewhat stereotyped, . The rather disparate groupings of participants do not lend themselves to a good design for a comprehensive training program. Further, there is little evidence that this kind of education really "sticks" anyway. There seems to be very little evidence that the authors of the project received consultative assistance from the University of North Dakota, even though the region plans to use available medical specialists as instructors. Recommendation: Non-Approval I - the application was considered totally inadequate in its present form. The recommendation carries the suggestion to the Region that should the proposal be resubmitted, the applicant should seck help in its total redesign. NORTH DAKOTA RHP ~ bee RM 00060 7/70.1 Project #9 - Cancer Registry Critique: This program was developed with the assistance and consultation of RMPS staff, The reviewers felt that the. project in general is a good one and fills a very real need in the Region. The resources are identified and the reviewers felt thes it is laudable that the North Dakota RMP is looking into the cancer program in the state of North Dakota. While the Committee unanimously endorsed this project, there were some reservations, There is no indication that the services of the Cancer Registry will be extended to the two Indian hospitals in the region, It was noted that these are the sources of medical treatment and care for Indians living on the three reservations in the state. The application does not indicate any awareness on the part of physicians of the high cervical cancer rate in the Indian population, There does seem to be a full complement of capable physicians available for the treatment of patients with cancer, but no indication that these are reference points for the Indian population. There was some doubt expressed as to the ability of the region to continue. an effective registry within such a modest budget, It was suggested that with the incorporation of the suggestions of the reviewers, a more realistic budget could be negotiated for the second and third years of support. The Review Committee also questioned the lack of a stated interface with the Intermountain RMP which has an ongoing automated cancer registry for all of the Mountain States, The project staff of Intermountain were consulted by ND/RMP in organizing a registry for N.D., and one would expect some plan for data from North Dakota would continue. Recommendations: Approval I ~ the conditions to this approval are: Cl) The region must attempt incorporate in the registry the Indian Health Service data through the existing Indian hospitals in this region for a broad comprehensive cancer registry program; (2) the North Dakota RMP should submit annual reports relative to cancer in North Dakota including all of its citizens and (3) additional funds will be added for the continuation years via an “open end" negotiable award for this project, designed for.all its citizens. Ol-Year Q2-Year 03-Year es set Ta $18, 1 126 ‘ to be negotiated to be negotiated SUMMARY OF. RECOMMENDATIONS Project Ol 02 03 #5 $33,506 $31,250 $28,950 #6 0 0 0 #7 0 0 0 ' #8 . 0 07 0 #9 $18,126 to be negot, to be negot, Total $51,632 - $31,250 $28,950 RMPS/GRB/7/10/70 a A Privileged Communication SPECIAL ACTION NORTHEASTERN OHIO REGIONAL MEDICAL PROGRAM RM 00064 7/70.1 FOR CONSIDERATION BY JULY’ 1970, ADVISORY COUNCIL Program Coordinator: Barry Decker, M.D. This is a request for special action by Council to consider a revision of a project disapproved by the March 1970 Council. During the May negotiation meeting for their first operational grant, the RAG chairman, the Case-Western Reserve School of Medicine Dean and the Coordinator expressed such concern about the effects of the disapproval for this activity on RMP development that RMPS staff agreed to consider special handling of a revised project proposal. The revised application was received too late for Committee consideration and review. Requested ist Year 2nd Year 3rd Year Total Direct costs $48,233 $50,145 $26,076 $124,454 “Indirect costs 3,823 4,014 2,108 9,945 Total $52,056 $54,159 $28,184 $134,399 Background: The initial three~year operational grant application for $3,623,467 (d.c.o.) was reviewed by Council in March 1970. Council concurred with the Review Committee and the site visitors in their recommendation that this Region be awarded operational status. Council recommended partial funding at $2,395,104 for core and four proj- ects. Six other proposals were disapproved, two of which were considered inappropriate for RMP support. The Region had demonstrated capable lead- ership in developing cooperative arrangements throughout the area, estab~ lished data collection mechanisms and a priority system, and recognized the need fot strengthening evaluation processes. Present Application: This is a revision of Project #7 Requested which received a non-approval II First Year - action by Council in March 1970. Strong feelings about $48,233 the importance of this project were expressed by the NEORMP representatives, including the chairmen of the RAG and Board, during the negotiation meeting, May 1970. It was agreed that a specific summary of its deficiencies would be submitted to NEORMP to allow the local resources the epportunity to improve and resubmit the project for appeal to the next meeting of Council. Hence the reason for the request for special action. In considering the original project, the reviewers were most impressed with the Project Director's interest in promoting greater community Northeastern Ohio RMP 7 2- RM 00064 7/70.1 ‘efforts toward rehabilitating stroke patients. His enthusiasm as an orthopedist in private practice and the interest of the Crippled Child- ren's Center in expanding its basic mission to include adults, were considered strong assets for the potential of the program. However, the objectives and procedures were quite diffuse and it was difficult to determine what the project would actually contribute to medical care in this area. A major concern was that the project seems to indicate a primary focus on primary care. Other essential aspects of a RMP demon- stration, e.g., training, continuing education, linkages between other hospitals and communities, were not adequately explained. As proposed by the Lake County Society for Crippled Children and Adults, the goal of this revised project is to develop and apply the concept of comprehensive and more efficient care for stroke patients in a sub-region (out of Cleveland) of NEORMP where such care is not presently available. RMP funds are requested to develop the necessary training, continuing education, communication and agency cooperation and necessary linkages to sustain a comprehensive stroke care program in three counties. The objectives include establishment of a comprehensive ambulatory stroke care program, emphasizing early rehabilitation and continuity of care in the hospital and after discharge; demonstration to increase public and medical awareness of the benefits of comprehensive stroke rehabilitation, including economic feasibility; and to establish a replicable model of comprehensive ambulatory stroke care in a non-hospital setting. A stroke rehabilitation team, under the supervision of the Project Director, will ‘work closely with the attending physician in determining course of treat- ment. The attending physicians, in charge of the patient at all times, will be encouraged to participate as part of a team including periodic case handling reviews. The Project Director, the Consulting Neurologist and a Nurse Coordinator will introduce the program through a series of meetings and contacts with the medical community. Followup by mail and personal contact is planned. Evaluation will be based on comparative studies relative to the impact of the project in terms of patient manage- ment and community response. An annual caseload of approximately 85 is anticipated and is the basis of the support requested from RMP. Efforts are to be made from the beginning to place the program on a self-support- ing basis by the end of the third year. The Regional Coordinator has communicated with RMPS staff about this proj- ect and its relationship to the whole NEORMP. He indicated that there is an imperative need for credibility of RMP in the area to be served by this project. He further stated that the project represents an activity outside of Cleveland with a sincere attempt to provide better coordinated care of stroke patients. A successful demonstration may serve as a model for another similar area in NEORMP. ‘The Coordinator stated that approval of the project is extremely important to regionalization in NEORMP. Second Year: $50,145 ‘ Third Year: $26,076 Northeastern Ohio -RMP ~ 3- RM 00064 7/70.1 REVIEW AND FUNDING HISTORY DIRECT COSTS. ist Year Planning 1/1/68 - 6/30/69 (18 mo.) $267,911 (November 1967 Council) 2nd Year Planning 7/1/69 - 6/30/70 1/ $462,663 The 02 award included funds for three feasibility studies (diabetes training, library and development of a laser unit for line of sight intra-hospital television transmission). Initial Operational Application (Site Visited February 1970) (March 1970 Council) Approved Approved Project Project Period Funded Future Level 7/1/70-6 /360/73 Core 2 years, 9 mo. 2/ (01) $481,424 (02) $586,910 (03) 629,735 #1 - Hospital Library Consulting Services 3 years (01) 24,112 (02) 24,112 (03). 24,112 #2-- Northeastern Ohio Regional Program for Continuing Education 3 years (O1) 79,844 (02) 70,358 of Nurses in Coronary (03) 79,844 Care #3 - Rheumatic Fever Pre- vention Program by a 3 years (O01) 104,807 (02) 104,807 Streptococcal Culture (03) 52,496 Program : #4 - Organization for University Cooperation Approved but NEORMP elected the option of in Health (OUCH) reallocating these funds to #3 #5 - Continuing Education Non~Approval If for Physical fherapists #6 - Televised Post-Graduate Non-Approval II Medical Education Program #7 ~ A Comprehensive Out-Patient Non~Approval IT Stroke Kehabilitation , Demonstration Northeastern Ohio RMP -~ 4. RM 00064 7/70.1 #8 - Dial Access Non-Approval II #29 - Summer Workshop in Non~approval I Career Development #10 - Medical Taxi Service Non~Approval I for Residents of Rural Geauga County TOTAL , (01) $690,187 (02) $786,187 (03) $786,187 _1/ Includes Carryover $31,086 _2/ 02 planning year was extended to September 30, 1970 to allow NEORMP to expend the estimated unexpended funds (approximately $96,000) allowing RMPS to modify 01 operational funds by that amount ($786 ,187 minus $96,000 = $690,187). , RMP 7/10/70 A Privileged Communication SPECIAL ACTION NORTHLANDS REGIONAL MEDICAL PROGRAM RM 00021 Subject: Diabetes Detection and Education Center, Project #18 Request: Emergency interim support for the Diabetes Detection and Education Center in Minneapolis. It is requested that the NRMP be authorized to reallocate unexpended funds from the O01 operational grant year to support this operational project entitled ")tabetes Regional Center Educational Program" in the amount of $81,621. This would provide interim financing for the Center for the remainder of the Northlands RMP 02 budget period, ending February 28, 1971. The Region proposes to submit to RMPS a project proposal requesting support for the program when it submits its next applica~ tion. 1970. “this included 9999,238 of carry-over en from the Ol year. The Region has an additional $90,000 of carry-over from which it is requesting the $81,621 direct cost to support the Center for the period July 1, 1970 through February 28, 1971. RMPS staff believes this activity is meritorious of support. The delegation by the National Advisory Council to staff for approval of requests for expansion of approved activities or initiation of activities ancillary to Regional Medical Programs is limited to $50,000. Therefore, the Northlands Regional Medical Program request for $81,621 is veferred to the National Advisory Council for special action. The Diabetes Detection aud Education Center in Minneapolis was stablished in 1967 under a grant from Community Health Services Division. The basic support for this center expired in June 1970. The Center stresses comprehensive care for diabetics, health care teamvork, optimum delivery of health care services, secondary preven~ tive medicine, and ambulatory out of hospital care. The Northiands Regional Medical Program has two projects funded by the RMPS which are based at the Diabetes Detection and Education Center. One of the protects (Project #5 ~ Diabetes Regional Center ~ Diabetes De tectic ducetion Center) was funded March 1, 1969, and utilizes the Cen “its cpsonnel to train teans in community hospitals in diabetic education vrograms for patients. The three-year program plan will stablish self-sustaining teaching programs for diabetic patients dn eight prominent “commund ty hospitals distributed throughout Minnesota. The other project which has been funded by the Rips (Project #15 + An Fducational Program in Clinicel Nutrit rion) was developed by the head dietician at the Diabetes Center and will provide refresher SPECIAL ACTION - Northlands RMP “Qo ‘ . Rif 00621 © training and continuing education for dieticians and nutritionists throughout Minnesota. These two operational projects represent one- fifth of the active projects in NRMP, Since both of these projects are based at the Diabetes Center, they wili have to be discontinued 1£ the Center is forced to close because of lack of support. The North Dakota Regional Medical Program also has an operational proposal under review which is also dependent upon the Diabetes Center. It is entitled "An Educational Program for the Nutritional Management of Persons with Diabetes end Other Chronic Diseases." DRMP/GRB 7/9/70 REGTONAL MEDICAL, PROGRAMS SERVICE DIVISLON OF REGTONAL MEDICAL PROGRAMS SUMMARY OF A SUPPLEMENTAL OPERATIONAL GRANT APPLICATION (A Privileged Communication) NORTHWESTERN OHIO REGIONAL MEDICA]. PROGRAM RM 00063 7/70.4 2313 Madison Avenue June 1970 Review Committee Toledo, Ohio 43624 Program Coordinator: C, Robert Tittle, Jr., M.D. Requested lst Yr. 2nd Yr. 3rd Yr. TOTAL Direct Costs $180,971 $161,831 $167,789 $510,591 Indirect Costs 45,770 47,799 49,587 143,156 $226,741 $209,630 $217,376 $653,747 History: An initial planning grant of $274,450 (d.c.) was awarded to the Northwestern Ohio Regional Medical Program beginning January 1, 1968, VYhe second-year planning award of $271,137 (d.c.) was supplemented by $141,137 and extended through June 30, 1970. A preoperational site visit was conducted during April 1969, The present annualized level for Core support is $335,200, direct costs only, while the Regton currently has $490,502 allocated to six operational projects (see History Supplement for breakout of this total) for the first-year operational period - July 1, 1969 through June 30, 1970. According to the application, the priorities established during the planning period were to include: 1) continuing medical education; 2) improved rehabilitative care; and 3) better and more prompt diagnostic methods. To accomplish this, the Region envisions its primary goal as being provision for the continuing education needs of the practicing physician, nurse and allied health personnel. During the February/March 1970 review cycle, the Region submitted an application for expanded Core renewal plus requests for four new operational projects. The Council recommended that the Core components be renewed for one year at the current Level of support ($335,200); and further recommended that a site visit be made to the Region to determine whether the $116,914 increase requested for Core support is justified; to determine the amount of support for Core in future years; and to review the three proposals (one proposal in stroke and two in continuing education) which were a part of the November 1969 supplemental application, One proposal in the November 1969 application (#12 - Emergency Medical Care) was considered to be inappropriate for RMP funding. In addition, the reviewers believed that the site visit team should study the entire operational structure of the Region, including the total regional plan, identification of needs, assess- ment of objectives and priorities. The site visit is scheduled for May 21 and May 22. A report of the site visit team will be available during the June/July review cycle. NORTHWESTERN OHIO Regional Medical Program -2- RM 00063 7/70.1 Requested First Year Present Application: This application requests support for two projects, which are revisions of proposals reviewed and not approved during the November/December 1969 review cycle, Direct costs only are noted in the following project summaries, Project #16 - A Program in Continuing Medical Education for $69,825 Physicians in Northwestern Ohio (Medical College of Ohio at Toledo, Northwestern Ohio Institute for Continuing Medical Education). This proposal was originally reviewed during the November/December 1969 review cycle and was disapproved. The reviewers believed that the objectives of the proposal were too generalized and seemed to lack any continuous educational effort or reinforcement of the knowledge disseminated. The evaluation procedures appeared to lack a defined focus and there is no indication as to the staffing provisions for evaluation. The initial proposal appeared to be nothing more than an equipment purchasing request with no allotment for service in the future years, and without a sufficient number of adequately trained personnel to transport and maintain the equipment. This revised project proposes to provide for continuing medical education of practicing physicians in Northwestern Ohio by developing a program of regional conferences and clinical programs. It is proposed that one regional conference will be held each month of the academic year in each of the five subregions,at different hospital locations. The subject matter of the regional conference will be supervised and coordinated by the County Continuing Education Coordinator, The Hospital Chief of Staff or the hospital's Education Committee will be responsible for the planning of the conferences to be held in their hospital, Specialists from the faculty of the Medical College or from outside the subregion will attend the appropriate conference and will act as principal discussants. The clinical program, which is an extension of the regional conference program, will consist of two or more coordinated educational activities conducted in a hospital on a given day, or, on occasion, will be conducted on two successive days, with joint nurse and paramedical personnel participation. The procedures to be used will be: bedside rounds, seminar on key problems, problem-solving conference, demonstrations and simulation. The clinical program will be under the direction of the Associate Dean for Continuing Education of the Medical College of Ohio at Toledo, who is also the Director of the Northwestern Ohio Institute for Continuing Medical Education. Edited videotapes of selected regional conferences and clinical programs will be made available for use by doctors and other health care personnel, Single-topic videotapes will be prepared to be used by health professionals throughout the Region. Closed circuit television backed up by conference telephone is in the developmental state in this Region. When developed, this will serve to link the hospitals in Toledo with the Medical College of Ohio in Toledo. Approximately $39,500 of the first year's total request of $63,609, is for personnel. Second Year: $61,028 Third Year: $63,609 NORTHWESTERN OHEO Regional Medical Program -3- RM 00063 7/70.1 Requested First Year Project #17 - "Patient Problem Oriented" Education Program $111,146 for Professional Nurses and Allied Health Personnel in Northwestern Ohio (Medical College of Ohio in Toledo). This project was originally reviewed during the November/December 1969 review cycle and was not approved, with the recommendation that the project be revised. The initial objectives proposed for the series of one-day programs appeared to be over-ambitious and the entire proposal would not contribute positively to the regionalization process. Questions were also raised regarding the lack of specific objectives in terms of behavioral changes, and the evaluation seemed to be little more than pretesting and post-testing with no followup to determine whether the acquired information was translated into the individual hospital situation. Although the program was to involve allied health personnel, there seemed to be a total lack of input from this group in the planning of the program. According to the applicant, the revised proposal is designed to provide continuing education for nursing and allied health personnel in Northwestern Ohio. The principal objective is to help bring about a regional distribution of appropriate knowledge to all nonphysician health personnel regarding current trends and changes in the concepts of care.of patients with heart disease, cancer, stroke or related diseases. Four subregional areas (representing 21 counties) have been geographically identified. Each subregion has a planning committee, composed of representa- tives of all health personnel, The primary faculty at the Medical College will consist of a full-time Health Education Coordinator, a Health Education Evaluator and an Audiovisual Technologist who will be responsible for implementing and evaluating the program. They will plan cooperatively with the subregional committees. The presentations will be scheduled on a monthly basis throughout the year. The location of the educational programs will rotate within the four subregions. Each presentation will include group discussions of predetermined patient problem situations, demonstrations and return demonstrations, and panel discussions of actual case histories. Rach session will be made available by audiovisual recordings to those individuals unable to attend the regularly scheduled program. To provide for continuation of this activity beyond the three-year request for RMP support, each participant will be charged a registration fee, In addition, financial support of local units of the ACS and the Heart Association are possible avenues of continuing support after termination of RMP funds. A questionnaire will be given to each registrant and a followup questionnaire will be sent to each registrant, in an attempt to evaluate the program - indicating how this program has helped them increase the applicability of their own nursing skills, understanding and attitude of patients. Approximately $45,000 of the first year's total request of $111,146 is for personnel. Second Year: $100,803 Third Year: $104,180 NORTHWESTERN OHIO Regional Medical Program -4- RM 00063 7/70.1 _ HISTORY SUPPLEMENT LISTING OF CURRENT STATUS OF CORE AND OPERATIONAL PROJECTS IN NORTHWESTERN OHIO REGIONAL MEDICAL PROGRAM : Project Amount Recommended Number Title First Year 00 Core $335, 200* 1 Stroke Education Program 96,847 2 Uterine Cancer Detection 97,286 4 Coronary Care Training 88,176 5 Improvement of Respiratory Care 130,566 6 Action on Smoking and Health 33,392 7 Dial Access Tape Library 44,235 TOTAL $825,702 *Core is partially supported ($135,000) under the final year of the planning grant. Also, the Region was approved for a direct cost Core level of $400,400 but elected to distribute $65,200 to newly approved projects. Thus Core is presently supported at $335,200. DRMP 5/19/70 NORTHWESTERN OHIO REGIONAL MEDICAL PROGRAM RM 00063 7/70.1 STAFF OBSERVATION Project #16 ~ A Program in Continuing Medical Education for Physicians in Northwestern Ohio, This proposal was reviewed by the site visit team during the visit to the Region on May 21-22, 1970. Because of its similarity to Proposal #14 - A Program of Continuing Education for Physicians (which had been reviewed during the February/ March 1970 cycle and was recommended for deferral pending a site visit), the site visitors reviewed both proposals simultaneously. The team recommended that Proposal #14 be funded for one year as a feasibility study, in an amount not to exceed $75,000, and that the programmatic elements of Proposal #16 be merged with #14. ‘Therefore, if this recommendation is approved, Project #14 and the programmatic elements of Proposal #16 will be merged and considered as a Single study. 6/4/70 A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF E © JUNE 1970 REVIEW COMMITTEE RORTHWESTERN CHTO REGIONAL MEDICAL PROGRAM RM 00063 7/70.1 FOR CONSIDERATION BY JULY.1970 ADVISORY COUNCIL General: The Comaittee recommended that this supplemental operational appliceticn 7/70.1, which requests $510,591 (d.c.o.) for a three- year program pericd, be partially funded at $100,000, $50,000 per year for each of two years, to support project #17 as a feasibility study, not to~ be included as a part of core. Committee further recommended that the programnatic aspects of Project #16 be merged with Project #14 (see 7/70.2 - which is recommended for funding in an amount not to exceed $75,000 as a feasibility study for one yeary. Project #16 ~ A Program in Continuing Medical Education for Physichlans Critisue: . The Review Comnittee, as did the site visitors, believed this a proposal to be sosimilar in.goals and objectives to Project #14 - A Progrom of Continuing Education for Physictang «- (see critique of Project — #14 in 7/70.2) that the two prepusals were reviewed simultaneously. Project #14 was recommended for approval for $75,000 as a one year feasi« © bility study not to be included as a parc of core. Recommendation: het the programmatic aspects of this proposal be merged - with Project #14 described in 7/70.2. -Roth these proposals were the subject of a site visit on May 21-22, 1970, : is 4 Wee Project #17 - ‘Patient Problem Oriented Education Program for Professional - Rurcses and Aliied Yealth Personnel CO Critique: This project was originally reviewed during the November/December 1969 Review Cycle with the recommendation that it be returned ~ for revision, The Review Committee heard the report of the gite visit teem chairman. The Committee also considered the review of the proposal ~ by the Continuing Education Training Panel who recommended it was feasible under six specific conditions, The Reviewers were impressed with the amount of preeprogran plenning efforts which had alraady been accomplished on this proposal. It ie supported by lerge plomnine committees composed _of representatives of all health personnel in the region. Although the propesal is strongly oriented to nursea, the overall need for the project was wellestated and documented with the exception of the distribution of allied health personnel], Members of the Review Committee learned that this proposal has evolved basically under the leadership of the two nurses on the core staff, With this in mind, and considering the lack of leadex+ ship available in the Region (see core 7/70.2), members of the Committee, Northwestern Ohio RHP =-2.« RM C0063 7/70.1 acting on the recommendation of the site visit team, believed that the program has some merit and should be encouraged. Although Committee was convinced that the program should receive some support because of the progress and momentum which has already been achieved, it was believed that the budget requested was unrealistic. ‘This program might develop into the . Region's first example of a truly regionalized program through its sube regional committee and interprofessional aspects. The Committee concurred with the recommendation of the site visitors and recommended approval as a feasibility study, not as a part of core, in an amount not to exceed $50,000 (d.c.) per year for each of two years. Recommendation: Approval as a feasibility study, not as a part of core, in an amount not to exceed $50,000 (d.c.) per year for each of two years. SUMMARY OF RECOMMENDATIONS Project Number : Title ist Year and Year ° 3rd Year: #16 A Program in Continuing To be merged with Project #14 Medical Education For (described in 7/70,2) Physicians #17 “patient Problem Oriented” $50,060 $50,909 Educaticnal Program for (as a feasibility study Professionnel Nurses and not to be included as Allied Yealth Personnel a part of core) TOTAL $56,000 $50,600 Years, TOTAT, DERECT COSTS. 61) $50,000 02) 50,000 03) Hone TOTAL $100,006 FALOETS DIVISION Of REGIONAL MEDICAL PROGRAMS SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) NORTHWESTERN OHIO Regional Medical Program RM 00063 7/70.2 (formerly 3/70.1) 2313 Madison Avenue February 1970 Review Committee Toledo, Ohio 43624 March 1970 Council June 1970 Review Committee PROGRAM COORDINATOR: C. Robert Tittle, Jr., M.D. Requested: lst Year 2nd Year 3rd Year TOTAL Direct Costs: $1,386,294 $ 980,144 $1,009,523 $3,375,961 Indirect Costs: 267,276 275,902 286,215 829,393 TOTAL $1,653,570 $1,256,046 $1,295,738 $4,205,354 History: An initial planning grant was awarded to this Ragion be- ginning January 1, 1968 in the amount of $274,450 (d.c.0.). A second.year planning award of $271,137 was supplemented and extended through June 30, 1970, The annualized jevel for core support during the First year of operational support is $335,200 (d.c.o.). The prior- ities established during the planning period include? 1) continuing medical education, 2) improved rehabilitative care, and 3) better and more prompt diagnostic methods. The primary thrust will be to meet the continuing education needs of the practicing physician, nurse, and allied health personnel, The Region was approved for operational status, effective July 1, 1965 including supplemental support for core staff and six operational projects. The award for the first year of operation of $825,702 (d.c.o.) is described below. Core £335 ,200* Project #1 - Stroke Education Program 96 ,847 Project #2 - Uterine Cancer Detection 97,286 Project #4 - Coronary Care Training 88,176 Project #5 - Improvement of Respiratory Care 130,566 Project #6 - Action on Smoking and Health 33,392 Project #7 + Dial Access Tape Library 44,235 “$825,702 * Partial support of core ($135,005) is from an administrative @ continuation of funds from a planning supplement. : -2- : NORTHWESTERN OHIO Regional Medical Program RM 00063 3/70.1 Although the Region has submitted several additional projects, the Region has none in the approved but unfunded category. Present Application: This application requests renewal of core support for a three-year period and support for three new operational projects. One of the projects - #15 - Council for Continuing Education - Ottawa Valley, has been jointly requested by Northwestern Ohio RMP and the Ohio State RMP. The requested direct cost support is to be shared equally. Also, during the February/March Review Cycle, a fourth proposal to support a Council on Emergency Medical Care To Develop and Coordinate a System To Improve Such Services was considered. The February Review Committee recommended non-approval of the project request on the basis that it was inappropriate for RMP funding. The March 1970 Council concurred in this recommendation. Direct Costs only are noted in the following project description. _— Requested Ist Year Renewal Core: The Region is requesting renewed and expanded support of $452,114 core staff in the amount of $452,114 (d.c.o.). Although the region was approved for $400,400 (d.c.o.) for core staff duriag this period, it elected to distribute $65,200 (d.c.o.) among the newly approved operational projects. As a result, the present support for core staff is $335,200 (d.c.o.). The personnel category budget request reflects an increase of $39,690 over the currently supported six full-time professional personnel, five one-half time professional personnel and five full-time secretaries. This increase is recuested to support three full-time administrative assistants and one secretary. One of the administrative assistants will be responsible for budget preparation and review and the other two will work as liaison per- sonnel between the various reference panels. The Region accepted the advice of the preoperational site visit team of April 7-8, 1969 by increasing the staff to include an epidemiologist supported by both the Medical College of Ohio at Toledo and Northwestern - Ohio RMP. They have also employed an individual for program planning and evaluation, as suggested. The other budget categories request substantial increases over the current budget. In the category of Consultant Services, increases in the public relations/photographic and system consultants are noted. Additional equipment, including office furniture, addressograph and other mailing equipment, auto~ matic typewriters (MTST), and electronic data processing equipment is requested. The supplies, travel and publications budgets remain unchanged. The request for $64,310 in the Other category (a $35,620 increase) includes lease and operating costs of an automobile, insurance for both liability and equipment, increases in record fees, rental and utilities. Descriptions of the progress of the core staff in developing pro- jects, providing consultation, administration of funds and generating information are included in the narrative. Changes in the organiza- tional structure of committees and the Board of Directors are discussed. 03 Year: $465.571 Oo. Year: $479,700 Northwestern Ohic RMP =3- RM 00063 Critique: February 1970 Raview Cowmittee. Requested Firrt ore Renewal. Year Critique: The Committee noted that the Region was last site visited in April 1969. At that time, the team expressed concern over the Region's extremely small Core Staff. This was especially true regarding professional manpower. The team recommended additional staff, particularly in the area of planning and epidemiology, and suggested that the Region might wish to revise its entire staffing pattern in order to meet more specialized program needs. The Committee noted that the Region had partially heeded the advice of the site visit team by employing an epidemlologist and a director of program planning and evaluation. Included in this request are three full-time administrative assistants, one of whom will assist the Region in budget preparation, while the other two assistants will be liaison personnel, working with the various reference panels. Recommendation: Approval at the current level of support ($335,200) and deferral on the requested increase pending a site visit. Direct Costs Only: ist Yr. 2nd Yr. 3ed Yr. $335,200 Deferred Deferred ‘$116,914 deferred) >roject #13 ~ Comprehensive Stroke Program for the Northwestern $802,424 | Ohio Region. ‘This proposal was developed by the epartments of Neurology and Neurological Surgery at the Medical College of Ohio at Toledo, The proposal is to demonstrate the ways in which the Medical College and the community physician can interact to benefit stroke patients. The objectives of the program are: 1) To detect the stroke~- prone individual and institute preventive measures; 2) To pro- vide expert treatment for the acute stroke patient; 3) To pro- yide rehabilitation and long-term management of the patients’ neurological deficit; and 4) To provide the necessary services to allow the strong patient to function at home rather than in an institution. In order to provide for the orderly accomplishment of these objectives, three phases are proposed which include: 1) Setting up a 4ebed acute stroke unit at Maumee Valley Hospital, a county hospital to which a high percentage of lower econumic patients are referred, In addition, it is planned to have the intensive care unit become a model for nursing care and a focal point for the specialty training of nurses; 2) A chronic care unit is to be established at the 560OSRMP-CAI The Ohio State University Acting Director, Division of" Research Columbus, Ohio and Services The Ohio State University College of Gregory Trzebiatowski, Ph.D. Medicine Assistant Dean for Medical Columbus, Ohio “He , Education Development College of Medicine Mrs. Sally Navin, Ph.D. -The Ohio State University Associate Project Supervisor " Columbus, Ohio The Ohio State University Columbus, Ohio OHIO STATE RMP Site Visit -2- Mrs. Juliana Hushak Systems Programmer OSRMP-CAI Project Columbus, Ohio Mrs. Rosa M. Hartsook, OTR Consultant. to OSRMP-CAI Project for Occupational and Physical Therapists Columbus, Ohio ; Mr. Samuel Morrison Systems Analyst OSRMP-CAI Project Columbus, Ohio Robert C. Ringe, Ph.D. RMP Staff Liaison to OSRMP-CATL Director of Public Information OSRMP Columbus, Ohio ‘RM 00022 Lewis A. Schmidt, M.D. Surgeon and Course-Author —- OSRMP-CAI Project The Holzer Medical Center Gallipolis, Ohio Robert D. Berger, D.O. Medical Director Grandview Hospital Dayton, Ohio Mrs. Barbara Betz, R.N. Assistant Director of Nursing. The Holzer Medical Center Gallipolis, Ohio OHIO STATE RMP Site Visit ~3- "RM 00022 The site visit was convened to review the Computer-Assisted Instruction Project of the Ohio State Regional Medical Program. The project has been supported since May 1968 and was submitted for renewal during the February-March 1970 review cycle. At that time, Committee and Council recommended that a site visit be held to assess the project's effective- ness. More specifically, the site visitors set out to review and deter- mine: (1) the background and assessment of the present quality of the proj- . ect and its staff; (II) the project's future objectives; (III) the future staffing plans in light of recent personnel changes; (1V) future plans for evaluating the effectiveness of CAI as a tech- nique for continuing education of health care personnel. I. THE BACKGROUND AND ASSESSMENT OF THE PRESENT QUALITY OF THE PROJECT AND ITS STAFF Representatives of the Ohio State University Medical School and Ohio State RMP staff presented some general information at the beginning of the visit. Dr. Prior, Associate Dean of the College of Medicine, told the visitors about the pilot medical school, an independent study program “ at the medical school which includes CAI as an integral part of its pro- gram. The OSRMP CAI is using several of the medical school's programs, such as histology, gross anatomy review and physiological chemistry. The project also utilizes the University Computer Center. Staff believes they have demonstrated the operational feasibility of a CAI network which unites the University Medical Center to a number of community hospitals via a computer network. The project has gone through various changes in personnel and software to arrive at a smoothly func— tioning stage. While the technical competence of the staff appeared to be adequate, project management may have been less than optimal in the past. Apart from a number of changes in top project staff in the last year, the leadership of the project appeared to be the responsibility of four people - Dr. Gerald Gaston, Mr. James Griesen, Dr. Ayres D'Costa. and Dr. Pace, the OSRMP Coordinator. At the present time, uncertainty of RMP funding has led to reduction of project staff. However, they have contingency plans for holding key people on the project until they know whether support will be continued. . Staff reviewed some of the technical difficulties they have overcome during the past two years. The IBM program, COURSEWRITER III, is being revised to allow for analysis of student response and line usage, auto- matic self-registration of a large number of users under one sign-on-code and access to the computer's mathematical capability. The system is currently in operation 22 hours a day, seven days a week. The systems analysts are still working with the problem of accommodating the hard- ware and COURSEWRITER language to programs involving large amounts of OHIO STATE RMP Site Visit -4- RM 00022 i information, such as listings of drug and dietary material. Determina~ tion of educational needs has been based entirely on the opinions of potential users and university personnel. The process by which ideas are transmitted from hospital staffs to a computerized course has been reorganized twice. Under the latest version, a topic is selected by a particular hospital's Continuing Education Committee, composed of members of the medical, nursing, occupational therapy, physical therapy and dental professions. A Principal Author, the subject matter specialist, sets the criteria for the course, consults with the Course-Author team, who are trained in CAI and concentrate on course content presentation. An Author-Consultant Team, composed of an educational specialist, tech- nical editor and input coder, then advise strategies, technically edit the writing and enter the material into computer memory. The project presently supports two half-time Course Authors and one Author-Consultant Team, who would presumably be able to work with 30 to 50 principal authors. Project staff believes that what they have learned about how to combine the skills of subject matter specialists, trained CAI authors and programmers will now permit more rapid production of CAI software during the coming year. Physicians and a nurse from user hospitals expressed favorable opinions regarding the potential of CAI in solving in-service and continuing edu- cation problems in their institutions. However, they also reported that the currently available library of programs is too limited to have a major impact as yet. Physicians stated that they would like an informa~ tion retrieval capability built in and more problem-oriented programs added to the library. Physician use has been entirely on a voluntary basis and no change in that practice is anticipated. CAI is more system— atically encouraged and used by nursing and paramedical personnel. The * coronary care nurse course is being heavily used and nurses are being given released time to take it. Nurses, allied health personnel and physicians present all stated they saw CAI as a very useful tool to be used in conjunction with textbooks and lectures to help train entry level personnel, such as operating room assistants, ward clerks, occu- pational therapy assistants and to review basic sciences for nurses. AS such, it could relieve trainers and be used as an evaluation device to measure the gaps in learning. Doctors Schmidt and Berger, Mrs. Betz and Mrs. Hartsook were questioned about the effect of CAI on patient care. There did not seem to have been any serfous attention given to this type of evaluation other than the work performance checklists described in the evaluation supplement. As far as evaluation of student usage, the proposers have data available on frequency of use by course in each hospital and also on student respon- ses during a CAI course but most of this data has not as yet been analyzed and incorporated into their formal evaluation scheme. OHIO STATE RMP Site Visit -5- RM 00022 Il. FUTURE OBJECTIVES During the course of the site visit, it became apparent that a change in project orientation is underway. As a result of experience gained to date and feedback from users in the various hospitals, the computer-based program will be adapted to the individual needs and interests of the various professional groups and institutions. Physicians, for instance, want more problem-oriented information, instruction and services which can help them with patient management. They prefer shorter periods of time (10-20 minutes) at the terminal to obtain material which will help them with specific problems. Types of courses which they would prefer are those in electrolyte problems, drug information, etc. They are not favorably disposed toward didactic type courses of an hour or more in length. In response to these preferences, the project personnel stated: they are planning to develop patient management materials pertaining to pulmonary disease, rheumatic fever and infectious complications of cancer and stroke, during the coming year. Nurses have the greatest interest in coursework which will improve their basic science background and help them learn nursing care procedures. Occupational and physical therapy personnel have expressed the need for’ courses that provide information on procedures in their field. They mentioned that the Stroke Rehabilitation Course is fine, but that they didn't have time to take it. In addition to changing the orientation of the individual courses, the proposers also intend to expand the network to an additional six hospitals. A total of 16 hospitals is planned for 1971, and 30 by 1973. User hos- pitals will be asked to begin to partially support the cost of the ter- minals in 1970-1971 and by 1973-1974 to assume the full funding of the service. Since the project narrative submitted earlier this year does not reflect these changes, the site visitors asked the project staff to submit additional material spelling out these changes. III. FUTURE STAFFING PLANS As mentioned earlier in the report, there have been a number of staffing changes since the inception of the project. Dr. Ralph Ingersoll and Dr. Lloyd Evans served as co-project directors until September 1969 and October 1969 respectively. When Dr. Lloyd Evans left to become Vice Provost for Curriculum Development for Ohio State University, Dr. William Pace became the project director. He subsequently was appointed OSRMP Coordinator in February 1970. When he assumed that position, his time on CAL was reduced to ten percent and the supervision of the project was managed by a group of individuals, including Dr. Gerald Gaston, Mr. James Griesen, and Dr. Ayres D'Costa. This arrangement has not been conducive to coordinated leadership. OHIO STATE RMP Site Visit -6- RM 00022 During the site visit, the team learned of several additional changes. Dr. Gaston is leaving the project to establish an Educational Services and Research Division of the College of Dentistry. Dr. Pace will trans- fer his part-time duties on the project to Dr. Gregory Trzebiatowski, Assistant Dean for Educational Development at the College of Medicine Dr. Trzebiatowski, Mr. Griesen, Mr. Nime and Dr. D'Costa will serve in an advisory capacity to the project in computer services, evaluation and educational development. If the project receives funds for more.than a year beyond July 1, 1970, full-time project direction will come from Dr. Paul Ertel, a pediatri- cian and Chairman of Medical Reeords at the Children's Hospital, who has been with the project for about three months as course-author. Dr. Ertel seems to be spearheading the change of direction to a shorter, patient- care directed type of program, which would be modified to individual institutions. Dr. Ertel sees CAI as primarily a diagnostic-dependent, problem-type of information service, the effectiveness of which can be measured by changes in morbidity and mortality. The site visitors were impressed with Dr. Ertel and are convinced that he would provide stronger leadership than the project has enjoyed in the past. Individuals to fill the associate supervisor for evaluation and education positions are available from graduate students completing their work in the College of Education. The candidate for the evaluation specialist position is currently a fellow in medical education who has some famili- arity with the project. Mrs. Rich, a course-author, and Mr. Samuel Morrison and Mrs. Juliana Hushak, systems analysts, will continue with the project. Mrs. Graves and Mrs. Hearn, technical and secretarial level personnel, can be retained if the project receives continued support. Uncertainty of funding beyond June 30, 1970, has led to lowered morale and considerable disintegration of staff. While the Medical School would continue to develop its CAI programs, both project staff and user representatives emphasized the work that would be lost and the disillu- sionment that would occur in user hospitals if the RMP project were to fold. IV. FUTURE EVALUATION PLANS Evaluation efforts have lagged due to the major emphasis on deve lopment of an effective computer network and on a system for producing software. Physicians from user hospitals expressed the feeling that the programs are worthwhile, but they have not begun to assess whether it makes a difference in patient care. Pre- and post-testing of other programs has been rather limited, with small sample sizes and results showing no change. f \ oe” STATE RMP Site Visit -~7- RM 00022 Staff is collecting data on the use of the system by course, by time of ‘day, by hospital and type of personnel. Plans are also mentioned for instituting an evaluation which would relat2 performance within CAL programs to patient care recorded in medical records, although it was not clear how this could be accomplished since students are not regis- tered on the computer by name. staff's willingness and interest in investigating medical record audit data was not matched, however, by evidence of concrete planning along these lines. Staff described éxtension of the work performance type evaluation men- tioned in the first supplement and the CIPP evaluation model. The CIPP model developed in the College of Education at OSU includes evaluation of content, input, process and product. In the limited time available for discussion of the CIPP model, it was not clear what application they intend to make in terms of product specification. Cost benefit analysis was suggested, but the project personnel felt they could not begin this kind of analysis until the third year. The hope was expressed that this aspect would be included if funds are adequate. RECOMMENDATIONS © The site visit team has mixed feelings about recommending future support. On the one hand, much time, money and effort have gone into developing the cooperative arrangements, rapport, the hardware network, software, trained personnel, etc. to its present level. In addition, there is a lot of back-up expertise available to the project at OSU in conjunction with the pilot CAI curriculum in the medical school. The system has reached a point where more rapid expansion of the instructional program library can begin. Within the next three years they should be able to evaluate more adequately whether the availability and use of CAI in community hospitals has an important effect on the improvement of patient care. On the other hand, the site visitors believe there must be considerable emphasis on better evaluation techniques if the questions about the effectiveness of the program are to be answered in an effective way. Since not all of the hospitals have PAS-MAP (which could be adopted to provide certain types of patient care evaluation data if they knew how) , other types of data also need to be used. The site visitors asked the project staff to forward to RMPS an updated statement of goals and staf- fing and future evaluation plans, since there appear to have been a num- ber of important changes in these aspects of the project since the renewal application was prepared. in addition, the site visitors made the fol- lowing stipulations: (1) The emphasis on the project should move from the technical aspects © of the development of the CAI hardware and software to the develop- OHIO STATE RMP Site Visit -8- RM 00022 ment and application of instruction and evaluation. Evaluation should include references to support from sources other than RMP and use of PAS-MAP statistics or other data to evaluate the effect of problem-oriented CAI on morbidity and mortality, etc. (2), The project should not be expanded to additional hospitals until the above is well underway. It did not seem practical to extend the network until a larger number of more patient-care directed programs are developed, since the physicians and nurses, etc. at the present user hospitals stated that present courses were not the most practi- cal. In fact, proper evaluation techniques may prove more effective if fewer hospitals were used. However, the site visitors would not recommend dropping any, for obvious public relations reasons. ere shou e a full-time project director. %F- rtel seems com- (3) Th hould b full-ti j di Dr. Ertel petent to handle this responsibility. (4) RMPS staff should provide close scrutiny of yearly progress reports, with a site visit if necessary, to insure that better patient care evaluation techniques are being developed and employed. The site visitors realize that it will probably take three more years to ade- quately evaluate the effectiveness of the CAI approach. The potential appears to exist at OSU, but if RMP wants a satisfactory trial of CAI, adequate time should be allowed and the project monitored yearly to insure that the desired outcome is obtained. (5) RMP funds should not be used to purchase a computer in the second year. Time-sharing arrangements should be possible with all of the: computer resources available to the project. . While the site visitors reached a consensus that the project should be continued for an additional three years, they were not able to agree on the level of support. Both site visitors agreed that the level of fund- ing probably could be substantially reduced without impairing the project as a pilot test of CAI. One site visitor felt that the project could be accomplished at a level of a maximum of $100,000 per year- The other site visitor felt a level of approximately $192,000 for each year would be needed to adequately complete the pilot study on the assumption that additional hospitals would not be added to the study. An itemized budget for the $192,000 recommended level follows: \ ’ @ OHIO STATE RMP Site Visit Personnel: Project Administrator Assoc. Admin. - Evaluation Assoc. Admin. - Author-Consultant Systems Analyst - 50% Systems Programmer Technical Editor - 25% Coder Specialist Admin. Assistant Typist System Monitor Consultants (subject matter experts, course-authors, instructional materials specialists) Supplies Travel Publications Other: Line Charge - 10 lines Fee for Disk Storage - 10 Supply Allowance Telecommunications AV Accessories TOTAL $24,273 18,064 16,935 8,174 16,347 2,750 7,700 8,003 5,720 4,950 37,200 3,000 1,000 17,230 _ 1,260 RM 00022 $112,916 12,000 4,750 1,500 1,000 59 ,690 $191,856 7/15/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication), i! | t OHIO VALLEY REGICGNAL MEDICAL PROGRAM RM 00048 7/70.1 1718 Alexandria Drive June 1970 Review Committee P, 0. Box 4025 Lexington, Kentucky 40504 Program Coordinator: William H. McBeath, M.D. Requested Progragi ; Period: - ‘Lst Year Qnd Year 3rd Year ‘4th Year 5th Year Total, Direct Costs $640,178 $645,583 $668,544 $232,101 $61,695 $2,248,101 Indirect Costs 140,107 © 157,162 166,849 60,551 13,088 537,757 TOTAL $780,285 $802,745 $835,393 $292,652 $74,783 $2,785,858 History: The Region's planning grant was for two years, Janvary:1, 1967- December 31, 1968, During the first year a total ef $346,760 was made available and $407,238 the second, In November: 1968, following a September site visit, Council considered the initial operational grant application and recommended support of $866,000 (d.c.o.). Fiscal restrainta prohibited DRMP funding at the recommended level. A total of $799,195 (d.c.0.) was provided for support of Core Staff activities, a Comaunity Hospital Staff Development Project (#2); a Library Extension Service Project (4); a Univereity Continuing Education Resources Project (#5); and additional planning for a Regional Medical T.V. Project (#3); and a Drug Information Services Project (#6). in addition a Patient Origin Study was initiated under Core, with $50,000 carried over from the 02, planning year. In February 1969, Council considerel the Region's first operational' supplement application which consisted of four projects: Automated Multi- phasic Screening (7); Coronary Care Denonstration (#8); Radiotherapy Dosimetry (#9); Regional Stroke Management (#10); and Rural Home Care Demonstration (#11). The entire application waa deferred for a March 1969 site visit. In May 1969, Council again considered the supplemental application and recommended a total of $305,000 (d.c.02) for the first year support of the Multiphasic Screening Project (#7), the Stroke Managee ment Project @20), and the Home Care Demonstration Project (#11). The Coronary Care Project (#8) was disapproved with the advice that it be ‘ revised and resubaitted. Project #9. « Radiotherapy Dosimetry was also OHIO VALLEY Regional Medical Program +2- \ RM 00048 7/70.1 disapproved with encouragement that it be revised and resubmitted along the lines of the ;uidelines recommended by the special radiation therapy committe, which were endorsed at the May Council meeting. In regard to. Project #7 + Multiphasic Screening, the Council's approval was contigent upon submission of evidence that the project, as congoived, could be accom~ plished within the limit of the budget recommended. ” In December 1969, Council reviewed a revised proposal for project #7 jand found it acceptable. In its December 9, 1969 review of the Region's non=competing second-year operation grant application, RMP& staff believed that the progress of the individual operational components indicated that the Ohio Valley Program had evolved from a purely planning state into an operaticual one, Also, there was evidence of increased involvement in the program by medical schools, hospitals and Comprehensive Health Planning agencies throughout the Region, The Region reported that it had officially established as its number one priority, the development and more effec- tive utilization of health manpower for the delivery of improved ambula-~ tory care. As a result of this review, the Region was awarded the commited level of $749,195 (d.c.o.) for continued support of Core and four projects, in addition it was granted the use of $15,000 of carryover funds to initiate planning activities for Project #10 ~ Regional Stroke Management. The request to use $136,805 of unexpended 01 funds for partial restoration of activities was deferred pending submission of additional information, In March 1970, Staff reviewed the revised request to use $175,265 of adjusted unexpended 01 funds, The review resulted in $160,265 of un= expended funds being approved for use in, Core and projects 2,4,5, and 6. The Region's second-year operational program is currently funded at $924,466 (d.c.o.) of which $175,265 is from 01 carryover, In addition, _ two of the Regions*’approved but unfunded projects, #7 Automated Multi- phasic Screening ($200,000) and #11 Rural County Home Care Demonstration ($60,000) are to be funded in the near future from the recently released $5 million carried forward from Fy,1969, As a result, the total amount of direct cost funds available to the Region during the 02 year will be $1,214,460. (For detailed listing of projects see attached "Review and Funding History".) Present Application The Region emphasizes the point that the projects of this application have a direct relationship to the current thrust of OVRHP which is 'The development and more effective utilization of health manpower for the delivery of improved ambulatory care," This program emphasis was selected by the RAC ag the primary focus in an effort to achieve regional impact, and to serve as a basis for restriction and selectivity in the use of OVRMP resources, To further define "Thrust" for policy and operational purposes, the RAC selected six specific areas for priority, attertion: para-medical | personnel, emergency services, prevention and follow-up, coordiation of community resources, patient medical records and institutional ambulatory care programs, Of these it has become increasingly apparent that two particular areas ere of special concern throughout the Region; para-medical personnel, especially physician assistants, and improvement and expansion of organized ambulatory care programs, OHIO VALLEY Regional Medical Program #3 RM 60048 7/70.1 Requested Project #12 - Computer Assisted Radiotherapy Dosimetry Demonstration First Year This project was previously reviewed as Project #9, $222 ,884 during the February]l9©? Review Cycle at which time Committee recommenddd approval as requested, contingent upon Councils policy regarding funding of dosimetry. Council recommended the project be returned to the Region with encouragement to revise and resubmit along the lines of the guidee lines reconmnended by the Special Radiation Therapy Comalttee, which were endorsed by the Council at this meeting. This three-year project proposes to utilize the technical competencies and electronic analysis capability of the University of Kentucky Medical Center, the University of Louisville School of Medicine, the University of Cincinnati College of Medicine, and the professional skills of local radiotherapists in fifteen community hospitals to improve the ease and accuracy of radiation therapy dosimetry. Initially the program will be available to the medical center hospitals, “During the latter half of the first year, the program will be available coalimited number (at least six) of community hospitals, During the second year, service will be made available to all hospital radiotherapists employing supervoltage external beam therapy in the Region, Also, during the first year, a program of consultation visits to community hospitals will be initiated, a program to train dosimetry assistants will be initiated in each university center, and a program steering committee will be established. An evaluation plan is presented. Second Year: $258,405 Third Year: $277,704 Ln 7 Requested Project #13 = Advanced Radiologic Technologist First Year This four-year pilot project is sponsored : $85,261 _ by the University of Kentucky Medical Center, and five , collaboratinginstitutions; St. Joseph Hoppital of Lexington, Central Baptist Hospital of Lexington, Good Samaritan Hosptial of Lexington, Lexington Clinic and Louisville General Hospital. Its purpose is to investigate the possibility of improving the utilization of radio# logic manpower through the development of a program to train properly motivated, carefully selected Radiologic Technologists to perform many activities currently performed by a Radiologist. The overall plan is designed to determine which and how many of the Radiologist's present duties can be assumed adequately by analutionally trained Radiologic Technologist and to prove that selected Radiologic Technologists, can be trained properly to discharge these duties, In addition, information will be obtained, by testing techniques, abeut the selection of Trainees, the curriculum and teaching methods, First year activities include: Develop PERT Chart Symposium on Cirriculum, Teaching and Testing methods ‘Consultations with Radiologic Educators Formulate Tests for Applicants Develop Curriculum Assemble Instructional Material OHIO VALLEY Regional Medical Programs «4+ RM 00048 7/70.1 Project #13 - First year activities (cont.) Prepare Master Manual Detail Evaluation Proceedures Recruit aud Test First Class of Students Begin Training of First Class of Students An advisory group composed of members of four Radiology Associations will meet at unspecified intervals to advise on various aspects of the program, The students' initial year of Training, 48 weeks, will be taken in the Medical Center and a basic outline of the curriculum is presented, The second year, on-the-job training, will be taken in collaborating hospitals, Class size will be limited to elx trainees, or 24 trainees in four years. Specific program objectives and plans for evaluation are presented, A major item in the budget category is for maintenance income allowances for trainees, $500 a month per trainee for the fixst year and $200 a month for year two. No plan is presented as to how the project will be supported after the fourth year, when RMP support would be terminated, SeconlYear: $99,614 @hird Year: $109,798 Fourth Year: $113,284 Requested Project #14 = Brologic Assistant - This project is a First Year cooperative effort between the Cincinnati $37,966 Technical Institute, the University of Cincinnati College : of Medicine, the Cincinnati General Hospital and the Christ Hospital. It is designed to develop a two-year associate ‘degree _program for instruction of Urologic Assistants which would prepare them to perform selected activities which are currently the sole responsibility of Urologists, It will serve as a model that can be used in developing guidelines for a National Urological Assistant Training Program sanctioned by the American Medical Association and the American Urological Association, The program will consist of 5 teneweek quarters of classroom instruction at Cincinnati Technical Institute and 5 ten-week quarters of onethe-job training at one of the two collaborate hospitals. The hospital training will itself be subdivided into course work and practical experience, Two groups of students will alternate simultaneously between the school and the training sessions, The first class, which will initiate its studies in September 1970, will consist of 10 to 14 students and successive classes will gradually: be increased to meet local and national demands, Program content will be designed to equip the student to perform duties, which include diagnostic studies, assistance in surgical procedures, and: ONTO VALLEY Regional Medical Program =5= Ril 00048 = 7/70.1 related care. These duties might be in the home, RUESI Mme, ambulatory clinic, private physician's office or hospita... Prerequisites have been established for students and veeruitment will be done by repre sentatives of the Cincinnati Technical Institute who visit area high achools annually. Special interest is expressed in recruiting ex-military corpsmen. Specific objectives and a plan for their evaluation is presented. Upon termination of RMP support the program will be subsidized by the Ohio Board of Regénts. Second Year: $33 ,900 Third Year: $33,900 Reqtiested Project #15 - Clinical Associate First Year~ Tale fiveeyear pilot training project is $102,708 sponsored by the University of Kentucky Medical School and is supported by four’ participating institutions: Kentucky Medical Association, Kentucky Acadeny of General Practice, Kentucky Acadeny of Pediatrics and the University of Kentucky College of Education. Its pur- pose is to develop a two-year training program to prepare a new type of “health worker called a Clinical Associate to assist the practicing physic cian. in a greatly expanded clinical role. The first year of the project will be devoted to developing the curriculum, selecting and testing the trainees, and acquiring the faculty. The second year will begin the training. The £irsteyear course js a cone centrated study-practice course to prepare the generalist in the sence that the Clinical Associate will be trained to perform those activities which are general to clinical practice of any physician (history, physical exams, diagnostic lab.procedures, etc.), this training will be taken in the Medical Center. ‘The second-year course is a closely supervised preceptore ship during which the Clinical Associate will sharpen his skills and ine crease his competance under the tutorage of a carefully chosen practicing physician, At this time he will elect to specialize either as generalist or as an associate to one of the nedical ox surgical specialists. Class size will be limited to four trainees for the first class which will be initiated in the second project year. Six additional students will be accepted the third project year and tea students will be accepted the fourth project year. The fifth project year will be for completing the training of the last ten students and pheging out the project study. If feasibility is demonstrated, an ongoing Clinical Associate Training Program will be phased in as a permanent program of the Medical Center, Being considered is,the granting of an Associate Degree, professional certification of the academic program, and a Clinical Associate Professional Council with in the Medical Association. Specific objectives and a plan for evaluation ig provided. Second ee $111,024 $132 ,282 Fourth Year: $118,817 $61,695 : OHIO VALLEY Regional Medical Programs “Ge "RM 00048 7/70.1 @ Project #16 - Laser Treatment of Cancer Requested This three-year project proposes the utiliza~ First Year tion of the laser systems and expertise at the Universicy of $50, 000 Cincinnati Medical Center, to locate patients from throughout the Region. with various forms of malignancy which cannot be treated by con- ventional types of cancer therapy. Through the program, it is anticipated the number of patients) who will be treated by laser annually will increase nearly tenfold, Referrals will be made by attending physicians to their espective tumor boards, The laser treatment for the patient will be approved by the Laser Faculty Advisory Board of the Medical Center. The treatment cycle, after referral, would be ambulatory or inpatient as indicated. Arrangements for adequate follow-up will be made by the Laser Laboratory with the referring physician, in cooperation with the local community hospital Tumor Boards or other cancer facilitics. Special tests will be performed with lasers to diagnose pre-invasion cancer of the cere vix and breast tumors. In addition to providing patient care services, the Laser Laboratory will provide educational activities for health pro- fessionals in one Region, Specific objectives and an evaluation plan is presented. The first year budget consists of $40,000 for personnel and $10,000 for patient monitoring and calibration equipment. ®@ Second Years 49,000 Third Year: + $40,000 . Requested Project #17 - Pediatric Cardiac Clinics First Year This three-year project is designed to expand “$49, 1 175 and extend the scope of pediatric heart clinics conducted, throughout Southern Ohio, by the University of Cincinnati College of Medicine. The present clinic system, which offers basically diagnosic and referral services, serves Cincinnati and six counties. It will be extended by opening three additional clinics in the counties now being served, and expanded by opening clinics in six counties not presently being served, The frequency of the clinic sessions in the parti- cular localities is not finalized, however, indications are that twoe three clinics per year will be required, except in one county where bi-monthly clinics seem indicated, The school screening program for detection of heart disease which was recently introduced in two counties will be expanded throughout the area, with priority attention to those schools having unusually high enrollment of low income and minority groups. Plans for an educational aspect are to arrange county medical societies! meeting to coincide with the date clinics are scheduled in the respective counties, Attended by physicians and public health nurses, this would allow formal discussion of pediatric cardiolegy problems and afford ample opportunity for case conferences on referred patients, fn evaluation plan is presented, © Second Year: $39,700 Third & ar: $41,010 OHIO VALLEY Regional Medical Programs Jo RM 00048 7/70.1 Project #18 - Programmed Medical Bistory Requested - This preject is a cooperative effort by the _. - \Fiest Year University of Kentucky Medical Center, its sponsor, and the ~ $92,184 Clover Fork OutePatient Medical Clinic which serves the indigent of rural Appalachia. Its purpose is to develop methoils to help alleviate the manpower shortage in the care of ambulant patients and to determine the most cost-effective method of collecting patient medical history information, while at the same tine, maintaining the highest dagyne quality, and physician and patient acceptability. During the first half of the ¢ project year comparisons will be made of the effectiveness of various history-taking techniques applied to randomly selected patient groups at the General Medical Clinic at the University and at the Clover Fork Center, Using the Techniques found most costeeffective duving the initial sixemonth period these applications will be expanded into first the family practice clinic, then the other medical specialty clinics, and finally into all outpatient clinics at the University of Kentucky Medical Center. In the 03 project year the programmed historye taking technique found to be most applicable will be extended into the office of a private practitioner of internal medicine and into a group practice clinic, Utilizing the data base and experience accumulated during the first two years, it is also planned to develop diagnostic decision sup- port by computer during the 03 year. A plan of evaluation is presented, The Ol year budget reflects large amounts for computer time, $10,000 and equipment rental, $59,534, Second Year’ $62,940, Third Year: $33,850 OHIO VALLEY Regional Medical Program $e RM 00048 7/70.1 REVIEW AND FUNGING BYSTORY I dst Year Planning Award _ CGlovenber 1966 Council) 1/1/67 ~ 12/31/67 $346,760 4 : 2nd Year Award . 1/1/68 - 12/31/63” 346,791 | Qnd Year Planning Award Amended (February 1968 Council) 1/1/63 = 12/31/63 407,238 INLTIAL GPERATIONAL APPLYICATTON . (Site Visited September 1968) (November 1968 Council) APPROVED FUUBED (d.c.o.) PROJECTS PROJECT PERIOD O2-Year _ 02 Year HL = Core Staff Activities 3 years $376,761 $397,391" #2 = Community Hospital Staff Development 3 years 230,690 265,970 #3 = Regional Medical 1. V. 1 years 20,020 “0- #4)- Library Extension Service 3 years , 75,954 90 459% #5 = University Continuing Ed. Resources 3 years. 91,270 141, 440% #6 + Drug Information Service Additional 4,509 14,200« Planning FIRST OPENATIONAL SUPPLEMENT APPLICATION (February 1969 Council) (Site Visited March 1969) (May 1969 Council) . - , Oya FUTURE APPR FUNDED (d.c.0.) SUPPORT PROJECTS Ol Year 02 Year @3_ Year #7 - Automated Multiphagic Screening $200,000 (1) $200,000 “Qe #8 - Cornoary Care Demonstration Disapproval with advice to resubmit #9 = Radiotherapy Dosimetry Disapproval with advice to resubmit #10- Regional Stroke Management 15,000 ** 15,000 15,000 #1l- Rural Home Care Demonstration 90,060 (1) 127,654 127,654 REVISION OF #7 = Mutiphesic Screening (December 1969 Council) Original approval wus contingent upon submission of evidence that the project, as conceived, could be accomplished within the linit of the budget recommended, Council found the revised proposal acceptable, * Partially funded with O1 carryover #* Totally funded with O01 carryover (1) Funding anticipated in near future OHIO VALLEY Regional Medical Program = «9- RM C0048 7/70.1 SECOND OPERATIONAL SUPPLEMENT APPLICATION (arch 1970 Council) Project #3 = (Renewal) Regional Medical T. V. Disapproved with advice THIRD OPERATIONAL SUPPLEMENT APPLICATION ( duly 1970 Council) #12 - Computer Assisted Radiotherapy Rosimetry Demonstraion ft ‘ #13 « Advanced Radiologic Technologist #14 - : #15 « Z #16 - Cancer #17 = Pediatric Cardiac Clinics #18 ~ Programmed Medical History RMPS/GRB/5/21/70 A Privileged Communication SUMMARY OF. REVIEW AND: CONCLUSION OF JUNE 1970 REVIEW COMMITTEE OHIO VALLEY REGIONAL MEDICAL PROGRAM RM 00048 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee noted that this application requests funding for a variety of new operational activities in the Ohio Valley Region. Four activities related to training and the Committee's approval was based on the Ad Hoc Continuing Education and Training Panel's assessment oftheir technical feasibility; one project was a revision of a Dosimetry proposal returned for revision in line with Council guidelines on Dosimetry and while the Committee felt it was well-planned, they requested additional review by a member of the ‘Council's Ad Hoc Committee which developed the guidelines. Two pro- jects were returned for revision and one was disapproved. The overall application was approved with specific conditions. Project #12 - Computer Assisted Radiotherapy Dosimetry Demonstration Critique: ‘The Committee considered this project acceptable and worthy of support, noting it is an important first step toward providing regional radiotherapists with reliable radiation therapy dosimetry. However, it was felt that additional technical review was needed by a member of the original Ad Hoc Committee which developed the guidelines on dosimetry for Council's consideration. Recommendation: - Approval I - but recommended for technical review prior to Council. Years: O1 - $222,884 02 - $258,405 _ 03 - $277,704 an aed as, 5 ' Project #13 - Advanced Radiologic Technologist Critique: Committee concurred with the Continuing Education and Training Panel's view that this project is technically feasible and adequately planned. The educational needs have “been identified with data to indicate the acute shortage of radiologists . ‘and the lack: of likelihood that this shortage will be ameliorated. The objectives are stated in clear and measurable terms and are likely to achieve the Region's mission if attained. The application does not contain the details of program design, but rather methodology where- by such design will be determined. The time frame of the activities OHIO VALLEY Regional Medical Program — -2- RM 00048 7/70.1 seems reasonable and is well defined. The project probably can be carried out with the budget, personnel and plan proposed, although it is experient. The educational], resources in the Region are in- volved. Evaluation should provide Yébiable and valid data, and adequate staffing has been provided; but it is implied the program may become a part of a baccalaureate program and it would.be assumed that the tuition funding mechanism would then apply. It was noted that this project has been approved by the Manpower Utilization Branch, Nation Center for Health Services and Research “Development and that as of June 18, 1970, the Chief of that Branch was optimistic as to the possibility of its being funded. Recommendation: Approval I - to be funded only if not funded by. another agency. “Years: O1 - $85,261 02 - $99,614 03 ~ $109,798 04 = $113,284 Project #14 - Urologic Assistant Critique: The Committee generally concurred with the observation of “the Continuing Education and Training Panel regarding this project. The need is well-stated and documented. Objectives are stated in the general terms of activities in a time frame, rather than behaviors of the learners. The project appears feasible within proposed time frame, budget, and personnel. Educational resources are well described and involved in the project. Little attention is given. to-evaluation of the impact on patient care in quantity and quality dimensions., The budget is modest. This type of manpower specialist, to provide assistance to the physician, is so highly specialized that it would set a precedent for the establishment of numerous other training programs which might not have a direct bearing and impact on RMP activities. Special Note: Since Committee reviewed this project, it has been funded by the Division of Allied Health. Recommendation: Approval II ~ no additional funds recommended. Project #15 - Clinical Associate Critique: Committee concurred with the observations of the Continuing Education and Training Panel. The need for the project is described in generally accepted terms. There has been a '“gurvey of physicians in the Region and it would appear that they agree to the need for such a program and that a significant number would employ such assistants. The objectives are stated in measurable terms. The educational resources of the Region are involved. There are multiple foci on evaluation including re-examination of the criteria for acceptance 5. OHIO VALLEY Regional Medical Program . =3- RM 00048 7/70.1 of students, the adherence to objectives concerning task accomplishment, . evaluation of actual performance of the trainees and determination of the physician sharing of the trainees. It was questioned whether 25% effort of a research consultant will be enough to carry out the évaluation procedures. It was noted that the small number of trainees and the expected distribution of these trainees to various medical groups such as practitioners, internists, pediatricians, surgical specialists, etc., may make the problem of evaluation of the effective- ness of these men within each speciality difficult. The Committee suggested that an attempt be made to increase the number of trainees to provide a sounder evaluation of the effectiveness within each area of service. The increase in trainees would also serve to reduce the expense per student trained, which was considered very high. Although no specific plan is presented for phasing out, it is indicated that if ~-guecessful, the program would become a part of the regular curriculum ‘of the University and be funded in the usual fashion. Committee concluded the project is technically sound and capably directed, and althoughit is of high risk and great cost, it-should be endorsed to test the hypothesis . implicit in this experiment. Recommendation::. Approval I Years: 01 - $102,708 02 - $111,024 03 - $132,282 04 - $118,817 05 ~ $61, 6! Project #16 - Laser Treatment of Cancer Critique: The Committee considered the proposal too narrow in scope, involving primarily fellowship training and little else. The support requested for fellowship training and development is an aspect for which Committee requests Council policy. In addition, it was noted that there is no educational thrust provided for practicing physicians. Also, there is no clear indication the project would directly effect an increase in the number of patients treated. The problem of referral to this specialized center is not clearly spelled out, and there is no information on the’promotional techniques to be used to encourage this referrdl. The portion of the project concerned with colposcopy and -use of laser needs strengthening and amplification. o Recommendation: Non-approval II ~ return for revision. | Project #17 - Pediatric Cardiology Clinics Critique: Committee agreed with the Ad Hoc Cardiovascular Panel's comments regarding this project. It was noted. the proposal is justified on the basis that OVRMP emphasis. is on improved ambulatory eare services, but that the need for expansion of clinics is not clearly shown. The geographic areas where the clinics are to be maintained are “not specified as to exact locale: hospitals, health departments, etc.? The need for the phonocardioscan is not justified; it would appear that the trained cardiologist who will be in attendance at the clinic should ‘abtest OHLO VALLEY Regional Medical Program -4- ’ RM 00048 7/70.1 eliminate the necessity for this piece of screening equipment ~ “well-trained specialists are more effective in determining whether amurmer is functional or organic. Although objectives are enumerated and a means of attainment outlined, they are not presented in, quantitative terms thereby making it difficult to assess the adequacy of resources. and to evaluate the budget request. The -evaluation described is an appropriate record-keeping and accounting of the expansion and utilization of services, but does not take into consideration all the possible factors.and trends. Recommendation: Non-approval ITI.- return for revision. Project #18 - Programmed Medical History Critique: The Committee felt that initiation of this project should await tesults from the large number of studies relative to this type of activity being carried on in various positions of the county. The reviewers were not certain that programmed medical history utilizing computers is, in fact, time saving and valuable as indicated in this application, particularly with reference to its “extension to the community after the preliminary work has been. accomplished. . at the medical:center. The reviewers found the use of the computer in diagnostic decision assist an interesting part of the proposal. Recommendation: Non-approval I - no RMPS funding recommended. SUMMARY OF RECOMMENDATIONS Recommendation Ol Year Q2 Year 03 Year — 04 Year - 05 Year Total $758,99 I Approval I $222,884 $258,405 $277,704 -0- "=O Recommended - for: technical ipy Dosimetry review prior enone tration to Council tad; 3-Advanced ‘, Approval I ~ To 85,261 99,614 109,798. $113,284 -0 1 407,95 be supported only if not ; funded by the Manpower Utili- zation Branch of NCHSRD “Approval II - -0- -0- -0- -0- -0- =0- (no. additional funds recommended) & ~,. , OHIO VALLEY Regional Medical Program -5- RM 00048 7/70.1 : 'roject. itle & # Recommendation Ol Year 02 Year 03 Year 04 Year 05 Year Total - 5-Clinical Approval I $102,708 $111,024 $132,282 $118,817 $ 61,695 $526,526 \ssoclate L6-Lasar Non-Approval -0- -0- -0- -0- -0- -0- freatment Il - (return yf Cancer for revision) \7-Pediatric Non-Approval -0- -0- -0- -0- -0- -0- gardiac II - (return . clinic for revision) * 18-Programmed Non-Approval I = Q- -0- ~O0- ~O- ~0- -Q- Medical History TOTAL APPLICATION Approval $410,853 $469,043 $519,784 $232,101 $ 61,695 $1,693,476 : with : Specific Conditions satis (see individual projects) DRMP/GRB 7415/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) OREGON REGIONAL MEDICAL PROGRAM RM 00012 7/70.1 University of Oregon Medical School June 1970 Review Committee 3181 S$. W. Sam Jackson Park Road Portland, Oregon 97201 PROGRAM COORDINATOR: Edward M. Goldblatt, M. D. Requested Program Period ist Year 2nd Year 3rd Year Total Direct Costs: $59,375 $28,829 © $14,843 $103,047 Indirect Costs: To be submitted Total $59,375 $28,829 $14,843 $103,047 HISTORY: The Region's first planning grant application was submitted in May 1966, returned for revision by Review Committee, and resubmitted in August of that same year. This second application was approved and the 01 planning award ($166,494 d.c.o.) was made for the period April 1, 1967 through March 31, 1968. , Following a most encouraging site visit in February 1968, ORMP became operational on April 1, 1968, with an award of $171,910 (d.c.o.). This amount combined 02 planning funds with new funds for the support of one operational project. A supplemental award was made on July 1, 1968 ($343,045 d.c.o.) for six new projects, #2 ana #7. Another supplement for projects #8 - #12 was approved but unfunded in February 1969. ‘The Region was issued an 02 continuation award ($686,028 d.c.o.) effec- tive April1, 1969, with support for core and seven projects. At this time, there was also a site visit made to examine the accomplishments of the first year of operations and to make recommendations on two new projects to be acted on by the May 1969 Council. The visitors reported significant progress and recommended the projects be approved. On July 1, 1969, an amended award ($854,146 d.c.o.) was issued granting the use of carryover funds for one-year support of projects #9 — #12 (approved ~ unfunded) and the two projects, #13 and #14, approved by the May Council. The 03 continuation award ($764,381 d.c.o.) for the period beginning April 1, 1970 included support for twelve on-going projects and one OREGON ~2- RM 00012 7/70.1 Regional Medical Program new project, #15, which had just been approved by the March 1970 Council. A listing of all current projects follows the description of the present application. PRESENT APPLICATION: This is a request for an additional year's support for a project formerly approved for one year only, plus a request for three years' support for one new project. Project #12 R ~ Southern Oregon Diabetic Instruction and Requested Evaluation Project. This project had received First Year one-year approval for the period April 1, 1969, through March $14 ,872 unded until July 1969. In order to allow for a full year activity and to fit into the present yayier cycle, ORMP reguested and received a four-month extension for the period April 1, 1970, through July 31, 1970. 31, 1970, but was not Chori o 1 ¢ The purpose of this program has been to make available a course of instruction for diabetic patients which will help them to understand their disease and to regulate their diets and medica- tions. The ultimate goal of the course is to effect a signifi- cant reduction in morbidity. In addition to the basic program, there are activities concerming education of student nurses, registered nurses, public health nurses, student and licensed practical nurses, dietitions, institution cooks and physicians. Although in operation for only nine months, the Region contends that the project has made excellent progress and seems to be extremely well received by the community, a factor that has been noted by several national legislators from Oregon. While the original grant expected 600 patients to attend the course during the first year, the presently projected 230 patients and 80 family members seems a more realistic and attainable estimate. Also, there had to be a reduction in the number of students based on the experience gained after the first course when it was found that a great deal of individual counseling was necessary. The Region believes that this project is unique among ORMP projects in that it affects the lives of citizens directly in addition to improving the abilities and resources of the professionals who render health care. The original one-year authorization was based on’the premise that diabetic patient instruction schools are capable of self-support and that ORMP support was intended as seed money for the first _ year. ORMP believes that the time needed for this program to become self-sufficient was underestimated and is therefore requesting an additional year to be prorated on an eight-month basis due to the four-month extension mentioned earlier. OREGON ~3- RM 00012 7/70.1 Regional Medical Program Project #16 - A Training Program for Personnel of Oregon Requested Health Care Institutions. This program is First Year designed to improve care of patients in health care institu- $44,503 tions in the Oregon region by providing informational courses aimed primarily at the entire spectrum of subprofessional health care workers. The courses will be designed so that the students may comprehend and carry out their own specific responsibilities under existing formal institutional standards concerned with the control of significant patient care problems. Participating institutions will select a minimum of two trainees to attend courses in hospital care problem areas. Trainees will be selected on a multi-disciplinary basis and efforts will be made to include a participant from a supervisory level of the institution. Courses will be presented in specified areas of the state to permit maximum participation by the smaller and more remote institu- tions. Course content has been developed for the first year of presentation. An advisory committee will plan future courses based on needs and requests of participants. Evaluation of pre- and post-course achievement in skill, knowledge and performance will be accomplished by written tests and interviews. The project requests that funds collected through tuition be used to defray total cost of the program. The sponsoring organization, the Oregon Association of Hospitals, has outlined a plan whereby member hospitals of the Association will contribute one-third of the cost in the second year, two-thirds in the third year, and will continue the program at the end of the grant period utilizing the association's own resources. The Region believes that this proposal represents an approach unique in scope and without precedence among its activities in that it provides a multidisciplinary educational program directed towards actual worker implementation of modern hospital technology. The outlined program will constitute a major effort by hospitals to solve their own basic patient care problems. Second Year: $28,829 Third Year: $14,843 OREGON ~~ Regional Medical Program ; OPERATIONAL PROJECTS (Direct Cost Only) RM 00012 7/70.1 INCLUDED PROJECT # CURRENT UNEXPENDED DATE OF AND TITLE BUDGET FUNDS ACTIVATION Core $209,417 -0- #1 - Heart, Cancer, Stroke Circuit _ Postgraduate Course for the Oregon Region $174,204 ~O- 4/1/68 #2- Early Diagnosis and Therapy of Cerebrovascular Disease S 27,825 -0- 7/1/68 #4 - Diagnosis and Treatment of Cerebrovascular Disease and the Influence of a Stroke Clinic on Stroke Care: Stroke Project III § 56,859 -0- 7/1/68 #5 - A Stroke Continuing Education Program Planned by Community Physicians: An Evaluation of Effectiveness Stroke Project IV $ 31,567 ' $3,946 7/1/68 #6 - Mid-Willamette Valley Coronary Care Training Program $ 52,164 -0- 7/1/68 #7 - Training of Professional ; Nurses for Coronary Care $ 73,848 -0- 7/1/68 #9 - Central Oregon Heart, Cancer and Stroke Pilot Program $ 24,233 ~0- “7/1/69 #10 - Coronary Care Teaching Aids $§ 5,572 -0- 7/1/69 -#11-- Guiding Adult Patients with Aphasia $ 27,019 -0- 7/1/69 ‘#12 - Southern Oregon Diabetic In- struction and Evaluation Project $ 7,219 $7,219 7/1/69 #13 - Mobile Emergency Cardiac i Project - Phase I $ 6,249 $6,249 7/1/69 #14 - Training Programs to Promote Better Care of the Diabetic Patient $ 39,306 $32,306 7/1/69 OREGON ~5- RM 00012 7/70.1 Regional Medical Program #15 - Physician In-Residence Course in Technique of Cardiology $28,920 $28,920* 4/1/70 $764,381 $78,640 *Negotiations are now under way to fund this project with new supplemental money made available by the release of five million dollars to DRMP by the Bureau of the Budget. A PRIVILEGED COMMUNICATION SUMMARY OF REVIEW AND CONCLUSION OF JURE 1970 REVIEW COMMITTEE ORECON REGIONAL MEDICAL PROGRAM RM 00012 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL Project #12 R ~ Southern Oregon Diabetic Instruction and Evaluation Project. Critigue: The reviewers were favorably impressed with the progress made by this program in reaching out into the rural areas of the state to deliver this most needed gervice to diabetic patients. They also noted the support for the project on the part of both the profes- sional and consumer communities and the valuable nursing educational component. The Committee believed this program to be deserving of con- tinued RNP support. Recommendation: Approval I: time and amount requested Direct Costs Only: lst Year 2nd Year 3rd Year $14,872 =O ~O— Project #16 - A Training Program for Personnel of Oregon Health Care Institutions Critique: The Committee responded positively to what they perceived to be a unique educational effort on the part of a regional medical program in that it is aimed at the many levels of subprofessional personnel where policies set down by leadership must be translated into action and where breakdowns in communication frequently occur, The - reviewers further recognized the regionalization inherent in a program that would bring together people from health care institutions though- out the state to work out common problems. They were pleased to see the commitment of the Oregon Association of Hospitals to continue this pro- gram after the period of RMP support and were well satisfied with the overall design of the program, Recommendation: Approval I - time and amount requested Direct Costs Only: ist Year 2nd Year 3rd Year , $44 ,503 $28 ,829 $14,843 00012 7/70.1 SUMMARY OF FUNDING RECOMMENDATIONS Project O1-Year 02-Year ° 03+-Year Total (#12 R - Requested) ($14,872) (-0-) -— (-0~) ($14,872) #12 R + Recommended 14,872 -0- -0- 14,872 (#16 - Requested) (44,503) ($26 29) (14,843) _ ($88,175) #16 =~ Recommended 44,503 28 529 14,843 88,175 (Total Requested) (59,375) (28,829) (14,843) (103 ,047) Total Recommended $595375- | $28 ,829 $14,843 $103 ,047 RMPS/GRB/7/6/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY .OF AN OPERATIONAL GRANT APPLICATION (A Privileged Communication) PUERTO RICO REGLONAL MEDICAL PROGRAM RM 00065 7/70.1 (formerly 3/70.1) University of Puerto Rico February 1970 Review Committee Medical Sciences Campus March 1970 Council P.O. Box 4509 June 1970 Review Committee San Juan, Puerto Rico Program Coordinator: Adan Nigaglioni, M.D. Requested Program Period: lst Year 2nd Year 3rd Year Total Direct Costs $618,756 $496,173 $515,410 $1,630,339 Indirect Costs 78,630 83,811 88,002 250,443 TOTAL $697 , 386 $579 ,984 $603,412 $1,880,782 HISTORY: On June 1, 1969 Puerto Rico entered its second year continuation of planning activities, with a total award of $232,857. Asa result of affirmative action of the National Advisory Council at its meeting on May 26-27, 1969, a "Core Supplemental" award in the amount of $94,281 was made to support two new programs: (1) establishment of a Biostatistics Section ($54,636) and (2) establishment of an Office of Information and Public Relations ($39,645). Both activities have now been absorbed into Core staff responsibilities. A site visit was made on September 30 - October 1, 1969 to determine if the region, based on one year's planning experience, was ready to become operational. The team visited the San Juan City Dispensary No. 18, as well as the new Community Health Center at Guaynabo, the new hospital under construction at Mayaguez, and the Health Department Hospital at Ponce. With many years of experience in various kinds of health delivery service, the Commonwealth of Puerto Rico is now launching a plan to integrate the private and public sectors of medicine. This will have great significance for RMP and HSMHA. From a total of eight operational projects, six were recommended for funding, and this recommendation was endorsed by both the Review Committee and Council. Following a negotiation meeting on January 30, 1970, with the region, an operational award was issued effective March 1, 1970 in the amount of $846,000 with commitment for the second and third years for the same amount. Upon receipt of revised budgets from the region, the distribution of these monies among Core and appropriate projects will be determined. PUERTO RICO RMP -2- RM 60065 7/70. “ Project #9 - Community Approach to Combat Cancer in Ponce. Ist Year © This program will be based at the Ponce Oncologic $335,173 Hospital in Ponce, which-is the metropolitan area, with a a population of 162,300, in the southern part of the island. The Ponce region covers seventeen towns which are covered by the Ponce Oncologic Clinic, and all will be covered by the proposed Cancer Information Centers. The Ponce Clinic was established about twenty years ago, and is certified by the American College of Surgeons. There is a Radiotherapy Department with a cobalt machine and a modern laboratory. Under construction and soon to be opened in the area of the Ponce Medical Center, is a $1.5 million 50-bed hospital with facilities and equipment for treatment of cancer. This was built under the auspices of the Association to Combat Cancer. The project would establish three Community Cancer Detection and Early Diagnosis Clinics throughout the area now served by the Ponce Oncologic Clinic. About 1,500 patients each year may be treated (1) in the’ Oncologic Clinic four days per week; (2) in Damas Hospital (Womens Hospital) in Ponce two days a week; and (3) in the Community General Hospital in ~ Guayama (Santa Rosa Hospital) two days a week. Physicians and allied health personnel will participate in cancer management conferences, weekly cancer seminars, workshops, etc. A community health education program will be developed and will involve trained social workers. Six Cancer Information Centers will be located in neighborhoods indicating the greatest need, and it is hoped these will be able to reach 90% of the adult population. Ponce as the base is a natural selection since it is one of the three bdsic service regions of the Department of Health. The Cancer Information Centers will be established in: Adjuntas, Patillas, Arroyo, Yauco, Santa Isabel, and Guayama. . Each Center will be staffed with one or two Family Health Workers to cover a municipality, (with a total of eleven) conveniently located in each town, accessible to urban as well as rural residents. These will serve as community meeting places with activities such as conferences, institutes, workshops, seminars, etc., not only for professionals, but for technical personnel as well. Referrals will be to the Cancer Detection and Early Diagnosis Clinic of persons who show signs or symptoms of cancer. 7 Family Health Workers will receive two months training at the Puerto Rico Medical Center, with additional in-service training twice monthly. They will be knowledgeable in community resources and will coordinate with other health and social agencies, especially public health nurses. The region has attempted to utilize the private sector in its choice of: Santa Rosa and Damas Hospitals, both private non-profit institutions. , Through the passage of Public Law 56, indigent patients will be able to use these private medical facilities with the government reimbursing institutions PUERTO RICO RMP -3- RM 000605 7/70.] for these services. lvraining activities will be based at the Ponce Oncologic Hospital and wreliminary inquiries indicate the required number of recruits will be available. Weekly cancer seminars are planned with joint participation ot all three centers and staff of the treatment center. These seminars will take advantage of existing clinical material in the treatment center for case presentations. Any interested community physician will be able to parlicipate in a monthly day-long course at the Treatment Center, and it is hoped to reach at least 72 physicians per year through this course. Evaluation measures will involve several sources of measurement--trainees, teachers in the continuing education program, staff, patients, and other participating community agencies. Core staff will assist in the design. Staff requirements will be 28 professionals and sub-professionals, about 1]. of whom will be part time. Duties and responsibilities are included, as well as curriculum vitae of personnel already committed to the program. The project directors view this program as self sustaining in the future through funds accruing through Public Law 56, as well as private fees from patients who are able to pay. 2nd Year: $245,648 3rd Year: $254,002 Project #10 - Proposal for a Community-Family Prevention lst Year Program on Stroke. The program will be based $194,403 in the Guaynabo Health Center, located approximately 10 miles southwest of the Medical Center in San Juan with good access roads. The Center has a total of 22 hospital beds offering general medical services. Planning for the program resulted from the cooperative efforts of the Section of Physical Medicine and Rehabilitation of the Department of Surgery, the Section of Neurology in the Department of Medicine, University of Puerto Rico School of Medicine, and the Guaynabo Health Center. The Program Directors have organized the project based on a study conducted by Dr. Sanchez-Longo and his associates in which a 10-year experience with cerebrovascular accidents at the University Hospital was recorded. For the most part, patients with hypertension or otherwise predisposed to stroke, are not effectively managed anywhere in the island. Most cases are handled by general practitioners in small communities where they lack appropriate facilities and resources. There is no stroke registry to identify, accumulate and analyze data about patients. There is no intensive care unit for the treatment and demonstration aspects of a stroke program anywhere in Puerto Rico, and there is no educational program for the community, practicing physicians or allied health personnel. Further, there is no existing program fer the early detection and diagnosis by angiography or other diagnostic procedures for stroke patients. PUERTO RICO RMP -4- KM UUU0D fp ton The program is divided into six components: (1) Public Health Education: Services, (2) Screening Clinics, (3) Stroke Stations, (4) Follow-up Clinics, (5) Home Health Aide Servites, and (6) Continuing Education Activities. . C8 RPT Approximately 200 patients per year will be served in the Screening Clinics, mainly between the ages of 45-54, and the program will reach approximately 100% (30,000) of the adult population of Guaynabo by means of a Public . Health Education Program. These services will be coordinated through the press, radio, television, civic clubs, and volunteer agencies, particularly the Puerto Rico chapter of the American Heart Association. oo Two Screening Clinics will be established at the Puerto Rico Health Center and in the Guaynabo Health Center for the community in general. The clinics will be held daily at the University Hospital under the leadership of a neurologist with the assistance of other members of the neurological staff of University Hospital. Another neurologist, presently on the faculty at the University Hospital, will visit the Guaynabo Health Center on Monday afternoons to supervise screening in that area. A full-time physician will be assigned to the clinics. oe The Stroke Rehabilitation Station will be established at the Guaynabo Center with facilities for nursing and rehabilitative care. It will have beds for 8 patients, later increasing to 10, and under the supervision of a full-time physiatrist who will direct the overall functioning of the unit. He will also conduct training courses for physicians and other allied health personnel. The nursing services of the Stroke Station will be under the direction of a supervisory nurse who has specialized training in the rehabilitation of patients with cerebrovascular disease. A full-time physical therapist, an occupational therapist, speech therapist, and rehabilitation counselor will be recruited. A social worker will interview all patients and their families and a psycho-social evaluation will be made of the family of the patient. A Follow-up Clinic will be held every Wednesday afternoon from 1:00 P.M. to 4:00 P.M. This will be located at the Guaynabo center and conducted by the physiatrist for continuous evaluation of patients who have been discharged from the Stroke Station. These patients will also receive other ancillary services and possible further referrals for other diagnostic procedures, Yen Home Health Aides will be recruited, residents from various neighborhoods in Guaynabo at a minimum high school diploma level, and preferably from low-income families. They will be trained in basic nursing and physical therapy procedures. They will be supervised by a registered nurse who is experienced in teaching. The aide will be able to give injections, take temperatures, and perform basic urine analysis and advise about preparation of menus. She will accompany patients to Follow-up Clinics, encourage self- reliance, be a resource in the event of family crisis, participate in community education programs , etc. The component for Continuing Education for Medical and Allied Health Personnel PUERTO RICO RMP ~5- RM 00065 7/70.1 will of fer short training courses four times a year for general practitioners from smaller communities in techniques employed in rehabilitation of stroke patieuts, and modern methods of screening and prevention. In addition, other training courses will reach about 100 physicians, nurses, social workers, vocational counselors and other allied health personnel. The project's evaluation will be the overall responsibility of the Committee on Stroke of the Puerto Rico RMP, as well as by the Board of Directors of the project and the staff of the Dean of the School of Medicine. This will be through visits to the various components of the program, written questionnaires, clinical data, records of the Medical Center in the Guaynabo Health Center, etc. it is hoped to be able to compare the incidence, morbidity, mortality and incapacity of stroke victims in a similar community not now receiving the benefits of the program. The project authors anticipate the continuation of this program upon termination of federal funds through the joint efforts of the Department of Health of Puerto Rico and the University of Puerto Rico, Medical Sciences Campus (Medical School). 2nd Year: $193,356 3rd Year: $202,503 Project #11 - Project for Computerized Dose Distribution lst Year Calculations and Radiotherapy Treatment $89,180 Planning for the Radiotherapy and Cancer Division at the Puerto Rico Nuclear Center and, I. Gonzgalez-Martinez Oncologic Hospital. This vrogram will establish a program for automated radiotherapy dose calculation and treatment planning to provide individualized treatment plans and graphic dose distribution for each radiotherapy patient. Such a program will provide optimal treatment planning for individual patients undergoing external radiation therapy, and graphic representation of dose distribution within the treatment volume for each patient. The program will be based at the I. Gonzalez-Martinez Hospital which is dedicated exclusively to the care and treatment of cancer. The Radiotherapy and Cancer Division of the Puerto Rico Nuclear Center and the Radiotherapy Department of the Hospital, function as a single staff unit. The two radiotherapy areas at these institutions enjoy close physical proximity, a common Division-Department Head, and staff members who work in both areas on a monthly rotation program. The Radiotherapy Department has a daily patient census that ranges from 120- 160 cases per day, with a patient treatment load of approximately 550 teletherapy applications per week. At present dose information is determined by hand calculation and one point (central axis) tumor dose and is calculated for every teletherapy field. In general, complete dose distribution within the treated volume is done by hand and is reserved for a few specially selected cases. PUERTO RICO RMP -6- RM 00065) 7/70.1 , The proposal. requests funds for a programmed console system and the development of a computerized dosimetry service in Puerto Rico. The system will also provide for establishing a treatment planning center and a base of the training for radiotherapy residents in dose computations as well as the services of a radiological physicist for training in dose computation, treatment planning and computation techniques. 7 Because the PC system presently does not permit its utilization for interstitial implant dosimetry, supplementary computer facilities are also requested. Such computer time would be by subcontract to the Mayaguez — Campus of the University of Puerto Rico. This computer is an IBM 360-40. The first year will be phased into 2 parts: (1) to establish the autonomous mode of the PC system with concurrent utilization of the IBM 360-40 for interstitial implant dosimetry and (2) provide the means for renting 2 Xerox telecopier units, one to be located at the Puerto Rico Nuclear Center and the other at the Ponce Oncologic Clinic. The second year will add a Xerox telecopier at the Mayaguez Medical Center and will initiate charges for services on the basis of cost evaluation, studies so that the facility can become self-supporting. . Funds are requested for a Computer and Electronic Technician, a Dosimetrist Contour Technician (2 full-time and 1 part-time). In addition, the present staff of the center would devote varying periods of time to the project. 2nd Year: $57,169 3rd Year: $58,905 CRITIQUE: February 1970 Review Committee GENERAL: The reviewers found that this application was better than previous ones in documentation and directed at major health problems ia Puerto Rico as already identified by a recent site visit. This supplement seems to be well phased with the other components of the operational program and based on a ten-year health planning program for the island. The application has good regionalization aspects, especially with one project based at Ponce which will be the site of a second medical school in time. The Medical Center enjoys an acceptable level of medical practice in a modern sense, and has an active renal transplant program. Project #9 - Community Approach with Interagency Cooperation to Combat Cancer - Ponce. CRITIQUE: The needs for trained personnel including physicians in the southern portion of Puerto Rico is particularly acute. This’: point should be seriously considered in evaluating this project, since it appears that the program will not bring new people to the area, but may further dilute the activities of the available personnel presently performing medical care in this portion of the island. PUERTO RICO RMP -7- RM 00065 7/70.1 The project should be viewed as a strengthening of the impressive medical center in Ponce which was compared to an iceberg with only portions of its potential clearly visible. One weakness of the budget portion is the failure to identify perscnnel, which indicates that it is highly likely that the budget will provide total or partial funding for people already performing the medical care in the Region, and who are already in short supply. The competitive position of this application would be tremendously strengthened if the Region could assure that the budget will provde only for new people brought into the Ponce area. The request for $20,000 for consultant services appears to be unrealistic in that available consultants are already overburdened. Overall, the budget appears to be rather diffuse and difficult to evaluate with large amounts earmarked for equipment and sub-contracts. The evaluation program is vague, but this is understandable since the research associates who will determine the program have apparently not been selected. The Oncologic Clinic does have good background information of the population on cancer rates, stage and morbidity, and it would seem that a suitable evaluation program could be devised with appropriate direction. Generally, the program appears to be far too all-inclusive for the available medical and allied health personnel in the Ponce area. The Region does not indicate how the project would increase medical manpower, and from the evidence presented, it would appear that it would produce a further dilution of available limited manpower. RECOMMENDATION: Deferral for site visit for further evaluation of all concerns outlined above. Project #10 - Community Family Prevention Program on Stroke. CRITIQUE: There was no question in the minds of the reviewers that the need for such a program in stroke is critical in Puerto Rico. The limited economy, the shortage of personnel and facilities, the fatalistic attitudes and chronically low expectations to misfortune, make the locale eminently suitable for the Guyanabo area. The proposal is well planned and the interlocking relationship of the medical school and the district health center hospital at Guyanabo was believed to be strengthening to the program. The operational aspects have been clearly thought out and the relatively small population is an advantage in that it will be easy to reach. If personnel are available, this total operational system between the university and a community hospital should have a real impact on stroke. Another interesting aspect of the project is that it will primarily put to the test the success of the public education aspects, along with the PUERTO RICO RMP -8~ RM 00065 7/70.1 professional education of practitioners. The project will stand or fall on this key component. The reviewers noted that this important point is- well understood by the applicants. They noted that if Puerto Rico * succeeds in stroke care, general health care will improve, provided personnel and facilities become proportionately available. The reviewers found the budget somewhat perplexing. While a new project.” of this sort would entail a higher cost outlay in an effort to treat ee 100 patients yearly, screen an unknown number of the population of 60,000, and mount an educational program, the direct cost of approximately $200, 000, and a projected $800,000 over a three-year period, was considered excessive. It is quite obvious that almost every category of professional staff will require funding from RMP funds. Since this multiple-faceted project will not be able to be initiated all” at once, the reviewers felt that it would be wiser to phase the operation, giving priority to education and the stroke station first. This procedure should prove to be more economical. The evaluation impact of training and education is well-planned. The health evaluation portion is less developed. Although data components are given, there is no differentiation between medical record entries and hard data ~ relevant to searching inquiry to achievement of various objectives and sub-objectives. On the whole, this section is the weakest, but at the same time the reasons for its weakness are understandable. It was noted that there is no provision for data processing and publication except for a rather large, unexplained budgetary allotment of $2,500 times 3 years. Apparently no thought has been given to data analyses and develop- ment of conclusions. The project deserves serious consideration in that it makes an impressive effort to organize existing facilities into a regional plan to improve 7 and initiate prevention, diagnosis, comprehensive care, and lay professional education. The organization was believed to be feasible and the operational components are appropriate for the program content as presented. One problem may be in the recruitment of personnel although it was noted that the applicants are in contact with professional organizations which will probably extend assistance. The budget appears to be inflated for such a small population and this deficiency may be mitigated somewhat by postponing certain features, and phasing in others. For example, screening of the population for stroke proneness may prove to be an undesirable burden at first in the presence of known personnel shortages. Another suggestion was that the regional stroke station (the rehabilitation unit) can be initiated under the co-investigators aegis thereby saving for the first period on salaries for a full-time neurologist and a physiatrist. RECOMMENDATION: Deferral pending a site visit to explore all of the concerns and reservations as outlined above- PUERTO RICO RMP -9- RM 00065 7/70.1 Project #11 - Computerized Dose Distribution, Calculations and Radiotherapy. CRITIQUE: The Committee noted that the two radiation therapy centers for which this project is to be used are both well established, have active clinical programs, and see sufficient patients to warrant a budget as requested. However, it was noted that some reductions could be effected by reducing the Project Coordinator's salary (or even eliminating it), and by utilizing only one dosimetry and contour technician instead of two. It was further suggested that travel could be reduced, and for the first year at least the computer time could be reduced from about $12,500 to about $8,000, There was agreement that the project would improve the quality of radiation treatments as well as the accuracy cf the dosage. The application fails to justify the need for the program console. Also, the Region failed to document the present role of this equipment in clinical radiation therapy as well as the experience of others with it. The question of the need for individually plotted isodose distributions on every patient was also raised; it is also not apparent why an isodose plotter should be needed. Cervical cancer rate is high in Puerto Rico. There is a busy service of from 120 to 180 patients census. The department is headed by a good man. The request for technical items will need to be translated into how much the ability to plot doses with this equipment and trained technical staff will contribute to the treatment capability as well as the educational process and capability. The project raised the policy question of the computer aspects of the program and pointed up the need for a computer policy for adequate evaluation of this project. RECOMMENDATION: Deferral for a site visit to obtain more information regarding the feasibility and the soundness of the proposal and to clarify the concerns as outlined above. MARCH 1970 COUNCIL ACTION: Founcil concurred with Avril Committee's recommendation with one exception: With respect to project #10, Council agreed to delegate to the site visit team the authority to investigate it further and, if appropriate, to recommend its approval and determine the level of award (not to exceed the amount requested). SITE VISIT - May 18-19, 1970: A report will be available at the Committee meeting. PUERTO RICO RMP -10- RM 00065 7/70:1 ae OPERATIONAL STATUS ~ (DCO) PROJECT NUMBER TITLE : FUNDING LEVEL Core ° $ 213,386 (7-mo) 1: Northeast Regional Pediatric Medical Program * for Cardiovascular Diseases oo 250,000 2 Program in Hematology, Cancer Chemotherapy and . Blood Banking 84,533 3 Center for Management and Treatment of 256,168 Chronic Pulmonary Diseases in Children 4 Education Program in Diabetes Mellitus 80,000 5 Central Cancer Registry 50 ,000 6 Dial Access Disapproved | 7 | Education and Training of RNs and MDs in Intensive Cardiac Care 200 ,000 8 Stroke Demonstration Unit - Ponce Disapproved TOTAL $1,134,087 FUTURE RECOMMENDED LEVELS 02 03 Core S$ 316,942 $§ 347,596 Projects 873,818 852,468 $1,190,760 $1,200,064 DRMP-2/6/70. A Privileged Communication » SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE PUERTO RICO REGIONAL MEDICAL PROGRAM RM 00065 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee member who chaired the site visit team of May 18-19, 1970, reported to the Review Committee the team's findings and recommendations. (The report of the site visit is attached.) The region is just beginning to move into full operational status. The PR/RMP has con- tinued to refine its organizational framework under the leadership of Dr. Cristino Coldn, who is doing an effective job. Planning for RMP program outreach beyond the San Juan Medical Center area haf been a special achieve- ment in view of the centralization of private and university-based medical resources in San Juan. The site team was impressed by the development of major interest and enthusiasm of lay and medical leadership in Guaynabo, Ponce, and to a lesser extent, in Guayama. Dr. Nigaglioni, the official Coordinator, is more and more a background figure, but very valuable for his present planning for health aides and other allied health training in some of the Commonwealth's junior colleges, such as in Ponce. Membership from the lay power structure for PR/RMP R.A.G,. members and sub- committee members is still insufficient. The private medical sector in San Juan seems inactive in planning or participation. Industrial medical facilities developing at the Phillips plant and the Chem-strand plant at Guayama appear to be outside of RMP planning efforts. In Ponce, on the other hand, there is excellent lay liaison through the Oncologic Clinic, supported by the southern branch of P.R. Cancer Society, and through Dr. Rodriguez’ cardiovascular and renal dialysis and transplant program which has wide and enthusiastic public support (750+ dialyses for 35-40 patients in the past two years). The excellent private medical sector support. and participation in Ponce district projects is quite different from the Capital Area indifference and bodes well for effective RMP projects in this area, The nursing profession is still being slighted as an ally in health plan- ning, in traineeships, and in operational programs as instructors. The site team cited the desirability of broadening operational programs to effect a multidisciplinary approach particularly in training activities. The next eighteen months will be critical for the success of the PR/RMP within the $1,200,000 annual budget for eleven projects and an. additional nine ready for submission to RMPS. It is believed that a ceiling already has been reached in the 50 ~ 100% participation of physicians for the leadership and development of these programs. Future site visitors must carefully evaluate whether salaried time on the job in RMP programs is really being effectively applied by named participants, PUERTO RICO RMP -2- RM 00065 7/70.1 Project #9 - Community Approach to Combat Cancer in Ponce Critique: This project seems to be the most effective thus far in cancer, and builds on an already existing bridge between the Oncologic Hospital in Ponce and the Medical Center in San Juan. It is obvious that Ponce is developing rapidly as a center for cancer treatment. The Hospital, which is situated across the street from the District General Hospital, provides an excellent focal point for the management of all forms of cancer in a multidisciplinary fashion. The Program Director is an active young man, well-trained and dedicated to the success of the project. The Committee endorsed the recommendation of the site team that the inclu- sion in the non-professional staff budget of a number of full-time individuals seems illogical at this point, since it will be a while before the program 4s staffed and underway. Furthermore, the eleven family health workers who are requested at 100% would be better designated as trainees, since this is the true purpose of their involvement. It was noted that the regional junior college in Ponce now under construction will be a source of training of technologists and therapist assistants. The other two participating hospitals--the Damas Hospital in Ponce and the Santa Rosa Hospital in Guayama, about an hour's drive from Ponce, are actively ‘involved and enthusiastic about the program. A new hospital will be com- pleted in 1971 for the Damas facility, which is presently quite crowded. The Santa Rosa Hospital recently has been renovated and is quite well-designed. The Director, Dr. Garcia, reported that they are presently working out arrangements with two new large plants of the Phillips Petroleum Company and one of their subsidiaries, Fibers International, for a prepaid medical plan which the company proposes. Once the program for cancer detection and early diagnosis is underway, some patient care costs could be defrayed through a third party payment plan. The budget was believed to be unrealistic for the first year. Justification for the number of nurses, stenographers, social workers, health educators, etc., is difficult. On the other hand, the health educator and the group of family health workers (trainees) will be essential during the first year, but it was doubted that eleven could be recruited immediately. The request for consultants appeared excessive, but these are in fact instruc- tors to be utilized in training programs, and the recommendation was that they be so designated on a part-time basis. As for equipment, the suggestion was made that an attempt be made to get partial support from local sources. The laboratory services request was also recommended at a reduced level, as well as travel, publication, etc. Other costs in connection with materials for the clinic, alterations, telephone and rental of information center offices ( in the satellites) were thought to be reasonable and necessary for a program of this magnitude. While there was no representative of the local Cancer Society or of the nursing group present during the site visit, the regional representatives PUERTO RICO RMP ~3- RM 00065 7/70.1 assured the t2am that the former group is largely responsible for the planning and development of the program as well as the new hospital. The reviewers noted that there is an established tradition in Puerto Rico in the field of Oncology and this is now being translated into a sub- regionalization of the PR/RMP. This is emerging in the Cancer Chemotherapy- Hematology Program, in the Radiation Therapy Program, and with the intro- duction of new methods in radiation physics. This should generate interest in the centralization of the radiation therapy efforts on the southern side of the island. Recommendation: Approval I = to be conditional upon a revision of the budget in line with above suggestions and spelled out in more detail in the site visit report. : First Year Second Year Third Year $160,000 $160,000 $160,000 Project #10 - Community Family Prevention Program on Stroke and its Incapacitating Complications. Critique: The reviewers noted that this project was submitted to the February/March 1970 cycle, which recommended approval in a reduced amount of approximately $100,000, to be based on further review by a site visit team. The Chairman of the team reported to the Committee on the excellent Guaynabo area involvement and support for this program, (which includes the Mayor) and referred to the original operational submission which included a totally unacceptable stroke project. The leadership of this present project has not demonstrated strong administrative ability, and this was considered a potential threat to its success. A young neurologist who will finish his training this month, Dr. Hector Casas, beginning July 1, 1970 will. spend a year in Houston for further training in cerebrovascular disease, Upon his return to Guaynabo, he will be directly involved in the project. Also, the region has reported its identification of a full-time director--a lady physician. The reviewers believed this to be an excellent area for a pilot training center to which other areas in the island could look as a stroke resource. The project directors were receptive to the suggestion that the requested four practical nurses and four nurse assistants should be considered as trainees rather than permanent personnel, There is a desperate need for aides to physiatrists throughout the island, There are fifteen physiatrists in Puerto Rico, two of whom are in Mayaguez and two in Ponce, One resident is committed to join the Guaynabo program upon completion of his training. The site team noted that an entire area in the basement of one of the hospitals visited in connection with the Ponce project, was fully equipped for physical medicine and rehabilitation, but totally unused. The Director reported that two physiatrists who had been PUERTO RICO RMP -4- RM 00065 7/70.1 coming from San Juan on a part-time basis had to give up because they could not get any occupational or physical therapist assistance. It is reasonable to anticipate that the training of one or two aides from the Ponce area will make a significant contribution to the Ponce neutologist's ability to mount a stroke program. This suggestion was well received by the Guaynabo stroke staff, The budget request was difficult to assess. It was concluded that Guaynabo is an ideal location for this program, where patients can be found, brought into the clinic and some attention directed to the managment of the problems of hypertension and stroke. Optimal opportunities exist for rehabilitation, and evidence of the interest of the community at large was demonstrated, (The Municipal Government will provide an Emergency Services Program to be coor- dinatedwith this project and also provide minibuses. ) The region has submitted a revised budget in line with the recommendations of the site team, Recommendation: Approval I - with the following conditions: (1) RMPS staff ig to examine the revised project plan to be based on the suggestions of the site team and in line with the revised budget already submitted; (2) a technical site visit should be made during the first year of operational status of the project to see what progress has been made in line with the suggestion of the site team. Note: One Review Committee member dissented, First Year Second Year Third Year $112,163 $135,741 $165,214 Project #11 - Computerized Dose Distribution Caléulation in Radiotherapy Treatment Planning. Critique: The reviewers noted the outstanding leadership of this project under Dr. Victor Marcial. The regionalization and multidisciplinary aspects of the project were well received. The Puerto Rico Nuclear Center has had centralized services in association with the Oncologic Hospital since 1966. It also serves the Virgin Islands. Its three main services are ama lgamated-education, research and radiation therapy. In addition to serving two-thirds of the island (1,300 cases yearly), ten medical students and a varying number of technicians and physicists are trained each year. The reviewers heard. that eventually there will be three radiology. centers in Puerto Rico--San Juan, Ponce and Mayaguez, The Dosimetry Services Program will provide a teaching opportunity in radiation therapy not only for local trainees, but those outside the San Juan area 48 well, Cooperative arrange- ments are under negotiation with the groups in Mayaguez and Ponce. The Chairman of the site team reported to the Committee that between the time of the submission of the present application and the site visit, Dr. William Powers of Washington University, representing the American College of Radiologists, visited Dr. Marcial for several days. It was on Dr. Powers’ advice that a request was made for additional equipment in the form of a PUERTO RICO RMP -5- RM 00065 7/70.1 simulator, which Br. Powers felt would be essential for the proper operation of this program, As a consequence, additional funds are requested for pur- chase and maintenance of this equipment. In addition, Dr. Powers recommended that, instead of five part-time radio- therapists, one half-time radiotherapist and one half-time radiation physicist would be more appropriate, The reviewers concurred with the recommendation of the site team that this would be more realistic. The réquested program console is already in use in thirty radiation therapy centers in the U.S.,-Great Britain and Canada, The Puerto Rico group will be a part of a national cooperative which will evaluate this approach to radiation therapy. The site team Chairman reported that the application for this program was reviewed in terms of the seven points agreed upon by the Ad Hoc Group to Consider projects of Radiation Dosimetry Services, appointed at the request of Council and chaired by Dr, Michael Brennan. It was the consensus that more cancer patients will probably receive better isodese distribution with the program console, and the service will provide a teaching opportunity in radiation therapy. Also, there is excellent follow-up and assurances that the dosimetry services will become self-supporting as third party payments take over some of the costs. The excellent relationship of this program to existing chemotherapy and other cancer programs in Puerto Rico was noted, Finally, the Review Committee agreed that the cooperative group effort in the national program will be furthered by having this program console avéilable. a sceptics nmeent fa ma The addendum prepared as a result of the revised budget covers mainly the professional support at $27,876 for a half-time radiotherapist and a half-time radiological physicist. One dosimetry and contour techni- cian will be required the first year, and an additional one the second and third years for Ponce and Mayaguez, The equipment costs are mainly for the first year, with minor expenditures to add the two satellites in Ponce and Mayaguez the second and third years. The program console, isodose plotter and the simulator unit showld be considered as a whole, Commensurate with previous recommendations, the site team recommended, and the reviewers concurred that RMP support be limited to no more than 50 - 75% of this request, with the balance to be contributed from local sources. Further, the Review Committee endorsed the recommendation that income generated during the three years of support should be put in escrow in order to regain some of the personnel and main- tenance costs. Cost sharing aspects will be investigated by Dr, Marcial and Dr. Colon. On the basis of the well-planned regionalization aspects of this project, its excellent professional direction, its future self-supporting feature, and its role in the broadly—based cancer program for Puerto Rico, the Committee recommended its approval. Recommendation: Approval 1 - Conditional upon: (1) submission of a revised request which will incorporate the additional equipment © and increase in percentage of effort of professional personnel as referred PUERTO RECO RMP -6- RM 00065 7/70.1 é f to above; (2) plans for phasing of the project - organizing and de-bugging the first six months, adding Ponce and Mayaguez commensurate with the project's progress; (3) plans to obtain some (25% - 50%) local support for the program console and related equipment; and (4) the region's plan for managing funds accruing to the grant to be used to help offset maintenance and personnel costs. First Year_. Second Year Third Year $160,936 $67 ,436 $73,636 © SUMMARY OF RECOMMENDATIONS Project 01-Year 02-Year 03-Year #9 $160,000 $160,000 $160,000 #10 112,163 135,741 165,214 #11 160,936 67,436 23.636 Total $433j099 $363,177 $398 ,850 RMPS/GRB/7/15/70 A PRIVILEGED COMMUNICATION RM 00065 SITE VISIT REPORT PUERTO RICO REGLONAL MEDICAL PROGRAM May 17-19, 1970 REVIEW COMMITTEE Henry M. Lemon, M.D., Chairman, Professor of Medicine, University of Nebraska, Omaha, Nebraska CONSULTANT William S. Fields, M.D., Professor of Neurology, University of Texas School of Neurology, Houston, Texas RMPS_ STAFF Jessie F. Salazar, Public Health Advisor, Grants Review Branch Frank Nash, Public Health Advisor, Programs Assistance Branch _ REGIONAL ADVISORY GROUP Hector F. Rodriguez, Chief, Department of Medicine, Ponce District _ Hospital, Ponce, Puerto Rico Praxedes Norat, Department of Health, San Juan, Puerto Rico PUERTO RICO REGIONAL MEDICAL PROGRAM Adan Nigaglioni, M.D., Coordinator, Chancellor, Medical Sciences Campus, University of Puerto Rico Christino R. Colén, M.D., Associate Coordinator Merlin D. Lugo-Faria, M.D., M.P.H., Associate Coordinator-Health Services Orlando Nieves, Administrator ‘ Marta Tejada, Social Investigator Norris Blake, Director, Office of Information Project #9 - Inter-Agency Cooperation to Combat Cancer in the Ponce Region Hamlit Hazim, M.D, Jose N. Correa, M.D. Raul Armstrong M.D. Jorge Garcia Guzman, M.D. ‘ William Bracer, M.D. Joaquin Robira, M.D. Project #10 - Community Family Prevention Program on Stroke Carlos Armstrong Ressy, M.D. > Luis P. Sanchez Longo, M.D. Project #11 - Computerized Dose Distribution Victor M. Marcial, M.D. Theodore Villafdia, M.D. A PRIVILEGED COMMUNICATION RM 00068 SITE VISIT REPORT PUERTO RICO REGIONAL MEDICAL PROGRAM May 18-19, 1970 BACKGROUND: The first supplemental operational application, composed of three new projects was submitted for eeview by the February/ March 1970 cycle. The reviewera(Technical Panels, Review Committee, Council and Staff) found the application better than the previous ones in documentation and direction toward major health problems in Puerto Rico, as identified by a previous site visit in September 1969. The application was found to be well-phased with other operational components and based on a ten-year health planning program for the Island. There were a number of areas on each of the three projects, however, that raised a number of questions. In some instances, the budgetary requesk8 seemed over-ambitious (Project #9, Ponce Cancer Program). This project seemed to be too all-inclusive for present available med- (geal and allied health personnel in the Ponce area, There were other concerns about the evaluation program. Deliberations about Project #10, Community Family Prevention Program on Stroke also raised some perplexing questions regarding the budget. The proposed phasing of the program may present some burdems in terms of available manpower, Other problems inherent with the organization for such a program were noted, as well as how the region plans to go about the health evaluation por tion. In view of the findings of the previous site visit and the recommendation of the National Advisory Council which evaluated the region's first pper- ational proposal in December 1969, this project was conditionally approved with authority delegated to a site visit team to review all concerns and questions raised by the reviewing bodies and recommend an appropriate amount to be awarded. The final project (#11) for a Computerized Dose Distribution, Calculation and Radiotherapy Program, also presented some questions, some of which were technical and others largely concerned wWfith insufficient budgetary documentation. The application received a recommendation of "Deferral" for a site © visit to investigate and clarify all of the concerns of reviewers. Pro- jects #9 and #11 must be re-submitted to the review cycle of June/July 1970. Project #10, conditional upon appropriate alterations in budget and program as recommended by the site visit team, will be awarded from FY 1970 funds. GENERAL: The site team met first at the regional | headquarters with Core staff. Both Doctors Nigaglioni and Colon reported on recent developments in the region and gave an updating of the operational program. The region has continued to refine its organizational framework with the PUERTO RICO RMP -3- RM 00065 establishment of new Task Forces and by adding four new Regional Advi- sory Group members, all representative of the health consumer, These are an industrialist from the Ponce area, and insurance executive, a banking executive and an attorney. Insufficient recruitment still exists in the lay power structure for RMP RAG members, and sub-committee members. The private medical sector in San Juan seems quite inactive in planning or participation. Indus- trial medical facilities developing at the Phillips plant and the Chem-strand plant at Guayama appear to be outside of RMP operational planning. In Ponce, there is excellent lay liaison through the Oncologic Clinic, supported by the southern branch of the P.R. Cancer Society, and through Dr. Rodriguez’ remarkable cardiovascular and renal dialysis and transplant program which has wide and enthusiastic public support (750+ dialyses for 35-40 patients in the past 2 years). The excellent private medical sector support and participation in Ponce district projects is quite different from the capital area indifference and argues for strong development of the RMP projects in this area. Dr. Colon has developed more and more effective planning for RMP program outreach beyond the P.R, Medical Center area, a real achievement in view of the centralization of private and university-based medical resources in San Juan, and the physician deficiency outside of San Juan. We were all impressed by the development of major interest and enthusiam of lay and medical leadership in Guaynabo, Ponce, and to a lesser extent in Guayama, Dr. Nigaglioni, the official coordinator, is more and more a background figure but very valuable for his present planning for health aides a" allied health training in some of the Commonwealth's junior colleges such as at Ponce, Dr. Colén has much of the responsibility for maintenance of enthusiasm for RMP planning and projects, which declined with recent budget cuts and delays in funding. Dr. Correa in Ponce will become, along with Dr. Hector Rodriquez, major allies in RMP work on a regional basis, particularly since they are truly full-time physicians in their institutions in areas of cancer and heart disease. The nursing profession is still being slighted as an ally in health plan- ning, in traineeships, and in operational programs as instructors. It is suggested that the next site visit include a nursing educator to see how the traditional attitude of doctors towards nurses in P,R, can be changed. Mr. Norat, representing the Department of Health, expressed an interest in the training of health aides, since the Department is not budgeted for — such training. The high school graduate is Puerto Rico's largest source of allied health manpower. Another general issue raised by the site team was the desirability of broadening, where possible, operational programs so as to effect a multi- disciplinary approach, For instance, the Cancer Registry project could, once organized and running well, be broadened to include other diseases as a collaborative effort. Also, training programs should have some indentifiable common base which could be adapted to new areas and programs. PUERTO RICO RMP -4- RM 00065 The Model Cities and Family Planning Programs have been involved in plan- ing for training of home health aides for the projects under review and the team heard about a proposed program in nutrition which is being planned jointly with the Model Cities program, and a similar nutrition program for rural areas. If the present three proposals are funded, it would seem that the next 18 months will be critical for the success of the PR/RMP, since they will have to develop the operational aspects of 11 projects involving $1,200,000 annual budget. It is believed that a ceiling has already been reached, for the involvement of 50 - 100% participation of physicians for the leadership and development of these programs, Plans which look excel- lent on paper appear unrealistic when one views the limited physician participation in "full-time" Health Department or University activities, compared to their splintered individual private practice efforts into which costs of hiving have forced most of the professors. Dr. Colon and Dr. Nigaglioni are trying to develop group family medical practice, initially in the Guaynabo area, in order to develop more continuity of medical coverage, in both private and public sectors of medicine, Future site visitors must carefully evaluate whether salaried time on the job in RMP programs are really being effectively applied by named participants. Dr. Lemon and Dr. Fields consulted with Dr. Anatol Raventos in Washington D.C., with Dr, Paul Meadows of the Eppley Radiation Center in Omaha, with Dr. Giulio D'Angio, of Memorial Hospital for Cancer and Allied Disease, and with Marilyn Stovall, M.D, Anderson Hospital subsequent to the site visit. All consultants agreed that additional half or full-time assistance for radiation dosimetry would be equally as important as the program console, The latter is important chiefly in training and in improving the flexibility of planning radiation therapy. Miss Stovall stated that her institution has been programming for the Puerto Rico radiation facility for sometime. In her opinion the console requested by Dr, Marcial is sophisticated and will need large computer back-up, which is available. Project # 9 ~ Community Approach to Combat Cancer in Ponce. This project was reviewed by the site visit team on the second day of the visit in the Ponce Oncologic Hospital, the Damas Hos- pital and the Santa Rosa Hospital in Guayama. The team met first with the Program Director, Dr. Hamlet Hazim and the Program Coordinator, Dr. Jose N. Correa, and other members of the staff, The hospttal has been occupied three months, and it was pointed out that the facility resulted from ninetéen years of planning since he took over the responsibility for the cancer program in the Ponce District. © PUERTO RICO RMP -5- RM 00065 The Program Director is a very vigorous and active young man, who is dedicated to making the project an effective one. The Ponce Oncologic Hospital, which is situated across the street from the Déatrict General Hospital in the Medical Center, provides an excellent fo- cal point for the management of all forms of cancer in a multidisciplinary fashion in the southern part of the island of Puerto Rico, It was pointed out that the request to RMP is for support of training and not service, Dr. Armstrong, & surgeon, noted that the courses will be aimed at physicians who are working at health centers, To the question of where the project directors would place priorities for the program, the responee was first for professional (medical) persone nel and then on the training and education of the public. The planners view the gap between professional evaluation of cancer and the beginning of treatment as crucial, and it is hoped to give general practitioners, theough such training, an opportunity to do more "specialized" treatment, They pointed out with obvious feeling and justification, that if such a program in early diagnosis in cancer detection is initiated, some means of treating the increased load which would be generated must be provided. other at the Santa Rosa Hospital in Guayama have been identified, A third, on a partetime basis, would be located within the Oncologic Hospital Clinic itself, This is a lady physician (Dra, Whitney) who has not practiced for some years, but now that her family is grown up, she would like to become more active. The surgeon, Dr. Axmstrong, will devote 20% time to the pro- ject, Also present was Dr. Garcfla, who is involved in the hematology project ($2) which is pperational., Rounding out the program is a pathologist, who 4a located at the laboratory in the Damas Hospital, the radiologist, and the head and neck surgeon, An executive secretary is also requested, and support for an Administrative Coordinator of activities of this cooperative endeavor, The gentleman is already identified and was the administrative officer who was actively involved in planning of the Oncologic Hospital. © Two general practitioners, one to be located at the Damas Hospital and the The site team is of the opinion that the inclusion in the nonprofessional staff budget of a number of full-time individuals seems illogical at this point, since it will take quite a while to get a program of this nature staffed and underway, Furthermore, the eleven family health workers who are listed at 100% would be better designated as trainees, since this is the true purpose of their involvement. The team learned that the University of Puerto Rico has started a regional Junior College in Ponce and that construction is already underway. It is anticipated that from eighteen months to two years will be necessary for completion of the first units and that such a facility could be PUERTO RICO RMP -6+ RM 00065 integrated into the teaching efforts that could be a resource for training of technologist@and therapist assistants. A tour of the facilities led to some discussion of some alteratiomof a room adjacent to the operating suite which could be used for minor sur- gery. This appeared to be feasible and practical to the site team. The need for a 250 KV therapy unit was broached and it was pointed out that the available unit loeeted at the Damas Hospital is quite ancient and inadequately housed, There is auch a unit in the Oncologic Center in San Juan and presently not being utilized by Dr. Marcial and his group. The region will explore the possibilities of transferring this unit to Ponce, even temporarily, for more effective use, Thé site team visited the Damas Hospital in Ponce, where it was learned that the present facility is over fifty years old, with every square inch utilized. A new building, now under construction is expected to be ready for occupancy by the end of 1971. The Pathology Laboratory, whose Dir- ector is a partidipant in this project, is modern, spacious and appeared to be well-administered. After finishing the portion of fhe site visit located in the immediate Ponce area, the site team drove to Guayama, which is about an hour's dtive from Ponce, to visit the Santa Rosa Hospital, This is a modern facility which was recently renovated and repainted, The Outpatient Department and ite laboratory facilities seem to be understaffed and underutilized, On the other hand, of the 45 inpatient beds, 40 were occupied and nurses actively engaged, The building is well-designed go as to permit nurses easy access and sight of activities. It was learned from Dr, Garcfa, the director of this hospttal, that a large plant was recently opened by the Phillips Petroleum Company, and another by their subsidiary, Fibers International. This complex has a prepaid medical plan and is presently working out arrangements with this hospital, Dr. Garcia feels that once the program for cancer detection . and early diagnosis is underway, some patient care costs could be defrayed through a third party payment plan. Although most of the effort at the beginning will be directed toward private or part-paid patients, it is hoped that as the program becomes more effective, it will have an outreach into surrounding rural areas . where some of the indigent patients could be contacted and brought in for examination, This is the function earmarked for the two home health aides. The budget appeared to be unrealistic ($300,000) for the first year in view of the time that will be required to get such a project underway. The justification for she number of nurses, stenographers, social workers, health educators, etc., is difficult. It is questionable whether such a group of pedple would be necessary béfore the third year, On the other hand, the health educator and the group of family health workers (who should be considered as trainees rather than full-time employees) will be essential during the first year, It is doubtful, however, that eleven ean be recruited immediately, PUERTO RICO RMP -J- RM 00065 One health educator would seem to be sufficient for the first year, and once the project is moving, a second one at the Guayama Hospital would be advisable, During the first year, it seems unlikely that more than 50% of one social worker's time would be utilized, but daring the second and third years, should probably be full-time. One question was clarified during the budgetary discussions, The request for consultants, which appeared exeessive, are in fact instructors to be utilized in training programs, and the site team recommended that they be so designated on a part-time basis. It is believed that $5,000 will be suffieient for the first year for such clinical instructors, and approxi- mately $10,000for consultants in other specialties such as urology, etc. Consultant fees at the Damas and Santa Rosa Hospitals are justifiable provided they are engaged as part-time instructors. As for the equipment budget, the suggestion was made that an attempt be made to get partial support from other local sources, The team recommended that support for either purchase of rental of the 250 KV unit be reduced to 50% of the request. This does not imply that the early detection and diagnosis aspects would not be enhanced by such equipment--rather that local sources should be tapped for at least half the amount. The same rationale applies to the equipment for use in the minor surgery suite once the alterations have been accomplished. The laboratory services request, which includes routine work, biopsies, etc., was recommended at a reduced level, as were budget requests for travel, publication costs for printing educational material, and office supplies. Materials for the clinic, alteration costs, telephone and rental of infor- mation center offices are reasonable and necessary for a program of this magnitude, The visitors recommended that every effort be made to bring in trainees, not only from the Ponce and Guayama districts, but also from outside these areas, with the expectation that they would return to their locales and provide some outreach, It was also recommended that some attempt be made to integrate the educational efforts of this project with the stroke pro- ject. This could be the means of holding the physicians’ interest for a longer period and on a continuing basis, as well as utilize some of the available talent in the adjoining District Hospital, This would include Dr. Rodriguez, Director of the Cardiovascular Service and Dr, Garreras, the full-time neurologist, both of whom have been involved with RMP planning for the Ponce area. Another indication of the interest of the Ponce District Medical Association wag demonstrated by the presence of the President at the initial meeting with the site visitors, With the available group of vigorous physicians and surgeons in Ponce, the time is probably ripe for the development of a more comprehensive continuing education program for physicians, allied health personnel and, in particular, nurses. There has been an undercurrent of resentment on the part of Ponce physi-~ cians that major RMP attention has been directed toward university-centered PUERTO RICO RMP ~8- RM 00065 activities in San Juan to the neglect of needs of physicians around the periphery. Notable expeptions to this are Doctors Hazim and Correa who attest to the excellent liaison arrangements that do exist between the Ponce group and the San Juan headquarters. This is attributable to the dedicated efforts of Dr. Christino Coldén, who was born and brought up in Ponce and knows that area well, He knows personnally many of the doctors there and enjoys a good working relationship with them, The site team was désappointed that there was no representation of the local Cancer Society or of the nursing group. The regional representatives assured the vistors that the Cancer Society is indeed wery much interested in the project and were in fact largely responsible for the planning and development of the program and the new Oncologic Hospital. It was evident that the District Medical Association is supportive of thés project and is engaged in the development of a unified District medical library which will be organized in collaboration with the Catholic Univer- sity. Provision will be made for 250,000 volumes. There is an established tradition in Peerto Rico in the field of Oncology and it would appear that this is now being translated into a sub-regionali- zation of the Regional Medical Program, This is emerging in the Cancer Chemotherapy Hemotology Program, in the Radiation Therapy Program, with: the introduction of new methods in radiation physics and in the Early Diagnosis and Cancer Detection program on the south side of the island, Hopefully, within the next two or three years, there will be a greater degree df cooperation in these ventures with a resultant impact on the cancer problem, The site team agreed that this project should generate interest in the centralization of the radiation therapy efforts on the southern side of the island, The effort on the part of Dr. Correa and his staff to upgrade patient care in this field should permit private patients, a8 well as indigent ones, a better means of receiving proper treatment. In this event, it is likely that private radiation therapists, most of whom are trying to do both diagnosis and therapy and having difficulty in doing both, would be likely to get out af the therapy field and devote their attention to diagnosis. Project #10 - Community Family Prevention Program on Stroke and its Incapacitating Complications. The site visit team visited the Guaynabo District Health Medical Center in the afternoon and met with project directors, the medical director of the center, the Mayor of Guaynabo and other staff. It was pointed out by the site team that this proposal had progressed through the review process to the National Advisory Council, where a conditional approval was given in a reduced amount of approximately $100,000, to be based on further review by a site visit team. The proposal involves the establishment in the Guaynabo Health Center an eight-bed stroke unit to which patients from the area could be admitted, and, if necessary, transferred from there to the university hospital for PUERTO RICO RMP -9- RM 00065 further diagnostic evaluation. The Guaynabo area has a population of between 80 to 90,000, representing considerable spread in economic status, There are some indigent patients, some middle class and some fairly wealthy people in this community situated about 10 miles from San Juan. Dr. Luis Sanchez Longo gave an overview of the project including its progress since its submission. Complicated cases identified in Guaynabo will be sent to the university hospital, where every effort will be made to get them started on a rehabilitation program and sent back to Guaynabo for long term care and follow-up. It was evident that Dr, Sanchez Longo was thinking first of the improvement of his program within the University Hospital and secondarily- of the sateliite health center. He introduced the subject, but emphasized the need for improved facilities in the x-ray Department. In addition to a neurological screening clinic to be held daily in the morning at the university hospital, a similar clinic will be held in Guaynabo on Monday afternoons. In discussion of the required personnel, it was difficult for the site team to understand the roles of the requested staff, It was learned that a young neurologist, Dr. Hector Casas, ,who will finish his training this month, will be going to Houston about July 1, to spend a year for further training in cerebrovascular disease. He will then return to Puerto Rico, where he will be affiliated with the project. The site team found difficulty in seeing how one year's training in techniques he will learn in Houston will be applicable to the Guaynabo project, but on the other hand, he could be very useful in the university stroke program. Dr. Sanchez Longo reported on additional contacts made with agencies in the San Juan area to assist in creating the concept of such a stroke center in the community. There are eleven neurologists in Puerto Rico, all in San Juan except Dr. Carreras, who lives and practices in Ponce, In an attempt to get physicians involved, one day symposia are planned for intensive training in stroke, In the discussion about continuing education, it was evident that the project directors and other physicians connected with the program were thinking mainly in terms of physician education, albeit the application includes a curriculum for training of allied health personnel. While the request would appear adequate for a stroke unit on a 24-hour basis, they have not addressed the problem of getting people trained to offer some kind of service to the community at large. The project directors were receptive to the suggestion that the four practical nurses and four nurse assistants be considered as trainees rather than permanent personnel. They could be given on-the-job training and rotated at whatever interval the doctor in charge feels is appropriate for them to obtain sufficient knowledge to be useful as home health aides. Over the period of time that the site visit was in Puerto Rico, traveling and working closely with the Program Coordinator and the Associate Coor- dinator and other Project personnel, the concept of the Guaynabo project PUERTO RICO RMP -10- RM 00065 as a pilot training center, to which other areas in the island could look as a stroke resource, came more clearly into focus. The site team is con~ vinced that Guaynabo would provide an excellent area for such a pilot study. This will be impossible however, without some readjustment in the present plan and without dedicated direction. The region has identified such a person--a lady physician--Dra. Lluveras. She was unable to be present, but was represented by Dr. Lopez. The site team learned that there are about 15 physiatrists in Puerto Rico, two of whom are in Mayaguez and two in Ponce. One resident is committed to join the program upon completion of his training. There is a desperate need for aides to physiatrists in various parts of the island, During the site team's visit to the Santa Rosa Hospital in Guayama (Project #9 - Cancer Program for Ponce), an entire area in the basement of the hospital was equipped for physical medicine and rehabilitation. All of the expensive equipment has been pushed over to one side to make room for storage. In this instance the Director of the Hospital indicated that he had had two physiatrists who had been coming out on a part time basis from San Juan, but gave up because he could not get any help from occupational or physical therapists. While the site visitors were in Ponce the subject was discussed with Dr. Carreras, a neurologist who had submitted a stroke project in the first operation application which was disapproved, Dr. Carreras, appeared to be very upset about the disapproval, It was explained to him, however, that he should endeavor to work out a regional plan in collaboration with the project in Guaynabo, with the assistance and coordination of Dr. Colon and his staff. It seems reasonable to anticipate that the train ing of one or two aides from the Ponce area would make a significant con® tribution to Dr. Carreras’ ability to mount a stroke program, Dr. Carreras seemed pleased and receptive to this suggestion. The site visit team toured the facilities at the Guaynabo Center which had been open for three months. There did not seem to be much activity~-at about 3:00 P.M. on a Monday afternoon, There were no patients in the out-patients department and very few in-patients. The plan for an eight-bed unit seemed unrealistic to the site team, From population statistics and available manpower, two or three beds could be kept filled and this would seem more feasible, The site team had difficulty in assessing this project in terms of the budget request. Guaynabo is an ideal location for this program, where patients can be found, brought into the clinic and some attention directed to the management of the problems of hypertension and of the stroke patient. Optimal opportunities exist for rehabilitation which would be possible in this setting. Evidence of the interest to the community was demonstrated by the presence of the Mayor throughout the entire proceeding. He indicated that he is most anxious that his program get underway at the earliest possible moment. Also, the Mayor reported that the Municipal Government PUERTO RICO RMP -ll- RM 00065 of Guaynabo will operate an Emergency Services Program which will be coordinated with this stroke proposal; minibuses will be provided by the city for such emergency services, The question of funds accruing to the grant from other sources, which would free some monies for use elsewhere in the grant was discussed. For instance, the trainee stipends recommended could be utilized elsewhere, Another idea which the Coordiantor will pursue is training aides for private nursing homes. He stated that such training is nonexistent in Puerto Rico and that care provided by such long term care facilities is inferior. The site team recommends that RMPS staff examine whatever plan the PR/RMP decides upon, within the framework of the revised budget as recommended by the site team and already submitted, and further, that a technical site visit be made during the first year of operational status of the project to see what progress has been made in its development along the lines suggested by the visitors. The team believed that it is essential to the success of this program that it be initiated along the lines discussed with the project directors. Otherwise, it will probably not achieve the goals and objectives the region envisions for it. Project #11 - Computerized Dose Distribution Calculation in Radiotherapy Treatment Planning. This project was presented by Dr. Victor M. Marcial, who is the.director., The application was considered in light of the Ad Hoc site visit evaluation on Radiation Dosimetry Services, The Puerto Rico Nuclear Center has had centralized services in association with the cancer hospital since 1966, It also serves the Virgin Island. The three main services are now amalgamated--education, research and radia- tion therapy, under the direction of Dr. Villafana, who is a medical physi- cist. The AEC support has diminished to the point that the Center can no longer make long range plans, In addition to serving two-thirds of the island, which represents approximately 1,300 cases a year, ten medical students are trained each year, and a varying number of radiology technicians and physicists. Dr. Marcial's group has been active in developing a network of radiology centers in Puerto Rico--eventually there will be three such centers--in San Juan, Ponce and Mayaguez. At present they do not have the personnel to staff all three, The new group will be using an interdisciplinary pro- gram--chemotherapy, radiation therapy, surgery, etc. The Dosimetry Services Program will provide a teaching opportunity in radia- tion therapy not only for local trainees, but those outside the San Juan area as well. Cooperative arrangements are under negotiation with the groups in Mayaguez and Ponce, Between the time of the submission of the application and the site visit, Dr. William Powers, of Washington University, representing the American College of Radiologists, visited Dr. Marcial for several days. It was on Dr. Powers’ advice that the application was revised to include additional PUERTO RICO RMP -12- RM 00065 equipment in the form of a simulator unit, and an increase in percentage of effort of project staff. This addendum was presented for the site team's consideration. Dr. Powers recommended that, instead of five part-time radiotherapists, one half-time radiotherapist and one half-time radiation physicist would be more appropriate, The site team concurred that this would be far more realistic. For the present, Dr. Villafana will assume the function of radiation physicist. It was also learned the following day in a succeeding discussion of this project with the Director of the Oncologic Hospital, that he would also lean very heavily on Dr. Marcial for assistance in radiation physics. The addendum prepared as a result of the revised budget covers mainly the professional support at $27,876 for a half-time radiotherapist and a half-time radiological physicist. One dosimetry and contour techni- cian will be required the first year, and an additional one the second and third years for Ponce and Mayaguez. The equipment costs are mainly for the first year, with minor expenditures to add the two satellites in Ponce and Mayaguez the second and third years. ‘There was discussion concerning the computer usage via a telephone link to Mayaguez. The programs have apparently been written (La Jolla, California) although it was unclear what language was being used, and whether the plan was compatible with the IBM 360-40 system which is presently in operation in Mayaguez. It would seem reasonable to expect that programs are available for this purpose, but it did not seem that a sufficient amount of considera- tion had been given to the matter of how the software would be compatible with available hardware. The requested program console is already in use in thirty radiation therapy centers in the U.S. ‘There was a meeting attended by Dr. Villafana of users of this console recently. Dr. Villafana feels that the console would enhance considerably the capability in terms of patient load and the ability to produce information about dosimetry at a lesser cost and more rapidly, The Puerto Rico group will be part of a national cooperative which will evaluate this approach to radiation therapy. When questioned about the relationship of this program to the chemotherapy and other cancer therapy program, Dr. Marcial pointed out that during this particular visit he was wearing one hat, while on another day, he might well be wearing another. As Director of the Medical Services in the Oncologic Hospital at the Medical Center, he is responsible for directing all forms of cancer therapy, and all endeavors in cancer will be integrated, Dr. Marcial made it clear he was not going to evaluate a comparison between radiation therapy and chemotherapy, but rather evaluate split dosage where he would treat, then wait a while, then treat again. He believes he is in a better position to advise at the end of a specific period than to try to do too much in all of the fields. PUERTO RICO RMP -13- RM 00065 © The application was reviewed in terms of the seven points agreed upon by the Ad Hoc Group to Consider Projects of Radiation Dosimetry Services (appointed at the request, of the National Advisory Council, February 1969, and chaired by Dr. Michael Brennan). More cancer patients will probably receive better isodose distribution with the program console, The service will provide a teaching opportunity in radiation therapy. There already exists a coopera- tive arrangement among Ponce, Mayaguez and San Juan in radiation therapy. There is excellent follow-up in Dr. Marcial's treatment program, Dr. Marcial assured us that the dosimetry services will become self-supporting as third party payments take over some of the costs. In the beginning only two institutions will be participating across the island, Also, the site team believes that Dr. Marcial's cooperative group effort in the national program will be furthered by having this program console available. The program console, isodose plotter and the simulator unit, should be considered as a whole, Commensurate with previous funding, the site team believes that RMP support should be limited to no more than 50 - 75% of this request, with the balance to be contributed from local sources. Further, income generated during the three years should be put in escrow in order to regain some of the personnel and maintenance costs, The readjustments in the budget, incorporating those items to be retained from the original budget and those changes suggested by Dr. Powers, as well as the site team, were discussed fully with Dr, Marcial. The cost sharing aspects will be investigated by Dr. Marcial and Dr. Colon, © On the basis of the well-planned regionalization aspects of this project, its excellent professional direction, its future self-supporting feature and its role in the boradly based cancer program for Puerto Rico, including professional and technical training, the site team recommends approval on the basis of a revised budget as discussed with the Project Directors and Program Coordinator. SUMMARY OF RECOMMENDATIONS Project Amount Requested(d.c.) Amount Recommended (d.c.! #9 - Cancer/Ponce $335,173 $160,000 #10 - Stroke/Guaynabo 194 ,403 112,163 #11 - Computerized Dosi- metry 161,000 160,936 TOTAL $690,576 $433,099 © RMPS/GRB/7/15/70 ce REGIONAL MEDICAL FROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) SOUTH CAROLINA REGIONAL MEDICAL PROGRAM RM 00035 7/70.1 Medical College of South Carolina June 1970 Review Committee 80 Barre Street Charleston, South Carolina 29401 Program Coordinator: Vince Moseley, M.D. Requested Program . , Period lst Year 2nd Year 3rd Year TOTAL Direct Costs $454,769 $409,767 $497,988 $1,362,524 Indirect Costs 88,232 108 , 408 122,539 319,179 TOTAL $543,001 $518,175 $620,527 $1,681, 703 History: The Region's initial planning year began on January 1, 1967 and was supported by two awards totaling $123,527 (T.C.). An award of $379,246 (T.C.) was made for the. second year of planning 1/68-12/68. The Region became operational on August 1, 1968 following the submission of 20 projects and a site visit in April 1968. An award of $931,507 (T.C.) was made for support of seventeen projects. Shortly thereafter, two core awards totaling $559,342 (T.C.) were made to continue planning activities during the 03 planning year (1/1/69-12/31/69). Supplemental applications consisting of 10 new projects, #21-#31 excluding #27 which was withdrawn, were considered during the February 1969 Review Cycle and deferred for a site visit. The site visit was conducted in May 1969, All ten projects, plus two supplements to ongoing projects #15 and #16, were returned to the May 1969 Review Cycle. Both Committee and Council actions were consistent with the recommendations of the site visitors. Six projects were recommended for approval, two for non-appr oval and two for revision. The requests for supplemental funds for project #15 and #16 were disapproved. In July 1969 staff reviewed the continuation application for the 02 operational year which requested continued support for fifteen of seventeen originally funded projects. As a result of that review and a subsequent request for use of unexpended funds to support approved but unfunded projects, the Region was awarded $1,066,091 (d.c.). Of this, $202,256_ (d.c.) was awarded core for the seven-month period 1/1/70-7/31/70, $843,835 (d.c.) was awarded for 15 ongoing projects for the period 8/1/69-7/31/70 and three approved but unfunded projects for the period 11/1/69-7/31/70. This award served to incorporate planning and operational funds into one grant period. An application including two new projects was reviewed during the August Review Cycle, but neither project was approved. SOUTH CAROLINA Regional Medical Program -2- RM 00035 7/70.1 The Program Coordinator is Vince Moseley, M.D., who has served in this position for approximately 1 year. The RAG consists of 65 members, largely physicians, of which 20 represent the 10 districts designated by the South Carolina Medical Society. The Hospital Association has strong repre- sentation with six representatives. There are 15 Members-at-Large consisting primarily of M.D.'s and what appears to be other professionals. Apparently these people represent the consumer interests. Minority group representation is not identified, however, itshould be noted the site visitors in April 1969 cited minority group under-representaticn as a concern. The regionalization process is proceeding as scheduled with area program development offices being opened recently in Columbia, Spartanburg and Florence. Each office is staffed by a part-time coordinator and a full-time secretary. See attachment for summary of projects currently being supported and status of projects not funded. Background of Present Application Of the three projects in this application, two were considered during previous Review Cycles and were returned to the Region for revision and resubmission. The first, Project #36 - Chronic Respiratory Disease Training Program, was returned as a result of Committee members' belief that the project was rather unrealistic and global in its plans. They questioned the capability of the institutions to do all that they proposed. The educational impact was considered poor and the curricula for the professional trainees not clearly defined. Some doubt was expressed as to the qualifications of the personnel to be involved in the development and operation of a two-year program in inhalation therapy or to carry on continuing education for other professions involved. The equipment requests were considered unreasonable and unnecessary for either teaching or providing service. There was an obvious lack of coordination with Schools of Allied Health which also provides Inhalation Therapy Training. The Committee had learned that the State Department of Health had submitted a similar project to the Atlanta PHS Regional Office for 314 E support which had been disapproved. It was recommended these agencies get together. Project #37 - Coronary Care Risk Factor Educational and Screening Project was returned because of Committee's concerns over the following points: 1) the amount of $8.50 for laboratory services was considered excessive. It was advised the applicant look for more competitive services such as those provided by United Pathology Laboratories of Portland, Oregon; 2) who would benefit most by the project, the physician who receives the patient or the general public? 3) would a survey for hypertension be a preferred method to that outlined? The Committee believed the proposal required extensive revision, including documentation of the relationship to existing cardiology clinics, more adequately delineated follow-up procedures and a description of the plan for community out-reach. Furthermore, the patient did not appear to have continuous identity. It was noted there were physician and patient educational benefits, but no provision for follow-up or of controlled Therapeutic Trial. RENT ag te, OE, SOUTH CAROLINA Regional Medical Program. -3- RM 00035 7/70.1 Present Application Requested Project #35 - Comprehensive Coronary Care Program for Community First Year Hospitals in the Central Subregion of South Carolina. $106,900 The ultimate goal of this project is to improve the care of patients with acute coronary disease by developing intensive coronary care services in community hospitals of the Coastal Subregion. During the first year four unspecified hospitals will be enrolled and an additional four hospitals will be enrolled the second year. By the end of the third year, the coronary care programs should be well established and self-perpetuating. Eligible hospitals, with the assistance of SCRMP core staff, will develop a comprehensive coronary care plan. Training courses in the comprehensive programs wiil include: Hospital-wide CPR Training, conducted through the SCRMP CPR project of the South Carolina Heart Association; Coronary Care Nursing Supervisor Training, conducted through the SCRMP Coronary Care Nurses Training Program of the University of South Carolina School of Nursing; Coronary Care Familiarization Training for Nurses, organized in each hospital and assisted by core staff; Individualized Training for Coronary Care Medical Directors, provided by the Division of Cardiology at the Medical University; In-Service Continuing Education for Coronary Care Nurses, assisted by core staff and University's Coronary Nurses Train- ing Program. Communication systems will be established for consultation of EKG transmission, linking each participating hospital to the Coronary Care Unit at the Medical University Hospital or other major hospitals having a comparable well established CCU. A proposed patient registry is to provide the data required for evaluation of the effect of the program on patient care. In addition evaluation plans are provided for the educational program, communications systems, impact on patient care and for Cost/Benefit Analysis. The major items of the $106,900 first year budget are personnel, $84,900, and arrhythmia monitors and EKG strip recorders, $15,000. Second Year: $120,173 Third Year: $107,857 Requested Project #36 - Comprehensive Respiratory Disease Training Program. First Year This, the Region's first respiratory project, proposes $179,487 the establishment of a central laboratory/educational facility at the Charleston V.A. Hospital to be used in conjunction with existing hospital-based facilities for demonstration of care, diagnosis, and management of patients with pulmonary disease. It will provide a focal point for training of physicians and allied health personnel in addition to working with patients who have pulmonary disorders and offering an interim state-wide pulmonary referral base for community hospitals until they develop capacity for adequate programs of their own. A comprehensive classroom facility will be developed as the SOUTH CAROLINA Regional Medical Program ~4- RM 00035 7/70.1 initial phase of a state-wide educational program. The facility will have at its disposal 8 beds in an adjacent wing of the V.A. Hospital and beds at MUSC Hospital, and will accept patients from throughout the State with all types of pulmonary disease excluding active TB. Since many of the patients entering the unit will have respiratory failure, there will also be 2 beds in the existing intensive care facility with special monitoring facilities for respiratory failure. Within the unit will be developed two classrooms, 4 complete pulmonary function laboratory, an inhalation therapy service, and pulmonary medicine service. The present out-patient program of the hospital will be located here. Patients will be admitted from unspecified sources to either out or in-patient services regardless of financial status. Third party payment of fees will be disposed in accordance with policies of DRMP. The project will implement over 4 three-year period a five-point segmented educational approach: 1) In-Unit Educational Programs will be offered physicians, nurses, inhalation therapists, and pulmonary technicians; 2) staff will make lecture visits to institutions and groups within each of the 10-state planning districts; 3) upon specific invitation, project staff will be available to visit and consult with any hospital concerning establishment, improvement, or evaluation of pulmonary services at the institutions; 4) annual seminars will be held for physicians, nurses, inhalation therapists, and pulmonary technicians to cover the latest developments in the area of respiratory disease, 5) a Data Transmission Network will be established linking community hospitals, physicians' offices, and other interested organizations, agencies, or institutions into a computer atthe central program facility to provide immediate patient consultation services. Project evaluation will be carried out through the appointed Respiratory Disease Evaluation Committee which will receive all evaluation data, site visit the project at least once a year, and meet in a body during the tenth month of each project year to determine if the project is fulfilling objectives completely and at the projected rate. Second Year: $93,156 Third Year: $196,361 Requested Project #37 - Coronary Risk Factor Education and Screening First Year Project. This project is designed to apply methods $168,382 for identification and reduction of coronary disease risk factors through project services which include specific screening proce~ dures designed to cover large groups, project operated education/ action programs, referral to family physician, referral to State clinics and follow-up of high risk individuals. The basic concept involves opening an operations center at the University of South Carolina to initiate project services and to serve as a focal point for expansion of project services to a state-wide basis through establishment of satellite centers, and mobile screening teams. The operations center will maintain its own identification action-follow-up program, set overall policy and procedure, and SOUTH CAROLINA Regional Medical Program -5- RM 00035 7/70.1 act as a total resource base for the specific "identify-action- follow-up" activities of the satellite operations. Ten satellite centers will be developed over the life of the project with two being developed during the first year; one in Charleston and one in Greenville. Each satellite will consist of a skeleton staff which will include: a part-time medical director, secretary, nurse and nurses' aid. The satellites will have the same identification-action-follow-up goals as the operations center; however, will modify procedures to the extent necessary within the confines of available resources and medical patterns. Mobile screening teams and mobile education teams will be utilized in supplementing local program activities where necessary. Sources of patients to be screened will include: referral from physicians and the State Heart Clinic, County Heart Units service organizations, hospitals, schools, industries and various other health institutions and organizations. Screening results will be reviewed by the medical consultants and forwarded to referring physicians. Persons identified as having risk factors will be placed in the education/action program of the program upon referrals of their physicians. Specific education/ action programs include: 1) Diet and Weight Control, 2) Cigarette Smoking, 3) Physical Activities Programs, and 4) Hypertension. These programs will be established at the operations center and the satellite centers. Each individual entering the education/action portion will agree to participate in the follow-up program which will consist of: 1) Annual rescreening of pertinent risk factor(s), 2) "Status Card" made up on each individual from screening results and oral question- naire, A copy of the card will be mailed to referring physicians for information, 3) Annual Education Seminars will be held concerning each risk factor and will be both motivational and informative in content. The mainstay of the evaluation process will be the Heart Disease and Stroke Categorical review on an annual basis. The review will be based upon: 1) Project site visits of Committee members, 2) Project progress report data (quarterly), 3) Statistical data extracted from project participant flow and processes through the University's computer center, 4) Consultation from an impartial out-of-region expert in the area of coronary risk factors. Significant budget items include: Staff at $76,873, Consultant Services at $16,000, Equipment at $45,450, Supplies at $13,259 and Alterations and Renovations of a satellite center at $4,000. Second Year: $196,438 Third Year: $193,770 SOUTH CAROLINA Regional Medical Program -6- RM 00035 7/70.1 Summary of operational projects currently being supported by SCRMP. Project Title & Number Approved Project Funded 2nd Year Period (direct cost only) 8/1/69 - 7/31/70 Core 3 Years $202,256 #1 -_York General Hospital Coronary Care Unit 3 Years 33,600 #2 - Greenville Coronary 3 Years 7,782 Care Unit #3 ~ Spartanburg Coronary 3 Years 16,073 Care Unit #5 - University of South 3 Years 49,557 Carolina Coronary Care Unit #6 - Spartanburg General 3 Years 24,220 Hospital Heart Clinic i + ¥ § r t : #7 - Florence Cooperative 3 Years 25,748 Heart Clinic Program #8 - Cardiopulmonary Re- 3 Years 37,845 suscitation Training #9 - Cervical Cancer Screening 3 Years 95,501 Ay #10 - Cooperative Program on 3 Years 87,360 Carcinoma of the Cervix #12 - Pediatric Cancer Education 3 Years 109,117 and Service #13 - Demonstration Project for 3 Years 31,103 the Detection of Cancer of Gastrointestinal Tract #15 - Acute Stroke 3 Years 69,247 #16 - Stroke Rehabilitation 3 Years 40,718 #18 - Chronic Hemodialysis 3 Years 20,300 Demonstration Unit #20 - Health Education and 3 Years 54,207 Recruitment Funded lst 9 months (direct cost only) 11/1/69-7/31/70) #25 - Central Tumor Registry 2 Years 27,000 #26 - Statewide Radiation 2 Years 111,750 Therapy and Nuclear Medicine Program #31 - Medical Education in 3 Years 22,707 wie Community Hospital 7 Total $1,066,091 eo SOUTH CAROLINA Regional Medical Program -7- Status of Projects not Funded RM 00035 7/70.1 Project Title and Number Status ’ #1 #17 #19 #21 #22 #23 #24 #27 #28 e #29 #30 #32 #33 #34 Breast Cancer - Mammography Screening Stroke Rehabilitation Nuclear Medicine Diagnostic Unit Coronary Care Education and Screening (resubmitted as #37 in this app lication) Demonstration, Services and Education Core for Coronary Care Unit Planned Discharge and Progressive Care Nuclear Medicine Diagnostic Clinic Coronary Care Unit Telemetry Care of Children with Heart Disease Improvement of Nursing Services Chronic Respiratory Disease Training (resubmitted as #36 in this application) Coronary Care Unit - Beaufort Education of Head and Neck Cancer Returned for Revision Disapproved Disapproved Returned for Revision Approved - Unfunded Approved - Unfunded Disapproved Withdrawn Disapproved Approved - Unfunded Returned for Revision Returned for Revision Disapproved Returned for Revision DRMP /GRB 5/22/70 s .4 ’ 2 \ > (A Privileged Communication) = SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE SOUTH CAROLINA REGIONAL MEDICAL PROGRAM RM 00035 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY ,COUNCIL General: The Committee did not recommend supplemental funding for the ‘ South Carolina RMP for the projects for which funding is re- quested in this application. Of the two projects in this application which were previously returned for revision, #36 - Chronic Respiratory Disease Training was recommended for a site visit and #37 ~ Coronary Care Risk Factor Education and Screening was recommended for Non-Approval I, no RMPS funding recommended. Revision is required for the third project #35 - Comprehensive Coronary Care Program for Community Hospitals in_ the Central Subregion. Project #35 - Comprehensive Coronary Care Program for Community Hospitals. Critique: Committee concurred with the observations and recommendations of the Ad Hoc Cardiovascular Study Panel that this project has not been adequately planned. Although the objectives are clearly stated, the criteria for eligibility of participating hospitals may not insure that areas with the greatest need will receive appropriate consideration. Although a comprehensive chronology is presented, the procedures described leave many unanswered questions which relate directly to the success or failure of the project. The time requirements for training of coronary care nurses are not spelled out, Even though it is generally accepted that the effectiveness of acute coronary care will improve with quality training, this. aspect is not spelied put in the application. It is doubtful the nursing staf£ described can give adequate coverage to the system proposed either at the Univer sity or in the small hospitals. The ratio of staff nurses to patients raises questions as to patient care in special units and to patients on general medical services. Although the budget appears adequate, the break- down for training is unclear and the oscilloscope display equipment to be purchased should be more fully described and justified. Evaluation procedures which are briefly described do not spe¢ify how morbidity and mortality trends will be evaluated and baseline data for comparison is not mentioned, Comaittee concluded as did the Study Panel that the project should be returned for revision and resubmission to: give consideration to the development of other areas besides Charleston and plan linkages, design more appropriate in-service nurse training programs with educational objectives clearly defined, and develop with the proposed curriculum for CCU training an evaluation mechanism designed to meet objectives. Recommendation: Non-Approval II ~ Return for Revision. SOUTH CAROLINA Regional ° ~2~ RM 00035 7/70.1 Medical Program . Project #36 - Comprehensive Respiratory Disease Training Program. Critigue: The Committee agreed with the Continuing Education and Training Panel's conclusion: a_site visit is needed to gather additional information before a recommendation can be made. The RMP appears to be attempting to establish a central patient “care facility with a continuing education component added as an adjunct. The possibility of the V.A. Hospital or the University Hospital serving as an alternate center has apparently not been considered. The overall goals are broadly stated; no behavioral goals are set for the educational component. ‘A statewide need is clearly presented and well documented in relation to the patient disease and current manpower situation. The desire seems to be to establish respiratory centers in all hospitals, where it might be more appropriate to get statewide agreement for subregional centers. The budget is large, calling for extensive staff. In the third year, computer hardware is requested. The time frame proposed seems too short when consideration is made of the time needed to train the faculty and to establish the labora~- tory. The time allocated for staff for education and service is unclear, yet the tutorial approach to training would be time consuming. The resources of the Region have not only been identified, their interest has been engaged; but the proposal does not include information concerning their commitment to supporting the training effort now or in the future. In fact, it is not clear whether the hospitals are willing, or able, to establish the laboratories and treatment centers for which the trainees are being trained. Recommendation: No action taken - site visit needed for additional information and clarification of above questions. Project #37 > Coronary Risk Factor Education and Screening. Critique: The Committee considered the questions raised by the Ad Hoc Cardiovascular Panel concerning this project, but in line with their thinking on a similar proposal fromthe Bi-State RMP, concluded that the Region should not be encouraged to revise the proposal. The Region should be advised that the project was inappropriate for RMP funding. The Committee is concerned about a Region's devoting its resources to planning further an activity for which the ultimate effectiveness is uncertain. This project, for example, is addressed only to the first phases which are necessary without any attention given to follow-up measures. Volunteers are envisioned as an integral part of the program, yet no documentation is presented concern~- _ing theit ability to perform their roles. The screening procedures and follow- up seem inadequate for the objectives without proper involvement of the patients' physicians on whom so much would depend. Professional supervision of the activity is not adequately documented; it is not clear, for example, if a knowledgeable cardiologist with interest in risk factors, a nutritionist, or a health educator will be involved. Many aspects of the budget - the tread- mill, electrocardioanalyzer, travel, are not sufficiently justified. SOUTH CAROLINA Regional. ~3- RM 00035 7/70.1 Medical Program © In short, the Committee felt that the Region should be advised not to devote time to revising this proposal. SUMMARY OF RECOMMENDATIONS a See Project Title and # Recommendations Ol 02 03 Total #35 - Comprehensive Non-Approval II +0- -0- -0- -0- Coronary Care Return for Re- Program for vision Community Hospitals #36 ~- Comprehensive No Action Taken -0- «0+ -0- -0- Respiratory Needs site visit Disease Training for clarification ef cited concerns #37 - Coronary Risk Non~Approval I -0- -O- ~0- -0- and Screening DRMP/GRB 7/15/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) SUSQUEHANNA VALLEY RM 00059 =7/70.1 REGIONAL MEDICAL PROGRAM June 1970 Review Committe: 3806 Market Street P.O. Box #541 Camp Hill, Pennsylvania 17011 PROGRAM COORDINATOR: Richard B. McKenzie Requested lst Year 2nd Year 3rd Year TOTAL Direct Costs $296,650 $274,653 $191,736 $763,039 Indirect Costs To Be Negotiated TOTAL $296,650 $274,653 $191,736 $763,039 HISTORY: This Region began its planning in June 1967 and became operational on April 1, 1969. Council approved eight operational projects for one year of support, one project for three years of support and core for nine months; the periods of support recommended were the requested ones. The total current level of funding is $831,735; $239,125 for projects and $592,610 for core. $143,941 of the funds for projects is carryover. The grantee agency is the Pennsylvania Medical Society; the Coordinator was an executive assistant with the Pennsylvania Medical Society before assuming his present position. The Coordinator reports both to the Regional Advisory Group and the Executive Director of the Pennsylvania Medical Society. Assisting the Coordinator and the Regional Advisory Group in review and decision making are categorical Councils, four Area Committees, and a 20-member core staff. This Region has emphasized "grass-roots development" and coronary care. Of the 19 projects which the Region has submitted, 15 have dealt with some aspect of coronary care. Many of these projects appeared to Committee and Council to be a disparate group of primarily equipment requests with Little sense of their relation to the Region's overall plan for coronary care. Because the nature of the projects seemed to indicate some difficulty with regional planning, a site visit was held in February 1970 to assist the Region in better organization and delineation of its plans and organizational arrangements. The site visitors reported that the Region has been attempting to strengthen the regional decision making by the establishment of Planning and Evaluation Committees and the restructuring of core staff and that these changes had not had sufficient time to affect the written application. Review Committee and Council urged that while continuing to encourage grass roots SUSQUEHANNA VALLEY -2- - RM UUUDY fs fUet Regional Medical Program involvement, the Region should devote more attention to developing a regional decision-making process which selects projects for submission on the basis of a plan derived from the Region's, rather than just individual community's needs. ‘As evidence of efforts in this direction, the Region has introduced the projects in the present application with narrative relating to overall program planning and the role of each project in the context of the total program. Requested Project #20 - Emphysema Program. This project will attempt to First Year alleviate the emphysema problems by establishing a $52,475 specialized treatment center and applying a multidisciplinary approach to the use of equipment and personnel. The treatment center will be established in the Community General Osteopathic Hospital in Harrisburg and will draw patients from primarily a six-county area in the southern part of the state. Presently, there are only six such centers in the country; the proposed center will be patterned after the Moss Pulmonary Rehabilitation Unit in Philadelphia. Patients will be referred to the program by their physician. The patient will receive historical, medical and psychological evaluation and then be placed in one of five classifications from no restriction of normal activities to restricted to the home. The intent of treatment will be to progress the patient to less severe classifications. The project states two new patients will be admitted to the treatment center every week, but. it does not indicate how many patients the center can accommodate at one time. As an inpatient for a least two weeks, each patient will undergo intensive treatment which may include medical, physical, inhalation or occupational therapy, and health education. Periodic evaluation and correlation of physiological and psychological findings will be made, with an assessment of each patient's response by the team which consists of the project director, psychiatrist, nurse, social worker, psychologist, physical therapist, occupational therapist, inhalation therapist and pulmonary function technicians. When the patient has shown satisfactory progress, he will be prepared for discharge to the continuing outpatient program. After discharge, each patient will be periodically reexamined and tested to determine a change in classification. Data on this change will be correlated with the length and nature of treatments and evaluated. Physician and nurse education has been planned for. Physicians will be invited to attend team conferences and will be sent copies of summaries and reports on his patients. Nurses will also be invited ‘to attend team conferences and will also be instructed in the general nursing care of emphysema patients, the use of mechanical devices and the principles of pulmonary rehabilitation. SUSQUEHANNA VALLEY -3- RM 00059 7/70.1 Regional Medical Program The budget requests $34,250 for personnel, $14,225 for equipment, $3,000 in supplies and $1,000 in publications. The cost of inpatient care will be covered largely by private insurance and Medicare. The hospital will accept any patient, regardless of ability to pay. Outpatients not covered by Medicare will be offered a special package of 25 visits for $100. Second Year: $49,000 Third Year: $49,575 ; : Requested Project #21 - Enterostomal Therapy Training - Harrisburg Hospital. First Year The Harrisburg Hospital and the Harrisburg Hospital $18,883 Medical Education and Research Foundation, Inc,, are seeking RMP support to develop and organize a program to train enterostomal therapists. The Harrisburg Hospital has operated the training program on a pilot basis but will have to abandon it unless an outside source of funding can be found. Individuals who are qualified registered nurses, licensed practical nurses or other acceptable allied health personnel will be trained to provide services, training and instruction to patients with a permanent or temporary gastro-intestinal or urinary fistula, such as colostomy or ileostomy. The trained therapists will also provide instruction and training to nursing and physician groups. Initial priority in selecting students will be given to training at least one nurse from each hospital within the Region; second priority will be given to staff members of the Visiting Nurse Association. Twelve students will be trained each year in twelve four-week courses. One student is trained per course. The small discussion group is used in which the trainee receives individual instruction from two therapists, a physiciam, a hospital and a community resource individual. Trainees are also required to assist the enterostomal therapists in the stoma clinic and observe an ostomy operation. Each trainee will be evaluated by each instructor and by a review of 50 case summaries submitted by the trainee within six months after completing the program, as well as by reports from the graduate therapist and his supervisor. The $18,883 request for the first year includes funds for personnel, supplies, travel, and student expenses. Second Year: $19,814 Third Year: $20,695 Requested Project #22 - Physician and Paramedical Rehabilitation Training First Yea: Program, Williamsport Hospital. This project requests $35,837 funds to: 1) teach physicians the latest knowledge in diagnosis, rehabilitation treatment and psychology and use of special equipment; 2) train paramedical personnel in rehabilitation therapy; 3) deliver new and improved physical medical care to heart, stroke, cancer and neurologically handicapped patients throughout eleven counties in the northern part of the state; and 4) aid in restoration of the motor-body functions of patients when they are first disabled in order to provide prophylaxis against more serious and permanent disabilities. SUSQUEHANNA VALLEY -4- RM 00059 Regional Medical Program The sponsoring hospital, Williamsport Hospital, has recently completed an 80-bed rehabilitation center which is the only such center in the Northcentral Pennsylvania.area. A questionnaire sent to hospitals in the 15-county area indicated that 16 of 18 hospitals which replied would be interested in training for paramedical personnel and physicians in rehabilitation. On that basis two sets of courses have been planned. The first is a five-day course for physicians held twice a year for two years. Each course, including lectures by various specialists, demonstration of and participation in therapy, diagnosis and treatment of stroke patients, and conferences with ancillary medical personnel, will be limited to five physicians. The second group of courses is a ten-day paramedical training program, limited to 25 students each. It will attempt to give nurses, physical therapy aides and orderlies the techniques and execution of rehabilitation therapies. A curriculum is included. The program will be reviewed to determine its value to the participants, rather than attempting to measure the benefit to patients throughout the il-county area. > Second Year: $34,186 Third Year: None Requested: ~ Project #23 - Cartridge Viewing System Pilot Project, American Cancer First Yeat Society, Pennsylvania Division. The objective of this $4,973 one-year proposal is to evaluate two types of cartridge viewing systems - The Fairchild Super 8mm and the Technicolor Model 1000 B - in order to develop criteria and appraise all aspects of cartridge viewing systems. Five Fairchild projectors will be placed in five hospitals and five Technicolor projectors will be placed in five different hospitals. After three months usage, the ten hospitals will exchange projectors. After another three months usage, different hospitals will be selected. In two years, 20 hospitals will be involved in the comparative study. The American Cancer Society will administer the project by providing a variety of cartridge films and accompanying material, servicing the systems and tabulating the evaluation data. The schedule for the projector will be sent out in advance to enable the hospital to schedule films and involve the projector in their nursing and continuire medical education program. The projectors are also available for patient rehabilitation and public education. The projectors may also be put in the nurses and physicians’ lounges where individuals may review a film previously presented or one that they could not attend. An evaluation will be made in each hospital at the end of each of the four three-months periods. The intervening time between assignments should allow for planning a more complete use of the projector. There will be a single evaluation made by a hospital each time a projector is used, a comparative evaluation of the first and second usage of both projectors and a composite evaluation made each year for the twenty hospitals involved in the program. SUSQUEHANNA VALLEY ~5- RM 00059 7/70.1 Regional Medical Program A preliminary study was conducted at one hospital in Gettysburg where 104 viewings took place in a two-month period. The proposers stated that they felt the use of the projector was important in stimulating the development of this hospital's first continuing education program. Second Year: None Reques tex Project #24 - Nurses Training Program for Coronary Care Units, First Yeé Harrisburg Hospital. At the present time the entire $46,640 Susquehanna Valley Region has only one nurses' coronary care training program - the four-week program at the Geisinger Medical Center. The Geisinger Program has started its second year of operation under RMP funding and has more requests than it can handle in the Northeastern and Northern Areas alone. The project at Harrisburg Hospital would serve hospitals in the Southern Areas who estimate that they will need 285 nurses for coronary care units in the next three years. This project was reviewed by Council in December 1969 and returned for revision because the proposal had not documented the need for a twelve-week course and the curriculum was not adequately described. The objective of this revised proposal is to provide hospitals in the Southern Area with trained nurses who are capable of working independently in or supervising a coronary care unit. The Region feels that the presence of both four and twelve-week courses within the Region would offer an opportunity for a comparative evaluation. Ten to fifteen nurses will receive didactic lectures, participate in discussions and clinical experience in a twelve-week training program, utilizing the physicians and nurses of the Harrisburg Hospital. Three courses will be held per year. The course is designed for graduate nurses with at least six months experience in general duty. Both a course outline and the daily training schedule are included. Evaluation will consist of a comparison of mortality statistics of coronary patients before and after the establishment of a unit and a subjective evaluation of the graduate by his coronary care unit director. The hospital will provide room and board for the students during the course. Funds are requested from RMP for reimbursement of the instructors, supplies and equipment and dietary costs. Second Year: $47,960 Third Year: $49,918 Requested Project #25 - Nurses’ Training Program for Coronary Care Units, First Yea Altoona Hospital. This project would provide a four- $55,643 week coronary care course for nurses in the Appalachian-Highland area. December Council returned for revision an earlier version of this project also, because they could not ascertain this project's part in the Region's overall plan for coronary care units. This hospital, the reviewers thought should be encouraged to assume more responsibility for SUSQUEHANNA VALLEY -6- RM 00059 7/70.1 Regional Medical Program regionalization, such as offering assistance to nurses in their sponsoring hospital, after the course is completed. Salaries and equipment costs in the $55,643 first-year request seemed high. This hospital has already trained 25 nurses and is requesting RMP support to train a total of 96 nurses (twelve trainees per class and four classes per year) for hospitals in a four-county area. The program is planned to train the nurses in the use of monitoring equipment, electronic defibrillating, cardioversion, electrocardio~ graphic interpretation and specialized nursing techniques. The course is divided into 40 hours of lectures, 30 hours of lab and 80 hours of clinical instruction. The nurse must be a graduate RN with a current state license and recommended by the employing institution. Evaluation will stress relevant curriculum content, teaching methods and aids, participant feedback and follow-up. After two years the program will be subsidized by the Altoona Hospital and supported by tuition fees. Sécond Year: $55,643 Third Year: None Requested — Project #26 - Cardiopulmonary and CVA Transport Vehicle - York Hospital. First Ye°°*.>. The December 1969 Council reviewed this project and $82,206... - recommended returning it for revision. The reviewers had difficulty in assessing the need for the project and the adequacy of trained man- power to staff the mobile coronary care transport vehicle. The size of the area and characteristics of the population were not described. The application did not document the statements of high rates of complica- tions associated with hospitalized myocardial infarction patients which occur during transport. Although the vehicle would be staffed by both a physician and experienced nurses during the week, staffing of the vehicle on nights and weekends was unspecified. Also a more definitive protocol for evaluation than the collection of anecdotal records and routine mortality data would be necessary for proper determination of the effectiveness of the ambulance. The project will serve the greater York County area which includes 275,000 people divided approximately equally into urban and rural. This pilot project intends to provide a demonstration of the effective- ness of a cardiopulmonary transporter in reducing morbidity and mortali- ty from myocardial infarction and stroke prior to entry into the hospital in the York area. The proposers hope to evaluate the effect of bringing a physician, trained nurse and necessary monitoring and resuscitation equipment into contact with patients sooner than is possible under present conditions. SUSQUEHANNA VALLEY -]~ RM 00059 7/70.1 Regional Medical Program The basic cardiopulmonary transport vehicle would be a step van truck equipped with a self-contained resuscitation unit, a Bird pressure volume respirator and connected by two-way radio for initial and continuing voice contact with the hospital emergency room and coronary care unit. The vehicle would be dispatched either by a direct call to the medical resident in the coronary care unit of the York Hospital or through the existing York Police radio network in conjunction with a physician, industrial health nurse, etc. The van will be staffed normally by a driver, an orderly, a CCU nurse and a medical resident assigned to the CCU. On off hours on evenings and weekends it will be staffed by one of two medical residents on duty supported by the interns on cardiology. Specially trained nurses will also serve as staff on nights and weekends. The hospital's Educational and Care Evaluation Unit will supervise and standardize evaluation mechanisms. The criteria will include a detailed review of incidents, epidemiology, recovery, compared to before and after establishment of the mobile unit function. Evaluation of mortality statistics, as well as anecdotal and objective material, has been planned for. For the initial part of the study, no fees will be charged in order to stimulate use of the service. After the program has been established, the program will continue on a fee-for-service basis. The first-year budget consists of $52,000 for personnel, $10,500 for consultant services, $17,200 for equipment and $2,500 for supplies. Second Year: $68,050 Third Year: $71,548 RMPS /GRB/5/14/70 SUSQUEHANNA RMP @ - RM 00059 7/70.1 STAFF OBSERVATIONS Summary of Review Actions and Funding Project _ #1 - Evangelical Community Hospital CCU (02 year) #2 - Sunbury Community Hospital CCU (02 year) #3 - Shamokin State General Hospital CCU (02 year) #4 - A.C. Millikan Hospital CCU (02 year) #6R- Coronary Care Unit Nurses Training Program, Geisingec Medical Center (02 year) #7 - Stroke Care Unit, Mercy Hospital, Altoona (02 year) #8 - Home Health Care Project (02 year) © #9 - Regional Medical Information Service (02 year) #10- Training of Personnel for Coronary Care, Harrisburg Hospital #11- Nurses' Coronary Care Training Program, Altoona Hospital #12- Cardiopulmonary and CVA Transport, York Hospital #13- Travenal Resuscitation Cart, Pottsville Hospital and Warne Clinic #14- Emergency Coronary Care Program, Coaldale State General Hospital #15- Emergency Coronary Care Program, Locust Mountain State General Hospital #16- Radiological Health Training Program, Geisinger Medical Center (01 year) #17- Columbia Montour Home Health Services, Inc. (01 year) TOTAL Que with funds from the $5 million. Status and Current Support $ 4,264 2,231 4,160 3,900 26,978 55,339 15,952 55,580 Disapproved Disapproved Disapproved Disapproved Disapproved Disapproved 17,993 2/ / 15,900 + $202,297 5/12/70 A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM RM 00059 =7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Susquehanna Valley RMP submitted a supplemental application for seven projects requesting $763,039 for a three-year program period. The Committee concluded that the application should be supported . as follows: $101,083 the first year to support Projects #21 and #26, $87,864 the second year and $92,243 the third year to support the same. Projects #20, #22, #23, #24 and #25 were disapproved. Reviewers continue to see a lack of overall regional planning in the written application, but recalled that the February site visit team report- ed that progress is being slowly made. Three projects which had been revised and four new projects were reviewed. The technical panels reviewed all but one of the projects and were highly critical; with one exception, they found all of them technically unfeasible. The Committee regretted that their one member familiar with the Region's problems and priorities was unable to attend the meeting, and in the absence of this member, felt compelled to.accept the panels' technical assessment. Committee, however, was concerned about the effect of returning two projects for revision a second time. r Project #20 - Emphysema Program Critique: Reviewers appreciate the need for such a facility since no such facility exists for comprehensive treatment of emphysema and bronchitis in Central Pennsylvania. The Ad Hoc Cardiovascular Study Panel and Committee's principal concern relates to relationships between the Osteopathic Hospital and other agencies, institutions and physicians who would refer patients. Although surrounding hospitals have agreed to refer patients and health agencies have endorsed the project, reviewers were concerned about the future. of the project without commitment from the medical profession. With regard to the project description, the Panel believed that greater emphasis should be given to early detection, more details should be pro- vided on patient selection and consultation should be sought in evaluation to settle questions as to how data will be derived for comparison of re- sults of the hospital team approach and that of the private physicians. Portions of the psychosocial work-up might be considered research with little likelihood of obtaining definite conclusions. Susquehanna Valley RMP -2- ~ RM 00059 «=7/70.1 While the Panel deferred their recommendation pending a satisfactory site visit report, Committee concluded that since the bulk of the costs would support staffing of the: hospital, the project should be disapproved. Recommendation: Non-Approval I (no RMP funding xecommended). Project #21 - Enterostomal Therapy Training, Harrisburg Hospital Critique: This project appears to be a much needed resource for the entire Region, since it is the only training program of its kind in the Region. The objectives are clearly stated and the educational design appears sound. Training is individual with a great deal of time being spent on bedside instruction and practice. Evaluation of student performance appears sound. Committee recommended approval of this ongoing activity, which apparently will not be able to continue without RMP assistance. Recommendation: Approval in the amount and for the time requested. O1 02 oo 03 $18,883 $19,814 _ $20,695 Project #22 ~ Physician and Paramedical Rehabilitation Training Program, Williamsport Hospital Critique: The Continuing Education and Training Panel was very critical of this proposal. They found fault with the educational design, evaluation and the budget. For example, they found little evidence of the manner in which reinforcement would be provided in physician training. The depth of the reinforcing clinical experience for paramedical personnel could not be assessed since the distribution of learners in relation to numbers of patients was not stipulated. The evaluation, focused primarily on rates of participation, subjective responses to questions concerning interest and a questionnaire checkoff, would not indicate any change in behavior or measure outcome. The budget ($600 per student for five to ten days of instruction) seemed excessive. Committee acknowledged these comments and added that the aims of this project have already been demonstrated at many rehabilitation centers around the country. Consequently, although the need exists, the project in its present form is disapproved. Recommendation: Non-Approval I (no RMP funds recommended). Susquehanna Valley RMP -3- RM 00059 7/70.1 Project. #23 - Cartridge Viewing System Pilot Project, American Cancer Society, Pennsylvania Division Critique: The Continuing Education and Training Panel and Review Com- mittee agreed that this proposal is basically a request for purchasing equipment, rather than a valid evaluation of equipment or of educational outcomes because of its use. Technical assessment should be performed by the company who develops the equipment and not RMP. There is little effort to relate this project to educational objectives; assessment of the number of viewings for a novel media in such a short time span is really no evaluation. Recommendation: Non-Approval I (no RMP funds recommended) . Project #24 - Nurses Training Program for Coronary Care Units, Harrisburg Hospital Critique: Although this proposal had been returned and revised once before, it was again found unapprovable in its present form and returned for revision. Previous criticism related to the lack of documentation of the need for a twelve-week course and to the need for a more adequately described curriculum. Committee noted the Ad Hoc Cardiovascular Study Panel's comments, which indicated they still were not convinced that the twelve-week course would adequately produce supervisory nurses. The emphasis of the course seemed to be disease-oriented with minimal indication of the explicit supervisory skills and judgments needed, and a large portion of the last five weeks is devoted to nursing duty, including evening and night shifts. Evening and night tours of duty are strongly questioned by the National League of Nursing as ideal learning situations. The Panel stated the curriculum should include an indication of how specific objectives will be attained, nurse education consultation and input, and an evaluation scheme which would relate to conduct during the course and after return to the nurse's home hospital. Because the project has apparently not satisfactorily answered its pre- vious criticisms, Committee believed that a revision was needed to review it. Committee believed that what is needed is a better model for such a training program and consultation from leaders in nursing education in the state. Recommendation: Non-Approval II (revision required). Project #25 - Nurses' Training Program for Coronary Care Units, Altoona Hospital Critique: This is a request for the traditional four-week coronary care Susquehanna Valley RMP -4- RM 00059 7/70.1 nurse training program. The Committee noted that this project would serve. the western area of the Region, and that the only other coronary. care training program was at the Geisinger Medical Center in the eastern section of the Region. Although the project spoke to the comments of previous reviewers, the Ad Hoc Cardiovascular Study Panel: had additional criticisms: (1) the objectives are not stated in terms of education of the learners; (2) other than a general reference to follow-up, the pro- posal does not speak to any evaluation of the student's retention of knowledge or employment status after training and (3) evidence of nursing input into the curriculum is missing. In light of these comments and the absence of the Committee member who could provide input on the background of the Region's planning in this area, Committee accepted the Panel's recommendation of disapproval. Recommendation: Non-Approval I (no RMP funding recommended). Project #26 —- Cardiopulmonary and CVA Transport Vehicle, York Hospital Critique: Committee believed this revised project had, for the most part, met the criticisms of earlier reviewers, which included. deter- mination of need, adequacy of manpower to staff the vehicle, and evalua- tion protocol. The locale of this project in York, which is also involved in the Maryland RMP, was noted. The Ad Hoc Cardiovascular Panel's recommendation of disapproval was based on an erroneous belief that RMP policy forbade further expenditure of RMP funds on CCU ambulances until evaluation of present ambulance projects is completed. The Panel's suggestions that medical society endorsement be sought and that evaluation be further strengthened were adopted by Committee. Recommendation: Approval I with the conditions that evaluation be strengthened and medical society endorsement be obtained. 01 02 03 $82,200 $68,050 $71,548 Conclusion: A total of $281,190 was recommended for Projects #21 and #26 for a three-year period. 01 02 03 Project #20 - Emphysema Program Non-Approval I (no RMP funds recommended) Project #21 - Enterostomal Therapy $18,883 $19,814 $20,695 Training Project #22 - Physician and Para- Non-Approval I (no RMP funds recommended) medical Rehabilitation Training Program Susquehanna Project #23 Project #24 Project #25 Project #26 Valley RMP Cartridge Viewing System Pilot Project Nurses Training Program for CCUs, Harrisburg Nurses Training Program for CCUs, Altoona CPR and CVA Transport Vehicle, York TOTAL -5- RM 00059 =7/70.1 Non-Approval I (no RMP funds. recommended) Non-Approval II (revision required) Non-Approval I (no RMP funds recommended) 82, 200 68,050 71,548 $101,083 $87,864 $92,243 DRMP/GRB 7/13/70 DIVISION OF REGIONAL MEDICAL PROGRAMS SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) TEXAS REGIONAL MEDICAL PROGRAM RM 00007 7/70.1 P. O. Box "'Q" June 1970 Review Committee University Station 2608 Whitis Street Austin, Texas 78712 Program Coordinator: Charles B. McCall, M.D. Requested Program Period lst Year 2nd Year 3rd Year TOTAL Direct Costs: $610,363 $351,414 $295,655 $1,257,432 Indirect Costs: 161,951 | 115,998 98 ,090 376,039 Total $772 ,314 $467,412 $393,745 $1,633,471 History: Texas received an 01 planning award ($969,541) on July 1, 1966 and its 02 award ($1,039,295 deo) on July 1, 1967. A site visit was conducted in June 1968 to determine the Region's readiness for operational status and to review the proposed continuation of planning activities into the operational phase of TRMP's development. Of major concern to the reviewers was the apparent lack of central direction and coordination of the program. This was illustrated by the uneven progress made in the development of the nine subregional planning units and by the fact that operational proposals appeared to be "based on institutional interests and strengths with very little regard for community needs and goals - either regionwide or local - and only a few show evidence of true cooperative arrangments or even unilateral peri- pheral involvement.'"' The site team also observed that the Regional Advisory Group, though under strong leadership, had not been active in the identification of program goals and the development of program plans. The RAG was also weak in its representation of minority groups, consumers, allied health professions, and the practicing community. With these considerations in mind, the Council recommended a one-year approval of the Texas operational application, including the continued planning support, with future funding contingent upon demonstrated improvement in the areas mentioned by the reviewers. Accordingly, a one year operational award was issued on July 1, 1968 in the amount of $1,615,000 (dco), these funds to be divided evenly between operational and planning activities. This combined package included fourteen Texas Regional Medical Program -2- RM 00007. —-7/70.1 operational projects and a number of planning efforts which included core support and support for the nine institutional planning units. A subsequent visit was held in April 1969 to judge the progress made in fulfilling the conditions laid down the year before as necessary for further funding, that is, strengthening central administration and expanding the RAG. The reviewers were well satisfied that these require- ments were being met; a new coordinator had been appointed and had presented his plans for tightening up the organization, and the. RAG included nine new interested groups that had not been represented earlier. The Region received its 02 continuation award ($2,220,891 dco) on October 1, 1969. This award included support for core and eight planning bases, ten project renewals, and eleven new projects. Present Application: This application requests renewed support for three activities and supplemental support for two new projects. Direct costs only are noted below. Requested First Year Project #8(R) - State-Wide Cancer Registry System $184,396 This is a renewal application of a project now in the second year of development of a computerized regional cancer registry system. The Ol year award was $38,000 d.c. and 02 year funding was $80,000. This project grew out of the recommendations of a committee organized during the early planning stages of TRMP to look into improving the care given to cancer patients in the state. This group included representatives of the University of Texas, Baylor College of Medicine, the Cancer Committee of the state medical society, the state division of the American Cancer Society, and the State Department of Health. After evaluating the need for a more comprehensive medical information system for cancer, it was proposed that a central registry be established and that it operated out of the University of Texas School of Public Health. It was felt that by utilizing this resource, additional data process, consultation data analysis and statistical support could be provided to existing registries. The June 1968 operational site visit did not recommend any support for this project in the 01 year and encouraged the Region to resubmit it after some further development. TRMP, however, exercised its prerogative to fund the project on the basis of its importance to the Region. The April 1969 site team felt that sufficient progress had been made and recommended continued support in the 02 year. The goal of the renewal proposal is to integrate this central computer- ized cancer information system for the State to help improve the care of cancer patients by assisting physicians in their follow-up and treatment. Texas Regional Medical Program 3 RM 00007 7/70.1 This will be accomplished by establishing a central bank of cancer data and by extending this service to a larger proportion of the population within the Region. Such a cancer information system will promote research into the epidemiology and other population dynamics relative to cancer. Once this system has been developed, it will be tested for its applica- bility to other areas such as heart and stroke and may be expanded to include them. A staff, consisting of a M.D. coordinator, a Ph.D. demographer, a Ph.D. statistician-information scientist, a secretary, keypunch operator, and two clerk-typists, has been assembled. Information has been obtained by questionnaire on the nature and scope of existing registries both within and outside the State of Texas. Arrangements have been made to utilize the Texas State Department of Health Spectra 70/45 Computer, which will become operational during April 1970. San Antonio will be the site of a pilot project to test the reporting procedures and computer system, as well as to serve as a training unit. Cancer morbidity data for 1944-1966 for San Antonio are currently being placed on magnetic tape and edited. Projected future activities include: (1) development of a standard set of reporting forms and data codes, (2) the determination of systems design and computer program to allow flexible data handling and analysis, easy up-dating and fast retrieval, and (3) a clear definition of channels of information flow. Second Year: $132,251 Third Year: $97,542 Requested Project #14(R) - Stroke Demonstration Program for First Year Progressive Patient Care $196,244 This is a renewal application to continue the development of the Stroke Demonstration Program by the University of Texas (Southwestern) Medical School and Presbyterian Hospital, both in Dallas. This proposal was originally funded ($240,499 dco) on April 1, 1968 as a one-year ear- marked supplement to the planning grant. Due to the number of delays in the construction of the stroke unit itself, the program period has been extended to September 30, 1970 without additional funds. Construction of the special 22-bed stroke unit was completed the end of November 1969. A multi-disciplinary team consisting of neurology, nursing, and rehabilitation personnel has begun to provide intensive acute care, early rehabilitation, and continuing patient care within the framework of a demonstration project which also provides for continuing education of physicians, registered nurses, and allied health personnel in the North Texas area. Personnel from both Presbyterian Hospital and the faculty of The University of Texas (Southwestern) Medical School make up the project staff. Texas Regional Medical Program -4- RM 00007 —7/70.1 This program is also directed at both the early diagnosis of stroke (or impending stroke) and the training of physicians, nurses, and allied health personnel in comprehensive progressive care. The regional applica- tion of this program will be further implemented during the present fiscal year as the stroke unit becomes fully operational. Related or coordinated satellite units in surrounding community hospitals are planned. Second Year: $164 ,344 Third Year: $142,844 Requested Project #15(R) - Area-Wide Total Respiratory Care. This is a First Year request for renewal support for a third year for $80,000 the "Area-Wide Total Respiratory Care" project, now in operation at Baylor College of Medicine. The 01 year was funded at $174 ,388 d.c. and the 02 year at $242,915. Both the current program and this renewal application address the need for organized planning and increased services on a broad scale in the field of chronic obstnuc- tive pulmonary disease. The twelve counties surrounding Houston represent the area of involvement for community programs of early detection, application of preventive measures, and both public and professional education. Emphasis will be placed on an active program of continuing education for the community physicians and nurses in the area, utilizing the respiratory disease screening pro- : gram, teaching clinics, and bedside instruction in the medical center. s A pulmonary rehabilitation program will be undertaken in conjunction ~e with the RMP "Rehabilitation Management - Coordinated Community Action Program" at St. Elizabeth's Hospital in Houston. Through the efforts of this program, there has been an increase in activity in all of the Baylor College of Medicine-affiliated hospitals (Veterans Administration, Methodist Hospital, St. Luke's Episcopal Hospital, Ben Taub General Hospital and Jefferson Davis Hospital of the Harris County Hospital District) relative to respiratory disease screening, patient services and professional and allied health training programs. This project has also pointed out and clarified future needs in the delivery of health care in respiratory disease at the community level. These needs form the basis of the renewal proposal. There will be a continuation of the screening program for selected population groups in the twelve county-San Jacinto area. This activity will be rapidly advanced by the availability of a unique technique for the photo scanning and computer storage of information obtained by the screening expirogram. The resulting data will be used not only for educational purposes but also for both horizontal and longitudinal studies of prevalence, incidence and courses of all stages of identified respiratory disease. To date, there have been approximately 2,500 persons screened, 492 of whom were diagnosed as having chronic bronchitis. Texas Regional Medical Program -5- RM 00007. 7/70.1 The base staff organization at Baylor College of Medicine will remain largely intact without significant RMP support of pro- fessional personnel and will continue to serve as a center for the advanced training of physicians, nurses, and allied health personnel in the diagnosis, treatment and rehabilitation of respiratory illness. Through cooperative arrangements with The University of Texas School of Public Health, the prevalence and incidence data gathered by the screening program will be analyzed on a con- tinuing basis. Techniques to obtain representative samples of the population in rural areas are being developed. A program of nursing education activities will continue with the coordination and direction of an RMP-supported nurse coordinator. The Region believes this request for third-year support at a reduced level of funding will permit the preceding two years of groundwork to serve effectively in establishing at the community level the increase and improvement in health re- sources for the management of chronic respiratory problems. Second Year: None Third Year: None Requested Project #48 - Care of Patients Requiring Mechanical Ventilation First Year (based at University of Texas Medical School - San $26,717 Antonio). This project proposes to train registered nurses and other nursing personnel in the total care of patients who require prolonged mechanical ventilatory assistance or total mechanécal control of ventilation. The need has been manifested by requests from hospitals in South Texas for consultation in the design of intensive care units and by direct observation of the relative lack of training of the personnel who provide the care of patients requiring prolonged mechanical ventilation. The proposed project will establish intensive two-day in-service programs of continuing education for nurses in community hospitals, utilizing audio-visual aids, manuals of instruction, demonstrations, seminars, and bedside supervision. Each hospital requesting this program will be visited to estimate the demand for prolonged mechanical ventilation, determine the available resources, and test the knowledge and competence of the personnel who will take the course. This pre-testing will be accomplished by means of a multiple choice questionnaire. The curriculum of the course to be presented at each hospital will be determined by the results of this questionnaire. The same questionnaire will be administered immediately after the conclusion of the course to assess immediate recall. Follow-up evaluation will be made five to six months later Texas Regional Medical Program -6- RM 00007 7/70.1 by a site visit which will re-check all points covered in the pre- evaluation, plus modifications and innovations remaining in effect as a result of the course. This program is aimed primarily at the continuing education of pro- fessional personnel to increase the skilled delivery of specialized care to patients who are in urgent need of such services and for whom the quality and availability of such services are limited in many of the smaller community hospitals. The application states that it does not duplicate the operational projects, "Area-Wide Total Respiratory Care”, "Helping Hospitals Organize and Strengthen Inhalation Therapy Patient Care Programs" or "Coronary Care Training in Community Hospitals", but rather complements these programs. The areas of shared concern, e.g., pulmonary physiology and mechanical aids to ventilation, provide a basis for cooperative and interrelated programs of training and instruction. Second Year: $16,422 . Third Year: $15,607 Project #49 ~ A Centralized Electrocardiographic Analysis Requested System for A Six-County Area of Central First Year Texas. This project is designed to improve $123,006 the local delivery of health care through prompt, expert electrocardiographic diagnostic services from a centralized base. Its possible expansion and usefulness in many other areas in the Region is anticipated following proved achieve~ ment of the objectives of the project. This project is based at Scott and White Hospital and Clinic in Temple, Texas, and will serve a six-county area of Central Texas. This institution has provided requested EKG consultation for physicians and hospitals for some time but has been dissatisfied with the quality of service that could be rendered due to non- uniform equipment, variable technician capabilities, and delays in receiving the tracings and returning the interpretations by mail. For the past two years a data phone system between Scott and White and two other hospitals has been utilized, providing better, more uniform tracings and prompt reporting. The increased utilization of this service, plus requests from additional community physicians and community hospitals, has stimulated this proposal for a centralized system to provide improvements in technical quality, rapid transmission, same-day interpretation, increased storage canahilitv, and vector loop capability. A three channel Scalar and Loop Electrocardiograph specially designed for data phone transmission, using three Frequency Multiplex Signals and separate telephone lines at each participating hospital, will be installed. This will extend to eight hospitals with approximately a 300-bed capacity. The automatic central recording unit will be capable of microfilm IBM card reproduction of 12 Lead Scalar EKG plus the Frank System Vector Loops. It is recognized that vector Texas Regional Medical Program -7T- RM 00007 7/70.1 capability represents a research phase, but it is pointed out that this adds relatively little to the overall equipment budget. The budget was felt by the local review groups to be justified by the project objectives, and sufficient grant-generated income is anticipated to repay the equipment cost in two to three years as the project becomes self-sustaining. The equipment will lend itself readily to the anticipated computerized interpretation of electro- cardiograms. Readings will be provided twice a day by telephone (immediately, in an emergency) and copies mailed to each participating institution and physician daily. The maximum volume the system may handle is approximately 500 tracings per day. The project will be initiated by orientation programs at the action base with staff physicains and technicians from praticipating hospitals. Experience will be reviewed quarterly with the participating hospitals and deficiencies revealed will be corrected at that time. These meetings will serve a continuing education function as well as a service review. Second Year: $38,397 Third Year: $39,662 Texas Regional Medical Program -8- RM 00007 7/70.1 - History Supplement Project # Title Current Support Initiation (d.c.o0.) Date 1 Medical Genetics (MDA) $ 26,748 7/68 2 Child Welfare Workers Training (MDA) Approved/Unfunded 3 East Texas Teaching Chain (Grad. Div.) RMP Support Terminated 4 Inhalation Therapy Patient Care Programs $ 50,000 7/68 (Methodist) 5 Regional Consultation in Radiotherapy (MDA) 60,000 7/68 6 Consultation Service in Medical Physics (MDA) 49,584 7/68 7 Cancer Survey (MDA) RMP Support Terminated 8 Statewide Cancer Registry (Houston) 80,000 7/68 9 Educational Television (Grad. Div.) Disapproved 10 Microwave System Development (MDA) Disapproved ll Consultation Services ~ Radistherapy Disapproved via Television (MDA) 12 Dissemination of Cancer Literature (MDA) Disapproved 2 13 Communication Study (MDA) Disapproved . 14 Stroke Demonstration (Dallas) Extended without 7/68 additional funds 15 Area-Wide Total Respiratory Care 242,915 7/68 (12 counties) 16 Rehabilitation Program A (Baylor) 127,063 7/68 17 Rehabilitation Program B (San Antonio) 67,607 7/68 18 Rehabilitation Program C (Dallas) 74,620 7/68 19 Cardiac Work Evaluation (Baylor) RMP Support Terminated 20 Eradication of Cervical Cancer 90,000 7/68 (San Antonio) PLANNING CORE STAFFS 21 Coordinator's Office 721,219 7/68 22 San Antonio UT . 15,000 7/68 23 Dallas UT 3,260 7/68 24 Galveston UT 4,349 7/68 25 Dental Branch UT Support Terminated 26 UT Graduate Division ~- Houston 11,500 7/68 Texas Regional Medical Program -9- 27 & 28 M.D, Anderson 29 Baylor 30 Methodist Hospital - Allied Health 31 Long Distance Telephone Consultation (Dallas) 32 Cardiovascular Nursing Institutes (Texas Women's U.) 33 Coronary Care Nurse Training in Community Hospitals (St. Joseph's and Riverside Hospitals) 34 Regional Coronary Care & Training by Computer (Galveston) 35 Reduce Complications Following Radiotherapy (Dental Branch - Houston) 36 Inter-Regional Cooperative Serial Control Systems in South Central Library Region (Statewide) 37 ‘ Health Careers Personnel Program (Statewide) 38 Dial Access (MDA) 39 Annual Clinical Conference (MDA) 40 CE in CVD, Coronary Care and Intensive Care (Galveston) 41 Social Workers' Training in Neoplasia (MDA) 42 CE for Occupational Therapists (Dallas) 43 Educational Media Instructional Program for Allied Health Educators (Baylor & Methodist) 44 Health Occupations Improvement (Multiple locations) 45 Rehabilitation Management (Baylor) 46 Maxillofacial Prosthetic Services (Multiple) 47 Planning a Neighborhood Health Center * Funded from carryover RM 00007 7/70.1 3 9,500 27,725 13,000 35, 000% Unfunded 84,000 Disapproved 37, 000%* 28 , 000% 29, 801% 16, 500* 15, 000% Unfunded 7/68 7/68 7/68 10/69 10/69 10/69 10/69 10/69 10/69 10/69 Approved/ Unfunded 24 , 000% 17, 500* Deferred 160, 000* 100 , 000% Withdrawn DRMP/GRB 5/28/70 10/69 10/69 10/69 10/69 A Privileged Communication \ SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE TEXAS REGIONAL MEDICAL PROGRAM RM 000@7 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY, COUNCIL General: The reviewers recalled that the history of the Texas Regional Medical Program was a long and interesting one. They noted that the Region's early growing pains seem to be over, as judged by the last site visit in April 1969, and staff reports of interim organizational activity. The present application contains renewal requests for three ongoing projects and supplemental requests for two new projects. Committee recommended partial approval of the application; approval with specific conditions and funding restrictions for the three renewals and non~-approval for the two new activities. Project #8R - Statewide Cancer Registry System. Critique: The reviewers thought the Cancer Registry System seemed to be moving forward satisfactorily and that it had captured the attention of some of the appropriate groups in the oncologic power structure in the State of Texas. There was some concern, however, about the relationship of this registry to the existing registries in Texas, particularly the one at M.D. Anderson. Furthermore, the appli- cation addresses itself only to the upcoming year of activities, although three years' support is requested. There is no indication of what will be accomplished in the second and third years. There is also no evidence _as to how this activity is expected to be financed at the;close of the period of requested support. Some reviewers requested a clarification of the source of the registry's data base. A site visit was considered necessary. Recommendation: Approval I in the time and amount requested with specific conditions: 1. That a technical site visit team be satisfied as to the Committee’ four points of concern, i.e.: a. relationship of the project to existing registries; b. plans for the second and third years of requested support; , _c. future funding of the activity and. RMP phase-out; d. clarification of the source of data base. 2. In the event the technical site team has not made its recommenda- tions before the end of the current budget period, the award for TEXAS Regional Medical Program ~2- \ RM 00047 this project will carry a restriction on the use of any funds above the current level of expenditure. Approval by the site team will lift the restriction. Ol Year: $184,396 02 Year: $132,251 ,03 Year: $97,542 Project #14R - Stroke Demonstration Program for Progressive Patient Care. Critique: Despite the delays in the construction of the stroke unit, most of the staff for this project is now on hand and seems to be well qualified. However, the application itself is deficient in that it contains no indication of the number of physicians or nurses who will be trained during the three years for which support is requested and no estimates of the amount of time which will go into the poorly-defined external educational programs in community hospitals or the advice and consultation activities for commumity hospitals. The Committee reviewers, therefore, found it impossible to determine the educational cost/benefits of the activities. Further, the proposal contains no clear discussion of the intents during the second and third. years of the grant.renewal request. The discussion of the future support of the project refers to "grant generated income," but this apparently does not include hospital-generated dollars. It was felt that the application should be rewritten to provide the above information. Recommendation: Approval I in the time and amount requested, with the following specific conditions: 1. That the request be clarified to provide: a. aclear statement of the realistic estimates of the number of people to be trained as well as the amount of time which will go into the educational program; b. a discussion of the second and third year activities; c. an assurance that at the completion of three years no additional grant support for the project will be requested from RMPS and a statement of how hospital-generated income is and will be handled. 2. To assure continuity of support, the award for this project will be made prior to thé Committee's consideration of the additional material. Any additional funds over the current -level of expenditures should be restricted until Committee/ Council approval. Ol Year: $196,244 02 Year: $164,344 03 Year: $142,844 TEXAS Regional Medical. Program -3~ RM 00047 Project #15R ~- Areawide Total Respiratory Care. Critique: The Committee thought that this proposal documents extremely well the extensive cooperative arrangements that have occurred in the pulmonary area as well as the sequence of productive educational and health care efforts that have been developed and are ongoing. The region has been quite successful in garnering support for this project from multiple sources, and it is anticipated that by the completion of next year of activities, RMP funds no longer will be required. . Recommendation: Approval I in the time and amount requested. O01 Year: $80,000 Project #48 - Care of Patients Requiring Mechanical Ventilation. Critique: The Ad Hoc Cardiovascular Study Panel concluded that this project was unapprovable on the following grounds: two days is too brief a time in which to adequately and extensively learn the use of mechanical respirators; the curriculum is not fully described and the number of courses is not specified; and the budget appears high and equipment-oriented. Although some Review Committee members were not in agreement that the proposed courses were too short and the budget too high, disapproval of this project was recommended because the activity was considered fractionating in that mechanical ventilation is a technique which should be included in the general education of nurses. The application also does not address the proposed training vis-a-vis the activities of inhalation therapists. Recommendation: Non-Approval I - No DRMP funding recommended. Project #49 - A Centralized Electrocardiographic Analysis System for Six-County Area of Central Texas. Critique: The Committee agreed with the Ad Hoc Cardiovascular Study Panel that the project is well described and that there exist the cardiologic capabilities necessary to carry out the program. There was also consensus between the Panel and Committee that the funding system described appears strange. The reviewers were unable to understand why the charge for the service will be only $5.00 when the nationwide standard fee is $15.00. There was question as to why a slightly higher fee would not be justified as a mechanism for depreciating the initial equipment outlay rather than having the Federal Government subsidize the equipment expenses. The general feeling was that there must be some way to finance this commercial activity without cost to the government. Although the regionalization evident in the proposal was considered impressive, the Review Committee agreed that, in the absence of any educational component, this service project should not be funded. , TEXAS Regional Medical Program ~4- Recommendation: -Non-Approval I - No DRMP funding recommended, but RM 00047 with a message to the Region that the regionalization aspect of the project is good and that the Committee would be happy to consider a proposal which included regional education in cardiac care. : SUMMARY OF RECOMMENDATIONS and Title a Ql Year = 02 Year BR 14R 15R 48 49 Registry. . $184,396 $132,251 Stroke Demonstration Program for Progressive Patient Care. 196,244 164,344 Areawide Total Respiratory Care. 80,000 --0- Care of Patients Requiring Mechanical Ventilation. Non-Approval I A Centralized Electrocard- iographic Analysis System for a Six-County Area of Central Texas. Non~Approval I TOTAL $460,640 $296,595 DRMP/GRB 7/13/70 03 Year $§ 97,542 142,844 -~O~ $240,386 Total. $414,189 503,432 80,000 $997,621 ‘REGIONAL MEDICAL PROGRAMS SERVICE . * SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION © (A Privileged Communication) TRI-STATE REGIONAL MEDICAL PROGRAM RM 00062 7/70.1 2 Center Plaza June 1970 Review Committee Boston, Massachusetts 02108 Program Coordinator: Leona Baumgartner, M.D. Requested Program Period Ist Year* 2nd Year 3rd Year TOTAL Direct Costs $119,210 $ 96,813 $70,667 $286,690 Indirect Costs 34,711 32,542 22,849 90,102 TOTAL $153,921 $129,355 $93,516 $376,792 *(16 months) ‘History: Following a September 1967 site visit, the Region received a two-year (December 1967-December 1969) planning grant. During the first year a total of $579,468 was made available. Early during the second planning year and following a November 1968 site visit, the Region became operational. The first year operational awards totaled $436,122 during the period of February 1, 1969-December 31, 1969, for support of three projects, a Coronary Care Training Program for Nurses in New Hampshire and Massachusetts, a Cardiovascular Training and Care Program at Boston City Hospital, and a Comprehensive Cancer Care and © Training Program at the Boston University Medical Center. Support for the second year core staff and planning activities had been initially provided by a planning grant of $950,659. In May 1969 the planning grant was merged with the operational grant. The amount available for core staff and planning activities remained the same, $950,659. In August 1969, Council recommended approval of a supplemental application consisting of two projects, #5 ~ Training Program on the Diagnosis and Care of Chronic Chest Disease and #6 - Diet Counseling Service in Rhode Island. Also in August, the Region was given administrative approval to implement a feasibility study involving a Neighborhood Health Center in Rhode Island. None of these activities were funded due to DRMP fiscal restraints. In November 1969, Council recommended approval of a renewed core staff support for one year,as requested, at $1,348,730. Also partial funding was recommended for another supplemental application containing two projects: Project #7 - Looking for Gaps in Stroke Rehabilitation Care. A study in Rhode Island was not approved since it appeared to be in an early planning stage. Project #8 - Comprehensive Care of the Acute Stroke Patient was recommended for funding. Only the core staff application was funded and at the annualized level of the previous year, $994,008. Support for the second year of the operational grant, excluding core, was continued at $515,219; this amount included $102,000 of carryover funds from the first year to complete alterations and renovations and to purchase equip~ ment for the cardiovascular project (#3) at Boston City Hospital. Staff, however, TRI-STATE Regional Medical Program -2- RM 00062 7/70.1 found it necessary to place a $125,300 restriction on the $409,016 provided for the cardiovascular project pending additional information. Due toa number of inherent problems, the original proposal was approved with specific conditions. There was not sufficient evidence in the continuation application, nor in additional information recently submitted, that these conditions had been adequately satisfied. The $125,300 restriction is to remain in effect pending a technical site visit. The progress reports of the other two projects, the Coronary Care Training Program and the Cancer Care and Training Program, indicated that each was making satisfactory progress. In February 1970, the Region received administrative approval to use $64,900 of first year carryover funds to supplement Central Office core staff. The total amount, including carryover, currently provided for core staff and “ planning activities is $1,058,508. In April, administrative approval was also given to use $5,000 of carryover funds to supplement the cancer project. The Region's second year operational program is currently funded at $1,579,127 (d.c.o.), of which $171,900 is from 01 carryover. Two of Region's approved but unfunded projects, #6 Dietary Counseling and : #8 Care of Acute Stroke Patients, are to be funded in FY 1970 from the B recently released $5 million of the $20 million carried forward from FY 1969. = In FY 1971 DRMP anticipates funding the approved Feasibility Study Involving X a Neighborhood Health Center from the remaining $15 million carried forward. Present Application: Support is requested for a single program in the area of stroke. The Region believes that this project exemplifies its emphasis on the attempt to fill gaps in stroke care which has had less attention than cancer and coronary disease. Further, the three proposed centers in this project, in different sizes of community hospitals in very different communities, all linked to Boston University, should provide improved care of patients, simultaneous education of the professions om the stroke team and an opportunity for competent evaluation which will enhance the prospect for duplicating a successful demonstration. The project in this application has been through the Tri-State review process twice, having been strongly endorsed in principle, but returned for improvement in some aspects. Requested First Year - Project #9 - Regional Centers for Diagnosis and Treatment for Victims $119,210 of Stroke; A Plan for Health Care and Training - Under the administration of the Department of Neurology, Boston University School of Medicine, this three-year project proposes to organize stroke centers which will assure comprehensive diagnosis and treatment of patients with cerebral vascular disease through the development of stroke teams at community hospitals. The project is to be implemented in three stages: Stage One - organizing stroke centers at three hospitals in Massachusetts: Carney Hospital, Boston; Brockton Hospital, Brockton and Framingham Union Hospital, Framingham. Stage Two ~- educating and training members of the stroke team in the role of the team and the training, where necessary, of the members to perform their tasks. The mo team will consist of a neurologist, a fellow in cerebral vascular ed a on TRI-STATE Regional Medical Program -3- RM 00062 7/70.1 >... a staff of nurses, a social worker, a physical therapist, a vocational rehabilitation worker, a speech therapist, and a visiting nurse. Stage Three - Analysis of the operation of the stroke centers. Boston University Medical Center participants will identify the needed facilities and members of the stroke team and help recruit, organize and train personnel. The Medical Center will also assist in development of procedures for care of the patient. During last year (7/1/68-6/30/69) a total of 415 patients were admitted to the three hospitals. Patients admitted to the to be established stroke units would in most instances continue to be the private patients of the referring physicians who would work along with the Center Director, a4 neurologist, and his fellow in cerebral vascular disease. If a referring physician cannot continue to care for the patient, the Center Director will be available to assume responsibility for the patient. Unless otherwise arranged, patients admitted to the stroke center would be billed by the hospital and private physician. Training programs will be on two levels: (1) an inservice training program at the community hospital will be conducted by the B.U.M.C. Neurology Department with assistance from various medical and paramedical consultants and (2) a formal program conducted at B.U.M.C. School of Nursing, to train nurses either presently on the staff of the community hospital or new recruits with refresher courses in rehabilitative nursing in order to Qeecine on the stroke team. It is anticipated that 12 nurses will take this course during the first sixteen months. A Tentative Course Syllabus is included in the application. Evaluation plans are presented for each of the three stages of the project. Stage One will be the organizational stage which includes the hiring of personnel. The second stage toward establishment of a stroke center is the education phase. The third stage will provide an opportunity for the application of experience and will allow for defining the criteria selection of patients into the unit. Approximately 80% of the budget is for support of five part-time personnel positions: a Director, Coordinator, Assistant Coordinator, Secretary, and Center Director; and two full-time positions: an Administrative Assistant/ Data Technician and a Secretary. Funds are also requested for consultant services, equipment, travel, nurses tuition, and data processing. Second Year: $96,813 Third Year: $70,667 {RI-STATE Regional Medical Program ~4- REVIEW AND FUNDING HISTORY (Site Visit May 1967) lst Year Planning Award (12/1/67 -12/31/68 (Site Visited September 1967) (November 1967 Council) 01 Supplement (May 1968 Council) 6/1/68-12/31/68 01 Supplement (August 1968 Council) 9/1/68-12/31/68 Second Year Planning Award 1/1/69-12/31/69 (Site Visit November 1968) 02 Supplement 4/1/69-12/31/69 (February 1969 Council) INITIAL OPERATIONAL APPLICATION COMPONENTS (Site Visited November 1968) (November 1968 Council) Approved Project Period #1 - Continuing Education for Physical Disapproved with advice to rest.: Therapists #2 - Expansion and Consolidation of 3 yrs ‘Coronary Care Training-Northern Portion of the Region #3 - Inter-University Cardiovascular Pro- 3 yrs gram-Boston City Hospital FIRST SUPPLEMENTAL OPERATIONAL APPLICATION (February 1969 Council) #4 - Comprehensive Regional Medical 3 yrs Program in Cancer SECOND SUPPLEMENTAL OPERATIONAL APPLICATION (August 1969 Council) Approved Project Period #5 - Training Program on the Diagnosis 2 yrs and Care of Chronic Chest Disease #6 - Diet Counseling Service in Rhode 3 yrs Island RM 00062 7/70.1 $439,037 92,874 47,557 746,770 203,889 Funded (d.¢.o.) (01) $40,195 (02) (01) (02) (01) (02) 36,895 283,716 409,016 1/2/ 72,701 69 , 308 Approved, but not Funded lst Year Amount 107,085 TRI-STATE Regional Medical Program REQUEST FOR SUPPORT OF FEASIBILITY STUDY (August 1969 - Delegated Authority) id d progress for Provi ence (Rhode Island) THIRD SUPPLEMENTAL APPLICATION (November 1969 Council) #0-Core Staff and Planning Activities FOURTH SUPPLEMENTAL APPLICATION (November 1969 Council) #7 - Looking for Gaps in Stroke Rehabi- jitation Care #8 - Compre ngive, Care of the Acute REQUFSTS TO USE 01 CARRYOVER (February 1970 Administrative Action) #0 - Supplement to Core Staff (April 1970 Administrative Action) #4 - Supplement to Regional Medical Program in Cancer FIFTH SUPPLEMENTAL APPLICATION (July 1970 Council) #9 - Regional Stroke Centers 1/ Includes $102,000 of 01 Carryover 2/ $125,300 currently restricted 3/ DRMP Funding anticipated (The Maine RMP, Northern New England RMP and - Tri-State RMP have submitted jointly, an application for an interregional project entitled--"Interregional Coronary Care Management Information System". cation will be presented for review in earl FY 1971). RM 00062 7/70.1 Approved, but not Funded lst Year Amount Approved Project Period $ 48,620 Funded (d.c.o.) l yr $994 ,008 Approved ~- Unfunded Ist Year Disapproved with advice to resubmit 3 yrs $14,575 3/ Funded (d.c.o) 1 yr $64,900 1 yr $ 5,000 This appli- y DRMP 5/5/70 (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE TRI-STATE Regional Medical Program RM 00062 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee concluded that this single component application requesting $286,690 (d.c.o.) for a three-year program period should be approved at the reduced amount of $253,900. Project #9 - Regional Center for Diagnosis and Treatment for Victims of Stroke: A Plan for Health Care and Training. Critique: The Committee found this to be a straight forward approach for a program which would be under the direction of qualified personnel. The hospitals involved have the necessary equipment and will be adequately staffed. The training programs are designed to upgrade the capability of existing personnel. The only concern expressed by the Committee was that the project was overstaffed in the area of overall program direction. The budget requests support for a Director (10%); a Coordinator (80%) and an Assistant Coordinator (50%). The Committee believed that the equivalent of one full-time physician should be adequate rather than the 140% time represented by these three positions. Further, the amount provided for the full-time physician should be based on the annual salary requested for the Coordinator. Recommendation: Approval I provided the amount for personnel be reduced each year as outlined above. The approximate amounts recommended for approval are $105,300 the lst year, $85,600 the 2nd year and $63,000 for the 3rd year. Dr. Proger was not present during the deliberation of this application. DRMP/GRB 7/8/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) VIRGINIA REGIONAL MEDICAL PROGRAM RM 00049 7/70.1 Medical College of Virginia June 1970 Review Committee 12th & Broad Streets Richmond, Virginia 23219 Program Coordinator: Eugene R. Perez, M. D. Requested Program ; Period: lst Year 2nd Year 3rd Year TOTAL Direct Costs $268,552 $480 ,479 $533,504 $1,282,535 Indirect Costs 16,265 33,155 34,302 83,722 TOTAL $284,817 $513,634 $567,806 $1,366,257 BISTORY: (A list of the projects indicating Council action can be seen . on the attached Review and Funding History.) The Virginia RMP received its initial planning grant award in January 1967. The applicant organization was the University of Virginia School of Medicine in Charlottesville, Virginia. On July 1, 1967, Dr. Eugene RP. Perez was appointed as the full-time Program Coordinator. When the continuation application was submitted in late January 1968, the responsible fiscal agent was changed from the University of Virginia to the Medical College of Virginia in Richmond, now known as the Virginia Commonwealth University. Early in July 1968, the Virginia RMP submitted an operational grant application requesting funds for sixteen projects. Council did not approve operational status for the Region but did approve continuation support of planning activities. The Region resubmitted their initial operational grant application to the December 1969, Council and site visit was made to the Region on October 1~2,1969. The December 1969 Council concurred with the recom- mendation of the site visitors and the Review Committee that this Region be awarded operational status. Of the seven projects in the application, Council approved five projects and disapproved two projects. The amount VIRGINIA eae "RM 00049 7/70.2 Regional Medical Program - of funds approved for three years by Council for this applica- tion totaled $1,013,746 (d.c.o.) (01 year - $345,695, 02 year - $330,676, 03 - $337,375). In February 1970, the DRMP staff reviewed this Region's con- tinuation application requesting support of the core componént. Changes in. the staffing pattern were noted which had a net effect of diminishing the number and total effort of physicians involved in the core operation. Furthermore, the Region had expended only 55.1 percent of its funds. To permit time for the Region to clarify the rationale for the new staffing pattern and to project its rate of expenditures, an award was made at the committed amount of $475,255 (d.c.o.) with a restriction on the use of $100,000. The restriction is still in effect. In March 1970, Council approved the Region's first operational supplemental application requesting $662,694 (d.c.o.) for support of two. projects (#8 - State-wide Tumor Registry, #9 - Continuing Education for Nursing Personnel). PRESENT APPLICATION: This is a supplemental operational applica- tion requesting a funding level of $1,282,535 for three years support of one project. It is Project #10 - Virginia Model Multiphasic Health Screening System, a resubmittal from the initial operational application submitted to the December 1969 Council. The December Council concerns about this project were that the project needed to better identify the population it expected to reach, and should have included a formalized method for the selection of clinical testing and computer systems to be used. Project #10 - Virginia Model Multiphasic Health Screening _ Requested System - Virginia Commonwealth University. This First Year project is submitted by the Medical College of Virginia and it $268,552 proposes to demonstrate through a model program ways and means of more efficiently applying new technical knowledge to the benefit of more people through improved medical manpower utilization and economy of services. The project will develop and operate a model system of early disease detection which would demonstrate, stimulate and assist in the more effective application of new disease detection methods throughout the VIRGINIA -3- RM 00049 7/70.1 Regional Medical Program Virginia Regional Medical Program. The center will be designed primarily to serve the Richmond Medical area (population 570,909) and will be located at the Medical College of Virginia Clinical Center. The system of referral will be developed and operated through a cooperative arrangement (and/or contractual agreements) between the Medical College of Virginia, the Medical College of Virginia Hospitals, and: -private physicians -official health agencies -participating hospitals -welfare agencies ~medical societies -insurance and other third party -voluntary health associations payment organizations ~industries It is expected that during the first year 3,000 persons will be screened, second year of the.project 10,000 people will be screened and from the third year on, carry a patient load of 20,000 per year. The proposed screening tests to be performed will be procedures for the presumptive identification of: -Tuberculosis -Syphilis ~Visual defects -Diabetes ~Hearing defects ~Cancer -Cardiovascular diseases The model program will also be utilized for demonstrations, and training of medical and paramedical personnel in the application of multiphasic health screening. Some of these activities will be: to demonstrate the application of multiphasic health screening to 50 selected practitioners per year; to train 50 technicians per year in the performance of multiphasic health screening tests; to serve as a laboratory demonstrating multiphasic health screening service to 130 medical students per year; to serve as a physical model for the development of other screening facilities in the Virginia Regional Medical Program subregions. All cases detected with suspected disease will Le referred to their attending physician for a conclusive diagnosis and/or treatment. Screening results and a request for a disposition will be sent to physicians of patients referred from the screening center. In instances where follow-up review reports are not received by the screening center, the local health department will investigate and take action necessary to obtain follow-up and disposition. Follow-up VIRGINIA —— re RM 00049 -7/70.1 Regional Medical Program , , to final disposition of each case will be coordinated by the screening center. , The evaluation criteria to be utilized in this program will .involve a study of the following: reliability and vadility of tests utilized; productiveness of the screening tests; cost benefit ratio; adequacy of follow-up; and acceptance by physician health agencies and the general population. In the second year of the project, patients will be required to pay a $35 service charge which will give a revenue to the program. Because of this revenue, the amount of support. required from RMP grant funds will decrease during the second and third years and thereafter it will be self-supporting. The estimated budget request for 02 year is $480,479 (d.c.o.) and the expected revenue from the projected 10,000 people to be screened is $350,000. The estimated budget request for 03 year is $533,504 (d.c.o.) and the expected revenue from the pro- jected 20,000 people to be screened is $455,000. If the projected revenue for 02 and 03 years are realized the total support from the DRMP will be approximately $130,479 (d.c.o.) for 02 year and $78,504 (d.c.o.) for 03 year. Construction costs and major capital outlay for equipment will be supported on a matching basis between the Medical College of Virginia and the Hill-Burton Program. The major portion of funds requested from the DRMP are for personnel and rental cost for space in the Clinical Center. Second Year: $480,479 ‘Third Year: $533,504 VIRGINIA Se RM 00049 7/70.1 Regional Medical Program REVIEW AND FUNDING HISTORY lst-Year Planning Award 1/1/67-12/31/67 Amount of Award $226,800 (dec) (University of Virginia) 2nd-Year Planning Award 3/1/68-2/28/69 Amount of Award $254,000 (d.c.o.) (Grantee organization changed to the Medical College of Virginia, now known as the Virginta Commonwealth University) Planning Renewal Award 3/1/69-2/27/72 Amount of Award $475,255 (d.c.o.) (An operational applica- tion was submitted to the November 1968 Council which included 16 projects. It was disapproved by Council and instead this renewal award for Core planning was approved. ) Initial Operational Award 1/1/70-12/31/70 Funded (Submitted to December 01 - $ 345,695 1969 Council) (Site visit- Commitment October 1-2, 1969) (Award - 02 - 330,776 Pending Availability of Funds) 03 - 337,375 $1,013,846 (d.c.o.) PROJECTS #1 - Myocardial Infarction Funded Training Program (Medical O1 - $ 118,000 College of Virginia) (Previously Commitment submitted and revised) (req. 01 - 02 - 118,000 $223,792) 03 - 118 ,000 #2 - Coronary Care Evaluation Funded (University of Virginia) Ol $ 50,306 (req. O1 - $50,306) Commitment: 02 50,306 03 50,306 VIRGINIA 7 ~6- Regional Medical Program _ #3 - Cardiovascular Resucitation Training (req. OL - $75,865) #4 - Stroke in a Small Rural Community (req. O01 - $73,375) #5 - Stroke Program and Training Unit (Medical | College of Virginia)° (req. 01 - $308,800) # 6 - Virginia Model Multiphasic Health Screening System - (req. O01 - $253,662) #7 - Virginia Medical Information System (req. O1 - $124,010) First Operational Supplemental Application (March 1970 Council) #8 - State-wide Tumor Registry (req. 01 - $113,584) #9 - Continuing Education for Nursing Personnel (req. 01 - $111,860) Second Operational Supplemental Application (July 1970 Council) #10 - Virginta Model Multiphasic Health Screening System (req. O01 - $284,817) (resubmittal) RM 00049 7/70.1 Funded O1 - $48,589 ’ Commitment 02 - 39,995 03 - 41,294 Funded 01 - $63,800 Commi tment 02 - 57,375 03 - 62,775 NON-APPROVAL Revision Required NON~APPROVAL Revision Required Funded O1 - $65,000 Commitment 02 - 65,000 03 - 65,000 APPROVED APPROVED UNDER REVIEW VIRGINIA REGLONAL MEDICAL PROGRAM RH 00049 7/70.1 OBSERVATION: peta can meen Shane nM ML Project #10 ~ Virginia Model Multiphasic Health Screening System: (Virginia Commonwealth University). Addendum: Subsequent to the Review Committee meeting a revised budget was : received from the VRMP which decreases the direct cost and increases the indirect cost requested in the budget submitted with the application. The direct cost was reduced because the Region descovered that the facility which will house the project is owned by the Virginia Commonwealth University (Grantee) and it is inappropriate to charge rental for space to this project, The indirect cost was increased because the On-Campus overhead rate for salaries and wages is higher than the previously requested off-Campus overhead rate. The Comnittee's recommendations should be amended as follows: (Direct Cost) Initial Committee Amended Project Year Request Recommendation Request #10 O1 $268 ,552 $268,552 $252,302 02 480,479 480,479 447,979 03 533,504 533,504 501,004 TOTAL (d.c.0.) $1,282,535 $1,282,535 $1,201,285 RMPS/GRB/7/10/70 A Privileged Communication i 4 SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE VIRGINIA REGIONAL MEDICAL PROGRAM RM 00049 7/70.1 FOR CONSIDERATION BY JULY 1970 ADIVSORY COUNCIL The Review Committee concluded that this application which requests |: 2,282,535 (d.c.o.) for a three-year program period be approved with conditions at the requested level for three years support of Project #10- Virginia Model Multiphasic Health Screening System, IQ a o wt fag ~ Ro NE Background: This project was submitted to the December 1969 Council and was disapproved. The December Council's concerns about this project were that the project needed to better identify the population it expected to reach and should include a formalized method for the selection of clinical testing and computer systems to be used, Project #10 ~ Virginia Model Multiphasic Health Screening System: (Virginia Commonwealth University.) ique: Committee believed that this application represents a marked improvement over the previous application. Many of the previous. ptoblems have been corrected, The training, education and evaluation components have been developed in greater detail and strenthened. Cooperative | “arrangements have been documented, Consultation has been’ obtained on the selection of screening tests and on the use of computers respectively from the clinical staff of the Medical College of Virginia and from the Mitre Corporation, However, the project still has areas of weakness, such as no guaranteed adequate patient intake and specifics on how the computer time requested will be utilized. An influencing factor on Committee's decision to approve this project is the program's projection for revenue which will allow it to assume the major portion of support for the program during its second and third year and henceforth, Committee would like the Region to provide a machanism through which patient intake and revenue can be guaranteed, as has been projected in the second and third year of the project. Although the patient follow-up plan has been improved, Committee believes it can be further strengthened. Recommendation: Approval I - provided the Region submit additional informa~- | he tion showing: (a) Thet the Region can provide a mechanism which will guarantee the patient intake and revenue which it has projected, (b) That the Region can adequately justify the amount of computer time it has requested. If not, the amount requested for this item should be deleted when the firse year's award is granted. First Year, Second Year Third Year Meee EE metre UENCE SEAN SEPNe USE RANEL $268 , 552 $480,479 “5337508 wt ed r VIRGINIA RMP “Qe RM 00049 7/70.1 REVIEW COMMITTEE FUNDING RECOMMENDATIONS Project Year Requested Recommended #10 01 $268 ,552 $268,552 02 480,479 480,479 03 533,504 533,504 TOTAL $1,282,535 $1,282,535 | RMPS/GRE/7/10/70 A Privileged Communication ‘ SPECIAL ACTION VIRGINIA REGIONAL MEDICAL PROGRAM RM 00049 Subject: Project #4 - Stroke in A Smakl-Rural Community - Medical College of Virginia Request: The Virginia Regional Medical Program has requested that the restriction from the NAC on Project #4 be lifted so that the program can be activated. The approved level of funding is as follows: O1 year - $73,375; 02 year - $64,050; 03 year - $71,050; a total of $208,475 for three-years support. Background: The Virginia Regional Medical Program submitted to the December 1969 Council as one of its initial operational proposals Project #4 - Stroke in A Rural Community. Council action on this project was Approval I, as recommended by the site visit team, contingent upon the necessary certification of the Maple Lawn Nursing Home by Medicare as an extended care facility. This program will study the incidence of stroke and the management of patients with stroke by general practitioners in a rural community. It will attempt to discover what changes are needed and whet changes can be made in the pattern of care of patients with stroke by general practitioners in a rural community. This will be done by close and regular consultation with specialists from the medical center coming to the rural community and by providing for further training of the local personnel, both in their home community and the Medical Center. The small community in which this study is to be done is Blackstone, Virginia with a population of 5,000 and is located approximately 70 miles from the Medical Coilege of Virginia. In the community there are three general practitioners who have a group practice, a physical therapist and two Public Health Nurses. In addition to the three physicians in Blackstone, there are general practitioners in four small adjacent towns and all have agreed to cooperate in the program. A site visit to this Region was conducted in October 1969 and the visitors noted that the problems with Project #4 were basically the same as those reflected by a previous site team; specifically, that the Maple Lawn Nursing Home is functioning as an intermediate care facility but is not accredited to receive Medicare services. The site visit team, however, was impressed that the proposal has been expanded to include the participation of seven community physicians from the sur- rounding areas. The proposal has also been expanded to involve the community physicians in the training of other practicing physicians through the Region. These additional activities and the fact that one of the general practitioners involved in the program is the President of Virginia Academy of General Practice, were considered added strength. . SPECIAL ACTION - Virginia RMP -2- RM 00049 The site visit team felt the program had the pot ial outreach to strengthen much-needed regionalization for this gion, since it involves the Medical Center, community hospitals, community physi-~ cians, nurses, etc. The Virginia Regional Medical Program has indicated that the lack of certification for the Maple Lawn Nursing Home stems from: (a) the Home not providing 24-hour nursing service and (b) certain architectural deficiencies. Recent information received from the Region informs us that the nursing home has been purchased by a large nursing home corporation, Progressive Care, Incorporated. The new owners have indicated that all deficiencies that have prevented accreditation by Medicare will be corrected. Dr. Mack I. Shanholtz, State Health Commissioner, contends that the facility complies with Medicaid requirements but it still lacks Medicare certification. The Virginia Regional Medical Program also contends that the project and the nursing home are not inter-related except for an occasional patient that may become part of the statistical report of the study. The Virginia Regional Medical Program has expressed concern that the contingency of certification by Medicare will delay the implementation of this project indefinitely. They have indicated to staff that the project has a high priority and have requested that the restriction be lifted. Staff recommends that Council consider a temporary waiver of the restriction so that the project can be implemented immediately, subject to the condition that all deficiencies are corrected by December 31, 1970. This date is six months subsequent to new ownership and coincides with the end of the current grant period. This should allow the facility sufficient time for alterations and renovations to be implemented and the initiation of 24-hour nursing services that Medicare certification requires. DRMP /GRB 7/10/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) REGIONAL MEDICAL PROGRAM RM 00013 7/70.1 (formerly 3/70.1) for WESTERN NEW YORK February 1970 Review Committee. 2929 Main Street March 1970. Council Buffalo, New York 14214 June 1970 Review Committee Program Coordinator: John R. F. Ingall, M.D. Requested Program Feriod lst Year 2nd; Year 3rd Year Total Direct Costs $ 988,174 $ 872,987 S 895,199 $2,756,360 Indirect Costs 183,680 192,864 202,507 579,051 Total $1,171,854 $1,065,851 $1,097,706 $3,335,411 History: The initial planning period for the Western New York Regional Medical Program began in December 1966, and the first award for operational support was made in March 1968. This Region's annual level of support is $1,428,915 (total costs): $390,377 for core activities and $1,038,538 for six operational projects. Two additional projects (#'s 13 & 14) have been initiated from carryover funds. December 1969 Council recommended disapproval of a proposed Medical Genetics Clinic, but recommended approval of three projects in a total amount of $276,522 direct costs for the first year: Topical Chemotherapy Treatment for Precancerous Lesions and Cancer of the Skin (#13), Infor- mation Dissemination Service (#14), and a Respiratory Intensive Care Unit (#35), which is a supplement to the ongoing Project #3 - Chronic Respiratory Disease Program. A request for continuation of the present operational program will be submitted in mid-January 1970. Present Application: Support is requested for the initiation of three projects: A Total Regional Program in Dialysis (#15), a Regional Coagulation Reference Laboratory (#16), and A Regional Program for the Prevention of Atherosclerotic Disease (#17). A fourth project was originally submitted with this application--Radiotherapy Technician Training Program--but subsequently was withdrawn because of the DRMP policy not to support basic education and training in established health professions. REGIONAL MEDICAL PROGRAM for WESTERN NEW YORK -2- RM 00013 770.1 Requested First Year Project #15 - A Total Regional Program in Dialysis. $623,970 This project is designed to expand dialysis- transplant services in the Region through the development of a training program for all levels of personnel to be centered in five hospitals, (Buffalo General, Deaconess, E. J. Meyer Memorial, Roswell Park Memorial Institute in Buffalo and Hamot Hospital in Erie, Pennsylvania). It is hoped that the program will increase the number of patients for which treatment is available, develop a communications system among hospitals to insure referral of patients to hospitals which can provide care, make it possible to locate dialysis facilities throughout the Region, establish criteria for evaluating resources, and maintain a continuing education program and consultation service. The planned training program will permit each hospital to teach the techniques it uses with its equipment, form an integrated faculty with participants from each of the five hospitals, offer appropriate training aimed toward physicians, nurses, technicians, and patients' families (courses for other allied health personnel will be instituted at a later date), and train personnel to develop and expand the resources of the Kidney Bank and Research Society of Buffalo and Western New York. The training courses which have been planned are approximately six weeks in duration, and outlines of the content of each are provided as appendices. 1. Physicians. This program will consist of three parts: didactic, clinical observation and instruction in each of the five centers, and four weeks at the hospital of the participant's choice. The trainee could also accept a several-month fellowship, either at one of the participating hospitals or rotating among them. Funds for six such fellowships are requested. 2. Nurses. During the first two weeks the theory and factual basis for dialysis-transplant treatment will be presented. ‘The last four weeks will be devoted to clinical experience, during which time the nurse will learn to operate the equipment and provide optimal care to the patient. Conferences will be scheduled occasionally during the six weeks. 3. Technicians. In the course for nurse technicians, mecharical technicians and laboratory technicians, the initial two weeks will be spent on the theory and background of dialysis, and the remainder of the time on clinical experience appropriate to each type of technician. There will also be conferences. 4. Families of Patients on Home Dialysis. The training will start with two weeks of theory and background information (during which time the trainee will also observe dialysis in the hospital), followed by REGIONAL MEDICAL PROGRAM for WESTERN NEW YORK -~3- RM 00013 7/70.1 t several weeks of actual dialysis performance in the hospital under supervision, and terminating with a period of the trainees performing home dialysis with hospital personnel available for consultation. The length of this final period of training will vary according to individual need. Thereafter, the families will be encouraged to participate in periodic group discussions. It is estimated that 20 physicians and 100 nurses and technicians will receive training, with their hospitals paying their full salaries during the six-week training period and the grants providing $12 per day allowance. Ultimately, it is hoped that the employing hospitals will assume the Latter expense. Evaluation techniques will include pre- and post-training tests, faculty evaluation of trainees, and six-month follow-up assessments by employing institutions. When the program has had more experience, an evaluation of its impact on the community will be undertaken. The major portion of the requested budget is concentrated in the categories of personnel and "other." "Other" includes funds for fellowships, labor- atory tests, costs of blood, reimbursement to participating hospitals, maintenance and repair of equipment and per diem for trainees. Second Year: $615,856 Third Year: $625,722 Requested First Year Project #16 ~ Regional Coagulation Reference Laboratory. $256,041 This request is for the establishment of a blood coagulation reference Laboratory which would have training, service, and research components. Although Roswell Park Memorial Institute has been providing some free services in this field, increasing community needs and decreasing funds for Roswell Park have prompted the submission of this proposal. An education program will be developed which will include: 1. Medical Laboratory Technician Training. Students at the SUNY Buffalo Department of Medical Technology will receive instruction within the framework of the school's course in hematology and practical experi- ence in the laboratory itself (approximately 50 lectures and demonstrations per year), laboratory training will be provided technicians from community hospitals, and graduate laboratory technicians will participate in quarterly, week-long seminars and workshops. 2. Medical Students. Approximately 25 hours annually will be devoted to lectures and demonstrations in hemostasis and blood coagulation problems (will be incorporated into the Medical School's curriculum), REGIONAL MEDICAL PROGRAM , for WESTERN NEW YORK -4- RM 00013 7/70.1 third and fourth year students on clinical services will have access to consultations with the staff, and summer fellowships in coagulation will be available through the School of Medicine. 3. Post-Graduate Training. Periodic lectures, laboratory demon- strations, films and videos will be offered in cooperation with the Department of Post-Graduate Medical Education. The laboratory will also offer an intensive two-week course each year, and participate in two separate hematology fellowship programs. It is hoped that this educational program will produce an increase in experienced coagulation medical personnel and provide well-trained technicians for community hospitals. The proposal calls for the provision of clinical consultation services to physicians. Laboratory consultation service will also be offered because, although the laboratory will not perform any routine coagulation studies for area hospitals, in order to have clinical material available for the various training and testing programs, it is considered necessary for the laboratory to engage in limited clinical service. One hundred twenty cases per month is the estimated load of hematologic workups for more complex problems of blood coagulation and hematosis. Special diagnostic reagents and sera will be prepared and made available, work will be done on standardizing tests, and a voluntary program of quality control will be conducted. Research will not be emphasized, but will be conducted as necessary. The requested costs are primarily for personnel and equipment. Second Year: $183,282 Third Year: $192,186 Requested First Year Project #17 - A Regional Program for the Prevention of $108,163 Atherosclerotic Disease. In an effort to identify people in the Region with a high risk for heart disease and stroke, a reference lipid laboratory will be established to measure serum cholesterol, serum triglyceride, and lipoprotein electrophoresis on the following high-risk groups: Patients with coronary artery disease Patients with peripheral vascular disease Patients with xanthomata First-degree relatives of hyperlipemics. mH Nm Fe Although cholesterol determinations are being performed now in many hospital laboratories in the Region, neither triglyceride nor lipoprotein electrophoresis measurements are available on a service basis. The proposal states that in order to diagnose the exact lipid abnormality and prescribe the proper therapy, all these measurements must be performed. REGIONAL MEDICAL PROGRAM for WESTERN NEW YORK -5- RM 00013 770.1 According to the proposed protocol, all chemical determinations on the blocd sera will be done locally and the sera will then be shipped to the central laboratory where lipid analyses will be performed at no charge to the high-risk patients. The laboratory test results will be furnished the referring physician as well as the clinical director and nutritionist consultant of this study who will recommend to the physician appropriate diet and drug therapy. All therapeutic decisions are ultimately, however, those of the patients’ private physicians. On request of the physician, the proposed program will also offer direct dietary counseling service to. the patient (either by telephone or in person if the patient can travel to Buffalo) and provide specific dietary recommendations and appropriate teaching materials to the physician. The nutritionist will also work on developing new approaches to patient teaching. Therapy evaluation is planned. [It is hoped that the program will be self-supporting within three years. The requested budget is primarily for personnel and equipment costs. Second Year: $73,849 Third Year: $77,291 Critique: February 1970 Review Committee General: The Review Committee recommended that all three projects in this application receive a technical site visit and be returned to Committee. It was observed that the Western New York Region is one of the better RMP's: it is well organized, well managed, and has a reasonable spread of regional activities. The Committee noted that two of the projects in the current appli- cation (#'s 16 & 17) signify a trend of moving toward a series of isolated specialized laboratories instead of general diagnostic Laboratories, and was curious as to the economics of such a trend. Project #15 - A Total Regional Program in Dialysis Critique: Committee agreed with the Kidney Disease Program, Regional Medical Programs, that the proposed dialysis project is truly comprehensive with a well-organized plan of operation. The educational programs were considered excellent. The proposal speaks not only to the technological aspects of dialysis, but the social problems brought about by the impact of technology upon the patient are also considered. The Kidney Disease Program questioned the wisdom of establishing dialysis centers in five hospitals, and it suggested that the project be limited to two or three hospitals. This would reduce redundant expenditures. There was also some concern on the part of the Committee about the appropriateness of the five-hospital plan, especially since one of the hospitals is a cancer research institute. However, most Committee members approved of starting the program in the five hospitals, particularly in view of the fact that inte- gration of activities is planned. The Kidney Disease Program further had questions about some items of equipment, equipment main- tenance costs, and the lack of information regarding the intention REGIONAL MEDICAL PROGRAM for WESTERN NEW YORK -~ 6 - RMO0013 7/70.1 Other questions of the Committee included: 1. Is the New York Kidney Institute at Albany involved in this project and is this application to set up an alternate Kidney Institute in the Western part of the State? 2. Why is $62,500 requested for hospital costs? Will the New York Blue Cross/Blue Shield not pay for this? It seemed to the reviewers that the dialysis program should be able to support the beds (if Blue Shield does not) and the laboratory tests. 3. How long does the Region envision the training program's continuing? How many people need to be trained eventually? Will the educational program train only people from the Western New York Region or will it seek to provide trained personnel for other Regions? 4. How does the proposed program tie in or compare with the home dialysis training progamof Central New York (approved but as yet unfunded)? Although the Committee seriously considered recommending Approval II (no additional funds recommended), with the amount allocated to the project not to exceed $500,000, it was decided that in view of the questions raised a technical site visit would be worthwhile. Recommendation: No action taken - need technical site visit. Project #16 - Regional Coagulation Reference Laboratory Critique: Although the Committee could see the need for improvement of laboratory facilities, it was unimpressed with the teaching aspects of this proposal. The project appeared to the reviewers to be primarily basic service with an educational component tacked on as an afterthought. It was observed that Roswell Park already has an ongoing program in blood coagulation but that this institution is runningintofinancial difficulties and needs new sources of support. Eventual phasing out of RMP support is not discussed in the application. The proposal received a technical evaluation by the Coagulation Section, Laboratory of Blood and Blood Products, Division of Biologics Standards, NIH. Their reviewer had (1) concerns regarding the need of individual hospi- tals for specially trained staff since the referral laboratory will perform the more specialized tests, (2) specific questions as to reagent preparation and procedures, and (3) doubts about certain items in the supplies and equipment categories. The project was considered to be very expensive. In sum, although the Committee recognized the need for more specialized laboratories, the educational component of this proposal is unimpressive REGIONAL MEDICAL PROGRAM for WESTERN NEW YORK -~7- RM 00013 7/70.1 and the budget is extremely large. Consideration was given to a recommendation of Approval II (no additional funds recommended) to permit support of the project until funding from other sources could be obtained or until the activity became self-supporting, but it was decided finally that a technical site visit would be a more appropriate recommendation. Recommendation: No action taken - need technical site visit. Project #17 - A Regional Program for the Prevention of Atherosclerotic Disease Critique: The Review Committee observed that this proposed project seems to be hanging free in space and appears not to be coordinated with any other activities. The only backup letter is from the local Heart Association. The reviewers were concerned that it is not tied in with already existing programs of such groups as the Diabetes Association, VNA, Public Health Nurses or activities of the State Health Department. The Ad Hoc Cardiovascular Study Panel suggested that: (1) expert consultation be sought relating to the feasibility of the project, (2) consideration be given to deleting electrophoresis on all initial examinations, and (3) a site visit be made. The Panel also questioned the documentation of need for the project, whether a single dietician can perform all the duties outlined, and whether a greater precentage of the budget might not be assumed by the local or State Health Department. The Committee initially recommended that the application be returned for revision but on reconsideration decided to recommend a technical site visit. Recommendation: No action taken - need technical site visit. March 1970 Council Action: Council concurred with the recommendation of the Review Committee that the three projects receive a technical site visit Site Visit - May 18, 1970 A report will be available at the Committee meeting. RMPS /GRB 5/25/70 REGIONAL MEDICAL PROGRAM , for WESTERN NEW YORK - 8- RM 00013 2/70.1 HISTORY SUPPLEMENT ‘Current Year's Support or, Initiation Project # Project Title Status (DCO) Date 1 A Two-Way Communication Network $180,253 3-1-68 2 Coronary Care Training 168,152 3-1-68 3&35S Chronic Respiratory Disease Program 655,379 3-1-69 and Respiratory Intensive Care Unit 4 Immunofluorescence Service and Training 34,590 6-1-69 5 Computer-Based Regional Poison Control Program Disapproved 6 Pilot Study in Nuclear Medicine Terminated 3-1-69 7 A Test of Two Continuing Medical Education Techniques 17,920 6-1-69 8 Planning and Education Program in Renal Disease Terminated 6-1-69 9 Core 346 ,206 12-66 10 Tumor Registry 46 ,294%* 6-1-69 il Medical Genetics Clinic Disapproved- Inappropriate for RMP Funding 12 Provide via the Mass Media Information to the Impoverished Residents of the Region Disapproved 13 Topical Chemotherapy Treatment for Precancerous Lesions & Cancer of the Skin 47,454 4-1-70 14 Information Dissemination Service 31,960 4-1-70 * Total of $1,528,208 includes $347,046 carryover monies kk $23,147 restricted pending Council Action on this project (see Special Action) RMPS/GRB 5/25/70 (A Privileged Communication) ‘SUMMARY OF RILVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE WESTERN NEW YORK REGIONAL MEDICAL PROGRAM RM 00013 7/70.1 FOR CONSIDERATION BY JULY £970 ADVISORY COUNCIL General: February 1970 Committee recommended that the three projects “in this application (along with the Tumor Registry proposal which is presented as a Special Action) receive a technical site visit. The visit was made on May 18 and the report of the site team was available to the Committee reviewers. It was observed that the Western New York RMP is very well organized and has good regionalization. The Committee concluded that this application which requests $2,756,360 for a three-year rogram period should be partially supported at the reduced amount of 890,000. Project #15 - A Total Regional Program in Dialysis. Critique: The Committee reviewers were impressed with the regionalization evidenced by the project design and noted that the Region has the five components necessary to the success of such a program, i.e., dialysis capability, satellite centers, an organ retrieval system, a tissue typing facility, and transplant competence. Committee agreed with the technical site visitors that the educational component for nurses, techni- cians and other allied health personnel had considerable merit but that the plan for physician training was unrealistically ambitious. Further, the physician fellowship program falls outside the purview of RMP in that it is designed primarily for those who would use this time as part of their training for board certification. The equipment needs of the project were considered to be far less than indicated in the application. The Committee experienced the same difficulty as the site visitors in determining the rationale for creating five dialysis centers. Although the site team thought that a more efficient way to handle the training program would be to establish only three centers, the Committee reviewers preferred a reduction to. two. There was some sentiment among Committee members that perhaps Western New York had-more important problems. than end-stage renal disease. And there was concern, as well, as to the wisdom of establishing dialysis centers in the absence of any national blueprint. Parenthetically, the review of this project emphasized the problems caused by the lack of guidelines to be used in evaluating the plethora of dialysis projects being presented for Committee consideration. The following minocity report was submitted by one member. "ZT cannot support a dialysis program.of this scope which: is not integrated into interregional planning for terminal renal disease care, + Regional Medical Program is not educationally directed at anything but terminal _ renal disease and lacks pediatric renal diagnostic and preventive training, is solely community hospital based and does not have the direction of a major medical center, has no provision for subsequent funding at end of year 3. I suggest the Region has lost track of its real health priorities for doctors! priorities." reported enthusiasm of the project personnel, the regionali- zation aspect of the program, and the quality of the project itself prompted the Committee (with one dissenting vote) to recommend Approval I in a reduced amount of $250,000 for each of three years to provide for the establishment of dialysis centers at two hospitals. Specifically: the training courses for nurses, technicians, and other allied health personnel should be instituted as planned (but in two hospitals rather than five); the training program for physicians should be less ambitious and limit itself to familiarizing participants with aspects of dialysis necessary for local physicians; the personnel for training should be reduced to that necessary for only two centers; and the costs for all equipment, fellowships, laboratory tests and reimbursements to hospitals should be deleted from the operating budget. 01 - $250,000 02 - $250,000 03 - $250,000 Project #16 - Regional Coagulation Reference Laboratory. have such a central laboratory with personnel of such expertise, - the project goals appear overly broad in that, in addition to the training of technicians from outlying hospitals, the project design calls for the performing of complete coagulation studies on patients from throughout the Region in order to have clinical material. to teach medical students, techni- cians and other interested personnel. Physician education would result only as a consequence of discussion and handling cf referred cases. The Committee reviewers agreed with the technical site team that although the goal of having a reference and standardizing laboratory was an excellent one, the rest of the teaching and service aspects should be diminished considerably. .A more reasonable and adequate objective was seen to-be the training of techinicians ‘from outlying hospitals to perform coagulation tests. It was thought that a greatly reduced budget would be sufficient for such an endeavor. WESTERN NEW YORK ~3- KM UDULS ///UEL Regional Medical Program commendation: Approval I for three years in a reduced amount with the following conditions: 1. Revision of project goals as indicated above. 2. Provision with the third-year continuation request of a report on the progress and impact of the project in the first two years of operation including a discussion of the appropriateness of the testing costs, 01 - $60,000 02 - $40,000 03 - $40,000 Project #17 ~- A Regional Program for Atherosclerotic Disease. Critique: The Committee reviewers agreed with the technical site visit team that any study of the type proposed should be directed more toward primary than secondary prevention, that the value of performing electrophoresis on all patients was questionable, that the follow-up methodology was deficient, and that the budget was excessive. It was noted that the project had not received a review by a cardiovascular group at the Regional level. In general, the feasibility of the proposal was doubtful and the value of the dietary management and plans. for physician education left muct to be desired. Recommendation: Non-Approval I - no DRMP funding recommended. SUMMARY OF RECOMMENDATIONS : PROJECT Ol Year 02 Year 03 Year TOTAL #15 - Regional Program in Dialysis $250,000 $250,000. $250,000 $750,000 #16 - Coagulation Reference 60,000 40,000: 40,000 140,000 Laboratory #17 - Prevention of Atherosclerotic ~O0- -O-~ ~O- -0- Disease TOTAL $310,000 $290,000 $290,000 $890,002 DRMP/GRB 7/13/70 G Privileged Communication) SPECIAL ACTION REGIONAL MEDICAL PROGRAM FOR WESTERN NEW YORK RM 00013 February 1970 Review Committee March 1970 Council - pune 1970 Review Committee if Project #10 ~ Western New York Tumor Registry 7 When this project for a Tumor Registry was reviewed in April-May 1969, it was considered by Committee and Council to bé of good design with well-documented procedures. Approvaj, for a five-year period was recommended in the amount requested and the project was funded in June 1969. During staff review of the progress report and continuation application for the Tumor Registry in mid-February 1970, it was discovered that the three key people who submitted the proposal. had left Roswell Park and that a new project director had been found who, with the help of the Hospital Management Engineering Program of the, Western New York Hospital Association, evaluated the project design and concluded that the supporting services to be provided by such an automated system must be revised. Although the original proposers had envisioned the registry's usefulness in "epidemiological research, clinical-pathological- mortality correlations, and diagnostic/treatment method evaluation," and described a highly innovative and unique, technologically-oriented registry, an abstract form designed to include all the. proposed items is now deemed by the Region to be far too lengthy and complex, especially in light of the costs involved and the volume of paperwork which would be required. Consequently, the primary objective of the project has been revised to become improved patient care through improved followup. A shortened abstract form of 41+items has been adopted. In short, the registry which is now being implemented is significantly different from that originally proposed and approved by Review Committee and Council. In view of this change in design, the 02-year award for this project carried a restriction on use of half the funds until Review Committee and Council recommend acceptance of the revised plan. The Region has been asked to. submit information as to the degree and kind of difference between the original and the revised project, the acceptability of the revised design to the Regional Advisory Group, and the relative priority of this project in the Region's overall plan. Gritique: February 1970 Review Committee. Review Committee, recommended ; that a techriical site visit team evaluate the revised project as compared to that originally approved by Committee and Council. Committee noted that the revised tumor registry is of standard design and provides information for followup and teaching purposes. The reviewers thought that since the project plan now includes fewer facets than did the original proposal, the budget might be reduced. A technical site visit was considered necessary to evaluate the differences between the original end revised projects. It was suggested that the site tean also investigate the relationship of Roswell Park Memorial Institute to the Western New York Regional Medical Program. Recommendation: Defer for technical site visit and return to Committee. Western New York RMP -2- RM 00013 7/70 Special Action March 1970 Council Action Council agreed with the Review Committee that action should be deferred * pending the report of a technical site visit. Staff was authorized to arrange for funding to maintain the program until finial action is taken. t Site Visit - May 18, 1970 A report will be available at the Committee meeting. 1/ Ol - $72,137; 02 ~ $46,294; 03 - $50,438; 04 ~ $54,464; 05 - $58,726 I RMPS/GRB 5/27/70 (A Privileged Communication) ‘ SPECIAL ACTION WESTERN NEW YORK REGIONAL MEDICAL PROGRAM fora General: A technical site visit team evaluated the revised tumor registry proposal in comparison with the original design which was approved by April-May 1969 Committee and Council. Project #10 - Western New York Tumor Registry Critique: The Committee agreed with the technical site team that although the revised tumor registry does not embody the innovative aspects of the original proposal, it does represent a more realistic registry program for this region at this time. The early growth of the project was retarded by. the revisions in personnel and design, but the reviewers saw the possibilities of the registry as a good vehicle for regionalization. The active involvement of the Western New York Hospital Association and the plan for assumption of support by participating hospitals at the end of RMP funding were considered to be especially propitious. Recommendation: Approval I ~ was recommended for continuation of the’ cancer registry in the amount originally recommended by the National Advisory Council for the remainder of the period for which support has been committed. O02 Year: $46,294 03 Year: $50,438 . GRB 7/9/70 A PRIVILEGED COMMUNICATION RM 00013 TECHNICAL SITE VISIT REPORT WESTERN NEW YORK May 18, 1970 Site Visitors & DRMP Staff Victor Vertes, M.D. (Chairman) Director, Division of Medicine Mount Sinai Hospital of Cleveland University Circle Cleveland, Ohio 44106 Cyrus C. Erickson, M.D. University of Tennessee College of Medicine 62 South Dunlap Memphis, Tennessee 38103 Leonard Scherlis, M.D. - Professor of Medicine Chief, Department of. Cardiology University of Maryland Hospital Baltimore, Maryland 20201 Abraham Ringel Public Health Analyst Operations Research and Systems Analysis Branch Regional Medical Programs Service 5600 Fishers Lane Rockville, Maryland 20852 Eileen Faatz Public Health Advisor Grants Review Branch Regional Medical Programs Service 5600 Fishers Lane Rockville, Maryland 20852 Individual representatives of the WNYRMP are listed in the text of the report. Western New York -2- RM 00013 % PROJECT #10 - Western New York Tumor Registry _ . Pat Shine Regional Medical Program L. Donald Meyers Regional Medical Program Leonard Kaye Regional Medical Program Elsa Kellberg Regional Medical Program Marion Sumner Regional Medical Program John R.F. Ingall, M.D. Regional Medical Program Jehn C. Patterson, M.D. Regional Medical Program Dolores Celest Tumor Registry Ray Caputo W.N.Y. Hospital Association Bob Keefe W.N.Y. Hospital Association The original tumor registry proposal was approved by May 1969 Council and was funded in June 1969. The objectives and methodology of this project, however, were changed in midstream because of changing personnel, the three key people who developed the registry having left Roswell Park. Dr. Patterson, the new project director, with the assistance of the Hospital Management Engineering Program of the Western New York Hospital Association, evaluated the original design and concluded that it should be revised. In reviewing the request for continuation of the tumor registry into the 02 year, staff decided that the Review Committee and Council should approve the revised plan. February/March 1970 Committee and Council recommended that a technical site visit team evaluate the difference between the original and revised projects. The revised program is less innovative and sophisticated than the original but more feasible and acceptable to the participating hospitals. In fact, one of the reasons for revising the project was that hospital administrators and staff physicians looked askance at the expenditures which participating hospitals would incur under the original design. Revisions iri personnel and design retarded the early growth of the registry, and the system did not really get under operation until January 1970. Fourteen hospitals now are participating in the tumor registry, and six additional hospitals are expected to join the project soon, To date, only orehospital has refused to cooperate. It was the feeling of the site visitors that the revised project has more strength than the original in that it is more realistic for this Region at this time. Although there is nothing particularly novel about the present program, it does have a cancer hospital as its fulcrum (with which the WNYRMP has apparent good relationships), and it holds the possibility of gaining the cooperation of a number of outlying hospitals. Dr. Patterson explained to the site team that project personnel consulted with the New York registry which they found will provide them with only death information. Even though the project is off to a slow start and programming may have been premature, the visitors saw in the registry the potential for cooperative efforts among several hospitals in developing a standard service and educationally- oriented tumor registry. The development of this cooperative system was viewed as increasing the opportunities for physician education in cancer and the development of referral patterns in specialized facilities. Of extreme importance is the fact that the engineering group of the Western New York Hospital Association is participating in the implementation nee of the registry. At the end of RMP support it is planned that the partici- Na pating hospitals themselves ultimately will assume the costs of operation. The revised budget total is identical to that requested and awarded for Western New York Site Visit -~3- RM 00013 the original proposal, and the visitors considered the budget well within reasonable bounds. Recommendation In summary, the revised cancer registry does not have the unique character of the original proposal, but the site team viewed the changes as for the better. The recommendation is for continuation of the project in the amount originally recommended by the National Advisory Council for the remainder of the period for which support has been committed: i.e., the rest of the 02 year and the 03 year ($46,294 and $50,438). Although some members of the site team suggested that further programming be halted until the project has accumulated much more data and tested the existing programs, others felt that such a limitation was unduly prohibitive. PROJECT #15 - A Total Regional Program in Dialysis Dr. Albert D. Menno Meyer Hospital, Deaconess Hospital Dr. John M. Hodson Deaconess Hospital Dr. Roland Anthone Buffalo General Hospital Dr. Sidney Anthone Buffalo General Hospital Marion Sumner Western New York RMP Dr. John R.F. Ingall Western New York RMP, Director Dr. J.D. Lasher Hamot Hospital Mr. V. Sirak, Jr. Hamot Hospital Dr. G.P. Murphy Roswell Park Memorial Institute This proposal received generally favorable reviews from the Kidney Disease Program, the Réview Committee, and the National Advisory Council. There were concerns, primarily revolving around the wisdom of establishing dialysis centers in five hospitals, that prompted Committee and Council to recommend a technical site visit for this project. The site team was most impressed with the regionalization evidenced in the project design and with the fact that there are in this region tissue typing facilities and the beginnings of a kidney bank which encompasses Western New York and parts of Canada. The physicians and nurses involved in the proposed project are well trained and well motivated. The project representatives explained that the New York Kidney Institute at Albany is not involved in this program and the goal of this project is not to establish an alternate institute in the Western part of the State. The Albany program is mainly extramural and developed primarily in New York City. The group was not aware of the approved but unfunded dialysis training program in Central New York. A detailed analysis of the teaching program convinced the team that there is considerable merit to the educational component for nurses, technicians, and other allied health personnel. Plans call for training Western New York Site Visit -~-4~- RM 00013 these people at the rate of approximately 100 per year in six-week courses. There was, however, considerable concern about the physician training component. The goals appear overly ambitious in that at the end of a six-week education period it is expected that the 20 physicians trained each year will be capable of establishing dialysis units in their hospitals and handling the patients from conservative therapy through dialysis, transplantation, and possible rejection. A physician would have to leave his practice for six weeks in order to participate in the program. The project staff anticipates that 20 such physicians would be available each year. The intent of the program for nurses and physicians is to concentrate on training people from the Region, although the courses will be open to participants from other areas and Canada. The costs for Canadian trainees will not be charged to the RMP grant. The number of people who will need to be trained ultimately is a question the Region has not yet addressed, although it is expected that a number of the nurses will drop out because of marriage, pregnancy, etc. There are, in addition, plans for providing six fellowships for those physicians who whish to remain for a several-month period. These fellowships would be primarily for those who would use this time as part of their training for board certification, and the site team thought this training did not fall within the purview of RMP. The visitors questioned the need for equipment and wondered why RMP would purchase apparatus that the hospitals should have already. Project staff explained that the intent was that each hospital would have one kidney machine to be used solely for teaching purposes. Further, since patients being trained for the home would have to buy theif own equipment, the site team saw no reason why training could not be achieved on the machines to be used for a given patient in the home. In addition, it was agreed that the costs for laboratory tests, blood, and reimbursement to hospitals for beds could be eliminated from the budget if the teaching program would concentrate on those patients with Blue Cross, Medicaid, or other third-party coverage. Project staff failed to convince the site team of the desirability of having five dialysis centers, expecially since the didactic training would occur in only one institution (using personnel from all participating hospitals) and the experiential phases would rotate among the institutions. The visitors thought that a more efficient way of handling the training program would be to establish only three centers. This number would still provide the trainees with a varied background in dealing with different equipment and techniques. Recommendation The site visitors recommended approval of the program in a reduced amount of $250,000 for each of three years to provide for the establishment of dialysis centers at three hospitals. Specifically, they believed the training courses for nurses, technicians, and other allied health personnel are well-designed and should be instituted as planned (but in three hospitals rather than five). It was felt that the training program for physicians should be less ambitious and limit itself to familiarizing participants with aspects of dialysis necessary for local physicians. It was considered that the personnel for training is essential, but should be reduced to that necessary for three centers. Western New York Site Visit -5- kM QV013 Further, the costs for all equipment, fellowships, laboratory tests and reimbursements to hospitals should be deleted from the budget. PROJECT #16 - Regional Coagulation Reference Laboratory Lvis L. Mosovich, M.D. Department Pediatrics - Children's Hospital Norman B. Courey, M.D. Gynecology & Obstetrics - Deaconess Hospital Marion Sumner Regional Medical Program - Western New York Julian Anbrus, M.D. Roswell Park Memorial Institute Clara Ambrus, M.D. Roswell Park Memorial Institute Irwin B. Mink, M.D. Roswell Park Memorial Insititute Herbert E. Joyce, M.D. Regional Advisory Group The February/March review bodies recommended that this project receive a technical site visit, primarily because of the unimpressive educational component and the extremely large budget. The site visitors found that the expertise of the individuals involved with this project was exceptional and that their knowledge of coagulation and the existing laboratory facilities were most impressive. The tests described in the proposal are ongoing activities. The site team felt, however, that the goals of the project are too broad. Besides training technicians from outlying hospitals, the project personnel intend to perform complete coagulation studies on patients from throughout the Region in order to have clinical material to teach medical students, technicians, and other interested personnel. To accomplish this, the Director is applying for the complete furnishing of a new laboratory as well as funding for 13 technicians, a senior biochemist, and a senior physician. The site team thought that although the goal of having a reference and standardizing laboratory was an excellent one, the rest of the teaching and service aspects should be diminished considerably. It was the visitors' opinion that training technicians from outlying hospitals to be able to return to their own institutions and perform some of the coagulation tests was a more reasonable and adequate objective. It was thought that perhaps one-fifth of the budget would be necessary for this type of endeavor. Recommendation Approval of $60,000 for the first year and $40,000 for the second and third years, with revision of project goals as suggested above. PROJECT #17 - A Regional Program for Atherosclerotic Disease W.E. Mosher, M.D. Erie County Health Department, Commissioner Millicent Toppin ’ Erie County Laboratory Thomas Tiffany Erie County Laboratory Wallace T. Williams Dietetics & Nutrition, State University College George Johnson Erie County Laboratory Western New York \ Site Visit -6- RM 00013 | Christine Falkowski Erie County Laboratory Leonard Kaye Western New York RMP Leila Edwards - Erie County Laboratory - E.J. Meyers Memorial Hospital Division Michel A. Ibrahim Erie County Department of Health and Department of Preventive Medicine Ruth. Kocher NYS Health Department, Buffalo Max E. Chilcote ; Erie County Laboratory, Department of Chemistry, SUNYAB Marion Sumner Westetn New York RMP John R.F. Ingall, M.D. Western New York RMP, Director Robert Kohn, M.D. SUNY AB When this proposal went through the February/March 1970 Review Cycle there were many general questions as to the feasibility of the project, the coordination of this activity with others in the area, as well as more specific procedural concerns. A technical site visit was recommended. The visitors found that the positive aspects of this program included: (1) the interest and ability of project personnel to establish the laboratory and perform the analysis with quality control, and (2) more involvement of other agencies, such as the State Health Department, than had been expected. In addition, there is presently no facility in Western New York which handles such analyses on a routine basis. The project representatives described the goal of the program as being the provision of prompt prophylactic measures for atherosclerosis, yet the group which they will be treating has already had evidence of atherosclerotic disease. The value of this program was questioned seriously since the visitors felt that this type of study should not be directed toward the secondary group but should be looking more to primary prevention. There is an exclusion of patients who would benefit by primary prevention and, therefore, by the dietary control. No attempt will be made to deter- mine other high-risk factors in patients, such as documentation of the presence of hypertension,obesity, etc. The visitors further questioned the desirability of performing electrophoresis on patients with normal cholesterols and normal total triglyercides, but the project representatives offered no justifiable explanation. Another concern of the visitors revolved around the follow-up and evaluation scheme - the methods used to define the success of the project. The project will attempt to answer such questions as whether the patients follow the prescribed therapy and whether the prescriptions do, in fact, reduce lipids. But the problem of whether the therapy prevents atherosclerotic disease will not be addressed. The team considered this a major deficiency in the project design. The budget was considered excessive to the goal of establishing a referral laboratory. Furthermore, patients who are referred to the laboratory by their physicians but who do not fit into the defined high-risk group will be charged $20.00 per determination. This fee will not be applied to the ve Western New York Site Visit ~7- RM 00013 cost of the project but, rather, will go into a special research fund of the laboratory. Recommendation The suspicion of the visitors that this project had received no local review by a group knowledgeable in cardiovascular disease was confirmed. Although the team felt there was a definite need for a reference laboratory, the feasibility of the current proposal was in doubt, and the value of the dietary management and plans for physician education left much to be desired. It was the visitors' consensus that this project should be disapproved and returned to the Region for referral to a local hearta research group for funding or for revision and reorientation of the program to emphasize multiple risk factors and concentration on primary prevention. Conclusions of Site Team Recommendation Project # and Title Ol Year 02 Year 03 Year #10 Western New York* $46,294 $50,438 - Tumor Registry #15 A Total Regional $250,000 $250 ,000 $250,000 Program in Dialysis #16 Regional Coagulation Reference Laboratory $60,000 $40,000 $40,000 #17 Regional Program for the Prevention of Atherosclerotic Disease Disapproval - - Total $356,294 $340,438 $290 ,000 4 i *Continuation of 02 and 03 years recommended. GRB~-6 /23/70 -REGIONAL- MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) WESTERN PENNSYLVANIA RM 00041 7/70.1 REGIONAL MEDICAL PROGRAM June 1970 Review M-240 Scaife Hall Committee 3550 Terrace Street Pittsburgh, Pennsylvania 15213 Program Coordinator: Francis S. Cheever, M.D. Requested Program Period lst Year 2nd Year 3rd Year 4th Year 5th Year Total Direct Costs $43,911 $44 ,820 $46,995 $4,800 3,900 $144,426 Indirect Costs 11,062 11,474 12,030 1,229 998 36,793 TOTAL $54,973 $56,294 $59,025 $6,029 $4,898 $181,219 History: The planning grant was funded January 1, 1967 in the amount of $271,736 (D.C.). During the first year some organizational difficulties were experienced. This resulted in an extension of the grant, without additional funds, for 90 days, to March 31, 1968. A Program Director was named during this period and assumed full-time responsibility June 1, 1968. The Regional Advisory Group was expanded and reorganized to inc lude representatives of hospitals as well as county medical societies. The second year planning continuation grant was awarded effective April 1, 1968 in the direct cost amount of $260,484. With a carryover balance of $212,823, the new funding amounted to $113,942. A supplemental planning grant award in the amount of $93,750 (D.C.) was authorized by Council in January 1969 for Core activities in order to provide continuity to the program while the region awaited approval of its operational status. A site visit was made on February 24-25, 1969 to evaluate the region's request for operational status. The site team examined how the program had evolved, the extent of involvement of all health interests, how the region determines priorities, relationship between the grantee institution and the RMP, roles of the RAG and committees and future plans. Council concurred with the site visit team and Committee's recommendation of approval of five projects and Core. One project was returned for revision with advice to re-submit a request for the RMP-relevant portion only. The WP/RMP received its first operational grant award in the total amount of $1,157,896 ($934,041 D.C.) effective July 1, 1969. Project #4 to provide Weatern Pennsylvania RMP -2- RM 00041 7/70.1 training for hospital Emergency Resuscitation Teams, was supplementally awarded ($88,000 D.C.) for an eighteen-month period after issuance of the N.A.C, policy for projects of this kind. Project #8 - Laurel Mountain Home Health Aide Training and Demonstration Project ~- was recommended for disapproval by the November/ December 1969 reviewing bodies. After evaluating comments of the N.A.C., the local Advisory Committee for the three-county Area involved and the R.A.G. of WP/RMP reaffirmed their belief that the project is significant to the outreach of the WP/RMP, and asked for reconsideration for approval for implementation from unexpended funds. The N.A.C. recommended approval, with no additional funds, of support for such training costs. The present level of support for the region for Core and seven projects is $1,022,041 (direct costs). The operational activities are as follows: Project Funding Level (D.C.) Core $475,041 #1 - Postgraduate Faculty of Medicine 34,000 #2 - Hypertension Management 90 ,000 #3 - Regional Program for Nurses in Heart, Cancer, Stroke 160,000 #4 - Emergency Resuscitation Team Project 88,000 (18 mos.) #6 - Training of Nursing Home Personnel 125,000 #7 - RMP Library System 50,000 #8 - Laurel Mountain Home Health Aide Project No Additional Funds TOTAL $1,022,041 Present Application: GENERAL: After more than half-way through the first year of operational activities, the region feels that planning efforts are showing satisfactory results. A first Annual Planning Conference was held in the fall of 1969. This application reflects the priority expressed then. The Community Involvement Committee has completed the organization of nine Area Advisory Groups. This Committee has stimulated interest in development of health care programs for the poor and there is agreement that the RMP should focus on methods of improving the system of primary medical care for this segment of the population. Western Pennsylvania RMP -3- RM 00041 7/70.1 The Grants Review Committee membership has been broadened for a wider community representation in the Grant Review process, and in addition, the Committee is working with WP/RMP staff on project evaluation. lst Year , $43,911 Project #9 - Training of Cancer Chemotherapists for the Community Hospital This project proposes to develop a cadre of physicians who are interested and competent in the advancing field of chemotherapy. The appli- cation requests support for a preceptorship training program in cancer chemotherapy for practicing physicians in Western Pennsylvania. These physicians will serve as important members of cancer committees in hospitals throughout the region in line with the region's four highest priority interests. These Chemotherapists, in cooperation with other members of their medical staffs, will provide cancer patients with a balanced treatment program including cancer chemotherapy, radiation therapy, surgery, radioisotope therapy, etc. In addition to beginning the organization of a cancer treatment system for the region, the project is designed to make available the benefits of modern cancer chemotherapy to patients throughout Western Pennsylvania. The program emerged as a result of planning of the Cancer Committee of the Western Pennsylvania Regional Medical Program and its Task Forces on 1) tumor clinics and tumor registries; 2) angiography; 3) chemotherapy; 4) radiation therapy; 5) community education and motivation in oncology; 6) continuing postgraduate education in oncology; 7) nursing and paramedical manpower; and 8) screening and casefinding. The priorities for a Regional Cancer Program were developed by these Task Forces, discussed and modified by the Cancer Committee, and approved by the Regional Medical Program Advisory Committee (R.A.G.). Their objectives include 1) support of mlti-disclplinary efforts in cancer management by hospital staffs throughout the Region; 2) establishment of a network to link these multi-disciplinary groups to each other and to teaching hospitals in Western Pennsylvania; 3) cancer registries as needed; 4) postgraduate education efforts for health professionals and 5) an educational program to motivate the public to seek earlier care for symptoms suggesting cancer. The region's Cancer Program will be augmented by a feasibility study for which approval has been requested from the Division Staff. This study will be initiated by a nurse specialist in oncology in cooperation with the Pennsylvania Cancer Society. Initial programs will be carried out in cooperation with local units of the Cancer Society, but will also provide professional liaison with various lay groups stimulated by the Society, such as the Lost Chord Club, the Reach for Recovery Group, etc. The WP/RMP has developed a close relationship with the Hospital Utilization Project (HUP), which provides participating hospitals with a ready-made registry of all cancer patients admitted. ‘The registry in its present form provides only minimal information about therapy (surgical procedures primarily). Western Pennsylvania RMP -4- RM 00041 7/70.1 The project will also relate to the State Health Department which provides partial support of cancer registries in 31 hospitals and includes 687% of the hospital beds in Western Pennsylvania. By correlating the efforts of all three agencies (WP/RMP, HUP, and the State Health Department), it is hoped that the needs for data about cancer programs by local medical staffs can be met. The Cancer Committees in the various hospitals will consist of at least the hospital radiologist, pathologist and the community chemotherapist trained in the present program. In addition, a surgeon with special interest in cancer and other appropriate members will be chosen by the hospital's medical staff to join this committee. One physician member of the Chemotherapy Committee (Dr. John B. Hill) will give ten hours per week (1/4 time) as Project Director supervising the program attending to the administrative details, etc. He will be assisted by a secretary (1/3 time). The Project Director will work from his office at the Western Pennsylvania Hospital which will act as the fiscal agent for the program. An oncologist will be added to the WP/RMP Core staff to work closely with Dr. Hill and the University Health Center oncology group. He will assist in the full development of the Community Hospital Cancer Committees as a part of his major role, and will assist Dr. Hill in implementing program evaluation. Four to six students will be accepted in each six-month period over three years. Selections will be based on potential for service, taking into consideration woe training, age, health, hospital staff appointments, etc. All will be physicians ~ in practice, including both general and specialty practices. The faculty for the program will consist of 11 Pittsburgh physicians who are fully trained members of the Pittsburgh Chemotherapy Committee. Curricula Vitae are attached to the application. It is the intent of the training program to develop in the 36 participating physicians the knowledge and skills adequate to permit them to initiate certain kinds of commonly needed chemotherapy. They will take responsibility for the continuation of more complex or unusual treatments which are initiated in a referral center. Participating physicians will be encouraged to refer appro- priate patients to treatment centers for new or highly complex forms of chemo- therapy requiring special skills or facilities. They will also be encouraged to work with other members of their hospital staffs to provide a balanced cancer care program. During the final two months of the course, students will be encouraged to undertake the treatment of selected patients in their home areas, and will discuss these patients' problems with their preceptors. Refresher courses will be offered each six months in the form of another day and a half course. For one and a half years following the initial six months training period each community chemotherapist will report regularly on his chemotherapy practice. In addition he will make quarterly reports describing the progress of all oO patients. The steff oncologist and/or Dr. Hill will visit the chemotherapist ~~ in his community to provide on site consultation and guidance. Second Year: $44,820 Third Year: $46,995 Fourth Year: $ 4,800 Fifth Year: $ 3,900 western rennsylveanla KN UUU4E f/f / ULE STAFF OBSERVATION Attention is drawn to the internal reView-process of WP/RMP and specifically page 31, Section 6, which indicates that in evaluating the project, the R.A.G, made certain reductions in the budget. This accounts for the difference in the amounts on pages 8 and 9, which reflect reduction in the equipment and space rental requests. GRB 5/6/70 BA CLEVE Leyeu NARLERSULAU A DA CE A 1 \ SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE WESTERN PENNSYLVANIA REGIONAL MEDICAL PROGRAM RM 00041 7/70.1 , FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: ‘The Committee approved this application, requesting funds for one new project. This is the region's first effort at establishing a region-wide cancer program. It is a cooperative endeavor with local units of the Cancer Society, various lay groups, such as the Lost Chord Club, The Reach for Recovery Group, etc, It will also relate to the State Health Depart- ment, as well as the Hospital Utilization Project, which provides participating hospitals wth a ready-made registry of all cancer patients admitted, Project #9 - Training of Cancer Chemotherapists for the Community Hospital. Critigue: The proposal was found to be quite impressive and one of the best written of its kind. Jt indicates a great deal of sophistication in its development and is thoughtful and thorough in spelling out its details. The outreach aspects are excellent. The goals of the project are capable of measurement and in accordance with RMP goals. The reviewers noted excellent documentation as to numbers of patients who will be affected by this training activity. While the evaluation plan is appropriate, project staff identified for this purpose was not considered to be very strong. It was noted, however, that there is apparently a good evaluation backup on the WP/RMP staff. The suggestion was made that the applicant should be querried to make certain the evaluation they propose can be carried out within the requested financial allotment. , The overall plan seems sound except for a possible problem with trainees whose practices might interfere with their training schedules, It would appear that a busy practitioner's ability to spend one day a week would be difficult to accomplish. , ‘The reviewers also raised the question of the oncologist who is being recruited for the WP/RMP Core staff. They wondered if his salary would be partially financed otherwise. Recommendation: Approval I First Year Second Year wfhird Year $43,911 $44,820 $46,995 ¥ a yer WESTERN PENNSYLVANIA RMP ~2= RM 00041 7/70.1 SUMMARY OF RECOMMENDATION Project 01-Year “G9 ..Vear 03-Year Total #9 $43,911 $44 ,820 $46,995 ~ $135,726 Total $43,911 $44 ,820 $46,995 $135,726 RMPS/GRB/7/13/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF A SUPPLEMENTAL OPERATTONAL GRANT APPLICATION (A Privileged Communication) VESCONS EN REGLONAL MEDICAL PROGRAM RM 00037 7/70.4 J10 Hast Wisconsin Avenue June 1970 Review Committee Milwaukee, Wisconsin 523202 Propram Coordinator: John S. Hirschboeck, M.D. Requested lst Yr. 2nd Yr. 3rd Yr. TOTAL Nireet Costs $132,915 $125,215 $125,215 9383,345 Indirect Costs. 20,330 20,330 20, 330 60,990 TOTALS $153,245 $145,545 $145,545 S444 , 335 History: (See 7/70.2 for regional history of this application.) This application was originally submitted during July 1969 as a major vealth manpower development project with eleven subcomponents. The original program would establish a multidisciplinary and interinstitutional approach to the training of health science personnel through the development of a Department of Health Manpower and Continuing Education at the Marquette School of Medicine - with ten separate training components. However, during October 1969, the Region requested that the application be withdrawn from the review process. This request was made bécause of anticipated fiscal developments at Marquette, The school, which was in serious financial trouble when the application was originally submitted, is now receiving essential financial support for its operation from the State of Wisconsin. It was believed that an endeavor of this magnitude could not have been undertaken until the financial structure of the school became more solid. Therefore, the Region is now requesting that the original application be restored to the review system in a modified form and with reduced budgets. The modifications are defined in a letter from the Program Coordinator, dated February 12, 1970, which states that seven of the twelve original components were deleted (C,D,E,F,G,H, and J), and components A,B,I,and K were retained as integral parts of the application. The revised application now consists of the February 12, 1970 letter and the four components mentioned above, (Subcomponents A,B,I,and K are separated by pink papers in this application.) Direct costs only are noted, Requested First Year Project #18A - Department of Health Manpower and Continuing $50,765 Education at Marquette School of Medicine. The original request for Component A, for the first year, was $130,400. This has now been reduced to $50,765, Project Component A of the Health Manpower Development Project callis for the establish- ment of a Department of Health Manpower and Continuing Education at the Marquette School of Medicine. This department will be the key to the WISCONSIN Regional Medical Program -2- RM 00037 7/70.1 Requested development of continuing education in the Medical Center which First Year is being planned to be, among other things, the locus for inter- professional and interinstitutional continuing education coordination in the southeastern Wisconsin area, The project provides a base upon which the entire continuing education program can be developed. Since it relates to the Medical Center and the associated institutions, it should provide the basis for the coordination of teaching efforts not only for medicine but of the various members of the team effort in medical and health practice in the major teaching hospitals in this area, Its objectives should be therefore: 1. To develop and coordinate interdisciplinary continuing education for medical and health professionals in the Medical Center facilities. © 2. To provide the meeting place and communication for the coordination and development of continuing education of institutions and pro- fessional organizations outside the Medical Center. 3. To develop and maintain interprofessional and interinstitutional evaluation of continuing education both within and outside the Medical Center. 4. To act as a resource and consultation staff to professional and institutional organizations desiring to establish interdisciplinary and interinstitutional continuing education programs. Since the medical, center is not expected to be fully developed for several years, and the coordination of continuing education will be an ongoing task, it is proposed that staffing of the Department of Continuing Education begin on a half-time basis, including an asscciate dean in medicine, an associate director fur nursing, and an associate director for allied health, plus a full-time secretary. 80% of the budget request is for personnel. Second Year: $46,965 Third Year: $46,965 Project #18B - Nephrology. The original request for Component B $21,100 was for $26,959 for the first year. This has now been reduced to $21,100. Other than a total of $1,300 for supplies and travel, the remaining support requested is for personnel. A one-monti: block of clinical experience will be provided internists, surgeons, gynecologists, urologists, and general practitioners, geared toward: 1) improving their ability to interpret electrolyte and acid- base measurements, and translate this information into appropriate plans of therapy; and 2) improving skills in early detection of kidney disease, using simple routines available at all hospitals. Physicians who complete training will be invited to return and attend weekly teaching conferences of the Renal Service and other pertinent meetings. They may also elect to return at intervals, in order to add to their technical skills or gain more information about specific problems they encounter. It is hoped that 12 physicians will receive this training. WISCONSIN Regional Medical Program -~ 3 - RM GOO37 7/70.1 Requested First Year Registered purses will be offered one month of sudervised clinical training in the care of patients with disturbances in fluid electrolyte and acid-base metabolism. A detailed curriculum ig under development. Plans call for 12 nurses to be trained. Team teaching will be utilized and coordinated physician-nurse care is intended. Second Year: $21,100 Third Year: $21,100 Project #181 - Pulmonary Disease. The original request for $26,400 Component T was for $185,800 for the first year. vhnis hes now been reduced to $26,400, $22,000 of this totaj is for personnel, vhe Pulmonary Disease Component will be conducted as a small pilot portion of the total proposal, It will consist of a one-month- long program for physicians and nurses desiring to learn the treatment of patients in respiratory failure. 'rhis would include instruction in establishing a respiratory care unit in their hospital, experience in the use of all equipment utilized in the care of these patients as well as their actual management during the acute episode and through the recovery period. Instruction in the techniques of blood gas analyzers and the utilization of these determinations in patient management would be provided. Didactic sessions on basic pulmonary physiology and acid-base balance would be included." Objectives. 1. To enable physicians to treat and manage patients in respiratory failure, utilizing latest methods and equipment. 2, To enable nurses to care for patients in respiratory failure, including proper handling of tracheostomies, prolonged endotracheal intubation, utilizing latest techniques and equipment. 3, To enable physicians and nurses to work cooperatively in the care of patients in respiratory failure towards maximizing patient benefits from latest techniques and equipment. Second Year: $22,500 Third Year: $22,500 Project #18K ~- Closed Circuit Television Program. The original $34,650 request for Component K was for $61,675 for the first year, This has now been reduced to $34,650. Ali) of this amount will be utilized to support personnel. According to the Region, The Milwaukee Medical Jelevision Network is a fine example of interinstitutional cooperation with the goal of enhancing WISCONSIN Regional Medical Program -4- RM 00037 7/70.1 Requested ° First Year and coordinating continuing education in the medical care and health fields. It provides a focus around which the various institutions and professions can meet to consider their respective and joint goals in continuing education, Because of its ability to reach substantial segments of the professional audience any given time, it is a means for communication with the health and medical personnel of the area which is unparalleled by any other means. It can provide the basis for evaluation of the effectiveness of various teaching techniques with large segments of the medical health pro- fessional groups in different settings, in different places, but with common source material. The development of local programming and filming of local material should provide the opportunity for inter~ ~- disciplinary and interprofessional groups to cooperate and formulate , concerted. approaches to continuing education on an interdisciplinary basis. Television Program ~ Project K - Objectives. 1. Coordinated production of T.V. programming for cooperating health and medical care institutions. 2, Provision of uniform educational content to health and medical care personnel in cooperating institutions. 3. Provide intensive T.V. media programming to fill gaps in knowledge and abilities of personnel in cooperating institutions. Second Year: $34,650 Third Year: $34,650 Evaluation is planned at four levels. These are: 1. The extent to which the program has been established as approved and funded, i.e., staff recruited, readiness of facilities and equipment, etc. 2, Quantity of output as compared to proposal. 3. Quality or effectiveness of teaching. 4. hemonstration of new, enlarged or revised interinstitutional programs developed by stimulus of this program. PRMP ae 5/18/70 A Privileged Communication SUMMARY OF REVEEW AND CONCLUSTON OF JURE 1970 REVIEW COMMAS SIE WISC CRSTR REGEOSAL MEDICAL PROGRAM M 060037 7/70.1 FOR CONSIDERATION BY JULY 1970 ARVISGRY COUNCIL General: The Review Committee recommended that this supplemental operational application 7/70.1 which requests $383,345 (d.c.0.) be partially funded at $144,695 (d.c.0.) to support component 184 for a three-year program period, Committee further recommended that action on components 18B, 182 and 16K be non-approval, no RUPS funding recommended, History: This epplication was originally submitted during July 1969 as a major health manpover Gove opment project with eleven sub- components, The original program would establish a multidisciplinary and interinatitutional approach to the training of health science personnel through the development of a Department of Health Manpower and Continuing Education at the Marquette School of Medicine with ten separate training components, However, in October 1969 the Reglon requested that the appli-« cation be withdrawn from the review process. ‘This request was made bee cause of anticipated fiscal developments at Marquette, During February 1970, the Region requested that the application be restored to the review system in a modified form and with reduced budgets. Therefore, the Review Committee considered only components 104, B, £, and Project Component (104 © Department of Health Manvover and Continuing Educe OR eruepeerarouen en: gies .° eriginal request for this component s $130,400, This has been reduced to $50,765. Ie was further noted that this component prepoe te establish a Department of Health Menp: end Cont School of Medielue which dg to serve as. a locus for intevpeprofagslon at aud incersingtitu ireLonal education coordination in the Southeastera The Committee noted for the first year ¥ inuing Education at Marquette - _ r noted the review by the Continuing Education and Traintug Beanch Staff, which concluded, "Et would be a pleasure to see the educettonal poskthon rewrs Ceen by the project etaff preposed in the application.” In reconmendin & appreve of s gingle cessonent cf e confusing application, the @ believed this y provi the support necessary to enable the applicant: to. propese a better Gefined program. amount requasted. WISCORSTH REO a . RM 00037 7/70.1 Project Componeets #18E © and 18K e Le Po co a ” ej. Critique: The Review Conmittee was unanimous in recemmending noneapproval of ell three of these components, Although the total amounts originally requested have been substantially reduced in the modified ape plication, the Comalttee believed that these are simply requests for funds to support personnel wno are evidently already employed by the institution. In addition, the entire educational design of the various components, as written, were censidered weak. Recommendation: Noneapproval = no RHPS funding recommended, Doctor Philip White was not present during deliberation on this application. DALTONS AND ACTIONS OF SUMMARY OF RECO: JU 1970 REVIT COMMTETET Ditle lst Year 2nd Year 3rd Year ' Manpower Bovelonment } bh Mane $50,765 $46,965 $46,965 Component Department of Lt 184 power and Continuing Education 18b Kephrology Non-approvel » no RMPS funds recommended 18] Pulmonary Digesse " 18K Closed Circuit Television " Pree th earned eS mcuremiion a ‘ $50,765 $46,965 $46,965 Year Zotal. 01) $50,765 62) «46,965 3) 46,965. fe geen ge cre Risa ue, $144,695 7/10/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF A SUPPLEMENTAL OPERATIONAL GRANT APPLICATION (A Privileged Communication) WISCONSIN REGIONAL MEDICAL PROGRAM INC. RM 00037 7/70.2 110 East Wisconsin Avenue June 1970 Review Committee Milwaukee, Wisconsin 53202 Program Coordinator: John S. Hirschboeck, M.D. Requested Ist Yr. 2nd Yr. 3rd_ Yr. TOTAL Direct Costs $620,248 430,126 437,580 1,487,954 Indirect Costs 104,893 41,792 42,095 188,780 TOTALS $725,141 $471,918 $479,675 $1,676,734 History: The Wisconsin Regional Medical Program Inc. has been operating under grant support from the Division of Regional Medical Programs since September 1, 1966. The first year of a two-year planning period began on that date with an award of $319,458 (d.c.). During its second planning year the Region became operational, following a preoperational site visit in July 1967. Therefore, the second year (9/1/67-8/31/68) award of $548,866 (d.c.) provided continued support for Core planning and administration, plus support for three feasibility studies (two in dial access tape libraries, and one for single concept films). In addition, funds were provided to support three operational projects. These were in uterine cancer therapy, pulmonary thromboembolism and cancer chemotherapy for adults. The award for the period 9/1/68-8/31/69, was for $1,162,581 (d.c.). This provided continued support for Core activities, including the three feasibility studies mentioned above, plus nine operational projects. The Region is currently in its fourth year (third operational year, 9/1/69-8/31/70). The total award of $1,689,510 (d.c.) is composed of $1,548,430 basic and $141,080 carryover funds. (See History Supplement on last page for a breakout of this total.) Present Application: This application requests support for six (five new and one renewal) operational programs. The renewal proposal requests one additional year's support for a project designed to prepare inactive nurses for return to the practice of nursing. The remaining five proposals are in the fields: heart (3), cancer (1), and a proposal related to high-risk fetus and newborn infant. Direct costs only are shown in the following program descriptions. WISCONSIN Regional Medical Program -2- RM 00037 7/70.2 . Requested - First Year Project #13A (R) - Inactive Nurse Education - University of $60,800 Wisconsin Extension, This is a one-year renewal request for a project that was approved for a two-year period, during the November 1968 Council, for $60,000. The project initially was to start March 1, 1969. However, because of funding restrictions during 1969, the project was not funded and did not become functional until September 1969, The Region states that an additional year's support is necessary to fully meet the objectives as originally stated. The overall objective of this renewal request is, to facilitate the immediate and eventual return of the inactive nurse to the practice of nursing. The project plans to offer: 1) non-credit refresher courses for inactive nurses in selected areas of the State; 2) a series of telephone/radio conferences on a Statewide basis; and 3) individbal study guides on selected nursing topics. The refresher courses will be patient-oriented and the enrollees will be assigned to care for patients with commonly- seen conditions that will be discussed in formal classes. The courses will provide the nurse with the opportunity to update her nursing knowledge and practice as well as to learn about resources for keeping this knowledge current. The nurse will also learn about changing nursing skills and knowledge, organization, patterns of care, and current trends and concepts in nursing service and education, It is planned to include in this course the projected plans for the care of the patient after he goes home, and information about available community resources, : Three of these courses (four weeks each) were offered in the areas of Rhinelander, Neillsville, and Marinette during the fall of 1969, and a total of 17 nurses attended. Seven of these nurses have returned to practice and an additional six plan to go back to work in the near future. Another course started in Sturgeon Bay in March and plans are under way to offer a course in Monroe, and another in Portage or West Bend later during the year. The television/radio programs are offered on an hourly basis, twice a month, and have 575 inactive nurses currently enrolled. The sessions are designed to assist the inactive nurse in locating and using resource materials available to her. The sessions also include discussions on recent developments in nursing, changes in medication, clinical aspects and community health. The programs are taped and made available for loan to participants who are unable to attend the study sessions, and for those who are interested in forming study groups. The individual study guides will be implemented during the next budget year, and 80% of the nurses who are enrolled in the telephone conferences RM 00037 7/70.2 iw ' WISCONSIN Regional Medical Program - Requested First Year indicated an interest in the service. Some of the suggested topics to be developed include: 1) emergency care as it relates to shock, hemorrhage and childbirth; 2) nursing management of the patient with myocardial infarction (already developed) ; 3) the burned patient; 4) the unconscious patient; 5) congestive heart failure; 6) acute care; 7) disaster nursing; 8) psychiatric nursing, etc. At the conclusion of this project, the individual study units and the telephone conferences will be phased into the ongoing programs of the Department of Nursing, at the University of Wisconsin Extension. An overall evaluation of the enrollees will be conducted at the conclusion of the project, to determine the extent of the return to practice of the enrollees. The evaluation forms include: 1) a refresher course questionnaire (mailed six months after course terminates) ; 2) listener's response sheet and interim survey sheets for telephone conferences; and 3) evaluation form for individual study unit. Approximately $44,000 of the total request of $60,800 is for personnel and consultant services. Project #19 - An Educational Program to Improve the Care of the $136,040 High-risk Fetus and Newborn Infant - University of Wisconsin. This project proposes to organize and coordinate a limited number of specialized facilities which would be used as referral centers for the care of special problems related to the high-risk fetus and newborn infant. Plans are to develop at least five regional centers in La Crosse, Madison, Marshfield, Milwaukee and, tentatively, in Green Bay. These centers would provide intensive care for the high-risk newborns and specialized care for high-risk pregnancies during the antepartum and intrapartum periods. In order to provide the necessary trained personnel to staff the centers, several educational programs have been developed. One program would be aimed at preparing nurses who are currently employed in intensive care units for the newborn which do not have instructional personnel to meet the need of orientation and ongoing inservice training. This program would be offered concurrently in Madison and Milwaukee over a two-week period. A second program would be aimed at preparing nurses who would be caring for infants following their hospitalization in an intensive care unit. The infants may be transfer patients still requiring hospitalization, or may be ready for discharge. The nurse would be prepared to give continuity of care and subsequent followup into the community. A third program would involve consultation services made available to hospitals and communities for the purpose of training nursing personnel to recognize the high-risk mother and infant. WISCONSIN Regional Medical Program -4- RM 00037 7/70.2 Requested First Year The Madison Regional Center Program is designed to serve hospitals in the State of Wisconsin (except the Milwaukee Region) and could also be available to hospitals in Duluth, Minneapolis, St. Paul and Southeastern Minnesota. At present, there is an active intensive care center. An enlarged intensive care nursery is under construction and will have space to accommodate up to 28 high-risk infants. It is planned to operate 4-5 classes yearly, with a limit of four nurses per class in the first year - later expanding to five or six nurses per class. The instruction will take place primarily in the intensive care unit at St. Mary's Hospital in Madison, The nursery accommodates 2,000 newborns per year. The Milwaukee Regional Center has a 25 to 30-bed intensive care unit at Milwaukee County Hospital and serves Milwaukee’ County and South- eastern Wisconsin. The program will be conducted in the Milwaukee County General Hospital obstetric and nursery areas and will operate four to five classes per year, with four nurses per Class initially, jater expanding to five-six. The hospital has a total of 1,500 births yearly and more than 30% of these fall into high-risk groups. From the previous capacity of 15, the intensive care facilities are being expanded to accommodate 20 babies. The La Crosse Regional Center serves the Western area of Wisconsin and adjacent areas of Southeastern Minnesota, The target group would be the nurses in the La Crosse Regional Newborn Center at St. Francis Hospital, the nurses from referring hospitals within the Region, and physicians involved in neonatal care within the Region. The educational program would be conducted on a weekly or bi-weekly basis, utilizing resource people from the Madison Center program to participate with the La Crosse Regional Center nurses in the development and presentation of the program. The program for the nurses from the surrounding area would be held at the Regional Center, on a one-day seminar basis - two or three times yearly, and would involve lectures, demonstrations, and in-the-unit participation. Bi-monthly or monthly perinatal mortality conferences and perinatal care seminars will be conducted for the physicians. The Marshfield Regional Center Project is designed to serve the North Central Region of Wisconsin. The target group will be the nurses within the regional newborn center, the nurses from referring hospitals within the Region, and physicians involved in neonatal care within the Region. The organization of the course follows the same design as the program described for the La Crosse Regional Center Project. The development of a center in Green Bay is currently under way. This center will provide service to the Northeastern Region of Wisconsin. For the next two years the developmental and educational WISCONSIN Regional Medical Program ~5- RM 00037 7/70.2 Requested First Year aspects of the program will be carried on from the Madison Center. The educational program will be evaluated by: 1) written pre and postcourse tests based upon behavioral objectives; 2) comments from the participants; and 3) followup visits to the participants by the teaching staff. $114,240 of the total request of $136,040, for the first year, is for personnel. Second Year: $132,840 Third Year: $132,840 Project #20 - An Action Program for Detection and Management $116,125 of Gynecologic Malignancy - University of Wisconsin Medical Center. This project is an outgrowth of the Study Program for Uterine Cancer Therapy and Evaluation which has been funded through 8/31/70. This is a request for a one-year program to develop a network of regional centers designed to make available the techniques of colposcopy and directed biopsy to the physicians of the State and their patients. The present centers involved are: The University of Wisconsin Medical Center, Madison, Marquette Medical School-County Hospital Center, Milwaukee, St. Mary's Hospital ,Milwaukee, and the Marshfield Clinic, Marshfield. New centers will most likely be developed at La Crosse and Green Bay, Wisconsin and Duluth-Superior (Wisconsin and Minnesota). It is hoped that by substituting these techniques for the evaluation and management of patients with abnormal cytology, the use of the surgical cone will be reduced, thereby reducing hospital costs and surgical hazards. An informational program will be implemented to inform physicians of the advantages and availability of colposcopy and directed biopsy.’ The information will be disseminated through: 1) RMP newsletters and releases; 2) State Laboratory of Hygiene newsletter; 3) State Board of Health publications; 4) Wisconsin State Medical Journal briefs; 5) dial access tapes; 6) circuit seminars among the County Society, Councilor District meetings, etc.; 7) direct individual contact with physicians; and 8) "detailing" by county agents on the latest advance in medical developments. When it is judged that a reasonable physician understanding has been achieved, the State Laboratory will begin to include with each physician's report of abnormal cytology information on where and when this service can be obtained. The names of both physicians and patients will be distributed (at regular intervals) to the centers that are located in close proximity to both the patient and the physician. An attempt will be made to explain this service to the physician and to elicit his understanding and participation. When this is achieved, the physician WISCONSIN Regional Medical Program - 6 - RM 00037 7/70.2 - Requested First Year will send or bring his patient to a prearranged colposcopy clinic at one of the centers where a repeat cytology and directed biopsy will be obtained as colposcopy is performed. A report will be sent to the patient's physician within 48-72 hours, with suggestions regarding further diagnosis or therapy where appropriate. Followup on all contacts will be maintained by the cooperating centers, the State Laboratory of Hygiene and other participating agencies. Every effort will be made to maintain uniformity betwean centers in the collection of data concerning tissue interpretation and demographic information. Patient fees will be maintained at a winimum and will be initially limited to institutional charges. Professional charges for the diagnostic colposcopy and biopsy will not be made to referred patients, unless these patients are referred for definitive treatment. Indigent patients will be cared for at no cost. The applicant states that an interregional relationship (Section 9-10) is being developed with neighboring Regions such as the University of Minnesota and the University of Iowa which will allow: 1) their use of dosimetry programs currently available in this center; 2) their participation in clinical data collection and tabulation in gynecologic malignancy; and 3) the joint utilization of ideas, expertise and facilities of any one of the institutions by all participating centers. The budgets in the application for Iowa and Minnesota are samples rather than requests for funds. As a means of evaluating the success of the program, the number of patients being coned each year in the projected Regions or in the State as a whole, will be determined for a specific period of time. If the program is successful, it is expected there will be a decrease in the number of surgical cones and an increase in the number of colposcopic studies with biopsy. A second approach to evaluation will be possible, utilizing physician understanding of the place of colposcopy and directed biopsy as an indication of success. The preparation of a uniform reporting and evaluation system for gynecologic malignancy in the multiple Regions served should also be an indication of success. Staff was advised by the Program Coordinator that the Wisconsin RAG approved this proposal for one year to afford them an opportunity for a complete evaluation of progress. Second Year: None Third Year: None WISCONSIN Regional Medical Program -7- RM 00037 7/70.2 Requested First Year Project #21 - A Computerized Electrocardiogram Project for $124,581 Wisconsin - Marshfield Clinic Foundation. This is a three-year request for a proposal which would provide a centralized electrocardiographic interpretation service for the Wisconsin Region, The system would offer four distinct advantages: 1) direct service to the patient and physician; 2) decreased cost; 3) increased speed of interpretation and application of the results to the patient; and 4) better and more efficient utilization of the cardiologist's time by assisting in the interpretation of more tracings in less time. The initial target population will be those patients served by the following hospitals: 1) Park Falls Hospital, Sacred Heart Hospital, Ashland Community Hospital, Oconto Falls Hospital, Adams-Friendship Community Hospital, Medford Hospital, St. Joseph's Hospital, Marshfield Clinic, Neisville Memorial, and Black River Falls Hospital. These hospitals have a total bed capacity of 1,004 and run 25,111 electro- cardiograms per year. Most of the hospitals are rural and only one (St. Joseph's) has a full-time cardiologist. The eventual target population would include over 9,000 hospital patients in the State. The project will be administered by the Marshfield Clinic Foundation for Medical Research and Education, The cardiology, electrocardiographic, and the computer services of the Marshfield Clinic will be utilized to provide the personnel, equipment, and technical services. The educational programs will be provided by personnel from the Foundation, the Clinic and the 3M Company. The first three months of the project will be spent setting up the central operation (to be located within the Marshfield Clinic), training personnel and checking computer programs, A training program for technicians will be established and will involve an intensive program in EKG analysis, interpretation, and the use of the equipment for taking EKG's. The Marshfield Center technicians will be trained on site and the technicians from the cooperating hospitals will spend an initial week at the Clinic. Formal and informal seminars will be held in each of the cooperating institutions for physicians in an effort to familiarize them with the computerized EKG program and how it can be used as a service to both the physician and the patient. The second phase of the program will begin at the end of three months. At this time EKG's from the Clinic will be run to verify the programs and to establish the procedures to be used. In addition, during this phase of the project, the trainees from the cooperating hospitals, along with local hospital personnel, will receive further instructions. WISCONSIN Regional Medical Program ~8- RM 00037 7/70.2 Requested First Year The third phase of the project will begin approximately six months after initiation of the service to the regional hospitals. During the second year of the project, 10 to 15 additional hospitals will be incorporated into the network and 10 to 15 more in the third year. This program will be evaluated in five stages. The initial stage will be verification of the computer program and interpretation of the electrocardiogram by the center's staff cardiologists. This will be done for all electrocardiograms for the first six months, on a random basis. The second portion of the evaluation will deal with the user increase of the program. The third evaluation stage will attempt to determine whether or not the computerized electrocardiogram actually supplied the physician with the data which is useful in his diagnostic determinations. This will be tested in all cooperating hospitals. The fourth phase of the evaluation plan deals with computation of the cost of the electrocardiograms. Finally, continuing evaluation of the geographic area to be served will be made, to insure that the service will be made available to all areas which have a need. At the end of three years the project will be taken over by the Marshfield Clinic as a service function. $45,408 of the first year's total request of $124,581 is for personnel; $76,773 is for equipment; and $8,400 is requested for supplies and travel. Second Year: $125,667 Third Year: $128,533 Project #22 - Community-Oriented Continuing Education in $54,341 Rehabilitation Medicine for Physicians and Allied Health Personnel - Division of Health, Wisconsin Department of Health and Social Services. This is a three-year request for a project to provide physicians and allied health professionals with an opportunity to develop skills, increase their knowledge, and to improve the coordination of rehabilitation activities. The target area is a three-county nonurban area located in central Wisconsin. All three counties have a significantly higher percentage WISCONSIN Regional Medical Program -9- RM 00037 7/70.2 Requested First Year of people in the 65 and over age group than the State as a whole. The project's objectives are: 1) To improve the ability of physicians in the target community to respond to patients' reeds for treatment and rehabilitation through participation in interdisciplinary educational programs, As a result of these educational programs, it is anticipated that the physicians will be able to identify potential or actual disability, and determine the degree to which the condition diminishes the patient's ability to cope with his environment. In addition, the physician will be able to select and prescribe the appropriate therapy to minimize or prevent disability; and will also be able to contact and identify the appropriate allied health personnel to provide specialized therapy services when needed; 2) To improve the ability of allied health professionals to assist in the process of providing complete and coordinated care to patients in need of rehabilitation, by participating in educational programs, As a result of this objective, the allied health personnel will be able to determine the extent of the patient's disability and relate it to current techniques of their specialty. They will be able to recognize the needs of the patient for services which go beyond their own area of competence and training, and make proper referrals. In addition, the allied health personnel will be able to adequately perform their functions and provide their services in locations that lack the facilities ordinarily available in a hospital setting; and will be able to adequately perform consultative, teaching, and supervisory services, 3) To provide health professionals, persons in need of rehabilitation services, and their families with a source of information on the full range of rehabilitation services available in, or to, the target communities, The educational activities to be conducted include individual patient consultations, rehabilitation evaluation clinics, and formal teaching sessions. Consultation (provided by therapy consultants from the State Division of Health) to individual agency administrators, allied health professionals, and key agency personnel will be made available upon request, A referral and information service will be developed. Information on local, area and State resources will be compiled by the local coordinator with the assistance of the WRMP staff. The rehabilitation evaluation and teaching clinics will be held for a full day once a month in each community, for a period of ten months; and will be carried out by the project physicians and the therapy consultants and, occasionally, other medical or technical specialists. WISCONSIN Regional Medical Program - 10- RM 00037 7/70.2 Requested First Year Evaluation methods of Objectives I and II include: a) Pre-tests and post-tests to determine the health professional's knowledge of such factors as the identification of disability, appropriate therapy, current techniques, etc. b) Pre and post-use of a structured study to determine their understanding and concern with the patient's needs in rehabilitation. ce) Observation of course participants ina clinical setting. d) Examination of hospitals’ and physicians' records on disabled patients who receive care during the project period. e) Examination of nursing and other allied health personnel care plans and records, for information on sources of referrals, their types of functions, patients' treatments, and consultations. Methods of evaluating Objective III (which relates to the establish- ment of a referral and information source) include a survey of patients be So and/or their physicians with rehabilitative needs, to determine the a number of persons aware of the service and number who have utilized the service. Those using the service could also be surveyed to determine whether or not they actually received the services they needed. Approximately 16% of the first year's total request of $54,341 is in the personnel category. Second Year: $57,428 Third Year: $62,016 Project #23 - An Educational Program for Cardiac and Intensive $128,361 Care Nursing ~- University of Wisconsin, Milwaukee. This is a request for three-year support for a proposal to establish a comprehensive intensive and coronary education program for registered nurses in the Wisconsin Region, in an effort to improve the availability, effectiveness and efficiency of registered nurse manpower to hospitals with ICU-CCU. Plans are to provide training for 72 registered nurses each year of the three years. During the third year it is also planned to conduct workshops with School of Nursing faculties to identify that ICU-CCU content which should be included in basic and graduate nursing curricula. The core training program will be developed at the University of Wisconsin-Milwaukee School of Nursing in collaboration with Marquette University Graduate Department of Nursing, and Marquette School of Medicine. was WISCONSIN Regional Medical Program -ll- RM 00037 7/70.2 Requested First Year The teaching program is planned for five days per week for a six-week period, Four hours of. each day will be devoted to theoretical instruction and four hours to clinical experience. Of this, two hours are allotted to planned formal classes, one hour is allotted for self-study, and one hour for seminar and group discussion work and films. The seminar and group discussions will include various resource people such as dieticians, social workers, clergymen, Public Health nurses, and a former patient. The trainees will be selected according to the following criteria: 1) The trainee will have at least one year of postgraduate nursing experience; will have been employed within the past year; and will be a licensed registered nurse. 2) Preference will be given to trainees with experience in ICU/CCU and emergency room. 3) The trainee will have an employment contract to work in nursing during the ensuing year. 4) The sponsoring hospital will be asked for a written commitment to support the trainee in what he has learned. 5) When the trainee is from a hospital, the physician responsible for the CCU-ICU will agree to participate in two seminars conducted during the course of the training program. 6) The hospital will agree to participate in a followup evaluation and consultation visit involving the hospital administrator, director of nursing, and responsible physician. The applicant states that the objectives are described in terms of behaviors to be achieved at the end of the course. Evaluation then becomes a measurement of the attainment of these behaviors. Approximately $47,000 of the first year's total request of $128,361 is for personnel and $43,344 is for stipend allowance for 72 trainees. Second Year: $114,191 Third Year: $114,191 WISCONSIN REGIONAL MEDICAL PROGRAM - 12 - RM 00037 7/70.2 HISTORY SUPPLEMENT LISTING OF CURRENT STATUS OF CORE & OPERATIONAL PROJECTS TN WRMP PROJECT TITLE AMOUNT SUPPORTED (D.C.) NUMBER THROUGH 8/31/70 BASIC CARRYOVER 1 Core $438,974 -- 2 Study Program for Uterine Cancer Therapy and Evaluation 105 ,032 -- 3 A Pilot Demonstration Program for Pulmonary Thromboembolism 55,404 — 4 Cancer Chemotherapy for Adults 38,492 -- 5 Postgraduate Education for Health Professions 58,520 ~~ 6 Interrelated Programs in Radiology and Nuclear Medicine 112,059 11,141 poo 7 The Prevention, Diagnosis and Treatment of Cardiovascular Disease Part B - Coronary Angiography 5,800 -- Part C - Pediatric Cardiology 57,374 -- 8 Cancer Chemotherapy Program for the Metropolitan Milwaukee Area 66,725 -- 9 Community-oriented Continuing Education in Approved - no funds Stroke Rehabilitation for Physicians and recommended Allied Health Personnel 10 Cooperative Project in the Diagnosis and Approved - no funds Treatment of Secondary Hypertension recommended 11 Tissue Typing Program 51,350 -- 12 Uterine Cancer Screening Project 48,700 a 13 An Operational Program for Nurse Training (Two parts) ‘ A - Inactive Nurse 60,000 - B - Nurse Shock -- 12,400 4 © WISCONSIN REGIONAL MEDICAL PROGRAM ~ 13 - RM 00037 7/70.2 LISTING OF CURRENT STATUS OF CORE & OPERATIONAL PROJECTS IN WRMP (continued) PROJECT TITLE AMOUNT SUPPORTED (D.C.) NUMBER THROUGH 8/31/70 BASIC CARRYOVER 14 Cardiopulmonary Resuscitation Project Nonapproval 15 ' A Comprehensive Program in Renal Disease $ 450,000 -- (Note: This project was approved for a three-year period. The Division is currently negotiating a $450,000 annual level of support) 16 Medical Library Service -- 16,950 17 Nurse Utilization Demonstration Unit -- 100,589 SUBTOTAL $1,548,430 $141,080 © GRAND TOTAL (BASIC AND CARRYOVER) $1,689,510 DRMP 4/30/70 (A Privileged Comuuntcacion) SUMMARY OF REVIEW AND CONCLUSTON OF JUNE 1970 REVIEW COMMITTEE WISCONSIN REGIONAL MERICAL PROGRAM RM 00037 7/70.2 FOR CONSTDERATION BY JULY 1970 ALDVIEGRY COUNCT, The Review Committee recommended that this supplemental operational application - 7/70.2 - which requests $1,487,954 for a three-year program period, be partially funded at $551,604 dic.o. This is to support Protects #20 and #22 in the time and amount requested and Project #23 in the time requested, in a reduced amount. Committee further recommended approval of Project a (Rg) for the time requested but did not recommend additional funds. Project #19 was recommended for deferral pending technical review by the Maternal and Child Health Staff. Committee recommended that Project ##1 not be approved - no RMPS funding recommended, It was further recommended that Council convene a committee to explore areas of computer assistance and monitoring by remote control devices. Project #13A (R) - Inactive Nurse Education. Critique: Committee noted that this was a one-year renewal request for a project that was approved for a two-year program period during the November 1968 Council, However, hecause of funding restrictions during 1969, the project wes not funded and did not become functional until September 1969. While the Committee agreed that the need for this type of program is clear, results from programs of this type generally are poor. Apparently, this is true with this program since only seven out of 17 nurses who have participated, are actually back on duty. Members of the Comnittee noted the review and favorable recommendation of the Continuing Education and Training Branch Staff pertaining to this proposal, In recommending approval, the Committee believed that the one-year additional time period requested may serve to assist the project in meeting its objective However, it wes recommended that no additional RMPS funds be Toe allocated to this activity. Approval in time, with no additional RMPS funds recommended, Project #19 - An Educational Program to Improve the Care of the High-risk Fetus and Newborn Infant. Critigue: The Committee consider red and spreed with the review of the Ad Hoe Cardiovascular Study Panel which stated that the proposal is weil eresenteds; the need is deseribed Lis the educational objectives are weld gs ed but clear and concis: nts of "hoe" to accomplish the goais Yhe only major defictency noted Le a description of how this 2th peads In Wisconsin. ranks in relationship te other hee e WISCONSIN Regional Medical Program ~ 2» RM 00037 7/70.? It was noted that there was no clear evidence that nurses are available to participate in this specialized training and function. The Committee debated whether to recommend approval of this proposal for two years, with specific conditions, until a Program Coordinator (who was serving as-an ad hoc committeeman) suggested that the proposal be reviewed by the Maternal and Child Health Staff. From prior knowledge, he believed that similar types of programs were being supported out of Maternal and Child Health funds. The Committee accepted his recommendation that no action be taken pending a technical review by staff of Maternal and Child Health Services. This has been requested and should be available in time for Council meeting. Recommendation: Deferral pending review by staff of Maternal and Child Health Services. Project #20 - An Action Program for Detection and Management of Gynecologic Malignancy. Critique: The Review Committee noted that this is a worthwhile cancer project in spite of believing that. there is little interest in colposcopy in the United States. The Committee was interested in the statement that this will be a part of an interregional relationship (Section 910) which is being developed with Wisconsin's neighboring Regions - Minnesota and Iowa. © When this relationship is developed, it will provide for: 1) use of ‘, dosimetry programs currently available in Wisconsin by the participating out- | -of-State Universities; 2) participation in clinical data collection and tabulation-in gynecologic malignancy; and 3) the joint utilization of ideas, expertise and facilities of any one of the institutions by all participating centers. * The budgets shown in the application for Iowa and Minnesota are samples rather than requests for funds, - In addition, the reviewers noted that the Wisconsin RAG had approved this. proposal for one year only to afford an opportunity for a complete evaluation of progress, ; Recommendation: Approval in time and amount requested. Direct Costs Only: ist Year 2nd Year 3rd_ Year $116,125 None requested _ None requested Project #21 -.A Computerized Electrocardiogram Project for Wisconsin. Critique: The Committee concurred with the opinion of the Ad Hoc Cardiovascular Study Panel that although a limited need for this type of service by small hospitals in rural Wisconsin is described, the total forecast of need. | by. all small Wisconsin hospitals is not adequately documented. It was agreed s that while the objectives are quite clearly stated, the "state of the art" - of computerized ECG interpretation is not as advanced as indicated in this . " proposal. WISCONSIN Regional Medical Program -~ 3-0 RM 00037 7/70.2 o The reviewers questioned whether it was realistic to assume that a physician can be trained to understand and use ECG interpretation in a four-hour session. The method of evaluation proposed is unrealistic in that the Medical Systems Development Laboratory of the Public Health Service is no longer available for consultant service. In recommending nonapproval, the Review Committee accepted the Panel's conclusion that the application is unapprovable on technical grounds. Committee urged RMP Council to take action to convene an expert consultant committee to explore the entire area of computer assistance and monitoring by remote control devices. Recommendation: Nonapproval - no RMPS funds recommended. The Committee recommended that the RMP Council take action to convene a4 consultant committee to explore the entire area of computer assistance and monitoring by remote control devices. Project #22 - Community-oriented Continuing Education in Rehabilitation Medicine for Physicians and Allied Health Personnel. Critique: The Review Committee relied on the comments made regarding this proposal during the review conducted by the Continuing Education @. and Training Panel. - \. vhe educational design of the program is considered adequate. In establishing a need for the project, the applicant has done the necessary preplanning which includes: 1) the use of statistics on the extent of the problem; 2) the experience from other States; 3). review of the literature; . 4) a survey of existing resources; and 5) lack of manpower in the rehabilitation — field, Members of the Committee agreed with the Panel that the objectives are “stated in measurable terms. The Committee observed that the program,will: j) Utilize many staff members from other agencies. 2) Establish an Advisory Committee which will involve many resources and which will provide general guidance, interpretation, and liaison for their organizations. This will be the primary group with the responsibility for planning the continuation of the activities at the end of the three-year project period. The applicant states that the State Health Department will: continue the activity if it proves successful, 3) Develop cooperative arrangements throughout the Region. The Review Committee agreed with the Panel's recommendation of approval since this appears to be a technically sound and capably directed program. Recommendation: Approval in time and amount requested. ae “Direct Costs Only: Ist Year 2nd Year 3rd_Year $54,341 $57,428 $62,016 - | _. WISCONSIN Regional Medical Program -~-4- | RM 00037 7/70.2 “Project #23 - An Educational Program for Cardiac and Intensive Care Nursing. Critique: The Review Committee considered the review of the Ad Hoc Cardio- vascular Study Panel. Committee agreed with the Panel that the objectives are clearly stated and should be attainable providing appropriate applicants are available for training. i A question was raised as to the appropriateness of a six-week course for CCU nurses as compared to the usual four-week courses but it was recognized that six-week courses may be appropriate for intensive care training for nurses. Although the resources appear to be adequate, a‘'question was raised as to physician invoivement in the training program, This point is not covered in the application. The amounts requested for equipment, stipends, and publications were considered excessive. The necessity to develop and produce one dozen thirty-minute video- tapes (in view of the request of ROCOM) was questioned. _ The estimated $2,000 per capita cost is high when ‘compared to a per capita cost of - approximately $1,000 for similar courses funded by the Heart Disease and Stroke Control Program. The Committee believed that the Region should attempt to persuade the University of Wisconsin to waive the $115 tuition expense © requested y The reviewers concurred with the Study Panel's conclusion that the application is technically sound and capably presented but the budget is excessive. Therefore, as a condition of approval, the Review Committee requested that Staff suggest budget reductions which would bring the cost of this program ‘in line with the cost of similar programs. Staff suggested the following first-year budget: Direct Costs Fron To Personnel (reduce Project Director's time and salary by 10%). $ 46,997 45,064 Consultant Services - ~~ 6,000 6,000 (Same) Equipment (deletes $6,000 for Multimedia Instructional System). 14,170 8,170 Supplies 2,300 2,100 Travel (by reducing amount for trainee travel) 6,500 5,750 Publications. 3,750 3; Po0'tSeme) Other (Development of videotapes). 5,300 -0- Stipend Allowance 43,344 21,844 — TOTAL $198,361 92,678 $84,508 per year, for each of two years, is the amount suggested for the second and third year, The reductions are principally in trainee stipends and travel. Recommendation: Approval in time with the amounts and conditions as 4 stated above, . $92,678 $84,508 — $84,508 Tine Phitin WMhtita. waa nat nracant dAurindg daltharatinan af thie annlication. Direct Costs Only: Ist Year Ind Year 3rd Year @ WISCONSIN Regional Medical Program RM 00037 7/70.? SUMMARY OF RECOMMENDATIONS Project Number Title Ist Year and Year 3rd Year 13A (R> Inactive Nurse Education Approval - no additional funds recommended 19 An Educational Program to Deferral for special review (MCH) Improve the Care of the High- risk Fetus and Newborn Infant 20 An Action Program for Detection $116,125 None None and Management of Gynecologic requested requested Malignancy 21 A Computerized Electrocardiogram Nonapproval - no RMPS funding Project ‘ recommended 22 Community~oriented Continuing § 54,341 57,428 67,016 Education in Rehabilitation Medicine for Physicians and Allied Health Personnel 23 An Educational Program. for $ 97,678 84,508 84,508 Cardiac and Intensive Care Nursing TOTALS $763,144 141,936 146,524 YEARS TOTAL DIRECT COSTS 01) $263,144 02) 141,936 03) 146,524 i $551,604 7/15/70 Wisconsin RMP RM 00037 7/70.2 DEPARTMENT OF HEALTH, EDUCATION, AND METPARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Date: July 10, 1970 Reply to . Attn of: Rte “Subject: PEOPOSAL ~ "An Educational Program to Improve the Care of the High-risk Fetus and Newborn Infant" - Project #19 To: Acting Director Regional Medical Programs Service I apoereciate the opportunity to review this proposal. We are supporting a number of similar training programs as well as four neonatal intensive care unit projects, the latter with funds available for the first time in fiscal 1979. I have no doubt about the importance of increasing the understanding of the newhorn among areata and nurses. In xeviewing such an application as this, it is quite possible that my frame of reference may be different Erom yours since i respond from the background of the medical-care programs in © which I function rather than the Regional Medical Programs, “While education in itself is a desirable eee LI would ‘also be interested in, knowing what ba nefits would be expected from such a orogram., I would not give wisconsin a high priority since it has a favorable infant mortality rate among the states, “19.4 infant deaths per 1,000 in 1967. How much this program -would improve the situation »eyond the contributions which shave on made by the State Health Department for years is not ates . It is questionable that stich PEOSTESS can be made in Lo “improve «the maternity care of the high-risk obstetric satient and which will increase the availability of family planning services. The program may,be hampered if high-risk, low-income. maternity patients do not have resources to meet the costs of the comprehensive care they need. The page on program evaluation is weak. In conclusion, if gains in fetal and neonatal mortality and in low-birth-weight rates are among the criteria for approving such a@ proposal in Regional Medical Programs, this application does not seem to me to warrant a. favorable priority. ft AAA Luu CAE thurs oy Lesse cM. bisection: Hens .