ALABAMA © REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) ALABAMA REGIONAL MEDICAL PROGRAM RM 28-03 (AR-1-CSD) 2/71 The University of Alabama in Birmingham January 1971 Review Committee The Medical School Center 1919 Seventh Avenue South ' Birmingham, Alabama 35233 PROGRAM COORDINATOR: S. Richardson Hill, Jr., M.D. REQUEST FOR NEW FUNDS (Direct Cost Only) REGIONS OPERATIONAL YEAR 03 04 05 Total I. Core (Renewal) 558,061 790,921 839,284 2,188,266 II. Approved Unfunded Projects (5) 243,669 163,770 -0- 407,439 III. Renewal Requests (Projects) (2) 173 ,827 172,323 177 ,858 524 , 008 IV. Developmental Component (3 yrs.) 100,000 100,000 100,000 300, 000 @ Vv. New Projects (10) 800,852 762,914 457,971 2,021,737 Total Request 1,876,409 1,989,928 1,575,113 5,441,450 (Project #26 -Nutrition Project, Tuskegee, Alabama (Model Cities-RMP) an approved unfunded project will be funded with earmarked funds for model cities activities, per recommendation of the Acting Director of RMPS) Funds requested for this project have been omitted from the total request for approved/un funded projects (Item II). RMPS Staff Review of Non-Competing 03 Year Operational Continuation Grant Application (December 17, 1970. Recommended Award Commitment REGIONS OPERATIONAL YEAR 03 Year 04 Year I. Core (Sub-Regionalization) $178,658 -0- IL. Ongoing Projects (2) 61,342 -0- Total $240,000 -0Q- FUNDING HISTORY (Direct Cost Only) Grant Year Period Funded Planning Stage ol 1/1/67 - 12/31/67 $ 247,250 Alabama Regional Medical Program -2- RM 28-03 (AR-1-CSD) 2/71 Planning Stage Period Funded 02 1/1/68 - 12/31/68 $ 286,750 02S 6/1/68 - 8/31/68 11,695 02S 9/1/68 - 12/31/68 113,392 03 1/1/69 - 3/31/69 131,526 Operational Stage 01 4/1/69 - 3/31/70 Core 542,369 , Protects 192,509 Total 734,878 01(S) 4/1/70 - 3/31/71 Core 101,492 Projects 39,365 Total 140,857 01(S) 4/1/70 - 3/31/71 Core 160,490 Projects 40,145 Total 200,635 GEOGRAPHY AND DEMOGRAPHY: Alabama ranks 29th among the states with 51,609 square miles of land, The most recent population estimate (. Health Department's Bureau of Vital Statistics, 1967) is 3,562,850. It has a large rural population with a large Negro component (30%). In per-capita income Alabama ranks 47th among the states. In this state there are 67 counties - 35 northern counties are in the Appalachian development district. Trade, industrial and transportation patterns group the counties into areas similar to the seven used as the geographic framework for planning the Alabama RMP, The Alabama Region, as presently defined, represents some admixture of interest and health service functions between the extreme southeastern part of Alabama (especially the Dothan area) and adjacent parts of Georgia and Florida, The similar admixtures at Phoenix City, Alabama, with Columbus, Georgia, and in a few places along the Mississippi broader, The several interfaces across the political boundaries do not present problems and Alabama Regional Medical Program works compatibly with those that surround it (Mississippi, Florida, Georgia, Memphis and Tennesee Mid-South). The single Medical Center located very near the geographic center of the region contains the only complete constellation of medical, dental and nursing and allied health sciences resources for teaching research and service in the state. In an economic sense Alabama lies in the center of the cotton belt of Alabama RMP -3- RM 28-03 (AR-1-CSD) 2/71 the old South. Although agriculture remains a vital part of the states economy, a rapid increase in manufacturing and diversified industries have given the area a more balanced economy in recent years, Live stock, especially poultry, has become quite important to the economy. Alabama ranked second in the nation in pulp wood production. Additionally, lumber, furniture and wood projects are important. Bituminous coal, iron and bauxide are among the national resources of the state. There are a total number of 67 counties in Alabama and there is a 64 person per square mile density in population distribution throughout the state, The major portion of the population of Alabama is located in the Metropolitan areas of Birmingham, Columbus, Georgia ,- Alabama , Gatsden, Huntsville, Mobile, Montgomery, and Tuscaloosa, Alabama, Approximately 55% of the population of the state is urban. The medium age of the population of Alabama is 26.0. Approximately 70% of the population is white and 30% of the population is Negro. There is only one medical school in the state of Alabama, the University of Alabama Medical Center, which has an enroliment of 300. There are 14 schools of nursing of whieh two are collegiate institutions; 12 schools of medical technology of which 9 have a college affiliation; one school . of cytotechnology at the University of Alabama; eight of x-ray technology with three having collge affiliation; and a total of 140 hospitals of which nine are federal and 131 are non-federal, The total number of hospital beds available in Alabama are 26,553 of which 4,140 are federal facilities and 22,413 in nonsfederal facilities, There are a total of 2,842 physicians and there are four osteopaths in the state of Alabama which is approximately a rate of 86 per 100,000. There are a total of 7,150 nurses in the state of which 5,272 are presently active which is a rate of 159 per 100,000 population. HISTORY OF REGIONAL DEVELOPMENT: On July 17, 1965, the Medical Association of the State of Alabama appointed an Ad Hoc Committee to investigate the recommendation of the Presidents Commission on the treatment of stroke, heart disease and cancer. After careful study the Ad Hoc Committee recommended that all programs of the Regional Medical Programs be centered in the Medical College, University of Alabama but should be operated with the approval and guidance of the Medical Assoctation of the State of Alabama and the State Board of Health. On April 9, 1966 in anticipation of action under Public Law 89-239 the Governor George Wallace, appointed a State Advisory Regional Medical Program Committee. The members of this committee were nominated by the president of the Medical Association, State of Alabama and the Dean of the Medical College and included representatives of the Allied Health Professions, Voluntary Health Agencies and Consumers. The group recommended that the University of Alabama Medical Center be designated as the responsible agent for planning for the Alabama Regional Medical Program. Alabama RMP ~-4- RM 28-03 (AR=1 CSD) 2/71 The region's initial planning grant was awarded for a 24-year period beginning January 1, 1967. A total of $247,250 d.c. was awarded the first year. A second year award plus two supplemental awards which provided support for a subregional planning office in Mobile made available $411,837 for planning during the second year. During this planning phase the programcoordinator for the region was Dr. Joseph F. Volker, Vice-President for Health Affairs, University of Alabama Medical Center. In the initial review of the planning application the National Advisory Council expressed concerns that the Regional Advisory Group of the Alabama Regional Medical Program did not have representation of the consumer public minority interests, dentists and nurses (and there appeared to be token representation from the state hospital association.) The application also made no specific reference to an analysis of the overall medical needs of the region. There was inadequate allocation of administrative responsibility including failure to define the mechanism for coordinating the planning among the professional staff, the Advisory Committee, and the State Board of Censors, There was no systematic analysis of resources; no reference to work that had already been done in this field; no specification of cooperative arrangements among institutions to be involved, and no consideration for planning the most effective allocation of existing resources and personnel. On the basis of this criticism from the National Advisory Council the - region revised their planning application at which time the National Advisory Council did approve the planning grant which essentially satisfied earlier concerns. On November 1, 1968, Dr. John Packard was appointed director of the Alabama Regional Medical Program succeeding Dr. Benjamin M, Wells who then became Coordinator replacing Dr. Volker. The region submitted its first operational application on August 27, 1968, requesting $1,928,327 for the first 12-month period to begin January 1, 1969. It included 12 operational projects. A site visit was conducted on December 5, 1968 to determine the readiness of the Alabama Regional Medical Program for operational status, In reviewing the operational application the National Advisory Council indicated that the Alabama Regional Medical Program was in the early stages of maturity. The Council expressed the hope that the Regional Advisory Group would become more active in a leadership role under the direction of its new chairman. Also required would be an addition of a full-time program director in evaluation cf personnel, and the role of Core staff was expected to be strengthened, Council did note that the site visit team found the staff to be generally competent and under effective leadership. The role of the staff in establishing links of communication and in capitalizing and channeling ideas and ongoing activities was noted as a major strength of the program, In conclusion, the Council concurred with the recommendations of the site visit team which approved four of the eleven projects considered and recommended a total first year direct cost award of $734,878. In March 1970, Council approved a Core supplemmt for subregionalization of the Alabama RMP which involved the establishment of seven subregional Alabama RMP -5- RM 28-03 (AR-1-CSD) 2/71 offices. The region proposes through the core supplement to accomplish regionalization and coordinate RMP activities in Comprehensive Health Planning in the region. This region is unique in that the Alabama Medical Society is the official health agency at both the state and local level. This organizational framework gives the Medical Society responsibility for administering activity under title 18 and 19, "the partnership for health" (PL 89-749). In May 1970, a site visit was conducted to this region to take an in- depth look at the region's core and projects. The impression of the site visitors was that the Alabama RMP could eventually have one of the strongest health care programs of any state, if its overall scheme for integrating the strengths of the University, the Regional Medical Program, the State Medical Society and Comprehensive Health Planning is made to work, The RAG has been increased from 42 members to 62 members, The increase in membership has been directed toward expansion of consumer representation on the RAG. Each of the seven subregions were asked to appoint two candidates and six additional members were selected at large. In order to increase minority group representation on the RAG, each subregion will be required to select a minority group member as one appointee. With this increase in consumer representation on the RAG, the majority of advantage previously held by the Alabama Medical Association and the University of Alabama will no longer exist. The increase in involvement of the local community representatives on the RAG facilitates the regionalization process of this region. Dr. Robert Ross McBride present chairman of the RAG has indicated that the RAG will continue to select as chairman a practicing physician from communities away from the Medical Center. The region believes that this will improve the relationship of the ARMP with community physicians throughout the region. PRESENT APPLICATION: This is the triennial application in which the ARMP has requested a Core renewal of 2 projects, a dvelopmental component, supplemental funding of ten new projects, and continuation of a core supplement ( subregionalfzation) and two projects. The ARMP's proposed activities for the next twelve months are identified as follows: 1. Core Staff (a) Program Planning and Development ~ to implement plans for program direction as determined by long-range planning an executive committees, Regional Advisory Group, and key staff members. (b) Project Development_and Review - Try to develop a method of project development with increased involvement of RAG members Alabama RMP -6- RM 28-03 (AR-1-CSD) 2/71 and less staff time. To develop a more impartial project _ review process. — (c) Program Management - To maintain and improve management methods of programming projects in areas of personnel and physical . procedures. (d) Education - A three year plan for involvement in the education of: Health Manpower in Alabama. To help and assist in the implementation of an overall regional plan of basic and continuing edueation for health workers in Alabama in order to improve the Health Care . Delivery System to the people. (e) Communications - To increase the awareness of ARMP activities within the region, especially the need for program consistency. ‘ To improve communications systems.with core staff. (£) Program in Project Evaluation - To design evaluation methods for each ongoing project and to assist in writing new project proposals so that they include a cleaner and measurable set of objectives with a design for evaluation. To evaluate means and methods to achieve maximum utilization of ARMP dollars spent in the region. Continue to evaluate future medical needs of the community and determine what steps the providers of care must take immediately to meet these needs. To prepare a statement of health baseline data for the region which can be utilized as a comparison for future program evaluation. (g) Consultation - Key staff members, i.e., those in Assoctate Director and Assistant Director positions, will be responsible for consultation activities for the programs constituency. Consultation will be based upon the staff members role in the program, however, all consultation activities will be sensitive to the health needs of the state. 2. Subregional Offices The Birmingham and Montgomery subregions have established lists of objectives and priorities for the 314 (b) agencies. The ARMP-funded health planner in the Birmingham office, Mr. Al Rohling, will be involved in implementing these under the direction of Mr. George Rice (Executive Director, Community Service Council), while acting as liaison with ARMP by attending meetings with core staff and RAG. In Montgomery, Mr. David Carter has been named Executive Director of the state approved bu unfunded 314 (b) agency. He will be involved in further community development, identification of possible local sources of matching funds for the time when federal funding is available, and in identifying project proposals which would alleviate local needs and be appropriate for ARMP funding. Activities of the other four subregional health planners, all of whom have been appointed for less than four months ,will center about the involvement of local providers and consumers into a viable health planning council which can qualify for 314 (b) Alabama RMP -7- RM 28-03 (AR-1-CSD) 2/71 Status and which can identify local needs, set realistic objectives and arrange most of the next grant period, The following years will be utilized to implement the plans. Two regions (Tennesee Valley Area in Northern Alabama and the recently delineated Selma Area) have not yet been able to identify mutually satisfactory health planning councils. Core staff will continue to be involved, with representatives of the 314 (a) Agency, in encouraging the formation of such councils. This will probably be accomplished during the early part of the next grant period for the Tennessee Valley Area, and funds for hiring a seventh health planner are contained in the Continuation Application portion of Core staff. The Selma Area will probably not be in a position to use a health planner until the period 4/1/72 - 3/31/73 and funds are being requested for this position in that and the succeeding grant period. 3. Grantee Institution The Executive Committee of RAG recommends that part-time salary support to faculty members and support to staff be constantly reviewed to insure that effort and time expended on ARMP duties be probably compensated, Full-time staff will probably reduce the need for part-time staff with consequent benefits in management. They are further strongly recommending that the grantee institution appoint a full-time coordinator in line with their previous actions, Committee also recommended that data collection be purchased on a contract arrangement. The ARMP explains that office space for Core staff needs expansion, which cannot be effected in their present location. They indicate that during the next few months the Core staff must move into adequate quarters. 4, Regional Advisory Group At their June 1970 RAG meeting the members and Core staff identified the following as major issues needing work or improvement if the ARMP is to fulfill its potential and has recommended actions which have been started and will continue during the next twelve months: 1. Inadequate communication between RAG and Staff. 2, RAG involvement in project development and review. 3, Relationship between RMP, RAG, and UAB to be clarified. 4. Confused relationship between CHP and RMP. 5. Inadequate consumer involvement. 6. Decentralization - what and how much? 7. Programs versus projects The RAG also reviewed the following major program areas: 1. Consultation and resource service. 2. Continuing Education 3. Manpower development 4, Medical Services. Alabama RMP -8- RM 28-03 (AR-1-CSD) 2/71 In addition, the RAG is undertaking a reassessment of ARMP goals, objectives and priority setting which will be a continous’ process occupying at least the next grant period and will probably continue throughout the next three years. The categorical committees of RAG will be assisted by staff and outside consultants to reassess the planning goals established earlier and set priorities. A in depth study of the advantages and disadvantages of changing grantee institutions will be undertaken by an Ad Hoc Committee authorized by the Executive Committee of the Regional Advisory Group which appreciates the problems which arise from too close | an identification of ARMP with the University of Alabama and which may become more acute when the proposed medical school in Mobile opens in 1973. ORGANIZATIONAL STRUCTURE AND PROCESSES The Regional Advisory Group: The size of the Regional Advisory Group has been increased to include more allied health personnel as well as consumers. This growth is responsible for a broader geographical representation which ig in part responsible for the change in program emphasis from continuing education to manpower development and delivery of medical services. The RAG has been concerned with establishing a separate identity for ARMP to ey set it apart from the University of Alabama in Birmingham (UAB). In a June 1970 the recommendation was made that a full-time coordinator be S appointed by Dr. S. Richardson Hill, Jr., Vice-President for Health Affairs at UAB. Dr. Hill assumed thetitle of Coordinator without salary support in January 1970. In October 1970, the Executive Committee of the RAG authorized appointment of a committee to study the advantages and disadvan- tages of changing grantee institutions in light of plans by the University of Alabama, Mobile, to open a new medical school by 1973. The Regional Advisory Group is named by the applicant with the advice of the Chairman of the Regional Advisory Group. The membership of the Group shall be composed of members representing each of the following institutions and organizations, in number indicated, together with thirteen members at large representing the general public interest. Medical Association in the State of Alabama University of Alabama Medical Center Alabama Dental Association Alabama Hospital Association Alabama State Nurses Association Alabama Heart Association Alabama Division of the American Cancer Society State Health Department Vocational Rehabilitation Services Veterans Administration Subregional Advisory Group (2 each) Members At large Total BONEN EH wo Dh Alabama RMP =Q- RM 28-03 (AR-1-CSD) 2/71 Executive Committee: An Executive Committee composed of no less than five nor more than ten members shall be electedby the Advisory Group. The Executive Committee is authorized to act for the Advisory Group between ' meetings subject to subsequent approval of the Advisory Group. The Executive Committee has been composed of representatives from the offices of RAG, the Presidents of the Medical Association of the State of Alabama, the Alabama Hospital Association, a Chairman of the Board of Censors of the Medical Association, the Dean of the UAB School of Medicine, the Vice-President for health affairs of the UAB, the State Health Officer, and the Coordinator of ARMP, and thus involve the responsible officers of the most significant health providers and educators in the state. Recognizing the desirability of having a smaller committee, to include consumer representation and with the majority of members living in or near Birmingham, the 1970 RAG elected a six member Executive Committee comprised of the officers of RAG, the President of the Medical Association, and two laymen, one of whom is a past President of the Community Service Council (local 314 (b) Agency) and still serves on their Board of Directors. In addition, the Chairman of the Board of Censors, the Vice President for Health Affairs of UAB (who is also Coordinator of ARMP), Coordinator for Research Grants of UAB and the Director of ARMP are ex officio members. Education Committee: The Education Committee has been composed of faculty members of the UAB School of Medicine, Dentistry and Nursing which represented the resource for education of the providers. The committee has been expanded to include representation from propective students, junior and senior colleges, the Alabama Hospital Association, guidance counsalors, and from vocational education. The Project Review Committee: This Committee,with membership from the RAG, UAB and Core staff has assumed a portion of the functions of the Development Committee in review of proposals and of the final. draft of project application before RAG review. Long-Range Planning Committee: This Committee with membership from RAG, CHP, Appalachian Regional Commission and Core staff, assumes the remaining function of the development committee, including making recommendations for short and long-range goals, objectives, and priorities, evaluation mechanisms and methods of implementing the programs. Developmental Component Committee: This Committee with members drawn from RAG, the Office of Grants Administration, UAB and Core staff, will review and act on proposed expenditures from the developmental component. Allied Health Advisory Committee; This Committees' membership represents 13 different categories of nursing and other allied health personnel and it provides a forum for discussions of inter-disciplinary nature, focusing on common health problema. The Committee recommends studies to determine education needs of practitioners and encourages projects related to improving the expertise of these practitioners based on these identified needs, Major attention is given to allied health manpower needs and the Committee addressses itself to manpower distribution problems. Alabama RMP ~ | -10- «RM. 28-03 (AR-1-CSD) 2/71 Categorical Committees: These Committes continue to be’ responsible for planning, screening and evaluation of proposed activities in their field of interest. There are categorical committees in the following areas: . oe » Heart. Disease 5. Diabetes 1 2, Cancer 6. Dentistry 3. Stroke 7. Rehabilitation i ae . Renal Disease Each of the above committees, by its membership contributes to cooperative relationships, and each contributes in one fashion or another to planning and. project and program review. ; Sponsor Review Committee: This is the Committee of the grantee institution serving as an Advisory Committee to the Vice-President for health affairs and the Director, ARMP. The committee reviews all ARMP proposals, both Core and affiliate based, from the point of view of the grantee institution, to determine that no ARMP sponsored activities are in conflict with State laws, UAB policies or institutional objects. Following is the ARMP Organizational Chart. ALASAMA REGIONAL ME Qecorn ORGANIZATIONAL CHART Regional! Advisory Group {Policy & Direction) R. R. MeSryde, M.D., Chairman | S. Richardson Hill, Jr., M.D. | COORDINATOR UNIVERSITY OF ALABAMA IN BIRMINGHAM {Acrainistration & Fisea! Resnonsibility) Li. S. Richardson Hill, Jr., M.D. Vice-President for Heaith Affairs Health Programs Liaison (CHP, Appalachia, VA, Model Cities, Hill-Burton) Director {Chief Executive Officer) John Packard, M.D. : Robert P. Glaze, Ph.D. Coordinator of Research Grants Lester H. Buryn Office of Grants Administration Denuty Director M. D. Plowden Associate Directer Professional Liaison J.O. Finney, M.D. Associate Director Education Laurene Gilmore +i Associate Director, Cancer John Durant, M.D. . Associate Director, Heart —s and Stroke Harold Schnaper, M.D. Ls Associate Dirsetor, Kidney ; Thomas ©. Andreoli, ¥.D. | | | Assistant Director, Nursing Martha Lee Assistant Director Auciovisvals Robert Shaw t . . 7 Associate Director ae | Planninn and Pronram Associate Director, Program Acting { De oon t Managerient & Communications Associate Directar sveropmen James Rebertson Evaluation | Devid Cusic Dougias Patterson ~ fd a . | . . Assistant Director ‘ Assistant Director a Coordinater Community : Graphic Arts i Project Director an Operations Research & Development . Operational Projects John Gillespie Donald Prince Ida M. Reed Heatth Planners Subregional Offices Assistant Director | Communications Jean VWiatson Budoet Anslyst Virginia Buryn we {3} Y { : | : seat Heaith Program | Associate ia | Lisicon Specialists | Potty TEIN For i (2 en teat j Reslonal Programs V.A. (2) VLA, Hout to tent Poteet : Hocoits!, Birmingham | i $ t 1 aed October, 1970 Alabama RMP -12- RM 28-03 (AR-1-CSD) 2/71 Core Staff Organization: The Core staff of the Alabama Regional Medical Program has 56 employees, 40 at 100% time. and effort. Following is a chart which indicates the percentage of personnel costs as applied to the categories of ARMP proposed activities: 15% Program Planning and Development 14% Project Development and Review 14% Program Management 21% Education 12% Communicaticns 13% Program and Project Evaluation . 11% Consultation There are two parts of Core which have to be considered in this application, (1) the Core basic, (2) Core subregionalization. Core basic represents a renewal request which must be reviewed by the National Advisory Council and Core sub-regionalization is a continuation request for funds committed and authorized last year as part of a two year RMPS grant award. Although the Core subregionalization project was reviewed and approval was recommended by staff,this activity should be taken into consideration when reviewing the request for Core renewal because in 04 and 05 operational years of this region,the amounts necessary to continue this activity have been included in the total request for Core. The Gore basic budget of $558,061 direct costs compares with the current buéget of $526,199. This represents an increase of slightly less than $32,000. The region indicates that this is a minimum increase in the light of expanded proposed activities. The ARMP Core staff will in the next twelve months be engaged in multiphased programs as outlined in the proposed activities segment of the application. It should be noted that the program management phase includes administrative and supportive activities required to assist in the establishment and operation of subregional offices. The personnel category accounts for approximately $17,000 of the requested increase for Core basic. This increase is influenced by two major items: (1) the grantee institution (UAB) will expand its benefit programs requiring an increase from 13% to 18% on all 1971 Federal Grants to reflect a planned increase in Social Security Payments, Unemployment Compensation, TIAA, State Retirement and Health Benefits which will take place during the fiscal year 1971 - 1972, and (2) a minimum merit raise (5%) has been included on all filled personnel positions. The following is a list of the Core staff members of the ARMP including the staff utilized in the Core Subregionalization Program. Alabama RMP @ Name (Basic) Vv. Cc. Cc. Oo e Zim a ty * © @ @ e @ 6 ZS Preeraneayy = . e e . a ee @ J. Cc. Buryn Calvert Crooks Cusiec Finney, M.D. Gillespie Gilmore Green Hall Harper Hernandez Hunt Johnson Joiner, Ph.D. Klapper, M.D. Lamb Lee McCool Osborn Packard, M.D, Patterson Pigman Plowden, LLB Prince Reed Robertson Schnaper, M.D. Sentell Shaw Sheehy, M.D. Sheffield, M.D. Shield Sigler Slattery Snow Watson Whitman TBA TBA TBA L. Wilson Subregionalization) CM. Porter, M.D. Pum OnRaaG TB. Carter, Adm, Mosley, Adm, Brown, MHA Payne Moore, MHA Calhoun Cleino, Ed. D. Culley Rohling (2) ~13- RM Job Title or Function Budget Analyst Secretary Adminis. Secretary Assoc, Dir. Planning Assoc. Dir,. Prof, Liaison Ass't Dir. Operations Assoc. Dir. Education Secretary Secretary Secretary Resident & Staff Ass't Research Assoc, Secretary Research Analyst Advisor Con't Med. Fduca. Advisor Adm, Ass't Family Serv. Ass't Director Nursing Secretary Senior Secretary Director ARMP Acting Assoc, Dir, Eval. Research Analyst Deputy Director Ass't Dir. Graphic Arts Coord. Comm Res, & Dev. Assoc. Dir. Prog. Mgt. Ass't Dir. Heart & Stroke Secretary Administrative Ass't Medical Service Medical Service Secretary Secretary Senior Secretary Senior Secretary Ass't Dir. Communications Secretary Program Dev. & Eval. Spec. " " tt tt Secretary Secretary Director Medical Education Health Planner Adm. Assistant Health Planner Secretary Health Planner Secretary Health Planner Health Planner Health Planner Health Planners - 28-03 (AR-1-CSD) 2/71 % Hours Time or Effort 100 100 100 100 63 100 100 30 100 50 75 33 33 30 10 100 100 20 100 100 100 80 100 100 100 100 25 100 100 10 10 100 100 100 100 100 100 100 100 60 50 50 100 100 100 100 100 100 100 100 100 1n0 Alabama RMP -1l4- RM 28-03 (AR-1-CSD) 2/71 The day-to-day operation of the ARMP activities are supervised by the Director John Packard, M.D. and the Deputy Director M. D. Plowden, The Core staff of the ARMP is quite involved in project development, — implementation and monitoring of activities supported by the ARMP, These activities of Core in relationship to project are clearly identified in section [II-B page 43 of this application. PROJECT REVIEW PROCESS The Region indicates that the project review mechanism at the Alabama Regional Medical Program is presently undergoing some positive changes, The program is placing more emphasis on the following: (1) Crystallization of policy and initiative upward rather than being imposed from above; (2) There is maximum participation by the voluntary and private sector at the grass roots level. The feeling at Alabama Regional Medical Program is that consumers must play a stronger part in establishing policy and making major decisions effecting the delivery of heaith care and determining the needs in the community in which they live. The ARMP indicates that project proposals originate from a variety of sources and from many sectors within the region. Assistance in project design and evaluation, methodology is provided by Core staff elements. If the proposal originates from a subregion with a functional area Advisory Group and is applicable to that region, it is reviewed and approved by the area Advisory Group before submission to ARMP in summary form with a tentative budget. The concerned County Medical Society (ies) review all project proposals prior to submission to ARMP. Upon receipt, the ARMP Core staff reviews proposals to assure conformance with overall program objectives and provides initial administrative screening. At this time the Medical Association of the State of Alabama and their Board of Censors are informed. The region identifies a checklist form which is on page 17 of Section [II-B that will be utilized during the 1971 fiscal year by the ARMP staff for review of project proposals. Under the coordination of the Core staff, project proposals are routed to the following standing committees: (1) To the Categorical Committee for professional and scientific review. (2) Project Review Committee - for technical review, feasibility determination and for delineation of evaluation mechanism. This committee may also measure the project proposal against the regional framework or planning matrix of the Region. (3) Sponsor Review Committee - This committee for the grantee institution reviews the proposal to assure conformance with university fiscal policy and procedure and coordination with existing efforts of plans of the university in related fields. The ARMP Core staff is responsible for coordination of all planning and operational activities with the Comprehensive State Health Planning Alabama RMP , | -15- RM 28-03 (AR-1-CSD) 2/71 Agency (PL 89-749) and other major planning groups in the region such as; CHP (b) Agencies, Appalachian Regional Health Planning Commission, etc. The Comprehensive Health Planning Agencies (both (a) and (b)) as well as the Appalachian Regional Health Planning Commission Review and comment on ARMP projects before submission to the RAG. Favorably considered proposals are then presented to the RAG for final review and approval or disapproval action or disapproval action. A checklist form has been developed for utilization by the RAG in their review of projects, This form can be seen in section III-D Page 19 of the application. ANNUAL REPORT OF THE REGIONAL ADVISORY GROUP (RAG): The RAG identifies in its report the following Regional objectives which were modified in Jure 1970: (1) to increase and improve total community involvement in both the problems in modern health care and their potential solution; (2) to stimulate and support the creation of new health service manpower and to improve their distribution and utilization throughout the region; (3) to provide remedial and continuing education for the entire health service team in relevant categories. The RAG indicates that progress toward each of these objectives is essential to viability of ARMP and its service to the people of Alabama, but first priority must go to that area where the need is demonstrativelygreat, long- range benefits are likely to be most important when there is community involvement achieved through subregionalization, liaison, and promotion of cooperative arrangements. The RMPS has characterized its relationship with Comprehensive Health Planning as outstanding. Individual RAG members and Core personnel are continuing to work toward even more effective arrangements with CHP, and at the same time are developing support and cooperation involving many other organizations concerned with health. The RAG explains that subregionalization is the key mechanism whereby total community involvement and cooperation may be accomplished. They indicate that this is progressing well with area offices established and competently manned in five of the subregions, with prospects good for early establishment of the remaining offices despite reorganization of the region to increase the number from seven to eight subregions, conforming to the planning and development districts recently established by the Governor of Alabama, They explain that subregionalization facilitates continuing development of cooperative arrangements with the Medical Associa~ tion of the state of Alabama, the Alabama Heart Association, the Alabama Charpter of the American Cancer Society, the Alabama Hospital Association, and may other state, professional, and voluntary health organizations. They believe that subregionalization is an important means for pursuit of all program goals because it functions at the "grass roots" level and enables close contact with the consumer. In order to increase still further the communication with the subregions, the RAG at the June 1970 meeting voted to increase its membership from 40 to 60 by adding two consumers for each of the subregions and additional members at large. “Alabama RMP ~16- RM 28-03 (AR-1-CSD) 2/71 Through representation on the RAG and through the plannned effort of staff, virtually all significant health-oriented organizations have effective liaison with ARMP, This is accomplished at state-wide and to an increasing extent, at county and local levels. Core personnel include an Associate Director for Professional Liaison, Dr. J. 0. Finney,Sr., and a Community Service and Development Office, staffed by Miss I. M. Reed, In addition ,core staff members are active in a variety of professional associations. . The second ARMP objective improvment in supply and use of health manpower has been pursued by initiating projects such as the medical information service by telephone, nursing utilization studies and a state-wide coopera- tive mechanism involving the states junior colleges and the Regional Technical Instituté in training allied health personnel. In addition, ARMP has supported development of the Division of Family Practice and Ambulatory Medicine at the School of Medicine, training programs various types of assistance and exposure of medical school faculty and students to community hospitals. The RAC indicates that health career recruitment also is an objective of ARMP effort directed toward the goal of alleviating serious health manpower shortage in Alabama. The staff of the ARMP has invested many hours with the Health Careers Council of Alabama, the Alabama Hospital Association, and other groups developing ways to educate career guidance councilors concerning health careers and to direct the attention of young people to the satisfaction of work in the health field. Work toward the third objective to provide remedial continuing education has been approached through continuing medical education which has been the primary objective of several ARMP projects and an important aspect of several others, A RAG committee is concerned with a supplemental education and a staff member devotes full time to regional and subregional educational programs and educational consultant services in the health field. The ARMP cooperates with the UAB School of Medicines Division of Continuing Medical Education and with the Medical Association of the State of Alabama to provide educational services. Audiovisual and other educational materials are available through ARMP and more will be offered a¢ they become available. Tre -AG eyplains that a significant but lower priority aspect of the 4°éP thrust which requires, nevertheless, a good proportion of staff time and effort, is consulting and resource services. Here again an important function of the program is as a catalyst, to encourage cooperation among various agencies and to force their activities by others for improvements in both the nature and availability of health care. Position papers for Comprehensive Health Planning, consultation on Appalachian Regional Health Planning Commission Projects, provision of Audiovisual materials in guidance in health curricular technology are examples of this service, The Regional Advisory Group indicates that they had much difficulty Alabama RMP -17- RM 28-03 (AR-1-CSD) 2/71 in setting priorities within a specific program area and even greater difficulty in setting priorities between program areas. The RAG has however, submitted a priority listing of projects which is located in Section II page 7 of the application. The ARMP indicates that formal endorsements and letters of support have been given to the ARMP from all major health organizations within the region. They claim excellent rapport exists between the ARMP and the other two large Federal health planning programs within the region - Comprehensive Health Planning and the Appalachian Regional Commission. In addition to joint sharing of staff with the State CHP Office in Montgomery, and the Appalachian Regional Commission in Decatur, the recently funded subregionalization program provides a health planner in each of the seven subregions in the State who are responsible for assisting in the development and initiation of a 314 (b) agency for his subregion. The RAG indicates that one of the most serious challenges facing Alabama today is how to provide medical services to poor people in both the rural and urban areas of the State. They identify subregionalization as an activity which concentrates attention at the site of the problems in health care for the poor. The Alabama Regional Medical Program has been instrumental in setting up the Lawrence County Project, which is about to get under way with the Appalachian Commission, and to some extent, Blue Cross funds. ARMP will be a consultant for this project which emphasizes ambulatory care. A nutrition project aimed at areas of national priorities including Decatur has been submitted and approved and plans are to implement it by April 1, 1971. The RAG explains that although health needs of the poor tn Alabama are indisputably sertous, specific statistics are not available to document those needs. ‘This basic information is being gathered, however, on a county by county basis by several organizations in cooperation with ARMP, The data will be available to ARMP for analysis in relation to income levela and other factors and will be a valuable guide in the development of future projects. Two areas which the RAG indentifies as ready for early consideration in developing activities that would be beneficial to the poor are: (1) extending hours of patient clinics, and (2) providing transportation to clinics for the poor people. The RAG believes that the ARMP has made a significant impact on the delivery of health care to victims of heart disease, stroke, cancer and related diseases during its first year of operation. The ARMP is largely responsible for preparing a statewide plan for the management of cancer. PROGRAM EVALUATION: The Alabama Regional Medical Program recently instituted a systematic and indepth evaluation of all projects. Continuous evaluation of projects will be the responsibility of a full-time acting associate director for Alabama RMP -18- RM 28-03 (AR-1-CSD) 2/71 evaluation who was hired by ARMP on June 1, 1970, In addition to his employment, a number of-other significant developments occurred in the. .area of evaluation of ARMP projects during the past year. Some of these are the following: 1, The development of a written statement of the evaluation process and an evaluation model to be applied to Alabama RMP projects. 2, A similar development of the concept of evaluation as an integral part of project management. Evaluation is not an end in itself, but it is regarded as means to improve the effectiveness of project management. : 3. The development of the concept of the positive contributions of an evaluation process, The positive contributions will be stressed by project directors, In addition to the necessary function of determining how well goals and objectives are being met, evaluation of ARMP projects will be used tp permit early determination of serious departures from goal directed action, to disclose unrealized opportunities and to provide the basis for public or institutional support for projects. 4, The upgrading of the evaluation skills of the ARMP Staff through the attendance at conferences, meetings with key individuals at the national,regional and local levels and through other means. 5. Prelimary planning for program evaluation. The evaluation process used for ARMP projects consist of six steps. Following is a chart which illustrates the steps in the evaluation process which has been developed by this Region: Alabama RMP -19- - RM 28-03 (AR-1-CSD) 2/71 CHART I EVALUATION PROCESS i . | 1 1 i. DETERMINATIGN OF PROJECT GOALS | (Broad Stotemonts) DERIVATION OF PROJECT OBJECTIVES FROM PROJECT GOALS (Narrow) DETERMINATION OF MEASURES OF OBJECTIVE ATTAINMENT (Output Units ESTABLISHMENT OF STANDARDS "(In terms of Obicctive Atisinment stated in measurement units—cost-benefit ratios, percontase chonga in behavior, ete.) COLLECTION OF DATA ON PERFORMANCE (Output) COMPARISON OF NO. 4 AND NO. 5 (Actual vs. Desirad) SATISFACTORY UNSATISFACTORY Step No. 1 Step No. 2 Step No. 3 Step No. 4 Step No. 5 Step No. 6 eee ed Modify No, 2 i Mo ; 1 No.2 Improve Satisfactory and/or No. 4 Efficiency Continus Conclusion of |. (unreclistic (insfficlent Project objectives or al . reat us¢ of resources) siandirds) Recommend Discontinuance Alabama RMP -20- RM 28-03 (AR=1-CSD) 2/71 Overall evaluation strategy is continually being developed and improved upon by the ARMP, Changes in project development are taking place (that are in objectives, that are measurable for effective evaluation) because of improvement in evaluation techniques. It 1s indicated in the application that evaluation is important in ARMP because of the management control it provides for funded projects. The Region believes that effective evaluation techniques will improve project development, inerease control over funded projects, and lead to a more sophisticated program, DEVELOPMENTAL COMPONENT The ARMP has requested three years support for a developmental component at an annual level of $100,000. The Region explains that the plan for utilization of developmental component funds will be based on two principles: 1) close control and involvement 5 of the RAG in seeking improvement in the quality and delivery of health services, and 2) rapid implementation of worthy proposals. Thus, the participation of RAG members should be maintained at a high level, and the loss of interest on the part of the proposer - sometimes causing apathy or occasionally antipathy now experienced with the present project review mechanism, should be avoided. a % The ARMP proposes a two-step review procedure for requests submitted to them for developmental funds, First, one of the RAG categorical committees, if appropriate, will assign priority rating to the proposal, in reference to the goals of. the specific category. Second, the final decision on each expenditure will be made by a developmental component committee consisting of two RAG members, one of whom must be a member of the Executive Committee, and will act as Chairman; a representative of the Office of Grants Management of the University of Alabama in Birmingham; the Director, Deputy Director, and Associate Directors for Planning and Program Development and for Program Management of ARMP,. In case of doubt on the part of Development Component Committee as to the appropriateness or level of funding request, a proposal will be referred to the Executive Committee for recommendation with final action determined by the RAG. In all cases, RAG will approve the expenditure of funds of the developmental component at the first opportunity and will forward to RMPS a summary of the proposal, a description of its developmental review, in relationship to area wide ARMP priorities. The Region indicates that the availability of the developmental component 3 will strengthen inmeasureably the implementation of their subregionalization. It is proposed to retain approximately 75% of those funds for ARMP to use for funding proposals which have a regional wide impact, similar to the study to determine the need for, acceptance of, and best method to implement statewide dosimetry for radiotherapy cancer, which resulted in Project #27 being submitted in this application, The remaining 257, of the funds will be a apportioned to each of the eight subregions. While the RAG and the Core staff will not define for each subregion, Alabama RMP -21- RM 28-03 (AR-1-CSD) 2/71 the procedures to be used in determining subregional needs, assign priorities, or propose review mechansisms, it will assure that the subregion has developed an acceptable procedure and that proposals for funding have been approved by the Area Advisory Group(AAG) before submission to the Developmental Component Committee. Core staff consultation and advise will be available, especially during the formation months of the Area Advisory Groups, and assistance will be given in project development if the proposal warrants such action, Should subregions not submit acceptable proposals, funds will be distributed by RAG as they see fit. The region sees many advantages to the allocation of funds to each subregion, such as the following examples: fa) For the "mature" subregion, such as the five counties in the Birmingham area served by an approved and funded 314 (b) agency which has published a list of needs and priorities, and which has an effective project review mechanism for implementation studies or projects for which funds are anticipated but not yet received, and for activities which are desirable but not fundable by other agencies and which could be conducted with such a small expenditure that formal project is not justified. Top priority in this subregion is improvement in health services to the poor, (b) For the subregions which have been organized and staffed (Northeast, Southeast, Northwest, Mobile, and Montgomery), these funds should expedite the process of assessing needs, setting priorities and developing a decision-making routine, should overcome any feeling that deserved support has not been forthcoming, and will help the RAG and core staff communicate ARMP goals, priorities and accomplishments to the subregions so that a better perspective is obtained. Also, we hope such funds will make the planning process more fruitful. For example, one subregion has submitted a proposal to study the need and cost of providing hemodialysis service for the area. No evidence is submitted to show this is a high priority item for the area, nor that it has been reviewed by the local 314 (b) agency. The budget seems higher than necessary. Local determination of the best way to spend limited funds might well result in a different or less expensive proposal. (c) For the Tennessee Valley subregion, whitch has not yet found a common ground on which an areawide health planning advisory group (AAG) can be formed, and for the newly created Selma district which has not had time to organize, the funds in addition to the available salary Developmental Component from persons in these areas will not be considered until an areawide advisory group has been formed and found acceptable to ARMP, Although these funds combined will be less than $30,000, even smaller amounts have proved to be an effective lever in the formation of wher areawide groups. If, in addition, the available funds are diminished quarterly until an acceptable AAG is formed, the incentive may be greater. ‘Alabama RMP -22~ RM 28-03 (AR-1-CSD) 2/71 The region explained that they cannot overemphasize the value of being able to spend limited amounts of money in actions which have high local priority and which are tompatible with the objectives and goals of ARMP. This true decentralization allows local citizens to determine needs, and the availability of funds to implement approved proposals without many — months delay which in turn will sharpen the priority-setting mechanism and insure more active and interested participation. ue As ARMP reviews the proposals from the subregions, it will give RAG a clearer constantly updated view of local resources, needs, and priorities, . and will enable Core staff to disseminate (inovative) and functional ideas to other subregions. The RAG heartily supports this concept of the developmental component. SUUPLEMENTAL PROJECTS: a First Year \ Project #27 - Regional Radiation Therapy Cooperative Treatment Request Planning and Dosimetry Project. Through the $122,791 University of Alabama Cancer Research and Training Program this project proposes to provide an accurate systematic and rapid means to determine readiation dosage through a computer-telephone system and through expert personal consultation visits to the requesting site. In addition, a physics support system is provided through on-site consultation. This provides advice and technical expertise to determine accurate radiation output. It is explained that this is a regional project, and initially will provide services to seven geographically distributed hospitals through- out the state and will serve patients throughout the region, The project will provide through personal consultation another excellent medium for on-site continuing education, which will occur through the consultative process. It is explained that the ARMP goals and objectives are enhanced by this project and that the Core intent is to disseminate advanced medical knowledge to the local practitioner. In the priority rating of projects the region has ranked this activity as their eighth priority item. Second Year: $167,587 Third Year: -0- First Year 7 Project #28 - Continuing Medical Education within the Request i Office of the Medical Association of the $73,934 4 State of Alabama. The purpose of this project is to develop an office of continuing medical education with the Medical Association of the state of Alabama. Since this association is,in essence, the voice of the Alabama physicians, this project is designed to identify and be responsive to the continuing education needs of these health professionals, The new and creative instructional strategy will be explored in conjunction with ARMP and the Division of Continuing Education at the School of Medicine. Alabama RMP -23- RM 28-03 (AR-1-CSD) 2/71 The Comprehensive Health Planning Agency for the Birminham area stated that the project represents a constructive approach to Continuing Medical Education for Physicians within the state of Alabama with the anticipated results of improving health care for the citizens of Alabama. The ARMP indicates that this project will further strenthen the relationship between the School of Medicine, Medical Association of the State of Alabama, the Regional Medical Program and participating community hospitals. The Region in its priority rating of projects has ranked this activity 13th as a priority item. Second Year: $75,806 Third Year: $81,929 Project #29 - Improving the Life of the Ostomate, First Year This project proposal is essentially a Request continuing education program for Allied Health Profes-~ $21,130 sionals and supportive hospital staff and concerns the physical and emotional care to be provided to the ostomate, The purpose follows closely the ARMP objectives of improving patient eare through continuing education endeavors. It is to be implemented through physicians, a registered nurse, and ostomotherapists who will provide continuing education programs for health manpower within the region. In addition,clinical instruction to ostomates will be provided and will concern areas of physical management of ostomies., This patient therapist's interaction will lead to a close interpersonal environment so that the enterostomal therapists can provide vitaily needed emotional support for these individuals. The long term gains of the proposal will be the establish- ment of a program to train enterostomal therapist for the region. This project in the regions priority rating of projects is ranked 20th as a priority item. Second Year: $25,304 Third Year: $26,217 Project #30 - Intermediate Coronary Care Unit Instruction - First Year Mobile, Alabama. The purpose of this proposal Request is to reduce the hospital mortality of the newly discharged $72,535 coronary care unit patient by providing a mobile infirmary, a training program for hospital staffs and the techniques of intermediate coronary care. These techniques are based upon a firm understanding of CCU procedure as well as social "encounter" or "sensitivity" training sessions. The culmination of training and mobile infirmary will be realtzed in health manpower who are both technically and psychologically prepared to care for the coronary care patients, The region explains that this proposal is compatible with ARMP goals and Alabama RMP ~24- RM 28-02 (AR-1-CSD) 2/71 objectives and that advanced knowledge is disseminated locally, manpower will be developed, and improvement in the care of the coronary patient will be realized. In the regions priority rating of projects this component ranked 2ist as a priority item. Second Year: $62,794 / , First Year Project #31 - Physicians Assistant. Alabama is very short of Request physicians. There are many areas in the state $206,781 where physician availability and accessibility is critical or non-existent. For example, in one county with the region with over 10,000 population there are no physicians, and in other county there are three physicians for a population under 30,000. Through the provision of the physicians assistant training program at the University of Alabama, Birminham, this proposal represents a viable step in increasing the availability of medical care in "physician poor" areas. It is compatible with the ARMP goal of "facilitating the delivery of health care" and enhances an ARMP objective of "stimulating and supporting the creation of new service manpower" to be available for distribution in areas of critical need. This project in the regions priority listing of projects is ranked second as a priority item. Second Year: $210,726 Third Year: $221,034 Project #34 - Closed Chest Cardiopulmonary Resuscitation First Year Program. The purpose of this proposal is Request to increase the accessibility of knowledge in CCCR in the $93,480 region by providing to Alabama Heart Association field directors the necessary assistance required for them to perform the following task, (1) Facilitating the establishment of a CPR Committee in each hospitals which will provide a "Core" for inservice education for CPR training. (2) Facilitating the establishment of CPR teams in each hospital which will be responsible for administering CPR techniques in cardiac arrest crisis on a 24 hour basis. The region explains that dissemination of advanced knowledge ts a primary objective of the Alabama Regional Medical Program and hat this proposal is compatible with this objective. In the regions priority listing of projects this activity ts ranked feurth as a priority item. Second Year: $60,791 Alabama RMP -25- RM 28-03 (AR-1-CSD) 2/71 Project #35 - Northwest Florida and Southwest Alabama First Year Hospitals Coordinated Services Program. Request The Coordinated Services Program has been operational $37,830 on a limited basis in Northwest Florida and Southwest Alabama for one year, The program is designed to enable member hospitals to effect economy, increase patient services to share in health manpower and to provide continuing education for institutional manpower. Several accomplishments have been realized in the short oneeyear period. For example, through coordination and cooperation, an x-ray company has reduced prices for participating hospitals. Arrangements have been made with housekeeping companies to serve some of the smaller member hospitals when previously the company would not serve hospitals of under 100 beds. This type of action has resulted In a cost savings in those hospitals and has provided funds for education, In May of 1970, this project was reviewed by the RMPS Site Visit Team. It appeared that the team was favorably impressed with the scope of the proposals since they encouraged that it be submitted. This proposal is compatible with ARMP goals and objectives in that remedial and continuing education is provided for the health services team and that there is a lowering of patient costs with an improvement in services incorporated within the program. In the regions priority rating of projects this project is ranked #5 as a priority item. Second Year: $27,107 Third Year: $16,080 First Year Project #36 - Instructional Project In Cardiac Care - Request ‘Yalladega County. The purpose of this project Is $57,068 to reduce hospital death due to heart disease through a two-fold approach to improve the care of patients in Sylacauga, Talladega County, and other counties adjacent to Talladega County. The two-fold approach concerns provision of Coronary Care Educational Program and a Coronary Care Unit teaching facility. This program fs regarded to be compatible with ARMP objectives concerning continuing education and development of health manpower. This region has not had this type of educational program in a rural setting. In the regions priority Mating of the projects this activity is ranked 19th as. a priority item. Second Year: $25,153 First Year Project #37 - "Taking the lid olf" the licensed Practical Request Nurse, The region explains that in essence $70, 307 the life of the lincensed practical nurse has been "boxed in" by educational and personnel career "deadends." This proposal Alabama RMP -26- RM 28-03 (AR-1-CSD) 2/71 is a new and innovative approach to "taking the lid off" for this health worker. It is the first approach by the Regional Medical Program to lend support to closing the knowledge gap between the LPN and RN by more formal, but needed and innovative approach to the LPNs continuing education. , Recent studies indicate that 1,232 (20.8%) of the states licensed practical nurses practice in this area, Furthermore, this nurse population exhibits a younger age and less career ability due to the unavatlability of instruction courses leading to an Associate Negree , Nursing Program for the vocational school LPN graduates. Many interested groups in the state have expressed a great interest in developing an education program that would allow college credit for their vocational training as licensed practical nurses. By allowing this college credit, vertical mobility to become a registered nurse from a junior college program is facilitated. This effort provides a demonstration for the region in producing a type of manpower drawn from a new source. It will stimulate the establishment of a regular associate degree nursing program to insure a continuing pool of registered nurses in this community. In the regions priority listing of projects this project is ranked 10th as a priority item, Second Year: $65,150 Third Year: $70,215 First Year Project #38 - Continuing Education in Blindness Prevention. Request The region explains that in 1960 the estimated $44,996 number of legally blind in the United States was 385,000. This figure represents a prevalence rate of 2,14/1,000 population. In the 1960 study, Alabama was the fifth highest ranking state with a prevalence rate of 3.08/1,000 or 10,000 cases of legal blindness. Alabama is again ranked number 5 in the United States with an incidence rate of 20.7/100,000 (680 new cases). The region explains that preventive measures directed at the early detection and treatment of the four major causes of blindness(Glaucoma, Diabetes, Senial Cataract and Vascular Diseases) can potentially produce a 51.4% reduction or delay in the incidence of blindness in the United States. Therefore, the purpose of this project is to upgrade through a program of continuing education,the knowledge and skills of the optometrist of Alabama in the detection and identification of potentially blinding conditions, Noting that vascular diseases and diabetes are among the leading causes of blindness, the purpose of this project {fs compatible with ARMP objectives. This project in the regions priority listing of projects is ranked 11th as a priority item. Second Year: $42,496 Third Year: $42,496 Ne Alabama RMP -27- RM 28-03 (AR=-1-CSD) 2/71 RENEWAL REQUEST: First Year Project #4R - Health Manpower in Junior Colleges. This project Request is submitted to continue to improve the quality $76,974 of health care in the region by assisting the Jr. Colleges in attracting and holding qualified faculty, to continue to maintain and demonstrate innovative and creative health education programs, and to increase the supply of and to improve the education of selected kinds. of health manpower. This program has enjoyed some success and some failures, Some difficulty has been experienced in recruiting and retraining faculty members, The evaluators contributed much of this to the accute shortage of qualified nursing faculty in Alabama and to the instability often inherent in a young and rapidly expanding institution. All faculty positions have now been filled for the fourth quarter, including a qualified instructor for medical records technology. A nursing curriculum has been developed which incorporates a number of innovative features. The Jefferson State College is designated as the logical institution to assume an administrative role in the development of such a curriculum at the Jr. College level. This program was designed to appeal to older students, to male and black students. The percentage of students over 30 years of age in the program does indicate its attraction to the older student. The percentage of black students is increasing and is significantly higher than the state average for nursing program. , A total of 86 students have graduated from the nursing program and another 105 are enrolled in the summer quarter, a doubling of the number of students enrolled within the two-year period seems to be a realistic objective. In the regions priority rating of projects this project is ranked number one as a priority item. Second Year: $80,737 Third Year: $84,686 First Year Project #5R - Training Program - Reality Orientation Techniques. Request This application requests renewal for continuation $96,853 and expansion of the reality orientation program which has been carried out at the V.A. Hospital, Tusculusa, Alabama, since April 1969, This was the first, and to the region's knowledge remains the only, RMP project physically located in a V.A. Hospital. The project provides an educational service through a training program for all levels of health care personnel in Alabama and other states in order to improve the care of patients who are confused and disoriented from stroke, arteriosclerotic disease, or other causes, The region explains that this project has attracted national and Alabama RMP -28- RM 28-03 (AR-1-CSD) 2/71 international attention and it has done an outstanding job of training personnel, not only in Alabama, but throughout the country as evidenced by the evaluation report which is included in appendix 5 of the application. The project has improved the utilization of health manpower in Alabama, has enhanced the team concept of delivering health care, and has improved the care received by individual patients. In the regions priority Listing of projects this project has been ranked 16th as a priority item. Second Year: $91,586 Third Year: $93,172 APPROVED UNFUNDED PROJECTS: Requested Project #14 - Continuing Education for Medical Laboratorians. First Year This project proposes to lend assistance to $48,930 help personnel who wish to deepen, broaden and update their knowledge in skills as they relate to the Medical Laboratory and thereby assistance in giving better patient care through better accuracy in diagnosis, The project is consistent with the ARMP overall objective of providing retraining and continuing education for the entire health team. This is the kind of specialized effort that the Regional Advisory Group sees as an essential contribution of the region's only medical school. Other funding sources have been carefully explored. This program for continuing education for medical laboratorians was discontinued this past year because RMP was unable to fund this project. This program was initiated by the Department of Clinical Pathology in the Medical College of Alabama and was funded by the Cronic Disease Control Center for three years ending May 1969, ‘The Region believes that the experience gained and the equipment purchased during the first i three years of operation will be valuable in the future, The University hae developed an excellent base for Continuing Education of Technologists which presents an opportunity to expand the offerings to other categories of laboratory personnel. A program in which 100 Medical technologists, 40 physicians and scientists, and 31 technicians can be trained each year is projected. In the regions priority listing of projects this project is ranked 22 as a priority item. Second Year: $46,028 Project #15 - Medical Information Service by telephone. First Year This project was originally submitted {In Request November of 1968 and the original budget request was for $52,451 97,451 (d.c.). The project was disapproved by the Division of Regional Medical Programs on December 1968. The project was resubmitted by the region in July of 1969. The Regional Alabama RMP -29- RM 28-03 (AR-1-CSD) 2/71 Medical Programs approved the project in December 1969 but approved funding at a level of $52, 451. The. Region initiated a pilot project in July 1969 by rebudgeting of Core funds... The acceptance has been so great that additional WATS Lines and operators ‘have been required, a McBee System method of collating calls has been installed and further employees are needed to abstract the tapes. The activity is designed primarily to provide continuing education to the practicing physicians through the mechanism of consultation. The best teaching opportunity arises at the moment when the practitioner encounters a problem or a question in the course of his day-to-day activities in patient care. Person to person consultation is made available to him by telephone at this instant. Only when it is necessary and appropriate, reference will be made to the medically injured. However, upon this request the medical school library will provide him with a copy of the appropriate article or a Medlars Bibliography for reinforcing his learning. This project was reviewed by a site visit team from the Regional Medical Programs Service on May 26-27, 1970 at which time the visitors encouraged continuation of this activity. In the regions priority listing of project components, this project is ranked sixth as a priority item. Following are four projects which were reviewed by the November 1970 Council. The ARMP has Included these four components as a part of this application and has requested support to initiate these activities along with the other previously approved and unfunded projects. The projects involved are as follows: Project #23 - Guidance Counselor Continuing Education in the Health Field. (revision) In the regions priority listing of projects this project is ranked 18th as a priority item. Project #24 - Birmingham Community Medical Television Network. In the regions priority listing of projects this project is ranked 50th as a priority item. Project #25 - Production of Audiovisual Materials for Reality Orientation Training Program: In the regions priority listing of projects this project is ranked 23rd as a priority item. The National Advisory Council recommended that additional funds be provided to the Alabama RMP in the amount of Ol~year $246,950, 02-Year $185,924, 03-Year $127,421 to support projects #23, #25 and #26. Council did not believe that project #24 had sufficient regional outreach and recommends that a local source of funds be utilized to Alabama RMP -30- | RM 28-03 (AR-1-CSD) 2/71 support this program if it is considered a priority program by the RAC. The level of funding requested for Project #24 has been omitted _from the total requested for approved and unfunded projects in the front of this summary. Project #26 - Model Cities - RMP Nutrition, Project in Tuskegee. , In the region priority listing of projects this project is ranked 12th as a priority item. The Acting Director of Regional Medical Programs has approved an award for this project utilizing RMPS earmarked funds for Model Cities related activities, The level > of funding requested for this project has been omitted from the total requested for approved and unfunded projects in the front of this summary. RMPS/GRB/ 12/31/70 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION e Date: December 21, 1970 L. Reply to Attn of: Subject: Staff Review of Non-Competing Continuation Application from Alabama Regional Medical Program, 5 GO3 RM 00028, : . Tor i Acting Director Regional Medical Programs Service By Through: Chairman of the Month- Operational. Year. ane Request - Funding: 03 $2,116,409% $1,665, 557% 04 1,989,928 1,554,245 05 1,575,113 1,273,606 Total - $5,681,450 $4,493 408 *Includes $240, 000 commitment for Core supplement and 2 ongoing -projects.- CRITI QU : The Committee reviewed this triennial application in relation _ to the May 1970 program site visit findings which indicated that the ---Alabama RMP was at a critical point in its development. The ‘written “ application conveyed the impression that the Region has made rapid strides in the directionof a cohesive, broad program aimed at basic health care problems; the RAG appears to have taken responsibility; the Core staff hes ‘been strengthened by strong subregionalization staffing; and priorities are emerging. The Committee had no hesitation in recommending a level of “support for the Core and projects which would promote program growth; but felt it could not' make a decision on the Region's readiness for develop- mental funding, on the basis of the written application. While the “Region. seems to be | on the threshold of good development, the Committee felt that a site visit was needed to evaluate what is really taking place. Parenthetically, Alabama's remarkable change in development was cited tn general Committee discussion as an example of why three-year looks at Region! s may not provide the Committee and Council with adequate on~site feta with which to evaluate program development. ‘ The Committee. was intrigued with possible reasons “for Alabama's apparent strength tin development. . The Region is unique in that the Alabama Medical Society | is the official agency at-both the State and local levels and has | ‘responsibility for administering both Titles 18 and 19 and Comprehensive Health Planning. The University of Alabama at Birmingham administers the Medical Center, a complex consisting of the hospital clinics, dental school and ‘a full spectrum of resources for health education, health care and biomedical research. There are no similar resources in the State. Furthermore, the practicing physicians have supported the University Medical Center from its inception. The Regional Medical Program has been supported by both the Medical Society and the University as the organization to extend continuing medical education and the development of community health : services . ALABAMA RMP a RM 28-03 (AR-1-CSD) 2/71 The Regional Medical. Program works cooperatively with Comprehensive Health Planning, at both the State and local levels. The "A" agency has looked to the ARMP for leadership in statewide planning in cancer and _ heart diseases. The ARMP has taken an active role in the development of the CHP "b'" Agencies in the Region through the subregionalization Core staff. The Committee felt that all of these aspects have helped program develop- ‘ment. The role of the staff in establishing links of communication, in capitalizing on and in channeling ideas, as well as the projects, were noted as major strengths in bringing these forces together. In conclusion, Committee believes that during the past year many events have taken place which indicate that this Region has made great strides in developing a mature RMP. The. RAG has begun to exercise its influence in the development of the total program. It seems that the ARMP has acquired the respect, support and participation of most of the major health facilitators in the Region and involved the provider in its scheme for developing an effective health care delivery system. Through its subregionalization program the ARMP has extended the outreach of University resources into, the community; has strengthened the role of CHP in the Region and is fostering visibility of the ARMP in the rural community. Committee has deferred action on the developmental component pending a site visit to determine if this Region is headed in the direction it proposed to the May 1970 site visit team and has developed the level of maturity > which is indicated in this application. The impression of site visitors was that the Alabama RMP could eventually have one of the strongest health ‘eare. programs of any state, if its overall scheme for integrating the ‘strengths of the University, the Regional Medical Program, the State Medical Society and Comprehensive Health Planning is made to work. RMPS/GRB 1/20/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) Arkansas Regional Medical Program RM 00052 2/71.1 (S) 500 University Tower Building January 1971 Review Committee 12th at University mo, Little Rock, Arkansas 72204 Program Coordinator: Charles W. Silverblatt, M.D. Request (Direct Costs) 03 04 05 Total Committee/Council Review Two new projects 654,052 592,119 667 ,059 1,923,230 RMPS Staff Review Commitment 887 , 506 Currently in Carryover 112,982 staff review Total Request $1,000,488 Funding History Planning Stage Grant Year Period Funded (d.c.o.) 01 4/67 - 3/68 $341,846 02 4/68 - 1/69 $341,846 Operational Program Council Future Grant year Period Approved 1/ Funded (d.c.o.) Commitment O1 2/69-1/70 807 ,487 687,506 eee 02 2/70-1/71 1,818,045 1,001,306 2/ wre 03 3/ 2/71-12/71 1,595,820 . 887 , 506 04 1/72-12/72 659 ,623 106,596 Arkansas RMP -2- | RM 00052 2/71.1 (S) 1/ Also includes Council recommended amounts for all approved /unfunded projects 2/ Includes $113,800 carryover 3/ Change in budget period at the request of RMPS to facilitate transfer to anniversary review system - Figures for 03 year, however, are calculated on a 12—nonth period. 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’ 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 consider- ation was given to the limited resources the Region had to work with. One area of concern was Core staff's non-involvement in planning and administration, but concentration on project direction. 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 11 projects. In June 1970, the release to RMPS of funds that had been placed in administrative reserve by the Bureau of the Budget permitted an award of $200,000 for support of six additional projects. November 1970 Council, in recommending approval of supplemental funds for additional core personnel, commented favorably upon the Region's planned evolving shift from project to program development (with a concomitant increas® in RAG involvement and diversification) and strengthening of core technical assistance and service functions. The current annual support to the Arkansas Regional Medical Program, exclusive of carryover, is $887,506 direct costs ($304,425 for core and $583,081 for projects). (See history supplement following this summary for a listing of. projects.) The 03 year continuation application was submitted to RMPS on December 15, and is currently under staff review. Arkansas RMP -3- RM 00052 2/71.1 (S) Present Application: The present application requests supplemental support for two new projects. Project #36 - Continuing Education for Nursing Home lst Year Personnel in Heart Disease, Cancer, Stroke and Related $111,925 Diseases This request is for the continuation of workshops for nursing home per- sonnel previously funded by the Community Health Services of the U. S. Public Health Service. A sample survey of nursing homes has indicated that approximately 1,200 employees would participate in these programs. The proposed activities will address themselves to three facets of the problem: 1. Establishment of workshops -- twelve two-day presentations annually in various areas of the state are planned. 2. Development of an in-service education program which will follow the workshop presentations in each area. 3. Development of a family training program designed to assist family members, gain an understanding of adjustment to the nursing home environment and avoid disengagement of families from patients -- will be presented through two one-day workshops during the first year and as needed thereafter. It is expected that after three years of operation the program can be continued with multiple support from interested agencies. Second Year Third Year $113, 734 $122,884 Project #37 - A Comprehensive Program for Kidney Disease lst Year Control for Arkansas $542,127 A comprehensive and statewide kidney disease program is planned which has as its objectives: 1, To augment and improve the existing statewide cooperative transplant program at the University of Arkansas Medical Center. Facilities will be established to provide for handling a maximum of eight transplant patients, a tissue typing capability will be developed, an organ procurement team will be provided, and the project will participate in an existing organ donor program and a kidney recipient pool. 2. To develop and present home dialysis training programs. This pro- gram will be based primarily at the Arkansas Baptist Medical Center, but will use personnel and facilities of the Little Rock VA Hospital Arkansas RMP -4- RM 00052 2/71.1 (S) _as well, It is hoped that this program will train 40 patients and their assistants during the first year, 60 during the second year, and 100 per year thereafter. . 3. To develop and present programs of continuing education to physicians and paramedical personnel, A two-week course for physicians (at UAMC) and an eight-week course for paramedical personnel (at ABMC) are planned, and although all interested personnel will be encouraged to attend, priority consideration will be given those who will be working at the nephrology centers at the subregional community hospitals. 4, To develop a network of subregional satellite centers for the preven- tion, diagnosis, and treatment of renal disease and to expand the ~ dialysis capability of this network. Eight of the major community hospitals throughout the state have been chosen for this purpose. Steps are being taken so that at the end of three years there will be the necessary organization and local support to sustain the program under the leadership of the Arkansas Association for Kidney Disease and the Arkansas Kidney Foundation. The Arkansas Regional Medical Program considers this project the most ambitious, significant and comprehensive exercise it has undertaken thus far. It is stated that the project demonstrates more cooperation among health-providing groups and provides more opportunity for an effective ' impact on health care in the Region than any past activities. It is ‘viewed as a program from which many other total regional programs can be built. A letter from the Vice President for Health Sciences states that: In view of the significance of this program and the services it will provide within the State of Arkansas, the University of Arkansas Medical Center will, in addition to other con- tributions, contribute one-half of the amount of money which it would ordinarily receive as a result of the federally determined indirect cost rate charged for grant awards of this type. This is a major departure from policy that must be considered as a unique exception rather than as a change in principle or of accepted guidelines. We believe that this program is so important that we can justify this contribution. Second Year , Third Year $478,385 . $554,175 GRB/RMPS 12/21/70 ARMANSAS RMP Project it ~ 4 10 11 12 13 14-19 20 21 Core Support Coreaary Cave aad Supporting Diagaostic Untt tor Poste graduate Training of Paysielans and Nurses Nucses Coxonary Care Training O o 3 = ce mm pes N ao o G ry = "2 ? = v2 cr c << Peowalineedk Restonal Uaspital medical Lipeary System Guclear Modieiiaa Training Program Technology Dietetic Internship and Ch Program Western Ackansas Concer Study YY Tee Wane ad * aeereyiget en hoot Ck for Nevstas Persomet and Citizens ag Project #fs 23-33 Ravised North Centval Ackansas Reeion Chucer Center Toin-Loakes Rehabititation Cancer 2/71.1 5 365,924 | 1 \ i 87,545 * 60,403 * Un Funded 18,902 54,570 NowpVvoved fifataaied 18,377 (Ss) 467 N i on AWS 2-69 249 ARICTSAS RMP - 6 - History Supplement continucd. Project fitle 22 North Central Arkansas Stroke Rehabilitation Center 23 Revised as Project #34 24 Remote Computer Assistance to Avkansas Physicians 25 . _ C& for Physicians 26 CE for Pharmacists 27 Refrosher Training for Medical Technologists and Technicians 28 CE in Cardiology for Physicians 29 Model Cardiac Care Unit - Stuttgart Memorial Hospital 30 Area-Wide Intensive Care Unit and CE in corenery: Care for Physicians and Nurs 31 Instruction in Neurolosic Aspects of Stroke, Brain Tumor and Cancer 32 Dewonstration and Training in Care and Handling of Stroke Patients 33 ‘CE in X-ray Technology and Related Fields 34 Regional Laboratory Quality Control 35 , Continuing Education foc Dicticians and Health Facility Food Service Supervisors * ‘The O02 year of the projects indicated, RMO0052 Current Year! B Surport Ara Rot terete Noten Nan lt 16,500 % 100,000 Approved /Un funded Approved /Unfunded Approved /Un funded 10,060 Approved/Un funded Approved /Ua funded 16,585 Approved /Unfunded 23,500 Approved /Ua funded 2/71. 6270 6-70 award included $ 113,500 carryover funds for the partial funding GRB/RMPS 12/21/70 AA Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE ARKANSAS REGIONAL MEDICAL PROGRAM RM 00052 2/71. 1 (Ss) FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL RECOMMENDATION: Additional funds be provided for this application. : Committee Year ' _ Request , : Recommendation 03 | $654,052 | $111,925 * 04 592,119 113,734 05 667,059 122,884 TOTAL $1,913,230 $348,543 CRITIQUE: The Review Committee observed that the Arkansas Regional Medical Program will submit its first Anniversary Review Application for consideration during the October/November 1971 review cycle, and that the current supplemental proposal results from. the Region's exercising a transitional year option. It was further noted that because of the exigencies of this particular RMP (Arkansas is “at the bottom of the heap with regard to the presence of skilled manpower) , 48% of current funding flows into training and education activities. The reviewers agreed with the previous Committee and Council that the ARMP under its new coordinator, Dr. Silverblatt, seems effectively to be turning itself around with respect to increasing core capabilities, increasing RAG involvement, and bringing about a shift from project to program development and emphasis. Project #36 - ‘Continuing Education for Nursing Home Personnel in Heart © Disease, Cancer, Stroke.and Related Diseases. This activity was thought to be well planned and comprehensive. It meets ~ a need of the Region, is designed to reach nursing home personnel “in-even the hinterlands, appears to fit in with the ARMP overall program approach, and has planned phaseout of RMP support. As a side- light, the reviewers wondered whether this program might not serve’ to stablize the ubiquitous turnover among nursing home personnel. There was no doubt that inclusion of this project into the Arkansas program was well warranted. Project #37 - A Comprehensive Program for Kidney Disease Control for ‘Arkansas. ‘The reviewers agreed that this proposal —_ is: a superb bit of prose, but had difficulty in evaluating only the written word. It was noted that the Kidney Disease Control Program of. RMPS - ponsidered . the proposal an excellent one,based’ on an identification of needs and a logical and comprehensive plan to meet those needs. Arkansas presently. has a minimum of renal activities - some transplantation Arkansas RMP ~2- . RM 00052 2/71.1 but virtually no dialysis. And so the main problem with which the. _ Committee wrestled was whether the Region actually possessed the capabilities to carry out the fine program it has designed. There is considerable evidence of good community support and the reviewers also saw in this proposal the strong possibility of the program's ‘extending outside Arkansas and becoming an inter-regional resource. After lengthy discussion, the Review Committee ‘referred this project to a special ad hoc renal panel in order that the program be © considered in the context of national needs as well as other renal applications that have been submitted. The reviewers did want to stress the excellence of Arkansas' regional kidney plan, but suggested as well that a technical site visit be considered. 1/18/71 GRB/RMPS cc REGIONAL MEDICAL PROGRAMS SERVICE ‘SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) CALIFORNIA REGIONAL MEDICAL PROGRAMS RM 19-03 (AR-1 DS) 2/71 Room 600 January 1971 Review Committee 655 Sutter Street San Francisco, California 94102 REQUEST (Direct Costs Only) Region's Operational Year 03 04 05 06 Core . 407,967 4,548,409 4,766, 304 4,988,740 (Supplement for (renewal) (renewal) ’ (renewal) remaining 6 Months of 03 year) Developmental . Component 406,720 834,759 857,140 880 ,642 (For remain- ing 6 months of 03 year) - 9 New Activities (Projects) - 1,414 ,007 1,591,910 1,406,315 Total 814 ,687 6,797,175 7,215,354 7,275,697 eee ee ne ee eee eee ee ae a ee we en ee eae an Oe a Ee es me me me ome me mee een meme me FUNDING HISTORY (Direct Costs Only) Planning Stage Grant Year Period Tunded (d.c.o.) 01 11/1/66 - 12/31/67 (14 mos.) $1,368,137 02 1/1/68 - 2/28/69 (14 mos.) $2,613,500 Operational Program (Overlaps with planning stage) Grant Year Period Funded (d.c.0.) 01 7/1/68 - 6/30/69 $2,917,144 02 7/1/69 - 8/31/70 (14 mos.) $8,012,055 03 , 9/1/70 - 8/31/71 $7,548,457 (current) CALIFORNIA RMP -2- RM 19-03 (AR-1 DS) 2/71 GEOGRAPHY AND DEMOGRAPHY: The region is coterminous with the state, except for the Reno and Las Vegas, Nevada areas which are "shared" jurisdictionally with the Mountain States and Intermountain RMP. The region is divided into nine Areas, each centered around a medical school, The total land area is 156,573 square miles, with a population of 18,293,000 (1965). The population spread is 80% urban, with a median age of 30. The racial distribution is 92% White, 6% Negro and Other 2%. The region has nine medical schools, and one of the most recently established was a result of joint efforts of the Drew Medical Society (the NMA affiliate in this area o* Los Angeles) and the UCLA and USC Schools of Medicine (Areas IV and V). There are 62 nursing programs, including 42 that are collegiate. There are 20 medical technology programs and 615 hospitals with a total of 138,722 beds, The majority of these are non-federal, short-term hospitals. There are approximately 35,224 physicians in the region, including all but about 100 Osteopaths, and about 91,961 nurses, of whom 57,700 are active. HISTORY OF REGIONAL DEVELOPMENT: With the passage of PL 89-239, committees were appointed at UCSF, UCLA, Stanford and USC to study the legislation. The California State Department of Health organized the "California Coordination Agency for Training, Research, Education, and Demonstration in the Field of Heart Disease, Cancer, Stroke and Related Diseases." This agency included representatives from the California Medical Association, the California Hospital Association, and the Deans of the eight schools of medicine. The Agency was organized with the pur- pose of developing an “overall plan" for cooperative medical arrangements throughout the State. Planning for developing regional medical programs was to proceed at each:of the participating medical centers. The Coordination Agency would "develop suggestions" to delineate geographic areas of responsibility for each of the medical centers, and would coordinate and mediate other questions. The proposed method of operation relied heavily on systems analysis techniques. The Agency submitted an application outlining its structure and goals, as described above. At this time, the Agency Chairman was Dean Robert Glaser of Stanford, and the Project Director was to be Dr. Nemat Borhant of the State Department of Public Health. Reviewers criticized the proposal, feeling that it was "poorly tied together", had a vague chronological plan for development, and overemphasized systems analysis. CALIFORNIA RMP 3- RM 19-03 (AR-1 DS) 2/71 The major question raised by the application was the creation of a 'mega-region'' --a question not discussed in PL 89-239, The Office of Legal Counsel advised against RMP creating a central agency unless it were to coordinate a group of "subregions", The region decided on this kind of structure and UCLA withdrew the planning application it had independently submitted. The various medical centers agreed to reconsider at a later date whether to break up into several regions--perhaps before receiving operational grants. A revised application, incorporating the recommendations of the site visit team and the National Advisory Council, was submitted. The coordinating agency became a nonprofit corporation and changed its name to California Committee on Regional Medical Programs (CCRMP). The grantee became the California Medical Education and Research Foundation (CMERF), a second nonprofit corporation, the fiscal arm of CCRMP, with its own staff. The region's first Planning grant in the amount of $223,400 was made in November 1966 and Mr. Paul Ward was appointed Program Coordinator in February 1967. Another site team visited the region in February 1967 and expressed concern about the apparent lack of cooperation amoung the sub-regions and little evidence of overall planning. The region organized along the lines of its original plan and a site visit team went out in March 1967 to review progress and the "revised application". The full year award for planning included the Areas of UCSF, UCLA, USC, CMA and CHA. Three supplemental planning grants during the first year added the Areas of Davis, San Diego and Stanford. The first operational application indicated that each Area had begun to forge meaningful cooperative relationships within the community it served. There seemed to remain a lack of interaction between Areas, and total regional planning and direction were hard to discern. The region's first operational grant was made effective July 1, 1968, including nine projects out of a total of 21 submitted. The same award included a new planning area for the Northeast San Fernando Valley. In April 1969,a special site visit to each of the Areas, for a total of five days, was organized for the purpose of evaluating progress of the overall program and to review in depth the individual core staff requests. The site team was impressed with most of the Areas, particularly Areas 1, ILI,IV, V, VII, and VIII. Most impressive was the evidence of true peripheral involvement. During the visit Area IV (UCLA) raised the question of the possibility of making each CALIFORNIA RMP -4- RM 19-03 (AR-1 DS) 2/71 Area a separate region; there was little support for this position outside of Area IV. Subsequent review cycles have included supplemental project requests from this region, resulting in several program and technical site visits, With the award of the continuation for the third operational year, on September 1, 1970, the region is supported at the direct cost level of , $7,548,457, which includes a carryover from previous year's unexpended i balance of $480,168. “he current base level is $7,068,289, Staff review of the continuation application is attached to this summary. ° THE REVIEW & DECISION-MAKING PROCESS: The CCRMP review process has three stages: (1)determination of Area need (by the Area); (2) technical review (conducted by a panel responsible to CCRMP; and (3) regional consideration and priority setting. The review system has been operative for sometime and evolved from a great deal of study by the Committee on Organization and Procedures. The process begins when the Area Core Office notifies CCRMP that a proposal is in its final stages of development. A Staff Consultants Committee then recommends the precise categories from which an ad hoc review committee is established for the proposal. The latter is drawn from the Regional Technical Review Panel, composed of individuals from each Area in various categories -- heart disease, cancer, stroke, etc. The ad hoc Review Committee meets with the Coordinator, his staff and the author of the proposal. The proposal is examined from the standpoint of over- all appropriateness in terms of personnel, facilities, relationships, etc., and if found to be technically sound, it goes to the Area Advisory Group for approval, then to CCRMP, with a summary of the technical review. Only if there is conflict between the Area Advisory Committee and the Technical Review Committee will the CCRMP be expected to brihg additional considerations into its decision to approve or reject. Normally, CCRMP will only examine how the proposal fits into the regional design, and what priority it should be given. The Evaluation procedures were developed through the joint efforts of CCRMP central staff, headed by Dr. Jack Thompson, and an Evaluation Committee of the RAG. This committee has been responsible for pointing out ways in which evaluation can take place, including how program objectives can be crystallized by utilizing evaluation techniques. Evaluation is now an integral part of planning From the inception of a project, with assistance and guidance provided by the CCRMP central staff. INTER-AREA PLANNING ACTIVITIES: Stimulated by Review Committee and Council concerns and questions about this element of communication between Areas, region-wide committees are appointed as required to assure coordination between Areas and projects. Monthly meetings of Area Coordinators are held and serve as forums for planning. In CALIFORNIA RMP -5- RM 19-03 (AR-1 DS) 2/71 addition, there is planning between given groups--i.e., nurses, stroke activities, etc. Another example, the Coronary Care Unit Committee meets about every six weeks to assure non-duplication of effort, sharing of educational programs, priority systems for participation and cost- sharing a common registry, etc. There is increasing evidence that sincere, coordinated, statewide efforts are addressing common problems throughout the region, with a resultant lessening of Area autonomy. REGIONAL ADVISORY GROUP: This Group is called the California Committee on Regional Medical Programs (CCRMP). It is a heterogeous body including the Deans of the nine medical schools and two schools of public health, the Director of the State Department of Health, and representatives of the California Medical Association, the California Hospital Association, the California Heart Association, the California Division of the Cancer Society, TB and Respiratory Disease Association and representatives of the public. Dean Clifford Grobstein of the University of California San Diego Medical School, serves as Chairman of the Committee on Organization and Procedures. As an outgrowth of this committee's studies, the CCRMP, through the Coordinator's staff, has assumed a more active role in assisting the Areas in developing local objectives and priorities. The question of whether California should be one region or several has been discussed many times by CCRMP, and agreement continues that a confederacyof Areas creates a statewide cohesiveness and coordination not easily obtainable otherwise. This position has always been supported by spokesmen from the Heart Association, Hospital Association and other public representatives on CCRMP. It is also generally agreed that any administrative difficulties can be adjudicated. The CCRMP has turned greater attention during the past year to activities organized to help provide a service function for the public. Manpower development and means of developing services where they do not exist are concerns receiving more concentrated attention. Health provider interests give strong support to CCRMP, but RMP activities have been increasingly influenced by representatives of the general public. DEVELOPMENTAL COMPONENT In the view of the CCRMP, such funds awarded under this component should be srent in the implementation of nation- wide goals for versonal health services announced by DHEW, and funds allocated for Area Core activities should continue to be used in the implementation of the HSMHA goals that emphasize the disease processes of heart disease, cancer, stroke and reiated diseases. Indeed, this was the recommendation of the Objectives Committee and endorse. by the RAG. CCRMP may wish to select certain of the national priorities to coincide with known needs in California. For the first year, the region, has decided to apportion its priorities as follows: Fifty percent of Developmental Component funds will be earmarked for the achievement of National Goal 11- to stimulate efforts to improve and increase the California RMP -6- RM 19-03 (AR-1-DS) 2/71 health manpower pool, focusing on the professional and allied health personnel. Fifty percent will be allotted to National Goal 10 - to stimulate changes in organization and delivery of health services, particularly for the urban and rural poor, with priority to: preventive measures, prepaid group practice, use of allied health personnel, ambulatory care services and neighborhood care delivery units. In connection with services for the urban and rural poor, attention will also be given to the following: migrant farm workers, Indians, children under five years, and women of childbearing age. The general purpose of Developmental Component funds in California will permit the Areas, through their own collective professional capability and decision-making process, to move rapidly and expeditiously in responding to the identified national health priorities. The objectives envisaged by CCRMP are twofold: (1) development of projects that will serve the national priorities that are, in format and content, ready for submission to RMPS and other sources, and (2) development of ongoing community activities such as organization of methods or mechanisms for augmenting the delivery of health care to the high priority target groups. The region will emphasize the following elements for projects planned for Developmental Component funds: 1. acceptability - by the user and provider of the health care sytem. 2. accessibility - to the health care system by the user. 3. availability - of personnel and facilities to provide needed care. 4. quality care - both individual acts of health care and the health care system within which those acts are performed, must meet accepted standards of excellence. 5. reasonable cost - cost of care must be within customary and prevailing costs to the individual user and society. The review process of the Developmental Component funds will be the responsibility of the Organization and Procedures Committee of CCRMP. However, the Objectives Committee offered two recommendations in this regard: first, it appeared important that Development Component funds should be used for projects which increase the quantity of care, and second, that such funds be awarded on the basis of a competitive review in relation to goals and objectives, with not less than 25% to be awarded to Areas presently at a staffing disadvantage. California RMP -7- RM 19-03 (AR-1-SD) 2/71 New Supplemental Projects Requested lst Year Project #66 - R.E.A.C.H. - Area VII This project will $231, 014 provide for: (1) supplementary staff in six general hospitals in San Diego County to establish multidisciplinary planning teams in each; (2) a slightly modified team in two hospitals in Imperial County; (3) encouragement for physicians to assume an active leadership role for follow-up care under their directioa; and (4) continuing advance training for all allied health professionals currently involved in multidisciplinary planning in Area VII. Four discharge teams will be established in San Diego County the first year in Mercy, University, Sharp and Scripps Hospitals. Each team will have eight members: a coordinating nurse and family counselor at full-time, a physical therapist and dietitian as needed, public health nurse, rehabilitation counselor and occupational therapist half time and a full-time secretary. Each hospital will provide four members and RMP will provide four. The project was conceived as the result of studies of the San Diego Area Planning Committee, composed of representatives of numerous health organizations and voluntary agencies. The committee recommended that RMP give consideration to planning for the development of discharge teams plannéd along the lines of the Heart Patient Project for all local community hospitals. R.E.A.C.H. will build on the experience of the three-year pilot demonstration project--Heart Patient Project--sponsored by the San Diego County Heart Association and Ganeral Dynamics Convair Employees Contribution Club. Over the three-year period of this project, the hospitals will be contributing a total of approximately $249,495 in salaries for personnel they will assign to it. In addition, these participating hospitals will provide office space, equipment and other administrative support. Second Year - $344,131 3rd Year - $134,784 Project #67 - Respiratory Care - Area I Respiratory First Year teaching teams from $266,240 communities throughout the Area will be trained in the Bay Area by a faculty of respiratory care specialists. Such training will include specialized medical and teaching skills as well as the health team approach to comprehensive patient care. A preceptorship for physicians and a special course for junior college nursing faculty, combined with team training experience, will help to ensure the leadership needed for continued development of respiratory care practices in the community. The basic team program will be two weeks, and include small group sessions in the classroom, laboratory and at the bedside with expert teaching on one-to-one basis. Students and faculty will function as team members during all teaching rounds, seminars, and case presentations. California RMP -8- RM 19-03 AR-1-SD) 2/71 A special program has been developed for the junior college faculty. An eight-week course includes study of the pathophysiology of respiratory disease as well as general intensive and home care of the respiratory patient. In order to create a liaison between the junior college faculty member and the community team, the faculty member will spend a portion of her time with the team from her community. A one-week physician preceptorship will be available for two or three physicians six times a year in the Bay Area. Prerequisite for participation in this component of the program will be prior attendance at sessions carried out by the team in the community. The program has been designed to meet the requirements of all Areas. The composition of the teams will vary from District to District, depending on existing health manpower resources. Ideally, it will consist of eight members: a physician, an intensive care nurse, a hospital inservice educator, a home care nurse, 4 physical therapist, an inhalation therapist, and a pulmonary function technician. Seven teams (49 individuals) are to be trained during the first year, and will increase to 28 teams in the second and third. Second Year - $316,710 Third Year - $325,727 Project #68 - A compendium of Extended Learning - Area II First Year This project proposes to establish a mechanism $90, 207 for the planning, development, and implementation of a cohesive program of educational activities for members of the health professions in Area Il. The authors believe that an educational program, to be realistic, must address the entire continuum of health care as well as the entire range of professional skills. A foundation of two years of experience with several planning and experimental studies is cited. The program will address the gap in the various medical service areas between a reasonable or acceptable level of continuing education. for all health professionals and the actual esistence of such programs. The gaps are believed to be not so much in content but rather in the design and delivery of such rrograms. Factors contributing to this situation are: (1) only the large hospitals in Sacramento and Reno have appointed Directors of Medical Education; (2) in some instances, the energies of the Director have been consumed by the demands of recruiting and training interns end residents with little time to serve the professional staff; (3) most small hosritals cannot afford the salary of a D.M.E., nor can they in the future; and (4) some hospitals do not feel the need for such a resource. The Area II Advisory Council has endorsed the concept that continuing Education for health professionals should be the highest priority item. As a consequence, significant participation in the planning process has been provided by the Advisory Council, together with Area II staff, health professionals, hospital staffs, medical societies, voluntary agency staffs and representatives of the "RB" CHP Agency have contributed to the planning of this proposal. California RMP -9- RM 19-03 (AR-1-SD) 2/71 Five objectives are spelled out to deal with heart disease, cancer, stroke, renal disease and respiratory diseases. The ongoing Roseville pilot project will serve as a living laboratory for the development and testing of improved patient care and continuing education within a single community hospital. Second Year - $86,002 Third Year - $86,967 Project #69 - Respiratory Care - Area VII The project Requested was developed as a result of a detailed First Year survey of respiratory care facilities and personnel in $172,356 Area VII. The survey established both the priority needs and the resources within the Area which could be mobilized to meet them. Such information has led to the design of a multifaceted project which integrates Area resources to meet the most critical needs. Nine sub- programs are included in the project. The geographic location of the Area, in sharing an active border with Mexico and seaport for servicemen and civilians returning from the Far East, makes tuberculosis a continuing problem. Two recent pilot skin-test programs at San Diego City Coltege and University Hospital, disclosed positive tuberculin skin tests in more than 20% of the 3000+ persons tested. Also, there is in this Area a remarkably high incidence of pulmonary tuberculosis and pulmonary coccidiomyosis in children. There have been more than 48 admissions in children with severe tuberculosis in the last ten months at University Hospital. Many of these children had received inappropriate diagnosis and therapeutic management prior to their admission. Each sub-program will be responsive to a different Area need. Education of physicians and allied health professionals is the primary goal of the project as a whole, although some sub-projects will serve as models, pilots, or demonstrations in addition to their educative function. An outpatient rehabilitation program will be subcontracted to the TB and Health Association of San Diego and Imperial Counties. A Home Inhalation Therapy Program will be subcontracted to Scripps Memorial Hospital and the other sub-programs will be carried out by the cooperative efforts of a “core” of experienced personnel based at University Hospital, plus qualified personnel recruited from other Area health facilities. The planning, organization, and content of the project has been developed in a manner that should permit most of the sub-programs to become seif-~ sustaining in multiple Area facilities during the next three years. The project is envisaged as a means to upgrade and expand the diagnostic and therapeutic capabilities of Area VII by establishing effective educational programs in respiratory care for physicians, nurses and other allied health personnel. Second year - $176,702 Third year - $188,540 California RMP -10- RM 19-03 (AR-1-SD) 2/71 Project #70 - Multidisciplinary Continuing Education for Allied Health Personnel and Health Careers Counselling - Area IL First Year The proposed continuing education programs $50,400 will be multidisciplinary in approach for allied health personnel in Area II. They will be carried out in three phases: (1) planning _and development, (2) operational in several selected sites within the ‘Area and with continual evaluation; and (3) an extension of phase two with programs modified on the basis of evaluation during phase two, and in new sites. The target area is primarily rural with two urban centers, Sacramento and Reno. The data acquired by a survey made by the Office of Allied Health Sciences soon after its establishment on the Davis Campus in April 1969, served as the basis for the First Institute of Allied Health Science Education in Northeast California, as well as a basis for indicating the need for new programs, especially in continuing education. Planning has been developed by representatives of the Office of Allied Health Sciences, Area II RMP, the two Comprehensive Health Planning Associations, and various people from educational institutions. The resultant consensus was that such a project should be multidisciplinary, coordinated, and a conjoint program for all these groups, with the primary responsibility and sponsorship to reside in the Office of Allied Health Sciences at the University of California, Davis. Second Year - $69,220 Third Year - $69,560 Project #71 - Respiratory Care Training - Area LV First Year The project is based on cooperative $177,159 arrangements between the Tuberculosis and Respiratory Disease Association, practicing physicians, allied health personnel, and hospitals to encourage the development and improvement of respiratory care units in suitable hospitals, and to train key personnel in respiratory care in hospitals where specialized units are not appropriate. The program will involve a nine-county area. Based on a team approach, the two-part program will train physicians and allied health personnel in the theory and practice of respiratory care. The team will be a physician, nurse, {nhalation therapist, pulmonary function technician, and physical therapist. The training will require a total of four weeks for each visiting team from outlying hospitals. The first two weeks will be spent at UCLA attending a didactic educational program. The second two weeks will consist of assistance at the outlying hospitals. The course cycle will be repeated every three months, and there will be four complete course cycles each year. A ten-bed intensive respiratory care unit at UCLA will serve as the educational setting for demonstration and practical experience. During the first year, 55 (50 physicians and 5 allied health) trainees will be participating. Each year thereafter, 120 (15 physicians and 105 allied health) trainees will attend. California RMP -11- RM 19-03 (AR-1-SD) 2/71 The Area V (U.S.C.) RMP, in cooperation with Olive View Hospital and the Tuberculosis and Respiratory Disease Association of Los Angeles, are beginning a teaching project directed toward the problems of the chronic respiratory disease patient. The RCU Training Project will serve a complementary function. The Los Angeles County Tuberculosis and Respiratory Disease Association has pledged $10,000 toward the implementation of the project and an additional $5,000 will assist in the promotion of the various educational components. Also, it is planned to charge tuition, and income so generated will be used to offset expenses.incurred. It is estimated that $1,500 will be received in the first year and $3,375 in each of the succeeding years. Second Year - $183,140 Third Year - $196,071 Project #72 - Radiation Therapy - Area VIII Funds First Year are requested to provide continuing $71,957 consultation and continuing education for all personnel in the field of radiotherapy. These activities will include: weekly seminars, demonstrations, conferences, workshops for physicians, nurses, technicians, and students. These will be rotated among the participating hospitals. The needs of hospitals vary and the training and educational services provided will be tailored accordingly. The concerned personnel of each hospital, including the patients’ attending physician will be encouraged to participate in weekly tumor conferences, including patient presentation, review of all clinical radiographic, pathological, and laboratory findings. Each of numerous problems pertaining to radiotherapy of cancer will be discussed in one-hour sessions. Participating will be radiologists, surgeons, pathologists, chemotherapists, and specialists from other disciplines. Many institutions are in great need of technical assistance from a competent physicist to aid in complete treatment planning, to assist in the development of better techniques, and to provide a standard of uniformity in dosimetry. The radiation physicist requested for this program will be resnonsible for the calibration and maintenance of radiotherary equinment, measuring instruments, and shielding devices. It is hoped to be able to establish uniformity of terminology, techniques, definitions, dosage scales, and a descriptive classification of tumors. In addition, tumor boards will be organized in larger hospitals before which cases from neighboring small hospitals will be presented. This project has been in preparation since December of 1968 and represents the radiotherapy section of an Area-wide comprehensive cancer program. At the time of its original preparation, it requested funds for costly equipment, and for this reason, the radiological section was removed by the Area VIII Office. The present request is a modification and more modest version. Second Year - $64,761 Third Year - $58,284 California RMP -12- RM 19-03 (AR-1-SD) 2/71 Project #73 - Cancer Program - Area Ill This project First Year builds on planning efforts in Area III $301,123 over: the past two years. The program consists of four interrelated activities which represent the first stage of implementation of the long-range plan described as follows: (1) radiotherapy services (radiologic physics) ; (2) district tumor board; (3) oncology unit; and (4) consultative-teaching services. The purpose of this project is to fill the gaps in the Area-wide comprehensive cancer program, giving special attention to peripheral Districts 3, 4, 5.and 6, where the need is greatest. Both ongoing screening projects in Area III include screening examinations specifically for breast, cervical and lung cancer. In addition, the San Joaquin Medical Society sponsors both the screening project and the District Tumor Board in San Joaquin District; the Health Facilities Foundation is responsible for the screening of cannery workers in the San Joaquin Valley and elsewhere in Area III. All elements of the Area have been brought to bear in the planning for the cancer project. Also, Area I Cancer Coordinating Committee has assisted with planning in Area III, and to further coordinate their efforts, joint committees have been formed, with a view to pooling of resources of both Areas with respect to ideas, procedures and personnel. The organizational structure has already been developed as part of the planning. RMP District Cancer Committees (five) will be responsible for coordination of the program. For each of the four components-~Radiotherapy Services; District Tumor Board; Oncology Unit; and Consultative-Teaching Services, there will be a project director. The first component is concerned with provision of radiologic physics services by the Stanford Division of Radiotherapy to radiotherapists in the Area. This program will be located in the Stanford . Medical Center, but supported by other physics resources. Services will include calibration of radiation sources, and other supportive consultations, as well as transmission of treatment planning information via wirephoto. The District Tumor Board will provide consultative services to physicians, an educational program on cancer for physicians and other health personnel, a data base acquired through a cooperative hospital tumor registry, and an annual report on status of cancer detection and management in the District, including recommendations. The @ncology Unit will sponsor the development of a model oncology unit in a community hospital; extend resources and methods developed in this unit for establishment of other units in Area III; and improve knowledge and upgrade skills of professionals involved in the care of cancer patients. The Consultative-Teaching Services will be implemented by the creation of an Area Cancer Team consisting of a Cancer Coordinator (medical oncologist), an Associate Coordinator (radiotherapist), and a Nursing Coordinator. As an Areawide team, these persons will participate in District Tumor Boards ae on a scheduled basis and will assist in consultative service. They wiil Me California RMP -13- RM 19-03 (AR-1-SD) 2/71 also conduct or assist in planning educational programs (such as preceptor- ships and short-term training) sponsored by the District Tumor Boards and the RMP District Cancer Committees. Second Year - $296,698 Third Year ~ $287,396 Project #74 - Blood Banking - Area V This Project will First Year train 1,000 blood bank technologists from $53,551 Los Angeles and Orange Counties in the six subject areas (ABC Grouping, the Antiglobulin Test, and Rh Testing) over a three-year period. Technologists will be followed after training to determine of changes in performance due to the workshops persist:. There are a few postgraduate training opportunities for blood bank technologists in this Area, but the applicant feels these are not adequate to meet existing demands. The commercial serum companies workshops are felt to be somewhat slanted, others are held yearly by the American Soclety of Clinical Pathology, but are primarily for pathologists and not techno- logists, aad all are held too infrequently to supply local demands. The program would conduct workshops in blood banking on a full-time basis, directed by a Teaching Supervisor and one Assistant Teaching Supervisor. Another Assistant Teaching Supervisor will be responsible for the day-to-day preparation of specimens and other technical details. Other personnel requested are a Research Assistant (half-time) and a Shipping Clerk (half-time). The proposal has been coordinated and cooperatively planned by Areas IV, V and VII as a collaborative effort and would serve all three. A willingness to participate in the program has been indicated by 169 of the 223 hospitals in the two-county area. Second Year - $54,546 Third Year - $58,986 NOTE: Action on a supplement (11/70.1) was deferred from the last review cycle pending the findings and recommendations of a site visit scheduled for early December. The concerns expressed by reviewing bodies dealt with an apparent lack of any overall regional priority system. Some of the proposals appeared to be attempts to develop linkages from stronger Areas to others that are moving more slowly. However, the total application failed to indicate how the region had arrived at its choices of submission or to furnish background to ongoing activities which would allow the reviewers to assess the projects in their true context. These points were explored extensively by the site visit team, and are included in the site visit report which accompanies this present "package" from California. DRMP/GRB 12/17/70 “SUMMARY OF REVIEW AND CONCLUSION OF A PRIVILEGED COMMUNICATION JANUARY 1971 REVIEW COMMITTEE CALIFORNIA® REGIONAL MEDICAL PROGRAM RM 19-03 (AR-1 DS) 2/71 . FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: That a developmental component be approved at an annual rate of $400,000 to become effective for the remaining 6 months of the 03 year; that Core be renewed at the increased amount recommended for the 03 year ($3,878,346) to become effective for the - remaining 6 months of the 03 year; and that the level for, operational activities be continued at the current rate. ($4,085,648.) ., Committee recommends that these levels should prevail for a period of ‘18 months covering the last half of the 03 year and the entire 04 year, and further, when the region's triennium application is submitted to the July/August review cycle covering the 04, 05 and 06 years, the 04 : Funding for the 05 and 06 years will be determined when the entire triennium application is, year level should be within these limits. considered. The effect of these recommendations is: Requested By Recommended by Recommended by . July/Aug. Review Cycle $9,879,340 Region Site Visit Team Committee 03 Year Core $4,263,325 $3,878,346 $3,878,346 Dev. Comp. 813,440 400,000 400,000 Oper. ‘Act, 4,085,648 4,085 648 4,085 648 . | $9,162,413 $8,363, 994% 58,363,990 ‘04 Year : ne ~~ ore $4,476,491 $4,072,263 $3,878,346 Dev. Comp. 834,759 - 400,000 400,000 Oper. ‘Act. To be submitted in 4,572,263 4,085 ,648 i July/Aug. Review $9,044,526 . $8,363,994 | Cycle 05 Year ., “= Core 4 $4,700,315 $4,275 ,876 To be determined Dev. Comp. 857,140. ~" "400,000 in July/Aug. Oper. ‘Act. To be submitted in 45775 ,876 Review Cycle ‘ July/Aug. Review $9,451,752 i Cycle 06 Year Core $4,935 ,330 $4 ,489 ,670 - To be determined Dev. Comp. 880,642 400,000. in July/Aug. Oper. Act. To be submitted in 4,989,670 Review Cycle * This is an annual figure. The actual increase for the last 6. months of hel Nd vear is $407.768 ( $200,000 Developmental Component and $207,768 | i * California RMP ee RM 19-03 (AR-1-DS8) 2/71 California represents a testing ground of national significance in sub-regionalization of medical planning, which, in turn, affects a wide variety of educational institutions and people of diverse ethnic backgrounds and varying economic circumstances, The Watts-Willowbrook activities, in which approximately $1 million of RMP investment has generated approximately $50 million of other funds, has captivated national interest and enthusiasm. It is believed that this activity should serve as a model of reorganization and redirection of medical care in economically einadvantaged | and* medically isolated regions. .. . Another important innovation in California is the meshing and definition of the roles of RMP. and CHP. While there was not much evidence of coordination of CCRMP and the A Agency, there is some combined representation of personnel, both in CHP. and CCRMP. Also, California has given thoughtful attention to the health needs ‘of Indians, Black and Mexican-American communities and has given support for planning of OEO health centers in the moss’ Cities Program, The reviewers discussed at length the regional evaluation system, The site team had some misgivings about its effectiveness as well as its relationship to the regional priority system. This led to further consideration both pro and con of the efficacy of the region's approach to evaluation and its capacity to judiciously pick and choose among its operational projects, The magnitude of | - the funding level of California tends to inhibit objective examination. The analogy of residency accreditation visits was cited, and’ one member pointed out that the Review Committee has not, as yet, evaluated “mega-dollars" regions in terms of "accreditation." Evaluation as a "process", in the opinion of the reviewers, should include ongoing, independent audits of segments of the program, i. Ces _. Ganeer’ in Area I, Neurology in Area VIII, with firm documentation presented as to cost, accessibility, availability, ete. In summary, it was agreed that while California is difficult to judge on a total program basis, it does claim to be one region. Therefore, . the rationale of diversity must be questioned, as well as the foree: of the thrust of the central staff to monitor ongoing programs. The Committee was reminded that all site visits from the inceptio ‘of RMP in California emphasized evaluation. The region has been cautioned to build in a methodology from the beginning of project planning, continuing through its operational experience and ultimate termination. This, in turn, should lead to a realistic and meaningful “total program evaluation." If California is to be. judged as a laboratory, then. it must test, modify, redesign, discard--evaluate, ae California RMP : | -4- - RM 19-03 (AR-1-DS) 2/71 Developmental Component | ‘There was consensus that the region has the resources and decision-| making ability for responsible use of such an award. The region has proposed a strategy which will utilize such funds for specific objectives to maximize new opportunities and capabilities in responding to regional health priorities. The nine Area Core staffs have demonstrated program capabilities in a variety of activities generated by these staffs ih community outreach, coordination with CHP, volunteer agencies, utilization of manpower and resources. and Other local health planning efforts. Review procedures for such proposals will be considerably simplified. Projects will be more modest in scope and will have greater regional implications, A special Review Panel is in process of appointment with. representation from all voluntary, as well as public health agencies, ~The RAG membership views the autonomy inherent with Anniversity - Review status as a real challenge for CCRMP. It recognizes that some tough decisions lie ahead. The reviewers believe there is - ‘strong evidence that, in the face of reduced financial support, this responsibility will be equated with local (Area) progress, local needs and qualifications for such funds. it is apparent that California is already experienced in principle in Developmental Component techniques, and the region can be expected to be discriminating and sophisticated in its choice of activities for such funds, The region feels that such programs should yield early returns with good spin-off value. In addition to sub-regionalization at Area levels with visible, active, local decision-making, the California RMP has shown substantial development toward even greater depths of regionali- . gation. The Committee noted that Areas are divided into Districts, ~ which in turn, have Advisory Councils, representative of local health interests, Each Area conducts planning studies, exchanges information. to avoid unnecessary duplication and share experiences. Gore Renewal In discussing this segment of the application, Committee had difficulty in assessing a Core Renewal request in isolation from its ongoing operational projects. It noted the impressive produc~ tivity of some of, the more advanced Areas and a lesser degree in the underfunded Areas. However, in some of the late starters, limitation of Core funds has probably encouraged a certain creativity in planning and utilization of available resources, _ The reviewers agreed with the findings of the site team that the request for additional funding to equalize Core support throughout California RMP -5- RM 19-03 (AR-1-DS) 2/71 initially in a somewhat arbitrary fashion, There was also agreement that California's expanding interest in Comprehensive Health Planning and its extensive inter-relationships with other types of state and voluntary health agencies make it impossible for Coordinators with small staffs to stay abreast of regional linkages to further planning, as well.as develop active operational programs, © all nine Areas is valid, It recalled that such support was limited The Review Committee agreed with site visit findings that Core budgets of less than $250,000 for Areas of a 1.5 million population are unrealistically low. Further, the distribution of awards ranging from 4% to one Area and 25% to another, with an even wider range in the per capita distribution of funds, presents a handicap to smoothly working relationships of the various Core Staffs. However, the Review Committee discussion was fraught with many concerns of the reviewers in their inability to assess realistically such requests in relation to ongoing operational activities, The reviewers “were reluctant to accept the site visit team recommendation which would, they felt, have the effect of establishing a program level for a complete triennium prior to the submission of ‘the complete triennium request. Instead, the Committee voted to approve certain increases for an ve! 18-month period with the provision that the levels would be ™ re-examined at the time the operational activity portion of the © program is considered in the July/August review cycle... Committee agreed that a more realistic assessment of the "total" California’ program could be made at that time. ‘The dollar implications of their recommendation are shown on the first. page of this Summary of Review. CONCLUS TONS : A; number of issues ‘emerged during and as a result of the most recent site visit. These are outlined below: - 1. The Executive Director raised the.question of whether RMPS and - the National Advisory Council, in-effect, delegates its authority uhder ‘the Anniversary Review system, by authorizing expansion of any approved operational activities into other areas or institutional settings: without review and approval by Council. This does change Council! Ss. role somewhat, which has precedent for delegation of various authorities. The extent (how far) of such delegation needs to be examined. In the case of California, reviewers at the national level, have encouraged the region to refine its review and evaluation system in order to promote a more cohesive, integrated regional program, This has included the extension of planning techniques and programs from Area to Area and Districts to maximize available resources. The disposition of a large backlog of Council approved but unfunded projects, some of which have been dormant for almost two years raises the. question of how long do approved but unfunded activities.retain their Council approved status, The site team believes that. CCRMP » California RMP an a RM 19-03 (AR=1-DS) 2/71 vhas adequate capability to review these projects, and to activate’. “them within the limitations of the operational budget, provided — they carry out their technical review after a project has been inoperative for from twelve to eighteen months, If a second. local. review attests to its pertinence and viability, such projects could be moved into.a status where they could be considered for support along \ with other more current Proposals. 3, The site team identified ' ‘some , potential long- ~term policy implications in using RMP funds to support CHP activities as proposed by Lo. 1 California. .Does thé "relationship"™:as envisaged provide af . avenue whereby. CHP. avoids its statutory mandate requiring consumer . “yepresentation on planning boards, etc.? Or, are “there other more _, Subtle suggestions in. the use’ Of RMP funds. to: ad B agencies? =< “NOTE: Doctors Spellman ‘and Besson. were ‘invited | ‘to remain in the” *-.: room during the delibérations ‘since the- findings ‘and recommendations ‘of the site visit team were discussed ‘qhite candidly ‘with regional’ representatives. Doctor Besson remained; Doctor Speliman joined: the Committee for the last few minutes. , 1/20/71 GRB/RMPS REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) COLORADO-WYOMING REGIONAL MEDICAL PROGRAM RM 40-03 (AR-1-CDS) 2/71 me Review Committee Denver, Colorado 80205 A 2045 Frankling Street, Suite 410 Program Coordinator: Paul Hildebrand, M.D. REQUEST (Direct Costs Only) 03 Year — 04 Year 05 Year All Years 1/71-12/71 _:1/72-12/72 1/73-12/73 Continuation Commitment 1,103,772 98,415 1,202,187 (Core) (483,697) -- -- (483,697) (12 projects) (610,875) (98,415)1/ (709,290) (6 month extension of project to terminate 12/70) ( 9,200) -- -- ( 9,200) 02 Estimated Unexpended Funds 73,902 -- ~— 73,002 Additional Components 508,843 204,922 218,732 932,497 (Developmental) (109,000) ¢ O ) ¢ 0 ) (109, 000) (3 new projects) (370,777) (174,333) (184,792) (729,902) (1 approved-unfunded project) ( 29,066) ( 30,589) ( 33,940) ( 93,595) TOTAL 1,685,617 $303,337 $218,732 2,207,686 *Staff Action on Continuation Approved Cont. Committment 1,103,772 98,415 1,202,187 Disapproved Unexpended funds 47,428 47,428 Deferred Unexpended funds 25,574 25,574 Committee Action Required 508 ,843 204,922 218 732 932,497 FUNDING HISTORY Planning Stage Grant Year Period _ Funded_(d.c.o.) 01 1/1/67-12/31/67 $297,678 02 1/1/68-12/31/68 366,723 OPERATIONAL PROGRAM Council Funded Future Grant Yr. Period Approved (d.c.o.) Commitment ol 1/1/69-12/31/69 1,079,853 976,854 02 1/1/71-12/31/70 1,466,995 1,282,815 1/ COLORADO - WYOMING RMP RM 40-03 (AR-1-CDS) 2/71 -2- - Council Funded Future Grant Year Period _Approved (d.c.o.) Commitment LEE NS ; 03 1/1/71-12/31/71 1,472,782 ost 1,094,572 04 1/1/72-12/31/72 98,415 -- 98,415 1/ Includes $106,533 of 01 Carryover GEOGRAPHY The initial planning grant set the boundaries of the proposed region as co-terminal with those of the States of Colorado and Wyoming. The rationale for this proposal was that the University of Colorado Medical Center along with other referral facilities and health services of the greater Denver area serves as a nucleus for most of Colorado and Wyoming. However, since 90% of the population of the region resides in Colorado the boundaries of this state will be followed for data- gathering purposes. The adoption of political boundaries of the state of Colorado simplifies the collection of data and coordination of the Regional Medical Program with other state health programs. Another factor in this decision is that portions of the state of Wyoming fall under the influence of three Regional Medical Programs: Intermountain, Mountain States and Colorado-Wyoming. Studies have shown that patient referral patterns in some Wyoming communities reflect allegiance to all three regions. Land Area Square Population Number of Miles Per Sq. Mi. Counties Colorado: 97,400 17 63 Wyoming : 104 ,000 3 24 201, 400 87 DEMOGRAPHY Population: Colorado - Roughly 2 million Wyoming - Roughly .3 million Population Percent Urban: Colorado 1,480 ,000 74% Wyoming 171,000 57% Rural: Colorado 520,000 26% Wyoming 129 ,000 43% RM 40 (AR-1-CDS) 7/71 COLORADO-WYOMING RMP ao 3m Population ' Percent Race: Colorado 1,940,000 97% - White Wyoming 294 ,000 98% - White Colorado 60 ,000 3% - Other Wyoming 6,000 2% ~ Other Median Age Colorado - 27.9 Wyoming -~ 27.3 Health Statistics: Mortality Rate Rate for Heart Disease: Colorado - 285/100,000 Wyoming - 269/100,000 Rate for Cancer: Colorado - 114/100,000 Wyoming - 115/100,000 Rate for CNS Vascular: Colorado - 84/100,000 Lesions Wyoming - 84/100,000 Facilities Statistics: 1. 2. University of Colorado Medical School In the state of Colorado, there are three nursing schools with a baccalaureate program, four with diploma programs and five giving associate degree programs. In the Wyoming area, there is one baccalaureate program presented at the University of Wyoming, and two nursing schools with associate degree programs. There are 13 schools of Medical Technology located in Colorado one of which is university based. In Wyoming there is one school of Medical Technology. There is one cytotechnology facility located at the University of Colorado Medical School. There are 18 X-Ray Technology facilities located within this region, 16 of which are found in Colorado, all hospital based. There is a total of 92 hospitals in Colorado, the majority being non-Federal, with 16,655 beds. In Wyoming, there are 34 hospitals, again the majority being non~Federal, with 3,982 beds. COLORADO-WYOMING RMP -4- RM 40-03 (AR-1CDS) 2/71 Personnel Statistics: There are 3,201 M.D.'s (176/100,000) and 240 D.0.'s (13/100,000) in the state of Colorado In Wyoming, there are 322 M.D.'s (99/100,000) and 16 D.0O.'s (5/100/000). The number of active nurses in Colorado is 7,080 (389/100,000); in Wyoming, there’ are 1,082 active nurses (321/100 ,000). HISTORY AND DEVELOPMENT The Region submitted its first planning application in September 1966 and was funded at $297,678 d.c. the first year (1/1/67-12/31/68) with a commitment for the 02 year in the same amount. Although Committee and Council both recommended approval in their review they shared the concern that the Region's geographic overlap in Wyoming with two other Regions (Intermountain and Mountain States) might present a significant problem in the future. In December 1967 Staff reviewed the Region's request for the continuation of its planning grant into the second year (1/1/68-12/31/68). The wood request for expanded support of $414,112 (d.c) was considered very Se ambitious particularly in view of the slow progress and a reduced amount at the level of the first year (297,678 d.c.)was awarded. In its review Staff noted recruitment had proceeded slowly and only one planning activity had been developed very far. Staff was optomistic that the appointment of a new program director (Dr. Doan replaced Dr. Eisele) may accelerate planning. It was noted, however, that the Director's salary at $32,000 is in addition to the existing Program Coordinator's (Dr. Hildebrand) salary at $35,000. This was considered a heavy executive salary for a small inactive program such as Colorado/Wyoming. In June 1968 a supplemental award of $49,615 (d.c.)was made for the expansion of existing facilities and capabilities of a Pediatric Pulmonary Program at U.C.M.C. (with two additional years of committed support this program was later to become Project #13). Also in July 1968 the Region submitted a request for $133,973 (d.c.) supplemental planning funds along with an operational application consisting of five projects. These requests along with a three project supplemental request submitted in August were all deferred by Committee and Council for a site visit. A pre-operational site visit was conducted in September 1968. The team consisted of Dr. William Mayer, Dr. Mack Schanholtz, Dr. Robert Metcalf, Martha Phillips and James Beattie. The visitors expressed their confidence that the concept of regionalization was developing well. There was substantial evidence of involvement outside of Denver into Wyoming and interregional relationships were satisfactorily being COLORADO-WYOMING RMP RM 40-03 (AR-1-CDS) 2/71 worked out, in spite of earlier concerns. There appeared to be good understanding and cooperation between the Regional Medical Program and practicing physicians as well as with voluntary agencies, the medical center, the official health agencies of Colorado (and to a lesser extent of Wyoming) and the local CHP agencies. It was noted categorical standing committees not only review project applications but each was charged with developing a region-wide approach in its area of concern. The Region saw itself as moving from a "project approach” to a "program approach. The RAG appeared deeply involved in the program and was beginning to develop a more formal approach to its functions. The representation on the RAG was felt to be somewhat less than satisfactory. Allied Health representation was limited to two nurses and the only minority representative was the Executive Director of the Urban League. The large contingent of Spanish-American physicians had not been contacted and consumer representation had not been considered. Although an "administrative committee" of the RAG had undertaken the establishment of a method of priority-setting, no such system was applied to the first projects included in the first operational application or the supplemental request. (See Report of 1968 Site Visit). As a result of the site visit, and Committee and Council&S acceptance of the recommendations, the Region was awarded $25,331(d.c.) as a supplement to its 02 planning award which brought the total award for the 02 planning year to $366,888 (d.c.). Later the Region was also awarded $849,053 (d.c.) for the 01 operational year (1/1/69-12/31/69) , for support of Core and seven operational projects. This award was later revised upward by $127,801 d.c. to include two additional projects, bringing the total award for the O1 operational year to$976,854 d.c. In December 1969 Staff reviewed the 02 year (1/1/70-12/31/70) continuation application from the Region. While it was agreed the program appeared to be moving along much as anticipated, concern was expressed that the progress reports were vague in many respects. Three projects were cited as particular examples of this weakness. The requests for use of carryover funds were also found to be vague and poorly justified. As a result of this review the Region was awarded $1,082,881 (d.c.) for the 02 operational year with the option of submitting new requests for use of 01 year unexpended funds. In addition the Region was required to submit revised progress reports on the three weaker projects. In February 1970, Staff reviewed favorably a single request for the use of $33,016 of 01 unexpended funds to contract with Trans-Century Corporation to continue community planning in Pueblo, Colorado directed toward developing an improved health care system for the Spanish- American Population of Southern Colorado. An award in the amount requested was made. COLORADO-WYOMING RMP -6- ee oe eee In May 1970 Staff reviewed 15 proposals for use of $132,450 and recommended approval of ten totaling $73,517, but with on -proposal restricted pending a site visit. In addition Staff also reviewed the revised progress reports on the three projects for which such reports were requested. - - These were found to be basically weak, failing to relate to the questions posed in the advice letter. Many questions were not spoken to while others were answered in vague generalizations which characterized the original progress weports. The educational programs appeared unstructured and void of good educational design. Evaluation was obviously lacking and apparently no assistance in this area was being given by, or had been requested from Core staff or other competent people who are . qualified in this area. Lack of coordination between related educational projects was also evident. Staff concluded that inview of the substantial difficulties in the education and evaluation aspects of the projects, and the apparent reluctance of Core staff to oversee and assist, the Continuing Education Branch of RMPS should take immediate action to offer assistance. The Continuing Educatim Branch has since had extensive communications, including personnel meetings, with Dr. Doan and the Continuing Education people of CNRMP. As a result, the Continuing Education Branch of RMPS reports that the problem which was a breakdown in communication between the Continuing Education people and the Administrative staff, has been for the most part resolved. It appears relationships have been improved markedly with the Coordinator and the Executive Committee having a more favorable attitude toward the Continuing Education staff. Continuing Education staff now participates actively in staff committees dealing with project ideas rather than serving in a passive role as an occasional reviewer of projects after they were already designed. As a result of Staff's recommendation for approval of ten proposals for use of 01 unexpended funds and the Director's willingness to grant a special supplement of $100,000 to the Region for support of four approved but unfunded projects, a new amended award in the increased amount of $1,282,815 for the total program was granted in June 1970. A breakout of this award is presented on the last page of this summary. On November 25, 1970, staff reviewed the Continuation Component, the Region's first Anniversary Review Application. The Acting Director concurred with staff's recommendation which was: 1) approval of the request for $1,103,772 of committed support for continuation of Core and 13 projects; 2) disapproval of a $47,428 request for use of 02 year unexpended funds in eight projects and 3) deferral to the site visitors a request for use of $25,574 of unexpended funds to extend project #13. A site visit will be conducted on December 8-9, 1970 and a report will be presented to Committee at its January 1971 meeting. COLORADO-WYOMING RMP ~7- RM 40-02 (AR-1-CDS) 2/71 PRESENT APPLICATION Core Organization: Coordinator's -- Director's Office Paul R. Hildebrand, M.D. Coordinator Howard W. Doan, M.D. Program Director Rex D. Stubblfield Executive Assistant Elaine Deters Secretary Fiscal & Administrative Services Mildred Schnittgrund Administrative Assistant Kay Jones Steno-Secretary Sylvia Meek Telephone Receptionist Communication & Information Office J.P. Smith Public Information Officer Professional Activities Division Richard E. Boyle, M.D. Associate Director Anne Gough, R.N. Chief of Nursing & Allied Health Rogene Dilley Steno-Secretary Project Administration & Health Information Systems Division James C. Syner, M.D. Associate Director W.C. Morse, Ph.D. Chief, Project Administration FR. Normile Chief, Project Development Hubert Brandon Health Administration Specialist Gerald F. Fournier Health Administration Specialist William 0. Hastings Chief, Project Audit & Control Norman S. Holt Wyoming Liaison Officer Heinz Mueller Health Administration Specialist Dee Trees Steno-Secretary Peggy Oliver Steno-Secretary Continuing Education Division James E. Dyson, Ph.D. Associate Director * Cardiovascular Disease Division Robert C. Jones, M.D. Associate Director M. Lynn McCracken, R.N. Health Services Education Specialist COLORADO-WYOMING RMP RM40-03 (AR-1-CDS) 7/71 Regional Advisory Group Structure: Physicians and Dentists 4 1 5 , Medical Center Representatives 4 0 4 Hospital Administrators 3 2 5 Society and Association Representatives 4 1 5 2 Nurses Association 2 State Medical Society 1 Osteopathic Association Voluntary Agency ~- Representatives 2 1 3 Public Health Officials 1 1 2 Public ll 1 12 1 Spanish Sur~name 1 Negro Other 4 0 4 1 Nurse 1 Head Start 1 Model City TOTAL 33 7 40 Program Analysis Memo shows three meetings were hetd during 1969 with an average attendance of 29 (62%) members. - : o— . 3 go . ? ; DIVISION OF REGIONAL ME DE CAL PROGRAMS F Washington, D.C. x e e a oe . z Lo cog : Ce , g 38 a re REGIONAL ADVISORY GROUP . z ‘ . . . . . . . ot oO - , a : S STANDING COMMITTEES So , ; 4 ,? Continuing Education {° _ . yA oS - I _ Heart , : ADMINISTRATIVE COMMITTEE j. | 3 tA i *Stroxe * “8 : 3 >. | . ° ; T a Caneer , Lo 7 4 a? . ., ~~” oe ~] wt a~ , ! ' . TT — | EVALUATION COMMITTSE OFFICE OF COORDINATOR-DIRECTOR | CNRMP STAFF REVIEN COMMITTEES ‘| _ oe : = YISCAL & & ADMINISTRATIVE COMMUNICATIONS & SNFORMATION / SERVICES OFFICE | - OFFICE | TS | 4 f - DIVISION OF ! / | DIVISION OF PROJECT | orvisr ION OF CONTINUING . DIVISION OF PROPESSIONAL ACTIVITIES | | ADHINTSTRATION & HEALTH EDUCATION CARDIOVASCULAR DISEASE : j INFORMATION SYSTEMS : COLORADO-WYOMING RMP - 10 - RM 40-03 (AR-1-CDS) 2/71 -Region's Goal : The Goal or "Grand Ideal" of CWRMP is stated as follows: Reduce the adverse impact of heart disease,cancer, stroke, related and other diseases, and thereby improve the quality of life for all citizens." Region's Objectives (1) Provide support to the practicing physician to achieve an expansion of his productivity. (2) Assist in providing fox the: immediate health service needs of the poor in both urban and rural areas. (3) Provide quality care as geographically close to the patient as is consistent with the most economical allocation of scarce health resources. (4) Accomplish a continuous evaluation of progress towards program objectives. (5) Coordinate closely with the community hospital as a primary entry point for CWRMP influence in each health service area, to assist in transforming them into community health centers. (6) Develop an improved working alliance with Comprehensive Health Planning based on cooperative arrangements for project development utilizing the Community Comprehensive Health Planning Council, i-e., the 314 (b) agency. Region's Working Strategy The basic working strategy utilized by CWRMP to accomplish its objectives is through the establishment of cooperative arrangements in project planning, design, and implementation with the health resources of the region. © HEART COLORADO-WYOMING RMP _ PROJECT REVIEW PROCESS ; PROJECT PROPOSAL to CWRMP ¢ Determination of merit, RMP Guidelines relevance ' by knowledgeable CWRMP Staff and/or Consultants: CWRHP liaison assists : originator in development for presentation to CWRMP STAFF REVIEW COMMITTEE. “Originator and CWRIP Staff presents Project Proposal to appropriate categorical Comnittee for Scientific Merit and RiP relevance. na -l- - RM 40-03 (AR-1-CDS) /71- CANCER _ | STROKE CONTINUING | SPECIAL EDUCATION CONSULTANTS : ba ta at Revised Project Proposal presented to the Administrative Committee of RAG in broad abstract and budget form. Project Proposal revised into detailed form for {presentation to RAG. A Primary and Secondary Reviewer Designated Erom RAG for presentation to the Regional Advisory Group. "Blue Sheet" sent to each RAG member prior . to meeting which contains: “1. Proposal objectives, 2. Review cycle action, 3. Staff comments on merit, RAG Primary and Secondary Reviewers present finalized project proposal to RAG members. CWRMP Staff assists in presentation when requested, yAn approved Project Proposal is os forwarded. to DRMP for National Review Council Action. __ ? COLORADO-WYOMING RMP -12- RM 40-03 (AR-1-CDS) 7/71 New Operational Projects: Requested First Year Project #22 - Rural Health Services for Migrant and $164,466 Seasonal Workers. The Colorado Migrant Council with the assistance of Core Staff, drafted this proposal to help eliminate fragmentation of resources, and coordinate the existing services to the rural poor who are to a large degree, migrant workers who have settled permanately in the region. Five teams, each consisting of one area coordinator and two indigenous family contact workers, supported by the project will work to accomplish three basic objectives: _1. Develop health and supportive resources when they do not exist in impact areas. 2. Educate the farmworker and his family to utilize health services that are available. 3. Develop rural health "coalitions" in the impact areas to serve as the coordination bases for farmworkers, growers, agency efforts. The proposal is founded upon the basic working strategy of establishing cooperative arrangements among providers and consumers of health services and is no direct support of the CWRMP objective; to provide health care services to the poor. Second Year: $173,333 Third Year: $184,792 Requested First Year Project #23 - Comprehensive Community Neurological Service for $59,244 Denver. Request is being made by the Denver Department of Health and Hospitals for one year support of a project which was initiated on October 1, 1967 with 314 (e) funds and will terminate on December 31, 1970. The project provides comprehensive neurologic services to the patients of Denver General Hospital and the Denver Neighborhood Health Centers. Most of the patients are urban poor, medically indigent, and include a high percentage of Hispanos, Blacks, drug and alécohol abusers, the aged, and the chronically i111. Their most frequent diseases are stroke siezures of varying causes, and degradive disturbances related to alcoholism. The project encompasses an in-patient neurology service and. consultation service at Denver General Hospital, an out-patient neurology clinic, an electroencephalogram laboratory, and an intensive training program in clinical neurology for medical students, intern residents, and various other physicians affiliated with Denver General Hospital and the Univer- sity of Colorado School of Medicine. Support is requested for a project director, an EEG technician, a secretary, and a resident in neurology from the training program in neurology of the University. The Department of Health and Hospitals of Denver will assume financial responsibility when RMP support abates. COLORADO-WYOMING RMP -13- RM 40-03 (AR-1-CDS) 2/71 Requested First Year This project provides services to the urban poor, a group whose health care has been declared a high priority both nationally and by the CWRMP. First Year: $59,244 Second Year: - 0 - Third Year: - 0 - Project #24 - Family Health Workers as Agents of Change of $147,067 Primary Preventive Care -- 1971. This project is sponsored by the Tri-County Health Department (Adams, Arapahoe, and Douglas). It proposes a dual approach to removing barriers which impede access to the stream of health care for the consumer. It is an attempt to (a) initiate a family health worker training program and (b) introduce additional screening tests into a mobile unit program currently operating with a singular focus on uterine cancer detection. This proposal ig intended to demonstrate more effective methods of utilizing manpower and facilitating access to health care resources. Expansion is intended to proceed only after rigid assessment of each element introduced to insure that the system proposed is, in fact, dealing appropriately with consumer requirements. The training program for family health workers has as two of its objectives gaining program certification and defining more clearly the tasks to be performed by the trainee. Once these tasks are clearly defined, more realistic career patterns can be established. Detailed and flexible job descriptions which include guidelines for continuing education as well as for performance expectations, for four levels of family health workers have been prepared. The agency has a job appraisal system which emphasizes the superviser's participation in setting job-related goals. The objectives to which this project relates most closely are: dealing with the problems of the urban poor, providing health care services to females with cervical cancer, addressing itself to the health manpower problem and improving provision of preventive care. First Year: $147,067 Second Year: - 0 - Third Year:- 0 - COLORADO-WYOMING RMP RM 40-03 (AR-1-CDS) 7/71 -14- “Developmental Component The overall rationale for Developmental Component funds is to test the feasibility and potential of spontaneously occurring opportunities to further CWRMP objectives. The basic strategy to be followed 7 in determining allocation of funds . will proceed as follows: ; (1) Maintain and enhance in CWRMP core staff a state of "sensitivity" for new and potential "targets of opportunity," which hold promise of contributing to overall program goals. (2) Assure that CWRMP core staff are available to assist the "innovators" of ways to effect improved health care delivery. (3) Gather data and promote interpersonal relationships at community levels to establish a realistic definition of needs. (4) Encourage the involvement and the development. of cooperative arrangements among institutions, agencies, and organizations which can serve as resource functions in resolving problems. (5) Utilize the CWRMP Evaluation Committee to document, organize, and process information. (6) Coordinate all involved parties (innovators, community citizens, cooperating agencies, and CWRMP staff) to react to total imputs, and finalize an output which constitutes that action scheme designed to resolve the problem and, thereby, serve as a valuable contribution to the grand goal of CWRMP. COLORADO-WYOMING RMP RM 40-03 (AR-1-CDS) 7/71 -~15 - © Funded Operational Projects #1 -~ CORE STAFF #2 -- #3 -~ Objectives: This project is to support core planning and evaluation activities of the Colorado-Wyoming Regional Medical Program. Staff is divided into four offices and three divisions: (1) Professional Division; (2) Division of Continuing Education; (3) Project Administration and Health Information Systems. Full-time equivalent staff are requested as follows: Office of Coordinator (1), Office of Director (2.2), Office of Executive Assistant (13), Office of Communication and Public Information (3), Division of Professional Activities (7), Division of Planning and Operations (7.75), and Division of Health Data and Program Fvaluation ( (6). , COLORADO STATE CANCER REGISTRY Objectives: The basic objective of this project is to develop a computerized statewide cancer registry to improve follow-up to as near as 100% as possible and through utilization of registry data, to provide the cancer patients of Colorado with the best care and earliest diagnosis possible. Improved follow-up of (1) treatment failure, (2) second primaries in Kansas Cancer patients, and (3) determination of need for treatment changes in those patients known to have cancer. Extension of registries to all hospitals, improved continuing education and constant evaluation are also goals. This project relates to the third National Cancer Institute Survey of Cancer Incidence and Prevalence and a proposed six-state Rocky Mountain Tumor Registry. The Colorado Department of Public Health will be the headquarters for this activity. MULTI-MEDIA EDUCATION Objectives: This continuing education project will develop sa prototype system for videotape exchange and closed-circuit TV involving first, the Denver Medical Society, the University of Colorado Medical Center, Presbyterian Hospital and St. Joseph's Hospital of Denver, and later, seven other Denver hospitals. The TV system will be converted to color later and if CCTV is extended throughout Colorado and Wyoming, (1) will be ‘extended to hospitals through out COLORADO-WYOMING RMP: - ~ *o" RM 40-03 (AR-1-CDS) 7/71 the Region, (2) produce and distribute videotapes to hospitals in the Region, (3) produce and distribute single concept films, slides and film-strips to Regional hospitals. A catalog of existing educational materials and staff con- sultation to local hospitals are other features of the . project. The Office of Audio-Visual Education in the Health Sciences of the University of Colorado Medical Center is headquarters for the project. #4 -~ HOME DIALYSIS TRAINING PROGRAM Objectives: This project is to improve understanding of . health personnel and the public in the treat- ment of kidney disease and of the problems experienced by renal patients, to enhance community involvement in the rehabilitation of patients undergoing home dialysis, to provide consultation to community health personnel, to provide highly specialized laboratory services when required, and to develop the capability to provide emergency services for home dialysis patients. Training plans include: (1) three-day orientation for 30 physicians and 25 public health nurses; (2) five-day orientation for five physicians; (3) ten-day training for five physicians from hospitals , planning home dialysis service; (4) two-week training session for seven nurses and for technicians from hospitals planning a service program, three-day training for ten dieticians; (5) one three-day conference of 20 social workers and rehabilitation personnel; (6) one three-day orientation for five clergy, welfare workers, pharmacists and community leaders; (7) five one-two day conferences for 50 health related and community-oriented..individuals; and (8) six-week training for family members of patients. Travel and per diem is requested for all these groups. #6 -- TRAINING AND APPLIED RESEARCH FOR INTENSIVE AND RENABSLITATIVE RESPIRATORY CARE Objectives: To (1) familiarize physicians and paramedical personnel of the magnitude of the emphysema- chronic bronchitis problem; (2) disseminate knowledge on the latest advances in the treatment of the problem; (3) to promote and assist in the establishment of respiratory care. programs in local communities; (4) obtain greater know- ledge on the effectiveness of home oxygen for both hypoxemia and non-hypoxemia individuals; and (5) increase the effective- ness of therapy through the development of improved ventilators and nebulization devices as well as the addition of humidi- fication devices to existing oxygen equipment. ’ COLORADO-WYOMING RMP -~17-— RM-40-03 (AR-1-CDS) 2/71 * #7 ~- RADIATION THERAPY AND NUCLEAR MEDICINE #8 -- #9 -- #10 -- Objectives: Technology Training. To reduce the acute shortage of well-trained radiation therapy and nuclear medicine technologists by establishing Associ- ate Degree two-year training programs in radiation therapy and nuclear medicine technology. The programs will be offered by the Denver Community College in conjunction with nine hospitals in the Denver area: (1) Colorado General, (2) Denver General, (3) Fitzsimmons General, (4) Lutheran, (5) Mercy, (6) Presbyterian Medical Center, (7) St. Anthony's, (8) St. Luke's and (9) General Rose Memorial. It is expected that at least forty students per year will graduate from the training programs. COLORADO INTERAGENCY COUNCIL ON SMOKING AND HEALTH PROGRAM Objectives: To continue support of an Interagency Council on Smoking and Health. The prime source of funding for the Council (which paid the salary of a coordina- tor and a secretary) has been through a Special Project Grant from the Public Health Service. This source of funding is no longer available due to budget limitations. The general objectives of this proposal are: (1) coordination of Council member activities pertaining to smoking and health and pro- motion of more efficient communication between Council agencies; and (2) continuation of efforts on a long-range program aimed at permanent financing of the Council within the State of Colorado. CONTINUING EDUCATION CORE PROGRAM FOR NURSES Objectives: Based at University of Colorado School of Nursing, would provide integrated training in intensive nursing care. CONTINUING EDUCATION STAFF Objectives: Develop continuing education staff in Colorado~ Wyoming RMP to counsel with communities interested in developing local continuing education programs. Staff teams would “provide consultation to local hospitals. Development of local consultation teams would also be encouraged with RMP staff assistance provided to fill gaps in local expertise. “COLORADO-WYOMING RMP #13 -- #14 -- #15 -- #16 -- - 8 - RM-40-03 (AR-1-CDS) 2/71 PEDIATRIC PULMONARY Objectives: Expand existing facilities and capabilities of pediatric pulmonary program at University of. .Colorado Medical Center. Program will seck to familiarize the medical personnel in New Mexico, western Kansas, western Nebraska, Colorado, Wyoming, Montana .and Utah with the facilities at this Center to attract more and earlier referrals. Will concern itself with comprehensive management and training programs of all acute and chronic neonatal and pediatric pulmonary diseases. THE STATISTICAL DIAGNOSIS AND PROGNOSIS OF CANCERS Objectives: Involves a retrospective study of approximately 300 patients at the Penrose Cancer Hospital to determine the results of 15 routine diagnostic procedures or observations. An aspect of this proposal involves con- tinuing education of the physician. A REGIONAL PEDIATRIC ONCOLOGY CENTER FOR RESEARCH AND TRAINING Objectives: Assist the Children's Hospital of Denver develop as a regional center for pediatric oncology. Involves application and evaluation of new approaches in the treatment of cancer, continued evaluation of currently supported research projects, correlation of data with other research centers, and a continuing education, training and fellowship program. COMPREHENSIVE CARDIAC CARE PROJECT Objectives: Project is to be administered by the Colorado Heart Association through an affiliation agreement with the Colorado-Wyoming RMP. The overall ob- jective of improving the delivery of health care to patients with cardiac disease is to be accomplished by a ste@ by step plan. #18 -- IMPROVED CARE OF THE PATIENT WITH ADVANCED CANCER Objectives: This proposal is sponsored by the American Medical Center, a non-profit eighty-five bed hospital which provides care to cancer patients from all over the United States. The purpose of the proposal is to establish a train- ing program for nurses in the care of the advanced cancer patient, and to cultivate in these nursing personnel the more hopeful and challenging aspects of oncological nursing. #19 -- CHRONIC DISEASE EVALUATION AND MANAGEMENT PATIENT CARE Objectives: This project, sponsored by the University of of Colorado School of Nursing, Continuing Education Services, is designed to train nurses and other health workers in long-term care and rehabilitation of patients with chronic conditions such as diabetes, orthopedic and neurologic problems, cancer, cardiac disease and other Tannitavem Tlinannan COLORADO-WYOMING RMP = - ‘RM 40-03 (AR-1-cDS) 2/71 | mt SUMMARY OF OPERATIONAL PROJECTS CURRENTLY BEING SUPPORTED BY COLORADO-WYOMING RMP _- Future Years of Funded (d.c.) Project Title and Number Commit. Support 1/1/70-12/31/70 Core . 1j $489,451 Sub-Contract (Pueblo) 7 : 39,576 Total Core $529,027 #2 - State Cancer Registry a oa $ 50,340: #3 + Multi-Media Education 1 34,739 #4 - Home Dialysis Training Program 1 39,719 #6 - Training and Applied Research 1 , 120,738 for Intensive and Rehabilita- tive Respiratory Care #7 - Radiation Therapy and Nuclear 1 58,279 Medicine Technology Training #8 - Interagency Council on Smoking 1 25,294 _ and Health #9 - Continuing Education Core Pro- 1 70,912 gram for Nurses #10 - Continuing Education Staff - 1 90,687 #13 - Pediatric Pulmonary Center 0 , 75,956 #14 - Statistical Diagnosis and 1 13,317 Prognosis of Cancers _ #15 - Pediatric Oncology Center 1 73,727 #16 - Comprehensive Cardiac Care | Oo * 42,798 ‘#18 - Improved Care for th’ Patient 2 15,:700 with Advanced Cancer #19 - Chronic Disease Evaluation 2 41,582 and Management of Patient Care + . aT TOTAL $1,282,815 t wate “4 COLORADO -WXOHING RMP : = 2G0— Lf RM.40 = 03 (CAR-Leeps) 7776 -- STATUS OF UNFUNDED PROJECTS Project Title & Number Approved Project Status Period ; #5 - Multiphasic Screening 0 7 ‘ Not Approved ‘ .! oe for Funding . #11 - Facilitation of Learning Oo. Not Approved ‘ , for Funding #12 - Continuing Education Workshop 0 Not Approved for Funding -#17 - A Training Program for the ~ 2 Approved but Development of Ultrasonic Unfunded Techniques in Community Hospitals #20 ~ Daily Update of Laboratory 0 Not Approved Reports: for Funding #13R - Diagnosis and Treatment of 0 . Returned for _ Pediatric Pulmonary Problems . Revision #21 - Radiation Therapy Planning in 3 Approved but Community Hospital by Time- Unfunded Sharing Computer | SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE COLORADO /WYOMING » REGIONAL MEDICAL PROGRAM ‘ _RM 40- 03 (AR-1- CDS) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: No additional funds be provided for this application. Year : Request Recommended Funding Ist Year $508,843 -0- . 2nd. Year $204,922 ~0- 3rd Year $218,732 -0- Total $932,497 -0- Critique: Committee concurred with the site visit report which concluded - that this Region has not obtained the degree of sophistication “which might be expected after two years of planning and two years “of ‘operational status. At this point in time, it still remains project - oriented and little thought has been given to the expanded responsibilities -of the RAG in setting specific goals, objectives, and-priorities “which would represent a total program. Along the same lines, there is little evidence that the numerous data ‘resources within the Region are being used for the assessment of needs. Also the Region has not taken it upon itself to lead the way in stimulating projects related to a specific program, but rather has tended to serve more as a broker for projects spontaneously generated by. various health organizations. Based upon these observations. Committee agreed additional support for projects and the developmental component were not justified at this time, but that the Region should take its upcoming 03-year of operation to put its house in order for its Triennium Application. It was noted that this will be a critical year for CWRMP and hard decisions will have to - be made in order to turn from being project oriented, te which ‘it - 4s ‘somewhat locked, to being program oriented. Committee concluded as did the site visitors that talented resources exist within both “the RAG and Core staff to make the desired transformation, but it _.was.-agreed expansion of funding should be: reserved until.such transformation is demonstrated. Although Committee was aware of the fact that the site visit team had spent considerable time discussing its observations with the -yegional personnel, it emphasized the need for both written and “oral feedback by RMPS staff. While it was agreed the site visit report should not be made available to the Region, it was felt the written feedback should carry the same basic message and tone,- including Committee and Councii's input, and should be interpreted and: complemented by the verbal message. w@ ~ Colorado/Wyoming RMP -2- RM 00040 2/72 Two projects (#23 & 24) were given minor consideration in that » each were pick-ups of other federal grants which are terminating. “The site visitors believed RMPS support of these projects was inappropriate in view of the National Advisory Council's recent ~ policy re-affirming "Regional Medical Programs funds are not to . replace grants lost through discontinuance or reduction of other grant programs." Committee felt the site visitors were being too strict in their interpretation and pointed out that such pick-ups are appropriate so long as they: " (a) respond to a recognized need for local. regionalization and improvement; and (b) demonstrate that they are integrating into the Region's health care system in a way that will permit disengagement of Regional Medical Program funding within a short time." + . “Dr. Kralewski was not present during Committee discussion or action on the application. GRB/RMPS 1/13/71. 4 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) CONNECTICUT REGIONAL MEDICAL RM 00008 2/71.1 (CS) PROGRAM January 1971 Review Committee 272 George Street New Haven, Connecticut 06510 Program Coordinator: Henry Tf. Clark, Jr., M.D. REQUEST (Direct Costs) 03 Year (1/71-12/71) COMMITTEE/COUNCIL REVIEW: Renewal for CUPISS $60,496 New Project ~ Newborn Program 26,270 TOTAL REQUEST 86,766 RMPS STAFF REVIEW: Continuation Request Commitment for Core 381,000 Commitment for ongoing activities 939,750 Carryover 133, 860 TOTAL CONTINUATION REQUEST 1,454,610 Action on Continuation Request Approval of total commitment 1,320,750 Disapproval of carryover request -0- TOTAL 03 YEAR AWARD $1,320,750 FUNDING HISTORY (Planning Stage) Grant Year Period Funded (d.c.o.) 01 7/66-6/67 $344,796 02 7/67-12/68 $313,000 (18 months) CONNECTICUT RMP -2- RM 00008 2/71.1 a Operational Program Council Funded Future Grant Year Period Approved (d.c.o.) Commitment 01 1/69-12/69 $1,633,978 $1,320,750 ------- 02 - 1/70-12/70 $2,372,333. $1,650,9371/ ------- 03 1/71-12/71 $2,693,5832/ $1,320,750 9 --=---- 04 1/72-12/72 137,9652 None 05 1/73-12/73 145,4472/ None 1/ Includes carryover funding of $330,187 2/ Includes recommendation of November 70 Council HISTORY: The Connecticut Regional Medical Program began its two-year planning phase in July 1966. Transition to operational status was a lengthy process requiring multiple Committee/Council reviews and two site visits. The major areas of concern revolved around: (1) The Region's emphasis on a comprehensive approach with almost complete absence of categorical considerations, (2) Cooperative arrangements with, and support for the program of, groups upon which implementation would depend, specifically the practicing physicians ( as represented by the Connecticut State Medical Society). The reviewing bodies, after considerable deliberation, accepted CRMP's Grand Design, with its intermingling of RMP and CHP activities. Further, although CRMP's differences with the Connecticut State Medical Society were not resolved, it appeared that progress was being made toward resolution and that the rest of the Region was solidly behind the Program. An 01 year operational award of $1,320,750 was made in January 1969, calculated on the basis of 100% funding for core and 75% funding of the Council-approved amounts for projects. Staff review of the 02 year continuation application and a subsequent request for the use of carryover resulted in an 02 year operational award of $1,650,937, representing the commitment of $1,320,750 for core and twelve projects and carryover funding of $330,187 for expansion of four ongoing projects and initiation of six others. Although these six activities did not receive Council review, staff felt that CRMP's original operational application spelled out the broad thrust of emphasis and that these activities were covered well by the umbrella of Connecticut's grand design. A proposal in the October/November 1970 review cycle, which requested supplemental funding for seven new activities, resulted in approval in the reduced amount of $183,348. This amount was calculated on the basis of the requested funding for two projects -- Planning Neighborhood Services in Hartford and Southern Connecticut Kidney Disease Program. Neither activity has been funded. CONNECTICUT RMP -3- RM 00008 2/71.1 Connecticut's 03 year continuation request recently was reviewed by staff. the proposal received a favorable review, and it was agreed that the Region had done a superb job of explaining the grand design itself and relating all activities to the overall program objectives. Although the continuation application requested the use of approximately $130,000 carryover (with the promise of future carryover requests totaling around $60,000) the recent RMPS policy prohibiting awards of carryover resulted in CRMP's receiving an award in the amount of the 03 year commitment only -- $1,320,750. It was suggested, however, that when procedures are developed for Regions to apply for new money on a competitive basis, a request for some additional funding for the University and Community- based faculty at the University of Connecticut would be looked upon favorably by staff. The funding history at the end of this summary sheet provides details cn the distribution of the Region's funding level of $1,320,750 among the various segments of the grand design. Connecticut Regional Medical Program will submit its first anniversary application on August 1, 1971 for review by October /November 1971 Com- mittee and Council. PROGRAM EMPHASIS: CRMP's grand design was spelled out in the original operational grant application and has remained con- stant. The program objectives focus on quality of care, provision of service, and economy of delivering health services. The Region has been divided into ten health service areas for grass roots programming and planning, and within this context the community hospital is viewed as the primary entry point for CRMP influence in each area. Five categories of program emphasis have been identified as necessary to reach the Region's objectives: 1. Research and Evalution -- primarily directed toward research on health conditions and practices. 2. Health Service Area Program Assistance -~ channeling research findings into planning at the local level 3. University-Community Hospital Partnerships -- revolving around the theory that each community hospital will require a small cadre of full-time professional staff to provide the necessary leadership in implementing planning results and in developing educational programs, to be aided in turn by a cadre of university-based faculty oriented toward the problems and needs of the community. 4. Clinical Services -- charting more effective statewide clinical services. 5. Health Profession Education -- stimulating and assisting health education activities which have statewide implications. CONNECTICUT RMP - 4 - RM 00008 2/71.1 PRESENT REQUEST: The portion of the 03-year application for which Committee/ Council review is required consists of a renewal request for one additional year's funding for CUPISS and a supplemental request for support for a regional newborn program. Project #1R - Connecticut Utilization Patient Information and Requested Statistical System (CUPISS). This renewal 03 Year request is for a third year of funding for CUPISS. The system $60,496 is described as a new approach to the collection and utilization of basic health data on a large population group which can be used to promote quality and efficiency of health services, to help measure the effectiveness of various therapeutic programs, and assist in planning new facilities and services. RMP provided partial funding for this program in 1969 and 1970 totaling $173,161, and the main thrust of acti- vities during those two years pertained to research and development concerning the provision of institutional services through utilization review reports, institutional performance indices, and operating statistics. Initially it was expected that these services would be operational in several hospitals by the end of 1970. However, the ambitiousness of the design and the difficulty of its initial implementation have slowed progress so that the full system has been installed in only three. hospitals, although installation has begun in 17 others. The third-year support requested in this application is for analysis of data which is accumulating through the expanding system. This analysis is expected to provide basic data with which to evaluate the overall performance of CRMP as well as to provide guides to agencies concerned with the future development of the health delivery system of Connecticut. Requested First Year Project #33 - Yale-New Haven Regional Newborn Special Care $26,270 Unit. The primary purpose of this proposal is the improvement of care of critically i11 new born infants in Connecticut, through the development of more effective cooperative arrangements between the Yale-New Haven Hospital and the general hospitals of the state. Specifically, funds are sought to develop a model ambulance service, to purchase additional monitoring equipment for the existing newborn special care unit, and to complete the equipment of a radiological suite so it can be used for the cardiovascular investigation of newborn infants suffering from congenital heart disease. This request originally was submitted in May 1970 for funding from carryover monies. Although the general idea was viewed favorably, the fact of the proposal's being heavily an equipment request prompted staff to act negatively on the carryover request and return the proposal to the Region with the suggestion that it be resubmitted for Committee/Council review. The proposed activities relate to the portion of CRMP's grand design pertaining to University-Community Hospital Partnerships, and it is hoped that this program will encourage greater collaborative planning CONNECTICUT RMP -5- RM 00008 2/71.1 between pediatric specialists at Yale and physicians in community hospitals. The request is for one year's funding only. FUNDING HISTORY 03 YEAR Project & Sponsoring Institution SUPPORT DATE (1/71-12/71) INITIATED RESEARCH AND EVALUATION #1 ~ Connecticut Utilization & Patient Renewal in 1/69 Information Statistical System - Review CUPISS (Yale) #13 - Inventory of Health Resources (Yale) $11,250 1/69 #17 - Financing of Health Care (Yale) 18,750 7/66 #19 - Research Program Planning (Yale & U. Conn.) 36,831 1/69 #20 ~ Regional Blood Bank (U. Conn.) 49,365 6/70 #2B - Research Program Activities (Yale) 39,966 6/70 HEALTH SERVICE AREA PROGRAM ASSISTANCE #2A - Health Service Area Planning (Yale) 24,850 1/69 #3 - Continuing Care Demonstration (Yale) 93,000 1/69 #21 - Stroke Coordinator Demonstration (Gaylord Hospital) 32,000 6/70 UNIVERSITY-COMMUNITY HOSPITAL PARTNERSHIPS #5 ~ Community-based Regional Faculty 157,500 1/69 #6 - University~based Regional Faculty 282,707 1/69 (Yale & U. Conn.) #23 - Gastroenterology (Yale & Others) 42,073 6/70 #24 - South Central Diabetic Consultation (Yale) 25,194 6/70 CLINICAL SERVICES #7 - Regional Coronary Care (Hospital of St. 32,172 1/69 Raphael) HEALTH PROFESSION EDUCATION #11 - Nursing and Allied Health (Yale & U.Conn.) 32,000 1/69 #12 - Regional Library Service (Yale & U. Conn.) 62,092 1/69 CONNECTICUT RMP -6- (Funding History Continued) CENTRAL CRMP STAFF #18 - Core Total PROJECTS NOT FUNDED BY THE REGION Patient Care Workshops Study of Physician Office Practice Patient Status Study Organization and Delivery of Medical Care PROJECTS WITHDRAWN FROM CONSIDERATION High Energy Radiation Services DISAPPROVED PROJECTS Regional Clinical Reference Laboratory RM 00008 = 2/71.1 381,000 7/66 $1,320,750 University of Connecticut School of Nursing, Regional Faculty Regional Reference Laboratory Regional Nuclear Medicine Program University of Connecticut Planning for School of Allied Health Professions APPROVED/UNFUNDED PROJECTS Planning Neighborhood Services in Hartford Southern Connecticut Kidney Disease Program RMPS /GRB 12/16/70 ao weet (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE ~ CONNECTICUT REGIONAL MEDICAL PROGRAM RM 00008 2/71.1 (CS) FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL ° RECOMMENDATION: Additional funds be provided for this. application. . Recommended Year Request Funding 03 . $86,766 $70,496 CRITIQUE: The reviewers noted that the Connecticut Regional Medical Program will submit its first Anniversary Review Application for October/November 1971 Review Committee and Council. With the . current submission, the CRMP is exercising its option to present an interim application. ‘This proposal discusses the relationship of the request to ongoing activities and the overall Regional plan. The Review Committee observed that Connecticut is one of the Regions which has had a "grand design" and specific Regional thrusts since the-beginning of its operational experience, and although it occupies a somewhat pioneering position among the RMPs on that count; it seems sometimes to fall short in its identification of. regional needs. Another issue which was discussed was the recent resolution of the Connecticut State Medical Society that the CRMP limit its activities to "disseminating scientific knowledge and improving patient care in the fields of. heart disease, cancer, stroke and related diseases through the medium of education, research and demonstration and that CRMP "is not authorized by statute to advocate policies and fund: programs which promote restructuring | of established patterns of providing and financing health care services." It was noted that Dr. Margulies reply to this condemnation was an eloquent one and stressed the fact that the Medical Society's criticisms were not. on: firm ground, not being based on the most recent: legislation. ‘However, the, Review Committee did agree that since this is the second time CRMP has had a public dispute with the medical society (the first being in 1968 during the first application for operational ‘status), the: RMP might have been derelict in not having exerted major efforts over the last 2% years toward healing the wounds. Connecticut RMP , ~2- . RM. 00008 ~ “Lack of communication between the two groups appeared to be a foremost cause. Although this issue had no particular bearing on the current application, the Review Committee suggested that it “be investigated at the anniversary site visit next fall. The overall recommendation for the current application was for approval at a reduced level. The basis on which the approved amount was calculated is- discussed below. . Project #1R ~- Connecticut Utilization Patient Information and Statistical, System (CUPISS). The reviewers thought that an additional year's support for CUPISS was a reasonable request since the project is one which is closely related to Regional goals and one which is absolutely necessary to provide -a data base upon which. CRMP can plan. The report of the CRMP - Review and Evaluation Committee, which was included in the application, was thought to point up problems and offer suggestions which the project personnel should heed: i.e., the emphasis upon dialogue _ with medical staffs, the need for better communication with ‘potential users, and convincing hospitals and physicians that the system is sufficiently worthwhile to support it. Parenthetically the’ . ‘difficulties the Region has had in gaining the active support of : hospitals caused the reviewers to question the success of the University - Community hospital thrust of the CRMP. | However, the need for this type of data by the Region and the potential offered by the project insured a recommendation that - the activity be funded for one additional year in the amount : requested. - "Project #33 - Yale-New Haven Regional Newborn Special Care Unit. The Review Committee considered the development of a model ambulance service to be legitimate activity for two reasons: : 1.° Demonstrating whether adequate transportation actually saves infants' lives. 2. Building bridges between Yale-New Haven and the: periphery. . However the purchase of additional monitoring and radiologic equipment was seen to be the responsibility of Yale. ‘Therefore, the reviewers thought the CRMP should seriously consider limiting its support to -, the approximately $10,000 necessary for the development of a model ambulance service. - Mr.; Thompson was not present during Committee discussion or action on the application. GRB /RMPS 1/15/70 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) Florida Regional Medical Program RM 00024 2/71.1 (C&S) 1 Davis Boulevard, Suite 309 January 1971 Review Committee Tampa, Florida 33606 Program Coordinator: Granville W. Larimore, M.D. Request (Direct Costs) Regional Year 03 04 05 For Committee/Council Action New Funding a Four New Projects $ 735,651 $753,968 $801 , 838 For Staff Action Continuation 1,540,808 Core (692,645) © 9 Ongoing Projects (848,163) TOTAL REQUEST $2,313,862 $753,968 $801,838 Funding History Planning Phase Period Award Committed 11/1/67 - 10/31/68 $245 ,600 11/1/68 - 2/28/70 778,744 16 months Operational Phase 3/1/69 - 2/28/70 $ 706,688 3/1/70 - 2/28/71 1,721,648 3/1/71 - 2/28/72 $1,535,568 Florida RMP Qe RM 00024 2/71.1 (CéS) Background on Region: The Florida Regional Medical Program. covers the State of Florida with 67 counties. In the core section of the application, an excellent summary is given with charts showing the difficulties that the State of Florida has with the wide variations. Four counties report less than half the United States average income of $3,421 a year. Twenty-two counties are above the | half mark but below the average income. Thirty-six counties are near the average and five are above-average. The unique characteristics of the population of Florida relate to the number of retired people and their location throughout the State, the large migrant work force, the large agricultural work force which has somewhat the same kinds of health problem as the migrant work force, displaced Cubans, urban centers with big ghetto areas, rural poor, an uneven distribution of medical resources both physicians and hospitals, the descalation of space employment, and the large influx of vacationers. History of Grant: The Region received its initial planning funds on November 1, 1967, after submitting three applications. Three areas were established, based at the University of Florida in Gainesville, Tampa, and the University of Miami in Miami. The North Florida area moved rapidly ahead in the development of projects, while the other two areas were experiencing staffing and organizational difficulties. Shortly after the Region received its planning funds, a hypertension screening project was initiated from earmarked funds. The present coordinator was appointed in the Fall of 1968, and charged with coordinating the three area programs. Council approved operational status for the Region in February 1969 and funding for nine operational projects. A program site visit was made in January 1970 and the team reported a number of problems seriously hampering the program — the function of the RAG in relation to the Board of Trustees, representation of the RAG, the need for effective working committees, the gecessionist moves on the part of North Florida and program imbalance among three FRMP areas. The March Council accepted the team's recommendations: to maintain Florida as a single program, to give priority funding for the central and southern areas of the state, and to advise the Region that the RAG should be strengthened and the review process improved. In the past year, a number of organizational changes have been effected. Ten district offices have been organized under the coordinator in Pensacola, Tallahassee, Jacksonville, Daytona Beach, Orlando, Tampa, West Palm Beach, Fort Myers, Miami-Broward and Miami-Monroe. The medical school staff have been relieved of area programing development responsibilities. Project monitoring has been strengthened. Florida RMP ~3- RM 00024 2/71.1 (C&S) PRESENT APPLICATION Regional Advisory Group Report: The Regional Advisory Group report includes a fairly extensive descrip- tion of the Region's plans, priorities, organization and hopes. The RAG feels that this year has seen the opportunity to build the program on an established base of part-time physicians, medical schools, hospital educational programs, junior colleges, and voluntary health organizations. The by-laws call for an executive committee but it is felt that ad hoc committees requiring varied groups of RAG members will keep the executive committee from impeding the RAG in developing its role as an effective decision-making body. A major organizational change resulted from the report of a Conference Committee on the responsibilities and relationships between the Board of Directors of the Florida Regional Medical Program, Inc., and the Regional Advisory Group. The statement agreed to by all parties is delineated in the RAG report. The reorganization of the core, the RAG feels, was a critical develop- ment this year; ten district offices have been set up to be staffed by part-time physicians, superseding the three areas centered in the medical schools. This will not only enable the RMP Core Staff to service all areas but will provide for functional participation of the medical schools without having to be responsible for area development. The RAG report indicates that this change which has been supported within their committed funds has created funding problems. The district offices will share offices with the CHP (b) agencies where possible, a move which is expected to enhance Comprehensive Health Planning interrelationships. On the state level, the RMP and the (a) agency have had one joint project, a statewide health insurance study; one member of the Florida RAG is Chief of the Florida State Bureau of Comprehensive Health Planning and the Director of the Florida Regional Medical Program is a member of the Florida Health Planning Advisory Council. The Ad Hoc Committee on Directions and Priorities - seven people from the RAG, representatives from the Department of Health, labor, nurse association, dean of allied health school, Florida Hospital Association, the Bureau of Comprehensive Health Planning, and a practicing physician - have outlined the following priorities: Continuing education on a interdisciplinary basis. Improvement in health care delivery. Identification of health manpower needs. . Development of cooperative relationships with other planning groups. .. Personal health education. Wm WwW bh ke Six categorical task forces and task forces on continuing health educa~ tion have outlined priorities in their respective areas as well as the planning that must go into meeting these priorities. Florida RMP -4- RM 00024 2/71.1 .(C&S) The Regional Advisory Group report relates the new projects contained in this application to the regional objectives and priorities. The Juntor College Model will strengthen inservice education’ and inter- ... change of students among cooperating hospitals. The Post-graduate Intensive Service Education for Physicians will. allow the. physicians to return for study at the University of Miami. The. Statewide Cervical Cytology Program will. build on a program. that. has been. supported by the State Health Department and the Statewide Renal .- Dialysis Program will build a transplant network. oe Core Progress Report: There are only six core staff members in the’ central office. The Task Forces hawe been a major problem in developing a program approach because of their categorical project interests and clinical orientation. . The categorical versus the disciplinary approach. has been .a problem.for the Task Forces. It is felt that better staffing for the :Task Forces will help them develop a program outlook. Project Development and Review: The Committee on Directions and ’ Priorities sets.the tone through the priority framework for the Regional Medical Program. .A Task Force reviews each proposal and calls on special consultants as needed, either to make site visits or to review. The Regional .Advisory Group Ad Hoc Project Review Committee then reviews the project; the. Board of Directors of FRMP, Inc., looks at it from the standpoint of fiscal soundness and the affiliation agreements needed, and finally the RAG looks at it. The two CHP (b) agencies in the state will be brought into the review process early in the project review process. Evaluation: The Core report on Evaluation cites several examples of how the Region is going about its evaluation. Site visits were set for early December on two projects, Multi-phasic . Screening and the Computerized EKG Processing Center, as. a result of Staff evaluation (the Region has not submitted a request for continuing funding of these projects until the site visit reports are available to the RAG). Apparently a very hard look is being given to the ongoing projects to see whether they are accomplishing their purposes. In the Coronary Care Unit Training, they found the use of vignettes from students was a useful type of evaluation, more meaningful than some of the pre and post training that had been originally planned. The Evaluation Section indicates that the RAG is utilizing evaluation studies as guides for allocating the funds available to the Florida Regional Medical Program. NEW PROJECTS Project #37 - Florida Community Junior College Extended Campus First Year Concept. This project under the direction of Request Philip A. Frederickson from St. Petersburg Junior College, has $36,358 Florida RMP -5- RM 00024 2/71.1 (C&S) been conceived to assist community hospitals and nursing homes to improve the quality and availability of their inservice educational programs. It proposes an extended campus concept which develops cooperation between health care institutions and a community junior college through association with the project staff located at the college. The project has two segments, only one of which will be funded in part through funds from the RMP. The improvement of inservice education, it is felt, will favorably effect health care by: 1) improving skills and increasing the know- ledge of individual health workers in the community health care institutions; and 2) making the employees’ tasks more interesting and personally more satisfying thus leading to greater staff stability. The objectives are: 1) to develop a guide that will outline the steps and changes in administrative policy and structure in the Junior College and community health agencies that are needed to bring about a flexible relationship that utilizes community manpower, mindpower, hardware, software more efficiently. The guide will include suggested policy and procedure revisions relating to such areas as enrollment, attendance requirements, educational credits, tuition and fees, lending and borrowing of educational equipment and materials, etc.; 2) to develop a system whereby inservice directors, community health agencies, and the community junior college faculty can combine their talents and efforts to more effectively teach health workers basic "for the job" skills and continuing "on the job" skills. This will include joint development of teaching materials and shared manpower, hardware and software; 3) to develop a pattern of continuing education whereby the - directors of inservice education in the community health agencies are able to assist health workers to meet their continuing education needs. This mechanism will also provide the junior college with feed- back regarding community needs in continuing education and establishing other resource agencies and personnel outside the immediate area. The first year's activities will be directed toward the hospitals in Pinellas County, Florida, each of which has a functioning inservice education activity. At the beginning of the second year, nursing homes in Pinellas County will be encouraged to participate in the program. The third year will be devoted to consolidating experience gained and relationships developed in order to expand the concept throughout the region. The State Department of Education (Division of Community Colleges and Division of Technical, Vocational and Adult Education) will be primarily responsible for the regionalization phase of the project. This project was approved by the Continuing Education Task Force, the Board of Directors, and the Regional Advisory Group. 02 Year ~ $53,803 03 Year - $56,710 Florida RMP -6- RM 00024 2/71.1 (C&S) Project #38 - Florida Statewide System for the Care of the First Year Patient with End Stage Kidney Disease ~ The Request purpose of this project is to establish a kidney transplant $240, 260 network in Florida. This cooperative effort will: 1) provide a training curriculum of high quality for dialysis and trans- plant personnel to maintain and enlarge a recipient pool; 2) maintain an automated matching program with full information about each patient and the results of each matching effort in each transplant; 3) develop and implement a rapid and reliable transportation system for movement of donor organs among the participating centers; and 4) standardize and sustain the quality | of tissue-typing throughout the system. ° Long-term hemodialysis is offered to chronic renal disease patients in Miami, Tampa, and Cainesville at the present time. in addition, Miami and Tampa provide home-dialysis teaching. Two smaller hemo- dialysis units are opening in the near future at Clearwater and Lakeland, both of which will relate to Tampa. At Jacksonville, a major population center in the State, efforts have been underway for a year to initiate dialysis service. In Pensacola there is some dialysis equipment which may be developed into a center. There are approximately 114 patients undergoing dialysis in Florida at the present time of which 75 or 65% are thought to be suitable transplant candidates. By combining these persons in one recipient pool, each time a donor is available, it is estimated that there is a 48% chance for a match with any available recipient as compared to respective chances of 37% at Miami, 22% in Tampa, 16% at Gainsville, if these centers operate separately. Under the auspices of this project, four transplant centers will operate in Tampa, Miami, Gainesville, and Jacksonville. Each will have a tissue-typing technician, trained in the same techniques who will test all recipients at regular intervals and all donors as they appear. The existing computer-based system will monitor the potential recipients. When a donor organ is to be sent to another center, the transportation will be arranged by the transplant coordinators from the locations involved. Every active major dialysis group in Florida is involved in this project. The geography of the State is covered completely except in the Pensacola area which will be joined in the second year as the physician manpower becomes trained and available. Every surgical team that has done a transplant in the State is involved also. To supervise each center at representative network meetings, there will be a physician who possesses the full authority of his local colleagues to reach decisions and actions. A large recipient pool can be maintained only with an efficient dialysis facility, and it will be necessary to train the nursing Florida RMP -7- RM 00024 2/71.1 (C&S) manpower. This project will teach at least 36 nurses and technicians per year at a projected total cost of about $25,000 annually or less than $700 per trainee. Training will take place in Miami with 24 students and in Tampa with 12 students. The project budget includes a small amount of money to assist in the establishment of dialysis activities in Jacksonville. The equipment will be donated by a local hospital and space will be provided by another insititution. , An essential part of an organ transplant program is public education activity to create a positive atmosphere toward donation immediately upon death. A study done by the Florida Regional Medical Program staff indicates that the majority of people questioned agreed that they would sign a legal document giving the physician permission to remove the kidney to be transplanted to another person in the event of sudden death. Different messages are planned for the older popula- tion, the younger population, hospital personnel, physicians, and funeral directors, The application states that a Board of National Consultants were asked to review this project who sent mail evaluations and conducted a site visit in Miami on October 9. The individuals involved in this review were not named. The Board of Directors of the Florida Regional Medical Program reviewed it from the standpoint of fiscal feasibility; an ad hoc RAG Review Committee looked at it from the standpoint of program priorities before the final RAG approval. 02 Year - $256,541 03 - $266,746 Project #39 - Florida Statewide Cervical Cytology Program - This First Year project to detect early cervical cancer among Request the young, indigent, and medically indigent females over the $271,533 age of 20 has as its objectives: 1) the detection and necessary follow-up of treatment of cervical cancer; 2) the demonstration to hospitals and physicians of the feasibility and benefits of screening large numbers of women, utilizing residents, interns, and paramedical personnel; and 3) improvement of communications between the local health departments and hospitais and between the Pathology Department, the Out~Patient Clinic and the Tumor Clinics of these facilities. Salaries for nurses and clerks in the County Health Department and the respective county hospitals as well as three cytotechno- logists, for Dade County are requested. The patients will be from high, densely populated centers in Jacksonville, Miami, Pensacola, Tallahassee, Tampa, and West Palm Beach. Florida RMP -8- RM 00024 2/71.1 (C&S) The project hopes to "plug" the gap between the present health department network and the hospitals. The health department program has been supported from cancer control and 314(e) funds since early 1960. 02 Year - $281, 061 03 Year - $290,794 Project #40 - Postgraduate Introductory Intensive Inservice First Year Education for Physicians in Miami - This project Request is designed to establish, investigate and determine the value $42,810 of short-course continuing education for private physicians, using preceptors techniques and student curriculum selection. It will utilize the personnel facilities of a major medical complex in South Florida, including the major medical school teaching hospital (Jackson), a Veterans Hospital (Miami), and two prestigious private hospitals (Cedars of Lebanon and Mt. Sinai). This diverse environment will offer a broad selection from which physicians may choose their ideal training circumstances, ranging from an academically oriented medical school to a private medical office. Subject matter will be equally comprehensive, extending from common practice problems to emerging complicated technology. Questions to be answered by the project are: 1. What type of physician is attracted to and takes advantage of this type of education? 2. What special features make itsusefulness popular (away from home , medical school center environment, preceptor teaching, personally selected curriculum, course length, etc.)? 3. Do persons seek this kind of training when they have participated in nodher types for several months or years? . 4. What effect on medical practice habits and attitudes is mediated by the training program? A special information program will be used to announce the continuing education opportunity ‘to Florida physicians. There will be no emphasis on speciality or geography so that an evaluation of total impact can be conducted. The Journal of the Florida Medical Association will be used along with announcements and descriptions placed in bulletins of the 40 constituent counties or multi-county medical societies. Personal mailing to each practitioner will be made also. Enrollment will be accepted on a first come, first served basis, but this practice may be altered subsequent to accumulation of experience in the first 12 months. It is expected that 50 persons will be trained in the first year. The limit to the number of people to be trained is preceptor availability and trainee interest. Florida RMP -9~ RM 00024 2/71.1 (C&S) There is no salary support or reimbursement for the preceptors, the faculty members, and physician teachers. The budget requests an amount of $250 for each trainee to be placed in a special fund for the use of the preceptors in furthering their training purposes. This money may be used to purchase audio-visual aides, special books and teaching material and similar materials which will strengthen the program and develop a foundation for sustaining the work in the future. The monies will be under the control of the coordinator at each of the cooperating institutions. No stipends or replacement reimbursement is requested for the physicians: per diem expenses of $25 a day are requested. 02 Year ~ $66,975 03 Year ~ $48,200 Project #41 - A Hospital Based Program for Cardiopulmonary First Year Resuscitation ~ This project is a revision of Request an earlier proposal which was reviewed by the July 1970 Advisory $144,690 Council. During earliex review, the one-day training period was questioned, the support after RMP support is terminated was questioned; information on the pilot study that led to this proposal was lacking, information regarding the coordination of personnel, utilization of consultants, teaching methods, selection of trainees, and follow-up was also lacking. Under the direction of the Chairman of the Florida Heart Association's CPR Committee, this program is designed to reduce premature mortality arising from cardiovascular and respiratory arrest. Kducational training and modern cardiopulmonary resuseitation techniques are the means of attaining this objective. ‘he community hospitals will serve as the base of the operation for development of hospital-oriented programs. ‘The objectives are as follows: l. To train and retrain key physicians and registered nurses who will assume responsibility for training other hospital personnel. 2. To encourage and assist hospitals in establishing emergency resuscitation measures. 3. To establish uniform standards of training of hospital personnel according to the recommendations of the National Research Council. 4. To provide training for the future instructors {n CPR at the community hospital level through a decentralized delivery system. Information is presented in this application relating to the specific concerns raised in previous Council review. The pilot study findings are delineated, the personnel and the functions of the various personnel are itemized, the type of consultants and their functions are listed, Florida RMP -10- RM 00024 2/71.1 (C&S) and the evaluation protocol is outlined. The course has been changed from a one-day course to three one-day visits to each hospital. The trainees will be hospital personnel with medical or nursing backgrounds since it is expected that only such individuals can establish and conduct CPR and re-training programs in the hospitals. These "teacher" trainees will receive the three visit CPR training, will be provided with guidelines for the development and content of CPR training programs, and will conduct CPR training under supervision. Each hospital will be requested to select trainees from the following personnel categories: . § 1. Nursing supervisors, head nurses, and assistant head nurses. 2 . Inservice directors. 3. Representatives from Inhalation Therapy Department and Anesthesiology Department. 4. Chief Residents especially on medical and surgical services. Others to be invited include the Chief Physician in the Emergency Room, all members of the Hospital's Cardiopulmonary Resuscitation Committee and members of Heart Association Cardiopulmonary Resuscitation Committees. No class should include more than 20 trainees. 02 Year - $95,588 03 Year — $98,288 RMPS/GRB 12/30/70 SUMMARY OF REVIEW AND CONCLUSION OF ‘January 1971 Review Committee _ FLORIDA REGIONAL MEDICAL PROGRAM. RM 00024 2/71 (C&S). FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL RECOMMENDATION: Committee recommended that this application which requests o " support for five supplemental projects be supported as. - follows: : YEAR. REQUEST RECOMMENDATION. 03 7 $735,651 $200,000 04 | 753,968 160,000 ob 801,838. 145,000 ‘TOTAL | 2,291,457 505,000 Critique: When the ‘site visitors reviewed the Florida RMP a year apo, they found a Region in serious trouble, An impasse was developing between the Regional Advisory Group and the grantee agency, which had usurped some of the RAG's authority and responsibility. The RAG's operation had been ‘hampered by the lack of an Executive Committee and other subcommittees, There was inadequate representation on the RAG of consumers, minority group members and professional individuals familiar with Florida's health needs, Relationships were strained with the North Florida Area Coordinator and the. Dean of the University of Florida at Gainesville, who fostered the formation of area’ cooperative arrangements rather than those to enhance the development of a statewide RMP, and spearheaded moves- for secession.of the North Florida area from FRMP, Some of the ongoing projects were running . inté. serious technical and organizational. problems, and new projects were of uneven quality. In addition, because of the ambitious efforts of the North Florida area-during the early part of the program, an imbalance in. the number, of projects and amount of money “invested among the threa- aneas chad developed, Comni tee noted that the present application addresses most of the above ‘concerns, .As.a.result of a Conference Committee, relationships and responsibilities between the RAG and the grantee agency have been delineated and agreed to by both parties. Goals and objectives, while general, have been set; An Executive Committee and various other subcommittees: have been formed, Membership on the RAG has been broadened, Core has been reorganized to take the responsibility for area development out of the control of the medical schools, At the same time, secessionist moves on the part of the University personnel in North Florida have receded, The RAG has arranged site visits to two of the ongoing projects and is presently te ted considering phasing them out, The Region is also submitting more statewide, as wert as Mid and South-Florida-sponsored projects. . ‘The projects in the present application received a nixed response from. the “uh FLORIDA RMP ye | RM 00024 2/71 (C.& S): reviewers, Committee found interesting and unusual, the concept. of ', getting junior college and community hospital and nutsing home representatives “together to plan inservice educational progranis; however, they were unable to determine exactly how this should be carried out. It was recommended that the Region invest some funds for further planning in this promising — activity. A decision on project #38, The Florida Statewide System for the o Care of Patients with End Stage Kidney Disease, was deferred until: it ‘could. locked at by a national group, although Committee believed it should be assigned a lower priority in relation to other projects. in this application, because of the various inadequacies discussed in the memo by. the. Kidney Diseas e Control Program. While the Statewide Cervical Cytology Peogram (#39). would reach migrant and other indigent women, reviewers expressed the hope that after ten years of funding by the PHS, other agencies would assume its support. Project #40, Posteraduate Introductory Intensive Inservice Education for Physicians in Hiami, was enthusiastically endersed by Committee, As well as involving physicians in the South Florida area, the project presents a unique way of budgeting the educational. expenses, Rather than providing salary support for the preceptors, faculty members | and-teachers, the budget requests $250 for each trainee be placed in a- special | fund for the use of preceptors in furthering their training purposes, i.e., books, audio visual aids or other special teaching material, With regard to the Hospitalebased Prozram for Cardiooulmonary Resuscitation, the reviewers questioned the extent of involvement of all the individuals listed, They noted, however, that several national leaders ‘in this field from Florida, who had not been involved in the earlier “proposal, are now listed as participants. They concluded that while the project is faixrly-well organized, it could be supported ata lower level than requested, . REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) Greater Delaware Valley RMP RM 00026 2/71.13 (CS) 551 West Lancaster Avenue January 1971 Review Committee Haverford, Pennsylvania Grantee Agency: University City Science Center Program Coordinator: George R. Clammer, M.D. Request (Direct Costs) 03 year 04 year 05 year 4/1/71 - 4/1/72 - 4/1/73 - Total Purpose 3/31/72 3/31/73 3/31/74 All Years Continuation Commitment* 2,109,357 2,109,357 Continuation Request 2,142,503 1/ 33,926 2,176,429 Core (1,603,620) (1,603,620) 6 Projects (538,883) (33,926- (572,809) one project) Additional Components 565,946 174,416 164,259 904,621 4 new Projects (270,591) (174,416) (164,259) (609,226) 3 previously approved activities (295,355) (295.355) Totals 2,708,449 208, 342 164,259 3,081,050 *Staff Action on Commitment 2,109,357 33,926 mmm 2,143,283 Committee Action Required 565,946 174,416 164,259 904 ,639 1/ Continuation Request $33,146 over Commitment. Funding History Planning Stage Grant Year Period Funded (d.c.o.) O1 4/1/67 - 11/30/68 $1,358,270 02 12/1/68 ~ 3/31/69 (4 mo.) 256,152 Greater Delaware Valley RMP -2- RM 00026 2/71.1 (CS) Operational Program Council Future Grant Year Period Approved Funded (d.c.o.) Commitment 01 $2,215,967 Core 1,628,336 1/ ------- Proj. 596,201 02 - 4/1/70 - 3/31/71 2,248,070 Core 1,628,336 = = = =*+---- s Proj. 815,150 2/ . ‘ 03 4/1/71 - 3/31/72 2,289,691 eone $2,109,357 04 4/1/72 - 3/31/73 33,926 (#13 only) ---- 33,926 1/ Includes $155,478 carryover funds from 02 planning grant year. 2/ Includes $317,387 carryover funds from 01 year. Geography: This Region covers eastern Pennsylvania, all of Delaware, and southern New Jersey. Discussions to explore issues of mutual concern are held with the six adjoining RMP's: New York Metropolitan, Albany, Susquehanna Valley, Maryland, Central New York and New Jersey. Demography: A. Population: 8.5 million (1965) 1. White 92% 2. Non-white 8% B. Facilities 5 Medical Schools (Philadelphia) 1 School of Osteopathy C. Physicians 12,214 (medical) D. Osteopaths 1,090 Program Priorities: 1. Improvement of health care delivery systems with special emphasis on the poor. , 2, The continuing education, primarily of physicians but with attention to nurses and other allied health personnel. 3. The development of program activities, primarily for heart disease, cancer, stroke, kidney and respiratory diseases. Greater Delaware Valley RMP -3- RM 00026- 2/71.1 (CS) Review Procedure: A revised review procedure has been developed and recommended by the Grants Review Committee of the RAG. If the recommendations are adopted, the Crants Review Committee of the RAG will be replaced by the Regional Review Committee which includes members of the RAG. The RAG itself will remain the final reviewing committee. Review will be initiated by three paralled review committees: 1) Administrative Review Committee, Staff members to include the Executive and the Deputy Executive Director, the Associate Director for projects and members of his staff will review proposals individually and subsequently will meet to prepare a report of recommendations. 2) Technical Review Committee. A fifteen-member technical review committee will be appointed. A member of the staff will be appointed Executive Secretary without vote. Recommendations for nomination will be made by the Executive Director and appointments (for one year) by the Board of Directors. The chairman will also be appointed for a one-year term by the Board of Directors. Meetings will be held at least once a year, more often according to the number of proposals to be considered. 3) Area-Wide Committee. Each area-wide committee will review proposals originating from its respective area whenever the activities of the project directly involve the area. A Regional Review Committee will be appointed to recommend approval or dis- approval to the RAG. The Committee will consist of a representative from the Board of Directors, who will act as Chairman, a representative from the Coordinating Committee, the Chairman of the Technical Review Committee, the Chairman or representative of the area-wide committees and a represen- tative from the RAG, and a member of the Executive Director's staff. In reviewing proposals the Committee will receive reports from the Administra- tive, Technical and Area-Wide Committees, The RAG will take final action on all proposals approved by the Regional Review Committee and may act on any disapprovals at its own discretion or upon appeal for reconsideration by the sponsor. Regional Advisory Group. The RAG has been expanded to 53 members with representation from 17 counties of the Region and is representative of the broad spectrum of health interests, resources, and socio-economic groups within the Region. The RAG meets four times a year. Four committees appointed by the Chairman (Evaluation, Membership, Nomina- ting and Grants Review) holdindividual meetings throughout the year. Board of Directors. The new 1970 Board of Directors has been expanded from 6 to 17 members (all members of the RAG) and includes: 6 representatives of medical schools, 5 representatives of health agencies and 6 representatives of subareas. The Board is designed to function as Greater Delaware Valley RMP ~4- RM 00026 2/71.1 (CS) the policymaking body of the GDVRMP. Standing Committees and Local Action Groups. 1, Health Care of the Poor 2. Continuing Education 3. Categorical Disease (Heart Disease, Cancer, Stroke, Respiratory Disease and Kidney Disease) 4. Coordinating Committee 5. Project Review includes the Technical Review and Regional Review Committees. 6. Committee on Planning Methods (staff), General Concerns of DRMP Staff regarding Greater Delaware Valley RMP During March 1970, staff reviewed the Region's second year operational continuation application for the year April 1, 1970 - March 31, 1971. The continuation of the operational projects evoked little concern and, in general, were recommended for approval at their committed level. However, staff had very serious concerns regarding the basic organization of the Region and the functions and activities of the large core staffs both in the Executive Director's office and in the medical schools. Staff recom- mended that a program site visit be made to the Region to explore the inter- relationships of the Core staff with the projects, as well as the degree of coordination among the various staffs of the Core components. The site visit was conducted on June 18, 1970, and was composed of the acting director of RMPS and senior staff members. The major concern of the site visitors regarding the GDVRMP was that the Region lacked a coordinated planning effort between the Medical Schools, subareas and the Central Core staff. How funds were budgeted and administered was viewed as a major problem. A reflection of the inadequacy of fiscal procedures was the large amount of unexpended funds accrued during the 01 year. The site visitors were in agreement that although the various activities reported on by the medical schools were perhaps well conceived and implemented, they were - neither coordinated nor related to any long-term planning effort by the Region. The site visitors believed that each school had developed its own plan and activities based upon the interest of the staff at each school. The Coordinating Committee, made up of the Chiefs of RMP units based at the Medical Schools, reportedly functioned as a central planning, coordinating, and advisory committee to the Region and specifically to the Executive Director. However, it was concluded that it was more of a liaison group than anything else. The site visitors questioned the role and the primary focus of the grantee, the University City Science Center. It was pointed out to the site visitors that the UCSC was a non-profit stock corporation (established in 1965) and consisted of 23 owners (institutions). Membership is made up of the medi- cal schools, colleges, and teaching hospitals in the Philadelphia area. Greater Delaware Valley RMP -~5 = RM 00026 2/71.1 (CS) It was indicated that the primary emphasis was in research and development but that they are beginning to get more involved in community service pro- grams. The overall impression of the site visit team regarding the GDVRMP was that it did not truly represent a regional program - a program that had assessed its resources and problems in a systematic fashion, developed a plan, established priorities, etc. The Medical Schools and especially the staffs of the RMP units have initiated many excellent activities, but most do not fit into a total plan for the GDVRMP. The Central Core staff, especially the area coordinators, are primarily concerned with servicing the various sub-regions. Expansion in the membership of both the Board of Directors and the Regional Advisory Group was viewed positively by the site visitors. It was felt that with the leadership of these two groups, the GDVRMP has the potential to build a regional program that will be visable and responsive to the problems of the Region. Currently, the Region has the following approved/unfunded projects: Com- munity Health Coordinator, Wilmington Medical Center; Regional Radiation Therapy Network; Development of Tumor Control Centers in Delaware Medical Society; Thera-Flicks Delaware Curative Workshops; and Coronary Care Train- ing Program, Underwood Memorial Hospital; Coronary Care Training for Nurses, Crozer-Chester Medical Center and Fitzgerald-Mercy Hospital. Listing of Current Funding Status of Core and Operational Projects in GDVRMP. Amount supported Project Number Title through 3/31/71 00 Core 1) Executive Director $753,890 2) Hahnemann 153,814 3) Jefferson 142,332 4) Philadelphia Osteopathic 106,860 5) University of Pennsylvania 164,363 6) Temple 113,297 7) Women's Medical 119,404 Subtotal (Core) $1,553,960 *1 Coronary Care Training Wilkes-Barre General Hospital $ 91,338 *2 Coronary Care Training Reading Hospital 81,804 3 General Intensive Care Courses 94,278 x4 Philadelphia Regional Chronic Pediatric Pulmonary Disease Program 242,447 Greater Delaware Valley RMP -6- RM 00026 2/71.1 (CS) Amount supported Project Number Title through 3/31/71 5 Retraining Program for Women Physicians, Women's College of | Pennsylvania 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 Six Cooperating Philadelphia Hospitals 37,150 13 Renal Disease Patient Support Program 48,470 14 Improving Patient Care in Hospitals Through Self-Evaluation 59,963 15 Development of Three-Dimensional Models for Cancer Detection 14,413 Total $2,443,486 (d.c.) Carryover included above: #1 $17,391 #2 20,964 th 98,103 $136,458 The Region plans to submit its Triennial Application during fiscal year 1972. Present Application This application contains requests for: 1) One year continuation for support of Core activities and the following on-going operational projects: Coronary Care Training - Wilkes-Barre; Coronary Care Training - Reading; Intensive Care Training; Chronic Pediatric Pulmonary Disease Program; Retraining Women Physicians; and Renal Disease Patient Support. Staff will act on the continuation request for Core and the above projects. 2) A request for funds for five previously approved activities funded from Core and carryover. , 3) Four new operational projects. Greater Delaware Valley RMP -7- RM 00026 2/71.1 (CS) On-Going Projects Project #6 - Coronary Care Training - Wilmington, Delaware 03 Requesting 4/1/71 - 8/31/72 Direct Costs $69,600 The purpose of this project is to train graduate nurses in all respects of coronary care so that they will be able to assume responsibilities in caring for coronary patients in intensive care units, coronary care units, or related medical facilities. To date four four-week courses have been con- ducted and a total of 32 nurses from the first two courses were trained, At the time this request was submitted, information relative to the numbers of trainees completing the last two courses was not available. Project #8 - Respiration Care Centers, Wilkes-Barre General Hospital, Wilkes-Barré, Pennsylvania 03 Requesting 4/1/71 - 3/31/72 Direct Costs $71,179 The purposes of this project are: (1) to provide excellent acute respira- tory intensive care at the three participating institutions (Wilkes-Barre General, Hahnemann and Allentown Hospitals); and (2) to train physicians, nurses and inhalation therapists capable of providing good respiratory care by giving training programs in different areas of the Region four times a year. During the year from April 1, 1971 through March 31, 1972, four formal workshops in respiratory intensive care will be held. One will be given in both Allentown and Wilkes-Barre and two in Philadelphia. Each course will train a minimum of 15 physicians, nurses and inhalation therapists, The course will offer both formal lectures and bedside participation in the care of critically ill patients and each course will last two weeks. In addition, each hospital will use their respiratory care facilities as part of their in-service training programs. In May 1970, a 12-bed intermediate respiratory care unit was opened in Wilkes-Barre General Hospital. The unit is intended to provide skilled medical and nursing care to patients with severe respiratory disease who are recovering from an episode of respiratory failure. Also, in May 1970, a five-bed respiratory intensive care unit was opened at Hahnemann Hospital to treat patients who are acutely ill with pulmonary insufficiency. The unit has served as a training facility for medical students, interns, nurses and residents and to date, 39 medical students have completed a training program in respiratory care. In an attempt to increase the Greater Delaware Valley RMP -8- RM 0002€ 2/71.1 (cS) number of medical personnel who are trained in respiratory care, a two-week workshop has been developed. The first workshop was given at Allentown Hospital during March 1970, Five physicians, three nurses and one inhala- tion therapist were trained. The second workshop held at Hahnemann Hospital during July 1970 trained 17 students. Included were 8 physicians, four nurses and five inhalation therapists. Three additional workshops have been scheduled and to date 15 students have already been accepted. Project #10 - School of Radiotherapeutic Technology at Six Cooperating Hospitals 03 Requesting 4/1/71 - 3/31/72 Direct Costs $37,150 The objective of this project is to develop, through quality instruction, a technologist who will be fully capable of assisting the therapeutic radiologist in the examination, treatment and follow-up of the cancer patient, The training program involves the University of Pennsylvania Hospital, Hahnemann Medical College and Hospital, Jefferson Medical College and Hospital, Temple University Hospital, Mesericordia Hospital and the American Oncologic Hospital. It has been the intent of the program to train no less than 12 technolo- gists each year, however, due to recruiting problems, only about 50% of this quota has been reached. In June 1970, five students completed the prescribed twelve months training course and have passed the National Registry Examination. All are currently employed in Cancer Treatment Centers. Six students are currently in training. The applicant states that, at the present time, they are unable to identify any agency from which future funding might be secured. Project #14 - Improving Patient Care in Hospitals Through Self-Evaluation - Chestnut Hill Hospital, Philadelphia, Pennsylvania 03 Requesting 4/1/71 - 3/31/72 Direct Costs $84,846 The overall purpose of this project is to develop a self-evaluation approach for continuing education in six of nine hospitals to improve patient care based on a process of quality of medical care review. The project is proposed in three phases. Phase I would involve a two-day seminar to be held for the representatives from community hospitals -- a member of the board of trustees, at least two of the medical staff leaders, a member of the administrative staff, and a physician designated by the Greater Delaware Valley RMP -9- RM 00026 2/71.1 (cS) hospital as the person responsible for the educational programs of its attending staff. The purpose of the meeting would be to get a commitment from the hospitals that measurement of patient care in their hospitals is essential, Each hospital wanting to continue in this program has to agree to give to two of its physicians a mandate to evaluate patient care in the hospital. In return for the commitment, the GDVRMP will share equally with each hospital costs for the personnel needed for patient care evalua- tion and for the educational programs designed to meet the verified patient care needs. Phase II will determine needs. Through a series of meetings, each hospital will select a system of data retrieval, probably PAS-MAP, since most of the hospitals now have this service. Once this decision has been made, six months will be allotted for the self-selection of criteria and the collection of data and at least three high priorities of patient care needs, Phase III will be the educational program and evaluation. The educational coordinators at the hospital (the two physicians who have the mandate to establish the evaluation of medical care in that hospital) will construct the medical education programs designed to meet at least two of the three needs. Joint meetings among the hospitals will be held, and consultation will be available for this phase. Evaluation will be dependent upon the data or lack thereof supplied by each participating hospital. If improvement of patient care is documented, the activity would be considered a success in that hospital. If it is not documented, the proposal is considered to have failed in that hospital. The final evalua- tion of the success of the program would be the decision of the hospital board of trustees to assume full cost of the program after two years. Project #15 - Development of Three Dimensional Models for Cancer Detection Training, Temple University Health Sciences Center 03 Requesting 4/1/71 - 3/31/72 Direct Costs $32,580 The overall purposes of this proposal are: (1) to develop three-dimensional models which closely simulate the normal human rectum, female pelvis and female breast, in respect to sight and touch; (2) to develop methods by which simulated pathologic "lesions" can be incorporated into the models (breast lumps, rectal and pelvic masses, and so forth); (3) to develop models which could be produced commercially and sold at low cost; (4) to field test each model to determine its reliability and validity as an evaluation tool of physical examination skills important in cancer detec- tion programs; (5) to test the effectiveness of the models as learning devices for the development of physical examination skills; (6) to deter- mine the feasibility of acting as the clearinghouse for the GDVRMP in disseminating information about three-dimensional models useful in training physicians in allied health personnel. Greater Delaware Valley RMP - 10 - RM 00026 2/71.1 (CS) New Projects Project #25 - Greater Delaware Valley Regional Dialysis Training Project ’ Crozer-Chester Medical Center 03 04 05 Requesting 4/1/71-3/31/72 4/1/72-3/31/73 4/1/73-3/31/74 All Years Direct Costs $66,487 $49,612 $53,568 $169,667 The thrust of this proposal is to provide effective training in home dialysis to physicians, registered nurses, licensed practical nurses, technicians and social workers in the Region. The physician course will be limited to a maximum of four physicians and will be scheduled in a flexible but structured manner each requiring a period of three consecutive days. The courses are designed for physicians having had little or no first hand experience with a hemodialysis program. The Nurse course will be six weeks in duration and will be repeated four times yearly. Each course will be restricted to a maximum of eight students. Candidates will be referred from interested and cooperating hospitals. Candidates for the Dialysis Technician Training course must be referred from interested and cooperating hospitals and will be restricted to a maxi- mum of four students. The classes will be simultaneously with the classes for nurses. A one-week course given to provide overall orientation to hemodialysis will be held for community nurses. Each course will be restricted to a maximum of four students. The five-day orientation period will include three days in the training center and two days of field trips visiting dialysis patients in their home. The long range plan for this training program would be that it becomes self- supporting, relying upon tuition and contributed services. Project #26 - Demonstration and Evaluation of a Dialysis Training Program, Thomas Jefferson University 03 04 05 Requesting 4/1/71-3/31/72 4/1/72-3/31/73 4/1/73-3/31/74 All Years Direct Costs $75,725 $63,271 $65,657 $204,653 The goals of this proposal are three-fold in that training programs are to be directed toward additional nurses and dialysis technicians for staffing intermediate care facilities, training patients and families of patients in hemodialysis care, and continuing education of nurses and physicians specializing in care and treatment of kidney diseases. Greater Delaware Valley RMP -ll- RM 00026 2/71.1 (CS) One of the objectives is to provide training of personnel to staff inter- mediate care centers to provide dialysis care for patients who do not have facilities or capabilities for home care and who do not need hospital care. It is proposed to train about 27 nurses, technicians and assistants each year. Evaluation of the project is expected to be developed on the basis of production of qualified technicians and assistants, as well as a better understanding of the needs of kidney disease patients by nurses and physi- cians, The proposed plan carries the endorsement of highly qualified specialists in several hospitals in the Region who have indicated a desire to partici- pate in the training program. Project #27 - Director of Medical Education for Downstate Delaware Hospital - Milford Memorial Hospital, Inc., Milford, Delaware 03 04 05 Requesting 4/1/71-3/31/72 4/1/72-3/31/73 4/1/73-3/31/74 All Years Direct Costs $56,175 $37,693 $20,058 $113,926 This is a proposal to provide coordinated continuing medical education for physicians, nurses, technicians and other paramedical personnel in two lower counties of Delaware. The plan calls for employing a Director of Medical Education to coordinate the medical education efforts between three hospitals (Milford, Beehe, and Kent General) in the area serving a population of about 175,000 people. The three hospitals have a combined bed capacity of 446 and a total of 90 medical physicians and osteopaths. The primary responsibility of the Director of Medical Education will be for continuing education of staff physicians. He will be responsible for the following activities: 1) Evaluation of educational needs 2) Organization of educational activities 3) Organization of inter-hospital educational activities 4) Organization and implementation of continuing medical education activities for health professionals other than M.D.'s 5) Evaluation of educational programs and activities. The Director of Medical Education will also utilize part of his time to become familiar with educational programs and concepts being developed or utilized within the GDV Region and in other parts of the country. Evalua- tion of the program will be along several lines: (1) the number of educa- tional activities implemented in comparison to preceding activities, (2) the willingness of the hospitals to continue to support the coordinator or director of medical education on their own and the extent to which educational needs are defined and programs to fulfill these needs are implemented. Greater Delaware Valley RMP_ - 12 - RM 00026 2/71.1 (CS) It is proposed that, the cooperating hospitals will assume full financing — after three years, if the position proves to be of value to the hospitals. Project #28 - First Care Cardiopulmonary Resuscitation Training Program Delaware Fire School, Dover, Delaware ; } 03 04 — 05 Requesting 4/1/71-3/31/72 4/1/72-3/31/73 4/1/73-3/31/74 All Years : Direct Costs $72,204 $23, 840 $24,976 $121,020 The goal of this proposed project is to provide training on a statewide basis for persons who are likely to be confronted with such situations in methods of emergency care for victims of heart attacks and/or stroke. Training in cardiopulmonary resuscitation techniques would be provided for specially trained lay personnel, paramedical personnel and medical per- sonnel. The training programs will be specially designed to fit the needs of the various groups and the capabilities of the individuals taking the training. The program evaluation is to be developed on the basis of written examina- tions at the close of each training session. A substantial part of the first-year request is for equipment, particularly a Mobile Coronary Care Training unit to be used in the training program covering all trainees in all areas of the state. $49,500 of the total $72,204 request is for equipment. _ GRB/RMPS’ 12/17/70 (A Privileged Communicatien) SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE GREATER DELAWARE VALLEY REGIONAL MEDICAL PROGRAM RM 00026 (S) 2/71.1 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: The Committee recommends that this application which requests three*year support for four new projects be partially supported as follows: YEAR REQUEST RECOMMENDED FUNDING _ Ist Year $270,591 $50,000 I/ 2/ 2nd Year 174,416 -0- 3rd Year 164,259 -Q- TOTAL $609,266 $50,000 1/ Support of Project #28 - First Care Cardiopulmonary Resuscitation Trainics Program, Delaware Fire School, Dover, Delaware may be precluded by BMPS policy which limits support to training activities which are directed principally to medical and allied health personnel who are employed in hospitals and in other in-patient facilities, or in out- petient or emergency facilities operated by or directly related to institution in which follow-up care is immediately available, 2/ Projects #25 - Greater Delaware Valley Regional Dialysis Training Project and Project #26 ~ Demonstration and Evaluation of a Dialysis Tred ing Program, Thomas Jefferson University are to be further considered by a special Renal Committee which is to be convened before the February 1971 Council meeting. Background: The Committee was aware that staff on January 4, 1971 had reviewed the continuation component of this application. The request was for $2,142,503 for the (03) year continuation of Core activities and six projects and a supplemental request: for support of five approved but unfunded projects ($295,355 d.c.) which have been supported out of carryover funds or through rebudgeting of core funds. Staff recommended to the Acting Director, RMPS approval of continued funding at the (03) year committed level of $2, 109,357 rather than the requested $2,437,858, It was agreed that the five projects which have been previously supported out of carryover funds or through rebudgeting could be supported within the committed level of support. (The Acting Director has not taken action on this recommendation.) Therefore, the Review Committee was primarily interested in how the four new proposals were to interdigitate with the Region's total program. Greater Delaware Valley RMP -2- . RM 00026 (S) 2/71.1 Critique: This Region has many built-in strengths and much, as yet, untapped potential, Their objectives are extremely broad so that "almost -- anything will fit into them." On this basis, the RAG obviously has difficulty . in project selection and approval in relation to the Region's goals and objectives. . The Region has large core components supported in both the Executive Director's office and five of the six medical schools (approximately 1.6 million per year). In spite of this, the regional input for most of the projects igs not clear. This was made evident in this application for the support of two, almost identical, dialysis training projects. Project #25 - Regional Dialysis Training Project - Crozer-Chester Medical Center and Project #26 - Demonstration and Evaluation of a Dialysis Training Program, Thomas Jefferson University were reviewed simultaneously.. While both “these proposals wére referred and are schéduled to be reviewed by a special ‘Renal Committee, the Review Committee recommended that they be returned to the Region so.that they may consolidate the proposals and more important, describe how this type of activity will fit into the Region’ s plans for renal disease. The Review Committee did-not discuss Project #28 - First Core: Cardiopulmonary Resuscitation ‘Training Program in any depth. . In addition to a possible conflict: with RMPS policy, this was considered an equipment proposal ($50,000 of lst year budget of $72,000 is for Van). The needs were not documented and the proposal failed to describe how this type of program would fit the Region's priorities. Once-again the Committee questioned hew this type of proposal gets through the local review process. The Committee believed that this program, #27 - D,M,E, For Downstate Delaware Hospitals: 1) related to the broad goals and objectives of the region: and 2), would initiate an important continuation education activity” in a semi-rural area far removed from the medical school. The Committee believed that. the RMP should consider providing the "seed" money to initiate = the program, since it has good potential for continued support from local sources. ‘ : RMPS /GRB 1/18/71 | REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICAT ION (A Privileged Communication) HAWAII REGIONAL MEDICAL PROGRAM RM 01-03 (AR-1-SD) 2/71 Harkness Pavilion January 1971 Review Committee 1301 Punchbowl Street Honolulu, Hawaii 96813 PROGRAM COORDINATOR: Masato Hasegawa, M.D. REQUEST (Direct Cost Only) REGIONS OPERATIONAL YEAR 03 04 05 Total (Anniversary Review Package Due _ on May 1971) I. ,Developmental Component 92,314 92,314 11, Fg¥S-New Projects 412.647 381,675 __ 385,220 _ 1,179,542. Total 504,961 381,675 385,220: 1,271,856 RMPS Staff Review of Non-Competing 03 Year Operational Continuation Grant Application on 8/70 , Awarded Commitment Commitment REGIONS OPERATIONAL YEAR 03 Year 04 Year __.05_ Year. I. Core . 382,781 -0- -0- Il. Eight Ongoing Projects 563,758 149 ,909 96 ,647 Total 946,539 149,909 96 647 FUNDING HISTORY (Direct Cost Only) GRANT YEAR PLANNING STAGE Period Funded 01 7/1/66-6/30/67 . 108 ,006 02 7/1/67-6/30/68 122,297 OPERATIONAL STAGE Ol 9/1/68-8/31/69 Cere- 362,872 Projects- 475,031 Total- 837,903 OPERATIONAL STAGE (continued) Period Funded 01 5/1/69 - 8/31/69 . Pacific Basin Planning 30,000 02 10/1/69 - 9/30/70 Core 336,101 Projects- 471,503. Pacific Basin- 17,082 Total 824,686 02 6/1/70 - 9/30/70 Projects 90,000 03 10/1/70 ~ 9/30/71 Core 365,511 Projects 563,758 Pacific Basin~ 17,270 Total 946,539 Georgraphy and Demography: The Regional Medical Program of Hawaii (RMPH) is responsible not only for the Hawaiian Islands, but also for the Pacific Basin--Trust Territories (Micronisia), Guam, American Samoa, The State of Hawaii includes a long chain of islands almost exactly in the middle of the Pacific. It stretches from the Island of Hawaii to tiny Kure Island, approximately 1,500 miles to the northwest. The populated part of the state includes the seven major islands: Hawaii, Maui, Molokai, Lanai, Oahu, Kauai, and Niihau. These seven major islands are relatively close to each other. Hilo, Hawaii, is about 200 miles from Honolulu. Both Kahului, Maui and Sihue, Kavai aré approximately 100 miles from Honolulu airport. The Molokai Airport is about 54 miles from Honolulu. Lanai and Molokai are only eight miles apart at their closest point. Honolulu, the state capitol and largest city of Hawaii, is located on Oahu, as is Waikiki, the major tourist destination area. The resident population of Hawaii, according to the preliminary 1970 census count, is 748,182 persons, including 41,362 military personnel. The population has increased 18 percent since 1960 and is expected to reach more than one million by 1980, In addition to the resident population, Hawaii has approximately 1.4 million visitors each year. This number is expected to double by 1975. Medical needs of these visitors have a distinct bearing on medical planning for the state. Ethnically, the population of the Hawaiian Islands is 67 percent oriental and/or Polynesian, 32 percent Caucasian and 5 percent Negro. The median age is 24.3. The economy of Hawaii has expanded tremendously in the past two decades and is based on four major industries: sugar, pineapple, military expenditures and tourism. © Hawaii RMP -3- RM 01-03 (AR-1-SD) 2/71 In addition to the University of Hawaii which has approximately 20,000 students in undergraduate and graduate programs, there. are five small private colleges and five two-year public community colleges within the state. There are thirty-three hospitals in the State of Hawaii. Nineteen of these are accredited by the American Hospital Association and eight have approved training programs for interns and residents. The University of Hawaii's College of Health Sciences includes a two-year School of Medicine, a School of Nursing, School of Public Health, and School of Social Work. The community college system provides training for licensed practical nurses and other allied health workers. The Trust Territories include 2,100 islands (700 square miles of land) spread over 3,000,000 square miles of Pacific Ocean~an expanse greater than the territory of the continental United States, Guam is a single island (209 square miles) 3,300 miles southwest of Honolulu. American Samoa includes seven islands (76 square miles), 2,300 miles south-south~- west of Honolulu. There are 92,000 Micronesians in the Trust Territory, 76,500 mixed Chamorro in Guam and 26,000 Polynesians in American Samoa, History of Regional Development: The Region submitted its initial planning application in September 1966 (the first application received from any region) for establishment of a RMP consisting of Hawaii, Trust Territories, Guam, and American Samoa. In June 1966, the Region received its 01 year planning award at a funding level of $90,005 d.c. Very little progress was made in the first year. the Coordinator, Dean Cutting, has been unable to spend much time on RMP and the Deputy Coordinator, Dr. Graham, has apparently not stimulated either planning efforts or community involvement. Only $20,000 of the $90,000 award was spent. Concern was expressed that RMP was conceived mainly as a means of supporting the new medical school. In June 1967, Hawaii was awarded its 02 year planning award at a level of $91,978 d.c. In July 1967, a staff visit was made to Hawaii (Dr. Sloan, Dr. O'Bryan, Mr. Anderson). Staff was impressed with the enthusiastic and strong leadership of the RAG, The medical school did not appear to dominate the RMP; as a result, the physician community appeared to be warming up to the program. It was decided that the RMP offices would be moved out of the Leahi Hospital (next to the Dean's office) and into a "neutral" building at the Queens Medical Center. It became clear that a new program coordinator would be chosen. In April 1968, Dr. Masato Hasegawa was appointed Program Coordinator, Dr. Hasegawa, a pediatrician, was a prominent member of the medical community, with great interest in "community medicine." In October 1968, the Grantee changed from the University of Hawaii to the Research Corporation of the University of Hawail. nawatiL Wir ~iUS ANA OR Ur ee Ly a a The RMPH submitted its first operational application consisting of continuing core support and 10 project proposals in September 1, 1968. The major thrust of this application was in continuing education using Region Wide (liawaiian Islands only) resources, in the absence of a fully-developed medical school. The application also stated that RMPH goals included development of “advanced health systems" which would improve the delivery of health care, . ; A site visit was conducted to the Region in September 1968 (Drs. Millikan and Slater, Mr. Lewis and Mr. Jones). The site visitors were very impressed with the leadership of Dr. Hasegawa. In the few months he had been with RMPH, Dr. Hasegawa had clearly begun to involve diverse elements, over-~- come earlier hostility, and develop a separate identity for RMPH. Also, the visitors were profoundly impressed with Mr. Wilson Cannon, Chairman of the RAG, and with the vigor of the RAG as a whole. The visitors believed that the Core staff was developing well. In April 1969, this RMP received a $30,000 award for planning activities in the Pacific Basin-Trust Territories, Guam, Samoa. In making this award, Council sharply reduced the $100,000 requested out of concern that RMPH might “spread itself too thin" and not concentrate its efforts sufficiently on building RMPH in Hawail. During 1969, the Core staff expanded beyond the approved total level, and this posed a problem for the Region in terms of continuing support. The fiscal elements of the continuation application were particularly confusing, despite repreated inquiries to the Region. Finally, the Division asked the Regiun's fiscal officer to meet with Division staff in Bethesda, where the difficulties were ironed out. In January 1970, a site visit was conducted to the Region (Dr. Millikan, Dr.. Besson, Dr. Zippen, Dr. Komaroff, Mr. Morales). The visitors were encouraged by the increasing involvement of the Medical Society, hospitals, and paramedical personnel; Core staff had grown stronger; the RAG had become more broadly representatives; and planning. activities in the Pacific Basin had been initiated. The visitors were disappointed at the diminishing involvement of the previously vigorous RAG chairman, Mr. Cannon. They also believed that the RMPH had progressed where Dr. Hasegawa required administrative assistance. Staff reviewed on September 28, 1970 the RMPH 03 year continuation application and believes that this RMP has made remarkable strides in the past year. The RAG's role and strength is still not clear, but an ad hoc evaluation committee and established policies and procedures provide hope that the RAG effectiveness will be improved, The Executive Committee of the RAG is the strong force; two of its members also serve on the RAG. Also strong forces are the categorical committees, which appear to have veto powers that vitiate the RAG's role. TE SRS TTIR tLe Ce RT RT rr erent Hawaii RMP ~5- RM 01-03 (AR-1-SD) 2/71 Core staffing has been strengthened, both organizationally and with additional positions of an Associate Director, and the Chief of Con- tinuing Medical Education filled by Dr. Alexander Anderson (from George Miller's operation), The Region's responsibility for, and commitment to the Trust Territory has been expanding, and is a continuing source of concern to Dr, Hasegawa because of his limited resources of personnel, time and funds. The operational projects appeared to be well on schedule towards meeting their objectives, Organizational Structure and Processes: The Regional Advisory Group of the RMPH is composed of 45 members, 36 from Hawaii, 3 members each from Guam, American Samoa and the Trust Territory. The members from Hawaii are appointed by a Nominations Committee for three-year terms, The members from Guam, American Samoa, and the Trust Territory are designated by their respective chief executive. The membership of the RAG includes physicians (20), Registered Nurses (2), Hospital Administrator (1), Social Behavioral Scientist (2), consumers (18), labor official (1) and a high chief from Samoa, The RAG activi- ties have centered around project review and approval. Other major activities of RAG during the past year included the following: Establishment of appointment procedures and functions of RMPH, RAG and other Committees as appended. Recommendation for a change in grantee institution to RMPS which was approved, The new grantee institution is the Research Corporation of University of Hawaii. Recommendation for the use of project summaries to facilitate the review process. Selection of the ad hoc Evaluation Committee of RAG of RMP-Hawaii. Discussion about regional priorities and input from specific health professions. An ad hoc Evaluation Committee of RAG is presently doing a study to determine how the RAG can function as a policy and decision-making body. The Core staff of the RMPH has twenty-one employees, twenty at 100% time or effort. The Core staff organization has been reviesed to include an Associate Director and a Chief of Continuing Medical Education. Exclusive of the secretaries, the Core staff consist of thirteen presently active members plus an Associate Director and a Chief of Continuing Medical Education, Hawaii RMP -6- - RM 01-03 (AR-1-SD) 2/71 Following is a list of the core staff members and an organizational chart. NAME JOB TITLE TIME OR EFFORT % HOURS Masato Hasegawa, M.D. Program Coordinator 50% TBA Associate Coordinator 100% Alexander Anderson, M.D, Chief of Continuing Medical ‘ Education 100% Satoru Izutsu, Ph.D. Chief of Planning & Operations Pacific Areas 100% Omar A. Tunks Chief of Operations 100% Rosie K. Chang Chief of Allied Health Services 100% Ruth N. Denney Chief of Planning & Research Ser. 100% Norman S. Kuwahara Comptroller 100% Paul E. Cook Assoc. Chief of Operations 100% Nancy C. Fowler Assoc. Chief-Planning and Research Services 100% Clyde J. Winters Medical Librarian 100% Paul T. Okumota Audio-Visual Specialist 100% Nancy B. Crocco Asst. Chief-Cooperative Comm. Health Services 100% Patricia S. Coe Researcher 100% Thelma T. Fujisawa Bookkeeper 100% Vicki A. Johnson Executive Secretary 100% Ethel F. Kawano Secretary 100% Lynda Armstrong Secretary 100% Elizabeth K. Medeiros Secretary 100% Elizabeth M, Munoz Secretary 100% Verna May S. Okano Secretary 100% oToOUNnYO [neq “AW “WoW LSITVIOSdS 909 38d *SAW “ATW WAHOUV IAS ay “vn ~ 099039 AdUeN *SAW "Hd ‘Hh "W'K SOO) [Neg *3aW Sfueyo etsoy ‘sap SH0IAUAS HLIVAH ‘arn fnyey seuey YI0IAIO NOSIVIT SAOLTAUTS ALI NAWKOO LSTIOOIOINACId a * SNOILVURdO JO HLIVSH GaITIV FAL LVUEd009 9% NVIOILSIIVLISOId AQIHD “OOSSV JO AXIHO AZIHO “LSISSV _| *a'ud ensanzt NIOAeS V°a'W ‘syuny azeug ‘AW ‘a°W SUoszepuy xXeTY NISV@ OLALOVd “WH ‘ADUUAag YINY “SAW SNOILVUAdO NOTLvONda SNOLLVUGdO ¥ ONINNVId SAOIAURS AQ AHIHO TVOIGHN ONINNILNOO 30 dRIHO HOUVASSY 9 ONINNVId 40 daIHO 430 AdaTHO "S°oT’ Son . “W'd°9S ITM @pA1O “AW ] juosuyor THOTA * SAW BIeYeMNY vUeUAON *3AW MdLT TWOIdan LNVISISSV ‘NINGV UATIOULANOS t t j } t __a — ee er 1 ! — eran a eae — wl — — —— eel a 9 Or WOLOANIG ALNAIA 5 = N ' aA ‘ g &G ' a “q’W ‘emeSesey ojesen 5 < YOLOTAIA < Hawaii RMP -]- RM 01-03 (AR-1-SD) 2/71 The Region indicated in the continuation application that previously the fi leverage in influencing the health care system was by "project grant" e mechanisms. They bélieve they are now ready for new dimensions in their strategy which will involve RMPH central staff. The central core staff will provide resources for consultation in medical core systems, in continuing medical education, in health services research and development, in health data acquisition and retrieval systems, and in health education of the public. They will not be considered merely as overhead to operating projects. Following are the names and functions of the Committees of RMPH: Executive Committee: Acts as the policy-making body for the overall operation of RMPH. It consist of ten voting members representing the University of Hawaii School of Medicine, the Hawali Medical Association, the Hawaii Hospital Association and the consuming public. In addition, the chairman of the categorical disease advisory committees, the chair- man of the Advisory Committee on Continuing Medical Educailon, representa- tives of the grantee institution and the RMPH Direcotr serve as ex-officio members without vote. Finance Committee of Executive Committee: Studies and advises on the total fiscal maters of RMP-Hawaii. Personnel Committee of Executive Committee: Studies and advises on the functional organization of the Central Core staff. The Long-Range Planning Committee: Appointed by the Executive Committee « its members develop long-range goals, objectives and priorities of RMPH. Technical Review Committee: The Director nominates for the consideration of the Executive Committee, the chairman and members of this committee. These members will technically review all operational proposals prepared by RMPH for funding. Categorical Committees (Heart, Cancer, Stroke) Appointed by the Executive Committee the members encourage development of new projects and review all proposed projects in their subject areas. Other Committees: Advisory Committee for Allied Health Services Cooperative Community Health Program Advisory Committee Continuing Medical Education Advisory Committee Advisory Committee for Guam, Samoa & Trust Territory Hawaii County Advisory Committee Kauai County Advisory Committee Maui County Advisory Committee Project Review Process: Each project proposal begins the review process as a letter of intent submitted to the Director of RMPH. Ideas for project proposals are generated by individuals, agencies or organizations:: -. in the health field. The Director and Core Staff assess the revelance Hawaii RMP -8- RM 01-03 (AR-1-SD) 2/71 of the idea, proposed in the letter of intent,,to the overall plan of RMPH. If it seems relevant, the Director assigns an appropriate staff member to assist in further development of the project with the advice of the committee set up for this. The development of the project often takes several months. The Core staff works closely with the applicant organi zation, throughout to construct a proposal which follows RMP Cuidelines. After the final draft of a proposal has been completed, it is channeled through the appropriate Categorical and Technical Review Committees, then through the Executive Committee and the Regional Advisory Group. At any point, the proposal may be returned for revision, deferred, recommended for approval or disapproved. Upon final approval of the RAG, the proposal is sent to RMPS for national review. All proposals are reviewed in terms of: (1) Relevance to the overall plan of RMPH and the degree to which the proposal furthers regionalization and cooperative arrangements, to improve our present health care system in Hawati. (2) Identification of needs and opportunities within the region. (3) Definition of objectives in clear, measurable terms. (4) Assessment of resources, including the identification and use of existing resources, avoidance of duplication, and the initiation of cooperative arrangements and closer linkages between the available resources, (5) Involvement of individuals, organizations and institutions within the region. (6) Indication of. the priority level of the proposal in relation to the overall goals and objectives of RMPH. (7) Implementation, including strategy, methodology and techniques for accomplishing the stated objectives. (8) Evaluation protocol developed to measure achievement of the objectives and assess the overall effect of the proposal. Although there is no formal review relationship with CPH, projects are often discussed with CHP personnel during the preliminary stages of project development. A problem encountered with the present review mechanisms is the difficulty attendant upon the veto power of any one review committee. Clarification is required with respect to the effect of one review committee's veto on the continued progress of a proposal through the local review mechanism. Hawail WwIr . a a 7 KY VULTUO TART LOTOUyY SIE PROJECT REVIEW FLOW CHART GRANT APPLICATION (any agency, planning Staff RMPH) | ' ADMINISTRATIVE OFFICE | PROGRAM COORDINATOR (for. relevance to overall plan) | PLANNING SECTION (when grant comes from agencies other than RMPH for review by staff with expert advice as needed) CATEGORICAL ADVISORY COMMITTEE (for subject matter and excellence) WW TECHNICAL REVIEW COMMITTEE W EXECUTIVE COMMITTEE ws REGIONAL ADVISORY GROUP ~, ~™ DRMP » ; Washington, D.C. RESEARCH CORPORATION OF U OF H (copy of project-- for information only) Hawaii RMP -10- RM 01-03 (AR-1-SD) 2/71 Annual Report of the Regional Advisory Group The Regional Advisory Group of the RMPH expressed in their report their satisfaction of progress made by the RMPH to meet goals and objectives set forth for the past year, In an item- by~item review, the Committee members felt that progress was satisfactory in continuing medical education, expansion of RMP into the Trust Territory, stimulating new projects, providing practitioners access to latest knowl- edge, expand electronic data processing and develop pools of health data information. Two areas they indicate need continued and greater attention relate to public education and staff assistance to hospitals and health care institutionsin evaluating their needs for facilities and service programs, The RAG was impressed but somewhat concerned with the broad but imaginative new perspective set forth for the 03 year. There was a question of staff capability and availability of funds to achieve the expanded goals. There was concern that a broad gauge approach could either duplicate or dilute the effectiveness of projects and activities which should be pointed toward meeting specific and high priority health needs in RMPH. With this advice, the RAG members approved the new perspective goals and objectives of RMPH which broadly set forth the major areas of activities. As indicated in this application the new perspective and strategy of the RMPH is to improve the health care system of Hawaii by instituting the following: . Continuing Medical Education . Demonstration projects for improving patient care . Health services research and development . Involvement in assessment of the quality of medical care . Health education of general public . Data acquisition and retrieval system Dun Wh re Evaluation: The Region indicates that for the purpose of proper evaluation of operational projects, increased effort has been made to state project objectives clearly in every case so that per- formance can be effectively measured. The Evaluation Report by the RAG ad hoc committee is an important aspect of RMPH program evaluation. In order to further develop techniques for evaluation, the staff has con- ducted inservice workshops and sought the use of consultants. Developmental Component: The Developmental Component of the Regional Medical Program of Hawaii will follow the presently working review cycle and monitoring. The Region states that the Developmental Component provides the needed opportunity for RMP-Hawaii to establish innovative activities in continuing education as pilot studies; to test their feasibility, palatability and productivity on a Limited experimental basis before extending their scope and insuring their longevity through the formal mechanism of project proposals. These educational programs will include: A. Demonstration Projects of innovative patient care systems B. Feasibility and utilization study projects C. Staff development training programs 2 The Region believes that the availability of the Developmental Component will provide an immediate opportunity for the Regional Medical Program of Hawaii to influence the need for organizational change of individual hospitals and in the overall hospital system of Hawaii. The Region believes that instituting organizational change in the present hospital system is the most economical and feasible way of insuring that compre- hensive care is accessible to every citizen that is in need of medical care. Activities which are being considered for improvement of the hospital system under the Developmental Component include: (a) Studies of hospital emergency care departments (b) Shared services with hospitals joining together for the ’ operation of certain basic facilitative and supporting services, clinical and non-clinical in nature (c) Educational seminars for board members, hospital administrators and medical staff in understanding the role changes that are necessary in the organizational structure to provide compre- hensive medical care. (d) The operation of one or more sub-units of patient care by one central parent hospital corporation (e) Study of the feasibility of training doctor's assistants in hospitals. (£) Development of health manpower pools. (g) Investigation of the possibility of establishing an all-inclusive , hospital rate (h) Promotion of an identification program related to designating routes and publicizing availability of hospital and emergency care services to the public. The Region is requesting a funding level of $92,314 for the developmental component which is an amount equal to 10% of the annual direct cost funding level (not including carryover) of the Region at the present time. Supplemental Projects Requested Project #23 - Mobile Coronary Care. The primary purpose First Year of this project is to provide treatment $138,661 outside the hospital for acute, potentially lethal arrythmias by the utilization of a Mobile Coronary Care Unit. The Region explains that the two ongoing projects, the Cardiopulmonary Resuscitation Training Projects and the Coronary Care Training Project for Physicians and Nurses are preparing for expanded activities as approved their 03-year of operation. The Region believes that this project for Mobile Coronary Care will significantly extend the acute care capability in Hawaii and that these three projects inconcert should have an impact on death rates from acute coronary attack in the State. The Region also indicates that this project will also provide training for allied health personnel, a high-priority component of most RMPH projects. Second Year $96,493 $100,101 Third Year Hawaii RMP -12- RM 01-03 (AR -1-SD) 2/71 Requested Project #24 - Hawaii Smoking Withdrawal Clinic Project. First. Year The broad goal of this project is to $32,950 bring to the citizens of Hawaii an opportunity to reduce or discontinue existing smoking habits as an important step toward the reduction of heart disease, cancer, stroke and related diseases. Withdrawal clinics will be established to assist cigarette smokers in their désire to break the habit of cigarette smoking and to combat recidivism among those who have discontinued the habit. Second Year Third Year $42,000 $52,000 Project #25 - Establishment of Health Appraisal Units in Requested Hawaii, The major objective of this First Year proposal is to define the health of the individual in $139,510 the community through multiphasic screening and to link this appraisal closely to the medical care system. The Region indicates that this project is designed to maintain multiphasic screening as close as possible to the mainstream of medical care in Hawail. The Region believes that this proposal for establishment of Health Appraisal Units in Hawaii incorporates several of the areas within RMP-Hawaii's strategy and focuses on health-care costs as well, The Straub Medical Research Institute of Hawaii, Inc.,is the applicant organization for this project. Second Year Third Year $172,866 $160,585 Requested Project #26 - Improvement of the Intensive Care Unit-American. First Year Samoa. This proposal is requesting three years $37,857 support for the improvement of the Intensive Care Unit of the Lyndon B. Johnson Tropical Medical Center, the only hospital in American Samoa, Although an 8-bed Intensive Care Unit now exists at the Lyndon B. Johnson Tropical Medical Center, the medical staff recognize that it is not fully operable because of inadequate trained staff an an incomplete list of equipment. Second Year Third Year $6,280 $5,965 HdadwWail Wric : : os Project #27 - Improvement of Dietary Management and Dietary Requested Counseling in Hawaii. The goal of this First Year project is to improve care to patients with diabetes, $63,669 cardiovascular, renal, and other diet-related diseases by increasing dietary knowledge of medical and allied health professionals through discipline oriented seminars and to increase community services by establishing a dietary counseling service. The Region explains that the relation of this project to RMPH strategy is that it renders continuing medical education of physi- cians and allied health personnel, education of the public in self- ; care and the use of demonstration projects. Second Year Third Year $64,036 ' $66,569 . Present Year APPROVED AND FUNDED PROJECTS of Gperation Project #2 - Training in Rehabilitation in Catastrophic Disease 3rd Project #3 - Home Care Training Program 3rd Project #4 - Continuing Education of RMP support Nurses in Patient Settings Phased out Project #7 - Cardiopulmonary Resuscitation Training 3rd Project. #8 - Coronary Care Training (Queens Medical Center) 3rd Project #9 - Coronary Care Training RMP support (Hilo Hospital) Phased out Project #10 - Coronary Care Training RMP support (Wilcox Memorial Hospital) Phased out Project #11 - Region Pediatric Pulmonary Program 3rd Project #13 - Rehabilitation in Catastrophic Disease (Guam, and Trust Territory) 2nd Project #15 - Region Cooperative Chemotherapy Program 2nd Project #20 - Guam Memorial Hospital Constant Care Unit 2nd Hawaii RMP -14- RM 03-01 (AR-1-SD) 2//1 APPROVED AND UNFUNDED PROJECTS Council Approval Project #12 - Program for Treatment of Cardiac Arrest (Saipan) December 1969 Project #17 - Hawaii Mass Screening of Children for Heart Disease March 1970 Project #18 - Anti-Smoking Education Project for Hawaii March 1970 Project #21 - Cervical Cancer Program for the Trust Territory July 1970 Project #22 - Training of Health Aides in the Trust Territory July 1970 PROJECTS DISAPPROVED Project #5 - Continuing Education Program in Pathology Project #6 - Hawaii Tumor Registry Expansion Program Project #14 - Cervical Cancer Program for Trust Territory Project #16 - Hawaii Tumor Registry Project #19 - Continuing Health Education Council of Hawaii RMPS /CRB/11/19/70 \ A PRIVILEGED COMMUNICATION SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971° REVIEW COMMITTEE . . HAWAIL REGIONAL MEDICAL PROGRAM RM 01-03 (AR-1-SD) 2/71 FOR CONSTDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: Additional funds be provided for this application. Region's Recommended Operational Year Request Funding 03 Year $ 504,961 $366,300 (Developmental Component) ( 92,314) ( 92,314) (Five New Projects) (412 ,647) (273,986) 04 Year . (Five New Projects) 381,675 285,182 O5 Year (Five New Projects) 385,220 ' 285,119 Total $1,271,856 - > $936,601 Critique: Committee concurs with the site visit team that there has . been considerable progress made by the Hawaii RMP toward developing the general principles of regionalization, The Region has developed a framework for planning the achievement of goals and objectives. Methods for evaluation are being developed, The RMPH has developed a good working relationship with the Hawaii Medical Association, University of Hawaii, State Health Department, Comprehensive Health Planning, Hospital Association, etc, These relationships are discussed in a report of a site visit to this Region conducted on December 3-4, 1970. ‘ t The Program Coordinator, Dr. Masato Hasegawa, appears to have done a good job in pulling together the program since becoming Coordinator, Committee, however, believes that Dr. Hasegawa has built such a large organization with so many complexities, that he now requires the assistance of a full-time deputy to help him administrate the day-to-day operations, This would free Dr. Hasegawa to spend more time in developing the philosophy and direction of the program, . Hawaii RMP -2— > RM 01-03 (AR-1 SD) 2/71 This question was discussed in detail with both the Chairman of the - RAG, Chairman of the Executive Committee and with the Coordinator himself during the December 3-4, 1970 site visit. It was indicated to the visitors that steps are being taken to modify the existing situation by appointment of a deputy coordinator at this time. The Core staff has been strenthened by the addition of Dr. Alexander Anderson, who has assumed the position of Chief of Continuing Medical Education, -The core staff appears to be generally competent and _ seem to work. very well together. With the addition of the deputy coordinator the core staff should receive top level administrative direction for their activities. ' The RAG has not assumed full. responsibility in giving direction to the: RMPH and has played a minor role in stimulating project proposals, It is evident however, that the power group of the RMPH is the Executive Committee of the RAG, which has adequate representa- tion of the major provider institutions and significant insight into the health distribution problem and-the problem. of the cost of health care in Hawaii. This Committee is attuned to the general . thrust as well as the problems of the RMPH, In the Pacific Basin the RMPH has been coordinating its efforts with CHP because they have been active for several years in health planning _ throughout the Trust Territory and has come up with a comprehensive “health plan for the area. They have also coordinated their efforts with the Hawaii School of Public Health and the East-West Center. Tt .is. apparent to the visitors that the RMPH needs to have visibility in these areas, prior to establishing linkages with local health institutions. Just as the Cervical Cancer Project served to create visibility in Guam during the past year, the present proposal requesting the development of an intensive care unit training program at the L.B.J. Tropical Hospital in American Samoa will give visibility to RMPH with other existing institutions in Guam. Developmental Component While progress has been slow for this region, it has been in-the direction of a broadening and deepening involvement of RMPH with. the provider of health services and the community. The long-range goals of the developmental component involves three major items: a) a focus on hospitals as a major.mechanism for the delivery of comprehensive health care; b) the use of continuing education programs; c) and the development of a data acquisition system that will‘help to assess the quality of health care in Hawaii, The technical projects proposed for implementation of long~range plans regarding the relationship between RMPH and the hospitals in the community appear to be well thought out and implementation could ase RT REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) RM 00061-02 (AR-1-SD) 2/71 January 1971 Review Committee Illinois Regional Medical Program, Inc. 122 South Michigan Avenue Room 939 Chicago, Illinois Grantee Agency: Same Program Coordinator: Request (Direct Costs) Executive Director - Morton C. Creditor, M.D. 02 Year 03 Year 04 Year 2/1/71 - 1/1/72 - 1/1/73 - Purpose 12/31/71 12/31/72 12/31/73 All Years Continuation Commitment 1,525,192 427,122 1,952,314 (Core and 2 studies) (947,460) (112,722) (1,060,182) (7 projects) (577,732) (3 proj. 314,400) ( 892,132) Renewal Components -0- 1,443 ,608** 1,851, 190*** 3,294,798 (Core and 1 study) Additional Components 1,586,835 1,641,597 1,063,314 4,291,746 (Developmental) (158,564) -0- -0- (158 , 564) (2 new projects) (633,704) (772,882) (141,016) (1,547,602) (2 approved/un funded . projects) (275,155) - (477,181) (518,821) (1,271,157) (2 approved/deferred Renal) (519,412) (391,534) (403,477) (1,314,423) 2 Supplements 407, 258 407,258 Ongoing Activity (Core) (394,190) (394,190) (1 Project) ( 13,068) ( 13,068) Committee Action Required $3,519,285 $3,512,327 $2,914,504 $9,946,116 *k Includes $191,247 Renewal request for Educational Resource Study. **k Includes $201,000 request for Education Resource Study. Illinois RMP -L- Funding History Planning Stage ANDER Meee a ree Qe wey —pee Grant Year Period Funded {d.c.o.) ol 7/1167 ~ 6/30/68 $304,629 02 7/1/68 - 10/31/69 (16 mos) 976,341 03 11/1/69 - 1/31/70 (3 mos) 357,840 " Operational Program _ Grant Council ‘Funded Future | Year Period - Approved D.C. 0. Commitment 01 2/1/70 - 1/31/71 1,585,643 855,097*- Core aohen-- 730,546** Projects . 02 2/1/71 - 12/31/71 1,532,333 --ereree 1,532,333 03 “U/1/72 - 12/31/72 427,122 -------- 427,122 -“#% Includes Educational Support Resource Study $174 ,500° ** Includes Hypertension - St. Lukes $145,600 ae eee en meee Illinois RMP -3- RM 00061-02 (AR-1-SD) 2/71 Geography: The borders of the Illinois region are, like those of other regions, not defined. In the initial planning grant application the Illinois region was defined as encompassing the State. All of Illinois' five schools of medicine and the School of Osteopathy were located in Chicago. It was -felt that these institutions, working together could cover the requirements of the state better than could be done by apportioning parts of the state to each school. However, the Bi-State Regional Medical Program, based in St. Louis, Missouri, also designated approximately the southern half of Illinois as, in their view, being in that region. As time has passed and both regions have matured this "turf" problem, which remains unsolved, is taking on greater dimensions. On the west, Moline, Rock Island, and other communities of that area are a part of a metropolitan area which includes Davenport, Iowa. In health services, some relationship with Iowa City exist. Along the northern state line of Illinois there are no areas with very strong ties to Wisconsin. The state line appears to be an appropriate boundary. Based on present health service patterns, there are sharp differences of opinion in northwestern Indiana (Gary, etc.) as to their most appropriate region. The area is a part of the Chicago Metropolitan Area, but has substantial loyalties to Indiana. Demography A. Population: Approximately 11 million 1. Roughly 81% Urban 2. Roughly 89% White 3. Median Age: 31.2 years B. Medical Schools: at present seven, (including one College of Osteopathy) soon to be expanded to eleven. Cc. Hospitals: Approximately 300-350 D. Physicians: 14,000 medical and 363 Doctors of Osteopathy History of Regional Development On March 9, 1965, a committee of the five Medical School Deans in Illinois, members of the Illinois Division of American Cancer Society and the Chicago Health Department, was appointed by Dr. Morris Fishbein, President of the Chicago Heart Association, to discuss the possibilities of a RMP in Illinois. During July 1965, Mayor John Daley and Governor Otto Kerner appointed separate Advisory Committees for RMP which subsequently (January 1, 1966) were fused to form an original Regional Advisory Committee. Appointment, responsibility and authority of the membership to the RAG was vested in the Governor until changed on November 25, 1968. On that date the RAG appointment authority became vested in the RAG. From July 1, 1965 until July 1, 1969, the Coordinating Committee of Medical Schools and Teaching Hospitals of Illinois Illinois RMP ~4- RM 00061-02. (AR-1-SD) Peses served the function of Trustee, with the University of Chicago being the grantee agency and fiscal agent. The Coordinating Committee was comprised of the six deans of the schools and the administrators of some 16 major medical school hospitals. It had, and exercised, the responsibility for the policy decisions relating to core staffing and. administration, and to both planning and operational components of IRMP. a - The August 1966 National Advisory Council considered the initial planning application submitted by the Coordinating Committee of Medical Schools Illinois for implementation of RMP in Illinois. and Teaching Hospitals of Council rejected it, feeling the proposal was "superficial and inadequate." \ a 4 £ the local Advisory Group or its method of It contained no description o t of community medical procedure and there was no appearance of involvemen facilities. A revised planning application was submitted and approved by May 1967 Council at a reduced level for a two-year period 7/67 through 6/69. Several concerns were still present. These were: Loe Administrative structure appeared cumbersome. Heavily medical-school oriented with minimal involvement of other ~ health-care areas. . Advisory Group is physician-oriented; the only Negro member is elderly and out of touch with the regional planning. Lack of information about involvement of the central part of the state. During September 1968, the Illinois Regional Medical Program submitted its original operational application. Subsequently, this was withdrawn by the Regional Advisory Group following a November 1968, DRMP staff assistance visit. The visitors concluded that the Region contained the following weaknesses and strengths. Weaknesses 1. Little evidence of real commitment of leadership by the medical schools. 2. Inadequate representation from outside of Chicago on the various committees task forces and the advisory group. 3. Core staff is much too small for such a large and complex region. 4. Need for aggressive leadership by the power structure. 5. IRMP is too passive;should be more active. 6. The foundation of IRMP, its core staff and its planning leadership capacity. is not ready for the superstructure 0 f an operational program. rs E bh. i SE ERR " cee erp emage nye pee gence aerge PO TIAA ye ey oe tirc tte gener Illinois RMP -5- RM 00061-02 (AR-1-SD) 2/71 Strengths 1. The obvious interest and talent of many task force committee chairmen and members. . 2. The beginnings of hospital networks, related or potentially related to medical schools. The revised operational application was submitted for consideration during the July/August 1969 review cycle. The application contained a two-year request for support of planning and Core activities beginning November 1, 1969 (the grant period had been extended from July 1, 1969 to November 1, 1969) and support of three to five years for 8 new operational projects. A pre- operational site visit was conducted during June 1969. The members of the site visit team were impressed with the amount of planning and maturation that had taken place since the original operational application and the November 1968 staff assistance visit. Members of the site visit team recommended that on the basis of the evidence presented of cooperation between Medical schools, hospitals, councils, voluntary and public agencies, the region was now ready to mount an operational program. Seven of the eight operational proposals were recommended for approval. The team further recommended that the request for additional funds for core not be approved, until a new program coordinator could be appointed. The site visit team further recommended that if the IRMP was approved as an operational program, the Region should be made aware of the program recommendations of the team. These were: 1. That the Regional Advisory Group, Boards, Task Forces, and Committees contain minority group representation, both professional and lay consumers; 2. That there be broader distribution of allied health and health manpower involvement ; 3. That there be a more realistic relationship established between the Board of Trustees and the RAG pertaining to application review; 4. That concrete efforts be effected to solve the upstate versus the Down- state cast of the Region; 5. That a more organized, realistic approach to the collection and collation of data be obtained; 6. That the aims and objectives of contract arrangements be continually reviewed in relationship to their history, ready availability of any particu- lar 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; Illinois RMP. -6- RM 00061-02 (AR-1-SD) 2iggsss 8. That the Region appoint and establish a Region-wide representative Stroke Committee. Both the July Committee and August 1969 Council concurred in the recommendation of the site visit team. During February 1970, the Region was awarded opera- tional funds to support Core and the seven new projects. A breakdown is provided. t Project - Amount Supported (D.C.) Number Title “through 1/31/71 : 00 Core (Basic) 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 Sub- clinical Heart Disease 199,826 4 Regional Coordinated Cancer Program 108,950 5 Radiation Therapy Treatment Planning Center 24,300 6 Macon County Stroke Coordination Program 33,790 7 Comprehensive Stroke Rehabilitation Program 111,225 8 Comparative Endnoscopic Study and training program in the Early Diagnosis of Gastric Cancer TOTAL 71,330 $1,585,643 Following the recommendations of a June 1970 technical site visit team, the August 1970 Council recommended approval of four new operational projects; two in renal disease, one in cancer and one Unified Health Information and Counseling Service. Review Process Review is carried out in two stages. the application. Currently these are approved but unfunded projects. The first is a technical review done by either a standing committee or task force, or an Ad Hoc committee. The reviewers may recommend approval, disapproval or may recommend revision of The second review is conducted by the RAG, Illinois RMP -7- RM 00061-02 (AR-1-SD) 2/71 Regional Advisory Group The Regional Advisory Group is a 40-member body with representation from a broad spectrum of people involved throughout the Region in health care and health planning. Members are nominated by a committee composed of representatives from the Board of Directors, the RAG, the Heart Association, Cancer Society and State Medical Society. Members are elected by the Board of Directors with ratification by the RAG. The members are elected for five-year terms with one-fifth of the membership rotating each year. The group meets on a bi-montly basis and a five-member Executive Committee of the RAG meets on alternate months. The Executive Committee of the RAG prepares the agenda and considers matters requiring immediate attention, subject to approval by the group. The By-Laws of the Board of Directors and the RAG were revised on May 25, 1970 which provide for two major changes: 1. The membership of the RAG was expanded from 30 to 40 members in order to provide for broader representation of consumer and allied health interest from other areas outside of Chicago. Eleven new members were added most of whom represent minorities, consumer and allied health groups. Since the last election of members to the RAG, some of the original members have resigned, leaving a present membership of 36 individuals. Potential members are presently being sought from among minority and consumer groups, especially from the downstate area. 2. The RAG is now officially designated as the body responsible for overall policy and guidance for the IRMP in planning and operational programs. They conduct final project and grant application review. The revised By-Laws have relieved the Board of Directors of both project and application review responsibilities. Board of Directors This is a 22-member body which meets monthly (3 members also serve on the RAG) and has corporate responsibility for the financial and other affairs of the not-for-profit organization. Executive Committee of Hoard of Directors This is a 9-member group composed basically of the Deans of the Medical Schools which may act for the Board should it become necessary. This group met in the last year. The IRMP has recently reorganized its Committee and Task Force structure, and now contains the following: Health Information Manpower and Education Continuing Education Evaluation and Research 1. Task Force 2. Task Force 3. Task Force 4. Task Force 1. Heart Committee a. Sub-committee Myocardial Infarction Illinois RMP -8- RM 00061-02 (AR-1-SD) 2/74 2. Cancer Committee a. Sub-committee, Chemotherapy b. Sub-committee on Radiation Therapy 3. Stroke Committee 4. Screening Committee 5. Nursing Committee 6. Public Relations - Public Information Committee 7. Medical School Coordinators 8. Kidney Disease Committee (just forming) All committees and Task Forces are engaged in making policy recommendations and have advisory responsibilities. Major Changes in IRMP July 1, 1969 - applicant organization - fiscal agent changed from University of Chicago, College of Medicine to a separate not-for-profit organization, thé Illinois Regional Medical Program Inc., June 1, 1970 - Morton Creditor, M.D. assumed full-time duties as Executive Director of IRMP. Dr. Creditor Replaces the now retired Dr. Wright Adams who was IRMP's original full-time coordinator. Dr. Creditor has been responsible for creating a "new look" and emphasis for the Illinois Region. The RAG, committees, task forces and staff are now engaged in the setting of new program priorities. A site visit is to b. conducted on December 3-4, 1970. The report will be available during the January/ February 1971 Review cycle. Present Application This is a pentagonally structured 3-year renewal request. It contains requests for: A. Renewal of Core and continuation of seven on-going operational projects. B. A rather large supplement to the basic core component plus a supplement to one of the on-going projects (Home Health Services). C. the ‘Region wished to take. During the December 3-4, .1970 site visit, the Program Coordinator, the Chairman of the RAG and the Chairman of the . Board of Trustees advised the team that, after due consideration, it was decided that the application be considered a three-year renewal. request. ‘. ; RECOMMENDATION: The Committee recommended that this application, which . -. requests: 1) three-year renewal support at an increased level for Core activities, (including an Educational Resource Study), one-year ‘continuation for 7 projects and second year continuation for 3. of these projects; 2) a developmental component program; 3). support for “2 new projects; 4) support for 4 projects which are currently approved/ unfunded and 5).a supplemental request to an ongoing project; be partially . supported for $2,000,000 for a one-year period. Included as a part of the recommendation is that: 1) The amount requested for a developmental com- ponent ($158,564) for the first year not be approved. 2) The $2,000,000 is predicated that any carryover funds will not be available | to the Region as an additional amount. vend | REQUEST i RECOMMENDED FUNDING Ist Year $3,519,285 $2,000,000 ‘Qnd Year Ae 3,512,327 pone 3rd Year | | 2,194,504 none’ -- TOrALS $9,946,116 $2,000,000 : CRITIQUE : -In its deliberation, the Committee considered the Site Visit. be 2 Report, Illinois Regional Medical Program, December 3-4, 1970. ‘While the site visitors recommended triennial support be provided for direct cost funding in the amount of $2,000, 000 for each of three years, members of Committee, while concuring with the amount, recommended that support be. Titwteadoran ana waar Illinois Regional Medical Program -2- RM 61-02. (AR-1-CSD)2/71 — A member of the Review Committee, who was also a member of the December 3-4, 1970 site visit team, related the findings of the team to the Committee. . “‘He-reported the overriding positive factor in.this RMP is-the new program ' coordinator who assumed full-time leadership on June 1, °1970. In his... short tenure, he has caused the IRMP to assume a new personality, has started-the process of turning the program around and is definitely changing the program emphasis. He went on to state that Illinois already. -has. the necessary. strengths .and.potential to enable it to become one of. the leading Regions in the country. Both the composition, to include more minority members and consumer . interests, and ‘the role of the Regional Advisory Group has. been changed. 'fhere-was little doubt that: this group is now becoming deeply involved . as the primary determiner of goals, objectives, priorities and policy - for the Region. Core activities. have been reorganized into a four- - horned: structure which now includes regionalization, core functional activities, administration, and management, and regional program. development. The Committée was encouraged to learn that since the last total program review (June 1969), in addition to an attempt to improve the organization . and capabilities of both the RAG and Core Staff, there are now much . , stronger ties and relationships with. the medical centers and other agencies: and institutions within the Region. . ‘Sub-regionalization has always been a major problem in. this. Region, as it is in similar Regions, with a historical upstate versus a‘downstate’ cast’, Recently, the Region has been working closely with several sub+ regional health planning agencies (example - Springfield) in an effort to begin to solve this perennial drawback to an effective program... — “The Committee was concerned that a rather large core supplement was requested. A large portion of this was to increase support of the time: or effort of the present 5 part-time coordinators assigned to medical - “schools: from parttime to fulltime. Additionally, support for full-time - . coordinators ig requested for the two other already established: schools in the Region plus 4 new medical schools which are in the process of being - -: established. (Springfield, Peoria, Rockford, and Ghampaign). Both the: - site visitors and members of the Committee questioned the value of these assignments without some medical school-RMP written plans, expectations: cond guidelines. A. major weakness in the Illinois Region. is their evaluation. The Committee learned that in July 1970, the RMP employed a full-time evaluation specialist. In line with this, members of Committee commented that with the evaluation expertise that is already available in this Region, there is no excuse for evaluation of poor quality. In the future’ - high requirements for the activity are to be expected. arr - 7 eo As ‘Yeflected in the site visit report, the Committee was in. agreement: with coy a @ Illinois Regional Medical Program -3- . RM 61-02 (AR-1-CSD) 2/71 the team regarding the priority to which new projects should be supported. In arriving at a recommendation, the Committee generally agreed with the observations and conclusions of the site visitors that the Illinois RMP is obviously in the process of turning around and should be encouraged. While they also agreed with the yearly level of funding. recommended by the site visitors, they believed that $2,000,000 should be awarded for one year instead of the three years requested. The site visitors considered this to be a "new" Region in spite of its being in operational status for almost one year (since February 1970). Therefore, the Committee reasoned that the awarding of funds for a one-year period would provide the opportunity for the Region to prove its maturity and also allow time for the Region's planned total program renovation. , In conclusion, the Committee recommended that the total program as presented -{n this application be partially supported at $2,000,000 for a one-year period, rather than for the three-year period requested, This recommendation will cause’ the Region to reapply for triennial support in time for the . January/February 1972 Review Cycle. , Included as a part of the recommendation is that: 1) The amount requested for a developmental component not be approved. 2) The $2,000,000 is predicated that any carryover funds not be made available to the Region as an additional amount. a Further, the Review Committee strongly recommend that staff convey to the Region its concerns regarding the necessary planning which should take place before full-time RMP medical school coordinators are assigned and its concerns regarding the quality of evaluation which will be expected from-this Region. ‘Drs, Schmidt and Ellis were not in the room during the deliberation on this application. 2 DRMP/GRB 1/15/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) INDIANA REGIONAL MEDICAL PROGRAM RM 43-03 (AR-1-CSD) 2/71 1300 W. Michigan Street January 1971 Review Committee Indianapolis, Indiana 46202 PROGRAM COORDINATOR: Robert B. Stonehill, M.D. REQUEST (Direct Costs Only) 03 04 05 All Purpose 1971 1972 1973 Years Continuation 1,256,308 -0- -0- 1,256,308 Core & 3 Feasi- bility studies ( 422,573) -Q- -0- ( 422,573) (5 projects) (833,735) : ( 833,735) Renewal Components 671,122 | 517,891 559,673 1,748,686) (4 projects) Additional Components 136,005 -0- -0- 136,005 (Deve lopment) (127 , 000) -0- -0- (127,000 ) (1 new project) « 9,005) -0- -0- ( 9,005) Sub-Total 2,063,435 517,891 559,673 3,140,999 Supplemental Appl. Deferred 11/70 Council 2 projects 120,576 68,188 69,389 258,153 Total _ 2,184,011 586 ,079 629,062 3,399,152 Staff Action on Continuation 1,256,308 -Q- -0- 1,256,308 Committee & Council Action 927,703 586,079 629, 062 2,142,844 Note: 1) The continuation request includes the commitment $1,121,411 and carryover $134,897 to support core and seven projects. Three of the projects have been ongoing for two years; three were funded one year from carryover; and one approved for three years is to begin. 2) In addition, carryover was requested for continuation of #5 and #6. Subsequent to submission of the application, Grants Review Staff informed the IRMP that these two projects were approved and funded for one year only and must now be considered as renewals by February 1971 Council. Meanwhile, staff will consider extending their current support for three months with additional funds until the renewals are acted upon. INDIANA RMP | -2- RM 43-03 (AR-1-CSD) 2/71 FUNDING HISTORY (Direct Costs) . Planning 01 1967 $384,750 02 1968 592,106 03 1969 217,473 OPERATIONAL Grants Year Period Council Approved Funded Commitments 01 1/ 1969 $1,363,571 $1,363,571 02 1970 1,271,411 2/ 1,513,690 03 1971 1,121,411 1/ Merged with 03 planning _ 2/ Includes $242,279 carryover Demography A. Population: Approximately 5,000,000 in 1969 1. 65% urban 2. 93% white 3. median age 28.9 years (U.S. average - 29.5) 3. Land: 36,185 square miles C. Mortality per 100,000 1. Heart 373 2. Cancer 156 3. CNS vascular lesions 126 D. Facilities 1. Indiana University School of Medicine 2. 38 Schools of Nursing (12 of which are affiliated with colleges and Universities and 5 grant B.S. degrees) 3. Allied Health Programs: 17 schools of Medical Technology 2 cytotechnology facilities 18 X-ray technology facilities IUMC has a Division of Allied Health Sciences with programs in 10 professions, i.e., health education, P.T., 0.T. and inhalation therapy 139 hospitals with 36,335 beds INDIANA RMP -3- RM 43-03 (AR-1-CSD) 2/71 E. Manpower (1966) 1. 5,111 M.D.s and D.0.s - 100/100,000 2. 13,769 active nurses - 275/100,000 History of Regional Development: During September 1965, the Dean of the Indiana University Medical Center appointed a Study Committee which included representatives from the State Medical Association, State Health Department and Medical Center. After extensive preparation, the first meeting of the Regional Advisory Group was held in July 1966 followed by submission of a planning application to RMPS in September 1966. ‘The Region received a three-year planning grant beginning Januaryl, 1967. The current coordinator joined the staff in July 1967 and was named successor in his present position in January 1968. A site visit was made September 1968 to determine IRMP readiness for operational status. Impressed by the Region's leadership, community involvement and good working relationship with the university, the site visitors strongly recommended approval of the operational application. The November 1968 Council recommended approval for three years. The third planning year merged with the first operational year during which time $1,363,571 (d.c.o.) was awarded (03 planning - $152,295 ~ and 01 operational - $1,211,276) for core staff and five projects. On reviewing the second year continuation application, staff believed the IRMP was progressing satisfactorily. The amount of $1,513,630 (d.c.o.) was awarded for core and ten projects (3 continuing and 7 new projects approved by Council). The award included $242,279 use of carryover funds, most of which was for support of three approved and unfunded projects for one year with no continuing commitment. The current application for third continuation support was reviewed by staff November 24, 1970 and a summary of their comments is appended. Goals and Objectives: The overall goal remains to make available improved patient care through cooperative arrangements including continuing education and demonstrations in the areas of heart disease, cancer, stroke, kidney and related diseases. Original emphasis was in the area of expanding Continuing Professional Education, increasing manpower and stimulating appropriate research. Increased emphasis will now be placed on stimulating the delivery of needed patient care. Within the broad objectives, the RAG assigned priority ranking to all projects; 1 to 13. Ranking Order: REGIONAL ADVISORY GROUP PROJECT PRIORITY DETERMINATION Priority # Project (1) 2.89 4 Coronary Care ose e eset etree ecees (Funded until December 31, 1971) (2) 2.79 3 Stroke ..... cece eee eee ee teens (Funded Until December 31, 1971) INDIANA RMP , -4- RM 43-03 (AR-1-CSD) 2/71 Priority # Project (3) 2.67 13 Nursing in Coronary Care Units...(Funded until December 31, 1970) (4) 2.58 2 Multiphasic Screening ......-.-- (Funded until December 31, 1971) (5) 2.55 16 Chronic Pulmonary Disease ...... (Funded until December 31, 1970) (6) 2.50 18 N.W. Indiana Community Coronary Care. . (Approved-Unfunded) (7) 2.27 11 Nursing Continuing Education.... (Funded until December 31, 1970) (8) 2.19 21 Radiation Therapy ..... (Deferred for site visit by 11/70 Council) (9) 2.10 22 Respiratory Care Technician c" " " wots ) (10) 2.06 14 Library ....... dec eeeceeees .. (Funded until December 31, 1970) (11) 2.00 5 : Health Manpower ....-..--5- .. (Funded until December 31, 1970) (12) 1.95 9R Neighborhood Health Centers . (Funded until December 31, 1970) (13) 1.72 6 Health Hazard .......-..-++- | (Funded until December 31, 1979) 2 ? 23 Smoking Program ......-+-+++ . (To be considered by 2/71 Council) During the latter part of the year, the Regional Advisory Group turned its attention to the development of a long-range plan. Accordingly, a special committee, the Long-Range Goals and Objectives Committee, was formed to consider this matter. With assistance from Core Staff, the following set of goals and objectives was approved and recommended to RAG. These objectives are not intended to outline a set of programs that would be supported from Core Staff funds, but are intended rather to reflect patient care needs in the Indiana region and to suggest the kinds of activities and projects which the Regional Advisory Group would be likely to view favorably if they were submitted for approval. The document is perceived to be dynamic rather than static, and will likely be modified to reflect changing needs within the region; however, it should serve as a guide to those who will be submitting proposals for funding through IRMP. : The goals and objectives below fall into five categories: prevention, detection, treatment, rehabilitation, and a general category for objectives that overlap two or more of the first four categories. I. PREVENTION A. Goal It is the goal of IRMP to lower mortality and morbidity by means of strategies to prevent the occurrence of illness. B. Long-Range Objectives L. To make it possible for every Indiana citizen to live in an aed mn & mane nandAiei vA tan onnd health. INDIANA RMP -5- RM 43-03 (AR-1-CSD) 2/71 2. To enable every Indiana citizen to avail himself of every feasible prophylactic strategy, from personal health habits to immunization, to avoid disease and disability. C. Short-Range Objectives 1. To enlist the citizens of Indiana in attempts to deal with the the problems of pollution and environmental controls. 2. To increase the availability of proven immunization techniques, particularly for low-income citizens. 3. To increase the dissemination of preventive medicine information. II. DETECTION A.Goal It is the goals of IRMP to lower mortality and lessen disability by means of early detection (and subsequent treatment) of treatable disease B. Long-Range Objectives 1. To provide opportunity for periodic health screening for every Indiana citizen. 2. To educate every Indiana citizen concerning those danger signals of disease which he can himself detect. C. Short-Range Objectives 1. To increase the number of Indiana communities having free or low-cost health-screening facilities. 2. To increase the number of Indiana residents who receive periodic health-screening. , 3. To increase the incidence of disease~detection at a treatable stage. IIL. TREATMENT A. Goal It is the goal of IRMP to reduce mortality and morbidity by making quality medical care available to every sick Indiana citizen. B. Long-Range Objectives 1. To provide opportunity for treatment of illness and disability for every Indiana citizen. 2. To provide means for bringing the latest developments in medical knowledge and practice to the attention of physicians and medical para-professions and technicians. INDIANA RMP -6- RM 43-03 (AR~1-CSD) 2/71 C. Short-Range Objectives l. To increase the availability of medical care, particularly for residents of low-income areas. 2. To encourage and support programs intended to increase the ’ efficiency of health care delivery systems. 3, To encourage and support the continuing education of physicians and allied health personnel. IV.. .REHABLLITATION A. Goal It is the goal of IRMP that rehabilitation services be available to every Indiana citizen, so that the handicaps and limitations resulting from disease and disability be mitigated as much as possible. B. Long-Range Objectives 1. To make it possible for every Indiana citizen to receive professional help to offset and compensate for the debilitating sequelae of disease and disability, in order to allow each citizen to pursue as productive a life as possible. 2. To prolong the longevity and productivity of the elderly as much as possible. 3. To enable those born with physical defects to function normally and effectively in society. C. Short-Range Objectives 1. To increase the number of rehabilitation therapists (S.T., P.T., O.T.) practicing in Indiana. 2. To increase the number of students in rehabilitation training programs in Indiana. 3. Yo increase the availability of rehabilitation services to the rural and urban poor. V. GENERAL/RESIDUAL A. Goal It is the goal of IRMP to enhance the health program in Indiana by all ancillary services consistent with RMP guidelines. B. Long-Range Objectives 1. To bring Indiana to or above the national median in per capita eunniv af nhvsicians and allied health personne]. INDIANA RMP -]- RM 43-03 (AR-1-CSD) 2/71 2. To provide Indiana medical personnel with competence to utilize newly developed equipment and apparatus necessary in medical practice. 3. To stimulate systems for the delivery of health care most effective in utilizing resources and manpower to meet health needs. 4. To enhance a high degree of cooperation among the various groups concerned with health: practitioners, consumers, voluntary agencies, educators, governmental units, health insurance agencies,etc. 5. To encourage redefinition of medical practice patterns of physicians, nurses, and allied health professionals in order to permit more efficient and effective utilization of skills and manpower (i.e. broaden responsibilities of allied health professionals; develop new health disciplines). 6. To reduce the relative cost of quality medical care. Short-Range Objectives 1. To maintain a state-wide health data bank, including data regarding health facilities and manpower, morbidity, and mortality. 2. To support efforts to recruit medical manpower. 3. To extend to remote parts of the state, rural and urban, health care systems which have been demonstrated to be effective in local pilot projects. 4. To inaugurate and support community action groups concerned with health. 5. To develop continuing-education centers at the proposed regional campuses of I.U. School of Medicine. 6. To support the introduction of proven medical practice innovations to Indiana medicine. 7. To encourage changes in the Indiana legal code so as to reflect changing medical practice. 8. To study ways of utilizing available health manpower more effectively. 9. To study ways of developing new manpower in the light of emerging needs. 10. To enlarge the representation on, and. increase the activities and effectiveness of, the Regional Characteristics Committee. 11. To develop cooperative relationships for data collection and utilization with CHP, the Indiana State Board of Health and other agencies. INDIANA RMP -8- RM 43-03 (AR-1-CSD) 2/71 12. To develop methods for determining the cost-effectiveness of medical programs. 13. To increase the efficiency of health care systems. 14, To increase utilization of facilities and reduce per-unit cost. 15. To train technicians to perform tasks now performed by physicians and nurses. 16. To extend the availability of medical care among minority groups and the poor. Organization: The RAG consists of 49 members (22 physicians) provides overall advice and guidance to IRMP and considers all projects as well as the core staff budget. It elects its own officers, Chairman, Vice-Chairman and secretary. It also elects a 12-man Executive Committee to function in the name of the RAG in the interim between meetings. Minority representation includes 2 blacks. Consumers number nine and allied health is represented by 6. Sixteen Regional Committees have a membership of 150 and four area committees account for 118. The RAG meets 3 times each year. The Executive Committee meets two weeks prior to RAG meetings and at other times when necessary. According to the narrative, the committees and local groups are actively involved in planning program development, and project review. The fabrication reflects interweaving of cooperative efforts. The state is divided into 14 sub-regions for purposes and are the same as those for CHP. Because travel time from the central office is minimal, no sub-regional offices are planned. Plans include the use of field represen- tatives. Sub-regional programs are being created through CHPB. agencies (4 now in existence, 6 campuses of Indiana and Purdue University, hospitals participating in the graduate and continuing medical education system of the Indiana University Program for state-wide Medical Education and 7 Indiana University Centers for Medical Education). The project planning development and review process begins with the originator forwarding a summary to the Coordinator. If the idea is within the scope of IRMP, a team (1 central staff, 1 member of an appropriate IRMP committee and 1 representative of an appropriate health agency) are appointed to assist the applicant in the development of a proposal. If there is an active CHPB agency in the area, a representative is invited to participate in the development and review of the proposal. The completed proposal is reviewed by the Scientific Advisory Committee, after which a formal site visit is made. With the benefit of the reports from the Scientific Committee and site visit team, the Executive Committee reviews the proposal and makes recommendations to the RAG. The RAG makes the final decision based on their review including comments and recommendations of the three prior review including comments and recommendations of the three prior review groups. The project proposer appears before both the Executive Committee and RAG. DIVISION OF REGIONAL MEDICAL PROGRAMS INDIANA REGIONAL ADVISORY GROUP | COMMITTEE cre laid ttl EXECUTIVE ) RENT RULES and MEMBERSHIP “COMMITTEE LONG-RANGE GOALS and OBJECTIVES CENTRAL STAFF | ae Moc cadmiseunctan'ani CORONARY CARE CHAIRMAN Dr.. Fisch CHRONIC DISEASE Dr. Daly Dr. Matzen PEDIATRIC CARDIAC DISEASES CHAIRMAN Dr. Girod RESPIRATORY CO-CHAIRMEN comment BUDGET and. FINANCE COMMITTEE en EN A TE STANDING COMMITTEES ee REGIONAL CHARACTER- ISTICS CHAIRMAN Dr. Yoho NEIGHBORHOOD HEALTH CENTERS MULTIPHASIC SCREENING CHAIRMAN ‘ R, De Frantz CHAIRMAN Dr. Murray SCIENTIFIC ADVISORY PLANNING and EDUCATION | COMMITTEE | SAPS AAI TIO ORIENT COMMITTEE HEALTH MANPOWER CANCER CHAIRMAN J. Davidson CHAIRMAN Dr. Geisler HEALTH HAZARD PROGRAMMING CHAIRMAN Dr. Hall NURSING CHAIRMAN J,Schweer, R.N. 10-1-70 INDIANA RMP -10- RM 43-03 (AR-1-CSD) 2/71 Core staff is divided into four distinct budgets: the Coordinator's Office (central core), and three feasibility study core groups (Cancer Committee, Regional Characteristics Committee (data) and Continuing Education and Technical Support). The Central staff consists of 10 professionals and 4 secretaries. Pro- fessional personnel includes 3 new positions; 2 field representatives and a staff assistant. The staff assistant's role is geared to project control and evaluation (progress reporting, financial status and evaluation including determining costs effectiveness). Initiation of developmental component activities will add to existing staff responsibilities. Three positions are currently unfilled: the epidemiologist, one field representative and one secretary. ‘The Cancer Committee Core consists of a full-time physician and two secretaries. The Regional Cancer Committee and staff have established 13 sub-regional committees. The Regional Characteristics core (3 professionals and 3 clerks) is a data gathering group, including continuing studies of hospital discharge and related morbidity and mortality data. The Continuing Education and Technical Support staff's (3 professionals @ 25% time and 2 secretaries @ 50%) most significant contribution is apparently the planning and implementation of 10 postgraduate courses annually co-sponsored by IRMP and the Indiana University School of Medicine. Following is a list of core staff budgeted for the 03 operational year (1971) and the organizational chart. COORDINATOR'S OFFICE (Core Staff) Institution % Time Title Affiliation Effort Professional R. B. Stonehill, M.D. Coordinator Ind. University 100% - 12 mo. R. A. Hagstrom Dir. Program Management " " H. C. Smith Dir. Nurs. & All. Hlth. Sc. " " G. F. Leamnson Dir. Community Relations J. Svaan, Ph.D. Dir. Educational Services " " C. R. Hudson Dir. Admin. Services " " To be Appointed Epidemiologist " " J. B. White Field Representative " " E. Ferguson To be Appointed Staff Assistant Field Rep. INDIANA RMP -11- RM 43-03 (AR-1-CSD) 2/71 CONTINUING EDUCATION AND TECHNICAL SUPPORT (A Portion of Central Staff) Personnel Name & Title J. Royer, M.D. To be appointed To be appointed Sharon Bowers To be appointed Assist. Dir. of Postgrad. Ed. Conference Coordinator Education Evaluator Secretary Secretary CANCER COMMITTEE (A Portion of Central Staff) William M. Loehr, M.D. Project Director Mary Chitwood Carolyn Henry Name & Discipline Cancer Committee Activities Secretary Secretary (South Bend) REGIONAL CHARACTERISTICS SECTION (Core Staff) RMP Job Title or Function D. Parrott F. Brown M. Hensley R. Valentine C. Hensley S. Graves Research Associate Reg. Char. Analyst - Reg. Char. Clerk - Reg. Char. Clerk - Reg. Char. Clerk - Data Bank Analyst - Data Bank Institution Affiliation (Includ. Subunits, i.e., Institution Affiliation Time IUSM 25% LUSM 25% IUSM 25% IUSM 50% IUSM 50% Indiana University 100% Indiana University 100% Indiana University Part-Time (Hourly) Time or Effort Depts., Schools, etc.) % / Hours Indiana University 1007, Indiana University 1007, Indiana University 100% Indiana University 100% Indiana University 100% Indiana University 100% INDIANA REGIONAL MEDICAL PROGRAM ;--+ CENTRAL STAFF ORGANIZATION INDLA NA REGIONAL ADVISORY G , ROUP } bao REGIONAL MEDICAL PROGRAM COORDINATOR Dr. Stonehill paconassener a o E ASST. DEAN FOR #) | DIRECTOR OF N DIRECTOR OF tt OF ; DIRECTOR OF ff CANCER DIRECTOR OF DIRECTOR OF F POSTGRADUATE COMMUNITY {4 NURSING and * PROGRAM ADMINISTRATIVE }; COORDINATOR EPIDEMIOLOGY EDUCATIONAL] AND CONTINUING { RELATIONS {{ | ALLIED HEALTH +) | MANAGEMENT SERVICES ; SERVICES EDUCATION HM | Tomson fy SCIENCES | os B Dr. Beering 4 emai i H.C. Smith Hagstrom I C, Hudson b Dr. Loehr ti H Dr. Svaan . | =J smeeaad ed 1 i . i ' * { g 7 B Poms IAA " a a | a 5 a | e DIRECTOR OF STAFF DIRECTOR OF DIRECTOR OF | UMC MEDICAL FIELD : IUMC RESEARCH IUMC MEDICAL { EDUCATIONAL REPRESENTA- ASSISTANT COMPUTATION ILLUSTRATIONS | RESOURCES TIVES E “CENTER _—S) CORONARY CARE a A A I STANDING COMMITTEES ee PEDIATRIC CARDIAC DISEASES REGIONAL CHARACTER- ISTICS STROKE CANCER HEALTH MANPOWER CHAIRMAN Dr. Fisch _ CHRONIC CHAIRMAN Dr. Girod CHAIRMAN Dr. Yoho CHAIRMAN Dr. Dyken CO-CHAIRMEN Dr. Geisler Dr. Hornback HEALTH Dr. Matzen CHAIR MAN J. Davidson RESPIR! MULTIPHASIC NEIGHBORHOOD HAZARD eae SCREENING HEALTH CENTERS NURSING PROGRAMMING CO-CHAIRMEN CHAIRMAN CHAIRMAN CHAIRMAN CHAIRMAN Dr. Daly P. Johnson Dr, Murray J. Schweer, R.N, Dr. Hall 10-1-70 of INDIANA RMP -13- RM 43-03 (AR-1-CSD) 2/71 Annual Report of the Indiana Regional Advisory Group: The IRMP RAG addressed goals and objectives as outlined in that part of this summary . "This report covers year 02 of the Operational activities of the Regional Medical Program and sufficient data do not exist relative to cost effective- ness of such programs. Such information will emerge as more data are accumulated and more detailed program evaluation are made." Relationship to other programs concerned with planning and improvement of the organization and delivery of health services. "Direct participating relationship exists between the State and area~- wide Comprehensive Health Planning Programs (P.L. 89-749), for the Director of the State Comprehensive Health Planning Program is a member of the Regional Advisory Group and is Chairman of the Committee on Regional Characteristics of the Regional Medical Program. Equally there is direct participating of the Regional Medical Program and Model Cities Planning through the activities of the standing Committee on Neighborhood Health Centers. Metropolitan Health Council of Indianapolis has submitted a project request to Model Cities for funding of Neighborhood Clinics. Until recently, Indiana has not had a state OEO office. Plans will now be de- veloped to integrate appropriate OEO programs into Regional Medical Program's goal and objectives. Cooperative relationships exist with Medicare, Medicaid, welfare, Hill-Burton, atmospheric pollution, radiation health, manpower development, and various HEW programs involved with professional education, stipends, and continued education." Impact of the Program "Tt was suggested that the Regional Advisory Group evaluate the impact of the program in: (a) quality of individual care provided; (b) more efficient utilization and organization of resources; and (c) improved distribution of services so as to be more readily available and assessible to all within the Region. At the moment it would be more difficult for the Regional Advisory Group to evaluate items (a), (b), and (c) listed above. The program has not been operational to the point in time that would permit such qualitative evaluation by the Regional Advisory Group. Evaluation will require a related and mean- ingful system of data collection and analysis. The Regional Characteristics Committee is currently in the process of developing techniques whereby such data can be accumulated.’ Without the obvious advantage of quantitative and qualitative data it is the impression of the Regional Advisory Group that the impact of Regional Medical Program on the quality of individual care provided has been most positive. This is based on the activities of the following operational programs: Coronary Care, Stroke, Nursing in Coronary Care Units and Chronic Pulmonary Disease. INDIANA RMP. -14- RM 43-03 (AR-1-CSD) 2/71 It is further felt that there is sufficient utilization and organization of resources as demonstrated in the Flanner House Multiphasic Screening Program, and Health Hazard Appraisal Program. Improved distribution of services can be reflected in the activities of the Neighborhood Clinics of the Metropolitan Health Council, Stroke and Coronary Care Units." The RAG further reported that the IRMP is an excellent program under strong, efficient administration and with a staff which exhibits an unusual sense of pride in its organization. The grantee institution is the Indiana University Foundation, a non-profit organization chartered in 1936. The Foundation is a separate and distinct entity and does not come under the supervision of Indiana University. However, key officials of the University serve on the Board of Trustees of the Foundation. The relationship of the Foundation to IRMP is essentially that of a fiscal nature. The IRMP staff reports directly to the RAG which has administrative authority over the program and is responsible for the development of overall IRMP policies. The RAG acts in a stewardship role as well as advisory. The IRMP staff are employees of Indiana University and are, therefore, subject to all rules and regulations of the University. Salaries of staff are based on a survey of wage structures in and out of the Region. Evaluation: As indicated in the application, an effort is being made to strengthen this aspect. A staff assistant has been employed and will concentrate on this area. The "Regional Characteristics” section of core also plans to aid evaluation. Developmental Component: The IRMP has requested $127,000 which is an amount equal to 10% of the current level of funding, excluding authorized use of carryover funds. The Region believes that it has the capability of administering these funds that will permit them to move rapidly and effectively into new programs and activities. Much of this activity will be based on current and continued studies by Long-Range Goals and Objectives Committee. Potential areas: Rural Health Care, extension of health centers, disease prevention, studies of health care delivery systems, feasibility studies, coronary care programs, health manpower studies, leadership development, community information and referral programs, home health care, and program planning and development. The process of review and management is adequately described. Requests for more than $10,000 must be acted upon by the RAG. Applications for less than $10,000 may be approved by the Executive Committee without review by the RAG. Requests for less than $5,000 may be acted upon by the Program Coordinator (chief executive officer of the RAG). Supplemental Projects: Requested Project #23 - Cigarette Smoking Deterrent Program First Year This is a pilot program that will try to $9,005 develop a unique anti-smoking program at the high school level. The program will be carried out by a group of students in one high school. INDIANA RMP -15- RM 43-03 (AR-1-CSD) 2/71 A similar school will serve as a control. The project effectiveness will be evaluated by assessing behavior and attitudes of random samples of students in the two schools before and after the program. The special student group (council) will be selected by the project director in consultation with the school administration and faculty. No restrictions will be placed on the student council in the development of program. However, the project director and an Advisory Board will be available to consult and assist the students. Second Year Third Year -0- -0- Renewal Projects: Requested Project #5R - Health Manpower Recruitment This is a First Year request for renewal of a project submitted $25,000 with the initial operational application for three years support at an approximate annual level of $316,000. The September 1968 site visitors recognized the project director's enthusiasm about the proposal but did not believe the protocol was sufficient. The program was already ongoing supported by an annual budget of $60,000 provided from numerous community organizations, and there was no evidence of effectiveness. As recommended by the site visitors, the Review Committee and Council, the project was approved and funded in the amount of $25,000 for one year only. The current application indicates that the project is presently budgeted at $60,000, $25,000 from (5/12) IRMP, and $35,000 7/12 from CHP and the Indiana State Health Department with 314-D money. The purpose remains to be the motivation recruitment and admission of students and adults to education/training for health professions. The objectives and methods are unchanged. Much of the activity is devoted to dissemination of literature and responding to requests for information. Work is also carried out in the core city program through schools, i.e., consultation, in school programs, and workshops for guidance counselors. Second Year Third Year -0- -Q- Requested Project #6R - Prospective Medicine This is also a request First Year for renewal of a project which was submitted $20,734 with the initial operational application for three years' support at an approximate annual level of $370,000. The September 1968 site visit team noted the enthusiam among practitioners for the program and the concept of the health hazard approach seemed educationally stimulating. However, several deficiencies in the proposal were noted. The small number (40) of physicians receiving the continuing education reflected its high costs. The health hazard concept was innovative but the teaching techniques were traditional. No plans were outlined for evaluating the effect of the program in improving health care. As INDIANA RMP ~16- RM 43-03 (AR-1-CSD) 2/71 recommended by the site visitors, the Review Committee and Council, the project was funded for one year only in the amount of $20,734. The pro- ject also has received a grant of $73,830 for the period July 1, 1970- July 31, 1971 from the Indiana State Board of Health (314-D funds). The objectives of this project are concerned with the performance of health hazard appraisal in three different medical care situations; a small community hospital, the family physician's office and two neighbor- hood health centers. Accomplishments include a manual for the practice of medicine and exhibits at State and National medical meetings resulting in appraisals on 1000 physicians. Second Year Third Year -0- -0- Requested Project #9R - Neighborhood Health Centers This is a request First Year for renewal of a project which first began $584,827 as a feasibility study during the planning and received one year's support in the amount of $169,550 for one year during the 01 operational period. The site visitors (September 1968) found this to be an impressive endeavor directed by capable people. It was noted that RMPS support was only about one third of the anticipated costs and funds from other sources, i.e., local groups, Flanner House and 0.E.0., would be sought. The visitors had no hesitation in recommending its support, but believed it to be the type of activ-ty that could be supported in the future by Model Cities, CHP, 0.2.0. etc. Renewal for one year was requested, approved and funded in the amount of $169,550 for one additional year. The reviewers were somewhat uncertain as to the relationship of the project to the goals of RMP legislation. It was believed that an additional year would allow the centers to become firmly established and provide the necessary time to be brought under funding agencies for these purposes, i.e., Model Cities. Two companion activities serve the Indianapolis Model City; #2 "Multi- phasic Screening" and #9R "Neighborhood Health Centers". According to information received from the RMPS representative, HEW Region V Office, the projects qualify for Model Cities certification. The three health centers, each operated by a hospital, are sponsored by the Metropolitan Health Council. The aim of the project is to provide high quality continuing medical care to the disadvantaged. 130 patients were screened at the Southeast and Central Avenue Centers. The Martindale Center has seen 376 of 453 patients referred there from the multiphasic project. One or more diseases were diagnosed in 291 of their patients. Second Year Third Year $477,280 $524,058 INDIANA RMP -17- RM 43-03 (AR-1-CSD) 2/71 Project #16R -: Chronic Pulmonary Disease This is a Requested request for renewed support of a project First Year originally proposed, approved and funded for one year. $40,561 The support was to provide a five-day conference for individuals | trained previously and newly identified physicians. The RMPS Con- tinuing Education and Training Panel recommended disapproval on technical grounds stating that past progress had not been well docu- mented. Since the Region had already been authorized to use unexpended funds to begin the activity, the Committee believed it should be allowed one year to complete the program; the basis for it's approval and funding. The major aim of the current proposal is to improve education in Pul- monary Disease through the development of sub-regional centers by: 1) Training and continuing to train increasingly larger "target groups" of physicians from hospitals geographically representative of the various communities within the state; and 2) Maintaining continuous contact with these "trainees", (a) providing them with guidance and supervision, and with the teaching techniques, material and aids necessary to promote and encourage in their own institutions teaching activities intended to divulge information in this field to a larger group of community practicing physicians, and 99:1” (b) assisting them in making available in their respective communities diagnostic and therapeutic facilities and services, such as pulmonary function laboratories, rehabilitation stations and respiratory care units. The applicability of this educational model was evaluated and tested in the past two years, during which time the program was considered as a pilot, and feasibility study. From all the information available it can @ inferred that this educational system has been very successful. Beginning with 9 participating hospitals from large geographic areas within the state and with 12 "trainees," the various activities were gradually expanded to include at present 16 hospitals and 29 "trainees". At least 10 of the sub-regional "centers" so developed are now participating very actively within the functions of the IRMP. At this time it is felt that the scope and the operational scale of this program are ready to be expanded and it seems most desirable to have it supported over the ensuing three years. Second Year $40,311 ut ate Third Year $35,615 INDIANA RMP 7 -18- RM 43-03 (AR-1-CSD) 2/71. Projects Approved- -Unfunded or Partially Funded With no Commi tment ‘for Which Support is Now Requested. Project Years . oe Funded — “Ipproved 7 Commit . isnroned Commit ‘ a1 $ 82,036 2/ $51,450 $g8,850 -0- oe 4 #12 3/109,003 = -0- | - 69,702 -0- | $72,375 = -0- #13 40,428 2/ 40,428 36,947 -0- 38,720 = #14 27,497 2/ 26,197 29,064 | -0- = 30,026 -0- me 41,966 0-0 30,050 -0- 32,390 -0- Total $191,927 $118,075. «$254,613 —-0- $173,511.-0- ’ Footnotes: . 2/ supported » from carryover funds in the 2nd operational year 3/ approved with no additional funds. - GRB/RMPS 11/25/70 Reply to Altn of: Subject: To: Thru: Date: ¥ ' ) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE » e PUHLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION December 15, 1970 Staff review November 23, 1970, of Indiana Regional Medical Program's Continuation Application RM 00043-03 (AR-1-CDS) 2/71. Acting Director Regional Medical Programs Service Chairman of the Month I Ay Chief, Grants Management Branch ; . uw ee Oy F Acting Chief, Regional Development Branch , Va Be Ot ny Oot bar Request: The continuation request is part of the IRMP's initial applica- tion for $2,184,011 (d.c.o.) for their 03 operational year, This amount includes their supplemental application (two projects) con- sidered by the November 1970 Council and deferred for the December 1, 1970, site visit. . The continuation request is for $1,302,042 ($1,121,411 commitment and $180,631 carryover) for core and seven approved projects. Three of the projects approved with three year commitments have been ongoing two years. Three of the approved projects (two for three years and one for two years) were begun during the current year from carryover funds with no commit- ment. One approved for three years is to commence during the 03 year with support from both the committed level and carryover. Continuation of projects #5 and 6 from carryover was also requested, but GRE claff advised the Region that these were approved and funded for one your only and will now have to be considered as renewals by the February 19/1 Council, Meanwhile, an extension for three months with additional funds should be considered until renewal status is acted upon. Recommendation: Approval in the amount of $1,175,591 d.c.o. including the use of carryover or new funds in the amount of $54,180.. Basis for level recommended: Committed Carryover or Level New Funds Total Core $422,573 $422,573 #4 Ccu 157,250 157,250 #3 Stroke 271,000 271,000 December 15, 1970 Harold Margulies, M.D. -2- Committed Carryover _or Level New Funds Total #2 Multi Screening 225,000 225,000 #11 Nursing Allied : Health Cont. Ed. 45,588 42,747 88,335 #5 Health Manpower (3 mos.) 6,250 6,250 #6 Prospective Med. (3 mos.) "5,183 5,183 $1,121,411 $54,180 $1,175,591 The attached summary of O01 and 02 awards and 03 request and recommendations may be helpful. This recommendation is based on staff review and site visit information attained during the December 1, 1970, site visit. Project #11, Nursing and Allied Health Continuing Education, is a statewide program of vast importance to the Region. Core staff has invested a great deal of time in its development and necessary cooperative arrangements. Continucd support would allow completion of the two year activity. The site visitors agreed to recommend approval of renewal of projects #5 and 6. This then is the reason for staff's recommendation for their extension for three months until renewals are acted upon. Support is not recommended for project #18 (N.W. Indiana CC) because it is a three year project and there is no assurance of continuation. Also, like most projects, there would be some time required for tooling up. Projects #13 (Nursing in CC) and #14 (Library Program) were funded froin carryover funds with the understanding that no further RMP support would be required. A group recommendation was not agreed upon by staff during their November review. The above recommendation is based on the review and subsequent site visit - December 1, 1970. Messrs Says, GRB, and Robertson, RDB, were members of the team. Staff reviewers’ comments prepared prior to the site visit are attachcd, including Mr. Teets', GMB, who recommended approval at the commitment level. A site visit was made December 1, 1970, and a report will be pre- sented to the January 1971 Review Committee. The site visitors believe that in the absence of a meaningful specific data based statewide plan, the IRMP is not ready for a developmental component. llowever, the team expressed confidence in the coordinator and staff leadership, as Note: exc Harold Margulies, M.D. -3- December 15, 1970 well as general speculation of present project activities, The visitors will support a recommendation for approval of three new and four renewals ($927,703 d.c.o.). t The site visit confirmed staff's concerns about the need for better evaluation. Some effort has been made to strengthen this aspect, includ- ing the employment of a staff assistant. The regional characteristics section of core (health data unit located at the Indiana State Board of Health) seems to be a fragmented effort from planning, development and evaluation. Outside consultation might be beneficial. Also, IRMP should explore cost sharing of data service. The IRMP letter December 9, 1970, to you is an accurate accounting of the site visitors’ feedback and recommendations. Hopefully, the IRMP will consider the scope of work required prior to their next submission of August 1, 1971, and necessary rebudgeting. 4 | “N fy rye i a Coed x f ‘ wf ‘Sarah J, Silsbee Acting Chief Grants Review Branch - (fhorwwep re ort - 70 \ U Coe (| 2 Action by Director vt "| & cen LAOe.. { : one A Initials TVW / / Date Veo Attachments: 1. Summary of 01 - 02 awards and 03 request and recommendation by GRB and RDB 2. Recommendation by GMB 3, Review comments by GRB and’ OPPE staff 4. Copy of IRMP's letter December 9, 1970. RMPS staff who attended this continuation review meeting: L. J. Says, GRB Lee Teets, GMB Dale Robertson, RDB Leah Resnick, OPPE Mary Asdell, CETB A. PRIVILEGED COMMUNICATION SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE INDIANA REGIONAL MEDICAL PROGRAM RM 43-03 (AR~1 CSD) 2/71.1 & 2/71.2 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL - Recommendation: The Committee considered the supplemental portion of the s application for support of four renewal: projects, one new project and the developmental component. The supplemental application for support of two new projects deferred for a site visit by the November 1970 Council was also considered, In view of the site visit findings, the Committee recommended disapproval of the developmental. However, contrary to the site visitor's recommendation, the Committee recommends additional funding in the amount of only $150, 060 for . operational activities. Note: The continuation portion of the application was reviewed and acted 2 upon by staff, An award in the amount of ‘the committed level ($1, 121,411) for core activities and six projects was being processed in commensurate with IRMP's grant period beginning January 1,°1971. Critique: A draft report of the December 1, 1970 site visit was presented, findings of which were highlighted by a~Committee member of the site visit team, Of major concern to the site visitors was the broad general objectives and lack of a data base by which goals could be reduced to priority-oriented specific work to meet defined deficits in the Region. This problem coupled with the array of projects precluded a program prospective, Evaluation was cited as another weakness. Despite these problems, the visitors believe that the IRMP has.strength and potential capability, The organizational structure is basically sound, There was evidence of competent staff leadership, as well.as RAG involvement, The review process including technological input seems adequate, Although thereare no formal geographic sub- ~regions, outreach programs to the grass roots do exist. Linkages with. resources |, necessary to viable operations were apparent. The site visitors. concluded that in the absence of a meaningful and specific data-based “ statewide plan, the IRMP is not ready for a developmental. component and did not recommend its approval. The team, however, did express confidence in the Coordinator, and general speculation of the present project activities. The team recommended approval of the proposed three: new projects and four renewals ($800,703). The application and the site visit findings prompted a great deal of ‘discussion and debate about appropriate action to be taken. The ‘dichotomy between the written descriptions. and what has actually Sane Indiana RMP ~2- RM 43-03 (AR-1 CSD) 2/71.1 & 2 been done was recognized, and one of the values of site visits is finding out reality. . Concern. was expressed about disapproving the developmental component (approximately 10% increased funding), and on the other hand approving all new and renewal projects (60% increase). There was agreement that the site visitors found some good projects in the Region that just did not happen, They were nurtured by IRMP. The problem is that the activities are like stepping stones that lead no place. There was solidarity in'the opinion that the word must gét to IRMP. that their next Anniversary Review Grant Application reflect. the suggestions made to them by the site visitors. There was disparity in reaching a decision on recommendation of the funding level, The Committee questioned whether the Region had taken any positive action since the site visit. In response, staff advised that the IRMP got the site visitors’ message and that. they seem to undetstand the scope of work to be undertaken prior to their next submission in August 1971. A retreat for Core staff and. RAG was anticipated in January 1971. - Before reaching agreement on a recommendation, two motions did not carry. The first motion for “disapproval of the developmental and additional $400,000 for one year for projects with a clear message’, was defeated. The second motion "approval in the amount requested for one-year with a clear message", was not seconded, In conclusion, the Committee recommended additional. funds in the amount of $150,000 d.c.o. with strong advice to the Region: 1) that funds be used in-the necessary planning to move the program forward as ‘recommended by the site visitors; 2) future proposed activities be based on scientific study, of needs and priorities; and 3) evaluation include patient. care “: benefits. CRB/RMPS 1/19/71 ; REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) INTERMOUNTAIN REGIONAL MEDICAL PROGRAM RM 15-05 (AR~-1 CDS) 2/71 50 North Medical Drive January 1971 Review Committee Salt Lake City, Utah 84112 PROGRAM COORDINATOR: Hilmon Castle, M.D. FOR COMMITTEE/COUNCIL REVIEW 05 Year 06 Year 07 Year Total Developmental $ 75,000 $ 75,000 Two Renewal Projects 321,022 $328,336 $351,673 1,001,031 Three New Projects 367,014 368,508 389,194 1,124 ,716 TOTAL $763 ,036 $696 ,844 $740,867 $2,200,747 . FOR RMPS STAFF REVIEW 05 Request Core $ 973,090 11 Projects 1,489,034 $2,462,124 © Committed 2,446,230 See attached Summary of Staff Review. FUNDING 05 Year 06 Year 07 Year New $763,036 $696,844 $740,867 Ongoing 15,894 Now Committed $2,446,230 $2,417,167 -0- TOTAL DIRECT COSTS $3,225,160 $3,114,011 $740,867 FUNDING HISTORY Planning Year Awarded 01 S$ 456,415 02 350,294 Operational Year 01 1,832,760 02 2,267,074 03 2,445 ,193 04 2,986,791 Commitment 05 2,446,230 Intermountain RMP -2- RM 15-05 (AR-1 CDS) 2/71 GEOGRAPHY AND DEMOGRAPHY: The region encompasses an area of 564,000 square miles, including the State of Utah and parts of Nevada, Montana, Idaho, Wyoming and Colorado. The greater portion of the land area is arid or mountainous and is sparsely populated. Approximately one-third of all the people reside : in a small irregular rectangle some 80 miles long by 1 to 25 miles wide, centered in Salt Lake City. Most of those remaining, live in 13 cities of 20,000 to 50,000 population and 25 smaller towns of 5,000 to 20,000 persons. Some uncertainties relative to boundaries probably attend all areas except the State of Utah. Salt Lake City is the approximate geo- graphical center of the region, and it also represents the trade, educa- tional, religious, cultural, social, as well as medical center for all of Utah, southern and eastern portions of Idaho, western Wyoming, northern Nevada, southwestern Montana, and the area in Colorado which lies on the western slopes of the Rocky Mountains. Salt Lake City is the well- established center for all methods of transportion. The population numbers roughly 2.25 million for the region, with about 50% urban. In addition to the University of Utah School of Medicine, there are seven institutions of higher learning, each with a pre-medical program and training for allied health personnel. Four have nursing degree programs and two provide advanced studies in nursing. The University of Utah has a Bureau of Community Development experienced in conducting surveys of health needs. The region contains a total of 87 hospitals, with 10,230 beds. There are 2,100 physicians (94/100,000), and 7,000 registered nurses, 5,200 who are active (231/100,000)._ HISTORY OF REGIONAL DEVELOPMENT: The University of Utah School of Medicine began planning for a Regional Medical Program in mid-1965. In October 1965 a fulltime Coordinator was appointed. Numerous meetings throughout the region were conducted during this pre-planning period. The region based its planning on five areas: community and planning resources; manpower; inservice training programs; continuing health education; and hospital facilities and equipment. The Intermountain Regional Medical Program was one of the first programs to submit an application for operational grant funds. A site visit was made to the Region in November 1966, and the site visitors reported the program was ready for operational status, the RAG was prepared to assume responsibility for priority setting, and that the proposed activities Intermountain RMP -3- RM 15-05 (AR-1 CDS) 2/71 would extend existing expertise from the University of Utah Medical Center to hospitals throughout the five-state area. The proposed operational program was weighted toward continuing education and cardio- vascular disease activities. The inclusion of a physiological monitoring research and development project, under the direction of Dr. Homer Warner, was also proposed, and a special technical site visit was recommended, and later carried on to appraise this aspect of the proposed program. The first operational grant was awarded in April 1967 for a three-year period. During the next three years, new activities were added in stroke and related diseases areas; the initial thrust in the cardiovascular field was continued and heavy emphasis was placed on continuing education and training. In 1969 the region requested renewal support for Core and all ongoing projects, and a site visit was again made to the region in October 1969 to study the results of the three-year funding and the region's plans for the future. The 1969 site visitors were much impressed with the accomplishments that had ensued in the past three years. Patient care services and trained personnel existing throughout the region were direct results of the Regional Medical Program. The region had developed a capable core staff, apparent good working relations with physicians and nurses in hospitals and was beginning to think in non-categorical programming terms. The site visitors commended the core staff and the RAG for the accomplishments of the past three years, but urged them to consider turning the program in other directions away from the concentra- tion in categorical diseases diagnosis treatment, and toward prevention as well as un-met health delivery problems existing throughout the region. The site visitors also urged the region to concentrate more on developing people relationships and less on technology as the primary vehicle for regionalization. In the Spring of 1970, the region submitted a request for funding to develop multi-phasic screening activities for a 314(e) Neighborhood Health Center in downtown Salt Lake City for the urban poor. This was approved and funded. The application for the fifth operational year at the commited level was reviewed by RMPS Staff in November 1970. A copy of that review is attached. REGIONAL ADVISORY GROUP: Three new consumer representatives have been added during the past year. An effort to involve members in identification of high priority problems and in feedback is being attempted. Three new Task Forces on Health Manpower Problems, Health Services for Medically Impoverished, and Program Impact Evaluation have been organized. Membership on all such groups always reflects personnel from outside the Salt Lake City area. Some members of the RAG are also members of the Health Planning Council (314b), Intermountain RMP - -~4~ RM 15-05 (AR-1 CDS) 2/71 The region is reported to have developed a very comprehensive review process which was time-consuming but apparently responsible and mature. The RAG was involved in several stages of 27 steps in project development. PRESENT APPLICATION FOR ADDITIONAL FUNDING DEVELOPMENTAL COMPONENT: The amount requested is $75,000. These funds will be invested in pro- jects that can become self-supporting quickly. Not less than ten such activities will be ready for implementaion by April 1, 1971. Priorities will be aimed at health services to both urban and rural poor, and studies to improve productivity of physicians and health personnel for more efficient use of health resources. The RAG will allocate such funds and will analyze the proposals in light of needs, resources and program priorities. RENEWAL AND NEW PROJECTS: The application requests renewal support for two. on-going projects, #16R - Endocrine Program and #18R - Model Stroke Program, and funding for three new projects, #30 - Chronic Respiratory Disease Project, #31 - Diabetes Education, #32 - Head, Neck, and Oral Cancer Detection Training. A comparison of the types of activities supported now in this fourth operational year with the request in regard to the portions allocated to various areas follows: Components by Disease Category Present Proposed Heart 19.5% 17% Cancer 6% 82 Stroke 4% 52% Related Diseases 9% 17% Multi-Categorical 32% 22% General 29.5% 31% Components by Type of Activity Training and Education 21.1% 25% Demonstration of Patient Care 33.8% 30% Research and Development 15.5% 15% Administration and Planning 29.5% 31% Thus, it can be seen that the Region. is making a slight change in direction. The above figures do not include the proposed developmental component of $75,000, which will be utilized for venturing into new areas of programming. RMPS/GRB 12/1/70 Date: Reply to Alin of: Subject: To: DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HRALTH GERVICES AND MENTAL HEALTH ADMINISTRATION November 27, 1970 Staff Review of Continuation Portion of Application - Intermountain Regional Medical Program RM ~-15 Acting Director. Regional Medical Programs Service . Through: ; Chairman of the Month CP phe ‘ te —e Acting Chief, Regional Development Branchsj oo Acting Chief, Grants Review Branch of ghee | : General: The request for continuation of eleven ongoing projects, renewal of two, three new (supplemental) projects, one pre-termination project, Core staff activities and a proposal for a Developmental Component comprised the Anniversary Review application from IRMP, This memorandum will deal with the request for continuation of Core and existing projects and staff discussion and recommendations about the region, There were questions raised and some differences of viewpoint relative to how the region attempts its evaluation. In general, the staff agreed that it is an outstanding RMP, with agressive and dynamic leadership, and exhibits in the present application many examples” of efforts to improve and balance its health planning. These were noted in the newly developed Planning Guide which was designed as a working document for staff and R.A.G. to deal with accessibility, quality, efficiency and comprehensiveness of health care and services. The region has increased its sub-regionalization efforts through the delegation of some responsibility for project development and management to the Medical Education Coordinators (9). The Core staff has been reorganized into three Divisions, each headed by an Associate Coordinator: Operational Projects Division, Administrative Services Division, and Program Development Division, the latter as yet largely unstaffed. Total Core staff (exclusive of project personnel) numbers 52 FTE. An additional fifteen full and part-time are being recruited which will bring the FTE total to 63, The Coordinator continues in an Acting capacity. He has assumed the chairmanship of the Department of Community and Family Medicine at the University of Utah School of Medicine. A Search Committee of the RAG is seeking a full-time Coordinator, Page 2 ~ Acting Director, Regional Medical Programs Service Regional Advisory Group: _Three new consumer representatives have been added during the past year, A former Chairman of the R.A.G, now serves on the Review Committee at the national level, An effort to involve members in identification of high priority problems and in feedback is being attempted. Three new Task Forces on Health Manpower Problems, Health Services for Medically Impoverished, and Program Impact Evaluation have been organized. Membership always reflects personnel from outside the Salt Lake City area, but there was some concern expressed by staff about lack of répresentation from organizations such as the American Heart Association and other voluntary groups. Some members of the RAG are also members of the Health Planning Council (314 b). Evaluation: There was a difference of opinion as to the rang? or scope of the region's evaluation methodologies, Staff who participated in the renewal site visit of a year ago, recalled that the team had felt that, while the educational evaluation was scholarly and effective, the region had not broadened its evaluation process sufficiently to zero in on problem areas of individual projects. On the other hand, the representative of P & E, who has worked closely during the past year with Dr. Schorow, feels that IRMP has developed one of the outstanding systems in the country for project evaluation, which includes a mechanism for building in evaluative methods from the beginning of project development, and involving R.A.G. members throughout the process, . Financial Management: The region has a good record of sound fiscal management, The Director of Budgetary Services trains and assists project managers in preparation of budgets; monthly financial reports are prepared and the financial status of all projects is monitored by the Associate Coordinator for Administrative Services and periodic reviews are provided to the R.A.G. There is an unresolved question of balances accruing from previous years, for which the region has submitted*request for re-budgeting. The request coincided with the RMPS Director's memo dealing with carryover funds, and a request was submitted for a "special" consideration. This was approved and a letter is in preparation which will allow the region to request the amount that they would reprogram to remain unexpended at the remainder of the 04 budget year, This would permit the funds to be reauthorized for their use in the 05 period in addition to the committed fund level of $2,446,230. Cooperative Planning and Involvement: The Community Health Centers Foundation organization was the result of IRMP staff involvement with the encouragement of a R.AsG. Task Force on Poverty Problems. This has resulted in the funding from PHS and OFO of $953,739 for a new ambulatory care unit at the University Hospital, and improvements in rural health care for Utah, IRMP involvement is gradually phasing out as the Foundation hires its own staff, The establishment of the 314 B agency was also the result of IRMP staff efforts. The region referred to past misunderstandings with neighboring regions and cites several examples of cooperative efforts to improve understanding. Page 3 - Acting Director, Regional Medical Programs Service IRMP and Mountain States are jointly funding a Medical Education Coordinator for Pocatello and the Southeastern Idaho area, and the two RMPs will jointly sponsor a stroke rehabilitation workshop and an Allied Health Manpower Conference during the coming year. Regular meetings of IRMP and Colorado-Wyoming staff members have helped to strengthen lines of communication, The IRMP and Colorado-Wyoming RMPs are developing jointly a program in continuing education for Western Colorado and Eastern Utah. Developmental Component: The amount requested is $75,000. These funds will be invested in projects that can become quickly self-supporting. Not less than ten such activities will be ready for implementation by April 1, 1971. Priorities will be aimed at health services to both urban and. rural poor, and studies to improve productivity of physicians and health personnel for more efficient use of health resources. The RAG will allocate such funds and will analyze the proposals in light of needs, resources and program priorities. Questions: While there was consensus on the excellence of the applica- tion, progress of the region and its operational projects, there were several questions which should receive the attention of the site visit scheduled for December 3-4: Audiovisual plans for the future~-how long? Department of Community and Family Medicine support now being inaugurated via RMP funds--what happens after RMP? What about activities emanating from the medical center--clarification of who (out in the region) receives program output and how it is translated into action? P & E needs more information regarding priority setting and plans for involvement of voluntary agencies at the RAG level? What will Intermountain do with level funding? Estimate of timing of present dual role of Coordinator? Core Administration (Project #19) - ($973,090) - Will provide for 10% salary increase to cover employee benefits and merit increases consistent with U/U-policy. Will recruit several budgeted positions including Coordinator. Projects: #2 - Network for Continuing Education ($260,480). Has good sub-regionalization aspects and also cuts across regional lines. Has plans for placing a Medical Education Coordinator in each area, #5 ~ CCU Training for M.D.s ($109,044), Also has enlisted other RMP cooperation: Mountain States, California (Reng , Colorado-Wyoming and Grand Juction, Colorado, #6 - CCU Training - R.N.s & Cardiopulmonary Resp. ($100,321). New Pilot to train LPNs and will also compare two methods of instruction and applications. ‘ #7 - Clinical Cardiology Training ($64,348). Plans for making partially self-supporting in three phases: (1) elimination of stipends; (2) charge of fees for l-week training and elimination of short term stipends; and (3) charging of fees for long term training. #8 - Conmunity Cardiovascular Review ($103,340). No concrete plans for turnover. #10 - Computer Based Physiological Monitoring ($192,901) - Has added rage 4 = ACTING VITector, KegionaL MCGicaL rrogramS oervice one hospital (VA now in -~ Total of five). Plans for this upcoming year will initiate a charge schedule (month charge per terminal attachment) beginning April 1971--evenutally self-supporting by end of grant period (April 1973). #11 - Cancer Training & Continuing Education ($32,574). Adds an Operations Manager for six-state tumor registry, each state to pay a portion of his salary. Project viewed as an evaluation tool for physicians in cancer care, #20 - Radiology ($37,722). They have now recruited a certified radiologi- cal physicist, part-time, who has begun his training program which will qualify him to conduct safety surveys and calibration visits. #21 - Myocardial Infarction Data System ($171,812). Adds Research Assistant and more time for System Research Assistants. Grant-related income anticipated in future. #25 - Chronic Renal Disease ( $87,009) - Dr..Lawrence Stevens named Executive Medical Director, and Dr. Gary Maxwell as Education Director. Efforts to obtain a nephrologist and nurse continue. Funded July 1, 1970. #26 - Multiphasic Screening ($229,483) - Funded September 1, 1970. Remodeling of facilities underway, automated systems being designed, and project will start screening target population by April 1970. Note: If Intermountain does not obtain an increase to their $2,446,230, they will have to reduce their continuation support to provide for renewal projects and any approved but unfunded activity ‘they would support. Recommendation: Approval in amount requested ($2,462,124) to continue Core staff activities and above projects (#14 requests one year only in order to terminate). Amount committed is $2,446,230, which reflects a difference of $15,894, attributable to the fact that two projects (#20 and #21) have always been awarded one year at a time with no future committed support. Rebudgeting has been and will continue to be necessary for these’two programs. Site visit team to clarify the‘ issues raised in the staff review. An) ce pk on y (jessie F. Salazar Public Health Advisor Grants Review Branch Action by Director_ ‘ Initials Date RMPS Staff Present at Continuation Review Harold O'Flaherty Dale Robertson Rod Mercker Jessie F. Salazar Elsa Nelson Sarah J. Silsbee Edward Tapper, M.D. INTERMOUNTAIN RM 00015 2/71 Staff Observation Yhere were a number of questions and concerns raised about the Medex project at the last review cycle in October/November. In view of the region's emphasis of its significance to the overall program as well as clarification of issues that had been raised, additional comments were submitted in a letter of December 17, 1970, which is attached. For additional details, see site visit report. ~ GRB/12/28/70 : ~ aot = 7 KE ae 1 ID.w, Pn ia yoy FOS FT eT ! fl ma YE a ae 8, Pe TY 2A KROES BORLELE SVAOCUICaAL oPOO Vann LIteOPTROURtaI 50 North Medical Drive ¢ Salt Lake City, Utah 84112 {801} 322-7901 December 17, 1970 Harold Margulies, M.D. Acting Director Regional Medical Programs Service Health Services and Mental Health Administration .Parklawn Building, Room J]1--05 $600 Fishers Lane Rockville, Maryland 20652 Dear Dr. Margulies: We understand from informal conversations with some of the Reyional Medical Programs. Service staff and with members of the team which conducted a site visit of the IRMP on December 3 and 4, that questions have been raised regarding the IRMP Proposal to Train Poysician Assistants (Project No, 29). Since the proposal was. strongly endorsed by our Regional Advisory Group and was rated near the top of all IRMP oper- ational projects and pending proposals in a recent priority review by a panel of RAG and staff members, we should like to respond to the questions which have been raised,” Tne comment has been made that the IRMP proposal is patterned on the University of Washington MEDEX Program and may not be adapted ‘to the situation in the Intermountain Region. It is true that our proposal was based on a careful study of the MEDEX Program. Conditions in the Inter- mountain Region are very similar to those in rural Washington, with great need to provide prompt assistance to badly overworked rural general practitioners, A survey of some 36 rural physicians, and physician mem- bers of our RAG revealed a strong consensus in favor of a MEDEX type project. It is noted in the proposal that the Physician Assistant Project would also relate closely to the IRMP's continuing education activities and would also complement efforts to improve the accessibility of health care for urban populations (the OEO/CHP funded Neighborhood Health Conter in Salt Lake City). The Physician Assistant Proposal contains a very carefully designed effort to evaluate its effectiveness for the assistant, he. Harold Margulies, M.D., Acting Director Regional Medical Programs Service December 17, 1970 Page 2 the physician and his patients and would be carried-out in parallel with a .grant to the University of Utah Department of Community and Family Medicine to develop a model for an improved rural health care system Evaluation data will be shared with the University of Washington ME EX Program and other physician assistant training activities, in order to broaden ‘the base for decision making and any appropriate modification of activities as the project progresses. . a The University of Utah College of Medicine is currently adrait- ‘ting additional students and as pointed out in the proposal (page 16), i rot Ss planning for maximum expansion of its program. The Physician Assistant project is therefore supplementary to efforts to provide more primary physicians and is not just a poor substitute for more doctors in rural com- munities, . The question of acceptance by Intermountain physicians of the services of a MEDEX type assistant has also been rgised. As noted on page. 18 of the proposal, a sample of rural physicians in Utah was visited _by IRMP staff members and asked to respond toa questionnaire regarding -interest-in a MEDEX project. Twenty of the twenty-four physicians wno responded indicated that they would utilize a physician assistant ifa training program were implerenied in this Region. The number of doctors reached in this preliminary survey is probably less than 15% of the rural practitioners in the Region, yet the favorable responses totaled more than the number wnich can be accommodated in the first class proposed for the project. , We have not solicited letters of application from physicians, since commitment of funds fora MEDEX prograin has been uncertain. We - have had several physicians ask about the progress of our effort, however, including inquiries as to whether we could provide training for parame aical people already employed in some capacity by the physician. One unsolicited letter of application has recently been received and a copy is attached, A- letter frora IRMP inviting physicians’ applications has been prepared. in view of the high priority which this project has been given in our prograr. planning, we intend to mail this letter toa limited number of rural ohysie lans as soon as a method for selecting the most likely potential preceptors has been agreed upon. Re 1¢6) and a p Since submission of the proposal, the Utah State Medical Association Boa itd of Trustee has voted’ Support of the proposal Harold Marguliés, M.D., Acting Director, Regional Medical Programs Service : December 17, 1970 Page 3 , established a committee to provide liaison between IRMP and the Associ- ation, This conimittee has met twice and has recommended that the vee State Medical Association assist in deve lopment of legislative pronosa to facilitate employinent of physician assistants. The Association medico~-legal consultants are drafting such proposals. Action favoring the establishment of a MEDEX Prograrn has also been taken by the state medical societios in Nevada, Montana and Wyoming. After several discussions with representatives of the nursing profession, agreement with the project has been expressed by them, with the understanding that expanded roles for nurses be supported also. This the IRMP is doing. Pians are nearly - complete for a worx . a 3 * - on 2y. £.. Ne epee , oY - Enclosed is 4 copy of ap Emeuliry Cirected to you on 711.70. ad + > * ~e Sony fe ~ - + + ~ " { < Dowould vory mimen appreciate an answer. Perhans my previous PEE fe AY wey NT eset ‘ communication was mislaid, 1 . . . an you very iImich for your help. _.> { | July 11, 1970 "“MEDEX" University of Washington .Seatde, Washington Dear Sirs: Tama Genera] Practitioner, doing Family Practice in the small, rather iso- lated community of Milford, Utan. My practice is active and busy, and demanding. If I don't need some help now, I certainly will in the very near futuré, as my work load has increased yearly for the last 15 years. Thave read of your Program for training Physician's Assistants (Patient Care, April 30, 1970). I believe that my community would be ideal for accepting andutilizing a Physician Assistant. In my practice I have a young man who is an Ex-Corpsiman, who has . completed his 4 years of college, has a small family and is married to a young woman of this community. This young man thoroughly enjoyed nis work as a "medic" and has expressed very real interest in the "MEDEX” Prograrn. Talso have an office assistant, wno has worked for me as my Office Nurse for the past 15 years. She is vigorous and healthy and competent and intelligent. She is a Registered Lab and X-Ray Technician. She has also expressed sincere interest in pursuing the "MEDEX" Program, if it would be available to her. Hither of these people would be well qualified, dedicated, sensitive - individuals in the capacity of a Physician's Assistant, and I would be delighted to carry on the 9 months on-the~job training, in my office for either of them. . I would appreciate any information you can’send me, that would help me in my goal of obtaining effective, competent help. Please comment specifically as ‘to the suitability of the above Candidates for the MEDEX Program. Tnanks very much. for your help. Yours sincerely, D. A. Symond, M.D. " INTERMOUNTAIN REGIONAL MEDICAL PROGRAM STAFF OBSERVATION: Mr. Daniel Webster, Regional Office Representative, RMPS, Denver, Colorado, called to report the following about the Intermountain — Regional Medical Program: 1. Robert Satovick, M.D., has been appointed coordinator of the Intermountain RMP to replace Dr. C. Hilmon Castle. Dr. Satovich has served on the IRMP core staff, with special responsibiiity for developing the cerebrovascular program. . 2. Mrs. Irene Sweeney has retired. Her responsibilites for sub-- ‘yegional development will be assigned to Arthur Anderson, a member of the IRMP core staff whose former duties were in‘the renal program area. A PRIVILEGED COMMUNICATION SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE INTERMOUNTAIN REGIONAL MEDICAL PROGRAM RM 15-05 (AR-1 CDS) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: Award of $75,000 for a Developmental Component and $150,000 for operational activities. | Recommended Year Request ~ Funding 05 (Developmental Component) $75,000 $° 75,000 2 Renewal Projects 321,022 3 New Projects 367,014 150,000 Total $763,036 - . $995,000 y critique: The Chairman of the site visit team reported on the visit made on December. 3-4, 1970. The findings and recommendations of the team confirmed the previous visit of November 1969 which was organized for an extensive program review and renewal. IRMP has a well-trained and competent Core staff, good cooperative relationships with hospitals and a well-developed review process. The Review Committee discussed the implications of the search for a Coordinator, with Dr. Castle now Chairman of the Department of Community Medicine. For instance, the University resources for | postgraduate education and- family medicine have been placed in the- Department of Community Medicine, and the IRMP has concentrated on postgraduate. education. This may create problems for the new Coordinator, particularly when it is realized that the IRMP has a larger budget than the Department of Community Medicine. The new Coordinator will be designated as Associate, Dean of. the Medical School, and it --.was agreed that how he proceeds in efforts to persuade the IRMP in. directions outside the sphere of the Department of Community Medicine will be a real challenge. (Note: since the meeting of the Review Committee, RMPS has been formally advised by the chairman of the. IRMP RAG, ‘of the appointment of Dr. Robert M. Satovick as IRMP Coordinator.) the Committee was in agreement that’ the IRMP has exhibited the | necessary maturity and decision~making ability, both on the part. of the RAG and: Core staff; to justify an award of Developmental funds. Intermountain. RMP i RM 15-05 (AR-1 CDS) 2/71 As further demonstration of good judgment on the part of the RAG, a very modest D.C. was deliberately requested to allow the region to first gain experience in this direction. The reviewers noted the important step in sub-regionalization efforts through the appointment: of ten Medical Education Coordinators in ten -hospitals throughout the region, but also noted an apparent lack of understanding of the community organization necessary for such : Sub-regionalization. There is no clear strategy for accommodating the M.E.C.s with the University of Utah in order to expand education, training and health manpower. The Core staff. needs to be encouraged to utilize and seek the assistance of the resources of local organi- —_ rations, rather. than depending entirely on Core staff. . The plan for M.E.C€.s is a laudable first step away from ‘technically- oriented projects that IRMP has consistently emphasized, but the reviewers noted that this region will probably. always use a technological approach in view of its geographical and weather characteristics, The reviewers learned that the Physician's Assistant Project, which had been looked upon negatively by the Review Committee in October, was a very important element of high priority for IRMP.. The degree - Of physician. involvement in the planning and development of the program is impressive... The RAG, as well as Core staff, has indicated . they feel it is critical for IRMP to contribute to this program, even “if, funding for the educational portion emanates from the National Center for Health Services Research and Development. The Review Committee discussed the question of the TRMP RAG representa-_ tion. It was noted that the President of the University of Utah appoints members of the RAG, and while the very intricate relationships. — that exist between IRMP and the RAGs of Colorado/Wyoming and other neighboring regions are excellent, minority and consumer participation | is minimal. The reviewers feel that regional resources are well utilized, although it has necessarily depended on a variety of "multiple representation", where many, of the same people appear on all committees, : = ‘The Committee questioned the region’ s failure to come to grips with the problem of seeking other sources of support and phasing out projects. . There: was some feeling that such a monolithic structure motivates against a flexibility of such action. Further, the review process of IRMP apparently does not allow evaluation that would provide for such turnover or phasing out. Committee would be interested in demonstrated evidence of accomplishments of its various programs with an analysis of experience resulting from funds: invested. In the opinion of the reviewers, the IRMP needs to devélop criteria .for continuing ongoing programs, with scientific. documentation which = ‘Intermountain RMP -3- RM 15-05 (AR=1 cDs) 2/71 © will measure output of programs, their ability to "self-renew" or obtain dollar support elsewhere. Also, they should try to develop .a local process designed to eliminate projects that have (or have not) accomplished their regional goals. In a discussion dealing with an appropriate dollar recommendation for - IRMP, the reviewers addressed a per capita approach. The site team had recommended an additional $150,000 to support new projects, and noted a lack of enthusiasm about the Endocrine Laboratory and stroke programs. The matter was discussed by the site team with the region, and there was agreement that the program has not fulfilled its expectations. The Committtee's deliberations on the Developmental Component award elicited the opinion on the part of some of the reviewers that such an award should be provisional upon the receipt by RMPS of adequate data’on the progress of ongoing programs, particularly those that have had large investments of funds, This, in turn, led to an examination of the current level of funding and the site team's recommendation of $150,000 to be awarded for projects. There was consensus that the region is adequately funded for its — size, population, etc. The maturity of the region, the. capacity of RAG for responsible decision-making, and indications of objectives and priorities justify such an award, Also, these @ funds should enable the region to move more rapidly away from “project orientation, There was also agreement that the management of grant funds is well-designed and efficient. Core staff has ability to develop a more imaginative thrust, but will require new funds since the present grant fundsare tied up in ongoing activities. Sister Ann Josephine was absent from the room during the discussion. _ RMPS /GRB/1/22/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) LOUISIANA REGIONAL MEDICAL PROGRAM Suite 401 2714 Canal Street New Orleans, Louisiana 70119 PROGRAM COORDINATOR: Joseph A. Sabatier, Jr., M.D. Request (Direct Costs Only) RM 33-02 (AR~-1-CSD) January 1971 Review Committee 2/71 03 04 05 All Purpose 3/1/71-2/29/72 _3/1/72-2/28/73 3 /1/73-2/28/74 Years Commitment $628,369 $ 628,369 Core ($346,777) (346,777) 4 Projects ( 281,592) (281,592) Ad¢itional Components $1,678,644 $1,214,216 $1,193,121 $4,085,981 Developmental ( 62,837) ( 62,837) 6 Projects (1,400,096) ($1,080,577) ($1,065,597) ($3,546,270) 4 kpproved but ( 215,711) ( 133,639) ( 127,524) (476,874) Unfunded Projects Total $2,307,013 $1,214,216 $1,193,121 $4,714,350 Staff Action 628,369 628 ,369 Commitment Committee $1,678,644 $1,214,216 $1,193,121 $4,085,981 Action Required Funding History PLANNING STAGE Grant Year Period Funded (d.c.o.) ol 1/1/67-2/28/68 $490,448 02 3/1/68-2/28/69 454,445 03 3/1/69~-2/28/70 425,300 OPERATIONAL PROGRAM Council Funded Future Grant Year Period Approved (d.c.o.) Commitment Ol 3/1/70-2/28/71 $821,628 $673,887 02 3/1/71-2/29/72 705,611 $628 , 369 03 3/1/72-2/28/73 211,043 131,701 LOUISIANA RMP =~ RM 33-UZ (ARSL-USD) 2/7/11 Geography and Demography The Louisiana RMP serves the entire state of Louisiana, which has a population of approximately 3.7 mill:on. It has interfaces with the Texas, Arkansas and Mississippi RMP's. BY national standards, Louisiana is an economically poor state. In 1966, 29 of the 64 parishes were poorer than 90% of the counties in the U.S., and 15 other parishes were poorer than 75% of the U.S. counties. Thus 69% of the parishes are at a high poverty level. Much of this poverty is concentrated in rural areas of the state and is reflected in poor health status. There are three medical schools in Louisiana - Tulane University Medical School and the Louisiana State University Schools in New Orleans and Shreveport. The major teaching hospitals in the state, serving the three medical schools are charity hospitals, which treat the indigent patients. Louisiana has a legislatively fragmented health care delivery system, divided among the state charity hospital system, the private care system, and the State Department of Health. There are 156 hospitals in the state with approximately 26,637 beds. This number includes eight federal hospitals and ten state-operated charity hospitals with 4,898 beds. A total of 4,194 non-federal physicians practice | in Louisiana and 8,370 nurses are actively employed. Regional Development The original planning application, submitted by the Louisiana State Department of Hospitals as the grantee agency in Jurie 1966, was returned for revision en because reviewers thought it represented more of a pre-planning than a planning effort. The revised submission was approved in late 1966 with the conditions that the Region: 1) clarify how the program would cover areas outside metro- politan centers; 2) identify the person or organization adminstratively responsible for the program; 3) reduce the budget; and 4) clarify how the systems portion would fit into the overall aims of the program. After a National Advisory Council site visit by Drs. Peeples and Hurst, funds. were awarded in December 1966. About the same time, Dr. Joseph Sabatier was appointed Coordinator. During the first planning year, the Region requested and received permission to use planning funds to implement a coronary care unit program in Lafayette, Louisiana, with the purpose of testing the concept of RMP as a catalyst for development of an adequate community-wide structure .for long term community health planning. This experiment turned out later not to have been very successful. After second year planning funds were awarded, the LRMP began work on its operational application, which contained a request for core funds and two projects - Health Careers Recruitment and Delineation of Medical Service Regions. In reviewing this application, Council stated that, while the LRMP had made progress in planning, they did not believe the application reflected readiness for an operational program. The Region's second operational submission was approved.by the August 1969 Council, following a site visit in June, which indicated that the Region had been particularly successful in bringing together the important health institu- tions and organizations in the state. At the time the Region was beginning to LOUISIANA RMP -3- RM 33-02 (AR-1-CSD) 2/71 examine its organizational structure and to take steps to change the grantee @::: to a nonprofit corporation. The Regional Advisory Group appeared to be dominated by physicians and lacked adequate consumer representation. The site visitors expressed the hope that the Region would begin looking at project activities in terms of the total Louisiana area, not just the New Orleans Medical Center Complex. The operational application included funds for fcur projects: #1 - A Training Program for Tumor $116,956 Registry Secretaries #2 ~- A Proposal for Teaching Conferences 25,000 for Diabetic Patients #3 - Proposal to Establish an Office of 106,954 Research and Development in Educational Renewal. (ORDER) ‘#4 - Audiovisual Lecture Demonstrations in 24,791 Radiology and Radiologic Techniques $273,701 Funding of the first operational year was delayed until March 1970 due to federal fiscal constraints. Consequently, the Region is still in its first operational year. During this year the Region has submitted two supplemental pplications. The first requested $535,747 for project #5, Development of a egional Medical Center Coronary Care Training Unit. This proposal, which would have established a 19-bed coronary care unit at Charity Hospital, New Orleans, was withdrawn by the Region after the November 1969 Review Committee meeting and has been resubmitted in the present application as Project #18. The second supplemental application included these projects with the following action: #8 - Cardiopulmonary Resuscitation Revision Required #9 - Metropolitan Organ Bank Funding deferred pending development of Guidelines #10 - Study of Health Care Delivery Patterns of the Medically Indigent Approved #11 - Lymphomatous Tumors in Louisiana Approved without funds #12 - Telemetry of EKG's Returned for Revision #13 - Continuing Education Program for Physicians of Ruston, La. Approved without funds © Since none of the approved projects have been funded, all but project #12 have been included in the present application to be reconsidered for funding. Louisiana RMP . -4- RM 33-02 (AR-1-CDS) 2/71 Regional Objectives | . The Region has identified three critical health issues, which gave rise to the Region's objectives. These critical health issues are 1) health care needs ‘of the disadvantaged, 2) methods of improving the productivity of the health care delivery system, and 3) health care costs. The following are the objectives: 1. To improve and expand the "data base" and systems of data management for health planning in the region. 2. To develop planning aids (models and tools) to increase the effectiveness of the region's health planning related to achieving LRMP objectives. 3. To implement regional programs through "subregionalization" of the health services and delivery systems of the region: a. Contribute to the upgrading of medical care for those people in the region who have been found to be disadvantaged in terms of health care received. b. Promote efforts to make quality health care more accessible. c. Encourage the provision and utilization of comprehensive health care (e.g., prophylaxis, adequate patient follow-up and continuous eare). d. To promote efforts to contain or reduce the cost of quality health care. e. To promote efforts which are directed at improving the capacity of the health service and delivery systems (e.g., improving the number and utilization of health manpower and other resources). These regional objectives will be achieved within the framework of a regional conceptual strategy. This conceptual strategy includes the following five principles: 1) region-wide perspective 2) catalytic role 3) collaborative involvement 4) utilization of existing resources 5) involvement of a limited duration Organizational Structure and Processes At the time the grantee agency was changed to a nonprofit corporation, the Regional Advisory Group was reorganized by incorporating more groups with a central interest in RMP and by increasing consumer input. The 36-member RAG now consists of 9 ex-officio members, 21 elected representatives of organizations and institutions, and 6 public representatives. In addition to its project approval function, the RAG also considers program statements we LOUISIANA RMP ~5- RM 33-02 (AR-1-CDS) 2/71 6... and offers guidance to the planning committees and receives progress reports on core, The LRMP employs the following committees in its overall process: a) Program Planning Committees (Heart Disease, Cancer, Stroke, Epidemiology and Statistics, and Continuing Education and Health Manpower) are responsible for determining needs and developing programs within their assigned specialty. b) Ad Hoc Program Development Committees are temporary committees formed to aid in the development of specific projects and at the request of the project proposer. c) Ad Hoc Project Review Committees are established to evaluate the technical, scientific and operational excellence of each project. Consisting of experts in appropriate fields, these committees are usually from outside the region. d) Areawide Planning Staff Liaison Committee, composed of representa-~ tives of CHP b agencies and the a agency, provides liaison between CHP and RMP; it does not make official recommendations on projects. e) The Executive Committee of the RAG composed of the RAG Chairman, Vice-Chairman and four other members, represents the RAG between its regular meetings and reviews continuation requests. The LRMP review process comprises three steps: 1) administrative review by Core staff, 2) technical review by the Ad Hoc Review Committee (copies of which are included with each project), and 3) final evaluation by the RAG. For a discussion of Core structure and function, please refer to the continuation section of application component of the summary. PRESENT APPLICATION Developmental Component $62,837 The Developmental Component funds will play an important role in the three major activities of LRMP activity: 1) development and improvement of health planning and decision-making systems (including evaluation) ; 2) development of programs designed to meet specific needs; and 3) imple- mentation of programs. Examples of these activities could include: a) data gathering processing, interpretation and utilization; b) acquisition of authoritative information and advice; c) limited experimental studies in health care delivery systems or © applied clinical research; d) dissemination of information; and LOUISIANA RMP -6- RM 33-02 (AR-1-CDS) 2/71 e) development of certain ‘unusual operational projects key to the implementation of high priority programs. The Coordinator will submit a detailed explanation of the proposed activity to the RAG, who will then approve or disapprove it. Upon , completion of the activity, the Coordinator will report its results to the RAG. ‘ Continuation Component: These components have been reviewed by staff. Their program and funding recommendations are in a supplementary memo. Core $346,777. Medical School —————_—_———_- Coordinator re bo . Advisors Dr. Joseph Sabatier J / Deputy Director 1. Planning 2. Evaluator 4. Assistant Director for Section Administration | | 3. Project Development Staff Secretarial Business Section Writer Staff Manager 1. The Planning Staff will coordinate and implement activities in data gathering, resource planning and delivery systems planning. Examples of these are a feasibility study of developing a hospital discharge abstract system, an assessment of the region's radiation therapy facilities, and an evaluation of models to improve the quantity and quality of health care delivery to rural and urban poor. 2. The newly employed Evaluator will develop methods of program evaluation and refine the program's priority setting mechanisms. 3. The Project Development staff will stimulate and develop those projects specifically related to specific regional purposes. 4. The proposed activities of the Administrative staff include revising the regional guidelines and improving the regional communications systems. The LRMP has assisted health groups in other then project development. For instance, the RMP provided a panel of experts to investigate the current status of the Louisiana Hospital Television Network, a study recommended by the pre-operational site visit team. LRMP also provided assistance to the Cancer Commission of the State Medical Society in assessing problems of establishing a statewide cancer registry, as well as to several other organizations. Core staff also uses subcontract funds to conduct planning and feasibility studies. The LRMP has no subregional office staff of its own. It has, instead, LOUISIANA RMP -T- RM 33-02 (AR-1-CDS) 2/71 fostered the development of local CHP agencies. Financial and planning assistance has been offered to the six areawide health planning councils by LRMP. These agencies, in turn have been asked to comment on RMP projects in their areas. All of Core staff's 17 positions (15.5 F.T.E.) are filled. Continuation support in the amount of $281,592 is also requested for four projects: #1 - Training Program for Tumor Registry Secretaries #3 - Office of Research and Development in Educational Renewal #6 - Delineation of Medical Service Regions in Louisiana #7 7 noe . = i eens - Health Career Recrui fiient Program Approved but Unfunded Projects These projects fall into two categories: 1) Those which had funds approved by Council, but which RMPS, due to funding constraints, was unable to fund; and, 2) Those which received a recommendation of approval without additional funds from Council. Committee and Council consideration of these projects is needed in determining a funding level for the next year and not for approval of the activities. I. The Region has assigned both of these projects a high priority. let Year Project #9 - Metropolitan Organ Bank $102,035 Sponsored by Tulane University School of Medicine, this proposal would conduct a feasibility study on the development of an organ bank for the methodical procurement, preservation and supply of vital organs for purposes of renal transplantation in New Orleans. Second Year Third Year $77,242 $79,342 Project #10 - A Pilot Project to Establish a Method of Evaluating Health Care Delivery Patterns of Medically Indigent With Heart Disease, Cancer, Stroke and Related Diseases Ist Yr. -949,797 The Louisiana Capital Area Health Planning Council, & 314b agency, will initiate a pilot study to determine health care pattern characteristics of low income residents in Baton Rouge, Hammond, and New Roads and form an Ad Hoc Committee on Comprehensive Health Services for low income citizens which might help evolve a plan for comprehensive health delivery system in an urban target area. _~ LOUISIANA RMP -8- RM 33-02 (AR-1-CDS) 2/71 II. Both of these projects were assigned a relatively low priority rating by the Région. lst year Project #11 - Lymphomatous Tumors in Louisiana SOT The major purpose of this proposal is to establish a statewide surveillance system for identification and histologic classification of all newly- diagnosed cases of Hodgkin's disease occuring within a two-year period and to coordinate resources for treatment, The Tulane University School of Public Health and Tropical Medicine will sponsor the project. Second year Third year $46,994 $48,182 Project #13 - A Proposal to Establish a Continuing Education Program for the Physicians of the Lincoln General Hospital lst year $7,258 The physicians of Ruston, Louisiana, in conjunction with the development of a plan to supply health care services to the medically indigent, seek to develop a structured program to upgrade skills in their respective specialties. Physicians from Lincoln General will spend two weeks in appropriate specialty departments at Baylor College of Medicine in Houston following individually designed programs in their specialty. Conditions regarding the description of the courses, the parish-wide plan for comprehensive health care, and the ORDER's (project #3) involvement in evaluation, have been discussed by the project director. 2nd yr. Supplemental Projects $5,403 Committee and Counéil action are required on the following six projects, which the Region has grouped into roughly three priority groups: 1) High - Project #18 - CCU Training at Charity Hospttal Project #17 - Regional Pediatric Pulmonary Center Project #15 - Health Data Information Center 2) Middle - Project #16 - CCU Nursing in the Capitol Area 3) Low - Project #14 - Nurses Continuing Education Project #19 - CPR LOUISIANA RMP -9- RM 33-02 (AR-1-CDS) 2/71 \Project #14 - Coordinated Continuing Education Program for Nurses in Louisiana lst Year 3 Proposed by the Louisiana State Nurses' Association, this project would develop a statewide coordinated continuing education program for professional nurses and other nursing personnel. The program would be incorporated into the L.5.U. Adult Education Division. \ Because the intent of the project is to show relevance to the particular needs of the nurses in the subregions while upgrading the nursing manpower of the region, the project would serve the Region's third objective of implementing regional programs through subregionalization. Second Year Third Year $252,005 $249,331 “Tt Year Project #15,- Louisiana Health Data Information Center $63,348 The objectives of this proposal are three-fold: 1) Establish and operate an information resource for users of health and related data. 2) Stimulate studies in data acquisition and identify needs for data not currently available. im, 3) Develop an inventory which can be monitored over a long period and at a minimal expense. The proposal, sponsored by the Louisiana State Department of Health fulfills the primary project objective of establishing a data base for health planning. Second Year Third Year $53,580 $54,383 Project #16 - Ongoing Training for Cardiac Care Nursing Personnel in the Louisiana Capital Area lst Year 5 3 The Louisiana Capital Area Health Planning Council proposes to adopt the ROCOM system to construct a teaching program of 120 hours for participants in the CCU nurse training. Courses will be held in three hospitals in the Baton Rouge area. The project addresses the objective of improving the capacity of health services and delivery systems by increasing available manpower resources. Second Year Third Year $30,738 $31,646 LOUISIANA RMP -10- | - RM 33-02 (AR-1-CDS) 2/71 Project #17 - Regional Pediatric Pulmonary Center $460, 331 The Tulane School of Medicine Department of Pediatrics seeks funds to establish a multidisciplinary pediatric respiratory care unit in the children's ward, Charity Hospital, to deliver modern quality respiratory care to indigent children by establishing a four-bed special care unit, an inpatient ambulatory treatment unit and a teaching demonstration unit. Since the project is directed toward those who are disadvantaged in terms of having and paying for health care, it supports one of the Region's high priority objectives. Second Year Third Year $548, 765 5565, 247 Project #18 - Development of a Regional Coronary Care Training Unit at Charity Hospital of Louisiana at New Orleans $509,381 This project, sponsored by the Charity Hospital in New Orleans which serves the medically indigent, would attack the regional priority of providing medical care to the disadvantaged. Although the application states that LRMP recognizes RMPS' reluctance to approve funding of CCU hardware and architectural renovations, this two-year project requests funds from RMP primarily for alterations and renovations and equipment because state tax funds cannot be stretched to provide the same. The proposal intends to establish a model CCU with a 19-bed capacity. The LSU School of Nursing and LSU and Tulane Medical School would then provide three-week courses for nurses and one-week courses for physicians, This proposal was previously submitted to RMPS in 1968 and withdrawn by the Region after the Review Committee Meeting to strengthen the proposal. Second Year - $36,536 Project #19 - Cardiopulmonary Resuscitation Program $177,016 The Louisiana Heart Association as the sponsoring organization seeks funds to determine the extent of CPR training and the current level of competence of individuals involved in CPR programs in the state and then to establish a statewide program to train and retrain at periodic intervals such groups as physicians, registered nurses, licensed practical nurses, dentists and general hospital personnel. This proposal was returned for revision by the July 1970 Council because the proposal had not adequately delineated certain aspects of the training program, the previous experience with this activity in the state or certain items in the budget. This proposal would promote subregionalization of health care services (objective #3). Second Year - $158,953 Third Year - $164,990 DRMP/GRB 12/9/70 Date: Reply to Alin of: Subject: To: DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION December 14, 1970 Staff Review of Non-Competing Continuation Application from the Louisiana Regional Medical Program, 5 GO3 RM 00033 Acting Director Regional Medical Programs Service THROUGH: Chairman of the Month Cpe +? * C * rt Acting Chief, Regional Developmen Brangh 9 shnsan Chief, Grants Management Branch Ze & ‘ a oar (2h Acting Chief, Grants Review Branch The Louisiana Regional Medical Program is requesting continuation support for its 02 operational year for core and four projects. Since Louisiana's budget year does not start until March 1, 1971, and the ’ 45-day estimate of expenditures is not due until mid-January, requests ,_ for use of carryover funds have not been included in the present ‘ application. Therefore, the discussion was limited to general program .- issues and the following continuation request. Continuation Requested Amount Core $346,777 Project #1 Training Program for Tumor n Registry Secretaries 73,447 Project #3 Office of Research and Develop- ; ment in Educational Renewal 140,867 Project #6 - Delineation of Medical Service Regions in Louisiana 3,303 Project #7 - Health Career Recruitment Program 63,975 Sub Total Projects $281,592 Total Request " $628,369 Besides the continuation request, the Region has included in its AR application, a request for a one-year developmental component, funding of four approved but unfunded projects and six new projects. The Region Acting Director, RMPS - Page 2 | . was supported by a funding level of $673,887 during the Ol year. Recommendation: Approval of the committed amount of $628,369 for core and four projects. Staff also strongly urges, that in light of the Region's present constricted funding level and the quality of core staff, that serious consideration be given to increasing this Region's commitment for next year. , The following staff members attended the December 4 meeting: . 7 f h Miss Dona Houseal, Grants Review Branch an Mr. Michael Posta, Regional Development’ Branch Mr. Lawrence Pullen, Grants Management Branch Dr. Alan Kaplan, Continuing Education Branch Miss Mary Asdell, Continuing Education Branch Miss Joan Ensor, Planning and Evaluation Branch od, Miss Loretta Brown, Planning and Evaluation Branch “ ‘or et General Comments Staff was impressed with the present application and surprised that for a Region which has been operational for less than one year, it had begun to address a program concept so well. The regional goals and objectives are described, as is the regional conceptual strategy and critical health issues. Staff noted that the Region is attempting to address sone of the health care problems of the disadvantaged through its projects based at Charity Hospital. The LRMP has reorganized its RAG during the last year and has added consumer and black representation. The Region provides orientation to each new RAG member. Staff believes that with the new grantee agency, a nonprofit corporation, and the new guidelines and bylaws, which states that each RAG member votes on each project, a more democratic and active RAG should develop. Because of the recent reorganization, however, it is too early to tell just how strong it will be. At this point in time, it shows more promise than progress. ’ The regional review process up to the RAG level is strong. Core staff provides administrative review and Ad Hoc review groups composed of expert consultants generally from outside the Region provide a technical assessment of the proposals. The Region has included these assessments with the projects, as well as the reasons why the proposals, which the RAG disapproved, were turned down. One suggestion RMPS staff would make Acting Director, RMPS - Page 3 is to advise the Region to describe how the approved projects were changed as a result of the review. Core staff appears highly qualified. Although program evaluation efforts are still in the "to plan" stage, the evaluator has only just recently been employed and a methodology has been formalized. As far as data collection is concerned, core in conjunction with the Region's Epidemiology Committee, has been very adroit in using ~ outside resources and in avoiding duplication of effort. The program has excellent fiscal guidelines and monitors its expenditures closely. RMPS staff is concerned in the case of Projects #17, The Regional Pediatric Pulmonary Center, and #18, A Regional Coronary Care Training Unit at Charity Hospital, which contains large equipment and A and R requests, that LRMP staff is either weak in allowing the project applicants to include these items or else is flaunting national policy. In its introduction to one of these projects, however, LRMP states that it is aware of the national trend away from funding such items, but that local need for such units to serve primarily the disadvantaged is so urgent, that the Region wishes it to be considered. In fact, the RAG has assigned the coronary care training project the highest priority. 4 The progress on the ongoing projects appeared satisfactory. As for , the tumor registry secretary training, project #1, staff was concerned . that the project may be emphasizing training tumor registry secretaries without considering the need for producing better output data for tumor registries. The Office of Research and Development in Educational Renewal, project #3, seems to be operating as a genuine resource for project proposers, as well as for institutions and agencies throughout the Region. Staff was curious about the relationship, if any, between the project's Advisory Council and the Region's Continuing Education ‘ Committee. Conclusion: The committed amount of $628,369 is recommended for the Region's second operational year. ch a t r Meow oh bles Dona E. Houseal Public Health Advisor Grants Review Branch Action by Director “ngs / , qe ( Initials ] ne DP / s (A Privileged Communication) a: SUMMARY OF REVIEW AND CONCLUSION OF January 1971 Review Committee . LOUISIANA REGLONAL MEDICAL PROGRAM RM 33 (AR-1-CSD) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL RECOMMENDATION: Committee recommended approval of $400,000 in new funding for one year only. r “REQUEST YEAR COMMITMENT NEW FUNDS TOTAL Ist Year $628, 369 $1,678,644 $2,307,013 2nd Year wo , 1,214,216 1,214,216 . 3rd Year wns 1,193,121 | 1,193,121 TOTAL $628, 369 $4,085,981 -. $4,714,350 RECOMMENDATION YEAR | ___ STAFF COMMITTEE TOTAL Ist Year | $628, 369 $400,000. | $1,028, 369 2nd Year : cmt: Contingent on results of 3rd Year ; --- site visit CRITIQUE: , Committee thought that the LRMP -had-accomplished much during its first onerational year. It has established liaison with a wide variety of groups in the Region involved with planning for or delivering health care. It has added black and consumer representation to the RAG and is in the, process of reorganizing ongoing Committees which serve the RAG, The review process, which utilizes experts from outside the Region to technically review the projects, operates effectively. Goals and objectives, while somewhat vague, are well stated and in consonance with the general direction of RMP. Reviewers found several areas of. weakness to which they believed the_Region should devote their attention and efforts during their second operational year. ' Louisiana RMP -2- : RM 33 (AR-1-CSD) 2/71 Regional goals and objectives need to be further delineated as to how they would improve patient care, and the planning strategy should be developed on the basis of hard data which will show how regional activities will improve patient care, At the present it appeared that the generality of the goals and lack of systems analysis in establishing goals would make it difficult for the Region to select or reject as well as evaluate program and project activities. The efforts of the Region's Epidemiology Committee in dealing with the collection of data and the proposed project 15, Louisiana Health Data Information Center, which would coordinate data already collected by various agencies in the Region, wil] help overcome this lack. A closely related issue is the need to strengthen the planning and evalu- ation capabilities of Core staff. While planners and an evaluator have recently been added to Core staff, Committee noted that their specific backgrounds are not in the health care delivery or health planning and administration areas. Reviewers suggested that their experience be sup- plemented by outside consultants. Project as well as program evaluation should be buttressed. In conclusion, Committee recommended that $400,000 be added to the Region's funding level for the next year, and they stated that these funds could be used to supplement Core, including planning and feasibility activities, or fund projects. While no funds were recommended for future years, the Committee stated that funds would be approved contingent on a satisfactory showing of progress at a site visit when the Region's triennial application is submitted. Projects were not reviewed individually. Committee recommends that Council look at Project #9, the Metropolitan Organ Bank which has been previously approved by Council but not yet funded, with the kidney projects submitted by other Regions. RMPS /GRB 1V/15/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) RM 00044-03 (AR-1 CSD) 2/71 January 1971 Review Committee Maryland Regional Medical Program Suite 201, 550 North Broadway Baltimore, Maryland Grantee Agency: Johns Hopkins University Program Coordinator: Edward Davens, M,D, 1,363,149 03 year 04 year 05 year 3/1/71 - 3/1/72 - 3/1/73 - Total Purpose 2/28/72 2/28/73 2/28/74 All Years Continuation* $2,077,883 ----- wee- $2,077,883 Commitment (Core including Epidemiology & Statistical Unit) (808,161) = -+-- weer (808,161) 16 Projects (1,269,722) ----- ---- (1,269, 722) Additional Components 1,363,149 $1,045,401 $1,062,775 3,471,325 (Developmental) (100,000) (100,000) (100,000) (300,000) (4 New Projects) (1,263,149) (945,401) (962,775) (3,171,325) Totals 3,441,032 1,045,401 1,062,775 5,549,208 * Staff Action Commitment2,077,883 Committee Action Required 1,045,401 1,062,775 3,471,325 Funding History Planning Stage Grant Year Period Funded (d.c.o.) 01 1/1/67 - 12/31/67 $438,106 02 1/1/68 - 2/28/69 678,182 Maryland RMP -2- RM 00044-03 (AR-1 CSD) 2/71 Operational Program Council Future Grant Year Period Approved Funded (d.c.0.) Commitment , Ol 3/1/69 - 2/28/70 $2,294,177 724,360 Core (ee eee $1,208,523. Projects 02 3/1/70 - 2/28/71 2,314,535 . 784,556 Core | y western 1,420,101 Projects) 03 3/1/71 - 2/28/72 2,350,115 9 seer $2,077,883 04 3/1/72 - 2/28/73 145 ,000 [0 meres ; 145 ,000 (#19 only) * Includes $251,417 Carryover funds Geography: The Maryland Region includes the State of Maryland without Mont- gomery County (where the patient flow is traditionally into the District of Columbia) and York County, Pennsylvania. Demography: Ponulation . 2.4 million a. Urhan 73% bh, White o1% Facilities: a. Johns Hopkins University School of Medicine - Enrollment 350 b. University of Maryland School of Medicine - Enrol}ment , 367 Physicians: .a. Medical Doctors - 5,450 (1965) b. Doctors of Osteopathy - 20 (1965) Program Priorities 1. Continuous determination of needs through a well established RMP Enidemiology and Statistics Center. a. Consumer needs - extent and characteristics of diseases and health rnroblems. bh. Providers of service - adequacy and distribution of facilities and health manpower to deal with consumer needs. Maryland RMP -3- RM 44-03 (AR-1 CSD) 2/71 ; 2. Review and encouragement of innovative models for health care delivery, including primary health care. a, To identify promising experimental efforts and disseminate Lnowledge about collaboration among the directors of the new programs. ‘b, To identify geographic gaps in health care service and encourage development of organized services to fill the gaps. 2, Strengthening of Central RMP Core Unit, as well as support of innovative projects in the delivery of health care will be necessary to accomplish the priorities above. 4. Continuing Education 5. Expansion of inter-agency and inter-institutiona] cooperation. 6. Review and evaluation of ongoing operational and new projects. Review Process The review process includes: review by staff; examination by the Epidemiology and Statistics Committee to assure that objectives are clearly defined, methods of achieving these objectives identified, the data collection process is appropriate and the methodology for directly evaluating each project in terms of its achieving its own objectives and in terms of its relationship to the overaJ1 Program is established. Following this, the review of the Epidemiology and Statistics Committee is passed on to the scientific Advisory and Review body. When finally approved, the project will pass on with both the evaluative and the scientific Advisory and Review Committee's review to the Regional Advisory Group for final approval. Regional Advisory Group The 22-voting member Regional Advisory Groun has been broadened by adding six new members to fill vacancies. Three of these are black one from the field of nublic health, an obstetrician and one is involved in the field of social services for the disadvantaged. Three vacancies were filled during the October 16, 1970 meeting. These incJude the Director of Baltimore Mode] Cities Agency, a consumer representative from the Eastern Shore of Maryland, and the Executive Director of the Maryland Comprehensive Health Planning Agency. Two medical students (one from each School] of Medicine) have been added as non-voting members. The RAG meets ten times a year. Administrative Committee - This Committee is composed of the following ex-officio members: Deans of the two medical schools; Dean, Johns Hopkins School of Hygiene; Commissioner of Health; Coordinator of RMP; and Chairman of the RAG (without vote). The functions of the Committee are to: 1) appoint the Coordinator; 2) make final decision on all administrative matters; 3) appoint members of the RAG: and 4) establish policy for administrative operation, Maryland RMP -4- RM 4203 (AR-1 CSD) 2/71 Other Committees - The Region has seven categorical committees: Heart, Stroke, Cancer, Epidemiology and Statistics, Continuing Education, Kidney and Pulmonary. History of Regional Development Based on a series of preliminary planning conferences during 1966, Dr. William Peeples, State Commissioner of Health, Dr. Thomas B. Turner, Dean of Johns Hopkings Medical School, and Dr. William Stone, Dean, University of Maryland School of Medicine, a Regional Medical Program Steering Committee was formed composed of three representatives from the Johns Hopkins Medical Institutions, the University of Maryland Medical School and the Maryland State Department of Health. This Committee served as the overall Coordinating Committee for the Maryland RMP. The representatives on the Steering committee of each cooperating institution were selécted Ly and served at the pleasure of the Governing Roards of their respective institutions. This Committee appointed a 6 man enb-committee on Planning, who was given the responsibility for developing the application for a planning grant. An advisory Group, composed of representatives of the official and voluntary health agencies, the public at large, medical society, etc., was formed. During September 1966, the Maryland Regional Medical Program submitted its first planning, grant which was approved with the following conditions: 1. Clarification of fiscal responsibility for the grant; 2, Assurance from applicant of legality of the responsibility of administering the program; 3. Clarification of the responsibilities of the hospital administrators and staff, as well as the listed eleven professional] people; and 4, Statements as to how the integration of the components of the three participating organizations will be effected and managed. The first year planning award was for the period of January 1, 1967 - December 31, 1967. During the initial planning stages of the Maryland RMP, Dr. William J. Peeples, Chaittman of the Steering Committee was the Program Coordinator. In March 1967, Dr. Thomas Turner, retiring Dean of the Johns Hopkins University School of Medicine was appointed as Program Coordinator. In March 1967, staff considered a request from the Region for the second year to continue Core planning activities. Staff felt that although overall progress in this program during its first year had been modest, definite accomplishements had been achieved in the areas of (a) recruitment and organization of Core staff, (b) the development of a functional decision- making process which involves the RAG and appropriate planning Committee, (c) the stimulation of Cooperative relationships with Community hospitals, and (d) the delineation of regional boundaries. Staff recommended approval for a second year planning grant for the period January 1, 1968 - December 31, 1968, Also, during the second year of planning the Region received approval to initiate six feasibility activities in the following areas: Epidemiology Maryland RMP -5- RM 44-03 (AR-1 CSD) 2/71 and Statistics, Evaluation of Continuing Education or Medical Care, Heart, Stroke, Cancer and Continuing Education. Dr. William $. Spicer Jr., was appointed Acting Coordinator during January 194%. In August 1968, the Region submitted a planning renewal] request for the support of a Central Core Administration and seven other planning units. Also sub- mitted was the first year operational] grant application which included 14 operational projects. A site visit was made to the Region in December 1958, to review the planning to date as well as the request for operational funding. The site visit team was impressed with the "vigorous" leadership which the program coordinator had provided, and had recruited and organized what appeared to be a very competent staff. It was the recommendation of the team that the Core planning renewal be maintained at approximately the current level funding. The teams impressions of the operational application were generally favorable although there appeared to be a significant service orientation. In addition, some of the activities sponsored by the medical schools did not clearly reflect active or intended outreach to the broader community. The team concluded that this was a viable region prepared to mount an operational program. The team recommended approval of $1,511,812 for 14 of the proposals. The January 1969 Review Committee recommended a level of funding at approximately half the amount recommended by the site visitors, Because of the disparity between the recommendations of committee and the site visit team, Council appointed a special Council referee committee to restudy the entire back- ground and application materials and recommend a level of funding. Following negotiation$with the Region in March 1969, the Region received an award which included $742,360 (d.c.o.) Core activities and $1,298,523 (d.c.o.) for 13 of the operational proposals, a total of $1,932,883 (d.c.o.). In November 1, 1969, Dr. William S. Spicer resigned and Dr. Wm, Peenles former commissioner of the Maryland State Department of Health was appointed Program Coordinator. During February 1970, staff considered a request from the Region for the second operational year for the continued support of Core Staff activities and 13 ongoing projects. The request was composed of a total of $1,932,882 from Committed funds for support of Core staff activities ($728,523) and $1.2N4,259 for the 13 ongoing projects, and a portion of funding ($71,542) to initiate apnroved but unfunded project #19 - Tissue Typing Lakoratory. Also included in the request was a total of $187,655 from unexpended funds for the extension of two projects and additional funds for Project #19 (above). Staff was disappointed with the Region's progress and expressed the following concerns: 1. The application itself was uncoordinated and did not reflect any degree of organization. 2, The progress reports were prepared at an early date by the Region and as a result, reflect meager results. Maryland RMP -6- RM 44403 (AR-1 CSD) 2/71 3. It appears that little coordination exists between the various institutions with Gore staff, and less coordination exists among the projects and their staff. As a result, it was difficult to arrive at a firm judgement about how much progress had been accomplished during the Region's first seven months of support. However, no information was presented within the application which would justify disapproval of any of the components. Staff recommended approval as requested and further recommended that a program site visit be scheduled in early June 1970 with a member of Committee and Council and DRMP staff to explore the intrarelationships of the core staffs with projects, as well as the degree of coordination among the various core components, Listing of Current Funding Status of Core and Operational Projects in Maryland RMP, a Project Amount supported Number Title through 2/28/71 00 Core and Administrative Staff Central] Unit $218,960 Johns Hopkins University 98,271 University of Maryland 123,75] State Health Department 34,011 Epidemiology and Statistical Unit 239,992 Clinical Cancer Program 3,220 Continuing Education Feasibility Study - York 17,9446 Cancer Feasibility Study 12,900 Oral Cancer Detection 12,392 Symposium on Pulmonary Disease 1,913 Pulmonary Function Study 16,400 Conference on Delivery Medical Care 1,500 Maryland Hospital Education and Res. Education 6,900 CORE SUB TOTAL $784,556 ] 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 3 Early Detection of Cardiac and Malignant Disease in Pre-school Children - Mercy. Hospita] 24,173 4 A Program for Mass Detection of Heart Disease in School Children - Baltimore City Hospital 22 54? Early Detection of Heart Disease in the Newborn - Johns Hopkins 20,000 Maryland RMP -7- RM 44-03 (AR-1 CSD) 2/71 © Project Amount supported Number Title through 2/28/71 7 Coronary Care Program A) University of Maryland 79,700 B) Baltimore City Hospital 21,846 p Closed Chest Cardiopulmonary Resuscitation Maryland Heart Association 38,900 9 A) Acute Stroke Unit - Johns Hopkins 118,638 B) Chronic Stroke Unit - Baltimore City Hospital 179,821 19 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 University of Maryland 42,555 C) Proposal on Stroke - Rehab. Nursing Montebello Hispital 61,714 12 Proposed Coordinated Discharge Planning Program for Wicomico and Somerset Counties ~ Wicomico © County Health Department 15,983 13 Regional Medical Program for Outpatient Strokes Deer's Head Hospital - Salisbury 18,594 14 Demonstration and Training Program in 163,653 Rehabilitation of Stroke Patients - Sinai Hospital 16 An Ambulatory Program for Comprehensive Pulmonary Services - Maryland General Hospital] 90,999 19 A) Tissue Typing - Raltimore City - Johns Hopkins 83,347 B) Tissue Typing - University of Maryland 51,5953 TOTALS $2,204,557 * Includes $251,417 Carryover March 1970 Committee/Council recommended that action on a November 1969 Supplemental Operational Application be deferred pending the site visit. This November Application contained the following proposals: #94 ~ Position of Director of Continuing Education - Anne Arundel General Hospital. © #95 - Comprehensive Stroke Program - Prince George's General Hospital Maryland RMP -8- RM 44-92 (AR-1 CSD) 2/71 #26 - Stroke Rehabilitation Program in the Home and in the Prince George's County Health Department Rehabilitation Clinic #27 - Management of Intestinal Stomas - Baltimore City Hospitals (The site visit was conducted on May 11-12, 1970) The site visitors found that the RMP had bumped along, grown and evolved largely through the strengths that pre-existed in the two medical schools. It was apparent to the team that there are too few full-time people on the Central Core Staff and that they have found it difficult to guide, or in fact, counteract the strengths of the schools. Recommendations both to add funds and rebudget funds from institutional cores were made by the site visitors, and accepted by the July 1970 Council, which should strengthen the central core, not in an attempt to subjugate the Medical 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. Also, while large core staffs are partially supported in both Hopkins and Maryland, these appeared to the visitors to be little concern for developing interrelationships between the various program components. One of the overriding problems in this region is the rapid turn- over of program coordinators. The present coordinator, Dr. Edward Davens who ‘began on July 1970, is the fifth Coordinator since this Region began its planning phase during January 1967. The Region has received approval (unfunded) for the following projects: Projects #25 and #26 Combined - Comprehensive Stroke Prosram, Stroke Rehabilitation; #27 - Manapement of Intestinal Stomas; and, #21 - Rheumatic Fever Prevention. Present application: This is a request for four new proposals and a developmental component. New Proposals #22 - Continuing Education Program for Hartford Memorial Hospital] 03 Requesting 3/1/71 - 2/28/72 Direct Costs $33,909 The Hartford Memorial Hospital, Harve de Grace, Maryland is requesting a supplemental salary to employ a full-time Director of Continuing Education in addition to a secretary to assist him in his duties. The Director of Continuing Education will participate in the Maryland RMP seminars and forums for Directors of Continuing Education in order to lead the hospital more effectively to an expanding standard of excellence, become acquainted with expert consultants in various fields, and establish channels for rapid Maryland RMP -9- RM 44-03 (AR-1 CSD) 2/71 acquisition of materials and advice. He will have an active role in the many functions related to quality of care review, and will assume responsibility for coordinating various programs within the hospital in consultation with the chiefs of Service, relating these programs to the individual physicians and serving as liaison officer with the teaching Medical centers and surrounding health care facilities, He will arrange and moderate conferences, lectures, scientific sections of staff meetings, and assist with departmental meetings. In addition, the DOCE will assist the staff with specific problems regarding diagnostic and therapeutic procedures and will organize seminars for nursing and other paramedical personnel with emphasis on updating their education, He will have the responsibility for developing approprtate teachine- learning materials where none exist and in cooperation with the librarian, will suvervise the needs of the Library. By employing a Director of Education, the applicant states that the Hospital will have a more direct method of assuring itself that good health care is being rendered to its patients. The DOCE will be responsible professionally to the medical staff and its Executive Committee, and Administratively to the Board of Directors and the Administrator. The Objectives of the project will be to: 1) assist the Staff, Administration and Board through the development of structured Continuation and Reparative Education activities as part of the physician and hospital daily activity; 2) continue to arrange for cooperative educational] health care activities with surrounding smaller community hospitals, clinics and extended care centers; and 3) provide for inservice training for the Directors of Continuing Education as well as continuing education for the Staff. #33 ~ Comprehensive Regional] Approach to Education and Therapy for Chronic Renal Failure 03 N4 5 Requesting 3/1/71 = 2/28/72 3/1/72 - 2/28/73 3/1/73 - 2/28/74 All years Direct Costs $1,191,662 $859,378 $848,902 $? , 820,942 The primary purpose of this program is to expand existing facilities to provide an effective form of therapy for patients with irreversible renal failure. Currently, some 30 patients are being maintained on éhronic dialysis through four hospitals, and only 32 renal transplants have heen nerformed in three of these institutions. The objectives of the project will be: 1) increased dialysis and transplantation carabilities within the coorerating institutions as a demonstration of patient care. With current staff and space, maximum ‘ialysis facilities are: Baltimore City (19),Johns Hopkins (8), and University of Maryland (4), the total number of patients on dialysis at one time being 22. This project calls for expansion of facilities in some hospitals and initiation of program in others. Home training programs will be developed at Baltimore City, Maryland General, and Sinai Hospitals. Maryland RMP -10- RM 44-03 (AR-1 CSD) 2/71 Anticipated facilities are: Baltimore City (10), Good Samaritan (14), Johns Hopkins (8), Maryland General (6), Montebello State (4), Sinai (4), and Maryland University (8). The tota] number of patients on dialysis (in- patient) at any one time would be 56, It is also estimated that 25 patients could be moved to home dialysis during the first year. The Programs at Baltimore City, University of Maryland, and John Hopkins will accept patients from other institutions for Renal transplantations. Montebello will provide a service for patients from inaccessible areas of the Region awaiting Cadaveric transplantation. 2) Development of adequate referral systems for patients in need of treat- ment. Referring physicians may contact any of the cooperating institutions for evaluation of their patients. Based on the availablity of an opening the patients will be accepted for evaluation directly or referred elsewhere. 3) Training of physicians, nurses, and technicians in the referred specialized technique for care of individual patients locally and throughout the Region. Training opportunities will be provided for full-time physician trainees in the Departments of Medicine, Surgery, Urology or Pediatrics of the various hospitals, and for part-time community physician trainee who can acquire special skills in patient management which will be applicable in their own practice. Fellows will be assigned to the program from one to three years and will be given major clinica] responsibilities as their skills and knowledpe advance. Experience will] be provided in the management of patients on chronic hemodialysis, and during al] phases of renal transplantation. They wil] also be trained in renal physiology and transplantation immunology. Nurses will receive training in the basic principle of disordered renal physiology and the management of chronic renal disease along with the management of clinica] nroblems specifically related to dialysis and renal transplantation. This will be done through lectures and practical clinical experience. Technician traininginvolved through familiarization with the central dialysate despensing equipment, individual] delivery systems and maintenance of all dialysis equip- ment, 4) Encouragement of the development of additional facilities in other insti- tutions throughout the Region by means of an Educational Program. 5) Evaluation of the economics and efficacy of the various treatment forms used and the feasibility of the entire program. Methods of evaluation include monthly meetings of dialysis directors and transplantation team members to evaluate the status of each patient in the program and to discuss educational propress. Ag the home proeram pains momentum and as physicians, nurses and technicians enter the centers for training periods, their propress will be evaluated, Economic factors and therapeutic results will be periodically evaluated and comparison made among type of treatment. The Repion states that this program in Renal disease is fully congruent with the Maryland RMP's objectives and will be the framework for the Region-wide system of continuing education. Maryland RMP -ll- . RM 44-93 (AR-1 CBD) 2/71 #34 + Regional Oncology Affiliation 3 Requesting 3/1/71 - 2/28/72 Direct Costs $60,905 The nurnose of this proposal is to establish a continuing association between the Johns Hopkins Oncology Center and an increasing number of Community physicians and hospitals to provide a clear demonstration of modern muJ ti- disciplinary care of cancer patients and continuing post-graduate training in clinical oncology oriented about existing patient management problems, A basic goal of this proposal is the creation of an organization through which physicians can work together in a cooperative way to improve their capabilities in caring for patients with cancer. Full-time telenhone coverage will be provided so that patient problems can be handled as they arise and questions can he considered while they are fresh in mind and clinically pertinent. Rapid access will be provided to ambulatory patients for compre- hensive diagnositic evaluation and multidisciplinary consultation, A specific panel of specialists will serve this purpose. If treatment is required and cannot be administered by the referring physician, this will he provided by the Center staff. Where required, prompt admission will be provided for patients needing major diagnostic and treatment procedures. Continuing Education is also a basic goal of this proposal. The Johns Hopkins Oncology Center will provide the organization and supervision necessary to create a productive program. The major emphasis will be directed toward clinical application, The initial thrust of the professional education program will be directed along the channels of patient referral. Inquiries about specific problems will be answered promptly, but later will be repeatedly followed up by brief newsletters or references to new developments in the specific area of inquiry. Regularty scheduled visits to affiliated community hospitals will te made for the purpose of clinical consultation of postgraduate education. The standard methode of hedside teaching, presentations at staff rounds and special} seminars will he employed. An annual two or three-day oncology course will] he provided by the Center. A fully automated computer7hbased record keeping and communications will be developed at the center for the purposes of: a) clinical-educational communication; bh) evaluation of current manapement practices: c) program evaluation; and d) program planning. The anplicant states that it is exnected that the annual course will hecome largelyself-supporting after the first 3 years and some future support of the educational aspects of the program can he expected from the participating hospitals. Whenever possible professional fees will be collected by the University from patients in the program and will be applied to the costs of the rroject. Maryland RMP -12- RM 44-03 (AR-1 CSD) 2/71 #35 - Home Care Program Community Health Center - Bon Secours Health Center 03 Us 05 Requested 3/1/71 - 2/28/72 3/1/72 - 2/28/73 3/1/73 - 2/28/74 Direct Costs $66,673 $66,673 $66,673 This proposal for a Home Care Program,an activity of the Bon Secours Community Health Center, will be under the auspices of the Bon Secours Hospital Inc. The principal objective of the Community Health Center is to provide the hasis for a more efficient way of delivering health care ~ both quantitatively and qualitatively to a population of over 20,000 persons in West Raltimore. Initially, the Community Health Center will take care of 5,000 persons. It is rroposed that the Community Health Center will try to develop a strong and very broad ambulatory and home care program to aim at: 4) avoiding unnecessary hospitalization; b) implementing early hospital discharges; and c) practicing nreventive medicine to improve the community health standards. Thé Community health center will provide comprehensive health services based on family units and will try to coordinate all the health facilities forthe area for the benefit of the community. It is estimated that about 33% of the vopulation of the Bon Secours Hospital area is under age 15, and approximately 11% is over age 65. Based on these figures and on the experience of other home care programs. it is estimated that for a population of 5,000 the Health Center will make anproximately 890 nursing visits per month for reasons of chronic sickness. The community health nurse will] make about 16 of these visits ner month in addition to 24 visits per month for acute illnesses. The community aides will make about 64 visits per month for reasons of chronic sickness. The Community Health Center will utilize as much as possible residents of the area for the purpose of assisting patients at home in administering medications, cooking , etc. These Community Health workers will be under the direct super- vision of the Community Health Nurse and wil] receive a short-term training course for their activities. A training program is currently being developed for this purpose. The Community Health Center will also ase the personne] ana facilities of the city Health Department as much as possilJe to avoid duplication of effort and to economize resources. It is expected that the Center wil] have the part-time services of the Public Health Nurse who covers the Bon Secours Hospital Area. Developmental Component 03 04 05 Requested 3/1/72 - 2/28/71 3/1/72 - 2/28/73 3/1/73 - 2/28/74 Direct Costs $100,099 $100,000 $100,000 Use of Developmental Funds The Region intends to use the development funds to provide a means for the Core Unit to carry out its central function and responsibility of executing a broad strategy to improve the quality and distribution of health care services in the Region. The method of use may be through smalJ short term contracts, investigations, data collection or intensive exploration of broad collaborative projects. Any impediment or obstacle to achievement of improved Maryland KMY -13- RM 44-93 (AR<-1 CSD) 2/71 regionalization, comprehensiveness, availability and accessibility of health services will be a fitting target in using Developmental Component funds, An example of the use of Developmental] funds might be to enable the RMP Cancer Committee to conduct a series Of discussions around a collaborative, nulti- disciplinary effort among the several highly specialized teaching cancer centers and primary health care physicians in bringing expertise to medically needy, high priority population groups utilizing existing resources in the most efficient manner with each center relating to a defined peograrhical area of the Region. The Central Core unit with the assistance of Developmental] funds would attempt to serve as a catalyst in this enterprise. RMPS /GRB/12/19/70 (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSTON OF JANUARY 1971 REVIEW COMMITTEE MARYLAND REGIONAL MEDICAL PROGRAM RM 44-03 (AR-1-CSD) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL RECOMMENDATION: The Committee recommended that additional funds not be provided for this application which requests: 1) develop- mental component funding for three years; and 2) three years support for 4 new projects. . YEAR REQUEST RECOMMENDED _FUNDING 03 Year $1,363,149 ~0- 04 Year 1,045,401 -0- 05 Year 1,062,775 ~0- TOTAL 3,471,325 -0-, CRITIQUE: The reviewers noted that this Region has a history of the lack Se of strong and sustained leadership. It also pointed out that the strengths of the Region have historically evolved and grown largely through the strengths that pre-existed in the two Medical Schools. The Region lacks a spirit of cohesiveness and, in reality, insofar as its present committees and RAG are structured, it is a "Baltimore" program. In its deliberation, the Committee considered the May 1970 Site Visit Report and with reference to the weak Core Staff and were disappointed to note that little visible change has occured since the time of the site visit. Also, the Committee learned that staff in its December Review of the continuation application, could find little evidence of progress oF improvement on which to base a favorable continuation recemnendation. Along with this, members of the Committee commented that applications from this Region appear to have a futuristic tense. While the Region has received RMP support since January 1, 1967 (Planning and Operational) itis difficult to determine exactly what has been accomplished over the. years. A portion of this may be attributed to the rapid turnover of Program Coordinators. (The present Coordinator is the fifth). There was also a ‘doubt raised as to whom these individuals owed their allegiance, the Medical Schools or the RMP. Another problem noted by the Review Committee was that the collection of individual projects appeared to be the results of interests of the two, medical schools or of individual interests rather than a concerted program effort. The projects appear to be isolated and unrelated to each other and do not seem to fit into any organized plan. Because of the ne Maryland Regional Medical Program -2- RM 44-03 (AR-1-CSD) 2/71 problems associated with the MRMP, the Review Committee believed that no new funds should be awarded for the support of new operational activities. Therefore, review of new projects was minimal. “The reviewers were encouraged, however, to learn that the Region has partially complied with one of the recommendations of the site visitors and are beginning to include more minorities, consumers, and representatives from outside the Baltimore area. In spite of this one ray of hope, the Committee expressed disappointment in.the RAG's failure to show their strength in becoming a viable group capable of determining ‘the overall] goals, objectives and priorities for the Region. The Epidemiology and Statistical Unit at Johns Hopkins was believed to be a major strength of the Region. The Review Committee believed that this group has the potential to assist the Region by providing the necessary data on which to start to build a Regional program. In conclusion, the reviewers believed that from the information presented, while the MRMP may be a potential vehicle for the improvement of the Delivery, of Health Care Services, it is rambling around without direction now. On the basis of the above, the Committee concluded that the Region should not be awarded additional funds for either new projects or a Develop- mental Component at this time; rather, it should again be advised of the ° deep concerns of the Review Committee and staff with regard to its Core Staff, its lack of regionalization and most important, of a clear cut plan which will assist in solving some of the health care needs of the Region. Further, the Committee recommends that staff convey to the Region that this action should not be considered punitive against the new Program Coordinator, but rather should provide him with an opportunity to reconsider and develop a more realistic plan for the organization and- management of the Region. The Committee reinforced the recommendation of the 1970 site visitors that a method be found to enjoin the rather large staffs supported from RMP funds in the two Medical Schools under a more productive, more manageable system. Dr. Scherlis was not present during the deliberation. RMPS/GRB 1/19/71 REGIONAL MEDICAL PROGRAM SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION METROPOLITAN WASHINGTON D.C. Regional Medical Program Service 2007 Eye Street, North West RM 31-04 (AR-1 CDS) 2/71 Washington, D.C. 20006 January'1971 Review Committee Program Coordinator: Arthur Wentz, M.D. co . . REQUEST (Direct Cost) PURPOSE 04 Yr. 05 Yr. O06 Yr. ALL 3/71-2/72 3/72-2/73 3/73-2/74 YEARS Continuation $1,008,728 $189,082 - 0- $1,197,810 Commitment (Core) (571,201) (0) (0) (571,201) (4 Projects) (437,527) (189 ,082) (0) (626,609) Renewal Components 240,727 964,609 1,018,635 2,223,971 (Core) (0) (820,000) (870,000) (1,690,000) (2 Projects) (240,727 (144,609) (148,635) (533,971) ., Additional Components 3,161,406 2,848,680 2,743,458 8,753,544 (Developmental) (97,067) (110,000) (140,000) 347,067 (10 New Projects) (2,172,674) (2,259,630) (2,278,512) (6,710,816) (Core) (195,068) (0) (0) (195,068) (7 Approved-Un- : funded Projects) (368, 302) (245,803) (190,796) 804,901 (1 Deferred Project) (328,295) (233,247) (134,159) 695,692 __ TOTAL $4,410,861 $4,002,371 $3,762,093 $12,175,325 Staff Action on —- No final determination was made on the continuation Commitment recuest. It was the Acting Directors decision to defer all requests to the site visit team for consideration. A copy of Staff's review of the continuation component is attached to this summary. Committee Action Required $3,402,133 $3,813,289 $3,762,093 $10,977,515 “FUNDING HISTORY = ~~ —_ (Planning Stage) Grant Year Period Funded (d.c.) 01 1/1/67-.2/28/68 $188,000 (Operational Stage) Future Grant Year _ Period Council Approved Funded _ Commitment 01 3/1/68-2/28/69 = $592,148 - 02 3/1/69-2/28/70 ie $1,400,416 - 03 3/1/70-2/28/71 91,883, 320 $1,489,772 $1,008,726 . -«2- MM JL°UG (AR@1 CDS) 2/71 REQUEST - BREAKOUT BY COMPONENT Jan, 1971 Review Committee Continuation Commitment 04 °— 05 All Years 04 Year Committed 05 Year Committed Request CORE 571,201 571,201 ------ mo see 571,201 #1K - Freedmans Hospital 203,677 203,677 39,510 29,850 243,187 4s Stroke Station , \ #19 - Regional Cancer Registry 40,000 40,000 woractae H------ = 40,000 . #20 ~ Peripheral Vascular , . ' Facility 50,000 50,000 wane enn meen ene 50,000 #25 - Cancer Radiotherapy Unit Education, Consultation . Service . 143,850. 143,850 149,572 149,572 293,422 TOTAL 1,008,728 1,008,728 189,082 179,442 1,197,810 Renewal Request * All Years 04 Year 05 Year 06 Year Request CORE ., 820,000 870,000 1,690,000 #2R - Cerebrovascular Disease 2/ 140,727 144,609 148,635 433,971 Follow-up & Surveillance . System #12R - Mobile Coronary Care 100 ,000 aiatahetatenel Sarai 100,000 Unie 240,727 964,609 1,018,635 2,223,971 Additional Components CORE . 1/ 195,068 ~ 195,068 #17 - Health Careers Council= 35,200 53,825 - 55,368 ° 144,393 “#19 - Cancer Registry2/ 29,445 wren eee 29,445 “#20 - Peripheral Vascular 3/ 7 ' Facility 43,608 aiatanatanten mene cen 43,608 #23 - School of Inhalation4/ 86,490 = _-____. 0 meee , 86,490 #26 - Community Hospital Stroke Program >/ 80,61). 91,000 86,000 257,611 #28 - Coronary Care Nurse ~ Training 6/ 54,47]. 55,860 110,331 #31 ~ Area Hemodialysis i 328,295 233,247 134,150 695,692 Training Program . #37 ~ Early Detection of8/ 38,477 45,118 49 428 133,023 Chronic Obstructive , Pulmonaary Disease #39 - Exercise Stress Training Referral Services _ _ 17,724 72,120 74,827 224,671 #40 - Pediatric Pulmonary Program 200,205 - 230,845 285,310 716,360 _ METRO DC: . -3- RM 31-04 (AR-1 CDS) 2/71. mo January 1971 Review Committee #41 - Physicians Assistants Program ' 472,717 240,959 246,105 659,781 #42 - Hypertension Clinics in Economically Depressed Areas 185,181 174,154 178 ,982 538,317 #43 - Cervical Cancer De- tection 150,000 125,000 125,000 400,000 #44 - Interstitial Cancer - ‘Therapy 174,400 78,449 . 58,691 311,540 #45 - Home-based Care of Chronic Obstructive Lung Discase 42,720 53,650 58,880 155,250 #46 - Mobile Dialysis Center 39,527 =—s_—- 18, 668 19,443 77,638 #47 - Regional Nephrology 718,867 586,945 617,107 1,922,919 #48 - Nurse-Midwife, Maternity a, Nurse Clinician Program 411,333 678,840 614,167 1,704,340 DEVELOPMENTAL 97,067 110,000 140,000 _ 347,067 | TOTAL 3,161,406 2,848,680 2,743,458 8,753,544 GRAND TOTAL 4,410,861 4,002,371 3,762,093 12,175,325 © PREVIOUSLY REVIEWED PROJECTS if/Project #17 - Approved with no funds reconmended 2/Project #19 ~ Approved and funded - but requests supplemental support 3/Project #20 - Approved and funded - but requests supplemental support 4/Project #23 - Approved-funded first and second years with carryover 5/Project #26 - Approved - but unfunded 3/Project #28 - Approved-funded first year with carryover 7/Project #31 - Deferred pending further study of supporting such renal projects 3/Project #37 - Approved - but present request exceeds 02 and 03 years approved level 02 Year: $40,618 03 Year: $44,928 2/Project #2R - Deferred for site visit Tred Ww . “ LER fide be oy ad : Le ~--- ~- DE ow yory January 1971 Review Committee Cu pOGRAL. He the Metropolitan washington Regional Medical Program | is conpr ined of: ‘the Divetrict of Columbia re an Montgomery and Prince’ “George “Counties of 4 atyland Arlington and Fairfax Counties of Virginia , The City of Alexandria, Virginia | Pf OE Postal pegs Y The geography of this Regiou was “iufluenced prima wily by availabTe) hospital usage” statistics." (Vaxticipating hospitals are nunbered: on the map on the neat page. ) Projected, population growth, plysickan 8 distribution: and medical cducatfonal facilities were also influenti@#? in delineating the Repion. jnitially, there vas some di scussion concerning the Prince Georre's. « County delegation who expressed | an: initials des sire to- ‘participare with the Maryland Regional Medical Program, - Poweve ns | since more paliente attend medical facilities in the District of Columbia thaniin Baltimore, | co Prince Ceorge!s. County: decided to remain in Le weaperiaate i Rashington RMP. At. the same timej it was and) is undér stood by all Nthat any” vy out TE juxisdiction may participate in the Yetropolita area program as well as in the program within their respective state" The Hedical Society of the Dis strict of Columbia is the grantor organization. This decision was based on the discuesions held with representatives of each of the three medical schools (Geeryctuown, Gcorge Washington and Howard), the, D.¢. Health Department and certain members of the Medical Society. : METRO D C . -5- RM 31-04 (AR-1 CDS) 2/71 January 1971 Review Committe: MONTGOMERY “4 i a e } ie ARLINGICH PA) PCr GEORGES \ “UR RIOTDT ALEXANDRIA \ *, “ty, a METROPOLITAN WASHTNCTON REGLONAL MEDICAL PROGRAM FLLLRU Ls - we eee eee gee ee . January 1971 Review Committee DEMOGRAPHY Land Area - 1,483 square miles District of Columbia 61 miles Alexandria City, Va. 15 Montgomery Co., Md. 493 miles Arlington Co. ) Prince George's Co., Md. 485 miles Falls Church City; 24 Fairfax City ) 405 Fairfax Co. ) Population: (in thousands) 1960 Total 2001 District of Columbia 764 Montgomery County) 341 Prince George's Co.) Md. 357 Alexandria (city) 91 Arlington Co., Va. 163 Falls Church City, Va. 10 Fairfax Co., Va. 275 Percent Urban: Washington, D.C. ) Alexandria, Va. ) Talis Church, Va.) 1007 Fairfax Co., Va. 78%, Montgomery Co., Md. 86% Prince George's Co., Md. 83% Age of Population: (1960) Maryland Virginia Median U.S. D.C. Mont. Co, Prince Geo. Alex. Arl. Fairfax Age 29.5 32.2 28.1 25.2 28.0 30.8 24.5 Number Percent (in thousands) — Total. 12 6.2 65 yrs. of age and over D.C. 7 9.1 Mont. Co. & Pr. Geo. Co. 3 4.4 *Virginia 2 4,1 *Represents Alex., Arl., Co. & Fairfax Co. METRO DC -7- RM 31-04 (AR-1 CDS) 2/71 , January 1971 Review Committee Non-White (1969) ( jim thousands) Number Percent Total 498 254 D.C. 419 54. Mont. Co. 13 ws RBA~N Hw fn Prince Gee. Co. 32 9, Alexandria Ll Li. Arlington 9 5. Fairfay Co. 14 5. in 1967, G77 of populalion oF D.C. was nomewhite - de. $33,900 of 793,509 Family Lneame - in Montgomery County, moadiay family income is $%, (highest in the Nation). . Baivfax co. ranks Srd in Netion; im D.c., (LEGO) 13.00 of the farik Cincludiny, approximaiely 271,000 people) had incomes of Jess than Pesources: Medical Schools: Ceo.pcvown Medical School Enrollment 427 George Washington Univ. Med. Sch. Enrollment 366 Howard Univ. College of Hed. Enrollment 386 Schools of Nursing: TG. 7 UGE which 3 are university affiliated Md. - 1 which is college affiliated Total Area: 4 baccalaureate 4 hospital based diploma 3 new associate degree programs have been established (15% School of Medical technology: D.C. - 8 of which 2 are government hospital affiliated Lloauniversity affiliated Md. - 1 Other Types of Pacamedt cal Training: Cylotecimolopy - b.C..4 which is University affiliated Hospi tals: Federal Non-Fedceral Total Short Long Short Long Federal & Term Term Total Torn Term ‘Total Non-ederal 13 19 11 14 4 5 ho 2 6 lL 1 3 8 - 1 “ 3 10 23 é 26 38 D.C. Md. Va. ‘yotal oe 1 I 1 siren un : January 1971 Review Committee PROGRAM HISTORY AND DEVELOPMENT a AL ey The Region's first year of planning was a 14 month period 1/1/67-2/238/63 and was supported at $188,000 (d.c.). In February 1968 a pre-operational site visit was conducted to the Region. The site visit team consisted of George Miller, M.D.; Leonidas Berry, M.D.; Mieczyslaw Preszcynski, M.D.; Martha Phillips, RMPS Staff; Patricia McDonald, RMPS Staff and Dr. Thomas Bodenheimer RMPS Staff. The site visitors were impressed with the wide range of individuals, groups and practicing physicians that appeared to be actively interested in the program and who attended and participated in the opening . session of the visit. The D.C. Medical Society appeared to be committed to regional systems. Representation of Allied Health groups and nursing groups on the RAG was lacking and it was noted the Region had difficulty getting individuals who are not in medically-related fields to participate in the program. The site visitors commended the active involvement of the RAG and the extensive guidance and review it has given to the development of the program. It was felt the Region was aware of the need to cooperate with adjacent Maryland and Virginia RMPs. Concern was expressed that planning was being done for individual projects without interaction among them. It was noted, however, that this was probably due to insufficient staff to provide the necessary coordination. Although organized ° planning for the Region, local priority setting, and identification of regional strengths and needs had not been yet approached, the site visitors concluded the D.C. program was moving in the direction of truly regional coordination and that it would continue to be strengthened by the time the program was reviewed at the close of the first grant period. The site visitors endorsed the readiness of the Region to move into the operational phase of the program. + Committee and Council concurred with the site visitors recommendation and the Region was awarded $241,642 (d.c.) for planning and $350,506 (d.c.) for support of three operational projects, both for the period 3/1/68-2/28/69. On September 1, 1968 Arthur Wentz, M.D. replaced Thomas Mattingly as Program Coordinator. in February 1969 Staff reviewed 02-year continuation application. It was noted that some stage in the local management process caused an unexplained delay in notifying project directors that they couidc start their projects. ‘In addition other severe administrative dizficulties were evident from some questionable handling of other fiscal aspects of the program, It was also recommended, in addition to staff's recommendation to continue support, that appropriate staff visit the Region to review its procedures for program administration. On March 6, 1969,Grants Vanagement Personnel of RMPS visited the Region and succeeded in resolving many of the fiscal and policy problems which were noted in the February Staff Review. cd Metro D.C. ar -9- RM 31-04 (AR-l CDS) 2/71 January 1971 Review Comaittee During the 02 year of operational status, 3/1/69-2/28/70 the Region was awarded a total of $1,400,416 (d.c.), of this, $554,908 (d.c.) supported Core and $845,508 (d.c.) supported nine operational projects. As a result of concerns expressed by Committee and Council, regarding supplemental applications, during the August 1969 review cycle, a site visit was conducted to the Region in October 1969. The site visit team consisted of John Thompson, Chairman; Russell Roth, M.D.; Victor Vertes, M.D.; William DeMaria, M.D.; Walter Hangen, RMPS staff, and Michael Posta, RMPS staff. The visitors observed that the Washington program had not as yet achieved any real statement of goals and ‘objectives, and consequently was unable to set priorities in any kind of rational fashion. They found it difficult to judge the projects in light of the overall problems of the Region or the projected program of the Region. The only way the goals (which were really "areas of concern) were used, was to classify the individual projects as they were submitted into one grouping or another. Concern was expressed with regard to the separate organization of a post- graduate medical "faculty" within Core and outside the formal university setting. This activity was actually being carried on under the Hospital Council and there was no indication of how the educational effort of the projects would relate to the organization or center. The team concluded the D.C. RMP was moving slowly and continued to have very real problems in establishing its own identity. It was felt,however, the reorganization and formalization of the RAG will assist them to do better planning. In February 1970 Staff reviewed the Region's continuation for the 03 operational year (3/1/70-2/28/71). Staff agreed the application was the best yet submitted by the Region and that it seemed to reflect the leadership provided by the coordinator and his struggle to accept advice from RMPS and outside sources. The following issues were raised and the Region was asked to respond to them. 1. A plan of action for coordinative RMP planning and operations with health programs for inner-city populations, including model city, comprehensive health planning, health department and CEO programs. 2. A plan of action for increased involvement of inner-city representation in RMP planning. 3. An outline of procedures and time schedule of RMP priority committee. 4. A substantive description of activities of Continuing Education Staff working with the Hospital Council, including a list of hospitals for whom DME support is provided and the basis for support. 5. A plan of action for approach to overall health manpower planning. ‘ - aw AA JLTUG YLANTL GUD) L//L Metro D.C. January 1971 Review Committec In May 1970 the Region responded to the questions posed to them. In its review Staff observed that this Region has not made a significant contribution to planning for inner-city. With the exception of a number of funded RMP projects, few examples of specific achievements or plans could be cited. Although the Associate Coordin- ators at the universities were apparently charged with the responsibility of cooperative planning, they saw their role as being more " involved in the structuring of projects which reflect the institution's concept of their appropriate role in RMP activities"; a philosophy which is more consistent with the type of program that has evolved from this Region. The Region also cited as evidence of inner-city involvement and cooperative planning, the fact that twelve agencies which theoretically represented the inner-city were represented on the RAG. Staff questioned the degree to which these representatives were active participants, noting none served on RAG sub-committees. This review re-emphasized a second concern which various numbers of staff had harbored for quite sometime, namely the almost complete separation of the Center for Continuing Education with the Hospital Council from Core staff activities and management. It was noted: the Center's activities closely coincided with those of the Council in that they were hospital~oriented and for the most part catered to short-term needs, with little thought of cooperative planning on a long-term basis with various kinds of education institutions _at all levels. This observation was borne out by many activities and in particular the manpower surveys reported by the Region which focused just on employment needs of hospitals. Another concern of Staff was the fact that there was evidence the Center was instituting educational programs which were not only of questionable value, but also served to undermine established programs. In view of the concerns expressed regarding both the planning for the inner-city and the course pursued by the continuing education center, it was agreed some kind of strategy to help the Region change these aspects must be employed by Staff before the Region submits an application for Anniversary Review. The Region,as a result of RMPS Staff's efforts to assist, has taken steps to re-organize Core so as to strengthen the continuing education aspect of the program. Attempts to improve the staff concerns about the inner-city have resulted in the formulation of the Health Care Delivery Planning Committee which serves as a horizontal group composed primarily of Blacks who have specifically dealt with the immediate health needs of the disadvantaged in the center-city. Further, attempts to improve the organizational structure have resulted in the proposed Office of Program Planning, Office of Community Health and Program Activities and the Office of Program Appraisal. » [1] o« Metro. D.C. Ra 31-04 @AR-1-CSD) 2/71 Jee a - eoseeie cura Taman y- TSO ROL ew COmaErTTee PRESENT AL eLICAT ION se gm aia CORE STAFF The total amount requested for the Elrat year of the triennium beginning March i, 1971 for support of Core activities is $766,269. This total represents a continuation request for $571,201 committed support and a supplemental request for $195,068 of additional funds which would provide support for 10 new professional positions to Core staff. In addition to this first year req renewal of Core for the second the Trienniun. The 10 new positions being requested would raisa from thirty to forty the total number of Core Staff positions. Of the present 30 positions allocated to Core, 24 are filled. STRATEGY AND GOALS The Regton's overali program objectives is "To consentrate on increasing the Region's capability for sroviding outpatient, and preventive health and medical care cervices in heart disease, cancer, stroke, kidney disease and related disease to all the citizens of the Region." Each categorical planning committee has certain identified areas of emphasis: 1. Heart Disease Planning Committee: a. Program emphasis should be directed toward keeping private _ Physicians abreast of developments in the cardiopulmonary area. b. Qut-of-hospital programs for the patient aimed at primary and secondary prevention through early recognition and improved diagnosis should be supported. 2. Cancer Planning Ccmmittee: a. Start activities in flelds of public iaformation, patient education and professional skill training. b. Promote early screening and detection programs for those tumor sites which lend themselves to this approach. 3. Stroke Planning Comnittee: a. Institute a piacement center to assist patients and physicians in locating extended care, ambulatory and rehabilitative services. METRO DC ; . 212= RM 31-04 (AR-CDS) 2//1 MEDICAL SOCIETY OF THE ' January 1971 Review Committee DISTRICT OF COLUMBIA POLICY AND STEERING COMMITTEE PROGRAM COORDINATOR HEALTH COMMUNITY Expressions of Need . [MEDICAL DATA NX { puanninc COMMITTEES er of Needs PRIORITIES COMMITTEE Areas of Emphasis | PROGRAM GOALS Griteria for Activities [. REGIONAL \ ADVISORY ; GROUP 7" Evaluation of Goals NN of Region's Needs | Goals Do Not Meet Needs === Goals, Meet Needs — = aw oe awe ee om cow ewe ens: oo ewe ae tee we ocr ool Goals Partially Meet Needs : { V pce oe ered ‘ ome cum - — REGIONAL MEDICAL PROGRAMS SERVICE Federal Review METRO DC -12-4 RM 31-04 (AR-1-CDS) 2/71 January 1971 Review Committee Ae ent i . b. Establish consultative services based on cooperative relationships among local institutions to upgrade the quality of stroke care in hospitals and extended care facilities of the region. Renal Disease Planning Committee: a. Coordinate dialysis facilities within the Region to evaluate the capacity of the coordinated facility in delivering this therapeutic modality. b. Develop financial coordination to provide permanent funding for services through third party carriers and public assistance, Other Major Diseases Planning Committee: a. Improve diagnostic and screening centers which would provide broad support for community health activities. b. Develop a lead poisoning control program, Education and Training Planning Committee: a. Coordinate existing educational programs. b. Improve efficiency and effectiveness of in-service education and training. Health Care Delivery Planning Committee: a. Make effective use of existing and acquired facilities, funds and personnel. b. Design programs to improve quality of health care delivery in the Region. HEW, PHS, HMHSA Regional Medical Programs Servi g c Regional Advisory Group Medical Society of the District of Columbia T fees eee Planning, and Priority Committees Policy and Steering Committee LL nen me = ee ee ee Administrative anc MWRMP Program Coordinater Deputy Program Coordinator Od OWLaN wvicodd NOLLVZINVOUO | Coordinators for Categorical Disease Pr oO 49 ry fe 3 on Fiscal { oo Communications and Public Information en meme Office of | : , | . Office of | Office of Program . : Community | Program Planning . “ a | Health anc i Appraisal { | Program Activities |! oo : --- Administrative, Fiscal, Informational —~-——- =Palicy i Assoc. Coordinators for Med. Cors. ee ee Development: — ee we ee Continuing Educ. for Physicians i 4 Continuing Educ. for Nurses Allied Hlth. Educ. Poference Resource Libysry hg x on oS Fe a2ntret << ° at Om oS 0 Ow ~~ Ne g = ~ NS et ~ rad ~ ® ad e HETRY DC ~ aw wees we eres wey Hs REVIEW OF ACTIVITIES January 1971 Review Committe . STATED PROGRAM GOALS HEALTH COMMUNITY STATED CRITERIA slicited Unsolicited FOR ACTIVITIES roposals Proposals PROGRAM COORDINATOR ff. CORE P PLANNING STAFF 6G > | COMMITTEES Nn GUIDELINES saetiadaieilieadaiaieinaemneeel | EVALUAT IO a \ Rejection by Staff Meets Goals as not meeting the Fulfills Criteria \ RAG Program \ TECHNICAL ASS {STANCE \ COMMITTEE - Technical Review . ee el i Technically Adequate * Technical . Revision — e _ ev PRIORITIES COMMITTEE 7 7). a“ &# é a“~* / Ordering of Activities in Terms c -7 ¢ / Goals, Criteria & Funding 7 / / yo / / TOTAL PROGRAM 7? . a t i ¢ ( oF 7 7 / l REGIONAL ADVISORY GROUP ( / i; | Difference of Not Financially Program REVIEW OF TOTAL PROGRAM Opinion with Feasible Does Not Committee on Recommended Priorities Meet Goals Program goals met, Priorities Approved, Program Financially Feasible PROGRAMS SERVICE er | REGIONAL MEDICAL Metropolitan D.C. RM 31-04 (AR-1-CSD) 2/71 Jenuary 1971 Review Committee nontor seenemtcnt sam Core: As cited under the previcus section on Core jcaff, Requested the Region is requesting $571,201 committed support First Year and $195,068 supplemental support for the first triennium $820, 000 year. It is also requesting renewakt support in the form of a commitment, for the second and third triennium years. The purpose is to have Core and project support in phase, at least for the most part. Second Year - $870,000 Project #2R - Cardiovascular Disease Follow-up and Surveillance System This renewal request was previcusly submitted Requested to the November 1970 review cycle. Committee and Council First Year returned it for the upcoming site visit. $140,727 Request is made for 36 months additional support for this project sponsored by Georgetown University. The project was initiated in 1968 to acquire information on stroke occurrences in the Washington Region which can be used to provide better care for the stroke patient, planning for needed facilities (bads, rehabilitation centers) and eventually control and prevention of stroke. The goals of the project are; 1. To maintain a continuing reportiag system for evaluating medical care for stroke patients in the Region and to provide a means for measuring the effectiveness of the Regional Medical Program. The reporting system will provide community-wide information on stroke incidence, survival, rehabilitation, geographic distribution, hospital stay, demogranhy and epidemiology. 2. To provide a source of information for carrying out epidemiologic or demographic studies by providing a basic patient population upon which special studies could be based. These studies will provide the information necessary for control and prevention. Information on stroke patients is to be derived trom hospital records, private physicians and other pertinent scurees. During the initial two years of operation, the Stroke Surveillance System has established the basis for a Regional reporting system by concluding cooperative arrange- ments with 29 hospitals in the Region. The System will attempt to expand to all hospitals through the local Medical Societies. Other information sources are also being explored. Successful implementation of this program on a continuing basis will provide information on the extent of the stroke problem in the area as well as a mechanism for evaluating the Regional Medical Program stroke program. A comprehensive progress report is provided on the project's activities and success to date. Second Year - $144,609 Third Year - $148,635 January 1971 Review Commit Metropolitan D.C. RM 31-04 (AR-1-CSD) 2/71 - eagle Project #12R - Mobile Coronary Care Unit Renewed support Requested for one year is being requested for the First Year Mobile Coronary Care Unit in Montgomery County. The $100,000 purpose of the unit is to demonstrate that mortality from heart attacks can be reduced if the patient received care during the crucial perfod immediately following the attack. The mobile van, or heartmobile, provides the same services and equipment that can be obtained in a hospital coronary care unit. An important feature of the project is that it is staffed by paramedical personnel. A volunteer physician communicates with the team via a telemetry system. Preliminary evaluation as of July 14, 1970, shows that 59 percent of the total number of patients transported by the van were admitted to coronary or intensive care units. More extensive evaluation is being conducted in conjunction with the Department of Health, Education, and Welfare, Federal Heart Disease Control Program. METRO DC ~ 17 - RM 31-04 (AR-1 CDS) 2/71 January 1971 Review Committee PREVIOUSLY REVIEWED PROJECTS FOR WHICH SUPPORT IS BEING REQUESTED Project #17 - Health Careers Council Approved with no funds recommended. O01- $35,200 02 ~ $53,825 03 - $55,368 Project #19 - Cancer Registry Approved and funded, has committed support of $40,000 for upcoming year. Request supplemental support of $28,445 Project #20 - Peripheral Vascular Facility Approved and funded, has committed support of $50,000 for upcoming year. Request supplemental support of $43,608 Project #23 - School of Inhalation Therapy Approved and funded first and second years with carryover funds Request - Third year support at $86,490 Project #26 - Community Hospital Stroke Program Approved and unfunded Request 01 - $80,611 02 - $91,000 03 - $86,000 Project #28 - Coronary Care Nurse Training Approved and funded first year with carryover Request 02 - $54,471 03 - $55,860 Project #31 - Area Hemodialysis Training Program Deferred pending further study of supporting such renal projects Request O1 - $328,295 02 - $233,247 03 - $134,150 Project #37 - Early Detection of Chronic Obstructive Pulmonary Disease Approved and unfunded. Request 01 - $38,477 02 - $45,118 03 - $49,428 (Second and third year request exceeds approved level of $40,618 and $44,928) January 1971 Review Committee NEW OPERATIONAL PROJECTS Requested First Year Project #39 - Regional Exercise Stress Testing $77,724 Referral Services. This project sponsored by George Washington University proposes the establishment of exercise stress units in three hospitals orclinics. The objectives are to evaluate coronary disease status and support multifactoral approaches to coronary risk reduction and post-myocardial infarction rehabilitation. The units will be located so as to provide equitable availability to all citizens. After one year the equipment will be moved to other sites to start similar activities. Referrals will be made by physicians and patients will be returned to the referring physician for followup. The stress test will be a multi-stage, progressive submaximal test to the "Target Heart Rates" recommended by the Scandinavian Committee on Exercise Electrocardiography. Tests will be conducted by highly competent personnel who will educate others to assume the continuing operation of the programs at each site. Evaluation will cover the attitudes of both physicians and subject patients at or just after the testing, and what influence the results had on living habits and coronary risk factors in follow-up studies. The project relates to the program goals in that it emphasizes disease prevention. Second Year: $72,120 Third Year: $74,827 Requested Project #40 - Metropolitan Washington Pediatric Pulmonary First Year Program. This project sponsored by Georgetown $200,205 University Hospital has as its major goal, improved standards of care for children suffering with chronic asthma, cystic fibrosis and other severe respiratory illnesses. Under this plan, the outreach work benefit 92% of all children in the Washington Area. This proposal would: 1) Maintain the organizational framework of the Pediatric Centers now operating so that the evaluation of this initial effort can be completed. 2) Maintain the current computer based pulmonary registry for in-house patients. Modify the current automated system to include pulmonary outpatient data from the three university Pediatrics Hospitals Programs (Georgetown, George Washington and Howard). 3) In the second year, establish a specialized outpatient clinic for children with pulmonary disease at Providence Hospital which would serve as a model for the implementa- tion of similar facilities on a regional basis. METRO DC - 19 - RM 31-04 (AR-1 CDS) 2/71 January 1971 Review Committee 4) Extend the university based pediatrics programs to other affiliated hocpitals such as D.C, Genera. Vospital and Fairfax Hospital in the third year. 5) Continue training programs at the undergraduate, graduate and fellowship levels in order to meet the critical shortage of trained physician in the area of Pulmonary diseases. 6) Numerous opportunities for paramedical and allied medical training of personnel could be provided. Second Year: $230,845 Third Year: $285,310 Project #41 - Training Program: Cardiovascular Technicians and Requested Physicians Assistants. This project sponsored First Year by the Washington Hospital Center is a revised version of the $172,717 ongoing project #3 - Training for Cardiovascular Technicians, which will terminate at the end of the current year. It proposes the: 1) Continuation of the Cardiovascular Technicians Training Program in its present form to teach two 18-week classes a year. 2) Introduction of an extension of the above one-year program in order to produce a more highly trained individual capable of increased responsibility in the cardiovascular field. On graduation he receives a certificate representing one year of college work, approximately 28 credits. This "advanced program" is planned in conjunction with Montgomery College. 3) Introduction of an associate degree program in conjunction with Montgomery College to train more broadly based physician's assistants. This program will be entered directly by a candi- date who elects to do so. Candidates who have completed the basic and/or advanced Cardiovascular Technicians Training Program will be able to apply credits obtained in those programs to their associate degree. Second Year: $240,959 Thicd Year: $246,105 Requested Project #42 - Establishment of Selected Nypertension Clinics First Year in Economically Depressed Areas. This project $185,181 sponsored by the Hospital and Medical Care Administration of the Department of Humane Resources is designed to improve health care of patients with hypertension within the Region by establishing a reference and control center tying together five clinics. The District of Columbia General Hospital, Washington Hospital Center, The Anacostia Neighborhood Clinic, Freedmans Hospital and Columbia Hospital for Women. METRO DC - 20 - RH 31-04 (AR-1 CDS) 2/71 January 1971 Review Committee The referral center would be staffed to provide a community provides new services and facilities (objective #2) for stroke care, It will also encourage physicians to refer patients to these services. This project will coordinate the resources of six hospitals to insure that all stroke patients in a subregion receive the full range of services required. Second Year: $132,971 Third Year: $138,911 Project #16 - Professional and Patient Stroke Educational Program. $73,873 The aim of this project is to encourage and stimulate the staffs of ten community hospitals in Bergen County (population one million) to strengthen the management and prevention of cerebrovascular disease by participating in cooperative demonstration education programs designed to increase the knowledge and effectiveness of physicians, nurses, allied health personnel, and families of patients. Developed on the basis of recommendations: <.:.” of a feasibility study, this project attacks objective #3 by improving patient care through the education of physicians, nurses and other allied health personnel. It also helps to achieve a balanced categorical program for the region, promotes subregionalization and involves the practicing physician in planning. Second Year: $77,091 Third Year: $76,174 Project #17 - Regional Blood Freezing Program. $63,720 This project hopes to increase the opportunities for all patients in New Jersey to have access to a frozen blood program so that they will receive the advantages of newer and safer methods of blood replacement. Tt will accomplish this aim by expanding the Essex County Blood Bank to a region- wide system, educating health professions about the use of frozen blood, and increasing the emergency supply of blood in the region. This. project serves the region's second objective by decreasing the risk involved in multiple transfusions and increasing the effectiveness of organ transplants. It also provides an additional source of blood for emergencies and rare blood type needs. Second Year: $54,021 Third Year: $18,185 NEW JERSEY RMP -9- RM 42-0Qp (AR-1-CSD) Project #18 - Model Cities Community Health Improvement Program. $824,929 ‘The Model Cities Community Health Improvement Program has been formulated to provide health planners with the requisite information for designing needed improvements in the health care delivery system for ghetto residents. The Program will identify and describe the scope of ma jor health problems, the utilization of existing health services and the spectrum of obstacles to utilization - information, motivation, availability, accessibility, facilities, and financing. Through a large-scale mobile screening service, employing Model Cities residents, the proposed program will include inter- views, health examinations, referral and follow-up services, and provide a limited funding mechanism for the medically indigent. It will permit entry into the health care system, and give impetus to the improvement of local health care delivery through specific recommendations to Model Cities agencies resulting from the analysis of. program operations. This project is designed to offer screening and referral services until. the comprehensive health centers are more widely established. Second Year: $954,084 Third Year: $967,820 Fourth Year: $832,242 Fifth Year: $847,385 Project #19 - Comprehensive Family Health Service, Newark Beth Israel $1,219,595 Medical Center. This project would establish a three-year demonstration program to evaluate the effectiveness, acceptability, quality and cost of a family-oriented, group practice, comprehensive health service in an urban community hospital setting. The service is designed to fill the physician deficit in a central city area serving disadvantaged and medically indigent families, and to provide for direct consumer decision-making in the planning and operation of the service. This experience will provide the New Jersey Regional Medical Program with the ‘necessary information on personnel and facility and funding needs for deliver- ing acceptable and adequate medical care to this population through community hospitals. The information will be used to develop guidelines for the establishment and operation of a hospital-based ambulatory care service with recommendations for the funding required to provide this type of care for the entire region. High priority has been accorded by the Region to this project and Project #13 as ways to test the concept of providing comprehensive health services to the disadvantaged (objective #1) through the existing hospital facilities of the region, rather than through the establishment of new, costly free-standing centers. Second Year: $1,150,513 Third Year: $1,193,249 Project #20 - Decentralized R.N., L.P.N. Cardiac Nurse Training. $84 ,405 The aim of this proposal is to improve the care of patients with cardiac conditions by increasing the capability of local hospitals ina four-county NEW JERSEY. RMP. -10- RM 42-Up (AR-1-CSD) . subregion to conduct their own training programs for nurses, and by establishing a new role and training program for Licensed Practical Nurses in intensive cardiac care. The project resulted from a feasibility study of multimedia instructional systems which determined that, when utilized under the supervision of skilled faculty, this teaching method can be effectively and economically employed in local hospitals to train their own staff. The proposal furthers the aim of objective #3 by improving the knowledge and skills of R.N.s and L.P,N.s. : Second Year: $70,496 Project #21 - Nursing Education for Leadership and Clinical Teaching. $41,579 Proposed by Rutgers University, Extension Division, this project would attempt to meet the region's continuing need for leadership and teaching of hospital nursing staff in specialized clinical areas by inaugurating an educational resource within Rutgers, to develop the leadership skills of nurses and prepare them as clinical instructors in cardiovascular-cardiopul-~ monary patient care in the first year, and additional clinical areas in the second and third years. Second Year: $48,598 Third Year: $50,168 Project #22 - A Regional Radiation Automated Dosimety Project. $184,082 Project #22 is grouped under the objective of increasing the effectiveness and efficiency of existing health facilities and services. It will link the resources of major medical centers of the area to the community hospitals by establishing a mechanism to program radiation doses. Radiotherapists and physicists will be freed to extend their services to hospitals treating patients with megavoltage equipment, but without qualified personnel. Directed by the New Jersey College of Medicine and Dentistry, the project will make ‘available and accessible optimal radiation therapy for cancer patients through- out the region by providing radiation therapy consultation and automated dosimetry for patient radiation therapy departments having megavoltage radia-~ tion therapy equipment. The project developed as a result of a regional radiation therapy survey undertaken by the NJRMP Cancer Council. Second Year: $96,116 Third Year: $100,955 Project #23 - A Cervical Cancer Screening and Education Program. $162,825 Originally funded as a 3l4e grant, this project provides a means of delivering the benefits of a cervical cytology program (referral, screening and follow-up) to increase the early detection of cervical cancer among females at high risk in low socio-economic groups in a sub-region of New Jersey (Middlesex County: population 560,000 people); and also provides a demonstration program for other sub-regions of the state. The proposal is also expected to increase the region's knowledge about the extent of disease among the disadvantaged (objective #1). Second Year: $174,469 Third Year: $197,686 So NEW JERSEY RMP -11- RM 42-02 (AR-1-CSD) Project #24 - A Training Course for N.J. Tumor Registry Secretaries $19,140 Sponsored by the NJRMP, this proposal will organize courses and workshops to train tumor registry secretaries. It was generated from the activities of the ongoing Tumor Conference Board project, which saw the need for comprehensive and up-to-date records of cancer patients to insure follow- up and suggest the location of specialized facilities for cancer treatment. As such, it addresses the goal of improving the knowledge and skills of health practitioners (objective #3). Second Year: $19,142 Third Year: $19,778 Project #25 - Primary Rheumatic Heart Disease. $66,517 This project's purpose is to reduce the incidence of rheumatic heart disease through the early identification of streptoccoccal infection by providing free throat cultures to all school children with symptoms of sore throat in a sub-region, utilizing school nurses; by outlining and conducting an educational program on the importance of this procedure; and by providing a home follow-up mechanism for children failing to maintain penicillin treat- ment. It will increase the effectiveness and efficiency of existing health services (objective #2) by utilizing the services of the school nurse, Second Year: $59,035 Third Year: $56,792 Project #26 - Regional Medical Library and Information Network. $122 , 608 Sponsored by the New Jersey College of Medicine and Dentistry, this project "is designed to strengthen the capability of the region's community hospital libraries to provide readily accessible, comprehensive medical information for patient care by creating a regional library network, training personnel and expanding information services. The capability of community hospital libraries and their staffs will be increased and made more effective through this network, which will link all hospitals to the existing regional library resources at the medical schools. Second Year: $92,790 Third Year: $63,842 Project #27 - New Jersey Consumer Health Radio Program Series. $52,950 This project will call upon the resources of all 49 local radio stations within the region for disseminating specially prepared programs for the disadvantaged and the general public. The project will be organized and directed by the Communications Division of the New Jersey College of Medicine and Dentistry working with the scientific faculty. Thus, the project utilizes existing radio facilities and various departments and resources within the college, as well as informing the disadvantaged about good health practices, answering questions about special health problems, and providing information about access to available services (objective #1). The College conducted a pilot experiment in the use of radio to answer consumer questions concerning health and medical care with a grant from the Hunt Wesson Corporation, which produced exceptional results: an increase in registration at the Pre-Natal Clinic, Drug Abuse Clinic and Family Health Care Center and, some decline in the use of the Emergency Room for optional services. Second Year: $39,256 Third Year: $26,769 Date: cply to “hin of: Subject: To: DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE . PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION December 1, 1970 Staff Review of Non-Competing Continuation Application from New Jersey Regional Medical Program, 5 GO3 RM 00042 . rr Acting Director ‘Regional Medical Programs Service l a\v ~ fer THROUGH: Chairman of the Month, a2 yD iron ve / py ee Acting Chief, Regiohal vebetopment Branch | +" / The New Jersey Regional Medical Program is requesting continuation support for its 03 operational year for core and six projects. Since New Jersey's budget year does not start until April 1, 1971, and the 45-day estimate of expenditures is not due until mid-February, requests for use of carryover funds have not been included in the present application. It should be noted that the Region has no approved and , unfunded projects. Therefore, the discussion was limited to the following continuation request. - Continuation Requested Amount. Core — $656,931 #4 - External Cardiopulmonary Resuscitation 50,545 #6 - Evaluation of the Status of Implanted 68,104 Pacemakers #7 - Establishment of Tumor Gonference Boards 150,022 in New Jersey Hospitals #9 - Hemodialysis Training Program 40,144 #11- Cancer Care Course for Nurses 61,414 #12- Urban Health Component of Core 209,016 Total Request $1,236,176 Besides the continuation request, the Region has included in its AR application, a request for a one-year developmental component, one renewal and 15 new projects. The Region was supported by a funding level of $1,306,906 during the 02 year; this amount included $69,125 in ca rryover. Sime _ ese Ae Tae Acting Director, RMPS - Page 2 Recommendation: In view of the progress evidenced by the projects (some have exceeded their objectives) and the apparent competence of core staff, approval of the committed level for the 03 year is recommended. The following staff members attended the November 23 meeting: Miss Dona Houseal, Grants Review Branch ~ Mr. Lee Teets, Grants Management Branch Mr. Larry Witte, Planning and Evaluation Branch Dr. Veronica Conley, Continuing Education and Training Branch General Comments and Site Visit Issues: Staff found the application well-presented. Three regional objectives ’ are outlined, and throughout the application, past, present and future activities are related to these goals. The regional objectives are: 1) improving the accessibility, quality.and quantity: of health services for the urban disadvantaged; 2) increasing the effectiveness and efficiency of existing health facilities and services; and 3). increasing the skills and knowledge of health practitioners. The application informs us that the Regional Advisory Group's responsi- bility is to establish priorities and review proposals based on these objectives, while the Task Forces and Councils provide technical review of the projects and recommend policy in their special areas. Core staff involvement includes assisting with development of projects, conducting feasibility studies and staffing the Councils and Task Forees. Based on this information, staff raised the following concerns for the site visitors’ attention: - Review Criteria. The Region has not included its review criteria used by its Task Forces and Councils for technical review of projects. Since this type of review has now been transferred to the Regions, it becomes very important for national reviewers to have some judgment of this process. Therefore, the Region should be asked to discuss this during the site visit. Staff was also interested in knowing how ideas for feasibility studies for proposed projects are selected. - Reorganization of RAG. Following a major reorganization , the RAG now includes 13 general and consumer members, five of whom are blacks. As a result of this change, certain objectives have been set for the Region. Staff wonders what problems have occurred and how the RMP --- Core stafffecs, review groups and involved organizations ~~~ have coped with them. The ° question of Medical Society involvement is crucial here. Acting Director, RMPS - Page 3 - Evaluation. Who on Core staff is responsible for coordinating evaluation efforts, both project and program evaluation? oo" Medical School Involvement. Medical school development is in a state of flux in New Jersey. Staff is concerned about the degree of medical school involvement in RMP as a result of this change. - Status of Board for Grantee Agency. In November 1968, the RAG was reduced from a 57-member to a 25-member policy-making body which was to serve as a Board of Directors for the governing body of the grantee institution, the New Jersey Committee for Implementation of P.L. 89-239. Staff is concerned about this overlapping membership and that the RAG, by serving as the board for the grantee agency, may be advising itself. Staff would like the site visitors to explore this situation and determine whether such a conflict of interest exists in guidance of the program. - Support of Proposed Projects Without RMP Funds. The Region is requesting approximately $11,500,000 in supplemental project activities. Given the apparently bleak prospects for a significant increase in the national availability of funds for such activities in the next year, staff wondered if the Region had any plans for alternate sources of funding. , { Conclusion: The committed amount of $1,236,176 is recommended for the Region's third operational year. Sarah J. Silsbee i ae NS Acting Chief Hoe ; Grants Review Branch Action by Director Linooreh ‘Initials : rey Date y713al70 LJ | (A Privileged Comeuntcation) aa res a & Nau JERSEY ee UARY 1971 ADVISCRY COUNCIL for 15 new projects supparted es follovs: : T Oo "RATS Ce och a PG CI tn ERT TE TIN OA NEE a A MEME cs mad 03 $1,236,176 $5,691,233 $4,780,907 C5 . 5.259608 3,299,625 TOTAL $1,236,176 $123 $e 568 $11,761,107 $13,060,753 RECCY meres YEAR STAPS TOD soit -um a een 03 $1,236,176 $123, 53% $1,629,625 $2,989,501 05 1,276,666 - l, 276, 466. .$1, 236,176 “$123,500 . $4,264, 041 $5, 623, 147 “ Same as site visit recommendations Critigus: In its deliberation, the Committee accepted the report of the site visit to the Hew Jersey Region en Decenber 10-11, 1970, ad on the maturation of thig Region since the last the visitors report fey vee, NEW JERSEY RMP w2- ORM 42-02 (AR-1-CSD) 2/71 site visit. The reorganized Regional Advisory Group appears to be functioning very effectively as a policy-making body. The RAG has established three rather general goals and-priovities fox the operational projects which have been developed by a process of negotiations among the RAG members, Although not very systematic, the process warks well because the RAG is quite active and involved. Short and long-range objectives should be developed, however, to insure a plan of action that is consistent and measurable, The RMP has not established a data base, although they have had avaliable data collected from other agencies and has collected some dsta to support needs for some of the projects. The Region should devote more attention to establishing a data base, which would mainly involve the synthesis of data from other agencies. The project review procedures are well developed and appear to effectively ecreen projects, set priorities and monitor the success of already funded projects, The team recommended and Committee concurred that the review process should-include an adversary review step conducted by. individuals other than those who have worked on the development of. the. project, Further effort should also ba devoted te the establishment af a prodeet evaluation mechanism. ‘he organization is well formulated and is capably administered, Depending on the anount of new finding the Reston receives, an “additional Core staff meaber may be needed to handle the extra worklond (Since one of the present Core staff positions will- be funded out of a projéct budget in the future, this position could be dedicated to these efforts). As far as implementation of the program is concerned, this Region has made some important achievements. In the absence of streng medical schools ead affiliated medical centers, many community hospitals are assuming the lead-in sponsoring FUP continuing education and patient care denonstration activities, A continuing education framevork is being developed which uses the community hospital as the continging education. and training locus for physicians, nurses and other health personnel. BMP has also been a force in getting groups of hospitals together to plan regionally, such as for stroke care programs and radiation doginetry facilities, Reviewers were particularly intrigued by the proposed experiments to be mounted by community hospitals Gn Newark and New Brunswick) which would test the cost, acceptance and overall feasibility of the community hospital-based comprehensive health eare center in a large and small hos pital getting. Also impressive were the Region! g efforts in: the urban health. sector, _ The Region has several vocal black consumers en the: BAG, an active Urban ‘Health “Task Force and an Urban Health component of core which places staff in the nine Model Citiés to assist with the development of the health part of the Model Cities application. These urban health planners have also proved valuable in seeking other sources of funding for various programs, increasing the awareness of residents about health needs, and influencing the overall level of planing for other aspects of the Model Cities program, ‘The Region has been. effective in involving other statewide groups, such as the Medical Society, the Fospitel Association and the Nurses As sociation. NEW JERSEY RMP o3e .. RH 42602 (ARe1- cs :0) 2/71 » : . Medical School and C2P involvement at the present time is conditioned ° by. theix problens of growth and development. While the contention between the Grenter Delaware Valley. RY MP ‘and. the New Jersey. RMP over’ the ten southern counties in New Jersey is undar contreal, Coomittee agreed withe the site visitors. ‘that it should continue to be monitoreds One member of Co nun Eee brought: to the group! gs attention the- possibility of conflict of interest in the organization in which the Board members: of the. grantee igoncy,- the New Jersey Committers for the Implementation of PL. “892939, are all RAG members, While the site visitors believed ~_ that this situation doesn't necessarily dictate a conflict of interest, Comaittee thought that.in order to obviate any doubt in the future, it _ should be recommended that the Region adjust the Board's membership in ‘some wa ay >! possibly: by adding some noneRAG menbers, to the Board, assed with the program's progress “to assuage the inereased view procedures. Reviewers shat lowex nd accented in- conclusion, the revievers were impre to date and beliove the Region is rez esponsibility under che Anniversary I believed, however, that this could be accomplished at a somes funding level, he level determined by the site visitors by the Committee resulted from the exclusion of capital expenditures emanating from major organizational settings such as hospitals and medical schools. Funds fer a developaeatal component were included in the funding level. Kecouse this Region has a good record of using emall auounts of money imaginatively, as well as using funds to initiate activities while seeking other sources of support, Committee agreed that this Re gion merited the privilege of having this flexible money. cy GRB/RNE. 1/19/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) New Mexico Regional Medical Program . RM 00034 2/71.1 (S) University of New Mexico Medical School January 1971 Review Committee 920 Stanford Drive, Northeast Building 3-A Albuquerque, New Mexico 87106 Program Coordinator: Reginald H. Fitz, M.D. Request (Direct Costs) Committee/Council Review: 03 04 05 Total Project #16 $45,188 $55,558 $57,069 $157,815 (formerly #12) Note: This project was presented to Committee and Council review at the February-March 1970 cycle. The Committee's recommendation for a "Return for revision and resubmission to include clarification of certain concerns" was endorsed by the National Advisory Council. This present application represents these efforts. In order to keep the program active and in phase with the New Mexico school year, $16,000 was granted from unspent balances from the 02 year with the 03 year award, for six months only (September 1-February 28, 1971). RMPS Staff Review: Continuation Support for Core Staff and 11 ongoing $1,036,719 (commitment) activities Carryover | 133,452 Total (d.c.) $1,170,171 Funding History (direct costs only) Planning Stage Grant year Period ‘Funded O1 10/1/66-9/30/67 (grant extended from $384,317 10/1/67-11/30/67) 02 12/1/67-6/30/68 $252,379 (7 months) New Mexico RMP -2- RM 00034 2/71.1 (S) Operational Program Grant year Period Funded O01 7/1/68-6/30/69 $965,305 02 7/1/69-8/31/70 (14 mos.) 1,252,911 03 9/1/70-8/31/71 1,170,171 HISTORY OF PRESENT APPLICATION: This project was originally submitted for the February/March 1970 cycle and returned for revision in view of certain deficiencies, The reviewers felt that New Mexico is an almost ideal area to carry out a PhonoCardioScan screening program, and moreover noted that it was an indication that New Mexico had established an appropriate set of priorities. The primary concern about the application was that a program of this scope could not rely completely on volunteer technicians as was planned. Also, it was unclear how the computerized registry would be used for follow-up, and there were no other indications of such measures to be utilized. There were no plans presented for phasing out RMP support, nor a statement of how the state, county health departments or school boards, would eventually be called upon to provide support for the program. : There were other technical and budgetary concerns which were communicated to the region, as well as the suggestion that NM/RMP should seek assistance from other similar programs that are functioning well, such as Baltimore and Metropolitan District of Columbia. At the time of the submission of the request for continuation for the 03 year, RMPS staff gave special attention to a request for carryover funds (for one year only) to continue the salaries of physicians who had piloted certain demonstration activities. Staff agreed tothis proposa], in order to keep the project operational, and the continuation award of September 1, 1970 granted the amount of $16,000 to continue the program, but with the last six months funds restricted pending the receipt of an Anniversary Review package on November 1, 1970, to include a revision of the project in line with Committee/Council suggestions. NM/RMP decided to delay submission of the A/R application until February 1, 1971, which made it necessary to revise and update this New Mexico RMP ~3- RM 00034 2/71.1 (S) project request for three years, for submission to the January/February 1971 cycle. PRESENT APPLICATION: First Year The revised application has followed very closely the suggestions Requeated and concerns of the Review Committee and National Advisory Council. $45,188 The objectives are: 1. To detect previously undiagnosed organic heart disease in school children, 2. To provide initial evaluation and, if needed, long term follow-up for children who are found to have unrecognized organic heart disease, 3. To establish the prevalence of previously known and unknown congenital and rheumatic heart disease in New Mexico school children. 4. To "delabel" children who have been previously diagnosed as having heart disease, and are found to be free from cardiac disease by the screening physician, 5. To utilize these and other epidemiologic data to establish a registry for congenital and rheumatic heart disease, 6. To acquaint health professionals in New Mexico with this program, and to conduct education programs (e.g., in association with screening clinics) for practicing physicians and nurses, ‘ 7. To develop educational programs for children and parents related to the nature, prophylaxis, and treatment of heart disease, This proposal has been approved by the State Medical Society and has received favorable review by the Comprehensive Health Planning "A" Agency Council, Community acceptance has been excellent and many localities have requested the program on their own initiative. There have been no problems in recruiting volunteer technicians. In Los Alamos, an educational program for practicing physicians has been conducted in association with the local cardiac clinic. All communities requesting heart sound screening must obtain local medical society approval for one of the following two alternatives: (1) local medical society appoints one physician to conduct secondary screening in the school setting, or (2) requests the services of the Project Director or Assistant Director, or other physicians designated by them, The PhonoCardioScan Registry was established in order to facilitate accurate data collection and storage and to provide a means of continuing, regular follow-up of patients. An elaborate computerized system will not be necessary since the anticipated number of new cases will probably not be greater than 150 - 250 per year. It is possible that ultimately that the PhonoCarioScan data will be incorporated into the region's Health Information System which is New Mexico RMP -4- RM 00034 2/71.1 (S) planned. Data collection and storage will be manual but will be designed for adaptation fo computer systems if needed later on. The Project will be staffed by a Director, Dr. Robert F. Castle, assisted by Dr. Jonathan Abrams, (20% and 15%), a full-time Nurse Coordinator and full-time Assistant PCS Program Coordinator, plus two part-time clerical staff. Three PhonoCardioScan computers have already been purchased, one by the N.M. Heart Association and two by the NM/RMP. The Heart Association has also allocated $1,350 for travel expenses and provides office space and part-time additional secretarial assistance. The Heart Association has thus far absorbed telephone costs as well as office supplies, and has pledged from $10,00-$15,000 in 1974-75 with modestincrements thereafter. Cost of individual case detection will be computed periodically. Direct costs vary inversely with numbers screened, since the major outlay has been for the PhonCardioScan computers. Costs will be computed with respect to grade and socio-economic levels, although data collec- tion to date has not been so analyzed, but will begin with the appointment of the full-time Coordinator. The registry, when established, will provide efficient cost analysis, as well as preva- lence rates from different socio-economic and geographic areas, It is hopedthat the screening will become routine in most New Mexico school districts and some locally autonomous programs may be functioning by the end of the third year. In most school systems the program will include pre-school (Head Start) children, as well as 4th and 10th grade students. , Direct costs for the program from February 1969 through August 1970 totalled approximately $19,780. Cost per child screened was $1.20 (through June 1970). The cost of detecting each child with previously undiagnosed heart disease was $1,312. The latter figure reflects the large initial cost of the screening devices. These costs will decrease with more screenings per machine. During the academic year of 1971-72 an expansion of the program is projected. By this time, a group of physicians and trained volunteers should be established throughout the state conducting the program in many communities. Some long term support will be requested from CHP as well as state and local health budgets. 03 Year: $55,558 04 Year: $57,069 RMPS /GRB/12/22/71 ‘A PRIVILEGED COMMUNICATION SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE NEW MEXICO REGIONAL MEDICAL PROGRAM BM 00034 2/71.1 (S) FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: Additional Funds as requested to be provided with emphasis on the importance of follow-up data to be provided to the registry. Year Request . _ Recommended Funding 03 | $45,188 $45,188 04 55,558 55,558 05 . 57,069 . 57,069 Total . $157,815 $157,815 os Critique: Project #16 (formerly#12). The Review Committee was impressed . with the improvement in this revision, but still had reser- vations about part-time physician personnel. It was felt that the region should be encouraged to enlist additional assistance from volunteers: in order to maximize progress made thus far to maintain its momentum, The project is believed to be realistically planned for the needs of New Mexico children, The involvement of the Heart Association is noteworthy as is the interest of the Department of Public Health which will eventually take over the program, The reviewers questioned the Consultant costs ($10,000) in lieu of full-time staff, which will provide a-fee of $50.00 per half-day for the secondary screening, It was noted, however, that such physicians would be local, qualified, specially trained individuals, or full-time faculty of the University of New Mexico Medical School. In the latter ' case, the $50.00 honorarium will be paid to the Faculty of Medicine Fund and not to the individual physicians, The other concern expressed was in reference to the documentation of cases detected, Committee wondered if the registry will provide the means for continuing follow-up of these children, how they will be identified, etc. The emphasis here was on the importance of the registry being kept in an “active" status and not allowing the data to lie dormant without appropriate follow-up. The region should be cauticned about developing an excellent system, which without careful monitoring along the way, could fail the children for whom “it was designed, RMPS /CRR/1/18/71 SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) © REGIONAL MEDICAL PROGRAMS SERVICE New York Metropolitan RM 58-02 (AR-1-CDS) 2/71 Regional Medical Program Janaury 1971 Review Committee 2 East 103rd Street New York, New York 10029 Program Coordinator: I. Jay Brightman, M.D. Request (Direct Costs) Committee/Council Review 02 03 04 Developmental Funds ( 329,000) Four New Projects ( 811,686) $647 ,943 $760,512 Total New Funds $1,140,686 $647 ,943 $760,512 RMPS Staff Review Core ($1,146,791) 10 Projects ( 1,538,061) © Total Continuation Funds $2,684,852 TOTAL REQUEST $3,825,538 $647,943 $760,512 Staff Recommendation: Continuation Funding at Committed Level $2,539,887 ( 1,146,791) Core ( 1,393,086) Projects Funding Histor Planning Stage Grant Year Period Award 01 6/1/67 ~ 5/31/68 $ 967,000 02 6/1/68 - 9/30/69 1,688,875 03 10/1/69 - 1/31/70 516,000 New York Metropolitan RMP -2- RM 58-02 (AR-1-CDS) 2/71 Operational Stage Grant Year Period Award Commitment 01 2/1/70 - 1/31/71 $2,163,744 02 2/1/71 -12/31/71 $2,539,887 03 1/1/72 ~12/31/73 1,932,320 Background: The New York Metropolitan Regional Medical Program covers the five counties of New York and the contiguous counties of Westchester, Rockland, Orange and Putnam. It serves nine million people, including 35,000 physicians, 223 hospitals, 43,000 nurses and a multitude of other professionals. Seven medical schools are located in the Region: New York University, Columbia University, Albert Einstein, SUNY Downstate Medical Center, Mount Sinai, New York Medical College and Cornell University. The Associated Medical Schools of Greater New York is the grantee agency. This organization was set up for the Regional Medical Program and includes the seven medical schools and the New York Academy of Medicine. The Trustees are the seven deans and the director of the Academy. Nominees for the Regional Advisory Group are recommended by a Regional Advisory Group (RAG) Committee and appointed by the Trustees. The New York Metropolitan RMP was first awarded planning funds on June 1, 1967. Two projects were funded during the planning phase from earmarked funds for a mobile coronary care unit and a pediatric pulmonary diseases program. Dr. I. Jay Brightman was appointed coordinator in January 1969. The Region applied for operational funds in May 1969, and a site visit was made in July 1969 at which time the team was impressed with the organizational changes that had been made under Dr. Brightman's direction: broader representation of the RAG, the emergence of a Planning, Priorities, and Evaluation Committee, closer supervision of the medical school core staff and project operations by the Directors, and broader functions for the Technical Consulting Panels. Council approved operational status and funding for five of the eight proposed projects in August, but due to funding restrictions, the first operational grant was not made until February 1, 1970. Still, in its first year the Region has 10 on-going operational projects. Technical site visits were made to the Region in February 1970 and July 1970. A site visit to study the Region's readiness for developmental funding was made in December 1970. New York Metropolitan RMP -3- RM 58-02 (AR-1-CDS) 2/71 PRESENT APPLICATION Regional Advisory Group Report: The report describes the changes that have been made in the organization of the Regional Advisory Group. The rules were revised in 1969 by an Ad Hoc Committee on rules which has since been appointed a standing com- mittee. The Steering Committee was increased to a 35-member Committee on Planning, Priorities and Evaluation. A Screening Subcommittee was organized as well as a Subcommittee on the Developmental Grant and Priorities, a Subcommittee on Renewal Applications (which not only looks at renewal. requests but continuation requests) and a Subcommittee on Evaluation. Considering the geographic impact of the Regional Medical Program to date, the RAG report indicates that the Northern counties, especially Orange and Rockland Counties, are still behind in their organization. Queens County will now have a County Committee. There is cross representation with the New York City Health Services Administration, the Health Department, the Westchester Health Department, the Health and Hospital Corporation and the Hospital Council of Southern New York. The Comprehensive Health Planning (b) agencies have not yet been established although there is cross representation with the statewide CHP. The categorical disease planning groups completed regionalized plans in heart disease and cancer. Stroke, diabetes, and renal disease regionalized plans are well along the way in draft form. The RAG report indicates that the contribution and involvement of the medical schools faculties is still a problem. They found that the Associate Director positions had not worked out as well as expected and a Medical Allocations Committee has been set up, composed of two trustees, two members of the RAG, and the director, to look over the 12-month plans of medical school for budget and program. Manpower is considered an important problem in the region and there is an interdisciplinary committee on allied health education as well as an ad hoc committee on personal health services. The RAG report states that a project in Bedford-Stuyvesant was turned down in the technical review process; an appeal was made to the RAG indicating that the needs in that area were so great that this project was greatly needed; the RAG approved the activity and decided a different set of criteria was needed to look at these projects. The RAG report also states that the developmental component is considered an important element that would enable the region to go ahead with activities and not have to await national review or a turn down by the national review processes for things that they know are important locally. New York Metropolitan RMP -4- 0 RM 58-02 (AR-1-CDS) 2/71 Following is the number of people from various categories that are on the RAG and on the Committee on Planning, Priorities, and Evaluation: Membership ‘ RAG CPPE County Medical Society Dental District Nursing District Other Societies Voluntary Health Agencies Hospital Administrator Planning Groups RMP County Committees Public Health Agencies Educational Agencies Public Members _ DUWUUM®NH™UNMO WWONNrNANODOA PR Core Staff:. The progress report on core staff activity indicates that the organization and central office has proceeded along lines recommended by the Management Assessment Team that visited the region last summer. A new position has been established for Assistant Director for Field Services and the planning and evaluation activities have been separated and will be an Assistant Director for Planning and an Evaluation Specialist. An office in White Plains will be set up through the New York Medical College and an office in Harlem is staffed by the Columbia University Associate Director. Queens County will have eee a staff representative as well as a County Committee. The application states that plans to have the Comprehensive Health Agency review the applications have been delayed because the Mayor's Task Force on CHP is not in a position to review applications now. The core staff is helping the Mayor's Task Force on CHP. A data book has been published and is available to groups throughout the region. A number of studies have been made through the core staff operation which enable the region to involve new -geographic areas and program areas. Following is a list of the studies: 1. Intensive CCU Training with the Orange County Community College. 2. Epidemiology Survey of Cerebrovascular Diseases by the King County Medical Center. 3. Study of Facilities Services for Respiratory Diseases and Disorders. 4. Coronary Care Training Surveys. The medical school staffing for which about half of the budget has been allocated in the past, is now being studied and evaluated by a Medical Allocations Committee. While still a problem area, the application states that the medical school faculty 1s becoming more involved in the program. New York Metropolitan RMP -5- RM 58-02 (AR-1-CDS) 2/71 Developmental Component: The subcommittee for developmental grant and priorities has fairly well-rounded representation; three medical doctors, one doctor of Osteotrophy, and three consumers, including the RAG chairman. The application for the developmental component speaks to the need to build on the categorical disease planning that has taken place. The region-wide plans on the categorical diseases will serve as guidelines for priorities for program development. The region anticipates using developmental component funds primarily for pilot project-type activities which will determine feasibility, identify the problems, determine methods of overcoming the barriers and develop evaluation indices so that a major project can be developed. Each pilot pro- ject will be looked at from these criteria: will it serve more people, will it provide better service and will it help increase the manpower pool. A number of suggested ideas that might be considered for developmental funding are identified in the application. New Projects Project #25 - After Care Center for Chronically 111 Patients at First Year Montefiore Hospital - The project proposes to Request demonstrate the impact of a new modality of medical care through $164,310 the development of a Montefiore After Care Center for nursing home and home patients throughout the Bronx. Comprehensive diagnostic, theraputic, and rehabilitative services will be provided to the patients who are transported from their nursing homes or homes to the hospital. An estimated 300 patients would be served each year by the center. It is anticipated the project will provide better, more comprehensive care for more patients and that it will result in better utilization of scarce professional personnel by eliminating the travel time and single patient service now necessary for the home care service. It is also expected that the patients will benefit from the socialization and interaction with patients and hospital personnel. The project has the backing of all the major medical care institutions in the Bronx, the Visiting Nurse Association, Medicaid and the Bronx Medical Society. Based on current patient loads, it is expected that about 70 percent of the patients will be on Medicaid and/or Medicare and the services can be reimbursed. The project is expected to be self-supporting in two years. Cost effectiveness of the After Care Center Service and comparison of the program effects with additional home care programs, nursing homes, and extended care facilities will be studied. The project builds on a pilot study made by the Montefiore Home Care Service and the Department of Physical Medicine which indicated that six patients per hour could be served by a physicial therapist with the help of a physical therapy aides in the hospital setting, compared with six patients a day served by the home care service. New York Metropolitan RMP -6- RM 58-02 (AR-1-CDS) 2/71 The project will be directed by Dr. Isadore Rossman, Medical Director of the Montefiore Home Care and Extended Services. Experienced personnel from Home Care Service and other Montefiore Hospital de- partments will be utilized in the project. The review history indicates that the Home Care Technical Consulting Panel reviewed and approved this project with certain modifications regarding possible methods of self-support. The estimated third party reimbursements have now been deducted from the full cost of the project and RMP is expected to provide only those funds that are not reimbursable. The project was reviewed: and approved by the Committee on Planning, Priorities, and Evaluation and the Regional Advisory Group. 02-Year - $73,891 Project #26 - A Community Model for Barly Care of Heart Attack First Year Suspects ~ This demonstration project is designed Request to make changes both in the usual behavior, at the onset of a $150,650 heart attack, of patients and their families in a large defined population in Queens and in the responses of the medical care system serving this population. It represents the combined effort of the Health Insurance Plan and two of its Queens’ medical groups serving a population of 100,000 (50,000 age 35 to 74 years) and LaGuardia Hospital. The goal is to effect more rapid requests for medical care after the onset of a heart attack, and to institute a system capable at all times of a rapid and appropriate response which fully utilizes medical knowledge. The end goal is the reduction in the present high rate of sudden deaths from coronary heart disease. The project will be built around the HIP medical record which indicates those patients at high risk, those with prior coronary heart disease, hypertension, hyperglosterima; patients will be urged to visit their doctors once a year at which time the physicians will explain the program to them and the importance of calling into the system early. In addition, quarterly mailings of material will be sent to all the HIP clients in Queens. There will also be mailings of special project materials after they have been field tested. The project was originally conceived as having four main elements: 1) patient education; 2) centralized telephone screening at LaGuardia Hospital by physicians of calls from all possible coronary suspects will take place 24-hours a day, seven days a week, to reduce communication delay in bringing the patients’ symptoms to medical attention; 3) a mobile team of para- medical personnel trained in necessary techniques for emergency care of patients experiencing mild myocardial -infarction complications with telephone and radio communication with the project's physician based at LaGuardia Hospital; 4) the operation of a special pre-coronary care area at LaGuardia Hospital for the observation of patients in two defined categories: (1) persons who do not meet the usual current criteria for hospitalization but who may be in the early stage of an acute myocardial-infarction not yet recognizable; and (2) patients New York Metropolitan RMP -7- RM 58-02 (AR-1-CDS) 2/71 who might be experiencing an ischemic episode not destined to lead them to a mild myocardial-infarction but capable of inducing a fatal arrhythmia. After the original proposal was reviewed by technical review process, the mobile team aspect was eliminated from the project. The project director felt while this would be a positive contribution, he agreed with the site visitors assessment of the less relative importance of this particular component. The project director intends to make arrangements with existing community transportation facilities to assure rapid response to calls from the centralized coronary screening physician. The RMP site visitors also recommended that a separate, distinct, and well-staffed coronary care unit be established at LaGuardia Hospital; the project director gave definite assurance to the RMP that modifications would be made in the present coronary care unit to restrict it to coronary patients but it was not possible at this time to have the CCU located in close proximity to the pre- coronary area. Long-range effects of this demonstration program are anticipated once the results have been evaluated. The project advisory committee is seen as the mechanism for disseminating results throughout the region. The American Heart Association has indicated an interest in supporting the field testing of materials. Information on the RMP review indicates that the project received careful review which resulted in changes in scope and costs. 02 - $178,840 03 - $189,575 04 - $190,140 05 - $168,550 Project #27 - Ambulatory Care Nurse Training Program - This project is proposed by the Bronx Medical Center Hospital - Jacobi, Albert Einstein School of Medicine and will also involve Morrisania, Lincoln, and Fordham Hospitals in the Bronx. The project is based on four years home care experience which indicated a need for the home care patients to have one person in the hospital to whom they could relate for needed medical care. The project is designed to expand nursing practice in the ambulatory care clinic. It will make maximum use of the registered nurse in the setting of the ambulatory care nurse clinic; each patient will be assigned to a nurse after he has been seen in a diagnostic clinic or the emergency room. The nurse will follow her patients in subsequent clinic visits to see if therapeutic regimen prescribed by the physician is being carried out, to look for any changes in the patients' clinical status and in general, to provide a mechanism whereby the patient can avail himself of any hospital service he needs at any time. New York Metropolitan RMP -8- RM 58-02 (AR-1-CDS) 2/71 The Albert Einstein College of Medicine will expand its nursing training program to develop this type of ambulatory care nurse. A didactic program of 302 hours has been planned which will focus on nursing and medical care, and specific diseases, with strong emphasis on detecting changes in a patient's condition that will require the physician's intervention. The trainee will also spend a total of 521% hours in supervised clinical practice. The entire program will be six-months in duration. Eight ambulatory care nurses will be \ trained in the first year; 40 will have been trained by the third year. Each nurse, when fully trained, is expected to be able to handle a panel of 300 patients per year (or some 2,000 clinic visits per year); , one physician will be available to work with a group of four or five such nurses. Trained nurses will also serve as perceptors for new trainees. The project will be evaluated by an independent group of evaluators who will compare patients of the project nurses with the control group of patients with respect to each of the objectives of the program. The tooling up period is expected to take one year. The first eight nurses trained will be expected to go to four municipal hospitals to set up ambulatory care nurse clinics. A review history of this project, indicates that funding was found for the trainees’ salaries through the New York Health and Hospital Corpora~ tion. The RMP staff apparently did considerable work to emphasize the importance of the close collaboration between the nurses and physicians, and the applicant has accepted the New York Metropolitan RMP adopted principles relating to the expanded role of the nurse. 02 - $90,078 03 - $109,700 Project #28 - Early Detection of Breast Cancer - This project calls First Year for establishing two breast cancer screening programs Request in conjunction with cervical cancer screening programs at the $413,701 Metropolitan Hospital and Maimonides Medical Center in New York. The project will be directed by the Guttman Breast Diagnostic Institute, which has been established through support by the Guttman Foundation and the American Cancer Society to study, develop, and promote mass breast cancer screening on 4 practical basis. An estimated 20,000 women will be examined each year. At the present time, the Guttman Institute is performing 60 to 70 examinations a day to women over the age of 35, at fee of $15. A new type of mammography equipment (Senograph machine) is used for the mammography. The use of this machine has enabled the Guttman Clinic to speed up the process and reduce costs. Thermography is also used for selected patients. A mammography project has been conducted since 1963 with the Health Insurance Plan of Greater New York through the National Cancer Institute funding. It involved 60,000 women divided into two equal New York Metropolitan RMP -9- RM 58-02 (AR-1-CDS) 2/71 groups, one of which was periodically acreened and the other, control group, not screened to test the effectiveness of mammography as a screening méthod. The result showed a significant difference in mortality from breast cancer among the women screened (31 deaths) as compared to those in the control group (52 deaths). During the latter part of this period, the Guttman Breast Diagnostic Institute was established to experiment with more efficient methods of breast screening including mammography, thermography, clinical examination and history taking. This project will attempt to incorporate the methods utilized by the Guttman Institute into ongoing hospital procedures. Both Metropolitan Hospital and Maimonides Medical Center have had projects (no longer funded through 314(e) funds) to examine women for cervical cancer and have carefully established follow-up procedures. By adding breast cancer to the screening procedure, the follow-up procedures already functioning can be utilized. The cervical cancer screening will: continue to be done by the gynecology department. The mammography will »e done by the radiology department but the mammograms will be read by the Guttman project director and his associate. The Guttman Institute will set up the project, will provide the equipment, train technicians and clerks, arrange for processing and interpretation of the films, supervise the follow-up and keep the records. The East Harlem Screening Clinic is also mentioned in the application; apparently the project director will be providing consultation to the center which has its own equipment. The budget request funds for a radiology clinician and technician at each of the hospitals as well as two health aides and a half-time program coordinator. Senograph mammography machines are requested for each of the two hospitals as well as thermograph machines. It is expected that this project will become self-supporting in two years. Not as much information is presented concerning the review of this particular project. It was reviewed by the Committee on Planning, Priorities, and Evaluation and the Regional Advisory Group. There do not seem to have been any changes as a result of the review. It is stated in the application that screening for breast cancer is considered a high priority activity developed by the cancer region-wide planning group. 02 ~ $205,134 03 - $102,567 Ongoing Projects: (See attached November 30, 1970 memorandum on staff review of continuation application.) Ten operational projects are now funded by the New York Metropolitan Regional Medical Program. Four of these projects have been functioning New York Metropolitan RMP -10- RM 58-02 (AR-1-CDS) 2/71 only since July 1970. Project #11 - Continuing Education of Practicing Physicians at Brooklyn-Cumberland Medical Center and Project #12 - Development of an Area-wide Program of Continuing Medical Education for Physicians in Upper Manhattan Area at St. Luke's Hospital are both aimed at the physician unaffiliated with any hospital or without membership in education-oriented professional societies, of which there are about 3,000 in Manhattan, Brooklyn, and the Bronx. The Technical Consulting Panel on Continuing Medical Education and the RMP Associate Director of for Continuing Education are studying these projects. Project #13 - Regional Program for Treatment and Investigation of End- Stage Renal Disease ~ provides home dialysis training for professional personnel and for patients and families in the upper Manhattan and Bronx areas. Project #14 - Coronary Care Nurse Training Center - fits well into the region-wide plan for heart disease. Project #17 - Harlem Region Stroke Program - has not yet begun, but is designed to serve as a prototype of the entire region with its inadequate stroke service. Five of the older projects are being monitored by the following pro- cedures: bi-monthly observation by RMP staff, review by its respective Technical Consulting Panel during the last part of the fiscal year, fiscal control, evaluation procedures to be developed with core staff, and special presentations before the RAG or its Committee on Planning, Priorities and Evaluation. Project #1 - Mobile Coronary Care Unit - St. Vincent's Hospital - The Technical Consulting Panel ~ Heart Disease - would like to see mobile unit coverage extended to all of lower Manhattan, but no action is being taken in this direction until an RMPS National study is completed. Project #9 - Educational Program in Rehabilitation of Allied Health Personnel at Barbe Fondation Rehabilitation Center - Providing continuing education opportunities for rehabilitation personnel and developing career ladders for less skilled employes are high priority areas for the RMP. Cost-benefit analyses will be instituted in the second year. Project #2 - Pediatric Pulmonary Disease Center at Babies’ Hospital - has developed a more regional-type of program this year as contrasted with its early institutional bias. Self-support possibilites are to be fully explored during the third year as well as cost-benefit studies. Project #6 - Regional Cancer Program - Memorial Hospital - While the region has no doubt about the quality of this continuing education activity, the need to broaden its focus to the whole field of rehabili- tation is being studies. In addition, core staff reports difficulties in getting a clear cost picture of this project since it is closely a intertwined with other hospital activities. pets GRB/RMPS 12/29/70 -1l- DEPAREMENT OF HEALTH, EDUCATION, AND WELFAR: PUHILIC FICAL TEE SERVICE . HEALTH SERVICES AMD MLILUAL HEAISFEL ADMINISTRATION! i; ‘ \ ] wate Movember 30, 1970 Reply to Ath: of: Sujet: Stalf Review of Non-Compcting Continuation Application from New York ral Metropolitana Regional Medical Program ~, wen! o: Actiug Director Resfonal Medical Program Service THROUGH: Acting Chief Repional Development Branch c - . ry Neen Acting Chief .°/ Grants Review Branch Se gd Chief & “fos te Grants Management Branch This application is a part of the Region's first Anniversary Review and award application which requests support for the continuation of ten projects and core ($2,684,852 d.c.), a developmental component ($329,009 d.c.) and for a supplemental grant consisting of four projects ($811,686 d.c.}. Stafi's review of the continuation application concentrated on overall program issues rather than on individual projects. Major issues discussed by the reviewing staff were: (1) Although the Region states that emphasis during the past year has been on total program development, the application reflects more of a project orieuted type of operation by staff as well as commit- tees. Concurrently, it appears that projects are developed with RMPS as the principal source of support. Staff concluded that the Region should place additional cmphasis on the catalytic approach and that joint funding of activities should be encouraged .. (2) Planning activities described are the results of the various Technical Consulting Panels. Staff felt that the communities should be more involved in these plaoning activities. (3) Central Core Staff capability in Continuing Fducation and Training needs to be strengthenacd. (4) Tt was agrood that Dr. Brightscn bad made considerable preeress in laying the ground work for more active involvement by the medical schools in the Mew York Metropol ftan Ros toa Medfeal Prowrean and hopefully, the various cornmunities sarved. | However, docimentod } progress at this point is somewhat lacking in the application, i) Page 2 - Dr. Margulies (5) An accountant has been added to the central office staff as was recommended by the Management Assessment site visit team in July, 1970. Staff questioned whether the contract for fiscal services had been revised as a result of this and of equal importance, has the contract been reduced. Possible ‘payment for duplicative services prompted this discussion. In summary, staff believed that this Region, now applying for its second year of operational support, has made significant progress but that much improvement is needed in the development of the total program especially in regards to additional output from the medical schools. Recommendation: Approval. of continued funding at the committed level of $2,539,887 d.c. rather than the. requested $2,684,852 d.c. The difference in the requested and committed level of support is duc to the fact that the Region elected to request the National Advisory Council approved level for Project #17, Harlem Regional Stroke Program, rather -than the committed level. Since the Region will be given a twelve month budget for an eleven month year due to a change in anniversary dates, staff was of the opinion that funds would be available for this project if the Region believes additional support is necessary. CO eure Dan M. Spain Operations Officer Regional Development Branch Approved: ; i fl . J ” , ~ ., f : io Giles & an fee Let a Buy ) Date Wf, a ‘Acting Director, RMPS a The following staff members participated in the review of this Continuation Application: Mr. Morales sep lo Supplemental Funding of On-going Projects Project #2 - Multidisciplinary Improvement in Medical Care of Myocardial Infraction in Minnesota - Committee noted that this basic program has been progressing adequately with the amount of funds provided up to date, and believed that it would probably continue without additional RMP funds, Project #2 (S) - Committee believes this supplemental activity of Project #2, initially implemented with carryover funds, would allow the continued expansion of the current project. Expansion of the basic program appeared warranted. _ Project #3 - Pilot Study in Postgraduate Education in Pediatric Cardiology- The Committee believes that this project should be permitted to expand out of the cardiology field into the necnatology area, Committee noted that this project is involving a five-state area and is a good regionalization component which is involving 11 or 12 cardiologists. Project # 7 - Improving Stroke Rehabilitation through Regional Program of Continuing Education - The committee noted that the American Rehabilitation Foundation has a long record in education, specifically in allied health. There is a great deal of enthusiastic local commitment to this project which has now reached over 8,300 people. [Its multi-pronged attack is involving nurses, families and clergy. Project #12 -(Previously known as Project #8)- Pilot Program of Regional Postgraduate Medical Education (Mayo Foundation): This was an approved and unfunded project which was initiated with carryover funds, The region has requested new money for continued support of this program in its 02 year. The Committee wondered why the RMP wished to continue this project. Progress has been slow, and apparently something is wrong. The Committee believes that perhaps the RAG may not have had adequate opportunity to review the continuation request. Further, it appears that if Mayo was committed to the project they should be putting some of the institutions' funds into the program. RMPS /GRB/1/18/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) OREGON REGIONAL MEDICAL PROGRAM 3181 S. W. Sam Jackson Park Road Portland, Oregon 97201 RM 00012 2/71.1 CS January 1971 Review Committee Program Coordinator: J. S. Reinschmidt, M.D. REQUEST (Direct Costs Only) 04 05 06 Purpose 4/1/71-6/31/72 _7/1/72-6/30/73 7/1/73-6/30/74 All Years Continuation Commitment $311,064 $311,064 Core (229,765) (229,765) 3 Projects (81,299) 1/ (81,299) Renewal Components 329,210 $267,966 $229,612 $826,788 4 Projects (329,210) (267,966) (229,612) (826,788) Additional Components 317,872 196,625 191,144 $705,641 2 Previously . Approved Prj. (85,075) ( 59,147) ( 61,169) . (205,391) 5 New Projects (175,356) (137,478) (129 ,975) (442 ,809) i Supplement . to Core (57,441) 2/ (57,441) Total $958,146 $464 ,591 $420,756 $1,843,493 Staff Action Commitment $311,064 $311,064 Committee Action Required $647,082 $464,591 $420,756 $1,532,429 i/ (Three months of committed support for three of the four Renewal Projects below) 2/ (Three months of support for core requested to change Region's budget year to July 1) OREGON RMP -2- RM 00012 2/71.1 CS FUNDING HISTORY PLANNING STAGE Grant Year Period Funded (d.c.o.) 01 4/1/67 - 3/31/68 $166,494 5 02 4/1/68 - 3/31/69 $203,793 OPERATIONAL PROGRAM Future Grant Year Period Council Approved Funded (d.c.o.) Commitment Ol 4/1/68-3/31/69 $955,097 $522,287 02 4/1/69-3/31/70 885,994 854,146 03 4/1/70-3/31/71 921,948 837,328 i/ 04 4/1/70-6/30/72 319,854 $319,854 05 7/1/72-6/30/73 28,920 28,920 1/ Includes $107,795 in carryover. Geography and Demography The Oregon RMP is bounded by the Washington, California and Mountain States RMPs. The state has approximately 2.05 million people in its 96,248 square miles. The major portion of the population is concentrated in an area between the Pacific Coast and the Cascade Mountain Range. The remain- der of the population resides in widely separated cities, small communities and rural areas throughout the state. Oregon has a university medical school in Portland and seven schools of nursing. There are 87 general hospitals with a total of 7,608 beds. The population is served by 2,770 M.D.'s and D.O.'s and 7,851 nurses. Regional Development The second planning application was approved in February 1970 after the initial one had been returned for insufficient detail. Conditions were placed on the first award asking the Region to clarify the role of the medical school, community hospitals, practicing physicians and the Kaiser Foundation Health System, The first of four Coordinators to serve the program was Dr. Myron Grover, Director of Continuing Education of the Medical School, which serves as the grantee agency. Dr. Grover was succeeded by Dr. Goldblatt during the OREGON RMP -3- RM 00012 2/71.1 CS second planning year. When Dr. Goldblatt became Coordinator, the Region requested and received a modest planning supplement for planning and administration costs. The operational application was submitted in December 1967 and following an enthusiastic endorsement from a site visit team in February 1968, Council approved the submissions. Shortly afterwards, the Region sub- mitted two supplemental applications with eleven projects, which were all approved, #2 - Early Diagnosis and Therapy of Cerebrovascular Disease #3 - Surgical Treatment ef Vascular Lesions and Cerebral Complications of CVA Disease #4 - Diagnosis and Treatment of CVA Disease and Influence of a Stroke Clinic on Stroke Care #5 - Stroke Continuing Education Program #6 - Mid~Willamette Valley CCU Training Program #7 - Training Nurses for Coronary Care #8 ~ Educational opportunities for Physicians in Diagnosis and Therapy of Cancer #9 ~ Central Oregon Heart, Cancer and Streke Pilot Project #10 - Coronary Care Teaching Aids #11 - Guiding Patients with Aphasia #12 - Southern Oregon Diabetic Instruction and Evaluation The first six projects, which were awarded funds, are in their third year of support. Of the remaining five, the Region funded four out of unexpended funds. (The Region is requesting renewal support for Projects #1, 4, 6 and 7, and committed funds for a year of support for Project #8 in the present application.) Site visitors to the Region in April 1969 came away greatly impressed with all aspects of the program, including core staff, Regional Advisory Group, and evaluation efforts. Although the program appeared heavily producer and continuing education-oriented, there were indications that staff was developing activities involving other groups and in other areas. As a result of the site visit findings, continuation of core and approval of two supplemental projects #13 - Mobile Emergency Cardiac Project, and #14 - Training Programs to Promote Better Care of the Diabetic Patient, were approved and funded out of carryover. The Region's request for continuation of core and ten projects for the third year was well-received by staff. It appeared that the Region had come a long way in establishing itself as a broadlyebased, ongoing program as opposed to a series of isolated projects. The key to this trend seemed to be the RAG's increasing awareness of the meaning of local autonomy. The RAG, complemented by a capable core staff, had developed a mechanism for evaluating both incoming proposals and ongoing projects. As a result of this evaluation, the Region had prematurely terminated one project - #3, OREGON RMP -4- | ~ RM 00012 2/71.1 CS Although generation of project activity slowed down somewhat, the Region submitted and had approved the following projects: #15 - Physician In-residence Course in Cardiology (received new funds from RMPS) #12R- Southern Oregon Diabetic Instruction and Evaluation Project #16 - Training Program for Personnel of Oregon Health Care Institutions (funded from carryover) The third operational year has also seen two changes in coordinator. Dr. Goldblatt was replaced by Dr. David Johnson, who served as Associate Professor of Public Health and Preventive Medicine at the University of Oregon. Dr. Johnson resigned in November to become Regional Health Director for Region X, and has just recently been replaced by Dr. J. S. Reinschmidt, who has been with the Student Health Service for the past seven years (curriculum vitae attached). The Oregon RMP, then is in a state of transition. The new coordinator has just assumed his position. The core staff's time for the past six months has been consumed with preparing the AR application and therefore not devoted to developing the program. As the application aptly states, "daily routine drives out planning." The Regional Advisory Group has been struggling with RMP's changing role; it "has recently broadened its program beyond its conservative interpretation of public law 89-239." The Region is also requesting a change in its anniversary date from April 1 to July 1, because the November 1 national review deadline would require the Region to do most of the application preparation during the summer months which imposes a hardship on the Region. Oregon apparently has only two months of sunshine in which everyone takes their vacation. Thus, the Region is unable to get quorums for RAG and other review group meetings and project directors are not available for consultation. For this reason and because the Region needed more time with a new coordinator to develop their triennial look, RMPS gave the Region permission to change the anniversary date. Regional Objectives Within the goal of improving the care given to patients with the categori- cal diseases and the ultimate objective of reducing morbidity, disability and premature death by: (A) stimulating more widespread and effective use of the latest advances in the prevention, diagnosis, treatment and rehabilitation of these diseases and (B) by encouraging experimentation with and adoption of more efficient mechanisms in the dispensation and administration of health care services, the Oregon RMP has the following more immediate objectives: A - 1. To encourage the development of cooperative arrangements among the Region's medical school, research centers, health organizations, medical institutions, and individuals engaged in the delivery of health OREGON RMP m5 om. RM 00012 2/71.1 CS services or in the provision of health-related professional educational programs, 2. To assist persons involved in the delivery of health services on continuing educational programs to transform ideas for improving care into well-developed and expertly presented operational projects, and to consult with and advise such individuals in regard to potential sources of funds for these projects. 3. To assist directors of operational projects and affiliated insti- tutions in the efficient administration, responsible fiscal monitoring, and meaningful evaluation of their projects. 4, To provide for the continuing education of the ORMP staff and of appropriate members of the’ RAG and its committee system so that the latest and most effective administrative and instructional methods are employed and so that the volunteer policy-making component of ORMP can be assured that it will deterthine any new directions for the program in an informed and meaningful fashion, B- 1. To determine, in concert’ with the RAG, a consensual set of specific operational objectives for the ORMP; taking full cognizance of emerging RMP legislation and guidelines; to be completed by February 1, 1972; and to include explicit reference to the particular manner and extent to which ORMP can or should in the absence of increased fiscal resources, address itself to the issues of distribution of health care, innovative use of medical personnel, relationships with CHP. C - 1. To prepare by February 1, 1972, a consolidated AR application for program triennium review. Organizational Structure and Processes Oregon has a forty-member Regional Advisory Group, representative of most of the important health provider and consumer groups in the state. Its operation is facilitated by the following committees: a) a three-man Executive Committee responsible for administration of the program between RAG meetings. b) a Grants Application Review Committee, which reviews the applications. c) a Regional Cooperation Committee, which studies the coordination and activities of the various grantees in the state, through the use of subcommittees and consultants. d) an Evaluation Committee is available to evaluate funded grants, as well as the activities of the terminated projects. It will also accumulate and present factual evidence of the accomplishments of the entire RMP. It may draw on the resources of consultants. e) the Heart, Cancer and Stroke and Continuing Education Subcommittees are composed of experts in these respective areas. Their function is to (1) evaluate project ideas for feasibility, scientific soundness and OREGON RMP -~6- RM 00012 2/71.1 CS applicability to RMP, (2) make recommendations to the Grants Application Review Committee regarding project requests, (3) determine needs to improve care of patients with the categorical diseases, (4) provide solutions for needs, and (5) act as regional consultants. The grant application review schedule is attached. If the ORMP is not awarded monies to support all ORMP approved grant requests, a priority rating will be assigned by the RAG in order to determine which shall be funded, The rating will be made using the following eriteria: i. the amount of regionalization (the creation of cooperative arrange- ments, avoidance of duplication of existing effective efforts, written support from all appropriate agencies, and anticipated benefits to institutions other than just the applicant organization) ; ii, its concern with the prevention and/or early detection of categorical diseases, and to those directed toward commonly occurring illnesses, especially those tending to affect children or adults in the most pro- ductive years of life; 4ii. the inclusion of some element of continuing education either as a pre- dominant or as an important component part; iv. its orientation around the problem analysis approach, as outlined in the ORMP instructions for writing applications; and v. the cost per unit of accomplishment when compared to (1) other programs of a similar type, or (2) alternative solutions to the same problem. For a discussion of Core structure and function, please refer to the con- tinuation section of the application components. Present Application Continuation - These components have been reviewed by staff. Their program and funding recommendations are in a supplementary memo. 4th Year Core $287,206 The. Oregon RMP has a small core staff, which until this point in time, has been more organized to deal with the preparation of well-developed and well-written project applications, than with the stimulation of program. The Region admits that the broader RMP programs now envisioned may require a staff reorganization and the addition of. more members. There are seven full-time professional personnel and four secretaries. The professional positions include the Program Coordinator, Coordinators for Community Organization, Program Administration, Information and Communication, Nursing and Allied Health, Project Development and an administrative assis- tant. Evaluation services are provided throughcontract with the Northwest OREGON RMP ~7- RM 00012 2/71.1 CS Regional Educational Laboratory. Contract funds will-also be utilized | to. continue a patient origin study. Core funds are also being used to develop a physicians assistance program in conjunction with the Medical School Division of Family Practice. In addition to their application preparation function, staff provides assistance on request to various regional organizations. Examples of this type of help include: (1) providing data, special charts and reports to hospitals and conferring with architects and hospital consultants in four areas of the state; (2) serving on the Ombudsman Committee of the Oregon Medical Association and (3) involving many different organizations in the Portland area in an informal planning effort to explore means of improving the organization and delivery of health services, particularly for the low-income families. Continuation support is also requested for: 15 months for project #15, Physician Inresidence Course in Cardiology 3 months for projects #4, Comprehensive Stroke Care in the Regional Education; #6, Mid-Willamette Valley Coronary Care Training Pro- gram; and #7, Coronary Care for Professional Nurses and Physicians (These projects are also requesting renewal support for three additional years). The Region also hopes to fund the following Council approved projects from carryover: Project #9, Heart, Cancer and Stroke Pilot Project Project #10, Coronary Care Teaching Aids Project #11, Adult Patients with Aphasia Project #14, Diabetic Patient Care. Approved. but Unfunded Projects These projects have been previously approved by Council, but due to national funding constraints, have not been funded. Committee and Council consider-~ ation of these projects is needed in determining a funding level for the next year and not for approval of the activities, Project #8 - Educational Opportunities for the Oregon Regional Physician in the Diagnosis and Therapy of Cancer. Ist Year $42,369 This project will provide an intensive one-month in-residence course at the Medical Center for eight physicians per year. The curricu- Jum will be tailored to the physicians’ needs and those of his community. Second Year Third Year $59,147 $61,169 OREGON RMP - 8 - RM 00012 2/71.1 CS Project #16 - A Training Program for Personnel of Oregon Health Care Institutions ‘lst Year $42,706% The purpose of this project is to provide informational courses to a multidisciplinary spectrum of sub-professional health care workers. The courses will be designed so that students may comprehend and carry out) their own specific responsibilities under formal institutional standards concerned with the control of significant health care problems, This project has received some support from carryover funds since October 1970. *for a 15-month period Supplemental Projects: Committee and Council action are required on the following nine projects: Renewal Projects Project #1R - Heart, Cancer, Stroke Circuit Postgraduate Course for the Oregon Region. 4th Year $180,747* The purpose of the circuit course program is to provide continuing educa- tion for physicians, nurses and allied health personnel at 19 locations in the Region. Sponsored by the University of Oregon Medical School, faculty from this institution and selected private practitioners, through the use of video tapes and other teaching techniques, will bring medical care advances of the research laboratory and medical center to health personnel in the small community. During the past three years of operation, the courses have reached approx- imatelv 1600 physicians inover 100 presentations, 900 nurses in 23 courses and 70 medical technologists in five sessions, Since evaluation appeared weak, the proposers have taken steps to evaluate through a questionnaire changes in patient care practices as a result of the courses. Fifth Year Sixth Year $136,409 . $133,363 *Note: for a 15-month period. Project #4R - Comprehensive Stroke Care with Regional Education 4th Year $52,375* The Good Samaritan Hospital and Medical Center in Portland wishes funds to renew RMP support for a stroke program, which includes the following three elements: : OREGON RMP ~9- RM 00012 2/71.1 Cs a) a stroke evaluation and education team at the sponsoring hospital, b) satellite clinics at Bend and Astoria, and c) a series of 12-day courses in care of the stroke patient for nurses, As far as progress is concerned, the project has continued the activities of the Outpatient Clinic and assisted in the establishment of an inpatient Stroke Care Unit at Good Samaritan Hospital and Medical Center. Panel discussions and exhibits have been presented by the staff, directed toward both physicians and nurses. A formal 12-day course for nurses has been established, and a one-day Circuit Course was given in four communities during the last three months of this fiscal year. The Satellite Clinic in Bend has been established and clinical research is underway. A cost effectiveness study has shown that the savings from patients going home has resulted in a savings of almost three times the budget for the project for a year in hospital and nursing home costs, assuming a patient with a major stroke is cared for only one year in a nursing home, Fifth Year Sixth Year $54,444 $56,617 *Note: This project has three months of committed support ($14,215) from April 1 to June 30, 1971. If approved, the Project's level of funding for the 15-month period (April 1, 1971 to June 30, 1972) would be $66,590. Project #6R ~-Mid-Willamette Valley Coronary Care Training Program 4th Year $44, 313% A program of coronary care nurse training (four three-week courses for 32 nurses a year), advanced training and workshops for nurses, and a physician post~graduate education program would require three additional years of RMP support. A total of 110 nurses have been trained and over 500 physicians have attended the courses thus far. A spinoff of the project has been that all but one hospital in the state have policies governing coronary care as opposed to three at the initiation of the project. The training is con- ducted by the staff of the Salem Memorial Hospital in Salem, who will have trained 110 nurses and 512 physicians in these courses during the past three-year period, Fifth Year Sixth Year $37,438 $19,294 *Note: This project has three months of committed support ($13,039) for the period April 1, 1971 to June 30, 1971. If approved, the project's level of funding for the 15-month period (April 1, 1971 to June 30, 1972) would be $57,352. OREGON RMP -10-— RM 00012 2/71.1 CS Project #7R - Coronary Care for Professional Nurses and Physicians ‘Ist Year $51,775 Nurse trainees will come from approximately 16 Oregon hospitals with coronary care facilities to Sacred Heart Hospital in Eugene, for one or all of the following courses in coronary care nursing: (1) a three-week basic course held three times a year; (2) a 40-hour advanced course held five times a year, and (3) an advanced workshop for nurses once a year. Over 100 nurses have been trained to date. In addition, project staff will visit participating hospitals to conduct a six-hour training session for physicians. Second Year Third Year $39,675 $20,338 *Note: This project has three months of committed support ($18,460) for the period April 1, 1971 to June 30, 1971. If approved, the project's level of funding for the 15-month period (April 1, 1971 to June 30, 1972) would be $70,235. New Projects Project #17 -The Mid-Willamette Valley Diabetic Patient Project lst Year $17,516 The purpose of this proposal is to train out-patient diabetics and their families in personal care of diabetes. The Salem Hospital in Salem will provide 40 courses of 30 hours duration (ten patients per course) with special attention to those patients from smaller community hospitals and outlying doctors’ offices. Additional efforts will be directed to adoles- cents and deprived groups. The project would also provide additional information for physicians, training for paramedical personnel and increased public awareness of the need for patient education. The concept of this course is directed toward better patient care ina sub-regional area. The courses will make available facilities to diabetics otherwise not available to them, and by improving their care also reduce the economic loss to themselves, the community and public agencies. Second Year None Project #18 - An Operational Service for Remote Coronary Care Monitoring ist Year $79,501 Emanuel Hospital, Portland, would provide an operational coronary care remote monitoring system to community hospitals on a volun- OREGON RMP -~ ll - RM 00012 2/71.1 CS tary basis by transmitting the EKG signal via telephone lines from the outlying hospitals to the Emanuel Hospital CCU. Project nursing personnel would continuously monitor the signal on oscilloscopes. The service would also offer special education for the CCU nurse emphasizing common electrocardiographic patterns, techniques of defibrillation, and equipment procedures. Continuing education for physicians may also be arranged. This project stresses an operational mode for the improved care to patients with myocardial infarction residing in less populated areas of Oregon. The project also builds on the successful pilot programs demon- strating the feasibility of the larger central hospital's monitoring the coronary patient in a rural hospital. Second Year Third Year $67,758 $70,142 Project #19 ~ Pendleton Region Stroke Rehabilitation Project 1st Year $23,592 The Pendleton Stroke Education Group (PSEG), an unofficial group repre- sentative of the agencies and institutions involved in stroke care in Pendleton, was formed as part of one of the initial stroke projects. St. Anthony's Hospital in Pendleton, in conjunction with the PSEG, intends to improve the level of stroke care in the area by: 1. Identifying local problems in providing stroke care, 2, Improving the continuity and coordination of stroke care, 3. Providing continuing education in stroke rehabilitation for members of the health care team in the subregion, 4. Developing a home health program, and 5. Educating the public about the effectiveness of rehabili- tation for the stroke patient, The project contributes to ORMP goals by building cooperative arrangements among health personnel and institutions, improving patient care and utilization of resources and skills, as well as providing continuing education and developing innovative approaches to treatment. Second Year Third Year $18,874 $14,156 Project #20 - Community Coordinators of Continuing Medical Education lst Year $22,344 ORMP support is requested by the Oregon Medical Association to subsidize an integrated system of 17 volunteer coordinators of continuing OREGON RMP _ - 12 - RM 00012 2/71.1 CS medical education for Oregon physicians. Practicing physicians would be trained to determine needs in their communities and in educational tech- niques in order to enable them to act as part-time Directors of Medical Education for their communities. Coordinated by a central administrative information and resource unit, the physicians would also coordinate state educational resources and short preceptorship experience for physicians. The project relates to ORMP goals of utilizing existing resources more effectively, and of innovatively using mainly volunteer personnel to deal with the provision of adequate continuing education opportunities to physicians. Second Year Third Year $22,494 $15,650 Project #21 - A Drug Information Service for the Health Professions ist Year $32,403 A drug information center will be established at the School of Pharmacy, Oregon State University, which will serve as a central reference source collection with the capability for aiding all health practitioners in exercising a rational approach to drug therapy. A drug information specialist will answer specific requests for information and publish a bulletin containing drug information of general and current interest. The Drug Information Specialist will also encourage utiliza- tion of the Drug Information Service by seeking contact with health pro- fessionals through participation in local and regional continuing educa- tion activities of the various professional groups. The proposal contributes to improvement of patient care and represents a. cooperative effort of health professions to identify and meet local needs. It also increases the economy of health care delivery by sharing available resources. Second Year Third Year $28,352 $30,027 GRB/RMPS 12/17/70 . . . ] : . . 7 - “ . 2 - 13.0. . : : . CURRICULUM VITA# FOR J. 5, REINSCHMIDT, M.D, Born in Pensacola, Florida, 1925 and received education ‘through high * school there, ms .. , Military Service World War II, U.S, Army Married, 2 children oo, ve re Education: - + A.B, Vanderbilt University 1950 M.D. Vanderbilt University 1953 Postgraduate Training: F — ~ Internship (rotating) Colorado General Hospital, Denver, Colorado General Surgery Residency University of Colorado Medical Center » 1954-1956 and 1959-1962 included one year in research, Teaching ‘Of interns, residents and nurses part of responsibilities, Experience: mT, oo General Practice Tekoa, Washington, 1956-1959 7 Surgery and General Practice Pullman, Washington, 1962-1963 (Studen - . Health Service Washington State University) : Student Health Service University of Oregon Bugene, Oregon, 1963 to “present, Director since 1966-1967, , Member and current chairman of Medical Education Committee and menber of Library and Publications Committee Sacred Heart Hospital Medical Center, Eugene, Oregon, Served as 2 moderator in clinical seminars of the annual scientific “session of American Academy of General Practice 1968 and invited to nerve in like capacity for 1970, : Lone ‘Organizations: . American Academy of General Practice Lane County Medical Society (Secretary 1970) . ; Oregon Hedical Association (Delegate to House of Delegates and member of Venereal Disease Committee and. Ad hoc Subcommittee) American Medical Association oo American College Health Association (Member of Council 1968 to present) Pacific Coast College Health Association (President 1969-1970) Steff Sacred Heart Hospital Eugene a re - Eugene Surgical Society Soe OE Lane County Community Health Council pe Publications; ; “Traumatic Pancreatitis, An Increasing Problem", Henry C, Cleveland,M,D. Julian S, Reinschnidt, M.D.; William R, Waddell, M.D.: Surgical - ‘Clinics of North America Vol, 43, No, 2, April, 1963 o wy! we 14 - : J. S, Reinschmidt, M.D, - Publications: (continued) ‘ ae foot "Infectious Mononucleosis in American Negroid Students", 2. J. , 0 _ Carson, M.D; J. S. Reinschmidt, M.D,; H. C. Lemon, M.D.3- cot, Journal of the American College Health Association Vol, 16, ot No, 2, Decenber, 1967 , . oe "History and Physical Fora for Student Health Services", ’ J. S. Reinschmidt, M,D.; R. A. MacHaffie, M.D.; S, Carlson, PhD.; .. . 3 _ ° dames Tomboughs Northwest Medicine Vol, 67, No, 11, November, 1968 ° © FEASIBILITY REVIEW {DEA RECEIVED | inc G | © OREGON REGIONAL MEDICAL PROGRAM GRANT APPLICATION REVIEW SCHEDULE STAFF REVIEW —— MEETING WITH APPLICANT —— GRANT DEVELOPMENT——1O REVIEW CYCLE | Recorded | Filed L Acknowledged Feasiollity Xeroxed Suggestions to Applicant REVIEW CYCLE DEADLINES UBC OMM I TTEE ~ “Y ” | | . . ! Xerox Heart Staff Meeting Cancer Staff Report Stroke Mailed to Su. Con, Ed. &% and Applicant Evaluation Committee Aoolicent and Steff Working | | v Deadline Set 1 | Suggest to Complete or Low Priority DIVISION OF REGIONA MEDICAL PROGRAMS SE EXECUTIVE —____ GARC 499, C OMMITTEE RAB Zz | ee | ‘ i gz . 4 Review. Review Review / a ; .. Rec. and Staff Report . Decision Rec, and Staff Report Rec. and Staff Report Staff Report to Applicant and Subcommittees re Disposition of Grant Applicant and Applicant and Staff Staff Working Working (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COLOMTTEE OREGON REGIOUAL MEDICAL PROGRAM RH 00012 (cS) 2/71 FOR CONSTDES TION BY FEBRUARY 1971 ADVISORY CCUNCIL RECOMMENDATION: The Cosmnittee recommends approval of this application which ineludes requests for: 1) renewal for three years for four projects and 2) supplemental funds for three years for Five naw projects; 3) funds for two previously epproved but unfunded projects; and &) a supplement to Core, at the following reduced amounts: REGIGN's REGUEST YEAR COMITIED SUPPORT SUPPLEMANTAL REQUEST _ TOTAL OL $311,064 | $647 ,082 $ 958,146 02 . 464,591 - 464,591 03 ee res ws nme oe 204736 420,756 ‘VOTAL ss $311, 064 $1,532,429 $1,843,493 YEAR TAPE RECEGMDATION ___«—« COMME TYRE RECOENDATION _ TOPAL | o1 $391,128 4/ $613,986 $1,005,114 02 | 54,444 54,444 03 cone 6 OLD ee ee DOV GEL TOTAL $391,128 $725,047 $1,116,175 1/ Includes 3 months extension for Core and Project #15. Critique:. Committee reviewad the problems: besetting thie Region in the | developnent of the present application: : 1. .The Gregon REP has had three Coordinators during the past year, Dr. Reinschmidt having been appointed December 1, 1976. Reviewers recog~ — nized thet with this unusual turaover, program development has been in abeyance... 2, Because of difficulties in getting appropriate groups and pro- ject directors together during the summer months, the Region requested a change in their Anniversary dates from Apvil 1 to July 1. This change will not only allow the Region to submit their apolications in February OREGON RNP ° -2- RM 00012 CS 1/71 from now on, but during the present year it will give the Region and the new Coordinator additional time in which to plan its next AQ application, 3. ‘The Region is attempting to redefine its priorities in terms of the new perception of RUP. The present application reflects this struggle and the Leck of a clearly defined set of goals and objectives with projects ‘developed accordingly. As a result of these uncertainties, Cosmittee was reluctant. to approve funds for wore than the current year until reviewers could see evidence of progran development. Tha exception was project #4R, Comprehensive Stroke Care with Segional Education, which has shown that the savings from patients going home has resulted in a savings of almost three times the budget for the project for e year in hospital and nursing home costs, assuming a patient with a major stroke ig cared for only one year in a nursing home. The Counittee was impressed with a project which demonstrated such a cos savings, a3 well as an increase in the improverant of clinical renabili tation. One member of the Comnittee wanted a special commendation ta go to tha Region for this project, but ia other wembers thought the results needed to be verified before taking such an action, They suggested that the results be published and that the example be replicated elsewhere. Since the project effects such a (considerable cost savings, Comnittree reeommanded that Council policy regarding phase-out of renewal projects be waived for this project in order to keep ens program mobile, ‘The remaining reneval projects, #1R, 6R and 7R were recommended for phase-out in their fourth 3 year. The core supplement was approved in order to provide fer the shift in budget year. Punds were included for the approved but un- funded projects and for the new projects at a reduced Jevel with the adnonte tion te the Region to better coordinate their projects, spacifiec lly the new stroke project G19) and the ongoing one (42). NOTE: The:results of the staff review of the continuation component were not available in tine for Committee to consider it in recommending an overall level of funding for the Region. The Director approved continuation support for core, project #15 and three months support for projects #4 2°68 and 7R. Since staff was unable to recomend approval of the Region's request for use of $91,530 of unexpanded funds for projects number 9, 10, 11, and 14, the Region requests that Council consider approving new “Funds in that amount to complete the third year activities of these projects. The following is a list of the projects: , | Project #9 ~ Heart, Cancer and Stroke Pilot Project : Project #10 - Coronary Care Teaching Aids Project #11 « Adult Patients with Aphasia Project #14 - Diabetic Patient Care i RMPS/GRB 1/18/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF A PLANNING GRANT APPLICATION (A Privileged Communication) SOUTH DAKOTA REGIONAL MEDICAL PROGRAM RM 00067 2/71.1 School] of Medicine January 1971 Review Committee University of South Dakota 216 East Clark street Vermillion, South Dakota 57069 Program Coordinator (Acting): Henry M. Parrish, M.D., Ph. D. Requested (3 years beginning January 1, 1971) lst Year 2nd Year 3rd Year Total Direct Costs $597,700 $662,588 $689,123 $1,949,411 Indirect Costs 188,537 237,059 251,282 676,878 TOTAL $786,237 $899,647 $940,405 $2,626,289 Geography and Demography: Mobridge Aberdeen e e Watertown e @Pierre Brooking ° Rapid City oe Mitche]] Sioux Fal e oe Winner Pierre - State Capital Vermillion - University of South Dakota illion SDRMP Headquarters South Dakota RMP -2- RM 00067 2/71.) Population: (1960) 680,514 Urban- 39% Racial- 96% white Median Age- — 27.7 years (U.S. average 29.5) Land Area: 76,378 square miles a Mortality Rates: (per 100,000) . Heart- 355 Cancer- — / 143 CNS vascular lesions- 118 Facilities: University of South Dakota, School of Medicine Seven schools of Medical Technology | Six schools of X-ray Technology 75 hospitals (6,854 beds) Personnel: 564 physicians (82/100,000) 45 osteopaths 1977 nurses (288/100,000) Historical Development: The development of the Nebraska-South Dakota Regional Medical Program began in the Fall of 1965 and a request for planning was submitted in October 1966. The application represented individual planning programs by the Nebraska State Medical Society, University of Nebraska Colleges of Medicine and Dentistry, University of South Dakota Medical School and Creighton University School of Medicine. The November 1966 Council recommended approval with an expression of concerns about interrelationships of the five parties involved in planning and the apparent cumbersome administrative framework. The Nebraska-South Dakota Regional Medical Program was initially approved for two years of planning beginning January 1, 1967. A site visit was made in September 196& to assess the Region's capability for operational status (core and four projects). The site visitors observed the Region was in an early stage of regionalization. Two deterrent factors were the inability to complete major staffing until June 1967, and the need to create a new organizational structure to function as a whole. Planning also seemed to be by intuition rather than by design. There was a lack of adequate data needed to support project planning. Cooperative organization between the three medical schools (University of Nebraska College of Medicine, Creighton University School of Medicine and the University of South Dakota) was noted. There seemed to be good participation by Nebraska physicians, but much less involvement of South Dakota physicians, It was apparent’. > South Dakota RMP -3- RM 00067) 2/71.1 that the Nebraska State Medical Association, the grantee institution, played a dominant role in Regional affairs. The site visitors believed that although the rate of progress in program planning and development was slow, there were beginning signs of regionalization. It was also agreed that continued development of the Region would depend upon the initiation of some operational] projects to provide visibility and a focal point for the high degree of enthusiasm displayed. In view of the site visitors’ report, the Review Committee and Council concluded that operational status was premature and recommended approval for continuation in the planning phase, Accordingly, the three-year operational application was funded as a renewal planning grant. Summation of the planning funding: 1/67-12/67 1/68-12/68 1/69-12/69 lst Year 2nd_Year 2/ 3rd Year Total Direct Costs $289,350 $281,450 1/ $440,375 $1,011,175 Indirect Costs 60,989 67,917 l/ 70,831 199,737 TOTAL $350,339 $349,367 l/ $511,206 $1,210,912 J/ The planning renewal award (3rd year of planning) included $197,800 ($102,520 d.c.o. and $5,360) for one year of more planning of two projects, Audio Visual Continuing Education Services and Coronary Care Program. Stroke Rehabilitation Technician Training was disapnrroved 2/ The planning renewal award carried subsequent years recommended commit- ments (d.c.o.); 04 year - 1/70-12/70 - $350,239 and 05 year - 1/71-12/71 - $378,832 for Core staff. The Region applied for support for four operational projects in May 1969. A site visit followed in June 1969 to assess propress and to review the projects, Changes in the bylaws seemed to have influenced progress toward regionalization. Major changes included: (1) designation of the Presidents of the two State Medical Associations to serve on alternating years as Chairman of the RAG; (2) Presidents Elect of the two medical associations to chair the Executive Committee alternating annually; and (3) RAG repre- sentation was broadened to include minority group representation, volunteer health organizations and nurses (70 RAG members, 35 from each state). South Dakota, which previously was less enthusiastic about joining with Nebraska as a Region, appeared to have adjusted and was participating on a more equal basis, The three medica] schools continued to maintain cooperative relation- ships. Planning also seemed to be on a more sound footing. Concurring with the site visitors, the August 1969 Council recommended approval for operational status, The Council, however, remained uncertain as to the real involvement of South Dakota in this program which seemed to be a carefully balanced arrangement between the two Nebraska medica] centers. Staff discussed this with the Region representatives in negotiating the South Dakota RMP -4- , RM 00067 2/71.1 award, emphasizing the need for real program outreach - not simply repre- sentation on various committees. The Region has received $1,162,224 ($1,024,239 direct costs and $161,729 indirect costs) for core and four projects in the current first operational] year. The first concrete evidence of South Dakota's immense dissatisfaction and possible breakway was in the spring of 1969 when Governor Farrer of South Dakota wrote the Secretary, H.E.W., requesting permission to merge the South Dakota CHP and RMP efforts. A year later, Dr. Robert Hayes, then RMPS Associate Coordinator for South Dakota, in a letter (February 20, 1970) to the Director, RMPS, formally announced South Dakota's intention to with- draw from the current two-state RMP and establish its own Region. Subse- quent dialogue between RMPS staff, Dr. Hayes, and the Region Program Coordinator lead to South Dakota's submission of a preliminary draft application in May 1970. A staff team visit was made July 15-16, 1970, for the purposes: (1) assess the possibility of keeping the two states together in a mutually acceptable functioning program and necessary mechanics; (2) if South Dakota still desired separation, obtain clarification and elaboration of their draft ‘proposal, which was very general and inadequate; and (3) provide appropri- ate assistance. Part of the team visited key core staff and a past chairman of the RAG in Lincoln, Nebraska, and joined the rest of the team in Vermillion, South Dakota. Dr. Robert Hayes had recently become the State Health Officer and Dr. Henry Parrish, Associate Dean of the University, was serving as Associate Director for South Dakota and was to be the Acting Coordinator for the proposed SDRMP, South Dakota had a three-step agenda: (1) separ- ation from Nebraska, (2) setting up its own RMP, and (3) "merger" with CHP. South Dakota's intent to separate was clear and Nebraska seemed ready to acquiesce. RMPS staff reactions to the draft application were discussed in detail. The amount proposed (more than $1 million the first year) was extremely high. It was also pointed out that most Regions fall short of expending funds in the first year due to tooling up and recruitment problems and delays. The application was long on general background and history, but short on specificity about actual planning and projections for each year, The July 1979 Council preferred not to consider South Dakota's separation and the establishment of their own Region in advance of a formal application and the regular review process. For this reason, Council did not address a relevant question, whether or not South Dakota might assume administration of parts of the existing three funded operational projects to Nebraska- South Dakota RMP. A “Funding Summary” is appended, Present Application: Upon receint of this application, the applicant was advised that the issue of seperation had to be taken up by the November 1970 National Advisory Counci!] following a visit by two South Dakota RMP -5- RM 00067 2/71.1 of its members October 27. They were advised that the application would then be processed through the regular review process, Review Committee in January 1971, possible site visit and final consideration by the February 1971 Council. To provide interim support for Nebraska-South Dakota Regional Medical Program's core staff and three projects (beginning date January 1), the current first-year award is to be extended for six months until June 30, 197] at the current level of support. , On the basis of the visit of two of its members, the November 1970 Council approved the separation of Nebraska and South Dakota; each beginning in the planning phase. The report and recommendations approved by the November 1970 Council is appended. As requested by the visitors, SDRMP provided the following addition information: (1) letters of endorsement; (2) Core staff job descriptions, (3) biographical sketches for RAG members; and (4) South Dakota health study. Nebraska plans to submit an application for their separate RMP for review by the April 1971 Review Committee and May 1971 Council. This is a formal request from South Dakota for support for three years of planning, at which time they plan to separate from the present Nebraska- South Dakota RMP. The decision was approved February 1970 by the South Dakota members of Nebraska-South Dakota RMP. Nebraska members approved a resolution expressing their desire for a separate Region, The resolution’ was enclosed with a letter August 19, 1979, to RMPS from the NSD/RMP. As proposed by the Governor, the South Dakota RMP proposes a merger of their functions with those of CHP, The applicant organization for SDRMP will be the School of Medicine, University of South Dakota. The grantee for SDRMP will be the Office of the Governor. Both agencies will. have a common RAG consisting of 41 members (2] consumers and 20 providers). The providers include members of medical, nursing and paramedical professions, and representation from the medical school, hospitals, nursing homes, university, voluntary health agencies and official health organizations. All projects and grants are to be acted upon by the RAG and must conform to the State Plan and objectives also decided upon by the RAG. The bylaws provide for a Chairman, Vice Chairman, and Secretary. The latter two will be elected by the RAG. The President Elect of the South Dakota Medical Association shall serve as the Chairman of the RAG and the Executive Committee. The Executive Committee shall consist of nine members: the Chairman, Vice Chairman and Secretary of the RAG; a representative of the School of Medicine, designate of the Dean; and five consumer members of the RAG. At least one of the providers shall represent the South Dakota Hospital Association and one consumer shall represent the Indian population. The Chairman shall appoint the consumer members of the Executive Committee. The RAG will meet at least three times annually. The Executive Committee shall meet monthly to carryout business in the interim of RAG meetings. South Dakota RMP -6- RM 00067 2/71.1 According to the bylaws, the’ Program Director shall be a physician graduate of an AMA School of Medicine; one who is licensed or eligible for license in South Dakota. Demonstrated leadership qualities are also a requirement, and experience and/or training in administrative medicine is desirable. The Director shall be an employee of the grantee organization. His appointment and dismissal shall be the prerogative of the Medical School. However, the advice and consent of the Executive Committee will be sought. In the framework of six subregional areas, planning wil] be done by staff and approved or disapproved by the RAG, Ad hoc committees wil] be utilized as necessary to provide technical assistance, SDRMP and SDCHP will work cooperatively in planning. SDRMP will be responsible for planning relative to heart diseases, cancer, stroke, continuing health education, and health manpower. SDCHP will be responsible for planning in the areas of health services, health facilities, environmental health, Indian health and mental health.. Cost sharing will be considered beginning with the six subregional representatives. Planning for better health care being the major thrust, goals deal with health manpower, professional continuing education, medical care facilities (includes in-service education and transportation), screening, communications among providers and consumers, prevention, early diagnosis and treatment, rehabilitation and public education. Objectives formulated by the NSD/RMP's categorical disease task forces will be utilized in the planning process. Although a three-year planning grant is requested, it is implied operational status might be possible in one or two years. Objectives during the first year include evolving administrative procedures; recruiting core staff; devel- oping working relationships with CHP: recruiting health manpower and developing a supporting project; initiate and expand continuing education for health personnel, including the development of one or more operational support projects; begin six subregion activities including assistance in the development of CHP 314 B area planning prants; and train ambulance drivers in emergency health care, Much of the application addresses the history of the Nebraska-South Dakota RMP and reasons for South Dakota's request to separate from Nebraska to establish their own Region. The University of South Dakota, the applicant organization, is described as being established in 1862 with a present enrollment of five thousand students in its two colleges and six schools. Academic units: College of Arts and Sciences, School of Law, School of Medicine, School of Education, School of Business, Graduate School, College of Fine Arts and School] of Nursing. As one of the major research centers in South Dakota, the University has received grants from 15 agencies including the Atomic Energy Commision, the National Science Foundation, Health Manpower Education, the Bureau of Indian Affairs and the National Institutes of Health, of the $597,790 requested the first year, $37°,650 (463%) is for personnel. Sixteen full-time professional positions are budgeted (a Director, 3 assistant Directors, Administrator, Statistician, Epidemiologist, Soctolo- gist, Medical Care Planner, Community Developer, and six RMP representatives). Ten other full-time positions are budgeted (Administrative Assistant and % South Dakota RMP -7- RM 90067 2/71.1 ) ho Vion. and nine secretaries). Oher categories: consultant services - $5,909 equipment - $62,550, supplies - $48,000, travel for RAG and staff - $! publications - $10,000, other (rent, telephone and computer time) - § The budget reflects no costs sharing by CHP. Dn NEBRASKA-SOUTH DAKOTA FUNDING SUMMARY RM_00047 PLANNING Council — November 1966 November 1968 Site Visit - September 1968 ist Year : 1/1/67 - 12/31/67 Direct Costs $289,350 Indirect Costs 60 ,989 Total $350,339 2nd Year 1/1/68 - 12/31/68 Direct Costs $281,450 Indirect Costs 67,917 Total $349 ,367 3rd Year 1/1/69 - 12/31/69 Direct Costs $440,375 Indirect Costs 70,831 Total 1/ 2/ $511,206 Total 3 years 1/1/67 - 12/31/69 Direct Costs $1,011,175 Indirect Costs 199 737 $1,210,912 1/ The Region was initially approved and funded for two years of planning. Upon review of the three-year operational application, the Review Com- mittee and Council concurred with the site visitors that operational status was premature. Accordingly, the three-year operational application was funded as a renewal planning grant carrying commitments (d.c.o.), $350,239 the second year and $378,832 the third year. The Region became operational beginning January 1, 1970, and continuation of core, reviewed by staff, was funded for one year with a commitment the second year; core support must be renewed for the third operational year prior to January 1, 1972. 2/ The renewal award for the third year of planning included $107 ,880 ($102,520 direct costs and $5,360 indirect costs) for one year additional planning of two projects, #2 - Audio Visual Continuing Education Services and #3 - Coronary Care Program. Project #4 - Stroke Rehabilitation Tech- nician Training - was disapproved. SOUTH DAKOTA RMP _ -8- a RM 00067° 2/71.1 OPERATIONAL 1/1/70 - 12/31/72 Council -— 1969 August and December Site Visit - 1969 June Direct Costs Approved Approved Period Funded Future Level Core 1/ 2 years (01) $443,647 (02) $425,903 1/ (03) -0- #1 - Coronary Care 3 years (01) 313,138 (02) 313,138 (03) 367,871 #2 - Facility Communications 3 years (01) 132,715 (02) 132,715 (03) 171,390 #3 - Stroke Education Approved — Not Funded #4 - Neoplastic Disease 3 years (01) 134,739 (02) 128,739 (03) 128,739 TOTALS : . *(01) $1,024,239 (02) $1,000,495 (03) $668,000 *Note: O1 year award includes authorized use of carryover $23,744 ($17,744 Core and $6,000 mobile unit #4) Approved - Not Funded #3 - Stroke Education O1 02 03 Direct Costs $187 ,350 $187,350 $187,350 Total $562,050 South Dakota RMP -9- RM 00067 2/71.1 RMPS Vist to South Dakota Vermillion, South Dakota Date: October 27, 1979 Place: School of Medicine, University of South Dakota (Vermillion) RMPS Visitors: Bruce Everist - National Advisory Council, RMPS Clark Millikan - National Advisory Council, RMPS Personnel from South Dakota: Dr. Henry Parrish, Acting Director (Program Coordinator) South Dakota Regional Medical Program Dr. Robert H. Hayes State Health Officer Dr. J. Patrick Steel, Radiologist, Yankton, South Dakota; Member, National Advisory Council, National Institute of General Medical Sciences Earl B. Scott, Ph.D., Professor of Anatomy, University of South Nakota, School of Medicine Dr. Robert Quinn, Past President, North Dakota State Medical Association , Mr. William Murphy, Executive Secretary, State Hospital Association Dr. Warren L. Jones Mr. Richard Erickson, Executive Secretary, South Dakota State Medical Association Mrs. Bertha Damm, Executive Director, South Dakota State Nurses Association Mr. Peter Zwier, Executive Secretary, American Cancer Society, South Dakota Division Dr. Bruce Lushbough Mr. James R. Nordstrom, SDRMP Staff, 29 per cent South. Dakota RMP -10- RM 00067. 2/71.1 Mr. G. Halter, SDRMP-Staff,100 per cent Mrs. Schwab, SDRMP Staff, 190 per cent Mr. Don Brekke, SDRMP Staff, 50 per cent (SDCHP Staff, 50 per cent) . Miss Gloria Hansen, SDRMP Staff, 100 per cent Executive Assistant of President Richard L. Bowen, University of South Dakota , ce Dr. George W. Knabe, Jr., Dean, University of South Dakota, School of Medicine General: The Nebraska-South Dakota Regional Medical Program apparently began amiably in 1966 with what appeared to be a rationa] approach to regionalization involving two adjacent states. Enthusiasm was apparently high in both states. Some of the difficulties described at the time of our visit were: 1. The meetings were apparently held in Nebraska, and the South Dakota representatives had to spend considerable time traveling to and from Omaha. Without adequate airplane service, this meant a two-hour drive each way at a bare minimum. , 2. Ideas were germinated in South Dakota and come to fruition in Nebraska with little substitute change. 3. Princinal core personnel were placed in the two universities in Nebraska without similar attention or recognition at the University of Sout Dakota. 4&4. As South Dakotans see it, they were treated as country cousins; made to feel that they were lacking in sophistication, and therefore, having to attempt to make up for this with sincerity, enthusiasm and dedication. 5. The South Dakotans believe that there was inequity in the distribution of funds. 5. A variety of other items described in detail on pages 18, 19, 20, and 21 of the printed new planning grant application for a South Dakota Regional Medical Program. New application: RMP-CHP relationship. There is described an attempt to partially merge these two organizations, This was initiated by the Governor with a letter to H.E.W, and was concurred in by the power structure of medicine in South Dakota. This change (from the traditiona] arrangement) is that the Regional Advisory Group will be identical for both organizations and that certain South Dakota RMP -1l- RM 00067 2/71.1 individual employees may receive partial stipending from CHP and partial stipending form RMP (Mr. Don Brekke). There will be separate offices and separate directors for the two organizations. In a state with a limited number of professional people, this arrangement would seem to make good sense, save time and allow for greater cooperation among all involved persons. Currently, there is an A agency (annual budget 140,900 dollars) and one B agency that has not been funded (Rapid City. In the budget for the RMP planning grant application, it is proposed that six representatives be paid from the RMP budget but act as RMP-CHP representatives in the six regions of the state and that they initiate, as part of their job, the development of more B agencies. There is precedence for this in West — Virginia and Alabama. There need not be any specific difficulty arising from this arrangement; the cooperative undertaking might well be an inter- esting experiment. Bylaws of the Regional Advisory Group of the South Dakota Regional Medical Program, On the face sheet of the application, it is stated that the recipient of the grant will be the School of Medicine, University of South. Dakota, Vermillion, South Dakota. This should be a bit more carefully defined in the body of the application as on page 23 "the University of South Dakota" is mentioned, rather than the medical school as well as the matter on page 28 of the “appointment and dismissal (Director of the RMP) shall be made by the University of South Dakota" being of concern to the Dean of the medical school who wants to be certain that the distinction between the over-all university and the medical school is absolutely clear. Proposed Core. The prospective use and activity of the core staff, for which budget support is requested, is impossible to evaluate from the document given us. At the time of our visit to Vermillion, the authors of the application stated that they had originally planned to write a much more elaborate and detailed grant proposal but had been advised by staff to delete all extraneous material. The result is a synopsis of a synopsis and gives merely a listing of 16 professional staff people plus 10 other employees. We tried to discuss the duties of each of the professional people and it became more and more evident that this list constitutes an attempt to bring a basic staff of public health professionals into the state. The list includes: a biostatistician, an epidemiologist, medical sociologist, and a community developer. It appeared obvious that if these people can be found and employed, they probably would wear "many hats" but would share a basic dedication to improving the health of the people of South Dakota. It was obvious that the acting director of the proposed South Dakota RMP (Doctor Parrish) is public health oriented and has had experience in the mechanics of developing a foundation for health planning. We asked that the job descriptions of these 16 professional people be sent to the staff (in another document) prior to the National Advisory Council meetinp November 9 and 19. South Dakota RMP -12- RM 00067 2/71.1 University of South Dakota Medical School relationship with RMP, There apparently has been some uneasiness between the medical school and the Nebraska-South Dakota Regional Medical Program, Dr. George W. Knabe, Jr., the current dean, has had some interest but little, participation in the Nebraska-South Dakota RMP and has been annoyed by the RMP demands on the time of the medical school personnel. Now that the associate dean, Doctor Parrish, is the acting director of the South Dakota RMP, the dean is further annoyed by the amount of time demanded of Doctor Parrish in ‘developing the new RMP. Communication between the RMP personnel and Doctor Knabe has been faulty. Doctor Knabe has not been privy to the development and content of the current proposal, and is somewhat uncertain about some aspects of the document but does endorse the participation of the medical school in carrying out the objectives of the proposal. The dean is particularly interested in getting a full-time director of the proposed South Dakota RMP so that Doctor Parrish may return to full-time activity in the University Medical School. As we review the discussion in Doctor Knabe's office, we ~ feel there was more pique than substance in his uncertainties. Projects: The South Dakota grcup of the Nebraska-South Dakota Regional Medical Program has apparently lost interest in the communications project and the cancer project but they continue to be vitally interested in the coronary care project which has approved funding for a period of three years. The share of this project going to South Dakota is $129,900 a year of which $50,000 funds activities centered in the University of South Dakota Medical School and $70,000 funds the activities centered in. Sioux Falls, South Dakota, and Rapid City, South Dakota. From their : description of the project's success so far, it would seem that they have made a significant beginning with outreach to the smaller hospitals for continuation and with courses of two days' duration at the University. So far the instruction is primarily directed toward physiology, pharmacology and anatomy. The activities centered at Sioux Falls, South Dakota, under the direction of Doctor Woods appear to be more clinically oriented with a demonstration type coronary care facility. The entire group with whom we visited were unanimous in their hearty recommendation of need to continue this project as they refer to it as the first tangible evidence of "action" by RMP in South Dakota. In discussing the future, it appears that South Dakotans do not have any projects ready for immediate submission but do have a portfolio containing 22 project ideas in various stages of develop- ment. These have previously been discussed by the Nebraska-South Dakota RMP Regional Advisory Group. Recommendations: 1. South Dakota be designated as an independent RMP 2. Arrangements be made to supply “core support" of at least $40,000 per year to the new South Dakota RMP. If further written description of plans and of functions of the expanded core personne] requested by South Dakota is forwarded to the RMP Washington office, the staff and National Advisory Council consider increasing the $40,900 annual core support immediately. Seuth Dakota RMP -13- RM 00067 2/71.1 3. Funding of the coronary care project in South Dakota be continued, $120,000 per year -- total time three years. 4, South Dakota RMP be moved to “operational status" as soon as an acceptable operational grant application is received and processed. 5. Details of the separation of Nebraska-South Dakota RMP into Nebraska RMP and SDRMP be constructed and carried out by the Washington RMP staff -- being certain that the Nebraska RMP receives appropriate funding in the new arrangements. RMPS/GRB 12/8/70 SUIDIARY 08 EVEEW Ba ok Sa dhe REY SOUTH DAZOTA REGIONAL HEDICAL PROGRAN RM 00067 * 2/71.1 FOR CONSIDERATION BY PREERUARY 1971 ALVISORY COSHSIL fie Covmittes recommends appyveval of South Dakota’ application to become a separate Region and to begin planning. The reduced amount of $948,000 for three years is recommended for core (01~$259,509, 02-$313,600 and 03-$376,090). “In addition, $120,000 is recommended for ns + VeaE for support of the on-going coronary care be odect in three South Pakota hospitals, Total level of support recos is as follows: oD 7) 0 02 - 03 ee erate = $379,509 $313,009 _ $376,000 $1,068,500 port ef the October 27, 1S70 vis ¢ rey Council members The Comeaitte also benefited by input from one of its me jas pe ed with the state, The application was and short on ) Fegardin ng timing, iep eC Sta £ raported that der: and SPONI job descriptions and bionzant 1967-68", had been provided, as wall as a 65% t South Raketa’ ¢ he RAG and. the tie in Tne State Health The Committee believes that health interests can be sex. concept of coordinating SURV? to the Governor's office is 5 be a te d best yh TT ONT GG GN Dive ts Directors former associate i iu South Daketa, will provide esidual carry over of Hib, The SDRUP aleo seems to have the active . suppore of the 8. D, University School of Medicine, State Me rdical Association, Eospital Assectle elon and other key agencies. There are Oy hopes for a four yerr medical school, The Comnittce agreed that South Dakota may lack some "turf", but they are determined and the climate may be right to provide them with support to transfer their ideas into realism. The budget is high, particular] y personnel, equipment and supplies. The need for all of the full-time specialists listed is not warranted, even if recruitment capability were present. A headquarters staff with combinations of expertise and a field staff should suffice, The budget does not seen to allow for "tool up" tims, but rather is full blown from day one, In reaching a recommendation, the Committee considered the current South Dakota core bud: oi SOUTH DAKOTA RMP. -2- me RM 60067 2/71.1. ased on information provided by staff. The current anaual rate of support for Core activities is $111,700 and includes five fell tine positions (coordinator, nurse, planning assistant and two secretaries) end three partetime (field representative 50%, assistant coordinator 30%, and planning assistant 5%). The Committee believes that $250,000 d.c.o. for support of core the first year with noninal increuses in the second and third year should be adequate, The current coronary care project now beginaing its second year wes discussed. The project includes three South Dakota hospitals currently budgeted’ at $120,000 d.c.o. ‘The Committee agreed that South Dakota should be awarded funds for one year at the current level to provide continuity of this program until their projected plans are more crystalized. Whether the activity should be funded as an operational project or a Core staff feasibility siud " by stalk. ty can be best be det the Committee emphatically recommended that peels first effort should be training their personnal, ; and evaluation, This | might be accouwplished by one or maubinatih £ mathods, 1.@., enployuent of a trainer, purchase of consultcnts services, and visits to other appropriate Reps. : | ARE 9 BE REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD APPLICATION (A Privileged Communication) . SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM RM 00059 2/71.1 (AR-1 CSP) 3806 Market Street, P.O. Box 541 January 1971 Review Committee Camp Hill, Pennsylvania 17011 Program Coordinator: Richard B. McKenzie REQUEST (Direct Costs Only) 04 05 06 Purpose 4/1/71-3/30/72 4/1/72-3/30/73 4/1/73-3/30/74 All Years Continuation . Commitment, $545,915 $545,915 Core. (469,700) (469,700) 3 Projects (76,215) _ (76,215) Renewal Components $29,425 $31,551 ' $60,976 1 Project (29,425) (31,551) (60,976) Additional ; Projects $1,503,780 $1,482,065 $1,592,377 |. $4,578,222 4& Previously Approved Projs. (184,044) . (158,387) (98,534) (440,965) 7 New Projects (1,319,736) (1,323,678) (1,493,843) (4,137,257) Developmental ‘Component $54,596 $54,596 $54,596 $163,788 Total - $2,133,716 $1,568,212 $1,646,973. $5,348,901 Staff Action Commitment $545,915 Committee Action ' Required $1,587,801 $1,568,212 $1,646,973 $5,348,901 j FUNDING HISTORY 1 Planning Stage “Grant Year Period Funded (dic.o.) 01. : 6/1/67-5/31/68 $253,530 02 vee 6/1/68- 3/31/69 -. $250,056 SUSQUEHANNA VALLEY RMP ~2- RM 00059 2/71.1 (AR-1 CSD) ‘Operational Program ee nen ‘Grant Year | Périod | "Council approved co Funded ‘d.c.o. > | Conmitment O01 4/1/69-3/31/70 $698,052 _ $532,444 1/ 02 4/1/70-3/31/71 666,495 671,997 2/ 03 4/1/71-3/31/72 695,333 ; $545,915 04 4/1/72-3/31/73 650,075 . 497,644 05 4/1/73-3/31/74 483,294 1/ Represents 75% funding of projects 2/ Includes $124,390 in carryover Geography and Demography This Region consists of 38 counties in the central corridor of Pennsylvania bordering on Maryland in the south and New York in the north and separated from the Western Pennsylvania and Greater Delaware Valley RMPs by moun- tainous terrain. The total population of the Region is projected to be~* 2,323,751 (1970 Census). Much of this population is centered around the three urban areas, but the Region also contains large rural and forest areas with low population concentrations and underdeveloped facilities. The Milton S. Hershey Medical Center of the Pennsylvania State University was established in 1963. The first class of 40 medical students was enrolled in 1967. The Region also has 55 hospitals. It is served by 1,776 M.D.'s and 218 D.0O.'s. There are 8,909 active nurses. Regional Development In 1966 the Susquebanna Valley Committee on Heart Disease, Cancer and Stroke, presided over by the President of the Pennsylvania Medical Society (PMS), met to plan an RMP for the central Pennsylvania Region. The first planning grant, submitted by the PMS, was approved in June 1967 pending clarification of the role of the new medical school, the state health department and administrative and staffing .patterns, and assurance of allied health involvement. The Executive Director of the PMS, Mr. McKenzie, was appointed Coordinator in August 1967. During the second planning year, the Region encountered a number of problems with the completely lay Core staff and the grantee agency, which considered the RMP Core staff as another branch of the PMS, There was strong senti- ment among Core staff regarding the degree of control the PMS maintained over routine office matters and the relatively low salary scale, Several staff members resigned as a result. There was also some confusion about the relationship between the RAG and the PMS Board. A management consulting firm was retained to study the entire program and recommended certain ‘staffing changes, some of which have gone into effect. SUSQUEHANNA VALLEY RMP ~3- RM 00059 2/71.1 (AR-1 CSD) The Region began work on its initial operational application which would contain five coronary care unit proposals and a request to train coronary care unit nurses. A site visit was held in December 1968, The visitors recommended operational status to convince the local. physicians that RMP would actually help them improve patient care, While leadership from the RAG was slow in developing, the Region had an impressive amount of physi- cian involvement at the grass roots level through the Area Committee structure. In fact, the bywords for the SVRMP in these early days became "erass roots involvement" and "coronary care." Council approved the Region's request with the understanding that the CCU projects were pilot projects for. the Region with evaluation of the results before additional projects are funded and with the stipulation that 50 percent of the equip-~ ment funds be made available for physician training. Shortly afterwards three more proposals were submitted, approved and funded. They were a stroke care unit, a home health care project and a regional medical infor- mation service, New projects submitted during the second year, however, continued to emphasize coronary care. Reviewers found them, on the whole, to be a disparate group of projects, attacking the problems of coronary care in an isolated fashion. They disapproved the projects and recommended that’ the Region establish an overall plan involving greater coordination, coop- eration and consolidation. Core and the coronary care training proposal at the Geisinger Medical Center were renewed. A site visit held in February 1970 reviewed the overall progress of the Region and four new projects. They concluded that the Region should: 1) consider broadening the base of its grantee agency to insure that all appropriate groups feel represented. A change to a nonprofit corpora- tion was seen as a possible solution; 2) utilize consultants from both inside and ovtside the Region to improve efforts in data gathering and epidemiology; 3) appoint a liaison’ member of the Hershey Medical School faculty part-time, to the RMP staff to both improve relations with the new medical school and involve physicians on Core staff; 4) while continuing to encourage grass roots involvement, devote more attention to developing a regional decision-making process which selects projects on the basis of a regional plan, rather than just on a community's needs,- Projects funded during this past year include: 1) an extension of the original five ccU's with carryover funds for an additional year, 2) the CCU nurse training project, _3) the second year of the SVRMP library information service, SUSQUEHANNA VALLEY RMP ~4 - RM 00059 2/71.1 (AR-1 CSD) 4) project #7, the Stroke Care Unit and #8, the Home Health Service, out of carryover, and 5) projects #16, the Radiological Health Training Program and #17, Columbia- Montour Home Health Services. Projects #18, a Rheumatic Fever Control Program, and #19, a CPR project were approved but unfunded. The Region submitted one further application during its second operational year. Only the Enterostomal Training Program and the CPR and CVA Transport Vehicle, York, were approved, Council requested additional information on the CCU Nurse Training Program at the Altoona Hospital before it could be approved (this information has been received and will be forwarded to the February 1971 Council). The remaining four projects, including an emphysema program, a stroke rehabilitation and training program, a cart~ ridge viewing system pilot project and a supervisory CCU nurse training program, were turned down. The Region's present level of funding for its second operational year is $671,997. Note: A site visit was not planned for this Region; one had been held during the past year; and the Region informed RMPS only a week before the review deadline of its decision to include a request for a developmental component in its AR application. Regional Objectives The SVRMP frankly admits that its centralized program planning to date represents a disconcerted effort and that the Region does not have a specific plan which details specific objectives that result in specific applications. Interest in the past has happened to center on heart dis- ease and coronary units. At its fall 1970 meeting, the RAG established formal goals which set the stage for development of primary goals and specific objectives. The primary goal is to "improve the quality of patient care working with and through the providers of health care as they function in the existing health care system; and by influencing the’present arrangements for health services and by concentrating maximum effort on those activities which have the highest local, regional and national priorities." The primary goal is approached through specific goals in three basic areas - organization, strategy and program. Organizational Structure and Processes The SVRMP has organized a 30-member RAG, with representatives from each of the four Areas and from various health organizations and institutions of . the Region. The RAG has Executive, By-Laws and Nominating Committees and SUSQUEHANNA VALLEY RMP -5- RM 00059 2/71.1 (AR- CSD) is in the process of selecting Planning and Fvaluation Conmittees. The RMP has divided the Region into four Areas, each of which is served by a Comaittee ranging from 60 to 135 members. Each Committee has appointed subcommittees to serve as study groups and an Executive Committee. To provide review and planning at the regional level in specific functions, Councils (formerly Task Forces) have been established in the categorical areas, as well as in Facilities and Services -and Continuing Education, Fach Council also sets goals and objectives in its respective interest. The review procedure consists of the following steps: 1. Consideration by the volunteer Area Committees through their Executive Committee and specialized subcommittees, N : - Consideration by the members of categorical councils who supply spec~ jalized professional technical review on a regional scale. 3. Consideration of the relevance of the proposal to regional goals and objectives by the RAG. At each step, staff members provide administrative assistance, Formal , review procedures, including a set of criteria and a numerical ranking: system, which assigns all new projects a priority number, have been devised for the RAG. Plans are underway to develop a similar system for the Councils and Area Committees. PRESENT APPLICATION: Developmental Component $54,596 Activities initiated through developmental component funding "will seek to improve the quality of patient care by working with and through the providers of health care as they function in the existing health care sys- tem, by influencing the present arrangements for health care services, and by concentrating maximum effort on these activities which have the highest local, regional and national priorities." An example might be an explora-- tion of appropriate methods and means for developing improved patient care techniques and systems in kidney disease prevention and control. The review mechanism described under organizational structure and processes above will apply to the developmental component as well. : $54,596 $54,596 Continuation Component These components have been reviewed by staff. Their program and funding recommendations are in a supplementary memo. SUSQUEHANWA VALLEY RMP -6- , RM 00059 2/71.1 (AR-1 CSD) $469 , 700 The SVRMP Core staff is completely lay. Its Coordinator was the former FPxecutive Director of the Pennsylvania Medical Society, which serves as the grantee agency. An organizational chart for Core staff is attached to the summary. The functions can be briefly defined as follows: 1, Technical Services ~ plans, establishes and directs the technical ser- vices for: applications development, grants management, research and evaluation services, development and operation of library activities and general office management. 2. Communications - directs the production of communications material 3. Program Development - provides staff services to committees, councils and planning groups, coordinates educational activities and programs, assists with the establishment of regional goals, objectives and priorities, and provides personnel recruitment services for staffing. In addition, Field Services are included in this. branch. A field representative is assigned to each of the four Areas to provide regional coordination and staff services to all volunteer committees and groups in the Region. With the assistance of the field representatives, various Area Committees or subcommittees have developed standards for coronary care, sponsored a ‘* eancer detection clinic survey and conducted a cancer incidence and mor- tality survey. The SVRMP Core budget last year included funds for "program related acti- vities," These are funds in the magnitude of $50,000, which the Region used for various purposes, such as to conduct pilot studies of various proposed project activities, hold conferences, and supply educational mater- ials to health professionals. Types of activities for which these funds will be used next year include a conference for regional directors of coronary care units, an audio-tape cassette scientific program service, data collection and a consultation program for tumor clinics and tumor registries. “The budget for 1971-72 includes funds for 25 full-time positions, 22 of. which have been filled. The new positions would be a Systems Coordinator, Nursing Specialist and receptionist. ' co Continuation support in the amount of $76,215 is also requested for three projects? #9 - SVRMP Information Service #16 .- Radiological Health Training Program #17 -— Columbia~Montour Home Health Services “Renewal Projects oo oo 3rd Year Project #6R - Coronary Care Nurses! Training Program, Geisinger $29,425 Medical Center. The Geisinger Medical Center will conduct fat SUSQUEHANNA VALLEY RMP ¢ - 97 oo RM 00059 2/71.1 (AR-1 CSD) four, four-week coronary care courses per year, Each class will admit ten trainees, who are principally recent diploma graduate nurses. The curriculum includes lectures, laboratory work, and clini¢gal experience ‘in special nursing techniques for the cardiac patient. Community hospitals throughout the Susquehanna Valley Region, as well as border areas, may use this training program to staff their coronary care units with qualified nurses. This project was submitted with the Region's initial operational applica- tion and applied for and received one-year renewal support last year. Since its inception, it has trained 42 nurses. Fourth Year $31,551 Approved but Unfunded Projects These projects have been previously approved by Council, but due to nation- al funding constraints, have not been funded. Committee and Council con- siderations of these projects is needed in determining an overall funding -level for the Region for the next year and not for approval of the '. activities, ist Year Project #18 - Rheumatic Fever Control Program. This project $75,217 will impress upon physicians and the public the necessity for throat cultures in diagnosing streptococcal infections. Hospitals and physicians in 16 of the Region's 27 counties will receive free throat culture kits. The kits will be used on people between the ages of two and forty-five who have upper respiratory infection or a sore throat. The participating hospitals will interpret the cultures and send reports to the attending physicians. The physicians will follow-up with appropri- ate treatment, Although this project involves the demonstration of patient care, the aspects of continuing education are also present. . i i In addition, the promotional efforts of the Heart Association, who will participate in the program, will increase the public! s awareness of the value of the procedure. Second Year $64,417 , ‘lst Year Project #19 =‘Cardiopulmonary Resuscitation Training. — $16,693 Sponsored by the Heart Association, the purpose of this project is to establish an emergency cardiopulmonary resus citation team in every hospital in the Susquehanna Valley Region, SUSQUEHANNA VALLEY RMP - 8 RM 00059 2/71.1 (AR-1 CSD) First, the Instructor's Training Center at the Harrisburg Hospital will be expanded to include a special training course in emergency cardio- pulmonary resuscitation. Each year, teams from 18 hospitals will complete this course. Then, using the organizational framework of the Pennsylvania . Heart Association and its chapters, these newly trained teams will train other hospital teams. The wide geographical distribution of emergency teams will be ideal for training local ambulance crews, rescue squads, and other health personnel throughout the Region. Second Year | Third Year $15,481 ; $16,066 ist Year Project #21 - Enterostomal Therapy Training. The Harrisburg $9,934 Hospital will conduct twelve, four-week courses in enterostomal therapy per year. One student will be trained in each course. Training will include bedside instruction and practice, medical lectures, technical lectures, and conferences, . The graduate therapists will be able to provide patients with stomal care and management, therebyfreeing nurses and physicians for other work, In addition, the therapists will instruct patients in self-care and teach allied health personnel the principles of stomal management. . Second Year | Third Year $10,439 $10,920 ist Year Project #26 - Cardiopulmonary and CVA Transport Vehicle, $82,200 York Hospital. This pilot project will determine the effect of a specially equipped and staffed transport vehicle in reducing the compli- cations and deaths associated with heart attack and stroke. The custom-designed van which will contain a resuscitation unit, a respir- . ator, a two-way radio, drug storage facilities, and other emergency equip- ment, will be on call 24 hours a day, staffed by a physician or coronary -eare nurse, orderly, and driver. . Second Year Third Year $68,050 $71,548 New Projects “Ist Year Project #27 = Nurse Dial Access, Robert Packer Hospital, | $29,969 Sayre, Pennsylvania. Dial Access for Nurses will cover Central New York State and the entire state of Pennsylvania. It is a special telephone information system for RN's, LPN's, student nurses, and others -- particularly those practicing in an isolated setting -- who do not have the resources: available for their continuing education. Available on an around- SUSQUEHANNA VALLEY RMP -~ 9 - ~ RM 00059 2/71.1 (AR-1 CSD) the-clock basis from any telephone, it provides the caller with free, five-to-six minute taped messages on a variety of subjects, such as (1) nursing care for specific conditions, (2) new procedures and equipment, (3) availability of community resources, (4) nursing care in emergency situations, and (5) legal aspects of nursing situations, The Central New York RMP is presently funding a Physician Dial Access pro- gram out of the Sayre Hospital. SVRMP Core funds are being used to extend coverage of the physician program to their Region. Second Year . Third Year $29,453 $39,224 ist Year Project #28 - Automated Computer~Assisted Analysis of the $294,470 EEG, Pennsylvania State University. Four participating hospitals, located in three areas of the Region, will send computerized EEG signals to Penn State's Hybrid Computer Laboratory. The information will be interpreted by computer at Penn State and the diagnosis returned to the’ sending hospitals. Each computer diagnosis will be compared to the phy- sician's final diagnosis. The purpose of this project is to install and further develop this computerized EEG system, and at the same time, deter- ‘mine the feasibility of providing all hospitals throughout the Region with '. rapid and valid electroencephalogram interpretation service, Since January 1968, the Geisinger Medical. Center and the Pennsylvania State University have been conducting research on automatic computer analy- sis of EEGs. Second Year $82, 062 ist Year Project #29 - Computerized EKG Pilot Program. This project $300,186 would establish a computerized EKG transmission and analysis system which would link 13 hospitals in a 27-county area to a computer center at Harrisburg Hospital. EKG's would be transmitted to the center, - processed. and the interpretation transmitted to the originating hospital. A formal training program, conducted by a eardiologist. from the Hershey. Medical Center ig planned for physicians and technicians involved in the project. | The project resulted from a pilot program at the Harrisburg Hospital.; ‘Second Year Third Year $300, 186 . $300,186 ar ist Year Project #30 ~ Coordinated Home Cate | Program of Lancaster $106,128 County. The Coordinated Home Care Agency of 1 Lancaster County will arrange quality medical, nursing, social, and related services for patients in their homes. The central administrative Coordinated Home Care Agency will: - SUSQUEHANNA VALLEY RHP -~ 10 - RM 00059 2/71.1 (AR-1 CSD) 1. Coordinate community resources in the delivery of optimum home health care services, 2, Act as the one source of referral for the physicians, 3, Serve as a center for comprehensive planning, evaluation, and followup of home care services. 4, Act as an information service for physicians, patients, participating agencies, and the public. 5. Hold periodic joint conferences with physicians, other pr rofessional or allied persons, and consumers of service to determine how effectively the program is functioning. Second Year _ Third Year $106, 367 $115, 400- ist Year Project #31 - Family and Community Health Service Program, $145,630 Lancaster General Hospital. The main objective of the Family Health Service Program is to deliver comprehensive family-oriented, pri- _ mary health care as part of a community hospital, The new system also “geeks to create a structure which casts a physician as a health advocate for his patient. Home health aides will be used to provide health educa~ tion and develop communication with the clients. Residents of the low income areas will serve on a board to review and analyze the effectiveness of the delivery system, which includes Family Practice Residents and Nurse Practitioners. Second_ Year Third Year $145,724 . $159, 086 : ist Year Project #32 - Central Pennsylvania Cancer Education and $296,178 Treatment Center, Altoona Hospital. This project will provide physical facilities, equipment, and personnel to conduct a cancer education ‘and treatment center. It will utilize cobalt therapy, deep therapy, and isotopes for diagnosis and therapy and provide a firm basis for continuing education , for physicians in cancer detection and treatment, It will.also provide a: super voltage facility in an area geographically and economically separated /from the nearest similar facility by more than 50 miles, as well as allow for continuity of treatment, detection of recurrences, and new primary tumors, while maintaining identity with the patient's personal physician, The Region's Ad Hoc Committee on Radiation Therapy, which is studying the Region's radiation therapy resources, has reviewed the project and endorses the need for a facility in Altoona. '. Second Year ‘Third Year $202,075. : $210,050 SUSQUEHANNA VALLEY RMP - 11 - RM 00059 2/71.1 (AR-1 CSD) Project #33 - Hamilton Health Center. The Hamilton Health $147,175 Center, Inc., a nonprofit organization directed by a group of consumers and representatives of providers of health care, request support to establish a comprehensive health care system in a disadvantaged area of Harrisburg. The neighborhood health center will be served by a family health team, which includes community health aides recruited from the neighborhood. : Second Year Third Year $457,811 $678,897 oa . ‘aes AA mh es Secretar \t eaten £ or Ty =D at he or o he 2 > : " . q@ , =f ead irec: D fo sen POEL a, red FI fret car mn a et oO oO, _ 4 \sst D A Dp s samnsomeneretm é 1 Ly io es nat pons . “ : ° t t | i ! 1 | i Secretary 4 IA N; au es 3 . Nt re etd iebivit Coordi a rt aod ID eCLal PTL AN iv LOUCAGLONG f $4 § Fier An we a aad + Han woe ‘ t ‘ \ 2 § i . é 4 r w at TRECTOR Secretary mn 2 : fy po ey ee ce Q ° ow PB 4 odor a ; 3 vd 7 L tonne eens we ee wt { rs es ~ . Gort ~ oy 4 c “— ~ ~ — vo oO | a6 - bs Bou . 6 8 : e gO O oO; © 4 oO 9 wi oa 2 © Oo be eee yee cae a ’ he wor sex Nee rican manne Ie AaRamM em emenmea wen | : ta r sD & —- +: Seto Read mak Ae ere essen ec sto C : a do oS , Cae Bon | | tee a & <0 - , o3 C ve a! . 2 Oy © . o oak “4 oe Ga nt fake a : whee yet Da i NN ms ‘ y 2 Date: Reply to Alt of: Subject: Te: Thru: . . “2 43- DEPARTMENT OF HEALTH, EDUCATION; AND WELFARE PUDLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION - December 23, 1970 Staff Review of Non-Competing Continuation Application from the Susquehanna Valley Regional Medical Program, 5 GO3 RM 00059 Acting Director Regional Medical Programs Service Chairman of -the Month ; . sot . Acting Chief, Regional Developnient Branch ©! ba #4, Ghief, Grants Management Branch ,. * °~. Acting Chief, Grants Review Branch _ The Susquehanna Valley Regional Medical Program is requesting continua- st tion support for its 03 operational year for core and three projects. Since Susquehanna Valley's budget year does not start until April 1, 1971, and the 45-day estimate of expenditures 4s not due until mid-February, ° requests for use of carryover funds have not been included in the present application. Therefore, the discussion was limited to general program issues and the following continuation request. Continuation Requested ° oo Amount Core $469 , 700 Project #9, SVRMP Information Service ~ 45,614 Project #16, Radiological Health Training Program ; = , 17,501 Project #17, Columbia-Montour Home Health Services __ 13,100 Total . © $545,915 Besides the continuation request, the Region has included in its AR application, a request for a developmental component, funding of four. approved but unfunded projects, a renewal and seven new projects. The Region was supported by a funding level of $671,997 during the 02 year. Recommendation: Approval of the committed amount of $545,915 for core and three projects. ~14-) Harold Margulies, M.D. . 8 December 23, 1970 The following staff members attended the December 17 meeting: Miss Dona Houseal, GRB Mr. Dale Robertson, RDB Mr. George Hinkle, GMB Miss Mary Asdell, CEB Mrs. Patricia Mullins, PEB Miss Loretta Brown, PEB General’ Comments: Staff was pleased with this Region's progress during the past year. While this Region is only beginning to deal with the setting of more specific goals and objectives and is just starting to collect needed data, its efforts in coping with some of the problems identified by the site visitors and reviewers last year were encouraging: -]. The evaluation reports by a physician consultant of the five termina- ting coronary care projects, which have been sorely needed, have beén included in the application. The evaluation reports included with the. termination reports appeared thorough and the criteria developed should prove valuable to the other non-RMP funded units developed around the ‘Region, 2, The SVRMP core staff including the Coordinator is completely lay. While.this type of core can function with imagination and work very capably, in the past this has not always been the case, Several kinds of capabilities were missing from the staff and this weakened the program, For example, the continuing education segment has been marked by frag- mentation and a lack of awareness of what has been done elsewhere. Some of this may be solved by getting outside consultation (to be discussed below), but Core staff is also adding needed expertise in continuing education:and allied health. A program development director, systems coordinator and a research and evaluation specialist are also being em- ployed. Problems with the Regional Advisory Group caused by poor com- munications have prompted the staff to spend more time personally advising ithe RAG members of SVRMP activities and changing the presentation of written material going before the RAG 3. As a result of site visit recommendations in February 1970, the Region has sought consultation in planning. A group including Marshall Raffel, Penn State University; Dr. Joel Nobel, Emergency Care Research Institute; as well as state health department and Bucknell University personnel was called together to advise on the structure and composition of a proposed Planning Committee, There is also evidence that the Region has sought outside expertise in various technical areas. 4, The review process is being strengthened. Formal review procedures including a set of criteria and a numerical ranking system which gives Harold Margulies, M.D. me December 23, 1970 all new projects a priority number, have been devised for the RAG. Plans are underway to develop a similar system for the Councils and Area Committees, . 5. The relationship between the RMP and the grantee agency, the Pennsyl- vania Medical Society, has improved slightly. ‘The Medical Society still considers the RMP as a branch of their organization and maintains a degree of control consistent with this concept. Discussions have been held with the RMP and grantee agency concerning the establishment of a nonprofit corporation, but at the present its establishment seems a long way off, Conclusion: Approval of the committed amount of $545,915 is recommended so for the Region's third operational year. i an > / / i Dona E. Houseal Public Health Advisor . Grants Review Branch Action by Director 2 jfP lak ao, fT Initials yo 1. / bate fay 20_ REVISED REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD APPLICATION (A Privileged Communication) RM 00059 2/71.1 (AR-1 CSD) January 1971 Review Committee SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM 3806 Market Street, P.O. Box 541 Camp Hill, Pennsylvania Program Coordinator: REQUEST (Direct Costs Only) 17011 Richard B. McKenzie 04 05 06 Purpose 4/1/71-3/30/72 4/1/72-3/30/73 4/1/73-3/30/74 Ail Years Continuation Commitment $545,915 $545,915 Core (469,700) (469,700) 3 Projects (76,215) (76,215) Renewal Components $29,425 $31,551 $60,976 1 Project (29,425) (31,551) (60,976) Additional Projects $1,503,780 $1,482,065 $1,592,377 $4,578,222 4 Previously Approved Projs. (184,044) (158,387) (98,534) (440,965) 7 New Projects(1,319,736) (1,323,678) (1,493,843) (4,137,257) Developmental Component $54,596 $54,596 $54,596 $163,788 Total $2,133,716 $1, 568,212 $1,646,973 $5, 348,901 Staff Action Commitment $545,915 Committee Action Required $1,587,801 $1,568,212 $1,646,973 $4, 802,986 #26 Deleted - 82,200 - 68,050 - 71,548 - 221,798 REVISED TOTAL 1,505,601 1,500, 162 1,575,425 4,581,188 FUNDING HISTORY Planning Stage Grant Year Period Funded (d,c.o.) 01 6/1/67 - 5/31/68 $253,539 02 6/1/68 - 3/31/69 $250,056 SUSQUEHANNA VALLEY RMP ~2- RM 00059 2/71.1 (AR-1 CSD Operational Program Oe . Future Grant Year Period "+ Council:approved” |__ Funded _d.c.o,. Commitment Ol 4/1/69~3/31/70 $698,052 $532,444 1/ 02 4/1/70-3/31/71 666,495 671,997 2/ 03 4/1/71-3/31/72 695,333 $545,915 ‘ 04 4/1/72-3/31/73 650,075 497 ,644 ‘. 05 4/1/73-3/31/74 483,294 - 1/ Represents 754% funding of projects 2/ Includes $124,390 in carryover Geography and Demography This Region consists of 38 counties in the central corridor of Pennsylvania bordering on Maryland in the south and New York in the north and separated from the Western Pennsylvania and Greater Delaware Valley RMPs by moun- tainous terrain, The total population of the Region is projected to be 2,323,751 (1970 Census). Much of this population is centered around the three urban areas, but the Region also contains large rural and forest areas with low population concentrations and underdeveloped facilities. The Milton S. Hershey Medical Center of the Pennsylvania State University was established in 1963. The first class of 40 medical students was enrolled in 1967. The Region also has 55 hospitals. It is served by 1,776 M.D.'s and 218 D.0O.'s. There are 8,909 active nurses. Regional Development In 1966 the Susquehanna Valley Committee on Heart Disease, Cancer and Stroke, presided over by the President of the Pennsylvania Medical Society (PMS), met to plan an RMP for the central Pennsylvania Region. The first planning grant, submitted by the PMS, was approved in June 1967 pending clarification of the role of the new medical school, the state health department and administrative and staffing patterns, and assurance of allied health involvement. The Executive Director of the PMS, Mr. McKenzie, was appointed Coordinator in August 1967. During the second planning year, the Region encountered a number of problems with the completely lay Core staff and the grantee agency, which considered ‘the RMP Core staff as another branch of the PMS. There was strong senti- ment among Core staff regarding the degree of control the PMS maintained over routine office matters and the relatively low salary scale, Several staff members resigned as a result. There was also some confusion about the relationship between the RAG and the PMS Board. A management consulting firm was retained to study the entire program and recommended certain staffing changes, some of which have gone into effect, SUSQUEHANNA VALLEY RMP -3- RM 00059 2/71.1 (AR-1 CSD) The Region began work on its initial operational application which would contain five coronary care unit proposals and a request to train coronary care unit nurses, A site visit was held in December 1968, The visitors recommended operational status to convince the local physicians that RMP would actually help them improve patient care, While leadership from the RAG was slow in developing, the Region had an impressive amount of physi- cian involvement at the grass roots level through the Area Committee structure, In fact, the bywords for the SVRMP in these early days became “grass roots involvement" and "coronary care." Council approved the Region's request with the understanding that the CCU projects were pilot projects for the Region with evaluation of the results before additional projects are funded and with the stipulation that 50 percent of the equip- ment funds be made available for physician training. Shortly afterwards three more proposals were submitted, approved and funded. They were a stroke care unit, a home health care project and a regional medical infor- mation service. New projects submitted during the second year, however, continued to emphasize coronary care. Reviewers found them, on the whole, to be a disparate group of projects, attacking the problems of coronary care in an isolated fashion. They disapproved the projects and recommended that the Region establish an overall plan involving greater coordination, coop- eration. and consolidation. Core and the coronary care training proposal at the Geisinger Medical Center were renewed, A site visit held in February 1970 reviewed the overall progress of the Region and four new projects. They concluded that the Region should: 1). consider broadening the base of its grantee agency to insure that all appropriate groups feel represented. A change to a nonprofit corpora- tion was seen as a possible solution; 2) utilize consultants from both inside and outside the Region to improve efforts in data gathering and epidemiology; 3) appoint a liaison member of the Hershey Medical School faculty part-time to the RMP staff to both improve relations with the new medical school and involve physicians on Core staff; 4) while continuing to encourage grass roots involvement, devote more attention to developing a regional decision-making process which selects projects on the basis of a regional plan, rather than just on a community's needs. Projects funded during this past year include: 1) an extension of the original five CCU's with carryover funds for an additional year, 2) the CCU nurse training project, 3) the second year of the SVRMP library information service, SUSQUEHANNA VALLEY RMP -4- - RM 00059 2/71.1 (AR-1 CSD) 4) project #7, the Stroke Care Unit and #8, the Home Health Service, out of carryover, and . 5) projects #16, the Radiological Health Training Program and #17, Columbia- Montour Home Health Services. Projects #18, a Rheumatic Fever Control Program, and #19, a CPR project were approved but unfunded. The Region submitted one further application during its second operational year. Only the Enterostomal Training Program and the CPR and CVA Transport Vehicle, York, were approved. Council requested additional information on the CCU Nurse Training Program at the Altoona Hospital before it could be approved (this information has been received and will be forwarded to the February 1971 Council). The remaining four projects, including an emphysema program, a stroke rehabilitation and training program, a cart- ridge viewing system pilot project and a supervisory CCU nurse training program, were turned down. The Region's present level of funding for its second operational year is $671,997. Note: A site visit was not planned for this Region; one had been held during the past year; and the Region informed RMPS only a week before the review deadline of its decision to include a request for a developmental component in its AR application. Regional Objectives The SVRMP frankly admits that its centralized program planning to date represents a disconcerted effort and that the Region does not have a specific plan which details specific objectives that result in specific applications. Interest in the past has happened to center on heart: dis- ease and coronary units. At its fall 1970 meeting, the RAC established formal goals which set the stage for development of primary goals and specific objectives. The primary goal is to "improve the quality of patient care working with and through the providers of health care as they function in the existing health care system; and by influencing the present arrangements for health services and by concentrating maximum effort on those activities which have the highest local, regional and national priorities." The primary goal is approached through specific goals in three basic areas - organization, strategy and program. Organizational Structure and Processes The SVRMP has organized a 30-member RAG, with representatives from each, of the four Areas and from various health organizations and institutions of the Region. The RAG has Executive, By-Laws and Nominating Committees and SUSQUEHANNA VALLEY RMP -~5- RM 00059 2/71.1 (AR- CSD) is in the process of selecting Planning and Evaluation Committees. The RMP has divided the Region into four Areas, each of which is served by a Committee ranging from 60 to 135 members. Each Committee has appointed subcommittees to serve as study groups and an Executive Committee. To provide review and planning at the regional level in specific functions, Councils (formerly Task Forces) have been established in the categorical areas, as well as in Facilities and Services and Continuing Education. Each Council also sets goals and objectives in its respective interest. The review procedure consists of the following steps: 1. Consideration by the volunteer Area Committees through their Executive Committee and specialized subcommittees. 2. Consideration by the members of categorical councils who supply spec- jalized professional technical review on a regional scale. 3. Consideration of the relevance of the proposal to regional goals and objectives by the RAG. At each step, staff members provide administrative assistance. Formal review procedures, including a set of criteria and a numerical ranking~ system, which assigns all new projects a priority number, have been devised for the RAG. Plans are underway to develop a similar system for the Councils and Area Committees. PRESENT APPLICATION: Developmental Component $54,596 Activities initiated through developmental component funding "will seek to improve the quality of patient care by working with and through the providers of health care as they function in the existing health care sys- tem, by influencing the present arrangements for health care services, and by concentrating maximum effort on these activities which have the highest local, regional and national priorities." An example might be an explora-~ tion of appropriate methods and means for developing improved patient care techniques and systems in kidney disease prevention and control. The review mechanism described under organizational structure and processes above will apply to the developmental component as well. $54,596 $54,596 Continuation Component These components have been reviewed by staff. Their program and funding recommendations are in a supplementary memo. 7 SUSQUEHANNA VALLEY RMP -6-7 RM 00059 2/71.1 (AR-1 CSD) Core. $469,700 The SVRMP Core staff is completely lay. Its Coordinator was the former Executive Director of the Pennsylvania Medical Society, which serves as the grantee agency. An organizational chart for Core staff is attached to the summary. The functions can be briefly defined as follows: 1. Technical Services - plans, establishes and directs the technical ser- vices for: applications development, grants management, research and evaluation services, development and operation of library activities and general office management. 2, Communications - directs the production of communications material and provides liaison with the news media. 3. Program Development - provides staff services to committees, councils and planning groups, coordinates educational activities and programs, assists with the establishment of regional goals, objectives and priorities, and provides personnel recruitment services for staffing. In addition, Field Services are included in this branch. A field representative is assigned to each of the four Areas to provide regional coordination and staff services to all volunteer committees and groups in the Region. With the assistance of the field representatives, various Area Committees or subcommittees have developed standards for coronary care, sponsored a cancer detection clinic survey and conducted a cancer incidence and mor- tality survey. The SVRMP Core budget last year included funds for “program related acti- vities." These are funds in the magnitude of $50,000, which the Region used for various purposes, such as to conduct pilot studies of various proposed project activities, hold conferences, and supply educational mater-~ ials to health professionals. Types of activities for which these funds will be used next year include a conference for regional directors of coronary care units, an audio-tape cassette scientific program service, data collection and a consultation program for tumor clinics and tumor registries. The budget for 1971-72 includes funds for 25 full-time positions, 22 of which have been filled. The new positions would be a Systems Coordinator, Nursing Specialist and receptionist. Continuation support in the amount of $76,215 is also requested for three projects: #9 -— SVRMP Information Service #16 - Radiological Health Training Program #17 - Columbia-Montour Home Health Services Renewal Projects 3rd Year Project #6R -_Coronary Care Nurses! Training Program, Geisinger $29,425 Medical Center, The Geisinger Medical Center will conduct SUSQUEHANNA VALLEY RMP - 7-7 RM 00059 2/71.1 (AR-1 CSD) four, four-week coronary care courses per year. Each class will admit ten trainees, who are principally recent diploma graduate nurses. The curriculum includes lectures, laboratory work, and clinical experience in special nursing techniques for the cardiac patient. Community hospitals throughout the Susquehanna Valley Region, as well as border areas, may use this training program to staff their coronary care units with qualified nurses. This project was submitted with the Region's initial operational applica- tion and applied for and received one-year renewal support last year. Since its inception, it has trained 42 nurses. Fourth Year $31,551 Approved but Unfunded Projects These projects have been previously approved by Council, but due to nation- al funding constraints, have not been funded. Committee and Council con- siderations of these projects is needed in determining an overall funding level for the Region for the next year and not for approval of the activities. lst Year Project #18 - Rheumatic Fever Control Program. This project $75,217 will impress upon physicians and the public the necessity for throat cultures in diagnosing streptococcal infections. Hospitals and physicians in 16 of the Region's 27 counties will receive free throat | culture kits. The kits will be used on people between the ages of two and forty-five who have upper respiratory infection or a sore throat. The participating hospitals will interpret the cultures and send reports to the attending physicians. The physicians will follow-up with appropri- ate treatment. Although this project involves the demonstration of patient care, the aspects of continuing education are also present. In addition, the promotional efforts of the Heart Association, who will participate in the program, will increase the public's awareness of the value of the procedure. Second Year $64,417 ; lst Year Project #19 - Cardiopulmonary Resuscitation Training. $16,693 Sponsored by the Heart Association, the purpose of this project is to establish an emergency cardiopulmonary resuscitation team in every hospital in the Susquehanna Valley Region. DELETED PER REQUEST FROM REGION, SEE LETTER OF JANUARY SUSQUEHANNA VALLEY RMP - 8- RM 00059 2/71.1 (AR-1 CSD) First, the Instructor's Training Center at the Harrisburg Hospital will be expanded to include a special training course in emergency cardio- pulmonary resuscitation. Each year, teams from 18 hospitals will complete this course. Then, using the organizational framework of the Pennsvivania Heart Association and its chapters, these newly trained teams will train other hospital teams. The wide geographical distribution of emergency teams will be ideal for training local ambulance crews, rescue squads, and other health personnel . throughout the Region. Second Year Third Year $15,481 $16,066 ist Year Project #21 - Enterostomal Therapy Training. The Harrisburg $9,934 Hospital will conduct twelve, four-week courses in enterostomal therapy per year. One student will be trained in each course. Training will include bedside instruction and practice, medical lectures, technical lectures, and conferences. The graduate therapists will be able to provide patients with stomal care and management, therebyfreeing nurses and physicians for other work. In addition, the therapists will instruct patients in self-care and teach allied health personnel the principles of stomal management, Second Year Third Year $10,439 $10,920 ist Year Project #26 - Cardiopulmonary and CVA Transport Vehicle, $82,200 . York Hospital. This pilot project will determine the effect of a specially equipped and staffed transport vehicle in reducing the compli- cations and deaths associated with heart attack and stroke. The custom-designed van which will contain a resuscitation unit, a respir- ator, a two-way radio, drug storage facilities, and other emergency equip- ment, will be on call 24 hours a day, staffed by a physician or coronary care nurse, orderly, and driver. Second Year Third Year $68,050 $71,548 4, 1971, ATTACHED, New Projects lst Year Project #27 - Nurse Dial Access, Robert Packer Hospital, $29,969 Sayre, Pennsylvania. Dial Access for Nurses will cover Central New York State and the entire state of Pennsylvania. It is a special telephone information system for RN's, LPN's, student nurses, and others -- particularly those practicing in an isolated setting -- who do not have the NP Available on an around- resources available for their continuing education. SUSQUEHANNA VALLEY RMP -9- RM 00059 2/71.1 (AR~1 CSD) the-clock basis from any telephone, it provides the caller with free, five-to-six minute taped messages on a variety of subjects, such as (1) nursing care for specific conditions, (2) new procedures and equipment, (3) availability of community resources, (4) nursing care in emergency situations, and (5) legal aspects of nursing situations. The Central New York RMP is presently funding a Physician Dial Access pro- gram out of the Sayre Hospital. SVRMP Core funds are being used to extend coverage of the physician program to their Region, Second Year Third Year $29,453 $30,224 ist Year Project #28 - Automated Computer-Assisted Analysis of the $294,470 EEG, Pennsylvania State University. Four participating hospitals, located in three areas of the Region, will send computerized EEG signals to Penn State's Hybrid Computer Laboratory. The information will be interpreted by computer at Penn State and the diagnosis returned to the sending hospitals. Each computer diagnosis will be compared to the phy- sician's final diagnosis, The purpose of this project is to install and further develop this computerized EEG system, and at the same time, deter- mine the feasibility of providing all hospitals throughout the Region with rapid and valid electroencephalogram interpretation service. Since January 1968, the Geisinger Medical Center and the Pennsylvania State University have been conducting research on automatic computer analy- - sis of EEGs. Second Year $82,062 lst Year Project #29 - Computerized EKG Pilot Program. This project $300,186 would establish a computerized EKG transmission and analysis system which would link 13 hospitals in a 27-county area to a computer center at Harrisburg Hospital. EKG's would be transmitted to the center, processed and the interpretation transmitted to the originating hospital. A formal training program, conducted by a cardiologist from the Hershey Medical Center is planned for physicians and technicians involved in the project. The project resulted from a pilot program at the Harrisburg Hospital. Second Year Third Year $300,186 $300,186 lst Year Project #30 - Coordinated Home Care Program of Lancaster $106,128 County. . The Coordinated Home Care Agency of Lancaster County will arrange quality medical, nursing, social, and related services for patients in their homes. The central administrative Coordinated Home Care Agency will: SUSQUEHANNA VALLEY RMP, - 10 - RM 00059 2/71.1 (AR-1 CSD) 1, Coordinate community resources in the delivery of optimum home heaith care services. 2, Act as the one source of referral for the physicians. 3, Serve as a center for comprehensive planning, evaluation, and followup of home care services. 4, Act as an information service for physicians, patients, participating agencies, and the public. 5. Hold periodic joint conferences with physicians, other professional or allied persons, and consumers of service to determine how effectively the program is functioning. Second Year Third Year $106, 367 $115,400 : lst Year Project #31 - Family and Community Health Service Program, $145,630 Lancaster General Hospital. The main objective of the Family Health Service Program is to deliver comprehensive family-oriented, pri- mary health care as part of a community hospital. The new system also seeks to create a structure which casts a physician as a health advocate for his patient. Home health aides will be used to provide health educa- tion and develop communication with the clients. Residents of the low income areas will serve on 4 board to review and.analyze the effectiveness of the delivery system, which includes Family Practice Residents and Nurse Practitioners. Second Year Third Year $145,724 $159,086 lst Year Project #32 - Central Pennsylvania Cancer Education and $296,178 Treatment Center, Altoona Hospital. This project will provide physical facilities, equipment, and personnel to conduct a cancer education and treatment center. It will utilize cobalt therapy, deep therapy, and isotopes for diagnosis and therapy and provide a firm basis for continuing education for physicians in cancer detection and treatment. It will also provide a super-voltage facility in an area geographically and economically separated from the nearest similar facility by more than 50 miles, as well as allow for continuity of treatment, detection of recurrences, and new primary tumors, while maintaining identity with the patient's personal physician, The Region's Ad Hoc Committee on Radiation Therapy, which is studying the Region's radiation therapy resources, has reviewed the project and endorses the need for a facility in Altoona. Second Year Third Year $202,075 $210,050 SUSQUEHANNA VALLEY RMP -li- RM 00059 2/71.1 (AR-1 CSD) Ist Year Project #33 - Hamilton Health Center. The Hamilton Health $147,175 Center, Inc., a nonprofit organization directed by a group of consumers and representatives of providers of health care, request support to establish a comprehensive health care system in a disadvantaged area of Harrisburg. The neighborhood health center will be served by a family health team, which includes community health aides recruited from the neighborhood. Second Year Third Year $457,811 $678,897 GRB/RMPS 12/28/70 3 lt | | DIRECTOR: i i . p ‘ i . LL Asst Director fo . Asst Director | for . for Technical Serv Program Devel : ~ fl r-- Le + i | Grants 1 Educational Field. Management - poy stems I Comnunic Activities Service Coordinator] . Coordinator | Coordinator Coordinator ; Coordinator: , re fae em om ee ae + J : { eo ! tie } —- a | 7 Resear aan | | | esearch ! pie eect er & Eval Admin _ | Communic }- Nursing ! Field ° [Field Field eciaiist { |Specialist Specialist ‘ Specialist ppecialist Represen | {Represen | || Represen , taff Asst ; * Libr Serv . . N ‘ . wot +. ' ~ . - . Secretary Secretary } {Secretary ° - | Secretary . Secretary Machine - . STAFF ORGANIZATION Operator Recept . . . . “, bo. , SusQuEHANNA Valley RecronaL Meprcan PROGRAM Dete: Reply fo Alin of: Subject: To: J Thru: -13- DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH GEESE PIAL TH SOR VICES AMD Mini AL HEAL PTH AQDIAL HO LRATION December 23, 1970 Staff Review of Non-Competing Continuation Application from the Susquehanna Valley Regional Medical Program, 5 G03 RM 00059 Acting Director Regional Medical Programs Service Chairman of the Month Acting Chief, Regional Development srauch po ae fy ‘ of Ghief, Grants Management sranch Acting Chief, Grants Review Branch The Susquehanna Valley Regional Medical Program is requesting continua— tion support for its 03 operational year for core and three projects. Since Susquehanna Valley's budget year docs not start until April 1, 1971, and the 45-day estimate of expenditures is not due until mid-February, ~ requests for use of carryover funds have not been included in the present application, Therefore, the discussion was limited to general program issues and the following continuation request. Continuation Requested Amount Cores $469,700 Project #9, SVRMP Information Service 45,614 Project #16, Radiological Health Training Program 17,50) Project #17, Columbia~Montour Home Health Services 13,100 Total . $545,915 Besides the continuation request, the Region has included in its AR application, a request for a developmental component, funding of four approved but unfunded projects, a renewal and seven new projects. The Region was supported by a funding level of $671,997 during the 02 year. Recowmendation: Approval of the committed amount of $545,915 for core and three projects. -14- Harold Margulies, M.D. - . December 23, 1970 . The following staff members attended the December 17 meeting: Miss Dona Houseal, GRE Mr. Dale Robertson, RDB Mr. George Hinkle, GMb Miss Mary Asdell, CEB " Mrs. Patricia Mullins, PEb . Miss Loretta Brown, PER General Comuents Staff was pleased with this Region's progress during the past year. While this Region is only beginning to deal with the setting of more specific goals and objectives and is just starting to collect needed data, its efforts in coping with some of the problems identified by the site visitors and reviewers last year were encouraging: 1, The evaluation reports by a physician consultant of the five termina- ting coronary care projects, which have been sorely needed, have been included in the application, The evaluation reports included with the termination reports appeared thorough and the criteria developed should prove valuable to the other non-RMP funded units developed around the -Region. 2. The SVRMP core staff including the Coordinator is completely lay. While this type of core can function with imagination and work very capably, in the past this has not always been the case, Several kinds of capabilities were missing from the staf£ and this weakened the program. For example, the continuing education segment has been marked by frag- mentation and a lack of awareness of what has been done elsewhere. Some of this may be solved by getting outside consultation (to be discussed below), but Core staff is also adding needed expertise in continuing education and allied health. A program devclopment director, systems coordinator and a research and evaluation specialist are also being em- ployed. Problems with the Regional Advisory Group caused by poor con- munications have prompted the staff to spend more time personally advising the RAG members of SVRMP activities and changing the presentaLion of written pies ea) going before the RAG, 4 3. As a result of site visit recommendations in February 1970, the Region has sought consultation in planning. A group including Marshall Raffel, Penn State University; Dr. Joel Nobel, Emergency Care Research Institute; as well as state health department and Bucknell University personnel was called together to advise on the structure and composition of a proposed Planning. Committee. There is also evidence that the Region has sought outside expertise in various technical areas. 4. The review process is being strengthened. Formal review procedures including a set of criteria and a numerical ranking system which gives -15- Harold Margulies, M.D. - - December 23, 1970 ‘gall new projects a priority number, have been devised for the RAG. ‘ Plans are underway to develop a similar system for the Councils and ; Area Committees. . 5, The relationship between the RMP and the grantee agency, the Pennsyl- vania Medical Society, has improved slightly. ‘The Medical Society . still considers the RMP as a branch of their organization and maintains “a degree of control consistent with this concept. Discussions have bcen held with the RMP and grantee agency concerning the establishment of a nonprofit corporation, but at the present its establishment seems a long way off, Conclusion: Approval of the committed amount of $545,915 is recommended : for the Region's third operational year. 1 . f} a Ce f ‘ Dona E, Houseal Public Health Advisor Grants Review Branch . Action by Director “Vivir i} U Initials } EAN “ / / me pave___P/24f D0 -16- January 4, 1971 hy. Dale Robertson Programs Assistance Branch Regional Medical Programs Service Health Services and Mental Health Administration Parklawn Building, Room 15 5600 Fishers Lane Rockville, Maryland 20852 Dear Dale: This is to officially inform you that we are withdrawing Project No. 26, Cardio-Pulmonary and CVA Transport Vehicle. The reasons for this withdrawal is explained in the letter from the applicant, Robert L. Evans, 4.D., which is enclosed with this letter. We are pleased with the honest evaluation offered vy this institution and, therefore, must concur with the request. Although Project Ne. 26 has already been approved by the ational Advisory Council, it should no longer be considered a part of ovr request for funding in our Annual Application submitted November 1, 1970. Sincerely yours, Richard PB. MeKenzle Director RBM: Jz Enclosure fo ec: Miss Dona Houseal ¥ Mr. George Hinkle Mr. Clyde Couchman DEPARTMIENY OF MEDICAL EDUCATION . -1?- M.D.--DIRECTOR eOlRP L.. EVANS, LP. ANDREWS. M.D.-ASSOCIATE DIRECTOR POLES BM RELLY, M.D.--PEOIATRICS DAVID M. SHEARER, M.D.-INTERNAL MEDICINE - THOMAS BM. HART, M,O.—FAMILY PRACTICE DAVID J. JONES, M.D.—COMMUNITY MEDICINE December 24, 1970 * Mr. Richard B. McKenzie Director, Susquehanna Valley Regional Medical Program 1104 Fernwood Avenue : Camp Hill, Pennsylvania 17011 Dear Mr. McKenzie: Py DEC 29 is; 1 | wont cone yo tr Yue REAR ee PP Ak In reviewing our application for. "A Cardio- -Pulmonary and CVA Treatment Vehicle", it is our understanding that this applica- tion has been approved, and is awaiting funding through the appropriations bill recently passed by Congress. The original application for this project was made over two and one half years ago, when it was designed as a feasibility study directed at special services to patients suffering from coronary and cerebro-vascular problems. In the intervening ‘time, it has been shown repeatedly, both in the United States, .and abroad, that this service has guestionable justification. it is probably neither financially or professionally efficient, as first thought, nor a good use of over $200,000.00. Although we realize that this project has been approved for funding, and will be funded, we should like to withdraw our application. We simply do not feel that the project is, at this time, a justifiable use cf tax dollars with reasonable chance of productivity for our people. We hope you will understand and agree with our decision, and that we may work together in the future, on a more i 2 productive application. With warm best wishes for the Holiday season, ~. wa yours ZS Clem e Lee L. Evans, M. D. Vice President - Medical Affairs RLE:njh oc Ellsworth Rrowneller. M. D.. 2 Secretary of Health $31,551. (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM RM 59 (AR-1-CSD) 2/71 FOR CONSIDERATION BY FEBRUARY 197] ADVISORY COUNCIL POMMENDATT TON: Committee deferred their recommendatior on all but the renewal Project #6R (which was approved as requested) to Council with the suggestion that a site visit be scheduled to the Region, before the Council meeting, (Subsequently, the Director, RMPS determined that a site visit would not be scheduled at this time). The Region has requested new funding in the amount of $4,581,188 for renewal of one project, four previously approved but unfunded projects, seven new projects and a developmental component for a three-year period, The amount recommended for project #6R is: O1 - $29,425 and 02 - CRITIQUE: The Susquehanna Valley RMP's application was.difficult to evaluate because the Region is undergoing several major changes and the Committee had no member with on-site knowledge of the Region. ° (The member who had chaired last year's site visit has since left the Committee). Several problems were identified by the site visitors last year, and the Region is. taking steps to alleviate them. The Core staff, including the Coordinator, is completely lay and without combined significant experience in the health planning area. Although lay staff can function with imagination and work very capably, the Susquehanna Valley EP Sia needs additional capabilities in orcer to operate in this manner, The low salary scale which has been set by the grantee agency, the Pennsylvania Medical Society, has been partially responsible for the difficulties in getting highly qualified personnel, Several kinds of capabilities, particularly in continuing education, allied health, and evaluation, were lacking and this weakened the program, During the past year the Region has hired a continuing education director, a program development director, a systems coordinator and a research and evaluation specialist. The Region has scught consultation expertise in planning and evaluation, as well as in various technical areas. A group of planning experts from Pennsylvania State University, Bucknell University, and the State Health Department, among others, has been called together to advise on the structure and composition of a proposed Planning Committee, A physician has been retained as a consultant to coordinate evaluation of the coronary care units in the Region, including many which were not funded by the SVRMP, Progress has been made in the continuing education segment of the program, The newly appointed Continuing Education Coordinator on Core staff has worked with the Continuing Educetion Council, which has restructured its membership to include wider representation from non-medical professions, SUSQUEHANNA VALLEY RMP ~2~ . to look at the quality and accessibility of health care on a regional basis. The staff has also sought consultation in allied health from a neighboring Region and taken steps to strengthen the continuing education component of ongoing and new projects, The heavy emphasis on coronary care during the first two years of the program has been ameliorated, The present application includes requests for comprehensive health care centers, home health care coordination, nurses dial access program and a computerized EEG proposal, The only ongoing coro- nary care proposal would be the Geigsenger Medical Center CCU Nurse Training Program, the sole such resource in the Region, The proposer of an already approved project (#26), the York Hospital, has withdrawn its request for a CVA Transport Vehicle beceuse they believe it is no longer a wise use of Federal. funds, The Regional Advisory Group has formalized their review criteria and ‘ developed a numerical rating system which assigns a numerical priority to each project, Plans are under consideration for the adoption of a similer system for the Councils and Area Committees. Committee noted that only slight improvement had been made in the relationships with the Hershey Medical School and the grantee agency, thé Pennsylvania Medical Society. Since there seems to have been much change and redirection of the program, reviewers had difficulty in assessing a reasonable funding recommen~ dation. Individual projects were not reviewed, Several options were considered by Committee before deciding on their recommendation: -1) that the Region be funded at the present level with a consultation visit before next year's submission, 2) that the Region be advised to review and strengthen the staff capability, particularly in the program planning and evaluation area and that a site visit be scheduled later to review the Region's progress and determine whether further funding should be added to the program, 3) that the Region be given approximately $200,000, an amount comparable to the Region's request for previously approved but unfunded projects, for the next year, but that no funds for new projects be approved until a site visit is made to review the status of the program, 4) that the Region be site visited before any funds be approved for the Region, with the exception of the ongoing renewal project #6R, This last option was decided upon, partly in order to give the Region any additional funds at the beginning of, rather than later in the year, In light of the present funding stringencies, the need for such urgency does not apply. RMPS/GRB 1/19/71 ~ SUSQUEHANNA VALLEY . - RM 00059. 2/71 ae STAFF OBSERVATION © “PROJECT #25, ALTOONA HOSPITAL TRAINING PROGRAM FOR CORORNARY CARE NURSES The SVRMP first submitted this project, the Altoona Hospital Training Program for Coronary Care Nurses, for review in late 1969. ‘When it was returned (because Council could not ascertain this project's . part in the Region's overall plan for coronary caré units), the Region revised the proposal and resubmitted it for the June-July 1970 review cycle. Review Committee had additional technical concerns and recommended disapproval, The technical concerns were: 1) the objectives are not stated in terms of education of the learner; 2) other than a general ; referenoe to follow-up, the proposal 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. Council, however, recognized the need for and importance of the project in the Region since this project would be the only ccu ‘nurses training center in Western Pennsylvania, and indicated that if the project director submitted additional material speaking to Committee's concerns for their review, they would reconsider it. The Region has. forwarded the additional information for Council review and wishes the project to be considered in recommending a funding level for this application, 1/12/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) TEXAS REGIONAL MEDICAL PROGRAM RM 00007 (S) 2/71.1 P. 0. Box "Q" January 1971 Review Committee University Station 2608 Whitis Street Austin, Texas 78712 Program Coordinator: Charles B. McCall, M.D. REQUEST (Direct Costs) REGIONS OPERATIONAL YEAR 03 04 05 Total Four Supplemental Projects 212,736 219,499 177,568 609,803 FUNDING HISTORY (Direct Cost Cnly) . Planning Stage ~ Grant Year Period Funded (d.c.o.) Ol 7/66 - 6/67 969,541 02 7/67 - 6/68 1,039,295 Operational Stage Council Future Grant Year Period Approved Funded (d.c.o.) Commitment 01 7/68 - 9/69 1,700,000 1,615,000 -- 02 10/69 - 9/70 2,580,043 2,220,891 1/ -- 03 10/70 - 8/71 2/ 2,097,076 1,866,044 3/ -- 04 9/71 ~ 8/72 1,547,870 1,029,105 05 9/72 - 8/73 240,386 “ 214,050 1/ Included $444,178 carryover 2/ Change in budget period at request of RMPS to facilitate transfer to anniversary review. Award is for 11 months. 3/ Included $549,344 carryover a ? Texas Regional Medical Program -2- RM 00007 (S) 2/71.1 History: Texas received an 01 planning award ($969,541) on July 1, 1966 and its 02 award ($1,039,295) 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 thé 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 arrangements or even unilateral peripheral involvement." The site team also observed that the Regional Advisory Group, through 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 feel $1,615,000 (d.c.6.), these funds to be divided evenly between operational on and planning activities. This combined package included fourteen 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 requirements 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. On that basis, an 02 year operational award was made, but since the Division considered the Region still in probationary status as far as managerial direction was concerned, support for the 12 new approved projects was not included in the calculation of supplemental funds or of the commitment for the next (03) year. Instead, the Region was awarded and committed funds at the 01 year level. Consequently, ten of the new projects were funded from carryover to keep the Region from stagnating. When the Region applied for 03 year continuation, the financial bind in which it found itself was apparent. From an 02 year operating budget of $2,220,891, TRMP dropped to an 03 level of around $1,400,000. This substantial decrease resulted from a combination of the Core commitment's Texas Regional Medical Program -3- RM 00007 (S) 2/71.1 reduction because of the phasing out of planning bases and the Region's use of carryover to initiate a number of activities during the 02 year. In reviewing the application, staff emphasized that this fiscei digarray was not the fault of TRMP; rather it was the fault of circumstances and past Division policies. Staff review further emphasized that Dr. McCall's plan appeared to be working. The planning bases were phased out by — January 1970 (except for development of a subregional office in Houston) and for the first time the Region has a multidisciplinary core staff in Austin. Functional differentiations between the RAG and the core staff have been made. The RAG has adopted a set of by-laws and seems to view itself in a new light as being involved in program development. The five task forces, with their primary review responsibilities, have been made agents of the RAG rather than of the Coordinator. Financial management procedures have been altered with help from RMPS. Planning and evaluation functions have been consolidated in the Coordinator's office. There are obvious close relationships between TRMP and the Texas Hospital Association and a formal working arrangement with CHP. ‘Subregionalization is being pursued actively. There is the subregional office in Houston, and there are plans for establishing four additional subregional offices during the year and creating in Austin a Division of Community Health Organization. Because of the progress the Region had made during the past year, and because of the promise it showed for the future, the 03 year award was for $1,866,044. This figure included $549,344 in carryover funding to permit the Region to retain the momentum it’ had built up. The funding history at the end of this summary lists the projects currently supported. Regional Goals In the RAG report submitted with the August 1970 continuation application, the following regional goals and program objectives were outlined: 1. To assist in the advancement of the practice, knowledge, teaching, and education of medicine and allied health sciences. 2. To promote demonstrations and research in the delivery of health care services. 3. To promote and encourage cooperative arrangements among all segments of the health care community--both provider and consumer, official and voluntary. 4. Through planning and evaluation, to analyze existing health care programs, and through cooperative and collaborative efforts promote the effective, efficient and economic utilization of health care services. 5. To promote innovative approaches to the delivery of health care services on a regional basis. Texas Regional Medical Program -4- RM 00007 (S) 2/71.1 Present Application The present application contains requests for supplemental funding for four projects. The projects are presented below in the priority order in which the Region has ranked them. Two of the projects (#s 51 & 52) with slight modification, have been supported in the past by RMP, and two (#s 50 & 53) have been supported in the past by other agencies. Project #50 - Control of Hypertension and Chronic Renal Disease Requested The first three years of this activity were First Year supported by the Chronic Disease Program of the U.S. Public $140,000 Health Service, and the current year by the Moody Foundation of Galveston, Texas. Its stated purpose is the improvement of delivery of health services by developing the means for providing ready access to early diagnosis of high blood pressure and chronic kidney disease for the majority of the population. This is to be accomplished through a serial annual investigation of a cohort of 10,000 school children in Galveston county and assistance to the county schools to extend similar health care to all school children. Although the immediate effects of this project will be limited to health care consumers in the county, the information and experience gained can have applicability throughout the Region. Even through the project is envisioned as requiring a total period of twelve years (it is now in its fourth), RMP support is requested for only three years, during which time the investigations of the delivery system will be completed. After that, since the longitudinal studies to be carried out are research oriented, support will be requested of other sources. Among the four proposals in the present application, this activity has received the highest priority from the Texas RMP because of: the involve- ment of the Medical School, the County Medical Society, and the community; the preventive medicine orientation of the project; and its Regional program potential. Second Year - $144,659 Third Year - $149,551 Project #51 - Helping Hospitals Organize and Strengthen First Year Inhalation Therapy Patient Care Programs. This project $26,900 is the same, except for geographic coverage, as Project #4 of the same title which was operational between July 1968 and September 1970. When 03 year continuation was requested in August of this year, continuation of this activity was not included. During its previous operating phase the project was under the aegis of the Methodist Hospital, but when support resumes the Texas Hospital Association will assume responsibility. The objective of this project is to assist hospitals throughout the state in organizing and strengthening their inhalation therapy patient care Texas Regional Medical Program -5- RM 00007 (S) 2/71.1 programs. This will be accomplished by: (1) Four two-day institutes to acquaint administrators, nursing directors, potential inhalation therapy employees and others with the principles, organization and clinical application of an organized inhalation therapy program. (2) Four two-week periods of clinical experience for employees selected by their hospitals ao that the employees may return to help their in- stitutions organize and strengthen inhalation therapy patient care program. (3) Follow-up training education. The previous two years of experience was confined to approximately half ef the state, and the application states that as a direct result of project activities 20 hospitals have established inhalation therapy departments, 19 have strengthened their programs, and 11 are actively developing plans and soon will have organized units in operation. The two-day institutes were attended by 641 people from 103 hospitals, and 98 employees from 50 hospitals completed the clinical experience. The present application seeks to extend these activities to the other half of the state. Second Year - $26,500 Project #52 - Education Media Instructional Program for Requested Allied Health Educators This project is in much the First Year same situation as the one above, in that $20,860 it had one previous year of support by RMP as Project #43, and it, too, is being transferred from the Methodist Hospital to the Texas Hospital Association. It is designed to assist allied health educators to improve instruction through the use of educational media by: (1) Six one-day educational media institutes at selected sites throughout the state for personnel involved in allied health education programs in hospitals and other health care facilities as well as junior and senior colleges. (2) Six five-day in-depth workshops for allied health educators who will then be equipped to improve their instruction through better utilization of audiovisual media and the selection, design, and production of such media. (3) Supplemental foliow-up education and training. An Svaluation method is described. During the year in which this program previously operated, three institutes were presented for a total of 108 participants from 43 institutions. Evaluation questionnaires indicated to the Region that the three institutes were successful. Second Year - $22,250 Texas Regional Medical Program -6- RM 00007 (S) 2/71.1 Project #53 - Choricardiaoma and Related Trophoblastic Diseases The Trophoblastic Disease Center was established Requested in October 1967 under USPHS grant support which now has First Year terminated prematurely. Funding is being requested of $24,976 RMP so the Center may continue to provide HCGG determinations for all physicians who iheed the service, to compile and evaluate patient data, and to stimulate interest and provide consultation to all physicians who want it. The Center has progressed from an average of 30 sample assays per month during its first year of operation to the current level of 90 samples monthly. To date, 438 patients have been assayed, of whom 246 were diagnosed and reported as having some kind of trophoblastic disease. Although this proposal received the lowest priority ranking by the Region of the four projects in the present application, RMPT sees its function here as that of sustaining a needed service through its period of transition to self support. Second Year - $26,090 Third Year - $28,017 @ Texas Regional Medical Program -7- History Supplement RM 00007 (S) 2/71.1 Project # 10 11 12 13 14 15 16 17 18 oe Title Current Support Initiation (d.c.6.) Date Medical Genetics (MDA) 14,000 7/68 Child Welfare Workérs Training (MDA) Approved /Unfunded East Texas Teaching Chain (Grad. Div.) Inhalation Therapy Patient Care Prog. (Methodist) Regional Consulation in Radiotherapy (MDA) Consultation Service in Medical Physics (MDA) Cancer Survey (MDA) Statewide Cancer Registry (Houston) Educational Television (Grad. Div.) Microwave System Development (MDA) Consultation Services - Radiotherapy via Television (MDA) Dissemination of Cancer Literature (MDA) Communication Study (MDA) Stroke Demonstration (Dallas) Area-Wide Total Respiratory Care (12 counties) Rehabilitation Program A (Baylor) Rehabilitation Program B (San Antonio) Rehabilitation Program C (Dallas) Cardiac Work Evaluation (Baylor) RMP Support Terminated RMP: Support Terminated 30,000 7/68 45,000 7/68 RMP Support Terminated 105,300 7/68 Disapproved Disapproved Disapproved Disapproved Disapproved 151,000 7/68 80,000 7/68 72,068 7/68 48,000 7/68 47,000 7/68 RMP Support Terminated Texas Regional Medical Program aBa RM 00007 (S) 2/71.1 History Supplement - continued “roject # Title Current Support Initiation (d.c.o.) Date 20 Eradication of Cervical Cancer (San Antonio) 90,000 7/68 21 Core - 696,222 7/68 22-30 Planning Bases - Phased Out 31 Long Distance Telephone Consultation (Dallas) 20,000 10/69 32 Cardiovascular Nursing Institutes (Texas Women's J.) Unfunded 33 Coronary Care Nurse Training in Community Hospitals (St. Joseph's and Riverside Hospitals) 64,915 10/69 34 Regional Coronary Care & Training By Computer (Galveston) Disapproved 35 Reduce Complications Following Radio- fherapy (Dental Branch - Houston) 40,986 10/69 36 Inter-Regional Cooperetive Serial Control Systems in South Central Library Region (Statewide) 28,610 10/69 37 Health Careers Personnel Program (Statewide) 66,862 10/69 38 Dial Access (MDA) 19,963 10/69 39 Annual Clinical Conference (MDA) 13,520 10/69 40 CE in CVD, Coronary Care and Intensive Care (Galveston) Unfunded 41 Social Workers! Training in Neoplasia (MDA) Approved/Unfunded 42 CE for Occupational Therapists (Dallas) 24,311 10/69 43 Educational Media Instructional Program for Allied Health Educators (Baylor & Methodist) RMP Support Terminated bh Health Occupations Improvement (Multiple locations) Deferred (A Privileged Commmication) SPECIAL ACTION TEXAS REGIONAL MEDICAL PROGRAM RM 00007 January 1971 Review Committee y The June/July 1970 Review Committee and Couneil reviewed a request for a three-year renewal of Project #14R - Stroke Demonstration Program for Progressive Patient Care, which previously had received funds as a one~year earmarked supplement to the planning grant. Subsequent to the original award the project period was extended without additional funds to provide time for the completion of the construction of the stroke unit. In reviewing this request, the Committee and Council agreed that . most of the staff for this project is now on hand and seems to be well qualified and that the project should be continued. However, ‘the application itself was deficient in that it contained no indication of the numbers of physicians and nurses to be trained during the three years or the amount of time to be devoted to education and consultation activities for community hospitals. Further, the proposal did not contain a discussion of the intents during the second and third years of the grant renewal request. There was also needed a more full discussion of grant-and~hospital-generated income, Consequently, the recommendation was for approval in the time and amount requested, on the condition that information be provided to contain answers to the above questions as well as an assurance that at the completion of three years, no additional grant support for the project will be requested from RMPS. The Committee and Council also restricted the expenditure of funds over the current level of expenditures until the requested information had received approval. The amounts recommended (and awarded subject to approval of this material) were: Ol Year: $196,244 02 Year: $164,344 03 Year: $142,844 GRB/RMPS 12/29/70 (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE TEXAS REGIONAL MEDICAL PROGRAM RM 00007 (8) 2/71.1 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL “Recommendation: Additional funds be provided for this application. Year _ ‘Request. _. , Committee Recommendation .. 03 $212,736 $26,900 04 219,499 $26,500 05 177,568 _- Total $609 , 803 $53,400 Critique: The Review Committee thought the Texas Regional Medical Program had come a long way in the last year and a half, as is discussed in the yellow summary sheet. The Regional goals © . appear reasonable - the mission is broad - and priority setting among regional components is good. The reviewers admitted, however, that in order to get a complete picture of the overall TRMP activity we will have to wait for this Region's first anniversary review . application, which will be seen during the July/August 1971 review cycle. There was consensus, though, that RMPS is getting its money's worth in Texas. It was noted that two of the four projects in this supplemental application previously have been funded by other agencies but support has terminated and financing is being sought of RMP. The Review Committee thought the TRMP should be discouraged from sending in proposals of this nature unless their relation to regional goals and importance to the Region is clearly delineated. © Project #50 - Control of Hypertension and Chronic Renal Disease This project proposal provéked considerable discussion among the reviewers. It was agreed that in’the four years it has been in operation, this study has done an excellent job of developing cooperative relationships between the school system and the county medical society. It was also realized that this. project has suffered through PHS reorganizations and in looking .for other sources of funding has encountered the problem of research institutions saying the activity is service-oriented and service agencies claiming it is research-oriented. The Committee was concerned that such attitudes may spell the demise of a significant study - everyone's thinking someone else should support it. As a way out of this. dilemma, Committee would suggest to Council “that this is a potentially valuable project, but one which requires numerous years of support before resuits can be realized. It was (A. Privileged. Communication) SUMMARY OF REVIEW AND CONCLUSION OF January 1971 Review Committee Texas Regional Medical Program. RM QG007 2/71 (SPECIAL ACTICY) FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY. COUNCIL The Review Committee helileved the Texas Regional Medical Program had adequately answered the questions of the previous review groups concerning the Stroke Demonstretion Program for Progressive Patient Care. It was” agreed that the restriction on the expenditure of funds for this project should be lifted. RMPS/GRB 1/20/7] REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) VIRGINIA REGIONAL MEDICAL PROGRAM RM 49-02 (AR-1 CDS) 2/71 700 E. Main Street January 1971 Review Committee Richmond, Virginia 23219 Program Coordinator: Eugene R. Perez, M.D. REQUEST FOR NEW FUNDS (Direct Cost Only) REGIONAL OPERATIONAL YEAR 02 03 04 I. Approved, unfunded projects (1) $211,728 $263,685 $299,875 II. New Projects (2) 288 ,468 242,109 249,784 III, Developmental Component_ 40,000 100,000 125 ,000 Total $540,196 $605,794 $674,659 RMPS Staff Review of Non-Competing 03 Year Operational Continuation Grant Application on 11/30. Awarded Commitment Commitment Regions Operational Year 02 Year 03 Year 05 Year I. Core $475,255 -0- -0- II. Ongoing Projects (6) 442 536 $449,235 -0- Total $917,791 $449,235 -0- In addition to the above, the Region requested $193,189 of carryover funds to supplement Core ($39,184) and ongoing projects #1,#2,#3,#4,#7, and #9 ($59,203); to initiate the approved unfunded projects #8 - Tumor Registry ($83,928); and utilize $10,871 in Project #10 - Multiphasic Screening Program. These request for utilization of carryover funds were disapproved by the Director of RMPS. FUNDING HISTORY (Direct Costs Only) Grant Year Period Funded Planning Stage 01 1/1/67 - 12/31/67 $226,800 02 3/1/68 - 2/28/69 254,000 03 3/1/69 - 2/27/70 475,255 Operational Stage 01 1/1/70-- 12/31/70 Core 375,413 Projects 410,718 otal “786,131 Virginia RMP -2- RM 49-02 (AR-1 CDS) 2/71 Geography and Demography: The Virginia Regional Medical Program which is headquartered in the State Capitol of Virginia services the entire State of Virginia with a land area ~ of 39,838 square miles. The population of the state is 4,692,675 covering 96 counties (and 37 independent cities) with an average density of 100 people per square mile. +, The Virginia RMP is divided into five district areas which correspond to the same five regions of the Virginia Hospital Association, Fifty- seven percent of the Virginia population is urban and roughly 81% is white. The population has a median age of 24.1 years. There are ten major colleges in the state of Virginia. The state has two major medical facilities, the Medical College of Virginia and the University of Virginia Medical School. Within the state are 43 nursing schools which offer L.P.N. programs and 33 which offer R.N. programs (including 21 diploma degrees, six associate degrees, and six baccalaurate degrees.) There are eleven schools of medical technology, two of which are affiliated with medical schools (the others are affiliated with hospitals.) There are four cytotechnology facilties within the state, two being affiliated with medical schools and the other two being affiliated with hospitals. There are 20 x-ray technology facilities in Virginia of which two are affiliated with medical schools. , The total number of hospitals in Virginia is 156 (of which 107 offer general medical services) with 40,116 beds. There are 150 nursing homes within the state, (55 having extended care facilities) with 7,879 beds. There are in Virginia 5,018 physicians (123/100,000) and 38 osteopaths (1/100,000) within the Region, There are 15,883 nurses (R.N.s) and 5,743 (L.P.N.) nurses, History of Regional Development: Shortly after the approval of Public Law 89-239 the Governor of Virginia appointed a fourteen (14)member Governor's Regional Advisory Group representative of community and state interests. This group, under the Chairmanship of the State Health Commissioner, coordinated the development of an application for planning funds, which resulted in an initial planning grant award in January 1967 of $226,800 first-year support. The applicant organization was the University of Virginia School of Medicine in Charlottesville, Virginia with the Commonwealth of Virginia as the designated region, with some overlapping in the north with the District of Columbia. A continuing cooperative relation- ship was established with the Metropolitan Washington Regional Medical Program. On July 1, 1967 Doctor Eugene R. Perez, was appointed as the full-time Program Coordinator. The Regional Advisory Group consisted of twelve physicians, In their review of the planning application, Council expressed concerns about the absence of representation of Virginia RMP -3- RM 49-02 (AR-1 CDS)2/71 of paramedical personnel and minority groups on the Regional Advisory Group, the planning as submitted was quite non-specific and the evaluation plans and procedures were not emphasized. Early in December 1967, at the request of the Region, the planning grant was extended without additional funds through February 29, 1968, to permit additional time for organization and planning. When the continua- tion 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. , The Core staff at this time consisted only of a program director and an administrative officer. The Regional Advisory Group consisted of nine physicians and five laymen. There was an Executive Committee consisting of six members drawn from the Regional Advisory Group to exercise authority in the interim between meetings of the RAG. It appeared that the previous recommendations from Council to expand the RAG to include representation from Allied Health Professions and minority groups had not been met. Evidence of a cooperative medical school commitment to the program from the two medical schools was not present. Planning efforts continued to remain at a minimum level and evidence of sub-regionalization was at an elementary stage. Early in July 1968, the Virginia RMP submitted its initial operational grant application requesting support of 16 projects for a three-year period. The projects submitted included four in heart disease, six in cancer, one in stroke, four in continuing education, and one for expansion of core. A site visit was made to the region in September 1968, and the site visitors reported that the continuous problems with cooperative arrangements, regional planning and RAG membership still beset the Region. Council did not approve operational status for the region, but did approve the continuation support of planning activities. Council urged that the region be advised that core activities be strengthened, that a regional approach be used in project development and that the new operational plan tie in with the previous planning phase, Another recommendation which was again stipulated by Council was that the Advisory Group be increased in number and that it include representation from paramedical professions and minority groups. The region resubmitted their initial operational grant application to the December 1969 Council and a site visit was made to the region on October 1-2, 1969. The December 1969 Council concurred with the recommendations: 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 Medical College of Virginia continued to be the responsible fiscal agent for the Virginia RMP, Nine additional members had been appointed to the Governor's Regional Advisory Virginia RMP 74 RM 49-02 (AR-1 CDS) 2/71 Group, which brought the total present Regional Advisory Group member- ship to twenty (20) members. Four standing committees on heart disease, cancer, stroke and related diseases were created to replace Task Force members and were broadened to include dentists, nurses, hospital - administrators and minority representation. Regional representation was also taken into consideration in the formation of these committees. An Executive Committee,which consisted of six members and exercised ’ all of the authority of the Advisory Group relevant to its functions and interim between meetings of the Advisory Group was activated. Each medical school has an RMP Committee for heart disease, cancer, stroke and : related diseases. The chairman of each medical school RMP Committee acts in liaison capacity between the schools and the RMP Central Office and also as official members of the Coordinating Planning and Evaluation Committee. Other representatives on the Coordinating Planning and Evaluation Committee are two representatives from the Medical Society of Virginia, Committee on Heart, Cancer and Stroke, one representative from the Virginia Hospital Association, one representative chairman from a Standing Committee on Categorical Diseases, This Committee provides advice to the Regional Advisory Group and to the Virginia RMP Director regarding needs and resources 66 the Commonwealth of Virginia Region. It is also to determine proper relationships between program elements including the identification of needs, determination of priorities and analyze program performances and results. In carrying out these functions the Coordinating Planning and Evaluation Committee would designate and direct sub-committees, review proposals and submit recommendations to the RAG. In February 1970, the RMPS Staff reviewed this region's continuation application, requesting support of the Core component. Changes in staffing patterns were noted, which had the effect of diminishing the number and total effort of physicians involved in the Core operation. Furthermore, the region expended only 55.1% of its funds. To permit time for the region to clarify the rationale for the new staffing patterns and to project its rate of expanditures, an award was made at the committed amount of $475,255 (d.c.0.) with a restriction on the use of $100,000. Staff believed that thfs action served two purposes: (1) assured the RMPS that funds will be available for program development, either for a better documented Core plan or new operational projects that may beapproved; (2) permit RMPS to maintain a degree of stewardship over this rather shakey, but hopeful Regional Medical Program. The paramount issue currently involving the time and efforts of the Virginia Regional Medical Program are their plans for breaking away. from the present grantee, the Medical College of Virginia, and becoming a corporate body. They are presently developing guidelines for personnel policies which they hope will be the basis for forming a corporate structure. The motivating season for the proposed change from the present grantee stems from what the staff of the RMPS believes to be inadequate fringe benefits. It seems since the Medical College is a state supported institution, its employees are regulated by the State Merit System and given State retirement benefits. Since the VRMP employees are paid by a Federal grant and are not considered to Virginia RMP -5- RM 49-02 (AR~-1 CDS) 2/71 be state employees, they are not eligible for these fringe benefits and consider this to be an injustice. Ccnsequently, they feel their only alternative is to incorporate and provide their own fringe benefits, The Director of Regional Medical Programs Service believes these reasons are not only logical but of prime importance in the development of a productive program for the state of Virginia. With respect, however, to the By-Laws and Articles of Incorporation for the proposed corporation, the Director of RMPS has recommended that these documents be revised in order that the membership of the corpora- tion will be separate from that of the Regional Advisory Group. Indications from the VRMP at present are that if they have to separate the membership of these to groups, they may decide not to incorporate, In this anniversary review application the VRMP has requested support for the following: (1) Continuation support for core and operational projects #1, #2, #3, #4, #7, and #9; (2) a developmental component; (3) supplemental support for two new projects; (4) and new funds to activate Projects #10 - Virginia Model Multiphasic Health Screening System, and #8 - Tumor Registry. Staff review of the Continuation Application concerned itself with total program and not individual projects. Generally, everyone was in agreement that the region has made some progress during the past year. This was particularly reflected in the composition of the applica- tion which was a considerable improvement over previous submissions. The region has shown improvement during the past year in that they have reacted to staff suggestions regarding Core staff personnel by taking steps to strengthen the program evaluation and administrative sections. They have accepted the suggestions of staff that additional physician input on Core staff is needed and are actively recruiting for a physician to fill the deputy coordinator position. Organizational Structure and Processes: The Regional Advisory Group of the VRMP is composed of 20 members, 10 physicians, 1 registered nurse, 2 hospital administrators, 1 allied health representative, 4 non-health professionals, 1 labor official and 1 businessman. ‘These members are appointed by a nominating committee made up of no less than 3, nor more than 5 members of the Regional Advisory Group and then recommended by the RAG for appoint- ment by the Governor, Appointments shall be for a term of four years with the term of office of each member beginning with the March Meeting. The membership of the Regional Advisory Group shall not be less than 20 persons and they shall be selected in accordance with the provisions of P.L, 89-239, Regular meetings of the RAG are held on the third Thursday of the months of March, July and November of each year at a location designated by the Chairman. The RAG shall be the final authority for approval of all activities proposed during the planning and operational phases of the program and of all matters of policies related to the program, It is indicated in the application that RAG activities during the past year have included the following: (a) Regional Advisory Group review of goals and priorities submitted by the standing committees, and made final decisions on the Regions objectives; (b) the RAG has been involved in the proposed incorporation Virginia RMP -6- RM 49-02 (AR=1 CDS) 2/71 of the VRMP and has been studying and encouraging its implementation; (c) the RAG has worked toward the establishment of overall policy and a framework for the functioning of Core staff; (d) the Regional Advisory Group has given careful study and review to projects submitted for their action; (é) the RAG has formed three committees of the RAG which are the Personnel Committee, the Goals Committee and the Incorparation Committee, These committees were charged with investigating and recommending means to achieve a more effective organizational structure for the developing b program. Following are the names and functions of the committees of the RMP: Ad Hoc Committees: These committees contain expertise from various cate- gorical health service areas and are appointed by the chairman of the Coordinating Planning and Evaluation Committee. There are ad hoc committees in the following areas: Continuing Education for Nursing Personnel; Man- power Survey; Tumor Registry; Plan Multidisciplinary Stroke Programs; and Radiation Therapy. re ere Coordinating, Planning and Evaluation Committee: This committee functions as its title indicates. It is an essential mechanisim for program development, coordination, planning and evaluation, This committee has consultants available and has the right to form Ad Hoc Committees as necessary for special purposes. In addition, it can call on the Standing Committee for advice. The Coordinating, Planning and Evaluation Committee also screens and evaluates all operational grant proposals and makes recommendations to the Governor's Regional Advisory Group. Standing Committees: The standing committees' functions are directed by the coordinating, planning and evaluation committee, Their principle function is the generation of ideas that can be used on a State-wide basis in accordance with the RMP concept of regional cooperative arrangements, They also serve in an advisory capacity to the coordinating planning and evaluation committee. There is a standing committee for heart disease, cancer, stroke and one on related diseases, Taken into consideration when forming committees has been geographic distribution and representation from the variety of health professions. Each medical school has 49 RMP committee for heart disease, cancer, stroke and related diseases, The chairman. of the Medical School RMP Committees serve in a liaison capacity between the schools and the RMP Central Office and are official members of the Coordinating Planning and Evaluation Committee, The Medical Society of Virginia, Heart, Cancer, and Stroke Committee consists of ten members of the Medical Society of Virginia drawn from the ten congressional districts which affords broad geographical representation, The Chairman is an official member of the Coordinating Planning and Evaluation Committee, thereby having direct representation and participation in a committee concerned with all aspects of the program; he is also an ex officio member of the Regional Advisory Group. Following is an organizational chart utilized for planning and operation of the Virginia Regional Medical Program. @ @ _ ©@ VIRGINIA REGIONAL MEDICAL PROGRAM ORGANIZATION CHART FOR PLANNING AND OPERATION | , 5 GOVERNOR'S REGIONAL ADVISORY GROUP i ‘ 5 rc i Executive Committee | & by , 4 : — i Coordinator / Director . wax e . . & 2 t x tg: i : Hospital and Relatec | a: C Stat mee ee ew «= ICAL School; ; Health Organizations : i . i : Representatives i z j k ; | a i , s ’ om: x ee * 4 e + . ral —: hh t i iq - Fiscal Agent | t ; Ad Hoc Committees TNR 4 Venom ~ . _ q $ ] a . : : i , : Coordinating, Planning, j 7 d i a iF . . * tye tt : ; i and i Medical Society of Virginia i i Consultants ‘a me ae ee fom! 5 t : ‘ Evaiuation Committee ; : Heart, Cancer, Stroke Committee ' ay x . he ow! i i Heart Disease ; § Cancer ; 4 Stroke ‘ i Related Diseases j ony : 4 . i | ; Committee ; | Committee i ; Committee 4 s Committee i i 5 4 a a 4 4 i : i ° § y ¥ dW ebUESITA LL£/z (919 T-uVv) 70-67 Wa Virginia RMP ~8- RM 49-02 (AR-1 CDS)2/71 The Core staff of the Virginia RMP has 29 positions, 24 at 100% time or effort. The Core staff organization has been expanded to include an accountant, editorial and allied health officer positions and the time and effort for the unfilled positions of education research and evaluation officer have been increased to 100%,rather then 50%. The three positions of heart, stroke, and cancer consultants have been deleted and an internist has been proposed instead. The internist presumably will cover heart disease, stroke and Dr. Perez, the cancer field, The time and effort for the two Medical School representatives and the epidemiologist position have been reduced from 50% to 25%, The net effect of these changes diminished the number and total proposed time and effort of physicians involved in core staff operations, During the review of the continuation application the questions troubling staff were how Dr. Perez could direct the continuing planning effort and new operational activities, supervise a staff of 28 people, only four of whom are physicians (1.75) and five of whom are located in sub-regional offices, maintain the institutional and community relations necessary for a strong Regional Medical Program, and provide leadership for the RAG? Following is a list of the Core staff members and an organizational chart, TIME OR EFFORT NAME JOB TITLE % HOURS Eugene R. Perez, M.D. Director 100 A. S. Cann Communications & Public Information Officer 100 T. Y. Tully Editorial Assistant 100 C. O, Martin Administrative Officer 100 A. Burton Project Fiscal Officer 100 N. L. Doeppe Administrative Assistant 100 J. D. Bobbitt Secretary (Clerk-Steno) 100 D. K. Brooks Secretary (Clerk-Steno) 100 M. L. Cosby Secretary (Clerk-Steno) 100 K. F. Meyer Secretary (Clerk-Steno) 100 TBA Personnel & Payroll Clerk 100 TBA Purchase & Supplies Clerk 100 M. W. Proctor Survey Officer 100 TBA Heatih Planning Officer 100 TBA (Epidemiologist) 25 J, L. Mason Educational Sciences (and Evaluation) Officer 100 TBA, M.D. Medical Officer 100 F. L. Peters, R.N. Nurse Officer 100 TBA Allied Health Officer 100 B. L. Peace, R.R.L. Medical Record Officer 100 W.B. Hunt, Jr. M.D. (Medical School Liaison) 25 TBA Secretary 50 M.P. Neal, Jr., M.D. Medical School Liaison 25 TBA Secretary 50 TBA Chief, Community Liaison 100 F.L, Beamer Community Liaison Officer 100 H. D. Kauffelt Community Liaison Officer 100 We. W. Schmidt Community Liaison Officer 100 100 M.P. Gray Community Liaison Officer Virginia RMP -9- (CORE Staff) | RM 49-02 (AR-1 CDS) 2/71 VIRGINIA REGIONAL, MEDICAL PROGRAM Organization Chart as of 30 September 1970 ae EA Epidemiologi st ~ DIRECTOR © eer RH Medical School — | | Communications and (Vacant) DEPUTY DIRECTOR _ Liaison Officers (2) a Public Information | } | Editorial Assistant (Vacant) + ! ! 4 (Temporary) — Administrative Officer * Project Fiscal Officer Administrative Secretary Secretaries OT FERRE DS ESTAS Survey Officer 1 RMSE EE WSN BEI Ds Testi ees.) Par “Re Educational Sciences Officer on Projects Development and. Nurse and A Allied Health Officer { (Allied Health Vacant) AER nyt aE AE RAE gS PSR Se gee NITE a PUIG AEE A NT? RNR I Ge RTL. DAE ME EET Medical Officer (Vac a Medical Records Management Officer* ae Health Planner (Vacant) Officer Community Liaison Officers (4) (1 vacancy) SEM , i Ce. Deaton tor pd emanation 3 , FN ACE A a tT OO we Lanceraew necaseencommmnh nan Teak RT BS ar At ES ES TOL Virginia RMP , IX\S (200 [-HA) S0-@A Mi Following is a folow chart of the project review process of the Virginia ANOOH [ADICIM TAMOLDE SE AIMLOSUIV ‘Regional Medical Pro 10- =Q- Submission of Proposal Summary to VRMP - vy Staff. Review wrevi¥ Oh Kg L SUR 6 AE ls ' Committee (81a HOD) fe} RM 49-02 (AR-1 CDS). 2/71 qMa sialgiiv PARR ESEBR ton (lf Approved} *Review by the Eo TERE LATO verarerocena erg ed ic ag foardoe | BOIDON, )i g we ( Developmpnt ofthe > assistance fro voll xf *+Review by th and the Medical ANN A ENE, OUD FRA SoTL *s99iNO ovis tiainteg approved) (Vis 10a l)+Reviewl bythe Coordinatt TET PTRRTE approved) ew by the RAG | Isoari Joojo onl r2imoO | approved) plumage gerne Me CEN ewer o RMPS ovitsweininba , YRnopasad may to goals and eferred back to the egies of VRMP and/or e Sere [. referred back to the 10 further review, development and/or Re NILE TAG SAP RARE At te PLO, Gun “sch Not iid RMP bisa in the review ca Cage Fee Nee EE RA LA END Prowi das. £ALQuUbs: process. ne tte ere ERG Pic MTR INE Teele OR Hs ETE FETE Palla ‘bh 92 sy ee p BalLive formal review re appropriageypomystieg and/of Society Committee , Capra semen. ERE CEA CALE! BLL UE Se 2199iNO noakdE fApF srovedy CBA IGOR HOE LY TTT ee rer" BAER Ee OO at Be kere O! ran rete ort ‘nto a Torna I Qraed sd YTUIIC (jr BV) Society Comittee Ad Hoc Committees , pains tates Rawr AE AIR Ae MS TET ATO 7 Jatgoloiniobiqil ap lication with SOT AT ELE SAA ELIT INERT TTTE OOOO pr Ad Hoc Committees weaanbaabeaimmnapeamnel we ALR LIRR CRATE FL Ss OS RENO bas anoissotauertietoO ind Enelpptriceol ¢bupiidese | . (2) revision revisions... ze - , jasjete2A [sitotbel (rtso8V) 4 Lee otpiasmicerian SEENON TLE were Ses Fae NG ARES briginator for (1) not conforming Bppropriate review committee SAN LEK 1 eae OOS LLLd at: lationship wi pote! eather Pe barmrting aid “Che eR Mee (ingasvidslaabrbaidiAgq activities and mytual interest omnnrn"Annual Report. oO Regional Advisory Group (RAG) “er eee ances RAC THOTCACES Tipat as a result of fNational Adv ae Ja 58. Bik 41 Advisory Group Has become mo x L252 eo aver ect~trr yreater-depylr-tts-resporgd yooitt sean Afitex. oe -and_suabty of the RMPS red were implemented (a the RAG was sot Meee nos hee raph ataar® ° PAO 8A wat eae: Task Force) were ommendations , raphically; iversified bq (LY) atooitto (yousosy I) PUY STE TES OFT: FIOPRTIOR AYE t26 He OY. Laren. tetas Cree wee: Henna! fon when “Ep Hapy tee 12 Caner « Rag SLE | TLS en te CTE LY OANA CAN env ANCE LET no NCL reer Te eee reaneg * Lh CHP, .staffs of : apanQiaa JononaaubLe 19910 fi oe a rged:‘with representation and ccecgespm.t fo : BAGS Sb ee sal es Pe - re aT ore ibility 259 MO. InomogensM than fol Lowing changes. tr mesrre: b) ENA sD er mee the standing committees & oa th protessionay, and, EE profess tonai aint (JnnOBV) Virginia RMP -11- RM 49-02 (AR-1 CDS) 2/71 geograhically; (c) a stronger and more organized review procedure was initiated; (d) the core staff was enlarged; (e) the RAG adopted by laws. The Regional Advisory Group went on to identify its general goals and specific goals in the categorical areas of heart disease, cancer, stroke and related diseases, The RAG indicates that the enlargement of standing committees in the RAG provided for program representation of key health interest and agencies. In addition the staff of VRMP has worked.closely with many public and private health agencies, institutions, and groups throughout the region in development of program goals activities. They explain that as a result of activities generated by the VRMP many people from different disciplines and areas of interest, as well as members of the public have talked together about health care problems in the region for the first time. They identify some of these as the medical schools, practicing physicians, dentists,nurses, allied health groups and other health manpower in the region. The RAG indicated that it became apparent to them in early 1968 that there was a need for sub-regionalization in order that the program might be more effectively administered. After extensive study by the Core staff of various possibilities it was decided to adopt the Virginia Hospital Association Division of five sub-regions, The RAG explains that in order to relate the VRMP to the critical issues of the poor and the inter-city health problems,the Virginia RMP staff has been in contact with two model cities programs in the state. In addition the Model Cities Program was represented and participated in the VRMP Continuing Education Workshop for Nursing Personnel which was held in the Tidewater area of Virgnia in November 1969. Rapport has been excellent with both the Model Neighborhood Programs in Richmond and the Norfolk Model Cities Program. The RAG also indicates that it must be remembered that Virginia in contrast to many other regions, has rural health problems, which perhaps, supercede the urban health problems of this state. Many of the health problems in the states rural population are found in the Appalachian Region which covers 21 counties in the Southwestern portion of the state, Seven of these counties lie in the heart of the poor areas of Appalachia. The VRMP staff has concentrated considerable planning efforts into the problems of Appalachia and other rural areas of the region. The RAG indicates that the VRMP staff is also working very closely with the Virginia Council on health and medical care. The Virginia Council's main thrust is a health careers program, and the recruiting of physicians and allied health personnel for rural areas in the state, The RAG indicates that there is a good working relationship between the RMPS and other health related organizations such as the Comprehensive Health Planning, Blue Cross-Blue Shield, Virginia Health Insurance Council, Virginia Department of Vocational Rehabilitation, Virginia Heart Association, American Cancer Society Virginia Division, and the Virginia Appalachian Health Services Regional Health Demonstration Program. It also states that there is a close working relationship with the two medicalschools in the region as well as the Medical Society and the State Health Department of Virginia. Virginia RMP -12- RM 49-02 (AR-1 CDS) 2/71 Evaluation The Region explains that the core staff activity in the area of evaluation has been largely concerned with providing technical assistance in the writing, monitoring and reporting on theprogress of operational projects. The seasons given by the Region for these activities is the requirement that the RMPS sponsored activities conform to the seven criteria stated in the guidelines for RMPS. These criteria are essential elements; involvement identification of needs and opportunity, assessment of resources, definition of objectives, setting of priorities, implementation and evaluation. It appears that evaluation which is involved will be concerned with the individual component activities operational in the region, Sh Virginia Regional Medical Program Goals 1. The overall goal of the Virginia Regional Medical Program is improved patient care through continuous upgrading of the know- ledge and skills of physicians, dentists, nurses, and allied health professionals so that the latest and best in modern medical care for heart disease, cancer, stroke, and related diseases is available to all the people of Virginia. 2. The objective of improved patient care is to be achieved by establishing voluntary cooperative arrangements among the medical schools and/or medical centers. with the practicing physicians, dentists, nurses, and allied health professionals, primarily through programs of continuing education. 3. The mechanism of cooperative arrangements and the essence of the Regional Medical Program concept is the linkage of patient care with health research and education involving the full array of available health resources and personnel on a statewide basis to provide a mutually beneficial interaction. 4, The realization of the above goals with be achieved by project activities and other efforts which, when taken together, constitute coordinated programs to reduce morbidity and mortality in each of the categorical disease areas. These coordinated programs in turn represent the overall purpose of the Virginia Regional Medical Program. Developmental Component The Region is requesting a three-year developmental component award, as follows: Ol-Year $40,00; 02-Year $100,000; 03-Year $125,00; a total of $265,000 for 3 years support. The Region indicates that this award would provide the Virginia RMP with the capability of initiating activities not possible without the developmental component; and that these funds may be restricted to the conduct of conferences at which concepts can be thoroughly discussed prior to the preparation of a complete proposal. Funds may also be used to employ personnel on a short term basis to support _ a contractural service for the conduct of studies from which facts ES Virginia RMP -13-) RM 49-02 (AR~-1 CDS) 2/71 can be obtained and recommendations generated. It is anticipated thet each activity requesting developmental funds will be reviewed and administered in a matter similar to that of fully funded operational projects. Supplemental Projects First Year Project #11 - Emergency Coronary Care: The purpose Requested « of this project is to prepare Volunteer $92,916 Rescue Squads to provide optimum emergency care to acute coronary care victims in the city of Virginia Beach, from the time ' of their arrival on the scene until the transfer of the patient to the hospital emergency room. To accomplish this goal the project will provide emergency coronary care training and equipment for the ten volunteer rescue squads in the Virginia Beach Area. Data for analyses will be collected in all phases of the project to provide information for evaluating its effectiveness. After adequate review of the data by persons knowledgeable in the field, the design will be available for other communities to utilize in organizing similar activities, The region indicates that this project relates to the overall regional plan and goals established by theRegional Advisory Group. Under the strategy for heart disease, and immediate goal was approved for the initiation of a pilot study of pre-hospital neighborhood coronary care. It is the intention of this proposal on emergency coronary care to accomplish this goal and the proposal has been enthusiastically and © unanimously approved by the VRMP standing committee on heart disease. Second Year: $57,521 Third Year: $56,207 First Year Project #12 - Procurement of Cadaver Kidneys for Transplantation: Requested The purpose of this project is the development $195,552 of a mechanism by which Cadaver Kidneys may be procured to save the lives of patients dying of end-stage renal disease. The project will establish a program of professional, administrative and public education which the region believes is necessary to carry through the primary purpose of the program. The goals are consistant with the RMP goals as they require regional cooperation between medical schools and community hospitals not only within Virginia, but also in adjacent states. Second Year: $184,588 Third Year: $193,577 Approved and Unfunded Projects First Year Requested Project #10 - The Virginia Model Multiphasic Health Screening System. $222,602 The region is requesting new money to activate this approved unfunded project which was approved by Council in July 1970. This project proposes to establish a multiphasic health screening system with facilities for gathering data on patients physiological state and Virginia RMP -14- RM 49-02 (AR-1 CDS) 2/71 the follow-up necessary for the early detection of disease, Primarily,’ the project will look for non-manifest symptoms or risk factors associated with heart disease, cancer, and stroke. In the process, medical and health data will be generated which will be generally valuable to the referring physicians in the management of his patients. The total funds requested by the Virginia Regional Medical Program for ™ support 6f this activity in Ol-Year is $222,602, It has requested utilization of carryover dollars in the amount of $10,877 and $211,728 of new money. In its 02 and 03 projected revenue will be utilized ; to reduce the amount of new funds required for support of the program. Commonwealth University has stated that it will assume full financial responsibility for any deficit between the funds requested and granted and revenue anticipated in the second and third year of the program and subsequent years. The Council approved level for this project were as follows: 01 year $268,552; 02 year $480,479; 03 year $433,704. These levels of funding were approved with the condition that the VRMP could guarantee sources of revenue for the program. The region has responded to this condition to the satisfaction of RMPS staff. Approved and Funded Projects Present Year of Operation Project #2 - Coronary Care Evaluation First Year Project #3 - Cardiopulmonary Resuscitation Training Program , First Year Project #4 - Stroke in a Small Rural Community First Year Project #7 - Virginia Medical Information System First Year Continuing Education for Nursing Personnel First Year Project #9 Approved and Unfunded Projects Project #8 - State-wide Tumor Registry O1 $113,584 02 $ 98,600 03 $110,100 Project #10 - Virginia Model Multiphasic O01 $268,552 Health Screening System 02 $480,479 03 $533,504 Disapproved and Unfunded Projects Project #5 - Stroke Program and Training Unit RMPS /GRB/12/21/70 A PRIVILEGED COMMUNICATION e- SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE VIRGINIA REGIONAL MEDICAL PROGRAM RM 00049-02:-(AR-1 CDS) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: Additional funds be provided for this application. - Council's special attention is called to the Multiphasic Screening Program, + Region's ' Recommended Operational Year Request Additional Funding 02 $ 540,196 $211,728 03 605,794 263,685 04 674,659 299,875 Total ~ $1,820,649 ~ $775,288 (In addition to the above, the Region requested $193,189 of carryover ‘“ While the Region plans to continue the basie progrem initiated four years ago there will be a broadening of focus, Heart disease, cancer, stroke end related diseases rerain important. Continuing education, the found- ation of W/ARMP, continues to be an essential part of the goal of improving health care. Examples of cooperative arrangements are offered as follows: 1) A community coordinator group formed two years ago by appointment from the State Medical Association, the University of Washington School of Medicine and the RMP has proven to be en increasingly important Link among these three organizations; 2) Washington and Alaska Hospitel Associations - meaningful involvement of hospitals with the RHP has been slover to materialize than was this relationship with physicians and Medical Associations but progress has been made; 3) Relation to other programs concerned with health planning and improvement of health services - both the Seattle Model Citites and the State and Areaewide Comprehensive Health Planning Agencies are represented on the RAC. -Further, cross representation of staff and Advisory Committee members between the RiP and CHP at the Stete, Area-wide and County levels continucs and has been increased, There is a good climate of cooperation between RMP and CHP in the tyvo states and no epparent obstacles to accomplishing geod joint working relations in a program of mutual benefit; 4) Washington State Department of Health - Close and productive relations exist with the Washington State Department of Health which is now a part of the State Social and Health Services Department; 5) University of Washington School of Medicine - joint appointments between the RMP and the University School of Medicine continue. A total of 93 physicians from the School of Medicine has participated in RMP Continuing Education Programs and the close ties between the RMP Continuing Education and University of Washington Continuing Medical Education are mutually beneficial] in many ways; 6) Voluntary Health Agencies - There are multiple cross representations between members of the RHP and the two State Heart Associations and five jointly sponsored activities. The director has served as consultant to Washington/Alaska RMP -7- RBM 38-C4 (AR-1-CD) 2/71 the Rehabilitation Section of the inter sSoctety Commission on Cardiovascular ‘Disease and was on a panel at the seriean Heart Association meeting in. November 1970 which discussed ways: in which RMP's and Heart affiliates can work together to implement the ISCCV guidelines. A good cross representation continues to exist between the RHP, RAC and Cancer Committee and the Washington vigions of the American Cancer Society. Evidence of cooperative demonstrated by the contribution of both the Washington and Alaska divisioaus of the American Cancer Society to support the RHP Automated Tumor Regis and Alask % a oh e Boundaries: Both the states of Washington and Alaska continue to agree that the’ combination of the two states clearly fits into the regional concept and is beneficial. ‘The southern and eastern borders of the Washington portion of the Region have been the subject of some discussicn., For most purposes of the Pregram, the present boundaries of the State of Washington provide a reasonable and satisfactory delineation of their activities. Physicians and Rif's in Southvestern Veshington have indicated their desire for active participation in the W/A and to date, have expressed no desire to change the southern boundary. Theugh Spokane serves as the medical te a ce for Eastern ¢ om, Horthern Idaho and Western Montana and though W sai Continuing Edueatic on Programs spill over into these areas, cutside Vashin there has been no request to incorporate any portion of aed or F Hoatana into W/ARMP and such a step- does net seem necessary for purps of continuing education or to improve health care services, In two areas of Rastern ‘Washington on the border of Idaho namely, Pullman-Moscow and Lewiston- Clarkston, the professionals from both ¢ states have joined in developing activities in which W/ARMP and the Mountain States RHP jointly participate, Subregionalization: The Community Health Services and Developmental Programs have been given primary responsibility for taking more eggressive steps toward subregion 1a] development. Health Care | of Jedically I isedvantased: The RAC has decided that: .1) the Region should address itself to the health care needs of all the citizens in Washington and Alaska; and 2) should work to augment the efforts of other groups such as CEO and Model Cities whose primary mission is assistance to the medically needy. Cost of “Health, Care: It is hoped that appropriate modification of the health care systen ‘of which the RHP may properly be involved such as the wider use df allied health personnel, of ambulatory and home health services should lead to availability of quality care at lesser cost. j Quality of Care: Measureable improvement in the quality of care is an objective of all the continuing education projects. Better Utilization and Distribution of Health Care Resources: The Region has contributed in the planning and in the teaching of MZDEX personnel at the University of Washington. This program contributes to a better distribution of health services and a great availability of the same. The Region's small hospital autopsy pro ctect led to better utilization of the lecal general practitioner and nearby pathologist. “ Yashington/Alaska RY -&- RM 38-04 (AR-1-CD) 2/71 = mS Program Organization end Leadership Canability: The RAC, particularly through its Executive Cotmittee has worked closely with Core staff in improvements in program organization during the past year. These changes have produced clearer definitions of staff responsibility, better measures of performance, improved communication among staff, and between staff and RAC. The Core staff has demonstrated the genuine desire to serve in the “honest broker" capacity to coordinate efforcs toward improving the effective- ‘ness and satisfaction of health providers in their work and they are making quality health eare more available to the consumer in the Region, In this vay, and the conpetence of the staff, the Pregram has gained the respect of the heaith cere community. Organization and Structuve Upon the implementation of the "Blan for the Development of W/ARMP 1969-1973" an organization ¢ aualysig was initiated to determine whether or not the alignment of responsibilities was such staff could, by its activities, accomplish the goals and objectives as set forth, As a result, the organization was restructured on @ progrem basis ~~ a program being related groups of activities having common goals and Onjectives. The office of the Director was realigned for overall direction and Cea including subregional coordination, inter-agency coordination, tretive services, operational administration and public information. specific presrams were set up in Clie following areas: heart, cancer, stroke, continuing education, ¢ developmental program and community health services. An Advisory Committee, under the auspices of the RAC was assigned to each program area. The position of Associate Director vas created for each program, As the program manager, che assumes the usual xecutive functions associated vith the administration of his program, 3 including fiseal and personne] management, His program responsibilities are defined as administering, planning and coordinating program activities and projects. A detailed organization chart is shown on page 112 of the application. Regional Advisory Comittee, Executive, Planning and other Committees The RAC has demonstrated its willing acceptance of the policy and decision: making role that exceeds the definition of this body's responsibilities in law and guidelines. That some uncertainty as to the direction of the program lingered is shown by the continuation of the director of the program as Chairman of the RAC until November 1969. On that date, Mr. Robert Ogden, business man from Spokane and an appointee to the RAC at its inception was elected chairman. The RAC continues to meet every two or three months and the Executive Committee, composed of meribers of the RAC, meets once a month. Advisory Committees for heart disease, cancer, stroke and continuing education have existed since the beginning of the program. Committees for the developmental programs and community health services have more recently been formed. These committees, broadly representative of appropriate disciplines and with adequate geographic distribution, have met regularly and have functioned effectively in planning, edvising staff, reviewing applications for grants or other support and developing guidelines for care n the area of their responsibility and particular competence. In the - Washington/Alaska RMP , -9~ RM 38-04 (AR*1-CD} 2/71 spring end susmer of 1969 an ed hoc planning comaittee made up of members of the RAC met repeatedly to develop the W/ARHP Plan for 1969-1973, Provision ‘of the plan to make it appropiate for 1971-1974 was accomplished by special staff planning meetings at. which the RAC was represented and by the Executive Committee in preparation for presentation of the revised plan to the RAC fer their consideration, The RAC is composed of 42 members as follows: 19 physicians of whom two represent modical schools, one - the Medical Society, one » Comprehensive Health Planning Agency, one - the Heart Association, four - Public Health Dex nurses both of whom represent schools of nursing; three hospital administrators; one Allied Health representative; two Social and Behavioral Scientists, one of whom represents a medical school, the other a planning organization for Urban disadvantaged; three non-heelth professionals; ten business or managerial of whom one represents the University, three - Comprehensive leaith Planning ‘Les, one - organization for the Urban disadvantaged, and four -, Public or Consumer representatives; one labor official; and cone "other" professional. ‘ ‘iments, nine - practicing physicians, and one - RMP staff; two registered sf developed a very comprehensive revieu proce which is outlined in detail on pages 72 + 79 of the application, The process is broken into three major areas, initial contact and preliminary review, application preparation, and formal review. ‘Gore Staff Activities fhe program approach is made up of a total system which includes planning, control and eccountability for vesults of specific programme Each specific program within the master program is made up of related greups of activities having common goals and objectives. The basis for this type of program approach is detailed planning which provides for the step by _ step development of an operating plan which deseribes the results desired over a period of time. Using this approach, a revised plan for W/ARMP was epproved and provides the bacis for the overall regional/operating plan and an operating plan for each functioning project. These plans will be use as guidelines end basis for acticens for the program for 1971-74. This concept includes e plan for the total program, and operating plan for each function and each project, which describes in detail the overali goals and objectives, the detziled activities and schedule for each facet and the monetary anount signed to portion and part of the program, 4 : Planning and Feasibility Studies: ‘fo date Core staff funds were used to carry out or participate in eight planning studies during the 1970 fiscal year, These data, collection and analysis efforts were in addition to two information-oriented operational projects and selected data collection and analysis activities in support of educational programming. The eight planning studies and their states as of Octeber 1, 1970 are: - 1. Spokane Home Health Carve Aid Survey - to assess interest in resources of health and welfare service agencies concerning need for home health aid preparation end to prepare for: cooperately based provision in Spokane, Washington, Completed - 1970. Washington/Alaske RMP ~10- . RM 36-04 (AR-1-CD) 2/71 alth Planning Survey - to sélect 2. 8 th] alth wroblews and is i sues about which the Whitman County CHE could begin planning for health care, Completed August 1970. 3. Whateom, Skagit, Island end San Juan County Compr ehensive Health Planning Survey - to survey consumer estimates of health care s¢ primary and emergency care, Completed Mey 1970, 4, South Svokane County, University of Washington, Bureau of Co Development Survey - to assess patterns of health care of families ‘ predominatly rural region concerning the possibility of being able to support both additional medical manpower and the development of a combined extended care facility and rural area clinic. te ity Survey - to identify the health status of + e comunity of Willapa Harbor, resources arid facilities avaliable to meet the needs identified in relationship to status, and to involve a large segment of the cormunity in concerns for problems of health care delivery. Completed March 1970. 6. Washington State Nurses Association Continuing Education Survey - to determine preceived continuing eaucs ation need of Washington State nurses, In process, ‘7. Heart Sur istry ~ to obtain data regarding experience with _ heart surgery in the Wasington/Alaska Region. Ongoing. 8. Myocardial Infarction Registry ~ es a former planning project subsumed under Core staff support, the purpose of this project is: (1) to obtain baseline information as to morbidity and mortality ef coronary, artery disease in a selected sub- region of Washinton and Alaska, (2) the test the feasibility of a method of ooo eaineng such information about all categortes of disease of concern to the RMP throughout the Region, (3) to measure the reliability of medical records face sheets as source documents for coronary artery disease data gath- ering. (4) to test the feasibility and desirability of extend Hin ng this program throughout the entire Region. Terminated June 30, 1970. Evaluation: The Region's evalu sation plans are described in detail pages 84-89. sed upon the overall regional plan, an cperating plan for each function and project is developed and becomes the basis for actual provision of data which is utilized in the evaluation process, This concept of evaluation culminates.in an operating plen for each level of cpberation within the organization in a hierarchical fashion and permits the systematic gathoring of data at each leve RPearuktaa anel DAM Mem of the organization, which data is utilised by the vitbann fae tha carttuar Af nvetawitdans anA Aneteotann Washing gton/Alast ca RYE -10- RM 38-04 (AR-1-Cd) 2/71 2, Whitman County Comerehensive Health Planning. Survey - to select important health problems and issues about which the Whitman County CHP could begin planning for health care, Completed August 1970. 3. Whateon, Skepits Jsland and San Juan County Comprehensive Health - to survey consumer estimates of health care ary and engrgency care. Completed May 1970, 4, South Svokens County, University of Washingtou, Bureau of Cowseinity Development Survey - to assess patterns of health care of families ‘predominatly rural region concerning the possibility of being able to support both additicnal medical manpower and the development of a combined extended care facility and rural area clinic. Ln . Willap invey = to fence’ the health status of the population of the comm: ity of Willapa Harbor, resources and facilitics available to meet the needs identified in relationship to status, and to involve e large segment of the conmanh ty in , concerns for problems of health care delivery. Completed March 1970, 6. Washington State Nurses Association Continuing Education Survey to determine preceived continuing education need of Washington State nurses, ‘In process, Hes ery Registry - to obtain data regarding experience with heart surgery in the “Wasington/Alas ka Region. Ongoing 8. Myocardial Infarcti try - as a former planning project support, the purpose of this project is: subsumed under Core staff GQ) to obtain baseline information as to morbidity and. | mortality of coronary, artery disease in a selected sub- ' region of Washinton and Alaska. (2) the test the feasibility of @ method of obtaining such information about all categories of disease of concern to the RMP throughout the Region. to measure the reliability of medical records face sheets as source documents for coronary artery disease data gath- ering. , o_o voonast can nenaranean (BD seers Nee” to test the feasibility and desirability of extending this program throughout the entire Region. Terminated June 30, 1970. o~ oaks w Evaluation: The Region's evaluation plans are described in detail pages 84-89, Based upon the overall regional plan, an operating plan for each function and project is developed and becomes the basis for actual provision of. data which is utilized in the evaluation presess. This concept of evaluation culminates in an operating plan fer each level of operation within the organization in a hieverchical fashion and permits the systematic gathering of date at each level of the organization, which data is utilized by the. Rverwbtive and RAC Cfomnitteres For the serting af nriorities and decisione ” " Weshington/Alaska RMP . ohh RM 38-04 (AR-1 ulation and utilize these data in an effort to improve the MI/CCU operation, and to better define the potential value of this MI/CCU system in the community; 4) continue to expand efforts in education, both at the professional level and to the general community; and 5) secure additional funding for continued operation of the system beyond August 1, 1970. Progress indicators are: 1) syste: capable of operating with paramedical staff only; 2) lives saved; 3) public response indicated by increased number of calls; and 4) establishment of quantifiable data.Primary Evaluation indices: 1) system capable of operating with paramedical staff only; 2) number of lives saved; 3) public response indicated by increased number of calls; and 4) establishment of quantifiable data. oe Qo th w c hh th D H te 3 Ga rh K Q 3 Q rt n ° ny @ » 3 mu 4 o na 3 tr © a ou pele wa © Lvs] @ a Project #21 - Stroke Education-Personnel. This project is in the middle of the second year of its two-year program period and its goal is to promote and provide maximal modern knowledge and skills to medical, paramedical and appropriate lay persons in order to achieve optimal health care for all persons in Washington and Alaska who suffer from or are at high risk of stroke and/or related disorders. Its objectives are: 1) in- crease interest. and knowledge, and also improve and maintain abilities of appropriate persons regarding stroke and related diseases; 2) increase consul- tant availability in areas of need; 3) evaluate needs and methods of meeting these needs in the Region; and 4) promote cooperation and cooperate with other RMP and non-PMP projects. Progress indicators; 1) stroke specialist nurses developed and practicing in Region; 2) neuropathology technician developed and practicing in Region; 3) 450 nurses trained; 4) 50 physicians trained; 5) 200 lay people (educational programs) trained; and 6) 15 consultation trips completed. Primary evaluation indices: 1) 300 nurses, 100 physicians, and 50 lay people trained; 2) 3 consultation trips completed; 3) 1 stroke special- ist nurse trained; and 4) 1 neuropathology technician trained. Project #24 - Stroke Rehabilitation Nursing Program. This project is in the middle of the second year of its three-year program period and its goal is to improve stroke patient care in Washington and Alaska through increasing knowledge and skills of RN's in the area of rehabilitation. Its objectives are: 1) provide instruction in rehabilitative nursing for RN's at Good Samaritan Rehabilitation Center; 2) support community action in stroke rehabilitation; 3) evaluate impact of course on nurses and patients; and 4) determine project self-support potential. Progress indicators: 1) 116 nurses trained; 2) 5 two-week nursing courses held; 3) 1 follow-up course held; 4) four family stroke classes held; held; and 5) demonstrated change in patient care. Primary evaluation indices are: 1) 84 nurses trained; 2) 5,040 training days; and 3) demonstrated change in patient care. Project #31 - Lewis County Unit Washington State Heart Association Stroke & a s and Testorative Nursing Program. This project is in the middle of the second year of its two-year program period and its goal is to introduce and develop the concept of restorative and rehabilitative nursing into the hospitals, nursing homes and homes of Lewis and Thurston Counties. Its objectives are: 1) develop knowledge, skills, attitudes and techniques in restorative and rehabilitative nursing for RN's, LPN's and Nurses Aides; 2) promote the acceptance of utilizing the concept of restorative and rehabilitative nursing; 3) implement home health aide programs with rehabilitation and restorative nursing emphasis; 4) develop course for families so they may better understand and care for the stroke patient; and 5) evaluate impact of courses in knowledge and attitudes of students and on restorative and rehabilitative nursing in the community. Procress indicators: 1) 18 home health aides trained; 2) 54 nursing personnel trained; 3) 72 physicians oriented; 4) 150 participants in in-service treining; and 5) 500 hours in-service training completed. Primary evaluation indices: 1) 144 hours didactic instruction; 2) 192 hours laboratory; 3) 60 nursing personnel trained; 4) 500 hours instruction of in-service training; and 5) 150 in-service training participants. CANCER PROGRAM GOAL: Promote and engage in regionally coordinated activities directed towards a balanced program for the prevention, cure and optimal palliative care of cancer, where cure in not possible, for persons within the area. Project #12R ~ Radiological Physics Program. This project is in the third year of its four-year program period and its goal is to provide a radiological physics service to radio-therapists through the provision of accurate physical data, modern tools and communi - cation of improved techniques which will result in better care of the cancer patient. ts objectives are: 1) create an effective organization to provide a radiological physics service; 2) provide physical data essential for the practice of radio-therapy; 3) provide services of benefit to individual patients; 4) provide radiological safety service to the radio-therapy departments; and 5) provide devices and instruments of general use in radio-therapy. Progress indicators: 1) 80% of radiation therapy patients encompassed by the project; and 2) 50% enhancement of the quality of patient care by the use of the physics service indexed by the yearly increase in these services. Primary evaluation indices: 1) 75% of radiation therapy patients encompassed by the project; and 2) 20% enhancement of the quality of patient care by the use of the physics service indexed by the yearly increase in these services. Project #32 - Washington ‘Alaska Automated Tumor Registry. This project is in the middle of the second year of its two-year program period and its goal is to provide hospitals with Automated Tumor Registry services which will collect, combine, compare and evaluate uniformly defined RM 38 2/71.1 information on cancer patients designed to improve patient care and insure proper follow-up. {ts objectives are: L) provide a quality system of data collection and file maintenance so that meaningful reports are continuously produced, interpreted and used; 2) provide effective quality control of data and evaluate information by continuous training; 3) provide a follow-up service for all participating hospitals which can promote and expedite patient follow-up; 4) provide compar ative data Lists for all participating hospitals which will measure and corpare the quality of diagnosis and effectiveness of various treatment modalities; 5) conduct training seminars for all tumor recistry secretaries, WA special training for Automated Tumor Registry staff: %) provide consultation to hospital with respect to establishing new registries. Continuous guidance and assistance should ve available to abstract cases; 7) provide data sxchange for special studies; 8) stimulate interest in diagnosis and treatment of cancer by effective display of d bE stration between extent aud timing of diagnosis and treatment; and 9) forme- ation of a Tumor Pesistry Council with quarterly meetings. Progress indicatore: 1) actual Pebruary 1, 1971 cases 35,000 participating hospitals L, “s 19; 2) projected December 31, 1971 cases 45 ,000 participating hospitals 21. i Primary evaluation iidices: 1) actual February 1, 1970 - cases 19,000, participating hospitals 16; projected January 30, 1971 - cases 27,400, participating hospitals 17. REGIOKAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) VASHINGTON -ALASKA REGIONAL MEDICAL PROGRAM RM 00038 2/71.2 500 "U" District Building 1107 N.E. 45th Street Seattle,Washington 98105 Program Coordinator: Donal R. Sparkman, M.D. Requested Program : Period lst year 2nd year 3rd year Total Direct Costs $281, 803 $279,347 $199,016 $760, 166 Indirect Costs 48,047 51,189 29,494 128,730 Total $329,850 $330,536 $228,510 $888, 896 History: (See History of (AR=1-CD) 2/71.1 also under consideration) Background: In November 1970 Council considered a proposal from the W/A/RMP termed the Kidney Disease Control Program which contained eleven interrelated - - part® in four major areas: administration; traneplantation: kaviveie’ and education. The Council noted that the State of Washington has a well-known renal diseases center in Seattle and that the application reflected a coalition of proposals from renal diseases experts from both Seattle and Spokane, the only two densely populated areas to be served by the program, It appeared to the Council that the plan in this application had been developed by the renal experts with little input from the RMP core staff, In a sense, the full-blown plan seem to be imposed on the RMP. The application included considerable detail about the eleven individual proposals, but it failed to provide any analysis of the options available in planning kidney service programs in this type of geographic area; i.e., the cost of relocating and rehabilitating patients in center population area as compared to diffusing services transplant to areas; or information on the distribution of potential receipients. The program proposed to serve the Mountain States RMP as well as Washington and Alaska and coordinators are requested for both Seattle and Spokane. The Council questioned the need for the two full-time positions, The necessity of a medical advisor was questioned when consultants and advisory groups are available, Many of the activities have merit, some seem questionable for RMP support, some seem questionable from a scientific viewpoint , and several seem unnecessary. The clinical training activities appeared to have merit. In the absence of regional alternative priorities for the renal program in the area, the inclusion of several debatable activities and the expectation that this RMP with its strong RAG, capable core staff and a well-known pool Page 2 - RMP, Summary of an Operational Supplemental Grant Application of renal diseases expertise should present a more realistic funding request,, the Council concluded that no additional funds should be provided at this time The Council, however, expressed interest in reviewing a less diffuse renal diseases program that focused on clearly-delineated high priority areas of need for the Region. . Present Application: This is an updated revision of the original. proposal. In modifying the original request, two principles have been followed. (a) re- sources have been allocated only to those areas of highest priority and (b) maxi- . mum possible use has been extracted from existing resources, Accordingly, some of the originally proposed activities have been deleted and others re-oriented. The budget has been reduced for each year as follows: @1- from $858,501 to $281,803; 02- from $824,253 to $279,347; and 03- from $627,016 to $199,016. The areas of highest priorities have been identified as: (1) the institution of capability for coordination and planning at the regional level, (2) the expansion of transplant resources and (3) the evaluation of dialysis techniques and equipment. A synopsis of each of the 11 parts originally proposed and major modifications follow. The figures in parentheses are the originally requested amounts. Project #41 - Regional Administration - This aspect of ~ ‘the proposal would add an associate director for Kidney First Yo) >. disease to the WARMP core staff and a kidney coordinator for the Request... Mountain States RMP, as well as other staff, to assure continued ($112,170) coordinated planning and implementation of the kidney disease program, 57,200 Second Year -($119, 232) Third Year - ($126,550) 71,145 76,590 #41 Changes ~ Budget reduction. The administrative structure envisaged as originally proposed with moderate reduction in personnel and operating budget. Project #42 - Regional Transplant Program ~ The four activities included in this area of the program are all interrelated, The Tissue-Typing, Host- Craft and Professional Transplant activities are designed to increase professional and technical capability and distribute it among the major medical centers in the Region, as well as provide direct service to all areas, The Donor- Organ Retrieval System will involve ten or more Regional centers in supplying cadaveric organs. #42 Changes ~ The Host-Graft Project (420) will be deleted as it is still in the early developmental stage and will not have assured impact on cost of care. - Regional Tissue-Typing Laboratory - This project will First Year be directed by Dr. E. Donnal Thomas at the Public Health Service Hos- Request... pital in Seattle, The facility that the Public Health Service Hos- (465,20. pital has now, is primarily intended for research and cannot provide 7,1B~ Project #42A @ Page 3 - RMP, Summary of an Operational Supplemental Grant Application tissue-typing service for an augmented transplant program. It is necessary that tissue-typing capability be developed outside to provide services for Seattle to extend the time coverage and to reduce the costs. The funds requested would permit this facility to expand its operation to provide these services. In addition, they will determine the feasibility, economics, and ‘ efficiency of expanding the tissue-typing capability using one of two possible approaches, a central typing facility or blood banks. Four technicians will be trained in the course of this project each year; two from the facility at the Public Health Service Hospital and two from the Regional Blood Bank. Second Year ~ ($68,380) Third Year - ($10,000) 7,537 -O- #424 Changes - Budget reduction. Funds requested only to maintain activity at its present level. Project #42B - Regional Organ~Donor Retrieval System - This aspect First Year of the program will be directed by Dr. Henry Tenckhoff in the Depart- Request ment of Medicine at the University of Washington. This program will + ($32,588) develop a plan for Regional network for the harvesting and transportation 41,938 of cadaveric kidneys, train one or more surgeons in cadaveric kidney removal and preservation techniques in each of ten major medical centers within the Region, operate a regional donor-organ retrieval system, and coor- dinate development of the donor-organ retrieval system with the deve lopment of the tissue-typing laboratory and expansion of the transplant program. A start has been made on setting up this system in Spokane, In addition, nine other medical centers will be involved in the program - Tacoma, Bellingham, Bremerton, Yakima, Wenatchee, Boise, Billings, Anchorage and Olympia. Second Year ($29,695) Third Year ($1,000) 37,932 6,500 #42B- Changes - Budget increase. Change in personnel, Project #42C - Professional Transplant Capability - The director First Year of this activity is Dr. Thomas Marchioro from the Department of Request Surgery at the University of Washington. Specific objectives of this ($58, 700) activity to increase the professional transplant capability are to 20,950 recruit an additional full-time surgeon to work with the surgical transplant team, to provide one year training in transplantation surgery and to provide one year training program in immunology to two physicians. This project in interdigitated with the Professional Education Project ~- #44. Second Year (#58,995) Third Year - ($44,606) 7, 860 -0- © #42C - Change - Budget reduction. Original _proposal scaled down. Page 4 - RMP, Summary of an Operational Supplemental Grant Application Project #42D - Determination of Host-Graft Interrelationships - First Year This project will be directed by Dr. Gary Striker, Department Pequest of Pathology at the University of Washington, As a means of ($49,000) increasing the life of Renal transplent patients, this activity -0- will focus on increasing the knowledge of physicians on the use and interpreta- tion of the technique for detecting the blocking serum substance. Three i months! training will be provided for four physician trainees, The trainee physicians will be the surgical transplant trainee, the immunology trainees ; and the nephrology trainees who are enrolled in the Professional Transplant and Professional Education projects. In addition, technicians being trained under the Regional Tissue~Typing Laboratory Project will also receive special instruction. oO Second Year ($29,663) Third Year ($24,637) -0- -0~ #42D - Changes - Completely deleted. Project #43 - Regional Dialysis Program ~ Five distinct activities are proposed to improve the quality of dialysis care and the system of delivering care to the patient. #43 Changes - Assessment of needs for following cases (43C) has been deleted. Peritorial dialysis evaluation (43E) combined with Equipment Evaluation Project (43D) Project #43A - Kidney Failure. Registry - This project will be directed First Yr. by Dr. F. Kingsbury Curtis, Chief, Dialysis Unit, Veterans Administra- Request tion Hospital, Seattle, Washington. ($62,450) 31, 700 This will eventually collect data from all three - post - transplant and dialysis patients in the Region, thus involving physicians in local communities as well as those in treatment centers. It will develop a com- puter system to be used as a control data collection system for both transplant and dialysis aspects of the program. Second Year - ($108,695) "Third Year - ($103,265 37,270 41, 257 I oad aad 43A ~ Changes - Budget reduction in personnel time, consultation, and sub- contracts. Broject #43B - Evaluation of Home Dialysis Patient Training - First Year This activity will be directed by Dr. Tom Sawyer of the North- Request _ west Kidney Center in Seattle. The Eastern-Washington/Montana/ ($110,140) foe": Idaho Artificial Kidney Center in Spokane will also be involved. 43,075 Ne @ Page 5 - RMP, Summary of an Operational Supplemental Grant Application This activity will focus on evaluation of the present procedures for training home-dialysis patients, a revision of the curricula and testing of new approaches based on the evaluation and development of a final training package, This is noted as a great need for the country as a whole, Second Year - ($84,155) Third Year - (-0-) 40,108 -O~ #43B - Changes - Budget reduction in personnel costs, supplies and equipment. Project #43C - Assessment of Needs for Follow-Up Care in the Local First Year Community - The project director will be Dr. Jerry Pendras, Director, Request Northwest Kidney Center, Seattle, The Eastern Washington/Idaho/Montana ($70,663) Artificial Kidney Center in Spokane will also participate. -0- This activity is designed to quantify the needs for follow-up on a systematic and defensible basis, to identify personnel who should deliver care and to design and implement a pilot project to deliver the follow-up care needed by dialysis and transplant patients in their local communities. @ Second Year - ($85,503) Third Year - ($93,933) ~O~ -0- #43C_- Changes - Deleted Completely. Project #43D - Evaluation of New Dialysis Equipment and Techniques First Year Dr. James J. Cole, a Nephrologist in the Department of Medicine at Request University Hospital will direct this project. The Eastern Washington/ ($89,950) Idaho/Montana Artifical Kidney Center in Spokane, the Veterans 32,400 Administration Hospital and the Northwest Kidney Center in Seattle will also participate. This activity will evaluate dialysis equipment in laboratory, clinical, and home settings, will develop performance criteria for consideration at regional standards, will develop pre-test for personnel to be administered before they use the equipment and to assist the manufacturers in improving their equipment design and standards of quality control. Second Year - ($94,845) Third Year ~ ($100,230) 35,780 -0- Project #43E - Demonstration of New Equipment and Techriques for Home First Year. Peritoneal Dialysis and Testing Tts Role in the Management of Request Chronic Renal Failure. This activity will be directed by Dr. Henry ($94, 850) fenckhoff, Department of Medicine at the University of Washington, who -0- © also directs the Regional Organ-Donor Retrieval System under the Transplant Program. This activity will investigate the feasibility of long-term peritoneal Page 6 - RMP, Summary of an Operational Supplemental Grant Application dialysis based on a newly developed home fluid supply system in a variety of situations on a variety of patients. Training in the new techniques is also planned for physicians and other medical personnel. Second Year - ($29,550) Third Year - ($35,470) -0- -0- 43D and 43E_- Changes ~ Budget reduction, It is proposed to maintain evalua- tion activities in the Peritorial Dialysis project (43E) and combine this administratively with the Equipment Evaluation Project (43D) Project #44 - Regional Education Program ~ Dr. Christopher Blagg, First Year Nephrologist from the University of Washington Hospital, will Request direct the program, It is related to the other aspects of the ($113, 790) program, Regional Transplant and Regional Dialysis, It consists 47,415 of the following parts: (1) Clinical Traineeships - one-year training in transplantation surgery for one surgeon each year; one-year training in transplantation immunology for two physicians each year; one-year training in clinical nephrology for one physician each year; rotating training of two to six physicians each year to take a two to six month training in clinical nephrology; and four three-month training program in medical nephrology for "appropriate" urologic trainees each year. (2) Coordinated Continuing Education Program for physicians, nurses and dialysis technicians and it will include development of ten film strips, three TV shows, a traveling circuit course for eight communities in Washington, Alaska, Idaho and Montana, distribution of quarterly bulletin, and the support of travel expenses for consultations and continuing education for all types of personnel involved, Second Year-($115,540) Third Year - ($87,325) 41, 115 37,050 #44 Changes - Budget reduction. Clinical traineeships have been eliminated. Also, budget for continuing medical education activities has been reduced, Project will draw more heavily on the Education and Support Unit of W/ARMP. GRB/12/29/70 Wi PME KIDMEY COW TR -j- oe ame L PraGeam— — CR IGM ALS LEE UE fea fe > ra 427/99 | 01 Rleqvest Ol We quest oO3 [Request Atl Wears Prosedt — — 1 }o2o Jo. LEP Lee EE KH OT Orisi na) Ke Hed {Orig nul ev.sed | Crist |[eanses Deis nal| vse 4 TOTAL KUNE PICGRAM | 859. 50/| 291,03 \BA¥ 253 | 2743471 O27 O16 | 199,706 B, 307770 760/66 . U4 [- Aimivis TAMIL (12,170) (57.203) C79, 232)| (74 4/26 s90)| (e892) (as7gsh\2o4735) (42-TRaws PLANT PROGRAM) Pov vad) ( oor hve, 123) (e3,324) |(80,2/3)|( 6 soo) k¥7 v4) lay 649 HiA- Tiss e Typing hae. ey geo| 7/25] 2H 289) Zo h face) Tew fz, #9 | 1% 664 f2B~ Devsr Or Sem ec treba l Basse |, 738 | 24 49S | 37, 722 | L000 G, xo0| 63 29: | 86,379 4aC ~Tressplont apo! ty 58.700\ 20930) <8 9% | 7,060 | ¥¢ bob | -O7 [ez 30!) 2¥ 810 “20° Host rag I» ete ¥9 ooo | -0o- | zzee: | -o7 Jay o37 | 7 Oo 7 fee see | On (43- DiALYS/S PROGRAM) (v28 05 Mor. 125) kvon,2¢ 8 13, 788) (332,898)| ( 78,8764, 163,6 99 299409) WIA. Kgireg Fdrlre Pefitey | twee) 3/700 soe ers | SABIP A Mes ate $LBST | A744)? 1110, 27 Y3e~ Eval. Pat joo! Teale [yao | Ha ors] 84 oss] sot | — om | 37609 [Penis 20802 43c- Follow-V Care 70,663 | ~°— | ae sos | ~9~ 173933 | =O ase, OGF | —? YB0 -Fval Equip dP ig ec 413 779 ) sa, ¥o0 94, 48 Las 7¢0 [yea g34 |} mom bes SY evsfe WF Ue mo Fauso, bt irtin call Lests |F¢, 99% Lh aso SLY 7b Le FIO (44) - FouCAT Lope TROGLM ) ks voll worans <0) Cyrnsh (az ls7 059 Ps, € es)725 580) (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF © oo JANUARY 1971 REVIEW COMMITTEE WASHINGTON/ALASKA REGIONAL MEDICAL PROGRAM RM 38-04 (AR-1-CD) -2/71 1 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL RECOMMENDATION: Committee recommended that this application be approved and additional funding provided as requested, FUNDING RECOMMENDATION DEVELOPMENTAL . YEAR COMPONENT _ __ OTHER TOTAL Ist - $120,000 $1,592,144 $1,712, 144 yf ef 2nd 156,000 1,633,735 1,789,735 = i1/ (Difference between this figure and total shown on summary for 04 year represents an additional $8,929 recommended by staff as part of continuation application.) 2/ (Includes $1,512 »379 ‘continuation budget recommended for approval by staff, ) © 3/ (Includes $1,596,935 commitment for Core and 6 projects.) CRITIQUE: The Committee noted that this application had not been site visited since the Region had been subjected to two major site visits in 1969, The last site visit in October 1969 placed primary emphasis on program rather than project review. In the case of each site visit, significant progress toward the development of a mature Regional Medical Program was noted. The reviewers, including an individual who had served as chairman of the last visit and as a member of two previous visits believed that this application substantiated the extremely positive report of the October 1969 site visit. There was no doubt that this Region has reached a very mature stage of development. Some reviewers believed that the Committee would no longer have a function if all Regional Medical Programs were as strong as the W/ARMP. — RMPS/GRB © 1/19/71 (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTER WASHINGTON/ALASKA REGIONAL MEDICAL PROGRAM RM 38-04 (S) 2/71.2 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL RECOMMENDATION: The Committee recommended additional funds for this ) ~~ application pending a favorable review by the ad hoc Advisory Committee on. Kidney Disease Grant Applications YEAR REQUESTED (d.c.o.) RECOMMENDED (d.c.0.) Ist $281,803 $281,803 2nd 279,347 279,347 3rd 199,016 199,016 Total $760,166 $760,166 CRITIQUE: The Committee believed that this updated revision of the original proposal adequately responded to the major concerns raised in Committee's previous review. It was noted that the budget has been greatly reduced and the revised proposal clearly delineates high priority areas of need for the Region. . . RMPS /GRB . 1/19/71 WESTERN NEW YORK REGIONAL MEDICAL PROGRAM 2929 Main Street Buffalo, New York 14214 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) RM 13-04 (AR~1CDS) 2/71 January 1971 Review Committee PROGRAM COORDINATOR: John R.F. Ingall, M.D. Purpose Continuation Component (Core) (4 Projects) Renewal Project Additional Components (Developmental) (4 New Projects Anniv. Appl.) (2 New Projects Deferred Appl.) (3 Approved/ Unfund- ed Projects) TOTAL -Staff Action on Commitment Committee Action Required *The 04 Year Commitment for these activities is $1,029,459. Grant Year 01 02 Request (Direct Cost Only) 04 Year 05 Year 06 Year 3/71-2/72 3/72-2/73 3/73-2/74 All Years No No $1,029,472* Commitment Commitment $1,029,472 (379,234) (650,238) 171,516 174,304 177,236 523,056 1,078,517 869,740 646,777 2,595,034 (118,116) - - (118,116) (495,608) (434,990) (291,555) (1,222,153) (276,885) (234,227) (241,957) (753,069) (187,908) (200,523) (113,265) (501,696) $2,279,505 $1,044,044 $824,013 $4,147,562 $1,029, 459* $1,250,033 $1,044,044 $824,013 $3,118,090 Funding History (Planning Stage) Period 12/66-11/67 12/67-11/68 Funded (d.c.o.) $117,026 $271,185 Western New York -~2- RM 13-04 (AR-1CDS) °2/71 (Operational Program) - Council Funded Future Grant Year Period Approved (d.c.o.) Commitment 01 - 12/67-2/69 $615,015 $615,015 9 -==-=- 02 3/69-2/70 1,445,545. 1,340,769,, 9 --==—- 03 3/70-2/71 1,663,7772/, 1,667,6742/ = 04 3/71-2/72 1,383, 2244! $1,029,459 05 3/72-2/73 124,7882/ 1/Does not include $250,000 for approved/unfunded regional dialysis program. . 2/Includes carryover funding of $486,512 GEOGRAPHY AND DEMOGRAPHY The Western New York Regional Medical Program until recently was composed of eight counties (seven in western New York and one in northern Pennsylvania), but during the last year a second Pennsylvania county has been incorporated into the WNY program, bringing the total number of counties to nine. The largest town in McKean County, Pennsylvania (the recent addition to the Region), is on the New York border, and has a referral pattern dominantly to Buffalo. The Region is bounded by Lake Erie to the west and Lake Ontario to the north. The counties to the east of this Region traditionally have looked to Rochester for medical care. The approximate population of this 8,200 square mile Region is 3,002,000, and it is primarily urban and white. The two metropolitan centers of. Buffalo, New York and Erie, Pennsylvania account for around 750,000 of the total population. The area is served by 57 short-term hospitals with 8,800 beds, four VA hospitals with 3,100 beds, and two state hospitals with nearly 6,000 long-term beds. There are 2,661 physicians, 8,525 active and 4,550 inactive nurses. Major facilities include SUNYAB School of Medicine and Roswell Park Memorial Institute, as well as 15 schools of nursing (four degree-granting), six schools of medical technology, one school of cytotechnology, eight schools of X-ray technology, and one school of pharmacy. HISTORY OF REGIONAL DEVELOPMENT Regional planning was instituted late in 1965, and in the Spring of 1966 a formal planning application was submitted with Dr. Douglas Surgenor, Dean of the School of Medicine at SUNYAB, as interim program coordinator. Generally, the application was received enthusiastically by the reviewing bodies, although there were some questions revolving around the lack of program evaluation and the lack of relationships among the six planning projects which were proposed. After problems regarding the legality of the Health Organization of Western New York (HOWNY) were resolved, a planning award was made in December 1966. Western New York -3- RM 13-04 (AR-1CDS) 2/71 @ In the Spring of 1967 Dr. Ingall became the program coordinator. A planning supplement application later in the year requested funding for new activities and instigated a February 1968 site visit to make a determination as to whether the Region was entering, or should enter, its operational phase. The site visit team reported that the concept of regionalization was recognized and accepted by representatives of all of the counties, that RAG representation was well-balanced, that cooperative arrangements appeared to be substantial, and that administrative procedures were being developed. There was, however, little evidence of a unified approach to priority setting or identification of regional resources and needs. There was agreement that the Region should achieve operational status and an operational award was granted in March 1968. During the nearly three years since its first operational award, the Western New York Regional Medical Program has submitted project applications with regularity. Although there have been two technical site visits, program considerations were not involved, and the Review Committee and the Council have kept in touch with this Region primarily through its applications. Nearly every review body evaluating one of these proposals has commented on the diversity of interests and the wide spread of ongoing Regional activities. Of the four projects for which the national review bodies have recommended disapproval (in the areas of poison control, medical genetics, mass media information to ghetto residents, and atherosclerotic disease) in three instances © the negative recommendation was prompted by the questionable categorical relevance of the proposed activity. The 03 year award of $1,667,674 (which includes $486,512 in carryover funding) is supporting the following activities: Core Planning and Administration $435,902 Telephone Lecture Network 181,053 Coronary Care 168,152 Chronic Respiratory Disease 638,879 Immunofluorescence Service & Training 34,590 Test of Continuing Education Techniques 38,190 Tumor Registry — 63,794 Topical Chemotherapy for Pre-Cancerous Lesions and Cancer of the Skin 47,454 Funded entirely Information Dissemination Service 31,960 through carry- Regional Coagulation Laboratory 27,700 over & rebudget ing There is, in addition, on the books an approved but unfunded regional dialysis program. Western New York ~4- RM 13-04 (AR-1CDS) 2/71 ORGANIZATION AND REVIEW PROCESS \EGIONAL ADVISORY GROUP COUNTY COLMITTEES i 1 1 i I : 1 t t fone /Commaunications j 5 bee Seen: Crepneneanes an . ‘County Comittee ; (BOARD OF DIRECTORS! | | scHool OW MEDICINE ‘Liaison 4 | oF H.0,".N.Y. 1 S.U.N.Y.A.B. Telephone lecture). . | ‘Netuork oy a . See ' . : : a . oo ee pe. | lpersonnel and | _—_{prrecror iBusiness Lanagenent (ee See 4} __ | Associate, . i | hirector MANPOWUES DRVELOLMEHT | eee I |Gxanr 5: IOL . |_| pramumne |--—-_--__ evant On ar To ‘ LC a [AND RLSEARCH: j pan eet TECUHICAL MAVAGEEN cme were cece ree me ona | ot.Py Lisson | The above diagram, prepared by the Region, indicates the functional and organizational interrelationships that exist within WNYRMP. Solid lines indicate lines of authority. Dotted lines indicate specific channels of communication. The Anniversary Application states that this chart is intended to show: the effort within WNYRMP that is given to maintaining lines of communication between the RAG and the Director; the increased regional responsibility for program planning and translating evaluations and research into grant development, manpower development, and management; and the specific RMP staff linkage that has been established with CHP Western New York -5- RM 13-04 (AR-1CDS) 2/71 The Regional Advisory Group (Health Organization of Western New York -- HOWNY) is composed of nine county committees, ranging in size from nine to 78 members each. The total membership currently is in the neigh- borhood of 300. The executive body of the RAG is known as the Board of Directors of HOWNY. The Board has 29 members: nine representing the county committees, nine the county medical societies, with the remaining membership representing CHP, the health departments, Hospital Association, the University and Roswell Park. There are, in addition, three members chosen to represent the interests of urban minorities. The Board of Directors is the final arbitrating body of the RAG. The standing committee structure has been expanded during the last year to include groups on rural health manpower, telephone lecture network, evaluation, and health happenings. These are in addition to the previously existing committees on proposals, by-laws and constitution, coronary care, cancer, stroke, dialysis, and pulmonary planning. The WNYRMP sees one of theprimary benefits of the review process as its value as a continuing education experience for all involved. New project proposals receive preliminary review by the county committees before being received by the Proposals Committee. The Proposals Committee (often with outside technical assistance and reviews by the State Health Department, county health officers, University Department of Social and Preventive Medicine and others) provides a technical review and forwards the project and its report to the Board of Directors. The Board is vested with final decision-making authority. The Board recently has been looking at ways in which it might alter its review process in light of the annual review concept, and is considering the institution of site visits. It is thought that in addition to allowing a continuing reassessment of ongoing activities and priorities, site visits could involve consultants from throughout the Region and strengthen the regionalization process. Other changes contemplated include the establishment of a chronological priority rating system and the introduction of quarterly review of the grand design. The core staff includes 13 professionals, all but one full-time. The Region has been unable to fill a long-vacant slot for Associate Director for Epidemiology, so this position is no longer budgeted. The organization chart outlines current staffing patterns. The core staff pictured in the anniversary application is reflective of the emphasis the Region places on its role as broker/facilitator/enabling agency. REGIONAL OBJECTIVES The Region has developed a grand design, outlined in the Regional Advisory Group report. It is described as a fluid plan which permits easy revision in response to changing needs. Three overall program objectives have been identified: 1. Accessibility to medical care. 2. Quality of care, 3. Economy in the delivery of health services. Western New York -6- RM 13-04 (AR-1CDS) 2/71 In addition, thirteen policies are described. A policy is defined by the Region as a strategy for achieving program objectives. In brief form, the policies deal with: the development of specific relationships; increasing manpower resources and their effectiveness; correcting the maldistribution of health resources; upgrading abilities of health personnel; improving access to specialized diagnostic and treatment centers; developing ambulatory care facilities; developing comprehensive rehabilitation services; improving continuity of care within’ the Region; assisting physicians with information and services; enccuraging projects of patient education; promoting areawide planning and coordination of health services; and improving the management of health problems of the aged. As the Region moves away from project planning and toward total program planning, it will need constant baseline data for the definition and re-definition of Regional problems. The increased planning capabilities on core staff, the hopefully strengthened abilities of CHP (it is now apparently in a slump from which WNYRMP is helping it rise) and the information gained from the Information Support System (supported by an RMPS contract to the Harvard Center for Community Health and Medical Care) are expected to be of help in this regard. The Board of Directors apparently has not yet developed a system for the priority ranking of objectives. Neither have priorities been assigned the new projects in the Anniversary Application for which supplemental support is being requested, although on- going activities are ranked according to their importance to the Program as viewed by the Board of Directors. , PRESENT APPLICATION Continuation Components: The Region is requesting its final year of commitment for the continuation of five components, in the following amounts: Core $379,234 #2-Coronary Care 121, 237 #3-Respiratory Disease 439,962 #4-Immunofluorescence Service 35,359 #10- Tumor Registry . 53,680 TOTAL CONTINUATION REQUEST $1,029,472 The continuation request will be reviewed by staff, and its recommenda- tions will be the subject of a separate supplemental memorandum. Terminal Reports: Final progress reports for Project #6 - Nuclear Medicine, and Project #7 - Test of Continuing Education Techniques, are presented for information purposes only. No further RMP funding is requested. Western New York -7- RM 13-04 (AR~1CDS) 2/71 — Renewal Component Requested Fourth Year Project #1 - Telephone Lecture Network. Renewal $171,516 support is being requested for the fourth, fifth, and sixth years of operation of the Telephone Lecture Network. Although the primary objective of the network is stated to be the provision of continuing education programs to all persons involved in the delivery of health care, it has found wide use by the core staff and Coordinator as an easy access to the health community of the Region, especially for surveys, meetings, regional conferences, etc. It also is used for meetings of the Board of Directors and various committees. In addition to the regular lecture series, the network is helpful to other ongoing activities: it is used eccasionally by the Respiratory Care and Immunoflourescence projects, and it is a necessity to the operations of the Coronary Care Program and the Information Dissemination Service. It has been used for presentation of courses in Spoken English for foreign medical personnel and is used regularly by a community group, Parents of Diabetic Children. This project is considered to be the number-one funding priority by both the Coordinator and the RAG. It is seen as a most successful vehicle for regionalization. The Telephone Lecture Network connection has expanded from 36 to 60 separate locations throughout the Region and two counties outside the geographic boundaries of the RMP. Fifty-three of the receiving units are located in hospitals. Since its inception, over 300 specially-designed educational programs have been presented over the network. A survey is currently under way through which the staff can more thoroughly evaluate the effectiveness of the program and determine the extent of financial support that can be expected from participating institutions (the monthly contribution now is $20). Other avenues of support for the network are being investigated as well. It is stated that the development of a self-support mechanism for the network is of foremost concern to the Region. Fifth Year: $174,304 Sixth Year: $177,236 Requested Additional Components First Year $118,116 Developmental Component: The Anniversary Application explains that the developmental component is fundamentally problem-oriented and ultimately will be shaped by the definition of crucial problems in the receipt of adequate health care. This will involve an examination of new settings for the delivery of health care, new organizational and inter-professional relationships, and new roles for allied health personnel. Although the developmental concept is of an innovative and comprehensive nature, the Region already has identified certain specific areas in which such monies might be put to use: Western New York - 8 - RM 13-04 (AR-1CDS) 2/71 1. Definition of reasons for spiraling health care costs and measures to curtail them. 2. Inquiry into medical care patterns and self-administration of medicine in the area of diabetes. . 3. In association with other concerned agencies, definition of the problems of the underprivileged. 4. Work toward better communications among, and increased social consciousness of, health care planners. The Region intends to apply its developmental monies evenly throughout the first three quarters of the budget year. A priority system will be established, and judgments on distribution of funds will be made by the Board of Directors at intervals during the year. This request is for a developmental award for one year only, to coincide with the remaining year of core commitment. New Projects - Anniversary Application: This Anniversary Application requests support for the initiation of four new projects. The application states that the RAG sees these proposals as consistent with current priorities viewed in relation to the grand design. Project #20 - Regional Bone Pathology Laboratory. The Requested major objective of this proposal is to First Year improve the care of patients with bone diseases by $64,453 establishing a Regional Bone Pathology Laboratory at SUNYAB which will facilitate the diagnosis of musculoskeletal disease by evaluation of the bone biopsy or resected specimen, The consulting service will be aimed at the diagnosis of a wide spectrum of bone diseases, and there will be no charge to the patient, physician, or hospital. In addition, training programs are planned for private physicians and the house staffs of hospitals for the purpose of instruction in the management of bone conditions in their patients. The Telephone Lecture Network will be used for conferences and seminars. Finally, a regional bone tumor registry will be established in order to assess and improve current treatment. The proposal states that in three years, if the project has demonstrated its effectiveness, support will be sought from county and state health departments. Second Year: $48,398 Third Year: $49,567 Requested Project #21 - Choriocarcinoma and Related Trophoblastic _First Year Disease. This request essentially is for $50,856 RMP assumption of support for a Trophoblastic Neoplasia Center established in 1967 by SUNYAB and Roswell Park under a USPHS grant. Grant support was scheduled to continue until 1973 but was discontinued prematurely in September 1970. Although no charges Western New York -9- RM 13-04 (AR-1CDS) 2/71 will be made, the project directors hope the diagnostic services of the laboratory will become self-supporting within the next three years by instituting a schedule of reasonable charges. The purpose of the Center is to provide area physicians the means for diagnosis and follow-up of patients with trophoblastic neoplasia, provide consultative services on treatment, educate young physicians in the management of the disease, and conduct research to improve diagnostic methods and treatment. In addition the high-risk population (which is calculated to be 3,000 in the WNY Region) will be screened annually. Second Year: $52,795 Third Year: $54,830 Requested Project #22 - Comprehensive Continuing Care for Chronic First Year , Illness. This project will be located at $175,625 the E.J. Meyer Memorial Hospital in Buffalo, where a preliminary and small-scale program has been in operation since 1968 to develop a more coordinated approach to the care of patients with chronic diseases. Building on that base, this project will develop a model demonstration program ( using multidisciplinary teams) which will afford comprehensive, continuous care for chronically ill patients, whether in or out of the hospital, and will incorporate into the program the unique resources of a major university teaching hospital. Particular emphasis will be placed on patients who are economically deprived. Educational opportunities for physicians, nurses, social workers, and allied health personnel will be provided. The program will be evaluated to determine its efficiency in improving the quality of care, reducing hospitalizations, improving compliance with treatment regimens, reducing disability, and changing patient and health worker attitudes, as well as to ascertain the costs of such a program compared to the costs of traditional treatment. Second Year: $183,587 Third Year: $187,158 Project #23 - Planning of a Computer-Based Health Data Requested System. This two-year request is for the First Year development of a detailed master plan for a health data $204,674 network for the Western New York Region. Educational programs will be designed to acquaint health professionals with the capabilities and restrictions of the data system. Also, a systems analysis will be conducted to determine current data handling practices, standardization of these practices will be sought, and the data needs of each user will be defined. Finally, small-scale field trials will involve placing experimental terminals in two hospitals, one large nursing home, one health department, and the offices of five practitioners. During these trials, experience will be gained as to the volume and nature of input-output requirements, acceptance by users, problems of confidentiality, Western New York - 10 - RM 13-04 (AR-1CDS) 2/71 acceptable turn-around time, cost/information assessment, and other issues which would affect the design of the general plan. Once the full-scale operation is attained, every effort will be made to switch from external fund support to a self-supporting operation. : Second Year: $150,210 New Projects - Deferred Application: Two projects received ) recommendations of deferral from the November 1970 Advisory Council, although the Review Committee previously had suggested a recommendation of approval with no additional funding, and with the condition that no RMP monies be funnelled into Project #19 because of its inappropriateness for RMP support. In reviewing these two proposals, both Committee and Council had difficulty determining the relationship of project goals to Regional priorities and objectives, primarily due to an absence of a description of the Region's overall plan as well as the amorphous nature of project goals. Requested Project #18 - A Model Program for Comprehensive Family Health First Year The major objective of this project is to $170,977 demonstrate the efficacy of a multidisciplinary team approach to the provision of excellent primary medical care to a representative cross section of society. The Deaconess Hospital of Buffalo, the sponsor of the proposal, has established a Family Practice Center with a director, staff, including seven residents, and a waiting list of patients. RMP support is requested for those portions of the program related to community health nursing, medical social work and nutrition, and to study the applieation, utilization and correlation of these disciplines as applied to ambulatory patients. Funding is not requested for the service component or the residency training aspects. The development of the family practice model at the Deaconess Hospital will emphasize the four parameter of demonstration, education, research, evaluation and assessment, and service. Second Year: $138,310 Third Year: $142,406 Requested Project #19 - Prevention and Treatment of Respiratory Distress First Year Syndrome Due to Hyaline Membrane Disease in $105,908 Infants. The proposed project will be located at both Children's Hospital of Buffalo and the Roswell Park Memorial Institute. A study has been conducted in the use of urokinase activated human plasmin in infants with respiratory distress syndrome. Results of the study indicated that in the plasmin treated group there was a doubling of survival time, while in the sub-group consisting of those whose birth weight was two kg or less, plasmin therapy tripled survival rate. The purpose of this project is to extend the benefits of this study to all infants in the region. Two independent studies are planned: Western New York -1ll - RM 13-04 (AR-1CDS) 2/71 1. Prevention of respiratory distress syndrome with plasminogin. 2. Treatment of respiratory distress syndrome with streptokinase activated plasmin. If studies are successful, plans call for the introduction of these methods to all hospitals of the region which would be handling such infants. Second Year: $95,917 Third Year: $99,551 Approved/Unfunded Projects: These three activities received approval from previous Councils but have not been funded by RMPS. This year, however, project #'s 13 and 14 were initiated by theRegion with carryover funds and project #16 through rebudgeting of basic grant funds. Consequently, these activities have no future commitment. Requested Project #13 - Topical Chemotherapy for Precancerous Lesions Second Year and Cancer of the Skin. This is a proposal $49,631 for a program to provide community physicians a recently- developed technique of topical chemotherapy for the prevention and treatment of precancerous growths (solar keratoses) and cancers of the skin. The program was planned for three phases: I. Developing an operational system for implementing, co- ordinating, and evaluating the program. II. Professional education. III. The actual operational phase during which topical chemo- therapy will be performed as a treatment method.- Phase I was aided greatly by the Buffalo-Rochester Dermatologic Society which supported the project and formed a liaison committee for this activity. Phase II has been initiated and is progressing smoothly. Although PhaseIII will be deferred until Phases I and II have been completed, a number of physicians who have specialized training and experience will start this operational phase on an exploratory basis. This will provide information to guide the general implementation of Phase III. The two further years of support requested are consistent with the second and third years of support recommended by the December 1969 Advisory Council. Third Year: $52,180 Requested Project #14 - Information Dissemination Service. The Second Year objective of this program is to es- $38,275 tablish an information dissemination service to provide the physician and other health professionals with printed information from a broad spectrum of medical and scientific journals and books and to alert them to new developments in Western New York - 12 - RM 13-04 (AR-1CDS) 2/71 their field of interest through a current awareness service. The Telephone Lecture Network is the communication link used in this activity. The Health Sciences Library at SUNYAB is designated as the resource medical library. To date, 34 of the 53 hospitals in the telephone lecture network system have received orientations as to the services offered through this project; meetings have been arranged with the remaining 19 hospitals. Personnel at each participating in- i stitution are designated to channel requests to the resource I. library. As of July 1970, 72 requests for services had been received and filled. It is hoped that ulitmately the information dissemination services can be supported by hospitals and the local medical societies. The requests for second and third year of support for this project are approximately $6,000 in excess of the amounts approved by the November 1969 Review Committee. Third Year: $39,515 Requested Project #16 - Regional Coagulation Reference Laboratory First Year This proposal originally was submitted to $100 ,000 the February/March 1970 review cycle as a request for the establishment of a blood coagulation reference laboratory which would have training, service, and research components. Roswell Park Memorial Institute had been providing some free services in this field, but increasing community needs and decreasing funds for Roswell Park prompted the submission of this proposal. After a technical site visit, the June 1970 Review Committee recommended 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 to concentrate only on the training of technicians from outlying hospitals to perform coagulation tests. It was thought that a first year budget of $60,000 and second and third year budgets of $40,000 each would be sufficient for such an endeavor. The subsequent Council agreed, but expressed its willingness to allow the Region to increase the funding of this project to a maximum of $100,000, providing such a level of funding would be required to maintain this valuable regional resource. In September 1970, after assurances that the Laboratory was developing in the direction of training technicians from outlying hospitals, the Region received permission to rebudget $27,700 into this laboratory to retain trained staff personnel until the end of the current budget period. At the time the progress report was prepared, three technicians were receiving training, schedules were being established for two physicians, blood coagulation studies were being carried out, and physicians associated with the center had participated in 40 consultations. Three years additonal support is requested. Second Year: $108,828 Third Year: $113,265 GRB/RMPS 12/9/70 (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE: WESTERN NEW YORK REGIONAL MEDICAL PROGRAM RM 13-04 (AR 1CDS) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL . RECOMMENDATION: Additional funds be provided for this application. Committee _Year_ Request Recommendation 04 $1,250,033 $359 424 05 $1,044,044 $374,827 06 __$824 013 $113,265 TOTAL $3,118,000 $1,024,752 1 CRITIQUE: The Review Committee agreed with the site visit team that this Region has not yet completed the transition | from project to program emphasis, although it does appear to be trying. The Committee did not agree withthe site team's recommendation to provide developmental funding. In committee's view this Region is not yet ready for this type of flexibility. The Regional goals are global in nature and the strategies for achieving them (termed "policies" by the Region) even though more specific, appear not to ‘be based on a rational assessment of Regional needs. It was thought that the collection of projects for which funding is requested did not reveal a sound review process so far as blending proposed activities with overall goals of the Region. Although the RAG is composed of nine county committees and has a total membership in the neighborhood of 300, the final arbiting --body is the 29-member Board of Directors. ‘The Board is heavily -physician—oriented, and the Region is considering the possibility of expanding the membership with the addition of nine additional. non-physician representatives. The Review Committee agreed with the site team that the Region should be encouraged to accomplish this expansion. It was also thought that the decision-making and priority-setting role of the RAG should be strengthened. The “county committees were seen as having outstanding potential as forces for subregionalization, and the Review Committee, and the site team were in agreement that the Region should be urged to diversify the functions of these groups to include activities “beyond the mere review of projects. The county committees could serve as vehicles for genuine grass roots participation in program development. Western New York . . RMP ~2- RM 00013 The extent to which the resources of the Region have been involved in the WNYRMP was seen as one of the most exceptional features of this program. This has been accomplished by dint of constant concentration on this goal by the Coordinator and the Core Staff. The Region is beginning to make inroads in assessing the needs of the area and developing a planning base to use as a guide for the development of a total program and the setting of priorities. Likewise, efforts are being made in the direction of program. evaluation. Since the WNYRMP will be requesting core renewal in another year, and RMPS will then have another opportunity to take a close look at this Region, the reviewers thought it would be well if the Region devoted the coming year to completing its transition from project to program orientation, with emphasis on: _1. Developing. a sound program plan and priorities, based on identified Regional needs. 2. Increasing the decision-making role of the RAG and diversifying its membership through the proposed expansion. 3. Developing the county committees into something other than mere project review bodies, and working toward realizing their potential as forces for subregionalization. Consequently, the recommended monies for the Region's 04 year, although increasing the absolute award, represent a decrease from the 03 year operating level, which had been increased through the use of large amounts of carryover. The 03 year basic award of $1,181,162 was expanded to $1,667,674 by carryover. The 04 year suggested award of $1,388,883 represents a combination of continuation funding of $1,029,459 and renewal and supplemental funding of. $359,424 recommended by this Review Committee. Since no projects in the current application will be specifically disapproved, the feeling was. - that the recommended award is one which will maintain the Region during its 04 year but also force it to make decisions about. exactly where the money will be applied. The discussion below outlines ‘the basis on which the recommended new and renewal funding of $359,424 was calculated. It should be noted that this. is somewhat different from the funding level arrived at by the site.team, although it was prompted by the same considerations and is merely a slightly different means to the same end. DEVELOPMENTAL COMPONENT: Although the site team had suggested ~ : one years developmental funding on the basis of this Region's potential for imaginative use of these monies; the Review Committee was not persuaded that this Region was quite ready for a developmental component. The recommendation of the’ disapproval of developmental funding was based on all the deficiencies noted above as well as the RAG' s not yet having developed precise 7 ~ Western New York -3- . RM 00013 RMP RENEWAL REQUEST: The Review Committee agreed with the site team that the Telephone Lecture Network, for which renewal funding is requested, is one of the most exciting activities in this Region. It has been used in very imaginatiye ways. It ’ 4s an integral part of many ongoing and proposed projects, and is a definite force for regionalization. There was unanimous agreement that renewal funds for this component should be included in the award, although it was suggested that if the Region were to increase the presently nominal financial contributions by participating institutions, award monies would become available for rebudgeting into other regional activities. APPROVED/UNFUNDED: There are three projects which have received . approval from previous Councils but have not been funded by RMPS. During the 03 year, however, these three projects were initiated with carryover funds and through the rebudgeting of basic grant funds. Topical Chemotherapy for Precancerous Lesions and Cancer of the. Skin Information Dissemination Service . Regional Coagulation Reference Laboratory The Region is requesting that supplemental funds be awarded for the continued conduct of these activities. Although the site team had recommended supplemental funding calculated on the request for only one of these projects ( Information Dissemination Service) because of the good job it does in promoting regionalization, the Review Committee thought that since the projects already had been initiated, the entire request for their continuation should be recommended. The decsions to include these funds in the calculation of support really was an attempt to bring the Region's funding for the 04 year to a workable level, and it was recognized that the Region would have the option to rebudget these monies among Regional components as it saw fit. NEW PROPOSALS: The four new projects in the anniversary package and the two projects which were deferred by November Council for the site visit, brought the total number of new projects for which supplemental funding was requested to six. Regional Bone Pathology Laboratory Choriocarcinoma and Related Trophoblastic Disease Comprehensive Continuing Care for Chronic Illness Planning of a Computer-Based Health Data System A Model Program for Comprehensive Family Health Prevention and Treatment of Respiratory Distress Syndrome Due’ to Hyaline Membrane Disease in Infants Western New York ~4- RM 00013 RMP e- Since the Region did not demonstrate, and the site team could not discover, the relationship of these individual components to the overall program, and since there were no sound Regional priorities, the Review Committee agreed that there was no basis on which to. judge these proposals. Their technical sufficiency was presumed to be adequate, but the review process which approved these activities without any mesh with the overall Regional plan was questioned. In the absence of any basis on which to assess these activities the Review Committee agreed with the site team that although none should be specifically disapproved, they should not be included in the recommended funding calculation. This would not prohibit the WNYRMP from rebudgeting into any of these six activities. FUNDING CALCULATION First Year Committee Type Request. Recommendation Developmental Component $118,116 = 0- Renewal $171,516 $171,516 Three Approved/Unfunded $187,908 . $187,908 Six New Projects $772,493 Oe Total Supplemental Funding — $359,424 Dr. Perry was not present at the deliberation of this application. : 1/20/70 ~ GRB/RMPS REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REV 5 es 9 PROGRAM 5] 2 Se ; Zia |e OBJECTIVES 5 ol! ! Hie |g Re | t iq a Qa ’ 4 4 a kJ ‘ t ' i i 1! i) t 1 t f ! t J 1 i 4 1 t ' : COMMUNITY | ! TRUSTEES HIPS AREA 1 PRIORITIES ' t i i] t t 4 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIiW AND AWARD GRANT APPLICATION (A Privileged Communication) WEST VIRGINIA REGIONAL MEDICAL PROGRAM RMO0045 2/71 (C&S) West Virginia University Medical Center January 1971 Review Committee Morgantown, West Virginia 26506 Program Coordinator: Charles D. Holland Requested (Direct Costs Only) 02 03 04 All Purpose 1971 1972 : 1973 : Years Continuation']/ $535,467 $515,965 -O0- $1,051,432 Core l/ 485,713 490,740 - 0- 976,453 2 projects 1/ 49,754 25,225 -0- 74,979 1/ Includes $18,900 Carryover ($18,000 - core staff for renovating new quarters and $900 for project #6 (Helicopter Study) Supplemental $173 ,829 $186,094 $167 ,561 $ 527,484 Developmental - 0 - -0- -0- -0- Renewals -0- -0- - O0- -0- New $173,829 $186,094 $167,561 $ 527,484 3 projects Total Request $709,296 $702,059 $167,561 $1,578,916 *S8taff Action 535 467 515,965 -0- 1,051,432 Committee and Council Required Action $173 ,829 $186,094 $167,561 $527 ,484 *RMPS staff reviewed the non-competing 02 year continuation portion of the application and recommended approval in the amount of $534,567 including the use of $18,000 carryover funds for renovating new headquarters. G HISTOR d.c Planning: 01 1967 $ 150,798 02 1968 350,717 03 1969 378,045 WEST VIRGINIA RMP -2- RM45 2/71 (C&S) OPERATIONAL - Grant Year _Period Council Approved Funded _Commitments 01 1970. $395,048 $395,048 02 1971 $516,567 03 1972 515,965 APPROVED UNFUNDED PROJECTS (d.c.o.) ' lst_yr- 2nd yz. 3rd_ yr. Total #8 Self Audit $138,901 $184,556 $147, 292 $470,759 #9 Hosp. Assistance 33,583 32,626 -Q0- 66,209 #10 Multi-Unit 50,563 42,304 42,083 134,950 Comaunicetions Total $223,047 $259,496 $189,375 $671,918 GEOGRAPHY & DEMOGRAPRY: Land Area: 24,079 square miles Populations 1,811,000 Urban 38% White 95% Median Age 28.5 Mortality per 100,000 Heart Disease 422 Cancer ; 168 CNS Vasculer Lesioas 115 Facilities: 1) West Virginia University School of Medicine - 4 yr. school {enrollment approx. 250) 2) Eleven schools of nursing 3) Seven schools of medical technology 4) Ninety-one hospitals (5 federal) with 15,963 beds (1,396 federal) Seventy~-six ere short-term facilities. Personnel: Physicians (1968) 1550 (85,6/100,600) Csteopaths (1968) 112 ( 6.1/100,000) Registered Nurses (1966) 5011 (276.6/100,000) HISTORICAL DEVELOPMENT: In December 1965, De. Clark K. Sieeth, then Medicine, Bean of the Weet Virginia University School of convened a meeting to discugs the State's participation in RMP. The meeting was attended by representatives of the State Departments of Health and Welfare, the West Virginia Heart Association, the West Virginia Division of the American Cancer Society, the West Virginia WEST VIRGINIA DMP ~ 3- RMGS 2/71 (C&S) ny Medical Center and the general public, 5 cipate, the Medical Center was selecred to 4 ate aad coordinace plenmming to establieh the WURMP. A 26-member RAG was appolated and br, Sleeth was elected chairman, The RAG appointed a l2-wewher etafi committee to prepare the planning grant application. Hospits? Assoc! This Region received « slanning grasit for three yeurs beginning January 1, 1967. The amount awarded the second year included a supplement of $141,807 for four feanibilicy atudies; (1) Survey of a Hural Area (Blackwville); (2) Mechanical Morbidity Reporting by Phyeicians; (3) Corenary Care Unit; and (4) Physicians Self-Audit. The latter three were also sepported in the third year. The third year was extended seven months to dugust 31, 1970, and che Seif-Audit to September 30, 1970, with no additional funds. A site visit was made ia July 196° to asseas the Region’s capability to become operational. It was useted that when the WVRMP began, it nad many obstacles to overcome. The State suffered from critical economical crises, leaving most areas without adequate heaith care, Smail towna, rural and mountain areas, so predominant in West Virginia, lacked health personnel. The medical school waa only 11 years old and there was little evidence of effective continuing education into the hespitaia and medical profession, Adding to these problews, Br. Wilbur the Regional Coordinator, recruited in June 1967, died in January 1969. Mr. James G. Holland, Associute Coordinator, was serving as Acting Program Coor- dinagor. Despite the dearth of resources and the unfilled coordinator position, the site visitors believed the Region was veady for operational status. The West Virginia University Medical School had taken anu active role in the WVRMP and good physician and nurse parcicipation was evident. ‘Tre Region had also established appropriate cooperative arrangements. As pointed out to the Region, there was a need for mech better minority representation on the RAG. The 35-member RAG had only recently organized its committee structure, (Executive Committee, Project Review Coumittee, four planning Committees, and nine Sub-4rea Advisory Groups) and it wastoo early to determine how well it was working. + Sub-area offices based on joins plawning with Comprehensive Health Planning were projected for the near future. The August 1968 Council recommended approval for operatioual status for three years for core and four projects. Mr. Charles BD. Holland was appointed Regional Coordinator. To provide appropriate super- vigion of the medical aspects, a special Medical Advisory Cowmittee was cone stituted to assist the Coordinator. GOALS AND OBJECTIVES; Ag originally etated, the overall goal of WVRMP is to assist the aation’'s health resources in twking che best possible care for patients with heart disease, cancer, stroke and related diseases, Kidney diaecase has been added. The objectives have been refined and set to a time frame for management-monitoring. (Section ITiI - Appendix). Objectives: 1) Stimulate effective responses to community and area heaith needs by developing an waintaining a ayatem of area offices. 2) To provide for description and evaluation of health care systems for the purpose of pro- gram planning aad develooment by securing, walntaining and analyzing basic data concerning health related variabies - focusing particularly on facilities, personnel and their utilization. 3) To enhance patient care by essieting in WEST VIRGINIA RMP ~4- RM45 2/71 (C&S) the establishment of improved methods of continuing education for physicians, nurses and aliied health personnel. To assist in the establishment of new types of health manpower programs, to expand the capabilities of the tradi- tional health care providers and gain their acceptance through continuing education. 4) To analyze current problems and patterns of emergency medical care and to promote improvement. 5) Within the constraints of limited health resources, develop innovative programs to support rural family health maintenance. 6) Promote the development of necessary cooperative arrangements among health providers and related groups to improve health care. PRIORITY RANKING: lst level’ 1 + Core 2nd level (Continuation of on-going funded activities) 1 - #4 Nursing Care of Stroke Patients : 2 - #6 Helicopter Study 3rd level 1 - #11 Rural School Health 2 - #12 Cancer Education and Service 3 - $10 Multi-Unit Communications 4, = #13 Hospital Service 5 - #8 Self Audit 6 - #9 Hospital Assistance ORGANIZATION: The present application includes the annual report of the RAG, much of which is alluded to in this summary. — The organizational structure includes a RAG of 35 members which meets auarterly. During interim meeting of the RAG, a seven-man Executive Committee is authorized to transact business. ‘The WVU Medical Center Staff Committee is a special Com- mittee to guide the Coordinator and his staff. Other committees (40 members) include Planning, Review and Evaluation, Education, Demonstrations, and Research. Project applications are reviewed by the Review and Evaluation Committee, CHP "A" and "B" Agencies. The final review and recommendation is by RAG. The RAG is definitely not a rubber stamp group as evidenced by their change in the pricrity ranking of projects (Section III, pages 76-77). Ags indicated in the narrative some of the reviewers tend to ignore the criteria. Core staff is awate of the problem and believe promised guidelines from RMPS may be helpful. The number of professional core staff has increased from 16 to 20; an acdition of two field staff, a physician consultant and a pediatric nurse consultant. Because of the required travel, efforts failed to recruit an assistant Director and this position has been changed to Coordinator of Field Services. The Associate Director is now for Planning and Development. Other changes includes the addition of a Physician Consultant and Research Assistant. Clerical and secretarial positions have been increased from 9 to 11. Core progress includes staffing four of nine sub-regional offices. Two additional offices will be staffed during the second year. Core studies have included: hospital patient WEST VIRGINIA RMP ~5 - RM45 2/71 (C&S) s low; medical students’ choice of practice and iccation; rural health patterns nd resources: characteristics of users and the operation of emergency system in 4 complex medical facility. Activities have also included working with the RAG, Committees and project applicants in »rogram develepwent. Three core staff (a physician, nurse and secretary) will be committed for about one year in the development of a Pediatric Nurse Practitioner preject. Plans also include study and necessary planning for innovations in health manpower and renal disease. Efforts will include more involvement of the allied health professions, particularly physical therapists. RESOURCES: Cooperative arrangements with appropriate agencies continue, Most notable are those with the State Medical Society and CHP, A and B Agencies, There are no model cities programs in W. Va., but there are humerous 0,E,0, sponsored Community Active programa of which WVRMP has had contact with four-significant mutual activities are anticipated, The great distance between the central WVRMP in the northern part of the state and the Southern West Virginia Regional Health Council has been a deterrent to a coordinated effort in the Appalachian 202 multi-county demonstration in the southern part of the State. However, the two agencies continue to work toward the development of a "Guest- -Residency Program" in the Appalachian area. CURRENT PROJECTS: Of the four approved and funded projects during the first year, three were implemented and RMPS staff believe that progress is satisfactory. One (#1-Education for CCU Staffs) was funded for one year, but will continue after cessation of RMP support. Continued support s requested for continuation of #4 - "Nursing Care of Stroke Patients" for ts second year. Continuation is requested for two additional years for #6 ~ “Helicopter Feasibility Study." Project #5 = "Stroke and its Treatment" approved and funded for one year by RMPS ($31,400) was not implemented because of the problems in personnel recruitment. An unexpended balance of approximately $145,000 is anticipated in the current year and ig reflected mostly in the core budget and by not + funding project #5. EVALUATION: The Review Committee has responsibility for evaluating project proposals and recommending a priority ranking to the RAG. Core Staff ‘ts responsible for monitoring projects. However, detailed information about evaluation is Lacking. NEW PROJECTS: Requested , First Year Project #11 - Progressive School Health Programs for $89 , 366 Rural Cemmunities Sponsored by the Upshur County Board of Education at Buckhannon, the objective of this project is to develop a model school health program that can be repli- cated within the constraints of limited financial and human resources in rural areas of West Virginia. The project will have two elements: 1) education and 2) services. The school education aspect will be undertaken by training ele~ mentary grade teachers in curriculum content for health education. This ap- roach wiil be carried into higher grade levels later as curriculum develops @:: is available. The health services aspect will be directed by a registered nurse assisted by a school Health Assistant. The Health Assistants, a new type of manpower, will be trained (six the first year) to perform many tasks now WEST VIRGINIA REP -“ 6° BM45 2/71 (C&S) done by the school nurse. Supalemental services of a dental hygienist, pedi- atric nurse prectitioner ond physictan conguitant are pleuned. ‘he difference from other cimilar school programs is the planned followevp with fanily and community resources through the use of the school Health Assistant. Evalvation tc planned in terms of measuring progress in implementation and ultinate impact “£ the project. Plans include efforts to secure other sources of funding after cessation of WVRHP grant support. Second year Third year $86,791 398,154 . Requested Project #12 - Cancer Education end Service First Year $52,956 ‘ Sponsored by the West Virginia University Schooi of Medicine, this is a Cancer registry focused education program for 63 hospitais. Each of the hospital's registries will be the educational outlet for upgrading cancer information resulting in improved cara of cancer patients. The project will provide avail- able text books, periodicals, audio visuals and hardware to registry directors. Efforts will be made to utilize the existing West Virginie University Nurses Service's tele-lecture. unit heok-up to 45 hospitais (34 have tumor registries). Ags igtance will be given to registry directors to develop more meaningful information and follow-up progrems. in cooperation with the Liafeon Fellows of the American College of Suvgzons, the Anerican College of Radiology Comittee on Caccer Management and the Cancer Contrel Division of the West Virginia State Department of Heaith, problem-oriented workshcps are pierned through the West Virginia Chapter of Tumor Registrars. The current limited distribution of the annual report by the Central Registry is to be incressed to include all the physicians in the State. Evaluation will be based on the end resuit reports ~ hopefully improved survival. Continuation of the project supported by ozner scurces is planned after terni- netion of RMPS grant support. Secoud Year Tailed Year $53, 392 $55,252 Proicet #13 - Seczintebecur of Hespical Service Arveas Requested First Year $31,507 The ;ucpose of this prejece is to provide hecpitals in tie State more infor- matioa upon which to base incividual end cegional slauning decisions. Objectives: ij learn more about patient cherecteristics; 2} learn more about hospital information ceeds 3) develep some compatetive meacures of hospital care delivery; 4) sein better vaderctanding of type ond size of the community hospital planning onit woct uyptopriate to better aelivery of hospital cares 5) suetain the impetus for regional planning by input - to effect better hospital care; and 6) foster additionci resesréh on problems of health care delivery. The definition and anelyois of “marketing” areas will be used to assist in planning for exparsion of services and facilities; deternining areas and potential WEST VIRGINIA RMP -jJ- ; RM45 2/71 (C&S) patients that are not now adequately served, physician referral relationships, etc. The project will be completed in two phases during the 29-month period. The first phase (January ~ December 1971) test demonstration in a four-county. area which includes 5 hospitals and approximately 120 physicians. The second phase beginning in January 1972 will be implementation of the project on a state-wide basis to include 75 in-state hospitals,:19 out-of-state hospitals and about 300 physicians. The prograw is one of investigation and RMP continued support after the project period is not indicated. Second Year Third Year $42,911 $14,155 GRB/12/17/70 Revised 1/15/71 WEST VIRGINIA UNIVERSITY REGIONAL DIRECTOR ee eee een eeeee eee eeee ADVISORY GROUP EXECUTIVE COMMITTEE ASSISTANT TO INFORMAT LON THE DIRECTOR OFFICER STANDING COMMITTEES COORD INATOR- ASSOCIATE DIRECTOR FIELD OPERATIONS PLANNING AND DEVELOPMENT LKINS AREA PARKERSBURG HUNT INGTON OFFICE AREA OFFICE AREA OFFICE PROGRAM BEHAVIORAL BIOSTATISTICIAN RESEARCH PLANNER SCIENTIST ASSISTANT ORGANTOWN BECKLEY AREA CHARLESTON REA OFFICE OFFICE AREA OFFICE NURSE : PHYSICIAN CONSULTANTS CONSULTANTS pO NEST VIRGINIA UNIVERSITY STRATEGY FOR VOLUNTARY COOPERATIVE ARRANGEMENTS POT TTT TR ew mw mw me mm me reer t ! t ' t I i PROGRAM s June nee ene ee nee eee i ADVISORY GROUP DIRECTOR ' ! f ' ' EXECUTIVE COMMITTEE ' t ' t ‘ 1 ' i ; PLANNING COMMITTEE ' ' t 1 RESOURCE SUB- : 1 COMMITTEES FOR 1 ELIGIBLE ACTIV- BZ]! ' ITIES n HI ae i S m alt t me Se 1 SI HE] 1 : z, SS i REGIONAL SUPPORT TO RAG s| 5 ed S PROGRAM s) Z Pel CEPLCE AND COMMITTEES T e)2 |e OBJECTIVES 5 ool | ! a |S | 5 Ray} i n 2 > t t al a $ t me Q ea) i cerearaveunrenemananvnrmmiinescammanenens dt i ! t _ i q ' i i t 1 1 ft AREA \ i OFFICES x 9 ' i COMMUNITY i SYSTEMATIC PROGRAM _¢ TRUSTEES HLPS AREA DEVELOPMENT PRIORITIES i ' neater inannarmrntammaca all 5 1 1 ! ~10~- DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION December. 17, 1970 Staff Review of Non-Competing Continuation Application from West Virginia Regional Medical Program - Ri 00045 - 2/71.1 (C&S) Acting Director Regional Medical Prograiis Service * Fp EOS : fo [a Through: Chairman of the MonthS% ~~ as futon Acting Chief, Regional Development Branch eye West Virginia Regional Medical Program requests continuation support for the 02 onerational year for Core and two projects, plus use of $900.00 carryover. Staff concurred on the following recommendations: 1. Support in the committed amount for Core and Projects #4 and #6. 2. Disapproval of the $900.00 request for use of anticipated carryover. (Staff concurred that the activity planned for the use of carryover was needed and justified. However, lag-time in recruiting staff for Core in the 02 year should provide the funds necessary for support of this request. ) Summary of action recommended: 02 Year Staff Committed Asiount Requested Recommended Core $467,713 $467,713 $467,713 Project #4 15,054 15,054 15,054 Short Term Training Nursing Care of Stroke Patient Project. #6 33 ,800 34 ,700* 33,800 Helicopter Feasibility ee , ee _— Total $516,567 $517,467 $516,567 * Includes request for use of $900 anticipated carryover. -il-e- Page 2 - Acting Director, RMPS west Virginia RMP was approved. for operational status effective January 1, 1970, with funds provided to support Core and three Projects: ' #1 ~ Education for CCU Staffs (1 yr.), #4 - Nursing Care of Stroke Patients (2 yrs.) and #5 ~ Stroke and Its Treatment (1 yr.). In May, 19/0, Project #6 - Helicopter Feasibility Study was approved and funded. , The present application was submitted in the AR format presented at Airlie House and contains a request for supplemental funds to support three new projects as well as continuation support for Core and the two projects with commitments for the 02 operational year. No develop- mental component was requested at this time; however, a request was included to utilize $900.00 anticipated carryover. Staff review did not include consideration of the supplemental request as this will be considered by committee and Council in the January-February, 1971, Review Cycle. Staff discussion of the application included the orgar- ization, structure and functions of Core, the RAG, Executive and otner Committees, Regional priorities, accomplishments, etc. Staff noted Project #5 - Stroke and Its Treatment - approved for one year only, was never activated due to loss of two key project staff with no hope for replacement within the one year period. Reviewers concurred progress reported for Core and Projects #1, #4 and #6 was satisfactory. Project #1 was well received and provided training for a greater number of applicants than had been anticipated. As previously noted, this project was approved for one ycar only. The activity will continue on a reduced scale with non-RMP support. Staff also discussed a potential problem which developed in the Region after submission of this application. The University of West Virginia Medical Center can no longer assure contiguous space for new RMP staff - added to Core and is negotiating with a hotel in downtown Morgantown for a suite of offices for Core staff headquarters. It is anticipated approximately $18,000 will be needed to refurbish this space. At this time funds are available in the Region to support this. However, jt is uncertain whether arrangements can be completed prior to termination of the current grant year. In the event arrangements cannot be completed within the current grant year, staff agreed a request from the Region for use of carryover (or for new funds if policy precludes use of carryover) would be needed, and justified particularly for this one- time only expenditure. = Page 3 - Acting Director, RMPS Staff also highly recommended that all due consideration be given to funding the three projects recommended for approval by the National Advisory Council in the November 1970 meeting. It is the consensus of Staff that these activities are sorely needed to give the Region visibility and to assure continued support of affiliated and coop- erating groups and individuals in the Region. The following staff members participated in the December 7, 1970, meeting: Mr. Frank Nash, RDB Mr. Larry Pullen, GMB Dr. Margaret Sloan Mr. Luther Says, GRB Miss Carol Larson, CT& Additional comments submitted by reviewers are appended. aa Li ys f Le nde Verh Frank S. Nash Operations Officer Regional Development Branch Attachments Approved ¢-~ Date afefa _ Disapproved : [7g Zigeldd [ware qitiea Harold Margulies ,/M.D. Acting Director, RMPS \ 1 ! A PRIVILEGED COMMUNICATION SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTER WEST VIRGINIA REGIONAL MEDICAL PROGRAM RM 00045 2/71.1 (C & $8) FOR CONS IDERAT ION BY FEBRUARY 1971 ADVISORY. COUNCIL Recommendation: The Committee considered this application which includes requests: 1) continuation support for core activities and two projects and 2) supplemental support for three new projects. In reaching a recommendation for the level of funding, the Committee also considered three projects previously approved by Council but unfunded, and their program relevance including rank order by the WV/RMP, Funds requested by WV/RMP and recommended by Committee are as follows: Direct Cost Year Requested ; Recommended Funding . 02 1/ $ 932,343 © 2/ $ 776,567 03 1/ 961,555 , 2/) | 775,965 04 1/ 356,936 2/ 260,000 Total $2,250,834 ~~ $1,812,532 The Cowmittee also recommends that its concerns be communicated to the WV/RMP, Direct Cost A/ Request — 02 Year 03 Year 04 Year Continuation Core & 2 projects $535,467 - $515,965 -0- 3 New Projects 173,829 _ 186,094 $167,561 Sub Total $709,296 $702,059 $167,561 Approved & Unfunded 223,047 259,496 189,375 : . . . | | Total $932,343 ~ $961,555 $356,936 2/ The second year continuation request was reviewed by staff and $516,567 d.c.o. was recommended. Committee recommended additional funds in the amount of $260,000 each year for three years for new projects. a West Virginia RMP ~2- "RM 00045 2/71.1 (C & S) Critique: The Committee noted that although the Region has been operational for only one year, the program seems to be moving forward under effective leadership. The requested level of support is modest, particu~ larly in view of the dearth of needs in the State, The Committee noted the new core staff positions budgeted and wondered if ‘they could actually be recruited. As reported by staff, the Coordinator on a recent visit to RMPS indicated he expected no great problems in filling the positions. The. Rural School Health proposal, ranked first of the six new projects by the RAG, is an interesting concept and worthy of support. The Committee, however, was concerned about the assurance of adequate follow-up. The question arose as to the number of pediatricians available in the target area and a clearer statement of follow-up care is needed, Also, the amount budgeted for consultant services is high. By the nature of the goals of the "Cancer Education and Service" project, the current registry program appears to be only aquisition of data. . : The project is designed to upgrade and stimulate utilization of information gathered, Like Council, the Committee has little enthusiasm for the program. ‘The Committee believes that if WV/RMP considers funding this project, '. they should be aware of the November 1970 Council's discussion and action about. registeries. The Committee believed that the "segmentation of hospital service areas" project is a study concept that might be more appropriate as a Core planning activity and/or CHP. It would seem that some of these data would have been acquired during the WV/RMP planning phase. The concept of medical-self audit as represented by project #8 is recognized as a very innovative activity in WV/RMP and of great interest. , RMPS /GRB/1/19/71 3 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION © (A Privileged Communication) Wisconsin Regional Medical Program, Inc. RM 00037-04 (AR-1-D) 2/71 110 East Wisconsin Avenue , January 1971 Review Committee Milwaukee, Wisconsin 53202 Grantee Agency: Same Program Coordinator: John S. Hirschboeck, M.D. Request (Direct Costs) Purpose 04 year (9/1/70 - 8/31/71) Additional Component (Developmental) $200,000 Funding History Planning Stage Grant Year Period Funded (d,c.o.) © 01 9/1/66 - 8/31/67 $319,458 Operational Program Council Future Grant Year Period . Approved Funded (d.c.o.) Commitment 01 9/1/67 - 8/31/68 539,366 Core 415,093 = -#e--- Proj. 133,773 02 9/1/68 - 8/31/69 1,365 ,463 Core 438,974 = = 9 «9890 Proj. 723,707 03 9/1/69 - 8/31/70 1,338,194 Core 438,974 = = 9 +se-4- Proj. 800,536 1/ 04 9/1/70 - 8/31/71 1,794,257 Core 438,974 = = = 9 20-2" Proj. 1,153,299 2/ 05 9/1/71 - 8/31/72 499,425 $484,120 06 9/1/72 - 8/31/73 442,805 442 , 805 1/ Includes $141,080 Carryover © 2/ Includes $60,704 Carryover Wisconsin RMP -2- RM 37-04. (AR-1-D)2/71 Geography : The boundaries of the Wisconsin Region are coincident with those of the State. The University of Wisconsin Medical School sphere of medical care influence includes parts of Minnesota, lowa and Illinois; similarly, the Marquette University School of Medicine has medical care influence in the Michigan peninsula and part of Illinois. pemography: A. Population: approximately 4.5 million 1. Roughly 64% urban 2. Roughly 98% white 3. Median age 29.4 years B. Medical Schools: 2 C. Hospitals: Approximately 200 D. Physicians: 4,803 (medical) Region's Objectives: The objectives fall into three categories; those related to direct patient care, those related to requirements for effective support of direct patient care; and those related to basic research. The objectives are as follows: . Develop a plan to improve preventive medicine capabilities throughout the region in the fields of heart disease, cancer, stroke, and related diseases. Plan to improve diagnostic capabilities with the region as related to heart disease, cancer, stroke and related diseases. Plan for improvement of the capability within the region to provide long-term medical care and rehabilitation for patients with heart disease, cancer, stroke, and related diseases. . Improve patient care through a plan to increase nursing support within the region. Plan to improve the support capability of allied health personnel within the region. Plan to increase the number of physicians in the region and to improve utilization of physicians within the region. : Improve patient care through a plan for expansion of physical facilities, and the more efficient use of existing facilities within the region. Develop plans for expanding the effort in clinical research for heart disease, cancer, stroke, and related diseases. - . eH . aaka anwennavacctne and SEU ee yg ey ee wa a iret Yi Wisconsin RMP -3- RM 37-04 (AR-1-D) 2/71 information flow program for the region. Formulate a plan for the development of an optimum program for con- tinuing postgraduate education in fields of heart disease, cancer, stroke, and related diseases. Develop a plan which provides for the most extensive participation and utilization of the capabilities of such established organizations as the American Cancer Society, Public Health Services, Heart Associations, etc. Expand and diversify already strong basic research programs in cancer, heart disease, stroke and related diseases and initiate new research relative to rehabilitation. Priority Determination: The Region indicates that the priorities are tied to points of decision related to the overall planning process. At each decision point, priorities are required to allocate resources in the best possible way. Six steps are outlined which are required to produce results for WRMP proposals. Three of these steps concern decision making that concern priorities. In the first step, WRMP establishes what it wishes to do during a particular planning cycle and attempts to establish priorities among potential proposals. A number of methods may be used to establish priorities to begin a planning cycle: a) progressively defining and redefining the organizations, goals & objectives. Ultimately, such a process could identify a set of manageable activities; b) various data sources, such as profiles of emergency room activities, hospital discharge data and national Health survey can be used to isolate frequency of ailments and identify needs; c) a judgemental process could be used, presenting a decision maker with a set of possible programs and descriptive information expecting that he would add to this list. The results would be a raking of the possible proposals identified. The second step of the planning process is to examine the feasibility of high priority potential proposals identified in the first step. For example, the staff would be concerned with the overlap of these potential proposals, their feasibility for development during the planning period, the approximate amount of resources they might require and the availability of these resources. The third step requires staff and volunteer development of feasible proposals. The fourth step of the planning process is the local review. The decision makers of WRMP, (the RAG) are responsible for this decision. There are two basic results from this review: establishing basic merit for each proposal and ranking acceptable proposals in order of local preference. Step five is DRMP review and rebudgeting constitutes the last step in a planning cycle. Priorities during rebudgeting represent the specific allocation of the available resources to approved projects. Wisconsin RMP -4- RM 37-04 (AR-1-D) 2/71 Regional Advisory Group The group meets on a quarterly basis and is composed of 40 members representing the following areas: Medical, from Clinic to {ndividual practice: Nursing; Dental, Medical Education; Insurance; Labor Unions; Minority group interests; Legal; Industry; Finance area-wide planning agencies; Public Health and Comprehensive Planning; Voluntary Agencies; Public Relations and Industry and Mercantile interests. The RAG was recently reorganized for the purpose of becoming more actively involved in all aspects of the work of WRMP. The group provides overall advice and guidance in the planning and operational program of WRMP; is responsible for the development of the goals and objectives and is involved in the review and evaluation of ongoing planning and operational functions. All Committees and study groups are subcommittees of the RAG with the chair- man of each subcommittee a member of the RAG. The duties of the RAG have been combined with those of the subcommittee in ways that have effectively involved people of diverse skills in many areas of the health, health- related and allied fields in cooperative efforts toward developing a strong and viable RMP. The by-laws of the RAG have been amended to proved for a 5-member Executive Committee who shall act for the RAG between the regular quarterly meetings on matters specifically assigned a by the RAG for interim action. 2 Review Process The Project Review Committee is composed of six members of the Regional Advisory Group, representing hospital administration, nursing, and medicine. The committee meets before each i Advisory Group meeting to study the applications and provides the ws Regional Advisory Group with a detailed review of the advance or completed ? application for project support and recommends action regarding the * applications for final decision to the Advisory Group and endorsement 2 by the Board of Directors. : History of Regional Development In April 1965, both the University of Wisconsin and Marquette University submitted separate applications which were considered by the National Advisory Council on Regional Medical Programs, and were deferred with the suggestion that a revised application be submitted. It was further suggested that cooperative arrangements would be enhanced through closer 2 collaborative efforts between the two Medical Schools. During the interim between April 1965 and July 1966, the Wisconsin Regional Medical Program Inc., was formed as a collaborative venture by the Marquette School of Medicine and the University of Wisconsin. The Corporation is controlled by the Presidents of Marquette University and the University of Wisconsin. Management of the Corporation is vested in a 9-member Board of Directors with a broader representation which includes the State Medical Society of Wisconsin, The Wisconsin Hospital Association and Consumer interests. Dr. John S. Hirschboeck was elected secretary and appointed Regional Program Coordinator who is appointed by the Board of Directors. The Program Coordinator is directly responsible to the President of the corporation. The Board of Directors also appoints the Regional Advisory Committee and its chairman. rate “TNE Wisconsin RMP -5- RM 37-04 (AR-1-D) 2/71 In July 1966, the Wisconsin Regional Medical Program Inc., submitted a revised 2-year planning grant application which was reviewed and approved by Council for the period September 1, 1966 - August 31, 1968. After one year of planning activities 9/1/66 - 8/31/67, the second year planning grant was merged with the first year operational grant. The Region became operational following a preoperational site visit in July 1967. The second year (9/1/67 - 8/31/68) award 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. During its third year, 9/1/68 - 8/31/69 (second operational) the region received approval for the renewal support of Core planning and Administration. Also during this period the region requested support for nine new operational projects contained in two separate applications. Seven of these were recommended for approval. During its fourth year, 9/1/69 - 8/31/70 (third operational) the Region received approval for the following projects; A Comprehensive Program in Renal Disease; Cardiopulmonary Resuscitation Project; Medical Library Service; Nurse Utilization Demonstration Unit; and renewal support for Dial Access Library Service for Physicians; Dial Access Library Service for Nurses and Single Concept Films project. In August 1970, staff considered a request from the Region for the fourth (operational) year (9/1/70-8/31/71) which contained requests for continued support for Core ($438,974) and twelve ongoing projects (see listed below). The request was comprised of the total committed support of $965,444 and carryover in the amount of $60,704 as partial support for two approved projects; #16-Medical Library Service and #17-Nurse Utilization Demonstration Unit. Approval of continued support in the amount requested for the fourth year was recommended. Currently, the Region has the following approved/unfunded projects: Department of Health Manpower and Continuing Education; An Education Program for Cardiac and Intensive Care Nursing; and renewal support, with no additional funds for Inactive Nurse Education. Listing of Current Funding Status of Core and Operational Projects Project Amount Supported (D.C.) Number Title Through 8/31/71 1 Core $ 438,974 4 Cancer Chemotherapy for Adults 38,500 5A Library Service for Physicians 16,900 Wisconsin RMP -6- "RM 37-04 (AR-1-D)2/71 Table Continued Project | . Amount Supported (D.C.) Number Title Through 8/31/71 5B Library Service for Nurses . $ 19,020 5c » Single Concept Films 20,500 6 Radiology and Nuclear Medicine 126,906 7B Coronary Angiography 5,800 7C Pediatric Cardiology 57,256 8 Cancer Chemotherapy Program (Milwaukee) 64,384 11 , Tissue Typing Program 50,950 12 Uterine Cancer Screening Project — 50,820 15* ' Comprehensive Program in Renal Diseases 450,000 16 Medical Library Service 16,525 17 Nurse Utilization Demonstration Unit 119,613 20* Detection and Management of Gynecologic Malignancy 116,125 TOTAL $ 1,592,273 Carryover included above: #16 $16,525 #17 «44,179 $60,704 * Not considered during staff review of continuation application. Present Application This application contains 4 request for a developmental component in the amount of $200,000 for a one-year period beginning 9/1/70 - 8/31/71. Use of Developmental Funds The Regional Advisory Group identified areas of high priority program interest and recommended that developmental funds be made available for feasibility studies and program development. The following program areas were approved for use . of developmental funds: eee Wisconsin RMP -7- ' -RM 37-04 (AR-1-D) 2/71 the planning and promotion of an improved coronary artery disease care system for the Region. the planning and development of innovations in health care delivery and manpower utilization. the planning and development of improved hospital emergency care and improved transportation of the sick and injured. the planning and development of innovations to improve long-term patient care, including home care and Nursing home care. the planning and development of means by which education can be brought to those health professionals who are not presently served. the planning and development of continuing education which is designed to develop proficiency in using new knowledge or new technology. the planning and development of improved health care for isolated rural residents. the planning and development of improved health care services for the poor and those who find it difficult to enter the health care system. the promotion of further involvement of health profession schools and their faculties in RMP activities. DRMP/GRB 12/8/70 - ms (A Privileged Communication) @ SUMMARY OF REVIEW AND CONCLUSION OF January 1971 Review Committee WISCONSIN REGIONAL MEDICAL PROGRAM RM 00037-04 (AR-1-D) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: The Committee recommended that this application, which Tne cp ae nee aH into their. triennial application. YEAR : REQUEST RECOMMENDED FUNDING Ist Year $200,000 TOTAL $200,000 Critique: In its deliberation, the Committee considered the Site Visit Report, Wisconsin Regional Medical Program, December 8-9, 1970. While - ‘ the site visitors recommended approval for approximately $160,000 for one year: for the developmental component, rather than the $200,000 Ov: members of the Review Committee believed that action should be deferred with advice to the Region to incorporate their proposal for developmental funds into their triennial application, due May 1971. A member of the Review Committee, who was also a member of the December 8-9, 1970 site visit team, reported the findings of the team to the Committee. He reported that the Wisconsin RMP has many strengths and much potential. One of the’ positive factors is the Program Coordinator — who has fully devoted himself to the goals and objectives of RMP and who has done an excellent job through the years of maintaining control over the management and direction of the WRMP. However, the team agreed and suggested to the Coordinator that he could probably use another M.D. on his staff as back-up to himself and to coordinate monitoring of WRMP planning and operational activities. He went on to state that while the core staff appeared to be a cohesive group which has stayed together over. the years, they believed that it lacked sufficient depth and strength as to its ability to evaluate total program as related to objectives. Physically, the Core Staff is split ‘between Milwaukee and Madison. While the essential strengths are presently in the Milwaukee Core: offices, the Region is considering a plan to move and combine the two offices into one Central Core office which will be located in Madison. The Regional Advisory Group was viewed by the site visitors as being a well-balanced group, having broadened the range of professional and -health interests. Geographical representation has also been improved. It was noted that there is currently only one Black member.on the RAG, @ oe may be improved through appointment to a vacancy. The Committee a? ~ | , RM 00037 (AR-1-D @.... 2 oO - = - y ). 2/71. learned that the RAG has a strong role in policy direction and guidance of the program and has a strong input into the review pro@ess. The extent of the subregionalization efforts in Wisconsin was one of the concerns of the site visitors, although the Region is progressing in this effort, the team believed that further efforts should be made especially in the zara areas of the State. One of the major concerns of the site visit team was the lack of objective methods of evaluation. While the Region has the expertise available through the Universities, evidentally this talent is not being fully exploited. . - Members of the Committee learned of the team's concerns regarding the large Renal Disease Project which is currently being funded in the Region. While the Reviewers were aware of the recent funding of this activity, it agreed with the site visitors that some early technical assistance would be necessary if the project is expected to achieve its objectives. . While the site visitors agreed that the WRMP is a well-adjusted Region which has demonstrated that it has the machinery, expertise and local autonomy to successfully and prudently administer and use a developmental -omponent as a part of their total program, members of the Committee believed that the developmental component was too broad and all encompassing. It was believed that the Region should more adequately describe and specify how developmental funds would relate to the priority needs of the Region. In conclusion, in spite of the site visitors positive recommendation on the request for developmental funds, the Review Committee after a some- what lengthy discussion, believed that the awarding of a developmental ‘component at this time was not indicated. Rather, the Committee recommended that action on the developmental component be deferred with the thought, that the Region may wish to incorporate its proposal for developmental funds in the triennial application, which will be considered during the July/August 1971 Review Cycle. . In arriving at the recommendation to defer action on this application, the Committee believed that the delay would provide the Region with the opportunity to replan its anticipated use of developmental funds. Also, the Committee further recommended that a technical site visit to include members of RMPS Kidney Disease Program, be made to review and assist the Region with the Renal Disease Project. . Dr, White was not present at the deliberation of this application, : GRB /RMP 1/19/71